MICROSCOPICAL APPEARANCES.

129

them being occupied either by an increased amount of connective tissue, or by nuclei, cells, and fibres. The tubes themselves, in the earliest stage, are in some cases distended by a confused mass of cells and molecular matters, and their contents, more especially in the pyloric region, often project from their open ends, giving them the appearance of dark granular villi. At a later period of the disease, either the distinction between the tubes is lost, and a line of fatty cells alone remains to point out their original position; or the mucous membrane presents a series of flask-shaped bodies loaded with cells, fatty and granular matters in the site of the bases of the tubes; the rest of the mucous membrane being reduced to a tissue, in which no vestige of glandular structure can be recognised. (See plate 5, fig. 1.)

Chronic tubular gastritis is a less frequent form of the disease. In this the tubes remain separate from each other, but they are generally found more or less empty; a few cells, or a little granular matter, alone occupying their interior. At a later period the tubes are lessened in calibre, the basement membrane often appearing wrinkled; and in other cases their distinctness disappears, and a few scattered cells are alone visible. (See plate 5, figs. 2 and 3.)

These alterations produced by chronic gastritis are most frequently met with in the pyloric region; indeed, in the bodies of few persons above the age of forty who have died in our London hospitals, can the mucous membrane at this part be said to be in a perfectly healthy condition.

In the pyloric region we also frequently meet with another morbid appearance, first described by Dr. H.

K

Jones, viz., an enlargement of the solitary glands of the stomach. These form round or oval masses of small cells and nuclei, surrounded by a distinct membrane. They are usually situated between the secreting tubes and the muscular coat. Occasionally they present a cavity, bounded by a thick layer of cells and nuclei; and the secreting tubes in their neighbourhood are very frequently pushed aside and atrophied. (See plate 8, fig. 1.)

Cysts are also of very frequent occurrence in the pyloric region, and are to be referred to chronic inflammation of the mucous membrane. Two varieties of these formations may be recognised: one appears to be produced by the evacuation of the contents of an enlarged solitary gland, the opening through which it had been emptied having subsequently closed; the other seems to arise from the distension of a tube, the outlet of which has been obstructed. The latter may be distinguished by its being lined with epithelium, and being generally surrounded by the remains of glandular

structure.

In the forms of disease just described, the inflammation is confined to the mucous membrane; but it is not uncommon to find the subjacent coats of the stomach also affected. This generally occurs near the pylorus, and along the smaller curvature. Sometimes the whole of the pyloric region is diseased, at other times the morbid changes are limited to a patch one or two inches in diameter. In these places the coats of the stomach feel hard, tough, and leathery, and the mucous membrane does not retract when divided. The connective tissue below

HYPERTROPHY OF THE STOMACH,

131

the mucous membrane is much thickened, and the muscular structure is often fibrous. The peritoneal coat and its subjacent connective tissue are also much increased in thickness. The mucous membrane is usually diseased over the parts affected.

I have inserted the next case to show that this condition may affect the whole of the organ, and that it may arise from an injury to the epigastrium.

CASE 15. A gentleman, who had for some years been subject to bronchitis, fell overboard whilst superintending the repairs of a ship. He was swept away by a strong tide, until he grasped the paddle-wheel of a steamboat lying at anchor. On this he rested himself, bearing his whole weight upon the epigastrium. He remained in this position for about half an hour, and was much exhausted when rescued. On being carried home, he complained of pain in the region of the stomach; but I could discover nothing abnormal on examination. I attended him for many months, and, erroneously supposing that the pain in the epigastrium was caused by the liver being pushed downwards by an emphysematous state of the lungs, I directed all my attention to the relief of the chest.

Within nine months after the accident he died, gradually losing flesh and strength. He complained to the last of the pain in the stomach, and for a few weeks before death he vomited all his food. On postmortem examination, the stomach was found like a cricket-ball, round and hard. It did not collapse when cut into, from the great thickening of its coats. The mucous membrane appeared healthy to the naked eye.

Morbid changes are also very frequent in the duodenum. We often find the upper part of the intestine studded with the enlarged openings of Brunner's glands. These are in some cases greatly increased in size, and on microscopic examination their acini are seen to be distended with epithelium, which is often in a state of fatty degeneration. In others the fibrous tissue between the acini is increased, and the glandular structure is in a state of atrophy.

The villi present various alterations in chronic duodenitis. Sometimes the basement membrane is thickened, and the villi are loaded with nuclei; in other cases they are thin and transparent, as if wasted.

As we know so little about the functions of this part of the intestinal canal, it is useless to speculate upon the effects which such alterations in structure may produce upon nutrition; but there can be no doubt that they are of an important nature.

Since chronic gastritis is apt to accompany a number of the diseases of other organs, it is no wonder that a great variety of symptoms should have been attributed to it. I purpose, however, to mention only those that seem to arise more directly from the gastric affection.

In the more severe cases of this complaint pain is seldom absent, but in the slighter there is only uneasiness. When pain is present, it is chiefly felt at the epigastrium; sometimes it affects the back or right hypochondriac region. It is increased by food, and generally also by stimulants and hot liquids. As soon as the organ is empty the pain subsides, but is often followed by a craving, or sinking sensation

SYMPTOMS OF CHRONIC GASTRITIS.

133

at the pit of the stomach, which induces the patient again to have recourse to food.

There is almost always a certain amount of tenderness at the epigastrium on deep pressure, and this will be found to be present even when no actual pain is experienced during digestion. In using this as a test for chronic gastritis, care must be taken not to confound this tenderness with the increased sensation of the skin so common in nervous and hysterical subjects.

I

Vomiting is seldom a prominent symptom, but nausea is very general. It is not uncommon for violent retching to take place in the morning, and for a quantity of mucus to be then rejected. have very frequently examined this mucus with the microscope, and have usually found particles of food, along with torule or other forms of vegetable fungi entangled in it. When there is no vomiting it is common for the patient to complain of mucus at the back of the throat, which produces a difficulty of swallowing and a choking sensation. This symptom is generally associated with acidity, and seems to arise from irritation of the pharynx by the acrid eructations.

pain, if it exists, When examined

Waterbrash has been referred by authors to different causes. Two forms of it may be recognised. In one the patient states that the mouth is suddenly filled with water, but the epigastric is not relieved by the discharge. microscopically, the fluid will be found to contain only the epithelial cells of the mouth. It is, in fact, only an increased flow of saliva, produced by gastric

irritation.