Special Article

INDIA* fills the pockets between the rugae. The THE DYSPEPSIAS OF SOUTHERN body of the stomach as a whole may be affected and v thus the By IAN M. ORR, m.d? f.r.c.s. (Edin.) acid-secreting glands which are-situated in the are London Mission Hospital, Neyyoor, Travancore mainly body seriously interfered with 1 with a resulting fall in free hydrochloric we aus acid,' * ^ ^le conditions which or the of ? the stomach is more only pyloric portion may m n are called on to deal with, nothing be affected and the manifold hydrochloric acid in the an in one of its or ^ysPePsia stomach remain normal we a to treat- high, i.e., have for*1111011-!??s- ^ew diseases are so resistant and an acid and hypoacid gastritis. n , so persistent in their symptoms, /Etiology.?This will be discussed more fully as do the use so much chronic invalidism below, but it may be said here that the come to our taking dyspeptics of over-spiced and indigestible food, and irreg- ZS?TlaS-& rooms and outpatient departments ular habits about meals all tend to exaggerate wo su, ulcer ^or sif?ns of duodenal it. Oral no doubt a we sepsis plays part. The i f to evidence of that, , failing find definite exhibition of certain drugs for periods also which nearly long escribe an alkaline mixture, predisposes towards it; e.g., sodium of com- salicylate, ways gives some measure temporary arsenic, silver, mercury and the disease quinine, copaiba. ^ sufferer, but leaves An atrophic form may be found in association a j iinl oca and untreated. with in fact it be ted, undiagnosed, on the malignant disease; may said do not to at length wish dwell that malignant disease of the stomach is always < ulcer, imhar subject of duodenal and gastric associated with and malignant * is Ce^ ^ar as the peculiar disease of other such as the : , so. pathology organs, colon ,ln, to deal with the south India. Nor do I wish etc., and rise to it rather I breast, they usually give by ause of acute abdominal but the of toxins from the pain, and absorption disintegrating ould call your attention to the interesting tumour. rise to symp- aried list of conditions that give Symptoms.?Discomfort and sensation of mainly by oms somewhat similar, characterized fullness which may amount to about one and whose pain pain, and flatulence, hour after food. Appetite is diminished, and so varied. a Pathology nevertheless is there is nausea, bad taste in the mouth, dizz- iness, regurgitation and flatulence. This is due Stomach to the lack of acid ' and all who allowing decomposition and *S n?^ gutters carbon dioxide formation. Hydrochloric acid is 1 and epigastric lave hunger pain, vomiting, diminished and mucus is found in excess in suffering from the enaerness, are not necessarily fasting juice. If the pyloric portion of the gastric or duodenal ulcer. stomach is alone affected the hydrochloric acid is the first and most Chronic gastritis.?This may be high. I would draw your common condition to which Treatment.?Remove all bad teeth, septic attention. and deal with sinus infection if of the stomach tonsils, any. Pathology.?The lining with an ounce to the which blocks the Lavage hydrogen peroxide, ecomes coated with mucus of serves to remove the mucus The deeper pint water, and mouth of the secreting glands. allows the to be secreted cells and in gastric juice freely. becomes infiltrated with round ayer undergo This may be repeated daily for a week or until an the cells of the glands extreme degree the mucus disappears. If there is hypoacidity, cloudy swelling and may atrophy. acid in water with become larger, give hydrochloric meals. A The ruga3 of the stomach tonic containing iron, arsenic and this may be demon- general strych- firmer and more tortuous; of nine may be but if not well tolerated a small meal given, by aj-ray, giving it be by by the walls the stomach may injected in ampoule stratedbarium and water only, and pressing barium just form. ?t the stomach together, so that the Diet.?Avoid hot curries, spices, raw fruit, shell fish. Take milk, barley water, congee * Paper read to the Travancore and Tinnevelly water, wheat, junket, chicken soup, Horlick's Medical Association on 10th March, 1935. 572 THE INDIAN MEDICAL GAZETTE [Oct., 1935 milk; later, go on to toasted bread and butter, A mixture containing magnesium and bismuth boiled eggs, white fish, rice. to neutralize the acidity and belladonna to Mention may be made of atrophic gastritis in inhibit secretion and relax the sphincter is indi- contradistinction to the above hypertrophic type. cated. Sodium bicarbonate is not deserving of This is chiefly associated with the more severe the popularity it enjoys, for, though it does anaemias and chronic venous congestion. In neutralize the acid at first, it then irritates the certain inborn errors also, hydrochloric acid may gastric mucous membrane, causing more acid, be absent. The most useful method of deter- and the formation of carbon dioxide and belch- mining whether or not an absence of free ing. hydrochloric acid is merely due to mucus block- (b) Gastro-succorrhoea {i.e., excessive secre- ing the ducts or to an inborn error is to inject tion but not a hyperacid one). 0.5 c.cm. of histamine*, and immediately hydro- It is common in students at examination chloric acid will be poured out in simple gas- times, in girls at puberty, etc. It is charac- tritis. terized by nausea, belching and vomiting of Nervous disorders of the stomach.?The ner- large quantities, for no particular reason. In vous system and, particularly, the mental states bad cases the patient may be cold with a slow of fear, worry, excitement, nervous exhaustion, pulse and sometimes due to stimula- etc., have a marked influence over the stomach. tion of the vagus. We have all experienced the pre-examination This condition has to be diffentiated from:? feeling of not wanting a big meal, because of a acute gastritis?vomited material alkaline; complete failure of our stomach to secrete its migraine?headache worse and vomitus daily quota of free hydrochloric acid. Or the bilious; feeling of heaviness in the pit of our stomach alcoholic gastritis?occurs in early morning when we are disappointed, ill at ease, or dis- after drinking bout and vomitus is mainly tressed. Now let us examine these nervous mucus. of the stomach. upsets Treatment.?Gastric lavage 1-2,000 silver (a) in Hyperchlorhydria.?A point physiology nitrate to promote mucus formation. Bella- is to understand. Stimulation of the important donna should be given internally. causes constriction of the and vagus sphincters (c) is found in outflow of This stimulation of Hypochlorhydria.?This gastric juice. people suffering from nervous breakdown or the vagus may be reflexed from gall stones or extreme nervous exhaustion; also in states of There is a from the . lymphatic path fear. It may be an inborn error, or it may be to the and it has been appendix associated with one of the severe anaemias. demonstrated that chronic inflammation of the Symptoms.?Loss of appetite, sense of full- appendix causes a spasm of the pylorus, and ness, distaste for meat and there may be diar- an increase in free hydrochloric acid, a condition rhoea, the desire to go to stool occurring imme- favourable to the formation of gastric ulcer. after taking this is a reflex action A state of chronic nerve such as is diately food; strain, and is a common cause of chronic diarrhoea. common to men dealing in big business, is Treatment.?Give a diet rich in carbohydrate associated with hyperchlorhydria. Excessive in- and and poor in protein, the reverse in and have a condiments, dulgence pickles, spices smoking of the diet. Give an acid similar effect. is that the normal hyperchlorhydria My experience mixture with nux vomica and curve for the of south India is pepsin. acidity people id) Gastric is found in than for because of the exces- hypercesthesia.?This higher Europeans neurotic who of unusual sensa- sive stimulation of the mucosa hot people complain by curry tions in the of the and belch- stuffs. region epigastrium and describe their symptoms with a wealth are sensation of fullness ing, Symptoms.?These of detail which is apt to weary the physician. and discomfort in the epigastrium and belching. There is usually a completely normal test meal There may be epigastric tenderness. The test and ?-ray, but still the patient complains of meal reveals high acidity and yet the axray and tenderness and many other things, and shows no evidence of ulcer. pain positive vomit without relief. This is a pure Treatment consists in the may avoiding anxiety neurosis and must be treated removing the state if Avoid by possible. carbohydrates, espe- from the environment of and take boiled albumin patient sympathetic cially rice, meat, milk, friends. Sea bathing, interesting occupation, water, fish and green vegetables. Oily sub- toning the body by open-air exercise, massage stances have the effect of reducing the outflow or of the , and rubbing with spirit of gastric juice and relaxing the sphincter. Such a patient will not be satisfied Hence olive butter and cream should be camphor. oil, without and a tonic containing taken. medicine, general dilute phosphoric acid, tincture of nux vomica and peppermint water will convince him that * he is treated. The usual dos? of histamine is 0.0005 gramme, so being that the author is presumably referring to a solution One might mention here that belching which is a containing 1 mgm. to the cubic centimetre.?Editor, symptom common to almost all gastric disorders is in I. M. G. most cases due to simple air swallowing and not to OF SOUTHERN INDIA : ORR Oct., 1935] THE DYSPEPSIAS 573

way. That is, in south India it is nearly 60 1U If the iinawam gas ^le stomach. The patienttimes is more frequent. figures of central swallows and a useful method of were Settino- k- + air, and north Travancore examined, they re the an act 4 .lze fact and to repress it ofe\v*nn-1 bywould be twice or thrice that of south India in ^le a string round his neck above the ^hyroirf 4-Si cause of eac^ time he swallows he will What is the this remarkable n?tico ifCa !i u ain<^. general. In ? The most is there ;? f3 c!lec. simple stenosis, however,variation suggestive possibility r'se tn e!men??.n by j'east in acid medium givingthe diet. A diet of north India contains on dioxide. typical also tho In chronic venous congestion ar s amounts of milk, mutton, root ^esse ? the stomach wall fail to absorb large wheat, which o gas dal and fruit. The balance ccumulates and is eventually eructated. vegetables, cabbage, of protein, carbohydrate and fat is correct and Muscular disorders the vitamin elements are well represented in the wheat and vegetables. Compare that aiony and dilatation.?/Etiology.?milk, (1 W^n'C the diet of the poorer class Travancorean muscu*ar and enervatingwith surroundin^ where the staple article is tapioca and rice, both almost carbohydrate and almost totally the either by entirely living f0verloading ,?f stomach, devoid of vitamin substances. The very small or> *n the case of the very poor, by ?.we^' amount of mutton, fish and eggs that they are - ^ar?e quantities of food of poor m to in no way make up the ^ 0rder *? ?btain sufficient nourish-able get protein ttient deficiency, and the vegetables readily available ladies' Sedentary habits. such as brinjal, finger, cucumber, etc.' are deficient in protein and lack es)) Auto-intoxication from chronic very vegetable sepsis. vitamin A. Coconut is rather better and con- resemble gastritis and hvnf^TS-These? tains a fair amount of fat, but only a small 1Jorhydria and indeed may be associated With amount of vitamin A. Thus we are dealing dis? Pr ?f these conditions. There is ?? with a living on a high carbohydrate ?' deling of the population avnJr* fullness, flatulence, of an amount of vitamin e w 9??d but Laterdiet devoid adequate 0/n quickly satisfied. vitamins A and D being particularly becomes broad and theelements, Puis ^ ,gue flabby, short 1933). ?-S V> bands and there is headache (Orr, arif) clammy, laboratories at Coonoor for In the nutritional research 1?somn^a- Hydrochloric acid persists was out. Seventeen niiiol an interesting experiment carried than acids are , ^er normal, and organic rats were fed on a Travancore diet and 17 were form* ln typical a Madrasee diet which contains more stnm i exc.ess- ^-ray reveals large fed on a typical ' no duodenalrice and no tapioca. There was a control group fed on can % Peristalsis, and, while the n?^ a diet typical of the people of north ^ food can be well-balanced into ??6u ?*" itself, squeezed India. The control rats remained healthy, the tapioca- ? ^ There is no tenderness sop ii Pa'Pation. fed rats had a 94 per cent mortality and the rice-fed related to no cent defn T the duodenum, and rats an 82 per cent mortality. Forty-seven per of of the and per cent of the rice-fed r^nity duodenal cap, hence duodenal the tapioca-fed, thirty-five uj to have lesions of the stomach. Those excluded. Also the lack of rats were found peris- diet were to of the tal?/ CaDinia an fed on tapioca subject congestion organic stenosis The to ' es. unlikely. and and both epithelial overgrowths te give white chicken, cereals, matory changes in the mucous and submucous coats of toiafSj fish, duodenum and lower and colon oread with or Stimulants the stomach, to h? jam honey. changes in the glands, loss of lymphoid ? gastr^c as nux degenerative Qui .muscle, such vomica, and invasion of the bowel wall by bacterial nine elements, ' and eserine and out of ten ^ salicylate, are indicated organisms. In three monkeys thus fed, Kv8e?e.ra^ .tonic of iron, arsenic and strychnine gastric ulcer developed. injection if not tolerated the mouth. q- by to be little doubt then that stric lavage 3 hours after to There appears meals, prevent diet r?tention of is a high-carbohydrate low-vitamin produces Vol decomposing foodstuff, mucosa uable a or and renders the and, unless there is gastritis, magne- gastritis nn liable to ulcer formation. As to the cause of carbonate is as good a substance as any. authorities differ but the consensus of Gastric and duodenal ulcer.?This is one of the ulcer, to be in favour of the view held diseases of this of India opinion seems anri fommonest part of who has demon- because of its and the ease with by Wilkie (1911) Edinburgh, tyk- frequency the first of the duodenum is ^ resP?nds to treatment we are strated that part ri+l surgical branch of the to treat all our by a small pyloric artery, dv apt it lightly and pass supplied over the artery. This is an end' yspepsias to the surgeon. It is not a supra-duodenal thrombus in its lumen condition, in other parts of artery and any forming r^rnon however, well result from the duodenitis) '? McCarrison reports that in south India (which might 1 of of in every thousand of the suffer would produce a loss vascularity that part f' population with necrosis and ulcer formation. t duodenal or gastric while in of the gut J ulceration, the ?ore' wb^?b is typical of north India, only Once the ulcer is formed, gastric juice, which 0 <>0 per thousand are found to suffer in this 574 THE INDIAN MEDICAL GAZETTE [Oct., 1935 is made more highly acid than normal by reason (3) distaste for meat; and of the carbohydrate and the irritation of the (4) a deformity of the antrum of the stomach condiments, will prevent it healing and lead to in the rr-ray. chronic duodenal ulcer. Never wait to palpate a tumour before diag- The symptoms and treatment of duodenal nosing cancer of the stomach. The signs and ulcer are so familiar that I need not dwell upon symptoms apart from the above are often them here except to point out one or two im- indefinite and confusing, but it is far better to portant facts. operate and find no cancer than to wait until (1) We have seen already that many things secondaries have spread to the glands and liver. such as and gastritis hyperchlorhydria may There are certain other conditions that we cause and tenderness. pain, vomiting epigastric must consider to make our review which is of duodenal complete. (2) Hunger pain typical Gall stones and ulcer may occur in cases of .?'The special occasionally gall interest of this condition lies in the fact that stones, , dyspepsia, and excessive it is so uncommon in this of the smoking. very part world. In we examine the (3) A feature of ulcer which is not Neyyoor always peptic in our abdominal so other conditions is the marked gallbladder operations, produced by that few if in periodicity. That is, in the early stages the any gross pathological changes this have not been seen and dealt with; pain is present for a few days and then only in a series of abdominal for a to yet 2,300 upper opera- completely disappears long period only in 38 has return These of remission tions, only gallbladder pathology again. periods been a ratio much smaller than that become shorter and and in the late noted, shorter, found in western countries or even in central stages when there is much associated gastritis India. It is well recognized that the formation the patient may say that he has no remission of gall stones on three factors:?- of This corresponds to depends symptoms. periodicity increased cholesterin in some the and down of duodenal (1) blood, (2) healing breaking to the flow of and some ulcers. impediment bile, (3) chronic inflammation in the wall of the The of a ulcer gall- (4) vomiting typical peptic bladder. occurs at the height of the pain, it relieves the pain, and is highly acid in its reaction. Increase in cholesterin is found mainly in hence is more (5) The test meal and the a>ray are the final pregnancy, common in women. It to criteria by which we judge whether there is, or is said be increased in fever. It is in is not, a peptic ulcer and I would lay stress typhoid definitely increased certain diets and be reduced a choles- upon the use of the fluorescent screen and pal- may by diet. pation in the diagnosis. To see the stomach on terin-free the screen and mark the point of tenderness, to Biliary stasis is probably more associated witness the movements of the stomach and the with people living sedentary lives, and, as the way in which the duodenal cap fills is of the average Indian woman is more a domestic greatest importance. drudge than her European sister and wears Malignant disease of the stomach.?Here clothes which are freer and do not compress the again a few words will suffice to call your atten- lower thorax, she probably suffers less from tion to some important points. Moynihan biliary stasis. (1909) propounded the view that 70 per cent of Infection of the gallbladder is said to occur gastric ulcers became malignant and he conse- in typhoid fever. Cushing (1898) found 30 per quently treated all gastric ulcers as potential cent of these gallbladder cases had suffered cancer. Also he looked for previous ulcer from typhoid. Another observer, Chiari, found symptom in the diagnosis of cancer. Modern Bact,. typhosus in the gallbladder of 19 out of incline to the view that surgical pathologists 22 persons who had suffered from typhoid. only 5 per cent of gastric ulcers become malig- Now surely in a land like this, where typhoid is nant and that much of the material a Moynihan extremely common, we would expect to find based his statistics upon were not cancerous higher ratio of gallbladder disease. I have ulcers at but advanced of all, merely stages no experimental evidence to give you and can we must note however simple ulcers. The point only throw out a suggestion which perhaps of cancers of the stomach is that the majority someone may be able to substantiate or refute. we see will have a short history. Any com- Though the gallbladder mucosa is frequently plaint of dyspepsia with loss of weight and infected by typhoid, the other two factors a man over who appetite occurring in forty has necessary for stone formation are absent, never had anything wrong with his stomach namely, (a) increased cholesterin, as the poorer before is of disease. very suspicious malignant people at any rate live on a cholesterin-free Cancer of the stomach will show the follow- diet and (b) lack of biliary stasis due to the ing :? costume and activity of the poorer women. So (1) low or absence of free hydrochloric acid; it is an ill wind that blows nobody any good; (2) a trace of blood in every specimen of the diet that brings us peptic ulcer and gastritis the test meal; safeguards us from gall stones. OF SOUTHERN INDIA : ORR 575 Oct., 19351 THE DYSPEPSIAS and it is undoubtedly by this route that the we see ^ occur, chronic commonly arises. in h le i occasionally particularly , better affects di classes who can afford a richer Symptoms.?It middle-aged men and ^ a svn' fn behoves us to be familiar with thewomen; there is often previous history of Jptonis and differential diagnosis, typhoid. There is a general bodily wasting to' y\nPt?ms-?Periodicity is absent in contrastindigestion and attacks related to food but ^01 ^iere may have been attacks butwhich may last over one or two meals. The G tlier1 a a is and no relief. tlm ,ways continuous discomfort betweenappetite poor vomiting gives 11 in the iaunr? u8' T^ere usually a history ofThere is tenderness epigastrium radiating to the left and into left shoulder. thf> +?'CC' jaundice may not be present at examination. The and and more a sf "I10 patient, usually Stools.?Large bulky oily than an Da complains ofnormal. they show increase in0"H1 Aye^-uourished individual, Microscopically full ? r^bt hypochondrium, a feeling ofin fat, but they can be distinguished from the relieved lv- nes<: by not relieved byfatty stools of gall-stone obstruction in that ^ belching, an<^ made worse or a in ee? by taking fat there is great increase unsplit fats. The rp}v.nthis peculiar to gallbladder infection,unsplit fats can be distinguished from the split an'rl Uf staste t?r meat is typical of malignancyfats by staining with Nile blue which shows ? ? , ."ypochlorhydria. The free hydrochloricthe globules of unsplit fat as bright red spots anc* ? which Unaltered eont to^a^ acidity low, in a deep blue field. meat fibres will 1S+ w*th ^?e cjr- ra;Ls peptic ulcer and hvperchlorhy-be seen also, but there will not be much change tenderness is 0f u' most marked over the tipin carbohydrate metabolism. costal and is more marked on on +? cartilage tests depend the power of the pan- taking a Special deep inspiration. creatic secretion to digest gelatin. A drug such ^ Pigment stones and those on which ('?il as iodoform is given in a gelatin-coated capsule. ^las been are the .rlv.01!11]11 . deposited seen by If the pancreatic secretions are working actively an ^c'ea as to fbe function of the gall- the will be digested and iodine will bl'/n can be capsule rv-1 obtained by cholecystography, in the saliva in four hours. In pancrea- ^6 appear lse<\ses 01 'pancreas.?Reference will only disease however the be 11 e tic gelatin-coated capsule ? two that rise to chr conditions give will pass unaltered by the pancreatic ferments. ?nic abdominal,^? pain and indigestion. The diastase reaction is a very uncertain test calculi. and in extreme At iiiof, This is not common but we have only positive degrees. opera- '^'eulicIJlree ^ses to the , recently in Neyyoor. In one, tion the gland is often found be enlarged and typ*ca* and they are detailed below pronounced; hard. ^un Treatment.?Depends firstly on with subip?,J.'>aif,ent S'as ;,1 man, not like a gallbladder dealing coIioKr' Sl'ffered from repeated attacks of acute any duodenal or biliary sepsis by surgical c '?ft sfir, radiated to the left and to the measures, but, if no lesion in either of these 'lj'11 was n ? i tender in the and had a rIi epigastrium is a no of organs found, justifying cholecystectomy iaunrl.'o u- im raP1(* Pi'lse. There was history or the correct is an ?ught to have us the clue, for gastroenterostomy, procedure qff.0]^ ot1ch given JaunHi. biliary colic without at least a trace of to drain the gallbladder. This acts by draining ""common. Also the did not a source of i'a(iia(n(?f l pain away possible sepsis and also as the anc' as is ' Usual ; right scapular region and common ?-i- co , in the !? y '' but across the epigastrium and pancreatic fj]Q Jeff majority of people, open into the ampulla of \ ater it is a means of draining the pancreatic f?a^lire ?t pancreatic calculi which is of duct (figure 1). I have carried out this in four dii0nG va^ue Hilar that they contain large cases recently with good results. ca^c^um carbonate and are there- forp m scen rpin ca.,y by the x-ray; they can be . 'emoved by operation. Van !?mc. pancreatitis? This is of two GS' are ann ^n^r^?bular and interacinar. They effJw ^ s*milar in aetiology but differ in the CoUc b ley cause. The first affects only the ex^ernai on +i the interacinar tho^? secretion, *iaiK* a and *-s Seneral fibrosis of the gland affects the islets of rise u Langerhans, giving glycosuria. -'Etiology.?Infection plays the primary part; ttlay reach the gland by ^le Pancreatic and is more often aoi^-?-?~o duct, ciated with , blood iim stream in intestinal stasis, and follow pj,r ii ShowingShowing thethe commoncommon bilebile ductduct andand pancreaticpancreatic typhoid, or ductduct intointo ampullaampulla ofof Vater.Vater. HenceHence drainagedrainage there is an intimate openingopening the con -e ^mpbatics; ofof thethe gallbladdergallbladder willwill alsoalso indirectlyindirectly draindrain the (In between the lymphatics of the pancreaticpancreatic duct.duct. ?denum11]

Appendix dyspepsia (6) the presence of accessary bands or mem- branes, This carries far more much-maligned organ (c) changes in the body structure, and than its share of for responsibility surgical (d) altered mentality. because it is so to intervention, largely easy All who have low viscera have not got symp- remove a and the healthy appendix mortality toms and yet all who have symptoms of vis- of a is practically nil, while the removal gall- ceroptosis have low viscera. bladder is a more formidable So procedure. The principal organs affected by (a) are have an innocent many unfortunate patients (1) the stomach whose greater curvature may appendix skilfully removed and are left to droop into the pelvis and the lesser curvature suffer from chronic cholecystitis, salpingitis, or be kinked and U-shaped; visceroptosis. (2) the duodenum which may be more mobile Nevertheless apart from acute appendicitis and which is sometimes crossed in its third part there is a condition known as chronic appendix by the superior mesenteric artery which will be dyspepsia, and owing to the lymphatic drainage drawn more tense by the drag of the ptosed of the appendix and its connection with the intestines and constrict the duodenum causing duodenum an unhealthy appendix may upset duodenal (figure 2); the gastric function to a considerable degree. A few points on the diagnosis of chronic appen- dix dyspepsia will therefore be in keeping here :? (1) There will nearly always be a history of one, two or three acute attacks, rarely more. (2) Each attack tends to be worse than the last and pain remains in the intervals. (3) There is deep tenderness at McBurney's point. (4) The acute attacks commence at the umbilicus and spread to the right iliac fossa, and are associated with pyrexia; this is an important distinction from visceroptosis, which we will consider next. (5) The x-ray may reveal a kinked or fixed appendix, or barium may fail to fill it; all these suggest appendix trouble. (6) On dilating the colon with air from an of caecum on enema pump and over the distended Fig. 2.?Showing ptosis causing drag pressing mesenteric artery and of duodenum. sigmoid, pain will be felt in the right iliac fossa superior kinking in many cases of chronic appendicitis. the caecum be in the or more Visceroptosis.?This is the next cause of (3) may pelvis than normal and dilated or be chronic abdominal pain to which I would direct mobile may restricted unusual bands. The colon also is you. by more mobile and be kinked at certain In earlier in India I dismissed this may my years points by bands. subject as one to applying mainly European (6) The bands are definite in their situation women and not to be considered in with dealing and are known as Jackson's Lane's the Indian but attention is membrane, dyspeptic, my being membrane and Toldt's membrane drawn more and more to it. I have kink, Payr's repeatedly (figure 3). I once came across a case where operated on a spare melancholic young woman the transverse colon was kinked into a U, and suffering from the symptoms of duodenal ulcer the two limbs of the U held in apposition by a to find that there was no visible only palpable membrane 3). I treated this case which that the first of the duodenum could (figure ulcer, part was from the of intestinal be delivered outside the abdomen suffering symptoms unusually stasis and that the csecum was mobile by colectomy. easily, extremely (c) The changes in body structure fall into and had attached to it a innocent very looking two categories, virginal ptosis and maternal I found that if one removed the appendix. ptosis. appendix the patient was better for a time and (1) Virginal.?The patient is a young woman, then came back or went to some other again with tissues poorly developed, little fat, narrow surgeon with the same symptoms. thorax, loss of lumbar curve, and slightly pro- Let us consider the four factors in viscerop- truding lower abdomen. These signs are present tosis and see if they throw any light on this from childhood but only in adult life do symp- :? type of case toms appear. (a) abnormal mobility and dilatation of the (2) Maternal.?This occurs in elderly or gastro-intestinal tract, middle-aged women who have borne children. OF SOUTHERN INDIA : ORR 577 Oct., 19351 THE DYSPEPSIAS in childhood an act of till it loss acquired by will, The abdomen is broad with wide thorax, becomes second nature to stand and sit of the correctly of lumbar curve and a marked protrusion and the will no further part. In children do plays lower abdomen. The signs and symptoms of poor mentality brought up in and unhygienic not appear till after several pregnancies surroundings with little or no training, as are so many girls in this country, the will never acts strongly enough to maintain the correct posture and they go into adult life in the ptosis condition. In adult life with the increased strain put upon the body the ptosis becomes worse. Symptoms only appear, however, if there are present some of these congenital bands or membranes which kink the ptosed organ and eventually lead to intestinal stasis and toxic absorption. The symptoms are very varied but are all characterized by the fact that no matter what the nature of the pain, it is worse at the end of the day and is relieved by lying down. The patient has a typical bodily structure and feeble mental outlook, and while the patient is usually a woman men are sometimes affected. The symptoms may simulate the following diseases :? (1) Chronic appendicitis, but instead of two or three attacks there may be a history of numerous attacks, not getting worse as does kinks. the sites of bands and appendix dyspepsia. Vomiting is repeated and Fig. 3.?ShowingShowinS sites of bands and kinks. (1)nf' Jackson's??' membrane. (2) Payrs not just at the commencement of the attacks. Jackson's membrane. (2) Payr's I??nl1membrane.kink. Toldt's membrane. (4) Lanes and there no (3) Toldt's membrane. (4) Lane's kink. Pyrexia is absent is hyperesthesia over Poupart's ligament, but an area of hyper- associated are due to loss of muscular tone often esthesia to the right of the umbilicus. The of fat ca?cum is can be elicited and /figure 4). is dilated, splashing ' in mentality.?The patient there is frequently a ptosis of the right kidney. her condition fj espondent,Y'lanf/6s inclined to exaggerate This picture was implanted on my mind by a list of bodily can give off readily a long young unmarried woman who had had her appendix removed by another surgeon and came complaining of the usual pain in the right iliac fossa. Suspecting some adhesions or pelvic trouble I operated again and removed a large fibroid from the uterus. She was better for a time and then came again complaining of pain which was made worse after walking about but did not trouble her when resting. Careful pal- pation revealed a mobile right kidney and the x-ray revealed a general ptosis of the ca3cum. As she was well off I had a visceroptosis belt made for her which gave her great comfort and relief. (2) Peptic nicer may also be simulated, but there will be no periodicity and no freedom between attacks, and pain commencing after a meal has not completely disappeared before the next meal. The patient is relieved by lying down. There is loss of desire for food, but no Fig. 4.?(1) Normal contour. (2) Virginal ptosis. real fear of taking food. X-ray is typical and (3) Maternal ptosis. there may be local spasm suggesting ulcer. I have operated on many of these cases expecting to find an ulcer and instead have been con- Etiology.?There are two functions of muscle, fronted a duodenum which was one is to produce movement and the other to only by easy to deliver and a spasm of the which maintain bodily posture. These two functions pylorus are easily deceive one into an ulcer evidently carried "out by different parts of might thinking the existed. More careful pre-operative z-ray muscle fibre and the postural tone may be lost examination can exclude ulcer and the without the power of movement being lost general or diminished. This postural tone has to be 578 THE INDIAN MEDICAL GAZETTE [Oct., 1935 build of the patient ought to be a guide. means permit, and regular bowel movement by Duodenal ileus to which I have already referred means of liquid paraffin is desirable. When the can also be readily diagnosed by the a>ray by patient's circumstances make prolonged rest im- noting a fullness of the second and third parts possible a properly fitting abdominal belt often of the duodenum. gives relief, but massage and exercise must be Cholecystitis and cancer of the stomach may carried out as well. also be simulated, but rr-ray and response to The surgical treatment is unsatisfactory, but rest and lying down, and the typical figure must a mobile caecum may be fixed by a caecapexy be our guide. operation, and a ptosed stomach can be hitched Treatment of visceroptosis.?We must re- up by means of one of the various methods of member in treating this disease that there is no shortening the mesentery. The bands causing short cut, 110 easily-performed operation which kinking may be divided and duodenal ileus may will relieve the condition for we arc dealing with be relieved by a gastroenterostomy, or duodeno- people who have faulty postural tone, faulty jejunostomy, but it must be remembered that habits, membranes and bands, as well as ptosis such operations will not relieve a general viscerop- or a poor mentality which makes them unable tosis nor will they of themselves bring relief to co-operate. unless combined with rest, massage and exercise As the trouble in the virginal type starts in as described already. If the patient is neuras- childhood, more careful training in school and thenic never operate; it only makes matters by parents would prevent a lot of it. Until worse. girls arc treated with greater frankness and more freedom it is that the given unlikely References mental problems will be solved. In the established disease we must deal first Gushing, H. (1898). Bull. Johns Hopkins Hosp., Vol. 295. with the poor tone and faulty posture. The IX, p. R. (1931). Indian Journ. Med. Res., first is rest in bed and that time McCarrison, thing during Vol. XIX, p. 61. the muscles should be developed by massage McCarrison, R. (1931?). Brit. Med. Journ., Vol. I, and gentle exercise of gradually increasing p. 966. severity. Deep-breathing exercises to develop Moynihan, B. G. A. (1909). Brit. Med. Journ., Vol. I, p. 830. the thorax and restore the lumbar curve must Or, I. M. (1933). Lancet, Vol. II, p. 575. be carried out. A diet calculated to increase the Wilkie, I). P. D. (1911). Surg. Gyn. and Obstet., amount of fat must be given if the patient's Vol. XIII, p. 399.