A system of practical medicine. By American authors. Vol. 2

by Unknown

The diseases which are most difficult to distinguish from gastric ulcer are nervous affections of the stomach. Like gastric ulcer, most of these are more common in women than in men, and especially in chlorotic women with disordered menstruation and with hysterical manifestations. These nervous affections are manifold and their leading characteristics are not yet well defined. The most important of these affections are nervous dyspepsia, nervous vomiting, nervous gastralgia, and gastric crises.

The leading symptoms of nervous dyspepsia, as described by Leube,¹⁰³ are the ordinary symptoms of dyspepsia without evidence of anatomical alteration of the stomach, and with the proof by washing out the stomach that the process of digestion is not delayed. Nervous dyspepsia is often associated with other nervous affections, and is caused especially by influences which depress the nervous system. Epigastric pain, and especially tenderness on pressure over the stomach, are not common symptoms in nervous dyspepsia. Only those rare cases of gastric ulcer in which hemorrhage from the stomach is absent and epigastric pain is not prominent are likely to be confounded with nervous dyspepsia. In such cases, although the diagnosis of nervous dyspepsia is by far the most probable, the patient may be confined to bed and put upon the strict regimen for gastric ulcer. If in the course of ten days or two weeks essential relief is not obtained, ulcer may be excluded, and the proper treatment for nervous dyspepsia with tonics and electricity may be adopted (Leube).

¹⁰³ Deutches Arch. f. klin. Med., Dec. 18, 1878.

In nervous vomiting, which occurs most frequently in hysterical women, other nervous manifestations are present; there are usually less epigastric pain and tenderness than in ulcer; the nutrition is better preserved; the vomiting is less dependent upon the ingestion of food and more dependent on mental states; and there are longer intervals of relief than in ulcer. Still, it may be necessary to resort to the therapeutical diagnosis as in the preceding instance.

In this connection attention may be called to the importance of searching for reflex causes of vomiting, such as beginning phthisis, ovarian or uterine disease, cerebral disease, and pregnancy; also to certain cases of chronic Bright's disease in which gastric disturbances are the main symptoms.

Of all the nervous affections of the stomach, nervous gastralgia is the one which presents the greatest similarity to gastric ulcer. Its diagnosis from gastric ulcer is often extremely difficult, and may be impossible. The points of difference given in the following table may aid in the diagnosis:

NERVOUS GASTRALGIA.	ULCER OF THE STOMACH.
1. Pain is often independent of the ingestion of food, and may even be relieved by taking food.	1. Pain is mostly dependent upon taking food, and its intensity varies with the quality and the quantity of the food.
2. Pain is often relieved by firm pressure.	2. Pain is increased by pressure.
3. Pain is rarely relieved by vomiting.	3. Pain after a meal is usually relieved by vomiting.
4. Fixed point of tenderness and of subjective pain not generally present.	4. These are often present.
5. Relief is usually complete between the paroxysms.	5. Some pain often continues between the paroxysms.
6. Nutrition frequently well preserved.	6. Nutrition usually affected.
7. Usually associated with other nervous affections, such as hysteria, neuralgia in other places, ovarian tenderness, etc.	7. Neuropathic states less constantly present.
8. Benefited less by regulation of diet than by electricity and tonic treatment.	8. Benefited not by electricity, but by regulation of diet.
9. Not followed by dilatation of stomach.	9. Dilatation of stomach may supervene.

According to Peter,¹⁰⁴ the surface temperature of the epigastrium is elevated in gastric ulcer, but not in nervous gastralgia.

¹⁰⁴ Gaz. des Hôp., June, 1883.

Probably not a single one of the points mentioned in the table is without exception. Nervous gastralgia may be associated with gastric ulcer, and if the ulcer is otherwise latent the diagnosis is manifestly impossible. A diagnosis of purely functional gastralgia has been repeatedly overthrown by the occurrence of profuse hæmatemesis. There is no symptom upon which it is more unsatisfactory to base a diagnosis than upon pain. There is much difference among physicians as regards the frequency with which they diagnose gastric ulcer in the class of cases here described. It is probable that the error is oftenest a too frequent diagnosis of gastric ulcer than the reverse. Nevertheless, when there is doubt it is well to submit the patient for a time to the proper treatment for gastric ulcer.