192 Dilatation of the Stomach.

That bleeding from the bronchial mucous membrane cannot produce, or even simulate, true hmmorrhagic infarction.

That valvular disease of the left side of the heart is a very common starting point of all these pathological changes, but that such disease is by no means an invariable concomitant of pul- monary apoplexy.

ART. VIII .--Dilatat ion of the Stomac]t. a By ARTHUR WY~I~E FOOT, M.D. ; Junior Physician to the Meath Hospital.

TIt~ following case is one of great dilatation of the stomach, con- sequent upon narrowing of the pylorus, the result of an ulcer situated in that neighbourhood. I t was characterised by periodic vomitings of large quant.ities of acid, fermenting liquid, rich in sarcin~e. The patient derived much relief f?om the washing-out of the stomach with alkalised water, and died apparently from an attack of sub-acute peritonitis, for which, however, there was no obvious cause, and which did not appear to be in any way attributable to the use of the stomach-tube.

The subject was a country boy, aged nineteen, of the labouring class, who was admitted to the Meat h Hospital under mv care, 28th Oct., 1874, complaining of " a windy swelling " r i s ing in his abdomen, and at intervals ending with a copious vomiting of" liquid so sour as to injure his teeth, also of heart-burn, " a drunkenness in his head" (vertigo dyspeptics), and frontal pain. He further mentioned that he felt " a working and boiling" in his stomach; that this sensation and his almost constant heart-burn were relieved ibr the time by vomiting; that the vomited matters hissed and frizzled in the basin; that he felt his stomach as if it were a bag; that it " j o g g l e d " while he walked, so that he used a belt to support it. His appetite was very defective; his bowels generally acted once a week, and on one occasion not for twelve days. He suffered greatly from flatulence (gastric); tile wind always escaped upwards--never downwards. His teeth were perpetually " on edge" from the sourness of the periodic vomltings. Such were the symptoms he complained of on admission.

On personal examination he was found to be deficient in flesh and strength. He presented the facies dyspeptica, a dull, spiritless

�9 Read before the Medical Society of the College of Physicians, February 10, 1875. [For the discussion on this Paper, see page 245].

By DR. FOOT. 193

cast of features, with evcrted upper llp, open mouth, showing his teeth when he spoke, and a pinched, chilly expression, of face. The position of his stomach varied in the horizontal and erect positions. As he lay in bed the stomach seemed to lie flattened out over the whole abdomen, which gave the stomach note on per- cussion from the left nipple to either iliac fossa; percussion, moreover, excited musctdar movements in the stomach quite visible and palpable; he was well aware of this habit of his stomach of "gathering up into a ball." The ordinary tone of the precordial region was replaced by a tympanitic note; the hepatic dulness was encroached upon, but not materially diminished. When he stood up, the belly swagged forwards, the stomach and its fluid contents malting a protuberance below the umbilicus, which, from the fluc- tuation and dulness, simul~lted ascites. It was ascertained by percussion that the spleen was dragged down by the baggy stomach when he was in the erect position; by auscultating the abdomen, as he drank, while standing up, the liquid was plainly heard meeting the fluid in the stomach at a point two inches below the umbilicus. He was sensible of the undulations of the contents of the stomach when lateral percussion was made in the erect position; and when, in the horizontal position, the flat hand was applied smartly over the pubis, he felt the shock communicated to the liquid under the left nipple. " Hippocratic fluctuation," the splashing sound of a mixture of gas and liquid, was elicited by this manoeuvre. There was no solid turnout in the abdomen. He had a constant sense of weight and fulness in the belly, except after vomiting; he wore a belt to support the weight when up, and when in bed he adopted a peculiar position, in which he even slept--- namely, he sat up with the left leg extended, the right thigh flexed, so that the right knee was pressed up against the abdomen; the clasped hands, placed between the right thigh and belly, were kept pressed against the stomach to support it. He said that in this position he was less annoyed by the rising of the " sour, scalding stuff," than when he lay down, and was freer from a burning pain which passed fi'om the ensiform cartilage up his neck, accompanied with gulps of acid liquid. When he did lie down, it was on his left side. As he complained much of the soreness of his teeth-- that is, of their being "on edge," for he did not know what tooth- ache is--his mouth was examined, and he was found to possess a complete set of unusually white teeth--not one of them, thirty- two in number, exhibiting a trace of caries, but the cutting edges

O

195 .Dilatation of the Stomach.

of all the incisors were worn off half way to the gums, as if they had been filed away; he said this was the result of the sour vomit- ings, and had occurred since they came on. While he was in hospital he generally turned his head to the right side to discharge the acid fluid which rose to his mouth, as the basins were kept at that side of his bed, and he said that the teeth of the right side of the mouth suffered much more from being "on edge" than those of the left side.

There was no difficulty in making the diagnosis of dilatation of the stomach, but as the prognosis depended very much upon the cause of the dilatation, it was necessary to arrive at the etiology of the disease. Two circumstances in the previous history threw light upon this. Iu April, 1872, eighteen months prior to admis- sion, he received a hurt in wrestling from a man kneeling upon "his wind," the locus of which he referred to a point in the right hypochondrium corresponding to the region of the pylorus. He had continual pain in that region for several months after the injury. In October, 1872, six months after the receipt of the injury, he was suddenly seized with a profuse vomiting of blood, supposed to have been induced by a strain while ploughing; he estimated the loss of blood at " a gallon;" at all events it was very copious, as he " fainted for sixteen hours," and nearly died fi'om its effects. From that hmmatemesis he dated his gastric symptoms. His lungs being healthy I inferred that by the hurt received in wrestling, the coats of" the stomach, near the pylorus, had been injured ; that ulceration had ensued, of which the copious hzematemesis, six months subsequently, was a result, and that the cicatrisation or thickening about this ulcer, had, in the twelve months since then, narrowed the pylorus so as to prevent the stomach emptying itself in the ordinary way. Accordingly, an unfavourable prognosis was at once made, but treatment was directed, on the one hand, towards bracing up the muscular coat of the relaxed stomach, in the hopes of making its cgntractions sufficiently energetic to overcome the pyloric obstruction; and, on the other hand, towards rectifying the fermentative condition which the chronic gastric catarrh had produced. The former indication was attempted by bandaging the stomach, the use of hypodermic injections of liquor strychnine, and by faradisation, and afterwards galvanisation of the stomach. The subcutaneous injections of strychnia, ~ t h of a grain in each, were made between the umbilicus and epigastrium, but the needle pro-

By DR. FooT. 195

duced small pustules, probably from irritability of the tissues owing to his state of defective nutrition, and they were soon abandoned ; he used to feel the stomach " harden up" after their use; in their stead he was given 15 m. tinct, nuc. veto., in 1 oz. inf. quassi~e, three times a-day. Faradisation was effected with the primary current of StShrer's battery, one moistened pole at the umbilicus, the other applied along the spine. The current from 30 cells of Leclaneh~'s battery was afterwards used, and during its employment a muscular tumour, produced by the contraction of the stomach, was quite evident; this tumour originated in the left hypochondrium, and passed diagonally across the abdomen towards the right iliac fossa. He derived some relief from the support of a broad abdominal bandage.

As he always felt relieved by vomiting, he was, the day after admission, given an emetic (sulph. zn. gr. xx., vin. ipee. 5ij., aq. ad. ~ij.); this acted in about 20 minutes (with the assistance of his finger in the pharynx, for he was accustomed to unload his stomach by inducing vomiting in this way), and produced a basinful of intensely acid liquid, which was soon covered with a thick brown scum. The character of the vomited matters remained constant until a short time before his death~that is, they were always copious, liquid, extremely acid, turning blue litmus paper scarlet, giving off a smell of stale beer; the surface of the liquid was habitually covered with u brown scum, about half an inch thick, which gradually disappeared in the course of 24 hours. This scum was precisely like that which is seen collected among bushes overhanging a river in flood. There was much slimy mucus under- lying the liquid, mixed with a greyish gruel-like sediment, so that the basins exhibited three strata, the scum uppermost, the liquid and the slimy sediment at the bottom. Microscopic examination of the scum showed abundance of sarclna3, torula3, and various other fungoid spores, in addition to the ordinary histological appeax- ances of vomit. Observations were made as to the inflammability of the gases given off by the stomach and vomited matters, but there was no evidence of their capacity of ignition. The discharges from the stomach occurred at intervals of from 24 hours to 4 days, took place suddenly and without nausea, were attended with marked temporary relief, and, as has been observed in similar cases, appeared to exceed considerably the ingesta. Before his admission he had often recognised things eaten several days previously when they were returned partially digested. Sulphurous acid and

196 Dilatation of tile Stomach.

hyposulphite of soda appeared to have no modifying effect upon the character of the vomit; the same may be said of carbolic acid, which he took according to a formula of Dr. Alex. Keith (I~. acid. carbol. 5j, ac. acet. 5j., tr. opii 5j., spt. chlorof. 5j., aq. ad. 3viii., 5j., t. d.), nor did creasote, so highly approved of by Murchison for sarcinous vomiting, produce any marked change, although in addition to mixt. creasoti, ~i. t. d., he had creasoti ij. m. in pills of" Chian turpentine three times a-day. The flatulence, which was very distressing, was more relieved by magnesia, 20 grs. ter die, than by any other form of medicine.

Soon after his admission I began to use the stomach-pump, pumping in tepid water in which bicarbonate of soda was dissolved. I t was, at first, not necessary to pump it out, as he vomited freely with the tube in the (esophagus, discharging at the same time large quantities of ropy mucus. The entire tube, which was 30 inches in length, passed down, indicating that the fundus of the stomach was considerably below the umbilicus. Two large jugs of water, holding an ounce of soda in solution, were usually pumped into him ; this washing was made every second or third day; he highly ap- proved of it, and often passed the tube himself. By thus anticipating the time of the spontaneous vomiting he was saved much suffering from heart-burn, and uneasiness from the " working and boiling" sensations which preceded it. Indications were soon afforded that part, at least, of the stomach was in a state of paralysis, and that it was emptied chiefly by the action of the abdominal muscles; because percussion after the use of the stomach-pump showed the size of' the stomach to be little altered, and that the liquid contents had been replaced by air. An intelligent patient in the bed next him observed to me that more wind came off his stomach on the days the stomach was washed, and after the operation, than on other days, or before its use. The boy also remarked that latterly the second jug of water was retained in the stomach until he drank something, when he rejected both the drink and the water. I t was noticed that the contraction and "hardening" of the stomach, induced by striking the parictes of the abdomen, was generally at the right side of the middle line, whence it was inferred that the pyloric half of the stomach was in a state of active hyper- trophy, while the cardiac half was in a condition of paralytic distension ; this was found to be the case after death, a strong houx- glass constriction separating the two regions. I t now became necessary to pump out the remainder of the contents of the

By Da. FOOT. 197

stomach, after vomiting had removed a certain amount of the fluid introduced; this was done on sixteen occasions. Whenever he felt any tendency of the tube to nip or pinch the stomach, owing to the mucous membrane being applied against the orifices of the tube, he used partially withdraw it himself When the orifice of the stomach tube is not terminal but lateral, the fear of sucking some mucous membrane into the opening of the tube is almost without foundation. It happened once to Dr. Schliep, ~ in about six hun- dred applications of the pump (in cases of dilatation of the stomach), to bring up a small piece of the membrane, when the patient himself pulled out the tube somewhat suddenly after the finishing of the operation, but no bad consequences followed. As to his diet, as milk agreed with him, he was allowed two quarts of it, roast meat, a glass of whiskey, and toasted bread ; he had discovered fi)r himself that bread agreed better with him when well toasted than in any other condition. The use of the stomach-pump was, on two occasions, intermitted for a week in consequence of " bilious attacks," which appeared due to catarrhal irritation of the bile ducts, and were characterised by feverishness, pain in the right hypochondrium, and heat in the stomach; these symptoms were relieved by ice internally, and hot poultices externally. He sank under a third attack o f this nature, which lasted a week, and in which the vomiting became so constant as to preclude the adminis- tration of any food by the mouth; he was then supported with enemata of beef-tea and whiskey, but became rapidly emaciated. The character of the vomited matters at: this period became com- pletely changed from their barmy appearance, and were replaced by bilious liquid; he suffered much before his death from incessant and uncontrollable hiccough.

When the abdomen was opened the cavity appeared almost wholly occupied by the stomach, which, like a large bag-pipe, stretched from side t o side, and reached nearly to the pubis; water could not be made to pass, except in drops, from the stomach into the duodenum, even under considerable pressure, but could be made to pass, though wi th great difficulty and slowness, in the reverse direction, from the duodenum into the stomach. The cardiac end of the stomach was particularly loose and baggy, the pyloric end notably hypertrophied; the pylorus was so contracted as to only admit of a very fine glass rod being forced through it; the ~ntrum pylori was occupied by an ulcer with

I Brit. Med. Jour., 7th Dec., 1872, p. 642.

198 Dilatation of the Stomach.

reddish surface, round, depressed, the size of a florin; a gland, the size and shape of a filbert, appeared on the outside of the stomach, close to the seat of the ulcer. The lining membrane of the stomach was thickly coated with a very tenacious mucus; the organ exter- nally appeared much more vascular than usual, the veins being numerous, large, and tortuous. The liver and spleen appeared normal. There were appearances of peritonitis in flaky lymph upon the intestines; there was no fluid in the peritoneal cavity. There were no indications of irritation of the interior of the stomach from the use of the stomach-pump tube, which had been introduced twenty-six times.

Among the clinical observations which this case suggested were the following : --That dilatation of the stomach, as a morbid and serious condition, is distinguished from its temporary dilatation by food or gas by its speedy return, in the latter case, to its natural size when emptied, whereas in the former both percussion and ballottement show, as in this instance, that it does not do so; that it is most usually symptomatic of obstructed pylorus, and so most frequently observed between the ages of thirty and sixty, when the causes of obstruction of the pylorus are most prevalent, so that its occurrence at the age of nineteen is exceptional. The diagnosis of the fluctuating protuberance made by the baggy stomach in the erect position from ascites, though it was not difficult in this case, may yet become so when the stomach is adherent to the abdominal wall. Even where this was not the case, the operation of tapping has been performed upon a dilated stomach in mistake for ascites, as in the case reported by Chaussier of an individual with (edema- tous limbs and distended belly, who was tapped in the abdomen, there came out through the canula gas, and some pints of a mucous, frothy, blackish liquid; the patient at first appeared relieved, but died in the course of the night following the operation; there was no aseites, but a prodi~ously dilated stomach was found, pierced by the trocar, containing liquid similar to ,what had escaped, and with a scirrhous pylorus." The rebellion of the stomach to anti-zymotie remedies, such as creasote, carbolic acid, and the hypo-sulphites, as evidenced by the persistence of the fer- menting vomit, indicated that there was more than a mucous catarrh of the stomach to deal with, and that the alimentary sub- stances were unable to leave the stomach. I t was observed in this, as in similar cases, that the distance between the cardiac and

a Cruveilhier, Pa th . Ana t . Tome ii., p. 856. 1852.

By DR. FOOT. 199

pyloric orifices was not much altered--that is, that the expansion of the stomach was not at the expense of the lesser curvature, but at that of the greater, which, insinuating itself between the layers of the great omentum, descended to the pubis, thereby increasing the difficulty of food, which had fallen into such a gulf, reaching the comparatively fixed pylorus. The great curvature from oesophagus to pylorus measured 31 inches, the lesser curvature 6�89 Perhaps the greatest dilatation of the stomach on record is the case by Jodon, a in which the length of the stomach is given as 421 feet; it occurred in a woman forty-eight years of age, whd, from the gradual increase of her abdomen, thought herself pregnant, and when her time had passed, a physician whom she consulted thought her dropsical. She died affer a seven-days' illness, marked by fever, thirst, and great dyspnoea. It was impossible to coffin her, from the great size of her belly ; and, at the suggestion of her parents, an opening was made in the abdomen, which gave exit to a quantity of liquid estimated at ninety pints. The aperture was then plugged, and a more methodical examination instituted, when it was ascertained that the anterior wall of the stomach was intimately adherent to the abdominal parietes; that the collection of fluid was in the enormously dilated stomach, which was sown with hydatids, one of which--larger than the rest--occupied and obstructed the pyloric orifice.

The stomach-pump was employed in the above case only as a palliative remedy, an unfavourable prognosis having been made from the very first. I t has been laid down by Professor Kussmaul of Freiburg, the originator df this therapeutic use of the stomach- pump, that relief only, but no cure, can be expected--I, in cases of cancerous stricture of the pylorus; 2, if the pylorus be very consi- derably contracted by a cicatrix ; 3, if with even a moderate stricture the walls of the stomach have, in consequence of the chronic gastritis, undergone a permanent degenerationY That substantial relief may be afforded by the use of the stomach-pump is proved by the history of two cases of dilatation of the stomach thus treated by Dr. Attleck in Scotland, as both patients provided themselves with stomach- pumps, on their dismissal from hospital, to carry on the treatment for themselves2

The case which I have related was looked on as a hopeless one

L Cruv. op. cir., p. 852. Deutches Archiv. fur Klinlsche Medicin. Vol. VI., p. 455.

e Brit. Med. Jour., 18th May, 1872, p. 539.

200 Cirrhosis or Fibroid h~filtration of the Stomach.

from the beginning, but I was not quite prepared for so early a termination of it; and yet, looking at the condition such cases are reduced to, it is not to be wondered at that their powers of vital resistance are very slight; and I find, also, that such cases of dila- tation of the stomach, from obstructed pylorus, generally in the end succumb rapidly to a short attack of illness.

ART. I X . - - O n a Case of Cirrhosis or _Fibroid fl~ltration of the Stomach. By J. J. C~ARLES, M.A., M.D.; Demonstrator of Anatomy, Queen's College, Belfast; and late Assistant Lecturer on Comparative Anatomy, Edinburgh University.

IN :November, 1873, my attention was directed to an extraordinarily small stomach in an aged male subject in the Queen's College Anatomical Rooms. The whole body was much emaciated, and the heart very small, being considerably smaller than the closed fist of the body. The intestines were very pale, and only a little more than half the normal size, and the villi in their interior were so milch atrophied as to be hardly visible. The liver and other abdominal organs were small, but healthy, and the lungs normal

The stomach maintained most of its ordinary relations to surrounding parts; but as it lay somewhat more vertically than usual, it was confined almost entirely to the left hypochondriac region. Aider its removal from the body with a portion of the duodenum, it presented the following characters :--In appearance it closely approached its primitive condition of a tube, with a pouch on one side. It could scarcely be said to possess a "fundus," the splenic end projecting little, if at all, to the left of the oesophagus ; and the curvatures were but slightly marked, both borders being straighter than usual. The pyloric extremity was much thicker than the rest of the stomach, and tbr an inch and three-quarters from the pylorus it was of' nearly uniform diameter throughout, resembling in form. and size a portion of hypertrophied intestinal tube." There was no apparent difference in size between the pyloric end of the stomach and the duodenum. The principal dimensions of' the stomach, when slightly stretched, were as follows : - -

A B.~Greates t length from most prominent point of splenic end to pylorus, six inches;

a From this peculiarity in its shape, Professor Macallstex'9 of Dublin, when I showed him the stomach, observed the strong resemblance it had to the stomach of the myrmeco2haga.