The uncertainty of the anatomical diagnosis of dilatation of the stomach in some cases makes it all the more necessary, as has been repeatedly urged in the course of this article, to make a careful study of the evidences of disordered gastric functions. The symptoms of most importance in determining whether the condition called insufficiency of the stomach is present or not are fermentation of the gastric contents and the persistent presence of undigested food in the stomach beyond the limits of normal digestion. It is true that these symptoms may be present without any dilatation of the stomach, but they are likely to lead to dilatation if unchecked, and, what is of practical importance, they require essentially the same treatment as dilatation.
A differential diagnosis between chronic catarrhal gastritis and atonic dyspepsia on the one hand, and the early stages of dilatation of the stomach on the other, cannot be made with any positiveness.
Of course, with our present means of diagnosis the confounding of dilated stomachs with ascites, ovarian cysts, pregnancy, hydatid cysts (of each of these errors there are recorded instances), is inexcusable.
PROGNOSIS AND COURSE.—The prognosis of dilatation of the stomach depends first of all upon the nature of the primary disease causing the dilatation. The prognosis of cancerous dilatation is as unfavorable as possible. In dilatation due to non-cancerous stenosis the prognosis is in general more favorable. Life may be prolonged sometimes for many years, and the patient's condition greatly benefited by proper treatment. A permanent cure of stenotic dilatation is not impossible, but it is rarely to be expected. Even if temporarily relieved, the symptoms of dilatation are likely sooner or later to return and to lead to a fatal termination. The progress of the disease depends upon the degree and the stationary or advancing character of the stenosis. In the article on GASTRIC ULCER mention has been made of the cure of a few cases of desperate gastric dilatation due to cicatricial pyloric stenosis by means of resection of the diseased pylorus.
In general, the prognosis is more favorable in dilatation without stenosis. If the degree of dilatation be only moderate, a permanent cure may often be effected by proper treatment. If, however, the dilatation be considerable, while the symptoms may be relieved or even made to disappear for a time, relapses are prone to occur, and a permanent cure is rarely obtained. Undoubtedly, Kussmaul's publication in 1869, in giving to us a most valuable method of treatment, at the same time raised extravagant expectations of the frequency with which dilatation of the stomach can be cured. Too often the treatment with the stomach-tube proves only palliative and not curative.
The course of dilatation of the stomach is chronic. The mode of death is usually by inanition, very rarely from rupture of the stomach.
TREATMENT.—Reference to the causation of dilatation of the stomach will show that there is considerable scope for the prophylactic treatment of dilatation not referable to stenosis or incurable organic disease. Thus, the correction of the habits of eating or drinking inordinate quantities, or of imperfectly masticating the food in consequence of haste or bad teeth or vicious custom, may avert the development of gastric dilatation. Of especial importance is the timely treatment of cases of dyspepsia or of chronic catarrhal gastritis which are accompanied with fermentation or delayed digestion—conditions in which the stomach-tube is of great service.
Of the means at our disposal for meeting the causal and the symptomatic indications of dilatation of the stomach, the most important by far is the use of the stomach-tube for the purpose of emptying and of washing out the stomach. The introduction of this procedure by Kussmaul in 1867 marked a new era in the treatment of gastric disorders.
By washing out the stomach we accomplish three important things: first, we remove the weight which helps to distend the organ; secondly, we remove mucus and stagnating and fermenting material which irritates and often inflames the stomach and impedes digestion; and, thirdly, we cleanse the inner surface of the stomach and obtain the beneficial influence of the direct application of water, to which various medicinal substances can be added. It is probable that in removing the fermenting contents of the stomach we also remove a possible source of self-infection of the system (see page [596]).
By accomplishing these things we may possibly also enable the stomach to regain its lost elasticity and muscular contractility. But unless the normal elastic and contractile powers of the stomach are restored, the treatment with the stomach-tube, indispensable as it is for the relief of symptoms, is only palliative and not curative. Whether or not this restoration of the stomach to its normal functional activity is to be expected depends chiefly upon the cause and the degree of the dilatation. Unfortunately, as has already been stated under Prognosis, the permanent cure of dilatation of the stomach due to organic stenosis, although possible, is not to be expected, and the number of cases in which largely dilated stomachs can be restored to their normal volume or made to perform permanently their normal functions is small. There remains, however, a considerable number of curable cases—to be sure, not always easily diagnosticated—in which the muscular coat of the stomach has not been seriously damaged and in which the dilatation is generally only moderate. Furthermore, excellent results are obtained by the use of the stomach-tube in the cases which have been designated insufficiency of the stomach, and which are closely allied to dilatation—in fact, often represent its early stage. As has already been mentioned, the most important criteria of this so-called insufficiency are the fermentation of the contents of the stomach and the presence therein of undigested food after the period required for normal digestion (six to seven hours for an ordinary meal).