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.