This term was formerly used to denote nearly every form of chronic dyspepsia. Now that the great gastric neuroses and functional disorders are defined and separated off, chronic gastritis, though still an important matter, becomes a comparatively infrequent disease. In practice, however, the old loose usage of the term is still occasionally met with.
As in the case of acute gastritis, prophylactic treatment requires a knowledge of the causation.
It is possible that repeated attacks of acute gastritis may lead to this chronic state, but I believe that this sequence is only met with when the acute attacks are due to alcoholic excess. The causes, however, that have been mentioned as producing acute gastritis are also responsible for the chronic condition, but this chronic gastritis has a slow and insidious beginning and is seldom preceded by acute attacks except in alcoholic subjects. It can be set up by long-continued over-eating and over-drinking, by habitual hurry and food-bolting. The amount and character of the food, and the pace of eating, all play a part. Richness of food, generally synonymous with indigestibility, abuse of spices, condiments and ices, and perhaps of tea and coffee, should be noted. Tobacco-chewing will certainly produce it, and it is thought by some that excessive smoking can contribute to the causation. It is possible that carious teeth may have an influence through the swallowing of bacterial products in pyorrhoea alveolaris as well as through defective mastication. It is said that every one has the stomach which he deserves, and all these causes of what may be termed a primary chronic gastritis are avoidable.
But chronic gastritis may be secondary to other conditions. It is especially apt to occur in cirrhosis of the liver. In fact, the most typical examples are met with in that disease. Similarly it occurs as the result of the passive hyperaemia due to cardiac failure, and it often turns the scale in the final stage of valvular disease. It supervenes occasionally in long standing cases of hyperacidity, and some degree of chronic gastritis is commonly present with carcinoma of the stomach. Finally it may appear in various conditions of impaired health, such as tuberculosis, anaemia and chronic nephritis.
It will be seen on reference to the subject of motor insufficiency and dilatation of the stomach, that all these same causes are there in operation. And it is true that, given the same vicious diet or habits, or the same enfeebled health, one patient may develop a chronic gastritis and another a motor impairment and dilatation. It is not possible to separate these two conditions as sharply in practice as in theory, and they often co-exist.
The establishment of a suitable diet requires a knowledge of the state of the gastric secretion. As regards this point, Boas recognizes four varieties : (1) Gastritis acida, (2) anacida, (3) mu-cipara, (4) atrophicans. As regards the first of these forms, it has been already stated that a chronic gastritis may occasionally supervene on hyperacidity. Putting this uncommon occurrence on one side, we may say that in chronic gastritis the secretion of hydrochloric acid is diminished. On examination the acid is found to be present in combination with protein, but as free acid it is greatly diminished or absent. This deficiency and an increased production of mucus are, in fact, the main clinical features of the disease. In the atrophic variety, a late stage of great rarity, both combined and free acid may be absent, and even the gastric ferments become scanty or cease to appear. In a case of chronic interstitial nephritis with persistent vomiting under my care, the contents of the stomach an hour after a test-breakfast were neutral, and pepsin was entirely absent. Motor impairment is common in chronic gastritis, and some dilatation may take place, but in some cases muscular power is certainly normal, and peristalsis may even become visible.
In slight and early cases the recognition of the cause and its removal may allow a return to health, though a short course of milk diet will probably be necessary. But in severe cases it may be taken as certain that, if the diagnosis is correct, considerable changes have already occurred in the gastric mucosa, and the dietetic treatment will be a long and wearisome process. It should be pointed out to the patient that half measures are useless. He must devote himself entirely to his cure and must retire to bed. Lavage is always necessary.
If there is fair digestive power and free acid is found after a test-breakfast, it is sometimes possible to start with the diet which is suggested as the first step in the treatment of dilatation. But as a rule it is wiser to begin with a milk diet, and I think that milk alone should be given in spite of the disadvantages of its bulk and weight. Forty oz. of milk should be diluted with 8 oz. of lime-water, soda-water or barley-water, and of this mixture 8 oz. may be taken slowly every three hours for 6 doses in the day. It should not be cold, but the patient may have some choice in the temperature. Koumiss or kephir may be used, but many patients dislike them. The duration of this stage must vary with the results, but it is well to proceed very slowly, and a week or 10 days on this 800 calorie diet is certainly not too severe as a rule. If vomiting occurs, it will be necessary to peptonize the milk and to begin with smaller doses. The amount of milk may be gradually increased to 50 oz., and not until this amount can be taken without discomfort should any extension of diet be made. This point may not be reached for two or three weeks.
As regards the next step, it must be remembered that digestion of protein is at a low level and that carbo-hydrates, on the other hand, are apt to undergo fermentation with development of injurious organic acids, though something can be done to check bacterial and toruloid action by medicinal remedies. Both protein and carbo-hydrate food should be added to the diet, but both of these in small quantities. The treatment throughout must be tentative and cautious. Extra protein can be obtained by giving one or two eggs beaten up in milk, or from plasmon, or from raw beef juice, beef-tea, or somatose. The carbo-hydrate element is best given in the form of Benger's food or arrowroot. The following is an outline of such a diet, supplying about 1,200 calories: -
8 a.m..... Milk, 8 oz. with plasmon.
10 a.m..... Milk and egg.
Noon..... Beef-tea, 6 oz. or meat-jelly.
2 p.m..... Milk and plasmon.
4 p.m..... Milk and egg or junket and cream.
7 p.m..... Benger's food, 8 oz.
10 p.m..... Milk and plasmon.
Boas recommends the following diet at this stage, amounting to 2,200 calories : -
8 a.m..... Milk and flour soup, 200 grms (milk, 100 grms).
Bread, 50 grms.
Butter, 30 grms. 10 a.m..... Eggs, 2.
White bread, 50 grms., butter, 30 grms.
Or with this scraped beef, 60 grms. Noon..... Farina milk-soup, 200 grms.
Milk and rice, 200 grms.
Prunes, 100 grms.
3 p.m..... Milk and tea or coffee 200 grms. (3/4 milk).
White bread, 50 grms.
7 p.m..... Rice and milk-soup, 200 grms.
Zwieback, 50 grms.
Later the same diet can be adopted as is recommended as the first step in cases of dilatation of the stomach, eggs, fish, raw meat, toast and butter being permitted, while alcohol, tea, coffee, sugar, spices and condiments are still forbidden. Ewald's diet-list is as follows : -
8 a.m..... Tea, 150-200 grms.
Stale wheat-bread, toast or zwieback, 100 grms.
10 a.m.....Wheat-bread, 50 grms.
Butter, 10 grms.
Cold meat or ham, 50 grms.
Milk, 1/3 litre or one glass of light wine.
2 p.m.....Water, milk, or bouillon of white meats, 150-200 grms.
Meat or fish, 100-125 grms.
Vegetables, 30-100 grms.
Compote, 80 grms. 4.30 p.m. . . . Warm milk or chocolate or milk and coffee (half and half) 1/2 litre. 7.30 p.m. . . . Soup, 300 grms.
Wheat-bread, 50 grms.
Butter, 10 grms.
10 p.m.....Occasionally one cup of coffee and 50 grms. of wheat-bread, biscuit, or zwieback.
In a later stage the final diet recommended in dilatation of the stomach is suitable, a moderate mixed diet in six meals. And from some such diet there should be no hurry to depart. Alcoholic subjects should be urged to become total abstainers. In others a glass of Rhine or Moselle wine may be permitted at lunch and dinner, but under no circumstances should alcohol be taken except with meals.
For chronic gastritis with impairment of digestive power Wegele recommends the following diet, having a value of 2,400 calories : -
Morning .... Pepton-cocoa, 150 grms.
Butter on toast, 25 grms. Forenoon . . . One soft-boiled egg. Noon..... Oatmeal soup, 200 grms.
Fowl, 150 grms.
Carrot, 200 grms. Afternoon . . . Pepton-cocoa, 150 grms.
Butter and biscuits, 25 grms. Evening .... One egg.
Scraped ham, 100 grms.
Macaroni with toasted bread-crumbs, 100 grms. During the day . Wine, 200 grms.
Toast, 75 grms.
For cases with complete loss of digestive power, reference may be made to the food-stuffs mentioned under Carcinoma of the Stomach.