T JOURm 6 APRIL 21, 19231 THE CHRONIO . I MTDICAL JUmSA 667

I Now: Pains in bladder-intestines dropping. feels as if pressed on. A tight belt to push up all ins:de-makes nerves better. An Abbras Always " intoxication "- and flatulence. ON CASE II. THE CHRONIC ABDOMEN.* Miss M., aged 48. Seen in 1913, complaining of constant acidity, flatulence, vomiting of green fluid, etc. BY ROBERT HUTCHISON, M.D., F.R.C.P., History. At 5 years of age had severe jaundice and stoppage of bowels; PHYSICIAN TO THE LONDON HOSPITAL. always constipated. At 20: Influenza and bronchitis with prolonged fever; this left OumR surgical coleagues describe a condition which they "stomach trouble " which persisted. speak of, iu their clinical slang, as the "acute abdomen." At 32: " Dilatation of stomach," and was in bed three months. There is, another more At 33: Uter-us curetted; indigestiou better for a time. however, condition familiar to the At 36: Complete hysterectomy and Digestion physician may be appeudicectcmy. which designated with equal propriety the much better for over a year. chlronic abdomen," and if the one is, as we are told, a At 38: Digestion bad again-stomach lavage-much benefit for catastropbe, the ohfber is certainly a conundrum. a month. TThe subject of the clhronic abdomen is usually a woman, At 40: Cbolecystitis and "ulcer of stomach." At 42: Rest cure in hospital. Stomach massage. "Much generally a spinster, or, if married, childles and belonging to benefit." what are commonly termed-rather ironically nowadays- At 48: Exploratory operation. Profound visceroptosis with the '"comfortable" classes. To such a degree, moreover, do dilatation of stomach an pylorus. Stomach and colon fixed with her abdominal troubles colour her life and personality that catgut sutures. we may conveniently speak of her as an abdominal woman." One and a half years later she wrote: An abdominal man, -on the other hand, is by comparison " . . . Am glad to say I never now (since operation) get those a rare bird, and when caught has a way of turning out to turns of agonizing pain in region of gall bladder whicli used to be a Jew-or a doctor. suggest gall stones; but there is always a sore burning spot thlere, sometimes pretty bad, with often slight cutting sort of pains (but SYMPTOMS. only slight), and it goes when the apparent cause of corrosion of wind or food has moved. The symptoms of the chronic abdomen are many, various, " My old 'sore spot' (on left side under lowest rib near middle) and ever-renewed. Some of them refer directly to the has come back, and I am in constant distress from the buruing, abdominal organs, others are of a more remote and general gnawing sensation right across below waist line. Also all over character; but, whatever they are, they are always described back and under shoulder blades. witlh great prolixity and in minute detail. Amongst those "I have really been little more than an invalid for montlhs, finding it most difficult to continue my teaching, having scarcely commonly complained are abdominal aches and pains most of strength to speak. It seems to be the continued acidity and ot various sorts and in various places, but especially in the tremendous flatulence, and the sensation of wealiuess (I suppose) is right iliac fossa. Instead of actual pain the patient may because the heart is being almost continiually chioked ;viti dilata- speak of a "raw feeling inside," or of- "an indescribable tion of stomach. About a month ago it was ' nmurmuring'-I do not know if it is still doing so. It feels as if a heavy wveight is sensation in the stomach," or of a "dragging." Constipation pressing the heart and sometimes there is neuralgic pain in its of greater or less degree almost always figures prominently in region and in left arm and I can't breathe easily. But doctor says tlhe list of symptoms, and flatulence is also frequent. Amongst it is not due to heart itself; that appears strong, but the effect of the commoner remote symptoms one finds a feeling of general faintness and exhaustion is very bad sometimes, thouglh occa- or " exhaustion " (especially after an action of the sionally I am able to forget it for a day or more. Of course it hinders when bad. Am to say the bowels), " mental and physical torpor," "inability to think," sleep glad fearful violent jumping-which- was such a trial all the time in hospital anid for " a poisoned feeling," and "neuralgic pains all over." Head. eighteen months after-is almost gone and the rheumatisnm is aches and insomnia are also very frequent, and a great many better and the sudden turns of sickness less frequent. I rest all patients complain of undue susceptibilitv to cold and of a I can and do most of my work at home, so that if I find a heart constant catarrll in the throat. turn coming on I can drop lesson and let off the tremendous flatulence in violent noisy 'spasms.' If I check them J become helpless. EVOLUTION OF THE CHRONIC ABDOMEN. " I have just started to try and take olive oil (a large teaspoon a since so have felt easier and no If one inquires of a patient with a fully developed chronia day) and doing had spasms, but this may be chance, but shall persevere. Bowels need 20 or abdomen how her lamentable state has been arrived at it will 25 senna pods now to move them." be found tlhat the process of evolution is fairly constant. These sufferers are very fond of presenting anyone whom CASE III. they may consult with a full record of their previous medical MissJ., aged 29. Been in January, 1908. She had always been history and experiences, and the following are a few such delicate, especially as regards digestion. records as supplied by the-patients in their own words. They may be taken as typical. History. June, 1889: . Abscess came away into rectum. January, 1897: Entered on office work-health became worse. CASE I. October, 1898: Influenza (high temperature) followed by jaundice. Mrs. L., aged 47, gave the following record of her various Since have always had constipation. illnesses and their treatment: 1899-1900: becoming worse. Bad fall at 2 years of age. Rheumatic fever at 13. Always bad June, 1900: Operation-two abscesses in glands on right side of digestion anid overloaded bowel. Married at 21. After birth of abdomen, one of which had broken ; considerable amounjt of first child, ulceration of rectum. Uterus never strong. mat.er; slight perforation. Since digestionbas always been very 1900: Two operations for fistulae and abscesses-tumour (fibroid) troublesome. discovered in uterus. Always feeling ill -from auto-intoxication 1902-4: Digestion becoming worse and worse. (enemas curing this) and rheumatism in knees (cured by,inocu- October, 1903: Six weeks' " rest cure" in bed with massage; no lationi). permanent improvement. 1901: Cocaine poisoning. February to April, 1904: Being in Switzerland, six weeks' treat- 1902-1909: Cures at Aix, Strathpeffer, Bath, Carlsbad, and ment in hospital there; no improvement. Lausaune. May and June, 1904: Seven weeks' treatment in Zurich; no 1910: Operation for "chronic " and six tumours in improvement. uterus. Intestines never felt in place or strong after this. Same October, 19C4: Operation (gastro-enterostomy)-pylorus said to year: Pyorrhoea; inoculations. be fixed by adhesions. Digestion has sinice been very indifferent. 1911: Cancer of the breast-operation. Since last date, pain and distension at intervals of from tNvo to 1912: Went to Bath for "nerves." Several teeth extraoted. four weeks, lasting from periods varying from one to six or nmore 1913 (March): Played golf for first time and thought intes- weeks. tnes were dragged down. Jumped out of train and ran hard CASEIV. (April1st); iniside never comfortable since then; pains in bladder; Mrs. T., aged 41. Seen 1917, complaining of pain in epigastrium nerves I and left hypochondrium, flatulence and acidity. May: Small fibroid discovered. Uterus half size too large. In 1907 rightkidney fixed. and general Inflammation of bladder, uterus, tissue; nerves In 1908 removed. terribly bad; douches, etc., in a home. In 1909 operation for tubal pregnancy. August: Contrex6ville (concentrated urine and excess of urio In 1913 other tube and ovary removed-since then indigestion. acid). Contraction of intestines; pains in kidneys; always pain-in In 1915 rest cure. bladder-diarrhoea. Nerves-nerves. Constipation. Passed large In 1917 exploratory operation-nothing found except that the quantities of sand. omentum was adherent to the scar in tle riglht iliac region. Remained well for four months, when epigastric pain returned I Delivered before the Clinical Society of Manchester, March 8th, 1923. acutely with the symptoms described above. 113251I] LT 82mm"M 668 APRIL Ir, 1923] THE CHRONIC ABDOMEN, M ZDoAz. JOUNUAIL

CACE V. PHYSICAL AND MENTAL STATE. Mrs. aged 53. Seen for " H., 1915 obstinate constipation; neuritis" On a case in various parts of the body, swellinjg and tenderness of the examination of fully developed of the chronic breasts, etc. abdomen one will find that it lhas boih a physical and a mental aspect, and that more History. the latter is often the importaut i886: Haemorrhoids removed. of the two. 1837: Curetting. Physically the patient is undernourislhed and sallow. To- 1888: Five cauterizations of uterus. use an abominable term current at the moment, she looks 1898: Haemorrhoids retinuved again, and bowel stretched as far "toxic." The abdomen is of visceroptotic shape and the as they could reach. This resulted in loss of power in lower bowel and aggravated the trouble. surface criss-crossed with scars, the sians-manual of tlhe surgeons 1905 . Uterus and large fibroma removed and one ovary, in which who at one time -or another have conducted ex- was a cyst. The surgeon tlhought the fibroid growth behind ploring expeditions into the interior. The stomach is dropped the uterus was stranglinig the intestine, but the latter was not and splashy and the right kidney more or less movable; there improved after the operation. is tenderness at various points over the colon. Constipation 1910: Bismutb test and exploratory operation. Five places will probably be obstinate, and the where tight bands had grown rounid the intestines-worst place motions usually show the presence mucus or even left side of the colon three times round and a very thick string. It of membranes. left a deformed colon, but as the place seemed elastic they did not The mental side of the case is more difficult to analyse. cut it out. There is notable, in the first place, a general discontent, This trouble continues, and since May last I have had mucous "d isgruntlement," and peevishness, added to which is an . The sliglhtest solid unidigested matter causes stoppage, intense egotism which leads the and there is constant delfy. I only make matters go at all by daily patient to regard herself injections and aperients. The poisoning is resulting in nerve and her symptoms as of the utmost importance. In a play pain and swellings in different parts of my body. called The Mollwuc, which appeared some years ago, this aspect of the abdominal woman was admirably depicted, but It will be observed that the road to chronic abdominalism I noticed that all my patients of this type who went to see is paved witlh operations. The usual sequence seems to be it simply remarked, "How absolutely like Mrs. So-and-so !" this: the patihnt begins by complaining of pain or discomfort None of them recognized the Molluso as herself. Needless in the right iliac fossa, for the relief of which the appendix to say, the patient is also intensely introspective and liypo- is removed. For a few months she is better. (It is charac- chondriacal. She studies and catalogues her symptoms wilh teristic of tlle disease tlhat almost any new treatment, and minute care, and is expert in a knowledge of the action of any especially operation, produces benefit for a time.) Soon, drugs and a connoisseur of doctors and " specialists." however, her symptoms return. This is put down to "adhesions," and another operation is performed to remedy She has seen heaps of specialists," a doctor wrote to me of a these, with tlle same result as the first. Warming to his typical example, "and iio doubt will continue to do so. Ycu will be amused and interested to hear thiat she promptly went off to work, the surgeon undertakes bolder and yet bolder pro. another specialist after seeing you." ceedings; a complete hysterectomy is probably carried out or some short-circuiting device, or the colon is fixed, or even The operation habit has often a strona hold on her. partially removed, but still the patient is not cured of the Added to all tlhis, and nmost trying of all, is an intense paii,s, whilst the state of the nervous system has steadily craving for sympathy whicll must be satisfied at all costs, worsened. and it is noteworthy that there is usually someone in lier It is interesting to note at this point how medical history entourage who is always ready to supply the need. Some. repeats itself. Writing in the eighties of last century on the times an unmarried daughter is thje victim; sometimes it abuse of gynaecological operations in the treatment of is an over-devoted husband. One should not, however, visceral neurosis, Sir Clifford Allbutt said of the abdominal commiserate him too much, for, like the husband in Bunty, ,woman of that day: he is often a "weelin' victim" and always ready to kiss his chains. "She is entangled in the net of the gynaecologist, who finds her uteru3, like her nose, is a little on one side, or again, like that Her Incessant demand for sympatlhy and understanding , is running a little, or it is as flabby as her biceps, so that makes the abdominal woman a veritable vampire, sucking the unhappy viscus is impaled upon a stem, or perched upon a the vitality of all wlho come near lher. Half an hour will prop, or is painted with carbolic acid every wee, In the year her reduces her doctor to the consistence of "a piece of except during the long vacation when the gynaecologist Is grouse- chewed string," and is more to Ihim than the shooting or salmon-catchinjg, or leading the fashion in the Upper exhausting all Eiigadine. Her mind, thus fastened to a more or less nasty rest of his dai'y visits put together, for she is always dis- mystery, becomes inew y apprehensive and physically intro- covering fresh symptoms, will not admit any improvement in spective, anid the morbid chains are riveted more strongly than her condition, and has an objection to everything that is pro- ever. Arraign the uterus and you fix in the woman the arrow posed. Crabbe must have had her in mind wlhen he wrote of of hypochonidria, it may be for life."-On Visceral Neurosis, Gouistonian Lectures, 1884. the patients- "Who with sad prayers the weary doctor tease Substitute " surgeon" for "'gynaecologist" and "appendix" To name the nameless ever new disease." for " uterus " and the parallel is complete. At that time the uterine organs were the scapeaoat of the abdomen; now it is "My bete noire, Miss , is coming to see you soon," a tlle appendix-if, indeed, it is not already the teeth or the medical friend feelingly wrote to me of an extreme example. tonsils. Fortunately, however, she never sticks to one doctor long, bub Meanwhile, and between the more dramatic entries and is always rushing off after freslh advice, and her nurses can exits of the surgeon, the plysician has not been idle. The always be changed at short intervals; if they were not, they patient has been tlhoroughlly "investigated "-possibly at a would go mad. "team-work" clinic; she has certainly been provided with an x-ray picture-book of lher entire alimentary canal; her THE NATURE OF CHRONIC ABDOMINALISM. teeth have been extracted and her tonsils excised; her When one comes, thlen, to analyse a case of the chronic motions have been analysed by a biochemist and her mnind abdomen, it is found to consist on the physical side of a state by a psycho-analyst; she hias lhad several rest cures; she has of visceroptosis along, usually, with a greater or less degree been given prolonged courses of vaccines, of intramuscular of muco-membranous colitis, and, on the mental side, of that tonic injections, of intestinal antiseptics, and of endocrines; morbid psychological state whiclh was sketebed above. But she has been fed on sour milk or minced beef or raw vege. now comes the conundrum. How can the physical basis pro. tables; she has experienced various forms of massage, has duce the multiform symptoms of which the patient complains, been subjected to the latest kinds of electrical current, and and what is its relation to the mental side of the picture? lias had her colon repeatedly washed out at Plombihres or It is common knowledge, of course, that many women have Harrogate. pronounced visceroptosis without being much affected by it In a word, she has run the whole gamut of "modern" either physically or mentally. Wlhy, tben, do these particular them'apy, has submitted to every "stunt" and conformed to patients appear to suffer so much? Again, wbat part does every fad-but is none thie better. -And ju-st as she can only muco-membranous colitis play? It is true that one rarely escape the attentions of the surgeon when-as Sir Clifford sees a sufferer from that disease who does not exhibit in Allbutt said of the gynaecologist-he is "'grouse.ehooting greater or less degree the mental characteristics of chronic or salmon-.catching or leading the fashion in the Upper abdominalism, but what is the relation of the one to th, Engadine," so she is only at peace from -the physician when other? Does the colitis affect the mind, or is it the other the latter is recruiting his exhausted energies by a short way round? I need not remind you, of eourse, that there is holiday at an inexpensive seaside resort. a school thought whieh- would' attribute all the remote APRIL 2r, !923 IMAN'S POSTURE: ITS EVOLUITION AND DISORDERS. METDIL JOUBRNAL 669 physical symptoms of chronic abdominalism, and presnmably the mental symptoms also, to " auto-intoxication." This 34unttrian 3tIrturts doctrine lhas been so much discussed in recent years that I do ON not propose to weary you with a furtlher consideration of it; but altlhough there may be an element of self-poisoning in MAN'S POSTURE: ITS EVOLUTION some of these cases, I feel bound to express the opinion that AND DISORDERS. it will not account for all the symptoms. Nor have I any new theory to offer. There remains, when all is said, ani GIVEN AT THE ROYAL COLLEGE OF SURGEONS OF ENGLAND done, a good deal of mystery about the chronic abdomen, and BY it needs further study-especially, perhaps, from the psycho- logical' side and from the standpoint of the relation of the PROFESSOR SIR ARTHUR KEITH, F.R.C.S., F.R.S; vegetative nervous system to the emotions. CONSBRVATOR OF TE MUSEUM. [Abstract&.] TREATMENT. In the treatment of the chronic abdomen the most im- LECTURE VI. THE EVOLUTION OF THE HUMAN portant thing is- to catch the patient early. -If she has once FOOT. set her feet on 'the slippery slope whichi leads to successive WHEN dealing with the evolutionary history of the spine, operations she is undone. A timely " fattening cure," followed thorax, abdomen, and pelvic floor we found that the lluman by the provision of an efficient abdominal support, regulation condition was the last of a series of steps which are see 'to of the bowels by the mildest laxative, supplemented if neces- begin in the small orthograde ape, the, gibbon. The miosing sary by simple enemas, an abundant but unirritating diet, evolutionary stages are not those which- bridge the -hiatus soothing of the nervous. system by bromides-these are the between the great anthropoids and man, but those which fill phvsical measures. On the mental side the patient should the gap between the orthograde gibbon and the older prono. be encouraged to take up some definite occupation which wiill grade condition seen in monkeys. When, however, we came provide her with an interest outside herself. to consider the structure of man's groin and, to lesser extent, In an incipient case such means may suffice, but if one has his pelvic floor, we fouud that the evolutionary gap was seen to do with a confirmed example of the disorder one's task is to lie between the human and 'the antlhropoid stagles. This muchl more difficult. At the outset the question of operation is the case as regards all parts of man's lower extremities; is sure to arise. The patient will probably have already had more particularly is it true of his foot. Even in. the gorilla, her appendix removed at least, and if any further operation the anthropoid which shows the nearest approach to man in is 'decided upon it is best, I believe, to make it of a purely the use of its lower extremities for support of the body, the exploratory character. The incision should be large enougi great toe is free and uised as a grasping thumb. to permit of a thorough investigation of all the viscera-for The central evolutionary problem of the human foot is: even the chronic abdomen may be the seat of organic disease How did the thumb-like great toe lose its independent nature -any bands or kinks may be dealt with, but short-circuits and become merged in the metatarsal series? By wwhat pro. are to be avoided at all costs, and organs should not be cess did the free mobile great toe of the prehensile primate removed unless they are demonstrably diseased. Whether foot come to form the principal part of the rigid plantar arch fixation of the colon is worth while I do not know, as I have of man? The transformation is all the more remarkable not seen a sufficient number of cases in which at least two when we remember that a prehensile hallux was present at years lhave elapsed since the operation. Immediate benefit the first dawn of the primate type of animal, and has re- is no criterion of permanent relief, for, as I have already tained this form throughout the long history of the order, pointed out, these patients are always improved for a time with the exception of that aberrant being, man.* In him by a new treatment. Colectomy of any degree is a grave the hallux has reverted to a primitive position in the proceeding.-not to be undertaken liglhtly. In any case a metatarsal series. thorough exploration may at least satisfy the patient's mind as to the absence of serious organic disease, and so pave the Has the Foot of Man been Evolved from one wvhich wvas way for a healthier mental attitude in future. Prehen8ile 7 Apart from operation, the physical treatment will proceed At the very outset this question must be askd and on the same lines as in an early case, but success is much answered: Wbat evidence is there that the human foot has more difficult to attain. passed through a prehensile stage? The human foot has There remains the mental side to be dealt with. What is the same structural- composition as the ape's foot-the to be desired here is something which will dislocate the same bones, the same muscles, the same ligaments; it patient's mind from its perpetual revolution round her is only their arrangement and form that have become umbilicus and set it open to wider horizons. The war cured modified in the human foot. If in the higher primates some and loss of fortune and bereavement have cured others; we compare after bone, muscle after muscle, liga- but these are drastic remedies which it is not within our ment after ligament, we find in every case a -series power to prescribe. Suffragettism undoubtedly was the which leads from the type seen in the pure prehen. salvation of some abdominal women, but the suffragettes sile foot of monkeys to the stage 'reached in the human are now experiencing the tragedy of fulfilled ambition, and foot. Take, for example, the three contrahentes muscles probably many of them have relapsed. Marriage, and the to be seen in the sole of the monkey's foot; they 'serve advent of' a child-even an adopted one-are often potent to aproximate the heads of the metatarsal bones. In the remedies, and the fancy religions - Christian Science, sole of the human foot they are represented by mere fibrous Tlheosoplhy, Spiritualism, and so forth-may be ways of strands; the story of their degeneration can be read in the escape. One of my patients, an ex-nurse (and ex-nurses feet of tlle orthograde apes. They are still present in the furnish the most malignant types of the chronic abdomen), gibbon; they are in the retrograde stage in the chimpanzee, olice consulted a pafmist, who after looking at lher hand said, they are. almost as much reduced in the foot of the orang and "'lf I were your husband I would take a stick to you!" The gorilla as in that of man. The interosseous muscles of the advice was sound, and might often, perhaps, be effective. monkey's foot do not lie between thie metatarsal bones, as in Whether -the methods of M. Cou6- will help these patients the human foot, but on tlleir deep Or plantar aspect In the remains to be seen. 'The difficulty is that many of them, gorilla and orang they are set as in man; in the gibbon they 'despite their protestations to the contrary, really lack the OCCUPY an intermediate position. Yet as the interosseous will to be well, and their daily litany is: "1Day by day, and muscles appear in the foot of the human embryo they are set 'inevery way, I -get worse and worse." and arraiged as in pronograde apes. In the coure OF de ` I confess, therefore, to somae feeling of despair as regards velopment they take up their intermetatarsal position. We "Elie treatment of the more advanced cases of the chronic shall cite, when dealing With the structures which maintain Abdomen, and on the whole I am inclined' to think that the t6e^chQfthehuman foot, other evolutionary links which leAs 'one has 'to"do with them the better both for one's peace make us ertin that the human foot is but te culmii bf mind'and one's professional reputation. Yet, unfortunately, stMge n a series forethiadowed by anthropoid feet, °thleisehases are likely to increase in the future, for as civiliza- ~tion geth"more comnplexr, as fewer women in thle upper classes eries. lexion Lines of the Sole. '½Earry, or, being married, 'have- fewer -and fewer' children, all Jo mor e nvincsikg.evidence of the prehensile' hteorys of tl]o factors whlich favoulr the developmcent of chronic abd- th9;;human footct. be, cited;than the flexion lines tobi'on will be n;inalism mo:e'inLtense. fIFt-sa bleak prsp^Mec,t.- i ee Profe6qor Wood Jonests 4Irboi-eaf Mfan, 191k -