The main cause of the pain which accompanies a new growth in the stomach is undoubtedly the progressive infiltration of the tissues and the compression which is exerted upon the gastric nerves by extension of the disease along the perineural sheaths. There are, however, several other conditions which tend to modify both the severity of the symptom and its time of access.

(A) Influence Of Age

It is often stated that old persons suffer much more severely than those of middle life. To test the accuracy of this view we have arranged in the following table the ages of our various patients and the degrees of pain that accompanied their complaint.

(B) Influence Of Situation

The degree of pam varies according to the location of the growth. Brinton asserted that the symptom was most frequent and severe when the orifices of the stomach were involved by the disease, and this statement has usually been repeated by subsequent writers. Our own experience, however, has always led us to regard disease of the body of the stomach as the variety which is pre-eminently painful, and this appears to be confirmed by an analysis of our hospital cases.

An examination of the table shows that nearly one-fourth of the cases where the cardiac region was affected were devoid of pain, whereas this symptom was absent in only 3 per cent, of those in which the walls and curvatures of the organ were implicated. It is also obvious that severe pain was far more common in the latter than in the former. With regard to growths of the pylorus, pain was completely absent in 15 per cent., while the rest suffered equally from the occasional and severe varieties. It is interesting to note that when these cases were further classified according as the pyloric orifice was obstructed or not, an absence of pain was found to be entirely confined to the former class. The explanation of this phenomenon seems to be that when a malignant growth infiltrates the pylorus, without causing much obstruction, the mucous membrane is usually ulcerated and the disease often extends into the body of the stomach. On the other hand, a contracting scirrhus which produces great stenosis of the outlet is seldom extensive, and is usually accompanied by excessive vomiting, which in itself is rarely compatible with continued pain.

(C) Influence Of Ulceration

Severe pain after meals is always suggestive of ulceration. We have therefore compiled the following table, in order to show the relation between these two conditions in carcinoma of the different regions of the stomach.

Table 23.-The Relation Of Pain After Food To Ulceration Of The Growth

These figures are interesting from two points of view. In the first place, if they are compared with those shown in Table 22 (p. 113), it will be seen that the frequency of 'pain after food ' and of ' occasional pain ' is practically identical in growths of the same region of the stomach. In other words, that whatever designation is applied to this form of pain, it is due to direct irritation of the ulcerated surface by the food or its chemical products. In the second place, it is apparent that the liability to the symptom varies according to the situation of the disease. Thus, while it exists in almost every case of ulcerated carcinoma of the pylorus, it is present only in 76 per cent, of the cases of malignant ulceration of the cardia and in 65 per cent, of those where the central region of the viscus is affected. This apparent anomaly may be easily explained. As long as the pylorus remains unobstructed the gastric contents find a ready exit into the duodenum ; but if the orifice is contracted, both the food itself and the organic acids which arise from fermentation tend to accumulate in the stomach and to produce direct irritation of the raw surface. It is also probable that the severe and continuous form of pain that accompanies disease of the body of the organ frequently masks the less intense suffering that ensues from the ingestion of food.

(D) Extent Of The Growth

So many factors are concerned in the causation of the pain that it is impossible to determine whether the histological character of the growth exerts any decided influence upon the severity of the symptom. As it is often asserted, however, that diffuse infiltrations are more painful than localised growths, we have analysed our cases upon this basis.

Table 24.-Relation Of Pain To The Extent Of The Growth

It would appear that as a rule a circumscribed tumour is rather more often accompanied by pain than the diffuse variety, possibly on account of its greater tendency to deep ulceration and to the production of metastases.

(E) Secondary Growths

The gradual increase of pain which often marks the progress of the disease might possibly arise from implication of the peritoneum or of the neighbouring viscera. To ascertain the truth of this supposition we have analaysed our cases in the following way.

Table 25.-Relation Of Pain To Secondary Growths In The Abdomen

It would appear that while metastases in either tissue increase the tendency to pain, the symptom is most severe when the peritoneum is involved by the morbid growth.

Conclusions. - (1) Some degree of pain is present in about 85 per cent, of all cases. (2) The milder forms usually arise from flatulence, while the more severe are due to the infiltration and destruction of the gastric tissues. (3) Pain after food is a prominent symptom in 38 per cent., and is almost invariably associated with ulceration of the morbid growth. (4) Severe or constant pain occurs in 48 per cent, of all cases. If it arises at an early stage of the complaint, the walls or curvatures are usually affected, but as a late phenomenon it is often due to implication of the peritoneum or to metastatic growths in neighbouring viscera. (5) Its location and radiations vary with the situation and extent of the disease.