DILATATION OF THE STOMACH.
BY W. H. WELCH, M.D.
DEFINITION.—By dilatation of the stomach is understood a condition in which the stomach is abnormally large and is unequal to the performance of its normal functions. It will be observed that this definition of dilatation of the stomach includes an anatomical disturbance and a physiological disturbance. A stomach which, although unusually large, performs its functions perfectly well is not, in the clinical sense, a dilated stomach. The most characteristic functional disturbance in dilatation of the stomach is delay in the propulsion of the gastric contents into the intestine in consequence of inability of the muscular coat of the stomach to perform the work imposed upon it. This muscular insufficiency, whether primary or secondary, necessarily involves disorder of the digestive and absorptive powers of the stomach.
SYNONYMS.—Dilatatio ventriculi; Gastrectasia. It has been proposed to call the early stages of the disease insufficiency of the stomach (Rosenbach). The condition described by Chomel as dyspepsia of liquids is undoubtedly dilatation of the stomach.
HISTORY.—Dilatation as a disease of the stomach is not mentioned by writers of antiquity. Fabricius ab Aquapendente in 1623 was among the first to record an observation of dilatation of the stomach. During the following century cases of dilatation of the stomach were recorded more as curiosities than as of clinical interest. Most cases were attributed to eating or drinking inordinate quantities. In 1743, Widman clearly recognized stenosis of the pylorus as a cause of gastric dilatation. In the works of Van Swieten, Morgagni, Lieutaud, and J. P. Frank, during the latter half of the last century, different causes of dilatation of the stomach are recognized. The last writer especially distinguishes clearly between dilatation due to stenosis and that due to atony. The data as to the symptoms of the disease were still very imperfect. In 1833, Duplay1 published an important article in which the main points in the causation and symptomatology of dilatation of the stomach are clearly described. After this time the important works on the practice of medicine or on diseases of the stomach contain, in the main, correct descriptions of the disease under consideration. Since the publication in 1869 of Kussmaul's memorable article2 on the treatment of dilatation of the stomach by the stomach-pump, much greater attention has been paid to this disease than ever before, so that the literature upon this subject during the last fifteen years is very considerable. In 1875, Penzoldt published an excellent monograph upon dilatation of the stomach.3
1 Arch. gén. de Méd., Ser. 2, t. iii. pp. 165, 523.
2 Deutsches Arch. f. kl. Med., Bd. vi., 1869. Kussmaul first employed the stomach-pump in dilatation of the stomach in 1867, and in that year he reported a successful result (Schmidt's Jahrb., Bd. 136, p. 386).
3 Die Magenerweiterung, Erlangen, 1875. To this work I am indebted for most of the historical data in the text.
ETIOLOGY.—Dilatation of the stomach is the result of inability of this organ to propel its contents into the intestine within the normal space of time. In the performance of this mechanical work three factors are involved—namely, the muscular force of the stomach, the quantity and quality of the gastric contents, and the size of the opening between the stomach and the intestine. All causes of dilatation of the stomach may be referred to abnormalities of one or more of these factors.
The most important group of causes is represented by stenosis of the pyloric orifice or of the adjacent part of the stomach or of the intestine.4 Most cases of hypertrophic dilatation of the stomach—that is, dilatation with hypertrophy of the muscular walls of the stomach—are produced by causes belonging to this group.
4 Dilatation of the stomach in consequence of intestinal obstruction below the duodenum is so rare that no further attention is given to the subject in the present article. The term pyloric stenosis is often used in the course of the article to include any obstruction to the passage of the contents of the stomach into the intestine, whether the obstruction be in the duodenum, the pyloric orifice, or the pyloric region.
The most frequent cause of pyloric stenosis is carcinoma, either in the form of a diffuse infiltration of the gastric walls in this region or as a tumor projecting into the cavity of the pyloric portion of the stomach. Next in frequency are cicatricial growths resulting from simple ulcer involving the pyloric region. Much less frequent are similar cicatricial stenoses of the pylorus resulting from ulcers produced by swallowing corrosive poisons. Simple hypertrophy of the coats of the stomach in the pyloric region, particularly of the fibrous and muscular coats, is an occasional cause of dilatation. Obstruction of the pylorus by mucous polypi or by hypertrophic folds of mucous membrane is so rare as to have little practical interest. Likewise, stenosis caused by sarcomata, fibromata, myomata, lipomata, and cysts need be mentioned only for the sake of completeness.
Narrowing of the pyloric orifice may be caused also by pressure from outside of the stomach, as by tumors, particularly cancer, of the liver and of the pancreas, and by the contraction of fibrous adhesions and thickenings resulting from perigastritis. Obstruction of the duodenum by tumors growing in its walls, by cicatrices resulting from ulcers, and by external pressure may also cause dilatation of the stomach. According to Barker, compression of the duodenum by a wandering right kidney may induce dilatation of the stomach. The mere association of dilatation of the stomach and movable right kidney, however, cannot be considered proof that the former is caused by the latter, for the subjects of movable kidney (most frequently women with flabby abdominal walls who have borne many children) are often also favorable subjects for atonic dilatation of the stomach.
Sometimes with dilatation of the stomach the pyloric orifice is found abnormally small, without any thickening or other appreciable change in the walls of the pylorus. These cases in adults have been described by Landerer under the name of congenital stenosis of the pylorus, but his conclusions are not free from doubt.5 Congenital stenosis, and even complete occlusion of the pylorus, has been observed in infants.6
5 Ueber angeborene Stenose des Pylorus, Inaug. Diss., Tübingen, 1879. In the ten cases studied by Landerer the patients were all adults, mostly in advanced life. In only one case is it mentioned that indigestion existed from childhood; the clinical history in all is incomplete. With the exception of one case there was no marked hypertrophy of the muscular coat of the stomach, such as is usually found with benign pyloric stenosis and would naturally be expected with a stenosis existing since birth. The pyloric orifice varied from 1½ cm. to 2 mm. in diameter. Some of the specimens had been in alcohol for a considerable time. In my opinion, Landerer has not brought forward sufficient proof that in these cases stenosis of the pylorus existed since birth.
6 Wünsche, Jahrb. d. Kinderheilk., viii. 3, p. 367. Andral, Förster, and Bull have found congenital stenosis and atresia of the pylorus.
Spasm of the pyloric muscle, which, according to Kussmaul, may be referable to erosions, ulcers, and inflammations of the adjacent mucous membrane, can be admitted only as a hypothetical explanation of some cases of dilatation of the stomach.
Somewhat problematical, although not improbable, is the production of stenosis of the pylorus or of the duodenum by torsion and by displacement of these parts. Dilatation of the stomach is sometimes associated with scrotal hernia, particularly with that containing omentum or transverse colon. This dilatation Kussmaul explains by the production of a sharp bend between the movable first part and comparatively fixed second part of the duodenum, in consequence of the dragging downward of the stomach by the displaced omentum or transverse colon. In a similar way Kussmaul believes that the weight of an over-distended stomach may produce stenosis, and by this mechanism he explains the occasional occurrence of symptoms of complete pyloric obstruction when a large quantity of material has accumulated in an already dilated stomach, and the prompt relief of these symptoms when the burden of the stomach is removed either by vomiting or by the stomach-tube.7
7 Another explanation given by Kussmaul, and likewise based upon experiments on the cadaver, is that when the stomach is over-distended it may rotate upon its own axis, so that the pylorus acquires a sagittal direction and impinges against the first part of the duodenum. This rotation of the stomach, however, can occur only when the abdominal walls are flabby (Kussmaul, "Die Peristaltische Unruhe des Magens," Volkmann's Samml. klin. Vortr., No. 181).
The manner in which stenosis of the pylorus causes dilatation of the stomach is sufficiently obvious to require no especial explanation. It is, however, important to know that stenosis of the pylorus may be compensated, so that even a very considerable degree of obstruction of this orifice may exist without any dilatation of the stomach. The obstruction may be completely counteracted by hypertrophy of the muscular coat of the stomach, particularly of that in the right half of the organ. Leube suggests that this increased muscular force, by increasing the peristaltic movements, may also hasten the digestion and absorption of the food, so far as these processes take place in the stomach.8 The timely removal of the contents of the stomach by vomiting may also prevent over-distension of the organ. Another compensatory circumstance may be the reduction of the quantity of solid and liquid food taken by the patient. Conditions are often present, however, which oppose the development of these compensatory circumstances. Such conditions are feebleness of the patient, degeneration of the muscular coat of the stomach, chronic catarrhal gastritis, insufficient secretion of gastric juice, and delayed absorption, causing stagnation and fermentation of the food in the stomach.
8 Leube, in V. Ziemssen's Handb. d. spec. Path. u. Ther., Bd. vii. 2te Hälfte, p. 211, Leipzig, 1878.
Dilatation of the stomach may occur without any obstacle to the evacuation of the gastric contents into the intestine. The cases of so-called atonic dilatation of the stomach belong to this class. The degree of dilatation in these cases is rarely so great as when the dilatation is caused by stenosis. The cause of gastric dilatation in the absence of stenosis is not always clear, so that a variety of hypotheses, more or less probable, have been broached to explain these obscure cases.
Dilatation with unobstructed outlet of the stomach must be referable either to abnormalities in the quantity or quality of the contents of the stomach or to weakness of the muscular walls of the stomach. In most cases both of these causes are combined, and it is not easy to separate their action.
Abnormal gastric contents may be the result of improper ingesta or of disturbances in gastric digestion. Although in former times the frequency of excessive eating and drinking as a cause of dilatation of the stomach was doubtless exaggerated, nevertheless the efficacy of this cause cannot be doubted. Dilatation of the stomach is said to be common in people who live almost exclusively upon a vegetable diet and therefore require large quantities of food. The habitual drinking of large quantities of beer may cause dilatation of the stomach. The occasional association of a dilated stomach with diabetes is referred to the inordinate appetite and thirst which characterize this disease. If the food reaches the stomach imperfectly masticated, the process of digestion is delayed, and as a result the stomach may become dilated. Indigestible food, particularly that which readily ferments in the stomach, may be an indirect cause of the disease under consideration. A similar rôle may be played by swallowing foreign substances either by accident or by design. It is not proven that dilatation of the stomach may be referable to exhaustion of its muscular power by the abuse of agents which at first excite peristalsis, such as emetics, purgatives, alcoholics, tobacco, spices, etc. Equally doubtful is the production of dilatation by the misuse of narcotics, such as opium, which restrain peristalsis.
Of great importance in the production and continuance of gastrectasia are all circumstances which cause stagnation and fermentation of the contents of the stomach. These abnormalities of the gastric contents are referable both to muscular and to chemical insufficiency of the stomach, but in this connection it is desired to call attention especially to chemical insufficiency, although in the production of gastric dilatation this becomes always associated with muscular insufficiency. In this way chronic catarrhal gastritis is operative in the causation of gastric dilatation. In consequence of insufficient secretion of normal gastric juice and of delayed absorption, the food remains abnormally long undigested in the stomach, and fermentative changes, with the development of gas, occur. No less important, however, is the impairment of the muscular power of the stomach in chronic gastritis. Stagnation and fermentation of the contents of the stomach occur also in functional or atonic dyspepsia, which is to be reckoned as a cause of dilatation of the stomach. Naunyn9 emphasizes especially the importance of abnormal fermentations in the stomach (alcoholic, butyric acid, lactic acid, acetic acid fermentations) both as a cause and as a result of dilatation of the stomach. Ulcer and cancer of the stomach may cause dilatation by interfering with the normal digestive processes.
9 Deutsches Arch. f. kl. Med., Bd. 31.
We come now to the third and final group of causes of dilatation of the stomach—namely, those included under weakness of the muscular walls of the stomach. In the last analysis all causes of gastric dilatation come under this heading, for even with pyloric stenosis and with excessive contents a stomach will not dilate so long as its muscular power is equal to the proper performance of the work which is demanded. In this connection, however, reference is had especially to those cases in which impairment or restraint of the muscular movements of the stomach may be regarded more or less directly as the primary cause of dilatation of the stomach.
Clearest of comprehension are those cases in which the muscular power of the stomach is impaired by organic changes in the muscular coat. Here may be mentioned partial destruction of the muscular coat, particularly of that in the pyloric region, by ulcers and by cancers. Thus, ulcers and cancers which in no way obstruct the outlet of the stomach may cause dilatation of the organ. Inflammatory infiltration (inflammatory oedema) of the muscular coat has been adduced as a cause of its weakness in chronic catarrhal gastritis and in peritonitis. Whether this is the proper explanation or not, there is no doubt that the muscular coat of the stomach may become paretic in cases of chronic catarrhal gastritis, as well as the subjacent muscle in inflammations of other mucous membranes, as in laryngitis or in cystitis. Our knowledge of the relation between degeneration of the muscular coat of the stomach and gastrectasia is very imperfect. Fatty and colloid degeneration of the muscle of dilated stomachs is probably to be interpreted as a secondary change. It is probable that amyloid degeneration may be a cause of atonic dilatation of the stomach.10 Oedematous infiltration of the coats of the stomach in cases of cirrhosis of the liver, pulmonary emphysema, cardiac disease, and Bright's disease has been assigned as a cause of gastric dilatation, but without satisfactory evidence. Chronic interstitial gastritis (cirrhosis of the stomach) is more frequently a cause of contraction than of dilatation of the stomach.
10 Edinger, ibid., Bd. 29.
The restraint of the muscular movements of the stomach by adhesions and by dragging downward of the organ in hernia may cause dilatation. Relaxation of the abdominal walls, as in women who have borne many children, by removing the normal support of the stomach, has been thought to cause dilatation.
Atony of the muscular walls of the stomach may be a part of general muscular weakness and impaired nutrition. Here belong cases of adynamic dilatation of the stomach secondary to typhoid fever, cholera, tuberculosis, anæmia, chlorosis, cachexia, senile marasmus, neurasthenia.
Whether primary paralysis of the stomach can occur or not is wholly uncertain. We have no positive knowledge as to the occurrence of paresis of the stomach in consequence of organic or functional changes in the peripheral or central nervous system. Nor does our meagre information as to the relation between the nervous system and the muscular movements of the stomach justify the construction of any hypotheses as to this point.
For the sake of clearness the various causes of dilatation of the stomach according to the foregoing classification may be recapitulated as follows. Some of the more doubtful and of the rarer causes are omitted:
A. Stenosis of the Pylorus or of the Duodenum.
1. Cancerous;
2. Cicatricial;
3. Hypertrophic (of pylorus);
4. From external pressure;
5. Congenital (of pylorus)?;
6. From torsion of duodenum?
B. Abnormalities in Contents of Stomach.
1. Ingesta:
a. Excessive;
b. Imperfectly masticated;
c. Indigestible.
2. Stagnation and fermentation in consequence of chemical insufficiency of the stomach, as in chronic catarrhal gastritis and functional dyspepsia.
C. Impairment of Muscular Force of Stomach.
1. Organic changes in muscular coat:
a. Partial destruction by ulcers and cancers;
b. Inflammation, as in chronic catarrhal gastritis and peritonitis;
c. Degenerations (fatty, colloid, amyloid);
d. Oedema?;
e. Cirrhosis of stomach.
2. Mechanical Restraint:
a. By adhesions;
b. By weight of herniæ.
3. Impaired Nutrition and General Muscular Weakness, Adynamic dilatation from typhoid fever, tuberculosis, anæmia, etc.
4. Paresis from neuropathic causes?
As a rule, not a single one, but several, of the above-mentioned causes are operative in the production of dilatation of the stomach, and it is often impossible to say which is the primary cause. The various gastric functions are so dependent upon each other that if one is disturbed the others also suffer. If, for instance, atony of the muscular coat of the stomach exists, then in consequence of enfeebled peristalsis the secretion of gastric juice is insufficient, the food is not thoroughly mingled with the gastric juice, and the absorption of the products of digestion in the stomach is interfered with; in consequence of which the accumulating peptones still further hinder the digestive process. The pylorus remains contracted for an abnormal length of time, as it naturally is closed until the process of chymification in the stomach is far advanced, and this process is now delayed. The stagnating contents of the stomach readily ferment, and the irritating products of fermentation induce a chronic catarrhal gastritis, which further impairs the functions of the mucous and muscular coats of the stomach. Thus, in a vicious circle one cause of dilatation induces another. To assign to each cause its appropriate share in the production of the final result is a matter of difficulty, and often of impossibility. From this point of view the dispute as to whether in atonic dilatation the most important factor in causation is chemical insufficiency of the stomach (impaired secretion of gastric juice, fermentations) or mechanical insufficiency (weakened muscular action, stagnation), appears of little practical importance.
Of the causes of non-stenotic dilatation of the stomach, the first place is to be assigned to chronic catarrhal gastritis and to atonic dyspepsia, as this term is understood by most English and American writers.
As regards frequency, gastric dilatation is a common result of cancer of the pylorus. It is less frequently caused by simple ulcer. Other forms of pyloric stenosis than the cancerous and the cicatricial are rare.
Opinions differ as to the frequency of non-stenotic or atonic dilatation of the stomach according to the manner in which one interprets the cases. Non-stenotic dilatations which are comparable in degree to those produced by stenosis are rare. The lesser grades of atonic dilatation, however, are not rare; but here arises the difficulty of distinguishing these cases from mere chemical or mechanical insufficiency of the stomach, which often represents the early stage of the process. Hence it has been proposed to discard altogether the term dilatation, and to substitute that of insufficiency of the stomach. But this latter term is applicable to many affections of the stomach other than dilatation. A typical case of atonic dilatation of the stomach is a well-defined disease, and because it is difficult to diagnosticate its early stages is not sufficient reason for discarding altogether the designation.
Gastrectasia may develop at any age. It is most frequent in middle and advanced life. The largest number of cases of atonic dilatation is met with between thirty and forty years of age. The disease is rare in childhood.11 The disease occurs in all classes of life. Atonic dilatation seems to be comparatively more frequent in private practice and among the favorably situated than in hospitals and among the poor. Kussmaul says that the largest contingent of patients is furnished by persons who lead a sedentary life and eat and drink a great deal.
11 Kundrat and Widerhofer mention no case of stenotic dilatation of the stomach in children. They say, however, that atonic dilatation due to over-feeding, and particularly to rachitis, is not infrequent in children. Widerhofer reports a case of very large dilatation of the stomach in a girl twelve years old. The cause of the dilatation was not apparent, and the clinical history was imperfect (Gerhardt's Handb. d. Kinderkrankh., Bd. iv. Abth. 2). Lafage (Thèse, Paris, 1881) reports a case of gastric dilatation at ten years, and another at sixteen years of age. R. Demme (abstract in Berl. kl. Wochenschr., 1883, No. 1) reports a case of large dilatation of the stomach in a boy six and a half years old. Cicatricial stenosis was suspected. Pauli (De Ventriculi Dilatatione, Frankfurt, 1839) reports an enormous dilatation of the stomach, believed to be due to congenital stenosis.
SYMPTOMATOLOGY.—Inasmuch as dilatation of the stomach is usually secondary to some other disease, the symptoms of the primary disease have often existed a long time before those of dilatation appear.
The subjective symptoms of gastric dilatation are for the most part directly referable to disturbances of the functions of the stomach. These subjective symptoms alone do not suffice for a positive diagnosis of the disease. Of the greatest diagnostic importance are an examination of the vomit and a careful physical exploration of the stomach.
The appetite with dilatation of the stomach may be normal, diminished, increased, or perverted. In the majority of cases the appetite is diminished, and there may be complete anorexia. Sometimes the appetite is increased even to voracity, which is explicable by the small amount of nutriment which is absorbed. Polyphagia may therefore be a result as well as a cause of dilatation of the stomach.
Often there is excessive thirst in consequence of the small quantity of fluid absorbed.
Dilatation of the stomach in itself does not usually cause sharp epigastric pain, although it is often associated with painful diseases of the stomach.
There is usually in the region of the stomach a sense of fulness and weight, which is often distressing and may be accompanied with dull pain.
Heartburn and eructations of gas and of bitter or of acid fluids are frequently present. The gas is often odorless, but sometimes it is very offensive. It may contain sulphuretted hydrogen. In a number of cases—which, however, are exceptional—the gas has been found inflammable, burning usually with a colorless flame (hydrogen), but rarely, as in a case from Frerichs' clinic, with a bright yellowish-white flame (hydrocarbons). Detonation upon setting fire to the gas has been noted. The analysis of the inflammable gas has shown oxygen and nitrogen in approximately the same proportion as in the atmosphere, in addition to large quantities of carbonic acid and of hydrogen, also marsh gas, and in Frerichs' case olefiant gas in small amount.12 The oxygen and nitrogen are doubtless simply swallowed, but the carbonic acid and hydrogen are the result of abnormal fermentations in the stomach. The origin of the hydrocarbons in the gas is not clear, but they are probably also produced by fermentation within the stomach.
12 One of the analyses in Frerichs' case gave carbonic acid, 17.40; hydrogen, 21.52; marsh gas, 2.71; olefiant gas, traces; oxygen, 11.91; nitrogen, 46.44. In another analysis were found marsh gas, 10.75, and olefiant gas, 0.20. Sulphuretted hydrogen was also present (Ewald, in Reichert und Du Bois-Reymond's Archiv, 1874, p. 222).
One of the most frequent symptoms, although not a constant one, of dilatation of the stomach is vomiting. This symptom often presents characters which, if not pathognomonic of dilatation, at least raise a strong presumption in favor of its presence. The act of vomiting is sometimes accomplished with such ease that it is hardly more than regurgitation; at other times the act is accompanied with violent and exhausting retching. A feature particularly characteristic of dilatation of the stomach is the abundance of the vomited material. In no other disease is such an enormous quantity evacuated from the stomach at one time. Blumenthal relates a case in which the vomited material amounted to sixteen pounds. Such large quantities can accumulate in the stomach of course only when a considerable time intervenes between the acts of vomiting. The vomiting of gastric dilatation does not generally occur until some hours after a meal. It often presents a certain periodicity, occurring, for instance, at intervals of two or three days, and followed usually by temporary relief. It is often observed that as the stomach becomes larger and larger the vomiting becomes less and less frequent, but at the same time more abundant. Especially toward a fatal termination of the disease the walls of the stomach may become so paralyzed and insensible, and the patient so feeble, that the vomiting ceases altogether. Another valuable diagnostic sign furnished by the vomit is the presence of undigested food which has been taken a considerable time, it may be many days, previously.13 If the morning vomit habitually contains undigested food which has been eaten the previous day, gastric dilatation either exists or is almost sure to develop.
13 Ritter relates the case of a man who vomited cherry-pits, although he had not eaten cherries for over a year (Canstatt's Jahresbericht, 1851, iii. p. 260)!
The vomited matter is almost always in a condition of fermentation. If the vomit be allowed to stand in a vessel, it will separate into three layers—an upper, frothy; a middle, of turbid fluid, usually yellowish or brownish in color; and a lower layer, composed of solid particles, mostly alimentary débris. The vomit often emits an extremely offensive odor. The reaction is nearly always acid. Different kinds of fermentation—alcoholic, acetous, lactic acid, and butyric acid—are present, usually in combination with each other. The microscope reveals, besides undigested and partly-digested food, crystals of fatty acids, sarcinæ ventriculi, fungus-spores, and various forms of bacteria, particularly rod-shaped ones. The connection between sarcinæ and fermentative processes is not understood. There is no evidence that sarcinæ are capable of causing fermentation. Of greater importance is the recognition by the microscope of the spores of the yeast-fungus (Torula cerevisiæ). These spores are rarely absent, and their constant presence is evidence that fermentation is in progress. Fermentation often exists in undilated stomachs, but, as has already been mentioned, it is an important factor in the production of dilatation, so that its early recognition, if followed by proper treatment (washing out the stomach especially), may ward off the development of dilatation. The article on GASTRIC CANCER is to be consulted with reference to the habitual absence of free hydrochloric acid from the stomach in cases of cancerous dilatation. If cancer or ulcer of the stomach exists, blood is frequently present in the vomit, but even in the absence of ulcer or cancer or other demonstrable source of hemorrhage the vomit in cases of dilatation of the stomach may exceptionally contain blood, even for a considerable length of time. If the dilatation be due to pyloric stenosis, bile is not often found in the vomited material.
It has already been mentioned that vomiting is not a constant symptom of dilatation of the stomach. It remains to add that vomiting may be present without any of the distinctive features which have been described. Gastric dilatation, especially in its early stages, is often accompanied by attacks of acute indigestion (embarras gastrique) after some indiscretion in diet.
Constipation is an almost constant symptom of dilatation of the stomach. This is naturally to be expected when so little substance passes from the stomach into the intestine. The constipation is also to be explained in part by the absence of the usual reflex stimulus which the stomach during digestion normally exerts upon intestinal peristalsis, for the constipation is usually much relieved when the overweighted stomach is systematically washed out.
Occasionally, attacks of diarrhoea occur in cases of dilatation of the stomach. The diarrhoea may perhaps be explained by the sudden discharge of a large quantity of fermenting material from the stomach into the intestine.
With marked dilatation of the stomach, especially when there is profuse vomiting, the urine is often considerably diminished in quantity. Particularly in cases treated by systematic washing out of the stomach, but also in other cases, especially with abundant vomiting, the acidity of the urine is often much reduced. The reaction may be even continuously alkaline (Quincke). Crystals of phosphate of magnesium have been occasionally found in the alkaline urine of gastrectasia (Ebstein). The urine is prone to deposit abundant sediments. It often contains an excess of indican.
The patient may suffer from attacks of dyspnoea and of palpitation of the heart in consequence of flatulent distension of the stomach.
The general condition of the patient will of course depend chiefly upon the character of the primary disease and upon the severity of the gastric symptoms. A moderate degree of dilatation may exist without much disturbance of the general health of the patient. But as the disease progresses and the food stagnates more and more in the stomach, finally to be rejected by vomiting, the patient cannot fail to lose flesh and strength. In extreme cases of gastrectasia, even without organic obstruction, the patient may be reduced to a degree of emaciation and of cachexia indistinguishable from that of cancer. As in so many other gastric diseases, the patient is usually mentally depressed and hypochondriacal. His sleep is disturbed. He suffers much from headache and vertigo. He feels incapable of physical or mental exertion. The skin is dry and harsh; the extremities are cold. Toward the last, cachectic oedema about the ankles can often be recognized.
Kussmaul was the first to call attention to the occurrence of tetanic spasms in cases of dilatation of the stomach.14 This symptom has been observed almost exclusively in an advanced stage of the disease when the patient has become anæmic and weak. The spasms come on chiefly after attacks of profuse vomiting or after evacuating large quantities by the stomach-tube. The spasms may be preceded by a sense of pain or distress in the region of the stomach, by dyspnoea, by numbness of the extremities, or by great prostration. The tetanic spasms affect especially the flexor muscles of the hand and forearm, the muscles of the calves of the legs, and the abdominal muscles. The spasm may be confined to one or more of these groups of muscles, or there may be general tetanic contraction of the muscles of the body. Sometimes typical epileptiform convulsions with loss of consciousness occur. With general tetanic spasms the pupils are usually contracted, and often irresponsive to light. Sometimes there is abnormal sensitiveness upon pressure over the contracted muscles. The spasms may last for only a few minutes, or they may continue for several hours, or even for days. After their disappearance the patient is left extremely prostrated. Although tetanic spasms increase the gravity of the prognosis, they are not necessarily fatal.
14 Deutsches Arch. f. kl. Med., Bd. vi. p. 481.
Kussmaul considers that these spasms are analogous to those occurring in cholera, and are referable to abnormal dryness of the tissues in consequence of the extraction of fluid. This view is supported by the usual occurrence of the spasms after profuse vomiting or after washing out the stomach. Another explanation, which is perhaps more applicable to the epileptiform attacks, refers the convulsions to auto-infection by toxic substances produced in the stomach by abnormal fermentative and putrefactive changes (Bouchard).15
15 Laprevotte, Des Accidents tétaniformes dans la Dilatation de l'Estomac, Thèse, Paris, 1884, p. 48.
Coma, with or without the peculiar dyspnoea of diabetic coma, is a rare occurrence in gastrectasia. (For a description of this form of coma see page [205].)
The temperature in gastric dilatation is generally unaffected. Penzoldt, however, saw two cases with moderate rise of temperature in the evening, which could not be explained by any complication. On the other hand, abnormally low temperature with slow pulse has been observed (Wagner).
Essential to the diagnosis of gastric dilatation is the physical examination of the stomach.
If the stomach be markedly dilated, inspection may reveal an abnormal prominence of the abdominal walls in the epigastric region and extending a variable distance below the level of the umbilicus. This prominence is most marked on the left side. When the abdominal walls are sufficiently thin and relaxed, sometimes the outline of the greater curvature between the umbilicus and pubes, less frequently that of the lesser curvature, can be made out. Sometimes the peristaltic waves of the stomach can be perceived through the thin abdominal walls. By pressure or by passing the hand across the abdomen gastric peristalsis may sometimes be excited. The peristaltic movements of the stomach, however, are rarely perceived except when the dilatation is due to stenosis and the muscular coat of the stomach is hypertrophied. The peristaltic waves generally pass from left to right, rarely in the opposite direction as well. Careful attention to the situation, direction, and extent of these waves is necessary to distinguish them from similar peristaltic movements of the intestine.16 The diminution in size of the abdominal prominence caused by a dilated stomach after profuse vomiting or after washing out the stomach may aid in the diagnosis.
16 Kussmaul says that vigorous peristaltic movements of the stomach may be perceptible through the abdominal walls even when there is no dilatation of the stomach. Under these circumstances he attributes the peristaltic commotion to an independent neurosis of the stomach ("Die Peristaltische Unruhe des Magens," Volkmann's Samml. klin. Vorträge, No. 181).
An important aid in bringing out the contours of the stomach is the artificial distension of the organ by the generation within it of carbonic acid gas, as first suggested by Frerichs. For this purpose 20-30 grains of bicarbonate of sodium and 15-20 grains of tartaric acid, each dissolved in a little lukewarm water, may be given one after the other. If the stomach be much dilated and relaxed, it may be necessary to give much larger quantities of the powders (up to 2-2½ drachms of the soda and a corresponding quantity of the acid). It is well to have a stomach-tube at hand in order to withdraw the gas in case unpleasant symptoms develop. Sometimes the stomach fails to become distended by this procedure. This is due in some cases to the escape of the gas through the pyloric orifice into the intestine—a condition designated by Ebstein as incontinence of the pylorus. It may be that sometimes the gas produces such firm contraction of the gastric walls that the stomach does not expand by the pressure of the gas. Instead of generating gas, a similar result may be produced by simply injecting air into the stomach through a stomach-tube, as recommended by Oser and by Runeberg. The air may, however, escape along the side of the tube.
Palpation of the distended stomach yields an elastic resistance which has been compared to that of an air-cushion. By palpating carefully from above downward the greater curvature can sometimes be appreciated, but in general it is difficult to distinguish it from the transverse colon. Peristaltic movements may perhaps be appreciated by palpation when they are not evident on inspection. If a dilated stomach contains considerable fluid and the abdominal walls are yielding, fluctuation may be perceived by palpation. The lowest level at which this fluctuation can be felt may afford a clue as to the position of the lower border of the stomach, but not much dependence can be placed upon this sense of fluctuation unless many sources of error in its interpretation are excluded.
By pressing gently and repeatedly against the abdominal walls a splashing sound can usually be heard in cases of well-marked dilatation of the stomach (bruit de clapotement). This sound can best be brought out when the patient is in the recumbent position, with relaxed abdominal walls, by palpating near the left border of the ribs. The same sound can be produced by shaking the patient (bruit de glou-glou). This sound may be heard at a considerable distance from the patient, to whom it may be a source of much annoyance. In itself this splashing sound is without diagnostic significance, as the condition for its production—namely, the simultaneous presence of gas and liquid in the stomach—exists often in healthy persons. By paying attention, however, to the time at which this sound can be produced after eating or drinking, and to its greater or less constancy, some diagnostic importance can be attached to this sign. If the splashing sound can be usually produced two hours or longer after the ingestion of liquid or six hours after an ordinary meal, it generally indicates that dilatation of the stomach exists.17 It is necessary to exclude somewhat similar sounds which may be produced in the intestines, particularly in the transverse colon and cæcum. The series of gurgling sounds which may sometimes be produced in the intestine by palpation are not likely to be confounded with the single splashing sound produced in the stomach, but under certain circumstances a splashing sound may be produced in the transverse colon which cannot be distinguished from the gastric sound. If a dilated stomach contains a very large quantity of fluid, the splashing sound cannot readily be produced.
17 Baradat, Étude sur le Bruit de Clapotement stomacal, Thèse, Paris, 1884. Baradat says that this bruit is also diagnostic of dilatation when it can be produced by palpating below a horizontal line passing through the junction of the ninth and tenth ribs, but it is evident that motion might be transmitted to the stomach even when its greater curvature is above this line by palpating below the level of the umbilicus.
Leube has pointed out that the end of the stomach-tube (of course the hard tube), after it has been inserted into the stomach, can often be felt through the abdominal walls.18 He says that if the tube can be felt below a horizontal line passing through the anterior superior spinous processes of the ileum, dilatation of the stomach may be positively diagnosed, and the existence of dilatation is probable if the tube can be felt much below the umbilicus. No force should be used in trying to make the end of the tube palpable. Of course if the abdominal walls are thick or very tense the tube cannot be felt. Leube's method is simple and convenient, and applicable to many cases. As will be explained hereafter, a position of the lower border of the stomach even quite as low as Leube's rule demands cannot be considered by itself positive evidence of dilatation.19
18 Deutsches Arch. f. kl. Med., Bd. xv. p. 394.
19 According to Oser, there is a possible source of error in Leube's method—namely, that the sound may slide along the greater curvature of the stomach, and even reach the pylorus, so that the end may be felt higher than the lowest point of the stomach. Considerable objection has been made to Leube's method on the ground of its danger, but this objection is based on the assumption that greater energy is employed in pressing forward the sound than Leube recommends (Oser, article "Magenerweiterung" in Eulenburg's Real Encyclopädie, Bd. viii., 1881).
The length to which the stomach-tube can be inserted before meeting resistance may evidently give some idea as to the size of the stomach. The attempt, however, to establish any general law with reference to this point has not proven successful.
In many cases valuable information as to the size of the stomach is afforded by percussion. Over the greater part of the stomach the percussion note is tympanitic, sometimes with a metallic quality. Over the most dependent part of the stomach a dull sound is produced on percussion in case a sufficient quantity of fluid or solid material is contained in the viscus. In the upright position, therefore, in percussing over the stomach from above downward, the tympanitic note gives place to a dull sound, and this zone of dulness will change with the position of the patient, so that in the recumbent posture the dulness may entirely disappear. In order to prove that the region of dulness belongs to the stomach, Piorry caused the patient to drink a large quantity of water (a pint to a quart). In a healthy empty stomach this quantity of water suffices to produce a zone of dulness which does not descend below the level of the umbilicus. If, however, the dulness be produced below the level of the umbilicus, it is inferred that dilatation exists. Penzoldt's modification of Piorry's method gives more certain results.20 By withdrawing the fluid from the stomach by the stomach-tube the dulness may be made to disappear, and by injecting more fluid the dulness may be made to reappear at will. By noting the lower limit of the dulness thus produced the position of the lower border of the stomach may be determined. The farther this lies below the umbilicus the greater, presumptively, is the degree of dilatation. The artificial distension of the stomach with gas may also aid in determining its limits by percussion. It must be said that in general the separation of the lower limits of the stomach from the transverse colon by means of percussion is a matter of great difficulty, and sometimes is impossible.
20 Penzoldt, op. cit., p. 48.
Upon auscultation over a dilated stomach sometimes a fine crackling or sizzling sound, like that audible upon first uncorking a bottle of soda-water, can be heard.21 This is referable to the fermentation which is in progress in the stomach. Eichhorst says that a similar but finer crackling sound can be heard over a stomach in which carbonic acid gas is being artificially generated, and that this sound abruptly ceases when the ear passes below the limits of the greater curvature.22
21 Pauli was the first to record this phenomenon (De Ventriculi Dilatatione, Frankfurt, 1839).
22 Handb. d. spec. Path. u. Ther., Bd. i. p. 750, 1883.
The displacement of neighboring organs by a dilated stomach does not generally give rise to important physical signs. As the tendency of a dilated stomach is to sink down in the abdomen, there is not usually much displacement of the thoracic viscera. If, however, the fundus of the stomach be distended with gas, the heart may be pushed upward, and, being pressed against the chest-wall, its apex-beat may be more forcible and diffused than normal. The tympanitic stomach may impart a metallic quality to the cardiac sounds.
MORBID ANATOMY.—Considerable degrees of dilatation of the stomach are easily recognized by post-mortem examination. In extreme cases the stomach occupies all of the anterior region of the abdomen, covering over the intestines and extending down to the pubes or even into the true pelvis. Many cases are recorded in which the stomach was capable of holding six to twelve pints. Godon23 describes under the name ventriculi hydrops a hardly credible case in which it is said that the stomach contained ninety pounds of fluid! In the ordinary cases of gastrectasia the lower border of the stomach is found somewhere between the umbilicus and the pubes, frequently about a hand's breadth below the level of the umbilicus.
23 Diss. de Hydrops Ventriculi, London, 1646. This celebrated case is described with much detail. For three years the abdomen was enormously distended, but the patient, a woman, never vomited. The affection was supposed to be dropsy of the peritoneum. Death occurred in a condition of extreme marasmus. The pylorus was the seat of a hydatid cyst which extended into the duodenum. The stomach, which was enormously distended, contained ninety pounds of fluid, in which floated a great number of hydatid cysts, some of which were ruptured. The anterior wall of the stomach was adherent to the parietal peritoneum. The two orifices of the stomach were drawn close to each other. The length of the stomach equalled a Paris ell.
The fundus, being the most dilatable part of the stomach, is in most cases disproportionately dilated in comparison with the pyloric region. This excessive dilatation of the fundus is most noticeable in gastrectasia due to stenosis. In most cases of dilatation the pylorus sinks down somewhat in the abdomen, but in consequence of the distension of the lower segment of the stomach the long axis of the organ is more nearly transverse than normal. If the pylorus be fixed, the lesser curvature may be drawn down in its middle so as to acquire a hooked shape. The lesser curvature, which should be covered by the liver, may be found considerably below its normal level. The dilated fundus may extend from the left hypochondrium into the left iliac region.24
24 Fogt reports a case in which an enormously dilated stomach occupied a scrotal hernia of the left side. He refers to two other similar cases (Aerztl. Intelligenzbl., 1884, No. 26).
More or less dilatation of the oesophagus is associated with marked dilatation of the stomach. If dilatation of the stomach be due to obstruction in the upper part of the intestine, then the pyloric orifice and the intestine on the proximal side of the obstruction will be found dilated.
The walls of a dilated stomach may be hypertrophied, and such cases are called hypertrophic dilatation; or the walls may be of normal thickness or may be thinned, and these cases are called atrophic or atonic dilatation. In general, the thickness of the gastric walls in gastrectasia depends upon that of the muscular coat. As a rule, in cases of pyloric stenosis the muscular coat of the stomach is hypertrophied. This hypertrophy affects chiefly the muscle of the pyloric region. The gastric walls in stenotic dilatation may, however, be of normal thickness or even atrophied. In non-stenotic dilatation the muscular coat may be either hypertrophied or atrophied, but it rarely attains the thickness observed in cases of gastrectasia due to obstruction. Maier and others have repeatedly observed fatty and colloid degeneration of the muscular fibres of dilated stomachs.25 More frequently, however, no degenerative change has been found in the muscle.
25 Deutsches Archiv f. klin. Med., Bd. vi. p. 480; Landerer, op. cit. Maier designates as colloid degeneration a peculiar homogeneous, glistening appearance of the muscular fibres. This change is not such as would usually be called colloid, but this term is loosely used to designate a great variety of pathological changes. The form of muscular hypertrophy in gastrectasia is chiefly the numerical.
The mucous membrane in dilatation of the stomach is usually in the condition of chronic catarrhal gastritis. Although there are various statements as to atrophy of the gastric tubules and degeneration of the epithelial cells in the tubes in cases of gastric dilatation, satisfactory histological investigations of the mucous membrane of the stomach in this disease are wanting.26
26 For satisfactory studies of this nature it is desirable that alcohol or some preservative fluid should be injected into the stomach immediately after death.
Atrophy of various abdominal viscera—particularly of the spleen, which is usually small in this disease—has been attributed to the pressure of a dilated stomach. This atrophy, however, is probably in many cases only a part of the general emaciation and anæmia.
While well-marked cases of dilatation of the stomach cannot be mistaken on post-mortem examination, it is important to add that the pathological anatomist cannot always decide whether or not dilatation of the stomach exists in the clinical sense. The following considerations will make this evident: In the first place, the stomach is a very variable organ as regards its size, so that it is impossible to set definite limits, and say that a stomach exceeding these is necessarily dilated, while a stomach not exceeding these limits is normal. In the second place, it belongs to the clinical definition of dilatation of the stomach that the organ is insufficient for the performance of its normal functions. This insufficiency cannot be determined at the post-mortem table. To determine, therefore, whether stomachs which fall within certain not easily definable limits of size are pathologically dilated or not, it is necessary to correct and complete the results of the post-mortem examination by a knowledge of the clinical history.27
27 To deny all value to post-mortem examination in the determination of dilatation of the stomach, as has been done, is absurd. In the majority of cases this examination affords satisfactory evidence, but for some cases a reservation like that in the text must be made. Rosenbach in an able article shows the error of regarding dilatation of the stomach too exclusively from the anatomical point of view ("Der Mechanismus und die Diagnose der Mageninsufficienz," Volkmann's Samml. klin. Vorträge, No. 153).
DIAGNOSIS.—A considerable degree of dilatation of the stomach can generally be diagnosticated without difficulty by means of the symptoms and physical signs which have been described. The most important diagnostic features relate to the character of the vomiting and to the physical signs, together with the information afforded by the use of the stomach-tube. The diagnostic characters of the vomiting are the large quantity rejected, its occurrence several hours after a meal, its periodicity with long intervals, the temporary relief afforded, the presence of undigested food taken a considerable time previously, and the existence of fermentation. Washing out the stomach will also afford evidence of stagnation of food. The time generally occupied in the digestion of an ordinary meal is not over six to seven hours, so that in health the contents of the stomach removed by the stomach-tube at the end of this time should usually be free from undigested food. There are of course individual idiosyncrasies with reference to the time occupied in digestion, so that implicit reliance cannot be placed on this diagnostic test. Delayed digestion is in itself no evidence of the existence of dilatation, but the establishment of the presence of this symptom may confirm other points in the diagnosis.
Simple inspection, palpation, and percussion of the abdomen are sometimes, although rarely, sufficient for the diagnosis of dilatation of the stomach. Various devices have already been described which aid in the physical examination of the stomach, such as the administration of effervescing powders, the introduction of the stomach-tube, and Piorry's and Penzoldt's methods of determining the lower border of the stomach.28 It is not necessary to repeat here the diagnostic evidence afforded by physical examination. Excellent service as these devices often perform, it must be confessed that they do not always answer the purpose intended. The artificial distension of the stomach with gas does not enable us always to distinguish intestine from stomach. If the abdominal walls are thick or very rigid, this method, like most of the others, is of little or no assistance. Then, as already mentioned, the administration of the powders may fail to produce any distension of the stomach, and may possibly mislead by causing distension of intestine. Moreover, the artificial tympanites may cause the patient much discomfort. The method of determining the lower border of the stomach by Piorry's or Penzoldt's method is not always conclusive. If the stomach be much dilated, it may take a very large quantity of water to produce an appreciable zone of dulness. If the transverse colon be distended with feces, it will not be easy to separate the dulness of the stomach from that of the colon. Moreover, loops of intestine containing feces or gas may lie over the anterior surface of the stomach. The use of the stomach-tube simply for diagnostic purposes is, for various reasons, not always practicable. With due recognition of the important additions during the last few years to our means of exploring the stomach, it must be admitted that we are still far from any positive and universally applicable method of determining the size and position of this organ during life. This admission is the more necessary in view of the extravagant claims which have been made for various more or less complicated contrivances for physical exploration of the stomach.
28 Several other methods have been suggested for determining the size and position of the stomach, but they have not found general acceptance. Thus, Schreiber attaches a soft rubber balloon to the end of a stomach-tube, and after its insertion in the stomach inflates it (Deutsches Arch. f. kl. Med., Bd. 19). In Neubauer's method the long end of a syphon-tube communicating with the stomach is bent upward, and a glass tube is placed in the bent portion. The fluid will evidently stand at the same level in the tube as in the stomach in case the atmospheric pressure in both is the same. The atmospheric pressure in the stomach is produced by using a double tube or by passing a second tube into the stomach (Prager med. Wochenschr., 1879). Purjesz attached a manometer to a stomach-tube, and thought that he could fix the position of the cardia by noting the moment when in the passage downward of the tube the negative pressure changed to positive, but Schreiber has shown that the manometer may indicate negative pressure even after the tube has entered the stomach (Deutsches Arch. f. kl. Med., Bd. 33, p. 425). It has been asserted that by means of auscultatory percussion of a stomach artificially distended with gas the boundaries of the organ can be determined. Leichtenstern considers the metallic quality of the tone heard over the stomach under these circumstances more or less characteristic, while Skamper compares the characteristic tone to that produced by tapping with the finger on the dorsal surface of the hand of which the valar surface is placed against the external ear (Inaug. Diss., Berlin, 1879, p. 30). It has been claimed that the sound as of water dropping into a large cavity, which can be heard when the patient is drinking, can no longer be heard when the auscultating ear passes beyond the greater curvature (V. Bamberger). Wunderlich suggests the possibility of feeling the arteries of the greater curvature through the abdominal walls. Ferber calls attention in cases of gastrectasia to a strip of dulness, with absent vocal and respiratory sounds, corresponding to the posterior inferior border of the left lung. This dulness, which is produced by material in the most dependent part of the dilated stomach, disappears when the patient assumes the knee-elbow position (Deutsche Zeitschr. f. prakt. Med., 1876, No. 42). When it is impossible by other methods to distinguish the lower portion of the stomach from the transverse colon, it has been proposed to distend the colon with water, with gas, or with air injected through a tube passed into the rectum. Penzoldt (op. cit.) found that the length of a tube (hard) or bougie reaching the bottom of the stomach, estimating from the upper incisor teeth, should be in a normal stomach at least 5 cm. less than that of the vertebral column (occiput to coccyx), and at the most not much more than one-third of the length of the body (1:2.8-1:3.3). In three cases of gastrectasia he found the length of the tube inserted into the stomach considerably more than one-third of the length of the body (1:2.4); in one of the cases this length even exceeded that of the vertebral column, and in the others it nearly equalled the length of the vertebral column. Rosenbach's method of determining the elastic and contractile power of the stomach is ingenious, but hardly of practical utility. By injecting air into the stomach through a bulb apparatus attached to the end of a stomach-tube, he is able to tell when the point of the tube passes beneath the surface of fluid in the stomach by hearing on auscultation a characteristic moist bubbling sound. Elevation or depression of the level of the fluid can be determined by withdrawing or by pushing forward the tube. That quantity of fluid which, introduced into an empty stomach, causes no elevation, or perhaps causes a depression, of the level of the food in the stomach, indicates the utmost limit of the elastic and contractile forces of the stomach (Rosenbach, Volkmann's Samml. klin. Vorträge, No. 153).
The determination of the position of the lower border of the stomach does not in itself enable us to infer positively the size of the organ. It may be taken as a general rule that if the lower border of the stomach be found persistently below the level of the umbilicus, the stomach is dilated; but there are many exceptions to this rule. Sometimes an otherwise normal stomach preserves in adult life the vertical position which it had in the foetus, so that its lowest point may be below the umbilicus. According to Kussmaul, a vertical position of the stomach is a predisposing cause of dilatation. Occasionally a stomach has a looped shape, so that without any dilatation of the organ the lowest point may fall below the level of the umbilicus. It is, moreover, a clinical fact established by the experience of many observers that the lower border of the stomach may be found below the level of the umbilicus without the existence of any symptoms of dilatation.
The uncertainty of the anatomical diagnosis of dilatation of the stomach in some cases makes it all the more necessary, as has been repeatedly urged in the course of this article, to make a careful study of the evidences of disordered gastric functions. The symptoms of most importance in determining whether the condition called insufficiency of the stomach is present or not are fermentation of the gastric contents and the persistent presence of undigested food in the stomach beyond the limits of normal digestion. It is true that these symptoms may be present without any dilatation of the stomach, but they are likely to lead to dilatation if unchecked, and, what is of practical importance, they require essentially the same treatment as dilatation.
A differential diagnosis between chronic catarrhal gastritis and atonic dyspepsia on the one hand, and the early stages of dilatation of the stomach on the other, cannot be made with any positiveness.
Of course, with our present means of diagnosis the confounding of dilated stomachs with ascites, ovarian cysts, pregnancy, hydatid cysts (of each of these errors there are recorded instances), is inexcusable.
PROGNOSIS AND COURSE.—The prognosis of dilatation of the stomach depends first of all upon the nature of the primary disease causing the dilatation. The prognosis of cancerous dilatation is as unfavorable as possible. In dilatation due to non-cancerous stenosis the prognosis is in general more favorable. Life may be prolonged sometimes for many years, and the patient's condition greatly benefited by proper treatment. A permanent cure of stenotic dilatation is not impossible, but it is rarely to be expected. Even if temporarily relieved, the symptoms of dilatation are likely sooner or later to return and to lead to a fatal termination. The progress of the disease depends upon the degree and the stationary or advancing character of the stenosis. In the article on GASTRIC ULCER mention has been made of the cure of a few cases of desperate gastric dilatation due to cicatricial pyloric stenosis by means of resection of the diseased pylorus.
In general, the prognosis is more favorable in dilatation without stenosis. If the degree of dilatation be only moderate, a permanent cure may often be effected by proper treatment. If, however, the dilatation be considerable, while the symptoms may be relieved or even made to disappear for a time, relapses are prone to occur, and a permanent cure is rarely obtained. Undoubtedly, Kussmaul's publication in 1869, in giving to us a most valuable method of treatment, at the same time raised extravagant expectations of the frequency with which dilatation of the stomach can be cured. Too often the treatment with the stomach-tube proves only palliative and not curative.
The course of dilatation of the stomach is chronic. The mode of death is usually by inanition, very rarely from rupture of the stomach.
TREATMENT.—Reference to the causation of dilatation of the stomach will show that there is considerable scope for the prophylactic treatment of dilatation not referable to stenosis or incurable organic disease. Thus, the correction of the habits of eating or drinking inordinate quantities, or of imperfectly masticating the food in consequence of haste or bad teeth or vicious custom, may avert the development of gastric dilatation. Of especial importance is the timely treatment of cases of dyspepsia or of chronic catarrhal gastritis which are accompanied with fermentation or delayed digestion—conditions in which the stomach-tube is of great service.
Of the means at our disposal for meeting the causal and the symptomatic indications of dilatation of the stomach, the most important by far is the use of the stomach-tube for the purpose of emptying and of washing out the stomach. The introduction of this procedure by Kussmaul in 1867 marked a new era in the treatment of gastric disorders.
By washing out the stomach we accomplish three important things: first, we remove the weight which helps to distend the organ; secondly, we remove mucus and stagnating and fermenting material which irritates and often inflames the stomach and impedes digestion; and, thirdly, we cleanse the inner surface of the stomach and obtain the beneficial influence of the direct application of water, to which various medicinal substances can be added. It is probable that in removing the fermenting contents of the stomach we also remove a possible source of self-infection of the system (see page [596]).
By accomplishing these things we may possibly also enable the stomach to regain its lost elasticity and muscular contractility. But unless the normal elastic and contractile powers of the stomach are restored, the treatment with the stomach-tube, indispensable as it is for the relief of symptoms, is only palliative and not curative. Whether or not this restoration of the stomach to its normal functional activity is to be expected depends chiefly upon the cause and the degree of the dilatation. Unfortunately, as has already been stated under Prognosis, the permanent cure of dilatation of the stomach due to organic stenosis, although possible, is not to be expected, and the number of cases in which largely dilated stomachs can be restored to their normal volume or made to perform permanently their normal functions is small. There remains, however, a considerable number of curable cases—to be sure, not always easily diagnosticated—in which the muscular coat of the stomach has not been seriously damaged and in which the dilatation is generally only moderate. Furthermore, excellent results are obtained by the use of the stomach-tube in the cases which have been designated insufficiency of the stomach, and which are closely allied to dilatation—in fact, often represent its early stage. As has already been mentioned, the most important criteria of this so-called insufficiency are the fermentation of the contents of the stomach and the presence therein of undigested food after the period required for normal digestion (six to seven hours for an ordinary meal).
There are two principal methods of washing out the stomach—one by the stomach-pump, the other by the siphon process. The stomach-pump is the older method, and still has its advocates. The pump used by Kussmaul is the Wyman pump, described by Bowditch in the American Journal of Medical Sciences, vol. xxiii. p. 320, 1852. This (which is also called the Weiss pump), as well as other forms of stomach-pump, consists in principle simply of an aspirating syringe having at its anterior extremity two openings communicating with the barrel of the syringe. These openings can be alternately opened and closed by means of an arrangement of valves. Through one opening, which is made to communicate with an incompressible tube inserted into the stomach (the other opening being now closed), the gastric contents are drawn into the barrel of the syringe. This opening is now closed, and through the other opening the contents of the syringe are discharged through a tube externally. In a similar way fluid can be drawn into the syringe and pumped into the stomach.
In the siphon process the outer end of the tube inserted into the stomach is connected with a piece of elastic tubing about three and a half feet long, in the free end of which is inserted the extremity of a medium-sized glass funnel. A single elastic tube about six feet long may also be used. When the funnel is elevated, water which has been poured into it will run into the stomach. If now, before the water has all run out, the funnel be depressed below the level of the stomach, the fluid contents of the stomach will flow out through the tube according to the principle of the siphon. Figs. 20 and 21 will make clear the mode of operation of this process. (The tube shown in these figures is the Faucher tube, commonly used in France, and consisting, with the funnel, of one piece. A longer tube than that shown in the figure should be used.)
| FIG. 20.29 | FIG. 21.29 |
29 From Souligoux, De la Dilatation de l'Estomac, Paris, 1883.
Another convenient but somewhat more complicated method of employing the siphon process is according to Rosenthal's principle, and is represented in Fig. 22. To the outer end of the stomach-tube is attached a Y-shaped glass tube, one arm of which is connected with an elastic tube running to an irrigator, while the other arm is connected with the discharging tube. Through the irrigating tube water runs into the stomach, the discharging tube being compressed. If the discharging tube be opened while the fluid is flowing from the irrigator, and if then, after the establishment of a column of water in the discharging tube, the irrigating tube be compressed or the stopcock of the irrigator be closed, a siphon communicating with the stomach is formed and empties this organ of its fluid contents.
| FIG. 22.30 |
30 From Leube, in Ziemssen's Handb. d. spec. Path. u. Therap., Bd. vii.
In the siphon process the tube inserted into the stomach may be an incompressible hard-rubber tube like that employed with the stomach-pump, but by far the simplest, most convenient, and safest form of stomach-tube is the soft, flexible, red rubber tube, resembling the Jacques catheter, but of course larger and longer.31 This soft tube can inflict no injury, and in most cases it is readily introduced. Generally, the patient himself can best manipulate the introduction of the tube. After the tube is introduced into the pharynx, the patient, who should be in a sitting posture, makes repeated acts of swallowing, by means of which, accompanied by directing and gently pushing the tube with the fingers, the tube passes along the oesophagus into the stomach. Often at first the nervousness and inexperience of the patient occasion some trouble, but after a little practice he generally succeeds in introducing the tube without discomfort or difficulty. Before its introduction the tube should be anointed with a little vaseline or some similar substance. In an adult the tube is introduced for a length of at least 20 to 25 inches, and in cases of dilatation of the stomach of course for a greater distance. Whatever form of stomach-tube be used, it is important that the tube should be at least 30 inches long, and should be provided with one, and preferably with two, large eyes at its distal extremity.
31 Such a tube (marked 19 A) is made by Tieman & Co. of New York, and is to be had of most surgical instrument-makers. (For a fuller description of the tube and the mode of its employment see article by W. B. Platt, "The Mechanical Treatment of Diseases of the Stomach," Maryland Medical Journal, March 8, 1884.)
Oser's tube is 2 meters long, and is made of mineralized rubber. There are two sizes. The smaller has a lumen of 8 mm. The thickness of the wall is 2½ mm. In the larger tube the lumen is 10 mm., and the thickness of the wall 3 mm. He generally uses the smaller tube.
Faucher's tube is 1½ meters long. The external diameter of the tube is 10 to 12 mm. The walls are of such thickness that the tube can be bent without effacing its lumen. At one extremity is a lateral eye with two orifices. To the other extremity is adapted a funnel with a capacity of about 500 grammes.
Although the stomach-pump has the advantage of more completely evacuating the stomach and of removing coarser solid particles than is possible with the siphon, nevertheless its disadvantages—namely, the possibility of inflicting injury to the mucous membrane of the stomach,32 the expense and greater complexity of the instrument, and the circumstance that it should be used only by the physician—in contrast with the advantages of the siphon—namely, its cheapness, simplicity, safety, and possible employment by the patient or his attendants—have led to the general adoption of the latter process. Only the soft-rubber stomach-tube should be left to the employment of the patient.
32 A number of cases have been recorded in which pieces of the mucous membrane of the stomach have been detached by the stomach-pump. Although as yet no serious effects have followed this accident, the possibility of its occurrence can certainly not be regarded with equanimity.
Sometimes the flow through the siphon is interrupted by occlusion of the eye of the stomach-tube by a solid mass or by some cause not always clear. As already mentioned, it is desirable that there should be two openings at the gastric extremity of the tube. When the flow is interrupted the position of the tube in the stomach may be changed, or the patient may be directed to cough or to exert the pressure of the abdominal muscles, or more water may be allowed to run into the stomach in order to displace an occluding mass in the tube. It is, however, well for such cases to have, if possible, a stomach-pump and an incompressible tube in reserve. Moreover, as is apparent from the foregoing statement of the advantages of the stomach-pump, there are cases in which this instrument is much more useful than the siphon, so that one cannot decide unconditionally in favor of one instrument over the other.
The stomach-tube should be secured so that there can be no possibility of its being swallowed entirely. A string may be attached to the distal end of the tube. Leube33 has reported an instance in which the whole tube disappeared into the stomach, and Jackson34 has also narrated a case in which an insane patient swallowed the stomach-tube. In both cases the tube was subsequently rejected by vomiting.
33 Deutsches Arch. f. klin. Med., Bd. 33, p. 6.
34 Extracts from the Records of the Boston Society for Medical Improvement, vol. vi. p. 261.
For washing out the stomach after the greater part of the contents have been withdrawn, about a pint of tepid fluid is allowed to slowly run into the stomach, and is then siphoned out. This process is to be repeated several times. In general, tepid water suffices for washing out the stomach, but it is often better to use, at least a part of the time, a 1 to 2 per cent. solution of bicarbonate of sodium, which facilitates the removal of mucus. The artificial and the natural Vichy and Carlsbad waters are also excellent for this purpose. Various additions are also made to the water with the view of counteracting fermentative changes in the stomach. For this purpose perhaps the best agents are salicylate of sodium (1 per cent. solution) or resorcin (2 per cent. solution). Other substances which have also been recommended are carbolic acid, permanganate of potassium, hyposulphite of sodium, creasote, benzine. Simple water, however, accomplishes about all that is possible, and many are satisfied to use it without any medication.
As regards the frequency with which the stomach is to be washed out, one is to be guided by the symptoms and the effect obtained by the use of the stomach-tube. As a general rule, it suffices to wash out the stomach once a day, and often the process need be repeated only every second or third day.
Opinions are divided as to the best time of day to select for washing out the stomach. Kussmaul recommends the morning before breakfast, and the majority have followed his advice; others prefer the evening. There is much, however, in favor of washing out the stomach about half an hour before the principal meal of the day. The best opportunity has been offered for the digestion and absorption of the food taken at the previous main meal, and the stomach is placed in the best possible condition for the reception of more food.
The habitual washing out of the stomach is not without its drawbacks. We often remove, as has been pointed out especially by Leube, not only noxious substances from the stomach, but also the completed products of digestion. To withdraw from the nourishment of the body this chyme which the stomach has laboriously manufactured cannot be a matter of indifference. Still, with the weakened absorptive powers of the stomach, and its inability to properly propel its contents into the intestine, it is a question how much of this chyme would eventually be utilized for nutrition. Another point is worthy of attention. The relief which the patient experiences when his overloaded stomach is freed of its burden, and the knowledge that this method of relief is always at hand, may make him careless in the observance of the dietetic rules which are of great importance in the treatment of this disease. It is well, therefore, not to wash out the stomach oftener than is necessary, nor to continue the habitual use of the stomach-tube longer than is required.
There are contraindications to the use of the stomach-tube. In very rare instances the attempt to introduce the tube causes the patient so much distress, produces such violent spasm of the pharyngeal and adjacent muscles, or induces so much retching and vomiting, or is attended with such prostration or even syncope, that this method of treatment has to be abandoned. Great weakness, recent gastric hemorrhage, ulcer of the stomach in most cases (see page [523]), often cancer of the cardia or of the oesophagus, and aneurism of the aorta, are contraindications to the use of the stomach-tube.
If we group together the results obtained by the use of the stomach-tube in gastric dilatation, we shall find cases in which no benefit results; cases which are benefited, but are obliged to continue the use of the stomach-tube throughout life; cases in which recovery is slow and gradual; cases with more or less speedy relief or apparent cure, but followed by relapses; and cases of prompt relief and permanent cure.
The regulation of the diet is never to be neglected in cases of dilatation of the stomach. Here the guiding principles are that little fluid should be taken, and that the food should be small in bulk, nutritious, easily digestible, and not readily undergoing fermentation. The patient should drink as little water as possible, and should therefore avoid whatever occasions thirst. It is hardly practicable to carry out the plan of giving water mostly by the rectum, as has been proposed. In most cases milk is useful, but an exclusively milk diet is not generally well borne on account of the quantity of fluid required. Leube's beef-solution is often serviceable. Soft-boiled eggs and tender meats are to be allowed, particularly the white meat of fowl and rare beefsteak, especially that prepared from scraped and finely-chopped beef, as recommended in the treatment of gastric ulcer (page [521]). Fatty, saccharine, and amylaceous articles of food—hence most vegetables and fruits—are to be avoided on account of their tendency to undergo fermentation in the stomach. Alcohol in any form is usually detrimental. If gastric symptoms, particularly vomiting, be very urgent, or if food introduced into the stomach affords little or no nourishment, as in some cases of tight pyloric stricture, then rectal alimentation is to be resorted to.
An important indication is to restore the tone and contractile power of the muscular coat of the stomach. For this purpose electricity, in the form both of the constant and of the faradic current, has been beneficially employed. The best results are reported from the use of the faradic current. Both poles may be applied over the region of the stomach. The application of electricity to the inside of the stomach by means of electrodes attached to stomach-tubes or bougies is a more difficult procedure, but has its advocates. Uniformly good results are not obtained by the use of electricity in gastric dilatation, but there can be no doubt that in some cases decided benefit follows this method of treatment.
Nux vomica, particularly its alkaloid strychnia, has been much employed with the view of stimulating the muscular power of the stomach. Strychnia is given either internally or hypodermically. Hypodermic injections of ergotin have also been used for the same purpose. It has been hoped to increase the contraction of the stomach by cold applications to the abdomen, as by ice-bags applied immediately after washing out the stomach. The benefit derived from these various attempts to increase the tonicity of the gastric muscle is not very apparent.
A belt or bandage around the abdomen in order to support the stomach sometimes makes the patient feel more comfortable; in other cases it aggravates the symptoms.
In many cases digestion is promoted by giving dilute hydrochloric acid with or without pepsin. About ten drops of dilute hydrochloric acid may be given half an hour to an hour after each meal.
When the stomach is systematically washed out, the individual symptoms of dilatation of the stomach will rarely require special treatment. The sensation of fulness and weight in the stomach, the eructations, the vomiting, and the constipation are generally relieved, at least temporarily, by washing out the stomach. The appetite is improved, and an increase in weight is usually soon noticeable.
If heartburn and eructations of gas continue troublesome, an antacid, such as bicarbonate of sodium or prepared chalk, will be found useful.
Leube, in order to relieve constipation and to increase the peristalsis of the stomach, administers Carlsbad water (see page [522]). Not more than five or six ounces of the water need be given, and this should be taken slowly in divided doses. A laxative pill containing rhubarb may be given occasionally.
If anæmia be the cause or a prominent accompaniment of dilatation of the stomach, iron may be administered in a form as little disturbing the digestion as possible, as the effervescing citrate or the lactate, or arsenic in the form of Fowler's solution may be tried. In general, however, all drugs which impair the appetite or digestion are to be withheld. The digestion and the general condition of the patient are often benefited by massage.
Resection of the pylorus in cases of cancerous and of cicatricial stenosis of this orifice has been performed in several instances. The subject, as regards its medical in distinction from its surgical bearings, has already been discussed in connection with cancer of the stomach (see page [577]). Here it may be added that the propriety of resection is less open for dispute in cases of non-cancerous pyloric stenosis than it is in cancer of the pylorus.
Remarkable results have been reported by Loreta in cases of cicatricial stenosis of the pylorus. After performing gastrotomy he inserts his fingers through the constricted pyloric orifice and forcibly dilates the stricture.35 To judge from experience in divulsing strictures in other parts of the body, it does not seem probable that a permanent cure can be often effected by this bold and dangerous procedure.
35 Loreta has performed this operation successfully no less than nine times (The Lancet, April 26, 1884).
Acute Dilatation of the Stomach.
Under the name acute dilatation of the stomach36 have been described cases in which it has been supposed that a more or less suddenly developed paralysis of the muscular coat of the stomach exists. But the propriety of the term acute dilatation, and the very existence of an acute paralysis of the stomach, are, to say the least, questionable.
36 The literature pertaining to the subject of acute dilatation of the stomach is to be found in Poensgen, Die Motorischen Verrichtungen des Menschlichen Magens, Strasburg, 1882, p. 95.
As causes of this so-called acute dilatation of the stomach have been assigned injuries, particularly those affecting the abdomen, surgical operations involving the peritoneum, acute inflammations of the mucous and of the peritoneal coats of the stomach, acute fevers, especially during convalescence, and overloading the stomach with food or with liquids.
The symptoms which have been chiefly emphasized are severe abdominal pain, tympanitic distension of the stomach, and absence or cessation of vomiting if this has previously existed. It will be noted that inability to vomit under these circumstances implies not only paralysis of the stomach, but also that of the abdominal muscles.
The prognosis depends on the character of the primary disease causing the alleged paralysis.
If there be acute distension of the stomach with inability of the organ to expel its contents either externally or into the intestine, the stomach-tube may be employed to evacuate the gas and other material present.
In a case described by Hilton Fagge37 as acute dilatation of the stomach the symptoms of dilatation appeared suddenly and ran an acute course, but the autopsy showed that the dilatation was doubtless of much longer development than the symptoms indicated. In a case reported by Nauwerk38 of extreme dilatation in consequence of hypertrophic stenosis of the pylorus, after ten months of insignificant dyspeptic symptoms there suddenly appeared, after excess in eating, symptoms of dilatation of great severity, which continued until a fatal termination at the end of three months. Thus it appears that chronic dilatation of the stomach may cause little disturbance for a considerable time and then run a rapid course.
37 "On Acute Dilatation of the Stomach," Guy's Hosp. Rep., xviii. p. 4, 1873.
38 Deutsches Arch. f. kl. Med., Bd. xxi. p. 573.