Dilatation of the Stomach.
Definition.—An acute or chronic enlargement of the gastric cavity by over-distention, resulting in the retention, for a long' period, of food and the products of digestion.
Etiology.—Dilatation of the stomach may occur either as an acute or chronic condition, though the former is the more rare. Acute dilatation is the result of enormously dilating the stomach either by food or drink, especially the former, which may result in paralytic dilatation.
The chronic form more frequently results from stenosis of the pyloris than all other causes combined. This may be due to cancerous infiltration, to ulceration and subsequent cicatrization, or to thickening's of the tissues, the result of chronic inflammations. It may also be due to adhesions from below, as of the liver, pancreas, and gall-bladder, or from pressure from without by tumors or malignant growths.
In rare cases the stenosis is congenital. According to Kussmal, the stomach may assume such a position as to twist the pylorus in such a way as to produce stenosis. Dilatation, however, may occur without a narrowing of the pyloric orifice, as the result of atony of the muscular coats due to gormandizing, fearfully distending the stomach by ingesting large quantities of food or drinking large quantities of beer. The erosion of the mucous membrane in chronic gastritis may weaken the organ to such an extent as to furnish conditions favorable for distention. Impairment of the nerve-supply, together with faulty nutrition, will give us enfeeblement of structure, and thus lead to increased capacity.
Pathology.—We are to remember that an abnormally enlarged stomach does not necessarily mean dilatation of the organ. According to Ewald, a recognized authority on gastric troubles, the capacity of the stomach to come under the head of dilatation must be fifty-three ounces or more. Where the dilatation is extreme, the intestines are crowded downwards into the pelvis, while the liver, spleen, and diaphragm are made to occupy a much higher position than the normal. The character and degree of the dilatation also vary. Thus, where the dilatation is the result of stenosis of the pylorus and final thinning of all the gastric tissues, the distention is regular and uniform, while in cases where erosions or ulcerations precede the distention, there the dilatation is extreme.
My colleague, Dr. W. E. Bloyer, reports a case of dilatation in a young woman, where anemia and general debility were the causal factors, which extended to within a few inches of the pubes, or to a line drawn from the crest of one ilium to the other.
Where there is pyloric stenosis, the first effect is hypertrophy of the gastric walls; but later this is followed by atrophy, the walls becoming very thin, and the muscular fiber may show fatty degeneration. Where there is no stenosis, the walls become exceedingly thin, the muscular fibers becoming only a trace of the original.
Symptoms.—The early symptoms of dilatation are not at all characteristic, and depend largely upon the causes producing- the lesion. There is always evidence of indigestion, and in the acute form there may be pain and tenderness in the epigastric region. There is an unpleasant sensation in the cardiac region, finally amounting to palpitation, extreme pain, sometimes resulting in unconsciousness.
In the chronic form, the most characteristic and diagnostic symptom is the vomiting of large quantities of food and blood, from one to three gallons at intervals of from one to three days. The vomitus consists of particles of food from several meals, mixed with more or less mucus, and is sour and foul-smelling; lactic, acetic, and butyric acids, and various bacteria, sarcinse, and yeast fungi are found in abundance. Fermentation is rapid, the mass being frothy, and, on standing, separates into three layers,—"a brownish foam, a middle layer of yellowish brown, and finally a layer of cloudy liquid and undigested food." (Ewald.)
The appetite is variable, though hunger and thirst are usually marked features. Where there is stenosis, there is usually constipation of an obstinate character. There is frequent retching of an acrid and offensive material, attended by a burning sensation. The tongue is always coated, and the breath unbearably fetid. The gradual dilatation produces cardiac disturbances, such as palpitation or dyspnea.
The skin is dry and constricted, and as nutrition and assimilation are more and more marked, emaciation is progressive. Kussmal was the first to call attention to tetanoid spasms resulting from dilatation of the stomach. They were attended by pain, and occurred in the foot, leg, calf, hand, arm, and abdominal muscles.
Physical Signs.—Inspection.—The knowledge obtained by inspection depends largely upon the condition of the abdominal walls. If thin and the dilatation is marked, a bulging of the left hypochondrium, the epigastrium, a portion of the right hypochondrium, and also a portion of the umbilical regions, will be noted, the greatest fullness being on the left side. If the bulging be very low, the "troughlike depression" of Ewald is seen immediately above it, and is most likely the result of the long axis of the stomach assuming a vertical position. When this distention is not visible, it may be seen by inflating the stomach by means of a pump.
Percussion.—The outline of the stomach can be readily made on distending it with air, as above described. If the transverse colon be distended with gas, and doubt exists as to the condition, have the patient drink freely of water, one or two pints, and, while standing, percuss the same region, and the dullness will be readily outlined, the resonance beginning immediately above.
Auscultation.—The splashing sound heard one or two hours after drinking is suggestive of dilatation, and if the stomach be siphoned after the above test, and the splashing sound disappears, the evidence is conclusive.
Diagnosis.—This is reasonably positive, if the symptoms already noticed are kept in mind. The vomiting of large quantities of food every two or three days, the chemical condition of the vomitus, and the physical signs already named, are sufficient evidence to warrant a diagnosis; however, an abnormally large stomach may be confused with one of dilatation.
Prognosis.—In some of the acute cases, the prognosis is favorable; but in the chronic forms, the prognosis is unfavorable, and a careful and guarded statement should be made to the patient. Thus, if the dilatation be due to stenosis, the result of malignant infiltration, not only will there be no amelioration in the patient's condition, but death will follow speedily; while in stenosis from other causes, the prognosis will be favorable as to life, but unfavorable as to a cure for the dilatation.
While, in rare cases, a dilatation, resulting from enfeebled condition of the walls of the stomach, may be permanently cured, in the great majority of cases, such changes have taken place in the tissues as to preclude a permanent cure, though treatment may render the patient quite comfortable.
Treatment.—Lavage, which was first introduced by Kussmal in 1867, is one of the most important parts of the treatment. By this method the stomach is relieved of all irritating substances, the process of fermentation prevented, and the stomach, cleansed and emptied, is given an opportunity to rest and contract. The many distressing symptoms which result from indigestion are thus avoided. Vomiting is less frequent and gastric distention reduced to the minimum.
In the more pronounced cases, the stomach should be washed out daily, though two or three times a week will suffice after a few weeks' treatment. We can use asepsin in the water where fermentation is marked or where the odor is offensive. Where the mucus is abundant, sodium bicarbonate will be of much benefit. Boracic acid is also useful in many cases. Siphon out the fluid till it leaves the stomach perfectly clean. Some cases will be benefited by allowing several ounces of the alkaline wash to remain in the stomach.
The best time for washing out the stomach is just before breakfast or before the midday meal, thus interfering as little as possible with digestion. Should there be ulceration, and the introduction of the tube result in much pain, lavage will have to be abandoned.
Next in importance is the diet of the patient. He should take as little fluid as is consistent with health. All food taken must be of the most digestible nature, and be taken in small quantities. Starchy, fatty, or sweet foods should be restricted. Predigested foods are well received, and produce but little discomfort. Peptonized milk and meat preparations are valuable. Alcoholic and malt drinks are to be prohibited.
To add tone to the stomach and increase the muscular power of the organ, nux vomica and hydrastin phosphate will be found of special worth. Strychnia will be useful for the same conditions. Galvanism and faradism will also be found useful in stimulating muscular contraction. Rubinat condal, Hunyadi, or Carlsbad waters will relieve the constipation that attends nearly all these cases.