DR. CUNINOHAM ON CHOLELiA IN NORTHERN INDIA, 1872.*
QUIXOTIC ETIOLOGY'?
The Report of the Sanitary Commissioner with tlie Grovernment of India 011 the Cholera Epidemic of 1872 in Northern India, if it should not ultimately attain any higher position, does certainly hold a foremost place among the curiosities of medical literature. For some time in his annual reports, D r. Cuningham, when discussing questions relating to the etiology of cholera, has expressed opinions diverging widely from those commonly entertained in this country 011 the same subjects. In the present report he formulates his divergent views, and believes that he demonstrates, from the experience of the cholera epidemio of 1872 in Northern India, that the doctrines of the importability of cholera, and of the transmissibility of the disease through the medium of water, not only are disproved by observed facts in India, but also that the facts are such reasonable ground for their as equally show that there is 110 belief elsewhere. These doctrines," he holds, are the product of " the patient investigation of theoretical discussions," not of facts,?of all the facts so far as they can be ascertained j" and " it is to India we must look for their ratification, for 110 country in the world presents such a field for the study of cholera as India, where one portion is the home of the disease, and others are subject to such severe and fatal miasmas " (sec. 3). Hitherto observers have not merely failed to record all facts, but in particular they have disregarded negative facts, which, for purposes of investigation, are, according to Dr. Cuningham,''just as important and as necessary for forming a right conclusion" as positive facts (sec. 54) ; and the etiology of cholera, and indeed of other epidemic diseases, at least in the chiefly" discussed, has become largely a question of questions " In approaching the difficult questions connected authority." with any one of them, the first essential is to record the facts unswayed by prejudice and uninfluenced even by the opinions of the highest authority. This worship of authority, which is so common, is rot altogether unproductive of mischief. One medical officer, for example, whom we may call A, meets no fact in support of contagion or the water theory, but he believes in the authorities who support these views, and he concludes that although he has failed to find any such evidence, 13, C, D, and every other medical officer have been more fortunate. B does the same; so do C, 1), and so on. The consequence is, that events are often viewed through an * " Report on the Cholera Epidemic of 1872 in Northern India." By J. M. Cuningham, M.D., Surgeon-Mnjor, Bengal Medical Service, SanU Commissioner with the Government in India. Calcutta, 1873. tary
March 2,
1874.]
SELECTIONS.
ideal and therefore distorted medium, and much valuable advice is lost" (sec. 116). Dr. Cuniugham, happily placed for investigation, and holding that when we want to see our way in relation to cholera we are foiled by prejudice and authority, takes the observations made, as to that disease, in 1872, in Northern India, among 100 bodies of troops, and other communities, under careful medical supervision, and from these observations, given in the Appendix to the Report, checked by his own experience, he comes to the conclusions already stated. These conclusions, " lie admits, virtually put us hack to the same state of igno" rance as we were in a hundred if we are years agobut on a wrong road, the sooner we go back the better" (sec. 118). Now Dr. Cuniugham has undertaken to prove that we are in the wrong road, and to put us in the right road, in the moderate compass of 150 pages folio, report and appendix. We should be grateful to him for the compactness of his proof, as for the magnitude of its consequences, if we could really repose faith in it. But difficulties arise to such reception from the very beginning. It does not beget confidence to find Dr. Cuniugham (sec. 3) reiterating the popular fallacy, that because India is the home of cholera, it is therefore the place where, above all, it may be most clearly studied. The statement betrays a want of comprehension of the difficulties under which cholera is studied in India, which seriously compromises the judgment of the waiter. Dr. Cuningham's present report yields abundant evidence of the impossibility of studying exhaustively the etiology of cholera in the greater portion of the district to which his report refers ; an impossibility resting upon the necessary ignorance of very much relating to the disease which goes on among the native populations. India may be the place where the pathology of the disease can be best, because most continuously, studied ; but as to its movements and intimate etiology, these will, for a long time to come, admit of fullest observation among populations where the malady occurs at intervals, where a complete registration of the deaths and sickness from it is possible, and where its progress among all sections of society can be ascertained. What can be the value of negative evidence as to the importation of cholera (used in the English sense of the word) under conditions like the following, properly urged by Dr. Cuningham against internal quarantines??"Hundreds of grass-cutters, and other servants, must go out and in (the cantonments) daily. Supplies In many places the difficulty is must come from without. increased by the fact that they lie, like Umballa or Nowshera, The mails must on the great high road of communication. nor can ordinary traffic be pass, all travellers cannot be stopped, of the countrade arrested without interfering with the whole try. And in addition to the number of people who must not be stopped, there are the many who cannot be stopped." Dr. Cuningham rightly sees that the keystone of the etiolie attacks is the " contagiousness" of cholera. But this logy " contagiousness" he interprets in a way quite peculiar to himself. He treats of it from beginning to end as a question of personal contagion ; of the transmissibility of the disease directly from individual to individual, a question never seriously entertained by any person worthy of attention in these later days. This amazing error runs through the whole of the report and the appendix. The question discussed by Dr. Cuningham is not the contagiousness of cholera in the sense understood by our European teachers of mark, but it is the question, Does cholera spread like suiall-pox ? "Cholera," writes Dr. Cuningham, " is supposed to be analogous to small-pox (?) and on this a superstructure is raised which lias no real foundation, ^mall-pox, it is argued, is a contagious disease, and spreads only by contagion. Cholera belongs to the same class of contagious diseases, therefore it also spreads by contagion, and by contagion only. But do we know that small-pox spreads only by contagion ? Its annual rise and fall in this after country, recurring year year, are facts altogether inexplicable ou the doctrine of contagion, and prove incontestably that the law of contagion is not the law which governs the spread of it is the doctrine of contagion small-pox" (sec. 117). "Again, which has prevented progress. So long as men believe that all that is required to escape attack is to shun the sick, what interest can there be in sanitary progress (!)" (sec. 119). This marvellous doctrine of contagion, developed wholly out of Dr. Cuninghain's own consciousness, is that which is examined in reference to cholera in this report. The doctrine known in this country, in which the contagiousness of cholera is held to be peculiar to the disease, and to be developed under definite conditions, so far as this report is concerned, might never have
g3
It is with amazement we see that of this docforth in the masterly language of Mr. Simon, has done sucli enormous good in this country as directive both of sanitary and of scientific work, there does not appear to be any precise knowledge in Dr. Cuninghain's report, and the report of his co-adjutors, printed in the appendix. A Sancholike reference to the doctrine is made in sections 66 and 89, but merely to serve as a foil to Ur. Ouningham's astounding imaginations. Quixotic-like, his whole argument as to the contagiousness of cholera is addressed to his own conceptions. Similarly, in respect to the second great question, he raises the question of what he calls the " water theory." Dr. Cuningham is not dealing with the theory understood under that name in England, a theory applied to certain localisations of cholera. He treats of the theory which exists only in the minds of him-, self and certain other Indian epidemiologists. He treats of " the water theory irreconcilable with the geographical distribution of cholera!" (sec. 73). He writes of it as irreconcilable with the experience of " different camps, miles apart, supplied from altogether independent sources, and yet suffering severely from cholera !" (sec. 77). All this is sheer nonsense. He is not a whit more happy in dealing with it in respect to localised outbreaks. He gravely instances scattered cases in a community aa giving no support to it (e. g. of three cases in the Benares district jail, (p. 41). And in one instance, the St. Peter's College, Agra, where an outbreak must have suggested to English observers a probability of dissemination through water, he writes :?? " The history of the very violent outbreak in St. Peter's College, the most severe ever known in the whole course of the epidemic, is just one of those cases which should be explicable on the water theory, if the water theory is correct. But it admits of no such explanation. The water used by the boys was drawn from a well common to the College and a considerable native community, among whom, so far as is known, ten cases occurred. It may be argued that though nominally draion from the same source, in reality it was very likely taken from the College well employed in former years-~a ice 11 in most dangerous proximity to the old latrine, which is practically a well of filth close beside it. But this explanation accords with the fucts no better than the other, for the day boarders (twenty-seven in number) who drank of the same water as the boarders and orphans, and drank largely too?as I atn assured, and as might naturally be expected, in that very hot weather?all escaped, with the exception of one. Anxious to ascertain the circumstances under which the boy was attacked, I found on inquiry that he was the only one of the day scholars who lived close by?a fact which points strongly to localisation, not to water" (sec. 87). Now, we learn from a report in the appendix that this last-named dangerous well had been regularly used for the College till within six weeks of the outbreak, and that the supply was then obtained from a well a third of a mile away. It is obvious from Dr. Cuningham's statement that water could be taken from the dangerous well at the time of the outbreak, if the servants had thought fit to do so ; but in the detailed report there is not a trace of any inquiry such as might have been looked for, even " on the vague doctrine of impure water," as to the probable incidental use of the condemned water immediately preceding There were two sources of water at the the outbreak. command of the servants of the College; but it does not follow, as Dr. Cuningham assumes, that, if the bad source were incidentally used, it must be used by all persons frequenting the College alike. Dr. Cuningham cites this instance among others as " strikingly supporting the idea of the localisation of cholera in particular localities, dependent not on water, but on some other He says not a word of the drainas yet unknown condition." age of the College, and the detailed description of the outbreak in the appendix actually does not furnish the necessary data on this subject! It is not requisite to follow Dr. Cuningham's report in detail, for his entire argument is based on a complete misapprehension as to the doctrine of the contagion of cholera, and of the transmission of the disease through water, as maintained in this country. But as further showing how much the report falls short of that scientific character, the want of which he has so freely condemned in others, we may note that Dr. Cuningham discusses the question of importation of cholera, without any reference to the important facts recorded in tho appendix, that, with two or three exceptions, in all the districts under review, cholera is present from year to year. In answer to the question, "Does cholera (since railways) been enounced.
trine, which,
as
set
84
THE INDIAN MEDICAL GAZETTE.
travel any quicker now than it did before ?" lie gives a table of statistics from eight stations (Caw n pore, Allahabad, Agra, Meerut, Umballa, Kassonlie, Meean Meer) to show that " cases occur no earlier in the year, than they did before." He makes no reference to the fact that, according to the table and the data in the appendix, no year, not even at Kassonlie, passes without, cholera, and that the question of "travelling," as he puts it, could not have place with regard to any one of them. "There is nothing more remarkable," writes Dr. Cuningham, "regarding cholera than its localisation in particular quarters Abundant illusof a place, and even in particular buildings." In this tration of this fact is to be found in the report. respect, at least, cholera acts in India as it does in England. It. is to such localisation that the docrine of the peculiar contagiousness and mode of contagiousness held in England applies; and that the doctrine equally applies to India we have not the least doubt. Neither have we any doubt, as this report most fully shows, that this doctrine and its important practical applications are to the present time gravely misapprehended in India. Dr. Cuningham's observations on the importance of thorough drainage and of a pure water-supply read like a reductio ad absurdum after his discussion of the questions to which he has referred and the canons of observation he has laid down. If the negative facts are to be used as he would have them used, his opinions in these respects must have a like direction as his opinions on the contagiousness of cholera and on water as a cholera-carrier. Bad drainage and an impure water-supply are the common conditions of Indian towns, villages, and stations, but so is not cholera ; and the case is infinitely stronger against the influence of these conditions (as I)r. Cuningham argues) than against contagion and watercarrying. No number of apparent negatives can outweigh a positive, fact, and the single instance of the Theydon I3ois outbreak in 1865, to which Dr. Cuningham does not refer, casts all his arguments to the winds in respect to the contagiousness of cholera and its transmissibility through water. It shows also in what consists the difference between bad drainage which is not a cause, and bad drainage which is a cause, of cholera ; and between impure water which is not a cause, and impure water which is a cause, of cholera. It gives the clue, moreover, to the common causes of localisation of cholera in this country, and wo apprehend that it equally affords a clue to the common The earliest of the series of causes of localisation in India. facts in the Theydon Bois outbreak?we have it virtually from Dr. Cuningham (sec. 89) himself?are liable to occur in every town, village, and station in India ; the latter facts of the series, we have little doubt, will be found to follow upon the earlier when they are properly looked for. The facts of the Theydon Bois outbreak can be dealt with independently of any theory; audit is simply as a record of fact, and having regard to the magnitude of the interests at issue, that imposes the duty 011 every medical man in India to be prepared for their probable occurrence, and guard against such events. How little this common-sense view of the matter has been taken in India is painfully illustrated by the outbreak of cholera at Secundrrabad a short time ago, by the events at St. Peter's College recorded by Dr. Cuningham, and generally, by his report and the reports contained in the appendix to it. It is hardly credible that, in the case of St. Peter's College, a well iisused for pollution such as it was liable to should have been ieft so that water could be taken from it at the will of servants, who might dislike to seek a supply a third of a mile away. It is still less credible that the possible use of excrement-polluted water should not have been made the subject of immediate and most carefully conducted inquiry, of which there is no It is again incredible that such inquiry, having evidence. regard to the long admitted influence of impure water as fostering cholera, and that there was here question of water and most injurious manner, should polluted in the foulest seemingly have been made to depend upon belief or disbelief of a particular theory, or individual impression of a theory ! Dr. Cuningham rails against authority as influencing individual observation in sanitary matters. Dr. Cuningham's authority has gone forth against doctrines which, seen through ordinary spectacles, are the expression of well-ascertained facts. Let us hope that those who look to him as chief will not forget liis utterance as to the mischievousness of authority-worship when they read this report. There are authorities and authorities, it is a strange spectacle to see the Sanitary Commissioner with the Government of India careering against mere figments of his own imagination. Dr. Cuuinghaui's report is simply
Quixotic.?The Practitioner.
[March 2,
1874.
QUIXOTIC ETIOLOGY'?
The Report of the Sanitary Commissioner with tlie Grovernment of India 011 the Cholera Epidemic of 1872 in Northern India, if it should not ultimately attain any higher position, does certainly hold a foremost place among the curiosities of medical literature. For some time in his annual reports, D r. Cuningham, when discussing questions relating to the etiology of cholera, has expressed opinions diverging widely from those commonly entertained in this country 011 the same subjects. In the present report he formulates his divergent views, and believes that he demonstrates, from the experience of the cholera epidemio of 1872 in Northern India, that the doctrines of the importability of cholera, and of the transmissibility of the disease through the medium of water, not only are disproved by observed facts in India, but also that the facts are such reasonable ground for their as equally show that there is 110 belief elsewhere. These doctrines," he holds, are the product of " the patient investigation of theoretical discussions," not of facts,?of all the facts so far as they can be ascertained j" and " it is to India we must look for their ratification, for 110 country in the world presents such a field for the study of cholera as India, where one portion is the home of the disease, and others are subject to such severe and fatal miasmas " (sec. 3). Hitherto observers have not merely failed to record all facts, but in particular they have disregarded negative facts, which, for purposes of investigation, are, according to Dr. Cuningham,''just as important and as necessary for forming a right conclusion" as positive facts (sec. 54) ; and the etiology of cholera, and indeed of other epidemic diseases, at least in the chiefly" discussed, has become largely a question of questions " In approaching the difficult questions connected authority." with any one of them, the first essential is to record the facts unswayed by prejudice and uninfluenced even by the opinions of the highest authority. This worship of authority, which is so common, is rot altogether unproductive of mischief. One medical officer, for example, whom we may call A, meets no fact in support of contagion or the water theory, but he believes in the authorities who support these views, and he concludes that although he has failed to find any such evidence, 13, C, D, and every other medical officer have been more fortunate. B does the same; so do C, 1), and so on. The consequence is, that events are often viewed through an * " Report on the Cholera Epidemic of 1872 in Northern India." By J. M. Cuningham, M.D., Surgeon-Mnjor, Bengal Medical Service, SanU Commissioner with the Government in India. Calcutta, 1873. tary
March 2,
1874.]
SELECTIONS.
ideal and therefore distorted medium, and much valuable advice is lost" (sec. 116). Dr. Cuniugham, happily placed for investigation, and holding that when we want to see our way in relation to cholera we are foiled by prejudice and authority, takes the observations made, as to that disease, in 1872, in Northern India, among 100 bodies of troops, and other communities, under careful medical supervision, and from these observations, given in the Appendix to the Report, checked by his own experience, he comes to the conclusions already stated. These conclusions, " lie admits, virtually put us hack to the same state of igno" rance as we were in a hundred if we are years agobut on a wrong road, the sooner we go back the better" (sec. 118). Now Dr. Cuniugham has undertaken to prove that we are in the wrong road, and to put us in the right road, in the moderate compass of 150 pages folio, report and appendix. We should be grateful to him for the compactness of his proof, as for the magnitude of its consequences, if we could really repose faith in it. But difficulties arise to such reception from the very beginning. It does not beget confidence to find Dr. Cuniugham (sec. 3) reiterating the popular fallacy, that because India is the home of cholera, it is therefore the place where, above all, it may be most clearly studied. The statement betrays a want of comprehension of the difficulties under which cholera is studied in India, which seriously compromises the judgment of the waiter. Dr. Cuningham's present report yields abundant evidence of the impossibility of studying exhaustively the etiology of cholera in the greater portion of the district to which his report refers ; an impossibility resting upon the necessary ignorance of very much relating to the disease which goes on among the native populations. India may be the place where the pathology of the disease can be best, because most continuously, studied ; but as to its movements and intimate etiology, these will, for a long time to come, admit of fullest observation among populations where the malady occurs at intervals, where a complete registration of the deaths and sickness from it is possible, and where its progress among all sections of society can be ascertained. What can be the value of negative evidence as to the importation of cholera (used in the English sense of the word) under conditions like the following, properly urged by Dr. Cuningham against internal quarantines??"Hundreds of grass-cutters, and other servants, must go out and in (the cantonments) daily. Supplies In many places the difficulty is must come from without. increased by the fact that they lie, like Umballa or Nowshera, The mails must on the great high road of communication. nor can ordinary traffic be pass, all travellers cannot be stopped, of the countrade arrested without interfering with the whole try. And in addition to the number of people who must not be stopped, there are the many who cannot be stopped." Dr. Cuningham rightly sees that the keystone of the etiolie attacks is the " contagiousness" of cholera. But this logy " contagiousness" he interprets in a way quite peculiar to himself. He treats of it from beginning to end as a question of personal contagion ; of the transmissibility of the disease directly from individual to individual, a question never seriously entertained by any person worthy of attention in these later days. This amazing error runs through the whole of the report and the appendix. The question discussed by Dr. Cuningham is not the contagiousness of cholera in the sense understood by our European teachers of mark, but it is the question, Does cholera spread like suiall-pox ? "Cholera," writes Dr. Cuningham, " is supposed to be analogous to small-pox (?) and on this a superstructure is raised which lias no real foundation, ^mall-pox, it is argued, is a contagious disease, and spreads only by contagion. Cholera belongs to the same class of contagious diseases, therefore it also spreads by contagion, and by contagion only. But do we know that small-pox spreads only by contagion ? Its annual rise and fall in this after country, recurring year year, are facts altogether inexplicable ou the doctrine of contagion, and prove incontestably that the law of contagion is not the law which governs the spread of it is the doctrine of contagion small-pox" (sec. 117). "Again, which has prevented progress. So long as men believe that all that is required to escape attack is to shun the sick, what interest can there be in sanitary progress (!)" (sec. 119). This marvellous doctrine of contagion, developed wholly out of Dr. Cuninghain's own consciousness, is that which is examined in reference to cholera in this report. The doctrine known in this country, in which the contagiousness of cholera is held to be peculiar to the disease, and to be developed under definite conditions, so far as this report is concerned, might never have
g3
It is with amazement we see that of this docforth in the masterly language of Mr. Simon, has done sucli enormous good in this country as directive both of sanitary and of scientific work, there does not appear to be any precise knowledge in Dr. Cuninghain's report, and the report of his co-adjutors, printed in the appendix. A Sancholike reference to the doctrine is made in sections 66 and 89, but merely to serve as a foil to Ur. Ouningham's astounding imaginations. Quixotic-like, his whole argument as to the contagiousness of cholera is addressed to his own conceptions. Similarly, in respect to the second great question, he raises the question of what he calls the " water theory." Dr. Cuningham is not dealing with the theory understood under that name in England, a theory applied to certain localisations of cholera. He treats of the theory which exists only in the minds of him-, self and certain other Indian epidemiologists. He treats of " the water theory irreconcilable with the geographical distribution of cholera!" (sec. 73). He writes of it as irreconcilable with the experience of " different camps, miles apart, supplied from altogether independent sources, and yet suffering severely from cholera !" (sec. 77). All this is sheer nonsense. He is not a whit more happy in dealing with it in respect to localised outbreaks. He gravely instances scattered cases in a community aa giving no support to it (e. g. of three cases in the Benares district jail, (p. 41). And in one instance, the St. Peter's College, Agra, where an outbreak must have suggested to English observers a probability of dissemination through water, he writes :?? " The history of the very violent outbreak in St. Peter's College, the most severe ever known in the whole course of the epidemic, is just one of those cases which should be explicable on the water theory, if the water theory is correct. But it admits of no such explanation. The water used by the boys was drawn from a well common to the College and a considerable native community, among whom, so far as is known, ten cases occurred. It may be argued that though nominally draion from the same source, in reality it was very likely taken from the College well employed in former years-~a ice 11 in most dangerous proximity to the old latrine, which is practically a well of filth close beside it. But this explanation accords with the fucts no better than the other, for the day boarders (twenty-seven in number) who drank of the same water as the boarders and orphans, and drank largely too?as I atn assured, and as might naturally be expected, in that very hot weather?all escaped, with the exception of one. Anxious to ascertain the circumstances under which the boy was attacked, I found on inquiry that he was the only one of the day scholars who lived close by?a fact which points strongly to localisation, not to water" (sec. 87). Now, we learn from a report in the appendix that this last-named dangerous well had been regularly used for the College till within six weeks of the outbreak, and that the supply was then obtained from a well a third of a mile away. It is obvious from Dr. Cuningham's statement that water could be taken from the dangerous well at the time of the outbreak, if the servants had thought fit to do so ; but in the detailed report there is not a trace of any inquiry such as might have been looked for, even " on the vague doctrine of impure water," as to the probable incidental use of the condemned water immediately preceding There were two sources of water at the the outbreak. command of the servants of the College; but it does not follow, as Dr. Cuningham assumes, that, if the bad source were incidentally used, it must be used by all persons frequenting the College alike. Dr. Cuningham cites this instance among others as " strikingly supporting the idea of the localisation of cholera in particular localities, dependent not on water, but on some other He says not a word of the drainas yet unknown condition." age of the College, and the detailed description of the outbreak in the appendix actually does not furnish the necessary data on this subject! It is not requisite to follow Dr. Cuningham's report in detail, for his entire argument is based on a complete misapprehension as to the doctrine of the contagion of cholera, and of the transmission of the disease through water, as maintained in this country. But as further showing how much the report falls short of that scientific character, the want of which he has so freely condemned in others, we may note that Dr. Cuningham discusses the question of importation of cholera, without any reference to the important facts recorded in tho appendix, that, with two or three exceptions, in all the districts under review, cholera is present from year to year. In answer to the question, "Does cholera (since railways) been enounced.
trine, which,
as
set
84
THE INDIAN MEDICAL GAZETTE.
travel any quicker now than it did before ?" lie gives a table of statistics from eight stations (Caw n pore, Allahabad, Agra, Meerut, Umballa, Kassonlie, Meean Meer) to show that " cases occur no earlier in the year, than they did before." He makes no reference to the fact that, according to the table and the data in the appendix, no year, not even at Kassonlie, passes without, cholera, and that the question of "travelling," as he puts it, could not have place with regard to any one of them. "There is nothing more remarkable," writes Dr. Cuningham, "regarding cholera than its localisation in particular quarters Abundant illusof a place, and even in particular buildings." In this tration of this fact is to be found in the report. respect, at least, cholera acts in India as it does in England. It. is to such localisation that the docrine of the peculiar contagiousness and mode of contagiousness held in England applies; and that the doctrine equally applies to India we have not the least doubt. Neither have we any doubt, as this report most fully shows, that this doctrine and its important practical applications are to the present time gravely misapprehended in India. Dr. Cuningham's observations on the importance of thorough drainage and of a pure water-supply read like a reductio ad absurdum after his discussion of the questions to which he has referred and the canons of observation he has laid down. If the negative facts are to be used as he would have them used, his opinions in these respects must have a like direction as his opinions on the contagiousness of cholera and on water as a cholera-carrier. Bad drainage and an impure water-supply are the common conditions of Indian towns, villages, and stations, but so is not cholera ; and the case is infinitely stronger against the influence of these conditions (as I)r. Cuningham argues) than against contagion and watercarrying. No number of apparent negatives can outweigh a positive, fact, and the single instance of the Theydon I3ois outbreak in 1865, to which Dr. Cuningham does not refer, casts all his arguments to the winds in respect to the contagiousness of cholera and its transmissibility through water. It shows also in what consists the difference between bad drainage which is not a cause, and bad drainage which is a cause, of cholera ; and between impure water which is not a cause, and impure water which is a cause, of cholera. It gives the clue, moreover, to the common causes of localisation of cholera in this country, and wo apprehend that it equally affords a clue to the common The earliest of the series of causes of localisation in India. facts in the Theydon Bois outbreak?we have it virtually from Dr. Cuningham (sec. 89) himself?are liable to occur in every town, village, and station in India ; the latter facts of the series, we have little doubt, will be found to follow upon the earlier when they are properly looked for. The facts of the Theydon Bois outbreak can be dealt with independently of any theory; audit is simply as a record of fact, and having regard to the magnitude of the interests at issue, that imposes the duty 011 every medical man in India to be prepared for their probable occurrence, and guard against such events. How little this common-sense view of the matter has been taken in India is painfully illustrated by the outbreak of cholera at Secundrrabad a short time ago, by the events at St. Peter's College recorded by Dr. Cuningham, and generally, by his report and the reports contained in the appendix to it. It is hardly credible that, in the case of St. Peter's College, a well iisused for pollution such as it was liable to should have been ieft so that water could be taken from it at the will of servants, who might dislike to seek a supply a third of a mile away. It is still less credible that the possible use of excrement-polluted water should not have been made the subject of immediate and most carefully conducted inquiry, of which there is no It is again incredible that such inquiry, having evidence. regard to the long admitted influence of impure water as fostering cholera, and that there was here question of water and most injurious manner, should polluted in the foulest seemingly have been made to depend upon belief or disbelief of a particular theory, or individual impression of a theory ! Dr. Cuningham rails against authority as influencing individual observation in sanitary matters. Dr. Cuningham's authority has gone forth against doctrines which, seen through ordinary spectacles, are the expression of well-ascertained facts. Let us hope that those who look to him as chief will not forget liis utterance as to the mischievousness of authority-worship when they read this report. There are authorities and authorities, it is a strange spectacle to see the Sanitary Commissioner with the Government of India careering against mere figments of his own imagination. Dr. Cuuinghaui's report is simply
Quixotic.?The Practitioner.
[March 2,
1874.
