Imatges de pàgina
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more extensive than that caused by the mere outward application of an irritating agent, and to be attended by symptoms of inflammation or irritation of the bowels, and by some disturbance of the functions of other organs, which the inflammation of the stomach itself cannot explain.

The gastric disorder in yellow fever and in cholera, which is attended by great congestion of the stomach, and by effusion of fluids from the mucous membrane, which has many characters in common with those states which we designate inflammation, is probably brought on in this way, by the influence of some poison acting through the blood.

Another instance of inflammation of the stomach arising from an unhealthy condition of the blood is that which sometimes occurs in gouty states of the system, when the gout does not fix itself in the limbs, or when it suddenly leaves them. The stomach is more apt to suffer from the sudden retrocession of gout than any other organ; and two kinds of gastric disorder arising in this way have been recognised.

The first and most common kind usually occurs in chronic gout, and is chiefly marked by a feeling of weakness, or sinking in the stomach, with griping pain and a sense of cramp. The pain is relieved by pressure, and is seldom attended with vomiting, fever, or other symptoms indicative of actual inflammation.

When the disorder has these characters, it is best treated by warm alcoholic stimulants, and by sinapisms, applied with the view of recalling the gout to the joints that have been recently or oftenest affected with it.

The second kind of gastric disorder succeeds active inflammatory gout in the joints, and is marked by severe pain in the stomach, a high degree of fever, and frequent vomiting or retching, often attended by profuse diarrhoea. If the disorder be not controlled, the active febrile symptoms are early followed by a state of alarming and sometimes fatal collapse.

This affection of the stomach is, now-a-days, of rare occurrence, and has not been sufficiently studied. There can be little doubt that the disorder is inflammatory, but that, like gout in other parts, it has characters which may serve to distinguish it from common inflammation.

One of the most striking characters of gouty inflammation of the limbs is an abundant effusion of fluid into the synovial capsules, or into the cellular tissue. In gouty inflammation of the stomach, an effusion of the same kind sometimes takes place into the cellular tissue under the mucous coat, causing great thickening of the walls of the stomach. In illustration of this, I here show you a remarkable preparation, which I have found in the museum of the College. It exhibits a considerable portion of the pyloric end of a stomach, the walls of which are enormously thickened by what seems to have been coagulable lymph effused into the cellular tissue under the mucous coat. The preparation was left to the college by Dr. Hooper, and is thus described in his catalogue:

"A Portion of an Adult Stomach. There is considerable deposition of albumen between the coats-between the muscular and villous coats. The subject was labouring under acute rheumatic fever, with swelling of all the limbs, which suddenly disappeared, and his stomach seized with pain. He became delirious, and lived two days. Mr. Guthrie's stomach had the same appearance."

What is here termed "acute rheumatic fever" was, in all probability, acute gout affecting a great number of joints at once.

This peculiar form of inflammation of the stomach exemplifies a fact which must ever be borne in mind in the consideration of inflammatory diseases, namely, that the course and character, and, in great measure, the event, of inflammation in any tissue, depend on the nature of the influence by which the inflammation is caused.

When the gouty disorder of the stomach succeeds active gouty inflammation of the joints, and has itself the characters of active inflammatory disease, the most efficient remedies are leeches, or a blister, applied to the epigastrium; abstinence from all stimulating food; effervescing potash-water, in small quantities at a time, to allay thirst; and opium, to alleviate the severe pain, and to support the action of the heart. In conjunction with these remedies, sinapisms or other stimulants should be used, for the purpose of recalling the gout to the joints which it has recently left. Another form of inflammation of the stomach is now and then met with, in which

coagulable lymph becomes effused into the cellular tissue under the mucous coat, which coagulable lymph, if not soon absorbed, hardens and contracts, forming a dense gristly tissue, binding the mucous membrane to the coats beneath. Inflammation having this result, frequently occurs at the margin of old ulcers of the skin; but it often exists also, especially in the neighbourhood of the pylorus, independently of ulceration, or any other permanent change of texture in the mucous membrane. In such cases, the lymph is generally effused pretty evenly in the entire circumference of the pylorus, and leads to the formation of a gristly ring or band, which, by its contraction, permanently narrows or strictures the orifice. This form of the disease seldom occurs till near the age of forty, and is, I believe, almost invariably the effect of spirit-drinking. It is usually found in conjunction with marks of adhesive inflammation of the liver, spleen, and other organs, which spirit-drinking so frequently

causes.

The inflammation most probably involves the mucous membrane, as well as the cellular tissue beneath; and, at its onset, causes, like other forms of inflammation, pain, and tenderness of the stomach, and vomiting. The inflammatory symptoms subside as the mucous membrane recovers; but gradually the lymph in the cellular tissue contracts, and those disorders ensue which a narrowing of the pyloric orifice of the stomach occasions. The food is retained in the stomach longer than it should be; the stomach consequently grows larger, and the patient has an unusual facility of vomiting. Some years ago, I made a post-mortem examination of a gentleman who died of granular disease of the kidney, in whom narrowing of the pyloric orifice of the stomach, from adhesive inflammation of the areolar tissue, likewise existed. The only indication of this latter disease was an extraordinary facility of vomiting, which he had long had. He could empty his stomach almost when he pleased; but he sometimes vomited involuntarily, especially after having indulged more than usual in eating and drinking; and, on such occasions, it almost invariably happened that the liquids he had taken were rejected, while the solids were retained.

When the narrowing of the orifice is greater, and the action of the muscular fibres near the pylorus is impeded, the stomach seldom completely empties itself, and the acid residue of digestion in it ferments, causing heart-burn, sour eructations, and flatulence, and now and then excites inflammation of the mucous membrane. The stomach continues to grow larger, and, as its capacity augments, the vomiting may become less frequent, but more is thrown up at a time, and at length the disease destroys life by impeding the passage of the food into the intestine.

The same symptoms of obstruction are produced by cancer of the pylorus, which occurs at the same age, and from which the disease we are considering is distinguished by the slower progress; by the absence of any perceptible tumour; and by the circumstance, that it occurs almost exclusively in spirit-drinkers.

In some cases, the disease, instead of being limited to the pylorus, extends some distance in front of it, and the morbid changes, as well as the symptoms, are very difficult to distinguish from those of cancer.

During the inflammatory process, the disease, like adhesive inflammation of the liver, is probably much under the influence of treatment. When the inflammatory process is over, and the lymph has become hard and contracted, the treatment can only be palliative. The evils resulting from undue acidity and flatulence may be mitigated by remedies suited to these conditions. Vomiting and other gastric disorders may be lessened by proper regulation of the diet; but the most important point is, to make the patient give up his habit of drinking, and thus to prevent recurrence of the inflammation, and other addition to the mischief already done, than that which time of itself brings.

In the treatment of inflammation of the mucous membrane of the stomach, the fundamental point is to give the stomach sufficient intervals of rest, and to avoid irritating it by physic or food. For inflammation brought on by alcoholic drinks, or by undigested or irritating food, nothing more is generally necessary than cooling drinks, and restriction for a few days to a sparing diet, consisting of light broths. farinaceous substances, and milk. If the inflammation be very severe, causing much. pain and tenderness, with a sense of heat at the stomach, and frequent vomiting on the contact of food, leeches may be applied to the epigastrium; the stomach may be cooled, and its irritability much lessened, by sipping from time to time iced water, or by holding pieces of ice in the mouth, and swallowing the water as the ice dis

solves; and the diet may be still further restricted. Broths may be interdicted, and, for a few days, nothing more be allowed than the simplest drinks, and those farinaceous substances that are principally composed of starch. In active inflammation of the entire stomach, or when, from any cause, the digestive power is very feeble, there is usually dislike of animal food, and, by a natural instinct, arrow-root, gruel, &c., are substituted for it. Even farinaceous substances, when they contain much gluten, are found to be heavy and oppressive. The peculiar business of the stomach is to dissolve the albuminous constituents of the food. The gastric juice has comparatively little action on the starch, which, consequently, taxes the stomach less,most probably passes out of the stomach more quickly, and is certainly found, when the digestive power is suspended, to be less oppressive to it. As I have before observed, the restoration of the stomach to its healthy condition is greatly promoted by the active nutrition of its lining membrane.-Med. Times and Gazelle, June 3, 1853, p. 565.

49.-ON THE PHYSIOLOGY AND DISEASE OF THE PANCREAS.

By DR. BRIGHT and M. BERNARD.

[In 1832, three papers were read successively before the Medico-Chirurgical Society on this obscure but interesting subject; the authors being Dr. Bright, Mr. Lloyd, and Dr. Elliotson. These gentlemen directed attention to a peculiar and rare symptom.]

"The symptoms to which I refer," said Dr. Bright, who was the author of the first communication, " is a peculiar condition of the alvine evacuation; a portion more or less considerable assuming the character of an oily substance resembling fat, which either passes separately from the bowels, or soon divides itself from the general mass, and lies upon the surface, sometimes forming a thick crust, particularly about the edges of the vessel, if the fæces are of a semifluid consistence; sometimes floating like globules of tallow which have melted and become cold; and sometimes assuming the form of a thin fatty pellicle over the whole, or over the fluid parts in which the more solid figured fæces are deposited. This oily matter has generally a slight yellow tinge, and a most disgustingly fœtid odour."

The importance of Dr. Bright's views, as bearing upon recent investigations, will be seen in the following summary of them. He says:

"When we draw a comparison between the three foregoing cases, a very close analogy, or even identity, in many circumstances, may be traced. In all of them chronic ailment terminated, sooner or later, in jaundice; and in all of them a great peculiarity in the character of the dejections existed. In the result of the examination after death we have likewise some circumstances which coincide in all-obstructed biliary ducts; the liver gorged with bile; fungoid disease attacking the head of the pancreas; and malignant ulceration on the surface of the duodenum. The question to be solved is, upon which of the conditions indicated or caused by these morbid changes, if upon either, the peculiarity of the evacuations depended? That the obstruction of the biliary ducts, or even the total absence of all indication of biliary secretion, is not usually attended by the same peculiarity in the evacuations, many cases which have been cautiously detailed by various authors, and many which we have all observed, bear sufficient testimony; and I was therefore induced to ascribe it either to the existence of malignant disease, or to that disease being situated in the pancreas. That the simple fact of malignant disease existing is not necessarily productive of such appearances in the feculent matter, I infer from cases both of that form of disease and of melanosis in the liver to a very great extent being, within the scope of my experience, unaccompanied by any such discharge, though the evacuations were submitted to the most rigid observation. That simple ulceration in the bowels, to any known extent, is not attended by any such symptom, I am led to believe, from knowing that neither in the most extensive ulceration of the large intestines in cases of dysentery, nor in the worst cases of ulceration of the small intestines in fever, in diarrhoea, or in phthisis, does anything of the kind usually occur. Whether, however, malignant ulceration of the mucous membrane is accompanied by this symptom I cannot assert, though I have often seen most extensive ulcers of the pylorus and of the rectum, where, although the evacuations

were attentively observed, such fatty matter was not detected. As, however, a malignant ulceration of the membrane did exist in each of the foregoing cases, it is not impossible that this was the cause of this symptom; but we must bear in mind that such ulcerations are by no means uncommon, and that the phenomenon of which I am speaking is uncommon; and that in each of the cases it was accompanied by another morbid appearance, which is not common-namely, the malignant disease of the pancreas. The fact of the intestinal ulceration having, in each case, occupied the duodenum, does, however, somewhat diminish the weight of this observation, for that certainly is not so frequent an occurrence."

Such is Dr. Bright's analysis of the cases adduced by him, in which the peculiar discharge above mentioned-of fat in the evacuations-existed as a positively ascertained symptom. Let the reader not omit to weigh well every assertion and every reservation here set down; we beg to assure him beforehand that not one clause of the above paragraph is superfluous. Dr. Bright then proceeds to analyse several other carefully observed cases, bearing upon the question by the greater or less similarity of their symptoms and morbid appearances, but differing in the absence of the "peculiar symptom." In two of these cases there were some of the recognised symptoms of pancreatic disease, and this diagnosis having been made, was negatived by Dr. Bright on the ground of the absence of fatty matter in the evacuations. The negative opinion was correct; but so far from maintaining the reasoning on which it was founded to be unassailable, Dr. Bright, on the ground of later experience, believes his argument to have been in fact fallacious, and proceeds to relate three other cases in which pancreatic disease existed, even associated with a duodenal affection, without the occurrence of the fatty discharge. The first was one in which the pancreas was completely involved in scirrhous disease, the duodenum thickened, contracted, and cancerous, but not ulcerated, and the common bile duct absolutely obliterated at its duodenal extremity.-(Case 6, p. 34.) This case approaches very closely the first three; "the only point of distinction seems to be the condition of the duodenum, which in all the other cases had been affected by malignant ulceration, but in the present case was only united by the scirrhous disease to the pancreas." It is, however, barely possible that the fatty evacuation may have occasionally existed, and have escaped observation; for the case, though carefully watched, was not specially watched in regard to this symptom during life. The next case related is one of malignant disease limited to the middle third of the pancreas, with some degree of contraction of the duct at the duodenal end; contraction also of the bile duct (causing jaundice), and incipient cancerous thickening of the duodenum.— (Case 7, p. 36.) The alvine evacuations were "clay-coloured and yeast-like; but neither fatty matter nor mucus had been observed to be passed with them, and a few days before death they became very dark." (It is proper to mention that this observation was not made by Dr. Bright himself, nor are the number of examinations nor any of the details stated.) The last case was one of cancerous disease of the liver, involving the capsule of Glisson, the common duct, and the duodenum, which was ulcerated opposite the disease; the pancreas was questionably healthy, but its duct much obstructed and distended, behind the obstruction, to the size of "the largest swan's quill."-(Case 8, p. 44). This case is earlier in date than all, except the first of those in which Dr. Bright observed the fatty evacuation, and therefore occurred before this symptom could have assumed the importance in his estimation which it afterwards acquired; but he assures us, from his own observation, that "on no occasion was the fatty matter detected, though the character of the stools was frequently noted." He also observes, that the occurrence of fatty evacuations in this case, without their having been observed, is very improbable.

The facts of which we have given above a very brief summary, but which will be found carefully detailed in Dr. Bright's paper, are considered by him as sufficiently to invalidate the conclusion that serious disease or derangement of the pancreas is necessarily or constantly accompanied by the peculiar symptom to which we have adverted. The strict inductive inference from the whole would be, that the occurrence of fatty evacuations is not necessarily determined by pancreatic disease, or by obstruction of the pancreatic duct, unless such disease or obstruction be such as completely to intercept the function of the organ; and that even in the case of very considerable disease of the entire gland, the fatty evacuation may be absent, provided the duodenum be sound or not much diseased. Taking these considerations

in connexion with those in the paragraph which we have quoted above from Dr. Bright's paper, it will be seen that as he remarks,

"We bring the circumstances of the diseased structure in connexion with this symptom, within a narrow limit-disease, probably malignant, of that part of the pancreas which is near to the duodenum; and ulceration of the duodenum itself. These are the only two conditions which can be traced as being peculiar to all three cases."

[Hence we see that Dr. Bright's researches in 1832, have obtained a position of the greatest historical importance.]

The experiments of Bernard appear to show the remarkable rapidity and power with which the normal pancreatic secretion acts upon the neutral fatty bodies of the aliment, converting them into an emulsion resembling chyle. We say this in the full knowledge that many of the ulterior conclusions of Bernard on this subject have not stood the test of further inquiry, and that the careful and varied experiments of several impartial and well-known physiologists have led to results which must very materially invalidate those to which our scientific neighbours in France have, by their authorized tribunals, given so hasty and unreserved a sanction. After careful consideration of the whole subject, however, we cannot but acquiesce in the conclusion of Lehmann, as well as of Bernard himself, that though many other animal fluids possess the power, in a greater or less degree, of emulsionizing the neutral fats, the pancreatic juice is distinguished by this attribute in a high degree, and therefore is probably an important agent in the normal digestion of these bodies. It cannot, indeed, be admitted, as Bernard at first asserted, that the pancreas is the exclusive organ set apart for the decomposition and digestion of the fatty aliments; for the experiments of Bidder and Schmidt clearly prove that the decomposition and saponification of the fats is not a necessary part of the digestive process, and that the presence of the gastric fluid in the chyme tends to prevent that evolution of the fatty acids from their oils which takes place in contact with decomposing animal juices; and moreover, the emulsionizing of the fats and the absorption of milky chyle is proved not to be absolutely dependent on the pancreatic fluid, nor even on the pancreatic fluid and bile conjointly, but to be effected, in a certain measure, by the fluids of the intestine alone. While, therefore, we must admit that the normal digestion of fat is a process to which several factors, as it were, contribute-viz., the intestinal juices, and especially those of the duodenum, the pancreatic juice and the bile-it would appear highly probable that the pancreatic juice is among the most important and direct of the agents in the chylification of the fatty matters of the food; and that the bile, though not in itself possessed of much emulsionizing power, contributes powerfully, by an action (as yet imperfectly ascertained) upon the other juices above mentioned, to the digestion of the fatty matters in the duodenum and first portion of the small intestine.

Assuming for a moment the correctness of these propositions, it becomes of course of the greatest importance to science, to determine accurately to what extent the subtraction of any of the above factors influences the digestion of the fat. This branch of the physiological inquiry has not been neglected by those engaged in it: but the difficulties (as may readily be believed) of submitting some of these questions to the direct test of experiment are almost insuperable, and the results of such attempts appear, at first sight, hopelessly contradictory. Sir B. Brodie, in 1823, asserted that the fatty matters were not digested when the common bile duct was tied, and that the lacteals remained, in such cases, free of milky chyle. The observation was probably correct; but the experiments having been performed on cats, in which the ductus communis choledochus receives the pancreatic duct, as in man, the inference as to the effect of withdrawing the bile from the intestine cannot be admitted; and the subsequent experiments of Blondlot, Majendie, and others, together with numerous cases of jaundice, constantly under the observation of the physician, show that animals can exist for a protracted period without loss of flesh, although little or no bile reaches the intestine, the excrements being usually in such cases devoid of any marked excess of fatty matters, even when ordinary food, abounding in oil, is taken in nearly the usual quantity. Bernard's experiments appear to show, that the digestion of the fat is wholly arrested by the withdrawal of the pancreatic secretion. He has found that the pancreas may be entirely destroyed in dogs, by filling its ducts with oil (an ingenious procedure, capable of being turned to

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