severe form but yet one in which the symptoms are of the most serious character and a mild form.

There have been many descriptions of the clinical aspects of cholera, but for our purpose the report of Dr. Sutton on the characters of cholera in 1860 will suffice, the more so, as the symptoms of 250 cases were very carefully analyzed, and all these cases occurred in England. Sutton's description is therefore that of Asiatic cholera as seen when imported into England.

In the one case of cholera sicca described by Sutton, the history was shortly as follows: A man about 40 to 50 years of age, was seen walking in the public street; he suddenly cried out, put his hand to his belly and fell down. He was conveyed to the hospital without loss of time but died on the way.

The organs were generally healthy. But the duodenum was full of an opaque pale canary-coloured liquid; on following the intestine down the fluid got thinner, until when the ileum was reached it had all the characters of the so-called rice-water discharges. The small intestine was full of fluid. In the large intestine was a large quantity of semi-solid and solid fæces.

In other words in cholera sicca the person seems to faint to death without previous diarrhoea or other symptoms, and the only evidence of the cause of death being cholera is the state of the intestines.

Preliminary Diarrhea.-In a good many cases of cholera there is what has been called "preliminary diarrhoea." Of 41 cases in which diarrhoea preceded the choleraic symptoms, in 12 the diarrhoea had been present from periods varying from 12 hours to 24. In 13 the diarrhoea had preceded from 33 hours to 2 days; in the rest the periods were from 3 days up to 8 weeks. It is highly improbable that the longer periods (anything indeed over 3 days) had a direct connection with true cholera; cases in which diarrhoea, for instance, preceded the cholera symptoms for several weeks must have been ordinary diarrhoea on which the cholera grafted itself; it is reasonable to suppose that in cholera epidemics persons with disordered intestines are more likely to be infected than those who are in health; it is even a question whether even the shorter periods all belong to cholera. This supposition also affords a plausible explanation of the undoubted good that the early treat1 Ninth Report of the Medical Officer of the Privy Council.

ment of so-called preliminary diarrhoea does in the prevention of cholera extension. It may well be that a congested intestine affords the best soil for the cause of cholera, and by curing the congestion, the healthier secretions are able to destroy any contagium which may be swallowed.

The symptoms more particularly referable to cholera usually commence with great suddenness and are generally divided into a cold and a hot stage; the cold stage being that in which there is more or less collapse. The hot stage is the stage in which reaction sets in. The average duration of the cold stage in Sutton's cases was from 20 to 30 hours. The disease commences with frequent vomiting and violent purging, and the poison elaborated in the intestines is conveyed by the circulation throughout the muscular system, and fearful cramps and spasms result. The cold stage fully established, the eyes are sunken, the lips vivid, the tongue blanched, and the pulse may with difficulty be felt at the wrist. The voice is a whisper, but intelligence remains. The temperature (external) is always below normal, falling rapidly from 5 to 7 degrees below the standard, and in the reaction the temperature then is with few exceptions either normal or a little above. It hence follows that the so-called hot stage, is only a stage in which the surface temperature of the body is again approximately that of health, the term is a bad one, suggesting fever which does not exist. From first to last cholera is a depressor of vital function; but when the maximum temperature during the whole time is steadily below normal, such cases are likely to be fatal. The cold stage passes rapidly either to death or recovery. If the latter, either the patient sinks into a quiet sleep, or the countenance begins to look more natural, the pulse more perceptible, the skin warmer, the cramps and sickness with the purging stop, and gradually the functions are again resumed.

(388) Post-mortem Appearances,

The post-mortem appearances of cholera are seen in their most characteristic form in rapid cases which have died during the cold stage. The chief signs of cholera are to be found in the condition of the lungs and intestines. The ultimate tissue of the lungs is remarkably dry and light, the lungs weigh less than

normal, the right side of the heart is gorged with blood, and of course the vena cava, and the pulmonary arteries are also distended, the left or systemic side and the aorta and its branches are on the contrary comparatively empty.

The mucous membrane of the ileum, especially that of the lower part, is congested; there is loosening and detachment of the epithelium of the surface and of that lining the glands of Lieberkühn. There is a special congestion around Peyer's lymph glands. These alterations according to Koch are the effect of the comma bacillus which secretes a special chemical ferment. The changes are most pronounced in the lower part of the ileum, higher up the changes diminish in intensity and finally disappear in the upper part of the small intestine.

(389) Bacteriology of Asiatic Cholera.

In 1848 Pacini had described "vibrios" in the intestinal discharges of cholera patients. Klob also, in 1867, appears to have laid great stress on certain small organisms that he described, but whether these minute bodies described by Pacini and by Klob were identical with the comma bacillus of Koch is uncertain; the microscopes of that time were inferior in definition and in power to those now used, and the knowledge of bacteria of the crudest; however this may be, and whether the organisms described by Koch have been previously discovered or not, to Koch and the German cholera commission belong the entire credit of discovering that a particular micro-organism is always associated with Asiatic cholera, and with no other disease. This discovery was the outcome of the work done by the commission in the years 1883-4 in their extensive inquiry into cholera in Egypt, Calcutta, and France.

During the acute stage of cholera there are to be found in the rice water discharges minute bodies, which Koch calls, on account of their shape," comma bacilli ;" these by some are regarded as a spirillum (spirillum cholera Asiatica), by others as vibrios. In size they are of the same thickness as the tubercle bacillus but only half their length; they present the appearance of little curved rods, and so far resemble a comma that the latter is a good name. They are actively motile and liquefy the gelatin as most of the

moving micro-organisms do. The commas multiply by transverse division and after division the two offsprings may remain joined end to end in the shape of an S, and by further division they may grow into a spiral or wavy form. "It grows in and liquefies slightly alkaline gelatin; more slowly in neutral, scarcely at all in slightly and not at all in markedly acid gelatin. On a gelatin plate cultivation the individual colonies are round, lie in a funnel-shaped cavity, when viewed by transmitted light and magnified, they look like ground glass; the edge of the colony is finely notched. In a gelatin tube a funnel-shaped cavity forms at the top of the puncture made by the inoculating wire and lying in this cavity there is what looks like an inverted air bubble, with its top on a level with the surface of the jelly, and open to the air, along the puncture the gelatin liquefies, and in this may be seen with the naked eye the whitish mass of colonies more particularly at the lowest part; in from three to four weeks liquefaction spreads to the whole mass, the bacilli falling to the bottom as a greyish white sediment having a faint orange tint in certain lights, and if undisturbed, a perfectly transparent liquid separates a whitish scum on the top from the sediment below." In gelatin cultures growth is most rapid at from 80° to 100° Fahr. ; it grows slowly at 60°, and even at 50°, but below 50° it does not grow; it is not destroyed at a freezing temperature. If kept moist it will live for months; drying always destroys it, for hitherto no spore or resisting forms have been discovered. Milles and Macleod have, it is true, seen an appearance like endospores, and such bacilli bore forty-eight hours drying and yet recovered, but with longer drying death of the commas always resulted. In the absence of air, growth on gelatin ceases. commas " also grow well on agar-agar, on mucus flakes taken from the intestine, on potato, and in broth.

The

The opponents of the theory of the part which Koch and the German school assign to the comma spirillum in relation to cholera

1 An Enquiry into the Causation of Asiatic Cholera, by Neil Macleod, M.D., and Walter J. Milles, F.R.C.S., Public Health, vol. i. p. 322.

2 In Berekholtz's elaborate research (Arbeiten aus dem Kaserl. Gesundheitsamte. Bd. V. 1) on the effect of drying the cholera bacillus, he found cultures containing exclusively commas and S forms somewhat more resistant than cultures which contained no S forms. He considers it very probable that in nature the slimy mass of a culture may form a sort of protective capsule, and thus prevent the full drying and preserve the life of some of the commas. This he deduces from the different behaviour of the bacillus when dried on silk threads and on glass.

make the most of the easy destructibility of this micro-organism; not alone does drying destroy, but it falls a victim to feeble disinfectants, and, as before mentioned, even the acids of the guineapig's stomach effectually dissolve it. Surgeon-Major Cunningham 1 has shown that when cultivations of commas are added to water or to soil, the schizomytes attack the commas, and they tend to rapidly disappear. For example, Cunningham added to a pretty good drinking water cultivations of the comma bacillus; in one experiment none were found at the end of four days, in another all had disappeared at the end of five days. In yet another series of experiments excreta-polluted water was used, and all commas disappeared in a period varying from four to nine days, but when the water had been previously boiled the commas added could be found up to the twenty-fifth day. In ordinary garden soil the commas could be discovered from ten to twenty-six days after contamination. Garden soil previously polluted with fæces and then contaminated with commas, was more destructive, and the commas were not found in periods from six to nine days, a few afterwards, but if the same garden soil polluted with excrement was first sterilized by heat and then the comma cultivations added they were still present after forty-seven days. Kitasayo3 also found that ordinary fresh unsterilized fæces infected with the bacillus retain but for a short time living comma bacilli, but if the fæces are sterilized by steam or other means, the destruction is far less.

In other words, under ordinary conditions the agency of destruction is so powerful that it would seem impossible, if the cause is the comina spirillum choleræ, for cholera to be truly endemic in a country. Dejections cast into soil or water fall a prey to other micro-organisms, and contrary to the teachings of so many observers, Cunningham's experiments would tend to prove that the fouler the soil, the more chance of inimical schizomytes.

But on the other hand, Nicati and Rietsch have shown that the commas could live in the water at the port of Marseilles for eighty-one days, and in the absence of other organisms the life of

1 Scientific Memoirs by the Medical Officers of the Army of India. Edited by Sir Benj. Simpson. Part iv. 1889.

2 Macnamara arrived at very similar conclusions. He considered water polluted with cholera excreta ceased to become dangerous when after successive generations of animalcules, confervæ appeared; this in India happened about the third day. 3 Zeitschrift f. Hygiene. Bd. V. heft 3.