Under this head are included a large number of conditions which have this point in common, that the stomach is not emptied within the normal limits of time. With this defect there is often associated a secretory insufficiency, but this is not always the case. Motor insufficiency may exist without dilatation, but of all cases of dilatation of the stomach, motor insufficiency actual or relative is the immediate cause.
The group may be divided into three classes : -
Pure Motor Insufficiency (Gastric Myasthenia) without dilatation, an impairment of the expulsive power, which results in an abnormal tarrying of food in the stomach and a consequent shortening of the rest-periods of that organ. This may be regarded as the initial stage of the next class.
Dilatation (Primary Gastrectasis) without any pyloric obstruction. This results from continued motor insufficiency, delayed digestion and yielding of the stomach-wall, and it must not be confounded with mere temporary distension by gas. A knowledge of the causes of this condition will show that it presents a great field for dietetic treatment. In some cases it clearly arises from over-indulgence in food and drink, from sheer bulk and weight of material taken with short intervals into the stomach, which is often associated with imperfect mastication and rapid swallowing. Both on the motor and on the secretory side enormous demands are thus made on the stomach. The condition of the teeth must always be examined. In many such cases alcoholic drinks are also taken in excess, and in these, as is described elsewhere, a chronic catarrhal gastritis is often present. A moderate degree of dilatation may also occur in connexion with hyperacidity, and its mode of origin is mentioned under that heading. In all cases, therefore, of dilatation resulting from abuse of food and drink, from chronic gastritis, and from hyperacidity, the mere regulation of diet and the teaching of the principles of digestion will often go far to effect a cure.
In another class the myasthenia underlying the dilatation is the expression or result of some general condition. Thus it may follow many of the specific fevers. It occurs in connexion with tuberculosis, malaria, renal disease, and anaemia of all kinds, and, in fact, with any state of profound impairment of health.
Finally, it may occur as a part of neurasthenia, and it is probable that the same quick fatigue, slowness of repair, and absence of reserve are to be noted in the stomach as in the general musculature of such patients. The effect is liable to be greatly aggravated by strong emotion or strain. The treatment of such cases presents great difficulty.
Dilatation (Secondary Gastrectasis) , due to pyloric obstruction. In this class the actual muscular strength of the stomach is often increased, but owing to the narrowing of the exit there is a relative motor insufficiency. Under this head are included such matters as pyloric carcinoma, cicatricial stenosis of pylorus or duodenum, pyloric adhesions, hypertrophic stenosis, and perhaps some instances of pyloric ulcer with spasm.
On meeting with a case of gastric dilatation, the first necessity is to settle the question of its obstructive or non-obstructive character. In the former case treatment by dieting may be necessary, but it can only be palliative and surgical treatment should be adopted as early as possible.
In dealing with a case of non-obstructive dilatation a clear idea must be gained as to its origin, and in many directions, hygienic and therapeutic, a way may be seen by which some improvement can be quickly effected. The principles of dietetic treatment are plain. In many cases of slighter degree they are easily carried out, and are quickly effective. But the matter is one of much greater difficulty, when with the motor insufficiency there is defective secretion of hydrochloric acid. In such cases, which form the most severe type, the trouble is aggravated by fermentation and development of gas. The treatment of a neurasthenic woman of middle age with slow digestion, some dilatation of the stomach, and a moderate degree of gastroptosis is a most difficult task.
The immediate need is the use of food in minimal quantity and of minimal weight, of such a character that it shall be most easily prepared for intestinal digestion and expelled from the stomach. But there need be no fear of passing the patient if necessary- through a preliminary period of malnutrition, so as to evoke by a period of stomach-rest such natural tendency to recovery as may be possible. And in severe cases a few days of complete rest of body and stomach with the use of rectal saline injections should be the first step.
Food must be of small bulk and weight. Consequently fluids should be cut down to the minimum compatible with comfort, and a pure milk diet which would otherwise be desirable is out of the question. In severe cases it has been recommended that a really dry diet should be adopted, and that the required fluid should be administered per rectum. But a certain quantity of fluid is absolutely necessary in the stomach to ensure fluidity and ready expulsion of digested food, and 20-30 oz. of fluid by the mouth in twenty-four hours, taken in small quantities at a time, is essential for this purpose. Some patients can take less without discomfort. Alcohol should be entirely forbidden. There is evidence to show that its absorption from the stomach is followed by a secretion of fluid into the stomach. No spices or condiments should be allowed. Tea and coffee should be forbidden, as tending to delay digestion. Food should be hot rather than cold, and a temperature of 110-130° F. is safe and useful. Meals should be small and frequent, and in laying down details of the diet it must be remembered that every article should be of maximum nutritive value, and that digested food leaves the stomach in the shortest time if it is readily converted into semi-fluid or pultaceous form. Green vegetables are therefore excluded. If there is evidence to show that gastric secretion is of full value, protein may be freely given, but meat should be finely divided, and so slightly cooked as to be easily digested. Sweetbread and oysters may be given. Raw meat is often of use. If, on the other hand, secretory insufficiency is present, carbo-hydrates in the form most easily digested must form a larger proportion of the diet, notwithstanding their liability to undergo fermentation. Fat is of use, and fresh butter and cream are usually well taken. All food should be taken slowly and with deliberation, so that mouth digestion should have full time, and even in the slighter cases, an hour of complete rest lying down should be taken after the chief meals. A preliminary period of lavage is always necessary, and the result obtained will give a guide as to the necessity of continuing it. Massage, douching and electrical treatment are most useful.
In the first stage of treatment complete rest in bed is advisable. The diet, which allows of some variety, should consist of milk, plasmon, toast, rusks, butter, cream, eggs, raw meat or beef juice and perhaps pounded fish. Considering the great fall in the value of gastric digestion, one may be tempted to use the trade-preparations of peptones or rather albumoses, as calculated to take the place of protein. There is no doubt that such preparations can replace protein in the diet, and that the nitrogen-equilibrium can be so maintained. But though such articles as somatose, Denayer's albumose-peptone mixture, and Carnrick's peptonoids may be used in some cases with advantage (especially when the stay of food in the stomach is so prolonged that decomposition of protein may occur), it is better as a rule to depend entirely on intestinal digestion and to aim at giving such protein-food as shall be quickly discharged from the stomach. Oysters, sweetbread, raw scraped beef, pounded fish and chicken with a few ounces of milk fulfil this requirement.
A diet to supply about 1,500 calories may be arranged as follows :
8 a.m.....Milk (5 oz.) one or two eggs, two pieces of thin toast with butter. 10.30 a.m. . . . Milk (5 oz.) with plasmon (for use cp. gastric ulcer), a rusk, two raw meat sandwiches. 1 p.m.....Milk (5 oz.) fish-cake or fish-soufflee, custard, toast and butter. 4.30 p.m. . . . As at 10.30 a.m.
7.30 p.m. . . . Milk (5 oz.) one or two eggs, toast and butter. 10 p.m.....Cup of arrowroot with cream.
In a later stage the diet may be extended by the addition of chicken panada or soufflee, raw oysters, sweetbread, minced mutton, milk-jelly, potato-puree, other forms of carbo-hydrates, and cocoa. And if the results are favourable, a claret glass of water, plain or aerated, may be allowed at lunch and dinner. The following is an outline of such a diet, which is sufficient for a patient taking light exercise. Rest after the chief meals should still be adhered to.
8 a.m.....Cocoa made with milk, 5 oz. (or milk and plasmon).
One or two eggs (or fish-cake, 1 oz.).
Thin toast, 1 1/2 oz.
Butter, 1/3 oz. 10.30 a.m. . . . Milk, 5 oz.
Raw meat sandwich, 1/2 oz. of meat.
1 p.m.....Milk, 5 oz.
Fish-cake or fish-soufflee, 2 oz. (or oysters).
Chicken panada, 2 oz.
Potato-puree, 1 oz.
Blancmange, 2 oz. (or custard).
Toast, 1 1/2 oz.
Butter, 1/3 oz. 4.30 p.m. . . . As at 10.30 a.m. 7.30 p.m. . . . Milk-soup, 5 oz. (or milk).
Sweetbread, 2 oz. (or minced mutton).
Blancmange and cream, 2 oz. (or grape-nuts).
Toast, 1 1/2 oz.
Butter, 1/3 oz.
Water, 6 oz. .10 p.m.....Arrowroot with or without cream, 6 oz.
The following diet, supplying about 1,600 calories, is recommended by Wegele in gastric myasthenia with reduced secretory activity: -
Morning .... Leguminose cocoa, 150 grms.
Cream, 50 grms. Forenoon . . . One soft egg.
Toast, 20 grms. Noon .... Scraped beef-steak, 100 grms.
Mashed potato, 200 grms.
Malt extract, 20 grms. Afternoon . . . Leguminose cocoa, 150 grms.
Cream, 50 grms. Evening . . . Tapioca pulp, 250 grms.
Diastase malt extract, 15 grms. During the day . Toast, 50 grms. 10 p.m.....Milk, 200 grms.
Cognac, 10 grms.
Finally, in the stage of convalescence and for long thereafter, the diet must be simple and spare, and the meals small and slowly eaten. The amount of fluid should be kept in check, 30 oz. being an ample allowance in the twenty-four hours in most cases, 40 oz. being the outside limit.
In the non-obstructive form of dilatation we are concerned mainly with the ensuring of quick emptying of the stomach, and we rest content with intestinal digestion. But in the obstructive form, whatever may be the cause of the pyloric stenosis, our object is to ensure the greatest absorption of food products in the stomach itself. Here peptonized and predigested foods find their chief use. Peptonized milk, somatose, panopepton, Benger's peptonized beef-jelly, Valentine's meat-juice, maltine, and many other preparations are useful. The non-fermentable lactose should be substituted for other carbo-hydrates, and 1/2 oz. of it can be given in 8 oz. of milk. But dietetic treatment in this condition should only be a temporary measure pending operation.