Synonyms

Dilatation of the stomach; ectasia ventriculi; gastric insufficiency; stenosis of the pylorus.

Definition

An affection characterized by the constant presence of food in the stomach, even in the fasting state. There is always a retardation or retention of chyme in the organ.

General Remarks

The term "clinical dilatation of the stomach." as is well known, is applied by the majority of authors to a condition in which there is stagnation of food in the stomach. Taken in its true sense, however, the word "dilatation of the stomach," or "ectasia ventriculi," refers merelv to the dimen-sions of the organ. This explains the frequent misunderstandings caused by these expressions. Some speak of dilatation of the stomach as soon as the limits of this organ are found enlarged; others, however, only in those instances whore there are found rem-nants of food in the morning in the fasting condition. Rosenbach,1 therefore, suggested the term "motor insufficiency of the stomach," to designate that condition in which the transportation of food from the stomach into the small intestine is at fault. In an article recently published. Boas2 expresses the opinion that the terras "dilatation of the stomach" and "ectasia ven-triculi" should not be used at all, and suggests the term "gastric insufficiency of the first and second degrees" instead. The first degree corresponds to the atonic condition, the second to the stagnation of food.

Although, like Boas, I am fully convinced of the importance of differentiating between cases of stagnation of food and those in which the transportation of the chyme is only slightly retarded, I do not, however, believe that we ought to discard the expression "dilatation of the stomach," or that the proposed term, "gastric insufficiency of the first and second degrees" is well selected.

1 Rosenhach: Volkinann's Sammlung klin. Vortrage, No. 153.

1878.

2Boas: Deutsche med. Wochenschr.. 1894. No. 28, p. 576.

"Dilatation of the stomach" is a term applied to the condition of the volume of the stomach, and signifies an enlargement of its dimensions. Such conditions not only do exist, but are an every-day occurrence. There is, therefore, no reason for discarding the term "dilatation of the stomach." Whether this enlargement of the dimensions of the stomach has been due to physiological or pathological processes, or whether it creates abnormal conditions or not, will have to be investigated in every individual case.

The term "insufficiency" or "mechanical (motor) insufficiency of the stomach," signifying a retardation in the transportation of the food from the stomach into the intestine, appears to me ill chosen; for the word "insufficiency" or "mechanical insufficiency of the stomach," does not clearly point out the condition caused by the transportation of chyme from the stomach into the intestine. Moreover, the term "me-chanical insufficiency of the stomach "means that the fault for the non-transportation of food lies in the stomach, which is not the case in most instances.

Analogous to the expression "ischuria," which signifies an abnormal collection or stagnation of urine in the bladder, without giving the cause of this condition, the word "ischochymia"1 might be applied in order to designate an undue stagnation of chyme in the stomach.2 Thus "ischochymia" will embody a complex of symptoms without stating the cause. The latter will have to be discovered and further determined in each case.

Symptomatology

Ischochymia may last either a short period of time (a few days to one week) or it may become chronic or stationary.

Acute ischochymia is occasionally found as a result of an acute inflammatory process of the gastric mucosa in consequence of gross errors in diet and the like. Ischochymia, then, although quite rarely, may develop alarming symptoms and may even lead to a fatal issue. Several such instances have been reported under the heading of acute dilatation of the stomach by Hunter,3 Frankel,4 and Boas,5 the case of the latter author ending in recovery. Whether acute ischochymia is due to a paralysis of the gastric muscles, or whether it is caused by a spasmodic contraction of the pylorus, is as yet undecided. Probably both conditions exist. In these instances it appears that nothing passes from the stomach into the duodenum; anything which is taken in the way of food or drink collects in the stomach and distends it. The presence of gastric juice may still further increase the amount of liquid within the organ, and in this way aggravate the condition. The prolonged stagnation of chyme within the stomach gives rise to manifold processes of •decomposition and fermentation. Vomiting usually occurs and brings temporary relief. The direct cause of an eventual fatal issue is quite difficult to state.

It may be due to auto-intoxication or to some more direct injury to the vagus nerve.

1 Tschochyinia. from - detain, and =chyme.

2'see Max Einhorn: "Diagnosis and Treatment of Stenosis of the Pylons." Medical Record, January 10th, 1805. 3Himter: Medical Record. 1889.

4 A. Frankel: Deutsche med. Wochenschr., 1894. No. 7. 5 J. Boas: Deutsche med. Wochenschr., 1894, No. 8.

Fig. 66. - A Specimen of Chyme Obtained from the Stomach in the Fasting Condi-tion (from a Patient with Ischochymia [H.] ), showing (a) vegetable cells, (b) partly digested muscle fibres, (c) starch grains, (d) fat, (0) yeast cells, bacilli and cocci.

Transient ischochymia may appear in conditions in which the muscles of the stomach are weakened and fail to do their work properly, or in a beginning stenosis of the pylorus. In both instances the ischocbymia is only slightly marked - that is, while there is a retention of some food in the stomach, the greater part is transferred into the small intestine. In the fasting condition the amount of chyme present in the stomach is not large. In a few days the stomach, as a rule, recuperates and by more energetic action succeeds in accomplishing its work properly, that is, transports all the chyme to the duodenum during the night.

Constant ischochymia is always a serious trouble. Processes of fermentation are almost constantly present (Fig. 66). It is here that the occurrence of manifold gases has been described; as, for instance, sulphuretted hydrogen, hydrogen, marsh gas, oxygen, and carbon dioxide. In some of these patients the gas eructated burns with a flame if lighted (Ewald). Very often it is possible to hear, when auscultating the gastric region of these patients, a constant bubbling or sizzling sound, arising from the rapid formation of the gas. If the gastric contents of such patients be obtained and put in a cylinder, one can perceive the bubbles of gas rising to the surface. The amount of gas may be determined, according to Kulin,1 by placing small quantities of the filtrate in a fermentation tube which is kept at blood temperature for several hours.

Chronic ischochymia is almost always accompanied by the following train of symptoms: The appetite is frequently poor, although at times it may be abnormally increased. The sensation of thirst is usually augmented and in some cases constantly present, and the patient is continually tormented with a feeling of extreme dryness in his throat. A feeling of oppression almost always exists, which at times may alternate with more or less intense pains. The eructation of gas, which has a disagreeable odor, is often met with. Vomiting of large quantities of chyme, in which particles of food from previous days may be recognized, is one of the most important symptoms. The vomiting may occur once or twice a day, or once only in two or three days. There are very few cases in which the bowels work regularly; as a rule, the most obstinate constipation is found. Emaciation is present in almost all instances, and it may occasionally reach such a degree that the patient literally looks like a skeleton.

1 Kuhn: Deutsche med. Wochensehr.. 1892, Nos. 49 und 50.

In the advanced stages of ischochymia, the quantity of urine voided in twenty-four hours is greatly reduced, and may sometimes be less than 600 c.c.

Etiology

Ischochymia is due to a diminished muscular work of the stomach, or to stenosis of the pylorus, or to an open ulcer within or very near the pylorus. In the latter instances a spasmodic contraction of the pylorus takes place.

Course

The course of ischochymia will materially differ, according to the etiological factors causing this condition. Ischochymia due to muscular weakness of the organ (atony) may occasionally disappear without medical aid and is in most instances amenable to rational treatment. Ischochvmia due to stenosis of the pylorus will run a different course, according to the nature of the stenosis. If the latter be of a benign type (hypertrophy of the pylorus or stricture of the pylorus due to cicatricial contraction) there are at first ameliorations which are due to an hypertrophy of the muscles of the stomach and to increased compensatory action; frequently, however, the symptoms of stenosis return as soon as the pylorus has become still narrower, until at last sufficient compensation cannot bo effected. In this stage the only means of saving the life of the patient is surgical intervention in the way of establishing a larger opening between the stomach and the small intestine, which may be done either by Hoinecke-Mikulicz' pyloroplasty or by a gastroenterostomy.

In all these cases a radical cure can thus be accomplished. The patients then gain considerably in weight, have no pain, no digestive troubles whatever, and can attend to their daily vocations in life. They all feel as if "new-born," if I may be permitted to use this expression. In two of these patients I convinced myself, by means of several experiments, of the prompt forwarding of the contents of the stomach into the intestines. The chemical condition was not markedly changed; the gastric volume in the two patients was not appreciably lessened six months after the operation. In one of my newly observed cases,1 however, there was a marked diminution in the size of the stomach two months after the gastroenterostomy. If the stenosis is of a malignant type, then the course will correspond to the original disease. However, it is here also possible to relieve the symptoms of is-chochvmia by an early gastro-enterostormy.

1 Msix Einhorn: "A Further Contribution to our Knowledge of Ischochymia." Medical Record. June 19th. 1897.

Before taking up the diagnosis, we may consider some symptoms which are characteristic of the just-mentioned etiological factors: