Pain in carcinoma of the stomach: Preliminary report

In this paper we have attempted to outline in a general way the important pathways of conduction of pain from, and mechanics of production of pain in, the viscera in the upper part of the abdomen. The general principles involved follow a pattern similar to that encountered in cases of benign lesions of the stomach. We felt that, if gastric carcinoma superficially invades the tissues of the stomach and results in disturbances of its normal mechanics, pain may result. This pain would utilize pathways coursing along the splanchnic vessels. In order to be interpreted as pain, these irregularities in mechanics would require an “adequate” stimulus which, in this case, would be spasm or obstruction. If, on the other hand, the lesion burrows through the gastric wall into the tissues surrounding the organ, pain would be relayed to the spinal cord over the spinal sensory group of nerves and, in this instance, wide distribution and reference of pain may be produced. If the lesion invades the regions of the distribution of the phrenic nerve, pain will be referred into the left side of the thorax and to the “peripheral distribution” of this nerve which would be into the left shoulder and the base of the neck. Such a lesion is usually inoperable. Any stimulus which would initiate the sensation of pain on surfaces of the body also could produce pain in penetrating lesions. Applying these hypotheses to the problem of pain in cases of cancer of the stomach permits an explanation of the apparent paradoxical behavior of distress among patients harboring such lesions. Who, at operation or necropsy has not viewed with surprise tremendous cancers involving most of the stomach which have produced no pain whatsoever? After all, this should be no more the cause of astonishment than to witness surgical procedures on the stomach which caused patients no pain even though only local anesthesia was used. The mechanisms which produce pain in such cases depend on the production of an adequate stimulus, such as stretching or constriction of the circular muscular fibers which would require a mechanical disturbance, such as spasm or obstruction. If cancer does not set in motion this adequate stimulus, it is likely to produce no pain whatsoever. If, on the other hand, there is mechanical disturbance such as interference with normal emptying or invasion of the pylorus, pain or at least a sense of epigastric distress is likely to be one of the earlier manifestations of this disease. Cancer of the pylorus therefore is more often amenable to surgical treatment than are other types of cancer, not only because of its resectability from a physical standpoint but because of the fact that, as a rule, it produces symptoms relatively early. Shift of pain from original to secondary regions among patients who have cancer of the stomach is of varying significance. In the event that the lesion is small, for instance, a penetrating peptic ulcer harboring in its depth malignant degeneration associated with hyperacidity, a shift of pain may not be of very serious significance. If, on the other hand, the lesion is fairly extensive and the patient complains of shifts of pain from the original into secondary regions, the lesion will be found to be inoperable in almost all instances. This, of course, is owing to the fact that cancer has penetrated the wall of the organ and has invaded tissues contiguous to the stomach. The shift of pain, in such instances, is owing to invasion of the spinal sensory nerves. In a general way, it can be said that cancer of the stomach in which gastric chemistry is normal or is elevated is much more likely to produce a painful syndrome than that in which there is no acidity or only a trivial amount of hydrochloric acid. This is probably owing to the fact that the acid acts, as it does in cases of benign gastric lesions, as a trigger mechanism which initiates spasm and this, in turn, is responsible for the sensation of pain. Otherwise stated, with the exception of pyloric lesions which cause early obstruction, the presence of carcinoma of the stomach is suspected most usually by its complications and its systemic effects when the lesion has advanced beyond the bounds of operability.