Chapter IX: Part II (4)

"In a short time, a number of the most authoritative physicians
in Bombay, European and native, official medical officers and
private practitioners, submitted themselves for inoculation. It
is a matter of gratification to me to be able to quote, among
these authorities, the Head of the Medical Service of the
Presidency, Surgeon-General Bainbridge, who not only got himself
inoculated, but inoculated also the members of his family.
Previous to that, Surgeon-General Harvey, the able
Director-General of the Indian Medical Service, submitted
himself to inoculation in 1893 against cholera; and, in 1898,
against plague. It was the example of these gentlemen, whose
competence in the matter of health could not be disputed, that
encouraged thousands of people, rich and poor, in Bombay and
elsewhere, to come forward for inoculation. Thus his Excellency
the Viceroy thought it right to tell you here, in Poona, that
previous to his starting for the plague-stricken districts he
and his staff had also undergone the prophylactic inoculation.
In due course, mothers brought their children to be protected by
the new 'vaccination.'"

[33] It is said that the Jains object to inoculations on the
grounds of religion; and one or two witnesses before the Plague
Commission gave evidence to the same effect. But, at Bombay, the
high-priest of a great religious community addressed a meeting of
5000 in favour of the new treatment; and the rush of suppliants
for inoculation at Hubli and Gaday proves that there is no real
religious difficulty. Doctors have been assaulted, as at Poona, so
at Oporto; in neither case can we say _Tantum relligio potuit
suadere malorum_.

Within a few months, 8142 persons in or near Bombay were inoculated. It was not possible, in Bombay, during the rush of plague-work, to follow up every one of these 8142 persons. But there is reason to believe, making some allowance for oversights, that only 18 = 0.2 per cent. of them, were attacked during the epidemic; that, of these 18, only 2 died: and that these 2 died within twenty-four hours of inoculation, _i.e._, had the plague in them already at the time of inoculation.

And, with regard to a small group of the inoculated, there are the following more definite facts. This group lived outside Bombay, across the harbour, in a village called Mora. The population of Mora, at the time of the epidemic, was estimated at less than 1000. Out of this number 429 were inoculated; which, if the population be reckoned at 1000 exactly, left 571 uninoculated. Among the 429 inoculated, there were 7 cases of plague, with no deaths: among the uninoculated there were 26 cases, with 24 deaths.

Just a week after Haffkine had informed the Indian Government that he had tested his fluid on himself, plague broke out in the Byculla House of Correction, Bombay, on 23rd January 1897. Between the 23rd and the afternoon of the 30th, there were 14 cases, with 7 deaths. On the afternoon of the 30th, 152 prisoners were inoculated, and 172 were left uninoculated. The outbreak ceased on 7th February. The figures, as corrected by the Plague Commission, are, among the inoculated, 1 case, which recovered; among the uninoculated, 7 cases, with 2 deaths.

For a full and severe examination of the reports, statistics, and other evidence concerning this and other outbreaks in which preventive inoculations were made, the Report (1901) of the Indian Plague Commission must be studied. The Commissioners, Professor T. R. Fraser, Mr. J. P. Hewett, Professor (now Sir) A. E. Wright, Mr. A. Cumine, Dr. Ruffer, and Mr. C. J. Hallifax, Secretary, travelled and took evidence in India from November 1898 to March 1899: during which time they held 70 sittings and examined 260 witnesses, some at great length. The evidence and the report are published in five large volumes. The report, 540 pages in all, deals exhaustively with the whole subject. It represents the very least--what might almost be called the very worst--that can be said of Haffkine's fluid: and, of course, it reads rather differently from the reports of the men who, with their lives in their hands, and worked almost past endurance, fought plague themselves. The following paragraphs give, so far as possible, the bare facts of various outbreaks of the disease in 1897-99, in which Haffkine's fluid was used.

1. _Daman_

Plague broke out in Daman, a town in Portuguese territory, north of Bombay, and in constant communication with Bombay by sea, in March 1897. By the end of the month, when a Government cordon was placed round the town, about 2000 out of 10,900 had fled. The outbreak reached its height in mid-April, and was practically over by the end of May. Inoculations were begun on 26th March. The total population on that day (2000 having gone out, and 670 having died of plague) is estimated at 8230. Of these, 2197 were inoculated, and 6033 were left uninoculated. Among the inoculated there were 36 deaths = 1.6 per cent.; among the uninoculated 1482 deaths = 24.6 per cent.

The Commissioners criticise these figures severely, and do not accept them as exact. But they admit the evidence as to the results of inoculation among the Parsee community of Daman. Of this community, 306 in number, 277 were inoculated, and only 29 were left uninoculated. Among the inoculated there was 1 death = 0.36 per cent.: among the uninoculated there were 4 deaths = 13.8 per cent.

They admit, also, the house-to-house investigations made by Major Lyons, I.M.S., President of the Bombay Government Plague Committee. At the end of May, he visited 89 houses, in 62 of which both inoculated and uninoculated were living together. He found that out of 382 inoculated, 36 had died = 9.4 per cent.; out of 123 uninoculated, 38 had died = 30.9 per cent.

2. _Lanauli_

Plague attacked Lanauli, a small hill-station and railway depot, during April to September 1897. The entire population was estimated at about 2000. Inoculations were begun on 24th July in two wards of the town, and a daily house-to-house inspection was instituted. The figures reported, on the basis of the average daily strength of the two groups, are as follows:--

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

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

The Commissioners criticise the method on which these figures are based, and do not accept them as accurate. But they agree that inoculation "exerted a distinct preventive effect"; and they admit Major Baker's evidence--"In the place where inoculation had been made use of, the town was thriving and full of people; and the other part of the town was absolutely empty. One side had plague, and the other had none."

3. _Kirki_

The figures here were obtained under especially favourable circumstances; and the Commissioners have, practically, no fault to find with their accuracy. The following account is by Surgeon-Major Bannerman, Superintendent of the Plague Research Laboratory, Bombay:--

"Plague broke out in Kirki, in the artillery cantonment,
situated four miles from Poona; and the followers of the four
batteries stationed there suffered severely. These men were
living with their families in lines on a sloping plain, under
military discipline, and in circumstances far superior in a
sanitary sense to those of the average villager. When the
disease appeared, the lines were isolated, so that none could
enter or leave without the knowledge of the military. A special
hospital was erected close by, where all sick persons were sent
as they were discovered by the search parties of European
artillerymen, who visited each house thrice daily. It is
therefore probable that all cases of plague were promptly
discovered and removed to hospital: and in each case the usual
disinfection was thoroughly and systematically carried out. Yet,
in spite of all this, it was found that, in those not protected
by inoculation, 1 out of every 6 of the population was attacked,
and 2 out of every 3 attacked died. The epidemic was, therefore,
a severe one. The population of the lines numbered 1530; and,
out of these, 671 volunteered for inoculation. At the close of
the epidemic, the plague-hospital admission and discharge book
was examined, and compared with the register of those
inoculated, when the following result was got. The population
operated on being under military discipline, and confined to
their lines, makes the accuracy of the figures undoubted:--

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

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

"Here, then, is seen a body of people divided into two groups
by the fact that one had undergone inoculation and the other
not, _but differing in no other way_, reacting towards plague in
such a markedly different manner that the conclusion is forced
on one, that the inoculation must be the cause. Seeing the
absolute similarity of conditions, _the 671 inoculated should
have had proportionately 112 cases and 77 deaths, if they had
remained as susceptible to the disease as their uninoculated
brothers, sisters, parents, wives, husbands, children; but,
instead of that, they had only 32 cases and 17 deaths_. This
death-rate would doubtless have been still further reduced, but
for the fact that a very much weakened vaccine had to be used,
owing to the demand having got beyond the resources of the
laboratory at that time."

4. _Belgaum_

In Belgaum, a town of Southern India with a normal population of about 30,700, two outbreaks of plague occurred in quick succession. The first outbreak lasted from November 1897 to May 1898; the second, from July 1898 to January 1899. During the two epidemics, 2466 persons were inoculated. Of these, it was reported that only 61 (or 62) had been attacked, of whom 33 died = 1.34 per cent. But these figures, in the judgment of the Commission, cannot be accepted as even approximately correct. There are, however, two groups of these Belgaum cases, one of which the Commission admits as substantially accurate, and the other as absolutely accurate. These groups are, (1) the Army cases; (2) the cases reported by Major Forman, R.A.M.C., Senior Medical Officer of the Station.

(1) _The Army Cases._-These cases occurred in the 26th Madras Infantry, which was living in lines close to the cantonment and the city. The first case of plague in the regiment was on 12th November 1897. Ten days later, the regiment was moved out into camp. Inoculation was begun, by Surgeon-Major Bannerman, on 23rd December, up to which time there had been, among the regiment and its families and followers, 78 cases, with 49 deaths. The following account of the inoculations is given by Surgeon-Major Bannerman:--

"No difficulty was experienced in persuading the men to consent
to inoculation, when it was explained to them that they would be
free to return to their houses in the lines after being operated
on. General Rolland was the first to be operated on, and his
example, combined with that of the officer commanding, and their
medical officer, who were all operated on in front of the men,
sufficed to convince the Sepoys of the harmlessness of the
operation: and the only difficulty that then remained was to
perform the operation fast enough.... The community was,
practically, completely inoculated by the end of the year. The
total operated on was 1665, out of a population of 1746 living
in the lines at that date. The 81 not operated on were infants,
women far advanced in pregnancy, and the sick in hospital
chiefly, though one solitary Sepoy has, up to the present time,
refused to submit to operation."

From this time onward to the end of the first epidemic, though the disease was at its height in January in the neighbouring city and cantonment, and though the men were allowed to go freely to these places after inoculation, _only 2 out of the 1665 were attacked, and both recovered_.

When the second epidemic came, in July 1898, the troops, families, and followers, were reinoculated at their own request, 1801 in all. "Practically no one was left in the lines unprotected by inoculation." From this time onward to the end of the second epidemic, though it was much more severe than the first, only 12 cases occurred. _In the first epidemic, before inoculation, 78 cases occurred, and 2 after it: in the second, and much more severe, epidemic, though the sanitary measures adopted in both epidemics were similar, only 12 cases occurred._ "It would hardly appear to be open to doubt," says the Commission, "that the practical immunity of the regiment, during the second outbreak, was due to inoculation."

(2) Major Forman's evidence before the Commission is very striking, though the figures are small. The following abstract of it is given in the Report of the Commission:--

"The groups of persons, concerning whom Major Forman gave us
evidence, were his private servants, and the hospital attendants
of the Belgaum Station Hospital with their wives and children.
He inoculated these groups when plague first broke out in the
town, and was able to keep in touch with them continuously after
that time. Regarding the first group, he says, bringing down
their history to 3rd March 1899, 'Of my private servants there
were in all, including their wives and children, 28 people
inoculated. There have been no cases of plague, and no deaths up
to date. There were 3 uninoculated. One was a child of 9 years
of age, whose father refused to allow it to be inoculated. It
died of plague 12 days after the other people were inoculated.
The other 2 cases that were not inoculated were not so
distinctly under my own observation. One was a sweeper employed
in the cantonment, and sleeping in my compound: he, I am told,
died of plague some months afterwards. The other was my
water-carrier: he threw himself into a well: I was informed that
he had buboes and fever, and ran away to escape segregation. Of
the 28 inoculated, none died of plague: and of 3 uninoculated,
2 are said to have died of plague, and 1 undoubtedly died of
plague.'"

"Regarding the second group of which he gave us particulars,
Major Forman said that, out of 90 hospital servants, 87 were
inoculated. Of the inoculated persons, 1 died from fever and
endocarditis, and 1 died of plague. Excepting these two, the
rest of the inoculated were alive and well in March 1899. Only 3
persons remained uninoculated. Of these, one was not operated
upon, because she had recently been delivered; another was not
operated upon, because she was pregnant; and the third was a boy
of 16 years of age, whose father refused to let him be
inoculated. The boy died of plague, two months after the
inoculation of the rest of the hospital servants had been done.
One of the two uninoculated women died of plague two days after
the boy, she having been in attendance upon him. The other
uninoculated woman remained well."

5. _The Umarkhadi Jail, Bombay_

Plague broke out in this jail on the last day of 1897, and 3 prisoners died. Next day, 1st January 1898, all the prisoners were paraded, and all were willing to be inoculated. But it was decided to divide them into two equal groups, and inoculate one group. There were 402 altogether: 2, when their turn came, refused to be inoculated: thus 199 were inoculated, and 203 were left uninoculated. No distinction was made between the two groups: "They had the same food and drink, the same hours of work and rest, and the same accommodation." The plague did not come wholly to an end till March. The figures, since the inmates of a jail are a shifting population, are based on the average daily number of each group: this was 147 for the inoculated, and 127 for the uninoculated. The figures are:--

+-----------------------+--------+---------+
| Average Daily Number. | Cases. | Deaths. |
+-----------------------+--------+---------+
| Inoculated 147 | 3 | 0 |
| Uninoculated 127 | 9 | 5 |
+-----------------------+--------+---------+

The Commission draw attention to "the important fact that, during the whole period of the outbreak, the number of attacks among the inoculated was only one-third of the number among the uninoculated; and that the disease among the inoculated was remarkably mild, resembling mumps more than plague, though the cases among the uninoculated were of average severity." According to Surgeon-Major Bannerman, the hospital authorities were doubtful whether these three cases among the inoculated were plague at all.

6. _Undhera_

The figures for Undhera are very valuable: "The conditions," says Surgeon-Major Bannerman, "approached very nearly the strictness of a laboratory experiment." Even the Commissioners are enthusiastic here.

Undhera is an agricultural village, 6 miles from Baroda. Plague broke out in it, in January 1898. A careful census was taken, and showed a population of 1029. By 12th February there had been 76 deaths. On that day the village was visited by Mr. Haffkine, Surgeon-Major Bannerman, and other experts, and 513 persons were inoculated:--_By reference to the census papers, the whole of the inhabitants were called out, house by house, and the half of each household inoculated. In this way, an endeavour was made to inoculate half the men, half the women, and half the children in each family, and to arrange that a fairly equal proportion of the sickly-looking should be placed in each division._ The plague lasted 42 days after the inoculations, and affected 28 families. On 4th April a house-to-house investigation was made by Mr. Haffkine, Surgeon-General Harvey, Surgeon-Major Bannerman, and Captain Dyson. The figures are as follows:--

+---------------+-------------------+------+-------+-------------+
|Population on | |Cases.|Deaths.| Mortality. |
|12th February. | | | | |
+---------------+-------------------+--------------+-------------+
|1029 - 76 = 953| Inoculated, 513 | 8 | 3 |0.6 per cent.|
| | Uninoculated, 440 | 28 | 27 |6.0 per cent.|
+---------------+-------------------+------+-------+-------------+

Thus, out of 28 families, where the protected and the unprotected lived and ate and slept together, the protected, 71, had 3 deaths; and the unprotected, 64, had 27. The percentage of attacks was four times higher among the unprotected; the percentage of deaths was ten times higher.

7. _Khoja Community, Bombay_

The head of this community, H.H. Sir Sultan Shah, Aga Khan, K.C.I.E., opened a private station for the inoculation of the community in March 1897, and again in December of that year. He was himself inoculated three times, and many of the community so often as five times. The work of inoculation went on daily, and by 20th April 1898 the number of persons inoculated or reinoculated was 5184. The whole community, according to a careful census taken at the beginning of 1898, numbered 9350; but, since many families had fled to avoid the infection, this number is too low. The Commissioners guess 9770: Haffkine, to the disadvantage of his own statistics, guesses so high as 13,330. The number of the inoculated or reinoculated shifted, of course, as the work went on: their average daily number during the four months of plague, January to April 1898, was 3814.

During these four months, the number of deaths _from all causes_ in the whole community was 184. According to the average mortality of the community in times of no plague, the deaths _from all causes_ during four months would be 102. It may fairly be assumed that the extra deaths, 82, were due to plague: and, indeed, 64 plague-deaths were either acknowledged by the relatives, or certified by the burial-books of the community. _Of these 82 deaths, 3 occurred among the inoculated or reinoculated, and 77 among the uninoculated._

The Commissioners find fault with these figures: "Nevertheless, quite apart from the statistics put before us, which we think inaccurate, we do not doubt that inoculations had a good effect, especially as much weight must be allowed to the opinion of a community so intelligent as that of the Khojas."

8. _Hubli_

This, the greatest and most amazing of all instances of preventive plague-work, was done in a town of 50,000 persons. The following report, by Surgeon-Captain Leumann, was forwarded to the Plague Commissioners by Mr. E. K. Cappel, Collector of Dhárwár, with this comment:--

"The town of Hubli--a mercantile town of over 50,000
inhabitants--was attacked by plague in an epidemic form at the
commencement of the monsoon rains. The average rainfall between
April and October amounts to more than 28 inches. Under these
circumstances, although a large and weather-proof health camp
had been prepared for emergencies, complete evacuation of the
infected townsite was impossible; and the attempt to effect it
would have led to the severest hardships and to the immediate
spread of the disease into surrounding villages and districts.
It was for this reason that the determination was formed to make
a bold and comprehensive experiment with the prophylactic, and
not on any _à priori_ grounds. If this experiment had failed,
the results, judged by the actual mortality among the
uninoculated, would have been appalling. _All possible sanitary
measures in the shape of disinfection, unroofing of houses, and
segregation, were applied concurrently with inoculation, as
Government are already aware; but the rate of mortality among
those who held back from inoculation rose at one time to a
height which, I believe, has never been approached
elsewhere...._

"However, the experiment, in the hands of Dr. Leumann, did not
fail, and it has afforded a demonstration of success which is of
Imperial importance. Many thousands of lives have undoubtedly
been saved, and at the present moment the plague mortality is
merely sporadic, and Hubli is steadily regaining its normal
population and trade, though surrounded by infected villages."

The Hubli report must be put at full length, for the vivid picture it gives of plague in India, and of the difficulties besetting the magnificent work of the Indian Medical Service. It is a story that Mr. Kipling ought to write. And it is to be noted that Surgeon-Captain Leumann, who saved Hubli, recognised the extreme importance of other methods than inoculation--disinfection, isolation of cases, evacuation of infected districts. He says:--

"While paying the highest tribute to the value of Mr. Haffkine's
inoculation method, which I claim, here in Hubli, to have put to
perhaps the severest test to which it has yet been subjected, I
am of the opinion that individual protection is, on however
great a scale conducted, of less importance to that of general
protection and hygiene (considering each method separately, that
is to say), for it seems to me more radical, if not more
rational, to eradicate a disease than to leave it to pursue its
course and only protect people against its ravages."

Sanitation, therefore, was Dr. Leumann's faith. Now for his works:--

"I first started inoculation here on 11th May.... When I began
my inoculations, I operated first of all on some European or
native gentlemen in front of a crowd of poor and low-caste
people, whom I had gathered together in the worst-affected area,
and they were thus soon induced to ask for inoculation
themselves.... They have presented themselves, by the hundred,
at all times of the day, before myself and others, for the
purpose of being inoculated.[34] ... I have never experienced
the slightest difficulty in inoculating Mussulmanis or any
other purdáh women in Hubli.... The very men who, in March last,
created a disturbance in Hubli, were not only the first and the
most willing to undergo inoculation, but also to bring their
wives and families to my hospital, or to invite me to their
homes to inoculate them.

[34] Compare the account of the inoculations at Gaday, in the
_Lancet_, 11th February 1898: "To see the crowd waiting and
struggling to pass the barrier is a strange sight; old men and
women, young children, and mothers with babes in their arms, form
a daily crowd numbered by hundreds, who wait for hours to get
their chance of the day's inoculation."

"Inoculated persons holding certificates of double inoculation
have, at my special wish and order, been left in their homes
throughout this epidemic; only their clothes, house, and
property being disinfected on the occurrence of a plague case or
death in their house. As the vast majority of plague cases have
never been notified before death in Hubli (nor, in my experience
of nearly two years, elsewhere, if native supervision be largely
resorted to), it will readily be understood that the majority of
the inoculated have actually been living in the same house, or
even room, with a plague case (often of the pneumonic type,
whose terrible power of spreading the disease was first shown by
Professor Childe, I.M.S., of Bombay) during the whole of the
time that case was living, probably attending on the patient,
breathing the same stuffy air, and, perhaps, sharing the same
blanket; and I attach at the end of this report a long series of
cases where such conditions have occurred, _the non-inoculated
dying of plague, and the inoculated escaping, almost to a man_.

"Various critics on my work, not knowing what the actual facts
were and are, have at different times asserted that the
inoculated inhabitants of Hubli left the town in larger numbers
than the non-inoculated. Exactly the reverse was the case. The
British officers on plague duty here, and all the Divisional
Superintendents, invariably replied (officially and in writing
when so required) that the non-inoculated left Hubli in far
greater numbers and proportion than the inoculated; and my own
observations entirely bear out this statement.

"It has been urged that those who received inoculation were of a
class or classes better protected than others against plague by
reason of their habits, the food they eat, the houses they live
in, etc. In reply, I unhesitatingly state that if there be but
one town in India where that line of argument will not hold
good, it certainly is Hubli; for _not only were the poorer,
dirtier, lower-caste people the first to be persuaded to receive
inoculation, but I made it my personal and special duty to work
amongst them_. My first few thousand inoculations were almost
entirely amongst the lowest and poorest of the people. The
Brahmins are, perhaps, of all castes, supposed to be the most
cleanly in their houses, habits, etc., yet the Brahmins of Hubli
(who at first, imagining themselves immune, were the foremost
and greatest perverters of the truth concerning its efficacy,
and the last to apply for the protection inoculation affords),
simply inundated the various inoculation centres, as soon as
plague began to spread in their midst, clamouring for the very
method of which they had only lately tried to prevent others
from availing themselves.

"Unfortunately, the average native, educated or not, appears to
have the very greatest aversion to notifying any case of
sickness--plague or other--and hence, in my opinion, it becomes
more necessary than ever to protect the people by inoculation,
since they will not help to protect themselves by the foremost
and simplest of sanitary and hygienic measures.[35] With so few
police (and those none too good) to help one; an inadequate
British Staff; with so much reliance placed in Native
Superintendents and Supervisors, and a Municipality so bankrupt
that it could not apparently afford to buy enough blankets out
of its own funds for the patients in the Plague Hospitals--the
work of segregation, house-to-house inspection, etc., became,
from a medical point of view, absurdly insufficient.

"The total number of inoculations performed in Hubli, both on
actual inhabitants and on people from outside (villages) between
11th May and 27th September, amounts to some 78,000 altogether."

[35] Compare the account given by the Rev. H. Haigh (_Methodist
Recorder_, December 1898), of the plague at Bangalore: "The native
population do all they can to elude the vigilance of the
authorities. In order to escape segregation, the householders in
many instances refrain from reporting plague, and not infrequently
bury the corpse secretly. Not only is any spare piece of ground
used as a burial-place, but the body is at times thrown into a
well or tank, or dropped over the wall of some European compound.
During one week three plague corpses were found, badly decomposed,
in reservoirs commonly resorted to for drinking purposes."

I

+------------+---------+-----------+-----------+-------------------+
| | | | | Plague-deaths |
| | | | | among: |
| Dates. |Census of| Non- |Inoculated.+-----------+-------+
| | Hubli. |Inoculated.| | Non- |Inocul-|
| | | | |Inoculated.| ated. |
+------------+---------+-----------+-----------+-----------+-------+
|Five weeks |Fell from| | | | |
| from May 11|50,000 to| | | | |
| to June 14 | 47,427 | 44,573 | 2,854 | 47 | 1 |
| | | | | | |
|Week ending:| | | | | |
| June 21 | 47,082 | 41,494 | 5,588 | 22 | 3 |
| June 28 | 47,485 | 39,042 | 8,443 | 29 | 1 |
| July 5 | 46,537 | 36,020 | 10,517 | 55 | 6 |
| July 12 | 46,518 | 33,255 | 13,263 | 34 | 6 |
| July 19 | 45,240 | 29,716 | 15,524 | 82 | 7 |
| July 26 | 43,809 | 24,112 | 19,697 | 100 | 15 |
| Aug. 2 | 43,707 | 21,031 | 22,676 | 140 | 16 |
| Aug. 9 | 42,768 | 15,584 | 27,184 | 272 | 19 |
| Aug. 16 | 40,441 | 10,685 | 29,756 | 386 | 61 |
| Aug. 23 | 39,400 | 6,367 | 33,033 | 371 | 41 |
| Aug. 30 | 38,210 | 4,094 | 34,116 | 328 | 28 |
| Sept. 6 | 38,382 | 2,731 | 35,469 | 227 | 34 |
| Sept. 13 | 38,408 | 1,116 | 37,292 | 138 | 47 |
| Sept. 20 | 39,142 | 937 | 38,205 | 106 | 55 |
| Sept. 27 | 39,315 | 603 | 38,712 | 58 | 20 |
+------------+---------+-----------+-----------+-----------+-------+

II

+---------------+-------------------------+----------------------+
| | Plague death-rate. | |
| | Comparison per 1000 | Percentage reduction |
| Dates. | between | of Plague death-rate |
| +------------+------------+ in favour of the |
| | Non- | Inoculated.| Inoculated. |
| | Inoculated.| | |
+---------------+------------+------------+----------------------+
| Five weeks | | | |
| from May 11 | | | |
| to June 14 | 1.022 | .350 | Over 65 per cent. |
| | | | |
| Week ending: | | | |
| June 21 | .530 | .527 | About 1 per cent. |
| June 28 | .742 | .118 | Nearly 85 per cent. |
| July 5 | 1.524 | .570 | About 63 per cent. |
| July 12 | 1.022 | .452 | Nearly 56 per cent. |
| July 19 | 2.793 | .450 | 84 per cent. |
| July 26 | 4.147 | .761 | 82 per cent. |
| Aug. 2 | 6.656 | .705 | 89 per cent. |
| Aug. 9 | 17.325 | .698 | Over 96 per cent. |
| Aug. 16 | 33.694 | 2.083 | 94 per cent. |
| Aug. 23 | 57.011 | 1.241 | 98 per cent. |
| Aug. 30 | 80.116 | .820 | 98 per cent. |
| Sept. 6 | 83.112 | .958 | 99 per cent. |
| Sept. 13 | 112.903 | 1.260 | Over 99 per cent. |
| Sept. 20 | 113.127 | 1.439 | Over 99 per cent. |
| Sept. 27 | 96.185 | .517 | Over 99 per cent. |
+---------------+------------+------------+----------------------+

"It appears that if the 47,427 inhabitants had remained, as they
did--in their town, without running away by rail or otherwise,
or without camping out in a mass--and if no inoculation had been
resorted to--they would have lost 24,899 souls, or a little over
half of their number. The official records show that this has
actually occurred, during the present terrible outbreak, in a
number of large villages, of 2000 inhabitants and over, in the
Hubli _taluka_ and elsewhere in the Dhárwár District, where no
inoculation was done, and no camping-out was possible on account
of the wet weather." (Haffkine's commentary on Dr. Leumann's
report.)

That is the story of Hubli; and, as it stands, it is almost incredible. The Commissioners, by very strict inquiry, reduced it to credibility without robbing it of glory. The inquiry brought out more instances of the immeasurable difficulty of the work. Natives who wished to avoid inoculation would escape through the back door at the sight of a plague officer: bribery, personation, sale or transfer of certificates of inoculation, concealment of cases and of deaths, were all practised by those who wished not to be inoculated, or to get the privileges of the inoculated without inoculation, or to save their infected houses from being disinfected and unroofed. Again, with the people dying like flies, and many of them bearing no mark of identification, and with the medical officers overworked past human endurance, the wonder is, not that the statistics were faulty, but that there are any statistics at all. Certainly, the Commission is well within the mark in saying, "It is quite clear that a very large number of lives must have been saved in Hubli by inoculations during the whole course of the epidemic there. _Moreover, we may note that an arithmetical estimate is not the only criterion by which we can appreciate the value of inoculations. And in Hubli their value is approved by the consensus of opinions of officers who have seen probably far more of this process and its results in practice than any other persons in India, and who, having every facility for forming a sound judgment as to its effect where plague was really virulent, are satisfied as to its great value._"

Finally, as at Daman so at Hubli, there are lesser groups of statistics, of that kind which is _approved by the consensus of opinions of officers_. These are, (1) Lieutenant Keelan's house-to-house investigation; (2) the Southern Mahratta Spinning Mills; (3) the Southern Mahratta Railway employés.

1. Lieutenant Keelan made a house-to-house visitation of 200 houses, in each of which there were protected and unprotected persons living together, and in each of which there had been one or more cases of plague. The figures for 69 of these houses are appended to Captain Leumann's report. They are as follows:--

+----------------+----------+--------+---------+------------+
| | Inmates. | Cases. | Deaths. | Mortality. |
+----------------+----------+--------+---------+------------+
| Inoculated | 336 | 11 | 4 | 1.19 |
| Uninoculated | 144 | 84 | 80 | 55 |
+----------------+----------+--------+---------+------------+

These 69 houses were selected: there was nothing unfair in the method of selection, still, they were "good houses"; they are not, therefore, exact for statistics; but, as the Commissioners say, they are "of interest as quite special examples of successful inoculation."

2. In the Southern Mahratta Spinning and Weaving Company's Mills, a careful record of inoculation was kept and checked by the manager. The number of the workpeople at the time when inoculation was begun, 21st June, was 1173. At the end of the epidemic the figures were:--

+--------------------------+---------+---------------+
| | Deaths. | Mortality per |
| | | cent. |
+--------------------------+---------+---------------+
| Inoculated twice 1040 | 22 | 2.11 |
| Inoculated once 58 | 8 | 13.79 |
| Uninoculated 75 | 20 | 26.66 |
+--------------------------+---------+---------------+

Here, again, the figures have not a statistical value: "We are not informed whether the inoculations were performed simultaneously; or at what stage of the outbreak the average strength of the inoculated was reached." All the same, what Major Bannerman says of them is true--_The experience in this company's mill at_ _Hubli should be an object lesson to all mill-owners in plague-stricken towns._

3. The figures for the Southern Mahratta Railway are given by Major Bannerman in his "Statistics" (1900): they are not mentioned in the Report of the Plague Commission. They are of great value, because the daily shifting of the numbers was recorded as the work of inoculation went on, and the date of each case of plague was also noted. Major Bannerman gives the following account:--

"The railway employés were living in barracks, and in the
railway yard, apart from the general population of Hubli town.
_They were under close daily inspection by English officials_,
who formed a committee for this purpose, with Dr. Chenai as
their medical adviser. The results may therefore be regarded as
accurate in a high degree, the numbers dealt with not being
excessive, and the supervision strict."

The figures, based on the average numbers in each group, are as follows:--

+------------------------+--------+---------+---------------+
| | Cases. | Deaths. | Mortality per |
| | | | cent. |
+------------------------+--------+---------+---------------+
| Twice inoculated 990 | 6 | 1 | 0.1 |
| Once inoculated 270 | 5 | 1 | 0.3 |
| Uninoculated 760 | 35 | 21 | 2.7 |
+------------------------+--------+---------+---------------+

These eight instances must suffice: many must be left out--among them, Dhárwár and Gadag, where Miss Corthorn, M.B., did work as splendid as Leumann's work at Hubli; and Mr. Anderson's work in the Ahmednagar villages; and many more. These plague-reports are to be read, not for their record of heroic zeal and resourcefulness, but only as one more example of many thousand lives saved by a method learned from experiments on animals.

But, of course, there is not, and perhaps there never will be, a national acceptance and adoption of this method through the length and breadth of India. It does not work miracles; it is an uncomfortable process to submit to; privileges must be offered with it, or the native will often prefer to take his chance; the protection is of uncertain duration; all sorts of lies are told about it, partly by anti-vivisectionist writers, partly by native political agitators, partly by the _hakims_. For instance, at a meeting of _hakims_ at Masti, Lahore, on 11th April 1898, the following resolutions were passed:--

"That in the opinion of this meeting the bubonic plague is not a
contagious disease. It originates from poisoned air, and this
poison is created in the air on account of atmospherical germs
and the excess of terrestrial humidities.

"That this meeting, having carefully considered the Resolution
of the Punjab Government (11th January 1898), is of opinion that
the rules embodied in that Resolution (isolation, disinfection,
etc.), are unnecessary under the principles of Unani medical
science."

And among statements to be made to the Plague Commissioners was the following, from a native practitioner in Bombay (April 1899):--

"I do not think the plague was imported in Bombay from Hong Kong
or anywhere else. I attribute three sources of causes of
outbreaks of plague in Bombay:

(_a_) The predisposing cause was the Bombay Municipality; (_b_)
The exciting cause was the Nature herself; (_c_) The aggravating
cause was the Plague Committee."

All these difficulties were well stated by Surgeon-General Harvey, Director-General of the Indian Medical Service, at the discussion on Haffkine's discourse before the Royal Society, June 1899:--

"The people of England should consider the difficulties
attending the work of a bacteriologist in India.... He had no
doubt as to the value of the inoculations. At Undhera he
carefully examined the results of the experiment, and, as far as
he could judge, there was no possibility of error. The results
in that experiment were such as to be 90 per cent. in favour of
the inoculated against the uninoculated. The natives of India
were, however, a strange people, and it was difficult to
prophesy how they would act. In Calcutta, the mention of
inoculations had driven in hot haste from the city 300,000
people, many of whom afterwards returned and were inoculated;
while at Hubli he had seen the inhabitants come in their
thousands to be inoculated and pay for the inoculations. The
medical officer in charge at Hubli had performed about 80,000
inoculations, and had only observed some 12 abscesses. He
thought that 12 abscesses only, in 80,000 inoculations, showed
good results. But, after all, what were the numbers of
inoculations performed to the 300,000,000 inhabitants of India?
He felt that even if every one consented to be inoculated it was
impossible to provide the vaccine or the medical officers for
such a demand. It was accordingly to sanitary improvements that
he looked with the most confidence to protect India against the
plague."

Therefore, now and for many years to come, preventive inoculation must fall into line with the other world-wide ways of fighting plague--quarantine, notification, isolation, all sanitary measures, destruction of rats--_le rat, le génie de la peste_--evacuation of infected towns, disinfection or unroofing of infected houses. Happily, this is just what it does. That admirable paper, the _Indian Medical Gazette_ (September 1901), has put this fact very simply: "No one ever imagined that inoculation was the _only_ means of fighting plague. Its great value consists in its immediate application. To sanitate, ventilate, and practically rebuild a town or village takes time; and in the meantime thousands die." For sudden outbursts of plague--since rats are one chief source of infection, and notification is fundamentally abhorrent to native custom, and evacuation may ruin trade, or spread infection, or be impossible by reason of the rains--since "East is East, and West is West"--it is not always possible to provide, for an Indian village smitten by plague, the excellent arrangements of the Western world. In all such cases, and in all cases of epidemic plague within narrow limits, as in jails, barracks, mills, and the like centres of human life; and in all inner communities, such as the Parsee community at Daman, or the Jewish community at Aden--by every test of this kind, the saving power of preventive inoculation has been proved, again and again, past all doubt. As for those larger death-traps, Hubli, Dhárwár, and the rest of them, here, though the statistics are inexact, we have the word of the men and women themselves who stood between the dead and the living, and the plague was stayed. Such faults as there were, in 1899, in the treatment--the contamination of this or that stock of the fluid, and the inadequate method of standardisation--have been duly noted by the Commission. The rush for the fluid in 1899 may be estimated from the following paragraphs:--

(i.) _Paris._ "The preparation of anti-plague serum is being
rapidly proceeded with; up to the present time the Institute has
supplied it, in response to all the very numerous requests which
have come from Portugal, Spain, Italy, and Turkey, without
encroaching on the reserve kept in readiness for Paris and the
departments." (_Lancet_, 16th September 1899.)

(ii.) _India._ "The spread of plague westward to Spain and
Portugal seems to have excited more or less general alarm, and I
hear that an unprecedented demand has suddenly arisen for the
plague prophylactic fluid. The Government of India have been
asked the cost of supplying from 50,000 to 100,000 doses, and
the earliest date at which this quantity could be despatched. It
is also desired to know if in case of need 50,000 doses a week
could be sent to London. Russia desires to obtain a considerable
stock for Port Arthur. Italy has been making inquiries for home
use; and also Portugal, in order to inoculate at Mozambique. The
present laboratory is at Government House, Parel, Bombay, and
has only recently been fitted up by the Government of India.
About 10,000 doses a day can be turned out, but it is thought
that still further enlargements will be required if the demand
should increase beyond this amount." (_Lancet_, 23rd September
1899.)

* * * * *

It would take too long for the present purpose to consider what has been done, not only for the prevention of plague, but also for its cure by a serum treatment. The results obtained by this treatment in India have not been very good; but Yersin and others report better results in other countries. Good results are reported from Amoy (1896), Nhatrang (1898), Oporto (1899), and Buenos Ayres (1899-1900). In Glasgow, the prophylactic use of Yersin's serum seems to have done excellent service: the success of its curative use was not very striking. The curative results at Nhatrang (Yersin, _Annales de l'Institut Pasteur_, March 1899) are notable. Nhatrang is an Annamese fishing-village; and the plague, when it was left to itself, killed every case that it got:--

"La peste s'est montrée excessivement meurtrière chez les
Annamites. Sur 72 cas de peste, 39 personnes chez lesquelles la
maladie a évolué normalement, ou qui n'ont été traités que par
des médecins indigènes, sont mortes sans exception. Les 33
autres cas ont pu être traités par le sérum, quelquefois dans de
bonnes conditions, mais le plus souvent quelques heures
seulement avant la mort. Malgré cela, nous avons obtenu 19
guérisons et 14 décès, ce qui fait une mortalité de 42 per
cent., chez les traités. _Ainsi, d'une part, 100 pour 100 de
mortalité chez les non-traités; de l'autre, 42 per cent. chez
les malades qui ont reçu du sérum._ Ces chiffres confirment les
résultats que j'avais obtenu en Chine en 1896."

A long review of this curative treatment, fairly hopeful but nothing more, is given in the Report of the Plague Commission, vol. v., pp. 269-320. The Commissioners are of opinion that it ought not yet to be extended, as a general measure, over all the districts affected with plague; and that there is need of more work in bacteriology before it can be thus extended. "We desire to record our opinion that, though the method of serum-therapy, as applied to plague, has not been crowned with a therapeutic success in any way comparable to that obtained by the application of the serum method to the treatment of diphtheria, _none the less the method of serum-therapy is in plague, as in other infectious diseases, the only method which holds forth a prospect of ultimate success._"

It is a strange contrast, between this opinion and the statements made by the opponents of all experiments on animals. Some of these statements will be found in Part IV. of this book. Happily for the world, no amount of foul language can hinder the good work; and, when we talk of _Empire-building_, and of _deeds that win the Empire_, we must reckon bacteriology among them: as Lord Curzon did, in his speech at Calcutta, March 3, 1899--_What is this medical science we bring to you? It is built on the bed-rock of pure irrefutable science; it is a boon which is offered to all, rich and poor, Hindu and Mohammedan, woman and man._

IX

TYPHOID FEVER. MALTA FEVER

TYPHOID FEVER

The names of Klebs, Eberth, and Koch, are associated with the discovery, in 1880-81, of the bacillus of enteric fever, _bacillus typhosus_; and it was obtained in pure culture by Gaffky in 1884. It has been studied from every point of view, in man and in animals; in the blood, tissues, and excretions; in earth, air, water, milk, and food; in its distribution, methods of growth, and chemical products. Especially, the study of its chemical products has been directed toward (1) immunisation against the disease, (2) bacteriological diagnosis of the disease at an early stage.

The date of the first protective inoculations against typhoid is July to August 1896: they were made at Netley Hospital, by Professor Wright and Surgeon-Major Semple. The first inoculations in Germany, made by Pfeiffer and Kolle, were published two months later. The story of these famous Netley inoculations is told in the _British Medical Journal_, 30th January 1897. Eighteen men offered themselves--

"A good deal of fever was developed in all cases, and sleep was
a good deal disturbed. These constitutional symptoms had to a
great extent passed away by the morning, and laboratory work
went on without interruption.... With two exceptions, all these
vaccinations were performed upon Medical Officers of the Army
or Indian Medical Services, or upon Surgeons on Probation who
were preparing to enter those services."

Good luck attend all eighteen of them, and immunity against typhoid, wherever they are. The doses that they received were estimated in proportion to the dose that would kill a guinea-pig of 350-400 grammes weight; and the protective fluid contained no living bacilli:--

"The advantages which are associated with the use of such 'dead
vaccines' are, first, that there is absolutely no risk of
producing actual typhoid fever by our inoculations; secondly,
that the vaccines may be handled and distributed through the
post without incurring any risk of disseminating the germs of
the disease; thirdly, that dead vaccines are probably less
subject to undergo alterations in their strength than living
vaccines."

The first use of the vaccine during an outbreak of typhoid was in October 1897, at the Kent County Lunatic Asylum. The treatment was offered to any of the working staff who desired it:--

"All the medical staff, and a number of attendants, accepted the
offer. _Not one of those vaccinated--84 in number--contracted
typhoid fever: while of those unvaccinated and living under
similar conditions, 16 were attacked._ This is a significant
fact, though it should in fairness be stated that the water was
boiled after a certain date, and other precautions were taken,
so that the vaccination cannot be said to be altogether
responsible for the immunity. Still, the figures are striking."
(_Lancet_, 19th March 1898; see also Dr. Tew's paper, in _Public
Health_, April 1898.)

Certainly, they are striking; so is the story of the eight young subalterns on the Khartoum expedition, of whom six were vaccinated, and two took their chance. The six escaped typhoid, the two were attacked by it, and one died. But these figures are too small to be of much value.

The first anti-typhoid inoculations on a large scale were made among British troops in India (Bangalore, Rawal Pindi, Lucknow), when the Plague Commission, of which Professor Wright was a member, was in India, November 1898 to March 1899. These inoculations were voluntary, at private cost, and without official sanction; though the original proposal for them, in 1897, had come from the Indian Government. Pending official sanction, they were stopped. Then, on 25th May 1899, the Indian Government made application to the Secretary of State for India that they should be sanctioned, and should be made at the public cost. The application is as follows:--

"The annual admissions _per mille_ for 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 the _British Medical Journal_ an 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:--

+------------------+------+-------+----------+----------+
|Numbers under |Cases.|Deaths.|Percentage|Percentage|
|Observation. | | |of Cases. |of Deaths.|
+------------------+------+-------+----------+----------+
|Inoculated 2835| 27 | 5 | 0.95 | 0.2 |
|Uninoculated 8460| 213 | 23 | 2.5 | 0.34 |
+------------------+------+-------+----------+----------+

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. (See _British Medical Journal_, 21st September 1901.) The great majority of the troops tabulated were in India. Of the troops stationed at Malta, 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.