Synonyms.—Chronic Dyspepsia; Chronic Catarrhal Gastritis.
Definition.—A chronic inflammation of the gastric mucosa, increasing the mucous secretion, changing the character of the gastric juice, establishing conditions favoring the process of fermentation, enfeebling the contractility of its muscular coats, and so changing its integrity as to render normal digestion impossible, and frequently resulting in structural changes.
Etiology.—The same causes that give rise to acute gastritis, if continued, will result in this disease. In nearly all cases the causes may be summed up in a single word,—abuse. Rapid eating results in imperfect mastication and insalivation, and the coarse, starchy food, that should have been changed by the ptyaline into glucose, is washed into the stomach by one, two, or three cups of hot drinks or ice-water, either of which not only acts as an irritant, but also weakens the juices of the stomach to such an extent as to destroy largely their function.
Improper food, either as to quality or unfitness of preparation, is not an infrequent cause, while the use of alcoholic and malt liquors is one of the most common of all the exciting causes. Tobacco smoking and chewing are fruitful sources of dyspepsia, and lead to debility of the stomach.
The condition of the mouth must not be overlooked as an etiological factor. Neglect of the toilet of the mouth permits accumulations of food between the teeth and in cavities, which undergo decomposition, furnishing a rich soil for various bacteria, all of which mid their way into the stomach to act as irritants.
The disease is not always primary, and constitutional causes must be recognized. Tuberculosis, syphilis, diabetes, Bright's disease, anemia, gout, and many others, are known factors in producing this lesion. All diseases affecting the portal circulation must be taken into consideration when looking for a cause. We are not to forget a very important, though often overlooked, etiological factor, that of chronic diseases of distant organs, the gastritis being reflex.
In this line, rectal diseases occupy a very prominent place. Hemorrhoids, prolapsus of the bowel, fissures, and fistulous ulcers, rapillse and undue contraction of the sphincter, so often give rise to gastritis that to overlook these points is to court defeat in attempting a cure. Disease of the uterus, ovaries, and tubes, the urethra and bladder, frequently come in for their share of the blame. Wrongs of the blood influence the secretion of the juices of the stomach, thereby impairing their function, causing more or less derangement.
Pathology.—Two forms are now generally recognized by pathologists,—the simple and more common form, and the sclerotic.
In the first, the greatest changes take place in the mucous membrane near the pylorus, though, in the more severe and longer-continued cases, the entire mucous and submucous tissues are involved. The mucous membrane may be a bright-red or a pale or grayish color. It is covered profusely with a firm mucoid secretion. The swelling of the mucous membrane produces elevated folds, which give it a mammillated appearance, with here and there ecchymotic patches. This is especially marked at the pylorus, and where the submucous and muscular tissues are involved, there may be, quite a marked degree of stenosis.
Erosions and follicular ulcerations are not uncommon. The microscope reveals a marked infiltration of the interstitial tissue, with fine cells and parenchymatous changes, especially degeneration of glandular cells.
Eichhorst says: "The superficial epithelium of the gastric mucous membrane will be found involved in marked mucoid degeneration. The glandular cells exhibit granular turbidity, are in part shrunken and uniform, so that the differentiation between the parietal cells and the chief cells is lost. Accumulation of round cells, in greater or less number, has taken place between the gland tubules. The blood-vessels are dilated and greatly distended. Not rarely, remains of blood pigment are present, indicating and preceding hemorrhage."
As a result of this interstitial and parenchymatous change, the process may go on to complete atrophy, sclerotic gastritis, and may assume one of two forms: either a thinning of the coats of the stomach, simple atrophy, or phthisis ventriculi, where the normal size is retained "or even increased, or there will be an enormous thickening of all tissues, resulting in a marked decrease in its volume. This is known as cirrhosis ventriculi.
In the first form there is a gradual increase in the interglandular tissue, resulting in a progressive degeneration or obliteration of the gland-cells and arrest of its function. The mucous membrane presents a thin, smooth, white surface, which is dry and devoid of mucus.
In the second form, there is also a destruction of the gland cells, and consequent loss of function, but in this case there is enormous thickening of the walls of the stomach, by the overgrowth of both connective tissue and muscular fibers. As a result of the hypertrophied tissues, the cavity of the stomach may be so lessened as to hold but a few ounces.
Symptoms.—In chronic dyspepsia, which is but another name for chronic gastritis, the symptoms are legion, and embrace a wide range both as to local and systemic manifestations.
Among the earlier symptoms are a sense of weight and oppression after eating, which may last for hours, and, as the patient expresses it, has the sensation as though he had swallowed a stone or piece of lead; in addition there is actual pain of a burning or cramping character. This may follow shortly after taking food or may not occur for three or four hours thereafter. Later on in the disease, flatulence is a common and distressing symptom, the patient being compelled to loosen the clothing to get the slightest relief. Accompanying this, there are eructations of gas, or gas and acrid fluids combined. Nausea is frequent, and occasionally vomiting occurs a short time after eating. Where the patient is addicted to the drink habit, there is apt to be vomiting in the morning.
The vomitus consists of food mixed with slimy mucus. The tongue is usually broad, pale, moist, and more or less heavily coated, the breath offensive, and there is a bitter taste in the mouth. Sometimes the tongue is red and sleek, or red at tip and edges.
In the more severe cases, as fermentation proceeds in the stomach, there is a spasmodic closure of the pyloric orifice, and, simultaneously with this, a similar spasm of the esophageal opening occurs, and the imprisoned gas distends the stomach till its pressure upon the sensitive nerves of the heart brings on palpitation and frequently excruciating pain in the cardiac region, known as cardialgia. The patient, thoroughly alarmed, presents a frightened or anxious appearance, and the attack increasing in severity, gives rise to vertigo, and the suffering is not infrequently relieved by the patient becoming unconscious.
The appetite is capricious, sometimes ravenous, though, as a rule, there is but little relish for food. Digestion is slowly and but imperfectly performed; hence there is a period in nearly every case of chronic gastritis of diarrhea. The undigested food, passing into the intestinal canal, acts as an irritant, and frequent stools follow. This is, in turn, followed by constipation; the bowel, failing to respond to the irritant, becomes sluggish, there is an excess in the secretion of mucus, and the stools are more or less incased in mucus.
Headache is common, and, of all men, the dyspeptic is the most miserable. He becomes melancholy, and the world is a vast vale of tears. Hydrochloric acid is usually deficient, though butyric, lactic, and acetic acids are found in abundance.
On washing out the organ, we find undigested food that has lain for hours in the stomach. A microscopic examination reveals various bacterial organisms, yeast fungi, and the sarcinae ventriculi. A viscid, slimy mucus is found in large quantities, and the pale and doughy skin, together with a like abdomen, tells of general atony.
A stomach cough is sometimes a distressing symptom, and in one case that came under my notice the cough was the most distressing feature, and the one condition for which he came for treatment. When informed that his trouble was in the stomach, he doubted the diagnosis; but a few months'-treatment directed entirely to the stomach effected a complete cure.
Although dull and drowsy after a meal, the patient may become perfectly wide awake on retiring, and insomnia may be one of the most troublesome and intractable symptoms.
Diagnosis.—If attention be paid to the following points, the diagnosis is easily made: 1. History; the period of dyspepsia being very lengthy. 2. Carefully noting the afore-described symptoms. 3. By examining the contents of the stomach at different intervals after eating. If we remove, by the stomach tube, the contents of the stomach one or two hours after a meal, we find very little hydrochloric acid, but a great deal of mucus, butyric, and lactic acids. If the tube be used in from six to seven hours after a meal, we still find undigested food in the stomach, whereas in functional dyspepsia the stomach should be empty.
There may be some doubt in distinguishing this from cancer, where there is no tumor present, though even here we would have the pronounced cancerous cachexia in the latter disease, and also the presence of the coffee-ground material. In ulceration of the stomach, the boring, gnawing pain, together with vomiting of clotted blood, and the hyperacidity of the gastric contents, enables one to be quite positive in his diagnosis.
Prognosis.—This will be favorable in the large majority of cases, unless there be a malignant complication, gastric ulcers, or structural change in the tissues of the stomach. Remembering that it is often reflex, our attention is early turned to the orifices of the body, which often saves one weeks or months of useless medication. The most satisfactory results may be obtained if we keep in mind the nature of the disease, and do not attempt to cure the patient in a few weeks.
Treatment.—One of the most important means to insure a successful treatment is to impress your patient with the importance of following instructions to the very letter. Be positive in directions as to diet, and the battle is won before a dose of medicine is administered.
The diet, then, is of first importance. I find it a good plan to name the articles of diet that may be eaten before I give my list of don'ts; for if you begin by naming a long list of edibles that are to be strictly forbidden, your patient is at once discouraged. I do not believe in fasting, so say to my patients, you can eat the following articles, unless you find by experience that they do not agree with you: Rare, broiled, tender beefsteak; rare roast-beef, inner cut; broiled or roast chicken; stewed or broiled sweetbreads; young squirrel or lamb chops—these meats to be taken sparingly.
Of vegetables, a small baked potato, young and tender string-beans, young peas, spinach, etc. Light bread, at least twenty-four hours old, and cooked fruits of a subacid character. After naming this diet, the patient is your friend; he has been told that he is to live on skimmed milk, and he is charmed to find plenty of wholesome food on his diet list.
Now name the forbidden articles. No pork in any shape, no veal, no smoked or pickled meats, no duck or geese, nothing fried, no greasy food, and, as all fried victuals are greasy, this method of cooking must be avoided; no hot bread, no biscuits, muffins, waffles, or griddle-cakes; not very much in the line of sweets are allowed, and honey, syrups, jams, and preserves are also to be forbidden. Pies, rich pastries, and puddings are also to be placed on the forbidden list. The patient has agreed to all you have said about the diet, but now you must be firm in your last restriction.
No fluids to be drunk during a meal; in other words, a dry diet. No tea, coffee, milk or water, while eating, nor for two hours afterward. This is where the greatest fight is to be made. Your patient has acquiesced in all that you have said thus far, but when you say no fluids, he resents advice. Explain why he should avoid fluids, and he is won over. Tell him the reason of your restriction; that if he does not drink while eating, he will more thoroughly masticate his food; that in mastication the salivary glands are excited, and the food becomes moist with this secretion; that the ptyalin contained in the saliva converts the starchy portion of the food into glucose while yet in the mouth, and that one of the most important steps in digestion takes place in the mouth; that this step is destroyed when he drinks during a meal; that the food is bolted, or washed into the stomach imperfectly masticated and imperfectly salivated; that the gastric juice can not do the work of the saliva. Then, again, tell him that when he drinks while eating, the juices of the stomach are so diluted that digestion is delayed, that fermentation begins, and the nutrition of the food is largely destroyed. Tell him that man is the only animal that drinks at his meals, and that he is the only one that has dyspepsia. After talking to him in this common-sense way, he sees the reasonableness of the order, and is ready to obey to the letter. Of course, if he is a drinker of spirituous and malt liquors, these will have to be discarded; it is the price he has to pay to secure health.
The meal should never be eaten hurriedly, and all business or social cares should be left behind. The meal, however, should be a pleasant one, when all care is banished. Of course there will be some patients that can not have so liberal a diet as that already outlined, and they may even be restricted, for a few weeks, to milk and lime-water, malted milk, buttermilk, albumen water, chicken-broth, oyster-soup, or lamb-broth.
What will agree with one patient can not be taken by another, and the patient is to understand that, when he finds an article which disagrees with him, he is to discard it, even if he does find it on his list of things allowable.
Hygienic measures are of great importance. The patient should be in the open air as much as possible. All exercise, however, should stop short of fatigue. Walking, horseback riding, bicycling, boating, and light gardening, are all beneficial if not severe. Breathing exercises are among the most beneficial.
A cold sponge-bath, followed by a vigorous rub down with a coarse towel, will set the blood to moving in the capillaries, and prove of benefit. When the patient has the means, a change of climate or place will work wonders. A visit to the seashore, to the mountains, or to the lakes, will put new life into the patient; new faces and new scenes enable the patient to forget that he has dyspepsia, and his eye growls brighter, a new color comes to his cheek, the coating disappears from the tongue, and the patient, by getting away from himself, has assisted the physician in effecting a cure.
Medicines.—Before giving any remedy, we are to remove, as far as possible, any cause that is producing or continuing the disease. I have already called attention to the rectum, uterus, and urethra as outside causes, and where these troubles exist they should be corrected before medicating our patients. If associated with renal, hepatic, or cardiac lesions, our attention must be directed to these as well as to the local disease.
In order to receive the best results from our remedies, we must, place the stomach in such a condition that our medication can be readily appropriated. If there are large quantities of tenacious, viscid mucus in the stomach, our remedies will fail to influence the disease. It is of prime importance, then, to get a clean stomach for our base of operations. This can be best accomplished by the lavage tube, and, though disagreeable and unpleasant at first, the patient soon becomes accustomed to it, and can readily wash out the stomach without the aid of the physician. One of my patients had a nozzle and a stopcock attached to a fountain syringe; then, introducing the tube into the stomach, she would slip the free end of the tube on to the nozzle, turn on the water by means of the stopcock, and when the proper amount of water had been taken, a simple turn of the thumb and finger cut off the supply, and, slipping the tube from off the nozzle and depressing the end, the stomach would be emptied of its contents: then, without removing the tube from the stomach, she would again attach her hose to the nozzle, turn on the stream, and proceed in this manner till the water returned clear; We may use plain warm water or a weak solution of salt water; or a small quantity of sodium bicarbonate or boracic acid may be added.
If there be hyper-acidity, it is good treatment to allow four or six ounces of the alkaline water to remain in the stomach. If there be much mucus and the gastric juice is excessively acid, it is frequently due, not to hydrochloric acid, but to the organic acids; in such cases the administration of hydrochloric acid will be- attended with much benefit. If there be atrophy of the peptic glands and a defect of mucus, a reliable preparation of pepsin will prove of great benefit. With this exception, however, the beneficial effects of pepsins are greatly exaggerated. Pancreatin is also of much value in cases of this kind.
|Nux Vomica||10 drops.|
|Phosphate of Hydrastin||10 drops.|
|Water||8 ounces. M.|
|Sig. Teaspoonful every four hours.|
This will be one of the best prescriptions where there is general atony, pale tongue, slight nausea, bad taste in the mouth and a white ring around the lips.
With these conditions there is generally fullness of the abdomen, sluggish condition of the bowels, doughy condition of the skin, and all the evidences of atony at large.
Where there is great irritation of the stomach, small doses of aconite and ipecac will often give relief, though their happiest effect is to be seen in the acute disease. An infusion of the bark from young peach-twigs will nearly always give relief where there is great irritation.
Where there are acrid eructations, attended by a burning or scalding sensation, known as water-brash, subnitrate of bismuth or liquor bismuth will be useful. W here there is marked tenderness over the epigastrium, the older Eclectics obtained excellent results from the application of the old compound tar-plaster, known as "irritating plaster." This was allowed to remain till it produced a crop of pustules, after which it was dressed with simple cerate. As soon as it was healed, a fresh plaster was applied, and this treatment continued till all irritation disappeared. The same results may be obtained by the use of the thapsia plaster, which is not quite so severe; or we may use the old vinegar pack, which consists of a towel wrung out of vinegar-water, and applied on going to bed, a dry roller bandage applied over this; on rising, the pack is removed, and the abdomen sponged with salt water.
Where there is torpor of the liver, with pasty, yellowish coating on the tongue,—
|Tincture of Leptandra||½ dram.|
|Nux Vomica||10 drops.|
|Water||4 ounces. M.|
|Sig. Teaspoonful every four hours.|
The second or third trituration of Podophyllin will also be found very useful in these cases. Where the patient is constipated, fifteen or twenty grains of sodium phosphate two or three times a day will be found to give good results, though the prolonged use of any cathartic is to be discouraged; rather have the patient resort to kneading the bowels for five minutes in the morning before rising; after which instruct him to drink a glass of cold water, to which is added a drop of nux vomica, and after breakfast, at a regular hour each day, solicit a stool. This method, if persisted in regularly for several weeks, will overcome the most persistent and obstinate constipation. To encourage the bowels to move, the first few days an enema of glycerin four ounces, to water one pint, may be used.
As the gastric irritability subsides, or if a hypersecretion of mucus has been overcome, a tonic treatment will be of marked benefit. The old compound tonic mixture, the triple phosphate of iron, quinia, and strychnia, will be found beneficial in half-teaspoonful doses.
Nux and hydrastin are also quite helpful in these cases. Where the skin presents a yellowish or tawny appearance, chionanthus will afford relief.
When the patient grows nervous, and the pulse shows cardiac irritability, pulsatilla and cactus will be called for. Dr. Webster speaks very highly of tincture of [H]aploppapus laricifolius in from two to ten drop doses with these same symptoms.