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Thme CANADIAN MEDICAL ASSOCIATION JOURNAL 137 Aug. 1930] THmE CANADIAN MEDICAL ASSOCIATION JOURNAL 137 DYSPEPSIA By ROBERT HUTCHISON, M.D., F.R.C.P., Phystcian to the London Hospital, London, Eng. TIHE first duty of anyone who undertakes to may lead to error, as to that form, not so write about dyspepsia is to define what he very uncommon, in which vomiting and even means by the term, for it is a word which is some pain occurs after every meal; such used very loosely, as we all know, both by doc- symptoms when they occur in a young un- tors and by patients, and is often enough made married woman may easily deceive. Or take to cover any form of abdominal discomfort again the vomiting of the gastric crises in which a patient may experience. But accuracy tabes. When these crises occur, as they some- :of diagnosis and efficient treatment demand a times do, early in the disease and before more precise use than this, and I propose in the the deep reflexes have disappeared, the fact of present paper to include under the term only their nervous origin is easily overlooked, and such abdominal discomfort as is felt during the every physician and surgeon of experience progress of digestion, and which is due to organic must have known cases in which even a gastro- disease of the stomach or to a primary disorder jejunostomy has been performed for gastric of its functions. For the purposes of this defini- crises under the belief that the patient was tion the duodenum may be regarded as part of s-uffering from organic disease of the stomach. the stomach. Migraine, especially of that aberrant type met with sometimes in women about the menopause CONDITIONS WHICH SIMULATE DYSPEPSIu and in which headache is a very inconspicuolus On approaching the case of a patient who be- feature of the attack, is another nervous condi- lieves himself to be the subject of dyspepsia or tion often regarded as " dyspepsia, " and so whose symptoms suggest, prima facie, that diag- also is the vomiting caused by an intracranial. nosis, our first business is to make sure that the tumour, particularly in children. The vomit- primary seat of the trouble really is in the ing of chronic uraemia, too, is apt to be re- stomach and not elsewhere. This means that one garded simply as a symptom of indigestion must exclude at the outset those conditions which and the underlying renal disease overlooked. simulate dyspepsia as above defined. Any of It is true that there probably is in these cases the cardinal symptoms of dyspepsia-vomiting, a gastritis present, but my point is that this is pain and flatulence-may be produced by mor- not a primary disease of the stomach but is bid states which have nothing directly to do secondary to grave organic trouble elsewhere. with the stomach and so may lead to deception. Obstruction in the urinary tract from, for We may consider each of these separately. example, enlarged prostate or urethral stric- Vomiting from causes altogether outside the ture, may also produce vomiting and other stomach is a common source of confusion. gastric symptoms-so-called "uro-kinetic dys- Take the vomiting of pregnancy for example. pepsia "-which may be erroneously ascribed I believe that sooner or later everyone in to some primary disorder of the stomach itself. practice makes the mistake of diagnosing a Even glaucoma is apt to be diagnosed as case of the vomiting of pregnancy as one of dyspepsia from the prominent part which dyspepsia. I am not referring so much to the vomiting sometimes takes in the clinical pic- typical "morning vomiting", though even that ture. 138 THE CA.NADLA.N AUDIcALAssociATioN JOURNAL 1930 13:H AAINMDCLASCAINJUNL[u.13[Aug. Or take the case of pain. Real pain is met ORGANIC DYSPEPSIA with in the organic dyspepsias, but it has many other intra-abdominal causes as well, and some Having excluded " simulators" and settled that the is of these are specially prone to mimic disease patient really the subject of dyspepsia in the sense of the stomach. Gall-stones are a case in point. already defined, the next step in The pain and flatulent distension which they diagnosis is to determine whether the symptoms may cause make up a combination of symptoms are due to organic disease of the stomach or to which the term "gall-bladder dyspepsia" is merely to disorder of its functions. Now there now often applied, but a patient suffering from are three symptoms any one of which strongly gall-stones is not the victim of dyspepsia as suggests organic disease and these are, pain, defined above, nor is a patient who gets gastric vomiting and wasting. It is true that absence symptoms as the result of chronic appendicitis. of these does not exclude organic trouble, but The pain which results from chronic obstruc- the presence of any, and still more of all of tion in the colon or from recurrent hydro- them, makes it very unlikely that the case is nephrosis, or even from a renal calculus, may functional. also deceive, especially when accompanied, as it The pain must be real pain. Nervous patienits, often is, by vomiting. Yet in all of these cases as we all know, are given to describing any the stomach is free from organic disease and abdominal discomfort as "pain" but there are suffers from no primary disorder of its func- certain criteria one can apply in determining tions. whetlher the pain is real or not. If, for example, There are two common forms of flatulence ihe patient has to give up what he is doing and which are often erroneously regarded as due to lie dowin, or if he has to apply a hot-water bag dyspepsia-that which is the result of air-swal- to the abdomen, or still more if the pain makes lowing (eructatio nervosa) and that which is so him sweat or causes him to induce vomiting to often an accompaniment of the minor form of get relief, then it may be regarded as real. angina (stenocardia). The first of these is pure- Vomiting, again, is not a symptom of functional ly nervous in origin, brought about by a sort of disorder, excepting in the rare form of hysteri- tic of the cesophagus, and has nothing to do with cal vomiting, and that is really not dyspepsia but the digestive process itself, yet patients who a simulator of it. Wasting, too, is never func- suffer from it nearly always believe that their tional, unless the patient has been too strictly "wind" is the product of "fermentation" and dieted. are often treated under this belief by strict The organic causes of dyspepsia are few and dieting and stomach mixtures for months with- comprise, for practical purposes, only ulcer out success. To mistake stenocardia for dys- (acute and chronic), gastritis, and carcinoma. pepsia is more excusable for the pain may be Real pain should always suggest ulcer and if referred to the epigastrium and as it is often the pain comes on punctually at a certain time relieved by the bringing up of a mouthful of after each meal and is temporarily relieved by "wind" an affection of the stomach is naturally the taking of food and if the symptoms occur suggested. The cardinal distinction between in bouts separated by intervals of freedom, the heart pain and gastric pain, of course, is that diagnosis is almost certain, even in the absence the first is related to exertion and the second to of all other symptoms and signs. Pain soon the taking of food and interrogation of the pa- after a meal which is relieved by vomiting sug- tient as to this should enable one to avoid any gests acute ulcer. mistake. Chronic gastritis is an organic cause of dys- Mlost of these simulators of dyspepsia, and pepsia which is not attended by any pain nor others of which space does not permit mention, by wasting and rarely even by vomiting. Its may be detected if care is taken to subject every symptoms are loss of appetite, nausea (especially patient who complains of what seem gastric in the morning) and a feeling of slow digestion, symptoms to a general routine investigation of as if the food stayed too long in the stomach. It all the organs. It is through confining the ex- is the one form of dyspepsia a sure diagnosis of amination to the abdomen only that mistakes are which can only be made by a test-meal, for the made. demonstration of an excess of mucus in the HUTCHISON: DyspEpsiA 139 Aug. 1930] HuTcHIsoN: DYSPEPSIA 139 gastric contents is the only final proof of its it exists it is responsible for the patient's existence. Gastritis is really a comparatively symptoms is by no means easy to determine. rare cause of dyspepsia, and the tendency of At all events one should always be rather chary practitioners certainly is to diagnose it too often. of diagnosing the presence of an organic lesion In fact, it may usually be regarded as a "label" in a visceroptotic woman, even although her rather than a true "diagnosis". symptoms seem to point that way, unless the Carcinoma of the stomach may produce all radiographic evidence is positive. Sometimes, the symptoms of an organic dyspepsia-pain, iildeed, an exploration may be the only way of vomiting, wasting -but wasting is a more settling the matter. prominent and characteristic feature than the other two. It is in the early stages, of course, FUNCTIONAL DYSPEPSIA that diagnosis is most difficult, but the sugges- If *we have excluded "simulators" and the tive symptoms are impairment of appetite presence of organic disease we must conclude.
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