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 Papers by the Staff 
 
 OF THE 
 
 MEDICAL FACULTY, 
 
 mggill university. 
 
 ^ 
 
 /f- ■- 
 
Ij^l 
 
 ENTERO PTOSIS AND ITS RELATION TO FUNCTIONAL 
 
 DISTURBANCES 
 
 W. F/ITAMILTO]^T, M.D., 
 
 Lecturer in Clinical Medicine, McGiU University ; Assistant Physician to the Royal 
 
 Victoria Hospital, Montreal. 
 
 Reprinted from the Montreal Medical Journal, Se]Hember, 1899. 
 
 ^;i ..fi^lErtttiafc^.^-^ 
 
I 
 
 f i 
 
ENTEROPTOSIS AND ITS RHLATION TO FUNCTIOInAL 
 
 DISTUIIBANCHS. 
 
 I'Y 
 
 W. F. Hamii.ion, M.I)., 
 Lecturer in Clinical Medicine, McGiU Universitj ; AsHist.int I'hyHician to the Royal 
 
 Victoria Hospital, Montreal. 
 
 The condition described by the term Enteroptosis has been attracting 
 an increasing degree of attention during the past few years. Some 
 years before Glenard's monograpli appeared, Virchow, Leube and others 
 described the anomalous downward disphicement of diirorcnt abdomnml 
 organs, but in 1885 Glenard fornuihitcd liis views upon this sul)jc.;t, 
 accurately describing the condition of the abdominal viscera and the 
 nervous phenomena connected therewitli. Among tlie features prom- 
 inent in this symptom-group whicli Treves is pleased to call " that 
 medley of symptoms," are, downward displacement of the stomach, a 
 movable right kidney, various digestive disturbances and often very 
 typical neurasthenic symptoms. So sanguine was the pioneer observer 
 among the French, and indeed among all writers, that he had di'^covered 
 a 89lution to the diflficult problem of many cases of neurasthenui, that 
 he says at the close of one of his very early monographs upon the sub.ioct 
 in a free translation as follows :-"T can affirm that the i^hysician who 
 will follow my directions and strive to verify my statements in such 
 cases will find in his practice the satisfaction which a positive diagnosis 
 gives to both nhysician and patient from which alone a proper prognosis 
 can be made, ...d that satisfaction, the greatest of all, which directs the 
 treatment and avoids for the patient tlic trial upon him of so many 
 remedies, while at the same time it secures him relief and ^prevents the 
 physician himself from falling into therapeutic scepticism." 
 
 The next step of importance in the advancement of our knowledge on 
 this subject is marked by the appearance of Ewald's writings in 1890, 
 and those of Pick, Boas, Kumpf, and Hufschmidt in 1893. With 
 Ewald many of the Germans took sides against the French school on 
 several points to which we may refer later. The German school claims 
 that Glteard had reference but to the intestines in his descriptions, 
 while, associated with ptosis of these parts, displacement of other organs 
 was common. By the German school, the application of this term is 
 broadened and more comprehensive. Schwerdt believes he is .iiistified 
 in speaking of enteroptosis when at least two organs are found pro- 
 lapsed. 
 
 .■t 4>» i ufciaMjM*'> ' i i i i iiiiii«i''i" ' ' I ' "* 
 
2 
 
 T 
 
 f ' 
 
 It may he mentioned here, however, tliat EwaUl's methods of invest! 
 gatioii were more accurate than the)se of Glenard— for while it appears 
 the latter did not employ any means of inflating the stomach or 
 intestines, J'Avald claimed that such was a necessity and thus by Glenard's 
 method of diagnosis, mistakes were likely to creep in. 
 
 Treves, in England, has contributed to the study of the symptom- 
 atology and treatment of this disease, while Osier was the first in Ameri'vi 
 to include this subject in a text-book in 1893. 
 
 Glenard's disease or l-lnteroptosis or Splanchnoptosis, as it may be 
 called, according to Stiller's suggestion, should he considered indepen- 
 dently of those conditions of visceral displacement resulting from former 
 inflammatory process, such as frequently occur about the genital organs, 
 of females and result in pulling down portions of intestine or an isolated 
 organ. This view, however, is open to the criticism, that, upon the 
 normal position of any one organ the position of the others largely 
 depends, and it is possible to have very general ptosis result from such 
 a cause associated with all those signs incident to the true discr..:e. It 
 is acknowledged, however, that in a large number of such instances 
 the signs of the true disease are not prominent in the clinical picture 
 anc. may be absent entirely. 
 
 Meinert urges that the prominent pendulous abdomen resulting from 
 numerous pregnancies "has nothing whatever to do with Glenard's 
 disease. Such an abdomen holds a dilated stomach, not a dislocated 
 one." However conflicting these views may be concerning the classifi- 
 cation of cases under this head, it may be accepted as safe teaching, at 
 least for the present, that (I.) Enteroptosis may exist without subjective 
 signs, that (II.) the Enteroptosis of Glenard is associated with the most 
 pronounced subjective signs, chiefly of a neurasthenic type, that (III.) 
 in those oases where a pendulous abdomen is present the nervous fea- 
 tures of the case are less pronounced than in thin subjects with greatly 
 flattened belly walls, and that (IV.) Enteroptosis arising from inflam- 
 matory processes in the abdomen may be typically characteristic. — 
 (Treves). 
 
 The view of Mathieu is thus expressed, that Enteroptosis is of two 
 varieties, (I.) the form which shows itself plainly from without by a 
 pendulous abdomen and is rarely found associated with nervous manifes- 
 tations. The second form (II.) is that in which the abdomen is thin and 
 flat and where the neurotic element is very prominent, — the internal 
 variety. 
 
 The organs displaced in this disease may be all those found below the 
 diaphragm. Most frequently, however, the colon and small intestines, 
 the stomach, the right kidney and the liver are found in altered rela- 
 tions. It is not rare to find the left kidney also displaced ; the spleen 
 
a 
 
 of invest! 
 it appears 
 oniach or 
 Glenard's 
 
 symptom- 
 n Ame^i'^1 
 
 it may be 
 1 indopen- 
 om former 
 tal organs, 
 an isolated 
 
 upon the 
 ers largely 
 
 from such 
 lihcr.rjO. It 
 1 instances 
 cal picture 
 
 ilting from 
 I Glenard's 
 
 I dislocated 
 the classifi- 
 :eaohing, iit 
 t subjective 
 th the most 
 
 that (III.) 
 lervous fea- 
 ivith greatly 
 rom inflam- 
 acteristic. — 
 
 is is of two 
 ithout by a 
 5US manifes- 
 i is thin and 
 the internal 
 
 id below the 
 
 II intestines, 
 altered rela- 
 
 the spleen 
 
 very rarely is found away from its normal position wlaie the paiuTou^i 
 has been once recorded as dragged down (Uokilausky, Trevi-s). 
 
 Al^out the sul.ject of the i-Itiology ol' Enteroptosis much interest cen- 
 tres and numerous theories have been advanced to account lor .Is 
 occurrence. Kuttner and Dyer alllrm that no cases of congentuil ga.- 
 trontosis have been observed. Stiller (18!)(1) ..ays that huterop os.s .s a 
 congenital anomaly. It occurs in tl.ose whose mu.s.Ics are soil whose 
 bony orgamsa.ion is dchcate and upon them hul a sn.all .Ci-osil ol lat 
 ,„ay be iound. 'J here is usually f..una hi such patients a iloat.ng tenth 
 
 rib. 
 
 Enteroptosis is found in men as well as in women, although much less 
 frequently. Two of the cases herewith reported wore mde patients 
 although the percentage of men is much smaller in a large series o 
 cases as shewn by Glenard, Meinert, Sclnverdi and indeed by al 
 observers. The French writer reports 404 cases, JOb of which w ut 
 among women ; in Me.nert's series, 88-i.O per cent, were iemale,, 
 while in Schwerdt's series of 95 observations, 89 were in women. 1 1 .- 
 nancies and tight lacing are the chief causes, according to Manges, lor 
 this great dill'erence between the sexes. 
 
 In answering the question as to the etiology of tlie condi^tion, Ur 
 Schwerdt, of .otha, states that the e^^sence of this disease is to be sough 
 for in an atony of the ^vhole nervous system which affects he muscles 
 of the whole body. As active causes of such a condition he enumer- 
 ates heredity, unhealthful methods of living and working, all chronic 
 diseases, the weaving of corsets and lack of care in he pregnant state 
 and in childbed, He regards this disease as a conslilulional ailment. 
 
 The abdominal organs are kept in place very largely by a certain 
 degree of intra-abdominal pressure, and wlien this is greatly diminished, 
 ptosis is the result. The corset contributes to this conuition, among 
 other ways (1.) by diminishing the tone of the body walls and suspensory 
 ligaments of the organs, and (II.) by interfering with the mechamcal 
 and chemical functions of digestion thus impairing nu rition. Ihe 
 teaching of Schwerdt upon this point is more theoretical than hat of 
 Meinert, who regards the corset as a means of altering the relation ot 
 the parts chiefly by direct pressure. 
 
 There is doubtless no one cause or group of causes which will suflice 
 to explain the occurrence of this disease or condition. We may con- 
 clude then that : — 
 
 1. The intra-abdominal pressure is altered. 
 
 2. Many causes contribute to this end. _ 
 
 3. The organs may be displaced by being pulled down. 
 
 4. In all probability a congenital predisposition exists in the con- 
 
 WiiiM.i»ja"^w« 
 
 i .^',iw -- ir-ri^ 
 
1 1 . 
 
 1 
 
 hi I 
 
 forinily of thorax and tlio chanicter of fibre entering into tlic supporting 
 tissiicH of the organs. 
 
 The diagnosis of i'lnteroplosis, sincp the adoption of tlie method recoiii- 
 iiiendcd by j'lwiiid and others, is a matter of tM.mparative simplicity. On 
 the inspeetion, the contour of the abdomen may suggest a condition of 
 Sphmelmoptosis. Tiie epigastrium is lioilowed, the two h)wer quadrants 
 of tlie aljdomen, even with the patient in a recund)ent position, .ire 
 often quite prominent— while, as pointed out by Dr. J. C. \V ,.)ster in a 
 personal observation, the recti abdominis may Ito seen widely separated 
 in thin subjects when attempting to assume an erect position. In a 
 few cases 1 have seen the position of a disjilaeed stomacii indicated ity 
 the peristaltic waves extending from left to right. It is nece.ssary, how- 
 ever, to distinguish between a displaced and dilated stomach. In brief, 
 wc may say that it is all im])orlaiit to determine :— 
 
 Ist. the position of the lesser curvature of the stomach. 
 
 2nd. the relation of the greater curvature to the lesser. 
 
 In all cases where one can demonstrate the lesser curvature some 
 degree of displacement exists, and in proportion as the lesser curvature 
 approaches the umbilicus or falls below it, so is the degree of displace- 
 ment. Dilatation, as the result of atony, is a v..sual accompaniment of 
 gastrojjtosis and a transverse measurement of from four to five and a 
 half inches might still be within normal limits, and would not indicate 
 dilatation. 
 
 The hypogastrium may present a dull note from the close prolapse 
 of the small intestine. A point upon which Glenard laid great stress is 
 termed by him "la corde colique transverse," — by this he described a 
 small band which ran horizontr.lly across the abdomen about two inchos 
 or 30 above the umbilicus. He regarded this transverse band as the 
 "colon transversura." Upon this point there is much diversity of 
 opinion. The German teachers, led by Ewald, claim that tho French 
 teaching is wrong and that the "corde colique transverse" was the 
 pancreas. According to Frickhinger, who saw the intestine of a patient 
 with Enteroptosis inflated by Ziemsen, it is regarded as the transverse 
 colon, the hard cord, during the process, becoming changed into a 
 cushion-like and elastic body. On the other hand Ewald cites a case 
 reported by Krez m which an autopsy was done and the " corde colique 
 transverse " was apparently the pancreas. In Case No. 3 (Mrs. M.), the 
 " corde colique transverse " was plainly felt and during a laparotomy 
 done upon this patient, it was shown to be the pancreas. 
 
 Palpation of the abdomen usually reveals movable kidney, methods 
 of examination for which arc known to all. The liver, when displaced, is 
 usually more prominent in the epigastrium and may be rotated upon its 
 longest ax'n, the upper line of dulness falling mucli lielow normal. 
 
 
! supporting 
 
 Ihod rccoiii- 
 plictit}'. Oil 
 ;()ii(liti(in of 
 )r quiulranls 
 losilidi), are 
 v. .ister in a 
 ly soparated 
 Hon. In a 
 ndicated by 
 jssary, how- 
 1. In brief, 
 
 ature some 
 T curvature 
 of displaoe- 
 )aninient of 
 five and a 
 lot indicate 
 
 >se prolapse 
 3at stress is 
 described a 
 two inches 
 land as tho 
 liversity of 
 tho French 
 ! " was the 
 af a patient 
 ; transverse 
 iged into a 
 cites a case 
 )rde colique 
 rs. M.), the 
 laparotomy 
 
 y, methods 
 displaced, is 
 ed upon its 
 ow normal. 
 
 Another point upon which Glenard laid special stress, as one of 
 diagnostic worth, and which is to bo applied in all cases ..f Knteroptos.8 
 he described under the phiu^o '' Vepreuve de sa/t./^'" 'l'"« ^^'"^^ .'" 
 applied by the examiner, standinK I'l^l'i"^ ^l'« I'"^'^'"^ *'"* '''"" " '" 
 the erect position, and with both aaada laid Hatly over the lower zone 
 of tho abdomen, a firm but gentle pressure is made upwr.rds In tlie 
 great majority of cases this all'ords considerable relief to tiie (lislressing 
 dragging pain which is felt in the epigastrium and abdomen and whiclj 
 is one of the patient's chief complaints. At the same tinu' tlie result ot 
 this test is an index to treatment. 
 
 As illustrative of many of the above points in diagnosis, tlu; following 
 cases may be briefly described. With two exceptic I's tliey an' froni per- 
 Bonr.1 observation, and for these two I am greatly indcbttMl to Dr. .James 
 Bell and Dr. C. F. Martin. 
 
 Case N... 1, C, male, a-t. 25. admitted . I une, 1S!»!). Complamts were 
 of pain in right side of abdomen, loss of weight, jaundice and of recur- 
 rent attacks of indigesMon. In February, 1898, the patient had his first 
 attack of severe colic, which was referred to the liver—and regarded as 
 hepatic colic. During the past ten years he had frequent pain in the 
 region of stomach, especially marked after wali<ing, standing or riding. 
 These attaches were brief and on two occasions were followed by jaun- 
 dice. After the attack above referred to (February, 1898), the patient 
 was comparatively well for about a year with the exception of slight 
 " indigestion " and a dull heavy feeling at times. 
 
 In January, 1899, another attack similar to the first occurred and 
 since then every two or three weeks, this has been repeated, although 
 each attack was of a much milder type. Tho jaundice was associated 
 with clay-colored or colorless stools and high colored urine and he 
 remarked that on several occasions when the attack of abdominal pain 
 was passing off the urine, which had been scanty, became more copious 
 and light colored. The loss oi weight was about thirty-three pounds. 
 The patient was of a constipated habit. Quietness in bed relieved both 
 constipation and abdominal distress. 
 
 The patient is tall and slender, somewhat nervous in temperament; 
 the aVlomen is flat, the right kidney is freely movable and the stomach 
 is dis^ laced as shown in the drawing made from the gastrodiaphane ; 
 the corde colique transverse is faintly palpable. (See Fig. 1.) 
 
 Case No. 2. Mrs. G., a^t. 66 (Hospital No. . .). Complaint of pain in 
 stomach. The patient says that during the past twelve years she has 
 been subject to abdorn.inal pain coming on about two h.mrs after food 
 and lasting for three or four hours. These attacks have recurred at 
 intervals varying from three or four mcmths to one or two weeks. Great 
 care has been necessary with her diet in order to avoid an attack. She 
 
 \\ 
 
 I » 
 
6 
 
 I 
 
 is the subject of flatulence and constipation during these attacks. The 
 pain has been felt chiefly in the epigastrium but extends around the 
 back on the right side. She had never been jaundiced before coming 
 under observation and there is no history of over-indulgence in food 
 or drink or past stomach disorder, but she has partaken freely of con- 
 diments. 
 
 Her condition was one of emaciation, muscles, small and flabby ; ment;il 
 state wae irritable; the circulatory and respiratory sysloms wore negative. 
 On examination of the abdomen one observed that it was thin-walled and 
 very lax. There was the epigastric depression extending down to the um- 
 bilical level, below which fulness was manifest. The spleen and liver 
 were not palpable, while both kidneys might be readily felti Inflation 
 of the stomach and illumination of the same were confirmatory and 
 showed marked displacement downwards and to the right with no dilata- 
 tion as shewn by the diagram (Fig. 3). The lesser curvature was just 
 above the umbilicus. A test breakfast showed no hydrochloric acid and 
 no lactic acid. The patient was under treatment for some days in 
 the hospital upon a fairly liberal diet of gruel, sweetbreads, fish, toast 
 and tea, somatose, and koumiss. Farad ism was also api)lied to the 
 stomach. While under observation a severe attack of abdominal pain 
 supervened and on the following day the patient was markedly jaundiced 
 with bile in the urine. The degree of jaundice diminished to deepen 
 again only after another attack of pain. 
 
 This case illustrates the following points :— (I.) Marked digestive dis- 
 turbances for years ; (11.) Nervous irritability ; (111.) Constipation ; 
 (IV.) Epigastric pain followed by jaundice. 
 
 Case No. 3. Mrs. M. A. M., ict. 36. (Hospital Nos. 1,024, 4,029.) This 
 patient complained of '' disease of the liver, kidney and bladder." For 
 years she had suffered with pain in right hypochondrium; she had had 
 DO acute illness; she had borne two children, both of whom died in 
 infancy; one year previous to her admission to the hospital she suffered 
 from severe abdominal pain which was referred to the right flank and 
 was attended by " swelling and tenderness over the part." This attack 
 was but temporary and fully subsided. Since that time, however, she 
 has had ocoaisional vomiting and felt chilly sensations. 
 
 Present condition : — One was struck with the expression constantly 
 present on this patient's face. It was one of anxiety and distress; she 
 was of a dark complexion, thin and hollow-eyed, and I remember well 
 when going about the wards for the first time after she came into the 
 iiospital. She presented the striking picture of a neuasthenic patient. 
 Discovering neurasthenia written so plainly on the face of 
 this patient, I immediately examined the digestive system and abdomen 
 with the gratifying result herewith given in detail. Her tongue was 
 
 f'Uiimm!im:. ii V i 'V tk mi tii^^imi'mMimitm 
 
jks. The 
 ound tlic 
 e coining 
 a in food 
 y of con- 
 
 ly ; nicnt.il 
 
 negative. 
 
 railed and 
 
 the nm- 
 and liver 
 
 Inllation 
 itory and 
 no dilata- 
 ( was just 
 i acid and 
 3 days in 
 fish, toast 
 ed to the 
 linal pain 
 jaundiced 
 to deepen 
 
 estive dia- 
 stipation ; 
 
 )29.) This 
 ler." For 
 e had had 
 n died in 
 le suffered 
 flank and 
 'his attack 
 (vever, she 
 
 constantly 
 stress; she 
 imber well 
 e into the 
 ic patient, 
 face of 
 
 1 abdomen 
 )ngue was 
 
 flalilty, teeth poor and appetite capricious. She was often tn.uhied with 
 flatulence, the bowels were constipated, the abdomen was lint and flaccid. 
 Some general byperffisthesia wiw present, but especially niaiiii'esl over the 
 right hypochondrium and liypngustriiuu; the epigastrium was Hat and 
 hollowed, the lower alxlominal zone, if anything diirer.'nl, was com- 
 paratively prominent; on deep inspiratory raovemeuts one noticed in the 
 epigastrium and extcn<ling across this area, a wave passing from above 
 downward to a point al)(>ut two inches above the umbilicus and one 
 could feel a rounded body quite superficially. The right kidney was 
 readily palpable and moved freely on inspiraticui and could he pushed 
 up under the ribs. 
 
 The usual method of locating the stomach was resorted to and it was 
 found, as in the diagram (Fig. H) markedly displaced. 'I'he pelvic organs 
 were normal. 
 
 Case No. 4. Mrs. L. C, a3t. .'IS. (Hospital No. G,r)15.) .Admitted 
 June, 18'J7. I'atient complained of gastric distress consianlly present, 
 constipation, aching back and palpitation of heart. 'J'lie j)atient be- 
 lieves her present illness began three years before and during the past 
 few months it had been greatly aggravated. Although always of a highly 
 neurotic nature,, she ad been specially so during the past three years. 
 In Murcii, 1897, her menstruation ceased. (JuHtric (.listress, thitultMu-e, 
 pyrosis and constipation describe her digestive disturbances. 
 
 i'resent condition:- — 'i'he patient's nutrition was only fair as she show- 
 ed signs of emaciation; her facial expression wa.s trouhled and she was 
 decidedly neurotic. x\nxious introspection characterised her mental 
 state. Vasomotor instability manifested in visible flushing of her face 
 and body, was a feature of her case. There were no stigmaUi of hysteria. 
 The respiratory and circulatory organs showed no signs of disease. The 
 generative organs were not diseased; she had a left inguinal hernia, 'i'lio 
 abdomen was very lax with tenderness on pressure about two inches 
 below ensiform cartilage; the liver and spleen were not displaced. The 
 right kidney was palpable and movable to a slight extent. The chief 
 interest centres upon the stomach. A test breakfast was given but no 
 contents could be gained thereafter. Gastric inflation revealed downwarci 
 displacement of the stomach, the greater curvature presented three 
 inches above the symphysis pubis, the lesser curvature was seven inches 
 above this point, thus showing a transverse measurement of the stomach 
 of four inches (Fig. 4). 
 
 Remarks : — These two cases, Nos. 3 and 4, illustrate in the most 
 striking manner the neurasthenic symptoms associated with this con- 
 dition of the abdominal organs ; the facial aspect, the complaints, the 
 introspection, the self-observation and the results of treatment were 
 typical. In No. 3 treatment consisted first in nephrorraphy which 
 
 ^ itf i inMHT>hw»* *»- 
 
ir 
 
 III 
 
 I 
 
 III 
 
 m 
 
 8 
 
 avuilo.l n..tl.in«. Tho " .ordc c.li.iuc- Irai.svcrHe " wuh well markKl in 
 tl.iH iu8.' uii.l wus misluucling, inuHinuih ua it WU8 movable and associated 
 with loss of IK'sh and the absence of free hydrochloric acid in the 
 stonmch ronleiits after the test breakfast, it was stn.iigly suKgestive ol 
 niaii-'iiant disease of the stoinacli. but an explonitory incision bowed it 
 to bo the pamroaB. The wound healed but the patient was not improved. 
 Tlie treatment in Case No. 1 was more satislactory, although no 
 operation was done, under massage (general and local), suggestion and 
 reassurance, tonics and mild aperients and tiie wearing of a ban.lage, 
 much improvement was made and though she has not continued as well 
 as ever yet she is leading a fairly active life in ccniparativc comfort. 
 
 Case No. 5. Mde. St. D., let. IH. (Hospital No. (i.r.Ol.) (!omplaints 
 were of pain in loins and a feeling of weight and distress in upper 
 abdominal z-ne wbieh was wrse on the left side. The patient had 
 borne thirteen children, and at tin. second pregnancy twins were hern. 
 Ever since this event the abdomen has been pn.minent and flabby. 
 During the past twelve years llatulence had frequently troubled her ; 
 during the past five or six years vertical headaches and distress in 
 upper part of abdomen were complained of. While always nervous sho 
 has become much more so during the past few years. ^^ 
 
 ICxamination of the abdomen showed it to be one of '• hdrKjehauch, 
 the walls were very tlaccid and pendulous, the recti abdominis were 
 widely separated and between these muscles one could readily feel the 
 prolapsed contents of the abdomen. On examination of the different 
 organs of the abdomen one found the normal area of liver dulness a 
 resonant one. This organ was movable and could, at times, be easily 
 felt hetween the recti ; again it was with diiliculty made out, possibly 
 becoming rotated upon its transverse and longest axis. The left kidney 
 was felt on deep inspiration, while the spleen and the right kidney 
 could not ho felt. The stomach, on inflation, was dislocated downwards, 
 while the measurement of the organ when distended with gas indicated 
 some degree of dilation as well. The lesser curvature was three inches 
 above the umbilicus, the greater four inches below this, giving the trans- 
 verse measurement of the stomach as seven inches. (Fig. 5.) 
 
 This case illustrates a ptosis of the liver with gastroptosis occuring in 
 a woman with a multiple of pregnancies and in whom the recti were 
 widely separated, the stomach dilated and nervous symptoms manifestly 
 
 exaggerated. _ ,. , , 
 
 Case No. G. Mrs. K., ffit. 10. (Out patient.) Showed displaced 
 stomach, freely movable and tender right kidney, with occasional vomit- 
 insr ; epigastric pain and tenderness with pulsating area on the left of 
 the middle line ; some frequency of micturition. L'Epreuve de Sanole 
 was most satisfactory in her case, and the wearing of an abdominal 
 support was found very helpful. (Fig. 6.) 
 
 «w. 
 
iirkcd in 
 rtsociiilod 
 il ill llio 
 ;eslive «>l' 
 liowud it 
 mprovod. 
 
 Ollf^ll 111) 
 
 (tilin and 
 lmiiilaj,'o, 
 d as woU 
 i'ort. 
 
 )m|>laints 
 in uiipcr 
 Lii'iit had 
 t'lT born. 
 ,d flabby, 
 ded her ; 
 istress in 
 rvous she 
 
 inis wore 
 y feci the 
 I dilferent 
 dulness a 
 
 be easily 
 t, possibly 
 eft kidney 
 it kidney 
 oiwnwards, 
 I indicated 
 iree inches 
 
 the trans- 
 
 ) 
 iccuring in 
 
 recti were 
 
 manifestly 
 
 displaced 
 )nal vomit- 
 the left of 
 } de Sangle 
 abdominal 
 
 Uotuniing now to the Hccond part of our subject, wo may say I hat 
 the chief functional disturhaiict's to whicli Knten "ptosis is rchiti'd are : — 
 
 1. Ncurauthcnia, including digi-Htivc distiii'l)an('eH. 
 
 2. Anaemia. 
 
 ;{. Constipation. 
 
 4. .laundice. 
 
 r». (iiislric (lihitatioii. 
 
 6. Myxiudi'nia, Sclorodernia and Kxophthiilniic (Joitro. 
 
 The theories concerning the syinplonis associated in most instances 
 willi I lie altered position of the abdominal organs are numerous, but 
 for convenience of consideration we may classify them umler three 
 headings : — 
 
 1st. There is the mechanical theory from Olenard. 
 
 2nd. What may be termed the neuro-nieehanioal theory of Meinert. 
 
 3rd. 'I'he neuro-intoxieation theory of Schwerdt. 
 
 The first theory, although not purely a meehanical one, i.s chielly 
 such. It does not ask for any antecedent nervous cause, but it implies 
 a weakness of the suspensory ligaments of the transverse colon, cspeci- 
 nlly the colico-hepatic ligament. The descent, Cilenard claims, begins 
 at the hepatic tle.xure iind the other events ineiilent to the disease follow. 
 viz.: — The entero-stenosis due to a kinking of the colon at tho point 
 of prolapse, the corde colique transverse, the gastroptosis, the constipa- 
 tion, the auto-intoxication, the neurotic manifestations, etc. 
 
 The second theory, which we may chanicteriso as the neuro-mecliiini- 
 cal one, is advanced by Meinert ; in short, Meinert attributes the 
 symptoms associated with "dropping of tlie viscera" to the constiint 
 stimulation and irritation of the sympathetic nerves, as a result of 
 pulling and stretching of these nerve fibres. This has its deteriorating 
 efTect upon the blood, through the blood-forming organs, and the 
 general nervous system, and hence chlorosis, neurosis and all sorts of 
 vasomotor disturbances. 
 
 The third theory is that of Sehwerdt already alluded to in speaking 
 of the etiology of the disease. The nervous system is primarily at 
 fault — the fibre of the individual is toneless ; the functions of the 
 abdominal muscles, both parietal and visceral are not normal, intra- 
 abdominal pressure is lessened — ptosis takes place. There is stasis in 
 the blood and lymph vessels, the bowel contents decomjiose, the excre- 
 tions are not carried off, absorption of poisonous products goes on and 
 auto-intoxication results — dyspeptic manifestations, neurasthenia, head- 
 ache, anosmia, lack of energy, palpitation, etc., etc. Polyuria follows 
 as a consequence, while Graves' disease, scleroderma and myxcedema, 
 are theoretically possible as results of visceral irritation and intoxica- 
 
f 
 
 =1 
 
 
 'I 
 
 10 
 
 tion. However obscuxe the causes of the three diseases may be, few aro 
 ready to accept this as au explanation oi their etiology. 
 
 When we consider the altered relation of the abdominal viscera m a 
 condition of ptosis, the interference with the motor function of the 
 intestine, the great tendency to constipation, the resulting distress and 
 pain, it is not dillicult to understand how a state of mental depression 
 or nervousness and of general nerve weakness may result. In whatever 
 relation these two conditions may really be, it is not hard to understand 
 that enteroptosis may be a direct cause of the neurastheni- 
 
 Chlorosis and enteroptosis are doubtk'ss related in both respects. 
 
 dhlorosis on the one hand has been regarded as due to a neurosis, on 
 the oilier as an intoxication, and it would seem that in the teaching ot 
 I^lcincrt some ground for both these theories existed. The left-sided 
 pain is common in clil(.r.)-aiia>mia, and 'I'aylor refers this pain to dis- 
 tention of tlio colon in an or-an displaced downwards. In one of our 
 cases of marked enteroptosis tlu' pain was constantly referred to the lett 
 side of the abdomen in the upper (quadrant. 
 
 Jaundice in ..ach cases may be due to :— 
 
 1. Passive congostioi! of a displaced liver and its results upon the 
 
 bile passages. 
 
 2. To obstruction in the duodenum. 
 
 3. To direct pressure upon the bile ducts exerted by a floating kidney. 
 
 4. Other causes. 
 
 Constipation has already been explained. 
 
 Gastric dilatation was at one time thoujjht to be due to obstruction 
 to the duodenum and pylorus, caused by the floating kidney so com- 
 }v only found associated with it ; it is doubtful if such can be the cause. 
 'J'iio position of tlie stomach and the lack of tone so common in such 
 cases doubtless extends to the muscular wall of the stomach, and m 
 these conditions one finds sufficient explanation for the dilated condi- 
 tion which is rarely pronouced. 
 
 The indications for the treatment of enteroptosis as originally recom- 
 mended by Glenard, are as follows :— 
 
 1. The intestines must be elevated and kept in their new position. 
 
 2. The abdominal pressure must be increased. 
 
 3. Tlie bowels must be regulated. 
 
 4. The secretions of the intestinal glands must be increased. 
 
 5. The digestion and nutrition must be regulated and stimulated. 
 
 6. The whole organism must be strengthened. 
 
 These indications, in many instances, are met by the body binder po 
 applied as to exert upward pressure and thus support the prolapsed 
 organs while it increases the intra-abdominal pressure. It may be made 
 by ordinary grey cotton pinned flrmly about the body. 
 
 !> Jr 
 
 \ 
 
 I 
 
11 
 
 e, few aro 
 
 scera in a 
 on of tlie 
 stress and 
 depression 
 I whatevor 
 mdorstaiul 
 
 respects. 
 L'urosis, on 
 caching of 
 
 left-sided 
 ain to dis- 
 one of our 
 to the left 
 
 upon the 
 ng kidney. 
 
 obstruction 
 ey so cora- 
 i the cause, 
 on in such 
 ch, and in 
 ated condi- 
 
 ally recom- 
 
 jsition. 
 
 sed. 
 imulated. 
 
 hj hinder so 
 e prolapsed 
 lay be made 
 
 ^i 
 
 
 Then mild purgatives are neetU'd. Massage of tlu; abdoim-n olU'ii 
 does good in stimulating the movements of Hie bowel and giving tone to 
 the abdominal muscles. The same may be said of electrical (Faradic) 
 
 applications. 
 
 Then the use of alkalios and the choice of such a diet as is most 
 nourishing and easily di >ied arc of importance. 
 
 Recently both hot and cold baths 1- vo conu' into favor as giving 
 general tone to tlie circulation, and Buxbaum recommended the cold 
 Sitz bath as inducing favorable results, especially by reason of its action 
 upon the intestinal circulation and secretion. He advises that they bo 
 +sken daily for two — five minutes. 
 
 The chief advance in the treatment of the condition since 1886 has 
 been in surgery, by which some brilliai.t results have been brought 
 about. Eecently reported cases liave come from Treves, in England, 
 who sutured the liver to the abdominal wall ; Bernhardt, Ferrari, Ter- 
 rier and liartmann, in Europe, and Byron B. Davis, Stengel and Boyca, 
 in America. Gastropcxy and gastrorrhaphy liavo, in dill'i-rent cases. 
 given good results; while in Stengel's case, operated on by Dr. Beyea. 
 the gastro-hepatic omentum and gastro phrenic ligament were shortenctl 
 by a tuck made with multiple sutures, thus bringing the stomach up 
 
 towards its normal place. 
 
 BIBLIOGRAPHY. 
 
 1. 
 2. 
 3. 
 4. 
 
 5. 
 
 fi. 
 
 7. 
 
 8. 
 
 7. 
 10. 
 11. 
 12. 
 13. 
 14. 
 
 15. 
 16. 
 17. 
 
 48. 
 
 19. 
 
 20. 
 21. 
 22. 
 23, 
 24, 
 25 
 
 Glenard— Lyon Medicalc, iaa5. 
 
 Glenard— Revue de Medicine, 1887, p. 7.5. 
 
 Glenard Kiiteroptose et Neiinistlu-nie, Soeiele Med. de.s Ilopitaux. Purls, 1880. 
 
 Schwerdt-EnteroploHe u. Intra abdoininale nnick. Deut.sche M. Woclien- 
 
 schrift, 18H0. 
 Meinert-Gastropto.se niid Cliioro.se, I)eutsi-lie M. Woclu'n.sclinft. 18!M). 
 Leo "Giistroptose und Cliloros.-. IVutsche M. Woiliensclirift, IHiKi. 
 Meinert-Volk, Saninil. Klin. Voitran-, Nos. 115-lK), 1S95. 
 Treves— British Medical Journal, ISlHi. 
 Treves-Systcni of Medicine, Alllmtt, Vol. III. 
 Einhorn, Max-Medical News, September, 18!«i. 
 Kuttner und Dyer-Berliner K. Wocheii., 18!»7. 
 
 Pepper and Steugel-Tlie American .Journal of Medical vSciences, 1897. 
 Taylor— The Medical Press, December, 1891. 
 Langcrhans, (Leipzig)- Ueber Euteroptose, Monatschrift fiir Geburt.shiilfe und 
 
 Gyniikologie, Band. VIII. 
 Stengel and Beyea— The American .Journal of Medical Sciences, June, 1899. 
 Buret, M.— Revue de Chirnr., p. 421, 1S!K5. 
 Fleiner-Miinch. Med. Wochen., 1895. 
 
 Schwerdt-Beitrsge fur yl'^tiologie ; Symptomatologie u. Therapie der Krank- 
 heit Enteroptose ; Basedow Myxiedenie Sclerodemie Tena Fisher, 1897. 
 
 Lancet, Editorial, May 1st, 1897. 
 
 British Medical Journal, Epitome, 377, Oct, 31. 189(). 
 
 Ewald -Diseases of the Stomach, Mangos, 18i)7. 
 Einhorn— Diseases of llie Stomach, WW. 
 Osloi— Practice of Medicine, 2nd edition. 
 Fitz and Wood— Practice of Medicine 2nd edition. 
 
 Schmidt-Ergebnisse der allgemeineu Pathologie und Path. Anat. des 
 Menschen. u. Tierc 409, 1890. 
 
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