GAS :1^'yNTER0PT0SIS 
YCYEYT C. COFFEY GASTRO-ENTEROPTOSIS GASTRO-ENTEROPTOSIS 
BY 
ROBERT C. COFFEY, M.D., F.A.C.S. 
SURGEON IN CHIEF, SURGICAL HOSPITAL; CLINICIAN IN SURGERY, 
UNIVERSITY OF OREGON, MEDICAL DEPARTMENT 
/ 
SURGICAL MONOGRAPHS 
UNDER THE EDITORIAL SUPERVISION OF 
DEAN LEWIS, A.B., M.D. 
PROFESSOR OF SURGERY, RUSH MEDICAL COLLEGE 
EUGENE H. POOL, A.B.. M.D. 
ATTENDING SURGEON, NEW YORK HOSPITAL 
ARTHUR W. ELTING, A.B., M.D. 
PROFESSOR OF SURGERY, ALBANY MEDICAL COLLEGE 
D. APPLETON AND COMPANY 
NEW YORK 
LONDON 
1923 COPYRIGHT, 1923, BY 
D. APPLETON AND COMPANY 
PRINTED IN THE UNITED STATES Of AMERICA APPRECIATORY NOTE 
It seems to be the fate of many worthy surgical procedures and opinions 
to be compelled to fight their way through difficutlies raised by foolish or 
unscrupulous advocacy. As we pass in review the large number of new 
operations introduced during the last two generations, we are amazed to find 
with what indifference or open hostility many of them, now firmly and 
rightly established, have been received; and with what eager and thoughtless 
enthusiasm many were welcomed which are now banished from our work 
forever. We learn, too, with astonishment how much a reckless advocacy 
and an intrepid adoption, by surgeons of less judgment than courage, have 
done to prejudice in the eyes of the cautious practitioner, an operation which 
at last is found to be of great value. 
In consequence of the daring and ingenuity of surgeons, both of America 
and of Europe, most of the operations, which when newly tried were found 
to be of great difficulty, are now performed “according to plan,” are standard- 
ized, and are practiced with little or no variations by surgeons in all parts 
of the world. To perform an operation has become a fairly simple matter; 
technical difficulties have almost disappeared. The surgeons greatest task 
now is to decide in what circumstances an operation should be performed, or 
avoided, and to safeguard the patient, as far as is humanly possible, from 
all risks. This facility in the conduct of operations had led sometimes to 
their performance by surgeons of little skill and of less wisdom, with the 
result that an operation has perhaps suffered eclipse and become discredited, 
not for any defects in it as a technical procedure, but in consequence of its 
improper application to the individual case. 
For reasons such as these, the whole subject of visceral prolapse has been 
discredited in the minds of many physicians and surgeons. It is a subject 
about which the most confident and tenacious opinions have been expressed 
after the briefest and most perfunctory experience. Yet it is as difficult a 
surgical subject from which to unravel the truth as any with which I am 
familiar. Every one knows the frequency of visceral prolapse, of loose 
kidneys, of the flaccid abdomen, flat in the epigastrium and bulging over 
the pubes; and constipation seems the heritage of every race. Here is material 
in abundance for the surgical adventurer. Regardless of all else, the stomach 
may be lifted up and fixed by suture, the kidney anchored to the last rib, 
and constipation for the moment relieved by a short-circuiting or abstracting 
operation. The lot of the patients is hard. Constipation will soon return, 
the other kidney will fall down or the anchored one break loose, and the 
distress of the fixed stomach greatly exceed that felt in its vagrant days. 
V VI 
APPREC-IATORY NOTE 
That is the tale of all reckless surgery. Many surgeons turned away with 
dislike and distrust from such an unpromising and tainted subject. The 
action was perhaps a little cowardly, for there are many aspects of the con- 
dition worthy of the most anxious investigation; and the happiness of many 
sufferers depends upon a wise decision being reached as to the methods of 
their treatment. 
I know few subjects in Medicine so greatly in need of the best services 
that pathologists, physicians and surgeons alike can give; I know of none 
which requires in the investigator a quicker clinical sense, a shrewder or more 
deliberate judgment, and a more flawless integrity of utterance. 
For these reasons, I welcome the work of Dr. Coffey. All of us who 
are privileged to know him feel that we can trust him, and can most con- 
fidently rely on his honesty and sobriety of decision. He has devoted himself 
to this most difficult and perplexing subject with cautious enthusiasm; he 
has regarded it from all sides; he has treated his cases by a variety of 
methods and has watched them for long periods; he has confessed his early 
errors with a frankness that convinces us of his perfect sincerity. In this 
work, he is stating his full case in a manner which will command the respect- 
ful attention and admiration of all surgeons. In his hands the subject 
assumes a dignity and an importance which it has never yet commanded; 
and through his efforts we are most assuredly drawing nearer to the truth 
of the matter than we have ever been before. 
Leeds, England. 
Berkeley Moynihan PREFACE 
When I received a request from the Editorial Committee on Surgical 
Monographs of Appleton and Company to write a monograph on gastro- 
enteroptosis, I felt that I had been distinctly complimented. Before signing 
the contract for the production of the monograph, I began to consult many 
of my friends over the country, both by word and letter, in order to get 
their opinion as to the advisability of producing a book of this kind at this 
time. Almost with one accord, the advice was against it, some thinking the 
subject was too trivial, others that it was too dangerous. Some even sug- 
gested that my reputation was scarcely well enough established to risk it on 
such an adventure. Finally, I decided to turn for advice to my friend, Sir 
Berkeley Moynihan of Leeds, who probably has as large a perspective on 
the surgical problems of the abdomen as any one in the world. While he 
has always maintained an attitude of benevolent and dignified tolerance on 
this question, he was the first to recognize my original contribution by 
including it in the first edition of his Abdominal Operations. I have been 
pleased to note that he has not expunged it from the later editions of his 
book. In 1920, when I met him in Montreal, among his first words were: 
“I was speaking with some London surgeons a few days ago. They expressed 
the opinion that your work on the ptosis question would eventually ‘come 
home to roost.’ ” He mentioned a number of London surgeons who were 
working along this line, particularly George Waugh and Tyrrel Gray. His 
answer to my later request for advice was very positive. He urged me by 
all means to write the monograph, suggesting that I ignore critics, “for,” 
said he, “they know that in the mountain of rubbish there is a gem of purest 
truth. There are so many men about these days who seem to consider this 
a proper subject to drivel over, it is high time that some one, who above all 
must be a sane man, should burn the rubbish and cherish and preserve the 
truth.” After this encouraging and highly complimentary statement, the 
contract for the production of the monograph was signed. 
From the time of the first operation that I performed for gastroptosis 
in November, 1901, to November, 1911, a very careful study of all that 
was done and written on the various phases of this rapidly widening field 
of investigation was made. During those ten years, my surgical efforts were 
limited to bedridden patients who were approaching the terminal stages of 
this condition and were suffering from end results. The work of Lane 
and Rovsing, in dealing with this class of cases, was particularly outstanding, 
and so a trip to visit their clinics was made. On this trip, in addition to 
obtaining their viewpoint, I had the privilege of presenting my views on the 
VII VIII 
PREFACE 
subject to such clinics as those of Lane, Moynihan, Stiles, Rovsing and others. 
At Moynihan’s clinic, I first met George E. Waugh, who showed marked 
interest in this subject. A few days later, I had the pleasure of attending 
Mr. Waugh’s clinic at the Great Ormond Street Hospital in London. At 
that time and on other occasions, we discussed this subject. I am very much 
interested to note that case No. i in his long list of colopexies recently 
reported in the British Journal of Surgery was dated May 12, 1912, just 
four months after our conversation on this subject. 
On my return late in February of 1912, my views of the whole subject, 
along with what I had learned abroad, were presented before the Chicago 
Gynecological Society, and in October, 1912, were published in Surgery, 
Gynecology and Obstetrics under the title: “The Principles Underlying the 
Surgical Treatment of Gastro-intestinal Stasis, due to Causes other than 
Strictural or Ulcerative Conditions.” 
During these years and during the years of 1912 and 1913, I observed 
that my medical colleagues were producing very remarkable results by forced 
feeding, fattening and by certain exercises and orthopedic measures. 
By this time, X-ray examination of the gastro-intestinal tract was making 
unusually interesting revelations in connection with this class of cases as 
to changes produced by this treatment. This brought into the field of study 
the very important matter of the role of fat and its relation to intra-abdominal 
and intravisceral pressure. A large portion of the years 1912 and 1913 was 
spent in formulating a conception of the subject of ptosis and stasis. Early 
in the year 1913, the extraordinary honor of an invitation to deliver the 
Mutter lecture was tendered me. The lecture was delivered in Philadelphia, 
December, 1913. My conception of the ptosis question was presented at 
that time under the title, “Constipation Considered from the Standpoint of 
Anatomy, Embryology, Physiology and Pathology.” The intention was to 
present the fundamental underlying truths for the consideration of a group 
of highly trained specialists, both medical and surgical. Owing to the hostile 
criticism of anything pertaining to this question, by many of the leading men 
of the country, I decided not to publish the lecture until sentiment had some- 
what softened. I believe that time has come, in view of the fact that the 
most hostile critics must now concede that there is something very important 
connected with the subject. In this volume, therefore, is published for the 
first time my complete conception of the question as delivered in the Mutter 
lecture of 1913, as a basis for the clinical work which has followed and will 
follow. 
No new fundamental principles have developed since the delivery of this 
lecture. Much clinical work has been done during the intervening nine 
years by a few individuals in this country and in England. All of the reports 
are favorable. From these reports by a few men, we are able to add to the 
former conception of the condition, a more definite clinical conception which 
is beginning to tell us the meaning of certain symptoms as well as to indicate 
more clearly the proper form of treatment. PREFACE 
IX 
In an experience of more than three hundred and sixty cases treated 
surgically and more than six times as many treated medically in our clinic, 
we feel that much has been learned. We may learn much from such articles 
as that of Waugh in the January, 1920, number of the British Journal of 
Surgery, reporting nearly three hundred cases altogether, and giving his 
clinical conception of what may be termed “Right-sided Ptosis”; also from 
Rovsing’s many hundreds of cases of what may be termed “Mid-line Ptosis.” 
Besides these, there are numerous other clinics, both medical and surgical, 
in this country and abroad, which are giving much study to this class of 
cases. 
In formally opening this question, which I feel certain will prove extra- 
ordinarily fascinating, I wish to repeat the following warning which was 
published in my article of 1912: “I concede that in bringing forward this 
subject of ptosis and stasis, we are opening one of the most dangerous fields 
for surgical abuses that has ever been opened to the surgical 'confidence 
man,’ who needs no other excuse for performing a surgical operation than 
the consent of the patient. X-ray observation is of inestimable value in the 
study of these cases, but is, I concede, the most dangerous agent yet placed 
at the disposal of the unscrupulous surgeon, because it is so convincing to the 
laity, and at the same time so meaningless when considered independently of 
the history of the case, and not properly interpreted.” This warning is 
necessary because of the fact that there are probably more people afflicted 
with this abnormality than with any other disease known to human-kind, 
there being probably fully twenty per cent of individuals who are potentially 
ptotic. 
Those of us who have been attempting to promulgate this question have 
hoped that it would remain in the hands of conservative surgeons with 
recognized standing, until they could investigate it, in order that the develop- 
ment should proceed from their doors. As far as I have been able to observe, 
the investigation by conservative surgeons has not been very thorough. 
Fortunately, truth will not be ignored. This question will, I believe now, be 
passed on to the rising generation of surgeons for further development and 
final settlement. 
The purpose of this book is to assemble the most important facts that 
are known pertaining to the question and to coordinate them into a conception 
on which a clinical structure for the years to come may be built. 
Men of recognized ability and vision have been earnestly working on 
this question for a generation. 
Nearly a half century ago, S. Weir Mitchell, although working empirically, 
successfully coped with this question as it presented itself under the disguise 
of “neurasthenia.” The fact that he thought that by forced feeding and 
fattening he was padding the nerves instead of the gastro-intestinal tube did 
not materially lessen the importance of his clinical accomplishment. 
Glenard, in the late eighties, believed this question was one of metabolism 
and that it was primarily an obscure liver disease. X 
PREFACE 
Rovsing has taken a mechanistic view and has limited his activities chiefly 
to those organs which cross the midline and believes they are practically all 
due to the wearing of corsets or to childbearing. His treatment was purely 
mechanistic, consisting of firm fixation of the stomach to the abdominal 
wall. 
Lane has taught us most of what we know of the end results of stasis 
and of the nature of the acquired bands found in the abdomen. His law 
of the crystallization of the lines of force is probably the most important 
observation that has been made in connection with this subject. He failed, 
however, to recognize the importance of the normal prenatal fixations of 
certain abdominal organs and that deficient prenatal fixation was the under- 
lying cause of much of the membranous development. He, therefore, con- 
sidered it necessary to do very radical surgery as a therapeutic measure. 
Longyear discovered extraperitoneal fibrous tissue fastening a prolapsed 
colon to a movable kidney, which he classified as a ligament, but which in 
reality probably represented extraperitoneal crystallized lines of force laid 
down in accordance with Lane’s law. He made the important discovery 
that the kidney is probably pulled out of position by the weight of a movable 
colon acting through this fibrous tissue which he called the “nephrocolic 
ligament.” Elevation of these organs and bringing this fibrous tissue, hold- 
ing the colon and kidney together, out through the fascia and fastening it 
relieved the whole chain of symptoms in many cases. Longyear, fixing his 
attention on this one structure, attempted to make it the pivotal and funda- 
mental consideration of the entire ptosis quesion. 
Richard Smith observed the frail structure of ptotic patients and made 
valuable records. 
Goldthwait and Franklin Martin believed that the abnormal body con- 
formation produced most of the ills of these unfortunate and misshapen 
individuals, and they have devoted their energies to correcting these de- 
formities. Goldthwait, however, very early discovered the relation between 
deficient prenatal fixation of the colon and general ptosis. 
Klose was among the earliest to discover that deficient peritoneal fixation 
of the ascending colon was a very fundamental consideration in connection 
with this subject and, as early as 1907, fixed the cecum and ascending colon. 
Wilms, Waugh and others have assumed that a mobile cecum is the 
fundamental anatomical condition which is responsible for the ills of the 
entire ptosis question. Accordingly, their therapy consisted in firm fixation 
of the cecum. 
Jackson, Walton and others have concentrated most of their attention on 
the secondary membranes found in the neighborhood of the cecum and have 
cut the membranes. 
Klemm, Blake and others believed that the dilated cecum was the most 
outstanding feature connected with the subject. Therefore, they plicated the 
cecum. 
Wilkie, Kellogg, Codman and others believe that duodenal arteriomesen- PREFACE 
XI 
teric ileus is probably the most important pathology connected with the ptosis 
question. 
Homans, Taylor and others believe that bands in the neighborhood of 
the duodenum and gall-bladder constitute a real cause of much abdominal 
distress. 
Anatomists, basing their conclusions on postmortem examinations held 
on the cadavers of newborn babes, have noted the frequent occurrence of 
membranes and peritoneal folds at the beginning and ending of the fused 
peritoneal areas and gravely announce that all membranes and bands found 
in the abdomen are congenital. Lane is equally positive that they are all 
acquired. The everyday practical surgeon, seeing the results of acute in- 
flammatory conditions, believes they are all inflammatory. The casual 
observer, seeing this apparent difference of opinion, dismisses the entire 
subject as being mythical and unworthy of the attention of a strong-minded 
individual. 
As a matter of fact, all the observations enumerated in the above list may 
be verified by any abdominal surgeon who will carefully observe the structures 
in the abdomens of a large number of patients. He is unable to harmonize 
them because each enthusiast treats indifferently the observations of all the 
others. 
If this book has clearly brought together the teaching of all these men 
of genius into a harmonious workable conception of the ptosis question, it 
will have fulfilled its mission. 
I believe a careful study of this subject will convince one that the real 
reason for the apparent differences of viewpoint on this subject is that it is so 
far-reaching in its ramifications. Each of the above-mentioned authors has 
taken up a phase of the subject and worked it out and expressed it more 
thoroughly than a casual observer could do. In order to include the exact 
viewpoint of these original workers, I have, where possible, sought permis- 
sion to quote the exact words of the author even to the extent of several 
pages. For this privilege I am deeply grateful to the authors and publishers. 
I am especially grateful to John Wright and Sons, Ltd., Publishers of the 
British Journal of Surgery, and to the following authors whose articles have 
been published therein: Albert J. Walton, Sir Arthur Keith, Sir William 
Arbuthnot Lane, N. Mutch, A. E. Barclay, George E. Waugh, D. P. D. 
Wilkie. Also to Sir Berkeley Moynihan for his comprehensive and more than 
kind introduction. 
In presenting this book, I wish to thank Miss Gertrude Gray and Miss 
Maud Spacht for assembling the clinical records and literature for study 
and for typing the manuscript. I cannot fail to express my thanks and deep 
appreciation to Mr. Frank C. Trahar, who has produced all my illustrations 
on all subjects for the past twenty-one years, and whose brilliant mind, clear 
conception, genuine loyalty and helpful sympathy have meant far more to me 
than the mere making of pictures. 
Portland, Oregon R. C. COFFEY CONTENTS 
CHAPTER PAGE 
I. Structure of the Abdominal Wall ... i 
II. Shape of the Abdominal Cavity ... 3 
III. Suspensory Supports of the Abdominal Cavity 10 
IV. Intra-abdominal and Intravisceral Pressure 29 
V. Comparative Anatomy and Physiology of the Gastro-intestinal Tract . 46 
VI. Motility of the Large Intestine 53 
Abnormal Motility—Constipation, 59. 
VII. The Role of Habit in Constipation 65 
VIII. Relative Effect of Constant and Intermittent Obstruction .... 68 
IX. Acquired of Postnatal Developmental Processes 70 
Defects in Prenatal Peritoneal Fusion, 82—Significance of Bands and Mem- 
branes, 84—Pathological Description, 87—The Ptotic Body Habit, 94 
X. Pathology of Intestinal Stasis . 98 
Bacteriology, 98 — Toxicology, 103 — Organic Pathology, 107 — Mechanical 
Factor, in. 
XI. Abdominal Ptosis . 120 
General Ptosis, 120—The Cervical Fascia Important in Visceral Support, 122— 
Temporary Supports, 126—Exercise and Correction of Postural Habits, 126 
—Fresh Air and Feeding, 134—Complication of Ptosis, 131—Technic of Long- 
year’s Operation, 142. 
XII. Right-sided Ptosis 152 
Harmful Acquired Membranes and Bands, 154—Right-sided Pain with Right- 
sided Ptosis, 157—Types of Cases, i68---Gastric Type, 168—Duodenal Type, 
170—Biliary Type, 171—Renal Type, 172—Right Iliac Fossa Type, 173—Chil- 
dren, 173—Family History, 174—Personal History, 174—Pre-operative Diag- 
nosis, 175—Operative Findings, 175—Diagnosis and Indications for Treat- 
ment, 178. 
XIII. Midline Ptosis 190 
Virginal Gastrocoloptosis, 192—Complications and Consequent Diseases, 195— 
The Maternal Gastocoloptosis, 198—Postoperative Treatment for Abdominal 
Ptosis, 223. 
XIV. Duodenal Arteriomesenteric Ileus 227 
Physical Signs, 246—Pathology, 247—Symptoms, 247—The Toxic Symptoms, 
248—The Mechanical Symptoms, 248—Treatment, 249—Postoperative, 255. 
XV. Intestinal Stasis and Radical Surgery 263 
Importance of the Large Bowel, 263—Colectomy, 274—Ileocolostomy, 280. 
XVI. Medical Treatment of Ptosis 283 
XVII. General Indications for Surgical Treatment 289 
Conclusion, 296. 
XIII ILLUSTRATIONS 
FIGURE PAGE 
1. Strong white fascia of the front abdominal wall i 
2. Cross-section of the abdominal wall 2 
3. Plaster block containing cast of abdomen 3 
4. Anteroposterior section through pelvis, appendix and right flank .... 4 
5. Anteroposterior section through pelvis, psoas muscles and left flank . . 4 
6A. Diagram showing direction and shelf of the normal ascending colon ... 5 
6B. Diagram showing pendulous mobile cecum seen where rotation is not complete 5 
7. Cross-section of the abdominal cavity 6 
8. Cross-section of the abdominal cavity 6 
9. Diagram showing the relative position of the various parts of the colon to 
the median line of the abdomen 7 
IOA. Normal relation of the various parts of the colon to the anterior and posterior 
abdominal walls 8 
IOB. Relation of the various parts of the colon to the anterior and posterior abdomi- 
nal walls seen in an anteroposterior plane in a case of general ptosis ... 8 
11. Diagrammatic representation of fat cells 11 
12. Collapsed diamond after absorption of fat 11 
13. Portions of alimentary canal fixed by prenatal adhesion or fusion .... 13 
14. Repair following intestinal union ... 15 
15. Result following suturing of pig’s omentum to abdominal wall .... 16 
16. Blending of peritoneum of liver to abdominal wall 16 
17. Curves of blastodermic layers and division of mesodern in amniote embryo 17 
18. Mesogastrium in early life 18 
19. Vertebrae mesentery or dorsal mesogastrium before development of the 
pancreas . 18 
20. Ventral mesogastrium with developing liver 19 
21. Relation of liver, stomach and pancreas to the mesogastrium just before 
rotation 20 
22. Free mesoduodenum in sagittal plane 21 
23. Mesoduodenum folded to the right 21 
24. Fixation of head of pancreas and duodenum under cover of secondary parietal 
peritoneum 21 
25. Transposition of stomach to the left with beginning elongation of dorsal 
mesogastrium 21 
26. Schematic ventral view of stomach, duodenum and dorsal mesogastrium . . 22 
27. Semidiagrammatic representation of peritoneal membrane in human embryo 23 
28. Peritoneal arrangement before fixation 24 
29. Peritoneal arrangement after fixation 24 
30. A sagittal section through the right kidney and descending duodenum before 
adhesion of latter to parietal peritoneum 24 
31. Adhesion of mesocolon to duodenum and primitive parietal peritoneum, result- 
ing in formation of root of transverse mesocolon 24 
32. Relation of duodenum and kidneys to the colon and mesocolon in the normal 
individual ' 25 
33. Diagram of the formation of the great omentum . . . . . . .26 
34. Normal arrangement of human peritoneum and omental bursa (Infantile 
stage) 27 
35. Normal arrangement of adult human peritoneum 27 
36. Schematic sagittal section of dorsal mesogastrium and omental bursa in man 
and monkey 28 
XV XVI 
ILLUSTRATIONS 
FIGURE PAGE 
37. Area of adhesion between the dorsal mesogastrium and primitive parietal 
peritoneum in monkey 28 
38. Schematic sagittal section of abdominal viscera of a cat 28 
39. Peritoneal arrangement which would be produced by rotation and fusion of the 
viscera of a cat in the position corresponding to the human 28 
40. Experiment to illustrate the relation of intra-abdominal to intravisceral pressure 30 
41A. Diagram illustrating the role of fat in maintaining the tonicity of the hollow 
viscera 32 
41B. Patient reduced in health, fat having been absorbed 33 
42. Sagittal section through the left side of the abdominal cavity 34 
43. Sagittal section through the left side of the abdominal cavity .... 34 
44. Anatomical importance of the ileocecal valve 35 
45A. Roentgenogram showing case of completely incompetent ileocecal valve . . 36 
45B. Complete restoration of the valve 37 
46A. Roentgenogram showing distended ileum 38 
46B. Roentgenogram showing distended ileum 39 
47A. Common bile duct implanted into duodenum 40 
47B. Implanted common duct entering the duodenum 40 
48. Diagram showing submucous implantation of a duct into the intestine . . 41 
49. Testing competence of the valve in a removed specimen following submucous 
implantation in a dog 41 
50A. Normal valve in a dog’s bladder for comparison with fig. 40B .... 41 
50B. Postoperative valve following submucous implantation of a ureter in a dog’s 
large intestine 42 
51 A. Diagram showing influence of peristaltic waves on the gall bladder ... 43 
51B. The flow of bile from the gall bladder and duct following the wake of a 
peristaltic wave 43 
52A. Diagram illustrating a theory as to the probable cause of dialation of the 
52B. common duct following removal or destruction of the gall bladder ... 44 
53. Junction of large and small intestine of the gila-monster, showing the valve 
separating them - 48 
54. Gastro-intestinal tracr of iguana tuberculata 49 
55. Sectional view of the ceum of iguana tuberculata 50 
56. Ileocolic junction cecum and colon of agouti 50 
57. The ileocolic junction and ceca of black hawk 51 
58. Ileocolic junction and ceca of ostrich 52 
59. The human cecum open 53 
60. Figures illustrating four functional states of the ileocecal region of the bowel 
of rats 56 
61. Direction of fecal currents after operation 57 
62. Diagram in which the arrows indicate the normal fecal currents .... 58 
63. Extreme distention of the cecum without distention of the descending colon 
in gradual obstruction of the lower bowel 61 
64. Ligamentum nephrocolicum 71 
65. Transverse section showing the relations of Gerota’s capsule and the nephro- 
colic ligament 72 
66. Represents the distended loaded bowel dragging upon the resistances evolved 
to oppose its downward displacement into the true pelvis 77 
67. Diagram represents the anchored portion of ileum with its mesentery in an 
anteroposterior plane 77 
68. Diagram showing the normal unobstructed condition of the small intestine . 77 
69. Diagram illustrates the effect of the shortening of the under surface of the 
mesentery of the ileum by acquired lines of resistance 77 
70. Mechanism of the appendical tie or acquired resistance when the appendix 
forms the inner limb of the parallelogram of forces 78 
71. Duodenum usually terminates vertically at the root of the transverse mesocolon 
where it is continued into the jejunum as a gentle curve 78 ILLUSTRATIONS 
XVII 
FIGURE PAGE 
72. A kinked and filled ileum drags on the jejunum and develops an obstruction 
of the duodenal outlet in the form of resistances which are laid down as 
peritoneal bands indicated by arrows 78 
73. Diagram shows resistances in the form of membranes which fix the jejunal 
loop so as to avoid kinking 78 
74. Represents the prolapsed cecum 79 
75. Represents the several variations from the normal which the large bowel 
undergoes 79 
76. The descending colon fixed in the same manner as the ascending colon by 
crystallized resistances 79 
77. A cross-section through the sigmoid and mesosigmoid 79 
78. Irregularly contracted resistances or membranes showing double kinking of 
the sigmoid 80 
79. Volvulus of the iliac colon at the junction of the sigmoid and rectum ... 80 
80. Importance of last sigmoid kink in connection with intestinal stasis or con- 
stipation 81 
81. Thirty per cent of the weight is taken up by a 51° slope . . . . .82 
82. Normal peritoneal attachment of cecum and ascending colon to parietal 
peritoneum 83 
83. Picture illustrating the normal visceral and peritoneal relations of the ventral 
surface of right kidney 84 
84. Unfused cecum and ascending colon 85 
85. Third degree of nonfusion 85 
86. Complete nonfusion 86 
87. Pathology which sometimes accompanies mobile cecum 91 
88. Diagram indicates how pericolic membrane may become constricting band after 
hepatic flexure has been let down in process of general ptosis 92 
89. Acquired bands of the type which produce gall-bladder and duodenal symp- 
toms by the pull of a mobile pendulous colon 93 
90. Duodenal obstruction at two points 94 
91. The main lines of strain upon the duodenum 95 
92. Typical ptotic figure 96 
93. Fourth and fifth lumbar vertebrae and sacrum of laborer who carried loads in 
front of him 97 
94. A case of Raynaud’s Disease 116 
95. Application of the Achilles Rose adhesive plaster 126 
96. Style of abdominal bandage of a very desirable type for both men and women 127 
97. A corset abdominal support 127 
98. Same style of support applied to a male patient 128 
99. Form of corset for ptotic females which is very satisfactory 128 
100. Position advised for exercises described for ptotic patients 129 
101. Movement one 129 
102. Second act of first movement 129 
103. Movement two 130 
104. Movement three 130 
105. Movement four 130 
106. Movement five 131 
107. Movement six (a) 132 
108. Movement six (b) 132 
109. Movement seven (a) 133 
no. Movement seven (b) 133 
in. Stomach in case 21, three and one-half years after “Hammock” operation . . 138 
112. Colonin case 21, three and one-half years after “Hammock” operation and 
nine and one-half hours after bismuth meal 139 
113. Stomach in case 22, three years after “Hammock” operation 140 
114. In case 22, bismuth had passed into the rectum when picture was taken . . 141 
115. Longyear’s operation of nephrocolopexy 144 
116. The mobile colon is sutured to the posterior parietal peritoneum as the in- 
cision through which the appendix was removed is being closed .... 145 XVIII 
ILLUSTRATIONS 
FIGURE PAGE 
117. Sutures placed for fixing fibrous flaps of the kidney around a detached piece 
of the quadratus lumborum muscle 146 
118. Scheme of completed operation of swinging flaps of the fibrous and fatty 
capsule of the kidney around a piece of the quadratus lumborum muscle . . 147 
119. Complete “Hammock” operation used in general ptosis 148 
120. Extreme case of general ptosis 149 
121. Extreme case of general ptosis 150 
122. Cross-section of the upper abdominal wall 150 
123. Gangrene cecum and ascending colon and last six inches of ileum resulting 
from torsion of mobile cecum 158 
124. Midline ptosis, right-sided ptosis, mobile colon held by firm bands from the 
middle of the transverse colon by the appendix from its tip 176 
125. The transverse colon turned upwards 177 
126. Continuous fine double chromic catgut suturing the two longitudinal bands 
together to shorten and narrow the bowel 182 
127. Diagrammatic picture showing method of including each loop of continuous 
suture in the grasp of an interrupted chromic catgut suture 183 
128. Purse string peritoneal sutures for shortening the mesocecum and fastening 
it to the lateral parietal peritoneum 184 
129. Purse string sutures tied, or being tied 185 
130. The purse string sutures fixing the ascending colon and suspending first half 
of transverse colon tied 186 
131. The incision of the fascia 188 
132. The flap of fascia raised and turned outwards 188 
133. The flap of fascia has been fixed to the anterior white line of the ascending 
colon, except at the hepatic flexure 189 
134. Typical “Midline Ptosis” 191 
135. Rovsing’s method of gastropexy 199 
136. Rovsing’s method of gastropexy ; 200 
137. Rovsing’s method of shortening the gastrocolic ligament 202 
138. X-ray picture of stomach of a man whose digestion is symptomatically perfect 
but whose stomach empties tardily 203 
139. X-ray picture of same subject as shown in fig. 138, taken one hour after 
bismuth meal 204 
140. X-ray picture of same subject as shown in fig. 138, taken six hours after 
bismuth meal 205 
141. X-ray picture of same subject as shown in fig. 138, taken ten and one-half 
hours after bismuth meal 206 
142. X-ray picture of same subject shown in fig. 138, taken twenty-two hours 
after bismuth meal 207 
143. Ptosis of the transverse colon with fixation to the ascending and descending 
colon 208 
144. Condition existing ten years after what seemed to have been rupture of the 
gastrohepatic ligament 209 
145. Condition existing ten years after seeming rupture of the transverse mesocolon 210 
146. Stomach in case 26, eight months after operation 212 
147. Colon in case 26, eight months after operation 213 
148. Colon in case 27 before operation 214 
149. Colon in case 27, seven months after operation 215 
150. Case 39 before operation 216 
151. Colon in case 39 before operation and ninety-six hours after bismuth meal . 217 
152. Shortening the falciform ligament 219 
153. Falciform ligament shortened 220 
154. Method of placing sutures in doing the “Hammock” operation .... 221 
155. Diagram illustrating the placing of sutures for shortening the gastrohepatic 
omentum and for suturing the great omentum to the abdominal wall in 
“Hammock” operation 222 
156. Scheme of combined Beyea operation and “Hammock” operation .... 223 
157. Complete Beyea operation and “Hammock” operation 224 ILLUSTRATIONS 
XIX 
FIGURE PAGE 
158. Results following combined Beyea operation and “Hammock” operation . . 225 
159. Both incisions closed with the colon in its restored position 226 
160. First stage of the development of the intestinal canal and the peritoneum seen 
from the side 230 
161. Second stage of the development of the intestinal canal and peritoneum seen 
from the front 231 
162. Normal position of intestine after rotation 232 
163. Diagrammatic picture of duodenal arteriomesenteric ileus 233 
164. Sagittal section showing how drag on superior mesenteric vessels obstructs 
third portion of duodenum 234 
165. Diagram showing mechanics of duodenal arteriomesenteric ileus and widely 
dilated duodenum 234 
166. Acute dilatation of stomach and duodenum after a Finney gastroduodenostomy 235- 
167. Duodenal obstruction causing vicious circle after gastroenterostomy for 
duodenal ulcer 242 
168. Great dilatation of first part of duodenum and pylorus as seen at operation 
in case 4 243 
169. Distended third part of duodenum in case 4, bulging into wound when trans- 
verse colon was thrown upwards 244 
170. Duodenojejunostomy . 250 
171. Duodenojejunostomy 251 
172. Duodenojejunostomy 251 
173. Duodenojejunostomy 252 
174. X-ray picture of giant duodenum and stomach of a child four years of age . 259 
175. Suturing together the free edges of the intestinal loop 266 
176. Fixation of the intestinal loop of peritoneum, aponeurosis and skin by 
chromic catgut doubled 267 
177. Sectional view of the fixed loop 267 
178. Delatour colostomy bag 268 
179. Gradual destruction of the septum between two limbs of loop with rubber- 
covered clamp 268 
180. Destruction of the intestinal mucous membrane which passes through the in- 
testinal wall, by use of the cautery 269 
181. Intestinal fistula after the cauterized area has healed 269 
182. Incision for freeing the fistula from the abdominal wall and separating the 
layers of the abdominal wall 270 
183. Fistula freed and layers of the abdominal wall separated ready for closing . 271 
184. Sectional view of the fistula freed and the layers of abdominal wall separated 
ready for closing 271 
185. Closure of the intestinal fistula 272 
186. Closure of the abdominal wall 272 
187. Cross-section showing how all the lines of sutures are enclosed in the silk- 
worm sutures 273 
188. Longitudinal section of the completed operation 273 
189. Diagram showing the method of ligaturing the mesentery of the large bowel 274 
190. Diagram showing how the ileum is grasped between two pairs of forceps 
preparatory to division 275 
191. The pelvis colon drawn up out of the pelvis and grasped by forceps for 
division in a similar way to fig. 190 276 
192. The running suture securing the peritoneal and muscular coats .... 277 
193. The apertures of the ileum and colon held apart by forceps .< . . . 277 
194. Suture joining the adjacent margins of ileum and colon 278 
195. Completion of the suture of the bowel 278 
196. Method of inserting the continuous seromuscular suture 279 
197. Final suture of the mesentery 280 
198. Vicious circle following cecosigmoidostomy for constipation . . . . . 281 
199. Correction of vicious circle by removal of the ascending and transverse colon 282 XX 
ILLUSTRATIONS 
FIGURE PAGE 
200A. Roentgenogram illustrating a prolapsed, dilated, atonic stomach .... 287 
200B. Roentgenogram of same stomach shown in fig. 200A 287 
201. Normal small intestines of subject of hyperasthenic habitus 291 
202. Photo of woman of hyperasthenic habitus 292 
203. Normal small intestines of subject of asthenic habitus 293 
204. Photo of woman of astenic habitus 294 
205. Extreme degree of hypertonicity of small intestines 295 
206. Extreme hypotonicity of small intestine as seen in markedly asthenic and 
debilitated persons 296 GASTRO-ENTEROPTOSIS GASTRO-ENTEROPTOSIS 
CHAPTER I 
STRUCTURE OF THE ABDOMINAL WALL 
We have been accustomed to look upon the wall encompassing the ab- 
dominal cavity as a very elastic structure. This is far from the truth, as will 
be shown by the study of anatomy. In the first place, more than one half of 
Fig. i.—Strong White Fascia of the Front Abdominal Wall. (Modified from Toldt.) 
this wall contains bony structures. Some of the most important abdominal 
organs, including the liver, spleen, duodenum, stomach and kidneys, are almost 
entirely within the bony abdominal walls. The pelvis is chiefly surrounded 
by bony structures, particularly in the back. For four inches in the back, the 2 
GASTRO-ENTEROPTOSIS 
spine makes a wall entirely inelastic. The eight inches of the center of the 
abdomen, which extends from the pubes to the arch of the ribs, is firm and 
inelastic, made so by the two layers of aponeurosis surrounding the recti 
muscles. From the point of fusion of these two layers of fascia at the linea 
semilunaris, there are other layers of fascia which surround the lateral muscles 
and fuse in the back to form the lumbar fascia, which is inelastic. 
Therefore for all practical purposes, we may state that the peripheral 
abdominal wall is a flexible structure, composed chiefly of flexible and elastic 
muscle inclosed in a flexible but nonelastic aponeurosis. While the wall is 
flexible to a large degree, it is collapsible only in its front portion. Except in 
chronic processes, such as the development of a tumor by cellular increase, the 
Fig. 2.—Cross-section of the Abdominal Wall. (Toldt.) 
Picture taken at its most flexible part—the upper surface of the fourth lumbar vertebrae. 
This shows the strong fascia which limits elasticity. 
development of a cyst, or ascites, which has behind it the contrant blood- 
pressure, or the development of pregnancy, there is but little change in the 
capacity of the abdomen of an otherwise normal person. Extreme distention 
of the abdomen may seemingly enlarge the abdominal cavity by pushing up 
the diaphragm at the expense of chest capacity. By elevation of the ribs, the 
girth of the upper portion of the abdomen will be increased, but the lower por- 
tion will be correspondingly diminished. Elevation of the ribs plus extreme 
distention of the abdomen makes tense the collapsible part of the abdominal 
wall and increases the girth of the abdomen at all points, but the only actual 
increase of abdominal capacity is made at the expense of chest capacity by 
elevation of the diaphragm (Figs, i and 2). CHAPTER II 
SHAPE OF THE ABDOMINAL CAVITY 
The shape of the abdominal cavity is wonderfully adapted to the holding 
of its contained organs with the least possible friction or effort, Many who 
have written on ptosis have failed to give proper credit to this point. We 
shall, therefore, go into details. 
The exact shape of the abdominal cavity was determined as follows: The 
body of a man who had died of pneumonia was used. The weight of the man 
Fig. 3.—Plaster Block Containing Cast of Abdomen. 
A-A, line drawn through appendix from center of perineum to point of shoulder. A-B, 
corresponding line on left side. (Sections along these lines represented in Figs. 4 and 5.) C, 
section through appendix shown in Fig. 8. E, section lower pole of kidney represented in Fig. 7. 
was about one hundred and forty pounds; height five feet, eight inches. The 
table on which the body lay was leveled. The front of the abdominal wall was 
removed. The stomach and all the intestines except the base of the cecum and 
the appendix were removed. The liver, gall-bladder, kidneys, ureter and 
bladder were left and a string was pinned along the course of the ureter so 
as to make it prominent in the plaster cast. The body was made perfectly 
level. The cavity was filled with liquid plaster of Paris. Two days later the 
body was cut off from the cast. The cast was then dried and painted with 
iodin to give it color, and was covered with several coats of shellac to make a 
3 4 
GASTRO-ENTEROPTOSIS 
line of cleavage. The flat, or abdominal, side of the cast was placed on the 
bottom of a box so that the highest point of the cast represented the deepest 
point in the flank. An inch of liquid plaster was poured in around the cast, 
at which time the stakes shown in Fig. 3 were set to mark the lines for saw- 
ing, after the cast had dried. On the right side a line (A) was made which 
would pass through the deepest point of the flank, the appendix, and the 
deepest part of the pelvis. This line would correspond to a line drawn from 
the center of the perineum to the tip of the shoulder. A corresponding line 
Fig. 4.—Anteroposterior Section through 
Pelvis, Appendix and Right Flank. 
Plumb line represents perpendicular psoas line. 
Fig. 5.—Anteroposterior Section through 
Pelvis, Psoas Muscle and Left Flank. 
Plumb line represents perpendicular psoas line. 
(B) was made on the left side. A cross line (C) was made to pass through 
the appendix transversely. Another transverse line (E) passed through the 
lower poles of the kidneys, and still another line through the upper poles of 
the kidneys. The box was then filled with plaster, making a block 7 by 16 
by 18 inches (Fig. 3). This was dried and then sawed along each line. As 
each section was cut, Trahar made an accurate tracing of the cavity, which is 
shown in the pictures in solid black. The plaster sections are here checked 
off in squares corresponding to one inch. 
By these pictures (Figs. 4 and 5) it will be seen that with the subject 
standing erect, if a plumb line were dropped from the diaphragm so that it SHAPE OF THE ABDOMINAL CAVITY 
5 
passed through the abdominal cavity at the point where the appendix is at- 
tached to the posterior wall, much more than one half of the space on that 
side of the median line would be back of the plumb line, which we shall, for 
the convenience of study, call the perpendicular psoas line. If another plumb 
Fig. 6A.—Diagram Showing Direction 
and Shelf of the Normal Ascending 
Colon. 
Arrows indicate direction of pressure pro- 
duced by the weight of superimposed 
organs. 
Fig. 6B.—Diagram Showing Pendulous 
Mobile Cecum Seen Where Rotation 
Is Not Complete. 
This also shows its effect in displacing the 
right kidney, to which it is attached. 
Arrows indicate direction of pressure caused 
by the weight of superimposed organs. 
line were dropped so as to pass along the front surface of the kidney, this 
line would be three inches back of the perpendicular psoas line and may be 
called the perpendicular kidney line. Another line one and one-half inches 6 
GASTRO-ENTEROPTOSIS 
further back would touch the back side of the kidney. The attachment of the 
hepatic and splenic flexures of the normal colon is external to the kidney and 
is even with its posterior surface. This attachment is four inches back of 
the perpendicular psoas line, and passes from the hepatic flexure forward to 
Fig. 7.—Cross-section of the Abdominal Cavity. 
Area in square inches at the lower pole of the kidney. 
the cecum or appendix at a fifty-one-degree angle (Figs. 6A and ioA). It 
will be noticed by observing these lines that fully two thirds of the right lobe 
of the liver is back of the perpendicular psoas line, so that the really heavy 
organs are found not to drag with a direct pull at all. In fact, the kidney 
Fig. 8.—Cross-section of the Abdominal Cavity. 
Area in square inches through the base of the appendix and the psoas muscles, the “ Psoas 
Outlet.” 
rests on a four-inch shelf which is heavily padded with fat. It is held back 
by the normal retroperitoneal connective tissue plus the fused mesocolon, 
with its two layers of peritoneum, connective tissue, blood-vessels, etc. There- 
fore, in a normal individual, there is not the slightest tendency toward pro- 
lapse of the kidney. The ascending colon lies on a shelf and is held there by SHAPE OF THE ABDOMINAL CAVITY 
7 
fusion with the parietal peritoneum. It would not, therefore, even in the 
absence of intra-abdominal pressure, hang as a dead weight, as shown in 
Figs. 6B and 10B. On the left side, the splenic flexure is held at a higher 
level and further back than the right, or hepatic, flexure. These organs are 
held on this shelf to a certain extent by the strength of the abdominal wall in 
Fig. 9.—Diagram Showing the Relative Position of the Various Parts of the Colon 
to the Median Line of the Abdomen. 
This is represented on a horizontal plane. The white line A, B, C, indicates the line of 
section necessary to show the relation of the colon to the anterior and posterior abdominal walls 
on an anteroposterior plane as seen in Fig. 10 A. 
front, much as if you had set a vessel on a shelf not quite wide enough to 
prevent it from falling off and had then nailed a strip in front of it. The 
weight held by the strip would correspond to the part played by the anterior 
abdominal wall in holding up the abdominal organs. The abdominal wall, 8 
GASTRO-ENTEROPTOSIS 
therefore, because of the shape of the abdominal cavity, becomes an element 
in holding the organs in position. In a normally well-developed man standing 
erect, a plumb line from the tip of the shoulder-blade should just about touch 
the buttocks. Opposite the lower lumbar vertebrae there should be a concavity 
in the back amounting to two or three inches. If an anteroposterior section 
is made through the flank of a normal man so as to strike the edge of the 
Fig. ioA.-—Normal Relation of the Various Parts of the Colon to the Anterior and 
Posterior Abdominal Walls. 
This is obtained by straightening the line A, B, C, in Fig. 9. 
kidney, the base of the appendix, and the edge of the pelvis, the section of the 
abdominal cavity when looked at from the side is almost exactly the shape of 
a pear, the upper end corresponding to the large end of the pear, and the 
lower end, ceasing at the appendix, corresponding to the stem end of the pear. 
The pear, instead of standing erect on its small end, leans far back and rests 
on an inclined plane. It will be noted that the abdominal wall at the larger 
Fig. ioB.—Relation of the Various Parts of the Colon to the Anterior and Posterior 
Abdominal Walls Seen in an Anteroposterior Plane in a Case of General 
Ptosis. 
Note that the flexures are pulled out of the flanks and the kidneys are dragged out with them. 
end near the diaphragm is very thin posteriorly, while the abdominal cavity is 
correspondingly large at this point, as indicated by a cross section at the lower 
pole of the kidney, which represents a cross section of the plaster cast. The 
area of this cross section covers 44 square inches (Fig. 7). At the base of 
the appendix the posterior abdominal wall is several inches thick. This thick- 
ness is produced by the curving forward of the spinal column at this point, 
and the crossing of the psoas muscles from their attachment to the vertebral 
column in the iliac fossa. This line we call the transverse psoas line. The SHAPE OF THE ABDOMINAL CAVITY 
9 
area of the cross section of the abdominal cavity at the front of the crossing 
of the psoas muscle, which we have called the “psoas outlet” of the abdomen 
(Fig. 8), is 14 square inches. In other words, the abdominal cavity is more 
than three times as large at the lower kidney line as it is at the transverse 
psoas or appendix line. The psoas muscles make a very abrupt shelf. On 
this padded shelf the kidney, ascending colon, and a large portion of the liver 
rest. On the left psoas shelf the descending colon, left kidney, spleen and 
stomach rest. It will thus be seen that nearly all the heavy organs are located 
so that they rest principally on these shelves. The main reservoir of the 
stomach, the cardiac end, rests back in the left flank. The middle pyloric 
portion of the stomach and the transverse colon are the two notable exceptions 
to this rule. These organs must depend entirely on the direct suspensory 
supports, and upon the intra-abdominal pressure. Hence, their great tendency 
to prolapse independently. CHAPTER III 
SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 1 
It is often quite puzzling even to the doctor, unless a good deal of study 
is given, to understand fully the relation of the peritoneum to the various 
organs. I have used the following homely illustration: 
A chamber or room is built and lined with cloth. The cloth is held to the 
walls, ceiling and floor by a network of elastic threads, the meshes of which 
are arranged in the form of diamonds or squares. In the ceiling of the cham- 
ber there are three openings through which three bodies are suspended with 
strings. Through the first opening a solid object, which we may designate 
as object No. i, is suspended by a short string which barely allows it to go 
through the wall into the network. Through the second opening a solid body, 
which we may designate as object No. 2, is allowed to drop and push ahead 
of it a fold of the lining to such an extent that the lining and network of 
threads fall in behind it around the string. Through the third opening a 
hollow body, which we may designate as object No. 3, is dropped and is 
allowed to fall for a long distance, carrying the lining in front of it after 
which the lining and the mesh work of threads close in around the string. 
In the floor, there is a fourth opening through which a hollow body is pushed 
upwards. In front of it is pushed the lining. The lining and network fall in 
around the inserted hollow body. 
Object No. 1 does not come in direct contact with the lining. It cor- 
responds to the kidneys in relative position. In the instance of object No. 2, 
the cloth is glued to its surface and corresponds in its relative position to 
the covering of the liver. In the instance of object No. 3, which is a hollow 
body, the cloth has been glued to its surface and corresponds in relative posi- 
tion to the peritoneal covering of the gastro-intestinal tract. In object No. 4, 
which is a hollow body pushed up from the bottom, the lining membrane is 
glued to its surface part way and corresponds in relative position to the 
peritoneum covering the pelvic organs. The position of the string in case 
of the suspended bodies corresponds to the nerves, blood-vessels and lym- 
phatics which are distributed to these various organs. The network of 
threads arranged in diamond meshes correspond in relative position to the 
connective tissue outside the peritoneum. If these meshes are filled with 
some soft padding like cotton, the spaces between the layers of the fold of 
cloth pushed inward by objects Nos. 2, 3 and 4 will become very much 
widened and at the same time shortened. The cloth-lining, instead of hang- 
1Surg.J Gynec. and Obst., October, 1912, 365-429. 
10 SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
11 
ing laxly down beside the wall, would stand out for some distance from the 
wall and would assume the appearance of a cushion. All the space occupied 
by this stuffing would diminish the clear capacity of the room inside the 
lining by just so much. This padding corresponds in relative position to the 
intra-abdominal fat. 
In order to animate this illustration, let us state it in another way. The 
abdominal cavity is lined by peritoneum held to the wall by elastic connective 
tissue. Let us imagine that the germinal nuclei for development of the 
abdominal organs, including the kidneys, liver, gastro-intestinal tract and 
Fig. ii (Left).—Diagrammatic Repre- 
sentation of Fat Cells. 
These have been thrown into the shape 
of diamonds for the purpose of illustration. 
Diamond meshes filled with fat. Red lines 
indicate peritoneum. 
Fig. 12 (Right).—Collapsed Diamond after 
Absorption of Fat. 
This shows increase in length of mesenteries. 
White space shows increase of intra-abdominal 
space by absorption of fat. Red lines indicate 
peritoneum. 
genital organs, have been placed at various locations within the abdominal 
cavity just outside the peritoneum and have begun to develop and increase 
in size. The kidney grows in size but does not grow inward. The liver 
grows extensively and pushes in front of it a fold of peritoneum which be- 
comes an attached covering and helps to form Glisson’s capsule. The gastro- 
intestinal tract grows and pushes a fold of peritoneum inwards for a long 
distance. The peritoneum grows firmly to the surface of the gastro-intestinal 
tube. The pelvic organs grow upwards and push the bottom of the peritoneal 
lining upwards. In the female, the peritoneum grows fast to the fundus 12 
GASTRO-ENTEROPTOSIS 
and surfaces of the uterus and falls in folds over the round ligaments. 
Connective tissue has been pulled inward along with the peritoneum to which 
it is attached. The meshes of this network have all been filled in with fat. 
All the space occupied by fat diminishes the net capacity of the abdominal 
cavity within the peritoneal sac by just so much (Figs, n and 12). 
The sole suspensory support of the abdominal organs, aside from the 
problematical support afforded by blood-vessels and nerves, comes from 
the peritoneal layers of the mesenteries supplemented and supported by 
extraperitoneal connective tissue. The strength of these suspensory sup- 
ports is increased by the filling and spreading out of the meshes with fat 
which doubtless acts in a mechanical way by holding the force at different 
angles corresponding to the direction of the fibers, producing much the same 
effect as the fabricated small pieces of steel arranged at different angles, 
hold together two stronger pieces of steel in the construction of one of the 
main supports of a bridge. Engineers have found that such an arrangement 
gives much greater strength in proportion to the amount of steel used. 
By the above description, it will be seen that the abdominal organs are 
all extraperitoneal. This description corresponds to the arrangement of the 
mesenteries and peritoneum in the quadruped. As was shown in the second 
division of this chapter, the abdominal cavity is oblong. With the quadruped 
standing in a horizontal position, the organs are all suspended from just 
beneath the spinal column. This has been modified in the human being by 
the fusing together of certain peritoneal surfaces with the apparent purpose 
of fixing certain organs in preparation for assuming an erect position in 
which the oblong abdominal cavity stands on end. 
Huntington’s 2 book throws more light on the subject than any other pub- 
lication which has come into my hands. In this book the author has taken up 
his study from the standpoint of comparative anatomy and embryology. In 
his introduction he says: 
“In considering the anatomy of the human abdominal cavity and peri- 
toneum in the following stages, the explanation of the adult conditions 
encountered is based upon the development of the parts, and the successive 
human embryonal stages are illustrated by the examination of the lower 
vertebrates, presenting permanent adult structural conditions, which appear 
as merely temporary embryonal stages in the development of the higher 
mammalian alimentary tract.” 
In studying the abdominal cavity from the standpoint of comparative 
anatomy, by this method we find that in man the liver has fused with the 
diaphragm, while in the quadruped it is in the same way, as other organs, 
suspended by a mesentery. In man the duodenum is firmly fixed to the right 
abdominal wall, while in the quadruped it is freely movable. In man the 
ascending and descending colon and the two flexures are normally fixed to 
the posterior abdominal wall without the intervention of mesentery, while 
2 Anatomy of the Peritoneum and Abdomen, Lea Brothers, Philadelphia, Pa. SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
13 
in the quadruped the large intestine has a long mesentery, and is therefore 
freely movable. In man the great omentum grows down over the transverse 
colon and adheres to it. This does not occur in the quadruped. In man the 
omental bursa is usually obliterated by adhesion of its layers together. 
Obliteration does not take place in the quadruped. In man the pancreas 
has been rotated behind the peritoneum and fixed to the abdominal wall. 
In quadrupeds the pancreas lies between the layers of the mesentery. In 
Fig. 13.—Portions of Alimentary Canal Fixed by Prenatal Adhesion or Fusion. 
Movable or pendulous portions of canal have been removed. Red lines represent cut peri- 
toneal edges. Section of intestine made at junction of fixed and movable portions represent 
points where kinking may take place in certain cases of ptosis. Arrow passes through foramen 
of Winslow. Red lines indicate peritoneum. 
the monkey, which is a quadruped with a tendency to stand erect, the pan- 
creas becomes adherent and the duodenum is more firmly fixed than in the 
original quadruped (Fig. 13). 
A question which confronts us is, Why these differences between the 
animals walking on four legs and those walking erect? I believe these 
prenatal fixations by adhesion or fusion in the erect animal are without doubt 
for the purpose of holding the organs in their places, thus to prevent them 14 
GASTRO-ENTEROPTOSIS 
from piling up in the bottom of the abdominal cavity by gravity when its 
long diameter is perpendicular. 
In the lower forms of animal life, notably certain forms of fish, the 
alimentary canal is a simple straight tube. The capacity for variety of 
accomplishment and predomination of an animal is apparently dependent 
upon versatility of action which in turn calls for a variety of food. This 
necessitates a more complex alimentary canal in higher forms of animal 
life. In man the alimentary canal becomes a series of successive primitive 
canals, such as just referred to as existing in the lower forms of fish, arranged 
end to end, each performing an entirely different function and digesting a 
different kind of food. The mouth has an alkaline secretion and digests a 
certain small portion of the food. The bulk of the food is then passed on 
to the second section, the stomach, which has an intensely acid secretion and 
digests entirely different substances and breaks up other substances into a 
fine emulsion. This is passed into the third section, the duodenum, which 
receives pancreatic juice and other alkaline secretions and digests and further 
prepares the food just received from the stomach. The fourth section, the 
small intestine, absorbs most of the concentrated food products but passes 
a great part of the fluid bulk of the intestinal contents to the fifth part of the 
intestinal canal, the cecum. This is the great renovator and picks up certain 
valuable food products, including the water, which have passed through the 
small intestine without absorption, carefully separates them from nonnutritive, 
indigestible substances which are here destroyed or made inert by bacterial 
action and passes the waste on to the sixth part of the intestinal canal, the 
descending colon, sigmoid and rectum. 
In the simpler forms of animal life all these functions are performed in 
the one straight tube. In other words, the primitive animal may be likened 
to the pioneer life when each family grew its own food and raiment and 
prepared it for use independent of cooperative action. The great advantage 
of cooperation in business and in professional life, made known to us in 
recent years, is but the carrying out of the scheme that nature has adopted 
in the human alimentary canal. 
Between the lower fish, with its straight tube, and man, with his complex 
aggregation of digestive tubes, there is an infinite number of gradations, 
depending upon the kind of food consumed. Certain animals which are 
close companions of man, such as the dog and the hog, have adopted to a 
certain extent man’s diet. This is particularly true of the hog, who is man’s 
scavenger and therefore eats almost all the varieties of food that man eats. 
His alimentary canal is very similar to man’s. The alimentary canal of a 
dog is quite similar. By having several tubes combined in one, its length is 
correspondingly increased and it becomes necessary for the intestines to 
curve and assume certain positions in conformity to the cavity in which they 
are held. This process of acquired conformity is often referred to as rota- 
tion. While the various parts of the alimentary tract of the quadruped 
rotate into, assume, and permanently occupy, a definite position in the abdomi- 
nal cavity, they are by no means fixed in this position but hang from the SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
15 
spinal column suspended by the dorsal mesogastrium. The position of the 
organs thus assumed in the dog is made permanent in man and fixed by a 
process of prenatal adhesion or fusion. 
In Huntington’s introduction he says: 
“For the sake of clearness and brevity all discussion of the theories of 
peritoneal development has been designedly omitted. The assumption of 
peritoneal adhesion and consequent obliteration of serous areas offers many 
advantages in considering the adult human abdominal cavity, especially from 
the standpoint of comparative anatomy. The same has consequently been 
adopted without reference to divergent views and theories.” 
Fig. 14.—Repair Following Intestinal Union. (Modified from Barbat.) 
Dotted lines indicate obliterated peritoneal areas which have fused as a result of being 
held together by sutures. 
In the early fetal development of man, after the intestinal canal has 
become elongated and has adjusted itself, some of the primitive peritoneal 
surfaces coming in contact adhere to each other. The fibrous structures of 
peritoneum become intimately interlaced and actual fusion takes place such 
as takes place in the adult peritoneum when two peritoneal surfaces are held 
firmly together in an aseptic state (Figs. 14, 15, 16). What biological con- 
dition prevails in the development of the human fetus which causes these 
certain contiguous surfaces to fuse, while they do not fuse in the quadruped, 
apparently has not been satisfactorily explained.. 
In order to understand thoroughly these processes of rotation and fixation, 
it is necessary to review the embryo from the time of conception. As soon 
as the ovum has been fertilized by the spermatozoa, the cells begin to arrange Fig. 15.—Result Following Suturing of Pig’s Omentum to Abdominal Wall. 
This shows perfect blending. 
Fig. i 6.—Blending of Peritoneum of Liver to Abdominal Wall. 
Specimen removed from pip:. SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
17 
themselves in characteristic divisions which later are to play an important 
part in the formation of the various structures of the body. 
The principal divisions are the ectoderm, from which the skin and spinal 
canal are formed; the entoderm, from which the lining of the alimentary 
canal is formed; and the mesoderm, from which bones, muscles, ligaments, 
etc., are formed. The entoderm, which at first has a direct connection with 
the yolk sac, very early fuses and the yolk sac disappears, leaving the straight 
intestinal tube seen in the early fetus and in lower animals. In the mesoderm, 
two lateral cavities form, which later become the serous cavities of the 
body. In the abdominal part of the fetus, the space on each side of the 
Fig. 17.—Curves of Blastodermic Layers and Division of Mesoderm in 
Amniote Embryo. (Kollman.) 
intestinal canal is known as the ccelom. This is soon lined by a membrane 
which is later known as the peritoneum. These spaces extend from the back 
to the front of the body of the fetus. Between the two spaces lies the in- 
testinal tube (Fig. 17). That part of the mesoderm between these two body 
cavities is gradually absorbed except such as is necessary to develop the 
muscular wall of the alimentary canal and the two lining membranes. Thus 
the intestinal canal lies between the two layers of the membranous partition 
which extends from the primitive spinal column to the primitive anterior 
wall of the fetus (Fig. 18). That part of the partition in front of the 
primitive alimentary tract is known as the ventral mesogastrium. That part 
of the partition lying back of the primitive alimentary tract is known as the 18 
GASTRO-ENTEROPTOSIS 
dorsal mesogastrium. Between the layers of the ventral mesogastrium, the 
liver with its ducts develops, while between the layers of the dorsal meso- 
gastrium, the pancreas and spleen develop (Figs. 20 and 21). (A cross sec- 
tion in the line X-Y, Fig. 21, through the duodenum and the pancreas is repre- 
sented in two stages in Figs. 19 and 22.) The liver in the fetus is a very large 
organ. It rapidly develops between the membranes of this partition and 
expands in all directions, thus taking up the slack of the ventral meso- 
gastrium and thereby shortening it. The duodenum is drawn upwards and, 
as the alimentary canal develops, the stomach begins to grow backward 
between the layers of the dorsal mesogastrium and forms a curve (Fig. 21). 
At this stage of development it will be noted that the lesser curvature of 
i8 
Fig. i8 (Left).—Mesogastrium in Early Life. (Huntington.) 
Fig. 19 (Right).—Vertebrae Mesentery or Dorsal Mesogastrium before Development 
of the Pancreas. (Kollman.) 
Illustrated by schematic diagram. 
19 
the stomach is directed toward the primitive abdominal wall while the greater 
curvature is directed toward the spine. As the stomach and intestine in- 
crease in length, their relations must of necessity be changed. The duodenum 
rotates to the right (Fig. 23) until it comes in contact with the parietal 
peritoneum on the right side where the contiguous surfaces fuse, as indicated 
in Fig. 24. This rotation of the duodenum to the right and to the back 
must necessarily twist that part of the ventral mesogastrium which extends 
from the liver to the stomach a half turn on itself. At the same time the 
stomach changes its relations. The dorsal mesogastrium elongates (Fig. 
25) and this allows the stomach to change its position so that it rotates 
and slides toward the left side. That which was originally the left sur- 
face of the stomach now becomes the anterior surface and the greater SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
19 
curvature which was directed toward the spinal column is now directed to 
the left and downward (Fig. 26). That portion of the anterior meso- 
gastrium between the liver the stomach, instead of being parallel to the 
perpendicular axis of the liver, now becomes parallel to the transverse or 
horizontal axis of the liver and its name is changed to the gastrohepatic 
omentum or ligament. The large intestine, with its mesentery, which is a 
part of the dorsal mesogastrium, moves upward to the right and downward, 
stopping at the position indicated in Fig. 27, and settles back in contact 
with the posterior parietal peritoneum. The small intestine, which was 
Fig. 20.—Ventral Mesogastrium with Developing Liver. (Modified from Huntington.) 
Schematic profile view. 
primarily on the right side of the body, now shifts to the left side. The 
peritoneum of the colon and its mesentery of the right side of the body and 
on the left side of the body comes in contact with the parietal peritoneum 
and the contiguous surfaces blend (Figs. 28 and 29). Thus that portion 
of the back of the abdominal cavity represented by the ascending and descend- 
ing mesocolon is lined not only by the primitive parietal peritoneum seen in 
quadrupeds but by all the elements of the mesentery of the colon as well. 
The ascending and descending colon, along with the kidney, have during 
this process become partially retroperitoneal organs. A part of the transverse 
mesocolon fuses with the parietal peritoneum and with a portion of the 20 
GASTRO-ENTEROPTOSIS 
anterior surface of the duodenum (Figs. 30 and 31). Thus the duodenum 
has two fused layers of peritoneum behind it and two fused and one unfused 
layer in front of it at its lower portion. Fig. 32 shows the normal rela- 
tions of the duodenum, kidneys, colon and mesentery with the small intestine 
removed. (The cross section at the line P-Q, Fig. 32, corresponds to 
Fig. 29.) The transverse mesocolon adheres only in part to the parietal 
peritoneum. The transverse colon is suspended by its mesentery from the 
fused areas (Fig. 31). It is therefore freely movable and pendulous. 
While these processes of rotation and fixation are taking place, the great 
omentum, as seen in Figs. 27 and 33, is growing down over the colon where 
Fig. 21.—Relation of Liver, Stomach, and Pancreas to the Mesogastrium Just before 
Rotation. (Modified from Huntington.) 
its posterior peritoneal surface adheres to the peritoneum of the colon and 
mesocolon, and gives the colon two more fused layers of peritoneum for a 
support (Fig. 34). As a further support to the transverse colon, the omental 
bursa normally becomes obliterated by the adhesion of its contiguous peri- 
toneal layers, as shown in Fig. 35, thus giving two more supporting peritoneal 
layers by the formation of the gastrocolic ligament. In the dog, cat and 
other quadrupeds, the kidneys lie behind the one layer of peritoneum, as 
shown in Fig. 36, and may be picked up and almost pulled out through an 
abdominal incision. This is made impossible in the human being by the 
additional support of the fused mesocolon with the parietal peritoneum. Fig. 22.—Free Mesoduodenum in 
Sagittal Plane. 
This includes head of pancreas between 
right and left layers before rotation. 
Diagram corresponds to a section at the 
line X-Y in Fig. 21. Red lines indicate 
peritoneum. 
Fig. 23.—Mesoduodenum Folded to the 
Right. (Redrawn from Huntington.) 
Left leaf has become ventral; right 
dorsal, directed toward primitive prerenal 
parietal peritoneum. Red lines indicate 
peritoneum. 
Fig. 24.—Fixation of Head of Pan- 
creas and Duodenum under Cover 
of Secondary Parietal Peritoneum. 
(Redrawn from Huntington.) 
This is done by adhesion of opposed 
surfaces of mesoduodenum and primitive 
parietal peritoneum. Red lines indicate 
peritoneum, dotted red lines indicate 
obliterated peritoneal layers. 
Fig. 25.—Transposition of Stomach 
to the Left with Beginning Elon- 
gation of Dorsal Mesogastrium. 
(Redrawn from Huntington.) 
This diagram corresponds to a 
cross-section of Fig. 26 at the line X- Y. 
Red lines indicate peritoneum, dotted 
red lines indicate obliterated peritoneal 
layers. GASTRO-ENTEROPTOSIS 
22 
Huntington has drawn a diagram (Fig. 38) which shows the alimentary 
canal of the cat rotated into the position of the human alimentary canal. In 
case these organs were fused in the position shown, their relation would be 
represented in Fig. 39, which is not very different from the human, except 
that the liver is suspended by a mesentery in the cat, instead of being fused 
with the diaphragm as is seen in man. 
Fig. 26.—Schematic Ventral View of Stomach, Duodenum, and Dorsal Mesogastrium. 
(Modified from Huntington.) 
Taken after rotation of stomach and extension of omental bursa caudad beyond greater 
curvature of stomach. The ventral mesogastrium is detached along the lesser curvature. A, 
location of hepatic duct. B, portal vein. C, hepatic artery. D, gastroduodenalis artery. 
E, pyloric artery. 
In summing up the peritoneal supports of the various organs anatomically, 
we find that in normal man the liver has actually fused with the diaphragm 
at its back side. The free margin is supported at its middle by the part of 
the primitive ventral mesogastrium which remains in the form of the falci- 
form ligament. The pancreas is entirely retroperitoneal. The stomach is 
suspended from above by the esophagus and gastrophrenic ligament by which 
supports it is very firmly anchored. Its main body is located to the left of SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
23 
the median line in an almost vertical position with its lower margin above 
the umbilicus, in a patient reclining; but just below the umbilicus in a patient 
standing, as indicated by X-ray pictures of normal stomachs. The body of 
the stomach is suspended from its lesser curvature by a double layer of 
rather frail peritoneum (the gastrohepatic omentum of ligament). After 
passing the median line the pyloric end of the stomach rises slightly until 
Fig. 27.—Semidiagrammatic Representation of Peritoneal Membrane in Human Embryo. 
(Modified from Kollman.) 
Rotation or transposition is taking place preparatory to fixation or peritoneal fusion. 
the junction of the first and second parts of the duodenum has been reached. 
Here is found what may be termed the folded edge of the primitive ventral 
mesogastrium. Between the layers of this folded edge are found (Fig. 26): 
first, the common bile duct, which is intimately connected with the liver 
by its many branches at one end and is firmly inserted into the second portion 
of the duodenum at the other; second, the portal vein, which is fixed to the 
stomach and duodenum by branches coming to it from this organ and is Os 
to 
00 
N 
o 
to 
Fig. 28.—Peritoneal Arrangement before Fixation. (Redrawn from Huntington.) 
Scheme shown in transection of infracolic compartment of abdomen before fixation of 
ascending and descending colon. Red lines indicate peritoneum. 
Fig. 29.—Peritoneal Arrangement after Fixation. (Redrawn from Huntington.) 
Scheme shown in transection of infracolic compartment of abdomen after fixation of ascending 
and descending colon. Red lines indicate peritoneum, dotted red lines indicate fused or obliterated 
peritoneal layers. Section corresponds to line P-Q in Fig. 32. 
Fig. 30.—A Sagittal Section through the Right Kidney and Descending Duodenum 
before Adhesion of Latter to Parietal Peritoneum. 
Red lines indicate peritoneum. 
Fig. 31.—Adhesion of Mesocolon to Duodenum and Primitive Parietal Peritoneum, 
Resulting in Formation of Root of Transverse Mesocolon. (Redrawn from 
Huntington.) 
Red lines indicate peritoneum, dotted red lines indicate obliterated peritoneal layers. SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
25 
fixed at its upper end to the liver by penetrating it and distributing branches 
to all parts of this organ; third, the hepatic artery, which coming from the 
celiac axis distributes its branches to the entire body of the liver and is 
thereby firmly fastened at its upper end; fourth, the gastroduodenalis artery, 
a branch of the hepatic artery, divides itself into two branches, one penetrat- 
ing and disseminating its minute branches to the duodenum and the other, 
the gastro-epiploica dextra, which by anastomosing with the gastro-epiploica 
sinistra sends branches to both surfaces of the greater curvature of the 
Fig. 32.—Relation of Duodenum and Kidneys to the Colon and Mesocolon in the 
Normal Individual 
stomach; fifth, the pyloric is given off from the hepatic artery and runs 
along the lesser curvature of the stomach where its branches penetrate both 
walls. All of these structures at the junction of the first and second portions 
of the duodenum are vital structures and are therefore permanent and con- 
stant and probably contribute to the establishment of the second permanently 
fixed point of the alimentary canal, the first point being the esophageal end 
of the stomach. The fixed supports, which include these structures, pass in 
front of the foramen of Winslow, through which the arrow passes in Fig. 13. 26 
GASTRO-ENTEROPTOSIS 
The duodenum, from this point to the ligament of Trietz, is chiefly a retro- 
peritoneal organ and is held back by prenatal fusion of its peritoneum with 
the primary parietal peritoneum and later by the fusion in front of it of a 
part of the transverse mesocolon, also by the crossing over it of the superior 
mesenteric vessels. Its last portion is fixed by the so-called ligament or 
muscle of Trietz. From the ligament of Trietz to a point near the ileocecal 
Fig. 33.—Diagram of the Formation of the Great Omentum. (Redrawn from Sobotta). 
Peritoneum is red and walls of the bursa omentalis are shaded. Dotted red lines indicate 
fused or obliterated peritoneal layers. 
valve, the mesentery of the small intestine is long enough to allow consider- 
able freedom of motion. Near the ileocecal valve it becomes decidedly 
shortened. The cecum and ascending colon, with its mesentery, is fused 
with the parietal peritoneum on the posterior wall and right side of the 
abdominal cavity. Its lower end comes to a point where the psoas magnus 
muscle crosses diagonally from the spine to the iliac fossa. Its peritoneum 
has fused with the right and lateral parietal peritoneum up to a point cover- SUSPENSORY SUPPORTS OF THE ABDOMINAL CAVITY 
27 
ing the lower third of the right kidney. According to Longyear, very strong 
fibers attach the upper end of the ascending colon to the kidney. From the 
hepatic flexure, the colon swings, somewhat sagging, across the abdomen 
to a higher point on the left lateral and posterior wall, where it is fixed by 
a very firm fusion (the costocolic ligament) and is supported by the gastro- 
splenic ligament. This is, therefore, a very firmly suspended point of the 
alimentary canal. The transverse colon is suspended by its mesentery and 
34 
35 
Fig. 34 (Left).—Normal Arrangement of Human Peritoneum and Omental Bursa 
(Infantile Stage). 
Omental bursa not obliterated. Dotted red lines indicate fused or obliterated peritoneal 
layers. Red lines indicate peritoneum. 
Fig. 35 (Right).—Normal Arrangement of Adult Human Peritoneum. 
This shows obliteration of omental bursa and formation of gastrocolic ligament. Dotted 
red lines indicate fused or obliterated peritoneal layers. Red lines indicate peritoneum. 
by the gastrocolic omentum or ligament. The descending colon, beginning 
far back in the left flank, has fused with the lateral and posterior parietal 
peritoneum for from three to six inches, and thereby becomes a retroperitoneal 
organ and firmly fixed. The sigmoid flexure begins just above the crossing 
of the psoas muscle and has a long mesentery. After forming a fan-shaped 
loop twelve to eighteen inches long, it returns to the left iliac region and is 
again attached to the pelvic wall just below the psoas muscle. 36 
Fig. 36.—Schematic Sagittal Section of Dorsal Mesogastrium and Omental Bursa in 
Man and Monkey. (Redrawn from Huntington.) 
Taken before peritoneal fusion has taken place. Red lines indicate peritoneum. 
37 
Fig. 37.—Area of Adhesion between the Dorsal Mesogastrium and Primitive Parietal 
Peritoneum in Monkey. (Redrawn from Huntington.) 
Red lines indicate peritoneum. 
Fig. 38.—Schematic Sagittal Section of Abdominal Viscera of a Cat. (Redrawn from 
Huntington.) 
Taken after the intestines have been rotated to correspond to the adult human position, to 
show lines of peritoneal reflexion before adhesion. 
Fig. 39.—Peritoneal Arrangement Which Would Be Produced by Rotation and Fusion 
of the Viscera of a Cat in the Position Corresponding to the Human. 
(Redrawn from Huntington.) CHAPTER IV 
INTRA-ABDOMINAL AND INTRAVISCERAL PRESSURE1 
In the foregoing chapter, speaking abstractly, we have been studying a 
chamber in which is suspended certain objects. We have learned that the 
walls of this chamber are partially flexible but nonelastic. The capacity of 
the chamber itself cannot be materially changed. In this chamber, we have 
suspended a number of objects, some solid, some hollow. These objects 
have been suspended in several ways: first, by cords, then by membranes, 
and finally by a meshwork of elastic cords or fibers. The meshwork is 
normally filled with a substance which, it is believed, aids in the support of 
the objects. All of these objects and their supports take up space and 
diminish the aggregate amount of space in the chamber by the amount of 
space thus occupied. Up to this time, we have presumed that the chamber 
is filled with normal atmospheric pressure. Therefore, the entire weight of 
the objects must be carried by the supports enumerated. We have failed, 
however, to take into consideration the very important fact that we are deal- 
ing with a closed chamber which, while not necessarily a vacuum, is air-tight 
and is therefore adapted to the development of various degrees of pressure. 
I have made an interesting experiment as follows: An ordinary suction 
apparatus, connected with a water faucet by a rubber tube, which in turn 
is connected with an aspirating bottle by a T connection, tends to create a 
vacuum in the bottle, provided the distal end of the horizontal portion of 
the T is closed. If it is not closed, the air is drawn directly through the 
tube from the outside, and the air in the bottle remains in a state of 
equilibrium. If a very thin rubber bag is suspended in the bottle by a hollow 
tube passing through the cork and connecting the bag with the outside 
atmosphere, the air within the bag and within the bottle remains in a state of 
equilibrium so long as the distal end of the T connection remains open 
(Fig. 40 A). If this distal portion of the T connection is closed by forceps 
(Fig. 40 B), suction at once begins to reduce the pressure within the jar 
and thus tends to make a vacuum. Immediately the atmosphere rushes into 
the inclosed, suspended rubber bag and distends it in proportion to the degree 
of vacuum thus produced in the jar. 
Thus, a law analogous to the law of osmosis can be formulated as 
follows: If a thin, elastic container with an outside connection for a source 
of supply of fluids or gases is inclosed within an inelastic container, there 
is a constant tendency to establish an equilibrium of pressure. For example, 
1Journ. Am. Med. Assoc. (Butt, n), September 19, 1917, 69:683. 
29 30 
GASTRO-ENTEROPTOSIS 
if a portion of the contents consisting either of gas or of other substance is 
withdrawn from the outside inelastic container, the pressure on the outer 
surface of the elastic container is reduced, and a corresponding inflow of 
contents is brought into the elastic container from the outside for the purpose 
of establishing an equilibrium. 
We do not know the amount of intra-abdominal pressure. It no doubt 
varies under different circumstances. We know by the law of specific 
gravity that, if a body heavier than water is suspended in the water, its 
weight is diminished in proportion to the weight of the water displaced. It 
may be stated that a similar law probably holds good within the abdomen, 
in that the portion of the weight of the organs, which is borne by their 
suspensory supports, is diminished in proportion to the amount of intra- 
Fig. 40.—Experiment to Illustrate the Relation of Intra-abdominal to Intravisceral 
Pressure. 
A, air in jar and in bag in state of equilibrium; suction not operative on contents of jar. 
B, pressure in jar being reduced by suction apparatus, showing inrush of air and distention of 
rubber bag in the effort to reestablish equilibrium. 
abdominal pressure. As far as I know, the estimates which have been made 
are purely arbitrary. On one extreme, some believe that practically all the 
weight is maintained by intra-abdominal pressure while on the other extreme 
some believe that intra-abdominal pressure has no influence. Most conserva- 
tive estimates based upon facts obtainable are that about one eighth of the 
weight of the abdominal organs and their contents is held up by the sus- 
pensory supports and seven eighths by intra-abdominal pressure. It is prob- 
able that most of this seven eighths of support attributed to intra-abdominal 
pressure is in reality borne by the psoas shelf and the intra-abdominal pres- 
sure made potent by the anterior abdominal wall. These organs are held on 
this shelf in much the same way as if one had set a vessel on a shelf not 
quite wide enough to prevent it from falling off and had then nailed a strip 
in front of it. The degree of intra-abdominal pressure depends on the INTRA-ABDOMINAL AND INTRAVISCERAL PRESSURE 
31 
variable contents of the abdominal cavity. The variable contents are: (i) 
extraperitoneal and mesenteric fat; (2) the visceral contents. The visceral 
contents are liquids and gases and may he intermittently expelled at any 
time, thus acting as an immediate safety valve for the establishment of an 
equilibrium and a normal intra-abdominal pressure. The extraperitoneal 
and mesenteric fat is included within the inelastic abdominal wall, and lessens 
the abdominal cavity in exact proportion to the amount of fat thus included 
(Figs. 41 a and b). 
The law that we have just stated as to interchange of forces between 
cavities has its counterpart in the relation of intra-abdominal and intra- 
visceral pressure. 
Referring back to the law which we have stated and applying it to the 
abdomen, we may state that the abdominal wall is the outside, inelastic con- 
tainer, and the hollow viscera represent the inside, elastic container, with the 
outside source of supply through the mouth in the form of food. Within 
and partially filling the abdominal cavity is a variable quantity of fat. Intra- 
abdominal fat is apparently deposited under much lower pressure than are the 
cells of a tumor, pregnant uterus or ascitic fluid. The deposition of fat, 
therefore, within the abdominal cavity does not materially stretch the abdomi- 
nal wall in a normal person. However, it is sufficient to increase the size 
of an already existing umbilical or postoperative ventral hernia. 
If a large umbilical or postoperative ventral hernia exists for a long 
time in a fat patient, intra-abdominal fat is deposited in proportion to the 
extra-abdominal contents which have escaped from the abdominal cavity into 
the hernial sac, making it difficult, and at times impossible, to replace the 
hernial contents without removing some of the abdominal contents, such as 
the great omentum. 
A patient who has been moderately fat (Fig. 42) for some reason loses 
flesh; the fat in the abdomen is correspondingly absorbed. The intra-abdomi- 
nal pressure is lowered, and there is tendency to a gradual, atonic dilatation 
of the hollow viscera in establishing an equilibrium. Digestion is disturbed, 
bowel action becomes torpid, and all of the secretions are below par. The 
patient often develops into that low state of health ordinarily referred to 
as “asthenic,” and, in extreme cases, has usually been referred to as 
“neurasthenic.” If this poor state of health is permitted to go on for months 
or years, the abdominal muscles become weak and flabby and give way 
under the malnutrition and gas distention as well as the weight of the 
lowered organs, until finally the entire shape of the abdomen is changed 
(Fig. 43)- 
The late Weir Mitchell evolved a successful empiric way of treating these 
patients by rest, recumbency, forced feeding and massage. Being a neurolo- 
gist, he attributed his success to “padding the nerves with fat.” 
Having briefly discussed the relation of intravisceral to intra-abdominal 
pressure, and having given a hint as to its bearing on clinical medicine, I 
shall next consider the relative pressure in the various parts of the intestinal 
canal, and its clinical importance. The word “jejunum” means empty. Very 32 
GASTRO-ENTEROPTOSIS 
little gas or fluid is found in it at one time. As the food passes down to 
the ileum, gas begins to form, and the intravisceral tension is greater. In 
the large intestine, a portion of the food and waste takes on bacterial diges- 
tion, producing a great deal of gas, and as a consequence the pressure within 
the large intestine is much greater than within the small intestine. So great 
is this liability to distention that nature has produced a valve, which has 
been done by a form of intussusception of the small bowel through a hole in 
the side of the large (Fig. 44A and B). This valve in a normal person is 
Fig. 4iA.—Diagram Illustrating the Role of Fat in Maintaining the Tonicity of the 
Hollow Viscera. 
A, normal amount of fat in fairly stout person (fat represented by white); stomach and 
intestine of normal thickness and size. 
usually competent, so it is often found that the large intestine is greatly 
distended while the small intestine is relatively collapsed. A peristaltic wave 
traveling from the cecum toward the hepatic flexure creates diminished intra- 
visceral pressure behind it. This diminished intravisceral pressure, follow- 
ing in the wake of the peristaltic wave, permits the ileum to empty a portion 
of its contents into the distended large intestine. When the wave has ex- 
hausted itself, the normal intra-intestinal pressure is again resumed and the 
valve again closed. The gradual obstruction of the large intestine in its INTRA-ABDOMINAL AND INTRAVISCERAL PRESSURE 
33 
lower portion, by a growth of any kind, often produces such extreme intra- 
intestinal pressure as to reduce the normal intussusception of the small 
intestine into the large and thus to destroy the competence of the ileocecal 
valve (Fig. 44C and D). This I have demonstrated in doing Brown’s 
ileostomy for obstruction in the sigmoid, for in those cases fluid which has 
been passed through the distal segment of the ileum into the large intestine 
Fig. 41B.—Patient Reduced in Health, Fat Having Been Absorbed. 
Abdominal cavity is enlarged, intra-abdominal pressure is reduced, and hollow viscera are 
distended and thinned in an effort to establish an equilibrium. Compare with 41A. 
usually runs back, although the obstruction has been removed below, while, 
in ileostomy performed for ulcerative colitis, the colon may usually be 
flushed out through the distal segment of the ileum without a return from 
the colon through the ileocecal valve. Long-continued constipation, with 
large accumulations of gas in the cecum, is frequently followed by incom- 
petence of the ileocecal valve (Fig. 44C and D). If this incompetence is Fig. 42.— Sagittal Section 
THROUGH THE LEFT SlDE 
of the Abdominal Cavity. 
(Modified from Goldthwait.) 
This shows the distribution 
of extraperitoneal and mesen- 
teric fat in a normal individual. 
Lumbar curve normal, as shown 
by the plumb line. 
Fig. 43. — Sagittal Section 
THROUGH THE LEFT SlDE OF 
the Abdominal Cavity. 
This shows absorption of 
extraperitoneal fat and the 
letting down of all abdominal 
organs, constituting a general 
ptosis. The belly is pendulous 
and the organs are found chiefly 
in front of the perpendicular 
psoas line. The plane of section, 
instead of being pear shape, as 
in Fig. 42, is oval. The lumbar 
curve is gone and the patient 
has assumed the “ carrying posi- 
tion.” Point of section same as 
Fig. 42. INTRA-ABDOMINAL AND TNTRAVISCERAL PRESSURE 
35 
complete and the regurgitation is extensive, it often has important clinical 
significance. J. H. Kellogg has devised an ingenious operation for reproduc- 
ing the normal intussusception. 1 have seen a few cases in which the in- 
competence of the ileocecal valve produced such serious symptoms that I 
performed a modified Kellogg 2 operation for its relief, with functional satis- 
faction and complete mechanical restoration (Fig. 45A and B). 
I have had occasion to operate on a considerable number of patients who 
had had short-circuiting operations performed by other surgeons who used 
Fig. 44.—Anatomical Importance of the Ileocecal Valve. 
A, ileocecal slit and valve. (Gray’s Anatomy.) B, diagram illustrating a competent ileo- 
cecal valve. (Elaborated from Gray’s Anatomy.) C, partial incompetence of ileocecal valve. 
(Kellogg.) D, complete incompetence of ileocecal valve. (Kellogg.) 
Lane’s method. In some cases, when performed by amateurs afraid to do 
the complete operation, a simple ileosigmoidostomy without severing the 
distal portion of the ileum had been performed. In all cases, whether or not 
the ileum was severed, it was very much dilated, showing that when the 
ileum is subjected to the greater pressure of the large intestine by an absence 
of an ileocecal valve, it becomes permanently dilated, no matter whether 
there are clinical symptoms or not. Figures 46A and 46B show this point in 
one of my own cases following ileosigmoidostomy. The colon in this case 
was later removed, at which time the ileum was found to be much distended 
2 Surg., Gynec. and Obst., November, 1913, 17:658. 36 
GASTRO-ENTEROPTOSIS 
and thickened and it contained semisolid fecal matter for three or four feet 
above the point of anastomosis. 
Next we may consider the relative degree of pressure in the hollow 
viscera themselves, and in the glands and ducts emptying into the viscera. 
In 1908—1909, while I was experimenting with methods for removal of the 
head of the pancreas in two stages, the first of which included the trans- 
plantation of the common bile duct to another portion of the duodenum, it 
Fig. 45A.—Roentgenogram Showing Case of Completely Incompetent Ileocecal Valve. 
This shows filling of entire small intestine with barium enema; clinical symptoms very 
marked. 
was discovered that the duct which had been directly planted into the duode- 
num at the first operation was invariably found dilated at the time of the 
second operation (Fig. 47A and B). In one instance the duct was so large 
as the duodenum itself. The opening of the duct into the intestine was 
large, and all of the ducts well up into the liver were much dilated. This 
phenomenon, being observed in all cases, left but one rational conclusion to 
be drawn, namely, that the greater pressure within the intestine was too 
much when applied to the inside of the thin bile ducts. Investigation of the INTRA-ABDOMINAL AND INTRAVISCERAL PRESSURE 
37 
duodenum and bile ducts of dogs showed that the normal duct, after pass- 
ing through the muscular wall of the intestine, passed along immediately 
under the loose, movable mucous membrane for a distance of approximately 
half an inch before it entered the intestinal lumen. This was sufficient 
explanation of how the normal entrance of the bile duct prevented its dilata- 
tion by intra-intestinal pressure. The solution to the problem then was clear 
—the duct must be placed immediately under the loose, movable mucous 
Fig. 45B.—Complete Restoration of the Valve. 
Picture of same intestine shown in Fig. 45A, taken two months after operation, clinical 
symptoms entirely relieved. (Another picture taken one year after operation showed valve still 
competent. A picture taken two years after operation showed partial incompetence of valve 
with partial return of clinical symptoms.) 
membrane for some distance before it is permitted to emerge into the lumen 
of the intestine, if the intra-intestinal pressure is to be brought to bear in 
closing the duct (Fig. 48). The technic of implanting the duct in this man- 
ner was quickly devised and tried on the living dog. Six ducts were implanted 
by this method, and not a single one of the ducts thus implanted showed 
material dilatation, in contrast with six implanted by the direct method, all 
of which were enormously dilated. 38 
GASTRO-ENTEROPTOSIS 
While this experiment with submucous implantation of the bile duct had 
been a complete success, so far as creating a perfect valve was concerned, 
there seemed to be some doubt as to whether the ureter, which entered the 
bladder in much the same way, could be implanted into the intestine with the 
same degree of success. 
During the next year, after these experiments of the bile duct were 
undertaken, a series of experiments with the ureter were also performed 
Fig. 46A.—Roentgenogram Showing Distended Ileum. 
This commonly follows ileocolostomy. Ileum distended with gas and barium, immediately 
after one meal and twelve hours after another. 
with perfect success, so that at the meeting at the St. Louis session of the 
American Medical Association, 1910, I was able to take five kidneys in which 
the ureter was implanted into the large intestines of dogs by the sub- 
mucous method. In not a single instance had the kidney become diseased 
in any way. The valves formed by the submucous implantation were per- 
fect (Figs. 49A and B and 50A and B). A large series of clinical cases 
by Dr. C. H. Mayo and a smaller one by Lower, Hunner, myself, and others, 
have procured clinical results just as good, so that the principle will apply INTRA-ABDOMINAL AND INTRAVISCERAL PRESSURE 
39 
to the implantation of ducts at any point upon which it is depended to act 
for the proper control of intravisceral pressure. 
In connection with this point, I may call attention to two other 
observations. First, every surgeon has noticed that the common bile duct 
becomes dilated sometimes to a large size after the gall-bladder has been 
removed or has been functionally destroyed by contraction down on gall- 
stones. In one instance of contracted gall-bladder, I found the common duct 
dilated to fully three fourths of an inch in diameter, which caused me to 
Fig. 46B.—Roentgenogram Showing Distended Ileum. 
This commonly follows ileocolostomy. Barium and gas in widely distended ileum twenty- 
four hours after picture shown in 46A. 
open the bile duct looking for a duct stone, notwithstanding the fact that 
the patient had shown no jaundice or other evidence of common duct obstruc- 
tion. Nothing was found in the duct, and the mouth was well open into the 
duodenum. Second, when a gall-bladder fistula is established with the sur- 
face, all observers have noticed that the bile flows more freely during the 
night or during intervals of digestion than during digestion. In other words, 
the bile flows into the gall-bladder during the intervals of digestion. The 
gall-bladder seems to serve as an elastic safety reservoir which takes off the Fig. 47A.—Common Bile Duct 
Implanted into Duodenum. 
This is done as a part of the 
first stage of operation, for removal 
of head of pancreas and duodenum, 
by direct implantation without 
valve protection. 
Fig. 47B. — Implanted Common 
Duct Entering the Duodenum. 
This is shown taking place two 
weeks after implantation by the 
method shown in 4 7A. The duct 
has become widely distended and 
thickened during the intervening 
two weeks. INTRA-ABDOMINAL AND INTRAVISCERAL PRESSURE 
41 
pressure from the bile duct at certain times of the day. It seems likely that 
this may be explained on the basis that, during active digestion, peristaltic 
waves are intermittently passing down the intestine. In the wake of these 
Fig. 48.—Diagram Showing Submucous Implantation of a Duct into the Intestine. 
A, longitudinal section; B, cross-section. Arrows show how the intra-intestinal pressure, 
acting on the movable mucous membrane, collapses and makes a valve. 
waves there follows a diminution of the intra-intestinal pressure, which per- 
mits the temporary flow of bile from the duct. As soon as the wave has 
ceased, the normal intra-intestinal pressure is resumed and the valve is 
Fig. 49.—Testing Competence of the Valve in a Removed Specimen Following Submucous 
Implantation in a Dog. 
A, fluid run into the segment of intestine including the implantation area under pressure. 
B, outside pressure has been removed; intra-intestinal pressure closes valve completely. 
closed. During long intervals of digestion, and particularly during the night, 
the peristaltic waves are few. The intra-intestinal pressure is more nearly 
constant, and the bile is forced out into the gall-bladder, or out through a 42 
GASTRO-ENTEROPTOSIS 
gall-bladder fistula as the case may be (Fig. 51A and B). H. Kehr found 
that if he fed his patients frequently during the night the flow ceased as in 
the daytime. If the gall-bladder has been removed or destroyed, an equilib- 
Fig. 50A.—Normal Valve in a Dog’s Bladder for Comparison with Fig. 50B. 
Fig. 50B.—Postoperative Valve Following Submucous Implantation of a Ureter in a 
Dog’s Large Intestine. 
Picture taken 167 days after implantation. This represents the same specimen shown in 
Figs. 49A and 49B, in which the valve acted perfectly without leakage. 
rium of pressure in the gall-ducts and intestines is established in the long 
intervals between peristaltic contractions, with the result that the full degree 
of intra-intestinal pressure exerted on the bile ducts during the intervals of 
digestion produced permanent dilatation of the duct (Figs. 52A and B). To Fig. 51 A.—Diagram Showing Influence of Peristaltic Waves on the Gall-bladder. 
Arrows in the gall-duct and gall-bladder indicate direction of bile during intervals of peri- 
staltic waves. Arrows in duodenum show how intra-intestinal pressure closes the valve during 
intervals of peristaltic waves. 
Fig. 51B.—The Flow of Bile from the Gall-bladder and Duct Following in the Wake 
of a Peristaltic Wave. Figs. 52A, 52B.—Diagram Illustrating a Theory as to the Probable Cause of Dila- 
tation of the Common Duct Following Removal or Destruction of the Gall- 
bladder. 
A, during intervals of digestion (as at night) the valve is closed by intra-intestinal pressure, 
thereby producing an equal pressure in the ducts, causing them to dilate. B, during digestion, 
local intra-intestinal pressure is intermittently released in the wake of peristaltic waves, per- 
mitting the emptying of the dilated bile ducts, just as the normal duct and gall-bladder are emptied. INTRA ABDOMINAL AND INTRAVISCERAL PRESSURE 
45 
control this feature after cholecystectomy Terry feeds his patients frequently 
throughout the twenty-four hours. Careful application of the principles set 
forth and illustrated in this chapter, to the study of the atonic, dilated con- 
ditions of the gastro-intestinal tract accompanying the lowered intra-abdom- 
inal pressure of emaciated ptotic individuals, adequately explains the dilatation 
of the ducts and the stagnation of secretions known to take place in these 
patients and probably explains in a large degree the asthenic, toxic state so 
frequently manifested in such cases. CHAPTER V 
COMPARATIVE ANATOMY AND PHYSIOLOGY OF THE GASTRO- 
INTESTINAL TRACT 
The discovery of the principles of asepsis and anesthesia have made pos- 
sible, in the hands of a competent surgeon, such wonderful and revolution- 
ary achievements that the surgeon seems likely to be maddened with success. 
A competent surgeon can remove any organ in the abdominal cavity, with 
the possible exception of the liver and the pancreas, and he can remove 
even a part of these organs, and the patient will recover. A few years ago 
a surgeon’s success was measured by the fact that his patients did not die 
as a result of operation. Some still use this standard, but the time has 
arrived when our patients demand more. They demand now that we shall 
make them well and comfortable. In other words, our surgery has been 
purely anatomical in the past. We have now entered upon the physiological 
era of surgery. The noted anatomist and physiologist, Keith, of England, 
after studying the work of Lane, Metchnikoff and Barclay Smith, all of 
whom consider the large intestine as an unnecessary cesspool, the products 
of whose stagnation poison the entire body, says that if these statements are 
well founded, medical men are face to face with a condition which threatens 
the health and survival of modern civilized races. In an article published 
in the British Journal of Surgery, April, 1915, Keith has the following to 
say: 
“I have not any doubt that in years to come Sir W. Arbuthnot Lane 
will be recognized as one of the great pioneers in intestinal surgery. He 
was the first to perceive that disease of the great intestine was very common, 
and the real cause of untold illnesses. He had the courage to act on the 
belief that no colon was better than a diseased colon. But in so far as he 
regards the normal and healthy colon as a mere sewage system, I totally 
disagree with him. We must remember that its mucous membrane is a 
purely glandular structure of unknown—at least of uncertain—function. If 
we bring the glandular tissue together to form a solid mass, we have a gland 
considerably larger than the pancreas. All its cells are active. If we roll 
up its musculature, we have a mass of contractile tissue, furnished with an 
elaborate and complex neuromuscular system, big enough to form a muscle 
as large as the biceps of a blacksmith’s arm. That is not quite the com- 
position we expect in a merely mechanical, effluent sewage system. The fact 
that health can be maintained after complete removal of the colon does not 
prove that it is either a useless or a vestigeal structure; it is simply another 
46 COMPARATIVE ANATOMY AND PHYSIOLOGY 
47 
example of the well-known law that nature has endowed the animal body 
with a potentiality far beyond the demands of a routine life. We seldom 
use our lungs beyond one third or one half of their full fuctional capacity. 
We can excise the spleen and many other organs and parts of the body; 
but that does not prove that organs or parts so excised are useless; merely 
that the systems of the body have a wonderful adaptability and power of 
acting as partial or complete substitutes for each other. I particularly wish 
to insist on the unknown utility of the large bowel, because if we consign 
it to the list of useless or injurous organs, then we cease to regard it as an 
object which urgently requires research and investigation. The moment we 
relegate it to the position of a sewage pipe or a vestigeal organ, we have 
really excommunicated it from the minds of the young and hopeful scientists 
of the coming generation. 
“There is no doubt that in all cases of intestinal stasis there is a disorder 
of the neuromuscular mechanism of the great bowel, but we cannot explain 
that disorder in the present state of our knowledge.” 
f 
In another article published in the British Medical Journal, December 7, 
1912, Keith insists that before assigning so large a part of man’s digestive 
tract to the list of the useless structures, it would be well to inquire regard- 
ing the various members of the animal kingdom. Instead of practicing 
excision in the effort to adapt our digestive tract to our present dietary, 
Keith suggests that we may discover a diet which will be suited to our 
present digestive tract, and in order to do so, we must know something of 
the normal processes of the digestion of vertebrates in general. 
I am sure that Keith is correct and that the key to our present situation 
is to be found in a more thorough study of comparative anatomy and 
physiology. The large intestine, and particularly the cecum of an animal, 
almost tells the form of diet that is required. For instance, in herbivora, 
we find the large intestine long in proportion to the small intestine, while in 
carnivora it is short. The omnivora, which includes man and the hog, have 
a medium intestine. In man and hog the small intestine is about four times 
as long as the large. In the horse, rabbit and deer it is only about twice 
as long as the large intestine, while in birds of prey like eagles and hawks 
the small intestine is about seventy times as long as the large. 
The cecum is a very important part of the intestinal canal. We may 
profitably study two large lizards. The Gila monster found in the Central 
American countries feeds almost exclusively on birds’ eggs, a very easily 
digested food. His intestine does not change its size, and the only demarca- 
tion between the large and small intestine is a single valve or muscle by 
which food may be retarded (Fig. 53). The Iguana Tuberculata is another 
tropical lizard, somewhat larger but very much the same kind of animal, 
having entirely different diet. The Iguana has a small stomach and short 
small intestine and a tremendously large and complicated cecum (Fig. 54). 
Its diet is entirely vegetable and it is said that the cecum always contains undi- 
gested vegetable matter. In Fig. 55 it will be seen that the food in the 48 
GASTRO-ENTEROPTOSIS 
first place may be held in the small intestine by the small opening into the 
cecum until it is well mixed with the digestive juices. It then passes into 
one chamber and from this to another and another and another, being held 
in each one for some time in order that digestion already begun may be 
finished and additional preparation by bacterial digestion may take place in 
the cecum. The Agouti, a herbivorous animal resembling a raccoon, has 
a tremendously large cecum (Fig. 56). Considering birds, it is found that 
Fig. 53.—Junction of Large and Small Intestine of the Gila-monster, Showing the 
Valve Separating Them. (Redrawn from Huntington.) 
the hawk and the eagle have practically no cecum (Fig. 57). Their diet 
is chiefly meat with very little indigestible matter. On the other hand, the 
ostrich has a large intestine about twice as long as its small intestine and 
two large and long ceca (Fig. 58). The ostrich eats nuts with hulls and 
other forms of very indigestible substances and takes care of them. The 
hog, being an omnivorous animal, has a small intestine more nearly like that 
of the human than any other domestic animal; but the large intestine 
is arranged in loops like a radiator. The present-day refined and high- COMPARATIVE ANATOMY AND PHYSIOLOGY 
49 
bred hog has an intestine about 140 per cent longer than his ancestor, 
the wild hog. Whether this is due to the fact that high breeding has in- 
cidentally by selection picked the hog with the longest intestine, and, there- 
fore, the most perfect digestion, or whether his change of diet from nuts, 
worms and concentrated foods to the largely vegetable diet has caused an 
increase in his intestinal canal, is hard to say. His diet now is chiefly 
vegetable and he thrives on alfalfa, clover, etc. The large intestine in the 
present-day hog is quite necessary as shown by experiments. 
Fig. 54.—Gastrointestinal Tract of Iguana Tuberculata. (Redrawn from Huntington.) 
Note the long stomach, short mid-gut and large cecum. 
Alglave,1 in 1907, made a series of experiments on dogs and hogs as 
well as on herbivora. He found that an ileosigmoidostomy without exclu- 
sion did not materially affect the dog whose diet has gradually been changed 
by association and evolution from strictly carnivorous to that of his friend 
and companion, man. Ileosigmoidostomy with unilateral exclusion affected 
the dog’s nutrition, but did not prove fatal, while he found that the pigs, 
whose diet and intestines have been changed by evolution largely to that of 
herbivorous, on which ileosigmoidostomy with unilateral exclusion had been 
1 Rev. de Gynec. et de Chir. abd., 1907, 11:51. 50 
GASTRO-ENTEROPTOSIS 
performed, died within five or six months. Pigs on which ileosigmoidostomy 
without exclusion was performed were very materially retarded in growth and 
Fig. 55.—Sectional View of the Cecum of Iguana Tuberculata. (Redrawn from 
Huntington.) 
development, but did not die. The younger the pig when operated on, the 
more the health was retarded, as shown by the study of three pigs of the 
Fig. 56.—Ileocolic Junction, Cecum and Colon of Agouti. (Redrawn from Huntington.) 
same litter fed with the same food. On one, ileosigmoidostomy without 
exclusion was done at two months old. On another the operation was done COMPARATIVE ANATOMY AND PHYSIOLOGY 
51 
at three months old, and on still another no operation was performed. The 
first pig at a year old weighed thirty-four pounds, the second pig at the 
same age weighed seventy-nine pounds, and the third, upon which no opera- 
tion had been done, weighed two hundred pounds. It was found that ex- 
clusively herbivorous animals all died as the result of the simple short- 
circuiting operation without exclusion, while strictly carnivorous animals do 
well without the large intestine. 
Pig. 57.—The Ileocolic Junction and Ceca of Black Hawk. (Redrawn from Huntington.) 
In 1913, I had the opportunity to study the clinical work of the late 
Dr. John Young Brown of St. Louis, who had advocated ileostomy for a 
number of years, excluding the entire large bowel in certain cases. He 
showed me one case on which he had done a permanent ileostomy for 
mechanical reasons nine years before, and gave me the privilege of question- 
ing the patient. She was a hard-working woman and yet appeared to be in 
perfect health. I asked her what happened when she took vegetable in 
quantities. She said that it produced no disturbance, except that the vege- 
tables passed through undigested to a certain extent, and sometimes produced 
diarrhea. Dr. Brown also called my attention to the fact that there was 52 
GASTRO-ENTEROPTOSIS 
practically no odor to the escaping contents which were caught in a con- 
trivance bandaged to her side. The patient confirmed this by stating that the 
odor of her fistula was never noticed by members of her family. Dr. Brown 
informed me that this was the rule in such cases. I have had a consid- 
erable number of patients on whom the Brown operation has been done by 
me for disease of the colon, all of whom have markedly gained in weight 
and strength, and so far as we can tell are in good health with the entire 
large intestine completely out of commission many months after the operation. 
So it is clear that man can do without the large intestine if a concentrated 
Fig. 58.—Ileocolic Junction and Ceca of Ostrich. (Redrawn from Huntington.) 
diet is used, but inasmuch as a mixed diet is found best for man, it is much 
better to preserve this function, which is performed by the cecum. 
Cannon,2 of Boston, who has probably added more reliable data concern- 
ing the physiology of the cecum than anyone else, in studying the physiology 
of the large intestine, states that the cecum and the ascending colon contain 
a stagnant mixture of undigestible matter, food, cellulose, water and bacteria, 
which would seem to present an ideal condition for putrefaction and de- 
composition. He asserts that in the cecum and the ascending colon the last 
of the food disappears and the water is largely absorbed, which causes the 
2Journ. Am. Med. Assoc., July 6, 1912. COMPARATIVE ANATOMY AND PHYSIOLOGY 
53 
waste to become gradually more dense. He says that while the contents of 
the cecum and ascending colon are soft and mushy, the contents of the 
transverse colon may be found as firm as that which is discharged through 
the rectum. 
Barclay Smith finds that the digestive changes of food within the large 
bowel are due to the action of bacteria which have a permanent abode in the 
cecum, and that the purpose of the ileocecal valve is to prevent the contents 
of the cecum and colon, which are undergoing bacterial digestion, from 
being forced by antiperistaltic movements into the ileum, where a totally 
different digestion is in progress. 
A. E. Barclay 3 in a statement concerning X-ray findings has the follow- 
ing to say: 
“The ileocecal valve has been very carefully studied by Case, Hertz, Cole 
and others, by means of opaque enemata, and, apparently, it should normally 
be quite resistant to the injection; no leakage should take place into the 
ileum. In 16 per cent of cases, however, it is found that the injection does 
pass through to some extent, that is, the valvular action is incompetent. In 
one of my own cases, I saw an injection flow quite freely, not only into the 
ileum, but also into the jejunum; some of it I actually located in the duode- 
num. Case states that when this phenomenon is noted radioscopically, the 
incompetence can be confirmed at the operation by ‘milking’ the food or air 
in either direction, and Kellogg has devised an operation for the repair of 
the valve or the formation of a new one. As a cause of ileal stasis this 
defect is well worthy of consideration, and Cole asks if it is likely that the 
small intestine will tolerate regurgitated fecal matter without giving rise to 
symptoms of some kind, probably referred to the stomach. This incom- 
petency of the ileocecal valve is probably the explanation of the fact that 
patients sometimes state that they can taste a soap enema. A patient is 
stated to have actually vomited a part of an oil enema within half an hour.” 
There is much to be said in favor of the importance of the ileocecal 
valve, when we note in true stasis cases that the ileum is very much dilated 
following ileosigmoidostomy, either with or without exclusion, which indi- 
cates that intra-intestinal pressure is greater in the large intestine than in 
the small (see X-ray pictures in Fig. 46A and B). Barclay Smith believes, 
with Lane, that the modern diet is so concentrated and well prepared that 
no bacterial digestion is necessary, and that, therefore, the large intestine is 
not necessary. He observes that the preservation of a part of the cecal and 
colic contents is essential for the digestive economy of vegetable-feeding 
mammals, and if we admit that the digestive processes of the cecum and 
colon result from the action of certain bacteria, we see why nature has 
placed the proximal part of the colon outside of the influence of the ex- 
pulsory mechanism. He says that in the proximal part of the colon, anti- 
peristaltic retaining movements are observed and never the movements of 
complete expulsion, and also makes the interesting observation that the 
3 Brit. Journ. Surg., 2:638. 54 
GASTRO-ENTEROPTOSIS 
peculiarly strong stomachic digestion of fishes and the absence of a large 
intestine, and, therefore, the absence of gas formation, is nature’s provision 
for preserving the equilibrium of the fishes in water. He points out that 
if it were necessary for a fish to have a large intestine with bacterial digestion, 
such as a mammal, and particularly a vegetarian, the gas formed thereby 
would completely upset the equilibrium of the fish. 
The cecum in herbivorous animals always contains fecal matter and gas 
no matter how long the animal is starved, and this fecal matter is made 
up largely of bacteria, which seem to play an important part in completing 
intestinal digestion. The cecum seems to retain by antiperistalsis enough 
food to keep the bacteria alive during intervals of digestion. This active 
bacterial life is found mostly in herbivora and is essential to the animal’s 
very existence. This seems to act very much on the same principle as the 
septic tank, which, when properly constructed and not disturbed, destroys 
sewage entirely so that the water draining away from it is colorless and 
odorless. If the septic tank is not properly constructed, or if the bacterial 
growth is disturbed by agitation or by chemical antiseptics, the water flow- 
ing from the tank is not clear and has an odor. It is well known that 
bacteria, like animals, are unable to thrive in the presence of their own offal. 
If there is too little or too much water flowing through the septic tank, the 
bacterial equilibrium is upset and the tank does not work perfectly. There- 
fore, it seems entirely reasonable that pathologic antiperistalsis acts deleteri- 
ously not only by holding the intestinal contents in the cecum too long but 
also by returning the formed fecal matter, made up largely of the offal of 
the bacteria themselves, destroys them and limits their normal action and 
thereby creates a swill tank instead of a normal so-called septic tank. Physic 
or abnormal stimulation of any kind causes too rapid movements and dis- 
turbs normal bacterial digestion. It seems that the bacterial digestion tak- 
ing place in the cecum is for the double purpose of destroying the undigested 
vegetable matter and thereby preventing putrefactive decomposition into toxic 
substances, and also, in certain herbivora, for the completion of the prepara- 
tion of vegetable matter for absorption and use. CHAPTER VI 
MOTILITY OF THE LARGE INTESTINE 
Elliot and Barclay Smith1 have made an important observation concern- 
ing the difference in innervation of the large intestine in various animals. 
They found that in carnivorous animals, such as the cat and the dog, stimula- 
tion of the sacrovisceral nerves caused emptying of the large bowel from the 
cecum to the rectum, while in vegetable-eating animals it extended only to the 
Fig. 59.—The Human Cecum Open. (Keith.) 
It shows the ileocecal orifice, the retinacular bands, the cecal colon, and cecocolic sphincteric 
tract. One-third natural size. 
distal part of the colon, not including the cecum and the first part of the 
transverse colon. 
Cannon observed that the anastaltic wave starts in a cat at a tonically 
constricted ring near the cecum. Boehm describes such a ring in the human 
being in the transverse colon. Keith believes that he has observed sphincteric 
action near the middle of the ascending colon (Fig. 59). Keith refers 
particularly to Auerbach’s plexus, which furnishes the terminal filaments 
of the nerve supply to the large intestine. He calls attention to the fact 
that there is a tissue between nerve fiber and that of muscle fiber, which 
has not been named, but which for convenience he names “Auerbach’s tissue.” 
1 Quoted from Keith’s article in the British Medical Journal, December 7, 1912. 
55 56 
GASTRO-ENTEROPTOSIS 
He found in the rat a ring of ganglionic tissue around the terminal portion 
of the ileum between the two muscular layers (Fig. 60). This ganglionic 
mass extended along the anterior and the posterior wall of the ascending 
colon and cecum for some distance above and below the ileocecal opening. 
He found in the rat that this ring or mass of tissue controlled the movements 
of the ileocecal region. 
Fig. 6o.—Figures Illustrating Four Functional States of the Ileocecal Region of 
the Bowel of Rats. (Keith.) 
In A and C the ileocecal sphincter is closed; in B and D it is relaxed. In A and B the 
sphincteric tract is closed; in C and D it is open. Various conditions of the cecocolic sphincter 
are shown in A, B, C, and D. 
Roith 2 has materially added to the knowledge of the motility of the large 
intestine by the study of fecal fistulae. In five cases of fistula of the ascend- 
ing colon he found that feces began to escape from two to four hours after 
eating. There were two cases with fecal fistula at the center of the transverse 
colon, following transverse division of the gut in which both ends had been 
sewed to the skin. Evacuation occurred one, two, or at the most, three 
times during the twenty-four hours. It usually came on at about the same 
time each day and lasted only for a short time and was of semisolid char- 
acter. The same results were shown in sigmoidocolostomy. This is amply 
2 Mitt. a. d. Grenzgeb. d. Med. u. Chir., Band xxv, Heft i, S 203. MOTILITY OF THE LARGE INTESTINE 
57 
proved in the practice of every intestinal surgeon. I have noticed that a 
patient who is constipated before such a colostomy is just as much so after- 
ward. Roith noted the long retention of fecal matter in the first part of 
the large intestine and the tendency to return the contents into the cecum by 
antiperistalsis. In three cases of anastomosis of the ileum with the colon 
close to the hepatic flexure, transportation of the contents into the oral 
segment of the gut was noticed. In one of them a fecal fistula of a year’s 
standing persisted after implantation of the ileum 20 cm. distal to fistula, 
but closed spontaneously after a second implantation of the ileum into the 
Fig. 6i.—Direction of Fecal Currents after Operation. 
Diagram showing direction of fecal currents after transplanting severed ileum into the right 
half of the transverse colon and also into left half and for the curve of long standing fecal fistula 
of the cecum. (Drawn from verbal description of Roith.) The one operation does not cure the 
fistula, the other does. 
distal half of the transverse colon (Fig. 61). In two other cases fecal 
fistula of the stump of the colon came on after resection of the cecum and 
implantation of the ileum io cm. beyond the point of resection. In nine 
cases in which a similar anastomosis was made between the ileum and the 
left half of the transverse colon, the intestine was left open with the drain- 
age tube sewed into it. When the tube was finally removed, the fistula 
closed spontaneously. In a case in which the sigmoid had been divided and 
the two ends brought out through an opening in the abdominal wall, bis- 
muth mixture injected into the rectum ran out upon the skin and covered the 
opening of the proximal gut. X-ray afterwards showed that a considerable 58 
GASTRO-ENTEROPTOSIS 
quantity of this bismuth had been drawn into the upper segment, which was 
further proved by the fact that the bismuth passed out of the upper segment 
when the bowels acted. These experiments are borne out almost entirely 
by the excellent work of Cannon, of this country, and of Keith, of England. 
Roith concludes that normally there is both peristalsis and antiperistalsis in 
the region comprising the cecum, the ascending, and the first half of the 
transverse colon; peristalsis only in the left half of the transverse and in 
the descending colon; and again both peristalsis and antiperistalsis in the 
sigmoid and the rectum (Fig. 62). In a certain per cent of badly constipated 
Fig. 62.—Diagram in Which the Arrows Indicate the Normal Fecal Currents 
(Described by Roith.) 
patients, antiperistalsis is more marked and may be found along the entire 
large intestine. 
Barclay3 remarks on the extraordinary fact which showed up at the 
beginning of X-ray observations, that no movement of any kind was seen 
and yet from time to time it was noted that between two examinations 
separated by only a few minutes, the head of the column had passed through 
many inches of the colon. He says Holzknecht was the first to see and de- 
scribe such an actual movement. It was apparently a sudden movement in 
mass of the whole column in the colon and took place in some three seconds. 
Then Hertz took it up and confirmed the findings of Holzknecht. Barclay 
says that he has seen the actual movement now about ten times and he is 
3 Brit. Journ. Surg., 2:646. MOTILITY OF THE LARGE INTESTINE 
59 
absolutely convinced that this is the natural and normal movement. He 
quotes Jordan, Case and others, and then he has the following to say: 
“There is not, so far as I know, any theory, except this of ‘mass’ move- 
ment, that will explain the facts as we see them. All the observers agree 
that, without subjective sensations of any kind, the haustral segmentation 
disappears, and the whole mass rushes suddenly—in three seconds, Holz- 
knecht suggested—through a length of colon. In all my cases it happened 
that the head of the column was in the region of the hepatic flexure, and 
when the movement finished, the head of the shadow had passed on to the 
splenic flexure or further. The whole process is over in a very short time, 
and the haustral segmentation, and general picture of still life, are almost 
immediately restored. My impression is that the perfectly natural movement 
is somewhat slower; at any rate it has appeared to be so since I had my 
patients prepared by purgatives thirty-six hours before the first meal, that is, 
sixty hours before one expects to observe the large bowel. In one instance 
I timed the passage from the middle of the transverse colon to the pelvic 
brim as fifteen seconds; but in all the other cases the passage was so un- 
expected that it was almost completed before one had time to realize what 
was happening. The mechanism appears to be: (1) A relaxation of the 
tonic action of the muscular coats; followed by (2) a big peristaltic wave 
that sweeps the whole contents along. This movement probably occurs 
some three or four times a day. 
“Incidentally, it is interesting to note that the firm and solid appearance 
of the colon shadows, both on the plate and also on palpation, is due to the 
tonic action holding the more or less fluid feces in definite form.” 
ABNORMAL MOTILITY—CONSTIPATION 
In Chappie’s paper on the life history of fifty short-circuited patients of 
Lane’s, it is seen that approximately one-third of all the cases thus short- 
circuited later required removal of the colon on account of overfilling of the 
cecum by material which was carried up from the anastomosis. Other 
surgeons have found it necessary to remove the colon in a much larger 
percentage of short-circuited patients, in order to procure comfort. 
In 1906, I reported the first case of short-circuiting for severe intestinal 
stasis and stercoral ulcers that had been reported in this country—in fact, 
it was done before I had heard of Lane’s work. The patient was tem- 
porarily very much improved and was reported as cured, but a year later 
it was necessary to remove the entire colon, which was found packed full of 
fecal matter which had backed up. 
Some years ago I removed a colon, a year and a half after a short- 
circuiting operation had been done by a very prominent surgeon of this 
country. The patient observed that the fecal matter backed into the cecum 
in large quantities instead of passing through the rectum. A bismuth meal 
given by us was returned almost entirely into the cecum. The ascending 60 
GASTRO-ENTEROPTOSIS 
colon was removed together with half of the transverse colon. At the time 
of this operation, the short-circuiting operation which had been done a year 
and a half before was found to have been performed perfectly and there was 
no obstruction below the anastomosis; the sigmoid was dilated somewhat 
in a fusiform shape; the ileum was also dilated to approximately the same 
shape and size as the sigmoid; the cecum, despite all of our efforts to empty 
it before the operation, contained three or four pounds of fecal matter, and 
bismuth, which had been given six weeks before by the stomach, was found. 
After the operation the patient felt decidedly improved and had some diarrhea. 
Gradually the constipation returned, and the patient again complained of 
the fecal contents backing up into the stub of the transverse colon—in fact 
he was just as bad as before the previous removal operation. He insisted 
on having the remainder of his colon removed down to the anastomosis. 
At this operation, it was found that the left half of the transverse colon 
which had been left at the previous operation was packed full of hard fecal 
matter, just as the cecum and transverse colon had been at the first operation. 
Since the removal of the colon down to just above the ileosigmoid anas- 
tomosis, the patient has felt well, with slight diarrhea at first, and finally, 
constipation sufficient to require enemas. This is a case of typical hyper- 
repulsion or reverse peristalsis. 
Probably the most persistent form of reverse peristalsis is found in 
certain cases of gradual obstruction of the rectum or sigmoid by carcinoma. 
It is quite often found in those cases that the intestine near the growth is 
not distended at all while the cecum may be distended to enormous pro- 
portions, and in some instances the distention is sufficient to cause gangrene, 
as reported by Anschutz, Kruiter, and Roith. I have personally seen two 
cases in which gangrene had been actually produced. In addition, I have 
seen three other cases in which this hyperrepulsion, almost to the point of 
gangrene of the cecum, has occurred without distention of the colon near 
the growth (Fig. 63). 
By studying with X-ray a number of cases in which we had done an 
ileosigmoidostomy for other conditions, in which constipation did not exist 
before the operation, we found that reverse peristalsis did not take place 
and bismuth was not found going back into the cecum, regardless of the 
technic of the anastomosis. 
Keith believes that intestinal stasis and mucous colitis are due to a dis- 
turbance of the motor mechanism of the large intestine. As a preliminary in 
his article he relates his work on rats’ intestines, which convinced him of 
the correctness of his theory. He believes that in many of these cases there 
is a hypertonicity of the bowel instead of a hypotonicity, and believes with 
Hertz that the delayed passage of the ileal contents is not due to bands, but 
to hypertonus of the ileosphincteric tract. He calls attention to the fact 
that he has never been able to demonstrate an obstruction resulting from a 
peritoneal band by the X-ray; he believes that Jordan’s pictures show a 
spastic condition, but not an obstruction; that duodenal stasis may be due 
to a ptotic drag on the superior mesenteric artery. MOTILITY OF THE LARGE INTESTINE 
61 
According to Barclay, Hertz found in observations on students that the 
average normal times in which food should reach various points were: 
Cecum 414 hours 
Hepatic flexure 6l/2 hours 
Splenic flexure 9 hours 
Brim of pelvis n hours 
He calls attention to the fact that these are only average times, and wide 
differences are possible even in perfectly normal subjects. Barclay referring 
Fig. 63.—Extreme Distention of the Cecum without Distention of the Descending 
Colon in Gradual Obstruction of the Lower Bowel. 
to these figures says: “If we accept this ‘mass’ movement, described by 
Holtzknecht, occurring some three or four times a day, as the normal, it is 
evident why these wide variations are possible.” He continues the dis- 
cussion of constipation as follows: 
“Constipation has been defined by Hertz and others; but, holding the 
views I do, I would rather leave out any definition; each case is an individual, 
and this must not be lost sight of for the sake of making a definition. One 
sees patients who are always out of health if a daily action is not obtained; 
while one has also seen health regained when patients have ceased to worry 62 
GASTRO-ENTEROPTOSIS 
the intestines into daily actions, and reverted to a habit of twice a week. 
My own experience in the study of these cases indicates that there are two, 
and only two, real seats of stagnation in the large intestine (apart from 
kinks and adhesions), namely, the cecum and the rectum. Of these, the 
rectal stagnation is the most frequent, and to it Hertz has given the name 
of dyschesia. It is in reality a fault of defecation rather than a true con- 
stipation. In these subjects it is extraordinary to see the way in which the 
shadows accumulate and form great masses in the rectal ampulla without 
any call to stool being felt. The rectum is sometimes ballooned out to a 
great size, and is presumably atonic. When the bowels have been moved 
one finds that it is only a part of this shadow that has disappeared. 
“But in constipation proper, the delay is nearly always in the cecum and 
ascending colon, and these portions remain filled for days at a time, in spite 
of the fact that some of the contents may have moved on to various portions 
of the colon; in other words, there is a defect in the ‘mass’ movement, a defect 
not of one part of the colon, but of the mechanism. The position of the 
head of the shadow is not necessarily an index to the site of the portion of 
the gut that is responsible for the delay. One believes rather that the con- 
stipation is more likely due to some fault in obtaining a more or less fixed 
point,4 or a temporary sphincter at some point, from which to work, than a 
defect in the movement itself. 
“One has never seen, nor are there any records to show, that this move- 
ment takes place in the cecum itself. One has often seen movements in 
the lower part of the cecum of a peristaltic nature, and it is possible that 
these should be sufficient to raise the food to a position in the ascending 
colon in which this ‘mass’ contraction can catch hold and carry the food 
along. As a result of his researches in comparative anatomy, Keith believes 
that there is some form of sphincter between the cecum and ascending colon. 
Possibly, although one sees no radiographic indications of it in the ordinary 
course of events, there is some sphincter, as he suggests, and its function may 
be to prevent regurgitation when the ‘mass’ movement is in progress. In 
support of this hypothesis there are several observations: one has never seen 
the cecum empty suddenly between two observations, nor has the ‘mass’ 
movement of the shadow been observed to clear out the cecum. On the 
other hand, one has frequently observed large shadows left in the cecum 
while the contents of the hepatic flexure and transverse colon have passed 
far on towards the pelvic colon. Moreover, although the large intestine is 
always swept clean (except for definite scyhala possibly), there are often 
traces of the opaque meal left in the cecum for days—that is, it is not swept 
clean. 
“This ‘mass’ theory is so unparalleled in the human body that one hesitates 
to go any further than this brief suggestion of the normal. One finds widely 
ballooned colons and greatly narrowed colons—that is, apparently atonic 
and hypertonic types—and these have been described as the causes of con- 
stipation; but I doubt whether they are. Rather, I would suggest, they in- 
4 A point d’appui. MOTILITY OF THE LARGE INTESTINE 
63 
dicate the condition of the colon between the movements, for I happen to 
have seen the ‘mass’ movement sweep the shadow along both types of colon, 
and in both the movement was perfectly effective in displacing the contents. 
The part played by the cecum is not clear; but if my deductions are correct, 
this portion of the large gut has a separate mechanism or peristalsis for 
mixing the contents and feeding them into the ascending colon, preparatory 
to the occurrence of the ‘mass’ movement.’’ 
Since writing the above, Barclay again writes: 
“I have on two occasions noted the formation of a definite constriction— 
a point d’appui—such as I suspected was necessary for the efficiency of the 
mass movement. In each case it was near the hepatic flexure, and was not 
evident until this was palpated out with the spoon.5 I am not absolutely 
certain on the point, but believe that the sphincter was formed after palpa- 
tion of the cecum in the exploration of the appendicular region. In both 
instances the colon distal to the constriction lost its haustral segmentation, 
and the contents seemed to back up to the point d’appui, as if forming a mass 
ready to be propelled onwards when the ‘mass’ movement took place. In 
both cases a strong ‘mass’ movement occurred within half an hour, but I did 
not actually see it. In one instance the whole column on the distal side of 
the point d’appni was swept along; while in the other about half of it was 
left behind. In the latter case, however, the colon did not look healthy, and, 
in fact, there was mucous colitis. These two cases are at least distinctly 
suggestive that my hypothesis is correct, and I am now examining the hepatic 
flexure both before and after palpation of the cecum in order to obtain 
more evidence on the point. 
“It is too early to make a definite statement, but I am becoming more 
and more convinced that the keystone to the efficiency of this movement of 
the large intestine lies in the competence of the point d’appuij and that it is 
on the competence of this temporary sphincter that the natural action of the 
bowels depends. Inversely, the failure or incompetency of this valve is 
responsible for the constipation, that is, the ineffectiveness of the ‘mass’ 
movement when it takes place. For if there is no point d’appni the feces 
regurgitate into the cecum, possibly giving rise to the sloppy ceca that we 
recognize and think of as the cause of constipation. Not only so, but in 
time one would expect this to lead to inefficiency of the ileocecal valve. 
“Moreover, if the ‘mass’ movement is not effective, there is nothing 
except the comparatively feeble movement of the cecum to propel the food 
through the large intestine, and when the movements take place, they propel 
the feces in both directions, that is, the mass in the cecum has to act as an 
inefficient point d’appni.” 
5 “I have now seen the formation of a point d’appui in the splenic end of the transverse 
colon. The haustral segmentations first disappeared, leaving a fat sausage-shaped mass in 
which a constriction developed after a few minutes. Shortly after the formation of this 
sphincter, the mass distal to it started and moved comparatively slowly, in about 44 seconds 
I should say, around the splenic flexure and down to the rectum.”—Barclay. 64 
GASTRO-ENTEROPTOSIS 
As corroborative evidence of this theory of Barclay’s and, furthermore, 
of the probable truth of Keith’s suggestion that there is probably a sphincteric 
tract at the beginning of the ascending colon, I will relate the following case: 
The patient was a man, about forty years of age, who came to my associate 
Dr. Sears suffering from intestinal obstruction which proved to be a carcinoma. 
On May 20, 1920, I operated for carcinoma of the left half of the transverse 
colon. At that time most of the transverse colon was removed, practically 
all of the omentum, most of the transverse mesocolon, including the mesen- 
teric glands. The appendix was removed and the cecum anastomosed with 
the sigmoid colon. The proximal cut end of the transverse colon was turned 
in by a purse-string and allowed to remain. 
The patient always had trouble afterwards, although the contents of the 
cecum were delivered into the sigmoid. The condition gradually grew worse. 
The patient complained, giving symptoms of intestinal obstruction, although 
the bowels would move. An enlargement gradually developed on the right 
side of the abdomen with visible peristaltic waves. These waves moved 
from below upward. Our diagnosis was that a loop of small intestine had 
probably become strangulated and was partially obstructed, inasmuch as an 
opaque enema showed by the X-ray that the cecosigmoidostomy opening was 
good. 
On opening we found there was no obstruction of the small intestine; 
that there was a tremendously dilated ascending colon, up to the first part of 
the transverse colon, which had been turned in. At first it was quite puzzling 
to know why all these symptoms. Finally we concluded that the intestine 
had probably been dilated by peristaltic waves trying to force the contents 
of the cecum upward in its normal wave against the turned-in end of the 
colon. We, therefore, decided to remove the ascending colon and the first 
part of the transverse colon, which had been left at the former operation. 
This we did, removing the ascending colon down almost to the ileocecal 
valve, leaving just enough room for it to empty. We had a large cecosig- 
moid opening; therefore, we felt it was all right. 
This second operation was done on January 22, 1921. The obstructive 
symptoms have been entirely relieved and we feel our deductions were 
correct. In leaving the large dead end above the ileocecal valve at the first 
operation and expecting all the contents of the ascending colon to be delivered 
backward into the sigmoid, we had made a mistake. The peristaltic waves still 
continued to act as they did before. 
This case indicates that in certain individuals, at least if the fecal contents 
get by a given point in the ascending colon, the tendency is to drive toward 
the splenic flexure. It may be that this point is the point d’appni referred 
to by Barclay. CHAPTER VII 
THE ROLE OF HABIT IN CONSTIPATION 
Very few of us realize what an important role habit plays in all of our 
acts. By far the greater part of our work is done without a thought of how 
it is done. Rarely can a man correctly state the moves he uses to dress 
himself, or the surgeon to cleanse his hands, or to prepare a field for 
operation. 
We speak of habit. What do we mean by the word “habit?” James 
says. 
“The most complex habits are nothing but concatenated discharges, due 
to the presence there of a system of reflex paths, so organized as to wake 
each other up successively, the impression produced by one muscular con- 
traction serving as a stimulus to provoke the next until the final impression 
inhibits the process and closes the chain. ... In action grown habitual, 
which instigates each new muscular contraction to take place in its appointed 
order, it is not a thought or a perception, but the sensation occasioned by 
muscular contraction just finished. A strictly voluntary action has to be 
guided by an idea, perception and volition through its whole course. In a 
habitual action mere sensation is a sufficient guide, and the upper region of 
the brain and mind are set comparatively free. In habitual actions the only 
impulse which the centers of idea or perception need send down is the initial 
impulse, the command to start.” 
He further illustrates this point by comparing the formation of habit to 
water, which “in flowing, hollows out for itself a channel, which grows 
broader and deeper, and after having ceased to flow, it resumes, when it 
flows again, the path assumed by itself before. Just so the impressions of 
outer objects fashion for themselves in the nervous system more and more 
appropriate paths, and these vital phenomena recur, under similar excite- 
ments from without, when they have been interrupted a certain time.” 
Carpenter says: 
“Our nervous system grows to the modes in which it has been exercised.” 
In another place James refers to Rip Van Winkle, in Joseph Jefiferson’s 
play, who always excuses himself every time he is drunk by saying, “I won’t 
count this time.” 
65 66 
GASTRO-ENTEROPTOSIS 
James says: 
“Well, he may not count it, and a kind heaven may not count it, but it 
is being counted none the less; down among his nerve cells and fibers, the 
molecules are counting it, registering and storing it up to be used against 
him when the next temptation comes.” 
This is true even in the absence of a nervous system. Dumont says: 
“By habit a violin used by a master for a number of years acquires 
beautiful tones because the fibers of the wood at last contract habits of vibra- 
tion conformed to harmonic relations.” 
There is probably no other subject pertaining to disease in which habit 
plays such a conspicuous part as in constipation. 
Cannon, in discussing this subject says: 
“Inasmuch as defecation is a reflex initiated by the presence of feces in 
the rectum, it is a matter of much practical importance to know that the 
rectal mucosa soon becomes adapted to the presence of fecal accumulation 
and then fails either to induce a desire to defecate or to initiate reflex con- 
traction of the colon. If the call to defecate is not promptly obeyed, it ceases 
to be given and the feces stagnate in the rectum.” 
Constipation in animals, if on normal and well-balanced diet, is very 
rare. This is due partly to the fact that quadrupeds are not surrounded by 
conventionalism, and, unless trained, always permit the bowels to act when 
the impulse is given. It is very different with the human. Customs of our 
society are such that young people in the formative stage are very sensitive 
and falsely modest on these questions, and rather than let it be known to the 
opposite sex that these functions are performed, the contents of the bowels 
or of the bladder are retained at great pain and discomfort. Possibly the 
next day or some days afterwards the same necessity arises for holding the 
contents of the bowel. This time it is easier. Next day it is still easier, 
and as time goes on the sensation is gradually lost. The fecal matter be- 
comes hardened by lying constantly in the bowel, the chemicals that normally 
stimulate the bowels to act are absorbed, and finally the individual fails to 
recognize the presence of fecal matter in the lower bowel. As a result it is 
either lifted back into the cecum and other portions of the colon or remains 
in the rectum and sigmoid unnoticed. 
When I visited Sir W. Arbuthnot Lane, in January, 1912, he expressed 
his great disappointment that frequently his patients who had been short- 
circuited, or in whom the colon had been removed, were still very much 
constipated. Several years ago, I removed the ascending colon and part of 
the transverse colon, and implanted the ileum low down into the pelvic colon 
in a patient, for the reason that no ordinary means would produce normal THE ROLE OF HABIT IN CONSTIPATION 
67 
bowel action. For the first two months after the operation, she had diarrhea, 
which, however, gradually decreased; then for a few weeks bowel action was 
satisfactory. After that time she developed constipation practically as severe 
as before the colon was removed. X-ray pictures taken at this time showed 
that bismuth went through the small intestine in normal time, a part of it 
lingering in the ileum for a while, but practically all of it being in the rectum 
in six hours, where it remained for days without moving up or down, and 
without producing any sensation. We found that the remedy required, even 
though she had had an ileosigmoidostomy, was a simple enema. A few 
months later this case was examined, showing that the bismuth, instead of 
passing through the rectum, gradually passed into the dead end of the colon 
above the anastomosis. After these pictures were taken, the remainder of 
the colon was removed down to the ileosigmoidostomy opening. Severe 
diarrhea again developed immediately after the operation and continued for 
several weeks, gradually diminishing and becoming intermittent, at which 
time the patient felt quite comfortable for a few months. Now the patient 
is again severely constipated—in fact, is fully as miserable as before any 
operation was performed. At the time of this second operation, it may be 
stated that hard lumps of fecal matter were noticed for nearly four feet up 
the ileum above the anastomosis, although a cathartic had been given before- 
hand. This is not a case of hyperrepulsion, but of simple, habitual con- 
stipation, in which the intestine had ceased to respond to the stimulus of the 
presence of fecal matter. CHAPTER VIII 
RELATIVE EFFECT OF CONSTANT AND INTERMITTENT OBSTRUCTION 
That kinks in the gastro-intestinal tract, found in the ptotic individual, 
have anything to do with obstructing or retarding the onward flow of the 
gastro-intestinal contents, has been persistently disputed by many of the 
leading medical men and surgeons of the world, notwithstanding the fact 
that practically all of those who have carefully studied the subject agree 
that such kinks do produce a slowing of the gastro-intestinal contents. The 
chief reason given by those who dispute the bad effects of such angulations 
is that in an organic obstruction due either to a growth of a constricting ring 
or band, the wall of the viscus above the obstruction is always hypertrophied, 
and its musculature is greatly increased by its effort to overcome the obstruc- 
tion. On the other hand, in cases of so-called obstruction found in ptotic 
individuals, the cecum and other portions of the intestinal canal may be 
widely distended, with walls thin and atonic, and yet on the operating table 
may show no obstruction. We believe that it is not at all necessary to 
attempt to refute these well-known and well-established facts. There is one 
physical fact which has apparently been overlooked. It is that the obstruc- 
tions produced by angulations of the intestine of the ptotic individual are 
due entirely to gravity, and are positive only when the individual is in the 
erect posture—the kinks being relieved as soon as the patient assumes the 
recumbent posture. The obstruction in the ptotic individual is intermittent, 
while an organic obstruction is constantly present. 
In cases of midline ptosis, we often find a patient whose fat has been 
absorbed and whose stomach is down in the middle, dragging from its two 
fixed points, namely, the second portion of the duodenum and the oesophagus. 
In such a case we often have a stomach which does not empty in normal time, 
the contents of which become very foul and excessively acid, producing 
eructation of sour gas, and discomfort very similar to an organic obstruction. 
The same thing is true of the colon in midline ptosis with both of the flexures 
firmly fixed and the transverse colon prolapsed. The cecum, as well as the 
transverse colon, becomes dilated. Such patients when put to bed on forced 
feeding and bowel regulation diet are very soon relieved of their obstruction 
and the stomach and intestines rapidly come to normal. The reason for this 
phenomenon may be a purely physical one. The second fixed point of the 
stomach, which is at the second portion of the duodenum, is suspended by 
its firm supports located here, just as if a soft, flexible tube were hung over a 
nail on the wall. If the stomach were in this condition a perfectly lifeless 
68 EFFECTS OF CONSTANT AND INTERMITTENT OBSTRUCTION 
69 
organ, and if we were dealing purely with mechanical conditions, the greater 
the weight of the organ the greater the collapse of the tube at this point. 
This collapse, in the case of the bowel, is relieved as soon as the patient lies 
down. The matter of holding the contents without effort in these lazy, 
dilated, atonic stomachs until a suitable regularly established time for empty- 
ing arrives, becomes a habit with the muscles of the stomach, and but little 
effort is made to empty it until this favorable time comes. In other words, 
the tolerance to the presence of food may be established, which is often 
acquired to a degree that permits a large dilation of the stomach or the large 
intestine, as the case may be. This is more particularly true if intra-abdomi- 
nal pressure has been reduced by loss of fat. 
The types of bands described by Lane can only have a relation to in- 
testinal stasis when they tend to hold up a ptotic organ. The type of band 
which Dr. C. H. Mayo described as producing Lane’s kink and which holds 
the small intestine down to the side of the pelvis, and which I personally 
thought was very important at first, has not, in my experience, proved very 
important. Such bands we cannot detect by the X-ray, and they probably 
have very little to do with the production of intestinal stasis. It is probable 
that these bands are chiefly congenital or inflammatory and are not the 
acquired bands which have been laid down by the crystallization of lines of 
force in response to a drag by the weight of a prolapsed organ. Bands 
which have developed for the purpose of holding up the abnormally movable 
intestine, if limited in area of attachment, may form a sharp suspending 
point which may produce intermittent obstruction, such as is produced in the 
stomach and intestine, as just related. One of the best illustrations of this 
type of band is the shortening of the mesentery of the ileum about four 
inches from the ileocecal valve producing a fixed point and forming one 
side of the parallelogram of forces described by Lane (Figs. 66 and 90). 
Acquired bands which web the transverse colon to the ascending and descend- 
ing colon, as described by Pilcher, Lane, and by the writer (Fig. 142), as 
early as 1902, are of some importance in making a ptosis permanent. 
We shall see later in the clinical discussion of this subject that one of 
the principal diagnostic and prognostic points is that the patient who is 
constipated as a result of ptosis finds relief from the constipation on going to 
bed, with the proper diet, while a patient whose constipation is due to habit 
or possibly to other forms of defective or erratic motility is not relieved 
and is often made worse on going to bed. CHAPTER IX 
ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
A child born with an ascending and descending colon which has not 
normally fused with the parietal peritoneum possesses the potential elements 
for the development of the ptotic adult (by which we mean a patient with 
prolapsed ascending and descending colon, with movable kidneys) and in 
which the characteristic and well-known body habit of such patients exists. 
This condition is called “enteroptosis.” Such a condition cannot develop 
when normal prenatal peritoneal fusions have taken place and may, there- 
fore, be called “congenital abdominal ptosis.” 
Longyear has written a very lucid monograph 1 on “Nephrocoloptosis” in 
which he describes a bundle of fibrous tissue back of the colon which he 
claims connects the kidney with the posterior surface of the ascending and 
the descending colon. He believes, and has given good evidence to show, 
that the floating kidney is pulled out of position by the weight of the colon, 
which agrees with Glenard’s original statement, “Enteroptosis without 
nephroptosis, but never nephroptosis without enteroptosis.” The idea of the 
importance of the nephrocolic ligament was suggested to him by the follow- 
ing case: 
“The operation referred to took place at the Solvay Hospital, Delray, 
Michigan, December 3, 1903. The patient, a girl of sixteen years of age, had 
complained more or less of constant pain in the region of McBurney’s point 
and increasingly obstinate constipation for over a year. After a thorough 
examination (no radiograph), in which everything was negative, excepting 
a sensitive area in the supposed location of the cecum and appendix, appen- 
dectomy was decided upon. At the operation, the cecum, with the appendix 
deformed by adhesions to itself, was found in the bottom of the pelvic cavity. 
During the manipulation it was noted that the right kidney could be pulled 
well down into the abdomen by making traction on the cecum and, more- 
over, could be held in the prolapsed position by continuing the traction, so 
that it was impossible to return it to its normal position by counter-pressure 
with the finger inside the abdomen. On removal of the traction, however, 
the kidney quickly slipped up to its normal position. These observations led 
to investigations on both the cadaver and the living subject, with the object 
of ascertaining what connection there could be between the gut and kidney 
that was strong enough to give such a manifestation. The result was the 
isolation of the tissue, which I call the nephrocolic ligament, as the only 
1 Published by C. U. Mosby & Co. of St. Louis, Mo. 
70 ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
71 
union between the gut and kidney which was strong and inelastic enough 
to cause the kidney to be so readily pulled down. 
“This girl’s constipation continued to increase, and one year after the 
appendectomy, reasoning from my previous observations, I concluded that 
the torpidity of the bowel was due to the low position of the cecum, and 
made a nephrocolopexy, solely to relieve the constipation. The operation 
was a marked success, and has continued to be so up to a very recent date 
(October 17, 1908). At this operation the nephrocolic ligament was found 
Fig. 64.—Ligamentum Nephrocolicum. (Longyear.) 
This illustrates the location of the nephrocolic ligament, showing the right kidney attached 
to the colon and cecum by the peritoneum and the nephrocolic ligament. The peritoneum has 
been drawn aside with a cord, and the nephrocolic ligament is shown isolated and drawn away 
from the gut by the author’s forceps hook. The cecum has been turned half around in order to 
show the insertion of the nephrocolic ligament, the ileum being turned under the cecum. 
to be long and lax, which accounted for the kidney remaining in place with 
such a marked coloptosis” (Fig. 64). 
As far as I know, this was one of the earliest, if not the earliest, of 
intelligent suggestions as to the nature of what we now classify as “right- 
sided ptosis.” 
Longyear quotes Reed, of Cincinnati, and Zukerkandle, who contend that 
the fibers of this ligament are inflammatory. He also makes the following 
statement: 72 
GASTRO-ENTEROPTOSIS 
“Billington’s observation that this condition is peculiar to cases of 
nephroptosis coincides with that of the author, and seems to cover a valuable 
point in the anatomic experience of some others who, failing to find the 
ligament as described, base their opinions on the examination of subjects 
who have had no displacement of the kidney.” 
Fig. 65.—Transverse Section Showing the Relations of Gerota’s Capsule and the 
Nephrocolic Ligament. (Longyear.) (After Gerota, with supplemental notations.) 
1. Psoas muscle. 
2. Body of the sacrolumbalis muscle. 
3. Quadratus lumborum muscle. 
4. Peritoneum (dotted line). 
5. Kidney. 
6. Anterior lamella of Gerota’s capsule (be- 
coming attenuated as it passes downward and 
merges with the nephrocolic ligament). 
7. Colon. 
8. Subperitoneal fascia. 
9. Proper point of entrance to Gerota’s cap- 
sule in the operation of nephrocolopexy (close 
to quadratus lumborum muscle, and just below 
the twelfth rib). 
10. Improper point of entrance in the 
operation of nephrocolopexy (peritoneal cavity, 
and not Gerota’s capsule, will be entered). 
11. Nephrocolic ligament. 
12. Posterior lamella of Gerota’s capsule. 
Thus, Longyear himself practically admits that the ligament does not 
exist in a perfectly normal individual. In his monograph he uses a picture 
which illustrates the relation of Gerota’s capsule and the nephrocolic liga- 
ment (Fig. 65), and shows a colon attached to the front surface of the kidney 
by the nephrocolic ligament. The colon has not fused with the parietal peri- ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
73 
toneum over beyond the kidney, therefore is not normally fixed, as we have 
shown by the previous studies in embryology and anatomy. It is very clear 
that Longyear’s illustration is taken from such a case as we have described as 
the second type of nonfusion, and, therefore, does not represent a normal sub- 
ject. Longyear’s nephrocolic ligament, therefore, is without doubt an ac- 
quired or postnatal developmental process due to the laying down of crystal- 
lized supports in the form of strong fibrous connective tissue in response to 
the drag of the colon on its attachment to the kidney; corresponding to the 
acquired membrane described later in this chapter by Lane, except that in 
Longyear’s ligament, the crystallization takes place back of the peritoneum 
rather than in front of it. Longyear also frequently refers to the hepato- 
duodenal and hepatocolic ligaments, and gives a lucid description of the 
mechanism of right-sided ptosis, which practically all students agree affects 
not only the colon and kidney but also the duodenum, bile ducts and 
pancreas. Longyear’s description of what actually occurs in right-sided 
ptosis has scarcely been excelled in any publication, but he fails entirely 
to carry the reader back to the prenatal fusions, in which all authori- 
ties of embryology agree, and upon which the beautiful chain of clinical 
pathology which he has constructed must necessarily rest. While Longyear 
has thus failed to reach the fundamental underlying cause of ptosis, he has 
given us one of the most clear-cut illustrations of the evil effects of a mobile 
ascending and descending colon that has yet been given. Longyear has 
furthermore failed to grasp the importance of the shape and poise of the 
abdominal cavity. He also has failed to emphasize the importance of intra- 
abdominal pressure; but so accurate has been his observation of the clinical 
appearance of the case that he has evolved one of the most complete and 
effectual systems of therapy yet brought out. 
Sir W. Arbuthnot Lane, whose brilliant and startling work has attracted 
more world-wide attention than any one who has written on the subject of 
gastro-intestinal stasis, bases his theory of the relation of ptosis and gastro- 
intestinal stasis on what he terms the law of the crystallization of lines of 
force, which theory he developed from the study of the skeleton in the dis- 
secting room in the years prior to 1887, and from which studies he formu- 
lated the three following laws: 
“1. That pressure produces changes in the structure and form of the 
bones and in the form and function of existing joints, while it determines the 
formation of new joints. 
“2. That strain produces changes in the form of the bones, and in the 
form and function of existing joints, and also produces new joints. 
“3. That when, apart from the exercise of pressure or strain, it is impor- 
tant, from the altered mechanical relationship of the individual to his sur- 
roundings, that a mechanism should be modified or an entirely new one 
developed, such a change takes place.” 
He then calls attention to various occupational evolutionary changes in 
the skeleton and shows how the spine and thorax of a brewer’s drayman 74 
GASTRO-ENTEROPTOSIS 
becomes curved in such a manner that the barrel of beer practically rests 
on a shoulder of bone formed by the curved spine; how an arthrodial joint 
develops in the lumbar spine of the laborer who lifts weights from the ground; 
how the last lumbar vertebra is dislocated backward on the sacrum in the 
laborer who carries loads in front of him; how the spine becomes curved in 
the laborer who carries loads on the head; how a new joint forms in the 
neighborhood of the atlas and axis in the shoemaker; how shoulders of 
bone form in the neighborhood of the coal-trimmer’s joints, whose motions 
are limited to a few very definite movements, these shoulders of bone so 
encroaching upon the joints that it finally becomes impossible for the laborer 
to move them beyond these accustomed degrees of motion. He then attempts 
to apply these rules or laws to abdominal ptosis and gastro-intestinal stasis. 
He bases his entire theory of gastro-intestinal stasis on the question of 
evolutionary bands which have been called forth or laid down in response to 
nature’s efforts to hold up the abdominal organs with the subject in the erect 
posture. He, seemingly, would lead the reader to the assumption that all 
mankind is born with perfectly mobile abdominal organs and all have mesen- 
teries like those found in the quadruped. He ignores, and even ridicules, 
the theory of prenatal adhesion and fusion, which has been proven to the 
entire satisfaction of most embryologists and anatomists, and which is said 
to exist in 80 per cent of normal infants at birth. The reader is left to 
assume that the flexures of the colon are drawn up by evolutionary bands 
that have developed after birth, and he makes the statement that the earliest 
of these evolutionary bands is found in the neighborhood of the sigmoid, and 
is often developed as early as the second year after birth. He describes the 
cecum as a large, pendulous bag with a mesentery, which the reader is left 
to infer is the normal cecum, and shows how, in certain instances, these 
lines attempt to hold it up by a parallelogram of forces. In certain instances 
the outer limb of the parallelogram of forces is manifested in bands which 
seize the appendix and hold it from that side, while the inner limb of the 
parallelogram of forces is manifested by adhesions which shorten the mesen- 
tery of the ileum and hold this pendulous cecum from the other side. In 
some instances the appendix points toward the median line in these cases 
and has been caught up by the bands and forms the inner limb of the 
parallelogram of forces. The picture he describes is a very definite reality 
and has been seen by me on more than one occasion. 
Lane refers to what has been considered the normal fixation of the 
second part of the colon at the hepatic flexure as belonging to his classifica- 
tion of secondary evolutionary bands, and contends that the condition which 
we have denominated as midline ptosis is due to contractions of bands at 
these flexures, which become shorter as time goes on, thus making the flexures 
much sharper, instead of the belief that the flexures remain permanent at 
their normal points of fixation and the organs drop lower. Lane also refers 
to the folds in the neighborhood of the jejunum as secondary evolutionary 
bands, developed in response to a drag on this part of the intestine by a 
loaded ileum. ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
75 
It is without doubt true that Lane’s pictures of the evils and far-reach- 
ing consequences of intestinal stasis are tremendously overdrawn and it is 
probably true that his teaching has been the cause of some harmful surgery. 
It is equally true that there is something very important connected with the 
subject, that beyond any doubt intestinal toxemia is one of the important 
causes of disease and the distress which afflicts mankind. Lane, more than 
all others combined, has in stentorian tones sounded the alarm and called 
the attention of the people to this phase of practice. Being fearless and 
having a great personality, he has carried conviction and has caused even 
the most lethargic to arise and think. Lane’s observations have been so 
extensive and are so susceptible of proof in most instances that I quote from 
his article published in the Proceedings of the Royal Society of Medicine, 
No. 5, Vol. VI, March, 1913, setting forth briefly some of the principles 
which form the basis of his work. 
“In civilization the trunk is retained in a vertical position during the 
entire daytime, the reclining posture being assumed only at night. Even then 
the horizontal posture is modified in character from that normally assumed 
in savage life. The resting posture of the trunk is the prone position, which 
is that which is naturally assumed in sleep upon the ground. While in the 
erect position of the trunk all the viscera tend to displace downward toward 
or into the true pelvis, in the prone position the tendency is for them to fall 
upwards and forwards out of or in a direction away from it. If these 
attitudes were assumed in a normal association the structures in the abdomen 
would retain their normal relationship to the abdominal wall and to one 
another. If, however, the attitude of activity is not compensated for suffi- 
ciently by the corresponding resting posture, changes will certainly take place, 
varying in degree with the failure of compensation. It is now our business 
to study in detail the changes which arise in the several abdominal struc- 
tures in consequence of this. The portion which is affected in the first in- 
stance is our drainage scheme, or, as it is commonly described, the gastro- 
intestinal tract. 
“The large intestine forms the cesspool of this tract. As it retains its 
contents for a comparatively long time, and as most of these contents are 
of a solid consistence, it is natural that by its weight and situation it should 
tend to become displaced earlier in the lifetime of the indivdual. 
“In the erect posture the cecum and ascending colon become filled with 
more or less fluid contents, and by exerting a hydraulic pressure on the cecum 
tend to tire out its muscular wall and dilate its cavity. By the same means 
there is a tendency for the dilated cecum to be displaced downward into the 
true pelvis, where its presence is detrimental to the true comfort and func- 
tioning of the viscera, to which that space normally belongs. 
“This tendency to displacement in the cecum in a downward and inward 
direction may be regarded as acting along the resultant of a parallelogram 
of forces, and, to oppose this tendency, resistances develop which correspond 
in position and action to the sides of the parallelogram. These lines of 76 
GASTRO-ENTEROPTOSIS 
resistance are crystallized first as bands, and later as distinct membranes, 
which, as the outer limbs of the parallelogram, connect the peritoneum lining 
the abdominal wall to the outer surface of the colon in its immediate vicinity. 
A larger area of abdominal peritoneum and of colon is gradually involved, 
and later still, as is the case in all resistances which are crystallized in peri- 
toneum, the bands are replaced by a layer of peritoneum which clings and 
tends to support the colon from the outside. As these bands and membranes 
develop, blood-vessels form in them which later may become sufficiently 
large to require to be ligatured if divided. This particular resistance, when 
fully developed into a membrane, has recently been termed ‘Jackson’s mem- 
brane,’ and the manner in which it should be dealt with has afforded surgeons 
an excuse for doing many operations whose object is not very apparent, and 
which suggest ignorance of the factors determining its development as well 
as of its function. These crystallized resistances of peritoneum are not 
limited to the cecum, but may extend up along the outer aspect of the 
ascending colon, even to the hepatic flexure. 
“At this flexure a number of new bands are formed overlying the normal 
peritoneum and attaching the flexure. These bands as they develop drag 
the flexure upwards, and in some cases produce a distinct obstruction. 
“The bands or membranes are liable to constrict the lumen of the ascend- 
ing colon usually at the level of the crest of the ileum. 
“The inner limb of the parallelogram of forces is represented at an early 
period by opaque streaks on the under surface of the mesentery, attaching 
the last few inches of the ileum, and commencing at its base at a point most 
distant from the bowel. The reason of this development is obvious. Be- 
sides retaining the end of the ileum in position, the mesentery assists through 
the medium of the termination of the small intestine in holding up the cecum 
and in tending to oppose its downward displacement. 
“The thickening in the under surface of the mesentery becomes more 
distinct, and later develops into a membrane which extends to, and secures, 
the under surface of the circumference of the ileum, and gradually creeps 
around it till it reaches that portion of the circumference immediately opposite 
the attachment of the mesentery. As it extends around the ileum, it also 
contracts, with the result that it twists the ileum on itself along its longitudi- 
nal axis. In its earliest development, as is the case with most conditions 
which evolve during the lifetime of an individual, because of a variation 
from the normal in the relationship to his environment, the effect of this 
acquired ligament or mesentery is useful and physiological, but later, when 
it kinks and obstructs the lumen of the ileum, it exerts a progressively 
deleterious effect on the well-being of the individual.” 
In Figs. 66 to 76 inclusive, Lane has set forth very graphically but simply 
his idea of the mechanism of what he terms acquired bands. In Figs. 77, 
78 and 79, he calls attention to the various secondary developments in the 
sigmoid which are explained in the legends. 66 
Fig. 66.—Represents the 
Distended Loaded Bow- 
el Dragging upon the 
Resistances Evolved 
to Oppose Its Down- 
ward Displacement 
into the True Pelvis. 
(Lane.) 
The resistances exter- 
nal to the cecum are indi- 
cated as arrows showing 
the general direction of the 
strain exerted by bands, 
adhesions, and omental 
structures. The lowest of 
these secures the appendix, 
which in these circumstances 
is kinked. The effect ex- 
erted upon the ileum at its 
point of fixation by the 
weight of the loaded cecum 
on its proximal aspect is 
figured in the diagram. 
67 
68 
Fig. 67.—Diagram Represents the Anchored Portion 
of Ileum with Its Mesentery in an Anteropos- 
terior Plane. (Lane.) 
The contracting bands which develop on the under 
surface of the mesentery, shortening it and attaching 
progressively a varying portion of the circumference of the 
ileum in the vicinity of the mesentery with the consequent 
alteration in the form of the bowel are shown by the arrow. 
The compensatory shortening of the entire mesentery in 
this plane is not indicated in the diagram. 
Fig. 68.—Diagram Showing the Normal Unobstructed 
Condition of the Small Intestine. (Lane.) 
69 
Fig. 69.—Diagram Illustrates the Effect of the Shortening of the Under Surface 
of the Mesentery of the Ileum by Acquired Lines of Resistance. (Lane.) 
This also shows the effect of the loaded ileum on the attachment of the first part of the 
jejunum. 7i 
72 
70 
73 
Fig. 70.—Mechanism of the Appendical Tie or Acquired Resistance When the Appendix 
Forms the Inner Limb of the Parallelogram of Forces. (Lane.) 
The appendix is secured by an acquired membrane or crystallized resistance represented by 
the arrow. The cecum and ileal loop are both distended with fecal contents and have fallen into 
the true pelvis. 
Fig. 71.—Duodenum Usually Terminates Vertically at the Root of the Transverse 
Mesocolon Where It Is Continued into the Jejunum as a Gentle Curve. (Lane.) 
Fig. 72.—A Kinked and Filled Ileum Drags on the Jejunum and Develops an Obstruction 
of the Duodenal Outlet in the Form of Resistances Which Are Laid Down as 
Peritoneal Bands Indicated by Arrows. (Lane.) 
Fig. 73.—Diagram Shows Resistances in the Form of Membranes Which Fix the 
Jejunal Loop so as to Avoid Kinking. (Lane.) 
Nature sometimes avoids angulation and strain on the duodenojejunal junction by developing 
these resistances. The jejunum thus becomes secured from left to right to the under surface 
of the transverse mesocolon by peritoneal bands or membranes. (This is the ordinary membrane 
frequently discovered in doing a gastro-enterostomy and which in some instances it is necessary 
to cut in order to make a successful short loop in doing gastro-enterostomy.) 74 
75 
76 
Fig. 74.—1,represents the prolapsed cecum; 
2 and 7, the crystallized resistances which tend 
to oppose the downward displacement of the 
large bowel and sustain some of the weight of 
the transverse colon transmitted through the 
crystallized resistances 4; 3, the transverse colon; 
5, portion of the weight of the transverse colon 
transmitted through the great omentum to the 
convexity of the stomach; and 6, the acquired 
ligament that secures the duodenum and pylorus 
to the under surface of the liver and gall-bladder. 
(Lane.) 
Fig. 75.—Represents the Several Variations from the Normal Which the Large Bowel 
Undergoes. (Lane.) 
The normal condition is shown as a firm outline, and the altered condition as a dotted outline. 
Note the prolapse of the cecum and transverse colon, the telescoping of the iliac colon and the 
elongation of the pelvic colon. B, T, P indicates the brim of the true pelvis. The hepatic and 
splenic flexures are drawn up and kinked by the development of acquired resistances shown as 
arrows. 
77 
Fig. 76.—The Descending Colon Fixed in the Same Manner as the Ascending Colon by 
Crystallized Resistances. (Lane.) 
Transverse section seen from above. A, muscular and mucous coats. B, peritoneum. C, 
direction of adhesions or acquired resistances. 
Fig. 77.—A Cross-section through the Sigmoid and Mesosigmoid. (Lane.) 
This illustrates the direction and line of traction of the acquired bands. A, muscular and 
mucous coats. B, peritoneum. C, direction of adhesions or acquired resistances. 80 
GASTRO-ENTEROPTOSIS 
Axtell, of Bellingham, Washington, has for a long time laid a great deal 
of stress on the importance of this last sigmoid kink, and contends that it 
is very important in connection with intestinal stasis or constipation. His 
idea is expressed in Fig. 80. He says the symptoms are as follows: 
“Sigmoid constipation as outlined in this paper is insidious and very slow 
of development. The attention of the practitioner is seldom called to the 
condition until the patient has had recourse to all kinds of nostrums and 
78 
79 
Fig. 78.—Irregularly Contracted Resistances or Membranes Showing Double Kinking 
of the Sigmoid. (Lane.) 
DC, descending colon. S, sigmoid. R, rectum. Radiating lines, acquired resistances. 
Fig. 79.—Volvulus of the Iliac Colon at the Junction of the Sigmoid and Rectum. 
(Lane.) 
DC, descending colon. S, sigmoid. R, rectum. Radiating lines show acquired adhesions 
or resistances which produce the fixation and kinking of the colon. 
enemas and finds that, in spite of all treatment, the condition gradually grows 
worse. The first thing that calls attention to it is the increased and persistent 
flatulence, increased discomfort from pressure and sometimes a frequent 
desire for stool. At the time of stool there is an urgent desire but small, 
imperfect results. The relief obtained is not that feeling of well-being and 
comfort that comes from a normal, healthy ejection. There is a constant 
pressure and a feeling as if there were still more to come away. Continued 
effort only increases the discomfort and the difficulty. 
“Digital examination reveals the empty rectal vault and a boggy mass 
alongside of the rectum. Sigmoidoscopic examination reveals, as a rule, the ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
81 
rectum empty and, when the sigmoid is approached, instead of gliding over 
the folds of Houston and dropping into the sigmoid, the end of the instrument 
impinges on the wall at the angle as a complete barrier. If by any means 
the angle can be rounded, beyond is seen only a loop of the sigmoid packed 
with dry fecal material. There is constantly present tympanitis, and usually 
tenderness over the cecum.” 
This description by Axtell forms a graphic, clinical picture of the sig- 
moid kink set forth by Lane. I concede that the observations of Lane, as to 
Fig. 8o.—Importance of Last Sigmoid Kink in Connection with Intestinal Stasis or 
Constipation. (Axtell.) 
A, ulceration. B, adhesions. C, impacted and prolapsed sigmoid. D, acute angulation 
at rectosigmoidal juncture. E, angulation at splenic flexure. F, enlarged and distended cecum. 
these various secondary changes, are very instructive and accurate. In mak- 
ing this statement, however, I do so with the full belief that the pathology 
he describes rarely occurs except in those cases having deficient prenatal 
peritoneal fusion. I believe he has here overlooked the most fundamental 
point connected with this subject. I am heartily in accord with his law of 
crystallization of the lines of force and believe that these lines are crystallized 
when and where they are needed. But these membranes and bands will not 
develop under this law where normal prenatal fixation has taken place for 
the simple reason that they are not needed. 
In Chapter III, we have learned that normally the ascending and 
descending colon should be fused with the parietal peritoneum in a way 82 
GASTRO-ENTEROPTOSIS 
which practically fixes the intestine. This intestine is fixed on a shelf at an 
angle of fifty-one degrees. If we were dealing with a mechanical vessel in 
normal atmospheric pressure, 30 per cent of the weight of a rolling object 
would be taken up by being placed on a slope rather than suspended (Fig. 81). 
Defects in Prenatal Peritoneal Fusion.—Anatomists and embryolo- 
gists inform us that from 20 to 40 per cent of individuals have not 
had this normal development. In such individuals, the large intestine, par- 
ticularly on the right side, has a mesentery more or less like the arrange- 
Fig. 8i.—Thirty Per Cent of the Weight is Taken up by a 51 ° Slope. 
ment of the intestine in the quadruped. Waugh calls attention to an investi- 
gation made by an associate of his, Dr. Pirie, in a series of postmortem 
examinations of children under twelve years of age at the Great Ormond 
Street Hospital for Sick Children in London. He found, just as other 
anatomists have found, that there was a primitive mesentery or a portion 
of it in 20 per cent of all cases examined irrespective of the diseases from 
which they die. Therefore, 80 per cent started life with no remains of a 
primitive mesentery. In other words, 80 per cent had normal fixation of 
the ascending colon. 
Nonfusion on the left side has but little bearing on our subject except ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
83 
in consideration of general ptosis. Therefore, we shall devote our attention 
to non fusion on the right side. 
There are, of course, a great many variations in the type and extent of 
non fusion. I have divided right-sided nonfusion into four arbitrary types, 
all of which have been seen personally by me and pictured by Mr. Trahar. 
First, I will mention the type nearest to normal, namely, a simple mobility 
of the cecum with normal fixation of the ascending colon. It is probable 
that this type of case in a patient with ordinary normal intra-abdominal pres- 
sure rarely gives trouble. However, it is occasionally found that in such a 
Fig. 82.—Normal Peritoneal Attachment of Cecum and Ascending Colon to Parietal 
Peritoneum. (Sobotta.) 
case the cecum becomes distended, probably by gas and habitual constipation, 
falls over into the pelvis and develops pathological conditions, including the 
formation of membranes. The second degree of nonfusion is probably the 
one which creates most pathology. In this case, the colon has rotated over 
as far as and attached to the front surface of the kidney, the rest of the 
ascending colon and cecum remaining mobile (Fig. 84). Third, the large 
intestine has apparently not rotated over farther than the front surface of 
the duodenum to which it attaches and hangs as a dead weight, all of the 
ascending colon and cecum having a long mesentry (Fig. 85). The kidney 
is exposed. In the fourth type of nonfusion which we have described, the 84 
GASTRO-ENTEROPTOSIS 
ascending colon has not fused to the parietal peritoneum, and the kidney and 
duodenum are entirely exposed just as seen in the quadruped (Fig. 86). 
Floating kidney is rarely seen either in type three or four, lending much 
evidence to Longyear’s theory that the kidney is ‘dragged out of its position 
by an attached colon. 
From these four stages or types there are an infinite number of grada- 
tions, even to the extremes of nonmigration of the cecum from the left side, 
and, in one personal case, there was extension of the duodenum down around 
the end of the cecum, just as it is found in the dog. It is unnecessary to 
relate all these variations in the development of the general conception. 
Fig. 83.—Picture Illustrating the Normal Visceral and Peritoneal Relations of the 
Ventral Surface of Right Kidney. (Huntington.) 
Note that colon has rotated to the external side of the kidney. 
Significance of Bands and Membranes.—There is probably no more 
bewildering subject connected with the ptosis question than this. In reading 
the literature on this subject, one is reminded of Saxe’s poem of satire on 
theological disputes in which he describes six men of Indostan 
“ Who went to see the elephant 
(Though all of them were blind).” 
The first examined the elephant’s side and decided he was like a wall; the 
second examined his tusk and thought the elephant was like a spear; the 
third examined his trunk and thought he was like a snake; the fourth Fig. 84.—Unfused Cecum and Ascending Colon. (Cecum mobile, second degree nonfusion.) 
Fig. 85.—Third Degree of Nonfusion. (Colon attached to front surface of duodenum.) 86 
GASTRO-ENTEROPTOSIS 
examined his leg and thought he was like a tree; the fifth, who examined 
his ear, was sure he was like a fan, and the sixth who examined his tail 
thought the elephant was like a rope. 
“And so these men of Indostan 
Disputed loud and long, 
Each in his own opinion 
Exceeding stiff and strong. 
Though each was partly in the right, 
And all were in the wrong.” 
Fig. 86.—Complete Nonfusion. (Fourth degree.) 
Certain observers, basing their conclusions on postmortem examinations 
held on the cadavers of newborn babes, have noted the frequent occurrence 
of membranes and peritoneal folds at the beginning and ending of the fused 
peritoneal areas and believe that all noninflammatory membranes and bands 
found in the abdomen are congenital. Others are equally positive that they 
are all acquired. The everyday practical surgeon, seeing the results of acute 
inflammatory conditions, believes that they are all inflammatory. 
Just as the parts observed and described by the six blind men of Indostan 
were essential to the construction of a perfect elephant, so the three kinds ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
87 
of membranes and bands described in surgical literature are essential to a 
perfect picture of the pathology observed in the surgical abdomen. 
There are certain unusual membranes occurring around and below the 
ileocecal junction, around the beginning of the jejunum and at the beginning 
of the second portion of the duodenum, which are congenital and represent 
anomalous fetal developments. It is significant that these congenital mem- 
branes develop only at the beginning or ending of a fused area which indicates 
that they are probably peritoneal remnants in the process of a normal or 
possibly excessive prenatal fixation. Such membranes, as a rule, perform no 
function, do no harm and have no special significance in connection with this 
subject. 
- Then there are bands and membranes which have resulted from inflam- 
matory processes particularly around the ileocecal and appendical region, the 
pelvic colon and generative organs and in the neighborhood of the gall- 
bladder, which are produced in response to an infectious process, having its 
origin in these organs. These bands and membranes are purely inflammatory 
in origin and represent a residue of reparative or protective material. Such 
bands or membranes have no definite direction, have ceased to function, and 
have no bearing on this subject except in so far as they produce mechanical 
obstruction or pain by incidental suspension of a prolapsing organ. 
These two kinds of membranes must be sharply differentiated from those 
conservative membranes which have been alluded to as acquired membranes. 
Such membranes have been noted by J. W. Long, by Lane, and by other 
authors many years ago, but it was left for Jackson and Hall of Kansas 
City to give a perfect pathological description of such membranes. I was 
fortunate enough to be present when Jackson presented his original report 
at the meeting of the Western Surgical Association in 1908 at Minneapolis. 
Jackson’s report follows. 
“Pathological Description.—The following description of this condi- 
tion is presented from the report of Dr. Frank Hall, Pathologist to the 
Kansas City General Hospital, from a specimen found in a postmortem 
subject: 
“ ‘The specimen of ascending colon which you have presented to me as 
a type of the pericolitis you have been interested in exhibits the following 
gross and microscopic features: The specimen presents the caput coil with 
attached appendix, the ascending colon, and a short segment of the trans- 
verse colon. 
“ ‘From a point just at the hepatic flexure to three inches above the caput 
there spreads from the parietal margin over the external lateral margin to 
the internal longitudinal muscle band a thin vascular veil in which long, 
straight, unbranching blood-vessels course, most of which are parallel with 
each other and take a slightly spiral direction over the colon from the outer 
upper peritoneal attachment to the inner lower portion of the gut ending 
just above the caput. The appendix is not implicated in any way. 
“ ‘Coursing with the blood-vessels are numbers of shining narrow bands 88 
GASTRO-ENTEROPTOSIS 
of connective tissue which gradually broaden as they go and end in a slight 
fan-shaped attachment at various points on the anterior and inner surface 
of the colon. At these points of attachment the gut is held in rigid plication. 
“ ‘The entire specimen conveys to the eye the idea that an edematous 
fluid lies beneath this delicate membrane and reminds one of nothing so much 
as an edematous arachnoid, so often encountered on removing the dura 
mater from the brain of a dead alcoholic. The colon seems placed in a 
diaphanous bag slightly too short to contain it without wrinkling. At the 
beginning of the hepatic flexure the drawn membrane particularly angulates 
the contained colon. Here and there are spots and tags of fat beneath the 
cobweb. On handling, the specimen of colon slips about in its bag without 
entire freedom as a fetus without its amniotic sac. A portion of the parietal 
peritoneum has been removed with the colon and shows that the membrane 
and blood-vessels arise in, and are continuous with, the structures of the 
parietal peritoneum, as it sweeps over the colon. The entire structure seems 
to he peritoneum, loosed from its close connection to the abdominal wall and 
colonic surface by some serous exudate after which the particular vascular- 
ization and connective-tissue banding has occurred as a chronic reaction to 
irritative influence. 
“ ‘Miscroscopic sections prepared from blocks of tissue cut entirely 
through to the lumen of the colon present, first, a very loose external cover- 
ing, a normal musculature, a broad submucosa, and a normal glandular coat. 
Our chief interest lies in the serous coat, which is seen to have its fibers 
split asunder as if by a serous infiltrate, thus lifting the endothelial layer of 
the membrane, which is clearly demonstrated to exist as a covering over 
all. The blood-vessels present in cross section and are unusually large and 
thin-walled. Wherever a blood-vessel courses there also is a condensation 
of the white fibers into bands parallel to the vessel. The general aspect of 
the region under discussion is that of a mass of more or less isolated 
fascicles of white fibrous tissue with here and there a blood-vessel filled with 
blood, broad clefts lined with endothelium, and a few fat and connective- 
tissue cells sprinkled here and there 
“ ‘No fibrin, polymorphonuclear leukocytes, or other evidence of inflam- 
mation is present. The connective tissue next to the layer of longitudinal 
muscular coat is condensed and seems to penetrate in increased amount be- 
tween the muscle bundles. Aside from this questionable matter, the gut 
and its walls are normal. The endothelial covering in places on the surface is 
perfectly preserved and demonstrates beyond a doubt that we have here no 
new or false membrane but simply a rarefied and otherwise altered natural 
structure. The enlargement of the endothelial-lined clefts, so abundantly 
observed, suggests a chronic lymphstasis as an associate condition, which is 
possibly a key to the formation of the amount of fluid in the tissue spaces 
of the peritoneum.’ 
“In addition to this description wTe would add some observations of the 
condition as observed in quite a number of living subjects seen in the course 
of surgical operations. The transparent, vascularized veil-appearance of the ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
89 
membrane strikes one’s attention very forcibly, with the parallel bright red 
vessels running with the long axis of the ascending colon. In some instances 
it appears as though the membrane comes on to the colon from the lateral 
parietal wall just above the cecum and courses directly upward to disappear 
beneath the liver on the superior layer of the transverse mesocolon. In other 
instances it seems attached like an adhesion to the under surface of the 
liver, well anterior to the normal peritoneal reflection. Again, in other 
cases, it appears as though it had begun above and descended on the colon 
to its termination, usually just above the cecum. We have also seen it pass 
across and upward to the transverse colon, which, in one instance, was 
apparently drawn down by the membrane, practically paralleling the ascend- 
ing colon to the level of the cecum. In this case the gastric symptoms were 
marked as a result of the mechanical gastroptosis thus produced. In one 
instance this membrane was so dense as to lose entirely its apparent vas- 
cularity and transparency, and it looked like a solid sheet of organized 
fibrous tissue, beneath which the ascending colon was so lost that it could 
not be seen at all until the membrane was divided and brushed aside when 
an apparently normal, though contracted, colon became evident. 
“In no instance does this membrane resemble our ordinary conception of 
an adhesion. It is never adherent to the abdominal wall nor to any con- 
tiguous loops of small intestine. Instead, it resembles more closely than 
anything we can describe a thin pterygium. In recent cases the membrane 
is quite free and produces but limited restriction to the underlying colon. 
In more advanced and characteristic cases it seems to bind the colon close to 
the posterior abdominal wall and produces such marked angulations and 
convolutions of the colon as practically to produce a stricture of its lumen; 
in fact, in one case seen in autopsy when a stream of water was caused to 
flow into the cecum through the ileocecal valve, the cecum distended almost 
to bursting, and yet none of the fluid would pass through the ascending colon 
and past the hepatic flexure until it was milked through with the fingers. It 
is also noteworthy that in the large majority of cases the cecum was not 
involved in the membrane at all; nor was the appendix invested, except when 
it occupied an ascending position at the outside of the colon, and then it was 
covered by the membrane as it was reflected on to the colon from the lateral 
parietal wall. The appendix in almost every case, however, was rather 
small and sclerotic. We have seen the membrane in one case in which there 
had been, years before, an appendicular abscess, which was drained. In 
this case the cecum was likewise markedly involved in the membrane. The 
angulation of the colon is generally most marked at the hepatic flexure. 
There is always a very loose space where the membrane can be easily picked 
up at the outer angle, where it passed from the colon to the outer parietal 
wall.” 
Dr. C. H. Mayo, who was also present, was so impressed with the mem- 
brane of Jackson’s description, that he immediately christened it “Jackson’s 
Membrane.” 90 
GASTRO-ENTEROPTOSIS 
After having such a perfect description of this membrane, our next ques- 
tion is why and how does it develop? Formerly I thought, with Pilcher and 
others, that the immediate irritant which caused the development of such 
structures was bacterial in character. Lane has always contended that such 
membranes and bands represented crystallized lines of force laid down in 
resistance to the weight of prolapsing organs. With a much larger experience 
and a closer observation, I have become thoroughly convinced that Lane is 
right. Furthermore, I am sure that these membranes never develop in the 
neighborhood of the ascending colon except in the absence of normal prenatal 
peritoneal fixation. 
I have made the observation in many of my cases that the membrane 
usually develops on the intestine at a point corresponding, when the patient 
is standing, to the narrow outlet in the abdomen described elsewhere as the 
psoas outlet. So constant has been this coincident that I have begun to 
believe that the pressure of the prolapsed distended cecum with its stagnant 
contents between the psoas muscle on the one and the front abdominal wall 
on the other, may be at least an accessory factor in the formation of the 
membrane. These theories in reference to a possible, immediate cause of 
the development of the membrane do not in the least weaken the contention 
of Lane that they are laid down for the purpose of holding up a prolapsed 
organ in just the same way that the changes he describes as occurring in 
bony structures are laid down to meet the emergency. 
I have been much interested in the observation of the early stages of 
these membranes. My observations have been the same as those of Waugh 
and a number of others who have noted that these patients begin to show 
symptoms between eighteen and twenty-two years of age. The first symptom 
that attracts the attention of the patient, and later the doctor, is pain. The 
patient is usually operated upon for appendicitis, acute or chronic. When 
the abdomen is opened the appendix is found normal. An acute, red, 
edematous condition exists over the cecum and extends back of the parietal 
peritoneum. This growth is somewhat like a mass of red moss over the 
surface of the intestine. It has in all cases been found at the point on the 
intestine referred to above. A few years later a definite membrane or definite 
band forms and the acute red condition usually disappears. 
M. L. Harris has given a good description of the process of formation 
of this membrane in the following words: 
“In the early stages of the condition the wall of the ascending colon 
presents the appearance of being thickened or edematous and, on close in- 
spection, the visceral peritoneum seems to be raised from the bowel wall by 
reason of the appearance of a subdendothelial, hyaline-looking substance or 
exudate. The endothelial layer of the peritoneum, which is slightly movable 
on the bowel wall, gradually becomes separated from the bowel as a distinct 
layer beneath it, covering the bowel wall. There forms another layer of 
endothelial cells. A raised, thin, transparent membrane remains attached to 
the bowel at the longitudinal bands, at which point small blood-vessels may ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
91 
be seen entering and spreading over the thin membrane. Later this mem- 
brane is almost certain to acquire attachments to the anterolateral parietal 
wall. In older cases the membrane becomes thicker, particularly along the 
line of the blood-vessels, which also become larger and more numerous. In 
still later stages, the membranous formation becomes intimately attached 
to the ascending colon. It extends from pouch to pouch of the colon, and, 
on contracting, as all such new formations do, draws the pouches together 
and puckers them up so as practically to obliterate them from the external 
Fig. 87.—Pathology Which Sometimes Accompanies Mobile Cecum. 
This includes pericolic membrane; adherent and kinked appendix acting as a ligament; 
shortened mesentery of ileum producing kink as described by Lane, and also acting as a ligament. 
surface of the bowel. In this stage the membrane can be removed only with 
difficulty and leaves the bowel raw and bleeding.” 
I think there can be no doubt that this membrane has been developed 
for the purpose of holdifig up an intestine which has not been normally fixed. 
At times this membrane develops and remains to do valuable service (Fig. 
87). At other times, it stretches and forms bands (part of the membrane 
giving way and part of it holding the narrow, definite point), which are likely 
to cause severe pain in addition to adding to intestinal stasis (Fig. 88). 92 
GASTRO-ENTEROPTOSIS 
Similar membranous developments take place in connection with the gall- 
bladder and duodenum and present symptoms which often lead to unneces- 
sary, radical operations for their relief (Figs. 89, 90 and 91). 
About five years ago a patient came to our clinic with right-sided ptosis 
and asthenia. She had no pain; the cecum was low down in the pelvis. She 
was put to bed on forced feeding and rest in the recumbent posture. She 
gained about thirty pounds in weight and, at the end of four weeks, she 
began to take exercises consisting largely of walking. The weight kept on 
increasing. She left the hospital perfectly well. Before she left town, an 
Fig. 88.—Diagram Indicates How Pericolic Membrane May Become Constricting Band 
after Hepatic Flexure Has Been Let Down in Process of General Ptosis. 
X-ray picture was made showing the cecum in its normal position above the 
psoas muscle. She was in good condition for several months. Finally, for 
some reason, she lost most of her flesh. Coincident with the loss of flesh, 
she began to develop pain in her right side. She returned for examination. 
X-ray showed that the cecum was in normal position, not movable. Diagnosis 
of appendicitis was made. On opening the abdomen, the appendix was found 
healthy, but two or three strong bands, one of which was an :.nch wide, had 
developed between the parietal peritoneum and the cecum. The attachment 
of these bands corresponded exactly to the location of the pain. Appendix ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
93 
was removed. Bands were not cut but were used as material in the process 
of shortening the mesentery in making an indirect colopexy. Patient was 
completely relieved of pain and made a perfect recovery. 
The only conclusion we could draw from this case was that, during her 
recumbent posture, membranes developed, and the fat, encircling the abdomen 
and filling the mesenteries, continued to hold the intestine in place. During 
Fig. 89.—Acquired Bands of the Type Which Produce Gall-bladder and Duodenal 
Symptoms by the Pull of a Mobile Pendulous Colon. 
this period of recumbency she apparently developed the membranes and 
bands. They gave no trouble until she began to lose flesh. 
I have had another similar case in my experience which came with 
symptoms of appendicitis. She was treated three years before by forced 
feeding and rest in recumbent posture. In her case, however, the cecum 
had not been drawn back above the psoas muscle, and the bands were not 
sufficiently developed during the period of recumbency to hold the intestine up. 94 
GASTRO-ENTEROPTOSIS 
The Ptotic Body Habit.—Goldthwait and Franklin H. Martin have 
laid particular stress on congenital body formation in which the natural shelf 
of the body occupied by the kidneys and colon is much shallower than 
normal. Heredity has apparently much to do with this condition. Goldthwait 
describes such a child as follows: 
“Drooping shoulders, prominent scapulae, the spine inclining upward and 
backward from the lumbar region with very little curve, being almost straight 
Fig. 90.—Duodenal Obstruction at Two Points. (E. L. Kellogg and W. A. Kellogg.) 
Adhesions extend from the gall-bladder across the termination of the first and second portions 
of the duodenum to the prolapsed hepatic flexure of the colon. Treatment consisted of dividing 
adhesions, suturing cecum and ascending colon to posterior peritoneum and restoring the hepatic 
flexure. 
until the upper dorsal spine is reached, when it bends sharply forward. With 
this the abdomen is much larger in proportion than the rest of the body, the 
lower portion being the most prominent, while on palpation and percussion 
the parts are soft and tympanitic.” ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
95 
This theory of the development of the enteroptotic habit or body forma- 
tion is in accord with the observations of Richard R. Smith, who has made 
an extensive study of the enteroptotic habit in more than four hundred 
women and in one hundred and nine children, and also quotes from the 
paper of W. J. Butler, who made a study of one hundred and fifty-three 
children. He states that his findings agree in the main with those of Butler. 
Fig. 91.—The Main Lines of Strain upon the Duodenum. (Waugh.) 
These are shown by the puckered folds of peritoneum which are raised up when the hepatic 
flexure is drawn gently downwards. 
The conclusions of Smith, based on these two hundred and sixty-one frail 
children under twelve years of age, are as follows: 
“The enteroptotic habit of adult life finds its counterpart in the frail 
child presenting the same fundamental characteristics: Frailness, lack of 
fat, slenderness of muscle, lack of vigor in body development. Any actual 
collapse of the thorax, or diminution in the capacity of the upper abdomen, 
is seen only in elder children, and then only exceptionally, even in frail 
subjects. The prolapse of the kidneys, stomach, colon and intestines, which 
accompanies the enteroptotic habit of adult life, is not outspoken in child- 
hood (under twelve years) except in rare instances, and then usually late in 
that period.” 96 
GASTRO-ENTEROPTOSIS 
These observations by Smith have been most painstaking, and it is quite 
probable that any multiple of cases so carefully examined will continue to 
bring the same conclusions. Smith’s studies of this number of children, 
taken with his studies of more than four hundred enteroptotic women, con- 
stitute a very valuable link in the study of ptosis. But after going over all 
his work, we find that there is a missing link. He has examined all of 
these women and children and has found that certain conditions exist, and 
that this habitus develops after twelve years of age, but he fails to tell 
us why it develops at that time. It seems that Goldthwait’s studies 
along the same line have supplied the missing link. Goldthwait thought for 
some time that this characteristic condition, 
known as the enteroptotic habit, was due to 
faulty postures in early life. As his observation 
became more extensive he noted that his theories 
would not entirely account for these cases, and 
as his knowledge of the subject developed he 
reached the definite conclusion that there must be 
congenital defects in most cases. After making 
anatomical and embryological studies along the 
lines which have preceded in this paper, he states: 
“In this development, the colon which origi- 
nally has a free mesentery becomes adherent to 
the posterior abdominal wall in the ascending and 
descending portions, and to the omentum and 
indirectly to the stomach in the transverse por- 
tion. At the time of birth, the development 
should have reached this stage, but apparently in 
a considerable number of cases birth takes place 
before this development is complete. The child 
is born too soon from an embryological point of 
view, and begins life with a movable colon, and 
consequently with less natural support for the 
stomach. The obvious result of this is that, as 
long as the child is an infant and its activities and 
habits are largely those of the quadruped, very little disturbance occurs, but 
when the erect posture is assumed, the disadvantages of such formation are 
evident. With the stomach, the erect position must result in the sagging 
downward of the organ; and since the duodenum is almost always fixed, 
the early embryological mesentery upon this portion of the alimentary tract, 
having ceased to exist at an earlier period than is the case with the colon, 
the effect which this must have upon the evacuation of the stomach contents, 
with the disturbances of digestion resulting therefrom, together with the 
effect of the position and functions of the colon, has been sufficiently well 
described above. With such displacement, if the stomach is affected, there 
must result a gradual absorption of the retroperitoneal and intra-abdominal 
Fig. 92.—Typical Ptotic Figure. 
(Martin.) (Drawing from Rich- 
ard Smith’s collection.) 
Picture shows flat chest, straight 
back and cannon ball abdomen. ACQUIRED OR POSTNATAL DEVELOPMENTAL PROCESSES 
97 
fat tissue, thus naturally increasing the possibility of the visceral sag, and 
naturally interfering with the nutrition.” 
That the characteristic body conformation is due to incomplete fusion in 
the great majority of cases, I think is unquestionably correct. As soon as 
the child begins to keep the erect posture most of the time, these mobile 
organs begin to descend, which causes it to bend the upper part of the spine 
to relax the thoracic fascia. As the intestines have a direct drop (Figs. 
6B, 10B) instead of staying on the shelf and remaining fixed, they gradually 
fall off the psoas shelf, and become a direct 
load. The child, in addition to bending over 
to relax these supports, at the same time tilts 
the lower part of the spine and pelvis forward, 
making the lumbosacral junction much less 
acute and to a certain extent straightening the 
sacrum, as Martin has shown in his work. 
This is done in the effort to get the weight of 
these organs as nearly on the shelf or on a 
supporting point as possible, thus relieving the 
drag on their mesenteries. In other words, the 
individual is trying to carry a load, which, 
while inside the abdomen, is in front of the 
spine. He, therefore, assumes the position 
which an individual assumes who carries a 
load in his arms in front of his body. This 
I have denominated the “front carrying posi- 
tion.” Lane has called attention in his ana- 
tomical studies to the fact that, in the skeleton 
of an individual who habitually carries loads 
in front of him, the last lumbar vertebra is to 
a certain extent dislocated backwards on the 
sacrum (Fig. 93). This position of the 
straight lower back, leaning backward, with 
the curved upper spine leaning forward, makes 
the loins much shallower than normal, so that 
all organs in the abdomen have a direct drop 
and pull on their supports instead of resting on a shelf. Furthermore, 
owing to the disturbance of the gastro-intestinal tract, the nutrition of the 
individual is disturbed, he loses flesh, the peritoneum pulls away from the 
wall, and the organs fall to the bottom of the abdomen; the lower abdomen 
becomes permanently dilated by their presence and weight; the upper abdomen 
contracts to fill the vacancy; the fat is absorbed, thus diminishing intra- 
abdominal pressure; the intestine and stomach become dilated and filled with 
gas, as the result of the lack of the normal intra-abdominal pressure, and the 
digestion is thereby further disturbed, and an atonic gastro-intestinal tract is 
established. Intestinal stasis ensues from which definite pathological processes 
result. 
Fig. 93.—Fourth and Fifth Lum- 
bar Vertebrae and Sacrum of 
Laborer Who Carried Loads in 
Front of Him. (Lane.) CHAPTER X 
PATHOLOGY OF INTESTINAL STASIS 
For scientific information along this line, we must look largely to the 
British, working under the stimulation and leadership of Sir William 
Arbuthnot Lane. It has been studied under three headings: Bacteriology, 
Toxicology and Organic Pathology. 
In order to avoid misquotations and misrepresentations, I have obtained 
the permission of those who have done the principal part of this work to use 
much of their original records. 
Bacteriology.—Working under a grant from the British Medical 
Association, N. Mutch 1 prepared a very exhaustive and scientific study on 
bacteriology of the gastro-intestinal tract. With his kind consent, I am able 
to produce the summary of his work which is as follows: 
“In tracing the distribution of the aerobic bacteria of the alimentary 
tract in healthy adults, a moderately varied and luxuriant flora is met with 
in the mouth and stomach; the duodenum, jejunum, and most of the ileum 
are relatively sterile; a few bacteria are found in the lowest coils of the 
ileum, whilst the colon teems with innumerable organisms. There would 
seem to be a continual inflow of vegetable life through the mouth, a constant 
destruction in the stomach, and a studied encouragement of growth in the 
colon. The bacteria of the duodenum and jejunum probably represent the 
surplus which has escaped destruction in the stomach. Those of the ileum 
are the resultant of an ascending infection from the colon and the remnants 
of the inflowing stream from above. 
“Apparently the ideal which our vital mechanisms strive to attain is 
sterility of the alimentary tract above the ileocecal valve, with very free 
bacterial growth below that barrier. The reason for this is not far to seek. 
The upper portions of the intestinal tube are laden with food products, use- 
ful alike for human and bacterial life. The presence of many organisms in 
these parts would result, not only in much waste, but in the production of 
highly poisonous modifications of our food materials, such as amins and 
ptomains. On the other hand, although the colon can absorb sugar and 
proteolytic products as well as water and salts, normally it is given very 
small opportunity of exercising this function. Mere traces of absorbable 
carbohydrates and amido-acids pass the ileocecal valve, their loss is incon- 
siderable, and it is most important that toxic modifications should not be 
1 Brit, Journ, Surg., 2:6o8. 
98 PATHOLOGY OF INTESTINAL STASIS 
99 
produced. A luxuriant colonic flora is therefore provided, to ensure their 
rapid destruction into relatively innocuous bodies, such as phenol, ammonia, 
water, carbon dioxid, and hydrogen, whilst being stored up for daily 
evacuation. 
“To put the matter briefly, the upper alimentary tract is specialized for 
aseptic absorption of food, and the colon for the bacterial destruction of 
residues. It is conceivable that disease may arise from infection of the 
lumen of the upper alimentary tract, with the generation of poisonous de- 
composition products; or from infection through the walls of the alimentary 
canal, with discharge of bacterial toxins into the circulation.” 
Mutch then takes up the decomposition in the various parts of the alimen- 
tary canal. Concerning decomposition in the stomach, he says this is domi- 
nated by the amount of carbohydrate present and concentration of the hydro- 
chloric acid. Unless the acidity is very markedly diminished, only a limited 
variety of organisms can flourish. Even with marked hypo-acidity, gastric 
stasis is necessary for much bacterial action. Hypo-acidity and motor dis- 
ability are found in most cases of gastric carcinoma. They occur also in the 
simpler cases of intestinal stasis, in which neither cancers nor ulcers are 
present. He believes decomposition in the duodenum is rare under normal 
conditions. In constipation, however, there is often marked stasis in the 
duodenum and, from such duodenums, pathogenic bacteria can be cultivated. 
He studied the rate of stomach evacuation in 12 cases of marked duodenal 
dilatation. Dilatation was detected either by laparotomy or orthodiagraphic 
measurement. He gives the following table: 
Time of Emptying of Stomach in Duodenal Dilatation 
Patient 
Operative Findings— 
Dilatation 
X-Ray Measurements of 
Descending Limb 
Time (in hours) for 
Emptying Stomach 
R. J- 
moderate 
8 
K. L. 
extreme 
9 
P. S. 
extreme 
A. R. 
extreme 
8 
C. M. 
moderate 
5 
A. H. 
moderate 
A. B. 
moderate 
4 in. 
8 
D. P. 
moderate 
4 in. 
8* 
K. S. 
moderate 
4 in. 
5 
M. K. 
moderate 
S in. 
3 
J- F. 
moderate 
in. 
4 
A. S. 
moderate 
5 in. 
5 
(ClAf. (fi J 
“It will be seen that the stomach was empty in less than four hours in 
one case only, and that the average time of emptying was more than six 
hours. Extreme duodenal dilatation is, therefore, usually associated with GASTRO-ENTEROPTOSIS 
100 
marked gastric stasis. The probable teleological explanation of the phe- 
nomenon is, that delay at the upper end of the alimentary tube is nature’s 
remedy for a greater accumulation of food in the lower ileum than that 
portion of the canal can deal with at the moment. 
“The importance of this means of regulating the inflow of chyme into 
the jejunum is illustrated by the case of M. B., age twenty-six, who suffered 
from constipation, with marked ileal delay of about fourteen hours’ duration, 
gastric delay of six hours, and a gastric ulcer not producing pyloric stenosis. 
Gastrojejunostomy was performed, thereby overcoming gastric and duodenal 
stasis, but depriving the ileum of its means of protection against overfilling. 
When examined six months later, bismuth poured rapidly through the hole 
in the bottom of the stomach and collected in the lower ileum, where, by 
reason of its weight, it so aggravated the ileal delay that a large mass of 
bismuth failed to enter the cecum till after the ninety-sixth hour. On the 
seventh day the ileum was empty, and all the bismuth was in the colon. Even 
with the aid of liquid paraffin, ileal delay was more than fifty hours, although 
less than seventy-four hours. The actual mechanism of production of many 
cases of duodenal dilatation is kinking at the duodenojejunal flexure, brought 
about by the heavy pull, through gravity, of accumulated chyme in the lower 
ileum.” 
The following deductions were made concerning decomposition in con- 
nection with duodenal stasis: 
“i. It is usually associated with ileal stasis, ana is most marked when 
the lower ileum is distended with food. 
“2. It is usually associated with gastric stasis. 
“3. It gives rise to a localized tender area in the epigastrium. 
“4. It may be associated with duodenal infection. 
“In the present state of our knowledge it is impossible to differentiate 
between food poisons produced in the duodenal lumen and bacterial toxins 
produced in the walls of the canal.” 
Concerning decomposition in the ileum, Mutch makes the following open- 
ing statement: 
“It is admitted by all who have given attention to the subject that in 
disease the lower coils of ileum frequently contain microorganisms. It is 
easily proved by making cultures from ileal chyme removed at operation. 
That a few organisms occur in these parts of the intestinal tube in health is 
probable, but as yet lacks direct proof. There is, however, no doubt that in 
constipation the ileal flora is often immeasurably richer than in health, and 
that bacterial decomposition of the products of proteolysis gives rise to 
adverse symptoms in patients suffering from intestinal stasis. Most strik- 
ing proof of these statements is made possible by the variations in ileal in- 
fection found in different subjects. For the moment it will suffice to mention 
two facts, and then enter on the more detailed discussion. PATHOLOGY OF INTESTINAL STASIS 
101 
“i. The degree of infection of the ileum with coliform bacilli varies 
directly as the degree of ileal stasis. 
“2. Constipated patients with subnormal blood-pressures harbor B. 
aminophilus in their ileums; other constipated patients do not do so. 
“The relative frequency with which various aerobic organisms can be 
cultivated from one platinum loopful of diluted ileal contents (dilution 1-50) 
is: Coliform bacilli, 86 per cent; B. acidophilus, 68 per cent; Streptococcus 
brevis, 57 per cent; B. aminophilus, 36 per cent; yeast, 28 per cent; Strepto- 
coccus longus, 18 per cent; B. proteus, 6 per cent. 
“From consideration of a large number of cases it has been possible to 
detect the following factors which influence the coliform infection of the 
ileum: 
“a. The degree of infection is proportional to the ileal stasis. 
“b. The ileal kink acts as a protective barrier against ascending infection 
from the colon as shown by the fact that, in ten cases of marked ileal kink, 
the average measure of coliform infection was 0.75. In 10 cases without 
ileal kink, the measure was 1.7. In 6 cases of extreme coliform infection of 
the ileum, a definite ileal kink was present in' 17 per cent. In 10 constipated 
patients with relatively slight coliform infection, a definite ileal kink was 
present in 90 per cent. 
“This protective effect of the ileal kink is not due to concurrent altera- 
tions in ileal stasis, because the average ileal delay of 12 consecutive con- 
stipated patients with marked ileal kinks was equal to the average delay in 
12 consecutive constipated patients who had no ileal kink. 
“c. The coliform infection varies directly as the duodenal dilatation. 
“d. The coliform infection is uninfluenced by the acidity of the stomach.” 
Mutch examined the colon and lower portion of the ileum removed by 
Sir W. Arbuthnot Lane at operation on 50 cases and made the following 
points: 
“Although the whole abdomen of constipated patients emits a fecal odor, 
great differences can be observed between the offensiveness of the various 
portions of the intestinal canal, and the ileocecal valve forms a great dividing 
line. If the lumen of the ileum is opened up by a longitudinal incision, and 
its contents exposed as far as a point 3 to 4 mm. from the cecal aspect of 
the ileocecal valve, the odor emitted is extremely faint; but immediately 
after the valve has been cut through completely, the usual nauseating vapors 
of fecal matter become urgently obvious. It is quite evident that the con- 
tents of the cecum do not usually regurgitate through the ileocecal valve. 
This was demonstrated more completely still by bacteriological methods. 
Immediately after the abdominal wall had been opened at operation, a liga- 
ture was tied around the ileocecal junction. Swabs were subsequently taken 
from the cecum and lowest portion of the ileum. From the former, most 
luxuriant cultures were obtained; from the latter, comparatively slight growth. 
These observations dispose conclusively of the contention which Adami has 102 
GASTRO-ENTEROPTOSIS 
from time to time put forward, that bacterial activity reaches a maximum in 
the lower ileum. The majority of the bacteria in the feces may indeed be 
dead; but the number of living bacteria in 1 c.c. of cecal contents is so 
immeasurably greater than the number in 1 c.c. of ileal contents taken 1 cm. 
higher up the alimentary tract, as to convince one of the relative sterility 
of the small intestine. On several occasions a portion of the ileum four or 
five feet in length was removed, and cultures were made from its contents 
at various points, with similar results in all cases. For example, in the 
case of S. K., age forty, with lifelong constipation, on whom a colectomy 
was done in March, 1914, the results were as follows: 
Site 
Character of Growth 
Number of Colonies 
Cecum. 
very free growth of strepto- 
cocci and B. coli after 24 hrs. 
moderate growth 
immeasurable 
5° 
20 
1 
0 A few B. coli could be 
0 detected in these lo- 
0 l cations by working 
0 with larger volumes 
0 of chyme. 
Ileum at the valve 
Ileum io cm. above the valve.. 
Ileum 20 cm. above the valve.. 
Ileum 30 cm. above the valve.. 
Ileum 40 cm. above the valve.. 
Ileum 50 cm. above the valve.. 
Ileum 60 cm. above the valve.. 
Ileum 70 cm. above the valve.. 
moderate growth 
slight growth 
very slight growth 
very slight growth 
very slight growth 
very slight growth 
very slight growth 
“From these results it is evident that not only does the ileocecal valve 
prevent gross regurgitation, but it also acts as a very efficient barrier against 
bacterial invasion of the ileum. Whether this function is dependent solely 
on mechanical prevention, or is aided by some bactericidal action, remains to 
be investigated. It would appear also that the bacteria which live in the 
lowest portions of the ileum in constipation very rapidly diminish in number 
as the distance from the cecum increases. 
“Briefly, the coliform infection of the lower ileum in constipation is 
abnormal because: 
“i. It increases with increase in ileal delay. 
“2. Different strains of coliform bacteria are found in different ileums, 
B. aminophilus being present in a minority of cases. 
“Some of the symptoms met with in constipation result from bacterial 
decomposition in the ileum because: 
“1. Tyrosin decomposition-products in the urine increase with prolonga- 
tion of ileal delay, and are almost abolished by drainage of the ileum. 
“2. Tryptophan decomposition-products in the urine increase with in- 
crease in ileal stasis, whilst drainage of the ileum causes them to disappear 
almost completely. 
“3. Histidin, acting as precursor of j8-iminazolylethylamin, produces a 
low blood-pressure in those patients only whose ileums contain B. amino- 
philus.” PATHOLOGY OF INTESTINAL STASIS 
103 
Concerning decomposition of the colon, Mutch has the following to say: 
“This has received much attention at various times, but is probably quite 
secondary in importance to ileal decomposition. As stated in the earlier 
part of this paper, the colon is the site of destruction of residues by an 
extremely luxuriant bacterial flora. The substances formed are of the 
simplest nature and, in the amounts absorbed, their pharmacological actions 
are probably so very slight as to be negligible.” 
Toxicology.—It will be conceded by all physicians, as well as 
patients, that constipation or intestinal stasis has a very important influence 
upon the general well-being and efficiency of the individual. 
Lane,2 in discussing alimentary toxemia, says: 
“When these poisons or the products of their conversion exist in excess 
in the circulation, they produce degenerative changes in every tissue and in 
every organ of the body. It is probable that the textures of those organs 
whose business it is to convert, carry, or eliminate them suffer more than 
do the other tissues of the body which are merely permeated by them. In 
proportion as the stasis is prolonged, so, under the influence of a progressive 
strain greater than they are able to bear, these several organs undergo a 
degeneration which proceeds with increasing rapidity as the condition 
advances. What the organs are which convert and excrete these poisons, 
what share each takes in the process, and how any organ is affected in its 
physiology are very difficult to define accurately, especially as far as the 
ductless glands are concerned. We believe that the liver is the most impor- 
tant converter of these poisons, and that the kidneys and skin are the chief 
excretors of the products of conversion. 
“As to the part taken by the thyroid gland, the pituitary body, and the 
suprarenals, we possess little precise information. Our observations in this 
direction are purely experimental, and if our several operations on the drain- 
age scheme have done nothing more than demonstrate the damage done by 
these poisons, the remarkable power of repair which the several tissues of 
the body exhibit on being freed from their malign influence, and the extra- 
ordinary improvement in the functioning of the organs of the body after 
operation, they have been fully justified. They have, however, done more 
than this, since they have thrown a light on intestinal conditions which 
has simplified their treatment most materially, and has put them upon a 
definite mechanical basis, replacing what was little more than a nomenclature. 
“As corroborating the wisdom of attending to the drainage scheme of 
our bodies I would call your careful attention to some of Dr. Carrel’s ex- 
periments, since they throw a most important and instructive light on the 
subject. When I saw Carrel more than two years ago he showed me living 
tissues growing in a sterile medium on a microscopical slide. At that date 
they had been growing for twelve days. I asked him what would result 
from the defective drainage of the tissues, since the quantity of serum was 
2 Proc. Roy. Soc. Med., March, 1913, No. 5, 6:49-177. 104 
GASTRO-ENTEROPTOSIS 
limited and the products of growth must be ejected into it. He said he did 
not know, but expected to learn shortly. After a few days he found that 
the vitality of the tissues became diminished, that the growth of the cells 
was slowed, and that it ceased very soon after. Death of the tissue took 
place obviously because of the imperfect drainage, just as our bodies and 
tissues become depreciated and finally die from chronic intestinal stasis. To 
meet this when growth commenced to flag, he opened up the specimens of 
growing tissue and washed away the toxic products, and by so doing he 
gave the material another period of growth extending over about fourteen 
days. This he was able to repeat many times before death finally took place. 
A line indicating the extent of growth was for a time level, then descended 
gradually, and finally very rapidly, illustrating exactly what takes place in 
chronic intestinal stasis in the human subject. By attending more carefully 
to the drainage of the toxic products of his specimens he was able to carry 
the growth along a horizontal line with regular undulations. Again, by 
feeding them with the juice of fetal thyroid or spleen, he increased the 
growth of these tissues in an extraordinary manner, the increase during 
twenty-four hours varying between three and forty times the bulk of the 
original material. In this way he replaced the gradually descending line, 
representing the tissue growth ending in death, by one which is rapidly 
ascending, and shows no indication whatever of termination in death of the 
tissue. In other words, by attending carefully to the drainage and by giving 
suitable foods he gave that tissue a perpetual life and a rate of growth 
enormously in excess of the normal. He proved in an indisputable manner 
that decay is due to an inability of the tissues to eliminate waste products. 
Carrel’s observations are of the greatest service at the present moment, since 
they afford us the same confidence in our method of treatment that X-rays 
did in the case of operation for simple fracture when the opposition to that 
form-of treatment was intense, and to a great extent unscrupulous in its 
method. I am relating this to show how very simple and yet how very 
important is the problem involved in the consideration of chronic intestinal 
stasis. I have recently seen him perform the same experiment on a larger 
scale. He eviscerated a cat and so arranged the drainage of the intestine 
that it continued to perform its function normally during artificial respiration 
for a period of about ten hours. He hopes by preventing the death of the 
organs by peritonitis to 'prolong their life for a much longer period. The 
improvement in the growth of tissue which he obtains by attending very 
carefully to the drainage is well illustrated in the great and very rapid 
increase in the growth and weight of the child suffering from tubercle or 
rheumatoid arthritis which takes places after the large bowel has been ex- 
cluded from the gastro-intestinal tract.” 
Ochsner3 gives the following manifestations of intestinal stasis: 
Malnutrition.—Patients who are suffering from chronic intestinal stasis 
are badly nourished, because the condition reduces the appetite and thus the 
3 Surg., Gynec. and Obst., 22: 44. PATHOLOGY OF INTESTINAL STASIS 
105 
amount of food ingested, and because it impairs the digestion, and conse- 
quently the patient does not obtain the normal amount of benefit from the 
food taken. 
“Skin changes.—The complexion of patients suffering from intestinal 
stasis loses its clearness, the skin becomes yellow with brown spots, dark 
areas appear beneath the eyes, and there is pigmentation of the skin in the 
axilla, the groins and other flexures. 
“Impaired circulation.—In most instances the circulation is impaired, as 
is manifested by the presence of cold hands and feet, and the presence of a 
cyanotic condition of the skin. The patients are short of breath upon attempt- 
ing severe muscular exercise or upon mounting stairs. 
“Impaired muscular strength.—These patients complain of weakness and 
inability to perform their accustomed amount of physical work. They be- 
come exhausted easily and do not recuperate quickly upon taking rest. 
“Impaired resistance.—Intercurrent diseases are borne badly by these 
patients, as their normal resistance seems to be greatly below par. 
“Effect upon the nervous system..—These patients are greatly depressed 
nervously. They may develop melancholia or hysteria. It is, of course, 
important to determine which has been the primary condition in these cases.” 
Chappie4 in discussing intestinal stasis lays particular stress in the 
changes of the female’s breasts as follow: 
“The breasts showed changes, which in the early stages are similar to 
those usually described as chronic mastitis and later as cystic degeneration. 
The degree of these breast changes seems to bear a direct relation to the 
degree of auto-intoxication and affords a definite index to the extent of the 
latter. That these degenerated breasts are exceedingly liable to malignant 
change has impressed itself most forcibly on my mind, and in this study of 
fifty short-circuited cases, there is definite proof that this cystic degeneration 
slowly but surely disappears after an ileocolostomy and the breast becomes 
quite clear and supple again.” 
Mutch makes a very interesting statement concerning the cold hands and 
feet in connection with stasis as follows: 
“In the concluding paragraphs of this paper, I wish to discuss an almost 
universal symptom of constipation which probably originates from decomposi- 
tion in the alimentary tract. It is considered last, because proof that it is not 
to be classed as an infection through the wall of the canal is still lacking. 
“Almost every constipated patient suffers from coldness of the extremi- 
ties, affecting hands, feet, nose and ears. A slight fall of external tem- 
perature is sufficient to cause them acute discomfort in these parts. The 
phenomenon may be studied by means of a very thin-walled surface 
thermometer with a flat bulb. The patient is placed in a room at io° C. for 
4 Brit. Med. Journ., April 22, 1911. 106 
GASTRO-ENTEROPTOSIS 
a short time, and readings are taken of the temperatures of the palm, dorsum, 
and middle finger-pad of each hand, until these readings are constant. The 
right hand is then immersed in cold water at io° C. for a minute, and quickly 
dried without friction. A further series of temperature readings are taken 
over a period of half an hour, or until the normal temperature is regained. 
Tested in this way, the hands and fingers of healthy adults resume their 
original temperature in five to ten minutes; patients with intestinal stasis 
require much longer than thirty minutes. 
“The phenomenon is very definite indeed, and is abolished by drainage 
of the ileum; but the explanation is still lacking. It may be that small but 
persistent doses of pressor amins, which are quite inadequate to affect the 
blood-pressure, are yet sufficient to constrict the peripheral arterioles if aided 
by a cold stimulus, and produce thereby prolonged coldness of the extremities. 
It may also be related in some way to Raynaud’s disease, which, studied from 
the point of view of chronic intestinal infection, affords many points of 
interest.” 
Sometimes even very serious acute toxic conditions develop as a direct 
result of absorption of stagnant intestinal contents. 
Axtell5 described 12 cases occurring in a period of three or four years 
in which patients had been treated for from three to five weeks for typhoid 
fever, the temperature running above 105, with delirium and other very 
toxic symptoms. In all of the cases, impaction of several pints of fecal 
matter above the last angle of the sigmoid which Lane has called the “last 
kink” was the cause of the illness, as was proved by the fact that the patients 
were relieved of their symptoms immediately or within three or four days 
after the removal of the fecal matter. All of the 12 cases were reported in 
detail, 3 of which are related below for the purpose of giving the general 
course and symptoms: 
“Case 1. C. U., male, age thirty-one; ill two weeks. Admitted Februrary 
13, 1910. Abdomen, retracted, boggy; cecum, tender and tympanitic; rectum 
and sigmoid, full; sigmoid, angulated and partially invaginated into the 
rectum; diarrhea; temperature, 11 a.m., 104.2 degrees; delirious and rest- 
less. Enema removed at once more than an ordinary bedpan of foul and 
slime-covered scybala. Temperature, 10 p.m., 100.2 degrees; delirium rapidly 
disappeared. In twenty-four hours the temperature was normal and the 
nervous conditions had disappeared. In eleven days he had fully recovered. 
“Case 2. T. S., male, age thirty-two; farmer; ill five weeks. Admitted 
July 25, 1911. Dazed and semidelirious; had to be led by wife; temperature 
105 degrees; abdomen distended; cecum, tender and tympanitic; rectum and 
sigmoid, full; sigmoid, angulated, deviated to the right and invaginated into 
the rectum, and thickened at point of invagination and angulation. Enema 
and inflation through sigmoidoscope removed enormous quantities of foul 
scybala. Next day temperature normal and dazed condition largely gone. 
5 Proc. Am. Proctologic Soc., 17th Annual Meeting, 1915. PATHOLOGY OF INTESTINAL STASIS 
107 
One week later he returned unaccompanied. No return of the typhoid con- 
ditions, although it was several weeks before the fecal stasis and angulation 
of the sigmoid were corrected. 
“Case 3. Joe A., age sixty-two; ill two weeks; was arrested for insanity. 
Admitted July 12, 1913; temperature 103 degrees; delirious—almost 
maniacal; abdomen retracted, boggy; cecum enlarged; enteroptosis; rectum 
and colon impacted; sigmoid angulated and invaginated into rectum. Enema 
removed in two evacuations a fraction less than three quarts of scybala— 
in the last of which was a quantity of undigested white beans. Recovery was 
rapid from the mental aberration and fecal stasis.” 
Organic Pathology.—Every observing physician and surgeon has 
seen cases similar to those reported above. Such extreme conditions may 
develop without the existence of any notable organic pathology. In fact 
organic pathology connected with any of the forms of constipation is very 
infrequent and difficult to locate in the large intestine. 
Keith 6 made a very painstaking histological examination of six colons 
removed and sent to the Royal College of Surgeons of Great Britain by Sir 
Bertram Dawson, Sir W. Arbuthnot Lane, Sir Berkeley Moynihan and 
Professor J. W. Smith. Colons from 2 cases of mucous colitis presented 
such disease and disorganization of the muscle fibers and peritoneal coats 
that he felt that the intestine could never have been restored to normal 
activity. Therefore the removal operation was justifiable. In the intestine 
of one very profound case of intestinal stasis, he found evidence of a disturb- 
ance in the action of plasma cells but no signs of inflammatory reaction. In 
three other colons from cases of intestinal stasis, there was very little change 
except in the mucous membrane, and the writer believes that it would be 
possible to relieve such conditions and restore the patient to normal health 
without operation. 
A recent pathological report on Draper’s 7 specimens of colon and ileum, 
removed at the State Hospital for Insane at Trenton, N. J., has been made 
by James Ewing. This report is particularly interesting because of the 
authoritative position Dr. Ewing holds as a pathologist in this country and 
also because of his well-known conservatism on all matters. His report is as 
follows: 
“I have examined sixteen specimens of colon and ileum removed at opera- 
tion. The great majority of the specimens show very definite gross anatomic 
lesions which have resulted from chronic intestinal stasis and the ensuing 
chronic catarrhal inflammation. In several cases the lesions are extremely 
marked, in many they are well marked, while in a few there are no definite 
changes that can be regarded as more than minimal variations from the 
normal. 
“The most marked and constant lesion is pigmentation of the mucosa, 
which has rendered the inner lining brownish or at times dark chocolate in 
8 Brit. Journ. Surg., 2: 576. 
7 Am. Journ. Med. Sc., September, 1922. 108 
GASTRO-ENTEROPTOSIS 
color. This change is most marked in the cecum, diminishing toward the 
sigmoid, but often present throughout the specimen. Sections show the 
pigment to be lodged in large polyhedral cells, lying in the mucosa and at 
times in the epithelium. Pigmentation of the colon is fully recognized as a 
sign of chronic intestinal stasis and intoxication. It is sometimes associated 
with anemia and at times with severe and even fatal dystrophies of nervous 
and muscular systems. 
“Pouching of the intestinal wall amounting almost to hernial protrusions 
was observed in most of the cases. These pouches were from i to 2 cm. in 
depth. The wall of the pouches was generally thinned, sometimes very 
much thinned, and the mucosa at the bottom was generally eroded, some- 
times ulcerated. Through such erosions and ulcerations it is obvious that 
absorption of fluids and bacteria readily occurred. The usual contents of 
these pouches must have been fecal matter, and it appears that such material 
must have been practically incarcerated and seldom emptied. About the 
lower end of the cecum the pouches were especially numerous and deep, 
and access to them was tortuous, especially when external adhesions held the 
wall of the colon fixed. 
“The outer surface of the colon over the pigmented and especially over 
the pouched district, was generally the seat of a chronic productive inflam- 
mation with the formation of very numerous small granules of vascular con- 
nective or denser fibrous tissue. This granular appearance was doubtless 
exaggerated by hardening in formalin. 
“The loose serous coverings of the colon generally appear as thin mem- 
branes extending from the gut over the mesentery. These coverings often 
showed diffuse opacity from thickening, abnormal bands and striae, and 
occasionally definite cicatricial contractions. To what extent these changes 
were due to the conditions inside the gut it is difficult to say, but probably 
they were largely caused by the mucous membrane lesions. 
“The lymph-nodes in the mesentery accompanying the specimens were 
not, as a rule, enlarged, and often they were small and difficult to find. 
Sections of the nodes showed no inflammatory reaction of definite importance. 
It was noted that the lymph follicles were generally invisible in the colon 
and were reduced to a trace in the sections. Well-formed, recognizable 
Peyer’s patches were not found in any case. There was therefore a general 
atrophy of the lymphoid apparatus inside and outside of the gut. That 
bacteria were found by culture in the lymph-nodes of the mesentery could 
have been confidently predicted on the lesions of the mucosa and the lymphoid 
atrophy. 
“In general the impression gained from the study of these specimens was 
that the clinicians were dealing with extensive and somewhat unusual grades 
of chronic intestinal stasis and catarrhal inflammation with its sequels. In 
a few cases the conditions were such as to be practically irremediable except 
by mechanical straightening of the intestinal lumen. Whether or not extir- 
pation of the cecum is the most direct method of accomplishing this object 
must be a matter of surgical judgment. PATHOLOGY OF INTESTINAL STASIS 
109 
“In perhaps the majority of the cases, and certainly in some, the con- 
ditions were not so advanced that emptying of the colon was impossible by 
lavage or frequent catharsis. Here, again, the choice of methods must be 
regarded as a matter of clinical judgment. As for the specimens of ileum 
submitted, they failed to show any lesions that would necessarily call for 
extirpation. The indications for this procedure must rest entirely on clinical 
grounds. 
“The isolation of various bacteria from the mesenteric lymph-nodes does 
not appear to have particular significance, since bacteria pass the relatively 
intact intestinal wall under a great variety of pathologic conditions, many 
of which have no connection with the clinical state of these patients. More 
important is the demonstration of hernias, pouching, thinning of wall, pig- 
mentation and ulceration of the mucosa, which together form an impressive 
anatomic basis for the theory of intestinal intoxication, which undoubtedly 
existed in severe degree in the cases exhibiting such lesions. 
“Finally, I would venture to express my personal opinion that extirpa- 
tion of the affected portions of the cecum and colon was justifiable and 
probably the only effective means of relieving the condition found in the 
advanced cases, while in others with slight changes the condition could 
have been met by less radical means. The extirpation of considerable por- 
tions of the ileum appears to me unwarranted if based solely on the anatomic 
condition of this organ.” 
I have occasionally seen a stercoral ulcer, in fact my first short-circuiting 
operation was done in 1906 for stercoral ulcer. The patient was extremely 
toxic, with marked constipation and stasis. Reverse peristalsis took place 
and a year later the colon had to he removed. At that time there were no 
ulcers present in the intestine and no gross pathological changes. But the 
question which Lane has stressed so much is pathology remote from the 
immediate seats of stasis. The reader is no doubt familiar with Lane’s 
views as to the far-reaching consequence of intestinal stasis. Indeed Lane 
would lead one to believe that a great many of the most serious diseases are 
due directly to intestinal stasis. Concerning his views as to intestinal stasis 
being the cause of cancer, either directly or indirectly, I have failed to see 
any convincing evidence. Concerning ulcer, particularly of the duodenum, 
there is much more chance for argument. Those who have worked on the 
subject of duodenal arteriomesenteric ileus find some very suggestive evi- 
dence. 
Wilkie, in the October, 1921, number of the British Journal of Surgery, 
reports 2 cases of ulcer occurring with gastromesenteric ileus, in which the 
duodenum was obstructed below by the superior mesenteric artery and above 
by the scar of an ulcer. Practically all agree that a mobile cecum is a fre- 
quent cause of duodenal arteriomesenteric ileus. Therefore, indirectly the 
mobile cecum would be the real cause of an ulcer, as Waugh has suggested, 
and has substantiated his suggestion by the report of four of gastric and 
six of duodenal ulcers cured by fixation of the cecum and ascending colon. 110 
GASTRO-ENTEROPTOSIS 
A number of the cases of duodenal arteriomesenteric ileus which have been 
reported by other surgeons have been accompanied by duodenal ulcer. Like- 
wise, a number of cases of perforated duodenal ulcer have been found to 
have an accompaniment of arteriomesenteric ileus which have been reported 
by other surgeons as having been accompanied by duodenal ulcer. 
While these reports of Wilkie and Waugh are very suggestive, it may 
be said there is nothing in Wilkie’s histories to show that the ulcer did not 
precede the ileus. 
Indeed, it is possible and even probable, that the loss of fat consequent 
upon an obstructive duodenal ulcer might cause reduction of intra-abdominal 
pressure and lengthening of the mesenteries sufficient to produce a duodenal 
arteriomesenteric ileus. Thus, the ulcer may be the cause of the ileus rather 
than the ileus the cause of the ulcer. Furthermore, is it not possible that 
the two might be coincidental occasionally? 
Waugh’s 8 report on relation of ulcer and mobile colon is very interesting. 
He attributes much importance to the morbid consequences of a mobile 
ascending colon and, under the head of “Abdominal Diseases,” writes the 
following: 
“A list of surgical diseases of the abdominal cavity drawn up without 
reference to the contents of this quadrant would include little save those of 
the appendix and rectum, and abdominal operations would so shrink in num- 
ber as to lose their entirely preponderating position amongst present-day 
surgical procedures. 
“Surgical endeavor has been concentrated, for the last twenty years, upon 
the task of a successful modification of method and technic in the treatment 
of such end-stages of disease as gastric and duodenal ulcers, gall-stones, 
and prolapsed right kidneys. While meeting with an uncertain measure of 
success—an uncertainty that is revealed by the life history of gastroje- 
junostomy from its inception to the present time; by the rival claims of gastro- 
jejunostomy against gastrectomy; by a preference for the use of the cautery 
instead of the knife, for excision of a gastric ulcer, with renascent hope- 
fulness about the tissue; and by the hesitation that is experienced in attempt- 
ing to decide between the merits of cholecystectomy and cholecystostomy— 
it has been subconsciously realized that the problem of the origin of these 
diseases has not been solved, that the treatment evolved has not been based 
upon that knowledge, and that an erratic distribution of failures and successes 
is an inevitable consequence of empiricism. 
“Nor have scientific investigations upon animals, in spite of patient and 
brilliant research, been able to throw much light upon the human problem, 
or to add much, from the knowledge thus gained, to the successful treatment 
of these diseases in human beings. By means of cytotoxins and attenuated 
bacteria, some of the diseases, in some measure, have been reproduced in 
animals, but so lacking in faithful mimicry of the human lesion that it is 
impossible to escape from the conclusion that some factor has been wanting 
s Brit. Journ. Surg., January, 1920. PATHOLOGY OF NTESTINAL STASIS 
111 
from the experiments that has robbed them of complete success. This 
factor is possibly a mechanical one—one that would be difficult to improvise 
in the course of an experiment, but which is ready to hand in the human 
being, who is perpetually exposed also to the influences of bacteria and toxins. 
This factor, I venture to think, is resident in an abnormal mobility of the 
ascending colon; and by an appreciation of its significance some solution may 
be found of the general surgical problems which form the background for 
the study of these diseases. Some of these problems may be indicated 
briefly in the form of questions: 
“i. Why are all these diseases grouped together in one small area of the 
abdominal cavity? 
“2. Why are they almost unknown in childhood? 
“3. Why does their onset occur so frequently about the age of twenty 
years and onwards? 
“4. Why are gastric ulcers clustered around the pyloric region of the 
stomach, and why is it that duodenal ulcers are almost always in the first 
and second parts of the duodenum? 
“5. What are the prodromal stages of gall-stones, gastric ulcers, and 
duodenal ulcers? 
“6. Why is the right kidney so frequently mobile in these diseases, and 
why is it the mobile one in 80 per cent of all cases of movable kidney? 
(Thomson Walker.) 
“7. Why does the right kidney so frequently prolapse again after very 
firm surgical anchorage? 
“Mechanical Factor.—It is certain that, apart from some specific 
infective diseases, ulcers in most parts of the body—more especially the 
conjunctiva, tongue, septum of nose, legs, sacral and gluteal regions—are 
formed directly under the influence of a recognizable mechanical factor, and 
that healing can be brought about only when the mechanical irritant has 
been removed. The mechanical factor that leads to focal ulceration of the 
stomach and duodenum, to the stagnation of bile, and to mobility 
of the right kidney, may conceivably be provided by a mobile ascending 
colon. 
“Gastric Ulcers. Case 16. E. S., female, age thirty-one. One attack 
of hematemesis, June, 1915. Gatsric pains five years. Appendicectomy four 
years previously, dyspepsia many years. Laparotomy, August, 4, 1915; 
indurated ulcer size of a quarter on anterior surface of stomach just to left 
of pylorus; complete primitive mesentery to ascending colon; colon fixed in 
usual way. Made a very rapid recovery, and reported quite well on May 
30, 1918. 
“Case 17. D. H., female, age thirty-six. Had been treated for four 
years in different hospitals for gastric ulcer, during which period two grave 
attacks of hematemesis had occurred; appendix removed seven years pre- 
viously. Admitted, blanched from third attack of hematemesis, to Hamp- 
stead General Hospital on June 25, 1917. Very ill, and treated by conservative 
measures until August 9, 1917, when laparotomy was performed: Large 112 
GASTRO-ENTEROPTOSIS 
ulcer, size of a half dollar, on anterior surface and upper border of stomach 
to left of pylorus; complete mesentery to ascending colon, which was fixed 
in usual way. Up to date of operation had not been able to take anything 
more solid than Benger’s food, and then with severe pain; ate fish on tenth 
day, and meat on fourteenth day, after operation. Anemia rapidly improved, 
and she returned to work four months after operation. Reported herself 
quite well in June, 1919. 
“Case 18. J. D., female, age twenty-seven. Dyspepsia several years, 
gastric pain one year, severe melena on several occasions, and hematemesis 
on July 17, 1917, when she was admitted to Hampstead General Hospital. 
Laparotomy, August 25, 1917: Two ulcers present about size of a quarter 
and a dime respectively, on anterior wall of stomach and duodenum on 
either side of pylorus; true mesentery to lower half of ascending colon and 
pseudomesentery to upper half; colon fixed in usual way after apparently 
healthy appendix had been removed. Uninterrupted recovery, and reported 
on June 15, 1919, to say that she was in perfect health. 
“Case 19. A. H., female, age twenty-nine. Dyspepsia for some years, 
constant gastric pain for six months, even with fluid diet. Laparotomy, 
October 16, 1918: Ulcer size of a dime on anterior wall of stomach close 
to lower border, about one and a half inches from pylorus; complete mesen- 
tery to ascending colon. Fixed colon in usual way, and small, apparently 
healthy, appendix removed. Uninterrupted recovery. Wrote August 6, 1919, 
to say that she had never been better in her life. 
“Duodenal Ulcers. Case 20. D. B., female, age twenty-seven. Dyspep- 
sia one year, hunger pains three months, with two attacks of melena lasting 
about twelve days. Laparotomy, August 11, 1917: Complete true mesen- 
tery to whole of ascending colon. Ulcer size of a dime in second part of 
duodenum, just above hepatic flexure. Colon fixed in usual way, and healthy 
appendix removed. Writes August 10, 1919, to say that she has been in 
perfect health ever since operation. 
“Case 21. A. H., male, age forty-seven. Dyspepsia for some years. 
Hunger pains six months. One attack of melena lasting for ten days in 
January, 1918. Laparotomy, March 20, 1918: Large ulcer in second part 
of duodenum, just above hepatic flexure; complete true mesentery to ascend- 
ing colon. Colon fixed in usual way, and small healthy appendix removed. 
Reports September, 1919, that he is quite sound. 
“Case 22. E. H., female, age thirty-eight. Many years’ treatment for 
dyspepsia and chronic pain. Three attacks of melena during past five years. 
Appendix removed seven years ago. Laparotomy, May 11, 1918: Large 
ulcer in second part of duodenum; true mesentery to lower two thirds of 
ascending colon, and pseudomesentery to upper one third. Colon fixed in 
usual way. September, 1919, still has slight dyspepsia, but no pain, and 
considers herself to be better than she has been for many years. 
“Case 23. E. S., female, age twenty-six. Dyspepsia and hunger pains on 
and off for five years. Appendix removed two years ago, no relief. Laparo- 
tomy, March 2, 1919: Small ulcer in second part of duodenum; complete PATHOLOGY OF INTESTINAL STASIS 
113 
mesentery to ascending colon; gut fixed in usual way; August, 1919, so far 
very well. 
“Case 24. A. A., female, age thirty-one. Many years’ dyspepsia and 
pain, one attack of rnelena lasting seven days. Appendix removed three years 
ago; no better. Laparotomy, May 2, 1919: Ulcer size of a dime in first 
part of duodenum; complete mesentery to ascending colon. Colon fixed in 
usual way. September, 1919, has put on 10 lbs. since operation and is very 
well. 
“Case 25. F. L. C., female, age twenty-nine. Dyspepsia and chronic 
pain for last nine months, during which period had two attacks of rnelena 
and one of hematemesis. Laparotomy, May 22, 1919: Ulcer in first part 
of duodenum just to right of pylorus; complete mesentery to ascending colon; 
gut fixed in usual way, and small healthy-looking appendix removed. Novem- 
ber, 1919: Has been quite free from pain, and only has slight flatulence 
occasionally.” 
It is not stated whether these cases have been well all of the intervening 
time between the date of the operation and the date of the report. The 
intermittent character of ulcer symptoms makes the word “cure” a very 
uncertain and elusive term. 
In the days of heated contests as to the relative merits of medical treat- 
ment and gastro-enterostomy for duodenal ulcer, Dr. W. J. Mayo was 
accustomed jocularly to remark that he always refused to operate upon any 
patient for ulcer who had not had at least seven medical cures. Most ulcers 
have been cured one or more times each year for a number of years before 
the surgeon sees them. 
In discussing the connection between ptosis or stasis and ulcer, it is inter- 
esting to note that the statistics of Lane, Rovsing, and in fact practically all 
authorities working in the field of gastro-intestinal stasis, have found that 
approximately 80 per cent of ptosis and stasis cases coming to the surgeon 
are females, while the statistics of the Mayo Clinic and other prominent 
surgeons indicate that 75 per cent of gastroduodenal ulcers are found in 
men. My personal experience is that ulcer is most frequently found in pre- 
viously healthy young men who are quite clear of constipation. However, 
this is a question which requires a great deal more study before final settle- 
ment. 
It will be necessary for surgeons carefully to examine for the mobility 
of the cecum in all cases of operation for ulcer. As to Lane’s claim that 
appendicitis is a part of intestinal stasis, we have to say that so far as chronic 
appendicitis is concerned, we entirely agree with Lane but, as to acute appen- 
dicitis with the formation of pus, we have quite another story. For here, 
again, the majority of cases are found in young, and previously healthy 
males, and furthermore my own experience, which agrees with the experience 
of some others, is that acute appendicitis is not frequently found in the ptotic 
individual with a very mobile cecum. Indeed, it has been proportionately less 
frequent in ptotic individuals with stasis than in so-called normal individuals 114 
GASTRO-ENTEROPTOSIS 
whose intestinal canal has been normally fixed. Therefore the relationship 
between appendicitis and stasis is not yet settled and, like the relationship of 
ulcer, requires a great deal of observation and farther study. 
As to the production of gall-stones, there is far more to be said as to 
stasis being the direct cause. We have very little evidence to show that the 
intestinal canal has any influence on the production of tuberculosis other 
than the relation of the general weakened condition produced by stasis. 
One of the principal claims of Lane for colectomy is in the cure of 
chronic multiple arthritis, known as Still’s Disease, which Mutch believes is 
a secondary intestinal infection in which less usual organisms than the 
bacillus coli are found in the ileum, producing toxins which do harm rather 
than food decomposition products. Mutch 9 believes that Still’s Disease is 
due to these bacterial toxins. He quotes the following instance of Still’s 
disease which occurred in the practice of Lane: 
“D. W. (under the care of Sir. W. Arbuthnot Lane), a boy, age five, 
had been ill for two years, during the greater part of which he had been 
treated at one of London’s leading hospitals for children. The outstanding 
clinical features of his disease were marked wasting (his weight was 2 st. 
10 lbs.) and chronic enlargements of his joints. He was quite unable to 
walk, and his pain and weakness were so great that the assistance of two 
nurses was required whenever he was moved. The principal joints involved 
were the ankles, knees, wrists, elbows, and those between cervical vertebrae; 
but the changes were not confined to these regions. Swelling was consider- 
able, and chiefly in the periarticular structures. Most of his superficial 
lymphatic glands were enlarged. His spleen also was increased in size, and 
palpable. Blood counts revealed considerable anemia of a secondary type. 
His Wassermann reaction was faintly positive and his von Pirquet reaction 
negative. He had intermittent attacks of pyrexia. Blood cultures made 
during these attacks gave a pure growth of Staphylococcus citreus, and his 
opsonic index for this organism was 1.8, both of which points are of sur- 
passing interest when vievTed in the light of the following history of his 
alimentary canal. Seven hours were occupied in the evacuation of his 
stomach, although a little bismuth passed through the pylorus almost as soon 
as taken. The duodenum was elongated, and bismuth passed through it very 
slowly. There was great delay in the ileum, and very little bismuth entered 
the cecum during the first eight hours. The passage through the colon was 
sluggish, and after twenty-four hours most of the bismuth was still in the 
first half of the large intestine. Dr. Still kindly saw the patient, and agreed 
that the disease was identical with that peculiar form of chronic multiple 
arthritis which he personally had described. He expressed the opinion that 
under the usual recognized medicinal treatment the patient had prospects of 
life for a few months only. A laparotomy was made which confirmed the 
X-ray examination. The duodenum was seen to be distended. There was 
a marked ileal kink, and the pelvic colon was greatly elongated. Ileocolostomy 
* Brit. Journ. Surg., 2: 608. PATHOLOGY OF INTESTINAL STASIS 
115 
was performed, and cultures made from the ileum. From these a growth 
of Staphylococcus citreus was obtained. It is clear that the stagnant ileum 
had become infected with this organism, which had then gained entry to the 
tissues through the intestinal mucosa and produced chronic arthritic changes 
in all parts of the body. This circumstance is made even more striking by 
the fact that cultivations have been made by Dr. Eyre or myself from the 
ileal contents secured at operations on 55 other patients not the victims of 
Still’s disease, and that in no case has a single colony of Staphylococcus 
citreus appeared. After the operation rapid improvement took place, and 
in a few weeks’ time he was able to play about, entirely free from pain. 
Nine months later, stiffness reappeared in the vertebral joints, and although 
there had been no recurrence of pyrexial attacks, he was still thin and anemic. 
Cultures were made from the feces and blood, without detecting the presence 
of Staphylococcus citreus. X-ray examination demonstrated regurgitation 
into the blinded colon, bismuth being found in all parts of the large intestine 
as far as the cecum, forty-eight hours after a bismuth meal. Colectomy was 
therefore performed. A year later he was going to school and playing 
games. He was the backbone of the junior-school cricket eleven. 
“It is now two and a half years since he was seen by Dr. Still, and his 
recovery appears to be complete. He has gained 12 lbs. in weight during 
the last fifteen months, and his pallor and weakness have gone. The enlarge- 
ment of his lymphatic glands and spleen have entirely subsided. His joint 
movements are almost perfect.” 
Another disease which Lane has featured very much as being one of the 
remote results of stasis is Raynaud’s disease. Mutch quotes the following 
case from Lane’s clinic: 
“G. W. (under the care of Sir W. Arbuthnot Lane), a man age twenty- 
four, had suffered from Raynaud’s disease for nine years. 
“History.—His symptoms commenced with attacks of coldness of the 
fingers and toes during the winter. In later years the attacks involved his 
hands and feet, and even spread as far as his elbows and knees. At first 
they came on during the winter months only, but lately they had frequently 
occurred in the summer also. During the attacks, the affected parts usually 
became white and ‘dead,’ being devoid of all sensations; sometimes, however, 
they were blue and cyanosed. As early as eight years ago, trophic ulcers 
appeared on the finger tips, and these recurred, with much destruction of 
the superficial tissues in succeeding years. For three years he had suffered 
also from syncopal attacks, which showed no relation to the weather or to 
the peripheral spasm in his limb vessels. They varied in frequency from 
one per month to three or four per week. At these times he lost conscious- 
ness completely, and on waking up again felt drowsy for several hours and 
experienced severe headache, with palpitation and throbbing in his neck. He 
did not usually recover in time to see his friends raising him from the ground 
where he had fallen. These attacks were not associated with incontinence of 116 
GASTRO-ENTEROPTOSIS 
urine or biting of the tongue. No history was obtainable of dyspnea on 
walking, of precordial pain, or of edema of the legs. 
“His alimentary history was as follows: In his youth, defecation had 
been regular, and unaided by artificial means: but during the last few years 
he had suffered from alternating attacks of constipation and diarrhea. In 
his diarrheal condition his motions were watery, but normal in color and 
free from blood and mucus. Sometimes his bowels were open sixteen times 
in twenty-four hours, but there was no coincident abdominal pain. Before 
the onset of diarrhea his appetite became poor, but he rarely suffered from 
indigestion pains of any kind, and was never troubled by heartburn, nausea, 
retching, vomiting, or gastric flatulence. No other symptoms could be 
elicited. During the last two years he had received almost continuous 
Fig. 94.—A Case of Raynaud’s Disease. (Mutch.) 
Note the symmetrical and severe scarring of the finger tips. 
medicinal treatment, including faradism and light baths, but no improvement 
had taken place. The last few months he had spent in an infirmary, being 
so crippled that he could no longer earn his living. 
“Examination.—He was seen to be a thin man of normal height, with 
cold, bluish extremities. He walked very slowly and with a limp, because 
of the stiffness of the joints and tissues of his feet. His hands were clawed, 
and so stiff that he had great difficulty in dressing himself. The fingers 
were covered with scars, which reached their maximum distribution near the 
tips of the fourth and fifth digits (Fig. 94). The terminal segments of the 
little fingers were mere cicatrices supported by bone. The severity of the 
scarring diminished towards the radial margin and towards the hand and 
forearm, but four small scars marking the site of trophic ulcers were present 
about the wrist and lower part of the left forearm. Similar symmetrical 
changes were found in his feet. Here scarring was most marked on the big PATHOLOGY OF INTESTINAL STASIS 
117 
toes. On the inner aspect of the left leg, a little above the ankle, was a scar 
of a large and recently healed ulcer. It is interesting to note that the bones 
also showed changes. There was great rarefaction of the phalanges of the 
hand, which corresponds accurately in its distribution with that of the changes 
in the superficial structures. Evidently the arteries to the bones partook in 
the spasm at the same time as did those supplying the soft tissues of the fingers. 
There were no scars on the ears or nose. The physical signs in the alimen- 
tary system were hardness, tenderness and immobility of the terminal coil 
of the ileurn, slight tenderness over the third part of the duodenum, with 
hardness of the pylorus and slight tenderness over the iliac colon. His 
appendix was not felt. No sign of sepsis could be found in his mouth, nose, 
or pharynx. 
“X-ray-and-bismuth examination furnished the following results: 
“Stomach.—The greater curvature dropped to the pelvic brim in the 
vertical position. About eight hours were required for its evacuation. . 
“Duodenum.—The first and second parts filled readily, but bismuth entered 
the jejunum very slowly. The duodenum was elongated, the vertical part 
being four and three-quarter inches long. It was also dilated, and showed 
strong writhing movements, with regurgitation of its contents. The tender- 
ness of the third part was confirmed. 
‘'Ileum.—There was only slight delay in the ileum, but the last coil was 
fixed at a point about one inch from its termination, where it became kinked 
in the vertical position after the entry of the bismuth into the cecum. The 
tenderness of this coil was confirmed during the screen examination. 
“Appendix.—Bismuth entered its lumen. It was freely movable, not 
tender, and not controlling the ileum. 
“Colon.—The cecum was in the right iliac fossa. The transverse colon 
was elongated, and dipped into the pelvis even in the horizontal position. 
There was some elongation of the pelvic colon, and distention of the rectum. 
The iliac colon was tender, and bound down. Bismuth entered the cecum 
in two and a half hours, and reached the rectum in twenty-six hours; but 
much remained in the transverse, descending, and pelvic colons until the 
forty-fifth hour, although the bowels were opened at the twenty-fourth hour. 
“In this way were demonstrated dropping of the stomach, elongation of 
the duodenum, transverse and pelvic colon, and kinking of the ileum. There 
was marked stasis in the stomach, duodenum and colon, and a little in the 
ileum. 
“A routine examination was made of his lungs, nervous system, joints, 
thyroid gland, heart and blood-vessels; but no further abnormality was de- 
tected beyond a faint hemic bruit. 
“His blood yielded the following data: 
Brachial blood-pressure, 115 mm. Hg. 
Red-count, 5,040,000 cells per c.mm. 
Hemoglobin, 78 per cent. 
Color index, 0.8. 118 
GASTRO-ENTEROPTOSIS 
White-counts (at io a.m.), 13,400 (at 6 p.m.), 12,200; mean, 12,800. 
Differential-count: Polymorphonuclears 43 per cent. 
Lymphocytes 50 
Eosinophils 2 
Hyalins 4 
Mast-cells 1 
“He thus displayed anemia of a secondary type, and a positive lympho- 
cytosis. His urine gave distinct evidence of a coliform infection of the 
ileum. A twenty-four hours’ specimen was amber-colored, and its specific 
gravity 1017. Sugar, albumen, urobilin, aceton, diacetic and indolacetic acids 
were absent, but a little indican and considerable hydroxyphenylacetic acid 
were present. 
“Adrenalin 1-1000 did not produce any dilatation of the pupils when 
instilled into the conjunctival sac. 
“Operation.—Laparotomy was performed by Sir W. Arbuthnot Lane, 
and the X-ray findings accurately confirmed. The colon was removed, and 
the ileum jointed to the pelvic colon. Contents were withdrawn from the 
duodenum for bacteriological examination. At the commencement of the 
operation, the last coil of ileum was isolated from the colon by ligature, and 
its contents were examined about an hour later. 
“Examination of Intestinal Contents—Duodenal Contents.—The fluid was 
of a pale straw-color, faintly opalescent, and strongly alkaline to litmus. 
Plate cultures from five loopfuls on nutrose agar gave two colonies of 
Streptococcus brevis. Into 500 c.c. of peptone broth 1 c.c. of the fluid was 
inoculated and incubated for one week. The formation of pressor bases, 
including ergotoxin, was disproved by rendering the broth alkaline with 
sodium carbonate and extracting it with ether. The ether was washed, and 
allowed to evaporate at room temperature. The residue taken up in saline 
was injected into a ‘spinal’ cat without producing any effect on its blood- 
pressure. The conclusions to be drawn are that no pathogenic organisms 
other than a few short chained streptococci were present in the duodenum. 
“Ileal Contents.—The chyme was brown, gelatinous, odorless, and 
markedly alkaline to litmus. Plate cultivations yielded 200 colonies of coli- 
form organisms, 23 colonies of a short-chained Gram-positive streptococcus 
which produced a mauve pigment and liquefied gelatin, and 30 pale colorless 
colonies of Gram-positive streptobacilli. The last-mentioned organism was 
in the form of long narrow rods and grew freely in blood agar and blood- 
serum in small pin-point colonies. It formed acid from galactose, traces of 
acid from maltose, levulose and dextrin, but none from dextrose, lactose, 
dulcite and glycerin. It did not alter litmus milk, and grew very slowly on 
gelatin without liquefaction. A few minute colonies also appeared on agar. 
It resembled the predominant organism seen on direct examination of the 
ileal chyme. It will be seen that it grows well on blood media only, and 
rarely forms acid in sugar media. Spores were not observed in any of the 
cultures, and there was no gas formation. PATHOLOGY OF INTESTINAL STASIS 
119 
“I do not claim that these organisms are the cause of Raynaud’s disease, 
but their presence in the ileum is at least suggestive. Many other cases are 
needed before definite conclusions can be drawn. 
“Ileal contents were also inoculated into 500 c.c. of peptone broth, and 
organic bases extracted as before. The extract caused a distinct rise in 
blood-pressure in a ‘spinal’ cat, showing the formation of pressor bases. It 
did not cause any reversal of the adrenalin effect, from which observation 
it must be concluded that ergotoxin was absent. 
“The formation of the pressor body by the ileal flora is of interest in 
connection with the suggestion that the coldness of the hands of constipated 
patients is due to a reaction of the peripheral arterioles to the combined 
stimulus of slight cold and small doses of vasoconstrictors. The patient’s 
hands became warm immediately after the operation, and have remained 
warm persistently for seven weeks. Although before drainage of the ileum, 
ordinary cold water induced syncopal attacks in his hands, he could now, 
seven weeks after operation, wash in a mixture of ice and water in a 
moderately cold room with impunity. When his finger tips were tested, the 
reaction was similar to that of simple constipation, but the tissues in. the 
locality had been extensively destroyed and were largely cicatricial, so that 
the comparison was not a fair one. 
“One of the most striking features of his recovery was the speed with 
which the stiffness left his hands and feet. His hands became quite supple, 
and the clawing disappeared within twenty-four hours; seven weeks later he 
was walking about freely without a limp. 
“Although to a critical mind the suggestion that this case of Raynaud’s 
disease was due to an infection of the alimentary tract may not seem to 
have been completely proved, yet the following facts are significant: 
“1. Two unusual organisms were present in the ileum in great numbers. 
“2. There was marked chronic intestinal stasis. 
“3. The ileal flora produced pressor bases from peptone. 
“4. The disease was cured by colectomy.” CHAPTER XI 
ABDOMINAL PTOSIS 
Ptosis is a prolapse downward of one or more of the abdominal viscera 
to such an extent that their normal relations to adjacent and surrounding 
structures are materially changed when the subject is ip the erect posture. 
According to origin, the question may be divided into congenital and acquired 
ptosis. (Acquired ptosis is discussed in Chapter XIII.) 
Congenital ptosis is that form of visceral prolapse which is due to defi- 
cient, prenatal, peritoneal fusion between the primitive peritoneal covering of 
the ascending or descending colon and mesocolon, or of both ascending and 
descending colon, and the primitive posterior parietal peritoneum of the 
abdomen. (All children horn zvith this defect may be considered potential 
ptotics. Conversely, general ptosis is impossible without this defect.) 
Congenital ptosis may be divided according to its extent into general 
ptosis, right-sided ptosis, right-sided and midline ptosis, and left-sided ptosis 
(rarely, if ever, found). 
General Ptosis.—General ptosis is that form of abdominal ptosis in 
which, as a result of defective fixation of the ascending and descending colon, 
the viscera of the upper abdomen, including both kidneys, have descended 
from their normal position. The sequential phenomena of general ptosis are 
as follows: The child is born with defective prenatal peritoneal fixation of 
the ascending and descending colon. From the time of birth to puberty, the 
child may be normal but is usually considered a frail child who has frequent 
gastro-intestinal disturbances and who is said to have a weak stomach. Begin- 
ning with adolescent physical development, at which time the child, more or 
less, ceases to be a quadruped, the unfixed colon, having a direct drop from its 
incomplete attachment instead of resting on a shelf of 51 degrees, normal 
attachment, begins to slide over the psoas muscle and off the psoas shelf 
through the psoas outlet.1 The flanks or kidney fossae gradually become 
shallower. The kidneys, first the right and later the left, begin to slide 
downwards. The tug of the ascending colon and cecum, pulling on the 
duodenum and bottom of the stomach, gradually displaces the middle or 
pyloric portion, later the duodenum, liver and even the pancreas. Poor 
1 In Chapter II, it is seen that a transverse section of a plaster cast in a given subject is 
44 square inches. Four inches lower down, at the crossing point of the psoas muscles and 
promontory of the sacrum, a cross-section of the plaster cast of the abdominal cavity of the 
same subject is 14 square inches. This narrow point produced by the promontory of the 
sacrum and crossing of the psoas muscles, we have, for convenience, termed the psoas outlet 
of the abdomen. 
120 ABDOMINAL PTOSIS 
121 
digestion gradually supervenes with consequent loss of flesh. This loss of 
flesh diminishes intra-abclominal pressure in a corresponding amount and 
thereby accordingly reduces the visceral support normally furnished by intra- 
abdominal pressure. This reduction of intra-abdominal pressure permits of 
an increased amount of gas and fluids within the gastro-intestinal tract which 
gradually dilates the viscera. This dilatation with consequent stretching of 
muscle fiber gradually tires out the muscles, thins the walls and reduces 
peristalsis which, in turn, further reduces the efficiency of the digestive 
apparatus. Nutrition by this condition is brought still lower. The fat is 
still further reduced. There is a corresponding reduction in intra-abdominal 
pressure with further dilatation of the viscera. And so the vicious circle 
goes on as long as the patient maintains the erect posture. In the meantime 
the organs begin to occupy the lower abdomen to an increasing extent. Be- 
cause of the weight and also because of a reduction in vitality and a gradual 
stretching of the structures of the abdominal wall, the capacity of the lower 
abdomen is increased. At this time, the chest of the patient, who in 80 per 
cent of subjects is a young female, with soft young bones, gradually col- 
lapses, partly because of the vacant space left by the absence of the upper 
abdominal organs and also because of traction on the diaphragm and thoracic 
fascia. The descent of the ribs from their points of attachment becomes 
more marked and their angles with the spine sharper. By this means, the 
lower chest and upper abdomen are narrowed. These bones gradually be- 
come fixed in this position which reduces the space in the upper abdomen 
and thereby makes the habitat of the migrating organs permanent in the 
lower abdomen. During this process, nature has not been idle. As the 
organs have gradually slid off the psoas shelf, through the psoas outlet, she 
has tried to rescue them by tilting the lower part of the pelvis and spine 
forward in an effort to get under the sliding load. The upper spine has 
been tilted backward in the effort to hold the load by means of the thoracic 
fascia. As a result the normal concavity of the spine disappears and the 
spine becomes relatively straight with the lower end tilted relatively forward 
and the upper end backward. The effort to adjust the neck and keep the 
head erect and in normal poise creates a bend at the upper dorsal spine 
which makes a permanent hump in the back. This constitutes what has been 
termed the “ptosis habit.” This drag on the visceral nerves and sympathetic 
plexuses without doubt materially affects the nervous stability of the patient. 
Hence, the reason for classifying such patients under the head of “neur- 
asthenia.” Secondary bands, membranes and adhesions are relatively in- 
frequent in this type of cases, owing to the fact that all organs go down 
together, including the parietal peritoneum, which leaves no fixed point from 
which the development of the membrane begins. Severe constipation and 
intestinal stasis are not so marked as in the local forms of ptosis. 
With this conception of general ptosis in view, the rationale of the 
empirical “rest cure and forced feeding treatment” of neurasthenics devised 
by Weir Mitchell becomes apparent as does also the reason for the orthopedic 
and postural measures of Goldthwait and Franklin Martin. 122 
GASTRO-ENTEROPTOSIS 
Treatment.—In the field of general ptosis Goldthwait’s work stands 
out preeminently. Therefore, I am taking the liberty to quote Goldthwait’s 
idea of the principles which should be used in the treatment of this condition 
as published by Joel E. Goldthwait and Lloyd T. Brown:2 
“The question of treatment with a problem having so many phases as 
this involves so much that all that can be attempted at this time is to suggest 
the principles which must represent the basis of the treatment, leaving the 
carrying out of the principles or their adaptation to the many features 
presented by such cases to the individual observer. 
“Naturally the first thing to be desired is to restore the organs as nearly as 
possible to their usual position and at the same time to correct or relieve any 
imperfections in their function which may have resulted from the malposition. 
“Since it must be evident that the posture commonly assumed by the 
individual is a definite factor in the relative position of his viscera, naturally 
any undesirable position should be overcome, and, since the embryological 
changes which, when delayed, make it possible that some of these disturbances 
may go on after birth, and, according to the anatomists, they do go on to a 
more nearly normal condition, it should be our aim to see that, during the 
growing period of the child, especially the early period, the common postures 
are not harmful. It should also be our aim to see that not only are the 
postures not harmful, but that all possible contributing factors to visceral 
sag are eliminated, the costume especially being studied and harmful features 
corrected. It should be remembered that in the common droop of the body 
not only are the back muscles strained, but, with the crowding of the organs 
together, the pressure of one against the other must result in the stretching of 
the ligaments, and necessarily will lead to the absorption of the surrounding 
and supporting fat tissue. If, with this, external pressure is also added, 
such as would result from the use of tight or imperfectly fitted corsets, or 
tight waist-bands, the absorption of this fat tissue will be more marked, and 
consequently one of the important supporting elements of the viscera is lost. 
The writers feel that this represents one of the most harmful effects of 
corsets as they are commonly used. It is not the corset itself that is espe- 
cially harmful any more than many other parts of the costume that convention 
demands, but the abuse or the ignorant use of it. With the absorption of 
the normal fat tissue, the inference which such garments must have upon 
the abdominal muscles is, of course, also to be fully recognized. 
“The Cervical Fascia Important in Visceral Support.—The posture 
that is most favorable for normal health is with the trunk erect, as it would 
be if one were to stand as tall as possible without rising on the toes. In this 
position, as has been fully described in the article previously mentioned, all 
of the active supporting elements act most easily, and there is the least 
tendency to ptosis of the viscera. In this position not only is the framework 
favorable for such support, and all the abdominal muscles tight so that the 
support from below is the best that is possible, but also in this position the 
2 Boston Med. and Surg. Journ., No. 21, 162:695. ABDOMINAL PTOSIS 
123 
cervical fascia, which in its continuation through the pericardium is the sup- 
porting ligament of the diaphragm, is made tight. Since the liver and the 
stomach with the colon are largely suspended from the diaphragm, the 
importance of this cervical fascia in connection with the visceral positions is 
easily appreciated. Not only is this so, but when it is known that much of 
the weight of these viscera is thus suspended from the neck, the neck pain 
which is commonly mentioned in these cases is understood and the char- 
acteristic attitude assumed by patients having these congenital displacements 
is easily explained. The attitude is the same in general character whether 
the patient be old or young, and once the type is understood the position of 
the viscera is evident almost at a glance. The writers feel that the full 
significance of the cervical fascia as the supporting ligament of the diaphragm, 
and consequently as part of the support of the abdominal viscera, has not 
been generally appreciated and consequently is given especial emphasis at this 
time. In the X-ray study of this subject it has been clearly shown that, by 
merely changing the position from the droop to the erect position, the position 
of the bottom of the stomach can be raised from one to two inches. 
“In attempting to correct the position of these organs it is apparent 
from what has been said that the organs can be drawn up from the top and 
also pushed up from below. This latter feature is evident from the position 
of the stomach shown in such a case, the protrusion of the stomach forward 
as well as downward making it possible to place supports over and under the 
lower abdomen that can really push the stomach up towards its normal posi- 
tion. At times both of these elements of support have to be used, and by 
apparatus to hold the body erect so that the cervical fascia is tight, together 
with pads below, the ptosis can to a considerable extent be overcome. In 
planning these it must, however, be remembered that, if the attempt is to be 
made to force or draw the stomach upward, space must be allowed for its 
bulk when it is in its new position. If the clothing is tight it is evident that 
with the new position the bulk of the stomach may for a time lie directly over 
the pancreas and duodenum, with a resulting increase in all the symptoms. 
This has been seen so many times by the writers and is so anatomically 
reasonable that its occurrence should always be allowed for in managing the 
supports. 
“With this, of course, the nutrition should be planned so that the abdomi- 
nal fat can be replaced as fully as possible, and at times it is well to have 
the patient kept in bed while this is going on. If such is the case, or if for 
any reason it is necessary to keep the patient in bed, the possibility of the 
backward sag of the stomach upon the pancreas and duodenum should be 
remembered, and the continuous position upon the back be avoided. 
“Since it is possible to raise the stomach by tightening the cervical fascia, 
it is well, at the time when the stomachic digestion is going on most actively, 
to have the patient lie upon the back with a pillow under the region of the 
eleventh or twelfth dorsal vertebra and with no pillow under the head. This 
position of hyperextension should be kept for about half an hour, after 
which the position upon the side, or, better still, the knee-chest position, 124 
GASTRO-ENTEROPTOSIS 
taken for a few minutes, will overcome any harmful backward sag against 
the pancreas and duodenum and at the same time tend to unload the stomach 
into the duodenum. 
“If for any reason it seems evident that the condition is being made 
worse because of the scanty secretion of any of the glands or organs, these 
elements should be supplied in so far as is possible. The stomach elements 
and the pancreatic element are probably the most important of these. 
“If the organs cannot be brought back into place by the ordinary simple 
means, and the general condition is such that radical steps seem indicated, 
operative measures for such purpose are indicated. Such occasion will prob- 
ably not often arise, but in one case of the writers’, because of a constantly 
recurring gastro-mesenteric ileus whenever the stomach was, by posture and 
support, brought up to the region of the duodenum, such an operation was 
performed with relief by Dr. F. C. Kidner at the request of the writers. 
“If for any reason the colon cannot be properly drained by cathartics or 
lavage, and this seems to be the primary source of the diseased condition, 
operations for the thorough drainage of this organ are to be considered. 
This will also not often be required, but in two cases of the writers’, in which 
control was impossible with other means, a colotomy was performed at their 
request by Dr. Hugh Cabot, with entire relief of the symptoms in one case 
and with partial relief in the other. 
“Such, in general, are the principles which seem to the writers of chief 
importance in the treatment of these conditions. The body should be restored 
as nearly to its normal anatomical condition as is possible, because it is in this 
condition that the most perfect function can take place. Braces should be 
used, operations should be performed, exercises should be given, or any other 
measures may be considered if the result of such measures is the more perfect 
function of the part. Naturally the simplest course that will accomplish the 
result should be the one chosen, and the radical measures should be adopted 
only where the simpler ones have failed. The general hygiene should natur- 
ally be as perfect as possible, and with this the diet should be planned so 
that with the least effort the nutrition can be brought up to as near the 
normal as the individual is capable of. 
“When all of these things have been considered and braces have been 
used or operations have been performed, the treatment should not stop until 
the individual is in as nearly the normal condition as it is possible to obtain, 
and since so large a part of the support of the viscera consists of the muscular 
elements, these structures should be brought up to their proper tone. Special 
exercises should be given, at first cautiously, in order not to- cause joint strain 
or increase the visceral displacement, but with a gradual progression in the 
activity until the strength is such that the proper postures can be maintained 
and this part of the visceral support rendered as perfect as possible. With the 
exercises, massage or the special forms of bathing have, of course, their very 
definite place, as has any other measure that tends to increase the muscular or 
ligamentous tone. 
“With all this the patient should not be allowed to leave us until the ABDOMINAL PTOSIS 
125 
structures are in good tone and a practical explanation has been given of the 
anatomical and mechanical features of the visceral function, and with a 
proper understanding of the way in which the body is to be used in order 
to insure the least waste of body energy and consequently render the indi- 
vidual capable not only of health, but also of the greatest possible efficiency.,, 
Details of postural treatment by Franklin H. Martin have also done much 
in the formulation of our modern nonsurgical treatment of these conditions. 
In order that Dr. Martin’s3 principles may be thoroughly understood, I quote 
him as follows: 
“I. General visceral ptosis is indicated, among other things, by a ptotic 
figure that is characteristic, by a peculiar attitude of the individual when 
standing, and by marked muscular insufficiency. 
“II. General visceral prolapse leads to intestinal stasis, digestive dis- 
turbances and neurasthenia, and, in the author’s opinion, is one of the impor- 
tant etiological factors of the Lane kinks of the terminal end of the ileum, 
Jackson’s membranes, kinks of the pylorus, the cystic duct of the gall-bladder, 
the duodenol-jejunal junction, the appendix at the termination of its meso- 
appendix, the transverse colon and other portions of the large bowel, and to 
a distinct contraction of the parietes of the upper abdomen. 
“III. These various intestinal bends, when long continued and when 
subject to considerable mechanical irritation or to intercurrent inflammation, 
become fixed by adhesions, and, as they are in a disadvantageous position, 
their bends and fixations must be corrected before the ptotic individual can 
be successfully treated for his ptoses. 
“IV. In uncomplicated general ptoses or ptoses in which the complica- 
tions have been corrected by surgery, the treatment herein described gives 
prompt, and, if conscientiously followed, permanent relief, except in the con- 
genital type. In the congenital type, too, relief is obtained if the subject 
persists in the treatment. 
“V. The treatment consists in substituting active muscular exercise for 
passive exercise and rest, the active exercise being made acceptable and 
advantageous by directing that it be taken while the patient is in the Trendel- 
enburg position; and by reenforcing the muscular parietes, at the beginning 
of the treatment, by properly constructed supports to be worn by the patient 
while in the perpendicular position. 
“VI. Systematic persistence in this treatment strengthens the defective 
muscles and, by the aid of gravity, replaces the prolapsed viscera. The 
temporary supports retain the viscera at their proper level until the fat de- 
posited as a result of better nutrition, and the reconstructed muscular parietes, 
make a permanent anatomical support. 
“VII. The author’s results convince him that this treatment in relieving 
ptosis will prevent relapse of the complications of ptosis, if they are first 
relieved by appropriate surgery, and thus make unnecessary the radical 
3 Surg., Gynec. and Obst., 15: 150. 126 
GASTRO-ENTEROPTOSIS 
surgery of Lane, which involves ‘short-circuiting’ or extirpating the colon, 
or the operation of Coffey, which has for its object expansion of the upper 
abdomen. 
“Temporary Supports.—The most effectual and satisfactory prelimi- 
nary abdominal bandage is the Achilles Rose adhesive moleskin plaster, 
placed upon the abdomen while the patient is in Trendelenburg position, 
after the visecra have been restored (Fig. 95). If this is found to afford 
relief, and severe symptoms, which reveal adhesions or prolapsed viscera, do 
not follow its application in a short time, a well-fitting canvas abdominal sup- 
Fig. 95.—Application of the Achilles Rose Adhesive Plaster. (Martin.) 
Bandage applied with patient in Trendelenburg position. 
port or corset can be substituted for wear during the day. These permanent 
supports in the form of bandages and corsets are shown in Figs. 96, 97, 98, 
99. The essential thing in any abdominal support for the treatment of these 
cases is to have it uplift rather than compress the contents of the abdomen. 
“Exercise and Correction of Postural Habits.—The exercises are 
of two varieties, those which are practiced in connection with postural treat- 
ment in the Trendelenburg position and those practiced while wearing the 
abdominal support in the upright position. 
“The individual with the marked type of ptoses is required to arise from 
his bed each morning and assume a position on his back upon his extempor- ABDOMINAL PTOSIS 
127 
ted Trendelenburg table, without a bandage (Fig. 100). While in this 
position, simple active muscular exercises are indulged in. 
“In order to systematize these exercises and classify them for the pur- 
pose of giving instruction to my patients or to nurses who have charge of 
the cases, I have outlined a few simple maneuvers. 
“The first movement, which I frequently prescribe to my convalescent 
patients who have the ptotic habit and have been subjected to surgery be- 
cause of intercurrent difficulties or complications of ptosis, consists in the 
slow flexion of the leg on the thigh and the thigh on the abdomen, without 
unflexing or extending the leg and without lifting the foot from the bed. 
Fig. 96.—Style of Abdominal Bandage of a Very Desirable Type for Both Men and 
Women (Martin.) 
Fig. 97.—A Corset Abdominal Support. (Martin.) 
This shows effect of application on an exaggerated feminine type with ptoses. 
Fig. 101 depicts this simple act with either limb. Fig. 102 is the same 
maneuver with both limbs. 
“As this is one of the simplest exercises and reserved for convalescent 
patients it is carried out upon a cot at the side of the patient’s bed, the end 
of which is elevated by placing a chair under it to secure the Trendelenburg 
position. 
“The regular routine exercises hereinafter described are best carried out 
on an ordinary ironing board employed as a convenient substitute for the 
Trendelenburg table. 
“Movement two consists in slow, extreme expansion of the chest by 
deep inspiration and slow expiration. In my opinion, this is the most impor- 128 
GASTRO-ENTEROPTOSIS 
tant exercise that can be prescribed for a ptotic patient, and for that reason 
it is insisted upon as the alternate movement in connection with all the others. 
To secure the best effect in ptoses, this exercise should be practiced in the 
Trendelenburg position and should be performed with (a) pressing both 
hands upon the lower abdomen toward the diaphragm; (b) elevating the 
shoulders with arms extended slowly at right angles to the sides (Fig. 103) ; 
and (c) elevating the arms above the head perpendicular to the body. This 
movement brings into play the diaphragm, the abdominal muscles, the back 
muscles, the depressors and levators of the ribs, the shoulder muscles, the 
strong pectoral, the trapezius and even the strong cervical group of muscles. 
98 
Fig. 98.—Same Style of Support Applied to a Male Patient. (Martin.) 
Fig. 99.—Form of Corset for Ptotic Females Which Is Very Satisfactory. 
(Martin.) 
“The third movement is the elevation of the lower extremities at right 
angles to the trunk, with preliminary knee flexion (Fig. 104); then slow 
flexion at the knees, followed by extreme flexion of the thighs on the abdo- 
men ; and, finally, slow extension to beginning position. This movement may 
be carried out (a) with one limb at a time, or (b) with both limbs simul- 
taneously. 
“These two movements, when properly accomplished, exercise some 
muscles that are seldom brought into extreme action by the ordinary use of 
the extremities; especially is this true of the deep psoas muscles, the deep 
posterior sacral and back muscles, and most markedly the recti and pyrami- 
dalis muscles of the abdomen. Fig. ioo.—Position Advised for Exercises Described for Ptotic Patients. (Martin.) 
Fig. ioi.—Movement One. (Martin.) 
This consists of flexing leg upon thigh and thigh upon abdomen. 
Fig. 102.—Second Act of First Movement. (Martin.) Fig. 103—Movement Two. (Martin.) 
This consists of exaggerated expansion of the chest with arms above the head or, as in Fig. 
102, with pressure of hands over the lower abdomen. 
Fig. 104.—Movement Three. (Martin.) 
After extreme expansion of limbs, one at a time and then together, leg is flexed upon thigh 
and thigh upon abdomen, followed by return of extended horizontal position. 
Fig. 105.—Movement Four. (Martin.) ABDOMINAL PTOSIS 
131 
“The fourth movement consists of slowly elevating the lower portion of 
the trunk on the soles of the feet and back of the head and shoulders (Fig. 
105). This obviously brings into play the strong extensors of the back, the 
lumbar, dorsal and posterior cervical group, the anterior muscles of the thigh 
and the front and lateral muscles of the abdominal walls. 
“A fifth movement employed with the stronger patients consists in rais- 
ing the body to a sitting position with the hands by the side, or, if necessary 
at first, by grasping the edge of the board with the two hands to assist in the 
movement (Fig. 106). 
“These movements are the important ones, and rather than add confusion 
by multiplying them, I modify them slightly. To exercise the adductor and 
abductor of the thighs, and particularly to reach the little obturator and 
Fig. 106.—Movement Five. (Martin.) 
pyriformis which are both outside and inside the pelvis, in a sixth movement, 
the patients are instructed to (a) separate the knees widely with the two 
feet parallel, with the soles flat on the board (Fig. 107) ; or (b) a more 
difficult exercise, with the two feet extended at right angles to the body, 
slowly to separate them to the extent of comfort (Fig. 108). 
“Patients who are weak and unaccustomed to active exercise are assisted 
at the beginning by the nurse or a member of the family until such time as 
they can exercise by themselves. 
“Frequently it is desirable to employ the influence of posture, more par- 
ticularly in prolapsed or retroverted uteri, where these organs are not perma- 
nently fixed by adhesions. This I have designated as the seventh movement. 
“There are three influential factors that may be utilized in these cases 
in the gymnastic and postural treatment; (a) replacement of the displaced 
uterus by the knee-chest posture; (b) ballooning the vagina and sometimes 132 
GASTRO-ENTEROPTOSIS 
the rectum by distending them with air; (c) aiding these two measures by 
contracting and relaxing the abdominal muscles and the diaphragm. 
“The exercise consists of three movements in the hands-and-knees posi- 
tion either on a level surface, or, better, an inclined plane (Fig. 109). The 
Pig. 107.—Movement Six (a). (Martin.) 
(a) movement is slow, deep inspiration and expiration of the lungs in the 
knees-and-hands position; (b) lowering the upper portion of the body so 
that the chest and knees will be in contact with the board (Fig. no) ; (c) 
Fig. 108.—Movement Six (b). (Martin.) 
deep inspiration and expiration while in the last or true knee-ehest position; 
finally returning to the knees-and-hands position. 
“These movements may be repeated slowly from knee-hands to knee- 
chest and back again, with deep breathing interspersed. This maneuver is ABDOMINAL PTOSIS 
133 
usually prescribed as the last one of the series of exercises. The patient is 
then instructed to assume her bed or couch in Sims’ position for rest. 
“The ballooning of the vagina is facilitated and assured if there is any 
doubt about its being accomplished, by instructing the patient to slip a small 
Fig. 109.—Movement Seven (a). (Martin.) 
tube of glass or hard rubber with a vulva protecting flange into the vagina 
before beginning the maneuver. This insures an inrush of air into the 
vagina when the patient assumes the knee-chest position, thereby throwing the 
cervix high and into the hollow of the sacrum and favors a forward move- 
Fig. i io.—Movement Seven (b). (Martin.) 
ment of the fundus of the uterus by gravity and by the bellowslike or aspira- 
tive action of the abdominal cavity with the contraction of its muscular walls. 
Where still further action is required on the fundus of an impacted uterus, 
means should be used to balloon the rectum as well as the vagina. 134 
GASTRO-ENTEROPTOSIS 
“It is advisable, if exercises of the kind recommended in this paper are 
to be of any value, to impress upon the patient the importance of them, and 
to give exact directions in regard to the length of time to be employed with 
the movements and the exact kind and number of each movement. In order 
that the patients be well started with the exercise, it should be conducted at 
first under the supervision of a conscientious nurse. Later the exercises 
should be observed once or twice a week by a nurse or other reliable attendant, 
who will make a definite report on the progress of the patient. This report 
should include the weight of the patient and measurements at extreme in- 
spiration and expiration of the chest, waist, and abdomen, also measurements 
of the abdomen at the tip of the ninth rib with full chest expansion and con- 
traction. 
“At the beginning it is well to prescribe a few movements carried out 
slowly, ten to fifteen minutes’ time being allowed morning and evening. As 
the patients develop muscular strength, the movements may be increased from 
three or four of each of the principal movements properly alternated, to six 
or eight or even ten of each carried out more rapidly and occupying from 
fifteen to twenty minutes’ time for their execution. 
“In ptotic cases the bath and rubdown, consisting of a sponge bath in 
convalescent cases, with a coarse towel friction rub, should be given in the 
recumbent, or better, the Trendelenburg position. Then, after the required 
rest, a properly supporting abdominal bandage should be applied, with the 
patient in the Trendelenburg position. The patient should then be allowed 
to assume the upright position. 
“The patients should be enjoined carefully to avoid the compensatory 
stoop while in the standing or walking position. With the abdomen properly 
supported, and the viscera at their normal height, hugging the posterior 
parietes instead of dangling forward far from their normal attachments, the 
desire for the forward bend is partially eliminated and the individual finds 
that he can more easily maintain his normal position because the normal 
center of gravity is restored. 
“It is but a step now, when the patient finds that he can walk with ease 
without the feeling of weakness and insecurity in his abdomen that compels 
him to adopt the ptotic attitude, to the time when he will gladly walk long 
distances and adopt other outdoor exercises which will develop muscles 
naturally and give him an appetite for nourishing food and refreshing sleep. 
“Fresh Air and Feeding.—With the individual restored to such an 
extent that his digestive organs are functioning normally, with exercise that 
will send him into the open air, appetite will develop. Nourishing, fat-making 
food should now be prescribed for the patient and an accumulation of a 
normal amount of fat encouraged. 
“Complications of Ptosis.—Surgeons who have been looking for 
them have found accompanying, if not directly depending upon, general or 
partial ptoses, kinks or bends in the intestines which obviously have produced 
pathological stasis. These occur particularly at the pyloris, the duodeno- 
jejunal junction, the terminal end of the ileum, the transverse colon and the ABDOMINAL PTOSIS 
135 
sigmoid. Frequently the condition is made permanent by adhesions due to 
peritoneal inflammation caused by infection or excessive mechanical irritation 
of misplaced or overriding viscera. 
“A low-riding cecum distorts the appendix, causes a kink at the distal 
meso-appendix attachment and leads to chronic appendicitis. A descending 
liver produces flexion on the cystic duct and at periods of exacerbation causes 
gall-bladder symptoms which call for surgical interference, which interference 
reveals gall-bladder infection, and occasionally extensive adhesions about that 
region. An intractable kidney in which severe crises are a frequent symptom, 
and which cannot be relieved by abdominal supports, will be found to be one 
that is not easily replaceable. 
“These cases all require surgery. The kinks must be relieved from their 
adhesions and the organs replaced. This, however, in ptotic individuals is 
not sufficient. 
After the surgery has been accomplished, through a sufficiently large in- 
cision to enable the operator to do his zvork zvell and to assure him that he 
is not overlooking something important in these individuals so prone to 
multiple complications, the viscera should all be carefully restored to their 
proper level by the aid of the steep Trendelenburg position. Dressings should 
be placed in such a position on the abdomen that, by the application of a 
snug adhesive plaster corset, they will retain the hitherto displaced viscera 
in their normal position. 
“The patient is then transferred to a bed with a 150 Trendelenburg incline, 
and kept in that position for from forty-eight to seventy-two hours, or until 
such time as the replaced intestines and other viscera have reformed their 
adhesions (if they must be reformed) in an advantageous rather than the 
former disadvantageous position. The patient is then treated as a chronic 
ptosis case, along the lines already outlined in this paper. 
“In another communication I have dwelt upon the management of the 
adherent kinks at the terminal end of the ileum, the properly called Lane 
kink. At least forty such cases of my own have been treated by the above 
routine during convalescence. The success of the treatment has been remark- 
able in more than 80 per cent of the cases operated on, and the disappoint- 
ments have only been partial, and in direct relation to the failure of the 
patient to carry out the rather irksome details of the treatment. 
“I very often find in ptotic cases that mucous colitis promptly disappears, 
if the colon is free from adhesions and is replaceable, under the treatment 
I have suggested for general ptoses. The replacement of a nonadherent, 
prolapsed colon may be encouraged by filling it with water while the patient 
is in the Trendelenburg or knee-chest position. 
“Another definite complication of the general ptotic individual, for which 
I recommend surgery, is the narrow upper abdomen which contracts and be- 
comes permanently narrowed above the prolapsed viscera. The operation 
advocated has for its object the increasing of the capacity of the narrowed 
portion. The narrowed upper abdomen is a compensatory atrophy which is 
inevitable in direct proportion to the sagging and disappearing of its contents. 136 
GASTRO-ENTEROPTOSIS 
“The treatment I have outlined is particularly applicable to several of the 
processes leading to that condition. In a series of cases I have seen the 
upper abdomen and lower chest walls expand rapidly under the practice of 
the Trendelenburg position accompanied by the exercises outlined in this 
paper. This gravitates the prolapsed viscera to the neglected upper abdomen, 
and combined with forced expansion of the chest walls and exercises of the 
abdominal and back muscles, directly increases the capacity of that portion 
of the abdomen. The results of this treatment in this respect are so marked 
and prompt that I have been led to believe that its thorough trial will make 
the expanding surgery unnecessary?” 
Surgery.—Abdominal operations of one kind and another for general 
ptosis has brought surgery for ptosis into general disrepute among both 
surgeons and medical men. When we take into consideration the definition 
of general ptosis we have given at the beginning of this chapter, it is not 
hard to see the reason. Fixation of one organ while others prolapse is far 
worse than no operation. 
I wish to be particularly emphatic by reiterating that, when both kidneys 
are down, we have a general ptosis; that the kidneys never come down except 
in the presence of defective prenatal fusion of the ascending and descending 
colon to the parietal peritoneum. This was recognized twenty years ago 
when I did my third operation for ptosis—first operation for general ptosis 
—in a case of known locomotor ataxia. 
The patient was thirty-two years of age, had had the lightning pains and 
diminished reflexes for more than three years. When she consulted me, 
she had been in bed constantly five months with occasional attacks of light- 
ning pains down her legs and one or two typical attacks of gastric crisis. 
Nausea, vomiting and constipation were her principal constant symptoms, 
particularly marked when the patient attempted to stand on her feet. In 
fact, so great was the distress when standing that the patient had taken 
permanently to bed five months before I saw her. 
On examination, it was found that the stomach was well down in the 
pelvis when the patient stood on her feet; kidneys fell almost into the pelvis. 
The upper abdomen was very narrow, the chest was contracted, and the 
lower abdomen was expanded to a large degree. 
I recognized the importance of the case and, as I had performed only 
two hammock operations for midline ptosis prior to this time, I hesitated to 
propose surgery for her. But she was very anxious for relief, so in Decem- 
ber, 1902, the following operation was performed: Both kidneys were 
anchored firmly to the quadratus lumborum. The falciform ligament of the 
liver was shortened and extended into a Y ligament. The omentum was 
sutured to the abdominal wall above the umbilicus practically all the way 
across. The sheaths of both recti muscles were split below the umbilicus and 
closed after the method of Webster. The stomach symptoms were relieved 
and the patient’s stomach remains in good condition to-day (twenty years 
after operation), and her abdominal organs are functioning normally and ABDOMINAL PTOSIS 
137 
comfortably, although the patient still has no patellar reflexes, has very 
ataxic gait and still has lightning pains in her legs. 
Had I at this time simply anchored one kidney, or even both, I have not 
the slightest doubt that these kidneys would have been pulled down again 
by the intestine or the patient would have had dragging abdominal pains. 
The operation would have been pronounced a failure for the simple reason 
that the underlying etiology and pathology had not been reached. By anchor- 
ing the kidneys, and supporting the colon (which is the natural drag and 
which usually is the agent that pulls the kidney out of position), and by 
firmly anchoring the liver above and contracting the lower abdomen, some- 
thing of a normal state was produced. This good result was produced in 
face of the great handicap of the patient being a tabetic. 
My twenty-first case of ptosis—second case of general ptosis—was treated 
surgically. Mrs. Sch., operated on May 30, 1908. Preoperative symptoms: 
Nausea, anorexia, constipation, abdominal pain. Confined to bed most of 
the time for many months. Preoperative findings: Pendulous abdomen. 
Distance between umbilicus and anterior spine markedly increased. Upper 
abdomen and lower chest narrowed. Both kidneys, stomach, liver and colon 
entirely below the umbilicus, and uterus retroflexed. Typical enteroptosis 
habit. 
Operation and later course: Both kidneys anchored. Liver anchored 
by making a Y-shaped ligament. Omentum sutured to the abdominal wall. 
Upper abdomen expanded by the plastic operation. Six weeks later the 
uterus was supported by plicating the round and broad ligaments on the 
fundus and front surface of the uterus and the abdomen was contracted by 
making an autoplastic bandage of the external oblique. When the patient 
recovered, the contour of the abdomen was very much changed. She was 
gradually restored to health and three and one-half years after the operation 
was fairly well and able to do her own housework, but stomach and colon 
were lower than normal. Had hypermotility (X-ray Figs, m and 112). 
Ten years later, practically well. 
My twenty-second case of operation for ptosis—third case of general 
ptosis—was performed in September, 1908, with the following history: Mrs. 
B. L., age thirty, nurse, married, no children. Preoperative symptoms: 
Indigestion, constipation and neurasthenia to the point of invalidism. Had 
had a ventrosuspension performed five years before. Preoperative findings: 
Stomach, colon and both kidneys were prolapsed. Enteroptosis without the 
habit. 
Operation and later course: Appendix removed. Liver was suspended 
by making a Y-shaped ligament. Gastrocolic omentum sutured to the 
abdominal wall. Both kidneys anchored. Patient became pregnant im- 
mediately afterward and within a year bore a child, after which the uterus 
developed a hemorrhagic condition which produced a profound anemia (30 
per cent hemoglobin). The fundus of the uterus was removed in March, 
1910. At this time the hammock made at the operation in September, 1908, 
was inspected. The blending between the omental and parietal peritoneum 138 
GASTRO-ENTEROPTOSIS 
was perfect and continuous across the abdomen, corresponding to the entire 
length of the line of sutures placed at the time the hammock was made. No 
stretching had taken place. Three years after the hammock operation X-ray 
pictures were taken, as shown in Figs. 113 and 114. This patient was seen 
personally February, 1922, when she said she was in perfect health as far 
as her abdominal organs were concerned, just fourteen years after the opera- 
tion. 
Fig. hi.—Stomach in Case 21, Three and One Half Years after “ Hammock ” Operation. 
Dotted white lines indicate position before operation. (Typical Glenard’s disease.) 
Improved, but not cured. 
My thirty-third case of ptosis—fourth case of general ptosis—operated 
upon was Mrs. L. I. D., October 7, 1911. Widow, age fifty, had had sev- 
eral children. Health had been fairly good until seven years previous to 
operation. Began to lose strength and flesh at that time, condition gradually 
becoming worse, until the patient became a complete bed invalid. She had 
lost much flesh, her tissues were relaxed. Both kidneys were low down 
in the abdomen. 
At the first operation both kidneys were fixed. Ten days later the gastro- 
hepatic omentum was shortened. The great omentum was sutured to the 
abdominal wall all the way across, making a complete partition in the ABDOMINAL PTOSIS 
139 
abdomen; the upper abdomen was expanded; the lower abdomen contracted. 
Patient had trouble with intra-abdominal tension for a few days but recovered 
on time and began to gain flesh. She was seen personally eight years after 
the operation, was in perfect health, earning her living as a telegraph operator. 
This patient was a potential ptotic from birth, but because of a considerable 
amount of fat with otherwise general good health and well-being, the organs 
remained in their normal position until the patient was nearing the climacteric, 
Fig. i 12.—Colon in Case 21, Three and One Half Years after “ Hammock ” Operation 
and Nine and One Half Hours after Bismuth Meal. 
(Typical Glenard's disease with slight hypermotility.) Improved, but not cured. 
when her general health began to decline. From this time, she lost her flesh 
and all the organs went down. She had not developed the typical ptosis 
habit for the reason that the organs had not gone down in early life. 
Since that time, I have done a number of other complete operations of 
this kind, some of them on young individuals in the state of early adult de- 
velopment. These young patients were operated upon for early painful con- 
ditions in which a diagnosis of organic pathology had been made, usually the 
diagnosis of “appendicitis.” The kidneys in these young patients had pro- 140 
GASTRO-ENTEROPTOSIS 
lapsed to a moderate degree only. In some of them, bands were in the stage 
of acute formation. These surgical operations have been the most satisfac- 
tory I have ever done. 
In considering the technic of the surgery when indicated in these extreme 
cases of general ptosis, we necessarily reach out into all the other forms and 
fields of surgical treatment of ptosis. In this chapter, therefore, we will 
describe only those procedures especially required for the treatment of general 
ptosis. 
Fig. i 13.—Stomach in Case 22, Three Years after 44 Hammock ” Operation. 
White dotted lines indicate relative position before operation. Symptomatically cured 
(Case 1 of acquired general ptosis.) 
Bilateral floating kidneys, as stated before, are a pathognomonic sign of 
general ptosis. Longyear’s work, while incomplete, I believe represents one 
of the fundamental ideas of the treatment of ptosis. As stated in a previous 
chapter, the ligament which he has described as “nephrocolic ligament” is 
made up of fibrous connective tissue which probably represents crystallized 
lines of force laid down to maintain a connection between colon and kidney 
in case of mobile cecum, and is only present in such cases. It is, therefore, 
not a normal part of the human anatomy. That it is often, if not always, 
present in cases of floating kidneys has been proved by a number of ob- 
servers. That this tissue is sufficient to hold up the colon to a considerable ABDOMINAL PTOSIS 
141 
degree when used in the operation for floating kidney has been proved by 
Longyear and a number of other operators. The operation is fundamental 
but incomplete. In consideration of the subject in this monograph, however, 
I feel that a description of Longyear’s operation is necessary, both because 
it represents a fundamental principle and because one can easily imagine cir- 
cumstances under which it is advisable to do the Longyear operation, thereby 
avoiding opening the abdomen. While Longyear’s clinical report deals only 
with right-sided ptosis, his principles would apply equally well to the left side 
Fig. i 14.—In Case 22, Bismuth Had Passed into the Rectum When Picture Was Taken 
in general ptosis. In order more definitely to give Longyear's 4 conception, 
I quote the following concerning operative treatment of nephrocoloptosis: 
“Any surgical treatment of nephroptosis which ignores the accompanying 
and causative coloptosis must fail as a therapeutic procedure. A moment’s 
glance at the anatomic relations of the parts involved is all that is necessary 
to confirm this observation. Strip the fatty capsule from the kidney, fasten 
the kidney to the muscles of the loin or other tissues in that region, and what 
happens? The floating kidney may be cured, anatomically speaking, but the 
4 Monograph on “Nephrocoloptosis” published by C. V. Mosby & Co., St. Louis. 142 
GASTRO-ENTEROPTOSIS 
patient is not, as nearly all the symptoms, but especially the digestive and 
nervous symptoms, not only continue as before, but become even more aggra- 
vated. This is due to the connection of duodenum and ascending colon by the 
fatty capsule, the framework of which forms the nephrocolic ligament. The 
result of freeing the fatty capsule from the kidney is to increase the mobility 
of the ascending colon and cecum, so that the traction exerted by the large 
intestine on the duodenum not only continues in force, but is augmented. All 
symptoms would then be aggravated, excepting possibly those which may have 
been due to Dietl’s crisis. 
“The principal cause of the frequent failure of the usual operation of 
nephropexy is thus explained. 
“As the first step toward nephroptosis is made hy the relaxation of the 
hepatocolic ligament and the consequent increased mobility and dropping of 
the ascending colon and cecum, so must the first step toward a surgical cure 
be either the restitution of this support or the creation of a substitute for it, 
which shall do its work in the prevention of the downward drag of the colon 
on kidney and duodenum. It seems, therefore, that the prime factor in the 
surgical therapeutics is fixation of the colon, and that fixation of the kidney 
is of secondary importance.” 
Technic of Longyear’s Operation.—“The incision, about two and a half 
inches in length, is begun just over the lower margin of the twelfth rib, and 
at the outer margin of the quadratus lumborum muscle—which point is a little 
over two inches from the vertebral spine—and carried a little diagonally 
outward toward the iliac crest. Skin, fat and superficial fascia are severed, 
when blunt dissection is used through the latissimus dorsi muscle to the 
transversalis fascia, which is grasped by two Kocher forceps and incised 
between; or the fascia may be entered also by blunt dissection by thrusting 
through and opening the hemostatic forceps. The subperitoneal (not peri- 
renal) fat appears. Retractors are inserted and the fat pushed downward 
with the finger, when Gerota’s capsule (perirenal fascia) is seen at the upper 
angle of the wound, near the twelfth rib, as a pinkish-colored membrane, 
somewhat resembling peritoneum. This is grasped with the two fine-toothed 
tissue forceps and incised between, when the perirenal fat appears. If incision 
has been made through the transversalis fascia too far downward, and not 
near the twelfth rib, the peritoneum, and not Gerota’s capsule, will be opened 
at this stage of the operation. The index finger is inserted through the open- 
ing in Gerota’s capsule, and the lower pole of the kidney located—and it is 
important that the lower end of the kidney be made out definitely, as the 
nephrocolic ligament, if grasped and fixed at the side of the kidney, is secured 
in but a small part and will have little supporting strength. With the end of 
the finger against the lower pole of the kidney acting as a guide, the long 
Kocher forceps are thrust deep in beside the finger and about an inch below 
the kidney, opened wide, transversely to the axis of the kidney, and the tissue 
below the finger grasped by gently closing the forceps. Traction indicates 
to the finger the success or failure to locate the ligament. If properly held ABDOMINAL PTOSIS 
143 
by the instrument, the kidney may be pulled up forcibly against the finger by 
it, and the fasciculi of the ligament may be felt to pass from the forceps to 
the kidney. Several attempts may be made, in some cases, before the 
ligament is satisfactorily secured, but it if usually found at once. Occasion- 
ally the kidney lies low, or in such a position that the examining finger cannot 
reach the lower pole, in which case two forceps may be used, and the kidney 
brought up by a ‘climbing’ process, so that the ligament below the pole may 
be reached. When secured, the kidney is pulled up to the wound. This 
spreads out the fasciculi of the ligament in a fan-shaped manner, as the 
inner side of it is adherent to the peritoneum between the kidney and bowel. 
To gather together these separated fasciculi into one mass of parallel fibers 
is the next step, which is accomplished by means of the forceps-hook. While 
the assistant holds the ligament gently taut with the long Kocher forceps, 
the closed hook is passed, with the finger as a guide, into Gerota’s capsule 
anterior to the ligament and about an inch below the kidney, and pushed 
gently backward slightly beyond the lower pole of the kidney, the end being 
held upward, so that the hook lies parallel with the kidney. After it is 
placed in this manner, the end is turned toward the back of the patient, so 
as to cross the back of the ligament with the hook, and then drawn upward 
toward the wound. The finger, being removed at the same time from the 
anterior side of the ligament and placed on its posterior side—still within 
Gerota’s capsule—guides the end of the hook up out of the capsule and 
forces it through the tissues clinging to it. Examination is then made, and, 
if a good mass of tissue has been secured which pulls strongly on the kidney 
and holds it firmly up to the wound, the hook is opened about an inch, which 
strips some of the ligament from the peritoneum and forms a loop through 
which the fascia and capsule are to be sutured. After opening the forceps 
once, they are allowed to close, and are opened only when necessary in pass- 
ing ligatures under and drawing the edges of the capsule through. Some 
tough tissue is usually brought up on the tip of the hook, which is the part 
of Gerota’s capsule that passes down with the ligament to its insertion in 
the bowel, and should be included with the ligament, as it materially 
strengthens it. 
“The next step is the suturing of the overlapped margins of Gerota’s 
capsule under the loop of ligament. For this purpose a mattress stitch of 
catgut is used on each side, the first being passed twice through the free 
margin of the capsule on the abdominal side, the long ends brought through 
the loop of ligament under the hook with the curved ligature carrier, passed 
under the capsule on the vertebral side, and with the handled needle the 
separate ends passed through the capsule and tied about half an inch from 
the margin. A similar ligature is then made fast to the margin of the cap- 
sule on the vertebral side, the ends threaded through the eyes in the end of 
the hook and the hook withdrawn, bringing the catgut through under the 
ligament with it, when it is passed through the outside of the capsule 
on the abdominal side, about half an inch from the margin of the loop of 
ligament and tied under the edge of the flap. The loop of ligament is still GASTRO-ENTEROPTOSIS 
144 
held by the long Kocher forceps, which are not removed till the suturing 
around the ligament is finished. 
“The opening in Gerota’s capsule at each end of the projecting tissue 
of the ligament is closed with ligatures, after which the silver wire mattress 
suture is passed with the handled needle through the transversalis fascia 
from side to side, broadly, under the loop of ligament and fastened, thus 
bringing the margins of the fascia under and firmly against the tissue of the 
ligament. The wire is made fast by twisting the ends, and a small perfor- 
Fig. i 15.—Longyear’s Operation of Nephrocolopexy. 
This shows completed operation and method by which both bowel and kidney are supported 
by fixation of the nephrocolic ligament by the use of Gerota’s capsule and the transversalis fascia. 
For anatomical description, see Longyear’s monograph. 
ated silver shot run over the ends down to the shoulder and crushed with 
the shot-crushing forceps. The ends of the wire are cut flush with the shot, 
which leaves the suture in a condition free from any possibility of causing 
irritation to the tissues. No postoperative trouble is had with this buried 
suture made with this size of wire, protected by the silver shot. Further 
closure of the transversalis fascia is made with interrupted catgut sutures. 
“The long Kocher forceps are removed from the ligament, which is now 
covered over by the closure of the muscle and superficial fascia by inter- ABDOMINAL PTOSIS 
145 
rupted sutures, care being taken here—as, in fact, during the entire opera- 
tion—to leave no dead spaces or bleeding points” (Fig. 115). 
The results of Longyear’s work and his technic, beautifully illustrated, 
will be found in his monograph, which should be carefully read by every 
student of this subject. This report is very encouraging and gives positive 
evidence of the real merit of his work. 
Fig. 116.—The Mobile Colon Is Sutured to the Posterior Parietal Peritoneum As the 
Incision through Which the Appendix Was Removed Is Being Closed. 
While I have verified the soundness of Longyear’s principle, I have never 
used his exact technic, although I am sure it has a very important place. 
Before the issue of Longyear’s book, in ,which his operation was described, 
I had done a similar operation in effect. Through the usual kidney incision, 
the peritoneum was opened and the appendix removed. The ascending colon 
was then sutured to the peritoneum along the edges of this incision (Fig. 
116), after which the kidney fixation was performed. In certain cases of 146 
GASTRO-ENTEROPTOSIS 
general ptosis, even when it is necessary to do an intra-abdominal operation, 
a kidney which has been long displaced and painful should occasionally be 
fixed. 
The operation I have found most satisfactory for fixation of the kidney 
is a modification of the one described by Dr. R. B. Davis, of Omaha, many 
years ago and is performed as follows: The fatty capsule is carefully opened 
and pushed off the kidney; the kidney is brought up into the wound and an 
incision about an inch and a half long is made through the fibrous capsule 
Fig. 117.—Sutures Placed for Fixing Fibrous Flaps of the Kidney around a Detached 
Piece of the Quadratus Lumborum Muscle. 
on its convex border. From the ends of this incision, right angle incisions 
are made in the fibrous capsule toward the pelvis on each surface. These 
flaps are easily separated from the kidney substance. Three quilt sutures of 
chromic catgut are passed through each flap in the form of a loop and held 
in forceps (Fig. 117). A strip of muscle the size of a man’s middle finger 
is split off the quadratus lumborum, leaving the two ends attached. The 
sutures in the fibrous flap nearest the spine are drawn through this slit in 
the muscle, after which the kidney is slid upwards along the muscle. The 
opposing sutures of the two flaps are then drawn around the muscle and tied, 
care being taken not to strangulate the muscle. ABDOMINAL PTOSIS 
147 
Several other sutures are taken in the edge of the fibrous capsule which 
has not been lifted from the kidney at the ends of the denudation and fastened 
to the muscle. This operation brings the kidney substance in direct contact 
with the muscle and utilizes the fibrous capsule as a handle swung around 
the muscle and held by the sutures described. The fatty capsule is then 
drawn around the muscle in like manner, made taut and sutured (Fig. 118). 
Contrary to the observations of many authors, my experience with operations 
Fig. i i 8.— Scheme of Completed Operation of Swinging Flaps of the Fibrous and Fatty 
Capsule of the Kidney around a Piece of the Quadratus Lumborum Muscle. 
for floating kidney has been almost uniformly satisfactory, although I do 
not frequently do the operation. It is my opinion that this operation has 
been poorly done quite generally. The principle which we must always bear 
in mind is that we are dealing with an abdomen that has become permanently 
narrowed above. We, therefore, must not fix the kidney as high as the 
normal kidney. A kidney should never be fixed above the rib arch but 
should always be palpable in its fixed position after the patient has recovered 
from the operation. I have never known a kidney fixed in this way to come 148 
GASTRO-ENTEROPTOSIS 
down or give pain. However, we rarely do a posterior operation now, or 
even touch the kidney except in the most extreme or painful cases, or cases 
in which hydronephrosis is or has been present. Hydronephrosis in these 
cases is usually brought about by an anomalous artery which serves as a cord 
over which the prolapsing kidney falls, producing kinking and obstruction of 
the ureter. Such a condition usually calls for surgical interference which 
may be fixation of the kidney, or severing the vessel, or both. There is no 
Fig. i 19.—Complete Hammock Operation Used in General Ptosis. 
This is a combination of the cecal fixation of Klose and the original hammock operation, 
which I described, plus closure of the spaces on the two sides. After union, this forms a water- 
tight partition in the abdomen. 
feature in the ptosis question which responds more satisfactorily to postural 
or fattening treatment than the ordinary floating kidney going with general 
ptosis. Therefore, when surgery is necessary, the operation of choice is 
intra-abdominal shortening of the mesentery of the ascending colon (for 
technic, see Figs. 128, 129, 130), and suturing of the omentum to the ab- 
dominal wall entirely across the abdomen. This makes a complete partition 
over to and including the costocolic ligament, which combined operation is 
shown in Fig. 119. In general ptosis, it is frequently found that the liver ABDOMINAL PTOSIS 
149 
is prolapsed as in midline ptosis, in which case it is fastened to the anterior 
parietal peritoneum with sutures as indicated in Figs. 152 and 153 in Chapter 
XIII. Fig. 153 also shows the shortening of the gastrohepatic omentum 
by the Beyea method, which procedure is also advisable sometimes in general 
ptosis. 
In extreme cases of general ptosis, it is an easy matter to rearrange the 
capacity of the abdominal cavity as a supplement to the internal suspension 
Fig. 120.—Extreme Case of General Ptosis. 
The anterior aponeurosis (A) of the external oblique has been cut and reflected inward. The 
reflected edges are being sewed. The tendon of the external oblique (B) has been split and the 
flaps are being imbricated, thus narrowing the lower abdomen and making autoplastic bandage. 
operations by expansion of the upper abdomen as follows: Make an incision 
through the skin and fat down to the aponeurosis, dissect the fat off the 
aponeurosis for an inch or more on either side of the midline; open the fascia 
in the exact midline, taking great care not to open the sheath of either rectus 
muscle, split the anterior sheath of each rectus muscle an inch or more from 
the median incision; dissect the aponeurosis off from the muscle and reflect 
toward the median line. Pass silkworm sutures through skin, fat, a bit of Fig. 121.—Extreme Case of General Ptosis. 
Upper abdomen expanded. (A) Contraction of lower abdomen completed forming auto- 
plastic bandage. (B) (Pictures 120 and 121 first published in Surgery, Gynecology and Obstetrics, 
January, 1910) 10:91. 
Fig. 122.—Cross-section of the Upper Abdominal Wall. 
This gives scheme of operation for expanding upper abdomen shown in Figs. 119 and 120. ABDOMINAL PTOSIS 
151 
muscle and reflected flap of aponeurosis and leave the ends to be tied after 
other layers have been sutured. Bring the reflected edges of the fascial flaps 
together and suture in the median line with chromic catgut, including some 
of the muscle fibers of the rectus muscle, leaving the front surface of the 
recti muscles bare and the original median cut through the conjoined aponeu- 
rosis unsutured. Suture skin with horsehair and the silkworm sutures over 
gauze. It is well to place small drains through stab wounds, in the skin on 
either side of the central incision, if the wound is not entirely dry when 
closed (Figs. 120 A, 121 A and 122). This operation of expanding the 
upper abdomen is often used in midline ptosis. 
In the large, pendulous, dilated abdomen, sometimes accompanying long- 
standing general ptosis, it is wise to contract the lower abdomen as follows: 
First, split the fibers of the aponeurosis or tendon of the external oblique 
muscle parallel to its fibers in such a manner as to converge with a like 
split on the opposite side at a point just above the symphysis. Second, sepa- 
rate this tendon from the internal oblique muscle. Third, draw one layer 
under the other with quilt sutures of linen. Fourth, suture the remaining 
free edge of the fascia to the outer surface of the other layer with another 
line of quilt sutures of linen or chromic catgut and finally with a continuous 
catgut for approximation. The result is an abdominal supporter made of 
the patient’s own tissues; consequently it may be designated an “autoplastic 
bandage” (Figs. 120 B and 121 B). 
In recent years, we have been convinced that it is possible, by the pos- 
tural methods of Goldthwait and Martin, to materially expand the upper 
abdomen and to greatly strengthen by exercises the lower abdomen, which 
answers much the same purpose as the operation when it is successful. 
In this form of ptosis, increase of intra-abdominal pressure by fattening, 
strengthening of the abdominal walls by exercises, and regulation of the bowel 
by noncathartic measures constitute the essentials of postoperative treatment 
(see Chapter XVI on Medical Treatment). CHAPTER XII 
RIGHT-SIDED PTOSIS 
Right-sided ptosis is that division of congenital ptosis in which the 
fixation and supports of the splenic flexure have remained firm and potent 
while the defectively attached cecum and ascending colon have gone down 
with or without prolapse of the right kidney. The sequential phenomena of 
right-sided ptosis vary according to the extent of defect of prenatal peritoneal 
fusion. 
If the ascending colon has been largely fixed, leaving a pendulous cecum, 
the changes are local. These changes are usually limited to a baggy dilata- 
tion of the cecum which falls over the psoas muscle. It probably gives 
trouble only in combination with habitual constipation, in which case a pain- 
ful, sore condition sometimes exists. It is probable that this type usually 
passes unnoticed, and has been classed by the surgeon as “normal.” 
In the second degree of nonfusion, the cecum and ascending colon have 
a mesentery, the colon has become fixed to the front surface of the kidney, 
thus locating the hepatic flexure about an inch farther front than normal, 
making the drop of the movable cecum and ascending colon correspondingly 
more perpendicular. 
Many of these cases pass unnoticed as long as the patient has good health 
and normal intra-abdominal pressure. Some of these cases develop the fol- 
lowing sequential phenomena: In childhood, the patient is constipated, pre- 
sents frequent gastro-intestinal disturbances and sometimes right-sided ab- 
dominal pain. As a rule, however, this development is reserved for adult 
life. When the patient, who in 80 per cent of cases is a young female, 
begins to assume the erect posture for a long period during each day, it 
seems that the strain on the supports of the intestines produces an irritation 
in the suspending tissues which causes a deposit of some substance which, 
under proper circumstances, is capable of being organized into membranes 
or bands. During the pouring out of this substance and the process of for- 
mation of this new tissue, a painful process often develops in the right side 
of the abdomen. This pain begins with attacks which are usually diagnosed 
“appendicitis.” These attacks recur and gradually the pain becomes con- 
stant. The patient is operated upon with pre-operative diagnosis of “appen- 
dicitis.” On opening the abdomen, the surgeon finds a mobile cecum and 
ascending colon. Usually the appendix is uninvolved. At times, it is found 
that the appendix, while not diseased, is attached near its tip to the posterior 
parietal peritoneum high up under the liver and is acting as the only external 
152 RIGHT-SIDED PTOSIS 
153 
ligament of the cecum. At other times, although not diseased, it may be 
found attached to the mesentery of the terminal ileum and acting as a 
suspensory ligament supporting the cecum mesially. Occasionally, such an 
appendix will be found distended and diseased beyond the most fixed point 
of its attachment. 
Regardless of the appendix, it is frequently found that the peritoneum 
of the cecum, corresponding to the point where the cecum passes between 
the psoas muscle and the abdominal wall, shows an edematous, red, inflam- 
matory development. This development seems to extend along the mesentery 
diagonally upwards and outwards along the parietal peritoneum. If the 
patient is seen at a later stage, this edematous development has been trans- 
formed into a membrane. This membrane is sometimes continuous, at 
other times it has formed itself into bands, or bands combined with a 
membrane. 
The removal of the appendix relieves symptoms only in those cases in 
which the appendix is acting as a ligament and is actually diseased, and this 
relief is often only temporary, as indicated by the fact that 70 per cent of 
all cases going through our clinic who were operated on elsewhere for 
chronic appendicitis in years gone by have not been relieved by the operation. 
Upon continuation of the process, the fixation of the colon to the front 
surface of the kidney becomes more firm, thus adding to the sharp angulation 
and increasing the difficulties of the cecum and ascending colon in propell- 
ing the contents forward. At other times the weight of the colon drags the 
kidney out of its position, producing a right floating kidney. This drag 
on the kidney by the colon, and the consequent crystallization of the lines 
of force given in Lane’s law, has produced such an aggregation of fibrous 
tissues in many cases, that Longyear, in discovering it as an accompaniment 
of floating kidney, termed it the “nephrocolic ligament.” This development 
of ligament is never found in a subject with normal peritoneal fusion. The 
intraperitoneal membranes previously described are rarely formed in patients 
with normal peritoneal fusion. That these membranes and bands are con- 
servative and beneficent in function is proved by the fact that they often 
return after they have been cut, and, with their return, the symptoms also 
return. 
This type or degree of right-sided ptosis, if the kidney remains fixed and 
the colon maintains its attachment to the kidney, rarely produces upper 
abdominal symptoms, although occasionally it may make tension on the 
superior mesenteric artery. On the other hand, if the kidney has been pulled 
out of position, a secondary drag on the duodenum may be instituted. 
In the third degree of nonfusion, the colon has not reached as far as the 
right kidney, but has attached itself to the peritoneum on the front of the 
duodenum, from which the cecum and ascending colon make a direct drop 
and consequently a direct drag on the second and third portions of the 
duodenum and attached ducts. This attachment is often made stronger 
by the crystallization of lines of force which have extended upwards and 
have attached in certain instances to the under surface and tip of the gall- 154 
GASTRO-ENTEROPTOSIS 
bladder. In other instances, this development has taken place upwards over 
the duodenum and has produced bands across it, even going as far as the 
lesser omentum in some instances. 
This type of development, in addition to producing general intestinal 
stasis, produces symptoms which frequently lead to the diagnosis of gall- 
stones in what proves to be a perfectly normal gall-bladder and a duodenal 
ulcer in what proves to be a normal duodenum. In this type of cases, there 
is still greater tendency to make traction on the superior mesenteric vessels 
and thereby produce chronic duodenal arteriomesenteric ileus. In this type 
of cases, the mesentery is longer and bands external to the colon are less 
frequent. Floating kidney usually does not occur. 
In the fourth type of right-sided nonfusion, there has been no fusion 
of the ascending colon or its mesentery. The intestine is suspended by long 
mesentery just as in the quadruped. The duodenum has usually rotated and 
fixed to the posterior parietal peritoneum, but is not covered by the meso- 
colon and from an abdominal incision it appears in plain view for its whole 
length. 
In this type of cases, membranes are rare. The omentum coming off 
from below the pylorus has sometimes taken on extraordinary development 
and includes crystallized lines of force which have developed for the purpose 
of rescuing the transverse colon from descent. 
In this type of cases, the ascending colon and cecum are usually dilated 
but not to the same extent that is seen in the previous types in which the 
hepatic flexure has been located and fixed. It is probable that this type 
also strongly predisposes to traction on the superior mesenteric vessels and 
consequent duodenal arteriomesenteric ileus. In right-sided ptosis, long-con- 
tinued constipation with gas distention of the cecum causes the cecum and 
part of the ascending colon to become dilated. The opening in the side of 
the intestine, through which intussusception of the end of the ileum has 
been thrust, becomes correspondingly larger. The constant gas pressure in 
the torpid dilated cecum gradually overcomes muscular action and reduces 
the intussusception and destroys the ileocecal valve. This permits the heavily 
laden bacterial and putrefactive contents of the cecum to flow back into the 
absorbing part of the small intestine, many times to the detriment of the 
patient. 
In the harmful cases of this type, it is probable that something has gone 
wrong with the motor apparatus of the small intestine, which allows it to 
remain dormant or even under certain circumstances to propel the contents 
upward by reverse peristalsis, although this feature has not been satisfac- 
torily proved. This condition probably takes place rarely except in the pres- 
ence of mobile cecum. 
Harmful Acquired Membranes and Bands.—I believe with Lane that 
these membranes are crystallized lines of force laid down in response to a 
strain or a demand for help by the supporting tissues. Therefore, their pur- 
pose is conservative and beneficent. They are laid down for the purpose of 
remedying a defect in embryological development. If the development of RIGHT-SIDED PTOSIS 
155 
the membranes has been symmetrical, they often serve the purpose for 
which they were called out in a satisfactory manner. Unfortunately, these 
membranes frequently develop unevenly, and their forces are concentrated 
into small firm bands. In this instance their support is confined to narrow 
limitations in which the pull becomes definitely localized in one place, which 
in turn calls forth more material for crystallization and for strengthening 
this one place, and which in turn creates a stronger local pull, and so a vicious 
circle is established. This development often continues to great propor- 
tions, even to the point of partially cutting off the lumen of the bowel. 
The most striking case of this kind I have been called upon to treat was 
in the person of a friend who was a doctor. He was operated upon Novem- 
ber 12, 1915, with the following history: Age 46, well as a child, had 
trouble with his right side since a very young lad; his appendix was removed 
at the age of 19 by Dr. Deaver without much relief; had been constipated 
for twenty years and had used cathartics constantly. When taking vigorous 
exercise, he felt fairly well, but as soon as he began leading a sedentary 
life, his stomach trouble and intestinal symptoms returned. Gas would 
accumulate in the cecum, causing great distention and pain. After the 
abdomen was opened, it was seen that a number of strong acquired bands 
attached the ascending colon to the parietal peritoneum at intervals during 
its entire length. At the junction of the upper and middle third of the 
ascending colon, a very strong band had developed and completely sur- 
rounded the intestine. This band included fibrous connective tissue, fat and 
blood-vessels of considerable size. At the hepatic flexure a very strong band, 
including both fat and blood-vessels, was also noted. At the operation, this 
firm band around the ascending colon and also the extra development at the 
hepatic flexure were dissected away, exposing and freeing the upper end of 
the ascending colon. After the colon had been thus freed, the mesentery 
of the ascending colon was sutured firmly to the lateral parietal peritoneum. 
This line of sutures extended forward around the anterior abdominal wall 
to the beginning of the omentum, which was sutured to the abdominal wall 
over to the median line. The patient had a great deal of trouble with gas 
immediately and for several days following the operation. He soon recov- 
ered and went home. 
During the next four years, I saw him frequently. He came to my 
office several times to express his great satisfaction with the results of the 
operation. 
In October, 1919, he began to experience pain and evidence of return 
of his obstruction. Gas distention had increased. During February, 1920, 
he developed absolute intestinal obstruction. Finally he began to vomit 
fecal matter. Being a day’s ride away from Portland, he delayed operation 
until he had had obstruction nearly four days. He was operated upon soon 
after his arrival. A total obstruction was found. The obstruction was due 
to re-formation of the band which I had dissected away at the former opera- 
tion but it was even stronger. The intestine below the constricting band was 
normal and more or less collapsed. Above the constricting band, the intes- 156 
GASTRO-ENTEROPTOSIS 
tine was very much distended. The cecum and most of the small intestine 
had almost reached a state of gangrene. There were a number of dark spots 
on the cecum and also on the small intestine so that it was necessary to 
empty the intestine through an opening into which a tube was inserted. 
After thus emptying the intestine, an anastomosis was made between the 
cecum and the collapsed transverse colon. 
The patient did well at first. At the end of ten days he was eating very 
well but on the thirteenth day he began to show evidence of peritonitis, 
although there was no vomiting or other obstructive symptoms. He died 
two days later. 
Postmortem revealed eight perforations of the small intestine. These 
perforations apparently corresponded to dark spots noted at the time of 
operation. The hammock operation which had been done four years ago 
was a success. Everything was satisfactory except that the band high up 
on the ascending colon which had been removed at the former operation 
had reformed and strengthened itself until it finally produced a definite and 
complete obstruction. 
I believe it has been the experience of all operators that the mere cutting 
of bands gives only temporary relief. After the christening and illustration 
of “Lane’s kink” by Dr. C. H. Mayo, surgeons all over the world felt that 
at last something very definite had been given us. It was found very fre- 
quently holding the ileum down to the parietal peritoneum below the cecum. 
A great many surgeons, including myself, began to cut this membrane and 
free the ileum, obtaining what appeared to be temporary relief from the 
symptoms. I went to the extreme of calling in a number of my uncured 
patients on whom I had operated unsuccessfully for chronic appendicitis 
and suggested a second operation for the purpose of cutting these bands. 
Some of these patients seemed to be temporarily relieved. After a few 
months following this second operation, nearly all the patients began to com- 
plain of the same old trouble. It is very rare that I have noted complete 
relief from symptoms manifested in the ileocecal region by the cutting of 
bands and membranes. The experience of Walton, reported later in this 
chapter, is one of the most perfect demonstrations of this fact. The cutting 
of these membranes and bands temporarily produces relief by completely 
thwarting the plans of nature. These bands are usually re-formed and, with 
their re-formation, the symptoms return. The best means of checking the 
formation of these membranes is to relieve them of their burden by creating 
a uniform attachment over a sufficient area to give easy and even support. 
In other words, these membranes and bands as a rule should be extended 
over a raider area rather than destroyed. Under certain conditions, 
it is necessary to cut them in order to procure a coordinate adjustment 
of organs. In individuals with normal intra-abdominal pressure and intra- 
abdominal fat, the call for these membranes is not so strong even in the 
presence of a marked defect in peritoneal fusion. The development of mem- 
branes is, therefore, not so marked and the clinical picture often fails to 
develop under these circumstances. RIGHT-SIDED PTOSIS 
157 
Right-sided Pain with Right-sided Ptosis.—As early as 1908, Wilms 1 
reported 40 cases in which he had fixed a movable cecum for the relief of 
chronic appendicitis and expressed the belief that in many cases of supposed 
chronic appendicitis the symptoms were in reality due to gynecologic or neu- 
ralgic conditions, or to abnormal mobility of the cecum. At that time he 
described his method of making a large pocket in the retroperitoneal space into 
which he pushed the unduly long and movable part of the cecum. He fastened 
the corner of the peritoneum left from his triangular incision to the anterior 
parietal peritoneum. By this method he depended on adhesions to form over 
the surface of the cecum and hold it firmly without suturing. He reported 
excellent results. 
In another paper of 1909,2 he reported 52 cases treated between 1907 
and 1909. Seventy-five per cent of all the patients were freed from their dis- 
turbances, including their tendency to constipation. 
Klemm 3 presented a novel interpretation of the significance of a dilated 
mobile cecum in connection with chronic appendicitis. He ascribed the 
atony of the dilated cecum to some obstruction to the outflow of the secre- 
tion in the appendix. This resulted in slight inflammation, too mild to induce 
symptoms, but serious enough to injure the serosa of the cecum and impair 
the elasticity of the intestinal wall, which stretched and was followed by atony 
as the feces stagnated there. He recommended taking up a fold in the wall 
of the cecum (plication of the cecum). 
Klose 4 began to study these cases about the same time and as early as 
I9°9 promulgated the view that the mobility of the cecum was an index of 
defective development, which might not cause any disturbance, and, on the 
other hand, might produce colics and inflammation, which he said could 
he remedied by a simple intraperitoneal cecopexy. In 1910, in another article, 
he attempted to distinguish between the disturbances in an abnormally mov- 
able cecum with chronic inflammatory conditions responsible for the stretch- 
ing of the connective tissue from those disturbances due to anomalies in 
development. He contended that the developmental anomalies were much 
more frequent. He described the patient going from one physician to another, 
until finally he came to be regarded as a chronic neurasthenic or hysterical 
individual. In this article, Klose referred to complete torsion of the cecum 
in mobility. He stated that most of the disturbances persisting after ap- 
pendectomy for supposed chronic appendicitis were due to mobile cecum. 
He examined his pathological records and found that 25 per cent of all his 
cases of alleged chronic appendicitis were clue to habitual torsion of a long- 
movable cecum. He described the attacks of pain in connection with the 
mobile cecum in which he stated the main features of the attack were colic 
with distention of the cecum, increased peristalsis, sounds on palpation, obsti- 
pation followed by diarrhea and the pain from the tugging and distention 
with partial stiffness of the intestines. He found this condition in children 
1 Zentralbl. f. chir., Leips., September 12, No. 37, 35:1,089. 
2 Arch. f. klin. Chir., Berl., No. 3, 95:495-741. 
3 Ibid. 
4 Beitr. z. klin. Chir., Tubing., June, No. 3, 63:447-812. 158 
GASTRO-ENTEROPTOSIS 
in about 13 per cent of his total material. His treatment consisted of intra- 
peritoneal fixation of the cecum. 
About 1907, I was called to operate on a member of the family of a 
surgical colleague who had intestinal obstruction and was in a very serious 
condition. She had had three previous operations for intestinal obstruction; 
at these operations the cecum had been replaced and bands severed. At the 
last attack preceding this one, the surgeon had removed the entire omentum, 
believing it was the cause of the obstruction. On opening the abdomen, I 
found a large, gangrenous, cystic mass which I first took to be an ovarian 
Fig. 123.—Gangrene Cecum and Ascending Colon and Last Six Inches of Ileum Result- 
ing from Torsion of Mobile Cecum. 
This patient had had three previous operations for intestinal obstruction due to band 
formation. Omentum removed at previous operation to prevent formation of bands. 
cyst. On tracing it, I found it was a gangrenous cecum and ascending colon 
which had been twisted on itself sufficiently to produce gangrene. The 
segment shown in Fig. 123 was rapidly removed, tubes placed in the end of 
the ileum and transverse colon, after which the two limbs were sewed to- 
gether and the wound packed with gauze. Later the septum was cut with 
a clamp by the Mikulicz method. As the wound healed, a fecal fistula was 
left which was later closed. The patient made a good recovery. I saw her 
personally only a few weeks ago. She has been in better health since the 
removal of the cecum than ever before. In fact, she is now well, whereas RIGHT-SIDED PTOSIS 
159 
before she was constantly sick with what we now recognize as intestinal 
toxemia. It is interesting to note that this patient had been operated on three 
times on former occasions for intestinal obstruction. 
In 1911, Klose 5 reviewed the ptosis question and discussed the subject 
from the standpoint of embryology, anatomy, physiology and symptoma- 
tology, especially the clinical picture of movable cecum. He reported 134 
patients who had been treated in Rehn’s clinic including 12 children; 75 per 
cent of the patients were under 25 years old. In 70 per cent the trouble 
was evidently of congenital origin. The main symptoms were intermittent 
afebrile and subfebrile colic pains like neuralgia, generally located in the right 
side. In this paper Klose remarks that the questions of “pseudo appendicitis” 
and “intestinal hysteria” need to be studied anew by the internists, as this 
assumption of a movable cecum has knocked out most of the foundation for 
them. 
In the hospital reports of a few years ago, the tables showed from two 
to four operations for chronic appendicitis to one of acute appendicitis. This 
has been changed until now a well-conducted surgical clinic operates upon 
more acute cases of appendicitis than chronic. 
A very interesting and instructive paper was published by Dr. Charles 
L. Gibson in May, 1920, in the American Journal of Medical Sciences. He 
based his study on two questions: First, how often does the removal of a 
supposedly diseased appendix fail to relieve symptoms or improve the 
patient’s conditions? Second, what are the reasons for such failures and 
how can we avoid them? 
Gibson in this article proves the soundness of the work of his clinic by 
showing that, in the period from 1913 to 1919, 555 patients in the ward 
service of the First Surgical Division of the New York Hospital were 
operated upon for chronic appendicitis while 820 operations were done for 
acute appendicitis. Of these chronic cases, even after such careful selection, 
about 25 per cent were unrelieved. The percentage of satisfactory cases 
showed 72 per cent for women and 88 per cent for men, leaving the unsat- 
isfactory cases twice as great in women as in men, the prevalence bearing 
a striking relation to the relative prevalence of ptosis in women. 
John A. Lichty,0 before the meeting of the American Medical Associa- 
tion, May, 1922, discussed chronic appendicitis, and called attention to the 
very large percentage of cases with pain in the right side usually operated 
on for appendicitis which was not manifest, at the time of operation. In 
517 consecutive cases, compiled from a general and consulting practice, the 
patients had already been operated on for various conditions and the 
complaints “after the operation were the same as before the operation.” 
Of these 243 had been operated on for chronic appendicitis. Of 
the remainder, 78 were operated on for appendicitis and pelvic disease; 44 
for appendicitis and gall-bladder disease; 47 for gall-bladder disease only; 
41 for pelvic disease only; 16 for gastric ulcer only, and 39 for promiscuous 
5 Beitr. z. klin. Chir., Tubing., 74:1-754. 
6 Am. Med. Assoc., September, 1922. 160 
GASTRO-ENTEROPTOSIS 
conditions, including all kinds of operations. He concludes, therefore, that 
this is the most unsatisfactory surgery of the abdomen. 
Compared with his results for acute appendicitis, that for chronic appen- 
dicitis was a great disappointment. In two of his tables, 1,440 cases were 
studied, 120 of which were diagnosed as acute and 1,320 as chronic appen- 
dicitis. He thinks it is probably safe to say that not more than 60 per cent 
of the diagnoses were justifiable clinically. The remaining 40 per cent may 
consist of patients who suffer from certain neuroses or who may have a 
pathologic condition elsewhere in the body. Patients with chronic appendi- 
citis showed satisfactory results in about 60 per cent following operation. 
Some of these were not definitely cured but were better than before operation. 
Lichty asks the significant questions, “Why are the results so unsatisfactory? 
Why were there approximately 40 per cent of failures?” This is a difficult 
question to answer but it is no doubt the crux of the whole problem. 
Lichty very wisely says: “It is not unlikely that many of the patients 
which the late Dr. Weir Mitchell treated so successfully with his system of 
‘rest cure’ were cases which we now are too prone to call chronic appen- 
dicitis, and are attempting to cure by operation.” 
Lichty found 40 per cent of failures in his cases of chronic appendicitis 
which had been operated upon. My associate, Dr. Sears, some time ago 
went over many of our records and found that of the patients going through 
our clinic for routine examination who had had the appendix removed for 
chronic appendicitis elsewhere, 70 per cent had not been benefited. In going 
over our statistics and many of our histories, I am very sure that more 
than half of the patients coming with right-sided pain have no definite organic 
disease. A very large per cent of the right-sided abdominal pain is the result 
of defective fixation of the ascending colon. The pain is directly produced 
in two ways: First, by traction on acquired membranes or bands which help 
to carry the weight of the organs below. Second, by distention of a mobile, 
prolapsed cecum. 
Two notable contributions by distinguished London surgeons have been 
published in the British Journal of Surgery bearing directly on this discus- 
sion, one by Walton7 and the other by Waugh.8 It is strongly recom- 
mended that these original articles be studied. 
The principal feature in the therapeutic work of Walton was the cutting of 
bands and freeing of adhesions, while the principal feature in the work of 
Waugh consisted in fixing the cecum. It is quite apparent in reading 
rhe two articles carefully that they were dealing with exactly the same 
class of cases. Although one might be led to believe, in a casual reading, 
that there was a marked difference in the cases (for it will be noted that 
Walton found Jackson’s membrane in almost all of his cases, while Waugh, 
in one place in his article, claims to have seen only one instance of Jackson’s 
membrane in his more than 200 cases), this difference in findings is more 
apparent than real and is chiefly, no doubt, a difference in classification. 
1 Brit. Journ. Surg., 2:185. 
8 Brit. Journ. Surg., January, 1920. RIGHT-SIDED PTOSIS 
161 
Waugh has adhered to the letter of Jackson’s description quoted in Chapter 
IX, while Walton has extended the meaning to cover most acquired bands 
and membranes. Jackson himself contends that the typical membrane he has 
described is quite rare. In order that the reader may have abundance of 
evidence on which to base his conclusion, I am reproducing in the language 
of the author much of the evidence submitted in these two articles. 
Walton’s article was published nearly five years before Waugh’s 
article. 
Walton wrote under the title of “The Clinical Aspects of Viscerop- 
tosis,” and divided the subject into four groups: (i) cases resembling 
appendicitis; (2) cases resembling gastric ulcer; (3) cases resembling 
gall-stones; (4) cases resembling gastric carcinoma. 
Waugh, writing under the title of “The Morbid Consequences of a 
Mobile Ascending Colon with a Record of 180 Operations,” divides his 
clinical cases into five groups according to the character and localization 
of pain: (1) gastric; (2) duodenal; (3) biliary; (4) renal; (5) right 
iliac fossa. 
It will thus be seen that the two authors are attempting to deal with 
the same problem. Walton assumes that the membranes are superfluous 
while Waugh tends to ignore them and assumes that more fixation is 
the patient’s chief need. The two authors agree very closely in the pre- 
sentation of their clinical pictures. In presenting to the reader a clinical 
conception, I can do no better than to quote largely from these two 
articles. 
In a given period of time, Walton had 373 cases of true acute appen- 
dicitis. During the same period he operated 29 times on patients with a 
pre-operative diagnosis of “appendicitis” in which appendicitis did not 
exist. In 13 of these cases a diagnosis of acute appendicitis was made 
and, in 16, chronic appendicitis, but he says that this group does not 
include cases of true chronic appendicitis in which visceroptosis was also 
present. In the 13 cases of suspected acute appendicitis, he in every 
instance removed the appendix, although not diseased, and cut bands 
when they were present. Of the 13 cases, 7 showed evidence of recur- 
rence sufficient to cause the patient to return for further treatment. 
These attacks, upon the return of the patient, were relieved by the use 
of liquid paraffin and the administration of abdominal massage and 
exercise, combined by using the abdominal belt. 
He cites an illustrative case which gives an idea of the pathology 
and symptomatology present: 
“Case 1. C. P., male, age thirteen, stated that on August 14, 1914, 
there was a sudden onset of severe pain in the lower abdomen. At first 
it was most marked in the left iliac region, but passed from there to the 
right iliac fossa. The attack lasted for a week, and he then remained 
free from pain until the end of September of the same year, when there 
was a second attack, lasting about the same time. In neither attack was 162 
GASTRO-ENTEROPTOSIS 
there any vomiting. On December 14, a third attack commenced, and on 
December 16 he was admitted to hospital. 
“On admission, his temperature was ioo° and his pulse 124. He 
complained of tenderness in the right iliac fossa. There had been no 
vomiting. 
“At operation, the appendix was two inches long and was apparently 
healthy, with the exception of some membranous adhesions which bound 
it to the outer side of the cecum. The cecum itself was extremely 
movable, and covered with a typical Jackson’s membrane. There was 
a well-marked Lane’s kink. The appendix was removed, and the mem- 
brane on the under surface of the mesentery binding down the ileum 
divided. The wound was closed without drainage. 
“The next day the temperature had fallen to normal, and he made 
an uninterrupted recovery. He remained perfectly well for a month, 
but after this time had one or two mild attacks of pain similar to the 
previous attacks. These were in part relieved by the administration of 
liquid paraffin.” 
There is an interesting feature of Walton’s work in this connection: 
of the 13 acute appendicitis cases of this type, 11 were females, while it is 
a matter of record that there are probably more males than females 
affected with true appendicitis. In these acute cases, Jackson’s mem- 
brane was always present and was divided. 
Of chronic cases of appendicitis, there were 16. Operative findings 
were same as those diagnosed for acute appendicitis—freely movable 
cecum having a definite mesentery in its greater part, very distinctive 
Jackson’s membrane, but the fibrous accessory membrane on the under 
surface of the mesentery close to the terminal ileum was very frequent, 
being present to a marked degree in 6 of 16 cases. Mobility of the kid- 
ney was easily apparent through the incision. Operative procedures 
consisted in removing the appendix, division of Lane’s kink, suturing, 
and division of portions of the Jackson’s membrane, which appeared to 
give rise to kinking of the cecum. Of the 16 cases, 5 were apparently 
cured, 3 have been lost sight of, and 8 have shown only slight improve- 
ment. He gives the following case as illustrative of the symptomatology: 
“W. S., female, age thirty-three, married, one child, age six. Since 
the age of eight years has suffered from many attacks of abdominal pain 
which used to double her up, and which she was told were due to colic. 
Eight years ago there was a severe attack of pain which was localized 
to the right iliac fossa. There was no vomiting, but much diarrhea. For 
this she was kept in bed two weeks. Afterwards there were frequent 
small attacks which kept her in bed for one or two days. Three years 
ago there was a second severe attack which persisted for one month, 
during which there was much vomiting and dysuria. In May, 1914, there 
was a third attack which lasted for two weeks. Between the attacks there 
was often slight indigestion. For four years, she has worn a ring pessary. RIGHT-SIDED PTOSIS 
163 
“On examination, September 22, 1914, she was found to be thin and 
poorly developed, with a flabby abdomen, showing some separation of 
the recti and a narrow subcostal angle. There was deep tenderness in 
the appendix area and definite splashing over the stomach and cecum. 
The right kidney was easily palpable. 
“At operation, the appendix was found free. The cecum showed a 
long mesentery and was dilated. There was a well-marked Jackson’s 
membrane, and the right kidney was abnormally mobile. The appendix 
was removed, and the Jackson’s membrane ligatured and divided. She 
remained quite well for three months after operation, when she had 
another attack associated with vomiting. An abdominal belt, and liquid 
paraffin were ordered. On March 25, 1915, she stated that she was quite 
free from all symptoms when wearing the belt; but if this was omitted 
the pain tended to recur.” 
He reported 27 cases which had been diagnosed gastric ulcer. Of the 
27, 5 had gastric ulcer combined with visceroptosis, 22 showed viscerop- 
tosis alone. Of the 5 cases showing the presence of gastric or duodenal 
ulcer, 4 were males, 1 female. The average is forty years of age. In 
addition to the ulcer, they all showed clearly one or more of the patho- 
logical lesions characteristic of visceroptosis. Thus, in every case there 
was a large movable cecum with Jackson’s membrane and in others a 
Lane’s kink was present. In all of his cases of gastric or duodenal ulcer, 
the cecum and appendix were invariably examined. In the same period 
in which 27 were operated upon, he operated upon 83 cases of pure 
gastric ulcers and in only 4 of these was there a definite kink of the 
terminal ileum. In the same period he operated on 38 cases of duodenal 
ulcer and only 1 showed presence of kink. These figures, he said, seem to 
show that the combination is a rare coincidence; that it is far more 
frequent to find an ulcer without visceroptosis than with it. In contrast 
to the sex involved in the true ulcer cases, which showed 4 males and 2 
females, of the 22 cases of supposed ulcers and which proved to be ptosis, 
there were 18 females and 4 males. The average age was thirty-six, the 
oldest being fifty-eight and the youngest twenty-five. The symptoms 
had, as a rule, extended over many years, most commonly five or six, 
but occasionally as many as twenty. At the operation, there was no trace 
of ulcer found in the stomach or duodenum. The stomach was prolapsed 
into the U shape. All cases showed well-marked Jackson’s membrane. 
Kidney was usually movable. Lane’s kink was commonly present. 
Operative procedure consisted in dividing excessive bands and adhesions 
and if the appendix was bound down by the Jackson’s membrane, it was 
removed. 
The results of operative treatment could not be considered satisfac- 
tory. Nearly all cases showed marked relief for from two to six months, 
but after that time symptoms gradually returned. In one case, the patient 
stated two years later that she felt very well and was much better than 164 
GASTRO-ENTEROPTOSIS 
before operation, and this, in spite of the fact that the abdomen had been 
closed when the true nature of the condition had been discovered, without 
any operative measures having been taken. On cross examination, she 
confessed to one or two small attacks, the last of which had occurred 
six months previous. In other cases of like character, a certain amount of 
relief had been afforded by the use of the belt. We cite an illustrative 
case. 
“E. S., female, age thirty-three. For ten years has suffered from slight 
attacks of indigestion. For the last five they have been severe and 
almost constant, so that she would only be free from the trouble for one 
or two days occasionally. During this time the pain was situated in the 
epigastrium, and was present for the greater part of the day. It was 
always increased by taking food, being most marked one hour after the 
meal. One year ago she had a more severe attack, during which she 
vomited two or three times a day. Vomiting caused a certain amount 
of relief, but never caused the pain to disappear entirely. She was ad- 
mitted to a cottage hospital with a diagnosis of gastric ulcer, and was 
very strictly dieted and medically treated. This attack lasted two 
months, and under the medical treatment gradually improved. Six 
months ago the severe symptoms again returned, and continued until her 
admission to hospital on April 27, 1914. 
“On examination, it was found that there was local tenderness over 
the right rectus, and a certain amount of gurgling in the area of the 
cecum, but neither kidney could be felt. The test meal showed free 
hydrochloric acid, 0.06 per cent, and a total acidity of 41. 
“On April 29, the abdomen was opened by an upper right rectus 
incision, the muscle being displaced outwards. The stomach was found 
to be dilated and prolapsed, reaching well below the umbilicus. Its walls 
showed areas of local spasm. The duodenum was movable, and there 
were adhesions between it and the liver. There was no evidence of 
ulceration of the stomach or duodenum or of the presence of gall-stones. 
The cecum was long and lax, and was easily pulled out through the 
wound in the upper abdomen. There was a well-marked Jackson’s mem- 
brane on its surface. The appendix was normal. The terminal portion 
of the ileum was firmly bound down by a stout accessory membrane on 
the under surface of the mesentery (Lane’s kink). The accessory mem- 
branes were divided and the abdomen was closed. The patient remained 
perfectly well and free from all symptoms until October, 1914. For the 
next four months she had attacks of pain lasting for about one week, 
remaining free for intervals of three or four days between each. During 
the attacks there was pain—increased by taking food—and vomiting, 
which somewhat relieved the pain. An abdominal belt was ordered. She 
was last seen on May 20, 1915. She then stated that she had a certain 
amount of relief from the belt; but the pain had returned together with 
vomiting, and had persisted for the last six weeks.” RIGHT-SIDED PTOSIS 
165 
Walton reported 6 cases resembling gall-stones. General symptoms 
were indigestion and flatulence, or windy spasms, of the same type as the 
symptoms now recognized as so characteristic of gall-stones situated 
within the gall-bladder. As in the case of true gall-stones, it was found 
on further investigation that these symptoms consisted of slight discom- 
fort and fullness in the epigastrium and right hypochondrium coming on 
immediately after food or even before the meal was finished. As a rule 
these symptoms would occur every day without intermission, although 
in one case they were only present during severe attacks. Flatulence 
was a very marked feature. Eructation of gas would he followed by con- 
siderable relief. On examination the patient showed the usual ptotic 
shape of the abdomen. At operation the same pathological condition 
was found as described in previous groups. There was the same viscer- 
optosis, presence of bands and membranes and the evidence of local 
spasm in the stomach wall. In two of the cases, the kidney was found to be 
so movable that it was considered wise to fix it through an incision in 
the loin. Apart from this, the operative procedure consisted of divsion 
of the adventitious bands and adhesions and, if necessary, removal of 
the appendix. Later an abdominal belt was ordered. 
It is an interesting observation of Walton that the best results in 
these cases were when the kidney was fixed. This undoubtedly was due 
to the holding up of the colon by the fixed kidney. The simple removal 
of the appendix and division of membranes gave only temporary relief. 
The following is an illustrative case: 
“M. K., female, age forty-eight. For twenty years the patient had 
suffered from fullness and discomfort immediately after meals. These 
symptoms were associated with flatulence, the eructation of gas being 
followed by some relief. During the last two or three years she had had, 
in addition to the constant discomfort, several attacks of very severe pain, 
which would come on at any time irrespective of all food, and not 
infrequently would wake her at night. At these times the pain, which 
was situated in the right hypochondrium and passed to the back, was so 
severe that she had to walk about. It would be associated with retching 
but there was no vomiting. Several times she had been distinctly jaun- 
diced afterwards. There had never been any hematemesis. Occasionally 
the stools had been dark, suggesting melena. She was admitted to the 
hospital on November 19, 1914. On examination, there was tenderness 
in the right hypochondrium, but the gall-bladder could not be felt. The 
kidney was distinctly movable and there was a dilated cecum. The 
abdomen was narrow and the abdominal wall poorly developed. 
“An operation was performed two days after admission, the abdomen 
being opened by an upper right rectus incision. The gall-bladder was 
found distended with bile, but it was easily emptied, and no gall-stones 
were present. There was marked general visceroptosis, the stomach 
being prolapsed and somewhat dilated. The cecum was freely movable 166 
GASTRO-ENTEROPTOSIS 
so that it was easily withdrawn through the incision in the upper 
abdomen, and there was on the outer side a well-defined Jackson’s mem- 
brane. The kidney could be felt freely movable. The abdominal wound 
was closed, and the kidney fixed through a separate incision in the loin. 
Convalescence was uneventful, and, excepting for slight flatulence and 
discomfort after meals, she has remained well until now—six months 
after operation—the greater part of the symptoms in her case being due 
to the mobile kidney.” 
In 5 cases the patient’s abdomen was opened with the expectation of 
finding carcinoma of the stomach. In this case the sex relation differs 
in that four were males and one female. The following illustrative case 
shows the general findings: 
“C. A., male, age forty-eight. Until seven months before admission, 
he had enjoyed perfect health. Since that period he had had constant 
indefinite pain and discomfort in the epigastrium and right hypochon- 
drium. At no time had it been severe, but it showed a tendency to 
increase. There was no definite relationship to meals, food sometimes 
increasing and sometimes relieving the pain. With the discomfort there 
was much flatulence and regurgitation of bitter fluid. Vomiting was 
slight, but when present did not relieve the pain. On one occasion there 
was a slight hematemesis, but several times he passed dark stools, the 
color of which his doctor thought might be due to the presence of blood. 
Ever since the onset of his symptoms, his appetite deteriorated, so that 
on his admission to hospital on March 30, 1914, he felt no desire for food. 
During the same periods he lost twenty-one pounds in weight. 
“On examination, he was somewhat wasted. There was tenderness 
over the right upper rectus, but nothing could be felt in this area. Knee 
jerks were present. A test meal showed the absence of free hydrochloric 
acid and a total acidity of 41. The abdomen was opened by an upper 
right rectus incision, the muscle being displaced outwards. The stomach 
was found to be prolapsed and dilated, the walls readily passing into local 
spasm. There were membranelike adhesions between the ascending and 
the transverse colon. The cecum was movable and showed a well- 
developed Jackson’s membrane. The terminal ileum was bound down by 
an accessory fibrous band on the under surface of the mesentery. The 
appendix passed behind the cecum, and was partly covered by the 
Jackson’s membrane. The bands and adhesions were divided, the appen- 
dix removed and the abdomen closed. 
“He made an uninterrupted convalescence, and showed a certain 
amount of relief from the operation. He still continues, however, to 
have some discomfort after food, although his appetite has somewhat 
increased. Occasionally there is slight vomiting.” 
These cases of Walton form a very important clinical link in the 
development of the conception of the ptosis question. In all of this group RIGHT-SIDED PTOSIS 
167 
of cases which he has operated upon for what he supposed was an organic 
right-sided lesion, he found the same thing—a mobile cecum with mem- 
branes and bands. The results were the same in all the different symp- 
tomatic groups in that the majority were temporarily relieved by cutting 
bands, followed by recurrence of symptoms. Some relief was later brought 
about by the use of a belt in support of the abdominal organs. 
I have seen nothing in literature which more clearly proves that the 
membranes and bands are conservative developments for the purpose of 
holding up an otherwise mobile colon. To show that the band or mem- 
brane is not the real pathology, nothing is necessary except to call atten- 
tion to the fact that after the band has been cut, as in all this group of 
cases, the symptoms return no matter whether they are manifested in 
the stomach, gall-bladder, duodenum, appendix or kidney. 
Waugh’s paper deals with a group of 180 cases in which the colon was 
fixed. In addition to the 180 adult cases, Waugh has fixed the ascending 
colon in more than ioo children under twelve years of age. 
He divides his cases into five types, with regard to character and 
localization of the pain and says: 
“But they manifest clinical signs and symptoms which are common 
to all of them at first, and subsequently become obscured by the appear- 
ance of the type pain which in the estimation of the patient relegates his 
other symptoms to the background. The onset is generally dated by 
the patients from the age of twenty years or thereabouts, and described 
by them as the appearance of “indigestion.” This is no more than a 
feeling of fullness and discomfort after meals, flatulence, and some 
lethargy. This indigestion cannot be explained either by indiscretions 
of diet, bad habits of life, or unsuitable environment, and it is not 
amenable to any change from one of the supposed causes. The average 
duration of these symptoms is about six months, and then pain in one or 
the other region of the abdomen appears for the first time. 
“During these six months many remedies for ‘indigestion’ have 
generally been tried without effect, and, with the appearance of pain, 
the patient is no longer content to regard the trouble as being of a trivial 
nature. Particular emphasis must be laid upon one aspect of ‘pain’ in 
these cases: Although it is constant in type and constant in location for 
the individual case, it is characteristically erratic and irregular in its times 
of appearance, both with reference to the number of days on which it 
may be present, followed by lucid intervals of entirely irregular duration, 
and to its appearance, disappearance, and reappearance sometimes in the 
course of a single day. This erratic chronology of the pain is so essential 
a feature of these cases that it assumes the position of a sign of much 
diagnostic importance. Granted that the pain has an organic origin, then 
the factor that produces it must clearly be one that is erratic and variable 
in its action. 
“Now the load of the mobile ascending colon, and consequently the 168 
GASTRO-ENTEROPTOSIS 
strain that it exerts, are most certainly variable. Herein appears to lie 
the explanation of what is such a marked feature of these cases, namely, 
the constant inconstancy of the pain. Perhaps, too, this inconstancy 
affords an explanation of the diagnosis that had already been presented 
to so many of the patients that they were ‘neurotics’ or ‘neurasthenics.’ 
“Added to the presence of pain, loss of weight has now become a 
noticeable feature, and profound lassitude has become a disquieting and 
daily experience. Many of the patients in this series record a loss 
of from 14 pounds to 28 pounds during the first year of their illness. In 
the later stages general wasting and tissue degeneration all over the body 
is one of the grossest features of the condition. 
“With the exception of 31 cases out of the total series of 180, con- 
stipation had never preceded their symptoms; these 31 had been consti- 
pated since childhood, and in those who subsequently became so, 
constipation did not appear as a rule until after an average of four years’ 
suffering. Constipation in these cases is the result of the final breaking 
down of the colon in performing its natural function under mechanical 
conditions badly suited to it, and cannot be regarded as the cause of 
symptoms antecedent to it by about four years. 
“Pregnancy, as might be expected, affords great relief to these 
patients when the broad plateau of the gravid uterus supports the pro- 
lapsed colon. The symptoms generally disappear so completely that the 
patients are convinced of the soundness of the advice that ‘if only they 
couid have a baby they would get well’; their disappointment is bitter at 
the reappearance of their old symptoms when the baby is about two 
months old and their return to active life without the support of a gravid 
uterus has once more exposed their ascending colon to the unrestricted 
action of the force of gravity. 
“On examination of the abdomen, the fullness of the cecum and 
ascending colon is easily ascertainable, and, in 79 per cent of the cases, 
the right kidney shows variation of position between a gross prolapse 
and slightly increased mobility and palpability. This is a clinical sign 
that must be regarded as of more importance in considering the diagnosis 
of disorders of the alimentary tract than of the urinary tract, when taken 
in conjunction with the observation that, although a mobile kidney was 
present in so large a proportion of the patients, no symptoms were 
present that could possibly be attributed to it. A few of the patients had 
renal crises in addition to their other symptoms, and these were relieved 
by operation upon the colon without any surgical procedure being per- 
formed on the kidney.” 
TYPES OF CASES 
“These are recognized only when pain has made its appearance. 
“Gastric Type.—Pain is experienced in the stomach area somewhere 
along the left costal margin and ensiform process of the sternum. It RIGHT-SIDED PTOSIS 
169 
comes on very soon after food, within ten minutes to three quarters of 
an hour after a meal has been taken. But it does not come on after every 
meal, and it does not necessarily appear every day; sometimes it may 
come on just before a meal, and though as a rule the taking of food then 
makes it worse, it sometimes makes it better. It is generally described 
as being ‘nagging’ or ‘boring’ in character, and may radiate through 
to the back. Localized tenderness can often be detected by the patient 
over the point of maximum intensity. Thus the location and character 
of the pain are constant for each patient of this type, but the times and 
seasons of its appearance are variable. It does not necessarily appear 
after every meal in any given day, nor does it appear every day in an 
unbroken sequence. Sometimes there may be an interval of a few weeks 
between the attacks of pain, sometimes a few days, sometimes only a few 
hours; sometimes there may be many weeks of pain with only a brief 
lucid interval of a few hours’ duration. It is unaffected by the quality 
of the food taken. Most of the patients of this series, after several years 
of dieting under skilled advice, had thrown all restrictions away, and 
unhesitatingly affirmed that they had derived no benefit from model 
dietaries, and were no worse when they ate what they liked. 
“Several of the patients had been regarded as the victims of gastric 
ulcer, a diagnosis that is negatived by the erratic behavior of the pain. 
When an ulcer has once formed, pain is constant in its times of appear- 
ance; it always comes on after food, it is always made worse by food, 
and there are no lucid intervals. But when a pain is caused by a strain that 
is variable in its intensity, then it will make its appearance only when the 
strain is effective up to the point of producing pain, that effectiveness 
being determined by the load which the dropped colon is carrying. None 
of these patients with inconstant gastric pain have been found at laparot- 
omy to have had structural disease of the stomach; and all of them have 
had a mobile ascending colon; whilst in the patients in whom ulcers were 
known to be present before operation (see details of ulcer cases), and 
a mobile ascending colon was always found at operation, the pain had 
been constant in its appearance immediately after taking food, and so 
severe as to make each meal an intolerable experience. 
“This constant response to a stimulus is a characteristic of ulcers gen- 
erally in other parts of the body, and the gastric ulcer appears to be no 
exception. Moreover these patients (that is, those with gastric ulcers) 
had obviously benefited from restrictions of diet for brief periods; the 
restrictions were often self-imposed, but since they had no direct healing 
action upon the original ulcer, the time had come for most of them when 
even the taking of Benger’s food was an ordeal they hesitated to face. 
The inconstant gastric pain is not due to an ulcer, but to a variable strain 
produced by a variable load in the offending segment of gut. 
“Nausea is sometimes present, but actual vomiting appears, from the 
histories of the patients, to be of very rare occurrence. So clear does the 
differentiation seem to be, by means of the histories, between the pain 170 
GASTRO-ENTEROPTOSIS 
from the strain on the stomach of a mobile colon and from a gastric ulcer, 
that occult blood has never been searched for, and this omission has not 
been penalized by the unexpected discovery of an ulcer at the subsequent 
laparotomy. All the cases of ulcer had had gross hematemesis or melena, 
or both. The need for the test appears to arise from an inadequate 
evaluation of the patient’s symptoms, with the apprehension that a 
laparotomy may be performed and no ulcer be found. An operation 
should be performed with the certainty that no ulcer will be found and 
the high expectation that benefit will accrue from it. 
“Duodenal Type.—Pain is experienced in the right hypochondrium, 
and is characteristically a ‘hunger pain’ that appears about three hours 
after food and is relieved by the further taking of food. But once again, 
whilst its character and location are constant, its times of appearance and 
response to the taking of food are constantly inconstant. It is not neces- 
sarily a daily experience, nor, because it appears before one meal in the 
day, does it always recur before each subsequent meal. As a rule pain 
is relieved by the taking of food, but sometimes it is not relieved, and 
sometimes it is made worse. When the strain of the mobile ascending 
colon falls with maximum intensity upon the second part of the duo- 
denum—the site that is most liable to ulceration—taking of food can 
clearly have one of two effects upon the load in the ascending colon: 
Either the wave of peristalsis initiated by the next meal shifts the load 
into the transverse colon, and so relieves the strain upon the duodenum, 
or the meal merely silts up in the ascending colon, and adds to its load, 
thus failing to relieve, or even intensifying, the pain. As a rule the 
former happens, and so the phenomenon of a ‘hunger pain’—that is, a 
pain relieved by food—is established. Alternatively the pain is made 
worse—a rarer event—in an easily explicable manner, when the food 
merely adds to the load of the ascending colon. Further, a new light 
appears to have been thrown upon the origin of ‘hunger pains,’ which it 
must be emphasized have been studied in all these patients in whom no 
duodenal ulcer could be detected at the subsequent operation, in entire 
accordance with one’s expectations. 
“The time of appearance of a ‘hunger pain’ coincides as a rule with the 
time when most of the previous meal will have arrived at the ascending 
colon—that is, within from three to four hours after feeding. When pain 
has been established, it may as a rule be relieved by inducing further 
peristalsis in the alirrientary tract by taking food—a method of relief 
which sometimes quite significantly fails, as has already been explained. 
Hence the ‘hunger pain’ is really a ‘food pain’ determined by the arrival 
of food at a portion of the alimentary tract where it can exert a nocuous 
strain, exhibiting a variability that would be expected from a variable 
strain, and responding in an erratic manner to a method of relief, that is 
not strictly controlled, for augmenting or diminishing the strain. The 
difficulty of explaining a ‘hunger pain’ by the presence of a duodenal 
ulcer—even if the inability to detect an ulcer in all these cases was RIGHT-SIDED PTOSIS 
171 
assumed to be a personal failure—is that a duodenal ulcer, in being 
soothed by active movement and arrival of foreign material in the duo- 
denum—since the food must get out of the stomach some time—is made 
to exhibit characteristics which ulcers elsewhere do not display. On the 
contrary, in the few cases of actual duodenal ulcer in this series, the 
patients have been most emphatic in their statements that, after a pre- 
liminary period of many months and sometimes years of intermittent 
‘hunger pains,’ their pain in the right hypochondrium has been constant 
for many months, and is always made worse by food. They can recog- 
nize very vividly for themselves the change between the pain that was 
an erratic visitor soothed by food, and one that has now become a con- 
stant companion from which no relief can be found. 
“The knowledge of the association between ‘hunger pains’ and a 
duodenal lesion is a debt that surgery owes to Moynihan, and further 
elucidation of its details can be regarded only as an amplification of his 
pioneer work, and as a grateful recognition of the stimulus that he has 
provided to further endeavor. 
“Biliary Type.—Several patients have given a history of attacks sug- 
gestive of gall-stones—some have received expectant treatment with the 
diagnosis already provided by their medical attendant; but only those 
cases are included under this heading in which the actual crisis has been 
witnessed by the writer. The crisis is very severe, and characteristic of 
obstruction to the outlet of the gall-bladder, either at the neck or at the 
cystic duct. The onset is sudden, and intense pain is experienced in the 
region of the gall-bladder, leading to vomiting and collapse. The upper 
segment of the right rectus is too rigid for any underlying structure to 
be recognized by palpation. The attack may last for from twelve to 
thirty-six hours, and when it has passed off, with relaxation of the rectus, 
a tender, swollen gall-bladder can easily be felt. This shrinks to normal 
size in a few days’ time. Jaundice, except for an occasional faint tinging 
of the conjunctiva, does not appear; the stools contain plenty of pigment, 
and bile does not appear in the urine. The attacks are nonfebrile as a 
rule, although in one case elevation of temperature occurred for forty- 
eight hours. At the subsequent laparotomy, performed generally within 
a fortnight after the crisis, a healthy gall-bladder without calculi was 
present in each patient, and a mobile ascending colon with its primitive 
mesentery. But an additional feature of great interest, and needing 
further investigation, was present in some of the cases. The gall-bladder 
was attached either to the second part of the duodenum, or to the hepatic 
flexure of the colon, by a band of membrane passing from these structures 
to the ventral surface of the gall-bladder and cystic duct over most of its 
length. This membrane is so constant in its attachment along a line to 
the ventral surface of the gall-bladder that it does not appear to be of 
inflammatory origin. It has well-defined lateral surfaces with small 
blood-vessels upon them, a free edge towards the fundus of the gall- 
bladder, and a broad base that fuses with the anterior layer of the gastro- 172 
GASTRO-ENTEROPTOSIS 
hepatic omentum. On cutting the membrane to free the gall-bladder, 
two edges with cellular tissue between them are left along the line of 
section. Such features are suggestive of a persistence of a small portion 
of the primitive anterior mesogastrium, between the layers of which the 
gall-bladder develops, rather than of adhesions of an inflammatory origin, 
which would in all probability show a more haphazard distribution. The 
point needs further investigation; but of whatever origin, it is clearly one 
medium whereby the strain from a sagging ascending colon can be trans- 
ferred direct to the gall-bladder and cystic duct. The other medium is 
the gastrohepatic omentum, which, sagging under the weight of ther 
colon, bends the cystic duct at an abrupt angle to the neck of the gall- 
bladder. If complete obstruction is caused through either of these 
means, then an acute biliary crisis follows. But it is conceivable that 
only partial obstruction may be caused in a number of cases, not suffi- 
ciently severe to produce a crisis, but sufficient to add the element of 
stagnation to the circulation of the bile in the gall-bladder, so that the 
arrival of attenuated bacteria results in the formation of gall-stones. A 
few patients in this series, with a mobile ascending colon but no symp- 
toms suggestive of a lesion of the biliary apparatus, were found to have 
gall-stones also at the operation; in their case a silent formation of gall- 
stones had occurred without incidental complete blocking of the cystic 
duct either from within or from without. Since the gall-bladders of all 
human beings, and especially all typhoid patients, are subjected to the 
influence of bacteria arriving from the alimentary tract from childhood 
upwards, whilst gall-stones are not formed in all of them, it is pos- 
sible that stagnation is the inconstant factor, which, in its turn, de- 
pends upon the inconstant survival of the mesentery of the ascending 
colon. 
“Renal Type.—In addition to their general symptoms of indigestion, 
these patients experience renal crises of great severity. Several have 
given a history that ‘they were suspected of having a stone in the kid- 
ney,’ but for only four included amongst this type are those in whom the 
crises were witnessed by the writer. They were so severe as to produce 
collapse and vomiting, whilst the right kidney was swollen and tender. 
(One patient had eleven crises while under observation.) When the 
attack is over, the kidney rapidly shrinks in size, but there is no increased 
output of urine, and the normal quantity that is subsequently passed is 
found under the microscope to contain a few red blood corpuscles. 
Apparently a partial occlusion of the renal vein is brought about by the 
drag of the colon during the attack; and it is of interest to note that, in 
the case of multiple crises, the attack could be cut short by the adminis- 
tration of a high glycerine enema, accompanied by a hypodermic injec- 
tion of pituitrin. The usual routine examination for a renal or uteric 
calculus was made beforehand in all these patients, with negative results; 
their urine was normal in composition in the intervals of their attacks; 
and at the subsequent laparotomy it was not possible to detect anything RIGHT-S DED PTOSIS 
173 
wrong with the kidney or ureter in any of them. All of them had a 
mobile ascending colon. 
“Right Iliac Fossa Type.—In these cases chronic pain in the right 
iliac fossa is the salient feature, added to the usual dyspeptic symptoms. 
It is not focal, and has not the severity of the type pains. It may remain 
present for several days, and is often described as a severe discomfort 
experienced diffusely over the right iliac fossa. In some patients it is 
present in addition to the type pains, and is then considered a trivial 
disability in contrast with the type pain. It appears to be a sensation 
experienced from a chronically overdistended segment of gut, to which 
the element of dragging is added. Several of these patients also give 
histories of attacks of mucous colitis; but in one patient the operation on 
the colon was deliberately undertaken for the relief of persistent colitis 
of seven years’ duration. 
“In the other patients, in whom colitis was not continuous as in this 
one, but appeared as occasional attacks of about three weeks’ duration, 
there has been no recurrence of the attacks following the operation on 
the colon. On the other hand, it must be noted in connection with this 
difficult disorder that in one patient, not included in this series, who had 
been suffering for a year from a very grave bloody colitis, the ascending 
colon was not fixed at the operation deliberately undertaken for that 
purpose; and the patient made a complete recovery after the removal 
of the appendix and the fixation of the omentum to the abdominal wall 
to straighten out the hepatic flexure (Coffey’s hammock operation). 
“Children.—The condition is generally regarded either as ‘chronic 
appendicitis’ or merely as ‘dyspepsia’ in children. Pain, not very severe, 
which often lasts for several days, is complained of in the region of the 
right iliac fossa. It is intermittent in character, and examination of the 
abdomen seldom reveals any obvious explanation of its presence. There 
is no real tenderness, no muscular rigidity, but a full ascending colon can 
be detected when carefully sought for. Vomiting seldom occurs, but 
nausea and lack of appetite are invariably present. There is often high 
fever, with a quickened pulse-rate, and an abundance of acetone in the 
urine. The patient is clearly very ill, and the absence of guiding signs, 
in the region where the symptoms are experienced, is a source of anxiety 
that may lead to a panic removal of a healthy appendix. In the absence 
of tenderness, rigidity, and mass formation, no anxiety need be felt on 
this score; whilst the palpation of the outline of the overdistended 
ascending colon is sufficient to enable a diagnosis to be made. This can 
be subsequently confirmed, when the attack is over, by an X-ray exam- 
ination. The illness often passes off with a slight attack of diarrhea. 
The persistence of a mesentery to the ascending colon has been con- 
firmed at subsequent operation in more than ioo children under twelve 
years of age, in whom, rather as a diagnosis of despair than a profound 
mental conviction on the part of their medical advisers, who had wit- 
nessed several attacks in each of them, appendicular mischief was said to 174 
GASTRO-ENTEROPTOSIS 
be present. In 7 of them, disease of the appendix was also found at the 
operation, but in the remainder the appendix appeared to be healthy in 
every respect. These operations in children have not been included in 
the total series of 180 cases which are under review in this article. It 
has not been possible, under war conditions, to follow them up with 
sufficient precision to justify at present any exact conclusions. Several 
of them have been seen incidentally at long periods after the operation, 
and their condition was most satisfactory, but many mothers showed a 
reluctance to continue bringing their children to hospital merely for the 
purpose of inspection when they were apparently well.” 
The two clinical pictures given in Walton’s clinical report and 
Waugh’s general clinical summary are so similar to each other in general 
effect and so in accord with my own observations on right-sided ptosis 
that it would be supererogation for me to make any further statement 
but for the fact that I have an unusual case combined with an accurate 
record of pathological findings to relate, which shows a complete clinical 
picture of combined right-sided and midline ptosis. 
The patient was a young lady, just approaching eighteen years of age. 
Family History.—Her paternal grandmother had suffered a great 
deal with abdominal pain and was always a semi-invalid. Her father, 
president of a large teachers’ college, is of very thin ptotic build and has 
always had a good deal of distress in his abdomen, particularly in the 
right side. On April 18, 1917, her sister, who was then twenty-two years 
of age, was operated upon by me on the pre-operative diagnosis: “Pro- 
found intestinal stasis with block at the hepatic flexure,” evidenced by 
the fact that the patient rarely had a bowel movement oftener than once 
in two weeks. The findings were “extreme (almost complete) blocking 
at the hepatic flexure by adhesions binding together loops of intestine. 
Cecum enormously dilated and several inches longer than normal.” 
(This patient had been operated on elsewhere when she was fifteen for 
chronic appendicitis with no relief; was constantly sick until twenty-one, 
when she was operated upon again for adhesions. At this operation 
ptosis was discovered and some kind of an operation performed.) 
Personal History.—Very well as a child. Two and a half years ago 
(March, 1920), was going to school when she had a severe pain in her 
right side, lasting four days. It was located low down in the iliac region 
below McBurney’s point. The pain was severe for four days and the 
region was sore for two weeks. June 6, 1920, took a trip to California. 
On the way, she was seized with another severe attack similar to the 
first. At this time her lower right abdomen was sore for three months 
when she began to take on fat as a result of her prolonged rest. With 
the deposit of fat, the pain and soreness ceased, and she went back to her 
school. Began to lose flesh again. In January, 1921, she had another 
attack followed by soreness lasting several weeks. In July she had 
another mild attack, soreness again lasting several weeks. Upon pro- RIGHT-SIDED PTOSIS 
175 
longed rest, the patient again gained flesh. In December, 1921, she 
began to lose weight and a constant pain and soreness developed which 
was continuous. During the winter of 1921—1922, she had pain in the 
abdomen. The pain was tearing in character. From that time on she 
had soreness all the time. Left school in April, 1922. All the time she 
had soreness and a sensation of fullness in her right side. Her physician 
at that time urged her to be operated on for appendicitis but she declined. 
She never had fever at any time and was never constipated. In May, 
1922, with prolonged rest, she put on a certain amount of weight, after 
which she gained in health, but the soreness in her right side never dis- 
appeared. Lifting or dancing produced pain with the sensation of tearing 
or pulling. During her more severe exacerbations she had nausea and 
vomiting. 
In the course of the history-taking, the patient volunteered the statement 
that the most striking thing in her case was that, when fat, she was much 
relieved. On loss of flesh she became much worse. When she entered the 
hospital, August 14, 1922, she had been practically a bed invalid for several 
weeks and, as she was constantly suffering, it was thought unnecessary to 
complete the usual preliminaries of a thorough X-ray examination. 
Pre-operative Diagnosis.—The diagnosis before operation was so- 
called “chronic appendicitis,” but is probably “right-sided ptosis with painful 
bands.” 
Operative Findings.—Long right rectus incision. Uterus small, 
otherwise pelvic organs normal. All the lower portion of the ascending 
colon and cecum completely mobile. A strong membrane, split in places 
into white fibrous bands but showing evidence of activity, extended diagon- 
ally downwards from the parietal peritoneum to just below the middle of 
the ascending colon, where it attached itself and acted as a ligament. Appen- 
dix was more than eight inches long and was attached by firm adhesion 
about one inch from its tip to the posterior or parietal peritoneum well up 
under the liver. From the point of its attachment to its tip, the appendix 
was dilated and showed some evidence of disease. (It will be noted that this 
distended portion of the appendix was eight inches away from the painful 
area.) From this attachment of the appendix to the posterior parietal peri- 
toneum down to its origin, at the end of the cecum, the appendix was eight 
inches long, was strong and fibrous, and was acting as the chief ligament of 
the cecum, but was not diseased. There was a marked midline gastroptosis 
with extra fixation of the duodenum by an acquired membrane. The hepatic 
flexure of the colon was very firmly fixed by extra acquired bands. A strong 
white fibrous band attached the omentum near the colon to the tip and under 
surface of the gall-bladder. 
On lifting the transverse colon and omentum, an acquired membrane was 
seen extending from the root of the transverse mesocolon to the under sur- 
face of the colon and omentum. On cutting these membranes, a marked 
dilatation of the duodenum was observed below the colon. A groove in the 
posterior abdominal wall marked the location of the superior mesenteric 176 
GASTRO-ENTEROPTOSIS 
vessels crossing the last portion of the duodenum. Beyond this crossing, 
the jejunum was collapsed. Accompanying the vessels were definite white 
lines of secondary development which had apparently been laid down in 
accordance with Lane’s law to help sustain the intestines below. 
This is one of the most perfect and complete pictures of early ptosis due 
to mobile cecum that we have seen. Figs. 124 and 125 faithfully set forth 
Fig. 124.—Midline Ptosis, Right-sided Ptosis, Mobile Colon Held by Firm Bands from 
the Middle of the Transverse Colon by the Appendix from its Tip. 
Transverse colon supported by extra bands, one crossing the duodenum, the other going to 
the under surface of the gall-bladder. Omentum held up to show the relation of the intestines. 
the condition as it existed. The membranes, as will be observed, were 
entirely independent of the appendix. The pain of which she complained 
for two and a half years, located low down in the right side of the abdomen, 
had no connection with the only part of the appendix which showed the 
slightest disease. The attachment of the membranes to the ascending colon 
and the dilatation of the cecum corresponded accurately to the site of the 
pain. This development had taken place at a period beginning with the RIGHT-SIDED PTOSIS 
177 
sixteenth year and had reached this complete development by the end of the 
eighteenth year of age. 
The chain of pathology that may develop as a result of right-sided ptosis, 
or nonfixation of the right colon as shown by this case, follows: 
1. Nonfixation of the cecum and ascending colon. 
2. High fixation of the appendix and its mesentery well up under the 
liver. 
Fig. 125.—The Transverse Colon Turned Upwards. 
The same picture of the ascending colon and appendix as shown in Fig. 124. Additional 
membranes develop from the root of the mesentery to help further in holding the transverse 
colon. The short portion of membrane to the left continues across the transverse colon forming 
bands going to the liver and duodenum, shown in Fig. 124. A groove shows the superior 
mesenteric artery with evidences of lines of crystallization producing dilated duodenum, duo- 
denal arteriomesenteric ileus. 
3- Fixation of the hepatic flexure to the front surface of the kidney with 
acquired membranous development to strengthen the supports. 
4. Acquired membranes extending from the parietal peritoneum across 
to the mobile colon. 178 
GASTRO-ENTEROPTOSIS 
5- Acquired membranes along the under surface of the first part of the 
transverse mesocolon, for the extra support of this part of the colon. 
6. One band extending along the omentum from the colon to the under 
surface of the gall-bladder. 
7. Another extending from the colon across the duodenum, making extra 
fixation. 
8. A midline ptosis probably due to dilatation of the stomach, secondary 
to dilatation of the duodenum, which was produced by duodenal ar- 
teriomesenteric ileus. 
All the above features showed just as clearly as these pictures indicate, and 
when taken with the history of the case, make a complete clinical and patho- 
logical picture of right-sided ptosis. 
Diagnosis and Indications for Treatment.—The most important man- 
ifestation indicating surgical treatment for right-sided ptosis is right- 
sided pain or distress. Right-sided pain or distress was formerly con- 
sidered as positive evidence of organic disease. In the early nineties, 
the ovary was supposed to be the cause of much right-sided pain. There- 
fore, the right ovary or both ovaries were removed and the patient made 
a nervous invalid thereby, while she remained unrelieved. A few years 
later, chronic appendicitis became the vogue and many of these patients 
whose ovaries had been removed now had the appendix removed—without 
relief. Many of these patients had stomach troubles for which gastro-ente- 
rostomy was sometimes performed—again without relief. The gall-bladder 
was drained in many cases without relief, until removal of the gall-bladder 
came to the front—this also without relief. The enthusiastic, and optimistic 
surgeon who had removed the patient’s ovaries, later her appendix, done a 
gastro-enterostomy, fixed her right kidney, drained her gall-bladder 
and finally removed her gall-bladder, each time felt sure he was going 
to solve the problem even in the absence of demonstrable organic path- 
ology, but the patient went on with pain and distress. Finally, after 
having failed to relieve her, he gravely pronounced her a “neurasthenic.” 
Many of the ablest surgeons of our time have taken the view that 
this pain, if real, must be due to an organic lesion. If not due to an 
organic lesion, it is because the patient is a hypersensitive neurasthenic. 
I am certain that great injustice has been done these suffering and mal- 
treated individuals. We must draw a sharp line of demarcation between 
this class and the class of individuals who have pain, not only in the 
right side but in the left side; and in the shoulder; in the neck; in the 
back of the head, in any scar that may have been made by a surgical 
operation; from any demonstrable abnormality such as varicocele in the 
male, and painful coccyx in the female; from the result of suggestions 
of possible pathology, such as adhesions, etc. This latter type of patient 
is an entirely different individual, and may be termed a “psychasthenic.” 
This state does not necessarily bear any relation to the ptosis question, 
although it is often found with it. RIGHT-SIDED PTOSIS 
179 
With our modern clinics and means of investigation, the differentia- 
tion of organic and inorganic disease can usually be made. For instance, 
the typical abdominal pain which comes on suddenly, with severe grip- 
ing in the umbilical region with nausea and vomiting and fever, finally 
ending with soreness in the right side, and which disappears to reappear 
in a few months, is appendicitis, as a rule, and is, therefore, an organic 
lesion. The history of a typical gall-stone attack is almost unmistakable 
and the pain is clear-cut. All the acute conditions, such as perforating 
ulcer, pancreatitis, gall-stones, appendicitis, etc., are easily diagnosed. 
There is no excuse for a careful surgeon failing to determine an obstruction 
of the ureter, a stone in the kidney, a cystic ovary, etc. 
After eliminating organic lesions, by established clinical methods, in a 
patient who has had a long-standing right-sided pain, which seriously inter- 
feres with the performance of normal duties of life or makes life miserable, 
and which right-sided pain is always fixed and localized at the same point 
or points in the abdomen, and which pain is unrelieved by competent medical 
treatment, an exploratory incision is justified, whether former operations 
have been done or not. Occasionally, such an exploratory operation will 
reveal an obscure organic lesion as the cause of the pain; but usually the 
lesion is nonorganic. It is, therefore, a serious mistake to remove an organ 
on mere suspicion and leave untreated a mobile, sloppy cecum or an ascending 
colon which is being held up in places by bands or membranes. It is a mis- 
take to remove a normal blue gall-bladder for pain in its neighborhood, when 
we find a mobile colon dragging on the peritoneum back of the gall-bladder 
or on acquired bands attaching it to the gall-bladder. Supporting the colon 
by appropriate sutures gives better results and conserves a useful organ. 
Lane and others have recommended removal of the colon in some such cases. 
This is much more serious than the removal of the gall-bladder or appendix. 
While the removal of a chronically stretched-out chordlike appendix, com- 
monly referred to as “obliterated appendix,” does no particular harm, it is 
in my opinion a mistake to simply remove such an appendix and leave a large 
mobile cecum, with bands attached to its surface, without shortening its 
supports and placing it in proper position. I believe it is malpractice to 
simply remove an obviously healthy appendix and leave a movable cecum 
on which there is a red membranous development, without supporting the 
colon in its normal position by sutures. 
The chief indication for surgery in the treatment of right-sided ptosis 
is a chronic, localized, right-sided, abdominal pain or distress, in which no 
organic lesion can be demonstrated by any of the known clinical methods, 
nor by an exploratory incision, provided that a definite defect in the normal 
fixation of the ascending colon exists along with one or more of the various 
pathological manifestations usually occurring as sequelae to the defective fixa- 
tion. These pathological manifestations may vary. 
(a) They may be limited entirely to a large dilated mobile cecum, which 
is accompanied by constipation and chronic pain or distress on the 180 
GASTRO-ENTEROPTOSIS 
right side, low down. Pain is due to distention by gas and stag- 
nant fecal matter. 
(b) It may be painful right-sided floating kidney which is an indication 
of defective fixation of the ascending colon and which is accom- 
panied often by the intraperitoneal development of membranes and 
bands. 
(c) It may be right-sided pain which is constant, and worse when the 
patient is on the feet and especially if the pain is reflected upward 
and backward toward the right kidney region. 
(d) It may be pain in the gall-bladder region, due to a drag on acquired 
membranes and fibrous structures extending upward from the peri- 
toneal supports of the colon. 
The case reports and discussions by the various authors, which have been 
recorded in the preceding pages of this chapter, furnish the reader with 
the clinical data on which these conclusions are based. 
Surgical Treatment.—Inasmuch as the essential predisposing cause 
of right-sided ptosis is a defective fixation of the cecum and ascending colon, 
it naturally follows that the essential feature in the treatment of the ills 
resulting from this defect is the fixation of the mobile colon. Owing to the 
fact that secondary developments have sometimes changed the anatomy, it 
is usually necessary to do more than the simple fixation. For instance, in 
a widely dilated, much elongated cecum, it is often essential to both narrow 
and shorten it in order to get it back on the psoas shelf. While ordinarily 
the acquired membranes and bands are not interfered with during the course 
of an operation, at times they so distort the relations of the asscending colon 
and cecum that it becomes necessary to cut them. The prolapsing ascend- 
ing colon has frequently pulled the first part of the transverse colon down- 
ward, making tension on its peritoneal supports and calling forth acquired 
bands which cross the duodenum and give stomach symptoms. At times the 
colon has pulled the kidney out of position, and the prolapse has been so 
extreme and the distortion so great that it has produced organic dis- 
turbance of the kidney. In certain of such cases, fixation of the kidney from 
behind is necessary. As far as I know, Longyear was the first to consider 
and rationally apply the fixation of the ascending colon along with fixation 
of the kidney by using what he termed the nephrocolic ligament (see Fig. 
115, Chapter XI). Almost simultaneously, Klose and Wilms began to recog- 
nize the pathological importance of a mobile ascending colon and to do sur- 
gical fixation for its relief. Klose sutured the intestine to the parietal peri- 
toneum, while Wilms split the parietal peritoneum and inserted the end of 
the cecum and ascending colon into the slit without firmly suturing it. Both 
reported good results. The work of Klose appealed to me more than did that 
of Wilms. I began, therefore, to suture the cecum and ascending colon with 
linen thread. Soon I observed that there was some defect at the point where 
my sutures ceased and the transverse colon began. Therefore, I almost 
immediately began to combine the fixation of the cecum and ascending colon RIGHT-SIDED PTOSIS 
181 
with support of the first part of the transverse colon by suturing first its 
mesentery, and then its omentum to the abdominal wall over to a point 
slightly beyond the midline. This gave much better results. I occasionally 
encountered a very large, baggy cecum with stagnant contents which I could 
not get into place without shortening it. Klemm and Blake had both recom- 
mended plication of the cecum. I found that in two instances linen sutures 
used for plication of the cecum had suppurated, giving no end of trouble. 
I began, therefore, to suture the cecum with continuous catgut which both 
shortened and narrowed the intestine. Postoperative observations, in one 
case, showed that this did not make a permanent plication. I, therefore, com- 
bined this continuous suture with frequent interrupted sutures. I have found 
that this makes a permanent plication. The central feature of the operation 
that I now do for right-sided ptosis has been termed “right indirect colopexy 
and omentocolopexy,” which supports the colon over as far as or beyond the 
midline. In the majority of cases, it is not necessary to plicate the cecum. 
In certain cases, however, it is necessary. Cecal plication is done as follows: 
A straight needle carrying a No. o chronic catgut doubled is used for a con- 
tinuous suture, beginning at the convergence of the two principal longitudinal 
bands near the end of the cecum. The continuous suture is passed by taking 
first a bight of one band, then from one to three or four bights of the peri- 
toneal covering of the intestinal wall between the bands. Then a bight of 
the other longitudinal band is included (Fig. 126). This line of suture con- 
tinues as far as the intestine is dilated and baggy, usually about six inches. 
This continuous suture is drawn taut for the purpose of shortening as well 
as narrowing the intestine. This would seem sufficient, but experience has 
proved that a continuous suture does not make enough pressure to cause 
absorption of the endothelial peritoneal surfaces to a sufficient extent to 
permit firm fusion of the fibrous layers of the peritoneum. Therefore, the 
continuous suture is supplemented by interrupted sutures of No. o chromic 
catgut, which pick up the peritoneum on one side of the crossing of a loop 
of the continuous suture, pass under the loop and pick up peritoneum on the 
other side. These sutures are tied tightly and, as will be seen, include the 
continuous suture in their loops (Fig. 127). Flaving performed the cecal 
plication, or having decided that it is not necessary, I then proceed to per- 
form right indirect colopexy by shortening its supports and including the 
lateral parietal peritoneum as follows: The small intestines are packed away 
from the field of operation by moist gauze. The ileocecal junction is pulled 
upward and to the left by the hands of an assistant. A heavy chromic cat- 
gut (No. 2) suture picks up the true parietal peritoneum at the curved angle 
which is formed by the junction of the posterior and lateral abdominal wall. 
This suture is placed well above and external to the prominence of the psoas 
muscle. Successive bights of peritoneum are then taken up across the front 
of the psoas muscle and along the mesocecum to the end of the cecum. This 
makes a purse-string suture. At the discretion of the operator, this purse 
suture may be tied now, or left until similar successive sutures have been 
placed above. I prefer to tie this purse suture when it is placed, in order 182 
GASTRO-ENTEROPTOSIS 
to be sure of the relations that will be produced by its tying. Similar sutures 
are then placed every three fourths of an inch, for about six inches, toward 
the normal location of the hepatic flexure. In picking up the peritoneum at 
the intestinal end of the suture, it is desirable to limit the territory of the 
suture to the mesentery or, at most, the peritoneal covering of the colon at 
its mesenteric junction (Fig. 128). Often it is well to place several extra 
Fig. 126.—Continuous Fine Double Chromic Catgut Suturing the Two Longitudinal 
Bands Together to Shorten and Narrow the Bowel. 
sutures in order to make the fixation secure. After placing these purse-string 
sutures for this distance, it is desirable to gradually bring the colon forward, 
which is done as follows: The suture includes a bight of peritoneum and 
mesentery at its junction with the colon, crosses the space and picks up a 
bight of the lateral parietal peritoneum just above the last purse-string 
suture. The next similar suture picks up a bight of parietal peritoneum 
three fourths of an inch to the front and slightly above the other suture. RIGHT-SIDED PTOSIS 
183 
Four or five similar sutures bring the intestine in a graceful curve forwards 
to the anterior abdominal wall, when the sutures begin to pick up the edge 
of the omentum, which is penetrated just distal to the colon and is brought 
to the abdominal wall, thus combining omentocolopexy or the hammock oper- 
ation with right indirect colopexy (Fig. 129). This hammock operation is 
extended toward the left, as high up as possible, over to the median line 
or two or three inches beyond the median line, depending on the extent of 
the pathology and the necessities of the case (Fig. 130). 
Fig. 127.—Diagrammatic Picture Showing Method of Including Each Loop of Continuous 
Suture in the Grasp of an Interrupted Chromic Catgut Suture. 
This is necessary to produce fusion and permanent plication. 
This is all that is ordinarily required for right-sided ptosis. 
The typical case of ptosis, reported in detail on page 174 and illustrated 
in Figs. 124 and 125, combines a midline with right-sided ptosis, also 
with defective fusion of the descending colon on the left side which consti- 
tutes a potential left-sided ptosis. Therefore, in addition to cutting the mem- 
branes, remoxing the appendix, plicating the cecum, doing a right indirect 
colopexy and omentocolopexy on the right side, the omentocolopexy or ham- 
mock operation was extended all the way across to the costocolic ligament, 
making a complete partition in the abdomen (Fig. 119). Owing to the fact 
that this patient also had a duodenal ileus as a result of the drag, we placed 
three sutures above the colon and through the mesocolon between vessels, 
carrying out the suggestion of Pilcher. Patient made an uninterrupted oper- 184 
GASTRO-ENTEROPTOSIS 
ative recovery, took her food splendidly and soon gained thirty pounds or 
more and has been entirely well since, it now being more than six months 
since the operation was performed. The same indications for fixation of 
the kidney in certain extraordinary cases apply here as in general ptosis 
Fig. 128.—Purse-string Peritoneal Sutures for Shortening the Mesocecum and 
Fastening It to the Lateral Parietal Peritoneum. 
The end of continuous and last of plication sutures is seen at upper end. 
referred to in Chapter XI. It goes without saying that the appendix in all 
these cases is removed. In three or four cases, the gall-bladder has been 
removed and a drain placed above the colopexy sutures. 
The operation which we have described above as “indirect colopexy and RIGHT-SIDED PTOSIS 
185 
omentocolopexy” is the operation which we have most frequently used in 
our ptosis work—in about three fourths of the cases. 
We have seen the results following this operation several times as we have 
Fig. 129.—Purse-string Sutures Tied, or Being Tied. 
The first suture directly fastens the colon and mesocolon to the lateral peritoneum partially 
tied, gradually bringing transverse colon around to the front wall. Last suture shows the begin- 
ning of omentocolopexy. 
done subsequent operations for other pathology. In every instance, the 
omentum has been found solidly fused in an unbroken wall. 
In one very tragic case, we had the opportunity to observe that this wall 
is water-tight. It happened as follows: A case of cardiospasm came for 186 
GASTRO-ENTEROPTOSIS 
treatment. Shd was very thin, had marked gastroptosis with gastric stasis. 
I had read Rovsing’s suggestion that cardiospasm was probably due to 
ptosis and that the proper treatment was gastropexv. I therefore did a very 
complete hammock operation as described. The cardiospasm was not 
materially benefited by the operation, although the stomach was adequately 
supported, and so she returned a year later with the same symptoms. One 
Fig. 130.—The Purse-string Sutures Fixing the Ascending Colon and Suspending 
First Half of Transverse Colon Tied. 
Sutures for fastening the omentum to peritoneum of abdominal wall two inches to the right 
of the medium line are placed. Additional sutures picking up the peritoneum of the colon and 
parietal peritoneum are placed to make fixation more secure. This we have termed “ right 
indirect colopexy and omentocolopexy extending two inches to the left of median line.1' Usual 
operation for right-sided ptosis. 
of my younger associates had seen the work of Plummer and therefore pro- 
posed to use Plummer’s string and bougie. For some reason the string 
was not used and the bougie was passed with some difficulty. In doing so, 
the patient suffered a great deal of pain and was sent to the hospital. He 
had no thought of the seriousness of the accident so did not prevent the RIGHT-SIDED PTOSIS 
187 
use of water and food. The patient did not do well. Gradually the upper 
abdomen began to enlarge. At the end of a week, there was tremendous 
enlargement, stopping abruptly at a transverse line which would pass 
through the umbilicus. The tragic possibility then dawned upon us. The 
enlargement was opened under anesthesia and most of the water and food 
she had taken during the preceding days came out. The lower end of the 
esophagus had been ruptured by the bougie and the partition made by the 
hammock operation had proved itself efficient and water-tight, so that not 
a drop escaped into the lower peritoneal cavity. 
I have stated above that this operation which I have described under the 
head of “right indirect colopexy and omentocolopexy” is an elaboration of 
the intraperitoneal colopexy of Klose. Waugh has elaborated the work of 
Wilms and it is probable that the operation which he has described in cer- 
tain instances will be better than the one I have described above, but I 
believe that it should also be combined with the hammock operation. It 
is particularly applicable when the adhesions have been extensive and raw 
surfaces have been left where they have been cut on the outer side of the 
colon. I have included Waugh’s operation on occasions with very great 
satisfaction. Waugh’s technic 9 is as follows: 
“A sandbag is placed under the lower part of the thorax, as for gall- 
bladder operations, to render easier the access to the hepatic flexure. The 
lower two thirds of the right rectus is turned inwards, and the nerves are 
mobilized at the points where they pierce the sheath and the muscle respect- 
ively. As a rule it is then possible to preserve them intact, although the 
eleventh thoracic nerve is sometimes snapped by the displaced colon. The 
abdominal and pelvic contents are then carefully palpated and inspected, so 
that a view of most of the stomach, the duodenum, the biliary apparatus, 
the ileum and appendix, the ovaries and tubes, and finally the colon itself, 
is obtained. The region where the iliac colon passes over the left side of 
the pelvic brim is palpated to exclude any bands of thickening in its mes- 
entery. The ascending colon, from cecum to hepatic flexure, is then lifted 
out on to the towels, and at this stage the main lines of strain upon the 
stomach, duodenum and gall-bladder can be demonstrated easily by gentle 
tugs upon the hepatic flexure. The mobility of the second part of the 
duodenum is tested by lifting it up between the finger and thumb, where, 
more particularly in cases of hunger pains, it can be brought up to the level 
of the incision in the skin. The appendix is removed if present, bands be- 
tween the gall-bladder and colon divided, and rare bands, as those causing 
an ileal kink and those occasionally found at the brim of the pelvis on the 
left side, are similarly dealt with. The peritoneum and fascia are then 
incised just above the brim of the pelvis on the right side, and the incision 
is carried upwards parallel to the line of the colon and as close as possible 
to the root of its mesentery (Fig. 131). The upper limit of the incision 
corresponds approximately to the level where the colon crosses the duo- 
9 Brit. Journ. Surg., January, 1920. 188 
GASTRO-ENTEROPTOSIS 
denum. Here the fascia becomes much thinned, where it splits to inclose 
the right kidney. This curtain of peritoneum and fascia is then pulled out- 
wards, and the bed formed by the iliopsoas and quadratus lumborum muscles 
freed of fat and cellular tissue until the muscle fibers and nerves of the 
Fig. 131.—The Incision of the Fascia. (Waugh.) 
This incision covers the posterior abdominal wall and is shown by the dark line running from 
the level of the pelvic brim to the hepatic flexure close to the root of the primitive mesentery. 
lumbar plexus are seen (Fig. 132). Into this bed the colon is then gently 
coaxed, the cecum being placed into position first of all. The curtain is 
pulled over it, and attached by interrupted stitches of catgut to the anterior 
longitudinal white band of the colon. This is a convenient landmark which 
Fig. 132.—The Flap of Fascia Raised and Turned Outwards. (Waugh.) 
The lower pole of the kidney is just seen at the upper end of the bed formed for the colon, 
the ureter can just be seen mesially, and branches of the lumbar plexus of nerves are visible 
emerging between the psoas and quadratus lumborum muscles. 
insures the gut being held in proper position without torsion upon its own 
axis (Fig. 133). When gall-stones are also present—as they were in four 
cases of this series—they are removed in the usual way, and the gall-bladder 
drained after the fixation of the colon has been completed. RIGHT-SIDED PTOSIS 
189 
“ ‘Jackson’s membrane’ was only met with once in this series of cases. 
In cases of the ‘gastric type’ with a steep ascent of the transverse colon to 
Fig. 133.—The Flap of Fascia Has Been Fixed to the Anterior White Line of the 
Ascending Colon, Except at the Hepatic Flexure. (Waugh.) 
At this point the topmost stitch has been fixed to the gut wall above the external to the white 
line. 
the splenic flexure, the omentum is sometimes fixed transversely to the 
abdominal wall after Coffey’s method. The abdomen is then closed in the 
usual way.” CHAPTER XIII 
MIDLINE PTOSIS 
Midline ptosis is an acquired visceral prolapse involving one or more 
of the organs which cross the midline of the abdomen, the prolapse thereby 
materially changing the relation of these organs to the normally fixed points 
of the intestine at the hepatic flexure, duodenum and splenic flexure and 
tending to produce relative obstruction or kinking at these points (Fig. 134). 
The above title or designation has been adopted in preference to gastrop- 
tosis or gastrocoloptosis because of its wider significance. For it is not 
uncommon to find the liver down in these cases, which would not be in- 
cluded under either of these titles. 
The first efforts at surgical treatment were directed towards gastrop- 
tosis, and the operations were performed independently, and apparently 
without the authors’ knowledge of each other’s work. The pioneer opera- 
tions for this condition were done by Duret, Rovsing, Beyea, Bier, B. B. 
Davis, and the author of this monograph. Each of these writers, as he fol- 
lowed gastroptosis into the intricacies of enteroptosis, thought this was the 
primary condition and built his theory around it. This brought a great deal 
of ridicule from general surgeons, owing to the fact that they most fre- 
quently found gastroptosis as a part of a general process in which all of the 
organs were down, and the characteristic body formation previously de- 
scribed was shown. Even up to this time the majority of surgeons have 
failed to recognize the fact that gastroptosis and coloptosis producing symp- 
toms may occur entirely independent of any other ptosis. In fact, those 
cases of gastroptosis and coloptosis producing most marked obstruction at 
the second portion of the duodenum or at the flexures of the colon are 
usually found in patients whose ascending and descending colon and their 
mesenteries have normally fused; a condition which makes a general ptosis 
practically impossible, as we have shown in another chapter. This point was 
recognized quite early, but the proof came only in 1911, when I made 
a critical review of the patients upon whom I had performed the ham- 
mock operation for gastroptosis and found that in only 4 of 41 cases 
were the kidneys movable. These were recognized as general ptosis and 
both kidneys were anchored. The hammock operation was done, expanding 
the upper abdomen. It is evident that Rovsing has dealt quite largely 
with this type of cases, which he first called gastroptosis and has more 
recently called gastrocoloptosis. While he has at certain points mentioned 
floating kidney and prolapsed ascending colon, he has apparently not recog- 
190 MIDLINE PTOSIS 
191 
nized the fundamental congenital background which makes possible these 
cases of general ptosis, and has limited his study to midline ptosis, or 
acquired ptosis. 
He classes ptosis as virginal and maternal; he believes that the virginal 
type is produced entirely by the use of the corset, and that the maternal is 
due entirely to the bearing of children, by expanding the lower abdomen. 
Fig. 134.—Typical “ Midline Ptosis.” 
Middle pyloric portion of the stomach and transverse colon prolapsed while the fixed points 
at the esophagus, duodenum, and colonic flexures, as well as the kidneys, remain in normal 
position. The pylorus is dilated so that the duodenum is continuous with the stomach 
While I shall attempt later on in this chapter to prove that there are 
other very important factors entering into this subject, I take this opportun- 
ity to recognize Rovsing, who has limited his research to this particular 
type of ptosis and who, therefore, is entitled to a respectful hearing, as the 
pioneer in this work. I shall, therefore, with his consent, quote Rovsing’s 
own words very largely in connection with this subject. His conception of 
the subject of gastrocoloptosis was published in Annals of Surgery, January, 
1913- 192 
GASTRO-ENTEROPTOSIS 
“Confining the discussion, for the present, to gastrocoloptosis with 
women, I discriminate between two principal groups which, both as regards 
the pathogeny and the symptomatology, are rather sharply distinguished 
from each other; they are virginal ptosis and maternal ptosis. 
“Virginal Gastrocoloptosis.—In the course of the first or second 
year after the commencement of puberty, when the wearing of corsets usually 
commences, the previously healthy individual begins to suffer from persistent 
constipation, to which are quickly added weariness, headache, and loathing 
of food. In addition to these symptoms there occurs, after some time, 
cardialgia, in the form of severe pains which are always situated to the left 
of the center line and occur as soon as the patient partakes of food. The 
quality of the food has no significance so far as the rise of these pains is 
concerned, whereas the quantity—the mass and weight of the food—is of 
great importance, for which reason these patients can only get along by 
taking many quite small meals during the twenty-four hours. In many 
instances the commencement of the pains is accompanied by vomiting, and 
with a smallish group of these patients each meal is invariably and imme- 
diately succeeded by the discharge of a part or the whole of the food par- 
taken of. In the first instance, the patients may maintain an astonishingly 
healthy appearance for many years; but if they disgorge everything, and 
are furthermore frightened by fear of the pains from attempting to eat, 
emaciation sets in, which may often reach an extreme stage and present that 
aspect which I have called gastroptosis cachexia, and which may result in 
the death of the patient as a consequence of inanition. 
“By examining the chemical function of the stomach, one generally finds 
that the measure of acidity is normal, but in a certain number of cases one 
finds achylia, and in others, conversely, hyperacidity and even gastrosuccor- 
rhea. 
“In more than half of the cases, the motor of function is completely 
normal, inasmuch as the stomach empties itself entirely in the course of 
from four to five hours. In 30 to 40 per cent of the cases, there is a slight 
delay (five to seven hours), while food remains are rarely found eight hours 
after one of Bourget’s experimental meals. 
“With many of these patients, a whole series of nervous symptoms de- 
velop gradually as a result of this state of auto-intoxication and inanition, 
such as oppression across the loins, in the pelvis and the abdomen, clammy 
hands and feet, palpitation of the heart, physical depression; with some a 
mental relaxation and with others a sensation of dread. Finally disturbances 
in the function of the genital organs develop very rapidly, because the men- 
struation becomes irregular and is accompanied by diffuse pains in the abdo- 
men and a deterioration of the regular symptoms. The menstruation is 
frequently very deficient, and for years many entirely fail to appear. 
“The pathogenesis of this disease as shown by its symptoms is, in my 
opinion, as follows: the lacing up of the young girls’ gracile, easily relaxing, 
and plastic body in corsets involves an increasing deformation and straiten- 
ing of the lowest thorax aperture. This results in a shifting of the sub- MIDLINE PTOSIS 
193 
diaphragmatic organs. First of all, the pressure acts upon the massive 
liver, and this again by its great weight serves to dislocate the organs lying 
below. Paul Hertz has shown us in a very fine manner how nephroptosis 
arises from corset pressure, because this utilizes the liver as a lever to tilt 
the right kidney out of its niche, and we therefore understand why in the 
majority of cases the floating kidney is only on the right side. But to what 
still greater extent, and how much more invariably must the effect of the 
corset pressure on the liver extend to the stomach! 
“It is clear that if the liver is pushed down the stomach must follow suit, 
and hereby the esophagus, the gastrophrenic ligament, and the cardial peri- 
toneal covering in to to are stretched in a manner which corresponds with 
the extent of the subsidence. In this I perceive the cause of the invariable 
pains in the left side of the epigastrium, of which these patients always 
complain when they are up and doing, and especially during meals. But 
in addition, the posterior edge of the gastrohepatic and hepaticoduodenal 
ligaments must also become lengthened and dislocated. Together with the 
stomach, the transverse colon is pushed down, whereby more or less acute 
angled bends occur at the points of fixation at the heptic flexure and the 
splenic flexure. This involves a hindrance of the passage of the feces from 
the colon ascendens to the colon transversum and, if they enter the latter, 
they will again be retained here for an abnormally long time, and then the 
hard, gnarled feces still further and continuously weigh down the transverse 
colon. Hence the ever-increasing constipation. 
“I look for the cause of the virginal ptosis patients suffering so much 
more than the maternal ptosis patients do from pains and vomitings after 
meals to the circumstance that the tight abdominal wall and the narrow 
abdominal cavity do not permit of the free subsidence of the loosened organs. 
The result is that the stomach as well as the colon folds itself trans- 
versely with the longitudinal axis, and breaks and bends occur which hinder 
the natural passage of the food and produce stasis and pains. The fact of 
the matter is that all the vessels and nerves to the stomach from the large 
vessel and nerve roots have their course just between the peritoneal layers, 
which either form the suspensory ligaments or cover them. They form, 
so to say, an integral part of the suspensory ligaments and, when these are 
folded, are also subject to bends and folds; and, when the ligaments are 
stretched and lengthened by the subsidence of the stomach, a considerable 
drag is also exercised on the vessels and nerves. That such a distention of 
the sympathetic fibers and thereby of the ganglion celiacum and of nervi 
vagi, which, with the esophagus, extend into the thoracic cavity, cannot fail 
to affect the activity of these nerves, seems evident, and here, surely, is to 
be found the explanation of many of the nervous symptoms of these patients. 
As regards the invariable pains in the left side of the epigastrium, it seems 
to me that these are explained naturally as having their origin in the drag 
on the sensitive nerves which have their course in the subperitoneal tissues. 
“In these conditions we have a simple explanation of the pains and dis- 
gorgements of the virginal ptosis patients immediately after partaking of 194 
GASTRO-ENTEROPTOSIS 
food; and, if these symptoms become invariable, the consequent results are 
emaciation and waste of fatty and other tissues in the abdominal organs, 
which makes room in the abdomen for a further subsidence of the subdia- 
phragmatic organs, and makes the suspensory ligaments of these thinner and 
more relaxable. But, by this, the subsidence of the colon is increased, and 
the constipation by degrees becomes more obstinate. With the resorption 
of the stagnant feces and a poisoning of the organism, arises auto-intoxica- 
tion; but this is not all, because if the stagnation in the large intestine reacts 
on the function of the small intestine, the passage through the small intes- 
tine takes place more slowly, and, in certain cases, a real stasis may even 
occur in this. As assumed by Lane, this perhaps may be due to bends in 
the small intestine at its points of fixation (the duodenal kink and the iliac 
kink) where the subsided part of the intestine joins the fixed part; or, as 
Knud Lunn thinks, it may be only a result of the constipation, especially 
where valvulae bauhini are deficient. 
“According to Lunn’s observations, then, it seems as if the stasis is trans- 
mitted to the stomach, and we then get the delayed emptying of this, five 
to seven hours after the meal, which often occurs with gastroptotic patients, 
and which is interpreted by certain authors as a ‘primary atony,’ and even 
by Stiller is considered as being the cause of the ptosis. 
“The view of the matter is entirely beyond the point, because in more 
than half of the cases of gastroptosis the emptying is perfectly normal. 
The delayed emptying, on the contrary, which occurs with the minority of 
ptosis patients seems to me rather to be explained naturally by the difficult 
conditions of passage in the large and small intestines. 
“The diagnosis of the virginal ptosis is generally not difficult for him 
who has once had his eyes opened to the peculiarities of the aspect of the 
disease, but for him who has not it offers mkny difficulties and stumbling 
blocks. Certain it is that few diseases are so frequently misinterpreted as 
this. The three wrong diagnoses under the flag of which virginal ptosis 
most frequently sails are (i) ulcus ventriculi, (2) colitis, and (3) nervous 
disease of the stomach, or hysteria. 
“Those cases where violent cardialgia and vomiting occur as an imme- 
diate result of meals and dominate the aspect are naturally confounded with 
ulcus ventriculi. This confusion happens all the more easily because the 
violent and frequent vomitings by no means rarely show streaks of blood, 
or even such a strong admixture of blood that they assume the character 
of hematemesis. The presence of constipation, indeed, only strengthens the 
diagnosis, because it is so often a symptom with ulcus. 
“In addition to this, the examination of the position of the stomach by 
scraping auscultation, or by roentgenoscopy after a bismuth meal, often 
reveals a subsidence which is inferior in proportion to the acute symptoms. 
With most cases, this seems to controvert the diagnosis, inasmuch as these 
cases mean quite plainly that the acuteness of the symptoms must be pro- 
portionate with the degree of the extent of the subsidence. Not until one 
has realized that it is just the circumscribed conditions of space which MIDLINE PTOSIS 
195 
hinder the pressed-down stomach from freely sinking down and, on the 
contrary, jam it between the tight abdominal wall, the spinal column and 
the other abdominal organs, and force it to place itself in bends and folds, 
does one understand that these very circumstances, in spite of the apparently 
minor ptosis, produce such acute symptoms. 
“The differential diagnosis from ulcus is, as a rule, easily determined 
from the following facts: (i) The seat of the cardialgia is to the left 
of the center line. (2) The cardialgia does not depend on the quality of 
the food, but does on the quantity of this. An ulcus patient suffers pain 
from eating rich, sour, spiced food, no matter how small the quantity, but 
stands milk; while a ptotic patient stands all such food equally well so long 
as the quantities are quite small, but suffers severe pain from milk and other 
neutral food when the quantity is too large. (3) The position of the body 
influences the symptoms. These are always worse in an upright position, 
and always improve and often disappear entirely only with confinement to bed. 
“The cases where constipation dominates the aspect of the disease, while 
the stomachic symptoms are comparatively minor, are often confounded 
with colitis. In many cases the confusion is promoted by this, that the 
constipation involves in reality a colitis with periodically occurring diarrhea. 
Here, also, it is a differential diagnostic symptom of great value; 
with ptosis, confinement to bed has a highly favorable effect on the consti- 
pation; while constipation arising from other causes generally becomes 
more marked with confinement to bed. 
“The diagnosis hysteria and nervous disease of the stomach is generally 
given with such patients as have for a long time been vainly treated with 
ulcus therapy or anticonstipation treatment, partly because their having been 
vainly treated for a supposed organic disease leads to the diagnosis of func- 
tional neurosis, and partly because these patients, little by little, on account 
of their protracted sufferings and the fruitless treatment, become in a great 
degree psychically exhausted and nervous individuals. The differential 
diagnosis from hysteria is, however, by no means difficult, when one analyzes 
the history and the aspect of the disease; because it then always appears that 
constipation and dyspepsia have been the first symptoms and still constitute 
the central feature in the aspect of the disease. Scraping auscultation and 
roentgenoscopy show us the presence of ptosis, and, finally, an exact exami- 
nation shows that really hysterical stigmata are practically always wanting. 
“More rarely the pure ptosis is confused with cancer. This happens 
with those patients who have become completely emaciated by vomitings 
and abhorrence of food, lasting over many years, and who have acquired 
a cachectic complexion from the auto-intoxication arising from the stagnat- 
ing contents of the large intestine. 
“Complications and Consequent Diseases.—Some of my observa- 
tions indicate that the traction on the esophagus of the subsided stomach 
may involve a difficulty with the swallowing and passing of the food, and 
thereby, also, changes in the esophagus itself. It is peculiar to a rather 
numerous group of patients with virginal ptosis that they either permanently 196 
GASTRO-ENTEROPTOSIS 
or periodically, especially when in an erect position, disgorge the food im- 
mediately after swallowing it. In other instances I have observed the trouble 
with swallowing to be so serious that the patients have been admitted for 
stricture of the esophagus. That these cases are really due to the traction 
of the stomach on the esophagus seems proved by this, that the symptoms 
mentioned disappeared immediately and completely in all cases after gastro- 
pexy or after the employment of an effective supporting belt. 
“As regards the stomach itself, the folds and bends mentioned, which, 
with virginal ptosis especially, are the result of the narrow space, give rise 
to serious and interesting complications and to the consequent conditions. 
“I have already mentioned that, even where no trace of ulcus can be 
proved at the operation, hematemeses are not quite infrequent with gastrop- 
tosis. Such hematemeses are probably due to stasis in and swelling of the 
mucous membrane at the places where the wall of the stomach is creased. 
“Finally, in a certain number of cases, the virginal ptosis leads to the 
development of an hour-glass stomach. I think, indeed, that I dare assert 
that the solution of the so long disputed question of the pathogenesis of the 
hour-glass stomach is to be sought for in the fixation of the creases of the 
prolapsed stomach caused by corsets and laces. The two theories which have 
hitherto stood in opposition to each other are, as is known, the conception 
that the hour-glass stomach is a congenital deformity as opposed to the 
ulcus theory, according to which the hour-glass form should be due to cica- 
tricial shrinkage. Without venturing to deny the justifiableness of these two 
explanations with individual cases, I venture distinctly to insist that neither 
of them can be accepted as acccounting for the great number of this aston- 
ishingly frequent disease; because, if a congenital hour-glass is proved at 
all, it is proved, at the highest computation, only in one or two cases, of 
which the demonstrative force is doubted even by Moynihan, the advocate 
of the ulcus theory. Now, as regards this, it may, when considered super- 
ficially, seem to be well founded in the fact that, with an hour-glass stomach, 
ulcerations or cicatrices are often found on the partition wall. But further 
reflection shows that the theory does not stand the test. 
“The fact that we find an ulcus or a resultant cicatrix is really no proof 
that the ulcus is primary, because the hour-glass stomach itself, on account 
of the hindrance of the passage and on account of the stagnation and decom- 
position of the contents of the stomach, is greatly disposed to the develop- 
ment of ulcerations. 
“Especially is there far more reason to believe that ulcus is secondary 
in the majority of cases where such ulcerations occur in the proximal part 
of the stomach. But in a great number of cases neither ulcus nor cicatrices 
occur. 
“There is, in addition, another fact which is generally overlooked by 
most authors and which entirely precludes the correctness of the ulcus theory. 
What I am aiming at is this, that, while ulcus rotundum ventriculi is equally 
frequent with males and females, the serious forms which ought to be 
demanded for the development of such thorough changes are even more MIDLINE PTOSIS 
197 
frequent with men than with women, the hour-glass stomach being such a 
rare phenomenon with men that it must most appropriately be called a female 
disease. Here, so to say, the conditions quite resemble those of the gastrop- 
tosis. It was just this which directed my thoughts toward the possibility 
of the solution of the enigma, which the pathogenesis of the hour-glass 
stomach presents, lying in gastroptosis. 
“The study of the clinical features and my operative experience have 
greatly strengthened this supposition. An investigation of the history of the 
disease as regards 26 cases of hour-glass stomach which I have personally 
observed shows that the first symptoms of the disease have always occurred 
during the years of puberty, when the subsequent, simultaneous misuse of 
the corset and the tight lacing commence. In their main features, these symp- 
toms entirely resemble those of virginal ptosis. Little by little the increasing 
hindrance of the passage, the retention, and the dilatation in the proximal 
part of the stomach are maintained as an aspect of the disease, and, if 
hematemesis and melena occur in consequence of developing ulcerations, the 
aspect becomes more and more that of ulcus stenosis. 
“By my numerous operations for gastroptosis, I have been able to observe 
all the stages of the development of the hour-glass stomach, in consequence 
of which I have formed in my own mind a consecutive view of this. 
“With virginal gastroptosis, the bends of the creases occur essentially 
and naturally in two places: (1) On the lesser curvature at the transition 
between pars cardiaca and corpus ventriculi in the very place where the tri- 
angular solid ligamentum gastrophrenicum (called by some pars condensa 
omentum minora) ceases and is relieved by the more elastic portion of the 
omentum minus; (2) on the medial edge of ligamentum hepaticoduodenale 
where the free portion of the duodenum (with the pylorus) bends toward 
the fixed part. 
“The hour-glass formation is generally due simply to the fine adhesions 
which form themselves in the folds of the serosa surfaces which rest one 
upon the other (Figs. 1 and 2). 
“The development is some times greatly favored by this, that the omen- 
tum minus by coalescing with the omentum majus assumes a lace formation. 
With gastroptosis we very frequently find a complete loosening of the 
omentum minus, the central part of which subsides and hangs over the 
anterior side of the stomach like a tongue-shaped clump of the omentum. 
It may then come in contact with the tip of the omentum majus, and coalesce 
with this in a ribbon which draws a deep furrow in the stomach. The adhe- 
sion mentioned as occurring between the peritoneal surfaces, which I have 
seen in all stages, from those which are hermetically soldered, fixes the ptosis 
creases, and these, like partition walls, protrude into the lumen of the 
stomach. 
“I have dwelt so explicitly on the aspect and pathological importance of 
virginal ptosis because it is still so unknown and so misunderstood, though 
it is now fourteen years since I described it for the first time. The other 
form is far better known. 198 
GASTRO-ENTEROPTOSIS 
“The Maternal Gastrocoloptosis.—This is the form we find with 
women whose abdominal wall consequent to past pregnancies and confine- 
ments has become distended, roomy, and relaxed. Hereby the intra-abdom- 
inal pressure is altered, and the support which the air-filled intestines offered 
to the subdiaphragmatic organs, as long as the vigorous elastic abdominal 
wall acted fails. 
“With women whose stomachs lie in a normal and secure position at the 
moment when the relaxation of the abdominal wall commences, it depends 
entirely upon the strength of the ligaments whether a gastroptosis ensues 
at all. With strong women this does not occur; but with others, whose 
abdominal wall is less capable of resistance, a ptosis develops little by little; 
the development differing from the virginal ptosis in this, that the coloptosis 
is generally primary. The transverse colon, which is no longer borne up 
by the small intestine pelote, is weighed down by the heavy feces so that 
it hangs like a downward convex festoon suspended by the two flexures. 
The pull firstly affects the gastrocolic ligament and the mesocolon, which 
are elongated and dragged downward. It is quite common to find the gastro- 
colic ligament elongated from three to four times its normal length, when 
it is quite thin and perforated in many places. Secondly, it affects the 
stomach, the suspensory apparatus of which is also, little by little, stretched 
and elongated. The constipation and accumulation of fecal matter in the 
colon resulting from the coloptosis affects with steadily increasing strength 
the downward drag on the colon and the stomach. It frequently happens 
that the heavy, feces-filled colon lies right at the bottom of the pelvis and, 
like an anchor, holds the stomach fixed in its subsided position. Further- 
more, the stomach can drag down with it the lower part of the esophagus, 
and then we encounter gastroptosis in its extreme form. 
“With maternal ptosis the aspect of the symptoms differs from that of 
virginal ptosis in this, that the stomachic attacks—cardialgia and vomiting— 
are far weaker; are often, indeed, absent. It is due to the far more favor- 
able conditions of space, as the stomach is not jammed or liable to be folded 
and bent as is the case with the virginal abdomen. For the same reason 
these patients do not generally suffer the innumerable pains and nervous 
sensations which characterize the others. That it is the distinction as regards 
space which causes the difference in the aspect of the disease is quite clearly 
perceived in the transition of a virginal ptosis to a maternal ptosis. So soon 
as the first confinement is overcome, a great improvement occurs in the con- 
dition of the patient so far as these symptoms are concerned. 
“With maternal ptosis, the constipation with all its consequences is the 
dominant feature in the aspect. In course of time the effect of the auto- 
intoxication from the intestine reveals itself. The patient grows emaciated 
and sallow, suffers from headache and, in addition, from an ever-increasing 
sensation of subsidence, and from the unpleasant, depressing feeling that 
something is subsiding in the abdomen, and from an oppressive sensation of 
and feeling of fatigue across the loins. The drag of the subsided stomach on 
the cardia and the esophagus causes constant pain in the left side of the MIDLINE PTOSIS 
199 
epigastrium and, not unfrequently, difficulty in the passing of the food 
through the esophagus, so that a spasm of the cardia may arise. (Similar 
conditions sometimes occur with secondary dilatation of the esophagus.) 
“It is characteristic of the disease that all these symptoms improve or 
vanish entirely with confinement to bed, while they at once recur or become 
worse with an upright position: 
“The coprostasis may attain such stages that attacks resembling ileus 
may occur, and in extreme cases the stomach may also become so loose that 
volvulus ventriculi may occur.” 
Fig. 135.—Rovsing’s Method of Gastropexy. 
Rovsing 1 describes the technic of gastropexy as follows: 
“Parallel with the lesser curvature, I lead three strong silk threads in 
and out through the serous coating of the anterior surface of the stomach, 
leaving the pyloric portion free. The upper thread is placed close under the 
lesser curvature, and the two others, with an interval of about 2 cm., are 
placed in such a way that the greater curvature and a rather large piece of 
the wall above this are left free (Fig. 135). With a fine needle, the serosa 
coating between the threads is now scarified in all directions, also the surface 
1 Ann. Surg.j 1913, 57:1. 200 
GASTRO-ENTEROPTOSIS 
of the parietal peritoneum, and eventually that part of the under side of 
the liver to which one wishes the stomach to adhere. The ends of the silk 
threads are led out through the entire thickness of the abdominal wall; that 
on the left as far as the side of the rib curvature, and that on the right at 
about 3 cm. to the right of the center line. The peritoneum is now joined 
with catgut, and the fascia and skin with aluminum bronze, and, after the 
line of wound has been covered with collodion and cotton wool, the silk 
sutures are tied over a glass plate covered with sterile gauze (Fig. 136), 
the dimensions of which are a little larger than the stomach surface which 
Fig. 136.—Rovsing’s Method of Gastropexy. 
The silk sutures are held over a glass plate. 
has to be fixed. In this way it follows that the anterior surface of the 
stomach lies flat and close to the abdominal wall, without shrinkage and fold- 
ing. These threads are left for four weeks and are then easily removed. 
A perfectly secure and solid adhesion is thus obtained.” 
My experience leads me to concede that the corset is probably an impor- 
tant factor in squeezing down the organs and narrowing the upper abdomen, 
but it is not the sole cause by any means. In fact, it is not the major cause. 
A large percentage of our cases with narrow chests and general ptosis have 
never worn corsets, particularly of the type which squeezes the chest. MIDLINE PTOSIS 
201 
We are prepared to concede that maternity, if not accompanied by com- 
pensatory fat referred to in Chapter XVI, may be a very important factor, 
but it is by no means the most important factor. It is important inasmuch 
as it lowers intra-abdominal pressure described in Chapter IV. The corset 
is far more important in cases of potentially congenital ptosis in which the 
organs have begun to sag themselves, and to leave the upper abdomen vacant. 
It occurs to me that Rovsing had not completely differentiated the con- 
genital and acquired types of ptosis. In addition to the features included 
in Rovsing’s conception, I will present the following as my own conception, 
based on a considerable experience. 
We have in Chapter III called attention to the provision nature has 
made for holding up the cecum and ascending colon, which is in reality a 
second stomach, by fusion to the posterior abdominal wall, and to the evils 
resulting to the failure so to fuse. We have in our embryological studies 
called attention to the fact that the stomach lies principally on the left side 
and hangs vertically from its firm supports at the esophagus. On the other 
side, the second portion of the duodenum is firmly fixed. The splenic flexure 
is firmly fixed and the hepatic flexure moderately fixed, but between the 
esophageal and duodenal fixation of the stomach in the one case and the 
splenic and hepatic flexures of the colon in the other case, the middle pyloric 
portion of the stomach and the transverse colon necessarily have very feeble 
peritoneal supports, considering their great weights when filled. 
For anatomical reasons it has been impossible for nature to make fusion 
between the visceral and anterior parietal peritoneum. We have shown in 
the embryological studies how nature has attempted to remedy this as far 
as the transverse colon is concerned, first by fusing the posterior layer of 
the great omentum with the peritoneum of the transverse colon and meso- 
colon, and second by the obliteration of the omental bursa by the fusion 
of its two layers with each other. When this fusion has taken place, the 
colon has a second support from the bottom of the stomach in the form of 
the gastrocolic omentum. We find that in a considerable proportion of cases 
this second fusion or obliteration of the omental bursa has not taken place, 
in which case there is no functioning gastrocolic ligament, and, therefore, 
no support for the colon, which is derived from the bottom of the stomach. 
In this type of cases, the transverse colon is especially prone to ptosis 
with sharp kinking at the splenic flexure and a subsequent development of 
a very obstinate constipation. In a normal individual where the proper 
fusion has taken place, these peritoneal supports are sufficient to hold the 
organs in position, as laid down by anatomists, in which case the stomach and 
intestines usually function properly. Unfortunately, nature’s plans are often 
upset, even in a normal individual, by indiscretion and traumatic agents. 
Among these indiscretions we may first mention habitual constipation, which 
is developed usually in early manhood or womanhood, when enthusiasm is 
more markedly developed than discretion. Children in their enthusiasm and 
disregard for consequences fail to heed the warning of nature to evacuate 
the bowel at its normal time. This is repeated from day to day until finally 202 
GASTRO-ENTEROPTOSIS 
the presence of fecal matter in the large intestine and rectum is not detected 
by sensation. As a consequence, the bowel becomes loaded with solid 
matter. Active exercise often produces a severe strain on the supports of 
this loaded colon, gradually stretching its ligaments until it begins to sag. 
The splenic and hepatic flexures, having been normally fused to the parietal 
peritoneum, remain fixed, and especially is this true of the splenic flexure. 
As the transverse colon sags lower and lower, it is with more difficulty that 
the fecal matter is forced by the splenic flexure. It is probable also that 
these fixations become more firmly fixed, the result of the crystallization of 
the lines of force in response to the extra weight in accordance with Lane’s 
law. The colon becomes heavier and the constipation worse. The intestinal 
Fig. 137.—Rovsing’s Method of Shortening the Gastrocolic Ligament. 
canal becomes distended and the walls correspondingly thin and the patient 
is suffering from an obstinate constipation with toxic symptoms, which 
are described elsewhere. This condition probably occurs most frequently 
in the cases where the omental bursa has not been properly fused. The 
symptoms in this class of cases are nothing more than extreme constipation. 
The stomach is not involved. On the other hand, if the omental bursa has 
been properly fused, the stomach may be dragged down by the weight of the 
loaded colon acting through the gastrocolic omentum. 
The mechanism may be well illustrated by the accompanying X-ray pic- 
tures (all taken in the same position) of the gastro-intestinal tract of a man 
thirty-eight years of age, who is lean, but whose stomach and bowel actions MIDLINE PTOSIS 
203 
are perfect as far as he is able to determine symptomatically, but whose 
stomach seems to be somewhat dilated and prolapsed and empties tardily. 
The first picture (Fig. 138), taken immediately after a meal of three and a 
half ounces of bismuth mixed with one pint of mashed potatoes, shows a 
transverse stomach, the upper margin of which is barely above the umbilicus 
and the lower margin nearly three inches below. The second picture (Fig. 
139) was taken one hour later. It will be noticed that about one half of 
the bismuth was out of the stomach and in the intestine, and the stomach 
has risen almost an inch above the position it occupies in the previous pic- 
Fig. 138.—X-ray Picture of Stomach of a Man Whose Digestion is Symptomatically 
Perfect But Whose Stomach Empties Tardily. 
Picture taken immediately after a bismuth meal. 
ture. The third picture (Fig. 140) was taken six hours after the bismuth 
meal. In this picture a small portion of the bismuth still remains in the 
stomach, a little has passed through the ileocecal valve and barely enough 
is in the transverse colon to show its position. It may be stated at this 
point that the subject’s bowels had moved freely just before the bismuth 
meal was taken; therefore, the transverse colon was probably almost empty 
until the bismuth began to pass down. The bismuth at the time this third 
picture was taken, six hours after the meal, was nearly all out of the stomach, 204 
GASTRO-ENTEROPTOSIS 
and had not yet reached the transverse colon, except in very small quantity. 
The stomach and the transverse colon were, therefore, practically empty and 
the bismuth was between the stomach and the transverse colon. It will be 
noted in this picture that the stomach has risen so that its lower margin 
barely comes down to the umbilicus and the transverse colon is barely below 
the margin of the umbilicus. Now passing to the fourth picture of this 
series (Fig. 141), taken ten and one half hours after the bismuth meal, we 
find that the transverse colon has become filled with bismuth and presumably 
Fig. 139.—X-ray Picture of Same Subject As Shown in Fig. 138, Taken One Hour after 
Bismuth Meal. 
Stomach is half empty and has risen one inch. 
fecal matter, and is seen nearly three inches below the lower margin of the 
umbilicus. A small amount of bismuth still remains in the stomach, which 
indicates that the lower margin of the stomach, which was slightly above 
the umbilicus before, has gone down with the loaded colon so that it is 
again two inches or more below the lower margin of the umbilicus. The 
fifth picture (Fig. 142) was taken twenty-two hours after the bismuth meal. 
The bismuth is now all out of the stomach and has moved on to the splenic 
side of the transverse colon and to the descending colon, sigmoid flexure 
and rectum. It will be noted that the transverse colon just in the line of the MIDLINE PTOSIS 
205 
umbilicus has emptied itself of the bismuth to a certain extent and the trans- 
verse colon has again risen to its normal position just below the umbilicus. 
The bowels acted soon after this last picture was taken, so it is quite probable 
that the transverse colon at this time was nearly empty, the fecal matter 
having passed on to the lower bowel preparatory to evacuation. 
While the subject of these pictures is a perfectly healthy man and his 
food apparently passes through the entire alimentary canal in normal time, it 
is plainly seen that there is a tendency toward stasis in the stomach. It is 
Fig. 140.—X-ray Picture of Same Subject As Shown in Fig. 138, Taken Six Hours after 
Bismuth Meal. 
A small amount of bismuth still remains in the bottom of the stomach which has risen to the 
middle of the umbilicus (two and one-half inches higher than in the first picture). Most of the 
bismuth is in the small intestine and cecum. A small amount is in the transverse colon, which 
swings across barely below the umbilicus. 
but a short step from this mechanical condition to a ptosis which begins to 
show symptoms unless reasonable hygienic care is exercised. Gradually the 
stomach goes lower, until finally the difficulty of emptying it in the upright 
posture becomes more marked. The patient begins to suffer from dyspepsia 
and begins to take digestives. The condition becomes worse as the stomach 
goes lower and lower until finally the patient performs his or her duties with 
difficulty, and later becomes a complete invalid. If the condition goes on long 
enough, the stomach may permanently occupy the portion of the abdomen 206 
GASTRO-ENTEROPTOSIS 
below the umbilicus (see Figs. 134 and 143.) Fig. 143 shows how acquired 
bands and membranes, between a prolapsed transverse colon and the ascending 
colon and cecum, may make a midline ptosis permanent. My second case 
of midline ptosis was of this type and formed the subject of this picture. I 
have on several occasions found the transverse colon webbed not only to the 
ascending colon but the descending colon, as far down as the sigmoid, making 
the ptosis absolutely permanent and incurable by medical means. By cutting 
Fig. 141.—X-ray Picture of Same Subject As Shown in Fig. 138, Taken Ten and One Half 
Hours after Bismuth Meal. 
Transverse colon contains most of the bismuth and has gone down two and one half inches 
lower than shown in Fig. 140. Stomach still contains bismuth and has gone down with the colon. 
these webs and bands and suturing the omentum to the abdominal wall, entire 
relief is obtained. The esophageal end is firmly fixed; the second portion of 
the duodenum is firmly fixed; the middle of the stomach is dilated; the length 
is greatly increased; and its upper margin is below the umbilicus. The pylorus, 
as we have had occasion to see in several surgical instances, is widely dilated, at 
times admitting three fingers, while a sharp kink exists at the junction of the 
first and second portions of the duodenum, corresponding to the position of 
the hepatic vessels and ducts. This condition has occurred in a previously 
normal individual and is often due to heavy lifting or overstraining, com- MIDLINE PTOSIS 
207 
bined with habitual constipation. Case 32 of our series of 41 cases reported 2 
is in point. He was a German, a beer dealer, and prided himself on being 
able to lift a barrel of beer higher than any other man of his weight in the 
city. He was perfectly normal, and retained his strength until about two 
years before he came under my observation. He then began to develop 
stomach trouble, such as we have just described. He began to lose flesh until 
his weight went down to one hundred and nine pounds. He vomited his 
food regularly. Finally, a diagnosis of hour-glass stomach was made, with 
Fig. 142.—X-ray Picture of Same Subject Shown in Fig. 138, Taken Twenty-two Hours 
after Bismuth Meal. 
Most of the bismuth has passed into the sigmoid and rectum. Transverse colon has arisen 
two inches. 
probable carcinoma. All the means of investigation were used, including 
X-ray, which was wrongly interpreted. When the abdomen was opened there 
was found to be absolutely nothing wrong with the stomach except a midline 
ptosis with gastric dilation, and the pylorus would easily admit three fingers. 
There was a very sharp kink at the junction of the first and second portion 
of the duodenum. In consideration of the history of the case, the occupation 
of the man, and the position assumed in performing the feat of lifting the 
2 Surg., Gynec. and Obst., October, 1912. 208 
GASTRO-ENTEROPTOSIS 
heavy barrel on his abdomen, there is no doubt that this displacement was 
caused by lifting. 
Case 37 is another case pointing even more directly to traumatic or 
acquired ptosis. This woman gave a history of stomach trouble dating back 
about twenty years. At the time of operation, evidence of a healed ulcer 
with a partial obstruction of the pylorus existed. No adhesions were present 
in the neighborhood of the pylorous. In addition, there was a sharp kink at 
Fig. 143.—Ptosis of the Transverse Colon with Fixation to the Ascending and Descend- 
ing Colon. 
This has been described by the writer in an article on “ Gastroptosis,” Philadelphia Medical 
Journal, October 11, 1902, and also by Dr. Lewis S. Pilcher in an article on “ Surgical Aspects of 
Membranous Pericolitis,” Annals of Surgery, January, 1912. 
the junction of the first and second portions of the duodenum. As shown by 
the history, she had all the symptoms of gastric obstruction. About ten years 
before the operation and about ten years after the beginning of her stomach 
trouble, she was carrying a heavy load of wood in her arms, when suddenly 
she felt a severe pain in her abdomen, which caused her to remark to her 
family that something had ruptured inside. She was put to bed and remained 
there for a number of months. Since that time she has been an invalid to a 
certain extent, and has spent much time in bed. By remaining in bed her MIDLINE PTOSIS 
209 
stomach acted fairly well, and she was quite comfortable, but when up and 
about the stomach would scarcely empty at all. During this time she had a 
goiter removed, also the round ligaments shortened for uterine displacement 
at one of the world’s great clinics, with no benefit. On opening the abdomen, 
the condition of the stomach and intestines shown in Fig. 144 was noted. A 
large opening easily admitting a man’s hand, giving all the evidences of a 
tear, presented in the gastrohepatic omentum. Edges of the opening were 
Fig. 144.—Condition Existing Ten Years after What Seemed To Have Been Rupture of 
the Gastrohepatic Ligament. 
Appearance at the time the abdomen was opened. 
thick and comparatively fat, and showed unmistakable evidences of a scar. 
An opening equally as large presented in the transverse mesocolon, and also 
gave evidences of having been torn. Several feet of the small intestine had 
passed up through the opening in the mesocolon, the lesser peritoneal cavity, 
and through the opening in the gastrohepatic omentum. When the transverse 
colon was lifted up, the posterior wall of the stomach protruded through the 
mesocolon, as shown in Fig. 145. This case is unique, so far as I know, but 
taking the history and the condition found at the operation, there is very 210 
GASTRO-ENTEROPTOSIS 
little room for doubt that both these openings were the result of a tear at 
the time she was carrying the load of wood in her arms ten years before. 
It is quite certain that the predisposing cause of the rupture was a previously 
dilated stomach. The weight of the wood resting on the dilated stomach 
produced the rupture. The troubles of several of our other patients may be 
traced directly to heavy lifting. 
Fig. 145.—Condition Existing Ten Years after Seeming Rupture of the Transverse 
Mesocolon. 
Same case as Fig. 144. 
Patient No. 12, a woman about forty years of age, presented herself 
weighing about eighty pounds after having been confined to her bed for three 
months. During the previous two years, she had devoted her time to the care 
of a sick husband, who had to be lifted constantly. Before the time of his 
death she became a bed-invalid. Operative findings: Stomach and colon in 
pelvis attached to parietal peritoneum by a few frail adhesions. No other 
organs displaced. The gastrocolic omentum was sutured to the peritoneum MIDLINE PTOSIS 
211 
one inch above the umbilicus. Recovery was complete within three months. 
The patient has remained perfectly well up to very recently, fourteen years 
after operation. She now weighs one hundred and forty-two pounds. X-ray 
pictures when last taken showed the colon somewhat lower than normal. 
A number of other patients are Sisters who are nursing in the hospital, 
lifting patients. A number of others are teachers who stand in the school- 
room all day. All of these patients were apparently normal in their early 
manhood or womanhood. A moderate degree of midline ptosis may be 
greatly aggravated by adhesions following a pelvic inflammation or a surgical 
operation, making the ptosis permanent, even with the patient lying in bed. 
Patients with these marked symptoms usually give a history of being normal 
in their early years. The body formation is usually normal, except that the 
upper abdomen has contracted in its efforts to follow the stomach. The 
kidneys are not prolapsed. 
The following histories will serve to illustrate these points: 
Taking up case 26, we find a young man about thirty years of age. His 
father was a stock man and he spent his boyhood and early manhood as a 
cowboy until he developed symptoms of indigestion. He was examined and 
the symptoms could supposedly be traced to appendicitis. About six years 
ago, he was operated on and his appendix was removed, but the symptoms 
were not improved. He developed a hernia on the left side and about two 
years later a left inguinal hernia was repaired. Still the symptoms did not 
improve. About this time his father moved to the city and engaged in stock 
dealing. His health was not improved and he was troubled with indigestion 
and a nervous condition which unfitted him for the duties of his father’s office. 
He had tried all forms of medical treatment, including that offered by a 
number of the ablest medical men in our section, but received no benefit. The 
last five doctors who examined him made a positive diagnosis of gastric ulcer 
with obstruction. The examination of his stomach contents showed hyper- 
acidity. For several months prior to the operation, he had vomited a great 
deal of his food. For the six weeks prior to operation, he had vomited prac- 
tically all of his food, and was so emaciated that he was unable to sit up. No 
X-ray pictures were made of his stomach before operation. His weight was 
not taken but was estimated to be less than one hundred pounds. He had 
every symptom of obstruction at the pylorus. His upper abdomen was per- 
manently contracted. 
On opening the abdomen and examining the stomach, it was found that 
there was no ulcer, and that the pylorus, instead of being contracted, was 
widely dilated, making the duodenum continuous with the stomach. The 
free margin of the liver was even with the umbilicus. The upper margin of 
the stomach was at least two inches below the umbilicus and presented the 
typical picture almost exactly the same as is shown in Fig. 134; transverse 
colon was in the pelvis. The omentum had adhered to the site of the opera- 
tion for hernia and therefore had made the ptosis permanent. The point of 
obstruction was at the junction of the first and second portions of the duo- 
denum. There was no other pathology present in the abdomen. The 212 
GASTRO-ENTEROPTOSIS 
adhesion holding the omentum to the left inguinal incision was cut, the 
stomach replaced, the ligaments of the liver shortened, the gastrohepatic 
omentum was shortened, and the great omentum was sutured to the parietal 
peritoneum midway between the umbilicus and the ensiform cartilage. The 
upper abdomen was expanded. The patient began to improve immediately, 
never vomited after the operation, was well in three months, and six months 
after operation weighed more than he ever did in his life and has had no 
symptoms referable to his stomach since operation. X-ray pictures eight 
months after operation show stomach and colon in normal position (Figs. 
Fig. 146.—Stomach in Case 26, Eight Months after Operation. 
Dotted white line indicates relative position before operation. Symptomatically cured. 
146, 147). This patient had not been relieved by medical treatment and 
position because adhesions had made the ptosis permanent. He developed 
a gall-bladder infection ten years later. At operation the hammock was found 
perfect in unbroken continuity. 
Case 27 was a hospital sister, forty-eight years of age, and was first seen 
January 6. She had been constipated all her life, and for twenty years had 
not had a bowel movement without a drastic cathartic. The past few years 
she had spent chiefly as an invalid. The members of her order had reached 
the conclusion that she was a hopeless neurasthenic and that she was not as 
sick as her complaints indicated. She had vague rheumatic pains over her MIDLINE PTOSIS 
213 
body, sallow and discolored skin, tenderness over the lower abdomen on both 
sides, anorexia, but no symptoms of gastric obstruction. Stomach analysis 
showed nothing abnormal. Distention of the stomach showed no marked 
gastroptosis. An X-ray examination showed no marked gastroptosis but an 
extensively prolapsed transverse colon, as shown in Fig. 148. On opening 
the upper abdomen, two gall-stones were found which had never given pain 
or a symptom which could be attributed to them. There were no adhesions 
in the abdomen, and no displacement of any other organ. The omental bursa 
Fig. 147.—Colon in Case 26, Eight Months after Operation. 
Dotted white lines indicate relative position before operation. Symptomatically cured. 
had not been obliterated, which accounted for the prolapse of the colon with- 
out the stomach. The transverse colon was markedly distended and the 
splenic flexure markedly kinked without adhesions. The gall-stones were 
removed and the gall-bladder drained for a few days. The omentum was 
sutured to the abdominal wall midway between the umbilicus and the ensi- 
form cartilage. The patient made an uninterrupted recovery and her bowels 
began to act without a cathartic before she left the hospital. At last report, 
eighteen months afterwards, her bowels were moving regularly and she was 
working every day. X-ray picture (Fig. 149) taken seven months after the 
operation shows the colon swinging across the abdomen just below the 214 
GASTRO-ENTEROPTOSIS 
umbilicus. This case is typical of the colon ptosis due to nonobliteration of 
the omental bursa. 
Case 31, a female thirty-eight years of age, was a hospital sister and 
druggist. She was healthy in her childhood and young womanhood. Some 
time after she joined the Sisterhood, she began to have stomach trouble and 
was treated with the usual prescription of digestives of various kinds. As 
her case grew worse she was confined to her bed at intervals and did not feel 
well between the attacks of stomach trouble. Her skin was stained, abnor- 
mally muddy, and at times she had annoying skin eruptions. The case had 
been diagnosed on several occasions as gall-stones. She had been in bed for 
Fig. 148.—Colon in Case 27 before Operation. 
a number of weeks prior to the time the operation was performed, vomiting 
practically all food except when she was in bed. X-ray pictures showed dis- 
placement of the stomach and colon. 
The upper abdomen was opened by a median incision and all the abdominal 
organs were examined. The stomach and transverse colon were markedly 
prolapsed, and the cecum was mobile. No other organs were displaced and 
no other pathology was found in the abdomen. The omentum was sutured 
to the abdominal wall, the gastrohepatic omentum was shortened, and the 
upper abdomen was expanded. The patient made an uninterrupted recovery 
and was back at her work as prescription druggist six weeks after the opera- MIDLINE PTOSIS 
215 
tion. She has been perfectly well since the operation. Ten years after she 
was seen personally, and was in perfect health, filling one of the most respon- 
sible positions connected with her order of Sisters. 
Case 39 illustrates marked gastro-intestinal stasis due to a typical ptosis 
of both the stomach and the transverse colon. The patient, the wife of a 
farmer and timber man, was forty-three years of age, the mother of eight 
children, and had done most of her own housework during her married life. 
She had been constipated since childhood, the constipation growing worse in 
later years. For the few months prior to operation she had had spells of 
Fig. 149.—Colon in Case 27, Seven Months after Operation. 
Patient symptomatically cured. 
vomiting and no appetite. Her bowels had not acted oftener than once a week 
and then cathartics were necessary. Mouth was dry. She felt fairly com- 
fortable while in bed and digested her food well. If she took even a drastic 
purgative early in the morning and remained on her feet all day, it would not 
act until the next morning. If she took the same dose at bedtime it acted 
within eight hours. A dose of oil, taken after she came into the. hospital 
while lying in bed, acted well within six hours. The picture of the colon, 
taken twenty-four hours after a bismuth meal, showed bismuth in the cecum 
(Fig. 150). The pictures taken each day for three days thereafter showed 
the bismuth in the ascending and transverse colon. The picture taken ninety- 216 
GASTRO-ENTEROPTOSIS 
six hours after the ingestion of bismuth showed that none of it had passed 
the splenic flexure (Fig. 151). The patient presented a marked cachexia 
causing a provisional diagnosis of carcinoma to be made. 
When the abdomen was opened May 14, 1912, the stomach and colon were 
found well below the umbilicus. The pylorus was widely dilated, admitting 
two fingers with ease. The transverse colon was greatly distended and its 
walls were thin. No evidence of gastric ulcer was found and there were no 
gall-stones. No other organs were displaced. A few light adhesions attached 
the omentum to the parietal peritoneum low down, and two or three bands 
Fig. 150.—Case 39 before Operation. 
Bismuth has not passed the hepatic flexure in twenty-four hours 
extended from the transverse colon to the descending colon near the splenic 
flexure. These light bands were freed, the falciform ligament of the liver and 
the gastrohepatic omentum were shortened, the great omentum was sutured 
to the abdominal wall and the upper abdomen was expanded. The patient 
made a gradual recovery, the bowels acting well from the start, with a high 
enema. The stomach symptoms steadily improved until at the end of four 
weeks she was able to eat regular diet. At the end of eight weeks she left 
the hospital, at which time the bowels were acting without cathartics but, in 
order to ensure entire freedom from stasis for a while, she was given paraffin MIDLINE PTOSIS 
217 
to take when she went home and since that time has been taking a swallow 
of paraffin oil before breakfast. She reports that her stomach and bowels 
are acting well and that she is quite well eleven years after operation. 
In mild or early cases in which no complications exist, midline ptosis is 
relieved by the reclining posture, for the stomach and transverse colon, in 
gravitating toward the diaphragm, release the kinks at the fixed points so that 
digestion and evacuation proceed normally. These cases may be greatly 
relieved and often symptomatically cured by a long period of rest in bed with 
Fig. 151.—Colon in Case 39 before Operation and Ninety-six Hours after Bismuth Meal 
No bismuth has passed the splenic flexure. 
forced feeding, which produces fattening. Unfortunately midline ptosis, if 
continued long, produces complications which make the condition self-perpet- 
uating. The two principal complications are adhesions resulting from stasis 
or other inflammatory conditions, which hold the organs permanently out of 
place, and a permanent contraction of the upper abdomen resulting from the 
habitual absence of the transverse colon and pyloric portion of the stomach 
from that portion of the cavity. When the condition has continued long 
enough to produce either of these permanent complications, the problem 
becomes a mechanical one which can be relieved only by surgery. This con- 218 
GASTRO-ENTEROPTOSIS 
dition, unlike right-sided, or general, ptosis, is usually acquired and is found 
in patients who have previously been healthy. Habitual constipation and 
loaded colon, or overdistention of the stomach combined with hard labor or 
violent exercise, tend to stretch the peritoneal supports of these movable por- 
tions of the intestinal canal. The process once begun automatically grows 
worse, for the more obstinate the constipation or gastric stasis, the heavier the 
load for the supports, and consequently the lower the organs sag. The 
peculiarly weak point in the support of these parts of the alimentary canal is 
that they have a direct drop, being suspended only by the peritoneal supports. 
As has previously been shown, nature has taken two steps toward giving extra 
supports to the transverse colon; first, by fusing the posterior layer of the 
omentum to the mesocolon; and second, by the obliteration of the omental 
bursa. Other fixed points of the alimentary canal have been produced by 
fusion of the peritoneum of the organs directly to the parietal peritoneum. 
Thus it will be seen that, aside from taking advantage of shelves and angles, 
nature has depended chiefly upon making prenatal fusions to hold up the 
abdominal organs in fitting man for the erect position. When these fusions 
have failed, or the normal supports have given way, we can do no better than 
follow nature’s example by making supplementary peritoneal fusion. 
Rovsing has depended on suturing the stomach wall directly to the parietal 
peritoneum and reports 163 cases treated by this method. Of these 92 were 
completely cured, 24 were considerably improved, 18 slightly improved, 21 
unimproved, and 8 died. This work of Rovsing, it must be admitted, shows 
better results than one would expect from such a radical procedure and 
deserves a place alongside of the work Lane has done in intestinal stasis, 
in that, while the cure in his cases had been produced by more heroic means 
than the condition would seem to warrant, it has certainly taught us much as 
to the nature and importance of the subject of ptosis and stasis. 
On the other hand, Beyea has used a method which would be ideal if 
efficient. To one who has studied these profound cases of ptosis carefully 
and has noted how the gastrohepatic omentum is thinned until it has very 
little strength left, the Beyea operation cannot appeal very strongly as a 
method for producing a permanent cure. But it must be acknowledged to be 
a valuable aid in the treatment of the condition. The fact that the ligament 
has proved too weak to hold the stomach in the first place, when the shape of 
the abdominal cavity was normal and conducive to a normal position of the 
viscera, seems to be an ample argument that the patching up of this attenuated 
ligament to hold up a dilated and abnormally heavy organ in an abdominal 
cavity which has become distorted, and in a patient who has become generally 
depleted, is an entirely inefficient procedure. Furthermore, in cases of non- 
obliteration of the omental bursa, with ptosis of the transverse colon alone, 
the Beyea operation would be entirely inapplicable. The one tissue which can 
supply a ligament of extraordinary strength for both the colon and the 
stomach is the great omentum, picked up just below the colon and sutured to 
the anterior abdominal wall. 
Basing the treatment on the principles which have been set forth in this MIDLINE PTOSIS 
219 
book, in a given case of midline ptosis involving the free edge of the liver, 
the pyloric portion of the stomach, and the transverse colon, and in which the 
upper abdomen has contracted, the following operative procedures are 
indicated: 
An incision is made in the exact median line, beginning at the ensiform 
cartilage and extending about one inch below and to the left of the umbilicus 
and through the skin and fat. The fat is now pushed off the aponeurosis 
until the interlacing of the fibers of the aponeurosis of the two sides is thor- 
oughly exposed. If the incision is made at the exact point of the interlacing 
Fig. 152.—Shortening the Falciform Ligament. 
of these fibers, the opening of the sheaths of the recti muscles will be avoided. 
This precaution is taken with a view of expanding or relaxing the upper 
abdomen at the time of closing. After the abdomen is opened, the organs 
examined, and the necessary operation determined upon, the first step is 
reposition of the liver, which is done as follows: 
The falciform ligament, which is elongated, is shortened by purse-string 
sutures of chromicized catgut, taking two or three bights in the ligament and 
finally fastening to the parietal peritoneum (Fig. 152). Three or four of 
this kind of sutures are used. After this a number of quilt sutures are used 
to fasten the edges of the right and left lobes of the liver to the parietal 220 
GASTRO-ENTEROPTOSIS 
peritoneum. These sutures are passed from the outer side of the subperi- 
toneal fascia inwards through the liver and back out through the peritoneum 
and tied on the outside of the subperitoneal fascia. From three to five sutures 
are used on either side of the falciform ligament. This new ligament has the 
shape of a Y, the original falciform ligament being the stem (Fig. 153)- 
The second step is the reposition of the stomach and transverse colon by 
suturing the omentum to the abdominal wall. The incision is held wide open 
by retractors, and the parietal peritoneum at the edge of the wound is pulled 
Fig. 153.—Falciform Ligament Shortened. 
Sutures passed through the right and left lobes of liver for making a Y-shaped ligament. 
Sutures placed for shortening gastrohepatic omentum by Beyea’s method. 
out as far as possible, especially on the left side. A needle armed with 
chromicized catgut is passed through a good bight of the parietal peritoneum 
at the point on a line crossing midway between the ensiform cartilage and 
the umbilicus, and as far toward the left as the sutures can conveniently be 
placed with a needle holder. (In some instances we have closed the space 
entirely to the costocolic ligament.)3 The omentum below the greater curva- 
3 In my first case on which omentocolopexy was performed, only 3 sutures were used. 
In the second case, 8 sutures were used in the central portion of the abdomen. Now 
we use any number that seems to suit the case. Any operation, which fastens the omentum 
to the anterior abdominal wall for the purpose of supporting the stomach or colon, is 
termed “hammock operation.” MIDLINE PTOSIS 
221 
ture of the stomach is then inspected, and the direction of the vessels examined 
and the needle is passed through a bight of the gastrocolic, omentum one and 
one half inches below the lower border of the stomach. The omentum is 
now turned up and the same suture is passed, taking the second bite through 
all the layers of omentum just below the colon as shown in Figs. 154, 155, 
156, 157, 158. The two ends of the suture are now tied, the next suture 
is placed about one half inch nearer the median line. After three or four 
sutures are thus placed on the left side, it is well to place a like number on the 
right side so the normal relations may be preserved. Do not place the sutures 
Fig. 154.—Method of Placing Sutures in Doing the “ Hammock ” Operation. 
as far from the median line on the right as has been done on the left side, 
owing to the fact that the stomach is a left-sided organ. The operator now 
has his bearings and may place sutures on the right or left side, as seems best, 
until the line of sutures is completed to the edge of the parietal peritoneum 
and to a point near the center of the omentum. The omentum should be 
allowed to relax and should be inspected before the placing of each suture 
so as to avoid the blood-vessels and so to place the sutures that the omentum 
will come in contact with the parietal peritoneum without tension or twisting. 
When the sutures have been placed to a point within one and one half inches 
of each other in the center, it is well for the operator to begin to close the 
peritoneum of the abdominal wound from above with chromicized catgut and 
sew down with a continuous suture to a point where the omentum is being 222 
GASTRO-ENTEROPTOSIS 
attached to the abdominal wall, when he may take one or two bites of the 
omentum in his continuous sutures and thus finish the hammock. With the 
same sutures he now continues and closes the peritoneum to the lower end 
of the wound. In some instances the omenta are very thin and stretched out. 
Dr. L. S. Pilcher has passed some of the sutures through the transverse 
mesocolon. I have used this modification with great satisfaction. (See 
inserts in Figs. 155, 156, 158.) 
Dr. Charles A. L. Reed of Cincinnati has described an operation under 
the name of “Parietal Implantation of the Colon,” 4 in which he makes an 
Fig. 155.—Diagram Illgstratum* ~BHriSutures for Shortening the Gastro- 
hepatic Omentum and for Suturing tHeHjreat Omentum to the Abdominal Wall 
in “ Hammock ” Operation. 
Dotted suture line grasps mesocolon. 
incision transversely across the intercostal interval about three fourths of an 
inch below the tip of the ensiform cartilage, extending the same incision at 
an obtuse angle downward and to the right about a half inch below the costal 
margin for a distance of from five to six inches. This incision divides (a) 
the integument, (b) subcutaneous fat, (c) superficial fascia, (d) inner half 
of the left rectus, (e) all of the right rectus, and (/) the inner margins of the 
external oblique, internal oblique and the transversalis muscles, and finally, 
4Journ. Am. Assoc., September, 1916, vol. 67. MIDLINE PTOSIS 
223 
(g) the transversalis fascia through the entire length of the incision, care 
being taken not to extend the incision along this line through the peritoneum. 
He then opens the peritoneum and stitches the omentum to the denuded 
transversalis fascia by stitching the base of the former by its external surface 
to the lower margin of the denuded surface of the latter, employing a con- 
tinuous button-hole suture (Fig. 159). 
Without going into the finer details which he describes, I think I am justi- 
fied in saying that such an operation which cuts so many important structures 
is totally unnecessary. A properly performed omentopexy combined with 
Fig. 156.—Scheme of Combined Beyea Operation and “ Hammock ” Operation. 
Insert shows Pilcher’s method of inclusion of mesocolon in sutures. 
right indirect colopexy, as shown in Figs. 128 to 130 inclusive, never gives 
way and involves no important tissue. Peritoneal surfaces are brought to- 
gether by interrupted sutures tied sufficiently tight to make pressure enough 
to squeeze out endothelial layers and produce direct union of the fibrous layer 
of peritoneum which is as firm as the continuity of the peritoneum itself. I 
have seen more than 20 cases years after omentopexy and in every instance 
have found the omentum attached to the parietal peritoneum exactly where 
I left it. 
Postoperative Treatment for Abdominal Ptosis.—Of the 363 patients 
operated upon for ptosis, 5 died, 1 from pneumonia, 3 from pulmonary 224 
GASTRO-ENTEROPTOSIS 
embolism occurring from ten to fourteen days after operation and 1 from 
acute sepsis developing in the abdominal wall. It is interesting to note that 
the 3 deaths from embolism occurred during the first 150 cases, at which 
time a part of the postoperative routine was to keep the patient flat on the 
back for one week. On the death of the third patient, a postmortem was 
done. It was found that the clot had come from the left iliac vein. The 
internal iliac vein with all of its branches contained a firm clot, the end of 
which fitted on to the clot found in the pulmonary artery. I have every 
reason to believe that, in the other two cases, the clot was formed at the 
same place and I believe it is probable that, in most cases of sudden death 
Fig. 157.—Complete Beyea Operation and ‘ Hammock ” Operation. 
This is shown by reflecting the upper part of the abdominal wall downwards after the opera- 
tion is complete, including the closure of the abdominal incision. 
from pulmonary embolism following simple abdominal operations, the clot 
forms in this way and is due to the well-known anatomical anomaly found 
in certain individuals in which the artery crosses the outlet of the left internal 
iliac vein in such a way as to obstruct it with the patient lying on the back. 
In certain instances, possibly under certain blood conditions, it seems that 
the blood in the internal iliac vein becomes slowed to such an extent that a 
clot forms. This clot breaks away from the tenth to the fourteenth day and 
it usually occurs in patients feeling perfectly well. In every one of my cases, 
the patient has been especially hilarious just before death took place. Since 
the lesson of this postmortem, every patient, following an abdominal opera- MIDLINE PTOSIS 
225 
tion, has been turned on the right side, with the legs drawn up, for one hour 
after being put to bed and has then been turned to the left side for one hour; 
from that time on the patient changes position, first to the right side, then 
to the left side, then to the back, for the first three or four days after operation, 
exception being made when the patient is in the semisitting posture with 
legs drawn up such as is used in abdominal drainage cases and following 
stomach operations. Since adopting this plan, I have had no sudden death 
from pulmonary embolism in approximately 1,500 abdominal operations, 
Fig. 158.—Results Following Combined Beyea Operation and “Hammock” Operation. 
Insert shows Pilcher’s method of inclusion of mesocolon in sutures. 
whereas I had 7 deaths from this cause in approximately the same number 
previous to the adoption of this plan. 
I have often wondered whether the 3 patients who died from em- 
bolism might not have been alive to-day if this plan had been adopted. At 
any rate, I now believe that it is a necessary part of the postoperative 
treatment. 
At the end of two weeks after the stitches have been removed and it is 
possible to use the hot packs over the abdomen, the forced feeding and bowel 
regulation set forth in Chapter XVI on Medical Treatment is begun and 226 
GASTRO-ENTEROPTOSIS 
continued for two weeks with the patient in bed. Four weeks after the 
operation, the patient is allowed to sit up, continuing the forced feeding. 
After an adequate amount of fat is accumulated, the patient is encouraged 
to start walking, gradually increasing the distance each day. In the course 
Fig. 159.—Both Incisions Closed with the Colon in its Restored Position. (Reed.) 
of two or three weeks after beginning to walk, such a patient will be walking 
four or five miles and will have gained on the average of from twenty-five 
to forty pounds in weight. It should be made very clear to the patient that 
this flesh must be kept up, exercises maintained and bowels kept regular. 
Other cases will require longer medical treatment. CHAPTER XIV 
DUODENAL ARTERIOMESENTERIC ILEUS 
Duodenal arteriomesenteric ileus is an obstruction of the duodenum at 
the end of its third portion as a result of traction on the superior mesenteric 
vessels by the weight of that portion of the gastro-intestinal tract which the 
artery supplies. 
The development of this subject and its treatment within very recent 
years has given the ptosis question its most dramatic thrill. It is quite possible 
that careful study of this subject is going to explain many of the so-called 
functional diseases of the upper abdomen. The crossing of the end of the 
third portion of the duodenum by the superior mesenteric artery and vein 
is probably responsible for a large portion of the perverted physiology of the 
duodenum and the organs whose ducts empty into the duodenum. 
There are two elements in the ptosis question which may produce this 
traction. One is the mobile cecum with a long mesentery which permits a 
direct drop of the loaded colon into the pelvis through the psoas outlet. In 
such a case more or less traction on the superior mesenteric vessels is probable. 
The other element is marked loss of fat, which, in addition to producing a 
general reduction of intra-abdominal pressure, also thins the mesenteries of 
the small intestines so that they become elongated and permit the intestines 
to fall through the psoas outlet over the pelvic brim into the pelvis. Thus, 
the weight of the entire small intestine, with its contents, drags on the duo- 
denum and tends to obstruct it, thereby producing stagnation of its contents. 
This explains why certain ptotic patients do well only when the foot of the 
bed is elevated during most of the time for the first three or four hours after 
meals and in certain extreme cases it is required that the patient’s hips be 
markedly elevated by the knee-chest position, or even by such maneuvers as 
putting the head and chest off the side of the bed on pillows resting on the 
floor, while the hips remain on the bed. 
It is frequently noted on the operating table that a dilated mobile cecum, 
also prolapsed small intestines, are delivered from the pelvis only by consider- 
able force. The simple recumbent posture does not permit sufficient slack 
on the mesenteries and the superior mesenteric artery to release the obstruc- 
tion. Therefore, relief is obtained only when the head is sufficiently low to 
permit the intestines to gravitate out of the pelvis. 
With this conception of duodenal arteriomesenteric ileus in view, the 
rational treatment is apparent. If the condition is due to mobile cecum, it 
should be fixed surgically. If it is due to drag by the prolapsed small intes- 
227 228 
GASTRO-ENTEROPTOSIS 
tines on their mesenteries and mesenteric artery, the treatment consists of 
forced feeding and fattening with the patient’s head sufficiently low (some- 
times requiring the knee-chest position) to permit the intestines to gravitate 
out of the pelvis until such time as the fat has shortened the mesenteries, 
increased intra-abdominal pressure and narrowed the psoas outlet. In 
extreme cases in which the vessels and their surrounding connective tissues 
have taken on reinforcement in the form of crystallized lines of force and the 
intestines have established a permanent habitat in the pelvis, the duodenum 
has become permanently dilated and the obstruction is more or less fixed. In 
a few of such cases, it will be necessary to do a duodenojejunal anastomosis. 
About seventeen years ago, I was called in consultation to see a female 
patient fifty years of age. She had been vomiting for several weeks. The 
vomitus contained bile but no blood and no free hydrochloric acid. There 
was no palpable tumor present to act as an obstruction. She had lost con- 
siderable weight and had what we now term the “acidosis breath.” By intro- 
ducing solutions into the rectum, the life of the patient had been kept up so 
that while she was thin, her general appearance was not what we would have 
expected to accompany a malignant condition. She had never had severe 
abdominal pain, but on two or three occasions had had attacks similar to this. 
One thing concerning the importance of fat, which in our present light 
becomes interesting, is that she had lost flesh for some unknown reason pre- 
ceding the beginning of the present attack of vomiting which led us to fear 
possible malignancy on the lesser curvature of the stomach. After several 
days’ observation and all investigation at our command, for at that time we 
were not using the X-ray for gastro-intestinal diagnosis, we frankly admitted 
to the patient that we could not determine the trouble and suggested that our 
next step should be an exploratory operation to determine the nature of her 
trouble. 
She was sent to the hospital for operation the following morning. For 
some reason the operating room was engaged. In the meantime some mem- 
bers of the family had urged a mechanotherapist of some new variety. I told 
them I was unable to see how it could be of much benefit but, by the time I 
was able to get the operating room, the patient had definitely decided not to 
have an exploratory operation but to permit the mechanotherapist to try his 
hand. 
I heard nothing more of the patient for more than two years. One day 
in a public gathering, a very healthy, stout, middle-aged woman touched me 
on the arm and said, “You don’t know who I am, do you?” I said, “I do 
not.” She said, “I am the patient on whom you wanted to operate for cancer 
two years ago.” She seemed very friendly, so I asked her how the trans- 
formation had been brought about. She said, “You know the mechano- 
therapist that we had found that I had a kink in the intestine so he stood me 
on my head for several days and rubbed out the kink. My vomiting ceased, 
my appetite returned and I soon got fat with the result that I am now per- 
fectly well.” 
About this time and for some years later, I began to notice the writing DUODENAL ARTERIOMESENTERIC ILEUS 
229 
of Franklin Martin and Goldthwait, describing their methods of treatment 
of ptotic individuals by posture. We soon learned that the majority of these 
asthenic ptotic patients would gain flesh in the recumbent posture by the 
industrious application of the hot pack. Among these patients, however, 
there were a number who were unable to take the food, who would vomit and 
complain that the milk made them bilious. Some of these patients, we soon 
found, were better treated with the head lowered and in certain cases by 
elevation of the hips into a moderate knee-chest position by placing the patient 
on the face and supporting the lower abdomen about the pubes with 
pillows. In other cases, we found that by suspending the trunk over the 
edge of the bed with the chest and head lying on pillows resting on the floor, 
while the hips remained in bed, the patient would usually immediately begin 
to improve. Digestion would get better. 
After this treatment had been followed up for several weeks, the patient 
finally was cured of the nausea and anorexia, this improvement seeming to 
come with the deposition of fat within the abdomen. In some cases of this 
kind, we operated, expecting to find an organic obstruction in the duodenum. 
To our amazement, we found in practically all instances a dilated duodenum, 
sometimes existing to such an extent that the duodenum seemed to be a con- 
tinuation of the stomach. Even in these early years, we noted that the 
duodenum below the mesocolon was sometimes widely dilated. It became 
apparent to me that these cases of dilated duodenum were found almost 
entirely in the group which we call “ptosis patients.” We noted that these 
patients were usually relieved by fixation of the cecum and suturing of the 
omentum to the abdominal wall. 
In December, 1911, I saw Bloodgood in his clinic perform a colectomy for 
a condition of this kind, at which time he made the statement that he had 
done this operation on previous occasions with very satisfactory results. He 
felt that ptosis was the cause of the drag on the duodenum and that removal 
of the cecum seemed to meet the indications. This seemed somewhat far- 
fetched and I paid very little attention to it. 
Since that time, by carefully studying the literature on the subject, as well 
as by carefully observing my own cases, the conception expressed at the begin- 
ning of this chapter has been formed. I now feel sure that the first case 
related in this chapter was cured because the “mechanotherapist” lowered the 
patient’s head, allowed the small intestines and cecum to gravitate out of the 
pelvis and supplemented this by massage over the duodenum which helped it 
to empty. She was kept in bed for several weeks, gained many pounds of fat, 
increased her intra-abdominal pressure, shortened and thickened her mesen- 
teries and narrowed the psoas outlet which completely released the drag on the 
superior mesenteric vessels. We also now understand why certain ptotic 
patients who could not be successfully treated by forced feeding and rest in 
the recumbent position were immediately relieved and began to gain when 
they were turned on their faces with the hips elevated. 
The mechanism by which the superior mesenteric vessels obstruct the 
terminal portion of the duodenum is shown by rehearsing the steps in embryo- 230 
GASTRO-ENTEROPTOSIS 
logical rotation of the gastro-intestinal tract. The loop of primitive bowel 
which leads to the umbilicus contains the primitive vessel supplying all of the 
intestinal tract (Fig. 160). It is the superior mesenteric artery. After the 
loop has detached, the length of the bowel begins to increase (Fig. 161). 
This vessel continues to supply the small intestines and the first half of the 
large by its terminal branches. As the large intestine rotates upward and 
over to the right, the small intestines turn in underneath and locate on the left 
Fig. 160.—First Stage of the Development of the Intestinal Canal and the Peritoneum 
Seen from the Side. (Redrawn from Sobotta and McMurrich.) 
side. This rotation brings the superior mesenteric vessels directly across the 
end of the third portion of the duodenum (Figs. 162, 163, 164, 165). 
In the absence of normal prenatal fixation of the ascending colon, or in 
the absence of the normal intra-abdominal fat and intra-abdominal pressure, 
an individual becomes a potential subject for duodenal arteriomesenteric ileus. 
Stavely1 gives a history of gastromesenteric ileus and states that 
Rokitansky knew of it in 1842; Fagge reported cases in 1872 and 1873. 
H. Campbell Thompson in 1902 discussed the subject exhaustively. Glenard, 
Byron Robinson and Albrecht followed with the statement that mesenteric 
ligament or mesenteric artery was the cause. Glenard believed it to have a 
1 Surg., Gynec. and Obst., September, 1910, 11:288. Fig. 161.—Second Stage of the Development of the Intestinal Canal and Peritoneum 
Seen from in Front. (Redrawn from Sobatta and McMurrich.) 
The cecum and large intestine, as shown in this picture, gradually move upward and to the 
right side, and then downward; and the small intestines turn underneath and are thrown to the 
opposite side as shown in Fig. 162. 232 
GASTRO-ENTEROPTOSIS 
physiological purpose for holding duodenal contents in. It has been demon- 
strated that prolapse of the collapsed small intestines into the pelvis would 
produce it. Glenard estimated the pull of the empty intestines at 500 gm. 
Prolapse may follow relaxing of abdominal wall. 
In the development of the pathology of this condition, Bloodgood2 was 
Fig. 162.—Normal Position of Intestine after Rotation. (Redrawn from Sobotta and 
McMurrich.) 
This shows how, by the process or rotation, the duodenum is thrown behind the mesentery 
of the transverse colon and thereby becomes retroperitoneal. The superior mesenteric vessels 
have by this process of rotation been brought across and in front of the third portion of the 
duodenum. 
one of the early investigators to throw definite light on the subject. He reports 
a postmortem held on one of Finney’s patients after a pyloroplasty as follows: 
“In Fig. 166 the small intestines have been removed; the stomach is not 
dilated. The characteristic changes in the anatomy of the pylorus after a 
Finney pyloroplasty are beautifully shown; the dotted lines represent the 
suture. Just below this in the duodenum there is a kink always observed 
after this operation, but which has produced no obstruction. The suture had 
2 Ann. Surg., 46:736. DUODENAL ARTERIOMESENTERIC ILEUS 
233 
healed perfectly; it was covered with a thin fibrinous exudate and slightly 
adherent to the liver. The dilatation of the duodenum and its marked 
U-shape is well shown. When I cut away the transverse colon and the small 
intestines, the dilatation of the duodenum up to the mesenteric vessels and 
the collapsed jejunum forming the S curve were distinctly seen, and are 
shown in Fig. 166. When I cut the jejunum near the mesentery, it was empty 
and nothing escaped. When I pressed upon the duodenum there was no 
leakage. But when I passed my index finger through the jejunum into the 
duodenum, a large quantity of thin, brown fluid escaped, and the duodenum 
collapsed. At operation, therefore, in Case 1, and at autopsy in Case 2, 
Fig. 163.—Diagrammatic Picture of Duodenal Arteriomesenteric Ileus. 
This shows how the third portion of the duodenum is obstructed by mesenteric vessels result- 
ing from the weight of prolapsed intestines in certain forms of ptosis. 
compression of the duodenum could not force its contents past the obstruction 
behind the mesenteric vessels into the jejunum. It seemed to me there was 
a valvelike kink due to the tension of the distended duodenum, and not to 
traction on the jejunum by the weight of the small intestines—an explanation 
quite frequently given in the literature.” 
Bloodgood reports three other cases in which he has complete operative 
and autopsy findings and makes the following observations: 
“In all three cases, the obstruction began abruptly at the junction of the 
duodenum and jejunum, beneath the mesenteric vessels. In Case i, the duo- 
denum and stomach were tremendously dilated, the duodenum fixed in a high 
position. In Case 2, at operation, the stomach and duodenum were mod- 234 
GASTRO-ENTEROPTOSIS 
erately dilated; there was no positive evidence of pyloric obstruction; the 
duodenum was not examined in its third portion; at the autopsy in this case 
Fig. 164.—Sagittal Section Showing How Drag on Superior Mesenteric Vessels 
Obstructs Third Portion of Duodenum. 
Fig. 165.—Diagram Showing Mechanics of Duodenal Arteriomesenteric Ileus and 
Widely Dilated Duodenum. 
the duodenum was dilated down to the mesentery, the stomach was only 
moderately dilated. In Case 3, the duodenum and stomach were but mod- 
erately dilated, but the duodenum, except in its lower third, was abnormally DUODENAL ARTERIOMESENTERIC ILEUS 
235 
movable. Case i is a typical example of primary acute dilatation. We know 
nothing about the condition of the stomach and duodenum before the attack. 
Cases 2 and 3 give a clinical history which resembles a gastric neurosis more 
than pyloric stenosis or ulcer. I am of the opinion that chronic dilatation 
of the duodenum was present before operation in both cases (2 and 3). In 
Case 2, the condition became acute after operation. There is no evidence 
that the pyloroplasty was a factor in its production, and there is every reason 
to believe that this pyloroplasty did not and could not relieve the original con- 
dition. In Case 3, the exploratory laparotomy had no effect whatever on the 
clinical picture. In this third case, the stomach was washed out two and three 
times a day; this procedure may have prevented acute dilatation, but it had 
no curative effect upon the chronic condition. 
Fig. i 66.—Acute Dilatation of Stomach and Duodenum after a Finney Gastroduo- 
DENOSTOMY. (Bloodgood.) 
The transverse colon cut away. Note relation of mesenteric vessels to position of obstruction. 
“Theoretically, posterior gastrojejunostomy with a short loop may have 
been indicated in both cases. This procedure would have relieved gastric 
stasis, but might have increased the duodenal dilatation. Theoretically, also, 
a second anastomosis between the duodenum and the jejunum would have 
to be performed to drain both duodenum and stomach. Future experience 
may demonstrate that in cases of this character a simple duodenojejunostomy 
is indicated. This operation, as far as I know, has never been done, or even 
suggested before. It certainly meets the indications better than gastro- 
enterostomy and is simpler than a combined gastro-enterostomy and duodeno- 
jejunostomy. 
“In all three cases, the small intestines were collapsed, with absolute con- 
stipation in the first case, but some movement of the bowels in the other two 236 
GASTRO-ENTEROPTOSIS 
cases. In none of these cases can it positively be said that the small intestines 
were in the pelvis. In the two cases which I observed at operation (i and 3), 
the majority of the small intestines were not in the pelvis. Free fluid in the 
peritoneal cavity was absent in all, and there were no adhesions and no gross 
anatomical lesions to explain obstruction at the mesentery. Nor was I able 
to ascertain whether the dilatation of the stomach was primary or secondary.” 
Codman3 early expressed the belief that partial obstruction by the root of 
the mesentery would explain many cases of indigestion, nervous dyspepsia, 
etc. He believes the mesenteric artery is responsible for duodenal stasis. 
The duodenum is distended mainly by gas which leaks through the pylorus 
into the stomach, causing eructations. 
Stavely4 quotes Codman as follows: 
“People vary greatly in their discomfort in ordinary digestion, even 
though digestion be perfectly completed. The extreme cases without physical 
signs are called nervous dyspepsia and hyperchlorhydria. Perhaps such cases 
may suffer from duodenal distention and their duodenal peristalsis may be 
constantly overtaxed, because they happen to have more pressure at the root 
of the mesentery than other people. In such cases the distention is mainly 
with gas, which occasionally leaks through the pylorus into the stomach, 
causing eructations. In other cases, however, the fluid contents may flood the 
first portion of the duodenum and cause more or less acute distress. It is 
in cases of this sort that lack of exercise and outdoor life play an important 
part. In other words, a more unrestricted life allows the mesentery to move 
about more and relax its pressure.” 
L. F. Barker5 was one of the early students of this subject and was the 
first to suggest duodenojejunostomy for relief of chronic dilatation of the 
duodenum, thus preceding Bloodgood by one year. However, Albert L. 
Stavely was the first to perform duodenojejunostomy for chronic dilated 
duodenum in December, 1907. Stavely was an early and intelligent student 
of this subject. He mentions the diagnostic value of position. He thinks 
that periodical vomiting, described by von Leyden, characterized by attacks 
coming on at intervals varying from two to several weeks, occurring suddenly, 
lasting from a few hours to two weeks, and ceasing suddenly, may be due to 
arteriomesenteric ileus. There is nausea, vomiting of mucus and bile, gastric 
pain and headache. Nothing is retained and the patient becomes very feeble. 
Examination of the stomach contents shows nothing. Stavely also refers to 
the cyclic vomiting of children as follows: 
“Take the cyclic vomiting of children: These attacks come on suddenly in 
health and are quite similar to those just described. Prodromal symptoms 
8Boston Med. and Surg. Journ., 68:503. 
4 Surg., Gynec. and Obst., 11:288. 
8 Johns Hopkins Hosp. Bull., January, 1906. DUODENAL ARTERIOMESENTERIC ILEUS 
237 
are usually present, headache, lassitude, loss of appetite, and coated tongue. 
A slight elevation of temperature is frequently noticed. The abdomen is 
described as flat and pain is not usually present. Constipation is common and 
the stools are often white. Thirst is a distressing symptom. The vomitus 
contains frothy mucus and serum and sometimes blood. According to com- 
mon description, bile is not found. These attacks have been variously 
explained as due to a neurosis, faulty digestion, and toxemia.” 
The following treatment for chronic duodenal obstruction is suggested 
by Stavely: 
“In the chronic, relief may be obtained by vomiting the food ingested; but 
the continuation of the process favors starvation. Washing out the stomach 
is not feasible for the same reason. Presumably posture might be serviceable. 
Having the patient assume such a position as would relax the traction on the 
mesenteric ligament should relieve the symptoms for the time; and I believe 
posture, too, would be of benefit in some of these cases of gastric ptoses where 
angulation takes place in the duodenum. Leaning forward, as one would do 
in bending over a chair, would increase the angle between the spine and the 
mesentery and modify the amount of pressure. This has been referred to 
by Codman.” 
It is very interesting to note that that strange, but tireless and effective, 
scientific investigator, Byron Robinson, reports some very careful observations 
on this subject which give him the rightful place as a pioneer in this field of 
investigation. According to Stavely, he reports the following case of chronic 
duodenal ileus: 
“In 1895, Drs. Furth and Henry, of Ohio, brought me a patient, who had 
scarcely kept anything on her stomach for eighteen or twenty months or more. 
She was emaciated and I could detect only a distended or dilated stomach. 
The gastroptosis is easily detected; for after the stomach is washed out, it is 
pumped full of air and this method easily demonstrates its outline. I thought 
this patient had a stricture of the pylorus and possibly a carcinoma; but she 
did not lost flesh nor pale sufficiently for malignancy. On opening the abdo- 
men all we found was an enormous gastroduodenal dilatation, which extended 
to the pelvic brim. Finding nothing palpably pathologic in the pylorus, I 
performed a gastrojejunostomy with my segmented rubber plates. She made 
a good recovery and wrote me four years after the operation that she was 
perfectly well.” 
Robinson in this early period reported two other cases. The first was 
seen at autopsy in which he found an extensive gastroduodenal distention with 
marked distal dislocation of the stomach. The woman had vomited for a 
couple of years before her death, which appeared to be from marasmus. 
Death was thought to be undoubtedly the result of malassimilation, due to 238 
GASTRO-ENTEROPTOSIS 
disturbance in her system caused by extensive gastroduodenal dilatation. In 
the second case there was no positive information about the duration of the 
illness; but it was unquestionably chronic. A man, forty-five years of age, 
had been in bed five months with hip-joint disease. He had some lordosis. 
There was great abdominal distention and the vomiting was continuous. 
Thinking there was obstruction, he operated and, finding an enormously 
dilated stomach, he closed the abdomen. The patient subsequently died and 
at the autopsy he found a typical gastromesenteric ileus. He believed the 
prolonged confinement in bed made the progress of the dilatation rapid in 
its course. 
Stavely’s summary of cases of chronic gastromesenteric ileus is as follows: 
“We have reports of n cases, all subjected to operation or ‘postmortem’ 
examination. Seven are positively identified as gastroduodenal dilatations. 
The rest are designated as gastric dilatations and cannot definitely be proved 
on account of insufficient data; but there is little question as to their char- 
acter. In 5, there was reported the curious intermission or remission in symp- 
toms, which is so difficult to explain. Seven cases died of the condition. 
Four of these had submitted to operation. Two of the operations were 
exploratory and nothing further was done on account of the uncertainty as 
to the proper procedure. One had a pyloroplasty, which was undertaken 
through a mistake in diagnosis and of course was of no benefit, and the fourth 
had a gastro-enterostomy which was unsuccessful. There were three cures, 
one of Robinson’s treated by gastro-enterostomy, one of Scott’s by anterior 
gastro-enterostomy and one of mine by duodenojejunostomy. The remaining 
case, the second reported by me, is still under observation. She has improved 
in regard to some of the symptoms since the operation—cholecystectomy; 
but those of ileus still persist. If the condition becomes worse and the patient 
consents, a duodenojejunostomy will be suggested. In conclusion we must 
bear in mind that chronic gastromesenteric ileus is a distinct condition, which 
must be seriously considered by the physician and the surgeon, that it may 
be found to be the cause of much ill health and some deaths; that many 
gastric conditions, which are now differently interpreted, may be found to be 
dependent on it and that a better knowledge along these lines will result in 
mitigating the suffering of or bringing relief to many unfortunates.” 
Probably the clearest picture or conception of arteriomesenteric ileus yet 
published is found in Wilkie’s article printed in the British Journal of Surgery, 
October, 1921. In this article he relates 4 cases in detail which so admirably 
fit into each other that the subject is made perfectly clear, and in presenting 
these cases as the foundation for a clinical conception, he has without doubt 
established this condition as a definite pathological entity. It seems that he 
has been studying the subject for a number of years. He was first struck 
by the presence, in a certain proportion of a series of several hundred cada- 
vers in the postmortem room, of a chronic dilatation of the first three parts 
of the duodenum, and that this dilatation stopped suddenly at the superior DUODENAL ARTERIOMESENTERIC ILEUS 
239 
mesenteric vessels. Most of the patients had died of some other disease. 
Wilkie had also conducted experimental work on closing duodenal loops 
which showed how toxic duodenal contents were. These observations, taken 
with his experience with acute gastromesenteric ileus, caused him to raise 
the following questions: 
“i. Does a chronic obstruction of the duodenum from mesenteric com- 
pression never occur? 
“2. If it does occur, does it give rise to no recognizable clinical picture? 
“3. May it not be the precursor of the acute postoperative condition?” 
The fact that acute dilatation of the stomach had occurred a number of 
times in his experience, in cases where the pathology had nothing to do with 
the gastro-intestinal tract, caused him to believe these questions might be 
answered in the affirmative. 
The first link in the chain of evidence to prove this was in the following 
case which he relates. 
“Case 1. Female, age sixty-three; admitted to hospital with the diag- 
nosis of ‘acute intestinal obstruction.’ The patient was so ill that a detailed 
history could not be obtained, and, as she lived by herself and had no inti- 
mate friends, the following facts were all that could be obtained. For years, 
she had been troubled with her stomach and suffered from chronic consti- 
pation. For the past three weeks the trouble had been aggravated, and she 
had vomited daily and had kept no food down. For the past week, vomiting 
had been constant, day and night, and for four days there had been no 
action of the bowels or passage of flatus, in spite of enemata. The vomitus 
had been for the most part green and bilious; latterly, however, it had been 
darker in color. 
“On examination, patient looked very ill, with sunken eyes, dry tongue, 
a subnormal temperature, and a small thready pulse, rate 140. She was 
emaciated. The abdomen was tumid and tense; on palpation, splashing was 
readily elicited in the umbilical and hypogastric regions. No tumor was 
palpable anywhere. Immediate operation was undertaken. 
“Operation.—The abdomen was opened in the midline in the umbil- 
ical region. An enormously distended stomach was found filling almost the 
whole abdomen. A stomach tube was passed and eight and one half pints 
of dark bilious fluid were drawn off. As the stomach receded, it was seen 
that the duodenum was greatly dilated in its first two parts, and, on lifting 
up the transverse colon, the third part of the duodenum was seen bulging 
forward, greatly dilated, and distended up to the point at which it was crossed 
by the mesenteric vessels. Beyond this, the intestine was collapsed. On 
pulling up the loops of small intestine, which were all lying in the pelvis, 
they were seen to be empty, but congested, and to be studded with small 
ecchymoses. (The cause of the latter was found to be pressure on the 
superior mesenteric vein by the greatly dilated third part of the duodenum, 240 
GASTRO-ENTEROPTOSIS 
which had bulged over the accompanying vessels, and also almost certainly 
to pressure from the great weight of the dilated stomach.) A posterior 
gastro-enterostomy was performed. In spite of the administration of large 
quantities of saline intraperitoneally and subcutaneously, the patient never 
rallied, and died twelve hours after the operation. 
“At postmortem, the operative findings were confirmed. The great dila- 
tation of the duodenum was found to end abruptly at the crossing of the 
superior mesenteric artery. There was no evidence of any acute infective 
process anywhere which might have caused an acute toxic dilatation of the 
stomach.” 
This case settled in Wilkie’s mind that chronic duodenal obstruction did 
occur and was of clinical importance. 
In the second case, which follows, he was convinced that the usually 
rapid death following duodenal perforation was due in a large measure to 
the retained duodenal contents which he had found so poisonous experi- 
mentally: 
“Case 2. Male, age thirty-seven, had suffered for some nine months 
from indigestion. For three days before the onset of perforation he had 
been out of sorts and said to be suffering from gastric catarrh. At mid- 
night on April 2, 1920, whilst in bed, he was suddenly seized with very severe 
abdominal pain. When seen by the doctor at 7 A.M. he was found in a 
state of collapse and was sent to hospital. On admission, at 11 A.M., patient 
was in a state of intense shock and was obviously moribund. He could not 
stand a general anesthetic, but, under local anesthesia, an attempt was made 
to close the perforation. On opening the abdomen a very great quantity 
of bile-stained exudate escaped. He died on the table, however, within twelve 
hours of the original perforation. 
“The question arose as to why this well-developed man should have suc- 
cumbed so quickly to a perforation of no great size, coming on, as it did, 
whilst he was on low diet and under treatment for so-called gastric catarrh. 
“At postmortem, the first, second, and third parts of the duodenum up 
to the root of the mesentery were found very markedly dilated, the mucosa 
being intensely congested, in striking contrast to the pale mucosa beyond. 
No evidence of disease in other organs was found to account for the rapid 
collapse after the perforation.” 
The next piece of evidence was from the following case of death from 
“vicious circle” after gastro-enterostomy: 
“Case 3. Mrs. J. B., age forty-four. Had complained of occasional 
stomach trouble since the age of thirteen, but had been in fair health until 
four months before operation. At this time she began to suffer from severe 
pain in the epigastric region, coming on usually about two hours after food, 
frequently accompanied by vomiting, which always relieved the pain. She DUODENAL ARTERIOMESENTERIC ILEUS 
241 
frequently suffered from great nausea, coming on at irregular times and 
followed by vomiting, which gave instant relief. Rest in bed and milk diet 
relieved her symptoms, but a return to more ordinary diet was followed by 
a recurrence of the pain, nausea and flatulence. After treatment for ten 
weeks in a medical ward, a surgeon was called in. From the irregularity of 
the symptoms, and the fact that there was some tenderness in the right iliac 
and lumbar regions, it was thought that the gastric symptoms might be reflex 
from the appendix or proximal colon. 
“First operation, December 17, 1920.—Through a high gridiron incision, 
the appendix, which showed little abnormal, was removed, and a very mobile 
proximal colon was fixed after the method of Waugh. 
“Second operation, January 4, 1921.—Epigastric incision. A dilated and 
hypertrophied stomach and a duodenal ulcer, causing definite stenosis just 
beyond the pylorus, were exposed. A posterior gastro-enterostomy with a 
short loop was performed. The patient continued to vomit daily after the 
operation, for the most part bilious material. 
“Third operation, January 21, 1921.—The abdomen was reopened in the 
epigastric region, and an entero-anastomosis between the two limbs of the 
loop was performed. It was noted that the proximal loop was not distended 
as had been expected would be the case. After the third operation she con- 
tinued to bring up mouthfuls of bilious fluid and gradually became more 
emaciated, refusing all food. In spite of absorbing large quantities of saline 
and dextrose per rectum, she gradually sunk, and died five days later. 
“At postmortem, a duodenal ulcer causing marked stenosis of the first 
part of the duodenum was found. Beyond this, the duodenum was greatly 
dilated up to the crossing of the superior mesenteric artery. The mucosa 
was engorged and congested. Beyond the root of the mesentery the bowel 
was pale and empty, and the entero-anastomosis. was unavailing, as it was 
performed two inches beyond the seat of obstruction” (Fig. 167). 
The next case was the first in which Wilkie recognized the condition 
of chronic duodenal obstruction during life and treated it at operation: 
“Case 4. Female, age thirty-eight, married, six children. Complained 
of pain in the epigastrium after food; pain under the right breast, flatulence 
and vomiting. 
Ever since she was a young girl, patient had been bothered with 
flatulence after meals. Six years ago she had an attack of severe indiges- 
tion, accompanied by vomiting, lasting for several weeks. Two years 
ago she consulted her doctor for pains under the right breast, distention 
with wind after meals, and vomiting. Her doctor treated her for a sluggish 
liver, but without improvement. During the last two years she had never 
been free from pain and flatulence after food, and always had to loosen her 
clothes after eating. During this time she had several attacks consisting of, 
first, severe headache, blackness before the eyes; then a feeling of nausea 
and epigastric discomfort, followed by bilious vomiting, which gave her 242 
GASTRO-ENTEROPTOSIS 
relief. She lost twenty-eight pounds in weight during the past two years. 
For many months her diet consisted of milk, tea and biscuits. If she took 
more solid food she had within an hour a sensation of distention sometimes 
almost amounting to bursting in the epigastrium, only relieved by vomiting. 
After one of the attacks from which she suffered, her friends remarked 
that she was yellow and hollow-eyed. When she vomited she brought up 
large quantities of fluid, usually, though not always, yellowish green in 
color. During the last two attacks of pain and vomiting, she had definite 
shivering. 
“On examination, the patient was thin and hollow-eyed. The abdomen 
was flat. There was definite tenderness under the right costal margin, and 
the upper part of the right rectus muscle was rigid. 
“Provisional diagnosis, gall-stone in common duct. 
Fig. 167.—Duodenal Obstruction Causing Vicious Circle after Gastroenterostomy 
for Duodenal Ulcer. (Redrawn from Wilkie’s superb colored picture published in the 
British Journal of Surgery, October, 1921, p. 207.) 
The opening in the jejunum was the lateral anastomosis described in Case 3. 
“Operation, February n, 1920. On opening the abdomen through the 
right rectus, the gall-bladder was found to be normal in appearance and no 
gall-stones were present; the common duct was slightly dilated, but no stone 
could be felt. The stomach was distended with gas; the pylorus was widely 
dilated, admitting three fingers, and the first part of the duodenum was 
enormously dilated, resembling a second stomach (Fig. 168). The second 
half of the duodenum was likewise dilated. On throwing up the transverse 
colon, the third part of the duodenum, greatly dilated, bulged up into the 
wound. The dilatation extended to where the superior mesenteric vessels 
crossed the duodenum; beyond this the duodenum was collapsed and empty 
(Fig. 169). On passing a finger behind the mesenteric vessels, which were 
tightly stretched across the duodenum, and raising them, gas immediately 
escaped onwards into the jejunum. DUODENAL ARTERIOMESENTERIC ILEUS 
243 
“The obvious treatment was to anastomose the dilated third part of the 
duodenum to the jejunum. The peritoneum of the posterior abdominal wall 
over the duodenum was incised, the third part mobilized, and an angled 
Brunner’s clamp applied. The jejunum seven inches from the duodenojeju- 
nal juncture was likewise clamped, and a lateral anastomosis performed. 
Interrupted linen sutures were used for the outer layers, and continuous 
catgut for the inner layers. When the anastomosis was completed, the 
parietal peritoneum was fixed to the duodenum by one linen suture. 
Fig. i 68.—Great Dilatation of First Part of Duodenum and Pylorus As Seen at Opera 
tion in Case 4. (Wilkie.) 
“The patient made an uninterrupted recovery, and within a week after 
the operation was taking articles of diet which she had not dared to take 
for years previously. An X-ray photograph taken three weeks after the 
operation, two hours after a bismuth meal, showed that the duodenojejunol 
anastomosis was functioning well. 
“Ten weeks after the operation, the patient had gained twenty-one 
pounds in weight, and was feeling and looking very well.” 
The third case showed connection between a mobile cecum and ascending 244 
GASTRO-ENTEROPTOSIS 
colon while the fourth case showed that, by lifting up the mesenteric vessels, 
the gas in the duodenum passed out. 
This last observation of Wilkie corresponds exactly to E. L. Kellogg’s 6 
“Pressure Paradox” which he describes as follows: 
“In cases showing a dilated duodenum, pressure is made backward and 
upward for about thirty seconds by the hand placed just below the umbilicus, 
Fig. 169.—Distended Third Part of Duodenum in Case 4, Bulging into Wound When 
Transverse Colon Was Thrown Upwards. (Wilkie.) 
the patient being in a semirecumbent or reclining position. It might be 
thought that this would increase the amount of gas present in the duodenum; 
on the contrary, in the type of case we are considering, it will usually result 
in the undoing of the duodenojejunal kink, permitting the duodenum to 
empty itself, as shown by a relatively dull percussion note or marked diminu- 
tion in the size of the tympanitic area. At the same time it is often possible 
to hear and feel the gas escape as it rushes into the jejunum.” 
6 Stirg., Gynec. and Obst., 28:174. DUODENAL ARTERIOMESENTERIC ILEUS 
245 
After relating his experience, Wilkie gives his concrete clinical concep- 
tion of chronic dilatation of the duodenum or chronic arteriomesenteric ileus 
as follows: 
“Pathological Anatomy. The salient feature of the condition is the 
dilatation of the first three parts of the duodenum up to the crossing of the 
mesenteric vessels. The dilatation is most pronounced in the first part of 
the duodenum, which may look like a second stomach. The dilatation of 
this part may, however, be masked or modified by the presence of the scar 
of a duodenal ulcer. In three of my cases a duodenal ulcer was present; in 
another, a gastric ulcer. The wall of the duodenum is hypertrophied, the 
degree varying in different cases. In one of my cases it resembled the wall 
of the stomach when grasped between the finger and thumb. The pylorus 
is usually dilated; in one case it admitted three fingers. This is not invari- 
able, however, and the maintenance of the tonicity of the pylorus may 
modify the clinical picture, as will be indicated later. 
“The small intestines will, as a rule, be found empty and lying in the 
true pelvis. On drawing up the small intestines by pulling on the mesentery, 
a feeling of resistance is encountered and the intestines will sometimes leave 
the pelvis with a 'pop.’ In other cases it is the cecum and lower part of the 
ascending colon which occupy the true pelvis and offer resistance when an 
upward pull is applied to the mesentery. If the duodenum is distended at the 
time of examination, and a finger be passed behind the root of the mesentery 
and the latter lifted forwards, the duodenal content will immediately pass 
on and fill up the duodenojejunal loop. 
“Symptomatology. The patient is usually a female of somewhat spare 
build and of a visceroptotic type. She gives a history of stomach trouble 
for many years, usually since childhood. She will state that she has always 
had to be careful of what she ate, otherwise she suffered from epigastric pain 
and flatulence. Periodically she has had ‘bilious attacks,’ with nausea and 
vomiting. At the age of thirty or thereabouts the symptoms become aggra- 
vated. Epigastric discomfort and flatulence follow all but the simplest of 
meals. Walking and standing aggravate these symptoms; rest in bed gives 
a certain amount of relief. Some patients will volunteer that they have 
found that lying on the face or in the genupectoral position will give relief. 
In addition to the chronic flatulent dyspepsia so suggestive of a biliary con- 
dition, they suffer from what they term their ‘attacks/ These are the 
typical popular ‘bilious attacks’ consisting of, first, a day of headache and 
nausea and epigastric discomfort, sometimes amounting to actual pain; this 
is followed by vomiting, first clear, then bilious. This may last for a whole 
day, after which the patient feels completely relieved, although relatives 
remark that she looks hollow-eyed and has a tinge of jaundice. Such attacks 
tend to recur at intervals of from four to five weeks, and are ushered in by 
constipation. In a few cases the nausea, headache, lassitude, and epigastric 
pain are the most pronounced symptoms, and vomiting is an occasional and 
late symptom. In such cases it would appear that a tonic pylorus resists the 246 
GASTRO-ENTEROPTOSIS 
duodenal tension until at last it gives way, bile regurgitates, is vomited, and 
relief is obtained. The persistence of such symptoms over a prolonged period 
is apt to lead to a state bordering on, if not actually of, neurasthenia, when 
the subjective symptoms complained of multiply by analysis and make diag- 
nosis more difficult. 
“Physical Signs. In a pronounced case, examination of the abdo- 
men may reveal a definite epigastric fullness. This, however, usually will 
not be detectable. When asked to indicate the site where pain is felt, the 
patient will refer to a point about one inch above the umbilicus, and usually 
slightly to the left of the midline. At this area some superficial cutaneous 
hyperesthesia may be detected. In some cases the seat of pain is located to 
the right of the midline. Pressure by the examining hand from below up- 
wards tends to relieve the pain. Should the duodenum be distended with 
gas at the time of examination, a definite tympanitic swelling may be made 
out above the colon. This I have seen in one case, but it must certainly be 
unusual. Succussion will show the stomach to be dilated. Duodenal succus- 
sion I have never elicited.” 
The most extensive clinical experience with surgical treatment on record 
has been published by E. L. Kellogg and William A. Kellogg.7 The article 
by Kellogg is very exhaustive. In it the principal work connected with the 
subject has been abstracted and a complete bibliography of all that had been 
written on the subject is appended. 
In this article he relates his experience with 41 cases treated by duodeno- 
jejunostomy. The resume of his case reports follows: 
“Total number, 41. First duodenojejunostomy performed in 1915. 
Males, 16; females, 25. Ages, ten to twenty, 2; twenty to thirty, 12; thirty 
to forty, 15; forty to fifty, 8; fifty to sixty, 3; not stated, 1. 
“Previous operations were perfomed in 22 cases: Gastro-enterostomy 
alone, 5; gastro-enterostomy and appendectomy, 3; appendectomy alone, 5; 
appendectomy and nephropexy, 2; appendectomy and cholecystectomy, 2; 
hysterectomy and cholecystostomy, 1 ; hysterectomy alone, 2; tubal pregnancy 
alone, 1; laparotomy, nature not stated, 1. 
“Symptoms have been grouped as follows: Headache, 27; regurgitation, 
25; eructations, 30; borborygmus, 25; heartburn, 13; loss of weight, 35; 
constipation, 38; vomiting, 22; vomiting of bile, 19; vicious circle, 4; bilious 
attacks (constipation, headache and vomiting of bile), 9; pain, 34; localized 
in the epigastrium, 29; right hypochrondrium, 7; at the duodenojejunal junc- 
tion, 6; in the back, 9. The pain was definitely related to food in 11 cases. 
Dull in character in 11, sharp in 13, coliclike in 6. The gastric acidity was 
normal in 7, low in 9, high in 17 and not stated in 8. Impaired motor func- 
tion and bile found in the fasting stomach was noted in 23 cases. 
“X-ray report, correct diagnosis 18 in 33 examinations, ulcer wrongly 
diagnosed in 9 cases. 
7 Ann. Surg., May, 1921. DUODENAL ARTERIOMESENTERIC ILEUS 
247 
“Pathology. The stomach was dilated in io cases, ptosed in 3, and 
an ulcer found in 1. The duodenum showed an ulcer in 2 cases, was moder- 
ately dilated in 10, considerably in 11, greatly in 7, and not stated in 3. The 
cecum was dilated in 15 cases, prolapsed in 10. Adhesions were about it 
in 4, and in 3 there was a Jackson membrane. The hepatic flexure showed 
adhesions or prolapse in 7 cases. Chronic appendicitis was found in 4 cases. 
The small intestines were in the pelvis in 4, the jejunum was angulated or 
adherent in 11. 
“The indications for which duodenojejunostomy was performed were as 
follows: 3 cases, 1 suggestive of gall-stones, the other 2 of chronic appen- 
dicitis, in which a dilated duodenum was found; 1 in which ulcer was sus- 
pected or diagnosed, but in which the pathology was a dilated duodenum, 
or adhesions about it; 3 cases, 2 with a duodenal ulcer and 1 with a gastric 
ulcer as well as a duodenal dilatation. In these a gastro-enterostomy was 
also performed, 4 with vicious circle, 4 complaining of continued epigastric 
pain and vomiting of bile, after a previous gastro-enterostomy had been 
performed by various surgeons and in which a dilated duodenum was 
demonstrated; 14 with epigastric pain, vomiting, or typical bilious attacks in 
which a dilated duodenum was suspected or diagnosed before operation. 
Four of these also showed ulcer of the duodenum. Of the 41 cases operated 
upon, 31 have been followed up to a recent date, and are so completely 
relieved of their symptoms that it is justified to classify them as cured; 5 
cases were apparently cured at the time of their leaving the hospital, but 
we have been unable to get a subsequent report; 4 cases have been greatly 
improved, but still complain of some troublesome symptoms; 1 case feels 
that there has been no benefit from the operation. 
“The results convince us that duodenojejunostomy will save from in- 
validism a group of patients not amenable to other treatment, and should 
be recognized as a definite surgical procedure with well-defined indications 
and limitations.” 
Kellogg’s detailed case reports in this article are very interesting. 
The clinical picture of chronic duodenal obstruction as seen by Kellogg 
is as follows: 
“Symptoms.—For a clearer understanding, the cases may be grouped 
in accordance with the anatomical and symptomatic variations. 
“Anatomical Grouping. First. The asthenic duodenum: The symp- 
toms are latent or toxic. X-ray examinations may show delay and puddling 
of bismuth in the duodenum, with sluggish peristalsis and slight or no dila- 
tation. 
“Second. Duodenal obstruction with incompetent pylorus. Bile regurgi- 
tates easily into the stomach, dilatation is moderate or absent. 
“Third. Obstruction with hypertrophy (the writhing duodenum). The 
duodenum is elongated and its walls are thickened. Under the fluoroscope it 
is seen to labor over its contents. The pylorus functionates and little or 
no bile regurgitates; cramplike pains are the predominant symptom. 248 
GASTRO-ENTEROPTOSIS 
“Fourth. Dilated duodenum. The area of duodenal tympany is in- 
creased. Pain is usually present either steady and dull, or cramplike. This 
is the type most frequently recognized by the roentgenologist. 
“Symptomatic Grouping. First, latent; second, toxic; third, mechanical; 
fourth, toxic and mechanical. 
“Latent obstruction may exist without diagnostic symptoms, the condi- 
tion being recognized at operation or by X-ray examination. 
“The Toxic Symptoms.—Laboratory studies of duodenal toxicity, 
after ligation of the jejunum, have been made by Maury, McLean and An- 
dries, Whipple, Stein and Bernheim. Experimental animals die in a few 
days with weak pulse, low blood-pressure, subnormal temperature and dimin- 
ished secretion of urine. The last authors have shown that the cause of 
death is a chemical and not a bacterial poison. 
“In human beings we find these symptoms, together with the character- 
istic vomiting or regurgitation, in acute gastromesenteric ileus, in certain 
cases of vicious circle after gastro-enterostomy, and in the terminal stages 
of chronic duodenal obstruction. 
“The usual toxic symptoms are less severe, however, such as vomiting, 
headache, neuralgia, mental and physical depression, disturbed heart action, 
cold extremities, hyperesthesia, paresthesia, skin eruptions and neurasthenia. 
“The Mechanical Symptoms.—These vary with the mechanism of 
the attacks. When obstruction involves the first portion only, the symptoms 
are those of partial pyloric obstruction. Harris has made a study of this 
group and states that it is a chronic condition with remissions. His patients 
complained of distress or pressure in the epigastrium sometimes becoming 
a sharp pain, recurring two or three hours after meals and relieved by food. 
With this there is epigastric tenderness and excessive secretion of hydro- 
chloric acid. If compression takes place in the region of the ampulla of 
Vater, we may have papillary stenosis, as pointed out by Anders and Cam- 
piche, with deep chronic jaundice, acholic stools, enlarged and sensitive liver. 
In my experience, this is accompanied with pain referred to the right costal 
arch. 
“In all obstructions below the ampulla of Vater, the symptoms may be 
grouped together, except for pain at the duodenojejunal junction, which 
seems to be peculiar to constriction at that point. If due to prolapse of the 
intestines, there may be periods of comfort when the bowels are functioning 
properly, but with constipation the drag of the distended bowel inaugurates 
an attack. This is probably the mechanism of so-called bilious attacks char- 
acterized by constipation, headache, and vomiting of bile. 
“The condition of the pylorus will modify the symptoms, for with a 
resistant pylorus, pain is prominent, while with a relaxed one, regurgitation 
or vomiting of bile occurs without pain. Two areas of discomfort are 
observed, a pain or dull ache at the left of the median line, slightly higher 
than the navel (the duodenojejunal junction), relieved by deep pressure, and 
a pain above and at the right of the navel, extending under the liver and to 
the shoulders. This may be coliclike, due to peristaltic unrest, or steady and DUODENAL ARTERIOMESENTERIC ILEUS 
249 
dull, due to distention and often lasting until relieved by vomiting. Occa- 
sionally pain is limited to the back and is referred to the midline between 
the shoulder-blades. It may be of an intense boring character. Following 
an attack of pain the patient may feel something give (apparently the resist- 
ing pylorus yielding to pressure), the pain subsides and vomiting or regurgi- 
tation of bile follows. Frequently patients obtain relief from deep pressure 
in the median line of the abdomen below the navel (presumably by unlocking 
the duodenojejunal kink). Attacks of pain may simulate biliary colic or duo- 
denal ulcer or chronic appendicitis, and in operating for these conditions with 
negative findings, duodenal obstruction should be looked for. In the ma- 
jority of the cases there will be a combination of both toxic and mechanical 
symptoms. 
“In contrast with the above, pain is usually absent in acute gastromes- 
enteric ileus, or, if present in the beginning, disappears with the progress 
of dilatation. This, with the absence of fever, accounts for the frequent 
failure to diagnose the condition. 
“Treatment.—A minority of the cases are surgical* from the begin- 
ning, notably those having a hugely dilated duodenum, or continuous and 
copious regurgitation of bile into the stomach. 
“In the greater number, the dilatation is less marked, but they have at- 
tacks of pain, or bile regurgitation, or toxic symptoms with intervals of 
comiort between the attacks, the symptoms often not pointing clearly to the 
duodenum. For these cases, medical treatment should always be tried and 
it is usually successful. It consists of abdominal support, sleeping with 
foot of bed elevated, resting after meals, postural treatment, abdominal 
massage and exercises, lavage, duodenal and colonic irrigations, mineral oil, 
cathartics, rest cure and overfeeding. 
“When not successful, surgery is indicated. The procedure may be 
directed to the duodenum itself, or to some other part, the pathology of 
which is a factor in producing obstruction, frequently to both. The follow- 
ing operative procedures have been recommended: jejunostomy, resection of 
duodenum and reuniting anterior to mesenteric vessels, approximation of 
recti muscles, gastro-enterostomy, suturing the jejunum to under surface of 
transverse mesocolon, dividing adhesions with readjustment of duodenum, 
shortening the gastrohepatic omentum (Beyea), enlarging the mesenteric 
opening, stretching or dividing the ligament of Trietz, cholecystogastros- 
tomy, or enterostomy (for papillary stenosis), suspending the transverse 
colon (Coffey), plication and fixation of cecum and ascending colon, with 
restoration of hepatic flexure, resection of cecum and ascending colon, 
cholecystectomy (to prevent gall-bladder adhesions from reforming), duo- 
denojejunostomy. 
“The choice of procedure will be determined by the subjective symptoms 
and mechanical conditions. In obstruction of first portion, dividing adhe- 
sions, the Beyea or Coffey operations or gastro-enterostomy; of the second 
portion, the same, or cholecystectomy or duodenoduodenostomy; of the third 
portion, some procedure to relieve the intestinal drag, Coffey operation, 250 
GASTRO-ENTEROPTOSIS 
resection or plication and fixation of cecum and ascending colon, duodeno- 
jejunostomy.” 
I believe Kellogg has given the clearest demonstration of the technic of 
duodenojejunostomy yet published. Therefore, we will give the description 
of the operation in his words: 
“The operation is similar to gastro-enterostomy, but there are some prac- 
tical points worth emphasizing (Figs. 170, 171, 172, 173)- 
Fig. 170.—Duodenojejunostomy. (E. L. Kellogg and W. A. Kellogg.) 
The duodenum is exposed by an incision extending downward and inward. A large blood- 
vessel presents at the lower angle of the incision and may be easily injured. It should be repre- 
sented in the peritoneal layer instead of behind it. 
“Incision.—Upper right rectus or transverse if there is reason to antici- 
pate the encountering of adhesions from previous operation. The dependent 
portion of the duodenum is located retroperitoneally, below the transverse 
colon, in close relation to the hepatic flexure. The peritoneum is incised 
obliquely downward and inward and the opening enlarged sufficiently to give 
a satisfactory exposure. Large blood-vessels will present at the inner angle. 
“The duodenum is freed by blunt dissection behind the descending and 
transverse portions. Free mobilization adds to the ease of the subsequent 
procedure. The duodenum is drawn forward and the edge of the mesen- 
teric opening is sutured to it posteriorly. 
“The dependent portion of the duodenum and the superior surface of the Fig. i 71.—Duodenojejunostomy. (E. L. Kellogg and W. A. Kellogg.) 
Allis’ forceps are applied on the duodenum and jejunum to mark the points of the 
anastomosis. 
Fig. 172.—Duodenojejunostomy. (E. L. Kellogg and W. A. Kellogg.) 
The duodenum has been lifted from its bed after blunt dissection behind the second and third 
portions. Stitches are inserted for closing the peritoneal opening posteriorly. They pass 
through the peritoneal edge from without inward so as to invert the raw surface. 252 
GASTRO-ENTEROPTOSIS 
jejunum are approximated and held with traction stitches. A continuous 
suture of fine linen softened with vaselin is inserted, a gastro-enterostomy 
clamp is applied, and a one and one half inch incision is made in the duo- 
denum and a slightly shorter one in the jejunum. The suturing is then com- 
pleted as in gastro-enterostomy, particular attention being given to the angle 
stitches. In completing the outer anterior stitch, the approximation must 
usually be made entirely at the expense of the jejunum. This may be facili- 
tated by inserting the jejunal stitch at right angles to the incision and the 
duodenal stitch parallel with it. The opening in the mesentery is closed 
anteriorly by suturing to the duodenum. The procedure is more difficult 
than gastro-enterostomy, but postoperative experience leads to the conclusion 
that the mortality is lower and complications are less apt to occur.” 
Fig. 173.—Duodenojejunostomy. (E. L. Kellogg and W. A. Kellogg.) , 
Posterior peritoneal sutures are tied and traction stitches are inserted between the duo- 
denum and jejunum. On the jejunal side they are close to the mesenteric border, so that the 
jejunal incision will be on the superior surface instead of the free border. These sutures aid in the 
manipulation of the duodenum, which tends to retract, and also prevent angulation at the point 
of anastomosis. 
If anything further is to be added to the technic of this operation, it 
would be in the line of discarding the clamps. However, it must be con- 
ceded that Kellogg’s results are practically perfect. 
In his final conclusion he states, 
“The total number of duodenojejunostomies reported are fifty-eight. 
There has been no mortality.” 
Gregoire 8 describes a new technic for duodenojejunostomy, setting forth 
certain principles which are of interest. The following is a translation and 
abstract made by W. A. Brennan.9 
“The transverse mesocolon and the root of the mesentery from the two 
sides of an angle, the opening of which contains the end of the second and 
8 Surg., Gynec. and Obst., September, 1922, 192. 
9 International Abstract of Surgery, September, 1922. DOUDENAL ARTERIOMESENTERIC ILEUS 
253 
the beginning of *the third portion of the duodenum. This is the operative 
field of duodenojejunostomy. When this angle is a right angle, the oper- 
ative field is very large, but when it is acute, the field is greatly restricted. 
The peritoneum here is mobile and this mobility becomes a hindrance to the 
performance of duodenojejunostomy. 
“When the operative angle is large, laterolateral duodenojejunostomy is 
indicated because the mesocolic surface of the duodenum is large. The first 
jejunal loop is selected. The loop should not be turned to make the peri- 
stalsis of the two loops occur in the same direction. During the suturing, 
the duodenum is occluded by the fingers of the assistant who compresses its 
second portion against the left flank or the lumbar spine. 
“The technic of laterolateral duodenojejunostomy is exactly the same 
as that of any other laterolateral anastomosis, but there are two points which 
merit special attention, namely, the danger of injuring the superior mesen- 
teric vein, and the difficulty caused by the mobility of the peritoneum in front 
of the duodenum. In placing the seroserous buried sutures, care should be 
taken not to insert the needle too deeply so as to penetrate the musculature 
of the duodenum. 
“When the operative angle is acute, laterolateral anastomosis is almost 
impossible. This fact led Gregoire to try the Y-anastomosis on the cadaver. 
Duval has had the opportunity since to use it in a clinical case. However 
narrow the operative angle or short the accessible portion of the duodenum, 
it will always be possible to make the terminal discharge of the jejunum at 
the lowest point. The risks of the Y-anastomosis are not much greater than 
those of lateral anastomosis, but the operation takes longer. A duodeno- 
jejunostomy so executed when the laterolateral is impossible assures perfect 
drainage at the lowest point and avoids all danger of vicious circle.” 
I believe the authors I have just quoted have given us such a clear picture 
that we can now proceed with the clinical application in our everyday 
practice. 
In order to further elucidate this subject from my own personal ex- 
perience, I wish to give a stenographic report of two cases operated in my 
clinic within the last few months: 
Case i. One operation was performed October 28, 1922. No. 23470, 
Mrs. W. W. This patient is a female, thirty years of age; married very 
young; has had three children. She has had an interesting past from the 
standpoint of surgery. I believe it was in 1916 that she had both of her 
ovaries removed for some reason; in 1917, her appendix was removed; in 
1918, she was operated on for adhesions; in 1919, she was again operated 
on for adhesions; in 1920, she was operated on for some stomach trouble; 
in August, same year, she had some repair work done; in 1921, she had a 
gastro-enterostomy; in 1921, she went to a very distinguished surgeon in the 
east and, after a thorough investigation, he did an exploratory operation. 
From a letter written to her physician which was forwarded to me, I find 254 
GASTRO-ENTEROPTOSIS 
that when he opened her abdomen he found postoperative adhesions at the 
site of the abdominal operation and numerous adhesions about the pylorus, 
which he thought might have been caused by sutures placed there for the 
purpose of narrowing the pylorus at the time the gastro-enterostomy had 
been done. The gastro-enterostomy opening seemed to be working perfectly. 
At this time, the surgeon found that the gall-bladder was buried in adhesions 
and that there were no gall-stones present. He believed the adhesions were 
not due to gall-bladder. He separated the adhesions and explored all the 
abdomen but did not find any other disease. He found the uterus was hanging 
by a band from the abdominal wall; that the ovaries and tubes were missing. 
In this letter from the surgeon to the patient’s physician, it was stated that 
she would probably not be well until she reached the age when she would 
naturally go through the change of life. 
When I first examined this patient, I was very much inclined to take the 
same view and told the patient that I had very little hope of being able to 
do anything for her. I have often remarked that I have rarely seen a patient 
whose ovaries were removed before she was thirty who was not a wreck 
before she was forty, and I stated to the patient that my sentiments were 
the same as those of the eastern surgeon whose judgment I rely upon as being 
superlatively good. But when Mr. Trahar’s X-ray report came in, a markedly 
dilated duodenum with decided duodenal stasis was revealed. I have, there- 
fore, told her that in the light of the fact that she has so many local gastric 
symptoms and vomits most of her food since, as well as before, the operation; 
belches gas all the time and bloats up frequently; is losing weight and is not 
benefited by the psychic effect of her recent exploratory operation, I believe 
we are justified in another exploration on the grounds that, despite her 
neurasthenic tendencies, she has a widely dilated duodenum manifested chiefly 
in its second and third portions. 
We open the abdomen through the right rectus muscle and find moderate 
adhesions, particularly around the duodenum and gall-bladder; the omentum 
is adherent to the abdominal wall but is quite easily separated. On drawing 
the middle of the transverse colon out through the wound, I bring the 
anastomosis into view. The jejunal loop has been fairly long. There is a 
constricting mass of adhesions around the jejunum between the gastro- 
enterostomy and the origin of the jejunum. Above this, the jejunum is 
somewhat dilated. On pushing in the anterior stomach wall from above, I 
am able to pass two fingers through the anastomosis, so that I know it is 
functioning perfectly. There are no adhesions obstructing the jejunum below 
the anastomosis. The cause of the vomiting of bile does not appear in con- 
nection with the anastomosis. On lifting up the first half of the transverse 
colon and looking below it, I find a very widely dilated duodenum which 
comes into view below the mesocolon. I feel very sure that this will account 
for her distress and constant vomiting. I am therefore going to do a duodeno- 
jejunostomy. We split the mesentery or peritoneum over the duodenum and 
pull it forward with Allis’ forceps. I find that it is at least twice normal 
size; that its walls are exceptionally thick, showing that they have been DUODENAL ARTERIOMESENTERIC ILEUS 
255 
overdeveloped in the effort to overcome an obstruction. In this case, I am 
able to use clamps on the two intestines and we will do the anastomosis just 
as we would do a gastro-enterostomy.10 
Postoperative;—The postoperative course of this case was unusually 
smooth. The patient was never nauseated after the operation and began to 
take food on the second day and to gain rapidly before she left the hospital, 
three weeks after the operation. She never had a single symptom referable 
to the stomach after the operation was performed. 
One by one we have gradually lessened that group of cases which we 
can legitimately class under the head of “neurasthenia.” There are plenty 
of them left and this patient is probably one of them, but we must always 
bear in mind the fact that the anatomy of a neurasthenic is much the same 
as a normal individual, and the result of a distorted anatomy or perverted 
physiology will in these patients manifest much the same symptoms as in 
normal individuals. In her case we shall await later results with interest. 
Case 2. In the report of my clinic for December 2, I find the following 
case which is also very interesting: No. 23700, Mr. C. J. T. This patient 
is a clergyman, thirty-five years of age. For ten years has had attacks of 
indigestion and biliousness; has pains in the pit of the stomach from one-half 
to two and one-half hours after eating; feels a great deal of tenderness all 
through the epigastrium; has attacks of pain with vomiting of quantities of 
bile; belches very little gas but bloats after eating. For the last two weeks 
he has had pain through the right side of the rib arch, soreness under shoulder. 
He has been losing weight—losing about twenty pounds last year. Badly 
constipated. 
This case bids fair to tangle me up in my former statements, in which 
I said that I have never known a case of peptic ulcer in which achylia existed- 
Yet we have here a case in which there is a twelve-hour stasis, practically 
all barium still in stomach for twelve hours. The X-ray picture shows a 
slight deformity which looks as if it might be a duodenal ulcer, but he has 
an achylia which, according to our statements to you in the past, means that, 
if he has an ulcer, it must be syphilitic or malignant. Wassermann is negative 
and the patient is almost too young for malignancy of the stomach (except 
in rare instances). Therefore, we are confronted with the possibility of an 
ulcer or the scar of a peptic ulcer in which an achylia exists. If this is true, 
it is the first one I have ever seen and completely upsets our entire theory 
as to perpetuation of an ulcer. If we find that this is an ulcer, I shall still 
believe that the specimens of gastric contents must have been mixed in the 
laboratory. 
On opening the abdomen, we find a white scar just outside the pylorus. 
In fact, it is right in the pylorus, possibly a healed ulcer. I don’t quite 
understand that. I find concretions in the appendix. Will remove the 
10 This is E. L. Kellogg’s technic and was described in the Annals of Surgery, May, 
1921, 73:578. 256 
GASTRO-ENTEROPTOSIS 
appendix. There is a band which seems to be an acquired band and there 
is a certain amount of ptosis. Below the scar, which we thought was an 
old ulcer scar, I note that the second portion of the duodenum is dilated. 
This may be one of those duodenal stasis cases of which Wilkie has been 
saying so much lately—chronic duodenal arteriomesenteric ileus. I turn up 
the transverse colon and look beneath. See those acquired bands running 
along the superior mesenteric vessels. These have evidently been laid down 
in response to a strain on the mesentery. The duodenum is enormously 
dilated. 
Student.—“What do you do in such a case?” 
We shall do a duodenojejunostomy instead of a gastro-enterostomy. See 
what a tremendous duodenum this is. A peculiar thing about this type of 
case is that Wilkie has found a number of these cases in which an ulcer of 
the duodenum was found just outside the pylorus and, in three cases, he has 
had perforated ulcer just where the scar shows in this case. But you see 
this patient hasn’t an active ulcer. This accounts for the achylia. He seems 
to have had an ulcer but the question is whether there is a direct connection 
with this duodenal ileus. We split the transverse mesocolon which covers 
the duodenum and pull up the colon with Allis’ forceps; but find I am unable 
to use clamps in this case so I tack the peritoneum of the posterior wall of 
the abdomen to the duodenal mesentery and to the intestine. I see a very 
dangerous looking vessel there which I must avoid. I will turn the jejunum 
to the right in a graceful curve from its beginning and place it where it lies 
easily against the duodenum. I then place a traction loop and attach the 
proximal portion of the jejunum to the distal portion of the duodenum and, 
at the other end of the proposed anastomosis, I place another traction loop 
about two inches away from the first one. I now use a continuous peritoneal 
suture of linen from one of these loops to the other, because it is a little 
easier than making interrupted sutures and we are in an alkaline area and, 
therefore, there is no danger of secondary ulcer. Next I put in a row of 
interrupted linen suture which penetrates all of the coats. Note how thick 
the duodenum is in this case. Having placed these two layers of sutures, 
I cut down to the mucosa of the duodenum and find that, instead of cutting 
to it, I have cut through the entire thickness of the duodenal wall at one 
place. There are some duodenal secretions escaping so I enlarge the incision 
and pack the duodenum temporarily with a long gauze tape sponge. I then 
make my incision in the jejunum. I begin the suture with a chromic catgut 
suture on a curved needle and make a lock stitch on the back, just as if I 
were doing a gastro-enterostomy, and then complete the operation in front 
just as in a gastro-enterostomy. You will note I have placed back of the 
anastomosis a pad of gauze to catch the secretions. This I now remove. 
Now we have completed the duodenojejunostomy. This one has been a little 
more difficult than others I have performed but, at that, it is more quickly 
performed than a gastro-enterostomy. 
Kellogg has collected the cases of duodenojejunostomy for this condition 
and found 54 cases without a single death. Included in this list were several DUODENAL ARTERIOMESENTERIC ILEUS 
257 
operations by Quain of Bismarck, N. D., and Freeman of Denver and 
others. 
Student.—“Had there been an active ulcer there, would you have done 
this operation?” 
No, I think I would have done a gastro-enterostomy, although it is quite 
possible that later I would have had to have done this operation also, for I 
have had two cases in the past year in which I have had definite ulcer and 
have done a gastro-enterostomy and have later had to do a duodeno- 
jejunostomy in order to get relief. 
Student.—“How common are cases of this kind?” 
I do not know. This field is just being opened up. I had a letter from 
Wilkie of Edinburgh last week and he said he had found a number of them 
this year, one in a boy seven years old. Now an important question is, Where 
was this barium that showed twelve-hour stasis? Was it in the duodenum 
or was it in the stomach? I scarcely see how it could have been held in the 
stomach for there was no obstruction of the pylorus. It is quite possible, 
it seems to me, that this stasis might have been in the duodenum and yet 
it is my understanding that an obstruction of this kind often causes a reverse 
peristalsis from the duodenum into the stomach and thus produces a stasis 
in the stomach. You see the duodenum lies just directly back of the pyloric 
end of the stomach, so it is going to be a tremendously important thing to 
look this up and see if we can determine whether that residue was in the 
duodenum or stomach. This is the most thrilling and interesting field that 
has been opened for a long time and we are indebted to Wilkie of Edinburgh 
for giving us the best clinical picture of this condition, although it must be 
said for Bloodgood that he was one of the first, if not the first, to seriously 
consider chronic duodenal ileus. Stavely of Johns Hopkins was the first to 
do the operation of duodenojejunostomy. 
Postoperative.—This patient made an uninterrupted and complete 
recovery and has never had the slightest symptoms since his operation. 
Believing that this condition may develop very early in life, I wish to 
include the report of two very interesting cases as a basis for future in- 
vestigation. 
William A. Downes11 reported the following case under the title of 
“Giant Duodenum”: 
“B. W., male, age four and one half years. Admitted October 31, 1916, 
with a history of recurrent vomiting. Weight at birth six pounds—admis- 
sion weight twenty-nine pounds with clothes. Breast fed for five months. 
Vomiting almost from birth—at first very small quantities, later larger 
amounts. Periods of from one to two months without vomiting. As the 
feedings were changed from fluids to semisolids, the vomiting attacks con- 
tinued. Vomitus frequently contained food taken from one to three days 
before; always hungry, and could eat immediately after vomiting. At four 
months of age had a severe attack of diarrhea with blood and mucus. Sim- 
11 Ann. Surg., 66 '.436. 258 
GASTRO-ENTEROPTOSIS 
ilar attacks about every two months. At eighteen months had an attack 
lasting three weeks, accompanied by high fever and extreme prostration. 
Last severe attack January, 1916. Marked constipation between diarrheal 
attacks. Stools foul smelling. Abdomen always distended, especially in 
epigastric region. Raised great deal of sour-smelling gas. 
“Examination. Fairly well-developed, undernourished child, very bright, 
color good, moderate distention. After taking eight ounces of water, marked 
peristaltic waves of unusual character were noted in upper abdomen. The 
movements of the stomach were not of a definite peristaltic character, travel- 
ing as do the ordinary cases of pyloric stenosis from left to right, but there 
was an irregular set of contractions visible sometimes near the cardiac and 
sometimes near the pyloric end of the stomach. In the region below the 
pylorus, to the right, there was a very definite peristaltic action—the waves 
passing from above downward and below upward, usually concentric in char- 
acter. A large oval contracting mass could be felt in this region, and definite 
splashing sounds could easily be elicited. Percussion at this time gave a 
tympanitic note, although later on, when the pouch became filled with fluids, 
the note was flat. Lavage soon returned clear, to be followed later by bile- 
stainecl fluid with old food particles. No effort was made to distend the 
stomach or duodenum with air, as the X-ray had already given a clue to the 
diagnosis. Radigram taken by Dr. R. D. Baker showed the following: 
Fifteen minutes after bismuth meal (Fig. 174) the stomach was seen to be 
in normal position and of about normal size. Just to the right of the 
stomach was shown a pouch, extending nearly in a vertical direction and 
fully the size of the stomach, which was apparently the dilated duodenum. 
In the second picture, taken two hours later, the stomach had almost emptied 
itself, but the dilated duodenum remained about the same or was even larger, 
only a small amount of the bismuth having passed into the jejunum. Picture 
at twenty-four hours showed bismuth well into the colon, but the duodenal 
pouch could still be outlined distinctly. A study of these plates with the 
history and physical signs led to the diagnosis of partial obstruction of the 
duodenum, probably at the duodenojejunal junction, with saccular dilatation 
above. The patient was given daily lavage and small doses of atropin three 
times a day for one week. * 
“Operation (November 6, 1916), posterior no-loop gastro-enterostomy 
and closure of pylorus by silk ligature; upper right rectus incision. Stomach 
appeared normal with possibly a slight thickening of the wall; pylorus 
normal, easily admitted tip of index finger. Duodenum dilated to the size 
of the stomach. Wall smooth and three to four times thicker than normal; 
no diverticula observed. No adhesions or peritoneal bands. The disten- 
tion involved the entire length of the duodenum, ending abruptly at the 
point where the gut passed under the superior mesenteric artery. No effort 
was made to determine the nature of the stenosis or its cause. The jejunum 
from its very beginning appeared normal in every way. No distention or 
hypertrophy. There were no adhesions in the region of the fossa of Treitz.- 
No enlarged mesenteric glands. The usual posterior gastro-enterostomy was DUODENAL ARTERIOMESENTERIC ILEUS 
259 
performed; double zero chromic catgut used throughout. Complete division of 
the pylorus was planned as a part of the original operation, but the condition 
of the child would not permit the carrying out of this step, and we were 
forced to resort to occlusion by means of a heavy silk ligature. Vomited 
moderately for twenty-four hours after operation, otherwise convalescence 
straightforward. 
“Discharged, November 23. On mixed diet at this time, eating three 
meals a day. Condition very good. No distention and no fullness could be 
felt in region of duodenum. One week after discharge from the hospital, 
vomiting recurred—first in small quantities, but later in increasing amounts 
Fig. 174.—X-ray Picture of Giant Duodenum and Stomach of a Child Four Years of Age. 
(Downes.) 
and at one time vomited as much as one and a half quarts. Distention 
returned and the general condition of the child became much the same as 
it had been before operation. Readmitted to the hospital December 6, almost 
in collapse, temperature subnormal and abdomen greatly distended. Lavage 
brought away a large quantity of undigested food with immediate improve- 
ment in the general condition. 
“Daily stomach washing and strict dieting failed to give more than 
temporary relief, the waves reappeared in the right upper quadrant, the tem- 
perature remained subnormal and the whole appearance of the child became 
distinctly worse. It was quite apparent that the pylorus had opened up. 
Since the improvement had been so marked for the first four weeks follow- 260 
GASTRO-ENTEROPTOSIS 
ing temporary closure of the pylorus, complete division of this structure 
seemed to be indicated, and accordingly this was done on December 19. At 
this operation it was found that the ligature had cut partially through, and 
that there was free communication between the stomach and duodenum. The 
child did well for the first forty-eight hours following the second operation, 
then began to complain of pain in the epigastric region and at the same time 
a slowly forming mass could be felt in the right upper quadrant. This mass 
increased so that on the fourth day it occupied the entire right side of the 
abdomen. Temperature rose to 104°, and it was thought that peritonitis 
had developed. The distention in the right side was undoubtedly due to 
the fact that fluids and gas were accumulating in the duodenum via the gas- 
tro-enterostomy opening, and it did not seem possible that the suture line 
could stand so great a strain. However, on the fifth day, after repeated 
enemata, gastric lavage and the use of pituitrin, the bowels began to move 
freely, large quantities of gas passed and the distention along with the mass 
disappeared. Convalescence from this time, though slow, was without inci- 
dent. Discharged January 8, 1916. 
“For the first few weeks after returning home, weight remained at a 
standstill, but more recently has begun to gain. Bowels move regularly, 
appetite good, and no return of vomiting attacks. Has had no distention 
nor have peristaltic waves been observed since he was discharged from the 
hospital.” 
Downes comments on the fact that the patient was entirely relieved after 
the first operation until the ligature encircling the pylorus cut through and 
after the second operation was relieved entirely after the cutting off of the 
pylorus. He assumes that there was sufficient opening to permit of the bile 
and pancreatic juice going down through the obstruction. 
Downes in his closing remarks says, 
“I believe that duodenojejunostomy best meets the indications in the giant 
type of duodenal dilatation, and should have been adopted in the case here- 
with reported.” 
F. G. Dubose12 makes the following report of the case of a very young 
infant: 
“A search of literature finds no recorded case of giant duodenum in an 
infant. The symptoms in the case reported began when the child was 3 days 
old, persisting until the eighth week of its life when it was first seen by me, 
The condition was diagnosed from the physical and X-ray examinations. 
Downes, of New York, reports a case in a child four and one half years old. 
“The clinical course in the infant is similar to pyloric stenosis in its sub- 
jective expression, and in its effect in producing rapid emaciation. The dif- 
ferential diagnosis is made by the appearance of bile in the vomitus and in 
12 Surg., Gynec. and Obst., 1919, 29:278. DUODENAL ARTERIOMESENTERIC ILEUS 
261 
the absence of a palpable pyloric tumor. In the case here reported, there 
was a rapid loss of weight, vomiting occurring at irregular intervals without 
definite relation to food or fluid intake, and after nursing the regurgitated 
milk returning bile stained, and the subsequent vomitus containing bile and 
duodenal fluid, in larger amounts than fluids ingested. Through the thin 
and emaciated abdominal walls of the infant, as in pyloric stenosis, the vis- 
ible coils of intestines and peristaltic waves were easily observed. Imme- 
diately after nursing and before the onset of vomiting, the distended stomach 
and duodenum could be seen in the epigastrium. The roentgenograms demon- 
strated the abnormal condition with unusual accuracy and clearness of defi- 
nition. 
“Normal delivery, fourth child, of healthy parentage. Weight at birth 
seven and one half pounds. She began vomiting yellow fluid the third day. 
At this time the child was being nursed at two-hour intervals. The interval 
of nursing was lengthened to four hours without effect. Nursing with the 
head down and body elevated was tried, but the vomiting continued. Vari- 
ous medicines were prescribed by the attending physician without benefit. 
“When first examined by me, November 23, 1918, the child weighed 
five and one half pounds, showing a loss of two pounds in two months. She 
was apathetic, took no notice of people or things, never cried. Her eyes 
had the Mongolian slant. The tongue was larger than normal and slightly 
protruding. All of these findings and the facial expression were suggestive 
of cretinism. Vomiting occurred at irregular intervals, either bile-stained 
milk or duodenal fluid. She was fed a barium meal with a teaspoon, begin- 
ning at 11:20 A.M., under such difficulties that it required forty-five minutes 
to feed two ounces. 
“At 12:05 P M., November 23, 1918, the first X-ray plate was taken, 
showing a filled stomach, a narrow pylorus, an enormous ovoid duodenum, 
and some barium in the intestines. Ten minutes later shows the stomach 
smaller and the duodenum larger with a distinct pylorus. At 12:30 the 
stomach was almost empty, only a small portion of the barium meal remain- 
ing at the cardiac extremity. Fifteen minutes later the stomach was com- 
pletely empty and the duodenum filled. Some retching occurred but 
no vomiting in the next fifteen-minute interval, and taken at 1 :oo P.M., 
showed the stomach beginning to refill by regurgitation from the duodenum. 
Three hours and fifteen minutes were required, as shown 'in Fig. 174, for 
the duodenum completely to empty itself into the stomach, which is here 
shown refilled and distended with the barium meal. 
“The globular appearance of the duodenum in the X-ray plates would 
justify the opinion that there was possibly a diverticulum of the duodenum. 
The partial occlusion of the duodenum as it appears in the roentgenographs 
seems to be not the duodenojejunal junction, but cephaled to it in the fourth 
portion of the duodenum. Operation was advised as the only possible and 
as a very barely possible means of saving the infant’s life. The roentgeno- 
grams demonstrated the fact that the obstruction was partial, that it was 
caudad to the bile and pancreatic ducts. The duration of eight weeks with 262 
GASTRO-ENTEROPTOSIS 
a loss of two pounds in body weight was additional confirmation of partial 
obstruction. These facts made the operator prefer doing a gastro-enteros- 
tomy with occlusion of the pylorus as a surgical procedure in this case rather 
than a duodenojejunostomy, which is without question the operation of 
choice in complete arteriomesenteric obstruction at the duodenojejunal junc- 
tion. On November 28, 1918, under ether anesthesia through a median upper 
abdominal incision, a posterior gastro-enterostomy was done. The pylorus 
was tied off with a purse-string suture of linen and the gastroduodenal serosa 
approximated over this with interrupted Lembert sutures. The time con- 
sumed in operation was thirty-five minutes. It was observed on opening the 
abdomen that the duodenum was of enormous size, dilated and flaccid. There 
was neither diverticulum, constriction, adhesive band, or kink of the duo- 
denum, but the jejunum was collapsed beyond its origin at the mesentery, 
having an appearance such as is found in mechanical obstruction of the 
intestines caudad to the point of obstruction. It is probable that in this case 
we have a true arteriomesenteric obstruction at the duodenojejunal flexure 
from the superior mesenteric artery overlying it, or from some abnormality 
in the structure of the mesentery, with a resulting kink at the duodeno- 
jejunal junction, and that the megaduodenum was a sequence of this rather 
than a congenital giant duodenum. The postoperative convalescence was 
uninterrupted, with immediate cessation of periodic and persisting vomiting.” CHAPTER XV 
INTESTINAL STASIS AND RADICAL SURGERY 
My admiration of Sir W. Arbuthnot Lane for his vision, accurate obser- 
vation and courage to promulgate his conviction is unbounded. I believe his 
proclaiming the evils of intestinal poisoning has been and will be of untold 
value to humankind. Yet, by the most careful observation and study of my 
clinical experience, I have been unable to see any convincing proof that such 
diseases as cancer of the breast, tuberculosis, ulcer and cancer of the stomach 
are directly caused by bacterial absorption from the alimentary canal. I 
believe that the harmful effects of stasis are chemical more than bacterial, 
that the chemical agents absorbed into the blood from the stagnant contents 
of the bowel have an indirect bearing on disease by lowering the oxygen 
carrying powers of the blood and otherwise poisoning the vital centers and 
body tissues, thereby lowering resistance to direct infection. 
Importance of the Large Bowel.—Radical surgery, by which the 
large bowel has been removed, or completely excluded by ileostomy for one 
purpose or another, has given us positive, definite and final proof that the 
large bowel is not one of the vital necessities of mankind. It is not essential 
to the life of the carnivorous animals; it is essential to the life of the 
herbivorous animal. 
An ileostomy wound discharges its contents during a large part of the 
day, and would greatly handicap its possessor, without a reservoir to hold 
the discharge until a convenient time for its disposal. A colostomy wound 
at any point from the distal one third of the transverse colon discharges its 
contents intermittently from one to three times in twenty-four hours. In 
the one instance, the discharge is liquid and almost constant; in the other 
the discharge is by mass movement. In the one instance the discharge is 
practically odorless; in the other it has an offensive odor. This is due to the 
fact that the contents of the gastro-intestinal tract, from the stomach to the 
ileocecal valve, is practically sterile of bacteria in a normal individual. Nearly 
all of the ingested bacteria are destroyed in the stomach. Bacteria are even 
very scarce at the terminal ileum but very prolific in the cecum. 
In carnivorous animals, the entire large intestine may be emptied by the 
stimulation of the sacrovisceral nerves; in herbivorous animals, stimulation 
only empties the distal half of the large intestine and has no influence on 
the cecum. 
The large intestine of a purely herbivorous animal may possibly have an 
important digestive function. In man, the digestive function of the large 
263 264 
GASTRO-ENTEROPTOSIS 
intestine is negligible. Bacterial activity in the cecum is very great. Bacteria 
in man seem to act more in the capacity of scavengers and the cecum may 
be likened to a septic tank when functioning properly or a garbage can 
when not functioning properly. While it is said the cecum absorbs from 
50 to 80 per cent of the intake of water, this is by no means an essential 
function as shown by the fact that the discharge from an ileostomy opening 
rapidly becomes more concentrated and in the course of a few weeks or 
months, the small intestine takes up the function of absorption of all the 
normal water intake. The bacterial growth in the cecum seems to be largely 
for the decomposition and conversion of vegetable matter into harmless sub- 
stances so that the residue which is retained in the large intestine until a con- 
venient time for evacuation will do no harm. It is probable that the 50 to 
80 per cent of water normally absorbed in the cecum is brought there for 
the purpose of aiding bacterial life during this decomposition. After it has 
served its purpose in this capacity, it is absorbed for use of the body. Fluid 
injected into the rectum is chiefly carried to the cecum for absorption. After 
removal of the large intestine down to the pelvic colon, the ileum, in the 
course of a few months, takes up the function of the cecum to such an extent 
that it is frequently found that a patient who was constipated before is very 
likely to become constipated after removal of the colon. 
It will therefore be seen that the essential function of the large intestine 
is one of convenience rather than necessity, but that this convenience is very 
great and it is probable that an individual without a colon and without an 
ileocecal valve is by no means as well off as one who has a colon and an ileo- 
cecal valve. The importance of the ileocecal valve may be expressed by stat- 
ing that the ileocecal valve is an effective self-closing gate placed at the thresh- 
old of the true digestive apparatus to protect it against emanations from 
the septic tank or garbage can of the human body. This gate performs its 
function perfectly in 80 per cent of individuals, most of the 20 per cent of 
imperfect functioning being found in patients with habitual constipation or 
cecal stasis resulting from ptosis. 
In considering the advisability of the removal of the colon, we must 
also take into consideration the fact that the removal of a colon is not a simple 
matter when considered from the standpoint of mortality or morbidity, the 
former ranging from five to twenty per cent, depending on the skill of the 
operator, the latter being equally as serious, for a very large per cent of such 
cases subsequently have intestinal obstruction or painful adhesions. There- 
fore, after taking into consideration the mortality, morbidity, pain, expense 
and inconvenience of the operation, added to the handicap of the absence of 
an ileocecal valve and a function certainly not as good as that of the original 
colon, even if it were possible to remove all these handicaps, it seems unwise 
even to consider such a radical operation except in the most extreme cases 
for very special indications. I believe that radical surgery for intestinal 
stasis, which involves the removal or exclusion of the large bowel, has been 
more important from the standpoint of teaching physiology and pathology 
than for the establishment of an enduring therapy. However, it is undoubt- INTESTINAL STASIS AND RADICAL SURGERY 
265 
edly true that rare and exceptional cases will occasionally arise which demand 
some form of radical surgery for intestinal stasis. 
It is entirely possible and indeed quite probable, if we are to believe reports 
emanating from the New Jersey State Hospital for the treatment of insane, 
that there are certain cases of epileptiform attacks which may be traced 
directly to intestinal stasis, also certain forms of insanity. 
The radical views of Reed of Cincinnati, and what most surgeons believe 
to be his extravagant1 claims as to results following intestinal operations 
for epilepsy, have caused many conservative surgeons to go to the other 
extreme and refuse entirely to investigate the subject. It is probably true 
nevertheless that a certain per cent of seeming epileptics and insane patients 
may be-eured by this measure. 
Lane’s undoubted cures of what appears to have been Raynaud’s disease 
and of Still’s disease and other serious joint involvements and even very 
serious toxemia without local manifestations by removal or short-circuiting 
of the colon must in the minds of fair-minded surgeons require investigation 
at least. 
In these serious conditions in which, upon careful investigation, the 
physician or surgeon is convinced that there is a direct relation between 
obstinate constipation and the otherwise incurable malady which confronts 
him, it becomes his duty, as a conscientious physician acting in the interest 
of his patient, to take what seems to be very radical steps rather than permit 
the patient to remain in this distressing and hopeless condition. Fortunately, 
the late Dr. John Young Brown of St. Louis suggested a means of 
determining this without going to extremes. This is determined by producing 
a temporary ileostomy. Since Brown’s popularization of this operation, many 
hundreds of fistulae of this kind have determined that patients may live in 
perfect health with such a fistula. The making of such a fistula, combined 
with irrigation and medication of the excluded colon, should be a perfect 
test as to the responsibility of the colon for the production of these conditions. 
If the manifestation persists after the complete elimination of the colon as a 
functioning organ, it would be the height of folly to subject a patient to the 
dangers and added discomfort of a radical intestinal operation. 
I have used a technic for performing an ileostomy which may easily be 
performed under local anesthesia. Also a technic for closing such a fistula 
without the necessity of opening the abdominal cavity a second time in case 
the ileostomy proves that the colon is not at fault. The ileostomy is made 
and closed as follows: 
A wound about an inch and a half long is made down through the middle 
of the right rectus muscle about one inch and a half below and two inches 
to the right of the umbilicus. The cecum is located, a loop of ileum is brought 
up about twelve inches from the ileocecal valve, and the two limbs of the loop 
are sutured together by two lines of sutures, one along their mesenteric borders 
1 The word “extravagant” is used advisedly with no reflection on Dr. Reed’s veracity 
but rather to raise the question of the meaning of the word “cure.” It has been said 
that any type of operation on any part of the body will cure a certain percentage of 
epileptics temporarily. 266 
GASTRO-ENTEROPTOSIS 
and one along their free borders (Fig. 175). The loop is placed in the wound, 
protruding the desired distance, a fine chromic catgut suture is threaded into 
a small curved needle and is used double as a continuous button-hole suture, 
by which the peritoneum is fastened around the protruding loop. A similar 
suture is passed around the loop fastening it to the aponeurosis. Interrupted 
sutures threaded in a small cutting needle fasten the intestine to the skin 
(Fig. 176). The gas and fecal contents pass easily around this loop, so that 
it is not necessary to open it until convenient (Fig. 177). The opening is 
then made with a cautery, and a Delatour colostomy outfit (Fig. 178) used 
as a receptacle. I cannot recommend this device too highly. It has not failed 
in any instance to hold, so that such a thing as spilling and soiling the clothing 
Fig. 175.—Suturing Together the Free Edges of the Intestinal Loop. 
is unknown while the patient is standing. I have a number of such patients 
performing all of their duties and going to social functions as usual with no 
discomfort. The apparatus does not work so well when the patient is lying. 
After the test as to the toxemia in question has been completed and it 
has been determined that the intestine is not at fault, it is a very easy matter 
to close the opening without opening the peritoneal cavity. This operation 
is done as follows: 
A long, thin-bladed clamp is passed down into the two limbs of the loop, 
as in the Mikulicz operation (Fig. 179)- In a few days, by gradually 
increasing the pressure, the two limbs are cut together. With a cautery the 
mucous membrane and intestine protruding through the abdominal wall is 
destroyed down well into the wall, practically to where it leaves the peri- 
toneum (Fig. 180). This operation is somewhat painful, and produces a 
degree of nausea on account of burning the mesentery. Fig. 176.—Fixation of the Intestinal Loop of Peritoneum, Aponeurosis and Skin bt 
Chromic Catgut Doubled. 
Note peritoneal suture, aponeurotic suture and skin suture. 
Fig. i 77.—Sectional View of the Fixed Loop. 
This shows the passage of the intestinal contents through the loop. Fig. 178.—Delatour Colostomy Bag. (Tiemann and Company of New York.) 
Fig. 179.—Gradual Destruction of the Septum between Two Limbs of Loop with 
Rubber-covered Clamp. INTESTINAL STASIS AND RADICAL SURGERY 
269 
The patient is again allowed to be up, and again wears the Delatour bag, 
until the sloughing has taken place. In the meantime it is found that the 
Fig. 180.—Destruction of the Intestinal Mucous Membrane Which Passes through 
the Intestinal Wall, by Use of the Cautery. 
intestinal contents are passing on into the large intestine, and it is gradually 
becoming accustomed to work again. 
As soon as the wound has healed in well (Fig. 181), the fistula is closed 
as follows: 
Fig. 181.—Intestinal Fistula after the Cauterized Area Has Healed. 
i. Dissect out the old scar down to the fat, and make an incision around 
the fistulous tract, including a small strip of skin (Fig. 182), direct the point 
of the knife slightly away from the fistula so that it first comes in contact 
with the fascia about half an inch away from the fistula, in order to avoid any 270 
GASTRO-ENTEROPTOSIS 
possibility of opening the peritoneum. The incision should extend two inches 
or more above and below the fistula to allow for wide dissection. 
2. Dissect up the fat from the fascia for as much as two inches from the 
incision, draw it back, and clean off the fascia. 
3. Make an incision through the fascia, beginning at the upper end of the 
wound and coming toward the fistula. Dissect the fascia from the muscle 
for at least two inches in every direction. 
4. Dissect the muscle from the peritoneum in the same manner so that 
the peritoneum hangs loosely with the fistula standing up in its center, like 
a volcano and its crater. 
Fig. 182.—Incision for Freeing the Fistula from the Abdominal Wall and Separating 
the Layers of the Abdominal Wall. 
5. The little margin of skin which has been left with the edge of the 
fistula is now trimmed off (Figs. 183, 184). 
6. If the wall of the fistula is hard and cicatricial, making it difficult to 
turn it in, it is well to make an incision part of the way through the cicatrical 
tissue so that it may be turned in easily. 
7. The edges of the intestine are turned in with linen sutures which are 
knotted on the inside (Fig. 185). 
8. A second layer of sutures brings the edges of this incision and the 
connective tissue over the peritoneum along with the scar tissue, covering 
the turned-in fistula, to add temporary strength and bulk to the closure. The INTESTINAL STASIS AND RADICAL SURGERY 
271 
peritoneum and the rest of the wound is now thoroughly mopped or irrigated 
with salt solution to make it as clean as possible. 
Fig. 183.—Fistula Freed, and Layers of the Abdominal Wall Separated Ready for 
Closing. 
Direct view. 
9. Silkworm sutures are passed through the skin, fat, fascia, and muscle 
about a half inch or more from the edge, and are left untied, space being 
left at the upper end of the wound for drainage. 
Fig. 184.—Sectional View of the Fistula Freed, and the Layers of Abdominal Wall 
Separated Ready for Closing. 
Sagittal section. 
10. Suture the muscle loosely with a continuous catgut. 
11. Suture the aponeurosis with a strong double catgut. Fig. 185.—Closure of the Intestinal Fistula. 
Fig. i86.—Closure of the Abdominal Wall. 
This shows the closed fistula in the bottom of the wound and drainage tubes at the ends. INTESTINAL STASIS AND RADICAL SURGERY 
273 
12. Suture the skin with a horsehair buttonhole stitch. 
13. Place the drains, which may be tubes or cigarette drains, at each end 
of the wound (Figs. 186, 187, 188). 
Fig. 187.—Cross-section Showing How All the Lines of Sutures Are Enclosed in the 
Silkworm Sutures. 
These obliterate spaces and allow drainage to either side between the layers. 
We have never failed to close a fistula of either the large or the small 
intestine by this means when no obstruction existed below. 
By this stage-operation, we make of John Young Brown’s ileostomy an 
operation practically devoid of danger. 
Fig. i 88.—Longitudinal Section of the Completed Operation. 
This shows how the spaces drain around the ends of the tubes. 
In case the fistula relieves all the symptoms, it is still a question as to 
whether the patient should be subjected to the danger and morbidity which 
follows a complete colectomy. It seems that conservatism and the best 
interests of the patient would suggest that still another conservative step 
should be taken before going to this extreme. This step was suggested, or at 
least popularized, by Ochsner. It consists in severing the sigmoid and con- 274 
GASTRO-ENTEROPTOSIS 
necting the ileum with the distal segment of the pelvic colon while the proximal 
segment is brought out through the left rectus muscle. This leaves the patient 
with two mucous fistulae, but neither is uncomfortable nor seriously inconven- 
ient. I think the study of colectomized patients will show that they have 
suffered more discomfort than the patients who have the two mucous fistulae. 
On the other hand, there may be some cases in which the patient would 
prefer to take the extra chance of mortality and morbidity and be entirely 
rid of the fistulae. In such a case, Lane’s2 technic is probably the best. 
“Colectomy.—In this operation the surgeon’s chief object is to sep- 
arate the evolutionary adhesions from the mesentery in the first instance. If 
Fig. 189.—Diagram Showing the Method of Ligaturing the Mesentery of the Large 
Bowel. (Lane.) 
this is done carefully, the outer peritoneal aspects of the mesenteries are 
left smooth and intact. By doing this, not only is the removal of the bowel 
greatly facilitated, but little or none of the mesentery is denuded of its peri- 
toneal covering, so that the risk of adhesion to loops of the small intestine 
is reduced in a manner corresponding to the care that is taken. 
“In ligaturing the vessels, the inclusion of large masses of mesentery 
should be avoided, and subsequently all ligatured points should be rendered 
as inconspicuous as possible (Fig. 189). It is well to remember that one of 
the chief immediate risks of the operation is hemorrhage, which may result 
either from the escape of a vessel from the ligature in a fat subject, or from 
the friability of the ligatured vessels in a thin toxic one. 
3 Brit. Journ. Surg., 2:599. INTESTINAL STASIS AND RADICAL SURGERY 
275 
“If the surgeon is unfamiliar with the mode of development and attach- 
ments of the evolutionary bands, much difficulty may occasionally be experi- 
enced in the removal of the splenic flexure, where these bands are highly 
developed. This difficulty is probably responsible for the partial resections 
which are performed by some surgeons, who are satisfied to remove the bowel 
up to the middle of the transverse colon. I experienced the same difficulty 
many years ago, and very soon found the futility of this method, since the 
obstruction afforded by the splenic flexure and last kink militated greatly 
against the success of the operation. By separating the acquired from the 
Fig. 190.—Diagram Showing How the Ileum is Grasped between Two Pairs of Forceps 
Preparatory to Division. (Lane.) 
This is done usually by a cautery. 
normal mesenteries, the splenic flexure can be dealt with with great ease and 
at no risk. 
“In colectomy the ileum is divided as in ileocolostomy, usually within a 
few inches of its termination; but should there be much tuberculous ulceration 
of the ileum, or adhesion binding it down and obstructing it, more or less 
of the length of this bowel can be removed with safety (Fig. 190). The 
surgeon should remember that, while only a small proportion of the length 
of the small intestine is required for health, the longer the small bowel the 
greater is the increase in weight of the patient which results from the opera- 
tion of colectomy. When the patient is stout, the reduction in bulk and the 276 
GASTRO-ENTEROPTOSIS 
increase in activity which result from a shortening of the small intestine are 
a material advantage to the patient. 
“The pelvic colon is drawn up out of the pelvis, and grasped with two 
pairs of forceps about an inch and a half to two inches above the level of the 
pelvic brim, so affording a sufficient length of pelvic colon to which the end 
of the ileum can be securely attached (Fig. 191). 
“The end of the ileum is attached directly to the cut end of the pelvic 
colon. The innermost row of sutures perforates all the coats of the bowel, 
and is of the buttonhole type, while the outer rows secure the peritoneal and 
Fig. 191.—The Pelvis Colon Drawn Up Out of the Pelvis and Grasped by Forceps for 
Division in a Similar Way to Fig. 190. (Lane.) 
muscular coats in their grip and do not perforate the lumen of the bowel. It 
may be most convenient to secure the adjacent aspects of the ileum and colon 
by a running suture securing the peritoneal and muscular coats (Fig. 192). 
Then the apertures of the colon and ileum are held apart by means of clip 
forceps (Fig. 193). The adjacent margins of ileum and colon are sutured 
by means of a buttonhole suture (Fig. 194), after which the remainder of 
the circumference is closed (Fig. 195). Fig. 196 indicates the mode of 
insertion of the continuous seromuscular suture. 
“Some difficulty may occasionally be met in effecting the junction because 
of the difference in caliber of the two portions of bowel; but this can readily 
be met by arranging the sutures so that each picks up a correspondingly 
greater portion of the circumference of the pelvic colon than of the ileum. Fig. 192.—The Running Suture Securing the Peritoneal and Muscular Coats. (Lane.) 
Fig. 193.—The Apertures of the Ileum and Colon Held Apart by Forceps. (Lane.) Fig. 194.—Suture Joining the Adjacent Margins of Ileum and Colon. (Lane.) 
Fig. 195.—Completion of the Suture of the Bowel. (Lane.) INTESTINAL STASIS AND RADICAL SURGERY 
279 
Much fat in the peritoneal coat is another obstacle to the formation of a per- 
fectly secure junction, but most of this can be removed before the anastomosis 
is attempted. Again, a thickening of the walls of the colon and a reduction 
of its lumen by inflammatory changes which commence in the mucous mem- 
brane may render this operation difficult. None of these obstacles are 
insuperable, and by the exercise of a reasonable amount of skill and patience 
a perfectly safe junction can invariable be effected. 
“After this anastomosis has been rendered complete, the cut edges of the 
mesentery of the ileum and of the pelvic colon are sutured together, care 
being taken to leave no raw surface either on the upper or lower aspect of 
the junction. Fig. 197 shows the manner in which this closure is effected. 
An esophageal tube is introduced through the rectum and ileocolic junction, 
Fig. 196.—Method of Inserting the Continuous Seromuscular Suture. (Lane.) 
as described in the operation of ileocolostomy without resection of the large 
intestine. 
“I have not always employed this method of end-to-end anastomosis. 
In my earlier cases I made use of the method of lateral anastomosis, which 
was then most generally favored by surgeons. The cut ends of the ileum 
and pelvic colon were closed, and a large aperture of communication was 
established between the adjacent aspects of the small and large bowel. The 
objection to this method was that, however securely the ends of these por- 
tions of intestine were fastened down, they both dilated and formed sacs, 
that which projected from the ileum being considerably larger than that from 
the pelvic colon. This was not limited to my junctions, since I found that 
the same occurred in patients of surgeons who, as I knew, were very skillful 
operators. The accumulation of fecal material, in the ileal culdesac 280 
GASTRO-E NTEROPTOSIS 
especially, soon becomes a source of great discomfort, and calls for treatment. 
For a long period I employed an end-to-side anastomosis, closing the pelvic 
colon and introducing the end of the ileum into an aperture in its side. This 
was generally very effective. I occasionally came across cases in which 
obstruction occurred at the junction on the removal of the tube. This obstruc- 
tion did not always take place at once, but perhaps after a considerable inter- 
val; and again, it was not always persistent, but frequently intermittent. It 
seemed to me that this control of the ileal effluent resulted from some twisting 
Fig. 197.—Final Suture of the Mesentery. (Lane.) 
of the bowel at the junction, and in order to obviate its occurrence I employed 
the end-to-end method. The last has afforded me complete satisfaction, and 
has freed me from the anxiety associated with the end-to-side junction.” 
Ileocolostomy.—I have not mentioned ileocolostomy as a diagnostic 
measure for two reasons. First, it is much more dangerous than ileostomy; 
second, owing to the tendency of return of fecal contents to the cecum in 
these constipated patients, it would not be a fair diagnostic test in that it would 
not determine the relation between a given disease and the colon. 
As a therapeutic measure for intestinal stasis, I feel that ileocolostomy INTESTINAL STASIS AND RADICAL SURGERY 
281 
is not a good operation. It has been tried extensively and, in the hands of 
most operators, it has not been a success. A patient is usually benefited for 
a few months, gradually reverse peristalsis takes place, returning the feces into 
the cecum. In addition to this, the absence of the ileocecal valve causes the 
ileum to take up the function of the cecum with a return of the intestinal 
stasis. 
J. Rilus Eastman and others at one time advocated cecosigmoidostomy 
with the idea that the ileocecal valve would thus be saved. This was not 
successful for the reason that a vicious circle was established and the feces 
would make a circle around the large 
intestine following the direction of 
normal peristalis. 
This was exemplified by a case 
which came to me for treatment 
more than seven years ago. Three 
years before coming to me, the pa- 
tient had been subjected to the 
operation of cecosigmoidostomy for 
constipation. She had not been im- 
proved by the operation. X-ray 
showed there was a perfect circle 
and no evidence of obstruction. The 
patient, however, was suffering from 
a decided intestinal toxemia. I 
turned her over to Dr. Sears for 
medical treatment. He treated her 
for several months but could never 
make much headway. Finally he 
returned her to me for a surgical 
operation of some kind. X-ray pic- 
tures seemed to indicate that the 
fecal contents would come down through the ileocecal valve, around through 
the ascending, transverse and descending colon into the sigmoid from the 
sigmoid back into the cecum, and thus a vicious circle was formed (Fig. 198). 
I opened the abdomen, not knowing just what operation would be done. 
It was found that the ascending colon was very much dilated as was also the 
anastomotic opening and neighboring sigmoid. I then decided to remove 
the ascending colon and the first half of the transverse colon. With a purse- 
string we turned in the distal end of the transverse colon and turned in the 
cut end of the ascending colon, leaving practically no ascending colon above 
the ileocecal valve (Fig. 199). 
This was the first time we supplemented a cecosigmoidostomy with 
removal of the ascending and part of the transverse colon. This operation 
was done more than six years ago and the patient has been entirely well since. 
It is quite probable that, if other patients who have had cecosigmoidostomy 
performed upon them could have this operation performed, they would be 
Fig. 198.—Vicious Circle Following Cecosig- 
moidostomy for Constipation. 282 
GASTRO-ENTEROPTOSIS 
cured or very greatly improved. It occurs to me that if any radical operation 
is absolutely required for intestinal stasis, cecosigmoidostomy with the 
removal of the ascending and first half of the transverse colon should be the 
Fig. 199.—Correction of Vicious Circle by Removal of the Ascending and Transverse 
Colon. 
operation of choice. The operation is easy, the ileocecal valve is preserved, 
and in the two cases of mine, at least, the operation has been a complete 
success. CHAPTER XVI 
MEDICAL TREATMENT OF PTOSIS 
Ptosis is a perverted anatomical condition and not a disease. Medical 
treatment of ptosis is a paradox in that no medicine is used. 
Concurrent and sequential diseases, such as disorders of metabolism or 
renal function, myocardial changes or vascular diseases, psychoses or 
psychasthenic states, we must leave to the trained internist. 
Our problem as surgeons in the treatment of ptosis per se is to supply 
physical and mechanical materials and agents to compensate for the con- 
genital defects and sequential changes. The foremost material or agent in 
this connection is fat. 
The Role of Fat.—Fat is nature’s padding or filler. In youth, it is 
used near the surface to fill out irregularities and to produce symmetry and 
beauty. In late middle life along with deficient exercise and oxidation comes 
the deposit of excess of fat, which stretches the skin and connective tissues. 
With later life comes absorption of fat along with the degeneration of other 
tissues, and the overstretched skin and connective tissue of middle life falls 
in wrinkles and produces the picture of the aged. Likewise, in the abdomen 
of the young healthy child or adult, all the space not needed for perfectly 
functioning digestive and eliminative organs is occupied by fat. This fat 
is deposited under low pressure in the loose extraperitoneal connective tissue. 
It thereby produces that degree of intra-abdominal pressure which nature 
deems normal and at the same time makes tense and shortens the extraperi- 
toneal connective tissue meshes. As a consequence, the mesenteries are 
thickened and shortened. 
With the excess fat of middle life, there is an increase of intra-abdominal 
fat. This latter increase is to a large extent held in abeyance by the strength 
of the abdominal wall, and is therefore not in proportion to the increase of 
extra-abdominal fat. It is possible that, in certain instances, this increase 
of intra-abdominal fat may to an extent increase intra-abdominal pressure, 
but it seems more likely that most of the increase of intra-abdominal fat is 
compensated by a decrease of the lumina of the hollow viscera. 
In case of rapid and extensive loss of flesh, there is a diminution of intra- 
abdominal fat (although probably not in proportion to the loss of extra- 
abdominal fat). Intra-abdominal pressure is correspondingly lowered until 
the lumina of the hollow viscera have increased sufficiently to occupy the 
extra space and to establish a pressure equilibrium. Great loss of intra- 
abdominal fat and a corresponding reduction of intra-abdominal pressure is 
283 GASTRO-ENTEROPTOSIS 
284 
often followed by such a stretching of the elastic visceral walls by gas that 
the power of the muscular walls becomes seriously impaired, the fibers 
stretched and thinned and peristalsis diminished. Digestion and elimination 
is correspondingly impaired. The gastro-intestinal tract is said to be in an 
atonic condition and a general toxemia ensues with dilatation and stagnation 
of fluids in the organs and ducts emptying into the gastro-intestinal tract. 
At the same time, the mesenteries are thinned and elongated while the psoas 
outlet is enlarged, which results in the organs occupying a lowered position 
conducive to angulation and stagnation. In the past, the ills of these patients 
have been maltreated under the name of “neurasthenia.” In this connection, 
it is interesting to note that these ptotic, neurasthenic, irritable, under- 
nourished women are much healthier during pregnancy than at any other time. 
Also that during the childbearing period, healthy young women gradually 
increase in weight with each new baby. May it not be true that some of 
this increase in flesh is an effort of nature to compensate for the sudden 
reduction of intra-abdominal pressure after the uterus has been emptied? 
With this conception, fat becomes the sine qua non of the nonsurgical 
treatment of ptosis. 
Most of the details of medical treatment are included in the technic of the 
placing and distribution of fat. It is a curious fact that the first systematic 
and successful treatment of the ills of ptotic patients under the misnomer 
“neurasthenia” was devised and carried out nearly a half century ago by 
S. Weir Mitchell of Philadelphia who was probably the leading neurologist 
of his day. The principal feature of his treatment was bowel regulation, 
forced feeding and fattening, with the patient in the recumbent posture dur- 
ing the process. He laid great stress on keeping the patient in a quiet room 
without visitors. Being a neurologist, he believed that the nervous and 
neurasthenic manifestations indicated that the condition was a primary 
disease of the nervous system; that the good effects of the fat were due to 
the padding of the nerves with a cushion of fat. It is said of Weir Mitchell 
that much of his success in the treatment of nervous diseases was due to his 
overwhelming personality and his ability to control his patients by his per- 
sonality. 
In an experience with a large number of patients who have been treated 
by forced feeding, the importance of this quality has become very apparent. 
In the mild cases in which the digestive function has not been seriously 
altered and in which peristalsis and bowel action are normal, fattening is a 
very simple matter. By simple increase in the amount of cream, bread, butter, 
fats and carbohydrates generally, the patient with very little effort will put 
on fat rapidly, but in the cases which actually need the fat, the problem is far 
more complicated. These patients are already troubled with gas distention 
and deficient peristalsis with toxic stagnation of the secretions in the bowels 
as well as the organs and ducts emptying their secretions into the bowels. 
Furthermore, they have usually acquired an invalid habit which causes them 
to localize and identify every pain or distressing symptom. Such patients 
are usually constipated and believe (for they have been so instructed) that it MEDICAL TREATMENT OF PTOSIS 
285 
is absolutely essential for the bowels to act every day. They have therefore 
been taking all kinds of cathartics and nostrums of one kind or another. 
Such patients usually start out very glibly for a day or two. After they have 
gone two days or more without a bowel action and have been instructed that 
under no circumstances is a cathartic or enema to be administered, they 
usually become alarmed and distressed and from past experience conclude that 
the bowels will never act under such circumstances. The increase in quantity 
of food and decomposition gradually creates a very uncomfortable state, even 
after the bowels are acting normally. During the second week the patient 
often reaches that stage of discomfort at which relief seems imperative and 
cessation of food essential. If the patient is at home or among sympathetic 
friends or in a hospital with ordinary care, the patient will usually desist and 
finally give it up altogether as a hopeless undertaking. 
Great eloquence of persuasion and driving force of character combined 
with a knowledge and experience in dealing with this clags of patients becomes 
essential on the part of the attendant. A nurse possessing these qualities 
becomes a desideratum of prime importance. Such a nurse is rarely available 
except in an institution specially equipped and so these patients become essen- 
tially hospital patients. 
The steps in the process are (i) absolute rest in bed; (2) cessation of all 
cathartics or enemata; (3) regulation of the bowel by paraffin oil, agar 
and a large proportion of vegetables to furnish bulky food. 
Tn cases having inert torpid bowels, bran and buttermilk have a good 
effect. It may be administered as follows: A heaping tablespoonful of bran 
is placed in a dish, boiling water is poured over it and poured off immediately. 
It is then eaten with eight or ten ounces of buttermilk. 
In those cases having an irritable or painful bowel, bran and coarse 
vegetables of all kinds are contra-indicated. In these cases. vegetables are 
pureed. 
In addition to regulation of the bowel, the next essential is the persistent 
use of the hot pack which is applied immediately after meals as follows: 
Articles necessary: 
1 ordinary towel. 
1 bath towel. 
1 hot water bag (rubber). 
1 piece of oiled silk a little larger than surface of water bag. 
2 thicknesses of gauze size of oiled silk. 
Apply gauze over abdomen, oiled silk over gauze, then a hot moist towel 
folded (four thicknesses) ; next on top of which place a very hot water bag 
and cover with bath towel. 
It is usually necessary to apply the heat sufficient to produce irritation to 
the point just preceding blister and the heat should be applied for one or two 
hours after each meal. 
It is very essential to keep count of the calories taken for, aside from the 
scientific importance of this, it is necessary to have a record of the calories 286 
GASTRO-ENTEROPTOSIS 
for use in the argument with the patient setting forth the necessity for eating 
more. Each patient is a separate problem in the line of diet and much 
ingenuity and diplomatic skill is often necessary to keep a patient going on a 
diet sufficiently rich in calories to produce the required amount of fat. Gen- 
erally speaking, such articles of diet as milk, cream, eggs (used cautiously), 
cereals, bread, potatoes and a great variety of vegetables constitute the staples 
usually found most satisfactory in the production of fat. In addition to these, 
it will often be found necessary to apply a wide range in variety of enticing 
articles of food. 
At the end of about two weeks, it is well to have the patient get up and be 
weighed. After this, the amount of gain should be carefully noted and used 
as an argument with the patient. 
As the patient approaches the desired amount of fat, exercises are begun, 
most important of which is walking, which should begin with a short distance, 
gradually increasing as rapidly as possible without interfering with the 
increase in weight. In addition to walking, exercises for strengthening the 
abdominal wall and procuring a normal erect posture, such as related in 
Chapter XI by Dr. Martin. Under certain circumstances, exercises should 
be supplemented by massage. This, however, usually is not necessary. These 
exercises not only develop the muscles of the abdominal wall and body gen- 
erally, but they fix and solidify the fat. It is often very difficult to get these 
patients to retain the fat unless it has been fixed before they leave the dis- 
ciplinary care of the hospital. 
This, in general, is a successful technic. As before stated, however, there 
are many cases which do not respond to this routine treatment. One of these 
is the narrowed upper abdomen with slanting ribs and narrowed chest which 
goes with long-standing ptosis. In many of these cases, it is necessary to 
change the shape of the entire abdomen. We have stated the method of doing 
this in another chapter by surgical means, expanding the upper abdomen and 
contracting the lower. This is rarely necessary unless there are other reasons 
for doing surgical work. The upper abdomen can be very largely expanded 
by postural treatment. 
In addition to those procedures mentioned by Martin, very effective aids 
in expanding the upper abdomen are as follows: 
A roll under the middle of the back for a certain length of time during 
each day. 
The knee-chest position for an hour or more after each meal. 
Placing the patient’s head and chest on a pillow resting on the floor, while 
the thighs and hips remain on the bed. 
By combination of similar procedures, along with strengthening exercises 
for the lower abdomen, and postural exercises for the reestablishment of the 
normal psoas or kidney shelf, it is often possible to expand the upper abdo- 
men several inches. 
As before stated, there is another class of cases in which it is very impor- 
tant, in fact essential, that attention be paid to the physics of the abdominal 
cavity. I refer to duodenal arteriomesenteric ileus. In certain cases, it may Fig. 200A.—Roentgenogram Illustrating a Prolapsed, Dilated, Atonic Stomach. 
This is the case Of a young woman who had been a bed invalid for several months. Weight 
sixty-two pounds on admission. 
Fig. 200B.—Roentgenogram of Same Stomach Shown in Fig. 200A. (Courtesy of Dr. 
Sears, who directed the treatment.) 
This was taken two months after forced feeding had been completed and shows the small, 
tonic stomach with normal peristaltic waves. Patient restored to perfect health by forced 
feeding treatment. 288 
GASTRO-ENTEROPTOSIS 
be impossible for the patient to eat and digest the required amount of food; 
bilious vomiting may take place; great distress in the upper abdomen is noted 
after meals. When a condition of this kind arises, it is very important to 
determine whether this distress is due to traction on the superior mesenteric 
artery. By placing the patient in the knee-chest position, which is maintained 
by bending over a large roll in bed, or by the more extreme position of putting 
the patient’s head and chest on the floor, while the hips remain on the bed, 
a patient afflicted with this trouble is usually completely relieved, for it allows 
a mobile cecum or small intestine to fall out of the pelvis and release the 
traction on the mesenteric vessels, which in turn permits the duodenum to 
empty on time. In such a case, of course, it is evident that it is essential to 
keep the patient in this position as much of the day as is necessary to bring 
about perfect and comfortable digestion. This position in such cases supplies 
the double purpose of helping permanently to expand the abdomen and tem- 
porarily to permit the emptying of the duodenum. As the patient grows 
fatter in this condition, the mesenteries grow shorter, the psoas outlet, being 
naturally only one third the size of the abdomen four inches higher up, prob- 
ably narrows proportionately more rapidly and makes the psoas shelves 
broader. It is also probable that the retroperitoneal fat in the neighborhood 
of the crossing of the duodenum by the superior mesenteric artery may help 
to hold the artery forward and to solidify it in its position. At any rate these 
patients usually get relief. 
It is probable that fully 75 per cent of ptosis patients may be satisfactorily 
relieved and made fairly comfortable by this simple process of deposition of 
fat, application of postural treatment, exercises, bandages, etc., plus proper 
regulation of the bowel without cathartics. We have a great many cases that 
have been relieved and made perfectly comfortable by this means. The 
mechanism of the internal effects wrought by the treatment may be illustrated 
by X-ray pictures in Figs. 200A and 200B, which is only one illustration in a 
great many similar cases. Of the other 25 per cent, probably three fifths of 
the cases can be made very comfortable by a skilled internist. It is probable 
that about 10 per cent of the cases applying for treatment will require a 
surgical procedure in addition to these measures in order to give the patient 
the greatest degree of comfort. In the foregoing chapters, we have set forth 
the different surgical procedures which may be applied to meet the different 
indications arising. CHAPTER XVII 
GENERAL INDICATIONS FOR SURGICAL TREATMENT 
The most pertinent question a reader may ask concerning a book of this 
title appearing as one of a group of surgical monographs is, What are the 
indications for and what patients should receive surgical treatment? 
If it were possible by magic to eliminate operative mortality, postoperative 
morbidity and other inconveniences, I would unhesitatingly say the great ma- 
jority of cases should be operated upon. Unfortunately, this is not true. 
There is an operative mortality, although this is small. Besides the mortality, 
there are many inconveniences and discomforts connected with an operation 
of any kind involving the opening of the peritoneal cavity. 
To one holding Lane’s views, all of these patients would be better off 
without a colon, if the colon could be removed by magic without mortality or 
postoperative morbidity. I cannot subscribe to this belief, even if it were 
possible to produce an ileocecal valve by magic also. I cannot believe that any 
animal which has no fixed portions of its alimentary canal is at all fitted for 
the upright position. If we had no fixed portions of our intestinal canal to 
sustain the weight of the residue which must be retained for a considerable 
time at least, I have no doubt that our intestines would mass themselves in 
the bottom of the abdomen and that our abdomen would soon assume the 
shape of the kangaroo. I have no doubt that if a dog were compelled to stand 
on end for half the time, his intestines would soon mass in the bottom of his 
abdomen, the shape of his abdomen would change entirely and he would 
probably become unstable nervously and might be classed as a “neurasthenic.” 
I am sure that the large intestine is an important organ, although its function 
is largely, if not altogether, one of convenience. It is no doubt true that 
many individuals suffering from intestinal stasis would be better off without 
a colon if this could be brought about as we have stated, without mortality or 
morbidity. Unfortunately, this cannot be done. The mortality accompanying 
the removal of the colon is great. 
Draper in the September, 1922, issue of the American Journal of the 
Medical Sciences reports 77 cases of colectomy, 46 partial and 31 total, with 
a mortality of 12 per cent. I am very sure Draper’s mortality is not greater 
than the average mortality would be in the hands of good general surgeons. 
In Chappie’s report on the life-history of 50 short-circuited patients by 
Lane reprinted from the British Medical Journal, April, 1911, which probably 
represents as skillful work as it is possible to do in such cases, postoperative 
morbidity is very striking. From one to five subsequent operations have been 
289 290 
GASTRO-ENTEROPTOSIS 
performed on more than a third of these patients. We have all seen these 
patients after radical surgery has been performed for stasis, and the mor- 
bidity is even greater in the cases performed by other surgeons than these of 
Lane which have been reported by Chappie. Taking the mortality and mor- 
bidity connected with radical surgery, it is my belief that it is rarely justi- 
fiable, except in very extreme cases, even if there were no other surgical 
measures to which we might resort. On the other hand, I believe that all 
would agree that if it were possible to restore all of the abdominal organs 
to their normal position with normal fixation by magic, without postoperative 
mortality or morbidity, it should be done. Unfortunately, this is not true, 
but it is possible to restore these organs to normal position surgically with 
a very small mortality and practically no postoperative morbidity. 
The accompanying table includes the statistics of Rovsing, a group of 
Scandinavian surgeons, Waugh and myself. There are 827 cases reported 
with 18 deaths, a mortality of 2.2 per cent: 
( 
% 
15 
S 
<3 
3* 
Coffey 
Group of Scandinavian 
Surgeons (Reported 
by Rovsing) 
Rovsing 
to 
o 
00 
CO 
ON 
Co 
vO 
CO 
Os 
co 
Total 
Too Recent to Re- 
port Results 
vO 
+* 
o 
to 
Cured 
O' 
4> 
vO 
Cn 
to 
Cn 
O 
O' 
Per Cent 
Ov 
vo 
vO 
to 
Improved 
to 
CO 
o 
VO 
Ov 
Per Cent 
to 
o 
» 
00 
Fair 
6.68 
00 
« 
Per Cent 
" 
to 
No Improvement 
Co 
Os 
12.8 
Per Cent 
Cn 
No Report 
Per Cent 
to 
Cn 
CO 
00 
Died 
MD 
Ov 
Co 
00 
CO 
to 
4“ 
vb 
Per Cent 
It is probably true that each of the surgeons would have a good explana- 
tion for the death of these patients and might say that the deaths were not 
due to operation. This would be begging the question for it is quite probable 
that the patients would not have died at the time they did had it not been for 
the operation. In my own statistics, I have shown 363 cases in which some 
form of replacement or restorative operation has been performed. Of these, 
there were five deaths, mortality of 1.38 per cent. Of the total number, 293 
have been traced. Of the 293 traced, 194, 66.2 per cent, claimed to have 
been cured; 69, 23.6 per cent, have been very markedly improved, by which 
is meant that the patient still has some complaints which, although trouble- 
some, are not sufficient to require medical attention; 20, 6.8 per cent, have 
been somewhat improved but still have a great many troubles; 11, or 3.8 per 
cent, show no improvement. In no report has the patient complained of feel- 
ing worse than before the operation. In one instance, a patient died from an 
obstruction by a band four years after operation, but this band existed and 
was cut at the time of the first operation, which operation greatly relieved GENERAL INDICATIONS FOR SURGICAL TREATMENT 
291 
the patient for the intervening four years. I have heard of one other patient 
who has had symptoms of intestinal obstruction but who has not been 
operated upon and feels that it will not be necessary. It will therefore be 
seen that the morbidity is negligible. 
But, even with such a good showing as this and such a relatively low 
mortality, there is still that small mortality and operative risk and the dis- 
comfort going with any abdominal operation which must be taken into con- 
sideration before advising a patient to be operated on for gastro-enteroptosis. 
Therefore, we come to the point of answering our original question, What 
are the general indications for surgical treatment of gastro-enteroptosis? 
Fig. 201.—Normal Small Intestine of Subject of Hypersthenic Habitus. (Mills.) 
Compare with following photo. Small intestine generally high in position showing no 
tendency to massing in the lower abdomen, its loops discrete and of a high degree of tonus, its 
motility rapid. 
If a young individual who is just passing from adolescence to adult life 
develops a painful condition in the right side of the abdomen which first 
begins by mild attacks of pain coming on at intervals, which intervals grad- 
ually grow shorter until a soreness is almost constantly present, particularly 
when the pain extends from the right lower quadrant of the abdomen upward 
and backward toward the region of the kidney and this pain is sufficiently 
severe to justify a provisional diagnosis of chronic appendicitis, operation 
should be advised. If the appendix is found not definitely diseased and the 
cecum and ascending colon is found dilated and mobile, and particularly if 
the peritoneum is edematous or is being covered by a growing membrane or 
bands, the case is one of right-sided ptosis. The removal of the appendix 292 
GASTRO-ENTEROPTOSIS 
will bring only temporary relief; the attacks will recur and the chain of 
sequential symptoms and changes usually going with right-sided ptosis will 
gradually develop. In cases of complete mobility of the cecum, ascending 
colon along with an unlocated hepatic flexure, membranes as a rule do not 
develop. The pain and distress resembling appendicitis in this instance is 
due to gas distention of the cecum, or to an attachment of the appendix near 
its tip to the parietal peritoneum which makes of the appendix a ligament for 
support of the mobile colon. Removal of the appendix in such a condition 
as above noted will often bring temporary relief. Simply to remove a normal 
appendix and consign the patient to the class of “neurasthenics” is to be con- 
demned but little less than to remove a normal appendix and try to make 
Fig. 202.—Photo of Woman of Hypersthenic Habitus. (Mills.) 
Compare with type of small intestine shown in preceding figure. Physical characteristic- 
are great body weight, short deep thorax, very obtuse intercostal angle, long abdomen, relas 
tively narrow pelvis, high degree of visceral tonus and rapid alimentary motility. 
believe that it is diseased, for such cases, in the majority of instances, do not 
get well by the removal of the appendix. They do get well by removal of the 
appendix plus shortening of the supports of the cecum or some form of skill- 
fully fixing the cecum combined with the supports of the first half of the 
transverse colon by suturing the omentum to the abdominal wall. 
In short, I believe that surgery is justifiable and advisable in all chronic 
pains in the right side of the abdomen which are of sufficient severity to 
warrant a diagnosis of an organic lesion, particularly if this pain is discovered 
in the early developmental or adult life. I am very sure that if these young 
patients could be discovered and receive proper surgical treatment at this 
stage, the ptosis question would be very greatly diminished and an untold amount 
of discomfort and distress could be prevented and the physical efficiency of the GENERAL INDICATIONS FOR SURGICAL TREATMENT 
293 
population of the country would be very decidedly increased. For instance, in 
the case of hereditary ptosis described in Chapter XII and illustrated in Figs. 
124 and 125, I feel very sure that, by this timely operation, I have changed the 
course of this patient’s life from certain invalidism to perfect health. It is 
in this class of young people that I believe the principal fields of the surgical 
treatment of ptosis will be. Waugh’s experience in operating on over a 
hundred children leads him to hope that these defects may be discovered and 
diagnosed much earlier and that these children may be operated upon as we 
now operate upon the cleft palate. I can see many difficulties in this utopian 
hope, but cases such as I have described are coming regularly to every surgeon 
Fig. 203.—Normal Small Intestine of Subject of Asthenic Habitus. (Mills.) 
Compare with following photo. On the whole position is low, loops show tendency to massing, 
especially true of ileum. Tonus poor and motility slowest of any type. Differentiation of 
jejunum and ileum usually more marked in this type. 
who has a large practice and can be relieved by the means we have suggested 
if they are recognized by the surgeon. 
In class two, I would place a group of long standing invalids who have 
not been relieved by proper medical treatment and who have painful or 
obstructive symptoms located particularly on the right side either in the 
neighborhood of the cecum and ascending colon or the gall-bladder and duo- 
denum, and who, when the abdomen is opened, show no organic disease but 
rather a right-sided ptosis with the pathology described in previous chapters. 
There are cases of midline ptosis in which there has been development 
of acquired membranes or bands between the prolapsed transverse colon and 
the ascending or descending colon, or both, which makes the ptosis permanent; 
or in which the omentum has become adherent to the lower abdominal or 294 
GASTRO-ENTEROPTOSIS 
pelvic organs or to an operative incision by which the ptosis is made per- 
manent. In such cases the bands are cut, the colon is restored, the omentum 
sutured to the parietal peritoneum, after which forced-feeding and fattening, 
as in all other forms of ptosis, becomes the most important feature. There 
are, of course, other indications which each surgeon must determine for 
himself. 
The most important secondary question which the reader might ask 
would be, What does the X-ray show us that will help us to determine whether 
a case is or is not surgical? 
In answer to this question, I must say that while I consider the X-ray 
of supreme importance in connection with this class of cases, in the way of 
Fig. 204.—Photo of Woman of Asthenic Habitus. (Mills.) 
Compare with type of small intestine shown in preceding figure. Characterized by general 
frailty, light body weight, very long gracile shallow thorax with acute intercostal angle. Short 
abdomen longitudinally, wide pelvis. 
locating and determining the mobility and motility of the various parts of 
the gastro-intestinal tract, I think it would be very dangerous in our present 
state of knowledge to put down in print any X-ray findings which should be 
an absolute indication for surgical interventions. I am of the opinion that 
this is no department of surgery for the “rule-of-thumb” surgeon who would 
be likely to treat these cases surgically simply because the organs happened to 
occupy a certain position. It is a branch of work which should be taken up 
and carefully studied and practiced by surgeons who are trained in broad 
surgical principles. It is probable that the next great field for advanced X-ray 
work is going to be along the line of the cases discussed in this book. I think 
it is probable that we will be able to determine by roentgenology the amount 
of intra-abdominal and intravisceral pressure, the motility of the gastro- GENERAL INDICATION FOR SURGICAL TREATMENT 
295 
intestinal tract and many other things which will enable the broad-minded 
surgeon to make a sound estimate of his case and determine the proper course 
of action, provided he has availed himself of a proper knowledge of the 
fundamental principles involved in the entire ptosis question. 
Some very illuminating pictures along this line have recently been pub- 
lished by R. Walter Mills1 of St. Louis which are published in a paper 
entitled “X-ray evidence of Abdominal Small Intestinal States Embodying 
an Hypothesis of the Transmission of Gastro-intestinal Tension.” These pic- 
tures, reproduced in Figs. 201, 202, 203, 204 and 205, speak for themselves. 
I think nothing has been published which adds more strength to our theory 
Fig. 205.—Extreme Degree of Hypertonicity of Small Intestine. (Mills.) 
This is seen characteristically in subjects of markedly asthenic habitus and a high degree of 
tonicity, common as to visceral tonicity in general. 
expressed in previous chapters as to the importance of intra-abdominal and 
intravisceral pressure and its regulation by the deposition of fat within the 
abdominal wall than do these pictures. It might be said by the skeptical that 
these simply represent types of individuals. But we have had the opportunity 
to try out a sufficiently large number of cases before and after fattening to 
prove to our complete satisfaction that these differences in the X-ray appear- 
ance of the gastro-intestinal tract may be accounted for in many instances 
entirely by the amount of intra-abdominal fat and the strength of the abdom- 
inal wall. By these pictures of Mills, the loops of ileum and jejunum may be 
differentiated to a very large extent. In Fig. 206, a very extraordinary 
1 Am. Journ. Roentgenol., April, 1922, No. 4, 9. 296 
GASTRO-ENTEROPTOSIS 
picture is shown. The loops of ileum not only show the barium but show 
gas distention, with clear outlines of the loops of the small intestine. 
CONCLUSION 
Gastro-enteroptosis is a subject which deserves much more thoughtful 
consideration from the thinking members of the profession than it has 
received. There is a real, physical basis for it and many of the pains and 
discomforts of individuals so afflicted are as real as any other ills. Being 
a mechanical and physical condition, largely, mechanical and physical measures 
Fig. 206.—Extreme Hypotonicity of Small Intestine as Seen in Markedly Asthenic 
and Debilitated Persons. (Mills.) 
Gas-filled loops probably result of hypotonicity, not necessarily pathological but do not 
express admirable conditions. Small intestine as here shown not distinguishable from that of 
pathological causation except through consideration of other factors, especially habitus. 
are essential to its proper treatment. Most of the individuals so afflicted are 
subnormal physically. They can be made more nearly normal and most of 
their ills can be relieved by mechanical measures applied by physical and 
dietary training. There is a certain proportion of the cases in which it is 
necessary to use surgical measures in order to get results. It is probable 
that my estimate above is ultraconservative. While I have been engaged in 
general surgery for approximately twenty-five years and have had what may 
be termed a relatively broad general surgical experience, I unhesitatingly state 
that there is no part of my surgical work which has been more satisfactory 
than that pertaining to the ptosis question. INDEX 
Abdomen, bandage for, 126 
•—capacity of, fixed normally, 2 
■ increased by elevation of diaphragm, 2 
— cavity of, from standpoint of comparative 
anatomy, 12, 13, 14, 15 
—■ — shape of, 3, 12 
suspensory supports of, 10, 12 
— collapsible in front portion, 2 
— contents of, importance of cervical fascia 
in support of, 122, 123 
— exercise of muscles of, 127 
— function of wall in support of contents, 
7 
— lower, contraction of in general ptosis, 151 
— muscles of, 2 
— narrow, indications for surgery in, 125, 147 
— organs of all extraperitoneal, 12 
— pressure in. See Pressure, intra-abdomi- 
nal 
— “psoas outlet” of. See Psoas outlet 
— ptosis in. See Ptosis, abdominal 
— structure of wall of, 1 
—'thickness of wall of, 8 
— upper, method of expanding, 150, 286 
—variable contents of, 31 
Achylia gastrica, indication of type of ulcer 
in, 255 
Adhesions, painful following colon extirpa- 
tion, 264 
Allis’ forceps, in duodenojejunostomy, 254 
Aluminum-bronze, use of, in gastropexy, 200 
Amniote embryo, germ layers in, 17 
Anastaltic wave. See Wave, anastaltic 
Anastomosis, between small and large bowel, 
276, 279 
— end-to-end, satisfaction afforded by, 280 
— end-to-side, obstruction following, 280 
— lateral, 279 
in duodenojejunostomy, 243 
Anemia, secondary in Raynaud’s disease, 118 
Anesthesia, local, for ileostomy, 265 
Antiperistalsis, effect upon cecum of, 57, 58 
— in carcinoma, 60 
— in case of stercoral ulcer, 109 
Aponeurosis, of recti abdominalis, 2 
Appendicitis, frequently a wrong diagnosis, 
139, 152, 161 
— relation to stasis not settled, 114 
Appetite, production of, 134 
Artery, gastroduodenalis, relations of, 25 
Artery, hepatic, relation of, to celiac axis 
and liver, 25 
— pyloric, relation of, to stomach, 25 
— superior mesenteric, duodenal stasis due 
to drag upon, 60, 236 
Arthritis, chronic multiple, colectomy in, 114 
Ascites, alteration in capacity of abdomen 
from, 2 
Asthenia, and right-sided ptosis, 92 
— hypertonicity of small intestine in, 296 
“Asthenic” state, defined, 31, 45 
Atony, of gastro-intestinal tract, 284 
— primary, as a cause of gastroptosis, 194 
“Auerbach’s tissue,” 55 
/3. aminophilus in constipation, 101, 102 
Bacteria, destruction of, in stomach, 263 
Bandage, abdominal, 126 
Bath, use of, in treatment of ptosis, 134 
Beyea, method of, for shortening gastro- 
hepatic omentum, 149 
— operation of, as treatment of ptosis, not 
a cure, 218 
Bile, control of flow by frequent feed- 
ing, 45 
Bismuth, course of through gastro-intestinal 
tract, 203, 204 
Bran, use of, with buttermilk, 285 
Bursa, omental, effect of obliteration of, 218 
Cachexia, gastroptotic, 192 
— in midline ptosis, 216 
Calories, importance of keeping record of, 
285 
Cancer, of breast, not traceable to bacterial 
absorption from intestines, 263 
— of stomach, chemical origin, 263 
Capsule, Gerota’s, its encounter in Long- 
year’s operation, 142 
its relation to nephrocolic ligament, 72 
— Glisson’s, 11 
Cardialgia, in virginal gastrocoloptosis, 192, 
194 
— not marked in maternal ptosis, 198 
Cardiospasm, as a result of ptosis, 186 
Cat, accessibility of kidney in, 20 
—• comparison of alimentary canal with 
human, 22 
Cecosigmoidostomy, case report, 281 
297 298 
INDEX 
Cecum, anatomy of, 55 
— bacteria abundant in, 263, 264 
— distention of, in ptosis, 68 
—• effect of antiperistalsis, 57 
— effect of descent of, 135 
— extirpation of, 108 
—form of, as in index to diet required, 47, 
48 
—• fusion of, 26 
— gangrene of, following distention, 60 
— gas distention of resembling appendicitis, 
292 
— mobility of, in duodenal arteriomesenteric 
ileus, 227 
—• — simple, 83 
symptoms of resembling appendicitis, 
157 
— movable, importance of anchoring, 179 
— observations of Cannon upon, 52 
—’pain from gas in, 155 
—'pigmentation of mucosa in stasis, 107 
— plication of method of, 181 
—purpose of bacterial digestion in, 54 
—• relation to hepatic flexure, 6 
— stagnation in, 62 
— supported by fusion to abdominal wall, 
201 
— the appendix as an external ligament of, 
153 
— time of invasion of, by food, 61 
Cholecystogastrostomy, 249 
Climacteric, loss of fat during, as a cause 
of ptosis, 139 
Coelom, 17 
Colectomy, for ptosis, 229 
— Lane’s technic for, 274 
— mortality and morbidity of, 264 
Colitis, often a diagnosis for virginal ptosis, 
194, 195 
Colon, ascending, attachment of, to kidney, 
27 
delay in, causing constipation, 62 
fusion of, 26, 81 
— — partially retroperitoneal, 19 
support of, 6, 7 
— descending, fixation and retroperitoneality 
of, 27 
fusion of, 81 
partially retroperitoneal, 19 
— effect of excision of, in carnivora, 51, 53 
in herbivora, 51, 53 
— effect of use of corsets upon, 193 
— extirpation of, in chronic multiple 
arthritis, 114 
— fixation of, important, 142 
— flexures of, left higher than right, 7, 27 
— hepatic flexure of, 6 
— importance of, 263 
'in carnivora, 263 
—• — in herbivora, 263 
—■ — in man, 263 
Colon, in carnivora, emptied by stimulation 
of sacrovisceral nerves, 263 
— ligature of mesentery of, 274 
— meso. See Mesocolon 
—’motility of, 55 
abnormal, as a cause of disease, in 
fecal fistula indications of, 56 
—• nerve supply of, 55 
— parietal implantation of, according to 
Reed, 222 
— pigmentation of, as a sign of intestinal 
stasis, 108 
— splenic flexure of, 6 
— transverse, freely movable and pendulous, 
20 
Colopexy, right indirect, for right-sided 
ptosis, 181 
Coloptosis, importance of consideration of, 
in treatment of nephroptosis, 141 
Colostomy, Delatour outfit for, 266, 268 
— discharge from wound of, 263 
—• effect of, upon constipation, 57 
Colotomy, for drainage, 124 
Common bile duct, dilatation after cholecys- 
tectomy, 39 
— relation to liver and duodenum, 23 
Constipation, 59, 61 
— after complete colectomy, 264 
— (3. aminophilus in, 101 
— cause of, in maternal gastrocoloptosis, 198 
—• delay in cecum and ascending colon, 62 
— effect of colostomy upon, 57 
— effect of corsets in production of, 193 
— habitual, imperfect function of ileocecal 
valve in, 264 
operation for, indicated in selected 
cases, 265 
— ileal, reasons for abnormal coliform in- 
fection in, 102 
—• — tyrosin increased in, 102 
— in ptosis, less marked in general than in 
local, 121 
— rare in animals, 66 
— relieved by nephrocolopexy, 71 
— role of habit in, 65, 69, 201 
Coprostasis, causing ileus, 199 
Corsets, nephroptosis from use of, 193 
— proper form and use of, 126, 127 
— use of, as a cause of ptosis, 122 
— — as anchor for stomach, 123 
Crystallization, of lines of force, 202, 228 
Cytotoxins, in experimental reproduction of 
intestinal diseases, no 
Diet, forced feeding, for production of fat, 
226 
in duodenal arteriomesenteric ileus, 228 
— in medical treatment of ptosis, 286 
Dietl’s crisis, 142 
Dog, accessibility of kidney in, 20 INDEX 
299 
Duodenal arteriomesenteric ileus. See Ileus, 
duodenal arteriomesenteric 
Duodenojejunostomy, in duodenal dilatation, 
an indication for, 235, 236 
— operation of choice in complete obstruc- 
tion at junction, 262 
— technic of Kellogg, 250 
Duodenum, contents of, in Raynaud’s 
disease, 118 
— dilatation of, 243, 244 
due to kinking at duodenojejunal 
flexure, 100 
duodenojejunostomy in, 234, 235, 236 
time of emptying stomach in, 99 
— fusion of, 20 
— giant, in infancy, 259 
— kinking of, produced by midline ptosis, 190 
— rotation of, 18 
— “writhing,” 247 
Ectoderm, 17 
Emaciation, in virginal gastrocoloptosis, 192, 
194 
— rapid in giant duodenum, 260 
Embolism, pulmonary, cause of clot forma- 
tion in, 224 
— importance of postoperative posture in 
avoiding, 225 
Embryo, amniote. See Amniote embryo 
Embryology, review of, 230 
Enteroptosis, definition of, 70 
Entoderm, 17 
Epilepsy, cause of traced to intestinal stasis, 
265 
— temporary operative cure of, 265 
Exercise, in medical treatment of ptosis, 286 
— of seldom used muscles, 128 
Fascia, cervical, as a visceral support, 122, 
123 
— lumbar, 2 
— perirenal (Gerota’s capsule), 142 
Fat, intra-abdominal, increase of, 283 
role in correction of ptosis, 283 
Fistula, double mucous, after sigmoidos- 
tomy, 274 
— fecal, closing of following colostomy, 269, 
270 
— study of motility of colon through, 263, 
265 
Fixation, of abdominal viscera, 15, 20 
— of colon at hepatic flexure, 74 
Flexure, duodenojejunal, kinking due to 
dilatation of duodenum, 100 
— hepatic, effect of midline ptosis on rela- 
tions of, 190 
• moderately fixed, 201 
■ time of arrival of food in, 61 
— sigmoid, relations of, 27 
— splenic, difficult to remove, 275 
Flexure, splenic, firmly fixed, 201 
• kinking produced by midline ptosis, 190 
Foramen of Winslow, relation to fixed sup- 
ports of stomach, 25 
Fusion, absence of, on right side, 83 
— of omentum, following colopexy, 185 
— prenatal peritoneal, defects in, 82 
Gall-bladder, as a reservoir, 39 
Gall-stones, and intestinal stasis, 154 
Ganglion celiacum, irritation of, from use of 
corsets, 193 
Gastrocoloptosis, maternal, 198 
alteration of intra-abdominal pressure 
in, 198 
— so named by Rovsing, 190 
—• virginal, 192 
• Bourget’s meals in, 192 
—•—Cardialgia in, 192 
• complications and sequelae of, 195 
diagnosis of, 194 
—• —• disturbances in function of sexual ap- 
paratus in, 192 
influence of corsets in, 192 
—■ —• location of creases in, 197 
’Pathogenesis of, 192 
Gastro-enterostomy, vicious circle after, 248, 
253 
Gastro-intestinal Tract. See Tract, gastro- 
intestinal 
Gastropexy, Rovsing technic for, 199 
Gastroptosis, midline ptosis a better name, 
190 
Gerota’s capsule. See Capsule, Gerota’s 
Glisson’s Capsule. See Capsule, Glisson’s 
Habit, enteroptotic, 94, 95 
— postural, exercise and correction of, 126 
—’ptosis, definition of, 121 
— role in constipation, 65 
“Hammock” suspension (omentocolopexy), 
183, 187 
— for expansion of upper abdomen, 190 
— for hemorrhagic colitis, 173 
— in general ptosis, 148 
— postoperative inspection of, 137, 156, 212 
— use of the term, 220 
—Waugh technic in, 187 
Haustral segmentation, 59 
— relation to point d’appui, 63 
Hematemesis, in gastroptosis, due to stasis, 
196 
Hemorrhage, risk of, during ligature of 
mesentery, 274 
Hepatic artery. See Artery, hepatic 
Heredity, and ptosis, 94 
Histidin, in ileal constipation, 102 
Horsehair, used as suture, 273 
Hour-glass stomach. See Stomach, hour- 
glass 300 
INDEX 
Houston, folds of, 81 
Hydronephrosis, caused by presence of 
anomalous artery, 148 
—'Posterior operation for, 148 
Hypersthenia, small intestine in, 291 
Hysteria, often a diagnosis for virginal 
ptosis, 194, 195 
Ileocecal valve. See Valve, ileocecal 
Ileocolostomy, as a diagnotic measure, 280 
—'in chronic multiple arthritis, 114 
Ileosigmoidostomy, dilation of ileum follow- 
ing, 35 
— effect of exclusion in, 49 
Ileostomy (Brown’s), for sigmoid obstruc- 
tion, 33 
—'discharge from wound of, 263 
—• for ulcerative colitis, 33 
— technic for making and closing, 265, 266 
— temporary, to determine advisability of 
colestomy, 265 
— under local anesthesia, 265 
Ileum, assumption of functions of colon by, 
264 
— coliform infection of, in Raynaud’s 
disease, 118 
•—• culdesac of, collection of fecal matter 
in, 279 
—• division of, 275, 276 
-—gram-positive streptobacilli in, suggestive 
of Raynaud’s, 119 
— indication for extirpation of, 109 
Ileus, duodenal arteriomesenteric, 227 
accompanied by duodenal ulcer, 109 
a clear conception of, 238 
increased area of tympany in, 248 
—• — pathological anatomy of, 245, 247 
'physical signs, 246 
— —production of, 154 
— — relieved by posture, 286, 288 
symptomatology, 245, 247, 248 
technic of operation for, 239 
treatment, 249 
—■ gastromesenteric, absence of pain in, 249 
ulcer in, 109 
Indigestion, a percursory symptom of ptosis, 
167 
Insanity, as a result of intestinal stasis, 265 
Intestinal stasis. See Stasis, intestinal 
Intestine, rotation from right to left, 19 
— small, importance of length of, 275 
Intussusception, normal, of ileocecal valve, 
35 
Jackson’s membrane, 76 
—• classification of findings important, 160 
— development of, 90 
— following general visceral ptosis, 125 
— pathological description of, 87, 88, 89 
—'purpose of, 91 
Kidney, no tendency to prolapse in normal 
individual, 6 
— perpendicular line of, 5 
— retroperitoneal, 19 
Kinks, gastro-intestinal, 69 
— ileal, in chronic multiple arthritis, 114 
in Raynaud’s disease, 117 
— Lane’s, 75, 76 
case reports, 164 
frequency of presence, 163 
—• location of, 134 
— made permanent by adhesions, 135 
— of cystic duct, following general visceral 
ptosis, 125 
— sigmoid, importance of, 80 
— significance of, 84 
Ligament, costocolic, as an operative bound- 
ary line, 220 
in “Hammock” operation, 148 
— crystallization of, 153, 155 
— falciform of liver, shortening of, 216, 220 
— gastrocolic, relation to transverse colon, 
27 
Rovsing’s method of shortening, 202 
— gastrohepatic, 23 
— gastrophrenic, 22 
effect of corset-wearing upon, 193 
— nephrocolic, 70, 71, 153 
absent in normal individual, 72, 140 
postnatal development of, 73 
— of Trietz. See Trietz, ligament of 
— supporting, of diaphragm, 123 
— suspensory of subdiaphragmatic organs, 
relaxation of, 194 
Linea semilunaris, 2 
Liver, development of between layers of 
ventral mesogastrium, 18 
— effect of corsets upon, 193 
— effect of descent of, 135 
— fusion with diaphragm, 22 
— prolapsed in midline ptosis, 190 
— relation to psoas line, 6 
Lordosis, in a case of ileus, 238 
Lymphocytosis, marked in Raynaud’s disease, 
118 
Massage, abdominal, for relief of pain, 161 
— for the increases of muscle tone, 124 
— in medical treatment of ptosis, 286 
Membrane, Jackson’s. See Jackson’s mem- 
brane 
—• pericolic, 91, 92 
Membranes, acquired, purpose of, 154 
— extension, rather than destruction of, 
advocated, 156 
—'total obstruction from, 155 
Menstruation, irregular in virginal gastro- 
coloptosis, 192 INDEX 
301 
Mesentery, drag on vessels of, causing ileus, 
233 
— of large intestine, ligature of, 274 
danger of hemorrhage during, 274 
Mesocolon, fusion of with peritoneum and 
duodenum, 19 
— relation to kidney, 6 
Mesoderm, 17 
Mesogastrium, anterior, 19 
— dorsal, 17 
—•—-elongation of, 18 
—-ventral, 17 
—•—-primitive, 23 
Muscles, abdominal, 2 
— psoas, as support for heavy organs, 9 
Nephrocolopexy, Longyear’s operation of, 
144 
— success of, in relieving constipation, 71 
Nephrocoloptosis, 70 
Nephropexy, cause of failure of, 142 
Nerve, sacrovisceral, effect of stimulation, in 
carnivora, 55 
-on colon, 263 
— vagus, irritation from use of corsets, 193 
Neurasthenia, 255, 284 
— frequently a wrong diagnosis, 178, 292 
— orthopedic and postural measures for, 121 
— reason for the term, 121 
Neurasthenic state, defined, 31 
Omentocolopexy. See “Hammock” suspen- 
sion 
Omentopexy, combined with colopexy, 223 
Omentum, bursa of, early obliteration of, 20 
— during processes of rotation and fixation, 
20 
— gastrocolic, displacement of stomach by 
pull on, 202 
— gastrohepatic, shortening of, 216, 249 
Opsonic index, in chronic multiple arthritis, 
114 
Osmosis, application of law to pressure, 29 
Oxygen, diminished in blood an aid to in- 
fection, 263 
Pain, dyspeptic, case report, 174 
in children, 173 
— from gas in cecum, 155 
— in ptosis, inconstancy of, 168 
— right-sided, in ptosis, 157, 159, 167 
— types of cases indicated by, 168 
biliary, 171 
-duodenal, 170 
gastric, 168, 189 
renal, 172 
-—•—right iliac fossa, 173 
Pancreas, development of, between layers of 
dorsal mesogastrium, 18 
— retroperitoneality of, 22 
Pelvis, brim of, time of arrival of food at, 
61 
Peristalsis, diminished, 284 
■— effect upon cecum, 58 
— effect upon flow of bile, 41 
— effect upon intravisceral pressure, 32, 41 
— reverse. See Antiperistalsis 
*— separate process for mixing and promot- 
ing contents, 63 
•—waves of, few at night, 41 
Peritoneum, adherence of, in early develop- 
ment of fetus, 15 
Peyer’s patches, not recognizable in stasis, 
108 
Pigmentation, associated with anemia, 108 
— of colon, as a sign of intestinal stasis, 108 
Plexus, Auerbach’s, and the nerve supply of 
large intestine, 55 
•— lumbar, exposure of, 188 
Point d’appui, and a discussion of mass 
movement, 63, 64 
Portal vein. See Vein, portal 
Position, genupectoral, relief in ileus by 
assumption of, 245 
—-Trendelenburg. See Trendelenburg, posi- 
tion of 
Pregnancy, alteration in capacity of abdo- 
men in, 2 
•— improvement of health during, 284 
•— relief of ptotic symptoms during, 168 
Pressure, intra-abdominal, 29 
— — absence of, 7 
altered in maternal gastrocoloptosis, 
198, 201 
• amount of not known, 30 
degree of dependent upon contents of 
abdomen, 30 
determination by X-ray of, 294 
— — diminished by loss of fat, 31, 121 
■ increased by exercise, 151 
■— — lowered in ptotic individuals, 45 
regulation of, by fat depositions, 295 
— — relation to duodenal arteriomesenteric 
ileus, no 
role of fat in, 283 
— intra-intestinal, 37, 38 
— intravisceral, 29 
• effect of peristalsis upon, 32 
in hollow viscera and adjacent ducts 
and glands, 36 
Psoas magnus, relation to cecum, 26 
“Psoas outlet” of abdomen, 9, 227 
—• — dropping of unfixed colon through, 120, 
121 
enlargement from loss of fat, 284 
— — postural methods for narrowing, 288 
— — relation to Jackson’s membrane, 90 
Psoas, perpendicular line of, 5 
— transverse line of, 8 
Psychasthenia, definition of, 178 
Ptosis, abdominal, 120 INDEX 
302 
Ptosis, abdominal, acquired, definition of, 
120 
complications of, 134 
—•—'Congenital, definition of, 120 
general, conditions rendering practically 
impossible, 190 
phenomena of, 120 
surgical procedures for, 140 
how produced by corsets, 122 
inconstancy of pain in, 168 
indications for surgery in, 136 
—• — Longyear’s operation, technic of, 142 
'prevention by erect position, 122 
treatment of, 122 
Martins’ principles, 125 
postoperative, 223 
— classification of Rovsing, 191 
— early diagnosis of desirable, 292 
— effect of posture upon, 96 
— habit. See Habit, ptosis 
— maternal, 191, 198 
—■ medical treatment of, 283 
essential steps in, 285 
—■ midline, 176, 177, 190 
case reports, 211 
caused by habitual constipation, 218 
expansion of upper abdomen for, 151 
—• — indications for surgery in, 293 
operative procedures indicated in, 219 
—• right-sided, 71, 152 
—• — case report, 92 
—•—'diagnosis, 178, 291 
—• — indigestion in, 167 
pain in right side in, 157, 159, 167 
— —• — cause of, 160 
pathology following, 177 
'treatment of, 178, 180 
— surgical treatment of, general indications 
for, 289, 291 
—• — indication by X-ray of, 294 
mortality and morbidity of, 289, 290 
— use of indirect colopexy and omentocolo- 
pexy in, 184 
—• virginal, 191, 192 
Pyrexia, in chronic multiple arthritis, 114 
Raynaud’s disease, as a cause of intestinal 
stasis, 115, 117 
— caused by alimentary infection, 119 
— diminished susceptibility to cold follow- 
ing colectomy, 119 
—'lymphocytosis in, 118 
— operative cure of doubtful, 265 
Rectum, ballooning with air, 132 
Right-sided ptosis. See Ptosis, right-sided 
Roentgen ray. See X-ray 
Rotation, of abdominal viscera, 15, 18, 20 
Sigmoid flexure. See Flexure, sigmoid 
Sigmoidocolostomy, results shown in, 56 
Skin, effect of intestinal stasis upon, 105 
Specific gravity, application of law of, to 
intra-abdominal pressure, 30 
Spleen, development of between layers of 
dorsal mesogastrium, 18 
Staphylococcus citreus, in chronic multiple 
arthritis, 115 
Stasis, cecal, imperfect valve function in, 
264 
— duodenal and gastric, overcome by gastro- 
jejunostomy, 100 
— duodenal, due to ptotic drag on mesenteric 
artery, 60 
— gastric, as indicated by bismuth, 205 
—■ gastro-intestinal, harmful effects of chem- 
ical in origin, 263 
—ileal, reasons for, 102 
infection with coliform bacilli in, 101 
— intestinal, and radical surgery, 263, 264 
as a cause of epilepsy, 265 
— — causing diagnosis of gall-stones, 154 
chronic, importance of Carrel’s obser- 
vations in drainage, 104 
circulatory manifestations of, 105 
effect upon nervous system, 105 
—• — evidences of, in skin, 105 
—•—following general visceral prolapse, 125 
ileocolostomy not satisfactory therapeu- 
tically, 280 
• less marked in general than in local 
ptosis, 121 
— —'Organic pathology of, 107 
• pathology of, 98 
Peyer’s patches obscured in, 108 
•— — produced by kinks, 134 
Raynaud’s disease as a cause of, 115, 
n 7 
relation to appendicitis, 114 
—•—relation to tuberculosis, 114 
result of bands, 91 
—' — toxicology of, 103 
Stenosis, papillary, enterostomy for, 249 
Still’s disease, case report, 114 
—• operative cure of doubtful, 265 
— See also Arthritis, chromic multiple 
Stomach, effect of posture on position of, 
123 
—• effect of use of corsets upon, 193 
— esophageal end of, the first permanently 
fixed, 25 
— hour-glass, possible pathogenesis in use 
of corsets, 196, 197 
— normal position of, reclining, 23 
standing, 23 
— relation, to esophagus, 22 
— rotation of, 18 
—• — to dorsal mesogastrium, 18 
— ulcers of, from decomposition and stag- 
nation, 196 
Tabes dorsalis, operation for ptosis in. 136 INDEX 
303 
Toxemia, effect of colectomy upon, 265 
—■ gastro-intestinal, importance of, 75 
— general, following loss of fat, 284 
—• intestinal, result of stasis, 103 
Tract, gastro-intestinal, absence of proof of 
bacterial absorption from, 263 
—• —• atony of, 284 
—• — bacteriology of, 98 
— — comparative anatomy of, 46 
determination by X-ray of motility of, 
295 
dispensability of parts of, 46, 47 
infection of, as cause of Raynaud’s 
disease, 119 
—• — kinks in, retarding contents, 68 
—• — physiology of, 46 
—• — sterility of, from stomach to ileocecal 
valve, 263 
—• — weight on causing ileus, 227 
—. — X-ray pictures of, 203, 204, 205, 206, 
207 
—• ileosphincteric, hypertonus of, 60 
—■ sphincteric, 64 
Trendelenburg, position of, importance of 
following operation, 135 
in treatment of ptosis, 125, 126, 134 
Trietz, ligament of, effect of division of, 
249 
—• relation to duodenum, 26 
Tryptophan, in ileal constipation, 102 
Tuberculosis, bacterial origin from intestinal 
absorption not proved, 263 
— relation to intestinal stasis, 114 
Tympanitis, in sigmoid constipation, 81 
Tyrosin, in ileal constipation, 102 
Ulcer, duodenal, in ileus, 245 
— gastric, in ileus, 245 
— gastroduodenal, relatively greater fre- 
quency in men, 113 
—.mechanical formation of, HI 
— stercoral, in gastromesenteric ileus, 109 
removal of colon in, 109 
Ulcus ventriculi, often a diagnosis for virgi- 
nal ptosis, 194, 195 
Uterus, early relation of peritoneal folds to, 
11, 12 
Vagina, ballooning with air, 131, 133 
Valve, ileocecal, homely definition of func- 
tion, 264 
—• importance of competence of, 53 
— incompetence due to constipation, 33 
— not an indispensable structure, 264 
— purpose of, according to Barclay Smith, 
53 
■—-relation of point d’appui to, 63 
—- shortening of mesentery near, 26 
— sterility above, fertility below, of bacterial 
growth, 98 
— studies of, by use of opaque enemata, 53 
Vater, ampulla of, symptoms of obstruction 
below, 248 
Vein, portal, relation of, to stomach, duo- 
denum and liver, 23, 25 
— superior mesenteric, danger of injuring, 
253 
Vicious circle following cecosigmoidostomy, 
281 
— correction of, 281, 282 
Waugh, technic in colopexy, 187 
Wave, anastaltic, location of, 55 
Weight, as a cause of duodenal arterio- 
mesenteric ileus, 227 
— effect of lifting, 207, 210 
—-gain of, following omentocolopexy, 184 
— increase of, following colectomy, 275, 276 
— loss of, frequent in ptotic cases, 168 
— of food, of significance in cardialgia, 192 
Winslow, foramen of. See Foramen of 
Winslow 
X-ray, as an aid in diagnosis, 294