William Osler.

Modern medicine : its theory and practice, in original contributions by American and foreign authors (Volume v. 5) online

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absence of gastric juice. The enzymes are absent as well as the hydro-
chloric acid; mucus may be abundant.

Organic acids are not present except in small amounts, as a rule, and
only if there be stagnation of food. Lactic acid is not usually found where
a test meal has been given after a previously thorough lavage.

The motor power varies. As a rule, it is not greatly impaired, although
if insufficiency be present there is much more fermentation and the general
gastric symptoms are much more pronounced. In most cases of typical
chronic gastritis there is some atony, more readily induced by persistent
dietetic errors. The gastric functions are readily taken on by the intestines
where normal motor power exists. Gastrectasis is uncommon.

Some authors (Cohnheim^ and others) describe valuable aid from examina-

1 Arch. f. Verdauungskrank, 1896-, i, p. 238.
VOL. V. — 18



274 DISEASES OF THE ALIMEXTARY TRACT

tioii of h'ds of mucoufi membrane which sometimes come away with tlie lavage
water, but Lubarseh's^ stiulies have revealed the many sources of error liable
to result from trusting- too im])licitly to this means of diagnosis. The altera-
tions they present are often but semblances of inflammatory change, and
vice versa, even if the cells and glands be actually altered struc-turally, it
does not necessarily mean that they have been functionally inactive.

Course and Prognosis.— It is usually of long duration, and the general
health suffers eitiier pt'riodically or progressively, but alternation of good
and depressed health is the rule. The mental condition suffers, neuroses ap-
pear and often great jihysical dcj^ression as a result of the hyj)ochondriasis
and neurasthenia. The exacerbations usually depend on indiscretions, and
recurrences are very common, especially in alcoholics. The mild cases are
readily cured, but in the more severe ones the probability of cure depends on
the condition of the muscular wall, the state of the mucosa, and the kind
and degree of inflammation present.

With atony of the stomach, and especially gastrectasis, and with achylia
gastrica, the condition is much more difficult to treat successfully. When
the intestines are healthy, the chances of cure are naturally augmented.
The prognosis should be based less upon the general condition than upon
the outlook for securing a sufficient supply of nourishing food and a mainte-
nance of secretory and motor functions. In every case the individual affected
has himself most to do with the cure by observing due regard to the require-
ments of treatment, which, after all, are readily followed and are usually
of benefit in cases not too far advanced.

Diagnosis. — The condition is very often latent, and repeated observa-
tions may be necessary; the symptoms and signs as above described, with
the recognized etiology, render the diagnosis certain from exclusion rather
than from any other means. The main features in the diagnosis are:
(1) The etiological factors. (2) Persistent indigestion, with nausea and
frequent vomiting of much mucus, gastric pain, and tenderness. (3) The
relation of the symptoms to the ingestion of food. (4) The variations in
the course, with its exacerbations and remissions. (5) The moderate loss
of strength and weight as compared to the lowered nutrition in more serious
conditions. (6) The comparatively slight alterations on analysis of the
motor power. (7) The presence in the gastric secretions of much mucus
and variable quantities or acid from complete achylia to hyperacidity. (8)
The finding in the stomach contents of many leukocytes either in the mucus
or in bits of mucous membrane coming away in the washing. (9) The
beneficial effect of proper treatment.

Differential Diagnosis. — One must distinguish between primary and second-
ary forms, the latter whicli usually accompany other diseases being readily
recognized by detection of the original cause.

Chronic Gastritis and Gastric Neuroses. -^r-The differentiation is often
impossible, for in each case there may be evidences suggestive of the one
malady, and yet the course and other factors may indicate with some
degree of certainty that the other disease is present. The distinctive
features are as follows: In chronic gastritis: (1) The cause is usually
obvious. (2) The condition of the patient is poorer and the nutrition is
apt to sufl'er more. There is, moreover, less evidence of neuroses else-

^ Achylia Gastrica, Leipsic, 1897.



CHRONIC GASTRITIS 275

where. (3) The .symptoms occur during the digestive period, and are de-
pendent upon food, its quantity, quality, and time of ingestion. There is
vomiting of much mucus. (4) The analysis of the contents shows much
mucus, which often contains many leukocytes and the same may be found
in bits of mucous membrane which may have come away with tlic washings.
There is but little disturbance of motor power and the secretions arc variable
from complete achylia to hyperacidity (all of which results may, however,
be found in neuroses). (5) Examination for enzymes shows that their
])resence or absence keej^s pace with that of the hydrochloric acid, whereas
in neuroses there may be absence of hydrochloric acid, but enzymes are
then usually present. (6) The course is with exacerbations and remis-
sions lasting over weeks or months, while in neuroses the intervals of
change are much shorter and more variable. In the latter, days of appar-
ently complete health alternate with those of great mental and physical
depression.

Gastritis versus Cancer of the Stomach before Tumor is Evident. — In
the early stages this is often difficult and usually impossible at first. In
many cases the symptoms may justly be referred to either disease, and
development alone will determine the diagnosis. In gastritis the onset
is usually insidious, from a well-recognized cause, and there are exacer-
bations and remissions, usually associated with dietetic errors. In cancer the
disease, while often insidious at the onset, progresses when the gastric diges-
tion is still appareiitly good; a disturbance appears without cause, persists,
and progresses in spite of all care. In gastritis the nutrition suffers less;
there is no cachexia or great wasting; the pain is mild; no fever exists. There
is vomiting, although less frequently than in cancer, especially when the
cause is removed, and hsematemesis is much less common. In gastritis the
gastric analysis shows much less motor insufficiency, a variable amount of
hydrochloric acid, and rarely any lactic acid. The reverse holds for cancer.
The course of the disease in gastritis is less rapid, with frequent remissions,
and treatment has a beneficial effect upon all the symptoms. Later, ex-
clusion aids the differentiation, and in the absence of downward progress
and tumor or metastases the diagnosis of gastritis is strengthened.

Atrophy of the gastric follicles, achylia gastrica, is an occasional sequel of
chronic gastritis, as also an accompaniment of gastric cancer, pernicious
ansemia, etc. It may, however, occur as a neurosis. Thus, Ewald, Einhorn,
and others have found that for years there may be complete absence of
hydrochloric acid in the gastric secretions in individuals who are either
quite well or merely neurotic. These patients show no dyspeptic signs in
spite of the hydrochloric acid deficiency, and, moreover, show a mucosa
which is perfectly normal according to observations made upon bits of
mucosa removed in the washings. In many instances even after years of
achylia the secretions may return to the normal.

The presence of much mucus in the gastric contents in cases of achylia
is one of the chief determining factors of the diagnosis in favor of gastritis,
implying, as it does, a probable catarrh; and this will be strengthened by the
finding of a number of leukocytes in the flakes of mucus removed.

Treatment. — A detailed diagnosis is essential to the proper treatment
of chronic gastritis. Secondary gastritis must be treated according to the
cause, which will involve the therapeutics of the lungs, heart, liver, or general
constitution. In the primary cases, on the other hand, the treatment em-



276 DISEASES OF THE ALIMENTARY TRACT

braces prophylaxis, palliative and curative measures. The curative measures
are mechanical, dietetic, and metlicinal.

One must consider the cause of the disease as well as the condition of
the secretory and motor functions and the quantity of mucus present.

Prophylactic. — Prophylaxis is of some importance, and one should, there-
fore, remove any external conditions which tend to bring on or aggravate
the malady. Exces.'?es of all kinds must be guarded against; bad habits
cureil; the patient should be taught to eat slowly, to chew his food well, and
carefully to select his diet both as regards quantity and quality. Faulty
teeth, as forming an important factor in the etiology of gastritis, should be
repaired. The actual treatment is chiefly mechanical and dietetic, while
drugs play a comparatively unimportant part.

Mechanical. — The mechanical treatment consists mainly in lavage. It is
necessary that the stomach should be clean before any food enters, and for
this reason one must remove any mucus which covers up the superficial epi-
thelium and prevents proper action of the digestive juices. Lavage may be
carried out in the early morning, or, in bad cases, six hours after dinner
(which is usually taken at midday), and the evening meal should be as light
as possible. Under ordinary conditions one may wash the stomach out with
simple lukewarm water. If, on the other hand, much mucus is jiresent,
sodium chloride may be added, or, if there be much fermentation, boracic
acid; according to the severity of the case, lavage should be done daily or
every second day, for a few weeks, and on each occasion it should be con-
tinued until the water returns quite clear. When atony or much fermentation
is present this may require some practice.

When, for one reason or another, lavage is impossible, one may employ
"natural lavage" by means of frequent administration of mineral waters
of various kinds, especially the saline waters with carbonic acid, which
are often beneficial in reheving the stomach of its mucus and inducing a
combination of the organic acids. The alkaline sulphates, such as are
combined in Carlsbad waters, are useful for this purpose as well as for
relieving the constipation. Where, on the other hand, there is irritation
in the stomach with diarrhoea, they are best taken hot. Whenever atony
exists it is well to remember that only small quantities of fluid should be
taken at a time.

Daily cold baths or shower baths, with subsequent friction of the skin,
are of great benefit. Where pain or great discomfort is present, a wet com-
press may be placed upon the epigastric area and covered with gutta-percha
tissue. A suitable abdominal binder of thin wool is often soothing to
patients who go about, and is a protection to the sensitive abdomen.

Electricity is of doubtful value, but the proper regulation of rest and exer-
cise (which latter should always be moderate) is of the greatest importance.

A change of scene, climate, and general surroundings is one of the
most efficacious forms of treatment, both for its stimulating effect on the
constitution generally, and more particularly as an aid in dispelling the
accompanying neurasthenia. A sojourn at some of the numerous watering
places is often of the greatest benefit, not so much on account of the waters
taken (although they have their definite use), but on account of the diet
and general regime under which patients are placed, and under conditions
which are not usually followed at home. When this is impossible suitable
exercise and properly regulated diversion are commendable, especially if



CHRONIC GASTRITIS 277

accompanied by the regular use of mineral waters selected according to the
condition of the secretions.

Dietetic Treatment. — Dietetic treatment is of prime importance, although
often hard to regulate because of individual preference. The diet must
be administered with some regard to the severity of the case, but in all
instances the food must be non-irritating and easily digested, and for this
reason must require but little effort on the part of the gastric juice or mus-
cular action of the organ. When only the scantiest diet is tolerated, milk,
preferably diluted with lime-water, may be given at regular intervals, and
this, while the patient is at rest, may suffice, provided he can be induced
to take from one to two quarts per diem. We may say, however, that
in the large majority of instances, a mixed diet, selected with reference to
the needs of each case, is advisable.

When the motor power of the stomach is demonstrated to be normal, one
may administer albumins, starches, and fats. If, on the other hand, it is
deficient, it is wiser to exclude the fats. When, again, the secretory power
of the stomach is defective, a mixed diet is very easily given, so long as the
motor power remains unimpaired. In all cases, however, albuminous food
should be finely divided. Carbohydrates should form the bulk of the food
in those cases in which the hydrochloric acid is deficient, using preferably
those in which there is least residue after digestion is complete.

Fats are imperative when malnutrition exists, and for these cases butter
and cream form the most easily digested varieties. It is thus essential,
where possible, to give a mixed diet, non-irritating, finely divided, and
containing as much nutriment as possible within the smallest compass.
In severe cases, in addition to the milk, one may give gruel, milk soups,
light puddings, rice, arrowroot, toast, and then eggs. In some cases minced
meats may be added; but it is not wise to add spices or any rich sauce.
The craving which many patients with a chronic gastritis have for spicy
things, under the impression that they will stimulate the functions of secre-
tion, should not be encouraged. Of the lighter meats, etc., calves' brains
sweetbreads, chicken, fish, minced beef, are those most preferable.

Alcohol is best avoided unless in the form of very light wine. The quan-
tity of water taken with the meals should be restricted, unless there be hyper-
acidity, in which case it is well to dilute the food moderately. Instead of
ordinary water, effervescing alkaline waters may be tried with benefit.

The determination of the proper number of meals per day is based upon the
condition of the motor power. If this be good, three meals a day may suffice.
Where, on the other hand, there is atony, four or five meals, each small
in quantity, are more advisable. Weak coffee, tea, and cocoa may be
given except in those cases in which hyperacidity exists. As the patient
improves, such vegetables as spinach, carrots, maize, potatoes (mashed),
and macaroni may be added in small quantities and gradually. Bread
should be stale and not hot. When constipation is marked, it may be
well to give stewed fruits, such as apples, prunes, etc.

Medicinal. — Inasmuch as hydrochloric acid is deficient in many cases, one
may add with some benefit a few drops after each meal. Thirty drops of
dilute hydrochloric acid in a glass of water, to be sipped at intervals for
an hour after each meal, may be prescribed. On a scientific basis, there
is little to be gained from the use of pepsin, although practically one fre-
quently does find that its employment seems to afford considerable aid to



278 DISEASES OF THE ALIMENTARY TRACT

digestion. Pantrcatin ii^ doses of fifteen grains is perhaps better, and should
be administered with soila, aUhough rationally this should not he prescribed
unless there is some evidenee of atrophy of the gastric follicles. Papain
is also recommeniled by many. After all, tliese artificially prepared ferments
are realized to be of little use when one considers that the intestines carry
on the defective actions of the stomach.

It seems of prime importance, however, to give some stomachic before
each meal, and for this purpose one may try either dilute nitromuriatic acid,
in doses of n]^x to xv (1 cc), nux vomica, quassia, gentian, or condurango.
In many cases the greatest relief from the pain incident to chronic gastritis
is a pill consisting of silver nitrate, gr. -J- (gm. 0.01) ; pulv. opii, gr.^ (gm.O.OlG) ;
extract of hyoscyamus, gr. -} (gm. 0.03).

When fermentation is an annoyance the diet should be carefully looked
into; one may sometimes add thymol, carbolic aciil, or creosote to the other
modes of treatment. Germain S6q. has recently recommended the use of
strontium bromide, gr. 30 to 60 (gm. 2 to 4), especially when hyperacidity
co-exists with the fermentation. For a distinct pyrosis, bismuth subnitrate
and sodium bicarbonate, of each, 10 grains, combined with 3 to 5 grains
of calcined magnesia, will usually aft'ord relief. For persistent vomiting,
lavage is the most rapid means of giving relief. When this is impracticable,
a careful adjustment of the diet, with perhaps the administration of one or
other of the usual drugs for that purpose, may be of benefit.

Constipation is one of the greatest annoyances. It is well that the patient
should develop great regularity in his habits, going daily to stool at regular
hours, whether there be need therefor or not. As soon as possible there
should be added to his food vegetables containing much cellulose, also
stewed fruits, especially a combination of figs and prunes; or in the early
morning he should drink cold water or eat a fresh orange; and only in
aggravated cases should we resort to either purgatives or enemata. Where
purgation is necessary, it is a difficult matter to determine what drugs shoidd
be employed; only the mildest forms of purgatives should be given, and
of these aloes and cascara are probably the most beneficial. The use of
Carlsbad salts in the morning is another efficacious means of treatment in
the aggravated constipation which often accompanies chronic gastritis.

GASTRECTASIS.

Definition. — Gastrectasis is an acute or chronic enlargement of the
stomach cavity associated with a relative or absolute lack of power on the
part of its muscular wall to propel the food to and through the pylorus
within the normal time. In true gastrectasis there is permanent stagnation,
i. e., retention. It is a functional disturbance of motor power rather than
mere enlargement of the orffan.

Sometimes two stages are described; (1) Stagnation, with either simple
or severe atony. The stomach retains some of the food between each meal,
but not over night, and thus in the early morning it is empty and has a few
hours of repose. (2) Retention, the extreme degree with no interval of
gastric repose.

Introduction. — Modern methods of gastric analysis have demonstrated
the importance and value of estimating the motor power of the stomach {i. e.,
the ability of the gastric muscle to propel food into the duodenum).



GASTRECTASIS 279

In earlier days, when methods of examination were less accurate and
less satisfactory, attention was directed more to the size of the stomach
as an evidence of disease than to its physical and ch(!mical functions.
In this way extreme conditions only were observed, while the more insig-
nificant varieties, in which the size of the stomach was often not much
increased, were neglected. Increased capacity, however, does not in itself
imply anything more than enlargement, and does not coincide with the
idea of pathological function. The stomach is an organ whose size is
subject to very wide variations in health, and clinical experience demon-
strates the fact that mere increase in its dimensions does not imply a
pathological state of the gastric functions. It is an every-day experience
to find upon examination of patients that the stomach covers apparently
and actually almost twice its normal area in the abdomen, and yet the
subsequent examination with the stomach tube will reveal no disturbance
of its motor function. Rosenbach^ was among the first to point out clearly
that such conditions cannot come into the category of "dilated stomachs"
in the functional sense, and are certainly not included under the title of
gastrectasis, which is less an anatomical than a physiological term. Some
writers have employed the term megalogastria for the conditions in which
there is mere enlargement of the viscus without any evidence of disease, and
as such the term is useful not only in supposed congenital enlargement,
but it may well be employed for the numerous instances of mere dilatation
without impairment of motor power from whatever cause.

Probably the commonest form of gastric indigestion is that due to deficient
muscular power — the so-called atonic dyspepsia — a condition of "slight
motor insufficiency." Here again confusion seems to exist in the termin-
ology. Atony of the stomach is after all but a milder form of gastrectasis,
and while it may or may not be correct to place these two within the
same , category, the fact remains that in each the essential feature is a
delayed expulsion of food from the stomach, through lack of power (rela-
tive or absolute) on the part of the gastric muscle. The term atony may
be used also to imply mere laxity of gastric muscle without stasis of food,
and such a condition is of course quite common. Certainly all grades of
motor insufficiency occur from mere atony to extreme gastrectasis, although
whether or not these can be etiologically linked together in one chain is not
so certain.

Two conditions must exist to establish the rational use of the term gastrec-
tasis. There must be an enlargement of the organ, and its motor power
must be impaired. The deficient motor power may be merely relative,
i. e., the muscular activity may be even greater than is normal, and the fault
may lie at the exit of the stomach. In other words, a pyloric stenosis may
hinder the normally rapid outflow, and, even although the muscle be hyper-
tonic, food may be retained. Such a gastrectasis would be relative.

As already mentioned, mere enlargement may be very marked, and yet,
unless the motor power were disturbed, one would not be justified in regarding
the condition as true gastrectasis. Vice versa, a stomach may be of normal
size and its motor function so altered that food is retained for twenty-four
hours or longer. Here, again, although the motor power is disturbed in the
extreme, one cannot speak clinically or anatomically of gastrectasis. When,

^ Volkmann's Samml. hlin. Vortr., 1878, No. 153.



2S0 DISEASES OF THE ALIMENTARY TRACT

however, the two conditions are combined, ?'. c, increase in the capacity oi
the organ and definite diminution of its motor power, then, and then only
are we justified in the employment of the term gastrectasis, to which, whether
rightly or wrongly, a clinical entity has been ascribed. This terminology
applies, however, chiefly to the chronic forms, for the acute variety of dila-
tation, which in most cases is associated either with pyloric stenosis or a
sudden paresis of the gastric muscle, is in many respects essentially difl'crent
from chronic dilatation and will therefore be considered separately.

Acute Dilatation of the Stomach. — This is probably more common
than is generally supposed, and certainly as a terminal feature in pneumonia
and cardiac disease, as well as a complication in surgical conditions, it is by
no means rare. German students have been described by Ricdel as com-
monly affected after beer-drinking bouts, and it has followed other errors and
indiscretions in the diet. Brinton referred to the condition fifty years ago,
although Fagge^ first gave prominence to its clinical features. He recorded
two fatal cases in patients eighteen and thirty years of age, respectively, iii
whom the stomach filled up rapidly with fluid. His description holds good
to-day as one of the most complete pictures of the condition.

Campbell Thomson,^ in 1902, had collected 44 cases, and Neck,^ in 1906,
recorded 60 instances. The most recent reviews of the subject are that by
Conner,^ who analyzed 102 cases of the disease (1907), and Laffer,^ who col-
lected 217 cases in all. Doubtless many cases have not been recorded.

Etiology. — Various degrees of dilatation occur involving the stomach
alone, the stomach with the duodenum, the stomach with the duodenum
and jejunum, or the stomach with even a larger area of small intestine.
This fact suffices to indicate that the causes must be varied and the patho-
genesis different in various instances. There are predisposing and exciting
causes, although it is not easy to dissociate these in all cases, all the more



Online LibraryWilliam OslerModern medicine : its theory and practice, in original contributions by American and foreign authors (Volume v. 5) → online text (page 37 of 126)