MINOR ORGANIC AFFECTIONS OF THE STOMACH.
(CIRRHOSIS; HYPERTROPHIC STENOSIS OF PYLORUS; ATROPHY; ANOMALIES IN THE FORM AND THE POSITION OF THE STOMACH; RUPTURE; GASTROMALACIA.)
BY W. H. WELCH, M.D.
CIRRHOSIS OF THE STOMACH.
DEFINITION.—Cirrhosis of the stomach is characterized by thickening of the walls of the greater part or of the whole of the stomach in consequence of a new growth of fibrous tissue, combined usually with hypertrophy of the muscular layers of the stomach. The cavity of the stomach is usually contracted, but sometimes it is of normal size or even dilated.
SYNONYMS.—Fibroid induration of the stomach; Hypertrophy of the walls of the stomach; Chronic interstitial gastritis; Sclerosis of the stomach; Plastic linitis.
HISTORY.—The writings of the seventeenth and eighteenth centuries contain many records of extremely contracted stomachs with uniformly and greatly thickened walls (Butzen, Löseke, Storck, Portal, Lieutaud, Pohl, etc.). In the works of Lieutaud and of Voigtel may be found references to many such cases.1 Doubtless, some of these cases were examples of cirrhosis of the stomach, but in the absence of microscopical examination it is not possible to separate these from cancer.
1 Lieutaud, Historia anat.-med., t. i. p. 8, Venet., 1779; Voigtel, Handb. d. Path. Anat., Bd. ii. p. 450, Halle, 1804. Here it may be mentioned that Diemerbroeck's case, which is so often quoted to prove that polyphagia instead of causing gastric dilatation may produce hypertrophy of the muscular coat of the stomach, with contraction, was probably an instance of cirrhosis of the stomach.
Andral2 was the first to describe fully and systematically hypertrophy of the walls of the stomach. He attributed the lesion to chronic inflammation. He erroneously supposed that scirrhus of the stomach was only hypertrophy of the gastric walls. Cruveilhier3 distinguished between scirrhous induration and hypertrophy, which he considered to be a final result of the irritation accompanying chronic diseases of the stomach. Rokitansky's4 description of fibroid induration of the stomach, although brief, is accurate. He says that the process usually involves the whole stomach, and that it originates in an inflammation of the submucous connective tissue. This inflammation may occur either independently or in combination with gastritis mucosa. Rokitansky emphasizes the error of confounding the disease with scirrhous cancer. Bruch5 made an elaborate study of hypertrophy of the walls of the stomach, which he considered to be the final stage of various chronic diseases of the stomach. Fibrous or scirrhous cancer he considered to be nothing but this hypertrophy.
2 Précis d'Anat. path., Paris, 1829.
3 Anatomie pathologique, Paris, 1830-42.
4 Lehrb. d. Path. Anat., Wien, 1855-61.
5 Zeitschr. f. rat. Med., Bd. vii., 1849.
The best descriptions of cirrhosis of the stomach have been furnished by English writers, by most of whom it is properly regarded as an independent disease. Brinton6 first employed the names cirrhosis of the stomach and plastic linitis. Excellent descriptions of the disease have been given by Hodgkin, Budd, Brinton, Habershon, H. Jones, Wilks, Quain, and Smith.
6 Diseases of the Stomach.
While in former times cirrhosis of the stomach was confounded with cancer, in recent times it has not been separated by many from chronic catarrhal gastritis. In German systematic works the disease receives, as a rule, only passing mention in connection with chronic catarrhal gastritis.
ETIOLOGY.—Cirrhosis of the stomach is rare, but it is not so exceptional as to be without any clinical importance. I have met with three cases at post-mortem examination.
The disease is more frequent in men than in women. A considerable number of cases have occurred between thirty and forty years of age, but the greatest frequency is after forty. At an earlier age than twenty the disease is very rare.
The causation of cirrhosis of the stomach is obscure. Nearly all writers upon the subject have emphasized the abuse of alcohol as an important cause in this as in other diseases of the stomach. Intemperance cannot, however, be the only cause; and here, as elsewhere, it is not easy to say what importance is to be attached to it as an etiological factor. In only one of the three cases which I examined post-mortem could it be determined that the patient was an immoderate drinker, and in one case intemperance could be positively excluded. Other cases have been recorded in which the abuse of spirits could be positively excluded. In one of my cases syphilis existed, as was established by the presence of gummata in the liver. In some cases the disease has been attributed to cicatrization of a gastric ulcer. In a case reported by Snellen the disease followed an injury to the epigastric region.7
7 Canstatt's Jahresbericht, 1856, iii. 302.
Cirrhosis of the stomach, as well as cancer, ulcer, and most other chronic structural diseases of this organ, is usually associated with chronic catarrhal gastritis. There is, however, no proof of the prevalent idea that chronic catarrhal gastritis is the cause of the enormous new growth of fibrous tissue which characterizes typical cases of this disease.
SYMPTOMATOLOGY AND DIAGNOSIS.—The symptoms of cirrhosis of the stomach are not sufficiently characteristic to warrant a positive diagnosis. Sometimes the disease pursues a latent course. Like cancer of the stomach, it may put on various disguises. Thus, in a case of cirrhosis of the stomach reported by Nothnägel8 the symptoms were typically those of progressive pernicious anæmia. Association with ascites or with chronic peritonitis may lead to a false diagnosis. Thus, in one of the cases which I examined after death, and in which there was chronic peritonitis with abundant fluid exudation, the disease during life was diagnosticated as cirrhosis of the liver. Most frequently, however, cirrhosis of the stomach is mistaken for gastric cancer, from which, in fact, it can rarely be positively diagnosticated.
8 Deutsches Arch. f. kl. Med., Bd. 24, p. 353.
The symptoms are usually those of chronic dyspepsia, which sooner or later assumes a severity which leads to the diagnosis of some grave structural disease of the stomach, usually of cancer.
Indigestion, loss of appetite, oppression in the epigastrium, vomiting, are the common but in no way characteristic symptoms of cirrhosis of the stomach. There may be severe gastralgia, but in general the disease is less painful than either ulcer or cancer of the stomach. The inability to take more than a small quantity of food or of drink at a time, with the sense of fulness which even this small quantity occasions, has been considered somewhat characteristic of cirrhosis of the stomach, but this symptom is too inconstant, and occurs in too many other affections of the stomach, to be of much service in diagnosis. The symptoms of dyspepsia are often of much longer duration than in cancer, existing sometimes for many years (up to fifteen years), but on the other hand there have been cases in which the clinical history of gastric cirrhosis was as rapid in its progress as cancer. Moreover, cancer may be preceded by dyspeptic symptoms of long duration, but long duration is the exception with cancer and the rule with cirrhosis of the stomach.
As the disease progresses the patient loses flesh and strength, and usually dies in a condition of marasmus. Blood is rarely present in the vomit, but in a few cases the vomiting of coffee-ground material has been noted.
By physical examination sometimes a tumor in the region of the stomach can be felt. Under favorable circumstances it can sometimes be determined that this tumor is smooth, elastic, tympanitic on percussion, and presents more or less distinctly the contours of the stomach. By administering effervescing powder it may be possible to obtain further evidence that the tumor corresponds in its form to the stomach. The diagnosis of contraction of the cavity of the stomach is not easy. Some information may be afforded by noting the length to which the inflexible stomach-tube can be passed. The quantity of water which can be poured into the stomach until it begins to run out of the stomach-tube may also bring some confirmatory evidence as to the existence of contraction of the stomach.
Even should the physical signs suffice to determine that the tumor is the thickened and contracted stomach, still cancer cannot be excluded, for this also may grow diffusely in the gastric walls and may cause contraction of the cavity of the stomach. With our present means of diagnosis, therefore, the most which can be said is, that a special combination of favorable circumstances may render probable the diagnosis of cirrhosis of the stomach, but a positive diagnosis is impossible.
MORBID ANATOMY.—In most cases of cirrhosis of the stomach the stomach is contracted. The cavity of the stomach has been found not larger than would suffice to contain a hen's egg, but such extreme contraction is very rare. When the stomach in this disease is found dilated, either the thickening involves only or chiefly the walls of the pyloric portion, or the morbid process probably began there and was followed by dilatation.
In typical cases the walls of the entire stomach are thickened, but frequently the thickening is most marked in the pyloric region. The walls may measure an inch and even more in thickness. The thickened walls are dense and firm, so that often upon incision the stomach does not collapse.
Upon transverse section the different coats of the stomach can be distinguished. The mucous membrane is least affected, being sometimes thickened, sometimes normal or atrophied. The muscularis mucosæ is hypertrophied, and is evident to the naked eye as a grayish band. The submucous coat is of all the layers the most thickened, being sometimes ten to fifteen times thicker than normal. It appears as a dense white mass of fibrous tissue. The main muscular coat is also, as a rule, greatly hypertrophied; the grayish, translucent muscular tissue is pervaded with streaks of white fibrous tissue prolonged from the submucous and subserous coats. This last coat resembles in appearance the submucous coat, which, however, it does not equal in thickness, although it is, proportionately to its normal thickness, much hypertrophied. The free peritoneal surface usually appears opaque and dense.
To the naked eye it is apparent that the new growth of fibrous tissue is most extensive in the submucous coat, which it is probably correct to regard as the starting-point of the disease. The hypertrophy of the muscular layers is also in most cases an important element in the increased thickness of the gastric walls.
Microscopical examination9 shows sometimes a nearly normal mucous membrane. The tubules, however, are usually more or less atrophied. In the case reported by Nothnägel tubules could be found only in the pyloric region of the stomach. The essential lesion is the new growth of fibrillated connective tissue pervading all of the coats of the stomach. In an interesting case reported by Marcy and Griffith,10 which was believed to be caused by an extensive cicatrized ulcer, a new formation of smooth muscular tissue was found not only in the main muscular tunic and the muscularis mucosæ, but also throughout the submucosa. This peculiarity was probably referable to the cicatrization of the ulcer.
9 Microscopical examination is always necessary for a positive diagnosis of cirrhosis of the stomach. In a case which I examined post-mortem of double ovarian cancer, with multiple secondary deposits in the peritoneum and with chronic peritonitis, the stomach presented the typical gross appearances of cirrhosis, but here and there were to be found nests of cancer-cells in the prevailing new growth of fibrous tissue in the walls of the stomach.
10 Am. Journ. of the Med. Sci., July, 1884, p. 182.
Not infrequently adhesions exist between the stomach and surrounding organs. Exceptionally, a diffuse growth of fibrous tissue may invade the greater part of the peritoneum, particularly the visceral layer, and cause a thickening similar to that existing in the stomach. In such cases ascites is usually a marked symptom.
PROGNOSIS.—The prognosis of cirrhosis of the stomach is grave. The disease runs a chronic course, and usually terminates in death by asthenia. There is no reason to believe that the stomach can ever be restored to its normal condition. Still, cases have been reported in which it has been supposed that cirrhosis of the stomach has terminated in recovery.11 The diagnosis, however, in such cases must remain doubtful.
11 Lesser, Cirrhosis Ventriculi, Inaug. Diss., Berlin, 1876; Smith, "Cirrhosis of the Stomach," Edinb. Med. Journ., 1872, p. 521.
TREATMENT.—The treatment is symptomatic, and is to be guided by the general principles developed in previous articles concerning the regulation of the diet and the administration of remedies.
HYPERTROPHIC STENOSIS OF THE PYLORUS.
The various causes of stenosis of the pylorus have already been mentioned under DILATATION OF THE STOMACH, and the most important of these causes have received full consideration in connection with ULCER and with CANCER OF THE STOMACH.
Only one of the varieties of pyloric stenosis can claim consideration as an independent disease. This variety is the so-called hypertrophic stenosis of the pylorus (Lebert) or fibroid degeneration of the pylorus (Habershon12). Under the name of hypertrophic stenosis have been described cases in which the stenosis was due to hypertrophy of only one of the coats of the stomach, usually either the submucous or the muscular coat, sometimes only the mucous coat. In most cases, however, all of the coats of the stomach are involved, and the lesion is similar to that of cirrhosis of the stomach, but it is confined to the pylorus or to the pyloric region. In such cases there is new growth of fibrous tissue, most marked in the submucous coat, and hypertrophy of the muscular coat. The appearance of the pylorus in some instances of hypertrophic stenosis has been not inappropriately compared to that of the cervix uteri.
12 Habershon, On Diseases of the Abdomen, London, 1862; Lebert, Die Krankh. d. Magens, Tübingen, 1878; Nauwerk, Deutsches Arch. f. klin. Med., Bd. 21, 1878.
In the majority of cases the change here described is the result of cicatrization of a gastric ulcer, and some believe that all cases of so-called hypertrophic stenosis or fibroid degeneration of the pylorus are referable to ulcer, although it may be very difficult to discover the cicatrix of the ulcer. It is certainly not always possible to detect either ulcer or cicatrix, so that it seems proper to regard the hypertrophic stenosis in such cases as constituting an independent affection.
The symptoms are those of dilatation of the stomach, sometimes preceded by evidences of chronic catarrhal gastritis. The thickened pylorus can sometimes be felt during life as a small, cylindrical, usually movable tumor, either stationary in progress or of very slow growth.
In most cases the diagnosis of organic stenosis of the pylorus can be made. Cancer may sometimes be excluded by the long duration of the symptoms and the stationary character of the tumor if a tumor can be felt. The exclusion of ulcer is more difficult and hardly possible, for ulcer may have existed without producing characteristic symptoms.
The prognosis and treatment have been considered under DILATATION OF THE STOMACH.
ATROPHY OF THE STOMACH.
Atrophy of the stomach may be the result of stenosis of the cardia or of the oesophagus. The stomach may participate with other organs in the general atrophy attending inanition and marasmus. The walls of a dilated stomach may be very thin.
Especial importance has been attached in recent years to degeneration and atrophy of the gastric tubules. The glands of the stomach may undergo degeneration and atrophy in various diseases of the stomach, such as chronic catarrhal gastritis, phlegmonous gastritis, cirrhosis of the stomach, and cancer of the stomach. Parenchymatous and fatty degeneration of the glandular cells of the stomach occurs in acute infectious diseases, as typhoid fever and yellow fever, also as a result of poisoning with phosphorus, arsenic, and the mineral acids.
It is claimed by Fenwick that atrophy of the stomach may occur not only as a secondary change, but also as a primary disease attended by grave symptoms. Fenwick has described a number of cases in which the gastric tubules were atrophied without thickening of the walls of the stomach and without diminution in the size of the cavity of the stomach—cases, therefore, which cannot be classified with cirrhosis of the stomach.13 He attributes in many cases the atrophy of the tubules to an increase in the connective tissue of the mucous membrane, and draws a comparison between atrophy of the stomach and the atrophic form of chronic Bright's disease.
13 The Lancet, 1877, July 7 et seq.
In 1860, Flint14 called attention to the relation between anæmia and atrophy of the gastric glands. He expressed the opinion that some cases of obscure and profound anæmia are dependent upon degeneration and atrophy of the glands of the stomach. Since Flint's publication cases have been reported by Fenwick, Quincke, Brabazon, and Nothnägel, in which lesions supposed to be due to pernicious anæmia have been found after death associated with atrophy of the gastric tubules.15 Nothnägel's case, which has already been mentioned, was one of cirrhosis of the stomach.
14 A. Flint, American Medical Times, 1860. Further contributions of Flint to this subject are to be found in the New York Medical Journal, March, 1871, and in his Treatise on the Principles and Practice of Medicine, p. 477, Philada., 1881.
15 Fenwick, loc. cit.; Quincke, Volkmann's Samml. klin. Vorträge, No. 100 (case b); Brabazon, British Med. Journ., 1878, July 27 (without microscopical examination!); Nothnägel, Deutsches Arch. f. kl. Med., Bd. 24, p. 353.
The symptoms which have been referred to primary atrophy of the stomach are severe anæmia and disturbances of digestion, such as anorexia, eructations, and vomiting. The digestive disturbances are often not greater than are frequently observed in cases of severe anæmia.
In my opinion, the existence of atrophy of the stomach as a primary and independent disease has not been established. In many cases which have been described as primary atrophy the histological investigation of the stomach has been very defective. Degeneration and atrophy of the gastric tubules secondary to various diseases of the stomach and to certain general diseases is an important lesion when it is extensive, and must seriously impair the digestion, and consequently the nutrition, of the patient.
ANOMALIES IN THE FORM AND IN THE POSITION OF THE STOMACH.
These anomalies, so far as they have not received consideration in previous articles, are of more anatomical than clinical interest, and therefore here require only brief mention.
The stomach may have an hour-glass shape in consequence of a constriction separating the cardiac from the pyloric half of the organ. This constriction is sometimes congenital,16 sometimes caused by cicatrization of a gastric ulcer, and sometimes caused by spasmodic contraction of the muscle, which may persist after death, but disappears when the stomach is artificially distended. Hour-glass shape of the stomach has been diagnosed during life by administering an effervescing powder according to Frerichs' method.
16 A careful study of the congenital form of hour-glass contraction of the stomach has been made by W. R. Williams ("Ten Cases of Congenital Contraction of the Stomach," Journ. of Anat. and Physiology, 1882-83, p. 460).
Foreign substances of hard consistence which have been swallowed sometimes cause diverticula of the stomach.
Sometimes the fundus of the stomach is but little developed, so that the organ is long and narrow like a piece of intestine.
The stomach may be variously distorted by external pressure, as from tumors and by adhesions.
The loop-shaped stomach and vertical position of the stomach have been already considered in connection with DILATATION OF THE STOMACH (page [602]).
In transposition of the viscera the stomach is also transposed. In such a case difficulties may arise in the diagnosis of pyloric cancer, as in a case described by Légroux.
The stomach may be found in hernial sacs. Mention has already been made of the presence of dilated stomachs in scrotal hernia. More frequently the stomach is found in umbilical hernias. In diaphragmatic hernia the stomach is found more frequently in the thorax than is any other abdominal viscus. In 266 diaphragmatic hernias collected by Lascher17 the stomach was found either wholly or partly in the thorax in 161 cases. The clinical consideration of diaphragmatic hernia, however, does not belong here.
17 Deutsches Arch. f. kl. Med., Bd. 27.
Furthermore, the stomach may be displaced by tumors, enlargement of neighboring organs, tight-lacing, adhesions, and the weight of hernias. These displacements, however, are generally inconsiderable and of little importance.
In a case described by Mazotti18 the stomach, of which the pyloric portion was fixed by adhesions, was twisted around its long axis. Death was caused by uncontrollable vomiting.
18 Virchow und Hirsch's Jahresbericht, 1874, ii. p. 249.
RUPTURE OF THE STOMACH.
Sufficient attention has already been given to perforation of the stomach in consequence of diseases of its walls, such as ulcer, cancer, abscesses, and toxic gastritis.
A healthy stomach may be ruptured by violent injury to the abdomen even when no external wound is produced. An example of rupture of the stomach from this cause is that sometimes produced when a person has been run over by a heavy vehicle.
It has been claimed that a stomach with healthy walls may burst in consequence of over-distension of the organ with solids or with gas. The older literature is especially rich in reports of so-called spontaneous rupture of the stomach. Most of these cases were examples of perforation of gastric ulcer. In a case of apparently spontaneous rupture of a stomach which had become abnormally distended with gas, Chiari19 found that the rupture was through the cicatrix of a simple ulcer in the lesser curvature. It is hardly conceivable that rupture of the healthy stomach from over-distension can occur so long as the orifices of the organ are unobstructed.
19 Wiener med. Blätter, 1881, No. 3.
Lautschner20 reports a case of spontaneous rupture of the stomach in a woman seventy years old with an enormous umbilical hernia which contained the pyloric portion of the stomach. After drinking eight glasses of water and two cups of tea and eating meat, she was seized with vomiting, during which the stomach burst with a report which was audible to the patient and to those around her. She passed into a state of collapse and died in thirteen hours. A rent several centimeters long was found in the posterior wall of the stomach. Lautschner thinks that the pylorus was bent in the hernial sac so as to be obstructed. In the walls of the stomach he found no evidence of pre-existing disease.
20 Virchow und Hirsch's Jahresbericht, 1881, ii.
There is no satisfactory proof of the possibility of the occurrence of rupture of a stomach with healthy walls except as a result of external violence.
The symptoms and treatment of rupture of the stomach are those of perforation of the stomach, and have already been described. The prognosis is fatal.
GASTROMALACIA.
That the subject of gastromalacia should still occupy so much space in medical works the purpose of which is mainly clinical proves that many physicians still cling to the belief that this process may occur during life. It is, nevertheless, certain that the condition which, according to the ordinary and traditional use of the term, is designated gastromalacia, is always a post-mortem process and is without the slightest clinical significance. So long as the circulation of the blood in the walls of the stomach is undisturbed, self-digestion of this organ cannot occur. No one doubts that parts of the gastric walls in which the circulation has been arrested, and which are exposed to the gastric juice, undergo self-digestion, as has already been set forth in the article on GASTRIC ULCER. To describe cases of this nature under the name of gastromalacia, however, is misleading, and can cause only confusion, for the long-continued discussion as to whether gastromalacia is a vital or a cadaveric process applied certainly to a different conception of the term. In some of the cases which have been published, even in recent years, in support of the vitalistic theory of gastromalacia, and in which it has been proven that perforation of the stomach occurred during life, the solution of continuity took place through parts of the gastric walls in which the circulation had already been obstructed, particularly by extensive hemorrhagic infiltration. Some of these cases are probably also examples of perforation of gastric ulcer or of rupture of cicatrices from over-distension of the stomach, in which post-mortem digestion of the edges of the ulcer or of the cicatrix obscured the real nature of the process. The subject of gastromalacia should be relegated wholly to works on physiology and on pathological anatomy.