MONTHLY. JANUARY, 1901. THE GASTRIC NEUROSES. BY WM. C. GOODNO, M.D., PHILADELPHIA. EVEN Our special treatises give insufficient attention to the neuroses of the stomach, if one may judge from the frequency of stomach disorders of this class as compared with other stomach affections. We meet troublesome so-called functional disorder of this organ much more often than organic disease. As, in some cases of functional disorder of the stomach, serious organic change is the terminal event (ulcer, for instance), it is hardly possible to draw a hard and fast line of demarcation between functional and organic disease of this organ as viewed from the clinical standpoint. The intractable character of some stomach neuroses is another reason for the full and more thorough treatment of these affections. It appears to me that one of the most important lessons developed by an intimate acquaintance with neurotic affections of the stomach is their close relationship to and dependence upon some disorder of the general nervous system. This fact is often overlooked because of the absence of striking symptoms of a general character. These general symptoms are usually of the type called neurasthenic, i.e., symptoms developing out of exhaustion of the nervous system, their especial character depending upon the portion or portions of the nervous system involved. Irritability is the result of exhaustion of nerve centres; indeed the terms are almost synonymous, clinically, when VOL. XXXVI.-1 employed in relation to this system. Even when symptoms of this class are not obtrusive, one can often discover, upon thorough examination, evidences of slight irritability all along the lines of the cerebro-spinal and sympathetic systems. Another very practical fact is the relationship of certain gastric neuroses to diathetic conditions, especially the gouty. The frequent dependence of neurotic dyspepsia, as well as the underlying neurasthenia, upon gout, I have often demonstrated to my entire satisfaction. By gout I mean those varying symptomatic and pathological conditions associated with the excessive production of uric acid-not necessarily arthritis of the great-toe joint. Notable in this group are muscular pains, itching of the skin without eruption, urticaria, iritis, neuralgias, neuritis, arterio-sclerosis, high arterial tension, valvular and muscular heart diseases, renal sclerosis, etc. The importance of a proper recognition of this relationship will be appreciated when one comes to deal with the therapeutics of the disorder. Syphilis is a much more frequent factor than is generally believed. The neuropathic syphilitic with a gastric neurosis is a very ordinary patient. We must often guess at the existence of the syphilis as it is so frequently denied, or, on the part of the patient, honestly believed not to exist. Without a recognition of the gout or syphilis, or perhaps both, as the cause of the stomach trouble, little success will attend treatment. The form of gastric neurosis I have most frequently met is one of increased secretion with motor excitability. The principal complaint is of discomfort during the digestive process, which symptom may continue into the period of stomach emptiness, or be much increased at this time. If this is the case, eating may relieve the pain, and the patient may find himself ingesting a larger quantity of food than his nutritive state demands, as well as affording the stomach no time for rest, either of which favors a continuation of the disease. The evidence of continuous secretion is increasing discomfort with the emptying of the stomach, consequently diminished comfort before the mid-day and evening meals; and of even more importance is a night aggravation. Those who have heretofore been good sleepers become restless, wakeful, and distressed, usually four to five hours after the evening meal, and find it necessary to rise and eat in order to secure relief. Patients suffering with this type of gastric disorder often lose flesh rapidly—so rapidly, in fact, as to lead to a suspicion of malignant disease. The appetite is often excellent, as already noticed, and it may be with difficulty that it is properly restrained. The symptoms detailed, and many others belonging to this gastric neurosis, are the result of the irritant influence of an excess of hydrochloric acid in the stomach, and caused by an unhealthy stimulation of the nerves presiding over gastric secretion. We have seen that this excess may be related to the digestive period only, or the irritant fluid may continue to be formed during the empty state of the organ, when normally it should be at perfect rest. The influence of these two forms upon the symptomatology is apparent. The form represented by continuous secretion, known as Reichmann's disease, has been considered as practically incurable by some of our ablest specialists. The accompanying motor symptoms are interesting and variable. In all cases there is an acceleration of the digestive process, due not only to the large quantity of irritating gastric juice, but to the rapid emptying of the stomach as the result of increased motor irritability. Delayed discharge occurs in some cases, and is due to a state of spasm of the circular muscular fibres at the pylorus. This may be attended by energetic efforts upon the part of the organ to disgorge itself. I have recently met a remarkable instance of this sort. The patient was very thin, and it was possible to make out rhythmical efforts upon the part of the stomach, extending from left to right, and so forceful as to raise the abdominal wall and give the appearance of a moving phantom tumor. The pylorus could be felt, and at first suggested a neoplasm; but there was a condition of greater and then less tension, altering the feel of the part and suggesting spasm. The stomach was somewhat dilated and prolapsed. Spasm may also occur at the cardiac orifice. In such cases there may even be sufficient obstruction to interfere with the free passage of a bougie or tube, but more frequently the patient has sensations of a peculiar kind referred to the cardiac orifice. It may be a sense of a lump, a slight smarting with a sense of constriction, but, perhaps most frequently, sensations which extend along the esophagus to the throat. The same spasmodic action is undoubtedly developed in the œsophagus of some patients, leading to a sense of a ball low in the throat, with a feel |