Constitutional Gastralgia

Constitutional gastralgia is caused by some abnormal condition of the blood, due either to infection, intoxication, or malnutrition. Among the infections, malaria is frequently the cause of intense gastralgia. The gastralgia may be associated with other symptoms of this disease, chills, fever, etc., or it may appear alone. It is characteristic of gastralgia of malarial origin to appear either every day, or every other day, or every third day at the same hour. I have frequently seen this form of gastralgia accompanied by intense vomiting and by a condition of hyperesthesia of the stomach prevailing in the intervals between the attacks.

The intoxications causing gastralgia are very numerous. Thus chronic lead poisoning, an extensive use of the mercurial preparations, the excessive use of tobacco, frequently evoke typical attacks. Gout is also sometimes found to give rise to gastric attacks. Malnutrition, which is always associated with anaemia, is frequently found complicated with gastralgia, especially in young persons (chlorosis). In these rases it is, as a rule, very difficult to decide whether the gastralgia is due to the anaemia or to a real organic trouble of the stomach, namely, ulcer.

Reflex Gastralgia

This group occurs more frequently in women. Keflex gastralgia may be caused by abnormal conditions in distant organs, such as the uterus, ovaries, or tubes. In men also diseases of the genito-urinary organs give rise to similar troubles. Another frequent cause of reflex gastralgia is an abnormal position of the abdominal organs. Thus en-teroptosis, gastroptosis, nephroptosis, hepatoptosis are all occasionally the cause of gastric pains. Hydronephrosis has also been stated by Renvers1 to be the cause of gastralgia, and I myself have observed one case of this kind.

Diagnosis

To establish the diagnosis of gastralgia it is of importance to exclude (1) all organic and functional diseases of the stomach accompanied by pain, and (2) conditions likewise provoking pains in the gastric region which, however, are not due to the stomach.

Among the organic affections of the stomach which give rise to gastralgia, and may occasionally be confounded with idiopathic gastralgia, are: (a) Chronic gastric catarrh; (b) cancer of the stomach; (c) ulcer of the stomach; (d) stenosis of the pylorus.

In chronic gastric catarrh the pains are very seldom intense, they have a more continuous character, and do not appear in paroxysms.

In cancer of the stomach the pains may be intense at times, but they are also, as a rule, more steady, never leaving any perfectly free intervals, while in idiopathic gastralgia the pains appear in the form of attacks lasting only several hours and alternating with complete euphoria.

1 Renvers: Berl. klin. Wochenschr., 1888, No. 53.

Ulcer of the stomach occasionally presents much more similarity to the affection under consideration. The characteristic signs of ulcer (a circumscribed spot in the gastric region or to the left of the eleventh to twelfth dorsal vertebra, very painful on pressure, the aggravation of the pains after the ingestion of food, especially of coarse substances, a preceding hemorrhage) will, if present, make the differential diagnosis between this affection and idiopathic gastralgia very easy. Sometimes, however, all of the characteristic symptoms mentioned are absent, and then it becomes very difficult to distinguish between these two affections, for there undoubtedly exist ulcers of the stomach which give rise to more or less periodic paroxysms. In these doubtful cases it is advisable to institute the Ziemssen-Leube rest treatment of ulcer, and if this proves beneficial it will speak in favor of the affection having been an ulcer; the failure of this treatment would rather tend to indicate that the -affection is nervous gastralgia.

Stenosis of the pylorus is accompanied with typical attacks of gastralgia. When frequent vomiting and ischochyraia are present, the differential diagnosis is not difficult. If, however, the two symptoms mentioned are absent, it may sometimes become quite difficult to decide between the two conditions.

In diagnosticating nervous gastralgia, it will be still more important to differentiate between some functional disorders of the stomach which may be associated with pains. Such affections are: (a) Hyperchlorbydria; (6) periodic and chronic continuous hypersecretion; (c) achylia gastrica. In hypercblorhy-dria and hypersecretion the pains, as a rule, disappear after the ingestion of food, and even a severe attack may be checked by the taking of some food. In achylia gastrica the pains exist only while there is food in the stomach, but not in its empty condition, while in nervous gastralgia the pains appear independently whether there be food in the stomach or not. Besides these clinical symptoms in all of the functional disorders just mentioned, the exact diagnosis can be made by the results of the examination of the gastric contents.

There are other conditions which also provoke pains in the gastric region, which are not due to the stomach.

Muscular pains of the abdomen, due either to rheumatism or to overexertion, may give rise to mistakes in diagnosis. The pain in these affections, however, does not appear paroxysmally and disappears if due to overexertion when the patient assumes a recumbent position and the abdomen is relaxed.

Neuralgia of the lower intercostal nerves is characterized by extreme sensitiveness on pressure in a certain intercostal space, extending forward from the vertebral column; the pain is more superficial than in gastralgia.

Gall stones frequently give rise to attacks of intense pains which may be mistaken for gastralgia. Whenever there is a distinct history of cholelithiasis (a preceding icterus, the appearance of gall stones in the tacks of gastralgia, however, appear in intense form, the administration of an opiate can seldom be avoided. The best and quickest way to relieve the suffering is a hypodermic injection of morphine (one-sixth to one-fourth of a grain); suppositories of either codeine or opium in combination with belladonna are very useful. I frequently prescribe suppositories of two-thirds of a grain of opium and one-sixth of a grain of belladonna extract, to be taken every two or three hours until the pains cease.