3. Progressive emaciation, recognizable by the losses of water and fat, the lowered weight curve showing a daily loss of 30 Gms. or more; and finally by the signs of extreme exhaustion, senile facial appearance, deep lying bulbi, pointed nose, depressed fontanelle, pale anwmic skin stretched over the diaphanic bone, subnormal temperature, impaired suckling power, narcolepsy. etc.
4. The abdominal region is sunk, in, owing to the absence of intestinal contents, and the gastric region is distended like a drum, imparting to the abdomen a characteristic appearance.
5 Visible Peristalsis.—A highly characteristic phenomenon. which is but seldom permanently absent, consists in the considerable con tractures of the stomach which are visible through the attenuated abdominal wall. They occur in the sleeping as well as in the waking condition, and especially in the act of feeding and toward the end of the digestive period, either in the shape of stiffening or bulging of the entire stomach (gastric spasm, hypertonia) or as an undulating, pro gressive motion of hilly distentions, separated by rings and furrows (hyperkinesis: Finkelstein, Ibrahim; see Plate 51).
There is a certain protrusion as large as a walnut or an apple in the axillary line under the left costal arch, slowly advancing n-ith occas ional intermissions, transversely or obliquely downward toward the middle of the abdomen and even beyond. The protruding part is often surrounded by deep retractions of the abdominal wall. Before it has diappeared to the right in the parasternal or mammillary line, or excep tionally far beyond, another pscudotumor has usually appeared at the same place as the first, or is about to clo so. Hour-glass or figure-of-8 contractions may occur owing to two contractile waves running closely behind one another. This visible peristalsis of the stomach, which ap parently causes no pain, contrary to the spastic contractions of the pylorus with which it is sometimes accompanied, has often been observed by other authors besides myself as early as a few (lays alter the onset of vomiting.
Quite a similar and instructive picture as that observed at the abdominal wall can occasionally be obtained by projecting on the X-ray screen the picture of a stomach containing bismuth. Antiperi staltic movements have also been observed in isolated cases.
G. A further characteristic sign, which, however, is only exception ally and irregularly present, is the palpable pyloric "tumor" (Finkelstein). After the first week of illness, or later, it may be possible to gently advance with the finger through the relaxed abdominal wall at or above the level of the umbilicus slightly to the right of the median line, in the area of the frequently present reetus diastasis. A movable and rather firm
growth may be palpated, which has the size and form of a hazelnut or of a tumefied lymphatic gland. This growth corresponds to the hyper trophied pylorus, although its position is lower and more medial than the normal pylorus, which is usually impalpable owing to its protected position under the left lobe of the liver. It may soften or disappear entirely under the pressure of the palliating finger, but after a while it may again be felt as a hard knot (Thomson, Wernstedt).
7. A symptom of secondary importance is a volumen rentriculi auctunz which in some cases is apparently present. When the "stomach stiffening" occurs, and at the peristole, the lower margin of the parietal gastric region at the abdominal wall is outlined just above the umbilicus down to two fingers' width below, a phenomenon which may well be taken as a proof for the presence of a volumen aucturn if the small curvature is in normal position. Clapotage, percussion, etc. may serve to support this assumption. Reliable measurements of the capacity of the stomach in the living are not available; for the results of autopsy see below.
S. A noteworthy sign, which, however, is not always present, is lactophobia. Bottle or breast :s seized with mffility, but promptly re pulsed after a few swallows, under evident signs of distress, pain, or terror (cardiac spasm? Ibrahim), and so long refused until hunger overcomes the objections. This symptom is often mistaken for anorexia, from simi lar misinterpretations as prevail in mistaking deficient defecation for obstipation.
Examination with the stomach tube reveals the following disturb ances of gastric function:— 9. Ischoehyntia.—Gastrie motor function in regard to removal of the chyme into the intestine is considerably reduced. Large quantities of a meal (20-50 grams) can always be obtained by the tube in four to five hours and in exceptional cases even up to ten hours, unless the stomach has been depleted by copious vomiting. Food from meals taken in the course of the day are mixed with gastric juice, with the result that the stomach becomes almost never quite empty, unless recourse is taken to lavage. The existing motor insufficiency is a relative one.