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tion that the oesophagus 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 pneumogastric 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 oesophagus, 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 coeliac 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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XVIII. The pain and vomiting consequent on obstruction in the duodenum closely resembles disease of the stomach. Thus large biliary calculi, in some rare instances, ulcerate through the walls of the gall bladder, and become impacted in the duodenum. Other symptoms, however, when rightly estimated, will generally guide to correct diagnosis.

XIX. The neuralgic pain produced by herpes zoster or shingles may for a short time mislead, but the pain of shingles is not generally so local in its character, and extends backward to the spine.

XX. Whilst considering pain at the stomach, we are led to remark on the expression often made use of, namely, spasm at the stomach. Does such a state really exist? It has justly been said, that in many instances some crude undigested substance remains and is the source of the pain; and we have known a portion of undigested steak remain in the stomach undissolved for ten days, and no effectual relief could be obtained till it was rejected. Again, many such instances are due to distension of the stomach; others to pain in the course of the spinal nerves; in others there is contraction at the pyloric valve; but there are cases which cannot be so explained, and they are apparently attributable to a state of extreme irritability of the sympathetic nerves and ganglia, inducing unusual contractility of the muscular fibres.

As to the time and persistence of pain, we may remark, that when arising from disease of the stomach it is generally aggravated by food. It often extends through to the back, but is less persistent in its character than when it arises from other causes.

Vomiting.—Although the causes of vomiting are very numerous, it is generally at first referred to the condition of the stomach itself, or to the parts immediately connected with it; and this opinion is so often fraught with danger that we cannot too strongly urge the importance of close investigation. The causes of vomiting are even more varied and complex than those which result in pain; and they may be divided into those which originate in the stomach and intestines, and, secondly, into those which are sympathetic in their source; to several of the latter we have incidentally referred in the last chapter.

In the first division we must place, as causes of vomiting,—

1. Inflammation of the stomach, gastritis, and gastroenterite;

2. The presence in the stomach of undigested food, or foreign bodies;

3. Irritants and medicines;

4. Great irritability of the mucous membrane;

5. Ulceration of the stomach;

6. Obstructive disease of the pylorus;

7. Cancerous disease of the stomach;

8. Pressure on the stomach—as in ascites, tumours, &c.

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