A few of the symptoms of dyspepsia require a more detailed consideration. Any pain in the region of the stomach, and especially when associated with the consumption of food, is a dyspepsia. But all pains in the stomach are not due to the presence of food. There may be pain in the stomach when its cavity is empty, e.g. gastralgia, which is an actual pain occurring in paroxysms and relieved in all probability by taking food. But the pain in an empty stomach may be due to acute gastritis, to malignant disease, to neuralgia, to bacteria, or to poisons.

But pain occurring after food is far more common. This may be a localized or a diffused pain. A pain diffused over the epigastrium (pit of the stomach) may be due to acute gastric catarrh; acute gastritis due to alcohol, poisons, bacteria, or injury; or chronic dyspepsia and hyperacidity or organic acidity due to fermentation by bacteria. The thermometer would, of course, help to distinguish between them. A localized pain is due to an ulcer, sometimes a cancer, and such pain is not always in the stomach, but may be in the back and associated with tenderness in the dorsal region.

It should not be forgotten that a pain in the region of the stomach is not always due to a disease of that organ. A pain in the pit of the stomach may be due to distension of the transverse colon, abdominal neuralgia, muscular rheumatism, and allied conditions. Pain in the left side (lower part of axilla and hypochondrium) may be due to a dilated stomach, to distension of the stomach by gas; but it may also be due to an enlarged spleen, a dilated colon, or movable kidney. Pain in the right side may be due to disease of the liver, gall-stones, a loaded colon, and various other things.

The sensation of weight, discomfort, or fullness in the stomach, which occurs directly or some hours after meals, and is not attended by actual pain, is usually due to indigestion, gastric irritation, hyperacidity, loss of motor power in the stomach, dilatation of the stomach, distension by gas arising from bacterial fermentation. Such sensations, which are sometimes referred to the front of the chest or behind it (between the shoulders), may arise from the stomach being too full, overloaded by solids or liquids, especially when the motor power of the stomach is deficient. It may be the presence of some particular article which causes the pain or discomfort; for example, new bread, hot cakes, pastry, pork, veal, mackerel, salmon, lobster, pickles, cucumber, radishes, raw fruit or heavy vegetables. It may be caused by an excess of some condiment, such as vinegar, mustard, horseradish, or some other food accessory.

In acute catarrh of the stomach the pain is of a burning and darting character, often passing through to the back. It is frequently aggravated by deep breathing, and is accompanied by a similar pain in the chest and a sense of oppression. There is considerable tenderness of the region of the stomach. The abdominal muscles are frequently contracted in a spasmodic manner over the stomach, to protect the organ from pressure, and the breathing is shallow and frequent with the same object.

In chronic catarrh the pain is diffused over the whole region of the stomach, and often between the shoulders; it begins soon after a meal and lasts a time varying from a few minutes to several hours, or even until the time of the next meal. In this disease the pain is relieved by vomiting, and the patient, conscious of the fact that it is the presence of food which causes the pain, sometimes induces vomiting by putting the fingers into the throat. In mild cases the pain is less severe, and may not begin until an hour or two after food.

In dilatation of the stomach the symptoms arise somewhat later; pain occurs about four to six hours after the meal, and may occur only once in two or three days. The pain is referred to the stomach, but as this organ is often very much displaced, it is felt in the region of the umbilicus rather than at the pit of the stomach. The gastric sensation begins as a slight uneasiness or discomfort, and is accompanied by eructation of gas, distress of the heart, and difficulty in breathing. This discomfort may be a burning sensation or a dull aching pain, but it increases until it becomes more acute and is usually only relieved by vomiting.

In ulcer of the stomach the pain is one of the most characteristic symptoms of the disease. It is a localized pain, coming on after food, felt over an area of only one or two inches in diameter in the pit of the stomach, but usually (not always) goes through to the back and is felt on the left side of the spine, between the tenth dorsal and first lumbar vertebra. The anterior region where the pain is felt is marked by a local tenderness over a small area above and to the right of the umbilicus.

In duodenal ulcer there is the characteristic "hunger pain,"coming on after food. When an ulcer of the stomach or duodenum perforates it causes a very acute pain in the upper part of the abdomen sufficiently severe to double the patient up, and causes vomiting, faintness, and other signs of collapse. Although at first the pain is localized, it very soon becomes diffused over most of the abdomen, owing to the escape of the stomach contents into the peritoneal cavity.

In cancer of the stomach the pain is accompanied by local tenderness. In some cases, however, there is a mere sensation of weight and oppression which is quite insufficient to indicate the severity of the cause; in other cases, where the disease implicates some solid organ or bone, the pain is of a dull and gnawing character. Most usually, however, the pain is more or less intense, described as aching, burning, cutting, or stabbing, and referred either to the pit of the stomach or between the shoulders.

There are other pains in or about the region of the stomach. Sometimes when attending a patient for some other disease, the question arises as to whether the pain is or is not in the stomach. There is, for instance, the troublesome "spasm of the stomach" which one occasionally comes across. It is a sudden, severe, griping pain in the pit of the stomach, extending to the back, and causing faintness, a shrunken appearance of the face, cold hands and feet, and an intermittent pulse. It suggests to the mind either gall-stones or perforation. But although the pain is bad enough to make the patient call out, there is usually no tenderness over the stomach; on the other hand, the patient bears pressure well, and either presses his hands over the stomach or presses the stomach against something to relieve the pain. The attack only lasts a few minutes, at most half-an-hour, and ceases suddenly with eructation of gas or watery fluid or by vomiting. This, however, is not a disease of the stomach : it may be a nervous affection dependent upon an irritation of the branches of the pneumogastric nerves or solar plexus; possibly an inflammation of the nerve sheath, maybe a small tumour. Moreover, it may be of central origin and depend on some affection of the brain or spinal cord. It is observed in anaemic or chlorotic women; it is one of the most frequent symptoms of hysteria. It may arise from sympathy with uterine troubles, especially displacements, chronic inflammation, or ovarian mischief. But it is not confined to women, and it occurs in men who are gouty, have malaria, or some other blood disease, as well as from tumours on the nerves or central nerve diseases.

Similarly, the pain arising from gall-stones may suggest gastric trouble. An attack of biliary colic, however, begins unexpectedly and suddenly. It is a piercing, griping pain, which starts from the right side and spreads from the gall bladder over the region of the stomach, possibly over a large area of the abdomen, and even up to the right shoulder. The patient sighs and moans; perhaps doubles up and rolls about the bed or floor. But as soon as the stone passes through into the duodenum the pain ceases almost at once, although it leaves some pain and tenderness owing to the stretching of the bile duct and irritation of the nerves.

In intestinal troubles there is often considerable aching and griping; if the affection is in the small intestines this pain is referred chiefly to the umbilicus. When the large bowel is affected, however, the position of the pain varies. In inflammation the pain is often agonizing, and is due to spasmodic contraction and movements of the intestines. Similar pains, however, may arise from faecal accumulations. When this is in the hepatic flexure it may simulate some disease of the liver, perhaps gall-stones, biliary colic. Pain on the left side may not be from the stomach at all; it may rise from pleurisy, a localized peritonitis, movable kidney, hydronephrosis, or impacted faeces. If a large part of the colon contains impacted faeces, there may be a pain which very much resembles some of the gastric pains: and if the caecum is loaded it may simulate appendicitis.