?()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.