CHOLERA. 



209 



able symptoms. On examining the discharges, short- 

 ly after the occurrence of the diarrhoea, they were 

 observed to be foecal and bilious ; but they subse- 

 quently bore the serous character of those which 

 occur after the choleric stage is fully formed : they 

 were passed copiously and without much griping ; 

 while the feeling of debility which attends them was 

 great. The natural tendency of this purging was to 

 pass into the choleric stage ; but the transition has 

 frequently occurred shortly after some dietetic error, 

 either as to quantity or quality of food, or after ex- 

 posure to cold. The commencement of the purging 

 sometimes preceded by several days the accession of 

 the choleric stage, and occasionally only by eight or 

 ten hours ; but forty-eight hours was its mean dura- 

 tion, calculated from a great number of instances. 

 2. Symptoms of the Cold or Choleric Stage.- First 

 Period. As in India, the attack in Britain, in a great 

 majority of instances, generally commenced from two 

 to four o'clock in the morning. The patient felt an 

 uneasiness of the stomach, occasionally amounting to 

 pain, to which speedily succeeded vomiting of the 

 characteristic fluid described, and, if diarrhoea preced- 

 ed, which, in almost all the cases occurred, a 

 purging of the same fluid, the foecal contents of the 

 canal having been previously expelled. The vomits 

 ing was rarely full and effectual, consisting rather of 

 apparently unsatisfactory retchings than ot a full dis- 

 charge of the contents of the stomach ; but sometimes 

 these contents were expelled forcibly, as if squirted 

 from a large syringe. The discharges from the bow- 

 els were occasionally scanty, but much more frequent- 

 ly they took place copiously and forcibly. Simultane- 

 ously with the vomiting, or not unfrequently before 

 this symptom occurred, cramps took place ; and the 

 agony which attended them constituted great part of 

 the sufferings of the patient, who incessantly entreat- 

 ed that friction might be applied to the parts they af- 

 fected. The pulse was feeble and frequent; the 

 skin, in point of heat, below the healthy standard ; 

 the countenance shrunk, and, if not livid, pallid ; acd 

 the respiration hurried, if not checked, as it frequent- 

 ly was, by spasm of the diaphragm and intercostal 

 muscles. The circulation sunk remarkably, and 

 sometimes appeared momentarily to cease, on every 

 accession of severe vomiting or spasm. Second Pe- 

 riod. The mean duration of the preceding period 

 varied from about eight to twelve hours ; the vomit- 

 ing and spasms then either totally subsided or recur- 

 red at much longer intervals, and the patient sunk in- 

 to a state of extreme collapse. The pulse at the 

 wrist was scarcely or not at all perceptible ; the sur- 

 face universally moist and cold, excepting as heat 

 was imparted from without, for the instant that the 

 hands or other parts were exposed, they became of 

 an icy coldness ; blueness, if it existed at all, but 

 it was by no means a uniform symptom, was now 

 conspicuous on the face and hands, which last had 

 the shrunk and sodden appearance so generally de- 

 scribed ; the tongue was moist, and, if not actually 

 cold, at least cooler than natural ; and the voice o 

 that mingled huskiness and feebleness which strikes 

 the ear so peculiarly. In this condition there was 

 little suffering, excepting from the sense of weight 

 and oppression at the preecordia, of which the patient 

 complained much ; for even should spasms occur, 

 they were now too feeble to excite much pain ; the 

 respiration was slow ; the conjunctivae, especially hi 

 their inferior hemisphere, were frequently injected 

 with dark-coloured blood ; and the insensibility of the 

 stomach was so great, that the most powerful stimu- 

 lants might be given and retained without the organ, 

 being apparently more sensible of their presence than 

 if it were a lifeless pouch. The urine was suspended 

 throughout the whole course of the choleric stage. 



3. Symptoms of the Febrile Stage. The preceding 

 stage, in most cases, made a very gradual transition 

 into the febrile one. After the patient remained in 

 the collapsed state, probably for a considerably long- 

 er time than the medical attendant expected, some 

 degree of warmth was found returning to the surface 

 and the pulse proportionably developed, being very 

 perceptible at the wrist, generally about eighty, and 

 soft ; the vessels of the conjunctiva gradually became 

 distended with blood ; or if those ot the inferior he- 

 misphere were so during the stage of collapse, thc- 

 distension now diffused itself over the whole mem- 

 brane ; the patient, who, on his attention being rous- 

 ed, was perfectly sensible, complained of severe pain 

 in the head, of a sense of giddiness, and that the light 

 distressed his eyes. The tongue in this early stage 

 was clean and moist ; the bowels were readily acted 

 upon by medicine, and the discharges were feculent, 

 and, though somewhat clayey, contained a propor- 

 tion of bile ; but the urinary secretion was sometimes 

 either not restored, or was considerably deficient for 

 a day or two after the establishment of fever. In the 

 progress of the fever, the tongue became black, and 

 sordes accumulated about the teeth ; the eyes became 

 more and more injected ; the intellect more and more 

 torpid, though still the patient could be roused to 

 answer questions, and even to make one or two sensi- 

 ble remarks on his condition ; but the instant the con- 

 versation ceased, the eyes were turned up in the orbit, 

 exposing through the half-closed eyelids the red scle- 

 rotica, and the patient was in a state of profound 

 stupor : the urinary secretion was now established, and 

 the urine, which at first was dark-coloured and cloudy, 

 was now limpid and pale ; the alvine discharges were 

 darker coloured than at first ; and throughout the dis- 

 ease there was a deficiency of vascular action and of 

 temperature. However flushed the countenance 

 appeared, and it was often very considerably so, the 

 temperature of the surface was below the healthy 

 standard. Typhoid is not an inappropriate designation 

 of the condition here described ; but an individual who 

 had once watched the progress of such a case, would run 

 no risk of confounding it with typhus; the deficiency 

 of vascular and calorific power ; the peculiar vasculari- 

 ty of the eye ; the absence of subsultus and muttering 

 delirium (for though delirium occasionally occurs dur- 

 ing night, the condition of the intellect is throughout 

 much more one of torpor than of irregularity), would 

 be the. marks by which he would discriminate the two 

 affections. The duration of such a febrile stage was 

 from a week to ten days. Its termination was, in a con- 

 siderable majority of instances, fatal. In another form, 

 and one which supervenes on a minor degree of col- 

 lapse than the preceding, the symptoms do not differ 

 from those described above, excepting that there are 

 indications of greater excitement, more warmth of 

 surface, and more force and frequency of pulse. Deple- 

 tion could be more freely practised, and it was alto- 

 gether a more manageable form of disease. Themildest 

 and most tractable type of the febrile stage was denot- 

 ed by symptoms of general but moderate excitement, 

 with epigastric pain on pressure, headache and giddi- 

 ness ; the tongue being at the same time either clean 

 with a disposition to become dry and glazed, or slig it- 

 ly white and furred ; the skin warm ; the pulse free and 

 forcible ; the urine highly coloured, and the thirst con- 

 siderable. In such a case there is little or no confusion 

 of thought or delirium, and the eyes are not injected. 

 We need scarcely remark that examples of this mild 

 and tractable type of the febrile stage occurred after 

 a choleric stage, in which the symptoms of collapse 

 had been inconsiderable, in which the urinary secre- 

 tion had not been suspended, or which had not always 

 been attended with vomiting a symptom occasional- 

 ly wanting in slight cases. 



