It is unnecessary here to repeat the causes of acute gastritis, any
one of which continued over a long period of time will cause chronic
catarrh of the stomach, as it is sometimes called.
Spinal and rib lesions anywhere from the occiput to the coccyx, but
more particularly from the fourth to the tenth dorsal, will predispose
to chronic gastritis, the particular type and degree of local pathology
depending upon the exciting factor.
A commonly found _en bloc_ lesion is a flattening of the normal
convexity in this region, with more or less immobilization, shown by
attempting to reestablish the normal convexity through flexion.
In addition there may be single spinal or rib lesion in the same area,
or cervical lesions affecting the pneumogastric, which is the secretory
nerve to the stomach. (See chapter on the “Lesion and Its Applied
Anatomy.”)
=Pathology.=—Chronic gastritis probably never develops as such without
going through several preliminary stages beginning with alimentary
hypersecretion, or hypersecretion occurring only during the active
period of digestion. These are the cases usually classified as
hyperchlorhydria. At this time no actual pathology can be demonstrated
in the glandularis.
If the condition is not treated intelligently at this time the next
step will be periodic attacks of what is known as “hypersecretion
periodica chronica” followed by “hypersecretion continua chronica.”
The stomach contains abnormal amounts of gastric juice even after a
night’s rest. At this stage there is a transition from the functional
to the organic condition. All stages are characterized by an abundant
secretion of mucus.
If allowed to go on there will finally result a destruction of the
secreting cells known as Atrophic Gastritis or Achylia Gastrica in
which the stomach presents a smooth functionless appearance.
=Secondary Chronic Gastritis.=—Portal obstruction from any cause
predisposes to chronic gastritis. The most common of these is failing
compensation in heart lesions, which through back pressure causes
portal stasis; the same thing may follow obstruction in the liver
itself. Chronic gastritis is also a late accompaniment of the nephritic
trinity, kidneys, heart and arteries. It may also be associated with
diabetes, gout, anemia and other constitutional disorders.
Tuberculosis is commonly ushered in by symptoms of chronic gastritis.
We should be constantly on the alert to avoid the mistake so commonly
made of treating the stomach as an entity and overlooking the real
trouble in some other part of the anatomy.
It is probably safe to say that there are only two primary diseases of
the stomach, ulcer and cancer. All others are suspiciously associated
with diseased processes elsewhere, and when the spinal lesion is given
its full significance even these will be found to be directly traceable
to anatomical perversions somewhere within the mechanism of local
nutrition.
=Symptoms.=—These are governed by the stage of progress in which the
patient is seen. During the stage of hypersecretion of acid gastric
juice there will be vague feelings of distress, fullness and burning
in the stomach, and “heartburn” during digestion. When the stomach is
empty all symptoms will subside. Later there will be periods of a few
days or weeks when there will be more or less continuous distress with
some vomiting of highly acid gastric juice containing mucus.
When the condition has progressed to the stage of continuous
hypersecretion there will be continuous symptoms as above, but with
nausea, vomiting becoming more frequent especially late at night or in
the morning, always accompanied by sticky mucus.
Appetite is variable, there is often a disagreeable taste in the mouth
(the “dark brown” taste of the chronic alcoholic). Heart palpitation
and vertigo and other vagus symptoms are common.
=Diagnosis.=—On physical examination the stomach is found distended,
and in some cases displaced (gastroptosis). There will be diffused
tenderness on pressure over the whole organ which should help to
distinguish it from gastric ulcer or cancer in which the tenderness is
quite localized.
Chronic gastritis cannot be =positively= diagnosed without making a
gastric analysis. Many cases are wrongly diagnosed through neglect of
this very important procedure.
The cases in which gastric analysis should be made are so well stated
by Lockwood that we will take the liberty of quoting them in their
entirety.
“(1) Gastric analysis should always be made in every case of dyspepsia,
no matter whether these symptoms be apparently gastric or intestinal,
unless passage of the tube is contraindicated.
“(2) Gastric analysis should be made in every case of chronic diarrhea
that is not due to evident disease of the colon or rectum.
“(3) Gastric analysis should always be made in all cases of intestinal
toxemia, or recurring headache of toxic origin, and in patients who
complain of the symptom complex which is spoken of by the laity as
‘biliousness’.
“(4) Gastric analysis should be made in all cases of anemia and general
physical wretchedness without known cause and which are rebellious to
treatment.”
The finding of excessive gastric mucus intimately mixed with food
remnants is the chief differential point in the diagnosis of chronic
gastritis.
=Differential Diagnosis.=—A complete statement of differential
diagnosis by Kemp cannot be well improved upon.
“CHRONIC GASTRITIS.—No severe pain, no circumscribed spot, painful to
pressure; no hematemesis; no cachexia; no marked emaciation, except in
severe cases of long duration; free hydrochloric diminished or absent;
gastric mucus present; slow course.
“ULCER OF THE STOMACH.—Hyperchlohydria present, but not invariably
so; severe pain in the epigastrium with intervals free from pain when
stomach is empty; local tenderness which is circumscribed; dorsal
pain; hematemesis, or occult blood in the stool or gastric contents;
microscopic pus; no mucus; patient has appearance of suffering; no true
cachexia.
“CANCER OF THE STOMACH.—Age usually over forty-five; rapid course;
free hydrochloric acid usually markedly diminished or absent; lactic
acid present; pain generally continuous, but not so acute as in ulcer;
Boas-Oppler bacillus; cachexia; tumor on physical examination; small
amount of visible or occult blood; hematemesis much less than ulcer;
foul odor to vomitus at times present.
“ACHYLIA GASTRICA.—Slow course; scarcely any gastric juice; acidity
very low or entirely absent; absence of pepsin and rennin; usually no
mucus or lactic acid.
“These differential considerations apply to typic cases, and
the observer must be on the qui vive for various gradations and
modifications of these clinical pictures.”
=Prognosis.=—The outcome of chronic gastritis depends upon our ability
to locate and remove every factor in the etiology, the willingness
of the patient to cooperate and the patience and resourcefulness
of the physician. At best the progress is slow and one must expect
temporary setbacks usually due to failure of the patient to carry out
instructions.
=Treatment.=—The most successful treatment is prophylactic, but until
the public has been educated up to this form of economy we must begin
with conditions as we find them.
First get the patient’s confidence by making an intelligent
examination, a scientific diagnosis, and a reliable prognosis based
upon your findings. All lesions, bony, ligamentous, muscular and
psychic must be intelligently and carefully removed.
Specific lesions which would directly or reflexly interfere with the
nerve and blood to the stomach must be corrected.
The rigidness commonly found in the vertebræ and ribs of the splanchnic
area must be overcome first by specific adjustment, and the normal
flexibility maintained by teaching the patient proper exercises for the
purpose. This should include deep breathing with the spine flexed to
the limit, and the ribs fixed, by the patient reaching around as far
as possible and grasping the ribs as described by Dr. Harry Forbes.
This will tend to overcome the flat dorsal so characteristic in all
gastro-intestinal conditions.
Direct manipulation over the stomach has no particular value and may be
even harmful.
Inasmuch as nausea and vomiting and excessive gas formation are only
the result of hypersecretion we cannot expect to give more than
temporary relief except by methods which remove causes. Much comfort
may be given by inhibition in the splanchnic area. In severe cases
it may be necessary at times to wash out the fermenting, irritating
mass by gastric lavage. Outdoor life, frequent vacations and change of
occupation are often of decided benefit.
=Diet.=—Indiscretions of diet must be avoided and this cannot be too
positively impressed upon the patient. It is always best to make a list
of foods to be taken for breakfast, lunch and dinner and insist that no
other foods be taken without further instruction.
Just what these foods shall be depends upon the gastric secretions as
shown by gastric analysis. They should always be nutritious and given
in quantities sufficient to maintain nutrition.
The stomach should have rest and yet is expected to do its part in
the process of digestion. All foods must be given in a finely divided
form and well masticated to spare the stomach the mechanical effort of
grinding.
In hyperacid gastritis all foods of an irritating nature must be
positively prohibited. The classical breakfast of grapefruit, oatmeal,
ham and eggs and coffee will not do. Starchy foods must be reduced
owing to their tendency to ferment in the presence of highly acid juice
and the delay in the stomach due to the high acidity.
In subacid gastritis advantage must be taken of the fact that
carbohydrates digest well and proteins do not.
=Diet for Hyperacid Gastritis.=—Before breakfast: Wash the stomach with
warm water and an ounce of Phillips Milk of Magnesia, allowing the
water to remain in the stomach 20 minutes or a half hour, lying down
and turning from side to side on the face in order that the water and
magnesia may be brought in contact with all parts of the stomach.
For breakfast: Prunes, allowed to simmer for four hours, without
boiling, and put through a colander, to remove the skins. Soft cereals,
such as farina, cream of wheat, or wheatlet, thoroughly cooked, and
served with middle heavy cream, no sugar. Two eggs, soft boiled, or
poached. Zweiback, thoroughly masticated, with a liberal quantity of
butter. Cocoa (Phillips).
Luncheon: Puree of peas, beans or lentils, made with cream. Asparagus,
green peas, boiled rice, spinach chopped very fine, creamed carrots,
boiled onions, baked potato, well done. Chicken, boiled lamb or beef,
ground; oysters in any form but fried; fresh fish. Desserts: Choice of
junket, cornstarch, custard, rice pudding, floating island, gelatine or
tapioca.
Evening meal: Same as luncheon except substituting eggs for meat.
Cup of hot water before luncheon and dinner.
If patient requires quick building up give milk between meals and at
bed-time.