ON CHOLERA AS A FORM OF URAEMIA. By
Surgeon-Major J. B. Gaffney, Civil Surgeon, Seoni, C. P. Before giving expression to my views on the above subject, I quote as a justification of my presumption the opinions of well-known men on the etiology of cholera ; from these extracts it may be seen that the most opposite views are held by men competent to form an opinion. In the absence of any definite and accepted theory on the origin and nature of cholera, I hold it to be the duty of anyone who, after experience and deliberation, has arrived at conclusions differing from those now accepted by some and rejected by others, to submit his views for the consideration of the profession. i
I shall
more recent utter-
of
ence are
is
with the
distinguished men, regretting that in isolated position my opportunities for refer-
ances
my
commence
limited.
Dr. C. Macnamara* states, "Asiatic cholera * * * * a specific disease, ancj capable
of being communicated to persons otherwise in sound health through the dejecta of patients
suffering from the disease. These excreta are most commonly disseminated among a community and taken into the system by means of drinking water, or in fact anything swallowed which has been contaminated by the organic matter passed from cholera patients." Dr. Aitkcnf,?1" A disease which is the result of a specific poison, which reproduces itself during the course of the malady. It propagates by cojitagia given off mainly, if not only, by the stools, in which the .poison multiplies even after their discharge." Surgeon-Major T. R. Lewis!?" My former colleague, Dr. Cunningham, and myself have had considerable experience in investigating localised outbreaks of the disease, but in
single
instance have
ourselves that it Dr. *
was
we
been able to
spread
from
Joseph Ewart??"Such
man to
facts
as
no
satisfy man." these
Quain's Dictionary of Medicine, 1SS3. t Outlines of the Science and Practice of Medicine, second edition, 1SS2. X Report of Intercolonial Medical Congress at Amsterdam, Lancet, September 22nd, 1883 5 Ibid.
THE INDIAN MEDICAL
have convinced
disease."
Deputy Surgeon-General H. W. Bellew, c.S.l.f Were cholera really endowed with contagious properties, and were it really capable of being carried about and spread by man, we ?"
could not fail to have been overwhelmed with numberless instances of its importation from one part of the country to another by our railways, steamers, and other means of rapid locomotion in the present day. But what is our
experience not found
a
this
single
point
imported disease
the
from
was
?
Why,
that
instance recorded
past twenty years ecn
we
have
the that cholera has
proving
one area or
during
region
in which
naturally present, and with causing an outbreak of the
the result of there Whilst
disease.
the other
on
hand endl'ess
incontestable truth of
point
found
myself in opposition to the paratheory ; I have striven solely and always against the theory of simple contagion, which in my opinion is erroneous. * * * * When never
I
consider the results of
mission
in the
light prevailing fungus theory of the present day, I might hold it as most probable, seeing thst, as I have before said, cho" lera is no putrefaction poisoning, that intercourse with places in which the disease is endemic or epidemic, spreads an organism (.r) which
i-
causes
cholera in This
present.
some
poison
the or
ground,
as
host,
and
and which is
and it
"
proportion of his
activity
to
the greater
own
emigrations?
mission does not hesitate to tive.
* *
The Commission
that the *
Report
rapidity
transmissibility
reply
and
The Com-
in the affirma-
unanimously concludes
of Asiatic cholera is
of Intercolonial Medical
Congress
at
an
Amsterdim
Lancct, September 22nd, 18S3. t History of Cholera in India from 1S62 to 1881. t Cholera in India, 1862-1881.
poisonous
speak as nutriment either already in man be more likely, in the
himself, or, as seems to ground, and from thence attaches itself to ings situated on the ground, or to objects
singular
held at
its
serves so to
certain,
Sanitary Congress
losing
property, can only propagate itself if it finds a substratum (or nidus) ('y) which has its origin in
yet made its appearance in the natural course of its seasonal development, or into an area in which it is not naturally due at all."
Constantinople in 1866,unanimously adopted the Do not all these facts following proposition.! most demonstrate strongly that cholera is propagated by man, and with a greater swiftness
way unknown to us a1however, when brought
into other localities without
advocated
The International
the Cholera Com-
of the
trongly
not
It
sitic
foot pace, from an area in which the disease is prevalent into another area in which it has
a
admitting
sufficient to may be out that from that time to this I have
Pettenkofer??"
of cvery-day life in this country?prove that cholera cannot be carried by man, go he at railway speed or at
instances?nay, the experience
facts
proved by interpretation."
other
no
found therein."
in
1884.
[January,
most
experienced physicians practising in India, that the malady is not infectious, contagious, or catching from person to person." Sir Joseph Farer*?"He had himself seen hundreds of cases of sporadic and epidemic cholera, but had seen nothing to make him think that there was anything whatever of a contagious character in connexion with the
on
GAZETTE.
Dr. ParkesJ',?" Thus it appears that the of the disease
by
by
seems
erratic
accounted for in The
human some
dwellto.
be
carriage
intercourse, always writers, is now quite
also oretty clear that the cholera can be best
spread of this way."
Sanitary Commissioner
with the Govern-
ment of India"! "
The
experience
of fairs and other
gatherings
in this country has again and again testified to the truth of the conclusion that cholera is not car. ried by persons from one to another, so
locality
as
to cause persons, not themselves
necessary local the disease." I have
now
influences,
our
to
become affected
quoted sufficient
mited and uncertain is ? Appendix "
to
exposed
to show how
knowledge
the
by li-
of cholera-
to Army Medical Report for 1SS0. Report on the progress of Hygiene for the close 1SS0," by F. de Chaumont, m.d., k.r.s. || Practical Hygiene, Second edition, page 448. IT 18th Annual Report, 1SS1.
of the year
GAFFNEY ON CHOLERA AS A FORM OF XJR/EMIA.
Jam-ary, 1884.]
Joseph Fayrer, at the Intercolonial Medical Congress at Amsterdam, admitted that after 24 years' experience in dealing with cholera, "he felt that he was totally and absolutely ignorant of Sir
the
of the disease."
cause
Amidst cult for
a
so many conflicting opinions it is diffimedical officer on arrival in India to
really known about cholera. experience will probably convince little is really known about the
ascertain what is Ere
long
a
sad
but that in
modified form urine may bepassed? person apparently in health?which
a
by decomposing gives off emanations capable of reproducing the symptoms of uraemia on obtaining admission to the system of a suitable subject. That thus, through the agency of voided urine cholera may be spread in every direction carried by human intercourse, by air, water, or even
a
from the contaminated earth.
him that very disease, and he will be forced to think for himself.
emanating
Such
of urea will show what
was
India in
case
my
1867,
I
when,
was
sent
after my arrival in to do duty with the
soon
Cholera camp of H. M.'s 3rd Regt. (The Buffs); of a total strength of 800 men there were
out 101
deaths, and but
of treatment
was
recovery. Every variety tried without success: I have one
The last that
since been in several
epidemics. engaged my attention was an epidemic in this (Seoni) district in 1882, in which 3,213 seizures were reported, out of which 1,755 were fatal; in the cold weather I inspected nearly all the villages where cholera had been most prevalent, and as a result I worked out the following theory* which
seems
to
me
to harmonize with
all the
known facts of cholera. a
poisoning by azotysed matter therein?probably urea in a metamorphosed state. That the suppression of urine, always present in the advanced stage of the disease, is not merely a symptom, but is closely connected with the
cause
of die disease.
That the disease is caused
by
the introduction
into the system of some of the products of decomposing urine. I hat this product?which for convenience I shall call the
an
unstable
chemistry compound it
readily susceptible of metamorphosis. Urea only requires the oxygen and hydrogen of two equivalents of water to convert it into is,
and how
carbonate of ammonia. of ammonia
Cyanite
only requires
of heat to convert it into Urea is
the agency
urea.
decomposed by
heat into
cyanuric
acid and ammonia.
Cyanuric acid is converted into hydrated cyanic acid by great heat.* So that the simple elements of heat and water all that is necessary for the conversion of urea into other forms, that entering the system are
poisons, and when outside the system, originators or reproducers of a simiprobably lar train of chemical metamorphoses, which when brought in contact with the azotized elements of the blood, prevent their elimination in the ordinary manner. It is possible that such action may also take place in the urine of animals and re-act on the must act
form of uraemia, or bloodthe retention of some of the effete
I consider cholera
A few facts in connexion with the
as
as
human system. I have been struck with the fact that cattle had been housed amidst the
dwellings
of the
that had been
people in severely
most of the
visited
villages cholera.
by Decomposing cattle urine may give off emanations capable of producing blood poisoning, resulting in choleraic symptoms in the manner
zyme?introduced into the blood of the ordinary process of elimination from the kidneys, cither acting as an indicated. The practical deductions from the theories I irritant to the kidney and paralysing its action, have or so altering the advanced are briefly as follows :? specific gravity or character That our present system of of the blood as to interfere with, or suspend, the conservancy is a as no of osmosis. failure, adequate provision is made for the process efficient I hat when the process described has been disposal of urine. Our dry-earth syscarried on without check, the patient must die ; Fownes' Manual of Chemistry.
causes an arrest
*
IO
THE INDIAN MEDICAL GAZETTE.
tern,
matter how
no
cient in this We
are
perfectly important point.
carried out, is defi-
careful that the solid excreta but little
diposcd of,
or
attention is
no
safely paid to the arc
I have known of many prosecu-
fluid excreta.
and
Municipalities for breaches of bye-laws by defalcating in public places, but I have never known of a prosecution for micturating in other places than latrines. The importance of this point can be clearly shown by figures. The quantity of urea passed in 24 hours by an adult is, according to Parke?, 512 grains ; taking this in round numbers as one ounce (437^ grains equal one ounce) then, on the 19th January 1882 when, according to the SaniCantonments
tions in
tary Commissioner with the Government of million of
In-
assembled people Ganges and Jumna rivers assuming that one million people remained for one day at the fair, there would have been depo-
dia*, nearly
a
were
at the confluence of the
sited in the sands 28 tons of solid urea ! And from the 5th of January as the fair continued
February, the extent of contamination of the ground from urine must have been something frightful. I think it can be easily understood that people respiring air, or drinking water, contaminated with such noxious emanations, would readily become victims of blood-poisoning in a greater or lesser degree, the former dying from cholera and the latter conveying the zyme to previously non-infcctcd localities. In the form of decomposition of urine I have
to
the
3rd
of
alluded to, chemical action will for the phenomena ;
were
not alone account
it so, cholera would be
endemic or epidemic in all climates ; the peculiar climate of India must supply the initial action. The
exciting
ture, the
may be due to high temperacombined with moisture, or some
cause
same
meteorological condition
not
yet discovered. The
influence of these factors on the human system to the action of it may tend to render susceptible these abnormal agents, and combining with the animal excreta, on powerful effects produced results in the development and spread of
cholera. *
Eighteenth
Annual Report,
page 127.
[January, 1884.
As regards the prevention and treatment of cholera my deductions are, that a system of
conservancy, specially directed
to the
complete decomposition of urine, must be rigidly enforced, that no one be permitted to micturate, except in places set apart for that purpose, and that the stalling of cattle within villages be strictly prohibited. As regards treatment, I have not had sufficient opportunities of carrying my theory into practice, but I am of opinion that the principles
neutralization of the
of treatment are, to counteract the abnormal
con-
dition of the
blood, and to aid in the elimination of urea by the kidneys. To this end I look to some form of medicine which, chemically comwith the bining metamorphosed form of urea, forms a soluble salt capable of being eliminated by the kidneys or the skin, and as I think the is converted into some form of ammonia, I would expect acetic acid to be the most effective remedy, as it would form the most soluble comurea
pound of ammonia?the acetate, which is power-
fully
diuretic and
remedy
limited to not
diaphoretic,
with success, but a
few
cases
confidently
I have tried the
as
my experience was in the present year, I can-
recommend it
successful. I have
as
having
been
combination of acetic
given opii and spirits of chloroform, these combined with sponging over the body with vinegar and water, are deserving of further acid,
a
acetum
trial. I
am
aware
that Frerichs
originated
the theory
of uraemia
being the result of the chemical decomposition of the urea in the blood, and that Dr. G. Johnson advanced the theory that cholera was
a
aware
form
of
blood-poisoning,
if it has been
but I
suggested by
am
not
either that
cholera may be caused by the entrance into the system of the products of decomposing urine, and I think research in this direction may lead to valuable results?perhaps the discovery of the "
"
organism" (x) and the nidus" (y) of Professor Pcttenkofer, in the article quoted. Sconi, C. P., \6t/i November, 1883.
Surgeon-Major J. B. Gaffney, Civil Surgeon, Seoni, C. P. Before giving expression to my views on the above subject, I quote as a justification of my presumption the opinions of well-known men on the etiology of cholera ; from these extracts it may be seen that the most opposite views are held by men competent to form an opinion. In the absence of any definite and accepted theory on the origin and nature of cholera, I hold it to be the duty of anyone who, after experience and deliberation, has arrived at conclusions differing from those now accepted by some and rejected by others, to submit his views for the consideration of the profession. i
I shall
more recent utter-
of
ence are
is
with the
distinguished men, regretting that in isolated position my opportunities for refer-
ances
my
commence
limited.
Dr. C. Macnamara* states, "Asiatic cholera * * * * a specific disease, ancj capable
of being communicated to persons otherwise in sound health through the dejecta of patients
suffering from the disease. These excreta are most commonly disseminated among a community and taken into the system by means of drinking water, or in fact anything swallowed which has been contaminated by the organic matter passed from cholera patients." Dr. Aitkcnf,?1" A disease which is the result of a specific poison, which reproduces itself during the course of the malady. It propagates by cojitagia given off mainly, if not only, by the stools, in which the .poison multiplies even after their discharge." Surgeon-Major T. R. Lewis!?" My former colleague, Dr. Cunningham, and myself have had considerable experience in investigating localised outbreaks of the disease, but in
single
instance have
ourselves that it Dr. *
was
we
been able to
spread
from
Joseph Ewart??"Such
man to
facts
as
no
satisfy man." these
Quain's Dictionary of Medicine, 1SS3. t Outlines of the Science and Practice of Medicine, second edition, 1SS2. X Report of Intercolonial Medical Congress at Amsterdam, Lancet, September 22nd, 1883 5 Ibid.
THE INDIAN MEDICAL
have convinced
disease."
Deputy Surgeon-General H. W. Bellew, c.S.l.f Were cholera really endowed with contagious properties, and were it really capable of being carried about and spread by man, we ?"
could not fail to have been overwhelmed with numberless instances of its importation from one part of the country to another by our railways, steamers, and other means of rapid locomotion in the present day. But what is our
experience not found
a
this
single
point
imported disease
the
from
was
?
Why,
that
instance recorded
past twenty years ecn
we
have
the that cholera has
proving
one area or
during
region
in which
naturally present, and with causing an outbreak of the
the result of there Whilst
disease.
the other
on
hand endl'ess
incontestable truth of
point
found
myself in opposition to the paratheory ; I have striven solely and always against the theory of simple contagion, which in my opinion is erroneous. * * * * When never
I
consider the results of
mission
in the
light prevailing fungus theory of the present day, I might hold it as most probable, seeing thst, as I have before said, cho" lera is no putrefaction poisoning, that intercourse with places in which the disease is endemic or epidemic, spreads an organism (.r) which
i-
causes
cholera in This
present.
some
poison
the or
ground,
as
host,
and
and which is
and it
"
proportion of his
activity
to
the greater
own
emigrations?
mission does not hesitate to tive.
* *
The Commission
that the *
Report
rapidity
transmissibility
reply
and
The Com-
in the affirma-
unanimously concludes
of Asiatic cholera is
of Intercolonial Medical
Congress
at
an
Amsterdim
Lancct, September 22nd, 18S3. t History of Cholera in India from 1S62 to 1881. t Cholera in India, 1862-1881.
poisonous
speak as nutriment either already in man be more likely, in the
himself, or, as seems to ground, and from thence attaches itself to ings situated on the ground, or to objects
singular
held at
its
serves so to
certain,
Sanitary Congress
losing
property, can only propagate itself if it finds a substratum (or nidus) ('y) which has its origin in
yet made its appearance in the natural course of its seasonal development, or into an area in which it is not naturally due at all."
Constantinople in 1866,unanimously adopted the Do not all these facts following proposition.! most demonstrate strongly that cholera is propagated by man, and with a greater swiftness
way unknown to us a1however, when brought
into other localities without
advocated
The International
the Cholera Com-
of the
trongly
not
It
sitic
foot pace, from an area in which the disease is prevalent into another area in which it has
a
admitting
sufficient to may be out that from that time to this I have
Pettenkofer??"
of cvery-day life in this country?prove that cholera cannot be carried by man, go he at railway speed or at
instances?nay, the experience
facts
proved by interpretation."
other
no
found therein."
in
1884.
[January,
most
experienced physicians practising in India, that the malady is not infectious, contagious, or catching from person to person." Sir Joseph Farer*?"He had himself seen hundreds of cases of sporadic and epidemic cholera, but had seen nothing to make him think that there was anything whatever of a contagious character in connexion with the
on
GAZETTE.
Dr. ParkesJ',?" Thus it appears that the of the disease
by
by
seems
erratic
accounted for in The
human some
dwellto.
be
carriage
intercourse, always writers, is now quite
also oretty clear that the cholera can be best
spread of this way."
Sanitary Commissioner
with the Govern-
ment of India"! "
The
experience
of fairs and other
gatherings
in this country has again and again testified to the truth of the conclusion that cholera is not car. ried by persons from one to another, so
locality
as
to cause persons, not themselves
necessary local the disease." I have
now
influences,
our
to
become affected
quoted sufficient
mited and uncertain is ? Appendix "
to
exposed
to show how
knowledge
the
by li-
of cholera-
to Army Medical Report for 1SS0. Report on the progress of Hygiene for the close 1SS0," by F. de Chaumont, m.d., k.r.s. || Practical Hygiene, Second edition, page 448. IT 18th Annual Report, 1SS1.
of the year
GAFFNEY ON CHOLERA AS A FORM OF XJR/EMIA.
Jam-ary, 1884.]
Joseph Fayrer, at the Intercolonial Medical Congress at Amsterdam, admitted that after 24 years' experience in dealing with cholera, "he felt that he was totally and absolutely ignorant of Sir
the
of the disease."
cause
Amidst cult for
a
so many conflicting opinions it is diffimedical officer on arrival in India to
really known about cholera. experience will probably convince little is really known about the
ascertain what is Ere
long
a
sad
but that in
modified form urine may bepassed? person apparently in health?which
a
by decomposing gives off emanations capable of reproducing the symptoms of uraemia on obtaining admission to the system of a suitable subject. That thus, through the agency of voided urine cholera may be spread in every direction carried by human intercourse, by air, water, or even
a
from the contaminated earth.
him that very disease, and he will be forced to think for himself.
emanating
Such
of urea will show what
was
India in
case
my
1867,
I
when,
was
sent
after my arrival in to do duty with the
soon
Cholera camp of H. M.'s 3rd Regt. (The Buffs); of a total strength of 800 men there were
out 101
deaths, and but
of treatment
was
recovery. Every variety tried without success: I have one
The last that
since been in several
epidemics. engaged my attention was an epidemic in this (Seoni) district in 1882, in which 3,213 seizures were reported, out of which 1,755 were fatal; in the cold weather I inspected nearly all the villages where cholera had been most prevalent, and as a result I worked out the following theory* which
seems
to
me
to harmonize with
all the
known facts of cholera. a
poisoning by azotysed matter therein?probably urea in a metamorphosed state. That the suppression of urine, always present in the advanced stage of the disease, is not merely a symptom, but is closely connected with the
cause
of die disease.
That the disease is caused
by
the introduction
into the system of some of the products of decomposing urine. I hat this product?which for convenience I shall call the
an
unstable
chemistry compound it
readily susceptible of metamorphosis. Urea only requires the oxygen and hydrogen of two equivalents of water to convert it into is,
and how
carbonate of ammonia. of ammonia
Cyanite
only requires
of heat to convert it into Urea is
the agency
urea.
decomposed by
heat into
cyanuric
acid and ammonia.
Cyanuric acid is converted into hydrated cyanic acid by great heat.* So that the simple elements of heat and water all that is necessary for the conversion of urea into other forms, that entering the system are
poisons, and when outside the system, originators or reproducers of a simiprobably lar train of chemical metamorphoses, which when brought in contact with the azotized elements of the blood, prevent their elimination in the ordinary manner. It is possible that such action may also take place in the urine of animals and re-act on the must act
form of uraemia, or bloodthe retention of some of the effete
I consider cholera
A few facts in connexion with the
as
as
human system. I have been struck with the fact that cattle had been housed amidst the
dwellings
of the
that had been
people in severely
most of the
visited
villages cholera.
by Decomposing cattle urine may give off emanations capable of producing blood poisoning, resulting in choleraic symptoms in the manner
zyme?introduced into the blood of the ordinary process of elimination from the kidneys, cither acting as an indicated. The practical deductions from the theories I irritant to the kidney and paralysing its action, have or so altering the advanced are briefly as follows :? specific gravity or character That our present system of of the blood as to interfere with, or suspend, the conservancy is a as no of osmosis. failure, adequate provision is made for the process efficient I hat when the process described has been disposal of urine. Our dry-earth syscarried on without check, the patient must die ; Fownes' Manual of Chemistry.
causes an arrest
*
IO
THE INDIAN MEDICAL GAZETTE.
tern,
matter how
no
cient in this We
are
perfectly important point.
carried out, is defi-
careful that the solid excreta but little
diposcd of,
or
attention is
no
safely paid to the arc
I have known of many prosecu-
fluid excreta.
and
Municipalities for breaches of bye-laws by defalcating in public places, but I have never known of a prosecution for micturating in other places than latrines. The importance of this point can be clearly shown by figures. The quantity of urea passed in 24 hours by an adult is, according to Parke?, 512 grains ; taking this in round numbers as one ounce (437^ grains equal one ounce) then, on the 19th January 1882 when, according to the SaniCantonments
tions in
tary Commissioner with the Government of million of
In-
assembled people Ganges and Jumna rivers assuming that one million people remained for one day at the fair, there would have been depo-
dia*, nearly
a
were
at the confluence of the
sited in the sands 28 tons of solid urea ! And from the 5th of January as the fair continued
February, the extent of contamination of the ground from urine must have been something frightful. I think it can be easily understood that people respiring air, or drinking water, contaminated with such noxious emanations, would readily become victims of blood-poisoning in a greater or lesser degree, the former dying from cholera and the latter conveying the zyme to previously non-infcctcd localities. In the form of decomposition of urine I have
to
the
3rd
of
alluded to, chemical action will for the phenomena ;
were
not alone account
it so, cholera would be
endemic or epidemic in all climates ; the peculiar climate of India must supply the initial action. The
exciting
ture, the
may be due to high temperacombined with moisture, or some
cause
same
meteorological condition
not
yet discovered. The
influence of these factors on the human system to the action of it may tend to render susceptible these abnormal agents, and combining with the animal excreta, on powerful effects produced results in the development and spread of
cholera. *
Eighteenth
Annual Report,
page 127.
[January, 1884.
As regards the prevention and treatment of cholera my deductions are, that a system of
conservancy, specially directed
to the
complete decomposition of urine, must be rigidly enforced, that no one be permitted to micturate, except in places set apart for that purpose, and that the stalling of cattle within villages be strictly prohibited. As regards treatment, I have not had sufficient opportunities of carrying my theory into practice, but I am of opinion that the principles
neutralization of the
of treatment are, to counteract the abnormal
con-
dition of the
blood, and to aid in the elimination of urea by the kidneys. To this end I look to some form of medicine which, chemically comwith the bining metamorphosed form of urea, forms a soluble salt capable of being eliminated by the kidneys or the skin, and as I think the is converted into some form of ammonia, I would expect acetic acid to be the most effective remedy, as it would form the most soluble comurea
pound of ammonia?the acetate, which is power-
fully
diuretic and
remedy
limited to not
diaphoretic,
with success, but a
few
cases
confidently
I have tried the
as
my experience was in the present year, I can-
recommend it
successful. I have
as
having
been
combination of acetic
given opii and spirits of chloroform, these combined with sponging over the body with vinegar and water, are deserving of further acid,
a
acetum
trial. I
am
aware
that Frerichs
originated
the theory
of uraemia
being the result of the chemical decomposition of the urea in the blood, and that Dr. G. Johnson advanced the theory that cholera was
a
aware
form
of
blood-poisoning,
if it has been
but I
suggested by
am
not
either that
cholera may be caused by the entrance into the system of the products of decomposing urine, and I think research in this direction may lead to valuable results?perhaps the discovery of the "
"
organism" (x) and the nidus" (y) of Professor Pcttenkofer, in the article quoted. Sconi, C. P., \6t/i November, 1883.
