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THE STOMACH AND 
 OESOPHAGUS 
 
 A Radiographic Study 
 
 BY 
 
 ALFRED E. BARCLAY, M.A., M.D., B.C. (Cantab.). 
 M.R.C.S., L.R.C.P. 
 
 Medical Officer to the x-Ray and Electrical Departments of the 
 Manchester Royal Infirmary ; 
 Late Clinical Assistant, Electrical Department, London Hospital. 
 Council of Electro-Therapeutic Section of the Royal Society of Med' 
 
 THE MACMILLAN COMPANY 
 64-66, FIFTH ATE XL E 
 NEW YORK 
 
 1913 
 
14- abrty 
 
 3 a a 
 
PREFACE 
 
 r 
 
 This little volume is, in essence, a thesis.* Sir Clifford 
 Allbutt, Sir William Osier, Dr. R. Hutchison, and 
 others who read it were kind enough to suggest that it 
 was worthy of publication, and these pages are re-printed 
 with some alterations and additions from the Medical 
 Chronicle by the courtesy of the Editor, Dr. E . M. 
 Brockbank. The chief alteration is the inclusion of 
 Chapter VIII on the ./Etiology of Gastric Ulcer, which 
 was conceived and written after correcting the rest of 
 the proofs of this volume. To Dr. J. Gow I am indebted 
 for the Index, and to Prof. Dr. Gocht for the Bibliography. 
 
 March, 1913. 
 
 * Submitted for the degree of M.D., at Cambridge, in April, 1912, and 
 placed prox. access. Horton Smith prize. 
 
CONTENTS. 
 
 PAGl 
 
 Chapter I. INTRODUCTION i 
 
 Chapter n. Technique 5 
 
 Fundamental principles, method*, of examination, 
 protection of the patient, protection of the observer, 
 position of the patient, preparation of the patient, 
 foods used, special methods. 
 
 Chapter III. Tin.; Diagnosis <>v Ai it.c tions or THE CE80PHAGU8 '.■, 
 The causes of oesophageal obstruction, the stages of 
 oesophageal obstruction. 
 
 Chapter IV. Tin.; NORMAL STOMACH 22 
 
 Position, shape, capacity, tonic action, peristalsis, 
 control of the pylonis, control of peristalsis and tonic 
 action, notes on cases operated on. 
 
 Chapter V. The PATHOLOGICAL Stomach 30 
 
 Atony 3° 
 
 Pyloric Obstruction 33 
 
 Notes on Casks 36 
 
 Hypersecretion 37 
 
 Notes on Cases of Ulcers of Pyloric Regions - 37 
 
 Chapter VI. Gastric Ulcer and Hour-glass Stomach - - 39 
 
 Ulcer of the Fundus ------ 39 
 
 Ulcers of the Pylorus ------ 39 
 
 Ulcers of the Body of the Stomach - - - 40 
 
 Notes on Cases - - 43 
 
 Carcinoma of the Stomach 4 6 
 
 Notes on Cases -------- 48 
 
 Aerophagy --------- 49 
 
 Post Operative Examinations ----- 50 
 
 Incidence of Lesions of the Stomach - - - 53 
 
 Chapter VII. Small Intestine - - - 54 
 
 Duodenal Ulcer 54 
 
 Notes on Cases -------- 55 
 
 Chapter VIII. The ^Etiology of Gastric Ulcer - - - -62 
 
 Chapter IX. Conclusions -------- 73 
 
 Chapter X. Tabulation of Cases ------- 77 
 
 Class 1. Normal - 79 
 
 Class 2. Duodenal Irritation ------ 81 
 
 Class 3. Ulcers of Pyloric Region ----- 84 
 
 Class 4. Ulceration of the Body of the Stomach - - 85 
 
 Class 5. Carcinoma of the Stomach - - - - - SS 
 
 Class 6. Pyloric Obstruction ------ 89 
 
 Class 7. Adhesions -------- 05 
 
 Class 8. Post Operative Examinations - - - - 96 
 
 Bibliography -----------99 
 
 Index 123 
 
FIG. 
 
 i. Diagram. 
 2- 
 
 3- 
 
 4- 
 
 5- 
 6. 
 
 9- 
 
 10. 
 
 21. 
 
 Radiogram. 
 
 >> 
 Diagram. 
 
 ii — 14. 
 
 15- 
 
 16. 
 
 >> 
 
 17- 
 
 >> 
 
 iS. 
 
 Radiogram 
 
 19. 
 
 m 
 
 20. 
 
 j» 
 
 22. 
 
 >> 
 
 23- 
 
 Diagram of 
 
 24. 
 
 Radiogram 
 
 25- 
 
 Diagram of 
 
 26. 
 
 Radiogram 
 
 27. 
 
 ) y 
 
 28. 
 
 Diagram of 
 
 29. 
 
 Radiogram 
 
 LIST OF ILLUSTRATIONS. 
 
 FACING PAGE 
 
 Course of the oesophagus ic 
 
 Slight bulging of aortic arch - - - - 15 
 
 Large aneurism causing oesophageal obstruction 15 
 
 Growth in posterior mediastinum causing ob- 
 struction -------- i^ 
 
 (Esophageal obstruction 15 
 
 (Esophageal obstruction at cardiac orifice - - 15 
 
 (Esophageal obstruction due to small ulcer - 19 
 
 Cardiospasm 19 
 
 Air in the fundus of the empty stomach - - 23 
 
 Air in the fundus of a stomach that already con- 
 tained food ------- 23 
 
 Illustrating the manner in which the normal 
 
 stomach accommodates the food - - - 23 
 
 Bismuth food entering a stomach that already- 
 con tains food 3 1 
 
 Bismuth food entering an empty atonic stomach 31 
 
 Bismuth food entering an atonic stomach that 
 
 already contains food - - - - - 31 
 
 of an extremely atonic stomach (pyloric obstruc- 
 tion) 32 
 
 of an atonic stomach showing the rugae - - 32 
 
 of an atonic stomach with retained food. Type 1 
 
 of chronic pyloric obstruction - - - - 35 
 of an atonic stomach with retained food. Type 2 
 
 of chronic pyloric obstruction - - - - 35 
 
 of typical upper sac of an hour-glass stomach - 40 
 
 hour-glass stomach with atony - - - - 40 
 of an hour-glass stomach with small penetrating 
 
 ulcer (Haudek) - 40 
 
 hour-glass stomach with atony - - - - 40 
 
 of an hour-glass stomach ----- 43 
 of stomach with chronic penetrating ulcer giving 
 
 rise to no symptoms 43 
 
 a case of carcinoma of the stomach - - - 47 
 of a case of carcinoma of the stomach - - "47 
 
CHAPTER I. 
 
 INTRODUCTION. 
 
 The diagnosis of gastric and intra-abdominal lesions is 
 perhaps the most intricate and difficult branch of medicine, 
 
 and even in experienced hands the condition found post- 
 mortem or on the operating table is often very far different 
 from that which was suspected from a full consideration of 
 all the various signs, symptoms, and clinical tests available. 
 Therefore the importance of any new method that will be of 
 assistance in the diagnosis of these cases cannot be over- 
 estimated. The application of the A'-rays in the diagnosis of 
 these conditions has been productive of excellent results in 
 this respect. 
 
 In the early days of #-ray diagnosis one expected that by 
 merely seeing the shape of the shadow of the food in the 
 stomach a diagnosis could at once be formed. It was only 
 after a number of failures that one was driven to the obvious 
 conclusion that a thorough study of the normal stomach was 
 essential. A better knowledge of the limitations of the 
 method must be arrived at before undertaking the examination 
 of the pathological cases. The difficulties of interpreting the 
 shadows cast by the bismuth meal in the stomach are great ; 
 for not only is the organ absolutely different in shape during 
 life from the pictures one would expect from the study of 
 anatomy, but also even slight alterations in tonic action will 
 produce a picture that appears to be very different. Again, 
 the conditions found at operation were often quite the reverse 
 of what one expected from the ,^-ray examination. For 
 instance one reported, after .r-ray examination, a stomach of 
 normal size, and the surgeon at the operation found a large 
 flaccid sac and vice versa. And in the study of the normal 
 great difficulty was experienced, for it was found that even in 
 healthy subjects the stomach apparently varied to an amazing 
 extent, not onlv in shape and position but also in the manner 
 B 
 
2 Gastric and oesophageal affections 
 
 in which the muscular walls appeared to act. Another 
 difficulty was presented by the fact that the pictures seen when 
 the patient was in the upright position differed completely 
 from those obtained when the patient was examined lying on 
 the couch. One was also occasionally confronted with such 
 phenomena as that of a healthy subject whose stomach seemed 
 to conform to all one's ideas of what a healthy organ should 
 be on one examination, while on the following day a picture 
 that seemed to bear little or no resemblance to the previous 
 one was seen. 
 
 Up till the last two years it was often a matter of specula- 
 tion as to whether one would be able to obtain #-rays of 
 sufficient power to penetrate the abdomen of any but the 
 thinnest patients, and in a great number of the early cases one 
 had the utmost difficulty in obtaining even a rapid glance of 
 the shadow before the force of the currents used wrecked the 
 .r-ray tube. It w r as very seldom that one could study the pars 
 pylorica. Moreover, it was only when the apparatus was 
 working at its most efficient pitch, and when the #-ray tube 
 happened to be in exactly the right condition, that a radio- 
 graph could be taken, and even then the exposure had to be of 
 such lengthy duration that all detail was lost owing to the 
 peristaltic movements of the walls. 
 
 During the last two years, however, one has been able to 
 rely upon obtaining a satisfactory screen examination in 
 nearly all cases, and it is only in the study of the pars pylorica 
 that one could often have wished for greater clearness in the 
 screen image. Radiographs have often been taken but they 
 have seldom, if ever, revealed greater detail than could be 
 made out by the screen examination, owing to movements 
 during the lengthy exposures that were necessary. In the 
 last few months, however, the introduction of the intensifying 
 screen has reduced the exposures to a matter of a second or so, 
 with the result that whenever it is not possible to see exactly 
 what is going on, a picture may be taken that will be of con- 
 siderable assistance in the diagnosis. 
 
 Such are some of the difficulties which have beset the 
 earlier stages of this work, but apart from the technical 
 
Introduction 3 
 
 difficulties one conclusion stands out with great clearness; 
 no one picture can be taken to represenl tin- normal stomach, 
 and no detailed study of a .small number "I normal subjects 
 can be of great value in itself; it is only by the consideration 
 of a very large number of cases thai a clear conception of the 
 possible variations of the normal stomach can be obtained, and 
 it is only after this knowledge has been obtained that the 
 value of the .c-ray method of examination in the diagnosis of 
 pathological conditions of the stomach becomes of value. 
 
 I have been much impressed by the fact that frequently (/ 
 the symptoms of the severity in relation to extent of lesion 
 appear to bear very little relation to the extent of the disease 
 found at the operation — the nervous condition of the patient 
 apparently being responsible for the accentuation of subjective 
 sensations that in a phlegmatic subject would be accounted 
 of little moment. In this respect the contrast beween hospital 
 and private patients has been very marked. 
 
 The whole alimentary canal, but especially the stomach, 
 is an exceedingly sensitive muscular organ, and spasmodic 
 conditions have been found (and during the last two years 
 recognised) in a large proportion of pathological cases. These 
 spasmodic contractions have been a source of much trouble in 
 diagnosis, and it was not until I realised that they entered 
 into and complicated almost every active lesion involving the 
 mucous membrane that I appreciated their importance, not 
 only in complicating the diagnosis but in interfering with the 
 gastric functions, in man}' cases causing complete functional 
 biloculations of which no suggestion was found at the 
 operation. It was found that the extent and severity of the 
 spasmodic element of organic lesions did not bear any 
 relation to the size or appearance of the ulcerations, and the 
 suggestion is that theseveritv of the spasm depends rather on 
 the irritability of the ulcer than upon any other factor. 
 
 In this thesis, therefore, I propose to deal chiefly with the 
 explanation of the various difficulties met with in the normal 
 and pathological cases examined, and to lay down the signs 
 on which the diagnosis of morbid conditions may be given. 
 Full use has been made in everv case of the clinical history 
 
4 Gastric and oesophageal affections 
 
 and such other evidence as was available before giving a 
 diagnosis, and although one is so thoroughly convinced of 
 the enormous value of this method — especially in indicating 
 those cases that are suitable for operation — one must urge that 
 the #-ray method is only one of the means at our disposal, and 
 that if we do not use all the evidence available, the use of this 
 method by itself will lead to mistakes in diagnosis, and we 
 will be doing less than justice not only to the means of 
 diagnosis at our disposal but also to the patient. 
 
 I am quite conscious of having received many suggestions 
 from writers on the subject but, as will be seen, the thesis is 
 based almost exclusively on my own examinations. It is of 
 considerable size, and I have therefore omitted the historical 
 outline and summary of the work done by others in this branch 
 of medicine. 
 
 It was Cannon who first initiated the study of the intestinal 
 movements in dogs and cats by means of giving large doses 
 of bismuth, but as applied to the examination of the human 
 alimentary canal, Rieder of Munich was the pioneer, for it was 
 he who first demonstrated that the large doses necessary for 
 these examinations were quite harmless, although previously 
 Roux and Balthayan had attempted diagnosis by means of 
 
 5 drachm doses. Many observers have written on the subject 
 but the following names stand out most prominently : — 
 Holzknecht and Jonas of Vienna, Jolasse, Leven and Barrett, 
 Haudek, Groedel, Rosenthal, Kaestle and Hertz. 
 
 My own work on this subject commenced in 1906, and 
 since then I have availed myself of every opportunity of 
 examining both normal and abnormal subjects. I have notes 
 of nearly 900 patients examined* and there are many others 
 of whom I have no records, either owing to the rush of hospital 
 work, or, as in many of the normal cases, because nothing 
 worthy of note was found at the examination. As a routine 
 practice, I see each patient two or three times during the first 
 hour after the meal has been taken and then re-examine after 
 24 hours, so that the actual number of examinations must be 
 very large. + 
 
 * Up to December, 1912, 1,280 cases had been examined. A proportion of 
 these were examined in conjunction with my partner, Dr. Bythell. 
 
 t The double bismuth meal saves time, but I do not use it as there is less 
 likelihood of overlooking abnormalities, especially of the small intestine, when 
 one follows the whole process from the beginning. 
 
CHAPTER II. 
 
 TECHNIQUE. 
 
 i. Fundamental Principles. 
 
 The aj-rays penetrate all substances to a greater or lesser 
 
 extent, the resistance llinl is offered lo their passage being 
 approximately in direct proportion to the specitu gravity. 
 The walls of the alimentary canal do not differ from the rest 
 of the abdominal contents in this respect, and consequently 
 they give no distinctive shadow on the fluorescent screen or 
 radiogram. 
 
 The method therefore depends on filling the cavities with 
 some substance that differs as widely as possible in density 
 from that of the tissue structures, i.e., something very heavy, 
 such as a bismuth salt, or by inflating them with air or gas. 
 In the former case the contents obstruct the rays and therefore 
 a dark shadow is thrown upon the fluorescent screen, whereas 
 in the latter, the air allows the rays to pass more freely and 
 therefore the screen is more brilliantly illuminated. This 
 latter method is, however, of very limited value. 
 
 2. Methods of Examination. 
 
 The examination should be undertaken with the patient 
 standing with his abdomen pressed against the screen, and 
 the passage of the first mouthfuls should always be carefully 
 observed from the cardiac orifice to the lowest point. I have 
 found that examinations made in the upright position yield 
 infinitely more information than those conducted with the 
 patient lying down, and as these latter examinations give a 
 different picture which may be very misleading, I have 
 purposely omitted any description of them in order to avoid 
 confusion. 
 
 Radiographs are of comparatively little use except for 
 demonstration purposes, as they represent the picture at 
 one particular moment only, and give little indication as 
 to how the stomach receives the food, etc. Radiographs 
 
6 Gastric and oesophageal affections 
 
 are therefore expensive, and in many cases unnecessary 
 luxuries except for demonstration purposes, but a good 
 radiogram of the pars pylorica will reveal more detail than 
 can be made out on the screen. It must be understood that 
 the shadow represents only such of the contents as contain 
 bismuth, and will therefore give the outline of the cavity only 
 in so far as it is filled by this food. Consequently, where the 
 tone is good and the organ contracts upon its contents, the 
 bismuth shadow represents the true shape of the cavity, 
 except in the upper part (which usually contains some air, 
 showing as a light area beneath the left dome of the 
 diaphragm), but when the tone is defective all the food falls 
 to the lowest part, and it is only this portion of the stomach 
 that is outlined. 
 
 3. Protection of the Patient. 
 
 It is the soft rays, the ones which are easily stopped and 
 are therefore useless for this type of examination, that produce 
 .z-ray dermatitis. For this reason the patients have worn a 
 dressing-gown or other garment, and in practice this has been 
 found quite sufficient protection, as not a single case of 
 reddening of the skin has been noted, although many of the 
 examinations — especially for demonstration purposes — have 
 been very prolonged. Moreover, repeated examinations have 
 been necessary in practically every case, some of the early 
 ones being examined as many as eleven times. 
 
 4. Protection of the Observer. 
 
 From the outset — in 1906 — it has been evident that a radio- 
 graph of the stomach contents, no matter how perfect, could 
 be of little value in diagnosis, just as a photograph would be 
 useless in depicting an ataxic gait. Therefore examinations 
 have invariably been conducted by means of the fluorescent 
 screen, and this has necessarily involved a great deal of expo- 
 sure to the rays on the part of the observer. Great difficulty 
 has been experienced in devising apparatus for self-protection 
 that would yet allow of easy manipulation of the patient. 
 When examining with the subject lying on a couch there was 
 little difficulty, as one was not in the direct path of the rays, 
 
Technique 7 
 
 but for examination in the upright position the observer is 
 necessarily in front of the lube A protective diaphragm ••'.••! 
 
 therefore m.'ide by the hospital staff of enrpenlers, and the 
 
 quantity of rays that now penetrates is infinitesimal. 
 
 At all times #- ray proof gloves and apron have been v.orn 
 and no dermatitis has been sustained. In the early <\ 
 before the fluorescent screen was covered with «-ray proof 
 glass, irritation of the eyes was of frequent oecurrenre, but no 
 permanent ill-effects have resulted. 
 
 During periods of heavy work, before the operator 
 efficiently protected, it was found that excessive weariness and 
 mental inertia were the immediate result of a series of screen 
 examinations, but since the addition of the protective 
 diaphragm, already referred to, this effect has not been noted 
 to the same extent. The only ill-results now encountered, 
 even on the busiest days, being slight weariness and headache, 
 which are probably not due to #-rays but to working in a dark 
 unventilated room in which the air is in a partially ionised 
 condition. (Recently a ventilating fan has been placed in the 
 wall, and now there is apparently no undue weariness even 
 after the busiest morning's work.) 
 
 5. Position of the Patient. 
 
 (a) In gastric cases. It was at once apparent that posture 
 had an extraordinary effect on the gastric contents, and it 
 became a matter of choice whether to examine the patient 
 standing or lying down, as the limitations of time prevented 
 a routine use of both positions. In many cases, however, 
 both were employed, but the horizontal position practically 
 never yielded any information that one had not already 
 obtained, and its use was abandoned except for post-operative 
 cases where the patient was too weak to stand and it was 
 necessary to determine by what route the food left the 
 stomach. For this purpose the horizontal position sufficed, 
 but it is not capable of yielding reliable data as to the stomach 
 walls, and for this reason I think it futile to attempt ordinary 
 .r-ray diagnosis unless the patient can be examined in the 
 upright position. Another point that determined the use of 
 
8 Gastric and oesophageal affections 
 
 this posture was the fact that it is the usual position during 
 digestion, and it is while this process is going on that the 
 a'-ray examination is made. 
 
 The best view of the stomach is obtained with the abdomen 
 against the screen, but in certain cases it was found that the 
 pyloric portion seemed to turn somewhat backwards and its 
 shadow was thus foreshortened, but, by rotating the patient 
 slightly, this portion came into full view. The pylorus itself 
 is the most difficult portion to see clearly, not only on 
 account of the small quantity of food that it usually contains 
 but also because of the superimposed shadow of the vertebral 
 column. 
 
 (b) In oesophageal cases. The upright position is the easiest 
 and most useful as well as the most natural for oesophageal 
 cases. In the direct antero-posterior position the vertebral 
 column and heart form a very heavy shadow through which 
 it is impossible to see the oesophagus clearly, but if the 
 patient is slowly rotated so that the front of the right shoulder 
 is against the screen, a certain angle is found at which these 
 two shadows become separate ; a comparatively clear space 
 representing the posterior mediastinum is opened up, and it is 
 through this space that the oesophagus passes. In this 
 position the whole oesophagus is seen, from the pharynx to the 
 cardiac orifice. 
 
 6. Preparation of the Patient. 
 
 Patients should be prepared for all abdominal examinations 
 as if for an anaesthetic by means of purgatives, in order that 
 the stomach may be empty and that there may be no 1 shadows 
 in the intestines to confuse the picture. This also makes the 
 abdomen much more translucent to the rays, consequently 
 the picture of the stomach full of bismuth has a much sharper 
 outline than if no preparation had been made. These patients 
 are frequently taking some bismuth mixture; this should be 
 discontinued some days previously. 
 
 No special preparation is of course necessary for 
 oesophageal examination. 
 
Technique 9 
 
 7. Foods Used. 
 
 (a) In gastric examinations. The essential feature of the 
 food is thai ii should be oi sufficienl difference in specifi< 
 gravity from the abdominal contents to cast .'1 definite shado 
 This is attained by embodying in ii a s.-ili of one of the heavy 
 metals. Bismuth subnitrate was used in the early cases, as 
 much as 4 ozs. being taken with no ill-effed . Reports of 
 cases of poisoning wen- published 41 and the carbonate of 
 bismuth was subsequently used, the proportion being 
 approximately 1 ounce to 2 or 3 ounces oi the excipient. For 
 stout patients the quantity was increased if necessary in ordei 
 to get a denser shadow. The oxychloride of bismuth was 
 tried, but I could find no difference in the behaviour of the 
 stomach, although this salt is more correct theoretically as it 
 is not acted upon by hydrochloric acid. In practice I have 
 never noted the evolution of C0 2 into the stomach from the 
 use of the carbonate, and 1 find that patients prefer it to the 
 oxychloride, which has moreover a tendency to settle out 
 from the food, making the detection of hypersecretion 
 impossible. f The excipient used has been bread and milk, 
 thoroughly mashed up, or porridge. Other excipients, such 
 as mucilage of tragacanth, pounded biscuits, cake, bread and 
 butter, mince meat, vegetables, etc., have been tried with 
 more or less success, but the composition of the food seems 
 to be of no practical moment, provided it does not nauseate the 
 patient. The addition of raspberry syrup has been of some 
 service in obviating this difficulty, but it is seldom that 
 patients find the crude mixture too distasteful. 
 
 No fixed quantity has been given, but sufficient has been 
 used in each case to dilate the potential cavity of the stomach 
 to such an extent that the condition of the walls could be 
 deduced. The quantity, therefore, has varied from 2 ozs. to 
 
 * At least two cases of poisoning occurred in America, but I have been 
 unable to trace the references. Bennecke and Hoffman ("Munchener 
 Medizinsche Wochenschrift," 1906. No. 19) recorded a fatal case, the symptoms 
 being suggestive of nitrite poisoning, and nitrites were found both in the 
 blood and pericardial fluid. Later Bohmie proved that the administration of 
 bismuth sub-nitrate was followed by the appearance of nitrites in the faeces 
 and urine, but not in the blood. 
 
 t Specially prepared Barium Sulphate is now often used and is quite satis- 
 factory, except that it appears to be rather stimulating to the gastric muscle 
 and makes the detection of the duodenal irritation les- certain. 
 
10 Gastric and oesophageal affections 
 
 | pint — in one case of delusions as to the shape of the stomach 
 a patient took 4 pints of custard mixed with bismuth carbonate 
 (8 ozs.) with, no ill-effects. 
 
 It is quite unnecessary to give purgatives in order to clear 
 out the bismuth after the examination. In large doses the 
 salt passes through unaltered and gives rise to neither 
 constipation nor diarrhoea. 
 
 (b) In oesophageal cases. The same food stuffs have 
 usually been employed in oesophageal cases, but the consist- 
 ency has been varied according to the patient's statement as to 
 the character of food with which he has difficulty. Cachets 
 and capsules of bismuth have been discarded, as it was found 
 that they gave quite unreliable evidence; in a healthy subject 
 a gelatine capsule was delayed half an hour at the cardiac 
 orifice in spite of copious draughts of water, while a delay of 
 many minutes was sometimes seen behind the aortic arch. 
 The passage of a solid bougie was watched in one case, but 
 its use appeared to be so dangerous that I have never again 
 employed this method. 
 
 8. Special Methods. 
 
 (a) Physical methods. The most useful special method 
 employed is the application of abdominal massage. This 
 practice, which I introduced about three years ago, has been 
 of the greatest service, since by its use it is almost invariably 
 possible to distinguish between* alterations in the outline of the 
 stomach due to organic lesions and those due to spasm, and 
 where, as so frequently happens, there is a combination of 
 these two factors, a great deal of information may usually be 
 obtained as to the respective parts played by each in deter- 
 mining the shape of the resulting shadow. 
 
 Manipulation either by hand or more safely with a 
 wooden spoon (as suggested by Holzknecht) during the 
 examination, has frequently given information as to the fixity 
 or otherwise of various parts of the stomach, but care is needed 
 in making deductions as it is exceedingly easy to mistake 
 displacement of the contents for displacement of the stomach 
 wall itself. 
 
Technique 11 
 
 Inflating the stomach l>v means of sodium bicarbonate and 
 tartaric acid distends the fundus, and has occasionally yielded 
 information as l<> this portion oi the cavity, but, owing to tli«- 
 impossibility of excluding gastric ulcer, il has seldom been 
 
 used. 
 
 In the early cases, when good definition of the greater 
 
 curvature could not he obtained, I found that injecting air 
 per rectum was of some value, and in a few cases this method 
 showed up small irregularities that would otherwise have 
 escaped notice. 
 
 A mixture of bismuth and lycopodium has been tried for 
 more clearly demonstrating the level of fluids, but its use was 
 unnecessary and it has been abandoned. 
 
 Capsules made of gold-beater skin containing bismuth 
 have been given, in order to test the digestive power of the 
 gastric juice (suggested by Schwartz). I found that it was 
 not possible to determine at what time the capsules ruptured 
 and also that very frequently they were broken during deglu- 
 tition. As no other bismuth could be given until the 
 observations on these capsules were completed their use has 
 been abandoned. 
 
 (b) Actions of drugs. The only drugs that have been 
 examined to any extent have been sodium bicarbonate, bella- 
 donna, valerian, asafcetida, and alcohol. 
 
 Valerian and asafcetida have been found to diminish tonic 
 action in proportion as patients found them distasteful. 
 Those who disliked the smell or taste most showed the 
 greatest loss of tone. Alcohol, on the other hand, tended to \, 
 increase tonic action, the increase being more or less propor- 
 tionate to the patient's appreciation of the alcohol (whisky) 
 used in the experiments. 
 
 Belladonna acted in an uncertain manner. In some cases 
 of spasm it caused complete relaxation, while in others it had 
 little or no effect. In one or two cases of excessive peristalsis 
 this symptom was checked by its action. No cases of exces- 
 sive secretion have been tested with this drug as yet. 
 
 Sodium bicarbonate has also been found to check excessive 
 
12 Gastric and oesophageal affections 
 
 and painful peristalsis in a wonderful way in a proportion of 
 cases, while in others it has produced no effect. I have also 
 lately introduced the use of this drug for testing, in a very 
 rough but handy manner, the quantity of free acid in the 
 stomach. In healthy subjects there is well-marked evolution 
 of carbon dioxide, but in every case of marked hypersecretion 
 there has been much more profuse production of gas. 
 
13 
 
 CHAPTER III 
 
 DIAGNOSIS OF AFFECTIONS OF THE 
 (ESOPHAGUS. 
 
 Possibly none of the many striking conditions thai are 
 
 revealed by #-rays is so dramalir. as the demonstration of 
 oesophageal obstruction. A dogmatic positive or negative 
 diagnosis is expected and is freely given by the radiographer, 
 and it is usually accepted by the physician, for it is a gener- 
 ally accepted axiom thai it is a case of either 'guilty ' or ' not 
 guilty,' and that if the bismuth food passes freely down the 
 oesophagus there cannot be any obstruction. This is not 
 the case, for 'obstruction' is a relative term and depends on 
 three distinct factors, i.e., (i) the consistency of the food in 
 relation to (2) the degree of obstruction and (3) the power of 
 the oesophageal peristalsis, aided by the action of gravity. 
 
 The oesophagus, unlike the rest of the alimentary tract, 
 has approximately only one function namely to act as a high- 
 way from the mouth to the stomach, and anything that 
 interferes with this function causes the symptom of 
 oesophageal obstruction, which may arise from a variety of 
 causes. It is frequently the first and only sign of such serious 
 conditions as new growths and aneurisms, while comparatively 
 innocent lesions may give rise to precisely the same trouble. 
 I am convinced that in some of these latter, the patient's life 
 would have been saved bv a gastrostomy if the operation had 
 not been put off too long on the supposition that it was due to 
 malignant disease, and that it was not worth operating except 
 to avert death from starvation. 
 
 The methods of investigation available and their limitations. 
 Of the bougie it is difficult to write with patience. It is an 
 act of crude barbarity to pass such an instrument for diagnostic 
 purposes into a tube whose walls may be the seat of simple or 
 malignant ulceration or even eroded bv an aneurism, if other 
 
14 Gastric and oesophageal affections 
 
 less dangerous methods are available. The bougie is a most 
 useful surgical instrument, and in a large proportion of eases 
 it is the right instrument to employ for surgical purposes, but 
 for diagnosis there is no other such barbaric relic in the whole 
 of medicine or surgery. Plummer's method* of passing a 
 bougie, threaded on a swallowed string, seems to be the only 
 safe way of employing this instrument. 
 
 The cesophagoscope, on the other hand, reveals the whole 
 of the track down which it travels but that is all. It is blind 
 to conditions around the oesophagus and may be passed, all 
 unsuspectingly, within a fraction of an aneurism or growth that 
 by its pressure is causing difficulty in swallowing. 
 
 The .r-ray method shows the shadow of the food in the 
 oesophagus. It does not show the oesophagus itself, but it 
 reveals the presence of aneurisms and large new growths, 
 while from the shape and behaviour of the food shadow much 
 may be learned as to the nature of the lesion that gives rise to 
 the symptom. Moreover, it has two very great advantages, 
 it is entirely free from danger and it involves no distressing 
 manipulative procedure. 
 
 The Causes of (Esophageal Obstruction. 
 
 i . Those due to pressure from without. 
 
 2. Those due to changes in the walls themselves. 
 
 3. Foreign bodies. 
 
 4. Reflex causes. 
 
 (1) Due to external pressure. ((Esophageal compression.) 
 (a) Aneurism. 
 (6) New growth in the neck, mediastinum, or lungs. 
 
 (c) Enlarged glands. 
 
 (d) Spinal abscess and new growths arising from the 
 
 vertebral column. 
 
 (e) Bronchocele. 
 
 The diagnosis of these conditions does not fall within the 
 scope of this thesis and is therefore omitted. 
 
 *H. S. Plummer, -'Journal of American Medical Association, " August, 1908, 
 and June, 1910 ; J. S. Mayer, ibid., October, 1910. 
 
c=*- 
 
 Fiff. 2. 
 
 v^~* 
 
 ra 
 
 Fig. 3. 
 
 Fie, \. 
 
 Fig. 6. 
 
 Fig. 1 . Diagraraatic representation of the semi-lateral view of the posterior 
 mediastinum with the normal course of the oesophagus indicated by the dotted 
 line. (A. Aorta. H. Heart. JJ. Diaphragm. O. Oesophagus. V. Vertebral 
 column. 
 
 Fig. 2. Slight dilatation of aortic arch with delay of bismuth above it. 
 No real obstruction. 
 
 Fig. 3. Large aneurism of aortic arch with oesophageal obstruction. 
 
 Fig. 4. Growth in the posterior mediastinum surrounding and obstructing 
 the oesophagus. 
 
 Figs. 5 and 6 represent obstruction behind the aortic arch and at the cardiac 
 orifice respectively. 
 
Causes of oesophageal obstruction 15 
 
 (2) Due to causes on the walls themselves. 
 
 (a) New growl lis. 
 
 (h) Ulceration, with spasmodic contraction, 
 
 (c) Cicatrization, following ulceration from caustics and 
 acids, syphilis, etc. 
 
 It is seldom that these cases can be separated from one 
 another. The growths are usually too small to cause any 
 distinct shadow, while cicatrization, ulceration, and spasmodic: 
 contractions give exactly similar appearances. Belladonna 
 is of some value in relaxing the spasmodic element in these 
 cases I find, but it is not sufficiently reliable in causing relaxa- 
 tion of spasm to be of much value in diagnosis. 
 
 In this group of causes there are nearly always two 
 factors to consider, i.e., the organic and the spasmodic, and 
 I cannot too strongly insist on the importance of this latter 
 element which is often responsible for almost the whole of 
 the symptomatic disturbance. 
 
 The oesophagus, like the rest of the alimentary tract, is 
 highly sensitive, and a small abrasion or ulceration may set 
 up a spasm of such severity and persistence that complete 
 obstruction may result. The severity of the spasm appears 
 to depend, not on the size of the ulcer, but upon its irritability, 
 for I examined a case on the dav following operation for 
 removal of an eroded penny that had been lodged in the 
 oesophagus for four months, and found only the slightest 
 delay with quite thick food, whereas in another case, which 
 was examined by the cesophagoscope, I found complete 
 obstruction with dilatation although onlv a very small ulcer 
 was seen. I believe that simple, or peptic ulceration of the 
 oesophagus is of far more frequent occurrence than is 
 commonly taught. 
 
 It is in this type of case that the stage of dilatation with 
 leakage or temporary recovery is sometimes seen, and a 
 certain number of cases of simple ulceration are met with in 
 which the passing of a bougie may so stretch the base of the 
 ulcer that healing and complete relief of all symptoms may 
 follow, as I have seen on two occasions, one of the patients 
 being a man of over seventy. 
 
16 Gastric and oesophageal affections 
 
 The use of the bougie should never be attempted unless 
 the bismuth shadow shows a definite funnel-shape at its lower 
 end; a bougie may wander in an amazing fashion far away 
 from the opening into the passage. Force must never be 
 used, and even with the gentlest manipulation a round-nosed 
 bougie may pass into an ulcer and down between the mucous 
 and muscular coats, giving a sense of absence of obstruction 
 that, in one of the cases I examined, led to the death of the 
 patient from direct septic extension to the lungs. 
 
 (3) Foreign bodies in the oesophagus. 
 
 Most foreign bodies that are found in the oesophagus are 
 opaque to the .r-rays and the bismuth method of examination 
 is unnecessary for their detection. Plum-stones, fish-bones, 
 and certain kinds of tooth-plates however, throw no shadow 
 that can be distinguished, and in a few of these cases I have 
 been able to demonstrate their presence by observing the 
 behaviour of the bismuth food as it found its way past them. 
 In some cases the stream was divided, in others portions of 
 bismuth were left adherent to, or in pockets about, the foreign 
 body. On the whole, however, the detection of these trans- 
 lucent bodies has not been satisfactory. 
 
 (4) Reflex causes. 
 
 (a) New growths and inflammatory lesions of the larynx 
 
 and in the neck. 
 
 (b) Ulceration and new growths of the cardiac end of the 
 
 stomach. 
 
 (c) Neurotic and hysterical. 
 
 (a) New growths and inflammatory lesions of the larynx 
 and in the neck are readily diagnosed by other methods, and 
 it is very exceptional that the #-ray examination is of any 
 value except in demonstrating that, although the food enters 
 the pharynx, it does not get into the oesophagus. 
 
 (b) Ulceration and new growths of the cardiac end of the 
 stomach, when situated close to the cardiac orifice may give 
 rise to very marked obstruction, (figs. 6 and 8.) In one case a 
 healed ulcer, two inches from the orifice, was the only patho- 
 logical condition noted post-mortem in a case where the 
 
Stages of oesophageal obstruction 17 
 
 patient showed all the signs of extreme dilatation of the 
 oesophagus. This had led to surii weakness thai the patient 
 died from the shock of the operation of gastrostomy. In 
 
 another case, where marked dilatation had taken place and no 
 
 food appeared to enter the stomach, advanced can [noma was 
 found, but it did not involve the orifice which appeared to be 
 quite patent and normal in all respects. In both these cases, 
 although dilatation of the oesophagus had occurred, the post- 
 mortem reports state that the oesophagus was not dilated. 
 
 *(c) Neurotic and hysterical. I have seen no cases in which 
 this diagnosis was confirmed, but neurotic patients frequently 
 gave trouble by stating that they could not swallow. 
 Persuasion and distraction of the attention, however, usually 
 overcame this difficulty and demonstrated the nature of the 
 case. 
 
 The Stages of (Esophageal Obstruction*. 
 
 Whatever the cause the result is the same and there are 
 three definite stages, not only in the «-ray appearances, but 
 also in the clinical history of the cases. 
 
 Stage 1. Difficulty in swallowing. (Most marked in upper 
 part of the oesophagus.) 
 
 This is the stage of difficulty in swallowing. The patient 
 has not lost weight but gives a history of some difficulty in 
 swallowing, especially when he tries to eat his food fast and 
 without mastication. Usually there is little or no pain, 
 provided he masticates carefully and eats slowly, but he often 
 states that he has to force each mouthful down separately. 
 
 On examination with the ordinary type of bismuth 
 porridge it is probable that, at the most, a little delay is noted 
 at one particular part. If, on the other hand, we make up 
 
 •Recently I saw a case in which it was evident that the patient had to push 
 each mouthful down the oesophagus by sheer forceful deglutition as far as the 
 level of the clavicle. There was evidently no obstruction beyond this point, 
 the food passed down quite freely and easily and not a trace was left adhering 
 to the walls, while in the upper third traces of the food remained for a long 
 time. It was quite clear there was paralysis in the upper third, while the 
 lower two-thirds were quite normal. On making enquiry from Professor Elliott 
 Smith, I found that he had just traced out a dual nerve supply arising from two 
 separate nuclei in the medulla, while the same observation had been made by 
 Van Gehuchten and Molhant 6 months previously (" Le Xevraxe." June. 15. 
 1912, p. 55). 
 
18 Gastric and oesophageal affections 
 
 our bread and milk with lumps in it and make the patient eat 
 it quickly, we may find that there is definite delay at this same 
 point, and occasionally one sees a violent peristaltic wave 
 squeeze the food almost into a ball and force it through the 
 obstruction. 
 
 The oesophagus is called upon to do an excessive amount 
 of work, consequently hypertrophy occurs — it is the stage of 
 compensatory hypertrophy, and for the time being compen- 
 sation is established. 
 
 Stage 2. Pain after swallowing. (Not so well-marked in 
 the lower as in the upper parts of the oesophagus.) 
 
 This is the stage of painful deglutition and the patient has 
 begun to lose flesh. He states that he cannot swallow solids 
 at all and that even gruel sometimes regurgitates into his 
 mouth but he never actually vomits. Trie pain after swallow- 
 ing of food is the main feature, and it is his dread of eating, 
 far more than the actual obstruction, that leads to the wasting, 
 for although the food he eats is eventually forced through, 
 yet the pain is such that he prefers starvation. 
 
 On examination there is definite delay at the point of 
 obstruction ; there is seldom any mistake in the diagnosis 
 unless some such thin mixture as milk and bismuth is used, 
 which may pass through unobstructed. The food is held up, 
 it cannot pass on, and the oesophageal walls bring all their 
 peristaltic power to bear on the obstruction, and as the power- 
 ful waves move downwards, the food being unable to pass 
 through the obstruction escapes upwards in a narrow stream 
 through the descending contraction. When one sees the 
 picture one is not surprised that it is the stage in which pain is 
 the marked feature — it is sometmes so marked that it suggests 
 a life and death struggle. The waves are not a continuous 
 succession of contractions ; it is a case of one great effort 
 followed by a period of comparative rest while the muscle 
 braces itself up for another powerful contraction. This 
 curious intermittent feature of the contractions is, I believe, 
 characteristic of failing compensation, not only in the 
 
Fig. 7. Radiogram of oesophageal obstruction at the level of the 
 6th dorsal vertebra. The cause in this case was a small peptic ulcer. 
 The spasm that caused the obstruction was only brought on by giving 
 dry bread. It was after this procedure that the bismuth food was 
 given, and the radiogram indicates the complete obstruction that has 
 resulted. 
 
 Fig. S. Spasmodic oesophageal obstruction '(cardiospasm), (a) The 
 dilated oesophagus, (b) Bismuth food that entered the stomach more or 
 Less in a rush, indicating the spasmodic nature of the lesion very clearly 
 in this case. 
 
Stages of oesophageal obstruction 19 
 
 oesophagus but also in the stomach, in certain stages of 
 
 pyloric obstruction. 
 
 In this stage the compensation is failing and hypertrophy 
 is about to give place to dilatation. 
 
 Stage 3. Dilatation. 
 
 (Naturally, in cases where the obstruction is high up and 
 the oesophagus has no room to dilate, this stage is not so 
 well marked as in the lower two-thirds of its course.) 
 
 Clinically, it is the stage of starvation and the patient is 
 rapidly losing flesh, but the pain and difficulty in and after 
 swallowing are comparatively slight, so that the patient feels 
 and often becomes better for a time. There is no longer any 
 actual difficulty in making the food pass down, but sooner or 
 later it is brought up again — the lower down the obstruction 
 and the greater the degree of dilatation the longer will the 
 food be retained, so much so that in marked cases a diagnosis 
 of pyloric obstruction is not at all infrequently made. In one 
 of these cases quite considerable quantities of bismuth were 
 found in the dilated pouch that extended above the diaphragm 
 two days after it had been given, and the patient gave a 
 history of having recognised in his vomitus, food that he had 
 taken some days previously. Indeed, in a few cases, it is 
 absolutely impossible to recognise whether the trouble is 
 oesophageal or gastric, for the food returned from such a 
 pouch has the same acid smell as gastric vomit, and fermenta- 
 tion takes place just as readily in a dilated oesophagus as it 
 does in the stomach in pyloric obstruction. Moreover, the 
 stomach tube may give most misleading information, for 
 instead of stopping at the obstruction it may just as readily 
 pass into the pouch, whose thin walls give little sense of resist- 
 ance. I have seen a tongue, i\ inches long, pushed out from 
 a sac over the dome of the diaphragm by the sheer weight of 
 the tube in a fraction of a second, in a case where an entry in 
 the notes stated that bougies had been passed into the 
 stomach. On more than one occasion I have found complete 
 obstruction in cases diagnosed as carcinoma of the stomach, 
 
20 Gastric and oesophageal affections 
 
 on the evidence of the chemical examination of a test meal 
 that could not possibly have been in the stomach. 
 
 It would be expected that this state of affairs could not 
 last long, but when the cause is in part spasmodic, the com- 
 plete relaxation of the tone that allows the dilatation also 
 relaxes the spasm, and this is often the most important 
 element in the obstruction. When the cause is not rapidly 
 progressive, a cycle may be established reverting between the 
 second and third stages. Such cases are sometimes due to 
 simple or peptic ulceration, which I believe to be of more 
 frequent occurrence than is commonly supposed. The ulcer 
 causes a spasmodic obstruction that follows through the usual 
 three stages till dilatation is established. After a time the 
 oesophagus is too worn out to keep up its spasmodic contrac- 
 tion in spite of the source of irritation, and relaxation takes 
 place so that food passes through. Soon the muscle recovers 
 its power and contracts on the ulcerated surface and again the 
 spasm is produced. In the larger number of cases however, 
 a compromise is effected and there is no definite cycle, a more 
 or less permanent condition of dilatation with leakage being 
 the result, so that the patient lives in comparative comfort but 
 in a state of semi-starvation. 
 
 On examination, no matter what the consistency of the 
 food, it simply flows into the oesophagus and lies in the 
 dilated sac, for there are no peristaltic waves of sufficient force 
 to disturb it. If the sac is called upon to hold more than a 
 certain quantity, either the patient must vomit or the sac must 
 dilate still further. Sometimes dilatation is carried to an 
 extreme, especially in the lower part of the oesophagus. The 
 pouch distends along the line of least resistance which is by 
 displacement of the lung and burrows forward over the 
 dome of the diaphragm, occasionally even displacing the 
 heart to some extent. 
 
 Pathologically, it is the stage where compensation has 
 failed. The fight in which the musculature has called up all 
 its reserves has ended in defeat. The hypertrophied wall is 
 dilated, thinned out, and incapable of effective contraction. 
 One would expect that at the post-mortem we should find this 
 
Stages of oesophageal obstruction 21 
 
 state of affairs as in life, bul it is very seldom that it is recorded 
 in the post-mortem notes. The only explanation I ran 
 suggesl is, thai although the oesophagus has been so distorted 
 during life, in death the same conditions do not exist. 
 Probably rigor mortis and the contraction of the elastic 
 elements of the muscle restore the oesophagus to a semblance 
 of the normal. 
 
 Like all involuntary muscles the oesophagus has a wonder- 
 ful power of recovery, and even a grossly dilated oesophagus 
 may completely recover its activity and tone in a very short 
 time if rest can be secured, i.e., if the obstruction can be 
 reduced or feeding carried on by some other method. In one 
 patient, a woman, in whom the oesophageal shadow was noted 
 as two inches in diameter, the obstruction yielded of its own 
 accord, and when I saw her a week later it was impossible, 
 even with solid food, to note any abnormality. 
 
22 
 
 CHAPTER IV. 
 THE NORMAL STOMACH. 
 
 The anatomy of the soft parts, as seen in the dissecting 
 room, is not necessarily a true index to the condition found 
 in life, and although the stomach is retort-shaped after death 
 or on the operating table, it is a very different organ as it 
 fulfils its functions in life and with the patient in the upright 
 position. Like the rest of the alimentary canal it is tubular, 
 more or less J shaped, and almost entirely to the left of the 
 middle line. The lowest part reaches to about the level of 
 the umbilicus* and the pylorus is perhaps an inch higher and 
 slightly to the right of the middle line, but these data are 
 approximate only, as in practice it is found that even in 
 patients who do not know what indigestion is, the shape of 
 the shadow differs widely. Generally speaking, this is due to 
 defective tonic action, and therefore it is essental that this 
 property of the gastric muscle should be grasped before any 
 attempt is made to detect pathological changes. 
 
 The increased capacity for food is obtained by lateral 
 expansion of the tube, which should hold its contents up 
 against the action of gravity at a fixed level, and it is the tonic 
 action (see page 24) of the gastric muscle that is responsible 
 for this maintenance of the fluid level in the upright position. 
 
 The lowest border should not move wth respiration, and 
 compensation for diaphragmatic movement is automatically 
 taken up by the stomach walls. 
 
 In a paper t before the Electro-therapeutic section of the 
 Royal Society of Medicine, I showed that the contents are not 
 churned up but take up their positions according to their 
 specific gravities, except in the pars pylorica when the peris- 
 talsis is active ; consequently air always occupies the fundus, 
 
 * The level of the umbilicus is practically the same as that of the iliac crests, 
 so that there is no need to place a coin or other mark on this point to show its 
 position. 
 
 t "Proc. Roy. Soc. Med.," Feb., 1909. 
 
Fig. 11. 
 
 Fig. 12. 
 
 Fig. 13. 
 
 Fig. 14. 
 
 Fig. 9. Air in fundus of the empty stomach (A.S.). H. : Heart. D. : 
 Diaphragm. 0. : Umbilicus. I.C. : Iliac crest. S.P. : Symphysis pubis. 
 Fig. 10. Air in the fundus (A.S.) of a stomach that already contains fluid. 
 
 Figs. 11, 12, 13, 14. 
 Diagrams illustrate the filling of a normal stomach B. : Bismuth 
 food. CO. : Cardiac orifice. A. and B. in Fig. 12 indicate peristaltic waves. 
 
The normal stomach 23 
 
 and the heavier food gravitates to the lowesl part. Hence 
 the bismuth food outlines the lowest border in all cases. 
 
 The fundus occupies the left cupola of the diaphragm and 
 
 usually contains air which shows as a light area below the 
 shadow of the heart. 
 
 If the stomach is empty, the air appears as an oval shadow, 
 while if there is a quantity of food in the stomach, the shadow 
 represents the arc of a circle, its lower border being a straight 
 line which can be demonstrated as fluid by watching the 
 ripples on its surface on shaking the patient. 
 
 The empty stomach is a potential space, and into it the 
 bismuth food passes. The weight of a single mouthful may 
 not be sufficient to canalize the potential cavity for a little 
 time and hence the food stays in the upper part just below 
 the air, but as more is given the shadow is seen passing 
 downwards to the lowest point, and after a short time the 
 pyloric antrum is filled. After two or three mouthfuls have 
 been swallowed the shape of the shadow should be like the 
 letter 'J,' and as more food is given the increased capacity is 
 obtained by the lateral expansion of the shadow, and not by 
 any appreciable drop in the position of the lowest border, or 
 raising of the upper level of the shadow.* 
 
 It has been stated that the shadow of the bismuth filled 
 stomach does not represent the normal shape ; that the actual 
 weight of the food causes a distorted appearance. This, 
 however, can be easily disproved by giving an ordinary meal 
 and then watching a thin watery suspension of bismuth 
 permeate the ordinary food. The shape of the organ obtained 
 in this way differs in no detail from that obtained with the 
 usual bismuth method. 
 
 I have found that in infants the shape of the organ is 
 much more globular and during the first year of life is com- 
 paratively spherical, but as the child assumes the upright 
 
 * The description of the normal stomach is purposely vague — it is as 
 fruitless to apply the precision of descriptive anatomy to such an organ as it 
 would be to give exact figures and shapes for an indiarubber balloon. Its 
 capacity varies from zero to many pints, while its shape is determined not 
 only by its tonic action and the quantity of food it contains but also by the 
 pressure of the other intra-abdominal organs, particularly by the presence or 
 absence of gas in the splenic flexure. 
 
j 
 
 N 
 
 24 Gastric and oesophageal affections 
 
 position the stomach elongates. It is not, however, till near 
 the age of puberty that the lower border descends to the 
 umbilicus. 
 
 The stomach is not a fixed organ and it is easily displaced 
 by even slight forces. For instance if the splenic flexure is 
 distended with gas the stomach may be displaced to the right, 
 or if the patient's abdomen is pressed upon, the lowest border 
 may be moved upwards by two inches or more. 
 
 This is the description of the normal stomach, but, as I 
 have already said, it is by no means always found in persons 
 who have never suffered from any gastric trouble. It is a fact 
 that the stomach may present an appearance that is far from 
 normal and yet fulfil its functions perfectly. The part played 
 by tonic action or defective tonic action in the appearances 
 seen is the key note to correct interpretation in these cases, 
 and will therefore be considered. 
 
 Tonic action. 
 
 The upper border of the contents should be about the 
 cardiac orifice, and the increased capacity for more food 
 should be obtained by a widening of the tube. (See figs, n to 
 14.) Tonic action, therefore, may be defined as the constant 
 contraction of the stomach which maintains the contents in 
 tubular form, i.e., it is an automatic contraction that counter- 
 balances the action of gravity on the stomach contents. In 
 the recumbent position therefore, the tonic action is not called 
 upon to anything like the same extent, and it seems reason- 
 able to suppose that the benefit received by patients suffering 
 from atony from rest in bed is due, in part at least, to the 
 relief of the constant strain on this function. 
 
 A thorough understanding of this property of the muscle 
 is invaluable in gastric radioscopy. Tone is a property of 
 the living muscle, and is therefore not seen either in the post- 
 mortem room or as a rule on the operating table. It is under 
 the control of the central nervous system, and may alter very 
 rapidly. For instance, everyone knows the sinking feeling 
 that accompanies nausea, sudden fear, and disgusting smells, 
 and in these conditions I have invariably found that this sink- 
 ing sensation in the abdomen is accompanied by an actual 
 
Peristalsis 25 
 
 relaxation of the (one, and consequently by a drop in the 
 level of the lower border of the stomach, while an increase in 
 
 the tone accompanies tin- actual process of vomiting and 
 retching. I have made many experiments on toni< action 
 
 with various drugs such as valerian and asafcctida, and the loss 
 of tone seemed to be in direct proportion to the disgust in 
 almost every case. 
 
 Loss of tone is often associated with loss of appetite, while 
 appreciation of food tends not only to stimulate the flow of 
 gastric juice, as we know, but also to increase the tone. 
 Peristalsis. 
 
 It should be possible to make out the peristaltic move- 
 ments in all except very stout patients, and they appear to be 
 always present from the time food enters the stomach till it is 
 empty. The waves start opposite the cardiac orifice and 
 sweep along the greater curvature, gaining in force as they 
 approach the pylorus. 
 
 On the lesser curvature the waves are not seen so high 
 up. When they actually segment the bismuth shadow, 
 some distance from the pylorus, the peristalsis is more 
 powerful than normal, but peristalsis is so variable that 
 no conclusions should be drawn from this sign, unless the 
 waves are persistently noted as excessive on several occasions. 
 
 The persistent absence of peristalsis in a stomach otherwise 
 normal in appearance but containing retained food, is 
 associated with extensive ulceration — usually malignant — 
 involving the pyloric region and giving rise to obstruction. 
 
 Naturally, in a thinned out atonic stomach, the peristalsis 
 is likely to be much less powerful than in a normal stomach, 
 but even in extreme cases, when the lowest part is almost in 
 die pelvis, peristalsis can always be elicited by massage. In 
 these cases it is difficult to observe the movements, the shadow 
 of the sacrum and ilium obstruct the view, and unless the 
 £-ray tube is working well it may be impossible to make certain 
 of this point. 
 
 Reverse peristalsis is very seldom seen in this country and 
 when met with it indicates gross pathological changes, usually 
 at the pylorus, but I have only seen it in six cases. 
 
26 Gastric and oesophageal affections 
 
 The control of the pylorus. 
 
 By means of giving sodium bicarbonate and observing the 
 evolution of carbon dioxide, the acidity of the gastric contents 
 can be roughly estimated, and it is certainly not in those cases 
 in which the evolution of gas is greatest that the pylorus opens 
 most freely, but in the class of case that I have styled ' duo- 
 denal irritation ' (p. 55). In this type of case the food is seen 
 passing out almost at once into the duodenum and continuing 
 to pass on until the stomach is empty; one does not see any 
 hypersecretion and the evolution of gas is not more than in 
 healthy people. It looks therefore as if the degree of acidity 
 of the gastric contents is not the determining factor. 
 
 Such evidence as I have seems to prove that fatty 
 foods tend to remain longer in the stomach than the carbo- 
 hydrate and proteid meals usually employed, but I have not 
 noted any difference in this respect between the porridge and 
 bread and milk bismuth meals. 
 
 The rapid emptying in the duodenal cases is most striking. 
 Not only does the food go through more rapidly but also the 
 pyloric relaxation seems to be much more complete than in 
 the healthy subject, with the result that quite large quantities 
 pass through at a time and are easily seen on the fluorescent 
 screen, in contrast with the finer division and thin stream in 
 which the food leaves the stomach in perfectly healthy 
 subjects, which can only be detected on the fluorescent screen 
 under the most favourable conditions. In a certain number 
 of these I have also noted that the pylorus did not open at 
 once and no food was seen passing through for perhaps ten 
 minutes, but when once shadows were seen in the duodenum, 
 the stomach began to empty rapidly as if the mere 
 presence of food in the duodenum brought about pyloric 
 relaxation. In every case of actual ulceration of the 
 duodenum this rapid emptying has been noted, whether the 
 meal was made up of bread and milk or of porridge. 
 Distending the duodenum does not bring about closure of 
 the pylorus, rather the reverse, so far as I can tell from obser- 
 vations on a limited number of cases in which this portion of 
 the intestine has been overloaded either artificially by giving 
 
Control of peristalsis and tonic action 27 
 
 a very large meal, or pathologically by reason of cicatrization. 
 
 These observations suggest very strongly thai the control 
 
 of the pylorus is regulated by some sensory mechanism in the 
 
 duodenum, and an irritable slate of this part of the gtlt, 
 whether intrinsic or reflex, tends to abnormal pyloric relaxa- 
 tion. In two cases this relaxation was so marked thai I 
 actually pressed a large quantity of food through the sphincter 
 by manipulating the stomach through the abdominal wall. 
 
 The control of peristalsis and tonic action. 
 
 As I have pointed out,* 1 believe that tonic action and 
 peristalsis are entirely separate and independent muscular 
 functions. The evidence on which this opinion is based is 
 that even in the cases where atony was most marked, peris- 
 talsis was quite well seen, while in a limited number of 
 instances (type 2 of chronic pyloric obstruction) - ^ - an exactly 
 opposite state of affairs was found, i.e., perfect tonic action 
 with complete and persistent absence of peristalsis. 
 
 That both of these functions are influenced by the central 
 nervous system has been demonstrated in a variety of ways. 
 For instance, tonic action and even spasmodic contractions 
 have been relaxed when patients have been frightened. When 
 patients have become faint I have nearly always had warning 
 by seeing a sudden relaxation of tonic action — an observation 
 that has sometimes saved the patient from a nasty fall. If 
 there are a number of observers present the patient tends to 
 become nervous, and often I have failed to demonstrate exces- 
 sive peristalsis and hypertonic conditions that were invariably 
 present when I carried out the observations by myself. The 
 influence of nauseating smells in causing relaxation of tone 
 has already been referred to. 
 
 * Proc. Roy. Soc. Med., Electro-Therapeutic Section, Feb., 1909, p. 9. 
 t In advanced cases of pyloric obstruction two definite and widely differing 
 types are met with and will be discussed in detail later (p. 33) : — 
 
 Type 1. Is far the most common. The stomach is extremely atonic and 
 sags down into the pelvis. Peristalsis may be quite active and yet the food 
 may be retained for days. 
 
 Type 2. Is rare. The stomach is normal in shape, but distended with 
 retained food, and the bismuth is seen in the stomach for 24 hours or 
 longer. Frequently in these cases no peristalsis is seen and no movement can 
 be evoked by massage. 
 
«J 
 
 28 Gastric and oesophageal affections 
 
 In the earlv stages of pyloric obstruction, as we should 
 expect, peristalsis is more marked than in health, but the 
 phenomenon of very active peristalsis and hypertony, in 
 association with an abnormally patent pylorus in cases of 
 duodenal ulcer and duodenal irritation, suggest, that these 
 functions of the musculature are also influenced by some 
 reflex connection with the duodenum. 
 
 In the cases referred to as type 2, of chronic pyloric 
 obstruction, we have complete absence of peristalsis. Neither 
 massage nor electrical stimulation seem to be of any avail in 
 eliciting contractions. In these cases also an almost 
 hypertonic condition persists and is quite uninfluenced by 
 attempting to induce nausea. It is most striking that it is 
 only in this class of case that neither of these functions can 
 be influenced by any means I have tried, and the inference is 
 that the nerve supply which regulates them is cut off. The 
 actual pathological lesion found has always been of an exten- 
 sive nature involving the lesser curvature in the pyloric 
 region, and presumably this is where the nerve supply passes 
 into the stomach from the duodenum, either directly or 
 through sympathetic ganglia. The injury to these nerves 
 produces a complete absence of peristalsis while tonic action 
 is very pronounced, a condition that is in marked contrast to 
 the usual atonic condition found in type 1 of chronic pyloric 
 obstruction. It looks, therefore, as if tonic action is 
 an intrinsic muscular endowment, or that there are centres 
 controlling this function in the stomach wall itself or connect- 
 ing with the vagus and acting in a similar manner to the 
 centres in the lumbar enlargement for the regulation of 
 micturition. In the vast majority of chronic pyloric obstruc- 
 tion cases, I have found that peristalsis is present and that the 
 stomach is atonic. In some of these the pathological condi- 
 tions were precisely similar to those found in the rarer type of 
 case. If therefore my deductions are correct, it seems 
 probable that the production of one or other type depends on 
 whether or not these communicating nerve fibres are inter- 
 fered with by the progress of the disease. 
 
Notes on cases 29 
 
 Notes on Cases in which the Operation revealed a 
 
 Normal STOMACH. (Cases on p. y<jj. 
 
 In the cases filed under this head are included only those 
 in which no abnormality involving the stomach was found at 
 the operation, witli the exception of the duodenal cases, and 
 those in which the #- ray picture of 'duodenal irritation' was 
 present, which have been tabulated under ,-i separate heading. 
 
 For a description of the normal stomach, see p. 22. 
 
 In many apparently normal stomachs a certain degree of 
 spasmodic contraction of the middle of the body was noted, 
 but in most of them the application of massage to the abdomen 
 relaxed the spasm at once, while in a small number, notably 
 Nos. 369 and 398, the contraction was thought to be organic 
 in origin as it could not be relaxed by massage or the adminis- 
 tration of belladonna. In case 398 this spasm persisted, and 
 was so definite that at my instance the surgeon again explored 
 and found nothing whatever to account for it; while in case 
 369 the simple manipulation of the stomach at the operation 
 was sufficient to effect a perfect cure, and re-examination after 
 the laparotomy showed no trace of the contraction previously 
 noted. 
 
 Displacement of the lower part of the stomach is often 
 met with. The most common cause is distention of the colon 
 with air or fasces, and the examination 24 hours later will 
 nearly always make this point quite clear. Adhesions and 
 new growths are also factors in displacements, and the detec- 
 tion of these conditions depends, as a rule, on manipulation 
 of the organ, preferably when the colon is also filled with 
 bismuth. Under this heading are tabulated only those cases 
 in which the stomach itself was not involved by the lesion. 
 
 Case 296 is curious, in that several observers detected a 
 definite abdominal tumour near the pylorus. Radiographic- 
 ally I found no evidence of any abnormality, and no tumour 
 could be found at the operation. 
 
 Slight or even marked atony was noted fairly frequently 
 but was regarded rather as deficient physiological contraction 
 than as a pathological condition. 
 
30 
 
 CHAPTER V. 
 
 THE PATHOLOGICAL STOMACH. 
 ATONY* 
 
 Atony, the failure of the muscle to maintain the tubular 
 form against the action of gravity, is a complication of many 
 pathological conditions of the stomach, and the part played 
 by atony in the resulting shadow of the bismuth meal must 
 be appreciated before we can diagnose other lesions of which 
 the atony is merely a complication. 
 
 In the mildest degree of atony, so frequently met with, the 
 food is held up for a short time, and then gradually gravitates 
 to the lowest part ; there is, however, always some evidence 
 of the tubular formation remaining, even after a prolonged 
 period. In marked cases the food straightway gravitates to 
 the lowest part, and it is only the lowest border that is out- 
 lined. The picture of a really atonic stomach as seen upon 
 the screen shows that the bismuth meal, instead of being held 
 up in tubular form, sinks at once to the lowest point, where it 
 lies as in a sac. The whole bismuth meal quickly finds its 
 level in the lowest part, forming a more or less crescentic 
 shadow low down in the abdomen, and in extreme cases even 
 on a level with the pubes. 
 
 In such cases it is often difficult to persuade the patient to 
 take more than a very small quantity of the bismuth food, 
 but if he can be prevailed upon to do so, it is found that the 
 increased capacity is obtained by an increase in the vertical 
 depth of the shadow. In other words the stomach does not 
 contract upon its contents but appears to remain inert. 
 
 The manner in which the food enters the stomach suggests 
 that the walls of the upper part are in contact, i.e., it flows 
 down in a thick stream. Sometimes, at the junction of the 
 middle and the upper third, the stream breaks off in thick 
 
 * Strictly speaking atony should be considered with the normal stomach for 
 it is a defective physiological action rather than a pathological condition. 
 
Fiat. 15. 
 
 Fig. 16, 
 
 Fie. 17. 
 
 Fig. 15. Diagram of bismuth food entering a stomach that already 
 contains food or fluid, possibly secretion. 
 
 Fig. 16. Diagram of food entering an empty atonic stomach. The shaded 
 area represents the collapsed walls as I imagine them to be. 
 
 Fig. 17. Diagram of food entering an atonic stomach which already 
 contains food. 
 
Atony 31 
 
 'blobs' which drop to the lowest point, like tar falling 
 through water, showing that there is already some food in 
 the lower part of the stomach keeping the walls apart, and 
 through which the bismuth food sinks. 
 
 Fallacies in the diagnosis of atony. 
 
 That the bismuth shadow only outlines the lowest part of 
 the stomach after a time does not necessarily indicate loss of 
 tone, for it must be remembered that the stomach itself will be 
 secreting juice, which, being lighter than the bismuth food, 
 will consequently rise above it. Hence, although the tubular 
 form may be maintained, yet the upper part of the tube will 
 throw no shadow, because it contains none of the bismuth 
 mixture, for, as I have already said, there is no churning 
 action in the stomach except close to the pylorus. 
 
 For the same reason an atonic condition is suggested when 
 the stomach already contains food; the bismuth mixture 
 rapidly sinks through the stomach contents, which cannot be 
 seen, and hence only the lower border is outlined. The fact 
 of a full stomach is always suggested, however, before the 
 bismuth food is given by the shape of the air space, bounded 
 below 7 by the upper margin of the fluid. Also, when the 
 bismuth food enters, it passes down more rapidly than when 
 canalizing a passage between the collapsed walls, and in a 
 manner that at once suggests a heavy substance falling 
 through a lighter. Moreover, when a considerable quantity 
 has been given, the shadow indicates that it is only the lower 
 part of a column that we see, and further information on this 
 point is easily obtained by pressing the stomach contents 
 upwards. 
 
 The lowest border of the stomach is well below the 
 umbilicus in atony, but this is no proof that the stomach is 
 atonic, for the whole organ is displaced when the diaphragm 
 is below its usual level. This condition — visceroptosis — is 
 most important, as it gives rise to severe gastric symptoms in 
 some cases. 
 
 In a certain number of cases where we find the lowest 
 border of the stomach far below the umbilicus, the tonic action 
 
\l 
 
 32 Gastric and oesophageal affections 
 
 appears to be quite good. This condition is known as 
 gastroptosis, and it is said by Goldthwaite* that faulty posture 
 is the chief factor in its production. Certainly it can be 
 greatly improved by abdominal massage and exercises that 
 tend to increase the normal lumbar concavity, as I have 
 proved on several occasions. 
 
 It is a condition that places the gastric peristalsis at con- 
 siderable disadvantage. Since the plyorus is well above the 
 lowest part there is a tendency towards retention of food in 
 the stomach, which in its turn will lead to a constant strain 
 on the tonic action, and if this gives way, the lower border 
 falls still further with the result that there may be delay in 
 emptying. 
 
 Moreover, the transverse colon is attached to the lower 
 border of the stomach by the transverse mesocolon, and it 
 follows that in these cases this portion of the large intestine 
 is also found below the usual level. It is seldom that the 
 ascending and descending colon have any mesentery and con- 
 sequently there is a tendency to kinking of the large intestine 
 at both the splenic and hepatic flexures, although I am not 
 convinced that it actually occurs. As these patients appear 
 to suffer from constipation it is probable that mechanical 
 obstruction may plav a part, and Goldthwaite believes that 
 this condition with its resulting constipation is the cause of 
 many diseases, such as rheumatoid arthritis. He records 
 most encouraging cases in support of the treatment by 
 massage and exercises. In extreme cases he advises a short- 
 circuiting operation. 
 
 Frequently at operations the stomach which has appeared 
 at the #-ray examination to be quite normal is found as a 
 large flaccid sac, and vice versa. My explanation of this 
 discrepancy is that nausea, disgust, and fear, bring about 
 relaxation of tonic action, i.e., the stomach will tend to become 
 a large atonic sac, whereas I have always found that in the 
 act of retching or vomiting it is contracted up. Anaesthetics 
 inhibit the action of the involuntary muscle of the stomach, 
 and consequently the condition found at the operation is that 
 * Goldthwaite. "Boston Med. and Surg. Journal," 1904 and May. 1906. 
 
Pig. 18. Radiogram of a case of extreme atom in which ib<- lowewl 
 
 part of the s( ach extended nearly fi" below the umbilicus. \ little 
 
 rood has just been given, and is seen extending from the cardiac orifice 
 to the mass of food in the lowest part. Note how this is held np to some 
 extent in the upper pari by the walls of the stomach being in apposition. 
 (a) air, (b) cardiac orifice, (c) food sliding down, d) a peristaltic wave 
 showing as a feeble concavity in the shadow, and (e the mass of food in 
 the lowest part, (x) umbilicus. 
 
 Fig. 19. Radiogram of an atonic stomach. Pressure has been 
 
 applied to the abdomen so that the food lias been forced upwards. The 
 photo was taken as the food was again taking up it> position in the 
 lower part and shows the distribution of the rugae in parallel lines 
 coinciding with the axis of the stomach. (a] air, tin food held up 
 between the collapsed walls and passing down through the rugse to the 
 mass of food, (c);- (a) umbilicus. A suspension of bismuth was used to 
 obtain this result. 
 
Pyloric obstruction 33 
 
 in which the muscle happened to be when the anaesthetic adr-d 
 upon it, and is a mosi unreliable index to the natural 
 condition. 
 
 PYLORIC OBSTRUCTION. 
 
 Obstruction is a relative term and depends not only on the 
 narrowing of the canal through which the food has to pass, 
 but on the vis a tergo. These are the two main factors, but 
 when the stomach is atonic there is also the static disability 
 resulting from the fact that the lowest part, in which the food 
 collects, is far below the pylorus. 
 
 It seems impossible at present, even with detailed notes of 
 all these 84 cases before me, to analyse with certainty the 
 various stages, as I have done in the case of oesophageal 
 obstruction— the part that loss of tonic action plays is so 
 difficult to determine. In the large majority the loss of tone 
 is a marked feature, but in a small number perfect tonic action 
 persists in spite of the most striking retention, hardly any of 
 the bismuth food having passed on in 24 hours. Apart from 
 these rare cases, which I shall refer to later, the stages are not 
 so difficult to separate, although there is no definite dividing 
 line between them : — 
 
 A. In acute cases. 
 
 (1) It is very seldom that a really acute case is seen. I 
 have only seen two, but in both of these the writhing 
 and twisting of the stomach in its efforts to pass the 
 food out was a sight that is not readily forgotten. 
 In both of them it was a carcinoma of the plyorus 
 that was the cause of the trouble. The struggle 
 seems to be over in a short time and the picture 
 becomes that of a chronic obstruction in its third 
 stage, but whether under type 1 or type 2 I cannot 
 tell. 
 
 B. In chronic cases. 
 
 Type 1. (1) A normal stomach that exhibits rather active 
 
 peristalsis persistently and yet shows no signs of 
 
 emptying in, sav, three-quarters of an hour. Such 
 
 a picture is rather suggestive of slight obstruction 
 
 D 
 
34 Gastric and oesophageal affections 
 
 but far from diagnostic. In a certain number of 
 these cases hypersecretion has been noted. (See 
 P. 37-) 
 
 (2) A normal stomach that occasionally shows very powerful 
 
 waves (or successions of waves) of peristalsis with 
 periods of inactivity between, is suggestive that 
 peristaltic action is becoming worn out, and if this 
 sign is observed on one or two occasions it is practic- 
 ally certain that obstruction is present. I have seen 
 such peristalsis entirely checked both by tr. bella- 
 donnas and sodium bicarbonate, but the action of 
 neither of these drugs is constant in this respect. 
 
 There may be some delay in emptying but it is 
 seldom as long as six hours. These are the cases 
 most frequently met with in private practice and that 
 give most trouble in diagnosis. 
 
 (3) Retention of food is found when the peristalsis fails to 
 
 empty the stomach, and the patient nearly always 
 complains that he feels his ' food lying on his 
 stomach ' for hours. Tonic action is called into 
 play continuously, for the stomach is never empty, 
 and by degrees the organ becomes atonic. Owing 
 to the failure of tone, the stomach becomes stretched, 
 the muscle is thinned out and cannot produce peris- 
 taltic waves of the same power as formerly. Not 
 only so, but the work it is called upon to do in lifting 
 the food to the pylorus increases as the greater 
 curvature sags down towards the pelvis. Even 
 when the stomach becomes quite atonic, its lowest 
 border sometimes as low as the symphysis pubis, I 
 have very seldom, if ever, failed to see evidence of 
 peristalsis, provided the apparatus was working 
 efficiently. In one of these atonic cases I found quite 
 a quantity of bismuth food in the stomach five days 
 after it had been given, in spite of persistent vomit- 
 ing. (Figs. 18 and 20) 
 Type 2. I have no evidence whether or not the early 
 stages in these cases are the same as in type 1, but 
 
Fig. 20. Radiogram of a typical case of chronic pyloric obstruction, 
 Type 1. The plate was taken '21 hours after the food was given, and 
 the bismuth is seen lying about 5 inches below the level of the 
 umbilicus. None of the food appears to have reached the caecum. .\ 
 little more food has been given and can be seen sliding down between 
 the collapsed walls of the upper part of the stomach. The radiogram 
 does not happen to show any of the " blobs " of bismuth food falling 
 from this point into the lower part of the stomach. 
 
 X is the position of the umbilicus. 
 
 Fig. 21. Radiogram of Type 2 of pyloric obstruction. The plate 
 was taken 24 hours after the bismuth food had been given and none 
 of the food seems to have left the stomach. Note the perfect tonic 
 action, the absence of peristalsis, the wide column of fluid above the 
 bismuth shadow and the fluid line forming the lower margin of the 
 air shadow. X is the position of the umbilicus. 
 
Pyloric obstruction 35 
 
 the resulting «-ray picture is a mosl striking contrast. 
 
 Perfect Ionic action is always present and yet the 
 stomach is invariably full of fluid, and presumably 
 this fluid is food. Peristalsis is entirely absent, 
 
 or there mav be an occasional powerful wave. 
 
 The delayed emptying is just as marked as in the 
 atonic cases, and on examining the operative findings 
 
 I see that out of eight cases, six showed carcinoma 
 of the pylorus (20, 31, 80, 309, 682, 698), while of the 
 two others one (208) is reported as an extensive ulcer 
 of the lesser curvature close to the pylorus, and the 
 other (313) showed marked cicatricial contraction, the 
 pylorus being 1 one mass of fibrous tissue; precisely 
 similar lesions were found in some of the atonic 
 cases. Fig. 21 is a good example of this type. 
 
 In the latter stages then, pyloric obstruction gives rise to 
 retention of food, and the diagnosis rests on the determination 
 of this fact. The detection of retained food in the stomach 
 when the bismuth examination is made is of some importance 
 and will therefore be considered. 
 
 If the tone of the stomach is good we can see a broad fluid 
 line below the air, which ripples and splashes when the 
 patient is shaken, even though he has been starved for several 
 hours previously. On giving bismuth food a stream of dense 
 shadows is seen falling from the cardiac orifice down to the 
 lowest part of the stomach — like pitch dropping through 
 water. Naturally, only the lower border is outlined, and on 
 giving more food it is noted that the shadow suggests that the 
 bismuth is only indicating the lower part of the vertical column 
 of the stomach contents. The peristaltic waves are sometimes 
 excessive and when we see very powerful waves that are 
 followed by a period of inactivity it is practically certain that 
 obstruction is present, but of course all such observations 
 must be confirmed. 
 
 When the tone of the stomach is defective the retained 
 food sinks to the lower part and there is nothing, except the 
 
36 Gastric and oesophageal affections 
 
 way in which the food drops to the lowest part (see fig. 17, 
 p. 30), to indicate the presence of the retained food. The 
 picture is simply that of an atonic stomach in which peristalsis 
 is more violent than one would expect in a thinned-out organ. 
 
 Retention of bismuth food is the result of pyloric obstruc- 
 tion and Rieder laid it down that the whole of a bismuth meal 
 should have left the stomach within five hours. For diagnostic 
 purposes this is a good enough guide, but I never report 
 definite obstruction unless the delay is well marked. In 
 hospital practice eight hours retention is my standard, but, 
 in the vast majority of the cases recorded, some food was still 
 present in the stomach after 24 hours. In private practice 
 six hours is my standard, but I always repeat the observation 
 on at least one occasion to verify this finding when the 
 margin of delay is so small. It is quite possible that in the 
 early stages there may be rapid emptying as was noted in 
 case 126 in which an operation nine months later showed 
 quite well marked pyloric obstruction. 
 
 Bad teeth and septic conditions of the mouth must be 
 attended to before any reliance can be placed on these data. 
 I have seen a case cured by removal of carious stumps in 
 which quite a large quantity of food was still present in the 
 stomach after 24 hours. 
 
 Notes on Cases of Pyloric Obstruction. 
 (Cases on p. 89.) 
 
 The large number of cases that fall under this head is most 
 striking. In 84 out of 270 cases included in this tabulation, 
 pyloric obstruction was verified by the operative findings. 
 
 No attempt has been made to separate out the malignant 
 cases from the non-malignant, as so large a number were on 
 the border line, and nothing but a microscopic examination 
 would have determined the cause of the obstruction. As yet, 
 the #-ray examination reveals the mere fact of obstruction, 
 and does not give any definite clue as to the nature of the 
 lesion except when a portion of the gastric cavity is obliterated 
 — such cases have been tabulated in Class 5. From the 
 surgical point of view, however, the nature of the disease is 
 
Hypersecretion 37 
 
 of secondary importance ;is compared with the knowledge 
 that there is obslruclion present and that the patient can 
 almost certainly he relieved, for a time at any rate, no matter 
 what the cause may be. It is worthy of note in this conne 
 tion, that in some cases that were undoubtedly malignant, the 
 patient's general condition improved in a manner that was 
 quite as striking as in the non-malignant cases. Not only 
 so but the patients have, in one or two instances, been in 
 perfect health when enquiry was made six months and even 
 two years later. 
 
 The large number of instances of spasmodic and organic 
 contractions of the body of the stomach, in connection with 
 pyloric obstruction, is discussed on p. 46. 
 
 HYPERSECRETION. 
 
 I have met with a number of cases in which all the appear- 
 ances of a normal stomach were present but, after perhaps a 
 quarter of an hour, all the bismuth food occupied the lower 
 part of the stomach, while the upper part contained nothing 
 but thin fluid — the gastric secretion. Such a picture indicates 
 excessive secretion, and in the few : cases that have been sub- 
 mitted to operation an ulcer near the pylorus has been found. 
 The marked acidity of these excessive secretions is very readily 
 demonstrated by giving sodium bicarbonate and watching 
 the rapid increase of the air space in the fundus. The active 
 secretion cannot be detected when there is atony. Fig. 15 
 represents the appearance seen when secretion is very 
 excessive. 
 
 Notes on Ulcers of the Pyloric Region. 
 (Cases on p. 84.) 
 
 The pars pylorica contains comparatively little of the 
 bismuth food at a time and its shadow is therefore not so easy 
 to see as that of the large mass in the body of the stomach. 
 Moreover, the opacity of the vertebral column is superimposed 
 and renders it almost impossible to make certain of details. 
 As yet, I have never seen a case in which I obtained any 
 definite evidence of ulceration from the appearance of the pars 
 
38 Gastric and oesophageal affections 
 
 pylorica itself, but there are several signs that point towards 
 the presence of an active ulcer in this region. There is no 
 hard and fast line between the cases of ulceration with spasm 
 and those of organic obstruction of the pylorus, and in the 
 following list of cases I have included only those in which 
 there was either no really excessive peristalsis, no delay in 
 emptying, or no marked cicatrization of the pylorus found at 
 the operation. 
 
 In some of the earlier cases no indication of any patholo- 
 gical condition was recognised. Most of these have remained 
 in their original class (Class iv), i.e., under ulcers of the body 
 of the stomach. It is only recently that I have made the 
 observation that hypersecretion can be easily detected radio- 
 graphically. The number of cases that have been operated 
 on so far is comparatively small, but in those cases where 
 this phenomenon was well marked the operative findings have 
 shown active ulceration close to the pylorus. Unfortunately 
 there are degrees of hypersecretion, and in the less marked 
 cases the sign certainly does not necessarily indicate ulcera- 
 tion ; moreover, the ulceration of malignant disease will give 
 rise to the same sign. At the present time I am investigating 
 this subject and have found, as expected, that on neutral- 
 ising the secretion with a solution of sodium bicarbonate, 
 there is apparently a far less profuse liberation of C0 2 in the 
 carcinomatous cases than in those which are probably due to 
 ulceration. Although the number of cases is rather small I 
 have now little hesitation in suggesting a diagnosis of pyloric- 
 ulceration' if : — (i) the stomach is normal, (2) the peristalsis is 
 rather active, (3) no shadows are seen passing through the 
 duodenum, (4) there is very rapid secretion which gives off 
 CO a freely. 
 
 It will be noted that the picture, as stated, differs widely 
 from that seen in duodenal ulceration, (p. 54.) 
 
39 
 
 CHAPTER VI. 
 
 GASTRIC ULCER AND HOUR-GLASS STOMACH. 
 
 (Organic and spasmodic.) 
 
 (i) Ulcers of the fundus of the stomach are rare but two 
 cases that I examined came i<> the post-mortem room. ( )n<- 
 was a small cicatrized ulcer about two inches from the cardiac 
 orifice on the anterior wall, the other a malignant ulceration 
 of the fundus that did not involve the cardiac orifice. In both 
 of these cases the only symptom noted at the time of 
 examination was oesophageal obstruction and in both there 
 was very marked distension of the lower end. In one 
 of them a large quantity of bismuth food remained in the 
 oesophagus and was found there 24 hours later and this in 
 spite of the fact that the patient had been 'vomiting' and 
 that at the post-mortem there was no trace of obstruction or 
 of any pathological change at the cardiac orifice itself. I 
 think it is highly probable that many of the cases of 'cardio- 
 spasm ' recorded by Plummer* and others are in reality due 
 to ulcers near the cardiac orifice. 
 
 (2) Ulcers of the pylorus give rise to spasmodic contraction 
 of the pylorus. The actual obstruction in some cases is so 
 marked and so persistent that the stomach may become 
 completely atonic, extending to 4 or 5 inches below the 
 umbilicus, while only a very small quantity of the food is 
 passed out in 24 hours. Later on the ulceration leads to 
 cicatrization but as yet the .r-ray method does not yield us 
 any information as to the importance of one or other factor 
 in the production of the obstruction. In a few cases of 
 active ulceration close to the pylorus one has noted very 
 marked and rapid secretion of gastric juice, which is very 
 easily detected as it lies above the bismuth food. (See p. 37.) 
 
 *H. S. Plummer, "Journal of American Medical Association.'' August. 19US 
 and June. 1910; J. S. Mayer, ibid., October. 1910. 
 
40 Gastric and oesophageal affections 
 
 (3) An ulcer of the body of the stomach is nearly always 
 in an irritable condition and as a result it gives rise to 
 a spasmodic contraction of greater or less severity, the 
 effect, radiographically, being an hour-glass appearance that 
 can only with difficulty be distinguished from the cicatricial 
 hour-glass to which it ultimately gives rise. 
 
 That the stomach is an exceedingly sensitive muscular 
 organ is evidenced by the frequency with which spasmodic 
 conditions are met with, quite apart from organic lesions, 
 while it is very rare to meet with any active ulcerative 
 condition that is not complicated by a spasmodic element that, 
 from the functional point of view, is of far greater importance 
 than the actual lesion itself. For instance a small ulcer of 
 the greater curvature may cause an hour-glass contraction 
 that prevents the food passing into the lower part of the 
 stomach as in cases 207, 389, 400 and 406 where a gastro- 
 jejunostomy had failed to relieve the symptoms. 
 
 The contractions of the stomach most frequently met with 
 are about the junction of the middle and upper third, and the 
 picture given by the bismuth meal is that the food descends 
 to this point and assumes a cone shape. Comparatively 
 suddenly the spasm may relax and the bismuth food passes 
 on into the lower portion, often in a thick stream, giving a 
 somewhat bilocular appearance for a time. 
 
 When the bismuth food is held up in the upper portion of 
 the stomach I have found that rubbing the abdomen very 
 frequently relaxes the spasm so that the contents pass down 
 at once. When the tone of the whole organ is good the 
 resultant shadow is that of a normal stomach with possibly 
 a small indentation to mark where the spasm had occurred; 
 but if the tone is defective, as is common in these cases, the 
 contents drop into the lower part, possibly leaving a small 
 quantity at the point where the obstruction was noted. 
 Further abdominal massage usually causes the whole shadow 
 to gravitate to the lowest part, but if traces are observed for a 
 considerable length of time, in spite of massage and a drink 
 of milk, it is practically certain that there is definite ulceration 
 or cicatrization at this point giving rise to the spasm. The 
 
U.S. 
 
 ..L S. 
 
 Fig. 22. 
 
 ' 
 
 P.U. 
 
 L.S. 
 
 Fig. 24. 
 
 Fu 
 
 Fig. 22 Radiogram of typical upper sac of an hour-glass stomach. 
 This was a cicatricial hour-glass stomach. 
 
 Fig. 23. Hour-glass stomach. U.S. Upper sac. L.S. Lower sac. 
 0. Passage leading to lower sac. 
 
 Fig. 24. Radiogram of an hour-glass stomach. Massage made no 
 impression. Note the small pocket to the inner side of outlet from the 
 upper sac {P.U.) : this is one of the penetrating ulcers described by 
 Haudek. (L.S.) Indicates the lower sac. Extensive cicatrization of 
 the stomach forming a very typical hour-glass contraction. 
 
 Fig. 25. Hour-glass stomach is often associated with pyloric obstruc- 
 tion. The bismuth food is passing through the channel and falling in 
 drops through the retained food in the lower sac. 
 
Gastric ulcer and hour-glass stomach 41 
 
 more persistent the spasm in spile of massage, the more 
 probable becomes ihe diagnosis of actual ulceration or 
 cicatrization. Acute pain on deep pressure al the site oi the 
 constriction is very suggestive of the presence of an ulcer. 
 
 In .-i certain proportion of cases small pockets are formed 
 by chronic penetrating ulcers, as pointed out by rlaudek, 4 
 and these often hold their bismuth food for quite a long time 
 after the rest of the food has passed on (fig. 24). In one 
 patient 1 examined recently I found a verv marked p"< kel 
 on the lesser curvature (fig. 26). There is no doubt that it was 
 due to a chronic penetrating ulcer although the patient had no 
 gastric symptoms at all. The interesting point in this case 
 is that the patient had no gastric symptoms probably because 
 the ulcer did not give rise to any spasmodic contraction, i.e., 
 it was not irritable. On the other hand I saw a case in which 
 only a few ounces of food could be forced into the stomach, 
 forming a small funnel-shaped shadow, and after 24 hours all 
 this bismuth food was still in the same position. This patient 
 was operated on and there was nothing abnormal to be noted 
 about the stomach except a fairly large ulcer high up on 
 the greater curvature that was threatening to perforate. 
 There was no cicatrization. 
 
 These two extreme cases indicate the importance of the 
 spasmodic contraction resulting from ulceration, and all my 
 observations on this subject strongly support Hertz's views 
 on the subject of pain due to gastric ulcer: " I believe that 
 tension is the only cause of true visceral pain."f The 
 importance of examining while symptoms are present is 
 obvious. 
 
 Belladonna has a marked influence on some of the spas- 
 modic contractions. Relaxation ma}- be startlingly sudden in 
 some, while in others no effect is noted, although the massage 
 test has proved the condition to be spasmodic. In a very 
 marked hour-glass contraction, which was thought to be 
 partly organic, I found that this drug practically removed the 
 obstruction between the upper and lower parts of the stomach. 
 
 *M. Haudek, "Arch, of the Rontgen Ray," June. 1911. 
 
 I- A. F. Hertz, "The Sensibility of the Alimentary Canal." 1911. p. 47. 
 
42 Gastric and oesophageal affections 
 
 Acting on the suggestion of this examination, one patient has 
 lived in perfect comfort for the past eighteen months, taking 
 small doses of tr. belladonnae from time to time. 
 
 The shape of the upper sac in organic contractions is 
 nearly always as in fig. 22, but it is not diagnostic. 
 
 The shape depends on the fact that of the two curvatures 
 of the stomach the lesser is the more fixed : consequently any 
 contraction that takes place is towards the lesser curvature. 
 If however an ulcer occurs in some other part and produces 
 adhesions, the site of the ulcer itself becomes fixed and the 
 stomach is contracted to this part as in fig. 27 where the ulcer 
 on the posterior wall was adherent to the pancreas. 
 
 It is not easy in many cases to distinguish between a 
 functional and an organic hour-glass contraction. In both 
 cases the bismuth is held up in the upper sac, and it may 
 possibly be noted that retained food is also present in it. It 
 is always suggestive of a bilocular condition if the lowest part 
 outlined by the bismuth does not reach nearly to the level of 
 the umbilicus without showing some indication of turning to 
 the right as if towards the pylorus. 
 
 On watching carefully it is generally seen that some 
 portion of the shadow is passing on, either in drops or as a 
 thin pencil, and falling into the lower sac. If this is not seen, 
 the patient should be persuaded to take some more of the 
 bismuth meal, or a drink of milk, and this is often sufficient 
 to increase the intragastric pressure, so that the passage will 
 be canalized. 
 
 If, on rubbing the patient's abdomen, it is found that the 
 greater part of the shadow descends into the lower sac, the 
 condition is certainly spasmodic. But if manipulation makes 
 little or no difference in the rate at which food leaves the upper 
 sac, a true organic hour-glass condition is probably present. 
 A careful examination of the upper sac will usually reveal the 
 presence of peristalsis on the greater curvature, starting 
 almost under the diaphragm — that is to say, much higher up 
 than usual. I used to consider that the presence of peristalsis 
 in the upper sac was one of the diagnostic points between a 
 
Fig. 26. Radiogram of an hour-glass stomach. The opening from 
 the upper sac is not in the usual position on the inner side, but from 
 the posterior wall. Pyloric obstruction is also present, and the food 
 seen in the lower sac had been given 6 hours previously while that in 
 the upper sac had only just been taken. The condition was due to a 
 very dense mass of cicatrization adherent to the pancreas (accounting 
 for the position of the neck of the hour-glass) and marked thickening 
 of the pylorus. X umbilicus. 
 
 Fig. -11. Radiogram of case referred to on p. 42, and a normal stomach 
 with the exception of the pocket on the lesser curvature, indicated by 
 the arrow, due to a chronic penetrating ulcer (Haudek). X umbilicus. 
 
Hourglass stomach 43 
 
 true organic and ;i spasmodic obstruction, but this is not 
 the case. 
 
 It must be emphasized once again that there will be a 
 spasmodic elemenl in almost all organu lesions, and thai the 
 functional disability will not depend so much on the lesion 
 itself as upon the spasmodic contra) lion to which it gives rise. 
 
 Moreover there arc occasional cases of spasmodic hour- 
 glass contractions which give all the typical appearances, and 
 yet at the operation there is no gross lesion to be found to 
 account for the spasm. I believe that the spasmodic nature 
 of these cases can be diagnosed if the massage test is 
 thoroughly used. Since I have employed it I have been 
 misled only once, although 1 have seen several cases that 
 would formerly have been diagnosed as organic lesions. 
 The greatest safeguard, however, is the re-examination of the 
 patient on one or two other occasions; for spasmodic con- 
 tractions are not necessarily always present, whereas organic 
 contractions can never completely relax. 
 
 In the lower sac the food may show a variety of pictures, 
 but most frequently the shadow is well below the umbilicus, 
 and both atony and pyloric obstruction are present. In 22 
 out of 38 cases of ulceration of the body of the stomach there 
 was also evidence of a lesion at the pylorus, (see p. 47. ) 
 
 Notks on thf Cases of Ulceration of thf Body of thf 
 Stomach. (Cases on p. 85.) 
 
 Hour-glass Stomach. 
 
 Ulceration gives an entirely different .r-ray picture in the 
 body of the stomach to that seen when the pars pylorica is 
 involved, and I have therefore separated these cases from one 
 another. 
 
 An hour-glass appearance of the stomach is of very 
 frequent occurrence, and in the early cases one made many 
 mistakes through not recognising the fact that the stomach is 
 a highly sensitive organ, and is often the seat of spasmodic 
 contractions that may have all the appearance of organic 
 lesions. It was onlv when I discovered that gentle, or if 
 necessary forcible massage led to relaxation of spasm, that 
 
44 Gastric and oesophageal affections 
 
 mistaken diagnosis from this cause ceased to be of frequent 
 occurrence. Tincture of belladonna was also employed, but, 
 although it relieved the spasm in some cases, it absolutely 
 failed in others. Many cases of purely spasmodic contraction 
 have been met with, but there are four to which I wish to draw- 
 special attention: Class i, No. 369, and Class viii, Nos. 41, 
 363, and 398. In these the spasmodic contractions were so 
 marked that I diagnosed the presence of a definite organic 
 lesion, while the operation failed to reveal any underlying 
 cause. 
 
 Case 369. A marked contraction near the pylorus that 
 exactly simulated a carcinoma : patient only examined once. 
 The manipulation of the stomach at the operation cured the 
 patient and no trace of the spasm was afterwards seen when 
 he was re-examined. 
 
 Cases 41, 363, 398 had been operated upon and the gastro- 
 jejunostomy had failed to relieve the symptoms. In all of 
 them an hour-glass contraction had been noted before the 
 operation, and no trace of biloculation or ulcer had been 
 found to account for it, and when re-examined after the 
 operation the same appearance was noted. All these patients 
 either vomited or retched while under observation and it was 
 evident that it was because of the biloculation, for as soon as 
 all the food had passed down into the lower sac this tendency 
 to vomit ceased and the pain became less severe. 
 
 The most searching scrutiny of the outside of the stomach 
 failed to reveal any abnormality, although I think it probable 
 that some minute erosion or irritable point must have been 
 present. In another case (Class vi, No. 713), at which only one 
 examination was possible before the operation, I found a very 
 marked hour-glass in association with an early stage of 
 pyloric obstruction. In this case, although no lesion could 
 be found to account for the spasm, the patient stated that 
 relief of his ' hunger pain ' (a typical description) occurred as 
 the food canalized the 'middle sphincter.' I quite expect to 
 find that this patient is not cured by the gastrojejunostomy.* 
 
 * See footnote on p. 65. 
 
Hour-glass stomach 45 
 
 Turning to the records in whirl) .'i definite ulcer or evident e 
 of old ulceration was found, I have in the following list 
 
 tabulated 42 cases, and in 38 <>f them the lesion was indicated 
 
 radiograph ically by the hour-glass appearance that was due 
 in part to cicatrization, but to a greater extent ;is ;i rnl<- to the 
 induced spasmodic contraction. It is not possible to classify 
 the findings as these have varied widely, from a little 
 cicatrization about an ulcer to a constriction that completely 
 divided the cavity, but the #-ray picture has almost always 
 shown a very much narrower channel than was found at the 
 operation. In some cases this has been very marked indeed; 
 quite a small ulcer on the greater curvature with just a little 
 puckering around, has given' rise to a contraction so severe 
 and so persistent under massage that only a thin stream could 
 find its way down, and, on the other hand, a well marked 
 cicatricial hour-glass with an indurated ulcer might relax to 
 a great extent with massage, leaving a channel that appeared 
 to be more or less the same size as that found at the operation. 
 There was a greater or lesser degree of spasm in all these 
 cases, and, so far as I can gather from my notes, the severity 
 of the spasmodic element does not depend on the size of the 
 ulcer but rather, one would suppose, on its irritability. Hence (_ 
 the functional disability resulting from an ulcer of the body 
 of the stomach, apart from the stenosis of very marked 
 cicatricial contraction, cannot be gauged by the appearance 
 found at the operation. 
 
 In all these 42 cases there are only four in which an ulcer 
 of the stomach failed to give rise to a contraction that was 
 easily detected on the screen. 
 
 No. 24. Large ulcer of lesser curvature near pylorus — 
 one of the early cases in which the pars pvlorica was 
 not well seen, and no records of secretion or peris- 
 talsis were made. 
 No. 193. A small ulcer of the lesser curvature, one inch 
 
 below the cardiac orifice. 
 No. 418. Large ulcer of lesser curvature. Cicatrices of 
 
 the duodenum. 
 No. 760. Cicatrix of lesser curvature, two inches from the 
 pylorus. 
 
46 Gastric and oesophageal affections 
 
 It will be noted that in all these cases the ulcer was on the 
 lesser curvature, near one or other of the orifices. 
 
 With the exception of these four cases therefore, ulceration 
 of the body of the stomach has given rise to an hour-glass 
 contraction (about 905 per cent.). 
 
 The association of these hour-glass contractions with 
 pyloric obstruction is very marked. In 14 cases out of the 
 38 this condition was also present, and it is probable that the 
 four cases in which the gastrojejunostomy had failed to 
 relieve the symptoms (Nos. 206, 266, 389, and 400) should 
 also be added to the number. Ulceration of the pylorus was 
 also met with in four cases (Nos. 335, 599, 717, 720) and 
 presumably these would eventually have become cases of 
 pyloric obstruction. In at least a half of the cases of 
 ulceration of the body of the stomach therefore, there was also 
 a lesion at the pylorus. 
 
 Among the cases of pyloric obstruction will be found many 
 cases where spasmodic contractions of the middle of the 
 stomach were well marked, but in a far larger number, slight 
 spasmodic contractions were easily recognised as such, and 
 were not recorded. This association cannot be accidental, 
 but whether both conditions depend on some other unrecog- 
 nised condition within the abdomen, or whether the 
 contraction of the body of the stomach depends on the pyloric 
 lesion I cannot say, but am inclined to the former view. 
 
 In two cases (Nos. 418 and 420) cicatrization of the 
 duodenum was also noted. 
 
 In four cases ((Nos. 207, 389, 400, and 406) a gastro- 
 jejunostomy had failed to relieve the symptoms, and a further 
 operation showed the presence of an organic hour-glass 
 contraction above the stoma , as suggested by the #-ray 
 examination. 
 
 CARCINOMA OF THE STOMACH. 
 
 New growths in the abdomen throw no shadows which can 
 be distinguished from the general abdominal opacity ; they 
 can however often be demonstrated by reason of displace- 
 
Fig. 28. Carcinoma cf the stomach. The whole of the pyloric portion 
 and a part of the lesser curvature are invaded. 
 
 Fig. -21). Radiogram of a case of carcinoma of the stomach. The 
 pyloric portion of the cavity is almost completely obliterated. In some 
 cases the shape of the remaining cavity is most irregular. 
 
Carcinoma of the stomach 47 
 
 ments of viscera, irregularities caused by the inroads of the 
 growth into the stomach, and by obsini' tion to the passage ol 
 the food, all of which may be shown by giving the patient :> 
 bismuth meal. If the pylorus is involved, obstruction may 
 be noted, but this form of obstruction cannot as a rule be 
 distinguished from pyloric obstruction due to other causes. 
 
 Apart from pyloric obstruction, the diagnosis of carcinoma 
 depends upon the irregularities caused by the inroads of the 
 growth. 
 
 The inroads may be quite small, like the outline of a piece 
 of coral, or there may be more or less marked obliteration of 
 the cavity by the growth which displaces the bismuth and 
 consequently gives rise to deficiency in the normal shadow. 
 Such inroads may suggest peristaltic waves at first sight, but 
 on further observation it is noticed that they are permanent, 
 and that peristaltic waves sweep up to these notches, are lost 
 to sight, and reappear on the further side of them. In 
 advanced cases the greater part of the gastric cavity may be 
 completely obliterated. (See figs. 24 and 25.) 
 
 Growths involving the anterior or posterior walls some- 
 times invade the stomach so that bismuth is displaced and a 
 clear space is seen in the midst of the shadow . These clear 
 spaces may appear and disappear as peristaltic waves sweep 
 past, or on pressing the abdomen against the screen, but they 
 must not be confused with similar appearances caused by, 
 say, curds of milk which contain no bismuth. This fallacy 
 is always guarded against by making radiograms on two 
 successive days and a comparison of these will give the clue 
 to the real interpretation. 
 
 Spasmodic contractions mav simulate the appearance of 
 growths and therefore massage should be employed, and even 
 if there is no doubt a subsequent examination should be 
 undertaken for confirmation. 
 
 We cannot exclude the presence of new growths by this 
 method, but it is seldom that there is no clue to the diagnosis 
 if the new growth actually invades the stomach. 
 
48 Gastric and oesophageal affections 
 
 Notes on Cases of Carcinoma of the Body of the 
 
 Stomach. (Cases on p. 88.) 
 To place all the cases of carcinoma of the stomach under 
 one head was quite impossible as such a large number of the 
 pyloric cases were on the border line, and in many cases the 
 surgeon could not tell whether the thickening was due to 
 inflammatory causes or to new growth. All cases of pyloric 
 obstruction, whether due to growth or cicatrization, have 
 therefore been placed together in Class 4, and in the following 
 list are included only those in which the growth invaded the 
 body of the stomach. 
 
 In the diagnosis of carcinoma of the stomach reliance 
 must be placed on the displacement of the bismuth food by 
 the growth. In the large majority of cases a considerable 
 portion of the cavity was involved and there was no doubt as 
 to the diagnosis. In a smaller number definite inroads of 
 growth were noted, often difficult to distinguish from peristaltic 
 waves, especially when the apparatus was not working well. 
 Adhesions in some cases gave rise to indentations that were 
 mistaken for carcinoma, and in one case (recorded under 
 Class 1, No. 369) a pure spasmodic contraction gave rise to 
 the same mistake. 
 
 An hour-glass appearance is sometimes caused by the 
 obliteration of part of the cavity (fig. 25), and it may be difficult 
 to distinguish a carcinomatous biloculation from the cicatricial 
 condition, as in case 59, but when the growth is sufficiently 
 advanced to give rise to such an appearance, an abdominal 
 tumour can almost invariably be detected. 
 
 Clear spaces in the bismuth shadow have been noted on 
 several occasions (case 58 is the only one in the tabulation, 
 but in my notes I have records of eight such observations in 
 patients whose clinical symptoms left no room for doubt as 
 to the diagnosis). The chief source of error is the presence 
 of boluses of ordinary food or even curds of milk, but a 
 confirmatory examination will clear up this point. These 
 clear spaces are often only demonstrated by pressing the 
 patient's abdomen against the screen, and they tend to appear 
 and disappear as peristaltic waves pass over them. 
 
Aerophagy 49 
 
 The movements of the diaphragm are sometimes, but nol 
 often, restricted, and on many oc< asions I have found the liver 
 enlarged and the diaphragm pushed up on the right side, 
 indicating secondary growth in the liver. In no single 
 
 instance have I found secondary deposits in the lungs, in fad 
 the only instance of this complication I have mel with in 
 
 association with abdominal cancer was in a case where I 
 reported the stomach as normal and in which carcinoma of 
 the rectum was subsequently discovered. 
 
 Twenty-three cases only are tabulated out of a much larger 
 number in which the diagnosis has been perfectly plain, often 
 both clinically and radioscopically. In many of them the 
 #-ray report showed that operative interference would be 
 useless. This probably accounts for the presence of only five 
 cases of this type in the last 300 cases examined. 
 
 AEROPHAGY {air-swallowing). 
 
 Air-swallowing is not an uncommon condition, and one 
 which may give rise to severe gastric symptoms. 
 
 On giving bismuth food the outline of the stomach may be 
 perfectly normal, or it may suggest an atonic condition ; but 
 it is always noticed that as the patient swallows his food a 
 certain amount of air passes down the oesophagus with each 
 mouthful, and the air space gradually increases and may even 
 extend down even as far as the umbilicus unless eructations 
 occur. The cardiac portion may be dilated like a great 
 bubble, occupying the whole of the left hypochondriac region 
 and even displacing the diaphragm upwards. Such patients 
 swallow more air with liquids than they do with solid or semi- 
 solid food, so that any case where this condition is suspected 
 should be tested with a glass of water. 
 
 In well-marked cases violent and persistent eructations 
 may take place, and it is noted that the air shadow, instead of 
 becoming smaller, remains the same, or even becomes greater 
 in extent. Sometimes the air distends the lower part of the 
 oesophagus to some extent. 
 
 On more than one occasion I have seen the air apparently 
 sucked down the stomach to the level of the umbilicus. It 
 
50 Gastric and oesophageal affections 
 
 looks as if this is only possible when the lower part of the 
 stomach is anchored down by adhesions, but I have not been 
 able to satisfy myself on this point. 
 
 I have noted the occurrence of slight aerophagy in connec- 
 tion with appendicitis on a considerable number of occasions 
 when gastric symptoms were apparently due to this cause. 
 
 ADHESIONS. (Cases on p. 95.) 
 
 For the diagnosis of adhesions we have to depend on 
 the fact that under normal conditions it is possible to 
 manipulate the stomach through the abdominal wall and to 
 determine more or less accurately the fixity or otherwise of 
 the organ. Some cases are more or less obvious, e.g., 
 adhesions of the lesser curvature to the lower border of the 
 liver but, like all other observations on the stomach, one must 
 repeat the observation at a subsequent examination, for on 
 more than one occasion I have found that the confirmatory 
 examination revealed a perfectly normal stomach in cases 
 where I had been quite confident that there were adhesions. 
 
 In some cases they cause inroads into the gastric cavity 
 that are almost impossible to distinguish from carcinomatous 
 inroads, and in case 699 this mistake was made, while in 
 case 408 the stomach was segmented by a band of adhesions 
 near the pylorus and other small indentations were noted that 
 suggested this diagnosis, although there was some doubt in my 
 mind as to whether the case was or was not one of carcinoma. 
 
 In case 151 the persistence of atony (or ? gastroptosis), in 
 spite of massage and exercises, led me to suspect the presence 
 of adhesions fixing the transverse colon in the pelvis, as it was 
 impossible to raise the stomach by manipulation although it 
 could be pushed sideways, while the transverse colon appeared 
 to be fixed. The operation in this case showed the presence 
 of an old appendicitis and a cord-like adhesion to the trans- 
 verse colon. 
 
 POST-OPERATIVE EXAMINATIONS. (Cases on p. 96.) 
 
 Many patients in whom a gastrojejunostomy has been 
 performed have been examined, but in this table are included 
 only those in which the operation had failed to relieve the 
 
Post-operative examinations 51 
 
 symptoms. In the cases in which a cure was effected I have 
 not come across a single instance in which the stoma 
 closed. In a small number, aboul one-quarter oi these cases, 
 the bismuth food was observed passing through both the 
 
 stoma and the pylorus. 
 
 In only one case (524) was the appearance of 1 1m- formation 
 
 of a vicious circle noted (i.e., the continued presence of a 
 shadow in the duodenum) and at the operation it was found 
 that the stoma was occluded by adhesions and the duodeno- 
 jejunal flexure kinked. It seems probable, therefore, that the 
 theory of vicious circle vomiting" is at least an extremely rare 
 cause of failure, since not a single instance was found in the 
 cases recorded. 
 
 In seven cases (44, 416, 470, 471, 483, 524, 530) the .z-ray 
 examination showed that, either there was obstruction of the 
 small intestine just beyond the stoma, or that no food passed 
 through this opening, and in each of these the operation 
 showed the presence of adhesions, the obstruction as a rule 
 being due to kinking. 
 
 In seven cases, although the stoma was working perfectly, 
 
 there was a well marked hour-glass condition present, and in 
 
 most of them it was evident at the x-ray examination that 
 
 the patient vomited from the upper sac, and that so soon as 
 
 all the food had passed into the lower sac the discomfort and 
 
 inclination to vomit passed off. An exploratory operation 
 
 was performed in six of these cases with the following 
 
 results : — 
 
 41. No cause found to account for the hour-glass condi- 
 tion. Patient unrelieved, and still shows hour- 
 glass condition. 
 
 207. Cicatrix of greater curvature with active ulcer, and 
 partial organic hour-glass. 
 
 257. Adhesion (extra gastric) forming hour-glass. 
 
 266. Cicatricial hour-glass with active ulcer. 
 
 363. No cause found to account for the condition. Patient 
 unrelieved. 
 
 398. No cause found to account for the condition. Patient 
 relieved five weeks after operation, but this also 
 occurred after the previous operation. On this 
 occasion the appendix also was removed. 
 
52 Gastric and oesophageal affections 
 
 In one of the two cases of active ulceration the surgeon 
 noted at the time of the previous operation that a small ulcer 
 was present on the greater curvature, but it appeared to be 
 so insignificant that he did not not excise it, in the expectation 
 that healing would take place when the pyloric obstruction 
 was relieved by means of a gastrojejunostomy. Remarks 
 on the three cases of spasmodic hour-glass condition will be 
 found on reference to p. 44. 
 
 In two cases (209 and 357) an hour-glass condition had 
 been found at the time of the operation and the upper sac 
 united to the jejunum. In both of these cases pyloric 
 obstruction also was present with the result that food lodged 
 in the lower sac. Excision of the lower sac was performed 
 in both with complete relief of symptoms. 
 
 In case 419 the stoma was situated further from the 
 pylorus than in any other case I have seen. There was 
 marked pyloric obstruction and the peristalsis seemed to 
 squeeze the food into the pars pylorica, and this appearance 
 coincided with the pain. At the operation a growth of the 
 pylorus was found and excised. This relieved the patient, 
 for a time at any rate. 
 
 Cases 689 and 756 (entered in Class 6) were both sent for 
 examination because the symptoms persisted, in spite of an 
 operation, at which it was said a gastrojejunostomy was 
 performed. In both cases the #-ray findings were most 
 suggestive of an ordinary pyloric obstruction, and no trace 
 of a stoma could be seen. At the operations it was found that 
 no gastrojejunostomy had been performed. 
 
 In case 10 it was impossible to detect the cause of the delay 
 in emptying of the stomach, which was almost as marked 
 after as before the operation. The stomach was completely 
 atonic and, with the inefficient apparatus then in use, it was 
 impossible to make certain of details in the pelvis. 
 
 In case 594 the stoma was working perfectly, and no cause 
 for the persistence of symptoms was seen. On reopening the 
 abdomen it was found that the stomach was adherent to the 
 anterior abdominal wall, and the breaking down of these 
 adhesions brought about a cure. 
 
Incidence of lesions 53 
 
 INCIDENCE OF LESIONS OF THE STOMACH. 
 
 Il is interesting to nolc the sex incidence, of diseases of the 
 
 stomach as shown by figures taken from the tables included 
 in this thesis. The extraordinary preponderance <>f ul<<-rs of 
 
 the body of the stomach in females is most marked, almost 
 5 to i, while from lesions of the pylorus, including both simple 
 and malignant, the male sex appears to suffer most frequently 
 in the proportion of 9 to 7. The male sex also suffers most 
 frequently from carcinoma of the stomach (excluding pyloric 
 cancer), in the proportion of 2 to 1 . 
 
 The number of cases is comparatively small but the figures 
 are somewhat striking. 
 
 
 Ulcers of the body 
 of the Stomach. 
 
 Pyloric 
 Lesions. 
 
 Carcinoma of 
 the Stomach. 
 
 Total - 
 
 Male 
 
 8 
 
 54 
 
 16 .... 
 
 .. 78 
 
 Female 
 
 ••• 39 
 
 42 . 
 
 8 .... 
 
 .. 89 
 
 Total ... 47 96 24 167 
 
 Amongst the cases in which the symptom complex of 
 duodenal irritation was seen (see p. 54, et seq.) there are 
 30 males and only 8 females. In these cases although the 
 symptoms were gastric, the lesions were for the most part 
 secondary or referred. If these cases are included in the 
 tables the proportion of incidence of gastric symptoms is 
 nearly equal in the two sexes. 
 
 It would appear that success from operative treatment was 
 more probable in men than in women, for out of the 29 cases 
 in which the symptoms had recurred or in which the operation 
 had failed to give complete relief only 7 were males while 22 
 were females, but in two of the latter the subsequent operation 
 revealed the fact that no gastroenterostomy had been 
 performed. 
 
54 
 
 CHAPTER VII, 
 SMALL INTESTINE. 
 
 The food passes through the small intestines very rapidly, 
 it is squirted through the pylorus and sometimes, though I 
 do not consider it normal, it may be seen going round 
 the loop of the duodenum. The manner in which the food 
 passes on is peculiar. If a bolus can be seen in the jejunum, 
 it can be made out that it is tossed backwards and forwards, 
 gradually passing onwards. Together with these peristaltic 
 movements there is continual segmentation of the bolus going 
 on, so that almost immediately it is shredded into minute 
 sub-divisions and mixed with the secretions of digestion to 
 such an extent that, beyond a general impression of opacity 
 in the abdomen, no trace of the bismuth is seen until the 
 shadow appears near the caecum. An instantaneous radio- 
 gram, however, will show the fine division of the food that 
 has gone on. 
 
 In tubercular peritonitis and other forms of adhesive 
 peritonitis, I find that the segmentation contractions, if one 
 may call them by such a name, are defective, with the result J 
 that definite shadows are seen in various coils of small 
 intestine. Several instances of lesions of the jejunum have 
 been met with and in each of them, besides the evidence of 
 obstruction, a well marked duodenal symptom-complex has 
 been noted. 
 
 DUODENAL ULCER. 
 
 This condition cannot be definitely determined by x-ray 
 examination, but there is a symptom-complex which is very 
 strongly suggestive, if not of actual ulceration, at any rate of 
 irritation of the duodenum. The various points that are 
 noted are : — 
 
 (i) The stomach always exhibits good tone, even if ptosis 
 is present. Hypertonus is often noted. 
 
Notes on duodenal cases 55 
 
 (2) The peristalsis is more active than normal, esper ially 
 when the food has lonimciK :cd (o pass i h rough the duodenum. 
 
 (3) The food begins i<> leave the stomach almost at once 
 and as <-i rule continues <<> pass out very rapidly until the 
 stomach is empty. 
 
 (4) The pyloric relaxation is so < omplete thai large masses 
 of food arc seen passing through the duodenum instead oi 
 the line, almost imperceptible stream, thai ran only be 
 detected with certainty by means of an instantaneous 
 radiogram. In certain cases a separate bolus is seen remain- 
 ing, apparently in a pocket, in the duodenum. 
 
 Notes on Cases of Duodenal Irritation. 
 (Cases on p. 81 .) 
 
 I have separated these cases out from among those which 
 I had at first classified as normal because, although the 
 stomach appears to be quite normal both radiographically 
 and on the operation table, yet they appeared to show certain 
 radiographic features that I have learned to regard as a 
 symptom-complex. 1 It is quite possible that my own 
 technique (i.e., giving only a comparatively small quantity 
 of bismuth food made with bread and milk) is more favourable 
 for demonstrating this sypmtom-complex than that of some 
 other observers, as one worker (Dr. Thurstan Holland, of 
 Liverpool) has told me privately that he sometimes obtains 
 the signs I have described in perfectly normal subjects. On 
 the other hand, Hertz 2 has arrived at the same conclusions and 
 also Rowden, 3 of Leeds, who examines Mr. Movnihan's 
 cases. 
 
 The symptom-complex consists of the following signs: — 
 
 (1) A normal stomach but always more or less hypertonic. 
 
 (2) Active peristalsis. 
 
 (3) Rapid emptying of the stomach. 
 
 (4) Food seen passing through the duodenum with, or 
 
 without a persistent shadow in some part of the 
 duodenum. 
 
 1. " B. M. J./' Sept., 1910 ; " Archiv Rontgen Ray." Oct.. 1910. 
 
 2. A. F. Hertz. " Sensibility of the Alimentary Canal," 1911. p. 59. 
 
 3. B. G. A. Moynihan. "Lancet," January. 6. 1912. 
 
56 Gastric and oesophageal affections 
 
 (i) The stomach is invariably 4 J' shaped and not a trace 
 of atony is observed. In fact hypertony is often so marked 
 that it may require quite a large quantity of food to canalize 
 the empty stomach. Such cases are at first suggestive of an 
 hour-glass contraction, and in two of them (Nos. 97 and 273) 
 I actually suspected the presence of an organic lesion half-way 
 down the stomach, because of the way in which the contraction 
 of the walls resisted the passage of the food. 
 
 The action of gravity is an important factor in canalizing 
 the empty stomach, and it frequently happens that at the 
 lowest part of the organ there is a considerable pause in the 
 progress of the food before it enters the pars pylorica. 
 H. M. W. Gray, of Aberdeen, 1 interpreted this sign as an 
 indication that there is normally a sphincter at this point, 
 probably indicated by the incisura of His, and on this theory 
 laid it down that the stoma of a gastrojejunostomy should 
 be made beyond this point. 
 
 (2) Active peristalsis. This feature is often not observed 
 till the first food has entered the duodenum. One would not 
 describe the waves of contraction as excessive, but, on the 
 other hand, they are much more active than usual and segment 
 the shadow perhaps three inches from the pylorus. Such 
 peristalsis is seen in early stages of pyloric obstruction, but 
 in duodenal irritation there is no obstruction, in fact the pylorus 
 allows the food to pass on more rapidly than usual. 
 
 (3) The rapid emptying. The early observations I made 
 on cases of duodenal ulceration proved one point conclusively, 
 namely, that the stomach began to empty itself extremely 
 rapidly and in a manner that was not observed in the normal 
 healthy subject. In some cases a meal of half a pint of 
 bismuth food had left the stomach in less than half an hour 
 and it was exceptional to find more than a very small quantity 
 in the stomach after three-quarters of an hour. In only one 
 
 1. "Lancet," February 22, 1908, p. 549, and July 25, 1908, p. 224, and 
 December 3, 1910, p. 1610. 
 
Notes on duodenal cases 57 
 
 case (No. (>(>) was any delay in emptying noted, and in this 
 
 the duodenal canal was stenosed by the cicatrization. 1 
 
 Not only does the food pass out rapidly from the stomach 
 but il seems to reach I he large intestine in an extraordinarily 
 short time. I noted shadows in the caecum in half an hour 
 
 in one case. Il is likely thai this activity of llie whole tract 
 accounts for the frequent clinical history "My food does not 
 do me any good." 
 
 (4) Food seen passing through the duodenum. In the 
 healthy subject I do not expect to see the food passing through 
 the duodenum — it leaves the pylorus in such a line stream 
 that it is only by means of an instantaneous radiogram that 
 it can be detected with certainty, whereas in these cases one 
 sees quite large shadows pass through the duodenum, and 
 even the untrained observer has no difficulty in tracing the 
 progress from the pylorus to the duodenojejunal flexure, 
 although from this point onwards the sub-division of the food 
 proceeds so rapidly that no trace of it is seen on the screen. 
 The appearance is as if there were sudden intermittent relaxa- 
 tions of the pylorus that allowed more food to pass through 
 than the duodenum was capable of dealing with. 
 
 It is not after every peristaltic wave that the pylorus opens 
 in this way, nor is it necessarily in response to a specially 
 powerful wave, although it is always as a ring of contraction 
 forces the food against the pylorus that the shadow is seen 
 passing through the duodenum. 2 
 
 1. Although the food begins to pass out rapidly it does not necessarily 
 follow that the stomach is emptied quickly, for in several instances there has 
 been a little food still present after 5 hours, although no pelvic lesion could be 
 found at the operation ; only the duodenal ulcer. 
 
 2. This appearance can be produced artificially by giving a large quantity 
 of food rapidly, and on one occasion I even obtained distension of the 
 duodenum, but this was in a patient whose mental state was not stable. He 
 wished to prove that his stomach was abnormal, and although he had been 
 operated on, and although I had examined him previously on two separate 
 occasions, he would have me make an observation when he had ' quite filled ' 
 his stomach. He swallowed four pints of custard mixed with S oz. of bismuth 
 carbonate, and this distended the stomach, probably causing some pressure 
 on the duodeno-jejunal flexure, with the result that the duodenum also was 
 distended. (No constipation or pathological effect was noted as the result of 
 this huge dose of bismuth.) Dr. A. C. Jordan recently read a paper before 
 the Electro-Therapeutic Section of the Royal Society of Medicine ("Proc. 
 Roy. Soc. Med.," Dec, 1911), in which he described kinking of the 
 duodeno-jejunal flexure, and I believe that in the majority of his cases his 
 technique approximated to the above observation. He has told me privately 
 that with the ordinary methods he failed to obtain the appearances he 
 described. In my list of cases only one (No. 49S) showed obstruction at the 
 duodeno-jejunal flexure. 
 
58 Gastric and oesophageal affections 
 
 Where the ulcer or cicatrix is situated on the lower border 
 of the first part of the duodenum, it is sometimes found 
 that there is a definite shadow of retained food in this position 
 which appears to be almost continuous with the gastric 
 shadow. It is, however, unaffected by the peristalsis of the 
 stomach. When gastric peristalsis is well marked, it forms a 
 complete ring towards the pylorus, cutting off a portion of 
 the shadow which gradually diminishes in size as the con- 
 stricting ring passes on, the food escaping back into the 
 stomach. The shadow of food retained in the duodenum, 
 on the other hand, is unaffected by the peristalsis, and is 
 always present until after the stomach is empty. This picture 
 is only suggestive of duodenal ulcer in one position and is 
 not diagnostic, since it may be due to puckering of the 
 duodenum from other causes, such as carcinoma and 
 cicatricial conditions in this region, e.g., cholecystitis. 
 
 Examination of the patient, in the recumbent position, 
 may demonstrate a similar condition on the posterior wall of 
 the duodenum, and it is usual to examine all these cases in 
 the horizontal as well as in the upright position, because the 
 passage of food through the duodenum can be better seen 
 with the patient lying down than when he is standing up. 
 
 Very frequently a 'caput duodeni,' a shadow just beyond 
 the pylorus, is constantly noted until the stomach is empty, 
 but this is not I think of pathological significance; it is 
 often seen in cases where the duodenal symptom-complex 
 is not present. The appearance suggests that there may be, 
 in certain subjects at any rate, a second sphincter just beyond 
 the pylorus that is supplementary to the pylorus in regulating 
 the supply of food to the duodenum. 
 
 Apart from this 'caput duodeni,' a separate shadow seen 
 in the duodenum is very suggestive of the formation of a 
 pocket by spasmodic contraction, cicatrization, adhesions, or 
 growth. The appearance is not typical of any one condition. 
 In two of the cases (81 and 92) this feature was only detected 
 when the patient lay down. 
 Exceptions and anomalies. 
 
 In two cases only (Nos. 240 and 241) a duodenal ulcer was 
 
Notes on duodenal cases 59 
 
 said to be present (by the same operator) when the symptom- 
 complex was not noted, but case No. 241 died from an OCCtlll 
 haemorrhage a few days subsequently, and at the post-mortem 
 not only was no cause found for the bleeding, but also there 
 was a complete absence of even a suspicion of ulceration, 
 although grey patches were observed on the peritoneum. 
 Case 241 is therefore placed under the normals, while rase 240 
 remains in (his class, although somewhat discounted bv the 
 post-mortem on case No. 241. Slighl atony was noted in 
 only one case (No. 501) although all the other features were 
 well marked, while gastroptosis with absence of all the features 
 of the symptom-complex occurred in case 730. 
 
 In all these cases a certain train of appearances was estab- 
 lished, and on analysis I found : — 
 
 Duodenal ulceration - - 14 cases. 
 
 Cicatrization of the duodenum - 7 ,, 
 
 Adhesions about duodenum (gener- 
 ally in connection with gall-bladder) 13 ,, 
 
 Carcinoma in this region - - 3 ,, 
 
 Appendicitis, abscess - - - 1 ,, 
 
 Appendix fixed by adhesions near to 
 duodenum ----- 1 ,, 
 I used to record only the actual gastric lesion in my own 
 notes and did not appreciate the possible importance of 
 evidence of old appendicitis or other abdominal inflammation 
 as a possible primary cause of the trouble. 
 
 It seems probable that many different lesions in the 
 abdomen may give rise to what I believe to be irritation of 
 the duodenum, and will give rise to this symptom-complex 
 although it is most frequently found in association with actual 
 pathological lesions affecting the duodenum itself. 
 
 It often looks as if the ' duodenal irritation ' was the result 
 of some other lesion within the abdomen (as in case 658), and 
 that the presence or absence of actual ulceration was more or 
 less accidental. This is entirely in accord with Movnihan's 
 view : — ' I have long held the view that the diseases of the 
 stomach, duodenum and gall-bladder, with which the surgeon 
 deals, are not primary but secondary.' (Lancet, Jan. 6, 191 2.) 
 It is for this reason that I have termed this the symptom- 
 
60 Gastric and oesophageal affections 
 
 complex of 'duodenal irritation,' as I feel confident that 
 further investigation will prove that duodenal irritation and 
 ulceration are generally, if not always, secondary conditions. 
 
 In case 658 the symptom-complex was found in association 
 with a tubercular ulcer of the jejunum, this lesion being 
 discovered at the operation in consequence of the #-ray report, 
 while in a more recent case the same appearances were seen 
 in connection with an early carcinoma of the jejunum about 
 twelve inches from the duodenojejunal flexure. This case 
 is of particular interest as the symptoms were extremely vague, 
 and it was purely on the x-ray diagnosis of a lesion of the 
 jejunum that the operation was undertaken. Unfortunately 
 the patient died, from delayed chloroform poisoning it is 
 supposed, and the condition of the mucous membrane of the 
 duodenum showed that there had been some general inflamma- 
 tion (duodenal irritation) of which no trace could be seen on 
 the peritoneal surface. 
 
 (January 1913.) Since writing the above, 4 more cases of 
 lesions of the small intestine have been operated on, and in 
 each of them I had noted a very marked duodenal symptom- 
 complex as well as the accumulation of shadows in the small 
 intestine resulting from the obstruction and defective move- 
 ment caused by the lesion. I have also noted the symptom- 
 complex several times in association with mucous colitis. 
 In a recent case it was very markedly seen in a patient who 
 had a mouthful of septic teeth, and it was when looking for 
 a cause for the x-ray appearances, which gave one the impres- 
 sion of secondary gastric trouble, that the teeth were noted. 
 At the operation there was absolutely no evidence of present 
 or past disease to be found in the abdomen. It is also present, 
 to some extent at any rate, in appendicitis, if the symptoms 
 are at all gastric. I also noted similar appearances in a lady 
 who had quite severe symptoms, and in this case again one 
 had the impression that the symptoms were secondary. A few 
 weeks later the patient (aged 45) developed slight delusions 
 and her gastric symptoms disappeared. 
 
 The multiplicity of conditions then, in which duodenal 
 irritation, or even ulceration is noted, makes one more and 
 
Notes on duodenal cases 61 
 
 more convinced thai in the large majority of cases the 
 
 duodenal (rouble is, in the first place at any rate-, secondary. 
 
 It is as if the duodenal region were the storm centre for the 
 alimentary tract to which disturbances in other parts, or 
 possibly even in the nerve centres, mif_dil be referred, in many 
 cases before any local manifestations had developed. 
 Another interesting and suggestive phenomenon is the associa- 
 tion of spasmodic and organic hour-glass stomach with pylori' 
 obstruction (see p. 46); as if the lesions were complementary 
 the one to the other or, more likely, both secondary to some 
 common cause to which we have as yet not found the clue. 
 
 
62 
 
 CHAPTER VIII. 
 
 THE AETIOLOGY OF GASTRIC ULCER. 
 
 The aetiology of gastric ulcer has always pertained to the 
 department of the pathologist. Unfortunately the pathologist 
 can only study the dead subject and, as we know, the stomach 
 as it fulfils its functions differs widely from the flaccid sac that 
 we see in the post-mortem room or even on the operating 
 table. That morbid anatomy does not always give a true 
 picture of the cause of symptoms has been indicated on many 
 occasions and in the pages of this book there are references 
 to several cases that bear upon the point. For instance on 
 p. 16 a case of obstruction of the oesophagus is described in 
 which the patient was almost dead from starvation and the 
 oesophagus was dilated to a great extent. Yet the post-mortem 
 showed no sign of the obstruction that had been almost 
 complete nor of the dilatation that had followed, and this in 
 an extreme case in which the bismuth food was still found in 
 the oesophagus after 24 hours. Instances of spasmodic 
 contractions of the stomach of which no trace could be found 
 at the operation are very numerous. Special note is made of 
 three cases on p. 44 in which a gastroenterostomy had failed 
 to relieve symptoms and in which a very marked and persistent 
 hour-glass contraction was noted. In all these cases the 
 patient vomited from the upper sac and it was evident that the 
 hour-glass contraction was the cause of the trouble, and yet 
 no pathological change could be found to account for abnor- 
 malities that were causing symptoms which made life a 
 burden. It is clear that in many cases morbid anatomy tells 
 but half the tale, that half which relates to tissue changes and 
 infers that the functional disturbance is due entirely to these 
 changes. As I have already said (p. 40) it is often the smaller 
 ulcers (just as it is often the smaller renal calculi) that give 
 rise to the severest symptoms. On the other hand cases have 
 
The aetiology of gastric ulcer 63 
 
 been m<'i with in which gross pathological changes have 
 certainly been present in the stomach wall with practically no 
 Symptoms. A chronic penetrating nl<<-r is mentioned on 
 p. 41 as giving, and of having given, practically no trouble. 
 One of the mosl completely fibrous hour-glass contractions I 
 have seen had not given rise to very severe symptoms. In 
 fact the morbid anatomy docs not necessarily give the clue to 
 the actual disturbance and, apart from the patient's symptoms, 
 we have no guide to the functional effects of a lesion of the 
 stomach or intestines except by the r-ray method of examina- 
 tion which in its turn has its own limitations, for although it 
 shows us the functional results it is only by inference that we 
 diagnose the underlying cause, attempting to separate the 
 factors of spasm and morbid process that have produced the 
 effect. 
 
 It was while reading the final proofs of this book that the 
 ideas embodied in this chapter forced themselves upon me. 
 The interpretation of the pathology of the living assumed an 
 importance that I had not previously attached to it, even 
 though I was so fullv conscious of the importance of the 
 spasmodic element as a complication of organic lesions. And 
 this is just the crux of the whole argument. At the operation 
 one saw a small ulcer of the stomach whereas at the .r-ray 
 examination one had seen a typical and persistent hour-glass 
 contraction which must necessarily have been spasmodic. 
 One took it for granted that it was cause and effect, the ulcer 
 being the cause and the spasmodic contraction the effect 
 produced. And vet on looking back one found cases where 
 we had the effect apparentlv without the cause, the spasmodic 
 contraction without ulceration, and it was this that set me 
 thinking that perhaps cause and effect had been confused and 
 that possibly the ulceration was the effect of the spasm and 
 that the spasm was due in the first place to some other cause 
 although it could also be produced by the ulceration. 
 
 It was not a case of evolving a theorv and setting to work 
 to prove it ; the hypothesis forced itself upon me and it was 
 simply a case of analvsing the various impressions that have. 
 I believe, opened up the solution of a problem that I had no 
 
64 Gastric and oesophageal affections 
 
 thought of investigating. It is hardly likely that my observa- 
 tions cover the whole of the ground, but I am fully convinced 
 of the accuracy of the deductions as far as I have been able 
 to carry them during the few weeks that have elapsed since 
 I arrived at this new conception of their significance. 
 
 The observations on which the deductions are based are 
 as follows : — 
 
 (i) The stomach is very sensitive and many cases of 
 spasmodic contraction have been met with ranging from those 
 that were readily relaxed by massage to contractions that were 
 actually mistaken for organic lesions. Quite a large number 
 of spasmodic hour-glass stomachs have been examined and 
 found at operation to show no trace of ulceration or other 
 abnormality that, by local action, would cause the spasm. 
 These spasmodic contractions have been met with in the body 
 of the stomach and also at the pylorus. On several occasions 
 I have seen that the vomiting took place from the upper sac 
 and as soon as the food passed down the tendency to vomit 
 and the pain ceased. They are often present one day, absent 
 the next ; they can usually be relaxed by massage or manipula- 
 tion to some extent and are not necessarily found at subsequent 
 examinations. There is no pain over the site of the spasm on 
 deep palpation. 
 
 (2) Identical contractions have been met with, in fact are 
 almost invariably met with, in association with even quite 
 small ulcers, and I have always believed that the severity of 
 the spasm resulting from an ulcer was dependent on its 
 irritability and not on the size of the ulcer since small lesions 
 gave just as, if not more, marked contractions than the large 
 florid ulcerations. 
 
 (3) I have seen pyloric obstruction — as indicated by seeing 
 the greater part of the food still in the stomach after 24 hours — 
 permanently curedby removing bad teeth(p. 36). In an out-patient 
 with many decayed stumps practically the whole of the food 
 was still present in the stomach after 24 hours. On admission 
 he was made to use a tooth brush and when I examined him 
 a few days later practically all the food had passed out of the 
 stomach in five hours. He was a fairly intelligent man and 
 
The aetiology of gastric ulcer 65 
 
 had tried careful dining before he was admitted to the hospital 
 with no effect. 
 
 (4) In two cases I have been so much impressed by the 
 
 irritable appearance of the stomach that, in spin- of fairly 
 well-marked clinical evidence I reported that I though! the 
 symptoms were secondary, the condition of the teeth being in 
 
 my opinion sufficient to cause the radiographic appearances 
 noted; this in spite of the fact thai some retention of food was 
 noted on one occasion. In neither of these cases was any 
 evidence found at the operation of gastric or other intra- 
 abdominal lesion of any kind. 
 
 (5) An irritable condition of the stomach, or even an hour- 
 glass contraction, is frequently noted when there is severe 
 constipation. 
 
 (6) Spasmodic contractions, forming hour-glass stomachs 
 have been noted as being not so marked or entirely absent 
 after the bowels have been moved in cases of severe 
 constipation. 1 
 
 (7) In taking brief clinical histories of approximately 1400 
 cases I have been struck with the frequency of a history of 
 constipation and also by the presence of bad teeth or a history 
 of having had bad teeth removed after the onset of the 
 symptoms. 
 
 (8) In fully a half of the cases of ulceration of the body 
 of the stomach there was also evidence of retention of food 
 behind the pylorus and in the large majoritv of these latter 
 there was actual thickening of the pylorus. In two cases in 
 which no thickening of the pylorus was detected at the opera- 
 tion a gastrojejunostomy to the upper sac failed to cure and 
 a subsequent examination showed the bismuth retained in the 
 lower sac. A further operation showed well-marked thicken- 
 
 1. Case 713, quoted on p. 44, is instructive in this respect. There was a 
 very marked hour-glass condition in association with pyloric obstruction. 
 Nothing was found to account for the hour-glass contraction, but the pylorus 
 was thickened and therefore a gastroenterostomy was performed. I expected 
 that this patient would not be cured, but a year later he writes : " I have 
 put on two stone in weight and can eat everything. I was always very 
 costive, in fact I never had a motion without opening medicine, but have never 
 had a dose since the operation." In the light of other cases it looks as if the 
 operation had relieved the constipation and that this was the cause of the 
 spasmodic hour-glass contraction. 
 
66 Gastric and oesophageal affections 
 
 ing of the pylorus, and excision of the lower sac cured the 
 patient. 
 
 (9) In a very large number of the cases of pyloric obstruc- 
 tion a more or less marked spasmodic contraction was noted 
 in the bodv of the stomach. The relationship between spasm 
 or even ulceration of the bodv of the stomach and pyloric 
 obstruction is so marked that it can hardly be accidental. I 
 have often remarked that it looked far more as if lesions in 
 these two sites were dependent on some common cause than 
 on one another. 
 
 (10) Moynihan put into words a belief that had gradually 
 been taking shape in my own mind — " the diseases of the 
 stomach, duodenum, and gall-bladder, with which the surgeon 
 deals are not primary but secondary" (Lancet, Jan. 6, 1912). 
 I had been much impressed by what I called the inter- 
 dependence of abdominal conditions, e.g., when one found 
 an irritative condition of the large bowel, e.g., mucous colitis, 
 one usually found the appearances and often the symptoms 
 of duodenal ulcer, while in one case there was a gastric ulcer 
 with hour-glass contraction. The duodenal appearances and 
 symptoms were also noted in several cases of lesions of the 
 small intestine (carcinoma, tubercular ulcer and adhesions) in 
 which the actual site of the disease was indicated to the 
 surgeon solely by the #-ray examination. In one of these a 
 typical ulcer of the duodenum was also found, while in 
 another, who died a few days after the operation, the mucous 
 membrane was injected and inflamed although there was no 
 evidence of this on the peritoneal surface. In appendicitis, 
 when there were gastric symptoms, these same appearances 
 indicating duodenal irritation were also noted from time to 
 time at the #-ray examination. 
 
 (11) The excessive and rapid formation of gastric secretion 
 has been noted in all the later cases in which a pyloric ulcer 
 has been found, except those in which marked retention of 
 food was also present, this feature making it impossible to 
 detect the hypersecretion. Well-marked hypersecretion has 
 been noted in cases where there was slight delay in emptying 
 (six hours), and under medical treatment not only has the 
 
The aetiology of gastric ulcer 67 
 
 delay in emptying disappeared but also no hypersecretion 
 could afterwards be detected. The hypersecretion seems to 
 
 be the accompaniment of pyloric; lesions and disappears with 
 the pyloric " irritation." I have not yet seen hypersecretion 
 in association with an ulcer of the body of the stomach unless 
 there was an actual lesion of the pylorus also present. 1 In 
 one instance I found what was evidently the upper sac of an 
 hour-glass contraction of cicatricial type, and during the half- 
 hour I had the patient under observation (the surgeon was 
 waiting- to operate) only a very small quantity of food found 
 its way through into the lower sac but there was profuse 
 secretion into the upper sac and, as suspected, this indicated 
 an active ulcer of the pylorus. At the operation there was 
 only a very narrow channel connecting the upper and lower 
 sacs so that the secretion must have been poured out from 
 the cardiac end, suggesting very strongly that the hyper- 
 secretion of pyloric ulcer is a general secretory activity, 
 probably reflex, and not a local hypersecretion dependent on 
 the direct irritation of the ulceration. Whether the pyloric 
 lesion is the result of the hypersecretion or vice versa one 
 cannot say, but I suspect that they are both dependent on a 
 common cause and not necessarily on one another. 
 
 (12) In operations for gastric and duodenal ulcer there is 
 very frequently evidence of old appendix trouble. 
 
 (13) Gastric symptoms — the old symptom-complex of 
 gastric ulcer— have been cured by short circuiting the large 
 intestine in a case of severe constipation. (Lancet, February 
 8, 1913. Paris correspondent.) 
 
 (14) My own personal experience of oral sepsis indicates 
 that this is always worse when I am run down and improves 
 as soon as I take a holiday. Occasionally when I am below 
 par I have acid risings into my mouth, probably indicating 
 an excessive formation of gastric juice such as I have 
 frequently noted in association with pyloric ulcer in marked 
 cases, with "pyloric irritation" in the less marked cases. 
 
 1. If the stomach is emptying rapidly one has not the same chance of detecting 
 the presence of hypersecretion. 
 
68 Gastric and oesophageal affections 
 
 On two occasions I have been conscious of retention of 
 food for a prolonged period and once I actually brought up a 
 mouthful that contained fragments taken on the previous day. 
 A more thorough and persistent use of an antiseptic mouth 
 wash relieved this unpleasant symptom within the course of 3. 
 couple of days. 
 
 Occasionally I am also troubled with slight hunger pain. 
 
 I am certain I do not suffer from any gastric lesion for I 
 have perfect digestion in the ordinary course of events and do 
 not know what indigestion is nor does the radiographic 
 examination reveal any abnormality. 
 
 (15) The experimental production of gastric ulcer in 
 animals shows that these always tend to heal very rapidly and 
 a typical chronic ulcer has not yet, I believe, been produced, 
 even by causing local thrombosis. 
 
 (16) I know that there is considerable literature on the 
 subject but I have seen no case in which ulceration has taken 
 place at the site of a gastro-enterostomy ; and yet at this point 
 the mucous membrane is comparatively roughly joined, and 
 one would certainly expect that if ulceration was caused by 
 the action of the gastric juice this would be a very common 
 sequence to the operation, especially when we remember that 
 in most of the operations a clamp is used that must produce a 
 certain amount of bruising. This is certainly not the case 
 in the hospital with which I am connected 1 and it is incon- 
 ceivable that the mucous membrane is brought into perfect 
 apposition in every case. 
 
 (17) In the duodenum the conditions do not appear to be 
 exactly the same as in the stomach. Observations show 
 that in every case of duodenal ulcer, and also where there is 
 duodenal irritation, the stomach begins to empty itself very 
 rapidly and one can easily see quite large shadows pass 
 
 1. Neither the pathologist nor any of the surgeons at the Manchester Royal 
 Infirmary have seen a single case of ulcer occurring at the site of the stoma 
 (gastro-jejunal ulcer) nor have they seen a jejunal ulcer. The only case of 
 ulceration occurring in this region was an acute ulcerative process that almost 
 separated the jejunum from the stomach, but this was four years after the 
 operation had been performed. 
 
The aetiology of gastric ulcer 69 
 
 through the duodenum. In some cases there is a separate 
 bolus persistently present in some p-i n .-is if ,-i pocket was 
 formed but, in spiic of large- quantities passing through, I 
 have very seldom observed obstruction, and whenever this 
 has been seen there has been definite cicatrization or some 
 external cause found at the operation to account for the 
 retention. 1 1 seems therefore as if spasm, as seen in the 
 stomach, is not associated in the same way with duodenal 
 ulceration and I think i( likely thai some Other influence is at 
 work in these cases. 'The conditions thai obtain in the 
 Stomach and duodenum during life are as yet only partly 
 understood and the various factors that control the passage 
 of the food through the pylorus are by no means clear. I 
 have given my reasons (p. 26) for believing that the control 
 of the pylorus is influenced by the duodenal condition. In 
 all cases of duodenal ulcer and of duodenal irritation one sees 
 very abnormal pyloric relaxation as evidenced by the passage 
 of large masses of food, whereas in the normal subject it is 
 practically impossible to see the food passing through the duo- 
 denum, so fine is the stream that passes through the pylorus, 
 and so rapid the segmentation and shredding of the food. The 
 appearances suggest that the segmentation contractions that 
 normally shred the food in the small intestine are absent in 
 the duodenum when there is ulceration or irritation, otherwise 
 the large shadows would not be seen in the duodenum. We 
 know, therefore, that the pylorus is abnormally relaxed in 
 these cases and one suspects that the relaxation extends to 
 the duodenum and that the relaxation is sufficient to counter- 
 balance whatever tendency towards spasmodic contraction the 
 ulceration might give rise to. The absence of a spasmodic 
 contraction in these cases would account for the fact that they 
 frequently heal spontaneously, but the causation of these ulcers 
 does not appear to be the same as in gastric ulcer. 
 
 Taking all these observations together I think that they 
 become intelligible on the following hypothesis : — 
 
 Septic conditions in the mouth or other sources of 
 swallowed septic matter, constipation, mucous colitis and a 
 variety of other conditions are capable of producing spasmodic 
 
 1/ 
 
70 Gastric and oesophageal affections 
 
 contractions of various parts of the stomach. The spasm 
 produces a narrowing of the lumen that is of great functional 
 importance, causing a definite obstruction to the passage of 
 food. By an indiscretion of diet or want of masticaton some- 
 thing too large to pass easily through the channel has to be 
 forced through by powerful peristalsis. This leads to an 
 abrasion at the point where the lumen is narrowed and where 
 there is the constant irritation of food passing over it. Also 
 a surface is exposed that is not structurally fitted to withstand 
 the action of the gastric juice. In this way an ulcer is formed 
 which in its turn perpetuates the original spasm that deter- 
 mined the site of the ulcer. A vicious circle is established, 
 the ulcer now being actually the cause of spasm that prevents 
 healing so that even if the original cause of the spasm is 
 removed there is little if any improvement in the local 
 condition. 
 
 The stomach and duodenum are, as it were, the storm 
 centre for the alimentary tract to which peripheral stimuli are 
 referred, the result being either a general irritable condition 
 of the stomach and duodenum or spasmodic contractions of 
 one or more parts of the stomach. These stimuli are 
 referred to the stomach and duodenum either directly, from 
 swallowed septic matter, or indirectly from lower parts of 
 the tract as in the case of lesions of the small intestine as 
 indicated radiographically and proved by operation ; as in 
 the mucous colitis cases and constipation cases as indicated 
 radiographically and also by the subsequent history of 
 the cases. 
 
 Appendix dyspepsia is too well known to need mention. 
 Radiographically it is indicated as a rule by duodenal irritation 
 and Moynihan tells of the very large percentage of duodenal 
 ulcer cases in which there is evidence of old appendicular 
 trouble. 
 
 Now these spasmodic contractions give rise to all the 
 radiographic appearances of actual lesions — on more than one 
 occasion a surgeon has re-opened an abdomen at my sugges- 
 tion because of the persistent hour-glass contraction that has 
 been noted above the stoma of a gastro-enterostomy which was 
 
•• The aetiology of gastric ulcer 71 
 
 functioning perfectly. Three of these patients were actually 
 
 observed vomiting from f lie upper sac ol the hour-glass 
 
 contraction, the pain and tendency i<» vomit disappearing 
 when once the food had passed down into the lower sac, and 
 
 yet no' cause was found a! the operation to accounl lor the 
 contraction. In several cases where I have reported definite 
 pyloric obstruction the surgeon could find nothing to indicate 
 gastroenterostomy, and in two of them a subsequent operation 
 showed thickening of the pylorus. There are many cases of 
 various types all pointing in no uncertain manner to the 
 obvious conclusion that the spasmodic contraction is of as 
 great importance functionally, as the organic, and that these 
 apparently purely spasmodic contractions are replaced by 
 actual organic lesions has been actually noted in some two or 
 three cases in which a second operation has been undertaken. 
 (This has been noted only at the pylorus as yet.) 
 
 That ulcerations of the alimentary tract are irritable and 
 give rise to spasmodic contractions 1 have seen proved time 
 and again, e.g.,, ulcers of the cesophagus tiiat only caused 
 symptoms (and obstruction) after the patient took dry bread 
 crumbs. (The ulcers were actually seen through the cesopha- 
 goscope afterwards.) The same has been noted in the stomach 
 very frequently. Hour-glass contractions with retention of 
 food in the upper sac have often been found, at operation, to 
 be due to quite small ulcers with practically no cicatrization. 
 
 If my contention is correct that purely spasmodic contrac- 
 tions are capable of producing functional obstruction which 
 leads to trauma of the mucous membrane, and that this ulcer 
 or abrasion is itself capable of producing a similar spasmodic 
 contraction, it follows that when once an ulcer is formed it 
 will perpetuate the spasmodic contraction even if the primary 
 cause of the spasm is removed. Hence it is clear that 
 removing the primary cause will not cure the patient, for the 
 ulcer when once formed continues to induce a spasm that 
 tends to the perpetuation of the ulcer. If on the other hand 
 an ulcer or abrasion has not occurred, the removal of the 
 primary cause whether it be teeth, nasal discharge or 
 swallowed pulmonary discharge, stagnation of faeces. appendix 
 
72 Gastric and oesophageal affections 
 
 inflammation or some other cause, will probably bring about 
 a rapid and lasting cure of the patient. It is probable 
 therefore that the chief factor in the production of gastric 
 ulcer is a physical one, but the connection between the various 
 primary conditions and the spasmodic contractions they 
 produce is a problem that is beyond the reach of radiography. 
 This theory covers the whole of the many and varied 
 observations I have detailed and I believe accounts satisfac- 
 torily for them all, including the failure to produce gastric 
 ulcers artificially that are comparable to those met with in man. 
 To what extent the gastric juice is responsible I cannot say, 
 but it seems reasonable to suppose that when once an abrasion 
 is formed a surface is exposed that is not adapted to withstand 
 the action of the gastric juice and will therefore tend towards 
 the extension of the ulceration. 
 
73 
 
 CHAPTER IX. 
 
 CONCLUSIONS. 
 
 The progress thai lias been achieved in (he diagnosis of 
 gastric disorders by means of I he bismuth method, has been 
 very marked during (he five and a half years in which the 
 material for this thesis has been collected. I have been 
 present at as many of the operations as possible, but have 
 had to take my records from the operation books in a very 
 large proportion of cases, and during the first two and a half 
 years the work was anything but encouraging. The opinions 
 I gave as the result of the /r-ray examination were as often 
 wrong as right, and in many of the failures in diagnosis it 
 seemed that I was hopelessly beside the mark; so much so, 
 that at times I had little confidence in the work and little hope 
 of ever becoming successful, the results were seemingly so 
 contradictory. During the next eighteen months, however, 
 the apparent inconsistencies gradually became fewer in 
 number, but even so it seemed doubtful if the results obtained 
 were worth the time and labour involved, especiallv when one 
 had to choose between this branch of investigation and others 
 which one knew would yield satisfactory results if one had 
 time to develop them. I had much encouragement from the 
 physicians and surgeons of the Manchester Roval Infirmary 
 and Ancoats Hospital, who have in this and other matters 
 always been most helpful to both my partner, Dr. Bythell, 
 and myself, when we have been carrying out any work. 
 During the last eighteen months the results have been much 
 more satisfactory, and the operative findings have seldom 
 shown anything that had not been indicated by the .r-ray 
 examination, although of course I did not always read the 
 signs aright. Some of the failures in diagnosis were in 
 connection with ulceration involving the lesser curvature, 
 which occasionally seems to give rise to no spasmodic 
 contraction ; as if some ulcers in this region were either not 
 
74 Gastric and oesophageal affections 
 
 irritable or interfered with the nerve fibres that should set 
 up localised spasm. 
 
 Purely spasmodic contractions have been another cause of 
 failure, but these have very seldom given rise to mistaken 
 diagnosis if the massage test was properlv applied, and if the 
 patients were re-examined as a routine procedure, a condition 
 that is often difficult to hold to in hospital practice owing to 
 the pressure on accommodation of the surgical beds. 
 
 The pars pylorica is still the most difficult region of the 
 stomach about which to obtain reliable information, and the 
 appearances of this part very seldom reveal such details 
 as will assist in the diagnosis. One has therefore to rely 
 almost entirely on the deductive evidence obtained from the 
 rate at which the food leaves the stomach, the tonic action, 
 the peristalsis, secretion, and so forth. 
 
 The point has not yet been reached at which it is possible 
 to say, ' there is no active pathological lesion of the stomach 
 walls ' — one has so often to make reservations as to the pars 
 pylorica; but, on the other hand, evidence is accumulating 
 that will I believe very soon lead to the possibility of always 
 making a definite positive diagnosis of pyloric ulcers, and 
 when this becomes possible, one w-ill be able to give a 
 definite negative diagnosis in the large number of cases of 
 suspected gastric trouble in which the dyspepsia is functional 
 or secondary to some other trouble. 
 
 The certainty with which pyloric ulcers (or, if one may 
 say it, pyloric irritation) may be distinguished from duodenal 
 ulcers (or duodenal irritation), is in marked contrast to the 
 clinical differentiation of these cases. 
 
 Defective tonic action is also rather troublesome in) making 
 a negative diagnosis, but the appreciation of the changes 
 brought about by defect of tone becomes intuitive after a time, 
 and I am now seldom troubled by the appearances it causes. 
 
 The connection between the train of symptoms, which I 
 have discussed under the head of duodenal irritation (p. 55), 
 with other lesions of the intestinal tract is most striking, and 
 confirms the impression that I took from A^r. Moynihan's 
 
Conclusion 75 
 
 lecture before the Manchester Pathological Society,* that 
 duodenal ulcer is probably often a secondary lesion. As I 
 
 wrile I have .'i patient under observation in whom this ir;iin 
 
 of symptoms is well marked, and the examination I have jusi 
 made (20 minutes after the food was taken) reveals a large 
 collection of bismuth in the jejunum, and, if confirmed, is 
 
 almost certainly indicative of adhesions or, us in the last 
 similar case, an ulcer of the jejunum, while the clinical 
 
 evidence only suggests duodenal ulceration. 
 
 In taking notes of all the cases the persistent recurrence 
 of a history of severe constipation, especially in women, s<-<-m 
 to indicate that the association of gastric lesions with this 
 trouble is more than a coincidence. In many cases 
 chiefly men, the teeth have been in a bad state, sometimes 
 actually at the time of the examination, and on several 
 occasions the cleaning up of the mouth has brought about a 
 wonderful change not only in the patient's condition, but also 
 in the #-ray appearances. Cases that have been diagnosed 
 clinically and confirmed radiographically as duodenal ulcer, 
 cases of pyloric obstruction with marked delay in emptying 
 and spasmodic contractions of the stomach, have all been cured 
 by attention to the teeth and bowels. 1 have little doubt now that 
 constipation and bad teeth are two of the main factors in deter- 
 mining the onset of ulceration of the stomach and duodenum. 
 Whether or not they are the actual causes 1 cannot say but 
 they are both capable of giving rise to spasmodic contractions 
 which have almost all the appearances of pathological changes 
 in the stomach walls. One is more and more impressed with the 
 importance of the physical element of spasm, not only in the 
 causation of true visceral pain but also perhaps in the actual 
 production of some of those lesions of the alimentary canal 
 that were at one time regarded as primary. 
 
 Statistics are of course worth very little, nevertheless 
 I thought it would be instructive to take at random from my 
 files the records of thirty consecutive cases and summarise 
 the results. In 19 I gave a definite report that was entirely 
 
 *" Lancet." February 24, 1912. 
 
76 Gastric and oesophageal affections 
 
 in accord with the operative findings. In six the diagnosis 
 was quite correct, but I could not give such a definite 
 report, e.g., suggesting that there was probably an ulcer or 
 growth present, but that the £-ray evidence was not sufficiently 
 definite to justify the diagnosis. Of the remaining five, 
 I find as follows: — (i) a case of extraordinary extensive 
 adhesions to the liver, which I had diagnosed definitely as a 
 carcinoma obliterating the gastric cavity ; (2) a case which I 
 only had the opportunity of seeing on one occasion, I mistook 
 a spasmodic hour-glass for an organic lesion, but also 
 suggested the probability of an ulcer at the pylorus, which 
 was found at the operation ; (3 and 4) in two cases I found no 
 evidence of ulceration, and the operation showed the presence 
 of an ulcer of the lesser curvature, in one case at the cardiac 
 end, and in the other near the pylorus (two of the four 
 cases met with in which an ulcer failed to set up a spasmodic- 
 contraction) ; (5) one case in which I gave a report that there 
 was probably an ulcer in the pyloric region. The operation 
 revealed a perfectly healthy stomach. 
 
 There is no useful purpose to be served in comparing these 
 results with those obtained by clinical methods in the same 
 series of cases, as the requisition cards are usually made out 
 by the house-surgeons or house-physicians, and are probably 
 filled in at random before an exhaustive clinical examination 
 has been made. 
 
 One conclusion is quite clear ; the more time one spends 
 on a case and the more one considers the #-ray findings in 
 connection with the clinical history, the more accurate will be 
 the diagnosis. The x-ray method is of some value by itself, 
 but when it is taken in conjunction with all the other available 
 means of investigation, it becomes the greatest of all aids we 
 possess in the diagnosis of diseases of the walls of the 
 intestinal tract. 
 
 That the work is of value is evidenced by the fact that 
 last year (191 1) I examined nearly 350 in-patients by means 
 of the bismuth method at the Royal Infirmary. But perhaps 
 the most noticeable feature is the fact that one no longer hears 
 of the successful diagnoses but of the failures. 
 
77 
 
 CHAPTER X. 
 TABULATION OF CASES. 
 
 To attempt the classification and tabulation of ili<- eighl or 
 nine hundred cases of which I have notes was obviously a 
 labour that would yield no definite information. I have 
 therefore only tabulated those in which the actual condition 
 was discovered either on the operating table or in the post- 
 mortem room, and have classed them according to the actual 
 pathological lesion found, and not according to the .r-ray 
 findings. Even so, the task was not easy, for there are many 
 cases in which the operation yields indefinite information as 
 to the exact nature of the lesion. This is especially the case 
 in pyloric obstruction, and for this reason all cases of this 
 nature, whether simple or malignant, are placed under one 
 heading. 
 
 Again, description of the operative findings is often so 
 meagre and so lacking in detail that one had to rely in many 
 cases on the memory of the surgeon or house-surgeon for 
 important information. A number of cases have been rejected 
 from this tabulation on the ground of insufficient data as to 
 the operative findings. 
 
 Class 1. Cases in which the gastric symptoms were not 
 directly due to a lesion of the stomach or duodenum. 
 
 Class 2. Cases in which the symptom-complex of duo- 
 denal irritation was found, or in which an actual 
 lesion of the duodenum was discovered. 
 
 Class 3. Cases of ulcer of the pars pylorica. 
 
 Class 4. Cases of ulceration of the body of the stomach 
 
 with or without the formation of a definite hour-glass 
 
 contraction. 
 
 Class 5. Cases of carcinoma of the body of the stomach — 
 not including pyloric carcinoma. 
 
78 Gastric and oesophageal affections 
 
 Class 6. Cases of pyloric obstruction — whether simple or 
 malignant. 
 
 Class 7. Cases in which the stomach was distorted by 
 adhesions — -apart from actual disease of the walls. 
 
 Class S. Cases in which surgical interference had not 
 been altogether successful. 
 
 I have added introductory remarks to each division with 
 a special note of any case, or class of case, to which I wished 
 to draw attention. 
 
 Strictly speaking, classes i and 2 should be under one 
 heading, but the symptom-complex of duodenal irritation 
 seems so clear that it will be readily seen why these cases are 
 classed separately. 
 
 The clinical diagnosis is taken from the requisition cards 
 which are filled up in the wards. 
 
Tables of Cases 
 
Gastric and oesophageal affections 
 
 79 
 
 ( Ulnioal 
 
 No. Ako. Sex. Diagnosis. 
 
 Clabs I. (See p. 290 
 NORMAL. 
 
 x-ray Binding! np.-n.ti ., Finding!. 
 
 
 6 53 M. 
 
 25 46 F. ? Carcinoma of 
 stomach. 
 
 28 35 F. ? Gastric ulcer ; 
 ? carcinoma of 
 stomach. 
 
 54 35 F. — 
 
 60 33 F. ? Carcinoma ; 
 
 ? gastric ulcer. 
 
 86 35 M. Pyloric ulcer. 
 102 22 F. ? Gastric ulcer. 
 
 125 39 F. — 
 
 154 40 F. ? 
 
 171 60 M. Carcinoma of 
 
 stomach. 
 182 22 M. ? 
 
 241 41 M. Duodenal ulcer. 
 
 248 70 M. Carcinoma. 
 
 249 40 F. Carcinoma of 
 
 stomach. 
 
 284 25 M. ? 
 
 296 35 F. Abdom. tumour 
 311 35 M. ? Gastric. 
 333 28 F. Gastric ulcer. 
 G 
 
 Nil. 
 
 Nil when standing; bismuth 
 segmonted over growth 
 when lying down. 
 
 Slightly atonic ; nil else. 
 
 Nil but visceroptosis. 
 
 Nil except slightly active 
 
 peristalsis. 
 Excess peristalsis ; nil else. 
 Nil except rather active 
 
 peristalsis. 
 
 Stomach normal ; nil except 
 some air swallowing 
 
 Stomach appeared to be 
 twisted upon itself ; nil else. 
 
 Nil abnormal. 
 
 Nil abnormal. 
 Nil abnormal. 
 
 Nil abnormal found. 
 Stomach atonic ; some viscero- 
 ptosis. 
 
 Normal, except rather marked 
 
 air swallowing. 
 No abnormalities found ; no 
 
 evidence of displacements. 
 Nil abnormal found. 
 
 Gastroptosis. but nil else. 
 
 .v. e\ Idenoe "' ulcer. 
 
 Carcinoma <<\ pancreas, etc. 
 stomach not invaded. 
 
 No abnormality found. 
 
 Nil in stomach ; nephropexy. 
 Nothing found. 
 
 No evidence of abnormality. 
 
 Nil except slight adhesions 
 near pylorus; no gastro- 
 jejunostomy. 
 
 Nil found ; kidneys fixed. 
 
 Nil found ; no gastro- 
 jejunostomy. 
 Carcinoma of pancreas. 
 
 Tubercular peritonitis around 
 appendix. 
 
 Surgeon described duodenal 
 scarring, and patient died 
 3 days later from occult 
 haemorrhage for which no 
 cause was found. 
 
 Abscess near appendix. 
 
 No abnormalities found, but 
 gastrojejunostomy per- 
 formed. 
 
 Appendix removed. 
 
 No abnormalities found. 
 
 Appendix thickened with ad- 
 hesions. 
 
 Nil in stomach : kidneys low 
 down : nephropexy. 
 
 J<-j'lh' 
 
 did I". t 
 relieve 
 
 rn« 
 
 .t DO 
 better. 
 
 Relieved. 
 
 No benefit. 
 
 Patient cured 
 
 No duodenal 
 ulceration 
 found at 
 post-mortem 
 
 Cured. 
 
80 
 
 Gastric and oesophageal affections 
 
 Clinical 
 No Age. Sex. Diagnosis 
 
 X-ray Findings. 
 
 Operative Findings. 
 
 Remarks 
 
 337 3S M. ? Gastric ulcer. 
 369 44 M. Dilat. stomach. 
 
 372 24 F. Dilat. stomach. 
 
 398 38 F. Dilat. stomach ; 
 
 ? Gastric ulcer. 
 
 402 33 F. 
 405 50 F. 
 423 47 M. 
 476 38 M. 
 478 27 M. 
 481 64 M. 
 485 30 M. 
 489 48 M. 
 497 26 F. 
 555 59 F. 
 593a47 M. 
 706 57 M. 
 612 47 M. 
 716 27 F. 
 721 36 F. 
 761 49 M. 
 
 772 47 M. 
 791 34 F. 
 
 Gastric ulcer. 
 
 Dilat. stomach. 
 
 Carcinoma ? of 
 stomach. 
 ? Gastric ulcer. 
 
 Gastric ulcer 
 
 Carcinoma of 
 stomach. 
 
 Gastric ulcer ? 
 Gastritis. 
 
 Carcinoma of 
 stomach. 
 
 Pyloric obstruc- 
 tion. 
 
 Duodenal ulcer. 
 
 Duodenal ulcer. 
 
 ? Gastric ulcer ; 
 
 ? appendix. 
 ? Tumour ; 
 
 ? gastric. 
 Carcinoma of 
 
 stomach. 
 
 Carcinoma of 
 
 stomach. 
 ? Gastric ulcer. 
 
 Stomach not involved 
 by the growth. 
 
 Stomach normal, except 
 marked contraction near 
 pylorus ; looked like car- 
 cinoma. 
 
 Aerophagy ; spasm of middle. 
 
 Hour-glass marked ; vomiting 
 from upper sac. 
 
 Nil except active peristalsis. 
 
 Nil found. 
 
 Nil, stomach displaced, but 
 
 not involved. 
 Nil peristalsis rather active. 
 
 Nil abnormal. 
 
 Nil abnormal noted. 
 
 Slightly atonic. 
 
 Nil. 
 
 Irregular card ; end looked 
 
 like adhesions. 
 Growth displacing stomach. 
 
 Nil abnormal. 
 
 Nil abnormal. 
 
 Normal. 
 
 Gastroptosis ; nil else. 
 
 Tumour not in relationship to 
 
 stomach. 
 (Esophagus obstructed with 
 
 pouching ; stomach looks 
 
 normal. 
 Stomach normal. 
 
 Stomach normal ; rather active 
 secretion; active peristalsis. 
 
 Growth of splenic flexure, 
 adherent to stomach. 
 
 Nil found; no gastro- 
 jejunostomy. 
 
 Nil found. 
 
 Nothing to account for the 
 hour-glass ; appendix re- 
 moved. 
 
 Appendix removed ; nil in 
 
 stomach. 
 Nil. 
 
 Growth of colon. 
 
 Nil in stomach; chronic ap- 
 pendix. 
 Nil; old appendix. 
 
 Stone gall-bladder. 
 
 Appendix removed; nil in 
 
 stomach. 
 Stomach normal ; appendix 
 
 removed. 
 Nil. 
 
 Growth of gall-bladder. 
 
 Gall-stones. 
 
 Growth of pancreas. 
 
 Few adhesions duodenum to 
 gall-bladder. 
 Stomach normal ; inflamed 
 
 appendix. 
 Growth of kidneys ; stomach 
 
 not involved. 
 Stomach normal ; gastrostomy. 
 
 Carcinoma of hepatic flexure. 
 Nil found in stomach. 
 
 Spasm 
 cured by 
 laparotomy. 
 
 Cured 5 
 weeks after 
 operation, 
 but relapsed. 
 
Gastric and oesophageal affections 
 
 81 
 
 Class II. (See p. 55.) 
 DUODENAL IRRITATION. 
 
 Hi/ "normal stomach" in their crises I mean that the organ exhibits eithci perfect tonu action 01 
 
 'more often In/perlon'icx. The .separate bolus in the duodenum refei i" the l'i"i' /'•',</ ./.ai/on-H mm 
 passing through the duodenu/m, not to the stationary shadow. 
 
 Clinical 
 A.g6. Sex. IMiiKiioHiH. X-rny KlmllnKH. OpmttlT* Finding!. irk«. 
 
 30 30 M. Dilat. stomach. 
 
 Stomach normal, rapid empty 
 
 Adhesioni <>i duodenum to 
 
 
 
 ing; peristalsis active; 
 
 liver. 
 
 
 
 separate bolus in duodenum. 
 
 
 
 66 31 F. Gastric ulcer ? 
 
 Stomach normal ; pcristalsi 
 
 Definite cicatrization of duo- 
 
 
 
 active; separate bolus in 
 
 denum ; posterior gastro- 
 
 Cured. 
 
 
 duodenum ; stomach emp 
 
 jejunostomy. 
 
 
 
 tied rather slowly. 
 
 
 
 70 37 M. Duodenal ulcer. 
 
 Stomach normal ; peristalsis 
 
 Cicatrization round duo- 
 
 Cured. 
 
 
 active ; rapid emptying ; 
 
 denum ; posterior gastro- 
 
 
 
 separate bolus in duodenum 
 
 jejunostomy. 
 
 
 78 28 M. Tumour. 
 
 Stomach normal ; rapid empty- 
 
 Extensive carcinoma not in- 
 
 
 
 ing, peristalsis active ; 
 
 volving stomach. 
 
 
 
 separate bolus in duodenum. 
 
 
 
 81 51 M. Duod. ulcer? 
 
 Stomach normal ; rapid empty- 
 
 Ulcer upper surface duo- 
 
 Cured. 
 
 
 ing, peristalsis active ; 
 
 denum. 
 
 
 
 separate bolus in duodenum, 
 
 
 
 
 when patient lay down. 
 
 
 
 92 35 M. Duod. ulcer ? 
 
 Stomach normal ; rapid empty- 
 ing, peristalsis active ; 
 separate bolus only when 
 patient lay down. 
 
 Duodenal ulcer. 
 
 Cured. 
 
 97 34 F. ? Gastric ulcer. 
 
 Stomach normal; peristalsis 
 
 Cicatrization about duo- 
 
 Much better, 
 
 
 active ; rapid emptying ; 
 
 denum ; nil in body of 
 
 but not 
 
 
 separate bolus in duoden- 
 
 stomach. 
 
 cured. 
 
 
 um ; spasm middle stomach. 
 
 
 
 101 62 M. Duodenal ulcer. 
 
 Stomach normal ; rapid empty- 
 ing, peristalsis active ; 
 separate bolus in duodenum. 
 
 Duodenal ulcer. 
 
 Cured. 
 
 120 56 M. Neurosis. 
 
 Stomach normal ; rapid empty- 
 
 Few adhesions ; nil else. 
 
 Patient 
 
 
 ing, peristalsis active : 
 
 
 developed 
 
 
 separate bolus in duodenum. 
 
 
 G.P. 1. 
 
 184 42 M. Duod. ulcer ? 
 
 Stomach normal ; rapid empty- 
 
 Duodenal ulcer ; gastro- 
 
 Cured. 
 
 
 ing, peristalsis active : 
 
 jejunostomy. 
 
 
 
 separate bolus in duodenum. 
 
 
 
 218 34 M. Duod. ulcer ? 
 
 Stomach normal ; peristalsis 
 
 Ulceration both sides of py- 
 
 Relieved, 
 
 
 active ; no separate bolus in 
 
 lorus ; adhesions to liver. 
 
 but not 
 
 
 duodenum ; rapid emptying. 
 
 
 cured. 
 
 219 22 M. Gastric ulcer? 
 
 Stomach normal : rapid empty- 
 
 Appendicular abscess : ad- 
 
 Patient not 
 
 
 ing ; peristalsis active ; no 
 
 hesions. 
 
 cured. 
 
 
 separate bolus in duodenum. 
 
 
 
82 
 
 Gastric and oesophageal affections 
 
 Clinical 
 No. Age. Sex. Diagnosis. 
 
 X-ray Findings. 
 
 Operative Findings. 
 
 Remarks. 
 
 240 36 M. Dilat. stomach. 
 
 289 46 M. Pyloric obstruc- 
 tion. 
 
 307 31 F. Stomach? 
 kidneys ? 
 
 314 37 F. Duodenal ulcer. 
 
 401 51 M. 
 
 412 54 M. Gastric ulcer. 
 
 417 54 F. Pyloric obstruc- 
 tion. 
 
 418 50 M. Carcinoma. 
 
 451 30 M. Duodenal ulcer. 
 
 468 38 M. Dilat. stomach. 
 
 475 37 M. Pyloric ulcer. 
 
 477 35 M. Gastric ulcer ? 
 
 486 34 F. ? Gall-bladder. 
 
 498 22 M. Gastritis. 
 
 Visceroptosis ; slight atony ; 
 
 peristalsis active. 
 Stomach normal ; rapid empty - 
 ■ ing ; peristalsis active ; 
 separate bolus in duodenum. 
 Stomach normal, except dis- 
 placed ; rapid emptying ; 
 peristalsis active; separate 
 bolus in duodenum. 
 Stomach normal ; rapid empty- 
 ing ; peristalsis active ; 
 separate bolus in duodenum. 
 Stomach normal ; rapid empty- 
 ing ; peristalsis active ; 
 separate bolus in duodenum. 
 Stomach normal ; rapid empty- 
 ing ; no active peristalsis ; 
 no separate bolus in duo- 
 denum. 
 Stomach normal ; rapid empty- 
 ing ; peristalsis active ; no 
 separate bolus in duodenum ; 
 small intestine overloaded. 
 Stomach normal ; separate 
 bolus in duodenum ; rapid 
 emptying. 
 Stomach normal ; rapid empty- 
 ing ; peristalsis active ; 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 active ; no rapid emptying ; 
 no separate bolus in duo- 
 denum. 
 Stomach normal ; peristalsis 
 active ; rapid emptying ; 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 active ; rapid emptying ; 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 active ; rapid emptying ; 
 separate bolus in duodenum. 
 Stomach normal ; rapid empty- 
 ing ; peristalsis active ; 
 separate bolus in duo- 
 denum ; obstruction at duo- 
 denojejunal flexure. 
 
 Duodenal ulcer. 
 
 Growth of lesser curvature. 
 
 Adhesions to distended gall- 
 bladder. 
 
 Cicatrix round 1st part duo- 
 denum. 
 
 Duodenum 
 not explored. 
 
 Adhesions 
 liver. 
 
 of duodenum to 
 
 Duodenal cicatrization. 
 
 Adhesions of 
 liver ; small 
 examined. 
 
 duodenum to 
 intestine not 
 
 Large ulcer lesser curvature, 
 and duodenal ulcer. 
 
 Adhesion duodenum to gall- 
 bladder; gastrojejunostomy 
 
 Scar on duodenum ; gastro- 
 jejunostomy. 
 
 Duodenal ulcer ; gastro- 
 jejunostomy. 
 
 Pericholitis ; adhesion to gall- 
 bladder, etc. 
 
 Post-mortem, 
 bladder. 
 
 stone gall- 
 
 Pericholitis ; duodenal ulcer ; 
 adhesions at duodeno 
 jejunal flexure. 
 
 No indica- 
 tion of the 
 gastric ulcer. 
 
Gastric and oesophageal affections 
 
 83 
 
 Clinical 
 No. Age. Hex. Dlagnoill, 
 
 501 3d M. Gastric ulcer. 
 
 . r )61 27 M. Gastric, ulcer. 
 
 586 40 M. Duodenal ulcor. 
 
 587 23 M. Gastritis. 
 
 588 35 M. Gastric ulcer? 
 
 589 31 M. Duodenal ulcer. 
 
 613 50 M. Duodenal ulcer. 
 
 619 36 M. Gall-stones. 
 
 638 29 M. Dyspepsia. 
 
 658 24 M. ?Duod. ulcer. 
 
 730 49 F. Dilat. stomach. 
 
 749 56 F. Dyspepsia. 
 
 X-ray Bindings. 
 Slight at ; rapid emptying ; 
 
 peristalsis active ; hi paral.e 
 
 bolus in duodenum. 
 Stomach normal ; peristalsis 
 
 active; rapid emptying; 
 
 separate bolus in dnodannm, 
 Stomach uonnal ; peristalsis 
 
 active; rapid emptying; 
 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 
 active; rapid emptying; 
 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 
 active ; rapid emptying ; 
 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 
 active ; rapid emptying ; 
 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 
 active ; rapid emptying ; 
 
 bolus in duodenum, which 
 
 does not move on. 
 Stomach normal ; peristalsis 
 
 active ; rapid emptying ; 
 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 
 active ; rapid emptying ; 
 
 separate bolus in duodenum. 
 Stomach normal ; peristalsis 
 active ; rapid emptying ; 
 coils of jejunum seen in left 
 iliac fossa. 
 Gastroptosis ; nil else. 
 
 OpsntlTc Bindings. 
 
 Rsm sifcs , 
 
 ' !ii ati i< ial duodenum. 
 
 Duodenal ul> «-r ; gantro- 
 
 jejunoftomy. 
 
 Thickening of duodenum. 
 
 Duodenal ulcer ; gastro- 
 jejunostomy. 
 
 Adhesions duodenum to gall- 
 bladder and colon. 
 
 Duodenal ulcer. 
 
 Cicatrices of pylorus and 
 duodenum. 
 
 Gall-slones ; adhesions. 
 
 Long appendix fixed by ad- 
 hesions very high up. 
 
 Duodenal ulcer and ring Duodenal ulcer 
 ulcer of jejunum and ring ulcer 
 
 (tubercular). of jejunum. 
 
 Nil in stomach; adhesions to 
 duodenum. 
 
 Stomach normal ; peristalsis Gall-stones and adhesions, 
 active ; rapid emptying ; no | 
 separate bolus in duodenum. 
 
84 
 
 Gastric and oesophageal affections 
 
 No. Age. Sex. 
 
 Clinical 
 Diagnosis. 
 
 Class III. (See p. 37.) 
 ULCER OF PYLORIC REGION. 
 
 X-ray Findings. Operative Findings. 
 
 Remarks. 
 
 143 55 F. ? Pyloric ob- 
 struction ; di- 
 lated stomach. 
 
 308 42 M. Pyloric ulcer. 
 
 335 39 F. ? Gastric ulcer. 
 396 44 M. Dilat. stomach. 
 
 579 40 F. Gastric ulcer. 
 593 31 M. Duodenal ulcer. 
 
 666 32 M. Carcinoma. 
 717 36 F. Gastric ulcer 
 720 40 F Gastritis. 
 
 723 32 M. Duodenum? 
 
 appendix ? 
 
 724 24 M. ? Gastric ulcer; 
 
 ? carcinoma 
 pylorus. 
 777 32 M. Dilat. stomach. 
 
 Large atonic stomach ; re- 
 tained food ; no delay in 
 passing food out. 
 
 Large atonic stomach with 
 retained fluid ; no marked 
 delay emptying. 
 
 Hour-glass ; secretion into 
 upper sac ; delay in empty- 
 ing lower sac (24 hours). 
 
 Atony ; hypersecretion. 
 
 Hour-glass ; cicatrization ; hy- 
 persecretion to upper sac. 
 
 Stomach normal ; hypersecre- 
 tion ; peristalsis active ; no 
 food seen passing through 
 duodenum ; ? delay empty- 
 ing. 
 
 Slight atony ; nil else noted. 
 
 Hour-glass ; excessive secre- 
 tion upper sac. 
 
 Well-marked hour-glass ; py- 
 loric obstruction ; rapid 
 secretion. 
 
 Hour-glass (spasmodic) ; pain 
 relieved when food passed 
 through ; active secretion ; 
 active peristalsis. 
 
 Normal ; active secretion ; 
 peristalsis active. 
 
 Stomach normal ; excessive 
 secretion ; active peristalsis. 
 
 Cicatrization about pylorus ; 
 small active ulcer. 
 
 Cicatrix near pylorus. 
 
 Typical hour-glass stomach ; 
 ulceration and cicatrization 
 of pylorus. 
 
 Thickening of pylorus ; gastro- 
 jejunostomy. 
 
 ' As though string had been 
 tied round stomach ' ; also 
 pyloric ulcer. 
 
 Thickening about pylorus and 
 lesser curvature. 
 
 Ulcer posterior wall 1 inch 
 from pylorus. 
 
 Cicatricial hour-glass ; ulcer 
 of pylorus. 
 
 Mass of adhesions, middle 
 lesser curvature ; thickened 
 pylorus with active ulcer; 
 inflamed appendix. 
 
 No hour-glass ; no ulcer ; 
 many adhesions about py- 
 lorus and ? ulcer pylorus ; 
 adhesions appendix. 
 
 Cicatrix about pylorus ; 
 active ulcer. 
 
 Ulcer pyloric portion on 
 posterior wall. 
 
 Cured. 
 
 Secretion 
 into upper 
 sac. 
 
 Hypersecre- 
 tion with 
 pyloric 
 ulcer. 
 
 Hypersecre- 
 tion with 
 ulcer of 
 pylorus. 
 
 Rapid secre- 
 tion with 
 ulcer of 
 pylorus. 
 
Gastric and oesophageal affections 
 
 85 
 
 Clinical 
 No, Arc. .Hex. Diagnosis. 
 
 Class IV. (See p, 48.) 
 
 ULCERATION OF THE BODY OF THE STOMACH. 
 Houk-Glass Contractions. 
 
 X-ray FlndlnKH. Operative KindinijH. K*rn»rk«, 
 
 24 50 M. ? Gastric ulcer. 
 
 Slight delay in emptying; nil 
 
 Largo ulcer middle lesser 
 
 ■ . 
 
 
 else. 
 
 curvature ; thickening about 
 
 by gad 
 
 
 
 pylorus. 
 
 j'-junoHtorny. 
 
 35 32 F. ? Pyloric 
 
 Definite hour-glass and pyloric 
 
 Typical hour-glass; contrac- 
 
 i by 
 
 obstruction. 
 
 obstruction. 
 
 tion and thickening of 
 
 (,'astropla«ty 
 
 
 
 pylorus. 
 
 and gastro- 
 jejunostomy 
 
 37 34 M. — 
 
 Hour-glass, partly spasmodic. 
 
 Ulcer lesser curvature; some 
 cicatrization. 
 
 Excised. 
 
 79 52 M. Gastric ulcer. 
 
 Spasmodic hour-glass, which 
 relaxed leaving indentation. 
 
 Ulcer anterior wall ; excised. 
 
 
 83 48 F. Obstruction of 
 
 Definite hour-glass small 
 
 Cicatricial hour-glass ; cica- 
 
 Cured. 
 
 pylorus. 
 
 channel ; definite delay in 
 
 tricial pylorus ; gastro- 
 
 
 
 lower sac. 
 
 plasty and gastro-jejun 
 ostomy. 
 
 
 89 47 M. Growth ? 
 
 Atonic with spasm about 
 
 Large stomach ; cicatrix on 
 
 Cured. 
 
 
 middle. 
 
 lesser curvature ; gastro- 
 jejunostomy. 
 
 
 91 42 F. Pyloric 
 
 Cicatricial hour-glass (funnel- 
 
 Ulcer greater curvature ; 
 
 Cured. 
 
 obstruction ? 
 
 shaped) ; no pyloric obstruc- 
 
 cicatricial hour-glass, with 
 
 
 
 tion. 
 
 adhesion. 
 
 
 93 41 M. Oesophageal 
 
 Huge pouching just above 
 
 Post-mortem, small ulcer 
 
 Xo dilatation 
 
 obstruction. 
 
 diaphragm. 
 
 anterior surface near car- 
 
 of oesophagus 
 
 
 
 diac orifice. 
 
 and no obstruc- 
 tion found 
 post-mortem. 
 
 137 42 F. Dilatation. 
 
 Hour-glass stomach ; upper 
 
 Cicatricial hour-glass. 
 
 Patient died 
 
 
 sac only seen. 
 
 
 suddenly 3 
 weeks later. 
 
 193 59 F. Gastric ulcer. 
 
 Atonic; slight delay empty- 
 
 Ulcer 1 inch below cardiac 
 
 
 
 ing ; some obstruction duo- 
 
 orifice ; ulcer just beyond 
 
 
 
 denum. 
 
 pylorus with cicatricial 
 contraction. 
 
 
 203 63 F. — 
 
 Hour-glass, and distorted by 
 
 Ulcers and cicatrices middle 
 
 
 
 adhesions ; lower sac in 
 
 of stomach ; growth at 
 
 
 
 right iliac fossa; delay in 
 
 pylorus. 
 
 
 
 emptying of lower sac. 
 
 
 
 207 30 F. Gastric ulcer; 
 
 Well-marked cicatricial hour- 
 
 Stomach not explored, but 
 
 Unrelieved : 
 
 gastrojejuno- 
 
 glass ; stoma working per- 
 
 kidney fixed November. 
 
 entered 
 
 stomy 1908. 
 
 fectly. 
 
 1909. 
 
 also in 
 Class VIII. 
 
86 
 
 Gastric and oesophageal affections 
 
 Clinical 
 No. Age. Sex. Diagnosis. 
 
 X-ray Findings. 
 
 Operative Findings. 
 
 Remarks. 
 
 207 31 F. Same case one 
 year later. 
 
 230 39 F. ? Stenosis of 
 pylorus. 
 
 239 40 F. Gastric ulcer. 
 
 266 43 M. Old gastro- 
 jejunostomy. 
 
 286 39 F. Dilat. stomach ? 
 gastric ulcer. 
 299 23 F. Gastric ulcer. 
 
 310 40 F. Gastric ulcer; 
 ? pyloric 
 obstruction. 
 
 331 29 F. Gastric ulcer. 
 
 335 39 F. ? Gastric ulcer ; 
 ? carcinoma. 
 
 364 37 F. Pyloric stenosis 
 
 367 43 F. Dilat. stomach. 
 
 371 39 F. Gastric ulcer. 
 
 389 40 F. Gastric ulcer; 
 old gastroje- 
 junostomy. 
 400 33 F. Gall-stone ? kid- 
 ney ; old gastro- 
 jejunostomy. 
 
 Exactly same picture as 
 above. 
 
 Hour-glass stomach, and de- 
 finite delay in emptying. 
 
 Funnel-shaped hour-glass ; in- 
 verted peristalsis in lower 
 sac; delay in emptying (24 
 hours). 
 
 Hour-glass stomach well 
 marked ; stoma working 
 perfectly. 
 
 Hour-glass stomach ; no py- 
 loric obstruction. 
 
 Hour-glass stomach, partly 
 spasmodic ; no pyloric ob- 
 struction. 
 
 Hour-glass stomach ; definite 
 delay emptying. 
 
 Division of stomach near Hour-glass stomach, 
 pylorus. 
 
 Stomach almost divided by 
 
 marked contraction. 
 Ring of ulceration of greater 
 
 curvature ; constriction of 
 
 pylorus. 
 Multiple scars forming tri- 
 
 locular stomach ; growth at 
 
 pylorus. 
 
 Hour-glass, with active ulcer. 
 
 Hour-glass ; probably active 
 ulcer. 
 
 Large ulcer lesser curvature ; 
 some puckering ; gastro- 
 jejunostomy to upper 
 pouch. 
 
 Trilocular stomach ; cicatri 
 cial pyloric obstruction. 
 
 Cured. 
 
 Cured by 
 gastroplasty ; 
 a small ulcer 
 of body had 
 been noted at 
 time of 1st 
 operation. 
 
 Hour-glass ; secretion into 
 upper sac ; delay in empty- 
 ing lower sac (24 hours). 
 
 Spasmodic hour-glass ; no 
 pyloric obstruction. 
 
 Hour-glass, chiefly organic ; 
 no pyloric obstruction. 
 
 Hour-glass ; no pyloric ob- 
 struction. 
 
 Hour-glass marked ; stoma 
 patent. 
 
 Perfect hour-glass ; stoma 
 patent. 
 
 Typical hour-glass stomach ; 
 ulceration and cicatrization 
 of pylorus. 
 
 Cicatricial hour-glass, with 
 active ulcer. 
 
 Large ; gastrojejunostomy 
 lesser curvature, with cica- 
 trization. 
 
 Hour-glass ; gastrojejunos- 
 tomy to lower sac. 
 
 Hour-glass, with ulcer ; 
 gastroplasty. 
 
 Cicatricial hour-glass. 
 
 Lower sac 
 quite large. 
 
 Secretion 
 into upper 
 sac ; also 
 entered in 
 Class III. 
 
Gastric and oesophageal affections 
 
 87 
 
 No. Ago. Hex. 
 
 Ollnical 
 Dl&gnoila 
 
 X-ray l-'i j.-I . i. | 
 
 Operative Flnrllr.KN. 
 
 EUaafa 
 
 406 26 P. Old gastro- 
 jejunostomy. 
 418 50 M. Carcinoma. 
 
 420 53 P. ? Stomach ; 
 ? Kidneys. 
 455 48 P. 
 
 461 39 F. Gastric ulcer. 
 465 39 F. Gastric ulcer. 
 
 482 29 F. Gastric ulcer ; 
 pyloric 
 obstruction. 
 
 490 24 F. Dilat. stomach. 
 
 492 31 F. Neurosis. 
 
 493 45 F. Abdominal 
 
 tumour. 
 573 18 F. Gastric ulcer. 
 
 579 40 F. ? Gastric ulcer. 
 
 583 28 F. Gastric ulcer. 
 589 39 F. Pyloric stenosis 
 618 36 M. Gastric ulcer. 
 686 34 F. Gastric ulcer? 
 
 695 45 F. Dilat. stomach ; 
 gastric ulcer? 
 
 717 36 F. Gastric ulcer. 
 720 40 F. Gastritis. 
 
 760 42 F. Gastric ? 
 kidney. 
 
 782 65 F. Gastric ulcer. 
 
 Hour-glass, chiefly spasmodic ; 
 
 stoma patent. 
 Nil; separates bolus in duo 
 
 doiium. 
 
 Spasmodic hour-glass, and 
 separate bolus in duodenum. 
 
 Cicatricial hour-glass. 
 
 Marked hour-glass. 
 
 Incomplete hour-glass; de- 
 layed emptying lower sac. 
 
 Hour-glass (cicatricial) ; no 
 pyloric obstruction. 
 
 Spasmodic hour-glass ; delayed 
 emptying lower sac. 
 
 Hour-glass, and delayed 
 emptying lower sac. 
 
 Hour-glass; no evidence of 
 growth. 
 
 Hour-glass ; some pyloric ob- 
 struction. 
 
 Hour-glass, cicatricial ; hyper- 
 secretion to upper sac. 
 
 Spasmodic hour-glass. 
 
 Hour-glass, cicatricial. 
 
 Hour-glass, chiefly spasmodic. 
 
 Hour-glass, partly spasmodic ; 
 no pyloric obstruction. 
 
 Hour-glass, cicatricial, pene- 
 trating ulcer ; retained food 
 (24 hours). 
 
 Hour-glass ; excessive secre- 
 tion upper sac. 
 
 Well-marked hour-glass ; py- 
 loric obstruction ; rapid se- 
 cretion. 
 
 Gastroptosis : pylorus dropped 
 2 inches ; nephroptosis. 
 
 Pyloric portion sacculated and 
 bound to liver; upper 
 portion suggested hour-glass 
 contraction 
 
 Hour glass, ei< atrii al, 
 
 above stoma. 
 Largo ulcer lesser curvature; 
 
 cicatrix in duodenum. 
 Hourglass and duodena] 
 
 ulcer. 
 Cicatricial hour-glass. 
 Cicatricial hour-glass, 
 i'yloric obstruction ; old 
 
 cicatrices anterior walla of 
 
 stomach. 
 Cicatricial hour-glass. 
 Thickening of pylorus. 
 
 Cicatrix of greater curvature 
 and also at pylorus. 
 
 Hour-glass, adherent to liver ; 
 pyloric obstruction. 
 
 Typical hour-glass ; no py- 
 loric obstruction or growth. 
 
 Ulcer lesser curvature ; 
 thickened pylorus. 
 
 ' As though string had been 
 tied round stomach ' ; also 
 pyloric ulcer. 
 
 Large ulcer middle stomach. 
 
 Cicatricial hour-glass. 
 
 Ulcer greater curvature. 
 
 Large ulcer lesser curvature ; 
 cicatrization. 
 
 Mass of adhesions middle 
 stomach ; hour-glass ; py- 
 lorus normal ; ant«rior 
 gastrojejunostomy. 
 
 Cicatricial hour-glass ; ulcer 
 of pylorus. 
 
 Mass of adhesions middle 
 lesser curvature ; thickened 
 pylorus with active ulcer : 
 inflamed appendix. 
 
 Cicatricial ulcer lesser curva- 
 ture, 2 inches from pylorus. 
 
 Hypersecre- 
 tion with 
 pyloric 
 ulcer. 
 
 Mass of adhesions of pyloric 
 portion stomach to liver; 
 old ulceration : ulcer of 
 pylorus 
 
 Xo pyloric 
 obstruction 
 although re 
 tained food. 
 Hypersecre- 
 tion with 
 ulcer of 
 pylorus. 
 Rapid secre- 
 tion with 
 ulcer of 
 pylorus. 
 
88 
 
 Gastric and oesophageal affections 
 
 Clinical 
 No. Age. Sex. Diagnosis. 
 
 Class V. (See p. 48.) 
 CARCINOMA OF THE STOMACH. 
 
 X-ray Findings. 
 
 Operative Findings. 
 
 Kemarks. 
 
 7 43 M. Carcinoma of 
 stomach ? 
 
 8 35 M. Carcinoma of 
 
 stomach. 
 
 9 43 M. Carcinoma of 
 
 stomach. 
 21 45 M. — 
 
 40 37 M. ? Carcinoma. 
 42 53 F. ? Carcinoma of 
 
 stomach. 
 48 52 F. Carcinoma of 
 
 stomach. 
 
 58 54 M. 
 
 64 39 M. 
 170 58 M. 
 233 53 F. 
 
 289 46 M. 
 
 297 34 M. 
 300 29 F. 
 
 342 66 F. 
 
 366 55 F. 
 
 380 43 M. 
 
 ? Carcinoma of 
 
 stomach ; 
 
 ? aneurism. 
 ? Carcinoma of 
 
 stomach. 
 ? Carcinoma of 
 
 stomach. 
 ? Carcinoma of 
 
 stomach. 
 ? Pyloric 
 
 obstruction. 
 
 Pyloric ulcer. 
 ? Carcinoma of 
 stomach. 
 
 Carcinoma of 
 stomach. 
 
 Abdom. tumour 
 
 Duodenal ulcer. 
 
 385 55 F. Carcinoma of 
 stomach. 
 
 403 50 M. — 
 
 469 66 M. ? Carcinoma. 
 
 582 52 F. Carcinoma of 
 ascending 
 colon. 
 
 614 60 M. ? Carcinoma of 
 pylorus. 
 
 776 47 M. ? Gastric ulcer ; 
 ? pyloric 
 stenosis. 
 
 Very excessive peristalsis ; 
 pars pylorica obliterated. 
 No delay in emptying. 
 
 Stomach invaded ; small ir- 
 regular cavity only left. 
 
 Inroads of growth well de- 
 fined. 
 
 Irregularity in outline of 
 greater curvature. 
 
 Irregularities of outline. 
 
 Inroads of growth near py- 
 lorus: retention of food. 
 
 ^Esophageal obstruction at 
 cardiac orifice ; no evidence 
 of growth of stomach 
 
 Light areas in midst of bismuth 
 shadow. 
 
 Irregular in outline. 
 
 Inroads of growth giving 
 hour-glass appearance. 
 
 Definite irregularities of out- 
 line. 
 
 Stomach normal ; shadows 
 well seen in duodenum ; 
 active peristalsis. 
 
 Irregular in outline. 
 
 Large atonic stomach ; nil 
 else. 
 
 Gastric cavity obliterated, 
 except along greater curva- 
 ture. 
 
 Obliteration of all the cavity, 
 except greater curvature. 
 
 Stomach cavity small and 
 irregular ; back pressure 
 oesophageal dilatation. 
 
 Nil abnormal made out. 
 
 Irregularity of pyloric portion. 
 Cavity nearly obliterated. 
 Cavity nearly obliterated ; 
 
 right side diaphragm pushed 
 
 up. 
 Irregularities near pylorus ; 
 
 no obstruction. 
 Marked inroad of pyloric 
 
 portion ; retained food. 
 
 Annular growth of pylorus. 
 
 Advanced carcinoma; inoper- 
 able. 
 Inoperable carcinoma. 
 
 Inoperable carcinoma. 
 
 Advanced carcinoma. 
 
 Carcinoma of pylorus ; gastro- 
 jejunostomy. 
 
 Post-mortem six weeks later; 
 growth of lesser curvature 
 5"X6"; cardiac orifice not 
 involved. 
 
 Inoperable carcinoma ; pos- 
 terior wall chiefly. 
 
 Advanced carcinoma. 
 
 Inoperable carcinoma. 
 
 Mass of growth in lesser 
 curvature. 
 
 Plaque of growth on lesser 
 curvature ; duodenum not 
 explored. 
 
 Growth lesser curvature. 
 
 Operation six months later ; 
 large mass involving an- 
 terior wall. 
 
 Post-mortem ; massive car- 
 cinoma involving whole 
 stomach. 
 
 Large mass extending from 
 lesser curvature. 
 
 Stomach one mass of growth. 
 
 Growth lesser curvature, size 
 
 of Tangerine. 
 Post-mortem ; carcinoma. 
 Large growth ; inoperable. 
 Growth involving colon and 
 
 stomach, secondary in liver. 
 
 Carcinoma of pylorus. 
 
 Carcinoma of lesser curvature 
 and pylorus 
 
 Excised 
 growth ; 
 patient died 
 18 months 
 later. 
 
 No contrac- 
 tion of car- 
 diac orifice 
 post-mortem. 
 Patient died 
 3 months 
 later. 
 
 No evid. of 
 growth of 
 stomach. 
 
 Patient died 
 36 hours 
 later, cause 
 unknown. 
 
Gastric and oesophageal affections 
 
 89 
 
 Clinical 
 No. Abo. Mux. DjukiiohIh 
 
 10 35 F. Dyspepsia. 
 
 20 52 M. ? Carcinoma. 
 
 24 50 M. Gastric ulcer. 
 
 29 54 M. ? Carcinoma of 
 stomach. 
 
 31 55 F. ? Carcinoma of 
 stomach. 
 
 41 32 F. 
 
 Class VI (See p. 36.) 
 PYLORIC OBSTRUCTION. 
 
 X-ray KintllngH. >'lvc Klri'linx*. 
 
 Etoanrki 
 
 Complete atony; bismuth ' Pyloric obftmotioil 
 
 56 44 F. ? Gastric ulcer. 
 
 65 25 F. ? Gastric ulcer. 
 
 72 61 F. Gastric ulcer. 
 
 80 46 M. ? Pyloric 
 
 obstruction. 
 
 88 47 F. Carcinoma of 
 pylorus. 
 
 94 32 M. Dilat. stomach. 
 
 98 43 F. ? Gastric ulcer. 
 
 seen in stomach for 5 days 
 
 after examination. 
 Normal stomach, full of fluid ; 
 
 bismuth in stomach after 
 
 24 hours. 
 Slight delay in emptying. 
 
 Marked atony ; retained rluid ; 
 slight delay. 
 
 Retained food ; tone perfect ; 
 bismuth retained 24 hours. 
 
 Hour-glass, partly spasmodic ; 
 peristalsis of upper sac ; 
 delayed emptying of lower 
 sac. 
 
 Visceroptosis ; delay in 
 emptying ; marked peri- 
 stalsis. 
 
 Some delay in emptying, in 
 spite of excessive peri- 
 stalsis ; some visceroptosis. 
 
 Extreme atony ; marked peri- 
 stalsis ; delayed emptying 
 (24 hours). 
 
 Retained food ; perfect tone : 
 defective peristalsis ; de- 
 layed emptying (24 hours). 
 
 Stomach atonic ; marked delay 
 emptying (24 hours). 
 
 Definite delay in emptying (12 
 hours) ; some atony. 
 
 Large atonic stomach with re- 
 tained food ; slight delay in 
 emptying ; marked peri- 
 stalsis. 
 
 (rial) ; gastro j"juii';HU;my. 
 Carcinoma of pylorus with 
 
 ulceration. 
 
 
 Ulcer of leaser curvature and Oared 
 
 thickening of pylorus ; "> ee a '*° 
 gastrojejunostomy 
 Ulcer surrounding pylorus; 
 gastrojejunostomy 
 
 ind<T Class 
 IV. 
 
 Extensive carcinoma involv- 
 ing pylorus; gastrojejunos- 
 tomy 
 
 Pyloric thickening ; no ulcer 
 of body. 
 
 Thickening of pylorus ; gastro- 
 jejunostomy. 
 
 Thickening about pylorus ; 
 gastrojejunostomy 
 
 Thickening about pylorus ; 
 gastro- j e j unostomy 
 
 Large mass about pylorus 
 
 Growth at pylorus ; huge 
 stomach ; gastrojejunos- 
 tomy. 
 
 Thickening of pylorus 
 
 Patient 
 cured. 
 
 Not cured ; 
 patient per- 
 sisted in 
 vomiting 
 from upper 
 sac. 
 Cured. 
 
 Relieved by 
 operation. 
 
 Cured. 
 
 ' Cured ' 2 
 years later. 
 
 Cured. 
 
 Adhesions along lesser curva- Cured, 
 ture and pylorus : ? as to 
 obstruction. 
 
90 
 
 Gastric and oesophageal affections 
 
 No. Age. Sex. 
 
 Clinical 
 Diagnosis 
 
 X-ray Findings. 
 
 Operative Findings. 
 
 Remarks 
 
 126 46 M. Duodenal ulcer. 
 
 175 42 M. Gastric ulcer. 
 179 34 F. — 
 
 192 51 M. 
 
 201 48 M. ? Duod. ulcer ; 
 ? malignant. 
 
 205 36 M. Duodenal ulcer. 
 
 208 35 M. Pyloric 
 
 obstruction. 
 
 217 36 F. Carcinoma of 
 stomach. 
 
 220 49 M. Duodenal ulcer. 
 
 226 29 M. Duodenal ulcer. 
 
 230 39 F. ? Pyloric 
 stenosis. 
 
 239 40 F. Gastric ulcer. 
 
 250 49 M Dilat. stomach. 
 
 269 40 F. 
 
 272 43 M. 
 
 ? Dilated 
 stomach ; py- 
 loric stenosis. 
 
 Duodenal ulcer. 
 
 293 35 F. Dilat. stomach. 
 
 Nil, except rather active 
 peristalsis ; stomach empty- 
 ing rapidly. 
 
 Definite delay in emptying; 
 some atony. 
 
 Very atonic stomach ; active 
 peristalsis ; slight delay 
 emptying. 
 
 Retained food; delay in 
 emptying. 
 
 Definite delay (24 hours) ; 
 stomach normal ; retained 
 food ; peristalsis not active. 
 
 Stomach normal ; violent peri- 
 stalsis occasionally ; slight 
 delayed emptying (10 hours). 
 
 Retained food 24 hours; per- 
 fect tone ; peristalsis absent. 
 
 Huge atonic stomach ; definite 
 delay in emptying (24 
 hours). 
 
 Stomach normal ; very active 
 peristalsis ; occasionally 
 some delay emptying. 
 
 Stomach toneless ; definite 
 delay (24 hours). 
 
 Hour-glass stomach and de- 
 finite delay in emptying 
 lower sac. 
 
 Funnel-shaped hour-glass ; 
 inverted peristalsis in lower 
 sac; delay in emptying (24 
 hours) . 
 
 Huge distended stomach full 
 of food; marked delay (48 
 hours). 
 
 Complete atony ; delay in 
 emptying (24 hours) ; in- 
 complete hour-glass. 
 
 Stomach, normal, but occa- 
 sionally active peristalsis. 
 
 Extreme atony; delay empty- 
 ing. 
 
 9 months later pyloric ob- 
 struction found. 
 
 Ulcer of pylorus ; adhesions 
 
 to liver. 
 Pyloric thickening and ulcer ; 
 
 stomach very large. 
 
 Growth about pylorus and 
 liver. 
 
 Cicatrix of pylorus ; gastro- 
 jejunostomy. 
 
 Old cicatrices about pylorus 
 and duodenum ; gastro- 
 jejunostomy. 
 
 Ring of ulceration round 
 
 pylorus. 
 Huge stomach ; growth around 
 
 pylorus. 
 
 Adhesion of pylorus and 
 
 duodenum to gall-bladder; 
 
 ? Pyloric obstruction. 
 Thickening of pylorus and 
 
 scarring of duodenum. 
 Ring of ulceration greater 
 
 curvature and constriction 
 
 of pylorus. 
 
 Multiple scars forming tri- 
 locular stomach ; growth at 
 pylorus. 
 
 Large growth of pylorus. 
 
 Cicatrices about pylorus 
 and smaller one on greater 
 curvature. 
 
 Adhesions and glands malig- 
 nant? about pylorus. 
 
 Growth at pylorus; gastro- 
 jejunostomy. 
 
 Rapid emptg. 
 noted in 
 early stage. 
 Cured. 
 
 Cured. 
 
 Cured. 
 
 Patient died 
 3 days after 
 operation ; no 
 cause known. 
 Cured. 
 
 Cured. 
 
 Cured. 
 
 Patient cured 
 (6 months). 
 
Gastric and oesophageal affections 
 
 91 
 
 OHnloal 
 No. A«o Hex. DlAgnoila. 
 
 294 43 M. Gastric, ulcer. 
 
 285 . r ;0 M. ? Carcinoma of 
 
 stomach. 
 
 309 56 M. ? hour-glass. 
 
 313 34 M. 
 
 320 37 M. Gastric ulcer. 
 
 330 47 M. Pyloric 
 
 obstruction. 
 
 335 39 F. ? Gastric ulcer ; 
 ? carcinoma. 
 
 338 40 M. Dilat. stomach. 
 
 340 65 M. Dilat. stomach. 
 
 342 42 M. Dilat. stomach ; 
 ? carcinoma. 
 
 355 65 M. ? Gastric 
 
 carcinoma ; 
 ? gastric ulcer. 
 
 359 60 F. Carcinoma of 
 stomach. 
 
 370 M. — 
 
 373 49 F. Pyloric 
 
 obstruction. 
 
 375 41 F. Pyloric 
 
 obstruction. 
 
 X-rny KlmlliiKH 
 
 
 EU BMfcl 
 
 Slight atony ; occasional 
 violent, waves of peristalsis ; 
 
 mi marker] delay emptying. 
 
 Definite delay in emptying; 
 
 occasion,! I violent peristal 
 sis; inroads of growth at 
 pylorus. 
 
 Rotaincrl fluid ; perfei t tour ; 
 |>rn:;l;i,l:;i:: : 1 1 > . . - ■ 1 1 1 ; ilc lioil ■ 
 
 delay (24 hours). 
 Retained fluid ; stomach 
 
 normal ; no peristalsis ; 
 
 delay emptying (24 hours). 
 Rather active peristalsis ; 
 
 some atony ; delay in 
 
 emptying. 
 
 Retained food ; active peri- 
 stalsis, but no marked 
 delay in emptying (10 
 hours). 
 
 Hour-glass ; secretion into 
 upper sac ; delay in empty- 
 ing lower sac (24 hours). 
 
 Atonic stomach ; delay in 
 emptying (24 hours). 
 
 Atonic stomach ; retained 
 food ; delay emptying (24 
 hours). 
 
 Retained food ; occasional 
 active peristalsis ; inroad 
 near pylorus ; slight delay 
 emptying. 
 
 Delay in emptying ; irregulari- 
 ties near pylorus. 
 
 Atonic stomach ; retained Pyloric thickening ; 
 food ; delay in emptying. stomach. 
 
 Thickening pylorus; gastro- 
 jejunostomy. 
 
 Growth ahout pylorus. 
 
 Largo growth around pyloruH ; 
 gasti lorny 
 
 Cicatrices; stenosis of py- 
 lorus. 
 
 Mass adherent to pylorus. 
 
 Thickening about pylorus. 
 
 Typical hour-glass stomach ; 
 
 ulceration and cicatrization 
 
 of pylorus. 
 Thickening of pylorus. 
 
 Large cicatrix. 
 
 Inoperable carcinoma of py- 
 lorus. 
 
 Pyloric thickening ; adhesions 
 to liver. 
 
 Cored, 
 
 huge 
 
 large 
 
 Retained food ; violent peri- Pyloric obstruction 
 
 stalsis ; no atony. stomach. 
 
 Atonic ; delay in emptying Carcinoma of pylorus ; gastro- 
 
 (24 hours). jejunostomy 
 
 Atonic ; delay in emptying (24 I Pyloric obstruction : gastro- 
 
 hours). jejunostomy. 
 
 Btomach th<; 
 
 flabbiest 
 surgeon had 
 handled. 
 
 Secretion 
 into upper 
 sac. 
 
 Patient died 
 1 week later. 
 ? cause. 
 
92 
 
 Gastric and oesophageal affections 
 
 No. Age. Sex. 
 
 Clinical 
 Diagnosis. 
 
 X-ray Findings. 
 
 Operative Findings. 
 
 Remarks. 
 
 383 59 M. Abdom. tumour 
 399 33 M. Gastralgia. 
 410 63 M. ? 
 
 411 36 M. 
 421 58 M. 
 
 422 57 F. 
 460 57 M. 
 
 465 39 F. 
 
 470 36 F. 
 487 21 F. 
 490 24 F. 
 
 Gastroptosis. 
 Duodenal ulcer. 
 
 Pyloric 
 
 obstruction. 
 Pyloric 
 
 obstruction ; 
 
 growth ? 
 Gastric ulcer. 
 
 Gastric ulcer. 
 
 Dilat. stomach. 
 
 Dilat. stomach. 
 
 Pyloric 
 
 obstruction. 
 Gastric ulcer ; 
 
 dilated 
 
 stomach. 
 
 531 42 M. 
 573 18 F. 
 
 580 43 F. 
 
 Atonic ; delay in emptying ; 
 
 no inroads. 
 Atonic ; retained food ; slight 
 
 delay in emptying (6 hours) 
 Retained food ; delayed 
 
 emptying ; tone perfect. 
 Delay in emptying (10 hours). 
 Irregularities near pylorus ; 
 
 delay in emptying (24 
 
 hours) ; tone fair. 
 Irregularities ; delay in 
 
 emptying (24 hours). 
 Delay in emptying (6 days) ; 
 
 stomach atonic. 
 
 Incomplete hour-glass ; de- 
 layed emptying lower sac. 
 
 Atonic ; slight delay in 
 emptying ; active peristalsis. 
 
 Delayed emptying ; atonic 
 stomach ; retained food. 
 
 Slight delayed emptying ; 
 spasm middle stomach. 
 
 492 31 F. Neurosis. 
 
 494 48 M. Duodenal ulcer. 
 
 500 46 M. Gastritis. 
 512 47 F. 
 523 42 F. 
 
 ? Gastric ulcer. 
 
 Pyloric obstruc- 
 tion ; dilated 
 stomach. 
 
 Hour-glass, and delayed 
 emptying lower sac (24 
 hours). 
 
 Stomach displaced ; retained 
 food ; delayed emptying. 
 
 Atonic ; delayed emptying 
 (24 hours). 
 
 Atonic ; retained food ; de- 
 layed emptying (24 hours). 
 
 Atonic stomach ; retained 
 food ; delayed emptying. 
 
 Atonic ; retained food ; de- 
 layed emptying (24 hours). 
 
 Hour-glass (cicatricial) ; hy- 
 persecretion to upper sac : 
 delayed emptying of lower 
 sac. 
 
 Atonic ; retained food ; de- 
 layed emptying. 
 
 Growth of pylorus. 
 
 Large ulcer pylorus. 
 
 Ulcer pylorus; gastro-jejun 
 
 ostomy. 
 Thickening pylorus. 
 Carcinoma of pylorus. 
 
 Carcinoma of pylorus; thin 
 stomach walls. 
 
 Growth of pylorus and duo- 
 denum. 
 
 Pyloric obstruction ; old 
 cicatrix ; anterior wall of 
 stomach. 
 
 Pyloric ulcer; gastrojejun- 
 ostomy. 
 
 Growth of pylorus ; gastro- 
 jejunostomy. 
 
 Large stomach ; cicatrix near 
 pylorus and also ulcer on 
 greater curvature ; gastro- 
 jejunostomy. 
 
 Hour-glass ; adhesion to 
 liver ; pyloric obstruction. 
 
 Large saddle-shaped ulcer 
 about pylorus ; adhesions to 
 liver. 
 
 Growth of pylorus. 
 
 Thickening about pylorus ; 
 
 gastro- jejunostomy 
 Thickening about pylorus ; 
 
 gastro - j e j unostomy 
 
 Stomach very large; cicatrix 
 
 about pylorus. 
 ' As though string had been 
 
 tied round stomach ' ; also 
 
 pyloric ulcer. 
 
 Cured. 
 
 Thickening 
 malignant. 
 
 of pylorus ; 
 
 Hypersecre- 
 tion with 
 pyloric 
 ulcer. 
 
Gastric and oesophageal affections 
 
 93 
 
 Clinical 
 
 No. A({e Sox. OIukiiohIh. 
 
 X-ray Finding!. 
 
 OpmtlTI I iri<llDK». 
 
 BwuMfa 
 
 582 29 M. ? 
 
 Delayed emptying (6 hours) ; 
 itomach atonic. 
 
 1 bickening of pyloroe. 
 
 
 583 54 M. Abdom. tumour 
 
 Atonic ; delayed emptying 
 (24 hours) ; no irregolarj 
 tics. 
 
 Carcinoma ol pylon 
 
 
 584 42 F. Pyloric 
 
 Atonic; delayed emptying 
 
 Post mortem ; tfa i Icened py 
 
 
 obstruction. 
 
 (24 hours). 
 
 lonifl. 
 
 
 585 43 M. Duodenal ulcer. 
 
 detained food ; .some delay 
 
 Thickened pylorus; gastro- 
 
 
 
 in emptying (8 hours). 
 
 jejunostomy. 
 
 
 585a44 F. Pyloric 
 
 Stomach normal ; active peri- 
 
 Adhesions and ci< .itrix about 
 
 
 obstruction. 
 
 stalsis ; hypersecretion ; 
 slight delay in emptying ? 
 
 pylorus and duodenum 
 
 
 586a62 F. — 
 
 Atonic; delay in emptying 
 (24 hours). 
 
 Carcinoma of pylorus. 
 
 
 590 21 F. Dilat. stomach. 
 
 Atonic stomach ; active peri- 
 
 Growth at pylorus ; gastro- 
 
 
 
 stalsis ; excessive secretion. 
 
 jejunostomy. 
 
 
 592 33 M. Gastralgia. 
 
 Atonic stomach ; delay in 
 
 Large ulcer at pylorus ; 
 
 
 
 emptying; retained food. 
 
 stomach large ; gastro- 
 jejunostomy. 
 
 
 600 40 F. Visceroptosis. 
 
 Atonic ; delay in emptying. 
 
 Thickening of pylorus; car- 
 cinoma? 
 
 
 687 60 M. ? Carcinoma of 
 
 Atonic ; delay in emptying 
 
 Cicatrix of pylorus. 
 
 
 stomach. 
 
 (24 hours) ; retained food. 
 
 
 
 682 27 M. Pyloric tumour. 
 
 Tone good ; delay in empty- 
 ing; no peristalsis; ob- 
 literation of pylorus. 
 
 Carcinoma of pylorus. 
 
 
 752 40 M. ? Duod. ulcer. 
 
 Atonic ; retained food (24 
 hours). 
 
 Ulcer of pylorus ; adhesions. 
 
 
 753 25 M. Gastric ulcer. 
 
 Atonic ; retained food ; dis- 
 placed pyloric portion ; 
 active peristalsis. 
 
 Large ulcer pylorus. 
 
 
 545 23 M. Hodgkin's dis- 
 
 Stomach normal ; occasional 
 
 Carcinoma at pylorus ; many 
 
 
 ease ; pyloric 
 
 excessive peristalsis ; exces- 
 
 secondary glands. 
 
 
 obstruction. 
 
 sive secretion ; gave off 
 little C0 2 . 
 
 
 
 664 28 M. Gastric ulcer; 
 
 Stomach normal ; occasional 
 
 Large growth of pyloric 
 
 
 pyloric 
 
 excessive peristalsis ; ex- 
 
 region and secondary- 
 
 
 obstruction. 
 
 cessive secretion ; gave off 
 little C0 2 ; retained food. 
 
 glands. 
 
 
 689 30 F. Gastric ulcer. 
 
 Stomach atonic ; retained 
 
 Pyloric obstruction marked : 
 
 Patient was 
 
 
 food; delayed emptying (21 
 
 old ulcer. 
 
 examined 2 
 
 
 hours) . 
 
 
 months before 
 and very 
 slight, if any, 
 delayed 
 emptying 
 was noted. 
 
94 
 
 Gastric and oesophageal affections 
 
 Clinical 
 No. Age. Sex. Diagnosis. 
 
 X-ray Findings. 
 
 Operative Findings. 
 
 Remarks. 
 
 698 45 M. 
 
 ? Carcinoma of 
 pylorus. 
 
 Retained food ; tone perfect ; 
 peristalsis absent. 
 
 Carcinoma of pylorus. 
 
 
 713 32 M. 
 
 Gastric ulcer. 
 
 Delayed emptying ; spasm 
 middle. 
 
 Ulcers about pylorus and 
 cicatrices. 
 
 
 753b48 F. 
 
 Carcinoma of 
 
 Retained food ; stomach 
 
 Carcinoma of pylorus fun- 
 
 
 
 stomach ? 
 
 atonic ; delayed emptying 
 (24 hours). 
 
 gating into stomach. 
 
 
 756 35 F. 
 
 Old gastro- 
 
 Stoma not working ; some 
 
 No gastrojejunostomy had 
 
 
 
 jejunostomy. 
 
 delay emptying ; looks like 
 pyloric obstruction 
 
 ever been performed ; cica- 
 trix of pylorus ; gastro- 
 jejunostomy. 
 
 
 764 47 F. 
 
 Pyloric 
 
 Retained food ; slight delay 
 
 Pyloric obstruction ; gastro- 
 
 
 
 obstruction. 
 
 emptying (10 hours). 
 
 jejunostomy. 
 
 
Gastric and oesophageal affections 
 
 95 
 
 Clinical 
 No. Ago. Sex. Diagnosis, 
 
 Class VII. (See p. 50). 
 ADHESIONS. 
 
 X-ray findings. Operative findings. 
 
 Kf-mark*. 
 
 151 38 F. Neurasthenia. 
 
 Stomach atonic; held down 
 
 Old appendix ; adhesions of 
 
 Not cured 
 
 
 to colon by adhesions; 
 
 colon. 
 
 1 9 mo-, later 
 
 
 transverse colon fixed in 
 
 
 iiiu'h better. 
 
 
 pelvis. 
 
 
 
 251 10 M. T.B. peritonitis 
 
 liilocular stomach ; food re- 
 
 Tuberculosis; peritonitis; 
 
 Relieved. 
 
 
 tained in many pockets of 
 
 multiple adhesions. 
 
 
 
 small intestines. 
 
 
 
 408 61 F. Gastric ulcer. 
 
 Bands divided stomach, and 
 
 Multiple adhesions ; old ulcer 
 
 
 
 as in Case 251. 
 
 below cardiac orifice. 
 
 
 472 60 M. Old perforated 
 
 Adhesions to liver, etc. 
 
 Adhesions anterior wall and 
 
 
 duodenal ulcer. 
 
 
 liver. 
 
 
 479 42 F. Old strangu- 
 
 Stomach bound down in 
 
 Adhesions small intestine, 
 
 
 lated hernia; 
 
 pelvis. 
 
 stomach and colon. 
 
 
 ? adhesions. 
 
 
 
 
 591 28 M. Dyspepsia. 
 
 Nil, except stomach dis- 
 
 Appendix adhesions on right 
 
 Long appendix 
 
 
 placed to right. 
 
 side ; stomach normal. 
 
 fixed up 
 towards 
 right hypo- 
 chondrial 
 region. 
 
 699 56 M. ? Carcinoma of 
 
 Stomach cavity represented 
 
 Mass of adhesions stomach to 
 
 
 stomach or 
 
 by 3 sacs, very small, 
 
 liver ; anterior gastroje- 
 
 
 oesophagus. 
 
 bound to liver; back pres- 
 sure oesophageal dilata- 
 tion. 
 
 junostomy. 
 
 
 H 
 
96 
 
 Gastric and oesophageal affections 
 
 Xo. Age. Sex. 
 
 Clinical 
 Diagnosis. 
 
 Class VIII. (See p. 50.) 
 POST OPERATIVE. 
 
 X-ray Findings. 
 
 10 35 F. 
 
 19 55 F. 
 
 26 19 F. 
 35 32 F. 
 
 41 32 F. 
 
 Old gastroje- 
 junostomy (see 
 Class VI.). 
 
 Pyloroplasty. 
 
 Perforated 
 gastric ulcer. 
 
 Old gastroje- 
 junostomy (see 
 Class IV.). 
 
 (See Class VI.) 
 
 44 25 F. 
 
 Gastro- 
 
 
 jejunostomy. 
 
 206 23 F. 
 
 Old gastro- 
 
 
 jejunostomy. 
 
 207 30 F. 
 
 Old gastro- 
 
 
 jejunostomy 
 
 
 1908. 
 
 209 31 F. 
 
 Old gastroje- 
 
 
 junostomy for 
 
 
 hour-glass. 
 
 257 49 F. 
 
 Old gastro- 
 
 
 jejunostomy. 
 
 263 41 F. 
 
 5 weeks after 
 
 
 gastrojejunos- 
 
 
 tomy. 
 
 266 43 M. 
 
 Old gastro- 
 
 
 jejunostomy. 
 
 357 52 F. 
 
 Old gastroje- 
 junostomy to 
 upper sac of 
 hour-glass. 
 
 Xo increase in tone ; food 
 still delayed in stomach 
 longer than 24 hours. 
 
 Hour-glass condition : no ob- 
 struction, stoma working 
 perfectly. 
 
 Food through stoma quite 
 freely. 
 
 Stoma working perfectly. 
 
 Hour-glass marked, but stoma 
 works perfectly when food 
 reaches it. 
 
 Obstruction in duodenum. 
 
 Stoma working perfectly. 
 
 Gastrojejunostomy working 
 perfectly ; marked spasm 
 middle of stomach forming 
 hour-glass. 
 
 Stoma from upper sac work- 
 ing perfectly, but food re- 
 tained in lower sac 24 
 hours after. 
 
 Adhesions forming hour- 
 glass ; stoma working per- 
 fectly. 
 
 Stoma working perfectly. 
 
 Hour-glass stomach ; well- 
 marked ; stoma working 
 perfectly. 
 
 Delayed emptying of lower 
 sac ; stoma from upper sac 
 works well. 
 
 Operative Findings. 
 
 
 Remarks. 
 
 
 
 
 
 
 
 Patient 
 
 
 
 
 unrelieved 
 
 Nil found to account 
 
 for 
 
 Patient per- 
 
 hour-glass. 
 
 Adhesions. 
 
 Marked cicatrix above stoma; 
 gastro-gastrostomy. 
 
 Well-marked pyloric obstruc- 
 tion ; lower sac excised. 
 
 Adhesions broken down. 
 
 Hour-glass, with active ulcer. 
 
 sisted in 
 vomiting 
 from upper 
 sac. 
 
 Patient spoken 
 to severely 
 and completely 
 cured. 
 Unrelieved. 
 
 Patient cured. 
 
 Cured. 
 
 Thickening of pylorus ; lower 
 sac excised. 
 
 Cured by 
 gastroplasty , 
 a small ulcer 
 of body had 
 been noted at 
 time of first 
 operation. 
 Cured. 
 
Gastric and oesophageal affections 
 
 97 
 
 OUnioal 
 
 No. Ako. Sox. DIiikikihIh. 
 
 363 41 F. 
 
 Old gastro- 
 
 
 jejunostomy, 
 
 398 38 P. 
 
 — 
 
 416 47 M. 
 
 Old gastro- 
 
 
 jejunostomy. 
 
 41!) 22 F. 
 
 Old gastro je 
 
 
 junostomy '2 
 
 
 months after 
 
 
 operation. 
 
 X-ray Pindlngl. 
 
 Opmtlrt i indinK*. 
 
 
 Spasmodic hour-glass; stoma 
 working perfectly. 
 
 Sour glass ; marked vomiting 
 
 from upper :iac. 
 
 Nil found to jircount for f'nr< 
 
 boor k'I ;i ««- 
 Nothing to account for tie- 
 liour glass ; appendix n 
 moved. 
 Adhesions about jejunum and Many adhesions 
 
 stomach. 
 
 Stoma working perfectly, hut 
 
 placed far from pylorus, 
 
 Growth of pylorus; adherenl 
 to g,-ill bladder ; 
 excised. 
 
 treeks 
 
 .'in. 
 
 470 36 F. 
 
 171 30 F. 
 183 30 M. 
 524 46 F. 
 
 539 35 M. 
 
 »63 36 F. 
 •30 47 M. 
 ■94 45 M. 
 
 '09 50 F. 
 189 30 F. 
 
 56 35 F. 
 
 57 34 M. 
 
 3 weeks after 
 gastro- 
 jejunostomy. 
 
 Gastro- 
 jejunostomy. 
 
 Old gastro- 
 jejunostomy. 
 
 Gastrojejunos- 
 tomy 5 years 
 ago. 
 
 Old gastro- 
 jejunostomy 
 
 1 year after 
 operation. 
 
 Old gastro- 
 jejunostomy 
 
 2 years ago. 
 Old gastro- 
 jejunostomy 
 10 months. 
 
 Old gastro- 
 jejunostomy ; 
 duodenal 
 obstruction. 
 
 Gastrojejunos- 
 tomy 2 years. 
 
 Gastrojejunos- 
 tomy 6 weeks 
 
 after operation 
 
 Old gastro- 
 jejunostomy. 
 
 Old gastro- 
 jejunostomy. 
 
 Jejunum kinked behind 
 stomach. 
 
 Stoma not patent. 
 
 Kink 6 inches from stoma. 
 
 Stomach atonic ; excessive 
 peristalsis ; stoma not work- 
 ing ; obstruction at duodeno. 
 jejunal flexure. 
 
 Food passing freely both 
 ways ; excessive peristalsis ; 
 stoma 5 inches from py- 
 lorus. 
 
 Stoma working perfectly. 
 
 Adhesions blocking jejunum. 
 
 Stoma working perfectly ; 
 hypersecretion. 
 
 Both stoma and pylorus 
 
 patent. 
 Stoma not working ; looks 
 
 like pyloric obstruction. 
 
 Stoma not working ; slight 
 
 Jejunum stitched up. 
 
 Adhesions. 
 
 Adhesions with kinking of 
 
 jejunum. 
 Cicatrization about stoma 
 
 jejunum, and adhesions. 
 
 The pa 
 
 due to ' ■ 
 
 OS of 
 
 the «t' 
 
 on the food 
 
 in the pyloric 
 
 port ion ; re- 
 lieved by 
 operation. 
 Cured. 
 
 Many adhesions dissected out. | Patient died 
 
 Adhesions anterior wall. 
 
 Cured. 
 
 delay emptying. 
 
 Stoma working well ; slight 
 obstruction in jejunum. 
 
 No gastrojejunostomy had Cured, 
 been performed ; cicatrix 
 of pylorus. 
 
 No gastrojejunostomy had 
 been performed ; cicatrix 
 of pylorus : gastrojejunos- 
 tomy. 
 
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 44, 3. 2319- 
 
Ind 
 
 ex 
 
Index 
 
 Adhesions, 50. 
 Aerophagy, 40- 
 Air, injection of, 1 1. 
 Anaesthetics, action <>n stoma* h, , • 
 Appendicitis, 66. 
 
 with aerophagy, 50. 
 Appendix dyspepsia, 70. 
 
 Bougies, 13, 16. 
 
 Capsules, gelatine, 10. 
 
 gold-beater skin, 1 1 . 
 "Caput duodeni," 5S. 
 
 Carcinoma of stomach, 46. 
 Constipation, 65, 75. 
 
 Dermatitis, 6. 
 Drugs, 11. 
 
 alcohol, 11. 
 
 belladonna, 11, 15, 41. 
 — bicarbonate of soda, 11, 26, 37. 
 
 valerian, 11. 
 
 Duodenal irritation, notes on cases, 
 
 55- 
 
 - peristalsis in, 56. 
 - ulcer, 54. 
 Duodenum, food seen in, 57. 
 
 second sphincter in, 5S. 
 
 segmentation of food in, 69. 
 
 Dysphagia, 17. 
 
 Euteroptosis, 32. 
 
 Foods, g, 17, 26. 
 
 Free acid in stomach, 12. 
 
 Fundamental principles, 5. 
 
 Gastric ulcer, 39. 
 
 aetiology, 62. 
 
 notes on cases, 43. 
 
 Gastrojejunostomy, examinations 
 
 after, 52. 
 Gastroptosis, 32. 
 Gravity, action of, 56. 
 
 Hour-glass stomach, 39, 44. 
 Hypersecretion, 26, 37, 66. 
 
 Inflation of stomach, 11. 
 
 I I I 11 II II I I I , I I 1 1 < I | , J _ 
 
 aftei gai tro enti i" tomy, 
 
 I ige, to, 2$, 4"- 
 Method "f • saminaf ion, gi m ral, 1 
 
 <>[ oe lophagu , 1 
 
 Mucou 1 1 "lit i , 
 
 Normal stomach, 22. 
 
 operation in, 29. 
 
 (Esophageal obstruction, 13. 
 pouch, 19. 
 
 (Fsophagoscope, 14. 
 (EsophagUS, dilatation, 19. 
 foreign bodies, 16. 
 
 peptic ulcer, 20. 
 
 power of recovery, 21. 
 
 spasm of, 15. 
 
 Penetrating ulcers, 41. 
 Peristalsis, absence of, 28. 
 
 in carcinoma, 47. 
 
 — — in duodenal irritation, 56. 
 
 nervous control, 27. 
 
 — — in pyloric obstruction, 34. 
 Position of patient, 7. 
 Post-operative examinations, 50. 
 Preparation of patient, S. 
 Protection from rays, 6. 
 Pyloric obstruction, 33. 
 
 notes on cases, 36. 
 
 peristalsis in, 34. 
 
 — retention of food in. 35. 
 
 ulcer, diagnosis, 38. 
 
 notes on, 37. 
 
 Pylorus, carcinoma, 35. 
 
 control of, 26. 
 
 Results after operation, 
 
 vSeptic conditions, 69. 
 vShadow, clear spaces in, 48. 
 
 pyloric, S. 
 
 Small intestine, 54. 
 
 Soft rays, 6. 
 
 Spasmodic contraction, 47. 
 
126 
 
 Index 
 
 Stomach., adhesions, 50. 
 
 - anatomy, 22. 
 
 atony, 30. 
 
 carcinoma, 46. 
 
 - displacement, 29. 
 
 — — honr-glass contraction, 39. 
 
 - hypersecretion, 26, 37. 
 incidence of lesions, 53. 
 
 - inflation, 11. 
 
 - nervous control, 24. 
 
 normal, 22. 
 
 peristalsis in, 25, 27. 
 
 physiology, 22. 
 
 rapid emptying, 26, 56. 
 
 vStomach (continued), 
 
 retention of food in, 36. 
 
 reverse peristalsis in, 25. 
 
 shape, 23. 
 
 — - spasm, 29, 39, 44, 62, 64. 
 - tone, 24, 27, 35. 
 
 Tabulation of cases, 77. 
 Teeth, carious, 64, 75. 
 
 Upright position, 5. 
 
 Visceroptosis, 31. 
 Vicious circle, 51 
 
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