Cancer of the Stomach.
Etiology.—The stomach seems to furnish a soil more favorable for the development of malignant growths than any other organ, for it occurs more frequently in this structure than any other, according to Einhorn, and second in frequency according to Osler, who gives the uterus as ranking first.
The exciting or actual cause of cancer of the stomach, like that of cancer of any organ or part, is not known, though certain factors or conditions predispose to the lesion.
Age.—First in order is age, the disease rarely occurring during the first twenty-five years of life, while seventy-five per cent of the cases are found between the ages of forty-five and seventy years.
Sex.—Hospital statistics show a slight increase in favor of males, though, as Einhorn well remarks, this proves but little, as a predisposing factor for the percentage of males treated in hospitals is larger than that of females.
Race.—The white race is far more liable to cancer than the colored, according to hospital reports.
Heredity.—This does not figure so extensively as one might expect, though it has some slight influence.
Chronic gastritis and ulceration are assigned as etiological factors; yet the percentage of cases where these conditions preceded the disease is quite small, and the gastritis found after death is most likely secondary.
The most frequent site of the disease, the pylorus, is explained by Brinton to be due to the greater amount of work or contraction of the muscular fibers at this point than in the rest of the structure. When the pylorus is involved, the upper portion of the duodenum usually shares in the destructive process.
Pathology.—Carcinoma has a predilection for the pylorus, according to Lebert, this portion being involved in fifty-one per cent of all cases, sixteen per cent affecting the lesser curvature, nine per cent affecting the cardiac orifice, while only four per cent involve the greater curvature.
The most common varieties are the encephaloid carcinoma, scirrhus carcinoma, adeno-carcinoma, and colloid carcinoma.
They always commence in the mucous layer, extending to the submucous, muscular, and serous coats.
The general appearance, character, and consistency depend, to a great extent, upon the variety, and may be quite limited or involve a large portion of the organ.
In all but the scirrhus, the surface presents an ulcerated condition with frequent "cauliflower" projections. The softer forms involve all the tissues of the stomach by infiltration, and are usually of a grayish-red color, owing to the amount of blood contained.
In the scirrhus form, a hard, indurated mass is formed, the resulting changes depending upon its site. Where the pylorus is involved, there is apt to be dilatation of the organ and increase in size, while an involvement of the cardia gives rise to atrophy of the stomach and dilatation of the esophagus. In rare cases, the growth takes possession of the entire organ, almost obliterating the cavity.
In one post-mortem of this variety, I found its capacity reduced to about one tablespoonful or less.
In the colloid variety, there is more universal invasion as a rule, and it more frequently extends to neighboring parts. Metastasis to other organs is not infrequent, the lymphatic glands suffering most frequently, after which the liver is next in frequency.
The omentum, intestines, spleen, lungs, pleura, and, in fact, any organ may share in the destructive process.
Adhesions sometimes take place between the stomach and liver, or the pancreas, colon, or abdominal walls may suffer in the same way.
Microscopically, the tubular lymph spaces are seen to be filled with columnar epithelium. In some cases adenomatous growths will be found in some parts of the growth; hence the term, adeno-carcinoma.
In the scirrhus variety, there is massed between the groups of cells a large amount of firm fibrous connective tissue, which accounts for the hardness of this form of carcinoma.
In the softer varieties, there is usually more or less erosion of blood-vessels, accompanied by more or less hemorrhage.
Perforation of the stomach is one of the rare complications. Since the gastric tubules are early involved, and later destroyed, there is necessarily a diminished amount, and in some cases an entire absence of hydrochloric acid. Anemia is present in every form of carcinoma, and the patient has a characteristic appearance known as cancerous cachexia.
Symptoms.—These present a wide range, from that so slight that the disease is only recognized post-mortem, to those characteristic of the most typical type, between which are every grade. A better idea may be formed by dividing the symptoms into general and specific, or functional.
General Symptoms.—The most constant symptom is the gradual and progressive loss of flesh and strength, though we meet with exceptional cases, where the patient retains his weight and strength to the end. There may be periods in this progressive emaciation, when, for a time, the general atrophy is stayed, and even an increase in weight gives encouragement to the patient, which only lasts, however, for a short period: thus a treatment that relieves the catarrhal condition, so constant in this disease, is a nutritious and easily digested diet. The same may be true of a strong mental impression, such as a favorable prognosis by a consulting physician, or the promise of a cure by Christian science, faith-healer, or magnetism.
The loss of strength is usually proportionate to the loss of flesh, though, where there is a temporary gain in flesh, there is not a proportionate gain in strength. With the general decline, there is, of course, a progressive anemia, the patient assuming a yellowish, cachectic appearance that is characteristic.
In about half the cases, fever rises in the advanced stages, though usually the temperature does not run very high. In exceptional cases the temperature is subnormal. Constipation is the rule, though a troublesome diarrhea is occasionally the exception. The stools, where there has been much hemorrhage from the stomach, are black and tarry. In the advanced stages of the disease, there is edema of the ankles, and not infrequently general anasarca.
Functional Disturbances.—Loss of appetite, with symptoms of dyspepsia, is common in all forms of cancer of the stomach, and, though occasionally a patient may retain his appetite to the end, it is quite exceptional.
With the anorexia comes nausea and vomiting; at first, at quite long intervals, but as the disease progresses, the vomiting becomes more frequent and persistent, especially when the orifices are the parts involved. If the cardiac orifice is the seat of the disease, the vomiting occurs at the time, or shortly after eating, while it is delayed for some hours if the pylorus is involved. The ejecta consists of food, mucus, various acids, yeast fungus, bacteria, and sarcinse, though not so often as in dilatation from stricture, and the whole mass is foul-smelling and sour.
There is almost always an absence of hydrochloric acid, and though it may be present in rare cases, its absence is considered of great value as a diagnostic feature. To determine its presence have the patient eat a roll, with a glass of water or tea, without sugar or milk, and in about one hour draw the contents by means of the lavage tube.
Gunzburg's test for hydrochloric acid is perhaps as easily made as any, and is certainly as reliable. It is as follows: Take phloroglucin, 30 grains; vanillin, 15 grains; absolute alcohol, one ounce. To two or three drops of this reagent, add an equal number of the gastric nitrate, in a porcelain dish, and slowly evaporate to dryness over a flame; if hydrochloric acid is present, a rose-red tint will appear along the edges. So delicate is the test that it will reveal acid, if present, in the proportion of one to twenty thousand.
Hemorrhage occurs in a large per cent of the cases, but not in large quantities. As the oozing of blood takes place, it is acted upon by the changed gastric secretions, and is changed to a dark coffee-ground color. While the "coffee-ground" vomit is present in cancer of the stomach, we are not to forget that it is also present in gastric ulcer.
Pain is one of the common symptoms, and is present in nearly every case, though some cases have run their entire course without this dread condition. The pain is most frequently located in the epigastrium, though it may be between the scapulae underneath the shoulder-blade, or in the dorsal and lumbar region. It is of a burning, gnawing, twisting, or lancinating character, and occurs when food is taken, and, later in the disease, is nearly always present.
Physical examination is of the greatest importance, and reveals more positive knowledge than all other symptoms combined. Have the patient lie on his back, with the legs flexed, when a fullness will be noticed in the epigastrium, and, in the advanced stages, peristalsis can be readily seen, as may the pulsation of the abdominal aorta.
On deep inspiration, the tumor may be seen to descend an inch or two. Deep pressure reveals the presence of a hard, nodular mass in the epigastric region, if the growth involve the pylorus, or it may extend to the umbilical region, and sometimes is felt in the hypochondriac region. When confined to the cardiac orifice, the growth can not be determined by palpation. When the patient is very much emaciated, the indurated mass may be grasped between the fingers.
The disease may be complicated by secondary growths, especially that of the liver, when the patient becomes very much jaundiced.
Diagnosis.—The location of the growth renders the diagnosis easy or difficult. Thus, when the pylorus is involved, the diagnosis is comparatively easy. The indurated mass can be readily felt through the abdominal walls; there is also dilatation due to the stricture. Add to these symptoms, pain, of a burning, gnawing character, various dyspeptic symptoms, frequent vomiting, especially the "coffee-ground" material, the presence of lactic acid after a test meal, and the continued absence of free hydrochloric acid, the lemon color of the skin, with great emaciation, render the diagnosis quite easy.
Where the growth is of the cardiac orifice, the tumor mass can not be felt by palpation, and should there be but slight loss of flesh and strength, as we sometimes observe, but little pain, and only occasional attacks of vomiting, the disease may not be recognized till near the end, and sometimes it takes a post-mortem to determine the true condition.
Prognosis.—This is unfavorable, few, if any, cases of genuine cancer recovering. The course of the disease is about two years, though some cases run their course in a few months.
Treatment.—It will be symptomatic, as different conditions arise, such as nausea and vomiting, hemorrhage, and pain. At the same time special attention should be paid to the diet. Such articles of food as are readily digested and assimilated in the intestines, should be used, and when obstruction of the pylorus occurs, predigested foods should be given, such as beef-peptonoids, and peptonized or pancreatinized milk-foods. When all nourishment is rejected, we will have to resort to rectal feeding. Much relief is afforded, in some cases, by lavage, while in others so much pain is occasioned by the process that we have to desist.
In the way of special remedies, hydrastin phosphate, echinacea, chelidonium, arsenicum, and like remedies, should be thoroughly tried. When the pain becomes too severe, we will have to resort to opiates, and render the sufferer as comfortable as possible.