A system of practical medicine. By American authors. Vol. 1

by Unknown

³⁷ Compare London Hosp. Reports, iii. 457.

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.

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 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 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 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.