cum, appendix and uterine adnexa, atresia with the resultant sacculation and displacement of the sigmoid, all are common factors which acting together or individually eventually cause a degree of enteroptosis, that sooner or later furnishes definite pathologic changes in the intestinal walls, resulting in a general stasis.

The subject of such a morbid condition within the abdomen has symptoms of general toxemia added to those of obstruction. The severity of the toxemia depending upon the extent of habitual overloading of the large bowel.

The surgeon frequently notes the existence of all sorts of variations from the normal relation and position of the abdominal viscera that is directly responsible for many cases of chronic constipation; such as dilatation often associated with considerable lengthening of certain portions of the intestinal tract Ex.

The caecum may reach into the true pelvis completely filling it; the transverse colon may form a loop, the lower limit of which may reach below the brim of the pelvis, and in this way displace and obstruct the caecum, the stomach and the small intestines may become dilated, the result of this obstruction of the caecum.

Fixation with associate atony of the muscular coat of the walls of the intestines are found especially marked in the upper part of the caecum, ascending colon, hepatic, splenic and sigmoid flexures.

Volvulus of the sigmoid, which probably never occurs when the intestines are normal, will form an acute obstruction. The same is true of volvulus of the caecum; from these causes the bowel becomes fixed and functionation is impaired to such an extent as to early cause wasting of the muscular coat. The diseased appendix becomes angulated and adherent, and stenosis resulting therefrom prevents the escape of its secretion, which thus leads to the formation of concretions within it.

The caecum, which may be described as the cesspool of the intestinal tract, when displaced and overloaded, is a determining factor in the impairment of function of not only the caecum and ascending colon, but as well would seem to affect the function of the entire colon and even the small intestines.

When any extent of pathology exists in this portion of the intestinal tract in women, it is always greatly augmented by the constriction of the waist from the use of corsets, and in both sexes by imperfect development of the muscles of the abdominal walls.

Many of that innumerable group of symptoms classed as indigestion are directly the result of defective intestinal drainage that has resulted through alteration in its position, shape and motility, and which are promptly relieved when the bowel is liberated and the tension, which is exerted by adhesions and bands, is removed, thus freeing the intestines from obstruction; the real cause of the symptoms.

Pain below the left rib, a system so frequently associated with indigestion, in the majority of instances is due to a dragging exerted upon the hollow viscera in the upper abdomen through adhesions, and is always severest when the patient is in either the erect or supine positions; in the latter instance it being due to backward dropping of the distended bowel. From the same cause traction may exert so disturbing an influence on the last dorsal, ilio-inguinal and ilio-hypograstic nerves as to cause a group of reflex pains that simulate renal disease, and for which malady they are often mistaken.

The caecum and ascending colon, when bound down by adhesions or held by bands, have great difficulty in emptying themselves of their fecal contents unless the subject so affected is in the supine position, and the fecal evacuation is further facilitated if the pelvis is raised by elevating the foot of the bed. These patients will often complain that the bowels never seem to want to move until they have retired. In other cases of distention of the caecum, dull pain will be complained of over the sacrum extending into the sacro-iliac joint, and will be much exaggerated during defecation. When so affected, the patient will complain that the evacuation is unsatisfactory, and always increases the sense of fullness in the rectum, which it never seems to overcome. This is probably accounted for by the enlarged and engorged caecum being forced still further downward during straining at stool. The pulling exerted by the loaded caecum, splenic and hepatic flexures, which are anchored or displaced by adhesions, renders it difficult for the

patient so affected to lie on the left side, and there is usually a dull aching pain, often severe, during the passage of feces through it.

As a result of this delayed intestinal drainage, the process of digestion may be so delayed or prolonged as to cause, in some instances, marked gastroptosia. This is due really to the excessive amount of gas resulting from decomposition and the presence of toxic material in the gastro-intestinal tract, and the toxic product soon finds its way into the general circulation, which obviously diminishes the resisting powers of the entire body tissues, and sooner or later permits the development of some one of the many bacterial diseases, and is the determining factor in the causation of ulcers, which, at first, are simple, but later, in many instances, become malignant.

Mechanical interference with the function of the appendix and ileum from kinking, strictures, angulation or dragging down of the pylorus or kinking, angulation or displacement of the colon and its several flexures, which are primarily the result of inflammatory bands or adhesions, brings about a chain of symptoms that should never be grouped among those due to digestive disorders incident upon a purely functional disturbance, the result of errors in diet.

SYMPTOMS.

As the result of this mechanical obstacle to free intestinal drainage, there is a well defined chain of symptoms, such as irregular distention, localized tenderness at or about the neighborhood of the morbid condition, irregular peristalsis, pain often followed by nausea or vomiting, and not infrequently a mass of agglutinated intestinal coils, tumors or displacement of the hollow viscera or other organs can be distinctly outlined on palpation.

The breath of these patients is usually very offensive; their bodies have a peculiar smell, which is especially marked about the various folds; a peculiar dissecting room odor eminates from their skin; this is especially marked when the abdomen is opened. There is usually a mental depression, such as inability to concentrate the mind upon anything, constant lassitude, especially leg tiredness, drowsiness, spells of faintness, irri

tability of temper, often some loss of flesh and a spurious diarrhoea will sometimes be present, a tendency to pigmentation especially about the skin folds is commonly observed. These symptoms are especially noticeable in those cases where gastroptosis is most marked.

TREATMENT.

When such evidence of morbid condition exists within the abdomen, as has been pointed out, little, if any result can be secured by medical treatment beyond the temporary benefit that results from a carefully selected diet and drugs that act by elimination. A person so suffering not only must remain throughout life an invalid, but worse still, is ever liable to inflammation and ulceration undergoing a transition from a simple to a malignant disease, as I little doubt, but cancer of the sigmoid, rectum, ilio-caecal region, pylorus and stomach are transitions from simple ulcers caused by inflammations primarily the result of anchored and displaced viscera, which so alter their position as to impair drainage, affect circulation, promote toxemias, and thereby diminish the resisting power of the digestive apparatus. The treatment of such a subject should be palliative only so long as is necessary to determine the character and extent of pathology present, for the case is from the onset a surgical one, and should be so dealt with sufficiently early to prevent permanent trophic changes taking place either in the walls of the viscera or in its position.

The surgical treatment need go no further in the majority of cases to secure permanent benefit or cure than the correction of mal-formation and faulty positions, division of bands, breaking up of adhesions, the removal of tumors, the replacement of the displaced viscera and removal of cicatricial strictures.

If a stricture involves a greater portion of the intestinaal wall than the serous coat, excision and anastomosis may be required. The more radical operation of colopexy advocated by Lane can be left to that extremely small group of cases where from long standing ptosis, the viscera has become so hopelessly displaced, angulated and dilated, that it is impossible to restore drainage sufficient to empty the loaded sacculated loops.

REMARKS UPON ALIMENTATION.

BY DR. CHARLES A. LONG, HUNLOCK'S CREEK, PA.
READ OCTOBER 23, 1912.

Man sees no creation nor knows any destruction. But as we stand in the midst of this variegated, glittering, iridescent ever changing phenomenon of life, we are confronted at every turn, upon every hand by the ever progressive changes which are taking place both in animal and vegetable kingdom as well as in the elements around about us. Some atom, body, combination or substance, more or less completely organized, is being metamorphosed in some manner to the use of other combinations either like or unlike the originals. Usually the component parts of a given combination are disseminated over a wide field during this disintegration or process of changing. The animal or vegetable kingdoms, the organized bodies and inorganic substances, solids and vapors, are ever changing. There is no stand still, waste and repair nearly cover the ground. The vegetable kingdom is living upon the very poisons which the animal kingdom is throwing off and vice versa. In some instances these changes are very slow and insidious as in the growth and development of animal or vegetable life, while in others it is rapid, even instantaneous, as in explosions and electrical changes, etc.

One of the brainiest men of modern times said: "I know that I existed heretofore and I believe that I shall exist in the hereafter." Obviously, by this expression he meant to convey the idea, that from previously existing matter he had been formed, and developed to his zenith, all through the changing of matter. Then degeneration began, to be followed by dissolution, decay and disintegration, back to the elements primitive, he goes to come up again.

"Dust thou art and to dust returnst," was not spoken of the soul of man.

"Know thyself," hath been well said. And I now wish to add to this ancient and honored axiom these few words, viz.: How shall we eat, and when, and what?

With a cursory examination of the human alimentary canal