At the present time (1884) it is the fashion to trace every disease to specific bacteria or analogous organisms. But it may be that the occurrence of cholera only furnishes the occasion for the development of these organisms, just as a certain temperature, hygrometric condition, and deficient light and air will cause mould to form on bread and other organic substances. The judgment pronounced by Dr. Beale in this question as long ago as 1866 appears now, as it did then, to approach the truth upon this point: "There is no good reason for supposing that the bacteria in such numbers in the alimentary canal in cholera have anything to do with this disease or with the falling off of epithelium from the intestinal and other mucous membranes. Bacteria are developed in organic matter which is not traversed and protected by the normal fluids of the body, and they invade the cells and textures in cholera after those cells and textures have undergone serious prior changes, just as they would invade textures removed from the body altogether. Nor would it be in accordance with known facts to infer that cholera was due to the invasion of some peculiar form or species of bacterium."48
48 Times and Gazette, Aug., 1866, p. 167.
We repeat, then, that while nothing can be simpler than the mechanism of cholera viewed as a gastro-intestinal hyperidrosis, nothing is more mysterious than the mechanism of the primary cause which gives rise to it. That its real nature has been correctly described is rendered all the more probable by the fact, presently to be insisted upon, that sporadic cholera morbus, which is always the consequence of a direct irritation of the gastro-intestinal mucous membrane, is often with difficulty distinguishable from Asiatic cholera, which, indeed, differs from the former disease chiefly by the intensity of its cause as measured by the gravity of its symptoms and by the nature of the special agent that produces it.
The above views regarding the essential cause of cholera were substantially indited before the Egyptian epidemic of 1883, but they are in accord with the more definite conclusions arrived at by the German and French commissions on the subject. Before their reports appeared, however, a communication was made by Dr. Kartulis of the Greek hospital in Alexandria, setting forth that the drinking-water and the stools and blood of the cholera patients contained, the first a mass of micro-organisms, and the others bacteria and micrococci, which, however, presented no distinctive characters.49 The German report was prepared by Dr. Koch, the French by Dr. Strauss.50 The former, alluding to the enormous quantity of micro-organisms found in the contents of the bowels and in the stools, did not perceive any connection between them and the phenomena of the disease. On the other hand, he did assign this relation to a species of bacterium found in the walls of the intestine, and which he compared to the bacilli of glanders. They were lodged in great quantities within the intestinal glands and behind their epithelium, as well as upon the surface of the villi and within them, and sometimes even in the muscular coat. They were most numerous at the lower end of the small intestine. Dr. Koch concluded that although these bacilli, beyond doubt, are in some manner associated with the development of cholera, they are by no means shown to be its cause, and may indeed be themselves the product of the morbid conditions belonging to cholera. All his attempts at that time to develop cholera in animals by inoculating them with the organisms gave only negative results. The conclusions of Dr. Strauss were in entire conformity with those of Dr. Koch, but involved an additional and very important statement—viz. that the shorter and the more violent were the fatal attacks of cholera the fewer were the bacteria found in the intestine. It is evident that this fact is the very opposite of what should have been found had bacteria been essential in the causation of cholera. The more recent investigations conducted in Calcutta by Dr. Koch, which have already been cited, led him, however, to attribute to bacilli of a specific form the absolute origination of the disease. He poses the question in the following manner: Either these "comma bacilli" are a product of the cholera process, or "the disease only arises when these specific organisms have found their way into the bowel." The former alternative he rejects, because, in his judgment, it assumes that the bodies in question must be pre-existent in every person who becomes affected with the disease—a hypothesis which he rejects, because they have never been found except in cholera. He therefore concludes that they are the cause of cholera. He points out that their first appearance coincides with the commencement of the disease, that they increase with it, and that they disappear with its decline.51 The statement of Strauss quoted above does not, however, appear to harmonize with this conclusion, since the bacteria are said by him to have been fewest in the more violent and fatal attacks of the disease. Another of Dr. Koch's remarks is also open to criticism. After showing how rapidly the cholera bacteria multiply when kept moist, he states that they die after drying more quickly than almost any other form of bacteria. "As a rule, even after three hours' drying every vestige of life has disappeared." It is evident that this statement is not in harmony with the numerous facts, several of which have been cited, that cholera fomites have preserved their infectious qualities after several weeks. Dr. Koch endeavored to produce in animals, artificially, with these bacteria, a disease analogous to cholera, but without success; and he adds, "If any species of animal whatever could take the cholera, it would surely have been observed in Bengal, but all inquiries directed to this point met with a negative result." Dr. Vincent Edwards, who, however, is of opinion that the cholera poison is "not an organism, but of the nature of a chemical compound of comparatively unstable nature," reports that he produced fatal cholera in pigs by giving them the dejections of cholera patients.52 But the Times and Gazette inclines to question that the pigs employed in Dr. Edwards' experiments were affected with true cholera.
49 Medical News, xliii. 377.
50 Archives gén., Dec., 1883, pp. 713, 722.
51 Times and Gaz., Mar., 1884, p. 398.
52 Notes on the Poison contained in Choleraic Atomic Discharges.
DIAGNOSIS.—The most characteristic symptoms of Asiatic cholera have repeatedly been mentioned in the foregoing pages. They are rice-water evacuations by vomiting and purging, rapid emaciation of the whole body, a cadaverous hollowness of the cheeks and eyes, a livid color of the face, hands, and feet, a feeble, thready, and at last absent pulse, an icy coldness of the extremities, face, and even the breath, a loss of the elasticity of the skin, a thin and feeble voice, and intense thirst. But every one of these symptoms may occur in cholera morbus produced by a direct irritation of the stomach and bowels. It is rather their nature, we repeat, than their phenomena that distinguishes these two affections from each other. In attempting to separate Asiatic cholera from other forms of cholera we must endeavor to dismiss from the mind the erroneous notion that the term cholera denotes a definite disease identical in its cause, phenomena, and results. It is no more a disease than dropsy or fever is a disease. It is a complex group of symptoms which have in common the fact that they proceed directly from gastro-intestinal irritation, whose degree of severity—i.e. the presence or absence of certain grave symptoms—and, above all, its issue, depend chiefly upon the nature and intensity of the cause of the attack, and also, necessarily, upon the degree of resistance opposed to it by the subjects of the disease. Nothing has led to more error in regard to epidemic cholera than the ignorance of this pathological fact by some and the disregard of it by others.
In the first portion of this article it was shown that the Greek, Roman, and Arabian conceptions of cholera morbus included a discharge of bile, the very symptom for the absence of which Asiatic cholera is notorious; and also that the classical cholera, or cholera morbus, ended in recovery even more frequently than Asiatic cholera terminates in death. But local epidemics of cholera morbus sometimes take place which are of a severe and even of a grave type, and which also appear to originate in some peculiar atmospheric influence, for they prevail to a limited extent and in connection with vicissitudes of weather. Still more circumscribed epidemics have been traced to unwholesome food and drink, and innumerable instances of individual attacks have been caused by irritants that are ranked as poisons and others which are reckoned as food or medicines. Now, under these various circumstances, which have in common gastro-intestinal irritation, there may be produced, if the irritation is excessive, a series of symptoms closely resembling, if not identical with, those of Asiatic cholera.