facts; and especially to this, that the average author derives his conclusions largely from the experience garnered in his immediate environment, which from some standpoints is usually of the best; and not from experience among all classes and from various sections; and lastly in the North and South the relation of cause and effect is constant in kind but quite different in degree.

ATONY OF THE STOMACH.

RY SEALE HARRIS, M. D., MOBILE, ALA.

Junior Counsellor of the Medical Association of the State of Alabama.

By atony of the stomach is meant the loss of tone of the gastric musculature, with inability to properly perform its motor function. It is conceivable that in the early stages of atony of the stomach, there is no dilatation, but certainly as the muscle tone is lost, the fibres become elongated, and dilatation results; so that clinically, atony of the stomach means also a more or less dilatation of the viscus. With this loss of tone and relaxation of the muscles of the stomach, there is practically always motor insufficiency, the ingested food remains in the stomach longer than normally, and a more or less degree of stasis, with fermentation of food and its products, follows. This retention of food, acting with the same causes that produce the atony of the stomach, results in the stretching and relaxation of the suspensory ligaments of the stomach and there follows a ptosis, which in some cases is so great that the pyloric end of the stomach falls vertically downward reaching, occasionally, nearly to the pubes. The same etiological factors that produce atony of the stomach practically always cause the same condition in the small and large intestines, there causing retention and fermentation of the waste products of digestiona constipation simply from lack of peristaltic power of the intestines. In gastroptosis, the pyloric end of the stomach, as it descends, brings down with it the duodenum, and the pressure of the stomach on the transverse colon also presses it downward. In these cases, there is nearly always a relaxation of the abdominal muscles, with a general ptosis of all the abdominal viscera, including the spleen and kidneys, the right

being the one usually affected. Clinically, we meet with all degrees of gastric and intestinal atony from a dilatation of the stomach which is hardly demonstrable with the best methods of diagnosis to the extreme condition just mentioned, which s known as Glenard's Disease.

Etiology. The congenital predisposition to atony of the stomach and intestines is a factor that should not be forgotten, and is evidenced by its frequent association with neurasthenia, which is so frequently seen in persons with a neurotic family history. The frequency with which we see dilated and prolapsed stomachs and intestines in children with rickets, and other diseases of malnutrition, would seem to indicate that this condition is sometimes acquired early; and probably many persons go through life thus handicapped because of the ignorance and carelessness of their parents regarding the feeding of infants. General diseases of nutrition, as chlorosis and anemia, causing general muscular atony, have among their symptom complex atony of the stomach and colon. In fact, this condition is so frequently associated with chlorosis and anemia, that some think that they are the propter hoc rather than the post hoc of those diseases. In other general diseases, as tuberculosis, atony of the stomach is a concomitant condition. In a number of cases of tuberculosis, which I have had the opportunity to observe in the very early stage, in what Baily calls the "pretubercular stage" the evidences and symptoms of atony of the stomach were the most important features. Indeed dilatation of the stomach and gastroptosis occur so often in tuberculosis, a disease with which malnutrition is so constantly associated, that it seems to me possible, in some cases at least, that the "atonic indigestion" is an important etiological factor in the production of tuberculosis. Atony of the stomach often results. from the indoor, sedentary life, and for that reason is seen more frequently in women than men. It is thought by some that the wearing of corsets, particularly the ill-fitting ones, and the weight of clothing suspended from the waist, causing atrophy and relaxation of the abdominal muscles, and an irregular supply of blood to the abdominal organs cause atony and ptosis of all the abdominal viscera. Atony of the stomach is no doubt frequently caused by the ingestion of more food or fluids. than the stomach can properly handle. In the beginning, there is motor insufficiency, not from lack of power of the muscles, but from the excess of work that the stomach is called upon to

perform. From this over-work, results loss of muscle tone, then retention of food and its products, then fermentation, with the formation of toxines which act directly upon the nerve terminals of the stomach, causing abnormal secretion and greater atony of the muscularis mucosa. Atony of the stomach may come on rapidly as a sequel or complication of the acute and infectious diseases, and it may develop suddenly after traumatism or intense emotional excitement.

Atony of the stomach may result from chronic gastritis, hyperchlorhydria or other disease of the stomach. In obstruction of the pylorus from ulcer, carcinoma, tumors or other causes, atony of the stomach with dilatation always results.

Symptoms:-The symptoms vary with the degree of atony. In the simple form, with but slight dilatation, there may be only a feeling of fullness or discomfort after the ingestion of food or fluid, the amount of discomfort depending entirely upon the amount of food or fluid taken into the stomach, the character of food bearing but little relation to the symptoms. There is usually belching of gas, and there may be eructations of fluid or food. The general health in mild cases is not affected.

As the atony increases and when there is dilitation of the stomach with retention of food, the symptoms become more severe. The feeling of fullness in the stomach may amount to a severe pain, and there is usually vomiting of the fermenting contents of the stomach. There is frequently anorexia, but even though the patient has sufficient appetite, he is afraid to eat, and there results anemia, loss of flesh and other evidence of malnutrition. Since there is generally atony of the intestines, constipation is usual, though when there is much fermentation, diarrhoea may alternate with the constipation. Palpitation, and irregularity of the heart-action, with dyspnoea from the gaseous distention of the stomach, interfering with the heart movements are frequently the most prominent symptoms. The nervous symptoms are often pronounced. Headaches and vertigo are frequent and severe. Migraine (periodic headaches) is thought by many to be caused by an acute dilatation of the stomach. Dr. Mangelsdorf, of Bad Kissengen, in 1904, reported a number of cases of migraine which he examined before, during, and after their attacks, and he found that there was always associated a rapidly passing temporary dilatation of the stomach.

The protean symptoms of neurasthenia are frequently found associated with atony of the stomach, and many cases of tetany

have been reported in gastrectasis, some of which have proved fatal.

The chemical examination of the stomach contents gives but little information, as there may be atony with anacidity or with hyperacidity. Some of the most marked cases of dilatation and gastroptosis that I have seen have been associated with a high degree of hyperchlorhydria, while others just as severe, have shown complete absence of hydrochloric acid. When there is retention with absence of or with but little hydrochloric acid, microscopic examination of stomach contents shows sarcinae and yeast cells, and other evidences of fermentation and stagnation are present.

Diagnosis. The diagnosis depends entirely upon the physical examination of the stomach.

Inspection. In those cases with slight degrees of atony of the stomach where the nutrition is good and the abdominal muscles retain their tone, inspection is usually negative; but when there is relaxation of the abdominal muscles, as is usually seen in the more severe cases, the outlines of an enlarged stomach may be distinctly visible. Upon distention of the stomach with air or carbonic acid gas, the outlines of the stomach become larger and if the abdominal walls are thin, particularly in cases with obstruction-there may be seen peristaltic waves over the stomach. The stomach may be satisfactorily outlined by transillumination with Einhorn's gastrodiaphone, or with Rase's circumscribing gastro-diaphane. The

tlines of the stomach may also be seen with the X-ray after giving the patient an emulsion of bismuth which will give a distinct shadow over the stomach when viewed through the fluoroscope. The lower border of the stomach may be found by giving two or three capsules of bismuth subnitrate, followed by one or two goblets full of water. Examination with the fluoroscope before the capsules have had time to dissolve shows them lying in the most lependent portion of the stomach.

Palpation:This is negative in the simple uncomplicated cases. But in the more marked cases, with relaxation of the abdominal walls and a stomach distended with gas, this organ can be felt very distinctly. In the obstructive cases from neoplasm, or ulcer with marked thickening of the pylorus, a tumor may be felt. In the majority of cases, a palpable, displaced, or floating kidney will be found.

The quickest and most satisfactory method of outlining the stomach that I have found is with Turck's gyromele. It is as easily introduced into the stomach as a stomach tube, and the end being padded with cotton covered with rubber tissue, causes no pain, and can do no more danger to the stomach than the food which we sometimes swallow, and certainly no more than the introduction of a stomach tube. It consists of a flexible cable attached to an ordinary revolving drill. When rapidly revolved, the vibrations can be distinctly felt through the abdominal wall over the greater curvature of the stomach, and if there is a patulous pylorus, this can also be determined. I have worked out the stomach from the vibrations of the gyromele and leaving the cable in the stomach have verified the outline by X-ray examination, which showed the cable lying on the lower border of the stomach. Some people object to the use of this instrument, and as the stomach can be frequently outlined in other ways, it is not necessary to employ it, but in cases of doubt, in my opinion, it is our most certain means of outlining the greater curvature of the stomach.

Percussion.-Frequently the stomach can be satisfactorily outlined by simple percussion, especially when it is inflated with air or carbonic acid gas. Some authorities object to distending the stomach with carbonic acid gas generated in the stomach by the patient swallowing a solution of bicarbonate of soda (30 to 60 grs.) followed by a solution of tartaric acid (30 to 60 grs.). I have never seen any harm, and but little discomfort, from this simple procedure, and it is one to which few patients object. At the Johns Hopkins Hospital where it has for many years. been employed as a routine measure, upon many thousand patients with all kinds of stomach diseases, no ill result has yet been seen. Of course, it should not be employed in a case of u'cer with recent hemorrhage, in inflammatory disease of the stomach or peritoneum, nor in cases with heart lesions where compensation has failed.

Auscultatory percussion is, in my opinion, a more satisfactory method of outlining the stomach, though not infrequently percussion of any kind is misleading because the tympanitic sound of the stomach is occasionally transmitted through the colon and small intestines. When the stomach contains fluid, the area of dullness can sometimes be outlined, which changes with the position of the patient.