GASTRECTAS1S. 
Read at the Meeting of the J. Aitken Meigs Medical 
Society, September 11, 1890. 
BY 
L. WOLFF, M.D., 
PHILADlgTPHIA, PA., 
Physician to the German Hospital of Philadelphia; Demonstrator of 
Chemistry, Jefferson Medical College, etc. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, JULY 15, i8gi. 
DETROIT, MICH. : 
GEORGE S. DAVIS, PUBLISHER. 
1891. GASTRECTASIS. 
DILATATION of the stomach is known 
as that condition of the stomach when 
it is abnormally enlarged and its muscu- 
lar fibres impaired to an extent that the 
gastric contents are only slowly or insuffi- 
ciently propelled through the pyloric orifice. 
Not all large stomachs are dilated ; in fact, 
there is quite a difference in the capacity of 
normal stomachs, so that, while some have 
been stated to have held only two hundred 
and fifty cubic centimetres, others are said 
even to hold as much as sixteen hundred 
cubic centimetres. . One can really speak 
of an abnormally enlarged stomach only 
when it holds more than the latter amount. 
Even large and enlarged stomachs may not 
give rise to pathological digestion, but the 
dilated stomach, which may be an outcome 
of the former, always indicates a pathological 
structural change, and invariably gives rise 
to a disturbed peptic act. 
There are two factors which may be con- 
sidered as etiological of gastrectasis. Pyloric 
stenosis is one, and muscular atony of the 
stomach constitutes the other. In the former, the condition of the obstructed pylorus may 
be compensated by a muscular development 
equivalent in propelling power to the obstruc- 
tion, similar to the compensation in valvular 
obstructions of the heart. This natural ten- 
dency to equalization of impaired function 
can exist for a limited period only, and must 
soon give rise to muscular atrophy and gen- 
uine dilatation. The causes of stenosis of 
the pylorus are manifold, and may depend 
upon mechanical obstruction by external in- 
fluence, as from floating kidney, pressure, and 
displacement of the duodenum ; or it may re- 
sult from pathological changes within the 
stomach, and its pyloric part in consequence 
of ulceration, inflammation, cicatrization, and 
neoplasm of either benign or malignant char- 
acter. Thus polypi may be the cause, as well 
as an abnormal development of the mucous 
membrane of the pyloric part of the stomach, 
and catarrhal hypertrophy may result in the 
same condition. The dilated stomach may 
give rise to displacement itself, and with it a 
partially or totally obstructed duodenum, 
which cannot be overcome by the already 
impaired muscular force of the viscus. An 
increased and abnormal acidity of the gastric 
juice may besides these give rise to spastic 
contraction of the pylorus, and though this 
may not be permanent, it may be followed 
by true gastrectasis. In the same manner 
are ulcers, abscesses, and even foreign bodies 
capable of producing spastic constriction of 
the pylorus with consequent dilatation. 
The gastric ectasis resulting from muscular 
atony of the stomach, the atonic dilatation of 
the stomach, may result by muscular exhaus- 3 
tion from over-exertion, or the insufficient 
nourishment of the muscle consequent on 
anaemia, chlorosis, and nervous affections. 
Under this class may be also counted the 
chronic gastric catarrh and the loss of chem- 
ical digestive secretion which is known to 
form a stimulus for gastric peristalsis. The 
nervous elements contributing to muscular 
atony of the stomach are not sufficiently ex- 
plained, though there seems no doubt a 
direct relation between a lack of intestinal 
peristalsis with gastric ectasis. As another 
cause of gastric dilatation may be mentioned 
the destruction of the muscular tissue pf the 
stomach by ulcerative processes of some ex- 
tent, though they may not themselves mate- 
rially give rise to a loss of tissue, but rather 
cause cicatrization, with distention of other 
parts of the stomach. 
The anatomical lesions of the muscular 
coat of the stomach in gastrectasis may pre- 
sent to microscopical inspection a hyper- 
trophic appearance, according to location. 
Hypertrophy, or what might be called such, 
from the fact that the muscular tissue is infil- 
trated with inflammatory products, cancerous 
material, etc., may be readily defined with 
the microscope. The same may be said of 
cicatricial tissue, which may cause hyper- 
trophy in the pyloric portion. Hypertrophy 
may and frequently does, in persons of ad- 
vanced age, result in atrophy. Atrophy, 
however, is more usually found in the car- 
diac portion, and may be caused by colloid, 
.but more frequently by fatty, degeneration, 
which increases, together with connective 
tissue, the interstices between the muscular 4 
fibres. The appearance of the mucous coat 
presents a picture of inflammatory changes, 
and it may be smoothly disposed or at times 
even mammillated ; there is no marked change 
in some of the glandular ostia, though the 
volume of the tubes appear enlarged, and the 
ovoid cells may be seen in a condition of 
partial destruction and turbidity, while in 
some of them they appear to be partly or 
totally wanting. 
Gastric dilatation is more apt to be met 
with in middle-aged people than in the young, 
though it has been reported in the young and 
even in children. The development of this 
condition is always more or less gradual, and 
on account of the prevailing symptoms it is 
in the beginning generally considered as sim- 
ple dyspepsia, attributable to errors in diet or 
nervous causes. To the general symptoms of 
anorexia, epigastric pressure and fulness, ab- 
dominal distention, buccal fetor, supraorbital 
headaches, and irregularity of the bowels, 
there is to be added, as a characteristic 
feature of extreme dilatation, the vomiting, 
which occurs at intervals, when by super- 
added ingesta and the fermentative changes 
they are undergoing the distended stomach 
becomes irritated and reflex vomiting takes 
place. This may occur in periods of several 
days only, or may be even more protracted 
where total paralysis of muscular structure 
has ensued. There is one unmistakable 
feature of the vomiting of gastrectasis, and 
that is the enormous quantities which are 
ejected at one time, the comparative ease 
with which the emetic act takes place, and 
the character of the ejecta, which are com- posed of the food particles of several of the 
meals previously ingested, together with the 
fermented appearance it presents and the 
gases arising therefrom on standing. The 
microscopic examination of the vomited mat- 
ters reveals the presence of yeast fungi and 
other cocci and bacteria of decomposition, 
together with sarcinse ventriculi, which at one 
time were considered so important, but have 
now no prognostic or diagnostic value. 
The chemistry of the functional dilatation 
is, in cases where marked chronic catarrhal 
symptoms are absent, a normal one, or rather 
perhaps one of subacidity ; in complete dila- 
tation from pyloric stenosis, it is held by such 
eminent workers as Ewald and Riegel that 
in all cases non-cancerous they had found 
HC1, though in a diminished amount. I 
have not been able to confirm their state- 
ments, as in the case which I will present to 
you to-night the gastrectasis which resulted 
from complete pyloric stenosis was during 
the whole time of treatment accompanied 
with anacidity, and the patient, though ap- 
parently cured of his stenosis and improved 
in dilatation, presents yet the picture of total 
anacidity. The second case which I will 
present to you to-night of a functional dilata- 
tion, with chronic gastric catarrh, has shown 
from the beginning of treatment total anacid- 
ity, and acidity is returning gradually as re- 
sult of treatment. The gastric distention in 
a dilated stomach is still further increased by 
the changes of decomposition, which give rise 
to gases of various kinds, such as C02, H, 
CH4, H2S, etc., which are only slowly regur- 
gitated through the oesophagus ; the patients, 
5 6 
besides, are troubled with pyrosis, from the 
presence of acetic, butyric, and lactic acids. 
This formation of organic acids and their by- 
products of gases are due to the lack of HC1 
in the dilated stomach. It is claimed that the 
irritant effects upon the gastric mucosa gives 
rise to another great symptom of gastrectasis, 
which is impaired absorption. The tests, 
hereinafter to be mentioned, with salol and 
KI, confirm this in an apparently clear man- 
ner, which, however, depends as much on a 
loss of muscular propulsion as on the chemi- 
cal irritation. The patients suffering from 
high-graded dilatation soon manifest marked 
inanition, and while in such cases the vomit- 
ing becomes less frequent, the fetor of the 
eructations becomes more marked. The near- 
lying viscera are displaced, fiecal discharges 
are more retarded, and dyspnoea and cardiac 
palpitation increase in a measure that the di- 
aphragm is pressed upward by the distended 
stomach. Intestinal absorption is also dimin- 
ished, causing dryness of skin and flabbiness 
of muscles, owing to the want of water of 
these organs. Nervous phenomena go hand- 
in-hand with this from the same cause, result- 
ing often in coma, convulsion, and cardiac 
impairment. All these symptoms have been 
ascribed to the presence of ptomaines, poi- 
sonous gases, and by Litton to aceton ; but it 
it is not apparent that, with a claimed lack of 
absorptive power, such auto-intoxication could 
be probable, and, in fact, Frederick Mueller 
has examined the contents of stomachs under 
such conditions for ptomaines without results. 
The diagnosis of gastric dilatation is not 
always easily effected in its early stages ; the 7 
ordinary symptoms of dyspepsia are more evi- 
dent than the deeper-lying etiological factor. 
Before the characteristic vomiting takes place, 
medical examination will not always be di- 
rected to the employment of physical diag- 
nostic measures. When this is done, inspec- 
tion may lead, in the case of thin and pliable 
abdominal parietes, to reveal a protruding 
hemisphere, if the stomach is distended with 
gases or liquids, extending from beneath the 
ribs from the left to the right hypochondriac 
region ; its lower segment extends to the line 
of the umbilicus, or any portion below this 
towards the symphysis pubis. The curve may 
be altered in various ways, according to the 
position of the ingesta ; gastric peristalsis may 
become sometimes apparent under such con- 
ditions. The inspection may become facili- 
tated by the employment of inflation of the 
stomach, which is best effected by an ordi- 
nary atomizer-bulb through a stomach-tube, 
more so than with the much-vaunted method 
of inflation by means of mixtures which gen- 
erate C02 in the stomach. Further inspec- 
tion in advanced gastrectasis reveals the ab- 
dominal parietes somewhat flabby and sunken 
over the empty viscus, the false ribs of the 
left side appear lifted up, and the skin is dry, 
pale, and of cachectic appearance. 
Palpation of the epigastrium in the simple 
form of gastric dilatation will be of little aid 
in regard to the distended viscus, but may be 
said to be of the greatest value in the deter- 
mination of the causes which lead to it. As 
I have already stated, complete gastrecta- 
sis is almost invariably, if not altogether, the 
consequence of pyloric disease and obstruc- 8 
tion. This latter is capable of being discov- 
ered by palpation alone. Thus carcinomatous 
and other tumors can be detected on the right 
side of the epigastric region, and floating kid- 
ney, or even pyloric hypertrophy may so be 
ascertained. 
The employment of percussion will be the 
first step to make the presence of dilatation 
more certain, if properly conducted ; thus the 
lower contour of the stomach may be with 
accuracy determined. If a stomach before 
inflation contains some fluid, or if the patient 
has been directed before inflating to take a 
glass of water, and he is thereupon examined 
in an erect position, the dulness of the water- 
line will be readily detected by percussion 
from above, while the lower segment of the 
fluid can be readily ascertained by the dulness 
which distinguishes it from the resonance of 
the colon from below. It may be necessary, 
however, for this latter purpose to inflate the 
colon, if it is not already tympanitic. Tumes- 
cence of the pyloric region may also be indi- 
cated by dulness of that part of the organ. 
Auscultation may be used to advantage in 
gastrectasis, if combined with a tube and in- 
flation in a stomach containing fluids. I have 
relied upon this method largely for deter- 
mining the lower segment and extent of the 
distention. To this end I employ an ordi- 
nary small stomach-tube, having previously 
ascertained that the stomach was empty, or, 
if not so, having, washed it out, I direct the 
patient to take a glass of water. If, now, the 
stomach is inflated while the ear is applied 
to the epigastrium, the point of greatest in- 
tensity of the bubbling sound of the air es- caping through the small quantity of water 
contained in the stomach will accurately de- 
termine the lowest part of the stomach. In 
patients with thin abdominal parietes this will 
besides become readily apparent to palpa- 
tion. The swallowing sounds, or “ Schluck 
Gerausche,” so important at times in the 
study of cardiac constriction, are of little, if any, 
importance in the study of gastric dilatation. 
The chemical diagnosis of gastrectasis may 
be twofold,—first, as to the propulsive power 
of the stomach. As already stated, the power 
of the stomach to rid itself of its contents 
through the pylorus depends largely, besides 
the lumen of the latter, on the action of its 
muscular coat. With atony and paresis of 
the latter this is retarded, and in complete 
pyloric stenosis entirely abolished. This has 
been ascertained with great ingenuity by the 
administration of salol, which is a compound 
ether of phenyl and salicylic acid radical, and 
in the alkaline intestinal contents readily 
splits up into phenol and salicylic acid, the 
latter of which promptly appears in the urine 
as salicyluric acid, easily recognized therein 
on the addition of neutral ferric chloride, 
which turns it to a rosy-red color. Experi- 
ments have proven that salol is not directly 
absorbed by the stomach, and that its decom- 
position is probably brought about by the 
pancreatic secretion. Under normal condi- 
tions, the presence of salicyluric acid in the 
urine may be demonstrated within forty to 
seventy-five minutes after the ingestion of 
salol. Any period longer than that may be 
attributed to a paretic condition of the mus- 
cular coat of the stomach. 10 
The chemical examination of the gastric 
secretion will indicate the pathological condi- 
tion of the digestive function arising from 
dilatation, rather than give an idea of an ex- 
isting ectasis. It must be said, however, that 
the determination of a faulty digestive secre- 
tion is, perhaps, the first step that leads us to 
suspect structural changes. I may say that, 
while I have examined numerous instances 
of gastrectasis in which I found HC1 present, 
the quantity in each one of these was below 
normal, while in the older and graver cases 
I have never discovered any HC1. The 
pathological changes in the mucous coat, 
showing a partial and often total destruction 
of the ovoid cells within the ostia of the pep- 
tic glands, and our knowledge of the origin 
of this acid from these cells, would point to 
the impossibility of HC1 secretipn in old and 
extensive cases of dilated stomach, contrary 
to the opinions and writings of some who 
claim that such is and can be the case. 
I have dwelt in several previous papers* 
on the subject regarding the technique of the 
chemical examination of the gastric secretion, 
and will, therefore, omit it here. I will state, 
however, that in numerous examinations of the 
secretion of dilated stomachs, in all stages, I 
have never failed to find the presence of pep- 
sin, as shown by its digestive power on coag- 
ulated albumen when acidulated with HC1. 
* “ Recent Advances in the Diagnosis and Treatment 
of some Diseases of the Stomach,” by L. Wolff, M.D. 
[Medical News, September 21, 1889); “Chemistry of 
Gastric Digestion,” by L. Wolff, M.D. ( Transactions of 
the Philadelphia County Medical Society, October 9, 
1889). As further physical means of determining 
the presence and extent of gastric dilatation, 
should be mentioned the complete filling of 
the stomach with water through a tube, and 
then siphoning out and measuring the water it 
contained. Any stomach found to hold more 
than two thousand cubic centimetres, or two 
litres, may be safely regarded, then, as di- 
lated. 
The prognosis of gastrectasis must vary 
with the causes of the dilatation ; as a dis- 
tended stomach itself is not a condition that 
would seriously impair health and life, the 
consequences rather than the structural 
change have to be taken into consideration. 
Dyspepsia and apepsia exercise, if not cor- 
rected, such pernicious influence on health 
that through malassimilation they may pro- 
duce inanition, and thus prematurely end life. 
The degree of these is, however, conditioned 
by the structural changes that take place at 
the pyloric orifice. If these are malignant, 
the fatality of the disease is obvious, unless 
interfered with surgically. This is also the 
case with polypi of the pylorus and cicatricial 
stenosis ; in this latter instance, however, the 
prognosis as to life is more favorable, not 
alone through the better results obtained 
with such cases by surgical procedure, but 
also by the removal of the hypersemia, which 
may be obtained by relieving the gastric mu- 
cous membrane of the irritation by the patho- 
logical digestive act. Most favorable are the 
atonic cases of recent distention, owing to 
continued errors of diet and excessive eating 
and drinking. In these cases, which we may 
term for convenience paretic ectasis of the 12 
stomach, good results will probably always fol- 
low proper treatment. As much cannot be said 
of cases where the distention is complete and 
the muscular fibres are in a state of paralysis. 
Under such circumstances, which are charac- 
terized by continued absence of HC1 from 
the stomach, much can be done to relieve 
the distress consequent thereupon, together 
with the dyspeptic symptoms, and a lack of 
the proper elaboration of chymus in the in- 
testines, and the malassimilation depending 
upon it. Little is to be hoped for reducing 
the viscus to its normal dimensions or estab- 
lishing in such stomachs a proper chemical 
digestive act. Such patients, however, may 
be kept for years in a comfortable condition 
by observing a proper regimen or avoiding 
errors in diet. It is true that, sooner or later, 
the dilatation may give rise to conditions 
which are not easily overcome by palliative 
treatment, and for which, then, the surgeon’s 
knife might hold out the only hopes for im- 
provement. Since we know, however, that 
persons with gastric ectasis, and an absence 
of proper HC1 secretion, may be able to live 
comfortably, and, under proper precautions, 
may certainly gain weight, such interference, 
when malignancy can possibly be excluded, 
should not expose patients to the risks of an 
operation until other measures have been ex- 
hausted. 
The treatment should be directed, first of 
all, to relieve the symptoms of indigestion, 
the vomiting resulting therefrom, and the es- 
tablishing of a proper peptic function. To 
this end it is obvious that emptying of the con- 
tents of the stomach, and the removal there- 13 
from of the accumulated mucus, together 
with the causative elements of fermentation, 
are of prime importance. While emesis, so 
characteristic of this affection, will probably 
meet the first contingency, that of rendering 
the stomach aseptic can be accomplished only 
by lavage. To this end the stomach-tube 
should be employed daily, or even twice in 
that period ; the quantity of liquid to be em- 
ployed depends on the condition supervening, 
but should not be suspended until the wash- 
ings return perfectly clear. Where the ca- 
tarrhal condition gives rise to the presence 
of viscid mucus, it is necessary to add to the 
water a drachm or two of sodium bicarbo- 
nate ; where the rank odor of butyric and 
acetic acids indicate the presence of organ- 
ized ferments, additions of similar quantities 
of either sodium salicylate or sodium borate 
should be made. The time best suited for 
washing out the stomach is before the princi- 
pal meal of the day, and may proceed this 
best by a half-hour. One of the most impor- 
tant features of the treatment next to this 
must always be the dietary regimen. Food 
substances which are slowly digested should 
be carefully avoided, as well as those which 
are prone to fermentation. It has been held 
that a dry diet should be the principal feature 
of such dietetic treatment, but I differ in this 
respect. A priori, it appears to meet the in- 
dications ; but when we consider that dry 
foods are not readily acted on by the peptic 
secretions, and that the stomach is certainly 
still capable of directly absorbing some liquids 
and liquid foods, the precaution appears super- 
fluous, and it has proven of no advantage in 14 
my experience. Milk diet, so freely and pro- 
miscuously ordered in all digestive troubles, is 
probably the most objectionable in this affec- 
tion. Scraped meat on toast, white meats of 
fowl, stewed mutton, or boiled beef answer 
to excellent advantage when followed by 15 
to 20 drops of HC1, diluted in a wineglass of 
water. Toast in limited quantities is more 
readily digested than ordinary bread, while 
succulent vegetables are permissible. One 
of the principal articles of diet is ordinary 
beef or mutton broth, to which, before being 
served, one or two raw eggs have been added 
and well beaten up. Of stimulants, noth- 
ing but dry white wines or clarets should be 
allowed at meals; pastry, puddings, and 
sweets must be, of course, studiously avoided. 
Such diet, however, may be suited for com- 
paratively mild cases- only. The graver cases, 
accompanied with almost complete apepsia, 
will be best maintained, per os, by the above- 
mentioned broths, with eggs, followed by 
HC1, while superadded to these must be rec- 
tal alimentation. As in such cases the bowels 
are always torpid, this measure is quite feasi- 
ble, and may be continued for a considerable 
period. Nothing will so benefit such patients 
as nutritive enemata properly made and ad- 
ministered. It appears to me a mistake to 
exhibit as such any food in a soluble con- 
dition without being predigested. The lower 
bowel certainly secretes no digestive ferments 
to change food to an assimilable condition, 
whereas its absorptive power is well known. 
For this reason only such food should be ex- 
hibited per rectum that may be directly ab- 
sorbed. I have been in the habit of using from two to four ounces of pure glucose dis- 
solved in starch mucilage, or even milk, as 
vehicle, three to four times daily, adding 
thereto one ounce of beef peptone, and stimu- 
lants if required. By such a course of rectal 
alimentation I have seen patients rapidly in- 
crease in weight and strength, and I have 
in my mind a case with complete pyloric 
stenosis who was carried to the hospital 
weighing eighty-nine pounds, and in three 
months thereafter left with a weight -of one 
hundred and fifteen pounds, which subse- 
quently increased to one hundred and forty- 
six pounds. I need scarcely mention that 
during rectal alimentation the bowels should 
be daily washed out with large enemata of 
lukewarm water. 
I have already referred to the constipation 
supervening in such cases, and in order to 
obtain rapid absorption of food free alvine 
discharges must be procured. As we have 
to depend with such cases largely upon di- 
rect gastric absorption, the salines seem to 
be alone eligible for the purpose ; the Carls- 
bad salts or sulphate of sodium dissolved in 
hot water, taken directly after lavage, may be 
preferably employed to that end. Medica- 
tion seems but little indicated. Besides the 
HC1 given freely after the albuminous food 
to make up for the lack of acidity necessary 
to form peptones, and pepsin always being 
present, there is but one remedy upon which 
we can rely to produce contractility of the 
muscular fibres, and that is strychnine. Its 
tonic properties in such cases cannot be too 
highly praised, while of the other remedy 
recommended in such cases—the condu- 16 
rango—I cannot say as much from my own 
experience. 
As I have already stated, in the older and 
severer cases little is to be hoped from any 
means for establishing a smaller lumen of 
the viscus, or a return of the acid secretion 
of its glands ; this at times may certainly be 
accomplished by the treatment employed 
with that view. The two measures to be 
relied upon for that purpose are massage and 
the faradic current. While the former ap- 
peals to the fashion of the period, and no 
doubt promotes a healthy nutritive circula- 
tion, the internal faradization of the stomach 
is the most rational and serviceable of the 
two. External bipolar faradization, prac- 
tised and extolled by some, will probably ac- 
complish just as much or as little as massage. 
Why it should be employed when internal 
faradization is so easily and safely accom- 
plished, and with such excellent results, is to 
be wondered at. The stomach electrode em- 
ployed by me consists of a small nickel- 
plated brass olive screwed on to a flexible 
copper wire about one yard in length, and 
insulated by being covered with rubber; it is 
easily introduced, either by the patient him- 
self or the medical attendant. Before intro- 
ducing the electrode, the patient should be 
directed to take one or two glasses of water. 
The current itself should be feeble at the 
beginning, and gradually increased until 
peristaltic movements are experienced by 
the patient, which may be even felt at times 
by the attendant through the external pa- 
rietes. 
As an illustration of what may be accom- 17 
plished in cases of gastrectasis, I will now 
bring before you this patient: 
R. M., aged 37, was born in Ireland, and is 
a stoker by occupation. He has been suffer- 
ing from dyspepsia for about three years, for 
which he sought relief in various quarters. 
He came under my care about three months 
ago, complaining of epigastric fulness, ano- 
rexia, eructations, frontal headaches, furred 
tongue, buccal fetor, together with marked 
nervous symptoms, consisting of insomnia, 
melancholia, hallucinations of persecution, 
and has lost greatly in flesh. 
Chemical examination of the gastric secre- 
tion revealed anacidity after trial meal, and 
on washing out the stomach large quantities 
of viscid mucus having an acrid odor were 
removed. Physical examination proved all 
organs, excepting stomach, to be normal. 
Inspection of stomach showed great disten- 
tion, and auscultation of the inflated viscus 
revealed the lower segment about three 
inches below umbilicus. Siphoning out 
proved capacity of stomach about six litres. 
He states that during the time he is at work 
he drinks large quantities (gallons) of water. 
There was no tumescence or tenderness in 
pyloric region ; no history of hsematemesis 
and no cachexia. Diagnosis : atonic gastrec- 
tasis, with chronic gastric catarrh. Ordered 
suitable regimen, followed by HC1, also 
grain of strychnine t. d., daily lavage before 
principal meal, Carlsbad salt to be taken in 
morning while fasting, and internal gastric 
faradization, together with abstinence from 
excessive potations. 
I will now extract some of the gastric se- 18 
cretions, and you will see that they give a de- 
cided HC1 reaction. On inflation you will find 
the lower segment of the stomach one inch 
above the umbilicus, and when I measure the 
contents of the full stomach, which I have 
siphoned out before you, I find it to be about 
three litres. You hear from the patient that 
his appetite is good, that he sleeps well, and, 
though still inclined to melancholia, he is so 
in a much less degree than formerly, also that 
he has gained in weight and strength.