NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Plague
Agency.]
33
2. In the larger places, i.e., towns with a population of
more than 10,000, the measures that will be found appli-
cable are disinfection, inoculation, the evacuation of specially
infected quarters, and (so long as infection has not spread
through the town) the isolation of the sick. In villages, the
chief measure to be relied on is evacuation, but inoculation and
chemical disinfection should also be resorted to so long as
there is sufficient staff to supervise those measures. Evacua-
tion in both towns and villages should be conjoined with an
opening up of houses sufficient for the admission of sunlight
and air whenever this is required. In carrying out these
measures it should be borne in mind that it will always be
better to apply one method efficiently and thoroughly than
to apply a number of methods with an inadequate and
insufficiently trained staff. Another point of importance is
that in places, where plague is constantly recurring and the
amount of plague is liable to great seasonal variations, plague
measures should be carried out with special vigour at the
season when the epidemic is at its minimum.
3. Experience has shown that it is hopeless to carry out
effectively any system of plague administration which is not
supported by the people, and in a wide-spread epidemic, the
resources of Government in the matter of funds and establish-
ment being limited, much must necessarily be left to the
people themselves. Steps should therefore be taken to inform
them beforehand of the measures they will be required to
submit to, and to convince them of the utility of the par-
ticular methods selected, so that they may be induced to carry
them, out not by force but by the exercise of their own free-
will and as a consequence of their appreciating and under-
standing the benefits to be anticipated therefrom. The
measures are new to the people, particularly in fresh areas of
infection, and if injudiciously or overzealously pressed, must
defeat themselves by exciting opposition instead of gradually
winning the co-operation of the people. On the other hand
if the services of the leading inhabitants are secured to assist
the Government officials in carrying out measures which are
clearly beneficial, it may often be possible, by reason of their
example and attitude, to carry out with good results measures
which would be ineffectual or injurious if enforced by definite
orders upon a population ignorant of their advantages and
suspicious of the objects with which they are adopted.
Agency for Working Plague Regulations.
4. Special attention should be directed to the restric-
tion, so far as possible, of the employment of subordinate
*
34
Plague
Agency,
Government
officials of the medical and police departments and
in especial to the advisability of enlisting to the utmost pos-
sible extent volunteer agency to assist in carrying ont plague
measures. Whenever practicable, public and private hospitals
and camps may be placed in charge of native practitioners.
Police officers should hold no inquiry into suspicious cases of
plague. Small representative committees of the inhabitants
may be appointed in various parts of a city to co-operate
with the authorities and to bring to their notice matters
requiring attention or inquiry.
5. As far as circumstances permit, Hindus should be
employed in those parts of a city where Hindus predominate,
and Muhammadans where Muhammadans are in a majority.
Officers of all grades should use the greatest courtesy and
consideration to the people, and should interfere as little as
possible with their habits, feelings and religious prejudices.
6. Where subordinate native agency is used, it is abso-
lutely necessary that Europeans should be appointed as
supervisors over small and convenient units.
7. The following procedure should be adopted in obtain-
ing the services of military officers for plague duty : —
I. A Local Government or Administration requiring
an officer or officers for plague duty will apply to the Govern-
ment of India, in the Home department, detailing the number
of officers required, and where and when they should be
ordered to join. . Such applications shall always be accom-
panied by an intimation whether the officer should bring horses
with him.
II. The Government of India will then address the
Adjutant-General in India, who will issue instructions under
the orders of the Commander-in-Chief to one or more Com-
mands to supply the officers wanted, the Government of India
being at the same time informed of the instructions issued.
III. On learning from the Ad jutant-General's depart-
ment from what Command the officers asked for will be
supplied, the Government of India will inform the Local
Government or Administration concerned, and all further
correspondence in reference to the individual officers detailed
by Commands, or their replacement, should they for any
reason revert to military duty, will be conducted between the
Local Government or Administration and the Lieutenant-
.General Commanding.
Discovery of Plague.]
35
IV. When the officers selected have joined their appoint-
ments, the Lieutenant-General Commanding will communicate
their names to the Adjutant-General's department, and their
services will then be placed at the disposal of the Govern-
ment of India.
IV-A. It is not considered desirable that a military
officer should remain absent from his regiment on plague
duty for more than a year at a time. The Lieutenant-
General Commanding has therefore instructions to arrange
with the Local Government for the relief by a substitute of
any such officer, who has been employed on plague work for
over a year.
V. When an officer's services are no longer required,
he should be directed by the Local Government or Adminis-
tration to rejoin his regiment, the Lieutenant-General Com-
manding and the Government of India being at the same
time informed, and the latter will then replace' the officer at
the Commander-in- Chief 's disposal.
8. No officers of the Indian Medical Service or the Royal
Army Medical Corps lent for plague duty should be permitted
to revert to military duty without the previous sanction of
the Government of India.
9. The use of troops for plague purposes should be
avoided as far as possible and their employment should be
confined to disinfection when local labour is not available.
Before engaging on plague duty, the sepoys should be
inoculated and each of them should be supplied with two
suits of white drill, one pair of boots, and two white turbans ;
they should not wear military uniform or carry arms
while so employed. The sanction of Government should be
obtained before requisitioning them, and where the employ-
ment of troops has once been sanctioned, the men may be
changed without reference to Government. Arrangements
should be made for the relieving detachment to be inoculated
before arrival.
10. . . :
Discovery of Plague.
11. The most important and the most difficult matter in
all operations against plague is to obtain early information
regarding the cases that" occur. The prompt discovery.of an
imported case of plague may enable the local authorities to
36
Isolation of Patients,
jprevent a local outbreak, and even where a few indigenous
cases have occurred, early information regarding each new
case may make it possible to prevent the outbreak from
spreading beyond a confined area. Every endeavour should
therefore be made to obtain information of each case of plague
that occurs, as soon as possible after the patient has been
attacked, or where this is not possible s soon after death.
12. For this purpose, the surveillance system as de-
scribed in regulation 1, should be mainly relied upon, and the
co-operation of the people in working it should be secured by
pointing out to them the advantage of protecting themselves
by not mixing with persons coming from infected areas and
by giving the authorities prompt notice of their arrival and
of any cases of plague or suspicious fever among them. In
towns, one or more volunteers of each caste should be
invited to assist the circle officers in prosecuting enquiries
and discovering plague cases. The risk of concealment of
cases is lessened where people see that their leaders have
ranged themselves on the side of the authorities.
13. Besides carrying out the other measures prescribed
in part I of the regulations, attention should be paid
to the improvement of the existing system of registering
deaths. In municipal towns special daily returns of mortality
may be called for and checked with the aid of trustworthy
subordinates posted at burning and burial grounds. In
villages whenever the deaths reported are found to be more
frequent than usual, or when any case of fever with glandular
swellings is reported, the tahsildar with the nearest medical
officer should at once proceed to the village and make inquiries
with a view to ascertain whether plague exists in the village ;
and the medical officer and the tahsildar should report to the
district medical and sanitary officer the facts and the reasons
for the decision arrived at by them as to the cause of the
mortality.
14. The employment of paid spies or informers as well as
the grant of rewards for information regarding plague cases
is prohibited.
Removal of Plague Patients to Hospital.
15. Plague patients who are left without any one to look
after them or who have no home should in all cases be removed
to hospital, and there can be no question that in dealing
Isolation of Patients.]
37
with imported cases or with an outbreak in a small place
upon which it is possible to concentrate a sufficiently strong
establishment, the first measure to adopt is the compulsory
removal of the sick to hospital. In dealing with early
indigenous cases the same policy may be advisable. But if this
policy prove unsuccessful in a large place, a point may soon
be reached where the authorities will not succeed in getting
the bulk of the cases. When this point is reached, the fact
must be faced that the evils of leaving the sick in their houses
are being incurred and that the attempt to remove them to
hospital may be super-adding to these the evils that result
from carrying about sick persons from house to house. At this
stage the less the sick are interfered with the better. All
that can then be done is to endeavour to palliate the evils
that result from leaving people in their houses by arranging
for continual visitation of the sick at home, the frequent dis-
infection of the infected room, and the encouragement of
inoculation among persons left in the houses with the sick.
16. Except in the cases mentioned above, the removal of
patients to hospital should not be made compulsory. Every
effort should, however, be made to induce patients to go
voluntarily to hospital and to lessen the aversion to hospital
by the following means—(1) by encouraging the establish-
ment of private and caste hospitals ; (2) by locating hospitals
near to infected quarters; (3) by limiting the size of hospitals
so that patients may receive more individual attention, and
accommodation may be more readily made available for their
immediate families and friends; (4) by arranging for the pro-
vision of an adequate number of medical attendants and
nurses and of ample and comfortable accommodation for
patients ; (5) by permitting at least two friends to be in
attendance on each patient so that the patient may never be
left alone ; (6) by allowing the patients to have their own food
and medicines and to receive visits from their relations s
friends and religious instructors ; (7) by taking care that all
arrangements for observance of caste customs and for the
comfort and convenience of patients and their attendants
are completed before inviting admission to hospitals.
17. Moribund patients should never be removed to hospital
except at the express wish of the friends or relations of the
patients. The risk of leaving in his house a patient whose
case is so serious that the medical officer thinks he has not a
fair chance of recovery is not great since, as the existence of
the case will have become known, there will be no difficulty
38
[Segregation..
in carrying out measures of disinfection during the progress
of sickness (if necessary), or after death.
18. The pneumonic variety of plague being the most con-
tagious, persons suffering from this type of the disease should
not be removed to the general wards of plague hospitals, but
should be isolated in separate wards of the greatest possible air
space. It is further advisable that such cases should not be
treated in private houses, unless in the opinion of the medical
officer, the room occupied by the patient is suited for his
complete isolation, and proper control over the number of
attendants and enforcement of disinfection could be had.
Segregation of Contacts.
19. Persons who have been in immediate contact with
plague patients are known as contacts. By segregating them,
persons who are likely to develop plague are isolated and cease
to be a danger to other people ; the plague-infected houses are
emptied for the process of disinfection, and the contacts
themselves are protected from further risk of infection from
those houses. To render segregation effective, the following
measures are necessary :—
(1) All contacts should be diligently searched for and
be detained for the maximum period of incubation, and
prevented from mixing with healthy people;
(2) Those in contact with each successive case of plague
that occurs in the segregation camp must be similarly dealt
with ;
(3) All clothing must be effectually disinfected on entry
into the camp and if plague cases have occurred in the camp
since the date of entry, at the time of departure also ; and
(4) The staff employed must be very strong relatively
to the number of cases that occur and must be trustworthy.
20. These measures are not always practicable and the
Indian Plague Commission are of opinion that the facts
investigated by them do not justify the conclusion that in an
outbreak the contacts from a house in which a case of plague
has occurred must be regarded from the point of view of the
protection of the rest of the community as so dangerous that
they ought to be compulsory removed to a segregation
camp. The Government of India have accordingly ordered
that the compulsory segregation of contacts should be aban-
doned as ineffective and harassing except when dealing with
imported, cases or when the infection is confined to so small
an. area that contacts can be accurately known and establish-
ments can be provided sufficient to secure the detention "of
Evacuation.]
39
every contact. Where tliese conditions do not exist, it is
"better to subject the contacts to mere surveillance at their
houses, as any attempt to segregate them will not only lead
to the general concealment of cases but also tend to scatter
the people and thus spread the infection to distant places.
While under surveillance, the contacts may be allowed to
pursue their daily avocations.
21. An officer who, not being on leave, is unable to perform
his official duties owing to a short period of segregation on
account of plague may be treated as on duty on full pay. In
the case, however, of officers who are segregated while
returning from leave and thus overstay their leave, the
period of detention may be treated as duty on half-pay, if it
is considered that some concession is required, but officers
who are suffering from plague should be treated in accord-
ance with the ordinary rules.
22. Officers in charge of plague camps should give deten-
tion certificates in the prescribed form [Appendix KJ to all
persons who were detained by them, on their discharge from
the camps.
Evacuation,
23. By evacuation is meant the emptying of all or some
of the houses in an infected town or village, with the idea that
they should not be occupied as dwelling houses until it is
believed that they can again be occupied without risk of infec-
tion, the people thus removed being lodged in temporary
camps in the open country. To make it thoroughly effective,
the following conditions are required : (1) the people should
all be got out promptly ; (2) their effects should all be dis-
infected ; (3) each now case should be immediately isolated;
(4) suitable accommodation should be available; (5) the
people should, be effectually prevented from visiting, or sleep-
ing in, the infected houses until either the houses shall have
been disinfected or until sufficient time shall have elapsed
for the infection to disappear ; (6) and lastly they should
not be permitted to scatter and spread the infection in the
neighbourhood.
24. Evacuation provides the most effective safeguard
against the spread of plague which has yet been discovered. Its
advantages are self-evident and it should be resorted to wher-
ever practicable. In villages and small towns (population not
exceeding 10,000) complete evacuation (i.e., evacuation of all
the houses) will be found to be generally possible. In large
towns, the extent to which it can be carried out will depend
on the willingness of the people, the season of the year, the
40
[Inoculation,
situation of the town, the facilities for providing camp
accommodation, and the strength of the available staff. It
will be found to be of the greatest value ab the very com-
mencement of the outbreak, for the removal of the small
number of people affected will not present any great difficul-
ties, and prompt evacuation of the infected quarter may save
the rest of the town.
25. Evacuation is, however, likely to do more harm than
good in the following cases :—
(a) During the rainy season, when it is impossible to
keep the people, after they have once been removed from
their houses, from going back to them. In such circum-
stances, the evacuated people are exposed to great incon-
venience and misery without deriving any countervailing
advantages from evacuation.
(b) When the infection is widely distributed among the
inhabitants of a large place, it is then advisable to agitate
the people as little as possible, especially when there are
among them a considerable number of artisans and traders
who may lose their occupation by being removed from the
town and are therefore likely to run away and infect other
places.
Inoculation.
26. The exhaustive inquiries made by the Indian Plague
Commission have established the fact that inoculation with
haffkiniue lessens the liability to plague and greatly increases
the chance of recovery from an attack of the disease, and
disproved the statement that serious ill-consequences have
resulted from such inoculation. The maximum period for
which protection is afforded by inoculation has not yet been
determined. For practical purposes, it has been fixed, for
the present, at six months, but it should be noted that inocu-
lation does not confer any great degree of protection within
the first few days. Recently inoculated persons therefore
incur risk of infection by remaining in infected places,
27. Inoculation should be encouraged wherever possible
and in particular among disinfecting staffs and the attendants
of plague hospitals. In places which, either owing to their
nearness to plague-infected places or to their having pre-
viously suffered from an attack of plague, appear to be specially
threatened with a visitation of the disease, no effort should
be spared to explain to the people the advantage of being
inoculated before the disease is among them and to secure
the co-operation of the more enlightened members of the
Inoculation.]
41
communities. At the same time, no compulsion of any sort,
direct or indirect, should be used. An awkward attempt, at
persuasion is liable to create opposition, resistance, and
occasionally, unfounded apprehension, and great circumspec-
tion is necessary in introducing inoculation in places where
there is no demand for it. The District Magistrate should be
consulted before starting inoculation at any place and the
people should be distinctly warned that inoculation is not by
any means a certain prophylactic, but that it considerably
reduces the chances of the inoculated getting plague, that
an inoculated person when attacked has increased chances
of recovery, and that the process, if properly conducted, is
harmless.
28. Only trained and reliable persons should be entrusted
with the actual operation of inoculation, and supervision
should be exercised over them to ensure that they use only
sterilized implements. To remove any possible ground for
distrust as to the conveyance of disease from one person to
another, the inoculation syringe should be sterilized in the
presence of the person about to be inoculated. The steriliza-
tion should be effected by immersion in carbolic acid, or
preferably carbolized oil kept hot by the flame of a spirit lamp
underneath. After a bottle has once been opened and only a
portion of its contents used, the remainder should invariably
be thrown away.
29. Inoculated persons should be furnished with certifi-
cates in the prescribed form [Appendix F]. The certificate
should bear the left thumb mark of the person inoculated and
should be issued immediately after one full dose has been
given, but the recipient should be recommended to return for
a second inoculation after ten days. The full close should
always be given at one time, unless for medical reasons it is
considered advisable to divide it. If it is necessary to do
this, a certificate should not be given until the equivalent of
two full doses has been given. If, however, no undue
reaction ensues after the first fractional dose has been taken,
it is advisable to give the full dose at once on the second
occasion, after which a certificate may be given.
30. The privileges attached to inoculation are mentioned
in regulation 51. They are not admissible in cases of
persons who have recovered from plague. As a further
encouragement the Government has authorized the grant
of three days' extra casual leave on full pay to all public
servants for the purpose of being inoculated, Students
v