NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Apps. XIX.
Investigating, etc., of infectious. disease.
(b) The diagnosis of the first eight will be made only on the isolation
of the specific organism, while the last will be reserved for cases diag
- n o s e d o n a r i s i n g W i d a l r e a c t i o n , o r i n w h i c h a s p e c i f i c o r g a n i s m
has not been isolated, but whose history, onset and clinical course,
are suspicious.
It is pointed out that, from a scientific point of view, the diagnosis
" E n t e r i c g r o u p " c a n n o t b e c o n s i d e r e d s a t i s f a c t o r y , a n d i t s
introduction in no way relieves officers in charge of cases of their
responsibility for ensuring that every laboratory method is used before
the case is so returned.
(c) The diagnosis " Enteric Group (B. fæcalis alkaligenes) " will
be made only in those cases in which B. fæcalis alkaligenes is isolated
from the blood and in which the patient's serum shows agglutinins
for this bacillus.
53. Diagnosis.—The following is the procedure to be followed : —
(a) Clinical methods.—In all cases of pyrexia for which there is no
immediately obvious cause (such as lobar pneumonia, acute tonsillitis;
etc.), the following procedure will invariably be adopted.
(i)
I m m e d i a t e l y o n a d m i s s i o n t o h o s p i t a l a b l o o d f i l m w i l l b e
made and examined for malarial parasites. If negative,
a second film will be taken on the following day and examin--
ed at once.
(ii) If pyrexia persists and the blood film taken on the day after
admission is again negative for malarial parasites, a blood
culture should be taken by the medical officer in charge
of the case. Bile media should be available in every hos-
-pital, and will be supplied from the nearest laboratory.
The earlier in the disease the blood culture is taken the
greater the likelihood of recovering the specific organism;
every attempt should therefore be made to take a blood
cultured early in the course of the disease. If a report is
received from the laboratory that the blood culture is
sterile or contaminated, a further blood culture should be
taken unless the temperature has become normal mean
-while. Such reports should be sent by laboratories to
hospitals as early as possible, and to outstations by tele
-gram.
The days on which serum for Widal reactions and specimens
of fæces and urine will be despatched to the laboratory are
laid down in Appendix XXI.
(iii) Differential and total leucocyte counts should be carried out
in all cases.
(b) Laboratory diagnosis—
(a) No organism should be diagnosed as of the enteric group
without definite serological proof of its identity.
Investigating, etc.,of infectious disease.
Appx. XIX.
(b) Dreyer's method of agglutination is to be employed for all
agglutination tests, and the results expressed in standard
agglutinin units. It should be noted that the results of
Widal tests between the 18th and 24th day from onset of
disease are of great importance in the estimation of the rise
of the agglutinin contents in the serum of a patient infected
with an organism of the enteric group.
(c) Confirmation of laboratory diagnosis. (i) As a check on the
accuracy of diagnosis a subculture of any supposed "en-
teric" organism recovered in a laboratory will be forwarded
for confirmation to the Enteric Laboratory, Kasauli.
(ii) Such subcultures will be forwarded to the officer in charge
of the Enteric Laboratory, Kasauli, as indicated in sub--
paragraph (vi) below, who will keep a register of all
subcultures, and will examine and classify them and report
the result of the examination without delay to the officer
from whom the subculture has been received.
(iii) Officers sending subcultures of organisms, recovered from
blood or excreta of patients, to the Enteric Laboratory,
Kasauli, for confirmation will maintain subcultures of
such organisms until a report has been received on the
original subculture sent there.
(iv) Any change in diagnosis considered necessary as the result of
confirmatory bacteriological examination will be noted on
all relevant documents.
(v) The diagnosis of a case based on the isolation of an organism
from the blood should not be changed on account of subse-
quent recovery of a different organism from the excreta of
the same patient.
(vi) Subcultures should be in agar stabs, and the tubes should
be sealed and securely packed for transmission through
the post. Each should be accompanied by I. A. F. M-
1265 D.
54.—Management and Disposal of Convalescents.
(A) British W. Os., N. C. Os. and men.
(i)With the exception of cases occurring in Burma, every case
of typhoid, paratyphoid or enteric group fever (except cases of infection
with B. fæcalis alkaligenes) will be transferred to the Hill Depôt,
Kasauli, as soon as possible after recovery. Such cases, before transfer,
must be fit to travel and no longer require active medical, surgical
or dietetic treatment. Cases occurring in Burma will be transferred
to Maymyo.
(ii)On the departure of a convalescent to the Hill Depôt, Kasauli,
or to Maymyo the following documents will in every case be posted
265
Appx. XIX.
Investigating, etc., of infectious disease.
direct to the officer in charge of the Enteric Laboratory, Kasauli
(officer in charge District Laboratory in the case of Maymyo).
(a) A. F. B. 181, Clinical Chart.
(b) A. F. B. 178, Medical History Sheet.
(c) A. F. I. 1237, Medical Case Sheet.
(d) I. A. F. M-1265B, Malaria Case Sheet (if under treatment for
malaria).
(e) A. F. I. 3056, Special report on a case of fever of the enteric
group.
(iii)
On arrival at the Hill Depôt, Kasauli, or at Maymyo, each
man will be placed as soon as possible upon a course of bacteriological
examinations of both fæces and urine. Normally this will consist of
30 examinations of each, viz., five per week for a period of 6 weeks.
As soon as tests have been completed, A. F. I. 3056 (special report on
a case of fever of the enteric group), with the remarks of the officer in
charge of the Enteric Laboratory, Kasauli or District Laboratory,
Maymyo, regarding the bacteriological and serological findings
entered thereon, will be returned to the O. C. military hospital con-
cerned, who will forward it without delay to the Director of Medical
Services in India through the usual channels. Necessary changes of
diagnosis will be made by the D. M. S. in India and notified by him
to all concerned.
Men relapsing will also be admitted to hospital ; on discharge
therefrom the series of examinations mentioned above will be com-
menced de novo.
(iv)
At the beginning of each month the officer in charge of the
Enteric Laboratory, Kasauli, and the officer in charge of the District
Laboratory, Maymyo, will submit nominal rolls of (a) men comm-
encing and completing examination during the previous month and
(b) carriers detected during the previous month, and (c) of those
remaining under examination on the last day of the month, giving
the following particulars :
—
(1) No., (2) rank, (3) name, (4) station from which received,
(5) diagnosis at own station, (6) date of arrival, (7) positive
findings with dates,(8) final diagnosis, and (9) remarks, if
any. These returns will be sent direct to the D. M. S..
in India.
(v)
A " carrier " will be held to remain a carrier until at least 20
negative examinations have been made since the time when enteric
organisms were last found.
(vi)
All " carriers " detected will at once be admitted to hospital.
(vii)
A carrier becomes, for statistical and invaliding purposes, a
" chronic carrier " if he continues to excrete enteric organisms persis-
tently or intermittently up to a period of six months from the date of
arrival for examination.
(viii)
A " chronic carrier," as defined above, will be brougt before a medical board and invalided to the United Kingdom. Army
(ix)
266
Investigating, etc., of infectious disease.
Appx. XIX.
Form B. 178 will be endorsed in red with capital letters "CHRO
-NIC CARRIER, B. TYPHOSUS" (Para. A or Para. B or Para.
C as the case may be). In every instance the fact that the invalid
is a chronic carrier will be noted on I. A. F. (Medical) 6 in red ink.
(xi)When a man is discharged from the depôt as free from infec-
tion, his medical history sheet (A. F. B. 178) with notes as to the
number of examinations carried out and the result endorsed thereon,
will be returned to the officer commanding military hospital, at the
station to which he will travel to join his unit.
(xii)Instructions when travelling :— Convalescent travelling to
Kasauli or Maymyo will be advised of the risk ensuing to the
community if precautions are not taken to avoid fouling of
station and carriage lavatories, etc. They should be instructed to
be scrupulously careful to wash their hands immediately after
using latrines or urinals. Similar instructions should be issued to
chronic carriers.
(xiii)No soldier is to be invalided out of India until declared
free from infection or pronounced a 'chronic carrier.' Where a
soldier is due for discharge from the service, however, on the termina-
tion of his period of engagement, he will not be retained in India
merely for the purpose of ascertaining whether he is a carrier or not
unless there is time to go through that process and have him despatched
in time to reach the United Kingdom for disposal there before the
date on which his engagement terminates. Where there is not time
to ascertain his condition his medical history sheet will be endorsed
in red ink according to circumstances "Typhoid (or Para. A or Para. B
or Enteric Group) convalescent" or "Typhoid (or Para. A or Para. B
or Enteric Group) convalescent examined . . . times all
negative" or "Typhoid (or Para. A or Para. B) carrier, last positive
examination ......" and the embarkation authorities will be notified
as in sub-paragraph (x) above.
(B) Officers (British).
British officers convalescent from enteric will not be sent to
Kasauli or Maymyo.
Such officers will be placed on a course of 30 examinations (5 per
week for 6 weeks) during convalescence. In stations in which no
military laboratory is situated specimens for examination will be
forwarded to the District Laboratory concerned in accordance with
the instructions laid down in Appendix XXI. An officer who is
found to be a carrier will be at once admitted to hospital.
(C) Indian Troops.
Twenty consecutive negative bacteriological examinations of stools
during convalescence will be carried out before patients are discharged
from hospital—where it is desirable to send such patients on leave to
their homes ten such examinations should be carried out on the patient's
return from leave. He should not be admitted to hospital for these
latter examinations.
267
Appx. XIX.
Investigating, etc.,of infectious disease.
TYPHUS FEVER.
55.Spread.—Typhus fever is especially liable to break out among
troops under active service conditions. Infection is carried by lice.
56.Preventive measures. —Patients should be isolated immediately,
and be completely freed from lice and their ova before admission to the
wards ; disinfestation will be carried out as indicated in para. 554.
Reinfestation must be prevented. Medical officers and attendants
on the sick should undergo disinfestation every day. They should
wear overalls fitting tightly at the neck, wrists and ankles, long gloves
and close-fitting caps. Contacts should be freed from lice and have
their clothing disinfested. They should be kept under daily medical
observation for a period of 22 days (10 days for incubation in the
louse plus 12 days for the patient). Effective disinfestation renders-
segregation unnecessary. When troops are exposed to the risk of
contracting typhus, special attention should be directed to the destruc-
tion of lice and ova in the hair ; and their clothing, bedding and textile
equipment should be disinfested at intervals not exceeding 14 days.
On the occurrence of a case, the above measures should also be applied
to quartermasters' stores, and the entire unit after disinfestation should
proceed whenever possible, to a new, clean camp. Special attention
should be paid to refugees, and no unauthorised persons should enter
the military area. The periodical disinfestation of vehicles is neces-
sary. Infective areas should be placed out of bounds and contact
with local inhabitants should be avoided as much as possible.
WHOOPING COUGH.
57.Spread.—By direct "droplet " infection or by infected utensils.
58. Preventive measures. —The patient should be isolated for a
minimum of 6 weeks from the onset. Disinfection will be carried out
as indicated in para. 554.
Contacts should be kept under daily medical inspection for 16 days
and children of infected families should be excluded from school for a
similar period.
268
Disinfecting solutions.
Appx. XX.
APPENDIX XX.
DISINFECTANT AND OTHER SOLUTIONS.
The following standard strengths are prescribed :—
(1) Chlorinated limewash.
Chlorinated lime (B. P.) . . . 2 ozs.
Quicklime . . . ½ gall.
Water to . . . 1 gall.
(2) Cresol Emulsion (1 in 160).
Saponified cresol . . . I oz.
Water to . . .
1 gall.
When disinfection of textiles must be effected in 30 minutes, the
a bove amount of cresol must be increased to 2 ⅔ ozs. (1 in 60).
When liq. cresoli saponatus is required to be used with sea or
brackish water, it should first be emulsified with 5 to 10 times its bulk
of fresh water, and then added to the required amount of sea water.
(3) Corrosive sublimate solution (0.1 per cent).
Corrosive sublimate (mercuric chloride) . . . 70 grs.
Hydrochloric acid . . . 3 drs.
Water . . . 1 gall.
The solution should be tinted with a sufficiency of commercial
aniline blue (about one grain to the gallon) to make it of a distinctive
colour. Mercuric chloride solution must not be stored or used in
metal vessels.
(4) Formaldehyde solution.
40 per cent. formaldehyde solution (formalin) 8 ozs.
Wat er t o . . .
1 gall.
One gallon should be used for every 400 square feet of surface to be
disinfected.
(5) P. C. Oil.
parts
Citronella oil . . .
1 ½
Kerosene . . .
1
Cocoanut oil . . .
2
to which is added Carbolic acid 1 per cent.
269
Appx. XX.
Disinfecting solutions.
(6) Formaldehyde gas.
The gas may be produced by vaporizing paraform tablets, 26 to
each 1,000 cubic feet, or by pouring formalin on to potassium per
-manganate, ½ pint to 5 ozs. per 1,000 cubic feet.
A temperature of 75°F. and a humidity of 75 is necessary for max
i-mum efficiency.
(7) Cresol and soft soap emul si on for fleas.
parts
Cresol . . .
5
Soft soap . . .
20
Water . . .
75
The cresol and soft soap are added to the hot water with continuous
stirring. For use make a 5 per cent. solution with water.
(8) Paraffi n and soft soap emul si on for fl eas.
Hard soap . . .
1 lb. (or soft
soap 1½ lbs.).
Paraffin oil . . .
4 gallons.
Hot water . . .
1 gallon.
Dissolve the soap in the hot water ; add very gradually the paraffin
oil, with continuous stirring. For use make a 5 per cent. solution with.
water.
270
Specimens for laboratory examination.
Appx. XXI.
APPENDIX XXI.
INSTRUCTIONS FOR SENDING SAMPLES OR SPECIMENS
FOR CHEMICAL AND BACTERIOLOGICAL EXAMI-
NATION.
A. WATER.
1. A chemical and bacteriological analysis of water is of great
use in ascertaining the quality of new sources of supply and in deter-
mining whether a protected supply remains free from contamination.
In the case of an unprotected supply, such as an open well or river,
the condition as regards contamination may vary from day to day
or even from hour to hour ; in such cases more reliance should be placed
on a thorough and careful inspection of the source and surroundings
than on analysis.
The scope of bacteriological analysis is rather wider than that of
chemical analysis, since it may provide definite information as to the
presence or absence of certain specific pathogenic organisms, e.g.,
cholera.
2. Receptacles and carriers—
(a) Samples for chemical examination should measure at least half-
- a - g a l l o n , a n d s h o u l d b e f o r w a r d e d i n " W i n c h e s t e r q u a r t " b o t t l e s
which contain that amount when full.
Should these not be available, other glass-stoppered bottles may be
used. Corks should only be used in emergencies, when they should
be quite new, and well secured by string and sealing-wax.
In all cases when its absolute cleanliness is in doubt, the bottle
must be rinsed out with strong sulphuric acid, the last traces of which
must subsequently be removed by repeated rinsings with the water
to be examined. A final rinsing must always be made immediately
before taking the sample.
(b) Samples for bacteriological purposes must be forwarded in
sterile bottles. Glass-stoppered bottles, to contain not less than
6 ounces, may be used.
3. The taking of samples will be carried out under the direct personal
supervision of a medical officer detailed for the purpose, who will be
responsible that the following directions are observed.
Great care must be taken that a fair average sample of the supply
is collected and submitted. In the case of piped supplies, samples
should be taken direct from the mains as well as from delivery taps
in houses. Samples for chemical and bacteriological examination
from any individual source must be taken at the same point and at
the same time.
(a) Chemical samples.—If possible, without disturbing any sedi-
ment that may be present bottles should be filled while
fully submerged—thus avoiding scum. Piped water
271
Appx. XXI.
Specimens for laboratory examination.
should be allowed to rúm to waste freely, so that impurities
in the pipe lumen may be washed out before a sample is
taken.
•
•
(b) Bacteriological samples.— The following additional precautions
•
are necessary:—
(i) If sampling from a tap, flame the tap for a minute and
then let the water run to waste
f or
three
minutes before
taking the sample
.
(ii) Before opening the sterilised bottle, flame its neck and.
stopper by means of a spirit lamp. With a similarly
•
sterilized pair of forceps, remove the stopper and hold
it thus until, after a final passage through the flame,
it is replaced in the bottle, which should meanwhile
have been completely filled so that no bubble of air is-
•
finally retained.
(iii) Pack the bottles in a box with ice and saw-dust, or with
dry saw -dust if no ice is obtainable.
4. Transmission, of samples and particulars.—To enable it to be
identified each sample should be securely labelled, giving full parti-
culars regarding its source.
Samples will always be forwarded by the most expeditious route.
Those for bacteriological examination should reach the laboratory
within 48 hours of collection. Except in cases of emergency they
should not arrive on a Saturday or Sunday.
Full particulars embodying information on the following points
must be despatched at the same time as, but separately from, the
samples :—
(i) The reasons for, and the exact nature of, the examination
required.
(ii) Date and hour of sampling.
(iii) Nature and location of source of water, ánd site of sampling.
(iv) Nature and distance of any source whence an inflow of
pollution appears probable.
(v) Geological strata (as far as readily ascertainable) likely to
affect the water constituents.
(vi) If the source be a well, depth to water, depth of water
steining, coping, covering, strata penetrated, method of
raising water.
• •
•
(vii) If a stored surface-water—nature of collecting surface and
conditions of storage.
(viii) Meteorological conditions, with reference to recent drought
or heavy rainfall.
(ix) Any treatment the water has received which may alter its
constituents, e.g., clarification, chlorination, softening or
boiling.
272
•
Specimens for laboratory examination.
Appx. XXI.
B.—FOOD AND BEVERAGES.
1. Bacteriological and chemical analysis of foodstuffs and beverages
are carried out at the Military Food Laboratory, Kasauli.
2. The following foodstuffs and beverages only may be sent for
examination to District or Brigade Laboratories, and no others except
in cases of unusual urgency— i.e. , fresh flesh food, fresh vegetables,
fresh petty supplies, milk, drinking water, mineral waters, ice. As a
general rule in District and Brigade Laboratories chemical analyses,
except of milk, are not carried out.
3. The submission of samples in connection with contracts or
routine examination of Supply Officers' stocks is dealt with in the
Standing Orders of the I. A. S. Corps.
In the case of analyses carried out in connection with contracts,
reports will be forwarded to the officer on whose behalf the sample is
submitted, a copy being sent to the Director of Contracts, Army Head-
quarters. In the case of analyses for the routine examination of Supply
Officers' stocks, reports will be forwarded to the Officer Commanding
the Supply Depôt Company concerned.
4. Samples other than those referred to in para. 3 above, should be -
taken under the direct personal supervision of a medical officer detailed
for the purpose, and he will be responsible for ensuring that the direc-
tions contained in the following paragraphs are carried out.
5. In the collection of samples special care is necessary, in every
case, to ensure that a fair average of the substance is obtained, e.g.,
both the crust and crumb of bread, and the rind and interior of cheese,
should be included. In the case of milk, the supply should be tho-
roughly mixed by stirring or pouring from one receptacle to another
before the sample is taken.
6. The original container should be forwarded unopened, if possible.
Otherwise, if practicable, it should be forwarded with the sample.
Articles not packed in original containers should be packed as
follows:—
(a)Liquids.—In clean, glass-stoppered bottles of such a size that
the sample completely fills the bottle.
(b)Solids.—In clean biscuit or other suitable tins.
(c)Semi-solids.—As in either (a) or (b) above according to which
may be more suitable, or in clean earthenware jars fitted
with clean bungs.
(d)Samples for bacteriological examination should be packed
(with sterile precautions) in sterile glass-stoppered bottles..
The use of paper or other packing inside the receptacle in which
any of these samples are forwarded is prohibited, except when the
sample is contained in its original wrapper.
273
Appx. XXI.
Specimens for laboratory examination.
7. The minimum quantities which should be sent for examination
are as follows :—
Milk.
.
.
.
.
.
. 6 ozs.
Condensed milk
.
.
.
.
. 1 tin
Dried milk, milk foods, etc.
.
. . 2 ozs.
Butter, margarine, ghi, etc.
.
. . 4 ozs.
Cheese.
.
.
.
.
. 4 ozs.
Bread.
.
.
.
.
.
. 8 ozs.
Biscuits
.
.
.
.
.
. 8 ozs.
Flour.
.
.
.
.
.
. 4 ozs.
Oatmeal
.
.
.
.
.
. 2 ozs.
Atta.
.
.
.
.
.
. 4 ozs.
Rice
.
.
.
.
.
.
. 4 ozs.
Tea
.
.
.
.
.
.
. 2 ozs.
Coffee.
.
.
.
.
.
. 4 ozs.
Cocoa .
.
.
.
.
.
. 2 ozs.
Tinned meat, fish, etc. .
.
.
. 1 tin
Sausage
.
.
.
.
.
. 8 ozs.
Dried or smoked meat, fish, etc.
.
. 8 ozs.
Lard or its manufactured substitutes
. 4 ozs.
Tinned or bottled fruits, vegetables,
etc. .
.
.
.
.
. . 1 tin or bot
tle.
Sugar.
.
.
.
.
.
. 4 ozs.
Jams, syrups, etc. .
.
.
.
. 4 ozs.
Confectionery, sweets, etc.
.
.
. 4 ozs.
Pepper, mustard, species, etc. .
.
. 1 oz.
Vinegar, sauces, etc.
.
.
.
. 5 ozs.
Lime juice and other similar preparations . 5 ozs.
Beer or stout .
.
.
.
.
. 10 ozs.
Spirits.
.
.
.
.
.
. 10 ozs.
Aerated water
.
.
.
.
. 1 bottle or
syphon.
8. Each sample should be securely packed labelled and sealed by
the sampling officer, and forwarded by the most expeditious route.
A report regarding each sample will be despatched separately by re-
gistered post.
9. Reports, forwarded as above, should embody at least the following
information :—
(a) The nature and quantity of the sample.
(b) The source of the sample and the date of procuring it.
274