THE CONVICTION OF THE BOWEL AS THE SEAT OF INDIGESTION.
A similar routine may be followed as has been described is the case of the stomach. The patient lies on his back, with knees supported by a pillow, head and shoulders being slightly raised, and is asked to relax as far as possible his belly walls. The appearance of the abdo men is then observed. If there is any undue prominence or retraction its locality is noted, specially with regard to the organs which lie within the cavity in that situation. Reference to Plates XII. and XIV. will assist anyone to decide what organs lie under that part of the belly wall.
In some cases of bowel disease, specially when a coil of bowel is narrowed or bound down in the way described, or blocked in any way, the ordinary gentle spiral movement (peristaltic) is exaggerated, in the endeavour, so to speak, of the bowel to liberate itself or to force its con tents onwards, and this exaggerated movement may be visible on the belly wall over a limited area. Specially is this likely to be so in the case of obstruction which has existed for some time, since, if one part of the tube is narrowed, the part immediately above the block is likely to bulge unduly from a collection of retained material. Reference to Plate XII. and its description will assist one in deciding what part of the bowel it is that is involved in this unusual movement.
The hand of the observer is then laid on the abdomen to determine whether the whole of the belly wall is equally soft and yielding, or whether it is soft and yielding in one place and held rigid at another. By the movement and pressure of the hand and fingers the presence of swelling, increased resistance, pain or tender ness, may be settled, and the Plates noted will aid in suggesting what organs are in the neigh bourhood of the swollen or painful or tender part.
In the case of the bowel one cannot obtain, in the same way as one can in the case of the stomach, a sample of the contents for chemical analysis. It is clear, however, that evidence of a kindred kind may be derived from the material passed from the bowel. Although the value of such information is limited by the fact that, while the disturbance may be high up in the bowel, the material is not obtained till it has passed along the whole remaining length, and in this time it will have undergone much change. Nevertheless the examination of the motions may yield most important information. In cases where such information seems likely to be valuable, one washes the motions. This is done by mixing the motions in a perfectly clean vessel with water, to every pint of which a tea-spoonful of salt has been added.
The simplest way is to prepare a large jugful of salt and water, to break the motions down with a piece of stick, then pour on plenty of the salt and water. Stir and then allow to settle. In a short time, half an hour or so, gently pour off the coloured water, again break down any masses left, pour on again plenty, of the salt and water, and again allow to settle. Repeat this till no coloured material remains to stain the water. The remnants, which are
usually small, can then easily be examined, and it will surprise many to learn how easily its constituents may be identified. The process, it may be remarked, is perfectly inoffensive, provided large quantities of salt and water be used. As soon as the motions are well covered with salt and water, smell ceases to be given off, and no one who did not know could tell, by appearance or smell, whence the undis solved residue had been obtained, if it has been properly washed. In it it is quite easy by the naked eye to identify apple-pips, fig seeds, grape seeds and skins, grains of undigested oatmeal, undigested fibres of meat, pieces of banana, uncooked apple, and so on.
Not seldom will such a process reveal the mischief going on. In mucous disease of the bowel flakes or large pieces of mucus, like skin, are the evidence of a chronic catarrh of bowel. Clumps of thread-worms, or portions of tape worm, are easily identified, and under the micro scope the eggs of intestinal worms may be de tected. While mucus in any quantity would point to an irritation of the bowel, the presence of parts of worms would suggest the possible cause, or, in the absence of anything else, quan tities of fruit seeds, orange peel, pork rind, oat grains, or wheat husks would suggest merely errors in diet.
Quantities of undigested meat fibre hint at either excess in the consumption of meat, or want of power of the digestive juices to deal with it.
Of course at the very beginning of such a washing process one could not fail to notice, what so many people who suffer from marked bowel symptoms never think of observing, the colour of the motions, whether claylike from lack of bile, tarlike from presence of altered blood, or frothy and yeasty because of intestinal putrefactive change. In the same circum stances, too, the shape of the motions will not escape notice, whether of the ordinary full rounded form, or in small hard round masses speaking of delay in passing along the bowel, or flat and ribbon-like, or small like pipe-stems, suggesting a narrowing of the canal of the bowel near the outlet.
In short, in long-continued bowel disturb ance, washing the motions affords frequently an immediate clue to the nature of the disease, and, we repeat, the process is easy, and if pro perly done entirely inoffensive.
The pancreatic juice is most active in the digestion of fat, and when the pancreas is seriously diseased much fat may escape digestion and appear in the stools.
Thus these simple methods of observation, when combined, will have yielded much infor mation as to (1) The presence or absence of swellings or growths and the part of the bowel in volved.
(2) The locality of pain.
(3) The activity of the intestinal juices.
(4) The presence or absence of bowel irrita tion.
(5) The occurrence of fermentation in the bowel.
(6) Deficiency or not of bile.
(7) The digestion of fat.
(8) Whether there is delay in the passage of the waste along the bowel.
(9) Errors of diet.
(10) The presence of worms or other foreign matters.