Diseases of the digestive canal : (sophagus, stomach, intestines) / by Dr. Paul Cohnheim ; from the 2d German edition, ed. and tr. by Dudley Fulton.

  • Cohnheim, Paul, 1867-
Date:
[1909], ©1909
    secondary, or reflex, stomach and intestinal affections, which are s3'mptoms of some constitutional disorder, or are second- ar)^ to a disease of some other organ, are to be treated with reference to the primary cause. I shall give only one example: Phthisis produces very often, at first, a loss of appetite and pressure in the stomach, which arc frequently attributed to chronic catarrh of the stomach; and such patients are often prescribed a liquid diet for a long period, in the supposition that an organic stomach trouble exists; when, in fact, only the treatment of the primar}^ disease,—in this case, phthisis,—would cause a disappearance of the symptoms of dyspepsia. It is appropriate to mention in this place that persons afflicted with lung, heart, kidney, liver and nervous disorders are very frequentl}^ sent to the specialist for treatment of dyspepsia. The examiner must, therefore, in every case of stomach or intestinal disease, make it his absolute duty to examine all the internal organs and also the central nervous S3'stem. The epigastrium, with its numerous sympathetic nerve- ganglia, offers a focus toward which the diseases of all possible organs throw their rays. This explains the fact, not com- monly known, that a large percentage of ''stomach troubles" are of a functional nature; and therein is found the explana- tion of the surprising truth that a great many patients suffer- ing from chronic stomach trouble obtain relief through "quacks," after having vainl}" sought relief for years in the regular schools of medicine. Indeed, the physician who, in clinical instruction in the universities, comes in con- tact with organic maladies almost exclusively, is naturally inclined to consider most stomach and intestinal affections as organic. Stomach pathology, more than any other department of medicine, shows the influence of bad habits, excesses "in Baccho et Venere," non-hygienic living, worry, anxiety and the restless haste and strenuousness of modern business life. In every rational therapy, therefore, it is of the greatest
    importance to establish the cause of the dyspepsia by investi- gating the occupation, home environment, habits, diet, and general physical condition of the patient. An exact anamnesis is always the most difficult and prolonged and also the most important part of the examina- tion, because the clews thus obtained furnish not only the best fulcrum for the diagnosis, but also the best indication as to the causal therapy. The contents of the book are arranged in the following manner: In the General Section on Stomach Diseases tliese topics are considered: 1. The anamnesis, with the different subjective symp- toms; 2. The methods of physical examination, particularly palpation; 3. The chemical and microscopical methods of examina- tion. The Special Section on Stomach Diseases is divided into three parts: 1. The organic, or anatomical, local diseases; 2. The functional disorders, or atony, neuroses, etc.; 3. The symptomatic stomach disorders, secondary to diseases of other organs. The same arrangement is employed in the Section on Intestinal Diseases, except that the presentation is much shorter, in order to avoid repetition. In the beginning of the Special Section on Stomach Diseases, I have given a short abstract on the Diagnosis and Therapeutics of Diseases of the Oesophagus. As an appendix, I have added a diagnostic and thera- peutic glossary, which will be convenient for the practitioner. At the end of the book are outlines of balneotherapy, electrotherapy, diet, etc., appropriate to our subject.
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    DISEASES OF THE DIGESTIVE CANAL GENERAL SECTION Anamnesis and Subjective Symptomatology Patients are unable to differentiate between the important and the unimportant symptoms of disease. Therefore, in ob- taining the history of a gastro-intestinal affection, it is essential that the physician should not allow the patient to enumerate aimlessly all his subjective disturbances, but should require him to give short, precise answers to the following questions: 1. How long have you been ill? Indefinite statements, such as "'A long time," or ''Several months," are without value. The physician must ascertain exactly how many weeks, months, or years the patient has suffered from indigestion, when the symptoms first appeared, whether the trouble developed suddenly or gradually, and whether the disease has been intermittent or progressive. The information derived from these answers immediately enables him to differentiate acute from chronic affections. 2. Do you suffer constantly or only occasionally? This question is important, because the course and pro- gress of the disorder, and the variations of its intensity, are significant in every primary disease of the stomach and intes-
    tine. For example, gastric pains which occur periodically are typical of peptic ulcer or of the gastric crises of tabes, etc.; while, on the other hand, sA'mptoms which are constant are characteristic of chronic gastritis, nervous dyspepsia, etc. It is especially necessary to determine whether periods of normal digestion have alternated with periods of dyspepsia. 3. Can you s w a 1 1 o \^• all kinds of food w i t h o u t d i f f i c u 1 t y ? With this ciuestion, the physician begins the incjuiry concerning the symptoms pertaining to diseases of the different portions of the digestive tract. If the patient answers this question in the negative, some affection of the oesophagus exists. More detailed questions will determine whether solids only are swallowed with diffi- culty, whether such are vomited, and whether the impediment to deglutition is constant or periodical. (See details in special chapter on Diseases of the Qilsophagus.) 4. Have you actual pain or only pres- sure? This question is of the greatest possible significance, because a purely functional dyspepsia never causes actual pain. Pain occurs exclusively in organic diseases of the stom- ach (ulcer, stenosis, carcinoma, etc.), or some neighboring organ (gall-bladder, appendix, colon, etc.). It should always be kept in mind, that unless patients are very careful on this point they usually say they have "pain," no matter what may be the exact nature of their discomfort, and it also frequently happens that they are really unable to distinguish between actual pain and other sensory disturbances. I include as painful all sensations of a crampy, colicky, cutting, stabbing, boring, or burning nature. Among those that are not painful, I would classify sensa- tions of pressure, fulness, discomfort, distention, nausea, weight, heaviness, or globus hystericus.