It is necessary to keep in mind the fact that the contour of the abdomen is determined by the organs within. Though in the effort to determine the degree of development of the various organs in these individuals allowance must be made for the deposition of fat in the abdominal walls and in the cavity– a task that is not always easy of accomplishment with exactitude.
When confronted by several individuals it will be noted that the degree of development of the abdomen and its conformations are not the same in all. In one we will note a deep, broad and long abdomen, in another one that is deep, broad but short, in another one that is long and narrow. In one we will find the pelvis broad and roomy while in another it will be narrow and shallow. And these variations will be found in a group of individuals of the same stature.
That these differences in structure have etiologic, diagnostic and therapeutic significance is easily to be seen, since by the very nature of the organic development the functions and reactions will be different. Yet it is doubtful if they have ever received the attention their importance warrants. It is never the case that a given morbid process– an hepatic cirrhosis, mesenteric tuberculosis or scrofulosis, an acute or chronic colitis — will present an identical clinical course in two or more individuals of different type or of different degrees of development of the involved organ. Much speculation has been indulged in to find an explanation for this, but with little success. What purports to find an explanation is usually nothing more than a series of statements.
Did we realize that the character of the organic development determined the character of the functions, and so the reactions, we should seek for the cause of not only the variations in the clinical course of a morbid process, but also for the cause of predisposition and susceptibility where it is really to be found, namely, in the constitution of the organs and their correlations, that is, in the morphology of the whole organism. Different degrees of development means different capacities for function and different degrees of power to react.
This is in strict accord with the law of cause and effect. That is to say, different conditions of structure constitute different causes. It is well to occasionally remind ourselves of the fact that without organization there can be no functions and no reactions. Organization is the fundamental fact, the sine qua non. Hence arises the necessity to give most careful attention to those morphological criteria which alone from the basis for a logical and scientific procedure.
It is unnecessary to do more than allude to the character of the abdominal development of the newborn, its conformations and proportions, to show how radically it differs from that of the normal mature individual. And that it likewise differs in the character of the functions is also well known. What the newborn has in the way of development is a natural consequence of the degree and character of the functional activity of the various organs during the prenatal period, and is in strict keeping with the functional requirements at that period of life. The liver, because of the active service it performs during the prenatal period is not only larger but is the most perfectly developed.
Cell differentiation has reached a more perfect state in it than in the other organs. The organ has attained a degree of growth and development which enables it to meet all normal requirements without further change in structure during the first twelve or fourteen years of life. If during this period other organs grow and develop in a normal manner the disproportions which are found at birth will have been overcome and a balance will have been established.
But this, unfortunately, is rarely the way things go. Due to ignorance of the laws of growth and development and of what constitutes a normal development and what is required to bring this about, things go on in a more or less hit and miss fashion, with the result that fully 75 per cent. of all adults have abdominal proportions strikingly similar to those they had at birth, namely, large upper segment and a relatively small lower. The size and contour of the hypochondriac regions will be found large, the gladio-umbilical line will be greatly in excess of one-tenth of the stature, the inferior sagittal diameter of the thorax will be in excess of 4 cm. over the upper diameter.
It may be well at this point to refer to the insufficiency of the pleximetric method for determining the size of the liver. It is easy to see that with a high and deep vault of the abdomen the organ may lie in its normal horizontal position. In this position it presents but a narrow marginal surface in contact with the abdominal wall on which percussion is made.
Thus it may be, and often is true, that the organ is considerably above the normal in size and yet the area of dullness is little or no greater than what is considered normal. On the other hand in a narrow and constricted cavity the organ is forced out of its natural horizontal position, tilted in such a way and to such a degree that the normal area of dullness is considerably increased by a perfectly normal organ, even by one that is less than normal in size.
When we examine individuals due regard must be had for the relative proportions of the upper and lower segments of the abdomen and to the body as a whole, and for its contour as a whole. When this is done it will be noted (1) the abdomen is in good proportion in its various regions and to the organism as a whole; (2) the abdomen large in relation to the body as a whole; (3) the abdomen small in relation to the body as a whole; (4) the upper segment large, the lower small; (5) the bi-hypochondriac and bi-iliac diameters in proportion, or the upper wide and the lower narrow; (6) the abdomen rotund or flat.
These various conditions indicate above all else different degrees of nutrition and different predispositions and susceptibilities. In the first instance there will be found a state of general good nutrition, good general vigor; roundness but no special tendency to obesity unless the personal habits with regard to eating and drinking are unreasonable, or possibly a sedentary life is led and the amount of nutritive material which is consumed is not fully utilized. However, it is true that where the thoracic development is deficient, a functional consequence of which is suboxidation, there often is a strong tendency to obesity even with a normal abdominal state and with normal habits of living.
In the second instance there will be over-production, with consequences not difficult to imagine– obesity, lymphatism and a long train of conditions which have their origin in imperfect catalytic processes due to over-production and incomplete consumption. The predispositions are to arterio-sclerosis, arthritis, hepatitis both acute and chronic, nephritis, diabetes, hepatic and renal calculi. (Bouchard, Diseases Relating to Nutrition, Conclusions based on a study of 1200 cases.) In children the predispositions are too large tonsils, adenoids, engorgement of the mucosa and parenchymatous organs, rickets and lymph node inflammations.
In the third instance the vigor of the digestive functions will be below normal always. The individual will be a dyspeptic; he will be anemic, thin; have scarce musculature, little vitality, low resistance. And if the lower abdominal measurements are less than normal the conditions will be still worse. These will indicate a poorly developed intestinal tract. It has been shown that the vigor of the digestion is in a large measure in relation to the development of the intestines.
This is readily seen when we call to mind the fact that vegetables constitute a large portion of the ordinary diet, and that these are digested in the intestines almost wholly, their proteids requiring an intestinal ferment to be broken up. Moreover, a vegetable diet is a bulky diet, hence in a small intestinal tract the process of elimination will be slow, giving time for a good deal of putrefaction. All this will mean habitual denutrition. In this type we will find also a strong predisposition to gastro- intestinal catarrh, both acute and chronic; enteroptosis; and when associated with an exaggerated nervous development, gastric and intestinal neurosis.
Some years ago–1907–B. Stiller in his monograph, “Die Asthenische Konstitutionskrankheit,” called attention to the constant relation between the presence of a tenth floating rib and neurotic and dyspeptic conditions. He tells us that when the tenth rib is found floating in a child one can say with certainty that the individual is a candidate for future neurasthenic and dyspeptic troubles. This sign of Stiller is occasionally found in persons built on the broad plan and who appear robust. But here the meaning is the same as it is in the long and tubular type, somewhat modified, of course, by other conditions.
In the fourth instance there will be over-activity on the part of the intake organs and deficient function on the part of the organs of elimination. Sluggish intestinal activity will certainly be present. The bowels may move daily, but examination will show by the putridity and by other signs that the fecal mass has been too long retained. Habitual constipation is the general rule in these cases, especially if there is a general neurotic habit. Again there will be alternate constipation and diarrhoea.
In the fifth and sixth instances the conditions will be determined in a large measure by other factors. These will be largely contributions to other conditions.
The significance of the width of the gastric angle is too well known to require special mention. The wide angle is invariably found in those with a voluminous abdomen and the narrow angle in those with the long and tubular abdomen. It is a point that should never be overlooked in the examination; yet it should never be made the sole point on which a conclusion is based. It is only one thing that indicates the character of the organic development. For instance, though it gives us some idea of the width of the cavity, it tells us nothing of the depth, to say nothing about its telling us nothing of the character of development of the intestines.
Now regarding the development of the alimentary tract we learn from the anatomists that the average total length from mouth to anus is from ten to eleven meters, or six or seven times greater than the stature, and that the small intestines are about eight meters long and the large from 1.30 to 1.70, possibly two meters. These figures merely give the average. Goldwaithe, I think, tells us that the intestinal tract has been found on autopsy as short as ten and as long as forty feet. That with such an astonishing difference in development there must be a marked difference in degree of functional activity goes without saying.
No one can possibly doubt this. To imagine an equal degree of activity is to imagine that something that doesnt exist can function, or else to say that thirty feet of intestine is of no use, is just so much redundant tissue and absolutely useless. Of course, everyone will admit that where there is so great a difference in degree of development there will also be great difference in degree of functional activity; but some may deny any importance where the difference is only a few feet.
Well, in some instances a few feet may not seem to make much difference, but in others, depending on other conditions, a few feet may make a very great difference. It is just these slight variations, especially where there are a number of them, that account for those conditions which in our ignorance, and to hide our ignorance, we call idiosyncrasies.
But how do we determine the degree of development of the intestines? Recall what was said at the beginning of this discussion: “the contour of the abdomen is determined by the organs within.” If this is true then it follows that an abdomen that is shallow, short from the umbilicus to the pubes, and the pelvis is narrow, all indicating a small cavity, will contain a small intestinal tract. Large organs cannot be put in small cavities. Nature doesnt build that way.
A case is recalled of a lady of forty-five, who all her life had been subject to diarrhoea,and all her menstrual life to frequent and profuse menstruation. Both processes were more or less painful. The X-ray showed considerable enteroptosis. At various times the uterus had been prolapsed, though at time of her first visit she was not troubled with this. For a period of fifteen years and up the time of her visit she had not had a single normal stool, but on the contrary several large, soft, mushy or again watery and slimy stools every day. The menstrual flow was never less than seven days, and profuse a good part of the time.
There were, of course, a great many other symptoms. The morphological examination showed among other things a deficient development of the nervous system, likewise of the thoracic system, and a marked excess in development of the abdomen. The abdomen was 5.5 cm. excess in length and the pelvis was 3.7excess in diameter. Putting these three things together and we have what ? Low degree of nervous activity, deficient respiratory function and all that this means to all the functions, and a flabby, watery, plethoric state of every organ and tissue in the abdomen.
Another case is that of a man now about sixty. He reports that he doesnt recall a time when his bowels have not been constipated. In this case the morphological examination showed an over development of the nervous system, a normal thoracic development, a gladio-pubic line that is 4.6 cm. excessive and an umbilico-public line that is 2.5 deficient, and a pelvic diameter 3 cm. deficient.
Here we have a case that is the direct opposite in both structure and function to that of the first. Both cases had had every conceivable kind of treatment with little or no benefit. The lady was in the hands of an osteopath at the time I was asked examine her, and the man had given up everything. During his years of effort to find relief he had been in the hands of practically every materia medica specialist in the previous thirty-six years.
In both these cases the primary factor was structural, and the best that anyone had been able to do for them was palliative. Their defects ought to have been recognized in earliest childhood and by the intelligent control and direction of the life forces they should have been helped to grow to a normal maturity. But intelligence of this kind is still lacking, not only in the home but in the medical profession, as well.
We sit by and patiently wait for something to develop that tells us that things are not right, then try and remove the effect, all the while oblivious of the true condition. Moreover, we compound our blunder by trying to teach and by thinking we are learning materia medica by merely repeating words and phrases about effects. It would be to laugh, were the results not so tragic.