710 ACUTE INFECTIOUS DISEASES. 



the simple and painless diarrhoea, while previously they have perhaps 

 worried the physician about every insignificant colicky pain. The first 

 passage is soon followed by a second, this by a third, and so on till a 

 great number have occurred at short intervals. The evacuations are 

 very copious and fluid, and, as they lose their fecal odor and become 

 colorless, they soon acquire the rice-water appearance. Even after the 

 second or third passage, many patients feel very weak and depressed, 

 or they may be so faint as to be unable to move from the close-stool to 

 the bed without assistance ; at this time, also, painful contractions of 

 the muscles of the leg usually begin, and a longing for drink, which 

 increases with every passage. The more the patients drink, the sooner 

 the diarrhoea is accompanied by vomiting, by which at first merely the 

 contents of the stomach, but, after a time, large quantities of a pale, 

 yellow liquid, are evacuated. The patient rapidly grows weak, the 

 voice loses its power (vox cholerica), the evacuations are passed in- 

 voluntarily, the secretion of urine ceases, the painful muscular cramps 

 increase and return more frequently ; the torturing thirst cannot be 

 allayed, and these symptoms are accompanied by a feeling of great 

 anxiety and oppression, which, together with the cramps in the legs, 

 forms the most painful symptom of cholera. Meantime the appearance 

 of the patient has become frightful ; the eyes are sunken, the nose 

 pointed, the cheeks hollow (facies cholerica) ; the skin of the hands is 

 wrinkled like that of a washerwoman who has washed all day ; if it be 

 picked up in a fold, the fold remains for a time and disappears slowly. 

 The lips, extremities, and genitals, grow blue ; the whole surface some- 

 times assumes a bluish or grayish look. The radial pulse, which be- 

 comes smaller after the first passages, frequently cannot be felt an hour 

 after the commencement of the cholera attack. Finally the pulse dis- 

 appears from the carotids also, the impulse and sounds of the heart 

 become indistinct, and, while the circulation grows more imperfect, 

 while less warm blood reaches the periphery, the temperature becomes 

 corpse-like, particularly at the uncovered parts (stadium algidum). 

 Rarely the patients complain of headache, more frequently of black 

 spots before the eyes, noises in the ears, or dizziness. The mind is 

 not cloudy, but most patients are apathetic ; while they complain of 

 pain and oppression they are indifferent to the danger, and answer in- 

 attentively and slowly. Reflex excitability is diminished ; in severe 

 cases even irritating vapors induce neither coughing nor sneezing ; the 

 patients do not wink if the finger be approached to the conjunctiva, 

 and do not wince if we dash water on them. It cannot be wondered 

 at, that in the first cholera epidemics even those physicians who re- 

 garded rice-water passages as pathognomonic of cholera, who ordered 

 careful anti-diarrhceic regimen for their patients, and treated every diar- 



