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acter of the discomfort may be pain, fulness, burning, or sensations of cold
occurring after meals. In some instances, not only does the food cause
discomfort, but the normal amount of hydrochloric acid will cause pain,
similar to that found in hyperacidity, and it may exist even when the acid
is diminished or absent. Attention has been called to this fact by Talma,
Stockton, and Steele.

Under the subjects of achylia gastrica and hyperchlorhydria, it was shown
that symptoms of hyperacidity occasionally exist in achylia gastrica; in these
cases there is evidently a hyperaesthesia of the gastric mucous membrane,
which is so sensitive that it cannot tolerate even the normal amount of acid.
Again, a condition is often observed in which the percentage of acid may be
far in excess of normal, and yet the individual have perfect health without
gastric disturbances. This indicates that the acid itself is not alone sufficient
to produce the symptoms of hyperacidity, but that there must be in addition
a hyperaesthesia of the gastric mucosa. In the cases described by Talma there
was an idiosyncrasy for hydrochloric acid, the slightest quantity producing
pain in the stomach; these manifestations are due to an abnormal sensitiveness.

Etiology. — As a primary affection, hyperaesthesia is found in neuras-
thenia and hysteria, and frequently in anaemic females; it occurs secondary
to affections of various organs, such as ulcer of the stomach, chronic gastritis,
and disease of the kidneys (uraemia). It may be produced by excesses in
food and drink, the abuse of coffee, tea, alcohol, indulgence in highly seasoned
food and tobacco, or it may come from drug habits, such as opium or cocaine.
The taking of insufficient food, fasting, living on an exclusive diet, or eating
irregularly are also etiological factors. Hyperaesthesia is the affection from
which conditions such as anorexia nervosa, nervous nausea and vomiting,
gastralgia, and sitophobia often take their origin. In this series of 1592
cases there were 31 cases of hyperaesthesia (2 per cent.).

The following table represents the number of cases in males and females
arranged according to age:

Age. Males. Females.

10 to 20 1 12

20 to 30 1 8

30 to 40 2 2

40 to 50 3

50 to 60 2

Symptoms. — The sensation produced is that of mild pain, fulness, and
burning, appearing soon after meals and continuing during digestion, and
ceasing when the stomach is empty. In some cases the pain is greater,
and may cause nausea and vomiting. The disturbance is often greater
from liquid than from solid food. On account of the discomfort produced.



MERYCISM OR RUMINATION 139

much food is discarded and the patient emaciates and loses stn^ngth. As
has already been stated, some of the cases manifest the symptoms of hyper-
chlorhydria, notwithstanding the fact that thf; acidity may he normal or
subnormal. In these cases the discomfort appears several hours after
meals and disappears on the ingestion of food or the taking of alkalies. C)n
palpation the whole gastric area may be sensitive to pressure but free from
localized painful points. The gastric secretion shows a normal percentage
of free acid, with occasional slight variations. The motor function of the
stomach is not disturbed.

Diagnosis. — This is usually made with ease, provided the symptoms
above described are present together with a normal gastric secretion. Hyper-
sesthesia must be differentiated from ulcer and chronic gastritis. In ulcer
there is a localized painful area and the pain is proportionate to the quality
and quantity of food ingested. In chronic gastritis there is usually a diminu-
tion of gastric secretion, together with the presence of mucus, while the
symptoms of distress do not appear immediately after meals, but some time
later.

Treatment. — In all instances the patient should be required to remain
in bed, at first on a milk or egg albumen diet, and, if possible, combined with
a systematic rest cure, the food being increased gradually, until solid food
is taken. In serious cases, rectal alimentation must be practised for a few
days at the onset. Cold compresses should be applied to the abdomen.
Galvanization is efficacious in some cases. Nitrate of silver may be given
by mouth, grain | (gm. 0.008) in solution, three times daily, or it may be
administered by means of the stomach douche. At times the bromides,
valerianates, and sumbul prove useful, especially in those forms due to
neurasthenia and hysteria.

Attention must always be directed toward the treatment of the underlying
neurasthenia or hysteria. In the cases dependent upon anaemia, iron is
indicated.

Gastric Idiosyncrasies and Abnormal Sensations. — There are
certain individuals who manifest an idiosyncrasy toward certain foods which
when taken produce gastro-intestinal disturbances or some eruption on the
skin. Among the foods causing this class of symptoms are fish, berries,
cheese, etc. Fever, headache, gastric pain, nausea, vomiting, and urticaria
are accompanying symptoms. The writer has constantly noticed the condi-
tion in a certain patient after eating eggs. The only means of preventing
it is to order the individual to abstain from the food that causes this dis-
comfort. There are abnormal sensations met with in neurotic individuals,
such as cold, heat (stomach burn), epigastric pulsations, constrictions, and
sensations of a foreign body in the stomach. The gastric secretion is normal
in all these instances, and there are usually other neurasthenic symptoms
present that indicate the nature of the disorder. The treatment must be
directed to the nervous system in general. For this purpose massage,
electricity, hydrotherapy, and psychotherapy play an important role. The
bromides and belladonna are at times of some value.



MERYCISM OR RUMINATION.

By merycism is meant that condition in which there is a regurgitation of
food into the mouth which is again masticated and then either reswallowed



;^40 DISEASES OF THE ALIMENTARY TRACT

or spit out. This act is accompanied by a more or less pleasurable sensation
and without nausea or effort, and occurs some time after meals. Rumination
in man is comparable to the same condition found in certain animals.
Some authorities, following Damur,^ attribute this disorder to a paresis of
the cardia, while others consider it a reflex neurosis causing a temporary
relaxation of the cardia. Rosenthal holds it is due to an irritation of the
vagus, producing an opening of the cardia through Openchowski's dilator
fibers, occasioning an antiperistalsis of the oesophagus. In opposition to
the view that the condition is due to paresis of the cardia is the fact that the
deglutition sounds remain perfectly normal, and that, if the stomach is in-
flated, the air does not escape. According to Luschka and Arnold, regurgi-
tation is produced by a dilatation of the lower part of the oesophagus. There
are two classes of phenomena aiding in the production of the disorder, one
active, the other passive; the active consists in depression of the diaphragm
and contraction of the muscles of the abdomen, both of which produce a
void in the thoracic cavity; and contraction of the abdominal muscles which
compress the stomach. "The passive phenomenon consists in the elongation
and widening of the oesophagus and the diminution of the lumen of the
stomach" (Spivak).

Etiology. — Heredity plays a role in a number of cases which have been
reported. Rossier has reported this condition in a father and two sons,
and Loewe cites a family in which four members were ruminants. The
writer has observed the condition in a father of fifty-one and a daughter
aged fourteen years. In many cases other neurotic and hysterical tendencies
have been observed. At times the condition is acquired by imitation.
Koerner reports a case of this character in which a governess addicted to this
habit imparted the condition to her two pupils.

Among the cases to which rumination is said to be due are rapid eating,
worry, fear, nervous strain, and sudden shock. A large number of cases
occur among idiots and the insane. The disease is observed more frequently
among men than women. It is found at all ages, and is most common in
highly intellectual men. In the series of 1592 cases of gastric neuroses there
were 24 cases of merycism (1.5 per cent.). The following table represents
the proportion among males and females at various ages:

Age. Males. Females.

10 to 20 . ,3 1

20 to 30 2 2

30 to 40 4

40 to 50 6 1

50 to 60 3

60 to 70 2

Among them were five students, one artist, two lawyers, three physicians,
five clergymen, two merchants, one baker, and one mechanic. According
to Johannessen,^ the regurgitated material shows free acid at the end of
rumination. The state of the gastric secretion varies in merycism. Alt
found a hyperacidity in one of his patients, Boas a subacidity in one case, and
Jurgensen found no free hydrochloric acid whatever. The gastric contents
were examined in 19 of the 24 cases of this series; a normal acidity existed

* De la paralyse du cardia on merycism, These, Berne, 1859.
2 Zeitschrift f. klin. Med., Bd. x, S. 274.



REGURGITATION 141

in 11, hyperacidity in 3; subacidity in 2; anacidity in 1; and hcterochylia in
2 cases. Atony was found in 3 cases, while in the others the motor function
was normal.

Symptoms. — Rumination usually begins as a voluntary process in an
insidious manner; on account of gastric discomfort the food is first n^gurgi-
tated, producing a pleasurable sensation it is again rcswallowed, and finally
the condition of merycism is established as an inv(jluntary process. The
regurgitation usually takes place during the early period of gastric digestion ;
it rarely occurs in the fasting stomach; the remastication continues as long
as the regurgitated food has a pleasant taste; as soon, however, as it be-
comes acid (during the late period of digestion) it is either swallowed at once
or ejected. Rumination may take place after every meal and last for a very
short period of time or extend over hours.

Merycism occurs alone or may accompany other gastric disorders; it is
occasionally associated with atony and dilatation of the stomach. Von
Hacker and Singer have shown that an insufficiency of the card! a and a
dilation of the lower third of the oesophagus may be due to the mechanical
expansion occasioned by the regurgitation of large bits of food. As a rule,
the general nutrition of patients suffering with this disorder is good ; although
when large portions of all meals are not reswallowed emaciation is produced
and the general nutrition becomes markedly affected.

Diagnosis. — This is made, as a rule, without difficulty. It differs from
regurgitation in that in the former condition the food is again masticated,
while in the latter this process does not take place. In vomiting, nausea
and retching are present, while merycism is accompanied by pleasurable
sensations.

Prognosis. — This is often good, especially if the patient makes the effort
to overcome the habit. This condition may extend over a long period of
time, being present occasionally during the entire life, or it frequently dis-
appears for a longer or shorter period, to recur again following some mental
strain or shock.

Treatment. — This consists essentially in an autosuppression. In a cer-
tain number of cases the patient can be taught to overcome this disease. He
should be required to eat slowly and masticate thoroughly; 3 patients of this
series were cured in this way. The state of the gastric secretion occasionally
gives a clue as to treatment. Hydrochloric acid is useful in cases of sub-
acidity, while alkalies are of benefit in superacidity. Intragastric electricity
has been recommended, and was of great benefit in 2 patients. In those
who are much run down and weakened by disease a thoroughly regulated
rest cure with psychotherapy is most effective; 3 patients were cured in
this way. Strychnine and quinine have been recommended, inasmuch as
their taste destroys the desire to remasticate. Lavage has been used by
Johannessen and gavage by Jurgensen.



REGURGITATION.

By regurgitation is meant that condition observed in hysterical and nervous
individuals when food is brought up in small quantities from the stomach
into the mouth and usually ejected. This disorder is much like rumination,
except that food is not remasticated; rumination, however, may develop from



142 DISEASES OF THE ALIMENTARY TRACT

long-continued regurgitation. The following case illustrates this condition:
A. T., a lawyer, aged thirty-five years, has always been in good health;
three years before seeking medical advice he began to regurgitate his food;
this occurred usually after mental strain or excitement; at first the condition
took place exceptionally; finally, it came on at times when the patient found
it impossible to eject the food from his mouth. Pie then began to ruminate,
and has done so ever since. On examination, no organic disease was dis-
covered and the gastric contents were found normal.

Etiology. — ^This is the same as that of rumination. The condition is
usually found in neurasthenic and hysterical individuals, and is at times
voluntary; however, as the habit becomes established it becomes involuntary.
Regurgitation may be occasioned by a nervous strain or shock, or may be
secondary to some other gastric disturbance, such as dilatation, catarrh, or
hyperchlorhydria. This disorder is also largely found in adult males, and
more frequently in individuals pursuing intellectual pursuits. It occurs
more frequently than rumination. In the series of 1592 cases of gastric
neuroses it was present in 32 cases (2 per cent.), 26 being in males and 6 in
females. As to age, 2 were in the second decade, 10 in the third, 7 in the
fourth, 9 in the fifth, 3 in the sixth, and 1 in the seventh.

Among those suffering from this affection, there were two artists, three
students, three physicians, six lawyers, five ministers, four teachers, three
merchants, one mechanic, and one laborer. The gastric secretion is usually
normal. In the series of 32 cases the gastric contents were examined in 29,
and normal acidity was found in 23 (79 per cent.), hyperacidity in 3 (10
per cent.), subacidity in 2 (8 per cent.), and heterochylia in 1 (3 per cent.).
The motor function was usually normal, a slight atony existing in five.

Symptoms. — The onset is gradual, and consists in the regurgitation of
food from the stomach soon after eating and persisting during the entire
period of digestion. It is not preceded or accompanied by nausea, and if
it occurs early in the process of digestion, the regurgitated material has the
same taste as the food swallowed. Later it becomes sour from the mixture
of the acid of the gastric juice. At times this process can be suppressed, at
other times not. The food is not remasticated and swallowed with pleasure,
as in the cases of rumination. Regurgitation may occur after any meal,
or only after certain ones; it may disappear for a time, to recur after some
mental strain or excitement. When large portions of all meals are habitu-
ally regurgitated and ejected, the general nutrition of the patient is likely to
suffer, and he may become materially emaciated and anaemic.

Diagnosis. — Regurgitation is differentiated from vomiting by the
absence of the usual signs of the latter, nausea, retching, salivation, etc.
It is distinguished from oesophageal regurgitation due to stenosis of the
oesophagus by the presence of the gastric secretion in the regurgitated matter.
The difficulty or inability to pass the tube in oesophageal stenosis aids in
differentiating this from gastric regurgitation.

Prognosis. — This is usually favorable, provided the patient will assist
in the act of suppression of the condition; the health of the patient becomes
seriously affected only in those instances in which all food is constantly
regurgitated.

Treatment. — The general condition of the patient should be looked into
and the associated neurasthenia or hysteria treated by appropriate means.
An important factor in treatment consists in teaching the patient voluntary



ERUCTATIO NERVOSA I43

suppression. In emaciated inilividuals tliis form of treatment may be
assisted by a rest cure with isolation. This treatment proved highly satis-
factory with three of this series. The patient should be required to eat
slowly and masticate his food thoroughly. Intragastric electricity is valu-
able in some cases. Strychnine and the bromides have been used with good
results.

ERUCTATIO NERVOSA.

Eructatio nervosa is a condition characterized by periodic or paroxysmal
attacks of noisy belching; it occurs in neurasthenic and hysterical individuals.
The question of the origin of the gas expelled has attracted much attention.
The following sources have been suggested: the fermentation or putrefaction
of food, causing the formation of gases, or the swallowing of air (aerophagia).
It is now generally admitted that the gas which is expelled in eructatio
nervosa is swallowed, and that the air passes into the stomach by an act of
deglutition. The swallowing of small quantities of air is a natural phenome-
non accompanying the deglutition of food. Aerophagia, on the other
hand, occurs as a voluntary act, induced to relieve an uncomfortable sensa-
tion in the stomach or oesophagus by the expulsion of gas that has been
swallowed. Aubert^ considers aerophagia a voluntary act, the mechanism
of which is similar to that of swallowing food, while Bouveret^ ascribes it
to a clonic spasm of the pharynx and divides the eructation into two acts,
the deglutition and the expulsion of air. Convulsive deglutition is accom-
panied by forcing air into the oesophagus and stomach, while expulsion is
occasioned by contraction of the oesophagus expelling the accumulated air
with a loud characteristic sound.

Oser^ ascribes this condition to aspiration, air being suctioned in and
expelled through the oesophagus by expansion and contraction of the stomach.
Linnosier believes that aerophagia is much like regurgitation, and that while
in regurgitation there is an expulsion of food, in aerophagia there is an
expulsion of gas. In some cases, as Ewald points out, the belching has no
connection with the stomach, but originates from the oesophagus by contrac-
tions of the muscles of the neck.

Etiology. — Eructatio nervosa is usually found in hysterical or neuras-
thenic individuals. It is more common in females, and in younger than in
older persons. In the series of 1592 cases of gastric neuroses there were
54 cases of eructatio nervosa (4 per cent.), 42 in females and 12 in males.
As to age, 12 w^ere under twenty, 15 in the third decade, 15 in the fourth,
8 in the fifth, 3 in the sixth, and 1 in the seventh.

While this condition is usually a simple gastric neurosis produced by some
mental excitement, such as anger, worry, or great sorrow, yet it may occur
as a result of some other gastric disturbance. Catarrh, gastroptosis, or a
reflex condition secondary to disturbances of other organs, such as the
genito-urinary organs and heart, may produce it.

Symptoms. — This disorder usually develops suddenly and is accompan-
ied by noisy eructations, which vary in duration and intensity, the paroxysm
lasting from a few hours to days. Frequently there is a period of quiescence

* Lyon Medical, 1891, Ixvii, pp. 463, 510, 547.

2 Revue de Med., 1891, 148. = Die Neurosen des Magens, 1885, S. 137,



144 DISEASES OF THE ALIMENTARY TRACT

between the paroxysms, the attack presentino; no definite relation to tht
quality and quantity of food taken. The number of eructations varies
greatly. In the ease of Cortelliere/ 2500 eructations were produced in one
hour. Spivak^ calls attention to two forms of nervous eructations, voluntary
and involuntary. In the first variety the patient controls the condition, and
is able to inhibit this hal)it at will; in the second, which generally occurs
during an attack of hysteria, he is unable to do so. The attack is spasmodic
in character and cannot be controlled. The paroxysm usually disappears
suddenly and ceases during sleep. On examination, patients suffering
Avith nervous eructations present a rather increased sensibility to pressure
in the epigastric region. These areas on pressure occasion eructations
(aerophagenic points, Bandouin). Examination of the gastric contents may
or may not reveal normal conditions. In this series of 54 cases the gastric
contents were examined in 51; normal acidity existed in 42 cases (82 per
cent.), superacidity in 6 (12 per cent.), and subacidity in 3 (6 per cent.).

Diagnosis. — This is not usually difficult. The characteristic paroxys-
mal attacks can scarcely be mistaken. There is usually an absence of
organic disease; the gastric contents are frequently normal (82 per cent,
of this series) ; the gas expelled was atmospheric air and showed no signs of
fermentation, while the examination of the patient usually revealed other
neurasthenic or hysterical symptoms.

Treatment. — Mild forms of the disorder may be combated by ex-
plaining its nature to the patient and urging him to control the attack.
Sometimes, however, this is difficult, and we must content ourselves with
tlie treatment of the neurasthenic condition. This may be accomplished by
hydrotherapeutic measures, electricity, and change of scene. In persons
who are much run down and have lost much flesh nothing will accomplish
such excellent results as a well-regulated rest cure. At times good results
may be obtained by means of lavage, douching the stomach, or by means of
intragastric electricity. Drugs are usually of little value. Among those
employed in this condition with more or less effect are the bromides,
chloral, codeine, and belladonna.

NERVOUS VOMITING (VOMITUS NERVOSUS).

The act of vomiting is a very complicated process; not only does the
nervous system play a part in the act, but also the muscles that govern the
movements of the stomach. In addition to the centres Q-overning; the stomach
movements there is a coordinated action of the vomiting centre from which
this act takes its origin. The vomiting centre is in the medulla in the vagus
nucleus in close proximity to the centres transmitting impulses to the muscles
of the stomach, diaphragm, and pharynx. During the act of vomiting the
abdominal muscles and diaphragm contract, the pylorus is closed, and
the cardia opened, while the stomach contracts and throws its contents into
the oesophagus. The oesophagus is shortened and widened by the con-
traction of the longitudinal fibers, the epiglottis closes and shuts off the larynx,
while the soft palate closes the nasopharynx. The contents of the stomach
are forced into the mouth by the antiperistaltic contraction of the oesophagus.

• Wiener Allg. med. Zeit, 1885, S. 3.

^ New York Medical Record, April 29, 1905.



NERVOUS VOMITING I45

Etiology. — Vomiting may l)e due to one; of three conditions: to some
abnormal state of the food, to some disease of the stomach itself, or to some
disturbance of the nervous system. The form with which we are here con-
cerned comes under the latter, head, and is termed nervous vomiting. It
may be divided into three groups:

1. Cerebrospinal vomiting due to a lesion or functional disturl)ance of
the nervous centres.

2. Nervous vomiting proper, or vomiting due to neurasthenia or hysteria.

3. Reflex vomiting.

Stiller^ points out the following features as characteristic of this form:
(a) The ease of the vomiting. (6) Its non-dependence upon the quality and
quantity of the ingested food, (c) The capriciousness with which very
bizarre articles of food are retained to the exclusion of others, {d) The
occasional elective vomiting that consists in selecting only one form of food
which is separated from the chyme, {e) The ease with which patients
bear this condition even for a long period of time. (/) The very slight
degree of inanition produced by the habitual vomiting. (9) The extraor-
dinary influence of the slightest external or internal causes that react on the
patient's temperament. (Ji) The occurrence of vomiting frequently, even
on a fasting stomach, and the appearance of this condition independently of
the meal, (i) The presence of other nervous symptoms associated with the
vomiting or alternating with it.

In this series of 1592 cases of gastric neuroses there were 49 of nervous
vomiting (3 per cent.), 34 in females and 15 in males; as to age, 6 were in
the first decade, 6 in the second, 14 in the third, 11 in the fourth 8 in the



Online LibraryWilliam OslerModern medicine : its theory and practice, in original contributions by American and foreign authors (Volume v. 5) → online text (page 18 of 126)