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increased (hypertonic) peristalsis, a contraction may be seen separating
the pyloric end from the rest of the stomach. Though it may have an
hour-glass appearance; the neck comes from the most dependent portion,
the construction rings are equal and the hour-glass appearance does not
appear in all the radiographs thus differing from the organic type.

In other cases, with ulcer of the lesser curvature, a deep incisura is
seen in the greater curvature. This is liable to indicate hepatic adhesion
and the incisura is spastic and often disappears when the patient lies down.
Thus spastic contracture sometimes occurs when there are no adhesions.
Sometimes the greater curvature may be drawn up by adhesions and the
radiograph appear to be hour-glass on standing but this disappears when
the #-ray is employed in the Trendelenburg position.

Hypotonic Hour-glass Stomach. Hertz describes a ptosed and atonic-
ally dilated stomach which sags so extremely that in the radiograph the
lower segment contains bismuth the walls meet above this obliterating
the lumen and some bismuth accumulates above.

This gives an apparent hour-glass stomach which disappears when the
patient lies down or if the shoulders are depressed (moderate Trendelen-
burg).

Operative procedure is the only method of cure.

DISLOCATION OF THE STOMACH

The fundus may be dislocated upward. Among the causes are:

Absorption of a pleuritic exudate on the left side; after contraction
of the lung or any process which is accompanied by upward dislocation
of the diaphragm; excessive distention of the abdominal cavity, forcing
the diaphragm upward, such as from pregnancy, ascites, tumors, and
rneteorism and diaphragmatic hernia.

The cardiac end of the esophagus may become bent. Lateral dis-
location is rare, and may be caused by tumors of the spleen, distended
colic flexure, or lateral pressure from an enlarged liver. As a rule, the
latter forces the stomach downward.

Downward dislocation (gastroptosis) is the common form.

DIAPHRAGMATIC HERNIA. EVENTRATION OF THE
DIAPHRAGM. VOLVULUS OF THE STOMACH

Diaphragmatic Hernia. With this condition, the stomach and
colon are most frequently involved though diaphragmatic hernia of
nearly all the viscera may occur. In the majority of cases there is
more or less torsion of the stomach in the vertical or longitudinal axis, in
addition to its upward displacement, and the colon may lie above it.



44O DISEASES OF THE STOMACH AND INTESTINES

This type of hernia may be congenital through some defect of develop-
ment; or acquired in which event the hernia takes place through one of
the normal openings in the diaphragm, chiefly through the esophageal
opening and there is a true hernial sac. Finally, there may be traumatic
hernia due to laceration of the diaphragm from wounds by knife or bullet,
crushing, or severe blows or falls. If a portion of the stomach form the
hernia, or torsion of the organ is marked, strangulation and gangrene
may occur, or the esophagus, pylorus or duodenum may be occluded.

Symptoms In congenital cases they may appear soon after birth,
there being cyanosis, dyspnea, cardiac misplacement to the right, inter-
ference with left lung expansion and rapid death. Occasionally there
are milder cases, or the symptoms develop later in life. In these there
are digestive disturbances, attacks of pain and vomiting of yellow fluid,
later of blood, increased tympany in the anterior axillary line, at times
jaundice, distention in the upper left quadrant of the abdomen. Relief
may follow vomiting, or sudden death may follow from gas pressure o'n
the heart, or peritonitis may result.

In the acquired cases, symptoms of less severe type may occur as noted
above or there may be sudden strangulation with its symptoms, hemate-
mesis, etc., or in some cases obstruction of the esophagus with distention
and no vomiting.

In the traumatic cases, the symptoms follow the injury, or may occur
later, such as dyspnea, thoracic and epigastric pain, cyanosis, shallow
breathing; vomiting or attempts to vomit if torsion of the esophagus, with
distention and marked thirst. In the chronic types there are attacks of
recurrent vomiting and pain after meals the latter worse in the erect
posture. Subsequently if strangulation occur there may be hematemesis,
or inability to swallow if the esophagus is obstructed, collapse, and per-
forative peritonitis.

Diagnosis, The physical signs are distention of the chest on the af-
fected side, restriction in pulmonary expansion, intestinal peristaltic move-
ments communicated to the thorax (in some cases) ; epigastrium retracted
or distended depending on the degree of hernia, and rigidity of the upper
abdominal wall. There may be a tympanitic note at the base of the lung,
or a dull area due to the spleen, omentum or fluid contents of the stomach.
Artificial distention of the stomach and colon increase the tympanites.
Gurgling sounds are present over the stomach, respiratory sounds are no
longer distinct. Compression of the lung occurs above the hernia and the
heart is usually displaced to the right.

Radiographs. If the colon forms part of the hernia, bismuth or barium
enema will demonstrate its presence above the line of the diaphragm. The
bismuth meal will show a curved shadow line with the concavity down-
ward, i.e., the upper wall of the stomach. Below this is usually an air
bubble which in turn lies above the diaphragm level. With diaphrag-
matic hernia there is a mottled appearance of lung tissue visible through
the gas lying in the stomach, which does not occur with eventration of the
stomach (Giffin).

Paradoxical Expiratory Displacement. On forced inspiration the dia-
phragm descends normally on the right side, but on the left side it ascends.



GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 441

On forced expiration the reverse occurs, and the shadow line on the left
side is found high up.

Differential Diagnosis. With eventration of the stomach, the mottled
appearance of lung tissue is not visible in the radiograph through the gas
in the stomach, as it is with diaphragmatic hernia. The shadow lines in
the radiograph or by fluoroscopy may give information. With two curved
shadow lines, if after artificial distention of the stomach, the lower one
move upward against the upper, then the lower is stomach and the upper
diaphragm. If the upper Hne was stomach, then it would move up higher
after distention. However, a single shadow line may represent both
stomach and diaphragm, but distention will cause the pyloric end of the
stomach to unfold.

Recurrent attacks of pain and vomiting after injury to the lower thorax
point to hernia. With pneumothorax we have the physical signs, and fre-
quently signs in the other lung; there are fewer gastric symptoms. Radio-
graphs show an unbroken line of the diaphragm and no bismuth or barium
deposit above it.

With subphrenic abscess, there is a previous history of gastric or duo-
denal ulcer; leukocytosis and increased polynuclears are present. The
.T-rays show the stomach below the diaphragm.

Prognosis. This is grave in all cases, though operation after early
diagnosis, has proved successful.

Treatment. For acute distention with cyanosis, lavage affords tem-
porary relief providing the esophagus is patent. Surgical procedure is
indicated.

Eventration of the Diaphragm. This consists in a thinning and
weakening of the diaphragm usually on the left side, so that it bulges
upward and forms a sac into which the stomach or other viscera may
enter. The condition is often congenital and lack of development of the
left lung is associated. It may be acquired by atrophy or degeneration
of the muscle of the diaphragm, or as a result of paralysis of the phrenic
nerve.

Radiograph. This shows a high line of the diaphragm unbroken and
overlying the bismuth area in the stomach.

Symptoms. These are not characteristic and the "physical signs re-
semble those of hernia (diaphragmatic) which are described under that
section.

Treatment. Only symptomatic treatment can be employed.

Volvulus of the Stomach. This consists of an abnormal rotation of
the stomach on one or more of its axes, resulting in the occlusion of one
or both of its orifices (the pylorus most frequently). The volvulus may
be partial or complete. While the cardia is still patent vomiting occurs
and lavage affords relief. Later cardiac occlusion occurs and the tube
can no longer be passed.

Axial rotation is usually from below forward and upward, the anterior
form, and less frequently from below backward and upward, the pos-
terior form. Rotation about the vertical axis is less frequent and then
more generally from right to left. The degree of rotation varies; mild
cases with pain, distention and vomiting may spontaneously recover. The



442 DISEASES OF THE STOMACH AND INTESTINES

rotation is usually 180 degrees or more producing strangulation, the
stomach becoming greatly distended.

Etiology. Among the causes are diaphragmatic hernia, tumors, hour-
glass stomach, adhesions, trauma produced by displacement of liver or
spleen, a blow or a fall ; gastroptosis has been given as a cause but I doubt
it. Some so-called idiopathic (non-explainable) cases are reported.

Symptoms. There are the previous symptoms of hour-glass stomach,
adhesions, or diaphragmatic hernia in some cases. In others there is
sudden intense and continuous pain in the epigastrium or lower left
thoracic region ("douleur thoracique" as described by Faure) with severe
pressure over the heart as if the thorax would break; vomiting, often
hematemesis; later the vomiting stops and distention increases and it is
impossible to pass a stomach-tube, due to torsion of the esophagus. There
is an effort to vomit but no ability to do so. Localized rigidity of ab-
dominal muscles appears early and spreads. Death occurs from collapse
or peritonitis.

Differential Diagnosis. With diaphragmatic hernia, there are the
usual signs, with heart displaced to the right.

With intestinal obstruction vomiting persists while with volvulus it
stops and the stomach-tube is blocked. This last also differentiates it from
acute dilatation of the stomach where the tube is readily passed and
affords relief. With acute pancreatitis we have epigastric peritonitis,
tenderness at Robson's and other points, subnormal temperature, general
hemorrhagic tendency, jaundice, the history, etc.

Prognosis is bad as a rule.

Treatment. Early lavage when possible may aid in spontaneous re-
duction. Surgery is otherwise indicated.

GASTROPTOSIS ENTEROPTOSIS GLENARD'S DISEASE

(Synonyms. Gastroptosis Rose; Visceroptosis; Splanchnoptosis; Abdominal Relaxa-
tion or Atonia Gastrica Rose; Atony of the Third Degree)

Definition. Gastroptosis may be denned as a prolapse or downward
displacement of the stomach, right kidney or both kidneys, and other
organs of the abdominal cavity, which may be associated with disturbances
of the gastro-intestinal tract and pelvic organs, together with various
nervous symptoms. Ptosis of the heart may also occur.

Nephroptosis is a stigma of gastroptosis.

Introduction. I here use the term "gastroptosis" with the usual
definition (ptosis of the stomach), though Rose has shown it correctly
means descent of the belly (spalnchnoptosis). The reader must remember
that gastroptosis is a quite frequent condition, and that it may be acci-
dentally discovered in some cases which have no symptoms whatever.
On the other hand, there are various degrees of ptosis of the stomach, in
some of which the symptoms are rather mild in character, while in others
there may be the symptoms-complex of Glenard's disease.

It is not the position of the lower border of the stomach which con-
stitutes a ptosis, but that of the upper border; with the relaxation of the
suspensory ligaments of the stomach the lesser curvature sinks as well as



GASTROPTOSIS ENTEROPTOSIS GLENARD'S DISEASE 443

the greater, and we may have varying degrees of ptosis, from moderate
obliquity of the upper border, to a vertical stomach; while on the other
hand, the entire organ may sink and give the crescentic form of gastro-
ptosis. The determination of the lower border alone is not diagnostic,
since it may merely be evidence of a dilated stomach. Hundreds or
even thousands of cases of nephroptosis have been reported as having
dilated stomachs, the dilatation being imputed to pressure of the kidney
on the duodenum, and no investigation has been made of the position
of the lesser curvature.

From my own experience, I do not hesitate to say that movable kidney
(nephroptosis), with the lower border of the stomach lower than normal,
is diagnostic of gastroptosis. Dilatation of the stomach is often associated
with gastroptosis, but kidney pressure on the duodenum, in my opinion,
has no bearing as to its production. This combination has been found in
cases at the Manhattan State Hospital. Furthermore, treatment for
gastroptosis will generally cure this condition. Ptosis of the stomach in
some of these cases may be of extremely mild type.

Anatomic Considerations. It is necessary to briefly allude to certain
anatomic features. The liver, as we -know, is suspended from the dia-
phragm by ligaments derived from the peritoneum. The cardiac end of
the stomach is held quite fixedly in position by the esophagus, and there
is a peritoneal attachment to the diaphragm at this point, the gastro-
phrenic ligament. In this location the stomach lies in close relation to the
diaphragm, while the lesser curvature is suspended from the liver by the
lesser omentum (gastrohepatic). The spleen lies in close relation to the
diaphragm, being attached thereto by ligaments (processes of the peri-
toneum), and to the stomach by the gastrosplenic omentum.

It is thus readily understood how compression of the lower part of
the thorax or effusions above the diaphragm may mechanically force down
the latter and produce ptosis of organs so closely associated. The descent
of the intestines is a natural accompaniment.

A tumor of the pylorus may cause ptosis of the stomach, and prolapse
of the transverse colon and of the other viscera follow.

On the other hand, a severe type of dilatation of the stomach may
be followed by ptosis of the organ and then general visceroptosis. These
primary types of gastroptosis are not so very frequent.

The transverse mesocolon surrounds the transverse colon and con-
nects it with the back of the abdomen at the spine. The transverse colon
is attached to the abdominal surface of the eleventh rib on each side by
a fold of peritoneum. As the colon passes across the abdomen it sags
somewhat, presenting a slightly concave surface superiorly. Glenard,
whom we must justly credit as the first to describe splanchnoptosis as a
pathologic entity, believes enteroptosis (ptosis of the transverse colon)
to be the starting-point. He thinks the transverse colon is fastened to
the pyloric end of the stomach by a band (ligament), and that the hepatic
flexure first sags, followed by the transverse colon, causing thus a sharp
flexion at the attachment of the ligament, and a hindrance to the progress
of the intestinal contents, with resulting accumulation in the ascending
and transverse colon. From the point of stenosis the transverse colon



444 DISEASES OF THE STOMACH AND INTESTINES

passes downward diagonally across the abdomen as a hard cord-like mass
(corde colique transverse).

The sagging of the transverse colon exercises traction on the pylorus
and omentum, thus causing descent of the stomach and liver. The
descent of the hepatic flexure, he believes, causes traction on the parietal
peritoneum and encourages ptosis of the right kidney. The gastro-
intestinal tract, he noted, was suspended in the form of loops, six in
number, by means of ligaments; and he believed in the possibility of too
great a bend at such an acute angle, that it might cause a partial obstruc-
tion to the passage of the contents. This might occur at the gastroduo-
denal, the duodenojejunal, transverse colon, or sigmoidorectal curves.

The gastroduodenal and transverse colon ligaments Glenard holds
to be the weakest, and if they give way, with resulting ptosis of the in-
testine, increased traction and angulation is produced at the next fixation
point, causing an enterostenosis.

Glenard found the transverse colon displaced and stenosed in numerous
autopsies, and was the first to realize that many cases of so-called nervous
dyspepsia were dependent upon these abnormalities.

Riegel has demonstrated that the hepatic flexure is not dislocated
downward in the majority of cases, and Glenard's explanation I hardly
believe tenable, as there are other very important factors which have a
bearing. A tumor, however, of the transverse colon or adhesions may
produce primary enteroptosis.

We must remember there is one type of case, a congenital constitutional
defect, the patient with long narrow thorax, who suffers from splanchno-
ptosis.

Keene finds in autopsies on babies evidences in favor of the congenital
origin of enteroptosis. In many of these there was a redundant colon.
A potential enteroptosis is, therefore, present, which is latent. Later,
through some cause, weakening of the abdominal musculature or diminu-
tion of intra-abdominal pressure, sagging of the intestine occurs and
symptoms develop. The writer believes there are quite a number of
these congenital cases. The round-shouldered, hollow-backed position,
Reynolds 1 holds, results in the formation of pot-belly and leads to the
production of splanchnoptosis. Undoubtedly, spinal curvature or rickets
may be factors.

The major number of cases of gastroptosis, however, are acquired from
various causes; and in my opinion the development of the prolapse of the
various organs generally occurs synchronously, the stomach, right kidney,
and transverse colon most frequently prolapsing together; while in other
cases the left kidney or the rest of the viscera may descend in addition.

These following are the prominent factors which have a marked bearing
in preserving the proper position of the viscera:

1. The abdominal muscles.

2. The maintenance of normal intra-abdominal pressure.

i. Abdominal Muscles. In an interesting article, the late A. Rose 2

1 Jour. Amer. Med. Assoc., Dec. 3, 1910.

2 Surgery, Gynecology, and Obstetrics, November, 1906, Physiology and Pathology
of the Abdominal Muscles.



GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 445

calls attention to the fact that in addition to the usual functions described
in the text-books, in assisting expulsion of the fetus, bowel action, urina-
tion, and vomiting, the abdominal muscles aid in the preservation of the
physiologic position of the abdominal organs. The crosswise arrange-
ment of the external and internal oblique and transversalis muscles-
supported by the recti effect a narrowing of the abdominal cavity and
prevent visceral ptosis.

Groddeck, of Baden-Baden, has, moreover, described the mechanical
influence of healthy muscle, by the alternate contraction and expansion,
in assisting the circulation of the blood and lymph, and an atonic condi-
tion of the abdominal musculature would certainly interfere with the
maintenance of the normal relations between the extra- and intra-
abdominal circulation. Moreover, clinically, simple inspection will
differentiate between normal conditions and the typic "pot-belly" of
the gastroptosis patient. Acute or wasting disease may also cause
changes in the muscles.

2. Infra-abdominal Pressure, Normal abdominal muscles also main-
tain the normal intra-abdominal pressure necessary to preserve the posi-
tion of the viscera.

Walkow 1 has made a very exhaustive study of this question and has
demonstrated, for example, on the cadaver, with the upper part of the trunk
elevated (the reversed Trendelenburg position), that after abdominal
section, mobility of varying degrees of the kidney is found, which did not
previously exist.

Sturmdorf has found similar results after laparotomy on the living.

Clinically, changes in the intra-abdominal pressure, the result of child-
birth or tapping for ascites, have resulted in the production of splanchno-
ptosis, the thinned and distended musculature of the abdomen also being a
factor.

Rapid loss of weight from emaciation and absorption of omental fat is
another example.

Nephroptosis. Movable kidney, in probably 95 per cent, of cases in
my own experience, is one of the stigmata of gastroptosis. The congenital
type, with long mesonephron, or those cases due to traumatism, are com-
paratively few in number.

The right kidney has a longer pedicle and lies lower on account of the
liver.

Stiirmdorf refers to certain skeletal deformities as influencing the shape
of the bony receptacle for the kidneys, and which in some cases predisposes
to prolapse; but gastroptosis is associated with these same conditions.

It has been claimed that there is a nephrocolic ligament connecting
the kidneys to the ascending and descending colon, and that traction of
the colon may influence its descent. Reversed peristaltic action occurring
intermittently in the ascending colon, which does not take place in the
descending, is believed to have an influence, arid the peritoneum over the
left kidney is said to be thicker. The fact that the tail of the pancreas
lies in front of the left kidney seems to me to have some bearing on the ques-
tion. Absorption of the fatty capsule is probably another factor.

1 Med. Rec., Jan. 13, 1906.



446 DISEASES OF THE STOMACH AND INTESTINES

The peculiar position of the right kidney and lessening of intra-ab-
dominal pressure seem to be the chief causes of its more frequent descent.

With gastroptosis we have also a relaxation of the gastro-intestinal
musculature and of all the peritoneal ligaments. Changes in the position
of the stomach and in its secretory and, at times, in its motor functions
account for the gastric disturbances. The secretory function one might
expect to be influenced by circulatory disturbances following displacement
of the organ.

Associated are changes in the position of the duodenum productive of
stasis, and which readily account for gall-bladder symptoms simulating stone,
so often attributed to nephroptosis. Similar disturbances in the intestine,
constipation, diarrhea, mucous colic, or chronic appendicitis can thus be
accounted for. There is a relaxation of the broad ligaments and with it
ovarian and uterine descent, and even descent of the pelvic floor, with
dysmenorrhea and various symptoms of the pelvic organs. I do not
agree with Edebohls' theory of compression of the superior mesenteric
vein by the kidney as a cause of congestion of the appendix.

Occasionally, Dietl's crisis from torsion of the kidney pedicle and,
rarely, nephritis or hydronephrosis occur. More rarely the kidney may
become adherent to the gall-bladder or appendix. In addition, circula-
tory disturbances and marked neurasthenia, the latter due chiefly, I
believe, to auto-intoxication, are present; and from the severe type of
splanchnoptosis we have the symptoms-complex of Glenard's disease
all of which the "kidney experts" attribute to nephroptosis.

Etiology. We must remember that the vertical stomach is the fetal
position of the organ. Some hold that every infant is born with it in this
position and that after a few weeks or months, through the weight of the
food and the action of the diaphragm, the position of the stomach becomes
normal. Recently radiographs of the stomach, of very young infants and
children, apparently show that the position and shape of the infant stom-
ach is not always constant, though the normal organ lies in its entirety-
above the umbilicus. Occasionally, it may remain vertical, but I believe
this is true more especially in those suffering from the congenital consti-
tutional defect, to which I shall refer.

The causes of gastroptosis may be divided into congenital and acquired :

i. Congenital constitutional defect, the long narrow thorax, with the
diaphragm and liver pushed down. In these, splanchnoptosis is a con-
stitutional defect. Stiller's floating tenth rib is usually present. Butler, 1
from more recent investigations, holds that the floating tenth rib is rare
in adults; though fully 50 per cent, of all children have a movable tenth
rib, though it is rarely unattached. Mobility of this rib is not a stigma
of enteroptosis in children. Butler holds that the ptoses are usually first
noted at the period of puberty. The enteroptotic habit of the adult finds
its counterpart in the child, with frail habit, lack of fat, slender muscles



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