i8o8 



THE CHOLERAS 



ment of the solitary and agminated glands, as well as of the mesen- 

 teric glands. 



The liver is generally congested, and the ducts full of bile; the 

 spleen is shrunken; the kidneys are swollen, and often ecchymotic, 

 with tubules blocked with granular debris and cells in a state of 

 cloudy swelling. The right heart is often dilated, and the whole 

 venous system full of blood, while the arterial system and the left 

 heart is empty. The lungs are collapsed, dry, and anaemic, and 

 the brain may be congested. 



Microscopically, the vibrios may be seen in Lieberkiihn's follicles 

 in the epithelial cells, and in the mucosa of the intestine and the 

 stomach. The kidney shows vascular congestion and destruction 

 of the epithelium. Usually the vibrios do not penetrate into the 

 blood-stream, and therefore the disease is mainly a general intoxica- 

 tion; but Rebowski records cases in which they have been found 

 in the liver, the kidney, and the heart, thus producing a general 

 infection. 



If the post-mortem is held on a case which has died during the 

 state of reaction, pneumonia and the signs of other secondary 

 infections may be lound. 



Symptomatology. — A typical case of cholera has an incubation 

 period which varies from a few hours to a few days (three to six). 

 The onset is usually sudden, but there may be prodromata in the 

 form of diarrhoea, or merely a feeling of illness and malaise. The 

 attack begins with diarrhoea, with or without colicky pains in the 

 abdomen. The motions are at first faeculent, and contain bile, but 

 soon assume the typical rice-water appearance, in which they are 

 fluid and acholic, containing numerous white flakes, which, when 

 examined, are found to be composed of mucus containing vibrios 

 and epithelial cells, while exceptionally the motions contain blood. 

 Vomiting generally appears early, food being first expelled, followed 

 later by a watery fluid, with which bile and occasionally blood may 

 be mixed. The patient complains of thirst, and at times of hiccough. 

 As the purging and vomiting proceed the urine diminishes, and may 

 stop, and fluid departs from the subcutaneous tissues, which there- 

 fore contract, so that the f acies alters, the nose becoming sharp, the 

 cheek-bones prominent, the eyes sunken, and the skin of the fingers 

 becomes wrinkled like that of a washerwoman. Whilst this is 

 taking place, the circulation becomes profoundly affected, the blood- 

 pressure falls, the pulse becomes weak and rapid, the heart-sounds 

 diminish, and the lips, face, and nails become bluish. The patient 

 now has difficulty with his breathing, and his voice becomes weak 

 and husky. Painful cramps appear in various muscles, but espe- 

 cially in the calf, arm, and abdominal muscles, while the reflexes 

 are diminished. The mind is quite clear, but the patient is apathetic, 

 except when agonized by the cramps. The skin feels cold, and the 

 axillary temperature falls below normal, but that of the rectum 

 may be considerably raised. If no change for the better takes 

 place, the patient passes into the algide stage, in which the failure 



