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Tis scarcely necessary to state that the successful treatment of motor and mechanic conditions of the stomach must be based on a correct conception of the conditions present, both in general and in the particular case. The physician whose diagnoses and conceptions are based on actual demonstration, critically considered in each case, soon finds that many plausible theories concerning the stomach are far from correct.

For example, there is a surgical dictum that obstruction at the cardia goes with a small stomach, obstruction at the pylorus with a large one-a natural inference, but by no means always true either way.

Again, we naturally associate motor weakness of the stomach with prolonged retention of its contents an equally logical yet still more incorrect premise. A primary obstacle at the pylorus, whether this be due to extrinsic pressure, to local tumor or cicatrix, to idiopathic muscular hypertrophy (if there is such a condition) or to reflex contraction resulting from an adjacent ulcer or some unknown factor, almost inevitably delays the passage of the contents into the duodenum. However, this condition is almost always followed by increased muscular power on the part of the stomach generally, exactly as valvular obstruction of the heart is followed by an attempt at compensation. Likewise, as in the case of the heart, functional attempt at compensation is often, if not regularly, followed by true hypertrophy, although in either organ dilatation and muscular weakness, even atrophy, ultimately develop. Rather frequently the anterior wall of the stomach can be felt as a tough, dense wall, and the organ is small. The more the clinical picture of the case resembles cancer, the greater the suspicion that the palpability of the gastric wall is due to infiltration; the more clearly achylia and general fibroid changes are demonstrable, the more must we lean toward the diagnosis of a true

interstitial gastritis; yet in many instances, whatever the probabilities, we ultimately find a genuine muscular hypertrophy.

On the other hand, true muscular atony is not incompatible with a very rapid passage of contents through the stomach. Provided that the stomach is not a pouch mainly below the pyloric level and that the gastric wall generally and the pylorus are equally weak, in that case bland, soft, semiliquid contents which are such as are expected from the usual advised or selfimposed diet in such cases easily slip through into the duodenum. There has been considerable dispute as to the proper conception of achylia gastrica and relaxatio pylori, so called. There certainly is a tendency to combine these chemic and mechanic factors of weakness, but there is no necessary association.

Another fact, extremely puzzling in its therapeutic demands, is the lack of connection between the competence of the pylorus and of the cardia. However, the cardia is normally a very weak sphincter, and it is, therefore, not surprising that it is especially apt to allow regurgitation in those cases in which the pylorus is spastic or organically obstructed.

To make a complete diagnosis of the conditions here considered requires a thoroughly judicial attitude. What is the stomach doing chemically? At what time, do its contents escape? Is there obstruction of some kind at the pylorus? What is the size, the shape, and the location of the stomach? What is the consistence of its walls? What definite lesions are present?

All these questions should be answered on direct evidence, without being prejudiced by the evidence on one, to jump at a conclusion with regard to another. If we make diagnoses on the theory that if one thing is so another thing ought to be thus, our therapeutics will also be on the basis of what ought to happen, whereas the

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Atonic Gastric Dilatation Defined

Atonic dilatation of the stomach is a marked enlargement and relaxation of the organ, occurring from essential weakness, without organic obstruction, at the pylorus, and is quite analogous to certain types of cardiac dilatation without valvular disease, although the latter may be marked by murmurs. It is favored by distention, either with gas or with large quantities of ingesta, particularly water. It is also favored by ptosis-and these two conditions may develop concurrently. Gastric catarrh naturally favors its development, both because the latter is apt to be complicated with true degenerational processes in the musculature and because catarrh is usually attended with deficient hydrochloric acid and ferment activity, so that digestion is slow and gas formation marked. Anemia and systemic depression generally favor its development, not only directly, but because slow digestion and fermentation with lack of hydrochloric acid are usually present in such cases. But note that we are speaking of tendencies, of phenomena that may be expected as sequalæ, not of inevitably cooperating processes.

We may have a weak, atonic stomach which recovers without ever reaching the stage of dilatation. Such a stomach is usually atonic in secretion as well as in muscular action, but not necessarily so; even with deficient hydrochloric acid and peptic power there may be a surprising lack of fermentative processes. We must take the case as it is.

A stomach which is strong in secretion and motion, even if larger than the average, can not be considered dilated. A hardworking man or even a human hog may habitually eat and drink large quantities, even including carbonated waters, and beer and vegetables, which inevitably ferment to some degree, yet neither the actual weight nor the distending influence of the ingesta bring about a true dilatation.

On the other hand, unless an organic stricture or spasm due to ulcer or other cause involves the pylorus very gradually

tion, genuine obstruction at the pylorus does not usually produce dilatation immediately, but only after compensation has failed, almost precisely in analogy with the heart. Thus there seems adequate reason, both from the practical and the theoretic standpoint, for recognizing atonic dilatation as a distinct type.

By many writers, especially surgeons, ptosis and dilatation of the stomach are more or less 'confused, and it must be admitted that they have a common etiologic factor-intrinsic weakness of tissuesalthough in the former rather affecting ligamentous, in the latter, intrinsically muscular tissues. It is also true that, on the one hand, ptosis, by imposing (literally as well as figuratively) uphill work on the organ, tends to cause dilatation, while, on the other hand, the accumulated material in the lower part of a dilated stomach tends to pull down the whole organ and to cause a ptosis. Still, in the majority of cases, reasonably pure types will be met with.

It should not be supposed, as some critics have assumed, that the contention for a sharp differentiation of ptosis and dilatation-unless actually combined-is a purely academic matter. In the one case, the problem is to support, to lift up, in the other, to contract, although in both we have the common indications of strengthening and, if possible, of shrinking tissues. The crucial differential test is to determine the site of the upper part of the stomach.

A very practical point to consider is the fact, contrary to the general impression, that ptoses of different organs are not very frequently combined.

General splanchnoptosis (a protest may here be entered against the mongrel term visceroptosis) is a very rare condition, if one assumes the proper attitude of the man from Missouri. The writer has seen three or four cases in twenty-three years of practice, eighteen devoted to the digestive organs and abdomen. So far as gastroptosis is concerned, the existence of other forms of splanchnoptosis is significant, as follows: A flabby multipara who has uterine prolapse, including posterior displacement, may be expected to have a low-lying, approximately horizontal stomach; nephroptosis usually develops in a slender-waisted, anemic young woman of low vitality. Such a one is apt to have a relatively vertical stomach which does not drain easily and which tends to become ptotic. When there is really general splanchnoptosis, including several organs, and among them the liver, the diaphragm is practically always depressed, carrying the supports of the stomach and spleen with it.

At the risk of repeating a warning already emphasized, it must be remembered that ulcer, catarrh, secretory disorders of various kinds, and many more remote diseases, such as chronic colitis, appendix lesions, hepatic sclerosis, gout, anemia, and so on, are to be considered, not as alternatives in a differential diagnosis, but one must decide whether they are present or not, in addition to the ptosis or dilatation or both. No attempt, however, will be made at this time to discuss their diagnosis or treat

ment.

Diagnostic Methods

In the diagnosis of gastric conditions, the question, What is the stomach doing chemically? can be fully answered only by the examination of a test meal extracted by the tube. The writer's effervescence test is of some value in determining acidity, more particularly after a preliminary thorough examination of the stomach-contents. Symptoms count for something, but not very much. The most typic picture of hyperchlorhydria, as described in textbooks, is found in cases of gallstones, with or without hydrochloric-acid secretion, indifferently. Buckets, test capsules, indirect methods depending on examination of the blood, urine, feces, and so on, are of little value in determining the exact state of the stomach.

Another advantage in taking the bull by the horns, by passing the tube, is that we also derive much information as to motor power, gastric capacity, time of emptying, mastication of food, carelessness in swallowing foreign matter, regurgitation from intestine, degree and kind of saprophytic growth in the stomach, and evidence of

organic disease furnished by the presence of blood, mucus, epithelium, and so on.

The diagnostic methods have been so thoroughly discussed that allusion will be made to only a few more or less original details, including points in which practical experience does not corroborate theoretic

statements.

In judging of motor power, allowance must be made for the former use of small tubes and inefficient means of extraction. Using a tube of 12 to 14 millimeters diameter and a suction-bulb, we usually get about 100 Cc. one hour after a test meal of bread with butter and water, or a similar meal amounting to 200 or 250 Cc. Such a meal should have left the stomach empty in two or three hours, while four or five hours is the proper allowance for an ordinary, fairly hearty mixed meal. We may feel satisfied if the stomach gets rid of a banquet over night. Abundant watery contents nearly or quite equalling or even exceeding the original bulk of the test meal generally indicates excess of secretion, usually, too, with an excess of hydrochloric acid, which reflexly stimulates the pylorus to close.

As a rule, stagnation of stomach-contents for a few hours, even the presence of parts of two meals taken only five or six hours apart, is not a serious matter. When we find a liter or more of contents, rich in lactates, even containing rotten meat and with particles that can be dated back several meals, there mostly is something more than mere ptosis or dilatation. Such contents almost always mean organic obstruction at the pylorus or in the duodenum, and, in the vast majority of cases, of cancerous nature. I have found fruit skins, seeds and core scales, and the like, dating back six weeks. With such conditions, the question comes up as to whether the pylorus is absolutely sealed. This can be answered by giving charcoal or purpetrol (pure mineral oil) and watching the feces.

Determining the Contour of the Stomach

In judging the size and shape of the stomach, we can tell something by ordinary percussion. The writer prefers auscultatory percussion, tuning-fork auscultation, and so on, and has corroborated the results by means of the x-rays, by operation, and by autopsy.

The writer was the first to employ the bismuth method in this country (spring of 1897), being a few months behind Roux of Paris and acting independently of him. Allowing time for the bismuth to coat the gastric wall and using a fluoroscope, these methods correspond almost exactly. Recently, especially in Germany and in the United States, the preference has been given to radiography, which is certainly safer and a little more delicate.

With many persons, "seeing is believing," and attention has been called to the discrepancies between radiograms and gastric maps by auscultatory percussion, the implication being that the latter method is unreliable. Now, a fairer view is that both visual and auditory sensations must be revised before drawing conclusions. A radiogram is practically the same as an instantaneous photograph. It is correct in the sense that it shows a momentary kneading of the bismuth mass, but the successive shadows of the same stomach differ widely from minute to minute and no one of them gives a correct impression of the shape of the stomach. Contrast the bizarre shapes of radiograms with the stomach exposed at an autopsy or operation. Did anyone ever see such a stomach?

Mark I. Knapp has called attention to two ingenious and very simple methods of determining the gastric area, one by sighting on the slant the waves communicated to the abdominal wall by the resistance to respiratory waves of an underlying organ, the other by palpation of a stomach cooled by ice water. The former method requires some practice and corroboration by other methods. The latter method is liable to error from cold produced by evaporation; indeed, the present writer is somewhat undecided as to whether we actually feel the stomach as a cold organ or whether the ice water acts reflexly on peripheral vessels to produce dilatation and local perspiration and hence coolness of the overlying parts.

The stomach-tube is a valuable aid to the diagnosis of the gastric area, using it to

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distend the organ with water (not beyond safe limits) or with air, listening to air introduced beneath the water level, to effervescence produced by chemic interaction, and so on. The tube, curled within the stomach, strikes various levels as it is pushed down and withdrawn. Spurts of air from a syringe bulb can thus be made to mark approximately the upper curve of the stomach. Similar tests, or the deglutition murmurs alone, will afford positive evidence if, by transposition of viscera or marked downward displacement, the gastric area is far out of its normal location.

Three Types of Gastroptosis

Let it be assumed that, with or without dilatation, we have diagnosed a gastroptosis, the crucial point in the diagnosis being the demonstration that the upper border of the gastric area is too low-say, below the seventh rib in the mammillary line, with the organ moderately distended.

Three types of gastroptosis may be distinguished, namely:

1. The banana- or gourd-shaped stomach, lying horizontally at about the umbilic level, i. e., where the transverse colon ought to be. The therapeutic problem is easy, in the same sense as the problem of trisecting an angle or squaring the circleit is insoluble unless, possibly, by surgical means. Fortunately, this condition is rare, the writer having seen only two or three. In one, there was esophageal dilatation low down, requiring lavage, although there was no marked obstruction to the passage of food through the cardia. One can, however, employ an elastic bandage, and the same general lines of treatment as in more favorable forms, to help along.

2. The upright, prolapsed stomach. This may be due to lacing, a custom by no means common at present, but it is more likely to be due to a failure of development of the upper abdominal zone. The naturally wasp-waisted woman has inadequate space for lungs, liver, stomach, and the renal niches are absent. With insufficient breathing space; inadequate tissue for the numerous functions of the liver; the constant nervous shock due to the tugging of one or both movable kidneys; the stom

ach forming a standpipe, with the tendency to stagnation in its lower end, pulling down the whole organ; the blood, circulation, and trophic control below par, genuine gastroptosis is extremely liable to develop.

If the underlying condition is artificial, there is some hope that, by loosening the corsets or discarding them for a light garment supporting skirts and hose from the shoulders, the lower ribs will gradually resume their normal girth under respiratory exercises. When the body has simply failed to develop, when we can estimate the thickness of ribs, skin and muscle, and imagine how little space there is left after allowing for the vertebral column and a modicum of liver, we can readily appreciate that the stomach can be nothing more than a tube the size of the colon. The only hope of radical relief in such cases is to turn the victims loose in early girlhood, with shapeless dresses, to a hoyden's life.

If seen too late for this, there is usually a movable kidney to be supported; and for this purpose as well as for the support of the stomach itself, an elastic belt covering the lower part of the abdomen is about as satisfactory as anything, the real support coming from the intestines crowded up against the kidneys and stomach. A straight-front corset sometimes works well, but rather more in the next kind of cases. Operation should be advised against strongly, as, sooner or later, these patients will fall into the hands of the sort of surgeon who will operate on anything, with the excuse that, if medical treatment fails, surgery should be tried.

All the dietetic and medical precautions against overdistention and overweighting of the stomach required for other cases should be practised here. In addition, we must remember that the limitation of gastric capacity is a serious matter. Unless great pains are taken to choose concentrated foods, the solids necessary for a day's ration amount to about one liter, while the liquids should amount to three liters. These naturally slender-waisted women can scarcely take this total in three meals a day. While the stomach is rarely of less capacity than a liter, it should not be dis

tended to its full capacity, and especially not in these cases in which the upper part of the stomach is small, the axis of the organ vertical and the only available room at the bottom. Often, we must establish a regimen of four meals, select concentrated foods, separate solids and liquids, and most sedulously avoid carbonated drinks, fermentation, and stagnation.

Regarded theoretically, from the mechanic standpoint, pregnancy provides an almost ideal support for a gastroptosis, acting gradually and tending to enlarge the abdomen and stimulate metabolic functions by its increasing demands. Very often, such women do improve during early pregnancy. Sometimes the improvement is permanent, sometimes the strain on the system during later pregnancy, or the ordeal of delivery, or the subsequent drain of lactation or of increased household duties after the sudden withdrawal of the internal support is disastrous.

3. The relatively horizontal stomach of flabby, often multiparous women with large abdomens. Such a stomach has an axis deviating from the normal of approximately 45 degrees, but in exactly the opposite way to that previously considered. The organ itself is as likely to be too large as in the previous instances it was to be too small, and the patient must be guarded against overeating as much as formerly we had to consider the danger of underalimentation. The indications regarding bandaging, control of gastric distention and weighting are, however, about the same. If the kidneys are movable at all, they are usually so in a less degree. While pregnancy offered a possible, though doubtful, means of relief in the former cases, here it is often the determining factor in rendering the woman a shapeless mass, without tonicity. However, in many cases, as encountered, we are justified in considering that a few more children will make no appreciable difference.

How far anything short of a "pexy" operation, which is applicable only to the last class of cases of gastroptosis, can affect the suspensories of the stomach, is doubtful. Certainly there is no drug that can directly contract or, by absorption,