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?()f ilntuait Jlftctrical (?>a|cttc. DECEMBER 1, 1875.
CHOLERA IN SIMLA.
A ground plan of Simla presents the general aspect of a
parabola with its concavity opening to the south-west and
convexity pointing north-east. From the convex aspect of the curve houses extend towards the north, north-east and
east, the number situated in the latter direction, on Jacko
Hill, being more considerable than elsewhere. The summit or
central portion of the curve is the most crowded part
of Simla. It is, indeed, Simla proper, and here is situated
the central bazaar in which the native population of the
sanitarium is massed. This part of the station is also the most
insanitary. It encloses a gorge into which is poured the filth of
the densely peopled neighbourhood. It was on this locality that the brunt of the outbreak fell. 138 cases occurred here, and 75 in the vicinity, at Chota Simla, where the large following of
a native grandee resided. Nowhere else was any special con-
centration of the disease obvious. Cases were dotted all over
the station with the exception of a limited area to the north-
west, which appears to have escaped. The reports do not con-
tain any detailed analysis of special conditions peculiar to
particular localities; but, if we except the central area above
alluded to, there does not appear to have been any remarkable
localization or exemption. The truth which lies ou the surface
of the narrative is a very trite one, namely, that places where
overcrowding and other insanitary influences most abounded
fared worst. There was not, moreover, any definite progress
of the disease through the station traced ; nor are any evidences
forthcoming indicating its propagation by infection and trans-
portation. On this point Surgeon-Major Adley writes :? " The preponderance of facts during the late epidemic tends
clearly to the inference that the disease was not spread from the sick. In several instances two persons living in the same house were attacked consecutively, but in these cases other members of the family did not contract the disease. In the case of Mr. S.
six or seven friends living in different houses acted as nurses,
and not one of these suffered. The hospital attendants in
constant contact with the sick did not, in any instance, fall ill.
Many similar instances might be quoted." The population of Simla during the outbreak was estimated at 15,000, of which
13,500 were natives and 1,500 Europeans. Of the former class
December 1, 1875.] CHOLERA IN SIMLA. 329
315 were attacked and 170 died, and of the latter 25 and 14.
Thus the proportion of attacks and deaths was greater in the former case?2 33 and 1*26 percent against 166 and -93. The
death-rate among Europeans was somewhat higher?56 against 54. The severer incidence and mortality among natives is also
apparent when the following of the Government of India is considered alone. This is said to have consisted of 1,038
Europeans and Eurasians and 879 Natives. Among the former a
percentage of 1*56 cases and '78 deaths took place, and among the latter 4 43 and -91. Europeans are generally considered to he more prone to cholera than natives, and in the higher ratio
of seizures and deaths of the latter is implied another proof that insanitary influences were largely responsible for the pre-
valence of the disease. The lighter death-rate of natives is
in accordance with a well-established rule. Of the natives
attacked, 198 were hill-men or 63 percent of native seizures, and of these 125 died or 63 per cent. The population of
hill-men present during the outbreak is not specified ; but
it must have been comparatively small, for at the commence- ment of the outbreak they are said to have fled.. The pecu-
liar proneness of these races to contract the disease and
their feeble resistance to it is therefore strikingly illustrated.
This is, also, in accordance with a very well-established law. One very remarkable feature of this outbreak was the large pre- ponderance of males affected. Of the 341 cases (includ- ing the 6 which occurred after the 11th of August) 282 were
males?S2'7 per cent?and 59 females 17*3. Among natives the
numbers were 203 and 53 and among Europeans 19 and 6. This
curious result is attributed to several causes?less exposure to
infection as regards European females, natives of the plains not
being accompanied by their families, and polyandry among hill- nien. The sanitary state of Simla prior to and during the
epidemic appears to have been unsatisfactory in the last degree. The season, moreover, seems to have been a peculiarly unhealthy one. This is well indicated by the statistics of fever furnishbd
by the dispensary returns. In the months of May, June and
July the numbers treated in the years 1873, 1874, and 1875 were
as follows :?
1873.
61 55 47
1874.
135 120 149
1875.
374 259 148
163 404 781.
Deaths from fever were proportionately more numerous. Other
?diseases, such as dysentery, diarrhoea, bronchitis, pneumonia, etc, do not appear to have been more common or fatal than usual.
The excessive prevalence of " fever" may, however, be accepted
as a good index of the exceptional insalubrity of 1875. The
particular sanitary defects which are most prominent in Simla are overcrowding, impure water and bad conservancy. Over-
crowding was most prevalent in the main bazaar where also cholera was most severe. Here both natives and Eurasians are
closely packed in houses too small and ill-constructed to afford them healthy conditions of existence. Surgeon-Major Adley writes:?"A site originally selected and deemed sufficient for the
population required to supply the wants of a few Europeans (in 1841 only 206) is now called upou to accommodate the increased
number of natives necessery for 1,500 Europeans?for the most
part householders of the wealthier classes. Eight and ten
natives may be found inhabiting a room 8 x 10 and 10 feet
high, utterly devoid of means of ventilation when the doors are closed. A large number of clerks in Government offices live in this bazaar and the gorge below."
The water supply is both scanty and impure, and no proper
means of storing or conservation exist. In the hot weather the
supply is very scarce and the sources limited to two or three and these are open to serious causes of contamination. In the rains
there is no deficiency of supply, springs multiply rapidly on the hill sides, but it is certain that surface impurities get freely washed into them. We have repeatedly written on this subject and discussed various projects for the remedy of those defects
which are so glaring and perilous, The true solution of the
difficultv seems to be the construction of a reservoir or reservoirs
beyond reach of pollution and distribution by pipes. This is a
question of engineering, and we are glad to observe that, since
the close of the epidemic, Mr. W. Smith, whose name is so honor-
ably associated with the supply of pure water to Calcutta, has
met Dr. Adley and others interested in the sanitation of Simla
in committee for the purpose of considering measures to remedy this and other sanitary defects in Simla. No evidence is forth-
coming in favor of the view that water agency was concerned in the dissemination of cholera. Cases could not be associated with
any particular source, taking into account the proportion of
people resorting to the several sources available at the time ;
nor does it appear that those resorting to any particular source were exceptionally exempted.
Nothing can be more repulsive than the conservancy of
Simla as described by Surgeon-Major Adley. Public and pri- vate privies were alike abominable, and the disposal of their contents by heaping rank and noisome ordure on the hill side, or throwing it down a neighbouring gorge, filled the air with
foetid putridity. A radical reform is obviously imperatively necessary, and this question lias no doubt also engaged the attention of the committee already referred to. With an abun-
dant water supply distributed by pipes, an efficient system of water closets and sewerage ought to be of easy contrivance. Meantime some approved method of deodorising and scaveng- ing ought to be stringently carried out.
As regards preventive measures, all that could reasonably be expected was done during the outbreak?more perhaps than those who scout the infectiousness of the disease would incline
to approve. Vigorous attempts were made to promote cleanliness and disinfect premises when the disease had appeared, but
that these must have been feeble and futile is but too probable when the magnitude of the defects just alluded to is considered.
Medical relief measures were adopted with promptitude and
vigour; medical officers and subordinates were quickly summoned to the spot; and, through the agency of the medical department, supplied without delay. 1 Surgeon-Major, 2 Assistant Surgeons, 9 Hospital Assistants, 4 Native Medical Pupils and 1 Dresser
were deputed on special cholera duty in addition to the officers and subordinates already in the station. Hospitals and dispen- saries were established throughout the station, and a system of house to house visitation organized. Cases were thus treated in their early or premonitory stage when medical treatment is
believed on good ground to be most effective. There can be no
330 THE INDIAN MEDICAL GAZETTE. [December 1, 1875.
doubt that much good was done and many lives saved by these
means; and it is satisfactory to find that, while the mortality prior to the opening of dispensaries was 69 87 percent, of attacks, it was only 37*2 after they were put in action. Part of this
reduction may be reasonably attributed to the waning virulence
of the epidemic and less severe character of the cases treated, but there can be no doubt that early treatment is the most effi-
cacious, and that by acting vigorously on this principle a great
saving of life was effected. The lesson of the Simla epidemic of
1875 appears to be that the neglect of sanitation, even in circum-
stances otherwise favorable to health, is fraught with the
utmost peril to human life, and the practical deduction from this conclusion?one which admits not of rational doubt?is
that, if Simla is to retain its rank and repute as a sanitarium, it
must be cleaned and kept clean.
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