ON THE ETIOLOGY AND HYGIENE OF CHOLERA?PART II.
ISy
T.
Oughton, Staff
Assistant
Surgeon, Neemuch.
(Continued from page 150.^ understood, with reference to the third conclusion, by any means grant the necessity of there being a numerical parallelism between the admissions from one day to another. That such has been the case in former epidemics, as exemplified in the above tables, only proves the futility of the means which have been taken hitherto, by isolation or otherwise, to prevent susceptible persona coming into contact either with the patients themselves (primary centres) or with healthy and secondary centres; and the fault does not Let it be
that
we
do not
to lie so much in the Grst as in the second particular, wherein there seems to be great scope for future hygienic manipulation. Neither should the ratio of susceptible persona in a community, of necessity, bo a constant and invariable quantity, and here it behoves us, by tho employment of every useful measure of sanitation, to reduce this ratio to its smallest limit. seem
r
July 1,
ETIOLOGY AND HYGIENE OF CHOLERA.?EY T. OUGHTON.
1873.]
The fourth conclusion points to a very short period of incubation, and instances are not wanting in which healthy troops have been invaded by the disease within forty-eight hours of their arrival at an infected part. The recent epidemic at Neemuch which prove a short incubatory stage.? 59th regiment was taken very ill with cholera on 28th June last year, and was carried to the hospital on the back of two of his comrades: one of the latter was admitted into with cholera on the 30th June, and the furnishes two
examples, 1"^.?A private of the
other
on
instance. cholera
hospital 1st July,
the disease 2nd.?A soldier of the same the
carefully attended by
was
a
proving fatal in every regiment lying ill with comrade only a day or
the admission of the latter with all the sympprevious Let us suppose the stage of incubation toms of the disease. to be three days, and it may be understood quite in to
two
readily
what manner the remarkable sequence of cases, as shown in for the period of tue preceding tables, may be explained; incubation will be as dangerous, in accordance with the present tueory, as that of actual invasion. This consideration
suggests
important hygienic principle, viz., that any man who, district, is suffering from the slightest premonitory diarrhoea, should be immediately secluded from his neighbours and placed under medical supervision. It may be affirmed that more mischief is effected by a man having the incubatory symptoms who associates with his fellowmen than by a man who is actually down with the disease and confined in hospital. The following brief outline of an epidemic occurring in Her Majesty's 76th Regiment stationed at Thayetmyo in the year 1869 may be introduced in this place, not only because it indicates the course of enquiry that should be pursued by medical men in tracing the progress of a local epidemic, i.e., they should search earnestly for evidence of communication most
a
in
a
cholerous
either direct or indirect, between case and case, but likewise because it appears to illustrate the facts that are contained in the present head of argument, and to throw an encouraging light on the theory under consideration. It is the synopsis of a small portion of a report on this epidemic by Surgeon
Thompson, M.B., 76th Regiment, and is presented in of a diary for the sake of brevity. We may premise that the disease had been present in a neighbouring bazaar for some twelve or fifteen days previously, and would refer the W. A.
the form
reader to
a
perusal
of this valuable
report for further infor-
(See Army Medical Report, year 1869.) day.?Mrs. A, a soldier's wife, taken ill. Second day.?l'rivate B, from the same building First
Mrs. A,
admitted. Table III.
showing
EriDItMIC.
1st
the
grouping of
cases
Group.
of
2nd
Third day.?Child G, from the same building, admitted. Also Also child Mrs. D from a barrack-block, 60 yards distant. E admitted from a detached bungalow, a long distance from the infected barrack This child had breakfasted, however
on
the
buildings. morning of the second day
in the same
admitted from the camp in the fort.
Unfortunately
no
7 tli .1 uly -j to V
Neeniuch,
18G5
{ I t
llnltn, 1 b65
1
I
Umliaila, 1867 Chinsurah, 18G8
Thayetmyo,
1809
17th July ) 20 th Slay -j
f
to 3oth May j 20th J uue ) to
1st July 19th April to 29th April 7th April
?
tli April flth May to !)th May
i:
i
0
days
be admitted however that
a communication, either with a prisecondary centre (the child), may have actually existed, notwithstanding direct evidence of such a fact may
mary or
a
have been non-apparent.
Fourth day.?Child I admitted from the camp in the fort; private H. also, his wife
dying the same day. Fifth day.?Private admitted, whose child died the previous day. Mrs. K. also, living in the same building as Mrs. D.,? G.
another instance of short incubation. Sixtli day.?Private F., having been in attendance
on
day. Seventh day.?L., an ayah, in attendance on Mrs. K. The preceding brief epitome affords proof of a short incubatory stage, and abundant evidence of communication having been established between case and case, and transmission of the disease from one to the other. This is an outline merely of the first outbreak, and the report goes on to show that the in the
patients
hospital figured
very
in a
extensively
subsequent
outbreak. III. Another interesting feature in the natural history of cholera is the peculiar grouping of cases, as illustrated in Table III. A group of cases is followed by an interval of apparent health more or less prolonged, and to this succeeds a second and perhaps a third or fourth group of cases, each group being separated by the intervention of a period of general healthiness. There is are
in
a
an
apparent
state of silent
lull in the storm, but the elements neither can the epidemic
commotion;
regarded as having terminated until the complete cessation periodical outbreaks. Cases of diarrhoea crop up which become more frequent and are soon attended with bilious vomiting as well; the virus is strengthened gradually by the addition of increment to increment until the storm at length bursts forth with all its original furv. Are not such cases of
be
Cholera in several
July
epidemics (from Army
3rd
~\
j llOthAug. 7th
30
(.
19
?
99
?
days
'
100
Sept.
?
r
2
\
?
)
tilth July /
") V
4
?
31
?
)
May
Medical Reports).
4th
Group.
?
These
)
{(.
cases
29
)
Group.
}
)
23
?
June to June 30th Aug.
")
(,24th
)
f
39
days
5
days
\
/30th
Oct. J
("20th
(.2nd*Sept.
have reference to a different corps.
Nov.
I 2nd?Dec.
[
)
")
t to days i C 3rd N^ OV. J
.}
(_22ud
days 1
?let. Oct. ( 12th
26
13th Oct. to 16th Oct
(. (18th Oct.
->
t0 7th Aug. J
( 9th Sept. ")
](. 16thtoSept. )[ '
20th
V.22nd May ("3Uth July
.
*
3rd
)
1 6th?May j May t
32
to 25th Sept 3rd J uly*
his wife
since the third
Group.
2Gth
evidence
that either of these three sick persons had communicated with those taken ill previously, or that child E had called at the fort on its return homewards. It will
forthcoming
is
a
Peshawur, 1862
building
in which the first three cases had been seized; it is an interesting case, proving the period of incubation to have been less than thirty-six hours. Also Mrs. F, child G, and Mrs. H, were
of these
mation.
as
177
j*i (.
7th Sept. to 8th Sept
j
57
THE INDIAN MEDICAL GAZETTE.
?^g two
together
or
more
chain
consideration of the
given
from
And should they not, as an hygienic precaution, be confined within their own limits ? An interval of one hundred days of immunity is found to separate the first and second outbreak in the Neemuch epidemic
epidemic ?
(see table III), but it is reported that diarrhoea and dysentery were very prevalent during this period. Ilence it cannot be granted, if my theory be a correct one, that an epidemic terminated on the 30th May, and a second epidemic commenced on the 7th September. The only legitimate conclusion will be that the epidemic of that year extended from the 24th May to the 16th October, and it may be suggested whether it might not have been checked at the termination of the first outbreak by the exercise of a due amount of vigilance in discovering and eliminating such cases of diarrhoea and dysentery. IV. A third characteristic in the history of cholera, although drawn perhaps in less defined lines than the two already mento tioned, is the tendency that is manifested to confine itself certain districts (the sudder bazaar for instance) or castes. " This fondness for localisation," says Dr. W. A. Thompson, is often met in his history of the Epidemic at Thayetmyo, with during epidemic visitations, and is evidently one of the peculiarities of the disease." He speculates that the cause may be some organic substance having the property of assisting the propagation and activity of the poison for the time being; of 1865
mild
"
and he continues:?""What this substance, or influence, or I have before stated atom may be, has yet to be discovered. that there was nothing of an insanitary character to be discovered in the buildings attacked or in their vicinity. Should the scourge visit the cantonment next year, it will probably
select a different site for its ravages." The present theory would accord such influence of localisation to the well-known intercourse subsisting between the members residing in different sections of a district or town, as well as to the cliques of different castes in India. That locality has little reference to the localisation of cholera, and intercourse every reference, would
be the lesson that has been conveyed by the Neemueh during 1872; whilst the other corps at this station have enjoyed more or less immunity from the disease, it has adhered to the soldiers of Iler Majesty's 59th Regiment with obstinate pertinacity?and this, notwithstanding the regiment has been shifted to five or six encamping grounds seem
epidemic
to
at
in various directions out of Neemuch.
markable localisation in about to all the
points
influence
infecting
of
since I was informed ment came
V. cal
The
question
this
can
re-
any particular tent or set of tents, the officer commanding the detach-
by
that of all the cases, about from the same tent.
man
Neither
particular
corps, although shifted of the compass, be attributed to an
one
thirty
has been asked
in
number,
publicly,?Does
communicate the disease to his
patients
two
only
the medi-
in
hospital impossible
under treatment with other complaints ? It would be to frame a reply to the above query which is founded upon indisputable proof, as the cholera cacozyme cannot be caught and examined, after the manner of the aearus scabiei, under the microscope. The judgment seems however to be materially assisted in
replying to the query affirmatively, by such considerations as the following:?1??.?Patients in hospital, and especially in military hospitals, are a isolated class of individuals.
comparatively
The inmates of the various small-pox, fever, or cholera hospitals, for instance, are not supposed to infect the 2nd.?There is scarcely community in their immediate
vicinity.
to the statement that " a cholera-report embraces the history of an outbreak the
an
exception
hospital."
among
invariably patients in
The following, in conclusion, are some of the indications in jespect of hygienic treatment which have been suggested by a
1873
previous remarks, and I purposely refrain to any plans of procedure having reference to the sanitary removal of a tendency to the all important condition of susceptibility, the disinfection of evacuations, &c., as not hearing on the matter in hand. Several useful measures of sanitation may undoubtedly be involved in the hypothesis oV which do not occur to primary and secondary infectious centres " Pioneer" newspaper, for the writer of these remarks. The
a
outbreaks in any
diarrhoea secondary centres of the disease, and links in which binds
[July 1,
alluding
instance, in reference to my former paper, advanced a most sensible suggestion wherein a central hospital system is advocated for adoption in infected towns and military cantonments. ls?.?The central hospital system, signifying the construction
a lazaretto or the establishment of tent in a central situation which every case should be immediately despatched from the different quarter of a town or different regimental corps, and having its staff of medical officers, hospital attendants, and servants, &c., all of whom are supposed to be maintained in a
of to
state
of
perfect quarantine
until the termination of the
epidemic,
appears to be a sound policy. It is not an uncommon practice for medical men to visit their neighbour's cases of cholera, and, considering the number of instances in which patients in hospital the first to show the disease, it is one to be discouraged merely satisfying a morbid curiosity without effecting any good end. The first case that occurred in the 1st West India Regiment at Bathurst in 1867 was that of a man in hospital with ophthalmia, and several cases were there lying in the colonial hospital at a short distance. Moreover, it not unfrequently happens that comrades will solicit the medical officer for permission to attend their fellow-soldiers during their sickness, an act of kindness which should be firmly denied them; an example of the evil arising from this practice has been given already. It is desirable, in cases where no sufficient are as
time has been afforded for the establishment of the central that a tent should be pitched at a little distance from hospitals as a preliminary measure for the reception of cholera cases, although even here there appears to be some
hospital system,
having a single medical officer to attend the two classes patients. Floating hospitals may be resorted to with advantage for the above purpose in important seaport towns. Ind.?Every case of diarrhoea, cholerine, or dysentery should be sedulously segregated for several days both during and for some period subsequent to an outbreak, whereby any fostering of an epidemic will be effectually minimised, There should be two wards or tents therefore in the central hospital system, viz., one for the reception of actual sickness and the other for secondary centres or suspicious cases. It is found in military life that the soldier is extremely loath to report himself sick, and the author identified a case of cholera by seeing a man vomiting in the barrack-square who confessed that lie had been suffering from looseness of the bowels for several days pre- ^ viously. So that, it would appear a duty on the part of the
risk in of
'
medical officer in
munities to search
charge
of
healthy
sections of troops
or
com-
for every such case and forward it immediately to the proper quarter. And let it he borne in mind with due emphasis that the cessation of any group of
diligently
appears to be the precious interval set apart for utilisation the hygiest, for the purpose of strictly eliminating every discoverable secondary centre and with a view to crushing tho
cases
by
at the onset. 3rd.?No vessel should be granted praetiquc on arrival from an infected part after a short voyage in which a case of
epidemic
diarrhoea has occurred on board during the voyage. This may appear to bo a severe, and perhaps unnecessary restriction, but it is justified in strict accordance with the present theory. Reference may be made likewise to the introduction of tho of 1865 into Gibraltar by tho 2nd battalion, 22nd on its arrival from Malta, where cholera was raging. Tho regiment was reported to have been " healthy and free
epidemic
Regiment,
from choleraic
touch"
previous
to
leaving Malta, and, wit
r
July 1,
CASE OF MALFORMATION.?BY A. GARDEN.
1873.]
the exception of one trifling continued to enjoy apparent
case
of diarrhoea at sea, the corps
good health for eight days after disembarkation, when a private presented himself to the medical officer in charge labouring under cholera (see Army Medical Keporf, "Vol. ), and hence the origin of the epidemic at this station.
4th.?The encampment of an infected regiment subserves the useful purpose of sub-dividing a body of men into a considerable number of small sections, but the success of the That measure has been very discouraging in several instances. it is a step in the right direction, seems to be proved however by the very mild epidemics among native regiments, where the men live in huddled
together
rooms
separate in
a
or
tents
instead of
barrack room. The failure is aggregated into too small a
being probably
due to the tents being compass, and I would suggest that a clear space of from 13 to 20 yards on every side of each tent would be found a useful modification of the camping system, by scattering the men and their intercourse. were, and would
Such a
perhaps
diminishing
plan would isolate each
tent as it render the inconvenient and constant
of camps an unnecessary procedure; on a case of occurring in any given tent, for instance, let it be immediately struck for disinfection, and its inmates transferred to another tent that is similarly removed at a distance of 15 the other tents. The men should not be or 20 yards from shifted indiscriminately from tent to tent?moreover each tent
shifting cholera
should have its allotted number of certain individuals. Another evil arises from soldiers crowding the canteen and
grouping
themselves about its precincts, and it appears that any danger arising from this source might be obviated by the beer and spirits being carried round periodically for sale. 5th. The convalescent from cholera should be isolated for several
days?a fortnight perhaps?after
symptoms.
The occasional
occurrence
the of
disappearance of all relapses would in-
dicate that a cure may not be equivalent to the entire removal of all traces of the cacozyme from the system.
^
179
ISy
T.
Oughton, Staff
Assistant
Surgeon, Neemuch.
(Continued from page 150.^ understood, with reference to the third conclusion, by any means grant the necessity of there being a numerical parallelism between the admissions from one day to another. That such has been the case in former epidemics, as exemplified in the above tables, only proves the futility of the means which have been taken hitherto, by isolation or otherwise, to prevent susceptible persona coming into contact either with the patients themselves (primary centres) or with healthy and secondary centres; and the fault does not Let it be
that
we
do not
to lie so much in the Grst as in the second particular, wherein there seems to be great scope for future hygienic manipulation. Neither should the ratio of susceptible persona in a community, of necessity, bo a constant and invariable quantity, and here it behoves us, by tho employment of every useful measure of sanitation, to reduce this ratio to its smallest limit. seem
r
July 1,
ETIOLOGY AND HYGIENE OF CHOLERA.?EY T. OUGHTON.
1873.]
The fourth conclusion points to a very short period of incubation, and instances are not wanting in which healthy troops have been invaded by the disease within forty-eight hours of their arrival at an infected part. The recent epidemic at Neemuch which prove a short incubatory stage.? 59th regiment was taken very ill with cholera on 28th June last year, and was carried to the hospital on the back of two of his comrades: one of the latter was admitted into with cholera on the 30th June, and the furnishes two
examples, 1"^.?A private of the
other
on
instance. cholera
hospital 1st July,
the disease 2nd.?A soldier of the same the
carefully attended by
was
a
proving fatal in every regiment lying ill with comrade only a day or
the admission of the latter with all the sympprevious Let us suppose the stage of incubation toms of the disease. to be three days, and it may be understood quite in to
two
readily
what manner the remarkable sequence of cases, as shown in for the period of tue preceding tables, may be explained; incubation will be as dangerous, in accordance with the present tueory, as that of actual invasion. This consideration
suggests
important hygienic principle, viz., that any man who, district, is suffering from the slightest premonitory diarrhoea, should be immediately secluded from his neighbours and placed under medical supervision. It may be affirmed that more mischief is effected by a man having the incubatory symptoms who associates with his fellowmen than by a man who is actually down with the disease and confined in hospital. The following brief outline of an epidemic occurring in Her Majesty's 76th Regiment stationed at Thayetmyo in the year 1869 may be introduced in this place, not only because it indicates the course of enquiry that should be pursued by medical men in tracing the progress of a local epidemic, i.e., they should search earnestly for evidence of communication most
a
in
a
cholerous
either direct or indirect, between case and case, but likewise because it appears to illustrate the facts that are contained in the present head of argument, and to throw an encouraging light on the theory under consideration. It is the synopsis of a small portion of a report on this epidemic by Surgeon
Thompson, M.B., 76th Regiment, and is presented in of a diary for the sake of brevity. We may premise that the disease had been present in a neighbouring bazaar for some twelve or fifteen days previously, and would refer the W. A.
the form
reader to
a
perusal
of this valuable
report for further infor-
(See Army Medical Report, year 1869.) day.?Mrs. A, a soldier's wife, taken ill. Second day.?l'rivate B, from the same building First
Mrs. A,
admitted. Table III.
showing
EriDItMIC.
1st
the
grouping of
cases
Group.
of
2nd
Third day.?Child G, from the same building, admitted. Also Also child Mrs. D from a barrack-block, 60 yards distant. E admitted from a detached bungalow, a long distance from the infected barrack This child had breakfasted, however
on
the
buildings. morning of the second day
in the same
admitted from the camp in the fort.
Unfortunately
no
7 tli .1 uly -j to V
Neeniuch,
18G5
{ I t
llnltn, 1 b65
1
I
Umliaila, 1867 Chinsurah, 18G8
Thayetmyo,
1809
17th July ) 20 th Slay -j
f
to 3oth May j 20th J uue ) to
1st July 19th April to 29th April 7th April
?
tli April flth May to !)th May
i:
i
0
days
be admitted however that
a communication, either with a prisecondary centre (the child), may have actually existed, notwithstanding direct evidence of such a fact may
mary or
a
have been non-apparent.
Fourth day.?Child I admitted from the camp in the fort; private H. also, his wife
dying the same day. Fifth day.?Private admitted, whose child died the previous day. Mrs. K. also, living in the same building as Mrs. D.,? G.
another instance of short incubation. Sixtli day.?Private F., having been in attendance
on
day. Seventh day.?L., an ayah, in attendance on Mrs. K. The preceding brief epitome affords proof of a short incubatory stage, and abundant evidence of communication having been established between case and case, and transmission of the disease from one to the other. This is an outline merely of the first outbreak, and the report goes on to show that the in the
patients
hospital figured
very
in a
extensively
subsequent
outbreak. III. Another interesting feature in the natural history of cholera is the peculiar grouping of cases, as illustrated in Table III. A group of cases is followed by an interval of apparent health more or less prolonged, and to this succeeds a second and perhaps a third or fourth group of cases, each group being separated by the intervention of a period of general healthiness. There is are
in
a
an
apparent
state of silent
lull in the storm, but the elements neither can the epidemic
commotion;
regarded as having terminated until the complete cessation periodical outbreaks. Cases of diarrhoea crop up which become more frequent and are soon attended with bilious vomiting as well; the virus is strengthened gradually by the addition of increment to increment until the storm at length bursts forth with all its original furv. Are not such cases of
be
Cholera in several
July
epidemics (from Army
3rd
~\
j llOthAug. 7th
30
(.
19
?
99
?
days
'
100
Sept.
?
r
2
\
?
)
tilth July /
") V
4
?
31
?
)
May
Medical Reports).
4th
Group.
?
These
)
{(.
cases
29
)
Group.
}
)
23
?
June to June 30th Aug.
")
(,24th
)
f
39
days
5
days
\
/30th
Oct. J
("20th
(.2nd*Sept.
have reference to a different corps.
Nov.
I 2nd?Dec.
[
)
")
t to days i C 3rd N^ OV. J
.}
(_22ud
days 1
?let. Oct. ( 12th
26
13th Oct. to 16th Oct
(. (18th Oct.
->
t0 7th Aug. J
( 9th Sept. ")
](. 16thtoSept. )[ '
20th
V.22nd May ("3Uth July
.
*
3rd
)
1 6th?May j May t
32
to 25th Sept 3rd J uly*
his wife
since the third
Group.
2Gth
evidence
that either of these three sick persons had communicated with those taken ill previously, or that child E had called at the fort on its return homewards. It will
forthcoming
is
a
Peshawur, 1862
building
in which the first three cases had been seized; it is an interesting case, proving the period of incubation to have been less than thirty-six hours. Also Mrs. F, child G, and Mrs. H, were
of these
mation.
as
177
j*i (.
7th Sept. to 8th Sept
j
57
THE INDIAN MEDICAL GAZETTE.
?^g two
together
or
more
chain
consideration of the
given
from
And should they not, as an hygienic precaution, be confined within their own limits ? An interval of one hundred days of immunity is found to separate the first and second outbreak in the Neemuch epidemic
epidemic ?
(see table III), but it is reported that diarrhoea and dysentery were very prevalent during this period. Ilence it cannot be granted, if my theory be a correct one, that an epidemic terminated on the 30th May, and a second epidemic commenced on the 7th September. The only legitimate conclusion will be that the epidemic of that year extended from the 24th May to the 16th October, and it may be suggested whether it might not have been checked at the termination of the first outbreak by the exercise of a due amount of vigilance in discovering and eliminating such cases of diarrhoea and dysentery. IV. A third characteristic in the history of cholera, although drawn perhaps in less defined lines than the two already mento tioned, is the tendency that is manifested to confine itself certain districts (the sudder bazaar for instance) or castes. " This fondness for localisation," says Dr. W. A. Thompson, is often met in his history of the Epidemic at Thayetmyo, with during epidemic visitations, and is evidently one of the peculiarities of the disease." He speculates that the cause may be some organic substance having the property of assisting the propagation and activity of the poison for the time being; of 1865
mild
"
and he continues:?""What this substance, or influence, or I have before stated atom may be, has yet to be discovered. that there was nothing of an insanitary character to be discovered in the buildings attacked or in their vicinity. Should the scourge visit the cantonment next year, it will probably
select a different site for its ravages." The present theory would accord such influence of localisation to the well-known intercourse subsisting between the members residing in different sections of a district or town, as well as to the cliques of different castes in India. That locality has little reference to the localisation of cholera, and intercourse every reference, would
be the lesson that has been conveyed by the Neemueh during 1872; whilst the other corps at this station have enjoyed more or less immunity from the disease, it has adhered to the soldiers of Iler Majesty's 59th Regiment with obstinate pertinacity?and this, notwithstanding the regiment has been shifted to five or six encamping grounds seem
epidemic
to
at
in various directions out of Neemuch.
markable localisation in about to all the
points
influence
infecting
of
since I was informed ment came
V. cal
The
question
this
can
re-
any particular tent or set of tents, the officer commanding the detach-
by
that of all the cases, about from the same tent.
man
Neither
particular
corps, although shifted of the compass, be attributed to an
one
thirty
has been asked
in
number,
publicly,?Does
communicate the disease to his
patients
two
only
the medi-
in
hospital impossible
under treatment with other complaints ? It would be to frame a reply to the above query which is founded upon indisputable proof, as the cholera cacozyme cannot be caught and examined, after the manner of the aearus scabiei, under the microscope. The judgment seems however to be materially assisted in
replying to the query affirmatively, by such considerations as the following:?1??.?Patients in hospital, and especially in military hospitals, are a isolated class of individuals.
comparatively
The inmates of the various small-pox, fever, or cholera hospitals, for instance, are not supposed to infect the 2nd.?There is scarcely community in their immediate
vicinity.
to the statement that " a cholera-report embraces the history of an outbreak the
an
exception
hospital."
among
invariably patients in
The following, in conclusion, are some of the indications in jespect of hygienic treatment which have been suggested by a
1873
previous remarks, and I purposely refrain to any plans of procedure having reference to the sanitary removal of a tendency to the all important condition of susceptibility, the disinfection of evacuations, &c., as not hearing on the matter in hand. Several useful measures of sanitation may undoubtedly be involved in the hypothesis oV which do not occur to primary and secondary infectious centres " Pioneer" newspaper, for the writer of these remarks. The
a
outbreaks in any
diarrhoea secondary centres of the disease, and links in which binds
[July 1,
alluding
instance, in reference to my former paper, advanced a most sensible suggestion wherein a central hospital system is advocated for adoption in infected towns and military cantonments. ls?.?The central hospital system, signifying the construction
a lazaretto or the establishment of tent in a central situation which every case should be immediately despatched from the different quarter of a town or different regimental corps, and having its staff of medical officers, hospital attendants, and servants, &c., all of whom are supposed to be maintained in a
of to
state
of
perfect quarantine
until the termination of the
epidemic,
appears to be a sound policy. It is not an uncommon practice for medical men to visit their neighbour's cases of cholera, and, considering the number of instances in which patients in hospital the first to show the disease, it is one to be discouraged merely satisfying a morbid curiosity without effecting any good end. The first case that occurred in the 1st West India Regiment at Bathurst in 1867 was that of a man in hospital with ophthalmia, and several cases were there lying in the colonial hospital at a short distance. Moreover, it not unfrequently happens that comrades will solicit the medical officer for permission to attend their fellow-soldiers during their sickness, an act of kindness which should be firmly denied them; an example of the evil arising from this practice has been given already. It is desirable, in cases where no sufficient are as
time has been afforded for the establishment of the central that a tent should be pitched at a little distance from hospitals as a preliminary measure for the reception of cholera cases, although even here there appears to be some
hospital system,
having a single medical officer to attend the two classes patients. Floating hospitals may be resorted to with advantage for the above purpose in important seaport towns. Ind.?Every case of diarrhoea, cholerine, or dysentery should be sedulously segregated for several days both during and for some period subsequent to an outbreak, whereby any fostering of an epidemic will be effectually minimised, There should be two wards or tents therefore in the central hospital system, viz., one for the reception of actual sickness and the other for secondary centres or suspicious cases. It is found in military life that the soldier is extremely loath to report himself sick, and the author identified a case of cholera by seeing a man vomiting in the barrack-square who confessed that lie had been suffering from looseness of the bowels for several days pre- ^ viously. So that, it would appear a duty on the part of the
risk in of
'
medical officer in
munities to search
charge
of
healthy
sections of troops
or
com-
for every such case and forward it immediately to the proper quarter. And let it he borne in mind with due emphasis that the cessation of any group of
diligently
appears to be the precious interval set apart for utilisation the hygiest, for the purpose of strictly eliminating every discoverable secondary centre and with a view to crushing tho
cases
by
at the onset. 3rd.?No vessel should be granted praetiquc on arrival from an infected part after a short voyage in which a case of
epidemic
diarrhoea has occurred on board during the voyage. This may appear to bo a severe, and perhaps unnecessary restriction, but it is justified in strict accordance with the present theory. Reference may be made likewise to the introduction of tho of 1865 into Gibraltar by tho 2nd battalion, 22nd on its arrival from Malta, where cholera was raging. Tho regiment was reported to have been " healthy and free
epidemic
Regiment,
from choleraic
touch"
previous
to
leaving Malta, and, wit
r
July 1,
CASE OF MALFORMATION.?BY A. GARDEN.
1873.]
the exception of one trifling continued to enjoy apparent
case
of diarrhoea at sea, the corps
good health for eight days after disembarkation, when a private presented himself to the medical officer in charge labouring under cholera (see Army Medical Keporf, "Vol. ), and hence the origin of the epidemic at this station.
4th.?The encampment of an infected regiment subserves the useful purpose of sub-dividing a body of men into a considerable number of small sections, but the success of the That measure has been very discouraging in several instances. it is a step in the right direction, seems to be proved however by the very mild epidemics among native regiments, where the men live in huddled
together
rooms
separate in
a
or
tents
instead of
barrack room. The failure is aggregated into too small a
being probably
due to the tents being compass, and I would suggest that a clear space of from 13 to 20 yards on every side of each tent would be found a useful modification of the camping system, by scattering the men and their intercourse. were, and would
Such a
perhaps
diminishing
plan would isolate each
tent as it render the inconvenient and constant
of camps an unnecessary procedure; on a case of occurring in any given tent, for instance, let it be immediately struck for disinfection, and its inmates transferred to another tent that is similarly removed at a distance of 15 the other tents. The men should not be or 20 yards from shifted indiscriminately from tent to tent?moreover each tent
shifting cholera
should have its allotted number of certain individuals. Another evil arises from soldiers crowding the canteen and
grouping
themselves about its precincts, and it appears that any danger arising from this source might be obviated by the beer and spirits being carried round periodically for sale. 5th. The convalescent from cholera should be isolated for several
days?a fortnight perhaps?after
symptoms.
The occasional
occurrence
the of
disappearance of all relapses would in-
dicate that a cure may not be equivalent to the entire removal of all traces of the cacozyme from the system.
^
179
