to quench the thirst and subdue the sickness. In aggravated cases where medicines are rejected, enemata of starch and laudanum, or the hypodermic injection of morphia, ought to be resorted to. Counter-irritation by mustard or turpentine over the abdomen is always of use, as is also friction with the hands where cramps are present. When sinking threatens, brandy and ammonia will be called for. During convalescence the food should be in the form of milk and farinaceous diet, or light soups, and all indigestible articles must be carefully avoided.
In the treatment of this disease as it affects young children (Cholera Infantum), most reliance is to be placed on the administration of chalk and the use of starch enemata. In their case opium in any form cannot be safely employed.
Malignant Cholera (synonyms, Asiatic Cholera, Indian Cholera, Epidemic Cholera, Algide Cholera) is one of the most severe and fatal diseases. In describing the symptoms it is customary to divide them into three stages, but it must be noted that these do not always present themselves in so distinct a form as to be capable of separate recognition. The first or premonitory stage consists in the occurrence of diarrhoea. Frequently of mild and painless character, and coming on after some error in diet, this symptom is apt to be disregarded. The discharges from the bowels are similar to those of ordinary summer cholera, which the attack closely resembles. There is, however, at first the absence of vomiting. This diarrhoea generally lasts for two or three days, and then if it does not gradually subside either may pass into the more severe phenomena characteristic of the second stage of cholera, or on the other hand may itself prove fatal.
The second stage is termed the stage of collapse or the algide or asphyxial stage. As above mentioned, this is often preceded by the premonitory diarrhoea, but not infrequently the phenomena attendant upon this stage are the first to manifest themselves. They come on often suddenly in the night with diarrhoea of the most violent character, the matters discharged being of whey-like appearance, and commonly termed the “rice-water” evacuations. They contain large quantities of disintegrated epithelium from the mucous membrane of the intestines. The discharge, which is at first unattended with pain, is soon succeeded by copious vomiting of matters similar to those passed from the bowels, accompanied with severe pain at the pit of the stomach, and with intense thirst. The symptoms now advance with rapidity. Cramps of the legs, feet, and muscles of the abdomen come on and occasion great agony, while the signs of collapse make their appearance. The surface of the body becomes cold and assumes a blue or purple hue, the skin is dry, sodden and wrinkled, indicating the intense draining away of the fluids of the body, the features are pinched and the eyes deeply sunken, the pulse at the wrist is imperceptible, and the voice is reduced to a hoarse whisper (the vox cholerica). There is complete suppression of the urine.
In this condition death often takes place in less than one day, but in epidemics cases are frequently observed where the collapse is so sudden and complete as to prove fatal in one or two hours even without any great amount of previous purging or vomiting. In most instances the mental faculties are comparatively unaffected, although in the later stages there is in general more or less apathy.
Reaction, however, may take place, and this constitutes the third stage. It consists in the arrest of the alarming symptoms characterizing the second stage, and the gradual but evident improvement in the patient’s condition. The pulse returns, the surface assumes a natural hue, and the bodily heat is restored. Before long the vomiting ceases, and although diarrhoea may continue for a time, it is not of a very severe character and soon subsides, as do also the cramps. The urine may remain suppressed for some time, and on returning is often found to be albuminous. Even in this stage, however, the danger is not past, for relapses sometimes occur which speedily prove fatal, while again the reaction may be of imperfect character, and there may succeed an exhausting fever (the so-called typhoid stage of cholera) which may greatly retard recovery, and under which the patient may sink at a period even as late as two or three weeks from the commencement of the illness.
Many other complications are apt to arise during the progress of convalescence from cholera, such as diphtheritic and local inflammatory affections, all of which are attended with grave danger.
When the attack of cholera is of milder character in all its stages than that above described, it has been named Cholerine, but the term is an arbitrary one and the disease is essentially cholera.
The bodies of persons dying of cholera are found to remain long warm, and the temperature may even rise after death. Peculiar muscular contractions have been observed to take place after death, so that the position of the limbs may become altered. The soft textures of the body are found to be dry and hard, and the muscles of a dark brown appearance. The blood is of dark colour and tarry consistence. The upper portion of the small intestines is generally found distended with the rice-water discharges, the mucous membrane is swollen, and there is a remarkable loss of its natural epithelium. The kidneys are usually in a state of acute congestion. This form of cholera belongs originally to Asia, more particularly to India, where, as well as in the Indian archipelago, epidemics are known to have occurred at various times for several centuries.
Much light has been thrown upon Asiatic cholera by Western experience; and the study of the disease by modern methods has resulted in important additions to our previous knowledge of its nature, causation, mode of dissemination and prevention.
The cause is a micro-organism identified by Koch in 1883 (see Parasitic Diseases). For some years it was called the “comma bacillus,” from its supposed resemblance in shape to a comma, but it was subsequently found to be a vibrio or spirillum, Causation.not a bacillus. The discovery was received with much scepticism in some quarters, and the claim of Koch’s vibrio to be the true cause of cholera was long disputed, but is now universally acknowledged. Few micro-organisms have been more elaborately investigated, but very little is known of its natural history, and its epidemiological behaviour is still surrounded by obscurity. At an important discussion on the subject, held at the International Hygienic Congress in 1894, Professor Gruber of Vienna declared that the deeper investigators went the more difficult the problem became, while M. Elie Metschnikoff of the Pasteur Institute made a similar admission. The difficulty lies chiefly in the variable characters assumed by the organism and the variable effects produced by it. The type reached by cultivation through a few generations may differ so widely from the original in appearance and behaviour as to be hardly recognizable, while, on the other hand, of two organisms apparently indistinguishable one may be innocuous and the other give rise to the most violent cholera. This variability offers a possible explanation of the frequent failure to trace the origin of epidemic outbreaks in isolated places. It is commonly assumed that the micro-organism is of a specific character, and always introduced from without, when cholera appears in countries or places where it is not endemic. In some cases such introduction can be proved, and in others it can be inferred with a high degree of probability, but sometimes it is impossible to trace the origin to any possible channel of communication. A remarkable case of this kind occurred at the Nietleben lunatic asylum near Halle, in 1893, in the shape of a sudden, explosive and isolated outbreak of true Asiatic cholera. It was entirely confined to the institution, and the peculiar circumstances enabled a very exact investigation to be made. The facts led Professor Arndt, of Greifswald, to propound a novel and interesting theory. No cholera existed in the surrounding district and no introduction could be traced, but for several months in the previous autumn diarrhoea had prevailed in the asylum. The sewage from the establishment was disposed of on a farm, and the effluent passed into the river Saale above the intake of the water-supply for the asylum. Thus a circulation of morbid material through the persons of the inmates was established. Dr Arndt’s theory was that by virtue of this circulation cholera was