after the occurrence of the urgent symptoms. The child was seized with vomiting during the night, and almost immediately became collapsed. In another case two evacuations, one very copious, and the other scanty, occurred in quick succession, and the patient then rapidly sunk into fatal collapse. In two other fatal cases, the collapse seems to have ensued upon two or three more or less copious evacuations."

Dr. George Burrows, after stating that he had never seen a case either during the epidemic of 1832-33 or 1848-49, in which the discharges were quite out of proportion to the symptoms of prostration, says:

"The case of most rapid collapse which I witnessed during the present epidemic, was in a male, æt. 29. This young man stated, that an hour before his admission, he felt himself quite well; he was suddenly seized with profuse diarrhoea, vomiting and cramps, which symptoms continuing, he died in 18 hours."

Dr. Basham says:

"Several cases have come under my observation, in which the fatal collapse has borne no relation to the amount or duration of the previous serous discharges. The master of a vessel lying opposite the Horseferry at Millbank, went into the city at eight o'clock in the morning, and returned at 10, complaining of not being well. He went and lay down in his berth. At 12 he was brought to the hospital in a state of complete collapse. There was no vomiting and he had had but one serous evacuation. He died at eight o'clock the same evening.

"Whilst discharging the duties at the Millbank Prison for my friend Dr. Baly, two cases occurred amongst the convicts, illustrating this inquiry. They had been but eight days in the prison, and were reported to have gone to bed quite well. One complained of being taken suddenly ill with prostration and looseness at 2 A.M. The other with the like symptoms at 4 A.M. Both were passed to the Infirmary at the hours mentioned, I saw them at 11 A.M. They were both livid and cold and pulseless. There was no vomiting or purging, but most urgent cramps. Both died before sunset. I could repeat several similar instances."

Dr. Burchell of Kingsland says:

"I have several times observed perfect collapse fully established after only two serous evacuations, and from that time the discharges have ceased."

"I can bear testimony to the fact, but, from want of time, was unable to note the particulars of cases.”

Together with these replies were many others of a negative kind, stating that in all the cases observed, the severity of the symptoms was in proportion to the amount and rapidity of the discharges.

There is in most of the above evidence a want of precision, inseparable, in a great degree, from the nature of the case, it being scarcely possible to estimate accurately the amount of fluid lost. The frequency of the evacuations is obviously no test whatever, for the amount passed at any one time may be out of all proportion greater than at another; and, moreover, it is to be borne in mind that, during severe collapse there was often a continued draining of fluid from the body without any effort at evacuation; and after death it was not uncommon to find the cavity of the small intestines distended with effusion.

Notwithstanding the incompleteness of the data, we conclude that, although, in a large number of instances, the intensity of the symptoms is in a general way proportionate to the amount of the effusion, yet that this will only in part explain the attendant collapse which often appears to be in no inconsiderable degree due to the adynamic state of the ganglionic nervous system, induced either primarily by the poison or secondarily by the lesions of the affected mucous surface. A further elucidation of this subject is yet a desideratum.

PATHOLOGY OF THE STAGE OF REACTION.

THE Cholera poison is comparable to those deleterious agents whose action on the body is transient, what after-phenomena there are being due to the accidents of the primary operation.

The normal issue of the disease is to a uniform and complete restoration of the several functions without any degree of reaction which can be considered morbid.

Such a result is not unfrequent, even where the previous symptoms have been severe. "I have seen," says Mr. Grainger*, "a man stand at his door on Wednesday, who on Monday was in perfect collapse;" and his observation accords with the experience of others.

When the powers of life are feeble or greatly reduced by the violence of the disease, reaction is often imperfect and protracted, and there is a tedious fluctuation between collapse and recovery. The pulse returns to the wrist, but the circulation remains embarrassed, the warmth of the skin is partial, and often attended with sweating. The urinary secretion is suppressed, and there is a tendency to coma. After a longer or shorter struggle death may ensue or the several functions be slowly re-established as in the more normal cases. The pathological conditions are here those of the cold stage, except that in general the lesions in the gastro-intestinal membrane are less marked.

A third issue of Cholera is into the so-called consecutive fever, which has been divided into different forms according to the prominence of particular symptoms. Such divisions are but of little practical value, as their boundaries are not constant, and they mislead by fixing the attention exclusively upon one organ, where, from the circumstances of the case, the whole system is more or less deranged.

Amongst the more important lesions are those of the kidneys. Not only are these organs, in the first stage, occasionally subject to the cholera-process, but, from the complexity of their circulation, the state of the blood, and the depressed nervous power of the ganglionic system, they slowly recover their function, and, from the persistent congestion, the secreting structures undergo changes similar to those found in acute albuminuria from other causes. In addition to the evidence on this subject given in another part of this report, we may add the following from Dr. Gairdnert, who says, "The kidneys appeared in many cases to have undergone morbid changes; the cortical sub* Report on the Epidemic Cholera of 1848-49. + Monthly Journal of Medical Science, 1849.

stance being pale and turgid, and the tubuli uriniferi gorged with imperfectly-developed epithelium, which was mostly loaded to an unusual extent with oleo-albuminous granules."

The urinary secretion was correspondingly affected, being either entirely suppressed or small in quantity, and of low specific gravity.

As to the frequency of albumen in the urine after the cold stage of Cholera, there is a universal accordance amongst different observers both in this country and on the Continent. In more than 40 cases observed on board the Dreadnought*, in every instance but one, the urine first passed was albuminous. Of 67 cases in which the urine was examined by Dr. Begbie at the Cholera Hospital in Edinburght, the results were noted as follows:

Reinhardt and Leubuscher found the urine coagulable in most of their cases, and Hamernik ‡ attributes the principal pathological phenomena of the typhoid state to disorder of the kidneys; he terms it "reaction with uræmic phenomena."

When albumen was present, a microscopical examination of the urine discovered the desquamated epithelium of the uriniferous tubules, and at different times all the varieties of fibrinous casts met with in Bright's disease, and frequently blood corpuscles.

Eighteen specimens of urine were analysed by Dr. Begbie, in order to determine the amount of urea present in them. In eight the quantity was too small to admit of being estimated, and in the other ten below the normal proportions. These observations would have been complete had the whole amount of urine passed in 24 hours been noted, but we may conclude, from the general history of such cases, that it was below the average.

Dr. Letheby§ also made two analyses of urine passed after protracted suppression. The first specimen was passed on the fourth day from the accession of severe symptoms; the second on the fifth. In both the amount of urea was deficient, and neither contained albumen. The extractives were in great excess in both. The results *Lancet, June 9, 1849.

+ Month. Journ. Med. Science, 1849.

Die Cholera Epidemica, p. 235.

§ Medical Gazette, 1848, p. 1011.

were as follows, the standard of healthy urine being given for com

Whilst attention is drawn to these derangements of the urine, we cannot leave out of consideration the state of the blood and the disturbances of the general circulation from the previous collapse, conditions which would greatly favour the retention of the urinary excreta in the system.

The following comparison between the symptoms of ordinary uræmia and of the typhoid stage of Cholera will serve to exhibit their identity. Those which characterise the Cholera typhoid we have set down from the excellent treatise of Reinhardt and Leubuscher on Cholera in 1849, and those depending upon ordinary uræmia are described mostly in the words of Dr. Addison's paper of 1839*; thus avoiding the influence of any hypothesis as to the relation here insisted upon.

ORDINARY URÆMIA.

"Dulness of intellect-sluggishness of manner. 3 Drowsiness proceeding to coma, and more or less stertor, with or without convulsions." These symptoms being "very frequently preceded by giddiness, 2 dimness of sight, and pain in the head." There is "a quiet pulse, a contracted, or undilated, or obedient pupil, and the absence of paraly. sis."

Guy's Hospital Reports, 1839.