Clinical Review. MARCH, 1904. Original Articles. HYPOCHLORHYDRIA NERVOSA.*-By WILLIAM H. WASHBURN, M. D., Milwaukee, Wis.; Professor of Medicine in the Wisconsin College of Physicians and Surgeons; Physician to St. Joseph's, Milwaukee County, and Mt. Sinai Hospitals. The gastric neuroses are among the most common as well as the most perplexing disturbances of digestion. As a consequence the victims are very prone to go from one physician to another in a search for relief which is often vainvain largely because, very commonly, they imperfectly carry out the instructions of their medical attendant, but not infrequently owing to the inefficient methods of treatment and inaccurate diagnosis. There are certain organs of the body which depend for the due performance of their functions upon certain nervous influences. These organs are those often referred to as organs of vegetative life, the heart, the blood-making organs, the gastro-intestinal canal, etc. A disturbance of innervation may easily be supposed to affect very decidedly the functions of these organs. The fact that nervous influences may produce a decided effect upon the digestive tract is within the experience of almost every one, either in the direction of causing anorexia, delaying digestion, or inducing catharsis. Read before the Milwaukee Medical Society, January 26, 1904. When we remember that the functions of the organs of digestion are completely governed by the nervous system and that their every act whether of excess of defect is, in a large measure, due to nervous influences, we shall come to appreciate in a high degree the fact that gastric neuroses are important and frequent disorders. Dr. Goodhart, in a lecture "On Common Neuroses" is said to have made the following statement: "If I were going to write a book on indigestion I should first devote myself to a volume on diseases of the nervous system." And also "It is no great exaggeration to say that there are only two forms of indigestion: that produced by over-eating and drinking, and that due to a failure of nervous power." The effects of nervous influence upon secretions in general are indicated by the fact often observed that fright or mental anxiety causes the salivary secretion to become arrested, that sudden perspiration or abundant secretion of urine may be caused by mental emotions of various kinds, and that the secretion of milk may be entirely arrested by fright. The teaching of the earlier physiologists to the effect that secretion of gastric juice is excited by the application of indifferent irritants such as glass, stones, etc., has been shown by recent investigation to have been erroneous. These substances do in point of fact excite a flow of some kind of fluid from the gastric walls, just as the presence of a foreign substance under the eyelids causes a flow of tears, but this fluid is not a gastric juice capable of digesting food substances. Bidder and Schmidt, Pawlow and others have demonstrated experimentally that the secretion of gastric juice may be excited reflexly by the sight or smell of food of an appetizing kind. The importance of appetite as a factor in gastric digestion has long been recognized, but it is only within the past year that an adequate explanation of this circumstance has been evolved. Pawlow, as a result of his experiments, has distinguished between a chemical gastric secretion and a psychic secretion. The former is the ordinary gastric secretion; the latter is a secretion stimulated by appetite. This latter secretion is far more efficient as a digestive fluid than the secretion which results merely in obedience to mechanical or chemical irritation of the gastric mucous membrane. We have here an explanation of the fact that food consumed in satisfaction of an obtrusive and imperative appetite, even in cases of such severe diseases as typhoid fever, rarely harms the patient, and we have scientific grounds for humoring the desires of most patients in the matter of diet. The wisdom of consulting the appetite and taste of the patient is further indicated by the remarkable discovery of Pawlow, that for every kind of food the stomach pours out a special kind of secretion. In other words, the gastric mucosa has the power of distinguishing between different kinds and varieties of food stuffs, and providing a special or specific kind of secretion to meet each case, in the same way that other organs of the body have the power of elaborating specific germicidal substances and antitoxines for various bacteria and their products. Leube, who has written much upon gastric neuroses and who wrote the article on Diseases of the Stomach in Ziemssen's Hand Book, has divided the gastric neuroses into three groups, as follows: (1) Cases in which the sensibility of the organ is either increased or reduced. (2) Cases in which the contractility of the organ is increased or reduced. (3) Cases in which the secretion of the organ is either increased or reduced. With the first two of these groups we have nothing to do at present, this paper dealing entirely with the last group, comprising those cases in which there is a deviation from the normal in the amount of the gastric secretion and this in the direction of a diminution. For the purpose of illustrating some of the phases of this group of cases the following clinical histories are reported: Case I.-H. E., aged twenty-nine years, by occupation a foreman machinist. The family history in this case is unimportant. The father, who is still living and aged fiftyeight years, has some chronic gastric disturbance the nature of which is not known, and the mother is somewhat subject to rheumatism. The patient himself has had no previous iHness and has never been subject to either headaches or neuralgias. The patient's present illness began about six months ago. Just prior to this time the wife of this man had suffered from a severe illness which caused him a good deal of mental anxiety and interrupted his sleep very much. The first symptoms complained of were sensations of gastric distress after eating. The sensation was one of distension and weight, but often it amounted to a dull, aching pain which began from about forty-five to sixty minutes after each meal. The sleep became broken and the bowels became constipated. As the case progressed the symptoms became more severe; the pain and distress more intense; the insomnia and constipation more pronounced. The patient became very nervous, restless and mentally despondent. He complained that meats caused greater distress than any other kind of food, and there developed a great disinclination for any active exertion. On examination the patient appeared fairly-well nourished, weight 142 pounds, he appeared selfconscious, nervous and excitable. The pulse became rapid under examination but soon fell to a normal rate. On palpation slight tenderness over the epigastric region was demonstrated localized just below the ensiform cartilage and about the umbilicus. The stomach contents were removed on several occasions after a test breakfast and the total acidity and free hydrochloric acid present were estimated by titration. The total acidity varied from 20 to 26 while the free hydrochloric acid ranged from 8 to 12. A diagnosis of hypochlorhydria nervosa was made and the patient treated accordingly. Case II-Mrs. A., aged twenty-three years, mother of two children, the youngest being two years of age. The pregnancies and menstrual functions have been normal. Family and previous personal history negative. Domestic troubles having arisen during her second pregnancy she suffered much from mental worry and anxiety and began to be troubled with gastro-intestinal disturbances. These disturbances were of the same character as those detailed in the preceding case, and were of about two years' duration at the time of her first visit to my office. The nervous symptoms were particularly well marked. Occasional attacks of migrainous headache, insomnia, mental despondency, great nervousness, sudden noises causing great agitation and often crying, were the chief of these symptoms. In appearance she was tall and rather spare in build but with red cheeks, weight 125 pounds, height about 5 feet 8 inches. The bowels were constipated, the appetite poor, and the patient became easily fatigued. During examination this patient exhibited a great capacity for describing minute details of her illness and for noting sensations of an abnormal or painful sort in various parts of the body. The stomach contents were removed on several occasions after test breakfasts and the total acidity and free hydrochloric acid present estimated by titration. The total acidity varied from 18 to 30 while the amount of free hydrochloric acid ranged from 10 to 15. A diagnosis of hypochlorhydria nervosa was made and the case treated accordingly. Case III.-A. P. T., aged fifty-one years, by occupation a stationary engineer, but for several years following various other occupations. This man comes from a decid |