Malignant diseases are so often accompanied by pain that it might reasonably be expected that a cancerous growth in a highly organised structure like the stomach would be associated with considerable suffering. In the majority of cases pain certainly constitutes the most prominent of the local symptoms ; but occasionally it is conspicuous by its absence, not only at the commencement, but throughout the whole course of the malady. Brinton estimated the frequency of these painless cases at 8 per cent., and Lebert at 25 per cent., while in 14 per cent, of those in our hospital series it was stated that pain was either absent altogether or extremely slight. As this latter figure tallies with the experience of Osier and McCrae (13.3 per cent.), we are inclined to adopt it as the nearest to the truth. The pain varies greatly, not only in different cases, but also in the same individual at different times, being sometimes aching or burning in character, intermittent in appearance, and moderate in degree, while at others it is stabbing or lancinating, agonising, and more or less continuous. In 48 per cent, of our cases the symptom was described as ' severe ' or ' continuous,' and in 38 per cent, as ' occasional.'

Situation

The part of the abdomen to which the pain is referred varies to a great extent according to the situation of the growth. In pyloric disease the epigastrium, right hypochondrium, or even the umbilical or hypogastric region, may be the chief seat of the suffering, according as the pylorus maintains its usual position or has been dislocated by traction of the enlarged stomach. When the body of the organ is affected, pain is principally experienced in the epigastrium or left hypochondrium, while in disease of the cardia it is often felt in the left side of the chest, in the throat, or behind the lower end of the sternum. Pain in the back is most often encountered with disease of the posterior wall, associated with ulceration of the growth and adhesions between the stomach and the pancreas or the vertebral column. Moderate pain, such as arises from flatulent distension of the viscus in the early stages of pyloric stenosis, is usually referred to a spot in the centre of the chest, beneath the left mamma, or between the shoulders.

. Radiations.-At the climax of an attack the pain may become diffused over a large area of the body, or be reflected along the course of certain nerves. Thus it not infrequently extends over the greater part of the abdomen and chest, or radiates to the back and upwards between the shoulders. Occasionally it is reflected along the nerves of the brachial, cervical, or lumbar plexuses ; or, should the disease have involved an intercostal nerve, severe neuralgia may be experienced round the lower part of the chest or upper abdomen, accompanied, perhaps, by an herpetic eruption. Pain in the right shoulder is sometimes associated with the adhesion of a pyloric growth to the under surface of the liver; while invasion of the diaphragm is often accompanied by a sense of constriction of the thorax, with difficulty of inspiration and tenderness along the course of the phrenic nerves in the neck. Extension of the growth to the lumbar and sacral glands may give rise to pain in the nerves of the lower limbs which simulates sciatica, and extreme irritability of the bladder or rectum may ensue from implication of the pelvic peritoneum. In those rare cases where the disease destroys the spinal column constant localised pain in the back may be followed by paraplegia.

Time Of Access

At an early stage of the complaint pain is usually experienced after meals, and in this respect it resembles that of simple ulcer. As a rule, however, it is less acute, more variable in appearance, less localised, and often relieved by the eructation of gas. As the disease proceeds it gradually increases in severity, and becomes more continuous and less dependent upon digestion. It may also be observed that, unlike the pain of ulcer, it is often increased rather than relieved by a milk diet, and does not subside entirely after vomiting. The situation of the growth also exerts a certain amount of influence upon its development. When the cardiac orifice is involved, pain is usually experienced immediately after swallowing, and is excited more rapidly by solid food than by liquids, and by hot or cold drinks than by those of a medium temperature. Disease of the body of the organ is chiefly accompanied by pain after food, which in its situation and time of access closely resembles that of simple ulcer. The pain that accompanies carcinoma of the pylorus varies in its appearance, according as the growth has ulcerated or has given rise to obstruction of the orifice. In the former case there is usually an exacerbation within half an hour of the ingestion of food, while in the latter a sense of distension and abdominal discomfort ensues immediately after meals.

Table 21.-The Relation Of Age To The Severity Of The Pain

It will be observed that while pain in one form or another is more frequent at the earlier period of life, continuous or severe suffering is slightly more common after forty-five years than among younger patients.

Effect Of Posture

The subjects of simple gastric ulcer often find relief by lying upon the back or upon one side during an access of pain, and the position they habitually assume affords a general clue to the situation of the ulcer. In malignant disease of the stomach, however, a recumbent posture usually aggravates the pain, and the patient repeatedly turns from side to side in his efforts to obtain relief, or walks about the room. This extreme irritability under the influence of pain is very characteristic, and its existence will often suggest the possibility of malignant disease even when the other features of the complaint seem to favour a diagnosis of simple ulcer.