It is however by no means rare to meet with cases where there is a good deal of cerebral excitement at the last stage; perhaps it would be more correct to say, a good deal of excitement of the motor centres, uncontrolled by a mind, which in all other respects seems to be unaffected.
And a sad sight it is to behold, indeed. I allude here to the closing scene of cholera. The patient, cold and clammy, with a pinched and ghastly countenance, gasping, now and then groaning, becomes unreasonable-delirious. It is the delirium of the cold stage, or the stage of cold delirium which is rarely followed by any other, for it is, as a rule, the last. Now what is most striking, and therefore most distressing to the bystanders in this sad state of things, is the persistent muscular unrest patient insists in exhibiting, inspite of extreme exhaustion under which he labours. If ever a man required rest, it is a cholera patient after he had gone through the ordeal peculiar to the disease. Yet this man is bent upon consuming his last strength in moving about, or rather in trying to move about, for he is by far too weak to leave his bed; and if were not for the support he receives from the bystanders, he might sink back upon his first attempt to raise his head. Is it anxiety which makes him so restless? By no means. With the beginning of the stage of collapse it may be said that whatever there may have been of anxiety gradually gives way to a stage of indifference. The patient looks and behaves as if he had come to the conclusion that it is useless continuing the struggle, or as if he had willingly resigned himself; and the same tenure of mind prevails during the stage of the so-called cold delirium. In fact the whole delirium solely consists in most cases in an unreasonable muscular restlessness, bordering almost on a sort of unintentional suicide by self-deprivation of necessary rest.
This muscular unrest at the lose of the stage of collapse owing to congestion of the motor centres in the measure as the blood from the surface, is so much the more remarkable, as the stage of collapse itself is, as a rule, marked by a cessation of cramps. Muscular activity in that stage is indeed at its lowest ebb; exhaustion prevails everywhere, bordering on dissolution. And in many cases the scene closes in fact by a calm and gradual extinction of the vital functions. In the class of cases under consideration it would however appear, as if after a stage of extreme depression, inaugurated by what we call the stage of collapse, a return to the previous stage of abnormal muscular excitement takes place. The respiration from having been slow, indifferent and superficial, gradually, often visibly, becomes deep and gasping. The struggle for breath leaves no doubt that spasmodic oppression of the chest has supervened afresh. It is a reactionary attempt on the part of the medulla oblongata to re- establish a more vigorous respiration. In a healthy man overcome by dyspnoea such respiratory efforts would muscular system, setting up asphyctic convulsions. Not so in the case of our patient; be it, that the muscles are too little irritable for violent contraction, or that the respiratory excitement is not strong enough to impart the proper stimulus to the muscles of the body- the result is, that instead of asphyctic convulsions, there is an irresistible tendency towards being on the move, which is just as involuntary as the usual asphyctic convulsions in a man otherwise constituted. Sometimes the excitement spreads from the motor centres over the whole cerebral organ and then there is more or less of mental derangement, although muscular unrest is still the prominent feature of the delirium. At last the patient falls into a sort of comatose (uraemic) sleep from which he seldom or never awakes.
