NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
19
Western Command (Western Independent District) remains without any cases
and the increase in the total cases diagnosed is seen to be due to Eastern and
Southern Commands.
The recognition of the clinical disease and its confirmation by serological
investigation is probably still far from complete, even amongst military
per-sonnel, and requires continued study. The disease is probably prevalent in the
civilian population in many areas and passes unrecognised under the heading
of fever or typhoid.
At Kasauli in Northern Command there was this year one definite case of
Typhus of the OXK serological type from which a strain has been isolated in
guinea pigs. Work has been continued on the reservoir of infection and on the
transmission of OXK.
Evidence has been collected that rats may serve as the reservoir.
Re-garding transmission—the Trombiculidae present in the Simla Hills are being
investigated and it may be mentioned that the breeding of these mites has now
been accompl i shed. Transmi ssi on experi ment s wi t h l aborat ory bred l arvae
and strains of Typhus maintained in guinea pigs are now being conducted.
10. Enteric Group of Fevers
The incidence of all groups of these fevers amongst troops remains at a
very satisfactory figure. For British troops there has been the very slight
increase of one case and one death, but for Indian troops a corresponding re
-duction of 3 cases and one death.
The reduction in the inefficiency and loss produced by this once
d e v a s t a t - i n g d i s e a s e i s w e l l s h o w n i n t h e f i g u r e s f o r t h e p a s t 2 0 y e a r s . A s r e g a r d s I n d i a n
troops it should be realised that the accuracy of diagnosis was increased from
1926-27 and accounts for the apparent rise at that time. Amongst military
personnel there are now probably relatively few real cases of the disease which
are missed.
TABLE No. 20
Comparative table of incidence of Enteric Group Fevers over 20 years
Year
(Ratios per 1000)
British
troops
Indian
troops
1913 . . .
2.3
1.6
1919-1928 (Average 10 years) . . .
3.3
0 . 9
1929 . . .
4.2
2.9
1930 . . .
3.7
2.3
1931 . . .
3.3
2.5
1932 . . .
3.4
2.2
1933 . . .
3.2
2.5
1934 . . .
1.7
1.9
1935 . . .
2.0
1.4
1936
1.5
0 . 6
1 9 3 7 . . .
0.8
0.9
1938 . . .
0 . 9
0 . 8
Various small outbreaks of cases and the well recognised prevalence of Enteric
infections amongst the civil population show the need for constant vigilence
and protection of all military personnel against this group of diseases. These
small epidemics are probably cases of mass infection impinging on a point of
failure in our preventive armament, such as persons who have missed or possibly
refused protective inoculation and exposed themselves to risk by use of extra
-neous sources of milk, water or foods.
20
In Northern and Southern Commands there was a slight increase in the
admission for this group. Poona and Ahmednagar had 4 cases each amongst
British troops. In Western Ind. District there were no British troops cases
for the second year in succession. This immunity is definitely attributed to
inoculation because such cases as have occurred were amongst officers all of
whom were due for inoculation. The prevalence of cases of dysentery shows
that the opportunity for infection by intestinal infections was amply present.
The relative proportions of the members of this disease group are shown
below.
TABLE 21
Comparative Table of Types in the Enteric Group—Actual admissions and deaths
1935
Years
Ty-
phoid
British troops
Indian troops
Para
A
Para
B
Para
C
-
Entc.
Group
To-
tal
Ty-
phoid
Para
A
Para
B
Para
C
Entc.
Group
To-
tal.
A . . .
27
13
4
. . . 66 106
55
46
1
. . .
62 164
D . . .
8
. . . .
. . . .
. . . .
1
9
8
3
. . .
. . .
2
13,
1936
A . . .
14
13
1
1
47
76
29
14
1
. . .
33
77
D . . .
2
. . .
. . .
. . . 1
3
3
. . .
. . .
. . .
2
5
1 9 3 7 A . . .
6
2
2
. . . 26
36
36 23
. . .
. . .
29
88
D . . .
3
. . .
. . .
. . .
1
4
6
1
. . .
. . .
1
8
1 9 3 8 A . . .
15
2
4
. . . 1 6
37
38
15
1
1
30
85
D . . .
3
. . .
. . .
. . .
2
5
5
. . .
. . .
. . . 2
7
The decrease in the Para A group noted in 1937 for British troops has been
maintained and Indian troops show a similar satisfactory decrease this year.
There are however indications that the Para A group may show increases for
1939. The reduction of cases remaining ungrouped over the past 4 years is
satisfactory.
The seasonal incidence of the group is similar to last year ; but with a
tendency to prolong into the autumn, possibly on account of the extension
of the warm weather [see paragraph 5( a )]. The monthly figures indicate that
some factor connected with the warm-wet months is the cause of many of
such of the infections as have occurred, similarly to those for dysentery. The
probable factor appears to be fly prevalence with fly . borne infection of milk
and foods.
TABLE No. 22
Seasonal distribution per cent of Enteric Group fevers—British and Indian Troops
Command
Number
of cases Jan. Feb. Mar. April May June July Aug. Sep. Oct. Nov. Dec.
Northern .
64
9.4 6.2 3.1
. . .
4.7 20.8 12.5 15 . 6 7.8 10.9 3 . 1 6.2
Southern .
24
8.3 4.0 12.5
. . .
. . . 12.5 20.8 8.3 8.3 4.2 8.3 12.5
Eastern .
22
4.5 4.5 9.1 9.1 13.6 9.1 4.5 9.1 9.1 13.6 9.1 4 . 5
Western (I..)
Distt.
All India .
12
. . .
8.3
. . . 8.3
. . . 16.7 8..3
. . . 25.0 16.7
. . . 16.7
122
7.4 5.7 5.7 2.5 4.9 16.4 12.3 9.8 9.8 10.7 4.9 8.2
The absence of infections in the dry or hot months and relative absence
in the coldest months, that is in the non-fly seasons, is strikingly shown by the
figures given in this table.
22
For troops the following table shows the period after inoculation at
which infection occurred.
TABLE No. 24
Enteric fevers—Periods after inoculation at which infection occurred
Total enteric group of fevers
Typhoid cases
bacteriologically proven
0—6
months
Per cent
6—12
months
Per cent
12—18
months
Per cent
0—6
months
Per cent
6—12
months
Per cent
12—18
months
Per cent
1929 . .
32.2
50.5
17.5
31.2
58.3
10.4
1930 . .
37.6
43.6
18.8
32.7
46.6
20.7
1931 . .
35.4
35.4
29.2
34.4
34.9
30.2
1932 . .
33.7
38.0
28.2
30.9
45.4
23.6
1933 . .
32.0
44.0
24.0
26.0
45.8
29.2
1934 . .
33.7
35.1
31.1
40.0
24.0
36.0
1935 . .
30.0
43.3
26.6
21.7
43.4
34.7
1936 . .
32.3
40.0
27.7
15.4
30.8
53.8
1937 . .
29.6
40.7
29.6
. .
50.0
50.0
1938 . .
29.7
59.5
10.8
6.7
73.3
20.0
From the relation of the period after inoculation to the occurrence of the cases
shown by these figures for bacteriological proven cases it became obvious that,
although improvement was being obtained in the earlier months, the period
after 12 months to 18 months was showing an increase in the percentages.
It was decided to make a change in the procedure and the extent of T. A. B.
inoculation, and this decision has been carried into effect during the year under
review. The method now is to retain the double doze, 0.5 cc and 1 cc given
at a ten day interval, for all primary inoculation ; but all subsequent inoculations
will consist only in one doze of 0.5 cc T. A. B. at 12 monthly intervals. This
change was brought into action in the second half of the year and results are
being carefully watched. In view of the reduction of the dose the Para A
moiety may not be adequate and may require an increase in future.
TABLE No. 25
Fevers of the enteric group—Inoculation state among B. 0. Rs
Ratio per 1,000
Group .
Cases
Deaths
Case
mortality.
per cent
Protected . . .
0.90
0.12
13.51
Unprotected . . .
. .
. .
. .
See note below Table No. 26
TABLE No. 26
Incidence of fevers of the enteric group among Protected and Unprotected officers,
other ranks, women and children
Admissions
Percentage. Typhoid Para
A
Para
B
Para
C
Enteric
group
Total
Officers
(B. S. & I. S.)
Protected . 95.86
. .
2
. .
. .
2
4
Unprotected 4.14
1
3
. .
. .
5
9
British other
ranks.
Protected . 98.46
15
2
4
. .
16
37
Unprotected
1.54
. .
. .
. .
. .
. .
. .
Women
Protected . 95.84
1
2
. .
1
4
Unprotected
4.16
2
. .
. .
. .
1
3
Children
Protected . 90.02
1
1
. .
. .
1
3
Unprotected
9.98
3
2
. .
. .
1
6
NOTE.—The absence of cases amongst unprotected B. 0. Rs. is notable but their
numbers are relatively few and hygienic control of their general health is careful.
23
The 1 . 54% unprotected B. 0. Rs. appear to have been exceedingly lucky.
Their apparent immunity to infection may be due to old standing protection,
from past inoculation or to the relative protection of sanitary measures,
and food protection in barracks.
11. Dysentery, Diarrhoea, Colitis and Amoebic Hepatitis
A very different picture indeed is presented by this group compared with
those of the previous disease groups which have been steadily reduced. In
fact there is a tendency to increase rather than decrease.
For British troops this is shown by the graph for the past 6 years which
gives a very distinct rise in the rates of cases admitted.
Dysentery and Diarrhoea—B. O. RS.
Ra t i o p e r 1 0 0 0
YEAR
That this increase is not merely a temporary wave of incidence is shown by
the more extended figures given in the following table for British and Indian
troops. From this it will be seen that there has actually been a steady increase
for British troops and Indian troops are showing no signs of permanent re-
duction.
24
TABLE No. 27
The incidence of the Total Dysentery-Diarrhoea Group
Year
British
troops
Indian
troops
1913 .
.
.
..
.
.
.
.
18.5
25.9
1919 .
.
.
. . . . . . .
45.3
31.1
1925 .
.
.
.
.
.
.
.
.
.
.
24.3
20.3
1929
.
.
.
..
.
36.3
24.6
1930 .
.
.
.
.
40.5
27.7
1931
.
.
.
. . . . . . . .
43.9
22.6
1932 .
.
.
.
.
.
.
.
. . .
38.2
21.8
1933.
.
.
.
.
.
.
.
40.2
23.3
1934.
.
.
. . . . .
40.4
30.2
1935.
.
.
.
.
.
.
.
.
.
43.1
17.8
1936.
.
. . . . . .
40.7
17.2
1937.
.
.
.
.
.
.
.
.
.
41.8
17.9
1938 .
.
.
.
.
. . . . .
44.8
24.7
A study of the monthly incidence of this disease group by Commands and
the All India figures together with the reiterated comments of experienced
Hygiene officers indicates clearly that the majority of the infections are flyborne
and come from the vast reservoir of adjacent bazaars or cities in which sanita-
tion is primitive. The monthly figures are given in the following table.
TABLE No. 28
The Seasonal incidence of the Dysentery- Diarrhoea Group
British
Indian
1936
1937
1938
1936
1937
1938
January
.
.
1.4
1.7
1.6
0.6
0.8
0.6
February
.
.
1.3
1.5
1.9
0.5
0.4
0.4
March .
.
.
3.2
3.3
3.7
0.6
0.8
0.7
April .
.
.
5.7
6.4
6.3
1.5
1.6
2.3
May
.
.
.
4.3
5.0
4.6
2.0
1.8
3.1
June .
.
.
3.3
2.6
4.7
1.9
1.6
2.9
July .
.
.
5.1
3.5
6.3
2.0
1.9
3.8
August.
.
.
4.1
5.3
5.0
2.2
2.9
3.7
September .
.
3.2
3.6
2.2
1.6
2.1
2.3
October. .
3.0
2.2
2.7
1.4
1.7
1.7
November .
.
3.1
3.7
3.0
1.4
1.7
1.9
December
.
.
2.3
2.5
1.7
1.3
1.0
1.0
All Ratios per 1,000.
In the various areas of this vast country there are naturally differences
in the periods favourable to fly breeding, but the figures above indicate the
two rises in case incidence which correspond with the periods at which fly
prevalence is known to increase ; namely the spring period of March and April
25
and the moist hot period of July to the end of August. In the south where a
double monsoon prevails there is often a second increase in sfly prevalence and
of consequent cases of the dysentery group. This year Secunderabad surpassed
itself with 103 British admissions and Poona had 76, though Southern Command
as a whole showed a decrease in total admissions compared with 1937.
The relative incidence of the component diseases of this dysentery group
is shown in the following table for six year period.
TABLE No. 29
The incidence of Dysentery, Diarrhoea, Colitis and Amoebic Hepatitis
Ratios per 1,000
Dysentery. Diarrhoea.
Colitis
Total.
Amoebic
Hepatitis.
Liver
Abscess
1933
.
.
.
24.9
15.3
1. 0
41.2
0.65
0.13
1934
25 . 5
14.9
0.8
41.2
0.96
0.09
1935
.
.
29.2
13.9
0.4
43.5
0.46
0.08
1936
.
.
24.6
16.5
0.9
42.1
0.29
0.04
1937
.
.
25.5
16.1
0.3
41.9
0.23
0.06
1938
.
.
.
26.8
18.0
0.2
45.0
0.53
0. 07
In this 6 year period Colitis shows a steady reduction. This is considered
to be due to the improvement in laboratory technique and improved methods
of diagnosis of cases which now pass to the more definite dysentery groups.
In amoebic hepatitis and liver abscess we also have a tendency to reduction
which over the longer period from 1920 has been definite.
The ratio per 1,000 of amoebic hepatitis, which unfortunately has been
doubled in the present year, is still only two thirds that of 1933.
The cases of liver abscess have decreased steadily. In the seven year
periods 1920-26 and 1927-1933 the average actual admissions were 30.6 and
9.8 respectively and in the last five year period only 3.4.
The steady drop in the sub-groups, amoebic hepatitis and liver abscess,
is in contrast with the dysentery-diarrhoea sub-group which is undoubtedly
fly-borne. This fact seems again to indicate that fly carriage may not be the
main cause of spread of these amoebic infections. It was pointed out in last
year's report that the extensive improvement in water supplies and the chlo-
rination of water may well have been responsible for this, and that chlorina-
tion must have a greater effect on the cysts of E. histolytica than. is generally
supposed.
It is in the fly-borne dysentery-diarrhoea, sub-group, in which there has
been no improvement, the rates of incidence ranging steadily about 25 and 16
per 1,000 respectively over a long period of years. A study of the tables and of
figures from Commands makes it clear that there has been no tendency for the
incidence to be reduced over a period when malaria, sandfly fever and enteric
have shown pronounced reductions. Yet dysentery and diarrhoea are strictly
preventable diseases.
C
26
It is considered that the reason lies in the fact that, having no sound
preventive inoculation against these diseases and the diseases being fty borne
the sanitation of the surroundings of our cantonments plays a predominant
part in the incidence of the infections. The sanitation, " save the mark "
of bazaars, even in cantonments and particularly in any adjacent uncontrolled
areas, is so bad as to pass the belief of any one who has not studied it. Open
ground, nullahs and drains such as exist are freely used as latrines, latrines
where they exist afford every facility for flies to obtain easy access to faecal
food and the dysenteric infection. Flies can be found breeding every where,
massive reservoirs of infection abound in the population and the completely
insanitary habits of the bulk of the bazaar population completes the circle of
infectivity from the sources of infection to the food of troops.
Under these circumstances, until the civil population is educated and the
sanitation improved, the only real and possible remedy lies in the protection of
food supplies of all kinds for troops, officers and families by fly proofing all places
connected with food.
In Western Independent District, where there was an increase of 26 cases,
Karachi had the majority in February and March while Quetta had them in
June, definitely in the fly seasons. An outbreak of dysentery occurred amongst
a large draft of R. A. F. men at the Transit camp at Karachi and was held to be
due to faulty dish washing and the lack of fly proofing of food stores, dining
rooms and kitchen annexes.
In Eastern Command, Jhansi had the highest figures for any station in the
Command. This was attributed to the fly infestation caused by the municipal
trenching grounds which are sited much too near cantonments. Action is
being taken to try to remedy this condition. A comparison of the admissions
in Jhansi with those at Agra which is relatively near, but has no closely adjacent
large bazaars or trenching grounds, is of interest in this connection.
TABLE No. 30
Dysentery and Diarrhoea at Jhansi and Agra
Ratios per 1,000
Jhansi
Agra
Year
British
Indian
British .
Indian
1936
43.3
27.3
28.4
29. 4
1937
91.5
28.4
22.7
6.7
1938
64.4
49.1
35.5
16.7
In Waziristan, at Razmak an epidemic started in April amongst Indian
troops and spread to British, attributed to congestion in the camp and tempo-
rary disorganisation in sanitation due to a break-down of the refuse destructor
and marked prevalence of flies.
The distribution of the four disease types by Commands shows that there
is little variation in them from year to year.
27
TABLE No. 31
Dysentery by Commands for the years 1936-37-38
Command
Bacillary
Bacillary
exudate
Protozoal
Clinical
Total
Norther
.
6 . 9
8.6
11 . 5
4.0
3.4
2.8
1.8
1.9
1.5
8.1
20.9
7.2
21.0
5 . 4
214
Western
.
.
12.5
11 . 2
18 . 7
5.0
6.7
6.0
2.5
1.5
1.7
15.3
35.3
8.5
27.3
16.2
42.5
Eastern
.
.
13.8
15 . 8
16 . 4
6.5
4.2
4.1
3.3
3.6
5.5
4.0
27.7
5.5
29.0
3.8
29.8
Southern
.
.
14.0
13 . 5
12 . 1
6.3
7.0
7.2
2.3
2.8
3.9
0.8
23.4
2.3
18.5
2.4
25.6
As regards diagnosis, the percentage of types shown below indicates
clearly that a common standard of diagnostic procedure is carried out
successfully in all Commands and variations are within narrow limits, clinical
and exudate cases decreasing as bacteriologically proved cases increase.
TABLE No. 32
Percentage diagnosis of Dysentery Diarrhoea Group
1935
1936
1937
1938
Dysentery Protozoal
.
.
.
.
10.3
10.8
10.4
12.7
Dysentery Bacillary (proved) .
.
41.5
46.1
49.3
51.3
Dysentery Bacillary (exudate) .
.
.
23.0
22.4
19.6
17.4
Bacillary clinical .
.
.
.
25.3
20.7
20.7
18.5
12. Cholera
In spite of the epidemic of cholera which spread explosively over the
greater part of eastern and northern India [Paragraph 5(c)] there was only one
British case. This occurred in the Lucknow District, a mild case which
recovered.
Energetic precautions and a very careful watch over possible sources of
infection had to be taken in all Commands from eastern Bengal to the limits
of the frontier in Peshawar, Kohat, Waziristan and Baluchistan. Except in
a few isolated cases amongst Indian personnel these measures proved success-
ful.
13. Diseases of the Digestive System
With an increase of nearly 200 admissions the rate per 1,000 has risen.
1936
.
. . . . . . . . .
103 . 1 per 1,000.
1937
.
.
.
.
. . . . . . .
99 . 4 per 1,000.
1938
.
.
.
.
.
.
.
.
. 113 . 6 per 1,000.
This is concomittant with the rise in the general dysentery group and as far as
the cases of intestinal infection go is dependent on similar causes. Tonsillitis,
which curiously is included in this group, has produced 91 more cases than last
year and accounts for a large number of hospital admissions every year (1,453
cases) and is again third in the list of principal causes of admission.
•
28
Of Catarrhal Jaundice there were 256 cases this year and Gastritis pro-
duced 326 cases. Pharyngitis which also curiously is included in this list pro-
duced 444 cases.
In connection with the increase in messing allowance for the provision
of suppers, which was introduced in the autumn of 1937, one medical specialist
expresses fears that there may be a general increase in digestive disorders
because on this account the British soldier receives an extra meat-meal and will
now be eating 3 meat meals a day ! We are quite sure that there is little like-
lihood of such an untoward effect.
14. Cysticercosis
There was only one case of this distressing condition which occurred at
Lahore. It was a case typical of the complete unexpectedness of the condition.
The details are as follows :
Sergeant W. Service in India 10 years. No history whatsoever of worm
infection or anything abnormal. He was a patient in hospital
for a traumatic ulcer of the leg. A smart and able N. C. 0.
He was seen by the Assistant Surgeon on duty recovering from
a " Fit ".
There was nothing to account for this until X-ray revealed the presence
of cysticeri in leg and thigh, pelvis and skull.
Epilepsy.—There were only 11 cases of Epilepsy major invalided amongst
British troops compared with 22 the previous year.
Tape worms infections .—Amongst British troops there were 121 cases
of T. saginata and 4 cases of T. solium compared with 132 and 20 in 1937 and
134 and 17 in 1936.
In the present year the majority of the cases of T. saginata infection are
from southern and central India. Two of the four T. solium cases were in
northern India viz. Cambellpore and Nowshera ; the third at Bareilly ; the fourth
was at Madras. Of the T. saginata cases Poona, Ahmednagar and Nasirabad
had 10 cases each. The Deputy Assistant Director of Hygiene in the report of
the Western (Ind.) District comments that T. saginata is very common in the
Quetta area, 8 men and 3 children were admitted in Quetta for this complaint.
At Karachi a piece of " measly " beef was actually issued to a unit, but was
detected before use.
Amongst Indian troops there were 26 admissions with T. saginata
but 7 with T. solium. In 1937 there were 24 admissions for T. saginata and
13 far T. solium and an investigation into the type and class of personnel
concerned revealed the fact that infection with a particular type of worm bore
no relationship to the religion of the patient, T. saginata being present in
Hindus and T. solium in Mussalmans.
29
15. Oriental Sore
There were only 8 admissions amongst British troops but 86 from
Indian troops. But the numbers under out-patient treatment are very consi-
derable. The admissions over 5 years are shown below.
TABLE No. 33
Oriental Sore Admissions
Year
British
troops
Indian
troops
1934
5
103
1935
67
1936
34
172
1937
12
135
1938
8
86
In the endemic area of Quetta Rs. 2,000 was allotted by Government as a
special anti-sandfly measure for Quetta city and surrounding areas. In 1936
the numbers of cases with oriental sore in the military and civil population
became great enough to cause anxiety and under the orders of the Government
of India, Dr. Smith from the Central Research Institute, Kasauli was detailed
to investigate and report. This report showed that conditions were exceptional-
ly favourable for sandfly breeding and the spread of oriental sore infections.
It recommended the bricking of all the main nullahs. In the cantonment this
improvement is now being carried out.
The incidence of Oriental Sore in Quetta apart from actual admissions
is shown in the following table. It will be seen that the numbers have again
jumped considerably.
TABLE No. 34
Incidence of Oriental Sore in Quetta Cantonment
British
troops
Indian
troops
and
followers
Total
1936
63
448
511
1937
36
165
201
1938
53
391
444
In 1938, of the 391 cases 124 I. 0. Rs. and 137 Followers or 261 cases
belonged to the Cavalry Regt., and of these 137 Followers 119 were syces.
As far as this area is concerned there must therefore be some factor present in
the horse lines which accounts for this prevalence.
In pursuance of this feature trials were made with Stomoxys Calcitrans
which is abundant in the lines. Mechanical transference by this means was
clearly proved by the production on volunteers of sores 5 and 6 months after
the experimental bites by this fly. It should be noted however that the condi-
tions for ample sandfly breeding in and round these lines has been almost ideal.
During the present year traps, spray guns and spraying were extensively
used in every barrack and quarter of this unit. The rise in incidence is dis-
appointing and arrangements have been made to intensify the campaign and.
to ensure protection and to cover of all open sores to prevent transmission to
others.