NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
327
There could not have been a more conclusive proof of the efficacy of the treat-
ment than the marked difference of the results obtained. The experimenters thought
themselves therefore at this stage, entitled to the conclusion that by Prof. Lustig's
method a serum with high curative properties could be prepared.
Further experience substantiated this belief, although disappointments were not
wanting.
The experiments were continued till 31st of October 1898, during a recrudes-
cence of the epidemic, which is known for its high mortality.
The treatment was then discontinued till February 1899, while serum was being
prepared locally at the Municipal Laboratory at Parel.
In February 1899, when the severest epidemic Bombay ever saw, was rapidly
increasing, the treatment commenced again and has been continued without in-
terruption up to date.
As the bulk of patients were naturally treated when they wore numerous, the
results reported here have been chiefly obtained during the height of three epidemics
of exceptional virulence.
Considering this, and the exclusion of mild cases, and the most unfavourable
conditions of application in a large Indian plague hospital, it can be said, without
exaggeration, that the serum has been put to a test as severe as can be conceived.
And now to the statistics.
From the 12th of March till the 31st of October 189S, and from the 1st of
February till the 31st of May 1899, 403 patients have been treated with the
serum at the Arthur Road Hospital, of whom 154 recovered, the recovery rate being
38.21 per cent. During the same time 1,190 patients were treated without serum,
with 233 recoveries, the recovery rate being 19.57 per cent. Altogether 1,593
acute cases were admitted into the hospital, 387 of which recovered, the rate
being 24.29 per cent.
If the serum has really saved lives, the total recovery rate at the Arthur Road
Hospital must have been higher than in other hospitals in which a similar class of
patients was admitted. But none of the other public hospitals receives the ordinary
low caste patients who form the bulk of admissions at the Arthur Road Hospital;
still we shall take for comparison the Maratha and the Modikhana Hospitals and
will see what was the recovery rate from plague there during the same period.
At the Maratha Hospitals, 3,378 patients were admitted from the 1st of March
till the 31st of October 1898, and from the 1st of February to the 31st of May 1899
of whom 646 recovered ; the rate of recovery being 19.12 per cent.
At the Modikhana Hospital, 1,384 patients were admitted during the above
period, of whom 295 recovered ; the rate of recovery being 21*31 per cent.
In both hospitals together, 4,762 patients were admitted, of whom 941 re
covered ; the rate being 19.76 per cent.
The recovery rate at the Arthur Road Hospital was therefore 45.3 per cent.
higher than in the former two hospitals, although the patients admitted to them aro
in general, of a better and more resistant class, better fed and, as a rule, earning
wages.
330
The recovery rate at the Arthur Road Hospital was 22.19 per cent. in
February 1898, rising to 24.89 per cent. in March, whereas at the Maratha
Hospital the rate was 18.84: per cent. and 12.28 per cent. respectively. (In the City
of Bombay, 4,750 attacks and 4,493 deaths have been recorded in February 1898,
and 4,780 attacks and 4,969 deaths in March.)
À similar increase in the recovery rate following the introduction of the treat-
ment was experienced in February 1899. In January of this year, 178 patients were
admitted, of whom 29 recovered, the rate being 16.29 per cent. Although the
number of admissions was 324 in February, indicating the rising epidemic, the-
recovery rate was 20.68 per cent. or 4.39 per cent. higher than in the previous month.
The Maratha Hospital, on the contrary, had 430 admissions in January 1899 with
85 recoveries, the rate being 19.76 per cent. or more than 3 per cent. higher than at
the Arthur Road Hospital in January. It had 769 admissions with 127 recoveries in
February, the rate being 16.51 per cent. or more than 4 lower per cent. than at the
Arthur Road Hospital in the same month. In the City of Bombay 1,879 attacks
and 1,591 deaths were recorded in January 1899, against 3,476 attacks and 8,088
deaths in February, the rate being 15.32 per cent. and 12.60 per cent. respectively.
The corresponding figures of the Modikhana Hospital could not be given, as the
recovery rate for single months is worked out on a different basis, but there is no
doubt that also there the rate followed the general cours. of the epidemic, which was
at its worst in March 1898 and in February and March 1899.
I have nothing further to add to the above. Even the most sceptical will admit;
that the increase of the recovery rate at the Arthur Road Hospital in both years and
just in the month of the beginning of the serum treatment, cannot have been
accidental considering that the rate became lower everywhere else.
As might bo expected, the influence of the serum treatment tended to show itself
not only in the saving of life, but also in the prolongation of life in patients who
eventually died.
The patients with the hopeful red L on their temperature charts—the sign of
the serum treatment—lived distinctly longer than their less fortunate neighbours,
who died with appalling rapidity.
If we look into the statistics for the expression of the prolongation of life, we
find it in the reduction of the mortality within the first 48 hours after admission.
Comparing the mortality within the first 48 hours after admission in the different.
periods of the years 1898 and 1899, the reduction due to the serum treatment is
unmistakable The following tables give the details :—
No. 1.
Admissions ...
Deaths within 48 hours
Percentage
NON-SERUM TREATMENT
1808.
Jan. till 12th
March, Nov.
till Jan.
1471
720
48.94
1899
January.
178
115
G4.G0
SERUM TREATMENT.
1898.
12th March
till Nov.
Gü3
309
40.60
1899
Feb. till June.
473
50.86
331
No. 2.
Admissions
...
...
Deaths within 48 hours
Percentage
SERUM PERIOD.
12th March till
10th Nov. 1898 ;
1st Feb. till June,
1899.
1,593
782
49.08
INTERMEDIATE
PERIOD.
Nov. Dec. 1898.
Jan.1899.
273
156
57.14
Most remarkable is the reduction in the mortality within 48 hours which took
place from January to February 1899. It amounts to 14per cent. and is fully estab-
lished in February, the month of the beginning of the treatment with 324 admissions
and 165 deaths within 48 hours. What was to be expected from an epidemic which
in its initial stage had a mortality of 64 per cent. within 48 hours after admission, can
probably be gathered from the records of other hospitals.
The prolongation of life is still more evident from the following table :—
Deaths within 48 hours
Deaths later on
Recoveries
Total ...
NON-SERUM: CASES.
Total.
672
285
233
1,190
Percentage.
56.47
23.94
19.57
SERUM CASES.
Total.
110
139
154
403
Percentage.
27.29
34.49
38.21
It is to be seen that the non-serum cases have only double the number of deaths
later on, although their total number is three times larger than that of the serum cases.
It is further interesting to observe that in the non-serum cases the percentage is
highest for the deaths within 48 hours, lower for the deaths later on, and lowest for
the recoveries. In the serum cases just the opposite is the case. This corresponds
with clinical observations.
In a certain number of patients the serum seems to have no effect whatever.
They die within the first two days.
In a large number there is so decided an improvement after the first injections
that recovery is hoped for. Then the patient gradually changes for the worse in spite
of the continued treatment. It seems as if by the first injections the infection has
been overcome ; but the patient dies in consequence of the irreparable degenerative
changes which have already taken place.
In the largest number of patients in whom such change3 are not established, the
improvement after injection is followed by recovery.
As it has been said that the results of the serum treatment are not in conformity
with the axiom of serotherapeutics, "that the earlier the treatment the more favourable
the prognosis"—an axiom which in this relation holds good for any kind of treat-
ment—I shall analyse the distribution of the recoveries over the different days of ill-
ness on which the patients came in for treatment.
332
In this connection I should like to correct an error regarding this distribution
which occurs in Capt. Childe's report, dated the 4th of April 1S99, No. 226, to Sur-
geon-General G. Bainbridge, M.D., concerning 148 patients treated with Prof. Lus-
tig's serum from February 2nd to March 27th. Capt. Childe gives on page 19 a
table showing the number of patients treated on the different days of illness. Ac-
cording to this table, out of a total of 148 patients, 30 received treatment on the first
day of illness. He states further, on page 20, para. 6, that 22 of them died, the mor-
tality being 73.3 per cent. and demonstrates that, contrary to the axiom of serothera-
peutics, the mortality of the patients treated on the first day is higher than that of all
the patients who underwent the treatment ; the figures being 73.3 per cent. and 69.7
per cent. respectively, and continues by saying "that this points to the same conclusion,
namely, that treatment by Prof. Lustig's serum has not much influence on the
course of plague."
These statistics need rectification. By looking closer through Capt. Childe's
report one will find that of the 30 patients admitted on the first day of disease 4 re-
ceived the treatment on the day after admission, that is, on the second day of disease.
On the first day there were therefore 26 patients treated, of whom 18 died and 8 re-
covered ; the mortality being 69.2 per cent.
Hence the mortality of the patients who received treatment on the first day
was lower than the mortality of all the patients who underwent the treatment ; the
figures being 69.2 per cent. and 69.7 per cent. respectively, instead of 73.3 per cent.
and 69.7 per cent. as stated by Capt. Childe.
This error to consider the day of admission as identical with the day of the
beginning of the treatment amounts to 11 for the patients admitted on the second
day of illness and has vitiated the corresponding statistics and the conclusions drawn
from them, which latter had in any case a very limited value indeed, based as they
were on results which could be materially altered by an error of 4.
It is worth mentioning here that in Capt. Childe's report the Maratha Hospital
shows 3 patients treated on the first day, in a total of 12, and the Arthur Road
Hospital only 12 such patients in a total of 125.
After this necessary digression I return to my subject. The relation between
recoveries and days of illness on which the treatment, commenced, is shown in the
following table :—
Days of illness.
1st
2nd
3rd
4th
5th
6th
7th
No. of patients
treated.
37
140
117
54
24
13
18
403
Recoveries.
34
49
39
26
12
6
8
154
Percentage of
recovery.
37.8
35
33.3
48.1
50
46.1
44.4
38.21
In remarking on the above it is surprising that so few patients received
treatment on the first day of illness. The reason is that only about 6 per cent. of the
admissions are patients in this early stage, at least at the Arthur Road Hospital.
These patients are moreover mostly in a very bad condition. Their mortality is
very high and many of them die soon after admission.
334
remission of symptoms indicated by a fall in the temperature so frequent on the
third or fourth day. Patient and disease seem to gather strength for the final
struggle.
At this stage, before the relapse comes on, the serum has proved useful ;
hence the quicker declining of the mortality on the fourth day. We have really a
new first day of disease, and the patient who had resistance enough to survive the
more dangerous first onslaught comes easier over the second one with the help of
the serum, than with his own exhausted resources.
Were it not for this critical relapse the serum could not have any influence on
the course of the disease after the third or fourth day, as it can only act against the
infection and not against its established consequences.
The possibility of checking or mitigating the relapse is a most important and
favourable feature of the treatment in Indian plague hospitals whither patients come
usually too late for the treatment of the first attack.
We understand now why the rate of recovery in patients of the later days is
cent. per cent. higher than in those of the earlier days. The absolute number of
recoveries is naturally always higher among the more numerous admissions in the
first days of illness.
I have tried to bring the results of the limited statistics available into harmony
with the knowledge derived from the clinical observations of the disease and of the
treatment, and I admit willingly that my deductions may have to be modified in the
light of later experiences. Still the chief point in question, the efficacy of the serum
treatment, even at a later stage, will remain untouched, however the connection of the
facts may vary.
I have little more to say about the patients of the Arthur Road Hospital. The
great majority of them were low-caste Hindu males who have generally a morta-
lity 2.3 per cent. higher than Hindu females, so that also in this respect the
serum was not favoured.
All ages were represented, the youngest child was four months, the eldest man
75 years. Forty children under 10 years had a recovery rate of 50 per cent. It can
be said that they answer best to the serum treatment. Their mortality is in general
the lowest.
In order to judge of the seventy of the treated cases I attach copies* of the
charts of temperature of the first 100 patients who recovered under the serum treat-
ment as well as the corresponding ones of the patients who were under the ordinary
treatment. They bear out fully what has been said about the selection of cases.
No other clinical details are given than the curve of temperature during the acute
stage, which may be taken as an approximate index of the course of the
disease.
Certain charts have been signed on the right corner as "mild"; taking as
criterion the shortness of the acute stage, the low temperature and the admissions on
the later days. This classification has no scientific value and does not always cor-
respond with the facts ; it only facilitates comparison. Strictly speaking, such
comparison is impossible as the mild course in many serum cases was brought about
by the treatment.
* These copies only accompany the Commissioner's copy.
337
In order to facilitate a review of the facts relating to the efficacy of the serum
that have been brought forward in this report, the following summary may be
given :—
(a) Clinical statement—
1. Fall of temperature.
2. Increase of arterial pressure.
3. Mitigation of nervous symptoms.
4. Lessening of tenderness in the bubo.
5. Diminution of size of the bubo.
6. More frequent re-absorption of bubo.
(b) Statistical statement—
1. Varying efficacy of the different sera employed.
2. Higher recovery rate in the serum cases than in the non-serum
cases.
3. Higher total recovery rate in the serum periods than in the inter-
mediate period.
4. Increase of the monthly recovery rate coinciding in both serum
periods with the commencement of the treatment.
5. Lower death-rate within the first 48 hours after admission during
the serum period than during the intermediate period.
6. Higher total recovery rate at the Arthur Road Hospital during the
time of the serum treatment than at other hospitals where the
serum was not employed.
There is no missing link in this chain of proofs and the curative properties of
Prof. Lustig's serum have, therefore, to be accepted as an established fact.
If I were to compress the conclusions to be drawn from this evidence in one
sentence, I should say that "by Prof. Lustig's method a curative plague serum can
be prepared which has shown in its experimental stage results which allow a hope
that the serum will become an effective weapon in combating the disease."
Considering now the application of the remedy to a disease which attacks so
numerously the poorest class of the population, one has to admit, hard as it is to
admit it, that the practical value of the serum is in direct proportion to the percentage
of recoveries which can be obtained under the unfavourable circumstances common
to such a class of population. If this percentage falls under a certain standard, the
cost of the preparation of the serum may be prohibitive.
Having ascertained by the clinical method, that the serum cures, it is all impor-
tant therefore to ascertain, by an adequate method, which will be also convincing to
the public at large, hoto many it cures. The treatment with the serum is there-
fore being continued at the Arthur Road Hospital, every alternative case being sub-
jected to it.
No fundamental objection can be raised now against statistics as the experi-
mental stage of the treatment is past. Variations on the preparation or application
which may still have to be adopted, will serve as improvements only. Such improve-
ments are already under contemplation. They have not been attempted until
339
In private practice a higher recovery rate will be obtained.
If the above estimated benefit is approximately correct, would the increase of the
recovery rate from plague by 30 per cent. constitute the practical value of the serum
and would the co3t allow of its preparation on a corresponding scale ?
When the serum treatment was begun in Bombay, the public interest was con-
cerned with Prof. Haffkine's prophylactic, the method of which is wholesale applica-
tion. By an unconscious mental process which was facilitated by the still existing
confusion, between the names, the requirements of the one were applied to the other,
although they differ essentially.
The prophylactic treatment is confronted with the ubiquitous possibility of infec-
tion and must, therefore, be wholesale in order to be effective.
Quite different are the requirements of a curative treatment. Its object is the
sick, and its aim recovery, which latter is the direct proof of the efficacy : but as re-
covery is not possible in every case, a curative treatment is always selective and ought to
be confined to those who can be influenced by it. Such selection is feasible in
plague as very often the possibility of recovery is absolutely excluded. It is also
necessary as without selection the preparation of a sufficient quantity of serum would
be difficult and the cost considerably increased. The question therefore stands
thus :—
Shall we cure none because we cannot treat all ?
There should be only one answer to this question. But whatever the answer
may be, and whatever the future of the serum treatment of plague here in India, the
knowledge that there is a remedy for those sick of the pestilence will be of value to
mankind, while the merit of having been instrumental in the acquisition of this know-
ledge will always remain with the Bombay Municipality and their advisers, Col. Weir
and the late Commissioner Mr. Snow, who were active in initiating the serum treat-
ment.
APPENDIX No. III.
REPORT ON THE TREATMENT OP PLAGUE
BY
DR. GALLEOTTI'S CURATIVE SERUM
BY
CAPTAIN L. F. CHILDE, I.M.S.
Statement of Plague Cases treated by Dr. Galleolti's Serum at Marátha Plague Hospital.
No.
1
3
4
6
6
7
8
9
10
11
12
Name.
Narbada Laximan ...
Maruti Gopal
Saku Malji
Bhicu Ramaji.
Uma Mahadu...
Dagdu Honaji
Sayi Tukaram
Kalappa Basappa
Babaji Narayan
Narayan Bhanu
Ganu Kalu
Radha Hari
Date of
Admission.
2nd February 1899
2nd
do.
3rd
do.
3rd
do.
3rd
do.
4th
do. ...
4th
do. ...
5th
do. ...
7th
do.
7th
do.
7th
do.
11th
March 1809
Age.
Years.
18
20
35
6
15
30
15
20
30
25
30
20
Sex.
Female.
Male ...
Female.
Child ...
Female.
Male ...
Female.
Male ...
Do. ...
Do. ...
Do. ...
Female.
Caste.
Hindu
Do. ...
Do. ...
Do. ...
Do. ...
Do. ...
Do. ...
Do. ...
Do. ...
Do. ...
Do. ...
Do. ...
Day of
Disease.
2 days ...
1 day ...
1 „ ...
1 „ ...
1 „ ...
1 „ ...
3 days ...
1 day ..
1 „ ...
1 „ ...
1 ,, ...
2 days ...
Date of Serum
injected.
3rd February 1899.
2nd
do.
3rd
do.
...
3rd
do.
3rd
do.
4th
do.
6th
do.
5th
do.
7th
do.
7th
do.
7th
do.
1st day.
Morning
c. c.
18
15
20
5
...
19
15
15
10
15
Evening.
c. c.
15
15
...
12
10
19
19
19
19
15
15
AMOUNT OF SEBUM INJECTED.
2nd day.
Morning.
c. c.
15
10
10
10
10
18
19
...
19
...
16
Evening
c. c.
15
15
19
...
19
...
19
3rd day.
Morning
c. c.
19
10
10
19
...
19
Evening.
c. c.
19
19
15
4th day.
Morning.
c. c.
19
...
Evening.
c. c.
10
5th day.
Morning.
c. c.
Evening.
c. c.
6th day.
Morning.
c. c
Evening.
c. c.
...
...
Result.
Died 8.50 P.M., 6th
February 1899.
Recovered.
Died 6 P.M., 6th
February 1899.
Died 4.80 P.M., 4th
February 1899.
Recovered.
Died 7.50 P.M., 5th
February 1899.
Died 5 A.M., 7th
February 1899.
Recovered.
Died 12-30 P.M.,
11th
February
1899.
Died 7 A.M., 11th
February 1899.
Died 1-10 A.M., 10th
February 1899.
Died 11-30 A.M.
12th March 1899.
REMARKS.
Vapour bath
in addition
given.
Vapour bath
in addition
given,
Heart failure
342
Statement of Plague Cases treated by Dr. Galleotti's Serum, at the Arthur Road Hospital.
No.
12/1
13/2
14
¿
15/4
16/5
17/6
18
7
19
8
20
y
21/10
22/11
23/12
24
13
25/14
Name.
Series
Girza Babu...
... 1st
T. J. DeSilva
... do.
Unknown
do.
Rama Raghu ... do.
Bhambu Raju
... do.
Mahadu Ithu
... do.
Shiva Issu
do.
Ganesh Khedu
... do.
Biranji Ganesh ... do.
Deuba Gainu
... do.
Esu Kondaji
... do.
Gannu Gosai
... do.
Pandu Gopal
... do.
Shiva Hari
... do.
Date of
Admission.
29th January 1899 .
28th
do,
31st
do.
1st February 1899.
1st
do.
31st January 1899.
1st February 1899.
1st
do.
1st
do.
2nd
do.
1st
do.
2nd
do.
2nd
do.
4th
do.
Age.
Years.
10
61
42
20
20
10
40
38
25
18
30
29
15
30
Ses.
Child ..
Male ,.
Do. ...
Do. ...
Do. ..
Child ..
Male ..
Do. ..
Female .
Víalo ..
Do. ...
Do ..
Do. ..
Do. ...
Caste.
Hindu ...
Christian...
Hindu ...
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do:
Do.
Date of
Disease.
2 days ...
4 „
...
1 day ...
4 days ...
4 „
...
4 „
...
2 „
...
2 „ ...
3 „ ...
3 „ ...
5 „ ...
3 „ ...
1 day ...
4 days ...
Date of Serum
injected.
29th January 1899.
30th
do.
...
31st
do.
1st February 1899.
1st
do.
1st
do.
1st
do.
..
1st
do.
1st
do.
2nd
do.
2nd
do.
2nd
do,
2nd
do.
1th
do.
1st day.
Morning.
c. c.
...
20
...
15
15
10
...
15
...
...
Evening.
c. c.
18
15
15
...
10
15
15
15
...
15
15
15
15
AMOUNT OF SEBUM INJECTED.
2nd day.
Morning.
c c.
...
...
10
15
5
15
10
...
15
18
15
Evening.
c. c.
10
15
10
5
15
15
10
10
10
15
3rd day.
Morning.
c. c.
...
10
5
15
15
15
15
15
Evening.
c. c.
15
10
10
IB-
IS
15
15
15
4th day.
Morning.
c. c.
...
10
10
20
...
Evening.
c. c.
...
10
15
20
...
5th day.
Morning.
c. c.
10
5
...
...
Evening.
c. c.
20
5
15
6th day.
Morning.
c. c.
15
5
15
Evening.
c. c.
20
5
15
Result.
Died 3-15 P.M., 31st
January 1899.
Died 2-15 A.M., 31st
January 1899.
Died 12 o'clock, 1st
February 1899.
Recovered
Died 10 P.M., 1st
February 1899.
Recovered ...
...
Do
Died 7 A.M., 4th
February 1899.
Died 6-50 P.M., 4th
February 1899.
Died 9 P.M., 3rd
February 1899.
Died 7 P.M., 3rd
February 1899.
Died 12-15 P.M., 3rd
February 1899.
Died 8 A.M., 5th
February 1899.
Died 9-15 P.M., 6th
February 1899.
REMARKS.
Temp. 106-4.
Moribund.
Septic type.
Moribund.
Intestinal hæmorr-
hage.
Septic type.
Improvement
and
then relapse.
Meningeal symptoms
and Hæmatemesis.
Multiple buboes.
Moribund.
Moribund.
Semi-conscious
on
admission.
Died of heart
failure.
343