Epigastrium

“ In order to be able to make a sure diagnosis, there must be a localized pain, together with tenderness on pressure from without on the painful spot. A great many persons in good health are tender in the epigastrium, so that you have to be on your guard in this direction, too. From the occurrence of hæmatemesis in an otherwise healthy person you can, with great probability, diagnose ulcer of the stomach. ”

“ The animal is dull, prostrate, weak, lies on its belly, but rarely long in one place, and when up has arched back, stiff movements, and tucked up abdomen. The epigastrium is painful to touch, which tends to arouse vomiting of food or bloody mucus. As in the horse the rejected matters are very acid. Constipation may alternate with diarrhœa, the fæces being blackened (melæna) or even streaked with blood. The occurrence of suffering after meals, the constancy and persistency of the symptoms and the steadily advancing emaciation and weakness are very characteristic. ”

“ In searching for a point of tenderness it should be remembered that many persons are very sensitive to pressure in the epigastrium, and also that pressure is not without danger to those who are the subjects of gastric ulcer. ”

“ SYMPTOMS.—The symptoms of inflammation of the stomach present wide differences in their intensity, depending upon the degree of severity in different cases. In acute inflammation caused by the direct action of poisonous irritants they are pronounced and highly diagnostic. The patient immediately complains of burning pain, referred to the epigastrium, followed by intense thirst and vomiting. The thirst is apt to be very great and the act of vomiting painful. The vomited matters contain mucus, saliva, sometimes bile, and not unfrequently, in fatal cases, black, grumous, coffee-ground material. ”

“ Appetite is poor or irregular, the nose dry and hot, the mouth fœtid, the tongue reddened around the borders and furred on its dorsum, the teeth coated with tartar, the animal dull and prostrate, vomits frequently a glairy mucus mixed with alimentary matters or yellow with bile, and there is constipation alternating with diarrhœa. The epigastrium is tender to the touch, the back arched, the fæces glazed with mucus or streaked with blood, and offensive in odor. Emaciation advances rapidly and death may occur from marasmus. ”

“ In addition to these, sinapisms may be applied to the epigastrium, and champagne, when the circumstances of the patient will permit it, should be given in the place of whiskey or brandy. When everything is rejected by the stomach, recourse must be had to nutritious enemata. Constipation is to be overcome by gentle purgatives, as the use of powerful cathartics is very apt to be followed by troublesome diarrhoea. If this should come on, it is best treated by small doses of opium in combination with a mineral or vegetable astringent. ”

“ The affection is not accompanied with any constant lesion. Pascal21 made post-mortem examinations in six cases and found the mucous membrane of the duodenum a little reddened: the gall-bladder contained thick bile, and in a few cases there was congestion of the sympathetic ganglia. The attack is usually marked by certain prodromic symptoms. The patient complains of malaise, loss of appetite, a load in the epigastrium, embarras gastrique, dull pains in the colon, borborygmi, and cramps or tingling in the limbs. For the first few days the bowels generally move several times daily. ”

“ This is especially noticed in children and young persons before the ribs become firm and resisting, the negative pressure exerted by the lung being in part annulled by the presence of the fluid. The diaphragm is notably depressed, and pushes the liver, the spleen, and the stomach below their usual point. So great is this centrifugal force that the heart's impulse may be felt in the epigastrium. ”

“ An overloaded condition of the large intestine may cause inflammation of the liver or dropsy of the abdomen. When the colon is distended, it becomes a mechanical impediment to the free circulation of the blood in other organs, and causes congestion of the portal system, predisposing to chronic inflammation or cirrhosis of the liver. This latter is a structural affection, and may, in turn, give rise to abdominal dropsy. In a word, the accumulation of feces in the colon irritates both the large and small intestines, thus causing congestion of the bowels, liver, or stomach. ”

“ It then descends, through the oesophagus, into the stomach, where it becomes digested, and, in a great measure, dissolved, by the gastric juice, which is secreted by the arteries of the stomach. It is then pushed through the pylorus, or right orifice of the stomach into the duodenum, where it becomes mixed with the bile from the gall bladder and liver, and the pancreatic juice from the pancreas. These fluids seem to complete the digestion: after this, the food is continually moved forwards by the peristaltic motion of the intestines. ”

“ As the disease very often implicates the stomach (gastro-enteritis) , the usual lesions of gastritis will be seen. Most commonly the lesions are best marked in the small intestine, and again in other cases in the colon, but usually there is more or less change in all parts of the intestinal canal. The small intestine is almost devoid of aliments and the mucosa deeply congested in patches or striæ, with at points thickening, softening so that it crushes under the finger, hemorrhagic discoloration, and even ulceration, and necrotic changes. ”

“ The large intestines are easily cured, but the small ones with difficulty, and the jejunum is utterly incurable, from the multitude of its convolutions and the magnitude of its vessels, and owing to its coats being thin and nervous; besides, it receives all the bile in an undiluted state, and is nearest to the liver. The under and fleshy parts of the stomach we may attempt to cure, for we may succeed, not only because these parts are thicker, but because curative medicines are more readily applied to them, owing to their situation. ”

“ Hitherto we have been accustomed to regard the phases of digestion, gastric digestion, pancreatic digestion, and intestinal digestion, as almost separate processes, any of which we might increase indefinitely without doing any harm to the patient. We forget the relation which each bears to the other; and yet such a relation undoubtedly exists, for we find that when pepsin is mixed with bile it is precipitated and rendered inert. Further transformation of foods by the gastric juice is thus arrested as soon as the chyme leaves the stomach. ”

“ This is owing to the frequent concurrence of the two conditions, the gastric symptoms taking precedence of the others. The more complex nature of the intestinal function is another reason, intestinal indigestion having more modifications in its phenomena. In the stomach there is only one active secretion; in the intestine there are three, all participants in the act of solution. An alteration in the quality or quantity of one of these—the bile, for example—would lead to different symptomatic results than would follow another defective secretion, as that of the pancreas, for instance. ”

“ Not only so, but in cases where the liver is beginning to re-assert itself, and its tremendous overaction sends down such a supply of bile as to provoke inversion of the pylorus, an enema may often act sympathetically beyond that portion of the intestine actually reached by it, and change the direction of the intestinal movement, so as to convert the deadly nausea excited by the presence of bile in the stomach into a harmless diarrhea which at once removes the cause of the suffering. ”

“ He proved that bile, which used to be considered an excretion, was really an important digestive secretion. He was not able to demonstrate the function of bile as completely as he had done for the gastric juice. The problem of intestinal digestion is much more complicated than that of stomach digestion, and involves a number of factors for which allowance has to be made if the value of any one of them is to be accurately determined. Even in our own day all of the physiological problems in the functions of biliary secretion are not solved. ”

“ By its means the stomach is cleansed of mucous accumulations and particles of undigested food, thus enabling it to perform its functions satisfactorily. If, as is often the case (more especially with dyspeptics) undigested food remains in the stomach, it ferments, causing what is known as sour stomach, and is productive of many evils. If we keep the ferment out of the stomach by occasionally washing it, and prevent the generation of foul gases in the colon, by regularly flushing it, the bile will effectually prevent any fermentation in the intestines ”

“ Solid food given to the child before it has cut its teeth, enters the stomach unreduced to pulp by the grinders, and unmixed with the saliva, which should help its solution, and which the undeveloped salivary glands do not yet furnish. Too large a quantity of food, or food of an unsuitable character, on which the gastric juice cannot act readily, may pass into a state of fermentation; vomiting, flatulence, sour and offensive breath will be the result, and the food will pass into the intestine unprepared to be acted on by the bile. ”

“ I wish to emphasize the fact that one of the constant symptoms peculiar to this class of inebriates is constipation. As a class these people carry very large quantities of fecal matter in their lower bowels. This constantly loaded condition of the lower bowels is relieved occasionally by a sharp, irritative diarrhea, accompanied by nausea and vomiting or not. The diarrhea is often preceded by a few hours of acute pain that causes some talk of appendicitis and operation but, much to the discomfiture of the doctor, the bowels start up and relieve all suffering. ”

“ Only in our own day has come the greatest confirmation of the notion then first introduced into physiology, of the surpassing importance of intestinal digestion. The removal of the whole stomach for malignant disease is now undertaken without any fears as to the ultimate result on the patient's general nutrition. The operation has been done many times, and the surgeon's confidence that the intestines would compensate, as far as digestion of food was concerned, for the absent stomach has been amply justified. ”

“ From what we have just said it is evident that the proper emptying of the stomach and, therefore, the proper carrying on of the whole process of digestion, depends upon the formation and outpouring of ample supplies of acid-containing gastric juice. A failure of gastric secretion is bound to be followed by a failure of the stomach to empty itself. Instead of going on to the small intestine where digestion is completed and the digestion products passed on to the blood stream to be used by the body, the food mass lies inert in the stomach. ”

“ The tongue is furred or dry and red; thirst is increased; the appetite is lost; there are frequent eructations, nausea, and constant vomiting of a clear, greenish, viscid fluid; the vomiting produces no sense of relief, and even increases the epigastric pain. The bowels are obstinately constipated. The epigastric region is tense, tumid, and excessively tender, so that it is usually impossible to elicit the physical signs of enlargement of the gland. There is moderate pyrexia, with evening exacerbations, and the pulse is increased in frequency. Jaundice does not occur. ”

“ Hepatic abscess may follow on an attack of amoebic dysentery, and is produced either by infection through the portal vein, or by direct infection from the adjacent colon. In general pyaemia multiple small abscesses may occur in the liver.
The Gall-Bladder.—The formation of biliary calculi in the gall-bladder is the chief point of interest here. At least 75% of such cases occur in women, especially in those who have borne children. Tight-lacing has been stated to act as an exciting cause, owing to the consequent retardation of the flow of bile. ”

“ Whether the liver be enlarging or diminishing in size, its functions are impaired, or indeed entirely suspended. As the digestive canal receives the bile immediately on its production, it will be best to begin with the gastro-intestinal disorders which accompany occlusion of the bile-ducts. The appetite is either wanting entirely and food is loathed, or an excessive or canine appetite is experienced. The latter belongs rather to an early stage of the disorder, and comes on after the first disturbance of the stomach belonging to the immediate effects of the occlusion. ”

“ The phenomenon of vicarious excretion may occur through the kidneys, lungs, skin, throat, nose, vagina, or uterus, thus keeping up chronic diseases and discharges that would not exist but for the chronic constipation or even for incomplete action of the bowels each day. Over-distention of the rectum, sigmoid and colon, due to the pressure of gases and the impaction of feces, results in inflammation, ulceration, stricture, appendicitis, abscess, strangulation, intussusception, and abnormal ballooning or roominess in certain portions of these intestines or conduits. ”

“ The retention of fluids, transuded serum, bile, intestinal juices, and partly-altered food is hurtful. Decomposition sets in and gas is developed, which by distending the bowel causes great suffering and increases the inflammation. The movements of the intestine are not entirely under control; the patient must be fed; digestion and assimilation involve the activity of inflamed parts. The stomach can be made to do most of the work, but the sympathy of action is so close between the stomach and intestines that one cannot function without the other being excited into activity. ”