William Osler.

Modern medicine : its theory and practice, in original contributions by American and foreign authors (Volume v. 5) online

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study, as taught us by Riegel, Ewald, Dujardin Beaumetz, and others, there
arose a tendency to multiply the number of gastric neuroses until the array
of titles in a modern book on stomach diseases becomes somewhat bewilder-
ing. Undoubtedly much good has come from this minute investigation of



FUNCTIONAL DISTURBANCES IN STRUCTURAL DISEASE 23

functional disorders of the stomach. Among other advantages, it has added
to our knowledge of the physiology, but now that so many years of conscien-
tious work have been paid out and so many valuable facts have been gathered
in, we are in an admirable position to review the field and to arrange the
material along the lines that experience and a sense of proportion would
direct.

When this has been well done we shall doubtless agree that our conception
of stomach troubles has undergone an absolute reconstruction since the
days when text-books treated of "indigestion" and "flatulent dysjjepsia;"
but we shall admit also that there has been something of overrefinement
in the classification, description, and management of the gastric neuroses.
It is rather remarkable that this outgrowth of recognized gastric neuroses
should have occurred during an epoch in which a basis in definite morbid
anatomy was required of practically all diseases; and when no structural
abnormality was shown to bear a constant relation to a sym^Dtom-complex,
the pathogenesis of that disease was held in doubt. Notwithstanding this,
our assembly of nervous affections of the stomach, for which no morbid
structural setting was found, was adopted into our nomenclature and was
not disputed by most of our clinicians.

Hereafter, as now, we shall doubtless admit that this was a decided
advance; but already we are discovering that we had in several instances
misconceived the real meaning of the situation. In accepting the doctrine
that we might have an array of motor, secondary, or sensory disturbances
merely as the expression of a neurosis, we became too oblivious of the fact
that this supposed neurasthenia might in fact rest upon some definite local
disease that escaped detection.

7. Functional Disturbances in Relation to Structural Disease. —

This oscillation of opinion that makes for a resting in the truth has come
in part as a result of the surgical treatment of abdominal diseases. It
was seen that after the removal of gallstones and the drainage or excision of
the gall-bladder, not a few of the supposed neuroses promptly disappeared,
and the physician who had rested satisfied with the diagnosis of liyperchlor-
hydria was disconcerted. Probably we have yet to learn the full number and
the importance of the gastric phenomena that may develop as the result
of irritation in the gall-bladder and its vicinity. We are already aware
that this irritation occasions gastric hypersesthesia, hyperchlorhydria, and
hypersecretion, besides the syndrome of transient pyloric obstruction with
characteristic delay in emptying the stomach and that well-known train
of symptoms which comes from food stagnation. This latter event may
be encountered in cases in which there is no actual stenosis, no structural
narrowing of the pylorus or duodenum, but, as pointed out by Soupult
and others, merely a reflex or spasmodic affection of the pylorus, with or
without coincident derangement of gastric secretion, but, necessarily, with
serious digestive disturbance both in the stomach and duodenum.

We have long known that this train of events was a natural accompani-
ment of pyloric or duodenal ulcer. Now that cholecystitis is admitted as
a cause, there is difficulty in persuading some men to believe that pyloric
spasm ever occurs as the result of a neurosis; on the contrary, they hold
that there is always local irritation in the region of the pylorus if it could be
found. They affirm the local cause and leave the burden of proof with those
who yet hold the position that there remains a proportion of cases in which



24 DISEASES OF THE ALIMENTARY TRACT

the functional element is the only and sufficient cause. As the evidence
that may be adduced in sui)portini;; this opinion has a fitting apjilication
to other supposedly functional ilisortlcrs, it may be jji-ofitably mentioned at
this point.

To begin with, only a neurotic origin has been able to explain a few
of the reported cases of congenital pyloric stenosis. Then there is the
analogy of spasm in the sphincter portion of other organs. The idiopathic
dilatation of the oesophagus following cardiospasm which Meltzer has eluci-
dated, is an examjile, to which may be added vesical and anal spasm, besides
the involuntary contraction in laryngismus, vaginismus, etc. Still further
evidence is found in the cure of these morbid contractions by measures
directed solely toward calming cxeitability. Finally, the surgeons have
learned from unfavorable expcricnee the futility of attacking neurotic affec-
tions by o{)erative measures, for the symptoms not only continue, but often
increase thereafter. That there may remain some obscure and hidden
structural defect is of course possible, but, in the light of all facts, improbable.
Indeed, when we come to analyze the cases of pylorospasm secondary to
a diseased gall-bladder, it will be found that some of them present no signs
of former ])crigastritis nor extension of inflammation to the pylorus or
duotlenum. In these very cases, then, we must admit some indirect functional
excitation, differing, it is true, from our conception of a neurosis, but leaving
still something that morbid anatomy fails to explain.

An unprejudiced view of all sides of the question would seem to warrant
our granting that a disordered nervous system may at times give rise to
cardiospasm or pylorospasm, but the w^arning should be kept in mind that,
except in comparatively manifest cases, we should seek the cause in some
marked irritation at or near the vicinity of the abnormal contraction.

8 Structural Changes Resulting from Functional Disorders. —
Accepting the doctrine that many gastric disturbances arise from nervous
causes with and without assignable irritation at some point remote from
the stomach, the question occurs as to how far it is possible for structural
diseases of the stomach to follow as a secondary result of severe or prolonged
insult to the nervous system. The belief has long been held that gastric
atony and even dilatation of the stomach may ensue from long-continued
nervous depression. It is not difficult to explain gastrectasis as the result
of pyloric or upper intestinal obstruction, l)ut there is a large residuum of
cases of this affection in which no obstruction is found, and their origin is
usually attributed to ])rolonged nervous (le[)ression and overtaxation of the
stomach with resulting myasthenia. In this connection it is interesting to
note the rapid accumulation of reported cases of acute dilatation of the
stomach following surgical procedures. These instances of acute gastrectasis
succeeding upon surgical shock are not limited to abdominal operations or
injuries, for there are Avell-authenticated cases which have developed after
extensive injury to one of the extremities, the joints, or subsequent to grave
pneumonia, or accompanying acute tuberculosis or carcinoma. In a pro-
portion of these cases a real obstruction is found, usually in the duodenum,
occasioned by compression of the gut bctw^een the root of the mesentery
and the spinal column, the result of dragging of the intestines downward.
This occurs in some conditions involving great relaxation of the abdominal
wall. In a majority of cases no obstruction or other causes save nervous
shock has been discovered.



STRUCTURAL CHANGES FROM FUNCTIONAL DISORDERS 25

It would seem that an important lesson is to be learned from these oases.
The fact that dilatation can occur within a few hours, with manifestations
so serious that death usually results unless proper intervention is resorted
to, and that this can occur without any direct injury to the stomach or other
abdominal viscera, seems a striking illustration of the relationship that exists
between innervation and the well-being of the digestive apparatus. If
shock can induce such acute and serious structural change in the stomach,
we may expect analogous behavior in the intestine and other parts. Until
autopsy becomes more general, we are not likely to know what percentage
of unexpected fatal terminations after surgical operations may depend
upon this accident.

If acute gastrectasis can arise from great depression of visceral innervation,
it is conceivable that depression of lesser degree and long continuance may
result in atony; and if to this we add the element of overtaxation of the
stomach from indiscreet eating, we may easily explain those cases of gastric
atony which do not result from obstruction.

One who has had wide experience in the examination of gastric contents
is aware of the striking influence which the state of the nervous system has
upon gastric secretion. It is not uncommon to find instances of hyperchlor-
hydria which disappear as soon as the patient follows a quiet, orderly life.
On the other hand, in hypochlorhydria systematic rest, with consequent
improvement in the general health, often leads to the return of normal
secretion. In many instances it will be found that the neurasthenic state
that gives rise to the gastric symptoms may not depend upon inherited weak-
ness nor upon general nervous exhaustion, but, as before mentioned, rather
upon the overfatigue of some particular part of the nervous system. Mere
local treatment of the stomach unaccompanied by improvement in other
directions is usually unsuccessful in inducing a cure.

One naturally inquires whether these long-continued disturbances of
secretion may not lead to inflammatory and other lesions of the gastric
mucosa. Gastritis has been given extensive consideration in most treatises
on stomach diseases, and when one recalls the importance of the affection,
this may not seem out of place. According to the experience of some, the
frequency of gastritis is exaggerated and such observers believe that the
affection is in fact much less common than is usually claimed. Neverthe-
less, gastritis is a troublesome affection, and its etiology should be carefully
looked into. The disease is to be regarded as an infection of the stomach.
One is impressed, however, with the truth long ago pointed out by Beau-
mont, that the recuperative and regenerative power of the gastric mucosa
is remarkable, and we find that not only inflammation, but moderate trauma
of the stomach, goes on to rapid repair, provided the general conditions are
favorable. What is usually regarded as gastritis is in fact a functional
irritability of the stomach lining, a hypersesthesia gastrica, and not a true
inflammation. In the extremes of age, however, or when the resisting power
of the organism has been greatly reduced by long-continued fatigue, general
infection, or great nervous depression, experience shows that gastritis is
readily excited, and that, when once present, it is likely to continue until
the general health is improved. It is interesting to recall that this also is
true of the gastric neuroses, and just as hypersesthesia and motor irregularity
may be caused and continued by systemic depression, so also may this be
true of gastritis. Apparently a good deal of confusion exists in the mind



26 DISEASES OF THE ALIMEXTARY TRACT

of the average practitioner as to when a case is inllaininatorv and when it
is merely one of functional irritability. It is imjjortant to make the diti'er-
entiation, but it is occasionally ditficult, as also is the recognition of etio-
logical factors upon which either aiVection is based. While it is not hard to
understand how a functional disturbance may arise as a result of nervous
depression or excitement, the view that gastritis may de})end upon a similar
train of circumstances is a view that has not gained sufficient recognition.
One must not dwell too much upon systemic depression as a cause in
the development of gastritis; of course, it is only a factor which predisposes
to infection. It is connnonly and justly believed that the toxannias also invite
gastritis. This ]irobal)ly results from a lowering of vitality in the gastric
mucosa such as the intoxications may induce in other tissues. Local dis-
turbances like acute c()nsti[)ation, hepatic congestion, and overloading the
stomach are factors which generally aid in setting up inflammatory reaction.
The point should be made, however, that while one person easily w-ith-
stands indiscretion in diet, another person under the same circumstances
immediately suffers from gastritis, and this is true because of the lowered
resistance to infections which exists in certain individuals, a truth that we
find paralleled in the course of infections in other organs. Thus, in indi-
viduals who are predisposed to appendicitis, colitis, and cholecystitis, it is
possible to find the explanation in reasoning along the lines here indicated.

9. Structure and Function in Relation to Peptic Ulcer. — In the

search for the etiology of peptic ulcer we have discovered a number of other
things, but not precisely that, and the ground has been so much tramped over
that the boundaries of the question are considerably obscured. It is highly
probable that when we include in one group cases found postmortem, those
produced experimentally, and those recognized clinically, we are not talking
about one and the same thing in each instance. Gastric ulcer has been
produced in animals experimentally by prolonged feeding on infected food.
Inferentially, the same result would obtain in man; nevertheless, except w^hen
stagnation exists, the stomach with peptic ulcer is remarkably free of the
usual evidences of infection. Virchow apparently solved the problem by
the hypothesis of thrombus, and this has been shown to be true of rare cases,
while it apparently has no place as a cause in the great majority. A like
conclusion may justly attach to the theory that gastric hyperacidity, lowered
alkalinity of the blood, local trauma, the accidental manifestations of other
diseases, like tuberculosis, syphilis, scurvy, or diabetes, are the direct and
single cause. That the gastric mucosa may suffer ulceration like other
surfaces of the body and from identical causes will probably not be disputed,
but it is scarcely justifiable to regard all these as Instances of peptic ulcer.
Undoubtedly some features are common to all these ulcerative gastric lesions
and the apparently identical processes observed in the duodenum, and rarely
in the cardiac extremity of the oesophagus. These common features appear
to arise from the pecidlar and similar experiences to which these parts are
subjected by the digesting and eroding action of the gastric juice upon tissue
relatively devitalized by any cause whatever.

If we limit our attention wholly to these characteristics of gastric ulcer,
namely, gastric hyperacidity and general lowering of the vitality of tissue,
we fail to account for the special cause that may explain the peculiar charac-
teristics of the peptic ulcer.

We should arrange and consider the following facts: (1) Classical



STRUCTURE AND FUNCTION IN RELATION TO PEPTIC ULCER 27

acute peptic ulcer is prone to occur in chlorotic young women, and, although
the exceptions are many, the rule must not be obscured. (2) Classical
chronic or indurated peptic ulcer is prone to occur in men past middle age.

(3) Peptic ulcer is prone to localize itself either at the lesser curve on the
posterior surface near the pylorus, or, as shown by Mayo, in the duodenum.

(4) Its tendency is to continue, to become chronic. (5) Some ulcers show
immediately a design to perforate, others seem forever limited to the mucosa.
In acute ulcer there is nearly always present an overactivity in the secretion
of very acid gastric juice.

In reviewing these special features we recall unquestioned instances
tending to nullify the rule; but too much weight should not be given to the
exceptions in a subject holding so many possibilities of confusion; we should
rather attempt to trace the usual lines more deeply, while at the same time
noting and interrogating the unusual. After doing this it would seem
clear that in the gastric ulcer of the dead house we are dealing with several
entities — differing in cause, tendency, history, and termination — although
there are certain manifestations in which they are alike.

It would seem that there is some as yet unknown factor at work in the
cause of true peptic ulcer, some factor which lowers the vitality of tissue,
especially in certain regions of the stomach and duodenum. Apparently
this factor is relatively common in early adult life in women, and after middle
life in men, and in the latter is more disposed to chronicity. What is this
factor? Will it be found in the local deficiency of antibodies, as suggested
by Weinland? In local ischsemia? In preceding lesions of neurotrophic
nature, analogous to herpes or to the perforating ulcer of the integument?
These questions remain unanswered, and the operative treatment of gastric
and duodenal ulcer, while proving that the disease is more frequent than
we were prepared to admit, and showing that, in men, duodenal peptic ulcer
is seen about as often as gastric ulcer, has not materially aided in explaining
the nature of the process. The hypothetical disappearance of antibodies
may well account for the loss of tissue, but how shall we explain the local
deficiency in antibodies ? May this not rest in the neurotrophic realm ?

Whatever may be the exciting cause, we are reasonably certain that
the increased activity of the gastric secretion and its overacidity contribute
much toward the rapid evolution of the ulcer and toward its chronicity.
The pain and gastric irritability are to be explained in part by the pyloric
and gastric spasm and by the delay in the onward passage of chyme^ Thus,
the rationale of the usual medical treatment by rest, diet, alkalies, local
sedatives, and external applications is made evident. When failure follows
this treatment, the result would seem to be attributable largely to the fact
that it requires the utmost attention and pains to prevent interruptions in the
course of treatment, and that a short interruption may prove sufficient
to overcome what has been gained by days of patient effort. Whether food
is denied or in proper form is given frequently and persistently, the idea of
of keeping the gastric acidity low and overcoming the element of spasm must
never be forgotten ; even after gastro-enterostomy done to procure drainage,
the benefit resulting from a modified diet and a lowered gastric acidity is
of considerable importance.

By a control of the functional activity of the organ we are able to modify
the course of the structural disease. Of course, this principle is not limited
to gastric ulcer, but it seems to illustrate the important and persistent inter-



28 DISEASES OF THE ALIMENTARY TRACT

relation tluit exists between ori];iins and l'nnetii)ns. Perhaps we should be
more earnest in tracking structural diseases to a starting place in functional
derangement, to the finding of lowered resistance in some areas of tissue as
the result of biochemical deficiency, possibly neurotrophic in its inception.
All this may strike some men as lacking the evidence of acknowledged ex-
perience, but such a decision woukl be premature. There are many facts
to be marshalled in its sui)i)ort. The bizarre and rather unaccountable
manifestations grouped by Osier under the head of angioneurotic oedema
should be rccalK-d as an illustration of visceral lesions apparently secondary
to neurotrophic disturbance.

We observe herpes facialis, sometimes persisting for weeks together,
ajipearing in some individuals whenever the health is depreciated by fatigue
or other general causes. Such eruptions are prone to attack a certain area,
reappearing in the same place and occasionally accompanied by severe pain.

We occasionally ol)serve jierforating ulcer of the arm or leg })ersisting
indefinitely, resisting topical treatment and recurring after excision. We
should recall Raynaud's disease and also the curious non-traumatic hiiema-
toina auris, particularly observed in the insane. INIarked subcutaneous
extravasations of blood appear in certain neurotics in various parts of the
body, disappearing, then recurring after a period of health. In one patient
the writer observed this at intervals during several years, sometimes alternat-
ing Avith, sometimes accompanied by, the classical symptoms of gastric ulcer,
and especially by lijematemesis of grave character. In er3'thema multiforme
one may observe the wide involvement of the mucous membrane, and one
severe case was observed in which this disease was accompanied by the
symptoms of gastric ulcer. This collection of presumably neurotic affections
associated with structural lesions shows an indubitable relation betAveen
the nervous system and the integrity of the tissue.

We have insufficient experimental evidence to prove that either a nerve
lesion or a neurotrophic disturbance is a frequent cause of peptic ulcer, but
the behavior of the affection strongly suggests the possibility. These state-
ments are intended to emphasize a principle that seems to be too little recog-
nized in pathological processes, that of the very close relationship existing
in all parts of the organism between the structure and the functions which
utilize that structure.

This is a recurrence of the thoughts already expressed, that we are prone
to tliink of structural disease as something separate and apart from functional
disease. It is true that we often find a structural change to explain the
supposed functional disturbance, but it seems equally true that the functional
disturbance is the forerunner of an etiological factor in, sometimes the cause
of, the structural disease.

The hyperchlorhydria so commonly present in peptic ulcer is often intensi-
fied by food retention, secondary to pyloric spasm, and the same cause is
responsible for some cases of that condition usually called gastrosuccor-
rhcea. It must be admitted, however, that there are cases without over-
retention from spasm, cases in which an excess of gastric juice is secreted;
and whether this is or is not commonly true in ulcer, the fact remains that
hyperchlorhydria is generally found. It was long believed that this might
be produced by local stimulation occasioned by the open ulcer. Pawlow's
observations tenrled to discredit this view. He failed to excite gastric
secretion in animals by irritation locally applied, although juice flowed freely



THE QUESTION OF SECRETION 29

at the sight of food and upon its introduction into the stomach. A highly
acid secretion is made to flow in dogs as a result of faradization of the
mucosa. Recently, A. Schiff has been able to excite the flow of gastric
juice by local stimulation when the factor of psychic effects and the presence
of food in the mouth or the stomach were eliminated.

Clinically, we find that the acidity is increased by feeding and even by
the suggestion of eating, as demonstrated by Pawlow. But we also know
that hyperchlorhydria is present in gastric ulcer even when the patient is
fasting and when the psychic influence is wanting. It is probable, therefore,
that gastric secretion is excited by the irritation of an ulcer as well as by
the suggestion or presence of food in the stomach.

One may conclude that there is usually an excessive secretion and at times
retention of gastric juice in this disease, and there can be no doubt of the
unfavorable effect of the hyperacidity in the course of the ulcer. Further,
we know that chlorosis, so often associated with ulcer, is generally accom-
panied by hyperchlorhydria, and that an impressionable nervous system
at least predisposes to the oversecretion.

10. Tne Question of Secretion. — The behavior of the stomach in the
matter of secretion presents a problem not yet satisfactorily elucidated.
By the action of certain proteids upon the mucosa of the pyloric end of the
stomach there is excited in the glandular structure of the part a substance
which passes into the general circulation, returns to the gastric mucosa, and
excites therein an active secretion of gastric juice. Pawlow and Popielski
have shown that this secretion occurs after the destruction of all nerves
connecting the stomach with the ganglionic centres. Edkins has shown
that it is not the result of a local reflex in the gastric walls, but is owing to



Online LibraryWilliam OslerModern medicine : its theory and practice, in original contributions by American and foreign authors (Volume v. 5) → online text (page 2 of 126)