VISCEROPTOSIS AS A CAUSE OF more physicians. In the writer's opinion, the "STOMACH TROUBLE." patient, and at times the family, may all be said to be in a state of neurasthenia. And small By William D. Reid, M.D., Boston. wonder, as they often have been given as many Visceroptosis has received a large share of opinions as they have consulted doctors,—some attention from orthopedists and internists dur- advising resort to surgery and others against. ing the past two decades, and medical literature This variation in the advice received generally is not lacking in excellent articles on the sub- has an upsetting effect. ject. Nevertheless, one continues to see cases At this point a few case reports will best serve not yet diagnosed, though they have passed to picture the type of patient to which the through the hands of one or more physicians. writer would draw attention. The type to which the writer refers is that in which the comes for relief of "stomach patient Case 1. Single woman. Seen June, 1915. not will trouble." It is held that this paper Aged 34 years. Canadian ; school teacher. Said present new facts, but it is hoped that it may to have gastric ulcer, but patient believes can- lay further emphasis on an important subject. cer to be the correct diagnosis. Family History The American Illustrated Dictionary defines —-Negative. Past History—Chicken-pox, scar- let fever and measles in childhood. "Sort of as "a or the falling down, visceroptosis prolapse, until 13 years old. Sore throat once a of " It is sometiues called Glenard 's puny" the viscera. year. "Rheumatics" past four or five years in disease, splanchnoptosis, enteroptosis, or gastrop- knees, back, and posterior aspect of left thigh. tosis, but the term visceroptosis seems prefera- The backache was bilateral and low down; no of trauma. v. t.i.d. of uncer- ble, as it is well known that the condition often story Aspirin gr. tain value. colds in winter of 1913- thoracic as well as those Repeated includes the organs '14. of the abdominal cavity; of the heart or ptosis Catamenia began at 13 years, regular, two ""dropped heart," is recognized by all cardiolo- days duration, rather painful. Bowels, "bad gists. all my life," sometimes fail to respond to two A lack of good physical development is typi- heaping teaspoonfuls of Epsom salts. Micturi- cal of the individual with visceroptosis. The tion : night once, none in the past three weeks ; never Drinks of such has been de- day, four to six; painful. eight appearance patient aptly of water 140 themselves glasses per day. Weight, pounds scribed by stating that they carry at 14 years, 125 to 130 about five years ago, in the "posture of fatigue." Any medical of- 130 in the fall of 1914; present weight is 102 ficers who happened to serve with the Special pounds and has been gaining of late. Training Battalion in France, as did the writer Present Illness—Dates illness from fall of About one week of for a short period, saw many examples of un- 1914. abnormally great with burning (Aug- developed young men who were physically un- appetite, epigastric pain. 1914, "severe cramps of bowels," but al- fit for ust, military duty. most nothing passed. Pain was located in the Malnutrition is also associated with viscerop- lower abdomen, and patient thinks that it tosis. In 1918, Max Einhorn, in a paper entitled ceased in about two days. About once every has similar milder attack. and Malnutrition,"1 again em- summer had a though "Enteroptosis Isn't certain if the attacks have occurred at the of one on the other. phasized dependence other times of the year. In 1906, there was a One further notes the close between relationship severe attack which confined the patient to bed the development and state of nutrition as found for two days. Not aware that there was any in the French children examined by the Ameri- fever at that time.) can Red Cross. The report by Dr. William P. Felt well until August to November, 1914. "rheumatism" in the never Lucas gives the figures for development as : Attack of fall; any Gradual appearance 19.4% ; fair, 37.5% ; poor, 42.4% ; and objective symptoms. good, of craving after meals, which was attributed to for nourishment as: good, 19.4%; fair, 44.3%, extra studying. This "gnawing discomfort" and poor, 36.3%. was immediately after meals, at first of limited But to proceed to the case as seen by the in- duration and later constant. "Would wake up ternist. Commonly one is told that he is to with ravenous appetite, eat a large unusual and then was ravenous all the morn- be consulted about a case of "Stomach trouble," breakfast, Strict milk diet and bismuth gave relief. and that the has ing." gastric ulcer, perhaps, patient Jan. 10—Feb. 5, 1915, was a patient in a been ailing for some time but has failed to ob- small Canadian hospital. Treatment consisted tain relief in spite of the attention of one or of rest and diet, or rather patient would eat but

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SANTA BARBARA (UCSB) on April 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. little—chiefly milk. Studies of the gastric con- food. She stated that at the Toronto General tents were made. Hospital a positive diagnosis of gastric ulcer weeks ' Feb. 6—March 25, 1915, was in the Toronto was made and yet in spite of seven treat- General Hospital. Gastric analysis and roent- ment, she obtained merely temporary relief. At gen examination were performed. Attack of the time of her arrival in Boston, this patient in of pain after taking a fruit drink (was told that was a state marked hypochondriasis and, the gastric contents did not show acid). Bak- as stated above, had fixed upon cancer in an in- ing soda did not give relief. Treated at first curable stage as her true complaint. of a by starvation and in the course of ten days the A diagnosis visceroptosis with possible diet was increased — gruel, junket, custard, chronic appendicitis was made and explained whipped white of egg; to cream of wheat, to the patient. Treatment based on this and poached eggs on toast, arrow root biscuits, etc. the mental condition was followed by a rapid On first to caused return to health ; in six weeks this lady gained starting eat, everything pain, win- but this gradually wore off. Milk and raw eggs 20 pounds and returned to Canada. By relieved the gnawing pain. Was improving the ter she had gained 40 pounds and was enjoy- last three weeks of stay in hospital, but felt as ing the snowshoeing. Save for an operation though the pain in the midepigastrium was for appendicitis, performed in 1918, her health just about to breakout. Diagnosis stated to have continues satisfactory. been gastric ulcer. March 25 to date (June, 1915) has been at Case 2. Woman, 26 years of age, single, seen home. Pain returned For three January 7, 1916. Chief complaint is "run promptly. ' ' ' ' " " a weeks remained in bed and on a restricted diet. down and indigestion. Has just had cry- and is so about her health." Since then has adhered to a soft diet, save for ing spell discouraged occasional breaks. Calcined magnesia and ant- Several "colds" this past winter and is said to No or acids have relieved at times. Some in have some nasal catarrh. cough sputum gain and this but is able to eat very little. at the present time. Gets tired easily strength, has been noticeable the four Present is, "I cannot eat without especially past complaint fair ; is apt to have gas and and so starve." There are very days. Appetite pain simply some discomfort if eats when tired. few that do not cause gastric things pain. Notes the symptoms one-half hour after meals, Liquid perolatum worked beautifully on sometimes, but are generally irregular in bowels for a while, but later diarrhea followed, they time of There are periods when so it was discontinued. The seems appearance. constipation the can eat all sorts of food without to cause Has had no emesis patient epigastric pain. discomfort. Bowels move but a since for three times daily, require December, 1914, except laxative medicine four or five days. Never noted like cof- every after calomel. anything No of "rheumatism," tonsillitis, or or food of the ; history fee grounds, blood, previous day the infectious diseases of childhood. maximum amount was less than one pint. Examination—Lying comfortably in ever a stool." Physical Doubts if passed "tarry bed. Poorly developed and thin. Chest flat, Physical Examination—Thin, nervous woman. costal arch narrow. Eyes, mouth, teethy Pupils equal and react to light and distance. glands, and lungs normal. Heart, apex impulse Mouth, glands, lungs, heart, and reflexes nor- in fifth space midclavicular line; percussion mal. Chest flat, costal arch narrow. Abdominal corresponds. Blowing systolic murmur at apex, wall shows moderate sagging. Liver palpable transmitted to base and slightly into axilla. one and on-half finger's breadth below costal Pulmonic second sound not accentuated, louder margin in right mamillary line ; upper border than aortic second. Sounds good quality, ac- at seventh rib. Right kidney easily palpable, tion regular. Pulses equal, regular, rate 81, non-tender. Slight tenderness in epigastric re- soft, fair volume and tension. Abdomen soft gion, no masses felt. Standing posture poor. and tympanitic, no masses or tenderness. Liver Hemoglobin 75%. Guiac test on stool nega- and kidnevs not palpable. Knee-jerks present tive. and ecmal. no Babinski, no edema. Weight Bismuth roentgen examination. No definite taken the following day) 96 pounds. evidence of disease. Moderate cecal stasis. Well- of the over- marked gastric and intestinal ptosis. This young woman was definitely ambitious type. She was a member of two high- The above patient came to Boston convinced grade choral societies in addition to helping that a surgical operation offered the sole re- her mother with much of the housework and tak- maining hope. A surgeon was consulted, there- ing an active part in the work of her church. fore, but he advised that medical treatment be She was always ready to take on more work. given a further trial. The patient previously The effect of poor nutrition and generalized had not treated herself fairly. On questioning ptosis was explained to her. She was advised about the diet, she learned that at times she to diet to increase her weight, and to rest more. dieted too strictly, living on nothing but milk Some temporary use was made of tonic and di- and working at the same time, or even went gestive medicines. The fitting of a suitable cor- was shown from one to three days at a time without any set was supervised and the patient

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SANTA BARBARA (UCSB) on April 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. the correct posture of the body. There has re- Prompt improvement followed treatment. It sulted a definite improvement in health. The is clear that the pelvic and foot conditions, patient has made a considerable gain in weight treated in the past as separate entities, were and has no further digestive trouble unless she but part of the general picture which the writer distinctly overdoes. terms visceroptosis. One cannot but doubt the The heart is obviously the type that is termed ' ' effort syndrome, "or" cardiac neurosis. ' ' This need for the gynecological therapy. case is introduced here because of the patient is of interest chiefly as illustrating the The handicap of visceroptosis to an ambitious young presence of points in the history which, together woman, and how large a part of this may be re- with the general appearance of the patient, lieved by recognition of its cause and suitable strongly the diagnosis. These points treatment. suggest are the history of pelvic displacement, ankle weakness and especially the fact that the pres- Case 3. August woman, 37 years; 22, 1919, ent gastric complaint was favorably influenced married. Chief complaint, "indigestion," es- pecially during the past four days. Sensation by rest and the horizontal posturs. of lump in throat one-half hour after meals. This lasts an hour or more and then there is a Case 4. Woman, 64, married, seen October sensation around the navel "as though some- 6, 1919 Is being treated for gastric ulcer by a one was kneading me with sharp knuckles." On "stomach specialist" in a western city. lying down, these symptoms are relieved, but Family History—Parents died of old age. they return promptly if the upright posture is One brother, two sisters, three daughters and resumed. Similar symptoms have been present one son living and well. at times in the past ten years, but have never Past History—Had the usual children's dis- been so severe. eases, never strong. Married at 27, childbirths Diet—Breakfast, cracked wheat and milk; easy. At 50 had pneumonia twice. Typhoid at lunch, an egg, milk, bread and butter, and a fever with good recovery at 51. Menopause simple dessert. Has eaten but sparingly of 53 and was quite miserable for two years. summer vegetables. Hemorrhoids which were cured about fifteen Bowels move scantily several times daily; no years ago. diarrhea. Has tendency to constipation. Has Digestive symptoms commenced more than chronic catarrh of nose and throat and is a lit- ten years ago. Terms them "sick spells," with tle short of breath on exertion. No cough. nausea and occasional régurgitation of mouth- Was in health" in June, 1919. In ful of material always of a watery nature. "splendid when the July, attempted to hoe in garden and now is These attacks occurred only patient In 1915 underwent tired even on making beds, sweeping, etc., so was overtired. cholecystec- that hands tremble. This over-fatigue passes tomy with the removal of one large gall stone. about in a day. Last catamenia two weeks ago; av- The preoperative symptoms were chiefly erage two days in duration and of but slight six attacks of severe pain in the course of two discomfort. Best 122 in 1903; vears. There was no jaundice. Patient is of weight, pounds, has of bene- one year ago was 98 to 100, and now is 105. the opinion that the operation been to her Past to wear corsets at the fit health. History—Began two has age of eighteen when patient was said to have Present Illness—In the past years had a slight curvature of the spine. Wore a had "sick spells" three to four times per year. stiff type of corset for three years and since May be sick a month and it is usually several she well. These are then one of the light girdle type. Is "tired" if weeks before is "spells" she doesn't wear her corset. At the age of 27 ¿haraeterized by pain of moderate intensity and The is years was "generally run down"; couldn't located in the epigastric region. pain walk without extreme fatigue and aching in the likely to be present about bed time, is indefinite lower back. Given a diagnosis of uterine dis- in type and duration, and apparently has no placement and treated for two years with tam- relation to meals. It never radiates to arms, as "not se- pons and pessaries. Didn't recover full health shoulders or back, and is described until at the age of 31 an orthopedist tilted the vere," and "it comes and goes." heels of her shoes to correct a weak posture of About September, 1918, was a patient in a the ankles. hospital in a western city under the care of a Physical Examination—Poorly developed and "stomach specialist." Gastric analysis was thin. Pupils, mouth, glands, lungs, heart ,and performed and a diagnosis of ulcer of the stom- knee-jerks normal. Chest long and narrow, ach given. Roentgen examination was not) with anterior flattening. Costal arch narrow. made until May, 1919. Patient was kept in bed Abdomen shows moderate sag to wall of lower for five weeks and treated by diet, alkalies, etc. half. Liver, sixth space to two and one-half A gain of 11 pounds in weight was achieved fingers breadth below costal margin in right and the symptoms disappeared. Is now on a mamillary line. Kidneys easily palpable. diet (of very bland type) and uses digestive

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SANTA BARBARA (UCSB) on April 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. powders (mostly magnesium oxide). Has again The symptoms are so irregular that no disease lost weight and is easily fatigued when the epi- is definitely pictured and one learns by experi- returns. There is little gastric pain very gas ence that such a history is consistent with vis- in the stomach. which often be at the Bowels have always been inclined to consti- ceroptosis, may suspected first of the In the of pation and do not move easily in spite of the sight patient. experience to in a daily use of laxatives. Micturition normal, oc- the writer, it is common find, addition, casionally once at night and six or more times mental state of the neurasthenic type. If the per day. Urine about one quart per 24 hours. physical examination shows well-marked viscer- Best 124 was 105 when mar- weight pounds ; and the of no other disease is ried and not above this in the ten optosis, picture past years; the becomes almost now 98 Not short of breath on reason- definitely present, diagnosis pounds. and able exertion; no swelling of feet. certain. But to be doubly sure, especially Physical Examination: Small, poorly devel- in case the patient is impressed that carcinoma oped and nourished woman of rather active, or some other serious disease exists, it is gen- carious root in nervous type. One mouth, up- erally necessary to include roentgen examina- teeth false. well in- per Heart—Apex impulse tion. If this latter fails to disclose definite evi- side mid-clavicular line, drop-shaped by percus- dence of one is in a to sion. Soft systolic murmur at apex with short organic disease, position transmission, pulmonic second sound accentu- talk just so much more convincingly to the pa- ated. Abdomen—Marked sagging of the lower tient. Thus, diagnosis is worked up from the half of the abdominal wall. Surgical scar ex- history, physical examination, laboratory tests, from the to McBur- tending right epigastrium such as the examination of the urine, blood, ney's point. Lower border of liver two and a half breadth below costal margin in guiac test on the stool, at times gastric analy- fingers' examination right mamillary line, upper border at seventh sis and, if possible, roentgen after rib. Right kidney easily palpable. Chest flat the bismuth meal, and, given the findings of vis- with narrow costal arch. Moderate lordosis of and absence of those of other disease, that ceroptosis lumbar spine. General posture strikingly the should he treated for the former. of patient visceroptosis. case of has Blood 135 to 60. Weight 98 pounds. Of course, not every visceroptosis pressure the with Roentgen examination was negative as far as gastric symptoms, and again patient any evidence of organic disease was concerned. visceroptosis may have gastric ulcer or other There was marked ptosis, particularly of all the lesion. That is why each case should be com- organs of the right side. The upper edge of pletely studied. was on the level of the twelfth dorsal the liver Treatment should be directed toward the vertebra, while the lower edge came well down toward his nu- to the crest of the ilium. There was ptosis of mental condition of the patient, cecum, ascending colon and hepatic flexure, but trition, and finally toward his mechanical the splenic flexure was in normal position. handicaps. colon. General stasis existed throughout the In the experience of the writer, most patients better if some are taken to ex- The above history does not picture gastric ul- cooperate pains the nature of visceroptosis. A comforting cer. The evident ptosis on the physical and plain is the statement that is roentgen examinations, the appearance or in- suggestion visceroptosis not a true disease but rather a state of imper- crease of the symptoms when the patient was a is fatigued and the absence of roentgen evidence fect physical development. Many patient to learn that there is a reason of organic disease indicate visceroptosis as the grateful finally an undue readiness to as some- true A recent letter gives informa- for tire, etc., diagnosis. the tion that this lady has obtained satisfactory im- times the failure to appreciate underlying cause has resulted in the being treated provement following treatment based on the di- patient agnosis of visceroptosis. as lazy or as a quitter. Those patients who have developed an un- DIAGNOSIS. favorable nervous state require all the sugges- The above case histories, it would seem, well tive therapeutics and personal attention suita- illustrate the so-called "stomach case" in which ble for that condition. These are the ones in evidence is of added visceroptosis is the cause. In accordance with whom negative roentgen the belief that a careful history is essential in value in convincing the patient of the absence the diagnosis of cases in which gastric symp- of cancer, ulcer, etc. The are under- toms present, one finds himself rather bewil- patients practically always dered after having completed the anamnesis. nourished, and if they can be made to put on

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SANTA BARBARA (UCSB) on April 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. some fat, much benefit is gained. W. R. P. Em- given exercises directed towards improving the . merson, who has been so successful in his nu- development. A recent article by Lloyd T. trition clinics, lists the causes of sub-nutrition Brown3 pictures, by the silhouette method, the as follows: physical defects, home conditions, striking improvement which may be obtained in over-fatigue, food habits, and insufficient food a child after but three months' treatment. In (poverty). One should investigate the patient's the more severe cases, it is generally necessary life with sufficient care to disclose and meet any to advise reclining for an hour after meals, of the above conditions. in a posture which relieves the downward drag Some patients have been underfeeding (as of the abdominal organs. Two positions which in Case I) so severely that an increase of food have been of use to the writer are : lying on causes distress. In such a case, it must be ex- the back with a pillow under the hips, none un- plained that to continue on the insufficient diet der the head, and the knees flexed ; and lying will never produce a return to health, and that prone with a pillow under the lower abdomen. it is better to eat and suffer, as the discomfort Textbooks on orthopedics and the numerous will cease after a few days. Suitable digestive articles in medical journals should be consulted medicines are indicated, and in case of real dis- by those desiring more detailed directions as tress, there may be need of a sedative to relieve to exercises, postures, etc. gastric Better tincture of hyperesthesia. give SUMMARY. valerian, bromides, or even codein or morphine, In this paper is on cases of temporarily, and start the patient on an increas- emphasis placed ing diet. It is suggested that the amount of visceroptosis presenting "stomach symptoms." A lack of and sub- food intake to which it is necessary to bring the good physical development be controlled by its caloric value (of nutrition are commonly associated with the patient, condition. course it should be readily digestible). Those case to not accustomed to estimate the caloric value of Four reports are given picture the under diets will find it quite simple if they will avail type of ease discussion. The is based on evidence obtained themselves of such helps as "Food Values in diagnosis Household Measures," by Franklin in the history, physical and roentgen examina- compiled be excluded in W. White,* and the food tables by H. D. tions. Organic disease should and Arnold.2 these by suitable laboratory tests. Treatment should be directed toward the pa- which is present, com- Constipation, usually tient's mental toward his subnutri- monly lowers the state of general health and condition, his mechanical the fecal load also mechanically assists in the tion, and toward handicaps. downward drag on the intestinal tract. It REFERENCES. llAm. Jour. Med. Sei., 1918, Vol. civ, p. 85. should be carefully treated, especially by in- 2 Jour. A. M. A., Dec. 24, 1910. 11 Boston Medical and Siurgical Journal, Feb. 19. 1920. See also structing the patient in the hygiene of the the group of articles in this same Journal for June 24, 1920. bowels, etc. The use of liquid petrolatum U S. P. is often helpful in this type of case. On the mechanical side, of course, the ortho- THE ESSENTIAL FACTORS OF CANCER pedist has led the way, but in case it is not CAUSATION. convenient to consult with an orthopedic spe- By James W. Shannon, San Diego, Calif. cialist, it is quite possible for the general prac- M.B., titioner to meet the need. Some sort of sup- (Concluded from page 609.) port is needed for the sagging abdominal wall. The practice of the Japanese in regard to A properly fitting, straight front corset can bathing differs from the methods customary in generally be made to give the desired support. this country and Europe chiefly by reason of It has always seemed desirable to the writer greater frequency, avoidance of cold water, to train the patient to adapt some stock form of and of the higher temperature at which the bath corset to her needs, as then she is in a position was taken. Inasmuch, then, as greater fre- to continue this form of treatment indefinitely, quency in bathing implies a greater exposure even if she ceases visiting a physician. to water, we should expect—other things being The patient should be instructed how to stand equal—the incidence of cancer upon the parts correctly and, especially if young, should be exposed to water in bathing (i.e., upon the * Obtainable of F. H. Thomas is Co., Boston. Mass. breast and skin) to be higher among Japanese

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