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 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 gastro-intestinal cavity. In protracted cases, however, the abdomen becomes sunken and hollowed. At all stages of the disease it is somewhat sore under pressure, especially at the epigastrium, and it generally has a doughy feel. As to the functions of the digestive organs, they are completely suspended during a typical attack of the disease. Not only are these organs incompetent to digest food, but they cannot even retain it.
Throughout such an attack not only is sleep apt to be prevented by the pain of the cramps and the frequent evacuations, but, as a rule, the patient is wakeful, and yet, apart from the restlessness which accompanies the paroxysms of pain, there is, on the whole, a tendency to a placid quietness. Mental excitement and delirium are probably unknown during the primary attack, but sometimes a degree of somnolence or of apathetic tranquillity exists, which, however, is quite distinct from coma. When the attack is prolonged, and especially when it merges into a typhoid state, the eyes become inflamed by their exposure to the air. The conjunctiva then grows blood-shot, and occasionally the cornea is ulcerated.
MORBID ANATOMY AND PATHOLOGY.—The appearance after death of a person who has died in the collapse of cholera is very characteristic. It comprises a shrunken aspect of the whole body, its prevalent grayish or leaden pallor contrasting with the livid hue of the abdomen and back, the fingers and toes, the lips and eyelids, and ears; the eyes are sunken deeply in their orbits; the nose is sharp and bent, the temples are hollow, and the skin seems to cling tightly to the bones beneath it. The connective tissue is very dry, and the muscles are hard as well as dry, and, owing to the wasting of the softer parts, stand prominently out. In consequence of the absence of moisture decomposition takes place very slowly. Cadaveric rigidity is very marked and persistent. A very notable phenomenon is the occurrence of muscular contraction after death. It may be excited mechanically or may occur spontaneously. A case is related (Eichhorst) in which three hours after death the fibres of the biceps were observed to move tremulously, and then the entire muscle contracted, causing flexion of the forearm. Even the fingers performed movements like those made in piano-playing. The lower jaw has also been observed to move, causing the mouth to open and shut repeatedly. The late Sir Thomas Watson long ago described this singular phenomenon as follows: "A quarter or half an hour, or even longer, after the breathing had ceased, and all other signs of animation had departed, slight, tremulous, spasmodic twitchings and quiverings and vermicular motions of the muscles would take place, and even distinct movements of the limbs, in consequence of these spasms."38 It was carefully studied by Barlow, from whose narrative the following is taken: The patient was a strong man; the course of his attack was rapid, and he suffered most cruelly from cramps. "Within two minutes of his ceasing to breathe muscular contractions began, becoming more and more numerous. The lower extremities were first affected. Not only were the sartorius, rectus, vasti, and other muscles thrown into violent spasmodic movements, but the limbs were rotated forcibly and the toes were frequently bent. The motions ceased and returned; they varied also: now one muscle moved, now many. Quite as remarkable were the movements of the arm: the deltoid and biceps muscles were peculiarly influenced; occasionally the forearm was flexed upon the arm—flexed completely, and when I straightened it, which I did several times, its position was recovered instantly. The fingers and thumbs were now and then contracted, and at times the thumbs were separately moved. The fibres of the pectoral muscles were often in full action; distinct bundles of them were seen at intervals beneath the skin.... After I had taken leave of the body the nurse was horrified by a movement of the lower jaw, which was followed by others; and I thought for a moment that the man was alive. The facial muscles became generally affected, and at length all was still."39 These muscular contractions succeed one another in a regular order, beginning in one lower extremity and extending to the other, then to the upper limbs, and finally to the face. Their degree varies from a slight quivering to a powerful contraction, and their duration from a minute or less to an hour and a quarter. Cases have occurred in which the legs were so forcibly retracted that they could with difficulty be straightened again. In one case, six hours after death movements took place in one leg, and the hand was drawn across the chest; in another, "the forearms were powerfully flexed, and the hands, approximating, gave the attitude of praying to the body."40 Again, Mr. Ward reports: "I saw the eyes of my dead patient open and move slowly in a downward direction. This was followed, a minute or two subsequently, by the movement of the right arm (previously lying by the side) across the chest." In the same paper Barlow says: "Mr. Lawrence mentioned to me that a gentleman who died in 1832 of rapid cholera was turned after death completely on the side by a strange and forcible combination of muscular contractions."41 These muscular phenomena after death form an interesting feature in the history of cholera, but they are by no means peculiar to that disease. They have been observed in other diseases, and especially in yellow fever—an affection in which the pathological condition is quite unlike that of cholera. In both diseases they have been manifested in robust persons and when the course of the fatal attack was both rapid and severe. Thus, Dr. Dowler of New Orleans not only found that they could be developed in such cases of yellow fever by striking the muscles, but he observed their spontaneous occurrence in several, of which the following is a remarkable example: "Not long after the cessation of the respiration the left hand was carried by a regular motion to the throat, and then to the crown of the head; the right arm followed the same route on the right side; the left arm was then carried back to the throat, and thence to the breast, reversing all its original motions, and finally the right hand and arm did exactly the same."42 In 1860, Drasche alleged that not unusually the skin covering the contracting muscles became reddish, while the local temperature rose ½°, 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.
38 Lectures, Am. ed. of 1872.
39 London Med. Gaz., Nov., 1849, p. 798.
40 Ibid., Jan., 1850, p. 185.
41 Ibid., pp. 185, 186.
42 Experimental Researches, 1846.