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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 cœci.

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 œsophageal orifice. This fact may lead to the supposi

tion that the œsophagus is the part affected, and the erroneous opinion may be strengthened by the rejection of food almost before it has reached the stomach.

VIII. Many conditions of functional disease are entirely free from pain. It is, indeed, well for us that there is such insensibility, otherwise the least deviation from healthy action might be followed by suffering, and the strict rules of a dyspeptic be essential in ordinary life.

IX. The pain in many functional diseases of the stomach is exceedingly severe; but it is often produced by a mal-condition of the nerves or nerve-centres, and it arises from the intimate connection of the spinal and sympathetic nerves. In some states of exhaustion the whole of the nervous system appears to be in a state of great irritability, and the sensibility of structures becomes greatly increased. We often find in these conditions that the stomach is incapable of bearing the presence of food; it is at once rejected, or produces intense pain, or flatulent distension is set up, or a sense of fainting; and the means best calculated to relieve are those which invigorate and strengthen the whole system. Of this class are the stomach diseases observed in connection with uterine disease, with loss of blood, exhaustion, mental anxiety, &c.; the deficient nervous supply also interfering, perhaps, with the right secretion of the gastric juice.

X. The effect of a diseased condition of the pneumo

gastric nerve at its centre, or at its peripheral branches, in connection with stomach disease, is of great importance, and it is probable that pain is sometimes the result. We have, however, more frequently observed vomiting, rather than pain, produced by an irritable condition of the pneumogastric nerve.

XI. In some forms of functional disease of the stomach in which severe pain comes on three or four hours after food, it is probable, as we have elsewhere stated, that extreme irritability of the pyloric orifice exists.

XII. The absence of pain often arises from the destruction of the pneumogastric nerve. This fact is sometimes remarkably shown in disease of the sophagus, as well as of the stomach.

XIII. Pain at the epigastrium, simulating disease of the stomach itself, also arises from spinal disease, the pain being referred to the extremity of the irritated

nerve.

XIV. Severe pain at the scrobiculus cordis is frequently present in chronic bronchitis and in obstructive valvular disease of the heart; in fact from any state which leads to over-distension of the cavities of the right side of the heart. In these conditions we very generally find that food produces pain and flatulence, and is very imperfectly digested; the vessels of the stomach and of the whole of the chlylopoietic viscera are much engorged; and the surface of the stomach is

very generally covered with a thick layer of mucus; a state of chronic catarrh of the mucous membrane is produced. Many observers, however, attribute the almost constant pain at the scrobiculus cordis in these instances to the over-filled cavities of the right side of the heart, and we are disposed to refer part of the distress to this

cause.

XV. In aneurism of the abdominal aorta, we have sometimes observed pain of an intense kind, and the disease might very easily have been mistaken for cancerous disease of the stomach with glandular infiltration, producing pressure upon the aorta. In one instance, which I watched with much interest, the aneurism existed at the position of the cœliac axis; it was rightly diagnosed, and the patient became exhausted and died from the intensity of the pain, the false sac not having given way. I dissected large branches of the sympathetic nerve spread out upon the surface of the tumour; and the intense suffering and fatal exhaustion appeared to arise from the implication of the nerve structures. No other cause of death could

be found on very careful inspection.

XVI. Abscess in the parieties of the abdomen near the scrobiculus cordis, at its earlier stage, simulates disease of the stomach itself.

XVII. Disease of the pancreas, especially of an inflammatory kind, is apt to be mistaken for disease of the stomach.

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