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 {593} 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.
[Footnote 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 {594} 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.
[Footnote 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.
{595} 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.
[Footnote 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 {596} 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]
[Footnote 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.
[Footnote 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 {597} 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.
[Footnote 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, {598} 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]
[Footnote 18: _Deutsches Arch. f. kl. Med._, Bd. xv. p. 394.]
[Footnote 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.
[Footnote 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 {599} being artificially generated, and that this sound
abruptly ceases when the ear passes below the limits of the greater
curvature.[22]
[Footnote 21: Pauli was the first to record this phenomenon (_De
Ventriculi Dilatatione_, Frankfurt, 1839).]
[Footnote 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.