belief is, that the majority of cancers of the stomach are preceded by ulceration. My observations have extended over a good many years of general practice and of a hospital service, and during many years as a teacher I have taught this. I then believed that this view was correct, and now I am more than ever firmly convinced that the majority of cases of cancer are preceded by ulceration. As stated by the essayist, when you have what would seemingly be a second or third recurrence of ulceration the probabilities are that you have the commencing stage of cancer.

I wish to state that I do not believe milk is the proper diet in these cases. I am confident that my patients do not do well on a milk diet, and I have abandoned its use in ulceration of the stomach, as I have in typhoid fever. In my opinion, milk is not a fit article of diet in these two diseases.

Dr John Dudley Dunham, Columbus, closing discussion: I simply wish to say a few words in reference to diet. It has been my custom in these cases to use milk as a routine diet with rest in bed. It has only been in the last few days that I have seen a case in the practice of Dr Hamilton which could not tolerate milk. The patient suffered agony when milk was administered to her, but on light soups she did very well. Perhaps with a larger number of cases one might find more patients of this sort.

Gastrectasia, Its Clinical Significance
and Treatment

By D. B. CONKLIN, M. D., DAYTON

Gastrectasia is that degree of motor insufficiency in which there is a permanent enlargement of the stomach with retention of its contents.

Clinicians differ widely as to the precise place in nosology to which gastrectasia should be assigned. While some, high in authority, consider it a disease per se, others, perhaps a majority, consider it merely an incident in a weakened gastric musculature dependent upon varied local and constitutional causes. Whichever view may be correct, and much can be said in support of both contentions, the symp

tom-complex and clinical history of a typical gastrectasia are so marked and characteristic as to justify its separate discussion.

Cases of gastrectasia naturally fall into two groups: First, the obstructive or secondary form dependent upon a more or less complete stenosis of the pyloric opening. Constriction of the pylorus by adhesions, cicatrices, benign or malignant growths either within or without the stomach, gall-stones and kindred lesions are responsible for the larger number of grave cases which come to the notice of the practitioner, and are therefore of great practical importance.

For obvious reasons, we shall confine our remarks to the second group in which the dilatation depends not upon a mechanical impediment to the passing of the gastric contents into the duodenum, but largely, if not wholly, to the hypotonicity of the gastric muscles, so-called gastric myasthenia (Boas) or ischochymia (Einhorn).

The acute form of gastrectasia due to muscular paralysis or spasm of the pylorus is rare, though not so rare as was taught by the older authors. This condition is usually due to gross excesses in eating and drinking acting upon a stomach already weakened by previous disease of a local or general nature and thereby predisposed to sudden dilatation. Boas and Riegel note the frequent occurrence of atony of the stomach in cholelithiasis, in heart and kidney lesions and in the later stages of the cachexias. Hereditary taint and errors in feeding during infancy figure prominently in the causation of both the acute and chronic forms.

Acute dilatation often passes away promptly with the passing of its temporary cause, but it may have a fatal termination as in the cases of Hunter and A. Frankel, and not infrequently lapses into chronic ectasy to the consideration of which we now pass.

In the chronic, as in the acute form, overloading of the stomach with indigestible foods and drinks holds the first place among the etiologic factors. The first effect of such unhygienic living is to produce a simple enlargement—

megalogastria-which under the baneful influence of a gastritis, nervous dyspepsia or hyperacidity, finally leads to degeneration of the muscular fibers, to dilatation and retention. Once started the vicious circle readily perpetuates itself. Fresh food is constantly added to the stagnant mass already in the stomach, gases are generated by fermentative processes, the walls of the stomach become thinned and inelastic and sag, more and more, under the weight of the retained ingesta until, in extreme cases, the fundus touches the rim of the pelvis.

The stomach not infrequently contains an immense quantity of fluid. In a case now under treatment there was drawn from the stomach at the first examination over a gallon of vile smelling, putrefying material, and yet the patient was goading himself to the management of a large manufactory.

The syndrome of symptoms which makes up the clinical picture of gastrectasia is not distinctive, and the diagnosis could rarely be made without direct investigation of the motor powers and capacity of the stomach. The symptoms proper are always modified by those of the diseases which bear a causal or complicating relation to it. Evidences of disturbed digestion are uniformly present and later emaciation and autointoxication manifest themselves. Thirst, which leads to immoderate drinking, is a distressing feature and is due to the small amount of fluid which passes the pylorus. To this same fact may be attributed the small quantity of urine voided and, in part, the ever-present constipation.

The quantity of feces discharged in 24 hours furnishes a rough index to the amount of material which is forced through the pylorus in the same period. In extreme cases the feces may be reduced to one-fifth the normal amount.

Vomiting is perhaps the most characteristic symptom. The attacks of emesis, separated by variable intervals, are preceded by abdominal distension and distress, ofter occur at night, and rarely at the maximum of digestion. They

exercise a safety-valve action on the over-distended stomach and invariably bring temporary relief, depending upon the thoroughness with which the undigested and fermenting material is removed.

Pyrosis and the eructation of gases are rarely absent. Riegel makes the statement that gaseous fermentation may be regarded as a positive sign of motor insufficiency, or better, of abnormal stagnation of stomach contents. These gases are usually foul smelling and occasionally are inflammable. The patient to whom reference has been made, on one occasion burned his nose and mustache by eructating when in the act of lighting a cigar.

Tetany is a rare but interesting symptom which is met with in a small proportion of cases. The attack commonly follows severe vomiting, or less frequently the use of the stomach-tube. Since Kussmaul (1869) pointed out the association of tetany with gastric dilatation and retention, numerous theories have been advanced in explanation. The consensus of opinion favors the theory of autointoxication but the special toxin has not been isolated. It is worthy of note that postmortem and operative examinations show that tetany occurs with greater frequency when the pyloric narrowing is due to a benign cause like the cicatrization of an ulcer in the stomach or duodenum than when it is due to malignant growths.

If the knowledge gleaned from the study of symptoms in gastrectasia is vague and uncertain, that which comes from direct interrogation of the stomach by modern methods is positive and reliable. In severe ectasy with retention, inspection and palpation will enable one to outline the enlarged and flabby organ and thus suggest a provisional diagnosis which may be verified by other means. Auscultatory percussion, as practiced by Benedict, gives valuable data, especially if the results obtained in the erect and prone positions are compared. Distending the stomach with air and the colon with water suffices to differentiate the sounds coming from these viscera.

Authorities are not agreed as to the estimate to be placed upon the presence of succussion sounds. Although Elsner's latest investigations show that distinct splashing can, not infrequently, be elicited in normal stomachs, yet when constantly present, under slight pressure, it certainly does furnish strong confirmatory evidence of a loss of power in the walls of the stomach.

Transillumination with Einhorn's gastrodiaphane, measurement with Hemmeter's intragastric rubber bag, exploration with Turck's gastric sound and the X-ray are all valuable agents, especially when safe-guarded by other means of examination, in determining the contour and capacity of the stomach, and also in differentiating mere prolapse or ptosis from dilatation. To avoid error it must be kept in mind that a simple enlargement of the stomach predisposes to both gastroptosis and gastrectasia, and, in fact, these conditions are not infrequently present at the same time.

Some practitioners still estimate the motility of the stomach by Ewald's salol test, especially as modified by Huber, but it is unreliable and in the presence of better methods should be discarded.

This brings us to the consideration of lavage and the test-meal which, under all circumstances, is the court of highest appeal. The normal stomach should empty itself in six or seven hours after a test supper, and the failure to do so indicates a degree of motor insufficiency proportionate to the amount of food which can be recovered by the stomachtube. The presence of a considerable quantity of undigested material in the stomach before breakfast is considered by Hemmeter and others to be pathognomonic of gastrectasia. Remnants of the evening meal may be retained in the stomach over night in chronic gastritis and in some acute disorders, and hence that degree of motor insufficiency indicative of gastrectasia can only be assumed when the quantity remaining is large and constant. In the severer forms the quantity may be enormous as in the case pre