201 gastro-oesophageal reflux, and oesophageal regurgitation: is effortless and repeated without pain or nausea (indeed it may give the subject so...

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gastro-oesophageal reflux,


oesophageal regurgitation:

is effortless and repeated without pain or nausea (indeed it may give the subject some satisfaction); the regurgitated bolus is of a limited volume, usually filling the mouth; although the food comes from the stomach, its taste remains pleasing, in some cases more so than when first eaten; and in general, rumination is involuntary and cannot be suppressed. It typically starts within thirty minutes of finishing a meal and continues for an hour or more. In some merycoles rumination ceases as the food starts to taste unpleasant or acidic. Rumination is encountered in three clinical settings7-9 - emotionally deprived or mentally retarded infants; mentally retarded adults; and a smaller but well-described group of intellectually intact adults. There is a familial disposition,4,1o,l1 particularly in the last group. The clinical background largely determines the importance of the syndrome. In the otherwise normal adult rumination is at its worst a social handicap and at its best a pleasurable, although usually surreptitious, act. In individuals with mental subnormality, however, the condition is a serious threat to nutrition and in some institutions mortality rates of 20% have been reported.8 In adults of normal intellect the disorder is uncommon, but doubtless there are more merycoles than generally perceived. The 17th and early 18th centuries saw numerous reports of rumination in man, after which little attention was paid to the subject until a sudden rekindling of interest at the turn of the century p2 Some of these latter descriptions were of physicians who gave very precise accounts of their symptoms; the most celebrated was perhaps Edouard Brown Sequard.12 In the majority there was some form of associated neurotic or neuraesthenic trait with symptoms worsening in response to the psychological the



During most of this century rumination in adults has again faded into obscurity, with only sporadic casereports" until the past few years. 11,13 Levine and colleagues" at the London Hospital reported nine patients in 1983, emphasising that the symptoms may pass unrecognised for years; several of their cases were discovered only by family studies. In their experience the habit was benign but not infrequently associated with minor psychiatric problems such as anxiety or obsessional personality. A report from Amarnoth and co-workers13 at the Mayo Clinic reaffirms the association with affective disorders and again points out how frequently the diagnosis is missed and inappropriately investigated and treated. Fifty-one merycoles were seen at the Mayo Clinic between 1975 and 1985, twelve of whom were studied by manometry. A characteristic manometric pattern was observed. Pressures were recorded at eight sites between the gastric antrum and proximal duodenum by means of a perfused multilumen tube and gastro-oesophageal regurgitation was recorded by a separate oesophageal pH

monitor. There were motility and there was

abnormalities of oesophageal disruption of the normal phasic migrating motor complexes, but synchronous pressure spikes were recorded at all sites coinciding with episodes of regurgitation. These findings confirm the long-held supposition that rumination is induced by an increase in intra-abdominal pressure forcing food out of the stomach into the gullet and is not due to any intrinsic defect of upper gut motility. The Mayo study documents the pathophysiology of rumination but such complex tests are not necessary for diagnosis. As with other functional gastrointestinal disorders, history, observation, and awareness of the condition are all that is required. Treatment has to be tailored to the patient. In emotionally deprived infants close holding and surrogate mothering have achieved good results.7,9,14,15 In mentally retarded patients the problem is more difficult in all age groups, but behavioural, satiation, and aversion techniques have all met with some success.7,8,14-16 Many merycoles of normal intelligence are quite content with their eating habits; those who find it embarrassing or unpleasant can sometimes unlearn the condition by behavioural therapy or biofeedback techniques.7,9,15 More radical therapies have been expounded; Hammond in 189417 cured one merycole by bilateral trephining, but as James Hendrie Lloyd18 wisely noted four years later: "the treatment is by suggestion and we can get ideas into peoples skulls without making holes to no


put them in".

INFECTIONS OF THE DURAL VENOUS SINUSES SEPTIC thrombosis of the dural venous sinuses usually affects the cavernous, lateral, and superior sagittal sinuses, the cavernous most commonly.1 In the. pre and the early antibiotic era (before 1960) sepsis of the cavernous sinus often followed infections of the medial third of the face, especially around the nose, in what was indelicately termed the "picking" area; bacterial pathogens reached the cavernous sinus via the facial veins. Otitis media was the second most common site of primary infection. A history of a predisposing illness was infrequent. With the introduction of antibiotics the incidence of septic thrombosis was greatly reduced, and cavernous sinus thrombosis is now increasingly associated with protracted illnesses such as chronic sinusitis. Infections of the sphenoid and ethmoid air sinuses have become major risk factors; spread to the cavernous sinus occurs via the emissary veins draining the air sinuses or directly. Although Staphylococcus aureus and streptococci are still the most common bacterial pathogens, anaerobes are becoming more important,2 probably reflecting the changing trend in predisposing factors and 14. Whitehead

5 Long CF. Rumination in man. Am J Med Sci 1929; 178: 814-22. 6 Brown WR. Rumination in the Adult Gastroenterology 1968 54.5.933-39.


Holvoet JF The etiology and management of rumination and psychogenic vomiting. a review. Monogr Am Assoc Ment Defic 1982, 5: 29-77. 8 Kanner L. Child psychiatry Springfield, Illinois: Charles C. Thomas, 1947. 214-20. 9. Whitehead WE, Schuster MM. Behavioural approaches to the treatment of gastrointestinal motility disorders. Med Clin North Am 1981, 65: 1397-411. 10 Runge EC. Three cases of hereditary rumination The Boston Medical and Surgical Journal. 1895. CXXXII. 515-16 11. Levine DF, Wingate DL, Pfeffer JM, Butcher P Habitual rumination: a benign disorder. Br Med J 1983; 287: 255-56. 12 Kanner L Historical notes on rumination m man. Medical Life 1936; 43: 27-72. 13. Amarnoth RP, Abell TL, Malagelada JR. The rumination syndrome in adults. A characteristic manometric pattern. Ann Intern Med 1986; 105: 513-18.

WE, Drescher VM, Morrill-Corbin E, Cataldo MF. Rumination syndrome in children treated by increased holding. J Paed Gastroenterol Nutrit

1985; 4: 550-56 15. Pazulinec R, Sajwaj T Psychological treatment approaches to psychogenic vomiting and rumination. In: Holzl R, Whitehead WE, eds. Psychophysiology of the gastrointestinal tract. Experimental and clinical applications. New York. Plenum, 1983: 43-63. 16. Rast J, Johnston JM, Drum C, Conrin J The relation of food quantity to rumination behaviour J Appl Behav Anal 1981; 14: 121-30 17. Hammond WA. Merycism Med J (NY) 1894; 60: 109-11. 18. Lloyd JH. Discussion: rumination in man by Sinkler W. JAMA 1898; 30: 834-37. 1. Southwick FS, Richardson EP, Swartz M. Septic thrombosis of the dural venous sinuses. Medicine 1986; 65: 82-106. 2. Gialldrenzi AF, Weiss WW, Furman DJ, Greenwald AM Septic cavernous sinus thrombosis in a diabetic after dental extraction J Oral Surg 1974; 32: 924-30


improved techniques for the isolation of anaerobic organisms. Septic thrombosis of the lateral sinuses remains an exclusive complication of middle ear or mastoid infection and may follow acute or chronic otitis media. It is a disease of young, otherwise healthy patients; a history of predisposing illnesses include sickle-cell anaemia,8osteopetrosis,9 and bacterial pathogens have been demonstrated in only 28% of cases. The organisms identified are those commonly associated with chronic otitis media--eg, Proteus spp, Staph aureus, E coli, and anaerobes.3 Whilst 48% of cases with septic thrombosis of the superior sagittal sinus follow bacterial meningitis, spread of infection from the ethmoid, maxillary, and frontal air sinuses accounts for 17% of cases. In addition, sagittal sinus thrombosis has been reported after tonsillitis,s and after pulmonary, pelvic, and dental sepsis.4,6,7 Predisposing illnesses include sickle-cell anaemia,8 osteopetrosis,9 and breast cancer. 10 The organisms responsible are usually those associated with meningitis. Streptococcus pneumoniae is the commonest pathogen, but various other organisms have been implicated--eg, &bgr;-haemolytic streptococci, anaerobes, and gram-negative bacteria. A case associated with severe Trichinella spiralis infestation has also been reported." The frequency of specific symptoms and physical signs related to septic thrombosis of the dural sinuses has not changed greatly with the use of antibiotics, although important focal neurological signs such as 6th nerve palsy and hypoaesthesia or hyperaesthesia of the ophthalmic and maxillary branches of the 5th nerve have been mentioned in some reports since the use of antibiotics.1 The symptom complex of 6th nerve palsy and 5th nerve irritation resulting in facial pain and otitis media-Gradeningo’s syndrome12—is a good indication of lateral sinus thrombosis, whereas superior sagittal sinus thrombosis is a more acute, generalised illness with a depressed mental state, hemiparess and quadriaresis and signs of brainstem

directed against the appropriate bacterial pathogens should be given intravenously, in high doses, starting as soon as samples have been taken for bacterial culture. The combination of penicillin, chloramphenicol, and possibly metronidazole would be a reasonable initial regimen (pending culture results) for all forms of dural sinus infections. An anti-staphylococcal agent (flucloxacillin) should be added if facial infection is present. For infection of the lateral dural sinus, the organisms responsible for the most recent ear infection (if available) may be used as a guide to initial therapy. Although Pseudomonas is frequently cultured from the external ear canal, this organism has not been isolated from intraoperative specimens. Addition of an aminoglycoside and an anti-pseudomonal penicillin (eg, azlocillin) may become necessary if infection with Ps aeruginosa or other gram-negative organisms is suspected. Surgical drainage of the infected air sinuses should be carried out whenever possible, but is mandatory if the patient remains febrile and toxic 24 h after starting antimicrobial therapy. Drainage of the dural sinuses should be avoided because the procedure may be followed by rapid clinical deterioration. Early anticoagulation with heparin in patients with cavernous sinus thrombosis might prevent spread of thrombosis to other connecting sinuses and reduce mortality;l anticoagulation is not recommended for other forms of dural sinus thrombosis and should be used only after careful consideration and exclusion of cortical venous infarction. Mannitol and steroids have been used to reduce cerebral oedema and reverse inflammatory cranial nerve

dysfunction, respectively.13 Although the mortality, morbidity,

compression. Since septic thrombosis

and complications associated with dural sinus thrombosis have been reduced since the introduction of antibiotics, the outcome of cavernous and superior sagittal sinus thromboses has not improved greatly. The mortality, at 30% and 78%, respectively, must still be considered high, emphasising the importance of early recognition and treatment of primary infections which have the potential for spread to the dural sinuses.

become a Clinicians


of the dural venous sinuses has condition it is frequently misdiagnosed. must be aware of this life-threatening complication when patients present with infections of the facial area, air sinuses, middle ear, and meninges. Investigations to confirm the diagnosis should include lumbar puncture, radiographs (including tomograms of the air sinuses), and computerised tomography of the brain, sinuses, and orbit. Whilst carotid arteriography with venous phase studies, dynamic brain scans, and orbital venography remain definitive methods of demonstrating dural sinus thrombosis, experience with these techniques may be available only at specialised centres, and there may be difficulties in confirming the diagnosis. However, antimicrobial therapy should not be delayed. Antibiotics rare

3. Schall LA. Treatment of septic thrombophlebitis of the cavernous sinus JAMA 1941; 117: 581-84 4 Stuart EA, O’Brien FH, McNally WJ Cerebral venous thrombosis. Ann Otol Rhinol Laryngol 1951; 60: 406-38. 5. Krayenbuhl M. Cerebral venous thrombosis. Clin Neurosurg 1967; 14: 1-24. 6. Strauss SI, Stem NS, Mendelow H, Spatz SS. Septic supenor sagittal sinus thrombosis after oral surgery. J Oral Surg 1973; 31: 560-65 7. Askenasy HM, Kosary IZ, Braham J. Thrombosis of the longitudinal sinus. Neurology

1962; 12:288-92 AA, Nones AW. Intracranial venous thrombosis

8 Pottera






1973; 50: 634-43.

Sjolin S. Studies on osteopetrosis. Acta Paediatr Scand 1959; 48: 532. Sigsbee B, Beck MDF, Posner JB. Non metastatic superior sagittal sinus thrombosis complicating systemic cancer. Neurology 1979; 29: 139-46. 11. Evans RW, Patten BM. Trichinosis associated with superior sagittal sinus thrombosis. 9. 10

Ann Neurol


11: 216-17.

THE report commissioned by the chairmen of the twelve health authorities in inner London (see p 232) illustrates once again that moves towards economy in the NHS do not always turn out as intended. In the first two years of the planning period which began in the four Thames regions in 1983 three-quarters of the beds targeted for reduction in the twelve authorities over ten years were in fact closed, yet only a third of the intended revenue saving was achieved. The pressures on the system could have accelerated turnover and improved bed occupancy, thus keeping up costs despite bed closures. Not by any means an unsatisfactory outcome-in terms of efficiency at least. The chairmen are at pains to emphasise that the report is not a special plea for London, though it may be seen as such in other parts of the land. What it does demonstrate is the need to compile a clearer and more detailed forecast of the sway now being imposed on the NHS’s provision for London and its surrounds. And, moreover, it points to the distinct possibility that the pace of redistribution in the four Thames regions has been too

rapid. 12

Jahrsdoerfer RA, Fitz-Huge GS. Lateral sinus thrombosis. South Med J 1968; 61: 1271-75.

13. Solomon OD, Moses L, Volk M Steroid therapy in cavernous sinus thrombosis Am J Ophthalmol 1962; 54: 1122-24.