Pathological anatomy, pathology and physical diagnosis. : A series of clinical reports comprising the principal diseases of the human body: Volume 2

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DISEASES OF THE ORGANS OF DI'GEC'I‘ION. [SECTIoN VI. mortem appearance after three days: The slightly swollen TABLE II. lips are brownish red, tough, and covered with thick, dark- FIG. 1.-Acutc Catarrhal Gastritis with Infiltration into and Ifyperplosio of the fll'ucous filemhrmze. red crusts. The stomach is here slightly dilated, the mucous membrane thickened, and its folds very prominent. The openings of Lieberkuhn's glands are enlarged and surrounded by circular ridges, plainly showing the orifices of the dilated sacs. The follicles are increased both in size and number, especially in the pyloric and (esophageal regions. The appearance of the membrane is less red than that shown in Table I, Fig. 2, of this Section, yet sufficiently injected to show a high state of hyperaemia and severe catarrhal inflammation. . oesophagus, and the region of the cardia are corroded in many places and present opaque white and yellowspots. In some places the surface-tissue still adheres to the under- lying, while in others there is solution of continuity between them. The injuries differ in the upper part of the The inner surface of the lips and the gums are opaque white, and unimpaired. The soft palate, pharynx, (esophagus from the lower in depth and intensity. lesions of the stomach are not very extensive. The Besides those situated in the cardia there are in the left half of the posterior wall and nearly in the middle of the organ :1 moderate number of ulcers. The ab‘aded portions are surrounded by wider or narrower hyperzemic borders. The FIG. 2.--Acute Gastric Catarrh, Corrosive Ulcerotion of the dfucous filcmhrcmc of the Stomach, Esophagus and Pharynm. Laryngeal Group. CASE- A child six years old. IIIIstory.- Is supposed to have swallowed some corro- sive liquid. Antidotes and other proper remedies to coun- teract the supposed poison were administered. The child constantly complained of pain in the throat and in the oesophagus, without being relieved by the treatment. Swallowing became more and more difficult, dyspuora ap- swelling, even in the vicinity of the extensive ulcers, is not very great. The edges of the largest ulcers are abrupt on nearly all sides. The bases of the smaller ulcers are in the middle layer of the mucous membrane, While the larger reach into the sub-mucous structures. A number of small, shallow ulcers are scattered over different portions of the inner surface. The pale-red mucous membrane shows a state of catarrlial inflammation, and is covered in many places with minute lizemorrhagcs of very recent peared on the fourth day and gradually increased in inten- date. The membrznc is covered with a tough, glassy mucus, slightly tinged with bile. The deeper layers of sity to the twelfth day, when it died of asphyxia. the walls of the stomach are unaffected. Post- great measure, prevent immediate contact of the injurious substances extends into the sub-mucous, the muscular, and even serous coats, with the walls of the organ. and renders the walls of the stomach dense and induratcd. But this power of hypersecrction has its limits; and when the injury is continuous, the stomach becomes so much deeper affected, for the epithelial tiSsuc becomes the less able to resist the more the exhaustive supersecretion has taken place. By far the commonest affection of the stomach is catarrhal inflammation, which may either be acute or chronic. In acute catarrh the mucous membrane is tinged either all over or in spots, dark red, swollen, and spread over with luemorrhagic spots of vari- ous dimensions. (Section VI, Table I, Figs. 1, 2.) The surface is usually covered with mucus, degenerated epithelium, and lymphoid cells. The cylindrical epithelium of the glandular orifices is in a state of mucous degeneration and exfoliation; the epithelial cells of the peptic glands are displaced and more granular than usual. The interglandular connective tissue contains very turgid blood vessels, and is infiltrated with lymphoid cells, more especially along the veins. The sub-glandular and sub-mucous structures are also much infiltrated, and the cells in the lymphatics are deeply altered. Such inflammatory conditions may exist within the whole stomach or only in parts. The pyloric region is usually affected in this manner. By far the greatest number of cases of gastritis are readily cured and very transitory, but here and there it assumes a chronic form which leads to extensive and deep changes in the organ. When the epithelial covering undergoes extensive destruction from massive infiltration, etc., it is hardly ever regenerated, but is followed by an atrophic condition of the glandular parenchyma. When the infiltration is excessively great, then both epithelium and connective tissue become destroyed and utterly obliterated. More or less extensive ulceration, is then produced. which gradually diffuses over the Whole surface. The ulcers differ in size, their depth is unequal, their limits indefinite. 0n the bottom of such ulcers numerous elevations of various heights, and differing in color, may be found. The edges of the ulcers either pass imperceptibly into the adjacent portions of the healthy tissue, 0 ' are distinctly or indistinctly outlined, and covered with excrescenccs or vcgetations in the form of polypi or ridges. When the ulcers increase to a size readily visible to the naked eye (Section VI, Tables II, III, IV), the glandular structures are found perfectly oblitc ‘atcd, and the muscular tissue, although still preserved, is filled with lymph corpuscles. The sub-mucous tissue is indurated and thickened, and contains far more connective-tissue cells and lymphoid corpuscles than the normal. Preserved portions of the mucous membrane are also infilt'ated, especially in the neighborhood of the indnrated parts. Some of the glands are very much constricted, seine enormously dilated, and the lymph follicles more numerous and much larger than normal. (Section VI, Table II, Fig. 1, F F.) Such extensive ulcerations after inflammation are rather of rare occurrence, but still sometimes do take place. Pigmentation, atrophy of the glandular portion and partial induration very frequently follow inflammation of the gastric mucous memb aim. The pigment is here as everywhere the remainder of former lu‘emorrhages, and presents grayish or gray-black spots. The atrophy of the membrane is easily recognizable by its thinness. W'hen hyperplastic formation is carried on to a very moderate extent, only the interglandular structure will be found increased in density, but when it takes The muscular tissue is sometimes completely obliterated, or becomes hypertrophic. P/Ilcgmomus inflammation of the stomach takes place either locally or generally; the latter is the most common. The seat of the inflammation is essentially in the sub-mucous tissue. In the circumscribed form perforating abscesses are formed. In the diffuse form the inflammatoiw process begins in the sub-mucous tissue by swelling and rendering it more (louse, whilst. the mucous tissue becomes either moderately swollen or remains unaltered The exudate is of a viseid puriform nature and often infiltrates into the muscular coat, extending sometimes even into the serous. Both become swollen,and the serous surface is often covered with pus or fibroi<_l-pus. In the advanced stages the tissues become softened, and the pus perforatcs the mucous membrane here and there; the muscular coat may likewise become perforated. Should the patient survive (which sometimes happens in small circumscribed phlegmons, and provided there is no perforation into the peritoneal cavity with discharge of pus), cicatrization will close up smaller perforations, and larger ones become covered with epithelium but permanently lose the sub-mucous structure. Idiopathic croupons and (lip/)t/acritic inflummations of the stomach are very rare, but as a part affection ofpharyngeal and (esophageal croup or diphtheria is of common occurrence. In scarlet fever, small-pox, and in other very acute infections, eroupous exudate, more or less extensive, is found upon the mucous surface either in the form of yellowish-gray membranes or plaques. In diphtheritis the superficial layer of the membrane becomes cscharotic, and the gangrenous process may extend into sub-mucous tissue and convert the whole into a black mortified mass. J-Ikcm orr/myrs. The great vascularity of the stomach makes it readily subject to liremorrhages. Mechanical, chemical, thermic injuries, inflammatory and other morbid alterations of the vascular walls, ulcerative prOcesscs, venous stasis in the liver and portal system, Scurvy, yellow fever, acute yellow atrophy of the liver, typhoid and severe exanthcmatous fevers, ctc., local as well as general infections and various dyscrascs may produce gastric lucmorrhagcs. Extravasated blood upon the inner surface of the organ soon assumes a deep brown or black color, owing to the reduction of its haunoglobin to hannatin by the acid secretion of the stomach. Ihcmorrhagc into the mucous membrane makes the tissue look either red, brown, or grayish black. Circulation in such an infiltrated tissue is either carried on very incon'ipletely or not at all, and consequently becomes subject to digestive action of the gastric juice and is soon destroyed. (A'ufoprpsia.) "Then the tissue is destroyed more or less extensive bleeding ulcers are formed. (Hacmorrhagic erosions.) Provided the necessary precaution is used by the affected person such ulcers very readily heal. Regeneration of the destroyed tissue begins with reactive inflammation, infiltration of the tissues adjacent to the ulcers, followed by formation of granulations and connective tissue; finally reproduction of an epithelial covering. Pathology. place in a massive manner then the mucous membnnes become sclerotic, and elevations in the shape of ridges and folds will appear Morbid alterations of the blood vessels of the stomach, which (Section either hinder or check altogether local circulation in the organ, are VLTab. VI,Fig. 4.) This rugous or warty appearance is designated the main causes of corrosive action of the gastric juice upon the anaemic tissue. Virchow, Rokitansky, Merkcl, and others have upon parts or nearly the whole inner surface of the organ. by French writers as "Eon? mmmlnc," or gastric polj/posis. The hyperplastie tissue is sometimes tough and fibrous, aml sometimes soft and cellular, and owing to loss of the epithelium part of the mucous glands becomes obliterated and part extremely dilated. The dilated cysts contain muco-scrous liquid, crumbling epithelial detritus, and often colloid balls. Larger cysts are sometimes filled with papilliform excrcscences. In all chronic forms of gastritis, and especially in the ulcerative, the development of connective tissue proved that recently-formed ulcers were due to closure of the cavi- ties of the smaller gastric arteries, brought about by embolism, thrombosis, fatty degeneracy, atheromatous or amyloid alteration of the walls. Pavy has shown that by ligating the gastric arteries of animals ulceration in the stomach is produced. In fact any cause capable of arresting gastric circulation to any great extent will produce circular ulcers.