ON CHOLERA. By Surgeon-Major W. E.
SAUNDERS,
Medical Staff. jiiVERY tew years, tliougli the interval happily is becoming greater, the whole of Europe is startled by an announcement in the columns of the daily papers, that epidemic cholera has appeared in the East; and its spread is watched with the greatest interest, lest it should reach some port in the south of Europe aud obtain a hold there. It is then that people awake from a state of lethargy, and demand that the sanitary authorities at the various seaport towns shall exercise greater vigilance, lest by any chauce the dread enemy invade their land and work its terrible havoc, such as we witnessed on the Sanitation continent only a year or two ago. then becomes a common topic of conversation, and measures proposed many years ago are brought up to be again discussed, aud perhaps after the scare has passed away, once more thrown aside, in consequence of the apathy and indifference shown by most persons in all sanitary matters affecting the public health. Fortunately in England this has much improved of late years, and people are now beginuing to take a much greater interest in the welfare of their fellow-creatures than formerly, and recognize the fact that many an outbreak would have been robbed of half its terrors had a greater state of purity of water and air been maintained aud the laws of health more strictly observed. It is fortunate that such epidemics, as lately visited the continent of Europe, are not more frequent; for life and morality would be altogether different from what they are if men and women were often compelled to live in that state of uncertainty which results from the conditions prevailing in a large city in the presence of a pestilence. Boccaoio has shown us, in his description of the plague that raged at Florence in the middle of the 14th century, what life may become under such conditions. The sense of helplessness produced recklessness, and " eat, drink, aud be merry, for to-morrow we " became the rule of life, at all events may die to those who had the necessary means. Saui-
Dr. SAUNDERS ON CHOLERA.
Dec., 1887.] tary science, however, lists
to sucli an condition of affairs is never recur again; but still there can be no doubt that abnormal conditions of life produce extraordinary developments of conduct. It is not merely that cholera has broken out which is the object of peculiar dread, but the factthat any partial outbreak of the disease may, under favourable conditions, become a general one. Fortunately, the favouring conditions are not now so frequently found existing, but what those conditions are which cause an endemic disease to become epidemic have yet to be fully extent since
then, likely to
that such
developed a
recognised.
The epidemic properties that are added to the endemic in certain localities, appear to have some relation to the meteorological phenomena of particular seasons of the The ye ar. cholera seasons of some places in India are
well-known. The great lesson to be learnt from previous epidemics is, that where there has been sanitary
with the presence of a dense cholera may be expected to matter whether the scene of its Indiau shrine or a Transatlantic
neglect, coupled population, there
originate,
ravages is
city.
110 an
towns of
England, where they took lessons taught, introduced a good water-supply, and improved the sanitary state in general, escaped altogether 011 its reappearance ; or else when introduced it failed to take any hold on the place. It will now be advisable to review some of the facts observed in previous outbreaks of cholera; and by investigating these, some light will be thrown 011 the etiology of the disease, and the precautions necessary to arrest its spread, and prevent its reappearance. The valley of the Ganges in lower Bengal has been called the home of cholera; and nearly all the epidemics that have visited Europe are supposed to have spread from that locality ; which means that endemic cholera if it bursts beyond its usual bounds in Hindustan becomes epidemic. But this is not the only home of cholera, though as regards Europe it for definite outmay have been the chief one, breaks have occurred in China which certainly had not come from India; and it is possible, indeed probable, that it has also originated in other countries such as the coast towns of Mexico, Cuba, Algeria, Mauritius, Java, and the deltas of great rivers. In Russia, the epidemic of 1869 71 commenced distinctly at Kiev in the interior ot the to the south, as country, while all the districts far as the Black Sea and Persian frontier, were quite free from it. The epidemic in Egypt iit originated in the delta of the Nile, piobably be adinstances other might and Daimietta, is the greatest endemic duced. Certain
liome the
Bengal proper
361
ami
perennial area of cholera ; but the N.-W* Provinces, Punjab, and Ouilh form the periodical or epidemic area of Hindustan. The season
which the cholera is at its minimum in the locality furnishes the maximum in the other. The meteorological conditions prevailing iu one or other area are in some respects assimilated at the time of the maximum prevalence iu each area. The first general fall of the rain extinguishes the disease in the endemic area, but fits every other province, lying within monsoon influence, for development of epidemics, if the cholera cause has already been distributed. In fact, each epidemic has been shown to be but a repetition of its predecessor. We must bear in mind that cholera re-appears in some places iu Upper India, in successive epidemics, almost to a day ; and it sometimes leaves off in* like manuer to a day. It enters one place and does not spread, but in another place, apparently similar, it spreads rapidly. It drops here and there in one town so capriciously as to seem trackless, in another it attacks, in successive epidemics, the same street, or even the same house. It sometimes occurs over a large tract of country almost simultaneously, and frequently fails to appear in an area contiguous to an infected one, human intercourse freely taking place between the affected aud non-infected areas. Locality is an important factor in the spread of cholera, and monsoon influences and other meteorological events allied thereto form essential factors in its spread; as these vary much from time to time, it becomes easy to understand why it spreads in one year and not in another. When heat and moisture reappear, a previously dormant infective poison is said to become free to act again, though there is no proof that this actually occurs. Individual cases iu the last quarter of the year very constantly precede the appearance of cholera in the following spring; these are also the seasons when enteric cases mostly occur. Cholera seldom if ever appears in India before the 20th of April in any year, unless prolonged from the previous year; in other words, not till after the gathering ut Hurdwar, where I take it the at
one
poison is,
more
so
to
active and
speak, manufactured by adding poisonous qualities to a pre-
I do not meau it to be inferred poison is originated for ex nihilo nihil Jit, but only the "development of new qualities in a pre-existing organism. In India, whenever people are massed to-
existing poison. that
a
new
and sanitary precautions are neglected, there you may confidently expect to find cholera carrying off its victims. The mode of life in an extreme among pilgrims is unhygienic at such places. assembled when These degree, conditions exist in peculiar force in connection with these pilgrimages to sacred spots, which The are so characteristic of Indian life.
gether
people
47
362
THE INDIAN MEDICAL GAZETTE.
who visit these shrines are much reduced by the fatigues of long journies, with privations of all kinds, and by sickness contracted on the road; and their condition does not improve much for years after. I firmly believe that the great pilgrim gatherings at Hurdwar and other spots are the starting points of many epidemics of cholera, in spite of the recent attempts to show that these fairs have nothing whatever to do with the spread of cholera. It is said that the people, when dispersing from Hurdwar, go in every direction, but that cholera always There may, however, be travels one way only. some reason for this which will some day be discovered ; but there can be little doubt that to such occasions as these several more or less serious outbreaks of cholera are to be traced. Cholera was very prevalent in parts of the Bombay presidency, in the cold season of 1884-85, because there was a fair at a shrine at Nassick in November, 1884, which was largely attended ; and cholera followed the track of the pilgrims on their homeward journey. Again, in May, India was visited Central 1885, by an outbreak of cholera which attained great proportions. One of these sacred gatherings took place at the city of Oojein, and occurring, as it does, only once in twelve years, was attended by a vast concourse of people from all parts, some The same even came from Scinde to visit it. tale of woe followed, thousands died of cholera, In consequence of this and other diseases. fair Mhow was visited by an outbreak of cholera, the like of which was never seen there before ; and the place was panic-struck in consequence. This was a very clear instance of being due to pilgrimages. The city of Oojein is about 150 miles in round numbers from Mhow, to the northeast and six hours or so by rail, which had not been open many years. Numbers of people left Mhow to visit the fair. Although cholera appeared soon, others followed their example, in spite of the warning given, and were present at the end of the festival, which broke up on the 29th of April. On this date a large number returned late at night by rail, and were encamped on an outside the cantonment (to leeward open spot, of the bazar) near the Epidemic Hospital, where they were detained in a sort of quarantine camp, which no doubt would have answered well, had not the people been too sharp for After thisTew came back by rail, the police. for they, finding they would be detained there, took tickets to some other station near Mhow, and walked in the remainder of the way, thus were not defeating the whole plan; for they came direct unless of the out they place kept at Mhow by rail. The first case that occurred who of a was the wife feeling ill at buniah, occurred of cholera case already having Oojein (a in the family) had returned at once by rail on the 1st of April. The following night at
[Dec.,
1887.
cholera, and died April. According to request I made a -post-mortem examination on this case, as some doubt was expressed regarding it, and 1 reported it to be a very virulent form of The body, eight hours after death, was cholera. in the typical fighting attitude, which once seen
9 P.M. she was attacked by about 6 A.M. on the 3rd of
will
never
be forgotten
;
the skin shrunken and
leathery, the face distorted, the eyes were sunken and parched up ; the mouth also. On opening the body the lungs were dry and collapsed ; the heart was firmly contracted, small and empty; the stomach was inflamed in patches; tlie small intestines were injected and of a pinkish tinge, contained some undigested food, and rice water fluid, the ileum, especially at the lower end, seemed pale and sodden ; the large intestine normal. Liver small, pale, and rather fatty ;
full. Bladder empty. There was intense catarrh of both kidneys. The following day two more cases occurred in the same family (April 4th); her daughter who attended on her was attacked and died ; and the other was a relative who had not been out of Mhow, but she recovered. During the next 36 hours six more cases occurred in people who had The returned from Oojein, but all recovered. weather was very hot and thundery at the time. Ou the 16th four more cases occurred, all of them proving fatal; and at the end of the month were reported, most of them a few more cases So that from the 3rd April to the 3rd fatal. May, there were altogether 27 cases, of which 15 died; the percentage being 55 per cent, of total Table I shows the number of cases reported. cases as they were reported, and it will be noticed that, contrary to the usual rule, they were just at the eud of the epidemic as at the as fatal beginning. Table number II gives the deaths according to castes, but,as this was compiled after all was over, the deaths are shown ou the dates when they actually occurred, and not in the way the other table was compiled; the numbers therefore do not agree. It includes only those cases that happened after the epidemic assumed large proportions, viz., the 3rd of May. It was on this day that the epidemic really began, and was severe for about ten days, when, with the exception of a second smaller outburst on the 25th and tew following days, it gradually subsided ; and after the 21st of June no more cases appeared. At the beginning most of the cases occurred among the Narnowli buniahs, who appear to have met on the night of the 2nd May lor a big feast of flour, coarse sugar (jagree)> ghee, and curds of milk. This mixture was allowed to stand all night in brass vessels, and' consumed the following day, portions being distributed to the poor. Now, a large number of those who partook of this feast were attacked with cholera, the greater number of cases proving fatal on the night of the 3rd aud moruiug of the
gallbladder much
Dr. SAUNDERS ON CHOLERA.
Dec., 1887.J
Central
Table 1.
Showing
the number
of admissions
cholera in the Cantonment of Mhow,
of April, May,
and
April
June,
and deaths
from
during the months
1885.
May.
India?1885.
Table showing the number of deaths according
to castes
and the dates on which they occurred in the Cantonment of Mhow during May and June, 1885. Cases?381.
Deaths?284.
June. Dates.
Dates.
?
o
2 4 5 22 75 44 23 6 24 22 21 19 13 12
1 2 3 4 5 6 7 8 9 10 11 ]2 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Totals
363
1
CJi
O
i>>
1
u
S
1.1 m
..
S.S ri ^
a % Q ?" o>'d CO
OJ
id SS
0)
?
5-1 -13
m
SAUNDERS,
Medical Staff. jiiVERY tew years, tliougli the interval happily is becoming greater, the whole of Europe is startled by an announcement in the columns of the daily papers, that epidemic cholera has appeared in the East; and its spread is watched with the greatest interest, lest it should reach some port in the south of Europe aud obtain a hold there. It is then that people awake from a state of lethargy, and demand that the sanitary authorities at the various seaport towns shall exercise greater vigilance, lest by any chauce the dread enemy invade their land and work its terrible havoc, such as we witnessed on the Sanitation continent only a year or two ago. then becomes a common topic of conversation, and measures proposed many years ago are brought up to be again discussed, aud perhaps after the scare has passed away, once more thrown aside, in consequence of the apathy and indifference shown by most persons in all sanitary matters affecting the public health. Fortunately in England this has much improved of late years, and people are now beginuing to take a much greater interest in the welfare of their fellow-creatures than formerly, and recognize the fact that many an outbreak would have been robbed of half its terrors had a greater state of purity of water and air been maintained aud the laws of health more strictly observed. It is fortunate that such epidemics, as lately visited the continent of Europe, are not more frequent; for life and morality would be altogether different from what they are if men and women were often compelled to live in that state of uncertainty which results from the conditions prevailing in a large city in the presence of a pestilence. Boccaoio has shown us, in his description of the plague that raged at Florence in the middle of the 14th century, what life may become under such conditions. The sense of helplessness produced recklessness, and " eat, drink, aud be merry, for to-morrow we " became the rule of life, at all events may die to those who had the necessary means. Saui-
Dr. SAUNDERS ON CHOLERA.
Dec., 1887.] tary science, however, lists
to sucli an condition of affairs is never recur again; but still there can be no doubt that abnormal conditions of life produce extraordinary developments of conduct. It is not merely that cholera has broken out which is the object of peculiar dread, but the factthat any partial outbreak of the disease may, under favourable conditions, become a general one. Fortunately, the favouring conditions are not now so frequently found existing, but what those conditions are which cause an endemic disease to become epidemic have yet to be fully extent since
then, likely to
that such
developed a
recognised.
The epidemic properties that are added to the endemic in certain localities, appear to have some relation to the meteorological phenomena of particular seasons of the The ye ar. cholera seasons of some places in India are
well-known. The great lesson to be learnt from previous epidemics is, that where there has been sanitary
with the presence of a dense cholera may be expected to matter whether the scene of its Indiau shrine or a Transatlantic
neglect, coupled population, there
originate,
ravages is
city.
110 an
towns of
England, where they took lessons taught, introduced a good water-supply, and improved the sanitary state in general, escaped altogether 011 its reappearance ; or else when introduced it failed to take any hold on the place. It will now be advisable to review some of the facts observed in previous outbreaks of cholera; and by investigating these, some light will be thrown 011 the etiology of the disease, and the precautions necessary to arrest its spread, and prevent its reappearance. The valley of the Ganges in lower Bengal has been called the home of cholera; and nearly all the epidemics that have visited Europe are supposed to have spread from that locality ; which means that endemic cholera if it bursts beyond its usual bounds in Hindustan becomes epidemic. But this is not the only home of cholera, though as regards Europe it for definite outmay have been the chief one, breaks have occurred in China which certainly had not come from India; and it is possible, indeed probable, that it has also originated in other countries such as the coast towns of Mexico, Cuba, Algeria, Mauritius, Java, and the deltas of great rivers. In Russia, the epidemic of 1869 71 commenced distinctly at Kiev in the interior ot the to the south, as country, while all the districts far as the Black Sea and Persian frontier, were quite free from it. The epidemic in Egypt iit originated in the delta of the Nile, piobably be adinstances other might and Daimietta, is the greatest endemic duced. Certain
liome the
Bengal proper
361
ami
perennial area of cholera ; but the N.-W* Provinces, Punjab, and Ouilh form the periodical or epidemic area of Hindustan. The season
which the cholera is at its minimum in the locality furnishes the maximum in the other. The meteorological conditions prevailing iu one or other area are in some respects assimilated at the time of the maximum prevalence iu each area. The first general fall of the rain extinguishes the disease in the endemic area, but fits every other province, lying within monsoon influence, for development of epidemics, if the cholera cause has already been distributed. In fact, each epidemic has been shown to be but a repetition of its predecessor. We must bear in mind that cholera re-appears in some places iu Upper India, in successive epidemics, almost to a day ; and it sometimes leaves off in* like manuer to a day. It enters one place and does not spread, but in another place, apparently similar, it spreads rapidly. It drops here and there in one town so capriciously as to seem trackless, in another it attacks, in successive epidemics, the same street, or even the same house. It sometimes occurs over a large tract of country almost simultaneously, and frequently fails to appear in an area contiguous to an infected one, human intercourse freely taking place between the affected aud non-infected areas. Locality is an important factor in the spread of cholera, and monsoon influences and other meteorological events allied thereto form essential factors in its spread; as these vary much from time to time, it becomes easy to understand why it spreads in one year and not in another. When heat and moisture reappear, a previously dormant infective poison is said to become free to act again, though there is no proof that this actually occurs. Individual cases iu the last quarter of the year very constantly precede the appearance of cholera in the following spring; these are also the seasons when enteric cases mostly occur. Cholera seldom if ever appears in India before the 20th of April in any year, unless prolonged from the previous year; in other words, not till after the gathering ut Hurdwar, where I take it the at
one
poison is,
more
so
to
active and
speak, manufactured by adding poisonous qualities to a pre-
I do not meau it to be inferred poison is originated for ex nihilo nihil Jit, but only the "development of new qualities in a pre-existing organism. In India, whenever people are massed to-
existing poison. that
a
new
and sanitary precautions are neglected, there you may confidently expect to find cholera carrying off its victims. The mode of life in an extreme among pilgrims is unhygienic at such places. assembled when These degree, conditions exist in peculiar force in connection with these pilgrimages to sacred spots, which The are so characteristic of Indian life.
gether
people
47
362
THE INDIAN MEDICAL GAZETTE.
who visit these shrines are much reduced by the fatigues of long journies, with privations of all kinds, and by sickness contracted on the road; and their condition does not improve much for years after. I firmly believe that the great pilgrim gatherings at Hurdwar and other spots are the starting points of many epidemics of cholera, in spite of the recent attempts to show that these fairs have nothing whatever to do with the spread of cholera. It is said that the people, when dispersing from Hurdwar, go in every direction, but that cholera always There may, however, be travels one way only. some reason for this which will some day be discovered ; but there can be little doubt that to such occasions as these several more or less serious outbreaks of cholera are to be traced. Cholera was very prevalent in parts of the Bombay presidency, in the cold season of 1884-85, because there was a fair at a shrine at Nassick in November, 1884, which was largely attended ; and cholera followed the track of the pilgrims on their homeward journey. Again, in May, India was visited Central 1885, by an outbreak of cholera which attained great proportions. One of these sacred gatherings took place at the city of Oojein, and occurring, as it does, only once in twelve years, was attended by a vast concourse of people from all parts, some The same even came from Scinde to visit it. tale of woe followed, thousands died of cholera, In consequence of this and other diseases. fair Mhow was visited by an outbreak of cholera, the like of which was never seen there before ; and the place was panic-struck in consequence. This was a very clear instance of being due to pilgrimages. The city of Oojein is about 150 miles in round numbers from Mhow, to the northeast and six hours or so by rail, which had not been open many years. Numbers of people left Mhow to visit the fair. Although cholera appeared soon, others followed their example, in spite of the warning given, and were present at the end of the festival, which broke up on the 29th of April. On this date a large number returned late at night by rail, and were encamped on an outside the cantonment (to leeward open spot, of the bazar) near the Epidemic Hospital, where they were detained in a sort of quarantine camp, which no doubt would have answered well, had not the people been too sharp for After thisTew came back by rail, the police. for they, finding they would be detained there, took tickets to some other station near Mhow, and walked in the remainder of the way, thus were not defeating the whole plan; for they came direct unless of the out they place kept at Mhow by rail. The first case that occurred who of a was the wife feeling ill at buniah, occurred of cholera case already having Oojein (a in the family) had returned at once by rail on the 1st of April. The following night at
[Dec.,
1887.
cholera, and died April. According to request I made a -post-mortem examination on this case, as some doubt was expressed regarding it, and 1 reported it to be a very virulent form of The body, eight hours after death, was cholera. in the typical fighting attitude, which once seen
9 P.M. she was attacked by about 6 A.M. on the 3rd of
will
never
be forgotten
;
the skin shrunken and
leathery, the face distorted, the eyes were sunken and parched up ; the mouth also. On opening the body the lungs were dry and collapsed ; the heart was firmly contracted, small and empty; the stomach was inflamed in patches; tlie small intestines were injected and of a pinkish tinge, contained some undigested food, and rice water fluid, the ileum, especially at the lower end, seemed pale and sodden ; the large intestine normal. Liver small, pale, and rather fatty ;
full. Bladder empty. There was intense catarrh of both kidneys. The following day two more cases occurred in the same family (April 4th); her daughter who attended on her was attacked and died ; and the other was a relative who had not been out of Mhow, but she recovered. During the next 36 hours six more cases occurred in people who had The returned from Oojein, but all recovered. weather was very hot and thundery at the time. Ou the 16th four more cases occurred, all of them proving fatal; and at the end of the month were reported, most of them a few more cases So that from the 3rd April to the 3rd fatal. May, there were altogether 27 cases, of which 15 died; the percentage being 55 per cent, of total Table I shows the number of cases reported. cases as they were reported, and it will be noticed that, contrary to the usual rule, they were just at the eud of the epidemic as at the as fatal beginning. Table number II gives the deaths according to castes, but,as this was compiled after all was over, the deaths are shown ou the dates when they actually occurred, and not in the way the other table was compiled; the numbers therefore do not agree. It includes only those cases that happened after the epidemic assumed large proportions, viz., the 3rd of May. It was on this day that the epidemic really began, and was severe for about ten days, when, with the exception of a second smaller outburst on the 25th and tew following days, it gradually subsided ; and after the 21st of June no more cases appeared. At the beginning most of the cases occurred among the Narnowli buniahs, who appear to have met on the night of the 2nd May lor a big feast of flour, coarse sugar (jagree)> ghee, and curds of milk. This mixture was allowed to stand all night in brass vessels, and' consumed the following day, portions being distributed to the poor. Now, a large number of those who partook of this feast were attacked with cholera, the greater number of cases proving fatal on the night of the 3rd aud moruiug of the
gallbladder much
Dr. SAUNDERS ON CHOLERA.
Dec., 1887.J
Central
Table 1.
Showing
the number
of admissions
cholera in the Cantonment of Mhow,
of April, May,
and
April
June,
and deaths
from
during the months
1885.
May.
India?1885.
Table showing the number of deaths according
to castes
and the dates on which they occurred in the Cantonment of Mhow during May and June, 1885. Cases?381.
Deaths?284.
June. Dates.
Dates.
?
o
2 4 5 22 75 44 23 6 24 22 21 19 13 12
1 2 3 4 5 6 7 8 9 10 11 ]2 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Totals
363
1
CJi
O
i>>
1
u
S
1.1 m
..
S.S ri ^
a % Q ?" o>'d CO
OJ
id SS
0)
?
5-1 -13
m
