The cut surface of the round tumor is soft and contains red spots (fungus hematoides). The glands at the hilum of the liver are of walnut size and grayish-white in color. They are rather soft. 2. The lesser curvature comes next after the pylorus as regards frequency of cancer of the stomach; 8, or 4, of my cases occurred here. This same condition was observed by Eppinger. In Louis and Wrany's reports the frequency is slightly greater, being, but Lebert gives less, , and Brinton gives. The average of the entire group is 15.6 per cent. In my series the left half of the lesser curvature was the most frequent site, being the origin of the tumor in five instances. The tumors here often reach a considerable size, perhaps because stenosis does not occur as readily as at the pyloric end, thus permitting the organ to function longer, giving the patient a longer lease on life. Lebert observed a tumor 12 cm. long and nearly as wide, and Eppinger,* in a man of 62, found an alveolar carcinoma of the lesser curvature, which had changed into a swelling as large as a child's head. In my cases the tumors often spread out over large areas. In 5 cases these were as large or larger than an adult's flat hand. The largest masses develop when the growth starts at the lesser curvature and spreads out over the anterior and posterior walls, as occurred in three of my cases. The entire lesser curvature was ulcerated in one of these, and an ulcerated surface extended 7 cm. over the posterior wall and 7 cm. over the anterior. When the stomach is split open and turned out, the entire ulcer often appears as an hour-glass-shaped growth with the narrow part in the lesser curvature. The circumference of the stomach at the fundus is so large that carcinoma perhaps never forms a complete ring around the stomach at this part, as occurs at the pyloric end. At times, however, the spreading edges nearly meet at the larger curvature. Thus, in one of my cases the advancing borders were only 2 cm. apart. 3. Only once did I find an annular scirrhus at the cardia. That cancer of this end of the stomach is not quite so rare as that is clear from the statistics offered by other observers. Lebert, for instance, found the cardia affected in of his cases. Dittrich and Brinton give. Wrany found carcinoma of the cardia in, and in Eppinger's statistics it occurs as frequently as in of the cases. The average then is 8.6 per cent. The carcinoma of the cardia is not so clearly limited to the stomach as is the case when the pylorus is involved. On the contrary, it often extends (Rokitansky) a varying distance up the esophagus. This had taken place in two of Lebert's and in one of my cases. However, the writers do not agree concerning this point. Förster, for instance, holds that carcinoma is nearly always limited to the stomach, even in this type. Carcinoma of the cardia often produces stenosis either by contraction or by extending into the narrow esophagus, producing occlusion. An instance of this type is cited by Abercrombief and others. * Loc. cit., p. 7. † Pathol. und praktische Untersuchungen über die Krankheiten des Magens, etc., Bremen, 1830, p. 87. 4. The posterior wall of the stomach seems to be not infrequently the seat of cancer. This is especially brought out by Eppinger's cases, there being 18 instances among his 131 cases. In the collected statistics the posterior wall follows the cardia in order of frequency, its percentage being 4.7. As a whole, the posterior wall appears more predisposed toward cancer than the anterior. This is perhaps due to mechanical factors, since the posterior wall lies right against the spinal column, whereas the anterior wall is everywhere in contact with soft tissue. 5. The average percentage of the greater curvature and the fundus is 3.3 per cent. This comparatively high percentage is also due to Eppinger's observations. In one of my cases a cylindric epithelioma occurred in the form of a pedunculated polyp in the fundus. 6. Diffuse forms of scirrhus and alveolar carcinoma occur in the entire stomach. A comparatively large number of this type have been reported, whereas only a smaller number of cases of carcinoma of the greater curvature and the fundus are recorded. This is not due to the comparative frequency of the two, but mostly to the fact that the diffuse forms have been more interesting than the circumscribed, and perhaps also to the discussion carried on as to the relation of cancer to hypertrophy of the stomach. The collected statistics bring out clearly how rare the diffuse carcinoma really is. It occurs in 2.8 per cent. One of my 30 cases was of the diffuse type. 7. Carcinoma of the stomach is rarest on the anterior wall. It occurs here in only 1.8 per cent.; in 1.4 per cent. it occurs on the posterior and the anterior walls, and only in 1.1 per cent. do several cancer nodules of the same age occur in the stomach. FORM, SHAPE, AND POSITION OF STOMACH Frequently the stomach retains its normal shape regardless of the location of a tumor (Lebert). The normal size of the stomach is hard to give, since its cavity varies vastly with the degree of contraction of its musculature. This has led to the wide limit given in figures showing the normal capacity of the stomach. Thus Sömmering* gives the cubic content of a non-dilated stomach as varying between 2500 c.c. and 5000 c.c. According to Luschka,† the female stomach holds 2500 c.c., and the male, 3200 c.c. Henle gives the length as 10 to 12 cm., and Luschka says it may reach 30 cm. Henle gives the depth as 3 to 4 cm., and Luschka as 15 cm. With these measurements as a standard I found the stomach dilated only once in a case of complete stenosis of the pylorus. In this instance the organ measured 50 cm. in length, but held only 3000 Hence its capacity was within the normal limits. It must be recalled, however, that in this case the entire pyloric end was filled by the tumor mass. Thus the dilatation was limited to the fundus and the c.c. body of the stomach. *Henle: Handbuch der Eingeweidelehre, p. 153. † Die Anatomie des menschlichen Bauches, 1863, p. 181. It has long been considered the rule that the stomach is enlarged when there is stenosis at the pylorus, because the accumulating food gradually increases the capacity of the stomach. Lebert was the first to recognize that this was by no means a constant condition. Still he found dilatation present in at least one-fourth of such cases. The dilatation was slight in several cases, in others more pronounced, and in one of his cases the stomach extended from the fifth rib to the iliac crest. Andral* cites another instance of cancerous infiltration without stenosis in which the greater curvature reached below the symphysis, and in which most of the large and small intestines were covered by the stomach. Such extreme degrees of dilatation are exceedingly rare. Less pronounced degrees of enlargements of the stomach have been so ambiguously reported that they cannot be depended on. How frequently the organ is dilated in carcinoma cannot be determined from the records. The musculature of the dilated stomach at times was atrophied and at others thickened. A decreased capacity caused by retraction of the organ is often found in the diffuse forms of carcinoma, when the entire stomach is involved. This diminution may reach a pronounced degree, so that the stomach may be reduced to the size of an ordinary loop of intestine; hypertrophy of the wall reduces the lumen still more. An old specimen from the museum will illustrate this: CASE III (Old Specimen, Preserved in Alcohol).—The stomach is greatly reduced and shrunken. It is sausage shaped, and about the thickness of the small intestines. It is 14 cm. long, and its diameter at the fundus is 6 cm., and that at the pylorus is only 31⁄2 cm. The cavity of the fundus holds two fingers, and the pyloric lumen admits only the little finger. A No. 16 French catheter passes with difficulty through the pyloric orifice. The peritoneal surface of the stomach is smooth. On the inner surface occur flat nodules from the size of a pea to that of a nut, which are more numerous at the pyloric end. The entire stomach-wall is diffusely thickened. The wall at the fundus is 8 mm. thick, 1⁄2 mm. of this comprising the serosa; the muscularis is 2 mm., the submucosa, 4.5 mm., and the mucosa, I mm. thick. In the pyloric end the wall is 1 mm. thicker than that of the fundus. The mucosa appears as a distinct border, independent of the tumor in the submucosa. A network of white bundles is seen in the muscularis. Microscopically the mass consists of connective tissue with numerous elastic fibers running through it. The finer structure cannot be made out because of the great age of the specimen. The stomach is often decreased in size, even in the circumscribed carcinomata. There is an old rule that cancer of the cardia diminishes the size of the stomach, since too little food enters. This rule has not been disproved, and in my case of cancer in this part of the organ the entire stomach was not larger than the normal pyloric antrum. But even when the carcinoma is located on the lesser curvature or at the pylorus, the capacity may be greatly reduced. Thus the stomach held only 520 c.c. in one of my cases of a circular carcinoma at the pylorus. In two instances of carcinoma of the lesser curvature the capacity was respectively 250 and 450 c.c., and the length of the organ was reduced to 14 and 16 cm. On the whole, the stomach is more frequently reduced Clinique Medicale, vol. iv, p. 83. 4. The posterior wall of the stomach seems to be not infrequently the seat of cancer. This is especially brought out by Eppinger's cases, there being 18 instances among his 131 cases. In the collected statistics the posterior wall follows the cardia in order of frequency, its percentage being 4.7. As a whole, the posterior wall appears more predisposed toward cancer than the anterior. This is perhaps due to mechanical factors, since the posterior wall lies right against the spinal column, whereas the anterior wall is everywhere in contact with soft tissue. 5. The average percentage of the greater curvature and the fundus is 3.3 per cent. This comparatively high percentage is also due to Eppinger's observations. In one of my cases a cylindric epithelioma occurred in the form of a pedunculated polyp in the fundus. 6. Diffuse forms of scirrhus and alveolar carcinoma occur in the entire stomach. A comparatively large number of this type have been reported, whereas only a smaller number of cases of carcinoma of the greater curvature and the fundus are recorded. This is not due to the comparative frequency of the two, but mostly to the fact that the diffuse forms have been more interesting than the circumscribed, and perhaps also to the discussion carried on as to the relation of cancer to hypertrophy of the stomach. The collected statistics bring out clearly how rare the diffuse carcinoma really is. It occurs in 2.8 per cent. One of my 30 cases was of the diffuse type. 7. Carcinoma of the stomach is rarest on the anterior wall. It occurs here in only 1.8 per cent.; in 1.4 per cent. it occurs on the posterior and the anterior walls, and only in 1.1 per cent. do several cancer nodules of the same age occur in the stomach. FORM, SHAPE, AND POSITION OF STOMACH Frequently the stomach retains its normal shape regardless of the location of a tumor (Lebert). The normal size of the stomach is hard to give, since its cavity varies vastly with the degree of contraction of its musculature. This has led to the wide limit given in figures showing the normal capacity of the stomach. Thus Sömmering* gives the cubic content of a non-dilated stomach as varying between 2500 c.c. and 5000 According to Luschka,† the female stomach holds 2500 c.c., and the male, 3200 c.c. Henle gives the length as 10 to 12 cm., and Luschka says it may reach 30 cm. Henle gives the depth as 3 to 4 cm., and Luschka as 15 cm. With these measurements as a standard I found the stomach dilated only once in a case of complete stenosis of the pylorus. In this instance the organ measured 50 cm. in length, but held only 3000 Hence its capacity was within the normal limits. It must be recalled, however, that in this case the entire pyloric end was filled by the tumor mass. Thus the dilatation was limited to the fundus and the c.c. body of the stomach. Henle: Handbuch der Eingeweidelehre, p. 153. † Die Anatomie des menschlichen Bauches, 1863, p. 181. It has long been considered the rule that the stomach is enlarged when there is stenosis at the pylorus, because the accumulating food gradually increases the capacity of the stomach. Lebert was the first to recognize that this was by no means a constant condition. Still he found dilatation present in at least one-fourth of such cases. The dilatation was slight in several cases, in others more pronounced, and in one of his cases the stomach extended from the fifth rib to the iliac crest. Andral* cites another instance of cancerous infiltration without stenosis in which the greater curvature reached below the symphysis, and in which most of the large and small intestines were covered by the stomach. Such extreme degrees of dilatation are exceedingly rare. Less pronounced degrees of enlargements of the stomach have been so ambiguously reported that they cannot be depended on. How frequently the organ is dilated in carcinoma cannot be determined from the records. The musculature of the dilated stomach at times was atrophied and at others thickened. A decreased capacity caused by retraction of the organ is often found in the diffuse forms of carcinoma, when the entire stomach is involved. This diminution may reach a pronounced degree, so that the stomach may be reduced to the size of an ordinary loop of intestine; hypertrophy of the wall reduces the lumen still more. An old specimen from the museum will illustrate this: CASE III (Old Specimen, Preserved in Alcohol). The stomach is greatly reduced and shrunken. It is sausage shaped, and about the thickness of the small intestines. It is 14 cm. long, and its diameter at the fundus is 6 cm., and that at the pylorus is only 31⁄2 cm. The cavity of the fundus holds two fingers, and the pyloric lumen admits only the little finger. A No. 16 French catheter passes with difficulty through the pyloric orifice. The peritoneal surface of the stomach is smooth. On the inner surface occur flat nodules from the size of a pea to that of a nut, which are more numerous at the pyloric end. The entire stomach-wall is diffusely thickened. The wall at the fundus is 8 mm. thick, 1⁄2 mm. of this comprising the serosa; the muscularis is 2 mm., the submucosa, 4.5 mm., and the mucosa, 1 mm. thick. In the pyloric end the wall is 1 mm. thicker than that of the fundus. The mucosa appears as a distinct border, independent of the tumor in the submucosa. A network of white bundles is seen in the muscularis. Microscopically the mass consists of connective tissue with numerous elastic fibers running through it. The finer structure cannot be made out because of the great age of the specimen. The stomach is often decreased in size, even in the circumscribed carcinomata. There is an old rule that cancer of the cardia diminishes the size of the stomach, since too little food enters. This rule has not been disproved, and in my case of cancer in this part of the organ the entire stomach was not larger than the normal pyloric antrum. But even when the carcinoma is located on the lesser curvature or at the pylorus, the capacity may be greatly reduced. Thus the stomach held only 520 c.c. in one of my cases of a circular carcinoma at the pylorus. In two instances of carcinoma of the lesser curvature the capacity was respectively 250 and 450 c.c., and the length of the organ was reduced to 14 and 16 cm. On the whole, the stomach is more frequently reduced * Clinique Medicale, vol. iv, p. 83. |