source of displacement is internal, and consists in abnormal intestinal adhesions. The stomach is naturally placed almost horizontally, the pyloric being only a small distance below the cardiac extremity; and from its greater curvature, the omentum extends to the transverse colon and spreads over the small intestine.

When the lower ribs are firmly compressed, especially during active growth and development, the stomach assumes an almost vertical position; the pylorus is then pressed downwards to the umbilicus, and the natural churning movements of the stomach, as well as the passage of the food along the lesser curvature, and backwards towards the cardia by the greater curvature, are interfered with; the semi-formed chyme gravitates unnaturally towards the pyloric valve, and portions pass into the duodenum before they have undergone complete solution. In this semi-dissolved state of the ingesta irritation of the intestine is set up, and pain produced. Borborygmi and flatulent eructations distress the patient, and a fertile source of hysterical complaint arises. When direct pressure is made upon the scrobiculus cordis, the movements of the stomach are differently modified; the firm pressure whilst digestion goes on, not only interferes with free movement, but excites irritation.

Again, cases are far from unfrequent where the omentum, attached as we have just said to the greater curvature of the stomach, becomes adherent at the lower part of the abdomen, or is fixed by hernial attachment.

The free distension that accompanies normal digestion is prevented, for the stomach is tied down; we find that pain in the side is produced of a fixed character, and this distress is increased by anything that distends the viscus, therefore especially by digestion; and the pain recurs after nearly every meal. Another form of dyspepsia of a mechanical kind is that arising from pressure upon the stomach by dropsical and other effusions. As the effusion accumulates in the peritoneal cavity, an uniform pressure is exerted upon the stomach, and no inconvenience may be felt as long as the stomach is not distended; but directly it is required to perform its normal work, and necessary movements, with which are also generally associated some increase in the volume of the stomach, either from food or gaseous evolution, pain is produced, and is frequently followed by the rejection of the contents of the stomach. And although the primary disease-the cause of the dropsy, whether it be chronic disease of the liver, of the kidney, or of any structure-may itself produce dyspepsia as one of its symptoms, still this mechanical pressure greatly aggravates the gastric disturbance. The patient becomes physically unable to take food; pain, eructation, and a sense of almost insufferable distension are produced. When the fluid or the pressure is lessened, the symptoms subside; and we have very frequently noticed that the stomach has suddenly regained its power after paracentesis abdominis had been

performed. Abdominal tumours, whether carcinomatous, hydatid, or of any other kind, sometimes exert pressure upon the stomach, and thus mechanically interfere with its healthy action.

3. As regards the changes in the coats of the stomach, they belong so exclusively to organic diseases that we shall not enter upon the consideration of them here; but it may be mentioned, that in fibroid disease of the pylorus, the stomach sometimes attains enormous proportions, so that with the pyloric valve close to the pubes, the viscus fills nearly the whole of the abdomen; and that without such valvular obstruction, the muscular coat becomes sometimes atrophied, and the cavity enormously distended, so that it is unable to contract upon its contents. In this latter case, the principal symptom is the tympanitic distension of the abdomen, with feebleness of digestion. We shall have again to, refer to distension of the stomach in speaking of fermentative changes.

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CHAPTER XIII.

SYMPATHETIC DYSPEPSIA.

THE extensive connection of the stomach with other parts of the system, by means of its supply of nerve filaments, leads to frequent disturbance of its function from disorder in other parts; and an intimate acquaintance with these sympathetic maladies is of the utmost importance; for without this knowledge, not only is the true source of disturbance overlooked, but, as a necessary sequence, the treatment is ineffective, because applied in a wrong direction.

It is not our intention to describe the nerves that supply the stomach, but only to state that this supply is from two sources, 1st, from the large branches of the vaso-motor nerve of the semi-lunar ganglia of the abdomen, by which it is connected, not only with the adjoining viscera in the abdomen, but with nearly every part of the body; this connection gives rise to disturbances of sight and hearing, and of the intellectual and sensory centres generally; the 2nd source is from the pneumogastric nerve, which also supplies the lungs and the heart.

Perhaps the most important form of sympathetic disturbance of the stomach is that connected with disease of the brain; and the consideration of this is the more necessary, because in such cases the true nature of the malady is often overlooked. There are some peculiarities, however, which serve to distinguish this form of malady; in one class the subjects are young, of an active mind, intelligent, and precocious. There may be some headache, and temporary disturbance of vision, grinding of the teeth, disturbed nights, and restless activity of mind during the day; they are generally precocious children, of bright and joyous disposition; and, without any very apparent cause, vomiting is set up, and the illness is regarded as a "bilious attack." This may soon be followed by more marked symptoms of cerebral disturbance, by severe headache, convulsion, and gradually increasing coma, in fact, by all the symptoms of acute hydrocephalus; or there may be a succession of such attacks, each slight in itself, but, as the mind is allowed to rest, and the irritation of the brain is diminished, the diseased state gradually subsides. This repeated disturbance of the brain favours the deposition of tubercular deposit in the membranes, and at length acute hydrocephalus is developed to the inexpressible anguish of the relatives of the child. Sometimes the symptoms of cerebral affection are preceded by those of gastric remittent fever, and then it is difficult without careful inves