"On the pathology and mode of communication of cholera--continuation of discussion from previous meeting"

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The minutes of the 20 October meeting were published in Lancet 2 (27 October 1849): 458-60. Comments on Snow's paper presented at the previous meeting appear under the headings, "Discussion on cholera" and "The bodies found in cholera evacuations," pp. 459-60.

Megan Anderson and Cori Heacock made the following transcription:

Mr. Nunn exhibited a drawing of a fungus of the bladder. The fungus was situated a little to the right of the median line of the bladder, and of the size of a small walnut. He reminded the Society of a case produced by him last session, of a similar nature; in both cases, no other evidences of disease than the passing of blood with the urine had ever existed. [458/459] He stated, that in both cases the amount of blood passed was always increased by the introduction of a sound or a catheter. In both cases the ordinary symptoms of malignant disease were not to be observed. The inference that he thought himself justified in drawing was, that where hæmaturia existed without such symptoms as would enable the practitioner at once to determine upon the precise seat of the disease, the discharge of blood being at the same time greatly aggravated by the introduction of instruments into the bladder, there fungus might be reasonably expected. Mr. Nunn particularly wished to express the obligation he was under to Mr. Partridge, for his kindness in lending him the drawing, and for the particulars of the case.

Mr. W. F. Barlow read a paper

He first detailed two striking cases in which these movements occurred after dissolution, and lasted for a very considerable time. The muscles of the arms, chest, and legs, and, in one of these examples, those of the face, were observed to be affected, some muscles being much more influenced than others. Some of the movements in respect of form were not unlike those of volition. In one of these cases the motions ensued two minutes after death; in the other, a quarter of an hour. In both, the muscles of the lower extremities were first affected, and the movements appeared successively in those of other parts. Two cases, very well marked, accurately observed, and presenting very similar features to the foregoing, and which had occurred long ago, in India, were referred to. The author described those more local and transient forms of the affection which were more commonly observed; the movements might be confined to the legs, the chest, the face, to a single muscle, or even to certain fibres of it. A case of cholera was on record in which paralytic muscles had been affected by spasms. These post-mortem contractions had been stated by an observer, to admit of excitement and aggravation by "pricking." The writer had endeavoured, in one instance well calculated for experiment, to repeat the observation, but had been unsuccessful. However, this was only a single remark, which he desired might be rated at its proper value. He had used, also, water of the heat of 150°, and of a yet higher temperature, in order to discover if the motions could be either induced or affected by it; no definite result could be obtained. Probably these motions, which had as remarkably narrow a sphere of action in some cases as they had a wide one in others, would have been much more frequently met with had they been oftener sought for. Attention was directed to the terror which they had caused to ignorant persons and persons not ignorant; they had given rise to unfounded notions of persons being buried whilst yet alive. They had been seen by friends, to their extreme amazement, as they were watching the bodies of their deceased relatives; and it was necessary, with the view of preventing groundless alarm and false conclusions, that all persons who might come in contact with the corpses of those who had perished from cholera should be informed that it was by no means extraordinary for such actions to be witnessed after death in this disease. The author had no explanation to offer of the cause or causes of these curious phenomena. For the present, they must be viewed as facts. Groundless speculations would only surround them with unnecessary mystery. He concluded by proposing a careful inquiry into all the circumstances under which they occurred; and some points were specified which it would be interesting to consider. Amongst other things, it was important to note their duration and the most protracted interval which might elapse between dissolution and their commencement.

Dr. Sibson resumed this discussion, and considered that hitherto no general and extensive view of cholera had been taken by any observer. He hoped, however, that one mastermind would eventually grapple with the entire subject, and throw some light on the very difficult question of the nature and origin of the disease. One point, it was true, we might put our hands upon, and that was the fact, fully shown in Dr. Webster's paper, that the disease made its appearance and continued its ravages during the prevalence of one particular kind of weather, and diminished as that weather disappeared. It was proved also, that want of all kinds, and all depressing causes, favoured the spread of the disease. So far we could go, but still the primary cause of cholera was as mysterious as ever. We found it, for instance, at Moscow and St. Petersburg, during the intense cold season, whilst at Paris it raged during the hot months. As to its origin and propagation by water, how could we explain by this cause the appearance of the disease in almost every part of England in one week. It was clear, from this fact alone, that water was not the only means of communication. Did the air act as a means of communication? It was curious if it did; yet we knew that the same state of air produced cholera and typhus, one at one time and one at another; but what cause produced the different result we did not know. He did not agree with Dr. Snow, that the primary seat of the disease was in the mucous membrane of the intestines, for often the complaint set in with the greatest intensity without any intermediate stage of diarrhœa, and, on the contrary, diarrhœa of a very depressive character might exist, and yet no cholera supervene. It had been proved, however, by the researches of O'Shaughnessy and Garrod, that if the blood were not primarily affected, it became so in the course of the disease; for it had been shown that the blood contained matters which ought to have been thrown off by the secretions. That the blood was so affected was also evidenced by the effects of the injection of salines into the circulation when the patient was in a state of collapse. In his own experience this proceeding had always succeeded in rallying the patient, who died, however, eventually, if the secretion of urine was not restored, but lived when the means of carrying off the poison returned. With respect to Mr. Barlow's very interesting paper, he would remind the Society that muscular contractions after death were not confined to patients who had sunk from cholera. Dr. Blake had found that when he injected bismuth into the circulation, the muscles continued to contract after death, and Sir B. Brodie having carried on artificial respiration in a decapitated dog, it continued in motion for an hour and a half. He had produced the same effects also by injecting tobacco into the veins. The irritability of the muscles remained after the death of the brain and nervous system, and in cases of cholera manifested itself in the lower extremities first, as they were the furthest from the nervous centres; and as the nervous force diminished upwards, so the irritability developed itself towards the great nervous centres. In cases where poisons acted at once on the nervous system, more irritability of the muscles remained than when death was slower in its process.

Dr. King had observed, in his labours as district visitor, that when, after the first rice-water evacuation, the patient had a "thin, raspberry-jam motion," he always died; but lived invariably when the motion was of the dysenteric character. He thought the bodies found in the dejections were decayed epithelial cells. He regarded the diarrhœa as distinct from cholera, and at most a predisposing cause of that disease. He thought there were two distinct kinds of cholera--one where the collapse was immediate, and the other where the diarrhœa and vomiting first presented themselves.

Dr. Holland, of Manchester, said, if the cholera depended, as some supposed, on the presence of organized bodies in a state of putrefaction in the water, we possessed a remedy for this in filtration. It had been proved that during filtration the changed bodies imbibed oxygen from the air. Thus nitric acid was formed; and this uniting with the salts in the water, an innocent soluble nitrate was formed.

Dr. James Bird said, that though ready to admit the affection of the intestinal mucous membrane to be prominently influential in the development of cholera, yet he was of opinion, from a careful analysis of successive phenomena, that this was only a secondary and progressive effect of the lost vitality of the blood, and of that congestion which followed in the pulmonary and cutaneous capillaries. While the Society had there heard the lucid statements made as to the extreme fatality of the disease, and the difficulty of investigating its nature and origin, he was not one disposed to despair of seeing a more definite and successful system of treatment introduced, if the profession, instead of expecting to find specifics for a complicated malady, which admits of none, would only seek after well-established pathological facts, from which might be ascertained, by induction, the laws which govern the phenomena of cholera, with the principles of a better therapeutic system. As to the propagation of cholera, whatever might be its origin, he had good grounds for thinking, with Dr. Lankester, that the disease was occasionally communicable from person to person, under favourable localizing conditions; and though he was not prepared to deny altogether the truth of Dr. Snow's views, that it could be multiplied through the medium of water, impregnated with the poisonous dejections of cholera patients, he could not believe that such medium of communication had more than partial effect in spreading cholera. He had now witnessed the endemic and epidemic outbreaks of this disease, in India, for a period of thirty years; and had come to the conclusion, that while endemic influences of low, [459/460] damp situations, vegetable and animal effluvia, bad water, imperfect ventilation, and deficient food, acted as predisposing causes, in giving rise to this intractable malady among the people, epidemic atmospheric constitution was necessary for its very general diffusion. The atmosphere is the principal channel by which cholera is disseminated, though the human recipient of the morbific miasm occasionally becomes, as in yellow fever and influenza, a secondary agent in propagating it. That it was so propagated sometimes, even in India, he had every reason to believe. When cholera was prevailing at Tannah, in 1818, the soldiers of a confined, ill-ventilated barrack-room in the garrison were attacked by it, in succession, as they lay along side of each other on their beds; and here infection seemed to act a subordinate part in the diffusion of an epidemic disease, not primarily infectious. Such, too, seems the nature of infectious yellow fever, arising out of endemico-epidemic fever of malarious countries, as that of Sierra Leone, where, as shown by Dr. Bryson's convincing evidence, the infectious fever which prevailed at different times on board her Majesty's ships, Bann, Eden, and Eclair, grew out of, as it were, the common endemic of the country. Cholera, moreover, in India, is admitted on all hands to attach itself to masses of the people assembled at religious festivals, and to be disseminated by them to persons previously free from it. In the extensive district of deep black alluvial ground, called the Southern Mahratta country, cholera, in 1841 and 1842, so invariably attacked the Madras regiments marching through it, that it came to be considered endemic to this part. It appeared to creep at this time from village to village, and was carried by bodies of religious pilgrims from district to district; yet, in the face of such strong characteristics of infectious disease, some have endeavoured to explain away the evidence by supposing that a specific poison, the essential cause of cholera, can lie dormant everywhere till accessory causes give it activity; but when not propagated by human contact, there is no satisfactory evidence to prove that this disease has any other source than a malarious and epidemic origin. He would only make one more remark on the subject of the disease becoming transmissible, under favourable conditions, from the sick to the healthy--namely, that having observed how cholera continued prevalent among the men and followers of native regiments attacked by it on their march, and allowed, immediately after arrival at a new station, to occupy the regimental lines of native mud huts, he recommended to the general commanding the division that all such infected regiments should be encamped in some dry and healthy locality, outside the cantonment, till all traces of the disease had disappeared, after which they were allowed to occupy the regimental huts. This precaution was followed by the happiest results; for after its adoption, the men and followers of regiments which had suffered from cholera on the march were altogether exempt from it in the lines. A combination of conditions may be necessary for the development of infectious cholera, but that it cannot frequently be self-multiplying in the human body seems an assumption contrary to fact.

Dr. Lankester said that Dr. Snow's theory of its progress and development involved the necessity of its being something generated in the mucous membrane, and capable of being diffused by handling, and especially through drinking-water. It was not more unlikely that the mucous membrane in cholera should produce a poison, than that the skin should in small-pox. No such poison had, however, yet been demonstrated to exist, and the only approach to it was the announcement of the presence of fungi in the evacuations and vomited matters of cholera patients, more particularly mentioned by Dr. Swayne. These bodies might be divided into two classes--the definite and indefinite. The latter consisted of all the bodies found in the air and the water, and which were probably organic substances of various kinds, and the smaller bodies from the evacuations and the vomited matters of cholera patients measuring from the 1/1000th to the 1/10000 of an inch in diameter, and which consisted of various organic and inorganic matters. The definite bodies were such as those exhibited by Dr. Swayne at the last meeting of the Society; they were probably from the 1/300th to the 1/1000th of an inch in diameter. Amongst these bodies, his friend, Mr. Busk, had succeeded in making out three forms. First, there were spores of a species of uredo--a fungus which produced smut in corn, and was often found in bread. These bodies appeared to be only drawn in Dr. Swayne's illustrations. Secondly, portions of vegetable membrane, of a dark colour, which resembled the membranous portions of a grain of wheat, and which were seldom absent from the finest flour, but were very abundant in the coarser kinds. Under a high magnifying power and deficient light, these bodies resembled the last. The third form of these bodies resembled starch granules. The two last bodies were evidently not independent organisms. He had examined Mr. Busk's preparations, and compared them with those of Dr. Brittain and Dr. Swayne, and he felt convinced of the correctness of Mr. Busk's inference, that no new organism had yet been demonstrated to exist in the body of those affected with cholera. All the bodies that had been observed by the microscope were evidently introduced by the food or were the natural products of the mucous membrane. He thought we must look in some other direction for the poison of cholera.

Dr. Webster and Dr. Snow having replied, the Society adjourned.