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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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9. Diseases of the duodenum;

10. Hernia, intestinal obstruction, intussusception;

11. Pharyngeal and œsophageal regurgitation. In the second division are

1. Diseases of the liver and gall bladder;

2. Diseases of the kidney;

3. Diseases of the supra-renal capsules; 4. Diseases of the uterus and ovaries;

5. Diseased conditions of the blood and general nervous system, as at the onset of the exanthems, fever, pyœmia, erysipelas, &c., ague, yellow fever, and cholera may, perhaps, be classed among these, as arising from blood change;

6. Diseases of the spine;

7. Diseases of the brain;

8. Diseases of the lungs.

I. There is something remarkable in the presence of vomiting when pain is absent; and in acute disease of the stomach, where only the mucous membrane is affected, the patient may be free from all suffering at the region of the stomach, except that produced by the violent straining of the muscles. Vomiting is a more persistent sign of inflammation of the stomach than is pain. We need only refer for confirmation to instances of poisoning by oxalic acid, by sulphuric acid, by arsenious acid, and by corrosive sublimate, cases of which have occurred without pain at the stomach; and in the symptoms of gastro-enteritis the same immunit

from gastric pain occurs, whilst vomiting greatly distresses the patient.

II. Undigested substances often remain in the stomach for some time without producing pain, unless they pass within the pyloric valve; and we sometimes find that they are retained for many hours, or even days, before they are rejected by vomiting.

III. In reference to vomiting caused by medicine and by irritants, it is only necessary to mention, that in some instances the action appears to be one of primary irritation of the stomach, in others it is secondary, through the medium of the blood; but whether this secondary action and its consequent vomiting arise from the excretion of the medicinal substance from the mucous membrane of the stomach is doubtful; thus, tartar emetic produces vomiting when injected into the blood, as well as when taken directly into the stomach.

IV. A state of functional irritability of the stomach is sometimes induced, and is generally associated with uterine or ovarian disease, or it is produced by irritation of the pulmonary branches of the pneumogastric nerve acting in a reflex manner upon the nerves of the stomach. In these instances food of every kind is at once rejected; and it is to this condition that Sir H. Marsh has given the name of regurgitative disease, in which food is rejected without any effort, and often without corresponding emaciation. In his valuable

paper on this subject he refers to its connection with pulmonary and with uterine disturbance.

V. In ulceration, vomiting often comes on as soon as food enters the stomach, or a period of variable length intervenes, the pain increasing till the rejection takes place.

VI. In obstructive disease at the pylorus, the vomiting is generally deferred till nearly the close of the digestive process; much, however, may be done to diminish this symptom by the use of suitable diet of a fluid kind.

VII. Cancerous disease, affecting the orifices of the stomach, constitutes a common cause of persistent vomiting. It must, however, be borne in mind that it is not a constant sign of cancerous disease of the stomach; if the orifices be free it may be entirely absent, although the disease is very extensive; and again, if sloughing take place, even when the orifices are diseased, vomiting often subsides, sometimes in consequence of the obstruction being removed by the sloughing; at other times, apparently from the destruction of the branches of the pneumogastric nerve. Further, the period at which vomiting occurs does not always indicate the seat of the cancerous obstruction. In some instances of obstruction at the pylorus with disease at the lesser curvature, vomiting takes place immediately after food has entered the stomach, so as to convey the idea of obstruction at the cardiac orifice,

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