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The bacteriological diagnosis of cholera, with special reference to pfeiffer's cholera reaction
253
T H E B A C T E R I O L O G I C A L D I A G N O S I S OF C H O L E R A .
2° Chloride of lime (onty serviceable when freshly prepared and kept in tight bottles).--It may be used either in the crude form as a powder or in a solution. The latter is made by adding two parts chloride of lime to ioo parts of cold water. After settling, the clear fluid is to be decanted. 3. Solution of soft soap (potash soap).--Three parts in ~oo parts of hot water. 4. Carbolic soap solution (strongly recommended).--Made by adding to every twenty parts ef the soft soap solution just described one part of ioo per cent. carbolic acid. 5. Steam disinfecting machines, preferably those working under pressure not less than one-tenth of an atmosphere. 6. Boiling.
3/[et/~od of usb~g Dfsb2fectbzg 2Wateriafs.--The evacuations of cholera-smitten persons to be thoroughly mixed with an equal quantity of milk of lime, and allowed to stand for at least one hour. If chloride of lime is used, there should be at least two heaped-up tablespoonfuls to each half litre of the stool% and the mixture be allowed to stand for twenty minutes. In certain circumstances the evacuations may be disinfected by an hour's boiling in water. The hands and other portions of the body should be disinfected with chloride of lime solution or solution of carbolic acid ~ in 20. Bed linen, etc., to be immersed in soft soap solution or the carbolic soap solution for twentyfour hours before they are further washed in water or passed through a steam disinfector. Articles of clothing which cannot be washed to be passed through the steam disinfector. Wood and metallic parts of furniture to be wiped with cloths moistened with carbolic acid and carbolic soap solution. The floor can also be washed with milk of lime, which can be removed after two hours. Wall papers are to be rubbed with bread, the crumbs of which are to be swept up and burnt. Privies should be disinfected with milk of lime, and the seat washed with either soft soap solution or carbolic acid i in 20, or carbolic soap solution, or milk of lime. Where the disinfection of mattresses, etc., is impossible by steam, they are to be placed outside, protected from. raiD, in a warm, dry place accessible to the sun. Warning is given against the waste of disinfecting materials, and it is pointed out that cIeanliness is better than a bad disinfection.
Directfo~zs for take)a% ~;ad forwardbzg s~ecf'me~as suspected of C/zo/era far fna"estigation :-~. The specimen should be quite fresh--the longer they are kept at the ordinary temperature the more unfit do they become for examination. All additional matter (such as water) acts injuriously. 2. In the case of corpses only three portions of
small intestine, each t 5 era. in length, to be taken from (a) the middle part o f the ileum, b) two metres lower down, and (c) just ahm
PAYMENT FOR bfAINTENANCE IN ISOLATION HOSPITALS. half an hour completely destroyed, while other different vibrios injected at the same time were perfectly unaffected. [This was determined by taking at intervals small quantities of fluid from the peritoneal cavity and examining it in the "hanging drop."~ H e concludes, therefore, that this fact will in difficult cases be able to be made use of for identifying vibrios cultivated from water. Dr. Dunbar found that in every one of his experiments confirmatory results Were obtained. In the control animals the vibrios developed a s usual, while the cholera bacilli were converted into granular matter. The experiment was extended to such vibrios as to which it was doubtful whether or not they were true cholera, notably the phosphorescent vibrios found by Dunbar in the water of the Etbe, and also in the dejecta of certain suspicious cases at Hamburg. These had been found to give every typical reaction of cholera, but they were phosphorescent, and the typical cholera vibrio has never been known to phosphoresce. It this case the phosphorescent cultures were injected into the peritoneal cavity of guinea-pigs along with serum of the biood of animals previously immunised by real cholera cultures. In no instance were the guineapigs affected. But when the reverse experiment was tried, and cholera baciIli and phosphorescent vibrios were injected into the peritoneal cavity of guinea-pigs that had been previously immunised against the phosphorescent vibrios, the lakter perished, and the former were unaffected. Hence it is apparent that the suspicious phosphorescent vibrios are quite distinct from the true cholera vibrios. Other suspicious vibrios found in water, etc., were tested in the same way, and of twenty-four different kinds nine reacted in a similar way to the cholera vibrios, and thirteen differently. Dunbar believes that in a similar way a sure and certain distinction will be able to be drawn between the bac. typhus and bac. coli communis. His conclusions are : - i. That by means of the preliminary treatment of animals with different kinds of bacteria, substances are formed in the blood, which show a specific action against those particular kinds of bacteria which had been used in the preliminary treatment. No one has succeeded hitherto in finding a foreign kind of bacteria which was influenced in the same way as the kind of bacterium used in the preliminary treatment, through the blood serum of animals which had been immunised against a definite kind of bacterium. 2. By means of this specific action of the blood serum, a more definite differentiation of bacteria is rendered possible. 3. It is possible to regard the Koch cholera vibrio as belonging to a very definite variety, as no matter from what epidemic the bacilli used in experimenting came from, every one gave the charac-
259
teristic reaction. The phosphorescent vibrios are distinct, but have relations with cholera vibrios. 4. A third variety exists, and possibly others. PAYMENT FOR MAINTENANCE IN ISOLATION HOSPITALS. T~E principle of not exacting payment from patients in isolation hospitals is now generally admitted to be sound in the interest of the public health. There are, however, some local authorities who still exact such payment, and for their benefi~ we give the following "Reasons for not Exacting Payment from Patients in the Isolation Hospital," which give a concise smmnary of the question. They have been compiled by Dr. W. L. Hunter, M.O.H. for Pudsey. i. The object of a fever hospital is to prevent the spread of infectious diseases. 2 . No attempts to prevent the spreading of infectious diseases can be thorough without corn plete separation of those who are sick from those who are well, and this can, as a general rule, be only done reliably by proper isolation in hospital, and therefore the persons removed to hospitals deserve the thanks of the whole community. 3. A hospital is built and maintained at great expense, and, to get a return for this outlay, the increasing desire of the public to avail themselves of the benefits of it should be encouraged by the sanitary authority to the utmost. 4. Making a charge for maintenance, without doubt, deters a number of persons from taking advantage of the hospital, and so the object of the hospital is frustrated, 5- The hospital is maintained, in the first instance, for the good of the whole public, and not merely for the patients who go in, although the latter share in the advantages also, as statistics show that the proportion of recoveries amongst cases treated in hospital is considerably greater than amongst those treated at home. 6. The use of the hospital is necessary for alI classes of the community, rich and poor alike. It is not a refuge for the poor, nor is it a charitable institution. 7. The hospital is built and supported by the ratepayers, and every ratepayer is entitled to the accommodation which he, jointly with his brother ratepayers, provides for their mutual benefit, and it is unjust to make a charge to those ratepayers for admission, more especially to the richer people who have contributed more in rates to the support of the hospital than their poorer brethren. In other words the payment of rates should carry with it the right to use the public hospital. 8. Other institutions maintained for the benefit of the whole community, such as the removal of house refuse, sewerage, free schools, etc., may be instanced where the charge is borne by the whole community.
T H E B A C T E R I O L O G I C A L D I A G N O S I S OF C H O L E R A .
2° Chloride of lime (onty serviceable when freshly prepared and kept in tight bottles).--It may be used either in the crude form as a powder or in a solution. The latter is made by adding two parts chloride of lime to ioo parts of cold water. After settling, the clear fluid is to be decanted. 3. Solution of soft soap (potash soap).--Three parts in ~oo parts of hot water. 4. Carbolic soap solution (strongly recommended).--Made by adding to every twenty parts ef the soft soap solution just described one part of ioo per cent. carbolic acid. 5. Steam disinfecting machines, preferably those working under pressure not less than one-tenth of an atmosphere. 6. Boiling.
3/[et/~od of usb~g Dfsb2fectbzg 2Wateriafs.--The evacuations of cholera-smitten persons to be thoroughly mixed with an equal quantity of milk of lime, and allowed to stand for at least one hour. If chloride of lime is used, there should be at least two heaped-up tablespoonfuls to each half litre of the stool% and the mixture be allowed to stand for twenty minutes. In certain circumstances the evacuations may be disinfected by an hour's boiling in water. The hands and other portions of the body should be disinfected with chloride of lime solution or solution of carbolic acid ~ in 20. Bed linen, etc., to be immersed in soft soap solution or the carbolic soap solution for twentyfour hours before they are further washed in water or passed through a steam disinfector. Articles of clothing which cannot be washed to be passed through the steam disinfector. Wood and metallic parts of furniture to be wiped with cloths moistened with carbolic acid and carbolic soap solution. The floor can also be washed with milk of lime, which can be removed after two hours. Wall papers are to be rubbed with bread, the crumbs of which are to be swept up and burnt. Privies should be disinfected with milk of lime, and the seat washed with either soft soap solution or carbolic acid i in 20, or carbolic soap solution, or milk of lime. Where the disinfection of mattresses, etc., is impossible by steam, they are to be placed outside, protected from. raiD, in a warm, dry place accessible to the sun. Warning is given against the waste of disinfecting materials, and it is pointed out that cIeanliness is better than a bad disinfection.
Directfo~zs for take)a% ~;ad forwardbzg s~ecf'me~as suspected of C/zo/era far fna"estigation :-~. The specimen should be quite fresh--the longer they are kept at the ordinary temperature the more unfit do they become for examination. All additional matter (such as water) acts injuriously. 2. In the case of corpses only three portions of
small intestine, each t 5 era. in length, to be taken from (a) the middle part o f the ileum, b) two metres lower down, and (c) just ahm
PAYMENT FOR bfAINTENANCE IN ISOLATION HOSPITALS. half an hour completely destroyed, while other different vibrios injected at the same time were perfectly unaffected. [This was determined by taking at intervals small quantities of fluid from the peritoneal cavity and examining it in the "hanging drop."~ H e concludes, therefore, that this fact will in difficult cases be able to be made use of for identifying vibrios cultivated from water. Dr. Dunbar found that in every one of his experiments confirmatory results Were obtained. In the control animals the vibrios developed a s usual, while the cholera bacilli were converted into granular matter. The experiment was extended to such vibrios as to which it was doubtful whether or not they were true cholera, notably the phosphorescent vibrios found by Dunbar in the water of the Etbe, and also in the dejecta of certain suspicious cases at Hamburg. These had been found to give every typical reaction of cholera, but they were phosphorescent, and the typical cholera vibrio has never been known to phosphoresce. It this case the phosphorescent cultures were injected into the peritoneal cavity of guinea-pigs along with serum of the biood of animals previously immunised by real cholera cultures. In no instance were the guineapigs affected. But when the reverse experiment was tried, and cholera baciIli and phosphorescent vibrios were injected into the peritoneal cavity of guinea-pigs that had been previously immunised against the phosphorescent vibrios, the lakter perished, and the former were unaffected. Hence it is apparent that the suspicious phosphorescent vibrios are quite distinct from the true cholera vibrios. Other suspicious vibrios found in water, etc., were tested in the same way, and of twenty-four different kinds nine reacted in a similar way to the cholera vibrios, and thirteen differently. Dunbar believes that in a similar way a sure and certain distinction will be able to be drawn between the bac. typhus and bac. coli communis. His conclusions are : - i. That by means of the preliminary treatment of animals with different kinds of bacteria, substances are formed in the blood, which show a specific action against those particular kinds of bacteria which had been used in the preliminary treatment. No one has succeeded hitherto in finding a foreign kind of bacteria which was influenced in the same way as the kind of bacterium used in the preliminary treatment, through the blood serum of animals which had been immunised against a definite kind of bacterium. 2. By means of this specific action of the blood serum, a more definite differentiation of bacteria is rendered possible. 3. It is possible to regard the Koch cholera vibrio as belonging to a very definite variety, as no matter from what epidemic the bacilli used in experimenting came from, every one gave the charac-
259
teristic reaction. The phosphorescent vibrios are distinct, but have relations with cholera vibrios. 4. A third variety exists, and possibly others. PAYMENT FOR MAINTENANCE IN ISOLATION HOSPITALS. T~E principle of not exacting payment from patients in isolation hospitals is now generally admitted to be sound in the interest of the public health. There are, however, some local authorities who still exact such payment, and for their benefi~ we give the following "Reasons for not Exacting Payment from Patients in the Isolation Hospital," which give a concise smmnary of the question. They have been compiled by Dr. W. L. Hunter, M.O.H. for Pudsey. i. The object of a fever hospital is to prevent the spread of infectious diseases. 2 . No attempts to prevent the spreading of infectious diseases can be thorough without corn plete separation of those who are sick from those who are well, and this can, as a general rule, be only done reliably by proper isolation in hospital, and therefore the persons removed to hospitals deserve the thanks of the whole community. 3. A hospital is built and maintained at great expense, and, to get a return for this outlay, the increasing desire of the public to avail themselves of the benefits of it should be encouraged by the sanitary authority to the utmost. 4. Making a charge for maintenance, without doubt, deters a number of persons from taking advantage of the hospital, and so the object of the hospital is frustrated, 5- The hospital is maintained, in the first instance, for the good of the whole public, and not merely for the patients who go in, although the latter share in the advantages also, as statistics show that the proportion of recoveries amongst cases treated in hospital is considerably greater than amongst those treated at home. 6. The use of the hospital is necessary for alI classes of the community, rich and poor alike. It is not a refuge for the poor, nor is it a charitable institution. 7. The hospital is built and supported by the ratepayers, and every ratepayer is entitled to the accommodation which he, jointly with his brother ratepayers, provides for their mutual benefit, and it is unjust to make a charge to those ratepayers for admission, more especially to the richer people who have contributed more in rates to the support of the hospital than their poorer brethren. In other words the payment of rates should carry with it the right to use the public hospital. 8. Other institutions maintained for the benefit of the whole community, such as the removal of house refuse, sewerage, free schools, etc., may be instanced where the charge is borne by the whole community.