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ing of its strength, its equilibrium, its measurable force-seems to be traceable by gradual modifications, through healthy fatigue to the feverish soreness of over-exertion, and through this to the universal muscular pain and prostration of various grave general ailments, so the indistinct sensation of the healthy stomach affords us the best clue to the acute sensibility of the diseased one, and allows us to trace a scale of a similar kind—from satiety to repletion; from repletion to distension and weight in the epigastrium; and from hence to the dull heavy aching of dyspepsia, the gnawing or burning pain of ulcer, and the sharp agony of cancer of the stomach.” (pp. 48, 49.)
Again, a few pages further on, we find the following:
“ The pain of gastric disease is grave in proportion not only to its severity, but also to its concentration and fixedness. In other words, a severe and continuous pain, confined to a single spot of small size, is a more serious indication than one which at times of equal (or nearly equal) severity, fluctuates in its different attacks, and ranges the epigastrium, of which it habitually occupies a wide area. Pain is graver in or near the median line, not only because (for many reasons which will readily suggest themselves) it is, cæteris paribus, more certainly gastric here than elsewhere, but because this situation (at least, such is my opinion) indicates a more serious derangement of the innervation of the organ than when the pain has a less exact correspondence with the solar plexus. Lastly, of all situations, a median and dorsal one (in anatomical language rachidian, and ranging from interscapular to lumbar), which is usually an addition and complication to a previous epigastric pain, is the most serious-so much so, that it will rarely be found associated with any but the graver gastric dyspepsias, and belongs chiefly to deep ulcers, or to cancerous lesions of the stomach, involving all its coats.” (p. 53.)
There is excellent matter for thought in all this; and it suggests, as does the whole book, the idea that more has been thought than is written. We would, however, interpose a caution which arises to our minds in copying these passages. Let the author jealonsly guard against his besetting sin, which is the over-use, sometimes amounting to abuse, of parentheses, commas, dashes, and all the other means invented by modern typography, for presenting sentences to the eye in the highest state of literary perfection. The necessity for employing to the utmost these arts of the intellectual cuisine is not always consistent with that robustness and vigour of style which is to be cultivated as the highest type of health; it rather indicates a kind of mental dyspepsia, not seriously affecting the vitality of the author, but interfering somewhat with his comfort and with the satisfaction of his readers. Let him take in good part this hint from a fellow-sufferer, who lias had to make great exertions, perhaps only in part successful, towards overcoming this malady. It is only a “danger-signal,” and possibly prophylactic of graver evils; but it requires watching.
In speaking of vomiting, the author advances the view that it is essentially an act of the cerebro-spinal centre, whether produced by reflex transmission of nervous influence, or by direct irritation. Even when the cause of irritation is introduced into the stomach, he holds that it operates not always through the special nervous systems of the abdomen, but (at least in the case of tartar-emetic) through a multitude of disturbed functions connected with the absorption of the poison into the blood, and telling their tale of distress upon the cerebro-spinal centre. This view is no doubt correci, at least as regards those poisons which, like tartar-emetic, produce the same results when introduced into the stomach and into the blood. We think that an important distinction is to be drawn, in this point of view, between different kinds of emetic substances. Some, like mustard, and, perhaps, sulphate of zinc, appear to act by direct irritation. Their operation is sudden, quick, complete as regards evacuation, but attended by little nausea, and no more permanent result than emptying the viscus. Others, like arsenic and antimony, are really very uncertain in their emetic effect (dose for dose), as compared with the preceding; but they produce grave constitutional disturbance, and the nausea, prostration, and death, which is their maximum result, are induced fully more readily by moderate than by large doses, because the latter tend at once to emesis
, and, therefore, to removal of the poison. In connexion with this elimination of irritant poisons by vomiting, Dr. Brinton has performed a remarkable experiment, which seems to
It is cer
assign to the stomach a higher office than that of merely resenting the presence of a deleterious substance. It would appear probable that the stomach is really an excretory organ of the first importance, as regards tartar emetic; for that poison, when injected into the blood of a dog, is soon found in the stomach in a state of concentration much exceeding that in which it must have been mingled with the mass of the blood." * This is a very important doctrine in relation to general pathology. Dr. Brinton points out that vomiting in disease must probably often be considered as an eliminative act ; and he refers, in illustration, to the vomiting at the commencement of fever. tainly a remarkable fact, that among the various means which have been proposed for cutting short the attack of contagious fevers, the only one which, to our mind, has any good authority, or any considerable amount of evidence in its favour, is that of an emetic administered during the first few days; and it is worthy of notice, that the class of emetics always recommended for this purpose consists of those which in all probability enter into the blood, and shake the nervous system to its foundations previous to their action on the stomach. These facts are strongly corroborative of the author's ingenious theory; which, moreover, derives additional interest, if not strictly scientific support, from the evident manner in which it would demonstrate the "final cause" of that kind of vomiting which accompanies poisoning by arsenic and antimony, when introduced into the system by other channels than the stomach. There is a purpose, too clear to demand explanation, in the selection of the stomach as the leading channel for the elimination of injurious substances, which find by that organ their usual entrance into the economy.
In regard to hæmorrhage, Dr. Brinton of course repudiates the old doctrine of hæmatemesis " by exhalation.” It is certainly true that some cases of fatal gastric hæmorrhage are very puzzling to the morbid anatomist; but, as the author remarks, it is not surprising that “ amongst the myriads of these minute tubes present in the mucous membrane), the eye often fails to detect the exact vessel or vessels involved in the lesion.” Dr. Brinton believes, and we think correctly, that the inter-tubular vessels are rarely the seat of bæmorrhage as compared with the superficial, or subra-tubular network. We believe, in fact, that the majority of what are called the “ hæmorrhagic erosions” of the gastric mucous membrane are the result of direct irritation, acting perhaps upon a mucous membrane accidentally denuded of its protective covering. And, if we mistake not, a very considerable proportion of the minute microscopic lesions described by recent authors are, in like manner, mechanical or chemical in their origin, whatever their importance or insignificance in regard to gastric pathology. This is evidently Dr. Brinton's view in so far as he goes into detail. Though he has apparently not been inclined to make a very pointed critical analysis of the observations of Dr. Handfield Jones on this subject, we gather from
few hints his opinion that an exaggerated importance has been assigned by that able pathological anatomist to appearances, the result, in many instances, of decomposition and manipulation of the mucous membrane. The recent researches of Dr. Wilson Fox will probably bring the subject once more under consideration, but we cannot stop here to enter upon it; nor, indeed, do we feel that we have a right to assume a tone of authority in 'relation to a matter depending on such delicate investigation. Certain it is that no intelligible relation has as yet been pointed out between the multitude of post-mortern changes, and the functional state of the organ during life; and, till this is done, we must decline to admit into the rank of diseases what are, at best, only problematical appearances of disease.
Dr. Brinton's doctrines on flatulence and on the symptoms connected therewith, are in some respects peculiar; and here we shall not say that he absolutely carries our convictions, but unquestionably he makes good show of weighty argument in favour of his own views. He entirely rejects the idea of secretion of air into the intestinal canal as a cause of this symptom; pointing out that the gas of flatulent intestines, even when not containing elements which cannot be procured from the blood in appreciable quantity, differs altogether in composition from the usual gaseous products of the sys
* See p. 61 of this work, and the author's article, Stomach, in the Cyclopædia of Anatomy;' also the 'Lancet' for. 1858, vol. 1l. p. 599.
tem as evolved in expiration. “It contains," he remarks,“ ten times the quantity of carbonic acid, and two hundred times the quantity of nitrogen found in expired air;" and he argues, not without force, that gas of this composition, is much more likely to be evolved from the food than from the process called “secretion," which has only been hypothetically called into existence to account for cases of enormous flatulent distension occurring within a very short period of time. Still, this is only, after all, a qnestion of probability, and it does not appear impossible that the gas of secretion may, when separately procured, present a different composition from that which has hitherto been analysed as intestinal flatus. Dr. Brinton lays great stress on the fact that in sudden and complete starvation the gases disappear from a great part of the canal; but the stoutest advocate for secretion will not deny, now-a-days, that gases are evolved in large quantity from the food; and, further, that the absence of food from the system diminishes, as respects the blood and the tissues, the sources from which waste gaseous matters are to be drawn, according to the hypothesis. The experiments of Magendie and Girardin (incidentally repeated by Frerichs), according to which gas is found in a coil of intestine for some time isolated by ligatures, and previously emptied by pressure, is objected to by Dr. Brinton on the ground that it is impossible by pressure entirely to empty the intestine of its contents; and that a single grain of starch or sugar remaining would, under decomposition, evolve gases equivalent to eight cubic inches of space. Surely this experiment is important enough to justify its repetition with additional precautions. There could be no difficulty, one would think; in washing out every particle of starch or of sugar from a coil of intestine, previously to the application of ligatures; besides, the character of the gases evolved would, in this case, at least, be ascertainable, and would be of great importance to the inquiry. This experiment is really crucial as respects the doctrine of secretion; and we cannot consider the negative of Dr. Brinton as carried until it has been thus tested.
Dr. Brinton insists much on the pressure to which the intestinal gases are subjected, as modifying their bulk, and believes that many of the cases of apparently sudden evolution of gas are really due to the expansion of the gas already in the intestinal canal by the temporary paralysis or at least relaxation of part of the wall. He explains the tympanitic distension of peritonitis in this way, and also that gastric flatulence which is the rapid result of taking a few mouthfuls of improper food. In the latter case, he believes that the irritation induces -- ist, an abnormal sensation, sometimes amounting to pain, or at all events to an impression on the nerves of the part, which causes, 2d, a relaxation in the coats of the stomach, and thereby, 3d, expansion and rarefaction of its contained air; 4th, a secondary rush of air from the duodenum through the relaxed pylorus; 5th, increased sense of pain or uneasiness by over-fulness of the stomach ; 6th, expulsive efforts of eructation. This view, which undoubtedly is favoured by many facts in the symptomatic history of colic and other flatulent affections, will bring to the mind of tắe reader the late Dr. Abercrombie's observations on ileus, which led him to the doctrine that spasm, commonly so called, was no part of the pathology of that affection, but rather a paralytic relaxation leading to over-distension of the bowel and undue retention of its contents. The most important novelty, perhaps, of Dr. Brinton's view is the idea that the pain of such attacks is not the effect of the accumulation so much as its cause, or at least its antecedent. The pain is the expression of an outraged sensibility, so to speak, of the mucous membrane; the paralysis and the distension follow after the nerves have reflected their abnormal impressions on the muscular apparatus of the organ. There is much in this view that commends itself to the practical experience of the physician, but we prefer to leave it, as Dr. Brinton does, without further development.
In all that the author says upon Acute Gastritis we cordially concur. He adopts the statement of Abercrombie, that acute inflammation of the gastric mucous membrane hardly occurs, except as a consequence of irritant poisoning; and he treats the idiopathic acute gastritis of nosologists as a practically non-existent disease.
We are disposed to go beyond our author in this point, and to assert very nearly the same thing of subacute and even chronic inflammation, for we have never seen anything coming distinctly within the range of inflammation at all in the gastric mucous membrane generally,
which was not to be accounted for on the supposition of mechanical or chemical irritation. In general terms we would say that according to our pathological experience, the gastric mucous membrane, considering the number and variety of the stimuli to which it is constantly subjected, enjoys the most remarkable immunity which it is. possible to conceive, from serious inflammatory disease, and has the most marvellous power recovery after even serious injury. And in no point is the stomach more wronged than in the facility with which dyspeptic and feverish symptoms are set down as the result of " chronic gastritis.” That the exposed stomach of Alexis St. Martin, tortured from day to day by the direct application of unmasticated food, habitually irritated by curious physiologists in search of gastric juice, and occasionally by strong alcoholic drinks, should only now and then have resented this treatment so far as to cease to give forth gastric juice, and to undergo a temporary congestion and partial extravasation of blood, seems certainly to us rather to disprove than the contrary the asserted liability of the organ to “ chronic inflammation.” . Consider that there is not a trace of evidence that pus was ever formed on this mucous membrane so irritated, and then consider the facility with which this product is evolved under the slightest forms of external irritation on all other mucous membranes excepting those of the alimentary canal, and it will be apparent, we think, how small a share is taken by general inflammation in the diseases of the stomach. The utmost that we can admit as at all common is the existence of transient congestions, resulting perhaps in an excess of mucous secretion and a temporary arrest of the proper digestive process. agree
with Dr. Brinton in doubting even the existence (considered as a disease) of the so-called “ chronic catarrh of the stomach,” but if it be really a disease, it is quite clear to our convictions that it bears no resemblance to inflamination.
It is more difficult to speak with confidence of the partial affections of the mucous membrane. Beyond all doubt the stomach is subject to disorganizing processes, limited to particular spots of the mucous surface, and the pathological character of these may reasonably be supposed to be inflammatory. Such are the simple perforating ulcer and the hæmorrhagic erosion. But the relation of these to the ulcerations of other mucous membranes is not a little obscure. The chronic simple ulcer of the stomach is an isolated fact in pathology. Nothing in its history, in its antecedents, in its consequences or accompaniments, throws the least light upon it; and except that the entirely normal character of the general mucous membrane, and the absence of all inflammatory products on the surface of the ulcer itself, seem to belie the supposition, we might as reasonably refer it to inflammation as to anything else. But the destruction of an accurately limited space of mucous membrane, bearing no relation to any special glandular structure, and this without sloughing or suppuration having ever been observed at any stage of the process, is a fact too anomalous to remain securely under this allcomprehensive pathological denomination. It is wiser, surely, to admit ignorance than to speculate in such vague fashion as this. And here again we find ourselves at one with Dr. Brinton, who declines to pronounce on the causes or mode of origin of the gastric ulcer.
We refrain from observations on the rest of the book, which is, notwithstanding, its major part. We have been chiefly anxious to bring before our readers such portions of the author's labours as have not been known to them from our own pages. It is unnecessary to enlarge here upon the exhaustive and admirable manner in which Dr. Brinton has treated of the Chronic Ulcer and on Cancer of the Stomach. The results of both these inquiries are given in this book as fully as is necessary for the busy practitioner, and in a form better adapted, perhaps, for his perusal than the original papers. The same conscientious care for truth has guided the author through every part of his researches, as is apparent in the ground we have now gone over ; and indeed not one sentence or phrase from beginning to end of this work will bear the construction that it is written at random, or without the most serious reflection. We sometimes differ from the conclusions adopted; but we are obliged to do so with the respect which is due to well-considered opinions. The practical man will miss some of those vague and dashing generalizations to which he is accustomed in works of this kind. But he will miss them greatly to his advantage if he imbibes in any degree the author's earnest and sober spirit of inquiry:
There is an introductory chapter, to which we have not alluded, on the Anatomy and Physiology of the Stomach. It is of the same character as the rest of the work, but does not aim at putting forward any new views or observations on the subject.
In the preceding remarks, it is to be observed, we have not attempted anything like complete analysis. Were we to have done so, we should have been obliged to re-write the book, which is, especially in the parts on which we have touched, far too condensed in expression to admit of further reduction of its argument. Indeed, we are sensible at some points of having even expanded the author's ideas in referring to them. We trust we have done them no injustice in thus handling them, and in venturing to indicate further points on which we would willingly see the author engaged. The enlargement of this volume by a chapter or two in a future edition would, we think, make it still more serviceable to the public and to the reputation of Dr. Brinton.
Practical Midwifery: comprising an Account of 13,748 Deliveries which occurred in
the Dublin Lying-in Hospital during a period of Seven Years, commencing November, 1847. By EDWARD B. SINCLAIR, A. B. F. K. and Q.C.P., &c. &c., Ex-Assistant-Physician to the Dublin Lying in Hospital; and GEORGE JOHNston, M.D., L. K., and Q.C.P., &c. &c., Ex-Assistant-Physician to the Dublin Lying-in Hospital.Dublin, 1858. 8vo, pp. 574.
The above volume, although purporting to be a treatise on practical midwifery, is essentially a statistical record of the deliveries which occurred in the Dublin Lying-in Hospital during the seven years' mastership of Dr. Shekleton, interspersed with some general observations on practice. We say essentially statistical, for there is scarcely a fact or an incident recorded in the volume which is not given in a statistical form; and it is curions to observe in how many ways the same fact may be numerically stated. As a mass of statistics, therefore, we regard the work as a valuable contribution to obstetrical literature, and those who attach more importance to such data than ourselves will doubtless accord to it a high tribute of praise. For ourselves, however, we cannot help thinking that throughout the work the practical has been too much sacrificed to the statistical—that an immensity of labour has been expended in stating facts numerically which are of little clinical importance, and that a too servile deference has been paid to the arbitrary rules of an artificial nosology. Thus, instead of the history of Face Presentations being given in a consecutive series, we find them scattered among different chapters of the book, in deference to nosological formulæ; so also is it with Puerperal Fever and
many other of the subjects treated of. We concede that a large array of facts and figures gives an imposing character to a work, and that where upwards of 13,000 deliveries are recorded, there exist ample materials for such a purpose; but we nevertheless think that the volume would have been more generally useful and available if less encumbered with figures and calculations, and as we do not think we could interest our readers by a merely statistical abstract, we shall rather endeavour to enucleate from its pages the spirit or principles which would appear to bave guided the practice in the Dublin Lying-in Hospital during the period over which its history extends.
Let us, however, premise a few generalities culled from the introductory observations. The report, as already stated, contains an account of the cases which occurred in the hospital during the seven years' mastership of Dr. Shekleton, which commenced in November, 1847, and terminated in November, 1854. During this period, 13,748 women