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1847]

Pain in the Stomach; Causes and Treatment.

99

tions," the pain may be indicative of Ulceration of the Stomach going on to perforation. This lesion often gives rise to very profuse hæmatemesis. The following is the description which our author gives of the usual course of such a case:

"The chronic ulcer of the stomach is not to be distinguished by any known signs, unless vomiting of blood, which has followed long-continued symptoms of pain and distress in the stomach, has taken place. Up to this time, it is easier to say what the disease of the stomach is not, than what it is.

"The patient has long felt pain after eating, without the symptoms of the presence of acid which I have before described. At one time one species of aliment, at other times another, seems to aggravate the symptoms. Solid meat is generally felt to be most distressing; and the state of emptiness is the state accompanied with the least pain, as in a case related by Mr. Travers in the Transactions of the Medical and Chirurgical Society. Suddenly the symptom of pain becomes accompanied by constant vomiting and a painful burning of the epigastrium, with extreme pain in the opposite vertebræ; the pulse becomes very small and weak; and cold extremities and shrinking features denote the approach of death, which occurs in a few hours after the aggravation of the symptoms: and on examining the body, perforation of the stomach,-simple nearly circular ulceration, without any thickening of the edges, without any inflammation of the surrounding mucous membrane, is seen. In such cases the patient has not lost flesh, as in the case of cancerous or fungoid disease. No examination, however careful, can distinguish before death either hardness or fulness; nor has the appearance of the tongue shewn by its bright redness that serious irritation is established in the stomach; neither does the external surface of the body present the straw-coloured appearance, arising not only from the absence of red blood, but as if the vessels were filled with size." P. 18.

Life is sometimes prolonged for weeks, and even months, after perforation of the stomach has actually taken place; adhesions having already been formed, so as to prevent the ready extravasation of its contents into the abdominal cavity. Dr. S. relates two cases: in one, the patient survived twelve days, and in the other five months. Both were young females. When, from the preceding pain and subsequent vomiting of blood there is reason to suspect the presence of simple ulceration of the stomach, Dr. Seymour strongly recommends the internal use of the oil of turpentine -3ij., with as much castor oil, being taken in the form of an emulsion, every, or every second, morning.

"I have never," says he, "seen a case which did not recover for the time being from this practice. In three cases where the patients had suffered from this disease, and the hæmorrhage had entirely ceased under the use of the oil of turpentine, healed ulcers, into which small branches of arteries could be traced, were observed on the surface, I believe, in all, on the posterior surface of the stomach; but in a great many more cases, where the patients are still living after a lapse of several years, and where of course the case cannot be proved, the disease gave way to the use of the oil of turpentine. Not only were large quantities of blood vomited in such cases, but large quantities passed half digested from the bowels, under the form of thick matter, resembling soot in appearance. I do not remember to have witnessed a single case in which this treatment has failed; and, notwithstanding that the medicine is very nauseous, it rarely happens that it is rejected by vomiting.

"I am not, however, to be understood to say that hæmatemesis always arises from ulceration of the stomach; that it does so in some instances has been proved; in others it may arise from simple exudation, or from vicarious men

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struation; occasionally from diseased liver; and occasionally from fungoid or cancerous disease of the stomach." P. 27.

If the turpentine excite much nausea, or otherwise disagree, the diluted sulphuric acid or the acetate of lead may be given; but neither of these medicines is equal in efficacy to the turpentine. The liquor stypticus of Ruspini has been used with decided advantage-3ij. every four or six hours.

At this part of his subject, our author flies off to the consideration of that most hackneyed subject-" Diet in general." There is nothing, however, in his remarks that deserve notice, although he has favoured his young friends in the profession, with a recipe for making beef-tea, which he purchased from a first-rate French cook! We pass on, therefore, to the notice of another common symptom in stomach-complaints, viz. Vomiting. Every medical man knows that this is a frequent, and sometimes not only a distressing but even an alarming, accompaniment of early Pregnancy. It is then often best relieved by one or two small blood-lettings. At other times, the use of opium, alone or in an effervescing draught, will be found most effectual. A mustard poultice, or a blister, to the epigastrium will often succeed. Confining the patient to a diet of equal parts of milk and limewater has answered, after other remedies had failed. The vomiting of Hysteria has sometimes yielded most speedily to creosote mj.ij. ter die. Minute doses of strychnine have been much recommended by some writers in obstinate hysterical and parturient vomiting.

Dr. Seymour makes the remark that "vomiting in Phthisis, occurring almost always after coughing, if it arise early in the disease, is the proof of a severe and rapid form of it; if late, it betokens that large collections of matter are locked up in the lungs, that is, have not yet found an outlet through the larger branches of the bronchi."

He briefly relates one case, and refers to several others, in which an accurate diagnosis was formed from attention to the symptom now mentioned. Dr. S. might surely have illustrated this point-one, according to him, of much practical importance-with greater minuteness and circumstantiality of detail. Equally unsatisfactory are his remarks on the Iliac Passion, of which he has seen three cases, in all of which recovery took place. Strange to say, he does not as much as allude to the use of enemata for the purpose of inducing" a strong (peristaltic) impression downwards,"* in the obstinate vomiting, which is the worst symptom in this distressing disease, as well as in Carcinoma of the stomach; although he thinks it worth while to tell us that the late Dr. Cholmely was in the habit of using crude mercury (in doses of 3iv) for the purpose, and that "in a very obstinate case of vomiting, also from organic disease, great relief was obtained temporarily from a scruple of calomel prescribed by Sir. H. Halford.".

We have repeatedly found the most obstinate vomiting give way to the use of a purgative injection, leaving the stomach entirely quiet, without either food or medicine being given for six, twelve, or twenty-four hours. The application, at the same time, of a mustard poultice to the epigastric region will often very materially assist in checking the inverted peristaltic action.

1847]

Vomiting, its Causes and Mode of Treatment.

101

Tubercular Disease of the Peritoneum is generally attended with very troublesome vomiting; and the appearance of the vomited matter is in many cases so peculiar, that it affords, in our author's opinion, a diagnostic sign of the disease. It is of "a green so dark that it is only to be compared with that which the sea acquires at great depths,-a blue as intense nearly as that of indigo; deep green when regarded in one way, blue in the other." The disease may exist without this symptom; but, "when this symptom is present, it is diagnostic of the disease." We must not omit to mention that Dr. Seymour maintains that tubercular disease of the peritoneum is of much more frequent occurrence than Mesenteric Disease. Nay, he goes so far as to say, that "mesenteric disease is very rare, and the disease in question by no means so; in fact, in hospital and private practice, where I have had occasion to verify the disease after death, this occurs at the least, in proportion to mesenteric disease, as five to one; and, I believe, in a still higher ratio."

The experience of most physicians will certainly not agree with that of our author as to the great rarity of mesenteric disease in children.

Vomiting, often of the most intractable description, is a conspicuous symptom of the passage of a Calculus along the Ureter. It is, of course, very important to distinguish the true cause, from the first.

"The distinction is to be found in the fixed pain in the direction of the ureter, most frequently about midway between the umbilicus and the spine of the ilium, but still more in the slow soft pulse, notwithstanding the intense pain which accompanies the disease. In inflammation, the universal pain over the abdomen, the patient carefully keeping the trunk of the body at rest, the pulse being small, hard, and very quiet, the alteration of the features, well distinguish it from the acute fixed pain, the constant vomiting, the throwing about of the limbs, the numbness in the thigh of one side, the patient seeking the half-recumbent posture, which appears to relieve the pain, which constitute the form and the picture of renal colic. The sickness, however, in females especially, is often frightful. I have seen it, almost without ceasing, continue for eight days consecutively, but there was no fever, no constipation, no wasting of the body; and a loaded state of the urine, or the passage of a small calculus, soon put a stop to the symptoms." P. 55.

Our author next alludes to the vomiting which attends Cholera, the Asiatic as well as the common form. He briefly says, with respect to the latter, that," almost always, the mixture of three grains of calomel with a grain of opium, will arrest the disease;" and straightway he tells us a story about a young gentleman curing his friend at Padua, by this prescription! So infallible are its virtues in the estimation of our author, that he thinks it worth while to put upon record this interesting piece of information :"For many years I have been in the habit of giving this prescription to friends of mine, or members of my family, when on foreign tours, and very often they have had occasion for its use: never has any evil resulted, nor has it failed of its efficacy in a single instance. To my knowledge, in the course of the last twenty years, the number who have benefitted by it is very great.” P. 59.

After this, who will be surprised to hear of "Dr. Seymour's Pills" for the use of travellers?

The last ten pages of this paper are occupied with rambling remarks on gastrite, and softening of the mucous membrane of the stomach; but there is nothing in them of the slightest value.

The next subject that Dr. Seymour discusses is Gout.

No fewer than

80 pages are devoted to its consideration. Dr. S. acknowledges that there are hundreds of books" on the subject; but still he thinks that something remains undone.

"I do not know," says he, "that I can say anything new, but the arrangement of our present knowledge on the subject, our treatment and the reasons for that treatment, are not satisfactorily stated, in my own view of the case, concisely and for practical use. It is to supply this (temporary if it be) want, that having experience on this subject, I undertake the task of making the following observations." P. 72.

Let us now see what is the nature of these observations. After a brief historical sketch of the disease as known to the Greeks and Arabians, the question "what is gout" is propounded for solution. The old physicians, it is well known, "recognised a specific morbid fluid mixed with the blood, which was thrown off upon the joints, thus purifying the blood, and producing in its elimination what we now call an inflammatory condition of the joints and tendons." Dr. Seymour's account of the modern theories of the disease is certainly not very lucid. He thus describes the opinions of English and French physicians in the present day.

"1st. The opinions popularly held in this country attribute the gout to vicious secretions of the stomach and liver; after some time, these derangements are followed by inflammation in the feet or hands, such inflammation being a natural termination or consequence of this disorder of the viscera, and of their suppressed or vitiated secretions. This is most generally the only explanation to be derived from those who have been taught in early life, that all diseases of the human body depend on disease or disorder of the secretions of the liver or of the bowels.

"2nd. The opinion most prevalent in France is, that the cause of gout is the indulgence in too succulent and nutritious a diet.* All the textures of the body become gorged, and more nourishment is afforded them than can be removed by excess of excretion. Two modes of excretion, the urinary discharge and the cutaneous perspiration, keep up for some time the equilibrium between the ingesta and egesta, but sooner or later it happens that these outlets are not sufficient, or one of them is completely obstructed by some temporary cause, and thus the over-nutritious particles, which ought to be carried out of the body, are transported to the fibrous articular structures. The nutrition is greatly increased in these structures, otherwise almost insensible, endowing them in some measure with a new species of vitality. They are transformed from parts formed for motion and passive resistance to sensible and irritable parts, no longer able to fulfil these functions, and disposed to become inflamed spontaneously, or from an ordinary exciting cause. Again, these nutritious materials in excess are deposited on the surface of the articular structures, and form the concretions composed in the greatest part of animal substance, as they for the most part consist of azote and animal matter.

"3rd. A still more modern theory supposes that the acid matter which is

* "The over animalization of the blood, consequent on an over nutritious diet, redundance of thick and viscid bile, explains the frequency of biliary calculi and gout. The secretion of bile affords one exit for the overnourished fluids of the body; still more the urine, and the highly loaded urine in gouty persons, sufficiently attests the state of the blood, which is far more than able to supply the necessary secretions in their normal state, and the nutrition of the body."

1847]

Gout, its Cause and Treatment.

103

distinguished in the urine and in the perspiration, and in the concretions in the joints, is formed in the blood, and very recently the changes in the blood produced by electricity are believed to form, in the living body, this acid so uniformly present in gouty excretions." P. 77.

We really were not aware that British physicians generally attributed the disease merely to "vicious secretions of the stomach and liver," nor the French to mere plethora-not congestion, as Dr. S. inaccurately terms it. This is an off-hand way of writing that is surely very objectionable; nor can we admire the accuracy of an author, who tells us that, gouty concretions" consist, for the most part, of azote and animal matter.' Dr. Seymour's explanation of the hereditariness of gouty complaints is given in these words:

"The blood is more highly animalised, and filled with noxious particles, which are thrown off by inflammation of the extremities, termed gout, when no longer to be borne; and this state and condition, when children are procreated, may be transmitted to them, as scrofulous virus and syphilitic virus notoriously are." P. 78.

But is there not this very marked difference?—that, whereas the signs of what our author calls the scrofulous virus, as well as of syphilis, are manifest in a child from its birth, those of gout seldom shew themselves before the period of adolescence? Dr. Seymour is scarcely correct even with respect to the ordinary exciting cause or causes of the disease in question. Is it really the case that those, whose blood is most highly animalised by" eating succulent food, with habits of a sedentary kind," are most subject to it? Such persons may become excessively full, bloated, and plethoric; but, if they have not indulged in the use of fermented or vinous liquors, they will very rarely indeed become gouty. In short, it is less what is eaten than what is drunk that predisposes to the disease. Spirit" drunkards, simply speaking, are not gouty:" Every one knows that. But can the same thing be said of those who are, or have been, in the habit of drinking their strong ales, and stronger wines, or both of them, as is often the case, together. No wonder that the only gouty patients to be seen in hospitals, are" decayed butlers and housekeepers." Dr. Seymour tells us that he once admitted four cases of gout into St. George's Hospital on the same day; and he goes on to say that he bid one of his pupils " ask those patients, quietly, how much meat they have been in the habit of eating daily?" The answer was, in one case, three times; in all the rest, twice daily, and largely. And how often had they left the house?' Not for weeks together!'

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True; but had not these butlers and housekeepers, besides their fat feeding and their lazy habits, been tippling daily with their wine and ale? The last element is quite as necessary as the two former for the production of the malady. It would be unprofitable to follow Dr. Seymour in his account of the mode of attack, and of the symptoms of gout, as there is nothing in it but what is perfectly well known to every reader. One observation only calls for notice. It is this:

"Where patients die, worn out as it is called with gout before arriving at a great age, I have generally seen enlargement of the heart (hypertrophy), and this was signified in the latter months of life by anasarca." P. 87.

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