Again, an amazing number of deaths from _Experiments on Animals

are due to wounds of the hands with toy-pistols. It is said that after

the Fourth of July festivities in 1899, no less than 83 cases of

tetanus were reported, 26 of them in and around New York. Almost all

of them were due to gunshot wounds of the hand with toy-pistols: the

unclean wad of the cartridge, made of refuse paper picked up in the

streets, penetrates deep into the tissues of the hand, taking the

germs of the disease with it, out of the reach of surgical

disinfection. These cases of tetanus in the United States from

toy-pistol wounds are so frequent, that immunisation has been

recommended for them. The _Medical News_, 1st June 1901, has the

following note:--"H. G. Wells states that tetanus is endemic in

Chicago, the specific organism being present in the dirt of the

streets. Every Fourth of July an epidemic occurs, because these

bacilli are carried deeply into wounds before wads from blank

cartridges.... The writer thinks that such cases should receive a

prophylactic dose, say, 5 c.c. of tetanus-antitoxin, as soon as

possible after the wound is first seen. It seems certain that if

antitoxin prophylaxis were adopted, there would be no further Fourth

of July epidemics, and this end would justify the means."

Again, a man might receive a lacerated wound under conditions

especially favourable to infection: he might tear his hand in a stable

where horses had died of tetanus, or he might cut his finger while he

was working at the disease in a pathological laboratory, or he might

receive a poisoned arrow-wound out in Africa. In any such emergency,

he could safeguard his life with a protective dose of antitoxin.

It remains to be added, that the modern study of tetanus has brought

into more general use the old rule that the wounded tissues in a

severe case of tetanus should be at once excised. Before Nicolaier's

work, while the theory still survived that the disease was due to

ascending inflammation of a nerve, this rule was neither enforced nor

explained.

The results published during the last few years (_Medical Annual_,

1905-1906) seem to show that the antitoxin has neither gained nor lost

ground as a remedy. It is, of course, used in conjunction with all

other remedies. Perhaps, in a few years more, something better will be

discovered. And that discovery, when it comes, will be, as it were,

Nicolaier's gift. The whole study of the disease goes back straight to

the rabbits inoculated in 1880-1884: neither is it possible that the

disease should be further studied, without the help of bacteriology.

RABIES

Pasteur's study of rabies began in 1880; and the date of the first

case treated--Joseph Meister, a shepherd-boy of Alsace--is July 1885.

The first part of the work was spent in a prolonged search for the

specific microbe of rabies. It was not found: its existence is a

matter of inference, but not of observation.[24] In his earlier

inoculations, Pasteur made use of the saliva of rabid animals; and M.

Valléry-Radot tells the story, how Pasteur took him on one of his

expeditions:--

"The rabid beast was in this case a huge bull-dog, foaming at

the mouth and howling in his cage. All attempts to induce the

animal to bite, and so infect one of the rabbits, failed. 'But

we _must_,' said Pasteur, 'inoculate the rabbits with the

saliva.' Accordingly a noose was made and thrown, the dog

secured and dragged to the edge of the cage, and his jaws tied

together. Choking with rage, the eyes bloodshot, and the body

convulsed by a violent spasm, the animal was stretched on a

table, and kept motionless, while Pasteur, leaning over his

foaming head, sucked up into a narrow glass tube some drops of

the saliva."

[24] This sentence was written before the publication of Professor

Negri's observations (see _Medical Annual_, 1906, p. 418).

But these inoculations of saliva sometimes failed to produce the

disease; and, when they succeeded, the incubation-period was wholly

uncertain: it might be some months before the disease appeared. Thus

Pasteur was led to use, instead of the saliva, an emulsion of the

brain or spinal cord; because, as Dr. Duboué had suggested, the

central nervous system is the chief seat, the _locus electionis_, of

the virus of rabies. But these inoculations also were not always

successful, nor did they give a definite incubation-period.

Therefore he followed with rabies the method that he had followed with

anthrax. As he had cultivated the virus of anthrax, by putting it

where its development could be watched and controlled, so he must put

the virus of rabies in the place of its choice. It has a selective

action on the cells of the central nervous system, a sort of affinity

with them; they are, as it were, the natural home of rabies, the

proper nutrient medium for the virus: therefore the virus must be

inoculated not under the skin, but under the skull.

These sub-dural inoculations were the turning-point of Pasteur's

discovery. The first inoculation was made by M. Roux:--

"Next day, when I informed Pasteur that the intracranial

inoculation offered no difficulty, he was moved with pity for

the dog. 'Poor beast, his brain is doubtless injured: he must be

paralysed.' Without reply I went down to the basement to fetch

it, and let it come into the laboratory. Pasteur did not like

dogs, but when he saw this one, full of life, inquisitively

rummaging about in all directions, he exhibited the greatest

delight, and lavished most charming words upon it."

Henceforth all uncertainty was at an end, and the way was clear ahead:

Pasteur had now to deal with a virus that had a definite period of

incubation, and a suitable medium for development. The central nervous

system was to the virus of rabies what the test-tube was to the virus

of fowl-cholera or anthrax. As he had controlled these diseases, had

turned them this way and that, attenuated and intensified them, so he

could control rabies. By transmitting it through a series of rabbits,

by sub-dural inoculation of each rabbit with a minute quantity of

nerve-tissue from the rabbit that had died before it, he was able to

intensify the virus, to shorten its period of incubation, to fix it at

six days. Thus he obtained a virus of exact strength, a definite

standard of virulence, _virus fixe_: the next rabbit inoculated would

have the disease in six days, neither more nor less.

As he was able to intensify the virus by transmission, so he was able

to attenuate it by gradual drying of the tissues that contained it.

The spinal cord, taken from a rabbit that has died of rabies, slowly

loses virulence by simple drying. A cord dried for four days is less

virulent than one that has been dried for three, and more virulent

than one dried for five. A cord dried for a fortnight has lost all

virulence: even a large dose of it will not produce the disease. By

this method of drying, Pasteur was enabled to obtain the virus in all

degrees of activity: he could always keep going one or more series of

cords, of known and exactly graduated strengths, according to the

length of time they had been dried--ranging from absolute

non-virulence through every shade of virulence.

And, as with fowl-cholera and anthrax, so with rabies; a virus which

has been attenuated till it has been rendered innocuous, can yet

confer immunity against its more virulent forms: just as vaccination

can protect against smallpox. A man, bitten by a rabid animal, has at

least some weeks of respite before the disease can break out; and,

during that time of respite, he can be immunised against the disease,

while it is still dormant: he begins with a dose of virus attenuated

past all power of doing harm, and advances day by day to more active

doses, guarded each day by the dose of the day before, till he has

manufactured within himself enough antitoxin to make him proof against

any outbreak of the disease.

The cords used for treatment are removed from the bodies of the

rabbits, by an aseptic method, and are cut into lengths and hung in

glass jars, with some chloride of calcium in them, for drying. The

jars are dated, and then kept in glass cases in a dark room at a

constant temperature. To make sure that the cords are aseptic, a small

portion of each cord is sown on nutrient jelly in a test-tube, and

watched, to see that no bacteria occur in the tube. For each

injection, a certain small quantity of cord is rubbed-up in sterilised

fluid; and these subcutaneous injections give no pain or malaise worth

considering.

Of course, the treatment is adjusted to the gravity of the case. A

bite through naked skin is more grave than a bite through clothing;

and bites on the head or face, and wolf-bites, are worst of all. The

number and character of the scars are also taken into account. An

excellent description of the treatment, by a patient, was published in

the _Birmingham Medical Review_ of January 1898. It gives the

following tables of treatment:--

1. _Ordinary Treatment._

Day of Days of Drying

Treatment. of Cord.

1 14 and 13

2 12 and 11

3 10 and 9

4 8 and 7

5 6

6 6

7 5

8 4

9 (1/2 dose) 3

10 (full dose) 5

11 5

12 4

13 4

14 (1/2 dose) 3

15 (full dose) 3

2. _Cases of Moderate Gravity._

Same treatment, up to 13th day.

Day of Days of Drying

Treatment. of Cord.

14 3

15 5

16 4

17 (1/2 dose) 3

18 (full dose) 3

3. _Grave Cases._

Same treatment, up to 10th day.

Day of Days of Drying

Treatment. of Cord.

11 4

12 3

13 5

14 5

15 4

16 4

17 (1/2 dose) 3

18 (full dose) 3

19 5

20 3

21 4

22 3

4. _Very Grave Cases._

Same treatment as 3, and in addition.

Day of Days of Drying

Treatment. of Cord.

23 5

24 4

25 (1/2 dose) 3

26 (full dose) 3

Furious criticism, unbelief, and flagrant misstatement of facts began

at once, and lasted more than two years. Of Pasteur's opponents, the

chief was M. Peter, who besought the Académie des Sciences, about once

a week, that they should close Pasteur's laboratory, because he was

not preventing hydrophobia but producing it. The value of M. Peter's

judgment may be estimated by what he had said, a few years earlier,

about bacteriology in general--"I do not much believe in that invasion

of parasites which threatens us like an eleventh plague of Egypt.

After so many laborious researches, nothing will be changed in

medicine, there will only be a few more microbes. M. Pasteur's excuse

is that he is a chemist, who has tried, out of a wish to be useful,

to reform medicine, to which he is a complete stranger."

But it does not matter what was said twenty years ago. In England, the

Report of the 1886 Committee, and the Mansion House meeting in July

1889, mark the decline and fall of all intelligent opposition to the

work. Among so many thousand cases, during so many years, it would be

a miracle indeed if not a single case had failed or gone amiss; but we

are concerned here with the thousands. Take, to begin with, four

reports from Athens, Palermo, Rio, and Paris. It is to be noted that

the patients, alike at Paris and at other Institutes, are divided into

three classes:--

"A. Bitten by animals proved to have been rabid by the

development of rabies in other animals inoculated from them.

"B. Bitten by animals proved to have been rabid by dissection of

their bodies by veterinary surgeons.

"C. Bitten by animals suspected to have been rabid."

It is to be noted also, as a fact proved beyond doubt, that the full

benefit of the treatment is not obtained at once; the highest degree

of immunity is reached about a fortnight after the discontinuance of

the treatment. Those few cases, therefore, where hydrophobia has

occurred, not only in spite of treatment, but within a fortnight of

the last day of treatment, are counted as cases where the treatment

came too late.

Finally, what was the risk from the bite of a rabid animal, in the

days before 1885? It is a matter of guess-work. One writer, and one

only, guessed it at 5 per cent.; another guessed it at 55, and a third

came to the safe conclusion that it was "somewhere between these

limits." Leblanc, who is probably the best guide, put it at 16; and

Pasteur himself put it between 15 and 20. But suppose it were only 10;

that, before Pasteur, out of every 100 men bitten by rabid animals, 90

would escape and only 10 would die of hydrophobia; then take this

fact, that in one year, at one Institute alone, there were 142

patients in class A, bitten by animals that were proved, by the

unanswerable test of inoculation, to have been rabid; and 1 death. And

every year the same thing; and in all the twelve years together, 2872

such cases (A) and 20 deaths--a mortality not of 10 per cent., but of

less than 1 per cent.

1. _Athens_

The _Annales de l'Institut Pasteur_, June 1898, contain Dr. Pampoukis'

report of three years' work at the Hellenic Institute, from August

1894 to December 1897. During this period 797 cases were treated--590

male and 207 female. The animals that bit them were--dogs, 732; cats,

34; wolf, 1; other animals, 13; and the 17 other patients had been

exposed to infection from the saliva of hydrophobic patients. Of the

797 cases, 245 were of class A, 112 B, and 440 C.

"Among the 797 persons treated, there are 2 deaths, one in class B and

the other in class C. Thus the mortality has been 0.25 per cent.

Besides these 2 who died of rabies there are 5 more, in whom the first

signs of rabies showed themselves in less than fifteen days after the

last inoculation.

"Finally, beside these 797 cases, there is 1 other case, bitten by a

wolf, in which the treatment failed. If we reckon this last case in

the statistics of mortality, we have 3 deaths in 798 cases = 0.37 per

cent.

"Beside these 798 cases treated at the Institute, there have been

others that have not undergone the antirabic treatment, having trusted

the assurances of those who are called in Greece _empirics_. Among

these non-treated cases there are 40 who have died of rabies."

2. _Palermo_

The _Annales_ for April 1896 give the report by Dr. de Blasi and Dr.

Russo-Travali of the work of the Municipal Institute at Palermo during

8-1/2 years, from March 1887 to December 1895. The number of cases was

2221; in 1240 (class A), the animals were proved to have been rabid by

the result of inoculations; in 981, there was reason to suspect

rabies.

"Setting aside 5 patients who died during the course of the treatment,

and 5 others who died less than fifteen days after the end of the

treatment, we have had to deplore only 9 failures = 0.4 per cent. Even

if we count against ourselves the 10 other cases, the mortality is

still only 0.85."

3. _Rio de Janeiro_

The _Annales_ for August 1898 give Dr. Ferreira's report of ten years'

work (February 1888 to April 1898) at the Pasteur Institute at Rio.

The number of cases treated was 2647, of whom 1987 were male and 660

female. Beside these 2647 there were 1234 who were not treated,

because it was ascertained that they were in no danger of rabies; 3

who were brought to the Institute, already suffering from the disease;

and 59 who refused treatment.

Of the 2647 persons treated, 10 had pricked their hands at work in the

laboratory, 3 had exposed chance scratches on their hands to the

saliva of rabid animals, and 1 had been bitten by a rabid patient. Of

the rest, 1886 had been bitten on the bare skin, and 747 through

clothing.

In 236 cases the rabies of the animal had been proved by inoculation.

In 1173 it had been recognised by the signs of the disease. In 1238

there was good reason to suspect that the animal had been rabid.

Of the 2647 patients, in 30 cases the treatment was stopped, because

the animals were at last traced, after treatment was begun, and were

found not to be rabid. In 65 cases the patients, after treatment was

begun, refused to go on with it, and 3 of them died of rabies. In 6

cases rabies developed during treatment; 5 of them had been very badly

bitten about the head, and 1 did not come for treatment till the

twenty-first day after the bite, and was attacked by rabies two days

later. And 5 cases died of other maladies that had nothing to do with

rabies. Setting aside these 106 cases, there remain 2541 cases, with

20 deaths = 0.78 per cent. But, of these 20 deaths, 9 occurred within

fifteen days of the end of treatment, before protection was fully

established. If these 9 deaths be excluded, the figures stand at 2532

cases, with 11 deaths = 0.43 per cent.

4. _Paris_

Dr. Pottevin's report on the work of the Pasteur Institute (Paris)

during 1897 (_Annales_, April 1898) must be given word for word,

without abbreviation.

During 1897, 1521 patients received the anti-treatment at the Pasteur

Institute: 8 died of rabies. The notes of their cases will be found

at the end of this paper.

If we exclude 2 of these 8 cases--the cases of Heniquet and Morin,

where death occurred before it was possible for the vaccinations to

produce their effect--the results of the vaccinations in 1897 are

Patients treated 1519

Deaths 6

Mortality per cent. 0.39

In the following table these figures are compared with those of

preceding years:--

+-------+----------+---------+-----------+

+-------+----------+---------+-----------+

| 1886 | 2671 | 25 | 0.94 |

| 1887 | 1770 | 14 | 0.79 |

| 1888 | 1622 | 9 | 0.55 |

| 1889 | 1830 | 7 | 0.38 |

| 1890 | 1540 | 5 | 0.32 |

| 1891 | 1559 | 4 | 0.25 |

| 1892 | 1790 | 4 | 0.22 |

| 1893 | 1648 | 6 | 0.36 |

| 1894 | 1387 | 7 | 0.50 |

| 1895 | 1520 | 5 | 0.33 |

| 1896 | 1308 | 4 | 0.30 |

| 1897 | 1521 | 6 | 0.39 |

+-------+----------+---------+-----------+

Patients treated at the Pasteur Institute are divided into three

classes, as follows:--

A. The rabies of the animal was proved by experiment, by the

development of rabies in animals inoculated with its bulb (the upper

end of the spinal cord).[25]

[25] It is satisfactory to know that rabbits affected with rabies

do not suffer in the same way as dogs and some other animals, but

become subject to a painless kind of paralysis.

B. The rabies of the animal was proved by veterinary examination

(dissection of its body).

C. The animal was suspected of rabies.

We give here the patients treated in 1897, under these three

classes:--

+------------------+---------------+---------------+---------------+

+--+-----+---+-----+-----+---+-----+-----+---+-----+-----+---+-----+

| | P | | M p | P | | M p | P | | M p | P | | M p |

| | a | D | o e | a | D | o e | a | D | o e | a | D | o e |

| | t | e | r r | t | e | r r | t | e | r r | t | e | r r |

| | i | a | t | i | a | t | i | a | t | i | a | t |

| | e | t | a c | e | t | a c | e | t | a c | e | t | a c |

| | n | h | l e | n | h | l e | n | h | l e | n | h | l e |

| | t | s | i n | t | s | i n | t | s | i n | t | s | i n |

| | s | . | t t | s | . | t t | s | . | t t | s | . | t t |

| | . | | y . | . | | y . | . | | y . | . | | y . |

+--+-----+---+-----+-----+---+-----+-----+---+-----+-----+---+-----+

| A| 15 | 0 | 0 | 81 | 0 | 0 | 46 | 1 | 2.1 | 142 | 1 | 0.7 |

| B| 106 | 0 | 0 | 539 | 4 | 0.74| 273 | 1 | 0.4 | 918 | 5 | 0.65|

| C| 30 | 0 | 0 | 244 | 0 | 0 | 187 | 0 | 0 | 461 | 0 | 0 |

+--+-----+---+-----+-----+---+-----+-----+---+-----+-----+---+-----+

| | 151 | 0 | 0 | 864 | 4 | 0.46| 506 | 2 | 0.4 |1521 | 6 | 0.39|

+--+-----+---+-----+-----+---+-----+-----+---+-----+-----+---+-----+

The following tables, giving the results obtained since the

vaccinations were first used, show that the gravity of the bites

varies with their position on the body, and that the mortality is

always below 1 per cent. among patients bitten by dogs undoubtedly

rabid:--

+-------------------+---------+-------+----------+

+-------------------+---------+-------+----------+

|Bites of the Head | 1,759 | 21 | 1.1 |

|Bites of the Hands | 11,118 | 53 | 0.47 |

|Bites of the Limbs | 7,289 | 22 | 0.30 |

+-------------------+---------+-------+----------+

| | 20,166 | 96 | 0.46 |

+-------------------+---------+-------+----------+

+---+---------+-------+----------+

+---+---------+-------+----------+

| A | 2,872 | 20 | 0.69 |

| B | 12,547 | 61 | 0.48 |

| C | 4,747 | 15 | 0.31 |

+---+---------+-------+----------+

| | 20,166 | 96 | 0.46 |

+---+---------+-------+----------+

III

In regard to their nationality, the 1521 patients treated at the

Pasteur Institute in 1897 were as follows:--

Germany 8

England 83

Belgium 14

Egypt 2

United States 1

Greece 1

India 33

Switzerland 33

That is, 175 foreigners and 1346 French.

Notes of the eight cases where the treatment failed:--

1. Camille Bourg, 26. Bitten 11th April; treated at the Pasteur

Institute, 13th to 30th April; died of rabies at the Lariboisière

Hospital, 26th May. Six penetrating bites on the ball of the left

thumb. The dog was examined by M. Grenot, a veterinary surgeon at

Paris, and the dissection gave evidence of rabies. Another person

bitten and treated at the same time as Bourg is now in good health.

2. Louis Fiquet, 23. Bitten 22nd April; treated at the Pasteur

Institute, 23rd April to 10th May; died of rabies at the Necker

Hospital, 4th June. Five bites, two of them deep, round the right

thumb. They had been cauterised five hours after infliction. The dog

was examined by M. Caussé, a veterinary surgeon at Boulogne, and the

dissection gave evidence of rabies. Another person bitten at the same

time as Fiquet is now in good health.

3. Annette Beaufort, 19. Licked on the hands, which were chapped, on

15th April. The dog was killed next day, examined, and declared to

have been rabid by M. Lachmann, a veterinary surgeon at Saint-Étienne.

Treated at the Pasteur Institute, 20th April to 7th May. Died of

rabies 14th October. Two other persons bitten by the same dog and

treated at the Pasteur Institute are now in good health.

4. Julien Heniquet, 53. Bitten 11th March, by a dog that M. Jenvresse,

veterinary surgeon at Beaumont-sur-Oise, declared after dissection to

have been rabid. One bite had torn the lower lip, the wound had been

sutured; three other wounds on the nose. The wounds had not been

cauterised. Treated at the Pasteur Institute, 18th May to 5th June.

First symptoms of rabies showed themselves 4th June, before the

treatment was finished; died 7th June. As the disease had its onset

during the course of the inoculations, this case should be excluded

from the number of those who died of rabies after treatment.

5. Germain Segond, 7. Penetrating bite on the bare right fore-arm,

23rd May. Cauterised an hour later with a red-hot iron. Treated 26th

May to 9th June; died of rabies 22nd July. The dog's bulb had been

sent to the Pasteur Institute. A guinea-pig inoculated in the eye 26th

May was seized with rabies 10th September.

6. Suzanne Richard, 8. Bitten 12th June on the left leg by a dog,

found on dissection to have been rabid by M. Touret, veterinary

surgeon at Sannois. The bite, penetrating 3 cm. long, had been

sutured; it had been made through a cotton stocking, and had been

cauterised in half-an-hour. Treated 13th to 30th June; died of rabies

2nd August. (Notes from M. le Dr. Margny, at Sannois.)

7. Joseph Vaudale, 33. Bitten on the left hand, 8th August. Six

penetrating bites on the back of the hand; had not been cauterised.

The dog was declared rabid by M. Verraert, veterinary surgeon at

Ostend. Treated at the Pasteur Institute, 11th to 28th August; died of

rabies 27th September.

8. Paul Morin, 38. Bitten 24th August on the left cheek, a single

bite, 2 cm. long; no cauterisation. The dog was sent to the Alfort

School, 25th August, and found to be rabid. Treated at the Pasteur

Institute, 26th August to 15th September. Died of rabies some days

after the end of treatment (three weeks after the bite, says a note

sent to us). The interval between the end of the treatment and the

onset of the disease being less than fourteen days, Morin must not be

counted in the number of patients inoculated under conditions which

permit successful inoculation.

* * * * *

We hardly need follow the work of the remaining years. The figures are

as follows:--

+-------+----------+---------+-----------+

+-------+----------+---------+-----------+

| 1898 | 1465 | 3 | 0.2 |

| 1899 | 1614 | 4 | 0.25 |

| 1900 | 1420 | 4 | 0.28 |

| 1901 | 1318 | 5 | 0.38 |

| 1902 | 1105 | 2 | 0.18 |

| 1903 | 628 | 2 | 0.32 |

| 1904 | 755 | 3 | 0.39 |

+-------+----------+---------+-----------+

The falling off in the number of patients at the Paris Institute is

related to the establishment of similar Institutes at Lyon,

Marseilles, Bordeaux, Lille, and Montpellier. But is it not possible

that a patient, after treatment at the Paris Institute, should die at

home of rabies, and his death not be notified to the Institute? The

answer is, that the Institute is very careful, so far as possible, to

keep in touch with its old patients. For instance, in 1903, it

recorded the case of a carpenter in a Welsh village, who had died of

rabies nearly two years after treatment. And, of course, an Institute

patient, wherever he was, would be of interest to his neighbours: and

a death from rabies would excite attention, and would hardly fail to

be reported.

It is not impossible that some sort of intensive modification of

Pasteur's treatment may be found, not for the prevention, but for the

cure of hydrophobia; and two successful cases of this kind have been

reported in the _Annales_ of the Paris Institute. Apart from this

faint hope, the _cure_ of hydrophobia is where it was in the days of

the "Tonquin medicine" and the "Tanjore pills."

VII

CHOLERA

The study of cholera was the hardest of all the hard labours of

bacteriology; it took years of work in all parts of the world, and the

difficulty and disappointments over it are past all telling. Koch's

discovery of the comma-bacillus (1883) raised a thousand questions

that were solved only by infinite patience, international unity for

science, and incessant research; and the Hamburg epidemic (1892) marks

the time when the comma-bacillus was at last recognised as the cause

of cholera. A mere list of the men who did the work would fill page

after page; it was bacteriology _in excelsis_, often dangerous,[26]

and always laborious.

[26] "In order to prove that this _vibrio_ is the cause of Asiatic

cholera, several tests upon themselves have been voluntarily made

by investigators in laboratories. These were carried out in Munich

and in Paris. The results to the experimenters were sufficiently

severe to indicate positively the pathogenic character of the

spirillum, and its capacity to produce cholera-like infections.

Such experimentation is, of course, to be deprecated; indeed, the

occurrence of accidental laboratory infections, one of which ended

fatally, furnished the necessary final proof of the specificity of

the cholera _vibrio_, and rendered unnecessary any exposure to the

risks belonging to voluntary inoculation." (Dr. Flexner, Stedman's

_Twentieth Century Practice_, vol. xix., 1900.)

There is the same heroic note in the story of the preventive treatment

of cholera by Haffkine's method; one of the men in whom Pasteur seems

to live again. He began in 1889, under Pasteur's guidance, to study

the immunisation of animals against the cholera-bacillus. Other men,

of course, were working on the same lines--Pfeiffer, Brieger,

Metchnikoff, Fischer, Gamaleïa, Klein, Wassermann, and many more--and

by 1892 the immunisation of animals was proved up to the hilt. Then

came the advance from animals to men, from laboratories to Indian

cities, villages, and cantonments; and here the honour is Haffkine's,

and his alone. Ferran's inoculations (Spain, 1885) had failed.

Haffkine, having tested his method on himself and his friends, went to

India, with a commendatory letter from the British Government:--

"Researches on cholera, with special reference to inoculation,

were undertaken and carried on in my laboratory, in the Pasteur

Institute in Paris, between 1889 and 1893. The experiments

resulted in the elaboration of the present method, which when

tried on animals was found to render them resistant against

every form of cholera-poisoning otherwise fatal to them.

"The physiological and pathological effect on man was then

studied on some sixty persons, mostly medical and scientific men

interested in the solution of the problem. The effect was found

to be harmless to health. The next step was to transfer the

operations to the East." (Haffkine's _Report to the Government

of India_, 1895.)

He reached Calcutta in March 1893, and at the request of Mr.

Hankin[27] was invited to Agra; here, in April, he vaccinated over 900

persons, including many English officers. From Agra to Aligarh; and

from Aligarh he was asked to more places than he could visit. In 1895

his health failed, and no wonder; and he came back to Europe for a

short time:--

"My actual work in India lasted twenty-nine months, between the

beginning of April 1893 and the end of July 1895. During this

period the anti-cholera vaccination has been applied to 294

British officers, 3206 British soldiers, 6629 native soldiers,

869 civil Europeans, 125 Eurasians, and 31,056 natives of India.

The inoculated people belonged to 98 localities in the

North-West Provinces and Oudh, in the Punjab, in Lower Bengal

and Behar, in the Brahmaputra Valley, and in Lower Assam. No

official pressure has been brought on the population, and only

those have been vaccinated who could be induced to do so by free

persuasion. In every locality, efforts were made to apply the

operation on parts of large bodies of people living together

under identical conditions, in order to compare their resistance

in outbreaks of cholera with that of non-inoculated people

belonging to the same unit of population. This object has been

obtained in 64 British and native regiments, in 9 gaols, in 45

tea-estates, in the fixed agricultural population of the

villages parallel to Hardwâr pilgrim road, in the _bustees_ of

Calcutta, in a certain number of boarding-schools, where the

parents agreed to the inoculation of their children, in

orphanages, etc. The vast majority of inoculated people lived

thus under direct observation of the sanitary and medical

authorities of India." (Haffkine, Lecture in London. _British

Medical Journal_, 21st Dec. 1895.)

[27] Mr. Hankin, whose name is had in remembrance by Cambridge

men, is Chemical Examiner and Bacteriologist to the North-West

Provinces and Oudh, and to the Central Provinces.

Altogether, upwards of 70,000 injections on 42,179 people--_without

having to record a single instance of mishap or accident of any

description produced by our vaccines_. Consider the colossal

difficulties of this new treatment: the frequent running short of the

vaccine, preventing a second injection; the absolute necessity, at

first, of using very small doses of a weak vaccine, lest one disaster

should occur; the impossibility of avoiding, now and again, some loss

of strength in the vaccine; the impossibility of knowing how long the

protection would last. Surely in all science there is nothing to beat

this first voyage of adventure single-handed to fight the cholera in

India.

Later than Haffkine's 1895 report, we have Dr. Simpson's 1896 report:

"_Two Years of Anti-choleraic Inoculations in Calcutta._ W. J.

Simpson, M.D., M.R.C.P., D.P.H., Health Officer, Calcutta." The date

of this report is 8th July 1896; and it gives not only the Calcutta

results, but all that are of any use for exact judgment:[28]--

"The results of Calcutta are fully confirmed by those obtained

in other parts of India, wherever it was possible to make all

the necessary observations with precision, and wherever the

cases were sufficiently numerous to show the effect of the

inoculation.

"Outside Calcutta, since the commencement of the inoculations in

India in April 1893, opportunities for an exact comparison of

the respective powers of resistance against cholera of

inoculated and non-inoculated persons presented themselves; (1)

in Lucknow, in the East Lancashire Regiment; (2) in Gaya, in the

jail; (3) in Cachar, among the tea-garden coolies; (4) in

Margherita, among coolies of the Assam-Burmah Railway Survey;

(5) in Durbhanga, in the jail; (6) in the coolie camp at

Bilaspur; (7) in Serampur, among the general population."

[28] For a summary of this report, see the _Lancet_, 8th August

1896. For more recent results, see Surgeon-Captain Vaughan and

Assistant-Surgeon Mukerji, in the thirtieth annual report of the

Sanitary Commissioner for Bengal (1897). Also the note published

by Surgeon-Captain Nott, in the _Indian Medical Gazette_, May

1898.

Here, then, in this 1896 report, are all the results that give an

answer to the question, What will happen when cholera breaks out

among a number of people living under the same conditions, of whom

some have received preventive treatment, and the rest have been left

to Nature?

I. _Calcutta_ (1894-1896)

"The number of people inoculated during the period under review

was 7690; of these, 5853 are Hindus, 1476 Mahomedans, and 361

other classes.... Considering that the system is a new one, that

the inoculations are purely voluntary, and everything connected

with them has to be explained before the confidence of the

people can be obtained, and considering how long new ideas are

in taking root among the general population--and in this case it

is not merely the acceptance of an idea, but such faith in it as

to consent to submit to an operation--the number is certainly

satisfactory for a beginning. The present problem can be

compared with the introduction of vaccination against smallpox

into Calcutta. It took 25 years before the number of

vaccinations reached an average of 2000; whereas the

inoculations against cholera have in two years nearly doubled

that average. This is a proof that, in spite of the difficulties

which every new movement naturally has to meet with, there are

large numbers of people anxious to avail themselves of the

protective effect of the inoculations.

"Although all sorts and conditions of individuals, weak and

strong, sickly and healthy, young and old, well nourished and

badly nourished, and often persons suffering from chronic

diseases, have been inoculated, in every instance, without

exception, the inoculations have proved perfectly harmless.

"The investigations on the effect of the inoculation are made

exclusively in those houses in which cholera has actually

occurred, the object being to ascertain and compare the

incidence of cholera on the inoculated and not inoculated in

those houses in which inoculations had been previously carried

out. _For this purpose, affected houses in which inoculations

have not been performed, and inoculated houses in which cholera

has not appeared, are excluded._"

Nature gave a demonstration in 77 houses. In one house, and one only,

all the household had been inoculated; in 76, inoculated and

non-inoculated were living together; but of these 76 houses, 6 are

excluded from the table of results, because the inoculated in them

were so few--less than one-tenth of the household--that their escape

from cholera might be called chance. The cholera came, and left behind

it this fact:--

654 uninoculated individuals had 71 deaths = 10.86 per cent.

402 inoculated in the same households had 12 deaths = 2.99 per

cent.

If we add the 6 houses which Dr. Simpson excludes, we find that in 77

houses there were 89 deaths from cholera, 77 being among the

uninoculated and 12 among the inoculated.

Moreover, of these 12 deaths, 5 occurred during the first five days

after inoculation--that is to say, during the period in which the

protective influence of the vaccine was still incomplete. _Then came a

period of more than a year, during which the uninoculated had 42

deaths, and the inoculated had one death._ The remaining 6 of the 12

deaths occurred more than a year after inoculation, and 5 of these 6

had received only one inoculation of the weak vaccine that was used

early in 1894.

Take a good instance that came at the very beginning of the work:--

"A local epidemic took place around two tanks in Kattal Began

_bustee_, ward 19, occupied by about 200 people. In this _bustee_,

about the end of March, 2 fatal cases of cholera and 2 cases of

choleraic diarrhoea occurred. The outbreak led to the inoculation

of 116 persons in the _bustee_ out of the 200. Since then, 9 cases

of cholera, of which 7 were fatal, and 1 case of choleraic

diarrhoea have appeared in the _bustee_, and it is a very

extraordinary fact that all these 10 cases of cholera have occurred

exclusively among the uninoculated portion of the inhabitants,

which, as stated, forms the minority in the _bustee_; while none of

the inoculated have been affected." (_Cholera in Calcutta in 1894._

W. J. Simpson.)

2. _Lucknow_ (1893)

The story of the outbreak of cholera in the East Lancashire Regiment

must be read carefully:--

"Rumour magnified the events connected with this outbreak, and

distorted the facts connected with the inoculations; and as a

result, the current of public opinion, which had previously been

in favour of inoculation, set in strongly in the opposite

direction. The advocates of anti-choleraic inoculations were

abused in no particularly measured terms, and the inoculations

were held up to be the source of every possible evil and danger

... of the most loathsome diseases, and of every ill which man

is heir to. The distrust engendered by these misrepresentations

and fulminations was, however, only of a temporary nature; and

when the exact circumstances came to be known and understood,

the confidence created by the Calcutta experience began to be

considerably restored. Inoculations were performed in May 1893,

in the East Lancashire, Royal Irish, 16th Lancers, 7th Bengal

Infantry, 7th Bengal Cavalry, and general populations in the

Civil Lines. In 1894, cholera appeared among the native

population of Lucknow, in the form of an epidemic distinguished

by its extreme virulence, patients succumbing in the course of

a few hours. It is stated that the epidemic was of a most

malignant type. In the latter part of July it entered the

cantonments, and attacked the East Lancashire, almost

exclusively confining its ravages to that regiment."

In the East Lancashire, 185 men were inoculated in May 1893. From the

statistical returns obtained from the military authorities at Lucknow,

it appears that at the time of the outbreak, in July 1894, the

strength of the men, including those in hospital, was 773; and of

these, 133 had been inoculated, as recorded in the inoculation

The following table shows the total number of attacks and deaths in

not inoculated and inoculated:--

+---------------------+-------------+------------+

| | Attacks. | Deaths. |

+---------------------+-------------+------------+

| | Per cent. | Per cent. |

| Non-inoculated, 640 | 120 = 18.75 | 79 = 12.34 |

| Inoculated, 133 | 18 = 13.53 | 13 = 9.7 |

+---------------------+-------------+------------+

The men were moved into camp; but this movement seemed only to make

things worse: "the epidemic in the camp appears to have been twice as

severe as in the cantonment."[29]

[29] "The moving into camp, notwithstanding this example, is all

the same an excellent measure of defence, and would with reason be

adopted in every outbreak." (Simpson, _loc. cit._)

Lucknow came so early in the work of inoculation, that weak vaccines

were used in small doses. The cholera, when it broke out, was "of a

most malignant type, senior medical officers of long experience in the

country stating that such a virulent cholera had not been seen by them

for very many years past." More than a year had elapsed between the

inoculations and the outbreak of the cholera. It is no wonder that the

regiment was not well protected:--

"The small amount of protection which the inoculations afforded

in this case may have depended on the mild effects which the

injections produced on the men at the time of the operation in

1893, in comparison with the severity of the epidemic which

attacked the regiment. It is recorded in the Lucknow Inoculation

Registers that only in two men, out of the 185 inoculated in

1893, a marked febrile reaction was obtained; in 77 individuals

the vaccinal fever was only slight, while in 66 there was no

reaction: an effect which was due to the weakness of the

vaccines procurable at that period of work, and to the small

doses used. The influence of the vaccines was possibly further

reduced, at the time of the epidemic, by a lapse of fourteen to

fifteen months." (Haffkine, 1895 Report.)

3. _Gaya Jail_

On 9th July 1894, an outbreak of cholera occurred in the Gaya jail,

and by 18th June there had been 6 cases and 5 deaths. On that day and

the next day, 215 prisoners were inoculated. The average number of the

prisoners during the outbreak was 207 inoculated, and 202 not

inoculated. Surgeon-Major Macrae, superintendent of the jail,

reports:--

"The inoculations being purely voluntary, no selection of

prisoners was possible, but all classes of the jail were

represented--male and female, old and young, habituals and less

frequent offenders, strong and weakly, convalescent and even

hospital patients sent their representatives; no difference of

any kind was made between inoculated and non-inoculated; they

were under absolutely identical conditions as regards food,

water, accommodation, etc., in fact in every possible respect."

Of course, the best results could hardly be obtained, because the

cholera was already at work: it took about ten days for the 1894

vaccine to produce its full effect; and two inoculations were

generally made, one five days after the other. This gradual action of

the vaccine is well shown in Dr. Simpson's table:--

+-------------------------+------------------+------------------+

| | NON-INOCULATED, | INOCULATED, |

| | 202. | 207. |

+-------------------------+------------------+------------------+

+-------------------------+--------+---------+--------+---------+

| During 5 days after 1st | 7 | 5 | 5 | 4 |

| During 3 days after 2nd | 5 | 3 | 3 | 1 |

| After 3 days after 2nd | 8 | 2 | 0 | 0 |

+-------------------------+--------+---------+--------+---------+

Haffkine's comment on these figures must be noted here:--

"In the Gaya jail, the inoculations were _for the first time_

applied _in a prevalent epidemic_, and _very weak doses_ of a

relatively weak vaccine were used.... Far higher results have

been obtained by an application of stronger doses. In the

_bustees_ situated round the tanks in Calcutta, where cholera

exists in a permanent state, the disease occurred in 36 houses

with inoculated people. In each of these houses there was one

part of the family inoculated and another not. The observations

were continued for 459 days, with the following results:--

During the first period of 5 days, subsequent to the inoculation with

first vaccine, cholera occurred in 8 houses.

75 non-inoculated had 5 cases, with 3 deaths. 52 inoculated had

3 cases, with 3 deaths.

During the second period of 5 days, subsequent to the second

inoculation, cholera occurred in 2 houses.

8 non-inoculated had 2 cases, with 2 deaths. 17 inoculated had

no cases.

_After the 10 days necessary for the preventive treatment had expired,

and up to the 459th day, the disease visited 26 houses._

_263 non-inoculated had 38 cases, with 34 deaths._

_137 inoculated had 1 case, with 1 death, in a child that had

not been brought up for the second inoculation."_

4. _Assam-Burmah Railway_

For a good instance of lives saved even during an outbreak, take the

Assam-Burmah Railway coolies:--

_"Three hundred and fifty[30] Khassia Hill coolies had been

collected for the survey party of the Assam-Burmah Railway, and

put under the escort of a detachment of Goorkhas, when cholera

broke out amongst them. The largest part of the coolies

immediately submitted to the preventive inoculation, the rest

remained uninoculated. The result was that _among the

not-inoculated minority there were 34 cases, with 30 deaths;

whereas the inoculated had 4 fatal cases_." (Haffkine, 1895,

Lecture in London.)_

[30] The exact number is 355, of whom 196 were inoculated; the

coolies numbered 343, and the Goorkhas 12. (See Dr. Simpson's 1896

Report.)

5. _Durbhanga Jail_ (1896)

The figures in this instance are small: but Surgeon-Captain E. Harold

Brown's report is very pleasant reading. Cholera broke out in the

jail on 31st March 1896, and by 9th April there had been 8 cases. Next

day, 172 prisoners were moved into camp 12 miles away; and 53 were

left behind, the sick in the jail hospital, the patients in the

cholera huts, with their attendants, the old and infirm, and a few

cooks and sweepers. That day, 3 cases occurred in the camp, and 1 in

the jail; and on the 11th, at 2 and 4 A.M., 2 more cases were reported

in camp. At 7.30 A.M., Haffkine and Dr. Green came to the camp:--

"The prisoners were spoken to on the subject, and seemed to be

pleased with the idea, the word _tika_ (inoculation), which was

familiar to them from its association with smallpox, appearing

to appeal to them. They were accordingly arranged in four rows

facing the tent, in front of which Dr. Haffkine was about to

commence operations. I was the first subject to be inoculated;

and after me the jailor, assistant jailor, hospital assistant,

and three warders. The first prisoner in the front rank was next

brought up and submitted cheerfully; after which, every

alternate man was taken, so that no selection of cases was made,

until one-half of the total number were inoculated. Those who

had not been inoculated were far from pleased at having been

passed over; and, to our surprise, they rose almost to a man,

and begged to be inoculated; nor were they satisfied when told

that the medicine was exhausted."

The dose administered on this occasion (11th April 1896) was stronger

than the Gaya jail dose (18th July 1894): it acted in a few hours, and

the reaction was well marked.

"There were fresh cases of cholera that day at 12 (noon), 6, 7,

and 7.30 P.M., and at midnight, all in those who had not been

inoculated, and all terminating fatally, despite the greatest

care and the most prompt and assiduous treatment. On the 12th

two further cases occurred, both among the uninoculated, and

both died; there being thus eight cases in succession, all from

the men who were not inoculated, and all proving fatal."

The inoculations were made at 7.30 A.M. Surgeon-Captain Brown had pain

within half-an-hour, and fever in three hours, with temperature 104°,

_but this was probably due to the fact that I was not able to rest_.

The prisoners, of course, went to bed: they all reacted before 4 P.M.,

but did not have so much trouble over it. The last case was on the

15th. The outbreak was a bad type of cholera; out of 30 cases 24 died,

some of them in 1-1/2 to 4 hours. "To summarise the combined results

of the camp and the jail, we find that of a daily average of 99

non-inoculated there were 11 cases, all fatal = 11.11 per cent.; of

110 inoculated there were 5 cases, with 3 deaths = 2.73 per cent."

6. _Bilaspur and Serampur_

Here again the figures are small, but worth noting. In a coolie camp

at Bilaspur (Central Provinces) 100 non-inoculated had 5 deaths, and

150 inoculated had 1 death. In Serampur, among the general population,

51 non-inoculated had 5 cases and 3 deaths, and 42 inoculated had 2

cases and 1 death.

7. _The Cachar Tea-Gardens_ (1895)

This series of inoculations was begun in February 1895, for the

protection of the coolies on various tea-estates. The results are

excellent, and deal with large numbers.[31] The latest report from

Dr. Arthur Powell, the Medical Officer, is quoted in Dr. Simpson's

1896 report:--

_At Kalain_--

1079 not inoculated had 50 cases, with 30 deaths.

1250 inoculated--3 cases, with 2 deaths.[32]

_At Kalaincherra_--

685 not inoculated had 10 cases, with 7 deaths.

155 inoculated--no cases.

_At Degubber_--

254 not inoculated had 12 cases, with 10 deaths.

407 inoculated--5 cases, all recovered.

_At Duna_--

121 not inoculated had 4 cases, with 2 deaths.

29 inoculated--no cases.

_At Sandura_--

454 not inoculated had 2 cases, with 1 death.

51 inoculated--2 cases, with 1 death.

_At Karkuri_--

198 not inoculated had 15 cases, with 9 deaths.

443 inoculated--3 cases, with 1 death.

_At Craig Park_--

185 not inoculated had 1 fatal case.

46 inoculated--no cases.

TOTAL.

Not inoculated, 2976, with 94 cases and 60 deaths. Inoculated,

2381, with 13 cases and 4 deaths.

[31] "As a field for testing the value of inoculation, the

tea-factories of India possess many advantages. The labourers

being under contract, the after-history of those inoculated is

easily followed up. Each morning the adults are paraded for

roll-call; and all sick must attend hospital, where a record is

made of their disease and treatment." (Dr. Powell, _Lancet_, 13th

July 1896.)

[32] "It is unfortunate that neither of the fatal cases among the

inoculated was seen by any medical man, not even an unqualified

doctor Babu." Dr. Powell does not think, from what was told him,

that one of them was cholera.

To the preceding instances, which are rather old now, must be added

the following more recent report, from the _Indian Medical Gazette_,

September 1901:--

"We are glad to see, from a paragraph in the Report of the

Sanitary Commissioner for Bengal (Major H. J. Dyson, I.M.S.,

F.R.C.S.), that an increased number of anti-cholera inoculations

were performed during the year 1900. Assistant-Surgeon G. C.

Mukerjee, who was in charge of this work, reports that in the

Puralia Coolie Depot no less than 13,291 persons were inoculated

against cholera, including over 1000 children. All these cases

of inoculation were among labour emigrants proceeding to the

tea-gardens of Assam and Cachar. The employers of labour are

beginning to realise the value of cholera inoculation. It is

unfortunately not always easy, or even possible, to follow up

the after-history of persons inoculated; but Major Dyson has

quoted a table, received from the Superintendent of Emigration,

which shows the number of cases among the inoculated and the

non-inoculated at Goalundo. From this table, it is seen that out

of 1527 non-inoculated coolies, who passed through Goalundo, 33,

or 2.09 per cent., got cholera; whereas of 873 inoculated

coolies, only 2, or 0.2 per cent., were attacked by the disease;

that is, the unprotected suffered about ten times as much as the

inoculated. Assistant-Surgeon Mukerjee also reports that during

his cold-weather tour he passed through some villages in the

Manbhum district, in which he had practised inoculation the

previous year: and, though there had been epidemics of cholera

in them, the inoculated persons escaped. They came to him in

numbers, stating that they owed their safety to the

inoculation."

Of course, the preventive treatment touches points only here and there

on the map of India, with its 300,000,000 people. Probably it will

never become so general in India as vaccination. Cholera in India

recalls what Ambroise Paré, more than 400 years ago, wrote of the

plague, "Here in Paris it is always with us." But, wherever preventive

inoculation has been done, there it has done good.

The _Medical Annual_ for 1905 contains an account of some preventive

inoculations recently made during an epidemic in Japan. Among the

inoculated, the attack-rate was much lower than among the

uninoculated; and the mortality was 45.5 per cent., as against 75 per

cent.

Another most important result of the discovery of the cholera bacillus

is its use in diagnosis. For example, if a case of suspected cholera

is landed at a British port, the sanitary authority at once takes

steps to ascertain whether the specific microbe is present; and,

according to the answer given by bacteriology, either allows the

patient to proceed on his journey, or adopts measures of isolation to

prevent the spread of the disease to others. Thus, thanks to the

insular position of Great Britain, this dreadful disease has for many

years been prevented from invading her population.

VIII

PLAGUE

The _bacillus pestis_ was discovered by Kitasato and Yersin, working

independently, in 1894. Yersin's discovery was made at Hong Kong,

whither the French Government had sent him to study plague: an

excellent account of his work is given in the _Annales de l'Institut

Pasteur_, September 1894. The first experiments in preventive

inoculation, in animals, were made by Yersin, Calmette, and Borrel,

working conjointly, in 1895. They found that it was possible to confer

on animals a certain degree of immunity, by the hypodermic injection

of dead cultures of the bacillus. These experiments were made on

rabbits and guinea-pigs.

Haffkine's fluid was first used on man in January 1897. It is a

_bouillon_ containing no living bacilli, and nothing offensive to the

religious beliefs of India.[33] He proved its efficacy on rabbits; and

then, on 10th January 1897, inoculated himself with a large dose, four

times as strong as the subsequent standard dose. A few days later,

Lieut.-Col. Hatch, Principal of the Grant Medical College, Bombay, and

other members of the College Staff, were inoculated. These first

inoculations were described by Haffkine in a lecture (1901) at

Poona:--

"In a short time, a number of the most authoritative physicians

in Bombay, European and native, official medical officers and

private practitioners, submitted themselves for inoculation. It

is a matter of gratification to me to be able to quote, among

these authorities, the Head of the Medical Service of the

Presidency, Surgeon-General Bainbridge, who not only got himself

inoculated, but inoculated also the members of his family.

Previous to that, Surgeon-General Harvey, the able

Director-General of the Indian Medical Service, submitted

himself to inoculation in 1893 against cholera; and, in 1898,

against plague. It was the example of these gentlemen, whose

competence in the matter of health could not be disputed, that

encouraged thousands of people, rich and poor, in Bombay and

elsewhere, to come forward for inoculation. Thus his Excellency

the Viceroy thought it right to tell you here, in Poona, that

previous to his starting for the plague-stricken districts he

and his staff had also undergone the prophylactic inoculation.

In due course, mothers brought their children to be protected by

the new 'vaccination.'"

[33] It is said that the Jains object to inoculations on the

grounds of religion; and one or two witnesses before the Plague

Commission gave evidence to the same effect. But, at Bombay, the

high-priest of a great religious community addressed a meeting of

5000 in favour of the new treatment; and the rush of suppliants

for inoculation at Hubli and Gaday proves that there is no real

religious difficulty. Doctors have been assaulted, as at Poona, so

at Oporto; in neither case can we say _Tantum relligio potuit

suadere malorum_.

Within a few months, 8142 persons in or near Bombay were inoculated.

It was not possible, in Bombay, during the rush of plague-work, to

follow up every one of these 8142 persons. But there is reason to

believe, making some allowance for oversights, that only 18 = 0.2 per

cent. of them, were attacked during the epidemic; that, of these 18,

only 2 died: and that these 2 died within twenty-four hours of

inoculation, _i.e._, had the plague in them already at the time of

inoculation.

And, with regard to a small group of the inoculated, there are the

following more definite facts. This group lived outside Bombay, across

the harbour, in a village called Mora. The population of Mora, at the

time of the epidemic, was estimated at less than 1000. Out of this

number 429 were inoculated; which, if the population be reckoned at

1000 exactly, left 571 uninoculated. Among the 429 inoculated, there

were 7 cases of plague, with no deaths: among the uninoculated there

were 26 cases, with 24 deaths.

Just a week after Haffkine had informed the Indian Government that he

had tested his fluid on himself, plague broke out in the Byculla House

of Correction, Bombay, on 23rd January 1897. Between the 23rd and the

afternoon of the 30th, there were 14 cases, with 7 deaths. On the

afternoon of the 30th, 152 prisoners were inoculated, and 172 were

left uninoculated. The outbreak ceased on 7th February. The figures,

as corrected by the Plague Commission, are, among the inoculated, 1

case, which recovered; among the uninoculated, 7 cases, with 2 deaths.

For a full and severe examination of the reports, statistics, and

other evidence concerning this and other outbreaks in which preventive

inoculations were made, the Report (1901) of the Indian Plague

Commission must be studied. The Commissioners, Professor T. R. Fraser,

Mr. J. P. Hewett, Professor (now Sir) A. E. Wright, Mr. A. Cumine, Dr.

Ruffer, and Mr. C. J. Hallifax, Secretary, travelled and took evidence

in India from November 1898 to March 1899: during which time they held

70 sittings and examined 260 witnesses, some at great length. The

evidence and the report are published in five large volumes. The

report, 540 pages in all, deals exhaustively with the whole subject.

It represents the very least--what might almost be called the very

worst--that can be said of Haffkine's fluid: and, of course, it reads

rather differently from the reports of the men who, with their lives

in their hands, and worked almost past endurance, fought plague

themselves. The following paragraphs give, so far as possible, the

bare facts of various outbreaks of the disease in 1897-99, in which

Haffkine's fluid was used.

1. _Daman_

Plague broke out in Daman, a town in Portuguese territory, north of

Bombay, and in constant communication with Bombay by sea, in March

1897. By the end of the month, when a Government cordon was placed

round the town, about 2000 out of 10,900 had fled. The outbreak

reached its height in mid-April, and was practically over by the end

of May. Inoculations were begun on 26th March. The total population on

that day (2000 having gone out, and 670 having died of plague) is

estimated at 8230. Of these, 2197 were inoculated, and 6033 were left

uninoculated. Among the inoculated there were 36 deaths = 1.6 per

cent.; among the uninoculated 1482 deaths = 24.6 per cent.

The Commissioners criticise these figures severely, and do not accept

them as exact. But they admit the evidence as to the results of

inoculation among the Parsee community of Daman. Of this community,

306 in number, 277 were inoculated, and only 29 were left

uninoculated. Among the inoculated there was 1 death = 0.36 per cent.:

among the uninoculated there were 4 deaths = 13.8 per cent.

They admit, also, the house-to-house investigations made by Major

Lyons, I.M.S., President of the Bombay Government Plague Committee. At

the end of May, he visited 89 houses, in 62 of which both inoculated

and uninoculated were living together. He found that out of 382

inoculated, 36 had died = 9.4 per cent.; out of 123 uninoculated, 38

had died = 30.9 per cent.

2. _Lanauli_

Plague attacked Lanauli, a small hill-station and railway depot,

during April to September 1897. The entire population was estimated at

about 2000. Inoculations were begun on 24th July in two wards of the

town, and a daily house-to-house inspection was instituted. The

figures reported, on the basis of the average daily strength of the

two groups, are as follows:--

Inoculated, 323, with 14 cases, of which 7 died = 2 per cent.

Uninoculated, 377, with 78 cases, of which 57 died = 15 per

cent.

The Commissioners criticise the method on which these figures are

based, and do not accept them as accurate. But they agree that

inoculation "exerted a distinct preventive effect"; and they admit

Major Baker's evidence--"In the place where inoculation had been made

use of, the town was thriving and full of people; and the other part

of the town was absolutely empty. One side had plague, and the other

had none."

3. _Kirki_

The figures here were obtained under especially favourable

circumstances; and the Commissioners have, practically, no fault to

find with their accuracy. The following account is by Surgeon-Major

Bannerman, Superintendent of the Plague Research Laboratory, Bombay:--

"Plague broke out in Kirki, in the artillery cantonment,

situated four miles from Poona; and the followers of the four

batteries stationed there suffered severely. These men were

living with their families in lines on a sloping plain, under

military discipline, and in circumstances far superior in a

sanitary sense to those of the average villager. When the

disease appeared, the lines were isolated, so that none could

enter or leave without the knowledge of the military. A special

hospital was erected close by, where all sick persons were sent

as they were discovered by the search parties of European

artillerymen, who visited each house thrice daily. It is

therefore probable that all cases of plague were promptly

discovered and removed to hospital: and in each case the usual

disinfection was thoroughly and systematically carried out. Yet,

in spite of all this, it was found that, in those not protected

by inoculation, 1 out of every 6 of the population was attacked,

and 2 out of every 3 attacked died. The epidemic was, therefore,

a severe one. The population of the lines numbered 1530; and,

out of these, 671 volunteered for inoculation. At the close of

the epidemic, the plague-hospital admission and discharge book

was examined, and compared with the register of those

inoculated, when the following result was got. The population

operated on being under military discipline, and confined to

their lines, makes the accuracy of the figures undoubted:--

Inoculated, 671, with 32 cases, of which 17 died = 2.5 per cent.

Uninoculated, 859, with 143 cases, of which 98 died = 11.4 per

cent.

"Here, then, is seen a body of people divided into two groups

by the fact that one had undergone inoculation and the other

not, _but differing in no other way_, reacting towards plague in

such a markedly different manner that the conclusion is forced

on one, that the inoculation must be the cause. Seeing the

absolute similarity of conditions, _the 671 inoculated should

have had proportionately 112 cases and 77 deaths, if they had

remained as susceptible to the disease as their uninoculated

brothers, sisters, parents, wives, husbands, children; but,

instead of that, they had only 32 cases and 17 deaths_. This

death-rate would doubtless have been still further reduced, but

for the fact that a very much weakened vaccine had to be used,

owing to the demand having got beyond the resources of the

laboratory at that time."

4. _Belgaum_

In Belgaum, a town of Southern India with a normal population of about

30,700, two outbreaks of plague occurred in quick succession. The

first outbreak lasted from November 1897 to May 1898; the second, from

July 1898 to January 1899. During the two epidemics, 2466 persons were

inoculated. Of these, it was reported that only 61 (or 62) had been

attacked, of whom 33 died = 1.34 per cent. But these figures, in the

judgment of the Commission, cannot be accepted as even approximately

correct. There are, however, two groups of these Belgaum cases, one of

which the Commission admits as substantially accurate, and the other

as absolutely accurate. These groups are, (1) the Army cases; (2) the

cases reported by Major Forman, R.A.M.C., Senior Medical Officer of

the Station.

(1) _The Army Cases._-These cases occurred in the 26th Madras

Infantry, which was living in lines close to the cantonment and the

city. The first case of plague in the regiment was on 12th November

1897. Ten days later, the regiment was moved out into camp.

Inoculation was begun, by Surgeon-Major Bannerman, on 23rd December,

up to which time there had been, among the regiment and its families

and followers, 78 cases, with 49 deaths. The following account of the

inoculations is given by Surgeon-Major Bannerman:--

"No difficulty was experienced in persuading the men to consent

to inoculation, when it was explained to them that they would be

free to return to their houses in the lines after being operated

on. General Rolland was the first to be operated on, and his

example, combined with that of the officer commanding, and their

medical officer, who were all operated on in front of the men,

sufficed to convince the Sepoys of the harmlessness of the

operation: and the only difficulty that then remained was to

perform the operation fast enough.... The community was,

practically, completely inoculated by the end of the year. The

total operated on was 1665, out of a population of 1746 living

in the lines at that date. The 81 not operated on were infants,

women far advanced in pregnancy, and the sick in hospital

chiefly, though one solitary Sepoy has, up to the present time,

refused to submit to operation."

From this time onward to the end of the first epidemic, though the

disease was at its height in January in the neighbouring city and

cantonment, and though the men were allowed to go freely to these

places after inoculation, _only 2 out of the 1665 were attacked, and

both recovered_.

When the second epidemic came, in July 1898, the troops, families, and

followers, were reinoculated at their own request, 1801 in all.

"Practically no one was left in the lines unprotected by inoculation."

From this time onward to the end of the second epidemic, though it

was much more severe than the first, only 12 cases occurred. _In the

first epidemic, before inoculation, 78 cases occurred, and 2 after it:

in the second, and much more severe, epidemic, though the sanitary

measures adopted in both epidemics were similar, only 12 cases

occurred._ "It would hardly appear to be open to doubt," says the

Commission, "that the practical immunity of the regiment, during the

second outbreak, was due to inoculation."

(2) Major Forman's evidence before the Commission is very striking,

though the figures are small. The following abstract of it is given in

the Report of the Commission:--

"The groups of persons, concerning whom Major Forman gave us

evidence, were his private servants, and the hospital attendants

of the Belgaum Station Hospital with their wives and children.

He inoculated these groups when plague first broke out in the

town, and was able to keep in touch with them continuously after

that time. Regarding the first group, he says, bringing down

their history to 3rd March 1899, 'Of my private servants there

were in all, including their wives and children, 28 people

inoculated. There have been no cases of plague, and no deaths up

to date. There were 3 uninoculated. One was a child of 9 years

of age, whose father refused to allow it to be inoculated. It

died of plague 12 days after the other people were inoculated.

The other 2 cases that were not inoculated were not so

distinctly under my own observation. One was a sweeper employed

in the cantonment, and sleeping in my compound: he, I am told,

died of plague some months afterwards. The other was my

water-carrier: he threw himself into a well: I was informed that

he had buboes and fever, and ran away to escape segregation. Of

the 28 inoculated, none died of plague: and of 3 uninoculated,

2 are said to have died of plague, and 1 undoubtedly died of

plague.'"

"Regarding the second group of which he gave us particulars,

Major Forman said that, out of 90 hospital servants, 87 were

inoculated. Of the inoculated persons, 1 died from fever and

endocarditis, and 1 died of plague. Excepting these two, the

rest of the inoculated were alive and well in March 1899. Only 3

persons remained uninoculated. Of these, one was not operated

upon, because she had recently been delivered; another was not

operated upon, because she was pregnant; and the third was a boy

of 16 years of age, whose father refused to let him be

inoculated. The boy died of plague, two months after the

inoculation of the rest of the hospital servants had been done.

One of the two uninoculated women died of plague two days after

the boy, she having been in attendance upon him. The other

uninoculated woman remained well."

5. _The Umarkhadi Jail, Bombay_

Plague broke out in this jail on the last day of 1897, and 3 prisoners

died. Next day, 1st January 1898, all the prisoners were paraded, and

all were willing to be inoculated. But it was decided to divide them

into two equal groups, and inoculate one group. There were 402

altogether: 2, when their turn came, refused to be inoculated: thus

199 were inoculated, and 203 were left uninoculated. No distinction

was made between the two groups: "They had the same food and drink,

the same hours of work and rest, and the same accommodation." The

plague did not come wholly to an end till March. The figures, since

the inmates of a jail are a shifting population, are based on the

average daily number of each group: this was 147 for the inoculated,

and 127 for the uninoculated. The figures are:--

+-----------------------+--------+---------+

| Average Daily Number. | Cases. | Deaths. |

+-----------------------+--------+---------+

| Inoculated 147 | 3 | 0 |

| Uninoculated 127 | 9 | 5 |

+-----------------------+--------+---------+

The Commission draw attention to "the important fact that, during the

whole period of the outbreak, the number of attacks among the

inoculated was only one-third of the number among the uninoculated;

and that the disease among the inoculated was remarkably mild,

resembling mumps more than plague, though the cases among the

uninoculated were of average severity." According to Surgeon-Major

Bannerman, the hospital authorities were doubtful whether these three

cases among the inoculated were plague at all.

6. _Undhera_

The figures for Undhera are very valuable: "The conditions," says

Surgeon-Major Bannerman, "approached very nearly the strictness of a

laboratory experiment." Even the Commissioners are enthusiastic here.

Undhera is an agricultural village, 6 miles from Baroda. Plague broke

out in it, in January 1898. A careful census was taken, and showed a

population of 1029. By 12th February there had been 76 deaths. On that

day the village was visited by Mr. Haffkine, Surgeon-Major Bannerman,

and other experts, and 513 persons were inoculated:--_By reference to

the census papers, the whole of the inhabitants were called out, house

by house, and the half of each household inoculated. In this way, an

endeavour was made to inoculate half the men, half the women, and half

the children in each family, and to arrange that a fairly equal

proportion of the sickly-looking should be placed in each division._

The plague lasted 42 days after the inoculations, and affected 28

families. On 4th April a house-to-house investigation was made by Mr.

Haffkine, Surgeon-General Harvey, Surgeon-Major Bannerman, and Captain

Dyson. The figures are as follows:--

+---------------+-------------------+------+-------+-------------+

+---------------+-------------------+--------------+-------------+

|1029 - 76 = 953| Inoculated, 513 | 8 | 3 |0.6 per cent.|

| | Uninoculated, 440 | 28 | 27 |6.0 per cent.|

+---------------+-------------------+------+-------+-------------+

Thus, out of 28 families, where the protected and the unprotected

lived and ate and slept together, the protected, 71, had 3 deaths; and

the unprotected, 64, had 27. The percentage of attacks was four times

higher among the unprotected; the percentage of deaths was ten times

higher.

7. _Khoja Community, Bombay_

The head of this community, H.H. Sir Sultan Shah, Aga Khan, K.C.I.E.,

opened a private station for the inoculation of the community in March

1897, and again in December of that year. He was himself inoculated

three times, and many of the community so often as five times. The

work of inoculation went on daily, and by 20th April 1898 the number

of persons inoculated or reinoculated was 5184. The whole community,

according to a careful census taken at the beginning of 1898, numbered

9350; but, since many families had fled to avoid the infection, this

number is too low. The Commissioners guess 9770: Haffkine, to the

disadvantage of his own statistics, guesses so high as 13,330. The

number of the inoculated or reinoculated shifted, of course, as the

work went on: their average daily number during the four months of

plague, January to April 1898, was 3814.

During these four months, the number of deaths _from all causes_ in

the whole community was 184. According to the average mortality of the

community in times of no plague, the deaths _from all causes_ during

four months would be 102. It may fairly be assumed that the extra

deaths, 82, were due to plague: and, indeed, 64 plague-deaths were

either acknowledged by the relatives, or certified by the burial-books

of the community. _Of these 82 deaths, 3 occurred among the inoculated

or reinoculated, and 77 among the uninoculated._

The Commissioners find fault with these figures: "Nevertheless, quite

apart from the statistics put before us, which we think inaccurate, we

do not doubt that inoculations had a good effect, especially as much

weight must be allowed to the opinion of a community so intelligent as

that of the Khojas."

8. _Hubli_

This, the greatest and most amazing of all instances of preventive

plague-work, was done in a town of 50,000 persons. The following

report, by Surgeon-Captain Leumann, was forwarded to the Plague

Commissioners by Mr. E. K. Cappel, Collector of Dhárwár, with this

comment:--

"The town of Hubli--a mercantile town of over 50,000

inhabitants--was attacked by plague in an epidemic form at the

commencement of the monsoon rains. The average rainfall between

April and October amounts to more than 28 inches. Under these

circumstances, although a large and weather-proof health camp

had been prepared for emergencies, complete evacuation of the

infected townsite was impossible; and the attempt to effect it

would have led to the severest hardships and to the immediate

spread of the disease into surrounding villages and districts.

It was for this reason that the determination was formed to make

a bold and comprehensive experiment with the prophylactic, and

not on any _à priori_ grounds. If this experiment had failed,

the results, judged by the actual mortality among the

uninoculated, would have been appalling. _All possible sanitary

measures in the shape of disinfection, unroofing of houses, and

segregation, were applied concurrently with inoculation, as

Government are already aware; but the rate of mortality among

those who held back from inoculation rose at one time to a

height which, I believe, has never been approached

elsewhere...._

"However, the experiment, in the hands of Dr. Leumann, did not

fail, and it has afforded a demonstration of success which is of

Imperial importance. Many thousands of lives have undoubtedly

been saved, and at the present moment the plague mortality is

merely sporadic, and Hubli is steadily regaining its normal

population and trade, though surrounded by infected villages."

The Hubli report must be put at full length, for the vivid picture it

gives of plague in India, and of the difficulties besetting the

magnificent work of the Indian Medical Service. It is a story that Mr.

Kipling ought to write. And it is to be noted that Surgeon-Captain

Leumann, who saved Hubli, recognised the extreme importance of other

methods than inoculation--disinfection, isolation of cases, evacuation

of infected districts. He says:--

"While paying the highest tribute to the value of Mr. Haffkine's

inoculation method, which I claim, here in Hubli, to have put to

perhaps the severest test to which it has yet been subjected, I

am of the opinion that individual protection is, on however

great a scale conducted, of less importance to that of general

protection and hygiene (considering each method separately, that

is to say), for it seems to me more radical, if not more

rational, to eradicate a disease than to leave it to pursue its

course and only protect people against its ravages."

Sanitation, therefore, was Dr. Leumann's faith. Now for his works:--

"I first started inoculation here on 11th May.... When I began

my inoculations, I operated first of all on some European or

native gentlemen in front of a crowd of poor and low-caste

people, whom I had gathered together in the worst-affected area,

and they were thus soon induced to ask for inoculation

themselves.... They have presented themselves, by the hundred,

at all times of the day, before myself and others, for the

purpose of being inoculated.[34] ... I have never experienced

the slightest difficulty in inoculating Mussulmanis or any

other purdáh women in Hubli.... The very men who, in March last,

created a disturbance in Hubli, were not only the first and the

most willing to undergo inoculation, but also to bring their

wives and families to my hospital, or to invite me to their

homes to inoculate them.

[34] Compare the account of the inoculations at Gaday, in the

_Lancet_, 11th February 1898: "To see the crowd waiting and

struggling to pass the barrier is a strange sight; old men and

women, young children, and mothers with babes in their arms, form

a daily crowd numbered by hundreds, who wait for hours to get

their chance of the day's inoculation."

"Inoculated persons holding certificates of double inoculation

have, at my special wish and order, been left in their homes

throughout this epidemic; only their clothes, house, and

property being disinfected on the occurrence of a plague case or

death in their house. As the vast majority of plague cases have

never been notified before death in Hubli (nor, in my experience

of nearly two years, elsewhere, if native supervision be largely

resorted to), it will readily be understood that the majority of

the inoculated have actually been living in the same house, or

even room, with a plague case (often of the pneumonic type,

whose terrible power of spreading the disease was first shown by

Professor Childe, I.M.S., of Bombay) during the whole of the

time that case was living, probably attending on the patient,

breathing the same stuffy air, and, perhaps, sharing the same

blanket; and I attach at the end of this report a long series of

cases where such conditions have occurred, _the non-inoculated

dying of plague, and the inoculated escaping, almost to a man_.

"Various critics on my work, not knowing what the actual facts

were and are, have at different times asserted that the

inoculated inhabitants of Hubli left the town in larger numbers

than the non-inoculated. Exactly the reverse was the case. The

British officers on plague duty here, and all the Divisional

Superintendents, invariably replied (officially and in writing

when so required) that the non-inoculated left Hubli in far

greater numbers and proportion than the inoculated; and my own

observations entirely bear out this statement.

"It has been urged that those who received inoculation were of a

class or classes better protected than others against plague by

reason of their habits, the food they eat, the houses they live

in, etc. In reply, I unhesitatingly state that if there be but

one town in India where that line of argument will not hold

good, it certainly is Hubli; for _not only were the poorer,

dirtier, lower-caste people the first to be persuaded to receive

inoculation, but I made it my personal and special duty to work

amongst them_. My first few thousand inoculations were almost

entirely amongst the lowest and poorest of the people. The

Brahmins are, perhaps, of all castes, supposed to be the most

cleanly in their houses, habits, etc., yet the Brahmins of Hubli

(who at first, imagining themselves immune, were the foremost

and greatest perverters of the truth concerning its efficacy,

and the last to apply for the protection inoculation affords),

simply inundated the various inoculation centres, as soon as

plague began to spread in their midst, clamouring for the very

method of which they had only lately tried to prevent others

from availing themselves.

"Unfortunately, the average native, educated or not, appears to

have the very greatest aversion to notifying any case of

sickness--plague or other--and hence, in my opinion, it becomes

more necessary than ever to protect the people by inoculation,

since they will not help to protect themselves by the foremost

and simplest of sanitary and hygienic measures.[35] With so few

police (and those none too good) to help one; an inadequate

British Staff; with so much reliance placed in Native

Superintendents and Supervisors, and a Municipality so bankrupt

that it could not apparently afford to buy enough blankets out

of its own funds for the patients in the Plague Hospitals--the

work of segregation, house-to-house inspection, etc., became,

from a medical point of view, absurdly insufficient.

"The total number of inoculations performed in Hubli, both on

actual inhabitants and on people from outside (villages) between

11th May and 27th September, amounts to some 78,000 altogether."

[35] Compare the account given by the Rev. H. Haigh (_Methodist

Recorder_, December 1898), of the plague at Bangalore: "The native

population do all they can to elude the vigilance of the

authorities. In order to escape segregation, the householders in

many instances refrain from reporting plague, and not infrequently

bury the corpse secretly. Not only is any spare piece of ground

used as a burial-place, but the body is at times thrown into a

well or tank, or dropped over the wall of some European compound.

During one week three plague corpses were found, badly decomposed,

in reservoirs commonly resorted to for drinking purposes."

+------------+---------+-----------+-----------+-------------------+

| Dates. |Census of| Non- |Inoculated.+-----------+-------+

+------------+---------+-----------+-----------+-----------+-------+

| from May 11|50,000 to| | | | |

| to June 14 | 47,427 | 44,573 | 2,854 | 47 | 1 |

| | | | | | |

| June 21 | 47,082 | 41,494 | 5,588 | 22 | 3 |

| June 28 | 47,485 | 39,042 | 8,443 | 29 | 1 |

| July 5 | 46,537 | 36,020 | 10,517 | 55 | 6 |

| July 12 | 46,518 | 33,255 | 13,263 | 34 | 6 |

| July 19 | 45,240 | 29,716 | 15,524 | 82 | 7 |

| July 26 | 43,809 | 24,112 | 19,697 | 100 | 15 |

| Aug. 2 | 43,707 | 21,031 | 22,676 | 140 | 16 |

| Aug. 9 | 42,768 | 15,584 | 27,184 | 272 | 19 |

| Aug. 16 | 40,441 | 10,685 | 29,756 | 386 | 61 |

| Aug. 23 | 39,400 | 6,367 | 33,033 | 371 | 41 |

| Aug. 30 | 38,210 | 4,094 | 34,116 | 328 | 28 |

| Sept. 6 | 38,382 | 2,731 | 35,469 | 227 | 34 |

| Sept. 13 | 38,408 | 1,116 | 37,292 | 138 | 47 |

| Sept. 20 | 39,142 | 937 | 38,205 | 106 | 55 |

| Sept. 27 | 39,315 | 603 | 38,712 | 58 | 20 |

+------------+---------+-----------+-----------+-----------+-------+

+---------------+-------------------------+----------------------+

| | Plague death-rate. | |

| | Comparison per 1000 | Percentage reduction |

| Dates. | between | of Plague death-rate |

| +------------+------------+ in favour of the |

+---------------+------------+------------+----------------------+

| to June 14 | 1.022 | .350 | Over 65 per cent. |

| | | | |

| June 21 | .530 | .527 | About 1 per cent. |

| June 28 | .742 | .118 | Nearly 85 per cent. |

| July 5 | 1.524 | .570 | About 63 per cent. |

| July 12 | 1.022 | .452 | Nearly 56 per cent. |

| July 19 | 2.793 | .450 | 84 per cent. |

| July 26 | 4.147 | .761 | 82 per cent. |

| Aug. 2 | 6.656 | .705 | 89 per cent. |

| Aug. 9 | 17.325 | .698 | Over 96 per cent. |

| Aug. 16 | 33.694 | 2.083 | 94 per cent. |

| Aug. 23 | 57.011 | 1.241 | 98 per cent. |

| Aug. 30 | 80.116 | .820 | 98 per cent. |

| Sept. 6 | 83.112 | .958 | 99 per cent. |

| Sept. 13 | 112.903 | 1.260 | Over 99 per cent. |

| Sept. 20 | 113.127 | 1.439 | Over 99 per cent. |

| Sept. 27 | 96.185 | .517 | Over 99 per cent. |

+---------------+------------+------------+----------------------+

"It appears that if the 47,427 inhabitants had remained, as they

did--in their town, without running away by rail or otherwise,

or without camping out in a mass--and if no inoculation had been

resorted to--they would have lost 24,899 souls, or a little over

half of their number. The official records show that this has

actually occurred, during the present terrible outbreak, in a

number of large villages, of 2000 inhabitants and over, in the

Hubli _taluka_ and elsewhere in the Dhárwár District, where no

inoculation was done, and no camping-out was possible on account

of the wet weather." (Haffkine's commentary on Dr. Leumann's

report.)

That is the story of Hubli; and, as it stands, it is almost

incredible. The Commissioners, by very strict inquiry, reduced it to

credibility without robbing it of glory. The inquiry brought out more

instances of the immeasurable difficulty of the work. Natives who

wished to avoid inoculation would escape through the back door at the

sight of a plague officer: bribery, personation, sale or transfer of

certificates of inoculation, concealment of cases and of deaths, were

all practised by those who wished not to be inoculated, or to get the

privileges of the inoculated without inoculation, or to save their

infected houses from being disinfected and unroofed. Again, with the

people dying like flies, and many of them bearing no mark of

identification, and with the medical officers overworked past human

endurance, the wonder is, not that the statistics were faulty, but

that there are any statistics at all. Certainly, the Commission is

well within the mark in saying, "It is quite clear that a very large

number of lives must have been saved in Hubli by inoculations during

the whole course of the epidemic there. _Moreover, we may note that an

arithmetical estimate is not the only criterion by which we can

appreciate the value of inoculations. And in Hubli their value is

approved by the consensus of opinions of officers who have seen

probably far more of this process and its results in practice than any

other persons in India, and who, having every facility for forming a

sound judgment as to its effect where plague was really virulent, are

satisfied as to its great value._"

Finally, as at Daman so at Hubli, there are lesser groups of

statistics, of that kind which is _approved by the consensus of

opinions of officers_. These are, (1) Lieutenant Keelan's

house-to-house investigation; (2) the Southern Mahratta Spinning

Mills; (3) the Southern Mahratta Railway employés.

1. Lieutenant Keelan made a house-to-house visitation of 200 houses,

in each of which there were protected and unprotected persons living

together, and in each of which there had been one or more cases of

plague. The figures for 69 of these houses are appended to Captain

Leumann's report. They are as follows:--

+----------------+----------+--------+---------+------------+

+----------------+----------+--------+---------+------------+

| Inoculated | 336 | 11 | 4 | 1.19 |

| Uninoculated | 144 | 84 | 80 | 55 |

+----------------+----------+--------+---------+------------+

These 69 houses were selected: there was nothing unfair in the method

of selection, still, they were "good houses"; they are not, therefore,

exact for statistics; but, as the Commissioners say, they are "of

interest as quite special examples of successful inoculation."

2. In the Southern Mahratta Spinning and Weaving Company's Mills, a

careful record of inoculation was kept and checked by the manager. The

number of the workpeople at the time when inoculation was begun, 21st

June, was 1173. At the end of the epidemic the figures were:--

+--------------------------+---------+---------------+

| | Deaths. | Mortality per |

| | | cent. |

+--------------------------+---------+---------------+

| Inoculated twice 1040 | 22 | 2.11 |

| Inoculated once 58 | 8 | 13.79 |

| Uninoculated 75 | 20 | 26.66 |

+--------------------------+---------+---------------+

Here, again, the figures have not a statistical value: "We are not

informed whether the inoculations were performed simultaneously; or at

what stage of the outbreak the average strength of the inoculated was

reached." All the same, what Major Bannerman says of them is

true--_The experience in this company's mill at_ _Hubli should be an

object lesson to all mill-owners in plague-stricken towns._

3. The figures for the Southern Mahratta Railway are given by Major

Bannerman in his "Statistics" (1900): they are not mentioned in the

Report of the Plague Commission. They are of great value, because the

daily shifting of the numbers was recorded as the work of inoculation

went on, and the date of each case of plague was also noted. Major

Bannerman gives the following account:--

"The railway employés were living in barracks, and in the

railway yard, apart from the general population of Hubli town.

_They were under close daily inspection by English officials_,

who formed a committee for this purpose, with Dr. Chenai as

their medical adviser. The results may therefore be regarded as

accurate in a high degree, the numbers dealt with not being

excessive, and the supervision strict."

The figures, based on the average numbers in each group, are as

follows:--

+------------------------+--------+---------+---------------+

+------------------------+--------+---------+---------------+

| Twice inoculated 990 | 6 | 1 | 0.1 |

| Once inoculated 270 | 5 | 1 | 0.3 |

| Uninoculated 760 | 35 | 21 | 2.7 |

+------------------------+--------+---------+---------------+

These eight instances must suffice: many must be left out--among them,

Dhárwár and Gadag, where Miss Corthorn, M.B., did work as splendid as

Leumann's work at Hubli; and Mr. Anderson's work in the Ahmednagar

villages; and many more. These plague-reports are to be read, not for

their record of heroic zeal and resourcefulness, but only as one more

example of many thousand lives saved by a method learned from

experiments on animals.

But, of course, there is not, and perhaps there never will be, a

national acceptance and adoption of this method through the length and

breadth of India. It does not work miracles; it is an uncomfortable

process to submit to; privileges must be offered with it, or the

native will often prefer to take his chance; the protection is of

uncertain duration; all sorts of lies are told about it, partly by

anti-vivisectionist writers, partly by native political agitators,

partly by the _hakims_. For instance, at a meeting of _hakims_ at

Masti, Lahore, on 11th April 1898, the following resolutions were

passed:--

"That in the opinion of this meeting the bubonic plague is not a

contagious disease. It originates from poisoned air, and this

poison is created in the air on account of atmospherical germs

and the excess of terrestrial humidities.

"That this meeting, having carefully considered the Resolution

of the Punjab Government (11th January 1898), is of opinion that

the rules embodied in that Resolution (isolation, disinfection,

etc.), are unnecessary under the principles of Unani medical

science."

And among statements to be made to the Plague Commissioners was the

following, from a native practitioner in Bombay (April 1899):--

"I do not think the plague was imported in Bombay from Hong Kong

or anywhere else. I attribute three sources of causes of

outbreaks of plague in Bombay:

(_a_) The predisposing cause was the Bombay Municipality; (_b_)

The exciting cause was the Nature herself; (_c_) The aggravating

cause was the Plague Committee."

All these difficulties were well stated by Surgeon-General Harvey,

Director-General of the Indian Medical Service, at the discussion on

Haffkine's discourse before the Royal Society, June 1899:--

"The people of England should consider the difficulties

attending the work of a bacteriologist in India.... He had no

doubt as to the value of the inoculations. At Undhera he

carefully examined the results of the experiment, and, as far as

he could judge, there was no possibility of error. The results

in that experiment were such as to be 90 per cent. in favour of

the inoculated against the uninoculated. The natives of India

were, however, a strange people, and it was difficult to

prophesy how they would act. In Calcutta, the mention of

inoculations had driven in hot haste from the city 300,000

people, many of whom afterwards returned and were inoculated;

while at Hubli he had seen the inhabitants come in their

thousands to be inoculated and pay for the inoculations. The

medical officer in charge at Hubli had performed about 80,000

inoculations, and had only observed some 12 abscesses. He

thought that 12 abscesses only, in 80,000 inoculations, showed

good results. But, after all, what were the numbers of

inoculations performed to the 300,000,000 inhabitants of India?

He felt that even if every one consented to be inoculated it was

impossible to provide the vaccine or the medical officers for

such a demand. It was accordingly to sanitary improvements that

he looked with the most confidence to protect India against the

plague."

Therefore, now and for many years to come, preventive inoculation must

fall into line with the other world-wide ways of fighting

plague--quarantine, notification, isolation, all sanitary measures,

destruction of rats--_le rat, le génie de la peste_--evacuation of

infected towns, disinfection or unroofing of infected houses. Happily,

this is just what it does. That admirable paper, the _Indian Medical

Gazette_ (September 1901), has put this fact very simply: "No one ever

imagined that inoculation was the _only_ means of fighting plague. Its

great value consists in its immediate application. To sanitate,

ventilate, and practically rebuild a town or village takes time; and

in the meantime thousands die." For sudden outbursts of plague--since

rats are one chief source of infection, and notification is

fundamentally abhorrent to native custom, and evacuation may ruin

trade, or spread infection, or be impossible by reason of the

rains--since "East is East, and West is West"--it is not always

possible to provide, for an Indian village smitten by plague, the

excellent arrangements of the Western world. In all such cases, and in

all cases of epidemic plague within narrow limits, as in jails,

barracks, mills, and the like centres of human life; and in all inner

communities, such as the Parsee community at Daman, or the Jewish

community at Aden--by every test of this kind, the saving power of

preventive inoculation has been proved, again and again, past all

doubt. As for those larger death-traps, Hubli, Dhárwár, and the rest

of them, here, though the statistics are inexact, we have the word of

the men and women themselves who stood between the dead and the

living, and the plague was stayed. Such faults as there were, in 1899,

in the treatment--the contamination of this or that stock of the

fluid, and the inadequate method of standardisation--have been duly

noted by the Commission. The rush for the fluid in 1899 may be

estimated from the following paragraphs:--

(i.) _Paris._ "The preparation of anti-plague serum is being

rapidly proceeded with; up to the present time the Institute has

supplied it, in response to all the very numerous requests which

have come from Portugal, Spain, Italy, and Turkey, without

encroaching on the reserve kept in readiness for Paris and the

departments." (_Lancet_, 16th September 1899.)

(ii.) _India._ "The spread of plague westward to Spain and

Portugal seems to have excited more or less general alarm, and I

hear that an unprecedented demand has suddenly arisen for the

plague prophylactic fluid. The Government of India have been

asked the cost of supplying from 50,000 to 100,000 doses, and

the earliest date at which this quantity could be despatched. It

is also desired to know if in case of need 50,000 doses a week

could be sent to London. Russia desires to obtain a considerable

stock for Port Arthur. Italy has been making inquiries for home

use; and also Portugal, in order to inoculate at Mozambique. The

present laboratory is at Government House, Parel, Bombay, and

has only recently been fitted up by the Government of India.

About 10,000 doses a day can be turned out, but it is thought

that still further enlargements will be required if the demand

should increase beyond this amount." (_Lancet_, 23rd September

1899.)

* * * * *

It would take too long for the present purpose to consider what has

been done, not only for the prevention of plague, but also for its

cure by a serum treatment. The results obtained by this treatment in

India have not been very good; but Yersin and others report better

results in other countries. Good results are reported from Amoy

(1896), Nhatrang (1898), Oporto (1899), and Buenos Ayres (1899-1900).

In Glasgow, the prophylactic use of Yersin's serum seems to have done

excellent service: the success of its curative use was not very

striking. The curative results at Nhatrang (Yersin, _Annales de

l'Institut Pasteur_, March 1899) are notable. Nhatrang is an Annamese

fishing-village; and the plague, when it was left to itself, killed

every case that it got:--

"La peste s'est montrée excessivement meurtrière chez les

Annamites. Sur 72 cas de peste, 39 personnes chez lesquelles la

maladie a évolué normalement, ou qui n'ont été traités que par

des médecins indigènes, sont mortes sans exception. Les 33

autres cas ont pu être traités par le sérum, quelquefois dans de

bonnes conditions, mais le plus souvent quelques heures

seulement avant la mort. Malgré cela, nous avons obtenu 19

guérisons et 14 décès, ce qui fait une mortalité de 42 per

cent., chez les traités. _Ainsi, d'une part, 100 pour 100 de

mortalité chez les non-traités; de l'autre, 42 per cent. chez

les malades qui ont reçu du sérum._ Ces chiffres confirment les

résultats que j'avais obtenu en Chine en 1896."

A long review of this curative treatment, fairly hopeful but nothing

more, is given in the Report of the Plague Commission, vol. v., pp.

269-320. The Commissioners are of opinion that it ought not yet to be

extended, as a general measure, over all the districts affected with

plague; and that there is need of more work in bacteriology before it

can be thus extended. "We desire to record our opinion that, though

the method of serum-therapy, as applied to plague, has not been

crowned with a therapeutic success in any way comparable to that

obtained by the application of the serum method to the treatment of

diphtheria, _none the less the method of serum-therapy is in plague,

as in other infectious diseases, the only method which holds forth a

prospect of ultimate success._"

It is a strange contrast, between this opinion and the statements made

by the opponents of all experiments on animals. Some of these

statements will be found in Part IV. of this book. Happily for the

world, no amount of foul language can hinder the good work; and, when

we talk of _Empire-building_, and of _deeds that win the Empire_, we

must reckon bacteriology among them: as Lord Curzon did, in his speech

at Calcutta, March 3, 1899--_What is this medical science we bring to

you? It is built on the bed-rock of pure irrefutable science; it is a

boon which is offered to all, rich and poor, Hindu and Mohammedan,

woman and man._

TYPHOID FEVER. MALTA FEVER

TYPHOID FEVER

The names of Klebs, Eberth, and Koch, are associated with the

discovery, in 1880-81, of the bacillus of enteric fever, _bacillus

typhosus_; and it was obtained in pure culture by Gaffky in 1884. It

has been studied from every point of view, in man and in animals; in

the blood, tissues, and excretions; in earth, air, water, milk, and

food; in its distribution, methods of growth, and chemical products.

Especially, the study of its chemical products has been directed

toward (1) immunisation against the disease, (2) bacteriological

diagnosis of the disease at an early stage.

The date of the first protective inoculations against typhoid is July

to August 1896: they were made at Netley Hospital, by Professor Wright

and Surgeon-Major Semple. The first inoculations in Germany, made by

Pfeiffer and Kolle, were published two months later. The story of

these famous Netley inoculations is told in the _British Medical

Journal_, 30th January 1897. Eighteen men offered themselves--

"A good deal of fever was developed in all cases, and sleep was

a good deal disturbed. These constitutional symptoms had to a

great extent passed away by the morning, and laboratory work

went on without interruption.... With two exceptions, all these

vaccinations were performed upon Medical Officers of the Army

or Indian Medical Services, or upon Surgeons on Probation who

were preparing to enter those services."

Good luck attend all eighteen of them, and immunity against typhoid,

wherever they are. The doses that they received were estimated in

proportion to the dose that would kill a guinea-pig of 350-400 grammes

weight; and the protective fluid contained no living bacilli:--

"The advantages which are associated with the use of such 'dead

vaccines' are, first, that there is absolutely no risk of

producing actual typhoid fever by our inoculations; secondly,

that the vaccines may be handled and distributed through the

post without incurring any risk of disseminating the germs of

the disease; thirdly, that dead vaccines are probably less

subject to undergo alterations in their strength than living

vaccines."

The first use of the vaccine during an outbreak of typhoid was in

October 1897, at the Kent County Lunatic Asylum. The treatment was

offered to any of the working staff who desired it:--

"All the medical staff, and a number of attendants, accepted the

offer. _Not one of those vaccinated--84 in number--contracted

typhoid fever: while of those unvaccinated and living under

similar conditions, 16 were attacked._ This is a significant

fact, though it should in fairness be stated that the water was

boiled after a certain date, and other precautions were taken,

so that the vaccination cannot be said to be altogether

responsible for the immunity. Still, the figures are striking."

(_Lancet_, 19th March 1898; see also Dr. Tew's paper, in _Public

Health_, April 1898.)

Certainly, they are striking; so is the story of the eight young

subalterns on the Khartoum expedition, of whom six were vaccinated,

and two took their chance. The six escaped typhoid, the two were

attacked by it, and one died. But these figures are too small to be of

much value.

The first anti-typhoid inoculations on a large scale were made among

British troops in India (Bangalore, Rawal Pindi, Lucknow), when the

Plague Commission, of which Professor Wright was a member, was in

India, November 1898 to March 1899. These inoculations were voluntary,

at private cost, and without official sanction; though the original

proposal for them, in 1897, had come from the Indian Government.

Pending official sanction, they were stopped. Then, on 25th May 1899,

the Indian Government made application to the Secretary of State for

India that they should be sanctioned, and should be made at the public

cost. The application is as follows:--

Again, an amazing number of deaths from tetanus, in the United States,