"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."
"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 happenwhen 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?
"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 inoculationshad 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."
"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 inoculationshad 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.
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 inKattal Beganbustee, ward 19, occupied by about 200 people. In thisbustee, 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 thebusteeout of the 200. Since then, 9 cases of cholera, of which 7 were fatal, and 1 case of choleraic diarrhœa have appeared in thebustee, 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 thebustee; while none of the inoculated have been affected." (Cholera in Calcutta in 1894.W. J. Simpson.)
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:—
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." Morethan 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.)
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 underabsolutely 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:—
Haffkine's comment on these figures must be noted here:—
"In the Gaya jail, the inoculations werefor the first timeappliedin a prevalent epidemic, andvery weak dosesof a relatively weak vaccine were used.... Far higher results have been obtained by an application of stronger doses. In thebusteessituated 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 theinoculation 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."
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."
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 thatamong the not-inoculated minority there were 34 cases, with 30 deaths; whereas the inoculated had 4 fatal cases." (Haffkine, 1895, Lecture in London.)
The figures in this instance are small: but Surgeon-Captain E. Harold Brown's report is very pleasantreading. 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 4a.m., 2 more cases were reported in camp. At 7.30a.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 wordtika(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 7.30p.m., and at midnight, all in those who had not been inoculated, and all terminatingfatally, 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 7.30A.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 4P.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."
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.
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 largenumbers.[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.
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.
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 theIndian 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 Indiarecalls 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.
TheMedical Annualfor 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.
Thebacillus pestiswas 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 theAnnales 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 abouilloncontaining 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.
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 investigationsmade 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.
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.
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."
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 intotwo 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."
"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 intotwo 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."
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 ofplague 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, thoughit 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."
"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."
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 onthe average daily number of each group: this was 147 for the inoculated, and 127 for the uninoculated. The figures are:—
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.
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:—
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.
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 inoculatedthree 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 deathsfrom all causesin the whole community was 184. According to the average mortality of the community in times of no plague, the deathsfrom all causesduring 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."
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:—