THE LANCET. A Journal of British and Foreign Medicine, Physiology, Surgery, Chemistry, MDCCCLXVIII. IN TWO VOLUMES ANNUALLY. VOLUME II. EDITED BY JAMES G. WAKLEY, M.D., M.R.C.S. ENG. THE FRANCIS A. COUNTWAY LIBRARY OF MEDICINE JUL 22 2003 402 28 LONDON: PUBLISHED BY JOHN JAMES CROFT, AT THE OFFICE OF "THE LANCET," 423, STRAND. GENTLEMEN,-There is no symptom having more varied relations, or a wider range of pathological significance, than vomiting, and none, therefore, in which more care is necessary in diagnosing, in any given case, its precise nature and indications. It may be a symptom of so trifling a character as hardly to deserve the name of a symptom, but rather to be a healthy and natural phenomenon, or it may be the gravest symptom of a fatal disease. An infant's stomach is a little too full of milk, and it vomits; it has hydrocephalus, and it vomits. There is hardly any pathological state with which it may not be connected; there is hardly any organ of the body from disease in which it may not result. A man has a blow on the head, or a tubercle in the brain, and he vomits; the heart's action fails, and the syncope is accompanied by vomiting; a man has tubercles in his lungs, and he vomits; the liver is enlarged, and vomiting is a symptom of it; a man has kidney disease, and vomits; a woman has an impregnated uterus, and vomits; a boy has a blow on his testicles, and vomits; a girl has ulcer of the stomach, and vomits; a calculus is passing down the ureter, and the patient vomits; a child's blood is contaminated with the poison of scarlatina, and he vomits; a man has colic, and he vomits; an emotion of disgust passes through the mind, and the subject of it vomits. Vomiting, therefore, per se, tells us nothing; it tells us, indeed, that the stomach has returned its contents, but it tells us nothing more; and if we want to know anything more about it, and to ascertain its real meaning, we must seek it in the antecedent and attendant circumstances of the case. Thus vomiting must be always studied in the light of its surroundings. In relation to diagnosis the great thing to be determined with regard to vomiting is, whether it is primary or secondary. By primary vomiting I mean stomach vomiting, that which depends on some diseased state of the organ which effects the act. By secondary vomiting I mean that in which the stomach is affected secondarily to some remote organ- as in head vomiting, kidney vomiting, uterine vomiting. In relation to prognosis the most important thing to determine is, whether the vomiting has an organic cause, or merely depends on functional disturbance. As examples of this method of classification I should call the vomiting of ulcer of the stomach "primary organic vomiting"; that of some dyspepsias, "primary functional vomiting"; the vomiting of hydrocephalus, or of Bright's disease, would be "secondary organic," and that of syncope, "secondary functional.” I think this is a classification that may be found practically useful. I wish to-day to call your attention to a case of vomiting of á curious and interesting kind-interesting from the peculiarity of its phenomena, and interesting in relation to diagnosis. Before making any comments about this case, or giving you any hints as to its nature, I will read you the full history of it. Eliza T, aged nineteen, one of eight children, all living and all healthy; her parents living and healthy, and residing at Bushey in Herts; of fair complexion, with light hair and eyes, and rather thin, but not very; has, with the exception of her present symptoms, always enjoyed good health. But all her life, as long as she can remember, she has suffered from the two classes of symptoms which now principally characterise her state-anomalous irregular pains in various parts of her body, and vomiting. They however suddenly acquired a muck greater intensity when she began to menstruate, which was when she was about fourteen years of age, now five years ago. But a long as she can remember they have existed; back into her earliest childhood she recollects that she used to throw up her meals almost immediately after swallowing them. No. 2340. But the vomiting was not so persistent and invariable as it has been for the last five years, and she would have intervals of a fortnight in which she would vomit nothing. She always had to take aperient medicine, or her bowels were never moved. Her appetite was always good, and as soon as she had vomited one meal she wanted to eat another. She always suffered from thirst. She never felt, and never feels sick-she vomited without any warning. She never had pain in her stomach after eating, but down in the left groin, where the act of vomiting also gave pain. Until she menstruated she never vomited her supper-it was the only meal that she invariably retained; since that period she has thrown up her supper as well as other meals. She looked a healthy child, and had a colour; she was nervous and excitable, and easily made to cry or laugh. Then, five years ago, with the appearance of menstruation, these symptoms, as I have said, received a sudden increase of severity-the vomiting became constant instead of occasional, and other symptoms showed themselves. She began to have headache, which has continued ever since; and her other pains became much more severe. These pains principally lie at the bottom of the back and lower part of the abdomen, and the genitals are the seat of the worst pain of all. The pains extend down the legs, with a numby, burning feeling. Two years ago she lost the use of her left arm every morning, so as to be unable to lift it to her head or to hold anything in her hand; as the day advanced this would go off: she had it up to within the last six months, and then it gradually left her. A twelvemonth ago she began to be troubled with a lump in her throat; she has it just before she vomits, and the vomiting seems to relieve it. Sometimes she has it without any vomiting at all; indeed, it has been at its worst when the sickness has temporarily ceased. It feels like a ball in the throat, as if it would choke her; and compels her to keep on swallowing in order to get her breath. The pain in the lower part of the back extends across the sacrum from hip to hip, and is of an aching character, accompanied with darting pain into the pudenda. The pain in the pudenda sometimes amounts to an agony, so that she can hardly tell how to bear it; it keeps her awake at night, and often makes her cry. It is a sharp shooting pain— paroxysms are so frequent that the pain is almost constant. it comes, and is gone; but just before she becomes unwell the The parts are tender, and sometimes it seems when she walks as if something pricks her. She has an almost constant desire to pass water, and cannot hold it for long; if she attempts to do so, it puts her in great pain. She cannot tell how many times she passes it in the day, and in the night she often has to get up two or three times in order to relieve herself. As soon as she has passed water she seems to want to pass more. The water is very pale-sometimes quite white, like spring water,-and very abundant. But at the monthly period, although the want to pass water is more urgent than at any other time, she passes less than usual. At this period it gives her great pain to have her bowels moved, but not at other times; she then also is troubled with piles, which vanish when menstruation ceases. Her headache is frontal: the worst time for it is the afternoon, as soon as she has had her dinner. This is much worse also at the monthly period. For the last twelvemonth she does not think she has passed a day without vomiting, with the exception of three occasions since she has been in the hospital. As a rule, she has vomited every meal she has swallowed; it comes up immediately, even before she has finished eating. She sometimes vomits part, and then finishes the meal afterwards. Even the vomiting does not for a moment interfere with her appetite; she always feels hungry, even craving. She is equally prone to vomit one meal as another; but while the breakfast and the tea come up without any effort at all, the dinner is often brought up with difficulty and violent retching. In quantity the vomited matters seem generally quite as much as she swallows, and sometimes more. The food comes up unchanged, just as she swallows it. As a rule it comes up directly, and if she does not vomit at once she does not vomit at all; on some rare occasions, however, food has remained in her stomach as long as twenty minutes, and has then come up. At her breakfast and tea the return of the food hardly seems to deserve the name of vomiting; it seems simply to rise into her mouth. One very curious thing is that she cannot be sick if a stranger is present; she is obliged to go away in order for the food to come up. It occasions her great discomfort, and "seems to want to come up," but it does not actually rise to her mouth till she goes away; she thinks it would eventually, but would take a much longer time. As soon as she goes away, or the person goes away, it is up in her mouth at once, and the thing is over. Any member of her own family, or anyone she is accustomed A |