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. Godon[23] 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.
[Footnote 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]
[Footnote 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 {600} 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.
[Footnote 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]
[Footnote 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]
[Footnote 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 {601} 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 {602} 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.
[Footnote 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 {603} 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.
{604} 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. {605} 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.)
[Illustration: FIG. 20.[29]]
[Illustration: FIG. 21.[29]]
[Footnote 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.
[Illustration: FIG. 22.[30]]
[Footnote 30: From Leube, in _Ziemssen's Handb. d. spec. Path. u.
Therap._, Bd. vii.]