A system of practical medicine. By American authors. Vol. 2

by Unknown

CANCER OF THE STOMACH.

BY W. H. WELCH, M.D.

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DEFINITION.—Cancer of the stomach is characterized anatomically by the formation in this organ of a new growth, composed of a connective-tissue stroma so arranged as to enclose alveoli or spaces containing cells resembling epithelial cells. The growth extends by invading the tissues surrounding it, and frequently gives rise to secondary cancerous deposits in other organs of the body. The forms of cancer which occur primarily in the stomach are scirrhous, medullary, colloid, and cylindrical epithelial cancer. The disease develops usually in advanced life. Rarely latent, occasionally without symptoms pointing to the stomach as the seat of disease, gastric cancer is usually attended by the following symptoms: loss of appetite, indigestion, vomiting with or without admixture with blood, pain, a tumor in or near the epigastric region, progressive loss of flesh and strength, and the development of the so-called cancerous cachexia. The disease is not curable. After its recognition it rarely lasts longer than from twelve to fifteen months.

SYNONYMS.—Carcinoma ventriculi; Malignant disease of the stomach. Of the many synonyms for the special forms of cancer, the most common are—for scirrhous, hard, fibrous; for medullary, encephaloid, soft, fungoid; for colloid, gelatinous, mucoid, alveolar; and for cylindrical epithelial, cylindrical-celled or cylindrical or columnar epithelioma, cylindrical-celled cancroid, destructive adenoma.

HISTORY.—Cancer of the stomach was known to the ancients only by certain disturbances of the gastric functions which it produces. The disease itself was not clearly appreciated until its recognition by post-mortem examinations, which began to be made with some frequency after the revival of medicine in the sixteenth century. During the seventeenth and eighteenth centuries several instances of gastric cancer are recorded, the best described being those observed and collected by Morgagni (1761). During this period scirrhus was regarded as the type of cancerous disease. It was a common custom to call only the ulcerated scirrhous tumors cancerous.

With the awakened interest in pathological anatomy which marked the beginning of the present century, the gross anatomical characters of cancer and the main forms of the disease came to be more clearly recognized. After the description of encephaloid cancer by Laennec¹ in 1812, and the first clear recognition of colloid cancer by Otto² in 1816, these two forms of cancer took rank with scirrhus as constituting the varieties of cancer of the stomach as well as of cancer elsewhere. All that it was possible to accomplish in the description of cancer of the stomach from a purely gross anatomical point of view reached its culmination in the great pathological works of Cruveilhier (1829-35) and of Carswell (1838), both of whom admirably delineated several specimens of gastric cancer.

¹ Dict. des Sciences méd., t. i. and t. xii., Paris, 1812-15.

² Otto, Seltens Beobachtungen, etc., 1816.

During this period of active anatomical research the symptomatology of gastric cancer was not neglected. The article on cancer by Bayle and Cayol in the Dictionnaire des Sciences médicales, published in 1812, shows how well the clinical history of gastric cancer was understood at that period.

Cylindrical-celled epithelioma of the stomach could not be recognized as a separate form of tumor until the application of the microscope to the study and classification of tumors—an era introduced by Müller in 1838.³ Cylindrical-celled epithelioma of the stomach was first recognized by Reinhardt in 1851, was subsequently described by Bidder and by Virchow, and received a full and accurate description from Förster in 1858.⁴

³ Ueber den feineren Ban, etc., der krankh. Geschwülste, Berlin, 1838.

⁴ Reinhardt, Annalen d. Charité, ii. 1, 1851; Bidder, Müller's Archiv, 1852, p. 178; Virchow, Gaz. méd. de Paris, April 7, 1855; Förster, Virchow's Archiv, Bd. 14, p. 91, 1858.

Until the publication by Waldeyer⁵ in 1867 of his memorable article on the development of cancers, it was generally accepted that gastric cancer originated in the submucous coat of the stomach, and that the cells in the cancerous alveoli were derived from connective-tissue cells. Waldeyer attempted to establish for the stomach his doctrine that all cancers are of epithelial origin. In all varieties of gastric cancer he believed that he could demonstrate the origin of the cancer-cells from epithelial cells of the gastric tubules—a mode of origin which had previously been advocated for cylindrical epithelioma by Cornil⁶ (1864). Waldeyer's view has met with marked favor since its publication, but there are eminent pathologists who have not given adherence to it in the exclusive form advocated by its author.

⁵ Virchow's Archiv, Bd. 41.

⁶ Journ. de l'Anat. et de la Phys., 1864.

It is somewhat remarkable that although in the early part of the present century several monographs on gastric cancer appeared,⁷ all the more recent contributions to the subject are to be found in theses, scattered journal articles, and text-books. Of the more recent careful and extensive articles on cancer of the stomach, those of Lebert and of Brinton are perhaps most worthy of mention.⁸

⁷ Chardel, Benech, Daniel, Germain, Prus, Sharpey, Barras, etc.

⁸ Lebert, Die Krankheiten des Magens, Tübingen, 1878; Brinton, Brit. and For. Med.-Chir. Rev., 1857.

ETIOLOGY.—The data for estimating the frequency of gastric cancer are the clinical statistics of hospitals, series of recorded autopsies, and mortuary registration reports.

Statistics with reference to this point based exclusively upon the clinical material of hospitals have only relative value, as they do not represent in proper proportion both sexes, all ages, all classes in life, and all diseases. Statistics based upon autopsies surpass all others in certainty of diagnosis, but they possess in even greater degree the defects urged against hospital statistics. Not all the fatal cases in hospitals are examined post-mortem, and gastric cancer is among the diseases most likely to receive such examination. Hence estimates of frequency based exclusively upon autopsies are liable to be excessive. Estimates from mortuary registration reports, and therefore from the diagnoses given in death-certificates, rest manifestly upon a very untrustworthy basis as regards diagnosis, but in other respects they represent the ideal point of view, including, as these reports do, all causes of death among all classes of persons. It is evident that in all methods of estimating the frequency of gastric cancer inhere important sources of error. In general, the larger the number of cases upon which the estimates rest the less prominent are the errors. Such estimates as we possess are to be regarded only as approximate, and subject to revision.

From mortuary statistics Tanchou estimates the frequency of gastric cancer as compared with that of all causes of death at 0.6 per cent.; Virchow, at 1.9 per cent.; Wyss, at 2 per cent.; and D'Espine, at 2½ per cent.⁹

⁹ Tanchou, Rech. sur le Traitement méd. des Tumeurs du Sein, Paris, 1844. These statistics, which are based upon an analysis of 382,851 deaths in the department of the Seine, are necessarily subject to sources of error, but they do not seem to me to deserve the harsh criticisms of Lebert and others.

Virchow, Verhandl. d. phys.-med. Gesellsch. Würzburg, 1860, vol. x. p. 49—analysis of 3390 deaths in Würzburg during the years 1852-55.

Wyss, quoted by Ebstein in Volkmann's Samml. klin. Vorträge, No. 87—analysis of 4800 deaths in Zurich from 1872-74.

D'Espine, Echo médical, 1858, vol. ii.—mortuary statistics of the canton of Geneva, considered to be particularly accurate.

In 8468 autopsies, chiefly from English hospitals, Brinton¹⁰ found gastric cancer recorded in 1 per cent. of the cases. Gussenbauer and Von Winiwarter¹¹ found gastric cancer recorded in 1½ per cent. of the 61,287 autopsies in the Pathological Anatomical Institute of the Vienna University. From an analysis of 11,175 autopsies in Prague, I find gastric cancer in 3½ per cent. of the cases.¹²

¹⁰ Loc. cit.

¹¹ Arch. f. klin. Chirurg., Bd. xix. p. 372.

¹² Statistics of Dittrich, Engel, Willigk, Wrany, and Eppinger, in Prager Vierteljahrschr., vols. vii., viii., ix., x., xii., xiv., xxvii., l., xciv., xcix., and cxiv. Grünfeld found in 1150 autopsies in the general hospital for aged persons in Copenhagen 102 cancers of the stomach, or 9 per cent. (Schmidt's Jahrb., Bd. 198, p. 141).

I have collected and analyzed with reference to this point the statistics of death from all causes in the city of New York for the fifteen years from 1868 to 1882, inclusive.¹³ I find that of the 444,564 deaths during this period, cancer of the stomach was assigned as the cause in 1548 cases and cancer of the liver in 867 cases. Probably at least one-third of the primary cancers of the liver are to be reckoned as gastric cancers. This would make the ratio of gastric cancer to all causes of death about 0.4 per cent. This ratio becomes about 1 per cent. (0.93) if only the deaths from twenty years of age upward be taken: gastric cancer hardly ever occurs under that age. It is probably fair to conclude that in New York not over 1 in 200 of the deaths occurring at all ages and from all causes is due to cancer of the stomach, and that about 1 in 100 of the deaths from twenty years of age upward is due to this cause.

¹³ These statistics are obtained from the records of the Board of Health of the city of New York. These records are kept with great care and system.

The organs most frequently affected with primary cancer are the uterus and stomach. In order to determine the relative frequency of cancer in these situations, I have compiled the following table of statistics from various sources:¹⁴

Primary Cancers.		Stomach.	Uterus.
11,131	in Vienna	10 per cent.	31 per cent.
7,150	in New York	25.7 per cent.	24.2 per cent.
9,118	in Paris (Tanchou)	25.2 per cent.	32.8 per cent.
1,378	in Paris (Salle)	31.9 per cent.	32 per cent.
587	in Berlin	35.8 per cent.	25 per cent.
183	in Würzburg	34.9 per cent.	19 per cent.
1,046	in Prague	37.6 per cent.	33.3 per cent.
889	in Geneva	45 per cent.	15.6 per cent.
31,482	total	21.4 per cent.	29.5 per cent.

From this table it appears that in some collections of cases the uterus is the most frequent seat of primary cancer, while in other collections the stomach takes the first rank. If the sum-total of all the cases be taken, the conclusion would be that about one-fifth of all primary cancers are seated in the stomach, and somewhat less than one-third in the uterus. Even if allowance be made for the apparently too low percentage of cases of gastric cancer in the large Vienna statistics,¹⁵ I should still be inclined to place the uterus first in the list of organs most frequently affected with primary cancer, and to estimate the frequency of gastric cancer compared with that of primary cancer elsewhere as not over 25 per cent.

¹⁴ Vienna cases: Gurlt, Arch. f. klin. Chir., Bd. xxv. p. 421—statistical analysis of 16,637 tumors observed in the three large hospitals of Vienna from 1855 to 1878. New York cases: see preceding foot-note. Paris cases: Tanchou, op. cit., and Salle, Étiologie de la Carcinose, Thèse, Paris, 1877, p. 145 et seq.—fatal cases in Paris hospitals, 1861-63. Berlin cases: Lange, Ueber den Magenkrebs, Inaug. Diss., Berlin, 1877—post-mortem material. Würzburg cases: Virchow, loc. cit., and Virchow's Archiv, Bd. 27, p. 430. Prague cases: reference given above—post-mortem material. Geneva cases: D'Espine, loc. cit.

¹⁵ That this percentage is too low is apparent from the fact that the number of cases of gastric cancer is only twice that of primary cancer of liver in Gurlt's statistics.

The liability to gastric cancer seems to be the same in both sexes. Of 2214 cases of gastric cancer which I have collected from hospital statistics, and which were nearly all confirmed by autopsy, 1233 were in males and 981 in females.¹⁶ This makes the ratio of males to females about 5 to 4. This difference is so slight that no importance can be attached to it, especially in view of the fact that in most hospitals the males are in excess of the females.

¹⁶ My statistics regarding sex are obtained from Prager Vierteljahrschr., vols. xvii., l., xciv., xcix., cxiv.; Lange, op. cit.; Katzenellenbogen, Beitr. zur Statistik d. Magencarcinoms, Jena, 1878; Leudet, Bull. de l'Acad., t. 29, p. 564; Gussenbauer and V. Winiwarter, loc. cit.; Lebert, op. cit.; Habershon, Diseases of Abdomen, Philada., 1879; and Ann. d. Städt. Allg. Krankenh. zu München, Bd. i. and ii.

If to these accurate statistics be added collections of cases from heterogeneous sources, including mortuary statistics (Brinton, Louis, D'Espine, Virchow, Gurlt, Welch), there results a total of 5426 cases, with 2843 males and 2583 females, the two sexes being more evenly represented than in the more exact statistics given in the text. In this collection of cases Gussenbauer and V. Winiwarter's cases only up to the year 1855 are included, as the subsequent ones are doubtless in great part included in Gurlt's statistics. According to Brinton, gastric cancer is twice as frequent in males as in females.

The following table gives the age in 2038 cases of gastric cancer obtained from trustworthy sources and arranged according to decades:¹⁷

Age.	10-20.	20-30.	30-40.	40-50.	50-60.	60-70.	70-80.	80-90.	90-100.	Over 100.
Number of cases.	2	55	271	499	620	428	140	20	2	1
Per cent.	0.1	2.7	13.3	24.5	30.4	21	6.85	1	0.1	0.05

From this analysis we may conclude that three-fourths of all gastric cancers occur between forty and seventy years of age. The absolutely largest number is found between fifty and sixty years, but, taking into consideration the number of those living, the liability to gastric cancer is as great between sixty and seventy years of age. Nevertheless, the number of cases between thirty and forty years is considerable, and the occurrence of gastric cancer even between twenty and thirty is not so exceptional as is often represented, and is by no means to be ignored. The liability to gastric cancer seems to lessen after seventy years of age, but here the number of cases and the number of those living are so small that it is hazardous to draw positive conclusions.

¹⁷ The sources of the statistics for age are—Dittrich (160), Prager Vierteljahrschr., vol. xvii.; D'Espine (117), loc. cit.; Virchow (63), Virchow's Archiv, Bd. 27, p. 429; Leudet (69), loc. cit.; Lange (147), op. cit.; Katzenellenbogen (60), op. cit.; Gussenbauer and Von Winiwarter (493 cases up to 1855), loc. cit.; Lebert (314), op. cit.; Habershon (76), op. cit.; Gurlt (455), loc. cit.; Trans. N.Y. Path. Soc., vol. i. (41); and Trans. London Path. Soc., vols. i.-xxxiv. (43). The results correspond closely to those of the smaller statistics of Brinton and of Lebert.

Cancer of the stomach in childhood is among the rarest of diseases. Steiner and Neureutter¹⁸ failed to find a single gastric cancer in 2000 autopsies on children. Cullingworth¹⁹ has reported with microscopical examination a case of cylindrical-celled epithelioma in a male infant dying at the age of five weeks; it is probable that the tumor was congenital. It is not certain whether Wilkinson's²⁰ often-quoted case of congenital scirrhus of the pylorus in an infant five weeks old was a cancer or an instance of simple hypertrophy. Kaulich²¹ cites a case of colloid cancer affecting the stomach, together with nearly all the abdominal organs, in a child a year and a half old, but whether the growth in the stomach was primary or secondary is not mentioned. The case which Widerhofer²² has reported as one of cancer of the stomach secondary to cancer of the retro-peritoneal glands in an infant sixteen days old seems from the description to be sarcoma. Scheffer²³ has reported a case of large ulcerated encephaloid cancer of the fundus, involving the spleen, in a boy fourteen years old. Jackson²⁴ has reported an interesting case of encephaloid cancer in a boy fifteen years old in whom no evidence of disease existed up to ten weeks before death. These cases, which are all that I have been able to find in children, are to be regarded as pathological curiosities.²⁵

¹⁸ Prager Vierteljahrschr., vol. lxxxix. p. 77.

¹⁹ British Med. Journ., Aug. 25, 1877, p. 253.

²⁰ London and Edinburgh Month. Journ. of Med., 1841, vol. i. p. 23.

²¹ Prager med. Wochenschr., 1864, No. 34.

²² Jahrb. f. Kinderheilk. Alt. Reihe, Bd. ii. Heft 4, p. 194.

²³ Jahrb. f. Kinderheilk., xv. p. 425, 1880.

²⁴ J. B. S. Jackson, Extracts from the Records of the Boston Society for Medical Improvement, vol. v., Appendix, p. 109, Boston, 1867.

²⁵ Mathien (Du Cancer précoce de l'Estomac, Paris, 1884) has recently analyzed, chiefly from a clinical point of view, 27 cases of gastric cancer occurring under thirty-four years of age. Of these, 3 were under twenty and 14 were between twenty and thirty years. He also emphasizes the error of considering cancer of the stomach as exclusively a disease of advanced life.

Such statistics as we possess would make it appear that gastric cancer, as well as cancer in general, is somewhat less common in the United States than in the greater part of Europe.²⁶ These statistics, however, are too inaccurate, and the problems involved in their interpretation are too complex, to justify us in drawing any positive conclusions as to this point. It is certain that cancer is not a rare disease in the United States.

²⁶ Of 1000 deaths in New York in 1882, 19.3 were from cancer. The statistics on this point from some of the large European cities are—Geneva, 53 deaths from cancer per mille; Frankfort, 47.6; Copenhagen, 33.2; Christiania, 29; London, 28.7; Paris, 27; Edinburgh, 25.4; Berlin, 22.4; St. Petersburg, 15; Amsterdam, 12. These statistics are obtained from the Forty-fourth Annual Report of the Registrar-General (for 1881), London, 1883; from Preussische Statistik, Heft lxiii., Berlin, 1882; and from Traité de la Climatologie médicale, Paris, 1877-80, by Lombard, in whose excellent work will be found much information on this subject.

To judge from statistics in this country and in England, the death-rate from cancer is undergoing a rapid annual increase. Whereas in New York in 1868 this death-rate was only 12.6 per mille, in 1882 it was 19.3. In England and Wales in 1858 the deaths from cancer per 1,000,000 persons living were 329, and in 1881 they were 520. It seems probable, as suggested in the above report of the Registrar-General, that this apparently increasing large death-rate is due to increased accuracy in diagnosis. It may be also that decrease in infant mortality and prolongation of life by improved sanitary regulations may account in part for this increase. From this point of view Dunn makes the paradoxical statement that the cancer-rate of a country may be accepted as an index of its healthfulness (Brit. Med. Journ., 1883, i.).

It is said on good authority that in Egypt and Turkey gastric cancer and other forms of cancer are infrequent.²⁷ A similar infrequency has been claimed for South America, the Indies, and in general for tropical and subtropical countries; but all of these statements as to the geographical distribution of cancer are to be accepted with great reserve, as they do not rest upon sufficient statistical information.

²⁷ Hirsch, Handb. d. Historisch-geographische Pathologie, Bd. ii. p. 379, Erlangen, 1862-64.

I have analyzed the frequency of gastric cancer among negroes upon a basis of 7518 deaths among this race in New York, and I find the proportion of deaths from this cause about one-third less than among white persons.²⁸ It has been stated that cancer is an extremely rare disease among negroes in Africa.²⁹ The admixture with white blood makes it difficult to determine to what degree pure negroes in this country are subject to cancer.

²⁸ According to the Ninth Census Report of the United States, in the census year 1870 the deaths from cancer among white persons were 13.7 per mille, and among colored persons only 5.7 per mille; but it is well known that the registration returns upon which the vital statistics in these reports are based are very incomplete and unsatisfactory.

²⁹ Bordier, La Geographie médicale, Paris, 1884, p. 464. Livingstone speaks of the infrequency of cancer among the negroes in Africa.

The question as to what rôle is played by heredity in the causation of gastric cancer belongs to the etiological study of cancer in general. Probably in about 14 per cent. of the cases of cancer it can be determined that other members of the family are or have been affected with the disease.³⁰ The influence of inheritance, therefore, is apparent only in a comparatively small minority of the cases. As suggested long ago by Matthew Baillie, this hereditary influence is better interpreted as in favor of a local predisposition (embryonic abnormality?) in the organ or part affected than in favor of the inheritance of a cancerous diathesis. It has been claimed by D'Espine, Paget, and others that cancer develops at an earlier age when there is a family history of the disease than when such history is absent.

³⁰ This statement is based upon the collection of 1744 cases of cancer analyzed with reference to this question. Of these, a family history of cancer was determined in 243 cases. The cases are obtained from statistics of Paget and Baker, Sibley, Moore, Cooke, Lebert, Lafond, Hess, Leichtenstern, Von Winiwarter, and Oldekop. There is extraordinary variation in the conclusions of different observers upon this point. Velpeau asserted that he could trace hereditary taint in 1 in 3 cancerous subjects; Paget, in 1 in 4; Cripps, in 1 in 28. My conclusions agree with those obtained at the London Cancer Hospital (Cooke, On Cancer, p. 11, London, 1865).

The most remarkable instance of inherited cancer on record is reported by Broca (Traité des Tumeurs, vol. i. p. 151, Paris, 1866): 15 out of 26 descendants over thirty years of age of a woman who died in 1788 of cancer of the breast were likewise affected with cancer. As is well known, Napoleon the First, his father, and his sister died of cancer of the stomach.

It may be considered established that cancer sometimes develops in a simple ulcer of the stomach, either open or cicatrized. It is most likely to develop in large and deep ulcers with thickened edges, where complete closure by cicatrization is very difficult or impossible. It is difficult to prove anatomically that a gastric cancer has developed from an ulcer, and hence such statements as that of Eppinger, that in 11.4 per cent. of cancers of the stomach this mode of development existed, are of no especial value.³¹ No etiological importance can be attached to the occasional association of cancer with open or cicatrized simple ulcers in different parts of the same stomach. Of the comparatively few cases in which strict anatomical proof has been brought of the origin of cancer in simple gastric ulcer, probably the most carefully investigated and conclusive is one studied and reported by Hauser.³² It is, however, by no means proven that Hauser's view is correct, that cancer develops from the atypical epithelial growths often to be found in the cicatricial tissue of gastric ulcer. In a few instances both the clinical history and the anatomical appearances speak decisively for the development of cancer in a simple gastric ulcer;³³ and the establishment of this fact is of clinical importance.

³¹ Prager Vierteljahrschr., vol. cxiv.

³² Das chronische Maqengeschwür, Leipzig, 1883, p. 61. See also Heitler, "Entwicklung von Krebs auf narbigen Grunde in Magen," Wien. med. Wochenschr., 1883, p. 961. It seems to me that at present there is a tendency to exaggerate the frequency with which cancer develops from gastric ulcer.

³³ A particularly satisfactory case of this kind is reported by Lebert, op. cit., p. 503.

Many other factors in the causation of gastric cancer have been alleged, but without proof of their efficacy. This is true of chronic gastritis, which was once thought to be an important cause of gastric cancer, and is even recently admitted by Leube to be of influence.³⁴ Certainly the majority of cases of cancer of the stomach are not preceded by symptoms of chronic gastritis. Although in a few instances gastric cancer has followed an injury in the region of the stomach, there is no reason to suppose that this was more than a coincidence.

³⁴ In Ziemssen's Handb. d. spec. Path. u. Therap., Bd. vii. p. 134, Leipzig, 1878.

Few, if any, at present believe that depressing emotions, such as grief, anxiety, disappointment, which were once considered important causes of cancer, exert any such influence. Cancer of the stomach occurs as frequently in those of strong as in those of weak constitution—as often among the temperate as among the intemperate. If, as has been claimed (D'Espine), gastric cancer is relatively more frequent among the rich than among the poor, this is probably due only to the fact that a larger number of those in favorable conditions of life attain the age at which there is greatest liability to this disease. No previous condition of constitution, no previous disease, no occupation, no station in life, can be said to exert any causative influence in the production of gastric cancer.

It will be observed that the obscurity which surrounds the ultimate causation of gastric cancer is in no way cleared up by the points which have been here considered and which are usually considered under the head of etiology. It is impossible to avoid the assumption of an individual—and in my opinion a local—predisposition to gastric cancer, vague as this assumption appears. All other supposed causes are at the most merely occasional or exciting causes. The attempts to explain in what this predisposition consists are of a speculative nature, and will be briefly considered in connection with the pathenogenesis of gastric cancer.

SYMPTOMATOLOGY.—We may distinguish the following groups of cases of gastric cancer:

First: Latent cases, in which the cancer of the stomach has produced no symptoms up to the time of death. Many secondary cancers of the stomach belong to this class. Here also belong cases in which a cancer is found unexpectedly in the stomach when death has resulted from other causes. I have found a medullary cancer, slightly ulcerated, as large as a hen's egg, seated upon the posterior wall and lesser curvature of the stomach of a laboring man suddenly killed while in apparent health and without previous complaint of gastric disturbance. These cases, in which life is cut short before any manifestation of the disease, are without clinical significance, save to indicate how fallacious it is to estimate the duration of the cancerous growth from the first appearance of the symptoms.

Second: Cases in which gastric symptoms are absent or insignificant, whereas symptoms of general marasmus or of progressive anæmia or of cachectic dropsy are prominent. Cases of this class are frequently mistaken for pernicious anæmia, and occasionally for Bright's disease, heart disease, or phthisis. It is difficult to explain in these cases the tolerance of the stomach for the cancerous growth, but this tolerance is most frequently manifested when the tumor does not invade the orifices of the organ.

Third: Cases in which the symptoms of the primary gastric cancer are insignificant, but the symptoms of secondary cancer, particularly of cancer of the liver or of the peritoneum, predominate. In some, but not in all, of these cases the primary growth is small or has spared the orifices of the stomach.

Fourth: Cases in which the symptoms point to some disease of the stomach, or at least to some abdominal disease; but the absence of characteristic symptoms renders the diagnosis of gastric cancer impossible or only conjectural.

Fifth: Typical cases in which symptoms sufficiently characteristic of gastric cancer are present, so that the diagnosis can be made with reasonable positiveness.

It is not to be understood that these groups represent sharply-drawn types of the disease. It often happens that the same case may present at one period the features of one group, and at another period those of another group. Nor is it supposed that every exceptional and erratic case of gastric cancer can be classified in any of the groups which have been mentioned.³⁵

³⁵ In the thesis of Chesnel may be found many curious clinical disguises which may be assumed by cancer of the stomach, such as simulation of Bright's disease, heart disease, phthisis, chronic bronchitis, cirrhosis of the liver, etc. (Étude clinique sur le Cancer latent de l'Estomac, Paris, 1877). Layman (Med. Annals Albany, 1883, p. 207) reports a case of gastric cancer in which extra-uterine foetation was suspected.

A typical case of gastric cancer runs a course about as follows: A person, usually beyond middle age, begins to suffer from disordered digestion. His appetite is impaired, and a sense of uneasiness, increasing in course of time to actual pain, is felt in the stomach. These symptoms of dyspepsia are in no way peculiar, and probably at first occasion little anxiety. It is, however, soon observed that the patient is losing flesh and strength more rapidly than can be explained by simple indigestion. He becomes depressed in spirits. The bowels are constipated. Vomiting, which was usually absent at first, makes its appearance and becomes more and more frequent. After a while it may be that, without any improvement, the vomiting becomes less frequent, comes on longer after a meal, but is more copious. In the later periods of the disease a substance resembling coffee-grounds and consisting of altered blood is often mingled with the vomit. By this time the patient has assumed a cachectic look. He is wasted, and his complexion has the peculiar pale yellowish tint of malignant disease. Perhaps there is a little oedematous pitting about the ankles. During the progress of the disease in the majority of cases an irregular hard tumor can be felt in the epigastrium. While one or another of the symptoms may abate in severity, the general progress of the disease is relentlessly downward. Within six months to two years of the onset of the symptoms the patient dies of exhaustion.

Too much stress should not be laid upon any so-called typical course of gastric cancer. This course is modified by many circumstances, such as the situation of the cancer, its size, its rapidity of growth, the presence or absence of ulceration, the existence or non-existence of secondary tumors, the presence of complications, and the individuality of the patient. It is necessary, therefore, to consider in detail each of the important symptoms of gastric cancer. But in thus fixing attention upon individual symptoms one must not lose sight of the clinical picture as a whole. It is not any single symptom which is decisive; it is rather the combination, the mode of onset, and the course of the symptoms, which are of most importance in diagnosis.

Impairment of the appetite is the rule in gastric cancer. Anorexia is sometimes a marked symptom before pain, vomiting, and other evidences of gastric indigestion are noted. There is often a special distaste for meat. The appetite may be capricious; it is very rarely even increased. There are exceptional cases in which the appetite is preserved throughout the greater part or even the whole course of the disease. This seems to be more frequent with cancer of the cardia than with cancer of other parts of the stomach. Loss of appetite is a much more common symptom in gastric cancer than in gastric ulcer. In cancer, as well as in ulcer, the patient sometimes refrains from food less on account of disrelish for it than on account of the distress which it causes him.

Pain is one of the most frequent symptoms of cancer of the stomach. If the pain begins early in the disease, and continues, as it often does, with increasing severity, it renders gastric cancer one of the most distressing affections. The pain is usually felt in the epigastrium, but it may be more intense in the hypochondria. It is sometimes felt in the interscapular region, the shoulders, or even in the loins.³⁶ With cancer of the cardia it is often referred to the point of the xiphoid cartilage or behind the sternum. In general, however, there is so little correspondence between the site of the cancer and the exact locality of the pain that no weight can be attached to the situation of the pain in diagnosing the region of the stomach involved in the growth. Nor does any import attach to the quality of the pain, whether it is described as burning, gnawing, dull, lancinating, etc. Severe gastralgic paroxysms occur, although less frequently than in gastric ulcer.

³⁶ The pain in cases of gastric cancer may be felt in parts of the body remote from the stomach. Thus, in a case of cancer of the cardia reported by Minot the pain was felt, not in the epigastrium, but in the left shoulder, the back of the neck, and the pharynx. In several instances the pain has been interpreted as of renal origin. In a case of gastric cancer reported by Palmer each attack of vomiting was invariably preceded by pain in the middle of the shaft of the left humerus (Extr. fr. the Records of the Boston Soc. for Med. Improvement, vol. iv. p. 217).

The pain is usually aggravated by ingestion of food, although it may not become severe until the process of digestion is far advanced. Pain, however, occurs independently of taking food, and is occasionally a marked symptom when there are no evidences of dyspepsia. There can be no doubt that the cancer, as such, produces pain by involvement of the nerves of the stomach, but there is no specific cancerous pain, such as has been described by Brinton and other writers. There is usually tenderness on pressure over the stomach, and this tenderness is often over the tumor, if such can be felt.

In general, it may be said that the pain of gastric cancer, as contrasted with that of simple gastric ulcer, is often less dependent upon taking food, less intense, less circumscribed, less paroxysmal, less often relieved by vomiting; but there is so little constancy about any of these points that no reliance is to be placed upon any peculiarity of the pain in the diagnosis of gastric cancer.

The observation of several cases of gastric cancer without pain as a marked symptom leads me to emphasize the fact that absence or trifling severity of pain throughout the greater part or the whole of the disease, although exceptional, is not extremely rare. The frequency of painless gastric cancers is given by Lebert as 25 per cent., and by Brinton as 8 per cent., of the whole number. For many reasons, numerical computations as to the frequency of this and of other symptoms of gastric cancer are of very limited value.³⁷ Absence of pain is more common in gastric cancers of old persons and in cancers not involving the orifices of the stomach than it is at an earlier period of life or when the gastric orifices are obstructed.

³⁷ Gastric cancer cannot be considered as a disease with uniform characters. It is irrational to group together cancers of the pylorus, of the cardia, of the fundus, of the curvatures, cancers hard and soft, ulcerated and not ulcerated, infiltrating and circumscribed, and to say that pain or vomiting is present in so-and-so many cases of cancer of the stomach. There is not a sufficient number of recorded cases in which the symptoms are fully described with reference to the peculiarities of the growth to enable us to apply to gastric cancer the numerical method of clinical study with valuable results. The great discrepancy between Lebert's and Brinton's statistics as to the frequency of painless cancers of the stomach illustrates the present inadequacy of the numerical method, which is misleading in so far as it gives a false appearance of exactness.

The functions of the stomach are almost invariably disordered in gastric cancer. Sometimes, especially in the early stages, this disorder is only moderate, and is manifested by the milder symptoms of indigestion, such as uneasy sensations of weight and fulness after a meal, nausea, flatulent distension of the stomach relieved by eructation of gases, and heartburn. With the progress of the disease the uneasy sensations become actually painful; watery fluids, and sometimes offensive acrid fluids and gases, are regurgitated; and nausea culminates in vomiting. The breath is often very fetid. The eructation of inflammable gases has been observed in a few cases.

The most troublesome symptoms of indigestion occur with those cancers which by obstructing the pyloric orifice lead to dilatation of the stomach. Cases of gastric cancer in which the distressing symptoms of dilatation of the stomach dominate the clinical history are frequent. These symptoms are in no way peculiar to cancer of the stomach, but belong to dilatation produced by pyloric stenosis from whatever cause, and will be described in the article on DILATATION OF THE STOMACH.

Various causes combine to impair the normal performance of the gastric functions in cancer of the stomach. Chronic catarrhal gastritis is a factor in not a few cases. The destruction by the cancer of a certain amount of secreting surface can be adduced as a sufficient cause only in exceptional cases of extensive cancerous infiltration. Of more importance is interference with the peristaltic movements of the stomach, particularly in the pyloric region, where the cancer is most frequently situated. As already mentioned, dilatation of the stomach is a most important cause of indigestion in many cases. Of great interest in this connection is the discovery by Von den Velden³⁸ that as a rule (to which there are exceptions) the gastric juice in cases of dilatation of the stomach due to cancer contains no free hydrochloric acid, and that this gastric juice has comparatively feeble digestive power, as proven by experiments. As this alteration of the gastric juice interferes particularly with the digestion of albuminous substances, it is explicable why many patients with gastric cancer have an especial abhorrence for meat.

³⁸ Deutsches Arch. f. kl. Med., Bd. 23, p. 369.

During the progress of the disease the dyspeptic symptoms may improve, but this improvement is usually only temporary. In exceptional cases of gastric cancer dyspeptic symptoms, as well as other gastric symptoms, may be absent or not sufficiently marked to attract attention.

Hiccough, sometimes very troublesome, has been observed not very infrequently during the later periods of the disease.

There is nothing noteworthy about the appearance of the tongue, which is often clean and moist, but may be furred or abnormally red and dry. In the cachectic stage, toward the end of the disease, aphthous patches often appear on the tongue and buccal mucous membrane. An increased flow of saliva has been occasionally observed in gastric cancer as well as in other diseases of the stomach. Thirst is present when there is profuse vomiting.

Vomiting usually appears after other symptoms of indigestion have been present for some time. It may, however, be one of the earliest symptoms of the disease. At first of occasional occurrence, it increases in frequency until in some cases it becomes the most prominent of all symptoms. Vomiting may occur in paroxysms which last for several days or weeks, and then this symptom may improve, perhaps to be renewed again and again, with remissions of comparative comfort. There are rare cases of gastric cancer in which the first symptom to attract attention is uncontrollable vomiting, accompanied often with pain and rapid emaciation. Such cases may run so acute a course that a fatal termination is reached within one to two months.³⁹ In these cases, which have been interpreted as acutely-developed gastric cancers, it is probable that the cancer has remained latent for weeks or months before it gave rise to marked symptoms.

³⁹ For example, Andral relates a case in which death took place thirty-seven days after the onset of the symptoms, these being obstinate vomiting, severe gastralgic paroxysms, marasmus, and, about ten days before death, profuse black vomit. There was found a fungoid tumor the size of a hen's egg projecting into the cavity of the stomach near the pylorus. In this situation the walls of the stomach were greatly thickened by colloid growth (Arch. gén. de Méd., June, 1823). Here may also be mentioned the fact that in several instances pregnancy has been complicated with gastric cancer. Here the uncontrollable vomiting which often exists has been referred to the pregnancy, and has led to the production of premature labor.

The situation of the cancer exerts great influence upon the frequency of vomiting and the time of its occurrence after meals. When the cancer involves the pyloric orifice, vomiting is rarely absent, and generally occurs an hour or more after a meal. As this is the most frequent situation of the cancer, it has been accepted as a general rule that vomiting occurs at a longer interval after eating in cases of gastric cancer than in cases of simple ulcer. But even with pyloric cancer the vomiting may come on almost immediately after taking food, so that it is not safe to diagnose the position of the cancer by the length of time between eating and the occurrence of vomiting. As the cancer in its growth obstructs more and more the pyloric orifice, the vomiting acquires the peculiarities of that accompanying dilatation of the stomach. The vomiting comes on longer after a meal—sometimes not until twelve or twenty hours or even more have elapsed. It may be that several days elapse between the acts of vomiting, which then present a certain periodicity. The patient then vomits enormous quantities containing undigested food, mucus, sarcinæ, and gaseous and other products of fermentation. Sometimes, especially toward the end of the disease, the vomiting ceases altogether. This cessation has been attributed to reopening of the pyloric orifice by sloughing of the growth. It is not necessary to assume such an occurrence, as a similar cessation of vomiting sometimes occurs in dilatation of the stomach due to persistent stenosis of the pylorus. Cessation of vomiting in these cases is by no means always a favorable symptom.

Next to pyloric cancer, it is cancer involving the cardiac orifice which is most frequently accompanied by vomiting. Here the vomiting occurs often immediately after taking food, but there are exceptions to this rule. If in consequence of stenosis of the cardiac orifice the food does not enter the stomach, it is shortly regurgitated unchanged or mingled simply with mucus. It is this regurgitation rather than actual vomiting which in most common and characteristic of cardiac cancer. Even in cases in which the passage of an oesophageal sound reveals no obstruction at the cardiac orifice it sometimes happens that food, including even liquids, is regurgitated almost immediately, as in a case reported by Ebstein in which cold water was returned at once after swallowing.⁴⁰ In these cases Ebstein with great plausibility refers the regurgitation to reflex spasm of the oesophagus induced by irritation of a cancer at or near the cardia through contact of food or liquids, especially when cold, with its surface.

⁴⁰ "Ueber den Magenkrebs," Volkmann's Samml. klin. Vorträge, No. 87, p. 21.

When the cancer is seated in other parts of the stomach and it does not obstruct the orifices, vomiting is more frequently absent or of only rare occurrence. Vomiting is absent, according to Lebert, in one-fifth, according to Brinton in about one-eighth, of the cases of gastric cancer. Absence of vomiting is sufficiently frequent in gastric cancer to guard one against excluding the diagnosis of this disease on this ground alone.

Although in many cases the vomiting of gastric cancer can be explained on mechanical grounds by stenosis of the orifices, this is an explanation not applicable to all cases. Mention has already been made of spasm of the oesophagus as a cause of regurgitation of food in some cases of cardiac cancer. A similar spasm of the muscle in the pyloric region may explain the vomiting in certain cases in which during life there were symptoms of pyloric stenosis, but after death no or slight stenosis can be found. There is reason also to believe that atony of the muscular coats of the stomach may cause stagnation of the contents of the stomach and dilatation of the organ. In exceptional cases of gastric cancer in which the stomach is so intolerant as to reject food almost immediately after its entrance a special irritability of the nerves of the stomach must be assumed. It is customary to refer this form of vomiting to irritation of the ulcerated surface of the cancer by analogy with a similar irritability of the stomach observed in some cases of simple gastric ulcer. But there is little analogy between the ulcerated surface of a cancer in which tissues of little vitality and irritability are exposed and the surface of a simple ulcer in which the normal or slightly altered tissues of the stomach are laid bare. Finally, in the existence of chronic catarrhal gastritis is to be found another cause of vomiting in many cases of gastric cancer.

The presence of fragments of the cancer in the contents removed by washing out the stomach with the stomach-tube has been observed by Rosenbach⁴¹ in three cases of gastric cancer, and utilized for diagnostic purposes. A cancerous structure could be made out in these fragments by the aid of the microscope. Hitherto, the presence of particles of the tumor in the vomited matter has been considered as hardly more than a curiosity, and I have not been able to find a well-authenticated instance in which such particles in the vomit have been recognized by microscopical examination. According to Rosenbach, the fragments of the tumor in the washings from the stomach can be recognized by the naked eye by the red, reddish-brown, or black specks on their surface, due to recent or old hemorrhages which have aided in the detachment of the fragments. By this means such particles are distinguished macroscopically from bits of food. By employing soft-rubber tubes and the syphon process there is no danger, in washing out of the stomach, of detaching pieces of the normal mucous membrane, which, moreover, can be distinguished from the fragments of the tumor by the aid of the microscope and usually by the naked eye. It remains to be seen how frequently such fragments of the tumor are to be found in the fluids obtained by washing out the stomach. It is not probable that they will be found so often as Rosenbach anticipates. According to the experience of most observers, they are very rarely present. They would naturally be most readily detached from soft, fungoid, and ulcerating cancerous growths. In this connection may also be mentioned the occasional separation of bits of the tumor by the passage of the stomach-tube in cases of cancer of the cardia. The eye of the tube as well as the washings from the stomach should be carefully examined for such particles.

⁴¹ Deutsche med. Wochenschr., 1882, p. 452.

The habitual absence of free hydrochloric acid in the gastric fluids in dilatation of the stomach due to carcinoma of this organ was noted by Von der Velden.⁴² He found in eight cases of dilatation due to cancer of the pylorus that the fluids removed by the stomach-pump were free from hydrochloric acid, whereas in ten cases of dilatation due to other causes, such as cicatrized simple ulcer of the pylorus, free hydrochloric acid was only temporarily absent from the gastric juice. Von der Velden therefore attributes to the presence or the absence of free hydrochloric acid in the gastric juice in these cases great diagnostic importance. The observations which have followed Von der Velden's publication are not yet sufficient to justify us in drawing positive conclusions in this matter. Recently, Kredel⁴³ has reported from Riegel's clinic seventeen cases of simple dilatation in which free hydrochloric acid was only exceptionally and temporarily absent from the gastric fluids, and nineteen cases of cancerous dilatation in which, with very rare exceptions, free hydrochloric acid was continuously absent. Cases, however, have been observed by Ewald, Seeman, and others in which free hydrochloric acid has been found in stomachs dilated from gastric cancer. It is to be noted that free hydrochloric acid is absent from the stomach in other conditions than in gastrectasia due to cancer; of which conditions the most important are fever, amyloid degeneration of the stomach (Edinger), and some cases of gastric catarrh. Free hydrochloric acid is also usually absent during the first twenty minutes to an hour after a meal. We have not sufficient information as to the presence or absence of free hydrochloric acid in cases of gastric cancer without dilatation of the stomach. To Von der Velden's symptom no pathognomonic value can be attached, but it may prove, in connection with other symptoms, an aid in diagnosis. The presumption is against gastric cancer if free hydrochloric acid be found continuously in a dilated stomach. Less importance can be attached to the absence of free hydrochloric acid unless the observations extend over several weeks and fever and amyloid degeneration are excluded.

⁴² Deutsches Arch. f. klin. Med., Bd. 23, p. 369, 1879.

⁴³ Zeitschrift f. klin. Med., Bd. 6, p. 592, 1884.

The tests for free hydrochloric acid are most satisfactorily applied to the fluids withdrawn by the stomach-pump. After a sufficient quantity for examination has been withdrawn the syphon process may be substituted. Tests may also be applied to vomited material, although here the admixture of secretions from the nose, mouth, and throat may render the results less conclusive. Edinger's method of swallowing bits of sponge enclosed in gelatin capsules and attached to a string, by which they can be withdrawn, may also be employed. The sponge should be free from sand, deprived of alkaline carbonates by hydrochloric acid, and rendered perfectly neutral by washing in distilled water.

For clinical purposes the most convenient tests are those which depend upon certain changes in color produced in reagents which enable us to distinguish inorganic from organic acids. In the gastric juice the only inorganic acid which comes into consideration is hydrochloric acid, and the most important organic acid is lactic.

1. Saturated aqueous solutions of tropæolin, marked in the trade OO (Von Miller, V. d. Velden). The solution should be perfectly clear and of a lemon-yellow color. This solution is colored red by the addition of hydrochloric acid even in very dilute solution (0.01 per cent.). A similar change in color is produced by lactic acid in somewhat less dilute solution (0.06 per cent.), but the red color produced by lactic acid disappears upon shaking with ether, while that produced by hydrochloric acid remains, unless the acid was present in very minute quantity. Tropæolin is therefore a very delicate test for free acid in general, but it does not distinguish so well as some other tests hydrochloric from lactic acid.

2. Aqueous solution of methyl-violet (an aniline dye) in the strength of 0.025 per cent. (Witz, Maly). The solution should be of a violet color, and in a test-tube should allow the light to pass readily through it. The addition of hydrochloric acid in dilute solution changes the violet to a blue color, in stronger solution to a greenish tint. With lactic acid in stronger solution methyl-violet gives a similar but less distinct reaction. Methyl-violet, while a less delicate test than tropæolin, is better adapted for distinguishing hydrochloric from lactic acid.

3. Ferric chloride and carbolic acid test (Uffelmann). Mix 3 drops of liquor ferri chloridi (German Pharmacopoeia, specific gravity 1482), 3 drops of very concentrated solution of carbolic acid, and 20 ccm. of distilled water. The addition of even very dilute solutions of lactic acid (0.05 per cent.) changes the amethyst-blue color of this test-fluid to a yellow color, with a shade of green. Dilute solutions of hydrochloric acid produce a steel-gray, and stronger solutions a complete decolorization of the fluid. When both hydrochloric and lactic acids are present the effect of the lactic acid predominates unless only a mere trace of it is present. This is therefore a good test for lactic acid. It is necessary to prepare the test-fluid fresh each time before using.

4. It is well to test the digestive power of the filtered fluid from the stomach by suspending in the fluid a floccule of washed fibrin and keeping the fluid at a temperature of about 100° F. If free hydrochloric acid be present in moderate quantity, in a short time the fibrin will begin to be dissolved, but if the acidity be due to organic acid the fibrin will be dissolved very slowly or not at all.

In applying these various tests the fluids from the stomach should be filtered and the filtrate used. It is best not to rely upon a single test, but to employ them in combination. The fluids may be mixed in a test-tube. The reaction is sometimes most distinct when the fluids are allowed to mingle upon a white porcelain dish. It is sometimes of advantage to concentrate the mingled fluids by evaporation. The fluid obtained by the stomach-pump five or six hours after a meal is the most suitable for diagnostic tests. The presence of peptones and of dissolved albumen makes the tests less delicate for the gastric fluids than for simple aqueous solutions of the acids.⁴⁴

⁴⁴ For further information on this subject consult Von der Velden, loc. cit.; Uffelmann, Deutsches Arch. f. klin. Med., Bd. 26, p. 431; Edinger, ibid., Bd. 29, p. 555; and Kredel, loc. cit.

It is important to distinguish between the slight and the copious hemorrhages of gastric cancer.

The admixture of a small quantity of blood with the vomit, giving to the latter the so-called coffee-grounds appearance, is a very common occurrence in gastric cancer. Melænamesis, as the vomiting of brown or black substance resembling coffee-grounds is called, is estimated to occur in about one-half of the cases of cancer of the stomach. It is observed particularly in the cachectic stage, in which it is not rare for some brown or black sediment to be almost constantly present in the vomit. The brown or black color is due to the conversion by the acids of the stomach of the normal blood-coloring matter into dark-brown hæmatin.

The presence of blood in the vomited matter can generally be recognized by the naked eye. By the aid of the microscope red blood-corpuscles, more or less changed, especially decolorized red blood-corpuscles (the so-called shadows), can usually be detected. Sometimes only amorphous masses of altered blood-pigment can be seen. The spectroscope may also be employed, in which alkaline solutions of hæmatin produce an absorption-band between C and D, usually reaching or passing D. The presence of blood-coloring matter can also be readily detected by the production of hæmin crystals.⁴⁵ The slight hemorrhages are in most cases the result of ulceration of the cancer, by which process a little oozing of blood from the capillaries is produced.

⁴⁵ Hæmin crystals may be produced by boiling in a test-tube a little of the suspected fluid or sediment with an excess of glacial acetic acid and a few particles of common salt. After cooling, a drop from the lower layers will show under the microscope the dark-brown rhombic crystals of hæmin in case blood-coloring matter was present in not too minute quantity.

Copious hemorrhages from the stomach are not common in gastric cancer. They occur probably in not over 12 per cent. of the cases (Lebert). According to Lebert, they are more liable to occur in males than in females. Blood vomited in large quantity is either bright red or more or less darkened in color according to the length of its sojourn in the stomach. Following profuse hæmatemesis, some dark, tarry blood is usually passed by the stools, constituting the symptom called melæna. Copious hemorrhages from the stomach hasten the fatal termination and may be its immediate forerunner. Cases of gastric cancer have been reported in which death has occurred from gastrorrhagia before there has been time for any blood to be either vomited or voided by stool. As might naturally be expected, patients with gastric cancer do not usually rally as readily from the effects of gastric hemorrhage as do most patients with simple ulcer. Profuse gastric hemorrhage, if it occur, is most common in the late stage of gastric cancer, but I have known a case of cancer of the stomach in which copious hæmatemesis was the first symptom, with the exception of slight dyspepsia.⁴⁶

⁴⁶ In a case of cancer of the lesser curvature observed by Laborie fatal hæmatemesis occurred before there had been any distinct symptoms of gastric cancer (Bouchut, Nouv. Éléments de la Path. gén., ed. 3, p. 288).

Profuse hæmatemesis is more common with soft cancers than with other forms. The source of profuse hemorrhage is in some large vessel eroded by the ulcerative process. The same vessels may be the source of the bleeding as have been enumerated in connection with gastric ulcer. Cancers situated near the pylorus or on the lesser curvature are the most likely to cause severe hemorrhage.

While it is true that coffee-grounds vomiting is most common in cancer, and profuse hæmatemesis is most common in ulcer of the stomach, it is important to remember that either disease may be attended by that form of hemorrhage which is most common in the other.

Dysphagia is one of the most important symptoms of cancer of the cardia. Dysphagia is sometimes one of the first symptoms to attract attention, but it may not appear until late in the disease. It is usually accompanied with painful sensations near the xiphoid cartilage or behind the sternum, or sometimes in the pharynx. The sensation of stoppage of the food is usually felt lower down than in ordinary cases of stenosis of the oesophagus. Stenosis of the cardia can be appreciated by the passage of an oesophageal bougie, but it is important to bear in mind that dysphagia may exist in cases of cancer of the cardia in which the oesophageal bougie does not reveal evidence of stenosis. Dysphagia may be a prominent symptom in cancer occupying parts of the stomach remote from the cardia.⁴⁷ The dysphagia here considered is not likely to be confounded with the difficulty in swallowing which is due to weakness or to aphthous inflammation of the throat and gullet, which often attends the last days of gastric cancer.

⁴⁷ A case in point has been reported by J. B. S. Jackson. The cancer occupied the pyloric region (American Journ. of Med. Sci., April, 1852, p. 364).

From a diagnostic point of view the presence of a tumor is the most important symptom of gastric cancer. In the absence of tumor the diagnosis of gastric cancer can rarely be made with positiveness. A tumor of the stomach can be felt in about 80 per cent. of the cases of cancer of the stomach (Brinton, Lebert). With all of its importance, it is nevertheless possible to exaggerate the diagnostic value of this symptom. It is by no means always easy to determine whether an existing tumor belongs to the stomach or not, and even if there is proved to be a tumor of the stomach, there may be difficulty in deciding whether or not it is a cancer. Many instances might be cited in which errors in these respects have been made by experienced diagnosticians. The value of tumor as a diagnostic symptom is somewhat lessened by the fact that it often does not appear until comparatively late in the disease, so that the diagnosis remains in doubt for a long time. It is to be remembered also that tumor is absent in no less than one-fifth of the cases of gastric cancer.

In order to understand in what situations cancers of the stomach are likely to produce palpable tumors, it is necessary to have in mind certain points concerning the situation and the relations of this organ.

The stomach is placed obliquely in the left hypochondrium and the epigastric regions of the abdomen, approaching the vertical more nearly than the horizontal position. The mesial plane of the body passes through the pyloric portion of the stomach, so that, according to Luschka, five-sixths of the stomach lie to the left of this plane. The most fixed part of the stomach is the cardiac orifice, which lies behind the left seventh costal cartilage, near the sternum, and is overlapped by the left extremity of the liver. The pyloric orifice lies usually in the sagittal plane passing through the right margin of the sternum, and on a level with the inner extremity of the right eighth costal cartilage. The pylorus is less fixed than the cardia. When the stomach is empty the pylorus is to be found in the median line of the body; when the stomach is greatly distended the pylorus may be pushed two and a half to three inches to the right of the median line. The pylorus is overlapped by a part of the liver, usually the lobus quadratus or the umbilical fissure. About two-thirds of the stomach lie in the left hypochondrium covered in by the ribs, and to the left and posteriorly by the spleen. The highest point of the stomach is the top of the fundus, which usually reaches to the left fifth rib. The lowest point of the stomach is in the convexity of the greater curvature to the left of the median line. The lower border of the stomach varies in position more than any other part of the organ. In the median line this border is situated on the average about midway between the base of the xiphoid cartilage and the umbilicus, but within the limits of health it may extend nearly to the umbilicus. The lesser curvature in the greater part of its course extends from the cardia downward to the left of the vertebral column and nearly parallel with it. The lesser curvature then crosses to the right side on a level with the inner extremity of the eighth rib, and in the median line lies about two and a half fingers' breadth above the lower margin of the stomach. The lesser curvature and the adjacent part of the anterior surface of the stomach are covered by the left lobe of the liver.

It follows from this description that only the lower part of the anterior surface of the stomach is in contact with the anterior abdominal walls. This part in contact with the anterior abdominal walls corresponds to a part of the body and of the pyloric region of the stomach, and belongs to the epigastric region. The remainder of the stomach is covered either by the liver or by the ribs, so that in the normal condition it cannot be explored by palpation.

It is now evident that tumors in certain parts of the stomach can be readily detected by palpation, whereas tumors in other parts of the organ can be detected only with difficulty or not at all. Cancer of the cardia cannot be felt by palpation of the abdomen unless the tumor extends down upon the body of the stomach. Cancers of the fundus, the lesser curvature, and the posterior wall of the stomach often escape detection by palpation, but if they are of large size or if the stomach becomes displaced by their growth, they may be felt. Cancerous tumors of the anterior wall or of the greater curvature are rare, but they can be detected even when of small size, unless there are special obstacles to the physical examination of the abdomen. Cancerous tumors of the pylorus can be made out by palpation in the majority of cases notwithstanding the overlapping of this part by the liver. The pyloric tumor may be so large as to project from beneath the border of the liver, or the hand may be pressed beneath this border so that the tumor can be felt, or, what is most frequently the case, the weight of the tumor or the distension of the stomach drags the pylorus downward. The pylorus may, however, be so fixed by adhesions underneath the liver, or the liver may be so enlarged, that tumors of this part cannot be reached by palpation.

The situation in which cancerous tumors of the pylorus can be felt varies considerably. The usual situation is in the lower part of the epigastric region, a little to the right of the median line, but it is almost as common for these tumors to be felt in the umbilical region, and it is not rare for them to appear to the left of the median line.⁴⁸ Brinton states that the tumor is in the umbilical region more frequently in the female sex than in the male, in consequence of the compression exercised by corsets. Occasionally pyloric cancers produce tumors in the right hypochondrium. Exceptionally, pyloric tumors have been felt as low as the iliac crest or even in the hypogastric region.

⁴⁸ According to Jackson and Tyson, pyloric cancers are felt more frequently to the left than to the right of the median line.

Cancers of the stomach do not usually attain a very large size. Sometimes they form visible protuberances. An important criterion of cancerous tumors of the stomach is their gradual increase in size by progressive growth.

The consistence of cancerous tumors of the stomach is nearly always hard, as appreciated by palpation through the abdominal walls. The surface of the tumor is usually nodulated or irregular, but exceptionally it is smooth. The tumor may be movable or not, but in the majority of cases it is rendered immovable by adhesions. Mobility of the tumor, however, does not exclude the presence of adhesions. The tumor sometimes follows the respiratory movements of the diaphragm, especially when it is adherent to this structure or to the liver, but more frequently the tumor is not affected or but slightly affected by the movements of the diaphragm. If the tumor is not fixed by adhesions, it may change its position somewhat according to the varying degrees of distension of the stomach or in consequence of pressure of intestine distended with gas or feces. In consequence of these movements or of an overlying distended colon the tumor may even disappear temporarily. It is possible that the tumor may lessen or disappear in consequence of sloughing of the growth.⁴⁹ It is not rare for a certain amount of pulsation to be communicated to the growth by the subjacent aorta. This pulsation is most common with pyloric tumors.

⁴⁹ Symptoms which have been considered as diagnostic of sloughing of stenosing cancers of the pylorus are diminution in the size of the tumor, alleviation of the vomiting, hemorrhage, replacement of obstinate constipation by diarrhoeal stools which often contain blood, increased pain after eating, and rapid progress of cachexia.

The percussion note over the tumor is usually tympanitic dulness. Sometimes there is very little alteration over the tumor of the normal tympanitic note belonging to the stomach; on the other hand, exceptionally there is absolute flatness over the tumor.

It is often of assistance in determining that a tumor belongs to the pylorus to find dilatation of the stomach. An abnormal fulness of the epigastric and umbilical regions may then be observed, and through the abdominal walls, if thin, may be seen the peristaltic movements of the stomach. Other signs and symptoms aid in the diagnosis of dilatation of the stomach, and will be described in connection with this disease.

It is to be noted that what one takes to be the primary tumor of the stomach is not so very rarely a secondary cancerous mass in the stomach or in adjacent lymph-glands or in the peritoneum. Such nodules may also increase the apparent size of the original tumor. As has been pointed out by Rosenbach,⁵⁰ spasm of the muscular coat near a cancer or an ulcer of the stomach may produce a false tumor or enlarge a real tumor.

⁵⁰ Deutsche med. Wochenschr., 1882, p. 22.

The cancer, instead of appearing as a circumscribed tumor, may infiltrate diffusely the gastric walls, and so escape detection. When the greater part or the whole of the stomach is the seat of this diffuse cancerous infiltration, a sense of abnormal resistance may be appreciated by palpation in the epigastric region. In these cases the stomach is often much shrunken in size. The outlines of the thickened organ can sometimes be made out, but the physical signs do not suffice for the diagnosis of cancer.

With cancer of the cardia there is usually more or less atrophy of the stomach, which is manifested by sinking in of the epigastric region.

Sometimes the tumor eludes discovery on account of special obstacles to the physical examination of the abdomen, such as a thick layer of fat in the abdominal walls or a large quantity of ascitic fluid. Every aid in the physical examination of the abdomen should be resorted to. The patient should be examined while lying on his back with the utmost possible relaxation of the abdominal walls. If necessary, he should also be examined while standing or in the knee-elbow position. Sometimes a deep inspiration will force down a previously concealed tumor. The emptying of a dilated stomach by means of a stomach-tube will sometimes bring to prominence a gastric tumor.

The inflation of the stomach by the development in it of carbonic acid gas may render valuable assistance in the diagnosis of tumors of this organ and of surrounding parts. This method has been recommended by W. Ph. H. Wagner among others, and especially by Rosenbach.⁵¹ From 20 to 30 grains of bicarbonate of soda and from 15 to 20 grains of tartaric acid may be introduced into the stomach. The soda, dissolved in lukewarm water, may be given first and followed by the acid in solution, or, better, the mixed powders may be swallowed in the dry state and followed by a tumblerful of water. Some persons require a larger quantity of the powder in order to inflate the stomach. Occasionally the introduction of the effervescing powder fails to produce any appreciable distension of the stomach. This negative result may be due to the escape of the gas into the intestine in consequence of incontinence of the pylorus—a condition which Ebstein⁵² has observed and described especially in connection with pyloric cancer. When this pyloric insufficiency exists the resulting tympanitic distension of the intestine is a hindrance to palpation of tumors of the stomach. Failure to secure distension of the stomach is not always due to this cause. It may be necessary to make repeated trials of the effervescing mixture. It is well to have a stomach-tube at hand to evacuate the gas if this should cause much distress.

⁵¹ W. Ph. H. Wagner, Ueber die Percussion des Magens nach Auftreibung mit Kohlensäure, Marburg, 1869; O. Rosenbach, Deutsche med. Wochenschr., 1882, p. 22.

⁵² W. Ebstein, Volkmann's Samml. klin. Vorträge, No. 155.

In some respects simpler and more easily controlled is the method of distending the stomach by injecting air into it through a stomach-tube, as recommended by Runeberg.⁵³ For this purpose the balloon of a Richardson's spray apparatus may be attached to a soft-rubber stomach-tube. In this way the desired quantity of air can be introduced and at any time allowed to escape through the tube.

⁵³ J. W. Runeberg, Deutsches Arch. f. kl. Med., Bd. 34, p. 460, 1884.

When the stomach has been inflated the contours of tumors of the pylorus often become surprisingly distinct in consequence of the changes in the position and the shape of the stomach. When the tumor is fixed by adhesions, it may be possible to follow the contours of the stomach into those of the tumor. False tumors produced by spasm of the muscular walls of the stomach may be made to disappear by this distension of the organ. This procedure enables one to distinguish between tumors behind and those in front of the stomach, as the former become indistinct or disappear when the stomach is inflated. By bringing out the contours of the stomach the relations of the tumor to surrounding organs may be rendered for the first time clear. Assistance in diagnosis may also be afforded by distension of the colon with water or with gas or with air, per rectum, in order to determine the course of the colon and its relations to abdominal tumors (Mader, Ziemssen, Runeberg). A manifest contraindication to distension of the stomach or of the colon with gas exists if there is a suspicion that the coats of these parts are so thinned by ulceration that they might rupture from the distending force of the gas. There have been no cases recorded where such an accident has happened.

Only in exceptional cases are the bowels regular throughout the course of gastric cancer. Constipation is the rule, and not infrequently there is obstinate constipation. This is to be expected when the patient eats little and vomits a great deal, or when there is stenosis of the pylorus. In cancer, as in many other diseases of the stomach, the peristaltic movements of the intestine are inclined to be sluggish.

Occasional diarrhoea is also common in gastric cancer, being present, according to Tripier,⁵⁴ at some period or other in over one-half the cases. Constipation often gives place to diarrhoea during the last months or during the last days of life. In other periods of the disease diarrhoea not infrequently alternates with constipation. In rare cases diarrhoea is an early symptom, and it may be present exceptionally throughout the greater part of the disease. The irritation of undigested food sometimes explains the diarrhoea. When diarrhoea is persistent there probably exists catarrhal inflammation of the large intestine, or in some instances there may be diphtheritic and ulcerative inflammation of the colon, causing dysenteric symptoms during the last stages of cancer of the stomach.

⁵⁴ "Étude clinique sur la Diarrhée dans le Cancer de l'Estomac," Lyon Méd., 1881, Nos. 40, 41, 42.

Black stools containing altered blood occur for some days after profuse gastric hemorrhage. It is important to examine the stools for blood, as bleeding may occur from cancer of the stomach without any vomiting of blood.

There is no change in the urine characteristic of gastric cancer. Deposits of urates are not uncommon. If there be profuse vomiting or frequent washing out of the stomach, the urine often becomes alkaline from fixed alkali.⁵⁵ The amount of urea is diminished in consequence of the slight activity of the nutritive processes of the body. Rommelaere attaches unmerited diagnostic importance to this diminution of urea. A similar diminution of urea occurs in other like states of depressed nutrition.

⁵⁵ According to Quincke, when the acid in the stomach is not hydrochloric acid, but organic acid resulting from fermentation, then vomiting and washing out the stomach do not reduce the acidity of the urine (Zeitschrift f. klin. Med., Bd. 7, Suppl. Heft, p. 25).

Albuminuria does not belong to the history of gastric cancer, although a small quantity of albumen may be present in the urine as in other anæmic and cachectic conditions. A larger quantity of albumen may be due to parenchymatous and fatty degeneration of the kidney or to chronic diffuse nephritis, which are infrequent but recognized complications of gastric cancer. There is often an excess of indican in the urine, to which, however, no diagnostic significance can be attached.

The urine in gastric cancer sometimes contains an excess of aceton, or at least of some substance which yields aceton upon the application of various tests. This so-called acetonuria is present without any symptoms referable to it, so far as we know. Allied to this so-called acetonuria is that condition of the urine in which it is colored burgundy-red upon the addition of ferric chloride in solution (Gerhardt's reaction). It is not positively known what substance imparts this last reaction to the urine. V. Jaksch, who has studied the subject industriously, believes that the red coloring substance is diacetic acid, and he proposes to call the condition diaceturia. Fresh urine, which shows in a marked degree Gerhardt's reaction, often has a peculiar aromatic, fruity odor, as has also the expired air. Gerhardt's reaction has been studied mostly in diabetic urine, but it occurs sometimes in cases of gastric cancer and in a variety of diseases. This so-called diaceturia may be associated with a peculiar form of coma, but it is oftener observed without any symptoms referable to it⁵⁶ (see page [555]).

⁵⁶ The various tests for aceton in the urine are not altogether satisfactory. They are to be found in an article by Von Jaksch in the Zeitschrift f. klin. Med., Bd. viii. p. 115. For English readers a good abstract of an article by Penzoldt on these tests and on acetonæmia in general is to be found in The Medical News of Philadelphia, Aug. 9, 1884, p. 162, but this does not consider the corrections and additions to be found in V. Jaksch's article cited above. Acetonuria has been observed especially in diabetes mellitus, fevers, carcinoma, and dyspepsia.

The substance which produces Gerhardt's reaction is to be distinguished from other substances which may be present in the urine and give a red color with ferric chloride—first, by the fact that boiling the urine in a test-tube for five or six minutes destroys the first-named substance, or causes the red color to disappear in case this has been produced by ferric chloride; and, secondly, by the fact that ether extracts the substance from acidified urine, and that the red color produced in the ether extract by ferric chloride (it may be necessary to first neutralize the acid) fades away in the course of a few days (V. Jaksch, Zeitschrift f. Heilkunde, Bd. iii. p. 17). Urines which respond to Gerhardt's reaction in a marked degree yield aceton on distillation, but aceton or an aceton-yielding substance may be present in considerable quantity without response of the urine to Gerhardt's test.

Disorders of nutrition embrace an important group of symptoms, such as loss of flesh and strength, impoverished blood, and cachectic color of the skin. Emaciation and debility are sometimes the first symptoms of gastric cancer to attract attention, and often the first symptoms to arouse anxiety. More frequently these symptoms of disordered nutrition first appear after dyspeptic ailments or pain have existed for several weeks or months. It may aid in the diagnosis of gastric cancer to weigh the patient from time to time, as carcinoma is generally attended by progressive loss of weight.

The patient frequently becomes morose and depressed in spirits. His strength fails, sometimes disproportionately to the loss of flesh. There is no disease in which emaciation becomes more extreme than in cases of gastric cancer.

In many cases profound anæmia develops, and sometimes in such a degree that this symptom cannot be regarded always as simply co-ordinate with the other disorders of nutrition, but is to be regarded rather as an evidence of some special disturbance of the blood-forming organs. The blood may present the same changes as are observed in pernicious anæmia, such as extreme reduction in the number of red blood-corpuscles (to one million or even half that number in a cubic millimeter) and manifold deformed shapes of the corpuscles (poikilocytosis). In extreme cases the proportion of hæmoglobin in the blood may be reduced to 50 or 60 per cent. of the normal quantity.⁵⁷ There is occasionally a moderate increase in the number of white blood-corpuscles. In one case of gastric cancer I observed a leucocytosis in which there was one white to twenty red blood-corpuscles without enlargement of the spleen.⁵⁸

⁵⁷ The granular disintegrating corpuscles (Zerfallskörperchen of Riess) may also be found in the blood in considerable number. Leichtenstern has observed that toward the end of life the relative proportion of hæmoglobin in the blood may be increased, sometimes rapidly, and may even exceed the normal limit. This is due to concentration of the blood in consequence of the loss of water. In such cases the tissues appear abnormally dry and the blood thick and tarry at the autopsy (Ziemssen's Handb. d. spec. Path. u. Therap., Bd. viii. 1te Hälfte, p. 344).

It seems to me proper to distinguish two kinds of anæmia in gastric cancer—a simple anæmia, which is present in the majority of cases, and can be explained by the development of the cancer and the disturbance of the gastric functions; and a pernicious anæmia, which is present only in exceptional cases, and has the typical symptoms of progressive pernicious anæmia.

⁵⁸ In a case of large medullary cancer of the stomach reported by H. Mayer there was one white to fifty red blood-corpuscles. The spleen was not enlarged (Bayer, Aerztl. Intelligenzblatt, 1870, No. 21). A similar case is related by Lebert, in which, however, the spleen was enlarged (op. cit., p. 481).

To the pallor of anæmia is added often a faded yellowish tint of the skin which is considered characteristic of the cancerous cachexia. At the same time, the skin is frequently dry and harsh, and may present brownish spots (chloasma cachecticorum). The pallid lips, the pale greenish-yellow color of the face, the furrowed lines, and the pinched and despondent expression make up a characteristic physiognomy, which, however, is neither peculiar to gastric cancer nor present in all cases of the disease. There is no cachectic appearance which is pathognomonic of cancer; and in this connection it is well to note that there are cases of gastric ulcer, and particularly of non-cancerous stenosis of the pylorus, in which all of the symptoms described as peculiar to the cancerous cachexia are met with. Nevertheless, the weight of these symptoms in the diagnosis of gastric cancer should not be underestimated. There is no disease in which profound cachectic symptoms so frequently and so rapidly develop as in gastric cancer.

The profound nutritive disturbances of gastric cancer are referable partly to the cancer as such, and partly to the impairment of the functions of the stomach. It is impossible to separate the effects of these two sets of causes, and distinguish, as some have done, a cachexia of cancer and a cachexia of inanition. It is the combination of these causes which renders the cachexia of cancer of the stomach so common, so rapid in its development, and so profound as compared with that of cancer in other situations. The relation of cancer in general to cachexia need not here be discussed, save to say that there is the best ground for believing that the cachexia is directly dependent upon the growth and metamorphoses of the primary cancer and its metastases, and that there is not reason to assume any dyscrasia antedating the cancerous formation.

While the failure of the general health and the gastric symptoms in general develop side by side, it is especially significant of gastric cancer when the symptoms of impaired nutrition are more pronounced than can be explained by the local gastric disturbance. When, however, as sometimes happens, gastric symptoms are absent or no more than can be explained by anæmia and marasmus, then in the absence of tumor a positive diagnosis is impossible. Such cases of gastric cancer during life often pass for essential or pernicious anæmia. Otherwise, unexplained symptoms of anæmia with emaciation and debility, particularly in elderly people, should lead to a careful search for gastric cancer.

Finally, it is necessary to add that there are exceptional cases of gastric cancer in which there is no emaciation, and in which the general health appears to be astonishingly well preserved. In most of these cases death occurs either from some accident of the disease or from some complication.

Slight or moderate oedema about the ankles is a common symptom during the cachectic stage of gastric cancer. This oedema is due to hydræmia. This cachectic dropsy in rare cases becomes excessive and leads to anasarca, with serous effusion in the peritoneal, pleural, and pericardial sacs. Such cases are liable to be mistaken for heart disease, particularly as a hæmic murmur often coexists, or for Bright's disease. Ascites may be the result not only of hydræmia, but also of cancerous peritonitis or of pressure on the portal vein by cancer. Many cases of gastric cancer associated with ascites have been falsely diagnosed as cirrhosis of the liver, and sometimes the distinction is extremely difficult or impossible.

During the greater part of the disease the pulse is usually normal; toward the end it is not infrequently rapid, small, and compressible. In consequence of weakness and anæmia any exertion may suffice to increase the frequency of the pulse, and may induce palpitation of the heart and syncope.

As might be expected as the result of anæmia, hæmic murmurs in the heart and blood-vessels are not rare in gastric cancer.

Epigastric pulsation is often very prominent in cases of gastric cancer, as it may be in various other conditions. This pulsation is sometimes of a paroxysmal nature.

Venous thrombosis is not a rare complication in the last stages of gastric cancer. It is most common in the femoral and saphenous veins, and is rapidly followed by painful oedematous swelling of the affected extremity. Thrombosis of the subclavian and axillary veins is much less frequent. When it occurs there are the same symptoms of phlegmasia alba dolens in the upper extremity as have been mentioned for the lower. Lebert has recorded a case of thrombosis of the right external jugular vein.⁵⁹ The thrombosis is the result of marasmus, and therefore may occur in other gastric diseases besides gastric cancer, so that this symptom has not all the diagnostic importance for gastric cancer claimed by Trousseau. Being an evidence of great weakness of the circulation, marantic thrombosis in cancer of the stomach is of grave prognostic import.

⁵⁹ Op. cit., p. 394.

The temperature is often normal throughout the course of gastric cancer. Febrile attacks, however, are not uncommon in this disease. Elevation of temperature may occur without any complication to explain it. During the second half of the disease there may be either irregular febrile attacks or a more continuous fever, which is, however, usually of a light grade, the temperature not generally exceeding 102°. Slight chills may be experienced. Lebert describes a light and a hectic carcinomatous fever.

There may be subnormal temperature with collapse during the last days of life, and in general anæmia and inactivity of nutritive processes tend to produce a low temperature.

Dyspnoea on slight exertion may be present in gastric cancer as a result of anæmia or of fatty heart. In a few cases of gastric cancer have been observed symptoms pointing to a reflex vagus neurosis, such as paroxysms of dyspnoea, oppression in the chest, and palpitation of the heart, but these symptoms are less common in gastric cancer than in some other diseases of the stomach. Watson⁶⁰ relates a case of gastric cancer in which increasing dyspnoea and palpitation were such prominent symptoms that he was led to diagnose fatty heart with portal congestion as the sole trouble. At the autopsy the heart and lungs were found healthy, but there was extensive cancer of the greater curvature of the stomach. He subsequently ascertained that there had been symptoms pointing to gastric disease.

⁶⁰ Sir T. Watson, Lectures on the Principles and Practice of Physic, vol. ii. p. 471, Philada., 1872.

The various complications of gastric cancer which affect the respiratory organs will be considered later.

Depression of spirits, lack of energy, headache, neuralgia, sleeplessness, and vertigo are functional nervous disturbances which are often the result of disordered digestion from whatever cause, and are therefore not uncommon in gastric cancer. The theory that these symptoms are due to the absorption of noxious substances produced in the stomach and intestine by abnormal digestive processes is plausible,⁶¹ and more intelligible than reference to some undefined sympathy between the digestive organs and the nervous system.

⁶¹ This theory is elaborated by Senator ("Ueber Selbstinfection durch abnorme Zersetzungsvorgänge, etc.," Zeitschrift f. klin. Med., Bd. 7, p. 235).

The intelligence is generally not impaired in the course of gastric cancer.

Considerable interest belongs to coma as a symptom of cancer of the stomach, and more particularly to the occurrence of coma with the peculiar characters which have been described by Kussmaul as distinguishing diabetic coma.⁶² The most distinctive feature in Kussmaul's group of symptoms is the accompaniment of the coma by a peculiar dyspnoea in which, without evidence of disease of the lungs or air-passages, the respirations are strong and deep and often attended with a groaning sound in expiration. The breathing is either normal in frequency or oftener moderately increased. The pulse is usually small and frequent. The temperature is not much elevated, and sometimes is much below the normal. Sometimes the coma is preceded by a period of excitement, with restlessness, and perhaps with screaming. Gerhardt's reaction in the urine may or may not be present. When it is present in a marked degree there is often an aromatic, chloroform-like odor to the breath and to the fresh urine. The patient may come out of the coma, but in the vast majority of cases the coma terminates fatally.

⁶² Deutsches Arch. f. klin. Med., Bd. 14, p. 1.

It is now known that this dyspnoeic coma is not confined to diabetes mellitus, but that it occurs also in gastric cancer and in various other diseases.⁶³ Its occurrence in gastric cancer is rare. In this disease it does not usually appear until anæmia is far advanced, but it may occur in cases of cancer in which the patient's general health and nutrition are still fairly good. I recently made the post-mortem examination of an elderly man, fairly well nourished, who was found in the streets comatose and brought in this condition to Bellevue Hospital, where he died in about twelve hours. While in the hospital his breathing was increased in frequency, forcible, and deep. His temperature was normal. The urine contained a small quantity of albumen, but no sugar. No previous history could be obtained. Uræmic coma was suspected. At the autopsy was found a large, soft, ulcerated cancer of the lesser curvature and posterior wall of the stomach near the pylorus. The kidneys, brain, heart, and other organs were essentially healthy.

⁶³ Von Jaksch was the first to describe this form of coma in cancer of the stomach (Wien. med. Wochenschr., 1883, pp. 473, 512). He adopted the term coma carcinomatosum, and more recently coma diaceticum. L. Riess has reported seventeen cases of this coma occurring in a variety of diseases, such as pernicious anæmia, gastric cancer, gastric ulcer, tuberculosis, which all had in common profound anæmia. He proposes the term dyspnoeic coma (Zeitschrift f. klin. Med., Bd. 7, Suppl. Heft, p. 34, 1884). Senator has described two cases of gastric cancer with this coma. He uses the terms dyscrasic coma and Kussmaul's group of symptoms (ibid., Bd. 7, p. 235). In the cases described by Litten under the name coma dyspepticum, dyspnoea was absent, but Gerhardt's reaction in the urine was present. In Litten's cases structural disease of the stomach was not supposed to be present. The patients recovered from the coma (ibid., Suppl. Heft, p. 81).

We possess no satisfactory explanation of this form of coma. In diabetes it is considered to be due to the presence in the blood of some intoxicating agent. For a time this agent was thought to be aceton; it is now believed by Von Jaksch to be diacetic acid. Much stress has been laid upon the aromatic, fruity odor of the breath and of the fresh urine, and upon the presence of some substance in the urine which imparts to it a burgundy-red color upon the addition of liquor ferri chloridi (Gerhardt's reaction. See changes in the urine, page [551]). Although the whole aceton question is at present in a very confused state, there is no proof that aceton or its allies possesses the toxic properties assumed by this theory;⁶⁴ and it is certain that dyspnoeic coma may occur in diabetes and in other diseases without the presence of Gerhardt's reaction in the urine. It is also true that this reaction often occurs without any clinical symptoms referable to it. Riess and Senator believe that in non-diabetic cases anæmia is the most important factor in the production of this coma.⁶⁵

⁶⁴ Frerichs, Zeitschrift f. klin. Med., Bd. 6, p. 3.

⁶⁵ Riess refers the coma to the anæmia as such, whereas Senator thinks that, in consequence of the depraved nutrition of the body resulting from the anæmia, some toxic substance is developed which enters the circulation.

Coma, probably belonging to this same variety, may occur in gastric cancer without the peculiar dyspnoea which has been described. There is reason to believe that this dyspnoea is not a necessary symptom of the so-called diabetic coma.

Chronic Bright's disease terminating with uræmic coma is an occasional but not frequent complication of gastric cancer.

Coma and other cerebral symptoms may be produced by secondary cancerous tumors in the brain.

Stupor deepening into coma may develop during the often-prolonged death-agony of gastric cancer.

The distribution, origin, and frequency of cancerous growths secondary to gastric cancer are most conveniently considered under Pathological Anatomy. Symptoms referable to certain localizations of these secondary cancerous deposits, however, are so common, and so interwoven with the clinical history of cancer of the stomach, that it is desirable to consider some of these symptoms in the present connection.

Cancer of the liver is the most important of these secondary cancerous growths. It is estimated to be present in nearly one-third of the cases of gastric cancer, but by no means in all these cases does it produce symptoms. As a rule, the earlier hepatic cancer forms in the course of gastric cancer the more likely is it to be attended by symptoms. The most important symptoms of secondary cancer of the liver are enlargement of the liver, peritoneal exudation, and persistent icterus. When nodular growths can be felt in the free border or surface of the liver, the diagnosis is generally easily established. Sometimes the liver remains of normal size or is even contracted, and then the diagnosis is difficult or impossible. Ascites or exudative peritonitis is present in about one-half of the cases of cancer of the liver. Jaundice is less frequently present. It is only persistent jaundice which aids in the diagnosis of hepatic cancer.

The various combinations of gastric cancer with secondary hepatic cancer may be clinically grouped as follows:

1. Symptoms of gastric cancer with latent hepatic cancer.

2. Symptoms of gastric cancer followed by symptoms of hepatic cancer.

3. Symptoms both of gastric cancer and of hepatic cancer present when the case comes under observation.

4. Symptoms of hepatic cancer with latent gastric cancer.

5. Symptoms of hepatic cancer followed by symptoms of gastric cancer.

6. Both hepatic and gastric cancer latent. Symptoms of anæmia and marasmus, or of chronic exudative peritonitis, or of chronic pleurisy.

From this grouping it is evident that the existence of secondary hepatic cancer may aid in the diagnosis of cancer of the stomach, or may mislead, or may be without influence. The greatest assistance in diagnosis is rendered when the physical signs and the symptoms of hepatic cancer develop some time after the appearance of gastric symptoms which may previously have been equivocal. Much more difficult to diagnosticate are the cases of hepatic cancer accompanied or followed by gastric symptoms, inasmuch as cancer of the liver, whether primary or secondary, may be attended with marked disturbance of the gastric functions, including hæmatemesis. In these cases, unless a tumor of the stomach can be discovered, a positive diagnosis of gastric cancer is impossible. In view of the infrequency of primary cancer of the liver, however, there will be in many of these cases a strong probability in favor of primary cancer of the stomach. When it is remembered that over one-third of the cancers of the liver are secondary to cancer of the stomach, it is evident that in cases which appear to be primary hepatic cancer very careful attention should be given to the exploration of the stomach. But even then diagnostic errors will often be unavoidable.

Cancer of the peritoneum secondary to cancer of the stomach may produce no symptoms, and so pass unrecognized. The diagnosis of peritoneal cancer is readily made when, after the recognition of gastric cancer, secondary cancerous nodules in the peritoneum can be felt through the abdominal walls or through the vagina. There are cases of gastric cancer in which the symptoms are all referable to secondary cancer of the peritoneum. Cancer of the peritoneum is usually attended with fluid exudation in the peritoneal cavity. The chemical and the microscopical examination of this fluid withdrawn by paracentesis may aid in the diagnosis of cancerous peritonitis. Whereas in dropsical accumulations in the peritoneal cavity the quantity of albumen in the fluid is usually less than 2½ per cent., in cancerous peritonitis there is usually from 3 to 4 per cent. of albumen, the percentage rarely falling as low as 2½ per cent., but sometimes being as high as from 5 to 6 per cent. The percentage of albumen in ordinary peritonitis is usually over 4.⁶⁶ Clumps of cancer-cells are sometimes to be found by microscopical examination of the fluid. These cells are large, epithelioid in shape, and often contain vacuoles and fatty granules. It is only when these cells are arranged in clumps or as so-called budding cells, and when they are present in abundance, that they are diagnostic. They are to be sought especially in fibrinous coagula. They are present only when the cancerous alveoli actually communicate with the peritoneal cavity.⁶⁷ The development of cancerous nodules in the margins of an opening made in the abdominal walls by a trocar is also evidence of cancerous disease of the peritoneum. The same thickening and retraction of the mesentery and omentum may occur in cancerous as in tuberculous peritonitis. In both the exudation is often hemorrhagic.

⁶⁶ The conditions under which the estimation of the quantity of albumen in the peritoneal exudation may prove of diagnostic aid are fully considered by Runeberg (Deutsches Arch. f. klin. Med., Bd. 34, p. 1). Here also are given methods for making this analysis for clinical purposes.

⁶⁷ The literature on this subject is as follows: Foulis, Brit. Med. Journ., July 20, Nov. 2, 1878; Thornton, ibid., Sept. 7, 1878; Quincke, Deutsches Arch. f. klin. Med., Bd. 30, p. 580; Ehrlich, Charité Annalen, vii. p. 226; Brieger, ibid., viii.

Importance has been attached to enlargement of the supraclavicular lymphatic glands in the diagnosis of cancer of the stomach, but there are so many causes of enlargement of these glands that not much significance can be attached to this symptom, which, moreover, is absent in most cases. Still, under certain circumstances this glandular enlargement may aid in the diagnosis. The same remarks apply to enlargement of the inguinal glands, which is a common occurrence in case cancer involves the peritoneum. One must not mistake abnormal prominence of the lymphatic glands in consequence of emaciation for actual enlargement.

Gastric cancer much less frequently than gastric ulcer causes perforation of the stomach. Of 507 cases of gastric cancer collected by Brinton, perforation into the general peritoneal cavity occurred in 17 (3¹/3 per cent.).⁶⁸ In two cases of gastric cancer reported by Ellis perforative peritonitis was preceded by symptoms supposed to be only those of ordinary dyspepsia, hemorrhage and vomiting being absent.⁶⁹ Various fistulous communications like those described under gastric ulcer may be the result of perforation of gastric cancer, but with the exception of gastro-colic fistula they are much more frequently produced by ulcer than by cancer. In 160 cases of gastric cancer collected by Dittrich, gastro-colic fistula existed in 6 (3¾ per cent.).⁷⁰ In 507 cases collected by Brinton this fistula existed in 11 (2.17 per cent.). In Lange's 210 cases gastro-colic fistula existed in 8 (3.8 per cent.). Of 33 cases of gastro-colic fistula collected by Murchison, 21 were caused by cancerous ulceration.⁷¹ The symptoms characteristic of fistulous communication between the stomach and the colon are the vomiting of fecal matter and the passage of undigested food by the stools. These symptoms are not present in all cases, so that a diagnosis is not always possible. Fecal vomiting is influenced by the size of the opening between the stomach and the colon. With great obstruction at the pylorus, fecal vomiting, as might be expected, is absent or infrequent, while the passage of undigested food by the bowels is common. Under these circumstances vomiting is sometimes relieved after the establishment of the fistula. Aid may be afforded in the diagnosis of gastro-colic fistula by the introduction into the rectum or into the stomach of colored or other easily recognizable substances, and determining their presence in the vomit or in the stools in consequence of their escape by the unnatural outlet. V. Ziemssen has determined in a case of gastro-colic fistula due to cancer the escape into the stomach of carbonic acid gas artificially generated in the rectum, with failure to obtain distension of the colon.⁷² A number of instances of gastro-cutaneous fistula due to gastric cancer have been recorded, but this form of fistula is much less common than gastro-colic fistula, and much less frequently the result of cancer than of ulcer of the stomach. Subcutaneous emphysema may precede the formation of the fistula. Other gastric fistulous communications resulting from cancer, such as with the pleura, the lungs, the small intestine, are too infrequent to merit consideration under the symptomatology of the disease.

⁶⁸ Loc. cit. Lange (op. cit.) records in 210 cases of gastric cancer 12 perforations into the peritoneal cavity (5.7 per cent.).

⁶⁹ Extr. fr. the Rec. of the Boston Soc. for Med. Improvement, vol. iii. p. 116, and vol. iv. p. 109.

⁷⁰ Prager Vierteljahrsch., vol. xvii.

⁷¹ Edinb. Med. Journ., vol. iii. p. 4, 1857.

⁷² Deutsches Arch. f. kl. Med., Bd. 33, p. 237. He recommends for extreme distension of the colon in an adult the introduction, by means of a tube passed up the rectum, of a solution of about 5 drachms of sodii bicarb. and 4½ drachms of tartaric acid—injected not all at once, but in three or four doses at intervals of a few minutes, the tube being cleaned in the intervals by the injection of three ounces of water, so as to avoid generation of gas in the tube. The generation of a smaller quantity of gas would suffice for the purpose here in view.

As a rule, patients with gastric cancer die from gradual exhaustion. In a condition of extreme emaciation and feebleness the patient sinks into a state of collapse, accompanied often with stupor, sometimes with mild delirium. The death-agony is prolonged frequently from twelve to twenty-four hours, and sometimes even longer. On the other hand, death may occur somewhat suddenly in the last stages of gastric cancer, and without satisfactory explanation.

Death from copious gastric hemorrhage does not occur probably in more than 1 per cent. of the cases of cancer of the stomach.

In the rare cases of death from perforation of the stomach the patient is sometimes so exhausted at the time of perforation that the occurrence of this accident remains unrecognized in the absence of any complaint of characteristic symptoms.

The coma which sometimes leads to the fatal termination of gastric cancer has already been sufficiently considered.

Finally, death may be the result of certain complications more or less dependent upon the cancer. Of these the most important are suppurative peritonitis and pulmonary complications, particularly oedema, terminal pneumonia, and embolism of the pulmonary artery.

DURATION.—It is evidently impossible to determine the exact duration of a cancer of the stomach. Doubtless in all cases there is a period of growth of the tumor before it produces symptoms, and the duration of this latent period can never be determined. When symptoms appear they are often at first so mild as to be readily overlooked, and so ambiguous that even if recognized they are not clearly referable to the cancer. Gastric symptoms may have preceded, perhaps for years, the development of the cancer, so as to lead to the assumption of a longer duration of the cancer than is really the case. Estimates, therefore, of the duration of gastric cancer can be only of limited value.

From 198 cases Brinton⁷³ estimates the average duration of gastric cancer as about twelve and a half months, the maximum duration as about thirty-six months, and the minimum as one month. From 36 cases Katzenellenbogen⁷⁴ estimates the average duration as eighteen months, the maximum as five years and five months, the minimum as one month. From 112 cases Lebert⁷⁵ makes the average duration fifteen months and the maximum four years. In 4 per cent. of the cases Lebert found the duration less than three months, in 62 per cent. between six and eighteen months, in 42 per cent. between six and twelve months, in 17 per cent. between three and six months, and in the same number of cases between eighteen months and four years.

⁷³ Loc. cit.

⁷⁴ Op. cit.

⁷⁵ Op. cit.

Estimates of several years' duration (such as nine years in the case of Napoleon) are to be received with scepticism. In these cases symptoms of gastralgia or of dyspepsia or of gastric ulcer have preceded the development of the cancer. It has already been mentioned that cancer may develop in a simple ulcer of the stomach.

Mathieu,⁷⁶ from an analysis of 27 cases of gastric cancer occurring under thirty-four years, found the average duration in early life to be only three months. In only 2 out of 19 cases did the duration exceed one year. Although this analysis is based upon too small a number of cases, there seems to be no doubt that gastric cancer pursues a more rapid course in early life than it does in old people.

⁷⁶ Du Cancer précoce de l'Estomac, Paris, 1884, p. 40.

COMPLICATIONS.—Some of the complications of gastric cancer have been mentioned under Symptomatology. Jaundice may appear in the course of gastric cancer from a variety of causes, such as catarrhal gastro-duodenitis, impaction of gall-stones in the common bile-duct, and pressure on the bile-duct by cancerous growths in the pancreas, in the portal lymphatic glands, or in the liver itself. Pylethrombosis, which is likely to be suppurative, is a rare complication. In a case of cancer of the anterior wall and greater curvature of the stomach reported by Wickham Legg⁷⁷ the symptoms seem to have been mostly referable to a complicating suppurative pylethrombosis. Simple and cancerous pylethromboses also occur. Other forms of peritonitis than the cancerous may complicate gastric cancer, such as suppurative, sero-fibrinous, and chronic proliferative peritonitis. Catarrhal enteritis, and particularly diphtheritic colitis, are not infrequent complications, especially in the later stages of the disease. Chronic diffuse nephritis, both in the form of the large and of the small kidney, is a rare complication of cancer of the stomach. Hydrothorax, sero-fibrinous pleurisy, and emphysema may develop either with or without cancerous invasion of the pleura. Pericarditis is much less common; it is most likely to occur with cancer of the cardia. Pyo-pneumothorax, abscess, and gangrene of the lung may result from perforation of the pleura or of the lung by gastric cancer. Oedema of the lungs, splenization, and pneumonia, involving usually the lower lobes, are common in the last days of gastric cancer. Emboli derived from venous thrombi are sometimes carried into the pulmonary artery or its branches. Although much has been written as to the exclusion of tuberculosis by cancer, no such law exists. Both old and fresh tubercles have been repeatedly observed in cases of gastric cancer. Reference has already been made to the frequent development of aphthæ in the mouth, pharynx, and oesophagus in the final stage of gastric cancer. Fatty degeneration of the heart may develop in gastric cancer as in other anæmic states. Phlegmasia alba dolens has already been mentioned. It is not probable that insanity is to be regarded as more than an accidental complication of gastric cancer; still, it has been noticed in several cases—for instance, of Dittrich's 160 cases, 5 patients were insane, 2 with violent mania. Amyloid degeneration has been present in some cases. Purpura hæmorrhagica has been present in a few instances in the later stages (cachectic purpura). Chronic catarrhal gastritis and dilatation of the stomach are less complications than a part of the disease. The relation of cancer to simple ulcer of the stomach has already been considered. The various secondary cancerous deposits are most conveniently considered under the Morbid Anatomy. It is to be remarked that many of the complications of gastric cancer—as, for instance, pneumonia and peritonitis—may have a very obscure clinical history, as they often occur when the patient is greatly prostrated.

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.