CHOLERA. 



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 labours have 

 thrown much light on the condition of many parts, 

 and Uiat very great practical good has resulted from 

 tlw information thus obtained. That the nervous 

 system generally, and especially the ganglionic and 

 spinal nerves, and the spinal inn In I hi itself, are af- 

 fected, 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 con- 

 dition in cases which terminate favourably, remains 

 yet to be ascertained ; and it must be remarked, too, 

 that, in fatal cases, this inflammation has not been al- 

 ways detected. The state of the sanguiferous system 

 is very remarkable ; but here, too, we must feel some 

 doubt whether the feebleness or almost complete ar- 

 rest 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, tlirough the medium of 

 this system, from the condition of the alimentary 

 canal. Is the dark appearance of the blood to be ex- 

 plained 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 oxidia- 

 ed. This hypothesis explains readily the dark ap- 

 pearance 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 ah- ex- 

 pired oy patients in the choleric stage is colder, and 

 contains less than the usual proportion of carbonic 

 acid ; and that this is the case even when the breath- 

 ing is full, free, and rapid. The explanation offered 

 is confirmed by an observation of Mr Ellis, in his ex- 

 periments 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 af- 

 fection of the alimentary canal is essential and prima- 

 ry, 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 sus- 



pension 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 ;ip- 

 parent anomaly presented by the continuance of the 

 cutaneous and intestinal discharges amidst the gene- 

 ral suspension of secretion, is well explained liy Mr 

 Bell's distinction between this function and exuihi 

 tion or exhalation.* That the whole series of pheno- 

 mena 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 na- 

 ture of the primary change effected by it in various 

 organs or systems ; and it is to be feared that till 

 more accurate ideas are attained respecting the patho- 

 logy of fever in general, this ignorance will remain. 

 In the febrile stage, we would remark, there are in- 

 dications by no means equivocal of inflammatory af- 

 fection of the brain, and occasionally of other organs, 

 the analogy to fevers in general being in this rt-speH. 

 preserved? Were we to judge solely from what we 

 have ourselves observed of the commencement of the 

 disease, we should consider the alimentary canal to 

 be tlie 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, re- 

 ported from abroad, particularly from India, lead to 

 the opinion that in various instances the nervous sys- 

 tem 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 abate- 

 ment of the intensity of the disease, or from the im- 

 provement of the method of treatment adopted by 

 our medical men, or, as is more probable, from the 

 co-operation of both these circumstances, it was sub- 

 sequently 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 lias recovered in which 

 medicine had not been administered. From this ap- 

 palling statement, it is gratifying to humanity to turn 

 to the following records. According to the docu- 

 ments 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, 1664 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, 231 per cent, of the troops were attack- 

 ed, and that of these 22| 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 em- 

 ployed, and to medical science, in general. We hear, 

 in different situations, of rates of mortality infinitely 

 lower than this. Doctor Burrell, surgeon of the six- 

 ty-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 sta- 

 tion, makes the mortality much less, declaring that 

 the disease is not fatal in more than one in a hundred 

 of those who are early succoured. Doctor Burrell 

 found, too, that of a certain description of cases, those 

 attended with violent spasms, he saved eighty-eight 



* Treatise on Cholera Asphyxia, pp. 56, 57. 



