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A post-mortem examination was made, and there was found to be intense purulent peritonitis.
There was no lesion visible to the naked eye to account for this. A portion of the ileum and peritoneal
fluid was given to Dr. Klein.
Report by Dr. Klein—"In the peritoneal turbid fluid and in the solid masses of lymph, numerous
cocci—in clumps and as diplo-cocci—could be distinguished. The whole of the intestine was congested,
and in its cavity solid lumps of lymph containing the same masses of cocci. No common bacilli could
be found. Cultivations proved negative qua comma bacilli."
Shirley F. Murphy,
Medical Officer of Health.
Dr. Klein's Report.
St. Bartholomew's Hospital,
November 29th, 1893.
The Medical Officer of the London County Council.
Sir,
I beg herewith to report on the result of the microscopic and bacteriological examination of the
cases of supposed cholera that occurred during September and October last, within your district.
Before giving these results, it is necessary to state a few points concerning the pathological,
microscopic and bacteriological characters of the intestine in cases of Asiatic cholera.
Almost all pathologists and bacteriologists concur with Koch on the following points: (a) the
comma bacillus which Koch discovered in the stools and intestinal contents of cases of Asiatic cholera,
represents a well-defined species, which possesses certain characteristic morphological and cultural
features; (b) this species does not occur in any acute intestinal disease except in Asiatic cholera, it
certainly does not occur in sporadic cholera or cholera nostras, as far as our present knowledge goes;
(c) the comma bacillus of Finkler—to some extent morphologically and culturally resembling Koch's
comma bacillus—does not occur in cholera nostras or in Asiatic cholera.
Now, the generally recognized morphological and cultural characters of Koch's comma bacillus,
which for brevity's sake I will call the cholera vibrio, are for practical purposes sufficient to make a
diagnosis; but since last year's Hamburg epidemic, Dr. Dunbar has added to these one further test
(practically described already by Dunham), which I consider of very great importance. This further
test is the characteristic rose-coloured tint called the cholera-red assumed by the peptone-salt cultures
of the cholera vibrio on adding to them a drop or two of pure sulphuric acid. This red reaction is
distinct and definite, and may be demonstrated as early as six to ten hours after setting up the peptone
culture of the cholera vibrio.
The history of this test is as follows—It has been known for some years by the researches of
Bujwid that mineral acids added to a broth culture of cholera vibrio produce this cholera-red; but it
has been shown that also in broth cultures of other species of comma bacilli, the same red colour is
produced by the same methods, and Salkowski has taught us that the red colour is due to the presence
of nitrites and indol. Dunham has further shown that, in order to obtain the cholera-red reaction, the
presence of peptone in the broth is of importance, and he used for obtaining rapid growth and distinct
red reaction 1 per cent, of peptone and \ per cent. salt. Dunbar showed the important practical fact
that this culture-medium of Dunham is of great importance for a rapid detection and isolation of the
cholera vibrio—so much so, that in as little space of time as six or eight hours (though better still at
longer intervals), a considerable crop of the cholera vibrios may be obtained, even if at the outset (that is,
at the time of inoculation of the peptone fluid) only few vibrios are introduced. Although other intestinal
bacteria show growth in that peptone solution—proteus vulgaris, bacillus coli, vibrio of Finkler—yet the
cholera vibrio grows in the peptone incomparably faster, moreover the cholera-red reaction is not
obtained with these microbes even when abundant; as a matter of fact, I have had experience
of several cases in which though the microscopic examination of the contents of the ileum failed to
give positive indication of the presence of the cholera vibrio, yet the peptone cultures made from
such contents—teeming as they were with crowds of cocci, bacillus coli and spore-bearing
bacilli—yielded after 6, 8 or 10 hours incubation at 37° C. almost a pure crop of the cholera vibrio.
I need hardly point out the very great importance of this method in arriving at a rapid conclusion.
True, when initially the cholera vibrios are present in the intestinal contents in large numbers (I have
had to examine cases where they were present to the almost complete exclusion of other bacteria)
pure, cultures of the cholera vibro in broth, on Agar, on gelatine, in peptone, are obtainable with
comparative facility; but when one is dealing with cases such as I have mentioned above (and most
of the cases to be reported here were of this character) every other method, except the peptone
culture, failed to give positive evidence as to the presence of the cholera vibrio.
The indications that guided me in forming the diagnosis of cholera are briefly these—
1.—The condition of the stool, or the condition of the intestine, submitted for examination. In
true cholera the intestine is more or less injected in its mucosa and serosa; its cavity contains fluid
material, either like rice-water as in the typical cases, or of a light to dark brown fluid character (like
pea soup) sometimes blood tinged; the epithelium of the mucous membrane is altogether detached in
larger or smaller flakes, or is only loosely adhering and easily detached. The presence of actual epithelial
flakes in the cavity of the intestine forms an important point. I have had submitted to me stools
from certain cases, e.g., case 2, which were, to the naked eye inspection, not distinguishable from
typical rice-water stools of cases of Asiatic cholera; numerous flakes of the so-called "mucus-flakes"
were present, but these were not true epithelial flakes. As microscopic and cultural observations
showed, no comma bacilli could be discovered in them, and the patients that had voided those stools
rapidly recovered. My experience of Asiatic cholera coincides with that of all other observers on this
point, viz., that if in the (epithelial) "mucus-flakes" of the rice-water stools or of the contents of the
ileum, Koch's comma bacilli (as far as size, shape, motility and arrangement) occur in great numbers—
(in some typical cases they occurred in almost pure culture)—the diagnosis Asiatic cholera is quite