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 {557} 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examination of this fluid withdrawn by paracentesis may aid in the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.
[Footnote 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.]
[Footnote 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 {558} 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
(3-1/3 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.
[Footnote 68: _Loc. cit._ Lange (_op. cit._) records in 210 cases of
gastric cancer 12 perforations into the peritoneal cavity (5.7 per
cent.).]
[Footnote 69: _Extr. fr. the Rec. of the Boston Soc. for Med.
Improvement_, vol. iii. p. 116, and vol. iv. p. 109.]
[Footnote 70: _Prager Vierteljahrsch._, vol. xvii.]
[Footnote 71: _Edinb. Med. Journ._, vol. iii. p. 4, 1857.]
[Footnote 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.]
{559} 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 Brinton[73] 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
Katzenellenbogen[74] estimates the average duration as eighteen months,
the maximum as five years and five months, the minimum as one month.
From 112 cases Lebert[75] 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.
[Footnote 73: _Loc. cit._]
[Footnote 74: _Op. cit._]
[Footnote 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 {560} seems to be no doubt that gastric cancer pursues a
more rapid course in early life than it does in old people.
[Footnote 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 Legg[77] 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.
[Footnote 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] {561}
Pyloric region. 791 60.8%
Lesser curvature. 148 11.4%
Cardia. 104 8.0%
Posterior wall. 68 5.2%
The whole or the greater
part of the stomach. 61 4.7%
Multiple tumors. 45 3.5%
Greater curvature. 34 2.6%
Anterior wall. 30 2.3%
Fundus. 19 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.
[Footnote 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.
[Footnote 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 {562} 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]
[Footnote 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 {563} 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.
[Footnote 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.