Dr. J. R. Pennington, Chicago : The general practitioner mobility of the stomach, which is affected by the posi¬ is entitled to the same information as the specialist; conse¬ tion of the individual, by the weight of the stomach quently, I intended that this paper should contain statistical contents and by the tension or relaxation of the abdom¬ information not obtained the and other readily by average inal muscles. We have endeavored to determine the physician. Dr. Hirschman is to be commended for his normal of the stomach in a of valuable suggestions, and were they put into practice "by position study 1,000 insurance companies and others they would do much for the cases, and have come to the conclusion that in the control of this dreaded disease. supine position the textbook teachings are correct ; but in the upright position there is a wide normal variation depending on the anatomic make-up of various types of individuals. there seems to be as much A CLINICAL AND ROENTGENOGRAPHIC Indeed, difference in the size, contour and position of the STUDY OF GASTROPTOSIS stomachs of men as there is of their mouths. come so as OBSERVATIONS IN ONE THOUSAND GASTRO- We have also to the conclusion that far is it matters INTESTINAL PATIENTS gastric digestion concerned, very little whether a stomach is in the high position or in the brim SEALE HARRIS, M.D. of the pelvis, so long as its muscular tonus is good and AND the intra-abdominal pressure is normal. We have J. P. CHAPMAN, M.D. repeatedly found patients whose stomachs in the BIRMINGHAM, ALA. upright position were as low as it is possible to be, and yet who had no evidences of gastric indigestion. The added much to exactness in roentgen ray has We have found with a marked of gas- the of and from others, degree diagnosis gastro-intestinal diseases, troptosis, who complained of various digestive symp¬ it we have learned that are in many things helpful toms, yet after the relief of the gastric atony or with conditions about which we did a treating formerly the use of a abdominal supporter, and deal of The use of the roent- properly fitting great guessing. general after a few weeks' of and without some misin- regimen hyperalimentation gen ray, however, has not been abdominal all their discomfort of its This is true exercises, disappeared terpretations findings. particularly the of their stomachs was not of which, an incidental though position changed. gastroptosis, though only part the location of the stomach seems to have but of a habitus and associated with Indeed, general bodily always little to do with the of its normal function ; is treated as a performance enteroptosis, being separate entity by and in our there is no one normal of many who seem not to understand the underlying opinion position factors of the human stomach. etiologic visceroptosis. The the stomach to a extent Much of the regarding gastroptosis position of depends great misconception on the of the individual. In the so-called normal comes from the of textbooks on and type teachings anatomy human the stomach which assert that the normal type of average height and weight physical diagnosis posi- will be in the so-called normal i. the lowest tion of the stomach is in the upper left quadrant of the position, e., abdomen, the dome in the vault of the point of the greater curvature being above the umbili¬ lying diaphragm, same is as a and the lower border about 2 inches above the umbili- cus. The true of stout persons, rule. On the other hand, in the slender person with the cus. Anatomists formed their opinions regarding the long flat or narrow chest and with the slender in normal of the abdominal viscera from necropsy abdomen, position the the stomach almost made on cadavers on their backs, and standing position, invariably findings lying will be found in the left lower of the abdo¬ they were correct in their statements regarding the quadrant men, a position entirely normal with this type. The average position of the stomachs of persons in the these position. They seemed not to learn, however, position of the stomach will vary from two supine extremes as there are differences in the size and that the stomach is a mobile organ, and that shape highly of the chest and abdomen. the normal stomach of a healthy person while perfectly It is not the or the of the stomach may rest in the false but when position shape standing pelvic cavity, that the need be concerned about but its tonus. he lies down may to the upper left quadrant physician gravitate If the muscular tonus of the low stomach is of the abdomen. Diagnosticians fell into the same lying good, are no the error because their examinations of the abdomen were there symptoms. However, roentgen ray has demonstrated the fact that the stomach in the also made on patients in the supine position. high is more normal in tone than one Before the advent of the roentgen ray there was a position frequently lot of about locating the position of the that is found low in the abdomen. We have repeatedly "poetry" on examination in stomach and other abdominal viscera. If one will observed fluoroscopic of persons the that the atonic stomach would be attempt to outline a stomach by percussion, ausculta- standing position into a one when the con¬ with or without inflation, or changed hypertonic patient tory percussion, by splash¬ tracted abdominal thus sounds (Obrasztow's method), and check up his his muscles, increasing the intra- ing It would seem this the ray, he will be forced to admit abdominal pressure. from observa¬ findings by roentgen tion that the in with is a very large percentage of error. With the roentgen problem dealing gastroptosis not with efforts to treat the stomach so much as with ray the location of the stomach in various positions of measures to and the abdominal the body can be studied with exactness. strengthen develop muscles, or to increase intra-abdominal pressure tem¬ ROENTGEN-RAY STUDIES OF GASTROPTOSIS porarily by means of properly fitting abdominal In our roentgen-ray studies on gastroptosis, the most supporters. have been the marked of important findings degree INFLUENCE OF BODILY HABITS Read before the Section on Gastro-Enterology and Proctology at the most contributions to the the Seventy-Third Annual Session of the American Medical Association, Perhaps important St Louis, May, 1922. literature on visceroptosis have been the series of

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015 articles by Goldthwait.1 In his Shattuck Lecture he that certain races have gastroptosis more than others, classifies man into three anatomic types : ( 1 ) the nor¬ and that the mendelian law applies to the form and mal type with the moderately full and rounded thorax position of stomachs as well as to the color of the eyes, and upper abdomen, with costal arch from 70 to 90 and to other family and racial characteristics. degrees; (2) the splanchnoptotic (Glénard), congenital If two persons with visceroptosis marry each other, visceroptotic (Goldthwait) or carnivorous (Bryant) all their children probably will have a low position of i.e., the slender individual with the flat chest, the costal their stomachs and other abdominal viscera. If a nar¬ arch being an acute angle, a narrow upper abdomen row chested person with the long, slender abdomen and bulging lower abdomen; and (3) the herbivorous marries one of the so-called normal or stout type, it is (Bryant) of heavy build, broad back and large skeleton probable that in their offspring the abdominal viscera with excessive fat throughout the body. Goldthwait will be in a position between the so-called normal and lays much stress on posture, and blames the relaxed the extreme visceroptosis, unless one or the other muscles and ligaments for many of the ills which are should be of the dominant type. If it were possible to usually ascribed to visceroptosis. He says that "the mate human beings of different types as the Austrian body is most intimately related in its different parts so monk did the Andalusian fowls, it is probable that the that no one can be used wrongly without the whole positions of their descendants' stomachs could be fore¬ suffering. For this reason if these various groups of told with the same degree of accuracy as the varying symptoms are to be considered as purely local and colors of fowls can be determined before thev are born. distinct lesions, the results If the science of eugenics are sure to be unsatisfac¬ could be applied in mating tory. The body as a the stout human beings whole should be consid¬ with the slender habitus ered and not just the chest enteroptoticus type, it is or abdomen or other part." probable it would result in Mills,2 in a comprehen¬ marked racial improve¬ sive roentgen-ray study of ment for the reason that the form and position of the slender types as a rule the stomach, concluded have brighter minds and that "certain types of phy¬ more agile bodies, while sique are constantly asso¬ the thick, broad types have ciated with certain types better mental poise and of visceral topography, greater physical endurance. tonus and mobility." He In our opinion, what is classifies them into two called gastroptosis is nor¬ dominant ones : ( 1 ) hyper- mal with a large propor¬ asthenic habitus, the indi¬ tion of men and women vidual of massive build who go through life with¬ with stout thick chest and out any digestive symp¬ long abdomen; and (2) toms. It is an accepted asthénie habitus, charac¬ fact, however, that the terized by fraility of build, person with gastroptosis is long, narrow, shallow more likely to have gastric thorax and short abdomen, disturbances than one of with relatively wide pelvis. the normal type, just as He adds to this two the man with major Fig. 1.—Gastroptosis: stomach 2 inches below umbilicus; relaxed cardioptosis, types, sthenic and hypo- abdominal muscles. or the so-called "congeni¬ sthenic, and declares that tal" heart, under the stress the build of nearly all individuals will fall within these and strain of military service develops functional car¬ four groups, though he further subdivides the bodily diac symptoms. Indeed, the same type of individual types with their accompanying peculiarities into sub¬ inherits cardioptosis, nephroptosis, gastroptosis or types tending to the four major types. enteroptosis, as he does a more or less unstable nervous system. If such a person lives within his limitations he ETIOLOGY or she can be as efficient and as happy as one of the Gastroptosis is a condition, not a disease. It is so so-called normal type. Indeed, there seem to be certain frequently found that it can hardly be called an advantages which the highly strung, slender person anomaly. It should be termed a physical characteristic. has over a person of the phlegmatic or stout type. In our opinion gastroptosis, which we reiterate is Many of the most brilliant, the most efficient and the merely one phase of a bodily habitus in which there most useful men and women of our acquaintance is general visceroptosis, is nearly always of hereditary belong to the type who have gastroptosis. It would be origin. Therefore, in searching for the etiologic factors interesting to have roentgenograms made of the in gastroptosis, the ancestry of the individual is the stomachs of the 100 leading medical men in the United most important thing to be considered. It is probable States. In thinking over the bodily characteristics of the most celebrated of our we 1. and physicians acquaintance, Goldthwait, J. E.: An Anatomic Mechanistic Conception of are at are Disease, Boston M. & S. J. 172: 881, 1915; The Real Significance of convinced that least half of the habitus enter¬ Visceroptosis, Pennsylvania M. J. 17: 523 (April) 1914; Orthopedic type, and that the ray would reveal Principles in the Treatment of Abdominal Visceroptosis and Chronic optoticus roentgen Intestinal Stasis, Surg., Gynec. & Obst. 16: 587 (June) 1913. that perhaps the majority have gastroptosis. 2. Mills, R. W.: The Relation of Bodily Habitus to Visceral Form, it seems that the more the Position, Tonus and Mobility, Am. J. Roentgenol. 4: 155-169 (April) Indeed, highly developed 1917. race, the more likely it is to have visceroptosis. There

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015 are no statistics to prove it, but we have the impression characteristic is also held by John Bryant of Boston, that the English, the Scotch and their descendants in who in a recent personal letter said : "The thin type of America will show a larger proportion of persons with humanity which is particularly subject to visceroptosis visceroptosis than will be found among the Teutonic is certainly more frequent in the streets of this country and Latin races. In the study of our cases we have than in the streets of Hamburg or Berlin." also been impressed with the high percentage of gas¬ It seems that gastroptosis is less frequent in males troptosis among patients of Jewish descent. than in females. In our series of 1,000 patients, 532 Patients will frequently give a history of falls or were males and 468 females; of the 551 who had gas¬ injuries to the abdomen which they have been told is troptosis, 226 were males and 325 females. In Smithies' a cause of "fallen stomach," but in the light of our series of 300 males, only thirty-six had gastroptosis, present knowledge it would seem that trauma plays while of 300 females, 165 had gastroptosis. The bio¬ but little, if any, part in producing gastroptosis. logic fact that the female of the species is never so Oschner, in a recent communication, says : "I believe well developed physically as the male seems to apply to that one of the frequent causes of gastroptosis and human beings. Unquestionably, deficient muscular enteroptosis is the extreme gaseous distention of the development with associated relaxation of all the liga¬ abdomen due to faulty feeding during the infant's first ments of the body has much to do with the occurrence year of life, with overstretching of all the ligaments of gastroptosis. which normally should support the stomach and intes- The age decades were not taken in the study of the tines." The same thought first 500, but in the last has occurred to us,and one 500 cases, they are : seven of the questions that we between 10 and 19; sixty- ask all our gastro-intes¬ five between 20 and 29; tinal patients is : "Did you ninety-five between 30 and have digestive disease dur¬ 39; sixty-six between 40 ing infancy?" We have and 49 ; twenty-nine be¬ found many cases in which tween 50 and 59, and the symptoms date back to eleven between 60 and 69 improper feeding during years. We feel that no the first years of life. We importance can be attached are convinced, however, to age in gastroptosis in that the digestive disease this series because all of in infancy is more respon¬ our patients were adults sible for atony of the stom¬ and the proportion in this ach and intestines, which study is practically the causes the symptoms same as those with the usually ascribed to gastro- normal habitus. enteroptosis, than it is in Child-bearing has al¬ bringing about ptosis of ways been mentioned as an the abdominal viscera. important etiologic factor in gastroptosis, and un¬ OBSERVATIONS FROM A it does have STUDY doubtedly OF 1,000 some relation to the re¬ PATIENTS laxed abdomen ; but it is In a series of 1,000 pa¬ doubtful whether it has 2. of tients studied us Fig. Effect voluntarily contracting abdominal muscles in on by during increasing —gastric tone, stimulating peristalsis and elevating stomach to any bearing visceropto¬ the last eighteen months, level of umbilicus. sis. In our series, out of roentgen-ray examinations 325 females, only 182 have in the standing position disclosed that in 551 (55.1 per children, and there are 226 males, so that only about cent.) the lower border of the stomach was more than 58 per cent, have borne children. We think it likely, 2 inches below the umbilicus. These were all adult however, that women who have borne children are white patients, most of them native Alabamians, though more prone to have digestive symptoms, because they a few were from Mississippi, Tennessee, Georgia and often have relaxed abdomen with a consequent lowered Florida. The ancestral lines of the great majority of intra-abdominal pressure. whites in these states came from England, Scotland and the North of Ireland ; and they conform to the SYMPTOMS physical characteristics of the English and Scotch, who Gastroptosis is not a disease entity, and therefore is are likely to be tall and slender, though hardy races not responsible for the symptoms usually described as physically. from or associated with that condition. Per¬ 3 resulting Dr. Frank Smithies reports that in a recent study sons of the type whose stomachs lie low in the abdomen of the position of the stomach in 600 persons, gas¬ undoubtedly are more predisposed to functional gastric troptosis was noted in 198. It is presumed that disturbances than are the persons of the so-called nor¬ Smithies' patients were from Chicago, in which city mal and herbivorous types (Goldthwait) : the "sthenic" there is a large proportion of population of Teutonic and "hypersthenic" types (Mills). The "asthénie" or and Slavic ancestry, while in our series of cases a "hyposthenic" individuals are also more susceptible to very large proportion descended from the English and nervous disturbances. It is also to be remembered that Scotch. This view of visceroptosis being a radical the men or women with gastroptosis are mentally more alert and more active than are the "sthenic" 3. Smithies, Frank: Gastroptosis, in Ochsner's Surgical Diagnosis, physically Philadelphia, Lea & Febiger 2: 609, 1921. or "hypersthenic" types.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015 The symptoms usually ascribed to gastroptosis may the 1,000, ninety-one of the 551 with gastroptosis, and be due to many causes both intragastric and extragas- seventy-eight of the 449 with the high position of the tric, and they are the same without relation to the posi¬ stomach. Nearly all of these were ulcer or cancer tion of the stomach. In other words, the person with patients. gastroptosis may have any gastric or intestinal disease, Until the past year we did not make routine Was¬ though he is especially predisposed to atony of the sermann tests, getting specimens only in the cases in stomach and intestines. A study of the records of our which there was reason to suspect syphilitic infection. 551 patients who had gastroptosis shows that 345 com¬ Of the 1,000 patients, 509 had one or more Wasser¬ plained of gaseous eructations that come on at vary¬ mann tests, and of that number only seventeen were ing times after meals ; fifty-eight gave a history of sour positive. We doubt whether any of the other patients belching, and 105 had vomited at some time. These would have had positive Wassermann reactions if are not different, however, from the symptoms of the test had been made with them. This leads us which the 449 complained who did not have gastropto¬ to make the irrelevant statement that syphilis plays sis. Their symptoms are those that are usually seen a very small part in the etiology of the gastro-intes¬ in atony of the stomach from any cause. tinal diseases among the better class of people in Constipation, usually of the atonic variety, was pres¬ Alabama and surrounding states. ent in 389 of the 551 ; diarrhea was present in twenty- The fact that the Wassermann reaction was positive six, and 136 reported their bowels as being regular. in nine of the 551 gastroptosis patients, while plus in It is significant that 200 had indicanuria, which, when only eight of the 449 who did not have gastroptosis, considered with the fact cannot be of any signif¬ that more than two thirds icance. Avere would constipated, TREATMENT seem to indicate that in¬ testinal toxemia is an im¬ The mere fact of find¬ factor in the ing on roentgen-ray exam¬ portant ination a symptoms usually ascribed that patient's to stomach is low down in gastroptosis. the abdomen does not The nervous symptoms mean that he are those which predomi¬ necessarily needs treatment nate in our series of pa¬ directed tients who had gastropto¬ toward that organ. If his sis. Out of the 551, 340 physical poise is good and his abdominal muscles well gave a of being history or he nervous. Headache was developed, if has complained of by 279. sufficient fat in the retro- to Vertigo was another an¬ peritoneal spaces keep noying symptom with the intra-abdominal pres¬ many of them. Muscular sure high enough for gas¬ weakness and the general tric and intestinal function not to be interfered fatigue syndrome were with, with he needs no treatment prominent complaints his stomach rests many, though our records though on the brim of the are not complete on this pelvis. important syndrome in vis- If, however, as is fre¬ ceroptotic patients. quently the case, the per¬ son who has gastroptosis LABORATORY FINDINGS Fig. 3.—Horizontal position, patient on back, showing how completely is the stomach regains the normal position. It is unnecessary to elevate undernourished and he The laboratory records the foot of the bed, as is commonly practiced. has relaxed abdominal of the 551 patients with muscles, he should be gastroptosis may be of interest. Of the 551,only seventy- given treatment directed toward improving nutrition eight were found to have what is called normal degrees and with the effort to develop every voluntary muscle of hydrochloric acidity, that is, from 20 to 30 points ; in the body, particularly those of the anterior abdomi¬ fifty-six had low acidity, and twenty-three achylia, nal wall. Such patients are usually in a state of while 247 had an increase in the amount of hydro¬ chronic fatigue, and the psychasthenic element also chloric acidity. These figures are not very different in demands attention. In other words, it is the patient proportion than those obtained by Rehfuss in persons as a whole and not the stomach that should receive the who gave no history of indigestion. They show that physician's attention. hyperchlorhydria is of about the same frequency among The treatment of gastroptosis is not so much a mat¬ persons with gastroptosis as those who believe them¬ ter of medicine as of educating the patient. He should selves normal. be taught that gastroptosis is a part of visceroptosis, Urinalysis revealed albumin in eight, sugar in nine, which in turn is associated with an inherited bodily indican in 200; while in the 449 whose stomachs were habitus. in the so-called normal position, there was albumin in Psychic treatment is very helpful, particularly twenty-one, sugar in thirteen and indican in 160. This systematic encouragement, pointing out the fact that would seem to indicate that those who have visceropto¬ many of the happiest, most efficient and most useful sis suffer more from intestinal toxemia, while those of men and women in the world are those of slender, more the stout type are more prone to nephritis and dia¬ or less frail bodies, with visceroptosis, who live within betes. Occult blood was found in the stools of 169 of their physical limitations.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015 The visceroptotic individual should be taught the in the visceroptotic person to glide into the upper por¬ essentials of diet and nutrition: that if he would be tion of the abdomen. It is, therefore, wholly unneces¬ comfortable he must eat a full diet, with a liberal quan¬ sary to have the patient lie in an uncomfortable posi¬ tity of butter, cream and other fats ; plenty of the tion with his head down and feet up in order to elevate starchy and green vegetables, and the cereals; and 1 the abdominal viscera. The physical training of most persons is neglected, and the physician who treats visceroptosis must edu¬ cate his patients regarding the exercises which tend to develop every voluntary muscle of the body. Especial attention should be paid to deep breathing exercises and those that develop the chest and abdominal muscles. EXERCISES There are many good systems of exercises in treat¬ ing visceroptosis, any of which may be used. We have modified a group of exercises of considerable vogue with the idea of using every large group of voluntary muscles in the body, and have taught the movements to many patients, who report that they enjoy their morning exercises and bath, followed by massaging the entire surface of their bodies with the palms of their hands. One advantage of these exercises is that they require no apparatus, and they can be carried out in a very small room, most of them in a sleeping car berth. The patient begins with four of each exercise and increases one each day until he or she is taking sixteen of each before the morning bath. They may be repeated at night, provided one is not too much fatigued. OPERATIONS NEVER INDICATED The operation of fixation of the stomach for gastrop¬ to as Fig. 4.—Gastroptosis is usually associated with general visceroptosis. tosis is mentioned only be condemned irrational, The colon is very low on the pelvic floor. meddlesome surgery. The stomach is a very mobile organ, and no part of it should ever be fixed as is the or 2 quarts of milk a day. Bryant has pointed out that effect in all the various types of gastropexies proposed eggs and meats increase the toxemia in the visceroptotic individual, whom he calls the "chronic intestinal inva¬ lid." Sufficient proteins may be obtained from the milk and the legumes (beans, peas, etc.), though a small portion of tender meat (beef, lamb, chicken or fish) may be allowed once a day. Particularly should the patient with the habitus enteroptoticus be taught the diet and other measures to' overcome constipation and correct intestinal stasis and the resulting toxemia. THE REST CURE Rest in bed for a period of from four to six weeks is necessary in many cases. A "rest cure" in an infir¬ mary or sanatorium is best when the patient can afford such treatment. It is difficult to treat visceroptotic patients in their homes because it seems almost impos¬ sible for them to carry out in their accustomed envi¬ ronment the daily regimen required to increase nutrition and to develop the muscles. While the patient is in bed, his physician has the opportunity of directing his reading and of giving him daily talks on what he should do to get well, and of pointing out the routine to follow to keep well after his return to his home. In rare instances very intelligent patients have carried out the treatment successfully at home. Many clinicians have the foot of their visceroptotic beds elevated from 2 to 4 while some patients' feet, Fig. 5.—Effect of the dorsal position in elevating the stomach and advise the knee-chest position several times a day in colon several inches. order to get the stomach in what they call the normal position. We have proved by many roentgen-ray for gastroptosis. Roentgen-ray examinations by many examinations that the normal curve of the lumbar different observers disclose that the operation does not (spine) and the contour of the abdomen with the very permanently elevate the stomach, and many cases have smooth surfaces of the viscera and parietal perito¬ been reported in which the patients were in worse con¬ neum are sufficient to allow the stomach and intestines dition after the operation than they were before they

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015 were subjected to an operation which is not without they would not think of giving up an hour in the middle of serious danger to life. Our view that gastropexy is the day. And I think five minutes every half hour is infi¬ never a justifiable operation has been so pronounced nitely more valuable than a longer rest period in the 4 afternoon. that we sent questionnaires to a number of prominent surgeons and gastro-enterologists asking their opinion Dr. A. L. Levin, New Orleans : I should like to ask Dr. Harris if, in his cases of gastroptosis or he has of the merits of gastropexy. Replies were received enteroptosis, from all but and made observations a year after carrying out the line of two, treatment rest and exercises—to determine without suggested—diet, exception they whether the low position of the stomach or intestines has condemned the opera¬ been corrected; in other words, whether he has made exact tion. Among the sur¬ pictures to demonstrate that his treatment succeeded in caus¬ in geons who consider gas¬ ing the intestine or stomach to lift itself upward so that the t Fig. 6.—Exercise the horizontal po¬ sition: The chin is touched to the chest. tropexy an unjustifiable intestinal toxemia is relieved. After the symptoms are removed we should see then that the stomach operation may be men¬ by treatment, tioned Drs. M. T. W. E. and intestines have lifted themselves, thereby relieving the J. Finney, J. Mayo, Joel toxemia, if the latter is due to this cause. If we find the Goldthwait, Stuart McGuire, George E. Brewer, W. D. stomach and intestines still low and the condition is A. yet Haggard, Hugh Cabot, H. Royster, Charles A. L. improved, then the malposition of the organs is not the cause Reed, W. W. Crawford, James E. Thompson and of the pathologic condition. Louis Frank. Dr. Anthony Bassler, New York: In answer to Dr. The following gastro-enterologists heartily disap¬ Levin, I will say that in gastroptosis, chronic intestinal prove of any method of gastrofixation : Drs. Max toxemia is present in more than SO per cent, of all cases. Einhorn, George Roe Lockwood, John Bryant, Thomas If, in that 50 per cent, of cases, you permit the toxemia to R. Brown, Charles D. Aaron, Joseph Sailer, Julius continue, the largest pro¬ Friedenwald, John A Lichty, William Gerry Morgan, portion of the cases will Horace W. Soper, K. Simon and Franklin W. eventually revert to for¬ Sidney mer conditions, no matter White. There can be no that the con¬ question what you have done for sensus of both opinion among surgeons and gastro- the patient in the way of is to which enterologists opposed any operation Fig. 8.—Flexion of thighs, bringing rest, abdominal support, proposes to elevate and fix the stomach in any given knees up to chest. physical measures, diet, etc. position in the abdomen. I think that neglect of in¬ testinal toxemia is the reason why so many of these patients return after a conscientious effort to overcome the ptosis had ABSTRACT OF DISCUSSION been made. Another thing : I do not believe that it is possible Dr. John Bryant, Boston: Dr. Harris states that gas¬ to feel that a case of ptosis is what may be called cured until troptosis is of hereditary origin. I have done a certain the stomach is in normal position ; and our experience is that amount of work on the anatomic aspect of this question, and we succeed in restoring the stomach to its normal position I have not been able to find the stomach low in the fetus. only when we can keep the patient under observation for at It is a wholly acquired condition. On the other hand, I least six months and the elimination of the intestinal toxemia, think it is true that it is a familial trait. Members of fam¬ if present, is accomplished. There must be continuation of ilies through various gen¬ effort on the part of that person when he is up and around. erations are subject to I believe that the test of a cure in these people is what may visceroptosis. Dr. Harris be termed a riding stomach. After the increase of fat and referred to the question of intra-abdominal pressure, the building up of the patient of a high degree of devel¬ and all that sort of thing, you can never be sure that a opment in relation to ptosis patient is permanently well until, without any abdominal gastroptosis. I think it is support, the stomach is higher in the standing position than a question whether the peo¬ in the prone. That sounds ridiculous, but it is true : when, ple with a so-called high after treatment of a case of gastroptosis, the stomach is of are Fig. 7.—Exercise for strengthening the higher in the standing position than in the prone, you can degree development abdominal muscles: The is body raised on it that the will remain well. not somewhat undifferen- from the horizontal to the sitting posi¬ depend patient tiated. Many of their re¬ tion, the legs being kept straight. Dr. Leon T. LeWald, New York : The question has been actions are the same as raised as to congenital and acquired gastroptosis. I have those of children. One reason why they are brilliant is that they made a great many observations on infants and children. put everything into what they are doing and go the whole dis¬ Some of this work was done with the late Dr. Pisek, and, tance without thinking what is going to happen. There are more recently, with Dr. many things in the anatomic field which suggest that viscer¬ Kerley. Surprisingly few optosis is a reflection of an arrested development. As regards observations on young treatment, from a general point of view I think that visceropto¬ children have been re¬ sis is an indication of easy fatigability of the individual. If that corded, and many of the is true, the treatment is adequate rest, and it must come often conditions which we think enough to catch the person before he gets too tired. It is of as occurring only in well known that the curve of fatigue is a parabola. It starts adults we do see in chil¬ almost flat, then increasingly falls. In order to keep these dren ; and, in a consider¬ people going and improve their condition with the least pos¬ able number of cases, we sible waste of time, one has to order enough rest periods to have observed gastropto¬ Fig. 9.—With the knees extended, the raised the vertical catch the patient before he begins to go down hill. From sis in early childhood. We legs are to position. a practical point of view, I have found that perhaps the most believe that some of those valuable thing in the whole field of treatment is a five minute cases are definitely acquired from overfeeding, particu¬ rest period in every half hour. That may sound extreme, but larly in those children subsisting largely on milk, having you can get many people to give up that much time when extra meals of milk at school in addition to their ordi¬ nary meals. The proof of this is still somewhat vague, to this be in 4. The replies questionnaire will published another but there is no question as to the number of cases we article entitled "The Irrational and Unjustifiable Operation of Gastro- pexy." have seen of gastroptosis in young children. While a

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015 large number of adult cases of gastroptosis yield fairly in a great many of these cases. The corset support is impor¬ readily to changes in the mode of living, proper diet, and tant, not from the uplift of the intestine entirely, but largely the wearing of a support, I know of several instances in from the effect on the spine. Corsets are all made so that which surgical relief was the only solution of the problem. they have a stiffening effect on the spine. Then the patients One point was not brought out by Dr. Harris : not only the are taught to sit properly and not bend over and force the degree of ptosis, but also the functioning of the ptosed organ abdominal contents down. That is very important, and is not always taken into account. A small group of cases should be attended to early and often in children. It hardly can be relieved only by operative procedure. seems possible that enteroptosis does not cause symptoms in. Dr. John L. Jelks, Memphis : I want to ask Dr. Harris quite a percentage of cases, but, just as Dr. Harris has said, if he has found a psychic element to contend with in these the condition may be present without any symptoms being cases. Is it not, in his opinion, a misfortune, for a woman manifested. Thorough treatment of these patients and treat¬ especially, or any patient who is already neurotic, to learn ing them from every angle is, of course, necessary. A great that a condition of visceroptosis exists? Also, if he does not deal of nerve tire and disability is caused by another factor believe that in some cases the patient needs psychotherapy which has not been touched on, and that is focal infection. as much as other treatment? Many of these patients are Posture must have some effect on these patients because we married women who have borne children; others have had have had quite a large number with enteroptosis who have tumors removed; some have gone through a long period of been in a badly run-down condition, and yet were completely illness in which a great deal of fat has been lost, not only relieved by a properly fitting corset or even by posture alone. intra-abdominally, but the extraperitoneal fat cushions have It is not infrequent to find a gain of 30 pounds after postural been destroyed or markedly reduced. Also the modern dress, treatment. The fitting of this corset must be done under the which prevents continued development of the abdominal supervision of the physician. It must be made exactly right, parietes, undoubtedly has had a great deal to do with many with spring pads, the essential thing being to get the viscera cases of of the I have encountered; and I see a good many in the proper position before the corset is applied and to cases. I should them in connection with toxic and abdominal avoid postures which may dislocate them. like to know also whether, in the majority of cases wherein Dr. Seale Harris, Birmingham, Ala.: Regarding the ques¬ one notices an indicanuria and other indications of toxicity, tion of abdominal the fitted abdominal Dr. Harris does not also note adhesions. support, properly sup¬ porter is very helpful. But the visceroptotic person should not Dr. Charles D. Detroit: Aaron, Twenty-five years ago be condemned to wearing an abdominal support all his life. I a for the treatment of gastro-enteroptosis. presented bandage The idea should be to use an abdominal supporter as a tem¬ I have been that bandage up to the present time with¬ using porary measure until the patient can, through proper exer¬ out a single change in it. The results are marvelous. making cises, get an increasing abdominal pressure and also some treatment as laid down Dr. Harris, plus the Symptomatic by fat to help raise the stomach and to increase the intra- of a bandage, will bring about a clinical recovery. fitting abdominal pressure. As to visceroptosis not being hereditary Whether or not the stomach or intestine is back in position, because it has not been found in the fetus, the fetus has I do not know. We may not be able to restore anatomic not assumed the upright position. If men were to go on all arrangement, but we can restore the physiologic condition. fours, there probably would not be any gastroptosis. When I am led to believe, and I think all of you will agree with they assume the standing position, with the stomach dis¬ that if a suitable on the patient, this, me, you put bandage tended, descent of the stomach takes place. I think the will relieve the tension on the mesen¬ Therefore, by lifting abdomen, the condition is hereditary. Dr. Bryant's view that the condi¬ It is the tugging on the delicate nerves in the mesen¬ tery. tion is a fatigue syndrome is very important, for fatigue is tery that induces neurasthenia and nervous symptoms, not practically always present in those cases. In my the toxemia. The relief of that tension does away with the instructing in to rest, I also to them some If send the to the instrument maker, patients regard try give physical symptoms. you patient exercises and deep-breathing exercises and also exercises to a concern whose business it is to sell a you send her to develop the abdominal muscles. I instruct stenographers It is your to fit that bandage yourself; and bandage. duty and other office workers to take five or six deep breaths and if you fit it today, in a week from now it will not fit, because draw in the abdominal muscles at an open window every hour the abdomen has been held up, the mesentery has contracted, each day. It gives rest and also helps posture. It is very nec¬ and there is still tension. Patients when they first came who, to have these assume the with to walk after essary patients proper posture into my office, could not walk have been able the shoulders thrown back and the abdomen pulled in, and one of these for a short time. If you fit wearing bandages after a time they will assume that position naturally. This it will do the work. This and every it properly, bandage increases the intra-abdominal pressure and helps very much. fitted for the relief of should bandage gastro-enteroptosis As to the position of the stomach one year after treatment, the to the umbilicus and not extend just from symphysis we have not enough data of value in the way of statistics ; higher, and pressure should be firmly exerted on the small but in the majority of patients with visceroptosis whose intestine. If you make a pad for the small intestine, you symptoms have been relieved we find the stomach still low will raise the transverse colon easily, and that will raise the down in the abdomen. I do not think the position of the stomach. stomach has anything to do with the symptom. It is a ques¬ Dr. G. R. Satterlee, New York: I agree with Dr. Harris tion of tonus and intra-abdominal pressure. However, in a in the main. I agree with him also as to the familial tendency few of the cases the roentgen ray shows that the stomach toward enteroptosis. I have had quite a little experience has ascended 2 or 3 inches. But the psychic element is very with this condition, starting in some surgical work and important, and we should impress on the patient the fact that finally coming to the conclusion that we were not, strictly it does not make any difference if the stomach is low. Dr. speaking, doing surgery, but suspension. For four or five LeWald's remarks about the condition in infants and chil¬ patients who were going down hill very rapidly, surgical dren is very interesting. Dr. Ochsner has suggested that the suspension seemed to be the only thing to start them on the distention of the stomach and intestines in infancy causes right road. One interesting familial case was that of a visceroptosis. I think that gastro-intestinal diseases in infancy mother and daughter. The mother went down hill very rap¬ cause atony but not visceroptosis. I do not believe that any idly with gastro-enteroptosis. She had a suspension opera¬ operation for fixing the stomach or the colon or any other tion on the stomach. Her daughter had a similar condition, highly mobile viscus of the abdomen is going to do anything with homologous roentgenograms which could scarcely be but injure, because it interferes with function, and further¬ distinguished from each other. The daughter was treated by more, if you study the case with the roentgen ray after the posture and abdominal support; both are well today. Dr. operation of gastropexy you will find the stomach still low. Harris did not say very much about the effect of posture. Dr. Aaron spoke of the desirability of the physician himself In our work, we now believe that posture is a very important fitting the abdominal supporter. The important thing is to factor in the treatment of gastro-intestinal invalidism. I have a type of supporter which will fit tightly over the lower hardly believe that -we can get along without corset support part of the abdomen and loosely higher up.

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