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during fever, whether intermittent, or continued, or during the febrile state of symptomatic fever. In these conditions the stomach is affected in common with the whole system, all the glandular organs have their action retarded, the blood is modified, and the whole organism is disordered. The furred state of the tongue is often expressive of a general condition, rather than a mere local indication of the state of the digestive mucous membrane.

With sympathies so widely pervading the whole system, it is not surprising that gastric disease should present most varied indications in the disturbance of other organs; and, in like manner, that gastric phenomena of an abnormal kind should result from irritation, far removed from the stomach itself. The closest circumspection is required to discriminate between sympathetic affections, and those of a strictly local origin.

SYMPTOMS OF DISEASE OF THE STOMACH. 39

CHAPTER III.

ON THE SYMITOMS OF DISEASE OF THE STOMACH.

If we were to judge alone by the severity of the symptoms in diseases of the stomach, constant mistakes would be the result, especially in the earlier stages of disease; for in functional maladies, that is to say, those in which no structural change can be detected, the symptoms are often extremely urgent. The irritability of the stomach may be excessive, so that every portion of food is at once rejected, the pain may be severe, and the general distress constant, although the ailment is curable, and of a comparatively slight character.

It will be well to consider seriatim, the symptoms which are present in diseases of the stomach, and their relative value. The two symptoms which are regarded as of especial diagnotic value are vomiting and pain* in the region of the stomach. We have already referred to the intimate connection of the nerves of the sympathetic plexus with all the abdominal viscera, and with the spinal nerves; and this connection serves to explain the uncertain indications of these symptoms.

* The remarks on pain and vomiting are in great measure taken from my larger work on 'Abdominal Disease.'

As a sign of disease, pain is of doubtful value ; oftentimes it is a certain guide to the locality, if not to the character of morbid action; at other times on the contrary, its presence misleads, or its absence disposes us to under-estimate changes which may be going on in the system. Generally speaking we find that the mucous membranes, except where they approach the outlets of their respective canals, are free from ordinary sensibility, and may undergo very marked changes in their condition without any painful manifestation. Acute disease may take place in the mucous membrane of the kidney or bladder with complete immunity from suffering. A similar fact is observed in relation to the parenchymatous viscera; thus the substance of the liver and the kidney is often changed in a marked degree; and if disease, such as abscess, arises in their structure without much distension, the patient may be unconscious of morbid change. On the contrary, in serous membranes an opposite condition is found to exist; almost any change is appreciated, and in sudden or acute disease, the pain is often extremely severe in its character. All physicians well know the stabbing pain of pleurisy, the agony of acute peritonitis, and the intense suffering of severe synovitis. In each of these latter diseases, rest is a very essential element in the alleviation of the malady, and this rest can be attained to a great extent without the cessation of life. In pericarditis, on the contrary, we find, as was shewn

many years ago by Dr. Addison, that there is an absence of pain, unless there be pleurisy occurring at the same time. In the pericardium, however desirable rest may be, it is impossible, as the heart must beat as long as life lasts.

Pain.--In reference to pain as an indication or nonindication of disease we have to remark,

I. That acute inflammation and disease of the stomach may exist, with entire freedom from pain, if the mucous membrane only be affected. Acute gastritis is generally regarded as an exceedingly rare form of disease, excepting when produced by irritant poisons. This may be the case; but we are of opinion, that in many instances the absence of pain has led to this belief. In the gastro-enteritis of children, and not very unfrequently in that also of more advanced life, conditions of great irritability with cessation of the right function of the stomach, and probably with hyperæmia, must be regarded as closely approaching the character of gastritis. However this may be, we have evidence from the action of irritant poisons, that, while the mucous membrane is only affected by them, pain may be entirely absent, excepting that which is consequent on the violent muscular action exerted in the act of repeated vomiting. Thus, in a patient who had taken a large dose of oxalic acid, violent vomiting, with failing pulse and a sense of exhaustion, were produced, but no pain. In a few days, after taking demulcent

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forms of diet, she completely recovered. In an instance of poisoning by strong sulphuric acid, where a large portion of the mucous membrane of the stomach was destroyed, although the patient survived eleven days, she did not appear to suffer from any pain at the stomach. The same fact was still more strikingly shewn in a case of poisoning by chloride of zinc, in which life was prolonged for three months. But the absence of suffering was most remarkable till eight days before death, and the pain then induced was evidently caused by the formation of an abscess in the left hypochondriac region. I have witnessed the same immunity from suffering in poisoning by arsenic and by corrosive sublimate; and we are warranted in the belief, that acute disease may take place in the mucous membrane of the stomach without any pain.

II. Organic disease of the mucous membrane, as for instance cancer, may be comparatively free from pain. It frequently happens in cancerous disease of the liver, that after death tubercles or growths of a similar character to the primary disease are observed on the mucous membrane, and of which there had been no indication during life. Thus, a patient aged 60 died from cirrhosis, and after death a large villous growth was found attached to the anterior surface of the stomach; but the orifices were free. There was no complaint of any pain at the stomach, neither had she any vomiting; and it is probable that the burning

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