The important advances in hygiene and sanitary science, especially in the field of causation and prevention of infectious diseases, has made it necessary to revise the third edition of this well-known work in accordance with modern scientific conception of the subject.

Several contributors particularly qualified in their special lines of study have assisted in the revision. Among these are Surgeon-General Walter Wyman, of the U. S. Public Health and Marine-Hospital Service, who has revised the chapter on Quarantine; Dr. Francis W. Upshur, of the University College, of Richmond, Va., who prepared the articles on School Hygiene, Clothing, and Personal Hygiene; SurgeonMajor Walter D. McCaw, of the army, who rewrote the section on Military and Camp Hygiene, and Surgeon-Major Henry G. Beyer, of the Army and Navy Medical School, who rewrote the chapter on Naval Hygiene.

The subject of school hygiene is well considered, in so far as there is such active interest taken in the necessity for medical inspection of schools in recent years.

The chapter on epidemic diseases has had valuable additions since much research and observation have added to the knowledge of germ dissemination. The consideration of prophylaxis in contagious diseases, particularly in venereal diseases, is unfortunately not very complete. The medicinal measures suggested in the way of preventive therapeutics in the latter diseases would seem rather superfluous.

THE DIAGNOSTICS OF INTERNAL MEDICINE. By Glenworth Reeve Butler, M.D., Sc.D., LL.D., Physicianin-Chief, Methodist Episcopal Hospital, Borough of Brooklyn, N. Y., etc. With five colored plates and 272 illustrations and charts in the text. Third revised edition. D. Appleton & Co., New York and London. Cloth, $6.00.

Since the first edition appeared, Dr. Butler's book on diagnosis has been deservedly popular, both as a text and reference work. It has been written from the point of view of practical clinical work. and the author has taken into consideration the fact that the physician meets primarily symptoms and signs, and subsequently it is decided that the symptoms found indicate the presence of a specific ailment. The volume is therefore divided into two parts: first, a study of symptoms and their indications, and, second, a study of diseases and their characteristics. Part one comprises (1) a brief consideration of the clinical anatomy and physiology of certain organs and systems; practical points

of every day utility. 2. A description of the approved methods of examination. It has been well said by a capable reviewer that "the basis of the art of diagnosis is a thorough knowledge of clinical methods." 3. A careful consideration of the many signs and symptoms encountered in the practice of internal medicine. 4. A statement of the diagnostic significance of each sign and symptom, i. e., the disease or diseases, the presence of which is more or less strongly suggested by the finding of a given sign or symptom. While a prominent symptom seldom leads directly to the discovery of a disease, yet it is of importance to know the diagnostic value of individual symptoms. Part II. comprises diagnosis, direct and differential, and contains (1) succinct descriptions of recognized diseases and their symptoms, with (2) special reference to the diagnosis, direct or differential, of each disease. The qualifying terms applied to diagnosis are scientifically indefensible, but clinically useful.

This third edition has not been changed markedly, but some interesting additions and modifications have been made. The section on kryoscopy has been omitted as occupying space which can be used to better advantage, and the section on x-ray diagnosis has been curtailed for a similar reason. The section on examination of the stomach contents and feces has been much improved, and all other sections have been subjected to careful revision. In this period of awakened interest in tropical diseases it is fitting that a chapter on these maladies, which hitherto have been considered but lightly or not at all, should be added to a work of this kind. More detailed consideration of each would not have been amiss. Also new is the section on life insurance examination. This gives numerous suggestive points to be noted in such an examination, as well as some comparative tables. The various diagnostic tests are all well given. These include the latest methods of application of the tuberculin tests and the Wassermann test for syphilis with the Noguchi modification. Much space and attention have been given to the subject of modern laboratory methods, as the author fully appreciates the great value of these aids in arriving at a correct diagnosis and in aiding in the decision of correct treatment. Much attention is also given to the importance of symptoms, both subjective and objective. The author well says that everything has been subordinated to the main purpose of the book, which is to facilitate in a practical way the making of a thorough examination and a correct diagnosis. Special care has been taken to secure clearness and an appropriate arrangement. The mechanical work of the publishers is all that could be desired.

ALBERT E. BULSON, Jr., B.S., M.D.. Editor and Manager

VOLUME III

NUMBER 2

ORIGINAL ARTICLES

ACUTE DILATATION OF THE STOMACH.
ETIOLOGY, SYMPTOMATOLOGY, DIAGNOSIS AND
*
PROGNOSIS."

EDWIN WALKER, M.D.

EVANSVILLE, IND.

The occurrence of acute dilatation of the stomach after surgical operations has been long recognized, but only of recent years has it been generally acknowledged. It is much more frequent than we have thought, and if early recognized, can often be relieved.

Acute dilatation of the stomach from any cause was first described by C. Hilton Fagge in 1873. He reports two fatal cases, one due to a retroperitoneal abscess discharging into the duodenum; seven pints of fluid were evacuated by a stomach tube, but the patient died of exhaustion. The other case succumbed after three days' illness, and no other disease was discovered at autopsy. He did not attempt to explain the cause of the dilatation, but described the clinical history quite accurately.

The first case of dilatation due to a surgical operation that I was able to find was reported in 1887 by Dr. J. B. Hunter of New York. It followed an ovariotomy, and death occurred on the eighth day. T. R. Jessop, in 1888, in the London Lancet, reports a fatal case following excision of the hip; onset the thirtieth day; death in four days; dilated stomach, duodenum and six inches of jejunum found at autopsy.

Arthritis of the hip with sudden onset is assigned as cause by Kelynack in 1892, with death on fourth day. In the late nineties cases were reported by Albrecht following removal of mammary carcinoma and excision of elbow.

* Read before the Indiana State Medical Association, Oct. 8, 1909.

Fenger had a death following a cholecystotomy, and others were reported by various surgeons following operations. In 1902 Campbell Thompson was able to collect 44 cases, 12 of which followed surgical operation, 6 of which were abdominal and the remaining 6 varying from breast amputation to resection of the ankle.

In 1905 Appel collected 63 cases, 26 of which were due to trauma or surgical operations. Since this time many more cases have been reported, and the whole subject has been studied by many observers.

F. F. Simpson, in 1907, reports 80 additional cases to Thompson, 40 of which followed abdominal (including kidney) operations. Lewis A. Conner found, prior to March, 1907, 102 postoperative cases had been reported, 41 per cent. of which followed operations performed under general anesthesia; of these, 15 followed operations on the gall-bladder and bile passages, while all other abdominal operations furnish 17.

C. Jeff Miller thought, from reports at his disposal, it occurred with peculiar frequency after kidney surgery. Bloodgood has reported two cases following stomach operations (pyloroplasty and gastroduodenostomy). In almost all the cases in which the anesthetic was mentioned, chloroform had been administered. In one case ether, preceded by nitrous oxid gas, was used. In other cases (Conner) it is probable ether was used. In Halstead's case morphinether anesthesia was used. Finney, speaking of surgical causes, states that narcosis comes first as a cause, chloroform being the anesthetic most at fault. In experiments on dogs, Kelling showed that without anesthesia he could dilate the stomach only up to pressure of 25 c.c. of water, and at this point it was ejected, while under narcosis it could be distended up to 77 c.c. of water.

Conner found six cases complicating deformity of the spine, and Perry, Shaw and Kelling men

tion cases following the application of plaster-ofparis jackets to correct the trouble. MacEvitt reports four cases, and says, in looking through literature, finds numbers of them; one-half of these followed operations on parts remote from the stomach, amputation of limbs, breast, ischiorectal abscess and accidents.

We see, therefore, that acute dilatation of the stomach does occur in connection with a variety of diseases, for the most part acute infections and after narcosis, trauma and a great variety of surgical operations, the greater number being abdominal, but many followed operations on other parts of the body. The correct interpretation of facts has been quite difficult, and we cannot at present state that the pathology in all cases is understood.

The most constant post-mortem feature is the enormous dilatation of the stomach. The musculature may or may not present changes; hemorrhage into the muscular coat often occurs, and the muscular fibers may be torn apart; in other cases an unnatural thinness of the wall is found. The mucosa occasionally shows erosion. "The shape of the stomach seems characteristic. sharp angular bend is found on the lesser curvature which converts the organ into a tight V- or U-shaped cylinder, the cardiac end extending downward and the pyloric end upward and to the right."

A

The pathology in some cases seems fairly clear, but in quite a large proportion we have to fall back on supposition, a very dangerous method of dealing with scientific problems. In fact, we are compelled to admit that in quite a large proportion we are unable to fully explain, in the present state of our knowledge.

Pepper and Stengal suggested that spasm of the pylorus is the cause, but post-mortem findings show that obstruction is rarely ever at this point. Conner found the duodenum reported dilated in 55 per cent. of 69 autopsies, and thinks it probable that in some a dilated state of the duodenum was overlooked. In exactly one-half of the cases in which the duodenum was found dilated, the point of the obstruction existed at the crossing of the duodenum behind the mesentery at the duodenojejunal junction.

Albrecht accepted Glenard's suggestion, that an overdistended loop of small intestine may, by traction on the mesentery, convert the mesenteric artery into a constricting band at the duodenojejunal junction, and it is also possible that an overdistended stomach, pressing the intestines downward, may create a similar constriction. Albrecht investigated on the cadaver and found that the terminal end of the duodenum is normally flat, owing to an overlying mesentery, and

that traction on the mesentery in the direction of the pelvis would cause complete obstruction of the bowel at that point.

Conner examined ten cadavers and concluded that in a certain portion of normal individuals a pull on the mesentery, approximating, in direction and force, that which might be exerted by the empty small intestines hanging in the true pelvis, can produce obstruction at the lower end of the duodenum which will require considerable force to overcome. Finney states that acute dilatation of the stomach and gastromesenteric ileus cannot be differentiated clinically. Obstruction of the lumen of the duodenum by the root of the mesentery is probably of more frequent occurrence than has been supposed. Whether this is primary or secondary to the gastric dilatation, or whether this relationship is a constant one, has not been determined. However this may be, we can be reasonably sure that more than half of the post-operative gastrectomies are due to this form of obstruction, and lavage and proper posture will give relief. This does not explain all cases, since in some the obstruction was lower down; in one case the dilatation extended eight feet below the duodenojejunal junction.

Kelling considers that, after operations on the bile ducts, obstruction may be due to pulling on the ducts or adhesions, or expanding of dry gauze packing pressing on the duodenum.

The cases which followed application of plaster-of-paris jackets were probably due to pressure or traction on the small intestine. The obstruction of the duodenum by the mesentery is also favored by anything which causes the dropping of the intestine into the pelvis, as dorsal decubitus, and especially if adhesions are formed as may occur after hysterectomy and other pelvic operations.

The absorption of toxins is considered a cause by several authors. Halstead suggests these may be the result of the anesthetic, but for the most part no attempt is made to designate the character of the toxin or its source, and, so far as I am able to determine, nothing special has been adduced to support this theory. It is, however, a plausible explanation and further study may reveal the method of elaboration and the character of these poisons. We are in the habit now of attributing to vague toxemias anything we fail to explain, just as we used to blame them on reflex irritation through the nervous system. This may, indeed, prove to be the explanation of some of these cases.

Primary paralysis is also advanced by Thompson and others, but its claims are in the same category as that of the theory of toxins. Atony

of the stomach, another scape-goat for our ignorance, has not been shown to exist. Any or all of these may be factors and they seem the most plausible explanations at hand. It is true that it occurs more frequently in septic cases, and in this a toxin may be the cause.

The symptoms may come on immediately after an injury or surgical operation, but more frequently appear the second to the fourth day, in exceptional cases after a longer interval, one as long as the thirtieth day is recorded. Vomiting is the first symptom, and at the beginning is such as we often have after anesthesia; it gradually increases in severity and the quantity ejected is large, even as much as one or three gallons in twenty-four hours. The character is like paralytic gastrorrhea, thin, yellowish or greenish aromatic material, containing hematin and bile, the latter and pancreatic fluid may be present in large quantities. The odor is offensive but not feculent.

Epigastric or umbilical pain or distress usually comes later, the bowels are constipated, but movements may occur early. The quantity of urine is much diminished. The distention of the abdomen begins in the epigastrium and extends downward, and when extreme is more to the lower abdomen and to the left, while the right hypochondriac region is flat.

The percussion note is not so tympanitic as in obstruction and is flatter in the lower abdomen. There is a distinct splash and by it the location of the greater curvature may be made out. There is great thirst and the aspect of the patient indicates grave disease. The pulse becomes rapid and weak, while the temperature may be subnormal; it is usually from 100 to 101. If the stomach tube is used, a large quantity can be siphoned off.

The diagnosis is from obstruction and peritonitis with gaseous distention. Obstruction high in the small intestine cannot always be differentiated. "Bloodgood states that in high intestinal occlusion initial pain, with peritoneal shock, which may later somewhat disappear, and vomiting without marked distention, are the symptoms which differentiate it from acute dilatation." In the latter the pain follows the vomiting, collapse is gradual and progressive and the abdominal distention begins in the epigastrium. In high intestinal obstruction he (Bloodgood) found epigastric distention a very late symptom and had not found great distention present at the operation.

begins in the lower abdomen. The temperature is generally higher than in gastrectasis.

Prognosis is not so bad as at first supposed. The mortality is given 72 per cent. (Conner), 85 per cent. (Thompson and Appel). More recently it is much less, and with early recognition, prompt lavage and proper posture this mortality will be greatly reduced. In fatal cases death occurs usually in about 72 hours; it may occur in 11 hours, and has occurred as late as the tenth day.

BIBLIOGRAPHY.

Alleman, F.: Dilatation of the Stomach and Bowels Following Laparatomy, with Report of a Case, Pennsylvania Med. Jour., Pittsburg, 1900-'01, iv, 403-411.

2. Appel, T. B. Acute Gastric Dilatation Following Operations and in Disease, Pennsylvania Med. Jour., Pittsburg, 1904-'05, viii, 550-555.

3. Bonachi: Dilatation aigue postoperatoire de l'estomac, Bull. et mém. Soc. de chir. de Bucarest, 1905-'06, viii, 113-115.

4. Braun, W.: Nur akuten postoperativen Magenauftreibung, Deutsch. med. Wehnschr., Leipsic, 1904, xxx, 1553. 5. Braun, W., and Seidel, H. Klinisch-experimentelle Untersuchungen zur Frage der akuten Magenerweiterung, Mitt. a. d. Grenzgeb. d. Med. u. chir., Jena, 1907, vii, 533-578.

6. Callender, G. R.: The Condition of Acute Dilatation of the Stomach as a Postoperative Complication after Laparotomy, Ann. Gynec. and Pediat., Boston, 1908, xxi. 416-422.

7. Chavannaz, G.: Dilatation aigue postoperatoire de l'estomac Bull. et mém. Soc. de chir. de Paris, New Series, 1905, xxxi, 866-870.

8. Idem Dilatation, aigue de l'estomach apres gastroenterostomie, Jour. de med. de Bordeaux, 1909, xxxix, 5-7. 9. Cohnheim, P.: Ueber Gastrektasie nach Traumen, die Aetiologie der Magenerweiterung, etc., Arch. f. Verdauungskr., Berlin, 1899, v, 405-444.

10. Discussion on the Causes, Diagnosis and Treatment of Dilatation of the Stomach, Brit. Med. Jour., London, 1902, ii, 1389-1397.

11. Ferguson, A. H.: Three Cases of Acute Gestrectasia, Two Following Operations, Am. Jour. Obst., 1902, xlvi, 247-258.

12. Halstead, A. E.: Acute Postoperative Dilatation of the Stomach, Ann. Surg., Philadelphia, 1906, xliii, 469-472. 13. Idem: Acute Post-Operative Dilatation of the Stomach, with Report of a Case Following Nephropexy, Surg., Gynec. and Obst., Chicago, 1906, ii, 13-17.

14. Hamilton, J. A. G.: Acute Dilatation of the Stomach Following Abdominal Section, Australas. Med. Cong. Tr., Adelaide, 1907, 1905, vii, 265-268.

15. Knoll, C. A. F. W.: Ueber traumatische Magenerweiterung, Diss. Berlin, 1903, 8.

16. Lee, E. W.: Post-Operative Acute Dilatation of the Stomach, Internat. Jour. Surg., 1908, xxi, 20.

17. MacEvitt, J. C.: Post-Operative Acute Dilatation of the Stomach, New York State Jour. Med., 1906, vi, 284-288. 18. McWilliams, C. A.: Acute Post-Operative Dilatation of the Stomach; Report of a Severe Type with Recovery, Surg., Gynec. and Obst., 1908, Chicago, vii, 294-298.

19. Miller, C. J.: Acute Dilatation of the Stomach as a Post-Operative Complication, New Orleans Med. and Surg. Jour., 1907, lx, 621-629; also Tr. South. Surg. and Gynec. Assn., Philadelphia, 1907-'08, xx, 33-50; also Am. Jour. Obst., New York, 1908, lvii, 262-265.

20. Mueller, P. Ueber acute postoperative Magendilatation, etc., Deutsch Ztschr. f. Chir., Leipsic, 1900, Ivi, 486-511.

21. Neck: Die Akute Magenerweiterung Sammelreferat, Centralbl. f. d. Grenzgeb. d. med. u. Chir., Jena, 1905, viii, 529-534.

22. Nicolaysen, J.: Postoperative ventrikel dilatation, Forh, i. Kirurg. foren., 1907, Christiania, pp. 49-63.

23. Rogers, P. F.: Acute Post-Operative Dilatation of the Stomach, Milwaukee Med. Jour., 1908, xvi, 117-120. 24. Rousseau, P.: La dilatation aigue de l'estomac postoperatoire, These, 8 Bordeaux, 1907.

25. de Rouville: Dilatation aigue de l'estomac postoperatoire, Montpel. med., 1908, xxvi, 169-183.

26. Roux de Brignoles: Sur la dilatation aigue postoperatoire de 'estomac, Marseille med., 1906, xliii, 422-433. 27. Seelig, M. G. Post-Operative Acute Dilatation of the Stomach (Gastromesenteric Ileus), Interstate Med. Jour., St. Louis, 1907, xiv, 517-524.

28. Smith, S. B.: Two Cases of Acute Dilatation of the Stomach Following Abdominal Operation, Jour. A. M. A., Chicago, 1907, xlix, 941.

29. Stewart, J. W.: A Case of Acute Dilatation of the Stomach Associated with Operation; Fatal Termination, Lancet, London, 1903, i, 1303.

30. Thoma, F. Ueber akute postoperation Magendilata

denalverschluss, Deutsch. med. Wchnschr., Leipsic and Berlin, 1908, xxxix, 501-504.

31. Turner, C. B.: A Case of Acute Dilatation of the Stomach after an Operation on the Kidney, Lancet, London, 1905, ii, 292.

32. Vincent and Bernasconi: Dilatation aigue de l'estomac a la suite d'une operation de hernie inguinale, Bull. med. de l'Algerie, Alger, 1906, xvii, 397.

33. Wilkinson, H.: Acute Dilatation of the Stomach, Following an Operation for Suppurative Appendicitis, Jour. Kansas Med. Soc., Kansas City, 1908, xiii, 462-465.

34. Beck, C.: Akute postoperative Magendilatation im Kindesalter, Jahrb. f. Kinderh., Berlin, 1906, lxii, 102-119. 35. Hunter, J. B.: A Case of Acute Dilatation of the Stomach Following Laparotomy, Boston Med. and Surg. Jour., 1867, cvii, 361.

36. Conner, L. A.: Am. Jour. Med. Sc., March, 1907.
37. Simpson, F. F.: Am. Jour. Obst., September, 1907.
38. Fenger, Christian: Clin. Rev., Chicago, 1898.
39. Appel, Theo.: Philadelphia Med. Jour., October, 1898.
40. Editorials, Jour. A. M. A., August, 1899.
41. Editorials, Jour. A. M. A., October, 1902.
42. Box and Wallace, Lancet, London, 1898.
43. Bloodgood, Jos. C.: Ann. Surg., November, 1907.

Finney, J. M. T.: Boston Med. and Surg. Jour., 1906.
Halstead Surg., Gynec. and Obst., September, 1907.

DISCUSSION.

DR. MILES F. PORTER, Fort Wayne:-It will be apparent at once, I think, to all whose attention is directed to it, that when we come to think of the various names that have been applied to the condition about which we are talking now, that we are not very well settled as to the etiology of the condition. Whether it is correct to term this condition an arteriomesenteric ileus or not is open, I think, to grave question, because this name involves a theory which, while it has been established as regards a large number of cases, has failed in at least the lesser number of cases that have been examined. It has been termed by some acute duodenal obstruction, and this again involves a theory which has not been. substantiated in all cases reported upon. Whether this obstruction in the duodenum, when it is present, is due to the mesentery or not, or whether it is due to a band of fibrous tissue, extending from the left crest of the diaphragm, is also a mooted question.

Experiments have been made that seem to show, at least in a certain number of cases, that the obstruction is the result of this fibrous band of connective tissue. These experiments consisted in attempting to relieve the dilatation of the stomach, without dividing this band, and this observer found that the obstruction could be relieved without dividing it, provided the stomach was lifted up from the duodenum. He therefore concluded that one of the elements in the production of the dilatation, of great importance etiologically, was the distended stomach itself. However, in one case he succeeded in relieving the dilatation by simply dividing the bundle of fibers and allowing the stomach to remain distended, and press upon the duodenum at this point, showing at least in some cases that this band is an etiological factor, and in all cases perhaps as a primary or secondary etiological factor, we have the heavy stomach. Then, again, supposing it is due to the weight of the stomach; supposing it is an arteriomesenteric obstruction; what produces this arteriomesenteric obstruction? Why does it come on in one case and not

in another, and why should the stomach be prone to dilatation with this condition of things which is supposed to obtain in all cases, physiologic as well as pathologic?

This has led to the theory referred to by Dr. Walker, of Pepper, as to the toxic origin of this condition, and it has also led to the theory that the anesthetic has something to do with it. It occurs to me that if the anesthetic has anything to do with it, then these cases should occur immediately or very soon after the administration of the anesthetic; or if they occur later after the administration of the anesthetic, then the anesthetic is only one of the causes. The anesthetic, in other words, might well be blamed for dilatation of the stomach coming on four or five days afterwards, but in order to blame it justly under these circumstances it would seem to me we could only blame it by saying the anesthetic had produced degenerative changes in the liver and kidneys, and secondarily produced toxemia, and this would lead us back again to the toxic theory. But, after all is said and done regarding the probable causes, the fact is we have a condition here to deal with which is pretty well understood. The practical point is that we have a huge dilatation of the stomach, and in the minor cases, if we can relieve this dilatation and keep it relieved, our patients get well. Another practical point is that it is possible to recognize these cases before the dilatation becomes extreme, and in proportion as they are recognized early the results of treatment are favorable, and conversely. If there is anything in the theory of the dragging of the bowel down, so as to pull this mesentery over it, it has occurred to me that careful observation of the proportion of cases that come on when the Fowler position is used, as compared with the proportion of cases in the recumbent position on the side or back, would throw some light upon this dragging on the mesentery as an etiological factor in it. It would seem to be reasonable to suppose, other things being equal, if there is anything in this theory, those in the Fowler position would give the larger percentage of dilatation. One word as to whether post-mortem findings bear out the theory of pyloric stenosis or the reverse. If this stenosis is spasmodic in character, the post-mortem findings would not bear it out. So that we should hesitate before we apply too much force to the statement that the postmortem does not bear out this theory. Another practical point, it occurs to me, along the line of treatment, is this, that the proper adjustment of an abdominal bandage would remove or have a tendency to relieve in a measure or do away in a measure with many of the accredited causes of this trouble. It prevents downward traction, holds up the stomach, and also gives a certain degree of support and therefore has a tendency to overcome the atony.

One thing regarding injections in connection with lavage in those cases in which the stomach