2. A dilatation due to old lesions which have subsided, the atonic stretching not having been repaired.

It will be seen, then, that the condition may be met as a sequel to many different pathological processes. As such, therefore, it has no constant etiology nor necessarily distinctive features. In general it is recognized by tardiness in escape of gastric contents, associated with vomiting, the vomitus being distinctive, consisting often of old and undigested food, or perhaps of food which has rested in the stomach until putrefaction has occurred. The vomitus also contains evidences of fermentation, with sarcinæ and yeast cells and much mucus. In cases of ulcer it is usually very sour, owing to excess of free hydrochloric acid. When due to cancer the acid is usually due to excess of lactic acid, while hydrochloric acid may be nearly or totally absent. Even if vomiting does not occur after ingestion of food, heaviness and discomfort, with much eructation of gas, are produced. Constipation and diminished urine secretion are almost invariable accompaniments. When the obstruction is of the mechanical type a visible peristaltic wave can often be seen and felt, and this is a sign which should be regarded as always indicating operation.

Patients gradually lose flesh and become anemic and run down, suffering from what has been often vaguely called indigestion, their lives sometimes being terminated by starvation, occasionally by gastric tetany. The question of diagnosis can usually be settled by having the patient swallow the dissolved separate parts of a Seidlitz powder, one after the other, when the carbon dioxide released within the stomach will cause it to balloon up and assume that shape and position which the amount of its dilatation permits.

Gastric dilatation which does not quickly yield to lavage and suitable medication is of itself always an indication for operation. When accompanied by a tumor, especially if this move and change position with the stomach, a cancerous condition may be assumed, which, while not permitting a cure, may nevertheless be ameliorated by a gastro-enterostomy. In the absence of actual cancerous conditions the surgical treatment of chronic dilatation is exceedingly satisfactory.

This surgical treatment consists in the application of one at least of the following expedients:

The methods in vogue a few years ago for opening the stomach and merely stretching the pyloric outlet have been supplanted by other plastic operations which have proved more satisfactory because of the greater permanency of their results.

GASTROPTOSIS.

The downward displacement of the stomach, to which the term gastroptosis has been given, implies not only more or less actual dilatation, but also a stretching or lengthening of the upper attachments and peritoneal folds which should hold the stomach up in place. When these yield and the stomach is thus permitted to drop, more or less obstruction of the pylorus and kinking of the duodenum are apt to occur. The condition regarded surgically is not essentially different from that of chronic dilatation. When the stomach is distended with carbon dioxide its normal position may be easily recognized, while, at the same time, it is determined that it is perhaps but little dilated.

The causes which lead to this condition, aside from those which affect the stomach proper, include tight lacing, by which the supporting viscera are forced downward and the stomach permitted to fall with them. In addition to such a cause any previous disease by which the abdominal viscera have been affected or ligaments weakened would be of more or less effect. The condition leads sooner or later to one of dilatation, and always merges into it. Its symptoms are those of dilatation, only in milder degree. On account of the dragging upon the upper supports patients frequently complain of intense lumbago, and they nearly always become neurasthenic.