Intra-abdominal gastric fistulas result usually from perforation of gallstones or the escape of foreign bodies. Produced in this way they empty usually, though not always, into some neighboring portion of the intestinal canal.
TUMORS OF THE STOMACH.
Benign tumors are occasionally found in the stomach, and are most often of the adenomatous type. Papillomatous growths into the stomach have also been observed. Beneath the peritoneum, or in the submucous tissue near the pylorus, fatty tumors have also been seen. Myomas of mixed type have been described, and cysts have been met in the walls of the stomach. These have rarely attained a size larger than a hen’s egg. All of these non-malignant tumors are of pathological rather than surgical interest. Every one of them, however, will admit of successful surgical remedy when once recognized, operation consisting of excision, with suitable suturing.
CANCER OF THE STOMACH.
Carcinoma is perhaps as frequently seen in the stomach as in any part of the body, the breast possibly excepted. In about three-fifths of the cases it involves the pyloric region, in one-tenth of them the cardiac end, the balance occurring in the intermediate part. It is usually of the round-cell or scirrhous variety, and is generally supposed to be a disease of adult or advanced life. While this is generally true there have been exceptions. It is occasionally met in the young, and has been reported even in early childhood. True sarcoma of the stomach is exceedingly rare. It spreads especially in the submucous tissue and evinces a tendency to involve especially the lesser curvature.
The duodenum evinces an extraordinary immunity from malignant disease, even that involving the pyloric region. When the pyloric end is involved the lesion is frequently complicated by adhesions, which are present in considerably more than half of the cases. The lymph nodes of the adjoining mesentery are nearly always involved, practically always in cases which come to the surgeon for operation. As the disease advances it spreads in several directions, and adjoining viscera may be involved, or even those at considerable distance, while metastases to other parts of the body are common. It is somewhat more common in males than females. In proportion as the pyloric ring itself becomes infiltrated and involved pyloric obstruction is an early feature, with the inevitable gastric dilatation and greater frequency of vomiting. Pathologists and surgeons are learning that the most frequent cause of gastric cancer is gastric ulcer, and recent investigations are to the effect that in at least 80 per cent. of cases there has been ulceration which has been followed by this malignant change. This affords additional reason, then, for regarding gastric ulcer as a surgical disease and operating upon it early and before such transition has occurred.
Symptoms.
—As repeatedly emphasized throughout this work cancer is a disease without a pathognomonic symptomatology. For this reason it is rarely diagnosticated in its early stage, the symptoms which it produces being those of indigestion or dyspepsia.
The most distinctive features met with in gastric cancer are pain, vomiting, more or less dilatation, and presence of tumor. Pain is an early and constant symptom, the complaint at first being of heaviness and oppression, made worse after the ingestion of food, and later referred to as actual pain, which may be limited or may radiate to either side or to the back. Much will depend upon whether the cancer develop from the site of a previous gastric ulcer or independently.
Individual complaints are variant regarding the intensity and reference of this pain. In large measure it is due to the formation of adhesions, and its reference will depend much upon their location.