ON CANCER OF THE STOMACH WITH SPECIAL CONTENTS PAGE EXTENSION OF CANCER THROUGH LYMPH-VESSELS, THORACIC DUCT, CONNECTIVE TISSUE OF THE LIVER, AND AROUND THE LARGE VESSELS ABOUT THE SPINAL PREFACE It is the purpose of this dissertation, the material for which I have. *Thesis accepted by the faculty of the University of Copenhagen for the Degree of individual forms of cancer of the stomach and of its extension into neighboring organs. On account of pecuniary reasons I have been compelled to use only a very small number of the illustrations prepared in the course of this investigation. In order to save space I have included only the essential points in the postmortem reports of each case, and only a few reports are printed in full, mostly as examples. The advice and suggestions of Professor Dr. med. Reisz have been of great assistance to me during the course of this work, and I ask him to accept my thanks not only for his help, but also for his constant good-will. HISTORIC INTRODUCTION Without doubt cancer of the stomach existed in the earliest historic times as a common ailment of man. That a disease of such a sad and serious nature early attracted the attention of physicians is easily understood. But since the tumor existed in an organ not accessible from the exterior, recognition was impossible during older times, when autopsies were either utterly unknown or so rare that normal anatomy only could profit from them. Hence Hippocrates knew nothing of cancer of the stomach. It is, therefore, not strictly correct to assume with Rènè Prus* that Hippocrates† describes cancer of the stomach under "μeλaiva." To be sure, a number of the cases described under this term must have had cancer because of the symptoms, viz., weakness, emaciation, and vomiting of food and bile, and sometimes of a black fluid, often associated with a feeling of weight in the abdomen, but these symptoms are also the symptoms of other chronic troubles in the stomach, as ulcer, chronic catarrh, etc., and the one typical sign of cancer of the stomach-a palpable tumor in the cardiac or epigastric regions-was unknown to Hippocrates. Cancer of the stomach was apparently recognized by Galen,‡ for he writes that a "tuberculum carnosum" might prevent food from passing through the pylorus and thereby give rise to nausea and vomiting. He does not, however, consider this tumor a malignant growth, since in his volume on Organic Diseases, § under "de tumoribus praeter naturam," he fails to mention the stomach. Neither does he connect it with melena, the cause of which both he and Hippocrates see in black bile (atrabilis). Consequently neither Hippocrates nor Galen had any definite ideas of cancer of the stomach. The Arabian physicians|| mention outgrowths in the stomach, but they evidently obtained their knowledge from the Greeks, and not from dissections, since their religion forbade any mutilation of the dead.** In the long period from Galen (131-201 A. D.) to the sixteenth century practically no progress was made. But in the sixteenth century autop *Recherch. nouv. sur la nature et traitément du cancer de l'estomac, Paris, 1828. † Hippocrates: De morbis, edit. E. Littré, 1861, viii, pp. 111, 113, 115. Hepi vovour. Galeni: Opera, edit. Kuhn, vol. vii, p. 218. Loc. cit., vol. viii, p. 705. || Rènè Prus, p. 3. Morgagni: De sediles et causis morborum, 1761, Epist. xxix, 17. ** Förster: Handbuch der pathol., Anat., 1865, vol. i, p. 24. sies became more common. Yet the interest, of course, centered around normal anatomy, and it is in the year-books of anatomy that the names of the great men of that day, as Vesalius (1543), Fallopia, Eustacchio, etc., are found. This closer study of anatomy led to the finding of pathologic changes, and these in turn stimulated to research in pathologic anatomy. In the seventeenth century clinical histories, accompanied with autopsy records, appear both in systematic handbooks and in monographs on individual diseases. But the symptomatic conception of diseases still predominated, so that the pathologic observations associated with the symptoms were not used as a foundation for the classification of diseases—at any rate, not to the extent they should have been used and were used in the eighteenth century. Among writers of the seventeenth century I wish to mention only our famous countryman, Thomas Bartholin, because Plauquet* and Frank† mention him as having made the earliest or one of the earliest observations on cancer of the stomach. This, however, is not strictly correct, for both Plauquet and Frank refer to one of Bartholin's histories, "Tophi in Animalium Ventriculus."‡ But in this Bartholin simply describes the well-known spheric conglomerations of hair found in the stomach of horses, cattle, and sheep. These, of course, have absolutely no relation to cancer of the stomach. During the eighteenth century the anatomic investigations began to affect the theoretic classification of disease according to symptoms. The famous work of Morgagni, "De sedibus et causis morborum per anatomen indagatis," is the foundation of pathologic anatomy, and its importance for the recognition and understanding of diseases. In epistles XXIX and XXX of this work is found a complete and well-written clinical record of carcinoma of the stomach, accompanied by full pathologic descriptions, the pathologic data having been obtained partly by Morgagni and partly by his great teacher, Valsalva. Morgagni describes both the scirrhous (Ventriculus erat in pylore callosus) and the softer forms. Numerous clear descriptions of carcinoma of the stomach and of its accompanying symptom-complex were produced during this century, both in systematic text-books and in monographs dealing with diseases of the abdomen and of the stomach. Cancer is designated as scirrhus, steatoma, tumor, ulcus, ulcus cancrosum, and the like. In the journals are found reports of observations on cancer made by Danish writers. Thus Sibbern§ describes a case in which the stomach had contracted to such a degree that it barely held half an ounce of fluid. Berger|| mentions a scirrhous stenosis of the pylorus, and F. L. Bang** reports the * Litteratura medica, 1809, vol. iv, p. 308. Historiar. Anat. rar. Cent. II, Hist. XXI. † Praxis medica, 1835, vol. i, p. 652. § Einige anatomische Beobachtungen in Med.-Chir. Bibliothek, von Joh. Clem Tode, 1776, vol. iii, p. 193. Acta. Soc. med. Hauniensis, 1777, vol. i, p. 61. ** Acta. Soc. med. Hauniensis, vol. i, p. 274; vol. iii, p. 87. case of a man, sixty years old, who had suffered from gastralgia, vomiting, etc., for over half a year; palpation revealed a tumor the size of a fist over the cardia; the autopsy showed a cartilaginous tumor as large as a child's head in the right half of the stomach. He also mentions the case of a man, thirty-two years of age, who suffered from gastralgia and vomiting for two years. Postmortem examination showed the pylorus reduced to a cartilaginous mass as thick as a finger. At this time the disease was neither diagnosed nor recognized as cancer. Anything like a knowledge of the origin, structure, and development was impossible at that stage of the science of anatomy. However, the conception of minor pathologic differences was developed to such an extent that Baillie,* who wrote the first systematic anatomy in 1793, distinguished between round ulcer and cancer. The next advance was made possible by Bichat,† who created general anatomy, the doctrine concerning the individual tissues of which the organs are made up. By this a new field of investigation was opened also with respect to carcinoma of the stomach. It became necessary to investigate in which of the tissues of the stomach cancer develops, of what tissue it consisted, and how these tissues were related to its surroundings. Up to about 1840 the knife was used more than the microscope for examination of tissues. In one of the most famous monographs from this time Rènè Prus‡ gives accurate measurements of the increased thickness of the various layers, serosa, muscularis, etc. It was observed that the various layers became inseparable, and the frequently considerable increase in thickness of the muscularis and the submucosa led to the belief that these were the source of the cancer (Prus, Baillie). Increased thickness of the mucosa with pigmentation was also noted (Dejaer, Prus), and even thickening of the vagus was seen in the region of the cardia in some cases (Cruveilhier, Prus). The microscope was seldom used to study the structure of the carcinoma. The observers were usually satisfied to record what they could see with the naked eye. The principal varieties of cancer known at this time was the scirrhous, the encephaloid (Laennec§), and the colloid carcinoma (Otto||). The numerous subvarieties of these grew out of external differences of color, consistence, and similarities to organs and even plants. Thus under encephaloid cancer the following varieties were described: Fungus hematoides (Hey), called so because of its abundant blood-supply, mastoid or mammary sarcoma (Abernethy), spleen-like tumor of the mucous membrane (Monroe), nephroid tumor (Recamier), etc. The former varieties of scirrhous carcinoma were described as chondroid and nephroid, solanoid (like a bisected potato), napiform (like a cut turnip), "pancreatic sarcoma" (Abernethy), etc. * Morbid Anatomy of Some of the Most Important Parts of Human Body, London, 1793, p. 87. † Anat. gen., Paris, 1801. Recherches nouvelles la nature et le traitement de cancer de l'estomac, Paris, 1828. § Traité d'Auscultation mediate, 1837, vol. ii, p. 352. || Seltene Beobachtungen zur Anat., Physiol., und Pathol., Breslau, 1816. The theories held regarding the development of carcinoma were not based on anatomic observations. Laennec considered cancer to be made up of a substance foreign to the body, and existing as a parasite which lived a more or less independent life, consisting of two stages-the crude stage and the stage of softening. Chardel* held that the lymph escaped into the wall of the stomach and formed carcinomatous growths. Broussais, who originated the antiphlogistic treatment, looked upon cancer as a subinflammation of the lymph-vessels, the exciting cause of which was in the nervous system and in the blood-vessels-in the nerves in so far as they act on the blood-vessels, and in the blood-vessels because they are the seat of the inflammation which always precedes and causes the cancer. When chronic gastritis was not treated right, scirrhous carcinoma developed, because the time of the year, the climate, and the individual's constitution predispose to this, and persons with lymphatic temperament, in whom the lymph-vessels are irritable, are most predisposed to carcinoma. As soon as scirrhous carcinoma developed, the tissues became destroyed and the disease incurable. He also gives a fairly good account of the symptoms and the diagnosis, and emphasizes the palpable tumor present in cancer of the fundus and pylorus, but not of the cardia. Benech‡ believes that chronic catarrh of the stomach often leads to cancer, but emphasizes that hereditary predisposition plays an important part. The great difficulty of recognizing cancer of the stomach at that time was felt by Prus, who believed that neither the scirrhous nor the encephaloid form had a distinct structure, not being different from that found in "tumor albus" at the joints. He believed that both the blood-vessels and the lymphatics played a part in the development of cancer, but that the tissues themselves are changed to carcinoma. Andral§ failed to find any special difference between the scirrhous tumors of the stomach and the thickened mucosa of chronic inflammation of the rectum in chronic diarrhea. He, therefore, considered this type of carcinoma as a benign hypertrophy. He does, however, give a good description of the symptoms. Cruveilhier first believed that carcinoma originated in the connective tissue, but in his great atlas (1832-40) he gives excellent observations and pictures of the three types of cancer of the stomach-scirrhous, medullary, and alveolar. He has changed his views about the origin of the tumors, which he traced to the venous capillaries, since he had observed masses of cancerous tissue extending into the large veins. His ideas were not based on microscopic observation, hence are merely hypothetic. * * Monographie des degenerat. squirrheuses de l'estomac, Paris, 1804. Traité des cancers de l'estomac, Paris, 1829. § Precis d'anat. pathologique, Paris, 1829. |