in the cold stage, compared with those in the hot, was far greater in India, according to doctor Russell's experience, than here. Fourthly, the number of medical men and hospital attendants attacked with cholera during the present epidemic, in proportion to the whole employed, and to other classes of society, has been beyond all comparison greater here than in India under similar circumstances." Doctor Keir, of Moscow, gives the following description of the consecutive or secondary morbid state :-"A second ordeal now begins, sometimes as severe, and frequently not less fatal, though more slowly so, than the first: this is probably the effect of the morbid changes which have been induced during the first period of the disease. The appearance of the complaint is now entirely changed, insomuch that one who had not seen the patient during the first period, or been told of the symptoms, could not possibly know that he was suffering from the epidemic. I have observed the disease in this, its second period, to assume four forms: the first, an inflammatory, or rather sub-inflammatory state of the stomach and bowels, most frequently the latter, sometimes conjoined; the second, inflammatory irritation of the lungs, with pain of the chest, cough, viscid expectoration and fever, appearing as a critical metastasis of the disease; the third, bilious or bilio-nervous fever, with suppuration of the parotid glands-in one case, with axillary suppurating bubo, towards the end of the fever, an inflammatory irritation of the lungs took place, ending in vomica; and the fourth, a congestive sub-inflammatory state of the brain and spinal chord. This last, as was natural to expect from the nature and seat of the affection, proved by far the most dangerous and most frequently fatal form of the second period: it appeared generally to superand likewise between that which existed in Hindoostan and Ceylon, perhaps as considerable as those now observed by these intelligent physicians. In regard to what is stated in the extract referred to, relative to the greater frequency at Petersburg of the secondary "typhoid," or, as more commonly designated in India, "low biliary" symptoms, we confess that we observe a discrepancy when we read a subsequent part of the same Report, in which doctors Russell and Barry state, "Convalescerce from cholera has been rapid and perfect here, as is proved by the following fact:The minister of the interior had given orders that all convalescents, civil as well as military, at the general hospital, should be detained fourteen days. We inspected about two hundred of these déténus some days back, with sir J. Wylie, and found them in excellent health, without a single morbid sequela."

vene after the purging, vomiting and cramps had been relieved, and the external heat in some degree restored; the patient complained of pain in the back, between the shoulder-blades, or in some other part of the spine, sometimes along its whole tract; he appeared sleepy to such a degree that at first I was disposed to attribute this state, in part at least, to the effects of the opium given in the first period. But I was soon convinced that the cause of this symptom, and of another strongly characteristic of this form of the disease, namely, the filling of the vessels of the sclerotica with red blood, was a congestive sub-inflammatory state of the brain and spinal chord. This striking symptom at first began to show itself in the inferior part of the globe of the eyes; it gradually increased, and, little by little, reached the upper part, while the eyes turned upwards, exposing the lower part gorged with blood. This state of the patient generally ended in a complete coma, and proved fatal a few hours afterwards." Besides the various and appalling symptoms which indicate general derangement of the action of the solids, there are appearances in the blood drawn during the collapsed stage, showing that the fluids feel the influence of this formidable disease. These appearances are very uniformly expressed by the terms dark, black, or tarry, in regard to color, and by thick, ropy, sirupy, or semi-coagulated, in respect to consistence. This change in the condition of the circulating fluid is fully proved to be in the ratio of the duration of the disease; the blood at the commencement seeming to be nearly or altogether natural, and more or less rapidly assuming a morbid state as the malady advances. This condition was less conspicuous in cases of cholera ushered in by symptoms of excitement, than where the collapsed state of the system had occurred early; and in certain rare cases it was not observable at all, and the blood flowed readily from the vein; but the reverse was the fact, both with respect to its condition and the manner of its flowing from the arm, in an immense majority of instances. In general, after a certain quantity of dark, thick blood had been drawn, its color became lighter, its consistence less thick, and the circulation revived, such appearances always affording grounds for a proportionably favorable prognosis. There is some discrepancy in the accounts transmitted to us of the mode in which this diseased blood coagu lates. In some instances, we learn, the

coagulation is rapid, whilst in others it is slow and imperfect. Reporters are unanimous in declaring it deficient in serum, and destitute of the buffy coat. The latter is occasionally observed in cases attended with reaction, in which the blood is not black and thick.* The discharges from patients suffering under this disease were subjected to experiment by doctor Christie. The secretion consists of two substances, the one a transparent serous fluid, the other an opaque, white coagulum; the former perfectly soluble in cold water, the latter quite insoluble. These matters being submitted to the action of reagents, the fluid part was found to be pure serum, and the coagulated portion fibrin. The secretion, therefore, as the author remarks, has a composition similar to that of the blood deprived of its coloring matter; but the serum is in much larger proportion to the fibrin.

II. Character of the Epidemic as it appeared in Sunderland in 1831. Thus far (says the English writer) our account of this formidable malady has been derived from the very valuable mass of information with which we have been favored by our medical brethren in India, and the many intelligent men who have witnessed its ravages on the continent of Europe. Circumstances having brought it under our own observation, we shall endeavor to convey succinctly to the reader the results of our experience, prefaced by a few reflections on the character and designation of the disease which this experience has suggested to us. Were we to attempt a definition of epidemic cholera, the following, according to our experience, would comprise its distinctive symptoms:-After watery diarrhoea, or other generally slight indisposition, vomiting and purging of a white or colorless fluid, violent cramps, great prostration and collapse, the last occurring simultaneously with the vomiting and cramps, or shortly after them. Should the patient survive the last train of symp

* Madras Report, p. 30, &c.

By collapse, in this definition, is meant the feebleness or almost the arrest of the circulation; the death-like appearance, the coldness, shrinking, and occasional blueness of the surface, which may in other diseases be observed after they have existed some time, and as the powers of life are passing away; but which occur, in what we shall call the cold or choleric stage of the epidemic, in a short time after its commencement, as though they formed an essential part of it. The degree and early accession of this collapse, and the white discharge, are the only distinctive marks that we are aware of between this stage of the epidemic and ordinary cholera.

toms, a state of excitement and fever supervenes. We can convey a correct idea of the disease only by dividing it inte three stages, the incipient, the cold or choleric, and the febrile: the division accords with the character of the disease.

1. Symptoms of the Incipient Stage. In an immense majority of instances, diarrhoea has been the prominent symptom of this stage. Languor and lassi tude, and occasionally nausea and ver tigo, coexisted with the disorder of the bowels, and sometimes certain of these symptoms may have appeared without it; but its occurrence has been so common, that we have treated few cases in which it had not preceded the more formidable symptoms. On examining the discharges if we have an opportunity of doing sc shortly after the occurrence of the diarrhoa, they will be observed to be fœcal and bilious; but we shall find that they subsequently bear the serous character of those which occur after the choleric stage is fully formed: they are passed copiously and without much griping; the feeling of debility which attends them is great, and this diarrhoea is so exhausting, that we have met with patients, especially those advanced in life, in whom a considerable degree of collapse had occurred, with a feeble pulse, scarcely exceeding fifty, before the accession of vomiting and cramps. The natural tendency of this purging is, we believe, to pass into the choleric stage; but the transition has frequently occurred shortly after some dietetic error, either as to quantity or quality of food, or after exposure to cold. The commencement of the purging has sometimes preceded by several days the accession of the choleric stage, and occasionally only by eight or ten hours; but forty-eight hours has been its mean duration, calculated from a great number of instances. We have dwelt the more on this incipient stage, from a conviction, the result of considerable observation of the disease, that subsequent symptoms might often be prevented, and life preserved, by early and proper treatment of the diarrhoea.

2. Symptoms of the Cold or Choleric Stage. Our description will be more intelligible if we divide into two periods this very important stage, which has, in truth, given its name to the disease, and, by its fearful symptoms, has engrossed such general attention, that the facts of its being but part of a series of changes, has been too often lost sight of

-First Period. The time of invasion has been, as in India, in a great majority of

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. However 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

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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 consid erably 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 vomitinga 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, be 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 sea son 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 occur rence 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 mem branes more or less turgid with blood, par ticularly 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