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]
[Footnote 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 {578} 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.
[Footnote 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]
[Footnote 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]
[Footnote 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]
[Footnote 105: _Trans. London Path. Soc._, vol. xxviii. p. 126.]
{579} 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]
[Footnote 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.
[Footnote 107: _Arch. f. kl. Chirurg._, Bd. xxix. p. 609.]
{580}
HEMORRHAGE FROM THE STOMACH.
BY W. H. WELCH, M.D.
Hemorrhage from the stomach is a symptom, and not a disease. It is a
result of a great variety of morbid conditions in the description of
which it receives more or less consideration. Already the
symptomatology and treatment of hemorrhage from the stomach have been
considered in connection with its two most important causes--namely,
gastric ulcer and gastric cancer. It remains to give a summary of the
etiology and diagnosis of gastric hemorrhage.
Hemorrhage from the stomach is also called gastrorrhagia. The term
hæmatemesis is not synonymous with gastric hemorrhage, for blood may be
vomited which has simply been swallowed or has passed from the
intestine into the stomach.
ETIOLOGY.--The causes of gastric hemorrhage are as follows:
1. Ulcer of the Stomach.--Simple gastric ulcer is the most frequent
cause of abundant hemorrhage from the stomach. Tuberculous gastric
ulcers, typhoid gastric ulcers, and the ulcers of phlegmonous gastritis
are extremely rare causes of hemorrhage. Hemorrhagic erosion of the
stomach, which by many writers is assigned an important place in the
etiology of gastric hemorrhage, is not an independent affection, and in
my opinion is without any clinical significance.
2. Cancer of the Stomach.--(Non-cancerous tumors of the stomach hardly
deserve mention in this connection, so infrequently are they the cause
of gastric hemorrhage.)
3. Traumatism (mechanical, chemical, thermic).--_a_. Acting from
without the stomach: severe injury to the abdomen, as by a blow or a
fall; penetrating wounds of the stomach.
_b_. Acting from within the stomach: foreign bodies, particularly
sharp-pointed ones; corrosive poisons, as acids and alkalies; other
toxic inflammatory irritants; and very hot substances. Here should also
be mentioned injury from an inflexible stomach-tube and aspiration of
mucous membrane with the stomach-pump.
4. Diseases of the Gastric Blood-vessels.--_a_. Aneurism of the
arteries of the stomach. Miliary aneurisms have been found by Galliard
and others as a cause of profuse and even fatal hemorrhage from the
stomach. Especially in obscure cases should careful search be made for
miliary aneurisms.
_b_. Varices of the veins are a not unimportant cause of gastric
hemorrhage. They are most frequently associated with chronic passive
{581} congestion of the stomach, but they may be found without any
apparent disturbance of the circulation.
_c_. Degenerations of the vessels, particularly fatty and atheromatous
degeneration of the arteries. Probably gastric hemorrhage in
phosphorus-poisoning is to be attributed to fatty degeneration of the
arteries. Amyloid degeneration of the blood-vessels is a doubtful cause
of hemorrhage.
5. Active Congestion of the Stomach.--Here is usually placed gastric
hemorrhage as a result of severe inflammation of the stomach (as acute
catarrhal gastritis), although in these cases the inflammatory
alteration of the vascular walls is an equally important factor.
With more probability the so-called vicarious hemorrhages from the
stomach are to be assigned to active congestion. Sceptical as one is
inclined to be as regards vicarious hemorrhages of the menses, the
occurrence of such hemorrhages, although rare, must be admitted.
Doubtful, however, are alleged cases of gastric hemorrhage taking the
place of suppressed hemorrhoidal bleeding or of epistaxis.
6. Passive Congestion of the Stomach.--This embraces an important group
of causes of gastric hemorrhage. This hemorrhage is the result of
venous congestion caused by some obstruction to the portal circulation.
The obstruction may be--
_a_. In the portal vein itself or its branches within the liver, as in
pylethrombosis, cirrhosis of the liver, tumors, such as cancer or
echinococcus cysts, compressing the portal vein, occlusion of
capillaries in the liver by pigment-deposits in melanæmia, and
dilatation of the bile-ducts in the liver from obstruction to the flow
of bile. Next to ulcer and to cancer of the stomach, cirrhosis of the
liver is the most frequent and important cause of gastrorrhagia.
_b_. In the pulmonary blood-vessels, as in pulmonary emphysema, chronic
pleurisy, and fibroid induration of the lungs.
_c_. In the heart in consequence of uncompensated valvular and other
diseases of the heart.
For evident reasons, obstruction of the pulmonary or of the cardiac
circulation is much less likely to cause gastric hemorrhage than is
obstruction in the portal vein or the liver.
Possibly, gastric hemorrhage which is caused by violent acts of
vomiting may be caused by venous congestion of the mucous membrane of
the stomach. In support of this view, Rindfleisch advances the idea
that the veins in the muscular layers of the stomach, in consequence of
the thinness of their coats, are much more likely than the arteries to
suffer from the compression of the muscle during its contraction.
The occasional occurrence of gastric hemorrhage during pregnancy has
also been attributed to passive congestion of the stomach.
7. Acute Infectious Diseases--namely, yellow fever, acute yellow
atrophy of the liver, relapsing fever; less frequently cholera, typhoid
fever, typhus fever, diphtheria, erysipelas, and the exanthematous
fevers, small-pox, measles, and scarlet fever.
The cause of gastric hemorrhage in these diseases is not understood.
The usual explanation attributes the hemorrhage to dissolution of the
blood-corpuscles and secondary alteration of the walls of the
blood-vessels. Plugging of the vessels with micro-organisms has been
found {582} in only a few instances. The gastrorrhagia of acute yellow
atrophy of the liver has been attributed to dissolution of the blood,
not only by some infectious agent, but also by constituents of the
bile, and also to obstruction of the portal circulation by destruction
and occlusion of capillaries in the liver.
8. Other Constitutional Affections.--_a_. Hemorrhagic
diatheses--namely, scorbutus, purpura, and hæmatophilia. Strictly
speaking, a hemorrhagic diathesis exists in other affections of this
class.
_b_. Malaria. Here we may distinguish, first, periodical malarial
hemorrhages from the stomach which are cured by quinia; second,
pernicious gastric malarial fever, of very grave prognosis; and third,
hemorrhages in malarial cachexia due to extreme anæmia. Cases which
have been described as malaria with scorbutic complications belong
mostly to the last variety. Mention has already been made of gastric
hemorrhages attributed to malarial pigmentation of the liver.
_c_. Profound Anæmias. The most important affections in this category
are progressive pernicious anæmia, leucocythæmia, and
pseudo-leucocythæmia, including the so-called splenic anæmia.
_d_. Cholæmia. The hemorrhage is attributed to dissolution of the
blood-corpuscles by the action of the biliary salts.
Gastric hemorrhage is a rare event in Bright's disease, occurring more
especially with small kidneys. In one such case I found that the fatal
hemorrhage was due to the bursting of a miliary aneurism of a small
artery in the submucous coat. Probably in all similar cases the
hemorrhage is referable to disease of the vascular walls.
9. Neuropathic Conditions.--Although ecchymoses in the mucous membrane
of the stomach can be experimentally produced by injury of various
parts of the brain and spinal cord, there is no proof that gastric
hemorrhage which is of any clinical importance is referable to
structural diseases of the nervous system. The occasional occurrence of
gastric hemorrhage in progressive paralysis of the insane, in
tuberculous meningitis, in epilepsy, is to be attributed to other
causes.
In lack of a better explanation, however, the gastric hemorrhages which
have been occasionally observed in hysterical women may be classified
here. These constitute not the least important class of gastric
hemorrhages. The hemorrhages from the stomach in chlorosis belong
partly here and partly to anæmia.
10. Melæna Neonatorum.--Although in some cases ulcers have been found
in the stomach or duodenum, and in others a general hemorrhagic
diathesis exists, it must be said that the etiology of this grave
disease is still very obscure.
11. Bursting of Aneurisms or of Abscesses from without into the
Stomach.
12. Idiopathic Causes.--Under this unsatisfactory designation are
included cases which are aptly described by Flint[1] in the following
words: "Hemorrhage sometimes occurs from the stomach, as from the
bronchial tubes, the Schneiderian membrane, and in other situations,
without any apparent pathological connections, neither following nor
preceding any appreciable morbid conditions. It is then to be
considered {583} as idiopathic." A person in apparent health has
suddenly a hemorrhage, often profuse, from the stomach, which is
followed only by symptoms immediately referable to the hemorrhage. The
hemorrhage is naturally the source of great anxiety. Ulcer or cancer of
the stomach or some other grave disease is usually suspected. But the
patient develops no further symptoms, and often never has another
hemorrhage. Whatever hypotheses one may construct for these cases of
so-called idiopathic hemorrhage, the recognition of the clinical fact
of their occurrence is important.
[Footnote 1: Austin Flint, _A Treatise on the Principles and Practice
of Medicine_, 5th ed., p. 513, Philada., 1881.]
Inasmuch as hemorrhage from the stomach is usually made manifest by the
vomiting of blood, it is important to bear in mind that gastric
hemorrhage is not the only cause of hæmatemesis. Blood may gain access
to the stomach by being swallowed in cases of hemorrhages from the
nose, mouth, throat, bronchi, lungs, and oesophagus. Blood may also
enter the stomach from the duodenum in cases of simple ulcer of the
duodenum or of typhoid ulcers situated in the upper part of the
intestine.
The SYMPTOMS of hemorrhage from the stomach have already been described
in connection with ULCER OF THE STOMACH.
MORBID ANATOMY.--As is evident from the enumeration of the causes of
gastric hemorrhage, the lesions found after death are manifold. A
description of these lesions, however, does not belong here. It is
necessary, however, to say a few words concerning the demonstration of
the source of the hemorrhage.
The hemorrhage is arterial, venous, or capillary in origin. Ulcerations
from the stomach into the heart, which have been mentioned in
connection with gastric ulcer, are too infrequent to come into
consideration in this connection. If the bleeding is from a large
artery or vein or from a medium-sized aneurism or varix, the
demonstration of its source is not difficult. Often, however, in cases
of fatal gastric hemorrhage the search for the source of the hemorrhage
has proved fruitless. It is supposed that in many such cases the
hemorrhage is due to diapedesis, and not to rupture of a blood-vessel
(rhexis). Doubtless, small gastric hemorrhages, particularly those into
the tissues of the stomach, are often the result of diapedesis, but in
cases of profuse hemorrhages from the stomach where the source of the
hemorrhage is not demonstrable after death, the convenient assumption
of hemorrhage by diapedesis, in my opinion, plays too important a rôle.
In most cases of profuse gastrorrhagia the symptoms point to a sudden
outpouring of blood into the stomach; and our knowledge of diapedesis
does not warrant the belief that the red blood-corpuscles can escape
through the unsuffused walls of the vessels with that combined rapidity
and abundance which would be necessary to explain the sudden and
profuse hemorrhage. In these cases hemorrhage by rhexis is altogether
more probable even when ruptured vessels cannot be demonstrated. It
often requires a long-continued and careful search to find a small
vessel which is ruptured. In the case above mentioned of fatal
hæmatemesis from miliary aneurism over an hour of continuous searching
was required to find the pinhole perforation in the mucous membrane in
the bottom of which lay the small aneurism. Chiari[2] has reported a
fatal gastric hemorrhage due to rupture of a submucous vein. The
erosion of the mucous membrane was not larger than a hempseed. The
examination of the mucous membrane is often much impeded by the {584}
closely-adherent mucus and blood, which have to be carefully removed.
Injection of the vessels of the stomach with fluid may aid in finding a
ruptured vessel. It is not intended to assert that in all cases of
fatal gastric hemorrhage a painstaking search would reveal the source
of the hemorrhage, but it is believed that cases of fatal gastric
hemorrhage would less frequently be reported with negative anatomical
result as hemorrhages by diapedesis, or by exhalation, or as
parenchymatous or capillary hemorrhages, if such a search were made.
[Footnote 2: _Prag. med. Wochenschr._, 1882, No. 50.]
DIAGNOSIS.--Undoubtedly, small hemorrhages into the stomach often occur
which are not recognized, and in the absence of vomiting even larger
hemorrhages may escape detection unless a careful examination of the
stools be made. The patient may die from abundant gastric hemorrhage
before any blood has been vomited or has passed by the bowels.
When there is doubt whether the black color of the stools is due to
blood or to the administration of iron or of bismuth, it generally
suffices to add water to the stools. If blood be present, the water
will acquire a reddish color. Should doubt still remain, then the
microscope, the spectroscope, or the test for hæmin crystals may be
called into requisition (see p. 545).
Whether black, tarry stools are produced by hemorrhage from the stomach
or by hemorrhage in the upper part of the intestine can be decided only
by the clinical history. If hæmatemesis be likewise present, the
presumption is strongly in favor of gastric hemorrhage. The diagnosis,
however, between hemorrhage from duodenal ulcer and that from gastric
ulcer is very difficult, and can rarely be positively made.
The mere inspection of the vomit is generally sufficient to determine
whether it contain blood or not. Color more or less resembling that of
altered blood may be produced in the vomit by iron, bismuth, red wine,
various fruits, such as cranberries, and by bile. When a careful
inspection by the physician leaves doubt as to the presence of
blood--which will rarely be the case--then here also recourse may be
had to the microscope, spectroscope, and test for hæmin crystals.
Sometimes blood is swallowed and then vomited by hysterical females or
by malingering soldiers or prisoners for purpose of deceit. In such
cases there are generally no evidences of acute anæmia or of gastric
disease. The blood of some animals can be distinguished by the
microscope from human blood. When suspicion of deceit exists, there are
generally various ways of entrapping the patient.
When blood is vomited by nursing infants the possibility of its coming
from the breast of the mother is to be thought of.
Sometimes blood from the nose or throat is swallowed, particularly when
the bleeding occurs during the night. This blood may subsequently be
vomited. The inspection of the nose or throat will generally reveal the
source of the hemorrhage in such cases.
The diagnosis between hemorrhage from the oesophagus and that from the
stomach must be based upon the clinical history. The oesophagoscope,
however, has been successfully employed for diagnostic purposes.
Several cases have been reported of fatal hemorrhage from varices of
the oesophagus. Such hemorrhage cannot be distinguished from gastric
hemorrhage.
Much more frequently arises the question whether the hemorrhage is from
the stomach or from the lungs. Sometimes the decision of this point
{585} is very difficult, and it may even be impossible, especially when
the physician is obliged to trust only to the statements of the patient
or his friends. Difficulty in the diagnosis results mainly from the
fact that coughing and vomiting of blood are often associated with each
other. With hæmoptysis blood may be swallowed and then vomited, and
with hæmatemesis more or less coughing occurs. The diagnosis is to be
based upon the points contained in the following table: