The Cause of Gastroptosis and Enteroptosis, with Their Possible

Original Articles joints may be affected by such absorption and that it becomes a matter of accident whether the THE CAUSE OF GASTROPTOSIS AND ENTER- joints, the eyes, the heart, the blood vessels, OPTOSIS, WITH THEIR POSSIBLE IMPOR- or some other part, represent the area of greatest TANCE AS A CAUSATIVE FACTOR IN THE susceptibility. RHEUMATOID DISEASES.* In connection with this it has for a long time been shown that of the cases BY JOEL E. AND LLOYD T. BROWN, quite clearly many GOLDTHWAIT, M.D., M.D., BOSTON. derive their from the The paper which it is our to absorption gastro-intestinal privilege present tract, and while some of these have yielded easily to you this evening is a preliminary report of to treatment of this tract, others where there has work that has been carried on in the hope of been little of the the real cause of the chronic diseases question primary gastro-intes- finding joint tinal element have not only been difficult of con- commonly designated as rheumatoid arthritis, but at times to control. rheu- trol, entirely impossible osteo-arthritis, arthritis deformans, chronic It is the work that has been carried on in the etc. in an matism, It is presented incomplete to and control these form because be attempt relieve seemingly many years may required before cases that the basis of this all of the features that are hopeless represents necessarily involved It was that with some can be and because paper. early recognized fully solved, already enough of the cases relief was obtained for the seems to have been to he of joint accomplished practical the use of free use value in the treatment of such symptoms by special diets, by conditions, as well of the use of intestinal as to lines for other cathartics, by antiseptics, suggest investigations. such as beta It is the of the writers that the salicylic acid, salol, naphthol, etc., hope sugges- by the use of the lactic acid ferments, intestinal tions here made may stimulate other investiga- stomach washing, etc. With ail of tors to the of the same or lavage, these, study problem, parts has been no or cer- of however, there constancy it, with the natural result that the ultimate of and that which has relieved in solution will be reached more than would tainty control, quickly one case has failed so often to relieve in others be with observer. | possible any single that the of our In in uncertainty knowledge often led the previous work connection with these to rather than relief to both diseases there have been features which exasperation patient many and So many features, sug- have been and un- physician. however, definitely recognized clearly that the lesions even in of but there have been others that have gested joint many derstood, these cases were due to either not been understood or the seemingly hopeless pecul- full importance iarities of or disturbances in the and of them has not been clear. That gastro-intestinal significance tract that gave an added reason for the there are definite of these rheumatoid dis- they types study of this region for the fundamental cause. eases, there can be no question. That the patho- The fact that the exacerbations of the and clinical features of these are joint logical types Symptoms so often follow definite and constant is evident. ex- definitely recognized That the increase of or condi- of these features in some of digestive gastro-intestinal planation the types, the fact that attacks of so often the and the tions, vomiting hypertrophie gouty arthritis, sug- were followed by improvement in the joint Symp- gests disturbances chemical in character, while the fact that in connection with the ad- with the infectious and the toms, atrophie arthritis, ministration of ether there was often a marked elements the bacteriological represent probable improvement in the joint symptoms, even though cause, are facts of more or less general acceptance. the themselves were not the fact Of the bacterial it has been joints touched, types clearly shown that in certain cases so that the lesion is but is pregnancy supervening joint rarely primary was associated with or to some focus of disease elsewhere in commonly improvement secondary often entire relief to the symptoms so the In some of the cases the dis- joint long body. primary as the pregnancy the fact that ease exists in the throat or the lasted, many accessory passage patients became markedly worse after being sim- about the throat and nose, the joint features to bed under the most favorable the of ply put hygiene, representing simply result the absorption the fact that a number of the rheumatoid from this area. In such cases the correction of large cases die finally, after the has be- or the removal of this throat or nose helplessness primary come marked, of gastric conditions designated as condition makes the treatment of or the re- gastritis, intestinal obstruction, or by the newer lief of the joint lesion simple. The same thing term of gastromesenteric ileus, all these and is also true the i the — of gen to-urinary tract, many other observations made it seem increas- relief of the lesion much more joint being per- more certain to the writers that there was when the ingly fectly possible primary genito-urinary some of all these features, the under- lesion is controlled, and similar principles hold explanation in standing of which would undoubtedly do much regard to active inflammatory diseases in any for the relief of this class of than which other of the if with it there patient, part body, especially there can be no more of our be of deserving sympathy areas concealed suppuration. From such and interest. The in such cases is not disease areas take suffering systemic absorption may place, to be as is true in many of the other as the result of disturbances relieved, and, this, joint may diseases, death in a short of occur.. In such it is that hopeless by period study suggested appar- time, but life for many, many years is usually to ently other tissues than those peculiar to the be much of which the suffering *Read at the meeting of the Boston Orthopedic Club held July expected, during 21, 1910. must be faced, and during all of which the crip- The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIV OF UTAH ECCLES on December 1, 2014. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. pling and helplessness, with all the physical limi- twice as great as the distance between the ante- tations, as well as the mental distress, must be rior part of the vertebra and the anterior ab- borne. dominal wall, and at this level almost the entire The previous investigations which have been thickness of the body is used for the viscera. carried on by ourselves as well as by other ob- The anterior and, to a large extent, the lateral servers have been largely negative as to any walls of the abdomen consist of muscles, so that clear reason being shown why such conditions the exact depth of the cavity can vary consider- exist. The physiological-chemical work confirmed ably, but in the erect position the condition is the pathological findings, but went no further. approximately as stated. The tone of these The bacteriological findings were also in keeping muscles must naturally have much to do with with the pathology, but no new organism or no the support of and, consequently, the function real explanation of the condition was shown. of all of these organs, and beside all of these The pathological findings have largely supported various elements it should be remembered that the clinical findings, but went no further in the in and about the abdomen are masses of fat solution of the problem. As a last resort, and in which must play a very considerable part in the connection with some work carried on in relation visceral support. to the poise of the body, the anatomical features were studied, with results that are at least sug- STOMACH. NORMAL POSITION. gestive and are here offered for discussion. In In the normal position the stomach lies in the carrying on this anatomical work, the writers are left lateral spinal space under the to Thomas and Assistant diaphragm, indebted Prof. Dwight and fills a large part of this space. (Fig. 1, Professor John Warren, of the Harvard Medical Spalteholz.) It is held in place by the attach- School, for much valuable assistance. ment of the to the its own " esophagus diaphragm, In an article entitled The Relation of Poise mesentery, by the ribs, by the splenic flexure and to Human Efficiency and the Effect of Posture the left half of the transverse colon, by the upon the Position and Function of the Viscera," spleen, by the abdominal wall, by the retroperi- in the Medical and Surgical published Boston toneal fat and by the mass of small intestine that Journal, Dec. 9, 1909, one of the writers called fills the cavity below. Still farther, since the to fact that the of attention the position and, cardiac end or the esophageal attachment to the consequently, the function of the abdominal diaphragm is close to the spine, its point of viscera can be modified to a very considerable attachment, together with the posterior wall of extent by the postures assumed by the individual. the abdominal cavity, which naturally slopes In was shown that since the normal this article it forward as well as downward, must also give some function of the organ must depend to a consider- support for the stomach, and this is increased by able extent upon the position (because of the the ridge formed by the upper part of the left of the blood vessels and as arrangement nerves, kidney as well as by the attachment of and the as to the other well because of its relations organs), mass of the mesentery of the small intestine.

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