is, in the majority of cases, partially filled with liquid which has
the aspect of turbid serum, more or less mixed with the previous
contents of the bowel if death has taken place very rapidly, but
otherwise it is almost colorless. On the whole, however, it is less
pale and watery than the stools. It contains, like these discharges,
more or less epithelial flocculi, and generally more than were
observed during life in the dejections. The mucus scraped from the
lining membrane of the intestine and mixed with water renders it
turbid with epithelial débris. The same mucus examined microscopically
contains fragments, larger or smaller, of epithelium. These conditions
are said to predominate in the large intestine. Indeed, the proportion
of liquid increases from above downward. Hence in the more prolonged
cases the contents of the bowel at its upper part are less liquid and
are darker in color. There is, indeed, a striking contrast between the
appearance of the intestine in cases which have terminated in collapse
and its aspect in persons who have died during the stage of reaction.
It has been clearly presented by Dr. Sutton.[43] When death took place
in "the cold stage the mucous membrane was unusually pale in three
cases; in two it was healthy-looking; in other two it was pale
throughout, excepting that one or two of Peyer's patches were
congested; and in the remaining three there was more or less
congestion of the mucous membrane. When the mucous membrane was pale
throughout the entire intestine, the valvulæ conniventes looked
swollen and oedematous, and the color of the membrane was dead white.
The solitary glands were very distinct and prominent. Those of the
duodenum were remarkably so. In cases of imperfect reaction the mucous
membrane of the intestine was usually found very much congested and
ecchymosed. The congested portions were sometimes {744} granular, and
apparently denuded of epithelium. The mucous surface had often a dark
port-wine color, due to the extravasated blood and the hyperæmia, and
here and there the surface was covered with a dirty gray membranous
substance, likened to a diphtheritic deposit. I have, however, seen no
decided false membrane, such as could be peeled off, as in diphtheria.
The surface was also occasionally bile-stained, and the
greenish-yellow color of the bile and the deep red color of the
congested surface presented a very striking appearance. The solitary
glands were very prominent, and in some cases apparently enlarged."
The general paleness of the intestinal mucous membrane in the stage of
collapse, and its congestive redness whenever the signs of reaction
have existed before death, have a very important bearing upon the
pathology of this disease, for they demonstrate conclusively that the
gastro-intestinal evacuations in cholera have no relation whatever to
inflammation. On the other hand, they render it altogether probable
that the serous flux is in the nature of a sweat, an intestinal
ephidrosis.
[Footnote 43: _London Hosp. Clin. Lect. and Reports_, iv. 497.]
The nature of the exfoliation found in the intestinal canal has been
the subject of much discussion. As long ago as the first American
epidemic of cholera (1832-35) Dr. W. E. Horner, Professor of Anatomy
in the University of Pennsylvania, described an exfoliation of the
epithelial lining of the alimentary canal, whereby the extremities of
the venous system of the part are denuded, as being characteristic of
cholera alone. In 1849, Dr. Samuel Jackson, Professor of the
Institutes of Medicine, and Dr. John Neill, Demonstrator of Anatomy in
the University, in conjunction with Dr. William Pepper and Dr. Paul B.
Goddard, presented a report to the College of Physicians of
Philadelphia, in which they, too, showed that the "epithelial layer of
the intestinal mucous membrane was either entirely removed or was
detached, adhering loosely." This important fact--the most important,
perhaps, in the mechanism of cholera--was confirmed seventeen years
later by the eminent pathologist Dr. Lionel S. Beale,[44] who, when
referring to "the remarkable characters of the matter discharged from
the intestinal tube, and to the fact that the small intestines almost
always contain a considerable quantity of pale almost colorless
gruel-, rice-, or cream-like matter," added: "This has been proved to
consist almost entirely of columnar epithelium, and in very many cases
large flakes can be found, consisting of several uninjured epithelial
sheaths of the villi.... In bad cases it is probable that almost every
villus, from the pylorus to the ilio-cæcal valve, has been stripped of
its epithelial coating during life.... These important organs, the
villi, are, in a very bad case, all or nearly all left bare, and a
very essential part of what constitutes the absorbing apparatus is
completely destroyed.... It is probable that the extent of this
process of denudation determines the severity or mildness of the
attack.... It seems probable also that the epithelium may become
detached in consequence of the almost complete cessation of the
circulation in the capillaries beneath, but the death of the cells may
occur in consequence of their being exposed to the influence of
certain matters in the intestine or in the blood, in which case they
would simply fall off."
[Footnote 44: _Med. Times and Gazette_, Aug., 1866, p. 109.]
In this connection, and as complementary of the statements now made,
should be considered the further description by the same author--viz.:
{745} "Remarkable changes have occurred in the smaller vessels,
especially in the capillaries and small veins of the villi and
submucous tissue. The blood-corpuscles appear to have in a great
measure been destroyed in the smaller vessels, and in their place are
seen clots containing blood-coloring matter, minute granules, and
small masses of germinal matter evidently undergoing active
multiplication. Some of the arteries are contracted, but here and
there small clots destitute of blood-corpuscles may be seen at
intervals." Hence, the gastro-intestinal lesions in cholera, according
to their extent and degree, they remove the natural obstacles to
exhalation in the mucous membrane, and also, and in the same degree,
prevent the absorption of the contents of the alimentary canal. It
must not, however, be forgotten that this lesion is not altogether
peculiar to the intestinal mucous membrane. Dr. Beale long ago called
attention to the fact that in this disease there seems to be a
tendency to the removal of epithelium from the surface of all soft,
moist mucous membranes, but not from the follicles of the glands. The
first statement appears to be explicable by the shrinkage of all the
mucous membranes during cholera collapse, for by this merely
mechanical agency the inelastic epithelium must necessarily become
detached. As to the second statement, the remark may be made that the
whole follicular structure furnished with columnar epithelium is an
absorbing and not an eliminating apparatus, and that, since its
functional activity is from the beginning of the disease diminished by
an inadequate blood-supply, it can have but a small and indirect share
in generating the phenomena of the disease.
In 1884, Dr. Koch, during his investigations of cholera in India,
found bacilli in the bowel which he believed to be peculiar to the
disease, and which presented the following characters: they were not
straight, like other bacilli, but curved or comma-shaped; they
proliferated rapidly and displayed very active movements. Bodies of
persons who died of various other diseases did not present them,
although abounding in different bacteria. The bacilli were not found,
or only exceptionally, in the stomach, but abundantly in the
intestine, and most so in the diarrhoeal discharges that occurred at
the height of the disease. As soon as the stools began to be fecal the
specific bacilli disappeared from them. After death at the height of
the disease they were most abundant in the intestinal contents, and
especially in the lower part of the small intestine. When death took
place at a later period none of them might be detected in the liquids
in the bowel, but they would still be present, in considerable
numbers, in the tubular glands. They were not found at all in cases
fatal from some sequela of the disease.[45]
[Footnote 45: _Times and Gaz._, Mar., 1884, p. 398.]
Other abdominal lesions in cholera possess a very subordinate
importance. The isolated and the agminated glands are both prominent,
chiefly because they are swollen by the liquid imbibed from the bowel.
A whitish substance which they sometimes contain may perhaps be the
albumen or fat which they have taken from the intestinal liquid. A
very similar condition of the mesenteric glands is probably due to a
like cause. The liver is pale and flaccid when death takes place in
collapse, and it is also described as presenting a "dirty grayish-red,
homogeneous appearance, and indistinctness of the lobular structure,
as if some glutinous matter had been poured throughout the tissues of
the organ" {746} (Sutton). This appearance would seem to be due to the
total suspension of the blood-supply through the portal vein.
At all stages of the disease the gall-bladder is usually found full of
bile, which is apt to be dark during the collapse and more watery
after reaction has commenced.
The spleen is small, pale, and, as a rule, firm, but occasionally it
is soft.
The kidneys present no marked changes when death has taken place early
in the attack, or at most only exhibit a lighter color than usual of
the cortical substance and a darker one of the pyramids. They show
that the arteries are comparatively empty and that the veins are
congested. Similarly contrasted appearances are met after death from
obstructive disease of the heart and other causes that produce
obstruction of the venæ cavæ. In the tubules, later on, fatty
degeneration of the epithelium has been observed, and some cylindrical
casts. These alterations, especially of the tubules, are most marked
when death occurs in the stage of reaction, and are then apt to be
accompanied by more or less hemorrhagic transudation. The urinary
bladder is always contracted after death in collapse; after febrile
reaction its mucous membrane may be more or less coated with false
membrane.
The brain and the spinal marrow offer nothing peculiar; their venous
systems are everywhere more or less engorged, and sometimes effused
blood has been found in the spinal canal.
In the state of the respiratory organs the most important facts are
that in algid cholera the lungs are always more or less collapsed,
"shrunk and small, and lying back in the chest, toward the spine," and
that, so far from being congested, they are (with the exception of a
small portion of their posterior part rendered dense by hypostasis)
singularly bloodless, dry, and tough. As might be inferred from these
conditions, they are also lighter in weight than natural. To Dr.
Parkes belongs the credit of having first described this very
important fact in the morbid anatomy of cholera, as follows: "In
fourteen cases the lungs were completely collapsed, appearing in some
cases like the lungs of a foetus. In three cases they were
considerably, in eight slightly, collapsed, and in the remaining
fourteen cases the collapse was in some altogether, and in some
partially, prevented by old adhesions."[46] So Dr. Sutton found that
the average weight of the two lungs during collapse was about twenty
ounces, and after reaction--that is, after the passage of the blood
into the pulmonary artery had become completely re-established--about
forty-five ounces. In the latter condition also the lungs presented
the usual signs of congestion of those organs, being dark-red
throughout or in portions only. Sometimes also they contained masses
or nodules of apparent hepatization, and of these some may have
undergone partial softening.
[Footnote 46: _Med. Times_, 1848, p. 378.]
In absolute conformity with the condition of the lungs that has been
described is that of the heart. If the lungs are bloodless, it follows
necessarily that the left side of the heart must be empty, and almost
as necessarily that the right side of the heart must be distended with
blood. All careful investigators of the subject agree that such is the
condition of the heart when death takes place in cholera during the
stage of {747} asphyxia. All report that the pulmonary artery is
either empty or that it contains a small quantity of dark and usually
of thick blood; that the right side of the heart and the coronary
veins are distended with blood of the same description, while numerous
ecchymoses exist along the course of the coronary veins; that the venæ
cavæ are filled with half-coagulated blood of a tarry aspect; and that
even the femoral and splenic veins contain similar blood. On the other
hand, the left ventricle of the heart is usually contracted, and
contains a very little semi-fluid blood, with perhaps a small and pale
clot. This engorged condition of the right cavities and emptiness of
the left cavities of the heart diminish very slowly during the passage
from collapse to reaction, during which time the pulmonary
blood-vessels are being gradually replenished. Besides the thick and
tarry aspect of the blood above described, it has been observed that
when the blood is withdrawn by means of a pipette, its globules
rapidly subside and are surmounted by a transparent serum, and that
such blood may remain for a long time uncoagulated. The red corpuscles
are said to be pale and viscous, but not adhesive, and the white
corpuscles abnormally numerous and easily crushed. In the free
intervals are observed "very pale little objects, slightly elongated
and constricted in their middle," which multiplied in blood kept for
one or two days at a temperature of 38° C. (100.4° F.).[47] If death
does not take place until reaction is far advanced or has merged into
a febrile condition, the left ventricle is usually found not
contracted, and it contains a quantity of blood. The term "usually" is
employed to show that even to this rule there are some exceptions, and
that, as in all other diseases, the issue does not depend absolutely
and exclusively upon a definite degree of any anatomical lesion, but
upon the aggregate condition of all the functions upon which life
depends. The pericardium, like the pleura and the peritoneum, may be
covered with a saponaceous film which is albuminous.
[Footnote 47: _Rapport sur le Cholera d'Égypte en 1883_, par M. le Dr.
Strauss, etc.]
* * * * *
In looking now over the field that has been traversed in the foregoing
pages, and searching for some link that will unite in a consistent
whole the causes, symptoms, and lesions of cholera, it is evident that
only one factor can possibly be so described. That factor is the
gastro-intestinal flux. This it is that produces the vomiting and the
purging; that prostrates the patient and wastes away in a few hours
the fullest and the firmest form; that chills the limbs and afterward
the trunk; that thickens the blood so that the capillary vessels can
no longer convey it, and that spreads a cyanotic shadow over the whole
surface of the body; that cuts off the supply of blood from the lungs
and heart; that paralyzes the nervous system, ganglionic as well as
cerebro-spinal; that obstructs the kidneys and arrests their
secretion; and that, acting through the several links of this
pathological chain, becomes the cause of death. But the question still
recurs, What is the cause of the gastro-intestinal flux? To this also,
in the light of observation, it is possible to give only one answer.
It is a specific poison which originates in Hindostan, and, being
taken into the stomach and bowels, not only produces in the individual
the symptoms and lesions of cholera, but is capable of multiplying
itself and rendering infectious the discharges from the stomach and
bowels of the subjects of the disease, so that it may be transmitted
from {748} one person to another round the whole circumference of the
globe. Regarding the form and nature of that poison little or nothing
is definitely established, beyond what has already been stated as the
result of Koch's observations. As far as they go, they harmonize with
a long-prevalent opinion that the cholera poison consists of certain
microscopic germs, which, on being received into the bowels, propagate
their kind and destroy the epithelium. It is believed by some that
these bodies are products of the rice-plant on the banks of the
Ganges, and that, having once originated the disease, the germs
contained in the discharges become mixed with water or are borne upon
the wind, and enter the system of new victims, who, in their turn,
disseminate the plague. This theory will be further considered below.
Another view, that of B. W. Richardson, is that, "as pus undergoes
changes which convert it into a septic poison, so the excreted matter
from the alimentary canal is equally capable, under peculiar
conditions of oxidation, of producing an alkaloidal organic poison,
which, soluble in water, but admitting of deposit on desiccation,"
becomes the agent for disseminating the disease. In these theories a
false datum and a hypothesis are offered us in place of the fact which
we seek. The cryptogamous nature of the essential cause of the disease
has no positive proof, but only the probability of coincidence in its
favor. There is no proof, because one after another organic form has
been alleged to be the essential generator of the disease, and each
has been proved to be either not peculiar to cholera or has been shown
to be present in other diseases than cholera.
At the present time (1884) it is the fashion to trace every disease to
specific bacteria or analogous organisms. But it may be that the
occurrence of cholera only furnishes the occasion for the development
of these organisms, just as a certain temperature, hygrometric
condition, and deficient light and air will cause mould to form on
bread and other organic substances. The judgment pronounced by Dr.
Beale in this question as long ago as 1866 appears now, as it did
then, to approach the truth upon this point: "There is no good reason
for supposing that the bacteria in such numbers in the alimentary
canal in cholera have anything to do with this disease or with the
falling off of epithelium from the intestinal and other mucous
membranes. Bacteria are developed in organic matter which is not
traversed and protected by the normal fluids of the body, and they
invade the cells and textures in cholera after those cells and
textures have undergone serious prior changes, just as they would
invade textures removed from the body altogether. Nor would it be in
accordance with known facts to infer that cholera was due to the
invasion of some peculiar form or species of bacterium."[48]
[Footnote 48: _Times and Gazette_, Aug., 1866, p. 167.]
We repeat, then, that while nothing can be simpler than the mechanism
of cholera viewed as a gastro-intestinal hyperidrosis, nothing is more
mysterious than the mechanism of the primary cause which gives rise to
it. That its real nature has been correctly described is rendered all
the more probable by the fact, presently to be insisted upon, that
sporadic cholera morbus, which is always the consequence of a direct
irritation of the gastro-intestinal mucous membrane, is often with
difficulty distinguishable from Asiatic cholera, which, indeed,
differs from the former {749} disease chiefly by the intensity of its
cause as measured by the gravity of its symptoms and by the nature of
the special agent that produces it.
The above views regarding the essential cause of cholera were
substantially indited before the Egyptian epidemic of 1883, but they
are in accord with the more definite conclusions arrived at by the
German and French commissions on the subject. Before their reports
appeared, however, a communication was made by Dr. Kartulis of the
Greek hospital in Alexandria, setting forth that the drinking-water
and the stools and blood of the cholera patients contained, the first
a mass of micro-organisms, and the others bacteria and micrococci,
which, however, presented no distinctive characters.[49] The German
report was prepared by Dr. Koch, the French by Dr. Strauss.[50] The
former, alluding to the enormous quantity of micro-organisms found in
the contents of the bowels and in the stools, did not perceive any
connection between them and the phenomena of the disease. On the other
hand, he did assign this relation to a species of bacterium found in
the walls of the intestine, and which he compared to the bacilli of
glanders. They were lodged in great quantities within the intestinal
glands and behind their epithelium, as well as upon the surface of the
villi and within them, and sometimes even in the muscular coat. They
were most numerous at the lower end of the small intestine. Dr. Koch
concluded that although these bacilli, beyond doubt, are in some
manner associated with the development of cholera, they are by no
means shown to be its cause, and may indeed be themselves the product
of the morbid conditions belonging to cholera. All his attempts at
that time to develop cholera in animals by inoculating them with the
organisms gave only negative results. The conclusions of Dr. Strauss
were in entire conformity with those of Dr. Koch, but involved an
additional and very important statement--viz. that the shorter and the
more violent were the fatal attacks of cholera the fewer were the
bacteria found in the intestine. It is evident that this fact is the
very opposite of what should have been found had bacteria been
essential in the causation of cholera. The more recent investigations
conducted in Calcutta by Dr. Koch, which have already been cited, led
him, however, to attribute to bacilli of a specific form the absolute
origination of the disease. He poses the question in the following
manner: Either these "comma bacilli" are a product of the cholera
process, or "the disease only arises when these specific organisms
have found their way into the bowel." The former alternative he
rejects, because, in his judgment, it assumes that the bodies in
question must be pre-existent in every person who becomes affected
with the disease--a hypothesis which he rejects, because they have
never been found except in cholera. He therefore concludes that they
are the cause of cholera. He points out that their first appearance
coincides with the commencement of the disease, that they increase
with it, and that they disappear with its decline.[51] The statement
of Strauss quoted above does not, however, appear to harmonize with
this conclusion, since the bacteria are said by him to have been
fewest in the more violent and fatal attacks of the disease. Another
of Dr. Koch's remarks is also open to criticism. After showing how
rapidly the cholera bacteria multiply when kept moist, he states that
they die after drying more quickly than almost any other form of
bacteria. "As {750} a rule, even after three hours' drying every
vestige of life has disappeared." It is evident that this statement is
not in harmony with the numerous facts, several of which have been
cited, that cholera fomites have preserved their infectious qualities
after several weeks. Dr. Koch endeavored to produce in animals,
artificially, with these bacteria, a disease analogous to cholera, but
without success; and he adds, "If any species of animal whatever could
take the cholera, it would surely have been observed in Bengal, but
all inquiries directed to this point met with a negative result." Dr.
Vincent Edwards, who, however, is of opinion that the cholera poison
is "not an organism, but of the nature of a chemical compound of
comparatively unstable nature," reports that he produced fatal cholera
in pigs by giving them the dejections of cholera patients.[52] But the
_Times and Gazette_ inclines to question that the pigs employed in Dr.
Edwards' experiments were affected with true cholera.
[Footnote 49: _Medical News_, xliii. 377.]
[Footnote 50: _Archives gén._, Dec., 1883, pp. 713, 722.]
[Footnote 51: _Times and Gaz._, Mar., 1884, p. 398.]
[Footnote 52: _Notes on the Poison contained in Choleraic Atomic
Discharges._]