Morbid Anatomy

As gastritis as such hardly ever causes death, and inasmuch as the stomach after death quickly undergoes radical changes which destroy the true picture that had before existed, the minute histology of the affected stomach can be studied only with the greatest difficulty. Even nowadays we have no better description of the macroscopical aspect of the inflamed organ than that given nearly seventy years ago by Beaumont1 from bis observations made on the well-known Canadian St. Martin with his gastric fistula. The mucous membrane appears entirely or partially swollen and reddened and is marked here and there with small sacculations. Less gastric juice is secreted, and mucus covers the surface. The pyloric portion, as a rule, is more affected, and there exist more or less extensive extravasations of blood. The secretion is only weakly acid or neutral, or even alkaline.

1 Lebert: "Die Krankheiten des Maoris," Tubingen, 1878, p. 29. 2 Oser: "Magenkrankheiten." Eulenburg's "Realencyclopae-dia," vol. xii., p. 410.

Microscopically the principal cells are found to be more granular and cloudy, partly fatty and shrunken. There is no distinction possible between the parietal and the principal cells. In the interglandular tissue numerous round cells are found. They are also met with between the epithelial cells and appear to be wandering to the surface. These round cells, according to Sachs,2 give distinct pictures of karyokinesis.

Symptomatology

Immediately after a manifest indiscretion of diet there is experienced, first of all, a feeling of heaviness at the pit of the stomach; later on a sensation of fulness. There is a desire to belch, and a difficulty in doing so. After belching, the patient feels easier for a little while, but soon the heavv sensation reappears. This condition may persist unchanged for a few days, and then gradually disappear. This is the mild form of the acute catarrh. Very often, however, we meet with more alarming symptoms. At the beginning there may exist nausea, a sensation of weight, and slight pains in the gastric region, severe headache, sometimes rise of tern perature, later on vomiting, extreme anorexia, constipation, or diarrhoea. Soon the symptoms become less severe, and appear as described in the milder form.

1 Beaumont: l. c.

2 A. Sachs: "Zur Kenntnissder Magenschlemhaut in krankhaften Zustanden." Arch. f. experim. Pathologie. Bd. 22, Heft 3, and Bd 34. Heft 1 and 2.

Objectively the gastric region appears bloated, and is sensitive to pressure. The tongue is thickly furred, and the taste pappy. If vomiting occurs, the ejected matter contains no free hydrochloric acid, is of a slightly acid or neutral or alkaline reaction, and is frequently mixed with a great deal of mucus.

The duration of the affection is short, as a rule from one to three days. The more severe cases begin with a sudden rise of temperature (102° to 104° F.), which may be accompanied with chills. In such instances the gastric symptoms may at first be less marked than the symptoms caused by the fever. After a short period, however, the gastric symptoms become more pronounced.

The inflammatory process of the stomach not rarely extends into the intestines, and then causes constipation or diarrhoea. The affection may also invade the gall bladder, and then gives rise to icterus. In the febrile form of gastritis herpes labialis is of frequent occurrence.

Diagnosis

It is easy to make the diagnosis in those cases which are not accompanied by fever, and where the cause of the trouble is apparent. The analysis of the gastric contents or of the vomited matter shows a marked diminution in the secretion of gastric juice. An acute gastritis accompanied by fever will at times cause some difficulty in diagnosis. As is well known, most of the infectious diseases are accompanied by gastric catarrh at their commence-merit, but they can be easily excluded by the absence of their pathognomonic symptoms. It is less easy to make a differential diagnosis between a beginning typhoid fever and acute gastric catarrh. In fact, the distinction between these two conditions is sometimes almost impossible during the first and second days of the sickness.

The following may serve as differential points of diagnosis between these two conditions:

In typhoid fever the temperature is characterized by its gradual rise, while in gastric catarrh the rise of temperature is quite sudden; we may have at the very start a temperature of 108° or 104°. The remission in gastric catarrh will likewise be more pronounced. The presence of herpes labialis will speak in favor of gastric catarrh, while the appearance of Ehrlich's diazo reaction in the urine will point to typhoid fever. The presence of Widal's reaction will also speak for the latter affection.

Biliary calculi not causing very severe pains, and not accompanied by icterus, may sometimes be mistaken for a gastric catarrh. Such an error in diagnosis will, however, occur but seldom; as a rule, it is easy to differentiate between these two conditions.

Prognosis

The prognosis of gastric catarrh is very favorable, except in cases of very old people and invalids, in which the process may cause serious complications.

Treatment

The vis medicatrix naturae is best seen in this affection. In order to become freed of the undigested material, the stomach empties itself either by vomiting or transferring its contents into the small intestine, which in turn gets rid of them by diarrhoeal passages. The anorexia prevents the patient from taking food, and in this way the stomach can enjoy perfect rest and soon recuperate.

In our treatment we have to imitate or rather assist nature. If spontaneous vomiting does not take place, and a feeling of pressure and pains in the stomach are present, if percussion over the gastric region gives dul-ness, and belching of badly smelling gases occurs, then we may be certain that all the symptoms mentioned are caused by decomposed food within the organ. Here it is best to look for means which will remove this obnoxious material. Washing out of the stomach is the best way to accomplish this end. Instead of lavage, however, we may tell the patient to drink half a pint or even a pint of lukewarm water in which a small quantity of table salt has been dissolved, and then tickle the throat with the end of a quill or with the finger in order to produce vomiting. Camomile tea can also be taken in the same manner before bringing on vomiting.

Emetics are rarely given nowadays. In suitable cases it is best to make use of the subcutaneous injection of apomorphine (the dose being about one-half a centigram). Tartar emetic and ipecacuanha should never be employed except in children. The stomach after having been emptied should now enjoy perfect rest for some time. Thus during the first or second day of illness it is best not to give the patient anything substantial to eat. Strained barley or rice water or weak tea may be taken. On the third day, as soon as the appetite reappears, the patient is permitted to partake of a water soup (bread and hot water), of oatmeal or barley gruel, rice soup, and perhaps one soft-boiled egg. Later on French bread, butter, and oysters may be added to the dietary. If the improvement is steadily progressing, we begin on the fourth day with meat once a day, and thus slowly return to the usual bill of fare. As a rule, no medicines whatever are needed. If obstinate constipation exists, however, and the bowels have not moved during the first two days of sickness, some aperient may be given. A large dose of calomel (ten to fifteen grains) administered once is very serviceable. This remedy should especially be employed in the febrile form of gastritis.

If there is no fever, Seidlitz powders or a good dose of citrate of magnesia will serve the purpose.

In rare instances in which the symptoms appear in a very aggravated form they may require special attention. A pronounced sensation of pressure and fulness in the gastric region after the ingestion of food may be relieved by small doses of dilute hydrochloric acid (ten drops in a glassful of water three times daily half an hour after meals).

A high degree of pyrosis can be relieved by the following medication:

℞ Calcined magnesia,

Sodium bicarbonate,

Peppermint sugar,......aa 10.0

M. f. pulv. D. ad scatulam. S. A point of a knife every two hours.

Severe pains may be relieved by a small dose of codeine:

℞ Codein. phosph.,....... 0.1

Aq. menth. pip.,......40.0

S. One teaspoonful twice or three times daily.