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EXPERIMENTALREFERREDPAIN FROMTHEGASTRO-INTESTINAL TRACT. PART II.

STOMACH, DUODENUMAND COLON

By A. L. BLOOMFIELDAND W. S. POLLAND

(From the Department of Medicine, Stanford University School of Medicine,San Francisco)

(Received for publication March 30, 1931)

INTRODUCTION

In the preceding paper of this series (3) observations on the painresulting from inflation of the esophagus by small balloons weredescribed. The general methods and purposes of the investigationwere also outlined. The present communication deals with similarstudies of referred sensation from the stomach, duodenum and colon.

STOMACH

Methods and material. A large balloon of thin rubber, so shapedthat on inflation it assumed the general shape of the stomach, wasconstructed about the distal part of a mercury weighted stomach tube.The tube was passed into the stomach and then inflated by means of alarge luer syringe fitted with a valve so that the amount of air intro-duced could be measured. The stomach tube was also connected witha U mercury manometer to measure pressure (see Fig. 1).

Sixteen subjects were studied. They were hospital patients andincluded people with and without stomach disorders. The followingpoints were analyzed: (1) the amount of inflation necessary to producepain, (2) the location of the pain, (3) the character of the pain, (4)the relation of pain to spontaneous sensations and to that producedby inflation of esophagus and duodenum and (5) the mechanism of theinduced sensations. The results are summarized in Table I.

The character of the sensations. The main features of the referredsensation from gastric inflation was its indefinite quality. It was al-most impossible to get exact descriptions from the subjects, but on the

45330

PAIN: STOMACH, DUODENUMANND COLON

whole the sensations resembled those encountered ordinarily from over-loading the stomach-feelings of fullness, tightness or pressure withmore or less of a painful element superimposed. In several cases therewere reflex attempts to rid the stomach of the large foreign body bymeans of belching, or violent nausea and retching supervened. It was

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FIG. 1. STOMACHAND COLONBALLOONS-INFLATED AND COLLAPSED

of interest to observe how violently sick the subject could be as theresult of a purely mechanical stimulus. When more than 600-700 cc.of air were introduced the stomach outline began to stand out as avisible fullness; in no case was there visible peristalsis. Case 14 is ofinterest insofar as no definite sensation resulted from distension with1500 cc. of air. In other cases discomfort resulted (see Table I) from200 to 400 or 500 cc. Except in Case 14, who seemed to be generallyhyposusceptible to pain, no relation was found between the thresholdstimulus and the patient's general nervous make-up or the presence ofdisease of the stomach. Cases 12 and 15, for example, with pepticulcer responded very slightly to inflation.

When inflation was started the pressure in the bag rose rapidly toabout 40 mm. Hg. and then usually remained at about this level.Apparently the stomach dilated readily on further introduction of airwithout exerting much increased pressure.

The location of the induced sensations. Inflation of the stomach gavesensations which were much less sharply localized than those from the

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esophagus or duodenum. The subject usually placed his whole handover the general area which was affected, but the sensation was usuallydescribed as deep and not on the surface. The dots in Fig. 2 show thecenters of the areas indicated in the various cases; the total distributionof sensation corresponded roughly with the rectangular area. In no

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IFIG. 2. EACH DOT INDICATES THE CENTEROF THE AREAOF REFERRED

SENSATION-FROMINFLATION OF THE STOMACHIN SIXTEEN CASES.

case did inflation of the stomach give pain much below the umbilicus orabove the xyphoid with the exception of Case 9 who on each step in theinflation had severe pain in the temporal regions which was immediatelyrelieved by releasing the pressure.

Relation of induced sensations to spontaneous discomforts and toesophageal and duodenal pain. In several cases (Cases 4, 5, 7,12) theinduced sensations were said by the patient definitely to resemblespontaneous discomforts. In Cases 4 and 7 the induced stomachsensation resembled that produced by inflation of esophagus. In otherinstances (see below) there was a resemblance between esophageal andduodenal pain. The point of interest and of clinical importance is thedifficulty of identifying the site of the stimulus from the location of thereferred sensation.

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Mechanism of the referred sensations. The abdominal surface areaimplicated by the referred sensations corresponded to the 7th, 8th and9th dorsal segments. Weinterpreted the sensations as referred via thesympathetic. However, nausea and retching, and in Case 9 the painsin the head, seemed clearly to be reflexes through the vagus.

DUODENUM

Literature. Ivy, Vloedman and Keane (1) inflated the duodenum inthree normal men with 50 cc. of air and produced nausea and chilliness.Strouse and Shamberg (2) carried out similar experiments in a largerseries of people. In patients without abdominal disease they concludedthat pain was localized at the position of the balloon whereas in casesof abdominal disease the results were variable or the patient's spon-taneous pain might be reproduced. As will be seen below our experi-ments yielded somewhat different results.

Methods and material. A duodenal tube fitted with a balloon at itstip was used. The tube was passed in the usual manner and its posi-tion was verified under the fluoroscope. In a good many instances theballoon slipped back into the stomach as soon as inflation was begunso that only about one third of the experiments were successful.However, in twelve cases the procedure was carried out satisfactorilyunder fluoroscopic control. The exact position of the balloon, theamount of air necessary to produce sensation and the pressure in mm.of mercury, the character of the pain and other symptoms and thelocation of induced sensations were recorded. The subjects includedhospital patients with and without digestive symptoms.

Results. The main features of the observations are summarized inTable II and in Fig. 3.

The character of the referred sensations. The character of the referredsensations was similar to that obtained on inflation of the esophagusand stomach-deep seated more or less indescribable unpleasant feel-ings into which entered, in various cases, elements of pressure, fullness,burning, aching or colic. In a general way the induced discomfortsresembled those complained of by patients with indigestion, pepticulcer, gallbladder disease or other abdominal disorders. They pre-sented no specific features. In several cases nausea and vomiting wereinduced. On relieving the inflation the referred sensation alwaysdisappeared instantaneously and there were no after effects.

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FIG. 4. DOTTED CIRCLE INDICATES TOTAL AREA IMPLICATED BY RE-FERREDPAIN FROMTHE DUODENUM. Each dot indicates the site of painfrom a single inflation.

total area which was implicated. It is seen that inflation of the duo-denum may give pain from the xyphoid to the umbilicus although theright upper quadrant was most frequently referred to in these tests.Wewere unable to confirm Strouse and Shamberg's observation that innormals the pain was referred to the site of the balloon in contrast toother forms of reference in patients with intraabdominal disease;indeed in our cases there was no correlation of any sort. For the mostpart the referred pain was sharply localized (see diagrams) in contrastto the widely diffused sensations from the stomach. However thestomach and duodenal areas overlapped (see Fig. 7).

The degree of inflation necessary to produce pain. Table II shows thatpain appeared in different cases with variable degrees of inflation-from 40 cc. to 200 cc. of air. The pressure in the bag also varied con-

465


siderably. Case 7 had no sensation even after the introduction of 200cc. of air. It was impossible to correlate these variations with anyclinical features such as presence or absence of disease of the duodenum,certainly the three cases of duodenal ulcer were not specially sensitiveto inflation.

The relation of induced to spontaneous pain and of gastric esophagealand duodenal pain. Table III shows in summary these relations.In several cases inflation of duodenum reproduced the patient's spon-taneous symptoms; in some instances these also seemed identical withinduced pain from the esophagus. Obviously one should not go toofar in drawing conclusions from statements of patients as to subjectivesensations, but a point of great clinical importance is brought out in-sofar as one clearly must be very cautious in diagnosing the site oforigin of a pain from its situation alone.

COLON

Great difficulties were encountered in introducing the balloon (seeFig. 1) into the large bowel and our observations are confined to infla-tions of the left colon and sigmoid. In order to prevent coiling of thetube in the rectum, which otherwise invariably occurred it was neces-sary to introduce the tube into the sigmoid through a proctoscope andthen to attempt to pass it further. Successful observations, with theposition of the bag checked by fluoroscopy, were obtained in ninepatients with miscellaneous disorders, and except for Case 8 withoutbowel disease. Wehad found no reference in the literature to similarexperiments on the intact bowel. Since this paper was completed wehave learned that Chester M. Jones, of Boston, has presented a com-munication to the Cosmopolitan Club at their meeting on February27, 1930, dealing with the problem of referred pain from the bowel asthe result of inflation by means of balloons. From personal com-munication with Dr. Jones it appears that he has obtained resultsessentially similar to ours. It should also be pointed out that hispresent studies are the outgrowth of similar work on the esophaguswhich he reported several years ago at the meeting of the AmericanSociety for Clinical Investigation (5). Our work is therefore to beregarded as consequent and not antecedent to his.

Results. The results are summarized in Table IV and Figs. 5 and 6.

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Referred sensations of the same general sort as those originating inthe stomach or duodenum were obtained-more or less indescribabledeep discomforts involving elements of fullness, pressure or colic andobviously related to sensations normally experienced in connectionwith movement of the bowel. As a rule pain appeared with about 100to 200 cc. of air but in Case 7, 20 cc. sufficed and in Case 1, 500 cc. werenecessary. We were unable to correlate these variations with anyother features of the case. In some instances the pain was sharplylocalized as regards surface distribution as in Case 5; in others therewas a wide indefinite area as in Cases 1 and 6. In Fig. 6 each dotindicates the center of the area of referred sensation from a singleinflation. It is seen that the whole area from umbilicus to pubis isimplicated and that there was no definite relation between the site ofthe stimulus and the site of referred pain. Of special interest, forexample, was Case 9 who with the bag in the descending colon feltpain in the right lower quadrant. In some cases the bag could bemoved quite a distance without altering the position of the pain (Case3). It is evident how uncertain it would be clinically to draw inferencesas to the location of a lesion from the site of pain alone. As soon as thebag was drawn from the sigmoid into the upper rectum and inflatedthere a new type of sensation resulted, namely a pain low in the backsimilar to that experienced when the bowels are about to move.

SUMMARYAND DISCUSSION

These experiments show in brief that by inflating various parts ofthe gastro-intestinal tract with balloons referred sensations may beproduced which fall under the general heading of pain. More in de-tail, these sensations may be described as deep seated fundamentalmore or less indescribable forms of discomfort into which enter elementsclassed by the subject as pressure, fullness, distension, tightness,cramps or burning. In many cases the subject recognizes the inducedsensation as similar to spontaneous discomforts encountered in hispast experience and likens them to the sensations of overeating, ofindigestion, of desiring to go to stool, etc. For the most part theinduced sensations seemed to be referred to segmental areas via thesympathetic, although in some cases nausea, vomiting and remote painas in the head or face probably represented vagal reflexes.

471


The main object of our studies was to throw light on clinical problemsparticularly with reference to the relation of site of pain to its point oforigin, and it was brought out almost consistently that the superficialdistribution of the referred sensations was remote from the site of thestimulus. One may mention, for example, pain in the suprasternalnotch from inflation of the lower end of the esophagus, pain in thegallbladder region from inflation of the 3rd portion of the duodenumand pain in the lower mid-abdomen from inflation of the splenicflexure. While the total areas of referred sensation from esophagus,duodenum and colon are different, they overlap to some extent (seeFig. 7) so that at times it may be difficult to tell, for example, whetherpain originates in the esophagus or in the upper abdominal viscera.

These facts seem to sustain the thesis laid down in the precedingpaper (3) that symptoms of this sort occurring in patients do 'not bvthemselves enable one to make a diagnosis of the underlying disorder.This concept, even if not generally accepted at present, is not a newone and was championed by Sir James Mackenzie: "Attempts arecontinually being made to classify affections of the stomach, and thelack of agreement in these classifications is merely due to the fact thatattempts are made to differentiate what can not be differentiated.This will be realized when the nature of stomach symptoms is consid-ered. Apart from some characteristic vomits (blood, mucus). andcertain changes indicated in the position of the organ (and these referonly to a minute proportion of the cases), all the symptoms are of areflex nature, pain, cutaneous and muscular hyperalgesia, muscularcontraction, vomiting and air suction. As any adequate stimulusmay suffice to produce these symptoms, and as this adequate stimulusmay arise from the most various causes, trivial or severe, it follows thatthere is a great similarity in the symptoms in diseases of the most variedkinds" (4). If all this be true it would seem to be sounder practice toadmit the limitations of "digestive symptoms" in diagnosis and torealize that unless more conclusive evidence can be obtained by x-raystudy or in other ways it is unwise to set up criteria which actualexperience shows to be unsound.

472

A. L. BLOOMFIELD AND W. S. POLLAND 473

BIBLIOGRAPHY

1. Ivy, A. C., Vloedman, D. A., and Keane, J., Am. J. Physiol., 1925,lxxii, 99. The Small Intestine in Hunger.

2. Strouse, S. and Shamberg, A. H., Trans. Assoc. Am. Phy., 1925, xl,296. Air Inflation of the Duodenum in Pathological Conditions ofthe Duodenum and Gall-Bladder.

3. Polland, W. S. and Bloomfield, A. L., J. Clin. Invest., 1931, x, 13.Experimental Referred Pain From the Gastro-Intestinal Tract:Part I. The Esophagus.

4. Mackenzie, James, Symptoms arnd Their Interpretation. London,Shaw, 1909, p. 128.

5. Jones, C. M. and Richardson, W., J. Clin. Invest., 1926, ii, 610.Observations on the Nature of "Heart Burn."

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