48.-ON INFLAMMATION OF THE LINING MEMBRANE OF THE

STOMACH.

By DR. GEORGE BUDD, F.R.S., &c.

[Inflammation of a mucous membrane may induce, 1st, Alteration of mucus, rendering it viscid or opaque. 2nd, Effusion of plastic lymph, forming a coating of the membrane. 3rd, Formation of pus. But in all these cases no permanent mischief need follow. For obvious reasons the knowledge of the inflammatory diseases of the mucous membrane of the stomach is very vague. The simplest form is, perhaps, that produced by excess in eating or drinking, and]

The rapid recovery in such cases is owing to the active nutrition of the mucous membrane. In consequence of this active nutrition, the effects of inflammation of the mucous membrane of the stomach are much more transient than those of inflammation of the mucous membrane of the air-tubes, or of the urinary bladder, or of the urethra, or even of the intestines.

The mucous membrane of the air tubes, or of the urethra, or of the urinary bladder, wastes but little, and is slowly renewed. If it be much injured, the process of repair is long.

The mucous membrane of the stomach, on the contrary, has an active function. Its epithelium is frequently shed to effect digestion, and is rapidly renewed; and, in consequence, the superficial inflammation of it we are considering is very transient. [Another common cause of this disease is from the imbibition of alcoholic drinks, the intensity depending on the state of dilution.]

The effect of spirits on the coats of the stomach, like that of food which is hard of digestion, depends greatly on the previous state of the stomach, and of the general health, as well as on season and climate. Spirits hurt the stomach more when its mucous coat is already inflamed, or when, from an impediment to the passage of the blood through the liver or the chest, or from any other cause, the vessels of the stomach are congested, so that liquids are slowly absorbed from it; and in hot seasons, or hot climates. Under these circumstances, small quantities of fermented drinks may do much mischief.

In the observations I have cited from Dr. Beaumont, nothing is more striking than the rapidity with which the stomach recovered, under the influence of low diet and cooling drinks. Without this power of rapid recovery, the stomach would be unfit for its office. If the erythematous inflammation, which is excited by unwholesome food, or by excess in eating or drinking, took long to subside, the abstinence required for recovery could hardly be borne.

The inflammation, instead of subsiding rapidly, may, however, be kept up by repeated indiscretion in eating or drinking. Small quantities of solid food, or of fermented drinks, which, at other times, would do no harm, are sufficient to keep up a soreness that already exists.

The chronic inflammation so excited is attended with an increased secretion of mucus, and causes a thickening, and the so-called mammillated appearance, and occasionally, I believe, minute superficial ulcers of the mucous membrane. Its most characteristic symptoms are, constant slight tenderness at the epigastrium, slowness of digestion, pain or uneasiness in the stomach, and occasional vomiting after meals, especially after meals of solid food, and a white and furred tongue. The matter vomited contains viscid mucus, which, now and then, presents a few streaks of blood, more or less altered. The disorder, even after it has lasted a considerable time, generally disappears readily if the stomach be allowed sufficient intervals of rest, or the patient be restricted to cooling drinks, and a diet consisting entirely of farinaceous substances and milk.

A superficial or erythematous inflammation of this kind occurs, not only as a disease by itself in persons otherwise healthy, but also very frequently in the course of various other inflammatory or febrile diseases, when the food has not been brought down to the diminished power of the stomach. Under such circumstances the inflammation of the stomach is more difficult to recognise, from its symptoms being complicated, or masked, by those of the primary disease. It is thus often overlooked, and much mischief is in consequence done by the unseasonable use of sti

mulants.

XXVIII.-8.

Chronic inflammation of the kind we are now considering sometimes results, not from the digestive powers of the stomach being overtaxed, but from the existence of some impediment to the passage of the digested food from the stomach into the intestine. When, for example, a simple deep ulcer exists near the pyloric end of the stomach, interfering with the aetion of its muscular fibres, or when the pyloric orifice is slightly strictured, or is pressed upon by a large liver, the stomach cannot always completely empty itself, and what remains in it, after digestion is over, frets and inflames its mucous coat. As the inflammation, in such cases, results from an abiding condition, itis difficult to remedy, and thus occasionally leads to habitual vomiting of ropy mucus. This happened in a woman who died a few years ago, in King's College Hospital, from the effects of a large simple ulcer near the pyloric end of the stomach. Much ropy mucus was vomited for a long time before death, leading to the suspicion of cancer of the stomach, and, after death, ropy mucus of the same kind, hard to detach, was found coating almost the whole surface of the mucous membrane.

In the same way, if the urinary-bladder, or the gall-bladder, cannot completely empty itself, the retained urine or bile decomposes, or becomes too highly concentrated, and consequently frets and inflames the mucous membrane. Inflammation of the mucous membrane of the stomach would be caused in this way much more frequently if the contents of the stomach could not be discharged by vomiting. The stomach has, fortunately, two outlets for the escape of irritating matters.

The mucous membrane of the stomach may be fretted and inflamed by various conditions besides excesses in eating or drinking, and the swallowing of substances which are hard of digestion, or which exert an injurious chemical action upon it. Among these conditions may be severe or long-continued abstinence. The stomach is an organ whose action, like the actions of the voluntary muscles and the brain, is destined to be intermittent; and when the digestive power is exhausted, a certain period of total abstinence, or rest, is required in order to restore it. The first effect of abstinence is, then, to strengthen the stomach, and enable it to digest a greater quantity of food; but if the abstinence be complete, and exceed a certain limit, the nutrition of the mucous membrane becomes impaired; digestion then grows feeble, and changes in the texture of the membrane take place, which, in appearance at least, are very like those which inflammation produces.

This fact, which has been indistinctly perceived since the time of Hunter, was noticed, a few years ago, by MM. Andral and Gavarret, during a course of experiments to ascertain the influence of various conditions on the composition of the blood. M. Andral says:—

"In some experiments which I undertook with M. Gavarret, for the purpose of determining the composition of the blood in animals deprived of food, one circumstance particularly struck me,-namely, a notable augmentation of the fibrin. My astonishment ceased when, on opening the bodies of these animals, I found in their stomachs evident signs of inflammation, such as bright redness, softening, and numerous ulcerations of the mucous membrane."

He then gives the following details of one of the experiments in question:Three dogs, in good health, were bled on the same day, the 21st December, 1841, in order to ascertain the composition of their blood, and were then submitted to different degrees of abstinence until they died.

The first was deprived entirely of food and drink, and lived twenty-one days. Some blood was drawn, for analysis, at the end of the first week, and again at the end of the second week, and it was found that the fibrin had increased in the intervals of the successive bleedings from 2-3 parts in 1000 to 3.9 and 4.5 parts.

The second dog was deprived of food, but allowed to drink water, and lived twenty-five days. Like the former, it was bled at the end of the first and second weeks, and the proportion of the fibrin was found to have increased in the intervals of the bleedings, from 2-2 parts to 2.9 and 40 parts.

The third dog was allowed a small quantity of soup every morning, and lived thirty-three days. Blood drawn at the end of the first and second weeks had very little more fibrin than that drawn at the commencement of the experiment, but, at the end of the third week, when some blood was again taken, the fibrin was found to have increased from 16 parts to 3.3 parts.

M. Andral says that this dog, which was not completely deprived of food, was the

only one in which the stomach was not ulcerated, and that in it the redness of the mucous membrane of the stomach was less general and less vivid than in the others.

The last instance shows, that even a small quantity of food, if it contain all the elements requisite for nutrition, may protect the stomach, and prevent tho se destructive changes which total abstinence causes; and this accords with the wellknown fact, that persons who, from a scanty diet, are much wasted, can sometimes, like persons wasted by fever, digest great quantities of food.

The case is very different if a person be long restricted to food, which, whatever be its quantity, is not sufficiently varied for healthy nutrition. If such a diet be persisted in beyond a certain time, the nutrition of the mucous membrane of the stomach is impaired, as by total abstinence, the appetite fails, and digestion is greatly enfeebled.

This was well shown by experiments, first performed by Majendie; and subsequently repeated, and varied, by a Committee appointed by the French Institute, with Majendie at its head, to determine the nutritive properties of different kinds of food. The experiments proved that dogs kept exclusively on water, with the addition of oil, sugar, fat, or even of albumen, fibrin, or gelatine, in their pure state, soon die of starvation just as when kept on water alone.

The subject is further illustrated by the disorders of health that have been observed to occur in prisoners kept on a diet of bread and water.

A good account of these disorders has been given by Mr. Malcolmson, in a letter addressed, in 1837, to Sir Henry (now Lord) Hardinge, on the effects of solitary confinement and a bread and water diet on the health of prisoners in India. He says, "Many men, particularly those of indolent habits, endure a confinement of four or six weeks on bread and water, without injury to their health; but, in some instances, a shorter period is sufficient to cause a total loss of appetite; the bread is hardly touched, and on other food being allowed, the patient is unable to eat or digest it. The stomach becomes weak; there is uneasiness across the stomach, spleen, and liver; the latter is torpid. The bowels are confined, or they are relaxed; with slimy discharges, unaccompanied with pain; yet the swollen red tongue indicates the existence of irritation of the mucous membrane of the digestive canal. The pulse is quick and feeble; and the clammy skin, vertigo, debility, headache, and sleeplessness, show how much the constitution suffers from diminished nervous power. The convalescence is slow, and the treatment requires to be adapted to the enfeebled state of the system."

It appears from the instances given by Mr. Malcolmson, that when a man is long kept on such a diet, the health is irretrievably ruined: the subsequent allowance of food sufficient for the maintenance of health does not restore him.

These observations of Mr. Malcolmson are confirmed by the early Reports of the Inspectors of prisons.

The irreparable injury to the health produced by long continuance in a diet deficient in some of the principles requisite for nutrition, is also well shown in the curious and painful history of Dr. Stark, who, in 1769, when he was pursuing his medical studies in St. George's Hospital, heroically made himself the subject of experiment.

His experiments were commenced on the 12th June; and from this time till the 26th July, that is, for more than six weeks, he lived on bread and water only, increasing from time to time the daily allowance of bread from 20 ounces, which he took at first, to 38 ounces. For the next fortnight, from the 26th of July to the 9th of August, he varied the diet by subtracting, first 4, and then 8 ounces, from the 38 ounces of bread, and adding an equal quantity of sugar.

66

The person upon whom these experiments were made was, to use his own words, a healthy man, about 29 years of age, 6 feet high, stoutly made, but not corpulent, of a florid complexion, with red hair."

Once during the course of these experiments, he yielded to his craving for food of other kind, and ate 4 ounces of meat, and drank two or three glasses of wine; but otherwise he adhered rigidly to the diet. On the 9th of August, that is, at the end of eight weeks and two days, he was only 2 lbs. less in weight than when he commenced his experiments; but scurvy was making its appearance. The entries made in his Journal about this time show that the nutrition of the lining membrane of the stomach and bowels had become greatly impaired. He states, on different

occasions, that he had little appetite, that he ate the latter part of the allowance of sugar with great abhorrence,-that he had pains in the bowels, and frequent liquid stools, which contained some clear, gelatinous substance.

His experiments were pursued, with some slight variation, and the scorbutic symptoms made progress. Subsequently, there occurs the following entry in his journal : "On the 8th of September, I was so weak and low, that I almost fainted in walking across my room. Had four or five loose stools in the course of the day; was sick; and my tongue was foul."

The experiments were still continued, and the narrative goes on til! the month of February, when the Doctor, reduced to a most deplorable condition, fell a victim to his love of science.

It will be seen, that in Dr. Stark, as in the prisoners that fell under the observation of Mr. Malcolmson, the loss of appetite and enfeebled digestion that resulted from the defective diet, were attended by frequent slimy discharges from the bowels. A similar disorder of the bowels was noticed by Majendie in his experiments on dogs, and continually recurs in the early Reports of the Inspectors of Prisons. The insufficient diet leads, in the bowels as in the stomach, to impaired, and often to an inflammatory state of the mucous membrane.

Happily, severe disorders of the digestive organs, resulting from insufficient food, are, in this country, extremely rare; but it is probable, that there is sometimes truth in the popular notion, that in persons whose digestion is weak, the stomach is frequently much injured by too long fasting. It has often seemed to me, that a rigid diet, too long persisted in, in the early stage of continued fever, has been productive of much mischief in this way.

Inflammation of the mucous membrane of the stomach may be excited in another way still; namely, by some noxious matter in the blood.

This has been strikingly shown by experiments that have been made on the lower animals for the sake of ascertaining the effects of arsenic. Mr. (now Sir Benjamin) Brodie, in a paper on this subject, published in the Philosophical Transactions for 1812, says:

"Mr. Home informed me, that in an experiment made by Mr. Hunter and himself, in which arsenic was applied to the wound of a dog, the animal died in 24 hours, and the stomach was found to be considerably inflamed.

"I repeated this experiment several times, taking the precaution always of apply ing a bandage to prevent the animal licking the wound. The result was, that the inflammation of the stomach was commonly more violent and more immediate than when the poison was administered internally, and that it preceded any appearance of inflammation of the wound." After detailing some of his experiments, Mr. Brodie thus sums up the effects of the poison :

"These experiments were repeated, and the results, in all essential circumstances, were the same. The symptoms produced were,-1. Paralysis of the hind legs, and afterwards of the other parts of the body; convulsions; dilatation of the pupils of the eyes; insensibility;—all of which indicate disturbance of the functions of the brain. 2. A feeble, slow, intermitting pulse, indicating disturbance of the functions of the heart.. 3. Pain in the region of the abdomen; preternatural secretion of mucus from the alimentary canal; sickness and vomiting in those animals which are capable of vomiting;-symptoms which arise from the action of the poison on the stomach and intestines."

The following is the account he gives of the appearances observed on dissection :

"In animals killed by arsenic, the blood is usually found fluid in the heart and vessels after death; but otherwise, all the morbid appearances met with on dissection are confined to the stomach and intestines.

"In many cases, where death takes place, there is only a very slight degree of inflammation of the alimentary canal; in other cases the inflammation is considerable. It generally begins very soon after the poison is administered, and appears greater or less, according to the time which elapses before the animal dies. Under the same circumstances, it is less in graminivorous than in carnivorous animals. The inflammation is greatest in the stomach; but it usually extends also over the whole intestine. I have never observed inflammation of the oesophagus. The inflammation is greater in degree, and more speedy in taking place, when arsenic is

applied to a wound, than when it is taken into the stomach. The inflamed parts are in general universally red; at other times they are red only in spots. The principal vessels leading to the stomach and intestines are turgid with blood; but the inflammation is usually confined to the mucous membrane of these viscera, which assumes a florid red colour, becomes soft and pulpy, and is separable without much difficulty from the cellular coat, which has its natural appearance. In some instances, there are small spots of extravasated blood on the inner surface of the mucous membrane, or between it and the cellular coat, and this occurs independently of vomiting. I have never, in any of my experiments, found ulceration or sloughing of the stomach or intestine; but, if the animal survives for a certain length of time, after the inflammation has begun, it is reasonable to conclude it may terminate in one or other of these ways."

In another paragraph, he says:

"The inflammation from arsenic, occupying in general the whole of the stomach and intestine, is more extensive than that from any other poison with which I am acquainted. It does not affect the pharynx or esophagus, and this circumstance distinguishes it from the inflammation which is occasioned by the actual contact of irritating applications."

These experiments of Sir B. Brodie have been repeated by others, with the same results, and have been further confirmed by numerous cases in which arsenic applied to a sore, or to a large surface even of sound skin, or inhaled in the form of vapour, has proved fatal to man. In such cases, unless death occur early from the action of the poison on the nervous system or the heart, pain in the belly, with vomiting and the discharge of mucus from the bowels, almost always comes on; and after death marks of extensive inflammation of the mucous membrane of the stomach and intestines exist.

It seems probable that this inflammation results from some of the poison being eliminated at the mucous membrane of the stomach and intestines-a membrane which must be regarded, not as a mere lining of the tube, as the mucous membrane of the oesophagus is, but also as an expanded gland, destined to furnish abundant secretions, and by virtue of its active secreting power, occasionally instrumental in eliminating noxious principles from the blood.

Many other substances, when absorbed into the blood from the surface of the body, have, like arsenic, an especial action on the stomach and intestines. Jalap, for example, purges, and lead excites colic, when applied to a wound. There can be little doubt that some of the noxious principles that may be bred into the body act in a like special manner on these organs, and may excite inflammation or functional disorder of them.

When arsenic is given medicinally, it should be given largely diluted in order that it may exert no direct injurious influence on the stomach; but when this precaution is adopted, it often happens, after the medicine has been taken some time, even in moderate or small doses, that nausea comes on, with pain and a sense of burning heat in the stomach. These symptoms are usually the earliest distinct indications that the arsenic has been given in too large quantity, and it is very important to bear in mind that they depend on inflammation of the mucous membrane of the stomach. On the occurrence of these symptoms, the arsenic should be left off, but the patient should be kept on a sparing farinaceous and milk diet. The disorder of the stomach will then quickly subside.

If, after the occurrence of the gastric disorder, the use of the arsenic be continued, the sufferings referable to the stomach increase, and an inflammatory state of the bowels likewise comes on, causing griping pains of the belly, with diarrhoea and the discharge of slimy mucus. The inflammation of the stomach and bowels thus excited seems often not to depend on the direct local action of the arsenic on the coats of the stomach, but on the accumulation of it in the system. The pain in the stomach and nausea seldom come on till the arsenic has been taken for some time; and if, under proper management, they subside speedily, and the arsenic be then taken again, the disorder in most cases soon recurs.

Whenever inflammation of the stomach is excited by some noxious matter in the blood, which must necessarily be conveyed to every part of the mucous membrane, and be carried in the blood to every other part of the body, we may expect the inflammation, like that which results from the absorption of arsenic, to be