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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 withi 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

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 pain she had before admission into the hospital was of the character often observed in ordinary dyspepsia, for she was of intemperate habits. The freedom from any obstruction at the orifices of the stomach, and the fact that the growth involved only the mucous membrane, were, we think, the cause of the absence of pain. No supposition was entertained of the presence of this growth in the stomach during life. We have witnessed the same immunity from pain, in fact from any recognizable symptom, in extensive lardaceous degeneration of the gastric mucous membrane.

III. Diseases extending to the muscular and peritoneal coats produce severe pain, as observed in ulceration or cancer. This symptom is present as one of the most ordinary signs of ulceration, and in several instances, in which the suffering was very severe, we have found branches of the pneumogastric nerve involved in the thickened, dense, and fibrous edges of the ulcer. The pain often comes on in these cases directly after food has been taken. | IV. Over-distension of the stomach produces severe pain. The formation of the stomach and its peritoneal attachment are such as to allow moderate distension to take place during digestion; but whenever the distension becomes greatly increased, pain is the result.

V. Disease, especially of an acute kind, affecting the peritoneum is also, with few exceptions, accompanied with severe pain. In reference, however, to the position

of pain in peritonitis, it is not always a certain guide to the precise seat of injury. I well remember a young woman who was seized with sudden and severe pain at the scrobiculus cordis towards the left side, which was followed by rapid collapse. From the seat of the pain perforation of the stomach was diagnosed; it was, however, found to be perforation of the appendix coeci.

VI. Dr. Osborne has shewn that in some cases of gastric ulcer the position of greatest ease to the patient may serve as a guide to the exact seat of the disease; that if the ulcer be on the posterior surface of the stomach, lying upon the face would be the most comfortable position, and vice versa. Food, on its entrance into the stomach, generally passes directly along the lesser curvature, and if the viscus be contracted, it would come in contact with an ulcer, whether placed on the anterior or posterior aspect of the median line of the curvature. If more distended, there might be less direct application to the diseased surface. In the case of severe suffering from gastric ulcer previously referred to, the patient was most easy when leaning somewhat forward and towards the left side, a position which allowed fluids to gravitate from the ulcer.

VII. In disease of the lesser curvature, even near the pyloric orifice, pain is sometimes experienced by the patient as soon as the food enters the stomach, and, in some cases, this conveys the idea of disease at the oesophageal orifice. This fact may lead to the supposi

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