RETROGRADE VIEWS ON CHOLERA.? This report on the cholera epidemic of 1872 in Northern India forms, the author tells us, the first section of the ninth annual report of the Sanitary Commissioner with the Government of India. On account of its importance, copies of this section have been issued separately, and one is now before us. "We have read this report with the attention due to the reputation and to the official position of its author, and to the importance of the questions with which it deals. "We regret to say it has
rarely
been our furtune to meet with
a
more
disappointing
document. No one, we think, can read this report without being satisfied that the 150 pages of which it consists only give expression to a foregone conclusion. Consciously or unconsci* ."Report on the Cholera Epidemic of 1872 in Northern India. By J. M. Cnningham, ai.p., Surgeon-Major, Bengal Medical Service, Sanitary
Commissioner with the Government of India.
ously, Dr. Cuningham has been led captive by the theory of his able colleague, Dr. Bryden, that the sole agent worthy of serious notice in the propagation of cholera is air. We say this perfectly aware that, again and again in the report before us, Dr. Cuningham declares his intention of dealing with the question of the contagiousness of cholera, its diffusion by human intercourse or water contaminated by the excretions of cholera
affected persons, by no other method than a patient investigation of facts. Nor are we unmindful that the author says (section 121, page 35,) that " he does not write in support of the air-borne theory?" a statement involving as remarkable an exam' pie of self-deception as we have met with in the course of our reading or in the exercise of our critical duties. Dr. Cuningham gives in detail the progress of the epidemic from its " endemic area " in Lower Bengal. It must suffice to quote the passage in which he refers to the map prefixed to the
report.
"
Glancing
at the
map," he says," the epidemic
extend-
Febetjaet 2,
SELECTIONS.
1874.]
area, stretched upwards on the north-east, downwards on the south-west, and upwards again through the eastern districts of the North-West Provinces and through Oudh to Peshawur, and far beyond our frontier. And side by side is the tract which was either altogether exempted, or suffered so lightly that it cannot be included in the epidemic area, a tract which commences with Chota Nagpore, just outside the endemic area, and stretches for many hundreds of miles on to Ajmere, Scinde, and Cabul." Dr. Cuningham shows that, even within the epidemic area, although there is evidence of the general prevalence of an epidemic influence, the proportion of places that suffered was often very small. In Bengal Proper, out of a population estimated at 66, 856, 859, the deaths amounted to 46,901. In the North-Western Provinces the registered deaths amounted to 50,565. The disease was widely spread in Oudh. In the Punjab it was not violent, the western districts of the province escaping almost entirely. Cashmere suffered severely, while Afghanistan is said to have escaped. In Bokhara the epidemic was severe. The Central Provinces of British India were lightly visited, the disease having been confined to the south and south-west. In Berar it was slight. The epidemic affected the Bombay Presidency chiefly in the south. Scinde escaped altogether. In the Central Native States there is no registration of deaths; but the disease was severe only in a few places, although widely distributed. Cholera was more circumscribed in the Madras Presidency in 1872 than it was in 1871. In 1870, the mortality wa3 55.876 ; in 1871, it was 17,656 ; it fell in 1872 to 13,247. The deaths from cholera in British Burmah in 1872 were few. Turning to the European army of India, out of a strength of 77,235, including men, women, and children, there were 888 The disease was cases of cholera, of which 615 were fatal. almost confined to the troops serving in the Bengal Presidency, only two fatal cases having occurred among those serving in Madras, and 54 in Bombay. In this epidemic more hill-stations were attacked than was ever noticed before. Such was the general distribution of the disease. In the his report, Dr. Cuningham puts the opening paragraphs of " following questions: What is the history of this epidemic ? What are the facts connected with its spread and how do they tend to increase our knowledge ? Is cholera a contagious disease ? Is it a specific poison multiplied in those who are attacked, which is capable of being transmitted to, and of prodisseminaducing like symptoms in others ? and is it ted by means of water ? Or, setting aside the doctrine of contagion, both in the ordinary and modified acceptations of the term, is man the carrier of a specific entity from an infected locality, which germinates and bears its deadly fruit whenever the local conditions are suited to its growth ? Is human intercourse the great and indispensable means by which cholera is borne from its home and spread over the face of the earth?" The answers given to these momentous and the questions are to be sought for in the body of the report, evidence on which they are based in the so-called " Notes on outbreaks" appended to it. Dr. Cuningham denies that cholera is in any sense contagious, that it is a specific poison capable of multiplication in the bodies of those affected, or that it can be transmitted through the medium of water, or that human locomotion has anything to do with its propagation from place to place. It is hardly necessary to say that the above is wide as the poles asunder from the generally accepted doctrine of our highest sanitary authorities in Europe. We freely acknowledge that this is no reason for declining to examine the ground on which Dr. Cuningham rests it. This we have done; and we are constrained to say that, in our judgment, his proof fails at every point. From the carefully observed and recorded histories, not of one, but of many epidemics of cholera, not in India only, but in every country yet invaded by the disease, sanitarians in Europe believe that human locomotion is the means of its extension from one distant place to another; in other words, as Mr. Netten Itadcliffe has expressed it, " cholera does not travel, hut is carried?" while air and water are the main agents of its diffusion in the vicinity of a place into aided often by the agency of infected \ which it has been brought, or what has been contaminated clothing, bedding, by the excretions of those affected by the disease. To give the evidence rests would be to write the history of on which this opinion cholera ; and, strange as it may appear, one of our most imporDr. be himself. would tant witnesses Cuningham Turning to the "Notes of Outbreaks" appended to the report, let us take first the question of importation. Dr. Cuningham as it appears to us, shows the difficulty, nay the almost
ing out of the endemic
usually
truly, impossibility, of establishing round
a
station
or
cantonment
o5
really efficient quarantine, even with mounted and infantry troops aided by strong bodies of police. In spite of all such precautions, which he describes as most hateful to the people, men contrive to evade the sentries and pass to and fro. Yet, in the face of this, the evidence of non-importation by human locomotion contained in the "notes" consists throughout of such vague and negative statements as this, "the first case could not be traced to importation, nor was there any evidence to lead to the belief that the disease was spread by contagion." due to Again, "no reason to suppose that the first case was " notes." importation," and so on through every page of the What is the value of evidence such a3 this in a question of this kind ? Would Dr. Cuningham accept it himself if put forward by others? We think not; at all events, he can see the futility of it when he is arguing against quarantine. Even where importation seems in the highest degree probable from the " notes," Dr. Cuningham can shut his eyes or look another way. Thus, in the case of the artillery barracks in the cantonment of Lucknow, we are told, in the "notes," that the first case in the barracks occurred on the 6th of August, but that there had been other cases in the cantonment long previously, and some grasscutters of the artillery were seized shortly before any of the men ; yet it is gravely added, There was no question either of importation or of contagion," and so on. As regards the propagation of the disease by water contamination, Dr. Cuningham has the hardihood to commit himself, without the least reserve or qualification, to the following statement. " In India, where cholera is so prevalent, even in Lower Bengal, where it is always present, no case has ever been adduced in which there is good reason to believe that water contaminated with cholera evacuations has really produced cholera." Turning once more to the "Notes," we find the water evidence quite as unsatisfactory as that on importation. It is all of the same purely negative character. Unless all that has been published by the Sanitary Commissioners of India, and very notably by Dr. Cuningham himself, on the subject of Indian wells, tanks, and other sources of water-supply and channels of distribution, be altogether untrustworthy, we affirm without hesitation that, with the well-known habits and customs of the natives of India, nothing short of a miracle could prevent the excretions of cholera sufferers from contaminating the water-supply in innumerable instances in the course of so wide-spread an epidemic as this ; and, unless all the evidence on the effects of drinking water so contaminated observed and recorded in this and other countries, be entirely false and delusive, like results must again and again have followed, even if the facts and particulars have evaded the research of Dr. Cuningham and the observers on whose testimony he relies. In not a single instance recorded in the "Notes" does it appear that the water was subjected to anything worthy the name of examination. It is against all reasonable probability to suppose that, in this particular, there was anything exceptional in this epidemic, and that water-contamination did not contribute
in India, a
"
to its local diffusion. " The statements in the Notes" are generally to the following " effect. At Lahore The drainage is defective. There are 1,100 public and 300 private wells." At Meean Meer "The water used by the troops was supplied by a branch of the Baree Doab Canal. It is admitted to be open to pollution. People it when unobserved and against orders ; and not may wash in long before Dr. Cuningham's visit a dead body in an advanced was found in it." At the same nlace, stage of putrefaction ? the native troops drank from wells. In none of them could the cases of cholera which occurred be connected with the use The natives in the cantonment all of any particular well. " drank from wells." Again, Water drawn from these wells is naturally of excellent quality; but fault was found with the filtering arrangements, which rendered it impure." In a great many instances, indeed, the water arrangements are favourably the disease and the waterreported on, and any connection between " supply. so far as we can see in the Notes," is distinctly denied. Of the value of this evidence our readers must judge for themselves. With all this, no one is more emphatic than Dr. Cuningham on the necessity of a pure water-supply ; although, if impure water do so little harm as he seems to suppose, it is not easy to see the reason why. How far disinfection and isolation of the sick was attended with good, Dr. Cuningham declines to discuss, on the ground of insufficient data. The movement of troops from an infected locality is well spoken of, good having even followed such a partial movement as was made at Meean Meer ; he is, however, very earnest, and, we think, rightly so, in urging a more decided move. It i3 evident that, although an utter disbeliever in the possibility of infection by human inter-
50
THE INDIAN MEDICAL GAZETTE.
course, Dr. Cuningham believes in the deadly effects of living in an "infected locality," and in the danger of living in " infected buildings." No one, we add, in conclusion, is more aware how much the statements in this report run counter to received opinions than the Sanitary Commissioner himself. He may with truth be said to have the courage of his opinions, for he states them freely He admits that, if without qualification and without reserve. his views be right, we virtually go back to the same state of " ignorance in which we were a hundred years ago; adding, if we are on the wrong road, the sooner we go back the better." He even goes so far as to say that the opinions he controverts have prevented progress. This we take to be the most fallacious statement in the whole of this report. So far from this being the case, we contend that the doctrines to which he objects have been most fruitful in good results. To them, more than anything else, we in this country owe the blessing of our improved and improving water-supply. Calcutta would never have spent a million sterling in giving to her children the pure water-supply which has brought the death-rate from cholera, even in epidemic years, to a figure lower than has been known for thirty years, if sanitary reformers had not taught her a lesson which Dr. Cuningham wishes her to believe is a foolish fable; and, above all, it is to the happy prevalence of the doctrines which the Indian Sanitary Commissioner is doing his utmost to discredit, that England at this moment owes her immunity from cholera, which, introduced in the course of this year into London, Liverpool, and Southamptom, from foreign lands, where it widely prevailed, has on every occasion been " stamped out" before it had time to establish itself in its old haunts, and carry death to thousands of our countrymen.?The British Medical Journal.
[February 2,
1874.
rarely
been our furtune to meet with
a
more
disappointing
document. No one, we think, can read this report without being satisfied that the 150 pages of which it consists only give expression to a foregone conclusion. Consciously or unconsci* ."Report on the Cholera Epidemic of 1872 in Northern India. By J. M. Cnningham, ai.p., Surgeon-Major, Bengal Medical Service, Sanitary
Commissioner with the Government of India.
ously, Dr. Cuningham has been led captive by the theory of his able colleague, Dr. Bryden, that the sole agent worthy of serious notice in the propagation of cholera is air. We say this perfectly aware that, again and again in the report before us, Dr. Cuningham declares his intention of dealing with the question of the contagiousness of cholera, its diffusion by human intercourse or water contaminated by the excretions of cholera
affected persons, by no other method than a patient investigation of facts. Nor are we unmindful that the author says (section 121, page 35,) that " he does not write in support of the air-borne theory?" a statement involving as remarkable an exam' pie of self-deception as we have met with in the course of our reading or in the exercise of our critical duties. Dr. Cuningham gives in detail the progress of the epidemic from its " endemic area " in Lower Bengal. It must suffice to quote the passage in which he refers to the map prefixed to the
report.
"
Glancing
at the
map," he says," the epidemic
extend-
Febetjaet 2,
SELECTIONS.
1874.]
area, stretched upwards on the north-east, downwards on the south-west, and upwards again through the eastern districts of the North-West Provinces and through Oudh to Peshawur, and far beyond our frontier. And side by side is the tract which was either altogether exempted, or suffered so lightly that it cannot be included in the epidemic area, a tract which commences with Chota Nagpore, just outside the endemic area, and stretches for many hundreds of miles on to Ajmere, Scinde, and Cabul." Dr. Cuningham shows that, even within the epidemic area, although there is evidence of the general prevalence of an epidemic influence, the proportion of places that suffered was often very small. In Bengal Proper, out of a population estimated at 66, 856, 859, the deaths amounted to 46,901. In the North-Western Provinces the registered deaths amounted to 50,565. The disease was widely spread in Oudh. In the Punjab it was not violent, the western districts of the province escaping almost entirely. Cashmere suffered severely, while Afghanistan is said to have escaped. In Bokhara the epidemic was severe. The Central Provinces of British India were lightly visited, the disease having been confined to the south and south-west. In Berar it was slight. The epidemic affected the Bombay Presidency chiefly in the south. Scinde escaped altogether. In the Central Native States there is no registration of deaths; but the disease was severe only in a few places, although widely distributed. Cholera was more circumscribed in the Madras Presidency in 1872 than it was in 1871. In 1870, the mortality wa3 55.876 ; in 1871, it was 17,656 ; it fell in 1872 to 13,247. The deaths from cholera in British Burmah in 1872 were few. Turning to the European army of India, out of a strength of 77,235, including men, women, and children, there were 888 The disease was cases of cholera, of which 615 were fatal. almost confined to the troops serving in the Bengal Presidency, only two fatal cases having occurred among those serving in Madras, and 54 in Bombay. In this epidemic more hill-stations were attacked than was ever noticed before. Such was the general distribution of the disease. In the his report, Dr. Cuningham puts the opening paragraphs of " following questions: What is the history of this epidemic ? What are the facts connected with its spread and how do they tend to increase our knowledge ? Is cholera a contagious disease ? Is it a specific poison multiplied in those who are attacked, which is capable of being transmitted to, and of prodisseminaducing like symptoms in others ? and is it ted by means of water ? Or, setting aside the doctrine of contagion, both in the ordinary and modified acceptations of the term, is man the carrier of a specific entity from an infected locality, which germinates and bears its deadly fruit whenever the local conditions are suited to its growth ? Is human intercourse the great and indispensable means by which cholera is borne from its home and spread over the face of the earth?" The answers given to these momentous and the questions are to be sought for in the body of the report, evidence on which they are based in the so-called " Notes on outbreaks" appended to it. Dr. Cuningham denies that cholera is in any sense contagious, that it is a specific poison capable of multiplication in the bodies of those affected, or that it can be transmitted through the medium of water, or that human locomotion has anything to do with its propagation from place to place. It is hardly necessary to say that the above is wide as the poles asunder from the generally accepted doctrine of our highest sanitary authorities in Europe. We freely acknowledge that this is no reason for declining to examine the ground on which Dr. Cuningham rests it. This we have done; and we are constrained to say that, in our judgment, his proof fails at every point. From the carefully observed and recorded histories, not of one, but of many epidemics of cholera, not in India only, but in every country yet invaded by the disease, sanitarians in Europe believe that human locomotion is the means of its extension from one distant place to another; in other words, as Mr. Netten Itadcliffe has expressed it, " cholera does not travel, hut is carried?" while air and water are the main agents of its diffusion in the vicinity of a place into aided often by the agency of infected \ which it has been brought, or what has been contaminated clothing, bedding, by the excretions of those affected by the disease. To give the evidence rests would be to write the history of on which this opinion cholera ; and, strange as it may appear, one of our most imporDr. be himself. would tant witnesses Cuningham Turning to the "Notes of Outbreaks" appended to the report, let us take first the question of importation. Dr. Cuningham as it appears to us, shows the difficulty, nay the almost
ing out of the endemic
usually
truly, impossibility, of establishing round
a
station
or
cantonment
o5
really efficient quarantine, even with mounted and infantry troops aided by strong bodies of police. In spite of all such precautions, which he describes as most hateful to the people, men contrive to evade the sentries and pass to and fro. Yet, in the face of this, the evidence of non-importation by human locomotion contained in the "notes" consists throughout of such vague and negative statements as this, "the first case could not be traced to importation, nor was there any evidence to lead to the belief that the disease was spread by contagion." due to Again, "no reason to suppose that the first case was " notes." importation," and so on through every page of the What is the value of evidence such a3 this in a question of this kind ? Would Dr. Cuningham accept it himself if put forward by others? We think not; at all events, he can see the futility of it when he is arguing against quarantine. Even where importation seems in the highest degree probable from the " notes," Dr. Cuningham can shut his eyes or look another way. Thus, in the case of the artillery barracks in the cantonment of Lucknow, we are told, in the "notes," that the first case in the barracks occurred on the 6th of August, but that there had been other cases in the cantonment long previously, and some grasscutters of the artillery were seized shortly before any of the men ; yet it is gravely added, There was no question either of importation or of contagion," and so on. As regards the propagation of the disease by water contamination, Dr. Cuningham has the hardihood to commit himself, without the least reserve or qualification, to the following statement. " In India, where cholera is so prevalent, even in Lower Bengal, where it is always present, no case has ever been adduced in which there is good reason to believe that water contaminated with cholera evacuations has really produced cholera." Turning once more to the "Notes," we find the water evidence quite as unsatisfactory as that on importation. It is all of the same purely negative character. Unless all that has been published by the Sanitary Commissioners of India, and very notably by Dr. Cuningham himself, on the subject of Indian wells, tanks, and other sources of water-supply and channels of distribution, be altogether untrustworthy, we affirm without hesitation that, with the well-known habits and customs of the natives of India, nothing short of a miracle could prevent the excretions of cholera sufferers from contaminating the water-supply in innumerable instances in the course of so wide-spread an epidemic as this ; and, unless all the evidence on the effects of drinking water so contaminated observed and recorded in this and other countries, be entirely false and delusive, like results must again and again have followed, even if the facts and particulars have evaded the research of Dr. Cuningham and the observers on whose testimony he relies. In not a single instance recorded in the "Notes" does it appear that the water was subjected to anything worthy the name of examination. It is against all reasonable probability to suppose that, in this particular, there was anything exceptional in this epidemic, and that water-contamination did not contribute
in India, a
"
to its local diffusion. " The statements in the Notes" are generally to the following " effect. At Lahore The drainage is defective. There are 1,100 public and 300 private wells." At Meean Meer "The water used by the troops was supplied by a branch of the Baree Doab Canal. It is admitted to be open to pollution. People it when unobserved and against orders ; and not may wash in long before Dr. Cuningham's visit a dead body in an advanced was found in it." At the same nlace, stage of putrefaction ? the native troops drank from wells. In none of them could the cases of cholera which occurred be connected with the use The natives in the cantonment all of any particular well. " drank from wells." Again, Water drawn from these wells is naturally of excellent quality; but fault was found with the filtering arrangements, which rendered it impure." In a great many instances, indeed, the water arrangements are favourably the disease and the waterreported on, and any connection between " supply. so far as we can see in the Notes," is distinctly denied. Of the value of this evidence our readers must judge for themselves. With all this, no one is more emphatic than Dr. Cuningham on the necessity of a pure water-supply ; although, if impure water do so little harm as he seems to suppose, it is not easy to see the reason why. How far disinfection and isolation of the sick was attended with good, Dr. Cuningham declines to discuss, on the ground of insufficient data. The movement of troops from an infected locality is well spoken of, good having even followed such a partial movement as was made at Meean Meer ; he is, however, very earnest, and, we think, rightly so, in urging a more decided move. It i3 evident that, although an utter disbeliever in the possibility of infection by human inter-
50
THE INDIAN MEDICAL GAZETTE.
course, Dr. Cuningham believes in the deadly effects of living in an "infected locality," and in the danger of living in " infected buildings." No one, we add, in conclusion, is more aware how much the statements in this report run counter to received opinions than the Sanitary Commissioner himself. He may with truth be said to have the courage of his opinions, for he states them freely He admits that, if without qualification and without reserve. his views be right, we virtually go back to the same state of " ignorance in which we were a hundred years ago; adding, if we are on the wrong road, the sooner we go back the better." He even goes so far as to say that the opinions he controverts have prevented progress. This we take to be the most fallacious statement in the whole of this report. So far from this being the case, we contend that the doctrines to which he objects have been most fruitful in good results. To them, more than anything else, we in this country owe the blessing of our improved and improving water-supply. Calcutta would never have spent a million sterling in giving to her children the pure water-supply which has brought the death-rate from cholera, even in epidemic years, to a figure lower than has been known for thirty years, if sanitary reformers had not taught her a lesson which Dr. Cuningham wishes her to believe is a foolish fable; and, above all, it is to the happy prevalence of the doctrines which the Indian Sanitary Commissioner is doing his utmost to discredit, that England at this moment owes her immunity from cholera, which, introduced in the course of this year into London, Liverpool, and Southamptom, from foreign lands, where it widely prevailed, has on every occasion been " stamped out" before it had time to establish itself in its old haunts, and carry death to thousands of our countrymen.?The British Medical Journal.
[February 2,
1874.
