Case of Emphysema of the Sub-Mucous Cellular Coat of the
Stomach ; with remarks. By Francis West, M. D., of Phila-
delphia.
April 20, 1840. Thomas B., white, set. 34 years, shoemaker
by trade, of temperate habits, and sound constitution, had always
enjoyed good health until about a year since, when he began to
complain of not feeling perfectly well, although he still continued
to work at his trade. About six weeks before my first visit, ac-
cording to the history which he gave me, he began to suffer from
severe burning in his stomach, which steadily increased and ex-
tended throughout his abdomen, accompanied by loss of appetite,
vomiting, and a sensible diminution of his urine. About a fort-
night before he died, he had taken, by the advice of a Thompso-
nian practitioner, several powerful emetics, which operated most
violently. From this time he became much worse, and then
applied to a Homoeopathic practitioner, who, having been only
recently converted from legitimate medicine, had very wisely con-
joined with his “ little powders ” the free use of leeches and poul-
tices to the abdomen, with the effect of somewhat relieving him.
The symptoms, however, soon became threatening again, and in
view of approaching death, the patient was very willingly re-
signed into my hands. His condition was then as follows :—
Emaciation of face considerable, of rest of body moderate ; no
cedema or other swelling of the integuments ; face hippocratic and
expressive of severe internal uneasiness, which was constantly re-
ferred to the abdomen, pressure upon which, especially over the
stomach, very much aggravated his sufferings. He said that he
felt as if there was something in his stomach which ought to come
up, and begged that he might be vomited for the purpose. His
mouth was dry, with sordes about the lips and gums ; tongue also
dry, hard and pointed, and abraded in spots, but without any fur
upon it; voice weak, with great difficulty of swallowing, and
an intense desire for cold drinks, which were freely allowed him.
He had no disposition for food, although his stomach was quite
retentive ; abdomen very tumid ; bowels constantly open, with
much pain ; discharges consisting of bloody water; no cough or
pain in the chest; respiration weak but natural ; impulse of heart
feeble; pulse about 90; skin of natural temperature ; no sweat-
ing ; urine not very free. A palliative treatment was advised,
consisting of warm applications to the belly, with cool mucila-
ginous drinks, and the same kind of enemata ; chicken water for
nourishment. He gradually sank, as I had anticipated, and died
very easily on the 23d, about 72 hours after I first saw him.
Autopsy.—Thirty hours after death : usual rigidity of the body;
no decomposition or apparent tendency to it.
Thorax.—Lungs engorged with black blood ; no other lesion ;
no effusion into the pleurae. Heart soft and flabby, its tissue at
some points being easily broken down by pressure between the
fingers. Parietes thinned ; valves natural ; no pericardial effu-
sion.
Abdomen—The omentum was firmly adherent to the abdominal
parietes at several points, and at the same time closely invested
the intestines, being attached to them by false membrane, the re-
sult apparently of not very ancient inflammation. No extraordi-
nary fetor was observed when the cavity was exposed. On laying
open the stomach, attention was at once attracted to the projec-
tion into its cavity of a large, tense irregularly rounded swelling,
considerably exceeding a goose egg in size, surrounded by smaller
ones, similar in character, some of which were connected with the
large one, whilst others were only contiguous to it; the whole
resembling very much a collection of hydatids. On examination,
these swellings proved to be the result of distension or inflation of
the mucous membrane of the stomach, from air accumulated in its
sub-mucous cellular tissue. The parietes of these inflated tumors
could not be ruptured by pressure with the fingers, but on being
cut, the air which escaped from them was quite inodorous. This
fact was particularly noticed. The mucous membrane of the
stomach was eveiywhere of natural firmness, and could be readily
raised in strips of some length, leaving the parts beneath quite
natural. No signs of inflammation were present. No part of
this organ exhibited any sign of putrefactive decomposition. The
intestines examined throughout, presented no appearance similar
to the emphysematous condition of the stomach, neither was this
latter observable in any other part of the body. The other organs
were healthy.
Remarks.—The point of particular interest in this case is, of
course, the emphysematous swellings noticed in the stomach, and
in regard to them, the question at once arises, how were they pro-
duced ? Was the collection of gas the result of abnormal secre-
tion, or exhalation into the sub-mucous cellular tissue, or was it
merely the effect of incipient decomposition of the part after death,
or at some period nearly preceding dissolution ? To the latter
cause many persons may, at first view, be disposed to attribute it,
and similar gaseous collections, as M. Bouillaud has done, in his
article upon the subject in the Dictionnaire de M6decine et
Chirurgie Pratiques.
From the firmness and natural condition of the rest of the sto-
mach, and from the perfectly circumscribed character and consist-
ence of the swellings themselves, however, as well as from the
entire want of fetor in the air which escaped from them, we are
more disposed to regard the emphysematous condition as the re-
sult of actual secretion, or exhalation of air into the cellular tissue
during life, than as a consequence merely of putrefactive decompo-
sition. Neither the time of year, the nature of the disease, nor
the period which elapsed between death and the autopsy, seem to
favor the idea of putrefaction, which, on the contrary, appears to
be disproved by the entire localization of the swellings, as well as
by the natural appearance of the rest of the stomach, and the
entire absence everywhere else of any signs of decomposition.
May not the lesion have been connected in some way or other
with the violent vomiting to which the patient had been subjected,
and after which, as has been stated, he always complained of
feeling something in the stomach, which, as he expressed it,
“ ought to come up ?” The inflation of the inner membrane of
the stomach to the degree noticed, might very well, as we con-
ceive, have given rise to this peculiar sensation, and if so, we
are supported in the belief that the emphysema originated ante and
not post mortem.
Such an appearance of the stomach, we believe, has not often
been noticed.
Andral, in his Pathological Anatomy, page 124, of volume 2d,
under the head of “ Exhalation of Gases,” gives a case of the
kind, as reported by Cloquet, although he evidently regards the
appearance in question as one of very uncommon occurrence.
Cloquet, in his history of the case, says “ there was considerable
emphysema of the cellular tissue uniting the different coats of the
stomach, so that its parietes appeared to have been inflated, and
at several points were nearly an inch in thickness.”
This description accords perfectly with the one we have given,
and except in Cloquet’s case, we do not find any other reference
in authors to emphysema of the stomach, although that of other
organs is noticed.
Thus, Grisolle, in the first volume of his treatise on Internal
Pathology, under the general head of Morbid Secretions, called by
him “Pneumatoses ou Secretions Gazeuses,” when describing
“ emphysema,” says “ that it occurs also at times in the sub-mu-
cous cellular tissue, such as is found in the folds of the conjunctiva,
and in that separating the different coats of the intestines, but
more rarely in the subserous cellular tissue, especially that beneath
the epiploic reflections.” It is probable, he adds, that in these
latter cases, the emphysema constitutes a purely cadaveric lesion.
Murat, in his article upon “ Spontaneous Emphysema,” in the
Diet, de Medecine, or Repertoire des Sciences Medicales, says
“ these may possibly be referred to this sort of lesion, viz., “ em-
physema from exhalation,” the different windy tumors, observed
by Galen and Fabricius, as well as the collections of gases which
appear in different parts of the body, either after, or during cer-
tain diseases, or from exposure to cold, or in some cases of poison-
ing, as well as from the bites of certain insects and reptiles.”