Cancer of the Stomach.
Synonyms:—Carcinoma of the stomach; gastric carcinoma; gastric cancer.
Occurrence:—Malignant disease of the stomach occurs more frequently than any other form of cancerous development. Walsh showed it to be the seat of cancerous growth in 21.4 per cent of all cases of malignant disease—more than one-fifth. It occurs here primarily in most cases; it is seldom secondary.
Location:—Walsh also found that in 1,200 cases of cancer of the stomach, the disease was located in the pyloric region in 791 cases; at the lesser curvature in 148 cases; at the cardiac orifice in 104 cases; on the posterior wall in 68 cases; on the greater curvature in 34 cases; on the anterior wall in 30 cases, and on the fundus in 19 cases. It will be thus seen that nearly two-thirds of the cases involve the pylorus. Brinton explains this by the fact that the muscles in this location do a larger amount of work than those of any other part of the organ. It is probably also due to the fact that the contents of the stomach are brought more forcibly in contact with the walls of the stomach in this location, and that persistalsis tends toward this point. It is quite common for the duodenum to be involved also when the disease is located at the pylorus.
From the pylorus the disease spreads most rapidly and most widely in the sub-mucous tissue, is more rapid toward the cardiac orifice and in the lesser curvature.
Variety:—Most frequently the disease occurs as medullary carcinoma, second in order is the adenocarcinoma, and third, it occurs as scirrhus. The medullary form is of rapid growth, and necrosis of tissue occurs early while the disease is extending to other parts of the organ. In this, and also in the adenocarcinoma, there is a tendency to gelatini-form degeneration, with some hypertrophy in the shape of tumors, called colloid cancers. These are apt to cause adhesion between the stomach and other organs, and to extend their growth to other organs. Scirrhus cancer develops in the sub-mucous structures of a part or all of the stomach, in the form of a dense growth, causing the walls to become thick and hardened or leathery, sometimes designated as the india-rubber bottle stomach.
Etiology:—It has been argued that the disease follows chronic gastritis and ulceration, it being supposed that these diseases render the walls of the stomach favorable to the primary deposit of the cancer cells. Statistics, however, do not furnish much proof of this theory, as the percentage of cases is small in which these diseases were known to have previously existed. Indeed, it is true that very many patients who are found to have gastric cancer give a positive history of freedom from all symptoms of any previous stomach trouble, even of a mild character.
The disease occurs most frequently between the ages of forty and sixty years. Of these, thirty per cent occur between fifty and sixty. Lebert claims that the maximum liability is between the forty-first and sixtieth year. It seldom if ever occurs under twenty-one years of age, and is very rare under thirty. Heredity seems to exercise considerable influence in the causation of the disease. Fourteen per cent of about eighteen hundred cases furnished a family history of cancer. From hospital records it would appear that a very much larger portion of cases occurred in males than in females, but as a larger number of males are treated in hospitals than females, this may be erroneous. No race of people suffer from this disease in anything like the proportion in which the white race is attacked. While negroes suffer most from uterine cancer, the whites suffer far more from gastric cancer. The disease seldom occurs in the tropics.
Symptomatology:—The onset of this disease is often insidious. It is seldom if ever painful at this stage. In many cases there is no disturbance of the stomach, except perhaps a slight loss of appetite, which develops slowly. Conspicuous symptoms may not appear until the condition has been present a long time and has involved quite a considerable area of the stomach walls. Finally, the most common simple symptoms of stomach derangement occur, such as eructations of gas, and sometimes of food, a sensation of oppression in breathing after eating; eventually nausea appears, with occasional vomiting, which later occurs with increasing frequency, finally becoming persistent. If the vomiting does not occur until the food has had time to become digested, it may be inferred that the disease is located at the pyloric orifice. If there is some pain, with an inclination to vomit at the time the food is taken, the inference is that the disease is located at the cardiac orifice. In the latter stages of the disease the vomitus may contain considerable blood, or it may be composed of imperfectly digested food and some coffee ground substance, due to disintegrated blood corpuscles.
In another class of cases, pain is an early symptom, and continues throughout the entire course of the disease. It may exist in the form of a constant gnawing sensation or as a burning pain, or it may increase or diminish with the presence of food, or become at times sharp and colicky in character. Occasionally it may be located in the back, or in the loins, or beneath the shoulder blades, or in the right hypochondrium. Cancer of the pylorus is probably the most painful form of the disease.
From the first there is a loss of flesh and strength, although in rare cases this is not apparent. The patient becomes pale, the features shrunken, and gradually a marked anemia is plainly seen. The characteristic cachectic appearance may be observed early, and is plainly marked as the disease progresses. As the anemia increases, there is a peculiar pallor of the countenance, which, with the emaciation, is in itself a strong diagnostic factor. An examination of the blood shows appearances similar to those of pernicious anemia, usually with some leucocytosis, which increases if there is septic infection, ulceration or hemorrhage; the white cells may increase without leucocytosis.
In perhaps fifty per cent of the cases of gastric carcinoma there is a slight fever, which continues from day to day during the progress of the disease, although there may be no apparent rise in the temperature during the early stages of the disorder. The temperature does not exceed 100° or 100.5° F, and there may be a complete intermission at some period during each day. In other cases the temperature is subnormal, while the heart's action is weak and inefficient. The capillary circulation is usually imperfect. Constipation is quite persistent in most of the cases, but in rare cases diarrhea may be the rule, while in yet other cases constipation and diarrhea may alternate. Where hemorrhage has occurred the feces will be mixed with blood, more or less coagulated, or black and tarry from disintegration. Finally mild dropsical symptoms occur, such as swollen ankles or mild anasarca. If the disease extends to the liver, there is hypertrophy of this organ and jaundice. Occasionally these symptoms are so distinct as to cause a diagnosis of carcinoma of the liver to be made instead of the stomach. Extending to the peritoneum, the disease induces diffused peritonitis and ascites. Perforation of the stomach wall is a rare complication.
In an occasional case the nervous system becomes involved in the constitutional degeneration, and the patient becomes irritable, with occasional slight aberration. In other cases—and this condition is probably the most common—the patient becomes dull, indifferent, listless and is inclined to drowsiness as the fatal termination of the disease approaches. He sleeps a great deal, is difficult to arouse, and finally becomes comatose, with deep and labored breathing.
Diagnosis:—In making an examination over the stomach some hardness will be observed quite early; later the structural changes in the stomach are plainly apparent; whether of normal size or dilated, the outlines of the organ can be plainly seen. The hardened structure may be smooth and uniform, or it may be nodular and occasionally of movable masses. Sometimes these enlargements will be found to extend downward, a little to the right, and as far perhaps as even below the umbilicus. When the disease is in the lesser curvature of the stomach or at the cardiac orifice, it is with difficulty distinguished until it has become quite large. When the patient is lying on the back with the legs flexed, the pulsations of the aorta against the hardened mass may be plainly seen, and in rare cases peristalsis may be observed. The tumor moves usually with the respiration, a fact which is of importance in the diagnosis, as, if the induration is from gastric ulcer, it is likely to be immovable, as adhesions are more common.
The characteristic cachectic appearance of the patient is present in all cases, often being observed before other evidences have appeared. If there is pallor, emaciation and increasing debility without cachexia, this disease must be looked for, especially if the patient is above forty years of age. If Bright's disease and diabetes may be excluded as the cause of the anemia and pernicious anemia is not present, the presence of cancer may be inferred. The appearance of hypertrophy or tumor in the organ is reasonably positive evidence. This is confirmed if the characteristic burning, gnawing or twisting pain is present, accompanied with the vomiting of coffee-ground material. It must be remembered that in carcinoma of the stomach hydrochloric acid is almost persistently absent, and lactic acid is almost as persistently present. This may be determined by the use of various meal tests. The test for hydrochloric acid, as suggested by Gungburg, is as accessible as any. It is made of fifteen grains of phloroglucin, fifteen grains of vanillin and one ounce of absolute alcohol. The contents of the stomach, an hour after a test meal has been taken, are withdrawn and a portion of the fluid filtered. To a small quantity of the filtrate three drops of the reagent are added, and this is evaporated in a porcelain dish. A bright rose red tint will appear along the edges of the evaporated substance.
In an occasional case a microscopical examination will discover the cancer cells in fragments of disintegrated tissue, but the absence of cancer cells does not prove the absence of the disease.
Prognosis:—The prognosis is always unfavorable. If the case recovers from treatment, the diagnosis of cancer is questioned. An early diagnosis, followed by a surgical operation before the constitutional symptoms were too pronounced, has resulted in temporary relief from the disease and a prolongation of life. In a few cases, it is claimed, there has been no evidence of a return of the disease after the operation. The disease runs its course in from one to two years.
Treatment:—The medical treatment will be directed to the relief of the conspicuous symptoms, more than to the cure of the actual condition. I am positively in favor, however, of treating the early cases with our specific remedies. I believe we may thus antagonize the development and progress of the disease, may postpone anemia, emaciation, nervous irritation and organic complications, and thus materially prolong life. The use of hydrastis, capsicum, xanthoxylum and geranium maculatum will do much to preserve the integrity of the organ, and echinacea will antagonize the growth and development of the cancer cells. Hydrochloric acid should be given with every meal. The food should be selected with as much care as in cases of gastric ulcer. It should be predigested and its assimilation encouraged. When vomiting from obstruction of the pyloris is persistent, the food should be given per rectum. Nausea and vomiting should be treated in order to relieve, whenever possible. The hemorrhage must be persistently combated. Constipation should be overcome, and last, but not least, the pain should have constant attention. While various measures will relieve much of the pain, when mild, in the severe cases nothing but morphin will be found sufficient. Conium maculatum, cannabis indica and hyoscyamus should be used with other indicated remedies to relieve pain. Often the pain may be prevented by predigesting the food, or administering active digestives, with hydrochloric acid, during or immediately following the meal.
While gastric lavage is beneficial in a few cases, ordinarily it induces additional irritation and greatly increased pain, and often increases the danger of perforation.
When the disease can be determined as exclusively in the walls of the stomach, and not involving other structures, a surgical operation will usually prolong life. It is doubtful if a complete cure is ever effected by this means.