Section Ii. of the Stomach.

Few organs of the body are subject to such a variety, or to such early post-mortem changes as the stomach, many of which, being closely simulative of the effects of disease, render a satisfactory examination of this organ, in many instances, very difficult. Therefore, before entering upon an account of the morbid anatomy of the organ, I shall briefly notice those changes which are post-mortem in their origin.

The ordinary interval which intervenes between death and a post-mortem examination, is, in most instances, sufficient to seriously change the appearance even of the healthy stomach. Hence our knowledge of the healthy appearance of that organ, at least, previous to the experiments of Dr. Beaumont upon the stomach of Alexis St. Martin, was quite imperfect.

=Post-Mortem Changes.=

Among those changes taking place after death, which are no evidence of disease during life, may be mentioned:

First. Appearances of Congestion. Very soon after death, or at least within ten or twelve hours, by gravitation of the blood, the same hypostatic congestion will be found in the most dependent portion of the stomach, that is seen in a more marked degree in the lungs, or in the subcutaneous tissues.

Second. Coloring of Tissues. Not unfrequently, the tissue of the stomach will be found strongly tinged by coloring matter of food or medicine, such as the red color of wine or logwood, or the black color of the metallic sulphurets, etc.

Third. Change of Shape and Size. Variations in the shape and size of the stomach from the normal standard, are not unfrequently found after death. It is sometimes found unusually small, apparently from the influence of the rigor mortis, the contraction necessarily resulting in increased thickness of the walls. What is known as hour-glass contraction, although sometimes congenital in its origin, is frequently but a manifestation of the rigor mortis, when it may be distinguished from the former by inflation. Extreme dilatation, with thinning of the walls, is also sometimes seen, this condition resulting apparently from an absence of the post-mortem contraction.

Fourth. Exfoliation of Epithelium. The stomach of young adults, dying of some acute disease, not unfrequently is found to have thrown off the epithelial layer of its mucous lining, even when the examination is made soon after death, and in cold weather. In many of the healthiest animals slaughtered for food, the same change has been noticed as early as two hours after death. The detached cells are found floating in a thick mucus, the microscope also showing that the gastric follicles have thrown off their epithelial lining, with their pepsinous contents. With this change commences the post-mortem digestion of the stomach, to be soon noticed.

The younger and healthier the subject, and the more acute the disease causing death, as a general rule, the more rapidly and effectively does this exfoliation take place. It may affect only the summit of the folds into which the mucous membrane is thrown by the contraction of the muscular coat, or it may uniformly involve the whole mucous surface.

Fifth. Softening and Perforation. It is an interesting fact, that while the tissues of the stomach during life are unaffected by the gastric juice—the vitality of the tissues enabling them to resist its solvent power—after death, they immediately yield to its influence, and hence results a greater or less degree of softening of the coats, or even in some instances, complete perforation of the walls, the extent of the change depending upon the quantity of gastric fluid in the stomach at the time of death. In these cases there is, of course, no evidence of inflammation, while the tissues present a pulpy, gelatinous appearance, the walls being greatly thinned, and breaking down under the slightest force. In most instances, probably the actual perforation is the result of the force employed in lifting the stomach from its position. The opening in these cases is an irregular ragged hole, with soft, pulpy margins, and will more frequently be found at the large or cardiac extremity of the organ.

In some extreme cases, the process of softening has not been confined to the walls of the stomach, but has extended to the adjoining organs, as the spleen, liver, or diaphragm.

The whitish-gray and gelatinous appearances of these cases, will enable us to distinguish them from ordinary cases of softening and perforation from ulceration.

This form of softening is especially observed in cases of sudden death immediately after a meal, while the stomach contains a large quantity of gastric juice. It is also seen much more frequently in children and young persons than in the aged, or those dying from chronic forms of disease. It has often been noticed in cases of consumption, however, which is to be accounted for upon the fact that many of these patients retain a good appetite to the last.

Brinton, is of the opinion, that the solvent action of the gastric fluids upon the walls of the stomach, is promoted by the presence of vegetable or starchy food:—(1) by offering little substance upon which the fluids can expend themselves; and (2) by producing by its decomposition, an amount of acid, favoring an energetic action of the gastric fluids; while on the other hand, the action of those fluids is retarded, (1) by the presence of alkaline saliva, or bile in any quantity; and (2) by the presence of animal food upon which the juices may act.

CASE.—Perforation of the Stomach in a child two years of age—death from Hydrocephalus.

A child of Mr. T——, in its second summer, had an attack of hydrocephalus, finally dying in convulsions. The autopsy, made twenty-four hours after death, disclosed great congestion of the membranes of the brain, with two ounces of serum in the ventricles. Upon opening the abdominal cavity, all the viscera appeared healthy. In lifting the stomach from its position, a gush of colored fluid appeared from behind it, which at once led to the suspicion of a rupture. The whole organ was then carefully removed, when a ragged rent, through which the thumb could readily be passed, was discovered at the posterior portion of the cardiac end. The walls of the stomach at this point were extremely thin, soft and jelly-like; this condition being plainly the result of the post-mortem action of the gastric juice, while the rupture was the immediate consequence of lifting the organ from its position.

Pathological States of the Stomach.

=Gastritis.= Acute inflammation of the stomach rarely occurs, except as a result of some chemical or mechanical irritation. From the experiments of Dr. Beaumont, however, we learn that the stomach is extremely liable to various grades of inflammatory action, which passing rapidly through their several stages, end finally in recovery. By watching the effects of excesses in the use of alcoholic stimulants, food, condiments, and of exercise after meals, etc., he observed that the pale, pink color, natural to the mucous membrane of the healthy stomach, was exchanged for a somewhat livid erythematous redness, which was distributed throughout the organ in irregular patches of various sizes, and in its most intense form, amounted to a kind of ecchymosis.

Again, he noticed an excessive growth of epithelium, forming patches of false membrane like, which at various points appeared distended by an accumulation of a puriform fluid beneath, giving the appearance of little pustules.

The following forms of gastritis are generally recognized:

1. Catarrhal Gastritis. This, in its acute form, is seldom seen in post-mortem examinations. Chronic Catarrhal Gastritis, however, is by no means uncommon, and may be a result of the use of alcoholic drinks, the presence of various irritating substances taken either as food or medicine, and may attend many forms of chronic disease of other organs, or may be caused by obstruction to the circulation from disease of the heart, liver or lungs.

The post-mortem appearances are neither very marked, nor constant. The mucous membrane may be found red, or of a dark color, thickened and sometimes roughened. The submucous and muscular coats may also be thickened, while less frequently, small ulcers may be found.

2. Croupous Gastritis. This form is very rare, and seldom diagnosticated during life, but may be found with children who have died with croupous inflammation of the air passages, when small patches of false membrane may be found adhering to the mucous surfaces. It may be found in adults also, as an attendant of certain grave forms of disease, as typhus, puerperal fever, cholera, dysentery, or in death from irritating poisons.

3. Phlegmonous Gastritis, is another very rare form of inflammation of the stomach, in which the disease involves all the coats, although originating in the submucous, and may destroy the patient in a few days with symptoms of peritonitis. The submucous tissues will be found filled with an exudation of a sero-plastic, yellowish substance, which produces thickening of the walls, and which may be confined to a portion or involve the whole organ.

=Effects of Poisons.= The effects of caustic and other irritant poisons upon the stomach, as exposed by a post-mortem examination, will vary according to the nature of the substance, and the time it may have remained in the stomach. Redness in various degrees, and of various shades, ulceration, softening and perforation, may one or all, be detected in different cases.

In large quantities, the mineral acids may leave the mucous membrane black, and of a soft, tarry consistence, readily breaking down upon handling the stomach.

The peculiar action of the several poisons will be noticed in another place. (See Part IV.)

=Gastric Ulcer.= Ulceration of the mucous membrane of the stomach, is much less frequent than of other portions of the intestinal canal, except as a result of the corrosive action of poisons. A peculiar kind of ulcer, however—rare in this country, but said to be common on the Continent of Europe and in England—is sometimes found, which is of interest, from its occurring in tissues otherwise healthy, and often leading to a rapidly fatal termination. Rokitansky terms it the perforating gastric ulcer, from its marked tendency to perforate the walls of the stomach. It is situated in the region of the pylorus, and more frequently at the posterior surface and near the lesser curve. It is of a circular form, of three to six lines in diameter, and with as sharp edges as if a round piece of the walls had been punched out; the edges being bevelled off, however, from within, leaving the peritoneal opening less than that in the muscular or mucous coats. Being usually situated near the lesser curve of the stomach, some of the larger blood-vessels are liable to become involved, giving rise to hæmorrhage more or less severe. While but a single ulcer of this description is generally found, two, three or more, may be present.

A peculiarity of this form of ulcer, consists in its not being dependent upon irritation or inflammation, but rather upon a loss of vital assimulative power in the part affected.

This form of ulcer may heal at any time previous to perforation, and it is not uncommon to find a cicatrix in the mucous membrane of the stomach which has probably arisen in that way.

Gastric ulcer is much more frequent in females than males, and is mainly a disease of middle and advanced life.

=Hæmorrhagic Erosions.= The appearance of the stomach, where there has been frequent vomiting of blood from this cause, is thus described by Rokitansky: “There are several roundish spots of the size of a pin’s head or pea, or narrow elongated streaks at which the mucous membrane appears dark red, lax, soft and bleeding, and presenting a depression in consequence of loss of substance or slight erosion. This condition is invariably accompanied by hæmorrhage, the effused blood being mixed, in a more or less altered state, with gastric mucus. The erosions are often very numerous, studding, perhaps, every part of the stomach except the fundus, the pylorus being their chief seat.”

This condition of the stomach is not peculiar to any form of disease, or age, but is frequently associated with intemperance. It is rarely fatal, except by inducing some other lesion of the stomach, or by being united with some more general malady.

=Softening of the Stomach.= We have already referred to that form of softening of the stomach, which is attributed to the action of the gastric juice after death. Another form is sometimes met with, which evidently takes place during life, and in most instances is attributable to a chronic form of inflammation. It is not always easy to distinguish the two forms of softening without a knowledge of the previous history of the case. The distinction may, however, generally be made by attending to the following points:—1. The presence during life, of symptoms of disease of the stomach. 2. Appearances of congestion or inflammation, as well as softening, after death. 3. Extension of the morbid change to other portions than that affected by post-mortem softening, the latter being usually confined to the posterior portion of the cardiac end.

=Cirrhosis of the Stomach.= In some obscure cases of gastric disease, upon opening the abdominal cavity in a post-mortem examination, we may at once notice a marked change in the appearance of the stomach. It presents a peculiar whiteness and opacity, an appearance which is partially due to a dulness of the peritoneal coat, in marked contrast with its usual brilliancy; at the same time the organ may be either larger or smaller than the average size. Upon removing the organ, we find it greatly increased in weight and density, and presenting a hard, gristly feel, and with so much elasticity as to fail to collapse. An incision shows the walls uniformly thickened, to the extent of six or eight times their normal condition; the whole organ is comparatively bloodless, a condition strongly in contrast with the usual appearance after death.

A close inspection of such a specimen, shows the several coats—muscular, mucous and fibrous—to be remarkably alike, the thickening and increased density, resulting from the presence of a generally diffused imperfect fibrous structure, similar to that found in common fibrous tumors. The several coats of the stomach will be found unequally affected by this deposit. The submucous structure, as seen in a vertical section, being increased from ten to twenty fold, while the serous with the subserous may be increased seven to ten fold. The muscular tunic may be found from five to eight times its normal thickness, while the mucous membrane proper, is seldom more than double.

Notwithstanding the bloodless character of the walls of the stomach in this disease, the abnormal condition is unquestionably the result of a chronic form of inflammation. The symptoms during life are usually obscure, and although the hard contracted stomach may form a sort of epigastric tumor, noticeable upon the surface, the absence of acute symptoms, with the age at which the disease makes its appearance—usually between twenty and thirty—permits of a ready distinction being made between this disease and cancer, with which it might otherwise be confounded.

=Atrophy of the Stomach.= This condition of the stomach can hardly be looked upon as an independent malady, being rather an attendant of the general wasting of certain diseases, particularly of pulmonary consumption, marasmus, and starvation. The organ, in these cases, may be reduced to less than half its normal proportions, while its walls may be thinned and frequently softened.

=Dilatation of the Stomach=, is another condition that can scarcely be considered as a primary affection. A great variation in the size of this organ is evidently compatible with health, large eaters having necessarily large stomachs, yet as the result of certain other morbid conditions, dilatation to an enormous extent may be induced.

The following conditions may result in dilatation:

1. Obstruction of the pylorus, as in scirrhus of that portion of the stomach.

2. Destruction of a segment of the muscular coat by ulceration, or by becoming involved in a cancerous growth. Here the loss of contracting power, permits of a gradual dilatation, from the inability of the segment involved to aid in carrying on the contents, their accumulation above this point aiding in the distension.

3. An acute form of dilatation is sometimes met with, which can only be attributed to a paralysis of the muscular and secreting structures of the organ. It occasionally happens to a patient recovering from a fever. He has perhaps overindulged in eating, as is not unfrequently the case with convalescents, and is suddenly seized with intense pain in the stomach, followed by rapid and great distension, and finally death. The autopsy discloses the stomach enormously distended, and its contents, including matters, in some cases, which were ingested many days before. The mucous membrane appears but little changed, while the muscular coat is so thinned and stretched, as to appear like a scattered net-work of fibres.

Morbid Growths.

=Cancer.= This formidable disease occurs more frequently in the stomach, than in any other organ of the body, excepting the uterus of the female. The disease is usually primary in this organ, but frequently springs up secondarily in other parts.

The disease may occur in the three following forms—the scirrhus, medullary, and colloid; while Dr. Brinton adds a fourth, the villous cancer of the mucous membrane. The usual seat of the disease is at the pylorus. It may involve a portion or the whole circumference of this opening, and from this extend along the lesser curve. In some cases, it commences at the cardiac orifice, and very rarely involves the whole organ, the fundus usually remaining free. The walls of the stomach may become greatly thickened in this disease, the inner surface tuberculated and roughened, and the cavity much diminished in size. When situated at the pyloric end, the disease seldom or never extends into the duodenum, but when at the cardiac, it generally involves the lower portion of the œsophagus.

The fibrous or scirrhus form of the disease, is by far more commonly met with than any other, although it may be found occasionally combined with the medullary, or both these with colloid. Indeed, it is not improbable, but that in many cases, a growth originally scirrhus, becomes gradually converted into one of the other forms.

In almost all cases, cancer commences in the submucous tissue, in the form of a dense mass, of a white color. When cut, the surface presents a whitish-gray appearance, contrasting strongly with the vascular mucous membrane of the stomach, and presenting a distinctly striated appearance. A small portion under the microscope, or the juice scraped from the cut surface, will show the peculiar cancer cell, with granular matter.

Encephaloid or medullary cancer, may be developed upon or within the fibrous form, or it may occur primarily as knotty tumors projecting through the mucous membrane. The microscopic appearance is much the same as in the fibrous variety, except that the cells are not so closely packed, but are loosely held together by an abundant, soft, or liquid substance.

The colloid form of the disease, may originate either in the mucous membrane itself, or in the submucous tissue. It is known by its presenting a tough, fibrous-looking, white tissue, which, arranged in intersecting bands, incloses irregular spaces, which are filled with a clear, soft, or semi-liquid material, the proper colloid substance.

The villous cancer, Dr. Brinton describes as arising in the basement membrane of the mucous coat, and as but a modification of the epithelial cancer of other parts of the body.

The mucous membrane covering cancerous growths, is subject to a variety of changes. It may become converted into a sort of fungoid growth, which at points suppurates, showing the submucous scirrhus tissue; or it gradually softens, giving rise to hæmorrhages.

The cancerous mass itself, may also soften or suppurate, resulting perhaps in perforation and peritonitis; or adhesions may take place, followed by extension of the disease to the liver, spleen, pancreas, kidneys, etc.

Cancer of the stomach, in the great majority of cases, occurs in persons between fifty and sixty years, although it may appear as early as forty, or as late as sixty. Males appear to be more subject to the disease than females, in the proportion of four to three.

The obstruction which the presence of cancer of the stomach is liable to produce, may result in one or more of the following conditions:

First, hypertrophy of the muscular coat. From increased nutrition, the muscular fibres of the stomach may become considerably increased in size and darker in color, thus better enabling them to overcome the obstruction, which in some cases, amounts almost to occlusion.

Second, dilatation. This condition frequently attends the former, and indeed is seldom seen alone. It is confined to those cases where the cancer is at the pylorus, and is more noticeable at the fundus of the organ.

Third, contraction. This is seldom seen in connection with hypertrophy, and is far less common than dilatation. Generally found in connection with cancer at the cardiac orifice, it may be looked upon as the result of the constant regurgitation which the obstruction produces, preventing thus the cavity of the organ from undergoing its normal distension, by the presence of any quantity of food.

=Tumors.= With the exception of cancerous growths, tumors of the stomach are by no means common.

Fatty tumors are sometimes met with, originating in the submucous tissues, and as they increase in size, they may crowd either inwards towards the gastric cavity, or outwards towards the peritoneum.

Fibroid tumors, are also occasionally met with in the submucous tissues, generally in the line of the lesser curve, and about the cardiac orifice.

Polypoid growths may also be found springing from the mucous surface, presenting the character of those formations usually.