Page:EB1911 - Volume 08.djvu/284

 ulcers of greater or lesser curvature; the gastric cavity becomes “hour-glass” in shape. In addition, the stomach may be displaced downwards as a whole, a condition known as gastroptosis: if the pyloric portion only be displaced, the lesion is termed pyloroptosis. Ptoses of other abdominal organs are described; the liver, transverse colon, spleen and kidneys may be involved. Displacements downwards of the stomach and transverse colon, along with a movable right kidney and associated with dyspepsia and neurasthenia, form the malady termed by Glénard enteroptosis. A general visceroptosis often occurs in those patients who have some tuberculous lesion of the lungs or elsewhere, this disease causing a general weakening and subsequent stretching of all ligaments. Displacements of the abdominal viscera are almost invariably accompanied by symptoms of dyspepsia of a neurotic type. The rectum is liable to prolapse, consequent upon constipation and straining at stool, or following local injuries of the perineal floor.

Every pathological lesion shown by digestive organs is closely associated with the state of the nervous system, general or local; so stoppage of active gastric digestive processes after profound nervous shock, and occurrence of nervous diarrhoea from the same cause. Gastric dyspepsia of nervous origin presents most varied and contradictory symptoms: diminished acidity of the gastric juice, hyper-acidity, over-production, arrest of secretion, lessened or increased movements, greater sensitiveness to the presence of contents, dilatation or spasm. Often the nervous cause can be traced back farther,—in females, frequently to the pelvic organs; in both sexes, to the condition of the blood, the brain or the bowel. Unhealthy conditions related to evacuation of the bowel-contents commonly induce reflex nervous manifestations of abnormal character referred to the stomach and liver. Gastric disturbances similarly react upon the proper conduct of intestinal functions.

Local Diseases.

The Mouth.—The lining membrane of the cheeks inside the mouth, of the gums and the under-surface and edges of the tongue, is often the seat of small irritable ulcers, usually associated with some digestive derangement. A crop of minute vesicles known as Koplik’s spots over these parts has been lately stated by Koplik to be an early symptom of measles. Xerostomia, or dry mouth, is a rare condition, connected with lack of salivary secretion. Gangrenous stomatitis, cancrum oris, or noma, occasionally attacks debilitated children, or patients convalescing from acute fevers, more especially after measles. It commences in the gums or cheeks, and causes widespread sloughing of the adjacent soft parts—it may be of the bones.

The Stomach.—It were futile to attempt to enumerate all the protean manifestations of disturbance which proceed from a disordered stomach. The possible permutations and combinations of the causes of gastric vagaries almost reach infinity. Idiosyncrasy, past and present gastric education, penury or plethora, actual digestive power, motility, bodily requirements and conditions, environment, mental influences, local or adjacent organic lesions, and, not least, reflex impressions from other organs, all contribute to the variance.

Ulcer of the stomach, however—the perforating gastric ulcer—occupies a unique position among diseases of this organ. Gastric ulcers are circumscribed, punched out, rarely larger than a sixpenny-bit, funnel-shaped, the narrower end towards the peritoneal coat, and distributed in those regions of the stomach wall which are most exposed to the action of the gastric contents. They occur most frequently in females, especially if anaemic, and are usually accompanied by excess of acid, actual or relative to the state of the blood, in the stomach contents. Local pain, dorsal pain, generally to the left of the eighth or ninth dorsal spinous process, and haematernesis and melaena, are symptomatic of it. The amount of blood lost varies with the rapidity of ulcer formation and the size of vessel opened into. Fatal results arise from ulceration into large blood-vessels, followed by copious haemorrhage, or by perforation of the ulcer into the peritoneal cavity. Scars of such ulcers may be found post mortem, although no symptoms of gastric disease have been exhibited during life; gastric ulcers, therefore, may be latent.

Irritation of the sensory nerve-endings in the stomach wall from the presence of an increased proportion of acid, organic or mineral, in the stomach contents is accountable for the well known symptom heartburn. Water-brash is a term applied to eructation of a colourless, almost tasteless fluid, probably saliva, which has collected in the lower part of the oesophagus from failure of the cardiac sphincter of the stomach to relax; reversed oesophageal peristalsis causing regurgitation. A similar reversed action serves in merycism, or rumination, occasionally found in man, to raise part of the food, lately ingested, from the stomach to the mouth. Vomiting also is aided by reversed peristaltic action, both of the stomach and the oesophagus, with the help of the diaphragm and the muscles of the anterior abdominal wall. Emesis may be caused both by local nervous influence, and through the central nervous mechanism either reflexly or from the direct action of substances circulating in the blood. Further, the causal agent acting on the central nervous apparatus may be organic or functional, as well as medicinal. Vomiting without any apparent cause suggests nervous lesions, organic or reflex. The obstinate vomiting of pregnancy is a case in point. Here the primary cause proceeds reflexly from the pelvis. In females the pelvic organs are often the true source of emesis. Haematemesis accompanies gastric ulcer, cancer, chronic congestion with haemorrhagic erosion, congestion of the liver, or may follow violent acts of vomiting. In cases of ulcer the blood is usually bright and in considerable amount; in cancer, darker, like coffee-grounds; and in cases of erosion, in smaller quantity and of bright colour. The reaction of the stomach contents, if the cause be doubtful, yields valuable aid towards a diagnosis. Of increased acidity in gastric ulcer, normal in hepatic congestion, it is diminished in cancer; but as the acid present in cancer is largely lactic, analysis of the gastric contents must often be a sine qua non, because hyperacidity from lactic may obscure hypoacidity of hydrochloric acid.

Flatulence usually results from fermentative processes in the stomach and bowel, as the outcome of bacterial activity. A different form of flatulence is common in neurotic individuals: in such the gas evolved consists simply in carbonic acid liberated from the blood, and its evolution is generally characterized by rapid development and by lack of all fermentative signs.

The Liver.—The liver is an organ frequently libelled for the delinquencies of other organs, and regarded as a common source of ill. In catarrhal jaundice it is in most cases the bowel that is at fault, the liver acting properly, but unable to get rid of all the bile produced. The liver suffers, however, from several diseases of its own. Its fibrous or connective tissue is very apt to increase at the expense of the cellular elements, destroying their functions. This cirrhotic process usually follows long-continued irritation, such as is produced by too much alcohol absorbed from the bowel habitually, the organ gradually becoming harder in texture and smaller in bulk. Hypertrophic cirrhosis of the liver is not uncommonly met with, in which the liver is much increased in size, the “unilobular” form, also of alcoholic origin. In still-born children and in some infants a form of hypertrophic cirrhosis is occasionally seen, probably of hereditary syphilitic origin. Acute congestion of the liver forms an important symptom of malarial fever, and often leads in time to establishment of cirrhotic changes; here the liver is generally enlarged, but not invariably so, and the part played by alcohol in its causation has still to be investigated. Acute yellow atrophy of the liver is a disease sui generis. Of rare occurrence, possibly of toxic origin, it is marked by jaundice, at first of usual type, later becoming most intense; by vomiting; haemorrhages widely distributed; rapid diminution in the size of the liver; the appearance of leucin and tyrosin in the urine, with lessened urea; and in two or three days, death. The liver after death is soft, of a reddish colour dotted with yellow patches, and weighs only about a third part of the normal—about 1 ℔ in place of 3 ℔. A closely analogous affection of the liver, known as Weil’s disease, is of infectious type, and has been noted in