Part 117

Between the above, which is the mildest type of epidemic cholera, and the fully-developed disease must be placed that grade of the disease which is more appropriately called cholerine, comprising cases in which vomiting occurs as well as purging, with increased debility and a tendency, more or less decided, to collapse. The matters vomited, after the rejection of undigested food, are at first bilious, but they gradually become less and less so the longer the attack lasts, and, together with the stools, assume the appearance of rice-water--i.e. they consist of a pale grayish, semi-transparent liquid in which white flocculi are suspended. Its reaction is alkaline, and it has a faint albuminous or spermatic smell. Along with these symptoms the other effects of serous depletion arise--debility with pallor, duskiness, coldness, profuse perspiration, and a sodden condition of the skin, while the secretion of urine is diminished, {733} and all the symptoms that belong to the first stage of cholera are present in an aggravated degree.

A curious feature of this disease is that sometimes the onset even of its graver forms is not attended by any evacuations, although the stomach and intestine may be filled with liquid. It is perhaps chiefly in such cases that the patient experiences a rapid depression of all the mental and physical faculties. The senses are irritable, the head aches and is confused, there is a disinclination to sleep, the limbs totter under the weight of the body, the pulse is frequent and feeble, occasionally fainting takes place; the skin is cool and bedewed with perspiration. In other cases, again, the attack is sudden; the patient is smitten with an unaccountable feebleness, speedily followed by profuse vomiting and purging and general spasms, and dies without any suspension of the symptoms or any tendency to reaction.

But more usually the attack begins with the diarrhoea and vomiting described above, which then assume, more or less rapidly, a high degree of violence, expressed by their frequency and excess. The stools with proportionate rapidity lose all their fecal qualities and acquire the rice-water appearance before mentioned, and the liquid rejected by vomiting in all respects resembles them. It is poured forth less by an ordinary act of vomiting than by gushes, as if it overflowed from the throat and mouth; and it often escapes from the stomach and the bowels at the same instant. Such profuse evacuations necessarily occasion an urgent thirst which cannot be satisfied, for liquids are thrown up immediately on being swallowed. Sometimes a distressing hiccough accompanies these symptoms. It is indeed only one of the many spasms which may affect the muscular system. They generally begin in the fingers and toes, which become bent and stiff; they seize upon the muscles of the calves of the legs, and render the muscular wall of the abdomen as hard as a board. The pain they produce is extremely severe, and unless the patient is exceedingly prostrated he endeavors to assuage it by a constant change of position.

At this period the debility is very great, and progressively increases, and the patient is unable to rise, or even to move at all except under the stimulus of the painful spasms. The features are shrunken; the nose is sharp and pallid, and bent to one side; the dusky, lack-lustre, and sunken eyes, the thin lips, the hollow cheeks, and the contracted muscles that stand out like cords under the tense and clammy skin, present a physiognomy that belongs to no other disease in the same degree. The hands and feet grow cold, and steadily the coldness creeps upward toward the trunk; the temperature falls to 94° or 95° F.; the feeble and even flickering pulse ranges from 100 to 120. The integuments of the limbs are shrivelled and damp, and look as if they had been macerated in water; and if a fold of the skin is pinched up it subsides very slowly indeed. The eyes grow dull and dry, the tongue has a pasty or sticky feel, and the urine is almost suppressed. If any of this excretion can be obtained for examination, it is found to contain both albumen and sugar. As the attack advances the patient falls into a dull, listless, and motionless state, which may be mistaken for insensibility or even unconsciousness but is really due to exhaustion of all the faculties of mind and body. He may express no interest in anything, and hardly notice the {734} attention or the distress of his friends, yet he will generally give clear, although languid, answers to questions, and fall again into an inert and unobservant state.

As these symptoms continue and the fluids of the body decrease, the blood accumulates and stagnates in the veins, giving to the hands and feet, the nose and lips and other features, to the neck, and even to the entire surface of the body, a bluish, leaden, or violet tint, precisely like that of cyanotic children. The pulse, that was already weak and thready, is no longer perceptible; the carotids even and the impulse of the heart cease to be felt, and the second sound of the latter becomes inaudible. The skin is everywhere cold; the hands, feet, and face are sometimes of an icy coldness, and yet the patients seldom perceive that they are so; indeed, complaint is more apt to be made of suffering from internal heat. Even the breath as it issues from the nostrils feels cold. The blood no longer circulates, and the heart seems still. If a vein is opened a few drops of black and viscid blood will trickle from the wound, which if it coagulates, yields but little serum, and in place of a firm clot only a diffluent jelly. The voice has sunk to a mere whisper or is quite extinct. The features assume a distorted and frightful expression; the temples and cheeks are hollowed; the nose is twisted and pointed, and the nostrils are obstructed with dry and powdery crusts; the eyes are also dry, dull, and sunken behind the half-closed and purple lids; the conjunctiva is no longer moistened by its secretion and becomes bloodshot; the temperature in the mouth may fall to 79° or 80° F.; a viscid exhalation bedews the icy and marbled skin; and the whole body is so shrunken from its natural proportions as to lose all the marks by which its identity has been recognized. From this pulseless, exhausted, cold, and cyanotic condition there can be but one step to death. It generally comes on gradually, the patient sinking into the state of apparent insensibility before mentioned; on the other hand, he may expire suddenly on attempting to make some unusual effort.

At any period in the progress of cholera, except that of complete asphyxia, the contest between the system and the disease may be decided in favor of the former. If this occurs before profuse evacuations have taken place or blueness of the skin appeared, the recovery may be gradual and present no special phenomena. The pulse regains by degrees its natural force; the skin grows warm again, first upon the trunk and afterward upon the extremities; the breathing becomes easy, and, the diarrhoea having already ceased, convalescence is established. But in proportion to the severity of the symptoms, the intensity and duration of the cold stage, the cramps, and the evacuations, will there be a tendency to febrile reaction, with more or less passive congestion of the internal organs, and therefore a slower return to health. If the attack has been very severe, and particularly if the algid stage has been prolonged, fever of a low type is apt to occur, and indeed may terminate fatally. This fever presents all the characters of the typhoid state, and is marked by dryness of the tongue, a brown crust upon the teeth and gums, jerking of the tendons, delirium, and coma. These symptoms are partly evidences of exhaustion, of inability of the system to resume its normal action, and perhaps also they denote the retention of the effete products of nutrition in the blood; but sometimes they appear to be associated {735} with, and caused by, a local and latent inflammation of low grade, established usually in the lungs. Again, the nervous system seems to bear the brunt of the reactionary effort, and the patient is attacked by convulsions or perishes in an apoplectic fit. These phenomena appear to be due in most instances, if not in all, to renal obstruction, and, as it is supposed that their immediate cause is the retention of urea in the blood, they have received the title of uræmic. In other cases a wasting diarrhoea, due probably to the damaged state of the intestinal mucous membrane, is superadded to the already existing typhoid state. Occasionally the parotid glands become enlarged and painful, and sometimes a measly or roseolous eruption appears upon the skin.

It frequently happens that the convalescence from cholera is slow and irregular. The system seems to be shattered by the trial it has passed through; the nervous susceptibility is for a long time morbidly increased, or, what is still more usual, the digestive function is greatly impaired. The appetite is capricious and the digestion feeble. The mouth is pasty, the abdomen tympanitic, the bowels are irregular and alternately confined and relaxed. Finally, patients who leave the bed too soon or indulge prematurely in their ordinary diet are liable to a relapse, perhaps fatally, into the original disease. It has sometimes happened that such a relapse has taken place several days after an apparent restoration to perfect health.

COMPLICATIONS AND SEQUELÆ.--In a small proportion of cases, as above stated, cutaneous eruptions have been observed during the attack of cholera, or rather during its decline, for they coincide with the reaction or follow it, and may be regarded as indications of increasing vitality. They belong to the exanthematous class, and comprise roseola, erythema, urticaria, and rarely vesicular eruptions. But, instead of them, there may occur destructive tissue-lesions in the form of abscesses or ulcers. These affections are more usual on the limbs than on the trunk or face, but some of them may appear even in the mouth or fauces. Profuse sweats have been noticed elsewhere, and the important fact that they carry off large quantities of urea, which they deposit upon the skin. Diphtherial exudation has also been met with upon tender parts of the skin and in the fauces, as well as in the stomach and intestine. In some epidemics of cholera suppuration of the parotid gland is occasionally observed, while in others it may be entirely absent. Instances have been reported of double parotitis, and in several of them the termination of the attack was fatal. Still more rarely suppuration of the submaxillary or the cervical glands has been met with. Another sequela of cholera is a tetanic contraction of the flexor muscles of the limbs. Between the tenth and fifteenth days of convalescence the patient is attacked with a tearing, rending pain in the hands and forearms, the legs and feet, followed by tonic contraction of the flexor muscles of these parts. The sensibility is not impaired. The attack lasts for one or several days, and seems always to end in recovery (Guterbock).

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Some of the individual symptoms of cholera call for a more detailed notice than they have received in the foregoing epitome, in which the continuity of the narrative could not be interrupted by a description of variations depending upon the stage and grade of the disease.

{736} The first to be considered is the temperature. The animal temperature in cholera varies according to the part of the body at which it is taken more than in any other disease. In cases of average severity it rarely falls below 95° F. in the axilla. The temperature under the tongue does not furnish trustworthy indications. In the stage of asphyxia it seldom exceeds 87.8° F., and even in cases that recover it may fall to about 78.8° F. (Wunderlich). In the cold stage it is not uncommon for a difference of temperature to be noted of nearly ten degrees between the axilla and the rectum. In a female aged thirty-two the temperature in the axilla was 93° F., and that in the vagina 102.8° F. (Mackenzie). In other cases a vaginal temperature of 104° F., and even of 108.32° F., has been reached (Guterbock). Such high temperatures furnish an unfavorable prognosis. As Wunderlich has pointed out, during the algid stage temperatures taken in the mouth do not give an accurate idea of the general temperature; the rectal and vaginal temperatures are more nearly correct. The following are some results of thermometry in 74 cases of cholera: Lorain found the minimum rectal temperature in 1 case 93.2° F., in 2 cases 95°, and in 10 cases 96.8°. In 47 cases the normal temperature was preserved; in 27 it rose to 100.4°; in 15 cases to 102.2°; and in 1 to 104° F. Leubuscher gives the average temperature in the armpit 92.7° F.; under the tongue, 90.5°; upon the tongue, 81.5°, in the nostrils, 79.2°; and on the palm of the hand, 84° F. These numbers, however, only represent averages. It should be noted that the low temperature of the mouth and nostrils is caused not only by the evaporation from the surface of those cavities, but also by the relative coldness of the expired air, due to the partial suspension of the passage of blood through the lungs, and therefore to the heating of the air contained in them. According to Leubuscher also, the lowest temperature is found in the nostrils, and next under the tongue, and at the latter point it may vary from 79° F. to 90.5° F. In death by asphyxia the vaginal and rectal temperatures may rise to 104°-108° F. The axillary fluctuates less than the internal temperature. It is remarkable that during the algid stage the patients, at least before the temperature has reached its minimum, are not conscious of their coldness, but, on the contrary, complain of internal heat, precisely as happens in the congestive forms of periodical fever. When the febrile reaction assumes a typhoid type the temperature in many cases is normal or only slightly elevated, and it is of serious import if the temperature then sinks again below the normal grade (Wunderlich). On the whole, the maintenance of a uniform temperature, neither much above or below 90° F. in the axilla or under the tongue, may be regarded as favorable, yet recoveries have taken place even when the temperature at these points has fallen to 79° F. If the temperature of the parts just mentioned should rise rapidly to 104° F., it may be regarded as a very unfavorable sign.

The skin, as has elsewhere been described, is pallid, bluish, 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." 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." 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." 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." 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." 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.

{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.

The intestinal canal of those who die during the collapse of cholera 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. 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.

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, 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."

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.