AIaucH
HAFPK1NE ANt) SIMPSON ON
1895.]
(Original Qlommuniqntioits. A CONTRIBUTION
TO THE
J
^
ETIOLOGY OF
CHOLERA* By Mons. W. M.
Koch,
Haffkine and W. J. into
Simpson, tiie
m.d.
ol to the micro-orfound in man, and particularly to those
in bis
investigations
cause
cholera, directed liis attention
ganisms
be found in the intestines. By comparing the intestinal flora of patients suffering from cholera and other diseases with that of healthy men he out the comma bacillus as was enabled to single the organism peculiar to choleia. This is the direction which observers engaged in the working have since adopted out of the etiology of cholera in their investigations, and the result has been a views by all Westo-eneral confirmation of Koch's and friendly. hostile Among the ern schools, be mentioned Cornil numerous investigators may in Marseilles and Babes in Paris, Van Ermengen Rietsch in Marseilles, and Nicati in and Spain, in Paris, Schottelius, Watson, Cheyne and Doyen and Marpurgo in Canistrini Palermo, in Bologna, Lustig P-idni Tizzoni and Cattani in KiefF, Wiltschur in in Trieste, Ssawtschenko Weisser and Frank, Macleod and St and many others. The Milles in China, Ivarlinski obtained been not easily or without rpsnlt* have the beginning there were many At opposition. all cases further investigasceptics, but in almost most the sceptical of the reality of tion convinced most distinguished of the discovery. Among the Emerich mentioned Pettenkoffer, be these may Dr. Klein. Only a few have
to
Simone'in
Peters'burgh,
and
apparently
remained undecided, namely, Loesch, Lesage,
Cunningham. Of these the first cholera can be partly produced that three and partly by other microbes, by a comma bacillus that cholera is produced thinks last while the extraneous cause plus comma some unknown Macaione and
'think
by
^The
which have been perfect the methods frequently is the comma bacillus Thus in the most recent epidemics
more
adopted
the
detected.
more
the comma bacillus in observers have found or missed them in a very 100 per cent, of cases small number. Thus Karlinski, on a scientific 293 patients found the mission in Arabia, out of the microbe comma bacillus in 288, only missing in the cholera Wiltschur and hospital in five cases, in St. Petersburgh found them in 70 cases out of 70-
'. Parallel with these investigations researches have also been made on healthy people, and, as a o-eneral result, no commas have been discovered. In in or
,
.
isolated cases, however, they have been found healthy persons suffering from slight diarrhoea in
healthy
exposed
to
and
apparently
cholera infection.
resistant persons Thus during the
1894. Read at the Indian Medical Congress, December
CHOLEItA.
S'd
epidemic in Hamburgh, apart from cholera patients, comma bacilli were found in 19 persons, last
out of whom 10 had suffered from
diarrhoea for six from diarrhoea of one day without any general disturbance, and three had no disorder whatever. Almost all these people were ascertained to have been closely associated with cholera patients. In man commas have been found so rarely under conditions not connected with cholera that they have no bearing on the subject of the causation of cholera. In this category may be placed the comma found by Lewis on one occasion in his own mouth which may possibly have been a degenerated cholera comma. These observations, with experiments which followed, tend to one conclusion, that the commas are the causal agents of cholera. In the last epidemic in Europe, attention having been paid to the examination of waters, a number of micro-organisms were discovered which, from thsir resemblance to commas, led investigators to test them by the standards which had been adopted for the diagnosis of cholera commas, with the result that, whilst some corresponded to these standards others presented important differences. Thus Mendoza in Spain discovered commas in nine waters where suspicious cases of diarrhoea had occurred ; Max Bleisch in Kosel, Gunter in the River Spree, discovered commas which liquefied gelatine, but were not pathogenic to animals, Foker discovered comma bacilli in a Dutch harbour which was suspected to be infected with cholera ; the bacilli resembled cholera bacilli inseveral
days,
every respect, except being pathogenic to animals, Foker supposed them to be degenerated comma bacilli ; Fraenkel discovered comma bacilli with all the features of cholera bacilli in river water near a ship with a cholera patient ; Orloff found comma bacilli in a well in Lublin, around which many cases of cholera had occurred ; Bujwid found a comma resembling Koch's in river water. Neither Orloff nor Bujwid would give any opinion as to the nature of these commas. Weibel in Munich found commas in the water of a well, which a long time previously had been infected with commas ; they differed from cholera commas only in their mode of liquefaction of a stab culture and in other unimportant details ; yet Weibel does not recognise them as cholera commas ; Neisser in Berlin in the water of the Spree, which was contaminated with cholera dejecta, found a comma giving the Indol reaction, but liquefying gelatine very slowly ; he did not rank it as a cholera comma, although it seems to have been more pathogenic to animals than Koch's ; he named it Vibrio Heider found a comma in the Berolinensis. water of the Danube canal in a locality where cholera occurred the next day ; he also was unable to decide whether it was a cholera comma. Kutcher investigated eight commas isolated from the waters in Hamburgh, and of these seven were
phosphorescent?a property which he considered
90
INDIAN MEDICAL GAZETTE.
differentiate them from cholera commas. Sanarelli detected 82 commas in the Seine and Marne, only four of which gave the Indol reaction, and four of them were pathogenic to animals ; these and the others, though differing in form and character, he considered to be cholera commas. In Stettin a comma was isolated from water which was recognised in Koch's Institute as a cholera comma. Gunter found in the soil in Koch's Institute a comma which did not liquefy gelatine, nor give the Indol
to
reaction, did it but its
nor
act
pathogenically
on
animals,
grow well coagulate milk, morphological appearance and nor
nor
at 37? C., its growth
agar-agar and bouillon were the same as a cholera He called it the Vibrio Terrigenus. Bonhoff examined in Koch's laboratory water from Stolp in Pomerania and found two commas, one liquefying gelatine but not giving the Indol reaction, the other giving the Indol reaction and not liquefying gelatine. Russell in Naples found in a comma which he called Spirillum sea water Marinum, which rapidly liquefied gelatine. Renan in Paris isolated from a specimen of water a comma which rapidly liquefied gelatine, but was not pathogenic. Loeffler found in river water a comma which liquefied gelatine very rapidly like FincklerPrior's comma. Bluckstein found commas in Seine water, and distinguished them from cholera commas by the opaque appearance of the cultures. Fischer found a number of vibrios in sea water which differed from cholera chiefly in their preference for sea water. Pfuhl found in the waters of Berlin a comma which, by the manner in which it liquefied gelatine and its pathogenic powers on pigeons, he took to be Metchinkoff's comma. Sprong of Utrecht investigated eleven commas from waters in Holland, and compared them in fifteen different respects with cholera commas isolated from patients living in the same localities;but, such is the position of the question at the present time that even when he found many of the water commas corresponding in nearly every respect to the cholera commas, he hesitated to pronounce these water commas to be the same as the cholera Dunbar likewise, in observations on the commas. waters of the Rhine in different places, found comma bacilli resembling in every feature that of cholera bacilli and which disappeared contemporaneously with the cessation of cholera prevalence. Kutcher, however, on a later investigation of these commas, found a number to be phosphorescent, and owing to this property Kutcher believed them to be not cholera commas, because up to that time phosphorescence had never been observed in cholera commas. With regard to the differences referred to in the water commas, it should be noted that the experience of the laboratory shows in the course of the culture of one and the same specimen of comma bacilli constant modifications, which would indicate that the comma bacillus when cultivated on
comma.
'
[March
1895.
in nature will be found presenting under different conditions similar or even greater modifications. As a matter of fact D. D. Cunningham found in typical cholera patients a variety of commas, which induced him to classify them into several species. Similar observations have been-made in European epidemics, and have for a long time past given rise to and strengthened the opinion that the early characteristics ascribed to the comma bacilli, when first studied, are not of a fixed nature, nor are even those characteristics which have been given to them afterwards. Thus it commas are in that cholera a true patient happens found which do not liquefy gelatine, nor give the Indol reaction, nor have a pathogenic effect on animals, and in cholera cases commas have even been discovered with phosphorescent properties. It is accordingly seen that similar differences exist in commas with an unquestionable cholera origin as between commas that have been hitherto found in water, and the question arises whether all the commas found in waters cannot be considered as cholera commas ? Sprong, Dunbar, Dahmen, Sanarelli hinted at such a possibility, but evidently the proofs were wanting. We propose to add some facts regarding commas in nature from this point of view. In April 1894, when cholera was at its height in Calcutta, an investigation was undertaken by us to ascertain the distribution of comma bacilli in Calcutta, especially in waters. For this purpose 582 specimens were collected in 211 localities, and examined. Of the 211 localities 110 were from tanks, 15 from private wells inside houses, 26 from drains, 12 from the river Hooghly, 4 from canals, 4 from bathing platforms, 24 from street hydrants, and 24 from milk markets and vendors, 4 of food and 4 of air in infected houses. Of the 582 specimens, no fewer than 432 were of tank waters. The tanks or ponds form a special feature in the physical topography of Calcutta. Originally excavated to raise the surroundin order that huts and houses might be land, ing built on the raised land, the tanks became useful, first, as reservoirs of rain water for supplying the neighbourhood, or the surrounding cluster of huts, with water for drinking and for domestic purposes; and, secondly, as a convenient receptacle into which the drainage of the locality should flow. Different districts differ in the number of ponds which they contain ; some are honeycombed with these tanks, and during the rainy season there is actually in some areas more water than land, others have fewer tanks, and a number of them are protected from pollution by drainage. The public tanks are also, as a general rule, well looked after ; but the majority of tanks are the mere drainage cesspools of the locality. Much has been said regarding the filthiness of these ponds. They more or less resemble pea-soup in colour, and their composition has been officially reported as concentrated London sewage. The drainage from latrines often find an easy and convenient outlet into their waters ; soiled
March
1895.]
HAFFKINE AND SIMPSON ON CHOLERA.
clothes of the sick and of the healthy are washed therein ; men, women and children bathe and perform their ablutions in the pond, while oxen, buffaloes, horses, goats and other animals are taken down to the water's edge and there given a bath. In such water the inhabitants cleanse their utensils and soak, macerate and wash their rice and dahl, and not infrequently prepare other kinds ot food. !No analysis is needed to determine the unsuitability of the tanks for use for domestic purposes, because the color of the water and its smell is sufficient to condemn its purity. It is to these tanks that for years past localised outbreaks of cholera have been traced. So trethat now whenever a quently has this happened routine practice is to the occurs localised outbreak at the tank to prevent the ina place policeman habitants drinking the water. Of the 110 tanks examined, 4G were tanks around which cholera existed at-the time of the around which cholera investigation 5 were tanks weeks previously and had existed a month to six had disappeared, and 59 were tanks around which cholera had not appeared during the four months of 1894. The result of examination was as follows : which cholera existed Out of 46 tanks around in ?)1 h pei cent. ; in i.e., 42, tound were commas had disappeared a cholera out of 5 tanks where commas were found weeks previously month to six around which cholera in none. Out of 59 tanks had not appeared commas were found in 11, i.e., in 18*8 per cent., and were not found in 44, i.e., in in the interior of 81*4 per cent. Of the wells which there was no in houses in were G houses cholera and 9 in houses with cholera. Of the 15 wells examined commas were found in only 1, in a cholera house. In the water from 24 street hydrants, 9 ot no commas were which were in cholera localities, from the river taken directly water In found. from Pultali localities commencing 11 of Hooohly, Calcutta the of water-supply and at tlie intake Howrah at Bridge just above the terminating were found. We Port of Calcutta, no commas about the existence or ascertain to were unable Later cases in these localities. cholera of not any found in the unfiltered in the year commas were house a supplied from the river a little water of The supply was below the Howrah Bridge. and delivered river the by a pipe to pumped from this house an outbreak of cholera In house. the had occurred which was the reason for examining the filtered and unfiltered water on the premises. The water of the Chitpore Canal, which was used for drinking purposes, was also examined at broke out among the inhabia time when cholera Commas \tere found on its banks. tants residing in 5 specimens out of 18. The examination was made on the day on which the canal water was changed ; 13 specimens taken near the lochs were while 5 a little further away were 1
_
negative,
positive.
,
91
In another canal near which no cholera existed, and in an isolated locality, commas were found. Of 23 samples of milk, 4 of which were taken in cholera localities and 19 were bought in markets and from vendors in the street, one of the former and one of the latter contained commas ; of products of milk, eight samples of curd water were examined and in none were commas found. We examined food on only four occasions. In three there were no commas, in one we found commas under the following circumstances :? In a flour shop a man was pointed out to us as being attacked with diarrhoea. On examining him we ascertained that ho had washed his soiled clothes in a tank behind the shop, and we discovered the clothes still wet lying on a part of the flour exposed for sale. We took possession of the flour, and in the laboratory obtained from it a culture of comma bacilli. Air in infected houses was examined on four occasions, once in a room where two people died of cholera and in which' one of the bodies was still unremoved. The floor of the hut had been soiled with excreta. In the air passed through peptone for two hours no commas were found. Twenty-six open surface drains of the street were examined, 10 of which were in localities with no cholera and 16 in localities with cholera. In the drains in non-choleraic localities 5 drains were found infected with commas, and in the choleraic localities 5 drains were also found infected with commas. In one of these cases commas were found in an extremely large proportion in the water and rice in an open drain on the second floor of a house in which the last case of cholera had died a fortnight previously. The result of these investigations seems to narrow down the relationship between commas in tank water and cholera, whilst no distinct relationship of this kind could be discerned in the other objects examined. If the commas be admitted to be the cause of cholera in man, such a result is easily understood. It is unlikely that the microbes in drains could gain a direct access to man and reach him without the assistance of food or drink. The relationship, moreover, between hydrant water and cholera is excluded in Calcutta by the excellent arrangements for purification and filtration, and it is our belief, as matters stand, no case of cholera is produced in Calcutta by the Municipal filtered water. On the other hand, the inhabitants around the tanks have a most intimate connection with the waters. They bathe, wash their clothes, cleanse their mouths and frequently drink the water and clean their domestic utensils in the tank. But even in the tanks examined we did not find In commas present with an absolute regularity. 9 per cent, of those in which cholera existed we failed to find them, and in 18 per cent, where cholera did not exist they were discovered. Notwithstanding these exceptions the results
appear
92
INDIAN MEDICAL GAZETTE.
to us to be one of the strongest confirmation of the direct relationship between the comma bacilli and cholera. The 9 per cent, on the one hand, and the 18 per cent, on the other, seem to us to be within the limits of error as attached to the examination of large tanks, which are subject to all the conditions of their open and exposed nature. These results seem to be more demonstrative, as they correspond in some degree to the slight variations in the results of investigations in men. In a small proportion comma bacilli are missed in cholera patients owing to defects in technique, while in a small proportion of men in whom they are found they fail to produce serious disturbance owing, probably, to the resisting power of the infected individual. The method of the present investigation runs parallel to that of Koch's, which ten years ago started the lines of research adopted since by all bacteriologists in cholera, and which concentrated attention on the presence or absence of comma bacilli in choleraic and non-choleraic men. Having before us the advantage of a definite microbe and the further advantage of the improved methods for the detection of the comma bacillus, we made our researches on the presence or absence of this microbe in choleraic and non-choleraic localities in nature ; not only is the method parallel, but the results obtained by it conform to those obtained otherwise. The special question which this paper refers to is the following : In the beginning of our paper we quoted the great difficulties of distinguishing one comma supposed to be a cholera comma from another comma supposed to be saprophytic and non-choleraic owing to their great racial variations ; the result of our paper seems to us to show that in nature there appears to be no water commas, except those connected with cholera, varying, as found them, in their morphological and we physiological and biological characters. Before concluding this paper we take advantage of the opportunity of stating that in examining cows affected with diarrhoea, in different parts of Calcutta and Howrah, and in examining cesspools connected with cowsheds, in which cows had been ill, we found commas in the cows and in the cesspools. This opens up a new field for research, and the results of further investigation on this subject we hope to be able to communicate on a future occasion.
[Mahch
1895.