shrunken, and cold, and quite destitute of its natural firmness and
elasticity, so that when it is pinched into folds they subside very
slowly, as if they had been made on the skin of a corpse. It is
curious that, although the drain of liquids through the bowels is so
great, the skin not only remains moist, but generally is bathed in a
profuse cold sweat. Although the secretion of urine is reduced or
quite suspended, that of milk is said to be not {737} always so. Large
quantities of urea have been found in the urine, and in some cases it
has been visible upon the skin in the form of white scales. During
convalescence the skin may be the seat of the various eruptions
already enumerated. Of a graver nature, but, fortunately, of rarer
occurrence, are erysipelas, boils, abscesses, ulcers, and gangrene.
These several affections seem to result from the alternate obstruction
and freedom of the cutaneous circulation. They commonly appear first
upon the limbs, and afterward upon the face or trunk; they may affect
even the cavity of the mouth. Some observers have noted a relatively
frequent occurrence of diphtherial exudations in this disease, while
others do not allude to their existence. The former describe the false
membrane as affecting not only the mouth and fauces, but also the
stomach, the intestine, and the female organs of generation. A case is
reported by Joseph of a young man who, after an attack of cholera, was
affected with a blenorrhoea, due to a diphtherial inflammation of the
urethra.
The character of the heart- and pulse-beats in this disease is quite
peculiar. Their rate does not increase indefinitely, as it does after
hemorrhage; the pulse usually varies from 90 to 110, and indeed seldom
exceeds 120, but its volume, tension, and force progressively decline
until the beats become imperceptible at the wrist, and even in the
brachial and femoral arteries. At the same time, the rhythm of the
heart is interrupted, the energy of its impulse declines until it can
no longer be felt, and its sounds grow weaker and weaker until they
become quite inaudible. Sometimes, it is said, a pericardial friction
sound may be heard, which is attributed to the dryness of the
pericardium. That the decline and suspension of the heart's sounds and
impulse are due not only to the weakness of the cardiac muscle, but
also to the lessened volume of the circulating blood, is proved by the
fact that they persist, sometimes for many hours, after reaction has
commenced, and only become audible again when the arteries have been
replenished with blood.
In the description of the symptoms of cholera it has been mentioned
that the cyanotic color of the skin is produced by an accumulation of
blood in the veins. Many years ago Magendie, and after him
Dieffenbach, on examining the arteries of persons in the advanced
stage of cholera, found those vessels empty of blood. It might be
supposed that, under the circumstances, not only the right side of the
heart, but also the lungs, would be gorged with blood, and that
extreme dyspnoea would result. But, in point of fact, the respiration
in cholera is hurried and shallow rather than oppressed and labored,
while after death the lungs are not engorged with blood, but rather in
a bloodless condition. The pulmonary artery and its branches are also
empty, although the right side of the heart may be filled with dark
and soft coagula. These singular conditions seem to be due, on the one
hand, to the greatly diminished mass of the blood in the vessels, and
to its accumulating and stagnating in various parts of the venous
system, and, on the other hand, to the weakness of the heart, which is
shown by its suppressed impulse and sounds, and which lessens its
power to propel the venous blood into the lungs. The infarction of the
systemic veins and the threatening suspension of the circulation
necessarily impair the activity of all the functions, including those
of nutrition and disintegration, so that the effete detritus of the
economy tends to accumulate in the blood. This tendency is {738}
doubtless counterbalanced not only by the diarrhoea, but also, more or
less, by the almost total suspension of nutrition, due to the
inability of the cholera patient to digest or even to retain food, as
well as by the diminished oxidation of the blood in the lungs. It has
already been observed that, to a certain extent, the impediment to the
passage of the blood from the right side of the heart into the
ramifications of the pulmonary artery tends to prevent congestion and
infarction of the lungs. But this obstruction is precisely what occurs
during the stage of reaction in many cases, which then terminate
fatally by asphyxia, as in the previous stage still more perish by
apnoea.
In the milder attacks of cholera vomiting may not occur, and in the
most severe it not unusually is suspended for some time before death,
although the diarrhoea may continue. In the most malignant cases,
indeed, there may be no vomiting at all, in consequence of the extreme
muscular exhaustion, although the stomach may be distended with
liquid. When rejected, the liquid has the general aspect of
rice-water, which the stools also present. Its reaction is alkaline or
neutral, and it is said to contain a less proportion than the stools
of solid matter, but a larger proportion of urea. The act of vomiting
is strictly one of regurgitation, which is performed without effort or
pain. Sometimes, indeed, it seems to relieve the sense of weight
caused by the accumulated contents of the stomach. It is readily
excited by attempts to drink, and even by slight changes of posture.
The vomited liquid at first contains the various articles of food the
patient may have eaten. Their half-digested remains have sometimes
suggested the announcement of strange specific forms of cholera germs.
The liquid, after ceasing to be colored brownish or greenish, becomes
gray, and subsequently, in favorable cases, more or less green again;
while during the stage of reaction in grave and ultimately fatal cases
it is more or less reddened by an admixture of blood. Its most usual
and characteristic appearance is that of a grayish liquid containing
whitish flocculi. The nature of this liquid, whether discharged by
vomiting or by purging, has been variously estimated. Formerly, some
persons held the white granules to be leucocytes, but the greater
number agree that they are mainly epithelial fragments. When the
vomited liquid is allowed to stand, a sediment forms in it which is
composed almost entirely of epithelial scales, more or less modified
in their appearance by the accidental contents of the stomach, and a
film covers its surface in which globules of fat and phosphatic
crystals may be detected. They are frequently associated with sarcinæ,
produced by fermentation in the contents of the stomach, and after
standing for some time the liquid becomes crowded with vibrios
(Lindsay).
Although the propensity of the sick to discover a cause for every
symptom often leads cholera patients to attribute their diarrhoea to
some particular exposure to cold, error of diet, etc., yet, in fact,
this symptom, so far as it belongs to cholera, is primarily an effect
of the cholera poison alone, although it may be aggravated by causes
like those mentioned. It is of great practical importance to bear in
mind that a specific choleraic diarrhoea--that is to say, a diarrhoea
produced by the cholera poison alone--may continue to be very slight
as long as it lasts, which may be for several weeks; and hence, as
elsewhere insisted upon, a person who is not suspected of being
affected with cholera may, quite ignorantly, sow {739} the seeds of a
deadly epidemic of the disease. The danger in cholera is proportioned
to the volume of the discharges rather than to their frequency, just
as a single profuse hemorrhage is more serious than the loss of an
equal amount of blood divided among several successive days. The
special danger, however, is not, as in hemorrhage, from syncope, but
from the progressive loss by drainage of the water of the blood,
rendering it unfit to circulate, and therefore causing it to stagnate
in the veins. The spoliative operation of the diarrhoea has
occasionally been productive of benefit instead of injury, as in the
following case of Barlow: A man suffering from dropsy was attacked
with cholera, "and passed gallons of liquid by stool, had cramps, and
became livid and clammy, but his pulse did not disappear, as in
profound collapse, and he eventually rallied, and left the hospital
apparently well. When he began to recover from cholera his appearance
was almost ludicrous, from the manner in which the integument hung
loosely about him."
The stools pass through a series of changes corresponding to those of
the matters vomited, being fecal at first, and then becoming colorless
and watery. During reaction, if that occurs, they regain more or less
of their proper color, but if typhoid febrile symptoms prevail they
are usually bloody. Decomposed blood sometimes renders them dark,
tarry, and fetid; this condition has caused them sometimes to be
described as being composed of vitiated bile, which is, however, a
product not of the liver, but of the imagination.
In the intestine after death considerable quantities of epithelium are
found floating in the contained liquid or else loosely adherent to the
mucous membrane. It is usually in flocculi, but sometimes in fragments
large enough to form a continuous membrane. A microscopic examination
of cholera stools shows that their turbidness depends chiefly upon
desquamated epithelium, with which is mixed white corpuscles and
bacteria. It is remarkable that although the stools are drained
directly and so rapidly from the blood-vessels, they nevertheless
contain but little albumen, indeed hardly more than a trace of it. If,
however, blood is mixed with the stools, as happens in rare instances,
more albumen is present. Oil-globules are most abundant in cases that
have passed beyond the stage of collapse into that of reaction with
fever. In these it is said that oily matter may be found either in
concrete masses or as a scum of liquid oil. Of inorganic constituents
they contain crystals of the triple phosphate of ammonium and
magnesium and chloride of sodium in greatest abundance, but the
proportion of ammonium and potassium salts is small. Indeed, the total
amount of solids does not exceed 2 per cent. As the quantity of water
in the blood and solids is limited, and as in this disease the stomach
will not receive nor retain any liquid, it follows that the more
profuse the evacuations are, the shorter must be the duration of the
attack, for the sooner then does the blood become too thick to
circulate.
It has several times been stated that in cholera the urine is
diminished, and that, therefore, the blood retains a larger proportion
of effete products than in health. But it has also been remarked that
the amount of these products is abnormally small, on account of the
interference with nutrition of the abnormal state of the circulation.
Doubtless, as in other cases of renal obstruction, an increased
proportion of effete matter is eliminated by the skin, if not by the
bowels. When the amount of {740} urine excreted is only diminished,
its specific gravity may vary between remote extremes, as 1.012 and
1.030. Usually, however, when its quantity is very greatly reduced,
symptoms which are described as uræmic are apt to arise, and the urine
is found to contain the usual products of renal congestion--viz.
albumen, sometimes traces of blood, hyaline and granular casts, and
epithelial scales, with less chloride of sodium and more urea than
normal. It is remarkable that at the beginning of convalescence the
urine, which had been suppressed or greatly diminished, may become for
a time abnormally abundant. Rarely, if ever, does the derangement of
the kidneys now described denote or produce an organic lesion in those
organs. Like the disorders elsewhere, these are due to the loss of
balance between the arterial and the venous sides of the circulation;
both, indeed, have lost their functions more or less, the one by lack
of blood, the other by an excess of blood unfit for circulation.
The occurrence of cramps in cholera, which has bestowed upon the
disease one of its titles, spasmodic, has, however, no distinctive
relation to the Asiatic disease. Spasmodic phenomena occur in many
cases of poisoning by corrosive and irritant agents and in ordinary
cholera morbus, and in cholera infantum they are among the most
alarming symptoms, assuming, as they often do, the character of
general convulsions. In most of these cases they are clonic and
general, and therefore probably of central origin, primary or
reflected; but the spasms of cholera are tonic, and affect the muscles
of the upper and lower limbs, and most frequently the flexor muscles
of these parts, and especially those of the fingers and toes, which
become rigidly bent. The larger muscles contract into hard lumps, and
even those of the chest and abdomen do not escape the terrible spasms.
When they are severe they extort cries from patients who at other
times seem quite apathetic. It is stated by Macnamara that the natives
of Southern Bengal and other people of relatively loose fibre are much
less apt to be attacked by them than the natives of the upper country
or than Europeans. It may be debated whether their immediate cause is
a reflex irritation emanating from the gastro-intestinal mucous
membrane; or whether it is due to the rapid diminution of the supply
of blood to the nervous centres, or to the infarction of those centres
with thick and imperfectly oxygenated blood; or, finally, whether it
is occasioned by a diminished supply of blood, and that blood of bad
quality, to the muscles themselves. Probably all of these factors are
associated causes in producing the spasmodic phenomena of cholera. It
is well worthy of notice, however, that spasms, which are so frequent
in all infantile diseases, and especially in those affecting the
stomach and bowels, rarely attack children suffering from cholera.
This would seem to prove that the spasms in question are not reflex,
but either central and spinal, or else muscular--an inference which is
strengthened by their being tonic and not clonic. As stated, the
spasms, or cramps, frequently affect the limbs, but comparatively
seldom involve the muscles of the chest or abdomen, and those of the
face hardly ever. They are almost the only causes of pain in the
disease, which in not a few instances runs its whole course, even to a
fatal termination, without their occurrence.
As a rule, the abdomen is not so much retracted as might be expected
from the profuse discharges. Probably in some degree its form is
maintained by the constantly recurring accumulation of liquid in the
{741} gastro-intestinal cavity. In protracted cases, however, the
abdomen becomes sunken and hollowed. At all stages of the disease it
is somewhat sore under pressure, especially at the epigastrium, and it
generally has a doughy feel. As to the functions of the digestive
organs, they are completely suspended during a typical attack of the
disease. Not only are these organs incompetent to digest food, but
they cannot even retain it.
Throughout such an attack not only is sleep apt to be prevented by the
pain of the cramps and the frequent evacuations, but, as a rule, the
patient is wakeful, and yet, apart from the restlessness which
accompanies the paroxysms of pain, there is, on the whole, a tendency
to a placid quietness. Mental excitement and delirium are probably
unknown during the primary attack, but sometimes a degree of
somnolence or of apathetic tranquillity exists, which, however, is
quite distinct from coma. When the attack is prolonged, and especially
when it merges into a typhoid state, the eyes become inflamed by their
exposure to the air. The conjunctiva then grows blood-shot, and
occasionally the cornea is ulcerated.
MORBID ANATOMY AND PATHOLOGY.--The appearance after death of a person
who has died in the collapse of cholera is very characteristic. It
comprises a shrunken aspect of the whole body, its prevalent grayish
or leaden pallor contrasting with the livid hue of the abdomen and
back, the fingers and toes, the lips and eyelids, and ears; the eyes
are sunken deeply in their orbits; the nose is sharp and bent, the
temples are hollow, and the skin seems to cling tightly to the bones
beneath it. The connective tissue is very dry, and the muscles are
hard as well as dry, and, owing to the wasting of the softer parts,
stand prominently out. In consequence of the absence of moisture
decomposition takes place very slowly. Cadaveric rigidity is very
marked and persistent. A very notable phenomenon is the occurrence of
muscular contraction after death. It may be excited mechanically or
may occur spontaneously. A case is related (Eichhorst) in which three
hours after death the fibres of the biceps were observed to move
tremulously, and then the entire muscle contracted, causing flexion of
the forearm. Even the fingers performed movements like those made in
piano-playing. The lower jaw has also been observed to move, causing
the mouth to open and shut repeatedly. The late Sir Thomas Watson long
ago described this singular phenomenon as follows: "A quarter or half
an hour, or even longer, after the breathing had ceased, and all other
signs of animation had departed, slight, tremulous, spasmodic
twitchings and quiverings and vermicular motions of the muscles would
take place, and even distinct movements of the limbs, in consequence
of these spasms."[38] It was carefully studied by Barlow, from whose
narrative the following is taken: The patient was a strong man; the
course of his attack was rapid, and he suffered most cruelly from
cramps. "Within two minutes of his ceasing to breathe muscular
contractions began, becoming more and more numerous. The lower
extremities were first affected. Not only were the sartorius, rectus,
vasti, and other muscles thrown into violent spasmodic movements, but
the limbs were rotated forcibly and the toes were frequently bent. The
motions ceased and returned; they varied also: now one muscle moved,
now many. Quite {742} as remarkable were the movements of the arm: the
deltoid and biceps muscles were peculiarly influenced; occasionally
the forearm was flexed upon the arm--flexed completely, and when I
straightened it, which I did several times, its position was recovered
instantly. The fingers and thumbs were now and then contracted, and at
times the thumbs were separately moved. The fibres of the pectoral
muscles were often in full action; distinct bundles of them were seen
at intervals beneath the skin.... After I had taken leave of the body
the nurse was horrified by a movement of the lower jaw, which was
followed by others; and I thought for a moment that the man was alive.
The facial muscles became generally affected, and at length all was
still."[39] These muscular contractions succeed one another in a
regular order, beginning in one lower extremity and extending to the
other, then to the upper limbs, and finally to the face. Their degree
varies from a slight quivering to a powerful contraction, and their
duration from a minute or less to an hour and a quarter. Cases have
occurred in which the legs were so forcibly retracted that they could
with difficulty be straightened again. In one case, six hours after
death movements took place in one leg, and the hand was drawn across
the chest; in another, "the forearms were powerfully flexed, and the
hands, approximating, gave the attitude of praying to the body."[40]
Again, Mr. Ward reports: "I saw the eyes of my dead patient open and
move slowly in a downward direction. This was followed, a minute or
two subsequently, by the movement of the right arm (previously lying
by the side) across the chest." In the same paper Barlow says: "Mr.
Lawrence mentioned to me that a gentleman who died in 1832 of rapid
cholera was turned after death completely on the side by a strange and
forcible combination of muscular contractions."[41] These muscular
phenomena after death form an interesting feature in the history of
cholera, but they are by no means peculiar to that disease. They have
been observed in other diseases, and especially in yellow fever--an
affection in which the pathological condition is quite unlike that of
cholera. In both diseases they have been manifested in robust persons
and when the course of the fatal attack was both rapid and severe.
Thus, Dr. Dowler of New Orleans not only found that they could be
developed in such cases of yellow fever by striking the muscles, but
he observed their spontaneous occurrence in several, of which the
following is a remarkable example: "Not long after the cessation of
the respiration the left hand was carried by a regular motion to the
throat, and then to the crown of the head; the right arm followed the
same route on the right side; the left arm was then carried back to
the throat, and thence to the breast, reversing all its original
motions, and finally the right hand and arm did exactly the same."[42]
In 1860, Drasche alleged that not unusually the skin covering the
contracting muscles became reddish, while the local temperature rose
1/2°, and that as soon as the contractions ceased the temperature fell
below the normal and cadaveric rigidity set in. According to the same
observer, analogous contractions affect the unstriped muscular fibres,
in those of the skin producing a projection of the papillæ, and in the
genital organs a discharge of semen. This phenomenon is said to have
occurred an hour and a half after death.
[Footnote 38: _Lectures_, Am. ed. of 1872.]
[Footnote 39: _London Med. Gaz._, Nov., 1849, p. 798.]
[Footnote 40: _Ibid._, Jan., 1850, p. 185.]
[Footnote 41: _Ibid._, pp. 185, 186.]
[Footnote 42: _Experimental Researches_, 1846.]
{743} On opening the abdominal cavity of persons who have died in the
collapse of cholera one is struck by the general pink or rose tint of
the peritoneal coat of the intestines. It is produced by a repletion
of the minute branches of the portal venous system. Sometimes the
color is rendered very dark by the pitchy blood contained in the
veins. The surface of the peritoneum, like all the tissues, is
singularly dry, and often has a soapy or sticky feel, caused by a
layer of albuminous matter, which forms a lather when rubbed between
the fingers, and causes the intestinal folds to adhere to one another.
If death takes place during the stage of reaction, these appearances
are less distinct, and the intestines, which in collapse are usually
retracted, are then somewhat distended.
The stomach generally contains a thin, partially transparent liquid of
a greenish or grayish color, and occasionally reddish, holding in
suspension portions of coagulated mucus and an unctuous substance of
an albuminous nature, which adheres to the walls of the cavity. Fatty
globules may be observed floating in the liquid, which under the
microscope reveals epithelial débris, granular corpuscles, and
fragments of gastric glands. Under heat and nitric acid coagulation of
the liquid occurs, and on chemical examination it is found to contain
urea. The gastric mucous membrane is of a dark violet or pale pink
color, according to the stage of the disease; its follicles are
enlarged, and patches of superficial abrasion may be observed on it.