41 Dyspepsia
Derived from Greek roots meaning “difficult digestion,” dyspepsia has long served as a synonym for indigestion, one of the most common - and etiologically varied — of human miseries.
It has thus been as regularly employed to label the symptoms of diverse organic disorders as to identify a distinct disease, with the result that some gastroenterologists find the word uselessly elastic: “This is really a meaningless term because it has so many meanings.” The majority of practitioners, however, have reached a consensus to use dyspepsia to denote either the ailment of functional indigestion or the symptoms of peptic ulcer.Distribution and Incidence
Peptic ulcer dyspepsia is rare in people under the age of 20, but by age 30, 2 percent of the males and 0.5 percent of the females in a population have developed the condition. For men, the incidence increases steadily with age, reaching a peak of around 20 percent in the sixth decade of life. The incidence for women remains low, about 1 percent, until menopause, after which it climbs as rapidly as in men. A morbidity rate of nearly 14 percent has been reported in women in the age group 70 to 79. Death from peptic ulcer occurs three times as often in men as women.
The prevalence of functional dyspepsia, by contrast, is uncertain. Having no distinct pathology, being neither communicable nor reportable, and only occasionally motivating its victims to seek medical help, it does not generate statistics. The widely shared clinical impression is that women are affected more than men, and people under the age of 40 more than those over age 40. Functional dyspepsia is also believed to be more prevalent in developed countries.
Epidemiology and Etiology
Although the most common, peptic ulcer is hardly the only organic source of dyspepsia. Esophagitis; hiatus hernia; gastritis; carcinoma of the stomach, colon, or pancreas; Crohn’s disease; disease of the biliary tract; chronic nephritis; or any of several other conditions, including pregnancy, can produce indigestion.
In approximately half of the cases of dyspepsia, however, no lesion can be found, and symptoms arise from derangements of motor, secretory, or absorptive functions, especially delayed gastric motility, esophageal reflux, and hyperacidity. This functional indigestion has been related to physical stress (aerophagia, fatigue, dietary indiscretion) and, more commonly, to nervous stress. Anxiety, anger, frustration, and other indications of emotional turmoil can significantly impair digestive function in sensitive or tense individuals (a similar psychic component - chronic tension and repression of emotion - has been implicated in peptic ulcer). Because the symptoms of functional dyspepsia are virtually identical to those of peptic ulceration, the condition has also been termed X-ray negative dyspepsia and nonulcerative dyspepsia; the term endoscopy-negative dyspepsia has been proposed as well in recent years.Clinical Manifestations
That most eminent of Victorian dyspeptics, Thomas Carlyle, likened his torment to “a rat gnawing at the pit of the stomach.” Dyspepsia’s victims still complain of gastric pain, along with fullness or heaviness in the stomach, nausea and vomiting, belching, flatulence, and/or acid eructations. Finally, dyspeptics may suffer heartburn, a caustic pain behind the sternum that sometimes climbs into the throat, resulting from esophageal reflux. Heartburn is the special affliction of those with sliding hiatus hernia when they bend or lie down.
History and Geography
Great suppers do the stomach much offend, Sup light if quiet you to sleep intend.
So advised the author of the medieval Regimen Sanitatis Salernitanum, and no doubt his words were already age-old wisdom. Yet if indigestion has plagued the human race for as long as it has eaten, and no less hoary an expert than Hippocrates described its tortures, it was not until the nineteenth century that dyspepsia attained a prominent standing in pathology. Previously it was regarded as a too common but predictable and temporary discomfort brought on by immoderacy in diet.
Alexander Pope’s scolding couplets characterized pre-Victorian views (Davis 1966):[T]he stomach cramm’d from every dish, A tomb of roast and boil’d, of flesh and fish, Where bile and wind, and phlegm and acid jar. And all the man is one intestine war.
The sources of intestinal turbulence came to appear more numerous during the early nineteenth century. The distrust of sensuality that marked the Victorian ethos more than once expressed itself in the blaming of physical decline on moral perversion. And because dyspepsia was so often found in patients guilty of some excess and just as often lacked any apparent organic basis, physicians found it easy to explain the condition on the basis of any aberrant behavior that might plausibly have upset the patient’s system. Gluttony, of course, was still a sin, and doctors had no quarrel with Ambrose Bierce’s (1911) definition of a glutton as “a person who escapes the evils of moderation by committing dyspepsia.” They generally added to gluttony the bolting of inadequately chewed food, a practice that many charged was epidemic in the dining rooms of ever-in-a-hurry America. Nevertheless, a nineteenth-century attack of dyspepsia was just as likely to be blamed on the abuse of spirits or tobacco, to the reading of French novels, or to masturbation or “excessive venery.”
The nineteenth century’s list of dyspepsia’s causes was also lengthened by examples of fast living of a second type, that of the mental and emotional excitation accompanying the bustling anxiety-filled life of the industrial city. A. P. W. Philip’s Treatise on Indigestion (1825), which recommended against excessive venery, also warned, in the same breath, of the dangers of “too long application to business [and] severe study.” Such caveats would appear with increasing regularity in medical texts and home health guides alike until finally becoming mandatory with the ascension of neurasthenia, or nervous exhaustion, to the position of the disease of modem society during the last quarter of the century.
George Beard, neurasthenia’s prophet, declared “delicacy of digestion” to be “one of the best known and first observed effects of civilization upon the nervous system,” and his message that dyspepsia was on the rise as the special complaint of the modem brainworker and risk-taker met with universal acceptance. The 1873 proclamation of The Household Physician by Ira Warren and A. E. Small was not hyperbole for the time:Dyspepsia is a disease of civilization. Savages know nothing of it. It is the costly price we pay for luxuries. All civilized nations suffer from it, more or less, but none so much as the people of the United States. It is here, in the new world, that the disease has become domesticated, and we, as a people, who have threatened to monopolize its miseries.
The neurasthenia era, furthermore, defined “modern dyspepsia” as a nervous complaint that gave as good as it got, one that having originated in anxiety, then generated more anxiety, as well as irritability, depression, and other neurotic suffering in addition to mundane heartbum. This virtual equation of dyspepsia with nervousness led to its being defined almost exclusively as a functional condition produced by stress.
During the first half of the twentieth century, that same stress of coping with civilization seems to have brought about an abrupt increase in dyspepsia of organic origin as well. Between the two world wars, peptic (particularly duodenal) ulcer grew from a rarely encountered condition to a significant cause of disability, reaching a high point in the 1950s, then declining sharply to the present. This pattern has suggested that ulcer dyspepsia is less a disease of civilization than a condition of adjustment to civilization; the first generations to confront the pressures of urban-industrial life are buffeted more heavily than those born after the turbulent transition period. Functional dyspepsia, of course, might be expected to decrease for the same reason, yet its domain has been diminished still more rapidly by the X-ray and the endoscope, improved diagnostic techniques having transferred many cases of “nervous indigestion” to peptic ulcer’s column.
Advances in understanding of the neurohumoral mechanisms that regulate the digestive tract and the biochemical basis of emotion, furthermore, promise to provide organic interpretations for the dyspepsias now identified as functional. As a consequence, the very term “dyspepsia,” historically associated with nervous, nonorganic illness, is becoming antiquated. In the last decades, medical writers have taken to encapsulating the word in quotation marks to call attention to its quaintness, and inserting it into the index only to be followed with “see indigestion.”James Whorton
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