Section Ii.--Phenomena, or Symptoms.

The attack of this fearful disease is most generally sudden, the patient being at the time apparently unconscious of any depressing influence, or derangement of the system. It is not unfrequent, however, that some slight irregularity of the bowels, loss of animation and general vigor, or other apparently trifling indisposition, have preceded it. In some instances there are definite and decided premonitory symptoms which continue for a longer or shorter time prior to the attack, commencing usually with a pallor or collapse of the countenance, depression of spirits, slight pain in the forehead, noise in the ears, occasional or transient turns of vertigo, slight nausea, heat and pain in the epigastrium, oppression at the chest, with frequent sighing, nervous agitation, some loss of muscular power, general uneasiness, flatulence, with slight diarrhoea, sickness at the stomach, occasional twinges of the nerves, or cramps in the extremities, oppressed, small, feeble, and sometimes intermitting pulse, coldness, clamminess, or humidity of the surface, and general lethargy. Such are some of the premonitory symptoms which more frequently occur in the lower latitudes, where the general vigor becomes depressed by the long-continued and excessive heat of the climate. Their duration, whenever any of them do occur, varies materially; sometimes one, two, or three days--sometimes longer but not often.

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 diarrhoea, 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.