this reason it has become the custom of late years to describe it as
gastric {464} catarrh. This may be objectionable, for the reason that
it does not include gastric inflammation of every grade of intensity.
The term catarrh is generally applied to much more simple anatomical
structures than those pertaining to the stomach. We shall consider the
subject therefore under two forms--namely, (1) Catarrhal; (2)
Erythematous gastritis.
ETIOLOGY.--Certain conditions predispose to the disease. Acute
catarrhal gastritis is specially liable to occur in those who
habitually suffer from a disordered stomach. This may arise from
functional disturbance of the digestive process on the one hand, or
mechanical obstruction on the other. Mechanical causes are widespread
in their influence. Thus, weak heart-action from any cause tends to
disturb the normal adjustment between the two sides of the
circulation--arterial and venous. An abnormal amount of blood
accumulates on the venous side of the circulation, and chronic passive
hyperæmia of the abdominal viscera is the result. The effect of this
upon the stomach is to lower its functional activity and to invite
inflammatory action. The same condition results from structural
diseases of the heart, lungs, or liver. Persons suffering from valvular
diseases of the heart, emphysema of the lungs, or cirrhosis of the
liver are strongly predisposed to diseases of the stomach. Gastric
troubles are also apt to supervene during the progress of various
diseases.
Gouty and rheumatic persons are specially prone to suffer from gastric
catarrh; and eruptive disorders, such as scarlatina, diphtheria, etc.,
tend to erythematous forms of gastric inflammation. Catarrhal gastritis
is also a very common sequence of the whole class of malarious fevers,
including yellow fever, intermittents, and remittents. In its more
acute form gastric inflammation supervenes in the course of yellow
fever; and what is observed here in an extreme degree exists in a minor
degree in all the so-called malarious fevers. Intermittent and
remittent fevers are always attended with gastro-duodenitis and
gastro-hepatitis. The degree of this inflammatory complication
determines the continued character of the fever. Upon this point the
writer has very decided views based upon a wide field of observation in
malarious regions of country. We have lost ground in the treatment of
these diseases by directing our attention almost exclusively to the
febrile and malarious, to the exclusion of the inflammatory, elements.
Quinia is inoperative in the cure of these troublesome and often fatal
complications. Indeed, it is more than that: it is often positively
injurious. Arrest the local phlegmasia and secure freedom of abdominal
circulation, and we at once get the action of the specific remedy. It
may be going too far to affirm, as did Broussais, that gastritis
sustains a causative relation to all forms of fever, but that
gastro-duodenitis is an important secondary condition in all forms of
malarious fever, complicating and perpetuating the febrile state, there
can be no doubt; and it is equally clear that it constitutes one of the
most dangerous complications. Excessive alimentation, with the
injudicious use of tonics and stimulants, so often resorted to in the
treatment of these fevers in their early stages, only serves to
intensify the local inflammation. Abolish the congestive and
inflammatory element of a remittent, and it at once becomes an
intermittent.
Mention has been made of weak heart-action as a factor in catarrhal
{465} gastritis; also mechanical impediments to the return of blood
from the stomach to the heart. The stomach is thereby kept in a
constant state of congestion, the nutrition of the mucous membrane is
less active than in health, and its solvent juices are more sparingly
secreted. Thus in long-continued congestion produced by mitral disease
of the heart Samuel Fenwick found the formation of pepsin impaired. He
made artificial gastric juice from the mucous membrane of three males
dying of heart disease, and he found, on the average, only 2-9 grs. of
albumen were dissolved, whereas the amount digested by the mucous
membrane of persons who had died of other maladies was 4 grains. In the
cases of three females a still smaller amount of solvent power was
displayed. These facts have important bearings upon the question of
alimentation in fevers and the conditions in which there is chronic
congestion on the venous side of the circulation. Long-continued
passive hyperæmia of the stomach from any cause not only impairs its
functional activity, but strongly predisposes to inflammatory
complication.
Acute erythematous gastritis is most frequently met with in children.
It is a very common form of disease in early life, and the local nature
of the malady is frequently overlooked. Few questions in practical
medicine are more embarrassing to the physician. It has been known and
described as gastric and remittent fever, as continued typhoid, and
even as acute hydrocephalus. Writers and teachers describe and
dogmatize, while practical men hesitate at the bedside. There is little
doubt but in the background of these febrile manifestations in children
there is often an acute erythematous gastritis, which is more
successfully treated by a rigid milk diet, small doses of calomel and
bismuth, mucilaginous drinks, cooling saline laxatives, and sometimes
leeches applied to the epigastrium, than by the heroic doses of quinia
so frequently resorted to.
We must not, in this connection, lose sight of the fact, so clearly
pointed out by Broussais, that inflammation of the stomach is often
secondarily repeated in the brain. The whole field of clinical
observation abounds in illustrations of this. How often, for instance,
we can trace the sick headache, the delirium, and even convulsive
movements of the voluntary muscles, to primary gastro-intestinal
irritation! In the play of the sympathies morbid irritative action is
transmitted from the organic to the cerebro-spinal nerves; and of all
portions of the abdominal viscera the stomach and upper portion of the
intestinal track are the most frequent seat of these intense morbid
sympathies. Remedies which cool the stomach and lessen inflammatory
action diminish the excitement of the brain, and vice versâ.
EXCITING CAUSES.--Among the direct exciting causes of gastric
inflammation--exclusive of acrid or corrosive poisons--the most
frequent in this country is the excessive use of alcohol. It acts most
injuriously when it is but slightly diluted and taken on an empty
stomach. And next to this pernicious habit, in the order of importance,
is the use of large quantities of food--more than the stomach has
capacity to digest, and more than is necessary for the wants of the
system. Excessive alimentation is a prolific source of gastric
inflammation. It generally manifests itself, however, in a chronic or
subacute form.
Acute erythematous gastritis, so frequently met with in children, is
{466} often present in scarlatina. It is evidently not catarrhal in
character, for in the earlier stages there is no increased secretion of
mucus and but little injection of the mucous membrane. The changes are
observed in the deeper structures of the stomach, and principally in
the gastric tubules. They are much distended by granular, fatty, and
albuminous matter; and in this respect it is analogous to erythematous
affections of the skin with which it is associated in scarlatina.
Finally, acute gastric catarrh may be excited by all causes that weaken
the digestive power either by weakening the gastric juice or by
retarding the movements of the stomach.
ANATOMICAL CHARACTERS.--No disease requires more knowledge and caution
in determining post-mortem changes than those of the stomach. In the
first place, it presents in inflammatory conditions markedly different
degrees of intensity, with corresponding differences in anatomical
changes. Its diseases also present many special forms, and changes take
place after death which simulate morbid processes during life.
Moreover, intense vascular injections are apt to disappear in the small
superficial vessels after death. This applies to all mucous membranes,
but specially to the mucous membrane of the stomach, which is the seat
of varying amounts of blood in their physiological limits during life.
For this reason the observations of Beaumont made upon a living subject
are invested with peculiar interest. It will be remembered that in the
case of Alexis St. Martin the appearances noted were such as belong to
the milder forms of inflammation. Beaumont noticed in this case, after
indiscretions in eating or abuse of ardent spirits, a livid
erythematous redness of the gastric mucous membrane, with, at the same
time, dryness of the mouth, thirst, accelerated pulse, and, at the
height of the injection, an entire absence of gastric secretion. At
other times there was considerable muco-purulent matter, with oozing of
grumous blood, "resembling the discharge from the bowels in cases of
chronic dysentery." The fluid taken out through the fistulous opening
consisted mostly, however, of mucus and muco-pus which showed an
alkaline reaction. He describes also a condition of ecchymosis and
oozing of blood from certain red spots of the gastric mucous membrane,
and when thus limited the constitutional symptoms experienced by the
patient were correspondingly slight. Ecchymoses may be present in large
number, with exudates of false membrane, which Beaumont describes as
aphthous. Brinton also describes a severe form of gastritis which he
terms ulcerative, in which he observed hemorrhagic erosions.
In the catarrhal form of gastritis the mucous membrane is covered with
a thick, tenacious, stringy mucus; it is softer than usual, and
generally thickened. It presents at the same time a dead-white
appearance, corresponding to Virchow's cloudy swelling--a condition
analogous to that which is observed in acute Bright's disease. Even
casts of the tubes are sometimes met with.
This inflammatory change in the substance of the mucous membrane is
especially observed in the acute erythematous form of gastritis
complicating scarlatina. In the early stage there is no increased
secretion of mucus, and at a more advanced stage the membrane may be
even paler than usual.
In cases of acute toxic gastritis intense redness is seen over the
entire {467} surface of the mucous membrane, followed by rapid
exudations and sloughing of portions of the membrane.
In all forms of the disease there is a tendency to extension of the
inflammation into the duodenum and small intestines. In the more
chronic forms we almost invariably encounter the condition of
gastro-duodenitis.
SYMPTOMS.--The symptoms of inflammation of the stomach present wide
differences in their intensity, depending upon the degree of severity
in different cases. In acute inflammation caused by the direct action
of poisonous irritants they are pronounced and highly diagnostic. The
patient immediately complains of burning pain, referred to the
epigastrium, followed by intense thirst and vomiting. The thirst is apt
to be very great and the act of vomiting painful. The vomited matters
contain mucus, saliva, sometimes bile, and not unfrequently, in fatal
cases, black, grumous, coffee-ground material. There is marked
tenderness on pressure, the pulse is frequent and small, coldness of
the surface is marked, and hiccough is apt to occur. The expression of
the patient is anxious, the abdominal muscles rigid, and, in fatal
cases, the prostration becomes rapidly extreme. The patient dies by
asthenia. These symptoms apply to acute cases of marked severity,
usually of toxic origin.
In the milder forms of catarrhal gastritis more frequently met with
there is seldom complaint of pain. The sensation is rather that of
fulness, uneasiness, with more or less tenderness on pressure. The
symptoms are such as belong to acute indigestion and the embarras
gastrique of French authors. The phenomena may be those of a slight
bilious attack. The tongue is foul, the breath offensive, the bowels
confined, and the urine high-colored and scanty. There is also
generally a sense of fatigue, and soon secondary cerebral symptoms
supervene, such as cerebral hyperæmia, headache, vertigo, noises in the
ears, palpitation, sighing, yawning, dyspnoea, faintness, and in severe
cases marked physical and mental depression. Nausea and vomiting are
common, and if the inflammation extends to the duodenum and liver,
symptoms of gastro-hepatic catarrh manifest themselves. If fever
supervenes, urticaria sometimes complicates these attacks.
In young children the inflammation is apt to involve a general catarrh
of the whole intestinal track. Thirst is excessive, followed by
vomiting and diarrhoea. The discharges are liquid, watery, offensive,
acid, and out of all proportion to the amount of fluid absorbed by the
stomach. The pulse becomes weak and fluttering, the skin pale, the
features pinched, the eyes sunken, and the extremities cold. The
tendency is toward rapid collapse and fatal issue. The symptoms
describe what is usually known as cholera infantum. It has its analogue
in the cholera morbus of adults.
In erythematous gastritis nausea and vomiting are as general as in the
catarrhal form, but, unlike the catarrhal, pain at the epigastrium is a
prominent symptom. It comes on directly after taking food. In
phthisical cases the sensation is rather that of rawness of the
oesophagus and stomach. Thirst is a troublesome symptom; the tongue is
red or dry and glazed; tenderness of the epigastrium is marked;
diarrhoea is generally present; and, as in the catarrhal form, the
stools are fetid and unhealthy. The disease shows a marked tendency to
become chronic.
{468} DIAGNOSIS.--In the more acute forms of the disease the symptoms
are all highly diagnostic. Vomiting, burning pain of the stomach,
tenderness on pressure, intense thirst, with frequent and small pulse,
point with almost unerring certainty to acute gastric inflammation. But
vomiting of itself, however persistent, is not evidence of gastritis,
for it may be present from many other causes. If the vomiting be
attended by headache, it may be confounded with gastric irritability
from brain disease. Thus, chronic meningitis with persistent vomiting
strongly simulates gastritis, and in the case of children it is liable
to be mistaken for it. In gastritis the nausea is from the first a
pronounced feature of the disease. Vomiting in affections of the brain
is often unattended by nausea. In gastritis the tongue is more
frequently coated or red and glazed. Diarrhoea is also more frequently
present, especially in early life. In affections of the brain the
tongue may be clean and the bowels are usually obstinately confined.
When there is much fever, gastritis may be confounded with remittent or
typhoid fever. In periods of childhood this mistake is specially liable
to occur, for there are many symptoms in common. In all such cases the
early history of the case ought to be carefully inquired into. In
gastritis we may be able to detect the cause in any particular case.
The gastric symptoms are apt to occur suddenly, and, as already stated,
are prominent from the first. In meningitis the skin is more frequently
dry; in gastric catarrh perspirations are common. The more prominent
and characteristic symptoms of typhoid should also be carefully
excluded, such as the gradual invasion, peculiar eruption, bronchial
catarrh, enlargement of the spleen, gurgling in the right iliac fossæ,
with tympanitic abdomen. Peritonitis, with vomiting, may be mistaken
for gastritis, but the diffuse tenderness, the fixedness of position,
the rigidity of the abdominal muscles, and the tympanitic distension
serve to guide us in our diagnosis.
PROGNOSIS.--The prognosis must have reference to the cause. The more
violent forms of the disease resulting from corrosive poisons are
generally fatal. Death is apt to take place in a few hours from a
condition of collapse. The immediate cause of death is failure of
heart-action. It is also a dangerous disease in the extremes of life.
In its acute form in children it is apt to terminate fatally,
especially if it is not recognized early and judiciously treated. The
complications of the disease may also render the prognosis unfavorable.
Milder cases tend to recovery.
TREATMENT.--The most important indication of treatment, applicable to
all forms of gastric inflammation, is to secure complete or partial
rest for the inflamed organ. In dangerous cases no food should be taken
into the stomach. The patient should be nourished exclusively by
nutrient enemata. If food is permitted, it should be restricted to milk
and lime-water, administered in small quantities at short intervals. In
acute and dangerous cases, suddenly manifesting themselves, the
exciting cause should be carefully inquired into, and speedily removed,
if possible, by an emetic, or, if need be, by the stomach-pump, if the
poison be one which can be ejected; and following this antidotes are to
be administered according to the nature of the poison.
To allay the intense thirst small pieces of ice should be swallowed at
frequent intervals, or, what is often more grateful to the patient,
iced {469} effervescing drinks in small doses oft repeated. Injections
of water may also tend to relieve thirst. To allay vomiting the
physician is often tempted to try a great variety of remedies which are
usually worse than useless, for they aggravate rather than relieve the
distressing symptom. For the purpose of quieting the stomach opium is
the most reliable remedy we possess. It is best administered
hypodermically. Fomentations may be applied over the epigastrium.
Stimulants are, of course, contraindicated on account of their
irritating action on the inflamed membrane, but in case of rapid
tendency to death by failure of heart-action they should be
administered by the rectum or hypodermically.
In milder cases--which are much the more common--physiological rest of
the organ is also a cardinal principle of treatment. Rest of the body
is equally essential. In cases of any severity the patient should be
kept quiet in bed. For the condition of acute indigestion known as
embarras gastrique ipecacuanha in six- or eight-grain doses, given
three times within twenty-four hours, will often produce healthy
bilious stools, and in this manner accomplish the cure. One or two
grains of calomel may be added to each dose of ipecacuanha with
benefit. In all forms of catarrhal gastritis, especially if symptoms of
portal congestion are present, mild mercurial cathartics are attended
with benefit. Six or eight grains of calomel may be rubbed up with
sugar of milk and placed dry on the tongue, followed by a cooling
saline aperient. When diarrhoea is present in such cases, it should be
regarded as conservative, and encouraged by the administration of
half-grain or grain doses of calomel, combined with bismuth and
bicarbonate of soda. The diet should be restricted to milk and
lime-water or milk mixed with Vichy or Seltzer water. Demulcent drinks
should be freely given. In the slighter attacks effervescing drinks are
grateful to the patient; and if there be excessive formation of acid in
the stomach, antacids and sedatives should be administered.
Bismuth has a peculiar sedative and antiseptic effect in the milder
forms of inflammatory action of mucous membranes. It is especially
valuable in gastro-intestinal troubles of children. Its action is
mainly local surface action, and may therefore be given in liberal
doses if necessary. Children may take from five to ten grains, and
adults twenty grains or more. Hydrocyanic acid adds to its sedative
qualities, or when pain is present, with diarrhoea, opium in some form
may be added. The salicylate of bismuth is specially indicated when we
want to add to the antiseptic qualities of bismuth.
The general principles of treatment indicated here are applicable to
the so-called remittent fevers of children--namely, calomel in small
doses, combined with bismuth and bicarbonate of soda, followed by
occasional cool saline laxatives. Ipecacuanha is also a valuable agent
in correcting morbid gastro-intestinal secretions. When there is early
epigastric tenderness, with hot skin and elevation of temperature, two
or three leeches should be applied to the epigastrium, followed by warm
poultices of linseed meal. Dry cupping may also be used with benefit;
and if decided remissions occur, with suspicions of a complicating
malarious element, a few liberal doses of quinia may be tried. In many
such cases, however, it will be found unnecessary, and not unfrequently
hurtful. In acute gastro-intestinal inflammations of children--the
{470} temperature reaching 105° or more--no febrifuge, in the opinion
of the writer, is equal to the cool or cold bath, repeated from time to
time until there is a decided reduction of temperature. But the gastric
inflammation, rather than the fever, should mainly claim our attention.
Great care is necessary during convalescence from acute gastric
disease, particularly as regards the hygienic management. The apparent
debility of the patient too often tempts the physician to the early and
injudicious use of tonics, stimulants, and excessive alimentation,
which, if persisted in, can scarcely fail to perpetuate a chronic form
of inflammatory action.
Chronic Gastritis (Chronic Gastric Catarrh).
There is perhaps no malady more frequently met with than chronic
gastric catarrh, and none more frequently misunderstood. It comprises
many different forms of gastric derangement, which are grouped under
the general head of inflammatory dyspepsia, with many symptoms strongly
simulating ordinary functional dyspepsia. It includes, in the author's
opinion, a large number of cases of obstinate chronic dyspepsia, which
are badly managed because not recognized as of inflammatory origin.
ETIOLOGY.--In a more or less chronic form it is frequently met with as
a result of the acute affections. Hence the etiology is mainly that of
acute gastric catarrh. It may be caused--
1. By functional disorders of the stomach.
2. By mechanical causes which interfere with the portal circulation.
3. In connection with certain constitutional states, such as gout,
rheumatism, phthisis, renal disease, certain eruptive diseases, and as
a sequence of malarious fevers.
4. By the excessive use of alcohol and other gastric irritants.
5. By errors of diet, especially excessive alimentation.
6. By decomposition of ingested aliment owing to deficiency of gastric
juice.
7. By all causes that weaken the digestive power and lower the general
tone of the system.
Of all these causes, errors of diet are most apt to produce it, and to
perpetuate it when once established. And next to this, in the order of
importance, is the immoderate use of alcohol, especially by persons
whose general health and digestive power are below a healthy standard.
Such persons are apt to suffer from irritative and inflammatory forms
of dyspepsia, which, in various degrees of intensity, alternate with
the acuter forms of embarras gastrique.
The injudicious use of drugs may also be mentioned. There can be no
doubt that many transient and functional forms of indigestion merge
into the more chronic inflammatory forms of dyspepsia from the abuse of
stimulants, tonics, and purgatives. Anxious for relief, and urged on by
hope of recovery, the victims of functional dyspepsia are apt to have
recourse to every grade of quacks and to be subjected to every form of
harassing and mischievous treatment. Indeed, the use of potential and
irritating drugs, administered for all kinds of ailments, real or
imaginary, enters largely into the etiology of chronic gastric catarrh.