{471} such as offer impediment to the return of blood from the stomach
to the heart. In acute cases the congestion may be very intense.
Congestion of the same kind, but more gradual in its occurrence and
less in degree, may be present from all conditions affecting the
circulation of venous blood through the liver. General anæmia, by
producing weak heart-action, disturbs the normal adjustment between the
arterial and venous sides of the circulation. Blood accumulates in the
veins and capillaries, and morbid action propagates itself in a
direction contrary to the circulation. Hence in all conditions of
general anæmia there is tendency to dyspnoea, pulmonary oedema,
bronchorrhoea, special forms of liver disease, gastric catarrh, and
even temporary albuminuria. All mechanical obstructions to the free
transit of blood through the heart, lungs, or liver are followed by the
same results. A free secretion of mucus into the stomach is one of the
most commonly recognized. It is often vomited in large quantities. This
alkaline mucus, while it dilutes the digestive juices of the stomach,
furnishes favorable conditions for the development of low
micro-organisms, which contribute to the fermentative process. We may
not duly estimate the effects of these organisms on a mucous membrane
softened by long-continued passive hyperæmia.
Malarious fevers, from their congestive tendency, give rise to the more
acute forms of gastro-enteric inflammation. In the more chronic forms
of intermittent and remittent fevers more or less gastric inflammation
is invariably present. Indeed, in all forms of fever gastric
inflammation is a complicating element, and the recognition of the fact
has an important bearing on the treatment.
Certain constitutional diseases appear to involve special liability to
this affection, such as scrofula, phthisis, gout, rheumatism, syphilis,
and many chronic forms of skin disease; and in many cases the cause is
not apparent.
ANATOMICAL CHARACTERS.--The gross appearance of the stomach in chronic
gastritis is thus admirably described by Broussais, who faithfully
recorded what he "observed during many years in the bodies of those who
have long suffered from distaste for food, nausea, and vomiting." These
observations were made long before morbid anatomy had thrown much light
on the more minute structural changes of organs, and the general
picture will be recognized as faithful to-day: "Softening, friability,
and the reduction into a kind of gelatinous mass commonly occurs in the
region of the lower part of the larger curvature of the stomach; and
when closely examined it is perceived that it is not only the mucous
membrane that has undergone that species of decomposition, but that the
muscular has participated in it, and that the whole of the cellular
tissue which united the three membranes has entirely disappeared. The
parietes of the viscus are then reduced to a very thin lamina of serous
membrane, commonly so fragile as to tear on the slightest handling, or
even already perforated without any effort on the part of the
anatomist. The pyloric region, on the contrary, has manifestly acquired
more consistence and thickness; the mucous membrane there presents
large folds, the muscular appears more developed, and the cellular and
vascular are injected; sometimes even a true scirrhous state is
observed there. The portion of the mucous membrane which covers this
scirrhus is sometimes {472} ulcerated, but that in the surrounding
parts and at the border of the ulcer, far from being softened, is, on
the contrary, tumefied, indurated, and injected. Finally, though there
may or may not be ulceration of the pylorus, it is always manifestly
hypertrophied, whilst the lower part of the great curvature is the seat
of softening and atrophy."
These were the observations of the great anatomist apparent to the
naked eye. At the present time we can only confirm them by stating that
structural changes are particularly noticed in the pyloric region of
the stomach. The mucous membrane generally is vascular and covered with
a grayish, tough, transparent mucus. It is more opaque and thicker than
natural. The surface is usually changed in color: it may be red, brown,
ash-gray, slate-colored, or even black in spots. The darkened spots are
due to pigmented matter, and this is generally most marked in the
pyloric half of the stomach. It is most commonly met with in cases of
prolonged passive congestion of the stomach from portal obstruction,
and requires for its production the rupture of capillaries in the
superficial layers of the membrane and the transformation of the
hæmatin into pigment. The same condition often produces ecchymoses and
hemorrhagic erosions in spots. In other cases the mucous membrane is
strikingly uneven, being studded with numerous little prominences
separated from each other by shallow depressions or furrows. This
condition, which has been compared to granulations upon wounds, is
called mammillation. It is the état mamelonne of Louis, and is
considered by him as a sure and constant sign of inflammatory action.
Like many other structural changes, it is usually found in the
neighborhood of the pylorus. More rarely polypoid growths project from
the membrane, and little cysts also frequently appear in the mucous
membrane.
Chronic inflammation tends to thickening of the mucous membrane. It
sometimes is not only greatly thickened, but acquires an extreme degree
of toughness. Exceptionally, however, the membrane, either entire or in
spots, may be abnormally thin. The thickening of the walls of the
stomach, when it involves the pylorus, gives rise to constriction of
the orifice and consequent dilatation of the stomach.
When the disease has been of long standing the interstitial tissue
between the tubules becomes thickened, the stomach is changed in its
normal structure, and the tubules themselves become confused,
compressed, and much less straight and parallel than in the normal
state. Or they may in some cases be enlarged, according to Flint, in
consequence of swelling and parenchymatous or fatty degeneration of
their epithelial cells. Microscopic examination often shows changes
such as occur in other glandular organs. The glands and tubules become
the seat of degenerative changes, such as are observed in Bright's
disease of the kidney, and they are frequently found associated in the
same case. The mouths of the gastric tubules become blocked up, while
deeper parts are dilated into cysts; and at times they are atrophied or
filled with granular fatty matter.
Many cases of persistent anæmia may be traced, according to Flint, to
this degenerative process of the gastric tubules.
The SYMPTOMS of chronic gastritis are mainly those of difficult
digestion of an aggravated kind, and are liable to be mistaken for
those of {473} ordinary functional dyspepsia. Some points of
distinction were referred to in the section treating of functional
dyspepsia; and while there are many symptoms in common, it is vastly
important that the two forms of the disease should be early recognized,
for they are radically distinct in their pathology and treatment.
We now speak of what is usually known as inflammatory, irritative, or
gastric dyspepsia--a persistent and aggravated form of indigestion
which has its origin in the stomach itself, in contradistinction to
dyspepsia which originates largely from causes outside of the stomach
and transmitted to it through nervous impression. The one is functional
and indirect; the other is inflammatory and direct.
The symptoms referable directly to the stomach are mainly those of
difficult and painful digestion, and are alike characteristic of all
forms of indigestion, such as loss of appetite, sense of weight and
fulness of the epigastrium, distress after taking food, acidity,
eructations of gas, etc. But chronic gastritis is more frequently
accompanied by a burning sensation in the epigastric region,
accompanied by tenderness on pressure, which is generally increased
after meals. Sometimes this tenderness amounts to actual pain, which is
increased after meals. But we are liable to be misled by pain: gastric
pain is not a characteristic symptom; subacute forms of the disease may
exist without any fixed pain; the sensation is rather that of burning,
uneasiness, and oppression of the epigastric region. The appetite, as a
rule, is greatly impaired--indeed, the sense of hunger is rarely
experienced--and nausea and vomiting frequently follow the ingestion of
food. This is especially the case when catarrh of the stomach is
associated with renal disease, portal congestion, or chronic
alcoholism. Large quantities of mucus are brought up, the vomiting
taking place usually in the morning, and on examination of the mucus it
will frequently be found to contain sarcinæ and large numbers of
bacterial organisms. When stricture of the pylorus is present the
vomiting of putrid, half-digested food usually takes place about the
termination of the digestive process.
The tongue presents characteristics peculiar to chronic inflammation of
the stomach. In some cases it is small and red, with enlarged and red
papillæ; in others, it is broad and flabby and somewhat pale; but in
either case, on close inspection, the papillæ will be found red and
enlarged, this being more apparent on the tip and edges. In children of
scrofulous habits and in older persons of tubercular tendency the whole
organ is redder than natural, the papillæ standing out as vivid red
spots.
In other cases the catarrh of the stomach extends to the mucous
membrane of the mouth. In all cases of oral catarrh the tongue, instead
of being red and pointed, is large and apparently oedematous. It is
uniformly covered with a white or dirty brownish coat, and frequently
shows the impression of the teeth upon its edges. The secretions of the
mouth are depraved, the breath heavy and offensive, and the gums spongy
and unhealthy in appearance. Acidity is also common.
Thirst is a common symptom. It is rarely absent either in the acute or
chronic form of the disease. It is most marked in the intervals between
meals and in the evenings.
It is rare in gastric catarrh of long standing that it does not extend
to the intestines, and occasionally from the duodenum to the ductus
{474} choledochus; in which case we have the combined symptoms of
gastro-intestinal catarrh associated with jaundice. The nutritive
system becomes implicated, and patients are especially prone to develop
any diathesis to which they may be liable.
There remains a group of symptoms of great interest in the study of
gastric inflammation--important because liable to mislead as to the
real nature of the difficulty--namely, morbid conditions of the nervous
system. Few diseases have such a wide range of morbid sympathies, and
few, it may be added, are so generally misunderstood and
misinterpreted. Two main facts, as formulated by Broussais, deserve to
be restudied by the profession:
First, that irritations of the visceral parenchyma which do not
implicate their serous membranes only give rise to ill-defined
sensations, and they not painful;
Second, that most of the acute pains arising from visceral irritation
are rather referred to external parts than to the viscera themselves.
Unless the seat of very acute inflammation, mucous membranes are
remarkably free from pain, and yet the gastric mucous membrane is the
seat of a most exquisite internal visceral sense and has a wide range
of morbid sympathetic disturbances. These sympathetic phenomena are
often treated for primary neuralgias. No fact in the clinical study of
disease deserves more careful consideration than this. Absence of pain,
then, is calculated to mislead. It is often only the sensation of
uneasiness, depression and melancholy, want of appetite, thirst,
nausea, loathing of food, and derangement of the bilious and gastric
secretions, that directs our attention to the stomach. Moreover, in
gastro-enteric inflammations pain is more frequently felt in parts
sympathetically affected than in the stomach itself. "It is only when
irritations of mucous membranes are in the vicinity of the openings of
cavities that the irritations are distinctly perceptible in the seat
they occupy" (Broussais). Morbid irritative action commencing in the
stomach repeats itself in the cerebro-spinal system of nerves, and the
secondary irritation may develop a more immediately dangerous
inflammation than the primary. This is frequently observed in children,
who are specially prone to irritation of the visceral apparatus. Many
cases of primary gastric irritation terminate in acute cerebral
inflammation. Indeed, the greater number of phlegmasiæ of the brain are
only sympathetic irritations issuing from primary inflammation of the
stomach. Short of inflammation, the transmitted irritation may merely
give rise to reflex convulsions, and in adults to sick headache, or, if
long continued, to conditions of hypochondria. Headache is a prominent
symptom of gastric irritation. It is not usually acute, but rather a
sense of fulness and pressure, sometimes felt in the frontal, at other
times in the occipital, region. Many cases commonly called cerebral
hyperæmia and cerebral anæmia are nothing more than malassimilation
from chronic gastric catarrh. This fact deserves to be specially
emphasized at present, for we are apt to consider the cerebral the
primary lesion. Vertigo, as in functional dyspepsia, is also an
occasional symptom, and very commonly patients complain of extreme
degrees of sleeplessness and disturbed dreams and nightmare.
The heart's action is often disturbed in its rhythm, and sympathetic
dyspnoea leads to suspicion of disease of the lungs. And to all these
{475} nervous phenomena may be added unusual languor, lassitude,
irritability of temper, and a feeling of inability for either mental or
physical exertion.
But in the play of morbid sympathies it must be borne in mind that the
stomach may be secondarily affected. Irritations of all organs are
constantly transmitted to the stomach from their very commencement.
Hence the frequent loss of appetite, the thirst, the embarrassed
digestion, the deranged gastric secretion, and the altered color of the
tongue. This is markedly the case in all the malarious and essential
forms of fever. Gastric complication in these fevers is rarely, if
ever, absent, and if aggravated by the too early use of tonics and
stimulants and by harsh irritating cathartics, it becomes too often a
fatal complication.
Gastric symptoms are also associated with other constitutional
disorders, such as phthisis, renal disease, rheumatism, gout, and
almost all forms of chronic eruptive diseases.
Intestinal symptoms are rarely absent. Constipation is often obstinate,
and especially is this the case if the catarrhal condition is confined
to the duodenum. The lower down the inflammation the greater the
probability of diarrhoea, and when present the stools are offensive and
frothy; sometimes they are dry and scybalous and coated with a tough,
tenacious mucus which may form casts of portions of the intestinal
track. In other cases patients suffer from distressing intestinal
flatulence and a sense of general discomfort. Piles is a complication
frequently present without reference to complication of the liver.
The urine is more frequently disordered than in any other form of
disturbance of digestion. The most common changes consist in an
abundant deposit of the urates; exceptionally, however--especially in
cases of long standing in which there are marked nervous symptoms
associated with defective secretion of the liver and pancreas--it may
be of low specific gravity and pale in color from the presence of
phosphates. Slight febrile movement is not uncommon.
Finally, in all cases of chronic gastric catarrh the nutritive system
becomes deeply implicated--much more so than in functional disturbances
of the stomach. Emaciation is almost constantly present, the patient
often showing signs of premature decay.
DIAGNOSIS.--The disease with which chronic gastritis is most liable to
be confounded is atonic dyspepsia, the chief points of distinction from
which have been already alluded to. In general terms it may be said
that in chronic gastritis there is more epigastric tenderness, more
burning sensation and feeling of heat in the stomach, more thirst, more
nausea, more persistent loss of appetite, more steady and progressive
loss of flesh, more acidity, more eructations of gas, more general
appearance of premature decay, and greater tendency to hypochondriasis.
And yet all these symptoms, in varying degrees of prominence, may be
present in all forms of indigestion. To the points of distinction
already mentioned, then, a few circumstances may be added which will
afford considerable assistance in coming to a correct diagnosis:
1. The length of time the disease has uninterruptedly lasted. It is
essentially a chronic disease.
2. The local symptoms are never entirely absent, as is not infrequently
the case in functional dyspepsia.
{476} 3. The uneasy sensations, nausea, oppression, or pain, as the
case may be, follow the ingestion of food. They are not so prominently
present when the stomach is empty.
4. The result of treatment. In chronic gastritis it will be found that
all the local symptoms are exasperated by the usual treatment of
functional dyspepsia.
5. Stimulants and stimulating food are not well borne. Alcohol,
especially on an empty stomach, produces gastric distress. There is
also frequently slight febrile disturbance.
Chronic gastritis, with nausea, vomiting, hæmatemesis, general pallor,
and loss of flesh, may be mistaken for cancer of the stomach. But in
cancer vomiting is about as apt to take place when the stomach is empty
as during the ingestion of food; pain is usually greater, especially
when the orifices of the stomach are involved; the tenderness is more
marked; the emaciation and pallor more steadily progressive; the
vomiting of coffee-ground material takes place more frequently; and the
disease is more rapid in its progress. The age and sex of the patient
may also aid us in our diagnosis. Cancer is more frequently a disease
of middle and advanced life, and localizes itself oftener in the
stomach of males than females. Finally, the discovery of a tumor would
remove all doubts. Hæmatemesis in chronic catarrh of the stomach is
almost invariably associated with obstruction to venous circulation in
the liver, heart, or lungs.
In rare cases it may be difficult to distinguish chronic gastric
catarrh from ulcer of the stomach. In ulcer of the stomach pain is a
more prominent and constant symptom; it is more centrally located; the
vomiting after taking food is more immediate and persistent; the tongue
may be clean; flatulence is not a constant symptom; the appetite is
seldom much affected; the bowels are generally confined; and there is
nothing characteristic about the urine.
TREATMENT.--In this, as in the more acute forms of the disease, rest of
the stomach is important. From mistaken notions of disease we are prone
to over-feed our patients, and thus seriously impair the digestive and
assimilative processes. In chronic inflammation of the stomach a
restricted diet is of prime importance. The physician should most
carefully select the patient's food, and urgently insist on its
exclusive use. This of itself, if faithfully persevered in, will often
effect a cure.
The exclusive use of a milk diet--especially skim-milk--should be
thoroughly tested. In testing it we should allow two or three weeks to
elapse before any other food is taken. At the end of that time
soft-boiled eggs, stale bread, and well-cooked rice may be added, with
an occasional chop once a day. Some patients do not tolerate raw milk
well. In such cases we should thoroughly test the peptonized or
pancreatized milk or the peptonized milk-gruel, as suggested by
Roberts. This artificially-digested milk agrees wonderfully well with
many stomachs that cannot digest plain milk. Milk, in whatever form
administered, should be given at comparatively short intervals of time,
and never in quantity beyond the digestive capacity. Better err on the
side of under- than over-feeding. Nothing should be left to the fancy
or caprice of the patient. The food should be carefully selected by the
medical adviser, and given in definite quantities at definite times.
Even the moral {477} effect of such discipline is healthful for the
patient. After testing milk diet for a time, we may gradually add small
quantities of rare and thoroughly minced meat. Milk, eggs, and rare
meat are more easily digested, as a rule, than starchy substances.
Farinaceous food is apt to give rise to excessive acidity. But stale
bread may be added to the milk, and, if there is tendency to acidity,
better have it toasted thoroughly brown.
In addition to the dietetic treatment of the disease, diluents,
timeously administered, are of essential service. As a rule, patients
are too much restricted from their use, under the supposition that they
dilute the gastric juice and thereby impair the digestive power. This
restriction is proper at, and for some time after, the ingestion of
food. But at the end of the first hour after taking food several ounces
of gum-water, or some mucilaginous fluid sweetened and rendered
palatable by a few drops of dilute muriatic acid, should be
administered, and repeated every hour during the digestive process.
Diluents, thus administered, are not only grateful in allaying the
thirst of the patient, but are at the same time an essential part of
the treatment. The free use of demulcents at the termination of
digestion in the stomach is especially useful.
Beyond these general principles of treatment, applicable to all
varieties of gastric catarrh, we must have reference to the varied
etiology of the disease. This, we have seen, is most complicated. Hence
the difficulty in prescribing any rules of treatment applicable to all
cases. We should seek here, as in all cases, to generalize the disease
and individualize our patient.
Chief among remedial agents may be mentioned the alkaline carbonates.
When combined with purgative salines they are specially valuable in
gastro-duodenal catarrhs associated with disease of the liver. These
are a very numerous class of cases, especially in malarious regions of
country, and when present in a chronic form lay the foundation of
widespread disorders of nutrition. No treatment in such cases is
effective until we diminish engorgements of the liver and spleen, and
nothing accomplishes this so well as the use of alkaline saline
laxatives. These may be assisted in their action by small doses of
mercurials. It was a cardinal principle among the older practitioners,
in the absence of more minute means of diagnosis, to look well to the
secretions; and what was their strength is, I fear, our weakness.
Wonderful results often follow a course of the Carlsbad, Pullna, or
Marienbad waters, taken on an empty stomach, fasting, in the morning.
While taking the waters a rigid and restricted diet is enforced. This
is an important part of the treatment. And the fact that so many varied
ailments are cured by a course of these mineral waters with enforced
dietetic regulations only shows the prevalence of gastro-duodenal
catarrhs and their relation to a great variety of human ailments. To a
certain extent the potassio-tartrate of sodium and other saline
laxatives may take the place of these waters if perseveringly used and
taken in the same way. In feebler subjects minute doses of strychnia or
some of the simple vegetable bitters may be used in conjunction with
the laxative salines.