NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
354
No. 4816 OF 1899.
Prom
THE SURGEON-GENERAL WITH THE
GOVERNMENT OF BOMBAY ;
To
THE SECRETARY TO GOVERNMENT,
General Department (Plague),
Bombay.
Office of the Surgeon-General with the
Government of Bombay, Town Hall,
Bombay, 29th May 1899.
SIR,
With reference to your No. 2902-P., dated 28th ultimo, I have the honour to
submit the following observations upon the report of Khan Bahadur Dr. N. H.
Choksy on the trial of Professor Lustig's curative for plague submitted to you by
the Municipal Commissioner for the City of Bombay.
2. The series of 142 cases is the same as that reported on by Captain Childe,
I. M. S., and forwarded to you with my letter No. 4006, dated 2nd instant. The
only difference worth noticing in their details is that Captain Childe records 99
deaths, whereas Dr. Choksy gives only 97 ; but since this discrepancy does not
materially affect the conclusions to be drawn from the results, it may be disregarded.
3. The figures in each report, excluding six remaining cases, stand thus :—
Captain Childe
Dr. Choksy
Cases.
142
Deaths.
99
97
Recoveries.
43
45
Mortality
per cent.
69.7
68.4
Dr. Choksy's case mortality rate of 68.4 is therefore exactly equal to the mean
mortality among 8,998 patients treated, without any selection by ordinary therapeuti-
cal measures in cortain of the best organized plague hospitals during 1896-98, as
mentioned in paragraph 2 of my letter No. 4006 above quoted. As regards the
latter figures, I would remark that the close correspondence of those given in four
different reports is strongly indicative of their trustworthiness.
4. Dr. Choksy compares the results by Dr. Lustig's serum with those obtained
among patients in the Arthur Road Hospital not so treated, who yielded a case
mortality of 79.48 per cent. This ratio seems to me a very high hospital mortality,
and I am unable to allow that it can be adopted as a standard of comparison.
Dr. Choksy writes that the recent epidemic was of an extremely virulent type ;
but it would be necessary to carefully examine the figures before accepting either
this assertion, or hospital mortality of between 85 and 90 per cent. among all cases.
Dr. Childe apparently considered the latter point, and remarks that he has no means
of verifying the ratio.
5. Dr. Childe remarks that an endeavour was made to confine that treatment
to cases of average severity which had a reasonable chance of recovory, so that
patients obviously moribund, and thoso who were not severely attacked, did not
receive the treatment. Dr. Choksy also says that moribund cases wore excluded,
Yet Ï find that each of these gentlemen has entered in his tables as moribund 12 cases
which received the serum.
355
In my previous letter, I omitted to notice that Dr. Childe, whilst professing to
exclude hopeless cases, had in fact entered 12 as moribund. As regards
Dr. Choksy's remark that the death-rate amongst the cases not treated with the
serum would have been higher, but for the inclusion of convalescents and semi-
oonvalescents, I have already observed that it was, in my opinion, high enough,
and not a fair criterion of the effects of ordinary medicinal treatment. Had this
rate been made higher by the exclusion of convalescents, it would have been even
more inapplicable for purposes of comparison.
6. The average duration of the illness at the time of admission, as taken from
both reports, was in the fatal cases 2.5 days, and among the recoveries 2.4 days ;
so that, in this respect, the latter, so far as this record goes, had no initial advantage
over the former ; and the figures, as a whole, prove nothing as to the value of early
injection of the serum.
7. Dr. Childe, however, shows that the mortality among 80 patients who
received the serum from the first day of the disease was 73.3 per cent. ; and I concur
with him in the opinion that the inefficacy of this agent is strongly indicated by
such a result.
8. Dr. Choksy gives the case mortality in March as 4 per cent. lower than in
February: but I observe that during March the ratio of "moribund " cases to
admissions was only 6.7, whilst in February it was 10.3 per centum. If the mori-
bund cases in March had been equal in proportion to those during February, they
would have numbered 7.7 instead of 5, and the case mortality would have been the
same as that of February.
It is true that the severe cases were not limited to those marked " moribund ";
yet I do not see that Lieutenant-Colonel Wilkins is justified in his opinion that
the results obtained by the serum in March were more encouraging than those in
February.
9. Comparing the mortality under each sample of serum, I note that, except
in two series (Nos. I and IV), it was fairly uniform, but the figures do not appear to
teach anything, except that the death ratio might be as high as 77 and 84 per cent :—
Series.
I
II
III
IV
V
VI
VII
VIII
Cases.
18
11
17
13
17
47
13
6
Deaths.
14
8
10
11
12
30
8
4
Deaths
per cent.
77.7
73.6
59.0
84.6
70.5
64.0
61.5
66.6
10. I consider, therefore, that Lustig's serum has been well, though not severely
tested ; and that, although the deductions tobe drawn from a somewhat small number
of cases may not be absolutely conclusive, this series gives pratically no indications that
the remedy would prove efficacious on further trial ; I would remark, however, that
a more accurate estimate of the value of this remedy would have been possible if two
series of consecutive cases, or two series composed of alternate cases, had been utilized,
the one for testing treatment by the serum, and the other, for comparison, under
ordinary treatment.
I have the honor to be,
Sir,
Your most obedient Servant,
G. BAINBRIDGE, M. D., Surg.-Genl.,
Surgeon-General with the Government of Bombay.
Series.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Horse.
No.
1
4
3
1
5
3
1
4
1
2
5
1
3
8
4
2
9
5
10
7
1
6
12
9
SERUM PATIENTS.
Bleeding.
2nd bleeding
2nd
do.
2nd
do.
1st
do.
3rd
do.
3rd
do.
3rd
do.
3rd
do.
3rd
do.
2nd
do.
4th
do.
4th
do.
4th
do.
1st
do.
4th
do.
3rd
do.
.,
1st
do.
5th
do.
1st
do.
2nd
do.
5th
do.
..
1st
do.
1st
do.
2nd
do.
...
Total ...
Number
of
Patients.
23
6
16
6
16
24
36
37
4
15
23
35
25
26
24
34
16
25
25
11
17
19
10
7
480
Died.
15
2
12
5
11
16
26
23
3
8
15
25
18
20
13
23
10
21
18
8
12
13
6
5
328
Recovered.
8
4
4
1
5
8
10
14
1
7
8
10
7
6
11
11
6
4
7
3
5
6
4
2
152
Percentage
of
Mortality.
65.21
33.33
75.00
83.33
68.75
66.66
72.22
62.16
75.00
53.33
65.21
71.42
72.00
76.92
54.16
67.64
62.50
84.00
72.00
72.72
70.58
68.42
60.00
71.42
68.33
CONTROL PATIENTS.
Number
of
Patients.
23
6
16
6
16
24
36
37
4
15
23
35
25
26
24
34
16
25
25
11
17
19
10
7
480
Died.
15
5
9
5
12
21
32
29
3
12
13
33
19
17
18
28
11
20
23
9
11
18
8
6
382
Recovered.
8
1
7
1
4
3
4
8
1
3
5
2
6
9
6
6
5
5
2
2
6
1
2
1
98
Percentage
of
Mortality.
65.21
83.33
56.25
83.33
75.00
87.50
88.88
78.37
75.00
80.00
78.26
94.28
676.0
75.38
5.000
82.35
68.75
80.00
9200
81.81
64.70
94.73
80.00
85.71
79.58
TOTAL.
Number
of
Patients
46
12
32
12
32
48
72
74
8
30
46
70
50
52
48
68
32
50
50
22
34
38
20
14
960
Died.
30
7
21
10
23
37
58
52
6
20
33
58
37
37
31
51
21
41
41
17
23
31
14
11
710
Recovered.
16
5
11
2
9
11
14
22
2
10
13
12
13
15
17
17
11
9
9
5
11
7
6
3
250
Percentage
of
Mortality.
65.21
58.33
65.62
83.33
71.87
77.08
80.55
70.27
75.00
66.66
71.73
82.85
74.00
71.15
64.58
75.00
65.62
82.00
82.00
77.27
67.64
81.57
70.00
78.57
73.95
358
360
TABLE 3.
Serum Patients.
Patients
who die un-
der either
treatment.
60
Patients
who recover
under either
treatment.
40
Percentage
of
Mortality,
60
Patients
who die un-
der either
treatment.
80
Control Patients.
Patients who
but for the
serum die.
20
Percentage
of
Mortality.
100
All Patients.
Percentage
of
Mortality.
80
Although the serum has practically cured none, the comparison between the
two sides allows only one conclusion, viz., that the serum is very effective.
TABLE 4.
Serum Patients.
Patients
who die un-
der either
treatment.
40
Patients who
recover under
either treat-
ment,
40
Patients who
but for the
serum would
die.
20
Percentage
of
Mortality,
40
Control Patients.
Patients who
die under
either treat-
ment.
100
Percentage
of
Mortality,
100
All Patients.
Percentage
of
Mortality,
70
Although the serum can cure only 20 per cent., the comparison between the
two sides indicates an efficacy of GO per cent.
The four tables show the limits within which the distribution will vary continually,
With the distribution the results must change continually, not only quantitatively,
but also qualitatively. Only the comparison of the mortality of all the patients
with the average mortality from plague, which latter must either be known or
ascertained otherwise, tells us when the serum is effective and when it is not.
The conclusion is easy. With the present ratio between the mortality from
plague and the efficacy of the serum, the results obtained by the alternate treatment
might be utterly fallacious. They might be fallacious so long as the serum cannot
reduce the mortality from 80 per cent. to less than SO per cent. In this case a
distribution, as given in Tables 1 and 2, would be impossible. The alternate treatment
of patients as a method of investigation is therefore only admissible if a minimum
ratio exists between the degree of the efficacy of a remedy and the percentage of
the mortality of a disease. As it is just the ratio that we have to find out, the method
of the alternate treatment is illogical. This demonstration might modify the views
held with regard to the value of the method of the alternate treatment of patients
and might justify the unwillingness of the experimenters to subject the serum to such a
test before the efficacy had approximately been ascertained by more reliable means.
The proof for the efficacy of a remedy whether it is tried on clinically selected
patients or on patients selected by alternation is not given by the difference between
i he mortality of the treated and non-treated patients, but always by the reduction
of the mortality of all the patients. Thus the alternate treatment furnishes no
other or better evidence, whereas the treatment of clinically selected patients obtains
an absolutely larger number of recoveries which must always be the only aim of a
treatment also in its experimental stage. The alternate treatment is not only
illogical and expensive, it is also cruel, as it delivers patients to death- while the
remedy is at hand to preserve life. In short, it is not a method of the sick-room
361
but of the laboratory. Dr. Choksy and we ourselves have bitterly condemned
that method whenever we had to abandon a control patient to his untimely fate
whom the serum could in all probability have saved, or had to inject a patient
who, as we knew, would never benefit by the pain the injection might have
caused him.
The routine treatment was identical for all plague admissions—rum every
two hours, cardiac stimulants, sleeping draughts, wet pack, etc., whenever needed.
The serum was given exclusively by sub-cutaneous injections, that being the way in
which the serum can be administered on a large scale in Indian hospitals. Twenty to
40 c.c. were given in the morning and evening. With the growing experience,
one large dose of 50 to 80 c.c. once a day, if possible in the morning, was found
more convenient. All patients had a full dose on admission, except those evidently
convalescent, who received a nominal dose of 5 or 10 c.c. Then the dose was
varied as the case required it. The utmost economy was the rule, and the serum
was immediately omitted when the temperature had come down and the pulse was
fairly good. The quantity of serum marked on the charts of temperature as injected
gives therefore the best information of the gravity of the disease. The largest dose
injected at once was 80 c.c. The largest amount injected in a single case was
320 c.c. within five days, in a patient who died, and 300 c.c. in several cases that
recovered. The average quantity needed for recovery was 110 c.c, the average
amount injected in patients who died was 80 c.c. The total amount of serum used at
the hospital was 38 litres, only 14 of which were used for patients who recovered. The
total number of injections was 1,900, of which 1,175 were made in patients who died.
On an average, three injections were made in patients who died, and six in patients
who recovered, the convalescents being excluded. Any unfavourable influence of
large doses has never been observed ; on the contrary, all the experience points to
the fact that, with the present strength of the serum, large doses are the right
policy. Urticaria appeared seldom after injection, and pains in the joints seemed
not to be more frequent than in patients who did not receive the serum. Abscesses
on the seat of injection were rare except during the height of the epidemic when
several were observed in succession, no doubt due to deficient disinfection. It is
surprising that abscesses were not more frequent, considering that the staff of the
hospital was insufficient in number to deal with the amount of work imposed on
them by the serum treatment, so that the disinfection of the skin had often to be
left to the menial servants.
In order to give an idea of the conditions of the patients who roc vered, a
complete list with the necessary particulars is given :—
List of the Control Patients who Recovered—(contd.).
Current Number
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
Hospital
Number
1138
1140
1164
1211
1168
1228
1256
1250
1270
1273
1282
1293
1316
1357
1349
1386
1395
1405
1420
1433
1455
1485
1489
1543
1562
1588
1590
1825
1829
1849
1877
1897
1936
1913
1995
2035
2103
2169
2184
2191
2231
2243
2286
2300
2382
2494
2584
2779
Caste,
Hindu
.
Do.
Do.
Do.
Do.
N. Christian
Hindu
Do.
Do.
Do.
Do.
Do.
Mussulman
N. Christian
Hindu
Do.
N. Christian
Do.
"
Hindu
Do.
Do.
Do.
Do.
N. Christian
Hindu
Do.
D >.
Do.
Do.
Do.
Do.
Do.
N. Christian
....
Hindu
Do.
Do.
Do.
Do.
Do.
Do.
D •.
Do.
Do.
Do.
Do.
Mussalman
...
Hindu
Do.
Sex.
.. Male
.. Do.
.. Do.
.. Do.
.. Female
. Male
. Female
. Male
Do.
. Female
. Male
, Female
Male
. Do.
. Do.
Female
Male
Do.
Do.
Do.
Female
Male
. Female
. Male
Do.
'Female
Male
Do.
Do.
Female
Male
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Female
...
Do.
Do.
Do.
Male
Do.
Age.
40 years
24 do.
20 do.
8 do,
30 do.
13 do.
6 do.
23 do.
22 do.
20 do.
15 do.
25 do.
20 do.
15 do.
32 do.
12 do.
35 do.
30 do.
5 do.
8 do.
16 do.
35 do.
35 do.
52 do.
35 do.
7 do.
10 do.
36 do.
12 8o.
20 do.
30 do.
6 do.
40 do.
30 do.
22 do.
40 do.
25 do. 1
20 do.
25 do.
20 do.
25 do.
15 do.
28 do.
9 do.
35 do.
25 do.
8 do.
16 do.
Days of
illness or
admission
Unknown
2
3
4
6
8
6
2
1
6
2
2
2
11
3
2
10
2
Unknown
6
5
2
4
3
10
4
4
8
20
3
8
8
8
6
3
10
Unknown.
15
10
7
3
3
2
7
3
26
2
2
Manifestation of disease.
Double Femoral bubo ...
...
...
Supra hyoidal bubo
...
...
...
Cervical bubo
Inguinal do.
Femoral do.
...
Cervical do.
...
...
...
Supra hyoidal bubo
...
...
...
Axillary bubo
...
...
...
Inguinal do.
...
...
Femoral do.
Inguinal do.
...
...
Do.
do.
Duoble Inguinal bubo ...
...
Inguinal and Cervical bubo
...
...
Pectoral bubo
Femoral and Iliac bubo
Inguinal and Iliac do.
...
Axillary bubo
...
...
,..
Cervical do.
...
...
...
Femoral Iliac and Inguinal bubo
...
...
Cervical bubo
...
Femoral and Iliac bubo
Cervical bubo
Inguinal do.
...
Cervical and Axillary bubo
Femoral and Inguinal do.
Femoral bubo
...
...
...
Inguinal do.
... .
Femoral do.
...
Do.
do.
Do.
do.
Cervical do.
...
...
...
Femoral and Inguinal bubo
...
Do. bubo
Inguinal and Iliac bubo
Double Inguinal
do. ...
...
...
Femorol and Iliac do. ...
...
...
Femoral and Cervical bubo
...
Inguinal bubo
Femoral do.
Do.
do.
Do.
do.
Axillary and Cervical bubo
...
...
Do. bubo
...
...
Femoral aud Inguinal bubo
Axillary bubo
Inguinal do.
...
Axillary do.
...
...
...
Highest
tempera-
ture.
101°1
05°1
04°1
04°1
04°1
04°9
9°1
04°1
06°1
05°1
04°1
04°9
9°1
00°1
03°1
03°9
8°1
04°1
01°1
04°1
05°1
03°1
05°1
00°1
01°1
04°1
03°9
9°9
9°1
04°1
04°9
8°1
01°1
05°1
05°1
03°1
03°1
04°1
02°1
02°1
04°1
00°1
03°1
03°1
03°9
8°1
04°1
05°B
ubo
suppu-
rated.
1
1
1
1
1
1
1
1
1
::::::
1
1
1
1
1
1
......
1
1
1
1
1
1
1
1
.......
1
REMARKS.
Convalescent.
Convalescent.
Haffkinised.
Haffkinised.
Convalescent.
Convalescent.
Convalescent.
Convalescent.
Convalescent.
Do.
Convalescent.
Do.
Convalescent.
Convalescent.
Do.
Convalescent.
366
MONTHS.
1899.
May
September
...
October
November
December
1900.
January
February
March
April
May
June
Total ...
i
SERUM PATIENTS.
Number
of patients.
23
21
15
17
26
15
25
59
86
74
80
31
8
480
Died.
15
13
12
9
21
10
14
38
64
45
61
21
5
328
Recovered.
8
8
3
8
5
5
11
21
22
29
19
10
3
152
Percentage
of mortali-
ty.
1
65.21
61.90
80.00
52.94
80.77
66.66
56.00
64.40
74.41
60.81
76.25
67.74
62.50
68.33
ARTHUR ROAD HOSPITAL.
CONTROL PATIENTS.
Number
of patients.
23
21
15
17
25
16
25
59
85
75
79
32
8
480
Died.
15
14
10
16
22
12
23
45
68
59
62
29
7
382
Recovered
8
7
5
1
3
4
2
14
17
16
17
3
1
98
Percentage
of mortali-
ty.
65.21
66.66
66.66
94.11
88.00
75.00
92.00
76.27
80.00
78.66
78.48
90.62
87.50
79.58
EXTRA PATIENTS.
Number
of patients.
6
6
...
4
7
6
2
5
...
1
1
...
38
Died.
4
6
3
5
...
5
2
5
...
1
1
...
32
Recovered.
2
...
1
2
...
1
...
...
...
...
...
...
6
Number of
patients.
52
48
30
38
58
31
56
120
176
149
160
64
16
998
TOTAL.
Died.
34
33
22
28
48
22
42
85
137
104
124
51
12
742
Recovered
18
15
8
10
10
9
14
35
39
45
36
13
4
256
Percentage
of mortali-
ty.
65.38
68.75
73.33
73.68
82.75
70.96
75.00
70.83
77.84
69.79
77.50
79.68
75.00
74.34
MARATHA HOSPITAL
ORDINARY TREATMENT.
Number of
patients.
121
48
47
69
77
83
220
336
504
590
356
142
2,599
Died.
96
34
39
56
58
71
171
275
416
487
294
107
2,104
Recovered.
25
14
8
13
19
12
49
61
88
109
62
35
495
Percentage
of mortality.
79.33
70.83
82.97
81.16
75.32
85.54
77.72
81.84
82.54
81.71
82.58
75.35
80.95
369
371
of infection. If the patients were fairly distributed according to these factors, we
could be certain that the same was the case also with respect to the three classes
mentioned. We shall, therefore, compare in the following the details of the distribu-
tion one by one in the order given above, so far as it is statistically feasible. The
material for the statistics is taken from the charts of temperature of our patients,
which we have gone through carefully ourselves. We begin with the statistics of
the distribution according to the caste :—
Caste.
Serum patients
Control patients
Hindus.
404
405
Mussalmans.
21
27
Native
Christians.
47
40
Parsees.
8
8
Total.
480
480
No comments are necessary on this table. The same can be said of the following,
showing how the patients were distributed according to the sex :—
Sex.
Serum patients
...
Control patients
Males.
350
353
Females.
130
127
Total.
480
480
The next table gives the distribution with regard to the age period: —
Serum patients ...
Control patients ...
0-10
years.
50
60
10-20
years.
129
127
20-30
years.
162
159
30-40
years.
81
99
40-50
years.
37
25
50 years
and more.
21
10
Total
480
480
The distribution is here in favour of the controls which have 10 more children,
among whom the mortality is about 12 per cent. lower than the average, and 23
fever patients over 40 years, among whom the mortality is higher than the average
The individual resistance is dependent on caste, sex, age and previous immunisa-
tion. The benefit of the latter was identical, as on either side eleven patients had
been inoculated with the plague prophylactic.
With regard to the days of illness on admission the patients were distributed
as follows :—
Day of illness on
admission.
Serum patients...
Control patients.
1st
day.
18
20
2nd
day.
121
120
3rd
day.
186
100
4th
day.
79
67
5th
day.
32
38
6th
day.
17
25
7th
day.
4
13
8 th
day.
16
20
9th
day.
4
4
10 th
day &
more.
19
26
Un-
known
34
47
Total
480
480
The advantage lies here again with the controls. It is well known that the
mortality from plague in our hospitals is highest amongst the admissions of the
earlier days. A marked reduction of the mortality only takes place in the patienta
admitted after the fifth day of illness. If we divide the cases accordingly, we fiad
374
The results shown in this table fulfil our expectations, the mortality of the
serum patients repeating the fluctuations on the other side. We note here that the
reduction of the average mortality of the controls by 7 per cent. in the case of
Native Christians corresponds to a reduction of 24 per cent. on the serum side:—
The next table gives the results according to the caste and sex :—
Caste and Sex.
Hindus
Mussalmans
Native Christians ...
Parsees
Males
Females
Males
...
Females ...
Males
Females
Males
...
Females
Total
Serum Patients.
Number
of
patients.
291
113
18
3
37
10
4
4
480
Died.
207
75
13
1
19
7
2
4
328
Recov-
ered.
84
38
5
2
18
3
2
...
152
Percen-
tage of
Morta-
lity.
71.13
66.37
72.22
33.33
51.35
70.00
50.00
100.00
68.33
Control Patients.
Number
of
patienta.
293
112
22
5
33
7
5
3
480
Died.
236
90
16
i
22
7
5
2
382
Recov-
ered.
57
22
6
1
11
...
1
98
Percen-
tage of
Morta-
lity.
80.54
80.35
72.72
80.00
66.66
100.00
100.00
66.66
79.58
Considering only the larger figures we see that Hindu males have the highest
mortality on both sides. Contrary to the facts of the general statistics, which show
that Hindu females have a distinctly lower mortality than Hindu males, there is
hardly any reduction in Hindu females on the control side. It is otherwise under
the serum treatment. Already during the time of the selection of the patients it
was observed that females answer better to the serum treatment than males. In
the cases of Native Christians it is interesting that the chief reduction of the
mortality shows itself on both sides in males. This is correct, Native Christian
niales having generally a much lower death rate than females.
The results, according to the age period, are seen from the following table :—
Age period.
From 0-10 years...
" 10-20 " ...
„ 20-30 „ ...
„ 30-40 „ ..
„ 40-50 „ ..
„ 50-60 „
and more
Total ..
Serum Patients.
Number
of
Patients.
50
129
162
81
37
21
480
Died.
25
90
105
62
28
18
328
Recov-
ered.
25
39
57
19
9
3
132
Percentage
of
Mortality.
50 00
69.76
64.81
76.54
75.67
85.71
68.33
Control Patients.
Number |
of
Patients.
60
127
159
99
25
10
480
Died.
40
95
135
84
22
6
382
Recov-
ered.
20
32
24
15
S
4
98
Percentage-
of
Mortality.
66.66
74.80
84.90
84.84
88.00
80.00
79.58
Children had also during the time of the selection a mortality of 50 per cent.
They give the best results under the serum treatment. That the mortality from
plague is generally lower among children than in adults is noteworthy as in other
infectious diseases the full-grown individuals are more resistant. The two following
periods show specially on the control side differences of the mortality which are