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. In the importance of training the body to habits in the normal position the lesser flexure of the which there will be the minimum of displacement stomach is inclined almost downward, of cannot be In the straight the viscera overemphasized. while the general axis of the entire organ is article mentioned the chief attention was given downward, forward and to the right. The lower to the solid and while reference was viscera,' part of the stomach is about on the level of the made to the possible sags or displacements of the second lumbar vertebra (Fig. 2),1 which is also hollow viscera, the full significance of the dis- the level of the beginning of the duodenum (Fig. placements of these viscera was not then appre- 1), so that the passage of the stomach content ciated. into the bowel is achieved with the minimum of In which has been on since the work carried effort, being to a considerable extent a matter of this first article was completed, the importance gravity. of the displacements of these hollow viscera with the consequent resulting interference with their DUODENUM. NORMAL POSITION AND CHARACTER. function becomes greatly increased. In this pre- The end of the stomach is continuous was that if is pyloric vious article it shown the body with the first of the and this held erect there is the least for part duodenum, possible tendency of the duodenum as well as the stomach the abdominal to be either portion organs displaced has a and is of considerable downward or that the under mesentery capable forward, kidneys movement. The second or ductal and these conditions rest in or portion pockets upon shelves, the third or transverse of the duodenum and that the liver is held in portion naturally place by have no in rare instances. the bones and muscles. mesentery, except very ligaments, The first of these or the ductal lies was shown that in the erect two, portion, It there position at the right of the body of the vertebra (Fig. 3, the depth of the abdomen on the level of the last the axis directed backward lumbar vertebra a little more Spalteholz), being represents only and downward in its upper portion and down- than one third of the entire thickness of the ward and forward in its lower The with no lateral while in the portion. body, spinal spaces, or transverse lies across the or at the level of the last dorsal third, portion, spine upper abdomen, in front at the level of the upper part of the third vertebra, the lateral spinal spaces deepen the 1 The x-mya in lliia article were taken by Or. Percy Brown, of cavity so much that its total depth is practically Boston.

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. lumbar vertebra, and its general axis is transverse. into the left lateral spinal space, is partially The fourth or remaining portion lies at the left fixed and partially surrounded by mesentery. side of the spine, its axis being inclined backward When the body is erect and the stomach is in and a little upward. its normal position, it lies practically entirely above this third of the duodenum where EFFECT POSTURE portion OF FAULTY UPON THE POSITION it crosses the 0, If the OF THE STOMACH. spine. (Fig. Spalteholz.) body droops, however, or if for any reason the While these are the normal conditions, if for slot nach sags downward, since only the first part any reason the body is not held erect, with the of the duodenum can move, the fixed point general droop the diaphragm must be depressed upon which the movements of the stomach must or lowered, and the abdominal wall must be in part depend is at the right side of the spine, relaxed, so that two of the chief supporting ele- the position of the junction of the first and ments are taken away, with the result that the second portions of the duodenum. The result stomach must sag downward. With this down- from Ulis must be that as the stomach drops ward movement the chief sag must take place at downward it must be drawn toward the center first in the lower or pyloric half (Pig. 4), with or right side of the body and away from the the result that, if this position is long main- left. The result of this is that the bulk of the tained, the stomach changes its shape quite stomach, with at times its much enlarged con- markedly. Since, however, the possible downward tent, then lies in the median line of the body or movement of the pyloric end is limited by the over the spine, and since the transverse third firm attachment of the duodenum, the amount of portion of the duodenum crosses the spine di- sag of the pylorus is limited, but the rest of the rectly under the place where the stomach will organ can sag downward to almost any amount. rest under these conditions, it is not difficult to To allow this, the upper part of the stomach, see that the pressure of the stomach may be which is naturally the largest part, becomes enough to completely collapse or shut off the elongated and is stretched out, while the large or duodenum at this point. This may occur when prominent part of the organ develops in the the person is upright, but naturally will be me- middle, or much lower down than is normal. chanically more operative when the person is (Fig. 5.) Since the pylorus with the first part of lying upon the back and will be still more marked the duodenum can only move downward a slight if for any reason the natural involuntary pro- amount, it is evident that if the stomach is much tective action of the muscles is removed, as must sagged or enlarged the lower part will be con- be the ease in complete anesthesia. below the outlet of the Not siderably organ. GASTRO-MESENTERIO ILEUS. only this, but since with the downward sag of the stomach, increased by the weight which the Undoubtedly many of the cases of so-called contents of a distended stomach must represent, gastro-mesenteric ileus, or acute dilatation of the the drag upon the duodenum where its mesentery stomach, are to be explained in this way and ceases may be such as to mechanically narrow or represent not simply acutely dilated stomachs, possibly shut off this outlet. This interference but chronically relaxed and sagged organs, which with the outlet by " kinking " the duodenum, drag backward more than usual because of the together with the fact that so much of the stom- relaxation of the protective muscle elements. ach in such displacement is below the outlet, and The possibility of the closure of the bowel by as a still further contributing factor the lack of this backward drag of the stomach is made more tone in the involuntary muscles of the stomach, certain by the fact that the superior mesenterie which must result from the long stretching, artery with the inferior vena) cava) cross the explain with but little question some of the duodenum at right angles to its lumen (Fig. I), difficulty which exists in emptying the organ, over the anterior portion of the vertebra, in front and makes understandable the well-known symp- of the duodenum, but behind the pancreas, while tom of " splash." This being the case, the relief the vessels of the celiac axis (Fig. 3) lie over the that so often follows vomiting or the use of the pancreas and behind the stomach. This arrange- stomach tube is easily explained. ment of the vessels to the duodenum, which has been described may be THE fully by Codinan,2 easily EFFECT UPON DUODENUM OF THE DOWNWARD a factor in the constriction of or obstruction to DISPLACEMENT OF THE STOMACH. the lumen of the duodenum. Anesthesia to pro- The position and the anatomical formation of duce such interference is, however, not necessary, the duodenum is of much importance in connec- since it is possible in almost any case of gastrop- tion with the function of digestion and is defi- tosis in which the condition is at all marked to nitely concerned with the position of the stomach. bring on such a condition by simply managing As has already been stated, the first part is sur- the position so that this mechanical obstruction rounded by mesentery, so that movement of this is possible. Undoubtedly many of the cases of part is possible, but, as has also been stated, the that which is commonly called biliousness are to second part, in which the bile and pancreatic be explained in this way, and where so studied ducts enter, is fixed in place, as is also the third the symptoms and their relief become under- part, which crosses the spine at the lower part of standable. Since the constriction under such the third lumbar vertebra. The fourth part, conditions occurs in the third part of the duo- which ascends upward as well as drops backward 2 Boston Mbd. ano tíuita. Jouit., April 10, 190S.

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Copyright © 2010 Massachusetts Medical Society. denuiii, and since the common bile duct enters wards, the transverse colon must be pushed the second part, the bile, not being able to take downward as a result, and since the ends of the its usual course, must pass backward into the transverse colon are joined to the ascending and stomach, explaining this characteristic feature of the descending colon where these portions pass' the vomitus. behind the peritoneum, it is evident that if the The degree of displacement or distention of the transverse portion is drawn downward very much stomach that may be present in a given case may it may result in the narrowing or the possible be very great, so that when the body is erect the closure of the bowel at these angles where the organ may lie largely below the transverse part mesentery ceases. This would be the case if the of the duodenum (Fig. 5), and under these condi- normal conditions of mesentery and other me- tions it may not be until definite attempt is made chanical supports existed. If, now, it is recog- to draw the stomach back into place, or until nized that in a, considerable number of (tases, some posture is taken, such as the Trendelenberg estimated by Professor Dwighta to be one in position, in which the displaced organs tend to every five, and a condition fully recognized by sag back into their normal positions, that the the anatomists,'1 the ascending and descending symptoms which are the result of the stomach colons have a mesentery, it is at once apparent pressing upon the transverse portion of the that a part of the support of the transverse colon duodenum will occur. is lost, since the hepatic and splenic flexures are no longer fixed. Where such a condition exists, ENTEROPTOSIS. since the ascending as well as the descending (a) Small intestine. With the displacement of colon is no longer fixed, but is movable with a the stomach downward— the great mass of the mesenteric attachment, the downward displace- small intestine will naturally be forced downward ment (Fig. 8) of these portions of the bowel is also, and since under these conditions the circu- natural. Since both of these segments represent lation as well as the innervation of the bowel normally collapsible tubes with vertical axes, must be interfered with, it is evident that the downward sag must mean either the crumpling digestive processes must be performed at more of the tube together, telescoping or bending upon or less of a disadvantage, and with the increased itself, or the formation of kinks or angles. All length of the mesentery, resulting in the greater of these conditions have been seen during the freedom of movement of the bowel, it is probable study that represents the basis of this paper, and that temporary interference with the patency of in one case a blending of the two conditions the lumen, by twists or kinks, do occur and existed, due to the fact that the ascending colon explain some of the symptoms, such as colic, had mesentery except for about two inches in the seen in these cases. middle of its length, and the upper portion when It is also probable that with the general down- examined was folded over this attached portion so ward sag of the small intestine, entirely apart that the gas which was in the cecum could not from the possible compression of the structures, escape into the lumen of the bowe] beyond. Not the superior mesenteric artery must be stretched only this, but the investigations show that the and its lumen narrowed so that the circulation in arrangement of the mesentery may not be the the small intestine is less free than is normal. same on both sides, as is shown in Fig. 9, in If such be the fact, it is to be expected that the which the descending colon has no mesentery and intestinal digestion will be interfered with, partly is in nearly the normal position, while the ascend- because of this lessened tone of the small intestine ing portion has a free mesentery, with the result itself. that this portion lies crumpled up in the lower (b) Colon. With the large intestine similar right side. It is evident that with such conditions conditions exist,—- but to understand the symptoms present there would exist very definite mechanical resulting from disturbances of this organ it should reasons for the irregular evacuation of the bowel be remembered that usually the ascending colon Abnormal pockets may exist from which it is hard has no mesentery from just above the cecum to to express the content, the loose or collapsed the hepatic angle, where the transverse colon folds may form valves to interfere with the con- begins. This transverse portion is surrounded by tinuity of the lumen, while the irritation which mesentery and is attached by means of the might result from a distinct kink of the bowel omentuni to the greater curvature of the stomach. could easily explain some of the irritative or (Fig. 1.) The first part of the transverse colon is ulcerative conditions met with. In one case in nearly horizontal, but the second half inclines up- which a colotomy was performed for the proper ward and backward until at the splenic flexure it drainage of the colon the fecal matter was caked is almost at the very top of the diaphragm, well on to the wall of the bowel in some of these at the back. (Fig. 7.) From this point the pockets so that it definitely had to be scraped organ is retroperitoneal, having no mesentery off. It is easy to understand that if such a con- until the sigmoid flexure is reached. With this dition were present the putrefactive changes arrangement, under normal conditions the trans- which might go on under such a fecal mass verse colon is suspended as a festoon from the might lead to ulcération of the membrane itself. two ends, the left being much higher than 3 Lesshaft: From Professor Frozen Section of u the curve of the festoon also OwigHt, Child, the right, being p. 47. the attachment of the stomach. 4.1. Symington: Relation of Peritoneum to Descending Colon. supported by J. Anal, und Phya., 1892, xx, p. 52. If, now, the stomach becomes displaced down- L. Teatut et O. Jaeob: Anulomie Topographique, p. 243, vol. ii.

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. In the case operated upon there was a distinct GENERAL RESULTS FROM SUCH CONDITIONS. ulcerativo colitis, from which absorption was taking place and causing joint symptoms. The All of these conditions, the detention, unduly, colotomy was performed in order to relieve the of the food in the stomach, with the imperfect ulcerativo feature so that the absorption could stomach digestion due to the general atony of be checked. the organ; the possible interference with the of food into the with the ENTEROPTOSIS passage the duodenum, EFFECTS OF GASTROPTOSIS AND at this due to the UPON SECRETIONS OF THESE imperfect digestion point THE NORMAL interference with the function of the ORGANS, WITH THE SYSTEMIC EFFECTS. pancreas; together with the lack of tone or general atony Conditions such as these must naturally result of the bowel, would result in definite disturbance in interference of the normal function of the or- of the digestion that would ordinarily be chemical gans, and once present it apparently becomes a in character until the ilium is reached. After mere matter of accident as to whether the ab- that, because of the presence normally of the sorption or the systemic manifestation of the bacteria in the ilium and colon, the disturbances lesion is of a chemical and is of as nature, spoken might be chemical or bacteriological. Such con- disturbance of metabolism, or is bactériologie. if existent, result in a of ditions, long might naturally It seems to the writers also merely matter so to " " disturbances marked that they would lead accident as to whether the metabolic dis- abnormal and cause systemic mani- turbance manifests itself in the or in some absorption joints festations of varying typos. This may be still other structure, or whether the bactériologie con- further aggravated by the fact that almost in- dition shows itself as an arthritis or as an endo- when there is the distinct visceral etc. It needs little to make variably ptosis carditis, argument here described, the liver also sags downward evident the fact that if the stomach does sag from its normal position, with the possible downward the structure of the stomach itself interference with the circulation and innervai ion must be stretched and to the weakened, leading of that organ, so that its function also may be condition of or so well general atony atrophy impaired and result in an insufficient quantity known. In such a state of general atony or of bile furnished for the normal digestion. the which make so being atrophy naturally glands up The work of Maury is suggestive in this connec- much of the gastric membrane must be less active tion, showing that if the normal flow of these than normal, or at least their activity will be elements into the intestine is interfered from normal. Under it digestive different such conditions the bacterial life there may be disturbed, not to that the with, is be wondered at hydrochloric and under such conditions the organisms may be acid is present in less quantity than normal, nor found in the intestinal tract than is is that the element also varies higher up it surprising peptic normal, and not only may the jejunum be invaded, in amount. but the duodenum also. PANCREAS. ITS POSITION AND REASONS FOR Since it is normally in the ilium and in the INTERFERENCE WITH ITS FUNCTION. colon that the bacterial elements are chiefly When it is also that the pancreas found, it is probable that with general enterop- recognized with the function lies in the curve formed by the second and third tosis, and resulting imperfect portions of the duodenum (Fig. 3), it must be of these organs, the bacteria may develop in evident that in the downward of such quantities or reach such a degree of viru- displacement unable to the stomach the pancreas must be pressed upon lence that the individual becomes at the same time that the duodenum is com- resist and undesirable absorption takes place. pressed. When it is still further recognized that It seems probable that many of the cases of the mesenteric artery with the portal infectious arthritis arc to be explained in this superior whether the bacterial element is in vein crosses under the pancreas at about the way, and excess as result of retention of the middle of its length, while the splanchnic nerve, simply the with the vessels of the ecliac axis, lies in the fecal matter in the colon, or whether as the of with the function of space behind the stomach or in the region of the result the interference it is evident that whenever such the viscera above, the proper amount of digestive pancreas, very of mechanical conditions as have been described fluids, upon which the control the development exist, the full function of the pancreas cannot be of the bacteria must to a considerable extent expected. This interference with the function of depend, is not present in the bowel, it is, of to state at this time. Prob- the pancreas is probably one of the most impor- course, not possible tant parts of the disturbances which result from ably both elements are of importance, and the these visceral displacements, and in light of the Systemic conditions which naturally result from recent work of J. E. Draper Maury,5 the absence such abnormalities will not be fully corrected features are of or the diminution in the amount of the pan- until both of these recognized. creatic of the When such disturbances of normal chemical or juice probably explains many phe- it nomena met with in such cases. The well- bacteriological balance do exist, is apparently matter whether the mani- recognized atrophy of the pancreas with the a of accident systemic prominence of fibrous tissue in its substance seen festation takes the form of arthritis or whether some the other structures become at autopsies of the chronic joint cases is also of involved, with other lesions are met probably to be explained in this way. and the frequency which * Jour. Am. Med Asso., Jan. 1, 1910. in connection with the arthritis in the same indi-

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. vidual at once becomes understandable. Of the comes abherent to the posterior abdominal wall arthritic conditions, the type in which there is in its ascending and descending portions (Fig. true peripheral inflammation, the infectious ar- 15),° and to the omentum and indirectly to the thritis, and the type in which the peripheral stomach in the transverse portion. At the time manifestation is one of degeneration or atrophy, of birth the development should have reached the atrophie arthritis (the infectious element this stage, but apparently in a very considerable probably acting centrally), are probably both to number of cases birth takes place before this be explained in this way, and none of the cases development is complete. The child is born too seen since these visceral changes have been ap- soon from an embryological point of view, and preciated have failed to show their presence. begins life with a movable colon, and conse- Pig. 5 is the radiograph of a patient having the quently with less natural support for the stomach. infectious arthritis, and Fig. 10 is the radiograph The obvious result of this is that as long as the of a patient having the typical atrophie arthritis. child is the infant and its activities and habits The same is true of the hypertrophie form, in are largely those of the quadruped, very little " which for a long time the expression, disturb- disturbance occurs, but when the erect posture is ance of metabolism," has been used to áíiggest assumed the disadvantages of such formation are that some systemic disturbance other than bac- evident. With the stomach the erect position tériologie is the causative factor, and it seems must result in the sagging downward of the organ, probable that such a condition as is here de- and since the duodenum is almost always fixed, scribed may be the cause of the disturbance of the early embryological mesentery upon this por- the metabolism. Fig. 11 is the radiograph of a tion of the alimentary tract having ceased to patient having the hypertrophie arthritis of the to exist, at an earlier period than is the case with hip, the so-called ntaluni coxa) scnilis. the colon, the effect which this must have upon the evacuation of the stomach content, with the CONGENITAL FEATURES IN THE ETIOLOGY OF disturbances of digestion resulting therefrom, GASTROPTOSIS AND ENTEROPTOSIS. together with the effect upon the position and The fact that the visceral conditions as here function of the colon, has been sufficiently well described do exist, there can be no question. described above. With such displacement, if the That they are much more common than the stomach is affected there must result a, gradual writers had supposed is also evident., and at first absorption of the retroperifoneal and intro- it was supposed that the condition was wholly abdominal fat tissue, this naturally increasing acquired as the result of bad posture, irregular the possibility of the visceral sag, and naturally habits of eating, improper costume, etc., but as interfering with the nutrition. the work it soon became evident that developed TYPE OF THE CHILD WITH THE VISCERAL PTOSIS. while these features are of importance and may lead to moderate degrees of ptosis, in a very That such anatomic conditions exist is fully large number of the cases congenital conditions recognized by the anatomists, and that such con- represented the chief element. This fact was not ditions exist, clinically is perfectly evident, al- previously appreciated by the writers, and ¡is the though until recently the writers, at least, had literature makes no mention of it, it seems wise failed to recognize them. The type, once it is to consider the subject more fully here. If is understood, is perfectly easily recognized, and in known to the anatomists that a very considerable childhood is represented by the poorly nourished number of subjects, about one to every five, are child, standing badly (Fig. 16), with whom, in found to have a mesentery upon the ascending spite of most patient work with exercise and and descending colon, and with this the observa- massage, the condition changes but little. The tions of the writers seem to show that with this poise consists of the flat chest, with the drooping greater mobility of the colon there is a correspond- shoulders, the prominent scapula?, the spine in- ingly greater mobility of the stomach. To under- clining upward and backward from the lumbar stand such a condition the embryologies! devel- region, with very little curve, being almost opment of the individual is important. In the straight, until the upper dorsal spine is reached, beginning the entire alimentary canal has a when it then bends sharply forward. With mesentery and represents a single tube (Fig. 12)9; this the abdomen is much larger proportionately but as the development takes place and the va- than the rest of the body, the lower portion rious parts become differentiated, the alimentary being the most prominent, while to palpation canal not only ceases to be a single straight tube, and percussion the parts are soft and tympanitic. but becomes much elongated, this increase re- Such children have, as a rule, poor appetites, or sulting in many convolutions, as is shown most very peculiar appetites, the digestion is poor, perfectly in the small intestine. Other portions and the bowels arc usually inactive, although are turned bodily over, so that the former pos- occasionally the reverse of this latter feature is terior surface becomes the anterior, this being present and the movements are abnormally free. best shown in the stomach and the colon (Fig. 13),° Colics or disturbances due to the presence of gas with the resulting formation of the two peritoneal in the stomach or bowels are common, while cavities and giving the duodenum its posterior attacks of vomiting and nausea are also common. position. In this development the colon, which These latter usually occur without apparent provo- originally had a free mesentery (Fig. l4),° be- cation and last for a short time until the stomach » Dexter: The Anatomy of the Peritoneum. is thoroughly emptied. Following this the condi-

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. tion is much improved, with better appetite and ditions, the writers have cause to feel that the digestion until the stomach again becomes filled peculiarities here described may perhaps repre- with residue which cannot be gotten rid of by sent the cause of many of the other chronic con- the normal channels. Previous to the nausea and ditions, the etiology of which has not been vomiting the breath usually becomes progres- understood. It seems probable that the joints sively more offensive, due undoubtedly to the cannot be the only structures that would be decomposition of the food that must be retained influenced by these disturbances of the chemical when the stomach is displaced downward and its or bacteriological balance, and that while the tissues stretched, as is the case under such condi- hypertrophie and gouty arthritis may be due to tions. With the vomiting the disagreeable odor the first of these, perhaps also arteriosclerosis, of the breath, together with the coated tongue osteitis deformans, as well as some of the other which was previously present, disappears, only to general conditions designated as disturbances of reappear when the residue becomes sufficiently metabolism, may have the same origin. So, large in quantify or has undergone sufficient de- also, with the infectious and the atrophie arthritis, composition. As would bo expected in such cases, it seems possible that some of the cases of iritis, tonics or stomachic and digestive remedies have psoriasis, endarteritis, possibly some of the cases only indifferent influence upon the general poor of progressive deafness and also some of the dis- condition in which such children are found. The turbances of mental balance said to be due to degree of gastroptosis present at this age is auto-intoxication, etc., may be due to the same shown in Fig. 17. features of chronic toxemia or infection as shows As growth occurs the type persists (Fig. 18), itself in the joints. It is not, of course, possible the digestion as a rule remains poor, with fre- for the writers to do more in any of these prob- quently continued attacks of vomiting, often lems than to simply make the suggestion, but it- called bilious attacks, although the attacks occur has long been felt by many that once the funda- as a rule at much longer intervals than in early mental cause of one of these chronic diseases was life. At times after adult life approaches the found it would also explain the cause of many of attacks of nausea cease, and although the general the others. Whether that which has been here nutrition usually remains poor, the digestion, described can be considered as the fundamental while not vigorous, is considered indifferently causo or not must be proven, but in so far as the good. This apparently is to be explained by the writers have been able to go in connection with fact that with increasing years the displacement the joint lesions, such seems to be the case, and of the stomach becomes more marked, so that it as to the bearing it may have upon all of the lies well below the transverse duodenum and the other conditions here indicated, a large number pancreas, and the irritation to these parts that of observations must, of course, be made before was inevitable when the organ was so placed that definite conclusions can be reached. For the it necessarily rested upon them is not as marked. benefit, of those who will naturally carry on the It has been a matter of considerable interest to work in these other lines it may be of interest to the writers to study several families in which the know that in the few cases of these conditions children possess the same visceral conditions as (other than the joint conditions) that it has at least one of the parents. The physical type of been possible for the writers to study the visceral the child with the peculiar digestion and nutrition condition has been entirely similar to that here as well as the other characteristics has been so described. similar to that previously shown by the parent It also seems probable, and attention has that the similarity has in several instances been already been called to this fact by Codman, that recognized by the parent and the children brought such disturbances of position of the viscera, with for treatment in order to save them from much the resulting mechanical action, may result in that they (the parents) had been obliged to bear. pressure or the interference of function to such It seems probable to the writers that much of an extent that ulcerativo conditions follow. that which is spoken of as inheritance in the Should this be the case, the pylorus or pyloric causation of the rheumatic conditions is to be end of the stomach, the duodenum and the colon, explained in this way. The degree of ptosis in being the parts most disturbed, would naturally the child is, of course, not as great as with the be the regions where such ulcerativo processes adult, since years of constant drag and stretching would be found. Since these arc the portions of will be required for this, but the type is evident the gastro-intestinal tract most commonly af- beyond question, and in potential these children fected by ulcerativo lesions, and since the etiology possess the same extreme degrees of displacement. of these well-recognized ulcerativo processes has If, as is occasionally seen, the colon is the not been clear, the writers wonder if these mere organ chiefly affected, the other organs being- mechanical elements consequent upon such mal- well in place, the nutritive disturbances do not positions as are here described may not be of occur, and such an individual, while possessing distinct importance. The fact that in connection possibilities of imperfect absorption, is usually with the support furnished to the viscera in the. well nourished. treatment of joint diseases several cases have been relieved of conditions GENERAL INFECTIONS. rapidly long-standing diagnosed either as ulcerativo or as mucous While the work here reported was undertaken colitis make this seem possible, and when it is because of its bearing upon the chronic joint con- also appreciated that in the displacement of the

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. colon the cecum may be so much displaced that tissue. If, with this, external pressure is also its axis may be reversed, the unusual positions of added, such as would result from the use of the appendix are not to be wondered at and one tight or imperfectly fitted corsets, or tight waist naturally questions if these malpositions can bands, the absorption of this fat tissue will be have anything to do with the ulcérations of that more marked, and consequently one of the im- organ. Certain it is that a large number of portant supporting elements of the viscera is lost. these cases as they are studied have had appen- The writers feel that this represents one of the dicitis. most harmful effects of corsets as they are com- The'writers also wonder if any of the cases of monly used. It is not that the corset itself is thyroid disturbance can be due to this same especially harmful any more than many of the visceral ptosis. That such mechanical conditions other elements of the costume that convention would interfere with the action of the pancreas is demands, but that the abuse or the ignorant use evident. That there is some connection between of the corset is wherein the chief harm lies. With the pancreas and the thyroid is, they believe, the absorption of the normal fat tissue the inter- accepted. That the disturbances of the thyroid ference which such garments must have upon the gland have been present in a considerable num- weakening of the abdominal muscles is, of course, ber of the chronic joint cases in which the visceral also to be fully recognized. ptosis was marked is a fact, and that the thyroid disturbances were markedly aggravated in one IMPORTANCE OF THE CERVICAL FASCIA IN THE case by the treatment planned for the support, of VISCERAL SUPPORT. the viscera that caused an increase of the pressure in the region over the pancreas, with the rapid The posture that is most favorable for normal improvement, of Ihese aggravated symptoms once health is with the trunk erect, as it would be if the point of pressure was changed, is also a fact one were to stand as tall as possible without and is at least suggestive. The subject is simply rising on to the toes. In this position, as has mentioned at this time as a suggestion for those been fully described in the article previously who have greater knowledge and better oppor- mentioned, all of the active supporting elements tunities for the study of such problems. act most easily, and there is the least tendency to ptosis of the viscera. In this position not only TREATMENT. is the framework favorable for such support, and The question of treatment with a problem all the abdominal muscles tight so that the sup- having so many phases as this, involves so much port from below is the best that is possible, but that all that can be attempted at this time is to also in this position the cervical fascia, which in suggest the principles which must represent the its continuation through the pericardium is the basis of the treatment, leaving the carrying out supporting ligament of the diaphragm, is made of the principles or their adaptation to the many tight. Since the liver and the stomach with the features presented by such cases to the individual colon are largely suspended from the diaphragm, observer. the importance of this cervical fascia in connec- Naturally the first thing to lie desired is to tion with the visceral positions is easily appre- restore the organs to as nearly as possible their ciated. Not only is this so, but when it is appre- usual position and at the same time to correct or ciated that, much of the weight of these viscera relieve any imperfections in their function which is thus suspended from the neck, the neck pain may have resulted from the malposition. which is commonly mentioned in these cases is Since it must be evident that the posture understood and the characteristic attitude as- commonly assumed by the individual is a definite sumed by patients having these congenital dis- factor in the relative position of his viscera, placements is easily explained. The attitude is naturally any undesirable position should be shown in fig. I(> and Fig, 18 and is the same in overcome, and since the embryological changes general character whether the patient be old or which, when delayed, make possible some of young, and once the type is understood the these disturbances may go on after birth and, position of the viscera is evident almost at a according to the anatomists, do go on to a more glance. The writers feel that the full significance nearly normal condition, it.should be our aim to of the cervical fascia as the supporting ligament ' see that during the growing period with the of the diaphragm, and consequently as part of child, especially the early period, the common the support of the abdominal viscera, has not postures are not harmful. It should also be our been generally appreciated and is consequently aim to see that not only are the postures not given especial emphasis at this time. In the harmful, but that all possible contributing fac- x-ray study of this subject it has been clearly tors to visceral sag are eliminated, the costume shown that by merely changing the position especially being studied and harmful features from the droop to the erect position, the position corrected. It should be remembered that in the of the bottom of the stomach can be raised from common droop of the body not only are the back one to two inches. muscles strained, but that with the crowding of In attempting to correct the position of these the organs together the pressure one against the organs it is apparent from what has been said other must, result not only in the stretching of that the organs can be drawn up from the top the ligaments, but will necessarily lead to the and also pushed up from below. This latter absorption of the surrounding and supporting fat feature is evident from the position of the stomach

Fia. I, Position of stomach and duodenum. Fig. 3. Position of duodenum and pancreas,

Fio. 2, In all the \-niys a coin was placed on the um- Fio. 'I- bilicus, the level of which is approximately the crests of Uia.

Fio. <>. Sagiltal section, showing from top t" Fio. 8. botloui: liver, stomach, transverse colon, small intestine. The third part of the duodenum is shown adjacent to the vertebra, posterior fco and slightly above the transverse colon.

Fig. 10. Fio. 12. (Dexter.) .4. aorta Ac, alimentary canal. S, rudimentary stomach, ¡i, bend in intestine.

Fia. i«.

Fig. M. tDexter.) <\ colon. K, kidney, Mc, ascending mesocolon. T, connective tissue, /'/>, parietal peritoneum. •Si, small intestine.

Fio. 17.

Fie. 15. (Dexter.) Si, small Intestine. .1/, mesentery. C, colon. Me. ascending mesocolon. A", kidney. A, aorta. h's, retrapentoneal space. Pp, parietal peritoneum.

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. shown in Fig. 19, the protrusion of the stomach operations for the thorough drainage of this forward as well as downward making it possible organ are to be considered. This will also not to place supports over or under the lower abdo- often be required, but in two cases of the writers', men that can really push the stomach up towards in which control was impossible with other its normal position. At times both of these ele- means, a colotomy was performed at their ments of support have to be used, and by appar- request by Dr. Hugh Cabot, with entire relief of atus to hold the body erect so that the cervical the symptoms in one case and with partial relief fascia is tight, together with pads below, the in the other. ptosis can be to a considerable extent overcome. Such, in general, are the principles which seem In planning these it must, however, be remem- to the writers of chief importance in the treat- bered that if the attempt is to be made to force ment of these conditions. The body should be or draw the stomach upward, space must be restored to as nearly its normal anatomical con- allowed for its bulk when it is in its new position. dition as is possible, because it is in this condition If the clothing is tight it is evident that with the that the most perfect function can take place. new position the bulk of the stomach may for a Braces should be used, operations should be per- time lie directly over the pancreas and duodenum, formed, exercises should be given, or any other with a resulting increase in all the symptoms. measures may be considered if the result of such This has been seen so many times by the writers measures is the more perfect function of the part. and is so anatomically reasonable that its occur- Naturally the simplest course that will accom- rence should always be allowed for in managing plish the result should be the one chosen, and the the supports. radical measures should be adopted only where With this, of course, the nutrition should be the simpler ones have failed. The general hy- planned so that the abdominal fat can be re- giene should naturally be as perfect as possible, placed as fully as possible, and at times it is well and with this the diet should be planned so that to have the patient kept in bed while this is going with the least effort the nutrition can be brought on. If such is the case, or if for any reason it is up to as near the normal as the individual is necessary to keep the patient in bed, the possi- capable of. bility of the backward sag of the stomach upon When all of these things have been considered the pancreas and duodenum should be remem- and braces have been used or operations have bered, and the continuous position upon the back been performed, the treatment should not stop be avoided. until the individual is in as nearly the normal Since it is possible to raise the stomach by condition as it is possible to obtain, and since so tightening the cervical fascia, it is well at the large a part of the support of the viscera consists time when the stomachic digestion is going on of the muscular elements, these structures should most actively to have the patient lie upon the be brought up to their proper tone. Special exer- back with a pillow under the region of the elev- cises should be given, at first cautiously, in order enth or twelfth dorsal vertebra and with no not to cause joint strain or increase the visceral pillow under the head. This position of hyper- displacement, but with a gradual progression in extension should be kept for about an half hour, the activity until the strength is such that the after which the position upon the side, or, better proper postures can be maintained and this part still, the knee-chest. position, taken for a few of the visceral support rendered as perfect as minutes, will overcome any harmful backward possible. With the exercises, massage or the sag against the pancreas anil duodenum and at special forms of bathing have, of course, their the same time tend to unload the stomach into very definite place, as has any other measure that the duodenum. tends to increase the muscle or ligmentous tone. If for reason it seems evident that the With all this the patient should not be allowed any in condition is being made worse because of the to leave us until not only are the structures scanty secretion of any of the glands or organs, good tone, but until a practical explanation has these elements should naturally be supplied in been given of the anatomical and mechanical with a so far as is possible. The stomach elements and features of the visceral function, and the pancreatic element are probably the most proper understanding of the way in which the important of these. body is to be used in order to insure the least If for any reason the oïgans cannot be brought waste of body energy and consequently render back into place by the ordinary simple means, the individual capable not only of health, but and the general condition is such that radical also of the greatest possible efficiency. steps seem indicated, operative measures for such are indicated. Such occasion will prob- A MEMoniAL service for Dr. Howard Taylor Ricketts Purpose of not often but in one case of the writers', was held in the Leon Mandel Hall, University Chicago, ably arise, 15. Dr. Pratt Judson read a letter from the because of a May Henry constantly recurring gastro-mesenteric Bureau of Education of Mexico expressing appreciation ileus whenever the stomach was, by posture and of the woik of Dr. Ricketts and mentioning the honors support, brought up to the region of the duode- conferred upon him. He also made a brief address on and the essential facts of his num, such an operation was performed with relief the work of Dr. Ricketts, the writers. life and death were given by Dr. Russell M. Wilder, who by Dr. F. C. Kiclner at the request of Ricketts in his work in Mexico. cannot be was associated with Dr. If for any reason the colon properly Dr. Ludwig Hektoen delivered an address on the person- drained by cathartics or lavage, and this seems ality of Dr. Ricketts. Prof. Charles Henderson, of the to be the primary source of the disease condition, University, also spoke.— Jour. Am. Med. Asso.