And the Lord appointed a great fish to swallow up Jonah. And Jonah was in the belly of the fish three days and three nights. (Old Testament, Jonah 1:17)
Medical students are well known for experiencing symptoms of the conditions they are studying, codified by some authors as ‘medical student disease.’1 Working their way through respiratory pathology, then cardiac dysfunction and onto orthopaedics provides a movable feast of pain and suffering that leaves more than a few pondering each new ache and twinge. All those sleepless nights, worried about their ultimate mortality, may leave at least one important benefit: perhaps this helps engender a greater sense of compassion and humility when later confronted by patients in their care whose lives are being cut short by the ravages of human disease.
Interestingly, while touring through this cacophony of pathophysiology, I personally remember instinctively feeling more at ease with certain body systems at the expense of others. As a somewhat proficient anatomist with a strong visual memory, I felt more sympathetic to structural disorders of large edifices, such as bones, and those with clear histopathological features, such as lung cancer. Unfortunately, this left a range of disorders that were somewhat less explicable to my developing clinical prowess. And for me, they were pretty much all in the abdomen, where a knowledge of the anatomy did not seem to easily correlate with the apparent bewildering array of patients’ descriptions of bowel pain and the passage of their bowel actions.
Perhaps this unease with the abdomen related to the paucity of reliable investigations at that time. Having graduated from medical school in the radiological equivalent of the dawn of the Enlightenment, I clearly recall that the only objective method for diagnosing serious abdominal pain was a laparotomy! Yes, this was the same era when the publishers of the Beatles would also house the visionary leadership of Godfrey Hounsfield, who went on to earn a Nobel Prize (1979) for inventing the EMI (now computed axial tomography or CAT) scanner.
Interestingly, in the years that followed, abdominal problems increasingly fell into two clear but occasionally overlapping groups: those with visually demonstrable pathology (the ‘anatomical’ group), and those with disorders of how complex systems work (the ‘functional’ group, which has unfortunate and usually incorrect overtones of psychosomatic illness). Perhaps the best known of the latter are those clinical syndromes clustered around the headings of irritable bowel syndrome or food intolerance. Yet, even those in the first group required intensive primary and clinical research to pin down the processes at play. The best known is of course Helicobacter pylori, but increasing sophistication in clinical and laboratory assessment is helping to clarify and focus the vision on other conditions that have traditionally been considered to be without investigable causes.
In this edition of Australian Family Physician, we have commissioned a team of notable experts to discuss the impact of new information on the clinical approach to well-known abdominal diseases that fall within this loosely defined paradigm of ‘anatomical’ rather than ‘functional’. Tracey, Kirke, Armstrong and Riley2 discuss the increasing complexity of Clostridium difficule infections, while Turner3 explores the clinical challenges around chronic pancreatitis.
Perhaps the most intriguing aspect surrounding our understanding of these diseases, from a clinical practitioner’s perspective, are the substantive changes occurring in the pathological classification and interpretation of gastrointestinal biopsy material and the consequent impact on clinical management. Walker, Harris, Edwards and Talley4 walk through the increasingly complex and challenging field of disease classification and diagnosis as seen from the pathologist’s perspective.
The belly has an interesting place within the lexicography of early language, including both the organs that lie within and as a figurative place of emotions, distress or love.5 Modern medicine has long moved on from those metaphorical understandings. And fortunately for our patients, ongoing developments in basic, applied and clinical research are exploring new horizons, leading to better clinical outcomes.
Stephen A Margolis MBBS, MFM, MD, GEM, DRANZCOG, FRACGP, FACRRM, Senior Medical Editor, Australian Family Physician; Professor, School of Medicine, Griffith University, Queensland; Medical Officer with the Royal Flying Doctor Service.