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 cf 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 hat hiring 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. ness or flabbiness of the heart has been noticed in several instances, and both its cavities, and the vena cava 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 dis tended; 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

Soft

*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; warst 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 une 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

knowledge of the affection of any one organ in cholera which can be properly termed a proximate cause whence all the other phenomena arise; or acquired precise ideas respecting the nature of the affection of many organs which manifestly participate in the disorder; it is gratifying to acknowledge that their labors have thrown much light on the condition of many parts, and that very great practical good has resulted from the information thus obtained. That the nervous system generally, and especially the ganglionic and spinal nerves, and the spinal medulla itself, are affected, is manifest from many symptoms; but whether this affection arises from a direct impression of the remote cause of the disease on these organs, or from irritation propagated from the alimentary canal along the ganglionic nerves to the spine, we are ignorant. Doctor Keir's able researches have shown that, in some fatal cases, inflammation of a portion of this system has existed; but its precise pathological condition in cases which terminate favorably, remains yet to be ascertained; and it must be remarked, too, that, in fatal cases, this inflammation has not been always detected. The state of the sanguiferous system is very remarkable; but here, too, we must feel some doubt whether the feebleness or almost complete arrest of the heart's action is a primary effect of the cause of the disease, or, as suggested by Mr. Bell, arises from the affection of the ganglionic system; or, again, whether it results, through the medium of this system, from the condition of the alimentary canal. Is the dark appearance of the blood to be explained by the feebleness of the action of the right ventricle, as a consequence of which but little blood is transmitted through the lungs and exposed to the influence of the air? According to this view, which is suggested with diffidence, the imperfection of the respiratory process will arise from the same cause as in congenital malformation of the heart, such as the persistence after birth of the foramen ovale, or the aorta arising from both ventricles, in which a very small proportion of the whole mass of blood is oxidized. This hypothesis explains readily the dark appearance of the blood, its accumulation in the great veins of the viscera, the coldness and lividity of the skin, and the imperfection of the respiratory process, which has been so ably illustrated by doctor Davy. This gentleman was the first to show that the air expired by patients in the choleric stage is colder, and con

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tains less than the usual proportion of carbonic acid; and that this is the case even when the breathing is full, free and rapid. The explanation offered is confirmed by an observation of Mr. Ellis, în his experiments on respiration, that as the circulation declined, so likewise did the emission of carbon, and, consequently, the production of carbonic acid." The thickened consistence of the blood receives a ready explanation from the loss of its serous part by the abundant discharge from the inner intestinal surface, There are two morbid conditions of the lining of the digestive canal. In one it is in a state of manifest inflammation; in the other it is white and pulpy, and easily detached from the subjacent coat. Is this latter condition the result of a disorganizing inflammation which has itself passed away? or must we be content to describe the action which has produced it by the very unsatisfactory and vague expression, disturbance of the function of nutrition ? This is a question rather of general pathology than one connected solely with this disease; but it is one as yet undecided. The affection of the alimentary canal is essential and primary, if any part of the disease is so; and it were vain to attempt to trace it to a morbid condition of any other organ or system of organs. The general suspension of secretion, which is complete only when the collapse is extreme, appears to result from the disorder of those systems, the nervous and vascular, on which this important function depends. The apparent anomaly presented by the continuance of the cutaneous and intestinal discharges amidst the general suspension of secretion, is well explained by Mr. Bell's distinction between this function and exudation or exhalation.* That the whole series of phenomena results from the action of a morbific poison on the body, there can be no doubt; but as yet, as in the case of fevers, we are ignorant of the precise nature of the prmary change effected by it in various organs or systems; and it is to be feared that till more accurate ideas are attained respecting the pathology of fever in general, this ignorance will remain. In the febrile stage, we would remark, there are indications by no means equivocal of inflammatory affection of the brain, and occasionally of other organs, the analogy to fevers in general being in this respect preserved. Were we to judge solely from what we have ourselves observed of the commencement of the disease, we should * Treatise on Cholera Asphyxia, pp. 56, 57.

consider the alimentary canal to be the part of the frame which first felt the influence of the poison; but we should consider the condition of the nervous and vascular systems much too intense in degree to be merely sympathetic of the state of the stomach and bowels. Many cases, moreover, reported from abroad, particularly from India, lead to the opinion that in various instances the nervous system is primarily affected.

8. Proportionate Mortality. The mortality during the early prevalence of the epidemic in India in 1817 and 1818 was very great; but, either from the abatement of the intensity of the disease, or from the improvement of the method of treatment adopted by our medical men, or, as is more probable, from the coöperation of both these circumstances, it was subsequently very much reduced. There is no disease in which unassisted nature seems more powerless than this. We learn from the report to the medical board at Bombay, that there is reason to believe that, of 1294 cases which received no medical assistance, every individual perished; and it is added, that it is not ascertained that any case has recovered in which medicine had not been administered. From this appalling statement, it is gratifying to humanity to turn to the following records. According to the documents collected by the Madras medical board, the number of deaths caused by it in the army of that presidency during 1818 and the four subsequent years, was 4430, of which 695 occurred among the European troops, and 3735 among the sepoys. The number attacked was 19,494, namely, 3664 Europeans and 15,830 natives. The average strength of the army during the period included in the reports being 10,112 Europeans and 73,254 natives, it follows that, in five years, 233 per cent. of the troops were attacked, and that of these 223 per cent. were carried off, or 5 per cent. of the whole force of the army. This statement, though sufficiently distressing, is still a proud monument to the skill of the medical men employed, and to medical science in general. We hear, in different situations, of rates of mortality infinitely lower than this. Doctor Burrell, surgeon of the sixty-fifth regiment, reports, for instance, from Seroor, that out of sixty cases he lost four, being at the rate of 6.6 per cent.; whilst Mr. Crow, at the same station, makes the mortality much less, declaring that the disease is not fatal in more than one in a hundred of those who are early succored.

Doctor Burrell found, too, that of a certain description of cases, those attended with violent spasms, he saved eighty-eight out of ninety.* In taking these estimates into consideration, we must always recollect, however, that, in epidemics, there is often a very wide difference in the gravity of the disease at different points or in different years, indeed, sometimes at nearly the same point and in the same year; so that, when we hear of an extremely small loss in proportion to the number attacked, long experience does not permit us to doubt that in such a case the type of the disease has been very mild. The ravages of the disease in civil life, amid a comparatively unorganized population, where prompt assistance could not always be rendered to the sufferers, furnish a considerable contrast to this statement from the British army, and strongly confirm the opinion expressed of the importance of early treatment in a malady so rapid in its coursé, and in which the efforts of nature are so impotent. At Bushire, in the Persian gulf, we learn from Moreau de Jonnés, that in 1821 a sixth part of the inhabitants perished; and at Bassora, in the same year, Mr. Rich informs us that eighteen thousand died, of whom fourteen thousand perished within a fortnight. The number attacked in Moscow from September, 1830, to January of the following year, was 8130, of which perished 4385, or fifty-four per cent. In the small town of Redislscheft, of eight hundred sick, we learn from doctor Reimann, that seven hundred died in one week. The greatest success which has attended the treatment of the disease in the Russian empire, so far as the records have reached us, occurred in the district of Orenburg, the number attacked being 3590, of whom 865 perished, or about twenty-four and one tenth per cent., a result creditable to the vigilance of the Russian government, and to the skill and care of the medical men employed. The treatment adopted was that of our Indian practitioners-bleeding, calomel, opium, warmth and friction. The disease having, there is every reason to think, run its course through the town in which these observations were written [Sunderland], it may not be uninteresting to mark the amount of its ravages. A simple cal

*Bombay Reports, p. 68, &c.

+ Memoir of doctor Loder, physician to the em peror at St. Petersburg, dated January, 1831, and read at the academy of medicine at Paris.

Substance of a report published by the su preme medical board of Russia.