1847.] Alderson on Diseases of the Stomach, &c. 537 with the resemblance the new phenomenon bears to those of asphyxia, and experiments exhibit a real relation between asphyxia and etherization. But in ordinary asphyxia the nervous system loses its power under the influence of black blood, of blood deprived of oxygen: but in etherization it does so under the direct action of this singular agent. This is really all the difference; for in both there is the same loss of sensation and voluntary motion, and the same, at least temporary persistence of the respiratory movements-in one word, there is the same survival of the medulla oblongata over the spinalis. Etherization exhibits to us the entire mechanism of asphyxia-I mean the successive death of the various nervous centres. It isolates, just as mechanical experiments do, the intellectual powers, the coordination of the movements, sensibility, motility, life. The isolation of life, this point, this vital knot of the nervous system, forms the most striking fact of the new experiments. In an etherized animal one point alone survives, and while it does so, all the other parts retain at least a latent life, and may resume their active life: this point once dying all dies." We fear much light is not shed upon the subject by these experiments; for certainly no such exact order in the train of symptoms is observed in the human subject. We are yet, however, we repeat, in the very infancy of the investigation, and careful observation, well weighed deduction, and a not too hasty extension of inhalation for the relief of minor ailments, seem to be the indications for some time to come. That we have become possessed of a valuable instrument, not only as a therapeutical agent, but for the solution of more than one interesting physiological problem, we hold to be certain and it much behoves us not to discredit it in the eyes of the public or the profession, by a too rash and careless employment. One benefit the discovery has conferred medical men must feel keenly, the overthrow of the only tangible pretension of Mesmerism. It was thought by many, that the profession were remiss in not putting its boasted power of relieving pain to the test. Their joyful acceptance of a means unassociated with chicanery or humbug of any kind, amply proves that any backwardness in this particular did not arise from indifference or a want of duly estimating the importance of the subject, but from their scepticism and their unwillingness to mix themselves up with this wretched quackery. Mr. Robinson's pamphlet contains a brief history of the progress of the discovery from the period of its importation to the date of the publication. In our notice of his former work we commented upon his undue laudation of the American dental practitioners. We are now rejoiced in the opportunity of acknowledging the great obligation the human race is under to one of these-always supposing his claim, now litigated, is finally established. PRACTICAL OBSERVATIONS ON SOME OF THE DISEASES OF THE STOMACH THIS Volume contains part of the gleanings, in one particular field of professional research, of many years' extensive and carefully-observed experience in one of our large provincial towns and its neighbourhood. The work is thoroughly practical, and is but the faithful record of what the author has himself witnessed by the bed-side of the sick. He has wisely avoided enlarging its dimensions by the too common practice of introducing large quotations from the writings of others. There is a two-fold division of its contents; the first part being occupied with the consideration of some of the Structural Diseases of the Stomach and Intestines, and the second with that of some of their Functional Disorders. We shall be able to notice the former only. Dr. Alderson does not enter upon the histological characters of Carcinomatous deposites; nor is it necessary for us to allude to them again, after the ample exposition which we gave, in a late Number of this Journal, of all the most recent discoveries on the subject in our review of Dr. Walshe's classic work.* Next to the Uterus, the Stomach is the viscus of the body most frequently affected with Carcinoma. All its three forms-the scirrhous, the encephaloid, and the colloid or gelatinous-are met with in this organ; indeed, it is the special seat of the last-named form or species. The morbid deposit very generally occurs as an infiltration of the submucous cellular tissue. The pylorus is the part of the stomach most frequently affected; then the cardiac orifice; next the great, and lastly the lesser, curvature. More than two-thirds or even three-fourths of the organ may be involved in the destructive disorganizing process. When the disease is so extensive, it is generally of the colloid species. The muscular coat of a stomach affected with Carcinoma is usually thickened and hypertrophied; occasionally however-but this is rare-it becomes attenuated and wasted. The size of the organ varies much in different cases. It has been known to be so much expanded, that it nearly reached to the pubes; in other cases it has been found greatly shrunk and contracted. The former condition is present, when the pyloric orifice has become narrowed from the disease; while the latter is generally associated with a like condition of the cardiac. Carcinoma of the Stomach is more frequent in the male than in the female sex. It seldom occurs before 35 or 40 years of age. In the following extract it will be observed that our author associates together the Encephaloid and Colloid species of the disease under the common appellation of "areolar." "Of the various forms under which carcinoma attacks the stomach, there are two which, though usually considered as varieties of the same disease, tend to such different results when situated at either orifice, that I am induced to consider them separately. I am willing to admit that they have a common origin, and are only modified in their progress by incidental circumstances. "One of these forms tends to close the orifice or outlet by the deposit of a dense cartilaginous-like material, constituting scirrhous stricture (Simple Carcinoma). This form (scirrhous stricture) has very little, if any, of a softer material in its composition, and, when it is ulcerated, the abraded surface is small, and the ulceration superficial. The effect of the deposit is occlusion of the orifice, whether of the cardia or of the pylorus. "The other form, however the deposit may have first commenced in the part, is found, after death, in a softened, ulcerated state, and the outlet is comparatively *We have much pleasure in referring our readers to some valuable observations on Cancer in the last Number (for March) of the Edinburgh Journal of Medical Science, by Dr. J. Hughes Bennett. This distinguished observer discusses in his paper the following four questions connected with the disease, which more particularly interest the medical practitioner; viz.-1. Is there any anatomical character which will enable us positively to distinguish a cancerous from any other kind of growth? 2. Is there any evidence that Cancer is ever spontaneously curable? 3. What means do we possess of diagnosing cancerous from other tumours or growths in the living subject? and 4. What influence should our present knowledge of diagnosis have upon the treatment? 1847.] Different Forms of Carcinomatous Disease. 539 open. The deposit is of a mixed character, varying in density from that of scirrhus to the softness of brain or pulp: and the ulcerated surface is always extensive, and covered with fungous projections. This form is called 'Areolar Carcinoma. "However true it may be that these varieties are originally identical, and only in their subsequent development modified by incidental circumstances, I think it better to consider them separately, and endeavour, by a comparison of the symptoms during life with the appearances after death, to accumulate signs by which we may be able to distinguish them from each other in the living subject. Both varieties are alike constitutional, and both, when developed in certain situations in the stomach, are attended by the secondary deposit of encephaloid or medullary matter in the other viscera, especially in the liver: the particular situations will be hereafter indicated. The secondary deposit in the liver consists always of a soft homogeneous matter dispersed throughout the organ in the form of tubera, which, from their consistence, have been called encephaloid or medullary. "In consequence of the mechanical functions performed by the orifices of the stomach, which, when in a natural state, and not in action, are always contracted, we find the coats at the orifices to be composed of a denser and more compact structure than the rest of the stomach; and it may be to this peculiarity of structure that we must attribute in them the prevalence of the scirrhous form of carcinoma, uncomplicated, or nearly so, with areolar deposit, a supposition borne out by the fact that we never meet with scirrhus in its simple form in the larger curvature of the stomach."-P. 15. One of the most prominent symptoms of Carcinoma (whether in the scirrhous or areolar form) of the Cardiac orifice is the rejection of the food immediately, or very soon, after it has been swallowed. "The common saying among hospital patients is, 'that one mouthful brings another up,' which mode of expression, though rude, is almost literally true, since the distension of the oesophagus by a second mouthful causes the whole to be immediately rejected. This is sometimes accompanied by a sense of suffocation: the patient feels the food go to a certain spot, and then stop: pain is immediately experienced at that point, and vomiting succeeds. The pain is of a dull, aching kind, aad strikes through to the back and between the shoulders. "In the earlier stage and progress of the disease, vomiting does not occur invariably after taking food, but it is never absent during many days together; the interval gradually diminishes as the disease advances: when stricture takes place, vomiting becomes a constant symptom, always following immediately when nourishment has been taken. The food then returns in the same state as it has been swallowed, or mixed with ropy mucus, secreted by the lining membrane of the œsophagus. Ultimately, even liquids will not pass into the stomach, and the patient having subsisted upon his own fat, at last dies, emaciated, of starvation."-P. 21. The amount of suffering from Carcinoma of the Cardia is, as might be expected, greatly more severe, but much less protracted than when the Pylorus is the seat of the disease. In some cases, not a mouthful of food can find its way into the stomach, while the sharpest hunger is experienced all the while. There is then no other way of supporting life, except by the use of nutritious enemata. In no instance of cardiac Carcinoma, occurring in the practice of our author, did he discover on dissection any traces of encephaloid deposit in the liver. When Carcinoma occurs in the larger Curvature of the Stomach, it is invariably of the areolar form; true scirrhus being never met with in this part. Its presence is "Attended by symptoms of dyspepsia in an aggravated form, by vomiting at variable periods after taking food, by the escape of fetid air from the stomach, and usually by great pain at the pit of the stomach, which is increased by the slightest pressure. "There is a sense of great debility. The countenance is very anxious, and the spirits depressed; the complexion is exsanguineous and opaque; the tongue is always clean; the state of the bowels varies in different cases, but is usually confined. "In some few cases vomiting does not occur, and frequently, in the later stages of the complaint, it is superseded by 'sour risings,' by fetid 'mouthfuls,' which are brought up from the stomach. Less pain is experienced in this situation of the disease than when it occurs at either of the outlets. Emaciation takes place, but not to the extreme extent which accompanies scirrhous cardia. "There is always deposit of encephaloid tubera in the liver."-P. 53. As long as the Cardiac and Pyloric orifices remain sound, food can be received into the stomach; but the organ never contracts with its normal force upon its contents, and thus a greater or less degree of difficulty is always experienced in propelling the half-digested mass, either upwards into the œsophagus, or downwards into the intestinal canal. On examination by the touch, a tumour may very generally be detected in the epigastric region; as the disease, however, advances, this becomes increased in size, but less circumscribed and definite in form. "The increase of the mass, in this case, is to be attributed to the encroachment of an enlarged liver, and to subsequent adhesions between the liver, the stomach, and neighbouring organs. In consequence of the increase, the position of the tumour is no longer to be distinctly referred to one spot; and that, which was previously a comparatively distinct tumour, is superseded by a gradually increasing mass, which extends across the pit of the stomach, and below the cartilages of the ribs."-P. 54. Carcinoma of the Pylorus.-The pyloric extremity of the stomach, as we have already said, is by far the most frequent seat of malignant degeneration (which is generally of the areolar kind); and there is less difficulty in forming a correct diagnosis as to the disease, when it is situated in this than in any other part of the viscus. The tumour in the epigastrium is usually distinct and well defined, until adhesions between the stomach and the adjacent viscera have taken place, and then its form and outline become less distinguishable. The commencement and progress of the disease are usually indicated in the following manner: 66 Pyloric disease at its onset is usually marked by symptoms of dyspepsia. They are urgent and distressing, and do not yield to the remedies which are found to avail in functional disorders of the stomach. These will have been present for about two years before the disease approaches to a crisis. In the latter year the change to the true cancerous complexion marks the uncontrolled advance of structural disease. With a few exceptions, pain, which is aggravated by touch or pressure, is experienced in the region of the stomach, to the right of the ensiform cartilage. During the examination, when the diseased part is touched, it is usual for the patient, though suffering severely from the ordeal, to express a peculiar and melancholy satisfaction that you have touched the precise point from which all his pain proceeds. "Sickness is also generally a marked symptom of this situation of the disease; it comes on two or three hours after taking food, and is almost always preceded by pain."-P. 76. In some cases, indeed, little pain or vomiting is experienced; but the absence of these symptoms is, as might be supposed, quite an exceptional occurrence. The sickness is sometimes suspended for a period of several days at a time. "I have known an interval of fourteen days between the vomiting, when all at once the accumulation of nearly all that had been taken during the interval was vomited in a chymified state, mixed with mucus, or with vitiated secretion from the ulcerated surfaces. The greatest relief is experienced after this complete emptying of the stomach; and when it occurs for the first time, the patient has 1847.] Carcinoma external to the Stomach. 541 a delusive conviction that the complaint is finally subdued. The accumulation, however, soon again takes place; and it is painful to witness the corresponding depression which succeeds this temporary but disappointed hope. It is usual at this time for the spirits to begin to droop, and the patient is unable, upon the faintest excitement, to restrain emotion, even to tears."—P. 78. Ulcerated Carcinoma of the Pylorus is almost invariably associated with Encephaloid disease in the Liver; and not unfrequently, when the nodules or tubera of this morbid deposit are situated on the anterior surface of this viscus, they may be detected by careful examination through the abdominal parietes. Jaundice is not an uncommon result of this hepatic complication. The gall-bladder is almost always found to contain gall-stones. Dr. A. remarks, that several of his patients, who were the subjects of cancer of the pylorus, had previously suffered from attacks of gall-stones. Carcinoma External to the Stomach.-The following narrative of the pathological changes alluded to under this appellation will best enable the reader to appreciate the value of Dr. Alderson's descriptions : "Deposit of carcinomatous matter may take place beneath, or on the free surface, of the serous membrane covering the stomach, and the neighbouring viscera (as the duodenum, the head of the pancreas, the omenta, the mesocolon, &c.): the deposit varies in consistence from the hardness of scirrhus to the softness of pulp. It is difficult, if not impossible, to assign a position to the earlier deposit; as it increases, however, lymph is effused, and adhesions are formed, by which contiguous parts are glued together; the viscera become bound to the spine, and to each other, by these adhesions, and, as a consequence, the healthy performance of their various functions is interfered with. The adhesions often present a dark smoky hue, and jelly-like appearance, and are easily torn through: the proximity of organs, rather than the similarity of function, seems to be the cause of their being involved. The order in which the parts are severally included in the diseased mass may be inferred from the succession of the symptoms which will be hereafter detailed: this order, as well as the number of organs finally included, varies in different cases. In some cases the disease proceeds until portions of the stomach, the duodenum, the pancreas, the colon, and even the liver, are all involved in one diseased mass, forming an undefined tumour. In the latter stages of the disease, ulceration finds its way into the duodenum, the stomach or the colon. The ulceration has a peculiar character, differing from that which results when the primary seat of the deposit is in the submucous cellular tissue: the disorganizing process is, perhaps, more properly expressed by erosion, which takes place through the coats, where either hard or soft material of carcinoma is deposited."-P. 98. The Symptomatology of the disease is thus very accurately given : Amongst the earlier symptoms of this disease, unsatisfactory relief from the bowels is the most prominent. It is experienced for a year or more before the more urgent symptoms set in, and is accompanied at intervals by nausea, retchings and headache. Pain is also suffered, but not to any great extent, and it is referred by the patient to an unremoved accumulation in the bowels; it is described as situated at the pit of the stomach, or rather lower. The patient subsequently begins to lose flesh, the features shrink, the complexion becomes opaque, sallow and exsanguineous; the eye looks sunken, and the strength begins to fail; great anxiety about his health now possesses the patient, who is often prone to seek various opinions, until he finds a voice ready to flatter him with the delusive promise of a cure. "At this early period the tongue is tolerably clean, but not in the peculiar degree met with in carcinoma of the interior of the stomach; the pulse is, on the whole, natural, but inclined to be weak and frequent; there is often morbid No. 108 35 |