CHAPTER XXVII.

CHOLERAIC DIARRHEA AND CHOLERINE.

General Remarks.-An attack of Asiatic cholera being invariably the result of specific infection, it is but natural that the disease, like others belonging to the important class of infectious maladies, should give rise to symptoms differing widely in the degree of their severity. The special causative agent is the same in kind always. But it may find entrance into the system in large or small quantity, the result being, cæteris paribus, violent or mild manifestations. In addition, the usual modifying circumstances of acute disease, such as special predisposition or other imperfectly understood peculiarities, will of course influence to a great extent the gravity of the individual attack. Nevertheless the essential character of the clinical symptoms always remains the same. It is readily seen that in admitting the potent factor of personal predisposition, we must be prepared to allow that a small quantity of the causative agent may, in some cases, do as much mischief as a much larger quantity would create in certain others. For wherever the particular condition of the person infected favors a rapid multiplication of the virus within his body, it is clear that even an originally minute amount of the same may speedily assume very large proportions. But this does not in the least affect the general truth of the proposition made above concerning the usual relation between the quantity of specific poison introduced into the system and the severity of the symptoms that follow. For convenience of description, it is well to distinguish between three grades of infection from cholera, namely:-I. CHOLERAIC DIARRHOEA; II. CHOLERINE; III. PRONOUNCED

CHOLERA.

Before entering upon a separate examination of these three forms, the editor would again emphasize the fact that they constitute merely clinical types of one and the same disease. The division is, therefore, strictly speaking, an arbitrary one-a circumstance that, when lost sight of, is apt to lead to confusion.

Now Asiatic cholera in its mildest form may occasion so slight a departure from ordinary health that its existence, in many cases, will hardly be suspected, and indeed clinically it easily escapes recognition. In view of recent discoveries it may, perhaps, be possible to positively diagnosticate even the mildest cases by a careful employment of bacterioscopic methods, the practical details of which are fully explained in another chapter. But the ordinary methods of clinical examination are inadequate to accomplish this object. It is hardly necessary to emphasize the importance of this subject; for the history of cholera abounds in unfortunate illustrations.

of the fact that even the mildest attack of this disease may lead to the production in others of decidedly grave forms of the affection.

In other words, fatal infection may be quite innocently-because unwittingly spread by a person affected with painless choleraic diarrhoea. Contrast with this exceedingly mild manifestation of a specific infection the gravest types of fully-developed cholera, in which the poor sufferer is doomed, at the very outset, to a speedy death, and we may well stand appalled at a scourge that can assume the treacherous guise of such harmlessness, while its true nature seems ever ready to crop out in the shape of disastrous epidemics.

I. Choleraic Diarrhoea.-True choleraic diarrhoea-that is, diarrhoea dependent upon specific infection, is observed only during the prevalence of an epidemic. Scattered cases may of course occur before the nature of the affection has been recognized. But the epidemic character of cholera, after the disease has once been imported, cannot long remain hidden, except when desperate attempts at concealment or misinterpretation can be successfully carried out by the connivance of guilty authorities.

Choleraic diarrhoea, or cholera diarrhoea, has clinically no decidedly characteristic attributes. It occurs suddenly, as a rule, and the discharges are copious, and often quite thin and serous. They are generally a little bile-stained, and lose this attribute only when increasing frequency of purgation occurs. Ordinarily the passages do not exceed three or five in the twenty-four hours. Occasionally, however, their number is increased to ten or twelve. There is diminished appetite or complete anorexia. In addition, the patients commonly complain of thirst. dominal rumbling and gurgling noises are often present. But as a rule there is neither colic, griping, nor tenesmus.

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A slightly bitter taste, perhaps some nausea, general malaise, headache, tinnitus aurium, and occasionally cramps in the calves of the legs, include about all the subjective signs of this form of the disease. We find also a more or less coated tongue. So, too, a tendency to coldness in the extremities may be manifested, but actual lowering of the body temperature is rare, and generally indicative of further mischief. Slight febrile movements and sweating have been observed. A little later a sense of profound exhaustion, out of all proportion to the objective signs, may be experienced.

This diarrhoea may last from two days to two weeks, and even when it does not eventuate in the graver forms of the disease, it frequently shows a tendency to relapse during the whole course of an epidemic, and this too in individuals neither previously nor subsequently subject to such a disorder. (Lebert).

The specific nature of the diarrhoea is undoubted, as shown by ample experience. Nevertheless judicious treatment is potent for good, and a large proportion of cases make rapid and complete recoveries. It is in the neglected cases that choleraic diarrhoea so frequently becomes the precursor of the graver and more fatal forms of the disease.

The importance, therefore, of this type of cholera for the individual lies in the fact that it is premonitory of danger, though not in itself particularly dangerous. And the importance for the community results from the infectiousness of the dejections, and the possibility of a single case becoming the center of infection for a large number.

From the preceding it appears that, clinically, simple and choleraic

diarrhoea have so much in common that, as already stated, a differential diagnosis may be impossible in a given case. Nor are we helped over our difficulty by observing that babies, the very aged, and cachectic or weak persons in general, often succumb to this form of cholera from progressive exhaustion. For it is well known that protracted simple diarrhoea may result fatally in persons belonging to one of the classes just mentioned. But to repeat, if Koch's doctrine is true, then the detection by cultivation and otherwise of the cholera-bacillus would remove all doubt from a suspicious case.

II. Cholerine.-This form of Asiatic cholera differs but little clinically from ordinary cholera morbus. The arbitrary boundary line separating cholerine from choleraic diarrhoea is the occurrence of vomiting, in addition to the diarrhoea. The latter, however, need not always precede the vomiting. Indeed Griesinger states that simple diarrhoea is a precursor of cholerine only in a minority of cases a statement which is certainly at variance with the observations of many competent writers. Cholerine begins abruptly, as a rule. Several days of languor, and vague uneasiness, often associated with loss of appetite, may precede it. Usually at night, or toward early morning, the patient is suddenly attacked by purging. At first the dejections are colored with bile, but they quickly lose their bilious character, soon becoming more purely serous, and already showing a resemblance to the characteristic rice-water stools of pronounced cholera.

The dejections of cholerine are more copious and occur with greater frequency than those of choleraic diarrhoea. Purging once established, vomiting does not, as a rule, tarry long. At first only the contents of the stomach are ejected, then bitter and sour, and still later tasteless, watery fluid comes up. Marked debility with a tendency to collapse may quickly

supervene.

The patients complain of epigastric pain, and often suffer from a sense of abdominal pressure. Griping occurs, but it is by no means a constant symptom. Thirst may become distressingly intense. Vertigo and tinnitus, and even syncope are apt to occur. Painful sensations in the muscles of the legs, or actual cramps, frequently arise. The countenance soon becomes altered giving the first indication of the future "facies cholerica." The tongue is now pappy or dry. The skin grows cool, the voice rather faint and husky. The secretion of urine is more or less diminished, and albumen may already be present. If serous depletion still continues, in consequence of the profuse gastro-intestinal transudation, the urinary secretion speedily becomes almost or quite suppressed.

Cholerine is dangerous in proportion as its symptoms remain intractable and indicate a seemingly irrepressible tendency to run into the last type, that of pronounced cholera. But, on the whole, it may be said that recovery from cholerine is the rule. Convalescence, however, is apt to be marked by relapses, following the least provocation, such as slight errors of diet, cold, fright, and the like. This shows clearly enough the weakened and irritable condition of the whole body, and more particularly of the alimentary canal.

Sometimes a mild typhoid condition supervenes to retard recovery. The patients remain very weak, develop a slight febrile movement, have a mild diarrhoea, with thirst, sweating, coated tongue, and occasional albuminuria. But even from this somewhat alarming condition complete recovery generally occurs.

CHAPTER XXVIII.

PRONOUNCED CHOLERA, INCLUDING THE PRODROMAL STAGE, THE PERIOD OF ATTACK, AND THE STAGE OF REACTION.

THE fully-developed disease may be conveniently considered under three separate headings, embracing-A. THE PRODROMAL STAGE; B. THE PERIOD OF ATTACK; and C. THE STAGE OF REACTION.

Before we proceed to examine the various phenomena of these three divisions, it should be stated that although such a grouping is by no means unnatural, yet the transition from one stage of the disease to the following one may occur by practically unappreciable gradations. Moreover, careful observation has shown that different epidemics exhibit considerable variations in respect to the manner of development and the duration of these different stages.

Lebert justly says that nearly every epidemic has a physiognomy peculiar to itself.

With regard to its behavior at different times he writes: " It often begins. with the lighter forms and then passes into the graver, which may then prevail to the end, but it may also present a high mortality from the start. În some cases, it is rather the poor, in others all classes of the population, that are attacked. In many places it lasts a few weeks or months, in others a year and more. In medium-sized or larger cities, in which it has already prevailed, it is but little noticed by the majority of the inhabitants; while in others it snatches away one-fifth or one-fourth of the population, spreading universal terror and horror. In the same city we see some streets and public institutes more than decimated, while in the neighborhood the cheerfulness and frivolity, or the work of the inhabitants, are scarcely interrupted by the individual cases of disease and death. In the same epidemic there is such a complexity in the manifestations and course as can scarcely be exhibited in the most faithful description."

A. The Prodromal Stage. This marks the invasion of the body by the infectious agent. Concerning the period of incubation, which is held by different writers to last from twelve hours to several days, we have no definite knowledge. Frequently in a typical attack of cholera, the patient first experiences an undefined malaise, his spirits are depressed, he feels physically more or less exhausted, disinclined to follow his ordinary occupation. He becomes vaguely anxious, irritable, perhaps even a little confused. Ringing in the ears, giddiness, headache, epigastric oppression, restlessness, inability to sleep, may be added to these discomforts.

Griesinger also mentions a tendency to cold hands and feet, sensations