CHOLERA. 



211 



tioned above is found intimately mixed with the se- 

 rous 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 general especially in 

 the stomach and small intestines can be easily de- 

 tached by scraping, in the form of a thick pulp, from 

 the subjacent coat. These appearances are some- 

 times more or less partial ; but some of them are ge- 

 nerally 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 marrow examined ; and in that, strong in- 

 dications 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 soft- 

 ening of the substance of the spinal chord was some- 

 times met with, and marks of inflammatory conges- 

 tion in the larger nerves were detected.* The dis- 

 sections performed in Britain generally furnished re- 

 sults 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 fre- 

 quently 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 pro- 

 bably resulted from position. These organs were ge- 

 nerally crepitating, and free from structural change. 

 Softness or flabbiness of the heart has been noticed in 

 several instances, and both its cavities, and the venae 

 cavas and coronary vein, have been distended with 

 dark-coloured blood. In the abdomen, the liver has 

 been found gorged; but occasionally its condition 

 was natural. The gall-bladder was generally distend- 

 ed, 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 portee 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 for- 

 mer has often been slight in degree, and observers 

 have felt disposed occasionally to attribute it to the 

 exhibition of mustard or other 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 vascnla- 

 rity. 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 bladcferhas generally been found con- 

 tracted, and either empty, or containing^ small quan- 

 tity of urine. No softening or other $fsease of the 

 spinal marrow, a little venous congestion excepted, 



Madras Reports, pp. 32, 34. Anderson on Cholera Mor. 

 bus (Edinburgh Medical and Surgical Journal, vol. XT.). 

 Christie on (SJiolera (p. 47). Annesley, Diseases of Ind a 

 (yd edit., p. M>6 et geq.X Account of the Appearances after 

 Death, observed at Moscow, drawn up by Doctor Keir. 

 <"* 



was discovered in the examinations of this organ made 

 here. 



7. Nature of the Disease. Many writers of great 

 talent have endeavoured to trace all the phenomena 

 of the choleric stage, to a change in one part of the 

 system. But there is little accordance among medi- 

 cal 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 por- 

 tion 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 sub- 

 ject ; and probably, also, since they have all emanat- 

 ed from observing and ingenious men, an evidence 

 of the variable nature of the disease ; each reasc^er 

 being, perhaps, influenced by that portion of the ge- 

 neral phenomena of the epidemic which predominat- 

 ed in the cases it was his lot most frequently to wit- 

 ness. Their partial nature, too, may be in a consid- 

 erable degree ascribed to the unfortunate influence of 

 the expression proximate cause, as a substitute for the 

 more comprehensive term essence or nature of the dis- 

 ease, on medical reasoning. Even those who affect 

 to use it as an equivalent term for nature of (he dis- 

 ease, are yet insensibly influenced by the words they 

 employ. Amidst the crowd of phenomena present- 

 ed to their notice in certain maladies, they often as- 

 sume, 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 re- 

 specting epidemic cholera are compared with the ex- 

 planations offered of them, it will be found that each 

 medical reasoner has attributed the commencement 

 of the phenomena of the disease to an affection ot 

 some part of the frame, which affection unquestion- 

 ably 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 ra- 

 tional 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 pro- 

 ceed, 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 impor- 

 tance, 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-coloured blood from impeded respiration, and it 

 is right thus to explain them when possible ; but the 

 uniform endeavour 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 unphilosophi- 

 cal, but is too apt to tinge our practice with undue 

 partiality. Whilst we deem that no one writer has 



* 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, Uh Roche ard other French 

 writers, for the last 



Of 



