3G8 NITRITE OF AMYL IX THE COLLAPSE OF CIIOLEllA. 



attributed ; viz., reflex action from the intestines, and the direct 

 action of the cholera poison, whatever that may be, on the vessels 

 themselves. The occurrence of symptoms almost exactly resem- 

 bling those of cholera-collapse in cases of perforation of the 

 intestines, or of intense gastro-intestinal irritation by arsenical 

 poisoning, would seem to favour the first view. On the other 

 hand, the fact that there is no great lesion of the intestinal tube 

 in cholera during life — the denudation of epithelium, on which 

 Niemeyer laid much stress, being chiefly, if not entirely, a post- 

 mortem phenomenon — as well as the occurrence of symptoms of 

 collapse after intense malaria poisoning, as mentioned by 

 Goodeve,* is in favour of the second view, and between them I 

 cannot pretend to decide. Whatever be the cause of the con- 

 traction of the pulmonary vessels in cholera, we may, I think, 

 assume that the obstruction to the circulation is due partly to 

 it and partly to the thickened condition of the blood. 



The indications for treatment in cholera-collapse, then, are — 

 1. To remove the paralysis of the intestinal nerves. 2. To 

 dilute the thickened blood. 3. To dilate the pulmonary capil- 

 laries. 4. To oxygenate the blood passing through them. 



How the paralysis is to be removed I for one do not know. 

 That the copious secretion from the bowel eliminates the poison 

 from the blood is, I think, doubtful, and any benefit that may 

 result from it in this way is, I believe, more than counteracted 

 by the alteration wliich it produces in the condition of the 

 blood. That many cases in which the discharge has been pro- 

 fuse have ended in recovery, and that others in which it has 

 been scanty have terminated fatally, may simply show (if the 

 analogy between the secretion in the intestine and the sub- 

 maxillary gland be correct) that the nervous paralysis has been 

 more complete in the latter than in the former case, while the 

 accumulation of fluid in the intestine without purging, in the 

 so-called cholera sicca, would indicate paralysis not merely of 

 the secreting, but also of the motor, nerves of the bowel. "What 

 I have just said, however, is no argument against the use of 

 castor-oil in the treatment of collapse. When we know so 

 little of the pathology of the disease, or of the action of the 



* Eejn olds' Sj/stem of Medicine, toI. i, p. 17. 



