357
would be divided in ¿wo parts equal in all conditions influencing the recovery. As
the law of probability does not work out correctly on small figures and under
different circumstances of the surroundings, it was decided that at least about 500
patients should be treated alternately at the same hospital before a final conclusion
would be drawn. This method of alternate treatment was agreed upon with the
Municipal Commissioner in deference to the public opinion in Bombay which had
become familiar with it through the experiments with the plague prophylactic. It
was hoped that this merely statistical method of investigation would do away with
the objections raised against the clinical selection, and that the results would be
convincing to those for the benefit of whom the serum treatment had been initiated
by the Municipality of Bombay. The treatment was to be continued at the Arthur
Road Hospital which receives the lowest and poorest classes of the population,
representing the most unfavourable material for a serum treatment, so that it might
be relied upon that the results obtained there would be obtained again under all
other circumstances. It was to be directed as hitherto by Dr. N. H. Choksy, the
Chief Medical Officer in charge of the hospital, who knew how to use the serum to
its full advantage and could be trusted to do willingly the considerable amount of
extra work the serum treatment entailed.
The alternate treatment was carried out at the Arthur Road Hospital in
the
after admission, injected with the serum either by the Medical Officer or, m his
absence, by the Hospital Assistant on duty. Cases doubtful on admission were
kept under observation until the diagnosis was established. If found, to be suffering
from plague they were taken for the alternate treatment in the order in which the
disease was recognised. Such doubtful casas were few and far between, so that, for
statistical purposes, the day of admission may be considered as the day of the begin-
ning of the serum treatment, There were observation cases, 38 in all, with 6
recoveries, mostly patients without buboes or with pneumonia, in which the diagnosis
remained doubtful till death confirmed it, or until the recovery was so far advanced,
that it would have been superfluous to take them for the alternate treatment. These
were called extra cases and recorded separately. As the results obtained by the
serum treatment are only of value if the diagnosis of plague was substantially
correct, it will not bo out of place here to discuss to what extent errors might have
been committed and how such errors might have influenced the accuracy of the
results. We have regularly controlled the diagnosis in the patients of either side
clinically, and by bacteriological means also after death, and we have in no instance
tailed in verifying it. Almost all the patients had buboes, and of those who had none
all died except two. During the time of an epidemic the diagnosis of plague is
exceedingly easy in the great majority of the cases, at least in our hospitals, where
the patients come with few exceptions in an advanced stage of the disease. But
even if it were otherwise, and that frequent errors should have been made, they would
have been irrelevant under the alternate treatment, as they had to equalise themselves
like all other conditions. Errors of diagnosis could well have reduced the morta-
lity of all the patients, but could not have created a difference between the results of
the two sides. It was more difficult to avoid mistakes in the alternation, and special
precautions were taken in this direction. Two records were kept, one by the Medical
Officer with all the particulars of the patients, and one by the Hospital Assistant
present on admission. The patients were, moreover, divided in series according to
the bleedings of every horse, and this division, and the current number in the series
was made visible on the charts of temperature in the form of a fraction, to which
was added a red " L " on the charts of the serum patients, and " Control " on those
of the controls—"LJ/20 " would thus signify the fifth serum-patient of the 20th series,
and " Control 5/20". would be the corresponding control. The distribution of the
patients, according to the series and the results of the treatment, are seen from the
following table :—