PART II EXPERIMENTS IN PATHOLOGY, MATERIA MEDICA, AND THERAPEUTICS (continued 2)

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.

VI 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."

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 Treatment. Days of Drying 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 Treatment. Days of Drying 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 Treatment. Days of Drying 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 Treatment. Days of Drying 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.

I

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:—

Year. Patients treated. Deaths. Mortality per cent.

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

II

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]

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:—

Bites of the Head. Bites on the Hands. Bites of the Limbs. Total.

P D M p P D M p P D M p P D M p

a e o e a e o e a e o e a e o e

t a r r t a r r t a r r t a r r

i t t i t t i t t i t t

e h a c e h a c e h a c e h a c

n s l e n s l e n s l e n s l e

t i n t i n t i n t 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:—

Patients. Deaths. Mortality. Patients. Deaths. Mortality.

Bites of the Head 1,759 21 1.1 A 2,872 20 0.69

Bites of the Hands 11,118 53 0.47 B 12,547 61 0.48

Bites of the Limbs 7,289 22 0.30 C 4,747 15 0.31

20,166 96 0.46 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.

IV

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:—

Year. Patients treated. Deaths. Mortality per cent.

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.

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.)

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."

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 diarrhœa 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 diarrhœa 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 register, and 640 had not been inoculated.

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]

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, 202 Inoculated, 207

Cases. Deaths. Cases. Deaths.

During 5 days after 1st 7 5 5 4

inoculation

During 3 days after 2nd 5 3 3 1

inoculation

After 3 days after 2nd 8 2 0 0

inoculation

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.)

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.

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.'"

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:—

Population on 12th February. Cases. Deaths. Mortality.

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.

"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."

I

Dates. Census of Hubli. Non- Inoculated. Inoculated. Plague-deaths among:

Non- Inoculated. Inocu- lated.

Five weeks from May 11 Fell from 50,000 to

to June 14 47,427 44,573 2,854 47 1

Week ending:

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

II

Dates. Plague death-rate. Comparison per 1000 between Percentage reduction of Plague death-rate in favour of the Inoculated.

Non- Inoculated. Inoculated.

Five weeks from May 11

to June 14 1.022 .350 Over 65 per cent.

Week ending:

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:—

Inmates. Cases. Deaths. Mortality.

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:—

Cases. Deaths. Mortality per cent.

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.

IX 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:—