ORIGINAL LECTURES.

CLINICAL LECTURES

ON DISEASES OF THE ABDOMEN. By FREDERICK T. ROBERTS, M.D., B.Sc., F.R.C.P., Professor of Materia Medica and Therapeutics at University College, Physician to University Hospital, and Professor of Clinical Medicine, etc.

LECTURE II.

GENERAL ETIOLOGY AND PATHOLOGY OF ABDOMINAL DISEASES.

The

ETIOLOGICAL facts are often of considerable importance in relation to the diagnosis, prognosis, and treatment of abdominal affections, and, without entering into details, I purpose now to give a general summary of the causes of these affections, and of the conditions under which they occur. consideration of particular causes, and of the special etiological points relating to individual organs or diseases, will claim our attention on future occasions. In giving this summary, it will be practicable to indicate at the same time the nature of the principal diseases to which the abdominal structures are liable; and for convenience sake the causes may be arranged under certain groups and subdivisions.

GROUP I.-In many cases an abdominal disease is primary, independent, or local, that is, it is induced by causes acting more or less locally and directly, generally coming from without. Different organs or structures will be affected according to the precise nature of the cause, and the part it affects, while the effects produced will also necessarily vary. Under this group come the following subdivisions :

1. All kinds of physical injury and mechanical causes originating from without, such as strains, contusions, or wounds, swallowing foreign bodies, and external pressure, especially that produced by tight stays or belts.

2. Excessive local heat or cold, either directly applied to the abdomen externally, or coming into contact with internal parts, as the result of swallowing hot or scalding liquids, or, on the other hand, very cold liquids or ice.

3. Chemical agents, including certain recognised poisons, medicines of various kinds, and some articles of food, or such as have undergone decomposition or other deleterious changes. These act mainly on the alimentary canal, and the poisons belong either to the corrosive or irritant class; but it must also be remembered that certain medicinal agents, especially when taken injudiciously-as is often the case with regard to purgatives-injuriously affect this canal. Moreover, some poisons and medicines are liable to produce a remarkable local effect upon the kidneys, when introduced into the system in any way, and may thus cause more or less functional derangement of, or even structural damage to, these organs, such as cantharidis, turpentine, and copaiba.

4. Various causes connected with food and drink. These are but too familiar as originating numerous abdominal disorders and organic diseases, and in many cases they act locally and directly in connexion with the alimentary canal and its appendages. Not only may ticles of food and drink be hurtful in themselves, but there are various errors in relation to diet which are prolific causes of local affections, and which will need hereafter to be considered at some length. Liquids are often highly injurious in this way, as may be exemplified by the effects of drinking water in excess or bad water, abuse of tea, and, above all, intemperance in the use of alcoholic drinks, which act locally as well as generally.

As regards the nature of the affections produced by the causes belonging to this group, they include wounds and other forms of mechanical injury, burns or scalds, corrosion, active congestions, acute and chronic inflammations, spasmodic affections, functional disorders, and displacement of organs. The alimentary canal is, on the whole, far more liable than other structures to be affected by this class of

causes.

GROUP II.-In a comparatively few instances abdominal complaints result from causes originating from without, which act upon the general system, but tend to affect particular organs or structures in the abdomen. The connexion of this group of causes with the complaints which they are VOL. II. 1881. No. 1618.

supposed to produce is not always so clear and definite as could be wished, but their reality cannot be doubted. Thus, exposure to cold and wet, or general chilling of the body, may originate abdominal affections. In exceptional instances acute peritonitis seems attributable to such causes. Unquestionably they may disorder the functions of the digestive apparatus; but their most obvious effects are noticed in connexion with the kidneys, where they may produce congestion, acute Bright's disease, or probably, by their long-continued action, even chronic organic changes. Excessive heat is another agent to be noticed here. When the body is exposed for a prolonged period to a high temperature, especially in connexion with residence in tropical climates, not only functional disorders, but also serious organic changes are very liable to be set up in the liver and other abdominal organs. Summer diarrhoea is another illustration of a condition which probably depends, in many instances, at any rate in part, upon the injurious effects of a high temperature upon the body. Overcrowding, bad hygienic conditions, offensive effluvia, and allied causes, frequently cause gastric and intestinal disorders, and assist in producing more serious complaints. Want of cleanliness of the skin deserves particular notice here, as probably not uncommonly materially disturbing the renal functions, and assisting in the development of organic renal disease. Lastly, causes arising from food and drink, and especially alcohol, must again be mentioned under this group, for although their primary effects are local, secondarily they affect the entire system, and their injurious effects are often observed in connexion with organs and structures altogether remote from those with which they come into direct contact.

GROUP III.-There is a group of abdominal affections which may be referred ætiologically to derangement of some normal function or action, in consequence of which certain organs are liable to become more or less damaged, either functionally or organically.

1. A function may be entirely neglected or imperfectly attended to by the patient, either habitually or on some particular occasion, and in this way mischief may be set up. For instance, neglect of mastication and of proper ensalivation is a potent cause of digestive disorders, and may ultimately originate organic changes in the stomach. A want of attention to habit and regularity with regard to meals, as influencing the gastric functions, may produce similar effects. The injurious consequences resulting from neglect of the act of defecation are but too familiar; and not only do the intestines themselves suffer, but the other organs engaged in the process of digestion are also often implicated, while in some instances serious results ensue from accumulation of fæces in the bowels. Neglect of micturition is another cause of mischief to be mentioned here. I have recently seen a marked case in which temporary paralysis of the bladder resulted from the patient allowing his bladder to remain over-distended for a considerable time. Habitual carelessness in this respect may not improbably lead to permanent damage to the urinary apparatus.

2. Abdominal functions are not uncommonly disordered by remote causes, especially those connected with digestion, and in this manner certain complaints may be originated. These causes are often associated, and may be illustrated by the effects of deficient exercise, over-study, excessive smoking, and other injurious habits.

3. Disordered actions may give rise to serious conditions in the abdomen. Thus, severe vomiting or retching may lead to hæmorrhage or even rupture of the stomach under certain circumstances; straining at stool is often highly injurious; and even irregular and abnormal movements of the intestinal tube itself may cause its own displacement, or drive one part of it into another, thus originating intussusception.

GROUP IV. This is a very important group, for it includes those cases in which an abdominal disease is a part or complication of, or a sequel to, some general disease or condition, and they are of very common occurrence. The local disease may be comparatively insignificant and unimportant, or it may be of great consequence. This group can be arranged in certain subdivisions, according to the following plan:

1. Abdominal structures are frequently affected in connexion with acute febrile and allied diseases. In the first place, you must remember that mere fever or pyrexia always