Normal state (Glenard). A, aorta; E, stomach; C, cæcum; Cd, descending colon; CH, right flexure of the colon; D, duodenum; Du, bas fond of duodenum; F, liver; I, ileum; J, jejunum ; M, mesentery; Ms, superior mesenteric artery; R, kidney; Ra, spleen; Si, sigmoid flexure; Sr, suprarenal capsule; Vb, gall-bladder; W, foramen of Winslow; X, tenth rib; 1, œsophagus; 2, gast. hep. om.; 3, ligament, pylori.-colic; 4, ligament. mesent. sup. ; 5, suspensory fold of right flexure; 6, ligament pleuro-colic.

Hence, then, to sum up, a dyscrasic state of the blood produced by the presence of ptomaïnes formed in the dilated stomach, direct action of these ptomaïnes on all the departments of the organism, and, in particular, on the cerebro-spinal axis, the liver, the kidney, such, according to Glenard, is the mechanism by which we are to explain the symptomatology so peculiar and so variable of gastric dilatation.

There remains to be explained the primordial cause of the dilatation and the enfeeblement, for the most part congenital, of the muscular coat of the stomach. This is a point which is still very obscure, but it seems, nevertheless, that in those subjects whose stomachs lack equilibration, the origin of the dilatation goes back to the first periods of life, and results from the two following fac

I

tors,-heredity and faulty alimentation. have no doubt as to the first factor, and can affirm that I have often seen instances where individuals with dilated stomachs have had offspring who became sufferers from the same affection. Then, again, errors and defects of diet in early life have much to do with the genesis of the complaint; but we are obliged to call in, besides, another auxiliary factor, -namely, a predisposition of nervous origin which favors distention of the muscular coat of the stomach.

But what appears strange in this connection is that dilatations consecutive to mechanical obstructions of the stomach, dilatations which form a special group that is well known, are not accompanied by the nervous phenomena which we see supervene in subjects of gastrectasis, which I may call spontaneous. I have seen enormous stomachs resulting from an obliteration of the pylorus, and I have very rarely observed in these cases the symptomatic aggregate which characterizes those "whose stomachs lack equilibration."

Of the two theories, that of Glenard and that of Bouchard, which shall we choose? As for myself, I have long regarded Bouchard's theory as the most worthy of acceptance as being the most conformable to physiological data, and as involving less of hypothesis than the other.

It is in the large intestine that Glenard places the primordial and necessary cause of the enteroptosis, but this in his estimation is a mechanical trouble, bringing about physical disturbances. According to this writer, the prolapsus of the right flexure of the colon entails the downward displacement and contraction of the transverse colon, which he describes under the name of corde colique transverse (transverse colon-cord) on account of the corded feel of the gut. This downward displacement and this diminution of calibre enables one easily to feel the beatings of the aorta in the neurasthenic. To this corded condition of the transverse colon succeeds an ampullary dilatation of the left flexure of the colon, then a diminution of calibre of all the descending colon and of the sigmoid flexure to the anus. This is what Glenard describes under the name of cordon sigmoidal. (Fig. 2.)

I am far from having noted in all my cases of gastrectasia these mechanical and physical troubles, and even in a certain number I have observed, on the contrary, a dilatation of the descending colon, and I believe that there are a good many patients who present the nervous

Pathological state (Glenard), complicated with a nephroptosis of the third degree. A, aorta (batt. epig.); C, cæcum (downward and inward displacement); Cd, left flexure of the colon (in place), preceded by an ampullary dilatation; Du, bas fond of the duodenum; E, stomach, distorted by the transverse colon; F, liver; Ms, mesentery; R, kidney; Ra, spleen; Rm, kidney (ectopia of third degree); Si, cordon sigmoidal: Sr,

suprarenal capsule; Sm, ibid. on the right side, with its ligament of union to the kidney torn after distention (whence ectopia of the kidney, according to Glenard); TI, first part of transverse colon in prolapsus; T2, transverse colon cord; X, tenth rib; V, gall-bladder; W, foramen of Winslow.

tine.

These neurasthenic subjects, then, are sufferers from dilatation of the large intestine, and are to be cured, not by lavage of the stomach, but by antiseptic lavage of the colon and rectum.

Moreover, Glenard and Bouchard have much to say about the troubles of defecation which affect almost all victims of dilatation. There is constipation, the fæcal matters are pasty, fetid, and acid, the acidity, according to Bouchard, being due to acetic acid; there is sometimes, even, mucous or pseudo-membranous enteritis.

But, to come down to practical points, it is not necessary for you to bother yourselves too much about either Bouchard's or Glenard's theory, for, strange as it may seem, these two

theories, which are so dissimilar, result in therapeutic principles and means which are almost identical.

Glenard intends that his treatment shall fulfil the following conditions:

1. To combat the visceral prolapsus and augment the abdominal tension by means of an appropriate abdominal belt.

2. To regulate the intestinal evacuations. 3. To institute a special regimen in order to tonify the digestive organs.

If to these means you add gastro-intestinal antisepsis, you will have the treatment counselled by Bouchard, and in conjoining lavages of the stomach and intestine, you will have that which I propose.

Before entering upon the exposition of this treatment, which is the real object of this lecture, I ought to tell you what are the signs which will enable you to detect dilatation of the stomach, and how you ought to proceed to examine those whose stomachs lack equilibration; but were I to set forth all the details which pertain to this subject, it would take several lectures,-therefore I shall have to refer you to Bouchard's later writings, and especially to those of Glenard, who has stated with great method and perspicacity the mode of exploration of the abdomen in these cases."

I ought to remind you just here that the most important sign of dilatation is the bruit de clapotement. In order that there may be dilatation of the stomach, this bruit must, as you know, be perceived below the oblique line which passes from the borders of the false ribs on the left side to the umbilicus. Any bruit de clapotement heard above this line must be considered as physiological.

It is not always easy to perceive this bruit de clapotement, even in the case of dilatations that are considerable, and this for two reasons: first, the vacuity of the stomach, and, secondly and chiefly, the contraction of the muscles of the abdomen, and in particular, of the recti muscles.

It is easy to remedy the first cause by making the patient drink a glass of cold water while fasting, but it is more difficult to overcome the contraction of the abdominal muscles; you will, however, ordinarily succeed by making the patient take a long breath, or by pressing suddenly with one or two fingers over the abdominal wall, or, by

* Glenard, "À propos of a Case of Gastric Neurasthenia," Paris, 1887; "Conférences Cliniques de l'Hôtel-Dieu de Lyon" (Province Médicale, 1887).

grasping with both hands the two sides of the abdomen and making over the belly quick, violent movements, such as those which we cause when we wish to detect the Hippocratic succussion in cases of pneumothorax.

Do not forget to examine attentively the iliac fossæ; often you will find there a bruit of gaseous collision, which, by its timbre, is differentiated from the bruit de clapotement; this

bination :

Salicylate of bismuth,
Naphthol a,

Carb. lig., aa 10 grammes. M.

Powders to be taken in

I assign the first place here to intestinal antisepsis, advocating the views of Bouchard. As I have already said, I consider intestinal antisepsis as the capital point in the aggregate of therapeutic means to be employed in cases of dilated stomach.

This intestinal antisepsis comprehends several processes or sets of agencies. We may, for instance, endeavor to benefit our patient by pharmaceutical remedies, or we may hasten the expulsion from the intestine of septic matters we may interfere directly by washing out the stomach or intestine; or, lastly, by a special dietetic regimen, we may reduce to the minimum the quantity of ptomaïnes formed in the alimentary canal. Let us examine now how we are to proceed to fulfil each of these indications.

Among the pharmaceutical remedies, we have certain inert powders and disinfectant substances. The success formerly obtained by Trousseau in the treatment of diseases of the

stomach with subnitrate of bismuth, by Patterson with the mixture of magnesia and bismuth, by Belloc with his powder of charcoal, is today easily explicable, as all these substances are antifermentative, and to a certain extent prevent putrefactive changes in the stomach. The discovery of salicylate of bismuth, and more recently of naphthol, has enabled us still more effectually to carry out intestinal antisepsis.

You may, then, in your cases of dilated stomachs, make use of capsules containing these antifermentative powders. Where the dilatation is inconsiderable, and the gastric

Divide in chart., no. xxx. capsules.

The patient will swallow one of these capsules with his breakfast or dinner.

You should always prefer the naphthol a to the naphthol B, the first being, as Maximowitch has shown, more soluble, more antiseptic, and less toxic than the second. You should also remember that in certain persons with dilated stomachs, naphthol is not well supported, even in small doses; in such cases you will have to be content with the first formula.

Laxatives have a rather important rôle in the treatment of dilated stomachs. They enable us to obviate the constipation so frequent in this disease, and to expel from the economy the toxines which are produced throughout the whole length of the digestive tube. All the laxatives may be employed, from the purgative waters to the laxative powders (senna, sulphur, rhubarb, etc.).

As I intend to devote an entire lecture to the treatment of constipation and diarrhoea, I shall then set forth with considerable completeness .the history and uses of the new purgatives at your disposal.

I will content myself at present by telling you that I use ordinarily either the natural purgative waters,-Villa-Cabras or Rubinat,

a tumblerful being taken in the morning on an empty stomach, or the following laxative powder, of which the patient may take a dessertspoonful in half a glass of water between nine and ten o'clock in the evening:

Pulv. sennæ,

Pulv. sulphur, äå 6 grammes (3iss);
Pulv. anise,

Pulv. fennel, ää 3 grammes (gr. xlv);
Pulv. cream of tartar, 2 grammes (3ss);
Pulv. licorice, 8 grammes (3ii);

Pulv. sugar, 25 grammes (3 vi). M.

If the majority of patients with dilated stomachs are constipated, there are cases, on the other hand, where there is a manifest tendency to diarrhoea. I formerly counselled for these diarrhoeas sulphide of carbon water, obtained by agitating sulphide of car. bon with water; since the introduction of naphthol, I prefer this latter medicament.

In these cases, I modify somewhat the composition of the capsules, and have them prepared in this way:

Salicylate of bismuth, Naphthol a,

Prepared chalk,

Phosphate of lime, aa 10 grammes (gr. cl). M. Divide into forty capsules; one capsule to be taken with breakfast and dinner.

What, in my experience, succeeds best in these cases of dilatation with diarrhoea, is lavages of the intestine by the aid of antiseptic solutions.

This leads us to the third indication which we have to meet, in order to obtain in these subjects of dilatation, intestinal antisepsis.

In the great dilatations of the stomach, lavage of the stomach is obligatory, and this especially when the substances contained in the stomach have a tendency to putridity. I need not here dwell on the manner of performing lavage of the stomach, which I have treated quite fully in my "Diseases of the Stomach and Intestines," and in "New Medications."

The alkaline waters are generally employed for these lavages; when there is putridity, you can make use of antiseptic solutions, either of boric acid, 10 per 1000, or naphthol a, 1 per 1000.

These same lavages, applied now to the large intestine, are indicated, as I have already said, in two circumstances; when there is putrid diarrhoea, or when there is dilatation of the large intestine, with accumulation of gas and fæcal matters. Cantani has given to this therapeutic method the name of enteroclysm; the best method of practising enteroclysm consists in employing the Debove tube furnished with its funnel. Introduce, as high up as possible into the rectum the semi-rigid part of the tube, fill the funnel with the medicinal solution, and, according to the height, you will augment the force and rapidity of penetration of the liquid introduced into the large intestine.

If you cannot obtain a stomach siphon, you can make use of a large irrigator or fountain-syringe, furnished with a long rectal

canula. The quantity of liquid should not be less than a quart; as for the solution to employ, you can use tepid water, or, when the putrescence is very marked, water containing a little naphthol or boric acid. Dissolve I gramme (15 grains) of naphthol a in a quart of water, or use a one or two per cent. solution of boric acid. Every morning the patient should wash out the lower bowel with this solution.

The final indication under this head is to regulate the diet. This matter of dietetic regimen is of great importance, for thereby we may hope to combat both the intestinal putridity and the dilatation.

Three things are to be avoided by persons with dilated stomachs,-first of all, liquids, and, in general, articles of food in a liquid or semi-liquid state; then multiplicity of meals; and, lastly, aliments which may furnish ptomaïnes in too great abundance to the

economy.

Subjects of gastrectasia support liquids badly, and Chomel a long time ago gave to these particular digestive ailments the name of dyspepsia of liquids. Put your patients, then, on a dry diet, allowing them not more than half a pint of drink with breakfast and dinner, no liquid (if possible) to be taken between meals.

What shall the drink be? Plain water in preference to the gaseous waters, which are badly supported. As for the alkaline waters, the least gaseous should be selected, and when Vichy or Vals is drunk with meals, the bottle should be uncorked some time beforehand in order to allow the excess of carbonic acid to escape. As for wines, a light white wine should be chosen, like those of Central France. Pure wine and spirits should be eschewed.

In speaking of wine, there is a medicinal wine which should be interdicted; I refer to wine of quinine. There are many physicians. who have the habit of ordering quinine wine in all states of enfeeblement, without informing themselves beforehand of the state of the stomach; it is a bad habit, and deplorable in its conséquences. Quinine wine increases the digestive troubles in persons with dilated stomachs, and thus aggravates their condition. Hence you should be pretty sure of the integrity of your patients' stomachs when you prescribe it.

As before said, the patient is forbidden to drink between meals; is to take no tea or coffee, and is forbidden soup; the latter, however, may be permitted if made thick.

Quite as important is the prescription of the hours of meals. The slowness with which in persons with dilated stomachs alimentary substances pass from the stomach to the intestine, makes it imperative that there should be a long interval between meals, so that when food is taken it may find the stomach empty, or nearly so. There should be seven hours between breakfast and dinner, and the patient should not be allowed to eat between these meals.

supporters play a considerable part, hence Glenard places them at the head of his therapeutic measures, and he recommends an abdominal belt, which he calls sangle pelvienne, of which he gives a detailed description in his exposition of the treatment of enteroptosis (Lyon Médical, June 26, 1887). From this description I borrow the following details :

Glenard's sangle is a belt of elastic webbing, twelve centimetres (five inches) in width, and from sixty-eight to seventy-five centimetres (twenty-seven to thirty inches) in length. To one of the extremities are at

You may lay down the rules for meals as follows:

A light breakfast at seven o'clock; a second at 11.30 A.M.; and dinner at seven in the evening. Many persons can well dispense with the first breakfast, and in that case will take but two meals a day,—the one at 10 A.M., and the other at 7 P.M.

As for the kinds of food to be chosen, it is desirable to avoid the introduction of all alimentary substances capable of furnishing too great a quantity of toxines, and, in starting from this principle, you will have to prohibit, in the first place, game, then fish, which too rapidly spoils, also shell-fish and crustaceans and old cheese. In giving directions with regard to meats, you will insist that they shall be well cooked; cooking, in fact, opposes to a certain extent the production of cadaveric alkaloids. Hence, instead of ordering raredone meats, or meats scarcely cooked at all, you will prescribe meats thoroughly stewed, boiled, or broiled, beef à la mode, calf's jelly, broiled or roast fowl well seasoned, stewed chicken, etc.

But it is in these cases that the vegetarian regimen suits admirably. Vegetarianism is destined to have a rather important rôle in the treatment of affections of the stomach, and therefore I propose to devote an entire lecture to this subject. Let it be sufficient for my present purpose to advise you to prescribe for your patients a diet largely of eggs, cereals, green vegetables, and fruits.

I come now to the mechanical means which may be used to combat dilatation of the stomach. These mechanical means are of three orders,-abdominal belts, massage, and electricity.

In the theory of enteroptosis, abdominal

four and a half centimetres (about two inches) in width, and thirty-one centimetres (twelve inches) in length. To the other extremity are sewed three buckles, each five centimetres (two inches) in width, and placed side by side. Perineal straps fix this belt to the inferior part of the abdomen, so that it is placed just above the pubes, and its upper border does not extend above the crest of the ilium more than a finger's breadth.

The figure which I here show you indicates how this pelvic girth should be constructed, and if I insist upon all these details, it is because it is difficult in Paris to obtain a belt of the kind rigorously made according to the directions of Glenard. (Fig. 3.)

This supporter, which is especially applicable to subjects of dilated stomachs, with an abdomen lean and excavated, often gives patients considerable relief. Glenard insists that the relief thus obtained is a proof that his theory is right. I believe, with Bouchard, that the benefit derived from Glenard's supporter is due to the fact that the tractions on the dilated stomach are lessened thereby, whatever may be the theory adopted to explain this dilatation.

The other mechanical means for the relief of dilatation of the stomach is massage. You see massage performed every day in my hospital by one of my pupils, Dr. Hirschberg, of Odessa, who has published in his inaugural thesis, and in the Bulletin Général de Thérapeutique, the principal results thereby obtained.*

I refer you to these memoirs, where you will find described with great care the method to be employed in practising massage, only reminding you that it comprehends two parts, -the massage of the muscles of the abdomen

* Hirschberg, Thèse de Paris, 1889, and Bulletin de Therapeutique, September 30, 1887, and September 30, 1889.