Whenever, then, tenderness on pressure constantly exists, whether accompanied or not by constant or wearing pain, and whatever the other symptoms may be, whether heartburn, waterbrash, or weight, I think we are justified in employing local alterative means, mustard poultices, blisters, leeches, or cupping. Water compresses are not so efficient; I think those who fancy they have found them useful must have fallen in with other forms of gastric pain and mistaken them for tenderness. An all-important part of the treatment is complete rest. The action of this may be seen by the rapidity with which the patients got well in the hospital. Tenderness on pressure does not contraindicate an analeptic restorative treatment being conjoined with the local. Indeed, it demands it. Numerous instances of this may be seen in cases already cited, perhaps the most striking, from the symptoms being capable of being depicted in number and weight, is CASE XCVI, of a young Irish woman, who gained twenty-one pounds of flesh in twelve days, in spite of being leeched every other night during nearly all the time for waterbrash, with intermittent pain at the epigastrium and tenderness.1 Pain felt only on pressure in a part does not require any palliatives, except not to press. This is a platitude perhaps; but still both doctors and patients are the better for having the fact brought to mind, since these out of anxiety find it difficult to keep their fingers away, hoping each minute to find the pain gone, and those are tempted by a love of accuracy, hard to blame, into a needless frequency of examination. SECTION IX. Anomalous pains. CASE CXLI.-Mrs. S—, aged 40, used to come to me frequently in 1849 with a daughter, whom I was attending for cutaneous disease. One day, though at the time in perfect health, she desired to consult me about a curious.pain in the pit of the stomach, which from time to time assailed her. It came on gradually, was not severe enough to lay her up, but constant and worrying while it lasted, namely, for about a week or ten days at the most. The first thing I made out about it was that it usually succeeded to any 1 See page 137. mental worry or unusual bodily exertion for several days. On further inquiry I found it invariably coincident with the catamenial periods, which, however, were regular, not excessive, and accompanied by even less pain in the loins, uterus, or groins, than most women accuse. It appeared in fact to be a dysmenorrhoeic pain, misplaced at the wrong end of the abdomen. I gave her a course of quinine and iron for the nonce, and desired her to take a special dose of hydrocyanic acid and opium if the pain came on again. This seems to have been successful, for though she brought her daughter several times during the next year she said no more about herself. Though she appeared in perfect health, the mere fact of having an anomalous pain showed weakness and constituted the periodical discomfort which is the normal portion of the sex, or dys-menorrhoea. The above is a specimen of the most usual degree in which uterine pains are felt in the stomach, but sometimes they are more serious. CASE CXLII.-Jane R—, aged 25, a housemaid, was admitted under me at the hospital February 16th, 1852. She was a personable robust countrywoman, who had lately come up to service in London. Her tongue was clean, her pulse 84, full and strong, her skin normal, her urinary and fecal excretions reported natural. Her mistress said that for three days Jane had complained of pain in the lower part of the chest in front. That it was increased by food, and consequently she had "eaten nothing," that is to say, had taken only liquid food. She got an out-patient's letter to the hospital, but on her way to use it was taken so much worse that she was obliged to be admitted. She sat up in bed rubbing her epigastrium with her hand, and expressed herself as in great pain. Rubbing, however, gave her no relief, nor did pressure; but it could be borne without any increase of pain. The catamenia had been absent two months. A large linseed poultice was applied to the abdomen, she took a four-grain calomel powder immediately, and a senna draught three hours afterwards. The same day the catamenia occurred, not copious (they were never so, she said), but sufficient, the pain instantly ceased, and she was well enough to be discharged on the 18th. The disgorging of the portal veins, by a mercurial and a purgative, is a capital way of bringing on the catamenia in a robust, full-blooded person. Remember, however, that I do not recommend it in those more common cases where the amenorrhoea is merely an evidence of the absence of menstrual blood to be discharged. The retention of feces in the bowels is frequently assigned by the public as a cause of pain in the epigastrium. Their fondness for purgatives doubtless often leads to error on this head, but still I do think they are sometimes right, and that the mere retention in the colon and rectum of matters ready for evacuation may give rise to considerable pain in the epigastrium. It is not very easy to hit upon a good illustration of this, for most usually costiveness and even constipation depend on some morbid condition of the stomach or of the whole alimentary canal or of the whole body, and it is difficult to separate the effects of the retention from those of the condition. which has engendered it. Thus, for example, you will find that nearly all the chronic cases quoted in the first chapter had confined bowels, but no one would attribute the epigastric pains to that cause, seeing that an obvious indigestion existed in the stomach, the seat of those pains. In the following case, however, the cause of the retention of the feces was quite extraneous, and there was no proof of anything being the matter with the digestive organs. CASE CXLIII.-Anne M-, aged 23, a domestic servant, was admitted to St. Mary's October 15th, 1856, complaining in various parts of the body of obscure pains, which, however, after admission, seemed to have their definite seat in the epigastrium, and to be worst always after food. She had palpitation of the heart, nausea, and a tendency to faint. Her face was flushed, the skin hot, and the tongue coated; but otherwise her aspect was healthy. After a few days the nurse observed that her linen was stained, and the patient herself stated that she had a vaginal discharge. But digital examination found the organs of generation quite normal, and that the pus came from a small papilla, the remains of an old hæmorrhoid, on the edge of the anus. This was exquisitely sensitive, and the patient confessed that she had voluntarily retained her feces on account of the pain which defecation gave her. Warm baths and softening enemata, with the aid of valerian draughts, reduced the hyperesthesia, and with the emptying of copious solid stools from the colon the pain at the epigastrium ceased, and she got good rest at night. In cases of misplaced pains, I mean pains not in the locality of the parts truly affected, valerian is a very useful medicine. Its calmative effect on the nervous system is remarkable.) That was the reason of its administration to this young woman. It would have been cruel to forcibly open her bowels by purgatives, without first deadening the abnormal sensitiveness which had caused her to constipate them. These three cases are typical instances of the most common pathological states at a distance from the stomach, which cause pains in that organ without otherwise deranging it. I have no cases to quote which may not be referred to either the colon or uterus. 174 CHAPTER V. VOMITING. SECTION 1.-General remarks on the physiology of the process. SECTION 2.Vomiting of pus. SECTION 3.-Vomiting of mucus. SECTION 4.-Vomiting of blood. SECTION 5.-Acid fermentation of vomit. SECTION 6.-Fecal vomiting. SECTION 7.-Vomiting of unchanged food. Hysterical vomiting. SECTION 8.-Vomiting in pulmonary consumption. SECTION 9.-Occasional causes of vomiting. SECTION 10.-Sea-sickness. SECTION 11.-Review of remedies employed. SECTION I. General remarks on the physiology of the process. IN the normal passage downwards of food the involuntary nerves and muscles of the fauces, the gullet, and of the stomach are in vigorous action; whilst the voluntary abdominal muscles and the diaphragm exert no influence over the digestive canal. In vomiting a converse condition exists-the involuntary oesophagus is wholly or partially paralyzed and relaxed, the involuntary peristaltic wave of the stomach ceases, and at the same time the diaphragm and abdominal muscles are degraded from agents of volition to purely automatic instruments. The ceasing of the peristaltic wave allows the pylorus to close. It is converted from a portal somewhat stiffly held open by the circular fibres (as if in a sort of erection) into a collapsed valve. The pylorus being closed and the cardia open, it would not require any such very strong muscular effort to empty the stomach. But the muscles thus abnormally perverted into compressing the stomach are very large and powerful. Hence vomiting is a violent and explosive act. In spite, however, of the violence and explosiveness, a correct pathology must look upon vomiting as a lowering of the vital powers, as an atony of the digestive tube and its appendages, |