by the use of the bougie and it must be carefully differentiated from stricture
without dilatation. This may be done by passing one instrument into the
sac and another into the stomach. At times it may be difficult to pass a sound
into the diverticulum, but this may be more readily accomplished by the
use of a specially constructed sound slightly bent at its end.
Treatment consists in the dilatation of the stricture if it is present and by
feeding through the stomach tube. Rectal feeding may be found useful
as an adjunct to other means. Surgical measures, such as the formation of a
permanent gastric fistula, the relief of the causative stenosis by various oper-
ative procedures or the removal of the diverticula, may be employed as
indicated.
334 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
DISEASES OF THE STOMACH.
ACUTE CATARRHAL GASTRITIS.
Synonyms. Acute Gastric Catarrh; Gastric Fever; Acute Dyspepsia.
Definition. An acute catarrhal inflammation of the mucous membrane
lining the stomach due to simple irritation or occurring as a result of the
presence of the products of decomposing or fermenting food.
.Etiology. The disease may follow interference with the hepatic function,
it may ^e caused by exposure or it may complicate any of the acute infec-
tious diseases. The most usual causes, however, are over-loading the stomach
with indigestible or highly seasoned foods or the excessive drinking of alco-
holic beverages.
Pathology. The gastric mucous membrane becomes first congested and
swollen and its secretions are diminished. Later the mucous secretion is
increased in quantity and there may be an exudation of serum and emigra-
tion of white blood cells. More rarely there may be small hsemorrhagic
spots or haemorrhagic erosions upon the gastric lining.
Symptoms. The principal symptoms are lack of appetite, nausea, usually
followed by vomiting, which may bring relief to the patient, bad taste in the
mouth, headache, dizziness and general physical and mental depression.
Pain of greater or less degree may be present.
The lips and mouth are dry, the tongue is coated and palpation of the
stomach may reveal indistinctly localized tenderness and distention of the
organ involved. There are eructations of gas and of acid or bitter matter.
The vomiting may be frequent and the patient sometimes is unable to keep
anything in the stomach. The bowels are usually constipated, though diar-
rhoea is at times observed. The skin and conjunctivae may be jaundiced as a
result of an accompanying duodenitis. There may be a moderate febrile
movement, but elevation of temperature is not a feature of this disease.
With the fever the pulse is accelerated. The urine is scanty and highly
colored and usually contains urates in excess. Indicanuria is not infrequent.
An attack of acute gastritis usually lasts from two to four days.
The Stomach Contents as shown by the matter vomited or by the result
of a test-meal show an abnormal increase in mucus, a diminution in the total
acidity and a lack of free hydrochloric acid. Lactic, butyric, acetic acids
and bile are often present. The food is only partially digested and fre-
quently appears to have been little changed since it left the mouth.
Treatment. In persons susceptible to attacks of acute gastritis much may
be done in the way of prevention by the wearing of proper clothing. Con-
striction of the region of the stomach by improperly fitting or too tightly
laced corsets and especially the suspension of garments from the waist often
predisposes to gastric attacks in women and consequently these practices
ACUTE CATARRHAL GASTRITIS.
335
should be inveighed against. Chilling of the abdomen is likely to bring on an
attack, and to provide against this, snugly fitting garments, sufficiently warm
in texture and preferably not open below should be worn.
Dietetic prophylaxis consists in the avoidance of indigestible or highly
seasoned foods and especially those which may be adulterated with chemical
substances. The practice of food-adulteration is becoming all too common;
•coloring matters and preservatives are frequentl}' introduced and these sub-
stances are prone to disturb the susceptible stomach. Not only must the
quality of the ingested food be supervised but care should be exercised against
over-loading the stomach, the teeth must be kept in good condition and the
patient advised concerning proper mastication and salivation.
The treatment of the attack proper consists in insuring as complete rest
as possible for the organ involved, consequently it is wise to give as little food
and drink as possible until the gastric irritability has disappeared. There
is no reason why the patient suffering from acute gastritis should not fast
for a day or more, even though there is a sustained prejudice amongst the
laity against the practice. When excessive thirst is present the mouth may
be rinsed with cool water, which should not be swallowed, or cracked ice
may be sucked. A little dry champagne, a weak solution of hydrochloric
acid, carbonated waters, or cold tea without sugar may be employed in check-
ing thirst, but it is important that very little fluid of any sort should be taken
at a time.
After the day's fast the first food to be allowed is milk; this may be dilu-
ted with a little lime water or Vichy, peptonized or boiled and but a small
quantity should be given at a time. Beef or chicken broth containing egg or
rice may follow and on the third day zwieback or soda biscuit may be given.
By the fourth day the tolerance of the stomach and the patient's hunger
will have so increased that a return to a more general diet will be necessary
and such foods as calf's brain boiled in bouillon and broiled, broiled chicken
or squab, broiled sweet-breads and veal boiled in bouillon may be given; po-
tato puree soup, scraped beef, scraped ham, stewed ripe fruit, tapioca, rice
and eggs, soft boiled, scrambled or as omelet may be added by the sixth
day.
On the second day of the attack it is wise to administer calomel either in
six quarter grain (0.016) doses, one every half hour, or better in two large
doses of 5 grains (0.33) one at night, the other in the morning. By this means
any irritating substance which may have gotten beyond the pylorus will be
prevented from doing further harm and any accompanying constipation will be
relieved. The frequent vomiting of the fu-st day will usually interfere with
any medication by mouth, even were it necessary. This vomiting as a rule
empties the stomach effectually but should this not be the case and should
the emesis persist beyond the endurance of the patient, gastric lavage with
336 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONiEUM.
warm water by means of the stomach tube should be employed. In children
it is particularly beneficial. Here a soft rubber catheter of appropriate size
must be used and, while its eye may be too small to allow the admission of
the larger food particles, its introduction will induce vomiting and the wash
water poured through it wiU cleanse the stomach. During the lavage
the patient should be directed to change his position, standing erect, then
lying on the back and each of his sides in succession. Changes of position
are easily made in the case of children but in the adxilt unaccustomed to the
tube it will be found more difficult. The object of assuming different postures
is to permit the lavage to cleanse every portion of the stomach. A drachm
(4.0) of sodium bicarbonate added to each quart (litre) of the water used
will assist in dissolving the mucus from the gastric lining. When the water
returns clear a final washing with a disinfectant solution of thymol 8 grains
(0.5), boric acid ^ ounce (15.0) to the quart (litre) of water is advisable. As
a substitute for washing the stomach copious draughts of warm water may
be taken and emesis induced by applying the finger to the pharynx. The
use of emetic drugs is considered inadvisable by most gastrologists because
of the depression and increased gastric irritation which they produce.
However one may, if necessary, give a drachm (4.0) of syrup of ipecac to a
child; in the adult the hypodermatic use of apomorphine hydrochloride yj
of a grain (0.005) ^^ to be preferred to ipecac or antimony.
A few hours after the stomach has been cleansed the high colonic irrigation
consisting of a gallon (4 litres) of warm — 105-110° F. (40.5-43.3° C.) —
half saturated boric acid solution should be given in order to remove any
irritating substance which may be present; in asthenic patients this procedure
acts also as a stimulant of considerable value.
Very persistent vomiting is very exhausting to the patient and when not
relieved by emptying the stomach by lavage, may be controlled by bismuth
and cocaine in combination.
In rare cases weakness and tendency to collapse occur and may be com-
bated by small doses, ^ to i drachm (2.0 to 4.0) of iced champagne or
brandy and cracked ice repeated as indicated.
Pain or feeling of oppression in the abdomen may be relieved by hot or
cold applications or turpentine stupes. When fever is present the cold are
to be preferred; if the patient is chiUy the hot are indicated.
The use of morphine hypodermatically for the pain is not to be recom-
mended except under exceptional circumstances. In all ordinary cases
this symptom may be controlled by codeine by mouth or combined with bella-
donna in suppositories containing each a quarter of a grain (0.016) of codeine
and an equal quantity of extract of belladonna. One of these may be used
every 2 or 3 hours until the pain is eased.
Codeine by mouth may be given in tablet form or in solution. Quarter
CHRONIC CATARRHAL GASTRITIS. 337
to half grain (0.016 to 0.03) doses may be taken every 3 hours. This drug
may also be administered hypodermatically with good effect.
Following an attack of acute gastritis the appetite may be poor; in such a
contingency the bitter tonics, condurango, rhubarb, etc., may be given either
alone or with dilute hydrochloric acid to supply the lack of this substance
in the stomach. Ten drops of the dilute acid (0.66) may be given in a glass of
water before or during meals. The following prescription is also useful in
this connection and when there is need of a general tonic. ^ strychninae
sulphatis, gr. ss (0.03), acidi hydrochloric! diluti, gss (15.0), fluidextract of
condurango, 3vi (25.0), syrupi aurantii corticis q.s. ad §iv (120.0). Misce
et signa, one teaspoonful in a wine glass of water ^ hour before each
meal.
It should be remembered that mixtures containing hydrochloric acid should
be taken through a tube in order to prevent corrosion of the teeth.
CHRONIC CATARRHAL GASTRITIS.
Synonyms. Chronic Catarrh of the Stomach; Chronic Dyspepsia; Chronic
Gastric Catarrh.
Definition. A chronic catarrhal inflammation of the mucous membrane
of the stomach, usually associated with the hypersecretion of mucus and
abnormalities of the digestive elements of the gastric secretions.
.Etiology. This condition may result from repeated attacks of acute
gastritis or the complicating gastritis of the infectious diseases. It follows
the continued ingestion of too much or improper food or the abuse of medi-
cines, tobacco and alcohoHc drinks. Conditions which interfere with the
proper blood supply of the organ such as chronic endocarditis, cirrhosis of
the liver, chronic pulmonary disease and chronic nephritis often produce
this affection.
Pathology. The mucous lining of the stomach is swollen and congested,
it is grayish or brownish in color, may be ridged and usually is covered with
a viscid alkaline mucus. The peptic glands are first increased in size,
finally degenerate and become atrophic. The supporting connective tissue
stroma may be in a state of hyperplasia. In marked cases the glands may be
obliterated by this over-growth of tissue. These changes may involve the
entire gastric mucosa or a limited portion of this structure.
Symptoms. Pain is a frequent symptom and varies from a sense of dis-
comfort or fulness referred to the stomach to marked distress. Tenderness
may be present; it is, as a rule, diffuse. The appetite is diminished or lost
and even the thought of food may disgust the patient. There is an unpleasant
taste in the mouth, a coated tongue, nausea and oftentimes vomiting. The
338 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
vomitus consists of mucus and undigested food with, rarely, a little blood.
Its reaction may be acid or not; when the former is the case the acidity is not
due to the presence of the normal hydrochloric acid of the stomach but to that
of lactic, butyric and acetic acids, resulting from the fermentation of the
undigested food. The eructation of gas is a frequent symptom. In the
alcoholic type of the disease early morning vomiting of mucus — the so-called
water brash — is frequent. The bowels are likely to be constipated.
The urine is scanty, high colored and contains phosphates or urates in
excess, ^ndicanuria and oxaluria may at times be observed.
The patient complains of headache, dizziness and loses flesh as a conse-
quence of the lack of proper digestion and assimilation, he sleeps poorly
and may be melancholic. A febrile movement is not a characteristic of
this disease and the pulse rate is variable. Reflex dyspnoea and palpitation
may be present.
The so-called stomach cough is probably not due to any gastric condition
but is much more likely to be due to pulmonary tuberculosis and the clinician
should always be on the lookout for beginning apical lesions when indefinite
stomach symptoms are described. Many such cases are treated by the
gastrologist to the great detriment of the patient.
The course of chronic gastric catarrh is long and complete recovery hardly
to be expected. The symptoms can, however, be held in abeyance by proper
diet and treatment and the patient's usefulness and enjoyment of life may
continue with little impairment.
The Stomach Contents. The quantity withdrawn after a test-meal is
usually considerable and contains much mucus unless there is total atrophy
of the glandular coat. The hydrochloric acid and pepsin are deficient and
in cases of glandular atrophy there may be total achylia. Bacteria, a few
blood cells, sarcinae and epithelial cells are often seen. Usually a number
of test-meal examinations must be made before the true state of the case can
be determined with certainty.
Treatment. Prophylaxis consists in the avoidance of the errors in diet
and mode of life that are likely to cause this condition. The food should be
of proper quality and quantity, it should be eaten at regular intervals, slowly
and thoroughly masticated. Excessively hot or cold fluids should not be
drunk and the abuse of alcoholic beverages and tobacco must be avoided.
Proper attention should be paid to the care of the teeth and where these are
beyond repair artificial ones should be provided. The use of the tooth-brush
after every meal should be advised, together with the removal of all food
particles from between the teeth by means of a wooden tooth-pick or dental
silk. The mouth should also be rinsed after eating with a suitable wash
such as equal parts of hydrogen dioxide, liquor antisepticus, lime water and
water.
CHRONIC CATARRHAL GASTRITIS. 339
Conditions of the heart, Hver or kidneys to which gastric congestion is
often secondary should be carefully treated. In cardiac lesions when com-
pensation is likely to become disturbed digitahs, either alone or in combina-
tion with strychnine, should be prescribed. The digitalis is unlikely to
disturb the gastric function and under its use the congestion disappears, the
appetite and general condition improve. If the drug disturbs the stomach it
may be given per rectum in the form of the infusion or hypodermatically.
. Lavage. By this means we are able to remove from the stomach the
excessive accumulation of mucus with which it is burdened and to relieve
the organ of its retained content of fermenting food. It is the mode of treat-
ment par excellence in gastritis with excessive mucus production and muscular
atony. In this form of the inflammation frequent washings are necessary,
while in atrophic gastritis with little production of mucus the procedure need
not be undertaken so often. In mucous gastritis the frequency of the lavage
depends upon the state of the gastric inflammation, but usually once a day
is sufficient. In marked cases with large quantities of mucus and advanced
atony lavage before breakfast and in the evening may be necessary. The
most favorable time for stomach-washing is in the evening before supper,
since at this time the stomach has been quiet since the noon meal — which
in these cases should be the principal one — and the supper to be taken after-
ward will as a rule be light. The tube having been passed, the mucus may be
removed, allowing the water to run in under considerable pressure, the patient
being recumbent and directed to change his position from time to time. No
mucus may appear until the stomach has been relieved of whatever food it
may contain but after this has been washed out fiulher lavage will usually
detach mucus from the wall of the organ in considerable quantity. Certain
substances calculated to dissolve the mucus may be added to the wash water;
among these may be mentioned sodium bicarbonate (i to 250), lime water
(i to 500), and sodium chloride (i to 200). Alkaline mineral waters may
also be employed. If the stomach contains decomposing and fermenting
food a final washing with a disinfectant solution is indicated. Of these there
are a number, such as o.i percent, salicylic acid, i percent, boric acid, 0.6
percent, butyric acid, i percent, resorcinol, 0.6 percent, hydrochloric acid,
I percent, chloroform water. This last is prepared by adding the chloro-
form, shaking the mixture, allowing the chloroform to settle and using the
water poured off.
In the atrophic form of chronic gastritis, with little mucus, lavage should
be employed to stimulate the stomach-lining directly. Decinormal hydro-
chloric acid may be used and if stomach analysis shows enzymes to be still
present a solution of sodium chloride not stronger than i percent, is recom-
mended.
Drug treatment plays a less important part in the management of the
340 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
affection than do lavage and diet regulation. Of the drugs likely to prove
beneficial silver nitrate may be mentioned. It may be given by mouth — i.o
grain (0.065), ^o peppermint water i ounce (30.0); dose ^ ounce (15.0) three
times a day when the stomach is empty — by means of the intra-gastric spray
of a i-iooo solution, or the organ may be washed with a 1-2000 solution. Bis-
muth salts, especially the subgaUate and the subnitrate given together, often
produce a good effect. A powder of i part of the subgallate to 3 parts of
the subnitrate may be prescribed, of which the dose is 30 (2.0) grains 3 or 4
times a^ day, or this powder may be applied directly to the lining of the
stomach by means of an intra-gastric powder insufflator. The disadvantage
of the bismuth treatment is its likelihood to produce constipation, consequently
in connection with it laxative mineral waters and diet should be advised.
In the management of symptoms drugs are often necessary. Of the symp-
toms which are likely to need attention pain is one. Diet and stomach
washing may be sufficient treatment, but if the pain is very distressing the
patient may be put to bed and hot compresses applied over the stomach.
Opium should be used only as a last resort and may be administered hypo-
dermatically or -per rectum.
Vomiting is seldom distressing where lavage is employed. When neces-
sary, this symptom may be controlled by sucking bits of cracked ice, by iced
champagne taken in small quantitieSj and by intra-gastric sprays of weak
cocaine or menthol solutions.
Eructation may be controlled by lavage or by capsules of magnesia ponderosa
or sodium bicarbonate with or without the admixture of a little sodium sub-
salicylate. Animal charcoal in doses of from ten to twenty grains (0.66 to
1.33) is also useful.
Constipation is a frequent accompaniment of chronic gastritis. It should
not be treated by laxatives but by dietetic means, mineral waters, abdominal
massage and by irrigations, if necessary.
Loss of appetite may prove an annoying symptom. It may be managed
by various means. Stomach washing with sodium chloride or hydrochloric
acid solutions and the administration of the vegetable bitters, especially con-
durango, n\ix vomica and gentian, or of basic orexin are recommended. This
last is best given in broths in doses of about 3 grains (0.20) before meals.
Artificial digestants are of very limited value. The administration of
pepsin either alone or with hydrochloric acid does not increase the digestive
power but when there is lack of the stomach ferments and of hydrochloric
acid, the latter should be supplied. The dilute acid should be administered
in doses of about 20 drops (1.33) after meals, weU diluted and taken through
a glass tube; if not well borne the dose should be diminished or sodium bicar-
bonate and pancreatin in doses of 5 grains (0.33) each shoiild be substituted.
These are especially useful in old cases. By means of the pancreatin and
CHRONIC CATARRHAL GASTRITIS. 34 1
the alkali, which must be given in sufl&cient quantity to neutralize the acidity
of the stomach, if any remains, pancreatic digestion is performed in the stomach.
Other artificial digestants, of which there are a number on the market, are of
little use.
Mineral Wafers. The great benefit that sometimes accrues from courses
of spa treatment is probably due rather to the rigid regulation of diet and
mode of life than to any special therapeutic effect of the mineral waters drunk.
It may be stated, however, that in chronic gastritis the salt and alkaline
waters, as well as the alkaline-saline and alkaline-hydrochloric waters are
useful. When drtmk in large quantities they tend to cleanse the stomach
of its excess of mucus but in this connection they cannot, in more than a very
slight manner, take the place of lavage. It would seem that the alkaline,
alkaline-hydrochloric and sodium sulphate waters are likely to benefit gastritis
with increased or only slightly diminished hydrochloric acid while the alkaline
and saline waters are useful in diminished gastric secretion. In decreased
stomach motility with dilatation only small quantities at a time should be
allowed.
General Hygiene. For patients who have become weak and emaciated a rest
cure should be prescribed. For those of moderate bodily vigor a morning
cold tub or sponge, if there is good reaction afterward, is advisable. Cleansing
baths of warm water may be taken twice a week. Exercise in moderation
should be systematically taken. Five minutes' work with light wooden
dumb-bells or clubs before breakfast, at noon, and at bed time, together
with walking, golf, horseback or bicycle riding or a moderate amount of
swimming or rowing, is an excellent means of keeping the muscular system in
condition. Exercises of the muscles of the abdomen, such as those described
in works upon physical culture are important in all gastric abnormalities
except those attended by haemorrhage.
Electricity, while it probably has little or no effect upon the secretion or
motility of the stomach, is an excellent adjuvant to other treatment of chronic
gastritis. Both the galvanic and faradic currents may be employed. Fara-
dism acts in the same fashion as massage and should be administered by
applying one electrode to the spinal region while with the other the limbs,
and particularly the abdomen, are stroked. Intra-gastric electricity with
Einhorn's electrode by means of which both the faradic and galvanic currents
may be applied is useful and makes an excellent impression upon the patient.
Massage has a particularly good effect in gastritis with dilatation and atony
and in patients too weak to take proper exercise. Both general massage and
local massage over the abdomen are indicated. The latter plays an impor-
tant part in sustaining the tonus of the abdominal muscles, and when given
directly after a meal aids the atonic organ in passing its contents into the
intestine.
342 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
Diet is perhaps the most important factor in the treatment of chronic
gastritis. No fixed list of proper articles of food can be given but each patient
must be studied by himself both from a standpoint of his symptoms and with