CHAPTER II.

SECTION I.--PATHOLOGY.

The doctrine now universally accepted and prevailing regarding its Pathology is, that a poison, virulent, subtle, and unknown, has been absorbed, and primarily infects the blood, so that, after a longer or a shorter time, a primary disease of this vital fluid is produced, and that the poison undergoes an enormous process of multiplication in the living body of the cholera patient, as the direct result of this morbific process so established, and that changes are induced in the function of respiration directly consequent on this alteration of the blood.

This altered condition and rapid change in the life-sustaining principle of the blood, the loss of nerve-power, the impaired circulation and tendency to congestion, are the proper and distinguishing features of the disease; and the term "Algide," first used by the French Pathologists, very happily describes one of the most remarkable and constant symptoms, namely, the diminution of animal heat. The loss of temperature and its consequent effects upon the circulation, depressing and prostrating the nervous power, impairing and paralyzing the respiratory organs, suspending the functions of the liver and kidneys, enfeebling the action of the heart, and causing the capillary vessels of the mucous tissues to expand and pour off the serous fluid from the blood and every muscle and tissue of the system, with great rapidity, essentially constitute the phenomena of the Cholera. The constantly increasing augmentation of the poison and its intensified effects measure the malignity, the violence, and the rapidity of the disease.

It is this multiplication, and the disturbance which attaches to it, that in each case constitutes the disease and destroys life. Of this fact the circumstantial evidence is abundant and conclusive, and may account in part for the violence of the disease in its first irruption in any particular locality. The vomiting, purging, and cramps are now generally considered as secondary and non-essential phenomena, for numerous cases of cholera have occurred in every section where it has prevailed in its more violent and malignant form without exhibiting these symptoms. The poison was so potent, and its progress so rapid, that life was extinguished in a very short time. In its first irruption at Muscat, cases are reported in which only ten minutes elapsed from the first apparent seizure before life was extinct. Dr. Milroy, speaking of the violence and rapidity of the disease as it occurred in 1817, and again in 1845 and '6, at Kurrachee, observes, that "within little more than five minutes hale and hearty men were seized, cramped, collapsed, and dead." Instances of death taking place in two or three hours are extremely common. When it broke out at Teheran, in May, 1846, Dr. Milroy observes, that "those who were attacked dropped suddenly down in a state of lethargy, and at the end of two or three hours expired, without any convulsions or vomitings, but from a complete stagnation of the blood." In many places during its prevalence in 1832, and subsequently in 1834, and in 1848 and '9, the rapid fatal character of the earlier cases was observed and reported as the most severe and hopeless. In various cities and villages in our own country, cases of this description were not unfrequent. In all these the destructive nature and rapid process of the disease was so depressing and overwhelming as to prevent any effort of the "vis naturæ" to resist its progress.

Hence, from the autopsy of those who have fallen victims to its baneful influence in the first stage, or within forty-eight hours of the attack, no alteration of structure in any organ or tissue has been discovered. But in those cases where death has occurred at a later period, some lesions and slight changes in the appearance of some tissues have been traced. The more important of these, illustrative of the characteristic effects of the disease, are, in brief, the following:

The follicular structure of the intestinal canal has been found slightly swollen, and the intestine partially filled with a turbid, inodorous, semi-diaphanous fluid, resembling thin starch, or rice-water, and is supposed to be the remains of that peculiar secretion which had taken place during life. This fluid is sometimes acid, and sometimes alkaline. In the small intestines it is found in an unmixed condition. It consists of two liquids of different consistency; the one thick, the other thin. The latter constitutes the rice-water stools, and may be passed off without admixture with the thicker substance. The colon has been found generally much contracted, and the mucous membrane and the sub-mucous cellular tissue of the digestive canal presenting evident marks of congestion, in some cases approaching to a sub-inflammatory state, generally in spots or patches of various sizes, the color of these varying from a very dark congestion to a more roseate hue. The glands of Brunner and Peyer, as well as the solitary glands, are greatly enlarged. The stomach and bowels are frequently of a paler color than natural, both in their inner and outer surfaces. The liver, the spleen, and the kidneys have been found engorged with blood. The urinary bladder is always contracted, and empty. The gall-ducts are sometimes contracted, at other times not. The vena porta and all the other abdominal veins are loaded with black blood, resembling tar in its color and consistency. The membranes of the brain and cord are generally found congested, and the substance of the brain more or less dotted with small points or specks of blood than usual.

"The most common appearances in the lungs," says an eminent pathologist, "are the presence of blood in the large vessels, chiefly or solely; the collapse and the deficient crepitation arising from the more or less complete absence of air and blood, and from the approximation of the molecular parts of the pulmonary substance. In other cases there is more blood in the minute structure, a corresponding dark color of the lung, and a variable amount of frothy serum. The right side of the heart and the pulmonary arteries were generally filled, and in some cases distended with blood; the left side and aorta were generally empty, or contained only a very small quantity of dark blood; the left side evidently had received little or no blood, but had continued to contract, in some cases even violently, on the last drop of blood which had entered it."

Such are some of the prominent appearances which the body has presented when the patient has died in the first, or pulseless stage of the disease. But in other cases, where the premonitory stage has been definitely marked, and attended with diarrhoea or other depressing disorder affecting the alimentary canal, and where the patient has continued under the influence of the disease for a longer period, and has passed through the usual successive stages of it, other additional appearances have been noticed, which are here omitted, as they are of a secondary importance, and belong especially to the more protracted cases.

The _post-mortem_ appearances, the phenomena of the disease, the Algide, or diminished animal heat, and the loss of nervous power, all tend to show an obstructed circulation and consequent embarrassment of respiration resulting in the non-aeration and non-oxydation of the blood, from which a long train of secondary and non-essential symptoms arise. For it is affirmed that the mechanical part of respiration remains in a good degree perfect, and that the heart evidently continues to beat in many cases till stopped by the want of blood in the left side and by its accumulation in the right side. Hence, for the cause of this arrest of the circulation of the blood through the lungs, we are forced to look to the condition of the blood itself, and the deranged action of the ganglionic nerves.

Attempts have been made to trace out from analysis the exact chemical changes in the order of their occurrence which attend the period of transudation from the blood into the intestinal canal. "The most prominent phenomena of cholera," says Dr. Aiken, "during this period of transudation, consists in separation of the water and of the salts of the intercellular fluid (of the blood) through the mucous membrane of the intestinal canal, and the retention in the blood of an important excess of albumen and of blood-cells, with apparently less, but in reality with great diminution of the salts and fibrin."

"The inorganic constituents," continues the same author, "if compared to the water, are during the first four hours increased, because at this time the water is passing off with great rapidity; afterwards, as the salts pass off, the disproportion is lessened, and after eighteen hours or so, the proportion of salts is greatly diminished, and, if compared with the organic constituents, the diminution is enormous. With respect to the individual salts, there is in the blood a relative preponderance of phosphates over chlorides, and of potash salts over soda salts. By the end of eighteen hours or so, the blood-corpuscles are left in a most abnormal condition; the great loss of water and of salts, especially of the chloride of potassium--a most important constituent of the blood-cells--at once leads to the conclusion that their functions must have been greatly impaired. Accordingly, Dr. Schmidt found that the amount of oxygen contained in them was lessened by one-half." Dr. Robertson affirms that the "fibrin of the blood is usually in large amount and coagulable with great firmness;" while Dr. Parkes, speaking of the same condition of the blood, and relying on the accuracy of his analysis, observes, "The presence of fibrin in the blood was not indicated by any coagulation either in or out of the body; and whether coagulated or not, the blood has usually a dark color; but it generally acquired an arterial tint when brought into contact with the air in thin layers." * * * "When we remember the great share taken by the blood-globules in the respiratory and heat-furnishing processes, it is scarcely possible to avoid concluding that their loss of salts is connected with the characteristic cyanosis and lowered temperature in cholera." "The diarrhoea coincides with the first chemical changes in the blood--the transudation of some of the constituents of the serum." Hence the phenomena of the disease may thus be traced from this process as the starting-point. All other chemical changes in the blood, and the most marked symptoms, such as the abnormal respiratory process, follow as a matter of course. Such is the theory of the nature of cholera, now advanced and sustained by the most eminent pathologists, which embraces the doctrine previously advanced that the blood is the primary seat of the disease, and becomes contaminated by the absorption of a specific poison.

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.