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cells of the gastric glandularis, and a marked round-cell infiltration in the intertubular structures. The degeneration of the mucosa with the infiltration of the mucous and the submucous tissues gave to the interior of the stomach its smooth and thickened appearance. Here and there in

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Severe fatal form of acute gastritis. The flat appearance of the glandulature is due to swelling caused by hyperemia, infiltration of the mucosa with round cells and polynuclear leucocytes, general cloudy swelling of the glandular cells and superficial epithelium, and the exudate in the submucosa. numerous places over the surface of the organ are seen adherent masses of tough, cloudy-white mucus. The tunica propria of the entire stomach was involved, but below the submucosa the structures were not included in the inflammatory process. No pus or bacteria could be found.-(From Bassler's "Diseases of the Stomach.")

these stomachs there were thick clumps of mucus tightly adhering to the surface and small areas of superficial hemorrhage.

Examinations of sections from every part of these stomachs showed the pathology mentioned, and careful bacteriologic exami

nations of the contents of the stomach and tissues failed to disclose any bacteria associated with the condition. Examination of these stomachs for the presence of toxic substances, chemical in nature, were also negative, and there was not enough pathology in other tissues of the body to permit one to believe that these indigestions were symptomatic of something else or terminal to some serious condition in other organs. I believe that there is a severe type of apparently acute indigestion in children, those of middle age, and the old, which is commonly a symptom, terminal before death, of serious pathologies in other organs than the stomach; but I believe further that there is a type of acute gastritis which may be so severe in degree that death could be caused by it, the other organs being approximately normal. What the cause of this severe acute gastritis is cannot be stated, but it is probably due to some chemical error, causing, what has been so well put by Cabot, "chemical death."

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Treatment.

The treatment of the simple forms of gastritis due to indiscretions in food or drink, those which are acute exacerbations of chronic catarrhal or vagotonic and sympatheticotonic states, are relatively plain. The treatment of the terminal forms, in which these symptoms are due to other states, is the treatment of these other states, most of which are surgical, with the exception of the cardiorenal and vascular cases. The treatment of the fatal types of acute gastritis represented in the seven cases I have seen has been disappointing. Local treatment of the stomach has been of no benefit. I feel that there have been two cases that were saved by treatment devoted to the general condition of the body, of which I would mention hot packs, the hypodermic use of strychnin in rather large-sized doses, abstinence from food and drink, together with absolute rest in bed.

ANTHONY BASSLER, M.D. Professor of Clinical Medicine, New York Polyclinic Medical School and Hospital; Visiting Physician, New York Polyclinic Hospital; Chief Gastroenterologist, German Poliklinik; Visiting Gastroenterologist, People's Hospital; Consulting Physician, Beth David Hospital. 21 West 74th St., New York City.

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Acute Gastritis—Usually a Misnomer. EDITOR MEDICAL WORLD:-Following the old nomenclature of intestinal and gastric diseases, which is fast becoming obsolete, there are three terms which, while having some claim to existence, need to be carefully weighed before being used, viz., acute gastritis, chronic gastritis and ptomaine poisoning.

Chronic gastritis is a term used by many men to indicate any stomach condition having the element of chronicity and not easily identified as to its precise pathology. Like an ash pile, all conditions not readily identified are called chronic gastritis. Nevertheless, the disease is a distinct entity, and can be diagnosed positively and not merely by exclusion.

"Ptomaine poisoning" is a diagnosis made to fit painful enteritis or duodenitis associated with diarrhea, usually infectious. As a matter of fact, ptomaine poisoning affects the nervous system infinitely more than it does peristalsis; the symptoms are not essentially abdominal.

Definition of Acute Gastritis.

The main point of the paper is a criticism of acute gastritis or acute indigestion, so called. The term is indiscriminately used for a painful condition of the upper abdomen, abrupt in onset, severe in type, often intractable to treatment and at times fatal. The expression has been so frequently used that people are learning to be fearful of an attack of acute gastritis, on account of its

unfavorable termination.

Symptoms, Course and Treatment. As a matter of fact, acute gastritis is the simplest form of stomach disease. It arises from rapid eating or overeating or an injudicious meal; most frequently taken when the organ is in a condition unable to receive a meal; for instance, when bodily exhausted. Cold water or cold beer will give rise to it, a banquet may be the preceding factor.

There is an extreme degree of peristalsis; the organ making an unusual effort to empty itself creates the pain. A resisting pylorus generally creates reverse peristalsis, the meal comes up, and, except for the incident soreness next day, the disease has disappeared. The stomach may remain tender for several days. The remedy par excellence is rest and abstinence from food for 24 to 48 hours. Such is a typical attack of acute indigestion.

There is one exception, viz., toxic indi

gestion or toxic gastritis. This condition arises from taking into the stomach metallic poisons, such as copper, mercury, arsenic, acids or alkalies. Here the condition is one of tissue destruction, severe vomiting often with blood, prostration and death from peritonitis promptly, or later from cicatricial stenosis. But these cases are rare, and the history is generally suggestive.

Conditions Mistaken for Acute Gastritis.

There are a number of pathologic entities commonly interpreted acute gastritis, severe in type, serious in nature, some of which may be readily identified clinically, others requiring close study, and some can only be differentiated by laparotomy. The severe pain in the epigastric notch is misleading. Of itself it means nothing distinctive, since most pathologic conditions within the abdomen are reflected to that point. In attempting to properly interpret these seizures, clinical symptoms must be carefully analyzed and laboratory measures instituted, and, most essential of all, a careful history taken. This of itself will in many cases determine the diagnosis.

Among the conditions creating the symptom-complex of gastritis is acute pancreatitis. While this is difficult of diagnosis, the volume of the stool, the slate color, and lack of history suggestive of gastritis should cause one to bear it in mind. Perforating gastric or duodenal ulcer is often mistaken for gastritis. Ulcers above or below the pylorus may exist a long time and give rise

to but little disturbance. Unless a careful history be taken and a fecal examination made, its existence may not be known until perforation takes place.

Pylorospasm, with its sudden onset and frequent recurrences, may be called gastritis. This condition may be caused from hyperchlorhydria or hypersecretion, from ulcer within or beyond the pylorus, or it may be a reflex from a diseased appendix. Cholecystitis and cholelithiasis, with their gastric reflexes, may create the impression of gastritis. A similar error was made, to my knowledge, a year ago in the case of a perforated gall bladder.

The gastric crisis of spinal sclerosis, in the absence of a history, might be called gastritis. A malignant stenosis of the pylorus is at times unnoticed until almost complete, when pain and vomiting are at once pronounced and persistent.

These are but some of the pathologic en

tities which in the hands of a careless practician may be dubbed gastritis. It is well to bear in mind that, while acute gastritis is perhaps the simplest form of stomach disease, its symptoms are often and generally the first real evidences to the patient of any one of many serious diseases. If this point be kept in mind there will be fewer cases so diagnosed, and, on the other hand, many a patient be given a fair show to recover.

Such a diagnosis is always to be received. with suspicion except in children who eat rapidly and unintelligently, or in young men and women who are given to banquets, late suppers, and wine orgies. In middle or late life such a diagnosis should never be made without a very complete history and examination, and without excluding all the possible pathology with which pain and vomiting are associated. J. M. BELL, M.D.

826 Jule St., St. Joseph, Mo. [Our symposium on digestive diseases and associated ailments includes several articles that we cannot present in this issue for lack of space. We have now in type, which we are compelled to hold over till next issue on this account, an article on "Acute Indigestion," by Dr. W. F. Waugh, of Muskegon, Mich., in which is presented a wealth of material which Dr. Waugh assures us is not to be found in any textbook. Also an extensive and thoro article on "Chronic Indigestion," by Dr. J. L. Engle, of Philadelphia, which goes into the subject in a masterly way. "Intestinal Indigestion" will also be treated in January WORLD.-ED.]

tion of the vessels occurred. This was a distinct advance over other existing methods.

Vierordt in 1885 was enabled to measure arterial tension more accurately by means of the sphygmograph than had been possible up to that time, but stated that absolute values were not obtained by that method.

Since that time many investigators have devoted their attention to blood pressure, and mainly arterial tension; so that to-day the terms blood pressure and arterial pressure and arterial tension are practically synonymous terms.

Among those who have done yeoman work in this field of research and in the perfecting of instruments which have been placed at the disposal of the medical profession, since 1880, should be mentioned Basch, Mosso, Hurthle, Riva-Rocci, Hoepfle, Hill, Bernard, Oliver, Gaertner, Stanton and Janeway.

That blood pressure is more and more widely studied cannot be gainsaid. That it is important and of great service in the study and treatment of disease no reasonable medical practician for an instant will attempt to confute.

While there is and probably should be slight differences of opinion as to pressure significance, those best qualified to know seem to be a unit on two things concerning this pressure: One is that the observation should be made as routinely as the taking of the pulse and temperature or urinary or other analysis. And that a mercurial manometer is the most reliable type to be used.

The technique of the observation is so Blood Pressure; Its Determination and Sig- generally known and practised and has been nificance in a Few Common Conditions. EDITOR MEDICAL WORLD: The blood pressure, or pressure of the blood within the vessels, has attracted the attention of investigators since the time of Harvey. Kries and Mary respectively in 1875 and 1876 determined the capillary tension in the human animal by air pressure and later by hydrostatic pressure. This was done by inserting an arm or a finger into a cylinder and by means of a water or mercury column measuring the pressure. Subsequently, this was found to be quite faulty.

In 1878 Ray and Brown placed a membrane, stretched over a capsule, upon the skin and applied both air pressure and water pressure. By connecting the capsule with a water manometer the readings could be taken with the naked eye when the oblitera

detailed in THE WORLD to such an extent that it would be a redundancy to admit it here.1 But no other single observation, whether used in the study of cases seen by the physician for the first time, or used routinely in observing and treating them, will offer the attending doctor as many facts concerning their condition as will blood pressure. We do not mean to say that a diagnosis should be placed upon this determination alone, nor should one establish a diagnosis upon a cough alone. A cough may arise from many different conditions, as does a high or low blood pressure. A reasonable physician would never diagnose a case of pneumonia on a cough (some cases,

'A booklet on blood pressure and how to take it will be forwarded to anyone on receipt of ten cents in cash or stamps by applying to the author.

in fact, do not have a cough), nor would he be any more likely to arrive at a proper diagnosis by taking the blood pressure alone. We have stated in these columns before, and reiterate it again, that the determination of blood pressure is only one of many observations to be made in the proper study of

a case.

What might be described as a more or less unconscious determination of arterial tension has been practised by palpation of the radial arteries for centuries, but at best, and when taken by those with the most acute sense of touch, it is nothing more or less than a guess, and only the maximum or systolic pressure can be estimated; greater accuracy is demanded and we feel justly so at the present time. Not only is this the case, but thousands of determinations have shown the significance of blood pressure in both health and disease, and the vast array of facts have been obtained with clinical instruments of precision, without which no comparisons could have been obtained. Of no less importance is the relation between the diastolic and systolic pressure, and, as already stated, can only be measured by accurate instruments.

Hypertension.

After the careful determination of blood

pressure, what then? This question is frequently asked and ordinarily means what can be done to relieve high blood pressure? One might just as well ask what can be done to relieve ascites. In either instance it is essential to learn the cause. If the cause is not learned, treatment cannot be intelligent, and any, except intelligent, treatment is dangerous.

As there are about a score of well-known causes for ascites, there are probably about as many for hypertension, some of which are very well known. We do not believe that high arterial tension is in itself a disease, tho there are those who take this stand. While blood pressure may vary to a considerable degree in different individuals, just as the pulse rate or even temperature may and does in normal persons, any very great departure from the normal should be looked upon as a manifestation of some underlying pathologic condition. Whether a high blood pressure can or cannot be made to yield to treatment is, of course, a very different consideration. Even if the underlying pathology is known and even if it does not yield to treatment, it would not then be extraor

dinary, since many conditions well and definitely understood do not yield to any known treatment. But because certain hypertensions do not yield is no reason that proper study and treatment should not be instituted in every case.

There are certain malignant cases of measles, scarlet fever, diphtheria and syphilis, for instance, which are seen now and again that have a fatal trend from the very start, and which are not stayed by any means or methods at our disposal, and it should be remembered that the specific cause in two of the above-mentioned diseases is definitely known. But because, now and again, a ravishingly fatal case is met with is no reason that we should not use our best efforts in subduing every case. The indication holds just as true, we believe, in hypertension. In many diseased conditions, medical and surgical, when the offending cause has been discovered, a long step in treatment has also been made.

An erroneous notion concerning hypertension and arteriosclerosis seems common. From the most authoritative source it is learned that abnormally high pressures are observed in scarcely 50% of cases of demonstrable sclerotic vessels and confusion should no longer prevail.

Differential Diagnosis of Arteriosclerosis and Hypertension.

Here, again, the palpating fingers of the observer will ever go awry, and it is altogether likely that the two conditions have become confused thru palpation, and too much assumed, and even in typical cases of arteriosclerosis with hypertension the latter can often be found to be due to some other cause, and under treatment disappears, while the sclerosis remains. We are therefore forced to the conclusion that as many cases of arteriosclerosis are due to hypertension as there are cases of hypertension due to arteriosclerosis, that the two conditions often coexist, are at times related, but are independent and not interdependent.

The above error of confusing the two conditions can easily be eradicated, since the sclerotic changes scarcely ever affect all the peripheral arteries alike, and if upon observation the vessels of the two legs and two arms show considerable variation in pressure the lowest of these will be nearer the true value.

It must not be forgotten that quite frequently pressures lower than normal are

found in cases when the vessels are markedly thickened or even calcareous.

Conditions Causing Hypertension. Among the conditions responsible for high tension probably toxins of various kinds are most frequently responsible. Many of these are closely allied to the purin bodies, or purin bases, and these latter, as is well known, are of two classes: (1.) The endogenous, derived from tissue metabolism, as might be found in conditions of leukemia, probably also uremia and that very obscure condition and specific toxemia of pregnancy. (2.) The exogenous purins derived from certain foods rich in nucleins, such as sweetbread, brain tissue, etc., which, after ingestion, digestion, assimilation, secretion, and without proper excretion, yield these purins, as occur probably in rheumatism and gout.

Other poisons or toxins which are accompanied by high blood pressure in the late stages and by marked sclerotic changes also are those of syphilis, lead poisoning and diabetes. Neither of the two former produces high blood pressure per se, but there is a marked and rapid hemolysis in both cases, and a subsequent anemia comparable in degree with the virulence of the case. In these conditions there is undoubtedly a marked tissue metabolism and the arteriosclerosis is entirely secondary. While there are undoubted toxemias in these cases they are not toxins which produce an arterial tension, such as are seen in uremia or pregnancy. Nor do anemias produce high pressures; so it would seem in these intoxications that the high tension is due to and in direct proportion with the sclerotic changes in the vessel walls.

In diabetes the diminution of the lumen as well as thickening and hardening of the vessel walls occur and are probably due, in a considerable degree in the early stages, to the irritant sugar in the blood and in the later stages to the acidosis, diacetic acid no doubt playing an important rôle at this period of the disease. The sclerotic changes even here, tho more or less general, are markedly more pronounced in certain arteries, as exemplified by the death of a toe or foot or leg from the occlusion while its mate of the opposite side is not thus affected.

Blood Pressure in Pregnancy.

If the general practician does not utilize this blood pressure instrument in the routine

of his work there is no excuse for not using it in every case of pregnancy, and it is criminal not to do so. It is conceded by every obstetrician and gynecologist of note to-day to be the best possible index in the progress and care of women in the pregnant state.

No other single ominous development to-day is fraught with such peril or mortality to both mother and child as is eclampsia. In the greatest clinics of the world supervised by the ablest living obstetricians the maternal mortality varies from 8 to 25%, and in private practise much nearer the latter figure is a safer estimate, for from all procurable sources it is 20% and over in private work. This is appalling, and especially so, since the blood pressure is conceded by practically all authorities here and abroad to be the earliest and most constant sign of the approach of this death-dealing condition.

In the study of blood pressure extending over five years no less an authority than Starling2 states that during the normal term of pregnancy the pressure ranges from 110 to 120 mm. Hg. Any rise, even above 125 mm., would suggest toxemia and keep him. on the alert for developments. B. C. Hirst, in the study of 100 normal pregnancies, found the pressure to average 118 mm. Hg. up to 71⁄2 months and averaging 124 mm. in the last 12 months.

The lowest pressure in 39 cases of eclampsia and 18 cases of marked albuminuria, but not eclamptic on first observation, was 142 mm., and the highest which did not develop eclampsia was 192 mm. The highest reading in the eclamptic cases was over 320 mm., but the instrument would not record a higher reading.

Green separates the eclamptic seizures into three classes: the mild, severe and fatal, and states that the blood pressure seems definitely related to the class of the case and of value in prognosis and treat

ment.

J. O. Arnold, in a very recent report of sixteen cases of eclampsia before the Samaritan Hospital Medical Society of this city, including private and hospital practise, finds the lowest blood pressure to be 148 mm. Hg. in the series, and the next lowest to be 165 mm. The highest in the series was 220 mm.

In the case having but 148 mm. pressure,

2 Blood Pressure in Toxemia of Pregnancy," London Lancet, Sept., 1910.

'See "Blood Pressure in Toxemias of Pregnancy,” Boston Med. & Surg. Journal, April, 1910.

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