Jan. 1896.] HARE ON ANTT-CHOLTCRAIC INOCULATIONS IN ASSAM.

NOTES ON Dr. HAFFKINE'S ANTI-CHOLERA INOCULATIONS IN ASSAM, CACHAR AND SYLHET FROM OCTOBER 1894 TO JULY 1895.

By Surgeon-Captain Hare.

For observations on tlie effect of the anti- cholera inoculations, tlwre a?e probably no more suitable places in India than Assam, Cachar and Sylhet. Cholera is always present in one place or another; it is brought into the country every year by new coolies from the recruiting depots, and when introduced into a tea garden, it often spreads to the older residents,' and occasionally assumes an epidemic form. As Dr. Haffkine remarked in the pap r he read before the Indian Medical Congress, outbreaks of cholera among troops or in jails are very rare, and in the villsiges, where cholera exists among the free population; the history of the inoculated cannot afterwards be traced ; but on tea estates the coolie is exposed to the disease almost as much as the people in the surrounding villages, and his history can usually be followed.

It was in the hope of obtaining immediate observations on the protective effect of the in- oculations, that Dr. Haffkine visited Assam, and the result has been satisfactory, though the number inoculated is still too small to draw definite conclusions. The following table gives a detailed list of the

gardens on which inoculations were done. In all, there were 12,665 operations, including 8,553 first inoculations, and 4,142 second inoculations. The work was continued to the middle of July, and had it not been so late in the season, a

larger proportion would have been re-inoculated.

Table of Anti-cholera Inoculations 'performed from October loth, 1894, to July loth, 1895.

1st in- oculation.

Name of Garden.

Makum Tea Estate Assam Ry. & Trading Co Powai Ten. Estate Hukanpukri Tikak Colliery Hugrijan Tea Estate .. Balijan Tea Estate Sonajali Tea Estate

Kajurichcrra Raji^hat PusKuri Kalighat l.angla Sonatola Adamtilla Gambira Magheracherra Singlacherra Annipur Chargola Kalacherra Taroin

2nd in- oculation.

740 106 262 302 251 659 123 718

300 282 150 70 415 49 325 137 63 171

1,132

Remarks.

Lakhimpur, Assam.

260

230

559

J

Durransr, Assam.

1

j- South Sylhet.

Table of Anti-Cholera Inoculations, perfoi-japfr, frpfii October 15th, 18(J4, to July 1 bth i w/ ,?n

'i 11/ 11111;

1st in- 2nd 'in- oculation. oeulation.

H , fci,

II; ?)

? '' ' ( ?' ''.'?) I i; j i;. i! 11 ?) 1111 23 Digobar - ???4 Kurk^ori!; ' ;i) ?' ... 25 Ilathall i

10 INDIAN MEDICAL GAZETTE. [Jan. 1896.

be adopted to avoid the possibility of using them for the cultures. Every portion of the tube had to be examined in detail, and every particle of dirt scrutinized under a powerful lens. The parts where the growths were most liable to escape notice were around the inner borders of the cotton plug, where it came in contact with the glass, and on its free inner surface ; here one would often find a few spores of a mould, when the rest of the tube appeared free. Special attention had to be given to the microscopical examination of the cultures, taking specimens from those places where the naked e}Te appearance was suspicious, always remem- bering that an isolated growth which might have been so small as to escape even close observation would certainly develop in the incubator.

Sometimes foreign microbes were found microscopically, while the naked eye appearance of the cultures seemed good. The first time this occurred Dr. Haffkine thought the cultures were contaminated, until he examined the water which had been used to make the preparations. The origin of the foreign bodies was then o o obvious, the water had been taken from the household filter, which had been cleaned the same day. On several other occasions the same accident happened, and in the absence of distil- led water, he used soda water, which was

generally free from marked contamination. The Dose.?In the first days of the inocula-

tions in India, there was little previous ex- perience to determine what dose could be used with safety, and in Dr. Haffkine's early opera- tions in the Punjab and North-West Provinces the emulsions had often been too weak to cause

any marked reaction. In the gardens at Lakhim- pur, where the operations in Assam were first begun, a very small proportion of the inoculated had a marked rise of temperature ; but in Sylhet and Cachar, the dose was gradually increased, and an attempt was made to cause a reaction in every case. The quantity of vaccine for an adult is half a

cubic centimetre, and the measure of its strength is the amount of water added to make the emul- sion. In Lakhimpur and Tezpur water was added to ? up the agar, in Sylhet and Cachar it was reduced to then to between ? and -J-, and if the cultures had not been grown in favourable conditions less than this, the quantity of the dose remaining constant. If over 10^ of the inoculated had a temperature between 102? and 103?F. 16 to 20 hours after the operation, Dr. Haffkine considered that the strength of the dose had been sufficient. The reaction caused

by the increased doses was not exceptionally severe; most people were able to resume their work after 36 hours; though, when the strongest

? l

doses were given, there was a tendency for the swelling and pain at the seat of inoculation to persist longer than usual, and possibly for the fever to recur. After the above observation in

Kallein, the strength of the dose was reduced, and water was added to | the heighth of the agar. Immediate Effect of the Inoculation.?The

usual symptoms are as follows :?Nothing mark- ed occurs till about five hours after the opera- tion ; the patient then begins to feel faint, or has a slight rigour, with nausea and perhaps a loose stool, and the seat of inoculation becomes stiff, swollen and tender to the touch. . The feeling of faintness soon passes off, and the temperature rises till it reaches a maximum (102? to 103?F.) 8 to 10 hours later, the pain and swelling in the side increasing simultaneously. All the symptoms now diminish, the temperature reaches the normal within 24 hours of the time of the

inoculation, and after 36 hours the stiffness and

pain have become so insignificant that the patient is able to resume his ordinary occupations, though pressure on the side or any sudden movement will cause a feeling of uneasiness for a day or two more.

In certain of the inoculated the fever may be more severe, and may still be well marked 18 to 20 hours after the operation. In two Europeans the temperature rose to between 105? and 106?F: one had had cholera a year previously, the other was a medical officer in indifferent health. In those who have been suffering from ague the fever may recur periodically for a day or two. Sometimes people are met with on whom the vaccine has little effect, or even reduces their temperature below the normal.

Diarrhoea is a complication in 1 or Z?/o ; it is never of any significance. Vomiting is rare unless the stomach be irritable from injudicious feed- ing or drinking, and Dr. Haffkine relates one case in which he observed cramps to follow the

operation. The swelling in the side is occasion- ally observed to remain for some time or to appear again on the seventh or eighth day as a hard painful lump. In no case has sloughing of the tissues been known.

People of all ages were inoculated, young and old (from six months to eighty years), healthy and weakly, only excepting women in the last months of pregnancy, and people suffering from fever or who were markedly ill at the time of the operations. Children at the breast will have fever and sometimes diarrhoea after the mother's

inoculation, and it is possible that a child still in the womb might be affected in the same way.

The operation leaves no scar, and when the swelling and redness in the side have dis- appeared it becomes impossible to recognise an inoculated person with certainty ; hence the necessity to keep a very accurate record of the names, &c., of each person operated on. If some permanent mark could be made on the side, snch as a tattoo, it would simplify the collection of statistics. In a garden in Sylhet at the time of the first inoculations, a doubt arose whether a certain woman had been inoculated. Dr. Haff-

Jan. 189G.] ROGERS ON CREASOTE IN THE TREATMENT OF MALARIAL FEVERS. 11

kine examined her 24 hours after the operations, and finding she had no fever, told her to show her side, which she said was swollen and painful. Unfortunately for her she showed the right side instead of the left, and her deceit was discovered (the first inoculation is always given on the left side). Although she limped in her walk, and feigned pain on pressure, she had to ac- knowledge that she had made a mistake. Sup- posing this question had arisen a week later, when the local symptoms would have dis- appeared, there would have been no evidence by which to test her statement, except her name in the register, about which there was some question. A second case to the same effect :?Dr. Haff-

kine had just finished the reinoculations on a certain garden in Cachar ; a few days later it was authentically reported that a coolie belong- ing to the garden who had been tivice operated upon had died of cholera. The manager was absent from the garden when the report was made, but on his return he tried to find the man's name in the inoculatiou register, and failing, made personal enquiries from which it appeared that the coolie had never been inocu- lated, but that his relations had spread the report hoping to gain some advantage, and their word had been taken as correct by the hospital assistant who reported it. Had the man been permanently marked, it would have lessened the risk of such a mistake, and it shows how essential it is where the results of the inoculations are to be watched, to keep accurate registers of the inocu- lated, in the absence of a more permanent record. The length of time which may lapse between

the first and second inoculations has not yet been decided. On two gardens in South Sylhet, the coolies were reinoculated after a lapse of six to seven months without unusually severe effects. Dr. Haffkine when testing the microbe to be used for the second vaccine in Cachar, inoculated himself after an interval of two years with about three times the ordinary dose (| water). He had, I think, been inoculated twice previously ; his temperature taken at the time of the operation was OG^F., and 12 hours later it had risen to 101'4? or 4-6? of fever. The swelling at the seat of inoculation after an interval of a week or ten days, reappeared as a circumscribed painful lump, which was gradually absorbed.

The Microbes.?The microbes for the first vaccine were of the same race as had been attenuated in Europe some eight years pre- viously ; the cultures were characteristic, and it showed no tendency to degenerate. It was not, however, till the beginning of April that a microbe suitable for the second vaccine was found ; the one which had been in use hitherto had shown signs of involution, and Dr. Haffkine had abandoned it hoping to find another which would be healthy, and more suitable for the local operations than one of foreign origin. Post-mortem examinations from one cause or

another were rarely made, and. most of the

attempts to isolate the microbe were made from the dejecta. Commas from three different sources were isolated :?

1. The Kurkoori microbe was taken from the jejunum of a woman who died of what was described by Dr. Powell of Kallein as cholera of a viruleut type ; under the microscope it was small but characteristic. A.s a test of its viru-

lence -jV of an agar culture of 24 hours' growth was injected into the peritoneum of a guinea- pig weighing betweeu 350 to 400 grammes. The animal did not die.

2. The Silchar microbe was isolated from a

very feculent stool two days' old taken from a man who did not die. The test guinea-pig weighed 448 grammes ; of a tube was injected into the peritoneal cavity, and the animal died in 14 hours.

3. A microbe was isolated from a case of cholera at Badarpur in a child who recovered. It was discarded, as not likely to be strong. The choice of a microbe for the second vaccine

lay between Nos. 1 and 2. The former had cer- tain advantages, and it had been strongly recom- mended by Dr. Powell as a virulent microbe, but the test dose had failed to kill a guinea-pig. The Silchar microbe which had proved fatal was therefore chosen, and three preliminary passages were made to raise it to the " fixed strength." Dr. Haftkine inoculated himself with a culture from the second passage, and the Kurkoori, Digobar and Ilathall coolies were inoculated with cultures from the third passage. As the

microscopical appearance of this microbe was not satisfactory it was abandoned in favour of the Kurkoori microbe, which was used for all the subsequent operations.

Dr. Haffkiue isolated these microbes without the aid of peptone. Small quantities of cholera dejecta were placed in cups (previously boiled and covered with paper), diluted with an equal quantity of water, and put aside in a warm place ; the microbe was found in colonies in tho surface film in from 10 to 24 hours.