According to the observations and descriptions given by those who have had the best opportunities for becoming familiar with all its various phases, the symptoms attending its invasion and general course are too distinctly marked to be ever mistaken for any other disease. In the minds of many who have been called to witness the developments of cholera, they undoubtedly exist with such distinctness and vividness as to render the most labored and accurate description tame. In this treatise, however, a description of the leading and more prominent phenomena will be given, and so far as a general principle of practice is concerned, this might be very appropriately limited to its first or cold stage.
The commencement of the disease is often so insidious as to pass unnoticed till the system is fully prepared for the sudden and violent attack. The slight, painless diarrhœa, depression of the nervous power, and occasional vertigo may all pass unheeded, and the patient be apparently in perfect health. He may retire to rest entirely unconscious of approaching danger, and after enjoying a sound and undisturbed sleep for hours, be, on awakening from his slumbers, seized with a remarkable sickness, perhaps vomiting, accompanied with most remarkable and profuse discharges from the bowels. These inordinate evacuations are usually attended with severe pains, extending down the thighs, and a sense of complete and almost perfect exhaustion. The physical powers and vital energies are immediately prostrated. The temperature rapidly sinks below the normal standard—the body becomes benumbed with an icy coldness—the skin becomes shriveled up, and almost insensible to hot and stimulating fomentations—the breath, too, as it comes from the lungs, appears to partake of the same icy coldness, indicating the rapid elimination of heat, or caloric, from the body. The patient complains of being greatly oppressed, throws off his clothing—calls for cold water, which he eagerly and copiously drinks; though it afford no relief to his insatiate thirst, it ought not to be withheld. This peculiar icy coldness and loss of temperature is also further shown by the livid, blue, or purple appearance of the hands and feet, extending sometimes over the greater part of the body. The skin becomes, even in a few minutes after the seizure, not only shriveled up, but often curiously wrinkled, as in extreme old age. Severe spasms in the fingers, toes, legs, and abdomen, cause the patient to groan and writhe under their influence, and to call on his attendants, if fortunate enough to have any around him, for aid and relief from his agonies. As the disease proceeds, there may be noticed a peculiar, sharp and contracted state of the features, and a wild and terrified expression of the countenance, arising from the impression and fearful apprehension of rapidly approaching dissolution. These important changes may all take place in a very few minutes. To these most obvious and singular symptoms there is superadded constant vomiting—incessant purging—low, feeble pulse, though occasionally natural and sometimes rapid, yet in some instances, from the very first moment of attack, cannot be discovered either in the large superficial arteries or at the wrist. The voice is altered, becomes low, feeble, unnatural in tone, or sinks even to a whisper. Respiration becomes quick, irregular, laborious and imperfect. The inspiratory act being performed with difficulty, and expiration being quick and convulsive. The flow of bile into the intestines is suspended, the urinary secretion and micturition entirely suppressed. Almost the only organ which seems to preserve in any good degree its powers is the brain—the mental faculties in some cases being retained till the close of life;—in other cases feeble, weak, and much impaired. On the accession of the spasms, the vomiting—and the purging—the disease may be considered as being fully developed, and the crisis at hand, which, in a few hours, must decide the fate of the patient. Its progress is now rapid, and must speedily terminate either favorably or unfavorably. If the result be unfavorable, the patient may die with all these symptoms distinctly and strongly marked. If the termination, however, be favorable, these violent symptoms soon yield, and seem to be materially relieved; yet, though these indications favor the return of normal power—the weakness, the cessation of the pulse, the coldness and blueness of the surface, and the sepulchral expression of the countenance, clearly show that a few hours must close the scene. To many death thus often comes calmly and quietly, without any struggle to mark the precise time of this life's departure.
"If the patient," says an eminent author, "should happily survive the cold stage, the disease may terminate by a rapid recovery, or it may pass into the second or febrile stage." The former is the more usual course in India, the latter in Europe. The first symptom of returning health is shown by the patient falling into a sleep of unusual soundness, during which the respiration becomes light and easy, the pulse freer, while a gentle, warm perspiration bedews the whole body. This grateful pause in the disease appears to be the result of the returning powers of life, uninfluenced by medicine, for it often occurs where none has been given. After this balmy slumber the patient awakes refreshed, and often recovers so rapidly, that in the natives of India it almost resembles a restoration after syncope. In all the Presidencies, indeed, and especially in Bengal, the recovery of the European has, in general, been followed by a stage of reaction, usually slight, but in some cases assuming the form of the bilious remittent fever of the country, which has occasionally terminated fatally. In most cases, however, the reaction is more considerable, and the patient, in a few hours after the subsidence of the cold stage, labors under a severe form of fever, resembling the typhoid. During the first few hours after the febrile reaction commences the tongue is white, but it quickly becomes brown and dry, while black sordes incrust the teeth and lips. The eye becomes deeply injected and red, the cheek pale or flushed, the pulse rapid, and the temperature of the body a little above the natural standard. The patient, either delirious or comatose, then lies in a state resembling the last stage of the severest typhoid fever of this country. This struggle usually lasts from four to eight days, when the symptoms either gradually yield, or death ensues. In a few mild cases the fever assumes an intermittent type, or sometimes a quotidian, sometimes a tertian form: all these cases usually recover. Such is, in brief, a summary of the more important symptoms of the Epidemic, or Asiatic Cholera, especially in its earlier or cold stage. The phenomena, especially developed in, and belonging to, the stage of reaction, being of minor importance, they have received only a very brief consideration; sufficient, however, to show the general character and tendency of the disease in this stage of its progress and termination.
CHAPTER III.
Section I.—Unsuccessful Modes of Treatment—Venous Transfusion Explained.
In this discussion we shall avail ourselves of the researches and investigations of eminent Professors, whose observations, experience, and position give their views the highest authority. The latest and most deserving record on this subject is from the pen of Professor Aiken, of Edinburgh, who observes, "There are few diseases for the cure of which so many different remedies and modes of treatment have been employed as in Cholera, and, unfortunately, without our discovering an antidote to the poison. In Moscow it is said that the mortality was not greater among the destitute of medical aid than among those who had every care and attention shown them. It may be fairly inferred, therefore, that in the severer forms of the disease, the action of this poison is so potent as to render the constitution insensible to the influence of our most powerful remedial agents. When, however, the disease is mild, or on the decline, much may be done by obviating symptoms to promote the recovery of the patient."
"The heroic remedies that have been employed in Cholera are bleeding, and calomel and opium, either separately or conjointly. With respect to bleeding, it may be stated, that in every country the patients bore bleeding badly in any stage, and that the practice in Europe was at length limited to a few leeches occasionally to the head. As to calomel, that medicine was used to the greater part of an ounce in the twenty-four hours, but with so little success that many patients have been seized and have died under the full influence of mercury. On the appearance of cholera in Europe, opium was administered in the doses recommended by the Indian practitioners to the greater part even of an ounce of laudanum; but it was soon seen that in the cold stage it was inefficient in controlling the vomiting or purging; that it did not allay the spasms, and, moreover, hardly produced any narcotic effect. The action of the accumulated doses of opium, however, though suspended during the cold stage, was often fully developed in the last stage, and occasioned so much affection of the head that most practitioners either abandoned its use or limited it to a mere fractional dose of that usually given in India, namely, from three to twelve minims of the tincture of opium, or half a grain to a grain of solid opium every four or six hours."
Let us now turn to a paper by the justly celebrated Professor Maclean, whose observations and experiences have been more extensive than perhaps those of any other professional gentleman either in Europe or America. Unlike many of his brethren, he holds on this subject the safer doctrines of practice, and very frankly and earnestly expresses the same in the following language: "Opium in cholera should be given only in the premonitory diarrhœa. At this stage, in combination with a stimulant, it is of the highest value. If persevered in, particularly in the strong doses (justly reprobated), it is a dangerous remedy, inducing fatal narcotism, or, at the least, interfering with the functions of the kidneys, and so leading directly to uræmic poisoning."
"Urgent thirst is one of the most distressing symptoms in cholera; there is incessant craving for cold water, doubtless instinctive, to correct the inspissated condition of the blood, due to the rapid escape of the liquor sanguinis. It was formerly the practice to withhold water—a practice as cruel as it is mischievous. Water in abundance, pure and cold, should be given to the patient, and he should be encouraged to drink it, even should a large portion of it be rejected by the stomach; and when the purging has ceased, some may, with much advantage, be thrown into the bowel from time to time.
In the stage of reaction, the fever may be moderated by cold sponging, or by the wet sheet; the secretion of urine may be promoted by dry cupping over the loins by the use of chlorate of potash, and the like. But suppression of this secretion is most to be dreaded where opium has been too freely used in the treatment. In men of intemperate habits, we often see, during the stage of reaction, obstinate vomiting of thick, tenacious, green, paint-looking matter, probably bile pigment, acted on by some acid in the stomach or alimentary canal. It is a symptom of evil omen, and often goes on uncontrolled until the patient dies exhausted, and this although all other symptoms may promise a favorable issue. I have known it last for a week, resisting all remedies, and proving fatal when the urinary secretion had been restored and all cerebral symptoms had subsided. Alkalies in the effervescing form, free stimulation of the surface, and chloroform in small doses offer the best hope of relief. The patient should be nourished more by the bowel than the stomach when vomiting is present. Ice should be not only to dissolve in the mouth, but to swallow in pieces of convenient size."