Part 96

Discussion of the surgical treatment of gastric cancer of course does not belong to this work. The opinion entertained by the physician as to the propriety of surgical interference in gastric cancer is not, however, a matter of indifference, for cases of gastric cancer come first into the hands of the physician, and generally only by his recommendation into those of the surgeon. So long as the physician stands absolutely powerless before this disease, his general attitude as to the propriety of surgical interference should not be one of hostility. Experience only can determine the justification of surgical operation in cases of gastric cancer. As yet, it is too soon to express a positive opinion as to the value of resection of gastric cancer. Of 37 published resections of cancer of the pylorus, 27 died from the effects of the operation, and of the fatal cases 18 within the first twenty-four hours. These results are certainly not calculated to awaken much enthusiasm for the operation. Still, it would be wrong to draw definite conclusions from the existing statistics of resection of the cancerous pylorus, partly because the number of operations is as yet too small, partly because the operation has been done when it was certainly unwarrantable according to the best judges (Billroth, Czerny), and chiefly because the number of operators in proportion to the number of operations is too great. For the 37 published operations there have been 27 operators. Ovariotomy was not considered a justifiable operation until the excellent results of individual operators were obtained. It is probable that to an even greater extent resection of the pylorus will become the specialty of certain operators. Therefore, before concluding as to the value of resection of cancer of the stomach it is necessary to await the results of individual surgeons in a series of cases.

So much, however, is now certain, that with our present means of diagnosis the number of cases suitable for extirpation is very small. A {578} radical cure is to be expected only in the rarest instances, so that the value of the operation will depend chiefly upon the condition of the patient after its performance. As regards this point, the results in the successful cases have been encouraging. In several instances the terrible sufferings of the patient have given place to months of comparative health and comfort.

In cases of extreme cancerous stenosis of the pylorus which are not suitable for resection Wölfler proposed forming a fistulous communication between the stomach and the small intestine (gastro-enterostomy). The results of the operation have not been encouraging. Out of six cases in which this operation has been performed, only two patients lived after the operation.

For the same condition Schede proposed making a duodenal fistula (duodenostomy), but I am not aware that the operation has been performed.

The results of gastrostomy for relief of cancerous stenosis of the cardia or of the oesophagus have not been encouraging.

Non-Cancerous Tumors of the Stomach.

Little clinical interest attaches to non-cancerous tumors of the stomach. They are comparatively rare and usually unattended by symptoms. Even should a tumor be discovered, there are no means of determining the nature of the tumor; and if symptoms are produced by the tumor, the case will probably be diagnosticated as one of cancer. It is necessary, therefore, in the present work to do little more than enumerate the different forms of non-cancerous tumor of the stomach.

The most common of benign gastric tumors are polypi projecting into the interior of the stomach. These are usually so-called mucous or adenomatous polypi, being composed of hypertrophied or hyperplastic elements of the mucous membrane with or without new growth of submucous tissue. They may be present in large number (one hundred and fifty to two hundred in a case of Leudet's). Their development is usually attributed to a chronic catarrhal gastritis, so that a gastritis polypora has been distinguished. These polyps are important only when they obstruct one of the orifices of the stomach, in which case they may cause even fatal stenosis. This occurrence is very rare.

Benign adenomata appear less frequently as growths in the submucous coat of the stomach (Winiwarter).

Myomata and myosarcomata, projecting sometimes as polyps either into the gastric or the peritoneal cavity, may attain a very large size, as in a case reported by Brodowski in which a cystic myosarcoma of the stomach weighed twelve pounds.

Sarcoma, either as a primary or a secondary tumor of the stomach, is rare. Two cases of secondary lympho-sarcoma of the stomach (primary of the retro-peritoneal glands) without gastric symptoms have come under my observation. In a similar case reported by Coupland the symptoms resembled those of gastric cancer.

{579} In connection with gastric ulcer mention has already been made of the occurrence of miliary aneurisms in the stomach, which may be the cause of fatal hæmatemesis.

Sometimes the mucous membrane is studded with little cysts, as in a case reported by Harris.

Fibromata and lipomata are very rare.

Foreign bodies in the stomach, particularly balls of hair, have been sometimes mistaken for tumors, particularly cancer, of this organ. Schönborn removed successfully a ball of hair from the stomach by gastrotomy. Before the operation the tumor was considered to be a movable kidney.

{580}

HEMORRHAGE FROM THE STOMACH.

BY W. H. WELCH, M.D.

Hemorrhage from the stomach is a symptom, and not a disease. It is a result of a great variety of morbid conditions in the description of which it receives more or less consideration. Already the symptomatology and treatment of hemorrhage from the stomach have been considered in connection with its two most important causes--namely, gastric ulcer and gastric cancer. It remains to give a summary of the etiology and diagnosis of gastric hemorrhage.

Hemorrhage from the stomach is also called gastrorrhagia. The term hæmatemesis is not synonymous with gastric hemorrhage, for blood may be vomited which has simply been swallowed or has passed from the intestine into the stomach.

ETIOLOGY.--The causes of gastric hemorrhage are as follows:

1. Ulcer of the Stomach.--Simple gastric ulcer is the most frequent cause of abundant hemorrhage from the stomach. Tuberculous gastric ulcers, typhoid gastric ulcers, and the ulcers of phlegmonous gastritis are extremely rare causes of hemorrhage. Hemorrhagic erosion of the stomach, which by many writers is assigned an important place in the etiology of gastric hemorrhage, is not an independent affection, and in my opinion is without any clinical significance.

2. Cancer of the Stomach.--(Non-cancerous tumors of the stomach hardly deserve mention in this connection, so infrequently are they the cause of gastric hemorrhage.)

3. Traumatism (mechanical, chemical, thermic).--a. Acting from without the stomach: severe injury to the abdomen, as by a blow or a fall; penetrating wounds of the stomach.

b. Acting from within the stomach: foreign bodies, particularly sharp-pointed ones; corrosive poisons, as acids and alkalies; other toxic inflammatory irritants; and very hot substances. Here should also be mentioned injury from an inflexible stomach-tube and aspiration of mucous membrane with the stomach-pump.

4. Diseases of the Gastric Blood-vessels.--a. Aneurism of the arteries of the stomach. Miliary aneurisms have been found by Galliard and others as a cause of profuse and even fatal hemorrhage from the stomach. Especially in obscure cases should careful search be made for miliary aneurisms.

b. Varices of the veins are a not unimportant cause of gastric hemorrhage. They are most frequently associated with chronic passive {581} congestion of the stomach, but they may be found without any apparent disturbance of the circulation.

c. Degenerations of the vessels, particularly fatty and atheromatous degeneration of the arteries. Probably gastric hemorrhage in phosphorus-poisoning is to be attributed to fatty degeneration of the arteries. Amyloid degeneration of the blood-vessels is a doubtful cause of hemorrhage.