Stasis in Medical Research in CMC: Germ Theory, Suez Canal and Commercial Interest in Colonial India

“It appears that there were two Surgeons in the Medical College Hospital between the years 1860-94, one of whom occupied the Chair of Surgery and was designated the First Surgeon and the other occupied the Chair of Anatomy and was designated the Second Surgeon. These Surgeons had separate surgical wards, each having 60 beds under his charge.”[1] The mortality was rather high in those days of pre-antiseptic surgery. Among 38 deaths out of 199 operations performed in 1879, the following causes of death were noted:—

Primary Haemorrhage … … … 4

Secondary „ … … … 5

Tetanus … … … … 6

Erysipelas … .. – … … 5

Gangrene … … … … 4

Septicaemia … … … … 6

and Exhaustion … … … 8[2]

Moreover, in 1878, Dr. S. B. Partridge as having introduced the ‘Bloodless Method for Scrotal Elephantiasis’ by tying an Esmerch’s cord round the neck of the scrotum during its excision. Peritonitis was dreaded in operations for Hernia and the Sac was never opened if it could be avoided. It was in 1884 that J. D. O’Brien practised the opening of the Sac in every case of hernia.[3]

We can compare the following two pictures before and after the operations.

There is also a interesting account of the draining of a very big hydrocele and giving relief to the patient –

if a surgeon saw a man waddle into the surgical out-patient room with something dangling between his legs like a sporran, diagnosis and treatment followed swiftly. A grab was made at the tumour while the patient was trying to explain, a trocar was plunged in, fluid evacuated, iodine or carbolic acid injected, the sac well shaken up and the puncture given a hard pinch to seal the hole, all in less time than it takes to tell. The patient went on his way rejoicing at the restoration to usefulness of an organ which he had not caught sight of for some time and spread abroad the fame of the hospital where a radical (?) cure had been effected so speedily.[4]

Most of the readers should hardly concur to designate these feats as any original research work. Historically speaking, as early as 1831 the French Surgeon Delpech of Montpellier wrote to the famous British surgeon Sir Astley Cooper, which was published in the Lancet.[5] If we judge from historical point of view, the act of surgery (bloodless method of scrotal elephantiasis) was actually internationally done more than 4 decades ago. In CMC, maybe it was done with some improvisation. So it cannot be called that this was a stride towards new kind research.

In the Centenary, it was noted – “During the years 1876-81, a great deal of interest was aroused by the advent of Listerism. This controversy had been going on in Great Britain for at least ten years previous to this period and naturally opinions differed here also. In a Report of, 1877, we find that no effort at anti-septic precautions was observed in surgical operations.”[6] More elaborately,

It appears from the records that the application of Listerism was defective until Dr. Kenneth McLeod went to Edinburgh in 1876 and saw Lister’s work with his own eyes, returned to India in 1879 and introduced it in a better form. There was so much of stinking smell from “Hospitalism” in the wards in those days that the surgeons used to hang up baskets of charcoal as deodorants. Operations used to be performed under sprays of Carbolic Lotion and wounds used to be dressed with cotton wool soaked in Carbolic Oil, prepared by mixing one part of Carbolic Acid to seven parts of oil and later with Boracic acid ointment and Perchloride gauze. During the years 1876-81, a great deal of interest was aroused by the advent of Listerism. This controversy had been going on in Great Britain for at least ten years previous to this period and naturally opinions differed here also. In a Report of, 1877, we find that no effort at anti-septic precautions was observed in surgical operations.[7]

In 1885, Kenneth MacLeod of CMC wrote a letter to the editor of the Indian Medical Gazette, where his observation was – “I would urge is, that the observed advantages of the antiseptic method are sufficient of them- selves to justify its employment altogether be- side and apart from theoretical consideration. There are many surgeons, both in London and elsewhere; most of them belonging to the rising generation of surgeons, who follow Lister closely, and so doing, obtain the same results. The number of these is on the increase.”[8]

Historically speaking, ‘Listerism’ was introduced in the English and European practice more than a decade before it was practised in CMC. Lister himself published his seminal paper in the British Medical Journal in which he stated –

In the course of an extended investigation into the nature of inflammation, and the healthy and morbid conditions of the blood in relation to it, I arrived several years ago at the conclusion that the essential cause of suppuration in wounds is decomposition, brought about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds, upon portions of tissue destroyed by the violence of the injury … decomposition in the injured part might be avoided without excluding the air, by applying as a dressing some material capable of destroying the life of the floating particles. Upon this principle I have based a practice of which I will now attempt to give a short account.[9]

Lister concluded – “Since the antiseptic treatment has been brought into full operation, and wounds and abscesses no longer poison the atmosphere with putrid exhalations, my wards, though in other respects under precisely the same circumstances as before, have completely changed their character; so that during the last nine months not a single instance of pyæmia, hospital gangrene or erysipelas have occurred to them.”[10]

One may cogently ask why was it that if ether and chloroform anaesthesia could be introduced in CMC within a few months after their first application, what were the reasons behind introducing internationally accepted other surgical and aseptic methods to be introduced so late in CMC. The answer remains somewhere else which I shall explain shortly.

Experiments in surgery and some other techniques were not missing in CMC. What was missing was new research activities like discoveries of cholera bacillus (which was done by Robert Koch in Calcutta) or alike. In 1862, S. G. Chuckerbutty published two original research papers in the British Medical Journal, under the title “Iodide of Potassium in the Treatment of Aneurism”.[11] When Chuckerbutty took his charge as second physician to the CMC in August 1860, he found an Irish seaman admitted, whom he could not survive. In his words – “At the post mortem examination, on opening the chest, we found an aneurismal tumour lying immediately behind the upper part of the sternum, and rising in the neck as far as the junction of the trachea with the larynx on the right side. It sprang from the inner aspect of the innominate artery, and did not involve either the aortic arch or the right subclavian or carotid arteries. It was very heavy, and as large as a pear.”[12] Following this, another patient with similar symptoms was given “strong beef-tea, milk, eggs, custard pudding, and port wine; and iodide of potassium, four grains three times a day on December 2^nd.”[13] Until June 11, the patient was gradually recovering. But on June 12 suddenly “a gush of blood issued from his mouth and nostrils; and ere any notice could be sent to the officer on duty, he was dead. The quantity of blood lost was about half a quintalfull; i.e., about a gallon (3.785 litres).”[14]

On another occasion, another patient was given, besides usual remedies, “iodide of potassium internally”. Chuckerbutty observes – “As he is still in the hospital with a small remnant of the once large tumour, it will be interesting to watch what turn his case may hereafter take.” His conclusion was to apply iodide of potassium in the treatment of intrathoracic aneurisms and “if the iodide of potassium will always do that, it will prove to us of the greatest service.”[15]

During a half-year at the out-patients’ department of the Medical College Hospital, he treated a total of 5,839 cases, 4,835 males and 1,004 females, working out the age and sex distribution and noting that most cases were between twenty-five to thirty years of age. He classified the diseases under sixteen headings of which the General Affections accounted for 2,232 cases. The conditions included in this group were intermittent fever mostly malaria 771, remittent fever (mainly enteric) 13, syphilis 579 and common rheumatism 631. The diseases of the spleen and the liver were included under the Glandular Diseases; there were 319 cases of splenic diseases, 134 of hepatitis and four each of cirrhosis and jaundice. The heart diseases included endocarditis, pericarditis, hydropericardium, aortic and mitral valvular disease, cardiac dilatation, etc. Unlike his European colleagues, he had no difficulty in recognizing the skin diseases in Indians and recorded psoriasis, ichthyosis, pityriasis, etc. He recorded that phthisis was rapidly fatal among the natives and East Indians and counted many victims annually.[16]

Chuckerbutty was well aware of the fact that “granting all the praise and honour due to hard-working and intelligent professors, the European medical officers were at best birds of passage, and could not, therefore, permanently improve the position and prospects of the profession out of the service.”[17] In a move to replace these “birds of passage”, internalization of modern medicine was of prime importance. Notably, in Chuckerbutty, we find the man at the bed side of the patient, giving experimental therapeutics (iodide of potassium) to his patients, and corroborating symptoms of the living through post mortem after death. These were the hallmarks of the new medicine – hospital medicine. It is important that Chuckerbutty preceded similar British trials in this regard. His trial was published in BMJ in July 1862, while the British one was published in January 1863.[18]

It must be clearly understood that when I am talking about the phase of ‘laboratory medicine’ it is never a phase replacing ‘hospital medicine’. Hospital medicine forms the bedrock on which other phases of medicine (including techno-medicine of the 21^st century) have developed, NOT at the cost of it. My intention is to locate the vector of medicine – whether it puts emphasis on laboratory-centered research activities or remains confined to the basics of bedside teaching, autopsy, statistics gathering and the use of microscope only.

Self-Appraisal of a Bengali Physician in 1889

In 1889 in the Bengali journal Chikitsa Sammilani (Communion of Physic) a Bengali physician Jadunath Gangopadhyay, M.B. from CMC and of some eminence of the time, wrote an eye-opening article “বাংলার চিকিৎসক সমাজ” (The World of Physicians of Bengal).[19] At the beginning of his article Jadunath started his essay with these opening notes – “Fifty-five years ago) when Lord William Bentinck set up the Calcutta Medical College) who can say what great hopes stirred in his heart. He must have felt simply elated at the thought that once western medical practices were introduced in India, well-educated Indian physicians would apply European medicine on the Indians.”[20]

But

if today he were still alive, he would have witnessed that the physicians of Bengal, like so many children, are still blindly treading along paths according to the manner in which they are led by their European mentors. Like a child who cannot grasp for himself the truth of anything and learns only what the teacher or the guardian teaches him, we also let ourselves be guided by what the English or other European scholars teach us. There is no independent thinking, no commitment to experimentation through research work, no informed opinion, no eagerness to gain experiences) no attempt to make others learn. We are like a lump of clay, we have attained the English world of knowledge, but are not capable of radiating the light of knowledge on our own.[21]

Jadunath goes on to elaborate – “During these long years no physician has become famous for his independent findings. There has been no surgeon like Sir Benjamin Brodie or Sir Ashley Cooper[22] … During this long period not a single new book has come out. Whatever books on medicine have been published are all translations.”[23] Further he wrote,, “Alas! If Dr Mahendralal Sarkar (2^nd M.D. from the University of Calcutta and the founder of the internationally reputed research centre Indian Association for the Cultivation of Science in 1876) had not been there in our midst, nobody would have known that someone practices medicine in Calcutta. In a little over five decades, apart from … Surya Goodeve Chakravarty, all the good doctors who have flourished are Europeans. No Indian doctor could win fame in the period during which O’Shaughnessy … and others reached the pinnacle of glory.”[24]

Jadunath ruefully asked –

Why is it that the Bengali physicians remain silent spectators while medical sciences in Europe and America are advancing in giant strides? All physicians must reflect on this state of affairs. In my opinion) poverty and economic hardship are the root cause of the mental poverty of the Bengali doctors … Such a craving for a comfortable lifestyle grips the students who have passed out. A direction1ess mad rush towards those luxuries and comforts takes possession of the young physicians … since we are concerned only with making money, we treat patients merely as the source of money. The patient is treated according to his ability to pay.[25]

He traces some traits prevailing in present-day medical practice too – “There is a lot of dissention and contradictions among the allopathic doctors. When a young doctor seeks the advice of the senior doctor while treating a patient, the senior doctor under various pretexts feels it a duty on his part to undermine the worth of the young doctor.”[26] Moreover, “The static nature of the Indians as against the dynamism of the Europeans is the fifth barrier impeding the possibility of the acquisition of knowledge by Indian practitioners … How can we compete with the Europeans and Americans whose pace is comparable to that of the mail train when we move like snails?”[27] He emphasizes very strongly –

Let us continue to strive in our quest for truth … Our aim is to unveil the truth. The root cause of diseases, the true nature of medicines) the permanent or exact nature of the relation of medicine with the disease it seeks to cure-all these are the subjects of our investigation … Truth is not partial to any opinion … The physicians, in the years to come, will have to sift the truth from the mind-boggling mass of true and false claims which are now enshrined in countless medical texts. The violent storm raised by the investigation inaugurated by them will blow away the dust of untruth, thousands of books and conflicting opinions will get lost.[28]

Now the reason behind the question contrasting ‘the static nature’ of Indian science and ‘the dynamism’ of Euro-American scientific activities on the one hand and the pace of scientific advancements like ‘mail train’ and ‘snails’ respectively on the other remains open to the medical professionals, researchers and sensitive all at a time.

But it must be emphasized that about three decades before this “self-appraisal” Mahendralal Sircar (the founder of the Indian Association of Science in 1876) in an address (14 February, 1872) trenchantly raised the question – How is it that the Medical College of Calcutta, which has been in existence for nearly half a century, and within whose walls some of the noblest of the physical sciences are practically and experimentally taught, has not yet turned out a single student who has even thought of cultivating any of these sciences for which such ample foundation has been laid during his term in the College?”[29]

Stasis in Indian Medical Research

Sheldon Watts was the first researcher who strongly drew attention to the basic causes behind the static nature or stasis in medical research in India in the later part of the 19^th century in a paper of 2001.[30]

About during the mid-1860s there were reversals in cholera policy in India. According to Watts, “One of these reversals, extremely costly in non-white lives and earlier ignored by historians, took place in the middle months of 1868. The reversal involved attitudes in Britain … and cholera. Cholera was thought to be endemic (constantly present) at the mouth of the River Ganges, in Bengal, in India.”[31] Owing to such official reverse in the journey of cholera research fundamental researches in cholera especially, and all other fields of basic sciences in general, were thwarted. It hindered further development of medical science in India, as we can assume.

The pivotal point of these reversals were whether there would quarantine-free British trade through the newly opened Suez Canal or the British ships would be quarantined for a routine 10-day quarantine at the Canal, amounting to commercial loss for Britain.

In another paper Watts emphasizes –

After 1866, fears of the British Government that Egyptian and Ottoman International Quarantine Boards – comprising representatives of 13 mainland European member states plus Turkey, Egypt and Great Britain – would delay passage through the Suez Canal of vessels sailing ‘homeward’ from Bombay, had a devastating effect on cholera control policies in India and on scientific research in the UK. British policy contradicted the scientific findings of the Cholera Conference in Constantinople (1866) and the Vienna Conference (1874). The British held that Indian cholera was not a contagious disease, not caused by a germ (’germ theory’), not carried afield in the human gut. This was to deny the efficacy of quarantine. The result was to deter UK scientists from further work on ‘germ theory’.[32]

This particular space of knowledge was of much importance of the time. British scientists, at least in colonial India, faced a stiff challenge to further proceed in the field of researches on ‘germ theory’ of cholera. But, ironically enough, in 1854 John Snow’s

“pioneering epidemiologic investigation proved the mode of transmission of a waterborne disease that ravaged many parts of the world in the 19th century and still occurs in the 21st century. The V. cholera organism was originally grown in 1854 but was reported in local Italian medical literature and not recognized internationally. International recognition for the definitive identification and growth of the organism during his investigation of an epidemic of cholera in Egypt was given to the eminent German bacteriologist, Robert Koch in 1883. Filipo Pucini was ultimately recognized for the discovery in 1984 when the organism was formally named Vibrio cholera pucini 1854.”[33]

Erwin Ackernecht has shown – “A Cholera Quarantine Conference, organized in Paris by Melier in 1851, was practically without result, mostly because of English anticontagionist opposition under Sutherland … and that the British government denied the imported character of a cholera epidemic in Egypt as late as 1885.”[34]

The understanding of the nature of cholera was how much flawed and harmful to scientific inquiries on the one hand, and for the common people on the other can be well appreciated by an American poster in 1832.

(Hand bill from the New York City Board of Health, 1832. The outdated public health advice demonstrates the lack of understanding of the disease and its actual causative factors. Courtesy: Wikipedia)

For our present discussion British policy about cholera can be well understood by the activities of David Douglas Cunningham (1843-1914), a Scottish doctor in the Indian Medical Service, who from 1869 to 1897 was a scientific assistant to the Sanitary Commissioner with the Government of India.[35] “Cunningham was an implacable opponent of Koch, continually rejecting his bacillus as the true cause of cholera; when the latter’s views on the cholera bacillus were vindicated at the turn of the century, Cunningham’s work sank almost without trace. Cunningham’s conflict with Kochian bacteriology can be understood only when the Indian cholera story is re-told with his full role intact.”[36]

Its perilous impact on medical scientists in colonial India was the impetus for laboratory-centred research works on cholera (and consequently in other fields) were thwarted and buried too. As we come to understand from “self-appraisal of a Bengali physician” there was innovative trend towards ‘laboratory medicine’. Best of finest scientific minds were wasted.                                                                        (A representative photo of cholera epidemic in 1870s in India)

In actuality, the British politics and its changed position regarding sanitation and innumerable international debates and scientific discourses were intertwined with a particular disease (cholera in our discussion). And its pivotal issue was the official opening of the Suez Canal on 17 November, 1869. We shall come to see shortly that how the greed for profit in international trade deeply impacted the course of science and scientific discoveries and, additionally, the state policy toward science.

Medicine, politics and commerce were all entangled in layers to make earliest form of Medical-Industrial Complex (widely gaining currency since 1980, when the late editor of New England Journal of Medicine, Arnold S. Relman, coined the term) colonial India. Moreover, whether which type of original research would be allowed in the CMC was also implicated with this change of the British cholera policy in Indian colony.

The Search for Origin of Stasis in Scientific Inquiries

For more or less 200 years countless books, research articles, monographs and international Sanitary Commission’s reports have been written on ‘Asiatic’ cholera which originated in Bengal around 1815-1817, spread to other regions of India and throughout South Asia and Southeast Asia to the Middle East, Eastern Africa and the Mediterranean coast. Even it reached continental Europe and England. The spread of cholera was closely connected with territorial expansion during war.[37] Moreover, “In addition to war and trade, a third element assisted the diffusion of cholera: large gatherings of pilgrims housed in makeshift accommodations.”[38] Interestingly, cholera was also instrumental in the improvisation of scientific techniques during wars.

One such example is the method employed by an Australian military physician accompanying some 7,000 Australian and British prisoners of war during their forced march under Japanese occupation in Southeast Asia in 1943. Cholera was a great killer, but this adept medical officer designed a contraption from a small bamboo tube, an old tin can, and a piece of rubber tubing from his stethoscope, and administered nearly one hundred infusions of salt and water into the veins of his dehydrated patients, saving scores of lives.[39]

The second half of the nineteenth century witnessed an explosion of inter-national events. A list of international meetings of all scales and agendas contrasts twenty-four entries up to 1851 (and only one before I815) against 1,390 between 1851 and 1899. Scientific congresses multiplied and contributed to the development of international standards and to the professionalization of science. The International Telegraphic Union (1865), the Universal Postal Union (1874), the International Union of Weights and Measures (1875), and the fixing of the prime meridian in Greenwich as a basis for the world’s standard time zone system (1884) were examples of regulation in areas that could no longer be managed differently from state to state.[40]

The severity and havoc caused by cholera in India was an exemplar to the world. During 1867, the strength of the British Army in India was 34,603 until the close of the year. Of that total number, 1,071 died, 479 as a result of cholera, especially at Rohilakhand and in the Punjab. By contrast, soldiers’ wives and children suffered a mortality of 96.91 per thousand. In the disgraceful gaols of Bengal, mortality was 56.65 percent. By November 1869, four hundred natives a day were dying from cholera in the North-Western provinces, with 70 percent of those attacked perishing.

Cholera in India during 1876–1877 was particularly severe, with many reports indicating horrific loss of life along the Bombay and Baroda Railway. At Golwood, a village of 200 people, disease killed half in three days. By the spring of 1877, nearly 4,000 deaths at Madras were attributed to cholera. Reported numbers were worse at Akyab, Chitagong and the islands along the coast, where it was claimed the disease took 50,000 lives. According to official tables, total cholera cases in Bombay for 1881 reached 30,966 cases, with 14,282 fatalities.[41]

To what extent did cholera produce panic and anxiety internationally at various levels – in the field of medicine, trade, commerce and politics and, even, at the level of international diplomacy too – can be well assessed by the series of the histories international sanitary conferences in 19^th century. The first of the Sanitary Conferences was organized by the French Government in 1851 to standardize international quarantine regulations against the spread of cholera, plague, and yellow fever. In total 14 conferences took place from 1851 to 1938. Paris, 1851 – where a “a draft Sanitary Convention and draft International Sanitary Regulations” was adopted, Paris, 1859, Istanbul, 1866 – where discussion and common agreement on the propagation cause of cholera was accepted, Vienna, 1874, Washington, 1881 – when America participated for the first time, Rome, 1885, Venice, 1892 – where the first International Sanitary Convention was adopted, Dresden, 1893, Paris, 1894, and Venice, 1897.

It may be interesting to note here that – “During the 1840s, ships from the Orient with unclean bills of health underwent two days of quarantine at Southampton, Falmouth and Liverpool. In the sixties, quarantines were still imposed and cholera-stricken vessels were isolated for three days and inspected, and the ill sequestered. The British delegates to the 1866 Constantinople Sanitary Conference reported back enthusiastically in favor of quarantinist measures. During the summer of 1871, Sunderland and Seaham took steps to place infected ships in strict quarantine.”[42] Those very people who advocated “enthusiastically in favor of quarantinist measures” in 1866, were vehemently against quarantine after the opening of the Suez Canal in 1869. How such a huge reversal in cholera policy took place is the crucial part of my paper.

In 1865, four years before the opening of the Canal, cholera epidemic broke out in Alexandria. Strict quarantine measures were put into action. It lingered after the opening of the Canal too. As a result, those ships, especially coming from India, passing through the Canal was quarantined at the port for 10 days to observe if the ships were free from cholera and not a threat to Egypt.[43] It was quite detrimental to the profits of the British Empire.

(A photograph of early quarantine at the Suez port in the late 1860s)

Baldwin comments – “That country which most consistently opposed such restrictions because of their harm to commercial relations was, not surprisingly, Britain. Only here was the argument against quarantines formulated in universal terms – not in those of minor comparative advantage, but as an issue of general laws of nature and economics that could be violated only at the cost of debilitating loss.”[44] Moreover, as Baldwin observes, “Its role as the greatest shipping power and its commercial relations with the empire, especially India, made quarantine commercially undesirable.”[45]

It was the British who consistently argued the case against restrictions throughout the International Sanitary Conferences, starting already in 1866 with their insistence that whatever increased chance of epidemic attended free and proliferating communication was but a minor disadvantage compared to the vast benefits conferred. In direct opposition to the business interests of quarantinist nations, the British argued that theirs was a country which suffered more in commercial terms from restrictive practices than from an epidemic.[46]

Steadfastly pursuing commercial interests and their prophylactic consequences, Britain was brought into conflict with other European powers, especially France, in the Middle East. At the 1881 Conference, the European powers agreed to establish a system of sanitary surveillance of the Red Sea, the Egyptian ports and routes followed by pilgrims to Mecca. The British occupation of Egypt the following year, however, turned matters on their ear, ending Anglo-French cooperation.

The British now dominated the Alexandria Sanitary Council, nominally an international body, safeguarding their prophylactic interests through strategic alliances with the Egyptian delegates, several of whom, including the president, were in fact Britons. Since this meant largely unhindered passage of shipping between India and the homeland, the other powers accused them of neglecting the public health of Europe for their own gain. After cholera hit Egypt in 1883 and British dominance of the Alexandria Council continued to rile the other European powers, the Rome Conference in 1885 sought to break the impasse. Here the British proposed to exempt ships with clean bills of health travelling from India to England without calling at ports in between from the delays of inspection or quarantine at the Suez. Although the British presented their demands in general terms (quarantinism as an affront to human liberty, the only true guarantee of public health to be found in sanitary reform), their rivals rejected this as but special pleading for Britain’s shipping interests in the masquerade of universalism.[47]

Harrison observes –

The economic problems experienced as a result of quarantine in 1882 were particularly acute as the year had been a poor one for trade. Depressed markets in Britain had seriously damaged Bombay’s export economy, which, according to shipping experts, was ‘devoid of animation’ … Since the late 1860s most British-trained medical men had come to believe, though in the absence of concrete proof, that cholera was transmitted by man, albeit indirectly in drinking water contaminated with the faeces of an infected person. It was true, however, that the majority of British doctors agreed that quarantine was impracticable and a useless hindrance to trade.[48]

Moreover, as Harrison puts it, “In India, the government did its best to cover up the severity of the cholera epidemic afflicting Bombay and its hinterland. Yet, in view of the unsuccessful record of the Indian authorities in preventing the spread of cholera to the Middle East, it was thought necessary to introduce some new measure to allay the fears of the Egyptian board. With this in mind, the Bombay government announced in 1882 the formation of a medical board, comprising the principal of Grant Medical College, the surgeon of the European general hospital, and the health officer of the city.”[49]

Simply put, the British authorities of India, keeping their commercial losses in mind, were not in a position to allow quarantine for 10 days at the Canal. To establish their ‘unique’ explanations for cholera epidemic, two obedient and faithful delegates were chosen – “The two Indian delegates were Sir Joseph Fayrer and Timothy Lewis: convinced opponents of the Constantinople decision on the communicability of cholera. While Lewis and Fayrer were almost certainly chosen because of the congruence of their views with the political objectives of the Indian administration, they were not … untypical of medical opinion in India.”[50]

Moreover, as Harrison observes, “As expected, the conference, which was convened in 1885, proved to be a hotbed of controversy, the chief issue at stake being the nature of quarantine restrictions at Suez against vessels sailing from infected ports. The British and Indian proposal that ships agreeing not to dock before reaching England should be exempted from quarantine was heavily defeated, with only 6 of the 28 delegates voting in its favour.”[51]

What was the ‘unique’ explanation of Indian delegates? The first explanation was to emphasize on the types of cholera which were of two types according to the British explanations – ‘sporadic’ and ‘epidemic’. From Indian representation they were firm on establishing the ‘sporadic’ type as the primary one. “The Viscount Enfield, Under-Secretary of State for India, argued that if the present views of the sanitary boards were acted upon, India would be in ‘perpetual quarantine’ generating an ‘almost intolerable’ obstruction to communication between the United Kingdom and its South-Asian possessions. To him it was crucial to make the distinction between epidemic and sporadic cholera in India.”[52]

Powerlessness of Medical Profession

To add, carefully manoeuvring the logic, it was put forward – “It appears to his Lordship as useless and irrational to place in quarantine at Suez a perfectly healthy ship arriving from Bombay because there are a few sporadic cases of cholera among the 750,000 inhabitants of that city, as it would be to place in quarantine at Antwerp healthy arrivals from the Thames because London is hardly ever totally free from small pox or scarlet fever.”[53] To emphasize, such a project of reconstructing the nature cholera epidemic for commercial was jointly upheld by both the British colonial authorities and the highest medical authorities in England – “It is useful to point out here that, over the years, the British government and its apologists gave the appearance of being unaware that a cholera policy reversal had ever happened. To maintain general amnesia, they silenced critics at the Royal Army Medical College at Netley who knew what the score was.”[54]

All the free thinking scientific voices of the time were silenced for the sinister motive of the state. Does it reappear in today’s India after about 150 years? To add, the administrative and social position of the doctors at that time was not much esteemed then. Rather doctors were politically they were quite powerless.[55] Arnold comments – “because of the limited career prospects and financial rewards Western medicine offered, an Indian medical profession developed only gradually, more slowly than in the more lucrative and prestigious fields of law and government service.”[56] He has drawn attention to another fact – “The authority invested in the medical hierarchy could be effectively deployed to crush dissent and enforce compliance, as shown by the stifling of opposition to the anti-contagionist views held by J. M. Cuningham, Sanitary Commissioner with the Government of India from 1866 to 1884.”[57] The comparatively social slightness medical profession is made obvious from this remark – “the social prestige of medical men according to the British gentlemanly ideal remained inferior to other liberal professions in law, the ministry, and the military.”[58]

More on the Politics around the Suez Canal and Sanitary Principles

Harrison has commented on sanitary conferences and cholera connection – “the third of these conferences, was also the first to be devoted to cholera, with other important pandemic diseases, such as plague and yellow fever, taking a back-seat. It marked a turning point in sanitary diplomacy and ushered in a new concept of disease prevention in which the Middle East would become a kind of sanitary filter, protecting the West against Asiatic diseases.”[59] Again, “Until 1868, the post of Sanitary Commissioner with the Government of India was occupied by a non-medical man, Lt. Col. G.B. Malleson. Like most army officers, he held opinions on the spread of cholera and its prevention which inclined towards the use of sanitary cordons – a long-standing military expedient in dealing with epidemics.”[60]

(International mapping of the spread of cholera)

Harrison further points out – “In early 1870, however, the Egyptian and Ottoman boards of health issued more stringent regulations against ships from ports potentially infected with cholera, fearing that the Suez Canal, which had opened in November 1869”[61]. Additionally, “Much to the annoyance of the Government of India, these included its dependency, Aden, which was under the authority of the Government of Bombay. In the coming years, the Egyptian regulations became stricter (partly at French insistence), with a quarantine of around 30 days being imposed on all ships deemed to be in an unhygienic state or from ports considered likely to be infected.”[62]

Now the shrewd, vile and sinister games of politics and diplomacy began to operate amongst the European powers. It operated at various levels. Some of which were like –

(1) British tried hard to establish medically that cholera was not much contagious (rather non-contagious)

(2) The regulations of 1881 were reformed several times and to the shock of the non-European powers, in 1891 the number of Egyptian members was reduced from 17 to three, justified by the fact that it was an international institution after all. In exchange, the Egyptian government was offered the funds necessary to finance the construction of lazarettos and to amend the state deficit. Simultaneously the total number of members was reduced from 23 to 17, representing all the powers that had a self-defined interest in the Mediterranean and the ‘Orient’, that is Germany, Austria-Hungary, Belgium, Britain, Denmark, Spain, France, Greece, the Netherlands, Italy, Portugal, Russia, Sweden and Turkey as well as two Egyptian delegates with voting powers.[63]

(3) As a result of these fateful moves, international sanitary body was ‘denationalized’ on the one hand, and ‘internationalized’ (in the sense of European supremacy) on the other. But “In the case of disease protection this defect of internationalism was however particularly problematic as it was crucial to prescribe tight measures in order to ‘stop the progression of the diseases which rule in the Orient and which ships or caravans can transport into Europe’.”[64]

(4) Quarantine system was replaced by clean bill of health – “In the International Sanitary Conferences of 1894 and 1897 a series of new regulations about cholera and plague were implemented about the Suez. European vessels that had a clean bill of health were given immediate practique without any restrictions or requirements”[65]

(5) As a sum total of these vicissitudes in internal sanitary regulations British authority in India imposed stringent restrictions on medical theories of contagiousness of cholera and almost totally rejected ‘germ theory’ about cholera causation. Though, the principles of Indian government were often heavily criticized by epidemiologists and scientists of England. Interestingly, both of them lived under the same empire.

Difference in the Moves of Cholera Research in India

At the outset, it is interesting to note – “In 1875, Prime Minister Benjamin Disraeli had purchased cut-price government shares in the Suez Canal (funded by the banking magnate Lionel de Rothschild) that amounted to 44% of its total stock. Subsequently, when Egypt was declared bankrupt in the following year, Britain was its principal creditor.”[66] After this, creating some bogus and untenable alibi, British invaded and occupied Egypt in 1882 following there remained no more restrictions on quarantine. British monopolized their authority over the land.[67]

Cholera epidemic enhanced some technological discoveries like using telegraphic system/signal to send message to any nearby ship carrying cholera patients. It was then again sent to ports authorities. It was an extension of new information technology. Moreover, the use of new techniques like “chemical disinfection”, and “disinfection machines” began to be incorporated into the realm of medicine.

A discussion on cholera took place at the Medical and Chirurgical Society of London on 24 March, 1874. It “had a different interest from that which took place at the Epidemiological Society a few weeks previously. In both cases the Sanitary Commissioner with the Government of India, Dr. Cuningham, was the central figure; but at the Epidemiological Society he was in opposition with certain Indian opinions and experience, while the Medical Chirurgical Society he was in opposition with current English opinions and experience.”[68]

It is interesting to note that Dr. Cuningham changed his position on opinions and experience of cholera within a very short period. And that too was among the medical scientists of London/England. From all corners of medical scientists and epidemiologists present at the meeting he was badly and bitterly criticized. “It is not easy to treat seriously the position claimed by Dr. Cuningham for his researches in India, and particularly observations made by him and his coadjutors during the cholera epidemic in of 1872.”[69]

To emphasize, the person referred to above was James McNabb Cuningham, not to be confused with D. D. Cunningham, mentioned earlier.

It was also categorically pointed out that his sweeping “assertion at the meeting of Medical and Chirurgical Society, that not a single fact existed in India which justified the theory of contagiousness of cholera and the capability of transmission through water, may be left the Indian physician to deal with.” Moreover, it was also emphasized that “Dr. Cuningham used the terms “contagion” and “water theory” in a sense peculiar to himself, and having nothing in common with the sense in which the terms are used in this country.”[70] So to say, it was an “Indian theory of cholera” was strongly castigated by his country he belonged to.

Finally, “in the end Dr. Cuningham stood alone among the ruins he had created, and loomed before the mental vision of audience like GAVARNI’s cynical philosopher, who, sitting upon the dome of the Invalides, contemplates the beneath him through a reversed telescope.”[71] The report stressed that Dr. Cuningham’s utterly spurious, unscientific and faulty observation and theorization led him to insist “strongly upon as the special characteristics of the disease in India.”[72]

Before Cuningham’s report was derisively cricized in the Lancet, Practitioner journal published a more vitriolic report on Cuningham’s presentation.[73] It was observed – “For some time, in his annual reports, Dr. Cunning ham, when discussing questions relating to the etiology of cholera, has expressed opinions diverging widely from those commonly entertained in this country on the same subjects.”[74] Further, “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.”[75] And it was categorically stated, “the etiology of cholera, and indeed of other epidemic diseases, at least in the questions chiefly discussed, has become largely a question of “authority.”[76] So,

According to the journal, Cuningham was corrupted by placing authority over science and facts.

It went on to say that Cuningham had rightly attacked the “keystone” of cholera etiology – “contagiousness” of cholera – which was internationally accepted paradigm. Then the journal added “Quixotic-like, his whole argument as to the contagiousness of cholera is addressed to his own conceptions.”[77] He was shown to be of the same ‘quixotic’ nature regarding “water theory”.[78] Again, it was reported with fun that “Dr. Cunningham 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 as yet unknown condition.”[79]

Even an Indian journal could not fail to grasp the grievous harm done to science by Cuningham’s report. It reproduced Practitioner’s report in its pages – “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 his 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. Cuningham’s report is simply Quixotic.”[80] To conclude, “A Sancho-like reference to the doctrine is made in sections 66 and 89, but merely to serve as a foil to Dr. Cuningham’s astounding imaginations. Quixotic-like, his whole argument as to the contagiousness of cholera is addressed to his own conceptions.”[81]

The much debated, derided and outright-rejected high-placed medical authority Dr. Cuninngham wrote his book Cholera: What can the State do to Prevent it? (1894).[82] In the Preface of the book, he unhesitatingly wrote down – “The policy of the Government of India is to reject all theories as a basis of practical sanitary work. They are guided by their large experience, and this experience teaches in the most unmistakeable language that, in dealing with cholera, theories cannot be taken as a guide for any useful action on the part of the State”[83]. Following this state-determined position and line of thinking and logic, he asks –

There has thus been the most ample means of testing two great points on cholera history: 1^st, Do ships leaving India suffer from cholera as might be expected if modern views be correct? and 2nd, Do they convey cholera from India to other countries ? The answer to both these questions must be decidedly in the negative. The proportion of ships in which cholera appears at all is extremely small, and instances in which it assumes anything like the proportion of an outbreak are most rare.[84]

To refute the sanction for quarantine he even took recourse to ‘liberty’ of human being and ‘tyranny and oppression’ being perpetrated in the name of ‘truth and science’.

All interference with liberty in this matter would then be at an end—all that tyranny and oppression which are so often perpetrated in the name of truth and science. To sum up the whole matter, the doctrine that cholera is communicable or transmissible from man to man leads to no practical benefit. On the other hand, it leads to all the evils of quarantine, loss of personal liberty, worry and annoyance, social misery and anxiety, with grievous injury to trade. Panic is caused, the sick are not properly attended to, and, what is most to be lamented, sanitary improvements are neglected—the real evils of filth in every form remain, and money which might have been spent with so much profit to remove or remedy these evils has been more than wasted on the quarantine officials. If all nations will not admit the truth of what has been said, let Egypt and every other country take such measures as it may think proper to protect itself, let ships go through the Suez Canal in quarantine, and then it will soon be seen which countries fare best.[85]

He was ruthless enough to dismiss Robert Koch – “Dr. Koch has been entirely misinformed. It has already been shown that in the Delta of the Ganges cholera varies enormously from year to year, and that in many parts of India it is so constantly present that there is no room for supposing that it is due to re-introduction – that connection between pilgrimages and the diffusion of cholera in India is a popular error”[86] He admitted – “This has been the policy of the Government of India. It has acted on no theory of contagion or non-contagion, but only on the common-sense plan that certain measures in respect of cholera have proved in practice to be most useful, and that other measures, although strongly advocated on theoretical principles, have proved not only useless but positively mischievous.”[87]

Such was the position of the Sanitary Commissioner of India in 1884, in written words. Against this perspective, how could one expect fundamental, basic and unhindered scientific research in India? As a result and sequel, all medical scientific researches in India were completely stagnated for 30 years until the end of the 19^th century. CMC suffered as well.

(J Cell Sci (1886) s2-26 (102): 303–316. From p. 303)

After two years of Cuningham’s publication William Campbell Maclean’s book was published.[88] Maclean was late Surgeon-General of IMS and Professor of Military and Clinical Medicine in the Army Medical School, Netley. Mentioning Cunningham, Maclean wrote about official position regarding cholera – “The experience of fairs and other gatherings in this country (India) has again and again testified to the truth of the conclusion, that cholera is not carried by persons from one locality to another”[89]. Maclean scathingly noted –

It is impossible to resist the conclusion that, consciously or unconsciously, political considerations weighed with this able officer when he changed his opinions in this remarkable manner. It is certain that the Government of India was alarmed lest, if it could be established that cholera followed the great lines of human intercourse, foreign nations, in their jealousy of British commercial prosperity, should establish, to the detriment of Indian trade, quarantine regulations of an oppressive character. It is certain that both Dr. Cuningham and some of the high officials of the Civil Government lost no opportunity of expressing in strong terms their opinion, that to reason from facts before them, showing the influence of human intercourse or water in propagating cholera, on the part of medical officers, was highly culpable, and a practice to be reprobated.[90]

Maclean seems to dejectedly comment – “I would rather have avoided any reference to this unpleasant subject, but it is part of the history of cholera in India, and I cannot pass it over in silence.”[91] At the end of the book, in his “Farewell Address”, he emphasized – “– “From that time to the present (since time of the reversal of cholera policy since the middle of 1868) no lectures delivered in the Army Medical School by any of the professors have been published, with the exception of merely formal addresses delivered at the opening of the sessions, and then only for private circulation … I cannot publish under a censorship however mild, judicious, or even generous.”[92]

Concluding Remarks

After the forceful occupation of Egypt in 1882 everything, including Egypt’s own sanitary works and hygienic condition, changed. Lancet reported about Egypt – “In this respect the army occupation is several years behind the German Hospital, the Egyptian Government Hospital, the schools, hotels, and other large buildings in Cairo.”[93] What transpires from this observation of the Lancet is that in the field water filtering and clean water supply British system was lagging by several years behind the prevailing system of Cairo.

To proceed further, at the meeting of the Epidemiological Society, London, a meeting was held on 17 January, 1896, with the sole focus on “Experiences of Cholera in India”.[94] In that meeting Kenneth Macleod, ex-professor of anatomy of CMC from 1879 to 1892, and, also, professor of clinical military medicine at the Army Medical School at Netley, “maintained that the epidemiological method of inquiry had completely failed in India to elucidate the causation and propagation of the disease, for which the pathological and bacteriological investigation of individual cases was necessary.”[95] Summarily speaking, India had failed completely in advanced epidemiological science with regard to the understanding of cholera.

After all these debates and when the dusts around cholera causation controversy were cleared to an extent, an important article appeared in British Medical Journal in 1896.[96] It was observed in the article – “if proper regulations were framed and enforced as to food and drink, so that either by filtration or by recent cooking by fire all that enters the mouth should be sterile, more would be done to prevent cholera and to enable our troops to live safely through all epidemic prevalence of the disease all round than is effected by all the marchings and countermarchings which are at present imposed by the regulations.”[97] It was advised more emphatically – “But in addition to all this, wherever British troops are assembled, there should go the representatives of British science. The bacteriologist should be the pioneer; the water and the soil should be examined, and the movements of the troop should be made in accordance with the report. No longer should it be possible for troops to be forced out into encamping grounds, perhaps far more dangerous than the cantonments they leave, merely because a foolish man has brought the disease in with him from outside.”[98]

As we see in this new regulation for the British army, the incorporation of the bacteriologist for cholera control was finally accepted at the government level. But it was late by 30 years. In these years, it had done irremediable losses to science and research which was again taken up by U. N. Brahmachari especially in 1920s. All the best minds and cognitive spirit was completely stalled and ruined by the reversal of cholera policy from the later part of 1868.

On a different note, Arnold observes,

Kanny Lall Dey and Udoy Chand Dutt in the 1860s and 1870s and Chunilal Bose in the 1890s and 1900s played a crucial role in bringing India’s poison drugs and a scientific knowledge of their uses and properties to Western attention. There was nothing apologetic about this. In 1862, Dey compiled a list of Indian drugs sent to London for an exhibition that included poisons and abortifacients. In 1867, he published a more extended account of The Indigenous Drugs of India, which incorporated medicines and poisons sold in bazaars or used by Bengali vaids and hakims. In his own research, he devised an improved method of testing for the presence of Indian opium in forensic samples.[99]

Kanny Lall Dey (Kanai Lal Dey) also wrote a book Modified land scurvy with pingaemia in 1868. If we look at the year it is 1868 the watershed whence basic scientific researches were increasingly forestalled by colonial authority. Moreover, Kanai Lal did research on pharmacological properties of Indian plants, which was not affecting basic research on cholera.

We should also remember the almost-forgotten scientist Waldemar Haffkine who pioneered the vaccines against cholera and plague in late 1890s. After Haffkine’s path-breaking discovery new momentum was added to the spirit of scientific inquiries again.

But that is an altogether different history and narrative beyond the scope of this paper.

(Haffkine inoculating villagers in Calcutta in March 1894 – Wellcome Trust)

______________________

[1] Centenary, 50.

[2] Ibid, 51.

[3] Ibid, 51.

[4] Ibid, 157-158.

[5] Delpech, Pr., “Operations for Scrotal Elephantiasis”, Lancet (July 02, 1831): 439-440.

[6] Centenary, 52.

[7] Ibid, 53.

[8] Kenneth MacLeod, “From a Correspondent on Furlough”, Indian Medical Gazette (March, 1885: 68-71.

[9] Joseph Lister, “Antiseptic Principle in the Practice of Surgery”, British Medical Journal (Vol. 2, 1867): 246-248. Quotation on p. 246.

[10] Ibid, 248.

[11] 1^st part was published in BMJ (July 19, 1862): 61-64, and the 2^nd part in BMJ (July 26, 1862): 85-86.

[12] BMJ (July 19, 1862): 61-64.

[13] Ibid, 62.

[14] Ibid, 63.

[15] BMJ (July 26, 1862): 85-86 (86).

[16] For a full-length study on Chuckerbutty see, P C Sengupta, “Soorjo Coomar Goodeve Chuckerbutty: the first Indian contribution to modern medical science”, Medical History, 1970 14(2): 183-191.

[17] Chuckerbutty, “Address in Medicine: The Present State of the Medical Profession in Bengal (delivered on February 3^rd, 1864),” British Medical Journal 2 (July-December 1864): 88. Chuckerbutty, Popular Lectures, p. 143.

[18] William Roberts, “The Successful Use of Iodide of Potassium in the Treatment of Aneurism,” British Medical Journal (24 January, 1863): 83-85.

[19] Jadunath Gangopadhyay, “Banglar Chikitsak Samaj”, Cikitsa-Sammilani (Baisakh-Jaistha (April-June), B.S. 1296, 1889): 178-198. It has been compiled in Pradip Basu, ed., Health and Society in Bengal A Selection from Late 19th-Century Bengali Periodicals (New Delhi, London: Sage, 2006, 260-274. I have adopted the English translation from Basu, though page numbers mentioned here indicates pages in the original article in Bengali.

[20] Gangopadhyay, “Banglar Chikitsak Samaj”, 178.

[21] Ibid, 178-179.

[22] Sir Benjamin Collins Brodie (1783-1862) was one of the outstanding surgeons of 19th-century London. One of his major contributions to surgery was doing as little of it as possible, opposing the prevalent practice of indiscriminate amputation. Sir Ashley Cooper (1768-1841) was an English surgeon at Guy’s Hospital, London.

[23] Gangopadhyay, “Banglar Chikitsak Samaj”, 179.

[24] Ibid, 179.

[25] Ibid, 180-183.

[26] Ibid, 186.

[27] Ibid, 187-188.

[28] Ibid, 197-198.

[29] Mahendralal Sircar, “On the desirability of a national institution for the cultivation of the sciences”, Indian Journal of History of Science, 29 (Supplement, 1994): 1-48. Quotation on S2.

[30] Sheldon Watts, “From Rapid Change to Stasis: Official Responses to Cholera in British-Ruled India and Egypt: 1860 to c. 1921”, Journal of World History, Fall 2001 (12. 2): 321-374.

[31] Ibid, 321.

[32] Sheldon Watts, “Cholera and the maritime environment of Great Britain, India and the Suez Canal: 1866–1883”, International Journal of Environmental Studies, February 2006, 63 (1): 19–38. Quotation p. 19.

[33] Theodore H. Tulchinsky, “John Snow, Cholera, the Broad Street Pump; Waterborne Diseases Then and Now”, in Case Studies in Public Health (Cambridge, Massachusetts: 2018), 77–99. Quotation on p. 83.

[34] Erwin Ackerknecht, “Anticontagionism between 1821 and 1867”, Journal of Epidemiology, February 2009, 38 (1): 7-21. Quoted on p. 14.

[35] Jeremy D. Isaacs, “D D Cunningham and the Aetiology of Cholera in British India, 1869-1897”, Medical History, 1998 (42): 279-305.

[36] Ibid, 280.

[37]Myron Echenberg, Africa in the Time of Cholera: A History of Pandemics from 1817 to the Present (Cambridge:  Cambridge University Press, 2011).

[38] Ibid, 19.

[39] Ibid, 11. Italics added.

[40] Valeska Huber, “The Unification of the Globe by Disease? The International Sanitary Conferences on Cholera, 1851–1894” The Historical Journal, 49, 2 (2006), pp. 453–476. Quotation on p. 458.

[41] For a detailed study see, S.L .Kotar and J.E. Gestler, Cholera: A Worldwide History (North Carolina: MacFarland and Co., 2014)

[42] Peter Baldwin, Contagion and the state in Europe, 1830-1930 (Cambridge: Cambridge University Press, 2004), 150.

[43] For detailed discussion see, Jayanta Bhattacharya, History of Medical College, 1860 and Beyond (in Bengali), chapter 9 (Kolkata: Pranati Prakashani, 2023).

[44] Baldwin, idem, 206.

[45] Ibid. Italics added.

[46] Ibid, 207.

[47] Ibid, 207.

[48] Mark Harrison, Public health in British India: Anglo-Indian Preventive Medicine 1859-1914 (Cambridge: Cambridge University Press, 1994), 124.

[49] Ibid, 124-125.

[50] Ibid, 127.

[51] Ibid, 127-128.

[52] Valeska Huber, Channelling mobilities: migration and globalisation in the Suez Canal Region and beyond, 1869 1914 (Cambridge: Cambridge University Press, 2013), 258.

[53] Ibid, 258.

[54] Sheldon Watts, “From Rapid Changes to Stasis”, idem, 323.

[55] “Political Powerlessness of the Profession: A Proposal”, British Medical Journal (11 August, 1883): 330-331.

[56] David Arnold, Science, Technology and Medicine in Colonial India (Cambridge: Cambridge University Press, 2004), 65.

[57] Ibid, 58-59.

[58] Toby Gelfand, “The History of the Medical Profession”, in Companion Encyclopedia of the History of Medicine, ed. W. F. Bynum and Roy Porter, Vol. 2 (London, New York: Routledge, 1993): 1119-1150. Quotation on p. 1135.

[59] Mark Harrison, “The great shift: Cholera theory and sanitary policy in British India, 1867-1879”, in Society, Medicine and Politics in Colonial India, ed. Biswamay Pati and Mark Harrison (London, New York: Routledge, 2018): 37-60. Quotation on p. 37.

[60] Ibid, 42.

[61] Ibid, 50.

[62] Ibid, 50.

[63] Huber, ibid, 246-247.

[64] Ibid, 247.

[65] Birsen Bulmus, Plague, Quarantines and Geopolitics in the Ottoman Empire (Edinburgh: Edinburgh University Press, 2102), 146.

[66] David J. Mentiply, “The British Invasion of Egypt, 1882”, E-International Relations (March 2009): 1-7. Quotation on p. 2.

[67] M. W. Daly, “The British Occupation of Egypt, 1882-1942” in Modern Egypt, from 1517 to the end of the twentieth century, ed. M. W. Daly (Cambridge: Cambridge University Press, 2008), 239-251.

[68] “The Discussion on Cholera”, Lancet (April 4, 1874): 482-483.

[69] Ibid, 482.

[70] Ibid.

[71] Ibid.

[72] Ibid, 483.

[73] “Quixotic Etiology: Dr. Cuningham on Cholera in Northern India, 1872”, The Practitioner: A Journal of Therapeutics and Public Health, Vol. XI (July to December, 1873): 463-470.

[74] Ibid, 463.

[75] Ibid, 464.

[76] Ibid.

[77] Ibid, 466.

[78] Ibid.

[79] Ibid, 468.

[80] “Quixotic Etiology: Dr. Cuningham on Cholera in Northern India, 1872”, Indian Medical Gazette (2 March, 1874): 82-84.

[81] Ibid, 83.

[82] James. MacNabb. Cuningham, Cholera: What can the State do to Prevent it? (Calcutta: Supt. of Govt. Printing, 1884).

[83] Ibid, X.

[84] Ibid, 39.

[85] Ibid, 143.

[86] Ibid, 122-123.

[87] Ibid, 129.

[88] William Campbell Maclean, Diseases of Tropical Climates, Lectures Delivered at the Army Medical School (London, New York: Macmillan and Co., 1886).

[89] Ibid, 230.

[90] Ibid, 231.

[91] Ibid, 231.

[92] Ibid, 334-335.

[93] “Egypt (From our correspondent)”, Lancet (December, 1895): 1465-1466.

[94] “Experiences of Cholera in India”, Lancet (Volume 1, 1896): 296-297.

[95] Ibid, 297.

[96] “The Revision of the Cholera Regulations in Regard to British Troops Serving in India”, British Medical Journal (January 4, 1896): 42-43.

[97] Ibid, 42.

[98] Ibid, 43.

[99] David Arnold, Toxic Histories: Poison and Pollution in Modern India (Cambridge: Cambridge University Press, 2016), 74.