Ulcer Of The Stomach.

Part 6
1. Pain Pain is the most frequent and characteristic of all the symptoms. In the earlier stage of the disease there is a mere feeling of weight or tightness in the epigastric region. Sometimes the patient has the impression as though the food experienced a stoppage there. From such a dull, continuous feeling the pain gradually augments into a burning sensation and at last into a gnawing pain. In the majority of cases the pain comes on from two to ten minutes after deglutition of food and remains during the period of gastric digestion, at the close of which it gradually subsides and disappears. There are, however, exceptions to this rule, and we find cases of typical gastric ulcer where the pains appear half an hour or an hour or two and three hours after meals. Different kinds of food have a marked influence upon the pain. Coarse substances and many undigestible foods increase the pain, whereas a liquid diet, especially milk, may fail to bring on the pain. The quantity of food is also of import, a large meal causing more pain than a small one. The situation of the pain corresponds, as a rule, to the centre of the epigastrium, or to the median line of the abdomen immediately below the free extremity of the ensiform process. The portion of the epigastric region to which the pain is referred forms a circular area of rarely more than two inches diameter, some times a mere spot of less than half this size. There are, however, exceptions to this rule, and a spot of pain may be situated a little more to the right or to the left or also farther down than the above-described spot. Occasionally the pain is associated with a feeling of violent pulsation or throbbing in the epigastric region. At times this sensation is felt independently of the paroxysm of pain. The dorsal pain, first described by Cruveilhier, is also an important symptom. It generally appears later (a few weeks or months) than the epigastric pain, and is then almost as constant and characteristic as the epigastric pain. This pain is gnawing in character and situated, as a rule, to the left of the spine corresponding to the eighth or ninth dorsal vertebra,

and extending occasionally to that of the first or second lumbar vertebra. Like the epigastric pain, it has a fixed seat, generally remaining near the spot of its first appearance during the whole progress of the disease, although it also shows lateral as well as vertical deviation from its ordinary situation. Its worst attacks generally alternate with those of the epigastric pain. The epigastric, pain is increased on pressure. Even slight pressure with the finger upon the epigastric region below the ensiform process produces intense pain. This is the most important point characteristic of gastric ulcer. To test the sensitiveness to pressure by means of Boas' algesimeter, or to exert considerable pressure with the fingers, is not advisable. I perfectly agree with Brinton,1 who says in reference to the latter point: "It is not altogether superfluous to add another caution with respect to the above test (pressure): not only must it be applied with great care and delicacy in the first examination of a supposed case of gastric ulcer, but, as a rule, we can scarcely be too reluctant to repeat it, even to verify a presumed amendment. At any rate, its effects are sometimes so injurious that it is necessary strictly to prohibit the patient from all manipulations of the epigastric region, as well as from all pressure produced by dress (such as stays in the female) or work (as is the case with shoemakers)". 1 W. Brinton: l. c. The character of the pain, of becoming increased on pressure, is, however, not always present, and we find patients with gastric ulcer in whom the pain is rather subdued by pressure.