SECTION IV. THE DYNAMIC AFFECTIONS OF THE STOMACH. ALL the disorders of the stomach which present no characteristic pathological anatomy are classified as dynamic affections. The displaced stomach may become diseased, or the diseased stomach may become displaced, and it matters not whether the disease of the stomach be anatomical or dynamic. It may be thought preferable, when a displacement of the stomach exists, to consider, for the sake of simplicity, the dynamic affection as a complication or as an accidental association. In like manner an anatomical disease of the stomach may coexist with a dynamic affection, and the anatomical disease may develop either before or during the course of the dynamic affection. The symptoms are then the expression of the dynamic affection combined with the symptoms and signs of the anatomical lesion. These complex cases should receive recognition, and they are not rare, for disease often defies simplicity and exclusiveness. The dynamic affections have no characteristic pathological anatomy, but their existence is neither destroyed nor excluded by the presence of anatomical lesions of the stomach. The anatomical lesions may coexist with the dynamic affection, but they constitute a separate and distinct disease. Some of the dynamic affections may be described as "neuroses of the stomach"; some of them are "functional disorders"; but the dynamic affections of the stomach may be in their nature neither the one nor the other. Practically, this is one of the most important sections of the pathology of the stomach. Here disease presents itself in its genesis, and the subsequent evolution, unless arrested by proper treatment, may be represented by an inverted pyramid. The trouble grows along deviating lines, and becomes more and more irresistible. The physiological functions, one after the other, are enlisted with the forces which make for disease. The disease should be recognized and crushed in its preanatomical stage if permanent damage is to be avoided. This is the period when treatment will show its greatest power and give the most brilliant results. A general characteristic of these affections is the specialization of the unhealthy variation. The disease dissociates the functions of the stomach and affects some one of them persistently and in a particular manner. Now it is a disorder of secretion or a motor trouble; now it is a painful increase of general sensibility or a particular sensation of the stomach which demands attention. Digestion may be chemically perfect or the stomach may churn and evacuate its contents unconsciously, the appetite being good. One function is persistently disordered; the others remain intact. The affection may be paroxysmal or intermittent, but the variation from the normal always recurs in a particular case in the same manner. In the course of the disease, however, the tendency is to spread to the other functions, and the primary dynamic affection may be supplanted or overshadowed by another. The true dynamic affections of the stomach never appear “like a panorama with ever-changing scenes." Such disorders are symptoms and nothing more. To consider the variable gastric expression of a disease of another organ as a distinct morbid entity is manifestly erroneous. The gastric disturbances cease when the exciting disease is cured. A true dynamic affection is capable of an independent existence, be it primary or be it secondary. The manner of development is often peculiar. Suddenly beginning, without any dietetic error, and persisting for a variable length of time, the end may be no less sudden; or slow in its commencement, progressing by leaps, the termination comes when least expected. The unhealthy variation is not, or may not be, persistent, but intermittent. Rapid changes for better or for worse, without a perceptibly adequate cause, are characteristic. This obscure peculiarity is generally a contribution from the abdominal sympathetic, or from the brain, or from the general but temporary state of the body. The dynamic affections may be in no close relation with the digestive act or with the alimentation. The symptoms may exist only or chiefly during the digestive period in some of the cases; but it is also true that the symptoms may occur when the stomach is empty. Digestion as a chemical process may be perfect, and the digestive disorder may exist only because the patient suffers and complains during the period of functional activity of the stomach. A large, a small, a mixed, and a simple meal may be equally well or badly digested. The physical state of the food may be of no greater influence than in health. There may be no constant relation between alimentation and digestion on the one hand and the symptoms on the other. Nutrition may be well preserved, and sometimes even in spite of insufficient alimentation, although subnutrition (pain, vomiting, starvation) is sometimes as marked as in the grave anatomical diseases of the stomach. These peculiarities are often due to the existence of a trouble in some other part of the body which selects the stomach as the center of its manifestation. The dynamic affections of the stomach develop preferably in a particular soil. This is the neurotic or nervous temperament or constitution. Some persons are born with a delicate and overwrought nervous system, and others acquire it by the mode of life, by bad habits, and by too exclusive and excessive mental or moral development. The resulting condition is unstable nervous equilibrium-the forerunner often of the nervous affections of the stomach. Most of these affections are more frequent in women than in men, the proportion being about one to ten in youth, and gradually changing until the sexual difference becomes much less (about one to two) during the last third of life. The chief exciting causes in men are mental overwork and the reverses of fortune. The dynamic affections are common among women near the end of the social season in large cities, but are infrequent among country girls; for in spite of the pure air and sunshine of the country and the freedom from the withering touch of "culture," anxiety and sorrow and disappointment, and disorders of menstruation, of reproduction, and of lactation, have the same influence in the hut as in the palace. The predominance in women may be explained in part by their mode of life, their delicate organization, and their peculiar diseases. The marked influence of the mind and feelings on the functions of the stomach is a fact long established by observation. Physiology and anatomy have given no satisfactory explanation of this intimate relation of the central and sympathetic systems; but the recent studies of Kölliker and others have thrown some light on this obscure matter. The sympathetic is a richly ringed chain of unipolar and multipolar cells connecting with each other and directly and indirectly with the central cells of the cerebrospinal system. The units of both systems have psychic and somatic functions. As regards the central nervous system, the sympathetic cells are of two kinds the dependent and the independent. The independent ganglionic cells are chiefly motor, and innervate the whole involuntary muscular system, giving tonicity, producing contractions of the muscular fibers, and probably regulating also the caliber of the blood-vessels. Some of these cells are probably sensory, and influence secretion. The dependent cells. are in part sensory, and convey, particularly in disease, the indistinct visceral impressions to consciousness; and in part are motor, and enable the central system to influence indirectly, through the ganglia, both the involuntary muscles and the secreting glands. This discloses, in brief, the anatomical basis of the fact long known to the clinician-the influence of the mind and feelings on the functions of the stomach. In many of the dynamic affections of the stomach the nervous system is disturbed out of all proportion to the local trouble, and insomnia, disorders of sensation, tachycardia, faintness, dilatation of the pupils, hot flushes, and blushing are very common. In health the organ does its work silently, but when the sympathetic is irritable, digestion produces an indefinable discomfort, and distant associated disorders develop. The symptoms are not characteristic, and they may be very similar in the anatomical diseases to the manifestations of the dynamic affections. In the one, however, is the constant and controlling and palpable anatomical lesion, and in the other is the invisible abnormality, recognizable only by its effects. CHAPTER I. THE SENSORY DYNAMIC AFFECTIONS. I. BULIMIA. THE nervous affection of the stomach characterized by a sudden, imperative desire for food, and occurring in paroxysms and more frequently than in health, and greater than the needs of nutrition, is known as bulimia (Bʊʊę = ox, and λιμός hunger). Other names for the same affection are hyperorexia (únép excessive, and pets appetite) and (ὑπέρ cynorexia (zów dog, and pets appetite). = = = ὄρεξις = = Etiology. Bulimia is most frequent between the ages of fifteen and forty, and in the female sex. It occurs as a symptom or association of some cases of ulcer, of functional adenohypersthenia, of hypersthenic gastritis, and, very rarely, of carcinoma and of obstructive and myasthenic retention. In mental diseases, and in organic cerebral troubles, a noteworthy percentage of the cases occur. Hysteria and neurasthenia are responsible for some of the cases. Disease of the male and female sexual organs may excite the affection. Syphilographers report some cases occurring during the third and sixth months of syphilis. Basedow's disease, intestinal worms, pulmonary tuberculosis (first and second stages), and pregnancy are found among the causes. Rupture of the thoracic duct, tuberculosis of the mesenteric glands, menorrhagia, intestinal fistula, and intestinal hypermotility may cause excessive hunger; but it is not evident that the desire for food is out of proportion to the needs of nutrition. Bulimia may be central, reflex, nutritive, symptomatic, and idiopathic. As an unassociated affection of the stomach, it is most common in the neuropath. Pathology. The pathology of the affection is obscure. Irritation of the encephalic hunger-center seems a plausible explanation of the cases due to diseases of the brain and of nutrition. Other cases appear to be due to the irritation of the nerve-endings or centers of the vagosympathetic. Hunger is normally excited by the action on the medullary hunger-center of the changed quality or quantity of the blood. |