capillaries in the deeper layers of the mucous membrane, so that only venous capillaries and very small veins are found upon the surface. The color, besides being varied by the amount of blood present, may depend upon different pathological processes. As has already been stated elsewhere, a slaty color, which was brownish during life, and was changed to black by gases containing sulphur, points to previous hypersemia (gastritis chronica). Biliary coloring matter produces, especially in icterus neonatorum, a jaundiced color. Finally an opaque, yellow color, is of importance, due to cloudy swelling and fatty degeneration of the glandular epithelium.
- In order to be able to judge accurately of the pathological changes in the gastric mucous membrane, it is necessary to have a perfect knowledge of the great number of post-mortem changes which it undergoes. It has already been stated that these depend in great measure upon the quantity and character of the contents, and arise, aside from decomposition, especially from acids. The post-mortem changes are, as a rule, most intense at the fundus, where the contents collect. The least degree of acidity produces a gray opacity; when greater, a sort of digestion of the mucous membrane itself follows, so that it is converted into a soft, slimy, transparent mass, which is easily scraped off, and then the submucous tissue, or muscular layer, is laid bare.
<Callout type="warning" title="Acidic Content Risks">The stomach's acidic content can cause significant damage to its mucous membrane.</Callout>
Finally, the softening may go still further and involve the muscular and serous coats, when the already described softening of the stomach results. If this occurs in a stomach free from blood, it is termed white softening; if, on the other hand, the vessels are filled with blood, this is affected by the acid so as to present a brown or brownish-black color, the neighboring parts are infiltrated with the coloring matter, and a soft, more or less brown mass results,— brown softening of the stomach. A dirty green color is due here, as in most other organs, to actual putrefaction.
(6.) Special Morbid Conditions. The most frequent of the inflammatory affections are acute and chronic catarrh. The acute form is especially characterized by the large quantity of tough, transparent mucus, and by reddening of the mucous membrane; the chronic, by abundant, soft, gray mucus, projections of the mucous membrane, and by the slate color that occurs, especially near the pylorus.
<Callout type="tip" title="Identifying Chronic Catarrh">Look for abundant, soft, gray mucus and reddening in acute cases.</Callout>
Besides these simple inflammations a second form occurs (especially in drunkards), which is characterized by circumscribed hypertrophies of the whole mucous membrane (gastritis prolifera'), and produces little warty projections (gastritis verrucosa^; later, larger polypoid growths result (gastritis polyposa"). Dilatation of the glands, due to compression at their outlet, very frequently accompanies hypertrophy here, as was stated with regard to the uterine mucous membrane, so that small cysts result, which are especially met with on the divided surface of the polypoid growths.
In order to determine the part taken by the separate elements of the mucous membrane in the process of hypertrophy, thin sections made with the scissors, and then torn apart, answer every purpose. An attempt may also be made to obtain a section with the double knife. The arrangement of the pigment between the glandular tubes in cases of slatey discoloration of the mucous membrane can be best recognized in a horizontal section, made from the surface with the scissors.
The next in frequency is what is called by Virchow parenchymatous inflammation (^gastritis parenchymatosa vel glandularis vel gastroadenitis)^ and like the corresponding affection of the kidneys, liver, etc., which appear in certain cases of poisoning (phosphorus, arsenic), in acute infective diseases and similar affections (acute atrophy of the liver), consists in a cloudy swelling, and, at a later stage, fatty degeneration of the cells of the gastric glands. In this affection the mucous membrane generally appears to the naked eye swollen and opaque, at a later stage, yellow.
<Callout type="important" title="Fatty Degeneration">Fatty degeneration in the gastric glands can lead to cloudy swelling.</Callout>
In horizontal sections made with the scissors, the gland cells at an early stage of the fatty degeneration, may be seen to be filled with dark granules. These do not disappear upon the addition of a weak solution of caustic potash, like the granules that normally make their appearance in the formation of the gastric juice, and they are thus proven to be fat granules. When the process is more advanced, the glandular tubules are completely filled with fat granules, which become converted into little drops, and a similar appearance may be seen in the intertubular tissue.
Inflammation of the submucous tissue (^gastritis phlegmonosa'), which is accompanied by marked swelling not only of this but also of the mucous membrane, is rare, and only occurs in certain infective diseases, for instance, in malignant pustule, where the membrane may become so changed as to resemble a carbuncle. Suppuration of the submucous tissue is extremely rare.
Haemorrhage into the gastric mucous membrane is of common occurrence, both as a result of simple stagnation, and of inflammation. It appears very frequently in the vicinity of the cardiac portion and in the fundus, its favorite seat being the tops of the folds. It may be either recent, when it possesses the bright or dark-red color of clotted blood, or old, when it will have assumed a more black or blackish-brown color. In the latter case, small losses of substance in the mucous membrane are frequently seen, and will be directly considered.
Peculiar to the stomach is the occurrence of the simple ulcer, which is so frequently found in its different stages, especially in females. The simplest variety is a very shallow loss of substance, round and often oblong in shape, which is usually situated on the tops of the folds, the long axis corresponding to that of the folds; upon its base blackish or brownish masses composed of blood are frequently found, and easily scraped off. Small unaltered haemorrhages in the mucous membrane are frequently observed in the neighborhood of these ulcerations, and directly suggest that the gastric juice dissolves the mucous membrane at these points, and a loss of substance results, which has been termed hemorrhagic erosion.
These occur very frequently with stasis in the gastric veins in disease of the liver, heart, or lungs, and often also after severe vomiting. The so-called simple, round, or perforating gastric ulcer (ulcus ventriculi simplex^ rotundum, perforatus^), appears quite different from these slight losses of substance. It varies from the size of a five cent piece to twice that of a silver dollar and over, and possesses a sharp border, as if made with a punch. They are always situated along the lesser curvature, or in its immediate neighborhood, and are funnel-shaped.
<Callout type="risk" title="Perforating Ulcers">Perforating ulcers can lead to fatal peritonitis or hemorrhage.</Callout>
They do not penetrate the walls regularly but in the form of terraces, so that the loss of substance is greater in the mucous than in the sub-mucous tissue, greater in the latter than in the muscular coat, and in the muscular greater than that in the peritoneal coat, except, of course, where the ulcers do not extend beyond the mucous and sub-mucous layers. The axis of the funnel-shaped cavity formed by the ulcer does not extend perpendicularly through the walls of the stomach, but obliquely, from within and below (from the pylorus) outwards and upwards (towards the cardia), i.e., in the direction taken by the branches of the gastro-duodenal artery; the edges are much more abrupt towards the cardia than towards the pylorus.
Upon very careful examination, it is possible to find the stump of a small vessel in the deepest portion of many of these ulcers; others are covered with a blackish-brown mass like the hemorrhagic erosions, which make it extremely probable that many of these ulcers differ from the erosions only in degree, i.e., they are also hemorrhagic ulcers. Microscopic preparations show only a thin layer of tissue at the base of the ulcer, infiltrated with small granules possessing a dark contour. The surrounding tissue is devoid of all inflammatory infiltration, and there is an entire absence of purulent disintegration or necrosis.
The termination of these ulcers is various. Many heal after more or less of the wall is destroyed, when a white stellate cicatrix results, which is often difficult to find. Others extend constantly deeper and wider, and may cause death in two ways. They either perforate into the abdominal cavity and produce a fatal peritonitis, or they cause the opening of some large vessel and a fatal hemorrhage results.
If it is desired in such a case to find the opened vessel, it is best, after the stomach has been opened and washed, to inject the coronary arteries with water, when it will spurt from the eroded branch. They may terminate in another way. The walls may be eaten through, but perforation into the abdominal cavity is prevented by adhesions to other organs (pancreas, liver, spleen). The advance of the ulcer is not prevented by this means, but it extends into the adherent organ, and may attain a very large size.
In such cases it is well to remove together all the organs that are involved, which are usually held together by firm adhesions, as the examination can thus be made more conveniently in all respects. 4. Next in the list, after the ordinary gastric ulcers, are the new formations, of which the tuberculous and cancerous are among the first to be mentioned, as they almost invariably appear in the form of ulcers (ulcus tuberculosum, carcinomatosum). Disseminated miliary tuberculosis scarcely ever occurs in the stomach, although a structure appears in the mucous membrane in certain cases, namely, the lymph follicles, which may be easily mistaken for tubercles. These follicles have precisely the same appearance and the same characteristics as those in the intestine. They are gray, slightly prominent bodies, of the size of a pin's head, and uniformly distributed over the whole surface, or situated more upon one side or the other.
<Callout type="important" title="Lymph Follicles">Gray, slightly prominent lymph follicles can be mistaken for tubercles.</Callout>
If a vertical section is made with the scissors, the tubules may be seen to be pressed apart by the interposed follicle, which is composed of lymphoid cells closely crowded together, and contains small vessels. The presence of vessels, together with the entire absence of cheesy degeneration in the centre, form the surest guide in distinguishing them from tubercles.
These follicles may become involved in inflammation like those of the intestine. Tuberculous ulcers., which are rather rare, and, as a rule, seldom attain any considerable size, do not differ in their appearance from those of the intestine, which will be described hereafter in detail. The cancerous growths are most often seated at the two extremities of the stomach, at the cardia and pylorus; the pyloric end being far more frequently affected.
Three different forms may be distinguished, the soft (medullary) glandular cancer, the atrophic (scirrhus), and the colloid or gelatinous form. The statement that they appear generally in the form of an ulcer, applies to all three, a peculiarity that is evidently attributable to the effects of the gastric juice.
<Callout type="tip" title="Cancer Forms">Soft glandular cancer often appears as fungous growths.</Callout>
Only the first class, the simple glandular carcinoma, appears in two forms, as ulcerated and as fungous growths; the latter, as the name indicates, are characterized by the formation of a large fungous mass, which projects beyond the general surface. Of course, ulceration upon the surface of these is not excluded, but the growth predominates, and a potiori fits the denomination.
It is not difficult to distinguish the three forms in well-marked cases; simple glandular carcinoma is, as a rule, very-soft, rich in cells, and admits of cancer juice being easily pressed from the cut surface. This fluid contains well-marked cylindrical cells, especially in the fungous variety (consequently also called cylindrical-cell epithelioma). This form is also frequently very vascular, and the fungous growth is often so richly supplied with large vessels that the term telangiectodes seems appropriate.
This formation gives rise to numerous small hemorrhages, and causes the contents of the stomach to appear like coffee-grounds. The characteristics which belong to the scirrhous form in all other localities are especially well marked in the stomach, namely, the abundant formation of a tough, white, fibrous tissue that creaks under the knife; forms even occur in the stomach in which the development of cancer cells is relatively very slight, and in which it is impossible to discover the least trace of cancer juice.
Frequently it is only possible to determine their real character after a most thorough microscopic examination. This is especially true of those forms in which ulceration is the most prominent characteristic, and the mass of the tumor is consequently reduced to a minimum. It is then necessary to make sections perpendicularly through the edges, especially where they appear slightly everted, and through the base, extending to the serous coat.
The muscular coat is always involved in the formation, both actively, as the muscular tissue becomes thickened, and also passively, as the growth pushes forwards into the spaces between the muscular bundles, and even extends through them, frequently forming nodular masses in the subserous tissue. The latter being the part in which the disease is still progressing, microscopic sections, which may be easily made with the double knife, should be taken from here.
A careful examination of sections made through the edges, or horizontally through the base of the ulcer, is necessary in all cases where a differential diagnosis is to be made between cancerous and simple ulcers. Although small hemorrhagic ulcers of typical shape differ greatly from well-developed cancerous forms, larger ones, on the other hand, which have nearly lost their peculiarities, may be confounded with the latter, when the growth of the tumor is very slight; then they can only be discriminated by the most careful microscopic examination.
The diagnosis will be greatly aided by examining the epigastric lymphatic glands, which are almost always involved in cancerous degeneration. There is but little to be said concerning the remaining forms of tumors of the stomach. Sarcoma occasionally occurs and originates in the submucous tissue. The ordinary well-known methods of examination are used for its diagnosis.
Small myomata (usually from the size of a millet-grain to that of a bean) also occur, and arise from the muscular tissue, the mucous membrane over them being freely movable; there may be also a combination of the two forms, myosarcoma, and finally lipomata, etc., may be found.
- In conclusion amyloid degeneration is to be considered, and it is seldom absent in extreme cases affecting the intestines. The walls of the vessels constitute the essential seat of the change, although the tunicas propria of the glands may be affected in severe cases. In applying the iodine test to this change, there is danger of deception, owing to the unclean condition of the surface (especially from starch in food), and it is therefore absolutely necessary to remove all the mucus, etc., by scraping and washing, from the place where the test is to be applied.
It is also necessary to choose a point which is as free from blood as possible, as this fluid, when acted upon by iodine, gives [i color similar to that produced by amyloid material and this reagent. (c.) The Stomach in Cases of Poisoning. Cases of poisoning demand special consideration, both on account of the peculiar appearance of the stomach, and their medico-legal importance, and especially as they require a different method of examination.
- Method of Examination. In order to observe at once and on the same preparation the effects of corrosive poison in different places along the digestive tract, the physician is recommended to remove the organs of the throat and the oesophagus first, in connection with the stomach and duodenum, and in opening the cesophagus to extend the incision along the greater curvature of the stomach. In medico-legal cases, the Regulations direct that when poisoning is suspected, the internal examination is to begin with that of the abdominal cavity, and that before taking any further step, the external appearance of the upper abdominal organs, their position and degree of fullness, the condition of their vessels, and whatever smell they may happen to possess, are to be ascertained.
In considering the vessels it is necessary to determine, here as in other important organs, whether arteries or veins are being dealt with, whether the smaller ramifications also are filled, or only branches and trunks of a certain size, and whether the distention of the canal is great or not. The left lobe of the liver is then to be raised, and by pulling on it, the diaphragm is drawn as far downwards as possible, that the oesophagus may be tied just above its entrance into the stomach and just below the diaphragm.
The oesophagus ought to be opened at this point, and the incision should extend along the greater curvature of the stomach. The duodenum is then to be removed with the stomach, and the examination continued in the usual way. In cases where the poison has acted upon the stomach, the mucous membrane will show a variety of appearances, depending on the nature of the poison.
<Callout type="warning" title="Poisoning Risks">The effects of corrosive poisons can be severe and require careful examination.</Callout>
Key Takeaways
- Identify different types of gastric ulcers, including hemorrhagic and perforating ulcers.
- Recognize the presence of lymph follicles that can mimic tubercular lesions.
- Understand the diagnostic methods for distinguishing cancerous from non-cancerous stomach tumors.
Practical Tips
- Regularly monitor your digestive health to catch potential issues early, such as chronic catarrh or ulcers.
- Be cautious with acidic foods and beverages that can irritate the stomach lining.
- Maintain a healthy diet rich in fiber to support overall gastrointestinal health.
Warnings & Risks
- Acidic content in the stomach can cause significant damage if not managed properly.
- Hemorrhagic ulcers can lead to fatal complications such as peritonitis or hemorrhage.
- Perforating ulcers are particularly dangerous and require immediate medical attention.
Modern Application
While many of the techniques described in this chapter are rooted in historical practices, the principles of recognizing and managing gastric issues remain crucial. Modern medicine has advanced diagnostic tools and treatments, but understanding these foundational concepts can still be invaluable for survival preparedness, especially in situations where immediate medical care is not available.
Frequently Asked Questions
Q: What are the key differences between acute and chronic catarrh?
Acute catarrh is characterized by a large quantity of tough, transparent mucus and reddening of the mucous membrane. Chronic catarrh, on the other hand, features abund