Civilisation in relation to the abdominal viscera, with remarks on the corset
CIVILISATION IN RELATION TO THE ABDOMINAL VISCERA, WITH REMARKS ON THE CORSET.
By W. ARBUTHNOT LANE, M.S. Lond., F.R.C.S. Eng.,
SURGEON TO GUY'S HOSPITAL; SENIOR SURGEON TO THE HOSPITAL FOR CHILDREN. GREAT ORMOND-STREET.
We hear a great deal of civilisation, as it is called, and the enormous advantages that accrue to humanity through its influence. Perhaps the most apparent advantage is the safeguarding the individual from the possibility of damage by his fellow creatures. While I would not wish to dispute the benefits which are derived from it, I would like to call your attention to the fact that there are many very serious disadvantages associated with it. These deal chiefly with the mechanical relationship of the individual to his surroundings. I do not propose to do more than call attention to the number of conditions which very materially shorten the life of the man who makes his living out of laborious pursuits, and limit in a corresponding manner his capacity for the enjoyment of life. These physical conditions represent the fixation and exaggeration of attitudes of activity, and are all progressively depreciatory, since they necessitate a shortened life, not only of the joints affected, but of the entire body. Again, the fixation of attitudes of rest, such as lateral curvature, flat-foot, knock-knee, &c., has a similar damaging effect, both on the altered joints and on the body generally, and materially affects the length of life and the capacity of enjoyment of the individual.
What I wish particularly to call attention to is the disadvantage that the individual experiences from the habit of keeping the trunk constantly erect. This habit of keeping the trunk erect from morning to night, whether the erect or sedentary attitude is assumed, is almost universal in the condition of civilisation which exists with us in the present day. It is necessitated by our habit of using chairs and by the fact that circumstances and surroundings do not lend themselves to our lying or squatting on the floor. The erect posture affects men and women differently, for the reason that the abdomen of the woman is relatively much longer than that of the man, while the female thorax and pelvis differ materially from the male. The abdominal wall of the woman is also rendered less efficient by pregnancy and by the support afforded by her dress.
To reiterate, I would formulate three general principles. When an attitude of activity is assumed on a single occasion certain tendencies to change exist. If this attitude is assumed habitually these tendencies to change become actualities, and the skeleton varies from the normal in proportion to the duration and severity of the attitude. The skeleton is first fixed in the attitude of activity, and later that attitude is progressively exaggerated. The same is true of an attitude of rest assumed on a single occasion and also when assumed habitually. The skeleton of the ordinary or normal individual rests upon a combination of the tendencies to change consequent on the assumption of complementary attitudes of activity and of rest. Now, when the trunk is erect, there exist tendencies to the downward displacement of the viscera contained in the abdominal cavity. The several viscera are influenced by this tendency in a varying degree in proportion as they themselves vary in weight. For instance, the stomach and the large bowel are probably the most variable in weight, since a quantity of material collects in them and passes along at a comparatively slow rate. The more or less fluid nature of the contents of the large bowel assists in its accumulation at certain points, as, for example, in the cæcum and in the middle of the transverse colon, while in the stomach the pressure is exerted on its convexity.
The mechanics of the abdominal wall are such that the muscles exert a firm pressure on the viscera and tend to prevent their downward displacement. Still, in the abdomen, as well as in the body generally, the anatomy is so arranged that there must he a suitable relationship between the attitudes of activity and those of rest, or, in other words, that the erect posture, in which the viscera tend to drop, must be alternated sufficiently with a position in which all strain is taken off the viscera and the tendency for them to drop is in abeyance. This latter may be obtained by the assumption of the recumbent or of the squatting posture. In the former the viscera tend to displace upwards by their own weight, while in the latter they are forced upwards by the forcible apposition of the thighs. In our state of civilisation the recumbent posture is only assumed at night, and even then only partially, since the heavy buttocks and thighs sink deeply into the bed. The squatting posture, so common among savage races, is never employed. Therefore with us, from an early hour in the morning till a late hour in the evening, or for at least 16 out of the 24 hours, the tendency to drop of the viscera exists, while during the night this tendency is more or less in abeyance, but in a degree below the normal of the savage.
Nature deals with this modification of the normal mechanical relationship of the individual to its surroundings in precisely the same way as it deals with any specialised mechanical function, whether active or passive. First, as regards the large bowel or cesspool of the gastro-intestinal tract: it attempts to oppose the downward displacement of the cæcum into the pelvis by the formation of peritoneal bands, not inflammatory in origin, but functional, if I may so use the term, which pull upwards the hepatic flexure and secure it with as much firmness as possible in the upper and back corner of the right loin. Acquired bands secure the outer surface of the ascending colon and cæcum in a similar way to the peritoneal lining of the adjacent abdominal wall. They also grasp the appendix, commencing at its base and forming a new mesentery, which is more or less distinct from its normal mesentery. In this way a portion of the appendix takes on the function of a ligament of the cæcum, tending to oppose its downward displacement. Unfortunately for its new function, the appendix being a hollow tube whose mucous membrane secretes fairly abundantly, it is ill adapted for this purpose. The pull exerted by the heavy loaded cæcum upon such of the proximal portion of the appendix as is fixed by acquired adhesions to the abdominal wall produces a kinking of the appendix at the junction of the fixed and mobile portions. In consequence of this secretion tends to accumulate in the distal portion of the appendix and concretions form in it, or it may become more or less acutely inflamed, producing varying conditions of what is called appendicitis. And unluckily for the right ovary, the appendix becomes a near neighbour, and the irritation and annoyance of the ovary may result in a cystic degeneration of that structure. Again, the recurring menstrual engorgements of the ovary serve also to encourage the appendix to manifest the effects of its mechanical disability at these periods.
The transverse colon, especially when loaded, tends also to fall into and occupy the pelvis. The abnormal acquired fixation of the hepatic flexure in the right loin and of the splenic flexure in the left loin help to oppose the downward displacement. Some of the load is transmitted to the ascending and descending colon by means of acquired adhesions, which connect the descending and ascending portions of the transverse colon respectively to the ascending and descending colon. Above the connexion of these tubes is direct, exaggerating very much the kink at the flexures. Lower down the strain is transmitted along an acquired mesentery which stretches from one to another. The greater portion of the load is transmitted along the great omentum to the convexity of the stomach, which may itself be loaded up at the same time. This abnormal drag on the convexity of the stomach is met by the formation of peritoneal adhesions or bands, which attach the upper and anterior aspect of the pylorus to the under surface of the liver. The upper attachment commences in the vicinity of the transverse fissure and extends forwards along the under surface of the liver, not infrequently attaching the gall-bladder or its duct. The effect of this upward drag upon the pylorus and of the pull on the convexity of the stomach is to interfere with its normal functioning and to result in its progressive dilatation. The strain on the stomach is experienced along its upper margin, and especially on either side of the pyloric attachment. It would appear that in the male subject the tearing strain is greater on the upper aspect of the first piece of the duodenum, while in the female it is greater on the proximal side. This varying distribution of strain would be readily accounted for by the different form of the abdomen in the two sexes. Again, if the liver itself is mobile and displaced, and the pylorus no longer depends for support on it, the point of strain in the concavity of the stomach approaches the œsophageal attachment in a degree proportionate to the downward displacement of the liver. The importance of these points of strain is that in the presence of auto-intoxication these two factors produce engorgement of the mucous membrane, its excoriation, ulceration, and later its infection by cancer.
The descending colon acquires a connexion to the peritoneum lining the abdominal wall external to it, partly to fix it, and partly to transmit the strain exerted by the transverse colon through it. The loop formed by the sigmoid section of the large bowel falls into the pelvis and struggles with the cœcum. the transverse colon, and pelvic organs for the mastery. As the contents of the sigmoid are fairly solid, this piece of gut is a very unpleasant and obnoxious companion. Therefore Nature endeavours to fix it in the iliac fossa as a straight immobile tube connecting the descending colon with the rectum. This is effected in the manner already described—namely, by the development of acquired bands of adhesions resembling peritoneum in appearance. These tags connect first the outer surface of the meso-sigmoid and later the outer wall of the sigmoid to the iliac fossa, till finally a straight fixed tube, whose muscular coat is comparatively thin, with a partial peritoneal covering, replaces the original mobile loop. The left ovary is in immediate relationship with the outer aspect of the meso-sigmoid, and very frequently becomes involved in the tentacle-like peritoneal processes fixing the meso-sigmoid and later the sigmoid. Later it becomes embedded in the adhesions and then completely surrounded by them. After a time the ovary becomes cystic and enlarged, when it forms around itself a serous covering so that it moves freely in a cavity. This covering gives way, and when the aperture is sufficiently large the cystic ovary escapes. It continues to enlarge and elevates the cæcum, transverse colon, and stomach, and to a great extent meets the disabilities consequent on intestinal stasis, of which it is itself in this instance both the effect and the cure. Unfortunately, these cystic ovaries are more often malignant than was originally supposed. In a large number of cases in which I have removed large cystic ovaries I have been able to demonstrate, beyond a shadow of a doubt, the presence of the nest or cavity in which the cystic ovary grew.
In a certain proportion of cases the acquired tags or bands of peritoneum do not grip the meso-sigmoid uniformly owing to the escape of the centre of the loop. In this case they attach only the extremities of the loop, approximating them to one another and kinking both. In consequence, an obstruction exists at the junction of the descending colon and sigmoid, and again in a more severe form at the end of the sigmoid. In consequence of the latter obstruction the loop becomes abnormally large and nature's efforts being only partially effective produce a condition which is infinitely worse than the normal loop, and a so-called volvulus results. The fixation of the sigmoid as a straight tube is unfortunately associated with a diminution in its calibre and in its muscularity, and irritation, abrasion, ulceration, and cancer of the mucous membrane result. In some instances abscesses form in or about, the wall of the fixed sigmoid in consequence of the traumatism to which it is habitually exposed from the passage of its contents being rendered difficult by its fixation and limited calibre and muscularity. Associated with the intestinal stasis are the very serious symptoms that ensue from the absorption of toxins into the symptom.
The earliest, feature is the inhibition of the respiratory centre, and accompanying this, and apparently consequent on it, is the very definite enfeeblement of the circulation. These patients depend more or less completely on their diaphragm for obtaining enough oxygen to carry on their mechanical relationship to their surroundings which becomes more and more modified as the condition progresses. This brings about the several resting postures with which we are all so familiar and which we attempt to cure by exercises alone, regardless of the factor which produces them. Their resisting power to the entry of organisms is subnormal and the organism which most commonly effects a foothold is tubercle. The younger the subject the more readily does tubercle appear to be able to invade some tissue damaged by traumatism. The pulse is very feeble and soft. While the trunk is fairly warm, a hand passed over the shoulder of a toxic patient comes very abruptly at the level of the insertion of the deltoid on a cold zone, and this coldness becomes more marked as the hand descends to the fingers. The skin covering the back of the upper arm is reddish-blue, very thick and gelatinous in appearance and consistence. It is not infrequently rough from the presence of large prominent papillæ. This condition causes much distress to the mothers of girls who wear short sleeves. The skin of the forearm is bluish and marked into islands by lines of a darker hue which correspond to the superficial veins. The hand is mottled partly by blue, partly by yellow patches. The sensation imparted to the hand of the observer by that of the toxic patient is unmistakable. It is cold and clammy, and moist on its palmar surface. The ears are also bluish and feel cold, as also does the nose, but to a much less degree. These symptoms vary considerably with the surrounding temperature, but are readily recognised in the warmest weather.
The pigmentation of the skin in these toxic people is a very marked feature. Like many of the symptoms which result from intestinal stasis, but in a greater degree, it varies with the colour of the hair. While dark-haired people show pigmentation in a very marked manner, those with red hair show it slightly or not at all. In some peculiar manner red-haired people appear to possess a comparative immunity to the effects of intestinal stasis. Except for the face, the areas that show pigmentation most conspicuously are those exposed to friction, such as the inner aspects of the upper parts of the thighs, with the adjacent opposing surfaces of the buttock, the spines and abdomen where the corset or dress presses, the axillary folds, the bend of the elbow, and the neck. Pigmentation commences in the eyelids, spreads over the mouth, side of the nose, and later over the cheeks.
Loss of flesh is a very serious symptom and is productive of necessity of many secondary troubles. In the pelvis the loss of fat, aids in producing the elongated contracted cervix uteri and the flexions of the uterus which are so commonly present in these cases. In the loin it removes that elastic support which keeps the range of movement of the kidney in what is regarded as normal. The loss of fat in the face and neck produces an appearance of age, distress, and disappointment which is most pathetic, particularly in the young subject. The loss of muscularity is shown in a complete want of tone, the muscles being flaccid and inelastic. In the case of the abdominal muscles this is particularly serious, since one important factor in controlling the position of the viscera is lost more or less completely. The individual is also unable to lead an active physical life because of the poor muscular development. The muscles are not only small and feeble, but become very soft and friable, so that they tear readily, and when sutured yield and afford no security to the ligature. The condition of the breasts is also a very important one. First, the upper and outer zone of the left breast, and later the same portion of the right, show changes. In the young subject they become hard and nobbly, and may be sore and painful at the menstrual periods. Later in life they develop a cystic change, which may be painless or may be associated with attacks of pain owing to the distension of one or more cysts. Still later these degenerating breasts are very liable to develop cancer. Though the degenerative change commences in the upper and outer zones it may spread to the entire breast. It is very much more common in the virgin, and only arises in the married woman when intercourse is abstained from or is very irregular. These toxic people have very little or no sexual appetite, just as they lose their appetite for food and even hate the sight or smell of it. Perhaps the most interesting and accurate description of the influence of intestinal stasis on the sexual appetite has been written by Rudyard Kipling in "The Light that Failed." I do not think Kipling knew that his heroine was affected by intestinal stasis and probably constipated, but he describes an individual with that accuracy of observation and power of description in which l believe he has no equal. I need not recall the red-haired companion of the heroine, as I am sure all are perfectly familiar with the characters in the novel.
Perhaps one of the greatest of the many great men of whom America can boast was Brigham Young; he by irrigation converted a very poor district into one of the most fertile of the United States. He also attempted to popularise polygamy, and his efforts in this direction were met by a success almost equal to those in the direction of agriculture. I am unable to form any definite opinion as to how his action was influenced by the knowledge of the influence of intestinal stasis on women, and the benefit which these people derive from matrimony. His views on this subject certainly did not meet with encouragement in the United States, partly, I suppose, because of religious or legal objections, and probably to a great extent from the ignorance of the public and even of our profession on the subject of intestinal stasis. I am inclined to think that when women know more about the physiology of life they may exert some influence on legislation. This is more likely to develop, in the first instance, in the United States, where both men and women hold broader views and are less tied by creeds and tradition than they are in the old world.
The mental condition which is brought about by auto-intoxication is most distressing. While it renders the subjects miserable, and unable to concentrate their attention on work or pleasure or to control their tempers, it makes them most unpleasant companions. An alcoholic woman may be cheerful under the influence of her drug, but in no circumstance does the toxæmia of intestinal stasis produce other than a depressing influence on the mind and on the body generally. Medical men are very fond of calling this condition neurasthenia. These patients readily become melancholic. They frequently suffer severely from headache, either continuously or at intervals, and they awake in the morning with a headache, feeling they have obtained no rest or advantage from their sleep, and that they are just as tired and exhausted as when they went to bed. The world seems always chill and gloomy to them, quite apart from the intestinal pain and discomfort which they so often experience. My friends have often said to me that they were sure patients would never submit to such a serious operation as removal of the large bowel. They forget that to these sufferers life bas no attraction, and the risk of the operation at least affords them a chance of escaping from it. I do not think that any patient bas expressed to me the slightest anxiety on this score, but has most willingly grasped the opportunity of parting with his other troubles at all costs and at the earliest opportunity.
The patients usually suffer from abdominal symptoms, varying from a colicky pain due to obstruction at a flexure or at the sigmoid, or to a flatulent distension of the stomach or intestine due to decomposition produced by the delay in evacuation of the contents, or to the presence of a pancreatitis or of gall-stones. These conditions have resulted, partly from a direct infection of the pancreatic or biliary ducts by organisms from the small intestine whose level in the small intestine has been materially raised by stasis, and partly from a reduced resisting power to organisms consequent on the auto-intoxication. This infection of the pancreatic and biliary ducts does not appear to take place in such cases of intestinal stasis as arise early in life. I have never seen it in patients in whom loss of flesh has been a marked feature before 20 years of age. Infection of the gall-bladder and later of the pancreas arises in stout patients who develop intestinal stasis at or beyond middle life. It would seem that the loss of flesh and of vigour consequent on the toxæmia of intestinal stasis so affects the mechanics of the gall-bladder as to produce an accumulation of bile in it and in association with the infection of the ducts to determine the formation of stones in it. Here again intestinal stasis is responsible for an inflammation of these structures followed later by a cancerous infection.
I have endeavoured to indicate the importance of the fall of the viscera in the erect posture. Obviously the most effectual means of meeting this condition is by the exercise of a sufficient pressure exerted appropriate]y on the lower abdomen. For a long time women have been in the habit of wearing corsets for the purpose of supporting their dress and of affording attractive outlines to their bodies. The English corset is disastrous in that it exerts a constricting encircling pressure on the abdomen about the lower costal margin and exaggerates the tendency to downward displacement of the viscera. The straight-busked French corset is much less harmful, and if skilfully made and applied serves to exert a moderate pressure on the lower abdomen. The corset that is most efficient is one that, while exerting a firm and constant pressure in a backward and upward direction on the abdomen below the umbilicus, leaves the upper portion of the abdomen quite free. Owing to a want of knowledge of the pathology of intestinal stasis the corset has not received the attention it deserves, so that by far the most important factor in the treatment of intestinal stasis and of its effects has been left in abeyance. I would strongly urge its therapeutic value on the medical profession as being the most effectual means I know by which the trouble to which I have called attention in these remarks may be avoided or mitigated.
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