characterized by violent abdominal pain, nausea, and sudden, violent,
and incessant vomiting, and by purging of a watery fluid containing
little albumen and bile; attended with spasms of the muscles of the
abdomen and extremities, a pinched and sunken countenance, pallor,
cyanosis, and coldness of the surface of the body; a feeble and rapid
pulse, oppressed respiration, and great restlessness; dryness of the
tongue, great thirst, and diminished or suppressed urinary secretion
and a state approaching collapse, which may rarely prove fatal, but is,
as a rule, followed by reaction.
HISTORY.--The term cholera has been in use since the time of
Hippocrates, but he confounded with it every disease which seemed to
him to come from acridity or corruption of humors, as colics and
meteorism with constipation.[1] He well described cholera morbus in
saying that "it is a disease which appears in summer, due to imprudence
in eating, at the same time as intermittent fever."[2] If Celsus be
correct in deriving the name from [Greek: cholê] "bile," and [Greek:
reô] "I flow," it is more applicable to the disease now under
consideration than to the Asiatic disease, as it is the bile which is
absent in the colorless rice-water discharges of Asiatic cholera.
Trallian and Ruysch, however, ascribe it to [Greek: cholêra] the
rain-gutter of a house.
[Footnote 1: _Append. au Traité du reg. les Maladies aigues_, 19, ii.
p. 495, ed. Littré.]
[Footnote 2: _Epidémies_, lib. v., ed. Littré, 71, p. 247.]
In the Old Testament mention is made of a disease resembling cholera
morbus.[3] Its true pathogeny was known to Galen, and it was accurately
described by Celsus,[4] and Aretæus[5] mentions the nature of the
discharges and its frequency among young people and children.
[Footnote 3: _Hist. Méd. des Maladies epidémiques_, Paris, 1825.]
[Footnote 4: Lib. iv. cap. 2.]
[Footnote 5: Lib. ii. cap. 5.]
The first mention of epidemics was in the sixteenth century. Various
epidemics in 1695, 1717, and 1718 in Germany were probably cholera
morbus. Forestus[6] reports seven observations from 1559 to 1565 of
attacks due to indigestible food or drastic medicines. F. Hoffman,[7]
{720} J. Frank,[8] and L. Rivière speak of the benignity of the disease
as contrasting it with its apparently dangerous symptoms.
[Footnote 6: _Opera Omnia_, Rothomagi, 1633, "De stomachi affectibus,"
lib. xxviii.]
[Footnote 7: _Medicina rationalis systemica_, t. iv. pt. 3, 1734.]
[Footnote 8: _Praxeos medicæ universæ præcepta_, Leipzig, 1826, p. 43.]
Sydenham's[9] description of the epidemics in England in 1669-72 is the
earliest account of the disease in modern literature, and it was he who
gave it the name cholera morbus.
[Footnote 9: Sydenham Soc. edition, vol. i. p. 163.]
NATURE.--There prevails at the present time a great diversity of
opinion in regard to its nature; the want of uniformity in the
appearances presented by post-mortem examinations may in some measure
account for this. The present state of our knowledge, derived both from
pathological anatomy and a study of the symptoms, will not warrant a
positive opinion in regard to it.
Niemeyer,[10] in common with most German and some French authors,
considers cholera morbus to be a variety of gastro-intestinal catarrh.
Leube[11] thinks it a variety of gastric catarrh with simultaneous
inflammation of the intestines and running a peculiar course. It is
certainly not identical with the specific Asiatic disease, although in
some cases the symptoms and morbid anatomy are exactly similar, and any
differentiation is impossible. By some it is believed that cholera
morbus is due to surviving germs implanted by previous epidemics of
Asiatic cholera.
[Footnote 10: _Pract. Med._, 1879, vol. i. p. 480.]
[Footnote 11: _Ziemssen's Cyclopædia_, New York, 1876, vol. vii. p.
146.]
The slight changes found in some fatal cases would lead to the belief
that the effect of the exciting cause is something more than a
mechanical irritation of the gastro-intestinal mucous membrane.
The sudden onset, rapid development of symptoms, and dangerous collapse
justify the theory that there must be some previous change in the
individual or some peculiar result of food-decomposition. The nervous
system may be so enfeebled by prolonged heat that an irritant quickly
destroys its equilibrium and brings about vaso-motor paralysis of the
intestinal vessels and abundant serum transudation. Or the irritation
may be specific, depending upon the development of poison germs in food
which has been subjected to heat influences. There is a close
relationship between cholera morbus and cholera infantum in their
etiology, symptoms, and pathology.
ETIOLOGY.--Predisposing Causes.--The disease is more common in the
tropics, but is not confined to any climate. In temperate latitudes it
is more likely to occur in July and August, when the variation of
temperature between day and night is great, although the other months
of summer and autumn are not entirely exempt. It is said to be more
frequent and fatal in Southern Europe than in the northern and
temperate climates. In periods immediately preceding and following
epidemics of Asiatic cholera many persons are attacked, although there
is great liability to errors in diagnosis at these times.
It occurs more frequently in youth and adolescence than in advanced
life, and males seem to be more liable to attacks than females, but
difference in occupation may assist in this predisposition. Persons
endowed with an extreme sensibility of the nervous system and who are
subject to frequent attacks of intestinal catarrh are much more liable
to the disease. The exhaustion of the nervous system by heat, which is
the {721} probable explanation of the phenomena of cholera infantum,
has no doubt much to do with the development of cholera morbus. Mental
anxiety or overwork in summer increases this nerve-exhaustion and
renders the termini of nerves and the centres very susceptible to
peculiar irritation.
Exciting Causes.--It is probable that the cause of most attacks is a
septic material generated in the fermentation and decomposition of
food. This poison acts as an irritant upon the gastric and intestinal
nerves and gives rise to excessive peristaltic movements and vomiting.
Hence the quality of the food is an element of more importance in the
causation than the mere quantity ingested; and herein may reside the
chief difference between cholera morbus and Asiatic cholera, the latter
being due to a specific, imported, or acclimated poison which
invariably produces the same specific form in those exposed to its
action.[12] Unripe fruits, partially cooked or decaying meats and
vegetables, shellfish and fish some time from the water, may produce
the disease in those predisposed to it. The intemperate use of
ice-water and other cold drinks after a full meal or when the body is
exhausted by heat and fatigue, exposure to showers at the close of a
hot day, or passing from a heated room into damp cellars and
outbuildings, are frequent exciting causes.
[Footnote 12: "Bias the pugilist, naturally a great eater, had a sudden
choleraic attack after having eaten of succulent food" (Hippocrates,
lib. v. p. 247, ed. Littré).]
At times there exists a certain condition of inactivity of the
digestive organs when the gastric juice is not secreted in sufficient
quantity, and perfectly sound food may undergo fermentation and set up
an attack.
The offensive exhalation from a filthy alley which had been recently
cleaned was the exciting cause of a fatal epidemic in a London
school,[13] and Levier recounts an epidemic caused by the
drinking-water during the winter in Berne.[14]
[Footnote 13: _Lond. Med. and Surg. Gaz._, 1829, iv. p. 375.]
[Footnote 14: _Schweiz. Zeitschr. f. Heilk._, iii., 1864, p. 140.]
Nervous disturbance from other diseases may act as a cause. Leube
reports a case of intermittent fever which was followed by an annual
attack of cholera morbus preceded by febrile symptoms.[15]
[Footnote 15: Leube, _Ziemssen_, 1876, vol. vii. p. 148.]
Malaria, sewer-gas, and sudden and powerful mental emotions are
credited with the causation of some attacks.
PATHOLOGICAL ANATOMY.--In a few cases an examination of the body has
revealed no phenomena sufficient to account for the symptoms, even when
they have been the most severe during life. In these cases either the
inflammation has not passed the first stage of development and the
resulting hyperæmia has disappeared after death, or the irritation of
the gastro-intestinal nerves has been sufficiently intense to cause
death before the alimentary tract has undergone any consequent
structural change.
Usually, however, there are evidences of a general gastro-intestinal
catarrh: the mucous membrane is congested throughout and denuded of
epithelium. The solitary glands are enlarged and Peyer's patches
swollen and prominent. The blood is thickened and dark in color, and
the serous membranes dry, sticky, and covered with desquamated
epithelium. Indeed, the appearances may be identical with those
observed in true Asiatic {722} cholera. The kidneys are congested,
sometimes enlarged, and the tubules devoid of epithelium. In protracted
cases the general muscular system shows a beginning of granular
degeneration.
In no case, however, can a positive diagnosis between Asiatic cholera
and cholera morbus be made from post-mortem appearances.
SYMPTOMS.--The attack is usually sudden in its onset, but in some cases
is preceded by nausea, thirst, loss of appetite, and slight general
distress for some hours, or it may come on in the course of some
gastro-intestinal disturbance. Frequently it is developed during sleep,
particularly after midnight, the patient being aroused by a feeling of
pressure at the pit of the stomach, which is followed by nausea and
violent and incessant vomiting with intense pain, the contents of the
stomach being ejected with great force.
The matters first vomited consist mainly of the food last eaten, little
altered or mixed with gastric mucus and tinged with bile. In a certain
proportion of cases the amount of bile is increased, although it is
difficult to judge of the relative proportion by the color and taste of
the vomited liquid. The general belief that the liver is implicated and
the bile secreted in morbid quantity rests upon conjecture alone, and
has no solid basis. After a time only yellow, brown, or greenish mucus,
with more or less bile, is ejected, and in protracted cases hiccough is
most distressing.
Following the vomiting or at the same time with it purging comes on,
and it is usually preceded by borborygmi. In rare cases there is no
vomiting, but only intense pain in the bowels and copious alvine
discharges from the beginning to the end of the attack. The stools in
the beginning are normal in color, but soon become pulpy or semi-fluid.
As they increase in quantity they become watery, consisting of
blood-serum with mucus, cast-off epithelium and pus-cells, and are
nearly odorless, and sometimes resemble very closely the discharges of
Asiatic cholera, but almost invariably retain the yellow or green color
of the bile. Colorless rice-water discharges are observed in undoubted
cases of cholera morbus outside of any epidemic influence. The
discharges are acrid and irritating, and the neighboring parts become
red and excoriated.
At the same time there is intense burning or tearing pain in the
abdomen, generally centring at the umbilicus, great thirst and painful
contractions of the muscles of the abdomen and extremities,
particularly in the calves of the legs, and of the flexors of the
thighs, forearms, fingers, and toes. In the beginning there may be
tympanites, but this soon disappears, and the abdomen becomes retracted
and the muscles drawn up into knots. The cramps usually come on after
each act of vomiting and purging, but they may appear spontaneously.
Abdominal tenderness is either wanting or slight. As the transudation
continues the thirst becomes intense, the tongue cold, dry, and coated,
and the tissues shrivelled from loss of water. The skin is cold,
clammy, or covered with a viscid sweat, and the surface of the body is
cyanosed, violet, or in the extremities it may have a marbled
appearance. The nose is pointed, the eyes dark and sunken, and there is
a general appearance of collapse.
The mind may be clear throughout, but in protracted cases there is
great nervous prostration. The patient becomes dull and lethargic,
passing into stupor after great restlessness and jactitation. The voice
is faint {723} or whispering, the breath cold, and the respiration
sighing. The pulse in the beginning may be depressed, but soon becomes
rapid and often imperceptible, and there is great præcordial anxiety.
As the blood becomes thickened the urine is highly colored, small in
quantity, and it may be suppressed. An examination shows traces of
albumen, casts and desquamated epithelium, and a decrease in the amount
of urea and salts. In the last stages there may be a slight rise in
temperature, but it has no definite course and it is usually absent. In
collapse the temperature of the surface of the body sinks below normal,
but the temperature of the interior may rise as high as 101° or 102°
F., as shown by the thermometer in the rectum or vagina.[16]
[Footnote 16: _London Hosp. Reports_, 1856, vol. iii. p. 457.]
PROGRESS AND TERMINATION.--But, fortunately, the course of the disease
tends toward recovery in the large majority of cases. The discharges
gradually decrease in quantity, the intervals are longer, the
appearance becomes more natural, and a profuse perspiration is followed
by a refreshing sleep. The surface becomes warmer, the pulse slower and
more full, and the skin regains its normal color.
If the case has been a severe one or if it occurs in a person much
enfeebled by disease, it pursues a different course. The discharges
become almost uninterrupted, and at last are passed involuntarily. The
cramps are almost continuous or are convulsive, the pulse grows rapidly
weaker and is finally lost, coma succeeds stupor, and death follows in
collapse.
The duration of the disease varies from a few hours to two or three
days; death has occurred within twelve hours.
Recovery is generally complete after a few hours; and this rapid return
to the normal condition shows that there have been no textural change
of organs. Sometimes great emaciation, irritability of the stomach, and
slight diarrhoea persist for a few days, or symptoms of a general
gastro-enteritis may supervene.
DIAGNOSIS.--In making the diagnosis of cholera morbus it is necessary
to carefully differentiate it from epidemic cholera and the effects
produced by irritant poisons, such as the metallic salts, poisonous
fungi, etc.
Occurring during an epidemic of Asiatic cholera, it is not possible to
make a diagnosis, as the symptoms of cholera morbus and of mild cases
of the Asiatic disease are identical. From severe cases it is to be
distinguished by the absence of antecedent diarrhoea, by the presence
of bile in the vomited matters, and by the color and fecal odor of the
stools. The nausea and abdominal pain are more marked, while the
dyspnoea, cyanosis, and shrunken condition of the skin are less marked.
The mortality of cholera morbus is slight, whilst about one-half of
those attacked with epidemic cholera die.
In irritant poisoning the vomiting follows quickly after the ingestion
of a meal or poisonous matter; it continues for some time before
purging begins, and is out of all proportion to the diarrhoea. The
vomited matters contain blood and mucus and are never serous in
character. Corrosive poisons may cause redness, charring, or ulceration
of the mouth and throat and a burning sensation in the stomach. The
pain over the stomach is more constant and severe, particularly in the
intervals of {724} vomiting, and there may be abdominal tenderness and
bloody discharges. The expression is more anxious and the pulse rapid
and weak.
Elaterium and tartar emetic will bring on vomiting and purging which
resemble the symptoms of cholera morbus. Choleriform attacks due to
uræmia simulate cholera morbus. The distinction is to be made by the
previous history--pain and purging being relatively less prominent in
uræmia--by the presence of albumen and casts in the urine, and by the
early tendency to coma.
Acute peritonitis, attended by copious vomiting and purging, has been
mistaken for cholera morbus, and the true nature of the affection only
revealed by the autopsy.
PROGNOSIS.--As a rule, cholera morbus occurring in persons otherwise
healthy ends favorably in a few hours. Cases of secondary fever, with
gastro-intestinal catarrh, may prolong the attack from a few days to
two weeks. Should treatment have no effect in lessening the vomiting
and purging, and should the evidences of heart-failure become apparent,
a fatal result may be feared. Death has occurred within twelve hours,
and the mortality is 3 per cent. of uncomplicated cases.[17]
[Footnote 17: Bartholow, _Pract. Med._, New York, 1880, p. 58.]
Cases occurring in the course of other diseases possess a special
gravity.
TREATMENT.--During the summer months, and particularly in August and
September, when the hot days are succeeded by cool nights, iced drinks
should be used in moderate quantities; the diet should be light,
nutritious, and easy of digestion. Unripe fruits and articles of food
liable to fermentative changes should not be indulged in.
Exposure to the night air, particularly after a full meal, should be
especially avoided, and the clothing ought to be so arranged that
additions may be made as night approaches. Slight attacks of
indigestion should not be neglected, and any irregularity of the bowels
must receive immediate attention.
The period when the physician is called upon to prescribe for an attack
of cholera morbus is usually when the stomach has been emptied of food
and the patient is vomiting incessantly, purging, and writhing in pain.
If vomiting has not occurred and violent epigastric pain is the only
symptom, the stomach should be emptied by an emetic of hot water and
mustard repeated until the overcharged organ is completely emptied.
Partially-digested food in a state of acid fermentation will thus be
got rid of, and the sufferings may be immediately but not wholly
relieved.
If spontaneous vomiting has expelled the food, and the matters vomited
are green and watery, while pain and frequent stools with muscular
cramps, heart feebleness, and threatening collapse are the symptoms
presented, the remedy par excellence is a hypodermic injection of
sulphate of morphia (gr. 1/8 to 1/3) with sulphate of atropia (gr.
1/120 to 1/100). If one dose is not followed by decided mitigation of
suffering, the injection is to be repeated in a half hour or an hour,
not giving above one grain of morphia in divided doses. At the same
time, and while waiting for the full effect of the narcotic, efforts
can be directed to giving ease to the muscular spasms and pain by brisk
friction with stimulating lotions or by mustard poultices to the
abdomen and extremities. The morphia will be the best and quickest
stimulant which can be used; it will therefore be useless in most cases
to administer brandy, camphor, chloroform, {725} or other remedies of
that sort. Waiting and giving nothing by the mouth is the wiser course.
In twenty minutes to half an hour the most perfect bien être succeeds
to the previous agony and exhaustion. In some cases the vomiting,
purging, and cramps cease more gradually, and six hours will pass
before the patient is at ease. The intense thirst is best treated by
the giving of cracked ice sparingly at first, more freely later.
Nothing substitutes morphia hypodermically with success, but in some
instances or when the stomach is not very irritable it may be necessary
to give medicine by the mouth. In this case chloroform (xv to xxx
drops), chlorodyne (x to xx drops), or spirits of camphor (v to x
drops) every quarter or half hour in ice-water may be directed.
Chloroform and camphor can be combined with the deodorized tincture of
opium in ten- to twenty-drop doses. Time is wasted in expecting relief
from remedies which are inevitably rejected as soon as taken; it is
only when the stomach is very tolerant that it is judicious to begin
with them.
The weakness of the heart's action must be combated by brandy or
whiskey, given by the mouth with pounded ice or administered
hypodermically. A considerable quantity of brandy or diluted alcohol
may be introduced by repeated injections beneath the skin. Iced
champagne may be tried with good effect. H. C. Wood quotes Hall[18] as
recommending hypodermic injections of chloral in the cold stage of
cholera. Five to eight grains in twenty minims of distilled water can
be thus given, and repeated at intervals of fifteen to twenty minutes
until some effect is perceived.
[Footnote 18: _Lancet_, May 2, 1874.]
If vomiting persists after the other symptoms--pain and muscular
spasms--are relieved, it is due to the intense gastric hyperæmia;
giving nothing which is not necessary is the wiser plan. Carbolic acid,
hydrocyanic acid, bismuth, bromide of sodium, or small doses of calomel
are remedies which meet the indication. Food should be withheld as long
as possible; then iced barley-water, followed by milk and lime-water in
very small quantities at short intervals, will test the power of the
stomach to retain and digest food.
{726}
INTESTINAL AFFECTIONS OF CHILDREN IN HOT WEATHER.
BY J. LEWIS SMITH, M.D.
Entero-Colitis.
The summer affections of the intestines in children are chiefly of a
diarrhoeal character. Diarrhoeal attacks, as is well known, are much
more frequent and severe in the summer months than in other portions of
the year. Moreover, the diarrhoea of the summer season occurs chiefly
among children under the age of two and a half years, and is much more
common and fatal in the cities than in the country. In the large cities
this malady has heretofore been the annually-recurring scourge of
infancy, but of late years its prevalence has been in some degree
diminished and its severity controlled by the establishment of health
boards and the enforcement of sanitary regulations. Still, it remains
an important disease in all our cities, and one that largely increases
the aggregate mortality. The truth of this statement is shown by the
statistics of deaths taken at random from the mortuary records of any
large city. Thus, in New York City during 1882 the deaths from
diarrhoea reported to the Health Board, tabulated in months, were as
follows:
Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec.
Under
five 34 32 50 50 72 231 1533 817 362 195 68 35
years.
Over
five 14 15 14 20 15 19 131 149 84 55 31 24
years.
Therefore, in 1882--and the statistics of other years correspond in
this particular--it is seen that nine times as many deaths of children
under the age of five years occurred from diarrhoea during the five
months from June 1st to October 31st as in the remaining seven months
of the year. It is also seen, in corroboration of the statement that
diarrhoea due to hot weather is chiefly a disease of infancy and early
childhood, that during these same five months, which embrace the summer
season, the number of deaths from diarrhoea under the age of five years
was seven and a half times greater than the number over that age. These
statistics agree with the general experience of physicians in city
practice. The summer diarrhoea would indeed be comparatively
unimportant were its death-rate as low in the first five years of life
as subsequently.