THE CAUSE OF CHOLERA. By Surgeon-General W. J.
Moore, C.I.E.
I have read the address on cholera by the Hon'ble Surgeon-General Cornish, in the Indian Medical Gazette for June 1885?his last utterance on the subject in India?with great interest; as I had previously read SurgeonGeneral Cuningham's " Cholera: What can the " with similar interest. State do to prevent it? " Cornish perused the last Surgeon-General Commissioner of the with Sanitary production the Indian Government with feelings of regret that so little advance should have been made in regard to our knowledge of cholera during the twenty years sanitary officers have been working at and recording observations of epidemics." A similar feeling arose in my mind on the perusal of Cuningham's work. And not only this, for I closed the book with the impression that the facts and arguments adduced and marshalled with such consummate skill by the Sanitary Commissioner were nevertheless onesided arguments. According to the theory of when you know very little about compensation, a thing, you must talk a good deal about it. But there is no rule without the proverbial exception. A great deal has been said about cholera by persons who have had no experience, which certainly is not the Sanitary Commissioner's case. But 1 cannot help thinking that
THE CAUSE OF CHOLERA.
Sept., 1885.]
he has ignored the study and experience of local epidemics while formulating his views on the subject from a study of the general history. He has as it were, " held the eel of science by the tail," while neglecting to grasp the body. He regards the general history of cholera as affording great facts, while the local history of cholera is relegated to the limbo of "little facts," which, et when at variance with the general history of cholera, must be wrong." But both great facts and little facts should be considered and allowed due weight. The moon would look different if viewed at the other side, and so does cholera if viewed in other aspects from those presented by Dr. Cuningham. When the Queen of Sheba presented Solomon with a natural and an artificial rose, that sagacious monarch called on the bees to decide. Unfortunately we have no such facile method of deciding 011 questions regarding disease. We cau only hope to establish different degrees of probability, or, as some may regard it, of moral certainty. Now that we can certainly trace every form of fermentation and putrefaction to the development of saprophytes, or minute bodies, vegetating in decomposable organic matter, all the facts supporting the doctrine of zymosis, first introduced by the late Dr. W. Farr, go to strengthen the conception of disease But jrerins. Surgeon-General Cuuingrham *5 ignores germs in toto, and attributes cholera to epidemic or atmospheric influence or force. O
^
o
"
Epidemic influence," he says, "is a necessary What it is we factor even with eontagionists. do not know, but of its existence there can be 110 question, because its effects are manifest." This, however, is faulty reasoning, for that the presumed effects are due to the supposed cause has not been proved. Surgeon-General Cun-
271
General Cuningham asserts that epidemics, and therefore the force or condition causing epidemics, "have a general definite direction in Bengal always upwards: such a tiling as an epidemic moving downwards is absolutely unknown and by a search for isolated cases or epidemics of cholera in westerly countries, and by a comparison of dates, he has endeavoured to show that epidemics occurring iu Europe are due to the onward westerly progress of the epidemic force from India. And he endeavours to explain the erratic course of cholera-?the escape of some places and the visitation of others?? by fancifully comparing the epidemic force to showers of rain or storms which prevail or descend ' unequally.' A little consideration, however, will show, that if such were the case, ships would be more frequently attacked, for it is scarcely possible that the force would not prevail in the locality where some one of the numerous vessels journeying to India may be. But Cuningham himself observes : " ships sailing from Indian ports suffer very little from cholera; when they do, it is limited to persons who have And so far come from an infected locality." as I am aware, there is no recorded instance of cholera on board a ship proceeding to the east previous to having touched at an eastern port. My idea of cholera is an unknown atmospheric condition occurring more frequently in eastern than in western countries, and more in hot than in cold climates certain ; frequently but unknown conditions of matter presenting most usually in uusanitary localities ; the two factors generating an invisible chemically and microscopically unrecognizable germ, -which may be conveyed in all directions by human beings, by clothing, by some varieties of mer-
chandize, by water, by food, by insects, especially flies, or through the atmosphere to a very or atmosinfluence, epidemic ingham's limited but undiscovered and variable extent pheric condition, or force, as the sole cause of as both distance and time ; and probably cholera, is a retrogade step. Cholera has before in regards a more certain manner, and in a more to been attributed to lunar influences, pandemic virulent and to a greater distance, if form, to the tine constitutions to air, of waves, epidemic favourable atmospheric conditions prevail. constitution medicate cholerique, all being more These ideas do not credit Bengal with being the in middle or less relics of the ideas which the home and birth-place of cholera, and they ages attributed epidemics to comets, meteors, are opposed to the assumption of cholera being earthquakes, volcanoes, or sidereal changes: a malady which must spread in a definite direcmagnetism or electricity or force taking the tion from east to west. In fact, the records of place of Saturn or Mercury in the scheme of one epidemic (1840) show that it was presumed causation. A peculiar condition of atmosphere to have spread in an opposite course. Imported has so often been noticed in connection with into China by troops from India, it is said to outbreaks of cholera that it is not wise to deny have spread down into Burmah. Alterwards such influence. This was specially noted by from Bokhara down to Peshawar, and then Sir Guyer Hunter at the commencement of the doivn the river Indus to Tatta Kurrachee, and Egyptian epidemic of 1883, and termed by the other places in Sind. I believe western epiArabs el haioa el asfar. But accurate reasondemics would occur exactly the same if there that would to evidence atmospheric appear ing were no eastern epidemics. The atteutiou of conditions are only one factor in the creation of the Commissioner's Sanitary Department has to and that other factors are return to
cholera, are
required
the disease as surely as human beings Surgeonnecessary for its development.
produce
been so much directed to western countries that cholera to the east of Iudia has not been sought
THE INDIAN MEDICAL GAZETTE.
272
for.
Moreover,
knowledge
little in countries east of however, there would be just
we
of what
have
comparatively
occurs
India. I believe, much reason to assume our eastern spread of cholera as a western spread, if the facts were equally known. It might,with equal probability, be assumed, that the occurrence of epidemics of so termed malarious fever occurring in western countries are the onward march of eastern epidemics. For, like cholera, malarious fever and most frequently in occurs most severely When cholera has not been directly India. communicated by infection (meaniug through the atmosphere) or by contagion (meaning by conveying medi:i), I believe it results from a de novo formation of the cause. And I believe it does so result, as the extent of infecgenerally tion through the atmosphere must be comparatively limited : fresh air destroying germs, and, as conveyance by media, must have a limit in point of time ; for it is not probable that germs remain vital indefinitely, however well preserved they may be in favouring media. Disputas
de novo for it limits
ing
origin
appears
to
me
untenable,
of generation, power and I hold that what has been produced may be produced again. When in the presumed ouward westerly march of epidemics dates have not fitted, the theory of the re-vitalization of the germs of a previous epidemic has been brought forward as explanation. A revitalization theory is as difficult to understand as a de novo theory, and as it assumes the dormant condition of germs for an indefinite period of years, is much less probable. My views, as .expressed above, entail the credence of the communicabilifcy of cholera in various ways. In the present state of our I that it is not safe to deny advance knowledge, the communicability of disease in various ways, and still less is it safe to do so as regards cholera. What Cuningham calls e little facts,' such, for instance, as the arrival of a person from a distance, his suffering from cholera succeeded by attacks in the same house, cannot be ignored or explained away on the onward march theory, and must be attributed to direct communication, especially if the course of the importis opposed to the onward march. ers As regards conveyance by clothing and by some forms of merchandize, very similar remarks apply. The evidence of the conveyance of cholera by water has become, since first asserted by Snow, so overwhelming, that Cuningham's denial will not be sufficient to establish the The evidence as falsity of the doctrine. regards conveyance by food is perhaps not so well supported, but still it cannot be ignored, and Pettenkoler goes so far as to mention the variety of food most likely to convey cholera. And there can be no doubt that, as Macnamara observes, the atmosphere may be so impregto
one
act
[Sept.,
1885.
nated us to convey the disease, at least in the limited space of the wards of a hospital, although under our attention to ventilation and sanitary requirements it rarely is so. Mon. Ramon de Sima, at a meeting (1883) of the Academie des Sciences, expressed his views that the poison acts exclusively through the respiratory passages, when it certainly would come into more intimate relation with the blood spread out on the capillary net-work of the air cells, than when iutro duced with food or drink into the alimentary canal. It has been stated by some satirist that " all theorists not only believe any one else who has any doctrine on the subject to be wrong, but also cordially hate each other." This is not, however, my case, for I have known Dr. Cuningham long, and have always entertained the greatest respect for his opinions, and much he evinces in propoundmore for the ability ing them?ability which displayed in any other sphere of the public service would at least have secured him theK.C.S.I., instead of the C.S.I, with which he has been decorated. But that is no reason why I should not hold and state my own opinions. It may not be pleasant to imagine that one's friend who pays one a visit may introduce the cholera into the bosom of one's family. It may possibly conduce to an appreciation of the great Lexicographer's abhorence of clean linen, to recollect the possibility of disease being conveyed from the laundress. The pleasure to be derived from an additional tent, or an extra carpet, or a bale of goods packed in ' 4 gunny bags, may be subdued by the idea of The draught of water cholera lurking therein. often in this thirsty country, like the Nectar of the Gods, may be taken with suspicion. Food, fit for the suppers of Lucullus, fresh from the mysterious interior of the Indian cook-house, Nay may be eaten With fear and trembling. the very atmosphere may be inspired with the misgiving that cholera germs may be imbibed. But all this is as nothing to the results of the Bryden-Cuningham-theory, which asserts the onward march of the cholera force, and its arrival at a certain place, about a certain date, irrespective of any human means of prevention On the theory of commuwhich can be taken. nicability, the disease may be prevented if sufficient care is taken. On the onward march theory, prevention is impossible. Although not agreeing with the Sanitary Commissioner's theory of the causation of cholera, I agree with him as to the inutility of quarantine. Quarantine will not evidently prevent a de novo origin, and to this I attribute the greater number of epidemics and of isolated cases. Placing ships in quarantine at Suez, with a clean bill of health from India, is absurd, as the incubation of cholera is less than the number of
days
a
vessel takes
on
the voyage.
Cholera
Sept., 1885.]
THE CAUSE OF CHOLERA
only be conveyed in such a ship by the Experience demonstrates that it is rarely so conveyed, probably never after ten or twelve days. Similarly, experience of land could
cargo.
shows that the disease can no more the tide could be Certain subjects are so conclusive as to have met with ready assent from all mankind,?e.g., mathematics, geometry, arithmetic. The evidence of the inutility of quarantine is so complete, that quarantine, as now adopted on the continent, should be added to the list. If a ship arrives at a port with cholera on board, or in which cholera has recently occurred, prudence would dictate detention and isolation, but the arbitrary detention of all and sundry, is an utterly fatuous and unnecessary procedure. Surgeon-General Cornish advocates the testing of the question of the contagiousness of cholera by experiments on Indian criminals. The suggestion has been made before, but as it is now put forward by so eminent an authority it may perhaps be considered, as Dr. Cornish observes: "the suggestion has no element of cruelty about it, for it gives to a few condemned criminals a chance of survival otherwise unattainable." The importance of the question cannot be exaggerated, aud it can only be decided by such experiments. For, however well the matter may be argued on either side, the phases of cholera are so varied that objections may be advanced to every argument brought forward, with the result that the opposition come to regard the opponents as knowing no more about it than the companions of Ulysses knew of the Sirens singing after they had filled their ears with wax. Dr. Cornish says:?" The civilized world, in its laws, has takeu the view that cholera is a disease of the infectious or contagious class, but the chief sanitary authority iu India, and the Indian Government acting on the representations of: its responsible advisers, declare, that European nations are mistaken." I think they are mistaken in regarding cholera as so virulently and decidedly infectious or contagious as they do. But what the Iudian sanitary authorities should show to confound continental nations is, that it is not inAnd this is not fectious or contagious at all. to be effected by argument, but by direct experiment in which continental experts should be invited to take a part.
quarantine
be
kept out by cordons than stayed by a wall of rushes.
J
HURDWAR PILGRIMS AND CHOLERA.
273
Moore, C.I.E.
I have read the address on cholera by the Hon'ble Surgeon-General Cornish, in the Indian Medical Gazette for June 1885?his last utterance on the subject in India?with great interest; as I had previously read SurgeonGeneral Cuningham's " Cholera: What can the " with similar interest. State do to prevent it? " Cornish perused the last Surgeon-General Commissioner of the with Sanitary production the Indian Government with feelings of regret that so little advance should have been made in regard to our knowledge of cholera during the twenty years sanitary officers have been working at and recording observations of epidemics." A similar feeling arose in my mind on the perusal of Cuningham's work. And not only this, for I closed the book with the impression that the facts and arguments adduced and marshalled with such consummate skill by the Sanitary Commissioner were nevertheless onesided arguments. According to the theory of when you know very little about compensation, a thing, you must talk a good deal about it. But there is no rule without the proverbial exception. A great deal has been said about cholera by persons who have had no experience, which certainly is not the Sanitary Commissioner's case. But 1 cannot help thinking that
THE CAUSE OF CHOLERA.
Sept., 1885.]
he has ignored the study and experience of local epidemics while formulating his views on the subject from a study of the general history. He has as it were, " held the eel of science by the tail," while neglecting to grasp the body. He regards the general history of cholera as affording great facts, while the local history of cholera is relegated to the limbo of "little facts," which, et when at variance with the general history of cholera, must be wrong." But both great facts and little facts should be considered and allowed due weight. The moon would look different if viewed at the other side, and so does cholera if viewed in other aspects from those presented by Dr. Cuningham. When the Queen of Sheba presented Solomon with a natural and an artificial rose, that sagacious monarch called on the bees to decide. Unfortunately we have no such facile method of deciding 011 questions regarding disease. We cau only hope to establish different degrees of probability, or, as some may regard it, of moral certainty. Now that we can certainly trace every form of fermentation and putrefaction to the development of saprophytes, or minute bodies, vegetating in decomposable organic matter, all the facts supporting the doctrine of zymosis, first introduced by the late Dr. W. Farr, go to strengthen the conception of disease But jrerins. Surgeon-General Cuuingrham *5 ignores germs in toto, and attributes cholera to epidemic or atmospheric influence or force. O
^
o
"
Epidemic influence," he says, "is a necessary What it is we factor even with eontagionists. do not know, but of its existence there can be 110 question, because its effects are manifest." This, however, is faulty reasoning, for that the presumed effects are due to the supposed cause has not been proved. Surgeon-General Cun-
271
General Cuningham asserts that epidemics, and therefore the force or condition causing epidemics, "have a general definite direction in Bengal always upwards: such a tiling as an epidemic moving downwards is absolutely unknown and by a search for isolated cases or epidemics of cholera in westerly countries, and by a comparison of dates, he has endeavoured to show that epidemics occurring iu Europe are due to the onward westerly progress of the epidemic force from India. And he endeavours to explain the erratic course of cholera-?the escape of some places and the visitation of others?? by fancifully comparing the epidemic force to showers of rain or storms which prevail or descend ' unequally.' A little consideration, however, will show, that if such were the case, ships would be more frequently attacked, for it is scarcely possible that the force would not prevail in the locality where some one of the numerous vessels journeying to India may be. But Cuningham himself observes : " ships sailing from Indian ports suffer very little from cholera; when they do, it is limited to persons who have And so far come from an infected locality." as I am aware, there is no recorded instance of cholera on board a ship proceeding to the east previous to having touched at an eastern port. My idea of cholera is an unknown atmospheric condition occurring more frequently in eastern than in western countries, and more in hot than in cold climates certain ; frequently but unknown conditions of matter presenting most usually in uusanitary localities ; the two factors generating an invisible chemically and microscopically unrecognizable germ, -which may be conveyed in all directions by human beings, by clothing, by some varieties of mer-
chandize, by water, by food, by insects, especially flies, or through the atmosphere to a very or atmosinfluence, epidemic ingham's limited but undiscovered and variable extent pheric condition, or force, as the sole cause of as both distance and time ; and probably cholera, is a retrogade step. Cholera has before in regards a more certain manner, and in a more to been attributed to lunar influences, pandemic virulent and to a greater distance, if form, to the tine constitutions to air, of waves, epidemic favourable atmospheric conditions prevail. constitution medicate cholerique, all being more These ideas do not credit Bengal with being the in middle or less relics of the ideas which the home and birth-place of cholera, and they ages attributed epidemics to comets, meteors, are opposed to the assumption of cholera being earthquakes, volcanoes, or sidereal changes: a malady which must spread in a definite direcmagnetism or electricity or force taking the tion from east to west. In fact, the records of place of Saturn or Mercury in the scheme of one epidemic (1840) show that it was presumed causation. A peculiar condition of atmosphere to have spread in an opposite course. Imported has so often been noticed in connection with into China by troops from India, it is said to outbreaks of cholera that it is not wise to deny have spread down into Burmah. Alterwards such influence. This was specially noted by from Bokhara down to Peshawar, and then Sir Guyer Hunter at the commencement of the doivn the river Indus to Tatta Kurrachee, and Egyptian epidemic of 1883, and termed by the other places in Sind. I believe western epiArabs el haioa el asfar. But accurate reasondemics would occur exactly the same if there that would to evidence atmospheric appear ing were no eastern epidemics. The atteutiou of conditions are only one factor in the creation of the Commissioner's Sanitary Department has to and that other factors are return to
cholera, are
required
the disease as surely as human beings Surgeonnecessary for its development.
produce
been so much directed to western countries that cholera to the east of Iudia has not been sought
THE INDIAN MEDICAL GAZETTE.
272
for.
Moreover,
knowledge
little in countries east of however, there would be just
we
of what
have
comparatively
occurs
India. I believe, much reason to assume our eastern spread of cholera as a western spread, if the facts were equally known. It might,with equal probability, be assumed, that the occurrence of epidemics of so termed malarious fever occurring in western countries are the onward march of eastern epidemics. For, like cholera, malarious fever and most frequently in occurs most severely When cholera has not been directly India. communicated by infection (meaniug through the atmosphere) or by contagion (meaning by conveying medi:i), I believe it results from a de novo formation of the cause. And I believe it does so result, as the extent of infecgenerally tion through the atmosphere must be comparatively limited : fresh air destroying germs, and, as conveyance by media, must have a limit in point of time ; for it is not probable that germs remain vital indefinitely, however well preserved they may be in favouring media. Disputas
de novo for it limits
ing
origin
appears
to
me
untenable,
of generation, power and I hold that what has been produced may be produced again. When in the presumed ouward westerly march of epidemics dates have not fitted, the theory of the re-vitalization of the germs of a previous epidemic has been brought forward as explanation. A revitalization theory is as difficult to understand as a de novo theory, and as it assumes the dormant condition of germs for an indefinite period of years, is much less probable. My views, as .expressed above, entail the credence of the communicabilifcy of cholera in various ways. In the present state of our I that it is not safe to deny advance knowledge, the communicability of disease in various ways, and still less is it safe to do so as regards cholera. What Cuningham calls e little facts,' such, for instance, as the arrival of a person from a distance, his suffering from cholera succeeded by attacks in the same house, cannot be ignored or explained away on the onward march theory, and must be attributed to direct communication, especially if the course of the importis opposed to the onward march. ers As regards conveyance by clothing and by some forms of merchandize, very similar remarks apply. The evidence of the conveyance of cholera by water has become, since first asserted by Snow, so overwhelming, that Cuningham's denial will not be sufficient to establish the The evidence as falsity of the doctrine. regards conveyance by food is perhaps not so well supported, but still it cannot be ignored, and Pettenkoler goes so far as to mention the variety of food most likely to convey cholera. And there can be no doubt that, as Macnamara observes, the atmosphere may be so impregto
one
act
[Sept.,
1885.
nated us to convey the disease, at least in the limited space of the wards of a hospital, although under our attention to ventilation and sanitary requirements it rarely is so. Mon. Ramon de Sima, at a meeting (1883) of the Academie des Sciences, expressed his views that the poison acts exclusively through the respiratory passages, when it certainly would come into more intimate relation with the blood spread out on the capillary net-work of the air cells, than when iutro duced with food or drink into the alimentary canal. It has been stated by some satirist that " all theorists not only believe any one else who has any doctrine on the subject to be wrong, but also cordially hate each other." This is not, however, my case, for I have known Dr. Cuningham long, and have always entertained the greatest respect for his opinions, and much he evinces in propoundmore for the ability ing them?ability which displayed in any other sphere of the public service would at least have secured him theK.C.S.I., instead of the C.S.I, with which he has been decorated. But that is no reason why I should not hold and state my own opinions. It may not be pleasant to imagine that one's friend who pays one a visit may introduce the cholera into the bosom of one's family. It may possibly conduce to an appreciation of the great Lexicographer's abhorence of clean linen, to recollect the possibility of disease being conveyed from the laundress. The pleasure to be derived from an additional tent, or an extra carpet, or a bale of goods packed in ' 4 gunny bags, may be subdued by the idea of The draught of water cholera lurking therein. often in this thirsty country, like the Nectar of the Gods, may be taken with suspicion. Food, fit for the suppers of Lucullus, fresh from the mysterious interior of the Indian cook-house, Nay may be eaten With fear and trembling. the very atmosphere may be inspired with the misgiving that cholera germs may be imbibed. But all this is as nothing to the results of the Bryden-Cuningham-theory, which asserts the onward march of the cholera force, and its arrival at a certain place, about a certain date, irrespective of any human means of prevention On the theory of commuwhich can be taken. nicability, the disease may be prevented if sufficient care is taken. On the onward march theory, prevention is impossible. Although not agreeing with the Sanitary Commissioner's theory of the causation of cholera, I agree with him as to the inutility of quarantine. Quarantine will not evidently prevent a de novo origin, and to this I attribute the greater number of epidemics and of isolated cases. Placing ships in quarantine at Suez, with a clean bill of health from India, is absurd, as the incubation of cholera is less than the number of
days
a
vessel takes
on
the voyage.
Cholera
Sept., 1885.]
THE CAUSE OF CHOLERA
only be conveyed in such a ship by the Experience demonstrates that it is rarely so conveyed, probably never after ten or twelve days. Similarly, experience of land could
cargo.
shows that the disease can no more the tide could be Certain subjects are so conclusive as to have met with ready assent from all mankind,?e.g., mathematics, geometry, arithmetic. The evidence of the inutility of quarantine is so complete, that quarantine, as now adopted on the continent, should be added to the list. If a ship arrives at a port with cholera on board, or in which cholera has recently occurred, prudence would dictate detention and isolation, but the arbitrary detention of all and sundry, is an utterly fatuous and unnecessary procedure. Surgeon-General Cornish advocates the testing of the question of the contagiousness of cholera by experiments on Indian criminals. The suggestion has been made before, but as it is now put forward by so eminent an authority it may perhaps be considered, as Dr. Cornish observes: "the suggestion has no element of cruelty about it, for it gives to a few condemned criminals a chance of survival otherwise unattainable." The importance of the question cannot be exaggerated, aud it can only be decided by such experiments. For, however well the matter may be argued on either side, the phases of cholera are so varied that objections may be advanced to every argument brought forward, with the result that the opposition come to regard the opponents as knowing no more about it than the companions of Ulysses knew of the Sirens singing after they had filled their ears with wax. Dr. Cornish says:?" The civilized world, in its laws, has takeu the view that cholera is a disease of the infectious or contagious class, but the chief sanitary authority iu India, and the Indian Government acting on the representations of: its responsible advisers, declare, that European nations are mistaken." I think they are mistaken in regarding cholera as so virulently and decidedly infectious or contagious as they do. But what the Iudian sanitary authorities should show to confound continental nations is, that it is not inAnd this is not fectious or contagious at all. to be effected by argument, but by direct experiment in which continental experts should be invited to take a part.
quarantine
be
kept out by cordons than stayed by a wall of rushes.
J
HURDWAR PILGRIMS AND CHOLERA.
273
