NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
52 [ APPX.L—Discovery of Plague.
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 over-zealously pressed, must
defeat themselves by exciting opposition instead of securing
the co-operation of the people. On the other hand, if the
leading inhabitants are induced to assist the Government
officials in carrying out measures which are clearly beneficial,
it may often be possible, with their help, 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.
(2) Advantages of Early Discovery of Plague.
4. 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
prevent 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, soon after death.
Appendix I.—Segregation.]
53
5. For this purpose, the passport system as described
in the rules 1-36, 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 coining 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.
6. Besides carrying out the other measures prescribed
in the regulations, attention should be paid to the improve-
ment 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 subordi-
nates 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.
(3) Segregation of Contacts.
7. Persons who have been in immediate contact with
plague patients arc known as contacts. By segregating them,
persons who are likely to develop plaguu are isolated and coase
to be a danger to other people ; the plague-infected houses arc
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 bo 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 ;
54
[Appendix I.—Evacuation.
(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.
8. These measures are not always practicable and the
Indian Plague Commission was of opinion that the facts
it collected do not justify the conclusion that in an out-
break 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 compulsorily 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
every contact. Where these conditions do not exist, it is
better merely to subject the contacts to 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.
(4) Evacuation.
9. By evacuation is meant the emptying of all or some
of the houses in an infected town or village, so that they may
not be used as dwelling houses until it is believed that
they can again be occupied without risk of infection, the
people thus removed being lodged in temporary camps in the
open country. To make such evacuation 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 new case of plague should be immediately
isolated ; (4) suitable accommodation should be available ;
(5) the people should be effectually prevented from visiting
or sleeping in the infected houses until either the houses
have been disinfected or until sufficient time has elapsed
for the infection to disappear ; (6) and lastly they should
not be permitted to scatter and spread the infection in the
neighbourhood.
Appendix I.—Inoculation.]
55
10. Evacuation provides the most effective safeguard
against the spread of plague that 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
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 at 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.
11. Evacuation, is, however, likely to do more harm than
good in the following wirier cases :—
O
y
(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 people who are removed are exposed to great
inconvenience and misery without any countervailing advan-
tages being derived 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.
(5) Inoculation.
12. The exhaustive inquiries made by the Indian Plague
Commission have established the fact that inoculation with
Haffkine's vaccine 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-con sequences 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,
56
[Appendix I.—Inoculation.
13. 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
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
a certain prophylactic, but that it considerably reduces the
chances of getting plague., that an inoculated person when
attacked has increased chances of recovery, and that the
process, if properly conducted, is harmless.
14. 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.
15. Inoculated persons should be furnished with certifi-
cates in the prescribed form [Appendix II—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 dose 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,
Appendix I—Disinfection,3
57
it is advisable to give the full dose at once on the second
occasion, after which a certificate may be given.
16. The privileges attached to inoculation are mentioned
in Bule 121. 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
attending Government and aided schools, who undergo inocu-
lation, will be marked in the registers for not more than
three consecutive days as " under inoculation," and such an
entry will be regarded as equivalent to attendance. No
subsistence allowance can be granted to inoculated persons
for the period during which they are incapacitated for work
owing to the operation.
17. The Sanitary Commissioner is in charge of all measures
connected with inoculation and will issue the necessary rules
as to the conduct of the operation, supply of. Haffldne's
vaccine, inoculation syringes, &c.
(6) Disinfection.
18. Chemical disinfection ought to be resorted to wherever
possible. Of all measures of disinfection, it is the only one
which, when effectively carried out, immediately destroys
the infective material present in a room and renders the room
at once practically safe for re-occupation. It is, however,
essential that it should be carried out by a trained agency,
and experience shows that where such an agency cannot bo
employed, it is better to rely on gradual desiccation rather
than on a process of disinfection which is likely to be
incomplete and ineffective. Imperfect disinfection involves
waste of energy and material, brings discredit on the system
by exhibiting unsuccessful results, and engenders a false
sense of security with regard to localities which have been
incompletely disinfected and still contain the living germs
of plague.
19. According to present knowledge, perchloricde of mer-
cury is the most effective chemical disinfectant. It should
be used in a strength of 1 in 1,000, to which 2 per 1,000 of
hydrochloric acid and a little aniline blue should be added.
If the owners have no objection, interiors of plague-infected
houses should, as a rule, be treated with Wilkinson's coloured
solution which contains the perchloride in the strength stated
H
58
[Appendix I—Disinfection.
above. To ensure that the chemical is free from impurities, it
should be obtained from the Madras Medical Store depot by
submitting indents through the district medical and sanitary
officer and the Surgeon-General. The perchloride should be
issued in the form of a concentrated solution in acid and clear
instructions should be forwarded with each consignment as to
the amount of water to be added. With a view to securing
that the dilutions prescribed should be the solutions in which
the disinfectant shall actually be employed, the capacity of
the vessels used for measuring out the concentrated solution
shall be accurately adjusted to that of the wooden buckets in
which that solution is diluted for use. Further, the buckets
employed should be of such capacity as to hold just the
quantity of water sufficient to dilute the measure of concen-
trated solution to the desired effect. The perchloride may
also be issued in the solid form in packets, the contents of
which are accurately adjusted to the size of the vessels in
which they are to be dissolved for use.
20. Steam-sterilisers, unless their working is committed
to skilled and trustworthy operators, are found in practice to
be quite ineffective, and are therefore not suitable for general
application. Their use is limited to ports for the disinfection
of the effects of native crews and native ship passengers
bound for ports out of India. Full instructions as to the
mode of working them should be supplied with each machine.
21. In cases where it is not possible to carry out chemical
disinfection, the disinfecting agency of desiccation should
be relied upon. For this purpose, the house ought to be
thoroughly cleaned out; the removal from the house of
cowdung and other moist accumulations should be particularly
insisted upon, and the inmates of the house should be induced
to remain away for a period of at least two months until the
process of desiccation is complete. Disinfection by desicca-
tion cannot, however, be relied upon during the rains.
22. The breaking of holes in the roof or walls and
partial untiling will not accelerate the process of desiccation
to such a degree as to counterbalance the damage done to
the house. This measure should not therefore be adopted
in the case of masonry houses with concreto roofs. As a
rule, such houses can be disinfected without great difficulty
and are to a certain extent open to light and air. But
in rural areas, where the majority of the buildings are of a
comparatively poor character it will rarely be possible to
provide for efficient chemical disinfection. The removal of
Appendix I—Disinfection.]
59
portions of the roof of such huts can be done with no
structural injury to the huts and at small cost and is
permitted.
23. Owing to the risk of infection from the blowing about
of the floor-dust and owing to the fact that it is practically
impossible to secure that the whole material shall be carried
away, the digging up of floors with a view to kiln-burning
them ought not to be resorted to.
24. The actual burning down of: houses should not be
resorted to except in the case of temporary structures which
are of little or no value or in the case of houses which are unfit
for human habitation.
25. With a view to encourage people to produce their
goods for disinfection and to prevent them from secreting
them, nothing which could by any possibility have any
value for its owner should be broken up or destroyed by
fire. Liberal compensation should be promptly paid for any
articles that may be necessary to destroy, when the loss
would fall upon people in very poor circumstances to whom
it would be a great hardship to bear it.
26. Disinfection of personal effects should not be attempted
in the case of travellers by road or railway but should be
carried out in the case of—
(a) native crews, third class or deck passengers and
native servants leaving infected or healthy ports
for ports out of India. This should be done on
shore ;
(b) plague patients and contacts removed from
infected houses, ships or railway carriages;
(c) plague patients discharged from hospitals and
persons returning to their houses from health or
suspect camps.
27. That the disinfection of the person is effective is
indubitable as is proved by the practice of washing the
hands with disinfectants in bacteriological laboratories and
in surgical, operations. The measure, however, is extremely
unpopular, and has been ordered to be abandoned in the
case of travellers as very little is to be gained by disinfect-
ing them. It will be found useful in the case of persons
taken out from plague-infected houses into health camps and
in the case of plague convalescents leaving hospital.
28. Laboratory experiments and practical experience
alike tend to show that there is little danger of the spread
6O
[Appendix I—Disinfection.
of plague by means of ordinary articles of merchandise, and
that it is therefore u either advisable nor necessary to take
any steps towards their disinfection. The only restriction
found necessary is the prohibition against the importation
from infected localities of rags, waste paper and soiled linen.
Any such articles brought in contravention of this prohibition
should be destroyed. Old newspapers and any paper
used for packing purposes are not included within the prohi-
bition, but washed linen articles such, as washed dhotis, come
within the meaning of the term. " soiled," although they
have not been worn since they were last washed. Persons
who send parcels by railway or post from plague-infected
areas are required to declare in writing that the parcels
do not couvain any soiled linen and bedding, rags or waste
paper
29. When any carriage from an infected area is detached
from a train at any railway station in the Madras presidency,
it shall be disinfected and ventilated by the railway author-
ities in the following manner as soon as possible and before it
is again brought into use, and if such carriage is detached at-
an inspection station such disinfection and ventilation shall be
effected to the satisfaction of the inspecting medical officer :—
(i) Third and intermediate class carriages—
The interior wood-work of the carriages, especially
the ñoors and seats, shall be thoroughly washed with a solution
of perchloride of mercury (1 in 1,000) and of hydrochloric
acid (2 in 1,000) ; the doors and windows shall be opened, and
the vehicle exposed to the air ; the sweepings shall be carefully
collected and be burnt.
(ii) First and second class carriages—
The floors and wood-work shall be treated as above,
the cushions being also brushed and thoroughly cleansed and
exposed to the sun for not less than four hours.
30. (1) Any railway carriage from which a passenger who
is suffering from the plague has been removed shall be detached
at the nearest convenient station, and shall be disinfected
by the railway authorities as follows, and if that station is an
inspection station, such disinfection shall be effected to the
satisfaction of the inspecting medical officer :—
(i) The carriages, after being detached from the
train, should be thoroughly washed with soft soap. After an
interval of two to three hours, this should be washed off with
plain water, and then the following disinfecting solution
Appendix
I-Rat-Plague.]
61
should be thoroughly sprayed all over the interior as well
as the exterior of the carriages by means of a syringe : —
Corrosive sublimate
Hydrochloric acid
Water
1/2 oz.
1 „
3 gallons.
This solution should be allowed to dry on the car-
riages. Special care must be taken to direct the solution
into all the cracks and crevices and jilmills.
(ii) After disinfection, the carriage should be kept
out in the open for 48 hours. They can then be brought
into use again.
(iii) In the case of ñrst and second class carriages,
which afford greater facilities than third-class compartments
for the harbouring of plague germs, it will be necessary, if
the carriages are contaminated, to burn the cushions and to
disinfect the wood-work in the manner indicated above, and
re-paint the interior.
(2) If a compartment has been used by a suspicious
case of plague, it shall be treated as directed in the preceding
section. If of the third or intermediate class, its use
may be permitted as soon as it is thoroughly dry ; but if it
be of the first or second class, it shall, after such disinfection,
be kept locked and unused until the nature of the case be
definitely ascertained, when the question as to whether or
not the cushions be destroyed and further disinfection be
effected, shall be decided in accordance with the preceding
clause (1) (iii) of this paragraph.
31. Detailed instructions as to the mode of disinfection
to be adopted in each case will be issued by the Sanitary
Commissioner and, in respect to the management of hospitals,
by the Surgeon-General.
(7) Rat-Plague and Destruction of Rats.
32. Rats have been observed, and have been proved by
experiment, to be very susceptible to plague, and a large
mortality among rats has often been found to precede an
epidemic of plague among human beings. It is probable that
rats, when infected, carry the disease from house to house,
and are thus important agents in its dissemination. Their
destruction, and the observation of any special sickness or
mortality among them is thus very important.
33. Granaries are the favourite haunts of rats, and
grain bags arriving from any place suspected of being infected