532 DISEASES OF THE STOMACH. 



miliaiy tuberculosis, which has a slow course, and where the folds of 

 the pleura almost always become adherent, if the destruction goes as 

 far as the pleura. The cases where the inconvenience is so slight that 

 a certain diagnosis of ulcer of the stomach is impossible, or where the 

 patient is so little troubled that he does not seek medical aid before 

 the occurrence of the perforation, or the haematemesis, are, however, 

 rare when compared to those where the disease is readily recognized, and 

 where it excites very annoying symptoms. Among the most frequent 

 and troublesome symptoms of chronic ulcer of the stomach are pains in 

 the epigastrium. The patients complain partly of a steady pain in the 

 pit of the stomach, which is increased by pressure, and is generally par- 

 ticularly severe at some circumscribed spot ; partly of paroxysms of se- 

 vere pain, which, starting from the epigastrium, extend toward the back, 

 and are designated as attacks of cardialgia. The sensitiveness to 

 pressure in the epigastrium, when the ulcer is extending in breadth or 

 depth, is sometimes so great that the patient can hardly bear even the 

 pressure of light bed-clothes ; this is because there is slight peritonitis 

 over the affected part. The cardialgic attacks generally occur soon 

 after meal-times, and are severe in proportion to the coarseness and 

 roughness of the food that has been taken. The patients sigh, groan, 

 double themselves up, and often do not find ease till the stomach has 

 been emptied by vomiting ; if there be no emesis, the attacks of pain 

 may last for hours. The seat of the ulcer may be determined with 

 some certainty from the length of time at which the pains follow the 

 meal ; if they come immediately after eating, we may suppose that the 

 ulcer is near the cardiac orifice ; if they come an hour or two later, it 

 will probably be in the pyloric portion. Although, as a general rule, 

 the attacks of pain occur after eating, and are the more severe the 

 more indigestible and the rougher the food, there are some exceptions, 

 and it is important that we should know these even if we cannot ex- 

 plain them. In these exceptional cases, while the stomach is empty 

 there is pain, which is relieved by taking food ; or after eating indiges 

 tible food the patient remains free from pain, while it becomes very 

 severe if he eat easily-digested articles. The attacks of pain are usually 

 attributed to the irritation of the surface of the ulcer by the motion of 

 the contents of the stomach ; while in an empty stomach such causes 

 are absent. Another explanation is that the gastric juice secreted on 

 the introduction of food irritates the ulcer and excites the pain, while 

 there are intermissions, because, while the stomach is empty, a mucus 

 which is but slightly irritating covers the ulcer. But when we consider 

 that perforation of all the coats of the stomach may occur without ex- 

 citing these attacks of pain, and that, on the other hand, the most se- 

 vere pain often continues when the ulcer has healed, but the stomach 



