Part 102

Leube, in order to relieve constipation and to increase the peristalsis of the stomach, administers Carlsbad water (see page 522). Not more than five or six ounces of the water need be given, and this should be taken slowly in divided doses. A laxative pill containing rhubarb may be given occasionally.

If anæmia be the cause or a prominent accompaniment of dilatation of the stomach, iron may be administered in a form as little disturbing the digestion as possible, as the effervescing citrate or the lactate, or arsenic in the form of Fowler's solution may be tried. In general, however, all drugs which impair the appetite or digestion are to be withheld. The digestion and the general condition of the patient are often benefited by massage.

Resection of the pylorus in cases of cancerous and of cicatricial stenosis of this orifice has been performed in several instances. The subject, as regards its medical in distinction from its surgical bearings, has already been discussed in connection with cancer of the stomach (see page 577). Here it may be added that the propriety of resection is less open for dispute in cases of non-cancerous pyloric stenosis than it is in cancer of the pylorus.

Remarkable results have been reported by Loreta in cases of cicatricial stenosis of the pylorus. After performing gastrotomy he inserts his fingers through the constricted pyloric orifice and forcibly dilates the stricture. To judge from experience in divulsing strictures in other parts of {610} the body, it does not seem probable that a permanent cure can be often effected by this bold and dangerous procedure.

Acute Dilatation of the Stomach.

Under the name acute dilatation of the stomach have been described cases in which it has been supposed that a more or less suddenly developed paralysis of the muscular coat of the stomach exists. But the propriety of the term acute dilatation, and the very existence of an acute paralysis of the stomach, are, to say the least, questionable.

As causes of this so-called acute dilatation of the stomach have been assigned injuries, particularly those affecting the abdomen, surgical operations involving the peritoneum, acute inflammations of the mucous and of the peritoneal coats of the stomach, acute fevers, especially during convalescence, and overloading the stomach with food or with liquids.

The symptoms which have been chiefly emphasized are severe abdominal pain, tympanitic distension of the stomach, and absence or cessation of vomiting if this has previously existed. It will be noted that inability to vomit under these circumstances implies not only paralysis of the stomach, but also that of the abdominal muscles.

The prognosis depends on the character of the primary disease causing the alleged paralysis.

If there be acute distension of the stomach with inability of the organ to expel its contents either externally or into the intestine, the stomach-tube may be employed to evacuate the gas and other material present.

In a case described by Hilton Fagge as acute dilatation of the stomach the symptoms of dilatation appeared suddenly and ran an acute course, but the autopsy showed that the dilatation was doubtless of much longer development than the symptoms indicated. In a case reported by Nauwerk of extreme dilatation in consequence of hypertrophic stenosis of the pylorus, after ten months of insignificant dyspeptic symptoms there suddenly appeared, after excess in eating, symptoms of dilatation of great severity, which continued until a fatal termination at the end of three months. Thus it appears that chronic dilatation of the stomach may cause little disturbance for a considerable time and then run a rapid course.

{611}

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. 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.

Andral 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. Cruveilhier distinguished between scirrhous induration and hypertrophy, which he considered to be a final result of the irritation accompanying chronic diseases of the stomach. Rokitansky's description of fibroid induration of the stomach, although brief, is accurate. He says that the process usually involves the whole {612} 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. Bruch 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.

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. Brinton 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.

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.

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 Nothnägel the symptoms were {613} 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.

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.