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Academy of Sciences of Munich, the Medico-Chirurgical Society of the Hospitals of Bordeaux, the University of Lund, the Smithsonian Institution, and the Surgeon-General of the United States Army.
A collection of the Sanitary Reports of Manchester was presented by Dr. J. E. Morgan, and of those of Leicester by Dr. John Barclay.
A series of his Reports on the Rain Fall of Great Britain was presented by Mr. G. J. Symons.
A. set of photographic portraits from paintings in its possession was presented by the Royal College of Surgeons.
A copy of Cheselden's Treatise on the High Operation for the Stone,' containing the autographs of Cheselden, Prout, and Sir B. Brodie, was presented by Mr. Charles Hawkins.
Thomas W. Garlike, Esq., F.R.C.S., was admitted a Fellow of the Society
Thomas Bridgwater, Esq., M.B., was proposed for election as a Fellow of the Society.
The following communication was read :
On some analogies of Cholera in which suppression of Urine
is not accompanied by symptoms of Uræmic Poisoning. By WILLIAM SEDGWICK, M.R.C.S., and L.S.A. (Received August 14, 1867.)
As an assistance towards lessening the difficulty which attended the investigation of cholera, analogy, in so far as it enabled us to trace out and establish a resemblance between it and other morbid conditions of the system which admitted of being more readily explained, would be useful, provided the principle was sound on which the analogical reasoning was based. For it had become a necessary and in some respects an unpleasant duty to direct attention to the fact that in the investigation of cholera, as of other baffling diseases, attempts had on many occasions been made to establish false analogies in support of unfounded theories of the disease, or of ill-devised plans of treatment, which, after attracting popular attention, had for the most part been soon slighted and forgotten. In order, therefore, to avoid the errors which resulted from false principles in theory or in treatment, and to check the ever recurring tendency in discussion to substitute assumption in the place of fact, it was proposed, in the following attempt to trace an analogy between cholera and allied, but less obscure affections of the system, to limit the inquiry to a comparison between the well-defined and characteristic group of symptoms and pathological changes which accompanied the collapse of that disease, with special reference to the suppression of urine during life and an empty and contracted state of the bladder after death, and such cases of collapse, resulting either from poison or from disease, in which a corresponding condition had been developed and observed. The cases in which such an analogy could be more or less clearly established were acute poisoning by corrosive sublimate, by arsenic, and by mineral acids, especially nitric acid; the effects which occasionally followed the eating or drinking of poisonous animal matters, such as tainted or simply unwholesome meat or fish, and milk which has undergone some injurious, but as yet unknown change; decomposing vegetables and some of the poisonous fungi, and the excessive action of certain drugs, such as some of the drastic purgatives, especially croton oil. In cases of poisoning by corrosive sublimate, both the symptoms during life and the appearances after death were in many important particulars, and especially as regarded the urinary secretion, closely analogous to those of cholera. Among the evidence cited in support of that analogy was a case of acute poisoning by corrosive sublimate, which had been under observation in Guy's Hospital in 1843. The patient lived four days, and did not pass any urine during the whole of that time; and after death the bladder was found
empty and contracted.
In cases of poisoning by arsenic, it had been observed that, in addition to the more common results of poisoning, there were others which, as in the preceding class of cases, sometimes closely assimilated its effects to those of cholera, in consequence of which Devergie had referred to it as one of the poisons which best simulated cholera. Among the symptoms and pathological appearances which had been noticed, and to which more particular attention should be directed, were suppression of urine, cyanosis, conjunctival injection, and a physical alteration in the condition of the blood closely analogous to that which occurred in cholera, together with such a failure of the circulation, that occasionally, even for some hours before death, neither pulse nor beating of the heart could be perceived. There was evidence of the urine being suppressed in cases of collapse from poisoning by muriatic acid, reported by Devergie and by Dr. Collas ; by sulphuric acid, reported by Casper and by M. Stanski; by nitric acid, reported by M. Tartra ; and by chloride of antimony, reported by Dr. Crisp. In a case reported on by M. Girard, the analogy between the symptoms of poisoning by fungi and of cholera was very great, for it had been especially observed that the alvine dejections were nearly always white, like rice-water and flaky; and in another case of a similar kind it had been observed that the blood after death was “very black and very liquid.” The closeness of the analogy in the preceding cases was perhaps to be regarded as in some measure favorable to the theory which referred cholera to a specific blood-poison; and if the reasoning from analogy were limited to such cases, it would be almost allowable to assume that the abdominal centre of the sympathetic nervous system might be only secondarily affected through the ramifications of the vaso-motory nerves; for such a theory was to some extent, though not altogether, reconcilable with the irritant and corrosive effects produced on the gastrointestinal mucous membrane, and which, in all of the above-cited cases, were associated with, if they did not occasion and develop the collapse simulating that of cholera. But there remained to be considered a group of cases, characterised by a closeness of analogy approaching in some respects almost to identity with cholera, in which it would not be allowable to assume that a blood
poison was the cause of the collapse. Well-marked illustrations of such occurrence of collapse, altogether independent of any possible connection with blood-poisoning, were to be met with in cases of perforation, rupture, and laceration of the stomach and small intestines, over-distension of the stomach, and impassable obstruction in the small intestines. In all those cases, with some others of an allied character which would be incidentally noticed, there was usually a condition of collapse associated with suppression of urine, which not unfrequently had been, and almost unavoidably was, very liable to be mistaken for that of cholera. Further inquiry in the same direction, and a more extended acquaintance with the literature of the subject, having convinced him that there was a very close relation between perforation and cholera, the author endeavoured in 1856 to prove in his work, “On the Nature of Cholera as a Guide to Treatment,” that the theory which ascribed cholera to an impression on the sympathetic nervous system, conveyed through the medium of the stomach or intestines, was very strongly supported by the analogical evidence of such and other allied cases which could be cited in its favour; and he in consequence proposed to include them with cholera under the head of disorders of the sympathetic nervous system depending on diminution or arrest of its functions, and produced chiefly through the medium of the stomach." In all such cases there was essentially the same condition of collapse, which was usually accompanied, as in cholera, with suppression of urine during life, and an empty and contracted state of the bladder after death. As an illustration of the extent to which that important condition in the analogy prevailed, he referred to the case of a patient who had lately died in the cholera ward of the London Hospital, after an illness of about two days and a half, from perforation of the duodenum near the pylorus. In the published report of the case, there was no mention of the state of the urinary secretion or the bladder ; but on subsequently writing to the medical officer who had reported it, he was informed that there was “undoubted and continued suppression of urine." The additional information which was obtained in that case derived increased importance from the fact that another case of pseudocholeraic collapse occurred in the same hospital only seven days afterwards, in which the symptoms supposed to be indicative of “sudden cholera collapse" were described as follows :
.“ Almost pulseless, quite cold, with general lividity of the surface and blueness of the finger-nails;" but it was important to notice in the history of the case that whilst "several ounces of clear urine were drawn off," the patient was only semi-conscious. After death, which occurred in the cholera ward, all the organs, with the exception of the supra-renal capsules, were found to be healthy. So far as regarded the literature of the subject, it was acknowledged that the positive evidence in favour of suppression of urine during the collapse consequent on perforation was somewhat incomplete ; but the author cited cases illustrative of the effects of perforation of the duodenum, jejunum, and ileum in this way. After fully discussing the evidence in favour of suppression of urine in perforation and obstruction of the ileum, the author reviewed the opinions which had been expressed by the various authorities which he had cited, respecting the diagnostic value of suppression of urine in such cases, and he remarked that they were all defective in so far as the suppression was alleged to be connected with or dependent on something which was not essential in its occurrence, although it might be, and perhaps often was, associated with it. Hence the importance of carefully collating the clinical history of all those cases in which, as in cholera, it characterised the collapse ; for by thus extending the range of the inquiry it would be conclusively proved that suppression of urine occurred in corresponding conditions of collapse, independent of any one of those four cardinal phenomena-of pain, vomiting, intestinal obstruction, and intestinal flux—which had each been referred to by distinguished writers on the subject as its correlative. With respect to the suppression of urine, it had been satisfactorily demonstrated by the researches of Dr. Garrod and other able investigators of the chemical pathology of cholera, that the formation of urea was checked or suspended during choleraic collapse; and although there were no corresponding observations on the suppression of urine in analogous cases of collapse, and, consequently, no direct authority for stating that the suppression in such cases was due to a like arrest of organic function, yet the presumptive evidence was very great, if not almost conclusive, in its favour. Before,