Gastralgia (Gastrodynia, Cardialgia, Spasm of the Stomach)

Under the head of neuroses of the stomach have been variously described the conditions indicated in the heading of this section; and a certain amount of confusion has arisen in the use of these terms from the fact that they represent subjective sensations common alike to organic and functional forms of indigestion: pain, for instance, is felt in gastritis, cancer of the stomach, and ulcer of the stomach. Indeed, it rarely occurs independently of some disorder of digestion or structural lesion of the stomach.

By gastralgia, considered as a distinct affection, however, we mean a purely neuralgic condition of the sensory fibres of the stomach, excluding inflammatory and structural changes on the one hand and chronic forms of atonic dyspepsia on the other. The attacks are usually periodical in character, with constricting pain in the pit of the stomach, and the intervals are not necessarily associated with symptoms of dyspepsia. It chiefly occurs in females of nervous temperament at the catamenial periods.

Two forms of the disease have been described—one depending on hyperæsthesia of the sensory fibres of the pneumogastric, the other on hyperæsthesia of the solar plexus. This may be correct in theory, but practically it can be of little importance to make the discrimination, even if it were possible to do so.

Clinically, the disease is presented to us in two forms. In one the pain is agonizing, comes on without premonition, is sometimes intermittent or remittent in character, and conveys to the sufferer the idea of spasm; hence it has often been described as colic of the stomach. If not relieved by appropriate remedies, the pain may last for hours or days. This is the acute form. In the other the pain is more of a neuralgic character and is not so severe. There may be varying exacerbations which may last for months or years. This is not an unfrequent form, and may consist simply in the more acute form becoming chronic.

ETIOLOGY.—With the limitation indicated, we have naturally to seek the causes of the affection, says Ziemssen, in two directions: either in the abnormal nature of the irritants to which the gastric nerves are subjected, or in an altered condition of the nerves themselves, which therefore react abnormally with the normal degree of irritation. This briefly covers the whole ground of the etiological relations of the disease.

The predisposing causes are such as produce general depressed vitality, embracing at the same time special conditions of extreme nervous excitability. Some of these general conditions were pointed out while speaking of atonic forms of dyspepsia. Indeed, the two conditions are often associated, and practically it may be difficult to separate them, although the connection between them is not necessarily an invariable one. Like atonic dyspepsia, gastralgia is apt to affect anæmic persons, and notably anæmic females at menstrual periods. Thus, the association between gastralgia, chlorosis, and hysteria is a matter of common observation. Of 350 cases noted by Briquet, only 30 had no signs of gastralgia; and this observation is a fair average expression of the experience of others.

Certain blood-poisons are also known to give rise to the disease. Infection of the blood by malaria was observed by Niemeyer to produce spasm of the stomach instead of the paroxysms of intermittent fever; and in malarious regions of the United States the same observation has been made. Gout and rheumatism are also known to sustain causative relations to the disease. Certain idiosyncrasies also enter as a factor into the somewhat complex etiology of the disease. Thus, some persons suffer immediately from eating certain kinds of food and fruits, such as shellfish, strawberries, honey, and even milk and coffee. The pain and spasm are produced by direct contact with the sensory fibres of the stomach; i.e. they react abnormally to normal stimulation. But disease of the nerve-centres may enter into the causation. This is seen by the effects of morbid growths impinging upon nerve-trunks; their terminal branches often become extremely irritable and painful, and this condition may be intensified by idiosyncrasy. Excessive acidity of the stomach, seeds of fruit, certain articles of food, the presence of worms in the stomach, and draughts of ice-water may simply act as exciting causes to a centric predisposition.

Of the more direct causes operating upon nerve-centres, all the depressing passions and emotions deserve special mention; so do all causes which produce an exhausted state of innervation, such as venereal excesses, onanism, the abuse of narcotics, etc.

But chief among the causes are those of a reflex kind. Painful affections of the kidneys, irritable conditions of the bladder, diseases of the liver, and, above all, morbid conditions of the female genital organs, sustain a direct and close relation to painful and spasmodic conditions of the stomach. It is a common accompaniment of versions, flexions, prolapses, inflammations, erosions of the os, as well as diseased conditions of the ovaries. When such local conditions are associated with anæmia and hysteria, patients rarely fail to have painful gastric complications.

SYMPTOMS.—The symptoms of gastralgia, like most of the neuroses, are characterized by severe pain occurring in paroxysms, followed by remissions, and sometimes by complete intermissions, again to recur with varying degrees of severity. The pain in the acute variety is of a violent, spasmodic character, and is referred to the epigastrium immediately beneath the ensiform cartilage. Frequently it extends from the epigastrium to the back and chest and into the right and left hypochondrium. No one has so briefly and so accurately described the immediate attack of gastralgia as Romberg: "Suddenly, or after a precedent feeling of pressure, there is severe griping pain in the pit of the stomach, usually extending into the back, with a feeling of faintness, shrunken countenance, cold hands and feet, and small, intermittent pulse. The pain becomes so excessive that the patient cries out. The epigastrium is either puffed out like a ball, or, as is more frequently the case, retracted, with tension of the abdominal walls. There is often pulsation in the epigastrium. External pressure is well borne, and not unfrequently the patient presses the pit of the stomach against some firm substance or compresses it with his hands. Sympathetic pains often occur in the thorax under the sternum, in the oesophageal branches of the pneumogastric, while they are rare on the exterior of the body. The attack lasts from a few minutes to half an hour; then the pain gradually subsides, leaving the patient much exhausted, or else it ceases suddenly with eructation of gas or watery fluid, with vomiting, with a gentle soft perspiration, or with the passage of reddish urine."

Besides the violent paroxysmal pain referred to the stomach, symptoms of derangement of other organs are often present. Prominent among these are hysterical phenomena which are protean in their manifestations, and if not recognized they are liable to mislead. Thus, with gastric pain there may be violent palpitation of the heart, with shortness of breath, cough, globus, hiccough, and convulsive affections, and in a certain proportion of cases there is marked melancholia or hypochondriasis.

The stomach is variously modified in its function. In many cases it is entirely unaffected. The desire for food may be indeed increased, and its ingestion may give a sense of relief. In others vomiting may be severe, while in still others there may be merely a condition of anorexia. The tongue is, as a rule, clean, the skin cool, the temperature undisturbed, and there is absence of tenderness over the epigastrium. Generally pressure relieves the pain.

DIAGNOSIS.—Functional and structural troubles of the stomach very markedly simulate each other; therefore the diagnosis requires to be made with great caution, and this is best done by a most rigid and careful exclusion; and this becomes difficult because the symptoms are mainly subjective.

It is a matter of great moment in differentiating the disease to take into account all constitutional states which predispose to nervous asthenia. Thus in conditions of chlorosis and hysteria the presumption is strong that the pain is neurotic or spasmodic in character; and this presumption is intensified if there be no accompanying constitutional symptoms which indicate inflammatory action. We exclude inflammatory conditions of the stomach by the frequent and complete intermissions, by the absence of thirst, tenderness, and all febrile movement. Moreover, the pain of inflammatory affections, unless produced by corrosive poisons, is rarely so severe as in neuralgic affections; nor are nausea and vomiting so uniformly present in neurotic affections. Then the time at which the pain is experienced is a matter of importance. In inflammatory affections it is felt immediately on taking food. In neurotic affections it may occur when the stomach is empty, and it is not unfrequently relieved by food. In ulcer and cancer of the stomach pain is a common element, and, as in gastralgia, it is referred to the epigastrium. But in gastric ulcer the pain is rarely absent; it is of a dull, gnawing character, is strictly localized in the centre of the epigastrium, and is aggravated by pressure and by food. Moreover, the vomited matter often contains blood. In cancer of the stomach the pain is not as severe and spasmodic in character as in gastralgia, the vomiting is a more prominent symptom, and the material vomited has the characteristic cancerous look. Cancer is more apt to occur too in advanced life, and it is characterized by a steady progressive emaciation.

Gastralgia may also be confounded with rheumatism of the abdominal muscles as well as neuralgia of the inferior intercostal nerves, and it is liable to be confounded with colic resulting from biliary calculi. Colicky pains in the transverse portions of the colon may also be mistaken for pains in the stomach. "It is no exaggeration to say," says Trousseau, "that in perhaps half the cases which are called gastralgia the affection is nothing more than cholalgia." The more fixed the pain is to one spot, and the nearer it is to the median line, the greater is the probability of its being gastric.

PROGNOSIS.—Notwithstanding the severe and apparently alarming nature of the symptoms, the prognosis of gastralgia is in the main favorable, although the prospect of a permanent and speedy cure is small. The duration of the disease depends on the nature and persistence of the exciting causes, and these are so often associated with an exhausted state of innervation that speedy recovery from the disease cannot be promised. In the simpler varieties, caused by improper food, the disease will disappear by removing the cause, and the hysterical forms are liable to disappear with advancing life. So also cases arising from malaria, anæmia, chlorosis, uterine disease, rheumatism, and gout may be relieved by removing the cause. But there are cases produced by unknown causes, and especially cases associated with a general and unexplained cachexia, in which the prognosis is not good.

TREATMENT.—This is both radical and palliative. The radical treatment must have reference to the diseases which have given rise to it. If, for instance, the gastralgia can be traced to sympathetic disturbances of the uterine organs, no remedy can be permanently effective until the cause is removed. Since chlorosis and anæmia are so often found associated with it, benefit may be expected from the ferruginous preparations in some form. Iron occupies a prominent place as a remedial agent. The precipitated carbonate is to be preferred on account of its peculiar influence over the nervous system, and especially over painful neuralgic conditions. It may be given in drachm doses, or even larger, combined with ginger or aromatic powder. If the stomach will not tolerate it, other preparations may be tried.

Quinia is a valuable addition to iron, and it is specially valuable in cases of suspected malarious origin. Sometimes a few large doses will break up the paroxysmal pains as no other agent will.

In the more chronic forms of the disease arsenic is one of the most reliable remedies we possess. It has a well-deserved reputation in the treatment of a great variety of nervous affections, and in none more than in the disease now under consideration. It should be given for a length of time—three or four minims of Fowler's solution, gradually increased and given immediately after food—and in cases of anæmia it should be associated with iron.

In irritable, broken-down conditions of the nervous system nux vomica, or its alkaloid strychnia, is a useful remedy. But it is a powerful stimulant to the spinal nerve-centre, and care should be used in the too protracted use of the remedy or in its administration in too large doses. It may be combined with the phosphate or the valerianate of zinc, or either may be given separately. The nitrate and oxide of silver have also been used with asserted success. Nitrate of silver may be given in pill form with opium.

If there is a strong hysterical element, the bromides and antispasmodics may be tried in connection with remedies calculated to strengthen the nervous system. The judicious employment in such cases of hydro-therapeutic measures is of great value. Good results are also obtained from electricity. The constant current should be preferred.

Among palliative remedies—i.e. remedies that act directly on the painful gastric nerves—the subnitrate of bismuth has long been regarded with great favor. Its action is mainly local; it may be given, therefore, in drachm doses or more three or four times a day. If there is nothing to contraindicate its use, aconite or dilute hydrocyanic acid may be given with the bismuth.

For the immediate relief of pain, however, there is no substitute for opium. The subcutaneous injection of morphia will generally give immediate relief. But there are many reasons why we should try other palliative remedies. In a disease so painful in character a remedy that gives such prompt relief is liable to abuse. The formation of the opium habit should be carefully guarded against. Spirits of chloroform may be tried, therefore, as a substitute for opium, followed by large draughts of hot water—hot as the patient can possibly sip it. Hot water of itself often gives immediate relief.

An important part of the treatment consists in well-regulated hygiene. Change of air, travel, pleasant mental surroundings, together with carefully regulated diet, are in a majority of cases more efficacious than drugs.