Cancer And Other Tumours Of The Stomach | by Samuel Fenwick

This book, divided into two parts, gives information on Gastric Carcinoma and various other Tumours which affect the Stomach and the Duodenum.

Title	Cancer And Other Tumours Of The Stomach
Author	Samuel Fenwick
Publisher	P. Blakiston's Son
Year	1903
Copyright	1903, P. Blakiston's Son
Amazon	Cancer and other tumours of the stomach

Preface: The present volume is divided into two parts, the first of which deals with Gastric Carcinoma, and the second with the various other Tumours which affect the Stomach and the Duodenum. The general d...

Historical Introduction: Cancer of the stomach has been known from the earliest times, but its symptoms were usually confused by the ancient writers with those of other forms of abdominal disease. Several instances in which t...

Part I. Carcinoma Of The Stomach. Chapter I. Morbid Anatomy And Histology: Tumours of the stomach may be classified as benign and malignant. The former are comparatively rare, and most of them are merely pathological curiosities. The latter constitute nearly 94 per cent. of ...

Primary Carcinoma: The neoplasms which belong to this group originate in the epithelial and glandular structures of the organ, and have been variously described at different times. By the earlier writers they were class...

Scirrhus (Hard Spheroidal-Celled Carcinoma): This variety is chiefly met with in the pyloric region of the stomach and is characterised by its firm structure and its tendency to contraction. (a) It usually commences immediately inside the ori...

Medullary Carcinoma (Soft Spheroidal-Celled Cancer): This variety of the disease is characterised by an exuberant soft growth, which infiltrates all the coats of the stomach and is usually attended by extensive ulceration. As a rule it commences in the ...

Adenocarcinoma (Cylindrical-Celled Carcinoma): This variety may occur in any part 01 the stomach, but is most common in the pyloric region. (a) It usually presents itself in the form of a soft red fungoid tumour, which springs from a broad base...

The Relative Frequency Of The Different Carcinomata: Out of 180 cases collected by Brinton, 130, or 72 per cent., were scirrhus, thirty-two, or 18 per cent., medullary, and seventeen, or 9.4 per cent., colloid ; and upon the authority of these figures i...

Relation Of The Type Of Disease To Its Location: It is usually taught that the orifices of the stomach are most frequently attacked by scirrhus, while the body of the organ is the seat of the medullary and adenomatous forms of carcinoma. This statem...

Multiple Carcinomata: -According to the statistics quoted in the first table, in about 3 per cent, of all cases the stomach exhibits two or more separate growths. The question therefore arises whether they should be regard...

Secondary Carcinoma Of The Stomach: It is commonly stated that secondary cancer of the stomach is extremely rare, and writers formerly accorded considerable prominence to a case in which Cohnheim discovered a nodule of scirrhus in the s...

Secondary Carcinoma Of The Stomach. Continued: The earliest signs of a departure from the normal consist of an active proliferation of the epithelium of a small group of glands, which leads to distension of the tubules with cells of various shapes...

Cylindrical-Celled Carcinoma: In this variety the alveoli are large and of various sizes and shapes, and are supported by a delicate stroma rich in blood-vessels. By mutual compression the cells assume different forms, and it may ...

Chapter II. The Sequelae Of Carcinoma. 1. Adhesions: The formation of adhesions around the seat of the disease is of considerable importance both as regards diagnosis and also surgical treatment. The adhesions themselves vary considerably in different c...

Effects Of Adhesions: The development of perigastritis is an important factor in the spread of carcinoma, since the morbid growth rapidly infiltrates the newly formed connective tissue, and thus extends by direct continuit...

Changes In The Shape Of The Stomach: Carcinoma is almost always accompanied by some alteration in the shape of the stomach. In most cases this takes the form of an increase of size, but occasionally the viscus becomes greatly thickened a...

Dilatation: In its most pronounced form a dilated stomach appears to occupy the greater part of the abdominal cavity, and in such cases the pylorus is almost always found to be the seat of a localised scirrhous g...

Contraction: The most noticeable examples of contraction of the stomach are met with in cases of diffuse scirrhous infiltration, when the viscus is converted into a thick tube, from four to six inches in length, a...

Irregular Deformity: A growth situated between the orifices may produce considerable alteration in the shape of the stomach. The most frequent deformity from this cause is the partial division of the organ into two sacs (...

Ulceration: According to Lebert ulceration is met with in three-fifths of all cancers of the stomach; and with this statement our own observations closely coincide, since we find that it was present in 64*5 per c...

Haemorrhage: Extravasation of blood into the stomach is a frequent result of malignant disease. In the majority of the'cases it is very slight, and merely imparts a brownish or black tinge to the gastric contents ...

Perforation Of The Stomach: Perforation of the coats of the stomach is a frequent result of a cancerous growth, but its effects vary considerably under different conditions. If no adhesions have previously formed around the base...

Acute General Peritonitis: This result of perforation is a comparatively rare cause of death in cancer of the stomach. Brinton noted its occurrence only in seventeen out of 507 cases, or in 3.3 per cent.; Lange in twelve out of...

Perigastric Abscess: A localised abscess may occur under three conditions : (1) If idhesions have previously formed around the base of the dissase in such a manner as to prevent extravasation of the gastric contents into ...

Perforation Of Neighbouring Organs. A. The Solid Viscera: Perigastric adhesions are a frequent cause of the extension of malignant disease to neighbouring tissues, and it is by no means rare to find a large secondary tumour in the substance of a solid viscus...

Perforation Of The Bowel-Internal Gastric Fistula: (1) Gastro-Colic Fistula This constitutes the most common form of internal fistula. Brinton noted its existence in eleven out of the 507 cases of gastric cancer which he collected (2.17 per cent.),...

Perforation Of The Diaphragm: This must be an extremely rare event, since it was not observed in the course of 1,850 necropsies upon cancer of the stomach, nor have we been able to find a single authentic example of it in the lite...

Perforation Of The Skin-External Gastric Fisttjlie: This variety would seem to be even less, frequent in cancer than in ulcer of the stomach, since out of the twenty-eight cases of gastro-cutaneous fistula collected by Murchison, twelve were due to the...

Contrast Of Perforation In Cancer With That In Simple Ulcer: A simple ulcer is far more prone to perforate the wall of the stomach than a cancerous growth. According to our clinical statistics this accident occurs in 7 per cent, of all chronic ulcers,1 but only...

Invasion Of Other Viscera And Secondary Growths: Carcinoma of the stomach often exhibits an extreme degree of malignancy, and almost always extends beyond the confines of the organ before death. As the result of Brinton's researches it is usually ta...

Direct Invasion: The fact that a morbid growth invariably invades the submucous tissue for some distance beyond its apparent confines suggests that it would frequently extend by continuity into the oesophagus or duode...

Lymphatic Infection: The epithelial offshoots from a cancerous tumour penetrate the surrounding structures in the direction of the least resistance, and therefore soon find their way into the spaces in the connective tiss...

Lymphatic Infection. Continued: This brief review of the lymphatic system of the stomach and its principal connections serves to illustrate three important points. In the first place, the stomach itself would seem to be naturally di...

Vascular Infection: Carcinoma of the stomach is apt to involve the vessels in its neighbourhood either by direct extension or through the medium of the lymphatics. As a rule the veins are more affected than the arteries,...

Transplantation: This is chiefly observed in the case of the peritoneum, where the implication of the serous coat of the stomach or of the great omentum is sometimes followed by the development of cancer in the lower ...

Jaundice: This was present in 13.7 per cent, of our cases at the time of death. Its frequency varies according to the situation of the growth in the stomach. Thus it occurred in 35 per cent, of the cases where ...

Ascites: An excess of fluid in the peritoneal cavity was noted in 26 per cent, of our cases. The amount varied from six ounces to several quarts, the average being about two and a half pints. As a rule the flu...

Thrombosis: The formation of a clot in a vessel is not an infrequent event during the later stages of cancer of the stomach. As a rule the veins are more often affected than the arteries, especially those of the ...

Diseases Of Other Organs: A careful examination of the various tissues of the body after death from cancer of the stomach brings to light two important facts. In the first place, it would appear that although the disease may b...

(A) The Heart: The heart participates in the general wasting, and consequently appears after death to he remarkably small. According to our statistics its average weight in the male cases was 8.2 oz. and in the fema...

(B) The Organs Of Respiration: An excess of fluid (hydrothorax) in one or other pleural cavity was noted in 3 per cent, and a bilateral effusion in 6 per cent, of our cases. Acute pleurisy existed in 14 per cent., and was usually a...

(C) The Spleen: The average weight of the spleen in our male cases was 5 oz., and in our female cases 4.2 oz. Since its normal weight varies up to 10 oz., it is obvious that the organ is considerably reduced in size ...

(D) The Liver: As the liver is especially liable to secondary growths, it was necessary to select only those cases in which its structure was normal in appearance. The average weight of the viscus in the males was 5...

(E) The Kidneys: The average weight of these organs in our male cases was 11.1 oz., and in the female 9.5 oz. As the average normal weight in the former sex is 10 oz. and in the latter 8 oz., it will be seen that the ...

(F) The Alimentary Canal: (1) The Esophagus Stricture of the cardiac orifice is usually attended by slight dilatation of the lower third of the oesophagus and hypertrophy of its muscular coat. Invasion by the malignant grow...

Chapter III. Etiology: 1. Frequency The frequency of carcinoma of the stomach may be estimated either from data supplied by a large series of necropsies, from a study of the bills of mortality of different countries, or ...

Post-Mortem Statistics: Out oi 8,468 necropsies collected principally from British hospitals, Brinton found cancer of the stomach recorded in eightyone, or in about 1 percent.; while 14,974 performed at the London and London...

Bills Of Mortality: Our knowledge derived from this source is very imperfect, since most of the registration returns refer to carcinoma generally rather than to its relative incidence upon different viscera. The material...

Clinical Statistics: These have been collected from the official reports of six general hospitals in London, and extend over a period of ten years or more. Their chief value lies in the fact that they probably represent t...

The Relative Liability Of Different Organs: Much discussion has taken place regarding the liability of the stomach to carcinoma as compared with that of the other organs of the body. Brinton considered that the gastric lesion constituted about ...

The Increase Of The Disease: That the death-rate from carcinoma generally is steadily increasing in almost every part of the civilised world hardly admits of doubt. In the report of the Registrar-General for England for 1896, the...

The Increase Of The Disease According To Sex: It was formerly the custom to regard the disease as especially common in men, and the statement of Brinton, that it is twice as frequent in males as in females, was for a long time regarded as indispu...

The Increase Of The Disease According To the Age: Carcinoma of the stomach may be said to be a disease of maturity. Scheffer found that only 2 per cent, of the cases which he collected were less than thirty years of age; Brautigam's estimate, made o...

The Increase Of The Disease According To The Geographical Distribution: The chief difficulty of determining the relative frequency of carcinoma in different parts of the globe is due to the extraordinary deficiency of trustworthy observations. In many instances our sole i...

The Increase Of The Disease According To The Topography: Moore was the first to point out that carcinoma is more prevalent in the southern and eastern parts of England than in the northern and western districts ; and that if a line be drawn across the count...

The Increase Of The Disease According To The Race: Want of evidence renders it difficult to determine the exact influence of race upon the inception of the disease, but all the information we possess seems to indicate that savage peoples enjoy a compa...

The Increase Of The Disease From Heredity: Statistical inquiries relative to an hereditary predisposition to cancer -have shown that in 13.22 per cent, of all cases of the disease some relative of the patient had died from a malignant growth. ...

The Increase Of The Disease According To The Occupation: The most careful inquiries have failed to show that occupation exercises any material influence upon the development of gastric carcinoma, while the fact that married women suffer from the complaint e...

The Increase Of The Disease According To The Diet: The inordinate frequency with which carcinoma attacks the alimentary canal naturally suggests that the infective agent, if such there be, is usually introduced into the body with the food. It is there...

The Increase Of The Disease According To Hygiene: The frequent occurrence of carcinoma of the stomach in old houses and in those whose drainage systems are defective has led to the belief that insanitary conditions either predispose to or excite the ...

The Increase Of The Disease Due to Traumatism And Mental Conditions: Carcinoma of the stomach occasionally follows a severe blow upon the epigastrium, iust as an ini'urv to the breast sometimes forms the starting-point of the disease in that organ. It is probable, howe...

Influence Of Seasons In Increase of The Disease: In the following table we have arranged 154 cases of carcinoma of the stomach according to the month in which the disease terminated and that in which it was supposed to have commenced. ...

Influence Of Other Diseases. (A) Gastric Ulcer: Cruveiihier was the first to point out that carcinoma is apt to attack the edge or scar of a simple ulcer, and the subsequent confirmation of this fact by Rokitansky, Dittrich, Brinton, and Hauser ha...

(B) Functional Disorders Of The Stomach: Chronic gastritis does not appear to favour the growth of carcinoma, while the alcoholic variety is, if anything, inimical to its development. Functional disturbances are also rarely followed by the d...

(C) Benign Growths: Persons who present innocent tumours of the skin or internal viscera are not especially prone to carcinoma of the stomach. Among our fatal cases of that complaint, uterine fibro-myomata were only pres...

(D) Tuberculosis: The frequency of obsolete tubercle m persons who have died from gastric cancer has often been the subject of remark. In our own series one or both lungs presented signs of former tuberculosis in 15.8 ...

(E) Rheumatism: Rather more than 8 per cent, of our cases had suffered from acute rheumatism in early life, and in about 7 per cent, there was evidence of disease of the mitral or aortic valves. Considering how commo...

(F) Malaria And Syphilis: It has been asserted that carcinoma is rare in malarious districts, and that those who have suffered from ague are seldom afflicted with malignant disease. For such statements, however, we can find no...

Chapter IV. Symptomatology: There are few diseases which at an early period of their course are more difficult to recognise than cancer of the stomach. The pain, vomiting, and haemorrhage that are usually regarded as especially ...

Mode Of Onset: It is the usual custom to describe the commencement of the complaint as insidious, and in the majority of the cases it is undoubtedly true that the local phenomena remain obscure until the morbid grow...

Symptomatology Case I: A medical man, aged forty-three, engaged in a large practice in London, consulted us in October 1895 for indigestion. He stated that he had been perfectly well until the 9th of September, when, after ...

Symptomatology Case II: A labourer, aged fifty-two, was admitted into the London Temperance Hospital for severe pain in the epigastrium of six weeks' duration. He stated that one afternoon, while lifting a heavy weight, he h...

Symptomatology Case III: A man, aged fifty-five, was admitted into the London Temperance Hospital with the diagnosis of chronic gastric ulcer. It appeared from his history that he had been perfectly well until four months pre...

Pain: Malignant diseases are so often accompanied by pain that it might reasonably be expected that a cancerous growth in a highly organised structure like the stomach would be associated with considerable ...

Cause And Variations of Pain: The main cause of the pain which accompanies a new growth in the stomach is undoubtedly the progressive infiltration of the tissues and the compression which is exerted upon the gastric nerves by exte...

Vomiting: According to Brinton, vomiting occurs in 87.5 per cent, of all gastric cancers. Lebert observed it in 80 per cent, of his cases, while in our own series it was recorded in 87 per cent., and in 9 per c...

Symptomatology Case IV: A man, forty-nine years of age, was admitted into the London Hospital for incessant vomiting of three days' duration. It appeared from his history that for several months he had suffered from indigest...

Haemorrhage (Haematemesis And Melaena): It is probable that some degree of haemorrhage occurs in every case of cancer of the stomach, and that in many it is practically continuous ; but since its clinical recognition depends upon its severi...

(A) Slight Hemorrhage: -In this category are included those small but frequent losses of blood which ensue from superficial ulceration of the growth or from engorgement of its vessels and of those of the surrounding mucous ...

(B) Moderate Hemorrhage: This variety closely resembles that which ensues from simple ulcer, and is generally evidenced by the vomiting of six to eighteen ounces or more of blood. This copious bleeding is usually brought abou...

(C) Excessive Haemorrhage (L'Hemorrhagie Foudroyante): Haemorrhage of such severity as to prove immediately fatal is very rare. Brinton estimated its frequency at 1 per cent., and this tallies with our own figures (0.75 per cent.) and those of other writ...

Anorexia: Loss of appetite is an important symptom of gastric cancer. Brinton observed it in 85 per cent, and Lebert in 80 per cent, of their respective cases. In our own series pronounced anorexia existed in 8...

Dysphagia: Difficulty of swallowing is by no means infrequent during the later stages of the disease. In many cases where the anorexia is extreme the patient ascribes his dislike to food to an inability to swall...

Case V: A man aged forty-eight became gradually affected with difficulty of swallowing, which in a few weeks prevented him from taking any solid food. Mouthfuls of milk and other liquids were easily disposed ...

Flatulence: This occurs in almost every case, and is responsible for many of the symptoms of dyspepsia. It is a constant phenomenon in stenosis of the pylorus, but comparatively infrequent when the cardiac orific...

Acidity: Burning sensations at the epigastrium, followed by scalding in the chest and throat and the regurgitation of an acid fluid which sets the teeth on edge, are much less frequent in carcinoma than in sim...

The Tongue: This presents no special features, but varies in appearance in different cases and at different periods of the complaint. In 32 per cent, of our cases it was described as ' clean ' or ' normal,' while...

State Of The Bowels: Constipation almost always accompanies the onset of the disease, and becomes gradually more and more pronounced as the case proceeds. As an early symptom it existed in 79 per cent, of our cases where ...

Failure Of Strength: Among the various subjective symptoms that accompany a cancerous growth of the stomach, gradual loss of strength is often the first to attract attention. Although inclined for work, the patient experi...

Loss Of Flesh: Progressive emaciation is an invariable symptom. At first the loss of flesh is only slight, and if it attracts attention is usually attributed to the indigestion or loss of appetite; but with the prog...

Anaemia (Cachexia): Loss of colour has long been recognised as one of the most striking features of malignant disease, and extreme pallor of the lips and conjunctivae is always a prominent symptom of the gastric complain...

Bed Corpuscles: In every case there is a notable diminution in the number of red corpuscles (Laache). The average number at the time when the tumour becomes palpable is about 3,500,000 per cubic millimetre, though oc...

White Corpuscles: An increase in the number of white corpuscles (leucocytosis) occurs in the majority of the cases, and is most frequent in growths of the medullary or cylindricalcell type, but it is not apparently inf...

Digestion Leucocytosis: Under normal conditions the number of white cells in the blood is increased during the period of gastric digestion, and a similar phenomenon is observed in chronic ulcer and in most of the functional ...

Hemoglobin: The colouring matter of the blood is invariably reduced, the average quantity varying from 50 to 30 per cent, of the normal. The haemoglobin value of the individual corpuscles is also diminished to a ...

Temperature: The absence of fever in cancer generally has led to the impression that malignant disease of the stomach is a non-febrile complaint. As a matter of fact, however, nearly one third of all cases of gast...

The Saliva: As a rule the saliva presents no deviation from the normal either in quantity or appearance. Occasionally, however, the secretion is considerably increased or is unduly thick and glutinous. A large pr...

The Urine: The quantity of urine is invariably diminished. When the body of the stomach is the seat of disease, and pain is the principal symptom, the daily amount may exceed thirty fluid ounces ; but if the ori...

Nervous Symptoms: Paralysis affecting the face or one side of the body was observed in 2 per cent, of our cases, and was caused either by ordinary cerebral haemorrhage, a metastatic growth in the brain, or by thrombosi...

Edema: The lower extremities frequently become oedematous during the last month or two of life, either from gradual failure of the circulation or from pressure of ascitic fluid or a growth upon the inferior ...

Chapter V. Physical Signs: The general aspect of a person suffering from carcinoma of the stomach is often highly suggestive of the nature of his complaint. When pain has been a prominent symptom the thin pinched face, the purs...

Inspection Of The Abdomen: Careful inspection of the abdomen seldom fails to reveal important information, while not infrequently the facts which it imparts are of the utmost possible value. In order to obtain the best results ...

(A) Shape Of The Abdomen: The loss of the omental and subcutaneous fat that occurs at an early period of the complaint gives the skin of the abdomen a loose appearance, as though it were too voluminous, and in stout persons wh...

(B) Situation Of The Stomach: The normal stomach occupies the left hypochondrium and epigastrium, and with the transverse colon produces a slight protuberance of the abdomen above the umbilicus. When the organ is much dilated it ...

(C) Visible Peristalsis: Under normal circumstances the stomach is invisible; but if its walls are thickened from hypertrophy of its muscular coat, and the abdominal parietes are attenuated, each contraction of the viscus can...

(D) Tumour: In addition to the swelling formed by an enlarged and dislocated stomach, the morbid growth itself often gives rise to a tumour which is visible to the naked eye. This is especially the case when the ...

(E) Enlarged Veins: Owing to the pressure it exerts upon the inferior vena cava, a dilated stomach is frequently accompanied by enlargement of the superficial veins of the abdomen. As a rule the condition is symmetrical ...

Examination Of The Stomach: This includes the investigation of the size and capacity of the organ, of its secretory and motor functions, and of the microscopical characters of its contents. Size And Position Tn addition to...

Exploration With A Tube: By the employment of a soft tube it is possible to determine (1) the existence of an obstruction to the entry of food; (2) the motorial activity and general capacity of the stomach; (3) the chemical c...

Free Hydrochloric Acid: The first investigations upon this subject were conducted by Golding Bird in 1842, who summed up a series of most admirable researches by the statemerit that ' the matter brought up (i.e. vomited) con...

Lactic Acid: It was formerly the custom among German writers to describe a stage of normal digestion which was characterised by the production of lactic acid. The experiments upon which this view was founded appea...

Microscopical Examination Of The Contents Of The Stomach. Micro-Organisms: In addition to various kinds of undigested food, vast quantities of torulse and other fungi may usually be observed in the residue upon the filter. It was formerly believed that the presence of sarcin...

Palpation: Palpation of the abdomen is a method of examination of the utmost importance. It should be performed, in the first instance, while the patient lies upon his back with his shoulders and head slightly r...

Local Tenderness: This is much less characteristic than in cases of simple ulcer. It chiefly exists over the site of the growth, and is especially noticeable when the disease has infected the omentum or some other neig...

Metastases In The Abdominal Wall: The occasional development of secondary deposits in the skin of the abdomen has long been recognised, although their importance has not been sufficiently appreciated. They may occur in the form either...

Abdominal Tumour: Tumours of the stomach vary so much in character, according to their situation, that in order to interpret their clinical significance aright it is necessary to bear in mind certain facts in connectio...

General Characters Of The Gastric Tumour: (A) Frequency According to the statistics of Brinton and Lebert, nearly 80 per cent, of all carcinomata of the stomach are accompanied by a palpable tumour. Osier and McCrae detected a tumour in 7...

Movement With Respiration: It is usually taught that a gastric tumour descends upon inspiration only when it is attached to the liver, the spleen, or the diaphragm. Such a statement, however, is totally at variance with fact; f...

Mechanical Mobility: Many localised tumours of the stomach may be displaced by pressure with the hand. The most mobile are those situated at the pylorus, which may sometimes be moved several inches in every direction; whi...

Special Features. Tumours of the Pylorus: These constitute about 60 per cent, of all gastric tumours, and three out of every four (75 per cent.) may be recognised by palpation at one period or other of the disease. Three conditions militate a...

Tumours Of The Body Of The Stomach (Walls And Curvatures): These are usually situated in the epigastric or umbilical region, and are often of considerable size. In shape they are globular, elongated, or irregular, and the surface is frequently nodular from im...

Tumours of the Cardia: Small growths in the immediate vicinity of the cardiac orifice can never be detected by palpation, but should they extend to the lesser curvature or to the fundus of the stomach they may give rise to ...

Tumours Composed Of The Entire Stomach: A palpable tumour may be formed by the entire stomach under two conditions : (a) Obstruction of the cardiac orifice with contraction of the empty viscus; (b) general infiltration of the gastric walls ...

Enlargement Of Lymphatic Glands: The fact that glandular tumours occasionally develop above the left clavicle has long been known, but the frequency of their occurrence and their clinical significance have been much exaggerated. Thus...

Chapter VI. Complications. Perforation Of The Stomach: Perforation of the stomach occurs in at least 8 per cent, of all cases, but its effects vary under different conditions. If no adhesions exist around the base of the disease, the gastric contents beco...

General Peritonitis: This constitutes the immediate cause of death in about 3 per cent, of all cases of gastric carcinoma, and is most common when perforation occurs on the anterior surface of the organ, near the pylorus....

Complications In Perigastric Abscess: A localised collection of pus as the result of perforation occurs in 3 to 5 per cent, of all cases of carcinoma of the stomach, and is rather more frequent in disease of the cardia than of the pyloric...

Fistulae. Gastro-Colic Fistula: A fistulous communication between the stomach and the transverse colon occurs in about 25 per cent, of all cases of gastric carcinoma, and is most frequent when the primary growth involves the great c...

Gastro-Cutaneous Fistula: This condition is much less frequent as the result of cancer than of simple ulcer of the stomach, and occurs in only 026 per cent, of the cases of the former disease (vide p. 51). It is interesting to...

Metastases: Secondary growths occur so frequently, and exert such an important influence upon the symptoms and signs of the gastric complaint, that it is necessary briefly to consider the clinical phenomena that ...

Metastases In The Peritoneum: These exist in about 35 per cent, of all cases of carcinoma of the stomach, and occur most frequently when the greater part of the organ or its upper margin is affected by the disease. Secondary growt...

Metastases In The Lung's: These occur in about 8 per cent, of all cases, and are chiefly met with in the lower lobes. In most instances they develop at a late stage of the disease, and are usually, though not always, associate...

Metastases In Lymphatic Glands: An invasion of the gastric lymphatic glands occurs in every case, but it is comparatively rare for their enlargement to produce any special symptoms. Occasionally, however, the great bulk of a pyloric...

Metastases In The Intestine: In the majority of cases the occurrence of intestinal obstruction is due to direct extension of the disease to the transverse colon ; but in three instances which have come under our notice the condit...

Venous Thrombosis: Venous Thrombosis is met with in about 4.5 per cent, of all cases of carcinoma of the stomach, and almost invariably occurs at a late period of the complaint, when the patient is confined to bed. It i...

Chronic Nephritis: -In 15 per cent, of our cases the kidneys presented a granular surface, with adhesion of the capsule and other signs of interstitial inflammation, but albuminuria existed in only about one-fifth of th...

Nervous Diseases: (1) Mental Derangements The depression that invariably accompanies the disease is very liable to pass into melancholia, which may be attended by suicidal tendencies. Less frequently delusional insa...

Purpura: A purpuric eruption sometimes accompanies venous thrombosis, septicaemia, or gradual failure of the heart. Thibierge has also described a hemorrhagic eruption which affects the anterior surface of bot...

Septicaemia: This is a very rare complication, and is almost always associated with extensive ulceration of the primary growth or with an abscess in the peritoneum or one of the neighbouring organs. In the majorit...

Chapter VII. Clinical Varieties: The protean features of carcinoma of the stomach afford a great temptation to differentiate a large number of clinical varieties, according to the predominance of some particular group of symptoms or ...

Carcinoma Of The Cardia: The cardiac third of the stomach is primarily affected in about 10 per cent, of all cases, and is more frequently involved in men than in women. As a rule the previous health has been extremely good, ...

Carcinoma Of The Body (Walls And Curvatures): Growths which affect the central region of the stomach are usually extensive, of soft consistence, and of rapid growth, and are consequently accompanied by numerous symptoms and important physical sig...

Carcinoma Of The Pylorus: Disease of this part of the stomach constitutes about 60 per cent, of all the cases. The initial symptoms are usually those of indigestion, and for several months the chief complaint may be flatulence...

Total Infiltration Of The Stomach: This condition is very rare, and is met with in less than 3 per cent, of all cases. When the morbid growth is fibrous in character the stomach becomes greatly reduced in size and presents the appearan...

The Latent Form: Cases are occasionally encountered in which the symptoms are either entirely absent or only appear at a late stage of the complaint. Three types of latency maybe observed: (a) Where gastric symptoms a...

Symptomatology Case VI: We attended the autopsy of an elderly gentleman who was supposed to have died from some mysterious disorder of nutrition. For nearly a year he had progressively but slowly lost flesh, and had become f...

Symptomatology Case VII: Phthisis : pleurisy, with effusion and thrombosis of the right common iliac vein, with latent cancer of the stomach. A woman, thirty-seven years of age, was admitted into hospital for severe cough and...

Symptomatology Case VIII: General oedema: albuminuria and pleurisy with latent cancer of the stomach. A man aged fifty-four was admitted into hospital for swelling of the legs. According to his history he had suffered from inf...

Symptomatology Case IX: Cardiac disease : no gastric symptoms, but a palpable tumour of the stomach. A woman, fifty years of age, was admitted into the London Temperance Hospital on account of urgent dyspnoea and oedema of t...

Symptomatology Case X: Latent cancer of the stomach with a secondary growth in the brain. A man, fifty-seven years of age, was admitted into hospital for paralysis of the right arm. It appeared from his history that three m...

Symptomatology Case XI: A woman, fifty-three years of age, was admitted into hospital under our care for ascites. She stated that about two months previously she had noticed a sensation of weight and fulness in the abdomen, ...

Symptomatology Case XII: A man, forty-one years of age, stated that for two months he had suffered from pain after meals, flatulence, and oppression at the chest. He had also vomited occasionally, but had never brought up any...

The Anaemic Form: It haslong been known that certain cases of carcinoma of the stomach are attended from an early period by an extreme degree of anaemia, the symptoms of which take precedence of those arising from the ...

(A) Anemia Due To Concealed Hemorrhage: This is by far the most common variety, and is often associated with a localised malignant ulcer of the posterior surface of the stomach. After a comparatively short period of ill-health the patient l...

Symptomatology Case XIII: A man aged forty-nine was admitted into the London Temperance Hospital for anaemia. He stated that he had enjoyed excellent health until about five months previously, when he noticed that he had grown...

Symptomatology Case XIV: A middle-aged man was admitted into hospital under our care on account of debility and loss of flesh. The first symptoms of ill-health had consisted of breathlessness, weakness of the legs, and flatul...

(B) Profound Anemia With Blood Changes Similar To Those Of Pernicious Anemia: Cases of this description are much rarer than those of the preceding group. The onset of the complaint is insidious, and characterised by progressive pallor of the skin and mucous membranes, which sub...

Symptomatology Case XV: A man about fifty years of age was admitted into hospital for ' pernicious anaemia.' He stated that his health had been failing for seven months, during which time he had lost nearly two stones in wei...

Case XVII: A man, aged fifty-six, was admitted into hospital for anaemia. The history was very indefinite, but he had apparently been out of health for four months, and had become too weak to pursue his work as ...

Carcinoma Originating' In Simple Ulcer (Ulcus Carci- Nomatosum): The frequency with which cancer of the stomach is preceded by a simple ulcer is a matter that has given rise to much discussion. According to Lebert, about 9 per cent, of all gastric carcinomata origi...

Case XVIII: A man, forty-eight years of age, was admitted into hospital under our care in 1887 for a chronic ulcer of the stomach. For more than a year he had complained of pain and sickness after meals, and on t...

Carcinoma Of The Stomach In Early Life (Acute Carcinoma): The rare occurrence of gastric cancer before the age of thirty has already been noticed (p. 88). Without much trouble we have been able to collect twenty-two cases in which the complaint developed bet...

Chapter VIII. Course, Duration, And Prognosis. Course: It is impossible to describe in any but general terms the course pursued by carcinoma of the stomach. Not only do the symptoms vary in intensity at different periods, but those which were at first mos...

Duration: The duration of carcinoma of the stomach is very difficult to determine. It has been shown that the onset of the symptoms rarely, if ever, coincides with the actual commencement of the morbid growth, ...

Prognosis: The prognosis of cancer of the stomach is always hopeless, for there is no authentic case on record in which the disease was ultimately cured. It is true that at one time the discovery of the partial ...

Chapter IX. Diagnosis: The problem of diagnosis is a threefold one. In the first place, it is necessary to consider the clinical aspect of the disease in its entirety, in order to establish the existence of certain general ...

General Diagnosis: In every other gastric disease the symptoms that ensue from the disturbance of digestion are not only the first to attract attention, but continue of primary importance throughout the whole course of ...

Early Diagnosis: In addition to the desirability of recognising a fatal disease as soon as possible, the recent advances which have been made in gastric surgery give ground for the hope that a malignant growth of the ...

Differential Diagnosis. Carcinoma Of The Cardia: This variety has chiefly to be distinguished from cicatricial stricture and spasm of the cardiac orifice. Of the three, the malignant affection is by far the most common, for, out of every hundred cas...

Carcinoma of the Pylorus: A morbid growth of the pylorus is chiefly attended by the symptoms and signs of dilatation of the stomach, and has therefore to be distinguished from two other conditions which produce stenosis of the...

Case XX: A middle-aged woman was admitted into hospital for cancer of the stomach. She was greatly emaciated and cachectic, and suffered from constant retching and vomiting. The illness was supposed to have la...

Carcinoma of the Body of the Stomach: A growth which involves the surfaces or curvatures of the stomach without implication of an orifice is often accompanied by such severe pain, vomiting, and haematemesis that its differential diagnosis...

Case XXI: A man, sixty-five years of age, was admitted into hospital under our care for haematemesis. He stated that about two years previously he had been attacked by severe pain in the stomach and sickness, w...

Case XXI. Part 2: Leuchaemia with a palpable enlargement of the spleen is very rare in carcinoma of the stomach, but when it exists the absolute exclusion of leucocythaemia is practically impossible. In most of the cas...

Case XXI. Part 3: Table 35.-Showing The Chief Points Of Distinction Between Carcinoma, Chronic Gastritis, And Nervous Dyspepsia Symptoms Carcinoma Chronic gastritis Nervo...

Chapter X. Treatment. General Measures: The well-known fatality and popular dread of cancer render it advisable that very guarded terms should be employed in the designation of the complaint until the diagnosis can be made with certainty. T...

Treatment. Diet: Both the appetite and the powers of digestion vary so much in different cases that it is usually best to favour, as far as possible, the patient's natural inclinations, and to abstain from hard and fa...

Medicinal Treatment: The search for a specific remedy has produced a long list of drugs, each of which at one time or another has been supposed to exercise a controlling influence upon the course of the disease; but from ...

Surgical Treatment. Carcinoma of the Pylorus: The surgical treatment of cancer of the stomach appears in a somewhat different light according as it is viewed from a surgical or a medical standpoint. To the surgeon the chief question is, what oper...

Contra-Indications To Pylorectomy: If the patient is desirous of a radical operation, two factors require consideration before it can be recommended-his general health and the physical signs of the disease. The general state of heal...

Indications For Gastro-Enterostomy: The production of an artificial communication between the stomach and the small intestine serves to allay the excessive vomiting that ensues from obstruction of the pylorus, and in many cases relieves...

Indications For Gastro-Enterostomy In Carcinoma Of The Cardia: When the morbid growth occupies the cardiac end of the stomach, its removal is impossible, and an obstruction to the entry of food into the organ is the main indication for surgical interference. In a...

Carcinoma Of The Body Of The Stomach (Walls And Curvatures): In these cases the disease has already made such considerable progress before an accurate diagnosis can be made that any attempt to excise the growth is practically foredoomed to failure. Removal of t...

Part II. Tumours Of The Stomach And Duodenum. Chapter I. Sarcoma Of The Stomach: Although the occurrence of gastric sarcoma was observed more than thirty years ago, it has only recently been recognised that it constitutes an important, and by no means an infrequent, variety of mal...

Round-Celled Sarcoma: This variety is the one most usually met with, and was observed in thirty-three out of fiftythree cases, or in about 62 per cent, of the entire number. As a rule, it occurs in the form of a dense infi...

Spindle-Cell Or Fibro-Sarcoma: This variety comes next in order of frequency, and constituted twelve out of the fifty-three cases, or 22 per cent. It usually presents itself as a round or oval circumscribed tumour of the wall of th...

The Myo-sareomata and Anglo-sarcoma: (3) The Myo-sareomata are much rarer than either of the preceding, only five examples having been recorded up to the present time. They form smooth or slightly nodular tumours in the gastric wall near...

Other Points Of Distinction From Carcinoma: Owing to the infrequent infection of the peritoneum there is usually a notable absence of the elongated and nodular epigastric tumour which is so often present in cancerous disease of the stomach from...

Other Points Of Distinction From Carcinoma. Part 2: In about 76 per cent, of all cases abdominal pain is experienced during some period of the disease. It varies greatly, however, in its character and severity. As a rule, it does not amount to more tha...

Other Points Of Distinction From Carcinoma. Part 3: Diagnosis So far as the recognition of the malignant nature of the disease is concerned, the sarcomata do not offer any particular difficulty. The intractable character of the gastric symptoms, cou...

Chapter II. Carcinoma And Sarcoma Of The Duodenum: Carcinoma affects the duodenum as a primary disease much less frequently than the stomach. In the course of 42,000 postmortem examinations made in Vienna, a primary malignant growth was found in the i...

Carcinoma Above The Biliary Papilla (Supra-Ampullary Or Parapyloric Cancer): In this position the growth may either form a ring round the bowel, just below the pylorus, or produce a deep ulcer with overhanging edges, the base of which is adherent to the liver or pancreas. In b...

Carcinoma In The Vicinity Of The Biliary Papilla(Cancer Of The Second Portion Of The Duodenum Or Periam- Pullary): In the second part of the duodenum the growth may commence either in the mucous membrane covering the papilla, or at some spot in its vicinity. In the former case the first indication is usually jaund...

Case XXII: A woman, aged fifty-four, was admitted into the London Temperance Hospital in a comatose condition, with deep jaundice. Her husband stated that about nine weeks previously she had been seized with pai...

Case XXIII: A coal porter, aged fifty-three, was admitted into hospital on February 5, 1883, for slight jaundice. He had enjoyed fairly good health until Christmas, when he caught cold. Since then he had had slig...

Carcinoma Below The Biliary Papilla (Cancer Of The Third Portion Of The Duodenum, Infra-Ampullary Or Juxta- Jejunal): This usually occurs in the form of an annular growth, which produces a considerable degree of stenosis. Both the stomach and the duodenum above the disease are much enlarged, and the pyloric orifice i...

Case XXIV: A carpenter, aged fifty-six, was admitted into the London Temperance Hospital with the following history. He had always been in good health until five months previously, when he was suddenly seized wi...

Case XXIV. Continued: Diagnosis Primary malignant disease of the duodenum is accompanied by two varieties of symptoms, one of which is common to all cases, while the other varies with the situation of the growth. The fo...

Chapter III. Polypi And Pedunculated Tumours Of The Stomach: Polypoid tumours are occasionally met with in the stomach, and may be classified according to their histological structure as pedunculated adenomata, fibromata, lipomata, and myomata. The so-called ' ...

Mucous Polypi (Polyadenomata): These tumours appear to be more common on the continent of. Europe than in England or America, since Ebstein met with fourteen cases in 600 necropsies (2.3 per cent.), while in London, according to ou...

Pedunculated Adenomata: These occur in the form of round, smooth, or lobulated tumours, of a greyish-brown colour and firm consistence, which are attached by short thick stalks to the mucous membrane in the pyloric region. W...

Case XXV: A man, fifty-seven years of age, complained for a long time of severe attacks of pain in the epigastrium, which were accompanied by nausea and vomiting. These symptoms occurred at irregular intervals ...

Case XXVI: A female, aged nineteen, of robust appearance, had enjoyed good health until twelve months ago, when she had an attack of herpes zoster on the left side. A short time afterwards she began to suffer fr...

Case XXVII: A man, aged sixty-four, was admitted into hospital with the following history. Nine months previously he had begun to experience discomfort after meals with colicky pains and excessive flatulence. Aft...

Case XXVIII: A man, aged twenty-one, was admitted into the Radcliffe Infirmary on June 28, 1895. His illness commenced about twelve months previously with pain across the upper part of the abdomen and vomiting. Th...

Chapter IV. Syphilis Of The Stomach: Syphilis may affect the stomach in three ways : (1) By the formation of gummata ; (2) by the production of endarteritis; and (3) by exciting chronic inflammation of its mucous membrane. (1) Gummata...

Endarteritis: Obliterative endarteritis affecting the gastric vessels must not be regarded as necessarily an indication of syphilis. It may be observed in the fibrous base of nearly every chronic simple ulcer, and ...

Chronic Gastritis: This may ensue either as a direct or as an indirect result of syphilis. The latter variety is by far the more common, and is due either to embarrassment of the gastric circulation from disease of the ...

Symptomatology: Chronic ulceration of the stomach due to syphilis is most common in men between twenty-five and forty years of age, in many of whom secondary symptoms of the infective disorder either have been very s...

Symptomatology. Continued: Mild forms of syphilitic gastritis occurring in adult life are practically indistinguishable from the alcoholic variety, while in the more severe cases the progressive loss of flesh, excessive debilit...

Chapter V. Concretions In The Stomach [Hair-Balls-Bezoars-Gastroliths]: Ceetain concretions are apt to form in the stomach, and to give rise to severe gastric symptoms attended by an abdominal tumour. As a rule they consist of hair, cotton, wool, tow or string, but occasi...

Hair-Balls: Out of the twenty-four cases of this variety no fewer than twenty-three were females, the youngest of whom was eighteen 1 and the oldest thirty-four at the time of death. There were never any indicati...

Case XXIX: A girl, eighteen years of age, had suffered for some time from pain and vomiting after food, a capricious appetite, and looseness of the bowels. In the epigastrium there was a tumour about the size of...

Case XXX: A lady, thirty-one years of age, was suddenly seized with severe haematemesis. She had not suffered from any gastric symptoms previously, but was known to have had an abdominal tumour since the age of...

Case XXXI: A factory-girl, aged twenty-one years, was admitted into hospital with the symptoms of acute intestinal obstruction. A large movable tumour could be felt in the epigastrium. After death the stomach wa...

Case XXXII: A girl fifteen years of age came under treatment for an abdominal tumour. For three years she had suffered from severe pain and vomiting after food. The tumour, which occupied the epigastrium and left...

Vegetable Tumours: These are even rarer than the preceding, and consist of undigested vegetable material, fruit skins, cherry stalks, or the fibrous roots of certain plants which had been swallowed on account of their r...

Case XXXIII: An individual, fifty-two years of age, came under medical treatment for severe pain and vomiting after food, with progressive loss of flesh. Haematemesis had occurred at intervals, and there was marke...

Case XXXIV: A woman, aged forty-three years, complained of violent pain in the abdomen after meals, vomiting, and constipation. Under the ensiform cartilage a hard fixed and tender tumour could be felt. After the...

Case XXXV: A woman, forty-five years of age, was admitted into hospital for an abdominal tumour accompanied by pain and vomiting. The tumour resembled a large spleen, but as it was ascertained that the patient h...

Gastroliths: The subjects of this curious complaint are usually men about middle age who, in their morbid desire for alcohol, frequently have drunk varnish, polish, or similar liquids containing it. As a rule the ...

Case XXXVI: A polisher, forty-four years of age, was admitted into hospital with the symptoms of chronic gastritis. He was extremely intemperate in his habits, and the gastric disorder was consequently attributed...

Chapter VI. Cysts Of The Stomach: Chronic inflammation of the stomach is occasionally accompanied by the formation of numerous cysts about the size of hempseeds, which project above the surface of the mucous membrane and are filled wi...

Case XXXVII: A man, aged twenty-one, succumbed to concussion of the brain. Attached to the cardiac end of the stomach, just below the diaphragm, there was a cyst the size of a pigeon's egg. Microscopical examinati...

Case XXXVIII: A woman died at the age of thirty years from cancer of the pylorus with secondary deposits in the liver. During life a smooth and very movable tumour was detected in the epigastrium. After death, in a...

Case XXXIX: A man, aged thirty-eight years, had suffered for five years with pain and sickness after food. At first these symptoms had been intermittent, but for six months the pain had been more or less constant...

Case XL: A female, twenty-two years of age, was suddenly seized with severe pain in the left side of the abdomen, which was increased by inspiration. The bowels were obstinately confined. After a week in bed t...

Case XLI: A middle-aged woman had suffered for a few months from vomiting, pain in the abdomen, and loss of flesh. Examination showed a large tumour in the umbilical region and left hypochondrium, which was som...

Case XLII: A man aged thirty-three died of enteric fever. In the wall of the stomach, close to the pyloric orifice, there was a cystic tumour the size and shape of a walnut. The tumour projected both externally ...

Case XLIII: A man, aged twenty-three, received a severe crush in the upper part of the abdomen, which rendered him unconscious. When he revived he complained of great pain in the left side of the chest and abdome...

Cysts From New Growths: These are usually too small to be recognised during life. Billroth, however, has recorded an instance in which an enormous cyst of the stomach ensued from the degeneration of a sarcoma, while in the f...

Case XLIV: A man, aged sixty-two, when apparently in good health, was seized with violent pain in the right side of the belly and vomiting. These symptoms continued and slight jaundice developed. Three days late...

Case XLV: A woman, aged twenty-two, was admitted into the London Hospital for pain and swelling of the abdomen. The umbilical and hypogastric regions were occupied by a large tumour, which could be moved slight...

Case XLVI: A middle-aged woman was sent to us by Dr. Latham, of Barnsbury, suffering from tumour in the abdomen. It appeared from her history that she had been in good health until about four months previously, ...

Chapter VII. Benign Tumours: The benign tumours of the stomach and duodenum which have not been described in the previous chapters are myomata, fibromata, lipomata, lymphadenomata, mryxomata, osteomata, and aneurysms. They are al...

Fibromata: Although several cases of ' simple fibrous tumour of the stomach ' have been recorded, a careful scrutiny of the descriptions given of their microscopic appearances throws considerable doubt upon thei...

Lipomata: (3) Lipomata occur as yellow round or lobulated tumours in the wall of the stomach about its centre. As a rule they form well-marked projections upon the inner surface, which vary from the size of a s...

Lymphadenoma: (4) Lymphadenoma may affect the stomach and intestines, either in the form of lymphoid overgrowths of the mucous membrane or by invasion from the exterior. In the former case the stomach presents a nu...

Osteomata: Certain tumours, such as fibromata and sarcomata, occasionally undergo partial ossification, and this explanation probably applies to the following case, which is otherwise unique: Case XLVII A ...