494 



NA TURE 



[March 22, 1894 



them succumbed to, the disease ; others came over to England 

 and to London, yet they did not produce an epidemic in the 

 localities in which they arrived or died, for the simple reason 

 that they were looked after, isolated, and their dejecta and be- 

 longings disinfected or destroyed. But they do not cease to be 

 cases of true cholera, though they were not followed by others. 



The following case, that occurred in England last September, 

 may serve as an illustration. A man, landlord of an hotel in 

 Retford, who for some days was suffering from diarrhoea, had 

 been to Doncaster, where he partook of oysters brought from a 

 cholera-infected locality. Soon after arriving home he was 

 seized with violent cramping pains of the arms and legs, sick- 

 ness, vomiting, and diarrhoea ; the doctor who was called in 

 noticed the altered voice, which was like a whisper ; the patient 

 was very restless, and complained of great depression ; the 

 evacuations were like rice-water, there was suppression of 

 ■urine ; he rapidly became collapsed, the extremities became 

 cold, and the surface of the body livid and shrunken. He died 

 after an acute illness of fifteen hours and a half. I have read to 

 you the clinical history of this case because it presents the pic- 

 ture of true virulent cholera, such as is described in text-books 

 as a most typical case of Asiatic cholera. It is presumable that 

 the above person became infected by eating oysters, because 

 these were derived from a place where cholera was rife, but it is 

 only presumably so ; the man had not been either at Grimsby, 

 Hull, or Cleethorpes, or any cholera locality ; but that he suf- 

 fered from, and succumbed to true cholera, can hardly be 

 doubted, and I shall give you presently further evidence to that 

 effect ; and yet this remained, thanks to the prompt sanitary 

 measures taken, the only case of cholera that occurred at Ret- 

 ford. You see, then, that a case remaining an isolated one does 

 Tiot necessarily cease to be a case of true cholera. 



As to {b). As regards the inability to trace every one of the 

 isolated cases that occurred in the different localities to a previous 

 focus of cholera, and the allegation on this ground that it 

 remains doubtful whether these cases were or were not true 

 cholera. It is unquestionably a great help, in order to make a 

 correct diagnosis and to take the necessary precautions, to trace 

 the manner in which the infection found entrance into a given 

 locality. But, unfortunately, the way in which thecontagium o( 

 cholera, as well as that of typhoid fever, travels, is not always 

 a straight one or easily followed ; in many cases the way can 

 be followed with approximate accuracy, but m others — amongst 

 them some epidemics of undoubted true cholera — the manner 

 in which the contagium was introduced has baffled even 

 experienced s-anitarians, and it is owing precisely to such 

 instances (they have occurred both in India and in Europe), 

 that the solution of the problem as to the origin of some of those 

 cholera epidemics is beset with great difficulties, and has called 

 forth a division of opinion amongst epidemiologists. If the 

 problem were of such simplicity as is implied by the assertion, 

 that in every case of cholera we must be able to trace the 

 infection to a known focus, the division of opinion as to the 

 oritjin of some of the epidemics of true cholera would long ago 

 have disappeared. 



Koch first showed that in the rice-water-like dejecta and in 

 the rice-water-like contents of the intestine of a typical case of 

 Asiatic cholera, there occur certain bacteria, which, on account 

 of their shape, were called by him comma-bacilli; he showed 

 that in some of the typical cholera cases, in which the dejecta or 

 the intestinal contents are of what is called rice-water-like 

 character (that is to say, in a more or less translucent fluid are 

 suspended large and small flakes, composed of the detached 

 epithelium lining of the intestinal mucous membrane), the flakes, 

 as also the fluid, contain these comma bacilli in enormous 

 numbers ; and that the flakes contain them in a characteristic 

 linear arrangement, occasionally to the total exclusion of other 

 kinds of baiteria, such as may be found inhabiting the normal 

 alimentary canal. 



1 exhibit here on the screen photographs of the microscopic 

 character of the rice-water-like dejecta of typical cases of Asiatic 

 cholera ; one from a case in India, several from typical cases 

 that occurred last year in England. The illustrations show 

 not only a great number of the comma bacilli and a total 

 exclusion of other bacteria, but also the characteristic linear 

 arrangement of the vibrios in the flakes. 



It is now agreed by all who have devoted attention to this 

 subject, that such a condition as I have shown you here does 

 not occur in any other acute disease of the alimentary 

 canal in man except in Asiatic or true cholera. A large number 



of cases of cholera nostras, or English cholera, have been 

 subjected to examination abroad and in England in non-cholera 

 years, and the result was always the same — viz. a condition such 

 as I described and showed to you does not occur in them. So 

 much so, that all pathologists agree that, supposing a case pre- 

 sents the principal symptoms of cholera, inclusive of the rice- 

 water-like dejecta, if the flakes suspended in the fluid portions 

 of the dejecta show under the microscope crowds of the comma 

 bacilli, particularly in the above linear arrangement, the 

 diagnosis " true cholera " is fully justified. Whether a case of 

 this kind is an isolated one, and whether we are able or unable 

 to trace the way in which the infection has come about, does 

 not, to my mind, alter the diagnosis in the .•■lightest degree. We 

 may he successful in putting our finger on the probable or 

 demonstrable path on which the cholera infection travelled, or 

 we may be baffled in this attempt ; we may say — as in the cases 

 that occurred in Hull and Grimsby, in Rotherham, Ashbourne, 

 North Bierley, and elsewhere — here we have a succession of 

 cases presenting all the clinical and pathological characters of 

 true cholera, showing the high fatality found only in true 

 cholera ; the flakes of the rice water-like evacuations show the 

 microscopic characters observed only in Asiatic cholera ; there- 

 fore we are dealing with true cholera, and we do not further 

 trouble ourselves (for the object of making correct diagnosis) 

 with finding out how the first case was introduced, particularly 

 if we remember that most of these places, owing to their situa- 

 tion, may have been exposed to importation of the contagium 

 from cholera-infected localities. Or we may say, as in the Ret- 

 ford case, we presume that the patient, having partaken of 

 oysters which came from an infected locality, caught the infec- 

 tion through these oysters, and the case, presenting all the 

 clinical and pathological characters of virulent true cholera, and 

 the flakes of the intestinal contents showing the microscopic 

 characters found only in Asiatic cholera, must be one of true 

 cholera, notwithstanding that the case is for Retford an isolated 

 one. But I fail to see how the assertion can be justified, that 

 has been repeatedly made during the last autumn, of various 

 isolated cases occurring in different localities — Leicester, Derby, 

 Westminster, and others — viz. the assertion that these cases, 

 which were all fatal, which presented the symptoms and 

 pathology characteristic of virulent true cholera, and which 

 showed in the flakes of the rice-water like dejecta the micro- 

 scopic appearances characteristic of, and found only in, true 

 cholera. The assertion, I say, that these cases cannot be true 

 cholera, because we were not able to trace the manner in 

 which infection was introduced, and because they have not 

 been followed by other similar cases, cannot be accepted. 



I take for illustration the noted case of the woman, the cleaner 

 in the House of Commons ; she died in Westminster last Sep- 

 tember, after a very short illness ; the symptoms were those of true 

 cholera; the pathological condition of the intestine, the micro- 

 scopic character of the flakes of the rice-water-like dejecta were 

 such as are found only in typical cases of true cholera, and in no 

 other known acute disease of the intestine ; but the manner in 

 which she contracted infection could not be discovered, nor was 

 this case followed by others ; rigorous sanitary precautions were 

 at once applied to the house in which she lived and all that 

 appertained to it. 



I show you here the microscopic character of the flakes of 

 the rice-water-like dejecta of this case, and you can see that 

 it presents in a conspicuous degree the characteristic ap- 

 pearances, both as to the number and arrangement of the 

 comma bacilli. 



The comma bacilli, derived from cases of Asiatic cholera, 

 when tested by cultivation under the different conditions, such 

 as are used in the laboratory for distinguishing one species of 

 bacteria from another, are admitted on all sides to represent a 

 definite group of organisms, of which the principal distinguish- 

 ing characters in cultivation and in microscopic specimens are 

 shown in these photographs. 



One character of particular interest which these cholera 

 vibrios, or cholera spirilla, or Koch's comma bacilli show, is 

 their behaviour when grown at the body temperature (37° C*) 

 in a solution containing peptone and salt ; in this solution they 

 grow well and multiply very rapidly, and produce in it nitrites 

 and indol ; the presence of these products can be demonstrated 

 already after a few hours (6-8) by adding to the culture a few 

 drops of pure sulphuric acid ; the culture at once assumes a 

 distinct rose»coloured tint ; this reaction is called the cholera- 

 red reaction. Now, there are known other species of comma- 



NO. 1273. VOL. 49] 



