G. May
1855 BMJ (Clinical Research Edition)  
1147 taned on the stomach, and produced two or three copious evacuations from the hitherto constipated bowels. July 6th. There has been scarcely any vomiting since the last report; but he has occasional attacks of pain, lasting an hour or two. They do not, however, exhibit any appreciable connexion with the scanty meals mentioned above; but occur indifferently before and after the ingestion of this food. On one occasion, he has brought up about a teaspoonful of blood, with about a quarter of a
more » ... int of an acid fluid. Tongue still furred as before. Ordered to vary the preceding diet, by substitutinig ground rice, sago, and tapioca, for the arrow-root. July 10th. He has had very little pain in the epigastrium since the last report, though the pain in the spiine is somewhat increased. Complains of the monotony of his diet. Ordered to take a small quantity of strong cold beef-tea; and repeat it twice or even thrice daily, if well borne by the stomach. A blister to be applied to the painful region of the spine. Omit the morphia. July 13th. An egg which he has been allowed to take since the last report, beaten up in a little cold tea, brought on scverc vomiting. With this exception, however, there has been uo vomiting, and scarcely any pain, during the last four days. His tongue is much cleaner; and he is sensible of much less pain in Iying on the left side. States that he feels greatly improved. The beef-tea seems not to cause the slightest uneasiness. To take ei'ht grains of the citrate of iron thrice daily, in an ounce of 3istilled water. July 17th. No pain or Vomiting since the last report. The soreness and tenderness to pressure on the epigastric region have also greatly diminished. Ordered on no account to repeat the manipulation on which he founded this statement. July 24th. Tongue much cleaner. In all other respects, reuiains as at last report. From this time, his diet was gradually enlarged; and his amendment steadily continued up to the period of his discharge from the hospital, at the end of August, or about six weeks from the cessation of the pain and vomiting. He was requested to continue attendance as an out-patieut. A few weeks after his discharge, he returned to the hospital, apparently in'much the same state as when first admitted. Hte stated that he had received an injury of the leg, for which, among other remedies, a surgeon who attended him had prescribed some pills, apparently of a drastic putrgative nature. They had made him extremely sick, and purged him; since which the pain and vomiting had returned, and were, in his opinion, as bad as ever. There was not much reason to expect a very succeesful result from treating a man of his habits and circumstances as an out-patient: and, owing to want of room in the hospital, he could not be readmitted that day as an in-patient. On the day fixed for his admission, he failed to come: and since then I have seen him no more. REMARKS. I have already alluded to all that seems worth noticing with respect to the diagnosis in this case: and, in the instances previously reportea in this JOURNAL the outlines of the above plan of treatment have been sufficiently explained. Hence there are few poiuts of any practical importance left for me to notice. The influence of intemperance in the production of gastric ulcer is once which can only be established by the careful collection and analysis of a large number of cases. But habits of this kind seem to be so frequently connected with the occurrence of this lesion for the first time in strong and well-nourished men of middle age, that it is scarcely possible to avoid the conclusion that such an influence often does obtain. And the instance under consideration offers us a good example of this coincidence. The manner in which the symptoms were suddenly aggravated by an error of diet, such as would perhaps hardly be expected to give rise to very marked results, is especially interesting. Where, as in this case, the general health and state of the constitution do not contraindicate so restricted a diet, I think we can hardly do better at first than adhere punctiliously to the simple regimen originally presecibed by Cruveilhier; into which we may afterwards gradually introduce the various alterations mentioued above. The blister in this case had, as is not infrequent, a marked influence in diminishing the dorsal pain. Was the patienit's account of his relapse a true one, especially as regards the cause to which he attributed the return of his symptoms ' Fromu what I have often seen in such cases, I should be disposed to think it might be. Once or twice I have known the symptoms of an ulcer of the stoinach greatly exaggerated by a dose of salts, an aloetic mixture, or a pill coutaining a grain or ttwo of calomel, with three or four of the comnpound extract of colocynth: in fact, by such an aperient as few would hesitate to prescribe, supposing the exact iiature of the malady unknown to themn. Examples of this kind teach us, I think, almnost to limit our selection of aperients to castor oil and enemata. The beneficial effects of the latter are generally restricted to the unloading so small an cxteut of the large intestine, that we are often obliged to use some more efficient aperient. But I have never known the castor oil do any mischief; and believe that even constant vomiting is scarcely a valid coutraindication of its use. Lastly, the above case well illustrates some of the difficulties which frequently attend the treatment of this malady; especially among the classes who form the umajority of our hospital patients. There is often no way of administering the necessaTy diet and regimen except by the most careful discipline and attention in the wards of an hospital. And even after thus effecting what seems to be a cure, the patient sometimes returns on our hands, reduced by accident, disobedience, or intemperance, to a state which again taxes all that our care or skill can bestow, with what is now scarcely any hope of a permanent cure. Whether the ulcer had really cicatrised in the above case, it is, of course, impossible absolutely to certify: but from the gradual nature of the amendment, and the length of time during which the symptoms had been completely interrupted, it is probable that it had thus healed. I have known a similar intermission last many months (instead of six weeks), and yet a single large meal of unusually indigestible food has brought back the whole train of symptoms, ending in the speedy death of the patient.
doi:10.1136/bmj.s3-3.156.1147 fatcat:qiefzqk5bjbt3kwmowuoomcknu