CHAPTER VI.

ON THE EPIDEMIC CHOLERA OF INDIA.

HAVING, in a previous work*, to which I have already had occasion to make frequent reference, treated of the history of this disease, I shall, in this place, confine myself to a statement of the symptoms and progress of the malady, its pathology, causes, and the treatment, which in the course of my practice I have found to be attended with the greatest success. The frightful ravages of cholera when appearing in an epidemic form renders the subject one of the deepest interest, and demands particular notice in a work professing to treat of the diseases of warm climates.

SECT. I.-On the Symptoms and Progress of Epidemic Cholera.

That the symptoms and progress of the disease may be fully brought before the reader, and that the view of the practitioner may be directed to those changes which indicate the commencing invasion of this disease, I shall call attention-first, to the description of its usual progress; secondly, to its early symptoms; thirdly, to the symptoms of the advanced stage of the disease; and, fourthly, to its Pathognomonic and Prognostic symptoms.

1. The progress of the disease is generally as follows: the patient feels, for several hours, or for a greater or shorter period, according to circumstances, a sense of general uneasiness and anxiety about the epigastrium, with a feeling of heat in this situa tion.

These symptoms increase more or less rapidly; and the countenance, which at first is merely expressive of uneasiness, soon becomes more and more anxious and distressed. The pulse, at this time, is generally quickened, and always oppressed. This state of the system forms the first stage of the disease-a stage which, from its importance in the treatment of the disease, I have called the stage of invasion.

* Sketches of the most prevalent Diseases of India, Lond. 1825, 8vo. Second edition, 1829, 8vo.

Accompanying these symptoms sometimes, but always supervening immediately to them, the patient complains of sickness at the stomach, and an uneasy sensation which seems to invade the whole track of the digestive tube. To this sense of general disorder, and of derangement more particularly of the alimentary canal, soon succeed a copious evacuation of the stomach and intestines, a sense of exhaustion, of sinking and emptiness, and an irregular spasmodic contraction of the muscles of the lower and upper extremities. The evacuations which take place at this time consist, in a great part, of the matters remaining in the stomach and alimentary canal at the period when the patient was seized with the disease; and, from the abundance of these evacuations, and the sense of emptiness and exhaustion produced by them, it seems as if the contents of the whole tube were completely discharged at this time.

The spasms, which generally come on at this period, soon increase; but, although they are tolerably general, especially in the extremities where they commence, they seldom attack the muscles of the back, loins, and face: the abdominal muscles are affected next in succession to the extremities, and lastly the thoracic muscles and diaphragm. With respect to the nature of the spasms, it appears to me that they partake more of the clonic, than of the tonic character; but the kind of spasm varies much, even in the same patient, in different stages of the disease; in some cases it presents more of the tonic character at the commencement, but gradually assumes the clonic form, which, upon the whole, seems to be the predominating kind.

With the supervention of spasm, and the evacuation of the alimentary canal, deafness, giddiness, noise in the ears, coldness of the extremities and surface of the body, are also present. Great oppression at the præcordia and epigastrium is now generally felt, attended by difficulty of breathing, and general collapse of the system. The pains sometimes felt in the abdomen are of a colicky nature, and often violent; but these, as well as the pain accompanying the spasms of the muscles of the abdomen, and of the extremities, are relieved by pressure and friction. The skin becomes colder and colder as the disease advances, and is covered with a damp, which increases to a copious, cold, raw moisture, which bedews the shrunk, sodden, and cold integuments, especially of the extremities. The countenance now assumes a contracted or collapsed, cadaverous, and anxious appearance. The eyes are sunk in their sockets, and are surrounded by a livid circle. The pulse becomes first

small, quick, oppressed; and afterwards, it scarcely can be felt at the wrist. Blood taken at this period is quite black, thick, and oily, and it frequently will not flow from the vein. The arterial blood also presents the characters of that usually circulating in the veins. The patient all the while complains of a burning sensation about the epigastrium and umbilicus, and of an unquenchable thirst. The tongue and mouth are, however, moist, cold, and white. The vomitings and stools are now frequent, and consist entirely of a fluid resembling rice-water, with mucous flocculi and albuminous matter floating in it. Sometimes these matters are muddy, turbid, and somewhat different in colour; but they are always without any admixture of bile. As the disease advances, these evacuations become less frequent, and sometimes subside for a considerable time before the death of the patient. The same may be said with respect to the spasms. The urine seems not to be secreted, and not only it, but even the saliva, and all the glandular secretions, appear to be completely arrested during the continuance of this dreadful malady.

As the disorder advances, the eyes and other features become more sunk, and the corneæ assume a flaccid appearance. The extremities are perfectly cold, covered with a cold, clammy moisture, and their surfaces sodden and corrugated. The voice becomes feeble, sepulchral, and unnatural; the respiration more and more oppressed, generally quick, and sometimes slow; and the air which the patient expires is cold. During this state, restlessness is generally observable, and is sometimes very urgent; the patient tosses about continually, and evinces the utmost distress. Although he is listless, impatient of disturbance, averse from speaking, and is altogether physically overwhelmed, still he retains his mental faculties to the last hour of his existence.

Towards the termination of the disease, the sense of anxiety at the præcordia and epigastrium increases. The restlessness appears to degenerate into a kind of jactitation; the vital actions gradually sink, and, at last, entirely disappear; and the patient dies, generally, within twelve, fifteen, twenty, or twenty-six hours from the invasion of the disease.

2. It is a matter of the most serious importance, that the symptoms denoting the invasion of the epidemic cholera be familiar to the practitioner. From these symptoms, I am fully convinced, that an attentive observer may discover the approaching invasion of the disease; and, by having recourse to suitable treatment, may prevent it from assuming that degree of severity which it inevitably

would assume, if it were left uninterfered with even for a very few hours; and which would lead to a fatal termination, in a great many instances, notwithstanding the employment of the best-adapted and most active means.

An experienced practitioner will discover, in the countenance of the patient, the earliest changes which mark the approaching invasion of cholera. It is expressive of something approaching a state of anxiety, although the patient himself may not be aware of his state, or even that he is at all ailing. If the medical attendant inquire how he feels at this time, he generally answers, "Very well:" but if pressed upon the subject, he acknowledges that he experiences feelings which he cannot distinctly describe, though he has neither pain nor sickness. His spirits are, however, low, and there is a clammy moisture sometimes on the skin, and the pulse, though occasionally full and strong, is evidently oppressed and labouring. It is not, however, that kind of pulse which will attract particular attention, unless we are upon the alert for this disease; but being prepared for such a visitation, it is impossible to mistake it: and bleeding at this moment will be attended with the happiest consequences. As this stage of the disease advances, the patient feels considerable nausea, and has his bowels more freely moved than usual; but the stools then generally consist of such matters as have been lodged in the large intestines, and consequently they present various appearances, according to the state of the digestive organs at the time of invasion. The patient, however, complains of no actual pain, even on pressure made upon the abdomen, either in this, or in the subsequent stage, but what is the result of the spasm in the latter. He feels chiefly a great degree of exhaustion, and inability to make the least exertion. Colicky pains are felt in the belly; but they often pass off, or are relieved by pressure and the free evacuations which take place in this stage. The urine, in the period of invasion, is often in small quantity, and seldom voided.

The abdomen is more than usually tumid, evidently from congestion of the viscera lodged in this cavity; this is sometimes remarked even in those cases where a sense of emptiness is complained of, after the repeated retchings and purgings. When the disease is fully formed, it seems as if the blood is almost altogether accumulated in the large venous trunks and viscera of the great cavities, occasioning the phenomena which constitute the second stage of the disease.

3. The symptoms usually looked for, as marking the advanced

stage of this disease, are vomiting and purging of a thin watery fluid, similar to rice-water, with white flocculent matter floating in it. Severe cramps supervene in the legs, arms, and muscles of the abdomen, and in many cases become even more general. The eyes are sunk, and the features sharp and collapsed. The skin is generally cold, and covered with a cold, clammy dew. There is scarcely any pulse at the wrist, and, if it be at all perceptible, it is small and thready, and generally quick; but it sometimes conveys the idea of oppression. The extremities are cold, livid, and shrunk. Sometimes there is considerable heat about the chest and epigastrium, and the head is in general hot. The respiration is oppressed, interrupted, laborious, and frequent or irregular. The tongue is not particularly foul, though, at times, it is covered with a thin coat of glairy mucus; or it is dry and white, having the appearance of being without blood; but it is not furred. The lips are cold and blue. The fluid stools are generally discharged from the bowels with a considerable degree of force, as if they were ejected from a syringe; but they are usually unaccompanied by pain.

During this stage the patient voids no urine; and, judging from the phenomena of the disease, and the appearances observed on the dissection of fatal cases, I believe that the functions of the kidneys are entirely suspended; the watery part of the circulating fluid usually secreted by the kidneys being completely drained off, by the diseased action of the mucous surface of the digestive canal.

The appearance of the extremities is peculiar, particularly of the superior extremities: the hands and fingers are shrivelled, as if they had been soaking in warm water for a considerable time. The nails are blue, and sometimes there is a blue cast over the whole skin. The prostration of strength becomes now excessive, and the thirst insatiable, evidently owing to the defect of the aqueous part of the blood, from the number of watery stools. Accompanying this insatiable thirst, the patient generally complains of an inward heat, and of a burning sensation about the umbilicus.

These are the symptoms which are generally observed when patients are first brought for assistance, both in natives and Europeans; they differ only in degree, and are merely modified according to the activity of the existing cause, and as the strength and vigour of the patient may have given rise to some degree of reaction of the vital energies of the system.

In this stage the spasms become more general; but the muscles of the back and of the face are uniformly exempt from them. Notwithstanding the urgency of the vomiting and purging, the patient