1416 The Lancet,] MR. LANE: CIVILISATION IN RELATION TO ABDOMINAL VISCERA, ETC. [Nov. 13, 1909.
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 be 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
