to the stomach. (1.) General, Characteristics. The size or distention of the stomach is evidently dependent, above all things, upon the quantity of the food which it may contain, although this always varies but little. Abnormal dilatations are frequent, partly acute (distention from gas), partly chronic (dilatation proper) ; the latter may be so extreme that the greater curvature reaches down to the true pelvis. This affection is usually the result of stenosis in some of the deeper portions of the digestive tract, especially from tumors in the duodenum; it may be, however, idiopathic, being produced by constant overfilling for a long time, and eventual paralysis of the muscular coat. Partial dilatation of the fundus and cardiac extremity also occurs, especially in connection with stenosis of the middle portion from cicatricial contraction (large chronic gastric ulcers, etc.). When the muscular coat is greatly stretched, it is sometimes marked by lines similar to those in the skin of the abdomen when the latter is greatly distended. Contraction of the stomach is much more rare than dilatation. It occurs with relative frequency accompanying the so-called atrophying cancer, scirrhus, which may involve the whole mucous membrane, and cause a great diminution in the size of the stomach by the contraction of its walls. Variations in shape occur as congenital anomalies, in the form of a diminution in size at or near the middle (furrow), so that the stomach is of an hour-glass shape. Frequently the same variation is pathological, caused by cicatricial contraction, which may be due to a chronic ulcer, or to a cancer situated at this point. Secondary variations in shape of different kinds, due to external mechanical influence (adhesions, tumors, etc.), are, of course, liable to be met with. Variations in position., either with or without a change in shape, are observed, and usually consist in a lower position of the pylorus than usual, the stomach occupying its foetal position (directed from above downwards) more or less. The color of the outer surface is usually gray. This assumes a whitish shade similar to that of fibrous tissue, when the serous coat is thickened by chronic processes of various sorts. When the walls are softened by acid contents, they appear translucent, gray, and gelatinous. They appear blackish from the effects of sulphuric acid, etc. 280 DIAGNOSIS IN PATHOLOGICAL ANATOMY. In cases of so-called softening the consistency may become like that of mucus, whether the softening is due to the acid contents of the stomach, or to poisons which have been introduced. It is increased in all those affections which are accompanied by a thickening of the serous, and especially of the muscular, coat ; in the case of diffuse scirrhus cancer of the stomach, the hardness may be like that of a board (formerly frequently called cirrhosis of the stomach). <Callout type="important" title="Important">The color changes can indicate different conditions; gray or whitish indicates chronic processes, while blackish suggests acid contents.</Callout> (2.) Affections of the Serous Coat. The serous coat of the stomach becomes involved in many affections of the mucous membrane, as well as in those of the peritoneum. Perigastritis chronica., which is frequently adhesive, is characterized by the thickening and white color of the serous covering, and by the adhesions to the liver, transverse colon, spleen, or diaphragm which it produces. It seldom extends over the whole stomach or over a great area, but is more frequently partial, being situated over circumscripted affections of the mucous membrane (ulcers, tumors), and decreases in intensity towards the periphery. Acute purulent inflammation is, in the majority of cases, a part of a similar general peritonitis. There is, however, a peculiar form of purulent inflammation, purulent lymphangitis., which is confined to the stomach, and is due to disease of the mucous membrane (tumors). In these cases delicate, varicose (in consequence of valves) vessels, some of which may be one centimeter in diameter, are seen beneath the serous coat, filled with yellow purulent material. They originate principally from one point, which corresponds to the place in the mucous membrane where the tumor is situated. The affection may extend to the diaphragm, and the pleura, when the previously described lymphangitis purulenta pleuralis and pulmonalis even results. The serous coat of the stomach becomes affected in general tubercular peritonitis, as well as in the purulent form. This affection is frequently not uniform, the anterior wall being more affected from its exposure, so to speak, to the tubercular germs in the abdominal cavity, than the protected posterior wall. Sometimes the anterior surface is found thickly studded with tubercles, while they are seen only in groups upon the posterior wall, and frequently follow the course of the vessels. Carcinomatous perigastritis may be a part of general carcinoma of the peritoneum, or it may occur alone as a secondary affection of the gastric mucous membrane. The latter is the most frequent form. Small nodules of varied size are seen at the point where the cancer is situated in the mucous membrane, which is usually indicated by depression and marked thickening of the serous coat, and frequently by adhesions. The nodules are usually arranged in groups, becoming smaller and more isolated towards the periphery of the latter. This secondary formation of cancer may occur in connection with lymphangitis purulenta. The lymphatic glands situated especially along the lesser curvature of the stomach, also become involved, and undergo carcinomatous degeneration. In all cases where perforation is suspected, the examination must be made with the greatest care. The post-mortem rupture of the stomach must be distinguished from those forms occurring during life. In the former case a varying quantity of the contents of the stomach is found free in the abdominal cavity, without any appearance of inflammatory reaction. The walls of the stomach, especially at the fundus, are much softened, and are frequently converted into a translucent, slimy mass. The cause of this change is found to be due either to abundant, strongly acid (fermenting) food, especially in children that have drunk much milk, or to the presence of poisonous substances (for instance, sulphuric acid), which have a similar effect. The effect produced by perforations occurring during life, range according to the relations of the surrounding parts ; a communication may be established with the abdominal cavity, or with a closed sack resulting from chronic inflammation, or the hole in the wall may become closed by the formation of adhesions between the stomach and other organs. In the first instance the result is a general peritonitis which is quickly fatal ; in the second, a circumscribed purulent or ichorous inflammation, which is frequently of long standing ; and in the last, as a rule, a chronic progressive ulceration. In such cases it is frequently necessary to vary from the usual method of performing the autopsy, and to remove the stomach in connection with the other organs, most frequently the pancreas and liver. In the first two classes of cases the opening in the walls is relatively small, and in the first, frequently not more than one to three millimeters in diameter, but usually appears as though made with a punch. Very often such perforations are closed by very delicate adhesions, which may be accidentally torn, thus making it doubtful whether the perforation previously existed or was artificially made. Similar perforations occur in the duodenum, but less frequently. The most frequent cause here, as in the stomach, is the so-called chronic, round or perforating ulcer, less frequently carcinoma. (5.) The Internal Examination. The examination of the interior is commenced by making a little horizontal cut with the scissors, at the lower extremity of the descending portion of the duodenum, and cutting through the middle of its anterior wall from below upwards ; the course of the incision is then changed in the direction of the horizontal portion, the anterior cut edge being drawn upwards. The incision is continued through the anterior wall, as the stomach is to be opened along the greater curvature. At the junction of the duodenum with the stomach, the blade of the scissors must be pushed forward as nearly as possible in the axis of the canal, otherwise it may catch against the fold which is formed by the projecting sphincter. The stomach is to be opened at first only as far as the fundus, that the contents may be easily removed with a cup. <Callout type="tip" title="Tip">When opening the duodenum and stomach, ensure the incision follows the natural folds to avoid damaging the tissue.</Callout> (1.) The Contents. In opening the duodenum it is necessary to notice both the nature and quantity of the contents, also any difference in them which may exist above and below the papilla of the gall duct, and the presence of biliary coloring matter in the lower part, or in the upper as well. In examining the contents of the stomach, the quantity, color, consistency, reaction, smell, and composition, and especially the morphological ingredients that may be present, are to be noticed. This is not only necessary in judging of the contents, but also of the mucous membrane, for peculiar post-mortem changes of the latter are produced by the contents under certain circumstances. For instance, there are numerous substances which, owing to their acid nature, possess the property of producing a kind of digestion of the mucous membrane, having nothing to do with pathological changes. The alteration may extend beyond the mucous membrane, finally involving the entire walls (softening of the stomach), when the contained food is of a kind liable to undergo acid fermentation, as is the case with milk, for instance. The reaction of the contents may often be recognized by the smell, but is determined accurately by the use of litmus paper. A bloody condition of the contents, caused by swallowing blood, or by a direct admixture of this fluid, deserves careful consideration. When blood which has come from the lungs is swallowed, it is filled with air bubbles and is frothy, while that which has come directly from the stomach is devoid of air bubbles, and is either in the form of large, compact, dark-red masses (haemorrhage from a large vessel), or uniformly mixed with mucus (hæmorrhage by diapedesis in cirrhosis, inflammation, etc.), or in the form of small, dark-brown masses resembling coffee-grounds (old haemorrhages from numerous small vessels, cancer). A yellowish or greenish tinge is due to biliary coloring matter. The contents are often of a leek-green color, when the digestive tract is obstructed, and in general peritonitis. 284 DIAGNOSIS IN PATHOLOGICAL ANATOMY. Besides the various admixtures of coarse morphological substances that may often be recognized with the naked eye as remnants of food, and the non-edible things that may be accidentally or purposely swallowed (coins, sticks, toys, needles, stones, etc.), there are a number of parasites that maybe met with. With regard to remnants of food^ peculiar roundish, white or yellowish-white, brittle clumps, are sometimes found in the stomachs of young children, and are composed wholly of coagulated milk, as may be easily proven by microscopic examination. Similar masses composed of fat (mutton or beef tallow) occur less frequently in adults. Animal parasites are rarely found (only a variety of ascaris is sometimes met with) ; on the other hand, the vegetable growths are very common. These, of course, can only be recognized with accuracy by the use of the microscope. The thrush parasite, which was described as occurring in the cavity of the mouth and oesophagus, occurs in the stomach, but much less frequently than in the former localities, and is found rather on the walls than in the contents. On the other hand, a form of parasite resembling the leptothrix of the mouth, is very frequently met with in the contents. The greatest development is in those cases where the fluids of the stomach are undergoing fermentation, and especially where that organ is distended. Besides the leptothrix, a parasite resembling the lea plant is always present in large quantities, and also the sarcina ventriculi. The former is in the form of small oval bodies, which often contain glistening oil drops, and are frequently arranged like a chain (also branched). The latter consists of small bodies resembling dice with rounded corners, which present on each surface a furrow in the shape of a cross, so that four planes of equal size are formed. This shape has been compared to a well-bound bale of goods. These bodies usually lie together in large clumps, which in turn often possess the dice form ; they are often present in inconceivably large numbers in the lower stratum of the contents of a distended stomach, and the frequent brown color of the latter is due to them. <Callout type="risk" title="Risk">The presence of parasites can indicate poor hygiene or food contamination; this should be taken seriously.</Callout> The secretion of the gastric mucous membrane will be considered hereafter, as it can be examined best in connection with the consideration of that subject. (2.) The Duodenal Mucous Membrane. After the removal of the contents of the duodenum^ the examination of its mucous membrane is to be continued. What will be said hereafter about the changes in the other portions of the small intestine or stomach will apply here, except that the duodenum presents those alterations which proceed from the lymph follicles much less frequently, and in a much smaller degree, than the lower portions of the small intestine. In this class are included follicular abscesses and ulcers, tubercular ulcers, and the changes occurring in typhoid fever, the latter being relatively the most frequent. It presents, on the other hand, certain changes that do not occur in the other portions of intestine. Among them is the chronic ulcer of the duodenum, which resembles the so-called round ulcer of the stomach, and like it tends to perforate into the abdominal cavity or into other organs (including the aorta), and in this way may cause death. Among the causes of these ulcers are very extensive burns of the integument. The changes (ulceration) that may arise from the presence of gall stones within the biliary tract are also peculiar to the duodenum, as well as those resulting from cancer of the head of the pancreas. Finally, perforation sometimes takes place, especially in the lower portion, by the side of an aneurism of the aorta or of one of its large branches. (3.) The Gastric Mucous Membrane. In order to examine the mucous membrane of the stomach carefully, it is best to remove the organ from the body. It may be desirable under certain circumstances (ulcers with adhesions, etc.) to remove it in connection with other organs. The lesser curvature is grasped, drawn downwards and separated from its surroundings, the lower end of the oesophagus and a small piece of the horizontal portion of the duodenum being removed with it. <Callout type="beginner" title="Beginner">For beginners, removing the stomach for examination should be done carefully to avoid damaging surrounding tissues.</Callout> (4.) General Appearances. That portion of the contents, which still remains adherent to the inner surface is to be removed with a small stream of water. 1. The secretion of the mucous membrane is then to be carefully examined. As is well known, the gastric mucous glands are confined to the pyloric portion, and consequently their secretion is to be looked for here. Usually there is only a very thin layer of mucus present, which may, however, under certain circumstances, be greatly increased, so that the whole surface is completely covered with a thick layer. The character of this mass varies greatly : sometimes it is soft, opaque, and gray ; at other times transparent, and so tenacious that it can only be scraped off with great difficulty. The last condition is characteristic of acute gastric catarrh, while the first occurs more frequently when the affection is chronic. The mucus may also contain various admixtures, as blood, or gall, which change its color. It has already been mentioned that a uniform admixture of blood is due to a very slight haemorrhage from a large number of small vessels. 2. The changes in volume of the mucous membrane consist chiefly in thickening of the same. This may be determined by the examination at the point of junction with the oesophagus. Normally the lower, jagged edge of the oesophageal mucous membrane projects over that of the stomach ; when the latter is thickened this relation is changed, so that both either occupy the same level, or the mucous membrane is the more prominent. Very frequently the mucous membrane is thrown into folds when it becomes hypertrophied (chronic catarrh), as the muscular layer, which is not increased, is no longer large enough to remain everywhere in contact with the hypertrophied mucous coat. The folds which are caused by a contraction of the muscular coat (on the same principle) must not be confounded with the above. They disappear if the walls of the stomach are stretched in a direction vertical to them, while in the former case they will remain under similar treatment. Not every enlargement of the mucous membrane causes folds, as there may be more or less swelling (oedema), which produces only an increase in thickness; this may be very marked, but the mucous membrane is soft and gelatinous. Partial thickening of the mucous membrane frequently appears in the form of little granules, or larger wart-like growths, which are caused by chronic gastric catarrh, and which will be fully described in treating of that subject.
Key Takeaways
- The stomach's size is dependent on the amount of food it contains.
- Chronic dilatation can be caused by tumors or overfilling, leading to potential perforations.
- Mucous membrane changes like color and thickness indicate different conditions.
Practical Tips
- Regularly check for signs of stomach distention in emergency situations as it may indicate a serious condition.
- Be cautious when examining the stomach; ensure proper hygiene to avoid introducing contaminants.
- Recognize that certain mucus characteristics can signal acute or chronic issues, aiding in diagnosis.
Warnings & Risks
- Perforations in the stomach or duodenum can lead to severe complications like peritonitis and should be treated urgently.
- Incorrect handling of the stomach during examination can cause damage to surrounding tissues.
- Presence of parasites indicates potential food contamination; this should be addressed.
Modern Application
While the techniques described in this chapter are from a historical context, understanding the anatomy and pathology of the digestive system remains crucial for modern survival preparedness. Knowledge of how to identify and manage stomach issues can help prevent serious complications during emergencies or when resources are limited.
Frequently Asked Questions
Q: What are some signs that indicate chronic dilatation in the stomach?
Chronic dilatation may be indicated by an unusually large, distended stomach. This condition is often a result of tumors or overfilling and can lead to potential perforations, which should be treated urgently.
Q: How can one differentiate between acute and chronic gastric catarrh based on the mucus?
Acute gastric catarrh is characterized by a transparent, tenacious mucus that is difficult to scrape off. Chronic catarrh, on the other hand, results in a soft, opaque gray mucus layer.
Q: What are some common causes of stomach perforations?
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