Acute Gastritis (Acute Gastric Catarrh)

Reasoning from the great functional activity of the stomach, from its daily periodical change of blood-supply, from its extensive glandular arrangement, and from its important relations to the functions of vegetative and animal life, we might readily infer that it would be frequently the seat of acute and destructive inflammation. But it is remarkable, all things considered, how seldom that is the case. Indeed, acute spontaneous inflammation of the stomach is almost unknown. When it occurs it most frequently results from toxic causes. In less severe forms, however, not attended with immediate danger to life, it is undoubtedly a disease of frequent occurrence, and in this more comprehensive sense the subject will be considered in the present section.

The mucous membrane alone is usually the seat of the disease, and for this reason it has become the custom of late years to describe it as gastric catarrh. This may be objectionable, for the reason that it does not include gastric inflammation of every grade of intensity. The term catarrh is generally applied to much more simple anatomical structures than those pertaining to the stomach. We shall consider the subject therefore under two forms—namely, (1) Catarrhal; (2) Erythematous gastritis.

ETIOLOGY.—Certain conditions predispose to the disease. Acute catarrhal gastritis is specially liable to occur in those who habitually suffer from a disordered stomach. This may arise from functional disturbance of the digestive process on the one hand, or mechanical obstruction on the other. Mechanical causes are widespread in their influence. Thus, weak heart-action from any cause tends to disturb the normal adjustment between the two sides of the circulation—arterial and venous. An abnormal amount of blood accumulates on the venous side of the circulation, and chronic passive hyperæmia of the abdominal viscera is the result. The effect of this upon the stomach is to lower its functional activity and to invite inflammatory action. The same condition results from structural diseases of the heart, lungs, or liver. Persons suffering from valvular diseases of the heart, emphysema of the lungs, or cirrhosis of the liver are strongly predisposed to diseases of the stomach. Gastric troubles are also apt to supervene during the progress of various diseases.

Gouty and rheumatic persons are specially prone to suffer from gastric catarrh; and eruptive disorders, such as scarlatina, diphtheria, etc., tend to erythematous forms of gastric inflammation. Catarrhal gastritis is also a very common sequence of the whole class of malarious fevers, including yellow fever, intermittents, and remittents. In its more acute form gastric inflammation supervenes in the course of yellow fever; and what is observed here in an extreme degree exists in a minor degree in all the so-called malarious fevers. Intermittent and remittent fevers are always attended with gastro-duodenitis and gastro-hepatitis. The degree of this inflammatory complication determines the continued character of the fever. Upon this point the writer has very decided views based upon a wide field of observation in malarious regions of country. We have lost ground in the treatment of these diseases by directing our attention almost exclusively to the febrile and malarious, to the exclusion of the inflammatory, elements. Quinia is inoperative in the cure of these troublesome and often fatal complications. Indeed, it is more than that: it is often positively injurious. Arrest the local phlegmasia and secure freedom of abdominal circulation, and we at once get the action of the specific remedy. It may be going too far to affirm, as did Broussais, that gastritis sustains a causative relation to all forms of fever, but that gastro-duodenitis is an important secondary condition in all forms of malarious fever, complicating and perpetuating the febrile state, there can be no doubt; and it is equally clear that it constitutes one of the most dangerous complications. Excessive alimentation, with the injudicious use of tonics and stimulants, so often resorted to in the treatment of these fevers in their early stages, only serves to intensify the local inflammation. Abolish the congestive and inflammatory element of a remittent, and it at once becomes an intermittent.

Mention has been made of weak heart-action as a factor in catarrhal gastritis; also mechanical impediments to the return of blood from the stomach to the heart. The stomach is thereby kept in a constant state of congestion, the nutrition of the mucous membrane is less active than in health, and its solvent juices are more sparingly secreted. Thus in long-continued congestion produced by mitral disease of the heart Samuel Fenwick found the formation of pepsin impaired. He made artificial gastric juice from the mucous membrane of three males dying of heart disease, and he found, on the average, only 2-9 grs. of albumen were dissolved, whereas the amount digested by the mucous membrane of persons who had died of other maladies was 4 grains. In the cases of three females a still smaller amount of solvent power was displayed. These facts have important bearings upon the question of alimentation in fevers and the conditions in which there is chronic congestion on the venous side of the circulation. Long-continued passive hyperæmia of the stomach from any cause not only impairs its functional activity, but strongly predisposes to inflammatory complication.

Acute erythematous gastritis is most frequently met with in children. It is a very common form of disease in early life, and the local nature of the malady is frequently overlooked. Few questions in practical medicine are more embarrassing to the physician. It has been known and described as gastric and remittent fever, as continued typhoid, and even as acute hydrocephalus. Writers and teachers describe and dogmatize, while practical men hesitate at the bedside. There is little doubt but in the background of these febrile manifestations in children there is often an acute erythematous gastritis, which is more successfully treated by a rigid milk diet, small doses of calomel and bismuth, mucilaginous drinks, cooling saline laxatives, and sometimes leeches applied to the epigastrium, than by the heroic doses of quinia so frequently resorted to.

We must not, in this connection, lose sight of the fact, so clearly pointed out by Broussais, that inflammation of the stomach is often secondarily repeated in the brain. The whole field of clinical observation abounds in illustrations of this. How often, for instance, we can trace the sick headache, the delirium, and even convulsive movements of the voluntary muscles, to primary gastro-intestinal irritation! In the play of the sympathies morbid irritative action is transmitted from the organic to the cerebro-spinal nerves; and of all portions of the abdominal viscera the stomach and upper portion of the intestinal track are the most frequent seat of these intense morbid sympathies. Remedies which cool the stomach and lessen inflammatory action diminish the excitement of the brain, and vice versâ.

EXCITING CAUSES.—Among the direct exciting causes of gastric inflammation—exclusive of acrid or corrosive poisons—the most frequent in this country is the excessive use of alcohol. It acts most injuriously when it is but slightly diluted and taken on an empty stomach. And next to this pernicious habit, in the order of importance, is the use of large quantities of food—more than the stomach has capacity to digest, and more than is necessary for the wants of the system. Excessive alimentation is a prolific source of gastric inflammation. It generally manifests itself, however, in a chronic or subacute form.

Acute erythematous gastritis, so frequently met with in children, is often present in scarlatina. It is evidently not catarrhal in character, for in the earlier stages there is no increased secretion of mucus and but little injection of the mucous membrane. The changes are observed in the deeper structures of the stomach, and principally in the gastric tubules. They are much distended by granular, fatty, and albuminous matter; and in this respect it is analogous to erythematous affections of the skin with which it is associated in scarlatina.

Finally, acute gastric catarrh may be excited by all causes that weaken the digestive power either by weakening the gastric juice or by retarding the movements of the stomach.

ANATOMICAL CHARACTERS.—No disease requires more knowledge and caution in determining post-mortem changes than those of the stomach. In the first place, it presents in inflammatory conditions markedly different degrees of intensity, with corresponding differences in anatomical changes. Its diseases also present many special forms, and changes take place after death which simulate morbid processes during life. Moreover, intense vascular injections are apt to disappear in the small superficial vessels after death. This applies to all mucous membranes, but specially to the mucous membrane of the stomach, which is the seat of varying amounts of blood in their physiological limits during life. For this reason the observations of Beaumont made upon a living subject are invested with peculiar interest. It will be remembered that in the case of Alexis St. Martin the appearances noted were such as belong to the milder forms of inflammation. Beaumont noticed in this case, after indiscretions in eating or abuse of ardent spirits, a livid erythematous redness of the gastric mucous membrane, with, at the same time, dryness of the mouth, thirst, accelerated pulse, and, at the height of the injection, an entire absence of gastric secretion. At other times there was considerable muco-purulent matter, with oozing of grumous blood, "resembling the discharge from the bowels in cases of chronic dysentery." The fluid taken out through the fistulous opening consisted mostly, however, of mucus and muco-pus which showed an alkaline reaction. He describes also a condition of ecchymosis and oozing of blood from certain red spots of the gastric mucous membrane, and when thus limited the constitutional symptoms experienced by the patient were correspondingly slight. Ecchymoses may be present in large number, with exudates of false membrane, which Beaumont describes as aphthous. Brinton also describes a severe form of gastritis which he terms ulcerative, in which he observed hemorrhagic erosions.

In the catarrhal form of gastritis the mucous membrane is covered with a thick, tenacious, stringy mucus; it is softer than usual, and generally thickened. It presents at the same time a dead-white appearance, corresponding to Virchow's cloudy swelling—a condition analogous to that which is observed in acute Bright's disease. Even casts of the tubes are sometimes met with.

This inflammatory change in the substance of the mucous membrane is especially observed in the acute erythematous form of gastritis complicating scarlatina. In the early stage there is no increased secretion of mucus, and at a more advanced stage the membrane may be even paler than usual.

In cases of acute toxic gastritis intense redness is seen over the entire surface of the mucous membrane, followed by rapid exudations and sloughing of portions of the membrane.

In all forms of the disease there is a tendency to extension of the inflammation into the duodenum and small intestines. In the more chronic forms we almost invariably encounter the condition of gastro-duodenitis.

SYMPTOMS.—The symptoms of inflammation of the stomach present wide differences in their intensity, depending upon the degree of severity in different cases. In acute inflammation caused by the direct action of poisonous irritants they are pronounced and highly diagnostic. The patient immediately complains of burning pain, referred to the epigastrium, followed by intense thirst and vomiting. The thirst is apt to be very great and the act of vomiting painful. The vomited matters contain mucus, saliva, sometimes bile, and not unfrequently, in fatal cases, black, grumous, coffee-ground material. There is marked tenderness on pressure, the pulse is frequent and small, coldness of the surface is marked, and hiccough is apt to occur. The expression of the patient is anxious, the abdominal muscles rigid, and, in fatal cases, the prostration becomes rapidly extreme. The patient dies by asthenia. These symptoms apply to acute cases of marked severity, usually of toxic origin.

In the milder forms of catarrhal gastritis more frequently met with there is seldom complaint of pain. The sensation is rather that of fulness, uneasiness, with more or less tenderness on pressure. The symptoms are such as belong to acute indigestion and the embarras gastrique of French authors. The phenomena may be those of a slight bilious attack. The tongue is foul, the breath offensive, the bowels confined, and the urine high-colored and scanty. There is also generally a sense of fatigue, and soon secondary cerebral symptoms supervene, such as cerebral hyperæmia, headache, vertigo, noises in the ears, palpitation, sighing, yawning, dyspnoea, faintness, and in severe cases marked physical and mental depression. Nausea and vomiting are common, and if the inflammation extends to the duodenum and liver, symptoms of gastro-hepatic catarrh manifest themselves. If fever supervenes, urticaria sometimes complicates these attacks.

In young children the inflammation is apt to involve a general catarrh of the whole intestinal track. Thirst is excessive, followed by vomiting and diarrhoea. The discharges are liquid, watery, offensive, acid, and out of all proportion to the amount of fluid absorbed by the stomach. The pulse becomes weak and fluttering, the skin pale, the features pinched, the eyes sunken, and the extremities cold. The tendency is toward rapid collapse and fatal issue. The symptoms describe what is usually known as cholera infantum. It has its analogue in the cholera morbus of adults.

In erythematous gastritis nausea and vomiting are as general as in the catarrhal form, but, unlike the catarrhal, pain at the epigastrium is a prominent symptom. It comes on directly after taking food. In phthisical cases the sensation is rather that of rawness of the oesophagus and stomach. Thirst is a troublesome symptom; the tongue is red or dry and glazed; tenderness of the epigastrium is marked; diarrhoea is generally present; and, as in the catarrhal form, the stools are fetid and unhealthy. The disease shows a marked tendency to become chronic.

DIAGNOSIS.—In the more acute forms of the disease the symptoms are all highly diagnostic. Vomiting, burning pain of the stomach, tenderness on pressure, intense thirst, with frequent and small pulse, point with almost unerring certainty to acute gastric inflammation. But vomiting of itself, however persistent, is not evidence of gastritis, for it may be present from many other causes. If the vomiting be attended by headache, it may be confounded with gastric irritability from brain disease. Thus, chronic meningitis with persistent vomiting strongly simulates gastritis, and in the case of children it is liable to be mistaken for it. In gastritis the nausea is from the first a pronounced feature of the disease. Vomiting in affections of the brain is often unattended by nausea. In gastritis the tongue is more frequently coated or red and glazed. Diarrhoea is also more frequently present, especially in early life. In affections of the brain the tongue may be clean and the bowels are usually obstinately confined. When there is much fever, gastritis may be confounded with remittent or typhoid fever. In periods of childhood this mistake is specially liable to occur, for there are many symptoms in common. In all such cases the early history of the case ought to be carefully inquired into. In gastritis we may be able to detect the cause in any particular case. The gastric symptoms are apt to occur suddenly, and, as already stated, are prominent from the first. In meningitis the skin is more frequently dry; in gastric catarrh perspirations are common. The more prominent and characteristic symptoms of typhoid should also be carefully excluded, such as the gradual invasion, peculiar eruption, bronchial catarrh, enlargement of the spleen, gurgling in the right iliac fossæ, with tympanitic abdomen. Peritonitis, with vomiting, may be mistaken for gastritis, but the diffuse tenderness, the fixedness of position, the rigidity of the abdominal muscles, and the tympanitic distension serve to guide us in our diagnosis.

PROGNOSIS.—The prognosis must have reference to the cause. The more violent forms of the disease resulting from corrosive poisons are generally fatal. Death is apt to take place in a few hours from a condition of collapse. The immediate cause of death is failure of heart-action. It is also a dangerous disease in the extremes of life. In its acute form in children it is apt to terminate fatally, especially if it is not recognized early and judiciously treated. The complications of the disease may also render the prognosis unfavorable. Milder cases tend to recovery.

TREATMENT.—The most important indication of treatment, applicable to all forms of gastric inflammation, is to secure complete or partial rest for the inflamed organ. In dangerous cases no food should be taken into the stomach. The patient should be nourished exclusively by nutrient enemata. If food is permitted, it should be restricted to milk and lime-water, administered in small quantities at short intervals. In acute and dangerous cases, suddenly manifesting themselves, the exciting cause should be carefully inquired into, and speedily removed, if possible, by an emetic, or, if need be, by the stomach-pump, if the poison be one which can be ejected; and following this antidotes are to be administered according to the nature of the poison.

To allay the intense thirst small pieces of ice should be swallowed at frequent intervals, or, what is often more grateful to the patient, iced effervescing drinks in small doses oft repeated. Injections of water may also tend to relieve thirst. To allay vomiting the physician is often tempted to try a great variety of remedies which are usually worse than useless, for they aggravate rather than relieve the distressing symptom. For the purpose of quieting the stomach opium is the most reliable remedy we possess. It is best administered hypodermically. Fomentations may be applied over the epigastrium. Stimulants are, of course, contraindicated on account of their irritating action on the inflamed membrane, but in case of rapid tendency to death by failure of heart-action they should be administered by the rectum or hypodermically.

In milder cases—which are much the more common—physiological rest of the organ is also a cardinal principle of treatment. Rest of the body is equally essential. In cases of any severity the patient should be kept quiet in bed. For the condition of acute indigestion known as embarras gastrique ipecacuanha in six- or eight-grain doses, given three times within twenty-four hours, will often produce healthy bilious stools, and in this manner accomplish the cure. One or two grains of calomel may be added to each dose of ipecacuanha with benefit. In all forms of catarrhal gastritis, especially if symptoms of portal congestion are present, mild mercurial cathartics are attended with benefit. Six or eight grains of calomel may be rubbed up with sugar of milk and placed dry on the tongue, followed by a cooling saline aperient. When diarrhoea is present in such cases, it should be regarded as conservative, and encouraged by the administration of half-grain or grain doses of calomel, combined with bismuth and bicarbonate of soda. The diet should be restricted to milk and lime-water or milk mixed with Vichy or Seltzer water. Demulcent drinks should be freely given. In the slighter attacks effervescing drinks are grateful to the patient; and if there be excessive formation of acid in the stomach, antacids and sedatives should be administered.

Bismuth has a peculiar sedative and antiseptic effect in the milder forms of inflammatory action of mucous membranes. It is especially valuable in gastro-intestinal troubles of children. Its action is mainly local surface action, and may therefore be given in liberal doses if necessary. Children may take from five to ten grains, and adults twenty grains or more. Hydrocyanic acid adds to its sedative qualities, or when pain is present, with diarrhoea, opium in some form may be added. The salicylate of bismuth is specially indicated when we want to add to the antiseptic qualities of bismuth.

The general principles of treatment indicated here are applicable to the so-called remittent fevers of children—namely, calomel in small doses, combined with bismuth and bicarbonate of soda, followed by occasional cool saline laxatives. Ipecacuanha is also a valuable agent in correcting morbid gastro-intestinal secretions. When there is early epigastric tenderness, with hot skin and elevation of temperature, two or three leeches should be applied to the epigastrium, followed by warm poultices of linseed meal. Dry cupping may also be used with benefit; and if decided remissions occur, with suspicions of a complicating malarious element, a few liberal doses of quinia may be tried. In many such cases, however, it will be found unnecessary, and not unfrequently hurtful. In acute gastro-intestinal inflammations of children—the temperature reaching 105° or more—no febrifuge, in the opinion of the writer, is equal to the cool or cold bath, repeated from time to time until there is a decided reduction of temperature. But the gastric inflammation, rather than the fever, should mainly claim our attention.

Great care is necessary during convalescence from acute gastric disease, particularly as regards the hygienic management. The apparent debility of the patient too often tempts the physician to the early and injudicious use of tonics, stimulants, and excessive alimentation, which, if persisted in, can scarcely fail to perpetuate a chronic form of inflammatory action.