NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
54
Description of Plague :
[ CHAP. II.
monsoon torreuts, and in the comparatively dry uplands of the Deccan.
But in all these places the hottest part of the year succeeded, com-
pletely or for the time, in subjugating the epidemic.
Statement and
chart.
A comparison of the course of the plague in different localities
with the variations in temperature during the epidemic is given in a
statement in Appendix III, and illustrates the above remarks. The
chart in Volume IV, page 26, affords a further illustration.
Altitude and
geological
characteristics
have no
influence on
piague.
Scheube states that neither the geological character of the ground
nor its altitude has any effect on the initiation of the disease. It is
unnecessary to elaborate this remark. The history and geographical
account of plague given in subsequent chapters will make its truth
at once evident.
Origin and Course of Plague Epidemics.
Origin of plague
epidemics.
It was formerly a subject of frequent contention whether plague
can have an autochthonous origin or whether an epidemic must in all
cases be started by previously existing germs of the disease. Modern
bacteriological research, in demonstrating that plague is due to a
specific bacillus, has thrown much light on this vexed question, but
it has not been settled beyond doubt whether the pathogenic cell may
be derived from an innocent one.
General course
of plague
epidemics.
Scheube makes the following interesting remarks on the general
course of plague epidemics :—
" If plague is imported anywhere, for the first three or four weeks
isolated cases occur in the neighbourhood of the imported case, and
subsequently dissemination of the contagion and a general spread of
the disease take place. An epidemic will at times last only a few
weeks or months, but may extend over several years. The abate-
ment generally comes rapidly, but sporadic cases will still occur at
times for years, and the epidemic may break out again without a
renewed importation from outside. "
Gradual growth.
These remarks are entirely in accord with the experience of previ-
ous and the present epidemics. The gradual manner in which plague
epidemics grow is a natural sequence of the fact that the infection is
not carried about in the air, but is in general disseminated amongst
the immediate surroundings of the sick, its virulence gradually in-
creasing in the fostering element of insanitary surroundings. The
phenomenon has been markedly characteristic of the present epidemic
in almost all places in which it has raged. This point will be made
CHAP. II. ]
its causes and characteristics.
55.
clear in subsequent chapters. It is practically of great importance in
the facility which it affords to stamping out an epidemic at the outset.
Duration.
The long period over which plague epidemics have lasted is a well
known feature of the history of plague in Europe. In India also, at
the beginning of the present century, there was a plague epidemic in
Gujarat which lasted ten years.
Recurrence in
endemic centres.
The plague centre on the northern slopes of the Himalayas affords
an Indian example of the manner in which plague epidemics may occur '
in a place where the disease is endemic at considerable intervals
of time without the introduction of fresh infection from outside.
Mild sporadic cases are the main link between successive epidemics.
The extent to which the disease may be kept alive for a considerable
period in surroundings favourable to the vitality of the bacillus is,
it has been seen, a matter about which a final opinion has not yet
been expressed.
Curative Treatment.
Paper by Dr.
Cantlie.
It is not within the scope of this report to give details of the
medical treatment in cases of plague. A paper by Dr. Cantlie on the
treatment of plague, which was circulated to Local Governments, is
given in Appendix I.
Small effect of
medical treat-
ment.
Influence of good
nursing and
healthy surround-
ings.
Parel Hospital,
Bombay.
The medical treatment is limited to the treatment of symptoms and
has proved of little effect in arresting the fatal course of the disease-
Experience has, however, shown that good nursing and healthy sur-
roundings are of material assistance. Surgeon-Captain Thomson, Parel
Hospital, Bombay, remarked as follows: " In the treatment of plague,
symptoms can be relieved and the chances of favourable termination
promoted ; but little can be done to shorten its course and ensure
recovery ....
The success of any treatment depends on early
and good nursing, and keeping the patients lying down until the
temperature has been normal for at least four days .... Abund-
ance of fresh air is of next importance, and in Parel each patient had
nearly 2,000 cubic feet of air space and free perflation of air."
Grant Road
Hospital,
Bombay.
The following extract is from Dr. McCabe Dallas' report on the (
Grant Road Hospital, Bombay
:—
" As regards the effect of medicine, it cannot be stated with satis-
faction that we possess any standard remedies of certainty. What
might seemingly cure one patient is ineffective in another of the same
type, and it is questionable, whether the successes shown are not
wholly due to scientific nursing and hygienic surroundings of a
56
Description of Plague :
[CHAP. II.
superior nature and to personal comfort and healthy ventilation.
This, of course, was impossible during the "opposition period" of
the epidemic, when a large percentage of patients were permitted to
remain where they fell ill, in low, dark, overcrowded, ill-ventilated
rooms, without proper food, or probably no food at all, and absolutely
unsupported by the administration of alcoholic stimulants. "
An important subject on which it is necessary to make a few
remarks is the endeavour that was made to utilise bacteriological
knowledge by attempting to cure patients by the injection of a
therapeutic serum.
M. Yersin's
curative serum,
Inconclusive
results.
During the Hong-kong epidemic M. Yersin experimented on the
effect of the subcutaneous injection of a curative serum derived from
horses immunized by injection of prepared cultivations of the bacillus.
A description of this method is given in a paper* by MM. Yersin,
Calmette and Borrel. On the outbreak of plague in Bombay
M. Yersin visited the city and pursued experiments with serum
supplied by the Pasteur Institute of Nha Trang. The result of the
experiments was inconclusive and medical opinion in Bombay was
unfavourable to the treatment. The serum had to be hastily prepared
and was weaker than that used in China in 1896.
Inconclusive
result of
experiments by
M. Haffkine.
M. Haffkine also endeavoured to cure patients by the injection of
therapeutic serum. At the time of the outbreak of plague he was
engaged in investigations connected with anti-cholera inoculation.
He was at once deputed to Bombay under the orders of the Govern-
ment of India, and was employed there throughout the epidemic.
In a letter of the 14th† July he described the result of his
experiments. A number of animals having been brought to a high
degree of immunity, the effect of serum derived from them was tried
on patients in whom the severity of the disease did not leave hope of
its yielding to the ordinary treatment. No clear results could be
obtained as to the effect of the drug. M. Haffkine then resolved to
prepare a large amount of serum, to be tested in the manner adopted
in the case of the serum for diphtheria, namely, by its application to a
very large number of cases, severe and mild, and by comparing the
mortality among these cases with the mortality amongst a similar
group of patients not treated. For there remained the possibility of
the therapeutic serum, without producing a clear effect in every case
influencing to an appreciable extent the general mortality. No
decisive results have been reported.
There is, however, distinguished authority in favour of the system
of injecting a curative serum, and it is possible that better results
may be obtained on a future occasion.
* Annales de l'Institut Pasteur, 1895, pages 589—592. | † Append x I.
CHAP. IL]
Us causes and characteristics.
57
Remarks by
General Gatacre.
The following remarks on the subject occur in General Gatacre's
report :—
" Despite the apparent failure of the treatment to have an appre-
ciably beneficial effect on the disease, the Committee (i.e., the
Bombay Plague Committee] wish to draw attention to the fact
that it is based on sound laws of scientific experiment and research,
that these have not yet reached the full perfection which it is reason-
able to expect, that the serum first used by Dr. Yersin was of
feeble immunizing power, and that the subsequent operations of Dr.
Yersin at Cutch-Mandvi with anti-toxin serum of a higher standard
than that which he used in the first instance in Bombay, were attended
with more commendable results. "
Remarks by the
German Plague
Commission.
The opinion of the German Commission was as follows :—
" The experiments* as to cure made with strong serum showed it
undoubtedly possesses curative properties, though of course this can only
be held to apply to the animals on which the experiments were made.
Whether a similar curative action can be attained in the case of man
must not, as the observations on the similarly sensitive grey monkeys
show, be rashly concluded, but must be found out by observations in
men sick of the plague. In such cases it seems that up to the present
only the older weaker sorts of serum have been used. "
Experiments of
the Russian
Commission on
monkeys.
The Russian Commission also experimented on monkeys and
stated the following conclusion :—
" Nos expériences dans cette direction et pour lesquelles nous
avons employé 96 singes nous ont démontré que :
1°. Le sérum de Yersin peut guérir les singes malades lorsque le
traitement a été commencé presque deux jours après l'infection
sous-cutanée, et lorsque les symptômes de la peste sont déjà très
manifestes, élévation de température, bubons, etc ;
2°. Le traitement par le sérum n'est plus efficace lorsqu'il est com-
mencé trop tard, c'est-à-dire 24 heures avant la mort des singes qui
servent de contrôle ;
3°. La quantité indispensable de sérum pour obtenir le guérison
des singes n'est pas très grande ; en moyenne, il suffit d'injecter 20
c. c. de sérum actif au
\1/10\;
4°. Si la quantité de sérum injectée est trop faible, ou si le
traitement est entrepris trop tard, ou peut parfois obtenir la guérison,
mais quelquefois cette guérison n'est qu'apparente : il peut se pro-
duire une rechute, qui cause la mort des animaux après 15 ou 17
jours. "
* Made on monkeys.
8
58
Description of Plague:
[ CHAP. II.
Favourable
comments by the
Russian
Commission on
the Versin
treatment.
The members of the Russian Committee commented favourably on
the Yersin treatment :—
" En ce qui concerne le traitement des malades par le sérum de
Yersin, nous devons dire que dans plusieurs cas nous avons été a
même d'observer les effets intéressants et frappants de l'action de
ce sérum. Après l'injection la température s'abaisse, la somnolence ou
le délire disparaissent, le malade retrouve le bienêtre, En général,
les résultats n'ont pas été aussi bons que nous l'aurions désiré ;
ils ont cependant réduit la mortalité a 40 % sur les malades traités.
" Nos expériences nous ont pourtant montré que le sérum a une
efficacité qui n'est pas douteuse. Cette mortalité encore élevée
s'explique pas des causes suivantes :
" D'abord les malades n'entrent que très tard dans les hôpitaux
trois, quatre ou cinq jours après que la maladie est déclarée.
" Ensuite, nous ignorons quelle sera la durée de la maladie qui n'a
pas la même intensité dans chaque cas. Des malades meurent en
24 heures, d'autres survivent pendant 24 jours.
" La troisième cause est que les hommes montrent des degrés très
variés de sensibilité à l'infection. Celle-ci est plus uniforme chez
les singes.
" Dans les cas de pneumonie pesteuse, c'est souvent la présence
d'autres bactéries, pneumocoques et streptocoques, qui explique la
difficulté d'obtenir la guérison par le sérum.
" Nous espérons obtenir de meilleurs résultats avec le sérum anti-
toxique que le Dr. Roux vient de préparer, celui qui a été employé
jusqu' ici est plus préventif qu'antitoxique.
" Quand même un remède n'aurait sauvé que quelques vies, cela
serait suffisant pour le faire remarquer et encourager à l'étudier.
"En réalité, le sérum de Yersin a sauvé un grand nombre d'exis-
tences et nous devons très chaleureusement recommender cette
méthode de traitement. Le sérum reste d'ailleurs jusqu'ici l'unique
remède à employer dans le traitement de la peste,"
Unfavourable
comments by
Dr. Bitier.
Doctor Bitter's opinion is unfavourable :—
" Mais aussi le traitement spécifique par l'injection du sérum
antipestenx de Yersin n'a pas, d'après ma connaissance, donné des
résultats concluants. Au point de vue théorique il y aurait, à mon
avis, à faire les remarques suivantes, qui nous démontrent que les
statistiques, quant à l'efficacité du sérum, doivent être recueillies
avec beaucoup de soin. D'abord environ 50 % de tous les cas
de peste (sauf les cas pneumoniques) se guérissent par voie naturelle.
Its n'ont donc pas besoin d'une injection de sérum. Pour les cas qui
ont la tendance de finir par septicémie, je crois que l'injection du
CHAP. II.]
its causes and characteristics.
59
sérum doit avoir lieu dès le début de la maladie, alors que les
bacilles sont encore confinés dans le bubon primaire, si l'on veut
avoir une chance d'empêcher leur entrée dans le sang. Une fois la
septicémie établie, a mon avis on n'aurait qu'une chance infinie
d'arrêter l'issue fatale même en employant un sérum tres fort. "
If Dr. Bitter's view is correct, M. Haffkine's experiments on
patients so far advanced in the disease that their recovery under
ordinary circumstances was hopeless could not have had a successful
issue.
Preventive Inoculation.
More hopeful
results of
preventive
inoculation.
A more extensive trial was given to the system of preventive
it oculation worked out by M. Haffkine, and on the whole with
more hopeful results.
M. Haffkine's
description of the
principle.
Ina report,* dated the 16th January 1897, he described the princi-
ple on which the inoculation system is based in the following terms :—
" In the course of the present researches I have found different
media which give rich cultures of the plague bacillus, permitting to
cultivate them in abundant and concentrated quantities.
"The virulence of these cultures is shown by the fact that 1 or 2
minims are sufficient to communicate certain death to the larger
rodents.
"The destruction of the bacilli in the culture by delicate processes,
such as the addition of essence of mustard, of very weak solutions of
carbolic acid, or by dessication, or by heat, deprives these cultures of
their fatal properties and makes a dose forty to fifty times bigger
than the fatal one, quite harmless to the animals.
"But while depriving the cultures of their noxious properties, the
above processes leave to them the powers of protecting the system
against fatal infection.
" Rodents which have had an injection of such cultures (with
microbes killed in them), when infected five days after the prophylactic
treatment, stand easily a dose which would be fatal to ¿en other not
protected animals. "
M. Haffkine's
inoculation of
himself.
Having established these facts, M. Haffkine caused himself to be
inoculated on the 10th January in order to observe the symptoms of
the operation in man. He suffered pain at the seat of inoculation, a
rise of temperature (maximum 102°F.), slight headache and a feeling
of faintness. The temperature became normal after 24 hours.
* Appendix I, Paper No. 12.
6o
Description of Plague :
[CHAP. II.
Persons
inoculated up to
the end of May.
Subsequently many persons were inoculated both by M. Haffkine
and by medical officers who were instructed by him. On the 31st of
May the Government of Bombay reported that 7,874 persons had
been inoculated in Bombay, and 4,352 in other places. The process
is still being continued and is being more widely adopted.
Experiments in
the Byculla Jail,
Bombay.
On the 17th February 1897, M, Haffkine submitted a report* on
experiments made with the prophylaoctic serum during an outbreak of
plague in the Byculla Jail at Bombay. Between the 23rd and 2glh
January nine cases of plague occurred in the jail, of which five proved
fatal. The population of the jail at the beginning of the outbreak
numbered 345. The prophylactic treatment was applied on the 30th
January, 154 out of a total of 337 volunteering to be inoculated. The
following is the result recorded by M. Haffkine. In an average
daily strength of 173 non-inoculated persons 12 cases occurred, of
which 6 proved fatal. In an average daily strength of 148 inoculated
persons 2 cases occurred, neither of which was fatal.
General
result
of 7,905 inocula-
tions.
In a report,* dated the 14th July 1897, M. Haffkine summarises
the general results of the experiments with the prophylactic serum
(excluding the Byculla Jail experiment) as follows :—
" Amongst the 7,905 persons inoculated in Bombay during the
epidemic, and who all came from the most threatened localities and
homes, there were
*
*
*
:—
(a) two persons who were already unwell at the time of
inoculation, and who developed unmistakeable plague
within the next twelve hours ; they eventually suc-
cumbed ;
(b) and sixteen persons, who were attacked more than twelve
hours after inoculation, and all recovered."
M. Haffkine remarks that he is specially confident with regard to
the number of fatal cases reported, whereas in the number of cases
which ended in recovery there may have been neglect in reporting,
as a large proportion of the cases were exceedingly mild. Any
increase in the number of cases ending in recovery would, M.
Haffkine observes, put in a still more satisfactory light the small
mortality among persons attacked by plague after inoculation.
Circumstances
militating
against the force
of the conclu-
sions.
Circumstances militating against the force of the conclusions to
be derived from these experiments are that the subsequent history
of the persons inoculated is not fully known, and that the inoculation
was to a large extent performed when the plague was on the wane
and on classes of persons not the most likely to contract plague.
* Appendix I.
CHAP. II.]
ils causes and characteristics.
61
The result nevertheless may be regarded as hopeful. The experiments
were followed by several of the medical officers employed on plague
duty in Bombay, and their opinion is distinctly favourable to the system.
Later report on
experiments at
Daman.
General results.
Inoculation in
homogeneous
groups oí
persons.
The objections alluded to above are of less weight in the case of
the extensive and satisfactory experiments made during the virulent !
plague epidemic at Lower Daman, with regard to which M. Haffkine
and Surgeon-Major Lyons made a joint report in November 1897.
The investigation into the results of the inoculation was very care-
fully carried out, and the circumstances were specially favourable to
a complete examination owing to the existence of unusual facilities
for ascertaining the subsequent history of the persons inoculated. A
careful contrast was also made between the mortality among persons
who were and who were not inoculated, living under similar condi-
tions and therefore equally liable to infection. The period of observa-
tion extended from the 26th March to the end of May and the
observations were made with respect to the whole of the inhabitants
of the infected part of the place. At intervals 2,197 persons were
inoculated and it is estimated that there were 6,033 persons in the
place who remained uninoculated. Rather more than a quarter of
the inhabitants were thus inoculated. Among the 6,033 uninocu-
lated there were 1,482 deaths, giving a mortality of 24 6 per cent.,
while among the 2,197 inoculated there were 36 deaths, giving a
mortality of 16 per cent. According to these figures the reduction
in the rate of mortality was 89 2 per cent. M. Haffkine considers
that the result might have been better had not the serum used in
some of the experiments been too weak. The report contains the
following interesting summary of the results of inoculating a portion
of the members of homogeneous groups of persons living under
similar conditions :—
" In a large number of households the whole of the members of the
family were inoculated, leaving none for comparison as regards sus-
ceptibility to the disease. This circumstance rendered it necessary
to compare the whole inoculated population with the whole of the
uninoculated population, as has been done above. However, in 62 of
the inoculated families in which cases occurred, there were 124 persons
who remained uninoculated, while the number of inoculated in these
families was 250. A comparison between this fraction of the inocu-
lated population with their uninoculated relatives shows the following-
results :—
124 uninoculated had 54 cases (43 5 per cent.) with 37 deaths
(29 8 per cent., case mortality 68 5 per cent.),
250 inoculated had 50 cases (20 per cent.), with 20 deaths (8 per
cent., case mortality 40 per cent.).
62
Description of Plague :
[CHAP. II.
"The inoculated households lived, therefore, under no specially
immune conditions, as the mortality among their uninoculated mem-
bers, 29·8 per cent., was 5·2 per cent. higher than the mortality in
the general uninoculated population. This must invariably be the
case, as only people from badly-affected or particularly-threatened
localities present themselves for inoculation. It will be noticed also
that this small number of 124 uninoculated had a mortality higher by
I death than the total mortality sustained by the 2,197 inoculated
inhabitants of Daman ; and that a comparison between the inoculated
and uninoculated members of these families shows that if the 250
inoculated had exhibited the same susceptibility as their 124 unin-
oculated relatives, they should have had 75 deaths instead of 20—a
difference of 73·3 per cent. "
" A similar conclusion is arrived at on comparing the mortality in
the Parsee community ....
which shows that the inocu-
lated members gave a reduction of 97·4 per cent. of deaths when
compared with the uninoculated of the same community. "
Inoculation in
Poona.
In Mr. Rand's report on plague in Poona, where 1,249 persons
were inoculated up to the beginning of May, it is stated that " the
officers in charge of the various plague hospitals were instructed to note
whether any cases of plague occurred among persons who had been
inoculated. No such cases have been reported, which is evidence in
favour of the efficacy of Professor Haffkine's lymph. It has to be
remembered, however, that the inoculations were not commenced till
after the epidemic had passed its highest point, that a large pro-
portion of the persons inoculated did not live in a highly infected
locality, and that most of them did not belong to the classes that
have been the chief sufferers from the plague in Poona. "
Symptoms
after inoculation.
The inoculation frequently results in temporary fever and some
physical suffering, but there was only one case where, for a short
time, a question arose whether inoculation had caused the death of
a person. M. Haffkine reported that a Brahmin got an attack of
hemiplegia and died on the eleventh day, but that medical investiga-
tion showed that the attack was connected neither with plague nor
with the inoculation.
Experiments
made by the
German
Commission.
The following are the results of the experiments made by the
German Commission in immunising monkeys :—
" For the purpose of artificial immunisation living and fully
virulent cultivations can be used only in the case of animals that are
but little sensitive. It proved necessary to operate with killed cultiva-
tions which possess a more or less high degree of protective power,
as proved by the experiments performed, as well as by Haffkine's still