Complete Text (Part 8)

di- minution of normal secretion and an outpouring of mucous, hence indigestion. Later there is either atrophic or sclerotic degeneration, resulting in com- plete absence of gland cells. ■■.■■.■■. In Chronic Interstitial Gastritis, the outpouring of mucous gives the same sensation of hunger, but the appetite is very quickly appeased on account of the hypo-secretion of gastric juice. Indigestion (i. e., an abnormal length of time nec- essary for stomach reduction of food) may result from eating unpalatable or insipid food, owing to the deficiency of "psychic" secretion in the stomach. 96 FUNCTIONAL DIAGNOSIS Pepsin-Hydrochloric-Acid Digestion. — Pepsin is an enzyme which, like other enzymes, is modified in its action by temperature, high temperature up to 40 degs. C. hastening, and low temperature retarding its activity. Unlike the enzyme, ptyalin, however, its activity requires the presence of an acid ; hence pep- sin digestion in the stomach is the joint result of pep- sin and hydrochloric acid. Pepsin converts proteids by a series of metabolic steps into peptones. Howell indicates this process by the following landmarks of transformation : Proteid, acid albumine, primary proteoses, secondary pro- teoses and peptones. The process is not always completed, and the chyme may be ejected into the duodenum in any one of the above stages of transformation, whence it ap- pears that pepsin digestion is not so important in itself as in its preparatory influence on the food looking to further digestion by the pancreatic juices. Fat is not, as a rule, influenced by pepsin and hy- drochloric acid, except that the breaking up of the proteids frees the fats from their combination with the proteids and prepares them for intestinal diges- tion. Rennin Digestion. — So far as is known, the only action of this enzyme is to convert the casein of milk and other casein-containing foods into para- casein, by a process commonly known as curdling, which we must suppose is beneficial to the ultimate FUNCTIONAL DIAGNOSIS 97 digestion of the casein, although the rationale of the process is at present obscure. Gastric Absorption. — Experiment demonstrates that very few foodstuffs undergo absorption in the stomach. "Water, formerly thought to be readily ab- sorbed, is known to pass through almost unchanged. Salt solutions are unabsorbed in any less concen- trated solutions than 3 per cent. Sugars and pep- tones are absorbed, but with difficulty. Acidosis in Diabetes. — Bainbridge, in The Lancet, points out that the onset of coma is usually pre- ceded for a day or two and accompanied by a fall in the output of the acetone bodies, the excretion of b-oxybutyric acid may sink from 15 grammes or more to as little as one gramme, and the acetone and di- acetic acid may be either absent or present only in traces. The decreased excretion of acetone in the breath also indicates that the production of acetone bodies is actually lessened and that the kidneys are not able to carry out their functions. The fall in the output of sugar and nitrogen, the fall of body temperature, and the lessened intake of oxygen all point to a decline in the total metabolism. Equally characteristic features of coma are the diminished alkalinity of the blood and its diminished content of carbonic acid. Acid intoxication, in the strict sense of the term — that is, poisoning by hydrogen ions — never occurs, since the tissues never lose their alkaline reaction; the term is justifiable, however, if it is used to de- 98 FUNCTIONAL DIAGNOSIS scribe the metabolic disturbances resulting from the abnormal production of acids in the body or from the administration of mineral acids accompanied by a fall in the alkalinity of the blood and tissues. The tissues are very sensitive to even a slight diminution in their alkalinity, and the acute intoxication pro- duced by mineral acids is believed to be due to a fall in the alkalinity of the blood and tissues or, in other words, to a diminution in the concentration of hy- droxyl ions relative to the hydrogen ions; this has been proved to occur as far as the blood is con- cerned. 1m J. % Intestinal Movements. — The intestines are supplied with both circular and longitudinal muscles. The former furnish what is known as peristalsis, by means of the successive contraction of the circular muscles distalward, the effect of which is to drive the contents of the bowel onward. Some physiolo- gists hold that this wave of peristaltic contraction is preceded by a wave of inhibition. That the progres- sion of the wave depends upon the arrangement of the musculature is shown by the fact that resection of a piece of the intestine and replacement in the opposite direction is followed by reversed peristalsis in the portion whose polarity is thus changed. Diarrhea and Constipation represent the two oppo- site abnormalities of intestinal peristalsis, the former being due to increased and the latter to diminished peristalsis. FUNCTIONAL DIAGNOSIS 99 In Intestinal Obstruction, if complete, the peris- talsis above the seat of obstruction is increased by the accumulation of feces, and eventually the pres- sure overcomes the distalward movement and fecal vomiting ensues. ■% ^i m Peristaltic Innervation. — Experiment and observa- tion make it probable that the muscular activity of the intestines, like that of the stomach, is automatic in origin, and regulated by the cerebro-spinal and sympathetic nerves. In both of these relationships it is undoubtedly a reflex act, in the former case me- diated by intrinsic ganglia, in the latter case by a spinal centre. The stimulus is doubtless a mechan- ical one, normally furnished by the entrance into the bowel of the food matter. The Small Intestine is innervated, both afferently and efferently, by fibers of the vagi, and sympathetic fibers from the dorsal vertibrae via the splanchnic and semilunar ganglia. The Large Intestine is innervated in its upper por- tions by the same nerve supply as the small intes- tine ; in its lower sections (descending colon and rec- tum), it receives fibers from the second to the fourth sacral nerves, and from the inferior mesenteric gan- glia of the sympathetic. , All of the cerebro spinal centres concerned in the intestinal movements are subject to direct stimula- tion and inhibition by the higher cerebral centres. The effects of emotions and ideas upon bowel centres. are familiar phenomena. 100 FUNCTIONAL DIAGNOSIS Diarrhea and Constipation, representing respect- ively increase and diminution of intestinal peris- talsis, are almost invariably due to a disturbance of the nervous reflex governing this muscular function. Diarrhea, the expression of an exaggerated peris- talsis, is most frequently due to a catarrh, either pri- mary or secondary, which renders the intestinal nerve ends irritable and leads to overstimulation of the peristaltic reflex. Psychical Diarrhea, such as accompanies sudden emotions, is doubtless brought about through vaso- motor mechanism. Certain emotions, such as fright, inhibit the splanchnic vaso-constriction, causing a congestion of the splanchnic vessels and overstimula- tion of the intestinal reflexes. Intestinal Dyspepsia is attended with diarrhea, be- cause the undigested food acts as a foreign irritant to the intestinal nerve ends and excites peristalsis. Undigested food is found in the stools. (Lienteria.) In Typhoid Fever and Cholera the bacteria and their toxins focus as a rule in the bowels, producing intestinal catarrh and exciting peristaltic reflex. In- testinal tuberculosis operates the same way. Gall Stones induce diarrhea by mechanical irrita- tion of the intestinal nerves. Worms excite peristalsis both by mechanical and chemical stimulus. In Intestinal Obstruction the accumulation of ma- terial above the obstruction acts as an abnormally powerful mechanical stimulus and increases peris- FUNCTIONAL DIAGNOSIS 101 talsis, but naturally the increased peristalsis does not result in diarrhea. The bowel being greatly dis- tended, the vigorous peristalsis can frequently be seen through the abdominal wall, and in connection with absence of defecation makes a characteristic syndrome, as well as a measure of the extent, of in- testinal obstruction. Exposure to Wet and Cold may produce diarrhea by means of vaso-motor reflex, the skin stimulus causing congestion of the splanchnic vessels and thus overstimulating peristalsis. Burns of the skin fre- quently act in the same way. Gastric Indigestion causes diarrhea by reason of the insufficient liquification of the chyme, which therefore exerts too great a mechanical stimulus on the nerves of the intestine. Reflex Nervous Diarrhea may result from reflex irritation from some other diseased organ. Constipation, the expression of diminished peris- talsis, is frequently due to, faulty innervation of the peristaltic reflex, either in its afferent or efferent phase. Neurasthenia, Hysteria, Anemia, Chlorosis, etc., are attended by constipation because of the diminu- tion in nerve energy, coupled with a debility of the muscles of the intestines. In Chronic Constipation the nerves lose their pe- ripheral sensibility on account of neglect to respond to the reflex desire for defecation. Later the intes- tinal muscles become flaccid. 102 FUNCTIONAL DIAGNOSIS In certain spinal diseases such as myelitis and meningitis, constipation results from involvement of the reflex arcs. All fevers in which there is no specific intestinal catarrh (as in typhoid, vida supra) are attended by constipation. This is due partly to the rapid absorp- tion of moisture from the bowel contents, making their passage difficult, partly in diminution in the amount of contents, lessening the reflex stimulus, and partly to malnutrition of the intestinal muscles, or weakening their intrinsic power. Diabetes is attended by constipation, due partly to rapid absorption of moisture and partly to diminu- tion of bowel contents, much of their normal solid constituents being eliminated by the kidneys. Constitutional Diseases (Tuberculosis, Syphilis, etc.) unless specifically attacking the bowel with ca- tarrh, exhibit constipation, due to malnutrition of muscle and faulty innervation. i. • ■% Intestinal Absorption. — The intestines are the chief absorbent portion of the alimentary tract. Their absorptive capacity may in general be said to range in precise ratio to the proximal topography — being greatest in the duodenum and diminishing un- til the least degree is reached in the rectum. This, however, is necessarily subject to modification ac- cording to the substances considered for absorption. In the Small Intestine absorption is very active, and proceeds simultaneously with digestion. The FUNCTIONAL DIAGNOSIS 103 process is accomplished by two forces (a) diffusion and osmosis, and (b) the selective and absorptive energy of the epithelial cells in the intestinal wall. In the Large Intestine the unabsorbed remnant from the small bowel remains a long time, during which digestion proceeds by means of the digestive juices derived from the upper bowel. No digestive juices are secreted in the large intestine, but absorp- tion takes place, especially of water and proteids, the former accounting for the eventual consolidation of the feces. The large bowel has an alkaline reaction, which favors the growth of putrefactive bacteria, so that putrefaction is a usual phenomenon in this locality. i. ?w "W The Pancreas, a glandular body of the tubular type (frequently called the salivary gland of the ab- domen) secretes a thin watery fluid, alkaline in re- action, of a specific gravity about 1.007, of which the essential digestive ingredients are enzymes called Trypsin, pancreatic diastase, and lipase. The first breaks up proteids or rather the proteid products al- ready prepared by the pepsin of the stomach; the second breaks up starch ; the third fat. Functional Pathology of the Pancreas is obscure and indefinite, owing to the fact, first, that its physi- ology is poorly understood and indissolubly blended with that of other organs; second, that its complete disablement is extremely rare and as long as partial integrity remains it performs its work with reason- able satisfaction. 104 FUNCTIONAL DIAGNOSIS Innervation. — The pancreas derives its nervous motive energy from the cerebrospinal and sympa- thetic systems by means of the vagus and fibers from the celiac plexus. Vaso-motor fibers play an impor- tant role in the proper functionating of the organ. The stimulus is supplied in a rather unusual fashion. The effect of the acid contents of the stom- ach, when ejected into the duodenum, is the pro- duction of a substance called secretion, which, being absorbed by the blood and carried to the pancreas, stimulates it to secretion. The functional pathology of the organ is further complicated and obscured by this nervous mechan- ism. Trypsin Digestion. — Trypsin is not elaborated as such by the pancreas, but as a stable zymogen known as trypsinogen, which is converted into trypsin by an enzyme of the duodenum called by Pawlow entero- kinase. As already stated trypsin completes the work al- ready begun by pepsin on the proteids. "While pep- sin works only in the presence of an acid, trypsin works best in an alkaline medium. The a.ction of trypsin is much more rapid and thorough than that of pepsin. The proteids, which are assumed to con- tain two groups of molecules, the hemis and the antis, are split up into primary and secondary pro- teoses, and thence into peptones corresponding to the proteid molecules hemi and anti-peptones. Tryp- sin, however, does not stop there, but breaks these FUNCTIONAL DIAGNOSIS 105 peptones up still further into tyrosin, leucin, aspartic acid, tryptophan, lysatinin, and other end products whose number and character of course vary with the length of time the food has been subject to tryptic digestion. No definite nutritive significance has yet been as- signed to these various products. Lysatinin is prob- ably the source of some of the urea formed in the body. Pancreatic Diastase Digestion is practically the same as that of ptyalin, namely, a hydrolytic action upon starch, converting it into maltose and dextrin. It evidently deals with such starchy elements in the food as escape the influence of the saliva. Lipase Digestion comprises three stages : (1) The enzyme splits up the fats of the food, by a hydrolytic process, into glycerine and fatty acids. (2) The fatty acids combine with the alkaline salts present to form soaps. (3) The soaps are broken up into minute globules which do not coalesce (emulsifica- tion). The latter process is not due to the enzyme lipase, but to the physical properties of the pancre- atic juice. Lipase is found in other tissues of the body where fats are concerned, notably the mam- mary glands, muscles, liver, etc. Its action is greatly assisted by bile. Fat in the feces, to any abnormal amount, is usu- ally regarded as presumptive evidence of pancreatic disability, but can only bear this diagnostic interpre- tation in the absence of symptoms pointing to sup- 106 FUNCTIONAL DIAGNOSIS pression of bile, intestinal tuberculosis, diarrhea, or large ingestions of fat. (See Composition of Feces.) Lipuria (fat in the urine) is subject to the same provisional interpretation. FUNCTIONAL DIAGNOSIS 107 THE LIVER. The function of the liver is threefold: (1) The secretion of bile, (2) the elaboration of urea, and (3) the formation and storage of glycogen. Suppression of Bile is a frequent symptom in pa- renchymatous diseases of the liver, notably in acute yellow atrophy, hepatic cirrhosis, malignancy, syph- ilis, and abscess. It is manifested as a rule by a more or less severe jaundice. Uremia, now generally recognized as a suppression of urea rather than its retention, is undoubtedly the direct result of abnormal hepatic metabolism al- though the exciting cause is the failure of the kidney to excrete urea. This phase of the hepatic function is too obscure to furnish any definite contribution to functional diagnosis. Disordered Glycogen Metabolism, and consequent starvation of the tissues, especially the muscular tis- sues, accompanies almost every degenerative disease of the liver. Coma due to retention and toxemia of metabolic products also accompanies all severe parenchyma- tous diseases of the liver, such as yellow atrophy, cirrhosis, etc. i. ^. ^. Bile. — This important secretion performs a two- fold office; one of an excretory and the other of a digestive character. Besides water and organic sol- ids, it contains bile-pigments, bile acids, cholesterin, 108 FUNCTIONAL DIAGNOSIS lecithin, fats, soaps, inorganic salts, and a species of aneho-albumin erroneously called mucin. Suppression or Retention of Bile is always accom- panied by disturbances of intestinal digestion, espe- cially of fat-splitting ferment whose activity it in- creases three-fold, and of the proteolytic and amy- tolytic ferments whose activity it doubles. These di- gestive disturbances are therefore always seen in conditions which interfere with the elaboration or discharge of bile, as yellow atrophy, malignancy, he- patic abscess, cirrhosis, cholecystitis, gall stones, etc. Nervous Disturbances also attend bile suppression or retention, due to the suspension of the excretory office of the bile and the consequent re-absorption of pigments, cholesterin, licithin, and similar excretory materials. ■Si "I. "m Bile Pigments. — The bile contains two principal pigments, bilvinbin and bilverdin, the latter being an oxidation of the former. These pigments are derived from the hemoglobin of the blood as a product of the disintegration of red corpuscles, the iron which is separated from them being retained for the forma- tion of new hemoglobin. The pigments are therefore in the nature of an excretion, and are passed largely with the feces in the form of urobilin and stercobilin. Some portion of them, however, is known to be ab- sorbed in the intestines and re-secreted by the liver, though to what purpose is not clear. FUNCTIONAL DIAGNOSIS 109 Suppression or Retention of bile invariably mani- fests itself by an absence of these pigments from the feces ; resulting in clay colored stools, common to all those diseases already enumerated as interfering with flow of bile. Excessive Bile, on the other hand, exhibits an ex- cess of pigments in the feces, producing dark green or very yellow stools, seen principally in excessive proteid feeding and in gall stones following on ob- struction of the duct and consequent accumulation of bile. ■I. -m 1. Bile Acids. — These acids are organic and are two in number, glychocholic and torocholic. They do not occur as free acids but in combination with sod- ium basis as acid salts. They are formed directly in the liver