The general description of the morbid anatomy of the malignant disease is based upon the post-mortem records of 3.679 cases which we collected from different sources ; while the more special phenomena connected with its pathology are derived from an analysis of 265 cases which were examined after death at the London Hospital and the London Temperance Hospital. With three exceptions the illustrations have been prepared for us from specimens contained in the museums of the aforementioned hospitals or in that of the Royal College of Surgeons.
The old method of classifying gastric carcinomata according to their macroscopical appearances has been responsible for so many erroneous conclusions respecting their pathology and clinical aspect that we have adopted the nomenclature suggested by Drs. Perry and Shaw in their admirable article in the Guy's Hospital Reports, and have employed the terms ' scirrhus," medullary ' and ' adeno-carcinoma ' to indicate growths which possess a definite histological structure. The substitution of the microscope for the naked eye has also had the effect of demonstrating that the infectivity of a carcinoma of the stomach is infinitely more rapid and diffuse than the presence of visible metastases has been held to indicate; and we are convinced that much of the non-success that has attended the performance of pylorectomy has arisen from a deficient appreciation of the widespread nature of the disease.
Since the histology of the gastric complaint does not differ materially from that of carcinoma of other organs of the body, we have contented ourselves with a general sketch of the subject, and for a more detailed description would refer the reader to one of the numerous text-books on pathology.
The investigations into the etiology of gastric carcinoma have been conducted upon somewhat different lines from those which custom has ordained, with the result that many of our conclusions differ materially from those of previous writers. We have endeavoured to show that the long-established teaching concerning the sex and age incidence of the disease has been founded upon errors which almost invariably accrue from the exclusive employment of hospital statistics, and that not only is the complaint equally common in the two sexes, but that the liability to it increases with each decade of life until about eighty years of age. With regard to the much-discussed question of the increase of carcinoma, it would appear that during the last four years there has been no appreciable augmentation of the number of those dying from the gastric lesion in this country. For much of the data by which we have sought to establish these and other kindred facts we are indebted to Dr. Tatham, of the General Register Office, who has not only afforded us a large amount of special information, but has given us much valuable help in the arrangement of our own statistical material.
Another point of interest in this connection is the varying mortality from cancer of the stomach in London at different periods of the year. We had long been aware that the disease was particularly rife in the wards of the London Hospital during the summer months, but until we analysed the figures we did not fully appreciate the fact that more than 60 per cent, of the total deaths occurred between June and November, while the admissions to the hospital during the winter months only constituted about 14 per cent, of the whole number for the year. Should further and more extended inquiries confirm these conclusions, much light may possibly be thrown upon, the etiology of the disease.
The symptomatology has been written from the study of 154 cases which were treated and examined after death at the London Hospital and the London Temperance Hospital. The adoption of this procedure affords, we believe, a more accurate idea of the clinical features of the complaint as it appears in everyday practice than could be obtained from the records of private experience, which are apt to include an undue proportion of obscure or exceptional cases. Each separate symptom is considered in reference to the condition, situation, and extent of the morbid growth, and the conclusions arrived at have been expressed as far as possible in the form of tables, so as to prevent unnecessary reiteration. Only such cases are quoted in full as were deemed necessary to emphasise some fact of unusual interest, and all details which were not strictly relevant to the subject have been omitted. As the work has necessarily been written from the standpoint of a physician, we have merely sought to indicate the various conditions which in our experience seem to warrant or to contra-indicate surgical interference, and have left all discussions relative to operative technique to those who are better qualified to deal with the subject.
In the Second Part the various Tumours of the Duodenum are considered, as well as those of the Stomach, and special attention is drawn to the symptoms and diagnosis of carcinoma of this portion of the digestive tract. Sarcoma of the Stomach, although comparatively rare, is a subject of increasing importance, and the success that has attended the removal of the spindle-celled variety gives hope of an ultimate cure being effected in many of the cases. Gastric Syphilis is another disease which has hitherto attracted less attention than it deserves, and there is little doubt that a better knowledge of its symptomatology would result in the cure of many of those troublesome cases of relapsing ulcer or chronic gastritis which defy the ordinary methods of treatment.
The chapters which deal with Polypi, Benign Tumours and Cysts of the Stomach are of the nature of clinical studies, owing to the rarity of the diseases of which they treat and the obscure nature of the symptoms and physical signs which were observed in the cases recorded. Hair-balls and Gastroliths are, strictly speaking, tumours within rather than of the stomach ; but the fatality which has attended them in the past, owing to a deficient knowledge of their physical signs, has induced us to devote a special chapter to the subject of Gastric Concretions.
In conclusion, we would tender our grateful thanks to Dr. Tatham for his invaluable help ; to Mr. C. H. Leaf and Mr. L. Galsworthy for several drawings they kindly prepared for us ; to Dr. Murrell for some statistical facts relative to cancer of the stomach at the Westminster Hospital, and to the Council of the Royal College of Surgeons, the College Board of the London Hospital, and the Board of Management of the London Temperance Hospital, for their kind permission to utilise the material contained in their respective museums.