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 labors have thrown much light on the condition of many parts, and that very great practical good has resulted from the information thus obtained. That the nervous system generally, and especially the ganglionic and spinal nerves, and the spinal medulla itself, are affected, 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 condition in cases which terminate favorably, remains yet to be ascertained; and it must be remarked, too, that, in fatal cases, this inflammation has not been always detected. The state of the sanguiferous system is very remarkable; but here, too, we must feel some doubt whether the feebleness or almost complete arrest 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, through the medium of this system, from the condition of the alimentary canal. Is the dark appearance of the blood to be explained 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 oxidized. This hypothesis explains readily the dark appearance 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 air expired by patients in the choleric stage is colder, and con

tains less than the usual proportion of carbonic acid; and that this is the case even when the breathing is full, free and rapid. The explanation offered is confirmed by an observation of Mr. Ellis, in his experiments 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 affection of the alimentary canal is essential and primary, 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 suspension 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 apparent anomaly presented by the continuance of the cutaneous and intestinal discharges amidst the general suspension of secretion, is well explained by Mr. Bell's distinction between this function and exudation or exhalation.* That the whole series of phenomena 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 nature 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 pathology of fever in general, this ignorance will remain. In the febrile stage, we would remark, there are indications by no means equivocal of inflammatory affection of the brain, and occasionally of other organs, the analogy to fevers in general being in this respect preserved. Were we to judge solely from what we have ourselves observed of the commencement of the disease, we should * Treatise on Cholera Asphyxia, pp. 56, 57.

consider the alimentary canal to be the 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, reported from abroad, particularly from India, lead to the opinion that in various instances the nervous system 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 abatement of the intensity of the disease, or from the improvement of the method of treatment adopted by our medical men, or, as is more probable, from the cooperation of both these circumstances, it was subsequently 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 has recovered in which medicine had not been administered. From this appalling statement, it is gratifying to humanity to turn to the following records. According to the documents 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, 3664 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, 233 per cent. of the troops were attacked, and that of these 223 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 employed, and to medical science in general. We hear, in different situations, of rates of mortality infinitely lower than this. Doctor Burrell, surgeon of the sixty-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 station, makes the mortality much less, declaring that the disease is not fatal in more than one in a hundred of those who are early succored.

Doctor Burrell found, too, that of a certain description of cases, those attended with violent spasms, he saved eighty-eight out of ninety.* In taking these estimates into consideration, we must always recollect, however, that, in epidemics, there is often a very wide difference in the gravity of the disease at different points or in different years, indeed, sometimes at nearly the same point and in the same year; so that, when we hear of an extremely small loss in proportion to the number attacked, long experience does not permit us to doubt that in such a case the type of the disease has been very mild. The ravages of the disease in civil life, amid a comparatively unorganized population, where prompt assistance could not always be rendered to the sufferers, furnish a considerable contrast to this statement from the British army, and strongly confirm, the opinion expressed of the importance of early treatment in a malady so rapid in its course, and in which the efforts of nature are so impotent. At Bushire, in the Persian gulf, we learn from Moreau de Jonnés, that in 1821 a sixth part of the inhabitants perished; and at Bassora, in the same year, Mr. Rich informs us that eighteen thousand died, of whom fourteen thousand perished within a fortnight. The number attacked in Moscow from September, 1830, to January of the following year, was 8130, of which perished 4385, or fifty-four per cent. In the small town of Redislscheft, of eight hundred sick, we learn from doctor Reimann, that seven hundred died in one week. The greatest success which has attended the treatment of the disease in the Russian empire, so far as the records have reached us, occurred in the district of Orenburg, the number attacked being 3590, of whom 865 perished, or about twenty-four and one tenth per cent., a result creditable to the vigilance of the Russian government, and to the skill and care of the medical men employed. The treatment adopted was that of our Indian practitioners-bleeding, calomel, opium, warmth and friction. The disease having, there is every reason to think, run its course through the town in which these observations were written [Sunderland], it may not be uninteresting to mark the amount of its ravages. A simple cal

* Bombay Reports, p. 68, &c.

+ Memoir of doctor Loder, physician to the emperor at St. Petersburg, dated January, 1831, and read at the academy of medicine at Paris.

+ Substance of a report published by the supreme medical board of Russia.

culation shows that the mortality amount ed to one in two hundred and one and a fraction of the whole population in which the disease prevailed: that of Sunderland was as one to about a hundred and fifteen of its population; that of Bishop Wearmouth as one to seven hundred and six, and, exclusive of Ayre's Quay, as one to somewhat more than one thousand; and that of Monk Wearmouth as one to three hundred and fifty-four. There is nothing very alarming in such a rate of mortality as we have described: it is high on the number attacked, but low on the amount of population; and the former circumstance, and the rapidity of the disease, will probably be found to constitute its most appalling features, if its course elsewhere in this country resemble that observed here. Other epidemics which visit us exceed it, whether we regard the number or the quality of victims, in the amount of evil inflicted; but none is to be compared with it in fatality, in proportion to the number attacked, or in the rapidity with which it accomplishes the work of destruction. Our friend doctor Ogden has furnished us with the following calculation, which is interesting, provided the results of similar calculations made elsewhere in this island correspond with it; for it will thus be shown that, in one point of some importance, the proportion of the sexes attacked,—the disease here observes a course directly the reverse of that witnessed elsewhere in its progCases of cholera, known to be such, buried at Sunderland, between the 28th of October and 22d of December:

ress.

Besides showing that, at the period of middle life, the number of female victims of the disease is double that of males, and that at the two extremes the numbers are as nearly equal as possible, this table shows how large a proportion of aged persous the whole amount of mortality comprises, these constituting more than one half of the total of deaths. The preponderance of attacks in females over those in males, at the period of middle life, is probably to be explained partly in the manner suggested by doctor Ogden, that the dress of the latter sex furnishes a better security against cold than that of the former; and in part by the circumstance that males, at the working period

of life, are better nourished than females, being frequently the only members of the family who partake of animal food.

6. Extent of Diffusion, and Causes of the Disease. On the first branch of this subject, we cannot be wrong, so frequently have its details been presented to the public, in assuming considerable knowledge, on the part of our readers; or in referring those who may wish for more minute information than is ordinarily possessed, or than we have space to give, to the admirable chronological table of M. Moreau de Jonnés. The present epidemic originated in the district of Nuddea, and perhaps in some other parts of the Delta of the Ganges, about the end of May or the beginning of June, 1817. It did not, during that year, extend beyond the territory of Lower Bengal; but in 1818 and the early part of 1819, it diffused itself throughout the extreme length and breadth of the Indian peninsula, moving in lines more or less diverging, and attacking in succession places generally more remote from the seat of its origin (though striking deviations from this rule were occasionally observed), and situated in various directions from it; but leaving untouched many districts placed between its lines of movement. Its progress along the lines it selected was wonderfully uniform, being, for some successive months, at the rate of about one degree in a month. As early as 1818, it extended itself beyond the boundaries of Hindoostan into the Burmese empire and other territories of Eastern Asia, and, making gradual progress through these extensive realms, reached China in 1820, and, in the following year, visited the numerous and populous islands situated in the Indian archipelago. The isle of France suffered its invasion in 1819, and some cases occurred in the same year at one point in Bourbon, in which island it has not since appeared. In 1821, it extended along the shores of the Persian gulf, and, during this and the following year, spread through parts of Arabia, Persia, Mesopotamia, Syria and Judea, and closely threatened Europe. It appeared in the Russian territories in 1823, at Saillan,Ghillan, Orenburg and Astracan; but its farther northern and western progress was for a time arrested. It, however, reappeared in Orenburg in 1828, and again in 1829, and in 1830 advanced through the southern provinces of the Russian empire till it reached Moscow, on the 28th of September of that year. Its subsequent progress through Russia, Poland, the Austrian do

which arrives from Central Asia at midsummer, or by the Kirghis, a semi-barbarous Tartar horde, from whom the government of Orenburg is separated by the river Ural, was, if not disproved, rendered in the highest degree improbable.* "When the disease attacked the sixth regiment at Colabah, in July, 1828," says Mr. assistant-surgeon Spence, of the fif ty-second regiment, "its commencement was a remarkable proof against its contagious nature. It was in the midst of the rainy season, and not a case had been seen for months either in or near Bombay, when assistant-surgeon Campbell, in paying his evening yisit to the hospital, found an old soldier, who had been under treatment some time for hepatic affection, suddenly seized with cholera. He went to the opposite extremity of the building for the purpose of consulting with the surgeon, and found him busily employed with another man, who had been almost simultaneously affected. Now, it is physically impossible that these two individuals could have received the disease by contagion, because that which does not exist cannot have issue." The disease proceeded with unabated violence, till it destroyed sixty men and several women.t The following example of personal intercourse between the healthy and infected without communication of the disease, is taken from Mr. Annesley's Sketch of the Diseases of India. Cholera attacked the field force stationed at Shalligaum in Kandiesh, and raged with great violence among the corps posted on the left of the line, while the seventeenth battalion of native infantry, who were posted on the right of the line, were exempt from it, though they had constant communication with the other men. 2. The gradual diffusion of a disease throughout a limited community, those near the sick being first attacked, and others in succession in proportion to their proximity, is strong evidence of a disease being contagious. But this evidence has rarely been furnished by cholera: the general statement from India, indeed, is of a totally opposite nature; for we learn that, on its appearance in any place, numbers are simultaneously attacked, and that, after committing unheard-of ravages for a short period, its cessation is as sudden as its invasion. One example, however, resembling in some degree this gradual diffusion, is given in the Russian reports; and this is

* Ibid.

Taken from Mr. Spence's Manuscript, since published in the Medical Gazette.

furnished by the staff-physician, doctor Schimanski, with regard to the extension of the disease at Iletsk. He says he was able to trace the progress of the disease in the first eight cases, thus:-The husband of the woman (a soldier's wife) from Orenburg, was taken ill three days after her; and about the same time, also, two girls, who lived in the immediate neighborhood of the soldier, and who visited him soon after his arrival from Orenburg; the aunt of these girls, who nursed him, was next attacked; and from her it passed to her own two sons. 3. There is no circumstance connected with the disease, on which the information received from different quarters is more contradictory, than the comparative liability to it of attendants on the sick and other members of the community. From India the testimony on this head is so conflicting that no conclusion can possibly be drawn from it: a state of complete scepticism is that in which it leaves the mind of an honest inquirer after truth. That from Russia is not of a much more decisive character: such as it is, we shall present it to the reader. During two months, observes professor Lichtenstadt, while the disease prevailed at Orenburg, and 299 patients were admitted with cholera into the military hospital, the personal attendants on the sick remained entirely exempt from the disease. They consisted of one hospital assistant, six pupils, as many Baschkir lads, and fourteen hospital servants, in all twenty-seven; and their duties were to perform blood-lettings, apply leeches, poultices and frictions, and administer baths, and the like, so that they were compelled to be constantly breathing the exhalations from the bodies and clothes of the sick, as well as to touch and handle them. The washerwomen of the hospital likewise escaped-a class of individuals, who, it is well known, are extremely apt to suffer from contagious diseases. On the other hand, doctors Russell and Barry inform us "that the number of medical men and hospital attendants attacked with cholera during the present epidemic, in proportion to the whole employed, and to the other classes of society, has been, beyond all comparison, greater here (St. Petersburg) than in India, under similar circumstances: twentyfive medical men have been already seized, and nine have died out of 264. Four others have died at Cronstadt, out of a very small number residing in that Edinburgh Medical and Surgical Journal, No. cviii. p. 130.