instances, from two to four o'clock in the morning. The patient is attacked with uneasiness of the stomach, occasionally amounting to pain, to which speedily succeeds vomiting of the characteristic fluid so frequently described, and, if diarrhoea have preceded, which, in almost all the cases that have fallen under our observation, has been the case, a purging of the same fluid, the focal contents of the canal having been previously expelled. The vomiting is rarely full and effectual, consisting rather of apparently unsatisfactory retchings than of a full discharge of the contents of the stomach; but sometimes these contents are expelled forcibly, as if squirted from a large syringe. The discharges from the bowels are occasionally scanty, but much more frequently they take place copiously and forcibly. Simultaneously with the vomiting, or not unfrequently before this symptom has occurred, cramps take place; and the agony which attends them constitutes great part of the sufferings of the patient, who incessantly entreats that friction may be applied to the parts they affect. How ever soon our visit may be made, the pulse will generally be found to be feeble and frequent; the skin, in point of heat, below the healthy standard; the countenance shrunk, and, if not livid, pallid; and the respiration hurried, if not checked, as it frequently is, by spasm of the diaphragm and intercostal muscles. The circulation sinks remarkably, and sometimes appears momentarily to cease, on every accession of severe vomiting or spasm.-Second Period. The mean duration of the preceding period varies from about eight to twelve hours; the vomiting and spasms then either totally subside or recur at much longer intervals, and the patient sinks into a state of extreme collapse. The pulse at the wrist is scarcely or not at all perceptible; the surface is universally moist and cold, excepting as heat is imparted from without, for the instant that the hands or other parts are exposed, they become of an icy coldness; blueness, if it exist at all,-but it is by no means an uniform symptom,--is now conspicuous on the face and hands, which last have the shrunk and sodden appearance so generally described; the tongue is moist, and, if not actually cold, at least cooler than natural; and the voice is of that mingled huskiness and feebleness which strikes the ear so peculiarly. In this condition there is little suffering, excepting from the sense of weight and oppression at the præcordia, of which

the patient complains much; for even should spasms occur, they are now too feeble to excite much pain; the respiration is slow; the conjunctivæ, especially in their inferior hemisphere, are frequently injected with dark-colored blood; and the insensibility of the stomach is so great, that the most powerful stimulants may be given and retained without the organ being apparently more sensible of their presence than if it were a lifeless pouch. The urine is suspended throughout the whole course of a choleric stage so intense as we have described.

3. Symptoms of the Febrile Stage. The preceding stage, in most cases, makes a very gradual transition into the present one. After the patient has remained in the collapsed state, probably for a considerably longer time than the medical attendant expected, some degree of warmth will be found returning to the surface, which, for a variable period, perhaps for a couple of days, has been almost of icy coldness; and the pulse is proportionably developed, being very perceptible at the wrist, generally about eighty, and soft; the vessels of the conjunctiva gradually become distended with blood; or if those of the inferior hemisphere have been so during the stage of collapse, the distension now diffuses itself over the whole membrane; the patient, who, on his attention being roused, is perfectly sensible, complains of severe pain in the head, of a sense of giddiness, and that the light distresses his eyes. The tongue in this early stage is clean and moist; the bowels are readily acted upon by medicine, and the discharges are feculent, and, though somewhat clayey, contain a proportion of bile; but the urinary secretion is sometimes either not restored, or is considerably deficient for a day or two after the establishment of fever. In the progress of the fever, the tongue becomes black, and sordes accumulate about the teeth; the eyes become more and more injected; the intellect more and more torpid, though still the patient can be roused to answer questions, and even may make one or two sensible remarks on his condition; but the instant the conversation ceases, the eyes are turned up in the orbit, exposing through the half-closed eye-lids the red sclerotica, and the patient is in a state of profound stupor: the urinary secretion is now established, and the urine, which at first was dark-colored and cloudy, is now limpid and pale; the alvine discharges are darker colored than at first; and throughout the disease there is

a deficiency of vascular action and of temperature, which we have not observed to the same extent in typhus or any other fever. However flushed the countenance may appear, and it is often very considerably so, the temperature of the surface is below the healthy standard; and we have not often found the pulse above ninety. Typhoid is not an inappropriate designation of the condition we have endeavored to describe; but we think that an individual who had once watched the progress of such a case, would run no risk of confounding it, on future occasions, with typhus; the deficiency of vascular and calorific power; the peculiar vascularity of the eye; the absence of subsultus and muttering delirium (for though delirium occasionally occurs during night, the condition of the intellect is throughout much more one of torpor than of irregularity), would be the marks by which he would discriminate the two affections. The duration of such a febrile stage as we have described, is from a week to ten days. Its termination has been, in a considerable majority of instances which have fallen under our observation, fatal. The brain has appeared to us to be the organ mainly affected; and by this view our treatment has been chiefly guided, though, at the same time, the condition of the intestinal canal has not been neglected. In another form, and one which supervenes on a minor degree of collapse than the preceding, the symptoms do not differ from those described above, excepting that there are indications of greater excitement,-more warmth of surface, and more force and frequency of pulse. Depletion could be more freely practised, and it was altogether a more tractable form of disease. The mildest and most tractable type of the febrile stage was denoted by symptoms of general but moderate excitement, with epigastric pain on pressure, headache and giddiness; the tongue being at the same time either clean, with a disposition to become dry and glazed, or slightly white and furred; the skin warm; the pulse free and forcible; the urine highly colored, and the thirst considerable. In such a case there is little or no confusion of thought or delirium, and the eyes are not injected. We need scarcely remark that examples of this mild and tractable type of the febrile stage occurred after a choleric stage, in which the symptoms of collapse had been inconsiderable, in which the urinary secretion had not been suspended, or which had

not always been attended with vomiting— a symptom occasionally wanting in slight cases. The writer met with but one example of considerable affection of the thoracic organs; and this occurred in a case, in point of general character, not unlike the form last described, though somewhat more collapsed. The affection was bronchial, and was relieved by a copious expectoration of very dark-colored sputa,

the patient recovering. In the preceding sketch of the febrile stage, it will be understood that, as in the case of the choleric stage, we have not attempted to depict all the various shades of intensity in which the disease manifested itself. The extremes are given: to have essayed to describe all the intermediate degrees would have swelled the article beyond reasonable limits, and would have proved a burden to the memory of the reader.

4. Prognosis. The danger of the disease is in all cases, we believe, to be estimated from the degree of collapse attending the cold or choleric stage. In India, it was remarked that the cases in which the spasms and vomiting were the most violent were by no means fraught with the most peril; and what we have seen of the disease enables us to bear testimony to the accuracy of the remark; for when we have heard the attendants exulting in the cessation of the spasms, and the facility with which the stomach retained medicine or food, and have felt, at the same time, the pulseless wrist and the cold and clammy hand, we have seen, in these apparently favorable omens, only the natural progress of the disease from a bad condition to one still worse. Whether we are to dread a fatal result in the cold or the excited stage, the intensity and duration of the collapse in the former of these stages are the measure of the danger; for if the patient die in this stage, he dies of collapse; and if he survive it, and pass into the state of fever, the character of this fever is malignant and dangerous in proportion to the same collapse.

5. Diagnosis. From ordinary cholera the cold stage is to be distinguished, as it appears to us, by the peculiar character of the discharges, which has been sufficiently dwelt upon, and by the degree of collapse and its early occurrence. Cases have been adverted to, which, at least in the choleric stage, could not be discriminated from ordinary cholera, excepting, perhaps, from their taking place at a season of the year when ordinary cholera is never observed; but it may be remarked that no one would infer the existence of

the epidemic from such cases, though he might be disposed to acknowledge that they belonged to it, if cases less equivocal were simultaneously prevalent, and especially if they originated under the circumstances mentioned in the preceding pages. Notice has been taken of sporadic cases which have occurred in several parts of the kingdom during the last year, and which have been reported in various publications. We have already stated our opinion as to the perfect identity of the group of symptoms in certain of these cases and those which characterize the choleric stage of the epidemic. These cases have generally been fatal as cases of cholera, and, probably on this account, have attracted attention and been reported; and hence what we should consider the experimentum crucis by which their essential alliance to the epidemic, as it has manifested itself in this country, or difference from it, can alone be proved, the intervention, or otherwise, of fever between the cold stage and recovery,-is necessarily wanting. We have been favored, by a gentleman of high character and attainments, with a report of two cases, regarded, at the time they occurred, as aggravated cases of the ordinary disease: both took place in the interior, under circumstances in which there was not the slightest ground to suspect contagion, and previously to there being any suspicion of the existence of the epidemic in this country. In one, the symptoms bore, unquestionably, a considerable resemblance to the choleric stage of the epidemic; but no fever supervened. The symptoms of the other shall be given in the words of the writer:-"The total, or nearly total suspension of the secretion by the kidneys; the watery vomiting and stools; the severity of the spasms; the shrunk and corrugated state of the skin on the hands and feet, and the blueness of his nails, persuade me that his disease was of the spasmodic type. In him, moreover, a slow fever succeeded the original symptoms, and long retarded his recovery." We need not remark that we would not attempt to discriminate between such a case as this and examples of the epidemic, believing their character to be identical. This case occurred in the beginning of July, 1831. There is a certain form of the febrile stage,—that which supervenes on a choleric stage, attended with extreme collapse,-which the deficiency of the temperature and the circulation, the congested state of the con* Doctor Fenwick, of Durham.

junctiva from the very commencement of the fever, and the peculiar torpor of the intellect, would enable, as it appears to us, the observer to discriminate from any fever which we are in the habit of witnessing in this country, provided he saw the patient early and watched him throughout; but in the majority of instances, the diagnosis can only be correctly drawn by coupling the preceding history of the case with the existence of fever and with its character.

6. Appearances presented on Dissection. The external appearance of body closely resembles that which has been noticed during life: the solids are shrunk, the surface is livid, the skin of the hands and feet is corrugated, the nails are blue, and the fingers often rigidly contracted. There is no evidence of any unwonted tendency to putrefaction, nor any characteristic fœtor from the abdominal cavity. In the head are found marks of congestion, and even occasionally of extravasation. Such appearances were not of uniform occurrence in the dissections performed in Hindoostan; but they were found very constantly in those made by doctor Davy, in Ceylon; and doctor Keir, of Moscow, discovered in the Russian disease the blood-vessels of the brain and its membranes more or less turgid with blood, particularly towards the base, with a fluid effused into its convolutions, and more or less of serum in the lateral ventricles. In the thorax, the pleura and pericardium are found, as the serous membranes generally are in this disease, perfectly healthy, with the exception, occasionally, of an unusual dryness. The lungs are sometimes in a natural state, but more frequently gorged with dark-colored blood, so as to resemble liver or spleen; or they have been found collapsed on each side of the spine, leaving the thorax nearly empty. This latter appearance doctor Pollock, of the fifty-third regiment, explained by supposing gas to be extricated within the cavity of the pleura; but the thorax having been opened in such cases under water, and no air having been found, Mr. Scot is disposed to ascribe it to a contractile power exerted by the viscus, sufficient to overcome the atmospheric pressure. Both sides of the heart are in general distended with dark blood, and the bronchi are frequently filled with mucus. In the abdomen, the vessels of the liver are often much congested, and pour forth blood copiously when incisions are made into the organ; but this congestion is not uniformly found; the gall-bladder is turgid

with black bile, and its ducts are sometimes constricted and impermeable, though occasionally in an opposite state. The peritoneum is often quite healthy, but the portion investing the alimentary canal has frequently an inflamed appearance from the exceedingly loaded state of its blood-vessels. This congestion is sometimes so great as to give the appearance of gangrene; but by drawing the finger over the surface, innumerable small veins may be found running in every direction, as in a preparation nicely injected, and the texture is found to be resisting and firm. This portion of the peritoneum, however, occasionally bears marks of actual inflammation, especially if the patient has lingered long before death. It then presents a thickened appearance externally, and its color varies from a pale vermilion, through all the deeper shades, to a dark purplish hue; the former being chiefly remarkable on the surface of the duodenum and jejunum, the latter on the ileum, where it terminates in the cæcum. At other times, the whole alimentary tube, instead of this congested state, presents a blanched appearance both internally and externally. The omentum is sometimes healthy; at others, it presents the same appearance of extreme vascularity as the peritoneal surface of the alimentary canal. The following appearances are discovered on laying open the stomach and intestinal tube. A white, opaque, and viscid substance is found adhering to the surface of some portions of the mucous membrane; and in many cases it is so abundant in the intestines as completely to fill parts of them of a greater or less extent. The stomach and portions of the intestine are filled with a transparent or turbid serous fluid, and frequently the viscid matter mentioned above is found intimately mixed with the serous fluid, or floating in it in the form of flakes. The mucous membrane, except when inflamed, which it not unfrequently is, has an unnatural whiteness, is often soft and pulpy, and in generalespecially in the stomach and small intestines can be easily detached by scraping, in the form of a thick pulp, from the subjacent coat. These appearances sometimes more or less partial; but some of them are generally found throughout the whole extent of the tube. They extend, in some cases, to the mucous membrane of the bladder and ureters, and have been found, in two or three instances, in that lining the bronchi. In one case only in India was the state of the spinal mar

are

row examined; and in that, strong indications of inflammation were detected in its sheath: the case, however, was in some degree a mixed one. But doctor Keir found, at Moscow, the blood-vessels of the vertebral column and spinal chord more or less loaded with blood, which was sometimes effused between its arachnoid and dura mater; partial softening of the substance of the spinal chord was sometimes met with, and marks of inflammatory congestion in the larger nerves were detected. The dissections performed in Sunderland have generally furnished results corresponding with those obtained elsewhere. In the head, venous congestion of the brain and its membranes has been the most uniform and prominent appearance. Serum has been found in the ventricles of the brain and at its base; but in many cases this has been in small quantity, not exceeding that frequently observed after diseases in which no affection of the encephalon was supposed to exist. In some cases, especially those in which death took place in a protracted stage, but occasionally in a rapid disease, fibrinous depositions existed between the membranes. In the thorax, the lungs have uniformly been found more or less gorged with blood, though in many cases the engorgement was in the posterior part, and probably resulted from position. These organs were generally crepitating, and free from structural change. Softness or flabbiness of the heart has been noticed in several instances, and both its cavities, and the venæ cave and coronary vein, have been distended with dark-colored blood. In the abdomen, the liver has been found gorged; but occasionally its condition was natural. The gall-bladder was generally distended, and the ducts were constricted, so that the viscus could not be emptied by pressure; but in some cases they were pervious. The abdominal veins have been found generally distended; but in several instances, the vena portæ and meseraic veins have constituted an exception to this rule, having been found empty. Vascularity and pulpiness of the mucous lining of the stomach have been frequently noticed; but the former has often been slight in degree, and observers have felt disposed occasionally to attribute it to the exhibition of mustard or other

*Madras Reports, pp. 32, 34. Anderson on Cholera Morbus (Edinburgh Medical and Surgical Journal, vol. xv). Christie on Cholera (p. 47). Annesley, Diseases of India (2d edit., p. 106 et seq.). Account of the Appearances after Death, observed at Moscow, drawn up by doctor Keir.

stimulants; whilst the latter has by no means been invariably found. The lining of the intestines has been found in many parts vascular and pulpy; but these appearances are not invariable, both lesions having been found wanting, and the pulpiness more frequently than the vascularity. The peculiar secretion has generally been found in the intestines. The kidneys have been observed to partake of the general congestion of the venous system. The bladder has generally been found contracted, and either empty, or containing a small quantity of urine. No softening or other disease of the spinal marrow, a little venous congestion excepted, was discovered in the few examinations of this organ made here. In concluding this rather unsatisfactory portion of our subject, we cannot refrain from expressing a conviction that symptoms during life throw much more light on the nature of the disease and its appropriate treatment, than appearances after death.

7. Nature of the Disease. Many writers of great talent have preceded us in this branch of the subject, and much ingenuity has been displayed in the endeavor to trace all the phenomena of the choleric stage, which has been the principal subject of investigation, to a change in one part of the system. But it must be remarked that there is little accordance among medical reasoners as to the part of the body in which the phenomena of the disease are presumed to originate; for the nervous system generally, the ganglionic portion of it exclusively, the blood itself, and the lining of the digestive canal, have each found advocates equal in ability to plead their cause.* The diversity of these views is a proof of the intricacy of the subject; and probably, also, since they have all emanated from observing and ingenious men, an evidence of the variable nature of the disease; each reasoner being, perhaps, influenced by that portion of the general phenomena of the epidemic which predominated in the cases it was his lot most frequently to witness. Their partial nature, too, may be in a considerable degree ascribed to the unfortunate influence of the expression proximate cause, as a substitute for the more comprehensive term essence or nature of the disease, on medical reasoning. Even those who affect to use it as an equivalent term for nature of the dis

*These are doctor Kennedy and Mr. Orton for the first, Mr. Bell for the second, Mr. Annesley and others for the third, and Mr. Christie, with Roche and other French writers, for the last.

ease, are yet insensibly influenced by the words they employ. Amidst the crowd of phenomena presented to their notice in certain maladies, they often assume, on very insufficient grounds, that some one fact is the original of all others; and this they invest with the title of proximate cause. If the facts related respecting epidemic cholera are compared with the explanations offered of them, it will be found that each medical reasoner has attributed the commencement of the phenomena of the disease to an affection of some part of the frame, which affection unquestionably exists in a very great number of instances, but neither with that uniformity nor with that priority of time which can warrant us in concluding that it was the cause of all the other symptoms. It seems a rational supposition that the remote cause of a disease may act, in some instances, first on one, in others on another part of the system, from some local weakness or peculiarity of individual constitution, or from some specialty in the mode of application of the cause; and yet that the disease shall retain in each case such a resemblance to a common type as shall prove its identity. It is likewise supposable that the remote cause may make a simultaneous attack on more than one organ or part of the system. Complex diseases, such as fever, appear to furnish examples of both these cases. The real philosophy of medicine seems to consist in ascertaining the actual state of the system of which symptoms are the signs; and if we can proceed, through the medium of these signs and post mortem appearances, to one sole change in one organ, the treatment is simplified, and science and art are gainers. But there are diseases-and this seems to be one of them-in which we meet with a variety and complexity of pathological conditions, all of importance, and all to be kept in view in their treatment. It is true that, of these conditions, some may arise from others, according to known physiological laws, as dark-colored blood from impeded respiration, and it is right thus to explain them when possible; but the uniform endeavor to trace all to one primary change, or rather, as is more frequently done, to assume one change to be primary, and all other morbid states to be but emanations from it, is not only unphilosophical, but is too apt to tinge our practice with undue partiality. Whilst we deem that no one writer has attained, either by inferences drawn from symptoms, appearances after death, or both, a