Subphrenic abscess is a complication which imperatively demands incision and drainage. Without operation this complication is invariably fatal. Of ten cases operated by free incision and drainage, three (Scheurlen, Debove, Rendu) recovered.

Ulcer may leave, as a sequel, gastric fistula, cardiac or pyloric obstruction, or a deformity producing retention. Gastro-enterostomy is the proper treatment of the latter condition, or adhesions should be broken, and multiple pouches, which have resulted from constrictions, should be connected. Gastric external fistula should be laid open down to the points where it perforates the parietal peritoneum, and packed so as to favor healing from the bottom. The treatment of obstruction of the orifices is discussed in another chapter.

CHAPTER III.

THE NEOPLASMS OF THE STOMACH.

THE neoplasms of the stomach are malignant or benign. The benign tumors are very rare, and, being curiosities of the dead-house, they are of very little interest to the physician. Lipoma of the stomach is usually multiple, is either submucous or subserous in origin, and consequently may form prominences on either the mucous or the peritoneal surfaces. These encapsulated and sometimes lobulated new growths are ordinarily about the size of a pea or nut, and produce no alteration of the mucosa or of the peritoneum, except the slight nutritive changes due to pressure. Fibroma or fibromyoma may develop toward the peritoneum, or toward the mucosa, forming a polyp. They are ordinarily about the size of a cherry, occur most frequently in old age, and are most commonly located on the anterior wall and in the pyloric region, and may consequently produce obstructive stagnation or retention. Lymphadenoma is rare, but unlike lipoma and fibroma it may ulcerate; this lymphatic disease, be it neoplastic or diffuse, is always associated with the same affection of the intestines; sometimes the liver and spleen are involved, and the rapid cachexia is accompanied by leukemia. Polyadenoma is a benign epithelial neoplasm, which may accompany chronic proliferating glandular gastritis, and which may undergo cancerous transformation.

The malignant tumors of the stomach are sarcoma and carcinoma. Sarcoma of the stomach is very rare, but secondary sarcoma of the stomach occurs more frequently than does secondary carcinoma. Sarcoma of the stomach presents the same histological characteristics as sarcoma of other organs. We have been able to find only 43 cases in literature. It is most frequent between the ages of fifteen and thirty-five, is nearly twice as frequent in men as in women, and it may suppurate, ulcerate, produce hemorrhage, and cause perforation. Its gastric symptoms and its functional and bacteriological signs are the same as those of cancer. There is oligocythemia, and there may be leukocytosis (polynuclear) as in cancer; but lymphemia is more frequent. The spleen is always enlarged, metastases are frequent and may be accessible to excision and the microscopical examination of a specimen. Sarcoma of the stomach, when it is diffuse, may convert the stomach into a stiff viscus and the pylorus into a rigid canal, producing incontinence instead of retention. Both primary and secondary intestinal sarcomata seldom produce obstruction.

CANCER OF THE STOMACH.

The stomach is one of the favorite sites of primary carcinoma, which is a malignant disease, progressive in its evolution, and fatal in its termination. As a result of modern diagnostic methods, cancer of the stomach may often be surely and early recognized, and a more favorable opportunity is thus offered for radical and palliative surgical treatment. By medical treatment also life may be prolonged and the suffering alleviated. On account of its frequency, malignancy, and the great importance of its early diagnosis, both to the physician and to the patient, the disease should receive. careful and minute study.

Frequency. The number of deaths due to cancer of the stomach varies in different localities, at different ages, and in the two sexes.

If reports are to be trusted, cancer of the stomach is very rare in Turkey, in Egypt (Griesinger), and in parts of South America (Heizmann). It is much more frequent in Switzerland, in Normandy, and in the region of the Black Forest than in other localities of Europe (Antenrieth, Häberlin). In Vienna (Nedopil) there are annually four deaths from cancer in every 5000 inhabitants, and of these one is due to

cancer of the stomach; and the mortality percentage due to cancer is 3.2 per cent., and to cancer of the stomach 0.8 per cent.

The mortality from cancer of the stomach is twice as great in Switzerland as in Vienna and Berlin, one person in every 2500 dying annually of it (Häberlin).

From the statistics of Bryant (official), extending over a period of ten years from 1884-1893, we obtain the following figures:

In these large cities 2.38 per cent. of all deaths are due to cancer, and Häberlin and Bryant have shown that this percentage is slowly increasing from year to year. For New York city the percentage is 2.8 in 1896, or I death from cancer to 1697 inhabitants. The average yearly death-rate from cancer in the six cities mentioned is 1 to 1825 inhabitants. From 25 per cent. to 40 per cent. of all cancers are primary cancers of the stomach. Häberlin gives 41.5 per cent.; d'Espine, 42.4 per cent., and Virchow, 35 per cent. About one per cent. of all deaths are caused by cancer of the stomach.

Cancer of the stomach is a rare disease before the thirtieth year. In 1150 autopsies performed on old men, Greenfeld found in nine per cent. that death was due to cancer of the stomach. Less than three per cent. of the cases occur before the thirtieth year, more than two-thirds of the cases between forty and seventy, about one-fourth between fifty and sixty, one-sixth between thirty and forty. Nearly one-half of the cases occur between the ages of forty and sixty. Mathieu (1884) collected from literature 32 cases before the thirtieth Wilkinson and Widerhofer observed congenital cases. Cullingsworth and Kaulich have reported cases occurring in infancy. Cancer of the stomach is almost unknown before the fifteenth year, but from this age the chances of dying from it increase with each decad.

About twice as many cancers occur in women as in men, and this preponderance is chiefly due to the frequency with which primary cancer attacks the uterus and the female breast. A compilation of statistics from many sources shows that in women cancer of the stomach is a little more frequent than cancer of the uterus. Cancer occurring in man, in from 40 to 50 per cent. of the cases attacks primarily the stomach; in women only in from 20 to 30 per cent. Bräutigam and Häberlin give the proportion as 6 or 7 to 5; Brinton gives 9% to 7; and Fox, 81⁄2 to 8. Louis, Valleix, and Lebert claim that cancer of the stomach is slightly more frequent in women. Statistics may be produced to support the contention in favor of the predominance in either sex, and the generally admitted predominance in man is so slight as to be of little moment to the clinician.

Etiology. The causation of cancer is unknown. Riches, poverty, season, country, city, hard mental and physical work, and inactivity exert no perceptible influence.

Clinical observation claims heredity as a predisposing cause. Remarkable instances of the persistence of the disease in members of the same family through several generations are on record, and cancer is not so frequent that the recurrences can be plausibly explained as accidental. But the reference to inherited influences often means nothing more than a confession of ignorance, and heredity is losing more and more of its domain each day as knowledge increases. Lebert reported that seven per cent. and Häberlin claims that eight per cent. of the cases are hereditary.

Long-continued and repeated irritation is always stated to be a predisposing cause. Some show of reason may be given this contention for cancer in some of its localizations, but on such grounds it would be difficult to explain the genesis of cancer of the stomach. A stomach constantly irritated escapes as often as one which receives better treatment, and one of the characteristics of cancer is its development at an advanced age in a stomach which has previously given no signs of disease. Cancer is a disease which has its favorite sites, and develops exclusively in certain tissues, some of which are remarkably well protected against mechanical and chemical irritation. In this respect it acts like a germ disease. A bacillus has been reported as its cause, and some observers have attributed the disease to sporozoa, or to sporozoa-like bodies, which develop in the epithelial cells. But it is generally admitted that the so-called sporozoa are degenerate cells, or represent endocellular changes in atypical epithelium.

Carcinoma may generally be conveyed from one surface to another with which it is in contact, and metastasis, such as occurs in pyemia and other infections, is frequent. But the metastasis of carcinoma seems to be a cellular transplantation, for the secondary neoplasms consist of the same cell as the mother neoplasm, wheresoever the secondary growths appear. The cancer cell grows and lives like a parasite, and it is hardly possible for a germ to cause the production of cells of a particular kind in organs where these cells do not exist. That the germ of cancer grows in the epithelial cell and imparts to it a malignant reproductive activity is an admissible hypothesis.

Pathological Anatomy.-Anatomically, cancer of the stomach is a disseminating new growth, consisting of a stroma whose interspaces are filled with cylindrical or atypical epithelium. The disease is essentially a malignant epithelial invasion.

The growth of carcinoma, beginning at a single point in the mucous membrane, is best studied along its borders. Proceeding with the microscopic study of the cut through the zone of dissemination toward the center of the new growth, it will first be noticed that the epithelial proliferation is confined within the glands and limited by a basement membrane. The epithelium next pushes out budding projections, over which the basement membrane disappears, and leaves the epithelial cells in direct contact with the very fine and newly-formed stroma, which is usually infiltrated with small round-cells. These projections unite across the tissues separating the glands, and extend into the submucosa and the deeper layers, where cancer cells collect in nests; or the neoplasm develops in lines along the lymphatic vessels, and the bundles of connective tissue and of muscular fibers.

In the formation of the neoplasm two tissues are chiefly concerned. The periglandular connective tissue is infiltrated with small cells and cell nuclei, and out of it is formed the stroma which is to serve as a framework. Contemporaneously with the development of new connective tissue new blood vessels are formed (vascularization), and in some cases the blood-vessels are very numerous. The characteristic feature, however, is the unconfined epithelial proliferation. The starting-point may be the epithelium about the necks of the glands, and the cancer is then cylindrical-celled; or it may be the epithelium of the fundus, when the epithelium of the new growth is atypical. The new cells stain intensely, and typical and atypical nuclear growth and division (karyokinesis)