The aspect of the patient is depressed, and the expression list less, and there is a remarkable appearance about the eyes, which, during the existence of epidemic cholera, has often served to warn myself and others that an attack of diarrhcea would proceed to the more fully developed disease. It is hard to describe in words; but consists of hollowness of the orbits and sinking of the eye, with a leaden color around, and a listlessness of expression. The color of the skin first assumes an earthy hue, subsequently pass ing into complete lividity, which lasts, especially on the hands, during the greater part of the stage of reaction.
The patient makes little complaint of pain, except that depend ent on cramps. By some the occurrence of cramp is regarded as the symptom which distinguishes cholera from simple vomiting and purging; it is simply an accident ; a very common one truly, but one which may not occur in real cholera, and may be pre sent when the case is unequivocally not cholera. There is no complaint of nausea, though the constant and urgent vomiting can scarcely be supposed to exist without it ; there is also no complaint of pain with the purging ; the sensations no doubt are blunted ; but this painlessness is an important feature in the case, and it may even excite surprise on the part of the patient him self, that such enormous discharges take place from the stomach and bowels, when he has so little feeling of internal derangement. In the beginning of an attack, the existence of diarrhces without pain or griping, will cause the medical attendant to be on the alert ; but, unfortunately, it has just the opposite effect with the patient, who cannot fancy that anything is seriously wrong when he has so little feeling of discomfort. Another remarkable fea ture is.the sensation of burning heat and oppression so often complained of, while the skin is cold and corpse-like ; the patient obstinately resists every attempt to raise the temperature by arti ficial means, and, in the restlessness of the disease, throws off the warm blankets in which he is wrapped.
Among particular symptoms are ranked the change of the natural sound of the voice into a hoarse whisper, the vox choleraica : and the circumstance of the tongue and the breath being sensibly cold to the hand of the observer. These facts may be interesting in any particular case, but, as they belong to the accidents of the disease, they must not be elevated into diagnostic symp toms.
The mental faculties are not obscured till an advanced period, when the pupils become contracted, the brain oppressed, and the patient comatose. Prior to this, there is only a condition of restlessness of body and inactivity of mind.
During the existence of an epidemic of cholera there can be no difficulty in classifying the cases which present well-developed features of the disease ; but its march is attended by coincident diarrhoea, and there is in reality no definite boundary between the one and the other. Every link is filled up by cases of intensity, from the very worst of cholera to the mildest of diarrhoea. The indications by which we are guided, the characters of the evacuations, the existence of collapse, and the suppression of urine, are not directly connected with the essence of the disease, and do not show where the line is to be drawn. Hence it is that one observer records a smaller mortality than another, because he includes a larger class of cases ; and that the same treatment appears to be followed by such varying success in different hands.
We have found the same obscurity in attempting to discriminate different classes of fever. But, while we cannot yet feel certain whether they arise from the same or from different causes, we have this remarkable difference between Asiatic cholera and sporadic or English cholera, that the one travels to us from the tropics, and never takes its rise in temperate climates, while the other occurs every year among ourselves. On the other hand, just as during the presence of an epidemic of typhus, there is extreme difficulty in distin guishing cases dependent on the epidemic influence from those naturally springing from endemial causes, which might have equally occurred during Its absence ; so during an epidemic of cholera, there is often much difficulty in recognizing a case of simply severe diarrhoea. In the one case or the other the distinction is only based on the totality of the symptoms, placing it rather under one denomination than the other; and until we know something more of the real nature of the disease, we must not forget to give its due weight to the d priori argument of its universality and its transmission from one place or person to another. In my own experience I have found that, when attention has been given to this point, distinctive characters have been observed which would otherwise have escaped notice.