The Indian Medical Gazette/Volume 39/January 1904/The Cholera Epidemic at Puri

THE CHOLERA EPIDEMIC IN PURI TOWN AND DISTRICT IN JULY, 1902, AND ITS SPREAD THROUGHOUT LOWER BENGAL.

By S. ANDERSON, M.B., B.Sc., CAPTAIN, I.M.S.

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Whilst acting as Deputy Sanitary Commissioner, Eastern Bengal Circle, I was deputed to proceed to Puri to supervise the arrangements made for the Rath Jatra festival and suggest other precautions necessary to prevent the spread of cholera.

In Puri town and district and throughout Orissa, cholera shows itself year after year regularly over a defined area, and from this “infected focus” the disease invades the same bazaars and villages, leaving the greater part of the district: untouched.

The usual course of the disease is intimately connected with the pilgrimages.

In Orissa, cholera is more or less endemic from January to August, during which period there are four pilgrimages, viz., in March the Dol-Jatra, in April the Baisack, in June the Snan-Jatra, and in July the most important of all, the Rath-Jatra.

Previous to the opening of the railway to Puri, cholera abounded along the pilgrim route, especially on the Cuttack-Puri road and adjoining country ; the outbreaks were always worst at the period when the pilgrims were passing in the greatest numbers to and from the shrine of Juggernath.

Since the opening of the railway on the 1st February, 1897, it is computed that only about one-tenth of the pilgrims now travel by road; and as the remainder travel by rail, the danger of epidemic cholera being widely disseminated over India from its home in Orissa during the time the pilgrims are returning from the Puri fairs has enormously increased.

The Sanitary Commissioner's Return of the relative intensity of cholera in each district shows that Puri cholera frequently becomes epidemic, and that when the mortality there is high it is also high in Cuttack, Balasore and Howrah, all traced to importation by pilgrims from Puri.

In 1901 the Puri district was placed first with the high death-rate of 9.20 per 1,000 of population, an increase of 5.44 as compared with the average of the previous ten years.

In 1902 isolated cases occurred for weeks previous to the great festival, both in Puri town and district, but some pilgrims were attacked on the way from their homes to the railway station, others on the railway, and from the 2nd to the 7th July in all some 12 cases were removed from the train, most of them in a moribund condition.

This indicates one of the ways in which the disease becomes disseminated, as not; only, are the occupants in the same compartment more liable to become infected, but they also infect pools and tanks at stations along the line.

Having to wait for three hours at a junction on the line, I noticed many of the pilgrims washing loin cloths and other garments in the pools close by the railway line; these pools could not fail to become infected, and, as many of the pilgrims cleansed their mouths and drank this water, they would assuredly be victims to cholera.

The number of people present in the town on the 6th and 7th July, the first two days of the festival, was as follows:--

Number by rail to Puri... 8 3 -+, 49,987

Number by rail to Sakhigopal wey ou a. $2,861

Local people from Puri, Cuttack and Balasore Districts 20,000

Total — 72,848

And if to this number be added the permanent population of Puri town, viz., 30,857, then over a lakh of people were present.

From the Ist to the 20th July there were 306 cases admitted to the Cholera Hospital from an average population of 50,000 or 6 per cent.; the mortality was 254 or 83 per cent.—-a high percentage indicating the degree of virulence of the disease.

Dr. H. Sen, in an article in the Indian Medical Gazette for April, 1903, has given a comprehensive statement showing the mortality from cholera for each month in the years from 1890 to 1901.

In the same paper there is given a diagram showing the incidence of cholera mortality in the district of Puri based on the averages of the twelve years from 1890 to 1801; from this it would appear that the disease reaches its acme of mortality almost yearly in the month of July.

It is unnecessary to reiterate here the conditions under which cholera flourishes in Puri town and district; suffice it to say, that these have been thoroughly gone into the aforementioned paper together with the measures then taken to alleviate them.

The main object of this paper is to indicate how the epidemic of cholera in July, 1902, spread throughout Lower Bengal.

What might be termed “ primary dissemination” takes place in Puri town, and more especially at the railway station, where pilgrims have to wait sometimes a day or even two days before they are allowed on to the station platform.

From July 8rd to July 20th 44 patients were admitted to the Puri Railway Hospital, of which 32 died, and of the whole number, 37 cases alone were removed from the station yard.

Then there is what might be termed “secondary dissemination,” which occurs on the Juggernath Road to Cuttack, and on the railway line to Calcutta, and from thence to the mofussil.

In the epidemic of 1901 Dr. Sen states “that polluted sources of drinking water were at the root of the spread of the disease, and could be easily traced,” and he gives an instance.

The intensity of the spread of disease depends to a great extent upon the degree to which the water of villages and towns en route is polluted by the infected amongst the returning pilgrims. Where the water-supply of such towns and villages is abundant, little cholera will prevail, as was fortunately the case in 1902; on the other hand, where the village tanks and water-supplies are low and scanty, as occurred in 1901, then pollution takes place easily and cholera abounds. There is thus a distinct relation between the rainfall and the intensity of the spread of the disease, and there is little doubt that in the year 1902 the spread of the disease was influenced thereby. In 1901, the rainfall was small and cholera spread rapidly; in 1902, the rainfall exceeded the average, and so the amount of the disease was comparatively less.

A circular letter was written to Civil Surgeons of districts from which the pilgrims came, requesting information as to the number of cases of cholera occurring in their respective districts during the period from 5th July to the 2nd August, 1902, These returns give but a rough indication of the number of cases caused by pilgrims arriving from Puri, as mainly those who came to the Civil Hospitals fur treatment are noted, not counting many who probably died in their homes beyond the cognisance of the Civil Surgeons or Registrars, Some cases of true cholera would be returned as “Acute Diarrhoea,” and so would not be shown in this return.

Statement showing the distribution of cholera throughout Bengal from bth July to 2nd August, 1908.

The insanitary condition of the villages in Puri district haa been admirably depieted by Dr. Sen, and He hag described how cholera is disseminated ainohgst the villagers; hy also details a scheme to prevent the inroad of cholera into villages.

It is an almost universal experience that a éholera epidemic rons its own course; but the prevention of the disease in Puri town iteelf, the focta of “primary dissettination,” is quite within the domain of practical sanitation.

Previous to the advent of the majority of the pilgriins, the lodging-houses were inspecbsd and their accommodation certified, private camping grounds and atreet camping were disallowed, ail public and lodging-house wells were perman- ganated, extra staff fur conservancy work waa entertained, and all lodgittg-house keepera were warned to notify the police or health officer on the occurrence of a vase of cholera, so that disin- fection measures might be carried out, and-th patient isolated.

Arrangements wete made for the ore the bodiea of ange dying from chdlera, Jée the cleaning of the steps and banks for the ptevention of promiecuous defr hear tatks, wells, &c., arid for the washing. f elothes in, vr drinking or carrying away water ‘from, the tanks. Moat of these moenatires were in the main well carried out, except those re- ferring to the washing of clothea in tanks and ‘the drinking of and carrying away of water from tanks, which measures were almost impos- aible to property carry out,

The ehtef sourees of infection in Puri town -#re tlie sacred tanks; at all the local festivals or melue the pilgrims largely resort to the Neren- ~dew and Makanda tanks, less so to the Indra- dyumna, whilst the Swetaganga, which is the ‘sesallest and is considered sonaielly holy, iain a deplorably insanitary state anc consists mainly of the washings and liquid sewage from the latrines in elose proximity all round the tank,

1 have frequently witnessed large numbers of people bathing in these tanks, and aa the clothes of infected people were continually being wash- ed in them, the water continues to be polluted and never gets a chance of purifying itself.

It will be understood to what extent these tanks are infected, especially the Narendra, when I mention the fact that many pilgrims came and lay down on the banks to die, much of whose dejecta was washed into the tanks and sone actually washed themselves in the tank whilst pea from the disease; these cases always orcurred during the night,

Though all the wells were permanganated, yet many of them are certain to have become infected with choleraic discharges. This is specially the cace with some of the private and lodging house wells, which are all shallow aurface soil wells, aud, as they have no pucea aligninent and no protecting wall, they must be eastly con- taminated either from actual surface washings or from percolation through the surface soil, I have myself observed people washing themselvea dnd their clothes close to the unprotected mouth of a well situated in the compound of & lodgings house in which cholera had occurred.

Another source of infection is the private lattines, very few of which have receptacles, and the ground thus: becomes saturated with filth before ita removal. Some of these latrines are in close proximity to the wells, and thus percolas tion easily takes place. ;

Pools and tanks on the roadside, more eapectal- ly on the Juggernath road from Puri te Cuttack, are a fruitful source of cholera. Pilgrims be- coming affected with cholera invariably go to the nearest pool and lie down close to the water's edge; the result is that these people contam- inate the water, and this being drunk by passers- by further disseminates the disease.

Same of the cases in the Cholera Hospital raced to the eating of the sacred food gat,” but being the only food allowed their stay in the Lown, it is con- ajits state of putrefaction and thus ag Ye disease. flitions under which the piigtim: the unavoidable overs

SWading, deficient ventilation, the impure water, the bad food and the general insanitary condi+ tion of the placs, all these tend towards dimi- nishing the resistance of the individual aud increasing his susceptibility to cholers.

To ameliorate these conditions and, if pos sible, prevent further outbreaks in places similar to Purl, where there are large gatherings of feople, it neeins to me, that in addition to the above, the following preeautionsare necessary :—

1st..—The provision of a perinanent cainping ground, where the pilgrimd would be housed int large corrugated iron sheds; the ground ghould be a good distance off from the town.

Suh a camp abould be furnished with the latest sanitary arrangemenéa ; sufficient latrine accommodation should be provided, and the wator-supply obtained from deep wells, the water being pumped up to 4 cisters and from thence supplied ly means of pipea on the tap system ; in this manner the tvater-supply would _ be safe-guarded from contamination,

A pucka masonry dhuli-ghat should- be provided for the washing of clothes, and the ground itself should be thoroughly drained,

2nd—The sanitation of the town — inust, especially during the rainy season, be as good as possible ; the acavenging, the flushing of drains, the removal of sewage and refuse, and above all, the removal aud dispusal of exereta to 4 good high trenching-ground.

3rd—That in view of the fuct that the sucred tanks never geta chance to purify themselves, the templé authoriiies be asked te proclaim that ona of the tanks is sacred for a week at a tino During that period the people would be alloyed to bathe in that tank, but only sprinkle water on their heads froin thd other three, --(.

. No one even dares to bathe in the Sweta- gangar, but each one of the other three tanks would then have a rest of two weeks in every three, and the action of the sun and air would considerably reduce the number of cholera germs and allow the bacteria in the water time to ehange the harmful organic matter present into harmless inorganic.

4th.—That it ba impressed upen the temple authorities the importance of supplying good ‘* Mahaprasad ;” the water used in boiling the rice should be beyond suspicion.

5th.—The immediate notification of a ease of cholera to the Health Officer, so that measures for disinfection of the place and removal of the patient to the cholera hospital may be effected.

At the Cholera Hospital patienta were placed © on straw mattresses, which could afterwards be burnt; every precaution to prevent dissemi-. nation was rigidly carried out, vomited matter : and stools were destroyed in an incinerator, hoe-. pital blankets, &e., were regularly. steeped in per- ehloride and boiled, and the floors were frequens- ly washed with lime-water, whilat the clathing of patients on discharge was burnt and new clothing given them. SS

During the first stage and previous to col- lapse setting in, patients are ordered the fallow- ing mixture:—

,

By Acidi Sulphurici dil. ... m. 20 Chiorodyne . «. m. 20 Tinct. Capsicj ... win, 5

Aquam Menth, Pip. ad 3j

Bie. One dose every two hours. —

During collapse, heat is supplied by means. of warm blankets, and hot battles are applied to the feet, thighs and sides of the chest; an injec- tion of ether and strychnine is given when, required, and the following mixture ordered :—

BR ! Tinct. Nucis Vomice - - mm 5 Spiritus Btheris Sulpharici ...m. 20 Rum wee va. oo. Si] Aquam Chloroformi ad . } M

Big.

One dose every two hours, During the stage of reaction, the following mixture is given :—

Tinct, Digitalis om. 5 Spiritus Etheris Nitrosi .. m, 10 Tinct. Capsici m 6 Inf. Chiratee ad a M

One dose every four hours.

In convalescence, patients are again ordered the sulphuric acid mixture and a powder containing lead acetate, opium and grey powder, which gives a good result. Light nutritious food, such as milk, sago and arrowroot, is given frequently in small quantities, whilst barley water is given to the patients when thirsty at any time during the attack.