Part 80

The kind of pain which is most characteristic of gastric ulcer is severe {489} paroxysmal pain strictly localized in a circumscribed spot in the epigastrium, coming on soon after eating, and disappearing as soon as the stomach is relieved of its contents.

More common, although less characteristic, than the strictly localized pain are paroxysms of severe pain, usually called cardialgic or gastralgic, diffused over the epigastrium and often spreading into the surrounding regions. This is like the neuralgic pain of nervous gastralgia, which is not infrequent in chlorotic and hysterical females. The pain may be so intense as to induce syncope, or even convulsions, in very sensitive patients.

The strictly localized pain is probably caused by direct irritation confined to the nerves in the floor of the ulcer. In the diffuse gastralgic attacks the irritation radiates or is reflected to the neighboring nerves, and sometimes to those at a distance.

In most cases of gastric ulcer localized epigastric pain and diffuse gastralgic paroxysms are combined.

The painful sense of oppression and fulness in the epigastrium which is felt in many cases of gastric ulcer after eating is simply a dyspeptic symptom, and is probably referable to an associated chronic catarrhal gastritis. This dyspeptic pain is of little value in diagnosis.

Most subjects of gastric ulcer feel in the intervals between the paroxysms a more or less constant dull pain, or it may be only a sense of uneasiness, in the epigastrium. When sharp epigastric pain is felt continuously, it is usually inferred that the ulcer has extended to the peritoneum and has caused a circumscribed peritonitis, but this inference is not altogether trustworthy.

The quality of the pain caused by gastric ulcer is described variously as burning, gnawing, boring, less frequently as lancinating.

More important than the quality is the situation of the pain. The situation of the localized pain is usually at or a little below the ensiform cartilage. It may, however, be felt as low as the umbilicus or it may deviate to the hypochondria. In addition to pain in the epigastrium (point épigastrique), Cruveilhier called attention to the frequent presence of pain in the dorsal region (point rachidien). The dorsal pain, which may be more severe than the epigastric, is sometimes interscapular, and sometimes corresponds to the lowest dorsal or to the upper lumbar vertebræ. It is usually a little to the left of the spine. The pain is often described as extending from the pit of the stomach through to the back.

According to Brinton, the situation of the localized pain gives a clue to the situation of the ulcer, pain near the left border of the ensiform cartilage indicating ulcer near the cardiac orifice, pain in the median line and to the right of this indicating ulcer of the pyloric region, and pain in the left hypochondrium indicating ulcer of the fundus. It does not often happen that the pain remains so sharply localized as to make possible this diagnosis, even if the situation of the pain were a safe guide.

Of the various circumstances which influence the severity of the pain in gastric ulcer, the most important is the effect of food. Pain usually {490} comes on within a few minutes to half an hour after taking food, although it may appear immediately after ingestion or be delayed for an hour or more. The pain continues until the stomach is relieved of its contents by vomiting or by their passage into the duodenum. It is unsafe to attempt to diagnose the position of the ulcer merely from the length of time which elapses between the ingestion of food and the onset of pain. It has sometimes been noticed that as improvement progresses pain comes on later and later after eating. As might naturally be expected, coarse, indigestible, imperfectly-masticated food, sour and spirituous liquids, and hot substances are more irritating than bland articles of diet. In some exceptional cases the ingestion of even coarse food, instead of aggravating, has had no effect upon the pain, or at least for the time being has even relieved it.

External pressure usually increases the intensity of the pain of gastric ulcer; in rare instances pressure relieves the pain.

Rest and the recumbent posture as a rule alleviate the pain of ulcer of the stomach. The position of the patient may affect the severity of the pain in a more striking way. It may naturally be supposed that that posture is most agreeable which removes from the ulcer the weight of the food during digestion. Hence it was claimed by Osborne that the site of the ulcer could often be inferred from the effect of posture on the pain. Thus, relief in the prone position would indicate ulcer of the posterior wall; relief in the supine position, ulcer of the anterior wall; relief on the left or on the right side, ulcer of the pyloric or of the cardiac region respectively. As ulcer of the posterior wall is the most frequent, relief should be obtained oftener by bending forward or by lying on the face than in the supine position. Experience has shown that the influence of posture on the pain is not a safe guide in diagnosing the location of the ulcer.

Mental emotions--particularly anxiety and anger--fatigue, even moderate exercise, exposure to cold, and the menstrual molimen may each cause exacerbations of pain in some cases of gastric ulcer.

Tenderness on pressure is a common symptom of gastric ulcer. A localized point of tenderness may be discovered even when the subjective pain is not localized. Pain sometimes follows pressure not immediately, but after a brief interval. A fixed point of tenderness can often be determined when the stomach is empty more accurately than when it is full. The tender spot can sometimes be covered by the finger's end. In searching for a point of tenderness it should be remembered that many persons are very sensitive to pressure in the epigastrium, and also that pressure is not without danger to those who are the subjects of gastric ulcer. Not only may pressure induce paroxysms of pain, but it may cause even rupture of the ulcerated walls of the stomach. Hence pressure should be cautiously employed and should not be often repeated.

In some cases of gastric ulcer pain is felt in regions at a distance from the stomach. The most frequent of these so-called radiation neuralgias are--neuralgia of the lower intercostal spaces, combined sometimes with {491} hyperæsthesia or with analgesia of the affected region, pain in the right shoulder (perhaps due to adhesions between the stomach and the liver or the diaphragm), pain in the left shoulder, and pain in the loins. In a case of ulcer reported by Traube terminating in perforation the sole complaint, besides loss of appetite and retching, had been difficulty in breathing and oppression in the chest. These symptoms, which may be combined with gastralgic paroxysms, are referred by Traube to transference of the irritation from the gastric to the pulmonary filaments of the pneumogastric nerve.

Sometimes the pain of gastric ulcer intermits for days or even weeks. When the intermission is of considerable duration it is probable that cicatrization has been in progress. It should, however, be remembered that gastralgic attacks may continue even after cicatrization of the ulcer is completed, probably in consequence of compression of nerve-filaments by the cicatricial tissue. Once in a while the pain exhibits a marked periodicity in its appearance. Thus in a case of ulcer ending fatally from hemorrhage the pain came on but once a day, and that with considerable regularity at the same hour. In this case the pain was relieved by taking food. The pain of gastric ulcer may be temporarily relieved by hemorrhage from the stomach, and perhaps by division of the irritated nerve by sloughing (Habershon).

The causes of the pain of gastric ulcer are not far to seek. Foremost is the irritation of nerve-filaments exposed by the ulcerative process. The irritation may be by mechanical, chemical, or thermic agencies. With our present imperfect knowledge it is profitless to discuss whether the pneumogastric or the sympathetic nerves are the chief carriers of the abnormal sensations. In the next place, we may have radiation of the irritation from these nerves to neighboring and even to remote nerves. Furthermore, the extension of the inflammation to the peritoneum and the surrounding parts, and the formation of adhesions, are additional factors in some cases in causing pain. Finally, the great differences in susceptibility to pain manifested by different individuals is to be borne in mind.

Next to pain, vomiting is the most frequent symptom of gastric ulcer. There is, however, little which is characteristic of ulcer in this symptom, unless the vomited material contains blood. In some cases of gastric ulcer vomiting is the most marked and most distressing symptom of the disease. It may, however, be absent during the whole course of gastric ulcer.

Vomiting occurs most frequently after taking food, and is greatly aggravated by an unregulated diet. Sometimes nearly everything which is taken into the stomach is vomited. The vomiting of mucus or of a {492} thin fluid unmixed with food is indicative only of chronic catarrhal gastritis. Alimentary vomiting, which is more indicative of gastric ulcer, usually occurs not immediately after taking food, but at the acme of a gastralgic attack caused by the food. Soon after the stomach is emptied by one or more acts of vomiting the pain is relieved. The act of vomiting is usually easy, and at times is hardly more than regurgitation of the food. Sometimes the patient experiences an excessively sour taste from the vomit.

Vomiting exhausts the patient by withdrawing nutriment, and when persistent may even cause death from inanition. But in some cases of gastric ulcer, especially in women, the vomiting seems to be mainly a nervous symptom, and even when long continued may be attended by little or no loss of flesh. Evidently, more food is retained in these cases than might be supposed.

There are two evident causes of vomiting in gastric ulcer--namely, chronic catarrhal gastritis, which is a frequent complication, and direct irritation of the nerves in the ulcer. Vomiting due to dilatation of the stomach is oftener a sequel than an immediate symptom of gastric ulcer.

For the diagnosis of gastric ulcer hemorrhage from the stomach is the most important symptom.

The frequency of only the larger hemorrhages can be determined with any degree of exactness. If the blood be effused in small quantity or slowly, it may be discharged solely with the stools and escape detection. Such slight hemorrhages doubtless occur in most cases of gastric ulcer. It is probable that easily-recognized hemorrhages from the stomach occur in about one-third of the cases of gastric ulcer. Hemorrhage is absent as a rule in the acute perforating ulcer of the stomach.

In most cases hemorrhage from gastric ulcer is preceded by pain, vomiting, and disturbances of digestion. Antecedent symptoms may, however, be absent, or may be so obscure that no suspicion of ulcer exists until the hemorrhage occurs.

The hemorrhage may be slight, moderate, or excessive in amount (Cruveilhier). The larger hemorrhages are those which are most distinctive of gastric ulcer.

The blood may be vomited, or voided with the stools, or retained in the stomach and the intestines.

As has been remarked, when the hemorrhage is scanty all the blood may escape by the bowel. Sometimes, although much less frequently, blood effused in large quantity is entirely evacuated with the stools. After hæmatemesis more or less blood is discharged by the bowel, sometimes for several days after the vomiting of blood has ceased. Blood which has traversed the whole length of the intestinal canal acquires a tarry consistence and a black or brownish color in consequence of the production of dark-brown hæmatin by the action of the digestive juices {493} upon the hæmoglobin, and in consequence of the formation of black sulphide of iron by the union of hydrogen sulphide in the lower part of the intestine with the iron of the hæmatin. The passage of these black viscid stools is called melæna. Inasmuch as we cannot presume gastric hemorrhage to be absent simply because no blood has been vomited, it is evidently important to examine the stools for blood when the diagnosis of gastric ulcer is obscure, and also in cases of gastric ulcer where there are symptoms of internal hemorrhage not accounted for by blood vomited. It should be remembered that certain drugs, particularly iron and bismuth, may blacken the feces.

In very exceptional cases of gastric ulcer the effusion of a large volume of blood causes sudden death before any of the blood has been vomited. The autopsy shows the stomach and more or less of the small intestine distended with coagulated blood.