Part 76

We now speak of what is usually known as inflammatory, irritative, or gastric dyspepsia--a persistent and aggravated form of indigestion which has its origin in the stomach itself, in contradistinction to dyspepsia which originates largely from causes outside of the stomach and transmitted to it through nervous impression. The one is functional and indirect; the other is inflammatory and direct.

The symptoms referable directly to the stomach are mainly those of difficult and painful digestion, and are alike characteristic of all forms of indigestion, such as loss of appetite, sense of weight and fulness of the epigastrium, distress after taking food, acidity, eructations of gas, etc. But chronic gastritis is more frequently accompanied by a burning sensation in the epigastric region, accompanied by tenderness on pressure, which is generally increased after meals. Sometimes this tenderness amounts to actual pain, which is increased after meals. But we are liable to be misled by pain: gastric pain is not a characteristic symptom; subacute forms of the disease may exist without any fixed pain; the sensation is rather that of burning, uneasiness, and oppression of the epigastric region. The appetite, as a rule, is greatly impaired--indeed, the sense of hunger is rarely experienced--and nausea and vomiting frequently follow the ingestion of food. This is especially the case when catarrh of the stomach is associated with renal disease, portal congestion, or chronic alcoholism. Large quantities of mucus are brought up, the vomiting taking place usually in the morning, and on examination of the mucus it will frequently be found to contain sarcinæ and large numbers of bacterial organisms. When stricture of the pylorus is present the vomiting of putrid, half-digested food usually takes place about the termination of the digestive process.

The tongue presents characteristics peculiar to chronic inflammation of the stomach. In some cases it is small and red, with enlarged and red papillæ; in others, it is broad and flabby and somewhat pale; but in either case, on close inspection, the papillæ will be found red and enlarged, this being more apparent on the tip and edges. In children of scrofulous habits and in older persons of tubercular tendency the whole organ is redder than natural, the papillæ standing out as vivid red spots.

In other cases the catarrh of the stomach extends to the mucous membrane of the mouth. In all cases of oral catarrh the tongue, instead of being red and pointed, is large and apparently oedematous. It is uniformly covered with a white or dirty brownish coat, and frequently shows the impression of the teeth upon its edges. The secretions of the mouth are depraved, the breath heavy and offensive, and the gums spongy and unhealthy in appearance. Acidity is also common.

Thirst is a common symptom. It is rarely absent either in the acute or chronic form of the disease. It is most marked in the intervals between meals and in the evenings.

It is rare in gastric catarrh of long standing that it does not extend to the intestines, and occasionally from the duodenum to the ductus {474} choledochus; in which case we have the combined symptoms of gastro-intestinal catarrh associated with jaundice. The nutritive system becomes implicated, and patients are especially prone to develop any diathesis to which they may be liable.

There remains a group of symptoms of great interest in the study of gastric inflammation--important because liable to mislead as to the real nature of the difficulty--namely, morbid conditions of the nervous system. Few diseases have such a wide range of morbid sympathies, and few, it may be added, are so generally misunderstood and misinterpreted. Two main facts, as formulated by Broussais, deserve to be restudied by the profession:

First, that irritations of the visceral parenchyma which do not implicate their serous membranes only give rise to ill-defined sensations, and they not painful;

Second, that most of the acute pains arising from visceral irritation are rather referred to external parts than to the viscera themselves.

Unless the seat of very acute inflammation, mucous membranes are remarkably free from pain, and yet the gastric mucous membrane is the seat of a most exquisite internal visceral sense and has a wide range of morbid sympathetic disturbances. These sympathetic phenomena are often treated for primary neuralgias. No fact in the clinical study of disease deserves more careful consideration than this. Absence of pain, then, is calculated to mislead. It is often only the sensation of uneasiness, depression and melancholy, want of appetite, thirst, nausea, loathing of food, and derangement of the bilious and gastric secretions, that directs our attention to the stomach. Moreover, in gastro-enteric inflammations pain is more frequently felt in parts sympathetically affected than in the stomach itself. "It is only when irritations of mucous membranes are in the vicinity of the openings of cavities that the irritations are distinctly perceptible in the seat they occupy" (Broussais). Morbid irritative action commencing in the stomach repeats itself in the cerebro-spinal system of nerves, and the secondary irritation may develop a more immediately dangerous inflammation than the primary. This is frequently observed in children, who are specially prone to irritation of the visceral apparatus. Many cases of primary gastric irritation terminate in acute cerebral inflammation. Indeed, the greater number of phlegmasiæ of the brain are only sympathetic irritations issuing from primary inflammation of the stomach. Short of inflammation, the transmitted irritation may merely give rise to reflex convulsions, and in adults to sick headache, or, if long continued, to conditions of hypochondria. Headache is a prominent symptom of gastric irritation. It is not usually acute, but rather a sense of fulness and pressure, sometimes felt in the frontal, at other times in the occipital, region. Many cases commonly called cerebral hyperæmia and cerebral anæmia are nothing more than malassimilation from chronic gastric catarrh. This fact deserves to be specially emphasized at present, for we are apt to consider the cerebral the primary lesion. Vertigo, as in functional dyspepsia, is also an occasional symptom, and very commonly patients complain of extreme degrees of sleeplessness and disturbed dreams and nightmare.

The heart's action is often disturbed in its rhythm, and sympathetic dyspnoea leads to suspicion of disease of the lungs. And to all these {475} nervous phenomena may be added unusual languor, lassitude, irritability of temper, and a feeling of inability for either mental or physical exertion.

But in the play of morbid sympathies it must be borne in mind that the stomach may be secondarily affected. Irritations of all organs are constantly transmitted to the stomach from their very commencement. Hence the frequent loss of appetite, the thirst, the embarrassed digestion, the deranged gastric secretion, and the altered color of the tongue. This is markedly the case in all the malarious and essential forms of fever. Gastric complication in these fevers is rarely, if ever, absent, and if aggravated by the too early use of tonics and stimulants and by harsh irritating cathartics, it becomes too often a fatal complication.

Gastric symptoms are also associated with other constitutional disorders, such as phthisis, renal disease, rheumatism, gout, and almost all forms of chronic eruptive diseases.

Intestinal symptoms are rarely absent. Constipation is often obstinate, and especially is this the case if the catarrhal condition is confined to the duodenum. The lower down the inflammation the greater the probability of diarrhoea, and when present the stools are offensive and frothy; sometimes they are dry and scybalous and coated with a tough, tenacious mucus which may form casts of portions of the intestinal track. In other cases patients suffer from distressing intestinal flatulence and a sense of general discomfort. Piles is a complication frequently present without reference to complication of the liver.

The urine is more frequently disordered than in any other form of disturbance of digestion. The most common changes consist in an abundant deposit of the urates; exceptionally, however--especially in cases of long standing in which there are marked nervous symptoms associated with defective secretion of the liver and pancreas--it may be of low specific gravity and pale in color from the presence of phosphates. Slight febrile movement is not uncommon.

Finally, in all cases of chronic gastric catarrh the nutritive system becomes deeply implicated--much more so than in functional disturbances of the stomach. Emaciation is almost constantly present, the patient often showing signs of premature decay.

DIAGNOSIS.--The disease with which chronic gastritis is most liable to be confounded is atonic dyspepsia, the chief points of distinction from which have been already alluded to. In general terms it may be said that in chronic gastritis there is more epigastric tenderness, more burning sensation and feeling of heat in the stomach, more thirst, more nausea, more persistent loss of appetite, more steady and progressive loss of flesh, more acidity, more eructations of gas, more general appearance of premature decay, and greater tendency to hypochondriasis. And yet all these symptoms, in varying degrees of prominence, may be present in all forms of indigestion. To the points of distinction already mentioned, then, a few circumstances may be added which will afford considerable assistance in coming to a correct diagnosis:

1. The length of time the disease has uninterruptedly lasted. It is essentially a chronic disease.

2. The local symptoms are never entirely absent, as is not infrequently the case in functional dyspepsia.

{476} 3. The uneasy sensations, nausea, oppression, or pain, as the case may be, follow the ingestion of food. They are not so prominently present when the stomach is empty.

4. The result of treatment. In chronic gastritis it will be found that all the local symptoms are exasperated by the usual treatment of functional dyspepsia.

5. Stimulants and stimulating food are not well borne. Alcohol, especially on an empty stomach, produces gastric distress. There is also frequently slight febrile disturbance.

Chronic gastritis, with nausea, vomiting, hæmatemesis, general pallor, and loss of flesh, may be mistaken for cancer of the stomach. But in cancer vomiting is about as apt to take place when the stomach is empty as during the ingestion of food; pain is usually greater, especially when the orifices of the stomach are involved; the tenderness is more marked; the emaciation and pallor more steadily progressive; the vomiting of coffee-ground material takes place more frequently; and the disease is more rapid in its progress. The age and sex of the patient may also aid us in our diagnosis. Cancer is more frequently a disease of middle and advanced life, and localizes itself oftener in the stomach of males than females. Finally, the discovery of a tumor would remove all doubts. Hæmatemesis in chronic catarrh of the stomach is almost invariably associated with obstruction to venous circulation in the liver, heart, or lungs.

In rare cases it may be difficult to distinguish chronic gastric catarrh from ulcer of the stomach. In ulcer of the stomach pain is a more prominent and constant symptom; it is more centrally located; the vomiting after taking food is more immediate and persistent; the tongue may be clean; flatulence is not a constant symptom; the appetite is seldom much affected; the bowels are generally confined; and there is nothing characteristic about the urine.

TREATMENT.--In this, as in the more acute forms of the disease, rest of the stomach is important. From mistaken notions of disease we are prone to over-feed our patients, and thus seriously impair the digestive and assimilative processes. In chronic inflammation of the stomach a restricted diet is of prime importance. The physician should most carefully select the patient's food, and urgently insist on its exclusive use. This of itself, if faithfully persevered in, will often effect a cure.

The exclusive use of a milk diet--especially skim-milk--should be thoroughly tested. In testing it we should allow two or three weeks to elapse before any other food is taken. At the end of that time soft-boiled eggs, stale bread, and well-cooked rice may be added, with an occasional chop once a day. Some patients do not tolerate raw milk well. In such cases we should thoroughly test the peptonized or pancreatized milk or the peptonized milk-gruel, as suggested by Roberts. This artificially-digested milk agrees wonderfully well with many stomachs that cannot digest plain milk. Milk, in whatever form administered, should be given at comparatively short intervals of time, and never in quantity beyond the digestive capacity. Better err on the side of under- than over-feeding. Nothing should be left to the fancy or caprice of the patient. The food should be carefully selected by the medical adviser, and given in definite quantities at definite times. Even the moral {477} effect of such discipline is healthful for the patient. After testing milk diet for a time, we may gradually add small quantities of rare and thoroughly minced meat. Milk, eggs, and rare meat are more easily digested, as a rule, than starchy substances. Farinaceous food is apt to give rise to excessive acidity. But stale bread may be added to the milk, and, if there is tendency to acidity, better have it toasted thoroughly brown.

In addition to the dietetic treatment of the disease, diluents, timeously administered, are of essential service. As a rule, patients are too much restricted from their use, under the supposition that they dilute the gastric juice and thereby impair the digestive power. This restriction is proper at, and for some time after, the ingestion of food. But at the end of the first hour after taking food several ounces of gum-water, or some mucilaginous fluid sweetened and rendered palatable by a few drops of dilute muriatic acid, should be administered, and repeated every hour during the digestive process. Diluents, thus administered, are not only grateful in allaying the thirst of the patient, but are at the same time an essential part of the treatment. The free use of demulcents at the termination of digestion in the stomach is especially useful.

Beyond these general principles of treatment, applicable to all varieties of gastric catarrh, we must have reference to the varied etiology of the disease. This, we have seen, is most complicated. Hence the difficulty in prescribing any rules of treatment applicable to all cases. We should seek here, as in all cases, to generalize the disease and individualize our patient.