"WELL PREPARED!! NUTRITIOUS!! EASILY DIGESTED!!"

I

STANDARD PREPARED

FOOD

S EARNESTLY RECOMMENDED as a most reliable FOOD for INFANTS, CHILDREN and Nursing-Mothers;-for INVALIDS and Convalescents; for Delicate and Aged persons. It is not a stimulant nor a chemical preparation; but a PURE, unsweetened FOOD carefully prepared from the finest growths of wheat, ON WHICH PHYSICIANS CAN DEPEND in FEVERS and in all gastric and enteric diseases. It is easily digested, nourishing and strengthening, assists nature, never interferes with the action of the medicines prescribed, and IS OFTEN THE ONLY FOOD THE STOMACH CAN RETAIN.

SEEMS TO HOLD FIRST PLACE IN THE ESTIMATION OF MEDICAL OBSERVERS.-"The Feeding of Infants," in the New York Medical Record.

A good and well made powder of pleasant flavour. ANY IMPURITY.-The Lancet, London, Eng.

CONTAINS NO TRACE OF

A valuable aid to the physician in the treatment of all the graver forms of gastric and enteric diseases.-The Prescription.

As a food for patients recovering from shock attending, surgical operations IMPERIAL GRANUM stands pre-eminent.-The International Journal of Surgery, New York. Not only palatable, but very easily assimilated.-The Trained Nurse, New York. IMPERIAL GRANUM is acceptable to the palate and also to the most delicate stomach at all periods of life.-Annual of the Universal Medical Sciences, Philadelphia, Penna. Highly recommended and endorsed by the best medical authorities in this country.-North American Practitioner, Chicago, Ills.

It has acquired a high reputation, and is adapted to children as well as adults-in fact, we have used it successfully with children from birth.-The Post Graduate Journal.

*

The results attending its use have been very satisfactory.- * *M.D., in New York State Medical Reporter.

Especially valuable in fevers, and often the only food the stomach will tolerate in many gastric and enteric diseases.-Dominion Medical Monthly, Toronto.

IMPERIAL GRANUM has stood the test of many years, while many competing foods have come and gone, and have been missed by few or none. But it will have satisfactory results in nutrition far into the future, because it is based on merit and proven success in the past.The Pharmaceutical Record, N. Y.

★ Physician's-samples' sent free, post-paid, to any physician-or as he may direct. ★ JOHN CARLE & SONS, Wholesale Druggists, 153 Water Street, NEW YORK CITY, N. Y,

very large, and may extend in life down to or even below the umbilicus without in any sense coming under the term "dilated," i.e., they may perform all of their functions with great regularity. We know also that stomachs may be very small and yet give all the clinical symptoms of dilatation. Thus it is evident that the size of the stomach is no criterion upon which to base our pathological conceptions. Nor is the thick

better criterion. Some large stomachs may be naturally thin-walled and yet functionate perfectly; others, which are in reality dilated and give rise to all the symptoms due to stagnation of food, may have thick, hypertrophied muscular walls.

So hard it is to give pre

During the past few years our views concerning many physiological and pathological processes in gastric diges-ness of the wall of the stomach any tion have been undergoing decided changes. We are learning to estimate more nearly at its real value the importance that attaches to the mechanical force of the stomach used in propelling its contents onward into the duodenum. We are learning that deficiencies in gastric secretion may be unattended by symptoms, but that muscular weakness of the stomach is always made manifest by unpleasant disturbances of digestion. For this reason, unusual attention has of late been paid to whatever concerns the motor functions of the stomach, and an effort to give precision to our present knowledge of the subject may not be out of place. Certain it is that those digestive disturbances which are due to impaired muscular action of the stomach are the most troublesome to the patient and physician alike. Chemical errors may be corrected largely by diet and drugs, but the symptoms due to muscular weakness are not so easily remedied. The nomenclature needs readjust-physiological function. ment to our present knowledge. The terms "atony" and "dilatation are not precise enough. It is difficult to-day to give an exact definition of the term "dilatation of the stomach." We know now that some stomachs are naturally

cision to the term "dilatation of the stomach," that some recent writers prefer to do away with the term altogether. Yet the name is too firmly fixed in the literature to be so easily eradicated, and for practical purposes any stomach may be considered dilated which is larger than normal and does not expel its contents with sufficient promptness into the duodenum to avoid fermentation or decomposition. As for the stomachs not dilated and yet muscularly weak, the term "motor insufficiency" is quite adequate. The term bears the same relation to the stomach muscle as it does to the heart valve, and simply signifies inability to perform

Regarding the methods of ascertaining the size of the stomach during life, these have appeared so often in recent literature that I shall not burden you with them here. A reliable resumé is given by Pepper and Stengel.' I can

I PEPPER and STENGEL: "Dilatation of I Read before the Academy of Medicine the Stomach," American Journal Medical of Cincinnati, April 5, 1897. Sciences, January, 1897.

These methods, however, have but a very subordinate value for clinical purposes. The only way to find out if the stomach empties itself promptly enough is to wash it out after a given interval. A stomach which contains food-remnants more than six hours after a Leube dinner has at least some motor insufficiency. If the stomach contains food in the morning before breakfast the insufficiency is always grave, and usually indicative of marked dilatation or pyloric stenosis. The importance of these practical tests is very great, and they have not been as generally employed as they should be.

not refrain, however, from saying a few | and the colon-tube. It is true, neverthings about the ordinary technique of theless, that in healthy persons a splash examination. Notwithstanding all that should not be elicited on less than 250 c.c. has been written, it is not possible to map out the exact size and position of the stomach intra vitam. And, for clinical purposes, this is wholly super fluous. What we need to know clinically is the approximate size of the stomach, whether it has materially descended in the abdomen, whether it lies vertically or obliquely in the abdomen, and, above all, whether it disposes of the food with sufficient dispatch. Now the approximate size of the stomach in cases other than gastroptosis is determined by noting the position of the greater curvature. If this be done by insufflation with carbon dioxide or atmospheric air, or by percussion or succussion after the ingestion of water or by auscultatory percussion, is immaterial so long as the examiner is thoroughly familiar with the method he himself employs. The easiest to carry out, and in many respects the most instructive, is the method of percussion and succussion as recommended by Boardman Reed.' After the patient has drunk 250 c.c. to 500 c.c. of water it is easy to map out the greater curvature by percussion, and succussion can usually be obtained over the area of the stomach when even a smaller quantity of water is drunk.

Regarding succussion, or "clapôtement," a word of warning may be in place. In persons with thin abdominal walls it is often easy to hear the splash after 150 c.c. to 200 c.c. have been drunk, and the tendency in such cases is to infer that some weakness of the muscles of the stomach exists. This inference is by no means justifiable, and time and again I have been able to elicit a splash after the ingestion of a very small quantity of water in persons whose stomachs empty themselves promptly. It is easy, also, to be deceived by splashes in the large intestine, and lately I have seen two cases of distended colon in which the splash suggested a dilated stomach. The differential diagnosis in these cases can easily be made by means of the stomach-tube

1 Med. Record, 1896.

Some idea of the muscular power of the stomach can be gleaned after a simple test breakfast of bread and water. One hour after such a meal (about 200 c.c. to 250 c.c. of water being employed) the stomach should contain from 10 to 50 e.c. of chyme. When the quantity is more than 100 c.c. some muscular weakness can be inferred with a considerable degree of correctness. Some caution should be used in making inferences from one lavage, as the mental and emotional conditions of the patient have considerable influence upon both the muscular and the secretory functions of the stomach. The results of examinations made at different times are, as a rule, however, quite uniform, and ordinarily vary less than one might à priori suppose.

Reserving, for the sake of clearness, the old phraseology, we can classify the various forms of muscular insufficiency of the stomach into the following groups:

I.-Motor insufficiency without dilatation. This includes (a) cases of primary muscular weakness; (b) cases of muscular weakness due to constitutional conditions; (c) cases associated with, and in a measure dependent upon, disease of the gastric mucosa.

II.-Motor insufficiency with dilata

tion.

III.-Motor insufficiency with gastroptosis and enteroptosis.

I (a). Primary muscular weakness. -Regarding primary muscular weak

ST

SP

ness of the stomach little is known and | substernal distress, obstinate constipanothing has been written. Yet many of tion, and mental hebetude. No nausea, you are familiar with patients in whom, no vomiting naturally, though the pafrom early childhood on, the stomach tient has learned the art of vomiting has refused to functionate properly. In whenever he wishes to. After a testsome cases this "weak stomach runs breakfast 120 c.c. of fluid were removed in families, and is apparently inherited. containing .11 per cent. of free HCl. It is difficult to tell in all cases just what After the ingestion of 150 c.c. of water the basis of this weakness is, but I be- on an empty stomach a succussion splash lieve that in some persons the muscles could be obtained over the whole abof the stomach-wall do not develop domen. When the patient stands there sufficiently, and the stomach retains the is bulging in the hypogastrium, and infantile condition. The stomach in fluctuation can be induced by the proper infancy and early childhood has, as you manipulation. (I shall pass about several know, a very thin muscular wall, much thinner, comparatively, than later in life. Now it is probable that in certain individuals the muscles of the stomach never do develop sufficiently, and the individual's stomach remains a source of distress throughout life. I have been led to this explanation by coming across, in the course of post-mortem examinations, several adult stomachs which had exceedingly thin muscular walls; and I have brought before you some infantile stomachs and one such typical adult stomach for comparison. You will note that the adult stomach has walls but very little thicker than the children's stomachs, and it is doubtful if this stomach had sufficient muscular power to dispose of an ordinary meal. The history of the individual from whom it was taken is, unfortunately, not known. In addition to this post-mortem evidence, a certain class of clinical cases can be explained only on the assumption of such a primary undeveloped condition of the gastric muscles. The characteristics of such cases are bloating after eating, epigastric and abdominal pains, usually of a burning character; obstinate constipation and the tendency towards dilatation and the symptoms of foodstagnation. The following case is illustrative:

FIG. 1.-A. T., case of primary weakness of the stomach (deficient muscular development).

succussion' after the ingestion of 150 c.c. water 19, vi, '96. Before treatment. Area of on a fasting stomach.

diagrams showing the seat of the succussion-splash under different conditions). The patient was put upon a very dry diet, cognac was taken after each meal, and all acid fruits were prohibited. In two weeks' time the patient showed only slight improvement. From this time on intra-gastric faradism with the Einhorn electrode was practised three times a week, each sitting lasting three to five minutes. Under this treatment improvement began almost at once. In three weeks' time the pain had markedly diminished, the sense of bloating was less, the appetite improved. The faradism was continued several months. At the end of this time the patient was wonderfully improved, the