"In comparing the recent analyses with those made during the last epidemic, it will be seen, that as far as concerns the physical properties of the blood, the diminished amount of water, and the consequent increase of the solid portion, also the high specific gravity of the serum, and its tendency to become less alkaline, our own conclusions perfectly agree with those previously made; and, therefore, that conclusions 1, 2, and 3, before given, are thus far confirmed. With regard to (4) and (5), concerning the salts and urea, our conclusions must be—

"4. That, in cholera, the saline constituents of the blood are not only not decreased in amount, but sometimes exist even in increased proportion, and that the diminution of its alkaline reaction is not due to the loss of salts, but to the impeded excretion of organic acids, which are constantly being formed in the system.

"5. That urea usually exists in increased quantities in cholera blood, but that the amount differs considerably in the different stages of the disease; being but small in quantity in the intense stage of collapse, increasing during reaction, and in excess when consecutive febrile symptoms occur."

The sinuses, and veins of the meninges, were more or Encephalon. less loaded with dark blood. In most cases this was the only morbid appearance. In 3 instances there was sub-arachnoid effusion; thus in a male, æt. 64, who died in collapse, an hour and a half after the injection of a saline solution into the veins, the whole duration of his severe symptoms being 16 hours, the brain was watery and soft, with several drachinis of fluid in the ventricles, and also great sub-arachnoid effusion. Again, in a male, æt. 56, who died in collapse, with asphyxia, after 18 hours' severe symptoms, the superficial veins between the convolutions were much distended with dark fluid blood; and a large quantity of serous fluid was effused beneath the arachnoid; each lateral ventricle also contained about half an ounce of clear fluid. In the third case, a female, æt. 53, who died suddenly in collapse, the vessels of the pia mater were moderately full of blood, with slight oedema of the tissue. In addition to these cases, 2 others were reported, in which there was effusion into the lateral ventricles; death took place in collapse, the duration of the severe symptoms being in one 30 hours, and in the other 12; in both, "the lateral ventricles were dilated and full of serum."

The brain substance was normal, except that it often presented on section numerous red points, from fulness of the smaller veins. In one of the cases noted above, and in 2 others, the tissue was rather moist.

The results given by Briquet and Mignot* are drawn from 22 cases: "For the most part the sinuses of the dura mater and the large vessels were full of blood. In 20, a fine injection of the capillary vessels of the pia mater gave a purple color to the surface of the hemispheres, more marked on the convexity than at the base of the brain. . . . . In 5, a general opalescence of the arachnoid was noticed, with patches of a milky whiteness. In 5 there was adhesion (?) of the pia mater to the cerebral substance; and in 10 sub-arachnoid effusion.

"The grey substance was dark colored, and the white dotted with points from the engorged vessels. The surface of the ventricles was frequently of a roseate tint. In 5 cases the ventricles contained a considerable quantity of serous fluid, slightly tinged with blood. The cerebral substance had the normal consistence. In some cases, the flattening of the convolutions seemed to indicate a certain amount of turgescence."

Virchow + observes that he met with no structural changes in the brain and spinal cord. "There was well-marked venous hyperæmia, with oedema of the pia mater, and sometimes a slight increase of fluid into the ventricles."

Reinhardt and Leubuscher report as follows:-"After death in the algide stage, we always found the veins of the meninges more or less congested, together with oedema of the pia mater in different degrees. The cerebral substance was healthy, occasionally rather vascular. In the ventricles nothing abnormal, except venous congestion of the plexus choroides."

* Op. Cit., p. 420. † Med. Reform, No. 12.

+ Op. Cit.,

P. 509.

MORBID APPEARANCES WHEN DEATH OCCURRED AFTER

Stomach.

REACTION.

THE mucous membrane of the stomach was either natural in appearance, or presented scattered patches of hyperæmia at different parts, especially at the greater cul-de-sac, and along the lesser curvature towards the pylorus. In a male, æt. 29, who died on the ninth day of consecutive fever, the mucous membrane of the stomach was of a dark color, from congestion, with numerous minute spots of ecchymosis. In a female, æt. 37, who died on the seventh day of the disease, "there was general and intense injection of the mucous membrane of the stomach, most marked along the lesser curvature and posterior surface; the injection was striate and punctate, the tissue not softened." Again, in a male, æt. 39, who died on the eighth day, "there was punctate injection in different parts of the stomach, and at the cardiac end a slough as large as a split pea nearly through the coats. The surface of the mucous membrane was covered with bloody mucus." In a fourth case, a male, æt. 45, death occurring on the third day with partial reaction, the stomach was "much contracted, the mucous membrane hyperemic along the lesser curvature and near the pylorus, the ridges of the rugæ being of a dark color, from vascular injection. About three or four inches from the pylorus there were two ulcers, the larger being about half an inch long; the edges were sharply defined and minutely injected.

Reinhardt and Leubuscher* observe that, "in the latter stages of the disease, the hyperæmia of the stomach was much less marked or altogether absent. Fibrinous exudations upon the surface of the mucous membrane were not observed."

Briquet and Mignot describe the morbid appearances occurring during the period of reaction under four distinct sections:

1st. As observed after death from asphyxia, reaction being incomplete.

Op. Cit., pp. 486, 492.

2nd. From cerebral congestion.

3rd. From meningo-encephalitis.

4th. From thoracic inflammation.

The following is a summary of their observations upon the gastric mucous membrane as recorded under these different sections. It was examined in 35 cases, in 23 of which there was some amount of congestion. This was greatest in the 5 cases contained in the first section, and which obviously belonged rather to the cold stage than to the period of reaction; in all the others it was but trifling.

This accords with the observations of others, that during the period of reaction, the congestion of the gastro-intestinal mucous membrane which characterized the algide stage, was lessened or entirely removed.

In a few of their cases these authors speak of softening of the mucous membrane, principally limited to the greater curvature, and never extensive. It was probably, from its seat, a post-mortem change, in confirmation of which probability they state that, in some cases, the softening was gelatiniform.

Small

The mucous membrane of the small intestine was Intestine, &c. generally pale or only slightly hyperæmic, and the pulpy edematous condition of the tissue and intestinal glands, occurring in the algide stage, had much diminished or entirely disappeared. There were, however, some exceptions to this tendency to resolution of the previous hyperemia, and restoration of the tissue to its normal condition; those parts of the mucous membrane which during the cold stage had been most affected by vascular injection, being occasionally subject, during reaction, to progressive diphtheritic effusion, which subsequently led, as described below, to disintegration of the tissue.

The glandular structures were not the seat of any special secondary affections. When they were in a morbid condition, which was rare, it was in common with the general mucous surface adjacent; but inasmuch as, at this period of the disease, the lesions of the first stage were receding, so the patches of Peyer and the solitary glands were either quite normal or less swollen and oedematous than in the cold stage.

The following are the particulars given by Reinhardt and Leubuscher, of the morbid appearances found in the intestinal tract in this stage:-"In one series of cases of which the numbers were small, the changes in the mucous membrane previously observed in the cold

stage were either receding or had entirely disappeared. The hyperæmia of the capillary veins in particular had lessened or was no longer perceptible, and only the larger ones were here and there congested. Corresponding to this change, the membrane, instead of being of a bright red, was of a dull grey or slate color. The solitary glands and Peyer's patches were now only slightly enlarged or quite normal. The contents of the canal fœculent. The intestinal tract often presented no further morbid appearances either when death had occurred in the typhoid stage, or when accidental complications had supervened. . . . . In a second and more numerous series of cases, some parts of the intestine were in the condition above described, whilst others presented, to a greater or less extent, appearances having the closest similarity to dysentery.

"The mucous membrane, and also the submucous tissue in the severer forms of the affection, were deeply reddened, vividly injected, and also infiltrated to a greater or less extent with extravasated blood. In the large intestine the affected parts were commonly in the form of longitudinal or oblique folds, or irregular bosses and protuberances, arising from œdema of the submucous cellular tissue; when incised and compressed, the serous fluid was discharged, and they collapsed. In the small intestine, the hyperæmia was mostly on the ridges of the transverse folds (valvulæ conniventes), which were also swollen from serous exudation. In only one of the cases of this series, where death occurred quickly upon reaction, were the changes in the large and small intestine such as are here described; in all the others the congested parts were infiltrated to a greater or less extent with a solid exudation, which, after Virchow, we would designate diphtheritic.' This exudation contained but little water, was of a greyish or yellowish-white color, and under the microscope was amorphous. It was rendered translucent by acetic acid and caustic alkali, but resisted the action of the former for some time. The deposit began in the superficial layers of the mucous membrane, and was mostly confined to the membrane itself, but in certain parts it extended somewhat beyond, as in the small intestine, where it filled up the spaces between the villi, fusing them together into a continuous mass, in which, by the aid of the microscope, the outline and tissue of some of the villi could occasionally be distinguished. The infiltration gradually extended from the superficial to the deeper layers of the membrane, and not rarely to the submucous tissue.