A CLINICAL AND PATHOLOGIC REPORT OF A CASE OF PROGRESSIVE DEMENTIA

CHARLES K. MILLS
1898 Journal of the American Medical Association (JAMA)  
there is any failure in the general health or recurrence of the neurasthenia. In one of the cases which I have reported the rumination ceased when the patient's general health had improved and did not return as long as he was under observation, although the attacks of migraine, for which he had originally come for treatment, persisted. There are practically no therapeutic measures of use in these cases, with the exception possibly of nerve sedatives and tonics. If there is gastric indigestion
more » ... stric indigestion this must be corrected. Lavage is an important procedure in the management of cases of rumination dependent upon indigestion. The diet should be carefully regulated, and what is of great importance, the amount of liquid taken with a meal should be reduced to a minimum. Thorough and complete mastication of the food is also an essential matter in this disease. The patient should be trained to control the inclination to regurgitation of the food. Hypnotic suggestion will probably prove useful in the management of such cases, although I have seen no record of any treatment by this measure. Hammond stated that the patient whose case he reported before the American Neurological Association was mentally defective, and with a view of relieving the psychical condition he trephined the skull, first in one parietal region and then in the other. The merycism ceased after the first operation and had not returned at the time that the case was reported. In this instance, no doubt, the checking of rumination was due to suggestion. DISC0SSION. Dr. James Hendrie Lloyd-This would seem to be a neurotic state allied to the condition of hysteric vomiting. I do not think in hysteric vomiting it is common to have true rumination, and there is constant attempt at retching-probably more a condition of esophagismus, a tendency to regurgitate through the esophagus. In an idiotic child that came under my observation there was regurgitation from the mouth, the food being disgorged, reintroduced into the mouth and eaten over again. The procedure resorted to in the case reported by Dr. Hammond seems hardly worthy of being followed. The treatment is by suggestion, and we can get ideas into people's skulls without making holes to put them in ! Dr, Charles H. Hughes-I think the better treatment is by digestion rather than suggestion. I have been accustomed to associate the majority of these cases with conditions of dyspepsia in persons of neuropathic diathesis. I have seen these cases in neurasthenia. When I first read Trousseau on "Apepsia Nervosa," and subsequently gained a great deal of experience with nervous dyspeptics, 1 found that there were many of these conditions in which regurgitation took place and in some instances the food was rechewed. Dr. Sinkler-I think the point is that rumination is not a condition of indigestion ; the food when returned is sweet and pleasant. As soon as it becomes fit for intestinal absorption it passes out of the stomach and ceases to be returned to the mouth. Dr. Lloyd's remarks remind me that several cases of rumination have been reported in idiots. There is one suggestion that can be made in regard to this habit, that it is a form of digestive perversion like sexual perversion. I think a lack of thorough mastication is probably one of the primary causes. The case under consideration presents the following history: Patient aged 64 years; married; has had five chil-dren, three of whom are living and in good health. She was always of a nervous, somewhat irritable, temperament, but mentally bright and clever, with linguistic and other accomplishments. After the birth of her first child she had an attack of mania; when about 23 years of age she had an attack of chorea which lasted several weeks. At 35 years of age, apparently as the result of unusual worriment owing to sickness, she became more irritable and her temper was afterward capricious. For about ten years previous to her death she was subject to spells of excitement which almost amounted to transient derangement, but she had no tangible delusions, although she had a tendency to persecutory ideas, frequently believing without cause that she was abused and ill-treated by others. During the same period she began to show a decided amnesia for names, this gradually but surely increasing, so that for several years before her death it was almost impossible for her to recall the names of acquaintances, and occasionally of objects with which she was familiar. She had, however, no motor aphasia and could converse and write well, having an unusual facility for letter writing until within three years of her death. ?Lu4-^A A Fig. 1.-Long pyramidal cells, showing moniliform swellings of basilar and apical dendrites. Region of second frontal convolution. Up to this time she had been less vigorous, but always attended to her business affairs, kept house and performed what other duties she had to do. During this third year previous to death she became so unreasonable that it was impossible to live peaceably with her, she having at times outbursts of uncontrolable passion. General failure of memory was first noticed about two years before death, during which time she became half bedridden. In January, 1895, she had what appeared to be an attack of grippe; there was rise of temperature and she Complained of intense pain in the right side of the head, also of pain in the back, extending down the legs in the course of the sciatic nerve. This attack lasted about a week and she apparently regained her usual health. In March of the same year she had a second attack, which was also accompanied by intense backache and pain in the head, the latter pain being persistent and always referred to the right parietal region. The patient did not improve as she 1 An abstract of a portion of this paper, with other illustrations, has been published as a "Preliminary Report," in the
doi:10.1001/jama.1898.72440670025002e fatcat:fcbqwkwazfhx3fd7t2uf4jjbmi