| | GASTRITIS.
| |
1. Tumor is present | 1. Tumor rare. | 1. No tumor.
in three-fourths of | |
the cases. | |
| |
2. Rare under forty | 2. May occur at any | 2. May occur at any
years of age. | age after childhood. | age.
| Over one-half of the |
| cases under forty |
| years of age. |
| |
3. Average duration | 3. Duration | 3. Duration
about one year, | indefinite; may be | indefinite.
rarely over two | for several years. |
years. | |
| |
4. Gastric hemorrhage| 4. Gastric hemorrhage| 4. Gastric
frequent, but rarely | less frequent than in| hemorrhage rare.
profuse; most common | cancer, but oftener |
in the cachectic | profuse; not uncommon|
stage. | when the general |
| health is but little |
| impaired. |
| |
5. Vomiting often has| 5. Vomiting rarely | 5. Vomiting may or
the peculiarities of | referable to | may not be present.
that of dilatation of| dilatation of the |
the stomach. | stomach, and then |
| only in a late stage |
| of the disease. |
| |
6. Free hydrochloric | 6. Free hydrochloric | 6. Free hydrochloric
acid usually absent | acid usually present | acid may be present
from the gastric | in the gastric | or absent.
contents in cancerous| contents. |
dilatation of the | |
stomach. | |
| |
7. Cancerous | 7. Absent. | 7. Absent.
fragments may be | |
found in the washings| |
from the stomach or | |
in the vomit (rare). | |
| |
8. Secondary cancers | 8. Absent. | 8. Absent.
may be recognized in | |
the liver, the | |
peritoneum, the | |
lymphatic glands, and| |
rarely in other parts| |
of the body. | |
| |
9. Loss of flesh and | 9. Cachectic | 9. When
strength and | appearance usually | uncomplicated,
development of | less marked and of | usually no
cachexia usually more| later occurrence than| appearance of
marked and more rapid| in cancer; and more | cachexia.
than in ulcer or in | manifestly dependent |
gastritis, and less | upon the gastric |
explicable by the | disorders. |
gastric symptoms. | |
| |
10. Epigastric pain | 10. Pain is often | 10. The pain or
is often more | more paroxysmal, more| distress induced by
continuous, less | influenced by taking | taking food is
dependent upon taking| food, oftener | usually less severe
food, less relieved | relieved by vomiting,| than in cancer or in
by vomiting, and less| and more sharply | ulcer. Fixed point
localized, than in | localized, than in | of tenderness
ulcer. | cancer. | usually absent.
| |
11. Causation not | 11. Causation not | 11. Often referable
known. | known. | 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| 12. Sometimes a | 12. May be a history
only temporary | history of one or | of previous similar
improvement in the | more previous similar| attacks. More
course of the | attacks. The course | amenable to
disease. | may be irregular and | regulation of diet
| intermittent. Usually| than is cancer.
| marked improvement by|
| regulation of diet. |
{571} 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
{572} 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 {573} 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]
[Footnote 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.
{574} 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.
[Footnote 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 cancers[96] or of fragments found
in the fluids obtained from the stomach.
[Footnote 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 {575} 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.
[Footnote 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.
[Footnote 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 {576} which is now admitted to
the hitherto relentlessly fatal forecast of this disease.
[Footnote 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.]
[Footnote 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. {577} 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.