Volume 2 — DISEASES OF THE DIGESTIVE SYSTEM. (continued 9)

⁷⁷ St. Bartholomew's Hosp. Rep., vol. x. p. 236.

MORBID ANATOMY.—The following table gives the situation of the tumor in 1300 cases of cancer of the stomach:⁷⁸

Pyloric region. Lesser curvature. Cardia. Posterior wall. The whole or the greater part of the stomach. Multiple tumors. Greater curvature. Anterior wall. Fundus.

791 148 104 68 61 45 34 30 19

60.8% 11.4% 8% 5.2% 4.7% 3.5% 2.6% 2.3% 1.5%

From this table it appears that three-fifths of all gastric cancers occupy the pyloric region, but it is not to be understood that in all of these cases the pylorus itself is involved. In four-fifths of the cases the comparatively small segment of the stomach represented by the cardia, the lesser curvature, and the pyloric region is the part affected by gastric cancer. The lesser curvature and the anterior and the posterior walls are involved more frequently than appears from the table, inasmuch as many cancers assigned to the pyloric region extend to these parts. The fundus is the least frequent seat of cancer. In the cases classified as involving the greater part of the stomach the fundus often escapes.

⁷⁸ These cases are collected from the following sources: Lebert, op. cit.; Prague statistics of Dittrich, Engel, Wrany, and Eppinger, loc. cit.; Habershon, op. cit.; Katzenellenbogen, op. cit.; and Gussenbauer and V. Winiwarter, loc. cit. Gussenbauer and V. Winiwarter assign to the class of cancers involving the whole stomach all cases which they found designated simply as carcinoma ventriculi without further description. This produces in their statistics an excessive number of cancers under this class. I have preferred, therefore, to estimate in their collection of cases the number of cancers involving the whole stomach, according to the percentage for this class obtained from the other authors above cited.

As was shown by Rokitansky, it is the exception for cancer of the pylorus to extend into the duodenum, whereas cancer of the cardia usually invades for a certain distance the oesophagus.

The varieties of carcinoma which develop primarily in the stomach are scirrhous, medullary, colloid, and cylindrical epithelial carcinoma.⁷⁹ The distinction between scirrhous and medullary cancer is based upon the difference in consistence, the former being hard and the latter soft. Cylindrical-celled epithelioma cannot be recognized as such by the naked eye. It presents usually the gross appearances of medullary cancer. Soft cancer (including both cylindrical-celled epithelioma and medullary carcinoma) is the most frequent form of gastric cancer. Next in frequency is scirrhous cancer, and then comes colloid cancer, which, although not rare, is much less frequent than the other varieties.

⁷⁹ I have not been able to find an authentic instance of primary melanotic cancer of the stomach, although this form is included by most authors in the list of primary gastric cancers. It is known that most cases formerly described as melanotic cancers are melanotic sarcomata, which originate usually in the skin or the eye and are accompanied frequently with abundant metastases. Secondary melanotic tumors have been several times found in the stomach. They were present in 7 out of 50 cases of melanotic cancer (or sarcoma) analyzed by Eiselt, although out of 104 cases not a single primary melanotic cancer occurred in the stomach (Prager Viertaljahrschr., vol. lxxvi. p. 54). The list of secondary melanotic sarcomata of the stomach might be still further increased. Of course gastric cancers colored by pigment from old blood-extravasations should not be confounded with melanotic tumors.

As all degrees of combination and of transition exist between the different forms of cancer, and as a large number of cancers of the stomach are of a medium consistence and would be classified by some observers as scirrhous and by others as medullary, statistics as to the relative frequency of the different varieties have very little value. Moreover, in most statistics upon this point there is no evidence that simple fibrous growths have not been confounded with scirrhous cancer, and as a rule little or no account is taken of cylindrical-celled epithelioma, which is a common form of gastric cancer—according to Cornil and Ranvier, the most common.⁸⁰

⁸⁰ For any who may be interested in such statistics I have collected 1221 cases of gastric cancer, of which 791 (64.8 per cent.) were medullary, 399 (32.7 per cent.) scirrhous, and 31 (2.5 per cent.) colloid. 22 cases described as epithelial have been included with the medullary; 29 cases described as fibro-medullary, and 1 as fasciculated, have been included with the scirrhous. The cases are from the previously-cited statistics of Lebert, Dittrich, Wrany, Eppinger, Gussenbauer, and V. Winiwarter, and from Fenger (Virchow u. Hirsch's Jahresbericht, 1874, Bd. i. p. 312).

Cancer of the stomach may grow in the form of a more or less complete ring around the circumference of the stomach, or as a circumscribed tumor projecting into the cavity of the stomach, or as a diffuse infiltration of the walls of the stomach. The annular form of growth is observed most frequently in the pyloric region. Cancerous tumors which project into the interior of the stomach are sometimes broad and flattened, sometimes fungoid in shape, but most frequently they appear as round or oval, more rarely irregular, crater-like ulcers, with thickened, prominent walls and ragged floor. The free surface of the tumor presents sometimes a cauliflower-like or dendritic appearance, which characterizes the so-called villous cancer. Diffuse cancerous infiltration is seated oftenest in the right half of the stomach, but it may occupy the cardiac region or even the entire stomach.

The relation of the cancerous growth to the coats of the stomach varies in different cases. The tumor usually begins in the mucous membrane and rapidly extends through the muscularis mucosæ into the submucous coat. In this lax connective-tissue coat the tumor spreads often more rapidly than in the mucous membrane, so that it may appear as if the cancer originated in the submucosa. The mucous membrane, however, is usually invaded, sooner or later, over the whole extent of the tumor. The dense muscular coat offers more resistance to the invasion of the tumor. Cancerous masses, however, penetrate along the connective-tissue septa between the muscular bundles, which often increase in number and size. In the muscular coat thus thickened can be seen the opaque white fibrous and cancerous septa enclosing the grayish, translucent bundles of smooth muscular tissue. Often, however, the whole muscular coat beneath the tumor is replaced by the cancerous growth, and can no longer be recognized. The serous and subserous connective tissue, like the submucous coat, offers a favorable soil for the growth of the tumor, which here appears usually in the form of large and small nodules projecting from the peritoneum. Adhesions now form between the stomach and surrounding parts, and opportunity is offered for the continuous growth of the cancer into these parts. In the manner described the tumor grows in all directions, sometimes more in depth, sometimes more laterally, sometimes more into the interior of the stomach.

Ulceration occurs in all forms of gastric cancer.⁸¹ The ulceration is caused either by fatty degeneration and molecular disintegration of the surface of the tumor or by the separation of sloughy masses. Doubtless the solvent action of the gastric juice aids in the process. The softer and the more rapid the growth of the cancer, the more extensive is likely to be the ulcer. Such ulcers are usually round or oval in shape, but their contours may be irregular from the coalescence of two or more ulcers or from serpiginous growth. The edges are usually high, soft in consistence, and often beset with polypoid excrescences. The floor is generally sloughy and soft, and often presents warty outgrowths. The edges and floor may, however, be hard and smooth. In the more slowly-growing scirrhous and colloid cancers the ulcers are more likely to be superficial. Partial cicatrization of cancerous ulcers may take place. The development of cicatricial tissue may destroy the cancerous elements to such an extent that only by careful microscopical examination can the distinction be made between cancer and simple ulcer or fibroid induration. The examination of secondary cancerous deposits in adjacent lymphatic glands or other parts becomes, then, an important aid in the diagnosis.

⁸¹ Ulceration was present in 60 per cent. of Lebert's cases, and in 66½ per cent. of Gussenbauer and V. Winiwarter's pyloric cancers.

Suppuration has been known to occur in gastric cancers, but it is extremely rare.

Each form of gastric cancer has certain peculiarities which require separate consideration.

Medullary carcinoma grows more rapidly than the other varieties of cancer. It forms usually soft masses, which project into the stomach and are prone to break down in the centre and develop into the crater-like ulcers already described. All of the coats of the stomach are rapidly invaded by the growth. The consistence of the tumor is soft, the color upon section whitish or reddish-gray, sometimes over a considerable extent hemorrhagic. Milky juice can be freely scraped from the cut surface of the tumor. The so-called villous cancer and the hæmatodes fungus are varieties of medullary carcinoma. Medullary carcinoma is more frequently accompanied by metastases than the other forms. In consequence of its tendency to deep ulceration medullary cancer is more liable to give rise to hemorrhage and to perforation than is scirrhous or colloid cancer. The continuous new formation of cancerous tissue in the floor of the ulcer and the formation of adhesions, however, greatly lessen the danger of perforation into the peritoneal cavity.

Histologically, medullary cancer is composed of a scanty stroma of connective tissue enclosing an abundance of cancerous alveoli filled with polyhedrical or cylindrical epithelial cells. The stroma is often richly infiltrated with lymphoid cells, and contains blood-vessels which often present irregular dilatations of their lumen.

Waldeyer describes with much detail, for this as for the other forms of gastric cancer, the origin of the tumor from the gastric tubules. According to his description, a group of gastric tubules, ten to twenty in number, sends prolongations downward into the submucous coat. These tubular prolongations are filled with proliferating epithelial cells, which make their way into the lymphatic spaces of the surrounding tissue and give origin to the cells in the cancerous alveoli. A small-celled infiltration of the surrounding connective tissue accompanies this growth of the tubules.

The tissue beneath and at the margins of medullary cancer may be predominantly fibrous in texture and contain comparatively few cancerous alveoli. This scirrhous base is often exposed after the destruction of the greater part of the soft cancer by ulceration and sloughing. It is probable that many of the scirrhous cancers are formed in this way secondarily to medullary cancer (Ziegler).

Cylindrical-celled epithelioma presents the same gross appearances and the same tendency to ulceration and to the formation of metastases which characterize medullary cancer. The consistence of cylindrical epithelioma may, however, be firm like that of scirrhus. Not infrequently the alveoli are distended with mucus secreted by the lining epithelium, and then the tumor presents in whole or in part appearances similar to colloid cancer.

Upon microscopical examination are seen spaces resembling more or less closely sections of tubular glands. These spaces are lined with columnar epithelium. Often in certain parts of the tumor the alveolar spaces are filled with cells, so that the structure is a combination of that of ordinary cancer and of epithelioma. The stroma is generally scanty and rich in cells, but it may be abundant. Cysts may be present in this form of tumor, and in one case I have found such cysts nearly filled with papillary growths covered with cylindrical epithelium, so that the appearance resembled closely that of the so-called proliferous cysto-sarcoma of the breast.

The origin of cylindrical epithelioma from the gastric tubules is generally accepted, and is more readily demonstrable than the similar origin claimed for the other forms of gastric cancer.

Scirrhous cancer assumes often the form of a diffuse thickening and induration of the gastric walls, particularly in the pyloric region, where it causes stenosis of the pyloric orifice. Scirrhus may, however, appear as a circumscribed tumor. Irregular hard nodules frequently project from diffuse scirrhous growths into the interior of the stomach. Scirrhous cancer and medullary cancer are often combined with each other.

The dense consistence of scirrhous cancer is due to the predominance of the fibrous stroma, the cancerous alveoli being relatively small in size and few in number.

Colloid cancer generally appears as a more or less uniform thickening of the gastric walls. All of the coats of the stomach are converted into the colloid growth. Nearly the whole of the stomach may be invaded by the new growth.⁸² The tumor has a tendency to spread to the omenta and to the rest of the peritoneum, where it may form enormous masses, but it rarely gives rise to metastases in the interior of organs. Colloid cancer may, however, form a circumscribed projecting tumor in the stomach, and in rare instances it causes abundant secondary colloid deposits in the liver, the lungs, and other parts.

⁸² In a case reported by Storer the whole stomach, except a little of the left extremity over an extent of about an inch, was converted into a colloid mass in which no trace of the normal coats of the stomach could be made out. The colloid growth replacing the gastric wall measured seven-eighths of an inch in thickness in the pyloric region. Digestion was less disturbed in this case than in most cases of gastric cancer (Boston Med. and Surg. Journ., Oct. 10, 1872). In Amidon's case (reported in the Trans. of the N.Y. Path. Soc., vol. iii. p. 38) there seems to have been an equally extensive colloid metamorphosis of the stomach.

Colloid cancer presents, even to the naked eye, an exquisite alveolar structure, whence the name alveolar cancer as a designation of this tumor. Bands of opaque white or gray connective tissue enclose alveolar meshes which are filled with the gelatinous, pellucid colloid substance. This colloid material is thought to be produced by a colloid transformation of the epithelial cells in the alveoli, but the same transformation seems to occur also in the stroma. Few or no intact epithelial cells may be found in the alveoli. Colloid metamorphosis may take place in all forms of gastric cancer, but it is particularly common in cylindrical epithelioma. Colloid cancer may originate in the peritoneum unconnected with any glandular structures. It occurs often at an earlier age than other forms of cancer. Deep ulceration rarely attacks colloid cancer.

Flat-celled epithelioma is found at the cardiac orifice and as a metastatic growth in other parts of the stomach. Originating in the oesophagus, it may extend downward into the stomach. By noting whether the structure is that of squamous or of cylindrical epithelioma it is often possible to determine whether a tumor at the cardiac orifice originates in the oesophagus or in the stomach.

Secondary cancer of the stomach, although rare, is not such a curiosity as is often represented. Without aiming at completeness, I have been able to collect 37 cases of secondary cancer of the stomach, of which the larger number will stand critical examination.⁸³ Of these cases, 17 were secondary to cancer of the breast, 8 to cancer of the oesophagus, 3 to cancer of the mouth or nose, and the remainder to cancer of other parts of the body. The large number of cases secondary to cancer of the breast is explained by the large statistics relating to mammary cancer which were consulted. Gastric cancer is more frequently secondary to cancer of the oesophagus than to cancer of any other part. In this category of course are not included cases of continuous growth of oesophageal cancer into the stomach, but only metastatic cancers of the stomach. A part at least of the gastric cancers secondary to cancer of the alimentary tract above the stomach I refer, with Klebs, to implantation in the mucous membrane of the stomach of cancerous particles detached from the primary growth in the oesophagus, pharynx, or mouth. This view is supported by the absence in some cases of any involvement of the lymphatic glands. The secondary deposits in the stomach conform in structure to the primary growth. They are usually situated in the submucous coat, where they form one or often several distinctly circumscribed tumors. The secondary tumors may or may not ulcerate. They rarely produce symptoms.

⁸³ These cases are from Dittrich, 2 (the remainder of his cases I rejected); Cohnheim, 1; Petri, 2; Klebs, 3; Lücke, 1; Weigert, 1; Coupland, 1; Cruse, 1; Hausmann, 1; Bartholow, 1; Oldekop, 5; Edes, 1; V. Török and V. Wittelshöfer, 8; Grawitz, 4; Haren Noman, 5. So-called melanotic cancers, cancers involving only the serous coat of the stomach, and those extending by continuous growth into the stomach, are not included in this list.

Primary cancers may be present at the same time in different organs of the body; for instance, in the uterus and in the stomach.⁸⁴ The possibility of multiple primary cancers is to be borne in mind in considering some of the apparently secondary cancers of the stomach, as well as in determining whether certain cancers are secondary to gastric cancer or not. Here the microscopical examination is often decisive.⁸⁵

⁸⁴ Case of A. Clark's (Trans. N.Y. Path. Soc., vol. i. p. 260), and a similar one reported by J. B. S. Jackson in Extr. from Records of the Boston Soc. for Med. Improvement, vol. i. p. 335.

⁸⁵ The subject of multiple primary cancers is considered by Kauffmann (Virchow's Arch., Bd. 75, p. 317), and by Beck (Prager med. Wochenschr., 1883, Nos. 18 and 19). V. Winiwarter reports a cancer of the stomach in a patient who died one year seven and a half months after extirpation of a cancer of the nose. He regards the case as one of multiple primary cancer.

Gastric cancer often causes important secondary changes in the coats and the lumen of the stomach. In the neighborhood of the tumor are often found hypertrophy of the muscular coat and fibrous thickening of the submucous coat. Polypoid hypertrophy of the mucous membrane near the cancer is not rare. Not only near the tumor, but over the whole stomach, chronic catarrhal gastritis usually exists.

The most important alterations are those dependent upon obstruction of the orifices of the stomach. This obstruction may be caused either by a tumor encroaching upon the orifice or by an annular thickening of the walls of the orifices. Even without apparent stenosis, destruction of the muscular layer at or near the pylorus may be an obstacle to the propulsion of the gastric contents into the duodenum. As a result of obstruction of the pyloric orifice the stomach becomes dilated, sometimes enormously, so as to occupy most of the abdominal cavity. The walls of the dilated stomach, particularly the muscular coat, are usually thickened, but exceptionally they are thinned. Sometimes with pyloric stenosis the stomach is reduced in size. This occurs particularly when a scirrhous growth extends diffusely from the pyloric region over a considerable part of the stomach. Obstruction of the cardiac orifice or in the oesophagus leads to atrophy of the stomach, although here also there are exceptions. Above the obstruction the oesophagus is often dilated. An existing obstruction may be reduced or removed by ulceration or sloughing of the tumor.

Both dilatation and contraction of the stomach may attend gastric cancer without any involvement of the orifices of the stomach in the cancerous growth. The cavity of the stomach may be so shrunken by scirrhous thickening and contraction of the gastric walls that it will hardly contain a hen's egg. Irregular deformities in the shape of the stomach, such as an hour-glass shape and diverticular recesses, may be caused by gastric cancer.

Changes in the shape of the stomach and the weight of the tumor may cause displacements of pyloric cancers, so that these tumors have been found in nearly all regions of the abdomen, and even in the true pelvis.⁸⁶ Such displaced cancers usually contract adhesions with surrounding parts.

⁸⁶ Lebert, op. cit., p. 420.

It is not necessary to dwell upon the formation of adhesions which may bind the stomach to nearly all of the abdominal organs, most frequently to the liver, the pancreas, the intestine, and the anterior abdominal wall. Adhesions of pyloric cancers are found in at least two-thirds of the cases, and probably oftener.⁸⁷

⁸⁷ Gussenbauer and V. Winiwarter found adhesions recorded in 370 out of 542 pyloric cancers. In considering the propriety of resection of gastric cancers it has become a matter of importance to know in what proportion of cases adhesions are present. I agree with Ledderhose and with Rydygier in believing that adhesions are present oftener than appears from Gussenbauer and V. Winiwarter's statistics. The fact that adhesions are not noted in post-mortem records of gastric cancer cannot be considered proof of their absence. Little has been done in the study of gastric cancer from a surgical point of view. Metastases and adhesions were absent in only 5 out of 52 cases of pyloric cancer in which either pylorectomy or exploratory laparotomy was performed (Rydygier).

Cancer of the stomach in the majority of cases is accompanied with metastases in other parts of the body. In 1120 cases of gastric cancer secondary cancers were present in 710, or 63.4 per cent., and absent in 410, or 36.6 per cent.⁸⁸ In about two-thirds of the cases, therefore, secondary deposits were present.

⁸⁸ These cases are from Habershon, op. cit.; Lebert, op. cit.; Trans. N.Y. Path. Soc., vol. i.; and Gussenbauer and Von Winiwarter, loc. cit.

In order to determine the relative frequency of the secondary deposits in various organs of the body, I have constructed the following table, based upon an analysis of 1574 cases of cancer of the stomach in which the situation of the metastases were given:⁸⁹

Lymphatic glands. Liver. Peritoneum, omentum, and intestine. Pancreas. Pleura and lung. Spleen. Brain and meninges. Other parts of the body.

551 475 357 122 98 26 9 92

35% 30.2% 22.7% 7.8% 6.2% 1.7% 0.6% 5.8%

⁸⁹ These cases include, in addition to those cited in the preceding foot-note, those of Dittrich (Prager Vierteljahrschr., vol. xvii.), Wrany (ibid., vols. xciv. and xcix.), Katzenellenbogen (op. cit.), and Lange (op. cit.). Metastases in the intestine formed only a small number of those under the heading peritoneum, omentum, and intestine, but as they were all included together in Gussenbauer's large statistics, the intestinal metastases could not well be placed separately. In 673 cases the peritoneum and omentum were cancerous in 21.7 per cent.

Secondary cancerous deposits are probably even more frequent in the lymphatic glands than appears from the table. In 1153 cases of gastric cancer in which the situation of the affected lymphatic glands is specified, the abdominal glands, and chiefly those near the stomach, were the seat of cancer in 32½ per cent. In Lange's 210 cases the cervical glands were affected in 4.3 per cent. In other statistics this percentage is much smaller. In nearly one-third of the cases there are secondary cancers in the liver. These may attain an enormous size in comparison with the tumor of the stomach. Cancer of the peritoneum and of the omentum is found in about one-fifth of the cases of gastric cancer. The spleen is rarely involved, except by continuous growth of a cancer of the fundus or in cases of widespread distribution of cancer through the aortic circulation. Cancer of the liver increases the liability to metastases in the lungs, but the latter may be present without any cancerous deposits in the liver. Secondary cancers may be present in the suprarenal capsules, the kidneys, the ovaries, the heart, the thoracic duct, the bones, the skin, etc. In an interesting case reported by Finlay⁹⁰ the subcutaneous tissue of the trunk was thickly studded with small nodules, of which two were excised during life and found to be cylindrical epitheliomata. This led to the diagnosis of a primary tumor of the same nature in the stomach or in the intestine. At the autopsy was found a cylindrical epithelioma of the stomach which had not given rise to characteristic symptoms. Secondary cancer of the intestine is rare if the deposits in the peritoneal coat be excepted. Several cancerous ulcers or multiple cancerous nodules may be found along the intestinal tract, involving the mucous and the submucous coats.⁹¹ These metastases seem best explained by the theory of implantation of cancerous elements which have been carried from the primary growth in the stomach into the intestine. In some of the cases the idea of multiple primary cancers may also be entertained.

⁹⁰ Trans. Path. Soc. London, vol. xxxiv. p. 102. Unfortunately, in Röseler's case of multiple skin-cancers with an ulcerated cancer of the stomach no microscopical examination of the skin-nodules was made. The interpretation of this case is therefore doubtful (Virchow's Archiv, Bd. 77, p. 372).

⁹¹ Cases in point are recorded by Wrany (loc. cit.), Blix (Virchow u. Hirsch's Jahresbericht, 1876, ii. p. 207), Lange, Katzenellenbogen, and Lebert.

It is not rare for gastric cancer to cause secondary deposits in the stomach itself. Sometimes it is difficult to decide which of two or more cancers in the stomach is the primary growth, as in Ripley's case of ulcerated cancer of the cardiac orifice with a similar growth around the pyloric orifice.⁹² It is probable that in very rare instances multiple primary cancers may develop in the stomach.

⁹² J. H. Ripley, Trans. N.Y. Path. Soc., vol. iv. p. 121. Maurizio has also reported a case of scirrhous cancer of the cardia with scirrhous cancer of the pylorus (Annal. univ. di Medicina, Oct., 1869). A similar case was observed by Barth (Gaz. hebdom., 1856, No. 24, p. 424).

Cancerous metastases are produced by the transportation of cancerous elements by the lymphatic current or by the blood-current. In a number of instances the portal vein or some of the branches which help to form it have been found plugged with a cancerous mass which may or may not be organized.⁹³ The cancer in these cases has burst through the walls of the vessel into the lumen, where it may grow both in the direction and against the direction of the current. On serous surfaces, and probably also, although rarely, on mucous surfaces, secondary cancers may develop from cancerous particles detached from a parent tumor and scattered over the surface as a kind of seminium.

⁹³ Cases of this kind have been reported with especial fulness by Spaeth (Virchow's Archiv, Bd. 35, p. 432), Acker (Deutsches Arch. f. kl. Med., Bd. 11, p. 173), and Audibert (De la Généralisation du Cancer de l'Estomac, Paris, Thesis, 1877).

Mention has already been made of the invasion of parts adjacent to the stomach by the continuous growth of gastric cancer. In this way lymphatic glands, the liver, the pancreas, the omenta, the transverse colon, the spleen, the diaphragm, the anterior abdominal wall, the vertebræ, the spinal cord and membranes, and other parts may be involved in the cancerous growth.

Under the head of Complications reference has already been made to various lesions which may be associated with gastric cancer. As regards the manifold complications caused by perforation of gastric cancer, in addition to what has already been said the article on gastric ulcer may be consulted. In general, the various fistulous communications caused by gastric cancer are less direct than those produced by gastric ulcer. The wasting of various organs of the body in cases of gastric cancer may be found on post-mortem examination to be extreme. Habershon mentions a case in which the heart of a woman forty years old weighed only 3½ ounces after death from cancer of the pylorus. As in other profoundly anæmic states, the embryonic or lymphoid alteration of the marrow of the bones is often present in gastric cancer.

PATHENOGENESIS.—The problems relating to the ultimate causation and origin of gastric cancer belong to the pathenogenesis of cancer in general. Our knowledge with reference to these points is purely hypothetical. It will suffice in this connection simply to call attention to Virchow's doctrine, that cancer develops most frequently as the result of abnormal or of physiological irritation, hence in the stomach most frequently at the orifices; and to Cohnheim's theory, that cancer as well as other non-infectious tumors originate in abnormalities in development, more specifically in persistent embryonic cells. According to the latter view, gastric cancer develops only in those whose stomachs from the time of birth contain such embryonic remnants. These unused embryonic cells may lie dormant throughout life or they may be incited to cancerous growth by irritation, senile changes, etc. According to Cohnheim's theory, the orifices of the stomach are the most frequent seat of cancer on account of complexity in the development of these parts.

For a full consideration of these theories the reader is referred to the section of this work on General Pathology.

DIAGNOSIS.—The presence of a recognizable tumor in the region of the stomach outweighs in diagnostic value all other symptoms of gastric cancer. The detection of fragments of cancer in the vomit or in washings from the stomach is of equal diagnostic significance, but of rare applicability. The discovery of secondary cancers in the liver, in the peritoneum, or in lymphatic glands may render valuable aid in diagnosis. Of the local gastric symptoms, coffee-ground vomiting is the most important. The relation between the local and the general symptoms may shed much light upon the case. While anorexia, indigestion, vomiting, and epigastric pain and tenderness point to the existence of a gastric affection, the malignant character of the affection may be surmised by the development of anæmia, emaciation, and cachexia more rapid and more profound than can be explained solely by the local gastric symptoms. The value to be attached in the diagnosis of gastric cancer to the absence of free hydrochloric acid from the contents of the stomach must still be left sub judice. The age of the patient, the duration, and the course of the disease are circumstances which are also to be considered in making the diagnosis of gastric cancer. These symptoms of gastric cancer have already been fully considered with reference to their presence and absence and to their diagnostic features.

It remains to call attention to the differential diagnosis between gastric cancer and certain diseases with which it is likely to be confounded. The points of contrast which are to be adduced relate mostly to the intensity and the frequency of certain symptoms. There is not a symptom or any combination of symptoms of gastric cancer which may not occur in other diseases. Hence the diagnosis is reached by a balancing of probabilities, and not by any positive proof. Notwithstanding these difficulties, gastric cancer is diagnosed correctly in the great majority of cases, although often not until a late stage of the disease. Errors in diagnosis, however, are unavoidable, not only in cases in which the symptoms are ambiguous or misleading, but also in cases in which all the symptoms of gastric cancer, including gastric hemorrhage and tumor, are present, and still no gastric cancer exists. Cases of the latter variety are of course rare.

In the absence of tumor the diseases for which gastric cancer is most liable to be mistaken are gastric ulcer and chronic gastric catarrh. In the following table are given the main points of contrast between these three diseases:

GASTRIC CANCER. GASTRIC ULCER. CHRONIC CATARRHAL GASTRITIS.

1. Tumor is present in three-fourths of the cases. 1. Tumor rare. 1. No tumor.

2. Rare under forty years of age. 2. May occur at any age after childhood. Over one-half of the cases under forty years of age. 2. May occur at any age.

3. Average duration about one year, rarely over two years. 3. Duration indefinite; may be for several years. 3. Duration indefinite.

4. Gastric hemorrhage frequent, but rarely profuse; most common in the cachectic stage. 4. Gastric hemorrhage less frequent than in cancer, but oftener profuse; not uncommon when the general health is but little impaired. 4. Gastric hemorrhage rare.

5. Vomiting often has the peculiarities of that of dilatation of the stomach. 5. Vomiting rarely referable to dilatation of the stomach, and then only in a late stage of the disease. 5. Vomiting may or may not be present.

6. Free hydrochloric acid usually absent from the gastric contents in cancerous dilatation of the stomach. 6. Free hydrochloric acid usually present in the gastric contents. 6. Free hydrochloric acid may be present or absent.

7. Cancerous fragments may be found in the washings from the stomach or in the vomit (rare). 7. Absent. 7. Absent.

8. Secondary cancers may be recognized in the liver, the peritoneum, the lymphatic glands, and rarely in other parts of the body. 8. Absent. 8. Absent.

9. Loss of flesh and strength and development of cachexia usually more marked and more rapid than in ulcer or in gastritis, and less explicable by the gastric symptoms. 9. Cachectic appearance usually less marked and of later occurrence than in cancer; and more manifestly dependent upon the gastric disorders. 9. When uncomplicated, usually no appearance of cachexia.

10. Epigastric pain is often more continuous, less dependent upon taking food, less relieved by vomiting, and less localized, than in ulcer. 10. Pain is often more paroxysmal, more influenced by taking food, oftener relieved by vomiting, and more sharply localized, than in cancer. 10. The pain or distress induced by taking food is usually less severe than in cancer or in ulcer. Fixed point of tenderness usually absent.

11. Causation not known. 11. Causation not known. 11. Often referable to some known cause, such as abuse of alcohol, gormandizing, and certain diseases, as phthisis, Bright's disease, cirrhosis of the liver, etc.

12. No improvement or only temporary improvement in the course of the disease. 12. Sometimes a history of one or more previous similar attacks. The course may be irregular and intermittent. Usually marked improvement by regulation of diet. 12. May be a history of previous similar attacks. More amenable to regulation of diet than is cancer.

The diagnosis between gastric cancer and gastric ulcer is more difficult than that between cancer and gastritis, and sometimes the diagnosis is impossible. The differential points mentioned in the table are of very unequal value. An age under thirty, profuse hemorrhage, and absence of tumor are the most important points in favor of ulcer; tumor, advanced age, and coffee-ground vomiting continued for weeks are the most important points in favor of cancer. As cancer may have been preceded by ulcer or chronic gastritis for years, it is evidently unsafe to trust too much to the duration of the illness. As has already been said, it is best to place no reliance in the differential diagnosis upon the character of the pain. Any peculiarities of the vomiting, the appetite, or the digestion are of little importance in the differential diagnosis. Cachexia is of more importance, but it is to be remembered that ulcer, and even chronic gastritis in rare instances, may be attended by a cachexia indistinguishable from that of cancer. Cases might be cited in which very decided temporary improvement in the symptoms has been brought about in the course of gastric cancer, so that too much stress should not be laid upon this point. Enough has been said under the Symptomatology with reference to the diagnostic bearings of the absence of free hydrochloric acid from the stomach, of the presence of cancerous fragments in fluids from the stomach, and of secondary cancers in different parts of the body.

One must not lose sight of the fact that the whole complex of symptoms, the order of their occurrence, and the general aspect of the case, make an impression which cannot be conveyed in any diagnostic table, but which leads the experienced physician to a correct diagnosis more surely than reliance upon any single symptom.

In the early part of the disease there may be danger of confounding gastric cancer with nervous dyspepsia or with gastralgia, but with the progress of the disease the error usually becomes apparent. What has already been said concerning the symptomatology and the diagnosis of gastric cancer furnishes a sufficient basis for the differential diagnosis between this disease and nervous affections of the stomach.

Chronic interstitial gastritis or fibroid induration of the stomach cannot be distinguished with any certainty from cancer of the stomach. Fibroid induration of the stomach is of longer duration than gastric cancer, and it is less frequently attended by severe pain and hemorrhage. Sometimes a hard, smooth tumor presenting the contours of the stomach can be felt, but this cannot be distinguished from diffuse cancerous infiltration of the stomach.

Non-malignant stenosis of the pylorus is of longer duration than cancer of the pylorus. The symptoms of dilatation of the stomach are common to both diseases. Cicatricial stenosis is the most common form of non-malignant pyloric stenosis. This is usually preceded by symptoms of gastric ulcer which may date back for many years. Non-malignant stenosis more frequently occurs under forty years of age than does cancer. The diagnosis between malignant and non-malignant stenosis of the pylorus is in some cases impossible.

Although the surest ground for the diagnosis of gastric cancer is the appearance of tumor, there are cases in which it is difficult to decide whether the tumor really belongs to the stomach, and even should it be established that the tumor is of the stomach, there may still be doubt whether or not it is cancerous.

The diagnosis between cancerous and non-cancerous tumors of the stomach, such as sarcoma, fibroma, myoma, etc., hardly comes into consideration. The latter group of tumors rarely produces symptoms unless the tumor is so situated as to obstruct one of the orifices of the stomach. Even in this case a positive diagnosis of the nature of the tumor is impossible.

Of greater importance is the distinction between cancerous tumors of the stomach and tumors produced by thickening of the tissues and by adhesions around old ulcers of the stomach. Besides the non-progressive character of the small and usually indistinct tumors occasionally caused by ulcers or their cicatrices, the main points in diagnosis are the age of the patient and the existence, often for years, of symptoms of gastric ulcer antedating the discovery of the tumor. The long duration of symptoms of chronic catarrhal gastritis and of dilatation of the stomach is also the main ground for distinguishing from cancer a tumor produced by hypertrophic stenosis of the pylorus.

Tumors of organs near the stomach are liable to be mistaken for cancer of the stomach. The differential diagnosis between gastric cancer on the one hand, and tumors of the left lobe of the liver and tumors of the pancreas on the other hand, is often one of great difficulty.

Tumors of the liver are generally depressed by inspiration, whereas tumors of the stomach are much less frequently affected by the respiratory movements. The percussion note over tumors of the liver is flat, while a tympanitic quality is usually associated with the dulness over tumors of the stomach. Light percussion will often bring out a zone of tympanitic resonance between the hepatic flatness and the dulness of gastric tumors. Gastric tumors are usually more movable than hepatic tumors. By palpation the lower border of the liver can perhaps be felt and separated from the tumor in case this belongs to the stomach. Most of the points of distinction based upon these physical signs fail in cases in which a gastric cancer becomes firmly adherent to the liver. The basis for a diagnosis must then be sought in the presence or the absence of marked disturbance of the gastric functions, particularly of hæmatemesis, vomiting, and dilatation of the stomach. On the other hand, ascites and persistent jaundice would speak in favor of hepatic cancer. There are cases in which the diagnosis between hepatic cancer and gastric cancer cannot be made. This is especially true of tumors of the left lobe of the liver, which grow down over the stomach and compress it, and which are accompanied by marked derangement of the gastric functions. The frequency with which cancer of the stomach is associated with secondary cancer of the liver should be borne in mind in considering the diagnosis.

There are certain symptoms which in many cases justify a probable diagnosis of cancer of the pancreas, but this disease can rarely be distinguished with any certainty from cancer of the stomach. The situation of the tumor is the same in both diseases. With pancreatic cancer the pain is less influenced by taking food, the vomiting is less prominent as a symptom, and anorexia, hæmatemesis, and dilatation of the stomach are less common than with gastric cancer. Of the positive symptoms in favor of cancer of the pancreas, the most important are jaundice, fatty stools, and sugar in the urine. Of these symptoms jaundice is the most common.

Should there be any suspicion that the tumor is caused by impaction of feces, a positive opinion should be withheld until laxatives have been given.

Mistakes may occur as to the diagnosis between gastric cancer and tumors of the omenta, the mesentery, the transverse colon, the lymphatic glands, and even the spleen or the kidney. Encapsulated peritoneal exudations near the stomach have been mistaken for gastric cancer. Where a mistake is likely to occur each individual case presents its own peculiarities, which it is impossible to deal with in a general way. Of the utmost importance is a careful physical exploration of the characters and relations of the tumor, aided, if necessary, by artificial distension of the stomach or of the colon by gas (see page 549). No less important is the attentive observance of the symptoms of each case. In doubtful cases fluids withdrawn from the stomach by the stomach-tube should be carefully examined for cancerous fragments, and the gastric fluids may be tested for free hydrochloric acid by methods already described.

Pyloric cancers which receive a marked pulsation from the aorta sometimes raise a suspicion of aneurism, but the differential diagnosis is not usually one of great difficulty. Gastric cancer when it presses upon the aorta may simulate aneurism, not only by the presence of pulsation, but also by the existence of a bruit over the tumor. The tumor produced by aneurism is generally smoother and rounder than that caused by cancer. The pulsation of an aneurism is expansile, but the impulse of a tumor resting upon an artery is lifting and generally without lateral expansion. The impulse transmitted to a tumor resting upon the abdominal aorta may be lessened by placing the patient upon his hands and knees. Sometimes the tumor can be moved with the hands off from the artery, so that the pulsation momentarily ceases. A severe boring pain in the back, shooting down into the loins and the lower extremities, and not dependent upon the condition of the stomach, characterizes abdominal aneurism, but is not to be expected in gastric cancer. With aneurism gastric disorders and constitutional disturbance are much less prominent than with cancer of the stomach.⁹⁴

⁹⁴ In a case of pulsating pyloric cancer observed by Bierner the symptoms were much more in favor of aneurism than of cancer. The cancer had extended to the retro-peritoneal glands, which partially surrounded and compressed the aorta. There were marked lateral pulsation of the tumor, distinct systolic bruit, diminution of the femoral pulse, and severe lancinating pain in the back and sacral region. With the exception of vomiting, the gastric symptoms were insignificant. The patient was only thirty-three years old (Ott, Zur Path. des Magencarcinoms, Zurich, 1867, p. 71).

Spasm of the upper part of the rectus abdominis muscle may simulate a tumor in the epigastric region. The diagnosis is made by noting the correspondence in shape and position between the tumor and a division of the rectus muscle, the superficial character of the tumor, the effect of different positions of the body upon the distinctness of the tumor, the tympanitic resonance over the tumor, and, should there still be any doubt, by anæsthetizing the patient, when the phantom tumor will disappear. Spasm of the rectus muscle has been observed in cases of cancer of the stomach.

Attention is also called to the possibility of mistaking in emaciated persons the head of the normal pancreas, or less frequently the mesentery and lymphatic glands, for a tumor.⁹⁵ As emaciation progresses the at first doubtful tumor may even appear to increase in size and distinctness.

⁹⁵ In the case of the late Comte de Chambord the diagnosis of gastric cancer was made upon what appeared to be very good grounds. No cancer, however, existed, and the ill-defined tumor which was felt during life in the epigastric region proved to be the mesentery containing considerable fat (Vulpian, "La dérnière Maladie de M. le Comte de Chambord." Gaz. hebd. de Méd. et de Chir., Sept. 14, 1883).

It is sufficient to call attention to the danger of mistaking, in cases where the gastric symptoms are not prominent and no tumor exists, gastric cancer for pernicious anæmia, senile marasmus, or the chronic phthisis of old age. In some of these cases the diagnosis is impossible, but the physician should bear in mind the possibility of gastric cancer in the class of cases here considered, and should search carefully for a tumor or other symptom which may aid in the diagnosis.

The possibility of mistaking gastric cancer accompanied with peritoneal exudation for cirrhosis of the liver or for tubercular peritonitis is also to be borne in mind.

The diagnosis of the position of the cancer in the stomach can usually be made in cases of cancer of the cardia or of the pylorus. The symptoms diagnostic of cancer of the cardia are dysphagia, regurgitation of food, obstruction in the passage of the oesophageal bougie, and sinking in of the epigastric region in consequence of atrophy of the stomach. It has already been said that catheterization of the oesophagus does not always afford the evidence of obstruction which one would expect. Cancerous stenosis of the cardia is to be distinguished from cicatricial stenosis in this situation. The diagnosis is based upon the history of the case, which is generally decisive, and upon finding fragments of cancer in the tube passed down the oesophagus.

That the cancer is seated at the pylorus is made evident by the situation of the tumor (see p. 561) and by the existence of dilatation of the stomach. There are many more causes of stenosis of the pylorus than of stenosis of the cardia, so that, notwithstanding the absence of tumor, cancer of the cardia is often more readily diagnosticated than cancer of the pylorus.

The greatest difficulty in diagnosis is presented by cancers which do not obstruct the orifices of the stomach. Many of these cancers run an almost latent course so far as the gastric symptoms are concerned, and in case they produce no recognizable tumor and are unattended with hemorrhage, the difficulties in their diagnosis are almost insurmountable.

In general, a diagnosis of the particular form of cancer which is present cannot be made, nor is such a diagnosis of any practical value. In very exceptional cases such a diagnosis might be made by the examination of secondary subcutaneous cancers⁹⁶ or of fragments found in the fluids obtained from the stomach.

⁹⁶ As for example, in Finlay's case, already referred to (p. 567). It is not safe to trust implicitly in this criterion, as the subcutaneous tumors may be of a different nature from the tumor of the stomach, as in an interesting case observed by Leube (op. cit., p. 125).

Although the diagnosis of gastric cancer can generally be made before the death of the patient, unfortunately a positive diagnosis in the early stages of the disease is usually impossible. Should resection of cancer of the stomach become a legitimate operation in surgery, it will be of the utmost importance to make the diagnosis in an early stage of the disease. Only those cases are suitable for resection in which there are no secondary deposits, the general health of the patient is in fair condition, and extensive adhesions have not been formed. It was to be hoped that the ingenious instrument devised by Mikulicz for exploring the interior of the stomach by electrical illumination would prove a valuable aid in diagnosis. The gastroscope in its present construction, however, has proved of little value.⁹⁷ It is, moreover, difficult to manipulate, and is not free from danger to the patient. We may be permitted, however, to hope for improvement in this direction.

⁹⁷ Mikulicz has observed with the gastroscope in a case of pyloric cancer immobility of the pylorus and absence of rugæ in the mucous membrane of the pyloric region (Wiener med. Wochenschr., 1883, No. 24). It does not seem probable that there can be anything peculiar to cancer in these appearances.

In cases in which there is reasonable suspicion of the existence of gastric cancer, and in which there is proper ground to contemplate resection of the tumor, it is justifiable to make an exploratory incision into the abdomen. It can then be decided whether or not cancer exists, and whether the case is suitable for operation. When this incision is made with all of the precautions known to modern surgery, it is attended with little or no danger,⁹⁸ and it should not be made except by surgeons who are practically familiar with these precautions.

⁹⁸ Of 20 exploratory incisions for tumor of the stomach performed by Billroth, not one had ended fatally (Deutsche med. Wochenschrift, 1882, ii.).

PROGNOSIS.—There is no proof that cancer of the stomach has ever ended in recovery. It may be admitted that partial cicatrization of gastric cancer may occur. We have, however, no sufficient reason to believe that cancer of the stomach has ever been completely destroyed by any process of nature or by any medicinal treatment.

A successful resection of a cancer of the pylorus by Billroth in January, 1881, made a great sensation in the medical world. Since that time the operation has been performed successfully ten times, and with fatal issue twenty-seven times. A radical cure has not, however, been effected, although life has been prolonged for a year and a half after the operation.⁹⁹ The possibility of permanent cure of gastric cancer by extirpation must be admitted. Enthusiasm over this possibility, however, is seriously lessened by the fact that a radical cure is not to be expected unless the operation is undertaken when the tumor is of small size, has produced no distant metastases, is free from many adhesions, and the patient is not greatly prostrated. In view of the difficulty of diagnosis in the early stages it is not likely that these favorable conditions can be fulfilled except in the rarest instances. Metastases may already exist when the tumor is small and before it has given rise to any symptoms.¹⁰⁰ Pylorectomy, moreover, will probably be successful in the hands of only comparatively few surgeons. It is therefore but a feeble glimmer of hope which is now admitted to the hitherto relentlessly fatal forecast of this disease.

⁹⁹ Several of the patients are still living (1884), but, so far as I can learn, no patient has survived the operation more than a year and a half.

¹⁰⁰ Birch-Hirschfeld relates a case in which a non-ulcerated cancerous tumor not larger than a silver half-dollar was found in the pyloric region of the stomach of a woman who died from injury. The tumor had given rise to no symptoms. Nevertheless, numerous metastases existed in the lymphatic glands of the omentum and of the lesser curvature (Jahresb. d. gesellschaft f. Natur u. Heilk. im Dresden [1882-83], 1883, p. 37).

TREATMENT.—Even up to the present time various drugs have been vaunted as effecting a radical cure of cancer of the stomach. Some of these, such as mercury, are positively harmful; others, such as conium, belladonna, and condurango, are often palliative; but not one has been proven to be curative. Since its recommendation by Friedreich in 1874, condurango has enjoyed the greatest vogue. The few observations in which, under the use of this agent, tumors, real or apparent, of the stomach have lessened in size or disappeared, admit of other interpretations than as cures of gastric cancer. There is, however, considerable testimony as to the virtues of condurango as a stomachic. In some cases it relieves the pain, vomiting, and indigestion of gastric cancer, but in many cases it is employed without benefit. The drug which passes by the name of condurango in the market is a very variable preparation. According to Friedreich's directions, decoction of condurango is prepared as follows: Macerate oz. ss of cort. condurango for twelve hours with fluidounce xij of water; then boil down to fluidounce vj and strain. The dose is a tablespoonful two or three times daily. The decoction of condurango may be combined with syr. aurantii cort.

While all specific treatment of gastric cancer is to be abandoned, much can be done for the relief and comfort of the patient. The treatment is symptomatic.

In general, the indications are similar to those in gastric ulcer. It is not necessary, however, to restrict the diet to the same extent as in gastric ulcer. The patient's tastes may be consulted to a considerable extent. Still, it will be found, as a rule, that the patient is most comfortable when his diet is confined to easily-digestible substances, such as milk, beef-juice, Leube's beef-solution, rare beefsteak, and other articles mentioned under the treatment of gastric ulcer.

The pain of gastric cancer will usually require the administration of opium in some form. There is manifestly not the same objection to the employment of narcotics in a necessarily fatal disease like cancer as in ulcer of the stomach. Opium may be given in pill form or as the tincture or deodorized tincture, or often most advantageously as hypodermic injections of morphia, to which atropia may be added.

Vomiting is sometimes controlled by regulation of the diet, particularly by iced milk. For this symptom also opium or morphia is often necessary. In addition, the customary remedies for relief of vomiting, such as bits of ice, iced champagne, soda-water, hydrocyanic acid, oxalate of cerium, creasote, may be tried. Cold or hot applications to the abdomen and mild counter-irritants, such as mustard plaster or turpentine stupes, sometimes afford relief. If the vomiting be incoercible, it may be well to administer food for a short time exclusively by the rectum, and in case of stenosing cancer of the cardia this method of administering food may be the only one possible.

Acid eructations and heartburn are often relieved by the antacids, as bicarbonate of sodium, lime-water, or calcined magnesia. Against fermentative processes in the stomach have been recommended salicylate of sodium, creasote, carbolic acid, and the alkaline hyposulphites. Charcoal tablets are as useful as, and less likely to disagree than, other antifermentatives. In view of V. d. Velden's investigations, already mentioned, the administration of dilute hydrochloric acid in an hour after a meal is indicated.

Excellent results have been obtained by regularly washing out the stomach in cases of gastric cancer, particularly in pyloric cancer with dilatation of the stomach. By this procedure pain, indigestion, and vomiting are often greatly relieved, and the patient experiences a renewed sense of well-being. Unfortunately, the benefit is only temporary. The syphon process is most conveniently employed. Contraindications to the use of the stomach-tube are copious gastrorrhagia and great weakness of the patient.

When constipation is not relieved by washing out the stomach, enemata should be employed. Drastic purgatives should not be given.

For diarrhoea opium may be given, particularly in the form of small enemata of starch and laudanum.

Scanty hemorrhage in the form of coffee-grounds vomiting requires no treatment. Copious hæmatemesis is to be treated according to the principles laid down under the treatment of hemorrhage from gastric ulcer.

Discussion of the surgical treatment of gastric cancer of course does not belong to this work. The opinion entertained by the physician as to the propriety of surgical interference in gastric cancer is not, however, a matter of indifference, for cases of gastric cancer come first into the hands of the physician, and generally only by his recommendation into those of the surgeon. So long as the physician stands absolutely powerless before this disease, his general attitude as to the propriety of surgical interference should not be one of hostility. Experience only can determine the justification of surgical operation in cases of gastric cancer. As yet, it is too soon to express a positive opinion as to the value of resection of gastric cancer. Of 37 published resections of cancer of the pylorus, 27 died from the effects of the operation, and of the fatal cases 18 within the first twenty-four hours. These results are certainly not calculated to awaken much enthusiasm for the operation. Still, it would be wrong to draw definite conclusions from the existing statistics of resection of the cancerous pylorus, partly because the number of operations is as yet too small, partly because the operation has been done when it was certainly unwarrantable according to the best judges (Billroth, Czerny), and chiefly because the number of operators in proportion to the number of operations is too great. For the 37 published operations there have been 27 operators. Ovariotomy was not considered a justifiable operation until the excellent results of individual operators were obtained. It is probable that to an even greater extent resection of the pylorus will become the specialty of certain operators. Therefore, before concluding as to the value of resection of cancer of the stomach it is necessary to await the results of individual surgeons in a series of cases.¹⁰¹

¹⁰¹ Already, from this point of view, the operation appears more hopeful. Czerny has performed 6 resections of the stomach with only 2 fatal results; 4 of the operations were pylorectomies for cancer. Billroth has performed the operation 8 times with 3 fatal results (Wiener med. Wochenschrift, 1884, Nos. 17 and 29).

So much, however, is now certain, that with our present means of diagnosis the number of cases suitable for extirpation is very small.¹⁰² A radical cure is to be expected only in the rarest instances, so that the value of the operation will depend chiefly upon the condition of the patient after its performance. As regards this point, the results in the successful cases have been encouraging. In several instances the terrible sufferings of the patient have given place to months of comparative health and comfort.

¹⁰² Billroth at the eleventh session of the Congress of German Surgeons said that he was amazed at the number of resections of the pylorus which had been performed. Out of 50 to 60 cases of gastric cancer, only 1 appeared to him suitable for operation.

In cases of extreme cancerous stenosis of the pylorus which are not suitable for resection Wölfler proposed forming a fistulous communication between the stomach and the small intestine (gastro-enterostomy). The results of the operation have not been encouraging. Out of six cases in which this operation has been performed, only two patients lived after the operation.

For the same condition Schede proposed making a duodenal fistula (duodenostomy), but I am not aware that the operation has been performed.

The results of gastrostomy for relief of cancerous stenosis of the cardia or of the oesophagus have not been encouraging.¹⁰³

¹⁰³ Of 76 cases of gastrostomy for the relief of cancer of the oesophagus or of the cardia, only 14 lived over thirty days (Leisrink and Alsberg, Arch. f. klin. Chir., Bd. 28, p. 760, 1882).

Non-Cancerous Tumors of the Stomach.

Little clinical interest attaches to non-cancerous tumors of the stomach. They are comparatively rare and usually unattended by symptoms. Even should a tumor be discovered, there are no means of determining the nature of the tumor; and if symptoms are produced by the tumor, the case will probably be diagnosticated as one of cancer. It is necessary, therefore, in the present work to do little more than enumerate the different forms of non-cancerous tumor of the stomach.

The most common of benign gastric tumors are polypi projecting into the interior of the stomach. These are usually so-called mucous or adenomatous polypi, being composed of hypertrophied or hyperplastic elements of the mucous membrane with or without new growth of submucous tissue. They may be present in large number (one hundred and fifty to two hundred in a case of Leudet's). Their development is usually attributed to a chronic catarrhal gastritis, so that a gastritis polypora has been distinguished. These polyps are important only when they obstruct one of the orifices of the stomach, in which case they may cause even fatal stenosis. This occurrence is very rare.

Benign adenomata appear less frequently as growths in the submucous coat of the stomach (Winiwarter).

Myomata and myosarcomata, projecting sometimes as polyps either into the gastric or the peritoneal cavity, may attain a very large size, as in a case reported by Brodowski in which a cystic myosarcoma of the stomach weighed twelve pounds.¹⁰⁴

¹⁰⁴ Virchow's Archiv, Bd. 67.

Sarcoma, either as a primary or a secondary tumor of the stomach, is rare. Two cases of secondary lympho-sarcoma of the stomach (primary of the retro-peritoneal glands) without gastric symptoms have come under my observation. In a similar case reported by Coupland the symptoms resembled those of gastric cancer.¹⁰⁵

¹⁰⁵ Trans. London Path. Soc., vol. xxviii. p. 126.

In connection with gastric ulcer mention has already been made of the occurrence of miliary aneurisms in the stomach, which may be the cause of fatal hæmatemesis.

Sometimes the mucous membrane is studded with little cysts, as in a case reported by Harris.¹⁰⁶

¹⁰⁶ Am. Journ. Med. Sci., April, 1869.

Fibromata and lipomata are very rare.

Foreign bodies in the stomach, particularly balls of hair, have been sometimes mistaken for tumors, particularly cancer, of this organ. Schönborn removed successfully a ball of hair from the stomach by gastrotomy.¹⁰⁷ Before the operation the tumor was considered to be a movable kidney.

¹⁰⁷ Arch. f. kl. Chirurg., Bd. xxix. p. 609.

HEMORRHAGE FROM THE STOMACH.

BY W. H. WELCH, M.D.

Hemorrhage from the stomach is a symptom, and not a disease. It is a result of a great variety of morbid conditions in the description of which it receives more or less consideration. Already the symptomatology and treatment of hemorrhage from the stomach have been considered in connection with its two most important causes—namely, gastric ulcer and gastric cancer. It remains to give a summary of the etiology and diagnosis of gastric hemorrhage.

Hemorrhage from the stomach is also called gastrorrhagia. The term hæmatemesis is not synonymous with gastric hemorrhage, for blood may be vomited which has simply been swallowed or has passed from the intestine into the stomach.

ETIOLOGY.—The causes of gastric hemorrhage are as follows:

1. Ulcer of the Stomach.—Simple gastric ulcer is the most frequent cause of abundant hemorrhage from the stomach. Tuberculous gastric ulcers, typhoid gastric ulcers, and the ulcers of phlegmonous gastritis are extremely rare causes of hemorrhage. Hemorrhagic erosion of the stomach, which by many writers is assigned an important place in the etiology of gastric hemorrhage, is not an independent affection, and in my opinion is without any clinical significance.

2. Cancer of the Stomach.—(Non-cancerous tumors of the stomach hardly deserve mention in this connection, so infrequently are they the cause of gastric hemorrhage.)

3. Traumatism (mechanical, chemical, thermic).—a. Acting from without the stomach: severe injury to the abdomen, as by a blow or a fall; penetrating wounds of the stomach.

b. Acting from within the stomach: foreign bodies, particularly sharp-pointed ones; corrosive poisons, as acids and alkalies; other toxic inflammatory irritants; and very hot substances. Here should also be mentioned injury from an inflexible stomach-tube and aspiration of mucous membrane with the stomach-pump.

4. Diseases of the Gastric Blood-vessels.—a. Aneurism of the arteries of the stomach. Miliary aneurisms have been found by Galliard and others as a cause of profuse and even fatal hemorrhage from the stomach. Especially in obscure cases should careful search be made for miliary aneurisms.

b. Varices of the veins are a not unimportant cause of gastric hemorrhage. They are most frequently associated with chronic passive congestion of the stomach, but they may be found without any apparent disturbance of the circulation.

c. Degenerations of the vessels, particularly fatty and atheromatous degeneration of the arteries. Probably gastric hemorrhage in phosphorus-poisoning is to be attributed to fatty degeneration of the arteries. Amyloid degeneration of the blood-vessels is a doubtful cause of hemorrhage.

5. Active Congestion of the Stomach.—Here is usually placed gastric hemorrhage as a result of severe inflammation of the stomach (as acute catarrhal gastritis), although in these cases the inflammatory alteration of the vascular walls is an equally important factor.

With more probability the so-called vicarious hemorrhages from the stomach are to be assigned to active congestion. Sceptical as one is inclined to be as regards vicarious hemorrhages of the menses, the occurrence of such hemorrhages, although rare, must be admitted. Doubtful, however, are alleged cases of gastric hemorrhage taking the place of suppressed hemorrhoidal bleeding or of epistaxis.

6. Passive Congestion of the Stomach.—This embraces an important group of causes of gastric hemorrhage. This hemorrhage is the result of venous congestion caused by some obstruction to the portal circulation. The obstruction may be—

a. In the portal vein itself or its branches within the liver, as in pylethrombosis, cirrhosis of the liver, tumors, such as cancer or echinococcus cysts, compressing the portal vein, occlusion of capillaries in the liver by pigment-deposits in melanæmia, and dilatation of the bile-ducts in the liver from obstruction to the flow of bile. Next to ulcer and to cancer of the stomach, cirrhosis of the liver is the most frequent and important cause of gastrorrhagia.

b. In the pulmonary blood-vessels, as in pulmonary emphysema, chronic pleurisy, and fibroid induration of the lungs.

c. In the heart in consequence of uncompensated valvular and other diseases of the heart.

For evident reasons, obstruction of the pulmonary or of the cardiac circulation is much less likely to cause gastric hemorrhage than is obstruction in the portal vein or the liver.

Possibly, gastric hemorrhage which is caused by violent acts of vomiting may be caused by venous congestion of the mucous membrane of the stomach. In support of this view, Rindfleisch advances the idea that the veins in the muscular layers of the stomach, in consequence of the thinness of their coats, are much more likely than the arteries to suffer from the compression of the muscle during its contraction.

The occasional occurrence of gastric hemorrhage during pregnancy has also been attributed to passive congestion of the stomach.

7. Acute Infectious Diseases—namely, yellow fever, acute yellow atrophy of the liver, relapsing fever; less frequently cholera, typhoid fever, typhus fever, diphtheria, erysipelas, and the exanthematous fevers, small-pox, measles, and scarlet fever.

The cause of gastric hemorrhage in these diseases is not understood. The usual explanation attributes the hemorrhage to dissolution of the blood-corpuscles and secondary alteration of the walls of the blood-vessels. Plugging of the vessels with micro-organisms has been found in only a few instances. The gastrorrhagia of acute yellow atrophy of the liver has been attributed to dissolution of the blood, not only by some infectious agent, but also by constituents of the bile, and also to obstruction of the portal circulation by destruction and occlusion of capillaries in the liver.

8. Other Constitutional Affections.—a. Hemorrhagic diatheses—namely, scorbutus, purpura, and hæmatophilia. Strictly speaking, a hemorrhagic diathesis exists in other affections of this class.

b. Malaria. Here we may distinguish, first, periodical malarial hemorrhages from the stomach which are cured by quinia; second, pernicious gastric malarial fever, of very grave prognosis; and third, hemorrhages in malarial cachexia due to extreme anæmia. Cases which have been described as malaria with scorbutic complications belong mostly to the last variety. Mention has already been made of gastric hemorrhages attributed to malarial pigmentation of the liver.

c. Profound Anæmias. The most important affections in this category are progressive pernicious anæmia, leucocythæmia, and pseudo-leucocythæmia, including the so-called splenic anæmia.

d. Cholæmia. The hemorrhage is attributed to dissolution of the blood-corpuscles by the action of the biliary salts.

Gastric hemorrhage is a rare event in Bright's disease, occurring more especially with small kidneys. In one such case I found that the fatal hemorrhage was due to the bursting of a miliary aneurism of a small artery in the submucous coat. Probably in all similar cases the hemorrhage is referable to disease of the vascular walls.

9. Neuropathic Conditions.—Although ecchymoses in the mucous membrane of the stomach can be experimentally produced by injury of various parts of the brain and spinal cord, there is no proof that gastric hemorrhage which is of any clinical importance is referable to structural diseases of the nervous system. The occasional occurrence of gastric hemorrhage in progressive paralysis of the insane, in tuberculous meningitis, in epilepsy, is to be attributed to other causes.

In lack of a better explanation, however, the gastric hemorrhages which have been occasionally observed in hysterical women may be classified here. These constitute not the least important class of gastric hemorrhages. The hemorrhages from the stomach in chlorosis belong partly here and partly to anæmia.

10. Melæna Neonatorum.—Although in some cases ulcers have been found in the stomach or duodenum, and in others a general hemorrhagic diathesis exists, it must be said that the etiology of this grave disease is still very obscure.

11. Bursting of Aneurisms or of Abscesses from without into the Stomach.

12. Idiopathic Causes.—Under this unsatisfactory designation are included cases which are aptly described by Flint¹ in the following words: "Hemorrhage sometimes occurs from the stomach, as from the bronchial tubes, the Schneiderian membrane, and in other situations, without any apparent pathological connections, neither following nor preceding any appreciable morbid conditions. It is then to be considered as idiopathic." A person in apparent health has suddenly a hemorrhage, often profuse, from the stomach, which is followed only by symptoms immediately referable to the hemorrhage. The hemorrhage is naturally the source of great anxiety. Ulcer or cancer of the stomach or some other grave disease is usually suspected. But the patient develops no further symptoms, and often never has another hemorrhage. Whatever hypotheses one may construct for these cases of so-called idiopathic hemorrhage, the recognition of the clinical fact of their occurrence is important.

¹ Austin Flint, A Treatise on the Principles and Practice of Medicine, 5th ed., p. 513, Philada., 1881.

Inasmuch as hemorrhage from the stomach is usually made manifest by the vomiting of blood, it is important to bear in mind that gastric hemorrhage is not the only cause of hæmatemesis. Blood may gain access to the stomach by being swallowed in cases of hemorrhages from the nose, mouth, throat, bronchi, lungs, and oesophagus. Blood may also enter the stomach from the duodenum in cases of simple ulcer of the duodenum or of typhoid ulcers situated in the upper part of the intestine.

The SYMPTOMS of hemorrhage from the stomach have already been described in connection with ULCER OF THE STOMACH.

MORBID ANATOMY.—As is evident from the enumeration of the causes of gastric hemorrhage, the lesions found after death are manifold. A description of these lesions, however, does not belong here. It is necessary, however, to say a few words concerning the demonstration of the source of the hemorrhage.

The hemorrhage is arterial, venous, or capillary in origin. Ulcerations from the stomach into the heart, which have been mentioned in connection with gastric ulcer, are too infrequent to come into consideration in this connection. If the bleeding is from a large artery or vein or from a medium-sized aneurism or varix, the demonstration of its source is not difficult. Often, however, in cases of fatal gastric hemorrhage the search for the source of the hemorrhage has proved fruitless. It is supposed that in many such cases the hemorrhage is due to diapedesis, and not to rupture of a blood-vessel (rhexis). Doubtless, small gastric hemorrhages, particularly those into the tissues of the stomach, are often the result of diapedesis, but in cases of profuse hemorrhages from the stomach where the source of the hemorrhage is not demonstrable after death, the convenient assumption of hemorrhage by diapedesis, in my opinion, plays too important a rôle. In most cases of profuse gastrorrhagia the symptoms point to a sudden outpouring of blood into the stomach; and our knowledge of diapedesis does not warrant the belief that the red blood-corpuscles can escape through the unsuffused walls of the vessels with that combined rapidity and abundance which would be necessary to explain the sudden and profuse hemorrhage. In these cases hemorrhage by rhexis is altogether more probable even when ruptured vessels cannot be demonstrated. It often requires a long-continued and careful search to find a small vessel which is ruptured. In the case above mentioned of fatal hæmatemesis from miliary aneurism over an hour of continuous searching was required to find the pinhole perforation in the mucous membrane in the bottom of which lay the small aneurism. Chiari² has reported a fatal gastric hemorrhage due to rupture of a submucous vein. The erosion of the mucous membrane was not larger than a hempseed. The examination of the mucous membrane is often much impeded by the closely-adherent mucus and blood, which have to be carefully removed. Injection of the vessels of the stomach with fluid may aid in finding a ruptured vessel. It is not intended to assert that in all cases of fatal gastric hemorrhage a painstaking search would reveal the source of the hemorrhage, but it is believed that cases of fatal gastric hemorrhage would less frequently be reported with negative anatomical result as hemorrhages by diapedesis, or by exhalation, or as parenchymatous or capillary hemorrhages, if such a search were made.

² Prag. med. Wochenschr., 1882, No. 50.

DIAGNOSIS.—Undoubtedly, small hemorrhages into the stomach often occur which are not recognized, and in the absence of vomiting even larger hemorrhages may escape detection unless a careful examination of the stools be made. The patient may die from abundant gastric hemorrhage before any blood has been vomited or has passed by the bowels.

When there is doubt whether the black color of the stools is due to blood or to the administration of iron or of bismuth, it generally suffices to add water to the stools. If blood be present, the water will acquire a reddish color. Should doubt still remain, then the microscope, the spectroscope, or the test for hæmin crystals may be called into requisition (see p. 545).

Whether black, tarry stools are produced by hemorrhage from the stomach or by hemorrhage in the upper part of the intestine can be decided only by the clinical history. If hæmatemesis be likewise present, the presumption is strongly in favor of gastric hemorrhage. The diagnosis, however, between hemorrhage from duodenal ulcer and that from gastric ulcer is very difficult, and can rarely be positively made.

The mere inspection of the vomit is generally sufficient to determine whether it contain blood or not. Color more or less resembling that of altered blood may be produced in the vomit by iron, bismuth, red wine, various fruits, such as cranberries, and by bile. When a careful inspection by the physician leaves doubt as to the presence of blood—which will rarely be the case—then here also recourse may be had to the microscope, spectroscope, and test for hæmin crystals.

Sometimes blood is swallowed and then vomited by hysterical females or by malingering soldiers or prisoners for purpose of deceit. In such cases there are generally no evidences of acute anæmia or of gastric disease. The blood of some animals can be distinguished by the microscope from human blood. When suspicion of deceit exists, there are generally various ways of entrapping the patient.

When blood is vomited by nursing infants the possibility of its coming from the breast of the mother is to be thought of.

Sometimes blood from the nose or throat is swallowed, particularly when the bleeding occurs during the night. This blood may subsequently be vomited. The inspection of the nose or throat will generally reveal the source of the hemorrhage in such cases.

The diagnosis between hemorrhage from the oesophagus and that from the stomach must be based upon the clinical history. The oesophagoscope, however, has been successfully employed for diagnostic purposes. Several cases have been reported of fatal hemorrhage from varices of the oesophagus. Such hemorrhage cannot be distinguished from gastric hemorrhage.

Much more frequently arises the question whether the hemorrhage is from the stomach or from the lungs. Sometimes the decision of this point is very difficult, and it may even be impossible, especially when the physician is obliged to trust only to the statements of the patient or his friends. Difficulty in the diagnosis results mainly from the fact that coughing and vomiting of blood are often associated with each other. With hæmoptysis blood may be swallowed and then vomited, and with hæmatemesis more or less coughing occurs. The diagnosis is to be based upon the points contained in the following table:

HÆMOPTYSIS. HÆMATEMESIS.

1. Usually preceded by symptoms of pulmonary or of cardiac disease. Bronchial hemorrhage, however, without evidence of preceding disease, is not rare. 1. Usually preceded by symptoms of gastric or of hepatic disease, less frequently by other diseases (see Etiology).

2. The attack begins with a tickling sensation in the throat or behind the sternum. The blood is raised by coughing. Vomiting, if it occurs at all, follows the act of coughing. 2. The attack begins with a feeling of fulness in the stomach, followed by nausea. The blood is expelled by vomiting, to which cough, if it occurs, is secondary.

3. The blood is bright red, fluid or but slightly coagulated, alkaline, frothy, and frequently mixed with muco-pus. 3. The blood is dark, often black and grumous, sometimes acid, and usually mingled with the food and other contents of the stomach.

If the blood has remained some time in the bronchi or a cavity, it becomes dark and coagulated. If the blood is vomited at once after its effusion, it is bright red and alkaline, or it may be alkaline if it is effused into an empty stomach.

4. The attack is usually accompanied and followed by localized moist râles in the chest, and there may be other physical signs of pulmonary or of cardiac disease. 4. After the attack the physical examination of the lungs is usually negative, but there are generally symptoms and signs of gastric or hepatic disease.

Bloody sputum continues for some time, often for days, after the profuse hemorrhage ceases. Black stools follow profuse hæmatemesis.

As it is important that the patient should be as quiet as possible during and for some time after the hemorrhage, any physical examination which disturbs the patient, such as percussing the posterior part of the chest or palpating the abdomen, should be avoided.

The diagnosis of the many causes of gastric hemorrhage belongs to the description of the various diseases which have been enumerated under the etiology.

PROGNOSIS.—It is exceptional for gastric hemorrhage to prove immediately fatal. According to Fox, such an occurrence is more frequent with cirrhosis of the liver than with ulcer or cancer of the stomach. The ultimate result of the hemorrhage depends greatly upon the previous condition of the patient. If this condition was good, he often rallies from the most desperate prostration immediately following the hemorrhage. A previously enfeebled patient is of course more likely to yield to the further anæmia and exhaustion caused by profuse hemorrhage. Although the symptoms of gastric ulcer and of cirrhosis of the liver are sometimes improved after hemorrhage from the stomach, nevertheless this hemorrhage can never be regarded as a welcome event.

For the treatment of gastric hemorrhage see ULCER OF THE STOMACH.

DILATATION OF THE STOMACH.

BY W. H. WELCH, M.D.

DEFINITION.—By dilatation of the stomach is understood a condition in which the stomach is abnormally large and is unequal to the performance of its normal functions. It will be observed that this definition of dilatation of the stomach includes an anatomical disturbance and a physiological disturbance. A stomach which, although unusually large, performs its functions perfectly well is not, in the clinical sense, a dilated stomach. The most characteristic functional disturbance in dilatation of the stomach is delay in the propulsion of the gastric contents into the intestine in consequence of inability of the muscular coat of the stomach to perform the work imposed upon it. This muscular insufficiency, whether primary or secondary, necessarily involves disorder of the digestive and absorptive powers of the stomach.

SYNONYMS.—Dilatatio ventriculi; Gastrectasia. It has been proposed to call the early stages of the disease insufficiency of the stomach (Rosenbach). The condition described by Chomel as dyspepsia of liquids is undoubtedly dilatation of the stomach.

HISTORY.—Dilatation as a disease of the stomach is not mentioned by writers of antiquity. Fabricius ab Aquapendente in 1623 was among the first to record an observation of dilatation of the stomach. During the following century cases of dilatation of the stomach were recorded more as curiosities than as of clinical interest. Most cases were attributed to eating or drinking inordinate quantities. In 1743, Widman clearly recognized stenosis of the pylorus as a cause of gastric dilatation. In the works of Van Swieten, Morgagni, Lieutaud, and J. P. Frank, during the latter half of the last century, different causes of dilatation of the stomach are recognized. The last writer especially distinguishes clearly between dilatation due to stenosis and that due to atony. The data as to the symptoms of the disease were still very imperfect. In 1833, Duplay¹ published an important article in which the main points in the causation and symptomatology of dilatation of the stomach are clearly described. After this time the important works on the practice of medicine or on diseases of the stomach contain, in the main, correct descriptions of the disease under consideration. Since the publication in 1869 of Kussmaul's memorable article² on the treatment of dilatation of the stomach by the stomach-pump, much greater attention has been paid to this disease than ever before, so that the literature upon this subject during the last fifteen years is very considerable. In 1875, Penzoldt published an excellent monograph upon dilatation of the stomach.³

¹ Arch. gén. de Méd., Ser. 2, t. iii. pp. 165, 523.

² Deutsches Arch. f. kl. Med., Bd. vi., 1869. Kussmaul first employed the stomach-pump in dilatation of the stomach in 1867, and in that year he reported a successful result (Schmidt's Jahrb., Bd. 136, p. 386).

³ Die Magenerweiterung, Erlangen, 1875. To this work I am indebted for most of the historical data in the text.

ETIOLOGY.—Dilatation of the stomach is the result of inability of this organ to propel its contents into the intestine within the normal space of time. In the performance of this mechanical work three factors are involved—namely, the muscular force of the stomach, the quantity and quality of the gastric contents, and the size of the opening between the stomach and the intestine. All causes of dilatation of the stomach may be referred to abnormalities of one or more of these factors.

The most important group of causes is represented by stenosis of the pyloric orifice or of the adjacent part of the stomach or of the intestine.⁴ Most cases of hypertrophic dilatation of the stomach—that is, dilatation with hypertrophy of the muscular walls of the stomach—are produced by causes belonging to this group.

⁴ Dilatation of the stomach in consequence of intestinal obstruction below the duodenum is so rare that no further attention is given to the subject in the present article. The term pyloric stenosis is often used in the course of the article to include any obstruction to the passage of the contents of the stomach into the intestine, whether the obstruction be in the duodenum, the pyloric orifice, or the pyloric region.

The most frequent cause of pyloric stenosis is carcinoma, either in the form of a diffuse infiltration of the gastric walls in this region or as a tumor projecting into the cavity of the pyloric portion of the stomach. Next in frequency are cicatricial growths resulting from simple ulcer involving the pyloric region. Much less frequent are similar cicatricial stenoses of the pylorus resulting from ulcers produced by swallowing corrosive poisons. Simple hypertrophy of the coats of the stomach in the pyloric region, particularly of the fibrous and muscular coats, is an occasional cause of dilatation. Obstruction of the pylorus by mucous polypi or by hypertrophic folds of mucous membrane is so rare as to have little practical interest. Likewise, stenosis caused by sarcomata, fibromata, myomata, lipomata, and cysts need be mentioned only for the sake of completeness.

Narrowing of the pyloric orifice may be caused also by pressure from outside of the stomach, as by tumors, particularly cancer, of the liver and of the pancreas, and by the contraction of fibrous adhesions and thickenings resulting from perigastritis. Obstruction of the duodenum by tumors growing in its walls, by cicatrices resulting from ulcers, and by external pressure may also cause dilatation of the stomach. According to Barker, compression of the duodenum by a wandering right kidney may induce dilatation of the stomach. The mere association of dilatation of the stomach and movable right kidney, however, cannot be considered proof that the former is caused by the latter, for the subjects of movable kidney (most frequently women with flabby abdominal walls who have borne many children) are often also favorable subjects for atonic dilatation of the stomach.

Sometimes with dilatation of the stomach the pyloric orifice is found abnormally small, without any thickening or other appreciable change in the walls of the pylorus. These cases in adults have been described by Landerer under the name of congenital stenosis of the pylorus, but his conclusions are not free from doubt.⁵ Congenital stenosis, and even complete occlusion of the pylorus, has been observed in infants.⁶

⁵ Ueber angeborene Stenose des Pylorus, Inaug. Diss., Tübingen, 1879. In the ten cases studied by Landerer the patients were all adults, mostly in advanced life. In only one case is it mentioned that indigestion existed from childhood; the clinical history in all is incomplete. With the exception of one case there was no marked hypertrophy of the muscular coat of the stomach, such as is usually found with benign pyloric stenosis and would naturally be expected with a stenosis existing since birth. The pyloric orifice varied from 1½ cm. to 2 mm. in diameter. Some of the specimens had been in alcohol for a considerable time. In my opinion, Landerer has not brought forward sufficient proof that in these cases stenosis of the pylorus existed since birth.

⁶ Wünsche, Jahrb. d. Kinderheilk., viii. 3, p. 367. Andral, Förster, and Bull have found congenital stenosis and atresia of the pylorus.

Spasm of the pyloric muscle, which, according to Kussmaul, may be referable to erosions, ulcers, and inflammations of the adjacent mucous membrane, can be admitted only as a hypothetical explanation of some cases of dilatation of the stomach.

Somewhat problematical, although not improbable, is the production of stenosis of the pylorus or of the duodenum by torsion and by displacement of these parts. Dilatation of the stomach is sometimes associated with scrotal hernia, particularly with that containing omentum or transverse colon. This dilatation Kussmaul explains by the production of a sharp bend between the movable first part and comparatively fixed second part of the duodenum, in consequence of the dragging downward of the stomach by the displaced omentum or transverse colon. In a similar way Kussmaul believes that the weight of an over-distended stomach may produce stenosis, and by this mechanism he explains the occasional occurrence of symptoms of complete pyloric obstruction when a large quantity of material has accumulated in an already dilated stomach, and the prompt relief of these symptoms when the burden of the stomach is removed either by vomiting or by the stomach-tube.⁷

⁷ Another explanation given by Kussmaul, and likewise based upon experiments on the cadaver, is that when the stomach is over-distended it may rotate upon its own axis, so that the pylorus acquires a sagittal direction and impinges against the first part of the duodenum. This rotation of the stomach, however, can occur only when the abdominal walls are flabby (Kussmaul, "Die Peristaltische Unruhe des Magens," Volkmann's Samml. klin. Vortr., No. 181).

The manner in which stenosis of the pylorus causes dilatation of the stomach is sufficiently obvious to require no especial explanation. It is, however, important to know that stenosis of the pylorus may be compensated, so that even a very considerable degree of obstruction of this orifice may exist without any dilatation of the stomach. The obstruction may be completely counteracted by hypertrophy of the muscular coat of the stomach, particularly of that in the right half of the organ. Leube suggests that this increased muscular force, by increasing the peristaltic movements, may also hasten the digestion and absorption of the food, so far as these processes take place in the stomach.⁸ The timely removal of the contents of the stomach by vomiting may also prevent over-distension of the organ. Another compensatory circumstance may be the reduction of the quantity of solid and liquid food taken by the patient. Conditions are often present, however, which oppose the development of these compensatory circumstances. Such conditions are feebleness of the patient, degeneration of the muscular coat of the stomach, chronic catarrhal gastritis, insufficient secretion of gastric juice, and delayed absorption, causing stagnation and fermentation of the food in the stomach.

⁸ Leube, in V. Ziemssen's Handb. d. spec. Path. u. Ther., Bd. vii. 2te Hälfte, p. 211, Leipzig, 1878.

Dilatation of the stomach may occur without any obstacle to the evacuation of the gastric contents into the intestine. The cases of so-called atonic dilatation of the stomach belong to this class. The degree of dilatation in these cases is rarely so great as when the dilatation is caused by stenosis. The cause of gastric dilatation in the absence of stenosis is not always clear, so that a variety of hypotheses, more or less probable, have been broached to explain these obscure cases.

Dilatation with unobstructed outlet of the stomach must be referable either to abnormalities in the quantity or quality of the contents of the stomach or to weakness of the muscular walls of the stomach. In most cases both of these causes are combined, and it is not easy to separate their action.

Abnormal gastric contents may be the result of improper ingesta or of disturbances in gastric digestion. Although in former times the frequency of excessive eating and drinking as a cause of dilatation of the stomach was doubtless exaggerated, nevertheless the efficacy of this cause cannot be doubted. Dilatation of the stomach is said to be common in people who live almost exclusively upon a vegetable diet and therefore require large quantities of food. The habitual drinking of large quantities of beer may cause dilatation of the stomach. The occasional association of a dilated stomach with diabetes is referred to the inordinate appetite and thirst which characterize this disease. If the food reaches the stomach imperfectly masticated, the process of digestion is delayed, and as a result the stomach may become dilated. Indigestible food, particularly that which readily ferments in the stomach, may be an indirect cause of the disease under consideration. A similar rôle may be played by swallowing foreign substances either by accident or by design. It is not proven that dilatation of the stomach may be referable to exhaustion of its muscular power by the abuse of agents which at first excite peristalsis, such as emetics, purgatives, alcoholics, tobacco, spices, etc. Equally doubtful is the production of dilatation by the misuse of narcotics, such as opium, which restrain peristalsis.

Of great importance in the production and continuance of gastrectasia are all circumstances which cause stagnation and fermentation of the contents of the stomach. These abnormalities of the gastric contents are referable both to muscular and to chemical insufficiency of the stomach, but in this connection it is desired to call attention especially to chemical insufficiency, although in the production of gastric dilatation this becomes always associated with muscular insufficiency. In this way chronic catarrhal gastritis is operative in the causation of gastric dilatation. In consequence of insufficient secretion of normal gastric juice and of delayed absorption, the food remains abnormally long undigested in the stomach, and fermentative changes, with the development of gas, occur. No less important, however, is the impairment of the muscular power of the stomach in chronic gastritis. Stagnation and fermentation of the contents of the stomach occur also in functional or atonic dyspepsia, which is to be reckoned as a cause of dilatation of the stomach. Naunyn⁹ emphasizes especially the importance of abnormal fermentations in the stomach (alcoholic, butyric acid, lactic acid, acetic acid fermentations) both as a cause and as a result of dilatation of the stomach. Ulcer and cancer of the stomach may cause dilatation by interfering with the normal digestive processes.

⁹ Deutsches Arch. f. kl. Med., Bd. 31.

We come now to the third and final group of causes of dilatation of the stomach—namely, those included under weakness of the muscular walls of the stomach. In the last analysis all causes of gastric dilatation come under this heading, for even with pyloric stenosis and with excessive contents a stomach will not dilate so long as its muscular power is equal to the proper performance of the work which is demanded. In this connection, however, reference is had especially to those cases in which impairment or restraint of the muscular movements of the stomach may be regarded more or less directly as the primary cause of dilatation of the stomach.

Clearest of comprehension are those cases in which the muscular power of the stomach is impaired by organic changes in the muscular coat. Here may be mentioned partial destruction of the muscular coat, particularly of that in the pyloric region, by ulcers and by cancers. Thus, ulcers and cancers which in no way obstruct the outlet of the stomach may cause dilatation of the organ. Inflammatory infiltration (inflammatory oedema) of the muscular coat has been adduced as a cause of its weakness in chronic catarrhal gastritis and in peritonitis. Whether this is the proper explanation or not, there is no doubt that the muscular coat of the stomach may become paretic in cases of chronic catarrhal gastritis, as well as the subjacent muscle in inflammations of other mucous membranes, as in laryngitis or in cystitis. Our knowledge of the relation between degeneration of the muscular coat of the stomach and gastrectasia is very imperfect. Fatty and colloid degeneration of the muscle of dilated stomachs is probably to be interpreted as a secondary change. It is probable that amyloid degeneration may be a cause of atonic dilatation of the stomach.¹⁰ Oedematous infiltration of the coats of the stomach in cases of cirrhosis of the liver, pulmonary emphysema, cardiac disease, and Bright's disease has been assigned as a cause of gastric dilatation, but without satisfactory evidence. Chronic interstitial gastritis (cirrhosis of the stomach) is more frequently a cause of contraction than of dilatation of the stomach.

¹⁰ Edinger, ibid., Bd. 29.

The restraint of the muscular movements of the stomach by adhesions and by dragging downward of the organ in hernia may cause dilatation. Relaxation of the abdominal walls, as in women who have borne many children, by removing the normal support of the stomach, has been thought to cause dilatation.