Causes

An excessively large stomach is not necessarily pathologic. So long as its muscular wall is capable of vigorous contractions and the organ empties itself of its contents in average time, it is not abnormal. A pathologic state of dilatation implies not only enlargement, but also imperfect muscular movements; therefore the long retention of food, and usually its very imperfect digestion and absorption. The fermentation that almost of necessity arises under these conditions increases catarrhal inflammation and sometime causes it. It is an object of treatment, therefore, to relieve gastritis as well as enlargement and muscular atony.

Pathologic dilatation of the stomach is due to two kinds of causes: First, to stenosis of the pylorus; second, to lack of muscular vigor without stenosis. The common causes of stenosis of the pylorus are cancer, cicatrices, polypoid folds of the mucous membrane, hypertrophy of the sphincter, compression of the pylorus or duodenum by peritoneal adhesions, pancreatic tumors, and a dislocated right kidney. Some of these causes can be removed by the surgeon. The cases of gastric dilatation due to stenosis are rarely curable, but they can often be much improved. The usual causes of dilatation without stenosis are excessive eating and drinking, gastritis, and gastric deformities that are most frequently the result of cicatrization following ulcers. All except the last cause are removable.

Treatment

Before dietetic or other treatment is begun the stomach must be perfectly emptied of its fermenting and often putrid contents. This is seldom accomplished thoroughly by vomiting, therefore lavage or stomach-washing is of the utmost importance in these cases. This is accomplished by passing a stomach tube through the mouth and esophagus by means of which water is introduced into the stomach and then siphoned out. This process is repeated until the water returns clean, free from particles of food and mucus. At first it should be practised daily so that no large amount of food can accumulate to distend the organ; that its mucous membrane may be kept reasonably clean and free from mucus; and that it may secrete and absorb in a natural way. The first indication for treatment in all these cases is to prevent an accumulation in the stomach. This can be accomplished in part by controlling the amount of food and drink that goes into it, but best of all by cleansing it at regular intervals. When the stomach contains much mucus, it is best cleansed by an alkaline water. Antiseptics also may at times be added advantageously to the water used for washing the stomach. Lavage is practised to-day exclusively with a soft-rubber siphon tube.

In order to promote contraction of the stomach not only is it necessary to relieve this organ of any considerable load, but also to stimulate its muscular walls to contract and to empty the contents of the organ into the intestine. Massage is of great service in accomplishing this object. Electricity is also resorted to, although it cannot be relied upon to effect so much as massage will. The electrodes are usually placed upon the skin of the abdomen. Sometimes one is inserted into the stomach by means of the stomach-tube. Strychnin and laxatives are also important stimulants of the muscular walls of the stomach.

The object of all dietetic regulations in this condition is also to prevent the accumulation of much food or fluid in the stomach, which, by its weight, might distend the organ; of course sufficient food must be given to maintain strength.

In the severest cases not only will the stomach absorb very little of its contents, sometimes even secreting more fluid than is taken through the mouth, but the passage of food from the stomach into the duodenum is prevented by obstruction at the pylorus. Under such conditions one must rely for the maintenance of life upon rectal nutritive enemata, but usually some predigested food may be given by the mouth in moderate amounts. Some cases that seem hopeless will improve greatly under patient treatment. An instance in point occurred in my service at Mercy Hospital. It was a case of undoubted gastric cancer at the pylorus. The stomach was greatly distended. The patient had become very anemic and too feeble to sit up in bed. Daily washings of the stomach, very careful feeding, gentle massage, and tonic and laxative medication produced slow improvement, which, at the end of ten weeks, was so great that soft foods could be eaten with comfort; the gastrectasis was entirely relieved, and so much strength had been gained that the patient could walk about the building without undue weariness. This was a case in which the pylorus was imperfectly obstructed, in which eating too much and abnormal fermentation of food produced great dilatation. The improvement lasted several months. Ultimately, however, the tumor grew so large as to cause greater obstruction at the pylorus, the old symptoms of gastrectasis returned, feebleness increased, and finally death ensued.

While all clinicians agree that when a stomach is dilated the quantity of food eaten must be small, easily digested, and nutritious, they do not all agree as to its character or the frequency of its administration. As a matter of fact, a fixed regimen cannot be prescribed for all cases. The character of the food must vary somewhat according to the varying power of the stomach to digest, the more or less abundant secretion of free hydrochloric acid, and the different kinds of abnormal fermentation in the stomach-contents. In the details of the diet prescription, the physician must be guided as one would be in cases of chronic gastritis.

When a patient is vigorous and his stomach will bear it, only solid food should be given and at long intervals, not oftener than three times daily, and sometimes only twice daily. Scraped meat or finely divided and well-chewed meat, fish, eggs (soft cooked and raw), Zwieback or pulled bread, a little lettuce, peas, asparagus, tomatoes, or spinach, as a relish should constitute the diet at first. As improvement takes place the quantity eaten at one time may be increased and the food varied. Dry bread, green vegetables, cereals, macaroni, orange-juice, stewed or baked apples or pears may be added to the foods already allowed. Liquids are particularly heavy, and therefore must be avoided when possible. A meat diet, such as has been described, creates thirst, wherefore patients should be permitted to drink a few swallows of water whenever they wish, but not to exceed from ten to fifteen ounces in twenty-four hours. They ought not to drink, however, while food is in their mouths, for they are then apt to wash it into the stomach before it is perfectly masticated.

In another group of cases the extreme feebleness and gastric intolerance make it necessary to improve strength and flesh and to prevent vomiting if possible. In these cases rectal alimentation may have to be relied upon, but a little liquid or semi-liquid food may be given by the mouth with comfort to the patient - as, for instance, one or two tablespoonfuls of peptonized milk each hour. If this is well borne and does not accumulate unduly in the stomach, a larger amount may be given at slightly longer intervals. In cases of moderate severity a modicum of food may be given every two or three hours. For instance, at seven in the morning, from three to four ounces of water or weak tea, an ounce or an ounce and a half of dry bread, and an egg; at half past nine, three or four ounces of beef tea or water, two ounces of stale bread and butter, or, if the patient's stomach is strong enough, three ounces of cold boiled ham or roast beef without fat, and half as much bread; at twelve, five ounces of beefsteak or roast beef, three and a half ounces of soft-boiled rice, or, if preferred, one of mashed potatoes and two of peas; half as much fish and a small omelet might be substituted for the meat; at half past two, from six to seven ounces of milk and two of bread, or one ounce of cream; at five, three ounces of cold lean meat and two ounces of crackers or stale bread, or three ounces of tea and two of toast; at half past seven, three ounces of tea or water or milk, and two or three ounces of a cereal; at bedtime, two or three ounces of milk or water.

In general it can be said that when the stomach is dilated, fats, sugars, and more than a small amount of starches are not well borne, as they are especially liable to undergo abnormal fermentation.

When the gastric juice is diminished in amount or wanting, hydrochloric acid and pepsin may be given advantageously. But no matter what the diet may be, as the first indication for treatment it should be remembered that food must be administered in small amounts and that the stomach must not be allowed to become distended by it.