"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 anyà priorigrounds. 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 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 anyà priorigrounds. 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 theslightest 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 greaternumbers 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; fornot 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 thosenone 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."IDates.Census ofHubli.Non-Inoculated.Inoculated.Plague-deathsamong:Non-Inoculated.Inocu-lated.Five weeksfrom May 11Fell from50,000 toto June 1447,42744,5732,854471Week ending:June 2147,08241,4945,588223June 2847,48539,0428,443291July 546,53736,02010,517556July 1246,51833,25513,263346July 1945,24029,71615,524827July 2643,80924,11219,69710015Aug. 243,70721,03122,67614016Aug. 942,76815,58427,18427219Aug. 1640,44110,68529,75638661Aug. 2339,4006,36733,03337141Aug. 3038,2104,09434,11632828Sept. 638,3822,73135,46922734Sept. 1338,4081,11637,29213847Sept. 2039,14293738,20510655Sept. 2739,31560338,7125820IIDates.Plague death-rate.Comparison per 1000betweenPercentage reductionof Plague death-ratein favour of theInoculated.Non-Inoculated.Inoculated.Five weeksfrom May 11to June 141.022.350Over65 per cent.Week ending:June 21.530.527About1 per cent.June 28.742.118Nearly85 per cent.July 51.524.570About63 per cent.July 121.022.452Nearly56 per cent.July 192.793.45084 per cent.July 264.147.76182 per cent.Aug. 26.656.70589 per cent.Aug. 917.325.698Over96 per cent.Aug. 1633.6942.08394 per cent.Aug. 2357.0111.24198 per cent.Aug. 3080.116.82098 per cent.Sept. 683.112.95899 per cent.Sept. 13112.9031.260Over99 per cent.Sept. 20113.1271.439Over99 per cent.Sept. 2796.185.517Over99 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 Hublitalukaand 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.)
"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 theslightest 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 greaternumbers 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; fornot 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 thosenone 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
II
"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 Hublitalukaand 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 isapproved 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 areappended to Captain Leumann's report. They are as follows:—
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:—
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 atHubli 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:—
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-reportsare 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 thehakims. For instance, at a meeting ofhakimsat 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."
"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."
"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 otherworld-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, theIndian Medical Gazette(September 1901), has put this fact very simply: "No one ever imagined that inoculation was theonlymeans 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 forthe 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.)
(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). InGlasgow, 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 otherinfectious 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 ofEmpire-building, and ofdeeds 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.
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 theBritish 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 vaccinationswere 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, inPublic Health, April 1898.)
Certainly, they are striking; so is the story of the eight young subalterns on the Khartoum expedition, ofwhom 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:—
"The annual admissionsper millefor enteric fever amongst British troops in India have risen from 18.5 in 1890 to 32.4 in 1897, while the death-rate has increased from 4.01 to 9.01; and we are of opinion that every practicable means should be tried to guard against the ravages made by this disease. The anti-typhoid inoculations have been, we believe, on a sufficiently large scale to show the actual value of the treatment, while the results appear to afford satisfactory proof that the inoculations, when properly carried out, afford an immunity equal to or greater than that obtained by a person who has undergone an attack of the disease; further, the operation is one which does not cause any risk to health. In these circumstances, we are very strongly of opinion that a more extended trial should be made of the treatment; and we trust that your Lordship will permit us to approve the inoculation, at the public expense, of all British officers and soldiers who may voluntarily submit themselves to the operation."
On 1st August, the Secretary of State for India announced in Parliament that this treatment, at the public expense, had been sanctioned.
On 20th January 1900, Professor Wright published in theBritish Medical Journalan account of these 1898-99 inoculations in India. "They were undertaken under conditions which were very far from ideal. In particular, there is reason to suppose that the results obtained may have been unfavourably influenced by a weakening of the vaccine, brought about by repeated re-sterilisation." In no case was reinoculation done. The statistics were compiled from information furnished by officers of the Royal Army Medical Corps actually in charge of troops in the various stations; and were supplemented by reports received from the commanding officers of the various inoculated regiments. They are as follows:—
If the inoculated had been attacked equally with the uninoculated throughout the period of observation, they would have had 71 cases instead of 27.
These inoculations belong to the early part of 1899. During the rest of the year, inoculations were made in India, Egypt, and Malta: the results are given in an appendix to the Report of the Royal Army Medical Department, 1899. (SeeBritish Medical Journal, 21st September 1901.) The great majority of the troops tabulated were in India. Of the troops stationed atMalta, 61 were inoculated, 2456 not inoculated; among the former there were no cases, among the latter there were 17 cases and 5 deaths. In Egypt, of 4835 troops, 461 were inoculated; among these there were no cases, among the uninoculated there were 30 cases and 7 deaths. In India, of 30,353 troops, 4502 were inoculated, leaving 25,851 not inoculated; among the inoculated there were 44 cases and 9 deaths, among the non-inoculated 657 cases and 146 deaths. Taking the Indian statistics, and estimating percentage to strength, we find, amongst the inoculated, admissions 0.98, deaths 0.2; amongst the non-inoculated, admissions 2.5, deaths 0.56. The cases which occurred amongst the inoculated men were in the majority of instances of a mild character. Taking Malta, Egypt, and India together, it appears that the inoculated, if they had suffered equally with the non-inoculated, would have had 108 cases and 24 deaths, instead of 44 cases and 9 deaths.
At the end of 1899, this treatment, only just out of the hands of science, was suddenly demanded for the protection of a huge army at war in a country saturated with typhoid. Still, the South African results, and other results during 1899 to 1901, show a good balance of lives saved. The following paragraphs give all results published from the beginning of 1900 to May 1902. They are put in order of publication. Doubtless a few other reports have been overlooked in compilation; but the list includes all that were easily accessible.
1.Manchester, England.TheBritish Medical Journal, 28th April 1900, contains a note by Dr. Marsden, Medical Superintendent of the Monsall Fever Hospital, Manchester, on the inoculation of 14 out of 22 nursesengaged in nursing typhoid patients. Of the remaining 8, 4 had already had typhoid. The inoculations were made in October 1899. The following table shows the subsequent freedom from typhoid of the nursing staff:—
2.Ladysmith, South Africa.TheLancet, 14th July 1900, contains a short note by Professor Wright, on the distribution of typhoid among the officers and men of the military garrison, during the siege of Ladysmith. The figures are as follows:—
The wide difference between the two groups, as regards the incidence of the disease, is well marked; but the case-mortality is practically the same in each group. (The statistics of the General Hospital, Ladysmith, also tell in favour of the preventive treatment: see Surgeon-Major Westcott's letter,British Medical Journal, 20th July 1901, in answer to Dr. Melville's letter,British Medical Journal, 20th April 1901.)
3.The Portland Hospital: Modder River and Bloemfontein.TheBritish Medical Journal, 10th November 1900, contains an account by Dr. Tooth of the cases of typhoid in this hospital. Concerning the preventive treatment, he says: "The experience of my colleague Dr. Calverley and myself may be of interest, though we fear that the numbers are too few for safe generalisation.
"Personnel of the Portland Hospital.We take first the relation of disease and inoculation among thepersonnelof the hospital. Twenty-four non-commissioned officers, orderlies, and servants of the Portland Hospital, and 4 of the medical staff, were inoculated on the voyage out. All these showed the local symptoms at the time; that is, pain, stiffness, and local erythema; 17 also presented well-marked constitutional symptoms—general feeling of illness, fever, and headache. Of the orderlies, 9 had enteric fever subsequently. Two had refused inoculation, and both of these had the disease very severely; in fact one died. Of the inoculated cases, 5 had the disease lightly, and 2 fairly severely. One of the sisters had the disease rather severely, and she had not been inoculated.
"Officers and men admitted to the Portland Hospital.We had under treatment at the Portland Hospital 231 cases of enteric fever, most of which came under our care at Bloemfontein. We have not included in these figures a number of patients who came in convalescent for a short time only, and on their way to the base, and who would therefore appear in the admission and discharge book of the hospital. If we did so, of course our percentages would be lower. Of these 231 patients, 53 had been inoculated at home or on the voyage out, and of them 3 died, making a percentage of deaths among the inoculated of 5.6 per cent.; 178 had not been inoculated, of whom 25 died; that is, amortality among the non-inoculated of 14 per cent. The general mortality in enteric fever with us was 28 deaths out of 231 cases; that is, 12.1 per cent., which seems to compare favourably with the experience of the London hospitals.
"It is interesting to record our experience among the officers taken separately. Thirty-three officers were admitted with enteric fever; 21 had been inoculated; that is, 63.6 per cent.; a much larger percentage than among the men. Only one of these officers died, and he had not been inoculated.
"These figures are small, but such as they are they are significant, and they dispose us to look with favour upon inoculation. So also does our clinical experience with our patients, for among the inoculated the disease seemed to run a milder course."
4.No. 9 General Hospital, Bloemfontein.TheMedical Chroniclefor January 1901 contains an account, by Dr. J. W. Smith, of the work of this hospital. He says: "The general impression amongst the medical officers in our hospital was that a single inoculation probably did not confer an immunity lasting very long—the lapse of time differing in individuals—and also that there was a tendency in the cases of enteric in inoculated patients to abort at the end of ten or fourteen days. I should say, however, that a very considerable number of our detachment who had been inoculated suffered from enteric, of whom 4 at least died. Of the medical staff, the only member of the junior staff who had not been inoculated died of enteric."
5.Scottish National Red Cross Hospital, Kroonstadt.TheBritish Medical Journal, 12th January 1901, contains an account of the work of this hospital by Surgeon-Colonel Cayley, Officer in Charge. He says:"The first section of the hospital, consisting of 61 persons—officers, nursing sisters, and establishment—left Southampton on 21st April 1900. During the voyage out, all except 4 were inoculated twice, at an interval of about ten days; 2 were inoculated once; and 2 (who had had typhoid) were not inoculated. Immediately we reached the Cape, the hospital was sent up to Kroonstadt in the Orange River Colony, and remained there as a stationary hospital till the middle of October. During this period there were always many cases of enteric under treatment in hospital. Further, some of the medical officers and student orderlies had charge of the Kroonstadt Hotel temporary hospital, which was crowded up with enteric cases; and the nursing sisters, for three weeks, did duty in the military hospitals at Bloemfontein in May and June, when enteric fever was at its worst. There was not a single case of enteric among thepersonnelof this first section of the hospital.
"The second section of the hospital—medical officers, nurses, and establishment, 82 in all—left Southampton in May 1900. On board ship nearly all of them were inoculated, but many of them only once. The material for inoculation had been on board for some time, and was not so fresh as in the first instance. Of this second section, 1 nurse had enteric at Kroonstadt. She was the only one, out of a total of 36 nurses, who suffered from enteric; and she was the only nurse who was not inoculated, excepting the 2 who were protected by a previous attack of enteric. A third section of the hospital, consisting of 4 medical officers and 16 nurses, went out in July; they were all inoculated, and none of them had enteric.
"Of the second section, 5 orderlies had enteric feverat Kroonstadt, of whom 2 died. Of these 5, there were 2 inoculated (once) and 3 non-inoculated. Of the 2 who died, 1 had been once inoculated, the other had not been inoculated."
6.Meerut, India.TheBritish Medical Journal, 9th February 1901, gives a short note by Professor Wright on inoculations in the 15th Hussars. He says: "Through the kindness of Lieutenant-General Sir George Luck, commanding the Bengal Army, I am permitted to publish the following officially compiled statistics, dealing with the effects of anti-typhoid inoculations in the case of the 15th Hussars:—
From 22nd October 1899 to 22nd October 1900.
It would thus appear that the incidence of enteric in the inoculated was represented by 0.55 per cent., and the mortality by 0.27 per cent.; while the incidence in the uninoculated was 6.14 per cent., and the death-rate 3.35 per cent."
If the inoculated had suffered equally with the uninoculated, they would have had 22 cases with 11 deaths, instead of 2 cases with 1 death.
7.The Edinburgh Hospital, South Africa.TheScottish Medical and Surgical Journal, March 1901, contains an account of the work of the Edinburgh Hospital, by Dr. Francis Boyd. Of the staff, 58 were inoculated (27 once, and 31 twice). Among these 58, there were9 cases of typhoid fever, with I death, in a patient who had old mitral disease. "Our experience has been that, while inoculation appears to modify the disease, completely modified attacks are met with in the uninoculated. Again, very severe attacks, with complications and relapse, occur in those who have been inoculated. One cannot from this conclude that inoculation has been valueless, for had not the patient been inoculated, the attack might have been still more severe."
8.Egypt and Cyprus.TheBritish Medical Journal, 4th May 1901, gives a short note by Professor Wright on inoculations during 1901 in Egypt and Cyprus. He says: "I am indebted to the kindness of Colonel W. J. Fawcett, R.A.M.C., Principal Medical Officer in Egypt, for the following statistics dealing with the incidence of enteric fever, and the mortality from the disease, for the year 1900, in the inoculated and uninoculated among the British troops in Egypt and Cyprus:—
These figures testify to a nineteen-fold reduction in the number of attacks of enteric fever, and to a threefold reduction in the number of deaths from that disease, among the inoculated.... The only case which occurred among the inoculated was that of a patient admitted to hospital on the thirty-third day after inoculation. It would seem that the disease was in this case contracted before anything in the nature of protection had been established by the inoculation."
9.Imperial Yeomanry Hospital, Pretoria.Dr. Rolleston, Consulting Physician to this hospital, writes in theBritish Medical Journal, 5th October 1901: "Among thepersonnelof the hospital (17 medical officers, 50 nursing sisters, 83 orderlies, etc.), total, 150, there were 22 cases of enteric fever, or an incidence of 14.6 per cent. Of the 150, 35 were inoculated, and of these, 6, or 17 per cent., suffered from enteric; while, of 115 non-inoculated members of thepersonnel, 16, or 13.9 per cent., suffered from enteric fever; the percentage is therefore higher among the inoculated. There were 2 deaths, both in non-inoculated patients. In 100 cases of enteric fever among non-commissioned officers and men, taken mainly from convalescent patients, only 8 had been previously inoculated; there were 3 fatal cases, all among non-inoculated patients. Among 42 officers who had enteric, no fewer than 19 had been previously inoculated; 6 of these 19 cases were severe in character, but none were fatal; of the 23 non-inoculated cases, 7 were severe, and of these 7, 3 ended fatally. The interval between inoculation and the subsequent incidence of enteric fever varied between one and twenty-one months, but in only four instances was the interval less than six months. The average interval between inoculation and the onset of enteric fever in these 19 cases was thirty-eight weeks.
"As far as these scanty figures go, they point to the conclusion (1) that anti-typhoid inoculation does not absolutely protect against a future attack of typhoid fever; (2) that when enteric occurs in an inoculated person, there is, as a rule, an interval of about six months; (3) that inoculation protects against a fatal termination to the disease."
10.Richmond Asylum, Dublin.TheBritish MedicalJournal, 26th October 1901, contains a note by Professor Wright on an outbreak of typhoid in this asylum during August to December 1900. Inoculations were begun on 6th September, by Dr. Cullinan, and by 30th November 511 persons were inoculated. After careful criticism of all doubtful cases, Professor Wright gives the following figures:—
Comparative Incidence of Typhoid Fever in Inoculated and Non-Inoculated, calculated upon the average strength of the representative groups during the period intervening between the commencement of the inoculations and the termination of the epidemic.
"It may be noted," he says, "that the result is in conformity with that of all the statistical returns of anti-typhoid inoculation which have reached me."
11.Deelfontein.TheLancet, 18th January 1902, contains a paper by Dr. Washbourn and Dr. Andrew Elliot, on 262 cases of typhoid fever in the Imperial Yeomanry Hospital at Deelfontein during the year March 1900 to March 1901. (See Dr. Washbourn's earlier letter,Brit. Med. Jour., 16th June 1900.) They say: "In 211 of our cases, it was definitely recorded whether the patient had been inoculated or not: 186 of these cases had not been inoculated, with 20 deaths, or a mortality of 10.7 per cent.; 25 had been inoculated, with 4 deaths, or a mortality of 16 per cent. The mortality was thus higher among the inoculated than among the non-inoculated." Of thepersonnelof the hospital, there were 59 inoculated, with 4 cases, and 25 not inoculated, with 4 cases.
12.Winburg.TheLancet, 5th April 1902, contains a short note by Professor Wright, on the 5th Battalion, Manchester Regiment. He says: "In view of the dearth of statistics bearing on the incidence of typhoid fever in South Africa in inoculated and uninoculated persons respectively, the following, for which I am indebted to Lieutenant J. W. West, R.A.M.C., Winburg, Orange River Colony, may not be entirely without interest. The statistics here in question give the results obtained in the case of the 5th Battalion, Manchester Regiment, for the six months which have elapsed since their landing in South Africa. The figures, which relate to a total strength of 747 men and officers under observation, are as follows:—
"The three attacks in the inoculated are reported to have been of exceptionally mild type, contrasting in a striking manner with the severe attacks which occurred in the uninoculated. At the time of sending in the report, some of the uninoculated patients were 'not yet out of danger.'"
Certainly, these instances show a good balance of lives saved, not only under the adverse conditions of the war, but also in Egypt, India, and the United Kingdom. But the bacteriological work on typhoid fever has been directed also to the working out of avery different problem: and that is the method of diagnosis which is called "Widal's reaction." The practical uses of this reaction are of the utmost importance. It is the outcome of work in different parts of the world—by Wright and Semple and Durham in England, Chantemesse and Widal in France, Pfeiffer and Kolle and Grüber in Germany, and many more. The first systematic study of it was made by Durham and Pfeiffer; and Widal's name is especially associated with the application of their work to the uses of practice. Admirable accounts of the whole subject are given by Dr. Cabot in his book,The Serum-Diagnosis of Disease(Longmans, 1899), and by Mr. Foulerton in theMiddlesex Hospital Journal, October 1899 and July 1901.
Widal's reaction is surely one of the fairy tales of science. The bacteriologist works not with anything so gross as a drop of blood, but with a drop of blood fifty or more times diluted; one drop of this dilution is enough for his purpose. Take, for instance, an obscure case suspected to be typhoid fever: a drop of blood taken from the finger is diluted fifty or more times, that the perfect delicacy of the test may be ensured; a drop of this dilution is mixed with a drop of nutrient fluid containing living typhoid bacilli, and a drop of this mixture of blood and bacilli is watched under the microscope:—
"The motility of the bacilli is instantaneously or very quickly arrested, and in a few minutes the bacilli begin to aggregate together into clumps, and by the end of the half-hour there will be very few isolated bacilli visible. In less marked cases, the motility of the bacilli does not cease for some minutes; while in the least marked ones the motility of the bacilli may never becompletely arrested, but they are always more or less sluggish, while clumping ought to be quite distinct by the end of the half-hour."
The result of this clumping is also plainly visible to the naked eye, by the subsidence of the agglutinated bacteria to the bottom of the containing vessel: and thus an easy practical mode of diagnosis is afforded by it.
As with typhoid, so with Malta fever, cholera, and some other infective diseases. And the unimaginable fineness of this reaction goes far beyond the time of the disease. Months, even years, after recovery from typhoid, a fiftieth part of a drop of the blood will still give Widal's reaction: and it has been obtained in an infant whose mother had typhoid before it was born. A drop of dried blood, from a case suspected to be typhoid, may be sent a hundred miles by post to be tested; and typhoid, like diphtheria, may now be submitted to the judgment of an expert far away, and the answer telegraphed back. It would be difficult to exaggerate the practical importance of this reaction for the early diagnosis of cases of typhoid fever, especially those cases that appear, at the onset, not severe.
The specific organism of Malta fever (Mediterranean fever), thebacillus Melitensis, was discovered in 1887 by Surgeon-Major David Bruce, of the Army Medical Staff. Its nature and action were proved by the inoculation of monkeys. The use of Widal's reaction is of great value in this disease:—
"The diagnosis of Malta fever from typhoid is, of course, a highly important practical matter. It is exceedingly difficult in the early stages." (Manson,loc. cit.)
As with typhoid, so with Malta fever, Netley led the way to the discovery of an immunising serum. In the course of the work, one of the discoverers was by accident infected with the disease:—
"He was indisposed when he went to Maidstone to undertake anti-typhoid vaccination, and after fighting against his illness for some days, he was obliged to return to Netley on 9th October. Examination of blood-serum (Widal's reaction) showed that he was suffering from Malta fever. It appears that he had scratched his hand with a hypodermic needle on 17th September, when immunising a horse for the preparation of serum-protective against Malta fever; and his blood, when examined, had a typical reaction on the micrococcus of Malta fever in 1000-fold dilution. The horse, which has been immunised for Malta fever for the last eight months, was immediately bled, and we are informed that the patient has now had two injections, each of 30 cub. cm. of the serum. He is doing well, and it is hoped that the attack has been cut short." (British Medical Journal, 16th October 1897.)
About fifty cases had up to September 1899 been treated at Netley "with marked benefit: whereas they found that all drug-treatment failed, the antitoxin treatment had been generally successful."[36]A good instance of the value of the serum-treatment of Malta fever is published in theLancet, 15th April 1899. For a lateraccount of this treatment and of its efficacy, see thePhiladelphia Medical Journal, 24th November 1900.
Another point is noted by Sir Patrick Manson, in his recent Lane Lectures (Constable, 1905). "For some time back," he says, "a commission of experts, working under the direction of the Royal Society, has been studying this disease in Malta. The commission has accumulated much detailed information; but the most important observation it has published is the fact that a large percentage of the goats in Malta are infected withMicrococcus melitensis, and that the milk of the infected goats contains the bacterium. May not this account for the great prevalence of Mediterranean fever there and in other places having perhaps a similar milk-supply?"
Within the last few years, it has been proved that the mosquito is an intermediate host, between man and man, of malaria, yellow fever, and filariasis (elephantiasis).[37]Just as the grosser parasites, the tapeworms, must alternate between man and certain animals, and cannot otherwise go through their own life-changes and reproduce their kind, so the micro-parasites that are the cause of malaria alternate between man and the mosquito, having the mosquito as an intermediate host. These organisms, once they get into the mosquito, pick out certain structures, and there carry out a definite cyclical phase of their lives, whereby their progeny make their way into the stylets of the mosquito, and so get back to man, who is their "definite host." Thus, malaria is not, strictly speaking, a disease of man; it is one phase in man of micro-organisms that have another phase in mosquitoes. So also with filariasis; the filariæ in man, their ova, and their embryo-worms, are one phase of filariasis; and the embryo-worms in certain structures of the mosquito are another phase. Theplasmodium malariæand thefilariaare instances of a law of animal life that holds good also of plant life:—