man 69 years of age whom I examined July 8, 1892, and found suffering from emphysema and cardialgia. Ascites developed more recently, and on Oct. 2, 1892, five liters of fluid were withdrawn by aspiration. The patient died Nov. 10, 1892, and Fig. 9, b and c, present the interesting facts found after death. The case was one of carcinosis of the peritoneum produced from cancerous tumors growing on the posterior walls of the stomach. In this case it was noticeable that the transverse colon, formerly lying in the hypogastrium, was, by the ascites, elevated to the upper part of the abdominal abdominal cavity, and becoming ad

ciency and passive congestion of the liver. He afterward became melancholy, and after wandering about for some days without taking food, died in consequence of a heat stroke. The autopsy showed the liver, which four months before had been enlarged to the navel, to be of normal size, and the right flexure of the colon, which had formerly been pressed down, in its normal position. The most striking changes are those which appear after death, and perhaps even during the last days of life, in case of stomachs which, when distended in life, reach nearly to the symphysis.

Fig 9, a, represents the condition of a

herent, did not sink down again after the fluid was removed. More marked still was the elevation of the stomach (Fig. 9, b). The force of the upward pressure was so great as to produce a retroflexion of that portion of the stomach which impinged against the diaphragm.

The observations which I have made concerning Glenard's views relating to the prolapse of the abdominal viscera in over five hundred living persons, and more than one hundred post-mortem examinations, may be summarized as follows:

Displacement of the abdominal viscera, a point to which I shall again revert, is

cast.VII

very frequent in women, and less frequent in men.

Every organ below the diaphragm, and even the diaphragm itself, may be involved. The part most frequently involved is the colon, next the stomach, then the kidneys, and last the uterus. The liver is very seldom prolapsed, and the spleen still less frequently. In relation to the small intestine, I can give no particular facts. The colon alone may be prolapsed; this occurs quite frequently. The same is true of the kidney, though seldom; also of the uterus, and most likely also of the spleen. The prolapse exists in all degrees, and there

of the cases, this portion of the intestine maintains its normal position. The left flexure of the colon, which can be examined only in cadavers, showed depression in only thirteen of my dissections. (Figs. 19, 21, and 29.) Still less can I conceive that, as Glenard believes he has discovered, the transverse colon decreases constantly from right below to left above, as in Fig. 15. In 38 per cent of the cases dissected by me, this portion of the colon had the form of a more or less depressed loop, but in the other 62 per cent, the cases do not correspond at all to Glenard's type. In 60 per cent of my observations upon living pers ons, I could

Fig. 9 a. (Intra vitam.)

Coecum

Rectum

is no positive boundary between the normal and the abnormal. In case a single abdominal organ is found prolapsed, we are able to establish the displacement in most cases. These cases may be unhesitatingly pronounced pathological. To this class belong especially cases in which gastroptosis and coloptosis occur coincidentally. This is not to be doubted, because these cases are generally found in full-grown persons, and always in a marked degree, but very seldom in the early stages of development. Glenard's theory concerning the depression, without exception, of the right flexure of the colon, we beg leave to correct, as we have found that in only about two thirds

Fig. 9 c. (Post mortem.)

determine with certainty the depression of the pylorus (the liver we are sometimes unable to recognize), but I was convinced. that in cadavers the pylorus is dislocated in 93 per cent of the cases. This dislocation may extend as low as the promontory, and even lower. (Fig. 23.)

The question how frequently gastrectasis may be found in connection with enteroptosis, cannot be answered in numbers, because neither the volume of the stomach nor the boundary between normal and enlarged volume can be actually determined; but in case two or three liters of carbolic acid gas can be developed suddenly in the stomach without creating pain, we may take it for granted

This

that considerable dilatation exists. is true of patients thirty years old and upward. On the other hand, it is a fact that we quite frequently find in young persons fully developed gastroptosis without simultaneous dilatation. At all events, we must consider the change of position as primary, and the increase in volume as secondary.

In 24 per cent of my post-mortem cases, I have found the form of the stomach somewhat resembling that of an hour-glass (Figs. 14 and 21), having observed that shape distinctly in four or five instances. (Fig. 22.) We can demonstrate this in living persons only very rarely (Fig 13), because the constricted portion is mostly covered by the ribs.

Abnormal spiral forms of the colon are, of course, dependent upon a prolongation of this section of the intestine. The smallest degree of this abnormality consists in a slight curvature of the transverse colon downward, and can be demonstrated only during life, because it is obliterated by a post-mortem shrinking, but may be observed especially in young persons, and in the first degree of enteroptosis; the more advanced and often odd forms belong to advanced years.

Most frequently (in 38 per cent of my post-mortem cases), the transverse colon was prolonged and twisted. The descending colon was seldom thus affected (in 13 per cent, Fig. 20), and the ascending colon very seldom (3 per cent, Fig. The sigmoid flexure was 19). often found affected in the same way, but my photograms of this deformity are ficient.

I found the right kidney dislocated downward in 31 (4 per cent) of my cases of enteroptosis. On the other hand, I was able to demonstrate dislocation or mobility of the right kidney in 51 out of one hundred cadavers. The right kidney was affected in living persons in only 2 per cent of the cases, and in cadavers in 38 per cent.

Descensus (respiratory mobility) of both kidneys I have determined in life in 8 per cent, and after death in 35 per cent of the cases; the left kidney was prolapsed in only 24 per cent of the clinical cases, and in 2 per cent of the post-mortem cases. These statements have reference to 305 patients, and to 100 cadavers with enteroptosis.

The considerable variation between the results of the clinical and the anatomical diagnosis, expresses the difficulties which oppose our efforts at diagnosis, especially in the case of the liver and kidney, which in some cases cannot be overcome, but which, on the other hand, is often a matter of personal skill.

Dr. Schottin, one of my former tutors, quite frequently found floating kidneys, which I, in spite of repeated examination, had not been able to find, and in the joint examination, under anæsthesia, he was usually in the right.

I have never observed prolapse of the spleen. Prolapsed and replaceable liver, I have observed twice in women with pendulous belly, one post-mortem (25) and one during life; but I do not classify the case of the pendulous belly during life with enteroptosis, and I shall give my reasons for this when I come to the etiological part of my subject. An

abnormal position of the uterus occurs often as a congenital condition, or in consequence of the disease of this organ or its adnexes, which I believe is frequently a feature of enteroptosis.

Among 161 of my clinical cases in which I have had an opportunity to determine the position of the uterus, I counted 70 (43.4 per cent) retroversions or retroflexions, and 37 (33 per cent) cases of pathological anteflexion. In all other cases I found the uterus bent neither upward nor forward, but its body inclined toward the right. I am of the opinion that these anomalies of position. are, in most cases, the result of the prolapse of the gastric organs which overlie them, a condition to which Glenard has called attention.

Finally, the position of the diaphragm in enteroptosis is subject to greater variation in persons in whom the abdominal organs are in normal position. In most cases of variation, it is either too high or too low.

But the displacements which I have found, somewhat exceed the average in number and in degree, as they have been determined by others from the observations made upon the larger number of cadavers. This difference may be explained by the fact that the post-mortem investigations which I made were, in most cases, on cadavers with depressed thorax.