than increased in size in cancer. The cubic content was less than normal in six of my cases, and more than normal in only one. Changes of shape are frequent in carcinoma of the stomach. Thus the organ is sausage shaped in case of diffuse cancers. When the carcinoma is at the pylorus, the right half of the stomach may be sausage shaped and the left half spheric. Such was the case in a scirrhous carcinoma to be described later. Again, Dittrich* found the stomach changed into a round structure about the size of an orange. The carcinoma was situated on the lesser curvature. This was entirely destroyed, and the cardiac and pyloric orifices were approximated to such a degree that food passed from the cardia directly into the duodenum without entering the rest of the stomach, which formed a sort of lateral dilatation between the two approximated parts of the digestive canal. Carcinoma of the lesser curvature extending over the anterior and posterior walls is accompanied by contraction, forming the well-known hour-glass stomach. The stenosis thus produced rarely reaches an extreme degree, since the stomach is rather roomy at this point. As the hour-glass stomach is not very common, I propose to go into some detail in considering the two cases I have had. CASE IV.-Carcinoma with cells of medium size. Large semisolid ulcerating tumor on the left half of the lesser curvature. Stricture in the middle of the stomach. Soft medullary carcinoma of the hepatic, the retroperitoneal, and the esophageal lymph-glands. Diffuse peritonitis. Johan Müller, age forty-nine, laborer. Autopsy September 21, 1872, twenty-four hours after death. The peritoneal cavity contains 370 c.c. of a purulent fluid. A fresh fibrinous coating is present on the peritoneal surface of the small intestines, as well as on the parietal wall of the peritoneum. The stomach is adherent to the left lobe of the liver, and contains 1000 c.c. of a grayish fluid. The stomach is distinctly narrowed at the center, but the stricture admits five fingers readily. This constricting ring divides the organ into two nearly equal parts. The peritoneal surface is free from carcinomatous growths. Along the lesser curvature is found a carcinomatous ulcerated tumor, 9 cm. long. It extends 51⁄2 cm. down over the posterior wall and 3 cm. over the anterior, and from the rough, somewhat stenosed cardiac orifice to half-way between the cardia and the pylorus, so that the right edge of the tumor reaches to within 6 to 7 cm. of the pyloric sphincter. There is a small tumor in the neighboring omentum. The mucosa surrounding the ulcer is thin and pale, without signs of cancerous infiltration. A more pronounced constriction in the middle of the stomach occurred in the following case: CASE V.-Mixed “cylinder-cancroid" and carcinoma. Semisolid, very large, ulcerated tumor, occupying almost the entire lesser curvature and extending far out over the anterior and posterior walls of the stomach. The floor of the ulcer is even and firm. Constriction in the middle of the stomach. Mixed carcinoma in the hepatic glands and in the liver. Miliary carcinoma of the peritoneum. Sophie Larsen, fifty-nine years old, widow. Autopsy December 30, 1871, twenty-four hours after death. The stomach is hour-glass shaped, due to a constriction at the very center of the organ. The constricted part barely admits two fingers. Along the external * Prag. Vierteljahresschr., 1846, vol. iv, p. 168. surface of the lesser curvature is an irregular mass of tumors varying in size from a pinhead to a walnut. These appear as white nodules on a red background-the injected peritoneum. From the lesser curvature the tumors have extended into the lesser omentum and the hepatic glands. The bile-passages are open, but on the neck of the gall-bladder is a white, pea-sized, soft, and freely movable tumor. When the stomach is laid open, a large ulcerated carcinomatous tumor is seen to occupy nearly the entire lesser curvature. It has spread 5 cm. over both anterior and posterior walls, so far that the edges are separated by only 2 cm. of comparatively normal mucosa, in which are found numerous pea-sized nodules at the periphery of the advancing tumor. Very marked changes of position are not to be expected in an organ situated like the stomach. The cardia is fixed, and the pylorus and duodenum have but very limited motion. However, carcinoma of the pylorus may, by its weight, either pull the pyloric end down into the abdomen, or, what is more frequently the case, may slide it down over the left side of the inner surface of the spinal column. These movements are possible only when the pyloric end is free from adhesions. By this movement the pylorus is made to lie directly below the cardia, and consequently the stomach has a perpendicular, instead of a transverse, position. This condition was first noted by Notta,* who found an instance where the cancerous pylorus had sunk down to the edge of the true pelvis and was compressing the iliac vessels. The lengthened lesser curvature ran perpendicularly and nearly parallel to the greater curvature. In my series there occurred four instances of carcinoma of the pylorus in which the stomach was more or less perpendicularly situated, because the pylorus had slid to the left without sinking to any degree. Only once did I find the lesser curvature lengthened to any considerable extent (20 cm.). This occurred in a case of adenocarcinoma of the posterior wall of the pylorus. This had slid down on the left side so that the tumor was felt during life in the left hypochondrium. But the lengthening of the curvature was not so much due to a sinking down of the pylorus, as it had come about through the large tumors of the lymphglands behind the pylorus over which the lesser curvature had to pass. THE MUCOUS MEMBRANE OF THE STOMACH The mucous membrane not involved in carcinoma of the stomach is often the seat of a more or less marked chronic catarrh. The mucosa is either thinner than normal and atrophied, or diffusely thickened, with a pronounced "état mamelonné," and with or without diffuse pigmentation (Lebert, Köhler‡). Fenwick§ has studied the minute changes in the mucosa in five cases of carcinoma of the stomach. He found the glands more or less abnormal in all. The cells were either granular, or changed into granular masses, the cell outlines being lost, and in a few cases they had been entirely displaced by connective tissue. Fenwick believes the mucous membrane to be more or less changed in all cases of carcinoma of this organ. * Lebert and Köhler: Loc. cit. † Loc. cit., p. 471. Loc. cit., p. 285. § The Morbid States of the Stomach and Duodenum, London, 1868, p. 344. I have examined the stomach mucosa of 20 cases, and found the following conditions: The mucosa appeared healthy and of normal thickness in 7 cases. In 4 of these the glands were unchanged, but the gland-cells of the remaining 3 were granular. In 4 instances there was a softening of the mucosa, which, however, looked like postmortem changes. The mucosa of 4 of my cases was atrophied and anemic. The gland-cells of 1 of these were unchanged, but in the other 3 the glands were few, indistinct, and often contained a granular débris without distinct cells. In 1 case the mucosa was atrophied and diffusely pigmented. Glands could be made out with difficulty in this instance. All that could be found were a few scattered gland fundi filled with granular débris. The mucosa was thickened in 2 cases. In both of these the glands were normal. Three times I found the mucosa thickened and diffusely pigmented. In 1 of these the glands were unchanged, but in the other 2 the glands, though distinguishable, were changed so that the gland-cells were highly granular in 1 and changed to detritus in the other. It is difficult or, more correctly, impossible to decide how great a factor the postmortem changes which occur early play in the production of the granular appearance of the gland-cells, because the secreting cells are very sensitive and rapidly undergo degeneration. But the existing atrophy is a definite pathologic change. When the glands are not visible even as dilated spaces filled with detritus, one is, without doubt, dealing with changes present prior to death. There is every reason to believe that atrophy was present during life in the cases where a granular débris was present in place of the glands. But too much importance must not be placed on the granular appearance of the gland-cells. Leaving such changes out of consideration, there still remain five cases in which the glands were more or less atrophied, but against these stand three cases in which both the mucosa and the glands were normal, both in appearance and in structure. For this reason I cannot agree with Fenwick, who claims that changes are present in all cases of carcinoma of the stomach. ADHESIONS Adhesions to the neighboring organs play an important and beneficent part in the otherwise sad drama of carcinoma of the stomach, because they hinder or prevent perforations into the large peritoneal cavity. The stomach may become adherent to any one of the surrounding organs. The particular one depends entirely on the location of the tumor, since adhesions outside of its immediate locality are very rare. This is due to the fact that the chronic irritation causing the formation of the exudate is rarely violent enough to cause inflammation outside of the periphery of the carcinoma. Adhesions rarely form before the carcinoma has entered or gone through the muscularis. Because of the relation of the stomach to other organs, exudate on the anterior wall forms adhesions to the liver-most frequently to the left lobe. The posterior wall will form adhesions to the pancreas and the posterior wall of the lesser peritoneal cavity; the fundus becomes adherent to the spleen and the diaphragm, and the greater curvature adheres to some part of the intestine-most frequently to the transverse colon. When some writers mention adhesions to the mesentery as being of frequent occurrence, this appears to me to be more or less incorrect, because the larger omentum is normally fastened to the stomach. When this, through the presence of a malignant tumor, is made to contract, and is pulled toward the greater curvature, it is principally the connection of these two organs that forms the adhesions. It It is generally recognized that the stomach most often becomes adherent to the left lobe of the liver. Lebert found such a condition present in 12 of 20 cases. The pancreas comes next in order of frequency. was adherent in 7 of 20 cases. This does not correspond exactly with the frequency according to location since, as has been mentioned, carcinoma occurs more often on the posterior wall than on the anterior. In my 30 cases the stomach was adherent to the pancreas in 6 instances, and only in 4 to the left lobe of the liver. Carcinoma of the lesser curvature extending on to the anterior and posterior walls was accompanied with adhesions in the majority of my cases, namely, in 6 of 8. Twice the stomach was fastened to the pancreas alone, twice to the left lobe of the liver, and twice to both these organs. One of the cases without adhesions terminated in perforation and subsequent death from peritonitis. The other led to a pronounced carcinoma of the liver, killing the patient at an early stage of the disease. Carcinoma near the pylorus seemed less apt to produce adhesions in my cases. Thus adhesions were found in only 3 of 18 cases. In 1 of these the stomach adhered to the transverse colon; in another, to the pancreas; and in the third, to the left lobe of the liver. The comparative rarity of adhesions in carcinoma at the pyloric end is doubtlessly due to the fact that this end is more movable than the lesser curvature, and the slight motion of this part may be still more restricted by tumors in the gastrohepatic ligament. These lead to a contraction lacing the stomach tighter to the hilum of the liver. COMPLICATIONS AND SEQUELÆ Some of these are closely connected with the carcinoma and the changes produced by it, others are more distantly related to the malignant growths and may be purely accidental. Abnormal communications between the stomach and other organs must be ranked first among the direct sequelæ of carcinoma. It is by no means rare that the destruction of carcinomatous tissue continues into an adherent neighboring organ, producing a fistula. A passage between the pylorus and the transverse colon was found 6 times in Dittrich's 160 cases, and once in 20 by Lebert. This condition must be suspected when, during the course of the disease, fecal vomiting Ulmer* who bases his views on one case, considers such an un"Einige Worte über Magenkrebs," Würtemb. med. Correspondenzblatt, 1852, Jahresber. 1852, vol. iv, p. 295. occurs. natural communication to have a beneficent effect on the course of the disease, by removing the effects of stenosis at the pylorus and permitting food to pass directly into the larger intestines. Fistulous communication between the stomach and the pylorus is most frequently due to carcinoma. Murchison* has collected 33 cases of fistulous formation between the stomach and the colon; 20 of these were due to carcinoma; 8 of the remaining were caused by gastric ulcer; 1 was due to carcinoma of the colon; 2 to ulcer of the colon, and 2 were produced by an abscess in the abdominal wall rupturing both into the stomach and into the colon. According to Murchison, the symptoms of this condition are fecal vomiting, foul breath, and the passage of undigested food per rectum. I found no abnormal communication between the stomach and the colon in my cases. Fistulous connection between the stomach and part of the small intestines is much rarer than that between the colon and the stomach (Rampoldt), but it may occur with the duodenum at its junction with the jejunum (Cruveilhier‡). Rupture into the peritoneal cavity is not rare. It occurred in 3 of Lebert's 57 cases, and in 7 of 160 according to Dittrich. I found this condition present twice-once through a semisolid ulcerated tumor of a mixed type, located on the upper wall of the pyloric end. The floor of the ulcer was made up of cancerous tissue, and in the center of this was a pea-sized opening with smooth edges. The other instance was an ulcerated scirrhous carcinoma on the lesser curvature, extending over both the anterior and the posterior walls. At the bottom of this ulcer, on the anterior wall, was an opening 1 cm. in diameter. Rupture of the floor of the ulcer may at times be caused by mechanical factors. Williams§ cites a case in which the perforation took place while he was making the patient sit up in bed. Just as the patient sat up he heard a sound which he considered was caused by the perforation. Fistula between the stomach and the left lung are very rare, but may be established when perforation of the diaphragm occurs (Lebert and Andral). Perforation of the abdominal wall is also very rare. Dittrich observed this once, and Murchison found a medullary carcinoma of the stomach connected with an abscess which had broken through the skin in the region of the umbilicus. Peritonitis without perforation occurs in a number of patients with carcinoma of the stomach. Dittrich** calls attention to this condition. He believes that the changes present on the external surface of the stomach immediately preceding the rupture led to peritonitis in 6 of his But he also found peritonitis present in 8 of his cases without 160 cases. Lancet, 1857, vol. i, p. 19; Jahrber. 1857, vol. iii, p. 182. Köhler: Loc. cit., p. 283. Maladies de l'estomac, Livraison 27, Pl. I, Fig. 2, Texte, p. 3. § Med. and Surg. Rep., 1868; Jahrber. 1868, vol. iii, p. 128. Transact. London Pathol. Soc., 1869, vol. xx, p. 167; Jahrber. 1870, vol. ii, p. 308. ** Loc. cit., p. 26. |