Atrophy of the Stomach, with the Clinical Features of Progressive Per- nicious Ancemia. BY FREDERICK P. HENRY, M. D., Professor of Clinical Medicine in the Philadelphia Polyclinic, Physician to the Episcopal Hospital, Philadelphia, AND WILLIAM OSLER, M. D., Professor of Clinical Medicine in the University of Pennsylvania. FROM THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, April, 1886. Extracted from the American Journal of the Medical Sciences for April, 1886. ATROPHY OF THE STOMACH, WITH THE CLINICAL FEATURES OF PROGRESSIVE PERNICIOUS AN.EMIA. Frederick P. Henry, M.H., PROFESSOR OF CLINICAL MEDICINE IN THE PHILADELPHIA POLYCLINIC, PHYSICIAN TO THE EPISCOPAL HOSPITAL, PHILADELPHIA, AND William Oslee, M.D., PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA. Although for many years past the attempt has been made to asso- ciate certain cases of profound anaemia with wasting and degeneration of the gastric tubules, the occurrence of a primary atrophy of the mucous membrane of the stomach is still doubted, and probably the majority of pathologists agree with the statement of Welch, in his recent article on this subject in Pepper’s System of Medicine, “ that the existence of atrophy of the stomach as a primary and independent disease has not been established.” The following interesting case is offered as a contribution toward the solution of the question: Samuel 1., white, male, cet. forty-two, was admitted to the Episcopal Hospital on June 15, 1885. Seven weeks before this date he began to complain of weakness, loss of appetite, and perverted sense of taste— “everything tasted like pepper.” Dyspnoea was also a prominent symptom. On slight exertion he would be seized with vertigo, and be compelled to sit down. There is no record of hemorrhage from any part of the body. There w’as, and still is (at date of admission), a tendency to constipation, the bowels being moved every other day. In the autumn of 1880 he had an attack of tertian intermittent. After treating himself with domestic remedies, among which vinegar and salt seem to have occupied a foremost rank, he was cured by Peruvian bark and port wine. Twenty-four years ago he had a venereal sore, followed by two suppurating buboes, but without other secondary symptoms. He was on the police force from 1872 to 1880, during which period and subsequently, up to December, 1884, he was in the habit of drink- ing freely—“twenty to thirty drinks daily,” many of them before break- fast—and eating at irregular hours. After leaving the police he drove 2 HENRY, OSLER, ATROPHY OF STOMACH. an ice wagon, and wTas afterward a cab-driver. Eight years ago be bad an attack of gonorrhoea. In 1876 he weighed 305 pounds, and wxas a prominent figure at a “fat-men’s ball.” His height is six feet two inches. In 1877 he began to grow thin, and continued to lose flesh at the rate of one, two, and three pounds daily. He was in the habit of weighing himself on the same scales in a shop in his district. He once during this period of rapid diminution of weight, lost seven pounds in twenty-four hours. This loss of flesh continued with intermissions for eight or nine months, until his weight was reduced to 147 pounds, when he began to regain, and in a year thereafter weighed 180 pounds. The patient’s memory of the exact dates of these fluctuations in his bodily weight is not absolutely accurate, though sufficiently so for the purpose of this clinical history. He attributed his loss of flesh to indigestion. At the period referred to, he was in the habit of vomiting almost in- variably after taking food, and was frequently obliged to leave the table hastily on this account. His weight at time of admission was 139 pounds. His skin possesses the peculiar yellowish pallor that is almost pathog- nomonic of pernicious amemia, and the ocular conjunctiva is of the characteristic yellow hue, which differs, however, from the tint of icterus. The palpebral conjunctiva is milky-white, apparently bloodless. The skin of the abdomen is flaccid, and easily gathered in folds by a grasp of the hand, which fact is corroborative of the patient’s statement regard- ing his former obesity. This statement, however, is proved by the best possible evidence, that of photographs in his possession. His girth was once fifty-two inches, and is now thirty-two. The patient dates his ill- ness from a period about eight weeks prior to his admission to hospital. It began with dizziness, nausea, palpitation of the heart, and a sense of great weakness. These symptoms have continued up to date of admission. The results of physical examination are, for the most part, negative. The heart sounds are very feeble and distant, and unaccompanied by murmur or bruit The lungs are free from any sign of disease. There is neither tenderness nor increased area of dulness on percussion over liver or spleen. There is decided tenderness over middle of sternum, and a tender spot was also found on one of the lower ribs when making per- cussion in the splenic region. There is no enlargement of the lymphatic glands. The tongue is exceedingly pale in the centre, with pink edges and tip, but without fur. The urine contains a minute trace of albumin; its reaction, is acid; its specific gravity 1.020; it is free from sugar and bile pigment. On June 16, 17, and 18, the temperature rose above normal: on the first of these dates to 101°, and on the two latter to 102°, in the evening. After the 18th the temperature was normal, while in hospital. June 17. First examination of blood. Number of red globules per cubic millimetre, 790,000. Proportion of white to red, Ito 158. The percentage of red globules, as compared with the normal number (5,000,000), that is to say, the “ haemic unit,” is 15.8. The majority of the globules are larger than normal and many of them are pear-shaped and oval. Microcytes present in considerable quantity. Schultze’s granule masses scantily present. The color, as tested by Gowers’s hoemoglobinometer, is 16 per cent.; therefore, the amount of haemoglobin is relatively normal. This is a cardinal feature HENRY, OSLER, ATROPHY OF STOMACH. 3 of pernicious ansemia. In all other forms of anaemia, the percentage of haemoglobin is lower than that of the red globules. In pernicious anaemia, it generally equals, frequently exceeds, and has been observed by Laache to be double, that of the blood globules. 18th. An ophthalmoscopic examination was made by Dr. Albert G. Heyl, one of the ophthalmic surgeons to the hospital: “ Both optic disks free from swelling, margins clear and distinct. In R. E. arteries of nor- mal calibre, veins of increased calibre, at least double the size of arteries. A large hemorrhage, for the most part decolorized, was seen above the disk, and a more recent one upward and inward, in some places quite dark, in others of a raspberry-red. In L. E. the main upper vein was very full and inclined to be tortuous. The corresponding artery was abnor- mally full. A hemorrhage was seen below the disk. The media were quite clear. The condition is that of engorgement of the retinal vessels, with hemorrhages such as occur in ansemia.” 24-th. Number of red globules per c.m., 1,195,000. Hsemic unit, 23.9. Color, 20 per cent. No white seen. The red globules vary greatly in size and shape, being oval, pear-shaped, and generally of irregular out- line. Some of them are four times the normal size. There is a moderate number of microcytes. The date on which the patient left the hospital is not preserved, but there are notes of a visit to him at his own home on June 26th, so that his stay in hospital did not exceed two weeks. July 2. Came to have his blood examined, walking a distance of nearly two miles. Was not fatigued, but complained of a slight “ numb- ness” in the legs. Number of red globules per c.m., 1,215,000. No white seen. Hsemic unit, 24. Color, 28. Globules abnormally large and irregular. 6th. Patient had an attack of diarrhoea, which began the day before (Sunday), although he had felt uneasiness in bowels since Friday, and had stopped his medicine in accordance with directions. He had been taking Fowler’s solution, and had reached eight drops thrice a day, when diarrhoea set in. 7th. Sent for. He had five watery stools the day before, and one large, liquid, very ofiensive stool to-day. During the night, about 1.30, he had a decided chill. Pulse full and bounding, 112; skin hot and perspiring slightly; temperature 103.2°, Ordered 1\ grs. quinise sulph. every three hours, and suppository of half a grain extract, opii aq. every three hours until diarrhoea is checked. Bth. Has had thirteen stools since 12 m. the day before, but feels decidedly better, owing to subsidence of the fever. Pulse 80 ; tempe- rature 99.8°. Wishes to get up. 10th (Friday). Sitting up and looking worse. Has had forty watery, offensive stools since Tuesday morning, five between 4 and 9A. M. None since 9, when last suppository was used. 12th. Came to have his blood examined. Not so much fatigued as when he came on July 2d, which, considering the recent attack of diar- rhoea, is remarkable. Number of red globules per c.m., 1,635,000. Globules, for the most part, much larger than normal, and of irregular shapes. No white in specimen. Hsemic unit, 32.5. Color, 40. 20th. Number of red globules per c. m., 1,605,000. Globules mostly very large, some of them three times the normal size, and very irregular in shape; a few microcytes. Hsemic unit, 32. Color, 30. The count is 4 HENRY, OSLER, ATROPHY OF STOMACH. almost the same as the last, although the patient feels decidedly better, and walks considerable distances without fatigue, in spite of the intense heat now prevailing; the thermometer to-day reached 100° F., in the shade. His appetite is good, and the bowels are moved once daily. Ordered ferri pyrophosphat., gr. iiss ter in die. Aug. 2 (Sunday). On Thursday patient came to have his blood ex- amined, but it could not be done at that time. On his way home he drank a glass of buttermilk and soon after swallowed a plate of mock- turtle soup and a glass of lemonade. The consequence was an attack of cholera morbus the same evening. He treated himself with laudanum and blackberry brandy, and by next day the attack had ceased. On Friday he weighed 185 pounds. Number of red globules per c. m., 1.640.000. Hsemic unit, 82.8. Color, 36. Average size of corpuscles still decidedly above normal. Very few microcytes. No granule masses. Shape of globules less irregular. No white cells seen. 10th. About the same. Blood not examined. Hydroleine prescribed. 15th. Feels much better. Weighs 140 pounds. Talks of getting to work—cab-driving. Has walked a distance of two miles without fatigue during the past week. Appetite good and bowels regular. Did not take hydroleine, but, by advice of an officious friend, took elix. ferri, quinise, et strychnia) phosphat., instead. Number of red globules per c. m., 1.805.000. Hsemic unit, 36. Color, 82. No white seen. Patient looks very pale and ghastly. Sept. 2. Has been working as a street-car conductor for a week, getting up at 3.30 a. m., and working until late at night. Got along very well until two days ago, when an attack of diarrhoea compelled him to stop work. 12th. Working again as car conductor. Rises at 4a. m. and does not get to bed until one o’clock next morning. He has, therefore, if his statement is correct, only three hours in bed. “ Never felt better in his life,” but looks exceedingly pale and thin. No. of red globules per c. m., 1,470,000. Hsemic unit, 29.4. Color, 85. Oct. 21. No. of red globules per c. m., 1,255,000. Hsemic unit, 25. Color, 20. White corpuscles to red as 1 to 500. Globules large and irregular. Patient complains of great weakness in legs on walking short distances. Has been continuously at work as car conductor, though not on full time. Nov. 19. Sent for, and found him lying down though dressed. Has not worked for a month and is exceedingly feeble. Has followed no regular treatment whatever, being incorrigible in this respect. Has taken lately some pills called “ tree of life,” which purged him freely and reduced his little remaining strength. He complained of difficulty in passing water, and stated that some years ago he had been treated for stricture by the late Dr. Maury. Passed a No. 15 (French) catheter and drew off a little limpid urine. No blood followed passage of instru- ment. (About ten days later No. 21 was passed without difficulty.) His quarters are very confined and dark, and exceedingly noisy from con- tinual passage of Pennsylvania I\. K. trains almost directly overhead. Dec. 10. Sent for late at night on account of alarming dyspnoea. When visited he was relieved, the relief having succeeded the belching of large quantities of wind. 17th. About the same. He had apparently sent to inquire whether HENRY, OSLER, ATROPHY OF STOMACH. 5 there was any prospect of his recovery. Ordered vin. ferri amar., gss, and liq. potass, arsenit., npiiss. ter in die. 21st. Worse. Diarrhoea began during the night and has weakened him considerably. This has been the invariable result of attempts to administer arsenic. The diarrhoea, which amounted to seven or eight watery stools, was checked by fifteen drops of laudanum. Ordered liquor ferri dialysat., gtt. v ter in die, to begin to-morrow, if diarrhoea does not return. 28th. Exceedingly pale and feeble. No conveniences at house for examination of blood. Taking ten drops of solution of dialyzed iron thrice daily. On Jan. sth, through the kindness of Dr. S. Weir Mitchell, he was ad- mitted to the Summer St. Hospital. For several days before, he had been exceedingly weak, unable to sit up, and complaining of a sense of utter prostration. 10th. He lay in a semi-comatose condition, from which he could be partially roused, but was unable to recognize any person. The pulse eighty, very small, soft, and compressible, and the respirations deep and sighing. Number of red globules per c. m., 315,000. Owing to the extremely pale tint of the blood, the color test could not be employed. The count was made at three o’clock. At half-past four, Dr. T. G. Morton injected into the left internal saphenous vein, at about the junction of the middle and lower thirds of the leg, fifteen fluidounces of a solution of sodium chloride, 100 grains to the quart of distilled water. Present: Drs. Hunt, Cantrell, T. S. K. Morton, and Orville Horwitz. Toward the close of the operation, which, it is needless to say, was performed with the greatest skill, the patient became restless, and opened his eyes, but could not reply to questions. Pulse before and after transfusion un- changed in frequency (80), but somewhat fuller after the operation. 8.30 p. m., patient in condition of heavy stupor; pupils moderately dilated; pulse extremely weak, but still 80 per minute; respiration labored and sighing, but not stertorous. Died at 12.30, four hours later. Autopsy, eleven hours after death. Rigor mortis present. Consider- able emaciation. Cicatrices on glans penis. Panniculus not more than half an inch in thickness; fat of a deep yellow color. Great pallor of skin and all organs. Muscles of a light red tint. In abdominal cavity, peritoneum smooth ; small amount of a dark yellow serum; the intestines distended with gas. In right pleura general adhesions. Pericardium covered with a moderate amount of mediastinal fat; slight excess of fluid in cavity. Heart large, right chambers full; walls flaccid; pre- liminary incisions show in right auricle much pale serum, with a large yellow clot; in right ventricle a colorless clot, infiltrated with serum, closely adherent to trabeculse and chordae ; ten ounces of a watery blood were collected from these chambers. The left chambers were nearly empty; small thin clots blocked the mitral orifice. On further dissec- tion of the heart, walls of normal thickness; muscle very amende, and evidently fatty ; right chamber looks dilated; valves normal. Aorta not atheromatous; coronary arteries healthy. Lungs pale, crepitant through- out ; the lower lobes very oedematous, and the infiltration extends to the adhesions which exist between the lobes; frothy mucus in bronchial tubes and trachea. Spleen is slightly enlarged, moderately firm; pulp of a deep purple- 6 HENRY, OSLER, ATROPHY OF STOMACH. red color; the Malpighian corpuscles not evident. Kidneys of normal size; capsules detach readily, surfaces a little rough ; on section, cut with increased resistance; cortical portions pale; small arteries at bases of pyramids very prominent. The suprarenal capsules are of average size, firm; cortical portions of a deep yellow color. Bladder contains several ounces of clear urine. Stomach looks natural, contains gas and about an ounce of dark fluid; pyloric orifice firmly contracted, and the ring seems thickened ; cardiac orifice normal; length of organ eleven inches; breadth, when opened, eight inches. Walls not increased in thickness; at fundus two to three millimetres, at middle of anterior wall two and a half to three milli- metres, and at pyloric zone, ten centimetres from the ring, eight to nine millimetres. General surface of mucosa pale; mucus covers the pyloric region; there are a few dilated venules in several places. At the fundus the mucous membrane is very thin, smooth, grayish-white in color, tough, and tears with difficulty. No trace of superficial softening. In the middle zone it has the same pale gray aspect, is smooth, and there is an entire absence of the velvet-like appearance of the healthy mucosa. About the middle of the lesser curvature there is an old cicatrix, plainly shown by four or five radiating lines. In the pyloric zone, the mucosa is more vascular and decidedly thicker. Scattered over the surface of the membrane, particularly in the central zone, are numerous small, grayish-white elevations the size of a pin’s head, most of them isolated, others in groups, and contiguous ones are joined by narrow lines of tissue projecting half a millimetre above the surrounding surface. Toward the pylorus there are larger, more flattened elevations, separated from each other by shallow areas of a pale gray aspect. With a low- power lens small orifices can be seen in these flattened elevations, and here and there in the smaller nodular projections little orifices and tiny cysts can also be seen. The general surface of the mucosa as examined with a hand lens, has a smooth cuticular appearance; the thin mucosa is readily movable on the muscularis; the submucosa does not appear thickened; and, with the exception of the pyloric region, there is no thickening of the muscular coat. The oesophageal mucous glands are unusually distinct. Duodenum contains a bile-stained mucus. Bile flows freely from the orifice of the duct on compression of the gall-bladder. Small intestines contain a thin mucus. The walls of the jejunum look of average thickness; those of ileum thin. Peyer’s gland, in the portions examined, normal. The large bowel was not opened. Liver looks large, is of a light yellow-brown color; capsule presents patches of thickening. Tissue cuts easily, and contains very little blood. Gall-bladder distended with pale bile. Pan- creas very large, weighs more than 100 grammes; looks natural, lobules distinct; on section, presents a very normal appearance. Thoracic duct normal. The thoracic and semilunar ganglia have a natural appearance. No enlargement of the hones. Marrow of ribs and sternum of a deep purple-red color. That of lower portion of right tibia lymphoid, the cancelhe at the end of the bone contained fat. Brain not examined. Histological Examination.—Stomach. Portions were taken from four different parts and hardened in alcohol. (1) From fundus, where the mucosa looked thinnest and had a very smooth, cuticular appear- ance. Entire thickness of section about 3.5 millimetres, of which HENRY, OSLER, ATROPHY OF STOMACH, 7 scarcely one-half is made up of the muscular coat. Neither glandular nor epithelial elements of the mucosa occur in the section, but immediately upon the muscularis mucosae there is a narrow layer (Fig. 2, a) of flat- tened and small round cells, embedded in an indifferent matrix. In the stained preparation the nuclei of these cells are distinct, but the outlines are feebly marked. The muscularis mucosae shows a remarkable altera- tion. There are two distinct layers, in the innermost of which the cells are cut longitudinally and form a prominent wavy band of fibres, which are marked even under low powers (Fig. I, d, Fig. 2, h). From twelve to fifteen muscle cells can be counted in this band, which varies some- what in thickness in different places. Below it, forming a much thicker and not so sharply defined layer, are the transverse fibres of the muscu- laris mucosae, seen in cross-section, arranged in bundles and groups, separated by more or less connective tissue (Fig. 1, e, Fig. 2, c). They Fig. I. Section through mid-zone under low power, showing relations of the layers, a, mucous membrane with two of the nodular projections, 6, 6; c, remnants of tubules; art of the organ. Hypertrophy of the muscularis mucosae. Remarks.—The patient with the foregoing clinical history presented a vivid picture of progressive pernicious anaemia. Every symptom was present in bold relief: the excessive pallor and prostration, the anaemic fever, the retinal hemorrhages, and, above all, the extreme reduction in the number of the red globules, with, at the same time, a normal pro- portion of haemoglobin, the alterations in the size and shape of the globules (poikilocytosis), and the presence of microcytes in abnormal amount. The most prominent symptoms were those of profound gastric disturbance, due to the prolonged abuse of alcohol, and the rapid dimi- nution of weight. In less than one year the patient lost more than one hundred and fifty pounds. This is by no means the first case of per- nicious anaemia to which gastric disorder stands in causative relation. Similar cases have been reported by Fenwick,1 Quincke,2 and Noth- nagel,3 through which a bright light has been thrown upon the pathology of this hitherto obscure disease, and it is for this reason that exception is now taken to the indiscriminate application of the term “ idiopathic ” to cases of progressive pernicious anaemia. The rapid loss of flesh may be regarded from another point of view than that of symptomatology. It is a well-attested fact that fevers, inflammatory and essential, are of more serious import in fleshy, so-called plethoric individuals, than in those of sparer habit, and, in explanation, von Recklinghausen4 sug- 1 Atrophy of the Stomach, 18cl, 3 Deutsches Archiv fur klin. Med., Bd. xxiv. 2 Volkmann’s Sammlung Klin. Vortrage. 4 Deutsche Chirurgie, 1883, Bd. i. p. 180. 12 HENRY, OSLER, ATROPHY OF STOMACH. gests that the rapid absorption of fat and the products of fatty meta- morphosis may give rise to a qualitative change in the composition of the blood. The conservation of the muscular strength is also worthy of notice in this and other cases. On August 15 the patient walked two miles with- out fatigue, when there were less than 2,000,000-red globules per cubic millimetre. A patient of Laache, of Christiania, walked three kilo- metres (more than two miles), the entire distance being up kill, when his blood contained less than 1,000,000 globules per cubic millimetre.1 Such facts acquire additional significance when taken in connection with the deep red color of the muscles in these cases. It would appear that the muscles in pernicious ansemia are nourished at the expense of the other tissues. All attempts at treatment in this case were rendered nugatory by the irritable state of the intestinal tract and by the patient’s wilfulness and perversity in regard to matters of diet. Leaving out the blood exam- inations, in which he always took a keen interest, it was impossible to secure his cooperation in any diagnostic or therapeutic procedure. Although repeatedly requested to save the urine secreted during the whole twenty-four hours, in order that its percentage of urea might be estimated, he only managed to do so once. On this occasion (June 26) the amount was 45 oz.; sp. gr., 1.012; percentage of urea, 2.05 (normal). There was no albumen. The only special lesion in the case was the atrophy of the mucous membrane of the stomach. This was evident to the naked eye in the thin, cuticular appearance, and was abundantly confirmed by the micro- scopical examination, which showed that the peptic glands had been destroyed over the greater portion of the organ. The numerous small elevations which existed in the middle zone, represented areas of the mucosa less advanced in degeneration, and are comparable to the nodules of relatively normal tissue which beset the surface of a cirrhotic liver. Toward the pylorus, where the atrophy was less advanced, the various stages of the process could be traced, consisting essentially in a small- celled infiltration between the tubules, such as occurs in all forms of slow interstitial inflammation; and we may reasonably conclude that this process, extending over many years, ultimately led to the condition here described. The only other alternative is the supposition that a creeping ulceration had at one time involved the greater part of the mucosa, with the exception of the little islets of tissue already mentioned, and in healing had left the membrane in this state. The radiating cicatrix at the lesser curvature no doubt indicates that the patient had had, at one time, probably in 1877, when the gastric symptoms were so marked, an 1 Die Aniimie, S. laache, Christiania, 1883, p. 147. HENRY, OSLER, ATROPHY OF STOMACH. 13 ulcer in this region, but the uniform, smooth appearance of the mem- brane, the absence of puckering, and the condition of the muscularis mucosae, are not consistent with the view that there had been extensive ulcerative destruction, such as in rare cases does involve the stomach. In these instances, the process is not confined solely to the layer of tubules, but involves the muscularis mucosae, which is infiltrated with round cells, and in healing the mucosa and submucosa are closely united to each other. Except at the site of the cicatrix, the mucous membrane was in this case freely movable on the muscular coat. The remarkable hypertrophy of the muscularis mucosae is an associated condition not easy of explanation, but we call to mind in this connection the increase in the unstriped muscle elements in other conditions associated with irri- tation or degeneration, as notably in the lung of the cat affected with the nematoid parasite Ollulanus ; and in the bronchial tubes of man in some cases of chronic bronchitis. The recorded cases of atrophy of the stomach with clinical features of pernicious anaemia are not very numerous. Fenwick1 describes four cases, Quincke2 one, Nolen3 two, and Brabazon4 one; and in all of these the mucous membrane was affected without special alteration in the thickness of the walls of the stomach, or any diminution in its capacity. Nothnagel’s case was one of cirrhotic contraction of the stomach and atrophy of the peptic glands, with the clinical features of pernicious anaemia. In some of these cases the histological examination was very defective, and the exact condition remains doubtful. In Fenwick’s cases the interstitial connective tissue was greatly increased, and the gland tubules atrophic, but there was not the extensive destruction of the glandular layer which was so marked a feature in our case. The histo- logical account in Nothnagel’s case, by W. Muller, makes it clear that there was complete atrophy of the tubules in the entire organ, with the exception of the pyloric region. There was great thickening also of the muscularis mucosae. It seems natural to conclude that in the case we have described, the abuse of alcohol, extending over many years, played a part in the causa- tion of the atrophy. Certainly he had chronic dyspepsia, and had suffered from a gastric ulcer; but while these not uncommon conditions may lead to moderate wasting of the mucous membrane, such extensive destruction of tubules is rarely seen. In the cases narrated by Fenwick there was no history of alcoholism. In connection with the extensive endarteritis of the smaller gastric vessels, and the existence of scars on the glans penis and in the groins, the possibility of a syphilitic process may be considered, but we know as yet very little of the influence of syphilis on the stomach, and the recent attempt of Gaillard5 to connect 1 Loc. cit. 2 Loc. cit. 8 Centralblatt f. d. med. Wissenschaften, Bd, xx. 6 Archives Generates, January, 1886. 4 Brit. Med. Journal, 1878, ii. 14 HENRY, OSLER, ATROPHY OF STOMACH. certain forms of gastritis with this disease cannot he regarded as in any way successful. It is quite possible, however, that the state of the small arteries may have had something to do with the production of the atrophy. We have learned of late years to connect indurative processes in other organs with arterio-sclerosis and the endarteritis of the nutritive vessels of the mucosa may really have played an important part in inducing the wasting. In a recent review of this subject, Martin1 sug- gests that certain lesions of the mucosa may be due to these end-arterial changes, but acknowledges that, with regard to the stomach, the facts are as yet too few to warrant any conclusions. To the other anatomical features of the case we do not propose to refer. The reader will doubtless have noted the identity of the condi- tions with those in pernicious anaemia, even to the hyperplasia of the bone marrow and the pigmentation of the cells in the organs. One point, however, is worthy of note, viz., the large size and healthy ap- pearance of the pancreas. This organ varies greatly in size, but we re- gard it as certainly hypertrophied in this case, and we may see here pos- sibly a compensatory effort to supply the defects in gastric digestion. A careful study of this case justifies, we believe, the conclusion that a primary atrophy of the mucous membrane of the stomach does occur; and it further bears out the original suggestion of Flint, confirmed by Fenwick, Nothnagel, and others, that certain of the cases of progressive pernicious anaemia depend upon profound alterations in the gastric tubules. For the sections and drawings we are indebted to the skill of Dr. J. P. Crozier Griffith. 1 Revue de Medecine, January, 1886. THE MEDICAL NEWS. A National Weekly Medical Periodical, containing 28-82 Quarto Pages in each Number. Published every Saturday. 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