A system of practical medicine. By American authors. Vol. 2

by Unknown

The mucous membrane alone is usually the seat of the disease, and for this reason it has become the custom of late years to describe it as gastric 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 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 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.