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several phenomena, which, though not occurring uniformly, were nevertheless so frequent as to leave no doubt that they were the result of actions set up in this disease. Of these the most remarkable, and, as respects our prognosis, the most important, is a marbled appearance of the integuments on the extremities and breasts. It occurs in the collapsed state, and chiefly when this stage has been of some duration. The appearance is doubtless produced by a stagnation or effusion of blood in the cellular tissue; for when the surface is subjected to pressure the discoloration remains unmoved, which would not be the case if the blood was circulating naturally in its vessels. Women only are affected with it; and those far advanced in pregnancy are peculiarly liable to it. I have before hinted at the importance of this symptom as regards our prognosis. All the cases which came under my observation, and in which this appearance was decidedly established, terminated fatally. Several cases having this symptom appeared to be proceeding favourably in other respects, yet in the end terminated in death. This fact gives great weight to this symptom, and leads us to investigate the nature of this affection.
Besides the changed state of the blood dependent on the escape of its serous portion through the mucous membrane of the stomach and bowels, a subsequent alteration of its qualities seems to take place; this consists in a tendency to separation between the colouring and fibrinous matter. It would be highly speculative to attempt an explanation of the means by which such a tendency is induced, seeing that various theories exist as to the nature and composition of a particle of this vital fuid ; but of the fact that such a tendency does exist, the appearance of blood drawn from the body, as well as that found in it after death, are sufficient evidence. This being granted, how are we to explain the nature of these appearances, and the fatal termination of such cases ? We may perhaps be allowed to say, that in such cases there is a greater tendency than common to the separation of the blood into colouring matter and fibrin, and this taking place, a portion of colouring particles are poured into the smaller vessels, where they are detained, partly owing to the oppression of the circulatory powers, but much more by the inability of the vessels of the part to convey the blood so decomposed. Of course the greater tendency which exists to this separation of the fibrin and colouring matter, the greater will be the extent of this obstruction in the minuter vessels ; and this obstruction at the extreme parts of the circulatory system being superadded to great oppression at its centre, is amply sufficient to account for the fatality of those cases in which it occurs. The fact of this being more observed in pregnant females is not to be overlooked; for we know that in these there previously exists a tendency to separation between the red particles and fibrin, which being further augmented by the new actions set up, raises it to the extreme.
These considerations may lead us to account for the great fatality of pregnant women attacked by cholera. Of the six cases admitted into the hospital, not one recovered. They do not sink rapidly, but remain a long time in collapse; in one case, the pulse was imperceptible during three days..
Another appearance somewhat analogous to that just described, is a state of the lower extremities somewhat approaching to gangrene. To great coldness is superadded a blueness and lividity, peculiar and differing from the usual dusky hue of cholera. The superficial veins streak the dorsum of the foot; they evidently contain stagnant blood, for all endeavours to press the blood forward are fruitless. If the patient lives sufficiently long, the characters of gangrene become very decided. It cannot be a matter of surprise, after taking into account the foregoing considerations, that such a state of the extreme parts of the body should exist.
Besides these unfavourable appearances on the surface, one of an opposite character is occasionally, though rarely observed, this is an eruption over the surface of the body resembling very closely urticaria. It rarely occurs, and only in mild cases, when the patient is recovering ;—the relief and benefit experienced by it is very great.
Tinnitus and deafness are occasionally complained of. They are unfavourable symptoms, as they generally precede stupor and coma.
It is not uncommon in cholera to find the pulse intermit; it gradually regains its regularity as the disease abates. It is not easy to determine whether this state of the pulse is entirely functional or produced by organic changes. I am inclined to consider such a state of the circulation to be induced in those systems where a slight organic change exists in the heart, which is not sufficiently great to produce any derangement of the circulation during health, but when the action of cholera is superadded, becomes the cause of the intermittent pulse.
The fluids ejected in cholera are not uniformly of the same character, nor in cases which terminate favourably is there always a gradual change from the serum to the bilious evacuations, without the intervention of some characteristic appearance.
The matter vomited is sometimes green, or brown; and the stools in some cases become bloody, in others they closely resemble weak water gruel. Vomiting of green fluid usually succeeds the serous vomiting. The serum becomés tinged green, which increasing, at length the fluid thrown up is of a bright green hue. It invariably happens that patients with this affection complain of pain or heaviness at the epigastric and right hypochondriac region. It occurs in both mild and severe cases. In the more severe, the green colour is frequently changed for a light brown, and when this occurs it is often the precursor of a typhoid affection. In some cases the evacuations per mouth and anum are tinged green; but in the majority the alvine evacuations have become of a natural character at the time that vomiting of green matter is going on. This green colour is doubtless owing to the presence of bilious matter in the evacuations, either depraved or altered by admixture with the effused fluids, and thus producing the bright green colour. On considering the circumstances under which this affection occurs, we may regard it as rather an accidental accompaniment, than as one of the stages of cholera. It is uniform in one respect only, viz. in being accompanied with pain or oppression at the præcordia or right hypochondriac region. In some cases the evacuations per anum throughout the attack have the appear. ance of thin water gruel; in some eases a similar fluid is vomited; but in most it seems combined with the vomiting of green matter, or the coinmon serous fuid. In a few cases, the evacuations had this character from the commencement of the attack. I have noticed that this appearance of the evacuation occurs in cases where the collapse is not great, although the other symptoms are very severe. The skin is generally moist. There is no uniformity in the termination of these stools. In some they are changed for the natural evacuations; in others they may continue until the patient is worn out; or they are changed for bloody evacuations. Frequent discharges per anum of this character continue obstinately unchecked by remedies; and although collapse does not supervene, yet the patient becomes exhausted, and at length worn out by the continuance of these discharges.
The alvine evacuations in cholera frequently become bloody. This only occurs in the later stages of the disease. The appearances presented are, first, a slight tinge of red in the serous Auid evacuated, in which the white flocculi are seen to float. This tinge gradually becomes deeper in colour, Generally patients complain of pain in the abdomen about the time when these evacuations are commencing. It is accompanied with some tenesmus, which symptom inclined us to suspect the seat of these effusions to be in the large intestines ; but post mortem examinations demonstrate it to lie higher in the intestinal canal; the small intestines through their whole course being intensely vascular, and containing a fluid closely resembling that passed per anum. The mucous membrane is softened and at the lower portion of the ileum frequently abraded.
Having thus shown the seat of this action to be in the small intestines, our next inquiry is, how this effusion is produced; and here the question resolves into two heads, whether this effusion of the red particles is merely owing to the continuance of congestion, and thereby effusion of the constituents of the blood, or whether it is mainly attributable to changes which have been produced in the structure of the mucous membrane by continued effusions from its surface. Several considerations lead me to conclude that the softening and abrasion of the mucous coat of the intestines is connected with that state of vessels, which, though caused by the continued effusion of the serous portion of the blood, at length allows the passage of the red particles.
It sometimes happens that a jelly-like fluid is passed, which appears to be composed of mucus and red particles of the blood. In these cases there is less pain of the abdomen, and the patient does not complain of tenesmus, probably from the quantity of mucus acting as a protection to the intestine.
On reviewing the symptoms which accompany these changes in the evacuations, it will be well to keep in mind that each change is accompanied by a particular symptom ; the green vomiting by pain or weight at epigustrium ; gruelly stools by absence of collapse ; and bloody stools by pain in abdomen.
ART. VII.-An Extraordinary Dilatation (with hypertrophy?) of all the Thoracic Portion of the Esophagus causing Dysphagia. Narrated by ALEXANDER J. HANNAY, M. D. Professor of the Theory and Practice of Physic, Anderson. University of Glasgow, formerly President of the Royal Medical Society of Edinburgh, &c.
lempts to as my mind
I was occasionally consulted by the person whose pathological inspection forms the subject of the following memoir. The many speculations I indulged in respecting this case—my repeated yet abortive investigations to fathom its nature, and attempts to accomplish a cure, invest it with an interest and importance in my mind which perhaps it does not deserve. But still, with due submission, I deem it to be worthy of a place in the records of observation, where, after a pretty extensive range of search, I do not find any example exactly if at all parallel.
VOL. XL. NO. 116.
ission, i decore, after a prely if at all
J. L. æt. 38, rather short of stature, was, however, well-proportioned, muscular, and of active babits. On taking food he experienced a sensation as if it were arrested in the @sophagus, a little way above the lower end of the sternum, giving rise to the most painful and protracted efforts to swallow. Early in the history of his case, there was merely a sense of uneasiness in the epigastric region created by taking food. This gradually became more distressing, and at a late period, occasionally amounted to an agonizing sense of distension. This suffering was worst after a full meal, and generally subsided slowly ; hours used to elapse before it was completely gone. The nature of the food or ingesta did not modify the complaint in any observable degree-yet a large quantity always increased the evils of his condition.' Immediate relief could be obtained by vomiting, which he was often induced to excite to remove his distress. After intemperate indulgence in spirits, to which he was much addicted for a considerable time previous to his death, the pain on taking food was aggravated, and the vomiting came on spontaneously. Under these circumstances, fluids alone, for ex. ample tea in the morning, gave rise to the agonizing feelings above described ; though when temperate, he only felt slight uneasiness from taking ingesta of this nature. No obstruction was experienced on passing a probang. The sounds of the chest on percussion and auscultation were natural.
The difficulty of swallowing had existed since boyhood ; at which time he received a violent blow on the chest inflicted by a club or shinty. It has left no external marks. Since that accident, he has had more or less uneasiness in the epigastric region,
and impeded ingestion ; but his memory failed him in describing • the circumstances which attended the injury, and his account of
the case at that time was most meagre and unsatisfactory. It has gradually become more urgent with advancing life, and has always been modified and aggravated by the circumstances before mentioned. His general health did not appear to suffer much from the dysphagia, and any changes which his constitution and aspect experienced were rather attributed to his intemperance than to the difficult deglutition. He had of late complained of a constant sense of oppression in the chest, made worse by running up stairs or by violent exertion.
The doubtful and mysterious nature of this case led to a vague and ineffectual practice.
His best remedy was temperance, to a course of which, how. ever, he was but little inclined. In vain did we employ any remedies, except when he abstained from excess and irregularity. When circumstances, which occasionally operated, compelled him to a punctilious observance of temperance, a manifest alle.