Page:Tropical Diseases.djvu/515

XXVIII] During the stage of reaction death may occur from a variety of complications; from pneumonia, from enteritis and diarrhœa, from asthenia, or from such effects of uræmic poisoning as coma and convulsions. In cholera there is a considerable variety in the character of the symptoms and in their severity, both as regards individual cases and as regards different epidemics. It is generally stated that during an epidemic the earlier cases are the more severe, those occurring towards the end of the epidemic being on the whole milder. Ambulatory cases occur during all epidemics. Such cases are characterized by diarrhœa and malaise merely; there is never complete suppression of urine, the diarrhœa never loses its bilious character, and it is not accompanied by cramps. The attack gradually subsides without developing a subsequent stage of reaction. Cholerine.— In another set of cases the diarrhœa may be somewhat more acute, and the stools assume the well-known rice-water appearance; but the looseness soon ceases without leading to suppression of urine, or to algide symptoms, or even to very severe cramps, and without being followed by a stage of reaction. Such cases are sometimes designated "choleraic diarrhœa" or "cholerine."

Cholera sicca.— A very fatal type is that known as " cholera sicca." In these cases, though there is no, or very little, diarrhœa or vomiting, collapse sets in so rapidly that the patient is quickly overpowered as by an overwhelming dose of some poison, and dies in a few hours without purging or any attempt at reaction. At the post-mortem examination the rice-water material, so characteristic of cholera, though it may not have been voided during life, is found in abundance in the bowel. Other cases die suddenly from apnœa caused, apparently, either by coagula in the right heart, or by spasm of the pulmonary arterioles, the lungs refusing to transmit the thickened blood. In certain cases, after temporary improvement relapse may occur and is nearly always fatal.