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Full text of "Cancer of the stomach; a clinical study of 921 operatively and pathologically demonstrated cases"

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CANCER OF THE STOMACH 



A CLINICAL STUDY OF 921 OPERATIVELY 
AND PATHOLOGICALLY DEMONSTRATED CASES 



/ ) 



BY 

FRANK SMITHIES, M. D. 

Gastro-enterologist to Augustana Hospital, Chicago; formerly Gastro-enter- 

ologist to The Mayo Clinic, Rochester, Minn.; formerly Instructor in 

Internal Medicine and Demonstrator of Clinical Medicine in 

the University of Michigan, Ann Arbor; Fellow of the 

American Gastro-enterological Association, Etc. 



With a Chapter on the 

SURGICAL TREATMENT OF GASTRIC 
CANCER 

BY 

ALBERT J. OCHSNER, M. D., LL. D., F. R. C. S. 

Professor of Clinical Surgery in the School of Medicine of the University of 
Illinois; Surgeon-in-Chief to Augustana Hospital, Chicago; Con- 
sulting Surgeon to St. Mary's Hospital, Chicago 



ILLUSTRATED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

191 6 



Copyriglit, 1916, bj' ^Y. B. Saunders Company 



Printed in America 



TO MY 

FIRST TEACHER IN MEDICINE 

DR. GEORGE DOCK 

AND 

MY FRIENDS 

DRS. JAMES B. HERRICK, RICHARD DEWEY, 

IRA DEAN LOREE 

AND 

WARREN PLIMPTON LOMBARD 



PREFACE 



This work attempts to set forth the facts which are 
considered valuable from a study of 921 operatively and 
pathologically demonstrated instances of gastric cancer. 

The cases and their records comprised part of my 
services, extending over ten years, at the University 
Hospital (Ann Arbor, Mich.), the Mayo Clinic (Rochester, 
Minn.), and my present clinic at Augustana Hospital. 

It is at least a decade since a monograph upon this 
subject appeared. The interim has been prolific in its con- 
tributions to our better clinical, pathologic and surgical 
knowledge of gastric cancer. It is to be hoped that the 
practical worth of the more important of these advances is 
sufficiently emphasized in the pages following. 

For numerous courtesies, I am indebted to many. Par- 
ticularly would I express my gratitude to Drs. William J. 
Mayo, Christopher Graham, William Carpenter MacCarty 
and Russell D. Carman of the Mayo Clinic, for permission 
to study cases and records, and for illustrations and material 
in the text. Dr. Frederick Hoffman, statistician of the 
Prudential Life Insurance Company, has generously al- 
lowed me to avail myself of the results of his valuable 
compilations. Dr. Albert J. Ochsner has kindly written 
the chapter entitled ''The Surgical Treatment of Gastric 
Cancer." It has been ably illustrated from sketches made 
at the operating-table by Mr. Thomas Jones. Drs. Oscar 
Nadeau and John Nuzum and Mr. E. Schmidt have helped 
with the illustrations and the text. My secretaries, Misses 
Pearl Empey and Frances Horgan, have been most faithful 
and painstaking. From my wife, I gladly acknowledge 
much practical aid and encouragement. 

13 



14 PREFACE 

Finally, it should be understood that this monograph has 
been written during a moderately busy life. It is by no 
means the ''last word" upon gastric cancer. It is simply 
one clinician's analysis of certain facts which he observed 
in a great group of patients affected with a like ailment. 

Frank Smithies. 

Chicago, Illinois, 
January, 1916. 



CONTENTS 



CHAPTER I 

Page 

General Distribtjtion axd Etiology 17 

CHAPTER II 
Morbid Anatomy: Gross, IMicroscopic and Experimental .... 51 

CHAPTER III 
Symptomatology 110 

CHAPTER IV 
Physical Abnormalities 160 

CHAPTER V 
Examination of Gastro-intestinal Function 193 

CHAPTER VI 
Roentgen Exaihnation in Gastric Cancer ' . . 268 

CHAPTER VII 
The Blood in Gastric Cancer 319 

CHAPTER VIII 

The Significance of Gastric Ulcer with Respect to Gastric 

Cancer 350 

CHAPTER IX 
Gastric Cancer in the Young 373 

CHAPTER X 

Differential Diagnosis 38,2 

15 



16 CONTENTS 

CHAPTER XI 

Page 

Surgical Treatment 417 

Bt Albert J. Ochsner, M. D., LL. D., F. R. C. S. 

CHAPTER XII 
Nox-suRGiCAL, Treatment 472 

Index op Names 501 

Index 505 



CANCER OF THE STOMACH 



CHAPTER I 
GENERAL DISTRIBUTION AND ETIOLOGY 

Definition. — Gastric cancer is a disease of the stomach 
produced by the development of a neoplasm in the wall 
of that \T-Scus. The affection is generally of a perniciously 
progressive natm'e, and occurs with the greatest fre- 
quency between the ages of 40 and 70 years. Fatal 
termination is the rule. The disease is characterized 
clinically b}^ imperfect gastric function. This malfunction 
usually manifests itself b}^ abdominal distress or pain, 
associated with loss of appetite and body weight, by 
weakness, anemia, cachexia, vomiting and the appearance 
of an epigastric tumor. 

The gastric extracts or the vomitus frequently exhibit 
deficient gastric empt^-ing power, diminished free hydro- 
chloric acid, altered blood and the presence of foreign 
organic acids, microorganisms and ferments. 

When the stomach is filled with substances opaque to 
the Roentgen t&j, alterations from the normal contour can, 
not infrequently, be demonstrated upon examination with 
the fluoroscopic screen or the x-ray plate. 

Frequency of Cancer in General. — Trustworthy statistics 
record that more than 75,000 deaths from cancer occurred 
in the United States during 1913. It is estimated that 
there were fully a half million deaths from malignant 
disease in the same period throughout the civilized world. 
Of the cancer deaths recorded in the United States Regis- 

2 17 



18 



CANCER OF THE STOMACH 



tration Ai'ea theii- ratio to deaths from all other causes in 
1911 was as 1 : 19.06. The differences in ratio geographic- 
ally are demonstrated in Table 1. 

Table 1 

T-v. 

State 



Michigan 

Vermont 

Wisconsin 

Wasliington . . . . 

Minnesota 

ISIaiae 

Massachusetts . 

CaJif omia 

Ohio 

Rhode Island . . 

New York 

Indiana 

New Jersey .... 
Connecticut . . . . 
Pennsylvania . . 

Utah 

Maryland 

Colorado 

North Carolina . 
Kentuckv 



Deaths, all 
causes 


Cancer deaths i 


Cancer ratio 


37,993 


2,137 


1:13. 05 


5,440 


396 


1:13.98 


26,987 


1,841 


1:14.65 


10,187 


679 


1:15.002 


21.988 


1,423 


1:15.24 


12.031 


738 


1:16.3 


53.003 


3.262 


1:16.55 


34,010 


2.053 


1:16.56 


65.466 


3,936 


1:16.63 


8.644 


510 


1:16.94 


142,608 


8,209 


1:17.37 


35.210 


1,943 


1:18.1 


37,779 


2,054 


1:18.39 


17,552 


895 


1:19.5 


111,842 


5,426 


1:20.61 


3,913 


188 


1:20.81 


20.694 


955 


1:21.5 


10.740 


459 , 


1:23.3 


6,672 


219 1 


1:30.46 


30,407 


986 


1:40.8 



Ratio of Cancer Deaths to deaths from all other causes in United States 
Registration Area in 1911. 

It is seen that 7 of the then registration states fell be- 
low the general average, while 13 states rose above such. 
The striking difference in ratio between cancer deaths in 
Michigan from those in Xorth Carolina and Kentucky 
(more than 3 times the minimum) would seem to point 
to either errors in diagnosis or local increase from unsolved 
cause in the states evidencing the maximum. 

Coniparison between the ratio of cancer deaths in the 
United States and foreign countries is estimated on the 
same basis of mortahty returns in Table 2 modified from 
Budav. 



GENERAL DISTRIBUTION AND ETIOLOGY 

Table 2 



19 



Country 



Ratio 



Country 



Ratio 



BrazH. (1908)! 0.41 

Portugal (1904) 2.39 

Spain (1903) 4.4 

Japan (1905) 5.3 

Belgium (1907) 6.02 

Victoria.! (1907)' 6.09 

Italy (1906) 6.09 

Hungary (1904) 7.00 

Germany (1907), 7.45 

Austria (1905)^ 7.5 



U. S. A (1908) 

England (1907) 

New Zealand .... (1907) 

Norway (1906) 

Holland (1903) 

Sweden. . . . (1890-1898) 

France (1906) 

Denmark (1907) 

Switzerland (1907) 



7.65 

9.08 

9.3 

9.75 

9.9 

9.96 

10.00 

12.2 

12.5 



Comparison between ratio of Cancer Deaths in the United States and 
in other countries.- 



Wide variations in cancer death ratio are shown. These 
cannot be explained wholly upon the theory of inefficient 
government mortality records or unproved diagnoses. 



Table 3 



Age period 


1911 


1901 


all ages 


Persons Males 


Females 


Persons 


Males 


Females 


Crude rate 


83.9 

77.6 

3.0 

1.2 

1.3 

2.3 

4.8 

13.9 

61.0 

166.3 

352.4 

566.7 

794.7 

155.7 
159.0 


64.2 

56.7 

3.1 

1.3 

1.0 

2.9 

4.9 

9.7 

31.1 

109.2 

283.4 

512.8 

730.5 

117.7 
117.9 


104.0 

97.2 

3.0 

1.1 

1.5 

1.7 

4.6 

19.4 

92.5 

227.0 

422.3 

617.8 

848.7 

195.0 
195.9 


65.8 

62.2 

3.4 

1.0 

0.9 

2.1 

3.9 

13.4 

60.2 

146.5 

268.3 

418.8 

557.6 

124.5 
127.2 


48.7 

43.6 

3.8 

1.3 

0.9 

1.9 

3.3 

9.4 

32.5 

90.0 

203.8 

366.0 

520.8 

90.9 
90.4 


83.0 


Corrected rate 


79.7 


Under 5 years 


3.1 


5 to 9 years 

10 to 14 years 


0.8 
0.9 


15 to 19 years 


2.2 


20 to 24 years 


4.5 


25 to 34 years 


17.5 


35 to 44 years 


89,6 


45 to 54 years 


205.4 


55 to 64 years 


331.8 


65 to 74 years 


468.9 


75 years and over 

25 years and over : 
Crude rate 


589.8 
158.7 


Corrected rate 


160.3 







Mortality from Cancer in the United States, 1901-1911. (Registration 
States of 1900; Rates per 100,000 of Population by Age and Sex.) 



20 



CAXCER OF THE STOMACH 



Increase in Cancer in General. — For much of our 
accurate knowledge that such increase is real and not 
apparent we are indebted to Hoffman. That this is so 
for the United States is exhibited in Table 3, compiled from 
the publications of the Department of Commerce. The in- 
crease is plotted for each set in Charts I and II (page 21). 

Emphasis is to be placed upon the fact that there has 
been an actual increase in general cancer mortality rate 
in all decades above age 40. Hoffman has computed, 
from an enormous experience, that in the United States 
the number d}dng from cancer at the present time is 
approximately 25 per cent, greater than 10 years ago. He 
finds that of the total mortahty from cancer in the regis- 



Tahle 4 
(Rates per 100,000 Population) 



1900 



1909 



Actual 
increase 



Per cent, of 
increase 



Switzerland 

Netherlands 

Scotland 

England and Wales. 

Norwaj^ 

German Empire 

Ireland 

Austria 

New Zealand 

Australia 

Japan 

Italy 

Denmark 

Spain 

Hungary'' 

Jamaica 

Serbia 

Ceylon 



129.9 
91.7 
79.0 
82.9 
90. S 
72.1 
60.8 
70.9 
56.3 
62.6 
45.4 
52.2 
46.2 
39.3 
36.7 
16.5 
9.4 
6.6 



126.7 
102.6 
101.6 
96.1 
94.6 
83.5 
SO.O 
78.6 
73.2 
72.3 
65.2 
63.5 
56.1 
51.0 
44.5 
18.3 
12.61 
4.0 



3.22 

10.9 

22.6 

13.2 

3.8 

11.4 

19.2 

7.7 

16.9 

9.7 

19.8 

11.3 

9.9 

11.7 

7.8 

1.8 

3.2 

2.6^ 



2.52 
11.9 
28.6 
15.9 

4.2 
15.8 
31.6 
10.9 
30.0 
15.5 
43.6 
21.6 
21.4 
29.8 
21.3 
10.9 
34.0 
39.42 



Average 



59.6 



73.5 



13.9 



23.3 



1908. - Decrease. 

International Cancer Statistics, 1900-1909. 



GENERAL DISTRIBUTION AND ETIOLOGY 



21 



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22 



CANCER OF THE STOMACH 



tration area during 1906 to 1910, the proportion of such 
deaths at the age of 45 and over was 83 per cent. 

In countries other than the United States this increase 
in cancer mortality practically is a constant finding, as 
shown by Table 4. 

The relative increase in Germany, England and America 
is demonstrated graphically in Chart III. These statistics 
return the significant information that 'Hhe cancer death 
rate in the civilized portion of the earth has increased 23.3 
per cent, in the past decade." 

In Gastric Cancer, the ratio of occurrence to that of 
non-cancerous disease is to be determined mainly from 
the study of hospital admissions and mortality records. 
Information obtained from examination of hospital ad- 
missions is of but relative worth inasmuch as reports of 
this type are not representative of the status of the whole 
mass of population. The class of patients frequenting 
large general hospitals is often not a true index of the kind 
of folk inhabiting a given zone. Moreover, it should 
be observed that not infrequently the statistics reported 
are from hospitals largely surgical, to which patients go 
on account of the reputed skill of some operator. 

Table 5 indicates the gastric cancer admission ratios 
in representative American and English hospitals. It is 

Table 5 



Hospital 


Total 
admissions 


Number of 
gastric 
cancers 


Ratio 


Johns Hopkins Hospital 


8,464 
11,812 

9,458 
18,958 
23,500 

4,643 


150 

129 

54 

98 

106 

20 


Ito 56.4 


Mass General Hospital 


Ito 91.5 


Montreal General Hospital 


Ito 175.0 


St. Thomas, London 


Ito 193.6 


St Bartholomew's, London 


Ito 221.6 


London Temperance Hospital 


Ito 231.2 







Proportion of Gastric Cancer admissions to total admissions of Repre- 
sentative Hospitals. 



GENERAL DISTRIBUTION AND ETIOLOGY 



23 



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/88S 
/886 
/687 
/S88 
/889 
/8JO 
/89/ 
/S92 
/893 

/89s- 
/896 

/8f3 

f900 
/90/ 
/90Z 
/903 

/907 
/908 
/909 

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24 CANCER OF THE STOMACH 

seen that while in general the above hospitals occupy 
similar positions in their respective communities, the 
admission rates exhibit a wide range in the frequency of 
gastric cancer. While in ratio, the London hospitals 
vary least, that of American hospitals along the Atlantic 
seaboard shows rather striking and unexplainable differences. 

Our 921 instances of gastric malignancy occurred in 
approximately 82,000 clinical admissions for all forms of 
medical and surgical disease. The average age of these 
patients was about 40 years. These figures return a ratio 
of the frequency of gastric cancer of approximately 1 to 
89 hospital admissions. 

The information returned from the study of mortality 
records is of but relative value. Until recently, the 
American mortality statistics were partly fact and partly 
estimate, owing to there being but a limited area of regis- 
tration. Even in registration areas the returns are open 
to question, inasmuch as they are based upon material 
which has been checked but rarely by pathologic re- 
ports. That mistakes in the diagnosis of gastric cancer 
commonly occur even in large city practice, is emphasized 
by Fenwick. He states that of 56 cases, admitted into 
London hospitals, under his care, with a diagnosis of gastric 
cancer, in only 31 (55.3 per cent.) was the disease proved 
to exist. In 25 instances (44.7 per cent.) the patients 
were free from the disease. These mistakes had occurred 
in spite of the fact that the average duration of the illness 
prior to hospital admission was nearly 4 months. An ex- 
perience similar to this can be furnished by any American 
hospital that makes a practice of requiring a pathologic 
or laparotomy diagnosis, instead of one based upon purely 
clinical or chemical evidence. Cabot states that in 



GENEKAL DISTRIBUTION AND ETIOLOGY 



25 



his large experience correct clinical diagnosis of gastric 
cancer occurred in but 72 per cent, of instances. 

Dependable mortality reports indicate that gastric 
cancer furnishes nearly 38 per cent, (or about 30,000 
cases annually) of all cancer deaths. These figures indicate 
that malignant disease of the stomach is more common 
than is malignancy of any other organ. The rate is fully 
10 per cent, higher in males than in females. In the 
latter, malignancy of the genitalia and peritoneum is 
more frequent. These various factors are well demon- 
strated in Table 6. 



Table 6 

(Rates per 100,000 Population) 

(Ages 40 and over) 

Males 



Number 



Per cent. 



Rate per 
100,000 



Stomach and liver 

Rectum, intestines and peritoneum . 

Buccal cavity 

Skin 

Other organs 



Total, ages of 40 plus . 
Total, all ages 



50,157 

11,980 

7,304 

6,252 

23,690 



50.5 

12.1 

7.3 

6.3 

23.8 



99,383 
109,299 



100.0 



96.6 
23.1 
14.1 
12.0 
45.6 



191.4 



Females 



Stomach and liver 

Generative organs 

Breast 

Rectum, intestines and peritoneum . 

Skin 

Buccal cavity 

Other organs 



50,388 
35,587 
22,190 
16,751 
3,303 
1,529 
24,598 




Total, ages 40 plus . 
Total, all ages 



154,346 
173,369 



Cancer Mortality by Organs or Parts Affected; U. S. Registration Area, 
1901-1910.— (Hoffman.) 



26 



CANCER OF THE STOMACH 



The increase in gastric cancer is real and alarming. At 
age 40 and above, it has increased more than 10 per cent, 
for both sexes. This is well brought out by Table 7. 

Table 7 
(Rates per 10,000 Population) 



Ages 


Males 


Females 


Actual excess in 
female rate 


Excess 
per cent. 


30 to 39 

40 to 49 
50 to 59 
60 to 69 
70 to 79 
80 + 


7.8 

34.2 

88.7 

182.9 

262.2 

207.6 


10.2 + 

39.0 + 

99.7 + 

192.2 + 

282.0 + 

201.2 + 


2.4 
4.8 

11.0 
9.3 

19.8 


30.8 

14.0 

12.4 

5.1 

7.6 








40 + 


96.6 


108.2 


11.6 


12.0 



Mortality from Cancer of the Stomach and Liver; U. S. Registration 
Area, 1901-1910. 

Sex. — Clinical and pathologic data, compiled from hos- 
pital and dead-house reports of a half century ago, would 
appear to indicate, with few exceptions, that gastric cancer 
is of rather more frequent occurrence in males than in 
females. Certain groups of statistics are often quoted in 
support of this statement. In 1859, Brinton declared, after 
studying reports of 600 cases, that the disease occurred 
twice as frequently in males as in females. In 1872, Fox 
collected 1,303 instances of gastric cancer from the litera- 
ture and his own practice. There were 680 males and 623 
females. Welch's analysis of 2,214 cases of gastric malig- 
nancy (recorded mainly in continental literature during a 
period when microscopic pathology was in its infancy) 
demonstrates the ratio of males to females as 5 : 4. Fen wick 
claims a proportion of males over females of approximately 
6:4. Friedenwald has recently collected 1,000 cases, clin- 
ically of gastric cancer (26.6 per cent, came to laparotomy) 
and records that there were 588 males and 412 females. 



GENERAL DISTRIBUTION AND ETIOLOGY 



27 



In our series of 921 cases, which were proven to be 
primary gastric cancer operatively and pathologically, 
there were 693 males and 228 females, or 3.04 males to 1 
female. 

This proportion is particularly interesting because it 
comes from controlled material; it is a distinctively Ameri- 
can experience; it has been returned mainly from living 
and not dead subjects; it closely approximates the sex 
ratio which is associated with simple chronic gastric 
ulcer. 




/-J ,o-,s 2JS-Z9 JO-39 ^-*y ^0-S9 60-69 TO-JS 80-3} So-iao 



Chart IV. — Incidence of gastric cancer by age and sex. The upper line 
represents males, the lower, females. — (Author.) 

Age. — According to modern writers, from 60 to 70 per 
cent, of the deaths from gastric cancer occur between the 
fortieth and seventieth years. In the Hving the incidence 
is commonly recorded as being greatest between the fiftieth 
and sixtieth years. Necropsy reports usually place the 
maximum age frequency rather higher than where such is 
determined from living patients. 



28 



CANCER OF THE STOMACH 



Table 8 shows the age incidence by decades and sex in 
the material which we have studied. Chart IV demon- 
strates graphically the age curves in relation to sex. 



Table 8 



Age 



Male 



Female 



Total 



1 to 9 
10 to 19 

20 to 29 
30 to 39 

40 to 49 
50 to 59 
60 to 69 
70 to 79 
80 + 















1 


1 


4 


5 


9 


54 


34 


88 


159 


73 


232 


284 


66 


350 


160 


40 


200 


31 


9 


40 


1 





1 



693 



228 



921 



Total Cases 921. Ratio Males to Females, 3.04 : 1. 

Sex and Age by Decades. — (Author's Series.) 



Certain facts of interest are brought out. The greatest 
number of cases occurred in the sixth decade (350 cases 
between ages 50-59). Between ages 40-69 there occurred 
84.9 per cent, of all our cases. Ten instances (1.20 per 
cent.) were tabulated below age 30. One case died of 
gastric cancer at age 19. In males the greatest number of 
cases feU between ages 50-59 (40.9 per cent, of the total 
for the sex), while 87 per cent, of all cases fell between 
ages 40 and 69. In females the disease appeared to occur 
at a rather earher period of life than in males. In this sex 
the greatest number of cases (73) were in the fifth decade, 
while 78 per cent, of all instances came between ages 40—69. 

Race and Nationality. — Friedenwald states that 5.2 per 
cent, of his cases of gastric cancer occurred in negroes. In 
this race the greatest frequency of the disease was in the 
sixth decade. Hoffman has made a careful study of the 



GENERAL DISTRIBUTION AND ETIOLOGY 



29 



difference in mortality from cancer of the stomach and liver 
in whites and colored (Table 9). 

Table 9 
(Rates per 100,000 Population) 



Ages 



Males 



Females 



WHte 



Colored 



WMte 



Colored 



30 to 39 


9.7 


15.2 


8.7 


11.3 


40 to 49 


28.3 


30.5 


31.3 


27.4 


50 to 59 


89.5 


84.4 


87.6 


91.0 


60 to 69 


221.0 


166.4 


151.6 


82.0 


70 + 


268.3 


152.3 


168.5 


160.6 



40 + 



105 . 5 



73.1 



84.5 



64.5 



Mortality from Cancer of the Stomach and Liver, by Races; District of 
Columbia, 1901-1910.— (Hoffman.) 

He observes that the death rates for negroes exceed 
those for whites, in males at ages under 50, and for females 
under 40. Above such ages, the white death rate is in 
excess of that of the negro. It would seem also that gastric 
cancer is becoming more prevalent among the American 
negroes. This is shown by the reports of the U. S. Dept. 
of Commerce, 1912-13. 

Our investigations record no case of gastric cancer among 
negroes. This, doubtless, happens because we rarely see 
a negro patient. 

While 40.3 per cent, of our patients were American born, 
yet nearly 80 per cent, were of foreign extraction. We have 
attempted to classify these facts in Table 10. 

It has been stated frequently that gastric cancer is 
uncommon in Jews. From a relatively small proportion 
of Jewish patients, our records show 17 (1.8 per cent.) 
cases in either American or foreign born Jews. There 
were 11 males and 6 females. It would appear that, Uv- 
ing under similar conditions, Jews are as prone to the 



30 



CANCER or THE STOMACH 

Table 10 



Nationality 


Number of cases 


Per cent, of total 


Americans 


372 

170 

143 

108 

73 

18 

12 

11 

4 

3 

2 

2 

1 

1 

1 


40.3 


Irish 


18.0 


Swedish 


15.5 


German 


11.7 


Norwegian 


7.8 


Austrian 


1.9 


Danish 


1.3 


Russian 


1.02 


English 


0.43 


Belgian 


0.32 


French 


0.22 


Italian 


0.22 


Alaskan 


0.10 


Mexican 


0.10 


Portuguese 


0.10 






Total 




921 


100 



Incidence of Gastric Cancer by Nationality — (Author.) 

disease as are other human famihes. It has been advanced 
that the explanation for the former supposition of the 
lessened habihty of Jews to cancer lay in the fact that 
Jewish families were usually large — whence the proportion of 
young Jews to old was relatively great. At present it is 
not uncommon to find many small Jewish families (par- 
ticularly in America), probably as the result of prosperity, 
heterodoxy, and altered mode of life. This may explain 
the evident increase of gastric cancer among modern 
Jews. 

While we have no specific data to offer, our observations 
would appear to indicate the relative infrequency of car- 
cinoma of the stomach among those races far removed 
from modern civilization, so called. It is quite possible, 
however, that accurately compiled statistics from the 
lands inhabited by such folk will eventually demonstrate 
the ubiquity of the disease. Certainly cases are not 



GENERAL DISTRIBUTION AND ETIOLOGY 31 

infrequently being reported from Japan (Miyake). Dr. 
Hie Ding Lin of Foo Chow, China, personally assures me 
that not uncommonly well-to-do Chinese die from chronic 
gastric disease, often of a type associated with cachexia 
and anemia. 

Occupation. — At the present state of our knowledge, 
it cannot be said definitely that any one type of work pre- 
disposes to gastric cancer. It has been observed by 
Tatham that the general cancer mortality during the 
period 1881-1890 was twice as great among the financially 
prosperous, having no particular occupation, as it was 
among occupied males with diverse vocations. Aschoff 
seems to havg shown that Berliners living on incomes or 
pensions furnished the greater part of the cancer mortality 
in their section. Roger Williams makes similar comments. 
These general studies are interesting, but by no means 
conclusive. It is perhaps possible that the explanation 
for the evident frequency of cancer in the retired, well- 
to-do part of the population may be found in the observa- 
tion that this class is mainly made up of individuals at 
the cancer age. Relatively few persons succeed in amassing 
sufficient material wealth before the fifth decade to enable 
them to stop working. It will be recalled that approxi- 
mately 8 out of 10 cases of gastric cancer occur above age 40. 

We have grouped our material, according to occupation, 
in Table 11. 

A very striking feature of the Table is the preponderance 
of farmers. The series demonstrates that 32.4 per cent, 
of our instances of the disease occurred in farmers, active 
or retired. The proportion of patients of this type is 
increased by 11.3 per cent, on analysis of the group 
labeled ''housework." These patients were farm-dwellers, 
living under similar conditions to the males furnishing the 



32 



CANCER OF THE STOMACH 



Table 11 



Farmers 

Housework 

Laborers 

Merchants 

Carpenters 

Traveling salesmen. 

Blacksmiths 

!Miners 

Teamsters 

Ph5'sicians 

Lawyers 

Lumber dealers 

Clergj^men 

R. R. conductors. . . 

Teachers 

Engineers 

Contractors 

Clerks 

Painters 

^Machinists 

Shoemakers 

Salesmen 

Postmen 

Plumbers 

Saloon-keepers 

Ranchers 

Insurance men 

Druggists 

^Manufacturers 

Grain dealers 

Stone cutters 

Liquor dealers 

Xurses 

Well drUlers 

Cooks 

Students 

Tailors 

Watchmen 

R. R. agents 

Bankers 

Bookkeepers 

Butchers 

Live-stock men 



299 

187 

43 

39 

19 

16 

14 

10 

10 

10 

9 

9 

9 

S 

8 

7 

7 

6 

6 

6 

6 



Barbers 3 

Car-shop laborers 3 

Dressmakers 3 

Brewers 3 

Liverj'men 2 

Jewelers 2 

Hotel keepers 2 

Dairymen 2 

Bridge buUders 2 

Construction engineers 2 

Restaurant keepers 2 

Dentists 2 

Photographers 2 



Electricians 

Peddlers 

Watchmakers 

Printers 

Auctioneer 

Woodsman 

Retired soldier 

Prison guard 

Brakeman 

Veterinary surgeon. 

Policeman 

Optometrist 

Real estate 

Judge 

Janitor 

Stage hand 

ElectrotjTDer 

Statistician 

Horse trainer 

Tinsmith 

SaUor 

Plast-erer 

Stenographer 

Gardener 

Gunsmith 

Brassworker 



2 

2 

2 

2 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

Unclassified 46 



Total 921 



Occurrence of Gastric Cancer According to, Occupation. — (Author's series.) 

''farmer" class. Certain other so-called ''out-door" oc- 
cupations largely contributing, actually or relatively, 



GENERAL DISTRIBUTIOX AND ETIOLOGY 33 

to the list are laborers, traveling salesmen, teamsters, 
ranchers, stockmen, Hverymen, construction engineers, 
well -drillers, contractors and gardeners. These occupa- 
tions make up nearly 55 per cent, of our total. Even 
when it is considered that mam^ of the patients seeking 
relief at the cUnics, where our work was done, are from 
rural communities, yet the figures are sufficiently remark- 
able to warrant consideration. In the study of general 
cancer etiology, Wilhams (loc. cit.) has observed that 
while much of the material which he studied came from 
Londoners following sedentary occupations, there was a 
strikingly large proportion of cancer cases among the group 
engaged in out-of-door work. Ochsner has frequently 
called attention to the fact that many individuals affected 
with gastric cancer are hberal consumers of uncooked or 
unwashed vegetables and fruits. This is not an un- 
common and preponderant diet at certain periods of the 
year in rural communities. Urban populations, especially 
the well-to-do, are able also to indulge liberally in similar 
deUcacies and frequently all the year round. In cities 
there is an increasing consumption of head lettuce, radishes, 
cucumbers, young onions, melons, plums, peaches, grape- 
fruit, etc. It may be that irritants, parasitic or chemical, 
are ingested with such unwashed or uncooked foods, which 
influence atypic metaboHsm. 

Our analysis fails to show the immunity of printers, 
miners, quarry-men or industrial workers to gastric cancer. 
It cannot be said that there is a pecuhar susceptibility to 
the disease among merchants, brewers, cooks, hotel- 
keepers, domestics, metal-workers or sailors. In this 
series carpenters, blacksmiths and shoemakers furnish a 
comparatively high proportion of instances of gastric 
cancer when one recalls the limited number of men, 



34 CANCER OF THE STOMACH 

per population, actually engaged in such labor. Hard 
physical effort, the swallowing of nails, bits of wood, etc., 
combined with Hability to abdominal injury, may be a not 
unimportant contributing factor in the production of the 
disease. 

Social Status. — It has been said that a high cancer 
mortaUty is an indication of general prosperity (Williams) . 
Material abundance in some way appears to favor the 
development of malignancy'. The highest cancer incidence 
is found in those communities where people are well 
housed, well fed and free from the cares associated with 
the struggle for bare existence. Where poverty is preva- 
lent, as in centers of dense population, prisons, asylums 
and almshouses, cancer is relatively infrequent. Williams 
has noted that Ireland has a much lower cancer death rate 
than has England. In the former country riches and the 
concomitant ease and abundance of food are somewhat 
rare. ^Moreover, in those parts of Ireland where the con- 
ditions of life are hardest and the people are uniformly 
under fed {e.g., Kerry), the cancer mortality is lowest. 
In an extremely interesting study of life insurance statis- 
tics, Hoffman proves that the proportionate mortaUty 
from cancer is measurably less among risks representative 
of the wage-earning population than it is among those 
risks from the prosperous and well-to-do group, even 
though the latter class is subjected to more rigid medical 
examination on entrance. At age 40-50, the proportionate 
mortality from cancer for males was 5.1 per cent, in the 
wage-earning group and 6.7 per cent, in the well-to-do 
division. For females at the same decade, the propor- 
tionate mortaUty was 13.7 per cent, for the wage-earning 
and 18.5 per cent, for the prosperous. 

The patients comprising our series of gastric cancers 



GENERAL DISTRIBIJTION AND ETIOLOGY 35 

were largely from that great middle class making up the 
bulk of the population of the Mississippi Valley, the 
northwest United States and southern Canada. There 
were few people extremely poor or uncomfortably rich. 
The great number was in easy circumstances; certainly the 
cases actually fighting for mere existence were rare. 
A large part of the group was made up of folk whose parents 
were foreign born, or who themselves had emigrated from 
other shores when young. While the early years of many 
had doubtless been strenuous, the later life had seen the 
majority installed in comfortable homes and surrounded 
with many material luxuries. It has been pointed out 
by numerous writers that just this type of population 
furnishes the mass of the never-ending cancer army. The 
environmental change, the unaccustomed abundance of 
meat and drink, combined with sedentary life at the cancer 
age and the urbanization of a class of people previously 
largely rural, appear to stimulate the metabolism of cells 
that are perhaps already of perverted tendency. 

Conjugal State. — Of our entire series 806 patients 
(87.5 per cent.) were married or were widows or widowers. 
Fifty-two were single. The status of 63 was not noted. 
In our series there were 7 instances where gastric cancer 
had developed in man or wife within 5 months of its in- 
ception or the fatal issue in the other. 

Diet and Nutrition. — Accumulated evidence fails to 
demonstrate that especial frequency of gastric cancer can 
be attributed to over-indulgence in any particular kind of 
food. Except in rare instances, chronic over-eating appears 
to be more detrimental to the stomach than does the kind of 
viands ingested. Statistical evidence in proof of this state- 
ment is not lacking. Reviewing the investigations of the 
Actuarial Society of America, Hoffman states that an 



36 CANCER OF THE STOMACH 

analysis of the relation of the physique of life insurance 
applicants at entry to causes of death was made. Those 
applicants who were over-weight at entry returned cancer 
death rates (age 15-19) of 0.9 per 10,000, while the under- 
weights in the same group had a cancer mortality of 
0.8 per 10,000. At ages 30-44, the cancer mortality of 
over-weights was 3.7 per 10,000 and of under-weights 2.4. 
At age 45 and over, the cancer mortality of over-weights 
was 15.6 and of under-weights 12.0 per 10,000. 

That excessive feeding puts unnecessary work upon the 
digestive glands is quite within reason. That this highly 
specialized type of gland may be stimulated to chronic 
over-activity by excessive amounts of food is well within 
the bounds of known physiology. What effect upon 
intraglandular metabolism this demand for special products 
may have we can but conjecture. It might be suggested 
that should these excessive demands ultimately leave an 
exhausted cell — that is, exhausted in so far as its specific 
function is concerned — such cell might not only be more 
susceptible to trauma (mechanical, chemical or parasitic), 
but reasonably might be expected to proliferate in a' 
vegetative, undifferentiated manner due to the stimulus 
of its individual over-nourishment. 

Careless mastication or the indulgence in hot or cold 
liquids appears to have little significance apart from the 
possibilities of intragastric trauma. 

Upon extremely slender evidence, it has been held 
that excess of proteid food was responsible for the preva- 
lence of gastric cancer. While such excess may be a 
contributory factor to a cause of the disease, yet it will 
be recalled that gastric cancer is rarely found in the North 
American Indian or the Esquimaux. The great labor- 
ing classes in the United States consume astonishingly 



GENERAL DISTRIBUTION AND ETIOLOGY 37 

large amounts of proteid food, and yet in these groups 
cancer has a low ratio of incidence. Our investigations 
demonstrate that less than 7 per cent, of the patients 
were excessive proteid eaters, while 58.8 per cent, subsisted 
upon a mixed diet. Dietetic information was not ob- 
tained regarding 29 per cent, of cases. 

Certain sects have in some unexplained way convinced 
themselves that abstinence from proteids (meats, eggs, etc.) 
prevents alimentary cancer. Rather more than 5 per cent, 
of our cases either had refrained from meat for years or 
had been strict and life-long vegetarians. As we have 
shown above, more than half of our cancer cases came from 
people living in small towns or rural communities, where 
an abundance of vegetables and fruit is eaten. Among 
many such people fresh meat is eaten rarely more than 
three times weekly. Whether or no the ingestion of an excess 
of raw or unwashed vegetables or fruits acts unfavorably 
upon the gastric lining has not yet been proven. How- 
ever attractive may be the theory, there is certainly no 
experimental evidence that a parasite causing gastric 
cancer is introduced into the body in this way. Fenwick, 
quoting Hendly, states that of 102 patients who were 
operated upon for general carcinoma at Jeypore, India, 
between 1880 and 1888, 59.8 per cent, were life-long 
vegetarians. 

Alcohol. — While there is much carelessly expressed 
opinion upon the matter, there is no proof that the partak- 
ing of alcoholic liquors predisposes to gastric cancer. In 
this relation, Williams calls attention to the following 
significant facts : Of several hundred female cancer pa- 
tients, the majority had led sober lives; of 116 male cancer 
patients, aged from 40-65, 50.7 per cent, had been total 
abstainers or habitually temperate, 25.7 per cent, had 



38 CANCER OF THE STOMACH 

been irregular drinkers, while 22.3 per cent, had been 
constant indulgers; the increase in alcoholism among 
women has been relatively greater than among men, yet 
cancer has proportionately increased among males; while 
it has been stated that those whose occupations permit 
of special facility in obtaining alcoholic drinks (hotel 
keepers, brewers, traveling salesmen, etc.) have a rela- 
tively high cancer mortality, it has also been noted that 
individuals engaged in certain vocations where drinking is 
very common (printers, iron and steel workers, com- 
positors, paper makers, miners, etc.) appear to be less 
prone to cancer than do their fellows in the same com- 
munity; and lastly, although cancer mortality is high in 
certain alcohol-consuming countries (Bavaria, Saxony), 
other sections equally intemperate (Spain, Italy, West 
Ireland) return a relatively low cancer death rate. Fen- 
wick claims that nearly 40 per cent, of his patients at the 
London Temperance Hospital were total abstainers. Re- 
viewing 150 cases of the disease, Osier and McCrae state 
that 51.3 per cent, had used alcoholic drinks, but only 5.33 
per cent, gave history of excessive indulgence. 

We have definite figures with reference to 258 males 
of our 921 gastric cancer cases. In females the question 
was frequently not put when taking the history. Of this 
group 53 (20.6 per cent.) were total abstainers. Of the 
205 remaining cases 11 (5.3 per cent.) were pronounced 
topers. The balance claimed either an occasional debauch 
or took small quantities of beer, light wines, "hard" 
cider or whiskey, as the desire visited them. 

Habits. — Tobacco. — Of 423 males from whom we were 
able to obtain information, 272 or 64.3 per cent, used to- 
bacco in some form. Of these, 41 or 15.1 per cent, were 
excessive smokers. 



GENERAL DISTRIBUTION AND ETIOLOGY 39 

Venereal Disease. — Definite information was possible 
in 504 males. Of this number 43 (8.5 per cent.) admitted 
gonorrhea and 6 (1.2 per cent.) had had hard chancres. 
It is quite possible that the proportion of those actually 
having had venereal disease is higher than our figures indi- 
cate. While the incidence of gonorrhea and syphilis 
among these gastric patients appears to have little, if any, 
direct etiologic bearing upon the disease, yet the ad- 
mission of such infection is a certain useful index of the 
patient's general habits. 

Traumatism. — Such may be mechanical, chemical, bio- 
chemical or parasitic. Injury, mechanically, to the gastric 
lining may result from ingestion of hard chunks of food 
or foreign bodies. Only rarely do such injure normal 
gastric mucosa. When such a lesion as peptic ulcer, atro- 
phic gastritis or neoplasm already exists, the consequence 
of frequent temporary irritation (as improper food) or a 
constant irritant (foreign body) cannot be overlooked. 
Carcinomatous change may be incited in benign gastric 
ulcer, as shown by Fiitterer, or acceleration in the rate of 
growth of a neoplasm already present might be expected. 
It is quite possible, although as yet unproved, that chemical 
irritants (alcohol, tobacco juice, etc.) or biochemical 
bodies (as the end digestion products of certain foods or 
substances formed as result of their deterioration) may 
act similarly. That parasites ingested in food are capable 
of actually causing certain atypic growths appears to 
have been shown recently by Fibiger. As a consequence' 
of his feeding rats upon roaches infested with a certain 
nematode, growths of a cancerous type developed in a 
large number of the stomachs of such rats. 

That external traumata of mechanical type sometimes 
influence the development of gastric malignancy appears 



40 CANCER OF THE STOMACH 

proved. One cannot always state that such injury deJfi- 
nitely caused cancer to develop, but there would seem to 
be abundant evidence that latent processes may be aroused 
to activity following certain injuries. 

We had 21 patients (2.6 per cent.) where traumata had 
occurred shortly before the onset of gastric malignancy. 
In 14 of these (1.5 per cent.), injuries occurred in the early 
history of the affection and were shortly followed by the 
appearance of symptoms. The traumata were usually 
blows, falls or kicks in the abdomen, or crushing accidents 
from such events as being run over by a vehicle. The 
following case is illustrative: 

F. V. — Male, age 52, teamster. Comes on account of 
epigastric distress, weakness, weight loss and recent hem- 
atemesis and melena. 

Family history negative. Denies venereal. Up to 2 
3^ears ago was in perfect health. At that time was thrown 
from a wagon. FeU hard upon his back, and was confined 
to bed for a week. On getting about again noted burning 
sensation in epigastrium, usually several hours post cibo and 
at night. This distress occurred on and off and was never 
severe. Relief was gained by rest, diet, and medicine 
given him by physician (alkali?). Appetite and bowels re- 
mained negative. There was some bloating and flatulence. 
Nothing different from the above was observed until 
about 3 months ago. At that time he received a severe 
blow in the ''pit " of the stomach. His ''wind was knocked 
out" and he suffered rather acute distress for a half hour. 
Several hours afterward he vomited about a pint of blood 
mixed with food. He felt "sick all over" and perspired 
rather profusely. For 2 or 3 days afterward he passed 
black stools. He has "never been himself since." He has 
continuous burning in epigastrium and no appetite. 

Condition on examination revealed weight loss of 40 
pounds (in about 2 months); hemoglobin, 87 per cent.; 
considerable emaciation, and a movable nodule in the 
upper, mid-epigastrium. 

Test-meal revealed free Hcl, 0; total acidity, 64. There 



GENERAL DISTRIBUTION AND ETIOLOGY 41 

were lactic acid and altered blood present. Glycyl- 
tryptophan test was positive. Pyloric obstruction was 
proved by persistent 12-hour food retention. 

Microscopically, Oppler-Boas bacilli were seen in abun- 
dance. 

Laparotomy disclosed an irremovable carcinoma involving 
the entire pyloric region of the stomach. The perigastric 
lymph glands were involved. Anterior gastro-enterostomy 
was performed. The patient died 11 days afterward. 

Hygiene. — We have called attention to the fact that 
approximately half of our patients came from rural com- 
munities or small towns. The majority of these people 
were farmers or had lived upon farms. Many subjects were 
foreign born or of alien parentage. While the plane of 
life of the American farmer is relatively high, yet it must 
be admitted that both general and personal hygiene are 
susceptible of improvement. This is especially so among 
immigrant farmers. One not infrequently sees housing 
conditions for horses and stock practically as perfect as 
those for the landsman himself. The residence is generally 
built after other things have been adequately taken 
care of. Consequently, over-crowding, with lack of fresh 
air and sunlight, are quite as common in country homes as 
in those located in towns. Bath-rooms are comparatively 
rare in the homes of the average foreign-born farmer. 
Privies of the disgusting and dangerous well-type are gen- 
erally located near the farm dwelling, and lavishly hos- 
pitable to hosts of infection-spreading insects. Poorly 
covered drinking-wells are the rule. Cattle-yards are 
generally conveniently adjacent to kitchen-gardens and 
milk-houses, and hence are a constant source of pollution. 

While it cannot be said that this existing state of affairs 
is directly responsible for the prevalence of gastric disorders, 
particularly ulcer and cancer, among farmers, it must 



42 CANCER OF THE STOMACH 

be recognized that the stage is perfectly set for the enactioD 
of any disease drama to which a rural population may be 
susceptible. The home envu'onment would seem not 
infrequently to counteract whatever tendency toward 
longevity the farming element might acquire by virtue of 
its physically active, open-air life. Over-eating and the 
sedentary habit is common during at least a third of the 
year among farmers. During the relatively inactive 
winter months, their diet is not reduced from that upon 
which they worked during the periods of tilUng, seed time 
and harvest. Not rarelj^ added richness of food is 
supplied by a home-cured porker, a beef or by the mul- 
titudinous examples of peasant culinary art whose crea- 
tion a full larder tempts. As a result of this prolonged 
gastronomic debauch, late winter, spring and early summer 
are seasons during which digestive disturbances among 
inhabitants of rural communities are so prevalent as to 
be almost fashionable, i.e., they are an index of prosperity. 
Teeth. — Relatively few foreign-born farmers and many 
of native parentage pay any attention whatever to oral 
cleanliness. In our experience with this class of citizen, 
gastric cancer and filthy mouths go hand in hand. Dirty, 
decaying, infected teeth, loosely imbedded in soggy, 
swollen, pus-laden gums, not only prevent proper mastica- 
tion of food, but also act as reservoirs from which a con- 
stant supply of poison passes into the lymph- and, perhaps, 
blood-streams. From such mouths can be isolated virulent 
cocci, baciUi, spirochsetse, leptothrix, flagellate protozoa 
(cercomonads, trichomonads), and amoebse. Pyorrhea 
alveolaris is a \dsible, local evidence of the damage which 
this infection may cause. We have no means of knowing 
at present what effect upon gastric mucosa such organisms 
may have as result of their passing into the circulation or 



GENERAL DISTRIBUTION AND ETIOLOGY 43 

from their lodgment and growth upon a damaged gastric 
Hning. What upset of gastric physiology may result from 
the constant ingestion of millions of microorganisms and 
the products of their growths we can but conjecture. Cer- 
tainly it is difficult to see how such intake can be in any 
way beneficial. 

From microscopic study of the gastric extracts of 2,406 
different individuals affected with "stomach trouble," I 
have shown that irrespective of the degree of acidity of such 
gastric extracts, bacteria could be isolated in 87 per cent. 
Degree of gastric acidity is by no means an index of the 
stomach's cleanliness bacteriologically. In my studies, 
cocci and diplococci were present in 83 per cent., short 
and long rods (often of the colon group) in 58 per cent., 
streptococci in 17 per cent., and Leptothrix buccalis in 24 
per cent. In cultural studies of the saliva from more than 
300 dyspeptic patients, I showed that streptococci and 
staphylococci could be obtained in 80 per cent., bacilli 
in 66 per cent., and leptothrix in 14 per cent. It would 
seem that many mouth organisms thrive in gastric juice, 
and only rarely is the degree of hydrochloric acid sufficiently 
high to act as a germicide or to retard bacterial proliferation. 
I also showed that saliva from the dirty mouths of 
dyspeptics not infrequently contains the amino-acid 
tryptophan, and that more than 90 per cent, of such salivse 
hold a ferment (?) capable of cleaving the dipeptid 
glycyltryptophan. 

Heredity. — In our series, a family or blood-relationship 
history of cancer, generally, was obtained from 78 indi- 
viduals (8.5 per cent.). Of this number, an hereditary 
history of gastric cancer was noted in 46, 58.9 per cent, 
of the group and 4.9 per cent, of the total number of cases 
(921). 



44 CANCER OF THE STOMACH 

Our material fails to demonstrate a predisposition to 
gastric cancer among children of the same sex as the affected 
parent, a view which has been advanced by some clinicians 
{e.g., Fenwick). In 11 instances where sons were cancerous 
the mother had had a like ailment; of such mothers there 
were 2 cancerous daughters. There were 11 instances 
where fathers had succumbed to gastric malignancy. 
In this group there were 9 males and 2 females. There 
were recorded 15 cases where brothers and sisters were 
affected with the disease. One male was observed both of 
whose parents had died from gastric malignancy. Another 
patient, aged 39, reported the recent death from cancer 
of the stomach of a brother and a sister. There were 2 
females whose uncles had died with the disease and 2 
males whose grandfathers had been likewise affected. 

While heredity appears to play a part in the predis- 
position to cancer in certain families, yet we feel from 
the analysis of our material that the exact significance of 
such influence is at present unknown. It may be that the 
transmission by parents to offspring of a mode and con- 
duct of life is a factor not without importance, Galton's 
famous twins to the contrary notwithstanding. 

Certain classic cancer families are frequently men- 
tioned. Napoleon I, his father, his brother and two 
sisters (Pauline and Caroline) are said to have died of 
gastric cancer. Monichon states that of 23 families with 
whose history he was conversant, there were 69 cancerous 
members; of these, 57 were affected with gastric cancer. 
Fenwick mentions a family where a father, his sister and 
three brothers all succumbed to the disease. Williams 
gives the following interesting analysis of a cancer family 
in which certain other cancer lesions were associated with 
142 consecutive uterine cancers. 



GENERAL DISTRIBUTION AND ETIOLOGY 45 

Table 12 



Member of family 



Part affected 



Father's brother (m 1 family) 

Father's brother and 3 cousins (in 1 famUy) . . 

Father's sister (in 3 families) 

Maternal grandmother (in 1 family) 

Mother (in 9 families) 

Mother's sister (in 6 families) 

Mother's brother and child of mother's 
sister (in 4 families) 

Patient's sister (in 8 families) 

Patient's brother (in 1 family) 

Patient's daughter (in 1 family) 



Face 

Stomach (brother) 

Breast (female cousin) 

Neck (male cousin) 

Foot (male cousin) 

Uterus 

Intestine 

Arm 

Uterus 

Uterus (2) 

Breast (2) 

Stomach (2) 

Intestine 

Abdomen 

Face 

Uterus (2) 

Breast (2) 

Not stated (2) 

Stomach (brother) 

Face (brother) 

Not stated (brother) 

Stomach (sister's child) 

Uterus (6) 

Breast (2) 

Stomach 

Uterus 



Summary. — Seats of hereditary disease, 38. Groups: 
uterus 13, breast 7, stomach 6, locaUty not stated 3, 
intestine 2, abdomen, arm and foot, each 1. 

The transmission of the same type of mahgnant tumor 
to homologous organs has been emphasized by Virchow 
in the case of anal melanosis in horses. The susceptibiHty 
to tumor implantation in strains of laboratory animals is 
common knowledge (Slye). Similarly in humans, the 
hereditary features have been brought out with reference 
to cancer of the penis, melanotic sarcoma, glioma and 
sarcoma of the kidney. 



46 CANCER OF THE STOMACH 



ASSOCIATION WITH OTHER GASTRIC DISEASE 

1. Gastric Ulcer. — (a) Its relation to gastric cancer. 
Chapter VIII considers this question in detail. It is proper 
to remark here that there has been much ancient and 
recent controversy regarding the question of the fre- 
quency of the association of benign gastric ulcer, of the 
type pathologically chronic, and carcinoma of the stomach. 
It is somewhat striking that those internists, pathologists 
and surgeons who have only meager evidence to present 
most staunchly proclaim that such transition but rarely 
occurs. Pathologists and clinicians acquainted with and 
practising modern methods admit that the question is 
still unsettled in many of its phases. They maintain, 
however, that until we are thoroughly acquainted with the 
facts bearing upon the cause and life history of gastric 
ulcer and of gastric cancer there is but little hope of scientif- 
ically proving how many benign gastric ulcers become 
malignant and how many continue to pursue a benign 
course. At present neither pathologist nor clinician can 
prognose the future course, histologically or cUnically, of 
any gastric ulcer, acute or chronic. In so far as many 
ulcera carcinomatosa and early gastric cancers present 
symptoms which it is common to associate with benign 
peptic ulcer, it behooves us to cease a valueless con- 
troversy over the frequency with which gastric ulcers 
become cancers, and to devote our energies to the dis- 
covery of diagnostic procedures which will enable us to 
recognize early malignancy, whether such arise in ulcer or 
primarily, from a previously healthy gastric lining. By 
so doing we can serve humanity and increase the sum of 
histologic and clinical knowledge. 

(6) Benign peptic ulcers are found sometimes in asso- 



GENERAL DISTRIBUTION AND ETIOLOGY 47 

elation with gastric carcinomata. Our observations re- 
vealed 12 instances where such combination occurred. 
In these cases it is often impossible to separate the pictures, 
clinically, until the neoplasm has brought about definite 
constitutional changes due to local digestive disturbances 
and malignant intoxication. Our series also demonstrated 
the concomitance of benign duodenal ulcer and gastric 
cancer 8 times. 

2. Gastric Syphilis. — Unless negative Wassermann reac- 
tion is returned, it is never possible to exclude gastric 
syphilis in patients with history of lues and chronic dys- 
pepsia associated with weight loss, anemia, achylia 
gastrica or epigastric tumor. There were 9 such cases 
among our patients. It is quite hkely that more extensive 
serologic investigations upon those so-called ''atypical" 
gastric neoplasms will demonstrate an increasing number 
of tumors which have a luetic etiology. 

3. Tuberculosis. — The stomach is rarely involved in 
tuberculous processes. Only 1 of our cases had associated 
with gastric cancer an ulcer which appeared grossly and 
histologically tuberculous. 

4. Achylia Gastrica. — That the absence of gastric se- 
cretions alone does not predispose to carcinoma of the 
stomach appears to be borne out by the clinical and 
laboratory evidence that patients with "primary" achylia 
can exist quite comfortably for many years without cancer 
resulting. Also, in the various secondary and essential 
anemias there is almost uniformly an absence of gastric 
secretion, without the succeeding development of a 
neoplasm. 

5. Actinomycosis. — Microscopic examination of the tu- 
mor mass in 1 of our cases revealed medullary cancer in 
association with abundant growth of ray fungi. The 



48 CANCER OF THE STOMACH 

patient was a male, farmer, without oral, nasal, pulmonary 
or body surface focus of actinomycosis. 

ASSOCIATION OF GASTRIC CANCER WITH EXTRAGASTRIC 

DISEASE 

1. Malignancy Primary in Other Organs.^ — In 5 female 
patients gastric cancer occurred as a metastatic process 
from cancer of the breast. In 3 females primary cancer 
of the genitalia was followed by stomach involvement. 
Three males had gastric neoplasms in association with 
hepatic cancer. In 2 females cancer of the gall-bladder re- 
sulted in succeeding gastric involvement. In 3 instances 
(2 males and 1 female) malignancy of the colon was re- 
sponsible for the stomach lesion. Adenomata of the thyroid 
were concomitant in 3 instances. 

2. Cholelithiasis and Cholecystitis. — -Gall-stones had 
previously been removed or were noted at laparotomy in 
18 of our patients. Cholecystitis in recognizable degree 
was observed in 28 of 214 patients where note was made. 
In 46 cases the appendix had previously been removed or 
was removed at the operation for cancer. 

3. Infectious Diseases. — (a) Tuberculosis. — Many writers 
have observed the frequency of healed tubercles in the 
lungs at autopsies of those who have died from gastric 
cancer. Fenwick noted such in 15.8 per cent. It has 
also been advanced that various forms of tuberculosis are 
more than ordinarily common in families where cancer 
later develops. Williams states that 50 per cent, of his 
cases of uterine and mammary cancer had tuberculous 
family history; Osier reports such in more than 31 per 
cent, and Fenwick 26 per cent, of gastric cancers. In our 
series there was a family or blood-relationship history of 
tuberculosis in 26 instances (4.3 per cent.) where definite 



GENERAL DISTRrBUTIOX AND ETIOLOGY 49 

facts were obtainable. It is suggested that inasmuch 
as the great mass of cancer deaths occurs after the fifth 
decade, age alone may account for the prevalence of 
healed tubercles in the lungs of 15 per cent, or more of 
these subjects. Their presence at necropsies of adults 
is by no means uncommon in individuals dying from 
diseases other than gastric cancer. 

(b) Rheumatism. — In 38 cases (4.1 per cent.) chronic 
rheumatoid affections were recorded. There were cardiac 
leakages in 14 instances. 

(c) Malaria. — -It has been claimed that carcinoma is 
not common in regions where malaria is endemic. Table 
VI shows that our lowest cancer death rates occur in North 
Carolina and Kentucky, sections of the United States 
where malaria is frequently endemic and active. Study of 
our records of gastric cancer patients demonstrates that 
of 732 cases where definite information was possible 
17 instances (2.3 per cent.) were recorded. This is a rela- 
tively high figure inasmuch as comparatively few of our 
cases come from the South. 

(d) Typhoid Fever. — A remarkably large proportion of 
our patients gave a history of having had t}-phoid fever. 
Of 689 instances where data were available 92 patients 
(14.8 per cent.) had been affected with the disease. 

(e) Other Infectious Diseases. — Yellow fever was noted 
in 1; gonorrhea in 43; asiatic cholera in 1; erysipelas in 2; 
pleurisy in 3; smallpox in 3; mumps in 12; scarlet fever 
in 18; tonsillitis or quinsy in 20; diphtheria in 22; pneu- 
monia in 29; measles in 34; la grippe in 54. 

4. Parasitic Infections. — Seven patients had passed 
tape-worms at some period of their lives. In one case a 
tape-worm passed 6 weeks before the patient came under 
observation, appeared to precipitate mahgnant symptoms. 



50 CANCER OF THE STOMACH 

Protozoa were isolated from the stools in 11 cases. 
They were found as follows: trichomonas hominis 4, cer- 
comonas hominis 2, endamcebse 4, and balantidium coh 1. 

5. Constitutional Diseases. — Asthma was observed in 
31 instances; Bright's disease 18 times; cirrhosis of the liver 
4 times; gout, eczema and diabetes each 3 times. 

REFERENCES 

Buday: Conference Internationale du Cancer, Paris, 1910, p. 89. 

Hoffman, F. L. : Transactions of the American Gynecological Society, 
1913; and Surg., Gyn. and Obst., 1914, June, p. 726. 

Fenwick, S.: "Cancer and Other Tumors of the Stomach," Phila- 
delphia, 1903. 

C-\BOT, R.: Jour. Amer. Med. Assn., 1912, Dec. 28, p. 2295. 

Brinton, W. W.: "Diseases of the Stomach," 1859; and Brit, and For. 
Chir. Rev., 1857, January. 

Fox, W.: "The Diseases of the Stomach," London, 1872. 

Welch, W.: "Cancer of the Stomach," Am. Syst. Med., II. 

Friedenwald, J.: Am. Jour. Med. Sc, 1914, Nov., p. 660. 

Miyake: Sei-I-Kwai :\Ied. Journ., Tokio, 1914, May 10, No. 5. 

Tatham: Supplement to Registrar-General's Fifty-fifth Annual Report, 
1897 (London). 

Aschoff: Cited by Williams. 

Williams, R.: "The Natural History of Cancer," New York, 1908. 

OsLER AND jMcCrae: " Cancer of the Stomach," Philadelphia, 1900. 

FiJTTERER, G.: Quoted by Mayo Robson and Moynihan, "Diseases of 
the Stomach," 1904. 

Fibiger: Berl. Klin. Wochnschr., 1913, Feb. 17, p. 289. 

Galton: Journal of the Anthropological Institute, 1876, vol. v, p. 391. 

Monichon: These de Paris, 1896, No. 415. 

ViRCHOw: Onkologie, II, p. 352. 

Slye: Interstate Medical Journal, 1915, July. 

Smithies: Arch. Int. Med., 1912, Dec, p. 1. 



CHAPTER II 

MORBID ANATOMY: GROSS, MICROSCOPIC AND 
EXPERIMENTAL 

CLASSIFICATION OF GASTRIC NEOPLASMS 

By clinicians, gastric tumors are usually grouped as 
benign or as malignant. 

The benign neoplasms are those that arise primarily 
within the wall of the viscus and confine their growth to the 
stomach. It is rare for them to invade adjacent viscera by 
contiguous extension or by metastases through blood- or 
lymph-channels. They are generally of relatively slow 
growth, but may bring about death of their host. The 
fatal termination most commonly ensues from the pro- 
duction of various types of stenoses. Starvation and 
malnutrition then result. Tumors of this type are myo- 
mata, fibromata, papillomata, syphilomata, tuberculomata, 
lipomata, cysts, osteomata, myxomata and aneurysms. 

Malignant gastric neoplasms most frequently arise at 
some part of the gastric wall. They may, however, 
secondarily involve the stomach as a consequence of 
metastasis from an extragastric tumor (uterus, liver, breast, 
etc.). This group includes carcinomata and sarcomata. 
Clinically, both may be styled cancer. These tumors are 
malignant in the sense that they are progressive in growth, 
bring about destruction of normal tissue, produce useless 
malformations of the viscus, often involve adjacent 
organs by direct extension or distant organs by metastases, 
and, if not disturbed, generally cause death of the individual 
by that metabolic derangement whose consequences we rec- 
ognize as cachexia. 

51 



52 CANCER OF THE STOMACH 

Of the malignant gastric tumors, sarcoma is of rare 
occurrence. The first authentic example was described 
by Virchow. Since then an occasional specimen has been 
mentioned in the literature. Eleven years ago the Fenwicks 
estimated that sarcomata constitute more than 5 per cent, 
of all primary neoplasms of the stomach. Interesting 
summaries of the affection have been made by Yates, 
Clendenning, Frazier and Campbell. They are infre- 
quently diagnosed before laparotomy or necropsy, inas- 
much as symptomatically they resemble carcinomata. 

Gastric carcinoma — commonly styled ''cancer" — com- 
prises nearly 94 per cent, of all clinically or pathologically 
known forms of neoplasm primarily arising in the stomach 
wall. Pathologicall}^ this type of tumor manifests itseK 
as a group of malignant histo-pathologic processes. It is 
necessary" to consider both gross and 77iicroscopic deviations 
from the normal, 

1. Gross Deviations from the Normal. — AMiile the line 
of demarcation between types of carcinomata of the 
stomach is a rather indefinite one, the classic descriptions 
of such embodied in the writings of Waldeyer and Roki- 
tansky comprise the most practical macroscopic classifica- 
tion of the disease. These pioneers recognized 3 general 
forms of gastric cancer. We have added a fourth group. 
The following classification is adopted from their descrip- 
tions : 

(a) Fibrous cancer; scirrhus; carcinoma fibrosum. Usu- 
ally a dense, well-delimited, poorly vascularized growth, 
generally forming circumscribed nodules, or arranged as a 
tumor of annular ty^Q. The stomach- wall is thickened, 
stiffened and puckered. Nodules project into its lumen. 
The tendency to ulceration is not great. The growth^can 
be moderately well outlined by the fingers. It is firm and 



MORBID ANATOMY 



53 



unyielding to the touch until secondary changes have taken 
place. 

(6) Medullary cancer; ''fleshy," ''cauliflower," cellular 
and vascular type; carcinoma medullare. Essentially a 
rapidly growing tumor primarily of the structures of the 
mucosa and submucosa. This results in soft, nodular 
protuberances which invade the lumen of the stomach, 




Fig. 1. — (Case No. 21,559). — Primary carcinoma involving the pyloric 
third, scirrhus type, pyloric obstruction. Great thickening of gastric wall, 
gland involvement, free fluid in abdomen. Specimen obtained at 
laparotomy. — (Courtesy of Mayo Clinic.) 



spread rapidly and ulcerate early. The actively proliferat- 
ing cancer cells quickly penetrate all layers of the stomach- 
wall; vascularization is generally free; adjacent organs are 
invaded by continuity or lymph and blood-stream metas- 
tases; perigastric lymph glands harbor the growth and 
distant organs early suffer malignant change. This cellular 
and vascular type of growth renders both primary and 
secondary tumors soft to the palpating fingers. 



54 CANCER OF THE STOMACH 

(c) Ulcerating cancer; ulcus carcinomatosum. This may 
result from cancerous change in a pre-existing calloused 
ulcer, or may occur from the secondary ulceration and 
sloughing of carcinoma medullare or carcinoma fibrosum. 
At laparotomy this type is of most common occurrence. 
The growth may be but 1 cm. in diameter, but may in- 




FiG. 2. — (Case No. 16,636). — Cancer of the pyloric end. Clinically 
scirrhus type. Great thickening of stomach wall, multiple nodules, peri- 
gastric gland involvement. No history of antecedent dyspeptic disturbance. 
Specimen obtained at laparotomy. — (Courtesy of Mayo Clinic.) 



volve as much as a fourth of the viscus. Its base is 
commonly firm. Its edges are not infrequently soft, 
ragged, vascular and undermined (but may be smooth and 
shiny). The process is often well deUmited. Malignant 
perigastric lymphatic gland enlargements are common. 
Metastases out of all proportion to the size of the local 



MORBID ANATOMY 



55 




Fig. 3. — (Case No. 16,186).— Primary carcinoma involving pyloric 
end of stomach. Medullary type with numerous points of ulceration. 
Extensive infiltration of gastric wall. Specimen obtained at laparotomy. — 
(Courtesy of Mayo Clinic.) 




Fig. 4. — (Case No. 16,765). — Multiple gastric carcinoma of the medul- 
lary type, involving pyloric third of stomach. Numerous nodules and points 
of surface ulceration. Thickening of gastric wall, perigastric gland involve- 
ment. Specimen obtained at laparotomy. — (Courtesy of Mayo Clinic.) 



56 



CANCER OF THE STOMACH 




Fig. 5. — (Case No. 15,694). — Large carcinoma of the medullary-scirrhus 
type involving the pyloric third of the stomach. Enormous infiltration and 
hyperplasia of stomach walls; superficial erosions; pyloric obstruction. 
Patient had precarcinomatous history, clinically that of peptic ulcer. 
Specimen obtained at laparotomy. — (Courtesy of Mayo Clinic.) 



MOKBID ANATOMY 



57 




Fig. 6. — (Case No. 14,897). — Large carcinoma of the posterior wall and 
pyloric end of the stomach; meduUary-scirrhus type; extensive invasion of 
the gastric wall; superficial necrosis, sloughing and hemorrhage; pyloric 
obstruction. Patient had precarcinomatous history, clinically that of 
peptic ulcer. Specimen obtained at laparotomy. — (Courtesy of Mayo 
Clinic.) 



58 



CANCER OF THE STOMACH 



gastric process may be discovered in adjacent glands or 
organs. 

(d) Colloid cancer; gelatinous cancer, mucoid cancer; 
carcinoma colloides. The diffusely infiltrating type, which, 
due to mucoid degeneration of the cells composing it, as 
well as to their excretion of a substance resembling clouded 




Fig. 7. — (Case No. 14,849). — Carcinoma involving the pylorus and lesser 
curvature. Extensive tumor of the meduUary-scirrhus type with small 
areas_ of colloid degeneration. Enormous infiltration of stomach wall, 
pyloric obstruction ; perigastric gland invasion. Patient had precarcinomat- 
ous history, clinically that of peptic ulcer. Specimen obtained at 
laparotomy. — (Courtesy of Mayo Clinic.) 



egg-white, presents a water logged, translucent, jelly-like 
appearance. It ulcerates rarely, spreads extensively, and 
may form metastases. It is the least frequent type of 
gastric cancer (excluding sarcoma). 

2. Histologic Deviations from the Normal. — While the 
above macroscopic classification of gastric cancer is a prac- 
tical clinical grouping, it must not be supposed that the 



MORBID AXATOMY 



59 




Fig. 8. — (Case Xo. 14,727). — Extensive primary carcinoma of the medul- 
lar j^-scirrhus type involving pyloric half of stomach; enormous thickening 
of stomach wall; pyloric obstruction; small gastric lumen ("leather-bottle 
type") ; perigastric gland involvement. Specimen obtained at laparotomy. — 
(Courtesy of Mayo Clinic.) 



60 



CANCER OF THE STOMACH 




Fig. 9. — (Case No. 20,468). — Ring cancer of the medullary-scirrhus 
type involving the pylorus; moderate hyperplasia of the stomach wall; 
superficial ulceration; perigastric gland involvement. Patient had pre- 
carcinomatous history, clinically that of peptic ulcer. Specimen obtained 
at laparotomy. — (Courtesy of Mayo Clinic.) 



MORBID ANATOMY 



61 




Fig. 10. — (Case No. 22,314). — Carcinoma of the scirrhus type involving 
the pyloric half of the stomach; enormous hyperplasia of gastric wall; 
pyloric stenosis; small gastric lumen ("leather-bottle type"). Specimen 
obtained at laparotomy. — (Courtesy of Mayo Clinic.) 



62 



CANCER OF THE STOMACH 




Fig. 11. — (Case No. 14,959). — Ring carcinoma of the scirrhus type involv- 
ing the pylorus and antrum; extensive infiltration of stomach wall; pyloric 
obstruction. Patient had precarcinomatous history, clinically that of 
peptic ulcer. Specimen obtained at laparotomy. — (Courtesy of Mayo 
Clinic.) 



MORBID ANATOMY 



63 




Fig. 12. — (Case No. 19,921). — Extensive carcinoma of the medullary- 
type involving pyloric third of stomach; moderate pyloric obstruction; 
areas showing necrosis, sloughing and hemorrhage; moderate invasion of the 
gastric wall. Patient had precarcinomatous history, clinically that of 
peptic ulcer. Specimen obtained at laparotomy. — (Courtesy of Mayo 
Clinic.) 



64 



CANCEE OF THE STOMACH 




Fig. 13. — (Case No. 16,426j. — Large medullary carcinoma of the papil- 
lomatous type; superficial erosions; enormous hyperplasia and infiltration 
of the gastric wall. Patient had precarcinomatous history, clinically that 
of peptic ulcer. Specimen obtained at laparotomy. — (Courtesy of ^Slayo 
Clinic.) 




Fig. 14. — (Case Xo. 19,832). — Medullary carcinoma involving the py- 
lorus; enormous hj'perplasia of gastric wall; pyloric obstruction; secoiidary 
ulceration of tumor. Patient had a precarcinomatous history, clinically 
that of peptic ulcer. Specimen obtained at laparotomy. — (Courtesy of 
Mayo Clinic.) 



MORBID ANATOMY 



65 




Fig. 15. — (Case No. 21,803). — Ring carcinoma of the medullary type 
involving pyloric end of stomach. Patient had precarcinomatous history 
of the peptic ulcer type. Specimen shows canalization of tumor obstruct- 
ing pylorus; enormous hyperplasia of stomach wall; perigastric gland in- 
volvement. Specimen obtained at laparotomy. — -(Courtesy of Mayo 
Clinic.) 




Fig. 16. — (Case No. 21,873). — Ring carcinoma involving the pylorus; 
superficial erosions; great hyperplasia of gastric wall, locally; pyloric 
obstruction; perigastric gland involvement. Patient had precarcinomat- 
ous history clinically that of peptic ulcer. Specimen removed at 
laparotomy. — (Courtesy of Mayo Clinic.) 



66 



CANCER OF THE STOMACH 




Fig. 17. — (Case No. 21,555). — Stereogram showing carcinoma associated 
with a large ulcer of the lesser curvature. — (Wilson and MacCarty.) 



MORBID AXATOMY 



67 







I 







/li 




Fig. is. — (Case No. 21,oo5). — Photomicrogram from the edge of tlie 
ulcer, bases of tubular glands show early carcinomatous change (X 100). — 
(Wilson and MacCarty.) 











;r:!afi| 



Fig. 19. — (Case No. 21,555;. — Pliotuiuicrugr^iai oi a_ section_ of the 
base of the ulcer, showing scirrhus cancer (X 100). — (Wilson and Mac- 
Carty.) 



68 



CANCER OF THE STOMACH 










^ f,? -^ 



' ,4.'' 









v. * 









Fig. 20. — (Case No. 21,555). — Islands of carcinoma in the 
submucosa. — (MacCarty.) 




Fig. 21. — (Case No. 21,555). — ^Irregularly shaped epithelial cells near the 
muscularis mucosae. — (MacCarty.) 



MOEBID ANATOMY 



69 




Fig. 22. — (Case No. 15,681). — Stereogram of a portion of the pyloric 
half of the stomach, showing carcinoma involving the lesser curvature and 
the pylorus. — (Wilson and MacCarty.) 




WM^^^iM 



Fig. 23. — (Case No. 15,681). — Photomicrogram showing hyperplastic 
epithelium in the swollen mucosa of the edge of the ulcer (X 100). — 
(Wilson and MacCarty.) 



70 



CANCER OF THE STOMACH 




Fig. 21. — (Case No. 15,681). — Photomicrogram showing atypical epithe- 
lial proliferation (X 100). — (Wilson and MacCarty.) 



^.-V-^-t:..' 



', ^.^'t^-- *• 







Fig. 25. — (Case No. 15,681). — Photomicrogram from the base of the 
malignant ulcer (X 100). — (Wilson and MacCarty.) 



MORBID ANATOMY 



71 




Fig. 26. — (Case No. 18,867). — Stereogram of the lesser curvature, show- 
ing proliferation of the muscularis associated with ulcus carcinomatosum. — • 
(Wilson and MacCarty.) 




Fig. 27.— (Case No. 18,867).— Photomicrogram of epithelial cells par- 
tially cut off from the surface, actively proliferating but not infiltrating the 
surrounding tissues (X 100). — (Wilson and MacCarty.) 



72 



CANCER OF THE STOMACH 




Fig. 28. — (Case No. 18,867). — Photomicrogram showing area of typica 
carcinomatous tissue (X 100). — (Wilson and MacCarty.) 




Fig. 29. — (Case No. 16,525). — Stereogram of the pjdoric two-thirds of 
the stomach; carcinomatous ulcer beginning on the lesser curvature. — (Wil- 
son and MacCarty.) 



MORBID ANATOMY 



73 




Fig. 30. — (Case No. 16,525). — Photomicrogram showing areas of scirrhus 
carcinoma (X 100). — (Wilson and MacCarty.) 




Fig. 31. — (Case Xo. 16,525). — Photomicrogram showing a cross-section 
of the hyperplastic epithelial elements with round-cell infiltration between 
the gland tubules (X 100). — (Wilson and MacCarty.) 



74 



CANCER OF THE STOMACH 




Fig. 32. — (Case No. 16,525). — Photomicrogram showing the bases of the 
glands clipped off by scar tissue (X 100). — (Wilson and MacCarty.) 









'^ 






Fig. 33. — (Case No. 16,525). — Photomicrogram showing active malig- 
nant proliferation with much round-cell infiltration (X 100). — (Wils(m 
and MacCarty.) 



MORBID ANATOMY 



75 




Fig. 34. — (Case No. 18,088). — Stereogram of the pyloric third of the 
stomach; multiple ulcers of malignant type. — (Wilson and MacCarty.) 




Fig. 35. — (Case No. 18,088). — Photomicrograph of the overhanging ulcer 
border (X 100).— (Wilson and MacCarty.) 



76 



CANCER OF THE STOMACH 




Fig. 36. — (Case No. 18,088). — Photomicrograph from submucosa showing 
aberrant proliferation and infiltration (X 100). — (Wilson and AlacCarty.) 



MORBID AXATOMY 



77 




-5 >, 
II 

-8 



5 3 






e ^ 



Q 



78 



CANCER OF THE STOMACH 




Fig. 38. — (Case No. 15,235). — Ulcus carcinomatosum of the antrum. 
Ulcer has smooth terraced borders and is surrounded by actively proliferat- 
ing carcinoma of the medullary type. Enormous infiltration and hyper- 
plasia of gastric wall. Patient had precarcinomatous history, clinically 
that of peptic ulcer. Specimen obtained at laparotomy. — (Courtesy of 
Mayo Clinic.) 



MORBID ANATOMY 79 

types described include definite and single histologic 
entities. It should be emphasized that all gastric cancers 
have in and about them histologic changes demonstrating 
attempts at resistance and repair on the part of the in- 
vaded tissues. Consequently, it is possible to define 
scirrhus, medullary, ulcerating, or even colloid areas, 
locally, in the majority of growths, where the process has 
existed for a considerable time. This is especially the case 
when specimens are examined from necropsies. Growths 
received from laparotomies contain fewer examples of 
retrograde changes. The latter type furnishes the most 
satisfactory material upon which to study cancer invasion 
and from which to offer a classification of the disease from 
the histologic standpoint. 

Various histologic groupings of gastric carcinomata 
have been advanced. Most of them are artificial, in- 
complete, confusing and unnecessary. 

Inasmuch as carcinoma is an atypical epitheUal neo- 
plasm (Waldeyer), and inasmuch as in the stomach, the 
neoplasm originates from the cylindrical epithelia making 
up the glands of the mucosa, it is evident that but few ele- 
mentary factors can enter into the histopathologic picture 
presented by its development. The facts to be con- 
sidered are: (a) the abnormal proliferation of gland 
cells; (6) the rate of their growth; (c) the direction of 
that growth; {d) the reaction of adjacent tissue to the 
presence of atypically proliferating and physiologically 
undifferentiated epithelium; and (e) retrograde changes 
in either epithelia or connective tissue or both. 

THE ABNORMAL PROLIFERATION OF GLAND CELLS 

No one has ever observed the earliest beginnings of 
any malignant process, histologically, in the human. 



80 CANCER OF THE STOMACH 

No one has ever experimentally produced a cancer in a 
human being, hence it is impossible to say just what intra- 
cellular change of what primary intracellular fault con- 
stitutes the beginnings of malignancy. The large ma- 
jority of histologic descriptions of malignancy, particularly 
of gastric cancer, are not those where the disease is in its 
inception, but are views of a pathologic process well under 
way. This fact is to be strongly emphasized with respect 
to those histopathologic reports from necropsies where 
patients have succumbed to gastric cancer. In such 
beginning cellular change cannot be described. The 
cellular battle is largely over. The primary disposition of 
the warring forces is a histologic secret. Unfortunately 
such end-results were painstakingly described nearly a 
half century ago, and have become rooted in the general 
mind and form much of the pathologic conception of the 
disease, whereas they only constitute the least interesting 
phase of it, namely, the end-result. From the viewpoint 
of cancer prophylaxis, their chief value lies in pointing out 
the moral — to emphasize the consequences of tumor growth. 
It is now generally accepted that early malignant proc- 
esses are in the nature of hyperplasia of already existing 
structural elements. Through some intracellular devia- 
tion from the normal, a tissue reaction takes place which 
results in undifferentiated growth of a particular cell 
group. In the majority of instances the initial structure 
of the part affected is reproduced, but commonly the 
specific function of the cells making up that structure is 
lost. Thus, so far as our knowledge extends, the earliest 
evidences of gastric malignancy occur in what were pre- 
viously normal cells lining gland tubules. At this stage of 
the process, there is as yet very little, if any, recognizable 
periglandular tissue reaction. 



MORBID ANATOMY 81 

Just what causes this intracellular fault in the cells 
involved, we are not at present able to state. It may be 
reaction to any irritant or group of irritants. These 
irritants may be chemical, biochemical, mechanical or 
parasitic. It would appear that in addition to the presence 
of cellular irritants one must consider the possibilities 
of an inborn or acquired susceptibility on the part of an 
individual cell, or a group of cells, to a metabolic upset 
from such source. Certainly, the same types of trau- 
matic agents, offered to like tissue in different hosts, cause 
widely varying cell reactions. 

Certain experimental evidence tends to support the 
above general description of the earliest phase of malig- 
nancy. At this stage rarely is a microscopic picture pre- 
sented, nor is it proper to term the early intracellular change 
a precancerous lesion. There would seem to be abundant 
proof that not infrequently similar early alterations occm- 
in cell-groups and yet do not progress to malignancy. To 
Rous and Murphy we are indebted for our microscopic 
conception of slightly developed neoplasms. Working 
with a chicken sarcoma implanted in developing chick 
embryos, they noted that first, the transplant occurred 
along the line of the tissue which had been injured by the 
inoculating needle. After 16 days this growth was well 
defined and had the appearance of scar-tissue. Vas- 
cularization took place in 4 days and shortly later than when 
the appearance of secondary nodules had occurred along 
the line of the vessels. Microscopically, very actively 
proHferating cells were seen enclosed in a loose mesh-work 
of supporting tissue. The early sarcomatous cells appeared 
larger than those of normal connective-tissue elements. 
That there seemed to be a definite intracellular difference 
was demonstrated by the fact that the cytoplasm stained 



82 CANCER OF THE STOMACH 

much more deeply with methylene blue than did that 
in normal cells. Nuclei were large, oval or elongated or 
vesicular. They contained a fine chromatin network 
and had a well-defined, deeply staining nucleolus. Pro- 
liferation was extremely active, as many as 69 per cent, of 
the cells being noted in various stages of division at one 
time. The growth took place mainly by amitosis. In 
the surrounding tissue the first influences of growth were 
those occurring as result of simple pressure. The neoplasm 
developed along the line of least resistance and metastases 
took place through the lymph spaces. Very early there 
developed about the growing tumor fragment a moderate 
amount of edema and exudation. Polymorphonuclear 
cells appeared coihcidentally. These were soon replaced 
by a small round-cell lymphocyte infiltration which usually 
became most marked where the invading cells were in 
actual contact with the cells of the host. This was followed 
by the appearance of fibroblasts, macrophages and newly 
formed capillaries at these points. A few giant cells often 
appeared. Sometimes the vascularization was tardy and 
before it occurred the tumor cells had invaded the tissue 
of the host at the points of contact with it. The growth 
proved to be most rapid along the normal blood-vessels 
and the connective tissue already present. At the advanc- 
ing margin there was not the tissue reaction as is seen in 
inflammation. Lymphocytes were few and often practi- 
cally absent. Of course, these investigators were dealing 
with embryos and in them few protective bodies had as 
yet been developed. When this histologic picture was 
presented the transplanted growth might be considered 
well established. The resultant great tumor was made 
up of accumulations of cells similar to the few which 
originated the process. Vascularization and progressive 



MORBID ANATOMY 83 

changes resulted. If, however, the host was not suscep- 
tible or there were some factors in resistance which are 
not as yet understood, retrograde changes occurred and 
the initial tumor soon disappeared. 

Working with an adenocarcinoma of the white rat de- 
scribed by Flexner and Jobling, Levin claims to have pro- 
duced certain local tissue reactions in non-susceptible 
animals which, later on, permitted the transplantation of 
a neoplasm. In other words, by chemical or mechanical 
means, or both, he claims to have so altered the inherent 
cellular resistance of tissue as to bring about a so-called 
''precancerous" state which later on permitted the 
growth of an implanted tumor. Levin injected into the 
testicle of a rabbit 2 or 3 minims of Scharlach R- 
oil. These injections produced a local tissue reaction 
simulating simple inflammatory hyperemia. There may 
have been some other local fault. When placed into this 
inflamed and hyerplastic tissue, tumors developed in a 
considerable proportion of instances. That the injection 
of the irritant does not itself produce anything more than a 
granulomatous tumor has been shown by the experiments 
of Snow. 

Recently, Erwin Smith has shown that if plant cells 
are submitted to a local irritant, cancer-hke growths 
result. Working with a bacillus isolated from galls of a 
daisy, he has succeeded in producing at will similar tumors 
in such plants. The bacillus is known as Bacterium 
tumefaciens. If healthy plants are inoculated with this 
organism, rapidly developing growths result which even- 
tually destroy the plant. Other plants are also susceptible. 
Certain metastasis-like secondary growths develop from 
the primary tumor. While many of the tumors described 
by Smith are of the granulomatous type, it would seem that 



84 CANCER OF THE STOMACH 

his experiments are not without value as showing in what 
manner normal tissue reacts to a constantly multiplying 
irritant. The reaction is essentially one of hyperplasia 
of certain cell groups. Not infrequently it is impossible 
to state where benign hyperplasia ends and malignant 
hyperplasia begins. 

With regard to the experimental production of gastric 
can(}er in animals, few facts are available. The most strik- 
ing investigations are those of Fibiger of Copenhagen. 
This investigator noted that not infrequently certain labo- 
ratory rats died as the result of cancer-Uke tumors 
developing in their stomachs. On investigating some of 
these tumors, he discovered that while they were histologic- 
ally carcinoma-like many of them contained cysts in which 
were lodged nematodes. Further investigations disclosed 
that these rats fed upon roaches which infested a certain 
sugar refinery from which the majority of the laboratory 
rats were obtained. These roaches on examination were 
found to be infested with nematodes. Fibiger then col- 
lected a large number of these roaches and fed them to 
non-infected laboratory rats. In the stomachs of many 
of these, carcinoma-like growths developed. "V\niile there 
is some doubt of the true carcinomatous nature of Fibiger' s 
rat tumors, the investigation is of value in showing the 
reaction of gastric mucosa to a parasitic irritant. It also 
shows the histologic dijOGiculty of differentiating hyperplasia 
of a granulomatous type from the hyperplasia of true 
malignancy. It is quite conceivable that the ingestion of 
such food as roaches acted as traumata to the gastric 
lining, and furnished a locus minoris resistentics, at which 
point the nematode could act mechanically, could bring 
about hyperplasia as result of undetermined infection of 



MORBID ANATOMY 85 

this parasite itself, or as a consequence of a chemical 
excretion, secretion or ferment. 

To the painstaking and brilliant work of MacCarty, we 
owe practically all our useful knowledge regarding the 
early histologic changes which are associated with the 
development of gastric cancer. This investigator has 
patiently studied the microscopic deviations from the 
normal of gastric ulcers and gastric cancers obtained at 
laparotomy. His observations are of particular worth, 
because they cover an experience extending over many 
years in handhng the largest number of specimens ever 
recorded; are upon fresh, and not dead-house, material; 
include both gross and microscopic studies (the latter 
with oil immersion ampUfication) ; have been carried on 
in a uniform manner and checked by comparative photo- 
graphs and the clinical courses of the affected patients. 
It is to be expected that MacCarty's results are as yet not 
generally appreciated. They are too highly specialized 
to come within the understanding of the pathologist with 
ordinary material for study because they are based upon 
a vast material and comprise a histopathology essentially 
cellular. They bear a similar relation to routine pathologic 
investigations that such maintain toward hand glass or 
gross pathology. It is significant that the intracellular 
deviations and the intercellular faults described by Mac- 
Carty are generally comparable to such recognized by re- 
search workers engaged in tumor implantation (Rous, 
Murphy, Gay) or cell culture studies (Carrel). 

MacCarty has shown that in gastric ulcer two basic his- 
tologic processes are in evidence: 

(a) Hyperplasia of the elements of the gastric mu- 
cosa and (6) hyperplasia of adjacent tissue; (2) retrograde 
changes in both locations. 



86 CANCER OF THE STOMACH 

1. Hyperplasia. — (a) This occurs in the gland structures 
of the ulcer edges or those lying superficial or deep in the 
submucosa. 

Such exuberant growth manifests itself by both cellular 
and intracellular change. The cellular change consists in 
multiplication of cylindrical cells in the stratum germina- 
tivum. The cells assume vegetative qualities rather than 
specific function. At first the overgrowth is confined to 



Fig. 39. — (,' :!-• A". 27,919). — >t i uim through a portion of the border of a 
benign chronic peptic ulcer. — (MacCarty.) 

the primary cell layer. The individual cells increase in 
number, swell and often stain abnormally with methylene 
blue or hematoxylin and eosin. The process may stop 
here. If not, the next step consists of such definite hyper- 
plasia as to result in the appearance of an inner, secondary 
layer of cells arising from rapidly multiplying cells of the 
basal layer. These, in turn, may be succeeded by such 
increase in cells as to completely fill the space formerly 
held as a gland lumen. Variations in cell shape and size 



MORBID ANATOMY 87 

appear, perhaps, as a consequence of some altered, in- 
tercellular relation (Fig. 37). Thus far the process is 
adenomatoid. 

Depending upon the directions in which histologic 
sections are cut, and their location with respect to mucosa 
and submucosa, isolated areas (''cell inclusions," often 
so-called) or filled gland-tubules may be described. Thus 
far there has been no alteration in the relation of the basal 
layer of cells to the surrounding structures. The hyper- 








* <> 


ii 


'^^ . 


' 




i^ 



Fig. 40. — (Cas-e Xo. 30,0-iO). — Photomicrogram showing hyperplasia in 
the mucosa at the border of a peptic ulcer. — (MacCarty.) 

plastic gland elements are well delimited. After the second 
gland-cell layer has developed the study of intracellular 
change reveals important variations from the normal. 
They must be looked for with oil-immersion objective. 
The individual cells vary much in size and form, while 
the basal layer remains cjdindrical, cuboid or flattened. 
The secondarily developing layers may be oblong, oval, 
rhomboid, rounded or irregular. The whole gland is 
often distended and distorted. At this time distinct nu- 
clear changes are visible (Figs. 21, 42 etseq.). Nuclear hy- 



88 CANCER OF THE STOMACH 

pertrophy occurs. This is associated with structural altera- 
tions in the nuclei themselves. Their increase in size is 
noticeable. Whereas, in normal gland cells, the relative 
proportion between nucleus and cytoplasm is approximately 
as 1 : 3 or 1 : 4, increase in the nucleus occurs to such extent 
that practically it may equal in volume the cytoplasm. A 
striking phenomenon is that of great variation in size, shape 
and staining reaction of these nuclei. In place of dense nuclei 




k 



mm-T 



Fig. 41. — (Case Xo. 27,919). — Photomicrogram of a portion of the 
border of a malignant peptic ulcer showing islands of carcinoma in the 
submucosa. — (MacCarty.) 

staining deeply with Unna's polj^chrome blue or with hema- 
toxylin, the nuclei stain much less densely and are poorly 
differentiated structurally. If the biochemical alterations 
associated with the gland hyperplasia are maintained, the 
nuclei divide so rapidly as to render mitotic figures visible. 
At any rate, proliferation appears accelerated. At this 
phase, the mass of hyperplastic cells may readily simulate 
adenoma. The most marked change occurs at the ulcer 
borders. 



MORBID ANATOMY 



89 



It would appear that the Hne of demarcation between 
simple hyperplasia and a malignant type of the same process 
is very indefinite at this stage. If the stimulation to the 
outgrowth is not stopped, however, the succeeding his- 
tologic picture often reveals alterations in the basal layer 
of gland-cells. At some point, or generally, they may 
wander through the '' basement membrane." This is 
the first actual evidence, histologically, of what seemed to 
be a simple, progressive hyperplasia assuming malignant 
characteristics. Such occurrence is most common where 




Fig. 42. — (Case No. 97,051). — Densely staining mucin within columnar 
cells. High amplification. — (Wilson.) 

hyperplasia is most active, i.e., at the edges of ulcers: the 
points where attempts at resistance and repair are being 
most persistently carried on. The phenomena occur less 
strikingly (and often later) in the scar-tissue forming the 
base of the ulcer-crater. Depending on the extent of the 
ulcerated area, the severity of the agent tending to destroy 
tissue and the ability of such tissue to oppose this, small or 
large areas showing these alterations may be described 
in the mucosa and submucosa. The discovery of a single 
gland tubule, where actively hyperplastic cells have pene- 
trated beyond the normal limiting membrane, is, however, 



90 CANCER OF THE STOMACH 

all that is required for a diagnosis of malignancy. Previous 
to this malignancy is questionable. The subsequent fate 
of such atypically growing cells depends upon their number, 
their relative position in the gastric wall, their stimulation 
to growth, the rapidity of their proliferation, and the 
degree of success which surrounding tissues have in repel- 
ling their invasion. There may be variation in any or all of 
these factors. Consequently, the above-described process 
may be halted at any stage of its advance. The mass of 
maUgnant hyperplastic epithelial elements, together with 



^^"3^ 


,'■»-■ 


^ &. 


- 2 




^^^1. 1 




^^^^ 


J 





Fig. 43. — (Case Xo. 94,647). — Photomicrogram (high power amplifi- 
cation) of section across a cyst of a pyloric gland in early gastric cancer. 
Columnar ceUs filled with mucin; crescentic nuclei. — (Wilson.) 

surrounding stroma, makes up the neoplasm. Wide 
variation in size is possible. The relation existing between 
volume of epitheHal cells and connective tissue determines 
the cHnical type of tumor resulting. It furnishes the basis 
of a rough histologic grouping. 

(6) Hyperplasia of the extraglandular structures con- 
stitutes evidences of tissue resistance. It is grossly a local 
index of the strength of the stomach's defensive forces. 
These may be vigorous during the early stages of the 
ulcerative process and then apparently become negligible, 



MORBID ANATOMY 91 

or, late in the development of a rapidly advancing ulcer, 
energetic resistance may be put forth and the process 
stopped. 

As we have stated, in the early stages of simple ulcer, 
hyperplasia is most active in the glands of the edges. This 
increase causes overhanging borders. There is fre- 
quently a similar hyperplasia in the base. Tissue resistance 
is manifested by an abundant infiltration of small lympho- 
cytes. Not infrequently polynuclear leucocytes are also 
present. The hyperplastic gland process is thus well walled 




Fig. 44. — (Case No. 94,647). — Same tissue as in Fig. 43, showing cells 
freely discharging mucin; spherical nuclei. — (Wilson.) 

off. There is little evidence of vascularization. Surface 
necrosis often keeps pace with the epithelial hyperplasia — 
the sloughing thereby giving the ulcer a characteristic 
crater-like form. In instances of moderate activity, the 
gland hyperplasia is checked apparently by the leucocyte 
invasion. Hyperplasia of scar tissue then occurs, and 
typical, protected, callous ulcer results. If, however, a 
source of stimulation keeps the epithelial hyperplasia 
active, and if the process becomes moderately extensive, 
the hypertrophied gland j^ tubules push aside the con- 



92 



CANCER OF THE STOMACH 



nective-tissue cells and diminish the number of avenues 
along which protective cells or fluids may be conveyed to 




Fig. 45. — (Case 53,784). — Hyperplasia of the epithelial gland elements 
with marked piling up of epithelium. High amplification. — (Wilson.) 

the pathologic area. There is, however, always evidence 
of an active resistance being carried on at the limits of 
the hyperplastic epithelial process. As a consequence, 




Fig. 46. — (Case No. 80,863). — Photomicrograph showing beginning 
multiplication of layers of gland epithelium. High amplification. — 
(Wilson.) 

not only may submucosa show hyperplastic connective- 
tissue changes, but such may be made out in the muscularis 



MOEBID ANATOMY 93 

and subserosa. The tendency is everywhere toward 
the production of dense, undifferentiated scar tissue. 
Deepening of the ulcer crater by surface sloughing together 
with extension of rapidly enlarging gland tubules may 
accelerate the process or increase its extent. 

The above attempt to resist invasion appears to be 
carried on by connective tissue concomitantly with epi- 
thelial increase until direct intrusion of the epithelial 
tissue occurs. After that essential, histologic, structural 
fault, some yet unknown influence seems to diminish the 
strength of the connective-tissue resistance. This is shown, 
histologically, by diminution of lymphocytes and leuco- 
cytes, by tendency to vascularization, more active growth 
of atypically located gland cells and by retrograde changes 
of tissue. These are frequently manifested early. When 
once this balance between tendency of gland cells to 
exuberant growth and inherent property of surrounding 
tissue to prevent such has been upset, the tide of cancer 
cells flows forward seemingly opposed very weakly. 

2. Retrograde Changes. — In ulcerating gastric mucosa 
progressive and retrograde changes are constantly inter- 
acting. While hyperplasia is yet simple, the surface 
epithelium undergoes cloudy swelling, granulation, mucoid 
degeneration and liquefaction necrosis. Microscopic or 
gross sloughs result. These changes form a part of the 
attempt at repair which is being carried on, and of which 
the process of hyperplasia of gland and connective-tissue 
elements is a part. 

If the agent exciting epithelial elements to attempt 
normal repair is not removed, and the false metaplasia 
which results in tumor formation ensues, retrograde changes 
are manifested in the neoplasm itself. They are most 
actively carried on toward the lumen of the stomach, but 



94 CANCER OF THE STOMACH 

may be exhibited at any part of its altered wall. These 
retrograde changes are resisted by the cancer cells just 
as normal epithelium resisted them. The altered physio- 
logic units, however, not infrequently fail to prolong 
such resistance. As a consequence, the cells at the surface 
of the neoplasm may rapidly undergo granulation, mucoid 
or colloid change and necrosis. The free vascularization 
of the more cellular types of growth permits extensive 
blood extravasation, cyst formation and frequently ex- 
tensive sloughing. The rapidity with which cell pro- 
liferation, necrosis and sloughing occur and cause the death 
of the individual rarely permit the retrograde changes 
going beyond the colloid stage. Occasionally, small cal- 
cified areas are seen in slow-growing tumors located deep 
in the submucosa. 

These progressive and retrograde tumor changes and 
the reaction of surrounding tissues have much to do with 
the gross characteristics of gastric tumors. Their evi- 
dences are largely responsible for the common clinical 
classification of such neoplasms into carcinoma medullare, 
carcinoma fibrosum, ulcus carcinomatosum, and carcinoma 
colloides. They also influence the histologic picture, so 
that we not infrequently see such groupings of the disease 
as spheroidal-celled carcinoma, cylindrical-celled carcinoma 
(adenocarcinoma) and mucous-celled (colloid) carcinoma. 
From the preceding attempt to explain the early changes 
constituting gastric cancer, it will be seen that any such 
classification is incomplete and misleading. So-called 
''types" of carcinoma occur entirely because cancer cells 
grow differently in relation to connective tissue and they 
are influenced by both progressive and retrograde changes 
in themselves and in surrounding tissue. These neo*- 
plasms are derived from gastric gland epithelium and 



MOEBID ANATOMY 95 

are thus essentially of the same parentage. At some 
stage in the development of any gastric cancer, it is quite 
likely that practically all so-called ''tj^Des" of cells could 
have been recognized and that degenerative processes 
could have been seen. The confused histologic and 
gross classifications that have been presented are accounted 
for largely because they have been based upon examination 
of specimens removed from patients who have died from 
the disease. In comparison we would mention that a 
full-grown flower rarely resembles its bud nor yet does the 
bud recall the seed which gave both, as well as the vine, 
their birth. 

THE RATE OF GROWTH OF GASTRIC NEOPLASMS 

That neoplasms in general may develop with astonishing 
rapidity is experimentally shown by the work of Rous. 
Fifteen days after transplanting minute fragments of 
chicken sarcoma into chick embryos, visible and tangible 
tumors were present. Histologically 69 per cent, of the 
tumor cells were shown to be dividing by amitosis. 

In human gastric cancer, the rate of growth varies 
widely. Those tumors confining themselves to the mucous 
membrane and the loose submucosa grow with the great- 
est speed. Such rapid advance occurs most commonly in 
so-called ''primary" gastric cancer (without antecedent 
ulcer, benign or mahgnant). In such location connective- 
tissue barriers are weak and few. Clinically, this type 
of tumor may cause death of the host, in our experience, 
within 7 weeks of the onset of symptoms. We have seen 
epigastric tumor increase in size threefold in rather more 
than a month. Tumors derived from gland-cell groups 
located deep in the submucosa and progressing in it or to- 
ward the muscularis increase in size with comparative slow- 



96 CANCER OF THE STOMACH 

ness. We have observed instances where epigastric nod- 
ules have existed in epigastria for more than a year and 
symptoms for as long as 3 years, and yet at laparotomy 
tumors have weighed less than 60 grams. Epithelial 
elements in such are generally well spht up with scar 
tissue. Not infrequently, it would seem that atypically 
growing epithelia exist in the edges or bases of ulcers 
for many months without progressing far. Sloughs may 
remove many such and be a prophylactic measure. These 
hosts often have ulcer symptoms for more than 5 years, 
but refuse surgical relief until stenoses or perforation 
occur. Examination of fresh tissue obtained at laparotomy 
reveals numerous areas of malignancy, frequently with 
extensive perigastric lymph-gland invasion or secondaries 
in adjacent or distant organs. Colloid cancers appear 
to spread rapidly because they are very rich in epithelial 
elements. That the age of the individual is a factor of 
relative value in the determination of rate of growth of 
gastric cancer seems to be well supported by clinical 
observation. We have observed 18 instances of the 
disease in patients below age 31. The average duration of 
life of 12 of these, after sj^mptoms had appeared, was less 
than 9 months. Of our gastric carcinomata over age 50, 
the average length of life after the beginning of the com- 
plaint was rather longer than 1)4 J^ears. In experi- 
mental animals where tumors have been transplanted a 
similar factor influencing ''takes" and growth rate has 
been emphasized by Bashford. 

The state of body nutrition appears to have an influence 
upon the rate of progress of gastric cancer. It has been 
our experience that such neoplasm developing in well- 
fed, robust patients of the erythremic type advanced 
rapidly not only locally, but also by metastasis. Lean, 



MOKBID ANATOMY 97 

spare, sallow folk appear to tolerate gastric cancer rela- 
tively well. Tumors grafted experimentally upon under- 
fed hosts would seem to grow more slowly than when 
hosts were supplied with an abundance of food. Such 
observations have been made by Moreschi and by Rous 
for mice and rats. 

The location of gastric cancer in the wall of the viscus 
only relatively influences growth rate. At the orifices 
where traumata are possible during chymification and 
passage of food, neoplasms in general grow very rapidly. 
At such points (especially in the pyloric third of the 
stomach) peristaltic movements are frequent and vigorous 
and digestive secretions have their highest potency. 
However, variation in epithelial cell content of the tumor 
mass would seem to be a not negligible factor in the rate 
of the development of the disease even at these points. 

Location of Gastric Neoplasms. — It is a waste of time 
to speculate upon the location of gastric cancers unless 
one is doing so for the purpose of determining the correct- 
ness of clinical signs or of symptoms in cases upon which 
laparotomy or necropsy is to be subsequently performed. 
That those most proficient in the diagnostic art not un- 
commonly fail in attempts at localization of the neo- 
plasm can be demonstrated by a sojourn at any busy 
surgical clinic or in a modern morgue. Not rarely cases 
clinically diagnosed gastric cancer prove to be primary 
affections of adjacent viscera. Consequently, the only 
tables of worth regarding the situation of gastric carci- 
nomata are those determined from post-mortem exami- 
nations or at laparotomy, and those where the growths 
have been grossly and microscopically proven to be cancer. 
From dead-house material it is impossible to say at what 
part of the gastric wall cancer began. One can only 
note what portions of the stomach are then involved. 



98 CANCER OF THE STOMACH 

Such figures are of but relative value. That they do not 
correspond with location of neoplasms removed at lapar- 
otomy is seen by comparing groups of collected statistics. 
The statistics for situation of gastric cancer commonly 
quoted in literature (even recent) follow. 

In 1859 W. Brinton analyzed 360 clinical cases and 
necropsies. He stated that in these the pjdorus was in- 
volved in 60 per cent, and the cardia in 10 per cent. In 
1871 Luton summarized the cases of Lebert, Dittrich and 
Louis. His study comprised 102 instances of the disease. 
The situations were given thus: pylorus 57.8 per cent.; 
lesser curvature 16.6 per cent.; cardia 7.8 per cent.; 
anterior or posterior wall 4.8 per cent.; greater curvature 
1.9 per cent.; general 0.9 per cent, and in various parts 
6.8 per cent. Welch later collected 1,300 cases of gastric 
cancer mainly from the continental literature. His tabula- 
tion is compiled largely from necropsy reports. He states 
that in 60.8 per cent, the pylorus was involved; in 11.3 
per cent, the lesser curvature; in 8 per cent, the cardia; in 
5.2 per cent, the posterior wall; in 4.6 per cent, the whole 
or greater part of the stomach; in 2.6 per cent, the greater 
curvature; in 2.3 per cent, the anterior wall and in 1.4 
per cent, the fundus. In 3.4 per cent, there were multiple 
tumors. In 1903 the Fenwicks analyzed 263 of their 
own cases. They state that the pylorus was involved in 
65.3 per cent. These investigators also submit an analysis 
of 1,850 instances of the disease collected from necropsies 
(?) in various countries. Of these, the pylorus was af- 
fected in 58 per cent.; the lesser curvature in 11.5 per cent.; 
the cardia in 9.8 per cent.; the posterior wall in 5 per 
cent.; the greater curvature in 2.8 per cent.; the anterior 
wall in 2.2 per cent.; the fundus in 1.5 per cent.; general 
involvement in 6 per cent. In 2.9 per cent, there were 
multiple growths. 



MORBID ANATOMY 



99 



The above summaries demonstrate that necropsy reports 
exhibit relatively sUght variations in the parts of the 
stomach involved by neoplasms that have, in the main, 
caused death of those affected. 

In our series of 921 gastric cancers, operatively and 
pathologically proved (but an occasional case was studied 
at necropsy), there were 854 instances where accurate 
locaHzation of the disease could be determined or was 
recorded. The summary is shown in Table 13. 

Table 13 







o 


s^ 


"3 




o 


1 














































Situation 


3 
u 

o 






o 

Pi 


o 
a 
•-3 

O 




o 

•c 
S 

c 
< 


§ 
■a 
a 


is-s 


No. of cases 


359 201 


102 


79 


30 


20 


20 8 • 26 


Percentages 


42 24.7 


12 


9.3 


3.0 


2.3 


2.30.9 2.9 



Analysis of Author's 854 Cases of Carcinoma of the Stomach Showing 
the Frequency of the Neoplasm in Various Parts of the Viscus. 

These figures are to be contrasted with those derived 
from study of post-mortem or unproved cUnical material. 
The following table demonstrates that the situation of 
gastric cancer as shown at laparotomy corresponds rather 
strikingly to the location of chronic, calloused gastric 
ulcer. 

Table 14 

Number of eases Per cent. 



Pyloric 

Prepyloric 

Lesser curvature . 

Near cardia 

Posterior wall . . . 
Anterior wall. . . . 



Total. 



65 


46.4 


5 


3.5 


43 


30.7 


9 


6.4 


12 


8.5 


2 


1.4 


136 





Showing Location of Benign, Non-retention Gastric Ulcers (Author) 



100 CANCER OF THE STOMACH 

Welch's figures for location of gastric ulcer also closely 
approximate those of the author for benign ulcer and for 
gastric cancer as here given. 

COMPLICATIONS OF GASTRIC CANCER (General) 

In our series many of the text-book complications of 
carcinoma of the stomach are missing, because a large 
number of instances were operated upon early. As a 
consequence numerous terminal compUcations of the dis- 
ease were lacking. 

A. Pyloric Obstruction. — ^This occurred in some grade 
in nearly 72 per cent, of instances. T\Tien it is recalled 
that fully 3 out of 5 of all ulcers and cancers are 
located in the pyloric third of the stomach, it is quite easy 
to realize the reason for this frequency of stenosis. T\Tien 
the pyloric obstruction was caused by ulcer in whose edge 
was demonstrated malignant tissue microscopically, or 
when the gastric affection was ulcus carcinomatosum, 
marked dilatation of the stomach was an apparently early 
manifestation of this obstruction. Where the pylorus was 
intruded upon by a nodular growth, dilatation of the 
stomach was rarely so marked as in the case of ulcer. 
The average amount of gastric extract removed from the 
fasting stomach of instances of pyloric obstruction due 
to malignant ulcer was 350 cc. The average amount 
from cases where a large tumor occluded the pyloric 
channel was 200 cc. Of course there were great variations 
from the figures in both illustrations. 

Pyloric obstruction is recognized readily by persistent 
vomiting of retained food, of copious vomitus and can 
usually be demonstrated at the Roentgen examination. 

B. Obstruction at Cardia. — This occurred in 17 instances 
or (1.8). It usually resulted from malignant ulcer at or 



MOKBID ANATOMY 101 

near the cardia, tumor situated at the fundus or high on the 
lesser curvature or from the pressure of gland metastases 
about the cardia. It is recognized clinically by dysphagia, 
vomiting soon after food ingestion, rapid emaciation, 
scanty urine, obstruction to the passage of a stomach tube 
with or without free bleeding and by a;-ray examination. 

C. Malignant Hour-glass. — This is a frequent com- 
plication in instances where a '^saddle ulcer" has become 
malignant or where large tumor masses project into the 
gastric lumen. While it may be suspected from the clinical 
history, the vomiting soon after eating, the nature of the 
abdominal tumor, the appearance of the stomach upon in- 
flation with air and the auscultation of the abdomen, it is 
most conclusively demonstrated at the Roentgen examina- 
tion. In our cases malignant hour-glass occurred in some 
degree, approximately in 1 out of 15 cases. 

D. Hemorrhage is a sign in from 15 to 25 per cent, of 
all cases. Hemorrhage occurred in more than 19 per cent, 
of our cases irrespective of the type of the lesion. In the 
instance where malignancy has supervened upon a previous 
gastric affection, usually of the type clinically classed as 
peptic ulcer, hemorrhage may be copious and associated 
with symptoms of shock. When malignancy has become 
well established, sudden, severe, copious hemorrhages are 
not the rule. There is in the large majority of instances, 
however, constant seepage. This may be recognized by 
chemical tests for altered blood in the gastric extracts and 
the feces. Such tests were positive in nearly 9 out of 
10 of our cases of gastric cancer. 

E. Perforation. — In advanced cancer of the stomach 
perforation occurs in from 2.5 per cent, to 6 percent, of all 
instances. It may be sudden or gradual. Sudden per- 
foration is as a rule readily recognized, if there is a history 



102 CANCER OF THE STOMACH 

of a malignant gastric affection rather chrome. This is 
associated with epigastric tumor in more than 3 out 
of 4 instances. Pain has generally been not so severe as 
to be classed as ''colicky." After vomiting, a fall, a heavy 
meal or some sudden exertion, sudden sharp lancinating 
abdominal pain may come on. This is associated with 
shock, subnormal temperature, abdominal distention and 
great prostration. Temperature generally rises fairly 
rapidly and terminal evidences of septic peritonitis be- 
come apparent. 

Gradual perforation of a cancer of the stomach sometimes 
occurs. There may be some attacks of colicky pain but the 
leakage from the stomach is so slight that opportunity for 
walling it off occurs. As a consequence, perigastric abscess 
or localized abdominal abscess between the stomach and 
other viscera develop. The following case illustrates 
these features: 

Perforating Gastric Cancer; Perigastric Abscess; Few symp- 
toms: 
Mrs. L. N. — Age 54, Swedish, housekeeper. 

Family History. — Mother died from carcinoma mammcs. 

Personal History. — Always well and strong to about 1 
year ago ; then began to lose weight gradually, but without 
symptoms. Two months since unaccountable anorexia 
developed. One month ago began to belch much gas 
following food intake. Two weeks since, had a sudden 
sharp pain in the left loin. It came on at night and dis- 
tress lasted 3 days. It then practically disappeared. A 
few days ago noted a tender swelling along the left rib edge. 
This increased in size and gradually advanced across the 
epigastrium to the mid-line. It became much larger and 
very tender. Thinks she had fever; had chilly sensations 
daily and sweated rather freely. 

Appetite. — Capricious. Never vomited. 

Bowels. — Costive. 

Urine. — Negative. 



MORBID ANATOMY 103 

Weight.- — One year ago, 180; three months ago, 170; 
present, 154. 

Examination. — Temp., 101; pulse, 100;resp., 24. Cheer- 
ful, comfortable appearing woman; mucosae pale, but cheeks 
pink. 

Throat and Neck. — Negative. 

Thorax. — Heart sounds weak; lungs, negative. 

Traube's Space. — Dull on percussion. 

Splenic dulness at eighth rib in axilla. 

Abdomen. — Tense swelling from left rib edge across lower 
epigastrium to right of navel. Fluctuation (?) 

Rectum. — Negative. 

Blood.~Rg., 70 per cent. ; r.b.c, 3,880,000; w.b.c, 16,000. 

Operation. — Incision over most prominent part of epi- 
gastric tumor. A quantity of creamy, thick fluid came 
out under tension. Drainage. 
Subsequent Course: 

Abdominal Examination. — After abscess had been drained 
revealed a firm, fixed mass occupying the entire left epigas- 
trium. 

Test-meal. — Marked 12-hour retention. Total acidity, 
50; free Hcl, 0; lactic acid-f; altered blood+; Wolff 4-, 
microscopic examination revealed large numbers of bacilli 
of the Oppler-Boas type. 

X-ray. — Entire pylorus, pars media and greater curva- 
ture involved with a fungoid growth. Almost complete 
pyloric obstruction. 



F. Fistulas usually result from perforation with a 
resultant abscess cavity or direct connection between the 
stomach or the large bowel or develop from necrosis of a 
contiguously extending tumor. Gastrocolic fistulse occurs 
in from 1 to 4 per cent, of late cases of gastric cancer. 
Clinically they are recognized by a previous malignant 
gastric disease later showing evidences of fsecal contents 
in the vomitus, in diarrhea of the lienteric type, hemorrhage, 
the speedy appearance of a test capsule of carmine in the 
stool or by the Roentgen ray. 



104 CANCER OF THE STOMACH 

Gastric Cancer, Involving Transverse Colon, Pancreas and 
Liver; Hemorrhage; Metastases to Pelvis; Anemia; Few 
Clinical Symptoms: 
Mr. L. J. — Age 57, Swedish, cabinet maker. 

Family History. — Mother died of cancer (pelvic). Father 
and sister died of pulmonary tuberculosis. 

Personal History. — Malaria many years ago. Denies 
venereal. 

Present Trouble. — Nearly 2 years ago began to have at- 
tacks of diarrhoea. These came on at intervals of from 
2 weeks to 3 months. Occasionally passed bright red 
blood in stool. Three months ago fainted away while at 
work, and was taken to a hospital. Since then has gradu- 
ally become weaker and has lost weight. 

Appetite.— Gradual failure. 

Bowels.- — Occasional diarrhceic stool. 

Weight. — One year ago 170 pounds; present, 117. 

Examination. — Tired looking, pale, emaciated blonde. 

Mouth. — Teeth poor; tongue coated. 

Neck. — Enlarged left supraclavicular glands. 

Thorax. — Heart, weak muscle sounds. 

Abdomen. — Irregular mass in high and middle thorax, 
moving on respiration, tender. Small amount free fluid 
in peritoneal sac. 

Rectal. — Several nodules in Douglas pouch. Bleeding 
hemorrhoids. 
Laboratory Examinations: 

Blood.— Kg., 40 per cent.; r.b.c, 3,490,000; w.b.c, 5,100. 

Wassermann and Luetin Tests. — Negative. 

Test-meal. — Twelve-hour retention. Total acidity, 20; 
free Hcl, 0; lactic acid+; altered blood-H; Oppler-Boas 
bacilli. 

X-ray Examination. — Filling defect involving pyloric 
half of stomach, and invading the transverse colon, pancreas 
and liver (?). 

Laparotomy . — High median incision. Mass involving 
pyloric half of stomach and extending along coronary 
artery to esophagus. Transverse colon, omentum and 
head of pancreas also involved. Few nodules in liver. 

Operation. — Explored. 

Pathologic Report. — (Post-mortem) Adenocarcinoma. 



MORBID ANATOMY 105 

G. Metastases occur most commonly to the lymphatics 
in gastric cancer. T\'e have tabulated their significance in 
Chapter IV. In more than 70 per cent, of our cases of 
gastric cancer, metastases to the perigastric lymph chains 
were demonstrated. As has been pointed out by ^NlacCarty 
and Blackford, the extent of perigastric lymph-gland in- 
vasion bears no relation to the size of the primary process 
in the stomach wall; the gross size of the individual lymph 
nodes is no definite evidence as to whether or no they 
contain mahgnant tissue; mahgnant glands are usually 
hard upon palpation and thek cut surface has a glistening 
white color. Upon the degree of lymph-gland invasion 
depends absolutely the prognosis in a given case, whoU}- 
irrespective of the size of the primary growth. 

Metastases to the liver occur in from 15 to 35 per cent, of 
all instances of late gastric cancer. In our series (which 
comprises many cases where the diagnosis of malignant 
disease of the stomach was made microscopicaUy) the 
liA-er was involved in 18 per cent, of cases. AYith the in- 
volvement of the liver one not infrequently notices the 
development of ascites. This is due to interference with 
the portal cumulation and also to direct involvement of the 
peritoneum. The ascites usually develops very gradually, 
but there are cases where a rapid accumulation of ascitic 
fiuid occurs. In such instances a fatal termination super- 
venes in a short time. 

Metastases to the Lungs. — If the disease is allowed to 
progress without interference, metastatic involvement of 
the pleura, pericardium, the lung tissue and the mediastinal 
lymphatics is noted in from 5 to 11 per cent, of aU instances. 
If the pleura is involved serous exudation may appear rapidly. 
The puncture fluid not infrequently shows blood cells, 
cells with at^-pical mitotic forms and an increase in the 



106 CANCER OF THE STOMACH 

incoagulable nitrogen (Roger Morris). If lung tissue is 
actually invaded, malignant consolidation or necrosis with 
abscess result, 

H. Jaundice may result from direct extension of the 
gastric growth to the liver or the gall tract, from pressure 
of a pyloric tumor upon the bile passages, from malignant 
invasion at the head of the pancreas and consequent obstruc- 
tion of the common bile duct or from pressure upon the 
biliary passages by malignant lymph nodes. In early cases 
of gastric cancer, jaundice is present in about 3 per cent, of 
instances. Where the growths are extensive, jaundice 
occurs in 12 to 15 per cent, of cases. 

I. Thrombosis is a terminal complication of gastric 
cancer. It is relatively infrequent. It may be arterial 
or venous. The vessels most commonly involved are the 
femoral, saphenous, the external iliacs, the subclavian or 
the brachial. If the patients are not too far gone, throm- 
bosis is evidenced by local pain, edema or discolora- 
tion of tissues. 

J. Enteritis occurs concomitantly with the majority 
of gastric cancers. It varies greatly in degree or extent. 
Not rarely tenderness over the bowels, colicky abdominal 
pains, diarrheic stools or the appearance of hemorrhoids 
indicate deficient function on the part of the small or large 
bowel. 

K. Nephritis. — It is difficult to estimate whether anoma- 
lies on the part of the kidneys are due to the disease or 
are malfunctions to be expected in individuals past middle 
life. In our series albumin was noted in 17 instances and 
casts in 19. 

L. Nervous complications are comparatively rare oc- 
currences in gastric cancer. A certain melancholy frame 
of mind not unnaturally develops in individuals who real- 



MORBID ANATOMY 107 

ize that they are fatally ill with a disease around which 

clings much popular dread. Fenwick claims that this 

may amount to insanity in 1.6 per cent, of instances. We 

have no case of insanity as a complication in our series. 

Neuritis, paralyses or sometimes general tonic spasms of 

the tetanoid type have been described associated with this 

disease. Whether such complications are directly caused 

by the neoplasm or are evidences of functional or toxic 

disturbances apart from the gastric cancer, it is difficult 

to state. 

ADDENDUM 

A RAPID METHOD OF CUTTING AND STAINING 
SECTIONS OF TISSUE (WILSON) 

Place a piece of tissue no thicker than 3 mm. on freez- 
ing stand and add enough dextrin solution of the consist- 
ency of molasses to cover. Then turn nozzle allowing the 
CO2 to escape until the tissue is just hard enough so that 
sections may be cut without crumbling. Under proper 
conditions such as a sharp knife, proper density of tissue, 
proper temperature, etc., sections may be cut as thin as 5 
microns. Keep the knife continually flooded with water 
while cutting the sections. Use ball of the finger to remove 
section from the knife and place section in a dish of water. 
Pieces of tissue that have been hardened for 12 to 24 
hours in 10 per cent, formalin can be cut with much 
greater ease than when not so treated. The sections so 
made may be stained either by the hematoxylin-eosin 
method and permanently mounted or stained by the 
following method which is much more rapid but less 
permanent. 

Rapid Method of Staining. — Place the section in a 
small dish containing about a dram of Brun's polychrome 
methylene-blue (Grubler's) solution for 10 to 15 seconds 



108 CANCER OF THE STOMACH 

and transfer immediately to water. After rinsing a few 
seconds, place in Brun's glucose medium to clear the 
sections. 

Formula for Brun's Glucose Medium. — (a) Glucose, 
240 cc. Hot distilled water, 840 cc. Mix thoroughly. 

(6) Spirits of camphor, 60 cc. Glycerine, 60 cc. Mix 
thoroughly. 

Mix (a) and (6) together and filter. 

After section has been in above solution a few seconds 
it is floated upon a microscopic slide, the excess fluid al- 
lowed to drip off and a cover slip placed in position. It 
is ready for examination. Under ordinary conditions the 
slide will keep 2 to 3 weeks. By this method one may have 
a well-stained section of tissue ready for microscopical 
examination within 3 minutes. Either the Spencer or 
Leitz freezing microtomes are suitable for this work. 
Either may also be used for the cutting of celloidin or 
paraflSn blocks. 

REFERENCES 

ViRCHOw: "Pathologie des Tumeurs," vol. vii, p. 236. 

Fenwick, S.: "Cancer and Other Tumors of the Stomach," Phila- 
delphia, 1903. 

Yates: Annals of Surgery, 1006, Oct., p. 599. 

Clendenning: Am. Jour. Med. So., 1909, Aug., p. 1. 

Frazier: Am. Jour. Med. Sc, 1914, June, p. 781. 

Campbell: Surg. Gyn. and Obstets., 1915, Jan., p. 66. 

Waldeyer: " Arbeiten uber den Krebs," Virchow's Archiv., 41, p. 470. 

Rokitansky: Lehrbuch der pathol. Anatomie, 3 Aufl., iii, p. 171. 

Rous: Jour. Exp. Med., 1910, vol. xii. No. 5; and Proc. Am. Philo- 
sophical Soc, 1912, vol. li. No. 205. 

Rous AND Jones: Jour. Exp. Med., 1914, vol. xx, No. 4. 

Rous, Murphy and Tytler: Jour. Am. Med. Assn., 1912, June 8, 
p. 1751. 

Murphy: Jour. Exp. Med., 1913, vol. xvii. 

Levin: Jour. Exp. Med., 1912, No. 12, p. 149. 

Snow: Journ. of Infect. Dis., vol. iv, No. 3, p. 385. 

Smith: Bulletins Nos. 213 and 255, U. S. Dept. of Agriculture, 1912. 



MORBID ANATOMY 109 

Fibigeb: Berl. Klin. Wchnschr., 1913, Feb. 17, p. 289. 

MacCartt, W. C, and Wilson: Am. Jour. Med.Sc, 1909, Dec, p. 846. 

MacCarty, W. C: Surg. Gyn. and Obstets., 1910, x, p. 449. 

MacCartt and Broders: Arch, of Int. Med., 1914, xiii, p. 208. 

MacCarty, W. C: Jour, of Iowa State Med. Soc, 1914, iv, p. 1. 

MacCarty, W. C: Am. Jour. Med. Sc, 1915, No. 4, p. 469. 

Rous and Murphy: Jour. Exp. Med., 1914, vol. xx, No. 4. 

Gay: Jour. Med. Research, 1909, Feb., p. 175. 

Carrel: Jour. Exp. Med., 1912, vol. xvi, No. 2. 

MoRESHi: Ztschrft. f. Immunitatsforch, 1909, vi, p. 651. 

Rous: Proceedings of the Society for Experimental Biology and 

Medicine, 1911, viii, p. 128; and Jour. Exp. Med., 1914, vol. xx, 

No. 5. 
Brinton: "Diseases of the Stomach," 1859. 
Luton: "Magenkrebs," Nouveau diction de Med., Paris, 1871. 
Welch: "Cancer of the Stomach," Am. Syst. of Med., ii. 
Fenwick, S.: {Loc cit.) 

MacCarty and Blackford: Annals of Surg., 1912, June, p. 811. 
Morris, Eoger: Arch, of Int. Med., 1911, Oct., p. 457. 
Wilson: Jour. Am. Med. Assn., 1905, Dec. 2. 



CHAPTER III 
SYMPTOMATOLOGY 

The work of the surgeon and of the cellular pathologist 
has demonstrated that the cases of gastric cancer which 
are cured, or given any considerable lease of life, are those 
where such early diagnosis of malignancy has been made as 
to permit of the resection of the neoplasm while it is still 
a locahzed process. 

The pathologist, familiar with fresh tissue examination, 
has proved that the highest proportion of operatively cured 
cases of gastric cancer makes up that group where the 
early diagnosis consisted in the recognition of malignancy 
(with the highest power microscope) in extirpated sections 
of the gastric wall in patients where the disease seemed 
chnically, surgically and macroscopically chronic, calloused 
gastric ulcer. 

The early diagnosis of malignancy in these curable 
cancer cases involved the histologic demonstration of 
intracellular progressive nuclear hypertrophy, undiffer- 
entiated (functionally) gland-cells, exuberant hyperplasia 
of gland structures and beginning invasion of hyperplastic 
epithelial cells into non-epithelial portions of the stomach 
wall. 

The cases deriving the greatest benefit from operation 
are those in which the fewest areas of malignant epithelial 
hyperplasia are found, or those where active gland-cell 
hyperplasia exists, which permit of a presumptive histologic 
diagnosis of malignancy. 

110 



SYMPTOMATOLOGY 111 

Specimens of extirpated tissue microscopically revealing 
the least advanced epithelial cellular faults are generally, 
but not always, associated with the minimum of peri- 
gastric lymph-gland malignancy. 

In gastric cancer, the extent of lymph-gland metastasis 
controls most certainly the prognosis. The size of the 
local neoplasm, in the stomach wall, is but a relative index 
of the possible extent of perigastric lymph-gland in- 
vasion. The size of gastric lymph glands, themselves, is 
no criterion of the degree to which they may be malig- 
nantly invaded. Minute glands may contain a greater 
number and more perniciously active cancer cells than do 
large glands. Hence, the diagnosis (and the prognosis) 
of the stage of a gastric cancer is primarily in the hands of 
the surgical pathologist. 

From the foregoing facts it would appear that the past 
decade has contributed the most radical clinical information 
regarding gastric cancer that has come to us since its 
classic description by Virchow and Waldeyer. It would 
seem that a great prophylactic advance were now possible. 
Previously, the clinician's complaint has been that the 
gastric cancer case came to him for aid only when the 
disease was so far advanced that the diagnosis and prognosis 
stood revealed on the face of the patient. One could run 
and read. Early diagnosis mainly implied detecting 
gastric malignancy before general carcinosis and early 
death threatened. Medical treatment but prolonged 
misery. The surgeons who operated on these patients 
offered little. But they were a bold lot: scientific vikings, 
who, by persistent exploration, have come back to the less 
venturesome members of their clan with an epoch-making 
discovery. We can now state that the early diagnosis 
of gastric cancer is a microscopic one; it is possible from 



112 CANCER OF THE STOMACH 

histologic study of freshly removed tissue; such tissue is seen 
least developed in those patients whose gastric history has 
been that of chronic, recurring peptic ulcer and in whom to 
eye and hand such ulcer appears at laparotomy. 

As is to be expected, this view of the situation is not 
as yet generally accepted. Healthy skepticism is a scien- 
tific virtue, but doubt, unsupported by facts, is a pernicious 
habit. This sluggishness of the professional mind might 
be discouraging to both investigators and trusting patients, 
had it not been shown that gastro-enterologic history 
is rich in similar examples. It is but a few years 
since ' ' catarrhal gastritis, " " hyperacidity, " ' ' Reichmann's 
disease" and "pyloric spasm" were considered definite 
disease entities. Only recently, and reluctantly, has 
the world medical accepted these pet ailments for their 
face value, as being symptoms of gastric malfunction 
associated with peptic ulcer or subinfections of the ap- 
pendix or gall-bladder. 

This introduction is necessary to support the grouping 
of symptom-complexes of gastric cancer which the study of 
the 921 instances comprising our series seems to establish. 

Our material can be grouped under the following symp- 
tom-complex heads : 

I. Gastric cancer in individuals who came to laparotomy 
for clinically benign gastric ulcer, and in whom cancer was 
diagnosed microscopically. 

II. Gastric cancer clinically developing in patients with 
years of antecedent dyspepsia of the "peptic ulcer type," 
in whom malignancy subsequently appeared. 

III. Gastric cancer in individuals who prior to the onset 
of a malignant disease had enjoyed perfect gastric health. 

IV. Gastric cancer in individuals in whom malignancy 
followed periods of gastric disturbance of no clinical type. 



SYMPTOMATOLOGY 113 

V. Gastric cancer in individuals who presented few clinical 
evidences of a malignant process primary in the stomach wall. 

VI. Gastric cancer secondary to an extragastric malignant 
process. 

Group I. Gastric Cancer in Patients Who Came to Laparotomy for 

Clinically Benign Gastric Ulcer and in Whom Cancer was 

Microscopically Diagnosed 

This group comprised 72 cases (7.8 per cent.). There 
were 44 males and 28 females. The average age was 56.5 
years. The shortest period of gastric distress was 3^ 
years, the longest 42 years, the average 13.7 years. There 
was a family or blood relationship history of malignancy 
in 3 instances (4.1 per cent.). 

Mode of Onset. — ^The disease had been periodic, without 
acute attacks in 42 cases (58.3 per cent.) . Between attacks 
until complications ensued (stenoses, perforation, etc.) 
the patients generally enjoyed good gastric health. The 
periods of exacerbation varied in frequency from 1 every 
week or 10 days to one in 3 or 4 years. Peculiar seasonal 
relationship of the ''spells" of dyspepsia were noted: fall 
or spring or both seemingly bringing such on, or aggravating 
an already present dyspepsia. 

In 19 cases (26 per cent.) the disease had been chronic 
and continuous. There were frequently noted times when 
the gastric malfunction was of increased severity. 

Eleven patients (15.2 per cent.) gave history of acute 
attacks of dyspepsia, either at infrequent periods or at 
some phase of a continuous ailment. These acute attacks 
usually implied severe, often colicky, abdominal pain, 
vomiting, hemorrhage with or without symptoms of shock, 
loss of appetite or strength, constipation, or occasionally 
jaundice. 



114 CANCER OF THE STOMACH 

The Digestive Disorder. — Anorexia was generally evi- 
denced only during the periods of abdominal discomfort. 
There was good appetite between such. Not infrequently, 
the fear of bringing on pain by ingestion of food, normal 
in amount and quality, the dread of precipitating hemor- 
rhage, or oscillations between various types of ''diet," 
resulted in the development of a poor appetite habit. 
Mild or marked degrees of stenosis at cardiac or pyloric 
orifices occurred in 30 instances (41.1 per cent.). In such 
cases poor appetite resulted from pain on ingestion, nausea 
or fear of precipitating vomiting. 

Dysphagia was a late symptom in 3 instances (4.1 per 
cent.). It resulted from calloused ulcer partly occluding 
the cardia or from severe spasm at that orifice as a conse- 
quence of an irritated ulcer high on the lesser curvature 
of the stomach. 

Water-brash with or without pyrosis often proved an 
annoying symptom. It was a major complaint at some 
stage of the disease in 55 cases (76.4 per cent.). In the 
ulcer patients exhibiting periodicity of complaint water- 
brash and pyrosis were generally early warnings that a 
''spell" was coming on. The greatest discomfort from 
these sources occurred from 1 to 4 hours following food in- 
gestion in the majority of instances. In cases where the 
digestive disturbance was continuous, patients frequently 
stated that they were rarely free from "sour stomach." 
Prompt rehef of these symptoms was commonly obtained 
by ingestion of food, the taking of alkahes, by vomiting, 
by gastric lavage, or by free catharsis. 

Bowels. — Constipation was observed in 47 cases (66.9 
per cent.). It was frequently periodic and heralded the 
approach of a dyspeptic storm. Diarrheic stools were 
described by 6 patients (8.3 per cent.). 



SYMPTOMATOLOGY 115 

The tongue was described as '' coated" in 62 instances 

(86 per cent.)- 

Nutrition. — There were 16 patients who had lost no 
weight and were in excellent flesh. Thirty-four cases had 
lost less than 10 pounds. In 22 the weight loss ranged 
from above 10 pounds to as great as 39 pounds. Weight 
was frequently noted as having been lost in the attacks or 
periods of exacerbation of the disease. It was commonly 
gained when the dyspeptic agony had passed. Associated 
even with marked and rapid weight loss, there was but 
rarely cachexia, such as is usually present in malignancy. 

Blood. — The average hemoglobin was 80 (Tallqvist or 
Dare). The red-cell count averaged 4,200,000. Leuco- 
cytes were above 9,000 in but 2 instances. These were 
both ulcers in which perforation was subsequently dem- 
onstrated. 

Strength was "poor" in 18 patients. 

Vomiting. — This proved a troublesome symptom at 
some phase of the ailment in 58 cases (80 per cent.). The 
vomitus was the color of ingested food, white, green or 
yellowish. Food was not infrequently poorly chymified. 
Copious vomitus of the ''delayed" type was a late mani- 
festation in 32 instances (44 per cent.) . Blood was vomited 
by 24 patients (34.5 per cent.). Emesis occurred with 
the greatest frequency from 2 to 4 hours following food 
ingestion. Five cases with cardiac or high lesser curvature 
ulcers vomited shortly after the swallowing of food. The 
vomitus was described as sour, bitter, or salt. 

Hemorrhage. — Hematemesis was experienced by 24 pa- 
tients (34.5 per cent.) and melena by 3 (4.2 per cent.). 
Helena without hematemesis occurred once. 

The stool examined at some phase of the ailment had 



116 CANCER OF THE STOMACH 

given chemical test for altered blood in 52 cases (71.1 
per cent.) by the benzidin or guaiac reactions. 

Pain. — Some form of abdominal distress was complained 
of by every patient in this group at some time during 
the disease. Only 3 instances were recorded where dis- 
tress was constantly below the level of the navel. These 
were lesser curvature or anterior wall ulcers in rather low- 
lying stomachs. 

There was usually general epigastric distress. In 23 
cases (31.9 per cent.) more intense pain was a local com- 
plaint in addition to its being of widespread distribution. 
In 18 of these instances the severe complaint was at or to 
the left of the mid-abdominal line. 

Type of abdominal distress varied. In 10 patients 
(14 per cent.) it was described as '^ colicky," "boring," 
"knife-like." Fifty-four cases (73 per cent.) complained 
of "burning," "soreness," "gnawing." In the remaining 
instances vague "full" — "heavy" — "bloated" or "pres- 
sure" sensations were complained of. 

The time of occurrence of abdominal distress bore 
definite relation to food intake in 58 cases (81 per cent.). 
In^these patients pain came on from 2 to 5 hours after eat- 
ing and disappeared, or was lessened by again taking food. 
Until complications ensued (especially stenoses) the quaUty 
of food eaten seemed to have little significance toward the 
stopping of the distress. Quantity frequently appeared to 
exert greater influence: longer relief was obtained after a 
heavy meal than after a small one, but when pain re- 
curred it was then generally of greater severity. Other 
forms of pain-relief were in the order of their usefulness: 
alkalies, vomiting or lavage. In about 13 per cent, opi- 
ates were required at some time. 

There were 5 cases where pain was relieved by none of 



SYMPTOMATOLOGY 117 

the routine remedies. It was continuous, rarely very sharp, 
and bore no relation to food intake. The patients had not 
been given opiates. 

There were 7 instances where pain was of so violent 
a character that ulcer perforation was suspected. Hem- 
orrhage was associated 3 times. At laparotomy, some 
grade of perforation was made out in 5 of these cases. A 
stone in the cystic duct was found once. 

Test-meal Findings. — A complete discussion of this aspect 
of this group of gastric cancers is found in Chapter V. 
Briefly: Twelve-hour retention was demonstrated in 33 
cases (46 per cent.); total acidity averaged 62, and free 
hydrochloric acid 38. Lactic acid was demonstrated by 
the Uffelmann test twice. Blood by chemical test was 
noted in 18 gastric extracts (25 per cent.). Wolff-Jung- 
hans' test for increased soluble albumin was positive 5 
times in 9 cases tested. Microscopic examination of gastric 
extracts revealed no instance where organisms of the Oppler- 
Boas type were seen. In 84 per cent, of the stomachs 
showing gastric retention, yeasts and sarcinse were observed. 

HISTORIES 
Cases Illustrating Group I Type of Gastric Cancer 

1. Chronic, Recurri7ig Peptic Ulcer of Non-stenosing Type— 
Excisio7i; Pathologically Malignant: 

Mr, F. B. — Age 53, German, farmer. 

Family History. — Negative. 

Personal History. — Denies venereal; married; 2 children; 
wife has had no miscarriages; measles at 12; never used 
tobacco or alcohol; always worked hard. 

Digestive History. — For the past 15 years has had attacks 
of ''stomach trouble." Up to 6 months ago these came on 
2 or 3 times a year, being especially aggravating toward the 
Christmas holidays. The attacks consisted of ache or colics 
in the right upper abdominal quadrant or toward the rib 



118 CANCER OF THE STOMACH 

edges. They would come on 3 to 4 hours p.c. or at night 
and last until he ate sometliing or forced himself to vomit. 
His appetite was generally good, but he hmited his eating 
at such times. Between the ''spells" of dyspepsia he w^as 
perfectly well. Six months ago he began to have rather 
constant distress accompanied by acid eructations and 
some nausea. Appetite became less sharp. One night 
while unlacing his shoes, he felt ''queer" and soon afterrv^ard 
vomited about a pint of red blood. Was in bed a week; 
then felt fairly well except for soreness in the pit of his 
stomach. Since the hemori^hage, has felt moderately com- 
fortable except for some weakness. Appetite has been a 
bit capricious. Bowels which were formerly constipated 
have been loose for past 2 weeks. Xever noted blood. 
Thinks he is about 15 to 20 pounds underweight. 

Status PrcBsens. — ^Moderately well nourished, lanky male; 
sclera clear; tongue large and coated heavily; teeth poor 
and dirty; /e^or ex ore. 

Neck and Chest. — Negative. 

Abdomen. — Somewhat full in epigastrium; tenderness 
with muscle spasm in right upper quadrant and at right 
rib margin; nothing abnormal palpated. 

Rectal examination negative. 

Blood.— Rg., 85 (Tallq\dst); r.b.c, 5,340,000; w.b.c, 
7,000. 

Test-meal. — Total acidity, 44. Free Hcl, 28. Combined 
acids and acid salts, 10. No 12-hour retention. 

Stool. — Trace of blood (benzidin) on milk diet. 

Laparotomy. — Calloused ulcer size of a half dollar on 
lesser cur^^ature in antral region; edges thickened; base 
clean; no enlargement of perigastric Ijonph glands; stomach 
moderately dilated. 

Operation. — ^Nlikulicz-Hartman, Billroth No. 2 with pos- 
terior gastro-enterostomy. 

Pathologic Report. — Early carcinoma of glands of edge 
and base of ulcer. Numerous areas showing epithelial 
wandering through basement membrane. Extensive round 
cell infiltration. 

2. Chronic Calloused Prepyloric Ulcer; Stenosis; "Delayed" 
Vomiting; Laparotomy: Indurated Ulcer on Lesser 
Curvature; Microscopically — Adenocarcinoma with much 
Scar-tissue: 



SYMPTOMATOLOGY 119 

Miss N. McD. — Age 42, stenographer. 

Family History. — Negative. 

Personal History. — Scarlet fever twice when young girl; 
many attacks of tonsillitis; has severe headaches at irreg- 
ular intervals. 

Present Illness. — Gives account of ^'stomach trouble" 
for 23^^ years. Onset was gradual but has never been free 
from dyspepsia since ailment began; has been worse for 
past 6 months. 

Complaint. — Pain. Is located in epigastrium, especially 
in right upper quadrant. Character is ''gripping" and 
aching; maximum distress is generally 2 to 3 hours p.c. or 
at night. There is no transmission of pain. Vomiting, 
diet and alkalies give relief; lying on left side, jolting or 
body movements aggravate pain. 

Vomiting. — Began 11 months ago; for 3 to 4 weeks 
vomited after every meal, usually between 10 and 11 a.m. 
Eating or ''crampy" pain appeared to precipitate vomiting. 
Later began to vomit at bed-time; material vomited fre- 
quently contained food eaten at breakfast. Vomitus was 
''blackish" once. Always felt relieved after vomiting. 
For past 6 months has vomited rarely up to 1 week ago. 
At that time had sharp epigastric pain and vomited until 
stomach was entirely empty; noted no blood in either 
vomitus or stool. Has been on liquid diet since. 

Regurgitation, pyrosis and water-brash very annoying; 
came on mainly at night. 

Appetite.- — Good desire, but afraid to eat. 

Bowels. — Always costive. 

Weight. — Eleven months ago lost 40 pounds; gained 20 
pounds and held it to 2 months ago; is now 25 pounds 
under normal weight. 

Menopause. — Eleven months ago. 

Status PrcBsens. — Rather poorly developed maiden lady 
but fairly well nourished. Skin dry and loose; sallow. 
Sclera clear; mucosae pale; tongue coated; teeth in fair state 
of repair. 

Head, Neck and Chest. — -Negative. 

Abdomen. — Somewhat scaphoid. Abdominal aorta pul- 
sated visibly and violently. Palpation: Tenderness in 
mid-epigastrium with slight rigidity of right rectus mus- 
cle. Stomach, splashy. 



120 CANCER OF THE STOMACH 

Vaginal and Rectal Examinations. — Negative. 
Laboratory Findings: 

Blood.— Kg., 70; r.b.c, 4,020,000; w.b.c, 10,600. 

Test-meal. — Twelve-hour retention. Total acidity, 68; 
free Hcl, 40. No blood. Microscopically, yeasts and 
small type sarcinae. 

Urine. — Negative. 

Laparotomy. — Calloused ulcer involving the pylorus and 
lesser curvature in antral region; ulcer 4 cm. in diameter; 
no gland involvement; diverticulum 1}4 cm. in diameter is 
seen on jejunum about 1 meter from the pylorus. 

Operation. — Pj^lorectomj^ ; posterior gastro-enterostomy. 

Pathologic Report. — Indurated ulcer with adenocarcinoma 
in edges and base. 

3. Acute Onset; Rapid Course; Hemorrhage Early; Weight 
Loss; Calloused Ulcer at Laparotomy; Malignant Micro- 
scopically: 

Mr. J. S. — Age 65, Swedish, laborer. 

Family History.- — Negative. 

Personal History. — Always well up to onset of present 
trouble. 

Present Trouble. — Three months ago had sudden and 
severe epigastric pain following food ingestion. Since 
then has never felt himself. Pain comes on immediately 
after eating and lasts about 4 hours; then it is relieved by 
vomiting. Recently pain has been particularly severe at 
night between 12 m. and 3 a.m. Cannot sleep until he 
vomits. 

Vomiting.- — Three to 8 hours folloT\4ng meals; vomitus 
consists of undigested food and blood. Is constantly 
nauseated. 

Appetite. — Very poor; is on milk diet. 

Weight. — Thirtj^ pounds loss in 3 months. 

Bowels. — Constipated for past 25 years. 

Urine. — Peculiar odor. 

Status Prcesens. — Aloderately well developed, but soft 
tissues flabby. Color, good; skin, soft and smooth; sclera, 
clear; tongue, clean; teeth, fair but dirty. 

Head, Neck and Chest. — Negative. 

Abdomen. — Negative except for slight tenderness in upper 
epigastrium. 



SYMPTOMATOLOGY 121 

Rectum. — Negative. 

Blood. — Hg., 80 per cent. 

Test-meal. — ^Moderate 12-hour retention; blood-tinged 
gastric extract. Total acidity, 58; free Hcl, 34; blood+ 
(benzidin test). ^licroscopically, few budding yeasts and 
red blood cells; many short, fat rods (colon baciUi). 

Stool.- — Blood+ (benzidin test). 

Laparotomy. — A hard indurated ulcer on the anterior 
wall and the upper surface of the pylorus; partial pyloric 
stenosis; moderately dilated stomach; no perigastric lymph- 
gland invoh^ement. 

Operation. — Pylorectomy ; posterior gastro-enterostomy. 

Pathologic Report. — Indurated gastric ulcer; much scar- 
tissue; in base are areas of adenocarcinoma. 

4. Short Duration; Few Symptoms, Hemorrhage; Malignant 
Anterior Wall, Ulcer: 

Mr. P. L., age 66, German, lumber dealer. 

Family History. — Mother died of a malignant growth of 
the phar\'nx. 

Personal History. — Always well to 6 months ago, when 
he began to have abdominal fulness, particularly after 
eating, belched much gas. No pain or vomiting; occasion- 
ally nausea. Appetite and bowels normal. One week 
ago had severe abdominal cramps. Was nauseated and 
could not get bowels to move. The next day passed a 
large amount of black blood by rectum. Has had no 
recurrence. 

Weight. — Thinks perhaps 10 pounds below normal. 

Status Prcesens. — Well nourished; good color; tongue 
clear. 

Head, Neck and Chest. — Negative. 

Abdomen. — Spasm in mid-epigastrium on palpation. 

Rectal. — Negative. 
Laboratory Examinations: 

Blood.— Kg., 85. 

Test-meal. — No retention. Free Hcl, 26. No blood. 

Stool. — Blood+ (benzidin). 

Laparotomy. — Calloused ulcer on anterior surface of 
stomach 4 cm. from pylorus; no glands involved; serous 
surface adherent; cholecystitis. 



122 CANCER OF THE STOMACH 

Operation. — Partial gastrectomy; posterior gastro-enter- 
ostomy; cholecystostomy. 

Pathologic Report. — Indurated ulcer. Adenocarcinoma 
in edges and base; moderate amount of scar-tissue. 

Group II. Gastric Cancer, Clinically Developing in Patients with Years of 
Antecedent "Dyspepsia" of the Peptic Ulcer Type 

Our series demonstrates that this group includes the 
majority of cases of gastric carcinoma. There were 436 
instances (47.3 per cent.) where patients appeared with a 
gastric ailment evidently malignant that had been super- 
imposed upon a previously benign type of dyspepsia. The 
form of antecedent gastric malfunction satisfied the com- 
monly accepted clinical complex of chronic peptic ulcer. 
The disturbance readily divides itself into two strikingly 
different periods : one benign and usually long drawn out, 
and the other malignant, continuous and progressing 
relentlessly toward a fatal issue. The anamnesis alone 
brings ou.t the characteristics of the disease in each of its 
stages. 

It is becoming more generally recognized that gastric 
diagnosis gains in accuracy in proportion to the diligence 
with which enquiry is made into the departures from proper 
stomach functioning previous to those which exist at the 
time when the patient appears for a solution of his dyspeptic 
dilemma. Accidental complications often of a mechanical 
nature not infrequently cause the gastric case to seek a 
doctor's aid. It is only by disengaging the patient (and 
often his physician) from the present state and endeavoring 
to determine and analyze his early departure from gastric 
health that one is able to accurately judge what sequence 
of clinical events led up to the immediately existing 
digestive anomaly. 

Study of our material has by no means shown that 



SYMPTOMATOLOGY 123 

gastric cancer most commonly attacks individuals whose 
stomachs had previously been, as Napoleon told his 
physician Automanchi ''Uke iron." On the contrary, the 
great number of these so-called ferruginoid stomachs 
have an important etiologic history behind them, even as 
did the classic gut of Napoleon. For, as we inquire into 
the early history of this oft-cited case, we find abundant 
evidence that the imperial stomach rebelled quite regularly 
and sometimes disastrously {vide battle of Leipsic.) 

(a) The Precarcinomatous Period. — The average dura- 
tion of all symptoms in the first stage of the ailment, 
that clinically benign, w^as 10.5 years. The shortest 
history of this phase extended over 2 years and the longest 
more than 45 years. This long antecedent history of 
gastric malfunction proves that the majority of our cases 
of gastric cancer did not develop in patients who had pre- 
viously been in good gastric health. The interpretation, 
clinically, that we place upon the nature of the early dyspep- 
sia, depends, naturally, upon the conception which experi- 
ence has given us regarding symptomatology of gastric 
disease, the value of facts making up the histories, and our 
observations of the subsequent course of the ailment. 

The point of greatest import in the consideration of the 
precarcinomatous picture of the disease, is, that while 
certain histologic changes of a malignant type may have 
lain latent in the gastric wall for years, it was, at this first 
period, impossible to recognize such, clinically. 

Symptomatically, this early period of the ailment satisfies 
the accepted clinical complex which we associate with 
chronic, recurrent gastric ulcer. This statement does not 
imply that the majority of gastric ulcers become cancers; 
it is simply a statement indicating that the greatest number 
of our proved cases of gastric cancer had had gastric ulcer 



124 CANCER OF THE STOMACH 

symptoms prior tO the time when their dyspepsias assumed 
maUgnant features. No one can offer opinion, based upon 
actual facts, as to the percentage of ulcers that undergo 
malignant transformation. Doubtless many ulcers heal 
or remain benign. The caution should be strongly urged, 
however, that in every gastric ulcer there exists the anlage 
of a future cancer, and that only by recognition of this 
possibility and by constantly watching the progress of 
individuals thus affected (especially as they pass beyond 
the fourth decade of life) can we hope to be of any actual 
service to those individuals, or to the race, with respect to 
cure or prevention of gastric malignancy. 

The symptomatology of the precarcinomatous period is 
in every way similar to that above outlined as comprising 
the whole course of cases making up Group I. It is not 
necessary to repeat it. The cases give typical ulcer 
histories. And, indeed, if such patients come to lapar- 
otomy at any time during this clinically benign stage, 
ulcers without evidence of malignant hyperplasia are 
demonstrated surgically and often pathologically. 

Briefly, the study of this early dyspeptic disturbance, 
"established the following facts in our material : 

Attacks or "spells" of indigestion occurred in 82 per 
cent, of instances. Seasonal relationship was not in- 
frequently demonstrated. Over-work, exposure and inter- 
current infectious diseases appeared to play a consider- 
able r61e in precipitating or aggravating symptoms. These 
''spells" of dyspepsia were characterized by epigastric 
distress or actual pain in 392 cases (90 per cent.). In 366 
instances (84 per cent.) the abdominal distress bore definite 
relation to the taking of food. Until complications super- 
vened, this "food relief" of pain was quite constant and 
characteristic. Other forms of pain relief were alkalies, 



SYMPTOMATOLOGY 125 

diet or vomiting. Pain was generally located, sympto- 
matically, in the upper two-thirds of the epigastrium. In 
270 cases (62 per cent.) pain had a point of maximum 
intensity. This was most frequently located at or sHghtly 
to the right of the mid-hne. In 224 patients (51.4 per 
cent.) pain was referred to some part of the back. The 
areas of referred distress were most commonly between 
the shoulders or to one or both scapular regions. 

Food desire was usually strong, but appetite suffered 
from fear of precipitating digestive upsets by eating. 

Weight was not infrequently lost in these attacks of 
limited food intake, only to be gained again when qui- 
escence supervened. The average weight loss was 15.8 
pounds. 

Constipation was noted in 209 instances (48.2 per cent.). 
Twenty-seven patients (6.5 per cent.) had experienced 
diarrhea at some time during this precarcinomatous 
period. 

Vomiting was recorded in 265 cases (63 per cent.). In 
217 of these patients who vomited (82 per cent.), the emesis 
was periodic. Retention vomiting was noted in 98 cases 
(37 per cent.). 

Bleeding (hematemesis or melena) was a sign in 92 
instances (21 per cent.), during this stage of the disease. 
Of those bleeding, 47 cases (50.6 per cent.) had experienced 
hemorrhage at least 2 years before the time when they 
came under observation. Of those instances (45) where 
bleeding had occurred more recently than 2 years, 28 
(62 per cent.) were patients whose dyspeptic history was 
longer than 10 years. 

Anemia was rarely marked in the chnically, benign ulcer 
stage. The average hemoglobin was approximately 75 
per cent. 



126 CANCER OF THE STOMACH 

Before proceeding to a study of the second (malignant) 
phase of this class of patient we would emphasize the group 
type by the following histories. 

1. Long Dyspeptic History; Ulcer Type; Early Hemorrhage, 
Supervening Malignancy; Free Abdominal Fluid: 

Mr. A. L. — Age 52, German, carpenter. 
Family History. — Negative. 

Personal History. — Married twice, first wife died of 
tuberculosis. 

Present Trouble. — Periodic dyspepsia from 18 to 21 years 
of age; this consisted of epigastric pain, sour eructations 
and belching, and occasionally vomiting of sour fluid. 
At age 22 vomited about a pint of blood; was in bed 2 
weeks; since then has had only rare attacks of the dys- 
pepsia until 17 months ago. He then began to have pain 
in the epigastrium. This was a gnawing and sore feeling 
and was worse about 2 hours after eating. Shortly after- 
ward he began to vomit. Recently has had night pain, 
with vomiting about 1 o'clock in the morning. He fre- 
quently vomits up what he had eaten for breakfast, and 
occasionally material eaten the day previously. 

Weight Loss. — Fifty pounds in 6 months. 

Physical Examination. — Much emaciated, sallow com- 
plexion, skin dry; weak and tired-looking; tongue coated. 

Thorax. — Negative. 

Abdomen. — Moderately distended; small umbilical her- 
nia; inguinal glands moderately enlarged. Percussion 
dulness in flanks, movable. No abdominal tumor palpable. 

Rectal Examination. — Negative. Liver and spleen, not 
enlarged. 
Laboratory Examinations: 

Blood.— B.g., 82 per cent.; r.b.c, 4,980,000; w.b.c, 6,200. 

Test-meal. — Total acidity, 28; free Hcl, 12; combined 
acids, 8; altered blood+. Moderate 12-hour retention. 

Microscopically. — Oppler-Boas bacilU (?). Yeasts. 

Stool. — Altered blood+ (benzidin test). Schmidt bi- 
chlorid test : hydrobilirubin. 

Laparotomy. — ^Long right-rectus incision. About 2,000 
cc. of serofibrinous peritoneal fluid. Large carcinoma in- 
volving greater curvature, with extension into pancreas. 
Secondaries in liver. 



SYMPTOMATOLOGY 127 

Operation. — Exploratory. 

Pathologic Report. — Gland removed shows carcinoma. 

2. Previous History Suggesting Ulcer at the Cardia Followed by 
Partial Malignant Stenosis; Young Patient: 

Mrs. H. S. — Age 26, Finnish, housewife. 

Family History. — Negative. 

Past History. — Negative. 

Present Trouble. — Dm'ing the past 5 years has had at- 
tacks of high epigastric pain coming on immediately after 
eating, and accompanied by vomiting of food that has been 
eaten shortly before. Sour stomach and acid eructations 
have been prominent in these attacks. Had no alteration 
in the symptoms until 3 or 4 months ago when noticed that 
solid food seemed to stick in the esophagus and would cause 
pain lasting from 3^ to 1 hour after eating. Relief of dis- 
tress was obtained by forced vomiting. During the past 6 
weeks the pain has been constant, and has been accom- 
panied by constipation and marked vomiting if patient is 
on ordinary diet. Recently pain has been very marked in 
the ''small of the back." 

Appetite. — Good, but afraid to eat on account of pain. 

Bowels. — Very constipated. 

Weight. — Has lost 26 pounds in about 3 months. 

Examination. — Patient poorly nourished; skin pale with 
acne-like eruption over face. Tongue coated; teeth dirty; 
breath heavy. 

Thorax. — Negative. 

Abdomen. — Flat; general tenderness in epigastrium; at 
the left costal arch a slightly movable tumor is palpated 
toward the pit, no tenderness. 

Vaginal Examination. — Negative. 
Laboratory Examination: 

Blood. — Hg., 40 per cent. (Dare). 

Test-meal. — Tube met resistance at cardia. There fol- 
lowed free bleeding. No contents obtained. Microscopic 
examination of blood clots in end of stomach tube showed 
chains of streptococci; many red blood cells and large, 
partly disintegrated, epithelial cells. 

Stool. — Altered blood-f- (benzidin test). 

Laparotomy. — High median incision. At the cardiac 
end of the stomach is a carcinomatous mass encircling the 



128 CANCER OF THE STOMACH 

orifice; it is very hard and about % of an inch broad. The 
cardiac lumen barely admits a little finger. The cardiac 
glands are greatly hypertrophied. 

Operation. — Exploratory; appendicectomy. 

Pathologic i^eporL— Gland from near cardia. Adeno- 
carcinoma with much scar-tissue. 

3. Carcinoma Following Ulcer History: Hemorrhages; Ob- 
struction: 

Mr. R. J. — Age 48, Swede, stone mason. 

Family History. — Negative. 

Personal History. — Pneumonia 3 years ago, otherwise 
well; denies venereal. 

Present Illness. — Gastric disturbance for 6 years. Com- 
plaint usually epigastric pain, coming on generally 2 hours 
after eating and most severe just before eating. Food 
intake promptly relieved pain. Pain transmitted to right 
upper abdominal quadrant and to back, between shoulders. 
Frequently awakened at night by pain. Body movement 
aggravated distress. Usually worse in fall and has periods 
of remission. 

Present Trouble. — Three weeks ago became nauseated 
and vomited about a cupful of blood. Never vomited 
before or since. Since then has had constant belching, 
pyrosis and has noted since then that stools have been 
blackish in color. Pain has diminished in intensity, bat 
has become constant. 

Appetite. — Poor; strength reduced. 

Weight. — ^Lost 42 pounds in less than a month. 

Physical Examination. — Well developed, but poorly 
nourished. Sallow color; tongue coated. Post-malleolar 
edema; skin loose and dry. 

Head, Neck and Chest. — Negative. 

Abdomen. — Marked rigidity of both recti muscles, par- 
ticularly on left side. Stomach dilated, great curvature 
extends 2 f.b. below navel. 
Laboratory Examination: 

Blood.— B.g., 65; r.b.c, 3,400,000; w.b.c, 12,000. 

Test-meal. — Twelve-hour retention. Total acidity, 76; 
Hcl, trace; lactic acid-h; altered blood-f; Wolff test-j- (400 
units of precipitable albumin) ; pepsin and rennin, trace. 

Stool. — Altered blood + (guaiac test). 



SYMPTOMATOLOGY 129 

Urine. — Albumin trace; few coarse granular casts. 

Laparotomy. — Carcinomatous mass, 10 cm. in circum- 
ference, on lesser curvature; glands involved. 

Operatio7i. — Exploratory. 

Pathologic Report. — Gland from lesser curvature: adeno- 
carcinoma. 

4. Gradual Onset, Ulcer Sympto7ns, Early Vomiting, Recent 
Rapid Weight Loss; Carcinoma of Pylorus loith Large 
Cardiac Glands: 

Mrs. M. B. — Age 48, German, housewife. 

Family History. — Negative. 

Past History. — Three years and 6 months ago, began to 
regurgitate food soon after eating. This seemed to be 
caused by a burning pain extending from the ensiform to 
the base of the tongue. Was worse after hesivj meals. 
Much sour regurgitation, nausea and pj^rosis. Xever 
vomited blood, but frequently large amounts of partly 
changed food. A few months afterward noted a pain in the 
left costal arch. It came on at once after eating, and was 
quite severe. Has been fairly constant since. Took ulcer 
cure in a hospital. At present there is much gas and bloat- 
ing for 3 or 4 hours after meals when patient is relieved 
by vomiting. Of late some difficulty in swallo'^dng large 
pieces of food; they seem to stick at the pit of the stomach. 

Appetite. — Has been poor. 

Bowels. — Constipated and stools of offensive odor. 

Weight. — Has lost 115 pounds in 6 months. 

Physical Examination. — ^Markedly emaciated; skin sal- 
low; looks cachectic; slight edema about the ankles; teeth 
very poor; tongue coated; breath foul. 

Chest. — Negative. 

Abdomen. — Xo palpable tumor; tenderness to left of 
navel; stomach splashy. 

Vaginal Examination. — Negative. 

Blood.— Rg., 60; r.b.c, 3,600,000; w.b.c, 8,400. 

Differential White Cell Count. — Pol^niuclears, 77.3 per 
cent. ; smaU lymphocytes, 20.7 per cent. ; large lymphocytes, 
1.1 per cent.; transitionals, 0.7 per cent.; eosinophiles, 
0.3 per cent.; 1 normoblast seen. 

Test-meal. — Stomach tube meets resistance at cardia; 
no bleeding. Gastric extract tan-brown in color, food 
poorly chj-mified; somewhat rancid odor, moderate 12- 



130 CANCER OF THE STOMACH 

hour retention. Total acidity, 34; free Hcl, 0; lactic 
acid+; altered blood+. 

Stool. — Small, mushy, light brown. Altered blood+. 

Laparotomy. — High right rectus incision. Tumor-mass 
the size of a croquet-ball involves the pylorus and antrum 
posteriorly. Tumor is freely movable; peripyloric glands 
enlarged. Very marked enlargement of glands at the car- 
dia, especially where the gastric artery meets the lesser 
curvature. 

Operation. — Partial gastrectomy; posterior gastroenter- 
ostomy. 

Pathological Report. — Diffuse infiltrating carcinoma. 

(b) The Clinically Carcinomatous Period. — The pre- 
ceding histories convey a fairly representative impression 
of the sequence of events leading up to a malignancy from 
a clinically benign affection. The change in the character 
of the disease is often a very gradual one. When we recall 
the pathologic alterations that are going on in the ulcer 
areas in these cases, it would seem quite reasonable that a 
neoplasm should well establish itself before it could be ex- 
pected to give any definite clinical warning of its existence. 

When we analyze the mode of onset of the apparently 
malignant stage of the dyspepsia we are impressed by the 
great number of ways in which the patient or his medical 
attendant are made aware that some sort of alteration in 
the ailment is in progress. Bleeding, constant nausea, 
vomiting, gassy distention, persistent abdominal discom- 
fort, loss of appetite, weight and strength, diarrhea or 
enlarging abdomen may usher in the pernicious phase of 
the disease. Whatever may be the form which the new 
type of affection assumes, the most characteristic manifesta- 
tion is the appearance of a continuous and progressively 
downward gastric disorder in an individual whose pre- 
vious dyspepsia had been periodic (82-1- per cent.). This 
occurs with or without the onset of pyloric or cardiac 



SYMPTOMATOLOGY 131 

obstruction or hindrance to the onward progress of food 
by loculation of the stomach fiom a neoplasm. Where 
previously there was abdominal discomfort in "spells" 
or attacks, frequently relieved by food or medicines, one 
observes food aggravation of such distress, persistent 
night pain, delayed vomiting, continuous presence of altered 
blood in the stools, diarrhea, anorexia, weight loss steadily 
maintained, weakness, anemia, peripheral edema, cachexia, 
sallow, di-y, scaly skin, lack-luster eye and a peculiar hope- 
less apathy reflected in the face. There often seems to be 
a sense of impending evil. ^Nlelanchohc symptoms may 
not be lacking. Introspective mental attitudes may be 
estabUshed in individuals who prevdously had been cheerful 
and optimistic. Rarely, suicidal tendencies are exhibited. 
While the above is the common clinical picture presented 
as cancer intoxication evidences itself, no especial change 
may be observed ^particularly by a busy indi\ddual with 
large interests) until an epigastric nodule or loose clothing 
bring him to a physician for an explanation. Not infre- 
quently patients attribute an unexplainable vague ''queer- 
ness" to over-work, physical or mental, and seek rehef 
through the medium of a hohday, osteopathy, ''christian 
science," patent ''tonics," and such ever-baited snares, 
only to appear some months afterward with an extensive 
and hopeless malignancy. It is often astonishing how 
child-hke may be the mental processes of otherwise mature 
and brilhant brains, when such occupy themseh'es with the 
consideration of bodily ills. Hence, the class of patients in 
whom gastric mahgnancy has its mild beginnings, most 
frequently come to a physician when the disease is farthest 
advanced. 'V\lien constant pain, vomiting or diarrhea are 
suffered early they often serve a useful purpose. Such 
patients consult the physician earliest : the science and art 



132 CANCER OF THE STOMACH 

of charlatan, the ''wise" neighbor and the cure-all almanac 
are soon exhausted. 

Duration of tJie Malignant Period. — At the time when 
patients came under observation, they had been affected 
with an evidently cancerous process for an average time of 
6.3 months. In other words, more than a half year was 
consumed by the growing neoplasm in making it evident 
to the patient, or his advisers, that he was not having a 
recurrence of his former dj^speptic disturbance. ^Tien we 
reflect that more than 4 out of 5 such patients had a 
continuous gastric malfunction succeed one previously 
'periodic, it is quite e^ddent that either the onset of the 
ailment has been insiduous or that professional advice has 
been timid or uncertain. ^Meanwhile the growth of the 
cancer has progressed so extensively that in but one- 
third of all our cases of the disease were the surgeon and 
the patient given the advantage of a locaUzed ailment 
when laparotomy was performed. Early abdominal ex- 
ploration of the chronic dyspeptic at the cancer age is the 
only way to change such experience. 

Abdominal Pain. — In but 74 of the cases (17 per cent.) 
comprising Group II was severe pain a complaint. It was 
usually described as ''raw" — "sore" — "duU, heavj^ ache" 
or "cramps." In 51 instances (11.6 per cent.) opiates 
were required to give relief of distress. "Gassy" and 
"bloated" sensations were quite generally complained of, 
particularly when the new-growth involved the orifices, 
and food was retained in either stomach or esophagus. 
Rarely was "food reUef " of abdominal discomfort observed. 
Food aggravation was the rule. WTiile intensity of pain 
was usually less than a given individual had suffered at 
some time in his premahgnant history, j^et the con- 
stancy of the distress frequently proved very annoying and 



SYMPTOMATOLOGY 133 

exhausting. This was particularly the case where night 
pain prevented sleep or where aggravation of gastric 
discomfort prevented the taking of proper nourishment. 

There was rarely a point of maximum epigastric distress. 
The complaint was commonly of a diffuse or general 
pain. In 35 cases (8 per cent.) in addition to epigastric 
discomfort, pains referred to the back, rib-edges, and the 
legs were recorded. Aggravation of abdominal pain 
by body movements was noted in 48 cases (11 per cent.). 
The common modes of pain relief in the order of their 
usefulness proved to be vomiting, diet, lavage, alkalies, 
opiates and rest. In certain instances the resourcefulness 
of the medical attendant was sorely taxed after the ex- 
hibition of all these remedies. 

Vomiting. — This symptom occurred in 390 instances (89 
per cent.) when malignancy supervened upon what had 
been a clinically benign process. In 315 cases (74 per cent.) 
the vomiting was of almost daily occurrence. 

Vomitus was more copious in this phase than previously. 
Not infrequently several quarts of material were raised. 
The odor of the vomitus was quite characteristic in mod- 
erately advanced cases. Whereas this had commonly 
been of a sour or yeasty odor in the earlier months or 
years of the affection, when malignancy was established 
the odor most frequently was cheesy, rancid or pene- 
tratingly pungent. When sloughs of cancer tissue, de- 
composed blood or contents of adjacent viscera were pres- 
ent as result of fistulse, the sickening, foul odor was almost 
pathognomonic . 

The color of the vomitus ranged from white to dark 
brown or black. The color was imparted by decom- 
posing food, blood or tissue. In but 88 cases (20.2 per 
cent.) was the vomitus "coffee colored," as is so often de- 



134 CANCER OF THE STOMACH 

scribed in connection with gastric cancer. When vomitus 
of ^this color was observed, the disease was far advanced in 
83 per cent, of instances and irremovable surgically in 
more than 3 out of 4 such. 

Excess of mucus, chunks of poorly chymified food and 
(rarely) blood-clots, tissue sloughs or puree-like, evil- 
scented fluid composed the vomitus. 

Group III. Gastric Cancer in Individuals who Prior to the Onset of a 
Malignant Disease had Enjoyed Perfect Gastric Health 

Symptomatically, the patients comprising this group 
satisfy the popular conception of what constitutes gastric 
cancer clinically. But, in even this class, wide variations 
in symptomatology are possible. What is commonly de- 
scribed as gastric malignancy is doubtless the picture 
presented, clinically, when affected individuals come for 
examination as a consequence of symptoms arising from 
mechanical interference to the easy, onward progress of 
food, constitutional evidences of a grave ailment or the 
accidental discovery of an abdominal tumor. In private 
or hospital practice, but rarely is the beginning of this 
form of the disease appreciated or diagnosed. As we 
have previously quoted, the Fen wicks state that 31 cases 
of gastric cancer entering their services had previously been 
ill for an average time of nearly 4 months, and this time 
had elapsed apparently before such danger signals had been 
observed as to indicate a serious malady. The failure to 
differentiate between disease entities and the symptoms 
associated with such is largely responsible for gastric 
cancer in its early progress being clinically styled ''acute" 
or ''chronic gastritis," "gastric catarrh," "achyliagastrica," 
"chronic dyspepsia," "liver trouble," "nervous prostra- 
tion" and the like. These terms are not fanciful: they are 



SYMPTOMATOLOGY 135 

such as were actually given by patients to describe the 
early status of their ailments. These ''diseases" were 
in the main, reflections of the viewpoint from which their 
medical attendants considered their early departure from 
gastric health. 

While it is true that mild beginnings characterize many 
instances of this type of carcinoma of the stomach, it is a 
fact that the average duration of early symptoms is of 
sufficient length to permit a careful analysis of the anomaly 
presented. Here we rarely deal with an emergency. This 
digestive or constitutional fault is certainly such as might 
reasonably warrant more than passing attention. Its 
salient factors are these: A dyspepsia in an individual, 
generally past middle age (at the so-called ''cancer age"), 
to whom such gastric disturbance is foreign. The mal- 
function is usually continuous. It is early manifested by 
anorexia, weakness, anemia, weight loss, cachexia, pain, 
vomiting, hemorrhage, diarrhea or abdominal tumor. While 
it is possible to associate many of these symptoms with 
benign gastric disorders, the professional mental attitude 
is seriously delinquent which does not regard all gastric 
malfunction in individuals past the age of 40 as malig- 
nant or potentially so, until it has been definitely proved 
to be benign. If pursued with common sense and tact, 
this course is quite possible without producing undue 
apprehension among patients. During the past decade 
there has been such widespread popular education upon 
malignant disease that reservations in diagnosis are 
often considered proper and necessary. 

Of the 921 cases of gastric cancer forming the basis of 
this study, there were but 294 instances (31.9 per cent.) 
where a malignant gastric ailment had occurred in pa- 
tients who previously had experienced no gastric com- 



136 CANCER OF THE STOMACH 

plaint. The most exhausting anamnesis failed to elicit 
any symptoms pointing to a disease of the stomach before 
an average time of approximately 7 months prior to the 
patients' coming under observation. Because there had 
been no gastric complaint previous to this average figure, 
it should be emphasized that one is not justified in main- 
taining that in such individuals there had been no gastric 
pathology anteceding 7 months. On the contrary, the 
not infrequent post-mortem or laparotomy discovery of 
healed ulcers or even neoplasms in subjects who have had 
no clinical pointings referable to such stomach anomaly 
should lead us to exercise caution with regard to insisting 
when or how malignant processes arise in the gastric wall. 
The longest history of dyspepsia in cases making up this 
group extended over about S^-i years; the shortest barely 
2 weeks. 

(a) Mode of Onset. — Many so-called "primary" gastric 
cancers have histories extending over weeks of time, 
where the symptom-complex closely approximates that 
which is our present-day conception of peptic ulcer, of the 
continuously active and progressive type. The clinical 
picture is different, however, in one important respect. To 
the ulcer symptom-complex are early added the mani- 
festations of a malignant systemic poisoning. There is a 
hurried progression through the clinical course of ''gastritis" 
and ''ulcer" to a definitely malignant disease. With 
regard to time, the whole course of the ailment forms a 
sort of "tabloid" from which careful analysis readily 
segregates parts closely approximating, clinically, those 
stretched out over years as exhibited by that great class of 
gastric cancers making up our Group II. The rapidity 
through which these different clinical stages of the disease 
may be passed seems to emphasize the necessity for our 



SYMPTOMATOLOGY 137 

demanding a separate and not altogether unimportant 
recognition of the term ' ' chronicity " in its pathologic 
sense and in its time-duration application (i.e., meaning 
years, months or weeks) of the existence of an ailment. 
It is reasonabty possible that the whole gamut of injury 
to the stomach lining, local or general gastritis, ulcera- 
tion and cancer may be run in a few weeks or months. 
The rapidity of change occurring in experimentally pro- 
duced tumors and in embryonic, undifferentiated tissue 
certainly would permit this conception of the develop- 
ment of gastric cancer. Such view explains whj^ the 
mode of onset of ''primary" gastric neoplasms varies 
widely. 

The onset in the ordinary case (there is no ''typical" 
case) is rarely acute. The transition from complete gastric 
well-being is commonly gradual. Aversion to certain 
kinds of food (meat, sweets, legumes) or beverages (beer, 
coffee, milk) is often an early manifestation. While the 
desire for some viands may be keen, the aversion to others 
may be marked and, for the individual, radical. Eructa- 
tions, sometimes of disagreeable taste, may be troublesome 
from the first. Gaseous distention of the abdomen is 
frequently annoying. Unexplainable nausea may cause 
concern. Diarrhea or diarrheic stools appeared without 
apparent cause in 40 of our cases (13.5 per cent.). Vomit- 
ing may be the first symptom and its copiousness, odor, 
taste and color distressing and alarming. Pain or abdom- 
inal discomfort of some degree is a frequent indica- 
tion that all is not well. It appeared early in 214 instances 
(73 per cent.) of this group. Sudden hemorrhage not 
infrequently startles a pre\dously well individual and leads 
to his seeking medical care. This happened in 12 cases 
(4,2 per cent.), comprising this group. Again, rapid weight 



138 CANCER OF THE STOMACH 

loss, with weakness and anemia may bring patients under 
observation. 

The following histories emphasize certain features of 
the onset and course of the disease in cases comprising 
Group III. 

1. Gastric Malignancy with Gradual Onset and without 
Severe Symptoms: 

Mr. C. B. — Age 60, Swedish, farmer. 

Family History. — Negative. 

Past Illness. — Denies venereal; had measles. Has been 
constipated for 15 years, and on account of irregular dys- 
pepsia has been taking medicine for past 2 years. 

Present Complaint. — About 2 years ago began to lose 
strength and weight. This was very gradual until a year 
ago, when appetite began to fail and on account of weakness 
patient was confined to bed for 2 weeks. At the end of 
that time was able to get up and be about, but did not feel 
quite himself. Appetite has remained poor and for 3 
months he has been on liquid diet. Food does not distress 
him, but more liberal diet causes vomiting about a half 
hour after meals. Never vomited blood. Never passed 
blood in stools. For past few months has had vague sore- 
ness in epigastrium but never real pain. Strength has 
diminished and for 2 weeks has had edema of the feet 
and ankles. Recently constipation has become obstinate. 

Physical Examination. — Poorly nourished; moderate ane- 
mia; 20 pounds under weight; skin dry and scaly; edema 
almost to knees. 

Chest. — Negative except for slight cardiac arrhythmia. 

Abdomen. — ^Liver dulness extends 2 finger breadths' 
below level of ribs in nipple Hne. On palpation, a mass 
may be made out running from 2 finger breadths' below the 
ensiform cartilage to the left and just below the navel. It 
moves downward on deep inspiration. No adenopathy. 
Laboratory Examinations: 

Blood.— Kg., 65 per cent. (Dare); r.b.c, 3,800,000; 
w.b.c, 11,600. 

Test-meal. — Total acidity, 36; free Hcl, 0; combined 
acid, 18; lactic acid 4- ; altered blood + (benzidin test) ; formol 
index, 26 (Sorenson-Schiff method). Moderate retention. 



SYMPTOMATOLOGY 139 

Microscopic Examination. — Bacilli of the Oppler-Boas 
type; few chains of streptococci; few small yeast colonies. 

Stool. — Altered blood+ (benzidin test) — on milk diet. 

Laparotomy. — High right rectus incision; carcinoma 
involving the greater curvature, pylorus and one-half of 
lesser curvature. Secondaries in the liver. Peritoneum 
extensively involved with masses resembling fish-eggs. 

Opera/^on.— Explored only. 

Pathologic Report. — Nodule from peritoneum shows car- 
cinoma of encephaloid type. 

2. Carcinoma Developing without Previous Gastric Mal- 
function; Diarrhea at Onset: 

Mrs. M. L. — Age 50, Norwegian, housewife. 

Fainily History. — Negative. First husband died of pul- 
monary tuberculosis; tlii'ee children well and strong; no 
miscarriages; has alwaj^s performed hard manual labor. 

Past History. — Ten years ago had malaria. After at- 
tacks of chills and fever, did not menstruate for 6 months. 
Five years ago had attack of dysentery which lasted 6 
weeks. 

Present Trouble. — Five months ago the patient for the 
first time in her life began to have trouble with her stomach. 
Noted gassy eructations and pjo-osis, together with burning, 
epigastric pain coming on soon after eating. Was never 
quite free from epigastric pain. For past 3 months has 
had attacks of diarrhea coming on every 2 or 3 weeks. Two 
months ago began to feel nauseated in the middle of the 
afternoon; 6 weeks ago began to vomit every day in late 
afternoon; vomiting resulted from epigastric pain and 
bloating. Never vomited blood, but frequently vomited 
material eaten for breakfast. 

Appetite. — Poor. 

Boivels. — Rather diarrheic; never dark colored. 

Weight. — Has lost 22 pounds in about 3 months, and feels 
much weaker than fonnerly. 

Physical Examination. — Anemic, poorly nourished, com- 
plexion sallow, slight peripheral edema, looks tired; tongue, 
coated; teeth, dirty. 

Chest. — Negative except for slight muscular weakness of 
heart. 



140 CANCER OF THE STOMACH 

Abdomen. — A hard, nodular, movable mass, size of adult 
fist in mid-epigastrium; is somewhat tender to the touch. 
No gland enlargements palpable. 

Pelvic Examination. — Negative. 
Laboratory Examinations: 

Blood.— Kg., 70 per cent.; r.b.c, 4,000,000; w.b.c, 6,200. 

Test-meal. — Total acidity, 74; free Hcl, 6; combined 
acids, 58; lactic acid-|-; altered blood + (guaiac test). Re- 
tention moderate. 

Microscopical Examination. — Occasional long bacillus 
of Oppler-Boas type; few leptothrix and short fat rods. 

Laparotomy. — High right-rectus incision; mass the size 
of grape fruit on lesser curvature near pyloric end. Tumor 
circumscribed. Shght gland enlargement. 

Operation. — Mikulicz-Hartman, Billroth No. 2. Posterior 
gastroenterostomy. 

Pathologic Report. — Adenocarcinoma. 

3. Alcoholism; Chronic Gastritis; Umbilical Metastasis: 

Mr. C. F. — Age 46, American, merchant. 

Family History. — Negative. 

Personal History. — Typhoid fever 9 years ago, very ill, 
since then has had scarlet fever, measles and whooping 
cough; denies venereal disease. Was a hard drinker up to 
a year and a half ago, since then temperate. 

Present Illness. — Gastric disturbance 1 year, previous to 
that says he not infrequently had indigestion, especially 
following drinking bouts. 

Complaint. — Dull aching pain, moderately constant in 
epigastrium; reaches its maximum about 3 hours after 
meals. Has found nothing that would relieve pain except 
rest and vomiting. 

Nausea, prominent symptom, comes on after every meal 
and is followed by vomiting. Vomits large amounts of 
finely divided food, whitish in color and sour to taste. 
Sometimes delayed vomitus. Never vomited blood. 

Belching almost constantly with much regurgitation of 
food, even on liquid diet. 

Bowels. — Constipated; never blood or dark stools. 

Weight Loss. — Seventy pounds in 8 months. 

Physical Examination. — Moderately well developed, but 
poorly nourished; color rather florid. Tongue coated. 



SYMPTOMATOLOGY 141 

Head, Neck and Chest. — Negative. 

Abdomen. — Scaphoid, no tenderness on deep pressure in 
any part. On inspiration, a hard, irregular mass is felt 
high in the epigastrium to right of median line. Is about 
4 inches long and not tender. 
Laboratory Examinations: 

Blood.- — Hg., 60 per cent. 

Test-meal. — Tube meets slight resistance at cardia with 
rather free bleeding. Small amount of retained food. 
Total acidity, 16; free Hcl, 0; combined acids, 10; lactic 
acid, trace; Wolff- Junghans' test for soluble albumin + (300 
units); altered blood + (benzidin test). 

Microscopic Examination. — Oppler-Boas bacilli; few bud- 
ding yeasts; streptococci and short, fat rods in chains. 

Stool. — Altered blood + (benzidin test). 

Laparotomy. — Stomach is involved in one mass of cancer, 
adherent to transverse colon and jejenum. There is a 
maUgnant metastasis to umbilicus. 

Operation. — Exploratory. 

Pathologic Report. — Perigastric gland shows cancer cells. 

4. Slow Onset with Vomiting a Prominent Symptom. Abdom- 
inal Tumor Noted for 8 Months: 

Mrs. A. D. — Age 46, American, housewife. 

Family History. — One sister died of " quick consumption." 

Personal History. — Pleurisy 5 years ago, lumbago for 
many years, otherwise well. 

Present Illness. — ''Indigestion" for past 23^ years; this 
has been characterized by pain in mid-epigastrium con- 
stantly present and of gnawing character ; pain transmitted 
to back between shoulders. Pain has been constant and 
not relieved by diet, medicine or posture. 

Nausea.- — A marked symptom, prostrating and comes 
any time of day or night ; worse when lying down. 

Vomiting. — For the past month vomiting after every 
meal; vomitus contains food but no blood; never bad 
taste; vomitus watery, never colored; relieves some of 
the distress; been on liquid diet but no relief. 

Belches gas constantly; never sour; no relief by soda. 

Constipation. — Marked; never blood. 

Flatulence. — Marked. 



142 CANCER OF THE STOMACH 

Weight Loss. — Twenty-four pounds in 2 years. 

Genito-urinary. — No urinary symptoms. Menopause 
1 year ago. 

Physical Examination. — Fairly well developed and nour- 
ished ; moderate pallor. 

Tongue. — Slightly coated. 

Head, Neck and Chest. — Negative. 

Abdomen. — Diastasis of recti muscles with dilatation of 
superficial cutaneous veins. Just above navel is a semi- 
lunar, freely movable mass 12 cm. long and 5 cm. wide, not 
tender; can be displaced up and down but not freely from 
side to side. Tenderness over gall-bladder. 

Vaginal. — Perineum lacerated. 
Laboratory Examinations: 

Blood.— Rg., 70 per cent.; r.b.c, 4,200,000; w.b.c, 
7,800. 

Test-meal. — Resistance to tube at cardia; no bleeding. 
Slight 12-hour retention. Total acidity, 24; free Hcl, 2; 
combined acids, 18; lactic acidH-; altered blood + (guaiac 
test); Wolff-Junghans' test for soluble albumin-}- (more 
than 200 units) . Glycyltryptophan test -1- ; f ormol index, 
22 (Sorenson-Schiff method). 

Microscopic Examination. — Few bacilli of Oppler-Boas 
type. 

Stool. — Altered blood + (benzidin test). 

Laparotomy. — Pylorus and entire lesser curvature car- 
cinomatous; stomach thickened, small (leather bottle type). 

Operation. — Explored. 

Pathologic Report. — Gland shows carcinoma. 

5. Rapid Onset and Few Symptoms. Cancer in Family: 

Mrs. E. S. — Age 79, German, housewife. 

Family History. — One sister dead, cancer of the stomach; 
1 daughter dead, cancer of the rectum. 

Personal History. — Past negative. 

Present Ulness. — Vague gastric disturbance for 4 months. 

Complaint. — Heavy feeling in abdomen immediately 
after eating; lasts 1 to 2 hours. 

Distress Relief. — When bowels move or when belches. 
Few eructations, no nausea or vomiting at any time. 

Bowels. — Constipated, never melena. 



SYMPTOMATOLOGY 143 

Appetite. — Fair. 

Physical Examination. — Well developed and moderately 
well nourished. Rather pale. 

Tongue. — Clean. 

Head and Neck. — Negative. 

Chest. — Heart; slight arrhythmia. 

Lungs. — Negative. 

Abdomen. — Small hard movable mass 1 cm. to left 
and 2 cm. above navel. Mass painful on pressure. Exami- 
nation otherwise negative. 
Laboratory Examinations: 

Blood— B.g., 50 per cent.; r.b.c, 2,800,000; w.b.c, 
12,000. 

Test-meal. — Moderate 12-hour retention. Total acidity, 
46; free Hcl, 8; combined acids, 22; lactic acid, trace; 
altered blood + (guaiac test) ; Wolff -Junghans' test -f- (300 
units) . 

Microscopic Examination. — Oppler-Boas bacilli, many 
cocci and small type sarcinse. 

Laparotomy. — Carcinoma of pylorus and antrum extend- 
ing to first part of duodenum. Roux operation. 

Pathologic Report. — Adenocarcinoma. 

6. Acute Onset, Severe Pain a Prominent Symptom; Carci- 
noma Involving Pylorus; Gall-stones: 

Mr. C. L. — Age 68, American, engineer. 

Family History. — Negative. 

Personal History. — Usual diseases of childhood; had 
pneumonia 3 times, 40, 14 and 7 years ago; had typhoid 
fever 35 years ago. Claims to have had 3 attacks of 
appendicitis, one 53 years ago, one 56 years ago and one 
6 years ago; in bed each time for from 5 days to 2 weeks. 
Had 7 attacks of severe la grippe. Denies venereal 
disease. 

Present History. — Three months ago was taken with 
severe cramp in lower abdomen, immediately after eating; 
it lasted 15 minutes. Twelve hours later again very 
severe cramp with nausea. No chills, fever, sweats or 
jaundice. Since then patient has constantly had hard 
epigastric ache with nausea, water-brash and eructations. 
Vomits immediately after eating and frequently vomitus 



144 CANCER OF THE STOMACH 

contains food eaten 24 to 48 hours previously. Never 
vomited blood or noted dark stools. 

Appetite. — Fair. 

Bowels. — Constipated. 

Weight Loss. — Twenty pounds in 2 months. 

Physical Examination. — Emaciated, anemic. Skin dry 
and scaly; post-malleolar edema; no adenopathy. 

Eye Reaction. — Normal. Eye grounds negative. 

Tongue. — Coated. 

Thorax. — Apices rather dull to percussion. 

Heart. — Slightly enlarged; second aortic tone roughened. 
Moderate arteriosclerosis. 

Abdomen. — Visible peristaltic waves running from left to 
right in region of navel. 

Stomach. — By percussion reaches almost to symphysis. 
No tumor palpable. Resistance in right upper quadrant 
to deep palpation. 
Laboratory Examinations: 

Urine. — Trace of albumin. 

Blood.— Rg., 40 per cent.; r.b.c, 3,060,000; w.b.c, 9,000. 

Test-meal. — Marked 12-hour retention. Total acidity, 
84; free Hcl, 12; combined acid, 38; lactic acid + ; altered 
blood + (benzidin test). 

Microscopic Examination. — Great numbers of Oppler- 
Boas bacilU; colonies of yeasts. 

Stool. — Altered blood + (benzidin test). 

Laparotomy . — High right-rectus incision. Gall-bladder 
6 times normal size. Adherent to omentum and contains 
several large stones. Stomach dilated. Carcinoma in- 
vohdng pylorus and antrum with marked stenosis. Ap- 
pendix adherent to anterior abdominal wall. Glands 
along lesser curvature carcinomatous. 

Operation. — Posterior gastroenterostomy; separation of 
gall-bladder adhesions; appendicectomy, cholecystostomy. 

Pathologic Report. — Gland : carcinoma. 

7. Acute Onset with Pain and Vague Dyspepsia; Rapid 
Weight Loss; Gastric Carcinosis: 
Mr. W. B. — Age 62, German, miller. 
Family History. — Negative. 
Personal History. — Patient was never sick in his life 



SYMPTOMATOLOGY 145 

until 6 weeks ago. Unaccountabl}^, he began to lose 
appetite and to experience pain from the epigastrium into 
the left flank. This pain was best described as a "pulling 
sensation;" a week later began to have soreness in the right 
hypochondrium, was never severe, but has been fairly- 
constant. Five weeks ago troubled with bitter eructations 
and water-brash 1 hour after eating; never vomited; 
appetite has been rather poor; hea^^ meals aggravate the 
p^Tosis. 

Bowels. — Constipated. 

Strength. — Poor; tires easily. 

Weight. — Has lost 40 pounds in less than 5 weeks. 

Physical Examination. — Patient poorly nourished; an- 
emic; mucous membranes pale; tongue coated; teeth poor; 
chest, negative. 

Ahdomen. — Marked peristaltic waves extending across the 
epigastrium to the right of the umbiUcus. No tumor mass 
palpable. No abdominal tenderness. 
Laboratory Examinations : 

Blood.— Kg., 30 per cent.;r.b.c., 2,400,000; w.b.c, 13,500. 

Test-meal. — Bleeding as tube passes cardia. Alarked 
12-hour retention. Total acidity, 32; free Hcl, 0; com- 
bined acids, 22; lactic acid, trace; altered blood + (guaiac 
test). 

Microscopic Examination. — Numerous bacilh of the 
Oppler-Boas tjqje. 

Stool. — Altered blood + (guaiac test). 

Laparotomy . — High median incision. Carcinoma in- 
volving the entire stomach except cardiac end. Appeared 
to be primary on posterior wall. Gall-bladder filled vAih. 
stones (261). Extensive gland involvement. 

Operation. — Gastrectomy, four-fifths of stomach re- 
moved; gastro-enterostomy; cholecystostomy. 

Pathologic Report. — Adenocarcinoma. 

8. Early Hemorrhage; Pain and Vomiting: 

Mr. J. S. — xlge 65, Swedish, laborer. 

Family and Personal History. — Negative. 

Comes for epigastric pain and vomiting of food and blood. 

Present Illness. — Three months ago moderately acute 
pain in high epigastrium. Pain now comes on at once after 
eating; lasts 3 to 4 hours. Pain reUeved only by vomiting. 

10 



146 CANCER OF THE STOMACH 

Vomiting follows every meal; greater in amount after 
heavy meal. Almost daily vomits bright bloody fluid. Is 
constantly nauseated. 

Appetite. — Poor; lives on milk and eggs. 

Bowels. — Constipated 25 years. 

Urinary System. — Negative except for peculiar odor of 
urine. 

Weight Loss. — Thirty pounds in 3 months. Is very weak. 

Physical Examination. — Well developed and well nour- 
ished, color fair, tongue and sclera negative. 

Head, Neck and Chest. — Negative. 

Abdomen. — Slight, deep tenderness in pit of stomach, 
negative otherwise. 
Laboratory Examinations: 

5Zood—Hg., 60 per cent.; r.b.c, 4,000,000; w.b.c, 11,000. 

Test-meal. — Dark brown liquid with small amount of 
retained food. Total acidity, 15; free Hcl, 10; combined 
acids, 4; lactic acid, 0; altered + blood (benzidin test); 
Wolff-Junghans' test+ (300 units of precipitable albumin). 

Microscopic Examination. — Many short rods; few bud- 
ding yeasts. 

Stool. — Altered blood + (benzidin test). 

Laparotomy. — Ulcus carcinomatosum, anterior wall near 
pylorus. 

Operation. — Pylorectomy, posterior gastroenterostomy. 

Pathologic Report. — Adenocarcinoma. 

(6) Symptomatology when the Cancer is Well Established. 

— Perusal of the foregoing histories demonstrates that cer- 
tain symptoms are fairly common after the neoplasm has 
advanced beyond its incipient stage. Factors which 
modify clinical manifestations are the histologic type of 
growth, the location of the neoplasm, ulceration, perfora- 
tion, the degree of involvement. 

Delayed vomiting was a sign in 211 (54 per cent.) of all the 
cases where emesis occurred. Such vomiting was most com- 
monly due to pyloric stenosis, malignant ''hour-glass," [or 
obstruction at the cardia, with dilatation of the esophagus. 

Appetite was ''poor" in 353 instances (81 per cent.). 



SYMPTOMATOLOGY 147 

It was ''fair" in 70 cases (16 per cent.). In but 13 patients 
(2.9 per cent.) was appetite recorded ''good" when the 
period of mahgnancy had come on. 

Dysphagia was noted in 8 cases of this group (1.8 per 
cent.). When such was present the neoplasm involved the 
cardia, the high lesser curvature or the fundus. 

Hemorrhage. — Of the whole number bleeding in this group 
(92 cases), 21 instances (22.9 per cent.) of hemorrhage oc- 
curred within 1 year of the patient's coming under observa- 
tion. Hematemesis was noted in 17 and melena in 4 
cases. 

^'Occult" Hemorrhage. — Tests for the demonstration of 
altered blood in the feces were positive in 86 per cent, of 
cases in this group where the reaction was sought {vide 
Chapter V). 

Temperature. — It has been stated that approximately 
one-third of gastric cancer patients have elevations in 
temperature during some portion of the malignant ailment 
(Fenwick). Ulceration, extensive metastases, perforation, 
sepsis of the cancer locally, or a systemic subinfection are 
considered causes of the increase. It is quite likely that 
the absorption of cancer proteid or products of its digestion 
may cause fever. Various observers, particularly Vaughan, 
have emphasized the fact that parenteral digestion of 
proteid by ferments in blood or body fluids may cause 
hyperpyrexia. It would seem that the presence of cancer 
proteid in the blood or lymphatic circulation, in the form of 
metastasizing cells, Hving or dead, or the products of their 
digestion by ferment activity, might account for fever, 
continuous or intermittent^ in gastric cancer. 

Of our cases, there were 79 instances where temperature 
records had been kept. In 12 cases (1.51 per cent.) 
temperatures above 99° F. were recorded. The lowest 



148 CANCER OF THE STOMACH 

was 99.2° F. (a case of fungoid cancer involving the pars 
media); the maximum was 102.6° F. (an instance of ful- 
minant gastric carcinosis with extensive metastases). 
The average temperature of this group was 100.4° F. 

Weight Loss. — Definite information was possible in 197 
cases in this group. Detailed information is given in 
Chapter IV. The minimum weight loss was 11 pounds; 
the maximum 72 pounds, and the average 22.7 pounds. 
Rapid decrease in weight was commonlj^ noted when 
stenoses of the orifices of the stomach brought on obstinate 
vomiting, or where marked anorexia or pain on food in- 
gestion Hmited nourishment. 

Urine. — One cannot always attribute changes in urine 
analysis to the nature of the disease. It must be re- 
membered that the majority of cancer patients are past the 
fourth decade, i.e., at a time when faulty kidney functioning 
is by no means uncommon. In febrile cases, one expects 
to find albumin and casts in the urine, as happens similarly 
in febrile benign affections. Indican, urea, total nitrogen, 
and sulphates are said to be increased. Total 24-hour 
quantity and chlorides may be considerably below normal. 
We have definite information respecting the urine in pa- 
tients making up this group, available in 141 cases. In 81 
cases (57 per cent.) the 24-hour quantity of urine was 
1,000 cc. or below. In 13 instances (9.2 per cent.) casts 
were noted. In 21 cases (14.9 per cent.) albumin was 
present alone or associated with casts. 

Duration of the Disease. — Approximately 6 out of 10 cases 
were dead within 1 year following theh coming under 
observation. Xot quite 2 out of 10 lived longer than 3 
years and but rather more than 1 out of 7 patients were 
ahve at the end of 5 years even when the most radical 
surgical procedures were carried out. 



SYMPTOMATOLOGY 149 

Group rv. Gastric Cancer in Individuals in Whom Malignancy followed 
Periods of Gastric Disturbance of Irregular Clinical Type 

There were 84 cases (9.12 per cent.) in this group. There 
were 38 males and 46 females. The average period of 
gastric disturbance preceding the evidently malignant 
disease was 9.1 years. 

As in cases making up Group II, there were two definitely 
separate types of dyspepsia in these patients, namely, the 
first, an indigestion of the cHnicaUy benign type, and second, 
a supervening gastric disturbance, easily recognized as 
mahgnant. The mahgnant stage of the disease averaged 
6.2 months. 

(a) The Precarcinomatous Stage of Dyspepsia. — During 
an average period of more than 9 years, patients in this 
group have been affected with, digestive disturbances sug- 
gestive of gastritis, cholecystitis, cholelithiasis, chronic 
appendicitis, pancreatitis or dyspepsia seemingly of func- 
tional foundation. But rarely did histories present a clean- 
cut symptomatology. The dyspepsia was continuous in 
type in 12 cases. Questionable hemorrhage had been noted 
in 7 instances (8.3 per cent.). 

Vomiting, usuaUy intermittent, occurred in 30 cases 
(36 per cent.). 

Abdominal pain was complained of by 70 patients (83 
per cent.). Severe colicky attacks were recorded 8 times 
(9.5 per cent.). 

Jaundice had occurred in 5 patients. 

Gall-stones had been removed in 3 instances. They were 
demonstrated at the laparotomy for the malignant affection 
in 4 other cases. 

Water-brash, eructations and pjTosis occupied a promi- 
nent place in the symptomatology of the affection at this 
stage. They had not infrequently formed a basis for the 



150 CANCER OF THE STOMACH 

early diagnosis of ''hyperacidity with probable gastric 
ulcer," but had not been associated with other clinical 
evidences of such disease. 

Weight loss had averaged 13.1 pounds in 77 cases, where 
definite data were recorded. Anemia and cachexia had 
been rare, except in several of the nervous patients. 

Appetite was usually good, except in the ''spells" of 
more or less pronounced dyspepsia. 

Constipation was noted in 51 cases (63 per cent.), diar- 
rhea was observed 4 times. 

(b) The Carcinomatous Period. — Its onset was rarely 
acute. In 2 cases severe hematemesis ushered in the stage 
of malignancy. In the majority of cases weight-loss, 
weakness, anemia, anorexia, continuous dyspepsia, ab- 
dominal discomfort, vomiting and epigastric tumor came 
on gradually. The course of this period of the ailment was 
in every way similar to that forming the second part of 
cases in Group II or to the whole course of cases making 
up Group III. Only the history of the early years of the 
dyspepsia identified the group. 

The following cases are representative of this class: 

1. Gastric Malignancy Following 12 Years of Irregular Dys- 
pepsia — Ulcer (?), Gall-Bladder (?): 

Mrs. A. V. — Age 68, American, housewife. 

Family History. — Negative. 

Personal History. — When young had scarlet fever, diph- 
theria, pneumonia. Ovariotomy 6 years ago. 

Present Trouble. — Up to 6 months ago had for 12 years 
irregular attacks of indigestion. These were character- 
ized by abdominal pain soon after eating, flatulence and 
occasional vomiting of green, watery fluid. In the attacks 
constipation was marked. Attacks lasted from 2 to 4 
weeks. Abdominal discomfort was relieved by vomiting 
diet and food ingestion (?). 

Six months ago began to notice gradual loss in weight 



SYMPTOMATOLOGY 151 

and gastric distress became more or less continuous. 
Vomiting came on daily soon after eating, and nausea, 
eructations and pyrosis were constant. 

Appetite. — Poor. 

Bowels. — Constipated. 

Weight. — ^Lost 40 pounds in 4 months. 

Examination. — Small, pale, poorly nourished female. 

Head, Neck and Chest. — Negative. 

Abdomen. — Tender to pressure throughout epigastrium; 
suggestion of a high transverse ridge just below the ensi- 
form. 

Rectal Examination. — Negative. 
Laboratory Examinations: 

Blood. — Hg., 84 per cent.; r.b.c, 4,480,000; w.b.c, 
17,500. 

Test-meal. — No 12-hour retention. Total acidity, 4; 
free Hcl, 0; altered blood +; lactic acid (?); Wolff test-j-. 

iS^ooL— Altered blood (?). 

X-ray. — Filling defect on the lesser curvature near the 
cardia; malignant hour-glass. 

Laparotomy. — High median incision, irremovable tumor 
of the body of the lesser curvature of the stomach; exten- 
sive perigastric gland involvement. 

Pathologic Report. — Gland removed showed carcinoma. 

2. Irregular Previous Gastric History — Ulcer {?), Pancreati- 
tis (?), Cholecystitis (?) — with Supervening Malignancy: 

Mr. E. H. A. — Age 57, Hebrew, salesman. 

Family History. — Negative. 

Personal History. — Negative, denies venereal. 

Duration of Present Illness. — For the past 20 years has 
suffered from epigastric pain associated with severe diar- 
rhea. Until 10 months ago this trouble occurred in spells. 
Pain was usually in the right epigastrium and was most 
marked 2 hours after eating. It would be relieved by 
vomiting, alkalies, diet or the belching of gas. The 
diarrhea was watery in type and frequently contained 
undigested food. Never passed blood. 

Ten years ago began to have constant diarrhea and 
epigastric distress associated with loss of weight and 
strength. Appetite became poor and anemia developed. 



152 CA^XER OF THE STOMACH 

Bowels. — Four to 6 movements a day; watery and mth- 
out pain. 

Weight. — Sixty pounds loss in a year. 

Examination. — Sallow, anemic male. 

Throat, Neck and Thorax. — Negative. 

Abdomen. — Scaphoid in shape; movable mass in the 
right upper quadi'ant from the mid-hne to the rib edge. 

Rectal. — Xegat i ve . 

Lahoratory Examinations. — Hg., 32 per cent.; r.b.c, 
4,000.000; w.b.c, 5,000. Small hTnphocytes 25.3 per cent.; 
large hnnphocytes, 8.7; pohmuclears, 60.7; transitionals, 1; 
eosinophiles, 2.6; basophiles, 1.7. 

Test-meal. — Xo retention. Total acidity, 9; free Hcl, 0; 
lactic acid+; altered blood + . 

Stool. — Altered blood+. 

Laparotomy . — High right rectus incision. Cancer the 
size of a cocoanut, invohing the stomach; metastases to 
the Uver and abdominal lymphatics. 

Pathologic Report. — Gland showed carcinoma. 

3. Previous Dyspepsia, Ulcer Type; Large Supraclavicular 
Fossa Metastasis; Few Recent Gastric Symptoms: 

Mr. E. K. B.^ — Age 61, American, travehng salesman. 

Family History. — Negative. 

Personal History. — Uses tobacco and alcohol in modera- 
tion. 

Duration of Present Trouble. — Up to 5 years ago had 
dyspeptic attacks characteristic of gastric ulcer. Epigas- 
tric pain 2 to 5 hom-s after eating which was relieved by 
food intake, alkalies or whiskey; these attacks occm'red in 
spells several times a year; 2 hemorrhages from the stomach 
30 years ago; moderate constipation. 

These attacks continued until about 5 j-ears ago when 
dyspepsia disappeared. Patient felt well until 6 months 
ago when he began to feel vague abdominal distress soon 
after eating, experienced nausea, began to lose weight and 
noted a gi'adually enlarging tumor above the left clavicle. 
This tumor was examined 4 days pre^^ous to his coming 
under our observation and pronounced Hodgkin's disease. 
Under .T-ray treatment this tumor became smaller but is 
again rapidly enlarging. 



SYMPTOMATOLOGY 153 

Appetite. — Poor. 

Bowels. — Slightly constipated. 

Weight. — One year ago 200 pounds; 6 months ago 190; 
present, 157. 
Examination: 

Throat. — Hypertrophied adenoid tissue. 

Neck. — Firm, nodular, tender tumor size of small grape 
fruit in left supraclavicular space. Tumor is fixed and 
below it are several smaller nodules. In left axilla lymph 
gland size of a walnut. 

Thorax. — Negative. 

Abdomen. — Rounded; tenderness on deep pressure 
over right and mid-epigastrium. Dulness on percussion. 
Greater curvature of stomach 1 f.b. below navel. 

Rectal Examination. — Negative. 
Laboratory Examinations: 

Blood.— Hg., 50 per cent.; r.b.c, 3,600,000; w.b.c, 
13,200. 

Test-meal. — Stomach tube meets resistance at cardia 
with free bleeding. Total acid, 62; free Hcl, 38; altered 
blood + ; lactic acid, 0; Wolff + . 

Microscopic Examination. — Yeasts; sarcinse; many diplo- 
cocci and short fat bacilli. 

Stool. — Altered blood + . 

X-ray Examination. — Filling defect, involving pars py- 
lorica; moderate gastric retention. 

Operation. — Block dissection of neck tumor showed sec- 
ondary carcinomatous metastasis from the stomach. 

Pathologic Report. — Carcinoma. 

Group V. Gastric Cancer in Individuals Who Presented Few Clinical 
Evidences of a Malignant Process Primary in the Stomach "Wall 

Such cases numbered 19, or 2.1 per cent, of our entire 
series. This class of case is extremely difficult to recog- 
nize clinically. The symptoms are very vague. Unless 
tumor appears the clinical picture is apt to be that of 
*' nervous" dyspepsia, arteriosclerosis, pernicious anemia, 
Bright's disease, Addison's disease, chronic gastritis, 
achylia gastrica, colitis, tabes or extragastric neoplasm. 



154 CANCER OF THE STOMACH 

In our series there were, however, certain ear-marks of 
maUgnancy even though such did not appear to primarily 
involve the stomach. All the patients had lost weight. 
The average loss was 18.2 pounds. 

Anemia was never pronounced. In only 1 case was 
hemoglobin below 50 per cent, and red cell count lower than 
3,000,000 cells. The color index averaged 0.72. 

Abdominal tumor was palpable in 5 cases. Its common 
situation was to the left of the mid-line. 

Diarrhea was a symptom in 7 cases (43.7 per cent.). 

Blood was noted in the stools twice. Abdominal dis- 
tress was complained of in but 3 cases. In but 1 instance 
was it severe. Vague ''uneasy" sensations were not un- 
common. Unaccountable nausea or anorexia, sudden belch- 
ing of gas or the regurgitation of bitter, salt, or ''rotten" 
fluid not rarely led to the visit to a physician. Dizziness, 
mental confusion, shortness of breath or profuse per- 
spiration on even moderate exertion were not uncommon 
complaints. Signs of mental depression, almost of mel- 
ancholic grade, developed in 1 patient. Laparotomy, test- 
meal analyses or Roentgen examination usually rendered 
positive a diagnosis previously but suspicious for malignant 
disease of the stomach. 

Some of the peculiarities of this group are emphasized in 
the histories below. 

1. Rapid Onset, Few Symptoms, Irremovable Carcinoma of 
the Greater Curvature: 

Mrs. I. M. — Age 50, Swedish, housewife. 

Family History. — Negative. 

Personal History. — For the past 6 weeks has had a bloated 
sensation in abdomen a few hours after meals. No belch- 
ing, eructations, or vomiting; no nausea. For the past 2 
weeks has had soreness in epigastrium and the left lumbar 
region almost continuously, and a week ago discovered an 
epigastric "lump." 



SYMPTOMATOLOGY 155 

Appetite. — Fair. 

Bowels. — Diarrheic during the last 3 weeks. 

Weight Loss. — Twenty pounds in 1 month. 

Physical Examination. — Well developed, but poorly 
nourished; mucosae anemic, tongue shghtly coated; chest 
negative. 

Abdomen. — At the left costal margin a mass the size of a 
hen's egg; it is hard and tender and moves downward on 
respiration. Abdomen otherv^dse negative. 
Laboratory Examinations: 

Blood.— Rg., 70 per cent.; r.b.c, 3,600,000; w.b.c, 
11,600. 

Test-meal. — SUght 12-hour retention. Gastric contents 
blood stained; total acidity, 14; free Hcl, 0; lactic acid +; 
altered blood + ; Wolff test + . 

Stool. — Altered blood. 

Roentgen Examination. — FiUing defect in pars media of 
greater curvature; malignant hour-glass; peristalsis absent; 
pylorus gaping; stomach j&xed. 

Laparotomy. — High right rectus incision; tumor mass 
involves whole of greater curvature; extensive gland in- 
volvement. 

Operation. — Explored. 

Pathology. — Gland showed carcinoma. 

2. Primary Carcinoma of Pyloric End of Stomach; Few 
Symptoms: 

Mr. A. S. — Age 49, Hebrew, tailor. 

Family History. — Had '^ quinsy" as a boy. Denies 
venereal disease. 

Present Trouble. — Has been constipated for 2 years. 
Four weeks ago, while bathing, noticed tumor size of a 
lemon in left abdomen. Since then has had sensation of 
tightness and pressure in the epigastrium; usually most 
severe 1 to 2 hours p.c. Belches gas occasionally. Thinks 
strength is somewhat diminished. 

Appetite. — Fair. 

Bowels. — Move once a week, "^-ith cathartics. 

Weight. — One year ago 129 pounds (normal) ; 6 months 
ago 125 (summer weight); present, 112. 



156 CANCER OF THE STOMACH 

Examination. — Thin, spare, neurotic Hebrew; skin 
sallow; slight edema about ankles. 

Throat, Neck and Chest. — Negative. 

Ahdomen. — Flat; panniculus thin; no tenderness. In 
left navel region is a freely movable mass the size of a 
tangerine orange. Stomach is moderately dilated. 

Rectal Examinaiion. — Hypertrophy of prostate. 
Laboratory Examinations: 

Blood.—'Rg., 75 per eent.;r.b.c., 4,500,000; w.b.c, 11,000. 

Wassermann. — Negative. 

Urine. — Negative . 

Stool. — Brownish-yellow; partly formed; hydi'obilii'U- 
bin+; altered blood + . 

Test-meal. — Shght 12-hour retention. Contents, pale 
yellow; free bleeding on lavage. Total aciditj^, 25; free 
Hcl, 3; lactic acid, 0; Wolff + ; altered blood -f. 

Microscopic. — Several groups of acid fast bacilli of Op- 
pler-Boas Xy^Q. 

X-ray. — Fluoroscopy demonstrates filling defect of py- 
lorus and part of antrum. ]Mass is freely movable. 
Stomach atonic and moderately dilated. 

Laparotomy. — High right rectus incision; large tumor 
involving pyloric third of stomach; glands moderately 
involved. 

Operation. — Partial gastrectomy; posterior gastro-en- 
terostom5^ 

Pathology. — Adenocarcinoma. 

3. Primary Gastric Cancer icith Few Symptoms: 

Dr. C. H. B. — ^Age 59, American, phj^sician. 

Family History. — Nothing important. 

Personal History. — Tj-phoid fever 25 j^ears ago; very ill. 
Leg lost by accident. No venereal disease. 

Present Trouble. — Had ''nervous" strain 5 months ago. 
To that time had had no gastric disturbance. Four 
months ago began to belch a httle gas and noted a slight 
gnawing in the epigastrium 4 to 5 hours after taking food. 
This was not distressing. 

Appetite. — Remained very good. 

Bowels. — Negative to a week or so ago, when movements 
became rather loose; never any blood. 



SYMPTOMATOLOGY 157 

Strength and endurance remained excellent. 

Weight. — One year ago 165; 6 months ago 155; present, 
140. 

Examination. — Tired looking, but well-nourished male. 
Tanned skin, but mucosae rather pale. 

Throat. — Negative; neck negative. 

Thorax. — Negative. 

Abdomen. — Deep tenderness over gall-bladder. Sensa- 
tion of deep resistance over mid-epigastrium, with dulness 
on percussion. 

Rectal Examination. — Negative. 
Laboratory Examinations: 

Blood.— Rg., 80 per cent.; r.b.c, 4,200,000; w.b.c, 6,000. 

Urine. — 0. 

Stool. — Altered blood, trace. 

Test-meal. — Moderate 12-hour retention. Total acidity, 
8; free Hcl, 0; lactic acid, trace; Wolff -h; altered blood -h; 
several bacilli of Oppler-Boas type seen. 

X-ray Examination. — Filling defect of pars media and 
posterior wall; malignant hour-glass. 

Laparotomy. — High right rectus incision. Large car- 
cinoma involving pars media; lesser curvature; posterior 
wall and pancreas. Irremovable. 

Pathologic Report. — Gland showed carcinoma. 



Group VI. Gastric Cancer Secondary to an Extragastric Malignant Process 

Such instances are rare. Our series comprises 16 cases 
(1.7 per cent.). The disease secondarily invades the 
stomach either by contiguity or by metastases through the 
lymph stream. We have records of 5 cases where gastric 
cancer followed cancer of the breast, 3 instances follow- 
ing malignant disease of the female genitalia, 3 cases of 
extension to the stomach of a hepatic cancer, 2 where cancer 
of the gall-bladder spread to the stomach, and 3 cases (2 
males and 1 female) of gastric malignancy associated with 
neoplasms of the colon. For reasons, often purely scientific, 
it is essential to differentiate actual metastases to the 



158 CANCER OF THE STOMACH 

stomach from a previously existing lesion, e.g., ulcer, which 
has becom.e mahgnant. 

History of previous operation upon mahgnant disease of 
breast, pelvic organs or bowel usually direct attention 
toward the stomach. The course of the ailment is similar 
to that when the disease has occurred primarily in the 
stomach. Clinically it is often distressing on account of 
its association with recurrent tumors at the original focus. 

The cases below bring out the essential features of this 
group. 

1. Cancer of the Liver, Jaundice, Secondary Invasions of the 
Stomach: 

Mr. C. H. — Age 53, German, railroad man. 

Family History. — Negative. 

Personal History. — Negative. 

Present Complaint. — Patient claims that he was perfectly 
well until 3 months ago; then became jaundiced. This 
has persisted and has changed from a canary yellow to a 
greenish-yellow tint. Two months ago began to vomit 
food, lost appetite, became drowsy and sleepy and mark- 
edly constipated. Urine has been of very dark color. 

Weight Loss. — Eighteen pounds in 2 months. 

Pain. — Has had no pain but feeling of fullness in epigas- 
trium. 

Abdominal Examination. — Patient emaciated, jaundiced 
deeply, mucosa rather pale. 

Bowels. — At present loose. The liver is enlarged extend- 
ing downward to within one finger breadth of the navel, it 
is very tender. The tumor moves up and down on respira- 
tion. 
Laboratory Examinations: 

Blood.— Kg., 75 per cent. ;r.b.c., 4,000,000; w.b.c, 14,500. 

Test-meal. — Moderate 12-hour retention; total acidity, 
22; free Hcl, 0; lactic acid (?) ; altered blood -f ; formol index, 
26.2. 

Stool. — Altered blood. 

Laparotomy. — ^Large carcinomatous mass involving two- 
thirds of the Hver; gall-bladder much distended and filled 



SYMPTOMATOLOGY 159 

with a whitish pus-like fluid; pancreas and lesser curvature 
of stomach invaded by a hard, nodular growth. 

Operation. — Cholecystostomy. 

Pathology. — Gland showed carcinoma. 

2. Lymphosarcoma of Colon: 

Mr. J. N.— Age 27, Swede. 

Family History. — Negative. 

Personal History. — Well until 2 years ago, at that time 
began to complain of pain in the epigastrium which lasted 
2 or 3 days and was usually followed by diarrhea. He had 
several of these spells during the first year and rather more 
than this during the last 9 months. Bowels were always 
constipated but he never passed blood. Abdomen not 
infrequently distended and at that time patient says he 
can hear gurgling sounds. The abdominal distention and 
the pains are brought on by solid foods. Two and a half 
weeks ago he felt a tumor the size of a hen's egg in left 
hypochondrium. 

Weight Loss. — Twenty pounds in last 6 months. 

Abdominal Examination. — Patient undernourished, ane- 
mic. 

Heart and Lungs. — Negative. 

Abdomen. — Hernia of the linea alba midway between 
navel and xyphoid. On standing a small tumor pro- 
trudes at this point. Just above the level of the navel 
in the left hypochondrium is a tumor the size of one's fist. 
It is fixed and tender on palpation. Percussion of the 
abdomen reveals a moderate amount of ascites. No 
external lymph tissue metastases palpable. 

Blood.— Rg., 60; r.b.c, 3,200,000; w.b.c, 9,600. 

Stool. — Altered blood -h. 

Laparotomy. — Low median incision; the abdomen is 
partly filled with free chylous fluid. There is a large 
adherent tumor involving the large intestine just below 
the splenic flexure, adherent to the stomach, several loops 
of small bowel run through it. 

Operation. — Entero-enterostomy. 

Pathology. — Gland showed lymphosarcoma. 



CHAPTER IV 
PHYSICAL ABNORMALITIES 

The General Appearance. — In the group of cases where 
gastric cancer is shown to exist only upon microscopic 
examination of extirpated sections of the stomach wall at 
laparotomy, frequently there are very few evidences of the 
disease on inspection. If the patient should be seen at a 
time when he is having acute exacerbation of his ailment, 
evidences of malnutrition are usually not lacking. 

When we recall that the clinical appearances of such cases 
simulate those of chronic gastric ulcer, we can readily 
understand why alterations that indicate systemic intoxica- 
tion of the malignant type are absent. 

In instances where early cardiac or pyloric stenosis has 
occurred, weight loss incident to the failure of nutrition as 
a result of vomiting is apparent in the disappearance of 
subcutaneous fat, in the loose skin and a certain pallor of 
the mucous surfaces. 

In patients where nausea is a common symptom, distress 
is plainlj^ indicated in the face by constant or intermittent 
pallor associated with profuse perspiration. The annoy- 
ance from pyrosis is frequently reflected in the face. Belch- 
ing may be constant and audible. 

If pain is a prominent symptom, the appearance and 
attitude of the patient may be characteristic. A pecuUar 
drawn look about the corners of the mouth, the facial 
expression indicating discomfort, or an unusual body pos- 
ture (bent over, hands over epigastrium, lying on one side, 

160 



PHYSICAL ABNORMALITIES 161 

etc.), may show that some departure from the normal 
is taking place. 

When malignancy has hecome well established the proof 
that such exists may be evident to even the casual on- 
looker. There is a peculiar apprehensive, or again re- 
signed, hopelessness in the general appearance of such 
patients. This is shown by the dull eye, the sunken cheek, 
and the posture. Such patients seem to partly collapse 
upon sitting down, or they lie in bed passively. The gait 
may be shufHing. Ph\^sical exertion generally leads to 
rapid exhaustion. 

In addition to the evidence of weight loss, as shown in 
the scaly skin, disappearance of normal fat accumulations 
about the body, the sunken eyes and the scaphoid appear- 
ance of the abdomen, there are external e^ddences of 
anemia which impart a grayish- white to yellowish-tan 
cast to the skin. It is unusual for a patient's skin to 
assume canary-yellow coloration, or for it to be moist or 
oily, associated with the presence of a nearly normal 
amount of subcutaneous fat such as one sees in essential 
anemias. Occasionally, however, the general appearance 
is strikingly similar. 

The mucous surfaces are often pale and dry. The tongue 
is generally heavily coated. It frequently shows fissures 
and hypertrophied papillae. There is usuallj^ marked 
fetor ex ore. This is due partly to accumulation of foul 
material in the stomach, the presence of microorganisms 
and food detritus in the mouth and bad teeth. The last 
are sometimes strikingly noticeable. 

Many instances of gastric cancer have decaying teeth and 

pronounced pyorrhea alveolaris. "While in such cases 

bad teeth have existed for years, it sometimes seems as 

though the onset of malignancy were associated with 
n 



162 CANCER OF THE STOMACH 

rapid deterioration of the teeth, together with the appear- 
ance of pyorrhea. From mouths containing poor or 
dirty teeth may frequently be isolated amoebae, flagellate 
protozoa, leptothrix or a multitude of pathogenic micro- 
organisms. It would be difficult to assume that the 
swallowing of such foreign substances is entirely beneficial 
to injured gastric mucosae. 

Edema not uncommonly occurs in the late stages of 
gastric cancer. It is rarely general. Usually it is evident 
by slight puffiness beneath the eyes or about the ankles. 
Where anemia has developed rapidly, one can often detect 
so-called ''false edema" behind the malleoli. We have 
noted only a few instances where the edema reached above 
the knees. In such instances it is not uncommon to find 
interstitial nephritis associated with the malignant disease. 

External Evidences of Metastasis. — These are observed in 
rather definite locations. Perhaps the most common 
external evidence of secondary malignancy is seen in the 
left supraclavicular space. Here the deep (or, more rarely, 
the superficial) lymph glands enlarge. We have seen 1 
patient in which the metastasis was as large as a medium- 
size grape fruit. Usually, however, the glands are as 
large as marbles or walnuts. They are commonly discrete, 
but may be confluent. It would seem that the reason for 
the frequent metastasis on the left side lies in the fact 
that the thoracic duct empties into the subclavian vein 
near where this gland chain is located. Metastases are 
apparently directly carried to this gland chain, and im- 
planted there quite early in the case of growths where there 
is abundant and rapid cellular proliferation. In many 
such instances examination of the mediastinal lymph 
spaces shows no evidence of metastasis involvement. 

Where there has been metastasis to the peritoneum one 



PHYSICAL .\BXORMALITIES 163 

may observe early evidences of ascites. In such abdomens, 
bulging in the flanks, "^hen the patient is recumbent, may 
be noted. This is in rather striking contrast to the lack 
of subcutaneous fat and the general flatness of the abdomen. 
When -such patient stands or lies upon the side, or assumes 
the knee-chest position, the fiUing out of the abdomen in 
the dependent portion may be observed. 

Where there has been rather rapid emaciation, enlarge- 
ment of the liver, due to secondary growths carried to it 
through the portal lymph stream, may be seen. We 
have noted several cases where small nodular infiltrations 
about the navel were prominent. Only rarely does one 
find visible evidence of metastasis in the inguinal glands. 

Nervous Signs. — There has been much written about 
patients with gastric cancer exhibiting melanchoHa, in- 
sanity and other psychoses. We have never observed a 
case in which such were markedly present. It is true that 
almost everj' patient who appears with abdominal tumor, 
rapid weight loss, deficient strength and other evidences of 
malnutrition, is greatly concerned regarding his exact 
status. It is quite natural that such a person should be 
grievously depressed. In an individual whose tempera- 
ment is rather unstable, one can readily conceive that 
such depression might amount to melanchoha, with even 
suicidal manifestations. In highly neurotic Jews, mental 
conditions which render the patient utterly irresponsible, 
may be expected. 

The Weight Loss. — As we have before stated, in the 
instances where the clinical picture is that of chronic, 
gastric ulcer, there may, or may not, be weight loss, accord- 
ingly as the patient comes under observation during a 
period of exacerbation, or when his process is quiescent. 
Even in circumstances where malignancy is estabhshed, 



164 



CANCER OF THE STOMACH 



one may see but slight physical evidences that such pa- 
tients have lost much weight. Unless a careful check has 
been kept upon the weight, the general appearance may 
not lead one to suspect that there had been a pronounced 
decrease. This appUes particularly to individuals who 
have been markedly over-nourished, or to patients of the 
large, '' raw-bone" type who have not had much sub- 
cutaneous fat to lose. In the average case, however, it 
is possible to judge from the looseness of the clothing or 
from the flabbiness of the muscles that there has been 
weight loss. 

Table 15. — Nutrition 



Months 


Minimum weight loss, 
pounds 


Maximum weight loss, 
pounds 


3 


4 


50 


4 


8 


72 


5 


10 


42 


6 


8 


100 


7 


20 


50 


8 


11 


60 


9 


7 


75 


10 


25 


50 


11 


50 


50 


12 


3 


60 


14 


40 


40 


15 


75 


75 


18 


35 


65 


24 


20 


50 


30 


40 


60 


36 


20 


75 



Showing Weight Loss in Gastric Cancer According to Duration of Symp- 
toms. — (Author.) 

We have instances where the disease had existed for 3 
months, 6 months, 9 months and even 12 months, where 
the weight loss has been respectively but 4 pounds, 8 
pounds, 7 pounds, and 3 pounds; in other cases where the 
disease has made itseK evident for such periods, the weight 



PHYSICAL ABNOEMALITIES ' 165 

loss has been 50, 100, 75, and 60 pounds respectively. Table 
15 shows the average minimum and maximum weight 
losses in individuals whose ailments have been evident for 
from 3 months to 3 years. 

It will be noted that there is a striking variation in the 
rate in which cancer patients lose weight. Certain factors 
are responsible for this : 

1. The Age at Which the Disease Occurs. — While no 
general rule can be formulated, it would seem that cancer 
patients past the age of 60 lose weight less rapidly than do 
those who are attacked by the disease below the age of 
40. In our experience, cancer in the young has always been 
attended by relatively rapid weight loss and other evi- 
dences of cachexia. We have seen, however, old people 
lose as much as 80 pounds in 6 months. 

2. Failure to Take Sufficient Food. — -This may be due 
to the loss of appetite which early appears in gastric 
cancer. Food desire may be greatly altered so that 
aversion may be manifested toward those things which 
have previously been eaten. As a result of this, the pa- 
tient may eat very Uttle, not knowing that with a change of 
diet food may be taken with comfort and relish. Constant, 
or intermittent, severe pain is also responsible for rapid 
weight losses. Many individuals are afraid to eat on 
account of bringing on or aggravating pain by so doing. 

3. Vomiting not Infrequently Precipitates Rapid Weight 
Loss. — If pyloric obstruction, obstruction at the cardia, 
or malignant hour-glass are developed, then early vomit- 
ing or constant nausea may result. In these instances 
the accumulation of foul material in the stomach is a not 
altogether negligible factor in bringing on early cachexia. 

4. Condition of the Mouth. — Poor teeth, missing teeth 
or sore.' mouth may render it impossible for a patient to 



166 CANCER OF THE STOMACH 

properly masticate food, or to take food which has definite 
strength-giving composition. 

5. The Poor-appetite Habit. — Many individuals with 
gastro-intestinal troubles are literally ''dieted to death." 
In the attempt to work out various novel theories 
regarding nutrition and metabolism, well-meaning in- 
dividuals not infrequently suggest dietetic regimes which 
are entirely foreign to the human family. Some of these 
are sufficiently distasteful to ''gag a buzzard." If the 
individual has a long precancerous, gastric history (fre- 
quently that of gastric ulcer) the poor-appetite habit may 
be already well developed at the time when the cancerous 
process begins. 

6. Mental Attitude. — It is not uncommon to find indi- 
viduals who, upon learning that there is a possibility of a 
malignant disease developing, or having developed, assume 
such an attitude of general disinterestedness in life and 
the things which pertain to it that not only are dietetic 
principles unheeded, but the general condition — the care 
of the teeth, skin, kidneys, bowels and the like — ^is entirely 
neglected. In such individuals, it seems that weight loss 
progresses very rapidly. 

THE ABDOMINAL EXAMINATION 

General Considerations. — Experience has impressed upon 
us the necessity of properly preparing patients for ab- 
dominal examination, and also of carrying on such in- 
vestigation under favorable circumstances. 

Whenever possible, abdominal examination should be 
conducted with the hollow viscera empty. If the stomach 
and bowels are filled with feces and gas, even those most 
expert in diagnosis may fail to detect abnormalities. 
Many a so-called clever diagnosis has its foundation upon 



PHYSICAL T^NORMALITIES 167 

thorough gastric lavage and vigorous catharsis previous 
to the carrying out of the abdominal examination. 

Our practice is to administer 2 ounces of castor oil, in 
a half glass of beer, malt-extract or acid fruit-juice, 12 
hours before the patient appears for study. If the bowels 
have not moved freely after this interval, an enema of 
soap-suds and warm water is then administered. A few 
obstinate cases require more potent enemata. We have 
found that in such instances the old-fashioned glycerin 
and salts clystra usually answers very well. But rarely 
has it been necessary to use so formidable an enema as that 
composed of milk and molasses, warmed (milk 600 cc; 
New Orleans molasses 400 cc; mix thoroughly; warm to 
37° C; inject in the usual manner). If the lower bowel is 
clogged with hardened feces, this enema is generally effect- 
ive where other types have failed. 

Just previous to the abdominal examination, the patient's 
stomach is emptied with the aid of a stomach tube of large 
caliber. After a fruitless search for a tube that would 
enable us to free the stomach of the foul mixture which it 
often contains where the pylorus is stenosed, or when hour- 
glass contraction has occurred, we devised the stomach 
tube described in Chapter V. Lavage with such tube, 
using 2 or 3 liters of warm normal salt solution, usually 
empties even the most dilated or malformed stomach in a 
short time. 

Following lavage, the patient should be stripped of all 
clothing, at least to the waist. We prefer to have patients 
appear for examination clad in only a thin, readily removed 
night-shirt or kimono. Some improperly educated folk — 
physicians as well as laymen — still believe that dependable 
abdominal diagnoses can be made without exposing the 
area of suspected disease. This applies especially in'!' the 



168 CANCER OF THE STOMACH 

case of females. Yet such modestce regularly display their 
anatomical perfections, wherever these may exist, to the 
eyes of the multitude in order to partake of the psychic 
comfort supplied by the "fox trot" or the ''bunny hug." 
Proper abdominal examination cannot be made unless 
the abdomen can be seen, felt and listened to. The 
ingenious American union-suit and its equally unsanitary 
rival, the fashionable corset, coupled with the ''don't-let- 
me-annoy-you " attitude of the popular attendant, with a 
medical license, are often responsible for gastric cancer 
reaching hopelessly inoperable stages before such is even 
suspected to exist. 

Nervous or excitable individuals sometimes require a 
quieting potion before being examined. Thirty grains of 
sodium bromid in a wine-glass of an gostura bitters usually aid 
these unfortunates. An attitude on the part of the physi- 
cian that inspires confidence is better therapy, however. 

We prefer routinely to examine the patient as he lies 
upon a table with his feet toward an unshaded window. 
His head should rest upon a small, firm pillow. The room 
should be clean, quiet, warm and not draughty. The 
physician's hands should be warm and unsoiled. In this 
age of motor cars, both these cautions are appropriate. 

A general physical examination should always precede 
the special study of the abdomen. The type of ''ab- 
dominal specialist" who can tell that an enlarged liver is 
not due to a tricuspid regurgitation or a nodular omentum 
not secondary to a pulmonary tuberculosis, without exami- 
nation of the primary focus of disease, is fortunately be- 
coming an extremely rara avis. All the information that 
it is possible to derive from chemic, microscopic, serologic 
or roentgenographic investigation should supplement the 
physical examination. 



PHYSICAL ABNORMALITIES 169 

1. Inspection may return no facts of clinical value in 
those cases where early carcinomatous change exists in 
the border of a peptic ulcer. Unless in severe pain, the 
patient lies at ease. The skin may be of good color and 
sleekly stretched over normal amounts of subcutaneous 
fat. The normal, bony boundaries of the belly may be well 
hidden. Cancerous change cannot exist long, however, 
before weight loss and cachexia are apparent. The fat 
of the abdominal parietes is usually diminished early. As 
a consequence, pale, dry, loose, wrinkled skin covers the 
belly and sags down in more or less marked folds in the 
flanks. Its hairy adnexa are often dry and brittle. 

The rib margins and the pelvic bones may become strik- 
ingly prominent. If an extensive neoplasm is present, 
degenerative changes take place in the muscle layers of the 
abdominal wall, resulting in their loss of tone. As a 
consequence, the belly appears flat or scaphoid. Not 
rarely a scaphoid or flat abdomen may have local areas 
of prominence due to visible gastric tumor, enlarged liver 
or pancreas, or metastases to the navel, omentum, or 
inguinal lymph nodes. Where free fluid is present in the 
peritoneal sac, but the peritoneal sac not filled, bulging in 
the flanks may be observed. This usually shifts with 
change of the patient's position. If there is a great ac- 
cumulation of fluid, the abdomen may appear rounded. 
The navel may bulge. 

Should marked emaciation have taken place, pulsations 
of the abdominal aorta are readily observed. They were 
recorded in 129 instances (15.01 per cent.) of our series. 

Local abdominal pro7ninences are due to the presence of a 
primary tumor, its metastases, encapsulated collections 
of fluid or air, or visibility of normal-size, solid organs as a 
result of extreme emaciation (liver) or hardened feces. 



170 CANCER OF THE STOMACH 

Respiratory movements cause certain alterations in the 
abdominal contour. Tumors of the stomach and in- 
testines usually change their position, and frequently their 
shape during respiration. Such prominences as occur 
from enlargement of the pancreas, abdominal aneurysm, 
retroperitoneal sarcoma, hypernephroma or various non- 
malignant tumors of the abdominal wall itself, may show 
no appreciable alteration during inspiration and expira- 
tion. Not infrequently, in an emaciated person, ripples or 
indefinitely outlined shadows are produced, by vigorous 
respiratory efforts, when free fluid exists in the peritoneal 
sac. 

Change of position causes important alterations in the 
appearance of the abdomen. Frequently when a patient 
lies upon either side, stands, or assumes the knee-chest 
posture, local or general bulging may occur from intra- 
abdominal tumors or fluid. This is a valuable maneuver 
and should not be neglected in doubtful cases. 

Visible peristalsis of stomach or intestines, or both, is 
not rarely made out when obstruction occurs (complete or 
partial) at the pylorus or in the small bowel. Occasion- 
ally where there is a secondary or primary malignant 
involvement of the transverse colon, local out-pouchings, 
usually on the proximal side of the obstruction, may be 
made out. While these do not as a rule show active peri- 
staltic waves, the variation in size of the bulging at dif- 
ferent examinations suggests the complication. 

When a malignant obstruction occurs at the outlet of the 
stomach the dilatation of the viscus is usually prompt and 
may be very extensive. 

In the early stages of gastric cancer before there has been 
secondary degeneration of muscle fibers in the stomach 
wall the peristalsis remains active. A vigorous attempt 



PHYSICAL ABNORMALITIES 171 

is made to force gastric contents through the narrow out- 
let. If the abdominal wall is not too thick, one readily 
perceives rhythmie waves passing from the left rib edge 
across the epigastrium. Such waves are usually more 
evident toward the pyloric region. They may occur so 
vigorously that the pylorus is brought forward toward 
the anterior abdominal wall and may appear as an evan- 
escent ''phantom tumor." 

Kussmaul first described this phenomenon in a case of 
non-malignant pyloric stenosis. It appeared in 12.2 per 
cent, of our cases where the pylorus was extensively involved. 
When the obstruction is marked, as in early scirrhus cancer 
developing in the edge of a chronic annular ulcer, reverse 
peristaltic waves may be observed. These pass from the 
right to the left across the epigastrium. They are rarely so 
well evidenced as are peristaltic waves in the normal direc- 
tion. In a good light, with the observer's eyes at the level 
of the stomach, they may be seen to develop in the right 
upper quadrant and fade away indefinitely toward the 
mid- or left epigastrium. When seen they always indicate 
a marked grade of pyloric stenosis. We have observed 
reverse peristalsis in 9 cases. Sometimes visible peristalsis 
may be brought out by gently tapping the abdomen or by 
several rather sudden ''dipping" movements upon the 
epigastrium. 

If the obstruction occurs — and this is very uncommon — 
in the small intestine, rather slowly forming, transient 
swellings, resembling the movements of an angle worm, may 
be made out in the low epigastrium or below the navel. 
It has been stated that such movements assume character- 
istic patterns depending upon the part of the small bowel 
obstructed. We have never been able to satisfy ourselves 
that these tumor patterns had any special diagnostic sig- 



172 CANCER OF THE STOMACH 

nificance with regard to enabling us to accurately prophesy 
where the obstructive point would be at laparotomy. 

Enlarged lymph nodes may be observed in the super- 
ficial inguinal chain. They rarely attain so great a size 
as do metastases to the glands of the neck or the axilla. 
Sometimes a metastasis occurs directly to the navel. 
This usually results in a retracted, malformed, fixed um- 
bilicus. It occurred in 59 (6.4 per cent.) of our cases. 
Very rarely one sees a surface ulceration of such a met- 
astasis. This is not apt to be extensive, but if secondary 
infection takes place, a granulomatous tumor may result. 
We have seen several instances where a perforated, anterior- 
wall ulcer resulted in accumulation of pus in the region of 
the navel. Such may closely simulate a metastasis from 
gastric malignancy. 

2. Palpation. — From this maneuver we gain the greatest 
amount of information regarding the abdomen in malig- 
nant disease. One should guard against hasty and vigorous 
palpation. The patient should be accustomed to light 
movements, pressure of the fingers, or the flat of the hand, 
before attempts are made to palpate deeply lying structures 
with the tips of the fingers. Particularly in the case of 
the abdomen, where the history of the patient is not clear, 
or has not been obtained, or where it is suspected that such 
a complication as hemorrhage or perforation has taken 
place, light palpation is an essential requisite for safety. 
It is well to accustom the subject to pressure of the hand 
over areas in which the disease is not suspected, before 
exploring disease foci. 

The tension of the abdominal wall in well-established 
malignancy is diminished unless there has been exten- 
sive involvement of the peritoneum with or without 
the accumulation of free fiuid. In early malignancy, 



PHYSICAL ABNORMALITIES 173 

where a previously complicated ulcer is undergoing can- 
cerous change, the abdominal wall tension may be nor- 
mal or even increased locally or generally. This is par- 
ticularly the case where a recent hemorrhage has occurred, 
perforation of an ulcer has taken place, or where great 
pain results in the patient's unconsciously tightening the 
abdominal muscles. In such event it is almost im- 
possible to successfully examine the intra-abdominal 
organs without the patient being given an anesthetic, or 
unless he has lain for from 15 minutes to 3^ hour in a bath 
tub filled with water above 373^-^° C The latter diagnostic 
maneuver is one of a few real advances in abdominal ex- 
amination that has been made in this countrj^ during the 
past 15 years. Its use has been emphasized particularly 
by Dock. We have found it an almost invaluable aid in 
the examination of hypersensitive indi^dduals, or in in- 
stances where perforation or obstruction have been sus- 
pected. After the patient has been in the hot water for 
the required time, the abdomen can be examined while he is 
still submerged, or immediately after he has been removed 
from the bath, dried and placed upon an examining table 
in a rather warm room. We have never found it necessary 
to administer a general anesthetic in order to facihtate an 
abdominal examination. There may be cases, however, in 
which such a procedure is entirely justifiable. 

The palpating hand in gastric cancer usually notes at 
once the temperature, dryness, scaliness and looseness of 
the skin covering the abdomen. Xot infrequently, due to 
the rapid disappearance of subcutaneous fat, the skin may 
be raised by the fingers several inches above the level of 
the abdomen. It falls back slowly and in loose folds due 
to the diminution of its elasticity. Occasionally, between 
the skin and the muscular waU, or superficially in the mus- 



174 CANCER OF THE STOMACH 

cular wall, one is able to feel small nodules or even tumors. 
These so-called "Nelaton" tumors are not infrequently 
confused with the tumor resulting from gastric malignancy. 
Lipomata are rarely deliixdted over the abdomen in this 
disease. Infiltration of the navel can be usually well made 
out if it is present. The navel remains more or less stiff- 
ened, fixed and adherent deeply. Sometimes inguinal 
glands that cannot be seen are palpable. They are rarely 
tender to pressure. The muscular wall in even moderately 
advanced cancer is loose and lax. If much weight has been 
lost it is apt to be very thin and the deeper structures 
easily made out through it. 

In instances where an accumulation of fluid has distended 
the peritoneal sac, the muscular waU while evidently 
thin is stretched and tight. Such abdomens may be tender 
if there has been a very extensive accumulation of serum. 
Unless there is very great distention of the abdomen by 
fluid, or unless the fluid is accumulated in small, well 
walled-off pockets due to the extensive involvement of 
the omentum and mesentery, one can usually demonstrate 
by tapping, fluctuating waves of greater or less definiteness. 

Deep palpation of the abdomen causes pain in the 
majority of instances. As a general rule, the epigastric 
distress on palpation is greater in early cancer developing 
upon ulcer, or in primary cancer which has later ulcerated, 
than it is where there has been an extensive or rapid growth 
of the neoplasm. In instances where a recent hemorrhage 
has occurred or perforation with inflammatory change 
in the peritoneum has taken place, the pain upon palpation 
may be as marked as in the acute abdomen due to other 
diseases (appendicitis, gall-stones and the like). 

If there has been much emaciation, the normal organs 
may be palpated with greater ease than usual. This 



PHYSICAL ABNORMALITIES 175 

applies especially to the liver, kidneys, the abdominal 
aorta, the bowels or the pancreas. Some of these may 
be invaded by secondary growths. 

The most important palpatory sign in gastric cancer is 
the determination of the presence or absence of an ab- 
dominal tumor associated with the stomach. 

THE ABDOMINAL TUMOR 

(a) Incidence. — In the observation of 150 cases clinic- 
ally diagnosed gastric cancer, Osier and IMacCrae report 
the presence of palpable tumor in 76 per cent. The Fen- 
wicks studied 154 instances of the disease. In 69 per 
cent, there were definitely demonstrated nodules; in an 
additional 8 per cent. '411-defined tumor" or ''sense of 
resistance" were recorded. Earher investigators (Brinton, 
Lebert, Leube, Hahn) place the tumor frequency at from 
80 to 86 per cent. In a recent study of 1,000 cases clinically, 
gastric cancer (only 26.6 per cent, came to laparotomy) 
Friedenwald reports the presence of recognizable abdom- 
inal ridge or mass in 71.9 per cent. 

The above figures exhibit a range of about 17 per cent. 
The stage during which the disease came under observation, 
and the skill possessed by the individual examiner, doubtless 
account for the seeming discrepancy in tumor incidence. 

Of the 921 instances of operated and pathologically 
demonstrated gastric cancer making up our series, ab- 
dominal tumor or ridge was palpated in 609 (66.1 per cent.). 
From this analysis all such doubtful things as ''ridges," 
"indurations" or "resistances" have been excluded. 

There were 312 cases (33.7 per cent.) in which abdominal 
tumor was not recorded as being palpable. One source of 
failure was undoubtedly the earliness with which some of 
the cancers were diagnosed. TMiere the proof of gastric 



176 



CANCER OF THE STOMACH 



malignancy rests upon microscopic examination of extir- 
pated tissue, only rarely is it possible to demonstrate tumor 
before laparotomy. Other reasons varying the possibility 
of tumor recognition are: the care with which the abdo- 
men has been palpated; the skill of the examiner; the 
preparation of the patient; the position in which he has 
been studied (examination in the knee-chest, lateral or 
sitting positions, with or without the added advantage of 
deep breathing or the hot bath, often aid in the discovery 
of an abdominal mass); the relative accessibility of the 
growth (neoplasms near the cardia, at the fundus and on 
the posterior wall are delimited with difficulty); the type 
of growth (encephaioid cancers, confining themselves largely 
to the submucosa, are not so readily palpated as are local- 
ized, nodular, fibrous tumors) ; the tension or thickness 
of the parietes; the pain caused by palpation and the pres- 
ence of metastases (tumor of the hver, omentum or colon or 
the existence of ascites). 

(6) Position of the Tumor. — In 515 instances (85.7 
per cent.) the palpable nodule or mass was located in the 
epigastrium proper. In 86 cases (13 per cent.) the growth 



Table 16 



Location 


Number of cases 


Per cent. 


Right upper quadrant . . 
Left upper quadrant .... 

Mid-epigastrium 

"Pit" of stomach 

Epigastrium, general 

At navel 


199 
165 
73 
47 
31 
27 
38 
21 
8 


32.6 

27.1 

11.9 

7.7 

5.1 

4.4 


Right of navel 


6.2 


Left of navel 


3.4 


Below navel 


1.3 






Total 


609 


99.7 



Position of Abdominal Tumor in Gastric Cancer. — (Author's Cases.) 



PETTSICAL ABNORMALITIES 177 

was found in the region of the navel or at about its level. 
But 8 times (1.3 per cent.) was the tumor below the level 
of the navel. Table 16 gives in detail the locations of the 
growth with the patient in the dorsal position. 

(c) Relation of Position of Abdominal Tumor to Part of 
Stomach Involved. — Our study shows that in 66.7 per cent, 
of instances the neoplasm involved the pylorus, antrum 
and the lesser curvature. Approximately 8 out of 10 such 
growths were palpated before laparotomy. In 12 per 
cent, the greater part of the stomach had been invaded. 
]More than 9 out of 10 of these were palpable. The 
posterior wall was the seat of the disease in 9.3 per cent. 
In this group, tumor could be felt externalh* in but 5 
out of 10. The anterior waU was involved in 2.3 per cent. 
These growths were palpable in 9 out of 10 instances. 
In 3.0 per cent, of oiu' cases the growth was at or near 
the cardia. But 3 out of 10 such tumors were palpable. 
The greater curvatiu'e was involved in 2.3 per cent, and 
6 out of 10 such tumors were delimited tkrough the ab- 
dominal wall. None of the tumors invading the fundus 
were palpable. Some part of the multiple tumors form- 
ing 2.9 per cent, of oiu' cases was palpated in more than 9 
out of 10 instances. 

Factors other than anatomic location of the gastric 
neoplasm which modify its ease of palpation have already 
been enumerated. In addition, we would emphasize that 
ver}' frequently tumors are rendered palpable and even 
visible by inflation of the stomach with ah or gas, either 
by means of a Davidson double-bulb syringe through a 
stomach tube, or by the administration of 4 grams of 
tartaric acid in 50 cc. of water, followed by -4 grams of 
sodium bicarbonate in 50 cc. of water, or by filling the 
viscus with fluid. It should be likewise emphasized here 

12 



178 CANCER OF THE STOMACH 

that distention of the stomach or filling it with liquid not 
infrequently cause a tumor already palpable to disappear. 
This is particularly apt to occur in the event that the 
neoplasm involves the posterior wall, greater curvature or 
the antrum. It is good practice to examine all stomachs 
suspected to be the seat of malignant growths both before 
and after air distention, or filling with water. 

{d) Size of the Tumor. — Ulcera carcinomatosa may be 
felt only as narrow finger-like ridges or small nodules, both 
before or after gastric filling. Other cancers range in 
size at palpation from that of a common marble to as 
great as a child's head, a medium-size squash or a discus. 
The tumor may fill the entire epigastrium and extend 
well into the left flank. It may be so large as to simulate 
a leukemic spleen. If invasion of the liver, pancreas or 
adjacent hollow viscera has taken place, a huge, irregular, 
plaque-like mass may occupy the entire upper epigastrium. 
Rarely does the growth extend below the navel, but if the 
omentum is involved, the tumor may be so extensive as 
to cast doubt upon its being primarily gastric in origin. 

(e) Tenderness of palpable tumors varies in degree from 
vague discomfort to actual pain. With the exception of 
ulcera carcinomatosa it is uncommon to have gastric 
cancer patients experience so much distress upon palpa- 
tion as do those affected with benign peptic ulcer. Even 
where malignant perforation has taken place, the resultant 
peritoneal invasion is accompanied by less pronounced 
evidences of inflammatory reaction than where this com- 
plication occurs in benign affections. 

There are but few gastric cancers which fail to exhibit 
some tenderness upon palpation. Of 572 instances where 
definite information is available in our series, 34 patients 
(5.9 per cent.) complained of no discomfort upon the manual 



PHYSICAL ABNORMALITIES 179 

examination of the growth. Of the 538 cases remaining, 
in 401 instances (70.1 per cent.) there was some degree of 
discomfort exhibited; in 137 cases (24 per cent.) palpa- 
tion was noticeably painful. Of our entire series of 921 
cases furnishing the basis of this study, there were 122 in- 
stances (13.3 per cent.) where some grade of perforation 
existed at laparotomy, and an additional 81 cases (8.8 
per cent.) where the serous surface of the stomach had 
been definitely involved in the malignant disease. From 
a consideration of these figures, it would seem that pro- 
tected perforation or peritoneal invasion without perfora- 
tiou may be present and their existence not be recognized 
even upon careful abdominal palpation. 

(/) Mobility of the Abdominal Tumor. — Factors influenc- 
ing the demonstration of the mobility of the palpable tumor 
in gastric cancer are: the histologic type of tumor; the 
duration of its growth; the position it occupies in the 
wall of the viscus; its relation to complications (perfora- 
tion, adhesions, contiguous extension, fluid in the peri- 
toneal sac); the position in which the patient is examined; 
its behavior when the stomach or colon is filled with air 
or fluid; the thickness of the abdominal parietes and the 
respiratory movements. 

While the majority of gastric cancers exhibit some 
freedom of movement, in only 437 instances (71.7 per cent.) 
of our cases was it possible to definitely move about the 
tumor with the palpating fingers. The remaining growths 
were either located in relatively fixed parts of the stomach 
or had been more or less immobilized during their develop- 
ment. 

It is of considerable importance to demonstrate me- 
chanical mobility (i.e., by the fingers) of gastric neoplasms, 
inasmuch as those in which the greatest freedom of move- 



180 CANCER OF THE STOMACH 

ment is demonstrated are generally most successfully 
treated surgically. 

The histologic type of the necplasm qualifies its freedom 
of movement. Cancers developing in ulcer edges, or can- 
cers rich in fibrous elements in which ulceration has oc- 
curred thi-ough surface necrosis are apt to be more mobile 
than so-called ''primary" gastric neoplasms of the med- 
ullary or colloid types. It will be recalled, moreover, that 
2 out of 3 tumors are located in the p^doric third — a por- 
tion of the stomach which, normally, has the greatest 
range of displacement. In this part of the stomach the 
muscle layers are also densest. It would seem that such 
might interpose a strong barrier to the rapid, external spread 
of the disease. General involvement of the stomach by a 
tumor of the clinically, scirrhus tj'pe, permits freedom of the 
viscus for the longest time. Extensive perigastric lymph- 
gland invasion may hmit such mobility. 

The duration of the disease affects the mobiUty of gastric 
tumors only in a general way. We have akeady emphasized 
that cell proliferation may occur with astonishing rapidity 
in gastric cancer. Consequent h\. we have numerous in- 
stances where malignant symptoms have existed for less 
than 2 months, and yet the resultant tumors were definitely 
anchored by secondary involvement of adjacent struc- 
tures. On the other hand, certain tumors may exist (par- 
ticularly in the pyloric region, or upon the lesser cm'vature) 
for as long as nearly I'^i years, and upon palpation and at 
laparotomy be shown to be entirely free. Of tumors where 
the evidently mahgnant disease had existed for from 6 to 
12 months, but 22 per cent, were mechanically mobile. In 
instances where a long precancerous history is obtained, not 
rarely the comphcations occurring during that period early 
limit mobihty of the supervening tumor. This is very 



PHYSICAL ABNORMALITIES 181 

likely to be the case if the early gastric history has been that 
which clinically we recognize as peptic ulcer. 

The position which a neoplasm occupies in the gastric wall 
greatly influences its freedom of movement. Carcinomata 
in the pyloric third of the stomach exhibit the greatest de- 
gree of possible displacement. Tumors of the anterior wall 
or of the greater curvature long remain free. Growths 
upon the lesser curvature proximal to the antrum remain 
relatively freely mobile, but on account of their tendency 
to metastasis to the pancreas, liver and adjacent thickly 
grouped lymph glands, they may quite early become only 
limitedly movable. Tumors of the posterior wall early 
become fixed by reason of extension to surrounding organs 
(especially to the pancreas). The anatomical limitation 
of movement at the cardia and fundus account for tumors 
in such locations being the least mobile of all gastric 
neoplasms. 

Complications may limit the mohility of a tumor at any 
stage of its progress. Such limitations may occur very 
quickly. Acute or chronic perforations, contiguous ex- 
tension to adjacent viscera, perigastric lymph-gland in- 
volvement, inflammatory adhesions or the rapid accumu- 
lation of free fluid in the peritoneal sac may immobilize a 
gastric cancer. Occasionally, such complications convey 
greater mechanical mobility — as, for example, when free 
fluid ''floats up" a tumor, or when an adhesion to the bowel 
or omentum permits the dragging about of a stomach 
growth. 

The degree of mobility of some gastric neoplasms is varied 
accordingly as palpation is carried on with the patient in 
different positions. Not infrequently a growth which was 
not palpable with the patient in the dorsal position, or was 
only indefinitely palpable or movable, becomes readily rec- 



182 CANCER OF THE STOMACH 

ognizable if he is placed in either lateral or knee-chest 
posture. Tumors of the body or fundus may be shown to 
be mobile by having the patient sit or stand after the 
location occupied by the growth in the dorsal position has 
been previously outlined. Placing the subject in the Tren- 
delenburg position occasionally causes tumors of the upper 
epigastrium to move upward beneath the liver, sternum 
or rib margins or to be lost through the change of position 
of free peritoneal fluid. - 

When the stomach or colon is distended with air or gas 
marked alterations in the location, the shape or size of 
gastric cancers may become evident. Upon gastric infla- 
tion we have seen carcinomata displaced as far as 9 inches 
from the place where they were palpated with the stomach 
empty. Pyloric tumors may travel from the left, upper 
quadrant to the mid-epigastrium, the right epigastrium, 
the region of the navel, the left hypochondrium, and rarely 
to the suprapubic region. We have observed one male 
patient in whom an immense, dilated stomach permitted the 
pyloric cancer to drop into the pelvis upon gastric inflation. 
In female subjects with low-lying stomachs, normally, 
the pyloric tumor is usually displaced to a lower point 
upon inflation than is the case in the average male patient. 
Tumors of the lesser curvature, fundus or greater curvature 
are often displaced as much as 5 inches upon gastric in- 
flation. Not infrequently the rotation of the distended 
stomach permits the ready palpation of a tumor which had 
before been indeflnitely recognized. While gastric inflation 
usually increases the size of a palpable mass, there are in- 
stances where a tumor is barely felt or even lost altogether 
after this maneuver. 

Most commonly, air inflation of the colon (through a rec- 
tal tube)_displaces gastric cancers upward or to the right. 



PHYSICAL ABNORMALITIES 183 

A low-lying .transverse colon adherent to an involved 
omentum, or to the gastric tumor itself, may drag down the 
neoplasm upon colon being inflated. Colon distention 
may push up under the edge of the ribs or beneath the 
margin of the liver, tumors which had been both visible 
and palpable. 

The successive inflation of the stomach and the colon is 
an extremely valuable procedure in the differential diagno- 
sis of obscure abdominal neoplasms. 

The thickness of the abdominal parieties may vary the 
ease with which gastric tumors are palpable to such 
extent that one may or may not be in doubt regarding the 
mobility of such. 

Respiratory movements displace practically all tumors of 
the gastro-intestinal system lying above the navel. In- 
spiration usually forces downward, or downward mesially 
or latterly, cancers of the pyloric third, the lesser curvature, 
the anterior wall or the greater curvature of the stomach. 
The extent of the displacement rarely exceeds 3 inches. 
Tumors of the fundus, high lesser curvature or the cardiac 
region may become palpable following deep inspiration. 
Inspiration not infrequently forces the stomach forward 
when the patient lies in the dorsal position, so that a tumor 
of greater extent may be felt at the end of deep inspiration 
than when the subject is in expiration or breathing quietly. 

If at the end of inspiration a tumor can be held down while 
expiration takes place, the possibility of adhesions to or 
contiguous involvement of such solid organs as the liver, 
spleen, or left kidney is less than if the expiratory move- 
ment carried upward the palpable epigastric tumor. Such 
diagnostic maneuver does not always indicate the opera- 
bility or the inoperability of a gastric cancer. Extensive, 
deeply lying adhesions (to pancreas, retroperitoneal tissues, 



184 CANCER OF THE STOMACH 

bowel) or widespread invasion of the lymphatic system 
may occur wholly irrespective of the degree of mobility of 
the primar}^ focus in the stomach. 

Gland Involvement. — The observation that enlargement 
is taking place in groups of surface lymphatics has great 
value in indicating methods of therapy. ^Tiere there has 
been malignant invasion of superficial lymphatics, it can 
hardly be expected that surgical procedures are of any 
permanent worth, excepting in rare instances where opera- 
tive measures are carried out for the relief of mechanical 
obstruction. The enlargement of such gland groups as 
those lying above the left clavicle (Virchow's gland), the 
inguinal nodes, about the navel or lying in the cul-de-sac 
posterior to the bladder, clearly indicates that the disease 
has been scattered far beyond its source of origin in the 
stomach, and it is but a question of time before fatal 
termination will result. Careful palpation should be 
carried on in a systematic manner in an effort to recognize 
these lymph-gland metastases. Sometimes the inguinal 
nodes are but slightly swollen. They may be as large as 
common marbles. They are usually the last of the lymph- 
gland chains to show involvement of intra-abdominal ma- 
lignant disease. The glands are as a rule discrete. They 
are rarely tender to the touch, and we have never seen a 
case where infiltration from such glands occurred in the 
surrounding or adjacent structures. We have never seen 
an instance of ulceration or necrosis in malignant involve- 
ment of such superficial lymph nodes. Invasion of the 
lymph tissue in the neighborhood of the navel is rather rare. 
It usually occurs when there has been quite active perito- 
neal involvement. 

"Blumer's shelf is not an infrequent site for the loca- 
tion of pelvic metastasis in mahgnant disease of the stom- 



PHYSICAL ABNORMALITIES 185 

ach. Upon rectal examination one is able to outline a small 
shelf-like or pouch-like projection posterior to the bladder. 
In a normal individual this is free, but where an extensive 
carcinoma has involved the stomach and freely metastasized, 
one can not infrequently delimit at the tip of the examining 
finger one or several discrete nodules lying in this pouch. 
Metastases to this location seem to occur with more fre- 
quency than to other lymph-gland areas. This is probably 
due to the fact that with the patient in an erect position 
cancer cells are carried into the pelvis along the peritoneal 
surface by force of gravity. There may be some other 
reason why there is an apparent predilection for gland 
invasion at this point. 

We have never seen a case, where enlarged glands were 
palpated as ''Blumer's shelf," that was operable, i.e., in 
the sense of permanent relief, even by the most radical 
resection. In our series of cases metastasis to this region 
was noted in 16 per cent. 

Enlargement of the supraclavicular glands might logically 
be considered at this point. We noted such enlargement 
in 11.5 per cent. We have already mentioned why it is 
that gland metastases from cancers in the stomach occur 
with rather striking frequency above the left clavicle. We 
have noted but a few instances where coincident or in- 
dependent enlargement of glands in the right supracla- 
vicular space could be demonstrated. We have never seen 
an instance where the malignant invasion of these glands 
occurred without the primary focus being beyond the hope 
of permanent relief by surgical measures. 

Another evidence of extensive gland involvement by 
cancer is shown upon palpation by the presence of free 
peritoneal fluid. The cancerous intoxication or irritation 
usually results in rather rapid accumulation of free ab- 



186 CANCER OF THE STOMACH 

dominal fluid. Palpation frequently enables one to roughly 
estimate the volume of such exudate by noting alterations 
in the local or general laxness or tension of the abdominal 
wall. The character of the abdominal fluid varies. It is 
usually thin enough to permit of its rapidly shifting from 
one part of the abdominal cavity to the other . Further 
considerations of abdominal fluid are given in Chapter VII. 

A palpable liver may result from secondary involvement 
of that organ through the lymph stream or contiguous in- 
volvement from the primary tumor. When the liver can 
be well outlined by the palpating fingers, either along its 
entire lower margin, or locally at any point, one can safely 
say that the primary growth is irremovable. In our ex- 
perience the liver was palpable in 23 per cent. 

Lymph glands about the pylorus or the lesser curvature 
can occasionally be felt where the disease is extensive, 
where the parietes is not too thick, or where the presence of 
free fluid does not interfere with palpation. In certain in- 
stances these glands may be largely responsible for pyloric 
obstruction. 

Where pyloric obstruction occurs early, while the peris- 
taltic activity of the stomach is still vigorous, during 
palpation the stiffening and increased tension of the gastric 
wall may be felt beneath the palpating hand. 

It is perhaps important here to emphasize the above 
seven signs of inoperability of gastric neoplasms. They are : 
evidence of gland enlargement above the left clavicle, Blu- 
mer's rectal shelf, to the umbilicus, local or general increase 
in size of the liver, presence of free peritoneal fluid, enlarge- 
ment of the inguinal lymph nodes, and palpable lymphatic 
metastases about the pylorus or along the lesser curvature. 

Even if the primary tumor is not itself large, or even 
though it may be freely movable, the discovery of any or 



PHYSICAL ABNORMALITIES 187 

all of the above external evidences of the spread of the 
disease seriously limits the prognosis from the various types 
of surgical operation. 

In all these instances where lymphatic involvement is 
determined an attempt should be made to remove one of the 
enlarged nodes for the purpose of microscopic study. 
It is usually quite possible to- remove one of these glands 
with the aid of a simple local anesthetic (ethyl chlorid or a 
2 per cent, cocaine solution). Examination of the tissue 
removed may be rapidly made with the aid of an apparatus 
for cutting frozen sections. These can be readily stained 
with Unna's polychrome methylene blue. It should be em- 
phasized here that the judgment of an expert is required 
in many instances to determine the histologic changes oc- 
curring in these removed lymph nodes. Operative proce- 
dures should never be neglected solely upon the evidence 
furnished by the examination of extirpated glands. 

Percussion. — This diagnostic maneuver is of but limited 
value. The greatest service it renders is in the determina- 
tion of enlargements of solid organs (liver, spleen), the dem- 
onstration of the amount and mobility of peritoneal fluid, 
and occasionally in enabling one to form an approximate 
estimation of the size of the gastric cancer. Sometimes it 
is possible to outline a dilated or distended stomach by 
percussion. When such gastric limits are checked by 
operative procedure or a:;-ray examination, one generally 
discovers that the percussion outlines only roughly esti- 
mate the actual size or even the position of the viscus. 

There are certain cases where no epigastric tumor can be 
definitely palpable, and yet percussion enables one to de- 
limit areas of dulness in certain parts of the abdomen where 
one suspects that a neoplasm exists. 

Percussion should be carried on with the use of both light 



188 CANCER OF THE STOMACH 

and heavy strokes. Not infrequently where hght percussion 
demonstrates tympany, deeper percussion results in high- 
pitched tones that suggest airless tissue lying below a 
gas-filled hollow vise us. 

In cases where the peritoneal sac is not too greatly dis- 
tended with fluid, one can delimit areas of dulness and 
tympany that frequently change their outlines upon the 
subject's assuming various positions. 

If the accumulation of fluid is great and the gastro- 
intestinal tract is empty, the entire abdomen may lack 
resonant tones upon light or even deep tapping. 

Occasionally, hollow viscera are floated upon moderate 
accumulations of free peritoneal fluid. As a result, the 
major portion of the abdomen may be tympanitic to per- 
cussion with the patient in the dorsal position. In such 
instances, however, it is extremely uncommon not to find 
dulness in the flanks or in the dependent portions of the 
abdomen when the patient sits up, stands erect, or assumes 
the knee-chest posture. 

We have frequently observed an interesting, and we 
believe a hitherto undescribed, percussion sign in cases where 
cancer involves the fundus or the anterior waU of the body 
of the stomach. 

WTien the patient is in the dorsal position percussion of 
Traube's space is not uncommonly dull instead of normally 
tympanitic. Examination by percussion of the same area 
at the end of deep inspiration, or upon the patient lying 
on the right side, or standing, sometimes results in the dis- 
appearance of the dull tones upon the percussion of Traube's 
space and the appearance of characteristic tympany. 
This sign we have observed in 18 out of 24 cases of carci- 
noma involving the superior portion of the stomach where 
an epigastric tumor could not be palpated. 



PHYSICAL ABNORMALITIES 189 

Auscultation is of relatively little diagnostic value in 
cases of gastric carcinoma. 

Occasionally it is useful to prove that the contents of the 
esophagus pass into the stomach where a growth is known 
to exist in the region of the cardia. If the orifice is patent, 
auscultation over the region of the cardia, anterior or 
posterior, enables the recognition of the second swallowing 
sound when swallowed liquid passes from the esophagus into 
the stomach, should the cardiac orifice be patent. If the 
individual is obese, or the cardia be moderately closed 
(particularly with a papillomatous growth) the second 
swallowing sound is usually greatly modified or entirely 
unrecognizable upon auscultation. 

Auscultation over the epigastrium proper sometimes 
furnishes an index of the peristaltic activity in a given 
stomach. This is sometimes of value in determining 
stomach outline upon inflation of the viscus with air through 
a stomach tube or the patency of a ring cancer of the 
pylorus, in allowing one to ascertain the degree of obstruc- 
tion by listening for gurgling sounds caused by the passage 
of air and fluid. 

In cases where an extension of the malignant growth to 
an adjacent loop of the bowel is suspected, with greater 
or less obstruction of the lumen of the bowel, auscultation 
sometimes permits us to state whether or no the air or 
liquid has passed beyond the suspected area of constriction. 

In rare instances, auscultatory evidences of the patency 
of a gastro-enterostomy stoma are established by listening 
over the region of the artificial opening, or over the bowel 
beyond. 

GASTROSCOPY 

During the last 3 decades a number of men have given 
their attention to the design of a practical gastroscope, 



190 



CANCER or THE STOMACH 



among whom should be mentioned Mikulicz, Rosenheim, 
Kausch, Forametti, Jackson, Kuttner, Kelling, Eisner, 
Janeway and Hall. 

As the result of the work of these men a number of in- 
struments have been made. These have met with more or 
less success. 

Sussmann Gastroscope. — Some 5 years ago. Dr. Martin 
Sussmann of Berlin constructed a crude model of a flexible 
gastroscope which seemed to fulfill the requirements in a 




Fig. 47. — Sussmann Gastroscope. 



theoretical way, but he experienced difl&culty in having 
the optical system and mechanical parts made. After 
4 years of experimenting, he finally succeeded in perfecting 
the instrument as shown in the illustrations (Fig. 47). 

Contrary to the impression one might first have from 
these illustrations, the instrument is extremely simple in 
manipulation. The appliance consists primarily of 2 parts, 
the non-flexible part A and the flexible part B. The total 
length from eyepiece to the lens at the distal end is 74 cm. 



PHYSICAL .iJBXOEMALITIES 191 

of which part .-i, non-flexible, is 24 cm. and part B 50 cm. 
The diameter is 12}4 mm. 

The non-flexible part A is set at an angle of 150° to part 
B, and in spite of this angle and the comparative great 
length of the instrument, a clear view can be had of the 
walls of the stomach when distended with air, due to the 
ingenious systems of lenses which have been adopted. On 
part A is mounted the ocular (9). The turning device 
with indicator (3) for revolving the objective at the distal 
end of part B, lever (2) for placing the instrument in a flex- 
ible condition, tension wheel (1) for replacing the instru- 
ment in a rigid position, connection for compressed air 
tubing (6), with needle air control valve (7) and a hook or 
finger rest (8). Part B is covered with a pure gum tube. 
At the distal end of the instrument is located the objective. 
Mounted on each side of the objective is a small flat tung- 
sten filament electric bulb, the objective and bulb being 
covered by a hood or protector which is made of glass and 
metal, preventing the entrance of moisture and mucus, 
which might otherwise cause difficulty in the illuminating 
on account of short-circuiting of the current. In earlier 
forms of gastroscopes this turning feature offered quite an 
objection, in that the entire tube was turned, making the 
procedure a painful one to the patient. 

Fig, 47 shows the gastroscope in a flexible position, and 
also in a rigid position, as set for the purpose of inspection. 
Fig. 47, 3 shows the method of introduction. Change 
from rigid to flexible is easily accomphshed by simply 
throwing back lever 2 from position A to B and giving 
it a sHght amount of pressure. 

The system of lenses employed deserves special mention, 
from the fact that they are unusual in many respects. It 
is generally considered that in passing the instrument the 



192 CANCER OF THE STOMACH 

shortest distance, from objective to the posterior wall or 
entrance to the cardia is 2 mm. and that the average dis- 
tance in a well-inflated stomach is 7 cm. from the objective 
to the part under inspection. The lens system, however, 
is universal in so far as an object will present a sharp, clear 
view, whether within 2 mm. of the lens or at a distance of 
7 mm. The eyepiece (9) may be adjusted so as to accom- 
modate itself to the lens system. The range of the field 
under observation at one time is sufficient so that an area 
measuring 6 cm. across may be observed without any read- 
justment of the instrument. This makes it possible to 
observe the entire wall of the stomach, since the lens sys- 
tem can be turned so as to describe a complete circle and 
the instrument may be moved downward to any point. 

The inventor claims that this instrument can be intro- 
duced without difficulty in every case where it is possible to 
introduce a stomach tube, and that the introduction is 
easier than with a straight, non-flexible instrument. 

Since the above illustrations were made, the inventor has 
added an important improvement to the gastroscope, in 
the shape of a second ocular, which permits of two persons 
observing the conditions of the stomach at the same time. 

There is an air inlet with automatic valve. To this is 
connected a double balloon or foot bellows for the inflation 
of the stomach. In order to be absolutely sure of just how 
much pressure one is using, a manometer may be used in 
connection. 



CHAPTER Y 
EXAMINATION OF GASTRO -INTESTINAL FUNCTION 

This concerns itself chiefly with analysis of gastric con- 
tents and feces. Of minor value are examination of vomitiis, 
determination of the position, size and shape of the stomach 
and demonstration of the patency, mobility and situation 
of the small and large bowels. 

(A) TEST-MEAL EXAMINATION OF GASTRIC FUNCTION 

In well-established cancer of the stomach, there is no 
method of chnical investigation which fields more infor- 
mation of worth than does properly appUed study of certain 
features of gastric function. There are few chnical methods 
■ — and certainly no chnical laboratory procedure — which 
enable one to estimate the status of a given case of gastric 
cancer so quickly, accurately and inexpensively as does in- 
telligent scrutiny of test-meal data. There is no disease of 
the stomach, per se, which returns gastric-extract analyses 
so characteristic as those exhibited in instances of what is 
chnically advanced gastric cancer. In cases where dubious 
information is furnished by test-meal analyses, it can be 
demonstrated to be a fact that other clinical and laboratory 
aids are rarely conclusive and that in these cases final opin- 
ion generally rests upon exploratory laparotomy and the 
report of the ceUular pathologist. These statements are 
based upon the author's personal analysis of 7,192 gastric 
extracts. 

Our series of cases gives us 701 instances of proved gastric 
cancer in which test-meal examination of stomach function 
was carried out. It is our purpose to consider this phase of 

13 193 



194 CANCER OF THE STOMACH 

clinical examination in the light of the facts returned by 
such analyses. It has been our endeavor to discriminate 
between essentials and non-essentials. 

Much opprobrium has been attached to test-meal work 
during recent years. This has resulted largely from the 
clinical laboratory being expected to do all the work rela- 
tive to making a diagnosis, and often from a few cubic centi- 
meters of material brought or sent to it; from certain labo- 
ratory men failing to distinguish useful, practical, clinical 
tests from those chemically fascinating, but often entirely 
of an experimental nature; from the eager pursuit of 
"specific" tests for each disease or every symptom of it, 
and from the failure of patient, analyst, pathologist and 
surgeon to ''get together" in an attempt to establish facts 
of worth from the mass of information collected inde- 
pendently. 

From rather more than a casual acquaintance with the. 
subject our records indicate that examination of gastric 
function has to do mainly with the investigation of (1) the 
emptying power of the stomach; (2) the chemical analysis 
of test-meal extracts or vomitus; and (3) the microscopic 
study of gastric contents or vomitus. 

INVESTIGATION OF GASTRIC EMPTYING POWER 

Scarcely a year passes without some ''new" method for 
estimating gastric emptying power being exploited. The 
very fact that clinicians of reputedly large experience fre- 
quently put forth these procedures would appear to indi- 
cate either that there is no satisfactory method of de- 
termining the time of the stomach's emptying or that the 
emptying-rate of the so-called "normal" stomach is un- 
settled. It is a waste of space and energy to catalogue the 
various novel and often amusingly ingenious " mo tor- tests " 



EXAZMIXATIOX OF GASTRO-IXTESTIXAL FUXCTIOX 195 

that have been described. TTe have found the following 
procedure useful. It has limitations. A not altogether 
unimportant feature of the information returned bj' this 
motor-meal, in our series, Ues in its having been adminis- 
tered to a large number of patients whose ailments were 
subsequently determined at laparotomy. 

(a) Physiologic Method of Estimating Gastric Emptying 
Power. — Its object is to prove whether food can pass into 
or out of the stomach. The contraindications are few: 
recent severe hemorrhage, clinical evidences of perforation, 
coma, extreme asthenia, severe cardio-renal distui'bances 
or mental upsets. 

Method. — The patient's stomach should be washed free 
from whatever material it contains. Following the lavage 
(pro'\T.ded the chnical histor}' of marked stenoses at the 
orifices has not been obtained) 2 ounces of castor oil are ad- 
ministered thi'ough the stomach tube or per or am. Three 
hours later the patient is allowed to eat a moderate-size 
meal of mixed food, in the manner that he ordinarily fol- 
lows. This meal contains anaong other ingredients, at 
least 50 grams of cold meat, 2 leaves of head lettuce, and 20 
raw raisins. Instructions are sometimes needed to insure 
the patient's swallowing the skins of the raisins. It is 
important that they should be eaten. Beverages are 
allowed, preferabh' water, milk, or weak tea. This meal 
has the advantages of being readily available, palatable 
and of sufficient bulk. The last consideration is of essential 
value in any motor-meal. It is impossible to estabhsh 
evidence of the anatomic condition of the stomach's orifices 
by motor-meals of the baby pap tx^Q. An interval of 
from 8 to 12 hom's is permitted to elapse before a stomach 
tube is passed and attempts at the recovery of remains of 
the motor meal are made. Experience has taught us that 



196 CANCER OF THE STOMACH 

food remnants present constantly in a stomach after 8 
hours generally indicate some mechanical hindrance to their 
free exit from the viscus. It is not uncommon in healthy 
individuals to demonstrate the presence of food in the stom- 
ach after 4 to 6 hours, i.e., the common time hmit for 
estimation of gastric emptying power. In many instances 
of. pyloric spasm, associated with peptic ulcer, disease of the 




Fig. 48. — Motor-meal and lavage tube showing distal end, markings on 
tube and the aluminum mid-piece. — (Author.) 

gall-bladder, the appendix, etc., intermittent (and some- 
times marked) 6- to 8-hour residues may be removed from 
the stomach. In pronounced atony, rather more than 4 
per cent, of cases exhibit food retained longer than 6 hours. 
For the purpose of readily removing gastric contents we 
some time since constructed the stomach tube illustrated 
by Figs. 48 and 49. 



Ex,\:\nxATiox of gasteo-ixtestixal FrxcTiox 197 

Motor-meal and Lavage Tube. — Stomach tubes, as ordi- 
narily made, seem to have the following faults: (1) the 
inferior rubber in their construction, which prevents ster- 
ilization by boiling (the only efficient method); (2) small 
lumina, which frequently render unsatisfactory the aspira- 
tion or expression of motor-meals or poorly ch^'mified 
test-breakfasts; (3) improperlj'- placed, too few or too small 
fenestra at their distal ends; (4) the incorporation into the 
tubes of '^ aspirating bulbs "^ of questionable service, which 
are difficult to keep clean. In an effort to remedy some of 
these defects, we have had constructed tubes of the t^^e 
to be described. They have given greater satisfaction 




Fig. 49. — Motor-meal and lavage tube showmg openiags in distal end. — 

(^Author.) 

than any other form in the last 1,800 cases examined in 
which test-meal examinations were made. 

The tube is constructed of the best quality of red rubber. 
The waU is 2 mm. thick and the lumen has a diameter of 9 
mm. The tube is made in two sections, distal and proximal, 
connected by a thin, but strong, aluminum mid-piece. 

The distal segment of the tube is 90 cm. long. It has a 
distal opening of 1 cm. diameter. Beginning 1 cm. from 
this tip is a lateral fenestrum '^Tig. 49) of elUpsoid form, 2 
cm. long and 1 cm. wide. On the opposite lateral surface 
to this is a second similar lateral fenestrum, which begins 
3 cm. from the tip of the tube. The fenestrum is placed at 
this point, not only to permit free siphonage of gastric 
contents, but also to facilitate the introduction of the tube. 



198 CANCER OF THE STOMACH 

Its location, 3 cm. from the tip of the tube, is the average 
distance in different individuals from the pharyngeal dip 
of the tongue to the introitus oesophagi. When the tip of 
the tube enters the pharynx, with the second lateral fenes- 
trum toward the tongue, the subject's swallowing motions 
promptly bend the tube at this fenestrum and the tip glides 
readily into the esophagus. Using a tube with a distal end 
of this type, we have not entered the larynx more than a 
dozen times in our last 5,000 cases. Eight centimeters from 
the tip of the tube are placed three round fenestra, of a diam- 
eter of 2 mm. They pierce the tube at the same level. This 
distal Segment of the tube, beginning 10 cm. from its tip, is 
marked off by encircling black lines (Fig. 48), every 5 cm. 
for a distance of 55 cm. from the distal end. These mark- 
ings permit of fairly accurate location of obstructions in the 
esophagus. The tube, in such instances, acts as a hollow 
sound through which the contents of esophageal saccula- 
tions and the like may be readily secured. 

The connecting aluminum mid-piece is 5 cm. long, with a 
wall 1 mm. thick and a lumen of 1 cm. diameter. It is 
sUghtly roughened and fits snugly into the rubber parts. 
It is non-rusting. 

The proximal end of the tube is 60 cm. long. It may be 
replaced, when necessary, by an aspiration bulb which fits 
onto the metal mid-piece. 

These tubes appear to have many advantages. They 
are durable; they may be boiled for months and still retain 
their form. The lumen is large enough to permit free ex- 
pression or aspiration of retention contents after the ad- 
ministration of a motor test-meal. The distal fenestra are 
so placed as to permit the easy passage of the tube and the 
rapid siphonage or aspiration of gastric contents. Free 
lavage is readily carried on, either for the purpose of de- 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 199 

termining retention (as in hour-glass stomach) or for thera- 
peutic effect. The tube acts as a safe and convenient 
esophageal sound. The aluminum mid-piece replaces easily 
broken glass connections. It enables one rapidly to con- 
vert the straight siphon or lavage tube into one of bulb 
type for the purpose of inflating the stomach with air or 
when expression of gastric contents proves difficult. 

In the passing of a stomach tube, we find it convenient to 
seat the subject upon a straight-backed chair. All cloth- 
ing to the waist is removed, except an undergarment. 
The patient places his hands flat, across the region of the 
navel. The head should be tilted slightly forward. This 
widens the introitus cesophagi. Appropriate rubber and 
linen covers protect the patient. It is rarely necessary to 
hold the subject's head, etc. After boiling, the stomach 
tube is kept until needed in a bowl of cracked ice. With 
the patient prepared, the end of the cold tube is rapidly 
passed to the pharynx, and as the patient swallows, it is 
advanced boldly and rapidly into the esophagus; then 
passed quickly, but carefully, into the stomach. Cough- 
ing, cyanosis and pain promptly develop if the tube has 
entered the larynx. When the tube reaches the stomach 
(recognized by gas, or contents coming from the tube or 
by the feeling of its passing the cardia) the patient is sharply 
commanded to press his hands upon his belly and to bend 
quickly forward. The gastric extracts usually spurt from 
the free end of the tube promptly. If none appear, the tube 
may be successively advanced and retracted cautiously, 
the patient instructed to cough, or an aspirating bulb 
used. We have rarely found it necessary to resort to such 
bulb. Sometimes the gastric contents are very thick or 
made up of large pieces of food. In this event one may 
have to dilute such or gradually wash the material out. 



200 CANCER OF THE STOMACH 

Every attempt should be made to secure contents with- 
out resorting to this procedure, because analysis of 
the material removed from a ^'fasting stomach" returns 
most useful information (particularly upon microscopic 
examination) . 

Frequency of Gastric Retention in Cancer of the Stomach. — 
Some degree of 12-hour retention was demonstrated in 
483 cases (69 per cent.) in our series of 701 instances where 
test-meal data are available. Frequently the amount varied 
considerably upon repeated examinations, but there were 
but 20 per cent, of cases where the neoplasm was located 
at the antrum or distal to it where some trace of food re- 
tained for from 8 to 12 hours could not be persistently 
demonstrated. 

THE MACROSCOPIC STUDY OF RETENTION EXTRACTS IN 
GASTRIC CANCER 

If the pylorus is patent the wash-water may return clear. 
This is especially the case where so-called scirrhus or colloid 
cancers are present. Fully 95 per cent, of all gastric cancers 
contain areas where cell-arrangement is of the medullary 
type. It follows, consequently, that the wash-water is 
frequently turbid or tinged with blood. 

Where retention exists from a few cubic centimeters to 
more than a liter of more or less altered test-food may be 
removed. Not rarely, large pieces of partly digested mate- 
rial, intermixed with mucus, together with puree-like fluid 
are secured. 

Color. — Traumatic blood was noted in nearly 47 per cent, 
of 223 consecutive cases in our series. Bile coloring was 
observed in 56 instances (8 per cent.). It commonly oc- 
curred where a tough fibrous cancer held partly open the 
pylorus. Classic coffee-colored or dark brown extracts were 



EXAMINATION OF G ASTRO-INTESTINAL FUNCTION 201 

noted in 149 cases (21.3 per cent.). Such growths were 
inoperable in more than 97 per cent. The color of gastric 
contents is quite as apt to be tan or brownish in non- 
malignant stenoses as in cancer. Occasionally, almost 
black extracts are removed. Such are often due to dis- 
integrated blood or necrotic tissue or medicines (bismuth, 
iron preparations). 

Odor. — In more than 80 per cent, of our cases, acrid, 
rancid odors were recorded. They are usually produced 
by volatile, organic acids. Such odors are almost pathog- 
nomonic of malignancy when associated with 12-hour food 
retention. Putrefactive odors, sometimes nauseatingly 
penetrating, may be encountered from sloughing of cancer 
tissue, deterioration of blood, perforation, or fistula to 
adjacent viscera. 

Mucus. — An excess is observed in more than 2 out of 5 
instances of malignant gastric retention. It is generally 
in tough, gelatinous strings or ropes, more or less intimately 
mixed with food, or the products of cancer growth. 

Chymification of Test-food. — Where peristalsis is below 
the normal strength or frequency, free hydrochloric acidity 
low, the test-food poorly masticated and retention pro- 
nounced, chymification is greatly diminished. Commonly, 
test-food eaten 12 hours previously is little altered, par- 
ticularly meat, lettuce or raisin skins. 

Acidity of "Fasting Stomach" Extracts. — Methods. — 
For practical clinical use sufficiently accurate relative re- 
sults are obtained by the Toepfer technique of determining 
acidity. The gastric extracts should be filtered, if quantity 
permits. If analyzed unfiltered, the readings are apt to be 
higher than where filtered extracts are examined. Other 
errors may occur. 



202 CANCER OF THE STOMACH 

"Free Hydrochloric^^ Acidity. — There is no absolutely 
reliable waj^ of estimating such in retention contents, be- 
cause, as Schryver and Singer have emphasized, hydro- 
chlorids of amino-acids (end-digestion products) act as 
acids, and organic acids (lactic, butyric and acetic) like- 
wise affect such indicators as dimethylamidoazohenzol and 
GUnzberg's reagent (phloroglucin-vanillin solution). For 
comparative work, however, it appears useful to estimate 
free hydrochloric acidity with dimethyl as an indicator. 

Method. — Ten cc. of gastric filtrate are placed in a 
white porcelain evaporating dish. To it are added 2 drops 
of 0.5 per cent, solution of dimethylamidoazobenzol 
in 95 per cent, alcohol. If free hydrochloric acid is pres- 
ent the mixture assumes a magenta red. The acidity is 
neutrahzed by slowly adding from a burette n/10 solution of 
sodium hydroxide. The end point is reached when the 
mixture in the evaporating dish becomes lemon yellow in 
color. The number of cubic centimeters or parts thereof 
required to bring about this color change is read from the 
burette. This figure multiplied by 10 gives the acidity 
per hundred parts. If the acidity per cent, is desired, 
multiply the resultant figure by 0.00365. 

Degree of Free Hydrochloric Acidity in Retention Contents. 
— In 319 cases (66 per cent.) no free hydrochloric acid could 
be detected by dimethyl in the extracts from fasting stom- 
achs. In the remaining 164 instances, free hydrochloric 
acid ranged from 2 to 70. The average was 26.6. In 
other words, practically 1 out of every 3 cases of gastric 
cancer with retention of food have free hydrochloric acid 
above an average of 26, in the fasting stomach contents. 

Total Acidity. — This is a term of but relative worth. Its 
physiologic significance is open to question. CHnically, 
high total acidity is not rarely associated with abdominal 
discomfort, nausea, pyrosis and eructations. Not a small 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 203 

part of this discomfort would appear to be due to the 
presence of organic acids in stagnant, gastric contents. 

Method of Determining Total Acidity. — Ten cubic centi- 
meters of gastric filtrate are placed in a white enamel 
evaporating dish. Two drops of a 1 per cent, alcoholic 
solution of phenolphthalein are added. There is usually 
no color change unless the total acidity is very low or the 
extract alkaline, n/10 sodium hydrate solution is added 
to the mixture from a burette. "V\Tien the acidity has 
been neutrahzed by the soda, the contents of the evapo- 
rating dish take on a pinkish-red hue. The degree of 
acidity is computed as in the case of estimating free 
hydrochloric. Total acidity includes free hydrochloric, 
combined hydrochloric, organic acids and acid salts. 

Degree of Total Acidity in Retention Contents in Gastric 
Cancer. — In none of the 483 cases in which 8- to 12-hour 
food retention was demonstrated was total acidity 0. The 
average total acidity was 40.3. The minimum was 4; the 
maximum 132. 

"Combined" acidity as estimated by using sodium aliza- 
rin solution as an indicator is a finding of dubious value. 

Method. — Ten cubic centimeters of gastric filtrate are 
placed in a white porcelain evaporating dish. To this are 
added 2 drops of sodium alizarin solution. The mixture 
is titrated against n/10 sodium hydroxide solution until 
the contents turn violet. Quantitatively, the estimation 
is made as in the determination of free hydrochloric. 

Degree of "Combined" Acidity in Retention Contents of 
Gastric Cancer. — Of the 483 cases in this series, combined 
acidity was never below 1.5. The average was 16.5. The 
minimum was 1.5, and the maximum 126. 

Acid Salts. — Schryver and Singer (loc. cit.) have pointed 
out in their admirable critique of the methods employed in 
gastric analysis, that in malignant tumors affecting the 
pyloric region of the stomach, the amount of secreted chlo- 



204 CANCER OF THE STOMACH 

ride is generally increased. Our 483 observations above 
detailed upon the relation of total, combined and free hy- 
drochloric acidity would appear to add, indirectly, certain 
clinical corroboration of this fact. 

Lactic Acid. — Tests for this and other organic acids are 
more commonly positive in retention contents than in gas- 
tric extracts where there has been no evidence of pronounced 
stagnation. 

Method. — Six drops solution of liquor ferri sesqui- 
chlorati are added to 3 drops of 95 per cent, carbolic acid. 
The resultant mixture is diluted in distilled water until 
it assumes a lively amethyst blue. To this last solution 
are then added from 5 to 10 drops of gastric filtrate. If 
lactic acid is present the amethyst blue color is discharged 
upon the addition of the gastric filtrate and a canary-yellow 
color is seen. 

Frequently gastric contents which have been extracted 
with ether, according to the method of Strauss, are em- 
ployed in the above outlined test in place of the unex- 
tracted gastric contents. 

By the adoption of this modification of the test a higher 
percentage of positives is returned in gastric cancer than 
where the original procedure was employed. 

In our series of retention contents lactic acid was dem- 
onstrated in 66.8 per cent. In instances where lactic acid 
was demonstrated 95 per cent, were inoperable carcinomata. 
Of this number 58 per cent, had no precarcinomatous 
history of dyspepsia. In the cases where there had been 
precarcinomatous history of indigestion, the antecedent 
indigestion had been of the type clinically peptic ulcer in 
only 42 per cent. 

Altered or "Occult" Blood. — Inasmuch as in 9 out of 10 
instances of carcinoma of the stomach tumor areas are shown 
which pathologically contain tissue of the medullary type, 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 205 

it is to be expected that from time to time, or constantly, a 
certain amount of seepage of blood will occur. As we 
have already pointed out this can often be recognized in the 
wash-water, particularly after vigorous manipulation of the 
stomach tube. Where the hemorrhage has been moder- 
ately profuse, the gastric contents range in color from light 
tan to dark brown or almost black. In the majority of 
instances it is not necessary to test retention contents for 
blood chemically. Sometimes, however, the administra- 
tion of blood-building or styptic medicines (iron, bismuth, 
tannic acid, etc.) imparts a color suspicious of blood to the 
gastric contents. Certain forms of food may also bring 
about such a change (red wines, soups, meats, chocolate, 
grape juice, etc.). It is, therefore, interesting in such an 
event to definitely prove whether or no the color is due to 
blood. Of course, it should be recognized that the result- 
ant positive test may come not from the bleeding of can- 
cerous tissue, but from the presence in retention contents 
of substances derived from food or medicine. 

Method. — Many tests have been suggested. If properly 
controlled the majority of them have a certain place clin- 
ically. The most common ingredients used in the "occult" 
blood test are phenolphthalein (Boas) guaiac, benzidin or 
orthotoluidin (Ruttan and Hardisty). 

The most reliable tests for the proof of blood, from a 
purely chemical standpoint, are the spectroscopic test or 
the demonstration of hemin crystals. 

The tests depending upon color change of fluids are, 
however, more convenient of application than are those 
which require elaborate apparatus or demand more or less 
expert knowledge of crystallography. 

Benzidin Test. — Clinically we have found that the altered 
blood test performed with the use of powdered benzidin 



206 CANCER OF THE STOMACH 

(pinkish-gray powder) is quite satisfactory. We have 
preferred benzidin to guaiac because we have found that 
positive tests to it are returned less frequently from food 
than in the event where guaiac is used. Our method of per- 
forming this test is as follows: 

Method. — To 5 cc. of gastric extracts are added 5 drops 
of glacial acetic acid. This forms an acid hematin if blood 
be present. This acid hematin is then extracted by the 
addition of 5 cc. of chemically pure ether, by frequently 
pouring from test-tube to test-tube. To the ether extract 
are added 15 drops of a 1 per cent, solution of benzidin 
powder in 95 per cent, alcohol (or in strong glacial acetic 
acid). The mixture is again poured from one test-tube to 
another several times. From 15 to 25 drops of active 
hydrogen peroxide are finally added (commercial peroxide 
of 3 per cent, strength is satisfactory). 

If blood is present in the gastric extracts a prompt color 
change takes place in the fluid. This color change varies 
from a lively emerald green to a greenish-blue or an indigo. 
If no blood is present, then the color change does not com- 
monly appear. We find it of value to allow the tubes to 
stand 1 minute after the addition of the peroxide solution. 
If no greenish or bluish color has developed, it is safe 
to say that any blood which may be present has little clinical 
significance. 

Instances of Altered or "Occult" Blood in Retention Con- 
tents.— Oi the 483 cases in which 12-hour retention was 
proven, the clinical test for altered blood was positive in 
82 per cent. Of this number, as is noted above, lactic acid 
was present in 66.8 per cent. 

MICROSCOPIC EXAMINATION OF RETENTION CONTENTS 

This should never be neglected. Apart from the evi- 
dence of stagnation, in the large majority of instances of 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 207 

moderately advanced, or extensive gastric carcinoma, even 
if no abdominal tumor can be palpated externally, one is 
able to discover a rather characteristic picture upon 
microscopic examination of stained smears with high-power 
amplification. To the expert, examination of unstained 
smears is usually sufficient to return a diagnosis as to the 
type of retention contents. However, the examination 
should always be made with high power. Even those most 
experienced in the microscopic examination of gastric ex- 
tracts cannot determine accurately the bacterial flora 
present using the 4-mm. or lower power objectives. 

Method. — Various methods of staining are in clinical use. 
Not infrequently the desired information may be obtained 
by the so-called 3-drop method. This is performed by plac- 
ing upon a clean glass slide 3 small drops of unfiltered 
retention contents. These drops are placed in a row about 
^ of an inch apart. The first one is simply covered with 
a clean cover slip ; to the second is added a drop of Lugol's 
solution and then a cover slip; to the third is added a small 
drop of osmic acid and a cover slip. The unstained speci- 
men permits of search for motile and non-motile organisms; 
the second drop, on account of the iodine stain, permits of 
examination for starch and vegetable food rests, yeasts, 
leptothrix and the like; while the third drop allows the 
recognition of fat or some of its products. If the cover slips 
are placed firmly upon the drops, one can, with the 
addition of a small amount of immersion oil to each cover 
slip, quite satisfactorily examine with the high power. 

This is a rough, clinical method, and is of limited use in 
an investigation of gastric contents from which information 
is desired regarding definite flora, food digestion and the 
like. 

For purposes of studying, and convenience in examining, 
a large number of specimens in a short time, we devised the 
following method. We have found it quite dependable and 
simple in its application. 



208 CANCER OF THE STOMACH 

Colored Agar Method for Staining Gastric Extracts. — 

Agar Solutions. — Two per cent, agar solution is made by 
boiling up an appropriate quantity of best grade strip agar 
in distilled water. The solution is filtered several times 
while very hot through double, hydrochloric-acid-washed 
filter paper. On cooling it solidifies as a firm jelly. It 
should be fractionally sterihzed and refiltered on 3 con- 
secutive days. 

For purposes of convenience, 5 cc. of the molten agar are 
poured into each of numerous sterile test-tubes. The 
tubes are plugged with sterile cotton and set aside at room 
temperature. The agar jellies and may be used as desired. 

Stains. — Thus far we have used coloring agents in combi- 
nation with agar solutions for two purposes: (1) for the 
differentiation of bacteria, blood-cells, epithelial elements, 
tissue-bits and the like, we have found most satisfactory 
Unna's polychrome methylene blue; (2) for the differentia- 
tion of starch residues, vegetable fibers, moulds, etc., we 
have employed freshly prepared LugoFs mixture. 

Procedure. — For each specimen of gastric extract or feces 
emulsion, we make t?wo agar-coloring matter combinations 
as follows: the 2 per cent, agar jelly is liquefied by heating 
over a Bunsen flame, or in a water-bath. Two cubic centi- 
meters of the solution are poured into each of two small test- 
tubes (those measuring 10 cm. X 15 mm. answer very well). 
Into each of the tubes are then poured 15 drops of filtered 
staining agent. For staining bacteria and the like we have 
found that Unna's mixture gives good results, while Lugol's 
solution colors starch elements better than simple iodin. 
The added stains are intimately mixed with the agar and 
the tubes promptly placed in a beaker containing boiling 
water. The agar is thus kept as a solution. 

Very thin smears of the gastric extracts or feces emulsions 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 209 

are made on cover slips. It is desirable to avoid getting 
gross particles of food in the smears. The smears may be 
dried in air or by rapidly passing through a gas flame. 

Onto the smear to be examined for microorganisms and 
allied elements, by means of a pipette with a 1 mm. 
bore, is placed 1 drop of the agar-methylene-blue mixture. 
The cover slip is promptly inverted on a clean glass slide. 
The agar-stain mixture rapidly spreads to the edges of 
the cover slip. As it cools the agar solidifies while the 
stain mixed with it permeates the smear. Similarly, to 
the smear to be examined for starch remnants and the 
like, is added 1 drop of the agar-Lugol's mixture. The 
cover sHp is mounted at once on the same slide as the 
first preparation. About 1 minute suffices for firmly 
mounting and staining ordinary material. In a series, 
the first preparations are ready for examination by the 
time the last are made. 

Examination. — The preparations are best examined by 
such fight as comes from a Nernst, Schwann or tungsten 
lamp. If electricity is not available, a Welsbach mantle 
light suffices. 'V^Tien the specimens are properly focused, 
using an oil-immersion objective, it will be seen that 
bacteria are stained blue or deep purple; blood cells and 
nuclei are differentiated by pale pink and blue, as are also 
epithefial elements; tissue bits, if small, may show atypical, 
mitotic cells; muscle fibers are pink to red, with deeper 
striation; mucus is in bluish strips or whorls. Unless the 
preparation is over-stained, vegetable fibers, leptothrix, 
moulds, etc., are but lightly colored. In the smear pre- 
pared with agar-Lugol's mixture, vegetable fibers, lepto- 
thrix, moulds, and starch remnants are appropriately dif- 
ferentiated. The latter may be amethyst-blue, with 
deeper staining centers or laminae, reddish-pink with 

14 



210 CANCER OF THE STOMACH 

mahogany-colored centers or faint pink or colorless. Bud- 
ding yeasts, moulds, and occasionally bacteria take a 
brownish-blue tinge. Vegetable cells stand out promi- 
nently as blue to brown reticula. Large masses of 
amorphous material stain variously, but are readily dis- 
tinguished from microorganisms. 

Uncolored Preparations. — The agar without coloring 
agents added may be advantageously used for mounting 
smears. In fresh preparations, when the smears are not 
dried, motile organisms (bacteria, protozoa) may be ob- 
served for a long time. This is facilitated when the speci- 
men is diluted with three volumes of warm normal saline 
solution before the smears are made. 

Advantages of the Method. — A routine, differential report 
on two dozen smears, from half as many specimens of gastric 
extracts or feces, may be made in about 30 minutes. The 
specimens are simultaneously mounted and stained. The 
solidification of the agar gives so firm a mount that the 
specimens may be examined with high or low power, with 
the stage of the microscope at any angle. The mounting 
is suflficiently permanent to allow future study (we have 
preparations showing good fields after 10 weeks), drawings, 
photomicrographs or demonstration. Comparison of the 
smears on the same slide, but differently stained, results in 
many interesting and instructive observations. There 
would seem to be advantages in using the method for the 
observation of motile bacteria, protozoa, or cells with 
ameboid activity, when uncolored agar solutions are 
used. 

Significance of Microscopic Examination. — ^In malignant 
retention contents, food in the various stages of digestion 
can usually be recognized. 

Food. — Unless food retention has been demonstrated 



EXAMINATION OF GASTEO-INTESTINAL FUNCTION 211 

macroscopically, the finding of food bits microscopically 
only has, in our experience, practically no diagnostic value. 

Bacteria in Malignant Retention Contents. — The investi- 
gation has occupied laborator}^ workers for many years. It 
was early shown by Oppler working in Boas' Clinic that 
malignant retention extracts contained a large number of 
long, non-motile rods. This observer also noted that 
such organisms were of comparatively rare occurrence in 
gastric contents, either of the retention or non-retention 
tj^e, in diseases other than carcinoma of the stomach. 
Later investigations upon the properties of these so-called 
''rather long bacilli" were carried on by Kauffmann. 
This observer proved that the bacteria described by 
Oppler and Boas were acid fast, fermented sugar, and 
were probabh' an altered form of Bacillus acidi ladici. 

We have made observations upon 221 consecutive in- 
stances of gastric cancer for the presence of bacteria of 
this type. We were early impressed by the fact that 
the bacillus described by Oppler-Boas, Kauffmann and 
others appeared to be not a distinct tj-pe, but rather 
partook of the nature of a group of bacteria having similar 
morphological and cultural characteristics. 

In addition to the microscopic examination of stained 
and unstained, wet and dry smears of gastric contents 
containing this organism, we undertook to attempt culture 
of the germ by perhaps a new method. A full report of the 
work is not yet available. Let it suffice to say that the 
information of the greatest worth which we are able to 
derive from our studies was derived from bacilli from 
mahgnant gastric contents grown in two types of media, 
namely: (a) a medium made from extracting fresh, sterile 
mahgnant tissue that had been ground up in a sterile 
meat grinder with a normal salt solution, and (h) a similar 



212 



CANCER OF THE STOMACH 



medium made from beef extract. We are prepared to 
ofifer the following morphological observations. 

Characteristics of Bacilli of the Oppler-Boas Group.— 
The bacilh vary in length from 15 to 60 microns. The 




Fig. 50. — Typical long bacilli — Oppler-Boas. Photomicrogram. 

(Author.) 




YiQ, 51. — Bent and club-shaped forms of Oppler-Boas bacilli. Photo- 
microgram. — (Auth6r.) 

short forms are straight, slightly curved, wavy or occasion- 
ally comma shaped. As the forms grow larger, they rarely 
remain straight, but may be bent or wavy with a tend- 



EXAMINATION OF GASTEO-INTESTINAL FUNCTION 213 

ency to curl up like a J or ''shinny "-stick at the end. In 
old retention contents the bacilli may assume U-shape, 
half circle forms, or may even have ring-like twists. 

It is uncommon to find Oppler-Boas bacilli over 20 mi- 
crons long that are absolutely straight. When they are 
above this size the wavy or bent forms become numerous. 
In addition to being bent or wavy, one frequently notes 
that an end of a bacillus is clubbed or bent at an oblique 
angle. 




Fig. 52. — Oppler-Boas bacilli showing different groupings and variation 
in size of individual bacilli. Photomicrogram. — (Author.) 

Long chains of organisms of this group are uncommon; 
short chains often occur. The individual bacilli making 
up the chains vary in length, but resemble each other, 
structurally. When the bacilli grow in chains they are 
usually blunt ended, but on account of the curved or 
wavy outline of the individual bacillus the resultant chain 
often has an irregular zig-zag appearance. In old, stagna- 
tion contents, some of these chains form loops, nearly 
complete ellipses or circles. 

Staining Properties. — The typical bacilli stain uniformly 



214 



CANXER OF THE STOMACH 



a bluish-purple with Unna's polychrome methylene blue. 
They absorb the blue about as deeply as do yeast cells. 
As the baciUi grow longer or form chains, they stain ir- 
regularly so that frequently there are alternate bands of 
deep and Hght color. This gives the organism a some- 
what beaded appearance. It may be that this bizarre 
staining appearance is due to the fact that the organism 




Fig. 53. — Oppler-Boas bacilli. Showing half-circle, "shinny stick" and 
ring forms. Photomicrogram of old retention contents. — (Author.) 

is wa,vj or corkscrew-like. If this be so, different portions 
of the bacillus come into focus at different times. Cer- 
tainly some of the more hghtly stained areas appear darker 
upon focusing. The bacilU take the iodine stain evenly, 
and are colored a hght amber-yellow by Lugol's solu- 
tion. This perhaps helps to differentiate them from 
leptothrix forms and from ordinary lactic acid bacilli. 

Artificial Culture. — Two types of culture media were 
used: (1) ordinary beef bouillon, and (2) bouillon made 



EXAZMIXATIOX OF GASTEO-IXTESTIXAL FrXCTIOX 215 

from fresh cancer tissue. The tubes were inoculated 
from a cancerous retention contents. Its acidity was: 
total, 15; free Hcl^ 0. 

Moxroscopic Examination. — After 24 hours the tubes 
containing bacilli in the cancer extract medium were 
slightly opalescent and had a fine, granular, compact 




Fig. 54. — ^losaic of yeast cells from case of benign retention. Photomicro- 

gram. — (Author.) 

precipitate on the bottom. The cultures had a slightly 
3^east-hke odor. Cultures made in the heef houillan 
medium were densely opaque, and had a heavy, fiocculent 
precipitate with faint yeast}^ odor. 

Microscopic Examination. — Smears made from the can- 
cer extract houillon exhibited an occasional yeast cell and 
from 3 to 6 bacilli of the Oppler-Boas type to a field. The 
bacilli were single or arranged in short chains in from 
2 to -4 organisms. They were fairly even in length, the 



216 CANCER OF THE STOMACH 

average being about 20 microns. Thej^ stained deeply 
and homogeneously with Unna's polychrome methylene 
blue. Some had rather club-shaped ends; those of others 
were slightly angulated. The ends were bluntly rounded. 
The individual bacilU joined each other in the chains at a 
broad oblique angle. In this medium were also seen 
numerous slender somewhat lance-shaped bacilH, arranged 
singly. They were occasionally curved at the middle, 
like a wide open U. Thej^ stained rather faintly. With 




Fig. 55. — Yeast colony from case of beniiin gaitric retention. Photo- 
microgram. — (Author, j 

Lugol's mixture, organisms of the Oppler-Boas tA'pe were 
colored Hght amber-yellow, as were also the lance-shaped 
bacilh above described. Occasionally one could see forms 
of the lance-shaped baciUi arranged singly and staining 
deeply. The average length of the small variety of these 
was three-fourths that of the diameter of a red blood 
cell. The large forms were twice as long as the diameter 
of a red blood cell. 

Cultures in Beef Bouillon. — ^The growth was very abun- 
dant. Great numbers of Oppler-Boas bacilli were seen. 



EXAMIXATIOX OF GASTEO-IXTESTIXAL FrXCTIOX 217 

They varied \'ery much in size ranging in length from half 
the diameter of a red blood cell to 3 times that diameter. 
They stained deeply. Their ends were bluntly rounded. 
The organisms were straight or somewhat bent in the 
middle or toward one end. Without regard to individual 





Fig. 56. — Old benign gastric retention. Yeasts and bacillus butyricus. 
Phot omicrogram . — (Author . ) 

size they were arranged in short chains or pairs. TThen 
forming chains they rarely fitted squarely end to end, 
but usually at an angle. Sometimes the bacilli were 
joined at different or opposite angles so that h-regular 
chains were formed. Occasionally,, the angles were similar 
in dhection. In this event curved chains resulted. ]\Iany 



218 



CANCER OF THE STOMACH 



long leptothrix chains were seen. These were much 
branched, bent, twisted and in irregular tangles. They 
stained more lighth' than did the Oppler-Boas bacilli. 
The individual segments of these chains were usually nar- 
rower and longer, rarely being less than 30 microns. They 




Fig. 



57. — Yeasts and sarcmae in case of benign retention. 
gram. — (Author.) 



Photomicro- 



took the stain not so evenly as did the Oppler-Boas type 
of organism, and their ends were rather acutely pointed or 
curved. Stained with LugoFs mixture, the Oppler-Boas 
baciUi in this medium were faintly amber. Leptothrix 
were more deeply colored. 

After 48 hours, macroscopicalh^ the culture on the 



EXAMIXATIOX OF GASTRO-IXTESTIXAL FUXCTIOX 219 

cancer medium was so heavy as to render the bouillon 
completely opaque. There was a heavy, coarse, flocculent 
precipitate. On the surface of the medium was a thin, 
grayish- white, superficial pelHcle. The culture had a 
musty odor. Microscopic examination of stained smears 




Fig. oS, — C'ppler-Buus Ixjcilli imm artificial uuiture cancer extract 
bouillon) showing variations in size,, and different groupings. Photomi- 
crogram. — (Author.; 

showed an enormous number of short, thick bacilli in 
small groups and clumps. Their average length was 
4 to 6 microns. They stained rather irregularly, some 
having beaded or club-shaped ends. They seemed dif- 
ferent from another organism present, a bacillus staining 
regularly and 6 to 12 microns long. These occurred in 



220 CANCER OF THE STOMACH 

short chains or singly. These forms were distinctly 
club shaped, the clubbed portion staining rather hghtly 
(vacuole?). When club shaped, these bacilli were always 
single. The smear showed also many round or oval 
sHght vacuolated cocci about 2 microns in diameter. These 
resembled very much the clubbed ends of the bacilli 
above described. Occasionally, one could see a bacillus 
longer than 12 microns, in which the vacuolated clubbing 
appeared at each end. There were a few bacilli in which 
this vacuolation and clubbing occurred in the middle. 
The non-clubbed forms were straight or sUghtly bent rods 
with an average length of 8 microns. They were frequently 
in short chains, arranged at angles to each other, or form- 
ing small loops like a twisted whip-lash. Sometimes the 
long, straight variety was rather obUquely angulated at 
one end. Occasionally, what appeared to be separated 
clubbed ends of bacilli formed large colonies of coccus- 
hke organisms. In these the transition from the clubbed 
end to the coccus form could be seen in all stages. Also 
it would seem that long, straight baciUi were gradually 
changed into the variety with clubbed ends. No yeasts or 
leptothrix were seen. 

Cultures in Beef Bouillon after 48 Hours. — These cultures 
were sUghtly cloudy. There was a coarse, flocculent pre- 
cipitate. They had a sHghtly musty odor. 

Microscopic examination of stained smears showed 
enormous numbers of leptothrix in the form of large, 
single, wa^-y segments, varying in length from 6 to 100, 
plus, microns. Occasionally there was branching, but 
usually end-to-end union occurred. The segments joined 
each other at angles. Sometimes the leptothrix were 
arranged in coarse networks, loosely wound skeins, spirals 
or whorls. They stained very irregularly with resultant 



EXAJVIIXATIOX OF GASTRO-INTESTINAL FUNCTION 221 

light and dark areas alternating. Occasionally, they pre- 
sented a coarsely beaded appearance. Comparatively few 
long bacilli of the Oppler-Boas type were seen. These 
were usually arranged in small groups or occurred singly. 
They varied in length from 6 to 20 microns. They were 
usually straight or slightly curved. Their ends were 
rather blunt or angulated. Xo clubbed- or bulbed-shaped 
ends were seen. Xo vacuolated forms were noted. They 
stained rather ii^regularly. Short chains occasionally oc- 
curred. These were made up of 2 to 4 organisms often 
arranged at sharp angles with each other. Stained with 
Lugol's solution, leptothrix were colored amber-yellow 
with no shade of blue, and took a color somewhat darker 
than do Oppler-Boas bacilli. 

Cultures after 72 Hours. — The growths on cancer 
extract medium were densely opaque and had a faint 
musty odor. Stained specimens showed an abundant 
growth of rods which varied in length from 4 to 18 microns. 
They were arranged singly, in pairs and in angulated 
chains, of from 2 to 5 organisms, or in compact masses. 
The larger rods were often shghtly curved or bent at the 
middle or toward one end. They stained deeph' and 
usually homogeneously. Their ends were commonly 
bluntly rounded, but some were almost square. The 
medium-size or the small rods were most often club 
shaped or bulbed at one end. In this bulbed end was a 
spore-like body which did not stain so densely as does the 
shaft of the rod. These forms were thicker and usually 
single or closely arranged in clumps. A number of round 
or ovoid spore-like bodies appeared irregularly. A few 
curved chains or loop-like strings were seen. These were 
made up of curved or bent bacilH. Xo leptothrix or 
veasts were seen. 



222 CANCER OF THE STOMACH 

Seventy-two-hour Growth in Beef Bouillon. — The medium 
was rather heavily clouded. There was a coarse, granular 
precipitate. Microscopic examination revealed leptothrix 
in dense networks, skeins, whorls and bands. These chains 
were made up of irregularly branching strands or long 
organisms crossing each other in every direction. Occa- 
sionally a bacillus resembling the Oppler-Boas type was 
seen, but no spore-Hke forms or bacilli with clubbed ends 
were found. No yeasts were present. 

Macroscopic Examination of Oppler-Boas Cultures after 
96 Hours. — The cancer extract medium was somewhat 
opalescent. There was a coarse, heavy, granular sticky 
precipitate. 

Beef bouillon cultures were cloudy. There was a thick, 
stringy, gelatinous sediment. 

Microscopic Examination. — Stained smears from the 
cancer medium cultm'es revealed very few long rods. 
Those that were present were shghtly bent or curved in the 
middle and were usually single. Some of the long rods 
were slightly club shaped at one end. They stained 
deeply and had blunt ends. There were manj^ spore-Hke 
bodies that appeared larger than in the 72-hour culture. 
Many of them were elongated and a few were dumb-bell 
shaped. Sometimes these spore-like bodies were joined 
end^to end and formed short chains of from 2 to 3 pairs of 
spores. An occasional leptothrix was seen. It usually 
formed a thin strand. 

Cultures in the beef bouillon medium showed enormous 
numbers of leptothrix. These were single or grouped in 
skeins, whorls, or dense masses. They usually stained 
diffusely. There were no clubbed or dumb-bell shaped 
bodies nor any spore-like structures. With Lugol's solution 
they stained light amber. 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 223 

Macroscopic Examination of Oppler-Boas Cultures after 120 
Hours. — Growths in the cancer medium were cloudy with 
abundant coarse, granular sediment and a rather yeast- 
like odor. 

Cultures in the beef bouillon were very cloudy. On their 
surface was a slimy pellicle. There was a thick, flocculent 
sediment and a strong, rather acid odor. 

Microscopic Examination of Cultures. — Smears from the 
cancer medium revealed an abundant growth of organ- 
isms from 6 to 20 microns long. They were arranged in 
long chains, loose groups or parallel bands. These organ- 
isms were bacilli, and while the majority of them were 
straight, the small ones were slightly curved. There were 
also long bacilli which were curved at the middle and 
occasionally wavy. When they formed chains, the bacilli 
joined end to end at an angle. In the very large bacilli 
there were many with club-like endings. Short chains 
were occasionally seen. These had a zig-zag appearance or 
formed curves or loops. The smaller bacilli sometimes 
showed bipolar staining but as a rule they stained fairly 
deeply and uniformly. The longer bacilli rarely showed 
irregular staining. No spore-like bodies were seen. 

Cultures in beef bouillon showed enormous growth of 
leptothrix arranged in chains, loops, skeins, twists, circles 
or long, single strands. There were many long, slender 
individual segments. These individual organisms appeared 
about half the width of the Oppler-Boas bacilli and varied 
greatly in length, so that without segmentation one might 
stretch across several microscopic fields (high power). 
Where segmentation occurred, the new segment fre- 
quently grew from the main one at a very sharp angle. 
These organisms stained uniformly. There were no bi- 
polar bodies. 



224 



CANCER OF THE STOMACH 



Small individual bacilli were also seen. They were from 
1 to 3 microns in length. Their ends were lance shaped. 
Thej^ were arranged in short chains. They never formed 
whorls or compact masses. There were no spore-hke 
bodies or any organisms that showed bipolar staining. 
No yeasts were seen. 

Table 17 





Total 


Sarcinse 


Yeasts 


O.B. 


Lactic 


Abs. 
Hcl 


Food 
rem- 
nants 


Tumor 


Occult 
blood 


Sarcinae 


71 





36 


65 


20 


31 


42 


56 


48 


Yeasts 


150 
221 


36 
65 



116 


116 



38 
50 


76 
132 


116 

178 


117 
186 


104 


Oppler-Boas. . . . 


172 


Lactic acid 


85 


20 


38 


50 





44 


57 


64 


76 


Ab. free HCl. . . 


180 


31 


76 


132 


44 





130 


128 


120 


Remnants 


194 


42 


116 


178 


57 


130 





146 


142 


Tumor 


208 
202 


46 
48 


117 
104 


186 
172 


64 
76 


128 
120 


146 
142 



147 


147 


Occult blood . . . 






Showing the Clinical Interrelationship Existing between Important Test- 
meal Findings and the Presence of Abdominal Tumor. — (Author.) 

Frequency of Occurrence of Oppler-Boas Bacilli in Gastric 
Cancer. — In 221 consecutive cases of the disease, in our 
series, organisms of the Oppler-Boas type were noted in 
93.6 per cent. Yeasts were associated in 52 per cent, and 
sarcinse in 29 per cent. 

Table 17 has been constructed to summarize the relation- 
ship between the presence of Oppler-Boas bacilli, abdominal 
tumor and main test-meal data. 



EXAMINATION OF SECRETORY FUNCTION OF THE STOMACH 
IN GASTRIC CANCER 

A test-meal is employed. It should be easily prepared, 
palatable and contain essential food elements. We have 
found useful a meal consisting of 

1. Sixty grams of second-day wheat flour bread and 
500 cc. of luke warm water, or, 



EXAMINATION OF GASTEO-INTESTINAL FUNCTION 225 

2. Two shredded wheat biscuits and 500 cc. of luke warm 
water or weak tea (Dock), or, 

3. Sixty grams of zweiback and 500 cc. of luke warm 
water or weak tea. 

Generally, the meal is removed by means of a stomach 
tube at the end of 50 minutes. In instances where the 
stomach's emptying rate is rapid, the test-meal should be 
removed from 20 to 40 minutes after it has been eaten. 

Macroscopic Study of Removed Contents. — In retention 
cases, unless the stomach has been thoroughly lavaged 
before the administration of the secretory meal, the test 
food may not be recognizable, on account of its admixture 
with stagnant gastric residue. In non-retention cases, 
the test-food appears poorl}' chymified, mixed with mucus 
and is often tinged with blood or bile. 

The amount varies. Of course, if gastric retention exists, 
the quantity removed ma}' be even greater than that of 
the test-meal given. In non-retention cases, from 50 cc. 
to 150 cc. are usually recovered. If a gristle-like cancer 
holds open a pylorus, the amount regained may be but a 
few cubic centimeters. 

The odor is characteristic only where retention, hemor- 
rhage or sloughing exists. The gastric extracts may 
then have rancid, flesh}^, or putrid odors. In non-reten- 
tion cases, the odor is not uncommonly of a peculiar, nau- 
seating sweetness. 

Acidity. — In retention cases, the average total acidity of 
the secretory meal was 32. The minimum was 2. The 
maximum was 67. In non-retention cases, the average 
totalacidity was 15. The minimum was 2. The maximum 
was 44. 

Free hydrochloric acid averaged 9.2 in those cases where 
retention had been proved. The minimum was and the 

15 



226 CANCER OF THE STOMACH 

maximum 29. TSTiere retention did not exist, the average 
free hydrochloric acid was 17.4. The minimum was 
and the maximum 73. 

''Combined" acidity averaged 13.2. The minimum was 
and the maximum was 104. In the non-retention 
group, the average combined acidity was 7.1. The 
minimum was and the maximum 27. 

Lactic acid was present in the secretory meal of 34.3 
per cent, of the retention cases and 16 per cent, of the 
non-retention cases. 

Altered (''occult") blood was demonstrated by the 
benzidin or guaiac tests in 68 per cent, of the retention 
cases and in 56.6 per cent, of cases of the non-retention 
group. 

Microscopic examination of the secretory meal revealed 
bacilli of the Oppler-Boas tj^pe in 87.2 per cent, of the 
retention group and in 36 per cent, of the non-retention 
class. 

Gluzinski's Method of Determining Acidity. — In gastric 
cancer or in cases where a peptic ulcer is suspected of being 
carcinomatous, Gluzinski claims that the relative increase 
in acidity after different test-meals aids in the segrega- 
tion of the two conditions. The method is particularly in- 
structive in the cases in which an ulcer is beginning to 
develop cancerous degeneration. The contents of the fast- 
ing stomach are siphoned out in the morning and the 
findings recorded as to amount, color, odor, relics of food, 
blood, etc., litmus reaction, free acid with Congo paper 
and free acid with phloroglucin-vanillin ; lactic acid with 
Strauss or Uffelmann tests, and occult blood with the 
guaiac-turpentine test. The amount of free acid and 
total acid is determined by titration. The microscopic 
findings are also recorded. Then the stomach is washed 



EXAMINATION OF GASTEO-INTESTINAL FUNCTION 227 

out clean with tepid water and an Ewald-Boas test break- 
fast is given. Forty-five minutes later the stomach con- 
tents are siphoned out again and the stomach thoroughly- 
rinsed out anew. The test-dinner is then given: about 100 
grams of chopped roast veal or boiled beef; 150 grams 
potato cooked with 20 grams fat and no fluid. The stomach 
contents are siphoned out anew after 2 hours. All this 
is done on one day. The finding of larger amounts of 
hydrochloric acid after the test-dinner speaks for ulcer; 
smaller proportions, for cancer. The insufiiciency of the 
stomach mucosa is revealed by the lack of acid after the 
test-dinner, even when some acid was found after the 
test-breakfast. Fordo regards such findings as absolutely 
conclusive in dubious cases. He tabulates the findings 
in 26 ulcer cases and comments on the value of the in- 
formation thus derived. In 4 other cases the findings 
proved dubious and the course of the cases showed that 
the ulcer at the time must have been just starting malignant 
degeneration. This procedure is one of much promise, 
and should be tried in doubtful cases as a matter of routine. 
Negative information should never, however, postpone 
laparotomy where the clinical history is suggestive. 

Tests for Gastric Ferments in Gastric Cancer. — Rennin 
and Pepsin. — It would appear that there is still much 
uncertainty as to the inter-relationship existing between 
acidity and ferment activity in gastric ailments. This is 
particularly the case in gastric cancer. It appears that 
proteolysis is closely associated with the presence of free 
hydrochloric acid, so long as the acid concentration is 
below 0.4 per cent., and that milk-curdling ferment follows 
similar laws. In malignancy peptolysis appears to be in- 
creased at the expense of proteolysis. However, Pelosi 
states that in gastric cancer the excess of milk-curdling 



228 CANCER OP THE STOMACH 

ferment and of -the proteid digesting ferment are diag- 
nostic in doubtful cases, where Hcl is absent. It would 
seem that lactic acid bacilli may exist in these cases of 
achlorhydria and that they may be responsible for in- 
creased milk curdling. As we show below (vide Glycyl- 
tryptophan Test), peptid-splitting, enzyme-like agents 
seem to be present in more than 40 per cent, of cases of 
cancer of the stomach. 

Edestin Test ("Peptic Index") of Fuld and Levison. — 
According to these investigators the peptic power of 
gastric juice in cancer of the stomach is diminished. Con- 
firmatory observations have been made by Schryver and 
Singer. Edestin is very difficult to obtain pure, com- 
mercially, but may be made in a well-equipped laboratory. 
The latter's modification of the original test is as follows: 

A pure preparation of edestin may be obtained in the 
laboratory by recrystallization from warm salt solution. 
From this is made a solution of 0.1 per cent, of edestin in 
0.12 per cent, hydrochloric acid {i.e., 30 cc. normal Hcl 
in 1 liter distilled water. Such a solution of edestin need 
not be made freshly for each observation, but that if used 
as stock it must be stored at zero temperature) . Into each 
of 10 small test-tubes 2.5 cc. of this solution are pipetted and 
left to take the temperature of the room (10 to 20° C). 
Into each test-tube is now dropped 0.1, 0.2, 0.3, 0.4, . . . 
to 1.0 cc. (in ascending series) of the gastric juice under 
investigation previously diluted to one-tenth of its natural 
strength. Each test-tube is shaken and left to stand. After 
30 minutes have elapsed 0.3 cc. of a saturated solution of 
sodium chlorid is added to each tube. If digestion has 
proceeded to a certain point, the solution remains clear, 
while with lower degrees of digestion a white cloudiness 
immediately develops. 

The peptic iridex in any case is designated as the number 
of tenths of a cubic centimeter of a diluted juice added to the 
first clear test-tube and divided into 100. This gives as a 
range of possible readings the ten numbers 100 (i.e., 100/1), 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 229 

50 (i.e., 100/2), 33 {i.e., 100/3), 25, 20, 17, 14, 12, 11 and 
10. For greater accuracy intermediate amounts of diluted 
gastric juice may be added, as 0.125, 0.150, 0.175 (between 
0.1 and 0.2), etc., but with practice it becomes possible to 
read such intermediate numbers without recourse to actual 
experiment. The average of healthy cases is about 50. 
Cases do occasionally present themselves with an index 
above 100 (i.e., in which even the test-tube containing only 
0.1 cc. of diluted juice remains clear on the addition of the 
salt solution). In such instances recourse must be had to 
the use of more diluted juice. At the other extreme, how- 
ever, it is seldom necessary to take readings below an index 
of 10 (i.e., in which even the test-tube containing 1.0 cc. 
of diluted gastric juice develops cloudiness on the addition of 
salt solution), for in such cases our experience seems to show 
that digestive power is probably almost absent. 

We have examined 108 cases of gastric disease by the 
method of Fuld and Levison. The results thus far ob- 
tained would appear to indicate that early and advanced 
cases of carcinoma where free hydrochloric acid is low 
exhibit high peptolysis and low proteolysis. In benign 
peptic ulcers both peptolysis and proteolysis are low, if 
acids are reduced. 

Formol Index. — We have made observations upon 827 
instances of gastric disease for the detection of specific 
ereptases in stomach juice. We have used the modifi- 
cation of the formaldehyde titration method of Sorenson 
and Schiff, suggested by Schryver and Singer. 

Method. — 20 cc. of a filtered 5 per cent, solution of Witte's 
peptone are mixed with 1 cc. of the filtered juice under 
examination. Another sample of a similar solution is 
mixed with 10 cc. n/10 sodium hydroxide solution, to 
which is also added 1 cc. of the gastric juice. Similar 
mixtures without addition of juice are kept as controls, 
and all the 4 samples are incubated for 20 to 24 hours at 
37°, with the addition of 1-2 cc. of toluene to prevent 



230 CANCER OF THE STOMACH 

putrefaction. After removal from the incubator, each 
sample was treated with 10 cc. of 40 per cent, formalde- 
hyde solution (commercial formalin), previously neu- 
trahzed to phenolphthalein by sodium hydroxid, and con- 
taining, therefore, some of the indicator (about }i cc. of 
0.5 per cent, solution of phenolphthalein in 50 per cent, 
alcohol to each 10 cc. of formahn). The formaldehyde- 
peptone mixture was then immediately titrated. 

In our experience, the average formol titration index in 
87 instances of operatively proved gastric cancer was 22.3; 
the average index in 22 cases of ulcus carcinomatosum 
19.8; the average index in 99 cases of duodenal ulcer, 12.4; 
of 57 cases of benign gastric ulcer 11.6; of 32 cases of 
benign achylia gastrica, 14.1; of 16 instances of pernicious 
anemia, 14.5 and 5 cases of cancer of the liver, 4.25. It 
would appear that, in certain cases, the estimation of the 
ereptic power of gastric juice toward peptone solutions is 
of considerable value when interpreted in the light of 
other clinical findings. 

Glycyltryptophan Test. — Various workers, notably Miil- 
ler, Fischer, and Abderhalden have reported that malig- 
nant neoplasmata contain certain peptidolytic enzymes. 
This discovery appeared to have clinical value when Neu- 
bauer and Fischer announced that simple peptids, par- 
ticularly the dipeptid, glycyltryptophan, were hydrolyzedby 
cancerous ferments. In the case of glycyltryptophan the 
amino-acid tryptophan, which is liberated by this cleav- 
age, can be recognized readily in acid solution by the 
rose-pink color occurring on the addition of bromine. This 
reaction forms the basis of the ^'glycyltryptophan test" 
for cancer of the stomach, advanced by Neubauer and 
Fischer. 

Clinicians generally have disagreed widely on the 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 231 

actual value of the test. The reaction's sponsors, together 
with Lyle and Kober and Weinstein, early reported en- 
thusiastically on the procedure. Later observers, es- 
pecially Warfield, Oppenheim, Kohlenberger and, most 
recently, Sanford and Rosenbloom, declare that the test 
is of dubious value. They admit that while certain cases 
of cancer of the stomach undoubtedly give the reaction, 
many non-malignant gastric disturbances give similar 
tests. Factors claimed to influence the reliability of the 
reaction are swallowed saliva and bacteria, bile or blood in 
the gastric extracts, low or absent free hydrochloric acid 
and regurgitated duodenal contents. 

In October, 1911, Weinstein announced that he had 
improved on the Neubauer and Fischer test. He stated 
that in extracts from cases of carcinoma ventriculi there 
exist free amino-acids, notably tryptophan, and that the 
latter can be tested for directly with bromine. This pro- 
cedure appeared to render unnecessary the addition of 
glycyltryptophan to such gastric contents, with search for 
its cleavage products subsequently. This so-called 'tryp- 
tophan test" was claimed as a reaction pathognomonic 
of cancer of the stomach. Weinstein did not, however, go 
so far as to state just how early in the progress of the 
disease this test could be regarded as pathognomonic. 
Certainly, in the clinical cases which he briefly quoted, 
when the tryptophan test was positive, other evidences 
of cancer were not lacking. Recently Hall and William- 
son and Sanford and Rosenbloom have recorded ob- 
servations which appear to indicate that Weinstein's 
test has even less value than, in their experience, had the 
glycyltryptophan test. 

We have tested more than 1,400 gastric extracts for 
the glycyltryptophan and the tryptophan reactions. On 



232 CANCER OF THE STOMACH 

1,175 different individuals, the gastric extracts were tested 
according to the modification of the glycyltryptophan 
and the tryptophan tests recently suggested by me. 
This modification appears to have the advantages of 
requiring less of the test ingredients than the Neubauer 
and Fischer method, of being a controlled procedure, 
and one in which the end-reaction may be easily deter- 
mined. It is our purpose at this place to include our 
experience with the cases tested by this uniform method. 
The test is set up as follows: 

Test-tubes of 10 cc. capacity are employed. These 
should be carefully cleaned with boiling water and dried 
inside. They are numerically marked for identification 
with a wax pencil. Into each test-tube is carefully meas- 
ured, by means of a sterile graduated pipette, 0.5 cc. of the 
glycyltryptophan solution. Five cc. of the recently se- 
cured filtered gastric extract are then measured by a clean, 
graduated pipette and poured into the correspondingly 
numbered test-tubes to which glycyltryptophan solution 
has already been added. Two control tubes are used. In 
one is placed 0.5 cc. of glycyltryptophan solution and 5 cc. 
of normal salt solution, and into the other is placed 5 cc. 
of normal salt solution, without adding glycyltryptophan 
solution. In the entire series, each tube next receives 0.5 
cc. of toluol (toluene, Merck). The contents of the 
tubes are then mixed by inverting several times. The 
tubes are next placed in a water-bath (an incubator may be 
used) at 37° C. for 24 hours. 

At the expiration of the incubation period, the test- 
tubes are removed from the water-bath. Clean test-tubes 
of 10 cc. capacity and numbered to correspond with the 
gastric extracts tested, as well as the controls, are set in 
racks. Into each of these tubes is measured by means of a 
graduated pipet, 2 cc. of the glycyltryptophan-gastric- 
extract mixture lying below the toluol in the recently 
incubated tubes. To each tube are then added 3 drops 
of a 3 per cent, glacial acetic acid in distilled water solution. 
The tubes are well shaken. Bromine vapor is allowed to 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 233 

flow in each tube until it appears amber-yellow above the 
contained fluid. The tubes are again shaken. Examina- 
tion by daylight (preferred) or by white, artificial light is 
now made for evidences of the characteristic rose-pink 
reaction between the amino-acid (tryptophan) and the 
bromine. 

Tryptophan Test. — -As, suggested by Weinstein, this is 
made, as routine, on the fresh gastric extracts, inasmuch as 
occasionally, swallowed saliva, amino-acids, regurgitated 
duodenal contents and the like may give the bromine 
vapor reaction, before incubation or without the addition 
of a dipeptid such as glycyltryptophan. Five cc. of 
each fresh, filtered gastric extract are poured into test- 
tubes of 10 cc. capacity acidulated with the 3 per cent, 
acetic acid solution and treated with bromine vapor as 
above. If no characteristic rose-pink color results, the 
tubes are incubated with the corresponding specimens that 
have been mixed with glycyltryptophan solution. For 
accurate work it has seemed best to us to cover these 
''tryptophan test" contents with a layer of toluol. At the 
end of 12, 24 and 48 hours, note is made of changes in color, 
and these results are compared with those obtained with 
the preparations in the first series. 

Certain precautions taken in the manipulation of the 
reaction might be mentioned briefly. All glassware was 
boiled in distilled water and dried before using. The 
solution of glycyltryptophan employed was obtained, in 
bulk and unopened, direct from the makers. To guard 
against its tendency to crystallize out in cold solution, 
the preparation was kept in a water-bath at 37° C. until 
used. All gastric extracts were carefully filtered be- 
fore testing, and the tests were set up within 2 hours, at 
the outside, from the time the contents were taken from 
the patients. In testing for tryptophan, before or after 
incubation, bromine vapor was preferred over bromine 
water. It is more readily controlled quantitatively and 
permits of better color determination. All end reactions 
were read by daylight. 



234 



CANCER OF THE STOMACH 



Typical Reactions. — When bromine vapor is used for the 
detection of amino-acid (tryptophan), its presence is indi- 
cated, even in small amounts, by lilac-violet to rose-pink 
shades. The color is usually a lively one, and appears 
quickly. Admixtures of much blood and bile produce, 
respectively, dirty, brownish-yellow and muddy green 
to drab. In such, gradations in shade are impossible. 
High organic acidity often gives rich purple or magenta 
hues. When the color change is opalescent, with bluish 
or delicate lilac cast, the results may be classed safely as 
negative. 

Results. — The gross results of our observations are as 
follows: Of 1,175 gastric extracts from individuals with 
gastric symptoms, clinically, 110, or 9.36 per cent., were 

Table 18 



Diagnosis 



Number 
of cases 



Diagnosis 



Number 
of cases 



Carcinoma ventriculi 

Ulcus ventriculi 

Carcinoma of the liver. . . . 

Ulcer of duodenum 

Non-malignant pyloric ob- 
struction 

Cholecystitis 

Gall-stones 

Hypochlorhydria 

Achlorhydria 



31 
9 
3 
3 

1 

11 

6 

7 
11 



Achylia gastrica 

Appendicitis 

Primary anemia 

Syphilis — stomach 

Various (gastritis, gastric 
neurosis, chronic diarrhoea, 
epilepsy 



Total. 



10 



110 



Summary of Cases giving Positive Glycyltryptophan Test. — (Author.) 

Table 19 



Diagnosis 


Number 
of cases 


Diagnosis 


Number 
of cases 


Carcinoma ventriculi 


I 

3 
1 
3 


Appendix lesions 


1 


Ulcus ventriculi 


Various (neuroses, achlor- 
hydria, arteriosclerosis) . . 

Total 




Ulcer duodenum 


Q 


Carcinoma of the liver 

Gall-stones 


24 











Summary of Cases giving Positive Tryptophan Test. — (Author.) 



EXAiVIINATION OF GASTKO-IXTESTINAL FUNCTION 235 



Table 20 



Case 
No. 



Diagnosis 



Total Free 
acidity HCl 



Blood 



Bile 



Lactic ^?sre« 
of re- 
action * 



acid 



61563 Gall-bladder infect 

9532 Anemia (post, mort.) 

61743 Duodenal iilcer — opr 

61000 GaU-bladder 

61795 Gastritis chr 

61857 Carcinoma stom. — opr 

61802 Gastritis; chr. append 

38406 Gall-bladder infect 

53228 Gastric neurosis 

61852 Carcinoma of stomach 

61910 Carcinoma of stomach — opr. 

61812 Epilepsy 

61940 Gastritis — chr 

61862 Gastric neurosis 

61974 Gastritis — alcoholic 

62100 Carcinoma of stomach — opr. 

62171 Carcinoma of stom. — opr. . . 

62086 Gastritis— chr 

62089 Gastric ulcer. 

62219 Carcinoma of stom. — opr. . . 

62154 Carcinoma of stom. — opr. . . 

62233 Carcinoma of liver — expl. . . 

62260 Pyloric obstr., non-mahgnant 

62399 Carcinoma of stom. — opr. . . 

53032 Duodenal ulcer — opr 

62562 Carcinoma of gall-bl. opr.. . . 

62665 Gastric ulcer 

37124 Carcinoma of stom. recur. . . 

61072 GaU-stones — opr 

62876 j Cholecystitis 

62912 Chr. ap. opr 

62971 Chr. ap. opr 

62977 Ulcer of stomach 

63026 Chr. appendicitis 

63051 Neg. stom. ap 

63093 Chr. diarrh. stom. — neg 

63129 Stom. ulcer and G. B. — opr. . 

63130 Chr. app. — opr 

62699 Cholangitis 

63030 Carcinoma of stomach 

63241 Carcinoma of stomach — opr. 

63292 Gastric ulcer 

63197 Multiple sclerosis 

63335 Duod. ulcer; cholecyst 

52034 Recurrent ca. of stomach . . . 

62876 Syph. stom 

63506 Gastritis 

63547 Resect, stom. ca 

63562 Arteriosclerosis 

63600 Appendicitis — neg 

63616 Appendix and G. B. — opr. .. 

63653 Ulcer stom. — opr 

63636 Gall-stones — opr 

63778 Carcinoma of stom 

36634 Ulcer of stom 

63383 Gall-stones — opr 

64057 Hypochlorhydria 



46 



86 

46 

14 



4 

6 

18 

4 



10 

24 

40 



20 

48 

10 

40 

24 

8 

24 

40 



50 

6 

28 

8 

56 

10 

22 

22 

48 

32 

36 

4 

32 





8 

56 

46 

20 

48 

10 



38 





44 

12 

32 

22 

14 

40 

6 



36 


80 

40 
6 




18 



10 

24 

30 





40 

12 


24 

32 


50 


28 


40 


18 


40 

32 

32 


30 




18 

46 
6 

40 



22 



40 


28 



30 



+ 
+ 



+ 

++ 
+ 



+ 
+ 

++ 
+ 





+. 
+ 




+ 



+ + 

Tr. 

+ 
Tr. 





Tr. 
Tr. 





-f- 





+ 


Tr. 

+ 
+ 



+ 




+ 





Tr. 

+ 
+ 


+ 






+ + 





+ 






+ . 



++ + 
+ 




+ + 



+ 
+ 
+ 



+ 
+ 
+ 

Tr. 

+ + 

+ 


+ 
-t- 








+ 
+ 
+ 

-1- 


+ 
+ 



+ 
+ 




+ 




+ + 











? 





++ 






+ 

+ 

++ 
































? 








+ 








+ 
+ 

+ 

+ 
++ 

+ 

++ 
++ 
++ 

+ 
++ 

+ 

+ 
+++ 

+ 

+ 

+ 

+ 

+ 

++ 
++ 

+ 

+ 

+ 

+ 
+ + 

+ 

+ 
+++ 

+ 

+ 

+ 

+ 

+ 

+ 



+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 



236 



CANCER OF THE STOMACH 

Table 20 — (Continued) 



Case 
No. 



64039 
61915 

64270 
64330 
64360 
64482 
64455 
64281 
34078 
64877 
65179 
65229 
65293 
65337 
37889 
65693 

22528 
65703 
65835 
65901 
5231 
65953 
66017 
66108 
66225 
64942 
66314 
66333 
66409 
66462 
56586 
66466 
63547 
66511 
66583 
66644 
66787 
66904 
66855 
66864 
67000 
45833 
67110 
67112 
67077 
67206 
67295 
67368 
67690 
67298 
67562 
67537 



Diagnosis 



Total 
acidity 



Free 
HCl 



Blood 



Bile 



Lactic 
acid 



Achlorhydria 

Hypochlorhydria 

Ulcer of stom. — opr 

Carcinoma of stomach 

Neurosis 

Care, of stom. — resect 

Hypochlorhydria 

Achylia gastr 

Neuroses 

Cholecystitis 

Appendicitis 

Ca. of stom. and liver 

Achlorhydria 

Cholecystitis, appendix 

Appendicitis — opr 

GaU-stones, and appendix- 

opr 

Duod. ulc. — opr 

Degen. gast. ulc 

Gen. care. prim. stom. . ; . . . . 

Carcinoma of stom 

Achlorhydria 

Achlorhydria 

Carcinoma of stom. ....... 

Gall-stone — opr 

Pernicious anemia 

Second, anemia 

Cholecystitis 

Gall-stones, — opr 

Achlorhydria 

Gastric ulcer 

Carcinoma of stom. — recur.. 

Achlorhydria 

Carcinoma of stom. — resect.. 

Achlorhydria 

Cholecystitis 

Carcinoma of stom 

Achlorhydria 

Achlorhydria 

Carcinoma of stom. — opr.. . . 

Hypochlorhydria 

Deg. gast. ulc 

Hypochlorhydria 

Cancer of stomach 

Gastric neurosis , 

Care, of liver and spleen 

Carcinoma of stom , 

Hypochlorhydria 

Carcinoma of stom 

Pernicious anemia 

Carcinoma of stom. P.A. (?). 

Gall-stone — opr 

Expl. carcinoma of stom 





4 

50 

14 

54 

8 

4 



42 

4 

36 



8 

16 

12 

38 



12 
30 

8 
40 
10 
30 
10 
20 
26 
48 
48 
12 

4 
50 
12 
20 
34 
26 
12 
26 

8 
20 
38 
80 
14 
18 
50 

4 
14 
12 
20 




4 

46 


50 




40 


26 




12 

14 











30 



26 

48 




50 




26 

12 

26 
8 


24 

80 

8 

50 










+ 
+ 



+ 

+ 
+ 





+ 





Tr. 

24 



+ 



+ 



+ 




+ 
+ 
+ 




Tr. 






Tr. 
Tr. 

+ 

+ 

+ 

+ 

+ 






Tr. 

+ 



+ 












+ 







Tr. 

+ 

Tr. 




+ 





























+ 





+ 











+ 

















+ 


































































































+ 














+ 





+ 











+ 
























Degree 
of re- 
action * 



+ 
+ 

+ 

+ 
+ 
+ 

+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 



Clinical and Laboratory Data of the Cases Returning Positive Glycyltryptophan Test 
(Author') . 

* Degree of reaction: Lilac equals +; rose-pink equals +-1-; rose-purple equals -l--f 4-. 



EXA^IIXATIOX OF GASTRO-IXTESTIXAL FUXCTIOX 237 

glycyltryptophan positive. In the same cases. 24. or 
2.0-i per cent, were tr^-ptophan positive, either before or 
after incubation. Tables 18 and 19 show, respectively, 
the number of positives with each test, associated with 
different diseases. Tables 20 and 21, respectively, con- 
sider the clinical and laboratory data. 

It will be noted that one of the valuable features of 
the tables is the fact that the majority of the cases ex- 
hibiting positive reactions were treated sui'gically; hence, 
the conclusions derived from consideration of the figm^es 
returned have a fahly definite pathologic basis. 

Tahle 21 



No. 



Diagnosis 



Total Free 
acidity HCl 



Blood 



BUe 



Lactic 
acid 



Degree 
of re- 
action* 



67644 Achlorhydria 4 

61508 Stom. neg j 36 

61496 Duod. ulcer — opr 56 

61567 : Gastric ulcer 42 

61552 Carcinoma of stom. — inop . . 38 

62223 CarcLQoma of liver and G.B. 24 

62784 Gastric \ilcer — clin 12 

62876 Achlorhydria and G.B 10 

62865 Appendix, chronic 24 

63051 Gastric neurosis 36 

63230 Carcinoma of stom. (mass) . . 8 

63241 Care, of stomach (resect.) — 58 

63221 GaU-stone empyema G.B 20 

63414 Duodenal ulcer — opr 80 

63408 Carcinoma of stom. — opr ... 66 

63653 Gastric ulcer — clin, 32 

63354 Tabes — crises 4 

63563 Arteriosclerosis — gen 

63536 GaU-stone— opr 22 

64394 Duodenal ulcer— opr 66 

64294 Carcinoma of stom. — opr. . . 14 

65693 Gall-stones and append — opr. 38 

5231 Gastric ulcer degen. post-opr. 8 

56586 Carcinoma of stom. — recur. . 48 

67112 1 Gastric neurosis 3S 









36 





38 





20 





18 


-f 


24 


-j- 


12 


4- 





_!_ 


18 


Tr. 


32 











18 


-{- 


20 





80 





60 





28 


Tr. 





-f- 














60 





4 


— 


14 


■b 














24 









Tr. 













CUnical and Laboratory Data of the Cases Eeturiiiiig Positive Trj-ptophan Test 
(Author) . 

'^ Degree of Reaction: Lilac equals — ; Rose-pink equals — — ; rose-purple equals -r-r + . 



Cancer. — The total number of proven cases of cancer 
of the stomach, primary or secondary, in this series is 87. 



238 CANCER OF THE STOMACH 

Of this number, 31 or 35.6 per cent., gave positive gly- 
cyltryptophan tests, while 7, or 8.04 per cent, were tryp- 
tophan positive. Of the 31 cases of cancer, in which 
the giycyltryptophan test was positive, the tryptophan 
test was positive but 7 times. In 3 cases in which the 
tryptophan test was positive, the giycyltryptophan test 
was negative. 

Of 9 gastric ulcers with fair evidence of carcinomatous 
degeneration (of the type described by MacCarty), two, 
or 22.2 per cent., gave the giycyltryptophan reaction. In 
these same cases there was no positive tryptophan test. 
If we combine the returns from these cases with those 
from the specimens of advanced carcinoma, we noted that 
the giycyltryptophan test is positive in 39.09 per cent, and 
the tryptophan in 7.28 per cent., or the giycyltryptophan 
test is positive approximately 5}i times as frequently as is 
the tryptophan test. 

Gastric Ulcer. — In none of 35 operated gastric ulcers 
(microscopically carcinoma-free) was the giycyltryptophan 
test positive. The tryptophan reaction was obtained 
once. 

Thirty-nine cases were clinically diagnosed as gastric 
ulcer. Three of these (7.4 per cent.) were glycyltrypto- 
phan-positive, and two (5.2 per cent.) were tryptophan- 
positive. 

Duodenal Ulcer. — Operations were performed on 78 
patients with duodenal ulcers. Of this number, three (2.6 
per cent.) gave giycyltryptophan and tryptophan tests. 
They were not identical cases and the reactions were not 
always associated with low acidity. 

Fifty-seven individuals had duodenal ulcer, clinically. 
One (1.7 per cent.) was glycyltryptophan-positive. None 
gave the tryptophan test. 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 239 



Table 22 



Group 



Number Number 
of posi- of nega- 
tives tives 



Group 



Number } Number 
of posi- j of nega- 
tives ! tives 



Extracts having no 
acidity 

Extracts having no 
free Hcl 

Extracts having di- 
minished Hcl 

Extracts having nor 
mal Hcl 

Extracts having in- 
creased Hcl 



14 
52 
15 
22 



Totals. 



20 

31 

214 

369 

431 



Extracts having de- 
creased T. A 

Extracts having 
normal T. A 

Extracts having in- 
creased T. A 

Totals 



88 

17 

5 

110 



515 

213 

337 

1,065 



Extracts having 
lactic acid 



11 



33 



110 1,065 



The Relation of Gj^lcyltryptophan Test to Acidity. — (Author.) 

Other Gastric Conditions. — It has been advanced by 
Weinstein, Warfield and Sanford and Rosenbloom that 
positive glycyltryptophan reactions are usually obtained 
in gastric extracts exhibiting achylia or low hydrochloric 
acid. These reactions are claimed to result from the 
presence of a peptid-splitting enzyme (Warfield) existing in 
saliva. Gies thinks that mouth-bacteria may be capable 
of splitting simple peptids under these conditions. In 
order to determine the results in our cases from the view- 
point of acidity, we have compiled Tables 22 and 23. It 
will be seen that about 60 per cent, of the positive glycyl- 
tryptophan tests were obtained from extracts showing no 
free hydrochloric acid, while in an additional 13.6 per 
cent., the free hydrochloric acid was low. In other words, 
nearly three-fourths of the positives occurred in gastric 
extracts showing diminished acidity. Table 22 also brings 
out the interesting fact that approximately 80 per cent, of 
the glycyltryptophan reactions were returned by contents 
in which the total acidity was low. 

The support which these figures apparently give to 



240 



CANCER OF THE STOMACH 



Warfield's saliva ferment action on peptids is qualified 
when one considers the negative glycyltryptophan tests in 
Table 22. Fifty-one of these extracts showed no free 
hydrochloric acid. In 214 extracts the free hydrochloric 
content was diminished. The combination of these results 
demonstrates that about one-fourth (24.8 per cent.) of the 
negatives were associated with low free hydrochloric acid. 
It could scarcely be maintained that all these extracts were 
saliva-free. Table 20 shows that some of the extracts 
were from cancerous patients. Approximately one -half 
(48.3 per cent.) of the negative glycyltryptophan tests were 
on extracts with diminished total acidity. 







Table 23 






Group 


Number 
of posi- 
tives 


Number 
of nega- 
tives 


Group 


Number 
of posi- 
tives 


Number 
of nega- 
tives 


Extracts having no 
acidity 

Extracts having no 
free Hcl 


1 
6 
10 
4 
3 


33 

77 
219 
387 

435 

1 


Extracts having de- 
creased T. A 

Extracts having 
normal T. A 

Extracts having in- 
creased T. A 

Totals 

Extracts having 
lactic acid 


17 
2 
5 


586 

228 


Extracts having di- 
minished Hcl 

Extracts having nor- 
mal Hcl 


337 


24 


1,151 


Extracts having in- 
creased Hcl 




2 


42 


Totals 


24 


1,151 1 



The Relation of Tryptophan Test to Acidity. — (Author. J 

A consideration of the relation of the tryptophan test 
to acidity is of interest. Of the positives 7, or 28.9 per 
cent, of the contents contained no free hydrochloric acid. 
In 17 (75 per cent.) of the positives the free hydrochloric 
acid was diminished or absent. This combined figure is 
practically identical with that returned by the glycyltrypto- 
phan positives, although the percentage of extracts con- 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 241 

taining no free acid is mucli lower. In the tryptophan 
positives it will be seen that 75 per cent, showed diminished 
total acidity as against SO per cent, in the case of glycyl- 
trj'ptophan positives (Table 23). 

Studying the negative tr^-ptophan reactions, we note 
that in 329 instances ''28.6 per cent.) there was absent or 
diminished free acid, while in 586 cases (50.8 per cent.) the 
total acidity was low. These figm'es closely approximate 
those shown by the tabulations from the negative gly- 
cyltryptophan reactions. 

It would appear that Weinstein's contention that his 
tryptophan test removes the consideration of contaminat- 
ing sahva as a source of error is not borne out by our 
study. Further, the presence of negative glycyltryptophan 
reaction, in so large a percentage of extracts with low 
acidity, leads one to the opinion that the significance of 
the peptidase, said to exist in sahva, as a factor in hycko- 
lyzing glycyltr^-ptophan added to gastric extracts, is quite 
Cj[uestionable. This opinion is substantiated by our work 
on saUva. (Arch. Int. Med., Dec, 1912, p. 1.) 

Organic Acid. — -Ten per cent, of the positive glycyltryp- 
tophan tests were associated with the presence of lactic 
acid. TVith the exception of one, the cases were carcinoma. 
Thnty-three negative reactions (3.9 per cent.) were in 
contents containing lactic acid. Eight and one-third per cent, 
of the positive tryptophan tests were present in lactic-acid- 
containing extracts, while -12 ('3.6 per cent.) negative 
tryptophan contents contained lactic acid. It would 
seem that organic acids have little bearing on the relative 
variation of the two tests. 

Of the entire number of gastric extracts ('1,175) analyzed 
in this series, 44, or 3.7 per cent., contained lactic acid by 
the controlled L'ffelmann test. Of the cases proved 

16 



242 


CANCEK OF THE STOMACH 
Table 24 






(A) The relation of bile to glycyl- 
tryptophan test 


(B1 The relation of bile to tryptophan 
test 


Groups 


Bile 
present 


Bile 
absent 


Groups 


Bile 
present 


Bile 

absent 


Glycyltryptophan 
positive 

Glycyltryptophan 
negative 


39 
320 


71 

745 


Tryptophan 
tive 

Tryptophan 
tive 

Totals. 


posi- 
nega- 


10 

349 


14 
802 


Totals 


359 


816 


359 816 



The Influence of the Presence of Bile upon the Glycyltryptophan and 
the Tryptophan Tests — (Author). 

to be carcinoma ventriculi, lactic acid was present in 25 
(28.7 per cent.). As we have shown in these cases, the 
glycyltryptophan reaction was positive in 31 (35.6 per 
cent.) and the tryptophan tests in 7 (8.04 per cent.). 
The relatively low percentage of extracts containing lactic 
acid may be explained on the basis of early diagnosis, 
many cases being operated on before marked obstruction 
and retention had developed. Emerson states that 
in his series of cases of carcinoma ventriculi, lactic acid 
was present in approximately 90 per cent. From our 
experience, it would appear that the great majority of his 
cases were far advanced, and exhibited marked retention. 
High mixed organic acidity frequently gives confusing 
U-ffelmann reactions. 

It has been held that the chyle in gastric extracts viti- 
ates the glycyltryptophan test, but need not be considered 
when making the tryptophan test. The presence of bile or 
evidences of tryptic digestion has been used as proof that 
duodenal contents have been mixed with gastric juice. 

The significance of this supposition is shown by analysis 
of Table 24. The gastric extracts were judged macro- 
scopically as to the presence of bile, and were also tested 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 243 



by means of the Pettinkofer or the fuming nitric acid reac- 
tion. It will be seen (a) that of 110 positive glycyltryp- 
tophan reactions, 39 (35.4 per cent.) contained bile; of 
1,065 negative reactions, 320 (20.4 per cent.) showed bile; 
of the 24 positive tryptophan tests; (6) 10 (41.6 per cent.) 
were in bile-containing extracts, while 349 (30.4 per cent.) 
negative tryptophan tests were bile positive. These fig- 
ures do not demonstrate that the tryptophan test is un- 
influenced by chyle in the extracts. It is worthy of note 
that a relatively high number of both glycyltryptophan 
and tryptophan reactions are found in bile-containing 
chyme. 

Table 25 



(A) The relation of blood to glycyl- 
tryptophan test 



Groups 



Bile 
present 



BUe 

absent 



(B) The relation of blood to tryptophan 
test 



Groups 



Bile 
present 



Bile 
absent 



Glycyltryptophan 
positive 

Glycyltryptophan 
negative 



Totals. 



56 


54 


236 


829 


292 


883 



Tryptophan posi- 
tive 10 

Tryptophan nega- 



tive 

Totals . 



282 



292 



14 

869 



883 



The Influence of Blood upon the Glycyltryptophan and the Tryptophan 
Tests— (Author). 



The effect of blood, traumatic or ''occult," in gastric 
extracts has at least two points worthy of consideration with 
regard to the glycyltryptophan and tryptophan tests. 
Traumatic blood of itself gives a tan or definitely red cast 
to filtrates. A color reaction such as we are discussing is 
readily affected by such shades. The second point of note 
is the possibility of tryptophan resulting from split diges- 
tion products of the blood itself, particularly in those cases 
in which there is marked gastric retention with much flora. 



244 CANCEK OF THE STOMACH 

Table 25 furnishes interesting data on the above points. 
In 56 (50.9 per cent.) of the glycyltryptophan positive ex- 
tracts, blood, traumatic or altered (benzidin test), was 
present. Of the glycyltryptophan negative extracts, in 
236 (22 per cent.) blood was demonstrated. Of the 
tryptophan positive extracts 10 (41.6 per cent.) contained 
blood. In 282 (24.6 per cent.) tryptophan negatives, 
blood was proved. These figures for both tests so closely 
approximate that it does not seem possible to state that 
advantage lies with either. The relatively high percent- 
age of positives in extracts containing blood should, how- 
ever, be borne in mind. 

Summary. — 1. In our series, more than one- third of the 
proved cases of cancer of the stomach gave positive 
glycyltryptophan reactions; more than one-fourth were 
lactic-acid positive and about one-thirteenth of the number 
exhibited the tryptophan test. Diagnosis of malignant 
disease of the stomach was in each case quite possible 
independent of the above chemical reactions. As a 
test associated with cancer of the stomach, it will be seen 
that in our series the glycyltryptophan reaction proved 
more consistent than test for existing free amino-acid 
(tryptophan) . 

2. While gastric conditions other than cancer exhibit 
positive glycyltryptophan reactions, in no single class of 
disease of the stomach is this test obtained so frequently 
as in cancer. This fact is of considerable significance 
chemically, and, perhaps, etiologically. While cancer of 
the stomach can doubtless be diagnosticated clinically 
without the glycyltryptophan test, one cannot state that 
the study of this and allied reactions will prove valueless. 

3. Our work does not show that the tryptophan test 
is, as has been advanced, pathognomonic of cancer. 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 245 

4. Low free hydrochloric or total acidity is frequently 
determined in gastric contents exhibiting positive gly- 
cyltryptophan, lactic acid and tryptophan reactions. 
One cannot state positively that this diminished acidity 
is causative. Many cases of low acidity were negative to 
the above tests. 

5. Approximately one-half of the positive glycyltryp- 
tophan and tryptophan reactions were in gastric extracts 
containing bile and blood elements. Approximately one- 
fourth of the negative extracts contained blood and bile 
elements. 

Wolff- Junghans' Test for Soluble Albumin.— Methods 
for the estimation of the soluble albuminous products 
of digestion have frequently been devised with the hope 
that such might prove of practical service in the dif- 
ferential diagnosis of gastric ailments. Of these methods, 
the well-known procedure advanced by Salomon had for a 
time the greatest vogue. Esbach's reagent and tubes 
proved, however, unsatisfactory and inaccurate from a 
clinical viewpoint. More recently the problem has been 
approached from the practical quantitative side and 
encouraging work recorded. 

Wolff and Junghans report a method for estimation of 
the amount of soluble albumin in gastric extracts which 
they claim have given excellent clinical information in 
Ewald's service at the Augusta Hospital, Berlin. 

Theoretically, their procedure has the following basis: 
In the normal aspirated test-meal there are demonstrable 
relatively large quantities of soluble albumin by means of 
precipitating reagents. This soluble albumin appears 
only through the agency of the gastric enzymes. This 
fact is proved by testing for soluble albumin a similar 
test-meal which has been chymified but not swallowed. In 



246 CANCER OF THE STOMACH 

such event, only minute quantities of dissolved albumin 
are present. 

Acting on these observed facts, Wolff and Junghans fed 
similar meals to sets of individuals revealing malignant and 
benign ach3dias. Their work appeared to show that in the 
malignant achylias, aspirated test-meals were rich in 
soluble albumin, while in benign achylias very little of the 
albumin could be demonstrated. 

Three suppositions have been advanced to explain this 
increased volume of dissolved albumin in the malignant 
achyhas. It has been suggested that the excess of albumin 
is due (a) to interference with albuminous resorption; (6) 
to a ''cancer milk" rich in albumin which exudes from 
mahgnant growths, and (c) to a specific, peptid-splitting 
ferment from the neoplasm, capable of carrjdng protein 
digestion as far as the completely soluble albumin stage. 

Clinically, the reaction was shown to be positive in 18 
of a series of 20 gastric cancers and negative in 14 of a 
series of 15 cases of simple achylia in Ewald's service. 
Recently, Rolph has reported positive tests in all of 7 
cases where cancer was present in the stomach or second- 
arily involved that viscus. In 8 cases of benign achyUa 
the test proved negative. Rolph states that gastric 
contents contaminated with blood beyond a dilution of 1 
to 3,000 may give the reaction and cautions against positive 
interpretation in instances where there is high combined 
acid present. In such event peptone is usually present. 
He claims that cancer of the cardia is not so Likely to 
give positive reaction as is cancer in other parts of the 
stomach. 

Author's Study. — In the last 3,950 patients presenting 
themselves for test-meal examination of gastric function 
in his service at the Mayo Clinic, three were 747 instances 



exa:\iixatiox of gastro-ixtestixal fuxctiox 247 

where gastric extracts showed achyUa or were associated 
with conditions confusable with malignancy. These 
gastric extracts were all tested by him for soluble albumin 
by the Wolff -Junghans" method. Records were kept of 
the association of the results of this test with other test- 
meal and clinical findings. When the tabulations were 
com.pleted the diagnoses were entered on the daily sheets. 
In 78.4 per cent, of cases it was possible to obtain check 
upon diagnoses by operation. 

Preparation for Test — The day previous to the examina- 
tion of his gastric extract the patient was given 1 ounce of 
castor oil at 4 p.m. This was followed at 6 p.m. by a 
motor test-meal consisting of mixed food. At 7 p.m. 
twenty raw. seedless raisins were given. Twelve hours 
later (7 a.m. the following morning) the patient was fed 
60 grams of second-day bread and 200 cc. of water. This 
secretory test-meal was removed from 50 to 60 minutes 
after administering. The specimen secured was thor- 
oughly mixed, filtered through double hydrochloric-acid- 
washed papers, and tested for dissolved albumin within 
an hour of its being obtained from the stomach. On 
account of the fact that, as had been shown in this chnic, 
but 52.2 per cent, of cases of gastric cancer jdeld gastric 
extracts reveahng absence of free hydrochloric acid, and 
that in 15.7 per cent, of cases, free hydrochloric acid 
ranges between 20 and 50 per cent., we deemed it ad- 
visable to apply the test for soluble albumin not only to 
achyhas but also to gastric extracts where the free hy- 
drochloric acid was below 20 per cent. In a few instances 
of suspected mahgnant ulcer we have performed the test 
upon gastric extracts with higher free hydi^ochloric acid 
content. In such we have been fully alive to the possi- 
bilities of error, but for the purpose of gaining informa- 



248 CANCER OF THE STOMACH 

tion and for comparison we have deemed it wise to make 
the test. 

Mode of Procedure. — Six absolutely clean test-tubes are 
required for each test. Those of the narrow type and of 
20 cc. capacity answer very well. The tubes are numbered 
serially from 1 to 6. They receive respectively 1 cc, 
0.5 cc, 0.25 cc, 0.1 cc, 0.05 cc and 0.025 cc of the 
filtered gastric extract. These amounts are readily meas- 
ured by means of a 1 cc pipette, graduated into Koo's cc 
By means of a 10 cc pipette, graduated into Koo's cc, 
the volume in each test-tube is next consecutively brought 
up to 10 cc. volume with distilled water. This gives from 
the tubes 1 to 6 dilutions of gastric juice varying re- 
spectively from 1 to 10 to 1 to 400 (viz., 1 to 10, 1 to 20, 
1 to 40, 1 to 100, 1 to 200, and 1 to 400). These figures 
we have termed ''units" of precipitable albumin. The 
tubes are then inverted several times to insure complete 
mixture of their contents. One cc. of the reagent to pre- 
cipitate the albumin in solution is then carefully layered 
upon the contents of each tube. The precipitating re- 
agent suggested by Wolff has proved satisfactory with us. 

It has the following formula: 

Phosphotungstic acid (puriss) 3 cc . 

Hj'drochloric acid (concentrated) 10 cc. 

Alcohol (96 per cent.) . 200 cc. 

Aq. dest .q. s. ad. 2000 cc. 

Mix and keep in a glass or rubber-stoppered flask in a cool place. 

Manifestation and Interpretation of the Test. — If there 
has been dissolved albumin in any of the tubes, the junction 
of the Wolff reagent with the diluted gastric extracts is 
marked by a pearly white zone or ''ring." This is better 
brought out if the tubes are inspected against a black 
background. (We have used a piece of black cloth such 
as photographers employ when focussing cameras). The 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 249 

tubes should be inspected at once after adding the Wolff 
solution. Prolonged standing allows cloudy zones to form 
which render comparative interpretation dubious. 

We have interpreted our results after Wolff and Jung- 
hans' suggestion. If the white ring of precipitated albumin 
appears in tubes 1, 2 and 3 (namely, units of albumin 
from 10 up to 50) and no further manifestations are present 
in the remaining three tubes we have called the test negative. 
If tubes 1, 2, 3 and 4 exhibit rings (units of albumin from 
10 to 100) we have considered the reaction suspicious. The 
presence of white rings in tubes 1, 2, 3, 4, 5 and above (units 
of albumin ranging from 10 to 200 to 400) we have taken to 
denote a positive test. 

Results, — The gross results of our work were as follows: 
Of 747 gastric extracts of the class described above, 318 
(42.6 per cent.) gave 200 to 400 units of precipitable 
albumin; 112 (15.7 per cent.) exhibited 100 units, and 
317 (42.4 per cent.) showed less than 100 units. In this 
grouping 71.5 per cent, of the gastric extracts were from 
cases showing some degree of gastric retention. 

Consideration of Cancer Cases. — There were 215 cases of 
operatively and pathologically demonstrated gastric car- 
cinoma in this series. In 141 (65.1 per cent.) units of 
precipitable albumin ranged from 200 to 400. In 29 
instances (13.4 per cent.) there were 100 units of albumin 
shown. Combining the returns it is evident that 170 
(78.5 per cent.) of the proved cases of gastric cancer gave 
either undoubtedly positive or suspiciously positive Wolff- 
Junghans' test. In 45 cases (21 per cent.) the test was 
negative, less than 100 units of precipitable albumin 
being demonstrated. Of this group of 215 cases of gastric 
cancer, 73.2 per cent, exhibited some grade of motor 
stagnation. 



250 CANCER OF THE STOMACH 

Gastric extracts from 15 cases of ulcus carcinomatosum 
were tested. In 11 instances (73.3 per cent.) units of 
precipitable albumin ranged between 200 to 400. In 3 
(20 per cent.) 100 units were shown. In other words, of 
the 15 cases of malignant gastric ulcer, 14 (93.3 per cent.) 
were either definitely positive or suspiciously so to the 
Wolff-Junghans' test. One case (6.6 per cent.) exhibited 
below 100 units of albumin. In this group, motor stagna- 
tion of some degree was present in 86.6 per cent. 

Combining the results from the cases of frank gastric 
carcinoma and those of ulcus carcinomatosum, it is seen 
that of a total of 230 cases, 184 (80 per cent.) returned 
positive or suspicious Wolff-Junghans' test. 

Relation of Manifestations of Test to Location of Malignant 
Process. — ^We examined gastric extracts from 10 cases 
of cancer involving the cardia. Six cases (60 per cent.) 
gave positive test, 1 (10 per cent.) was suspicious, and 3 
(30 per cent.) were negative. Thus 70 per cent, of our 
cases of cancer at the cardia showed units of precipitable 
albumin ranging from 100 to 400. 

There were 5 cases of cancer of the fundus in our series ; 
1 (20 per cent.) was positive, 1 (20 per cent.) was doubtful, 
and 3 (60 per cent.) were negative. 

We have records of 44 cases where the neoplasm involved 
mainly the lesser curvature of the stomach. Of this group, 
33 cases (75 per cent.) gave clearly positive Wolff-Junghans' 
tests, 4 (9.1 per cent.) were supicious, and 7 (15.8 per cent.) 
were negative. It is evident that 84.1 per cent, of cancers 
involving the lesser curvature show units of precipitable 
albumin ranging from 100 upward. 

In our series there were 3 cases of cancer of the greater 
curvature. Two cases (66.6 per cent.) were positive and 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 251 

the remaining case suspicious. Thus all showed 100 plus 
units of albumin. 

Eight of our cases were proved to have cancer involving 
mainly the posterior wall of the stomach. Of this group 
but 3 cases (37.5 per cent.) were positive to the test, while 5 
cases (62.5 per cent.) were negative. 

The pars media was involved 14 times. Of this number, 
11 cases (78.5 per cent.) gave positive tests and 3 cases (21.5 
per cent.) were negative. 

In 93 instances the malignant growth was at the pylorus 
and antrum. In this class, 59 cases (63.4 per cent.) 
showed units of precipitable albumin from 200 upward, 8 
cases (8.6 per cent.) were suspicious, revealing 100 units, 
and 25 cases (26.9 per cent.) were negative. In other 
words, 72 per cent, of the cancers at the pyloric region gave 
positive or suspicious Wolff-Junghans' tests. 

Our series includes 38 cases where the stomach showed 
general or extensive malignant involvement. In 26 in- 
stances (68.5 per cent.) the test was positive, in 3 cases 
(7.9 per cent.) it was suspicious, while 9 times (23.6 per 
cent.) negative results were obtained. 

Comparison of Other Test-meal Findings in the Cancer 
Cases with the Wolff-Junghans' Test. — It might be profitable 
here to emphasize the diagnostic relation of other tests 
associated with that for dissolved albumin in the gastric 
extracts from our malignant cases. It will be noted above 
that of the 230 cancer and malignant ulcer cases the Wolff- 
Junghans' test was positive or suspicious in 184 (80 per 
cent.). In this same group of cases, free hydrochloric acid 
was absent, in 52.2 per cent., lactic acid was demonstrated 
in 48.8 per cent., '^occult" or altered blood shown in 75 per 
cent., glycyltryptophan test present in 40 per cent. (141 
cases), the average formol index (method of Sorenson and 



252 CANCER OF THE STOMACH 

Schiff) was 21 (57 cases), and organisms of the Oppler- 
Boas group were demonstrated in 93.8 per cent. (146 
cases) by the colored agar method. Some degree of 
gastric retention was shown in nearly 74 per cent, of the 
entire group of cancer cases, irrespective of the location of 
the growth. 

The Wolff-Junghans^ Test in Extragastric Cancer: Liver 
and Gall Tract. — Our series includes 15 instances of malig- 
nancy in these locations. In 5 cases (33.3 per cent.) the test 
was positive, in 3 cases (20 per cent.) it was suspicious, and 
in 7 cases (46.6 per cent.) it was negative. Thus 8 cases 
(53.3 per cent.) of extragastric malignancy showed units of 
albumin from 100 upward. Some degree of motor stagna- 
tion was evidenced in 26.6 per cent, of these cases. 

The pancreas was the seat of malignant processes 3 
times. In no instance was a positive Wolff-Junghans' test 
obtained. Motor defect was not noted in any of these cases. 

There was 1 case of cancer of the transverse colon. It 
gave a negative test. There was normal gastric motility in 
this case. 

Gastric Syphilis.- — -We have tested gastric extracts for 
dissolved albumin from 5 cases. The reaction was positive 
in 2 instances (40 per cent.), suspicious in 1 (20 per cent.), 
and negative in 2 (40 per cent.). In one of the positive 
cases the specific process in the stomach was associated 
with multiple and exuberant ulceration. Gastric motility 
was interfered with in 1 case (20 per cent.) of this group. 

Primary Anemias {Mainly Pernicious). — Twenty-four 
cases of achylia in severe anemia comprise this class. In 
none of them was gastric stagnation present. Twenty- 
three (95.6 per cent.) of this group were negative to the 
Wolff-Junghans' test. In but 1 instance (3.3 per cent.) 
were the units of perceptible albumin above 200. 



EXAMINATION OF GASTEO-INTESTINAL FrNCTION 253 

Simple Achylia Gastrica.- — We examined gastric ex- 
tracts from 35 such cases. Gastric stagnation was proved 
in 4 cases (11.9 per cent.). In 22 instances (63 per cent.) 
of this tj^e of achylia the test was negative, in 9 instances 
(25.9 per cent.) suspicious,, and positive but 4 times (11.9 
per cent.). 

Ackylorhydria. — In addition to the cases of absent 
free hych'ochloric acid mentioned in the above groups there 
were 212 cases of non-malignant cUsease showing achylor- 
hydi'ia. Gastric motility was impahed in 22 cases (10.3 
per cent.). In this group 136 cases (64.1 per cent.) were 
Wolff -Junghans^ negative, 41 cases (19.3 per cent.) were 
doubtful, and 35 cases (16.5 per cent.) were positive. 

Simple Gastric Ulcer. — A number of cases of this affec- 
tion and of duodenal ulcer were stucUed for purposes 
of comparison with maUgnant disease. Their gastric 
extracts generally showed low free hydrochloric acid 
content. We tested extracts from 33 cases of operatively 
demonstrated gastric ulcer for dissolved albumin. In 
16 cases (48.4 per cent.) units of albumin ranged above 
200, in 6 instances (18.1 per cent.) the units ran as high as 
100, while in 11 cases (30.3 per cent.) units of albumin 
were below 100. It is thus apparent that 66.5 per cent. 
of the proved cases of simple gastric ulcer were positive 
or suspicious to the Wolff- Junghans' test. Gastric motiht}' 
was delayed in 39.4 per cent, of this group. 

Duodenal Ulcer. — Gastric extracts from 18 cases of 
duodenal ulcer were tested. In 12 cases (66.6 per cent.) 
units of albumin ranged above 200, in 2 cases Ql per 
cent), at least 100 units were present, while 4 times (^22.7 
per cent.) less than 100 units were demonstrated. It is thus 
evident that 78 per cent, of our cases of duodenal ulcers 
were Wolff- Junghans' positive or suspicious. In this 



254 CANCER OF THE STOMACH 

group, gastric stagnation was present in 55.5 per cent, of 
the cases. 

Nephritis and Cardiovascular Disease. — Our series in- 
cludes 12 cases of cardiorenal affections associated with 
obscure gastric complaint and anemia. The gastric ex- 
tracts showed achyha. In 6 instances (50 per cent.) the 
Wolff-Junghans' test was doubtful, while in an equal 
number it was negative. The doubtful cases were asso- 
ciated with some degree of gastric motor insufficiency. 

Cases Exhibiting Low Gastric Acidity. — -In this group we 
include 159 instances where gastric acidity ranged from 
2 to 70. The average was 18.7. This group furnished 
what might be regarded as controls on our reactions in 
other groups, as well as demonstrated what results might 
be expected from the Wolff-Junghans' test in extragastric, 
maUgnant, and non-malignant ailments. It should be 
emphasized that all of the patients examined complained 
of some gastric disturbance. The finding of the low 
free hydrochloric acid in some instances might have led 
to suspicions of malignancy by those who hold gastric 
acidity as a strong index of such condition. This might 
have been especially so when we recall that the average 
age of our patients is above 40 years. 

Clinically, this group was varied as to diagnosis. Among 
the affections were appendicitis, cholecystitis, cholelithia- 
sis, alcohoUc gastritis, gastric neuroses, pulmonary tuber- 
culosis, tabes, multiple sclerosis, tuberculous peritonitis, 
nephrolithiasis, pancreatitis, cirrhosis of the liver, preg- 
nancy, malaria, diabetes, aneurysm of the abdominal aorta, 
chronic constipation, hemophilia, cancer of the breast, 
cancer of the lip. 

Of this heterogeneous group of low gastric acidity cases, 
40 (25.1 per cent.) were Wolff-Junghans' positive, 38 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 255 

(23.9 per cent.) were doubtful, and 81 (50.9 per cent.) 
were negative. In other words, of this class nearly 50 per 
cent, of cases showed units of precipitable albumin from 100 
upward. Gastric motility was interfered with in some 
degree in 25 cases (15.7 per cent.). 

Relation of the Wolff- Junghans^ Test to the Presence of 
Blood in Gastric Extracts. — We have frequently tested 
gastric contents that were discolored bright red by trau- 
matic blood without getting positive Wolff- Junghans' tests. 
Of our entire series of 747 cases herewith detailed, '' occult" 
blood was demonstrated by the benzidin test in 43.2 per 
cent. Reference to the gross summary of our work above 
will reveal the fact that we obtained positive tests for pre- 
cipitable albumin in 42.6 per cent, of the gastric extracts of 
the entire series, while in 15 per cent, the test was doubtful. 
There may be more than a curious relationship between 
these groups of figures. 

Summary. — Our work appears to justify the following 
conclusions : 

1. When carefully performed and interpreted the Wolff- 
Junghans' test for demonstration of dissolved albumin in 
gastric extracts was positive or suspicious in 80 per cent, of 
our series of gastric cancer. In this series it was a more 
constant finding in gastric extracts than were absent free 
hydrochloric acid, the presence of lactic acid, and the 
glycyltryptophan test. It was rather more constant than 
tests for occult blood and the demonstration of gastric 
motor inefficiency. It was not so consistent in its 
manifestation as the demonstration of organisms of the 
Oppler-Boas group or the increase in the formol index. 

2. In extragastric malignancy, gastric syphilis, and 
nephritis the Wolff-Junghans' test seems inconstant. 

3. In the differentiation between malignant and non- 



256 CANCER OF THE STOMACH 

malignant achylias the Wolff-Junghans' test, when inter- 
preted in connection with other cUnical and laboratory 
data, is of considerable value. Positive reactions are 
rarely obtained in the achylias of primary anemia, simple 
achylia gastrica, and simple achlorhydrias, when such are 
unassociated with gastric motor inefficiency, 

4. Simple gastric and duodenal ulcers, especially when 
accompanied by pyloric stenosis or gastric atony, may give 
confusing responses to the Wolff-Junghans' test. 

5. The presence of blood in gastric extracts may be a 
factor in the production of certain atypical positive tests. 

(B) EXAMINATION OF THE FECES IN GASTRIC CANCER 

The routine examination of freshly passed feces should 
never be neglected. While in the majority of instances of 
the disease, analysis of the stool reveals little characteristic, 
not infrequently cases occur that are clinically suspected of 
being gastric cancer where stool analysis reveals not cancer 
of the stomach, but malignant disease of the large bowel, 
rectum or anus, anomalies of the biliary tract or pancreas, 
or the presence of intestinal parasites. 

Macroscopic clinical reference has been previously made 
(vide Chapter III) respecting the incidence of diarrhea and 
constipation in gastric cancer. The macroscopic examina- 
tion of the stool is of much value. Where constipation 
exists, its degree may be roughly ascertained by marking 
of the stools with two tablets of charcoal or 5 grains of car- 
mine. With the patient upon diet as nearly normal as pos- 
sible, the time of administration of the coloring substance 
is compared with that when the stool is passed stained 
black (charcoal) or brick-red (carmine). We have found 
the above simple method of considerable clinical value. 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 257 

Roentgen ray examination of tiie degree of stomach or 
bowel stasis is of but relative service. The large mass of 
opaque medium is not physiologically a food. It is not 
without its effect upon gastric and intestinal secretions, 
peristalsis or digestive-tract flora. Its weight is out of all 
proportion to its bulk as a food. We not rarely see in- 
stances where Roentgen plates show bismuth in the 
intestinal tract, or even in the stomach from 3 to 5 days 
following its administration, and yet charcoal or carmine 
colored stools are passed within 12 to 24 hours. It, 
therefore, appears that Roentgen estimation of gastro- 
intestinal motility when such substances as bismuth or 
barium form the basis of the test-meal is at present of 
dubious service. Its value can only be placed upon a firm, 
clinical footing when actinologists and clinicians, after 
years of co-operative work, have followed a large series of 
similar and different cases through medicinal or surgical 
treatment, or examined such at autopsy. Then it will be 
proper to draw conclusions from facts and not have such 
depend upon fancy or individual enthusiasm. 

The gross appearance of sluggish stools in instances of 
gastric cancer may differ little from the appearance of 
constipation stools in other ailments. If little food is 
passing into or out of the stomach, then the stools may be 
small, hard and often covered with mucus. In cases where 
the bile tract has been invaded by the neoplasm clay- 
colored or putty-like movements may be noted. Where 
there has been involvement of the pancreas, the stool may be 
large in amount, putty or gun-metal colored, pasty, greasy, 
foamy or fatty, contain much unaltered food (gobs of fat — 
butter-like or egg-yolk appearing — or chunks of poorly 
digested meat or vegetable fiber) and have a penetrating, 
pungent, acrid, musty or sour odor. Fistulous com- 

17 



258 * CANCER OF THE STOMACH 

munication between stomach and bowel may cause the 
stool to contain macroscopic blood, necrotic tissue, pus, 
undigested food or much mucus. Black or red stools occur 
when sudden extensive bleeding has resulted from the 
local growth in the stomach, or from necrosis which opens 
up a large blood-vessel as a consequence of secondary- 
invasion of other viscera. ' 

Diarrheic stools may be expected at any time during the 
course of gastric cancer. Frequent!}^ they are caused by 
faultj^ diet, insufficiencj^ of the digestive glands (stomach, 
liver, pancreas, bowel), asthenia, nervous disturbances, 
hemorrhage, cohtis associated with cardio-renal compHca- 
tions, abnormal intestinal microorganisms, or by pressure 
or actual invasion of the central nervous system by the 
neoplasm or by medicines. 

The stools may be small, frequent and watery, large and 
mush-like, foamy, sticky, sUmy, gelatinous or custard-like. 
The odor is often very offensive. The color varies widely. 
Green, tan, cream, j^ellow, red or black movements are 
not uncommon. Occasionally fleshy clots or spongy or 
friable chunks of tissue may be intermixed. 

CHEMICAL EXAMINATION 

Reaction. — Stools in gastric cancer are commonly am- 
photeric or alkaline to litmus unless there is a marked 
involvement of the pancreas or the bile ducts. In such 
event, the stools have acid reaction in a high proportion 
of cases. 

Hydrobilirubin is usually present, unless the free flow of 
bile is interfered with or there is marked cancerous change 
in the liver. 

Bile coloring matter is readily recognized by intimately 
mixing 10 grams (or 10 cc. in case the stool is fluid) 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 259 

of stool with about 4 times its volume of saturated 
normal salt solution of bichloride of mercury in a mortar. 
The fluid portion is poured off into a Petri dish, covered 
and allowed to stand for from 2 to 24 hours. If hydro- 
bilirubin is present a salmon to deep red color appears. 
Not infrequently, olive green color changes occur due to 
the presence of biliverdin. When this is present, chloro- 
phylaceous moulds or certain bacilli associated with " green 
diarrhea" must be excluded by spectroscopic examination 
of alcoholic extracts of the feces. Biliverdin shows no 
absorption bands spectroscopically. All stools of light 
yellow to putty color should routinely be examined for bile 
pigments. Very often, chalky or cream, pale yellow or 
black stools render it difficult to observe whether or not bile 
elements are present. Such stools are common when 
patients are on milk diet, have been examined by the 
Roentgen ray, or are taking certain medicines (bismuth, 
tannic acid, iron, etc.). 

Blood. — After severe hemorrhage, there is usually no 
difficulty in recognizing blood macroscopically in the stools. 
It is sometimes necessary to be sure that an ulcer sus- 
pected of being malignant is bleeding, or it is desirable to 
ascertain roughly how much seepage of blood is occurring 
in a known gastric neoplasm. For this purpose chemical 
tests for altered ('' occult") blood are useful. 

It should be strongly emphasized that positive chemical 
tests for blood only indicate that blood pigment is in the 
feces. The clinician must, therefore, exclude all possible 
sources of error before he can state definitely that a chemical 
reaction positive for blood indicates that such blood comes 
from the suspected gastric focus. It should be strictly 
seen that no likely source for these reactions lies in a 
lesion existing in the mouth, nasopharynx, respiratory 



260 CANCER OF THE STOMACH 

tract, or parts of the digestive canal outside of the stom- 
ach. Dependable reagents must be employed in making 
the test. Many preparations of phenolphthalein, guaiac, or 
orthotoluidin are chemically useless for the reaction. Ben- 
zidin is less likely to be unreliable, provided the pinkish- 
gray powder be used. If hydrogen peroxide or turpentine 
is employed, it is very essential that such possess de- 
pendable oxidizing properties. Thorough dietetic prepa- 
ration is necessary before chemical tests for blood in the 
stools ^can be interpreted clinically. It is our custom 
first to give the patient 2 ounces of castor oil and thereby 
empty the gastro-intestinal canal of material likely to be 
a source of error. He is then placed upon soft lacto- 
vegetable diet (avoiding excess of greens and fresh garden 
truck) for 3 days. A saline cathartic is then adminis- 
tered. For the following 24 hours nothing but parboiled 
milk is permitted. The bowels are then allowed to move 
naturally, or by a mild saline laxative. The second stool 
passed is examined. This furnishes the specimen to be 
tested for altered blood. 

The method of procedure has been described above (see 
Gastric Analyses). Care should be taken that at least 
5 grams of stool are employed and that its breaking up 
with acetic acid and its extraction with ether are thoroughly 
carried out. 

Clinical Interpretation of "OccuW Blood Tests. — If the 
reaction has been carefully checked as outlined above, a 
positive test means only that there is a bleeding point 
somewhere between the lips and the external anal ring. 
It is the physician's business to find where this point is 
located. Given a history of a malignant gastric ailment or 
of chronic dyspepsia of the ulcer type, it is most likely that 



EXAMIXATIOX OF GASTRO-IXTESTIXAL FUXCTIOX 261 

persistent seepage or intermittent bleeding come from 
such focus of disease. 

While a positive chemical reaction for blood in a given 
specimen of feces has a certain value diagnostically, yet 
when such are obtained in gastric cancer, other more 
easily and more dependable signs and symptoms of the 
existence of the disease are 'not lacking. Of the stools of 
gastric cancer patients where we have performed benzidin 
tests, the reaction was positive in approximately S9 per 
cent. Of this group of cases, abdominal tumor was pal- 
pated in nearly 75 per cent., gastric acidity was below 
15 in 83 per cent., bacilh of the Oppler-Boas type were 
present in stomach extracts in nearly 94 per cent., Roentgen 
findings were positive or suspicious in about 90 per cent., 
and the clinical history was that of malignancy in about 92 
per cent, of instances. 

The negative test for ''occult '" blood in the feces is a con- 
siderable aid in excluding gastric cancer where, with a 
doubtful clinical history, an atypical abdominal tumor is 
made out. 

Ferment Tests. — The main worth of such lies in gaining 
knowledge respecting the function of the pancreas. Tests 
for amylase (chastase) and trj^sin appear to have chnical 
value. While not infrequently low figures are returned 
when amylolytic and tryptic digestion are estimated in 
the event of involvement of the pancreas by a growth, 
primarily gastric, we have found that in cases of achyUa 
or hypoacidity of extragastric origin, similar results may 
be obtained. 

Wohlgemuth' s Method of Determining Diastase in the 
Stools. — Wohlgemuth has adopted the following quantita- 
tive method for determining the diastase in the stools: 
The fresh feces are well mixed, and 5 grams are thoroughly 



262 CANCEE OF THE STOMACH 

ground in a mortar with 20 cc. of 1 per cent, solution of 
sodium chloride, added a small quantity at a time. The 
emulsion is then left for half an hour at the room tem- 
perature, stirring it frequentlj^ meanwhile. It is now 
divided into two equal portions of 10 cc. each, and is 
transferred to graduated centrifuge tubes, which are 
centrifugahzed until all the solid material is collected at the 
bottom and stands at the same height in both tubes. 
The quantities of sediment and supernatant fluid are 
noted. Nine test-tubes are now taken. Into the first 
three, 1.0 cc, 0.5 cc, 0.25 cc. of the undiluted extract; 
into the next three, 1.0 cc, 0.5 cc, 0.25 cc. of an eight- 
fold dilution of the original extract, made with 1 per 
cent, sodium chloride; and in the last three, 1.0 cc, 
0.5 cc, 0.25 cc of a sixty-four-fold dilution are placed, 
so that each tube contains half the fecal extract of the 
preceding : 

1st tube 1.0 4th tube 0.125 7tli tube 0.0156 

2nd tube 0.5 5th tube 0.0625 8th tube 0.0078 

3rd tube 0.25 6th tube 0.0312 9th tube 0.0039 

To each tube 5 cc of a 1 per cent, solution of starch are 
then added. The tubes are now plugged with wool, or 
closed with corks, and placed in the incubator at 38° 
C. for 24 hours. At the end of that time they are filled to 
within a finger breadth of the brim with cold distilled 
water, one drop of a decinormal iodine solution is added to 
each, and the low^est dilution giving a blue reaction looked 
for. It is then assumed that the tube next lowest in order 
contains sufficient diastase to convert all the added starch, 
and from this the quantity of 1 per cent, starch solution 
fermented by 1 cc. of the fecal extract can be calculated. 
Knowing the proportion of sohd residue to hquid extract 
in the 5 grams of feces the quantity of ferment corre- 



EXAMINATION OF GASTRO-INTESTINAL FUNCTION 263 

spending to 1 cc. of this residue can be determined and 
from this the diastatic power of the total daily mass of 
feces can be determined. According to Wohlgemuth and 
Wynhausen, the average diastatic value of the feces lies 
between 470 and 500. To obtain satisfactory results, the 
feces must be homogeneous and alkaline in reaction, as 
diastase does not act in an acid medium. It is advisable 
to place the patient on a simple mixed diet, calculated 
to stimulate the functions of the pancreas to normal 
activity, for a couple of days before the feces are collected 
for examination (Cammidge). 

Gross-Wynhausen^s Method of Determining Tryptic Digestion 
in the Stools. — Wynhausen has suggested the following 
method for carrying out Gross' test quantitatively: 
Twelve test-tubes are taken. Into the first two are placed 
0.25 cc. and 0.1 cc. of the undiluted fecal extract; into the 
next five, 0.6 cc, 0.4 cc, 0.25 cc, 0.16 cc and 0.1 cc of a 
10 times dilution; into the next three, 0.05 cc, 0.25 cc, and 
0.1 cc, of a 100 times dilution; and into the last two, 
0.5 cc. and 0.25 cc of a 1000 times dilution. To each is 
now added 5 cc. and 0.1 per cent, casein solution. The 
tubes are closed with corks or wool and incubated for 24 
hours. At the end of this time they are tested with 1 
per cent, acetic acid. The digestion of 1 cc of 0.1 per 
cent, casein solution by 1 cc. of the filtrate is taken as the 
tryptic unit. Normally, the value exceeds 200 (Cammidge) . 

MICROSCOPIC EXAMINATION OF FECES IN GASTRIC CANCER 

The stools should be examined fresh and preferably 
warm. It is our practice to routinely have stools col- 
lected in warm pots, placed at once in an incubator built 
for that purpose (Fig. 59) and examined on a warm 
stage, with high power amplification. Stools should be 



264 



CANCER OF THE STOMACH 



examined within 2 hours after their being passed if one 
desires to learn facts of dependable worth regarding the 
flora of the intestinal tract or to make representative 
cultures. Whenever possible stools should travel from 
patient to microscope by the most direct route. Stools 



K»5fWte;>: 




Fig. 59. — Electric incubator for preserving stools warm until ready for 
examination. — (Author. ) 

which have stood about for hours, grown cold or allowed 
to ''ferment" return wholly unreliable findings upon 
microscopic examination. Food rests may have become 
digested or autolysized, motile bacteria or protozoa have 
died or encysted, or abnormal proliferation of such organ- 
isms as facultative aerobes taken place. 

Method of Microscopic Examination. — Much can be 
learned from examination of the fresh stool unstained but 



EXAMINATION OF GASTEO-INTESTINAL FUNCTION 265 

diluted about 3 times with warm normal salt solution. At 
least one preparation should be viewed in this manner, 
using all 3 regular objectives. This examination permits 
the recognition of motile bacteria, protozoa, parasite 
eggs, crystals and the like, relatively unchanged. Wet 
or dry stained preparations may next be observed. Wet 
preparations are conveniently made by adding a drop of 
Lugol's solution or solution of osmic acid to a like quan- 
tity of fresh, fluid feces upon a slide. By this method 
food digestion (starches, fats) can be made out. Dry 
preparations are available by making thin smears of fluid 
feces upon cover slips, passing through a Bunsen flame 
rapidly, and staining with Wright's solution, Unna's 
polychrome methylene blue, Loeffler's blue, hematoxylin 
and eosin or Gram's stain. In carcinoma of the stomach, 
staining by polychrome methylene blue or Gram's method 
is a satisfactory routine procedure. Where many speci- 
mens are to be examined in a short time, the agar staining 
technique which I suggested several years ago is very 
useful (see under Gastric Analysis). 

Microscopic Findings in the Feces in Gastric Cancer. — 
Where the malignant process is early or developing in a 
pre-existing ulcer, nothing characteristic is seen in the 
stools. If there is marked gastric stagnation of the benign 
type, an abundant growth of yeasts and sarcinse may be 
observed. Where gastric malignancy is well established, 
bacilli of the Oppler-Boas type may be recognized in as 
high as 60-85 per cent, of cases by the Gram stain. As- 
sociated with these long acid-fast bacilli, there are com- 
monly large colonies of streptococci and staphylococci. 

Protozoa may be recognized in unstained specimens ex- 
amined on a warm microscope stage. We have seen 
amoebae, trichomonads, cercomonads, balantidium coli, 



266 CANCER OF THE STOMACH 

and megastoma entericum in the feces of gastric cancer 
patients. Occasionally tape-worms, pin worms or flukes 

are seen. 

Undigested food is common in the stools of patients 
affected with cancer of the stomach. Large pieces of 
striated muscle fiber, vegetable reticula, or unaltered fat 
may be abundant. 

Red blood corpuscles and leucocytes (usually polymorpho- 
nuclears or of the large mononuclear type) are often present 
in sloughing gastric cancers, or where fistulse have der 
veloped. We have never seen mitotic cells in the feces of 
such cases. 

Crystals, particularly of cholesterin, ammonium phos- 
phate, fatty acids, leucin or tyrosin are not infrequently 
increased in the stools of late gastric malignancy. 

REFERENCES 

Smithies: "A New Motor-meal and Lavage Tube," Jour, of Am. Med. 

Assoc, 1914, Feb. 7, p. 453. 
ScHRTVER AND Singer: The Quarterly Jour, of Med., London, 1912, 

Oct., p. 71, and 1913, April, p. 310. 
RuTTAN AND Hardisty : Canadian Med. Assn. Jour., 1912, Nov., 

p. 1. 
Smithies: Arch. Int. Med., 1912, June, p. 736. 
Kaufpmann: Berl. klin. Wchnschr., 1895, No. 6, p. 1. 
Pelosi: Gazz. deg. osped. e de. Chn., Milan, 1912, Oct. 22. 
FuLD AND Levison: Biochem. Ztschrft., Berlin, 1907, Bd. vi, Hft. 5 

and 6, p. 473. 
SoRENSON AND Schiff: Ztschrft. f. physiol. Chem., 1909, xiii, p. 27. 
Muller: Ztschrft. f. klin. Med., 1889, xvi, p. 496. 
Fischer: Deutsch. Arch. f. klin. Med., 1902, Ixxii, p. 415. 
Abderhalden: Ztschrft. f. phj^siol. Chem., 1909, Ixii., p. 136. 
Neubauer and Fischer: Deutsch. Arch. f. klin. Med., 1909, xciii, 

p. 499. 
Ltle and Kober: New York Med. Jour., 1910, xci, p. 1151. 
Weinstein: Jour. Am. Med. Assn., 1910, Iv, p. 1085. 
Warfield: Bull. Johns Hopkins Hosp., May, 1911, p. 150. 
Oppenheim: Deutsch. Arch. f. klin. Med., 1910-11, ci, p. 293. 
Kohlekberger: Deutsch. Arch. f. klin. Med., 1910, xcix, p. 148. 



EXAMIXATIOX OF GASTRO-IXTESTIXAL FrXCTION 267 

Sakfoed and Rosexbloom: Arch. Int. 'Med., 1912, ix, p. 445. 

Weixsteix: Jour. Am. ^Sled. Assn., 1911, hni, p. 1420. 

Hall and "Willtaaisox: Lancet, London, 1911, clxxxi, p. 731. 

Smithies: Archiv of Int. ]Med., 1912, x, p. 357. 

SanTHiEs: Jour. Am. Aled. Assoc, 1912, April 6, p. lOOS. 

Gees: Quoted by Weinstein, Jour. Am. Med. Assn., 1911, Ivii, p. 1420. 

Emersox: "Clinical Diagnosis," 1906. 

Wolef axd Juxghaxs: Berl. klin. Wchnchrft., 1911, May 29, and 

1912, March 18; Medizin. KHnik. 1912, March 24, also Taschenbuch 

Magen und Darm Krankheiten, 1912. 
Rolph: Medical Record, New York, 1913, IMay 10, p. 849. 
SiHTHiEs: Am. Jour. Med. Sc, 1914, May, p. 713. 
Smithies: Jour. Am. Med. Assn., 1913, Xov. 15, p. 1793. 
Wohlgemuth: Biochem. Ztschrft., 1909, xxi. 
CAiiMiDGE: "Feces of Children and Adults," London, 1913. 
Wtxh^iusex: Berl. klin. Wchnschrft., 1910, No. 11, 



CHAPTER VI 
ROENTGEN EXAMINATION IN GASTRIC CANCER 

During the past 5 years, such advances have been made 
in the technique of examining hollow viscera (which have 
been rendered opaque with such substances as bismuth 
or barium), through the medium of the Roentgen ray, 
as to permit of the methods being of certain clinical value. 

Class of Cases in which Roentgen Examination is of 
Value. — It is well to admit that much of the positive in- 
formation which rc-ray examinations give us concerning the 
function or abnormalities of the stomach can be as well 
obtained by routine clinical examination. This especially 
applies to gross lesions of the stomach or bowel. In the 
large majority of instances, x-ray findings only concern 
what might be termed accidents in the progress of the 
disease process. By this we mean that such features as 
stenosis at either orifice, or on the course of the gastric 
lumen, alterations in shape or position of the viscus with 
relation to adjacent organs, or deformities in outline are 
determined Roentgenographically. Until such complica- 
tions occur, it is not unusual for Roentgen findings to be 
entirely negative. The diagnosis must be made clinically 
or chemically. This applies particularly with regard to the 
aj-ray diagnosis of malignant gastric ulcer and latent gas- 
tric cancer. 

Both by x-ray plate and flouroscopic screen it is quite 
impossible to accurately localize or even diagnose the 
majority of uncomplicated peptic ulcers. Until there has 
been such accumulation of scar-tissue as to make a lesion 

268 



EOEXTGEX EXAMINATION IX GASTEIC CANCEE 269 

1 to 3 cm. in diameter, very littie of definite value is de- 
rived from .r-ray examination. 

In tliese instances, the so-called .r-ray diagnosis of early 
gastric cancer is really based upon other clinical and 
laboratory data. Xot infreciuently valuable service is 
rendered by the Roentgen ray in actually demonstrating 
to us that, in a patient with ulcer symptoms, the disease is 
located in the stomach and not in the duodenum. This is a 
valuable fact, because it has been shown by the work of the 
surgeon and the cellular pathologist that onh' rarely does 
malignancy occur upon the site of a duodenal ulcer. In our 
experience, carcinoma of the duodenum, where there had 
been previously ulcer history, happened but 7 times in an 
analysis of the records of 1.000 duodenal ulcers. 

If the chronic, recurrent, calloused ulcer is located well 
within the stomach, as shown by the .r-ray examination, 
then, from a knowledge of the facts that Wilson and 
MacCarty have found cancerous tissue in 71 per cent, of 
such ulcers resected, the actinologist can C[uite reasonably 
entertain the suspicion that such ulcers may be cancerous 
and recommend surgical intervention. ^Moreover, if the 
duodenal ulcer, which is quite apt itself to be benign, is 
proved to extensively involve the pylorus at the x-ray 
examination, it is weU to suspect that such ulcer may be or 
is potentially carcinomatous. 

Similar observations may also be made regarding ulcers 
or scar-tissue about the ulcer causing local deformity or 
local irritation of groups of muscle fibers in the stomach wall. 
Here the various so-called signs are quite indefinite and un- 
certain, unless the facts which clinical history or chemica] 
examination of gastric function return are considered. 

AYhen a large accumulation of callus has formed, or 
when the ulcer breaks throtigh by perforation, or where the 



270 CANCER OF THE STOMACH 

surface mucous membrane has been lost as the result of 
necrosis, thus forming a crater-ulcer, or if, in the attempt 
to heal, fibrous tissue has caused contraction at the cardia 
or in the stomach lumen (hour-glass or narrowing at the 
pylorus. Figs. 60 and 61) the Roentgen examination of the 
stomach which has been filled with opaque medium gives 
testimony corroborative of the clinical opinion that such 
complication has occurred. 

We have already shown that the early beginnings of 
many gastric cancers are essentially microscopic alterations 
in epithelium lying in the areolar tissue at the edges or bases 
of gastric ulcer. When this pathologic fact is borne in 
mind, it is to be readily understood how the a;-ray examina- 
tion in these instances can only give information with 
regard to the presence or absence of calloused ulcer. It is 
not possible to state whether or no such is a benign ulcer 
or a malignant ulcer. Actinologists have learned from the 
clinical pathologists, however, that complicated ulcers of 
the calloused type which have crater diameters or scar- 
tissue infiltration broader than 1 to 3 cm. are very Ukely to 
be malignant. This applies especially to ulcers located 
at or neajr the cardia or the pylorus. 

With regard to ulcer in the antrum, pars media, or the 
body of the stomach, it is frequently impossible to make 
any Roentgen diagnosis whatever if such do not involve 
one or both curvatures and produce malformations of the 
stomach outline. 

Inasmuch as we have shown that the early diagnosis of 
gastric cancer is essentially that of the diagnosis of chronic, 
calloused ulcer, it will be seen that in such the x-ray evi- 
dence is wholly inefficient with regard to absolute diagnosis, 
and only of limited value with respect to presumptive 
diagnosis. It is to be regretted that in these cases which 



ROENTGEN EXAMINATION IN GASTRIC CANCER 271 




Fig. 60. — -Benign pyloric obstruction. 
Case No. 22,583— Male— Age 63. 

History of progressive gastric ulcer with recent obstruction; dilatation 
of stomach and weight loss. 

Abdominal Examination. — Marked tenderness to right of navel._ 

Test-meal. — Pronounced 12-hour retention; tan color extracts with yeasty 
odor. Total acidity, 68; free hydrochloric acid, 63; altered blood + (Benzidin 
test). 

Microscopic Examination. — Great numbers of yeasts and sarcinse. 

Clinical Diagnosis. — Pyloric obstruction, subacute perforating ulcer. 

X-Ray Diagnosis. — Pyloric obstruction. 

Plate shows "fish-hook" stomach; vigorous peristalsis; bulbous antrum 
and dilated duodenum. 

Surgical Diagnosis. — Pyloric ulcer with obstruction. 



272 



CANCER OF THE STOMACH 




Fig. 61. — Pyloric obstruction; duodenal ulcer; deficient visualization of 

pylorus and duodenum; malignancy questionable. 
Mr. A. Z.— Age 40. 

Family History. — Negative. 

Previous History. — Pneumonia as a youth. 

Comes on account of chronic indigestion and chronic constipation. 

Duration of Disease. — Has had dyspepsia all of his life in infrequent spells. 
These attacks always came on gradually and were characterized by epigas- 
tric distress 2 to 3 hours after meals and particularly at night. The distress 
was usually a burning sensation and occasionally he has had cramps. The 
pain usually lasted several hours and was frequently transmitted to the pre- 
cordia. The pain was aggravated by body movement and relieved by 
limiting the amount of his diet, gastric lavage, rest or by pear juice. 
Vomiting would come on regularly at night if the stomach was not lavaged 



ROENTGEN EXAMINATION IN GASTRIC CANCER 273 

make up the bulk of instances of surgically curable cancer, 
Roentgen examination fails as a clinical method of precision. 

With regard to early so-called ^'primary" gastric cancer 
— that is gastric cancer developing in stomachs that had 
previously functionated normally — the x-ray gives prac- 
tically no information. At the time when anomalies of 
the stomach, such as obstruction, filling defects, malignant 
adhesions or perforation, are exhibited, the disease process 
is well under way. 

There is a class of case, however, in which a:-ray examina- 
tion aids us in confirming the clinical suspicion that a 
gastric growth exists. Such instances are where the neo- 
plasm is located on the lesser curvature near the cardia, 
at the fundus, greater curvature or posterior wall. This 
group comprised not more than 6 per cent, of all instances, 
in a study of 187 consecutive cases. In such instances it 
is usually impossible to feel an abdominal tumor, the 
history is obscure and such thing as an atypical blood 
picture, diarrhea, or regurgitant vomiting, may make it 
necessary to exclude malignant involvement of organs 
other than the stomach. In no instance of this type has 
the x-ray examination returned positive information, 
however, where the presumptive diagnosis of gastric 

and vomitus would consist of sour food. Never suffered any nausea, but 
belching and water-brash were fairly constant. 

Appetite. — Food desire excellent. 

Bowels. — Markedly constipated, sometimes do not move for a week — 
bleeding. Had bloody "flux" lasting 3 days, age 22. Had no recurrence. 

Weight. — Six months ago, weight 130; present, weight 100; height, 6 
ft. 4 in. 

Temperament. — Markedly neurotic — says, "he is very delicate and sensi- 
tive." 

Clinical Diagnosis. — Peptic ulcer; enormously dilated stomach; mentally 
deficient. 

X-ray Diagnosis. — Perforating duodenal iilcer. Plate shows dilated 
ptosed stomach of the fish-hook type; hyperperistalsis; pylorus shows 
deficient filling with bismuth; irregular outline with a residue in the duo- 
denum. 

Surgical finding. — Extensive duodenal ulcer extending to and involving 
the pylorus; adhesions to pancreas but no perforation. 

18 



274 CANCER OF THE STOMACH 

malignancy had not been strongly considered clinically. 
In many cases the stomach-tube examination alone 
has been quite sufficient to estabhsh positive diagnosis 
in a few minutes and at little expense to the patient. 

In the great number of instances where the a;-ray ex- 
amination showed positive diagnosis, clinical facts had 
already estabhshed this. For example: in 147 consecutive 
cases of proved gastric cancer, there was palpable epi- 
gastric ridge or tumor present in 72 per cent. In this 
group, gastric retention of the malignant type was dem- 
onstrated in 74 per cent. ; occult blood existed in the gastric 
extracts in 92 per cent, and in the stools in 86 per cent. 
The microscopic examination of gastric extracts showed 
bacilli of the Oppler-Boas type in 93.8 per cent. In this 
group of cases, the a;-ray diagnosis was ''positive" for carci- 
noma, ''probably" or "possibly" carcinoma in 92 per cent. 

The information of the greatest value which the Roentgen 
examinations give us is that of roughly locating the posi- 
tion of a growth, determining the extent of such, visuahz- 
ing the deformity existing in the stomach, and sometimes 
indicating the invasion of adjacent viscera. Roentgen 
examinations have a not-to-be neglected psychic value. 
They make it much easier to convince the patient or 
medical attendant that carcinoma exists, or does not exist, 
than if such an examination had not been made. They 
also permit of interesting visualization of diseased organs. 
In this way, valuable service may be rendered by enabling 
one to regard the different phases of the disease in a patient 
under various types of surgical or non-surgical treatment. 

METHODS OF EXAMINATION BY MEANS OF THE ROENTGEN RAY 

There are two useful methods in vogue : the examination 
by making plates or films and the examination by means of 



ROENTGEN EXAMINATION IN GASTRIC CANCER 275 

the fluoroscopic screen. Our experience, from the study of 
the records of more than 2,000 gastro-intestinal a;-ray 
examinations, would indicate that neither method is all- 
sufficient, but that the greatest amount of information is to 
be obtained by a combination of both procedures. It is 
such method that we deem best to describe. 

EXAMINATION BY FLUOROSCOPIC SCREEN 

This examination has for its object two main ends. The 
first is to demonstrate the ability of the stomach to empty 
itself of ingested material. The second is the examination 
of the stomach filled with a medium opaque to the Roentgen 
rays for the purpose of noting abnormalities, with and 
without the aid of abdominal palpation or change in the 
patient's position. 

To test the emptying power of the stomach it is our practice 
to first wash out the stomach so as to free it from an ac- 
cumulation of food that may have resulted from improper 
diet. The next procedure is to empty, as far as possible, 
the gastro-intestinal tract by means of a cathartic. For this 
purpose, we use 2 ounces of castor oil in a half glass of 
beer or malt extract, or mixed with a small amount of iced 
water, lemon or orange juice. The patient is then kept 
on a liquid diet for from 8 to 12 hours. He is then fed a 
so-called "motor-meal." We have found it useful to feed 
this in the form of bismuth subcarbonate or barium sulphate 
in Cream of Wheat. The proportions are 2-A ounces of 
either of these drugs to 8 ounces (cooked weight) of Cream 
of Wheat. This mush may be flavored with fruit juices. 
A little cream is permissible. The patient eats the mush 
slowly, and is not usually told its ingredients. 

Six hours after this motor-meal, the stomach is examined 
by means of the fluoroscopic screen and x-ray tube. The 



276 CANCER OF THE STOMACH 

patient is stripped of all excepting a light surgical gown. 
We prefer to examine our patients standing, but there is no 
objection to conducting the examination with the patient 
seated (say upon a high bicycle seat) or even lying upon a 
proper table. The form of apparatus used is of Httle 
consequence so long as one has available a first-rate fluoro- 
scope screen (the best are imported from Germany or 
France) and a number of high-grade water-cooled x-ray 
tubes. Many good tubes are made. Those which have a 
cooling arrangement in the form of a continuous current 
of water (after the suggestion of Albers Schoenberg) are 
very satisfactory. The new tube devised by Coolidge is 
most excellent. 

Negative Findings. — If there is no mechanical interference 
to food entering the stomach (stricture at the cardia), to 
its passage through the stomach (tumor mass, mahgnant 
hour-glass, perforation, adhesions) or to its exit from the 
stomach (malignant stenosis at the pylorus), at the end 
of 6 hours the ''motor-meal" of bismuth or barium mush 
will have left the stomach. The mass of it will be located 
in the lower ileum or some part of the large bowel. 

Positive Findings. — If malignant obstruction has oc- 
curred, in the above-named fashion, one may see varying 
amounts of bismuth in the esophagus, in a loculus of the 
stomach or lying at the most dependent part of the viscus. 
In but few extensive gastric cancers does the stomach empty 
itself completely of the motor-meal. Even if the orifices 
are wide open, it is not uncommon to find ''rests" of the 
opaque-meal lying between projections or in the irregular- 
ities formed by the neoplasm. The absence of all the 
motor-meal from the stomach is not a conclusive proof 
that the orifices are not involved. It is not uncommon to 
discover at laparotomy, in such instances, a hard gristle- 



ROENTGEN EXAMINATION IN GASTRIC CANCER 277 

like neoplasm extensively involving the pylorus and 
antrum. This may so stiffen the gastric wall that the 
lumen remains patent and allows the opaque meal to pass 
rapidly into the small gut after the fashion of liquid 
flowing through a funnel. 

In our experience 6-hour opaque ''rests" of a motor- 
meal are seen in approximately 2 out of 3 cases of gastric 
cancer where there is moderately extensive involvement. 

Fluoroscopic Examination of Abnormalities in Gastric 
Outline. — For this purpose it is necessary to almost fill the 
stomach with a puree-like mixture. In this manner, one 
can then observe shape, size, position, contour, emptying 
power and tender points of the stomach. One can also 
determine the relation of the stomach to adjacent viscera, 
and rapidly note the effect of peristalsis or the influence 
upon the above factors brought about by change of position 
or by abdominal palpation. 

The opaque liquid which we have found useful consists of 
6 to 8 ounces of bismuth subcarbonate or barium sulphate 
in 1,000 cc. of buttermilk, ''fermilac," or thin starch-paste. 
These mixtures may be flavored with chocolate, vanilla or 
fruit juices. Usually little flavoring is necessary. 

After examining the stomach for a 6-hour ''rest" de- 
scribed under estimation of motor function, the patient is 
next permitted to drink 500 to 1500 cc. of the bismuth 
subcarbonate or the barium sulphate puree. While this is 
being taken, the esophagus is scrutinized with the patient 
in both the anterior, posterior and lateral positions. This 
maneuver permits of one gauging the size and patency of 
the esophagus and also makes it possible to note the freedom 
with which the opaque mixture passes the cardia. Note 
should be carefully made regarding these points and if there 
is abnormality observed, repeated examination should 



278 CANCEK OF THE STOMACH 

demonstrate its permanency or its transientness. If 
such anomaly be permanent, a record should be obtained of 
it upon plates. 

In cases where there is no abnormality noted in the 
esophagus or at the cardia, the stomach should be observed 
as the opaque meal enters. Depending upon the thick- 
ness of the abdominal parietes, the excellence of the 
tube and screen, and the success with which the opaque 
meal has been made, one usually observes in gastric cancer, 
first, that there is some fault in the gastric outline. This 
fault consists most generally of a diminution in the size 
of the gastric lumen. This is due to the fact that the 
majority of malignant growths extend into the stomach 
cavity and hence, at these points, there is a defect of normal 
gastric filling due to the intrusion into the lumen of solid 
tissue. This may be of greater or less extent. Generally, 
the most marked "filling-defects" are seen toward the 
pylorus, that is, in the region where gastric cancer is most 
common. They may occur, however, at any part of the 
stomach. They result in atypical irregularities of the 
lumen. In some instances they totally occlude the gastric 
cavity. On account of the fact that gastric cancers are 
generally of the medullary type, one not infrequently sees 
that the outline of the gastric lumen is irregular, or has a 
worm-eaten or old cheese appearance. This condition 
exists because the nodular projections of the growth permit 
of varjdng amounts of bismuth lodging between them. 
Hence, the Roentgen ray penetrates greater quantities 
of bismuth at some parts than at others. 

Whatever may be the situation of the gastric neoplasm, 
if it has advanced far enough to be recognized by the 
a;-ray, there is always encroachment upon the lumen of the 
organ at some point. In cases of scirrhus growth in- 



ROENTGEN EXAMINATION IN GASTRIC CANCER 279 

vading largely the submucosa, there is a smaller lumen 
than ordinarily shown. The lumen may be quite uniform 
in such instances, but due to the thickness of the gastric 
wall, the resultant cavity is contracted (so-called ''leather- 
bottle stomach"). 

When the growth is at the cardia, not infrequently such 
is difficult to recognize due to the left lobe of the liver, the 
lower ribs, the breast or the sternum lying in front of it. 
Careful examination, however, usually discloses some out- 
line defect or some atypical way in which the opaque me- 
dium enters the stomach. In normal cases, a fluid passing 
the cardia seems to closely hug the lesser curvature {magen- 
weg). Where there is some fault at the cardia, one not 
infrequently sees that the bismuth is delayed in the 
esophagus. When it does enter the stomach, it may pass 
in in several streams, may not hug the lesser curvature, or 
it falls through in large drops or gobs. Above neoplasms 
at the cardia there may be extensive dilatation or the 
esophagus may even be infiltrated by the tumor. 

When the growth is high in the lesser curvature, the lumen 
is usually encroached upon in a characteristic way. If, 
however, the growth is not very soft or papillomatous the 
outline of the lesser curvature may be fairly regular. The 
resultant appearance then may be difficult to differ- 
entiate from a normal lesser curvature pushed to the left 
by an extragastric tumor (liver, gall-bladder, pancreas, retro- 
peritoneal sarcoma). In this event an examination of the 
patient in different positions will often serve to delimit the 
esophagus. It may even be infiltrated by the tumor. 

When the growth is situated in the body or the pars media 
of the stomach, fluoroscopic examination usually makes 
evident local narrowing of the gastric lumen. The extent 
of this depends upon the size of the neoplasm. Often, hour- 



280 CANCER OF THE STOMACH 

glass loculation is seen. Occasionally, several gastric 
chambers are apparent, partly or wholly filled with the 
shadow-casting substance. Xot infrequently, in extensive 
tumor involvement, all that remains of the stomach's 
lumen is a narrow, usually tortuous, canal, through which 
the bismuth or barium mixture passes in an attenuated 
stream and is visible with difficulty. If such canal has 
between it and the screen a great mass of cancer tissue, 
opaque media in it may not be evident. The test-meal 
may then be seen in an upper (usually larger) loculus and 
appear again in a cavity toward the antrum or pylorus. 

Growths involving the antral or the pyloric region generally 
manifest their presence by such intrusion upon the gastric 
cavity as to produce partial or nearly complete obstruction 
to the onward passage of the bismuth or barium meal. 
In these instances gastric emptying power may be greatly 
deficient, delayed or lost. Consequently, even bimanual 
massage of the epigastrium cannot force the opaque 
mixtures forward in such amount as to permit the visualiza- 
tion of the pyloric channel or the duodenum. If the 
growth in these locations is firm or large, there is, com- 
monl}', compensatory dilatation of the stomach. Such 
neoplasms intrude so greatly into the narrow distal end of 
the viscus as to render much of its channel invisible or 
only recognizable as a wavy canal wandering between 
indefinitely delimited cancer masses. Not rarely, the entire 
pyloric third of the stomach appears chopped or torn off 
and only a few rests of bismuth or barium, in its general 
direction or lodged in the viscera beyond, indicate that 
some canalization of the mass exists. 

There is, as we have mentioned above, a certain type of 
tumor (usually of the class styled '^scirrhus") which may 
extensively infiltrate large sections of the pyloric end or 



ROENTGEN EXAMINATION IN GASTRIC CANCER 281 

even the entire wall of stomach, without producing ob- 
struction. In such cases, the pylorus may gape and gastric 
contents rapidly escape into the small intestine. Usually, 
however, the general thickness of the stomach wall results 
in narrowing of the gastric lumen, locally, toward the 
pylorus or, generally, throughout the stomach. The lumen 
thus appears small, often tapering in a funnel-like manner 
toward the duodenum. Its boundaries may be slightly 
fringed, wavy or irregular. In any event, a relatively 
small gastric shadow is visible upon the fluorescent screen. 
The shadow may be pyriform, gourd-shape or bottle-like. 

Cancers directly upon the posterior or anterior wall, unless 
large enough to produce deformity of the stomach, may 
reveal little evidence of their presence unless various por- 
tions of the stomach are successively silhouetted either by 
abdominal palpation, or by observing the filled viscus at 
different angles (anterior-posteriorly, standing and re- 
clining; laterally, from both sides, standing and lying, etc.). 
In the case of growths on the posterior wall, great difficulty 
may be experienced in differentiating such from tumors of the 
liver, pancreas, retroperitoneal tissues or left kidney. 

In general gastric carcinosis, occlusion of the normal 
lumen may be so extensive that very little may be recog- 
nized. Instead, ^'flecks" or larger ''rests," the shadow- 
casting media may be intermingled with gas bubbles and 
solid tissue, the whole giving indefinite shadows (mottling, 
dappling, sponge-like, or thick soap suds appearance) in the 
region where we normally locate the stomach, or where 
abdominal palpation permits the recognition of a tumor. 

In gastric cancer, where early or late ulceration has 
occurred, one can frequently delimit definite craters, with 
ragged edges, and these often retain rests of bismuth or 
barium. If such have become adherent to adjacent viscera 



282 CANCER OF THE STOMACH 

or perforated into these, then the adhesion or the false 
channel can sometimes be established. 

Peristalsis is generally not evidenced by vigorous gastric 
contractions in cancer of the stomach, unless the process is 
implanted on an ulcer and not far advanced, or unless a 
small (often ring-like) growth causes hour-glass contraction 
or pyloric stenosis. The invasion of the stomach wall by 
malignant disease appears to early bring about varying 
grades of gastric atony or palsy. In non-obstructive 
growths, where the stomach's emptying time is better than 
normal, it would seem that weakness of the walls of the 
viscus rather than strength or frequency of peristaltic 
waves permit the heavy, opaque mixtures to, roughly 
speaking, ''fall through" into the duodenum. This is 
particularly marked where there are few nodulations to the 
growth or where the neoplasm is located proximal to the 
antrum. 

Palpation is one of the most valuable maneuvers during 
fluoroscopy. By its use, one is able to establish the mova- 
bility of the stomach, to delimit the lumen completely, to 
fill or empty ulcer craters, to test the patency of the pylorus 
or cardia, to outline the boundaries of the duodenum, to 
prove the relationship of the stomach to other viscera, to 
locate a palpable abdominal mass with respect to its being 
gastric or extragastric, to test its mobility, to estimate the 
relative involvement of the stomach by such mass, or to 
uncover gastric neoplasms (as on posterior wall) which 
direct view, without palpation, does not reveal. Tender 
areas can be roughly located with respect to their associa- 
tion with parts of the stomach. Thus, one may sometimes 
gauge the presence or absence of perforation and peritoneal 
invasion. In instances, where free fluid exists in the ab- 
dominal cavity, palpation enables one to recognize its 



EOENTGEN EXAMINATION IN GASTRIC CANCER 283 

presence and extent and by observing the limits of such 
with the patient in different postures to demonstrate its 
situation with respect to the abdominal viscera. Of 
course, common clinical tests frequently return informa- 
tion equalty valuable. There seems to be a peculiar 
satisfaction, however, in the visualization of these phe- 
nomena, The psychic effect of these maneuvers upon the 
patient or his friends appears to be highly valued in some 
quarters. 

THE EXAMINATION BY MEANS OF ROE NTGENO GRAPHIC 
PLATES OR FILMS 

The perfection of the fiuoroscope has rendered this 
method largely obsolete, tedious, of little added clinical 
worth and unnecessarily expensive. There are few cases 
of gastric cancer where any Roentgenographic evidence is 
at all possible, that cannot be quite as successfully recog- 
nized by aid of the fluoroscopic screen as by a series of 
plates or films. The fine distinctions which certain ob- 
servers demonstrate upon 18 to 40 successive plates, while 
they may have artistic worth have little practical, clinical 
value. The multiplication or diminution of the number 
of shadows in an area in which already one knows that a 
tumor exists, while entertaining to certain minds is clinically 
as meaningless and non-essential as are the multitudinous 
incongruities of a cubistic canvas. 

The physical effort demanded of a desperately ill and 
generally weak patient in the making of a large series of 
plates is often a serious consideration. The expense of 
the maneuver is out of all reasonable proportion to the 
worth of the information returned. As we have men- 
tioned above, in a series of 147 gastric cancers where the 
x-rsLj examination gave information of possible or positive 



284 CANCER OF THE STOMACH 

diagnostic worth in 92 per cent, of instances, by such 
inexpensive and simple procedure as microscopic examina- 
tion of stained smears of gastric extracts or vomitus, bacilli 
of the Oppler-Boas type were demonstrated in 93.8 per 
cent. But rarely are bacilli of this type observed in non- 
malignant conditions. 

Certain value is found in the making of a few radio- 
grams in gastric cancer. Such enable one to keep a 
record of the progress of a non-operated case, to recognize 
recurrences after excision of a tumor, to corroborate fluoro- 
scopic observations and as an aid in advancing knowledge. 
It is thought by some that prints from plate series are 
not without advertising value, even if of little scientific 
worth, provided they be sent abroad appropriately be- 
decked. The unique scientific spirit which prompts this 
course is productive of much unwarranted cancerphobia. 
However successful a trade venture it may be, it cannot 
be too strongly condemned as a professional act. 

Mode of Procedure. — Ordinarily, after the fluoroscopic 
examination of gastric function, it is possible to proceed 
with the plate making. If records of an opaque-meal 
''rests" remaining after 6 hours is desired, plates may be 
made before the complete fluoroscopic examination- is 
made. 

After the fluoroscopic examination, the stomach should 
be filled again with bismuth or barium puree. This is to be 
especially urged if the gastric emptying time has been 
rapid. Radiograms of the partially filled stomach do not 
enable one to deUmit its outline accurately. 

When the stomach has been filled, plates are made in 
the usual manner. In uncommon cases, it is advisable to 
expose the plates with the patient successively standing, . 
recumbent or lying on one or the other side. In this 



EOEXTG 



:tEX examination in gastric cancee 285 





p,,, ,;o_ C'l^e No 19,539).— MaUgnant hour-glass stomach with ante- 
cedent ht.ton'o^Scexi partial obstmctTon at cardia, with bismuth m dJ^ated 
esophagus. Tuberculosis of stomach ^patient also had pulmonary tubei- 
culosisj. 



286 



CANCER OF THE STOMACH 





Fig. 63. — Irregular primary cancer history: involvement of cardia and 

pylorus. 
Mr. W. K.— Age 62. 

Personal History. — Negative. 

Duration of Present Ailment. — About 1 year, trouble has been continuous, 
with recent aggravation. 

Comes on account of dyspepsia, abdominal pain, weight and strength loss 
and anemia. 

Discomfort is located in the epigastrium, is described as a "dull ache" 
and "shuts off wind." It is more or less constant, but worse immediately 
following food ingestion. It is transmitted to rib edges. Distress relieved 
by limiting diet, bj^ vomiting and rest. 

Patient vomits two or three times a week (usually in the afternoon). 
Vomitus consists of sour liquid and food. The emesis is brought on by pain. 
Water-brash and pyrosis are annoying. 



EOENTGEN EXAMINATION IN GASTRIC CANCER 287 

way, one is least likely to fail in the recognition of a gastric 
deformity. Its extent can be better calculated by such 
procedure. 

If a series of plates is desired, such may be made rapidly, 
as, for example, 15 to 25 within 20 minutes followed by plates 
made at from 1- to 6-hour intervals until the gastro-intestinal 
tract has freed itself of bismuth or barium mixtures. There 
are numerous ingenious mechanical devices for making such 
a plate series. In admiration of the perfection of these 
contrivances one may readily lose sight of the fact that the 
information they return to us has little actual, chnical 
worth. 

The Information Derived from Roentgenograms in 
Gastric Cancer. — In early cancer there are no positive x-tslj 
signs beyond those of compHcated ulcer or obstruction, 
whatever may be the location of the growth. Where well- 
estabhshed carcinoma is located at the cardia permanent 
record may be obtained of dilatation, iuA'olvement or dis- 
placement of the esophagus, alterations in outUne, size, 
position and patency of the cardia and, rarely, evidences 
of perforation to adjacent viscera. 



Appetite is variable. 

Bowels have been constipated for 7 montlis. 

Weight. — ^Loss of 23 pounds in past year. 

Abdominal Examination. — Tender ridge in upper right epigastrium, 
moving to region of navel on inflation of stomach. 

Tesf-meaZ.— Stomach tube meets no resistance at cardia. Xo 12-hour 
retention. 75 cc. of cream yellow, rancid contents removed. Total acidity, 
8; free hydrochloric acid, 0; altered blood+; lactic acid,?; Wolff-Junghans' 
test, 0; formol index, 24. 

Microscopic Examination. — Few food bits, Oppler-Boas bacilH ?, sarcinse 
(large form); numerous deeply staining, lance-shaped rods; leptothrix-H; 
many polynuclear leucocytes. 

Stool. — Altered blood-}- (benzidin test). 

Clinical Diagnosis. — Aehlorhydria; ulcus carcinomatosum. 

X-ray Diagnosis. — Filling defect at cardia and pylorus, probable carci- 
noma, scoliosis. Plate shows a blunted "steer-horn" stomach, with 
moderate dilatation, peristalsis is almost absent. On high lesser curvature 
appears a filling-defect of the crater-ulcer type; the chopped-off pylorus 
appears to be due to a tumor. The duodenum is dilated. 

Surgical Diagnosis. — Inoperable carcinoma. 



288 



CANCER OF THE STOMACH 




ti020 



tt 




pa' 



iI^^bR 




Fig. 64. — (Case No. 19,020). — Inoperable gastric cancer, involving cardia 

and pars media. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 289 




Fig. 65. — Pyloric obstruction; gastric carcinosis. 
Case No. 23,650— Mr. J. H.— Age 78. 

Abdominal Examination. — Movable mass in mid-epigastrium; stomach 
moderately dilated. 

Test-meal. — Twelve-hour retention; gastric extracts, tan color; rancid 
odor. Total acidity, 10; free hydrochloric acid, 0; altered blood, ? (benzidin 
test) ; lactic acid + ; Wolff- Junghans' test, 0. 

Microscopic Examination. — Numerous food rests; great numbers of 
bacilli of Oppler-Boas type; few budding yeasts. 

Clinical Diagnosis. — -Pyloric obstruction due to inoperable gastric cancer. 

X-ray Diagnosis. — Carcinoma of stomach; marked hypertrophic arthritis 
of spine. 

Plate shows pyloric half of stomach and lesser curvature invaded by nodu- 
lar growth; lumen nearly obliterated in antrum and pylorus; no visualiza- 
tion of duodenum or distal viscera. 

Surgical Diagnosis. — Irremovable gastric tumor. 

19 



290 



CANCER OF THE STOMACH 




Fi.j. 06. — ^'ase Xo. 23,14,;. — Perforating ulcer malignant ?) on lesser 
curvature; gaping pjdorus. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 291 



Fig. 67. — Chronic perforating gastric ulcer; malignancy questionable; 

hour-glass contraction. 
Mr. H. C. C— Age 36. 

Previous History. — Negative. 

Comes on Account of chronic intermittent indigestion and chronic 
constipation. 

Duration of Disease. — Attacks of dyspepsia for the past 18 years; has 
three or four attacks a year. Is usually worse in spring and fall. Trouble has 
been constant during the last 3 months. The attacks are characterized by 
pain in the upper left epigastrium, come on usually 3 to 4 hours after eating 
and after he gets to bed at night. Pain is a soreness, a hard ache or a colic. 
At present he is never free from distress, but rehef is obtained by food inges- 
tion, vomiting, rest or alkaUes. Pain is usually transmitted to the left 
costal margin and to the tip of the left scapula. Vomiting is of almost daily 



292 CANCER OF THE STOMACH 

If the fundus or cardiac portion of the lesser curvature 
is affected, irregularities in outline with lagging of the 
opaque-meal, narrowing of the lumen or signs of adhesion or 
perforation may be determined. 

When the neoplasm has invaded the body of the stomach 
marked irregularities in the outline of the gastric channel are 
not rarely seen. There may be such constriction of the 
lumen as to produce hour-glass form. Peristaltic activity 
is usually diminished. It may be almost absent. Dilata- 
tion of the stomach or of one or both loculi (in the event of 
hour-glass type), with misplacement due to perigastric 
adhesions (often malignant) or perforation are not uncom- 
monly visualized. In some instances definite crater forma- 
tion upon the top of nodule projecting into the stomach 
lumen may be made out. When the growth is limited in 
extent or confined to the anterior or posterior walls, few 
radiographic signs, apart from alterations in peristalsis or 
rate of onward progression of the opaque-meal, may be 
evident. Observation made with the patient in different 
positions sometimes helps to elucidate a seemingly negative 

occurrence but usually follows almost immediately after food ingestion. It 
is brought on by abdominal pain and the sensation of food sticking "at the 
entrance to the stomach." Eructations, belching, water-brash and pyrosis 
are very marked. 

Appetite. — Capricious. 

Weight Loss. — None. 

Hemorrhage. — Helena IJ^ years ago followed by severe hematemesis. 
Nine days ago had severe hemorrhage from stomach and bowels and fainted. 

Bowels. — Constipation for the past 18 years. 

Ahdominal Examination. — Tenderness and dulness very marked in the 
mid-epigastrium . 

Test-meal. — Moderate 12-hour retention. Gastric contents, tan brown 
in color and of sour odor. Total acid, 70; free hydrochloric acid, 70; 
altered blood -H. 

Microscopic Examination. — ^ Yeasts; sarcinse. 

Clinical Diagnosis. — Subacute perforating lesser curvature ulcer with 
obstruction. 

X-ray Diagnosis. — Perforating ulcer of the stomach, lesser curvature; hour- 
glass stomach. X-ray plate shows bi-loculation of the stomach due to con- 
striction in the pars media. The channel is very narrow at this point and 
just above it on the lesser curvature is an ulcer crater containing a bismuth 
rest. The incomplete filling of the lesser curvature of the upper loculus 
makes it impossible to say whether this process is malignant or benign. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 293 





Fig. Gb.— (Case No. 20,Gl(Jj. — liour-gla.sb feLoiiiuch; _ saddle ulcer pars 
media; gaping pylorus; spasm at cardia. 



294 



CANCER OF THE STOMACH 




Fig. 69. — Achlorhydria; indefinite clinical picture. Filling defect of pars 

media. 



EOENTGEN EXAMINATION IN GASTRIC CANCER 295 



DESCRIPTION OF FIG. 69 

Mr. P. P. — Age 62 — Farmer. 

Past History. — Typhoid fever, 19 years previously. 

Comes on account of anorexia, weight and strength loss, anemia, mild 
dj'spepsia. Patient felt perfectly well up to 4 weeks ago. Gradually lost 
appetite and experienced vague, bloated sensations in the upper abdomen. 
These have been continuous, but are most marked soon after food ingestion. 
Recently has vomited in the late afternoon, and obtained relief of abdominal 
discomfort. Never vomited blood or food retained more than a haK day 
Suffers nausea soon after eating. Occasionally experiences regurgitation of 
food. Has been growing paler during past fortnight. 

Appetite. — Very poor. Bowels moderately constipated. Never noted 
melena. 

Weight. — ^Loss of 33 pounds in past 2 months. 

Abdominal Examination. — Dubaess and area of deep tenderness above 
the navel. Negative otherwise. ^ 

Test-meal. — No 12-hour retention; stomach slightly dilated. Gastric 
extract is cream colored and food poorly chymified. Total acidity, 10; free 
hydrochloric acid, 0; altered blood + (benzidin test); lactic acid, 0; Wolff- 
Junghans' test +. 

Microscopic Examination. — Shows a few budding yeast cells. 

Stool. — Altered blood. 

Clinical Diagnosis. — Achlorhydria; carcinoma. 

X-ray Diagnosis. — Apparent filling defect in pylorus, antrum and lesser 
curvature. Pylorus gapes. Suspicious of malignancy. 

Plate reveals a modified "fish-hook" stomach; peristalsis fairly active, 
duodenum well visualized, apparent canalization of a growth toward pyloric 
fifth of the stomach. 

Surgical Diagnosis. — Cancer at the pyloric end of the stomach. 



296 



CANCER OF THE STOMACH 




Fig. 70. — Carcinoma involving greater curvature and posterior wall. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 297 



DESCRIPTION OF FIG. 70 

Mrs. C. C. W.— Age 53. 

Previous History. — Hysterectomy 13 years ago. 

Comes on account of chronic dyspepsia, weiglit and strengtli loss, anemia. 

Duration of Disease. — Spells of dyspepsia on and oif for the past 20 years 
at infrequent intervals. Attacks have been characterized by pain in the 
upper left abdominal quadrant. Would last for days; were coUcky and 
gassy in character; were most marked when the patient had an attack of 
diarrhoea. Pains did not seem to be aggravated by dietetic variations. 
Were usually reUeved bj* rest or by vomiting, belching, pyrosis or regurgi- 
tation. 

Appetite. — Food desire very good. 

Boioels. — Four to seven movements a day for the past 10 months. Light 
in color. 

Weight Loss. — Thirty-five pounds in 1 year. 

Abdominal E.xamination. — Dulness in Traube's space. In upper mid- 
epigastrium a large thick tumor is palpated. Stomach holds 23 ounces, 
greater curvature is 3 finger breadths below the navel line. 

Test-meal. — 100 cc. of tan and brown poorly chyniified material removed 
after 57 minutes. Marked bleeding on manipulation of tube. ^Moderate 
amount of previous evening meal recovered. Very free hemorrhage on 
lavage. Total acidity, 22; free hydrochloric acid. 0; altered blood + (benzi- 
din test;) Wolff-Junghans' test -|-; lactic acid. 0. 

Microscopic Examination. — Oppler-Boas bacilli. Alany short bacilli 
in pairs. Numerous red blood cells and food remains. 

Clinical Diagno.ns. — Extensive inoperable gastric cancer with involvement 
of cardia. 

X-ray Diagnosis. — Probable carcinoma of the stomach. 

Plate shows steer-horn stomach with moderate ptosis and extensive filling 
defects in the region of the body, antrum and pylorus. 

Surgical Diagnosis. — Inoperable carcinoma. 



298 



CANCER OF THE STOMACH 




Fig. 71. — (Case No. 19,359). — Extensive cancer of stomach with filling 
defects at pars media and pyloric end. Pylorus is displaced to the left. It 
is patent. Duodenum visualized and dilated. 



EOEXTGEX EXAMINATION IX GASTRIC CAXCER 299 




Fig. 72. — (Case Xo. 1,906). — Scirrhus cancer of stomach.; funnel-shaped 
stomach; pj'lorus displaced to left and patent; duodenum visualized. 



300 



CANCER OF THE STOMACH 




Fig. 73. — History suggesting chronic perforating peptic ulcer; syphilis (?); 
lesser curvature ulcer (malignant ?); demonstrated. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 301 



DESCRIPTION OF FIG. 73 

Mr. W. P. — Age 58 — Farmer. 

Personal and Family Histories. — Syphilis.? 

Duration of Present Ailment. — Infrequent attacks of dyspepsia for 3 years. 
Trouble has been constant for past month. 

Complains of abdominal pain, indigestion and recent weight loss. Pain 
is marked in the mid-epigastrium, is of severe aching and "doubling up" 
type and usually transmitted to the right costal margin. Pain comes on 
usually 4 to 5 hours after meals and lasts until something is eaten. Is less 
comfortable on light diet. Relief of distress is also obtained by peppermint 
water and rest. 

Vomiting — ^usually brought on as result of sudden movement, occurs 
irregularly. Pyrosis is annoying at irregular intervals, but usually relief 
is obtained by drinking peppermint water. 

Appetite. — Fair. 

Bowels. — Constipation alternating with diarrhoea. 

Abdominal Examination. — To right and above navel is an indefinite, 
fixed, tender I'idge. Stomach splashy. 

Test-meal. — No 12-hour retention. Gastric extract is of light green color. 
Test food is well chymified. 175 cc. recovered. Total acidity, 30; free 
hydrochloric acid, 30; altered blood, 0; lactic acid, 0; Wolff -Junghans' test, ?; 
formol index, 19.2. 

Microscopic Examination. — Food remains, yeasts and diplococci. 

Clinical Diagnosis. — Subacute perforating ulcer lesser curvature. Malig- 
nant change.? Syphilis.? 

X-ray Diagnosis. — Calloused ulcer of the stomach. 

Plate shows ulcer crater on lesser curvature with deep incisura on greater 
curvature at about the same level. It is impossible to say whether or not 
the tilcer is malignant. 

Stomach empties freely, pyloric end is in state of moderate contraction; 
duodenum is poorly visualized. 

Surgical Diagnosis. — Ulcer on lesser curvature with chronic perforation. 



302 



CANCER OF THE STOMACH 




Fi(.. 74. 
Case No. 20,799— Male— Age 62. 

History that of chronic perforating gastric ulcer with suspicion of recent 
malignant change. 

X-ray Diagnosis. — Perforating ulcer on lesser curvature. 

Operative Findings. — Large ulcus carcinomatosum on lesser curvature. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 303 

case as shown by routine technique where in such case 
test-meal findings and clinical examinations strongly point 
toward gastric cancer. 

Carcinoma at the pyloric end of the stomach is commonly 
associated with some grade of gastric retention and quite 
often with compensatory dilatation of the viscus. This is 
not always demonstrated because occasionally the stomach 
is involved locally in a tough, gristle-like growth that 
stiffens the wall, thereby maintaining a widely patent 
lumen, with not infrequently a gaping pylorus. Little 
detail of the cancer, Roentgenographically, may be possible 
in such instances on account of the rapid emptying of the 
stomach. There may be few or no opaque-meal ''rests." 
Ordinarily, invasion of the antrum or pylorus results in 
great change in the caliber of the lumen. This may be 
narrowed, generally or locally, with resultant tortuous, 
irregular, bulbed, lobulated, funnel-shaped, or almost 
invisible gastric channel. Perforation or ulceration may 
produce accessory chambers filled with bismuth or barium, 
or reveal evidences of involvement of fiver, pancreas, 
adjacent bowel or the peritoneal cavity. 

There are instances where ring cancers at or near the 
pylorus produce striking local constriction of the lumen 
with marked obstruction. If such cancer occurs directly 
at the pylorus, the blunt, abruptly cut-off termination of the 
stomach, with dilatation of the viscus, generally, or the 
antrum, locally, associated with failure of visualization of 
the duodenum, is a fairly characteristic picture. In this 
type of neoplasm, peristalsis may be quite active. 

With the object of demonstrating the relative worth of 
Roentgenographic evidence in gastric cancer, we have ar- 
ranged a series of Roentgenograms in association with other 
clinical and surgical findings. It will be observed that in 



304 



CANCER OF THE STOMACH 





Fig. 75. — Pyloric obstruction; malignant ulcer (?) 



ROENTGEN EXAMINATION IN GASTRIC CANCER 305 



DESCRIPTION OF FIG. 75 

Mr. G. H. S. — Age 37 — American. 

Comes on account of chronic constipation and chronic intermittent 
dyspepsia. 

Previous History, — Typhoid fever when a youth. 
' Duration of Present Complaint. — For past 12 years has had attacks of 
painful dyspepsia, lasting for several weeks and coming on usually in the 
fall. These attacks have been characterized by soreness or gnawing pains 
in the pit of the stomach, which distress usually came on 1 to 2 hours after 
meals and at night. The distress would last until food was ingested or 
vomiting occurred . Alkalies and limited diet have been frequently required . 
Pain was generally referred to the back, between the shoulders. Vomiting 
occurred irregularly and was most common in the evening. Belching and 
pyrosis have been annoying. Dyspepsia constant and more marked past 
6 weeks. 

Appetite. — Good desire. 

Bowels. — Very constipated for 10 years. During the past 3 months this 
has been aggravated. 

Bleeding. — -Two weeks ago severe hematemesis. 

Weight. — Lost 10 pounds during past 2 months. 

Abdominal Examination. — Very tender in right upper quadrant. Stomach 
splashy. 

Test-meal. — Marked 12-hour retention; 300 cc. recovered; extracts are 
tan-brown and with yeasty odor. Total acidity, 48; free hydrochloric acid, 
46; altered blood, (benzidin test). 

Microscopic Exajnination. — -Many food rests. Yeasts and sarcinse in 
excess. 

Clinical Diagnosis. — Pyloric obstruction; duodenal ulcer. 

X-ray Diagnosis. — Pyloric obstruction; probable duodenal ulcer. 

Plate shows large "steer-horn" type stomach with hyperperistalsis and 
irregular filling out of pylorus; duodenum is but faintly visualized. 

Surgical Findings. — Chronic "saddle-ulcer" on lesser curvature at 
pylorus. 

Without microscopic examination it was impossible to tell whether ulcer 
was malignant or benign. 



20 



306 



CANCER OF THE STOMACH 




Fig. 76. — Achlorhydria : Nervous patient; irregular ulcer liistorj^ with 
recent exacerbation; pyloric cancer. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 307 



DESCRIPTION OF FIG. 76 

Mr. P. F.'jC. — Age 45— Manual laborer. 

Previous History. — Typhoid fever as a youth. 

Comes on account of abdominal pain, dyspepsia, nervousness, recent 
weight and strength loss. 

Duration of Disease. — Intermittent dyspepsia for past 5 years. The 
present attack has persisted for 3 weeks. 

The disturbance is characterized by distress across the mid-epigastrium 
and by belching and water-brash. These symptoms are moderately con- 
stant, but more pronounced when the stomach is empty, or immediately 
after eating. Distress is often transmitted to the precordia. It is relieved, 
partially, by food intake, catharsis or rest. Belching and water-brash come 
on usually soon after eating. Alkalies relieve the distress occasioned 
thereby. 

Mentality. — Below par, patient highly psychic and excitable. 

Appetite. — Poor. 

Weight. — Lost 11 pounds past 3 weeks and 29 in past year. 

Test-meal. — No 12-hour food retention; gastric contents cream tan in 
color. Total acidity, 10; free hydrochloric acid, 0; altered blood, (benzidin 
test); lactic acid, 0; glycyltryptophan test-f-. 

Microscopic Examination. — Numerous small lymphocytes and cocci in 
short stains and small groups. 

Stool. — Altered blood+. 

Clinical Diagnosis. — Gastric achlorhydria (carcinoma ?); psychasthenia. 

X-ray Diagnosis. — Carcinoma of pyloric end of stomach. 

Plate demonstrates "steer-horn" type of stomach, with extensive filling 
defect of the antrum and pylorus. Tumor is irregularly canalized. Pylorus 
is patent. Bulbus duodeni is deformed. Motor meal rests in ascending, 
transverse and descending portion of the colon. 

Surgical Diagnosis. — Cancer of pyloric end of stomach. 



308 



CANCER OF THE STOMACH 




Fig. 77. — Pyloric ulcer, motor meal residue — perforating ulcer. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 309 



DESCRIPTION OF FIG. 77 

Mr. P. W.— Age 48— Irish. 

Family History. — Negative. 

Comes on account of chronic intermittent dyspepsia. Duration of 
disease 20 years in spells or attacks. These attacks have been characterized 
by marked epigastric pain coming on 1 to 3^ hour after meals or at night. 
Pain is usually very sharp but sometimes a gnawing and burning sensation. 
Usually lasts several hours and is transmitted to the back between the shoul- 
der blades. Pain is relieved by food intake, vomiting and alkalies. Has 
several times required morphine. During the last 3 weeks the distress has 
been constant and vomiting has been an annoying symptom. Vomiting 
usually occurs about 13^ hours after meals and seems to be brought on by 
abdominal pain. The vomitus is sour water and sometimes food. There 
has been no delayed vomiting. Nausea has been marked especially in the 
evening. Eructations, water-brash and pyrosis are particularly distressing 
at night. They are relieved by alkalies. 

Appetite. — Poor. 

Bowels. — Constipated; never any bleeding. 

Weight Loss. — Eighteen pounds in 6 months. 

Clinical Diagnosis. — Partial pyloric obstruction, due to peptic ulcer 
(malignancy questionable), moderate dilatation of the stomach. 

X-ray Findings. — -Moderate 6-hour retention (Rieder meal); peristalsis 
active, incomplete visualization of pylorus and duodenum ; tenderness over 
region of pylorus, possible ulcer of the stomach or duodenum. 

Surgical Findings.- — Chronic perforating ulcer of the duodenum to liver 
and chronic appendicitis. 



310 



CANCER OF THE STOMACH 



R 

JSOfM 




Fig. 78. — (Case No. 20,594).- — -Clironic, recurrent ulcer (malignant ?) at 
pylorus with partial obstruction. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 311 



fl 





YiG 79— (Case No. 22,157).— Pyloric obstruction. Plate shows dilated 
stomach with extensive neoplastic involvement of antrum and pylorus; 
pylorus partly patent; fair gastric peristalsis. 



312 



CANCER OF THE STOMACH 




Fig. 80. 
Case No. 20,905— Male— Age 41. 

Iiivolvement of pyloric third of stomach by cancer following history clinic- 
ally that of ulcer. Rests of motor-meal seen below stomach in colon. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 313 




19218 




Fig. 81.- — (Case No. 19,219). — Cancer of pars pylorica following history 
clinically that of ulcer; partial pyloric obstruction to physiologic motor- 
meal. Dilated small bowel partly filled with bismuth, suggesting an 
obstruction distally. 



314 



CANCER OF THE STOMACH 








Fig. 82. — Pyloric obstruction, malignant. 
Case No. 23,652— Male— Age 48. 

Previous History. — Clinically that of chronic, recurrent peptic ulcer. 
Two previous operations demonstrated such. 

Abdominal Examination.— -Inde&nite ridge in mid-epigastrium. 

Test-meal. — Slight 12-hour food retention. Gastric extracts cream-tan 
color. Poorly chymified. Total acidity, 10; free hydrochloric acid, 0; 
altered blood, ? (benzidin test); lactic acid-1-; Wolff- Junghans'-j- test. 

Microscopic Examination. — Numerous bacilli of Oppler-Boas type; few 
budding yeasts. 

Clinical Diagnosis.- — Carcinoma following ulcer; questionably operable. 

X-ray Diagnosis. — Carcinoma of stomach. 

Plate shows tumor mass involving pyloric third, with irregular canaliza- 
tion of mass, but gaping pylorus, permitting rapid exit of bismuth into 
duodenum and small bowel (which are visualized). Lesser curvature is also 
infiltrated; 

Surgical Diagnosis. — Gastric cancer. 



ROENTGEN EXAMINATION IN GASTRIC CANCER 315 




Fig. 83.— (Case No. 20,730j.— Recumng gastric cancer, with partially 
patent gastro-enterostomy stoma. 



316 



CANCER OF THE STOMACH 




Fig. 84. — Pyloric obstruction; previous irregular peptic ulcer history; 
irremovable gastric tumor; syphilis. 



EOEXTGEX EXAMINATION IN GASTRIC CANCER 317 



DESCRIPTION OF FIG. 84 

Mr. M. S. — Age 40 — German — Merchant. 

Previous History. — Genital sore in youth. Abdominal section (else^vhere) 
1 year ago; gastric ulcer ?. 

Comes on account of chronic indigestion, weight and strength loss, anemia. 

Duration of Disease. — For past 12 years has had attacks of indigestion. 
These were characterized by epigastric distress several hours after meals, 
belching, pyrosis and loss of appetite. Distress and associated symptoms 
were relieved by food, alkalies or diet. Eighteen months ago the symptoms 
became so annoying that patient was unable to work. A year ago had 
laparotomy and thinks ulcer and adhesions were found. Did fairly well up 
to 3 months ago. Since then has had constant epigastric pain, worse 
immediately after meals and at night, and only partially reUeved by rest 
and limited diet. Eructations and pyrosis have been annoying. 

Appetite. — Poor. 

Bowels. — Unexplainable diarrhea for past 4 days. Never bled. 

Weight.- — Lost 11 pounds last 2 months. 

Abdominal Examination. — Healed laparotomy scar. In mid-epigastrium 
to right of scar and adherent to it is an oval, fixed, tender nodule. 

Test-meal. — Moderate 12-hour retention. Gastric extract cream color, 
with sour odor. Total acidity, 14; free hydrochloric acid, 0; altered blood+ 
(benzidin test;; Wolff-Junghans' test+; formol index, 20; lactic acid, 0. 

Microscopic Examination. — -Numerous bacilli of the Oppler-Boas type, 
budding yeasts and small form sarcinse, few streptococci. 

Clinical Diagnosis. — Pyloric obstruction; partial hour-glass; achlorhydria; 
gastric cancer on old ulcer. Syphilis ? Inoperable. 

X-ray Diagnosis. — Probable carcinoma or syphilis of the stomach. 

Plate shows small modified "steer-horn" type of stomach. The lumen of 
the pyloric half is encroached upon by a mass so extensively as to almost 
obliterate it; nodular infiltration is denoted by the irregular outline of the 
curvatures, particularly the greater; obstruction is shown by failure to visual- 
ize the duodenum or parts of the bowel distal to it. 

Surgical Diagnosis. — Irremovable gastric tumor. 



318 CANCER OF THE STOMACH 

the majority of cases, clinical diagnosis was quite possible 
without the added a;-ray examination; that in clinically 
doubtful cases, the Roentgenographic diagnosis was sim- 
ilarly dubious. The plates form, however, an interesting 
accessory record to the histories, and aid in selection of 
cases likely to be benefited by surgical procedures, by indi- 
cating, roughly, the location of the growths and the extent 
that they invade the gastric wall or involve other viscera. 



CHAPTER VII 
THE BLOOD IN GASTRIC CANCER 

The terms ''malignancy" and ''cachexia" have become 
so closely associated as result of years of clinical investi- 
gation, that the mention of one suggests the other. Of the 
numerous evidences of cachexia with neoplastic foundation, 
anemia is one most commonly recognized by both layman 
and physician. Certain gross manifestations of the cancer- 
ous anemia are often appreciated upon even casual ex- 
amination. 

The skin is usually dry, loose, scaly, muddy, grayish- 
white or of fawn or lemon-yellow tint. Were the early 
decrease in the amount of subcutaneous fat not of fre- 
quent occurrence, the skin-tint might readily be mistaken 
for that observed in such constitutional fault associated 
with that clinical picture which we call pernicious anemia. 
The sclera are commonly pearly white, but may be dis- 
colored or faintly yellow. Mucous surfaces exhibit varying 
degrees of paUor. They are generally dry and often shiny. 
Those of the Ups and tongue maybe fissured or herpetic. 
The tongue is frequently pale, dry, roughened and coated. 
Capillary edema accumulates about the malleoli. Some- 
times pufiness beneath the eyes indicates a hematopoietic 
dyscrasia or kidney malfunction. 

It should be emphasized here, however, that the above 
popularly accepted indications of the anemia in malignant 
disease only appear when the neoplasm is well advanced. 
Latent or early cancer may exist a considerable time before 
readily recognized systemic damage results. This is 
especially the case in carcinoma of the stomach. Well 

319 



320 CANCER OF THE STOMACH 

confined ulcera carcinomatosa or incipient, primary can- 
cerous change in the gastric Uning may produce few ex- 
ternal signs indicative of their presence. Moreover, in 
such event, even most carefully performed blood analyses 
may fail to demonstrate any suspicious cellular or serologic 
anomaly. 

The causes of anemia in gastric cancer appear to be 
multiple. It is only an exhibition of our lack of exact knowl- 
edge which permits the statement that the growth of a neo- 
plasm exerts deleterious influences upon normal metabolism. 
When physiologic and biologic chemists have discovered 
what factors are concerned in normal metabolism, it may 
then be possible to estimate the precise, constitutional 
significance of what are now considered by-products of a 
malignant tumor's cellular activity. That foreign sub- 
stances emanate from cancer tissue seems quite probable. 
The researches of Gay, Ascoli, Abderhalden, Weil, Jobling, 
W. Hamburger and others appear to demonstrate that in 
the development of a neoplasm some ferment-like body or 
bodies are manufactured or increased locally. These may 
exert pernicious effects by stimulating cell proliferation, by 
overflowing into the blood or the lymph streams, and thus 
acting as potential, if not actual, foreign substances, or, by 
acting, locally or generally upon already damaged or bio- 
logically immature tissue, they may liberate end-digestion 
products, which affect the body economy either by their 
presence in excessive amounts or by their entrance into the 
body fluids at a non-physiologic point. While there is no 
direct evidence that products of malignant growths directly 
injure the blood-forming centers, there is considerable proof 
that when cancer has become well established, the prod- 
ucts of the hematopoietic organs are of inferior quality, 
and not rarely, of diixdnished quantity. 



THE BLOOD IN GASTRIC CANCER 321 

Other factors likely to be of importance in the causation 
of anemia in gastric cancer are secondary infection, starva- 
tion, exhaustion (from vomiting, diarrhea or prolonged 
pain), hemorrhage, certain psychic abnormalities, or defi- 
cient function of the kidneys, liver or the pancreas. The 
development of extensive metastases sometimes exerts 
pernicious effects upon the blood picture. 

Blood changes observed in gastric cancer resolve them- 
selves into a consideration of the deviations from the normal 
of (1) formed elements (erythrocytes, leucocytes) and (2) 
the blood plasma. 

(1.) DEVIATIONS FROM THE NORMAL OF THE FORMED BLOOD 

CONSTITUENTS 

Quantitative Changes in Erythrocytes. — ^The average red 
blood cell count of 129 cases of gastric cancer examined by 
Cabot is given as 4,018,000 cells. In more than 75 per 
cent, of these cases the diagnosis was confirmed by operation 
or by autopsy. The cases remaining were clinically cancer 
of the stomach. 

The average red count from 59 cases studied by Osier 
and McCrae was 3,712,186. Their cases were clinically, 
or at post-mortem, cancerous. 

In our series, there were 267 instances of the disease where 
accurate red cell counts were made. Table 26 shows the 
summary of these investigations. 

It will be noted that the average erythrocyte count was 
4,380,000. This is a figure rather higher than the average 
given by other investigators. It is to be explained partly 
on the basis that many of our cases were diagnosed very 
early (often at laparotomy and then, microscopically) or 
the large number of patients returns a fairer average than 
does a relatively small list. The minimum erythrocyte 



322 



CANCER OF THE STOMACH 



Table 26 



Red cell count 



Per cent. 




Below 1,000,000 

From 1,000,000 to 2,000,000. 
From 2,000,000 to 3,000,000. 
From 3,000,000 to 4,000,000. 
From 4,000,000 to 5,000,000. 
From 5,000,000 to 6,000,000. 
From 6,000,000 to 7,000,000. 



Average 4,380,000 for . 



Showing Variations in Erythrocyte Count in 267 Cases of Gastric Cancer 
(Author). 

count was 860,000 cells. This was returned in a case of 
inoperable tumor with ascites and extensive general metas- 
tases. The maximum red cell count was 6,328,000 cells. 
This was from a patient with inoperable cancer of the lesser 
curvature and the body of the stomach. There were 
metastases to the rectal shelf and the peritoneum. It is thus 
seen that while low erythrocyte counts may be returned 
in instances where there are hopeless gastric neoplasms, 
high counts may likewise be obtained late in the progress 
of the disease. 

In more than 91 per cent, of our cases the red cell count 
lay between 3,000,000 and 7,000,000 cells. In nearly 
50 per cent, the counts fell between 4,000,000 and 5,000,000 
cells. 

The Influence of Metastases. — Our experience is sum- 
marized in Tables 27 and 28. 

Study of these two tables demonstrates that of the 267 
cases of gastric cancer in which erythrocyte counts are 
available, in 79.9 per cent, there were gross or microscopic 
metastases; of those instances in which metastases were 
present the red cell count was included between limits of 
from 3,000,000 to 6,000,000 cells in 90.4 per cent, where 



THE BLOOD IN GASTRIC CANCER 



323 



Table 27 



Range of erythrocyte 
counts 


Metastases 

(number of 

cases) 

+ 


Metastases 

(number of 

cases) 

+ + 


Metastases 

(number of 

cases) 

+ + + 


Free Fluid 

(number of 

cases) 


Below 1,000,000 








2 


1,000,000 to 2,000,000. 
2,000,000 to 3,000,000. 
3,000,000 to 4,000,000. 
4,000,000 to 5,000,000. 
5,000,000 to 6,000,000. 
6,000,000 to 7,000,000. 


3 

6 

23 

45 

17 










2 

1 

20 

16 

3 




9 
34 
17 




5 












Summaries 94 60 


42 


7 



To Demonstrate Relation of Erythrocyte Count to Metastasis in Gastric 
Cancer (Author). 

Table 28 



Range of erythrocyte counts 



Number of 
cases 



Per cent. 



Below 1,000, 
1,000,000 to 
2,000,000 to 
3,000,000 to 
4,000,000 to 
5,000,000 to 
6,000,000 to 



000 

2,000,000. 
3,000,000. 
4,000,000. 
5,000,000. 
6,000,000. 
7,000,000. 



9 
18 
28 

9 



13.9 
28.1 
43.1 
13.9 



Summary. 



64 



99.0 



Demonstrating Erythrocyte Counts in Cases where no Metastases Existed 
(Author) . 

metastases were limited in extent; in 100 per cent, where 
metastases were moderate in degree; in 88 per cent, where 
metastasis to lymph glands was very extensive, and in 
71 per cent, where free abdominal fluid occurred with or 
without other evidences of metastasis. The average per- 
centage of cases showing metastasis where the red cell 
count lay between 3,000,000 and 6,000,000 cells was 87.3. 

In the 64 cases in which no metastases could be demon- 
strated, in 85.1 per cent, the erythrocyte count lay between 
3,000,000 and 6,000,000 cells. 



324 



CANCER OF THE STOMACH 



It would seem from the above analysis of 267 proved cases 
of gastric cancer, that diminution in red cell count depends 
not wholly upon the development of metastases. On the 
contrary, a large group of cases with extensive metastases 
have higher average erythrocyte counts than have those 
free from metastases. 

Quantitative Changes in Hemoglobin. — Osier and Mc- 
Crae (loc. cit.) record hemoglobin estimations in 52 instances 
of cancer of the stomach. These cases returned an average 
hemoglobin of 49.9 per cent, and an average color index of 
0.63 (Cabot). 

We have records of hemoglobin estimations (Dare method 
for the majority) upon 454 cases. Table 29 shows the 
variations in the readings. 

Table 29 



Hemoglobin reading, per cent. 


Number of cases 


Per cent. 


Below 20 






Between 20-30 


9 
31 

76 
64 
82 
77 
106 
9 


1.5 


Between 30-40 


6.8 


Between 40-50 


16 7 


Between 50-60 


14.6 


Between 60-70 


18 1 


Between 70-80 


16 9 


Between 80-90 


23 4 


Between 90-100 


1.9 






Total 


454 


99 9 







Showing the Variation of Hemoglobin Reading in 454 Cases of Gastric 
Cancer (Author). 

It will be noted that in 72.2 per cent, of the patients, the 
hemoglobin ranged between 50 per cent, and 100 per cent., 
that in 42.2 per cent, it was above 70 per cent, and more than 
1 out of every 3 cases (38.5 per cent.) had a hemoglobin 
reading between 50 per cent, and 80 per cent. The aver- 
age hemoglobin percentage for the series was 64.3 per cent. 



THE BLOOD IN GASTRIC CANCER 



325 



The minimuin was 25 per cent, and the maximum 95 per 
cent. 

The Effect of Metastases. — In this respect we have studied 
hemoglobin records in a manner similar to that above 
described when considering the erythrocyte counts. Tables 
30 and 31 demonstrate the variations in hemoglobin when 
metastases were present and when they were absent. 

Table 30 



Hemoglobin percentage 


Metastases 
+ 


Metastases 

+ + 


Metastases 
+ + + 


Free fluid 


10-20 










20-30 




5 
5 


3 

8 


1 


30-40 


12 


1 


40-50 


20 


26 


6 





50-60 


24 


12 


11 


4 


60-70 


43 


15 


11 





70-80 


13 


14 


18 


2 


80-90 


46 


32 


12 


1 


90-100 


5 


2 












Summary 


163 


111 


69 


9 



Demonstrating Variations in Hemoglobin in Gastric Cancer Percentage 
when Metastases are Present (Author). 



Table 31 



Total. 



Hemoglobin percentage 


Number of cases 


10-20 




20-30 




30-40 


5 


40-50 


24 


50-60 


13 


60-70 


13 


70-80 


30 


80-90 


15 


90-100 


2 



102 



Demonstrating Variations in the Hemoglobin in Gastric Cancer when 
Metastases, are Absent (Author). 



326 CANCER OF THE STOMACH 

Of the cases in which metastases were proven, hemoglobin 
was above 50 per cent, in 131 cases or 80.4 per cent, of those 
where there was shght lymph-gland invasion; in 75 cases or 
67.5 per cent, where there were moderate metastases; 
in 52 cases or 75.3 per cent, where there was extensive 
lymphatic involvement, and in 7 cases or 77.7 per cent, 
where there was ascitic fluid. In other words, of 352 
cases (77.5 per cent.) showing metastases the hemoglobin 
was 50 per cent, or higher in 75.2 per cent. 

There were 102 cases (22.5 per cent.) where there were no 
metastases. In this group hemoglobin was 50 per cent, or 
higher in 73 instances or 71.5 per cent. 

It would seem from the above analysis that low hemo- 
globin percentages have relatively little value toward in- 
dicating the presence or absence of metastases. 

Color-index. — In the blood examinations of 267 consecu- 
tive cases the average color index was 0.73. The minimum 
index was 0.32 and the maximum 0.97. 

Shape and Size of Erythrocytes.^ — In well-advanced gas- 
tric cancer, when the hemoglobin is below 75 per cent., it is 
not uncommon to find red blood cells that exhibit wide 
variations in shape and, occasionally, in size. The studies 
of Osier and McCrae and Cabot {loc. cit.) seem to show that 
in malignant disease macrocytes are unusual findings and 
that the cancer anemia is of the type common to chlorosis. 
While this holds generally true, there are interesting ex- 
ceptions. Our records detail 17 blood studies where mac- 
rocytes were found and eight instances in which megalo- 
blasts are recorded. In 23 cases normoblasts were noted. 
We never observed macrocytes or nucleated erythrocytes 
where the hemoglobin was higher than 70 per cent, or the 
red cell count above 3,500,000. 

Of 204 blood analyses where definite record of red-cell 



THE BLOOD IN GASTRIC CANCER 327 

variations in shape and size were recorded, in 82 instances 
(40.3 per cent.) the variation was noted as being ''sHght," 
in 92 cases (45.09 per cent.) as of ''moderate degree," and 
in 30 instances (14,7 per cent.) as ''marked." 

Poikilocytosis, blood "shadows," or degenerative forms 
are quite common in the blood smears from well-established 
gastric cancer. From the blood of early cases they may be 
wholly absent. Not infrequently, these variations in 
erythrocyte structure seem out of all reasonable proportion 
to the red cell count, or the hemoglobin. We have not 
been able to establish any definite cause for this phenome- 
non. "Cancerous poisoning" of the blood-forming centers 
does not furnish a satisfactory explanation. In view of 
work done upon isolysins in malignant disease, it might 
be suggested that the rate of hemolysis was accelerated in 
gastric cancer. 

CHANGES IN THE LEUCOCYTES 

Quantitative. — Summarizing leucocyte counts in 23 cases 
of gastric cancer, DaCosta (quoted by Cabot) found an 
average count of 8,100 cells. The minimum was 1,000 
cells and the maximum 14,000 cells. Cunliffe's records of 
10 cases of the disease reveal an average white cell count 
of 17,280, with a minimum of 5,200 cells and a maximum of 
36,800 cells. Cabot {loc. cit.) analyzed the leucocytes in 
235 cases of cancer of the stomach. His study shows an 
average count of 10,600 cells. The minimum count was 
between 3,000 and 4,000 cells and the maximum between 
30,000 and 40,000 cells. 

A review of the literature demonstrates that high leuco- 
cyte counts are not uncommon in rapidly growing gastric 
neoplasms. The ratio between white and red cells may be 
greatly reduced. Cabot reports a case of Welch's in which 



328 



CANCER OF THE STOMACH 



the ratio of white to red cells was as 1:25 instead of the 
normal ratio of as 1 : 750. 

Of our series of gastric cancers, we have leucocyte counts 
in 261 instances. The average count was 11,270 cells. 
The minimum was 4,200 cells and the maximum 36,200 
cells. Table 32 groups the cases according to cell-count 
range. 

Table 32 



Leucocytes 



Between 
Between. 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 



4,000- 5,000. 

5,000- 6,000. 

6,000- 7,000. 

7,000- 8,000. 

8,000- 9,000. 

9,000-10,000. 
10,000-11,000. 
11,000-12,000. 
12,000-13,000. 
13,000-14,000. 
14,000-15,000. 
15,000-16,000. 
16,000-17,000. 
17,000-18,000. 
18,000-19,000. 
19,000-21,000. 
21,000-37,000. 



Number of cases Percentage 



15 


5.7 


17 


6.5 


33 


12.7 


56 


21.4 


31 


11.5 


27 


10.3 


18 


6.9 


15 


5.7 


6 


2.3 


16 


6.1 


9 


3.4 


3 


1.1 


3 


1.1 


2 


0.76 


3 


1.1 


5 


1.9 


2 


0.76 



Average 11,270. 



261 



99.22 



Demonstrating Variations in Leucocyte Count of 261 Cases of Gastric 
Cancer (Author). 



Study of the table shows that 55.9 per cent, of all cases 
had leucocyte count between 6,000 and 10,000 cells; that 
more than 4 out of 5 of all the cases had leucocytes between 
6,000 and 14,000 cells; that not quite 1 out of every 4 cases 
(24.22 per cent.) had white cell count above the average 
of the series, and that approximately 3 out of 4 cases had 
white cell count below the average for the series. 



THE BLOOD IN GASTRIC CANCER 329 

The complete blood count in the case with minimum 
leucocyte count was as follows : 

White blood corpuscles, 4,200; red blood corpuscles, 
1,830,000; hemoglobin, 30 per cent. 

Differential count of leucocytes: Polymorphonuclears, 
67.7 per cent.; small lymphocytes, 27.3 per cent.; large 
lymphocytes, 3.0 per cent.; eosinophiles, 2.0 per cent.; 
transitionals, 0.7 per cent. 

There was noted ''moderate" variation in the size and 
shape of the individual red blood cells. Pathologically, the 
case was one of inoperable cancer of the lesser curvature and 
the body of the stomach with extensive metastases and 
free abdominal fluid. 

The complete blood count in the case with the maximum 
leucocyte count was as follows : 

White blood corpuscles, 36,200; red blood corpuscles, 
4,980,000; hemoglobin, 82 per cent. 

The differential count of leucocytes: polymorphonu- 
clears, 81.3 per cent.; small lymphocytes, 13.3 per cent.; 
large lymphocytes, 3.0 per cent.; eosinophiles, 1.0 per cent.; 
transitionals, 0.3 per cent.; myelocytes, 1.3 per cent. 

There was recorded ''marked" variation in the size 
and shape of the individual erythrocytes. 

Surgically, this case was one of extensive carcinoma of 
the posterior wall of the stomach, with invasion of the pan- 
creas and extensive lymph-gland metastases. 

It has been held that leucocytosis in gastric cancer is an 
index to the extent of the metatases, the rapidity of growth 
of the tumor, or such complications in the course of the 
ailment, as hemorrhage or perforation. The validity of 
these claims has been questioned by Osier and McCrae 
and by Cabot. 

For the purpose of studying the effect of metastases upon 



330 



CANCER OF THE STOMACH 



the leucocyte count, we have compiled from our records 
Tables 33 and 34. 

Table 33 



Summary . 



84 



58 



54 



Leucocyte variations 


Metastases 

(number of 

cases) 

+ 


Metastases 

(number of 

cases) 

+ + 


Metastases 

(number of 

cases) 

+ + + 


Ascites 

(number of 

cases) 


4 000 5 000 


7 


3 



3 
3 




c; non - 6 000 s 




6,000- 7,000 

7,000 - 8,000 

8,000- 9,000 

9,000-10,000 

10 000 - 11 000 


5 
13 

2 
3 
s 


12 2 

13 16 






3 

12 

3 

5 


10 
10 


3 




11,000-12,000 7 

12,000-13,000 5 

13,000-14,000 11 

14,000-15,000 9 

15,000-16,000 2 

16,000-17,000 1 

17 000 - 18,000. 












5 










1 






2 




2 
3 
1 






18 000 - 19 000 ' 






19,000 - 21,000. ' 2 


2 




21 000 - 37 000 1 1 




1 













Showing the Relation of Leucocyte Counts to Metastases in Gastric 
Cancer (Author). 

Table 34 



Leucocyte variations 



Number of cases 





4,000- 5,000 


2 




5,000- 6,000 


6 




6,000- 7,000 


14 




7,000- 8,000 


14 




8,000- 9,000 


13 




9,000-10,000 


2 




10,000-11,000 


7 




11,000-12,000 


3 




12,000-13,000 


1 


Total 


62 







Showing Variations in Leucocyte Counts in Cases of Gastric Cancer 
without Metastases (Author). 



THE BLOOD IN GASTEIC CANCER 331 

Certain facts of interest are brought out by a study of 
these tables. It will be observed that there are 199 cases 
where metastases occurred, and 62 instances free from met- 
astases. Of the cases showing metastases there were 84 
instances (42.2 per cent.) where the involvement was small. 
Of this number the leucocyte count was 10,000 cells or 
below in 45.2 per cent, or 19 per cent, of the entire group 
showing metastases. There were 58 cases (29 per cent.) 
showing moderate degree of metastasis. Of this number 
74 per cent, exhibited white cell count of 10,000 cells or 
below (21.6 per cent, of entire group). There were 54 
cases (22 per cent.) with extensive metastases. Of this 
group 81 per cent, had leucocyte count of 10,000 cells or 
below (26 per cent, of metastasis class). Of the cases 
where ascites was demonstrated 100 per cent. (1.6 per cent, 
of group) had white cell count of 10,000 or below. Of all 
the cases showing metastases 13.6 per cent, had leucocytosis 
of 15,000 or above. 

Of the entire number of cases with metastases, leucocytes 
averaged 10,000 cells or below in 22.6 per cent. In this 
figure the cases classed under ascites are not included. The 
comparative average for the different groups is 66.5 per 
cent. 

In the group of gastric cancers without metastases (62 
cases) the leucocytes were at or below 10,000 in 82 per cent. 
There were no instances where leucocytes were higher than 
13,000 cells. 

From a study of the above analysis, it will be seen that 
while more than 4 out of 5 cases of gastric cancer without 
metastases making up our series had leucocyte count of 
10,000 cells or below, an average of but 2 out of 3 cases of 
the different groups showing grades of metastasis had leu- 
cocyte count so low. Of the whole number exhibiting 



332 CANCER OF THE STOMACH 

metastases the white cell count was 10,000 cells or below in 
but rather more than 1 out of 5 cases. 

Digestion Leucocytosis. — We have no original observa- 
tions to record. Miiller and Capps state that digestion 
leucocytosis is absent in more than 80 per cent, of gastric 
cancers. Osier and McCrae (loc. cit.) claim that ''the 
presence of digestion leucocytosis is too uncertain to be of 
much assistance in diagnosis." Recently, Bonhoff has 
made a study of this phase of the leucocyte count and claims 
that the observation of digestion leucocytosis is a valuable 
clinical aid in the differentiation between benign peptic 
ulcer and ulcus carcinomatosum. 

The Qualitative Variation in the Leucocytes. — In our 
series we have records of differential leucocyte counts in 
160 cases. The following facts are of interest: 

Poly nuclear leucocytes averaged 73.2 per cent. The 
minimum was 56 per cent, and the maximum 86.4 per cent. 

Small lymphocytes averaged 19.1 per cent. The minimum 
was 9.7 per cent, and the maximum 37.5 per cent. 

Large lymphocytes averaged 3.41 per cent. The minimum 
was 0.7 per cent, and the maximum 13 per cent. 

Basophile leucocytes averaged 1.28 per cent. The mini- 
mum was 0.3 per cent, and the maximum 5 per cent. 

Transitional leucocytes averaged 1.58 per cent. The 
minimum was 0.3 per cent, and the maximum 6 per cent. 

Myelocytes were observed in 43 cases (26.8 per cent.) 
where differential counts were made. The average was 
1.27 per cent. The minimum was 0.3 per cent., and the 
maximum 3.3 per cent. Myelocytes were frequently noted 
where the red cell count was above 4,500,000 cells, but "were 
observed in no instance where the hemoglobin was higher 
than 75 per cent. The lowest myelocyte percentage (0.2 
per cent.) was seen when the leucocyte count was 7,200. 



THE BLOOD IN GASTKIC CANCER 333 

The hemoglobin was 30 per cent, and the red cell count 
1,830,000. The highest myelocyte count was observed 
where the leucocytes totaled 6,900. In this case the hemo- 
globin was 40 per cent, and the red cell count 4,110,000. 

Eosinophiles were noted in 109 of the differential counts 
(67 per cent.). The average was 4.01. The minimum was 
0.3 per cent. The maximum was 7.7 per cent. 

In the case with the minimum percentage of eosinophiles, 
the leucocytes were 5,600, the erythrocytes 3,260,000 and 
the hemoglobin 38 per cent. 

In the case with the maximum percentage of eosino- 
philes, the leucocytes were 7,200, the red blood cells 4,180,- 
000 and the hemoglobin 65 per cent. 

In none of our cases of relatively high eosinophilia could 
we attribute the increase to such ills as lung affections, 
skin disease, high fever, medication, severe hemorrhage, or 
disease of the genito-urinary tract. 

(2) DEVIATIONS FROM THE NORMAL AS SHOWN BY THE 
BLOOD SERUM 

The gastric neoplasm can quite properly be regarded as 
itself being a parasite with the patient a host. From 
etiologic, histologic and clinical study, it would seem that 
the host has a form of protective mechanism. If such did 
not exist, it would be inconceivable why all members of the 
human family do not die of cancer, or why certain individ- 
uals live longer than do others when affected with the same 
histologic type of cancer in relatively the same part of the 
stomach. It would appear that the body's protective 
mechanism is similar in kind against all histologic forms of 
cancer. The strength of this defensive power seems not 
only to vary in different individuals, but may exhibit 
alterations in degree in the same individual at different 
times. 



334 CANCER OF THE STOMACH 

In the human, at least, the body's defensive abiHty ap- 
pears to rest mainly upon ferment-like agents. These 
agents are evidently essential components or products of 
protoplasm. They represent the most highly refined end- 
results of intercellular or intracellular biochemic change. 
These cell products, while apparently rigidly specific in 
their function, appear to act in a similar manner. These 
defensive substances are doubtless present in both cellular 
and fluid structures of the body. There is reason to sup- 
pose that in blood serum, lymph and spinal fluid protective 
agents against cancer are constantly present. If malignant 
neoplasms behave as do other parasites or foreign bodies 
when they invade their hosts, it would seem that the added 
demand for a specific defensive agent against such might be 
measurable by biochemic study of the body fluids, particu- 
larly of the blood serum and the blood cells. Much re- 
search along these lines has been carried on. While thus 
far there has been isolated no absolutely specific defensive 
agent against cancer, it would seem that certain biologic 
phenomena of blood sera indicate a broad, basic principle 
of defence, the exact significance of which has not yet been 
established. But a few aspects of the mechanism of this 
protective agent against cancer in general can be considered 
in a special monograph upon cancer of the stomach. 

The Hemolytic Reaction.^ — In 1902, Lang showed that 
in advanced cases of cancer, the erythrocytes were very 
resistant to anisotonic solutions of sodium chloride. In 
1908, Weil demonstrated that the blood serum of dogs 
harboring experimental lymphosarcoma was lytic for the 
erythrocytes of non-sarcomatous dogs, but not for the red 
blood cells of other dogs harboring like malignant tumors. 
Under certain limitations this observation appeared to 
be of diagnostic worth in human cancer. To Krida, we 



THE BLOOD IN GASTKIC CANCER 335 

are indebted for a detailed description of the method of 
performing the test, and for a resume of its diagnostic 
worth. 

Hemolysis in the Diagnosis of Cancer. — Krida employs the 
following technique: The blood for the test is obtained by 
puncturing one of the superficial veins after tying a tight 
bandage around the arm above the point of puncture. 
About 10 cc. are withdrawn; of this about 1 cc. is added to 
a centrifuge tube which has been previously half filled with 
a normal salt solution to which 1 per cent, sodium citrate 
has been added, and immediately centrifuged to throw down 
the cells. Or the cells may be obtained by defibrinating a 
small quantity of blood by shaking with glass beads. The 
rest of the blood is placed in a sterile test-tube, slanted and 
placed in the ice chest to clot and allowed to remain there 
for 12 to 24 hours. The cells as previously obtained are 
washed 2 or 3 times in salt solution, and then made up to 
a 5 per cent, emulsion with salt solution and placed in the 
ice chest until ready for use. Cells and serum are obtained 
in a similar manner from two normal individuals to act as 
controls and are also placed in the ice chest until ready for 
use. Several pathological sera may of course be tested 
with these two controls. 

When the test. is ready to set up, the hemolysis tubes are 
sterilized, then washed in normal salt solution. As many 
different combinations of cells and serum as possible are 
made, using 5 cc. of each, and the plan of the mixtures noted. 
The simplest procedure is to begin with one cell emulsion, 
placing 5 cc. in as many tubes as there are kinds of sera, 
and adding to each tube 5 cc. of the various sera. As an 
additional control, a preparation with cells and salt solution 
and cells and sterile water might be made; the hemolysis 



336 



CANCER OF THE STOMACH 



in the tube containing the sterile water will, of course, be 
complete. 

The rack containing the test is now placed in the incu- 
bator at 37° C. for 2 hours. Some make an entire duplicate 
set and heat it in the water-bath for 10 minutes at 55° C. 
before incubating (to destroy complement). At the end of 
2 hours, the tests are placed in the ice chest for 12 hours, 
and the results are then read off by some person who does 
not know the key to the plan of mixtures. Hemolysis is 
apparent by a pink or red discoloration of the supernatant 
fluid in the test-tubes. 

If the hemolysis test for cancer is positive the cancer 
serum should have hemolyzed the cells of both the normal 
controls. A reverse hemolysis, i.e., normal serum hemo- 
lyzing pathologic cells is considered characteristic of 
tuberculosis by Crile, but in this the results of the other 
observers are almost uniformly negative. 

The following table presents a summary of the results 
with the hemolytic reaction: 

Table 35 





Total 


Carcinoma 


Benign 

tumors 


Miscella- 
neous 
diseases 


Reverse 
reactions 


Normals 


Excised 

carcinoma 

without 

clinical 

recurrence 


Weil 


82 
591 

33 

35 
109 

75 

301 
328 
158 

100 


31 

164 
11 
35 
22 
25 

42 
73 
31 

38 


PL 15 
P1.141 
PL 10 
PL 12 
PL 8 
PL 18 

PL 36 
PL 35 
PL 14 

PL 28 


3 

55 

4 


PL 1 

PL 00 
PL 


42 
71 
18 


PL 9 
PL 7 
PL 2 






6 
211 


PI. 10 
PL 






Crile 

Arnold 


52 


PL 49 


37 


PL 


Jane way 














Whittemore. . . 






32 

40 

106 

103 

55 

40 


PL 6 
PL 4 

PL 17 
PL 
PL 9 

PL 20 


8 


PL 4 


39 
10 

85 

112 

24 

22 


PL 7 
PI. 1 

PL 4 
PI. 
PI. 1 

PL 1 






Blumgarten... . 










Johnston and 

Canning 

Richartz 


14 


PL 


43 
40 
45 


PL 7 
PL 21 
PL 2 


3 


PI. 


Smithies 


3 


PL 






Epstein and 
Ottenberg. . . . 






















1,812 


472 
pe 


PL317 
67 

r cent. 


79 

pe 


PL 1 

IH 
r cent. 


507 
pe 


PL 74 
15 
r cent. 


188 
pe 


PL 83 

44 
r cent. 


509 
pe 


PI. 14 
2.6 
r cent. 


40 
pe 


PL 

r cent. 



Showing the Diagnostic Significance of the Hemolytic Test in Cancer 
(Krida). 



THE BLOOD IN GASTRIC CANCER 337 

Of a total of 1,812 observations reported by ten different 
workers, 472 cases were carcinoma; of these, 317 or 67 per 
cent, gave positive hemolytic reactions. Seventy-nine were 
benign tumors, of which 1 or 13^^ per cent, were positive. 

Five hundred seven observations were made in a 
variety of diseases, 74 or 15 per cent, of which presented 
positive reaction. 

Five hundred nine observations were made on nor- 
mal individuals, 14 or 2.6 per cent, were positive. 

In 40 post -operative carcinoma cases without clinical 
recurrence, the reaction was uniformly negative. 

One hundred eighty-eight tests were performed on tu- 
berculosis patients; of these, 82 or 44 per cent, presented 
''reverse" hemolysis. 

Skin Reaction. — The basis of the skin reactions for 
carcinoma is the subcutaneous injection into the forearm 
of about 5 minims of a 20 per cent, suspension in physio- 
logical salt solution of red blood cells obtained from a 
normal, healthy individual. 

The quantity of blood necessary varies, of course, with 
the number of reactions to be carried out. For 10 or 12 
reactions, 2 to 3 cc. are obtained as described previously. 
Sufficient blood for two or three tests maybe obtained by 
simply puncturing the finger and allowing a dozen drops to 
flow into a centrifuge tube half full of salt-citrate solution. 
This is immediately centrifuged, washed 3 times as pre- 
viously described, and made into a 20 per cent, suspension 
in physiological salt solution. The suspension is placed 
at 0° C. for 24 to 48 hours and is then ready for use. A 
convenient method of keeping this suspension until ready 
for use is to draw up a sufficient quantity for individual tests 
into pipettes and seal the ends. The suspension does not 
keep longer than 5 days, and one should see that no hemol- 

22 



338 CANCER OF THE STOMACH 

ysis has occurred previous to using it for injection 
(Krida). 

If the patient's serum is hemolytic for normal cells, an 
oval area of discoloration about 2 by 5 cm. will appear at 
the site of injection in from 5 to 8 hours. 

The discoloration is described as ''brownish red to a 
maroon, wdth rarely a bluish tinge. The lesion is dis- 
tinctly raised from the surrounding surface." The dis- 
coloration persists from 1 to 3 hours, and usuallj^ begins 
to fade at the end of 8 hours, lea"\dng a greenish ecchymosis 
at about the end of 12 hours. The element of time here is 
variable, however, as we have found. If the patient is in a 
hospital, he should be observed about once an hour, begin- 
ning about 5 hours after the injection, and making 3 or 4 
obser^^ations. If the patient be at home, he may be con- 
veniently seen about 6 hours after the injection. If the 
observation then made be inconclusive, he may be in- 
stmcted to notify the physician should a reaction appear 
within 3 or 4 hours. 

Elsberg, Neuhoff and Geist have classified the results 
of their tests as follows : 

Carcinoma, positive or probable, 69 cases, 62 or 89.9 per cent, plus and 
2 or 2.9 per cent, doubtful. 

No carcinoma, 325 cases, 15 or 4.6 per cent, plus and 3 or 1.1 per cent. 
doubtful. 

Possible carcinoma, 9 cases, 7 or 77.8 per cent. plus. 

Carcinoma, advanced or mOiary, 11 cases, or 100 per cent, negative. 

Krida states that of 12 cases of carcinoma, the reac- 
tion was positive in 9, or 75 per cent. He states further 
that the reaction is not uniformly absent in the cachectic 
cases. Elsberg, Neuhoff and Geist have made such a 
subdivision and found the results negative in their 11 cases 
so classified. Warfield thinks the test of dubious worth. 



THE BLOOD IN GASTRIC CANCER 339 

It is certainly interesting from a biochemic, and perhaps 
anaphylactic standpoint. 

Cancer Diagnosis of Freund and Kaminer. — Miiller 
states that the blood serum of normal individuals some- 
times has the power to dissolve cancer cells. The blood 
serum of patients suffering from cancer frequently lacks 
this power, and has the power to inhibit the destruction of 
such cells by normal serum. 

When the blood serum of cancer patients is mixed with 
a cancer extract, a precipitate forms. 

Ingredients of the Test. — 1. An Emulsion of Cancer 
Cells. — Grind in a mortar the necrotic portions of the 
tumor, freed so far as possible of fat and extraneous cells, 
with about five volumes of 1 per cent, sodium biphosphate. 
Squeeze the suspension through several thicknesses of 
gauze. Allow the cells to settle, and remove the super- 
natant fluid with a pipette. Wash the residue with 0.6 
per cent, sodium chloride solution. Allow the cells to 
settle again, pipette off the supernatant fluid and cover 
the residue with 1 per cent, sodium fluoride. The last- 
named fluid should be first neutralized against alizarin 
till only a trace of violet color remains. This emulsion 
will keep for several weeks in the ice-box. 

2. An Extract of Cancer Cells. — Fresh tumor tissue 
obtained at autopsy, or tumor tissue preserved in alcohol 
may be used. Portions as free as possible of necrotic 
areas and fat are cut into small pieces and worked through 
a coarse-meshed cloth by the gradual addition of ten 
volumes of 0.6 per cent, acid sodium phosphate solution. 
Allow the cells to separate by settling or by careful cen- 
trifugation. Wash several times with the same fluid, 
and preserve at 0°. Sodium fluoride, up to 1 per cent., 
may be added as a preservative, provided care is taken 



340 CANCER OF THE STOMACH 

to see that it does not render the fluid alkahne. Thymol 
may also be used. 

For use add 5 cc. of 5 per cent acetic acid to 100 cc. 
of the fluid. Heat the mixture in the water-bath for 15 
minutes at 80° C, filter, cool, and neutralize to htmus wdth 
sodium carbonate . Heat again as above, cool and filter. 
Heating at 100° C. or over the free flame must be avoided. 
The activity of the extract is determined by testing with 
10 drops of known normal and cancerous sera whether 
the extract, undiluted, and diluted 10, 50, and 100 times, 
gives a precipitate wdth cancer serum, plainly visible in 
test-tubes held against the window, while the normal 
serum gives no such precipitate. The extract keeps for 
only 2 or 3 days. The extract if used in too concen- 
trated form causes a precipitate with normal serum, but 
if diluted to opalescence gives a dismal serum, or of an 
ether extract of horse serum. 

3. The Patient's Serum. — This is obtained in smy of the 
customary ways. The serum must be separated from the 
cells Tvdthin a few hours after the blood is drawn and can- 
not be used when it is more than 48 hours old. 

4. A hlood-counting chamber. 

5. Small test-tubes or small test dishes with parallel 
sides. 

6. Capillary pipettes, and volumetric pipettes, 1 cc. in 
1-100's. 

7. An incubator at 37° C. 

8. A 0.5 per cent, solution of sodium fluoride. 
Technique. — To 10 drops of the patient's serum add 1 drop 

of the 0.5 per cent, solution of sodium fluoride. Then 
add 1 drop of the cancer cell emulsion so diluted that when 
1 drop of the mixture is placed in the blood-counting 
chamber, about 10 to 20 tumor cells will be found in a 



THE BLOOD IN GASTRIC CANCER 341 

large field (25 of the smallest squares) of the apparatus. 
Close the ct>unting chamber carefully and place in the 
incubator for 24 hours. Count the number of cells 
again. 

It is said that a material reduction in the number of 
cells will be found when the serum is derived from a healthy 
individual, whereas, if the serum is derived from a cancer 
patient such a reduction does not take place. 

A second test is made by diluting normal serum with 
an equal amount of 0.6 per cent, sodium chloride solution, 
and also with an equal volume of the patient's serum. 
To each of these fluoride and the cell emulsion is added 
as above. If the patient's serum prevents the solution of 
the cells by the normal serum, this again constitutes a 
positive reaction. 

The test for a precipitate is made as follows: Place 10 
drops of the patient's serum in a small test-tube or test 
dish with parallel sides and add 2 cc. of the extract properly 
diluted as described above. Controls are made by add- 
ing to a separate quantity of serum a fluid identical with 
the tumor extract with the exception of the tumor tissue. 
In other words, if the extract was prepared from fresh 
tumor tissue this fluid is prepared by adding to 100 cc. 
of 1 per cent, acid sodium phosphate 5 cc. of 5 per cent, 
acetic acid, and neutralizing with sodium carbonate. 
When the extract is prepared from tissues preserved in 
alcohol, use 0.25 per cent, acetic acid neutralized with 
sodium carbonate. 

The precipitate forms at once and must be viewed by 
transmitted, not by reflected light. A distinct clouding 
under these conditions constitutes a positive reaction. 
Freund and Kaminer recommend that all three tests 
should be made when enough serum is available. This 



342 CANCER OF THE STOMACH 

calls for about 2.5 cc. of serum, representing about 6 cc. 
of whole blood (Miiller- Whitman). 

The Antitryptic Reaction. — In 1902 Petry demonstrated 
that cancers contain a proteolytic ferment. He showed 
that such proteids as gelatin or casein could be digested 
by an extract of the malignant tumor. The agent causing 
this digestion appeared to have the properties of a ferment. 
It was later shown that the passage of such proteolytic 
ferments into the circulation resulted in the formation of 
anti-ferments in the body fluids, especially in the blood 
serum. This anti-ferment was named ''antitrypsin." It 
was thought that a method of measuring the strength or 
the amount of the antitrypsin would indirectly serve as 
a method of diagnosing the existence of malignancy, inas- 
much as it had been demonstrated that normal blood 
serum contains relatively small amounts of antitrypsin. 
In 1908, Bergmann and Meyer announced a method whereby 
the antitrypsin content of blood sera could be estimated 
clinically. Their method is as follows: 

Estimation of the Antitrypsin Content of the Blood. — 
Principle: One determines what amount of trypsin is 
neutralized, as to its digestive power, by a certain amount 
of serum or blood. The substance to be digested may be 
either Loeffler's blood serum, as ordinarily used by bacteri- 
ologists, or a solution of casein. In the former case the 
criterion for the occurrence of digestion is the formation 
of a dimple on the surface of the serum; in the latter the 
non-appearance of a cloud, due to the precipitation of 
casein, on the addition of acetic acid. 

Practical Application. — Whitman states that the anti- 
trypsin of the blood is most markedly increased in cancer. 
Hence the method has been used chiefly for cancer 
diagnosis. 



THE BLOOD IN GASTRIC CANCER 343 

Method of Bergmann and Meyer. -Apparatus. — 1. A 1 
per mille solution of trypsin sice. (Gruebler) : dissolve 0.5 
gram trj^jsin in 50 cc. physiological salt solution, add 0.5 
cc. normal soda solution, and make up to 500 cc. 

2. Casein solution: 1 gram casein (rhenania) is dissolved 
in 100 cc. n/10 NaOH solution, with the aid of gentle 
heat. Neutralize to litmus with n/10 HCl solution and 
make up to 500 cc. 

3. Acetic acid solution: 5 cc. acetic acid, 45 cc. alcohol, 
and 50 cc. water. 

4. The patient's serum, diluted 20 times with salt solu- 
tion; 0.1 to 0.2 cc. suffices. 

5. Small test-tubes. 

6. Pipettes, 2 cc. graduated into 1-10's. 

Technique. — Titration of the trypsin solution. This 
must precede the test proper. In each of several test-tubes 
place 2 cc. of the casein solution and decreasing amounts 
of the trypsin solution as, for example, 1.0, 0.9, 0.8, 0.7, — 
0.2. Shake carefully and place in the incubator for }i hour. 
Then add the acetic acid solution drop by drop, observing 
which tube shows cloudiness after a few minutes. The tube 
containing the smallest amount of tr^^Dsin, and which 
remains perfectly clear, contains the ^^ completely digesting 
dose," which is used for the test proper. 

Estimation of the Antitrypsin. — In each of 6 tubes place 
0.2 cc. of the patient's serum, and increasing amounts of 
the trypsin solution, beginning with the completely 
digesting dose, and increasing by 0.1 cc. xldd 2 cc. casein 
solution to each tube and bring all the tubes to a like 
volume. Incubate as before for }4 tiour at 37° C. Acidify 
as before, and again note the tube containing the smallest 
amount of trypsin in which cloudiness can be seen. The 
amount of trypsin paralyzed by the antitrj^psin of the 



344 CANCER OF THE STOMACH 

serum is thus determined. If, for example, the completely 
digesting dose is 0.7 cc. and if, in the presence of serum, 2.0 
cc. of trypsin are required to bring about complete diges- 
tion, then: 

2.0 cc. - 0.7 cc. = 1.3 cc, 

or the amount of trypsin paralyzed by the amount of serum 
used (in this case 0.2 cc. of a 5 per cent, dilution, or 0.01 
cc. whole serum). One cc. of serum, therefore, paralyzes 
130 cc. of the trypsin solution. Furst, expresses the result 

as follows: 

37° C 
Antitrypsin j;rr — - = 130. 

Comparison of the values thus obtained with those given 
by normal serum shows whether the antitryptic power of 
the serum tested is altered (Mtiller- Whitman) . 

The method of Bergmann and Meyer was later improved 
by Weil and Feldstein, by the introduction of the '^viscos- 
imeter, " an instrument permitting accurate determination 
of the end point of digestion of a pure proteid by blood 
serum. 

From the perusal of a huge literature, it would appear 
that the ''antitryptic reaction" in the blood serum is 
positive in from 75 to 95 per cent, of all cancers. It is of 
comparative rarity in the blood serum of non-cancerous 
patients. That it has a definite place as an aid in differen- 
tial diagnosis is attested by Stockton, Bergmann and Meyer, 
Roche and others. 

Roche emphasizes the great importance of negative anti- 
tryptic reactions in excluding the diagnosis of malignancy. 

Abderhalden Method for the Detection of Specific 
Ereptases. — Numerous investigators have demonstrated 
the presence of ereptic ferments in blood serum. It 
remained for Abderhalden, however, to show that specific 



THE BLOOD IN GASTRIC CANCER 345 

ereptases were developed or increased by the presence of 
a foreign proteid (parenterally) or by the growth of neo- 
plasms in the body. The protective mechanism of the 
organism appears to take the form of a highly specialized 
ereptic ferment capable only of digesting the proteid com- 
posing the type of tumor exciting its production. 

Principle. — The blood serum of cancer individuals con- 
tains a specific ferment which digests cancer cells. 

Apparatus. — 1. Cancer tissue.- — Cut a fresh human cancer 
into small pieces, place in a wide dish, and wash in running 
(tap) water. The external portions may be separated and 
discarded, but this is not necessary. While the washing, 
which is for the purpose of removing blood, is going on, a 
large enamel basin or evaporating dish containing 1 to 2 
liters of water, to which 1 drop per liter of glacial acetic 
acid is added, is heated to boiling. Throw the washed 
cancer tissue into the boiling water, and continue the 
boiling for 5 minutes. Pour off the boiling water through a 
gauze strainer or plaited filter, taking care that the coagu- 
lated bits of cancer remain as far as possible in the dish. 
Pour on more water and boil again for 5 minutes. Now 
test a portion of the water for the biuret reaction as follows : 
To about 10 cc. of the water, add 5 cc. of a 33 per cent, 
caustic soda solution, mix and layer enough of a very dilute 
(0.25 per cent.) solution of cupric sulphate on top to make 
a layer 0.25-0.5 cm. deep. A red color at the zone of con- 
tact constitutes a positive reaction. If the process has 
been carried out rapidly, the test will always be negative. 

In place of the biuret reaction for peptone the more deli- 
cate triketohydrinden hydrate (Hoechst), may be used. 
This gives a blue color with compounds which have a COOH 
group and an amino-acid in the ''a" position. Albumin, 
peptone, polypeptids and amino-acids react. Place 10 cc. 



346 CANCER OF THE STOMACH 

of the fluid in a large test-tube, add exactly 0.2 cc. of a 1 
per cent, aqueous solution of triketohydrinden hydrate, 
bring quickly to boiling and continue the boiling for 1 
minute without interruption. When the reaction is posi- 
tive, a beautiful violet-blue color develops in a short time. 
When negative, the solution remains colorless, or takes on a 
yellowish tone. The use of the triketohydrinden hydrate 
is recommended, but it must not be used for the test proper 
unless the cancer tissue, as prepared above, has been shown 
to react negatively with it. 

If the water in which the cancer is cooked gives one or 
other of these reactions for peptone, the boiling must be 
continued as before till the reaction is negative. When 
this occurs pour the last cooking water, together with the 
cancer tissue, into a wide-mouthed flask. Cover with a 
layer of toluol, and cork tightly. The entire process 
requires not more than 3^ to 1 hour, and furnishes material 
for several hundred tests. 

2. Extraction thimbles. (S. and S. 579.) These should 
be kept under water and a layer of toluol, and should be 
tested for permeabihty to Witte's peptone before use. 
After being used, they may be carefully washed in running 
water and used again. They should never be used dry. 

3. The patient's serum. This must not be shaken. It is 
recommended to allow about 10 cc. of blood to flow directly 
into a centrifugal tube. As soon as the clot forms cen- 
trifugate, pour off the serum, and use at once for the 
test. If the serum contains any hemoglobin it cannot be 
used. 

4. Small heakers, Erlenmeyer flasks or especially designed 
cyHnders of such a size that the thimbles above mentioned 
fit into them leaving not more than 0.25 cm. between the 
shell and the wall. 



THE BLOOD IX GASTRIC CANCER 347 

5. Reagents for the biui'et reaction, or triketohydrinden 
hydrate, or both. 

6. Incubator at 37° C. 

7. Distilled water. 

Technique. — In one of the extraction thimbles, pre- 
viously tested as to its pemieabihty, washed, and kept as 
above described, place about 1 gram of the cancer tissue, 
crumbling it between the fingers into pieces the size of a 
wheat grain while doing so. Pour about 2 or 3 cc. of the 
patient's serum over the tissue in the bottom of the 
thimble. Add a few drops of the toluol to prevent putre- 
faction. Xow hold the thimble at the top, and rinse the 
outside thoroughly under the tap. Place the thimble in one 
of the beakers, described above, and add 15 cc. of water, 
outside the thimble. A thin layer of toluol is placed also 
on the outside. Controls should be prepared in the same 
wa3', consisting of the patient's serum alone, and of the 
cancer tissue alone, respectively. Place in the incubator 
for 12-16 hours. Xow remove 10 cc. of the fluid outside 
of the thimble, by means of a pipette, thrust below the level 
of the toluol, and test this for peptone with one or both of the 
reagents described above. When triketohydrinden hy- 
drate is to be used, it is especially important that as httle 
toluol as possible be transferred to the test-tube, as over- 
heating is then apt to occur. A glass rod may be placed 
in the test-tube to prevent bumping. 

A positive result is indicated when the dialysate gives 
a positive reaction for peptone. 

The method has been verified by R. Franz and by Frank 
and Heimann. 

The polariscope method of Abderhalden is sometimes 
used. It is too compHcated for general clinical applica- 
tion (Aliiller- Whitman) . 



348 CANCER OF THE STOMACH 

Ransohoff's Anaphylaxis Test for Cancer. — Guinea-pigs 
are sensitized by the intraperitoneal injection of blood- 
serum from (a) a normal patient and (5) a patient affected 
with advanced cancer. At the end of 10 days, each group 
of guinea-pigs is injected with known malignant serum, 
intraperitoneally. When such serum is introduced into 
guinea-pigs sensitized with cancer serum, typical anaphy- 
lactic reactions are claimed to develop. The injection of 
serum into guinea-pigs into whom non-cancer serum had 
been previously introduced causes very slight local or 
systemic disturbance or none at all. 

Ransohoff states that in his hands the test proved posi- 
tive for 92 per cent, of 26 cancer cases tested. 

The Miostagmin Reaction. — Ascoli and his pupils 
have presented a blood-serum reaction based upon certain 
principles of physical chemistry. They claim that when 
the essential principles of a specific antigen are extracted, 
the resultant extract, if added to a suspected blood serum, 
produces such alteration that variations in surface tension 
may be measured. These alterations are estimated by 
a Traube stalagmometer before and after incubation of 
the antigen-extract-serum mixture. Ascoli claims that 
such changes in surface tension occur when antigen and 
specific antibody unite, that the decrease in surface ten- 
sion may result in stalagmometric readings showing an 
increase of from 2 to 5 drops. 

The Ascoli reaction is very complicated. While in its 
originator's hands it seems to be a valuable aid in the 
diagnosis of cancer, numerous competent investigators 
(Kelling, Bernstein and Simons and others) claim that the 
reaction has little clinical worth. 



THE BLOOD IN GASTRIC CANCER 349 

REFERENCES 

Cabot: "A Guide to the Clinical Examination of Blood," New York, 

1904. 
OsLER AND McCrae: "Cancer of the Stomach," Philadelphia, 1900. 
Cunliffe: Medical Chronicle, Sept.. 1903. 
Bonhoff: Beitr. z. klin. Chir., Tubingen, 1914, June, xcii. 
Lang: Ztschrft. f. klin. Med., 1902, xiii, p. 106. 
Weil, R.: Arch. Int. Med., 1908, i, p. 28. 
Krida: Albany Medical Annals, 1910, May, p. 259. 
Elsberg, Neuhoff and Geist: Am. Jour. Med. Sc, 1910, Feb., p. 264. 
Warfield: Arch. Int. Med., 1911, Nov., p. 621. 
Muller: "Serodiagnostic Methods," 1913, Philadelphia and London. 

Translated by R. C. Whitman. 
Freund & Kaminer: Biochem. Ztschrft., 1910; also Wien. klin. 

Wchnrft., 1910, xiii., pp. 378 and 1221, and 1911, xxiv., p. 1759. 
Bergmann and Meyer: Berl. klin. Wschnschrft., 1908, xiv, p. 1673. 
Weil, R. and Feldstein: Proc. Soc. Exper. Biol, and Med., 1910, vii, 

p. 61. 
Stockton: "Diseases of the Stomach," New York, 1914. 
Roche: Arch. Int. Med., 1909, April, p. 1. 
Abderhalden: "Schutzfermente des tierischen Organismus," Berlin, 

1912; also Miinch.med. Wchnrft., 1912, Ux., pp. 1305, 1939 and 2172. 
Franz: Miinch. med. Wschnschrft., 1912, hx., p. 1702. 
Frank and Heimann: Berl. klin. Wschnschrft., 1912, lix, p. 1706. 
Ransohoff, Jour. Am. Med. Assn., 1913, July 5, p. 8. 
AscOLi: Miinch. med. Wschnschrft., 1910, Jan. 11, p. 63. 
AscoLi AND Izar: Ihid., 1910, Feb. 22, p. 403. 
AscoLi: Ihid., 1910, Oct. 11, p. 2129. 

Ascoli: Deutsch med. Wschnschrft., 1910, Oct. 27, p. 1997. 
Kelling: Wien klin. Wschschrft., 1911, Jan., No. 3. 
Bernstein and Simons: Am. Jour. Med. Sc, 1911, Dec. 



\'-- 



CHAPTER VIII 

THE SIGNIFICANCE OF GASTRIC ULCER WITH 
RESPECT TO GASTRIC CANCER 

During the past decade there has been a growing con- 
viction among clinical and laboratory workers that there 
exists an increasing number of cases clinically admitting a 
diagnosis only of chronic gastric ulcer which do not pur- 
sue an orthodox course of chronicity, but often rapidly 
assume aspects of malignant disease. If such cases come 
to laparotomy or necropsy, the surgeon or pathologist 
demonstrates cancer. 

Conversely, surgically and pathologically proved cases 
of gastric cancer frequently reveal an early clinical history, 
which at any stage prior to the terminal period of evident 
malignancy might logically be interpreted clinically as 
chronic gastric ulcer. 

The subject has etiologic, diagnostic and prognostic 
aspects. Inasmuch as this group of cases satisfies our 
present day diagnostic requirements for gastric ulcer and 
this process, of whatever nature it may be, later assumes 
characteristics that we associate with malignancy, it 
would appear imperative to determine how frequently 
this type of affection exists, in what manner, if any, it 
manifests itself, the possibilities of its recognition and the 
indicated treatment when demonstrated. 

At the present state of our knowledge it is impossible 
to prove how frequently gastric ulcers become cancers. 
Whatever individual opinion may be, this statement holds 
true. There are many reasons why conclusive facts 
cannot yet be given. Some of these we would emphasize: 

350 



THE SIGNIFICANCE OF GASTRIC ULCER 351 

(a) Regional variation in the incidence of gastric ulcer. 
In 1864 Brinton claimed that peptic ulcer was found at 
necropsy in from 2 to 13 per cent, of persons dying from 
all causes. The average incidence was approximately 
5 per cent. These figures have been much quoted and 
indiscriminately compared. It will be recalled that 
they were collected at a time when pathological 
methods were poorly developed. Modern writers have 
shown that not only is there a wide range in incidence of 
peptic ulcer in different countries, but that there is also 
striking variation in its occurrence in different parts of 
the same country. In a recent and careful survey of the 
subject Bolton points out that pathological statistics 
collected from Europe and America indicate that this 
variation ranges between 0.5 per cent, and 20 per cent. 
Bolton gives the average figures as follows: Denmark 
16.7 per cent., England 5 per cent., Germany 5 per cent., 
Austria 4 per cent., Switzerland 2.6 per cent., North 
America 1.3 per cent., Russia 0.8 per cent. It is said that 
in North Germany the disease is about as frequent as it is 
in Denmark, while parts of South Germany approximate 
the' average for North America. Whatever may be the 
estimated incidence based upon clinical diagnoses, post- 
mortem, or laparotomy statistics are the only figures upon 
which we can base dependable comparisons. We have 
already shown (Chapter I) that our 921 instances of 
operatively and pathologically demonstrated cases of gastric 
cancer occurred in about 82,000 hospital admissions. 
This indicates an incidence of 1.12 per cent. In ap- 
proximately the same number of admissions there were 
operatively demonstrated 1250 chronic or acute gastric 
ulcers, or a percentage of 1.51. It is seen that the 
incidence of proved gastric cancer and gastric ulcer in 



352 CA^XER OF the stoimach 

our hospital admissions did not vary greatly. Compar- 
ing the two percentages, it is remarkable to note that the 
cancer incidence is approximately 74 per cent, of that of 
gastric ulcer. TSTien the appended analj'sis of the rela- 
tion of ulcer and cancer is considered, it must be admitted 
that this figm^e is striking. The above is an American 
experience and, hence, scarcely comparable with that 
in other countries. ^Moreover, it is an experience largely 
from the Central and Xorthwest United States and 
Southern Canada. 

(b) Variation in pathologic opinion as to the life history 
of gastric ulcer and of gastric cancer. While the literature 
contains many excellent monographs descriptive of gastric 
ulcer, the researches of Bolton supply us with practically 
our only dependable evidence of such elementarj^ knowl- 
edge as that an acute gastric ulcer ma^^ progi^ess to chron- 
icity and is not a different clinical entity. Bolton's inves- 
tigations appear to be warranted by both histologic and 
clinical facts. This observer has not yet demonstrated car- 
cinomatous changes in any of his chronic gastric ulcers. 
Certainly if some of the photomicrographs submitted were 
examined by oil-immersion lens, it would be rather difficult 
to exclude the presence of h^-perplasia approaching the 
malignant form described by IMacCarty. 

With respect to the histologic demonstration of the 
beginnings of so-called ''primary'" gastric cancer, we are 
more uncertain than with respect to known cell change in 
gastric ulcer. Xo one has ever seen the actual transition of 
ga-stric mucosa from benignness to maUgnancy. One can 
only say of a given specimen that cancer is present or it is 
absent. It would appear, however, that careful study of 
fresh tissue with highest magnification reveals certain 
undifferentiated cells which aid in the segregation of 



THE SIGNIFICANCE OF GASTEIC ULCER 353 

benign from malignant hyperplasia (MacCarty). When 
such is present a "precancerous" state not infrequently 
seems to exist (vide infra). 

(c) The variation in an accepted clinical complex of 
gastric ulcer. We refer in full to this below. Modern 
investigations would certainly warrant the statement that 
the chnical diagnosis of gastric ulcer is by no means simple 
and according to well-marked symptoms and signs. It is 
now generally admitted by those who have followed the 
progress of any considerable group of cases that many of 
the instances which were formerly classed as gastiic ulcer 
are not such, but are gastric evidences of extragastric 
disease. This appUes especially to cases below age 30, who 
present many of our so-called ulcer symptoms, clinically. 

(d) The tendency to cloud our present-day knowledge 
with ancient statistics and imperfect pathologic and histologic 
descriptions. To those famiUar with the hterature, it is 
not necessary to point out the hindrances to the advance of 
knowledge that have resulted from the constant quoting 
of work done by investigators of a half century ago. 
Such researches were remarkably acute for their day, but 
modern science would indeed have cause for regret if it 
were not able to claim new facts with its added arma- 
mentarium for research. The developments of laboratory 
methods for the preservation and study of tissue, the im- 
provement in microscopes, the checking up of clinical 
material pathologically, the advance in hospital facilities 
for examination of disease, and the systematization and 
standardization of records, have all contributed toward 
rendering extremely questionable the points upon which 
classifications of gastric ulcer and cancer were made 20 to 
70 years ago. Except for the historical interest, one would 
hardly think of burdening himself with the pathology, his- 

23 



354 CANCER OF THE STOMACH 

tology and bacteriology of syphilis, meningitis, malaria or 
typhoid fever as set down three decades ago, yet strenuous 
attempts are still made to fit twentieth century gastric ulcer 
and gastric cancer to the conception of it a half century ago. 
It is quite possible that these diseases have altered in many 
ways as succeeding generations have harbored them, or 
that environment has had such effect. That variations are 
within the range of probability is evidenced by a study 
of the clinical history of syphilis, leprosy, typhus fever, 
poliomyelitis, gout, etc. 

For the purpose of returning facts regarding the relation- 
ship between gastric cancer and gastric ulcer, the author 
recently made an analysis of 566 operatively and patho- 
logically demonstrated cases of gastric cancer. 

CLINICAL CONSIDERATION 

Significance of History. — Sex. — In the 566 cases there 
were 436 males, and 130 females, or 3.1 males to each 
female. We have shown that this is very near the sex 
ratio existing in non-malignant, chronic gastric ulcer. 

Age. — The youngest patient in the series was 20 years 
of age; there were 26 patients aged over 70. More than 
three-fourths of the cases came between the ages of 40 and 
70 years. A comparative study of 134 .cases of non- 
malignant chronic gastric ulcers shows that rather more 
than one-half were in the 40- to 70-year period. 

Etiologic Factors. — A history of trauma was obtained 
in 3.4 per cent, of the cases. In 2.9 per cent, the trau- 
matism occurred in the early history of the affection, and 
frequently appeared to cause or precipitate symptoms. 
There were three instances in which husband and wife 
became affected with cancer within a few months of each 
other. A family or blood-relationship history was obtain- 



THE SIGXIFICAXCE OF GASTRIC ULCER 355 

able in 9.2 per cent.; and a history of tuberculosis in 1.2 
per cent. 

Previous Disorders of Digestion (the "Precancerous 
History). — INIore than 10 years ago Graham called attention 
to the significance of the eailj clinical history in patients 
presenting themselves in his ser^dce for evident gastric 
cancer. He stated that more than 47 per cent, of his 
operatively demonstrated cases of cancer had had previous 
histories which strongly suggested that the cancer had 
followed a chronic gastric ulcer, existing variouslj^ from 
3 to 37 years. Graham also emphasized the fact that 
nearly 40 per cent, of his cases of cancer were not asso- 
ciated with the pre^dous so-called ''ulcer history," but 
that in this group of cases cancer developed in stomachs 
which formerly functionated normally. 

The value of early history as indicating that succeeding 
cancer of the stomach has its origin in such hypothetic 
ulcer has been justly questioned. The weakness of the 
argument appears to be at least threefold: [1) the clinical 
variation in an ulcer symptom-complex, (2) the indefinite 
ideas existing as to the time element in the development of 
"chronic'' ulcer and of cancer, and (3) the difficulties in 
actually proving whether or not a process ichich is later 
shown to he malignant ivas ever anything else. I shall 
consider these points seriatim. 

1. To admit the indefiniteness of an ulcer symptom- 
complex is to grant at once that mistakes in diagnosis are 
readily possible. That this is a fact has come within the 
experience of all gastrologists who have handled either a 
few or a large number of cases. In spite of personal 
opinions, we must admit that the only gastric ulcers that 
we can positiveh^ say exist are those whicli we can see or 
feel. AATiile it ma}' be clinically safer to treat a given 



356 CANCER OF THE STOMACH 

case as gastric ulcer, as recommended by Shutz, never- 
theless such uncertain procedures have undoubtedly led 
to error, confusion and injury to patients. The prognostic 
aspect of the case is of greater import than the question 
of type of treatment based on uncertain diagnosis. 

In endeavoring to gauge the importance of the previous 
(the precancerous) gastric history of the cases in our 
series we found it necessary to group them according to 
accepted clinical symptom-complexes, of ulcer and of 
cancer, respectively. This mode of procedure has many 
faults, but it should be emphasized that this method of 
classification furnishes the bulk of the literature on the 
subject. 

The clinical symptom-complex considered for gastric 
ulcer is based on Friedenwald's recently analyzed 409 
cases, while that for cancer is compiled from the work of 
Osier and McCrae. If the value of such grouping is 
questioned, then the value of much that makes up accepted 
clinical knowledge of the diagnosis and the treatment of 
the two ailments must also be questioned. If the symptom- 
complexes indicated mean clinically ulcer or cancer of 
the stomach, then the facts that we have to present are 
not without significance. 

We have taken the following symptom-complex to mean 
gastric ulcer clinically: a form of gastric malfunction 
occurring usually between the ages 10 and 70 years, char- 
acterized by periodic or continuous abdominal discomfort 
or pain, frequently bearing definite relation to food inges- 
tion, and often associated with epigastric or dorsal tender- 
ness, vomiting, loss of blood (hematemesis or melena) and 
with hyperacid gastric contents. 

We have considered as '^ primary ^^ cancer, clinically a 
form of gastric malfunction of a downwardly progressive 



THE SIGNIFICANCE OF GASTRIC ULCER 357 

nature, usually occurring in persons between the ages of 40 
and 70 years, who have been previously normal gastrically, 
the imperfect function being characterized by abdominal 
distress or pain, usually associated with cachexia, loss of 
blood, epigastric tumor, vomiting and with gastric contents 
revealing motor defects, low free hydrochloric acid and the 
presence of organic acids and of foreign microorganisms. 

In grouping our material under these accepted clinical 
symptom-complexes, we find that of the 566 proved cases 
of gastric cancer, 239 or 41.8 per cent, fall into the cancer- 
following-ulcer classification, while 182 or 32.1 per cent, are 
in the ^'primary" cancer division. There is, in addition, a 
group which may be termed cases of ''irregular ulcer" that 
numbers 106, or 18.7 per cent. Twenty-two patients (3.9 
per cent.) had a previous chnical history of gall-bladder 
affection, while 17 or 3 per cent, had early symptoms point- 
ing to primary processes in the appendix, the pancreas or 
the bowel. Combining the returns from the two "ulcer" 
groups, it is seen that precancerous history indicates that 
60.5 per cent, of the subsequently demonstrated cases of 
cancer gave those cUnical evidences which we associate 
with chronic gastric ulcer, prior to the time when the ail- 
ment assumed the cUnical picture that we associate with 
gastric malignancy. In but 32.1 per cent, was the disease, 
from its inception, continuous and progressively downward, 
and in persons who had been previously sound gastric- 
ally. These figures are not to be taken as they stand to- 
indicate that nearly two-thirds of all chronic gastric 
ulcers later become malignant, because we know that 
ulcers frequently heal spontaneously or continue as chronic, 
inflammatory processes. Added significance, however, is 
given to the figures by the observation of the surgical 
pathologist that more than two-thirds of all excised chronic 



358 CANCER OF THE STOMACH 

calloused gastric ulcers show early evidences of malignant 
metamorphosis (Wilson and MacCarty). 

2. The analysis of any considerable material, ulcer or 
cancer, reveals many striking variations in the duration of 
the morbid process. Both clinical and pathologic differen- 
tiation should be made between the terms "old" and 
"chronic" as applied to ulcer and cancer. Chronicity, 
pathologically, does not necessarily mean that the disease 
is old, that is, of long duration in terms of months or years. 
Large, excavated, calloused ulcers may apparently develop 
in a few weeks, while many small, indurated round ulcers 
may give even obstructive symptoms for years. This 
also applies to cancer. Within 2 weeks of the onset of 
disabihty we have seen a patient exhibit general carcinosis, 
with a large primary mass in the stomach. Another patient 
may have noticed an epigastric nodule for a year, and yet 
laparotomy demonstrates a small mass well confined to the 
wall of the stomach. 

The average length of time of all symptoms in our 182 
cases clinically satisfying the symptom-complex of cancer 
was 7.1 months. Of this group the shortest history ex- 
tended over but 2 weeks, and the longest was about 3 years. 
In 9 cases (1.6 per cent.) cancer of the stomach was found 
at exploration, when there had been no indications of gastric 
disorder. Such cases have been described by Osier, 
Chesnel and others. 

Of the 239 cases clinically furnishing the symptom- 
complex of a chronic gastric disorder previous to the period 
of evident malignancy, the average duration of all symp- 
toms was 11.4 years. In this group the average duration 
of the supervening malignant course was 6.1 months. It 
seems thus manifest that the periods of downward progression 
closely approximate in the two classes of cases, wholly inde- 



THE SIGNIFICANCE OF GASTRIC ULCER 359 

pendent of the earlier gastric history of the case. From 
our knowledge of malignant processes in general, it would 
seem scarcely possible that the "primary" cases of cancer, 
mentioned before, existed for any considerable length of 
time without giving cUnical evidences of their presence. 
Especially is this emphasized when we are aware that be- 
tween 60 and 70 per cent, of all proved cases of chronic 
gastric ulcer and of gastric cancer are so located in the 
visceral wall as to early interfere with the stomach's 
emptying power. We have been frequently impressed by 
the fact that many so-called ''primary" gastric cancers in 
the early weeks of their disturbance gave such cHnical 
symptoms as are commonly ascribed, cUnically, to chronic 
ulcer. 

3. The demonstration that a long-standing gastric 
disturbance which is later shown to be malignant was ever 
benign leads largely into realms of speculation. The 
chief arguments in support of this supposition appear to 
be the following: 

(a) After gastro-enterostomy for chronic ulcer, when 
the ulcer is not excised, it is stated that such patient 
rarely develops gastric cancer (Paterson, Gressot and 
others). The argument loses much of its force when we 
recall that in such subject the entire physiology of the 
stomach and related viscera may have been upset. It is 
well recognized by able surgeons and phj^siologists that 
gastro-enterostomy is more than a simple procedure of 
''drainage." In the large majority of gastric extracts from 
stomachs where gastro-enterostomy has been performed, 
it is possible to demonstrate, chemically or microscopic- 
ally, both duodenal and jejunal contents. Just what effect 
these foreign substances have on gastric ulcers or gastric can- 
cers we have yet no means of knowing. We do know, how- 



360 CANCER OF THE STOMACH 

ever, that the parts of the aUmentary tract from which they 
come are rarely affected with cancer. In our series of cases 
of gastric cancers, there are four patients which later devel- 
oped cancer following gastro-enterostomy for ulcer. It 
also seems to hold that in cases of gastric cancer in which no 
pyloric obstructions are demonstrable gastro-enterostomy 
grants a longer lease of life than when such operations have 
not been performed. After gastro-enterostomy, stomach 
emptying is more rapid than before. This freeing the 
viscus of irritant food and secretions, and the cast-off 
material from ulcers or cancers, might be a not incon- 
siderable factor in the after course, histologically, of such 
lesions. 

(6) Duodenal ulcer of the indurated type is a relatively 
more common affection than is gastric ulcer, yet carcinoma 
of the duodenum is a rarity. It is held that if cancer 
develops on chronic ulcer a great frequency of its duodenal 
incidence should be expected. That the duodenum has a 
protective mechanism against malignancy appears to be 
shown by the surgical observation that only rarely does 
cancer at the pylorus, on the stomach side, pass to the duo- 
denum by direct extension. In our series but four such 
instances were noted. The difference in the character of 
the tissue in which the chronic ulcer is implanted is also 
demonstrated by the fact that it is not uncommon to find 
that primary ulceration of the duodenum which extends up 
to the pylorus, assumes malignant characteristics on its 
gastric side while the ulcer on the duodenal side remains 
benign. There are 6 such cases in our series. Recurrences 
after removal of cancer are extremely rare in the duodenum. 
We have also 5 cases in which mahgnant gastric ulcer 
was demonstrated together with benign calloused duo- 
denal ulcer. Cancers of the duodenum occur in the 



THE SIGNIFICANCE OF GASTRIC ULCER 361 

great majority of instances, at or about the papilla of 
Vater. It is well known that this region of the viscus 
suffers traumatism from gall-stones, altered secretion of the 
liver and pancreas and from infective processes of the 
gall-tract. The upper part of the duodenum, where 
ulcer is common, is relatively immune to these influences, 
and from the intense acidity and the associated pepto- 
lytic power of the gastric juice, which may irritate gastric 
ulcers. Further, food remains but a brief time in the duo- 
denum. It is rapidly passed on into the jejunum, where 
it stays but briefly. This region is also almost cancer- 
free. The chyle, however, passes more slowly through 
the ileum, and as the ileo-cecal valve is approached, malig- 
nant processes again appear. The cecum and ascending 
colon are common grounds of cancer. 

(c) Pathologists readily grant that there is a type of 
gastric affection which they class as ''ulcus carcinoma- 
tosum." They demonstrate this generally at post-mortem. 
They do not, however, explain why this type of ulceration 
exists, by revealing any characteristic changes in the 
gastric mucosa in which it occurs, nor do they show that 
from its beginning it was not anything else than malignant. 
They are willing to grant that it is something different 
from primary cancer which later ulcerates, but just what 
this difference is they do not state. This type of affection 
appears curiously to exist as an isolated entity with no 
explanation of its existence or prophecy as to its future 
course. 

(d) Clinicians hold that malignant ulcer exists in from 3 
to 6 per cent, of all ulcers of the stomach (Fenwick, Rosen- 
heim and others) . The various observers, however, do not 
detail just how to segregate this group clinically from benign 
chronic gastric ulcer, nor do they offer suggestions of 



362 CANCER OF THE STOMACH 

guidance for the determination of just what chronic ulcers 
are destined to pursue this course. 

In our series there were 239 cases which, up to within 
an average time of 6.1 months before being microscopically 
demonstrated as cancer, showed nothing to indicate that 
were a laparotomy to, be performed in that period anything 
other than benign chronic calloused gastric ulcers would be 
found. Only the subsequent course or the examination of 
fresh tissue, using high magnification, at operation, revealed 
the true nature of the affection. In this group of cases 
cancerous ulcers were found on laparotomy in 105 (43.9 
per cent.) and extensive carcinomas, with or without 
ulceration, in 134 (56.1 per cent.). Of the 183 cases with 
a clinical history of primary carcinoma, ulcus carcino- 
matosum was demonstrated in 28 (15.8 per cent.), while 
in 154 (84.2 per cent.) extensive growth was found. Of the 
106 cases with clinical history or irregular gastric ulcer in 
the precancerous stage, ulcus carcinomatosum was shown 
in 22 (20.7 per cent.) and in 84 (79.2 per cent.) exten- 
sive involvement, with or without secondary ulceration. 

These observations suggest several points. Develop- 
ment and careful interpretation of the early — the pre- 
cancerous — history permits patients coming to laparotomy 
at a stage when in more than one-half of the instances the 
maximum advantage of localization of the disease is 
available, and hence the maximum benefit accrues to the 
individual case. In about one-fifth of the cases of so-called 
primary and gastric cancer ulcus carcinomatosum can be 
demonstrated at operation, and these appear to be generally 
favorable cases for operative procedure, compared to their 
fellows. This is especially to be emphasized inasmuch as it 
has been shown by MacCarty and Blackford that time- 
duration of symptoms bears no proportionate relation to 



THE SIGNIFICANCE OF GASTRIC TLCER 363 

the size and extent of involvement of the Ij^mph nodes, and 
that the operative and the ultimate mortality are in direct 
proportion to the amount of involvement of the lymph 
nodes. 

It would appear from the brief consideration of the 
objections to the interpretation of the so-called '"precan- 
cerous" history with respect to the succeeding neoplasm 
having developed an earlier benign chronic gastric ulcer, 
that so far as we can judge, cUnically, the careful develop- 
ment of such history furnishes extremely valuable diag- 
nostic and prognostic information. It would appear 
from the facts submitted that such interpretation allows 
the greatest degree of operative benefit with the minimum 
of operative risk. These facts have especialh- to be con- 
sidered when we recall that we have no better clinical guide 
and that those who object to the significance of the ''pre- 
cancerous" history have nothing better to offer. 

SIGNIFICANCE OF CLINICAL SYMPTOMS 

Periodicity of Symptoms. — One of the strongest clinical 
evidences in the diagnosis of chronic gastric ulcer is the 
periodic recurrence of dyspeptic symptoms with perfect 
or fair health between the attacks. Graham, Friedenwald 
and ourselves have pointed this out. In 239 of the cases 
furnishing the material for this report in which there was a 
precancerous history of digestive disturbance, 81 per cent, 
complained of attacks of discomfort in that period; in 13.3 
per cent, the attacks were of rare occurrence, and 4.7 per 
cent, had had continuous disturbance. When the period 
of mahgnancj^ supervened on the intermittent dyspeptic 
storm the affection was continuous and progressive in more 
than 99 per cent., irrespective of the earlier history. In 
the 182 cases making up the "primary" cancerous group, 



364 CANCER OF THE STOMACH 

continuous disturbance was noted in 95.1 per cent, and 
frequent periodic attacks in 4.8 per cent. 

Types of Pain. — In the group of cases comprising cancer 
following previous dyspepsia, severe pain and colic were 
noted in 23 per cent., steady ache in 48 per cent, and 
abdominal discomfort in 28 per cent. In the primary 
cancer group coHcky pain was noted in but 6.6 per cent., 
steady ache in 32.4 per cent., and vague discomfort or 
•^ bloat" in 56 per cent., while in 4.3 per cent, there was no 
abdominal discomfort whatever. Opiate relief of pain 
was required in 6.5 per cent, of the first group of cases, and 
in 2 per cent, of the second group. 

Food Relation of Abdominal Pain or Distress. — In the 
diagnosis of chronic gastric ulceration, the reUef of dis- 
comfort by the ingestion of food (if this form of relief be 
fairly constant) is granted to be a most valuable diagnostic 
sign. In a chronic dyspeptic its continuous presence is 
often almost pathognomonic for ulcer. At the stage when 
the cases in our series came under observation, of the dys- 
pepsia-preceding-maHgnancy group, food ease was present 
in 20.9 per cent., food aggravation in 46.4 per cent., food of 
negative significance in 27.4 per cent., and uncertain in 
5.1 per cent. In the group of primary cancers, food ease 
was noted in but 3.2 per cent., food aggravation in 57.6 per 
cent., food of negative significance in 36.8 per cent., and of 
uncertain effect in 2.1 per cent. 

Hemorrhage. — Intermittent bleeding (melena, hematem- 
esis) is considered as almost conclusive evidence that peptic 
ulcer exists. While only but from 22 to 40 per cent, 
of gastric ulcers bleed (Friedenwald, Smithies), yet when 
hemorrhage occurs, other things being equal, it is clinically 
assumed that ulcer is present. In the series of cancers here 
analyzed, hemorrhage was noted in 97 cases. Of the group 



THE SIGNIFICANCE OF GASTRIC ULCER 365 

designated by history symptomatology as malignancy- 
foUowing-ulcer, hemorrhage occurred in 62.9 per cent.; 
in the group styled from early history ''irregular" ulcer 
hemorrhage occurred in 19.5 per cent., while in the group 
of ''primary" cancers hemorrhage occurred in 16.5 per 
cent. Of the whole number bleeding, 52 per cent, bled at 
least 2 years prior to their coming under observation, 
while 42 per cent, had bled within 2 years of that time. 
In 6 per cent, the time of hemorrhage was not determined. 
Of those who bled within the 2-year period, 77.5 per cent, 
were cases comprising the non-primary cancerous group. 

Anemia. — Of one or more estimations of hemoglobin in 
250 of the cases, the average hemoglobin was 69.6 per cent, 
for the primary cancerous group and 67.2 per cent, for the 
dyspepsia-bef ore-cancer class. The average for the series 
was 68.1 per cent. 

Vomiting. — Of the entire series 326, or 57.5 per cent., 
of the cases vomited, and of this number 57 per cent, 
vomited daily. Of the series, 132 (40.5 per cent.) exhibited 
delayed vomiting. In but 58 (15 per cent.) was the 
vomitus dark or "coffee-ground." 

SIGNIFICANCE OF PHYSICAL EXAMINATION 

Tumor or ridge in the abdomen (generally epigastric) 
was demonstrated in 411 instances (72.6 per cent.). It was 
movable in 63.6 per cent. Of the primary cancerous 
group tumor was present in 39.8 per cent., while in the 
ulcer-cancer class it was shown in 60 per cent. 

Metastases were demonstrated in 86 cases (14.7 per 
cent.) before laparotomy, and were, in the order of fre- 
quency, rectal and pelvic, cervical and axillary, navel 
and abdominal wall, and in the groin. In the primary 
cancerous group, metastases were present in 20.8 per 



366 CANCER OF THE STOMACH 

cent, and in the non-primary class in 13 per cent. When 
such metastases were present, the cases were generally 
inoperable. 

SIGNIFICANCE OF TEST-MEAL FINDINGS 

The secretory function of the stomach was determined 
by means of the Ewald breakfast. It was preceded 12 
hours by a motor-meal after the suggestions of Strauss 
and Hansmann. Routine quantitative and qualitative 
estimations were performed by the Topfer method. 

There is not space here to go into elaborate detail 
of the information derived from examination of gastric 
contents in our series of 566 cases of cancer. A few of 
the more important points will be detailed, and the com- 
plete report reserved for a subsequent paper. 

Food Remnants. — Motility was interfered with in 73.9 
per cent, of the entire series. Of the primary cancerous 
group, remnants were present in 64.8 per cent, and in the 
non-primary class in 74.2 per cent. 

Acidity of Gastric Extract.— In the primary cancerous 
group there were 55.4 per cent, of cases in which hydro- 
chloric acid was absent, in 11.5 per cent, hydrochloric acid 
was between 20 and 50. In this group 79 per cent, had 
total acidity under 50, and 84 per cent, had combined 
acidity and acid salts under 50. 

In the non-primary cancerous group, free hydrochloric 
acid was absent in 49 per cent., in 20 per cent, it was 
between 20 and 50, and in 46.3 per cent, it was under 50. 
Total acidity was below 50 in 78 per cent., and combined 
acidity and acid salts below 50 in 90 per cent. 

Lactic Acid. — In the primary cancerous group this 
was demonstrated in 52.2 per cent., while in the non-pri- 
mary class it was present in 44.9 per cent. 



THE SIGNIFICANCE OF GASTRIC ULCER 367 

Occult Blood.- — This was shown (benzidin or guaiac tests) 
in 73 per cent, of the primary cancerous class, and in 77 
per cent, of the non-primary group. 

Microscopic Examinations of Gastric Extracts. — These 
were made on the last 146 cases of gastric carcinoma by the 
agar-differential-stain method devised by the author. 

Oppler-Boas Bacilli. — This form of organism was dem- 
onstrated in 93.8 per cent, of all the cases. In this same 
series, yeasts were shown in 50.7 per cent, and sarcines in 
17 per cent. Oppler-Boas baciUi and yeasts were com- 
bined in 30 per cent., Oppler-Boas bacilli and sarcines in 10 
per cent, and Oppler-Boas bacilli together with yeasts 
and sarcines in 9.2 per cent. Cells showing atypical 
mitoses were present in 5 cases. 

Special Tests. — In 141 instances of demonstrated cancer 
the glycyltryptophan test was made. It was positive in 
40 per cent. We have already analyzed much of the 
material at another place in this book. 

In 31 cases the hemolytic reaction to alien erythrocytes 
in vitro was positive in 47.2 per cent. 

Woodyatt and Jacques have recently pointed out that 
in gastric cancers an ereptic ferment, as estimated by the 
modified formaldehyde titration method suggested by 
Sorenson and Schiff, can be demonstrated in excess in the 
gastric extract that has been passed through a Berkefeld 
filter. Our experience with the original procedure is 
briefly summarized as follows: The average formaldehyde 
index of 57 cases of gastric cancer was 21. The average 
index of 40 cases of benign gastric ulcer was 10.8 and the 
average index in 75 cases of duodenal ulcer was 11.9. 
In 17 cases of achylia gastrica, the average formaldehyde 
titration index was 14.1, of 10 cases of pernicious anemia, 
14.5, and in 5 cases of carcinomas of the liver, 4.25. It 



368 CANCER OF THE STOMACH 

would appear that in some instances, the estimation of 
the ereptic power of gastric juice toward peptone solu- 
tions is of some value when taken in consideration mth 
clinical history and sjTnptomatology. 

Wolff-Junghans' Test for Soluble Albumin. — By this 
quantitative estimation method we in this series have made 
260 tests on gastric extracts showing achyha or free hydro- 
chloric acid below 20 from cases in this series. There were 
83 cases of gastric cancer. The reaction was positive in 
86 per cent. In this group there were 20 cases of lesser 
curvature and cardiac malignancy, and the reaction was 
positive in 75 per cent. Of 11 cases of ulcus carcinoma- 
tosum without gastric retention the reaction was positive 
in 10 cases, or 90.9 per cent. In 11 cases of extragastric 
carcinomas (liver and gall-tract) the reaction was positive 
in 10 per cent.; in 17 cases of achyha gastrica, positive 
in 17 per cent. It would seem that this test is of value 
when taken in consideration with other evidence in car- 
cinomas not associated with pjdoric obstruction or pal- 
pable tumor, for example, growths at the cardia, the 
fundus, high on the lesser curvatm^e, and on the posterior 
wall, and in cases in which a large carcinoma, with con- 
siderable induration, holds a pylorus open. 

SURGICAL CONSIDERATION 

Location.^ — In 210 cases (39 per cent.) the ulcus car- 
cinomatosum or the growth was at the pylorus; in 27.1 
per cent, on the lesser curvature near the pylorus; in 19.3 
per cent, general; in 7.2 per cent, on the posterior waU, 
and in 4.2 per cent, at the cardia. The greater curv^e was 
involved in 1.1 per cent., the fundus in 0.75 per cent., and 
the anterior wall in 0.37 per cent. In 9 cases there were 
simple and mahgnant ulcers associated in the same stomach, 



THE SIGNIFICANCE OF GASTRIC ULCER 369 

and in 5 cases simple duodenal ulcer and malignant gastric 
ulcer. 

The figures for location are to be contrasted with those 
of Welch, Brinton, Lebert and others. These authorities 
observed generally the terminal results of cancer of the 
stomach; nor were their observations always in a con- 
secutive series, examined by uniform procedures. To 
any one who has had access to post-mortem material the 
difficulties connected with primary localization of gastric 
neoplasms need not be explained. The localization figures 
of our series, however, closely correspond to the location 
of chronic, calloused gastric ulcer, as shown by the tables 
of Welch and myself. 

Lymph nodes were involved in 71 per cent., irrespective 
of the early or late history. In 22.2 per cent., there was 
no lymph-node involvement and these cases were, as a 
rule, favorable for operation. Free fluid in the abdomen 
was present in 3.9 per cent. These were inoperable cases. 

There were 16 cases in which a carcinomatous ulcer 
had been previously excised, but in which the involvement 
of the lymph nodes (often microscopic only) had been 
noted — in which the subjects later returned with huge 
inoperable masses in the epigastrium. 

Twelve per cent, of the patients died within 6 months 
following operation, but 36.6 per cent, remained well for 
more than 3 years, and 22 per cent, remained well over 5 
years. 

Pathology. — It is not feasible to give here a detailed 
description of the specimens secured at laparotomy in this 
series of gastric cancers, and only a gross summary will be 
made. 

The specimens were first examined in frozen section 
within a few minutes after their removal from the patients. 

24 



370 CANCER OF THE STOMACH 

They were next fixed in Melinkow's modification of Kaiser- 
ling's fluid and again sectioned and examined. 

Full reports have been made by MacCarty and recently 
some of the specimens furnish part of the study of 
Wilson and McDowell. 

Types of Growth. — Adenocarcinomas were demonstrated 
in 556 instances (98.2 per cent.); colloid carcinomas, '5 
times; fibromas, 4 times, and sarcoma once. In 155 
instances (27.4 per cent.) ulcera carcinomatosa were shown. 
These may have been primarily such, had formed from pre- 
vious chronic ulcer or had resulted from surface pro- 
teolytic ulceration of preceding cancer. It is often im- 
possible to say, without clinical history or test-meal 
findings, whether an ulcus carcinomatosum developed as 
such or whether it is a secondary result of a ''primary" 
cancer. At the present stage of our knowledge, the sur- 
gical pathologist can positively say only that in a given 
specimen of chronic, indurated gastric ulcer, cancer is, or 
is not present. There appears to be a border-line class, 
however, in which surgical pathologists of the widest 
experience in the examination of fresh or fixed tissue can 
often distinguish cellular arrangement or intracellular 
change of such nature as to warrant their stating that the 
process is ''precancerous." Not infrequently the subse- 
quent course of the ailment bears out the histologic 
prophecy. 

In the experience of Wilson and MacCarty, 71 per cent, 
of 153 cases of undoubted gastric carcinomas presented 
gross and microscopic evidence of previous ulcer. These 
observers also demonstrated that 68 per cent, of resected 
chronic ulcers of the stomach and duodenum (the latter 
furnishing a very small proportion of cases) were associated 
with cancer. In several instances, MacCarty noted that 



THE SIGNIFICANCE OF GASTRIC ULCER 371 

the presence of erosions, simple round ulcer and ulcus 
carcinomatosum in the same specimen suggested possibili- 
ties of transition corresponding to that shoT\Ti by Wooley 
in cases of adrenal tumor. MacCarty has emphasized 
the diflB.culties of always differentiating between simple 
hyperplasia and mahgnant hyperplasia. He suggests that 
hyperplasia is a forerunner of malignancy, that hyperplasia 
varies in degree, that cancer is malignant hyperplasia, which 
also varies in degree, and that some degrees of both proc- 
esses are indistinguishable histologically. This \dew is well 
within the opinion of Adami. It seems to be partially 
substantiated by the recent work of Drew and of Levin in 
experimental tissue proliferation and inoculation of malig- 
nant tumors. 

Association of Malignant and Benign Processes. — In this 
series of gastric cancers there were five instances of simple 
ulcer of the duodenum associated with malignant gastric 
ulcer. In 9 cases, simple and mahgnant ulcers were found 
in the same stomach. Independent cancer of the stomach 
and of the duodenum was demonstrated once. There 
were 2 cases of multiple gastric cancers. Six times it was 
observed that mahgnant gastric ulcers stopped sharply 
when duodenal mucosa was reached, but in seven in- 
stances of extensive gastric cancers it was shown that the, 
duodenum was secondarily involved by direct extension. 

REFERENCES 

Bkinton: Diseases of the Stomach, 2nd edition, pp. 124, 133. 

Bolton, C: Ulcer of the Stomach, 1913, London, p. 6. 

BoLTOx: Quarterly Journal of Medicine, Vol. v. No. 20, p. 438; Brit. 

Med. Jour., 1910, Vol. i, p. 1222; Waus. Path. Sect. Ray. Soc. Med. 

(London), 1910, Vol. iv, No. 2, p. 57; Jour, of Path, and Bact., 1910, 

Vol. xiv, p. 418. 

1. Smithies: Am. Jour. Med. Sc, 1913, March, p. 340. 

2. Graham: Collected Papers by the Staff of St. Marj^'s Hospital, i. 111. 



372 CANCER OF THE STOMACH 

3. Shutz: Wien. klin. Wchnschr., 1912, Oct. 10, p. 1513. 

4. Fkiedexwald: Am. Jour. ]Med. Sc, 1912, August, p. 157. 

5. OsLER AXD ]McCrae: Cancer of the Stomach, Practice of ]Medicine, 

1912. 

6. WiLSOX AXD ]MacCarty: Am. Jour. Med. Sc, 1909, December, p. 

846. 

7. MacCarty: Surg., Gynec. and Obst., 1910, ^lay, p. -449. 

8. Osler: Philadelphia Med. Jour., 1900, p. 245. 

9. Chesxel: These de Paris, 1877. 

10. Patersox: Surgery of the Stomach, 1913, p. 248. 

11. Gressot: Berl. klin., Wchnschr., 1912, xHx, 22. 

12. Fextvick: Quoted by Paterson, Surgerj^ of the Stomach, 1913, p. 

248. 

13. Rosenheim: Ztschr. f. khn. Med., Breslau, 1890, \-ii, 116. 

15. Graham: Prominent Symptoms in the Diagnosis of Gastric and 

Duodenal Ulcers, The Journal A. M. A., 1908, Aug. 22, p. 651. 

16. Smithies: A Method for the Microscopic Examination of Gastric 

Extracts and of Feces, Arch. Int. Med., 1912, June, p. 736. 

17. WooDYATT, R. T. AXD Jacques, J. L. : The Peptolj^ic Power of 

Gastric Juice and Sahva with Special Reference to the Diagnosis 
of Cancer, Arch. Int. Med., 1912, December, p. 560. 

18. SoREXSON and Schiff: Zeitschr. f. phj-siol. Chem., 1909, xiii, 27. 

19. Welch: Cancer of the Stomach, American System of Medicine, ii. 

20. Brixtox: Brit, and For. Med.-Chir. Rev., 1857, J&misury. 

21. Lebert: Traite pratique des maladies cancereuses, Paris, 1851, 

p. 97. 

22. Welch: Simple Ulcers of the Stomach, Pepper's System of Medi- 

cine, ii. 

23. Wooley: Tr. Assn. Am. Phys., 1902, Xo. 17, p. 627. 

24. Ad ami: ^Malignancy; Principles of Patholog}', p. 616. 

25. Drew: Jour. Path, and BacterioL, 1912, July, p. 42. 

26. Levix: Jour. Exper. Med., 1912, Xo. 12, p. 149. 



CHAPTER IX 
GASTRIC CANCER IN THE YOUNG 

We have tabulated 18 instances of gastric cancer in 
individuals under age 31. These occurred in my study of 
the records of 921 pathologically demonstrated cases of 
cancer of the stomach. It is thought that their analysis 
will demonstrate certain facts of value in anticipating or 
detecting this grave malady at an age when it is not 
commonly suspected. 

Those who wish to familiarize themselves with the 
literature on this subject may refer to the excellent mono- 
graphs of Welch, Osier and McCrae, and Dock. 

A summary of these previous reports on gastric cancer 
in the first three decades may be of service. Six instances 
(often rather dubious as to cancer) have been recorded be- 
low the age of 10. In the second decade 15 cases are de- 
scribed. In but 9 of these there were rehable pathologic 
reports. In the thirteen instances occurring in the third 
decade, few descriptions are accompanied by pathologic 
findings. Many of the patients in this group, however, 
appeared to have been affected with a gastric malady, 
seemingly malignant. 

Incidence. — The relative frequency of gastric cancer in 

the young varies with the individual series studied. In a 

small series as, for example, the beautifully analyzed 150 

cases of Osier and McCrae, the proportion was 4 per 

cent. In a large series, collected for statistical purposes 

from various non-related sources throughout the world, 

as in the 2,038 instances tabulated by Welch, the ratio was 

373 



374 CANCER OF THE STOMACH 

2.8 per cent. In my own group of 921 consecutive cases, 
examined by a uniform method (and a distinctly American 
experience), the percentage was 2.17 per cent. Sex: 
There were 12 females and 8 males. Age: The youngest 
patient was aged 18; the oldest just past 30 years. The 
average age of the series was 27.2 years. Status: Twelve 
patients were married. In two instances (12 per cent.) 
there was a family or blood-relationship history of cancer. 
Only twice were more than ordinary indulgence in tobacco 
or alcohol noted. Apparently occupation had no etiologic 
significance. 

Duration of all Gastric Complaints. — This data concerns 
but sixteen instances. Most useful facts are brought out 
by study of this phase (see Table 36). It will be noted that 
the shortest time was^ 4 months, while in one instance the 
gastric disturbance had persisted for 15 years. The aver- 
age length of time of the disability was 4.2 years. 

Consideration of the earlier part of those histories in 
patients exhibiting protracted gastric complaints not 
infrequently reveals the fact that there is in the early stages 
a different clinical presentation of the disease than is 
exhibited toward its end. It would seem that the ob- 
servation of occasional cases of cancer in which the dura- 
tion of the gastric history had been long drawn-out, 
doubtless led such clinicians as Dock and Mathieu to 
venture the opinion that cancer of the stomach in early 
life runs a somewhat slow course. This opinion appears 
well-founded if one considers both the ''pre-cancerous" 
and the evidently cancerous portions of the history. 

Types of Gastric Histories. — In respect to types the 
histories divide themselves quite sharply into two groups : 
Group 1 includes cases in which there appeared a gastric 
affection, pernicious in nature and progressively downward 



Test-meal 



Surgical and pathologic findings 



14 

18 

^5 

15 

C4 

10 
10 

rs 

I}5 
S3 

M 



46 



14 



BNo contents. Tube could 
; not be passed beyond 
cardia. 



30 



Pylorus 



General 



Pylorus 



Lesser 
curve 
and py- 
lorus. 

Malig. 
ulcer 
on less, 
curv. 

Lesser 
curva- 
ture. 

Pylorus 



Lesser 
curve 
and 
post, 
wall. 

Lesser 
curve 
and 
ant. 
wall. 

Post, 
wall. 



Lesser 
curva- 
ture 

Post, 
wall. 



Lesser 
curva- 
ture. 



High on 
lesser 
curve 
and at 
cardia, 

Lesser 
curva- 
ture. 



Infiltra- 
ting mass. 



Infiltra- 
ting mass. 



Nodule (ul- 
cer?) size 
4 in. 

Huge ma- 
lignant 
ulcer. 



Inop. large] -f 
adherent 



+ + 



+ + 
Peri- 
to- 
neum 
+ -I- + 



Malignant 
ulcer. 

Inop._ infil- 
trating 
mass. 

Inoperable 



Malignant 
ulcer. 



Malignant 
ulcer. 



Large ma- 
lignant 
ulcer. 

Huge ma- 
lignant 
ulcer. 



Early ma- 
lignant 
ulcer. 



Malignant 
ulcer. 



Huge ma- 
lignant 
ulcer. 



Pylorus Large 





+ + 



+ + 



+ + 



Pancreas 
and liver. 



Pancreas, 
liver and 
perito- 
neum. 

Liver and 
perito- 
neum. 







Pancreas 



Gall- 
stones. 



Pancreas 



Liver, ova- 
ries, peri- 
toneum. 



Liver, pan- 
creas, 
periton. 

Pancreas 



Carcin 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 



Carcin- 
oma. 



Carcin- 
oma. 



Carcin- 
oma. 

Carcin- 
oma. 



Carcin- 
oma. 



Carcin- 
oma. 



Carcin- 
oma. 



Carcin- 
oma. 



Posterior gast.- 
ent. 



Explored 



Anterior gast. 
ent. 



Explored 



Posterior gast. 
ent. 



Witzel jejunos- 
tomy. 

Posterior gast.- 
ent. 

Explored 



Miculicz-Hart- 
man - Billroth 
No. 2 and 
post. gast.- 
ent. 

MicuUcz-Hart- 
man - Billroth 
No. 2 and 
post. gast.- 
ent. 

Pylorectomy 
and post, 
gast. -ent. 

Milculicz-Hart 
man - Billroth 
No. 2 and 
post. gast.- 
ent. 

Miculicz-Hart- 
man - Billroth 
No. 2 and 
post. gast. 
ent. 
Explored 



Anterior gast. 
ent. 



Died in 6 mos. 



Died 1 day 
after oper. 



Alive 3 years 

Died in 6 mos. 

Lived 5 years 

AUve. 

Alive 2 years 

Died in 1 yr. 

Alive 2 years. 

Died 8 mos. 

Alive 5 years 



Patient died 
l\i years la- 
ter with ova- 
rian metas- 
tases. 

Died_ 1 year 
ovarian and 
uterine metas- 
tases. 

Alive 1 year 



Died in 2li 
months. 



Anterior gast.- Died in 12 
ent. days. 



Table 36. — Clinical Data of Gastric Cancer in the Young (Author's Study) 



"ppeTji- 



Uloer? 

Typical 
Gall- 



Epigaat. 
Epigaat. 



high mid 
epigost. 



RC. 
I 2 to 3 



^^ieef- 



Clcrk. 



Houao- 



Night 
On full 



Pood 






Typical 

Typical 



Epigast. 
Bpigoat. 



colics, full. 



Surgical and patholoejo findiaga 



G».„l 


Infiltra- 
ting mass 


Pylorua 


Nodule (ul- 
cerT) BiM 


Lesser 


Hugo ma- 


2Ey- 


Sr°' 






TOlLs 


adherent 


'oS^'.- 


Malignant 
ulcer. 


Pjloru. 




L.«,er 


iDoperable 



AUvo. 



No. 2 and 



■ Pylorcotomy 

■ Alikuifcz-Hart 



Potient died 



■ Miculioi-Hort- 



Died in 2Vi 



In this ooluc 



indicates liquid; : 



GASTRIC CANCER IN THE YOUNG 875 

in course, in patients in whom there had been no previous 
gastric ailment. Group 2 comprises a number of cases in 
which, previous to the time at which they came under 
observation for a gastric disease of a mahgnant kind, there 
had been gastric complaints which frequently conformed 
to the type which we call clinically ''peptic ulcer." 

Group 1. — Two of the 16 cases studied fall into this 
class. The 'average duration of all symptoms was 4.5 
months. In these 2 cases the disease was from its inception 
progressively and perniciously downward in course and 
type, and there was no alteration in the character of the 
affection. There were, clinically, rapid emaciation, con- 
tinuous abdominal discomfort, early onset of vomiting, 
development of epigastric tumor and departures from the 
normal in the test-meal analysis (see Table 36). Laparot- 
omy revealed large, inoperable growths, with extensive in- 
volvement of the lymph nodes and pancreas. One patient 
died within 12 days following operation; the other lived a 
year. 

Group 2. — This includes 14 cases. These patients had 
been affected for an average time of 4.8 years with some 
gastric malfunction. In type the early part of their 
affection had been roughly classed among the "dyspepsias." 
A careful analysis of the character of these dyspepsias reveals 
•useful facts. In five instances (36 per cent.) the gastric 
complaint and course had fully satisfied the symptom- 
complex which we ascribe clinically to peptic ulcer. In 4 
cases (25 per cent.) so-called ulcer features were definite at 
some stage in the early period (in one instance in this group 
there was frank gastric hemorrhage). In 4 other cases 
(25 per cent.) the long-term history previous to onset of 
evident malignancy was that of peptic ulcer of irregular 
type. In the remaining case, gall-stone attacks were 



376 CANCER OF THE STOMACH 

typical through 4 years, and the stones were later found at 
laparotomy. 

The second part of the histories of cases making up 
Group 2 was typical of gastric malignancy, "\^^lile this 
phase differed widely in character from the early manifes- 
tations, yet it could in nowise be distinguished clinically 
from the whole course of the ailment in the 2 cases making 
up Group 1. If one had not carefully analyzed the early 
histories of these 14 cases in Group 2 he could have in no 
way shown their cUnical variation from cases in Group 1. 
The period of e\ddent maUgnancy in Group 2 averaged 7.8 
months in duration. The most rapid progress was 3 
weeks; the most protracted nearly 3 years. 

It might be useful to emphasize the fact here that of 
this group of gastric cancer cases in the young with long- 
time histories, 86 per cent, satisfied or approximated our 
present-day clinical complex of peptic ulcer at some time 
during a period averaging 4.8 years, previous to the time 
when the course became malignant; that during this time 
medical treatment availed nothing and the surgical oppor- 
tunity for cure was usually neglected; that the cases in this 
group, due to some unknown cause, did not pursue a course 
of chronicity of benign type, but later evidenced malignant 
pointings, and that the mahgnant course of the cases in 
this group exhibited an average duration nearly half again 
as long as occurred in cases of Group 1 in which no previous 
gastric disorder had been observed. 

Clinical Data. — Appetite. — ^In six instances (38 per cent.) 
the appetite was poor. In the remaining cases it was 
usually fair. 

Bowels. — All cases exhibited some degree of constipation. 

Weight Loss. — In the two instances of short-term cancer 
(the so-called '' primary cancers"), the average loss of 



GASTRIC CANCER IX THE YOUNG 377 

weight was 17 pounds. In the early period of the group 
of cases with long-term histories, weight loss generally 
occurred during the ''spells" of the disabihty, but was 
rapidly regained during the succeeding quiescent stages. 
In some of these spells the weight loss was as much as 35 
pounds. In the late stage of cases of this type (the mahg- 
nant period) the weight loss averaged 31 pounds. It 
was continuous and accompanied by other evidences of 
cachexia. Some rapid weight losses were observed, e.g., 
20 pounds in 2 weeks. 

Abdominal Pain or Distress. — In some degree, this was 
noted in all patients. It was commonly located indefinitely 
in the epigastrium, but occasionally the complaint was of 
distress in the back or the high ''pit." In two instances 
pains of so severe a degree and of such spasmodic char- 
acter were noted that perforation was believed to have 
taken place. 

In the 2 cases comprising Group 1 above ("primary 
cancers") the pain was never severe, never definitely 
locaUzed, was continuous, but was generally aggravated 
by the ingestion of food or drink. In these instances the 
common pain relief was obtained by limiting the amount 
of ingested food, vomiting at the height of distress, and, 
occasionally, by alkalies. 

Of the 14 cases included in Group 2 above (those in 
which the patients had had gastric distress before malig- 
nancy became evident), 12 (85 per cent.) had pain in 
"spells" or "attacks." In 7 instances, the pain at such 
times had borne fairly definite relation to food ingestion; 
in 4 instances, even when malignancy had supervened, the 
food rehef of pain persisted. In 10 cases former food 
reUef of pain had changed to food aggravation of pain, as 
the malignant process became manifest. In this group of 



378 CANCER OF THE STOMACH 

14 cases the common modes of pain relief were vomiting, 
lavage, limited or varied diet, alkalies, food intake and 
some form of opiate. 

Abdominal Tenderness. — This was exhibited on pal- 
pation by all patients. In 38 per cent, it was located 
generally in the epigastrium. In 3 instances, the maximum 
tenderness was in the left epigastrium. In rare cases 
was abdominal tenderness, such as is characteristic of 
chronic ulcer of the perforative type, noted even when 
laparotomy showed that the peritoneum had become 
extensively involved. 

Epigastric Tumor. — Tumor was palpated in 6 cases 
(38 per cent.) in the entire series (see Table 36). In but one 
instance was a large mass demonstrable. In the cases 
presenting no definite tumor, peculiar stiffness of the 
abdominal wall with a sense of deep resistance was fre- 
quently observed. 

Four times free fluid was shown to be present in the 
abdominal cavity before laparotomy. These were in- 
operable cases. In three metastases, as in the left supra- 
clavicular region and pelvis, were noted before operation. 
These patients had hopeless involvement. 

Eructations and Pyrosis. — Such were commonly noted 
particularly when gastric motility had been interfered 
with. 

Vomiting. — Vomiting, with or without nausea, was 
observed in all the cases at some time (usually in the 
terminal stage) in the course of the disease. In the two 
"primary cancers," vomiting came on daily soon after 
taking food, was large in quantity, rancid in odor, but 
never "coffee colored." 

In the fourteen instances in which malignancy had termi- 
nated a long-term gastric history, vomiting occurred from 1 



GASTRIC CANCER IN THE YOUNG 379 

to 8 hours after meals; in but one instance was it '^coffee 
colored," in all instances it contained food particles, was of 
a rancid color and relieved abdominal distress. In 8 cases 
"delayed" vomiting was observed. Such sign was usually 
associated with pyloric stenosis and huge, dilated stomach. 

Laboratory 'Data..— Blood. — In the fourteen instances in 
which the hemoglobin was estimated, it averaged 66 per 
cent. The range was from 25 per cent, to 70 per cent. 

Stool. — In ten instances (62.5 per cent.) altered blood was 
chemically demonstrated by the benzidin or the guaiac 
tests. 

Test-meals. — In fifteen instances facts of much interest 
were obtained by this mode of examination of gastric 
function. One case (No. 14, see Table 36) returned no 
information by test-meal analysis because the stomach tube 
could not be advanced beyond the cardia. There was 
obstruction due to extensive local growth. 

Gastric Emptying Power. — In 11 cases (73 per cent.) 
motility w^as interfered with and there w^as retained food 
at the end of 12 hours. In such instances, dilation of the 
stomach of various degrees had invariably occurred. 

Gastric Acidity. — In no case was achyha shown. The 
average total acidity w^as 59. It ranged from 28 to 64. 

Free hydrochloric acid was absent in but one instance. 
This was a case of fulminant, primary cancer. The 
average free hj^dro chloric acid estimation for the entire 
series was 26. It ranged from as low as 3 to as high as 60. 
The highest free hydrochloric acidities were noted in asso- 
ciation with large, cancerous ulcers. 

Combined hydrochloric acid and acid salts averaged 18.1 
per cent. It ranged from to 50. 

Lactic acid was demonstrated by the modified Uffelmann 
test in 6 cases (40 per cent.). 



380 CANCER OF THE STOMACH 

Altered blood was proven by chemical test in gastric 
contents 12 times (80 per cent.). 

Microscopic Examination of Unfiltered Gastric Extracts. — 
In but 6 instances (40 per cent.) were organisms of the 
Oppler-Boas group definitely identified. In 8 cases (53 
per cent.) yeasts and sarcinae were present. Microscopic 
food bits were recognized in nearly 90 per cent, of instances. 

The Laparotomy Findings. — Two cases had been ex- 
plored before coming to us. Both the patients had been 
operated on within the year. At both abdominal sections 
the surgeon had made a clinical diagnosis of ''benign" 
gastric ulcer of the chronic type, yet both of these patients 
were dead from inoperable gastric cancer before a year 
had elapsed ! The resection of the ulcer or the microscopic 
examination of a bit of extirpated tissue at the time of the 
initial laparotomy doubtless would have made known 
earlier the prognosis and have prevented further surgery. 
It might have saved life. 

Location of the Malignant Process. — Abdominal section 
revealed five instances in which the pylorus was involved; 9 
cases in which the lesser curvature and some part of the 
surface of the viscus were affected; one instance of infiltration 
at the cardia, and 1 case of general carcinosis. 

Lymph nodes had been invaded in 14 out of the 16 cases 
in this series. Nine times secondary growths were demon- 
strated in the liver, pancreas, omenta or pelvic organs. 

Character of Neoplasms. — In eight instances, extensive 
ulcera carcinomatosa were present. They were of the 
medullary type. In the remaining cases, adeno-carcino- 
matosa of the common type were demonstrated. 

Operative Procedures and Outcome. — In four instances 
exploration only was possible. In 5 cases some form of 
resection was performed with or without gastrojejunos- 



GASTEIC CANCER IX THE YOUNG 381 

tomy. In the remaining seven patients, ^'drainage opera- 
tions" to fit the case at hand were devised. 

Xine patients died within m years following operation. 
To the other patients of this series was granted a lease of 
life of from 2 to more than 5 years. 

REFERENCES 

1. Welch: Proceedings Boston Society for Medical Improvement, v, 

Appendix, p. 109. 

2. OsLER AND ]McCkae: Cancer of the Stomach, Philadelphia, 1900, 

p. 16. 

3. Dock: Am. Jour. Med. Sc, 1897, June, p. 665. 

4. Mathieu: Semaine med., 1895, p. 225. 

Smithies: Jour. Am. Med. Assn., 1914, Xov. 21, p. 1839. 

Note: We have since had opportunity of obser^dng three other cases. 
They were a male aged 24 and tvro females aged 18 and 27. 
Thev are not analvzed in the data herewith. 



CHAPTER X 
DIFFERENTIAL DIAGNOSIS 

General. — Every case of chronic dyspepsia should be 
broadly considered from two aspects, namely, the surgical 
and the medical. This applies with especial force to 
instances of indigestion — chronic or of recent onset — in 
patients above 35 years of age. The primary principle of 
differential diagnosis of intraabdominal disease, or disease 
with intraabdominal pointings, is that of segregating the 
group likely to be benefited by laparotomy from that 
where the hope of reUef lies in general medical care. It 
is admitted that this division of cases is not always easily 
made. Doubtful instances are of common enough oc- 
currence. There is, however, too much unnecessary and 
usually valueless quibbling over finer points of differential 
diagnosis in abdominal disease. This is often to the 
patient's detriment. While learned, pseudo-scientific in- 
vestigations are being carried on, or while certain medical 
attendants are awaiting the appearance of their pet 
differential points, not infrequently the subject of the 
research passes beyond any form of aid. Rash surgery 
is to be condemned, but a sharp scalpel is often a more 
satisfactory differential diagnostician than is the keenest 
mind, medically. 

Exploratory laparotomy has perhaps been needlessly 
urged in many instances of chronic dyspepsia. In these 
cases it is not infrequently found that but a limited study 
has been made of the gastro-intestinal functions before 
such laparotomy. Not rarely one could have accurately 

382 



DIFFEEEXTIAL DIAGNOSIS 383 

prognosed unsatisfactory' surgical findings or results from 
operation before laparotomy, if routine examinations had 
been systematically carried out. "WTbile there is a tend- 
ency on the part of many clinicians, particularly the sur- 
geons, to perform abdominal section in order to make 
optically evident intraabdominal pathology', yet this 
procedure must not be condemned as a diagnostic method 
simply because groups of poorly trained surgeons are 
getting negative results by it. 

WTien every case of chronic dyspepsia has been considered 
a strictty medical one before it is admitted to be surgical, 
exploratory laparotomy very often yields results which 
are satisfactory to both the patient and clinician. 

Internists have not been backward in claiming that 
abdominal surgery is too readily resorted to for the purposes 
of diagnosis, and that such procedure is essentially the 
lazy man's way of elucidating a problem which could 
have been xery well worked out along other hues. The 
internist's position, however, is not whollj^ an unassailable 
one. While much ma}^ be expected from the medical treat- 
ment of gastric ulcer in competent hands, it is a fact 
that the large majority of mahgnant gastric ulcers are 
allowed to progress to the hopeless stage before they are 
referred to the surgeon. 

Mortahty in gastric cancer can only be successfully 
attacked by a greater number of obstinate peptic ulcer 
cases being treated surgically than is at present the vogue. 
The physician's waiting until the so-called clinical picture 
of gastric cancer appears, is practically equivalent to sign- 
ing the patient's death certificate. From what has already 
been stated in Chapters II and III, it is quite evident 
that the early diagnosis of gastric cancer concerns itseh 
with the recognition of chronic calloused peptic ulcer, 



384 CANCER OF THE STOMACH 

particularly of the recurrent form. We would especially 
emphasize this point. Inasmuch as it cannot be too 
strongly urged, we offer the following summary of the 
essential points in the diagnosis of chronic calloused ulcer 
of the stomach and the duodenum. 

GASTRIC ULCER 

1. Facts Determined from History. — (a) Frequently, 
dietetic or hygienic irregularities. Males are more frequently 
affected than are females. 

(6) History of recurring acute infections. (La grippe, tonsil- 
litis, exanthemata, etc.). Seasonal relation of distress not 
uncommon, exacerbations occurring in fall or spring. 

(c) Association with disease of appendix or gall-bladder 
(with which ulcer, especially in subjects below age 30, is 
often confused). 

{d) Periodicity of complaint occurs in from 75 to 85 per 
cent, until complications set in. Between '^ spells" or 
attacks of indigestion, so-called, there is generally good 
gastric health. Weight is not infrequently lost during 
attacks and rapidly gained when such cease. 

(e) Epigastric distress is present in more than 95 per 
cent. It varies in severity, from discomfort to severe, 
gnawing or cramp-like pains. Discomfort has point of 
maximum location, subjectively, in practically 3 out of 
4 cases. Pain has usually reached its height within 4 
hours following meaJs. Pain comes on sooner past cibo 
in ulcers located near the cardia than where such are well 
toward the pylorus. 

(/) Food relief of distress occurs in four out of five in- 
stances of peptic ulcer of the uncomplicated type. Relief 
of pain frequently bears relation to amount of food taken, 
i.e., a large meal gives longer relief than a small one. Pain 



DIFFERENTIAL DIAGNOSIS 385 

is also relieved by vomiting, the taking of alkalies, by rest, 
diet and opiates. 

(g) Vomiting occurs in more than two-thirds of the in- 
stances; vomitus usually comes on at the height of gas- 
tric distress and when acidity is highest. Vomitus of food 
that has lain in the stomach longer than 6 hours (''delayed 
vomit") increases as complications (stenoses or perfora- 
tion) develop. Pyrosis, water-brash, eructations and sour 
belching are common on ordinary diet. 

(h) Hemorrhage (hematemesis or melena) occurs in 
from 20 to 40 per cent, of instances. While hematemesis is 
more frequent than melena, yet melena alone may occur 
wholly irrespective of the location of the gastric ulcer. 
Severe hemorrhage is accompanied by signs of shock 
and collapse. 

2. Facts Obtained by Examination. — (a) Patient is usually 
well nourished without toxic or cachectic appearance, un- 
less pyloric stenosis or ''hour-glass" contraction has oc- 
curred. 

{h) Average hemoglobin about 80 per cent, unless severe 
hemorrhage has recently taken place. 

(c) Area of epigastric tenderness in region of pyloric half 
of stomach. This is usually in the mid-epigastrium, but 
not necessarily so. The area is most frequently definitely 
local where acute or chronic perforation has taken place. 
A tender ridge may sometimes be palpated where a large 
chronic ulcer exists. 

(d) Dilated, splashy stomach occurs where marked pyloric 
spasm exists or stenosis has taken place. If this is ex- 
cessive, visible peristalsis (and rarely, "reverse" peris- 
talsis) may be noted. 

3. Facts Secured by Laboratory Examination. — (a) Test- 
meal. — Motility interfered with in more than 50 per cent. 

25 



386 CANCER OF THE STOMACH 

of instances. Gastric acidity increased with respect to free 
hydrochloric acid in the majority of non-stenosing ulcers. 
In stenosing ulcers, with dilatation of the stomach, while 
free hydrochloric acidity may not be above normal, the 
total acidity is increased in greater ratio. Blood may or 
may not be present in gastric extracts (macroscopically or 
by chemical test). Lactic acid is a rare finding. Pepsin 
and rennin are frequently increased. 

Microscopically where gastric dilatation has occurred, 
fermentative changes are proved by the finding of great 
numbers of budding yeasts and of sarcinse (large and 
small types) together with remnants of retained food. 

(6) Stool may show nothing pathologic. Recent hem- 
orrhages generally result in the passage of "tarry" stools 
for several succeeding days. Perforation of an ulcer to 
the pancreas, not infrequently brings on pancreatic in- 
efficiency with passage of stools containing undigested food. 

During periods of the ulcer's activity, if the patient is 
kept upon meat-free or milk diet for several days, at the 
end of such time the stool may be shown by chemical 
tests (benzidin or guaiac) to contain blood. Progressive 
ulcers, or ulcers undergoing cancerous change, generally 
show blood constantly in the stools by chemic tests. 

(c) X-ray Findings. — In many instances of uncom- 
pUcated ulcer no facts are returned after most careful 
examination by both fluoroscopic or plate methods. 
Complicated ulcers (stenosing, calloused, ''hour-glass" 
producing, perforating, etc.), are recognizable in nearly 
three out of four instances by the combined screen and 
plate method. 

1. Positive Signs. — The ''niche" or "accessory cavity," 
indicating calloused, penetrating ulcer. 

2. Corroborative Signs. — (a) "Incisura,'' i.e., local evi- 



DIFFERENTIAL DIAGNOSIS 387 

dence of halting peristaltic rhA-timi by spastic contraction 
of circular muscle fibers in the vicinity of an ulcer. Best 
brought out on screen examination dm'ing or after 
palpation. 

(&) "Hour-glass" stomach (biloculation). This may be 
permanent (callous ulcer, perforation, adhesion), or tran- 
sient (local spasm, with or without ulcer); should always 
be proved by repeated examinations with and without 
an antispasmodic (atropine, belladonna). 

(c) Gastric residue. This may varA' in amount. Its 
constant demonstration after 6 hours means atony or 
stenosis. Intermittently it may result from extragastric 
or gastric pathology causing pyloric spasm. 

(d) Fixation of all or part of the stomach (perforation, 
adhesion, fistula). 

(e) Area of tenderness to palpation, usually localized at 
some part of the stomach shadow. Should always be 
checked by repeated examination before and after an 
antispasmodic. 

(/) Alterations in gastric peristalsis, e.g., exaggerated per- 
istalsis, intermittent, frequently associated with spasmodic 
closure and relaxation of the pylorus. Antiperistalsis may 
be seen on rare occasions. 

DUODENAL ULCER 

1. Facts Elicited from History. — (a) Males are affected 
approximately three times as frequently as females. Be- 
tween the ages of 35 and 50 lie most of the cases. 

(6) Patients have generally had acid dyspepsia of the 
intermittent tj^De for from 5 to 30 years. Seasonal relation 
of complaint is often pronounced. 

(c) Periodicity of the complaint is marked. 

{d) Chronic appendix dyspepsia has frequently clouded 



388 CANCER OF THE STOMACH 

the early symptomatology. The appendix has not rarely 
been removed for early disability. 

(e) Epigastric pain associated with dyspeptic storms 
occurs in practically 100 per cent, of cases. This pain is 
often subjectively noted to the right of the mid-line or in 
the right posterior scapular region. Pain is usually a dull 
aching, gnawing or sore feeling. In rapidly developing 
cases or where perforative exacerbations have taken place, 
pain may be colicky, cramp-like or boring. 

(/) Pain time is most frequently at its maximum when 
the stomach is nearly or entirely empty. The ingestion of 
food usually relieves all symptoms, unless perforation or 
stenoses have supervened. The periodic repetition of this 
syndrome associated with ''food-ease" is characteristic of 
nearly 90 per cent, of uncomplicated ulcers. Pain relief 
is also obtained by alkalies, vomiting, rest or opiates. 

(g) Vomiting occurs less frequently in duodenal than in 
gastric ulcer (apart from the extrapyloric type), until 
perforation or stenosis takes place. When vomiting occurs 
it is apt to be more copious than in case of the majority 
of gastric ulcers, inasmuch as duodenal stenoses tend to 
more rapidly produce extensive dilatation of the stomach. 
''Delayed" vomiting is common. 

Qi) Hemorrhage (melena or hematemesis) occurs in 
about 30 per cent, of instances. Melena is a most fre- 
quent happening, but pronounced hematemesis may occur. 
The reverse is the rule in gastric ulcer. The hemorrhages 
are generally intermittent. Inasmuch as duodenal ulcers 
rarely become carcinomatous, and because they have a ten- 
dency to heal and to be protected by scar tissue, persistent 
melena (even by chemical demonstration) is unusual. 

(i) Eructations, pyrosis and water-brash are common, es- 
pecially 3 to 5 hours post ciho or at night (12 m. to 1 a .m.). 



DIFFERENTIAL DIAGNOSIS 389 

At these times maximum gastric acidity may be demon- 
strated. Vomiting, gastric lavage or alkalies generally 
bring about prompt relief. 

(j) Appetite is usually good except in attacks, but fear 
of bringing on pain by eating frequently leads to a poor 
appetite habit. Weight loss may be rapid during attacks, 
or when pyloric stenosis has supervened. Bowels are not 
infrequently constipated during periods of exacerbation. 

2. Facts Determined upon Examination. — (a) Patient 
usually of plethoric type unless starved by diet, recent 
hemorrhage or stenosis. Body nourishment generally 
good; toxic evidences or cachexia absent in majority of 
instances. 

(&) Hemoglobin averages 80 per cent, or above in un- 
complicated cases. 

(c) Epigastric tenderness may be lacking. There is no 
typical point of tenderness in duodenal ulcer, but usually 
spasm of the right rectus muscle may be elicited on both 
superficial and deep palpation. When recent or protected 
perforation results in peritoneal involvement, then local- 
ized tenderness of varying grades may be demonstrated. 
Occasionally tumor-like, tender ridges may be present 
where much callous has developed or adhesions have 
formed. 

(d) Dilated, splashy stomach may be outlined even 
without air inflation. This is common where stenoses 
have occurred. Visible peristalsis (Kussmaul type) is 
not uncommon where marked stenosis at the pylorus has 
developed and where the abdominal parietes is thin. 

3. Facts Obtained upon Roentgen Examination. — Upon 
fluoroscopic examination, uncomplicated ulcers frequently 
return nothing of definite diagnostic value. Evidence 
of pyloric spasm associated with hyperperistalsis are not 



390 CANCER OF THE STOMACH 

infrequently seen. Such conditions, however, are not 
typical of duodenal ulcer, even though frequently they may 
be associated with it. Local areas of tenderness are some- 
times delimited at the pylorus, or over the duodenum itself. 
If they are persistent after the hypodermatic administra- 
tion of atropine sulphate, and the clinical history is that 
suggesting duodenal ulcer, these areas of tenderness are not 
without certain relative diagnostic significance. 

Plate or film examination in instances of duodenal ulcer 
may readily demonstrate 6-hour retention of the opaque 
meal and over-vigorous peristalsis. 

If the duodenal ulcer is of the complicated type {viz., 
has exuberant callus, perforation, adhesions, or is large 
enough to form a crater) , plate or screen examination may 
reveal malformations of the duodenum, fixture of the 
duodenum by adhesions, various grades of obstruction, 
or even fistulas. 

It is well in suspected cases of calloused ulcer of the 
duodenum to make plates with the patient not only in 
the dorsal and prone positions, but after he has been placed 
in the left or right lateral positions. By this maneuver 
one not infrequently demonstrates malformations of the 
hulbus duodeni. 

Sometimes the degree of obstruction at the pylorus and 
the deformity of the duodenum may readily suggest some 
anomaly at the pyloric end of the stomach, on account of 
the abrupt termination of the stomach lumen or irregulari- 
ties in its pyloric outline. In such instances at laparotomy, 
one may find extensive adhesions, perforation or a duodenal 
ulcer which has become cancerous on the gastric side. 

The comparative worth of the different diagnostic points 
in gastric and duodenal ulcer and gastric cancer is 
further emphasized in Table 37. 



DIFFERENTIAL DIAGNOSIS 



391 



Table S: 







I>Jature of the disease 




Clinical 










symptoms 
and signs 


Carcinoma 


Peptic ulcer 
(gastric or 
duodenal) 


Peripyloric Gastric 
adhesions atony 


Extragastric 
tumor pressing 

on pylorus 
(liver-pancreas) 


Average age. 


i 

45 


40-50 


40-50 ; Often young 
adult. 


50 


Sex. 


Males. + 


Males, -t- 


Females. -1- Females. -|- 


Females ? 


Onset. 


Often prev. 


Intermittent 


Cholecystitis, Gradual. 


Progressive. 




idcer type; 


dyspepsia of 


gaU-stones, 








dyspepsia, 


ulcer type. 


colics, jaun- 








may be con- 




dice. 








tinuous and 












progress. 










Pain. 


Early, usually 
on empty 
stom. ; late, 
constant. 


1-5 hours p.c. 


Worse soon ' On full stom- 
p.c. orirreg- ach. 
ularly. 

■ 


Irregular. 


Vomiting. 


DaUy. Often 


Frequent. 


Frequent, Irregular some- 


Irregular, reten- 




ret. vomit 


Often ret. 


may show times, reten- 


tion type 




of rancid 


type; yeasty 


retention. ; tion type sour 


often, odor 




type. 


odor. 




or yeasty. 


yeasty or sour. 


Hemateme- 


In from 15- 


In from 20- 


Rare. 


Absent. 


Rare. 


sisor 


25 per cent. 


40 per cent. 








melena. 












"Weight loss. 


Pronounced. 


Intermittent. 


May be absent 


Intermittent. 


May be marked. 


Test-meal. 


12-lir. ret.; 


12 hr. ret. 


12 hr. ret. 


Intermittent 


12-hr. retention 




low or abs. 


Free Hcl 


variable; 12 hr. ret. 


free Hcl may 




free Hcl; 


averages 40 


free Hcl Hcl present 


be absent, 




lactic acid; 


altered bl. 


may be yeasts and 


lactic acid 




altered bl.; 


variable; 


normal; sarcinse may 


may be pres- 




increased 


yeasts and 


yeasts and be present. 


ent, Oppler- 




soluble albu- 


sarcinae may 


sarcinse may 


Boas baciUi 




min; Oppler- 


be abundant. 


be present. 


rare. Altered 




Boaa baciUi; 






blood rare. 




mitotic cells 










(?) 








Stool. 


Altered bl. 


Intermittent 


-lltered blood Altered blood 


Altered blood 




in 89 per 


presence of 


rare. 


absent. 


variable. 




cent. con- 


altered blood 










stantly; Op- 


yeasts and 










pler-Boas 


sarcinse. 










bacilli 60 












per cent. 








Tumor. 


In 65-75 per 


Infrequent. 


Infrequent. Absent. 


May be pres- 




cent. 








ent. 


Radiogram. 


Filling defect 


Ret. 6 hrs.; 


Malformed 


DUated stom- 


Retention 6 




pars pylorica; 


may be cra- 


bulbus duo- 


ach, poor 


hr. variable. 




ret. 6 lirs. 


ter ulcer, 


deni, ret. 6 


peristalsis; 6 


May be filling 






constriction 


hrs., may be hr. ret., vari- 


defect at py- 






or irregular 


irregular py- able. 


lorus but may 






pyl. outline. 


lorus; dilated 


be shown to be 






dilated stom. 


stomach. 


extra gastric 
on pressure. 


Metastases. 


The rule. 


Absent. 


Absent. ' Absent. 


May occur. 



Malignant Pyloric Stenosis and its Differential Diagnosis (Author). 



392 



CANCER OF THE STOMACH 



Not infrequently certain lesions of the esophagus or 
of structures in the thorax are confused with gastric 
cancer at or near the cardia. Table 38 summarizes the 
essential differential points in the diagnosis of these 
ailments. 

Table 38 





Nature of disease 


Clinical 














symptoms 


Carcinoma 


Car. of 
esophagus 


Cicatricial 


Cardio- 
spasm 


Esopha- 


Thoracic 


and signs 


at or near 
cardia 


stenosis of 
esophagus 


geal diver- 
ticulum 


tumor- 
aneurysm 


Average age 


45 


45 


Young 
adult. 


Young 
adult. 


45 


45 


Sex. 


Male. + 


Male. + 


? 


Female, -f 


Male. -1- 


? 


Onset. 


Prev. ulcer 


Gradual. 


Ulcer his. 


Sudden, 


Gradual. 


Usually 




or gradual. 




or corro- 
sives. 


rarely 
gradual or 
intermit- 
tent. 




gradual. 


Dysphagia . 


Intermit- 


Usually 


Progressive 


Often in- 


Progressive. 


Progressive. 




tent or 


constant 


and mark- 


termittent. 








progres- 


and pro- 


ed. 










sive. 


gressive. 










Pain. 


Soon after 


During 


During 


May be ab- 


During deg- 


During deg- 




swallowing. 


swallowing 
usually. 


swallowing. 


sent while 
eating. 


lutition , 
but may 
be absent. 


lutition. 


Vomiting or 


Fairly con- 


Constant 


Constant 


Soon after 


Soon p.c. 


Soon p.c. 


regurgita- 


stant soon 


during or 


p.c. 


or many 


or hours 




tion. 


p.c. 


soon after 
eating. 




hours after 
eating. 


after. 




Weight loss. 


Progressive. 


Progressive. 


Progressive 


Intermit- 


Little early, 


Progressive 








in late 


tent, may 


rapid late. 


but rarely 








stages. 


be marked 
late. 




rapid. 


Cachexia. 


Pronounced. 


Pronounced. 


Emacia- 


Usually not 


Rarely 


Not marked 








tion. 


marked. 


marked. 


until late. 


Hemor- 


Frequent. 


Frequent. 


Absent. 


Absent. 


Absent. 


Rare. 


rhage. 














Test-meal. 


Low acid, 


Food as 


Food as 


Food as 


Often ret. 


Often acid 




blood, Op- 


eaten. 


eaten. 


eaten, 


food rests. 


stomach 




pler-Boas 


blood pres. 




mucus 


much 


juice; may 




bacilli 


"cancer 




often ret. 


mucus. 


be reten- 




"cancer 


cells." 




food rests. 




tion. 




cells." 












Stool. 


Altered bl. 


Alt. bl. 


No blood. 


No blood. 


No blood. 


Rarely 
blood. 


Esophago- 


Tumor at 


Tumor in 


Cicatrix in 


May be 


Opening to 


Prssure on 


scope. 


cardia. 


esopha- 


esopha- 


negative 


sac may 


oesopha- 






gus. 


gus. 


or dilated 
esophagus, 
small car- 
diac ori- 
fice. 


be seen. 


gus locally. 



DIFFERENTIAL DIAGNOSIS 

Table 38. — Continued 



393 









Nature of the disease 






Clinical 












symptoms 


Carcinoma 


Car. of 
esophagus 


Cicatricial ^ j- 
stenosis of 9^^"^'°' 


Esophageal 


Thoracic 


and signs 


at or near 


diver- 


tumor- 




oardia 


esophagus ^P'*^^^ 


ticulum 


aneurysm 


Radiogram. 


Opaque 


Obst. to 


Obst. to Usually dif- 


Dilated 


Rarely op. 




meal rests 


opaque 


opaque ; fuse dila- 


esophagus 


meal rests; 




in esopha- 


meal, local 


meal; de- '. tation of 


^ or local sac- 


local stric- 




gus; fill- 


dilatation 


formity of esophagus 


culation. 


ture of 




ing defect 


of esoph.; 


esopha- tapering 




esophagus, 




at cardia. 


irregular 


gus. cardiac 




tumor or 






lumen out- 


. end. 




aneurysm. 






line. 








Duration. 


3 mo.-4 yr. 


Rarely 
more than 
2 years 


May be 
many yrs. 


Many yrs. 


Many yrs . 


Varies. 


Tumor. 


Late in pit . 


None. 


None. 


None. 


Local in tho- 
rax some- 
times. 


Local at 
times. 


Metastases. 


Occur. 


Rare. 


None. 


None. 


None. 


None. 



Table of Differential Diagnosis where Cancer Involves Cardiac Orifice. — 
(Author. ) 

Gall-bladder Disease. — Certain cases of chronic chole- 
cystitis or cholecystitis with cholelithiasis are associated 
with gastric achylia, pancreatic inefficiency and deficient 
function on the part of the liver. Not infrequently anemia 
is present and marked alterations of the biliary tract may 
occur without jaundice. Loss of flesh, diarrhoea, vomiting 
and epigastric pain may produce a symptom-complex 
which is difficult to distinguish from gastric malignancy. 
In the majority of these cases, the essential guide to the diag- 
nosis is a careful anamnesis, including particular inquir>^ 
into the earlier years of the patient's dyspeptic ailment. 
One not infrequently learns by such inquiry that the 
disease is more common in females, that there has been 
antecedent typhoid fever or malaria, that the earlier 
dyspeptic history is not the type which we associate clini- 
cally with chronic peptic ulcer; that obstruction has arisen 
late, or is entirely absent, and that certain acute attacks 
of indigestion have been associated with biliary symptoms, 



394 CANCER OF THE STOMACH 

namely, slight jaundice, gaseous abdominal distension, 
perhaps vomiting of bile, acute colic of a passing stone, 
irregular pain usually without definite relation to food 
intake, and not unusually transitory rises in temperature. 
Gastric analysis may show some retention of the 12-hour 
type. Retained contents are rarely of an obnoxious odor, 
and but infrequently contain lactic acid, altered blood or 
bacilli of the Oppler-Boas group. Free hydrochloric acid 
may be absent or very low, but is not so uniformly decreased 
as it is in gastric cancer. Stools may be diarrhoeic, they 
rarely contain blood or long acid-fast bacilli. The x-ray 
examination may show 6-hour retention of the opaque 
meal, dilated stomach, deficient peristaltic activity, and at 
times irregularities toward the pylorus. In these cases, 
however, filling defects of the gastric lumen with irregular 
outline, which outline is indistinct, are uniformly uncom- 
mon. Sometimes the screen or plate reveals gall-stones, or 
upon fluoroscopic examination one can fully delimit the 
boundaries of the pyloric channel and show that such are 
of normal contour. 

Cancer of the Gall-tract. — Malignant disease of the 
bihary passages, particularly of the gall-bladder, is asso- 
ciated with a history of cholecystitis or the presence of 
gall-stones in from 18 to 40 per cent, of cases. In such 
patients there is commonly an extensive precarcinomatous 
history of gall-bladder disease. The patient may even 
have passed gall-stones. The antecedent dyspepsia has 
been of irregular occurrence, and has not rarely been 
associated with jaundice or fever. At the time that the 
patient comes under observation, jaundice is not an un- 
common finding. 

Cachexia, associated with clinical evidence of pyloric 
obstruction, or the presence of an epigastric mass, may 



DIFFEEEXTIAL DIAGXOSIS 395 

render it difficult to exclude a neoplasm involving the 
stomach. In fact, the stomach is not rarely involved by 
contiguity in these cases. Cachexia is not, as a rule, so 
pronounced as in cases of gastric cancer. Vomiting is not 
so constant or copious as in gastric malignancy. Free 
hydrochloric acid may be present in gastric extracts, and 
at times, though infrequently, lactic acid, altered blood and 
Oppler-Boas bacilli may be found. Blood is rarely a 
constant finding in the properly prepared stool. The 
abdominal tumor is usually well to the right, in the mid- 
line, or beneath the edge of the ribs. It may move up and 
down upon respiration, but rarely changes position when 
the stomach or colon is inflated. The tumor cannot be 
moved during palpation, and can rarely be held down by the 
hands while the patient is in expiration. These tumors 
are apt to be of less irregular form than are the tumors of 
gastric cancer. They are apt to be more tender upon 
palpation. 

^Metastases develop more slowly than in the case of 
gastric cancer, particularly metastasis to the pelvis, navel 
and left supraclavicular space. Ascites may develop much 
earUer than where the neoplasm involves the stomach, and 
the accumulation of ascitic fluid is likely to be of much 
greater quantity than in the average instance of pyloric 
cancer. 

Roentgen examination may show at once that the tumor 
is extragastric. While not infrequently adhesions rapidly 
develop between the diseased gaU-tract and the stomach, in 
many instances the pylorus remains free and can be pushed 
away from the gall-tract tumor and shown to be of regular 
outline. There are some cases, however, in which extensive 
adhesions about the gall-bladder and the head of the 
pancreas may immobihze the pyloric end of the stomach, 



396 CA^XER OF the stomach 

and even give the appearance Roentgenographically of a 
canalized tumor involving the pylorus and antrum. 

Tumors of the liver are of comparative rarity. The 
left lobe of the liver is apt to be the seat of the disease. 
The early history of the infection is rarely that of a long- 
continued dyspepsia. Jaundice may appear early. Ca- 
chexia is a comparatively late manifestation of the disease. 
Persistent vomiting is relatively uncommon. Weight loss 
may be of extremely gradual onset, and may not be as- 
sociated with marked evidences of systemic cancerous 
intoxication. Anemia may be marked. Xot infrequently 
the TTassermann reaction is positive, owing to the fact that 
primary tumors of the liver are not uncommonly syphiUtie. 
Additional blood examination may show eosinophilia if 
the liver tumor is of parasitic origin (echinococcus) . In 
the early stages of the disease, alteration in gastric empty- 
ing power is uncommon. Free hydrochloric acid is apt 
to be normal and not diminished or absent until systemic 
cancer poisoning occurs. The stools rarely show the 
presence of '^ occult" blood. Diarrhoea may develop, 
and microscopic examination but infrequently shows the 
presence of long, acid-fast bacilli. A chemical examina- 
tion of the stool may show the absence of hydrobilirubin. 

The abdominal tumor usually lies high in the epigastrium. 
It is rarely localized definitely. It is not usually so tender 
as is a neoplasm involving the stomach. It cannot be 
moved freely upon palpation. It moves with respira- 
tion. Secondary metastases are rare. A-ray examination 
usually enables one to demonstrate that the tumor is 
extragastric, insomuch as an apparent filling defect in the 
stomach will disappear upon change of position of the 
patient or upon one's moving the stomach. 



DIFFERENTIAL DIAGNOSIS 397 

Disease of the Pancreas. — Instances of chronic inter- 
stitial pancreatitis, associated with enlargement of the gland, 
dyspepsia and cachexia, are not uncommonly confused 
with gastric cancer. The following case illustrates this 
type of ailment. 

Chronic Interstitial Pancreatitis; Emaciation and Epigastric 

Tumor: 
Mrs. M. B.- — Age 41, American, housewife. 

Family History. — Negative. 

Personal History. — Typhoid fever at age of 20. Recently 
had laparotomy performed for cholecystitis and perichole- 
cystitis. At laparotomy the pancreas was found to be 
3 times normal size, w^as hard and nodular. 

Comes on account of vomiting, weight loss, abdominal 
distress, and diarrhoea. 

Duration of Disease. — ^Twenty years off and on; has had 
several acute attacks of dyspepsia; characterized by abdom- 
inal pain, vomiting, chilly sensations and jaundice. 

At present has mid-epigastric distress constantly; the 
feeling is of ^'soreness and weakness;" it is vaguely trans- 
mitted to the back; it is only relieved by opiates. Vomiting 
of food and foul-tasting, green liquid occurs daily and is 
brought on by food intake. Belching, water-brash and 
eructations are nearly constant. 

Bowels.- — Diarrhoea for 6 months; stools are w^atery, 
small in amount, contain undigested food and have a dis- 
gusting, penetrating odor. 

Weight. — Normal 100 pounds; one year ago 96 pounds; 6 
months ago 88 pounds; present 55 pounds. 

Examination. — Thin, cachectic, bed-ridden female, afeb- 
rile; constantly belches gas and raises small quantity of 
watery fluid. 

Throat. — Infected tonsils. 

Thorax. — Small heart, with weak muscle sounds. 

Abdomen. — Stomach splashy below navel; slight Kuss- 
maul peristalsis seen; areas of tenderness over gall-bladder 
region and just above navel. In low epigastrium is a 
tender, nodular, sausage-shaped mass, slightly movable 
on palpation, but not upon inflation of the stomach. 

Rectal Examination. — Negative. 



398 CANCER OF THE STOMACH 

Laboratory Findings: 

Blood.— Rg., 60 per cent.; r.b.c, 3,900,000; w.b.c, 
7,000. 

Urine. — Few hyaline casts. 

Stools. — Thin, watery, greenish brown; much undigested 
vegetable and meat; microscopically enormous numbers of 
motile and non-motile rods, numerous yeasts and cocci. 

Chemical. — Alkaline reaction; altered blood, trace; tryp- 
sin absent; amylase over 600 units (in normal range). 

Test-meal. — Contents of stomach greenish-yellow. No 
12-hour retention. Total acidity, 0; free Hcl., 0; lactic 
acid, 0; altered blood, 0; Wolff, 0. 

Microscopically. — Few yeasts and small type sarcinse 
are seen. 

Roentgen Examination. — Markedly ptosed stomach of 
fish-hook form; atonic; pylorus and antrum well visuahzed, 
duodenum seems regular. Epigastric tumor is seen to lie 
3 f.b. above lesser ciu^^ature of stomach. 

Wassermann. — Negative. 

Laparotomy. — ^Large, hard nodular pancreas; chronic 
cholecystitis and pericholecystitis. 

Pathology. — Tissue (gland) inflammatory. 

After Course. — Patient alive after nearly 3 years; weighs 
99 pounds; still has epigastric nodule. 

Important differential points are summarized in Table 
39. Emphasis is to be especially placed upon the anam- 
nesis of the precachectic stage. This usually exhibits 
symptoms clinically referable to gall-tract malfunction. 
Test-meal findings are but rarely characteristic of gastric 
cancer at a stage when epigastric tumor can be pal- 
pated. While free hydrochloric acid may be low or ab- 
sent, 12-hour retention, altered blood, lactic acid, positive 
Wolff -Junghans' test, increase in the f ormol index, or bacilli 
of the Oppler-Boas type are commonly absent or irregularly 
found. The abdominal tumor is not generally movable 
upon gastric or colon inflation. The stools rarely ex- 
hibit altered blood. Tests for pancreatic ferments usu- 



DIFFERENTIAL DIAGNOSIS 



399 



ally reveal absence or diminution of amylase or trypsin, or 
both. Roentgen examination usually shows regular gastric 
outline, with the stomach perhaps at a distance from the 
palpable abdominal tumor. 



Table 39 









Nature of the disease 






Signs and 


Gastric 










Retroperi- 
toneal 
tumor 


symptoms 


cancer 


Tumor of 


Tumor of 


Tumor of 


Tumor of 




(body or 
fundus) 


liver 


pancreas 


colon 


kidney 


Age. 


45 


40 


Variable. 


40 


35 


Variable. 


Sex. 


Males. + 


Variable. 


Women? 


Males? 


Males? 


Variable. 


Onset. 


Previous 


Gradual 


Gradual 


Gradual 


Gradual; 


Gradual 




ulcer his- 


and pro- 


and prog- 


and pro- 


may have 


and pro- 




tory or 


gressive. 


gressive; 


gressive 


early he- 


gressive. 




primary 




trauma? 


acute with 


maturia. 






progres- 






obstr. 








sive dys- 














pepsia. 












Pain. 


Pres. in 95 


Indefinite. 


Rarely 


Intermit- 


Indefinite, 


Indefinite. 




per cent. 




marked. 


tent usu- 
ally; may 
be con- 
stant. 


sometimes 
colics. 




Vomiting. 


Common 


Irregular; 


Irregular; 


Rarely 


Infrequent. 


Irregular; 




and pro- 


may occur 


may occur 


early. 




may occur 




gressive. 


from pres- 
sure. 


from pres- 
sure. 






from pres- 
sure. 


Weight loss. 


Constant 


Progres- 


Irregular. 


Constant. 


Constant 


Constant 




and pro- 


sive. 






as a rule. 


but grad- 




gressive. 










ual. 


Cachexia. 


Pronounced 


Pronounced 
late. 


Variable . 


May be 
marked. 


Often pro- 
nounced. 


Present. 


Appetite. 


Poor. 


Variable . 


Variable . 


Variable . 


Variable . 


Variable. 


Bowels. 


Constipa- 


Constipa- 


Diarrhoea 


Obstipation 


May be 


May be 




tion the 


tion fre- 


not un- 


later diar- 


normal. 


normal. 




rule. 


quent. 


common. 


rhoea. 






Bleeding. 


Hemate- 
mesis or 
melena 15- 
25 per 
cent. 


Melena at 
times. 


Absent. 


Common, 
especially 
late. 


Absent. 


Absent. 


Urine. 


Often nega- 


Often nega- 


Often nega- 


Often nega- 


Local he- 


Often nega- 




tive. 


tive. 


tive. 


tive. 


maturia in 
about 60 
per cent. 


tive. 


Cystoscopic 


Negative. 


Negative . 


Negative. 


Negative. 


Blood or 


Negative. 


and pyelo- 










pus from 




gram. 










1 ureter; 
deformed 
pelvis on 
collargol 
injection. 





Table continued on page 400 



400 



CANCER OF THE STOMACH 



Table 39.— Continued 









Nature of the disease 






Signs and 
symptoms 


Gastric 

cancer 

(body or 

fundus) 


Tumor of 
liver 

! 


Tumor of 
pancreas 


Tumor of 
colon 


Tumor of 
kidney 


Retroperi- 
toneal 
tumor 


Test-meal. 


Low or ab- 
sent free 


Hcl may 
be abst. ; 


Hcl may 
be low or 


Hcl often 
low but 


Hcl may 
be low to 


Hcl usually 
low; 12 hr. 




Hcl; 12 


12 hr. ret. 


normal; 12 


may be 


normal; 


ret. vari- 




hr. ret.; 
Oppler- 
Boas ba- 
cilli; lactic 
acid; al- 


var.; rare- 
ly Oppler- 
Boas ba- 
cilli or 
lactic acid 


hr. ret. 
variable ; 
Oppler- 
Boas bac- 
illi, lactic 


normal; in- 
freq. 12 hr. 
ret. ; lactic 
acid, al. 
blood or 


12 hr. ret. 
rare, lactic 
and alt. 
blood, 
Oppler- 


able, lactic 
acid, alter- 
ed blood 
or Oppler- 
Boas ba- 




tered 


Wolff test 


acid or 


Oppler- 


Boas ba- 


cilli infre- 




blood; 


in 30-50 


altered 


Boas un- 


cUli very 


quent. 




Wolff test 


per cent. 


blood rare. 


common. 


rare. 




Stool. 


in 80 per 
cent. 
Altered 


Altered 


Altered 


Altered 


Altered 


Altered 




blood 89 


blood un- 


blood un- 


blood in 


blood rare. 


blood rare. 




per cent. 


common. 


common. 


70-90 per 
cent. 






Abdominal 


In about 60 


In from GO- 


In 50 per 


In 30-50 


In 75 per 


In 70-90 


tumor. 


per cent., 


GO per 


cent. 


per cent. 


cent, may 


per cent. 




often 


cent. 


moves 


moves on 


move on 


usually 




movable. 


moves 
with res- 
piration. 


with res- 
piration or 

with stom- 
ach. 


respiration 
or on colon 
inflation. 


respir. 


fixed. 


Radiogram. 


12 hours 


12 hours 


12 hours 


12 hours 


12 hours 


12 hours 




retention 


ret. un- 


ret. var. ; 


stom. ret. 


stom. ret. 


ret. vari- 




not un- 


common; 


palpation 


var. tumor 


variable ; 


able tumor 




common. ; 


palpation; 


on fluoro- 


mass ex- 


tumor ex- 


mass extra- 




filling de- 
fects. 


on fluoro- 
scopic 
exam, 
shows 
mass to be 
extra- 
gastric. 


scopy 
shows 
tumor to 
be extra- 
gastric . 


tragastric; 
colon 
exam, 
shows ret. 
of opaque 
meal and 
filling de- 
fects of 
bowel. 


tragastric. 


gastric. 


Ascites. 


Occurs late. 


May occur 


Uncommon. 


Very un- 


Very un- 


May occur. 


Jaundice. 


Late, due 
to metas- 
tases. 


early. 
May be 
early and 
constant. 


Variable 
according- 
ly as gall- 
ducts are 

obstructed. 


common. 
Rare. 


common. 
Rare. 


Infrequent. 



Differentiation of Gastric Cancer of Body or Fundus from Tumors in 
Adjacent Structures. — (Author.) 



Cyst of the pancreas is of infrequent occurrence. The 
history should be searched for facts relative to gall-stones, 



DIFFERENTIAL DIAGNOSIS 401 

trauma or perforating peptic ulcer. Pancreatic cysts 
often attain great size without giving marked gastric 
symptoms. Cachexia develops slowh^ The tumor can 
generally be shown to be distinct from the stomach by 
air inflation of the stomach and large bowel. Gastric 
examination by test-meals, commonly reveals free empty- 
ing power, normal free hydrochloric acid, and absence of 
altered blood, lactic acid or long acid-fast bacilli. The 
stools may be diarrheic ; they rarely exhibit altered blood. 
Pancreatic ferments may be lacking. Roentgen exami- 
nation may demonstrate that the tumor has no connection 
with the stomach. 

Abscess of the pancreas is commonly associated with 
history of infection of the gall-tract, penetrating ulcer, 
acute pancreatitis, or trauma. Shock may be marked 
early. Temperature and leucocytes are increased. Vomit- 
ing may be uncontrollable, and be bloody in kind. The 
abdominal tumor is rarely locahzed. It is usually fixed 
and tender upon palpation. The test-meal findings are 
variable. They may be negative unless previous gastric 
ulcer has existed. Stools rarely contain altered blood, 
but pancreatic ferments rasij be lacking. Glycosuria 
may be demonstrated. Roentgen examination shows the 
tumor to be extragastric, or reveals crater ulcer or mal- 
formations due to adhesions. If the abdomen is very 
tense, locaUy, exploratory puncture may reveal an abscess 
cavity that has no communication with a viscus. Carmine 
(gr. v) administered by the mouth may prove this lack 
of a fistulous tract. 

Carcinoma of the pancreas is generally secondary to 
mahgnant disease of the stomach, gall-tract or fiver. 
The history of the primary affection is usually char- 
acteristic and suggestive. It is impossible chnically to 

26 



402 GANCEK OF THE STOMACH 

separate some primary malignant pancreatic tumors from 
gastric cancers until laparotomy is performed. On ac- 
count of the early invasion of the stomach wall the symp- 
toms of the disease may closely mimic gastric cancer. 
Tumors of the pancreas early become fixed or move only 
on respiration, and not upon gastric or colonic inflation with 
air. Diarrhea, often prostrating, may be an early mani- 
festation. The stools rarely contain blood, macroscopically 
or chemically. Tryptic and amylolytic digestion may be 
reduced or lacking. Roentgen examination may show that 
the focus of disease is extragastric. 

Enlargement of the spleen may at times present a clinical 
picture that is confused with cancer of the greater curvature 
or fundus of the stomach. In splenic enlargements the 
anamnesis usually discloses history of a chronic, general 
infection, of malaria, trauma, or of blood dyscrasia. Ab- 
dominal examination generally demonstrates a tumor with 
a well delimited, rather sharp edge; the spleen ''notches" 
are recognized; the mass is smooth and moves on respiration 
but not upon inflation of the stomach or colon. Blood 
analj^ses often establish a leukemia. Secondary nodules 
are rare in disease of the spleen. When such occur, they 
are in the blood-forming organs or lymphatics. The liver 
may show enlargement nearly as great as that of the spleen. 
The test-meal rarely exhibits gastric retention. Low free 
hydrochloric acid may be observed, but organic acids, 
altered blood or bacilli of the Oppler-Boas type are rarely 
found. The stool contains blood chemically in almost 
50 per cent, of cases. Roentgen examination may prove 
that the tumor is extragastric. 

Tumors of the kidney, large bowel, omentum and retro- 
peritoneal tissues not infrequently offer problems in the 



DIFFERENTIAL DIAGNOSIS 403 

proof of their being extragastric. Table 39 summarizes 
the essential features of their differentiation. 

Primary tumors of the small intestine are of very un- 
common occurrence. Their most common location is in the 
first 3 feet of the jejunum or the terminal 3 feet of the 
ileum. They may give rise to only vague dyspepsia until 
stenosis occurs. On account of the occurrence of colicky 
pains, this dyspepsia is frequently mistaken for gastric 
ulcer or appendicitis until diarrhea, hemorrhage, emacia- 
tion or abdominal tumor develop. If the jejunum is 
involved just distal to the duodenum, gastric contents 
exhibiting retention (really duodenal) or low free hydro- 
chloric acid may be obtained. Rarely are organic acids, 
altered blood or Oppler-Boas bacilli noted. Early tender- 
ness of the tumor is observed. The bowel proximal to it 
is distended. The tumor shows little, if any, relation to 
the stomach upon that viscus being distended with air. 
Roentgen examination may show halting of the opaque 
meal with anomaly in outline of the bowel in the region of 
the tumor. When the ileum is the seat of the disease, 
stenosis may be the earliest sign, apart from cachexia. 
This evidences itself by constipation (occasionally bloody 
stools with diarrhea), colicky abdominal pains, tender, 
distended abdomen or irregular "false tumors^' due to 
accumulations of air and chyle in the small intestine. 
Roentgen examination may demonstrate the dilated ileum 
proximal to an alteration in outline of its lumen. 

Achylia gastrica (primary or associated with the anemias 
coincident to pernicious anemia, Addison's disease and 
cardio-renal malfunction) not infrequently occurs at the 
''cancer age" and may, on casual examination, be con- 
fused with gastric cancer. The essential differential points 
are summarized in Table 40. 



404 



CANCER OF THE STOMACH 



Table 40 







Nature of the disease 




Clinical 
signs and 
symptoms 












Gastric 


Achylia 


Pernicious 


Cardio-renal 


Addison's 


cancer 


gastrica 


anemia 


disease 


disease 


Age. 


45 


40 


35 


45 


30 


Sex. 


Males, -f 


About equally 
divided. 


Males. -{- 


Males. + 


About equally 
divided, 


Onset. 


Often malig. 


Gradual on- 


Slow and in- 


History of in- 


Insidious with 




after years of 


set; may be 


sidious; gas- 


fectious ail- 


progressive 




dyspepsia. If 


old history 


tric symp- 


ment or 


weakness. 




no prev. his- 


of gastritis. 


toms often 


cardio-renal 






tory of dysp. 


usually in- 


secondary. 


overstrain. 






prog. and 


definite "dys- 










continuous 


spepsia." 










indigestion. 










Pain. 


Present in 95 


Indefinite dis- 


Rare unless 


Rare or vague. 


Irregular 




per cent. 


tress. 


card, symp- 


Occasionally 


cramps at 








toms de- 


abdominal 


times. 








velop. 


"cramps." 




Vomiting . 


Common 
early and 
late in dis- 
ease. 


Irregular. 


Infrequent . 


Irregular. 


Irregular. 


Weight loss. 


Constant and 
progressive. 


Variable. 


Variable or 
intermittent. 


Variable. 


Progressive. 


Cachexia 


Pronounced . 


Rarely 


Not often 


Infrequent. 


May be pro- 






marked. 


pronounced. 




nounced; 
weakness out 
of all propor- 
tion. 


Blood pres- 


Reduced. 


May be re- 


Reduced. 


Increased 


Markedly re- 


sure. 




duced. 




usually. 


duced. 


Anemia. 


Erythrocytes 


May be slight 


Erythrocytes 


Slight secon- 


May be mark- 




average 


secondary 


usually be- 


dary anemia 


ed. Rarely 




above 3,500,- 


anemia. 


low 2,500,- 


the rule. 


high color 




000, Hg. 




000; Hg. re- 




index. Nu- 




above 60 




latively high; 




cleated ery- 




per cent. 




nucleated, 
red cells, 
variations in 
size and 
shape. 




throcytes may 
be found. 


Urine. 


Often nega- 


Often nega- 


Usually nega- 


Albumin 


May be nega- 




tive. 


tive. 


tive or mild 
albumin- 
uria. 


casts, ery- 
throcytes or 
alteration in 
daily quant. 
Phenosul- 
phona ptha- 
leiu test. 


tive. 


Hemorrhage 


In from 15- 
25 per cent. 


Very rare. 


Very rare . 


Rare. 


Rare. 



DIFFERENTIAL DIAGNOSIS 



405 



Table 40. — Continued 









Nature of the disease 




Clinical 






















signs and 
symptoms 


Gastric 
cancer 


Achylia 
gastrica 


Pernicious 
anemia 


Cardio-renal 
disease 


Addison's 
disease 


Test-meal. 


Low free Hcl; 


Absent free 


Low or abs. 


Acid may be 


Free Hcl and 




often 12 hr. 


Hcl; total 


acidity; rare- 


normal or 


total acidity 




food reten- 


acidity low; 


ly 12 hr. ret. ; 


low, not 


absent or low; 




tention ; Op- 


12 hr. ret. 


lactic acid 


usually ab- 


12 hr. ret. 




pler-Boas 


infrequent ; 


rare; altered 


sent; 12 hr. 


very rare; 




bacilli ;lactic 


lactic acid 


blood often 


ret. infre- 


lactic acid or 




acid; altered 


and altered 


in trace; 


quent. 


altered blood 




blood. 


blood rare. 


streptooo(3ci 
abundant; 
Oppler-Boas 
baciUi very 
rare. 




uncommon. 


Stool. 


Altered blood 
89 per cent. 


Infrequent. 


Often traces. 


Infrequent. 


Variable. 


Bowels. 


Constipation 


Diarrhoea not 


Diarrhoea not 


Alternating 


Diarrhoea not 




the rule. 


uncommon. 


uncommon. 


diarrhoea 
and consti- 
pation. 


infrequent. 


Appetite. 


Usually poor. 


Capricious. 


Variable . 


Often good. 


Capricious. 


Tempera- 


Infrequent . 


Normal. 


Often eleva- 


Normal or 


Frequently ele- 


ture. 






tions of 1° 
to 3° F. 


subnormal. 


vations of 1° 
to 3° F. 


Tuberculin 


Negative, the 


Negative, the 


Negative, the 


Negative, the 


Frequently 


test (sub- 


rule. 


rule. 


rule. 


rule. 


positive. 


cutaneous') . 












Radiogram. 


Gastric reten- 


Rarely ret.; 


No retention 


Cardiac 


Gastric atony 




tion; filling 


atony, no 


or filling de- 


changes 


marked. 




defects. 


filling de- 


defects; 


stomach 








fects. 


gastric atony 


may be 
normal. 




Abdominal 


In 3 out of 4 


Absent. 


Absent. 


Absent. 


Absent. 


tumor. 


cases. 










Metastases. 


Common. 


Absent. 


Absent. 


Absent. 


Absent. 


Ascites. 


Not infre- 
quent ; late 
in disease. 


Absent. 


Absent. 


May occur 
with per- 
ipheral 
edema. 


Absent. 


Edema. 


Small amt. 
at ankles. 


Rare. 


Small amount 
in extrem- 
ities. 


Often marked. 


May occur 



Differentiation of Gastric Cancer from Other Ailments Associated with 
Low Gastric Acidity, Anemia and Cachexia. — (Author.) 

Malignant peritonitis may result from lymphatic spread- 
ing of a primary gastric focus, cancer of the liver, the gall- 
tract, neoplasm of the bowel or the pelvic organs. It 
is rarely primary. Sometimes the clinical picture pre- 
sented is confusing on account of its association with 



406 CANCER OF THE STOMACH 

ascites. In its early stage it not infrequently resembles 
tuberculous peritonitis. It is rarely febrile, is apt to be 
less painful and is not, as a rule, associated with ulcera- 
tions of the bowel. The various differential facts have 
been brought out in Table 41. 

Ascites is of not infrequent occurrence in late gastric 
cancer. If the symptoms of the primary disease have 
been obscure, or have not been inquired into clinically, 
the presence of free intraabdominal fluid may render the 
diagnosis difficult. These facts have also been emphasized 
in Table 41. 

Usually careful anamnesis, examination of the gastric 
extract, search for ''occult" blood in a properly pre- 
pared stool, or Roentgen examination of the stomach, en- 
able one to locate the stomach as the original seat of 
trouble. 

A study of the ascitic fluid is not infrequently of much 
value in the differentiation between malignant, infectious 
or benign abdominal ailments. These facts have been 
fully emphasized by Dock. This investigator has shown 
that fluid, obtained from the abdomen by puncture, can 
sometimes be demonstrated to be malignant by a careful 
study of its cellular elements. These may be obtained from 
the aspirated fluid by successive centrifugalization. The 
making of smears from the precipitate in the tubes, dry- 
ing them, fixing and staining with Unna's polychrome 
methylene blue, Wright's stain, or hematoxyhn and 
eosin enable study of the different types. 

In cancer of the stomach, and not infrequently in other 
malignant intraabdominal diseases, large, swollen, irregu- 
larly shaped endothelial cells may be recognized. These 
show atypical mitoses, the nuclei being frequently large or 
of extremely bizarre shapes. 



DIFFERENTIAL DIAGNOSIS 



407 



Ta.ble 41. 



Nature of the disease 



Signs and Gastric cancer ! 

symptoms peritoneal or '. Cancer of i Tuberculous 
hepatic metas- j peritoneum | peritonitis 
tases 



Cirrhosis of 
liver 



Cardio-renal 
disease 



Age. 
Sex. 
Onset. 



Pain. 



Vomiting. 
Weight loss. 

Cachexia. 

Appetite. 
Bowels. 



Blood pres- 

siire. 
Jaundice. 
Abdomen. 



Tumor. 



Fluid. 



Test-meal. 



45 

Males. + 

Prev. peptic 
ulc. or pri- 
mary malig- 
nant gastric 
disease. 

Present in 95 
per cent. 

Common eariy 

or late. 
Progressive. 



Pronounced. 



Females. -|- 
Secondary to 
pelvic or 
gradual and 
atypic. 

Colics may 
occur early 
or late. 

Infrequent. 

Progressive. 



Pronounced. 



Young adults. 
? 

Pulmonary or 
abdominal 
tuberculosis 
(kidney, 
ovaries 1 . 

Colics or ache 
early. 



40 

Males. + 

Gastritis, 

alcoholic 

excesses. 



Distress late. 



Not the rule. Variable. 



40 

Males ? 

Infectious ex- 
posure or 
cardio-renal 
overstrain. 

Irregular 
cramps at 
times. 

Irregular. 



Poor. I Poor. 

Constipation Variable, 
often. 



Progressive 
but often 
very gradual. 
Pronounced 

late. 
Capricious. 
Diarrhcea 

variable. 



Marked in i Variable. 
late stages. 



Sometimes 

late. 
Variable. 
Constipation, 

diarrhoea at 

times. 



Reduced. 

Late if at all. 

Often scaphoid 
but may be 
distended in 
flanks or 

wholly. 

In 3 out of 4 
cases. 



Reduced. 

Rare. 
Distended 

late. 



Reduced. May be in- 

i creased. 
Rare. I May occur. 

May be early Tense or dis- 

tense or dis- tended. 

tended. | 



Infrequent. 

Often good. 

Diarrhoea and 
constip. al- 
ternating not 
infrequently. 

Usually in- 
creased. 

Infrequent. 

Distended. 



Usually free; I 
serous or 

bloody "can- i 
cer cells" (?).' 

Low or absent 
Hcl; 12 hr. 
ret. lactic 
acid ; altered 
blood or Op- 
pler-Boas ba- 
cilli. 



Early multi- 
ple nodules. 



Often in loculi 
bloody, chy- 
lous, or ser- 
ous; "cancer 
cells" (?). 

Low Hcl. 



Numerous 
ridges often 
above navel; 
slow devel- 
opment. 
Serous or 

cloudy, many 
small lympho- 
cytes, bacilli 
rarely found. 
Often low 
Hcl. 



Local enlarge- Liver may en- 
ment in right; large or no 
upper abd. I tumor pres- 
(liver) . I ent. 

Serous, rarely Serous, 
bloody but 
may be bUe- 
stained. 

Hcl may be Hcl may be 
normal. normal. 



Table continued on page 408. 



408 



CANCER OF THE STOMACH 



Table 41. — Continued 





Nature of the disease 


Signs and 


Gastric cancer 








symptoms 


peritoneal or 


Cancer of Tuberculous 


Cirrhosis of 


Cardio-renal 




hepatic metas- 


peritoneum peritonitis 


liver 


disease 


" 


tases 










Stool. 


Altered blood 


Blood rare. 


Blood late. 


Blood may 


Blood infre- 




in 89 per cent. 






occur late. 


quent. 


Urine. 


May be normal. 


May be nor- 
mal. 


Albumin late. 


Albumin late. 


Large volumes 
of albumin 
and casts 
often early. 
Phenolsul- 










phonphtha- 










lein test. 


Radiogram. 


Gastric reten- 


Usually nega- > Usually nega- 


Negative or 


Usually nega- 




tion variable; 


tive, tive. 


pressure de- 


tive. 




filling defects. 




feet from 
bver. 




Metastases. 


Common. 


Common to Involvement 


Absent. 


Absent. 






serous sur- 


of lungs, 










faces or belly 


liver, intes- 










wall. ' tines or pel- 










vie organs. 






Edema. 


Late and 


Late and Late and 


Late and not 


May be mark- 




limited. 


limited. limited. 

1 


often mark- 
ed. 


ed early. 


Tempera- 


Infrequent 


Infrequent 1 Irregular 


Elevation 


May be sub- 


ture. 


increase. 


increase. ! elevation. 


late. 


normal. 



Differential Diagnosis between Gastric Cancer with INIetastases to the 
Peritoneal or Portal System and Diseases Associated with Ascites. — (Author.) 

In tuberculosis, colorless or straw-colored fluid is usually 
obtained. Its cellular constituents are few. A study of 
the cell forms reveals excess of small lymphocytes. In 
extensive malignancy, bloody ascitic fluid may be present. 
In such instances red blood cells may be found together 
with endothelial cells showing atypical division. 

In a few cases of gastric cancer, particularly where there 
has been involvement of the large lymphatic channels, as 
for example the receptaculum chyli, or the thoracic duct, 
the ascitic fluid may be milk-like or creamy. This occurred 
in three instances in our series. A microscopic study of this 
fluid is not infrequently negative, with the exception of 
demonstrating a large number of lymphocytes and fat 
droplets. 



DIFFERENTIAL DIAGNOSIS 409 

The Incidence of Ascites in Gastric Cancer. — Free fluid 
is usually an evidence of late, hopelessly inoperable gastric 
cancer. When free fluid is present other signs of the 
disease are not lacking. It most commonly occurs with 
secondary involvement of the peritoneum itself, the liver, 
pelvic organs, the ovary, transverse colon, gastrocolic 
omentum and pancreas. In our series of cases, ascites was 
present in 86 instances or 9.3 per cent. These were all 
inoperable cases, and laparotomy usually disclosed exten- 
sive glandular invasion wholly irrespective of the size or 
position of the local growth in the stomach. 

Gastric cancer secondary to malignancy in organs other 
than the stomach occurred in sixteen instances in our series. 
It was secondary to tumors of the breast, the liver, female 
genitalia, colon and the pancreas. Invasion of the stomach 
was either by l}miph-gland metastases, or by contiguous 
involvement. Usually in these cases anamnesis and general 
physical examination disclosed a primary tumor. Xot 
rarely operative procedures had already been performed 
upon the primary growth. 

As we have already mentioned, it would seem c[uite neces- 
sary to differentiate many so-called secondary gastric cancers 
from primary malignant processes wholly independent of 
an extra-gastric lesion, to which they are sometimes con- 
sidered secondary. 

Syphilis of the Stomach. — Sj^phihs of the stomach is 
becoming more readily recognized since the perfection of 
blood-serum tests for lues. In the majorit}' of instances of 
gastric syphiHs anamnesis discloses an early specific lesion. 
Physical examination may demonstrate certain local or 
general evidences of secondarj' or tertiar}^ manifestation of 
the disease. 

Before the onset of a definite tumor growth in the 



410 CANCER OF THE STOMACH 

stomach, the history is not infrequently that which we 
associate with chronic peptic ulcer. Inasmuch as ulcera- 
tion of the stomach in gastric syphilis is apt to be multiple, 
epigastric pain and a continuance of the dyspepsia, instead 
of having it occur at intervals, may be quite markedly 
evidenced. 

Gummata of the wall of the stomach or extensive invasion 
of the mucous membrane may develop in time in the course 
of the disease and may be readily mistaken for cancer. A 
large growth may press upon the pylorus, may produce 
malignant hour-glass, bring about multiple tumors in the 
stomach, or, as a result of necrosis of a portion of these 
tumors, cause the development of numerous, seemingly 
maUgnant ulcers. 

Whenever a case of multiple gastric tumor or multiple 
chronic gastric ulcer is demonstrated, the Wassermann 
test should be made as routine. If this test is positive, then 
specific treatment should be pushed. This therapeutic 
differentiation is an important one. We have seen large 
multiple ulcers of the stomach and even gummata dis- 
appear under proper antiluetic treatment. 

Tuberculosis of the stomach is extremely uncommon. 
While tubercle bacilli are frequently swallowed, they do not 
seem to retain their viability in the presence of normal 
gastric juice. While it is conceivable that initial trauma 
in the gastric lining may furnish a lodging point for tubercle 
bacilli, and as a consequence ulcer may develop, it is more 
than likely that tuberculous ulcers or granulomata develop 
in the gastric wall as a consequence of bacilli being carried 
by the blood or lymphatic streams. 

Primary tuberculosis of the stomach is of such great 
rarity that when a large chronic tuberculous ulcer is found 
in this viscus, search for the primary focus of the disease 



DIFFERENTIAL DIAGNOSIS 411 

should be made. It is usually found in the lungs, kidneys 
or the peritoneum. The sj^mptoms of the disease are 
similar to those associated with non-tuberculous, benign 
gastric ulcer. The presence of these ulcer symptoms in an 
individual with no tuberculosis should be sufficient to 
suggest proper diagnosis. Extreme emaciation, the pres- 
ence of fever, abdominal tenderness and the positive tuber- 
culin reaction should render recognition of the condition 
apparently easy if the fact is borne in mind that such an 
affection is likely to occur. 

Gastric granuloma is a rare ailment and is not usually 
diagnosed until laparotomy or at the post-mortem table. 
Interesting cases have been reported by Meyer and Hardy. 
A syphilitic etiology not infrequently underlies the condi- 
tion. Epigastric pain, weight loss, vomiting, hemorrhage 
and sometimes the finding of a characteristic bit of tissue in 
either the vomitus or the stools are facts which are of service 
in diagnosing the existence of the disease in the stomach. 

Roentgen examination may reveal multiple gastric 
tumors, a gastric outline of small size and irregular form 
or occasionally the actual e\ddences of polypoid growths.1 

The importance in recognizing this condition is that of 
preventing patients coming to operation for a condition 
which, of course, is not curable surgically. 

Linitis plastica or cirrhosis of the stomach is a disease in 
which there is an enormous fibroid thickening of the gastric 
wall. This is usually general, although it appears in certain 
cases to progress from the pyloric end toward the cardia. 
This enormous thickening of the stomach wall results in a 
contraction of the stomach with the production of a small 
lumen. Obstruction mth vomiting, retention, absent 
hydrochloric acid, emaciation, anemia are usually clinical 
manifestations. A full account of this rather uncommon 



412 CANCER OF THE STOMACH 

condition has been given by Lyle. Clinically, the affec- 
tion is usually considered as extensive, scirrhus cancer 
of the stomach, or as sarcoma. Laparotomy and the 
examination of sections of extirpated tissue furnish the 
only reliable differential points in this disease. 

Sarcoma of the stomach is comparatively rare. It was 
present in 4 cases in our series. Excellent analyses of this 
condition have been made by Clendenning, Yates and 
Campbell. Clinically, there is not infrequently a previous 
history of gastric ulcer. The supervening malignant period 
is in every way similar to that of gastric cancer. Hemor- 
rhage is perhaps more common. Extensive metastases 
may occur early. 

We have seen one instance where invasion of the left 
supraclavicular lymph nodes resulted in a tumor the size of a 
grape fruit 2 months after the onset of a gastric disease 
apparently malignant, and following upon a previous ulcer. 

Foreign Bodies in the Stomach. — These are of rare 
occurrence in the human, but may attain great size. There 
is usually the history of swallowing of such things as nails, 
keys, hair, thread and the like. The patients are not 
infrequently neurotic or of the circus class. The foreign 
bodies may form recognizable abdominal tumors. Their 
traumata may bring about hemorrhage. Weight loss may 
be constant on account of obstruction or dread of pro- 
ducing pain on food ingestion. There is rarely associated 
with it cachexia coming from systemic poison as a con- 
sequence of malignant disease. 

Roentgen examination may definitely recognize the 
tumor as being intragastric, or demonstrate metal, stones 
and the like. 

Foreign Bodies in the Large Bowel. — ''Bezoar stones" 
are uncommon. They may result from inspissated feces, 



DIFFEREXTIAL DIAGXOSIS 413 

calcareous deposits, gall-stones or parasites. They not in- 
frequently occur in individuals who have worked on farms 
or have been associated with cattle and horses. The 
gastric findings are rarely confused with those of cancer 
of the stomach. ITnless there is obstruction, emaciation 
and cachexia are uncommon. The abdominal tumor is 
at^-pically situated and in the large majority of cases 
below the navel. Roentgen examination may definitely 
prove that the tumor is extragastric. Sometimes its 
character may be determined by plate or screen examina- 
tion. The following history- is suggestive. 

Tumor {71 Left Hy-pochondrium; Constipation; Bezoar Stone. 

Dr. J. C. — Age 46, American, veterinarian. 

Family History . — Unimp ort ant . 

Personal History. — Several severe attacks of la grippe. 
Intermittent dyspepsia of type. clinicaU}^^, duodenal tilcer 
for 6 to 10 years. 

Present Trouble. — Gradually developing constipation for 
past l}i years; at present has marked obstipation; asso- 
ciated with tills are abdominal pains (usually about navel) 
coming on when bowels have not moved for several days, 
sensations of gurgluig in abdomen, bloating and shght 
nau-sea. Several months ago, noted painless tumor just 
to the left of the navel. This has increased in size graduaUj^ 
since when first noted. 

Obstipation. — VerA' marked; can now get bowels to move 
only with great difficulty: never noted blood or pus in 
stools. 

Appetite. — Fair. 

Weight. — ^Lost 15 pounds in past 3 months. 

Examinaiion. — Stocky, weU-notirished, thick-set male; 
skin pale, saUow. 

Throat. — Peritonsihar redness. 

Thorax. — Negative. 

Ahdornen. — Hat, panniculus moderately thick. Stom- 
ach shghtly splashy and reaches to navel in mid-hne. Deep 
tenderness in right upper abdominal quach-ant (pylorus?). 
In the left h^TDOchonchium, extending from the rib margin 



414 CANCER OF THE STOMACH 

to the level of the iliac crest is a nodular, firm, sUghtly 
movable, not tender 7nass. It is about 3 inches long and 
1 to 2 inches wide. On inflation of the colon the tumor 
goes apparently posteriorly. 

Proctoscopic Examination. — Negative. Gastric inflation 
seems to indicate that the tumor is extragastric. 
Laboratory Examinations: 

Blood.— Kg., 90 per cent.; r.b.c, 5,000,000; w.b.c, 
8,400. 

Stool. — Small, hard, firm, no blood. 

Test-meal. — Slight gastric stagnation. Total acidity, 
62; freeHcl, 40. 

X-ray. — Stomach moderately dilated. Outline negative; 
peristalsis active. 

Colon. — On fluoroscopy a dense mass is seen in the lower 
half of the descending colon; it has fairly regular outline 
and appears fixed to deep structures. The mass is lost on 
fiUing the colon with bismuth. 

Laparotomy. — Calcified bezoar stone, densely adherent 
to the posterior wall of the descending colon; chronic 
perforation. 

Chronic obstipation occurs in patients past middle life. 
When associated with weight loss, anemia, and irregular 
gastric disturbance, it is sometimes confused with gastric 
malignancy. In these instances routine anamnesis, physical 
examination, analysis of the gastric contents, fluoroscopic 
examination of the stomach and Roentgen plates made 
of the abdomen, after the colon has been injected with 
barium sulphate, are usually sufficient to exclude gastric 
cancer and show malformation or malposition of portions 
of the large bowel. 

Protozoic Infections of the Bowel. — Even in the tem- 
perate zone there is a definite class of toxic, anemic, dyspeptic 
individuals who present themselves for diagnosis and in 
whom cancer may be suspected. Intermittent diarrhoea is a 
not infrequent finding. Altered blood may be present in 
the stools. The patients have not rarely lost consider- 



DIFFERENTIAL DIAGNOSIS 415 

able weight. The anamnesis in such instances discloses 
frequently the long-continued drinking of contaminated 
water or the eating of farm produce contaminated by water 
or the discharges of farm cattle, ducks, etc. The disease 
seems to be periodic in a large number of instances. At- 
tacks of diarrhoea last for several weeks, alternating with 
weeks, or even months, of fair health. As an end result 
anemia develops. It is usually of the secondary type, 
but in many cases there is an excess of eosinophils. The 
gastric secretions often exhibit absent or low free hy- 
drochloric acid. Pancreatic functional tests show diminu- 
tion in ferments. The examination of a fresh stool on 
a warm microscopic stage reveals protozoa associated with 
great numbers of motile and non-motile bacilli, chains of 
streptococci, yeasts and undigested food. From such 
cases we have been able to isolate endamoeba, trichomonas, 
cercomonas, balantidium coli and megastoma entericum. 

In the average case, ridding the bowel of these parasites 
goes a long way toward getting the patient well. 

X-ray examination of the stomach and bowel in these 
patients is negative. 

It should be emphasized that the above type of case 
is more frequently seen than is recognized in current text- 
books. These protozoic infections are chronic and usually 
intermittent. Thej^ seem to be due to precisely the same 
type of organisms which, under proper circumstances 
(chmate, diet, change of water, etc.), may be capable of 
causing acute colitis, with or without hemorrhage, ulcer- 
ation, abscess formation, and the like. 

Certain constitutional faults are occasionally mistaken 
for gastric cancer, and in fact may be associated with it. 
Among such we would mention, gout, diabetes and nephri- 
tis. The clinical history of these cases is different from 



416 CANCER OF THE STOMACH 

that of cancer. Analyses of the test-meal, feces, blood and 
urine generally bring out the essential differential points. 
Examination of the stomach and bowel by Roentgen ray 
aids in estabhshing the diagnosis of non-mahgnant disease. 

Certain drug addictions produce a systemic change re- 
sembhng that of gastric cancer. Among such are the 
habitual use of morphine, heroin, codein, bromides or 
the smoking of opiates. In these cases, however, careful 
examination usually demonstrates needle-punctures, alter- 
ations in the pupil, in the mental state, in the urine. To 
such the gastro-intestinal findings are entirely subordinate. 

In this class of patients especially, observations must be 
made with the clothing removed, and in doubtful cases the 
patient should be isolated and watched until the definite 
cause of the anomaly is established. 

Certain tumors of the abdominal wall may be considered, 
upon casual examination, as having connection with the 
stomach. Such tumors are lipomata, enchondromata, cysts, 
abscesses, or fibro-sarcomata. Careful anamnesis, physi- 
cal, chemical and x-ray examinations generally differentiate 
such conditions quite readily. When doubt exists, sections 
of the growth may be removed, or the tumor may be as- 
pirated or incised in order to permit microscopic study of 
tissue or pus. 

REFERENCE 
Dock, George: Amer. Jour. Med. Sciences, 1902. 



CHAPTER XI 
SURGICAL TREATMENT OF CANCER OF THE STOMACH 

BY 

Albert J. Ochsxee, B.S., M.D., LL.D., F.R.C.S., F.A.C.S. 

The value of surgical treatment of cancer of the stomach 
primarily depends: first, upon an early diagnosis; second, 
upon the complete excision of all of the cancerous tissue; 
third, upon the fact that the traumatism caused by the 
operation is within the margin of safety of the individual 
patient; fourth, upon a satisfactory mechanical result 
which wiU enable the patient to live comfortably with his 
changed digestive apparatus, and fifth, upon careful after- 
treatment. 

Fortunately, patients suffering from cancer of the 
stomach come for surgical treatment earlier in the course 
of the disease than in former times, and as a result of this 
condition it is possible to make a complete excision in a 
larger number of cases. There is a class in which it may 
not be possible to make a differential diagnosis positively 
between cancer of the stomach, ulcer of the stomach or 
duodenum, disease of the gall-bladder, adhesions in the 
region of the pylorus, or obstruction to the pylorus due to 
cicatricial contraction resulting from a previous ulcer. It 
is in this class of case that the surgeon has more frequently 
committed errors than in any other group. It is without 
doubt, in this type of case, that an operation should 
always be performed, because whatever condition may be 
found after the abdomen has been opened, it is proper that 
the condition be treated surgically. 

27 417 



418 GANGER OF THE STOMAGH 

The pride or personal conceit of the surgeon may suffer 
because of his inabihty to make a positive diagnosis in these 
cases and he may wish to continue his observations for a 
number of weeks or months in order to be certain before 
operating, so that he may be able to demonstrate the 
correctness of his diagnosis at the time of the operation. 
This plan is, however, exceedingly bad because in case of 
cancer, the condition may have progressed to such an 
extent that while a permanent cure might have been 
accomplished with an early operation, the late operation 
will result at best only in a temporary improvement. Con- 
sequently, after a very thorough examination has been made, 
if there is still doubt, an operation should invariably be 
performed. 

COMPLETE EXCISION 

By far the greatest number of cases in which the complete 
excision of all malignant tissue is feasible, belong to a 
class in which it was not possible to make a positive 
differential diagnosis between cancer and ulcer. There 
is, however, a class of cases in which the cancer seems to 
be almost entirely confined to the mucous membrane, and 
does not penetrate the entire wall of the stomach and is 
of sufficient firmness to prevent the loosening of cells to 
be carried to distant points for a considerable period of 
time. In this group of cases it is also possible to remove all 
of the cancerous tissue. 

In planning the operation, one should constantly bear 
in mind the distribution of lymph channels and lymph 
nodes described by Cuneo, because in this way it will be 
possible to remove the tissue which is likely to be in- 
fected with cancer beyond the tumor itself, together with 
the lymph nodes which are most likely to contain cancerous 
infection. 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 419 

Preparation for Operation. — The preparation for all 
operations for the relief of cancer of the stomach is the 
same, consequently it may be given here and then it may 
be applied to all of the operations upon the stomach which 
will be described through this Chapter. 

First, an attempt must be made to prevent as much as 
possible the introduction into the stomach of septic 
material. For this reason it is important to free the mouth 
and the nasal passages as thoroughly as possible of all 
infective material before the operation is undertaken. 
If the patient has decayed teeth or roots, or both, or suffers 
from pyorrhea, or from catarrh, or from tonsillar infec- 
tion, all of these conditions should be disposed of by 
proper ■ treatment, provided this treatment will not con- 
sume a sufficient amount of time to endanger the patient's 
condition from progression of his disease. In case of such 
danger, it is better to thoroughly spray the nasal cavities 
and the pharynx repeatedly with some mild antiseptic 
solution for 24 hours preceding the operation, giving the 
patient a good antiseptic gargle to thoroughly cleanse the 
teeth a number of times during the 24 hours preceding the 
operation, and to paint the roots of the teeth in case of 
pyorrhea with tincture of iodine; also to cleanse the tongue 
thoroughly and to get the cavities of the nose and mouth 
in as nearly an aseptic condition as we are able to get them. 

No noiurishment should be given that contains any 
septic material. It is best to give these patients broth 
only for 24 hours preceding the operation. The stomach 
should be thoroughly irrigated until the return fluid is 
perfectly clear. The patient should be given 2 ounces 
of castor oil the day before the operation, because this 
will carry away a great amount of foul material. It is 
well to place this castor oil in the stomach through the 



420 CANCER OF THE STOMACH 

stomach tube, after thorough irrigation of the viscus the 
day before the operation after all of the irrigating fluid 
has been siphoned out. By doing this, even though the 
passage between the stomach and the duodenum may be 
almost completely occluded because of the presence of 
the tumor, a sufficient amount of the oil will pass through 
this space, as a rule, to completely cleanse the intestines. 
The stomach should be washed out again within an hour 
preceding the operation. It is well to thoroughly cocain- 
ize the pharynx with a spray of 2 per cent, cocaine and to 
permit the patient to swallow this in order that the pharynx 
and the esophagus will become properly anesthetized by 
this substance. It is best to wait about 12 minutes after 
the spraying has ceased in order that the cocaine may 
have completely removed all sensation from the parts 
over which the stomach tube is to be passed. Not more 
than 2 drams of a 2 per cent, solution of cocaine should be 
used for this purpose, this amount being quite sufficient 
and there being no danger from cocaine poisoning if no 
larger amount is used. 

The patient should, of course, have all of the other 
ordinary preparations, such as a warm bath previous to the 
operation, etc. The abdominal wall should be treated in 
the manner which is usually employed in preparing for all 
abdominal sections. 

Cancers not Located in or Near the Pylorus. — The rare 
cases of cancer located away from the pylorus which come 
under surgical treatment sufficiently early to permit com- 
plete excision, are usually encountered accidentally either 
in the form of sarcoma of which we have had a few cases, 
or in the form of cancer developing at the bottom or in the 
edge of a gastric ulcer. In the case of sarcoma, metastatic 
tumors are not common early in the development of these 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 421 

growths and consequently it is possible to make a complete 
excision by remo^"ing tissue 3 cm. in every direction 
from the primary growth and then closing the wound left 
in the stomach in a manner to prevent obstruction from 
cicatricial contraction. 

Usually the Une of suture should be in a transverse or an 
obhque direction, but the location and the extent of the 
growth in the indi^ddual case must determine the direction 
of the closure. In case the growth involves the lower end 
of the esophagus, the chances of recovery after removal are 
so shght that the operation need scarcely be considered 
at the present time. 

Willy ^Nleyer is developing a technique in the use of his 
differential air-pressure cabinet, with which he hopes in time 
to succeed in satisfactorily remo^dng such growths and by 
reuniting the esophagus and stomach, by a tube constructed 
from a portion of the stomach with the remnant of the 
esophagus, prolong life. At the present time it is too early 
to discuss this operation. 

Carl Beck has devised an operation in which he utihzes the 
lower portion of the stomach for the purpose of construct- 
ing a tube, which can be used as an artificial esophagus, 
to be carried upward underneath the skin of the chest, in 
cases of carcinoma of the esophagus or of the cardiac end 
of the stomach invohT.ng the lower end of the esophagus. 
Unfortunateh^ these cases usuall}^ die so soon after the 
operation from the recurrence of the mahgnant growth that 
it is doubtful whether so severe and so extensive an opera- 
tion is indicated in a patient whose hfe expectancy is 
relatively short. In case one does not feel warranted 
in performing so extensive an operation in this class of 
cases which have advanced so far that food can no longer 



422 CANCER OF THE STOMACH 

be taken through the esophagus, it is well to perform a 
gastrostomy. 

Technique of Operation. — {WitzeVs Gastrostomy). — An 
incision 5 cm. long is made through the edge of the left 
rectus abdominis muscle just below the costal margin and 3 
cm. to the left of the median line. The incision is carried 
through all layers into the peritoneal cavity. The stomach 
is then examined to determine the exact extent and loca- 
tion of the tumor. A fold of the stomach-wall is drawn 
through the abdominal opening, the fold being chosen far 
enough away from the growth to prevent its involvement in 
the advance of the mahgnant growth. The skin outside of 
the deep fascia is then undermined upward over the costal 
margin for a distance of 4 cm. and a transverse incision is 
made through the skin. The undermined space is loosened 
to a width of 3 cm. in order that the fold of the stomach, 
which is to be drawn through this space, may not be unduly 
compressed and thus produce gangrene of the stomach 
wall. The tip of this fold, 13^ cm. long, is permitted to 
project through the transverse opening and is sutured in 
plac e with six or eight fine, silk sutures . A sec ond row of fine, 
silk sutures is placed so as to unite the wall of the stomach 
with the peritoneum and transversahs fascia and a few 
additional sutures are placed between the stomach wall 
and the edges of the rectus abdominis muscle and the 
anterior sheath of the rectus abdominis muscle. The 
wound is then closed. * 

If the patient is suffering from starvation, the fold of 
stomach projecting beyond the transverse incision is at 
once opened and a Jacobson retention catheter is passed 
into the stomach and some concentrated food and water 
are at once administered through this catheter whose 
distal end is closed by means of a cork or a clamp during 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 423 

the intervals between feedings. In these cases the patient 
should receive nourishment every 2 hours. If the patient's 
condition is not so serious it is well to postpone opening the 
stomach for 24 or 48 hours, until a strong adhesion between 
the stomach and surrounding tissue has been formed, in 
order that there may not be any infection from the stomach 
wound. The danger from such an infection is so slight that 
it need not interfere with the completion of the operation 
if the patient is in need of nourishment. This arrangement 
will prevent leakage from the stomach perfectly and 
permanently. 

There are many other operations equally as satisfactory 
as the one described (which was introduced by Professor 
Witzel) but none of them are simpler or more satisfactory 
than the above. 

In case the entire cardiac end of the stomach has been 
involved in a mahgnant growth, then it may become neces- 
sary to make the gastrostomy to the right of the median 
hne, and in that case the amount of stomach wall is usually 
not sufficient for this operation and the operation intro- 
duced by Senn will give fairly satisfactory results. 

Senn's Operation. — This operation consists in making a 
small puncture in the available stomach wall and intro- 
ducing through this a Jacobson's retention catheter, which 
has been stretched upon a probe so that the diameter of the 
rubber tubing is greatly reduced in order that it may thor- 
oughly occlude the puncture opening in the stomach wall 
upon contraction. A purse-string suture is then passed 
through the stomach wall 3^ cm. from the rubber tubing and 
tied snugly about the tubing. It is best to use fine silk for 
this purpose. This is introduced with a fine, curved needle 
in order that all of the layers of the stomach wall down to, 
but not through, the mucous membrane, may be engaged in 



424 CANCER OF THE STOMACH 

the suture in order that it may have a substantial hold, 
because of its passing through the submucous connective 
tissue. A second, third and a fourth purse-string suture of 
the same kind are introduced successively and then the 
stomach is attached by means of fine silk sutures to the 
peritoneum and transversalis fascia and the tube is per- 
mitted to pass out through the abdominal wound. This is 
closed by means of sutures on each side of this tube. In 
case there is leakage around the tubing, which may occur if 
the patient lives for a number of months after the operation, 
it is well to increase the size of the rubber tube sufficiently 
to produce a perfect closure of this canal. 

In order that the patient may have the pleasure of eating, 
he may chew the food he takes very thoroughly, place it 
in the barrel of a large glass syringe and then inject it into 
his stomach through this tube. Aside from the satisfac- 
tion the patient has in chewing the food, there is the ad- 
vantage of having the food mixed with saliva. Until the 
patient becomes accustomed to being fed in this manner it 
is well to continue the administration of concentrated 
food by means of enemata given every 3 hours, and also 
by the administration of normal salt solution by the drop 
method of proctoclysis. In most of these cases, the 
administration of from 5 to 10 drops of eucalyptus oil, in a 
little cream, by mouth from 3 to 6 times a day, serves to 
disinfect the malignant growth in the lower end of the 
esophagus and to increase the comfort of the patient. 

EXCISION OF CIRCUMSCRIBED GROWTHS NOT LOCATED IN THE 
REGION OF THE PYLORUS OR THE ESOPHAGUS 

In order to reduce the traumatism to a minimum, it is well 
to make a very large abdominal incision, so that the 
stomach may be brought out into view without unneces- 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 425 

sary tension or injury. A long stomach clamp with blades 
sufficiently thin and covered with rubber tubes to prevent 
injury from pressure, is applied at a distance of 10 cm. 
above and below the growth, in order to compress the blood- 
vessels supplying the region of the stomach to be operated. 
A thin, silk suture is then applied around each individual 
vessel 4 cm. away from the growth in every direction. 
(Before beginning the operation the stomach is thoroughly 
irrigated until the returning water is perfectly clear. It is 
well to use normal salt solution at a temperature of 105° F. 
for this purpose.) The stomach is then opened dkectly to 
the outer side of the line of sutures controlling the blood- 
vessels and fine tenaculum forceps are applied in such a 
manner that later they may be utilized as land-marks in 
closing the defect in the stomach. In case there is bleeding 
from the mucous membrane, the bleeding point is caught 
and ligated. After the entire growth, together with 3 cm. 
of the surrounding tissue, has been removed, the tenaculum 
forceps are utilized for bringing the edges together. A row 
of sutures of thin, chromicized catgut threaded double is 
used for uniting the mucous membrane. A second row of 
fine silk sutures is used for uniting the muscular layer and 
over this a row of fine, silk sutures is applied grasping all of 
the layers down to but not through the mucous membrane. 
In this way a perfect union can be accomplished without 
much infolding of the stomach wall. In case the tumor is 
small, the Connell suture may be used instead of this 
method. The suture is passed through all of the layers of 
the edge of the wound on either side, so that the serous 
surface is placed in apposition throughout. A second row 
of sutures corresponding to the third row which has just 
been described is placed over this and in this way the Connell 
suture is reinforced. In either of these cases there can be 



426 CANCER OF THE STOMACH 

no hemorrhage because all of the blood-vessels are thor- 
oughly controlled by the various rows of sutures. 

In case the growth is so near the pylorus that it will be 
necessary to constrict the pyloric end of the stomach by 
the apphcation of the sutures closing the defect, it is best 
to plan a gastro-enterostomy in addition to the excision of 
the growth. This will, however, be different in no way 
from the operation to be described in connection with the 
treatment of carcinoma of the pylorus. It is consequently 
not necessary to explain it at this point. 

CARCINOMA OF THE PYLORUS 

Nearly all of the cases of cancer of the stomach which 
come early enough to make it reasonable to expect a 
permanent cure following an operation, are located in 
the region of the pylorus. This is also true of a fairly large 
class of cases which can be much benefited by an opera- 
tion although there is no possibihty of a permanent cure. 
In nearly all of these cases the obstruction to the pylorus 
is so marked that practically no food can pass into the 
small intestines. This condition causes starvation, and 
also makes a foul retention cavity of the remaining por- 
tion of the stomach, in which the remnants of food and the 
mucus secreted by the stomach and the broken-down 
ulcerating carcinomatous tissue, produce a decomposing 
substance, portions of which will be absorbed through 
the stomach walls and will cause more or less severe 
symptoms of cachexia. 

On the one hand these patients are starved and on the 
other hand they are poisoned by these foul accumulations. 
Moreover, the vomiting which is caused byjthe latter 
serves to irritate the cancerous growth so that these 
patients are in a most deplorable condition. Even with 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 427 

repeated lavage, it is not possible to keep the stomach 
even fairly clean. These patients gain enormously by a 
properly planned and executed gastro-enterostomy, be- 
cause this will permit nourishment from the stomach to 
reach the intestines and will remove the suffering from 
starvation. It will prevent the accumulation of de- 
composing material in the stomach and will thus remove 
the auto-intoxication. It will in the same way alleviate 
the nausea and vomiting and the irritation from the 
latter to the tumor. The ulcerated surface of the tumor 
is likely to become clean as a result of this improved 
condition. 

The patient's life is naturally prolonged and his comfort 
is enormously increased by these changed conditions. 
Moreover, a patient may gain so much in strength that al- 
though the removal of the growth at the primary opera- 
tion would undoubtedly have resulted in death from 
shock, the increase in strength as a result of the improved 
nutrition and the absence of the other distressing con- 
ditions may make a secondary operation fairly, if not 
perfectly, safe. 

This leads us to the plan of operating for the relief of 
cancer of the pylorus in two stages in these greatly reduced 
patients. In order to perform the operation satisfactorily 
in two stages, however, it is of the greatest importance that 
the first operation be so performed that the intraabdominal 
condition will be favorable for performing the second 
operation at a later date. This presupposes that the 
first operation will not result in extensive adhesions, but 
simply in a union between the jejunum and the stomach 
at a point suflSciently distant from the malignant growth 
to make its complete excision possible at the second 
operation. If the first operation is followed by extensive 



428 CANCER OF THE STOMACH 

adhesions, then the second operation is liable to fail from 
two causes. In the first place the extensive loosening 
from adhesions is likely to produce a degree of shock so 
severe that the patient will succumb to the operation a 
short time after it has been performed. In the second 
place the traumatism causing these adhesions is likely to 
result in transplantation of the cancerous tissue, so that 
the adhesions will be filled with secondary carcinomatous 
growths. 

The location of the gastro-enterostomy opening in the 
stomach must be chosen so that practically the lowest 
portion of the stomach will contain this opening, pro- 
vided it is possible by doing this to remain far enough 
away from the original growth to make its excision possible 
or to prevent its encroaching upon this opening in cases 
which are so far advanced that complete removal is not 
possible at a later period. 

The operation of gastro-enterostomy is the same without 
regard to the other operation, consequently one descrip- 
tion will suffice as well for cases that are simply to have 
this operation for temporary relief, for those who are 
later to have the excision of the growth, and for those in 
whom the gastro-enterostony and the excision are to be 
performed at the same time. 

Posterior Gastro-enterostomy. — During the early period 
of stomach surgery we performed over 200 anterior gas- 
tro-enterostomies, always choosing the lowest point in the 
stomach in accordance with a suggestion made by W. J. 
Mayo 15 years ago. During the past years we have, how- 
ever, chosen the posterior gastro-enterostomy with a 
short loop of the jejunum in all cases in which this was not 
prevented by the location of the tumor, not that the results 
are any better, but because it has seemed to be the opera- 



SURGICAL TREATMENT OF CANCER OE THE STOMACH 429 

tion which impressed one as being more nearly correct from 
a mechanical standpoint. In cases in which it is likely 
that a secondary operation must be performed, the incision 
should be made through the median line from the ensif orm 
cartilage of the sternum to a point 3 cm. below the umbilicus. 
This will provide an abundance of space for bringing 




Fig. 85. — Anterior gastrojejunostomy made with gastric clamp for in- 
operable carcinoma of pyloric third of stomach with obstruction. A long 
loose loop of jejunum is carried over the greater omentum and colon. This 
is held in one half of the rubber covered gastric clamp, the other half of 
which is open to receive the portion of stomach held by the mouse-tooth 
clamps. The anastomosis is made just anterior to the greater curvature 
of the stomach and as close to the tumor as possible. Arrow indicates the 
direction of flow in the bowel. 

the stomach and intestine into view with the slightest 
amount of traumatism. 

The skin to each side of the abdominal incision is covered 
with towels and then the omentum and transverse colon 
are carried upward in order to expose the jejunum where it 
emerges from beneath the transverse mesocolon. It is 



430 



CONGER OF THE STOMACH 



well to have the mesocolon spread out so that one can fairly 
see its blood-vessels, in order that these will not be injured 
during the next step of the operation, which consists 
of the tearing of a hole in this structure sufficiently large 
to permit the union between the lower posterior wall of 
the stomach and the loop of the jejunum. The stomach 
wall is drawn through this opening and a point as far away 




Fig. 86. — Diagram to show the relations in a completed anterior 
gastro-enterostomy. 

as possible from the malignant growth is chosen. A pair 
of fine-toothed clamps is apphed to the lower margin of 
this space in close proximity to the gastro-epiploic vessels. 
A second pan- of forceps is appUed upward and a little to 
the right at a distance of 5 cm. from the first pair. A 
straight line between these two forceps indicates the location 
of the gastro-enterostomy opening to be made presently. 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 431 



This fold of stomach wall is now drawn through a pair of 
gastro-enterostomy forceps and the transverse colon and 
omentum are replaced in the abdominal cavity and held in 



-N^ 



^;-'o^-^'^* 




Fig. 87. — ^Steps in the making of posterior gastrojejunostomy by means 
of the gastric clamp. Portion of greater curvature nearest the pylorus 
brought through a tear in transverse mesocolon. Loop of jejunum in posi- 
tion for application of clamp. 

position by means of gauze pads saturated with warm 
normal salt solution. The loop of jejunum nearest the 
transverse mesocolon is then brought up into view and a 



432 



CANCER OF THE STOMACH 




4- 



Fig. 88. — Posterior gastrojejunostomj' for inoperable carcinoma of 
lesser curvature with obstruction of pylorus. Gastric clamp not used. The 
colon and omentum have been reflected upwards, an opening made into the 
transverse meso-colon, the greater curvature of the stomach brought through 
the opening and held with mouse-tooth clamps. The loop of jejunum, 5 cm. 
from its beginning, is attached with a continuous row of silk sutures to the 
stomach. Initial openings through both stomach and jejunum, 8 cm. long 
and extending to but not through the mucosae, have been made. 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 433 

pair of fine-toothed clamps is placed upon the wall of the 
intestine farthest away from its mesentery, 5 cm. from 
the mesentery of the transverse colon. A second pair of 
fine-toothed clamps is appUed in the same manner 6 cm. 
distally from this first pair, the distance being slightly 
greater than that between the two forceps on the stomach 
wall, because the longitudinal fibers of the jejunum will 
contract and bring these forceps near together. The fold 
of the jejunum is then drawn through the second blade of 
the gastro-enterostomy forceps in such a manner that the 




Fig. 89. — The gastric clamp applied, the posterior row of) Lembert 
sutures in place and the incisions through walls of stomach and jejunum 
made as close to Lembert sutures as possible and extending to the mucosae. 

forceps nearest the transverse mesocolon will be opposite 
the forceps farthest away from the gastro-epiploic vessels, 
and the other two forceps will also be in apposition. 

It is well now to make a straight incision through the 
peritoneum and muscle down to but not through the mucous 
membrane of the stomach wall between the two fine-toothed 
clamps which have been applied, and also between the two 
fine-toothed clamps on the wall of the jejunum. The 
incision will mark the location of the gastro-enterostomy 
opening. A fine, silk suture threaded in an ordinary cambric 
needle is ased to unite the serous surfaces. The thread 



434 



CANCER OF THE STOMACH 



should be about 75 cm. long and should be used double so 
as to prevent slipping and twisting. It is well to begin 
this suture at a point opposite the distal end of the gas- 
tro-enterostomy clamp and to make the sutures so that the 
serous surface will be in perfect coaptation, leaving a fair 
margin of 2 or 3 mm. between this row of sutures and the 
edge of the incision. This row of sutures is carried 3^ cm. 
beyond the end of the incision. The needle and thread are 
then placed to one side for future use. A fine, double 




Fig. 90. — Row of Connell catgut sutures being applied. 

chromicized catgut suture, the surface of which has been 
rendered smooth by rubbing with vaseline is next employed 
as a deep suture. This suture is begun at a point opposite 
to the conclusion of the serous suture in order that the knots 
of this suture may not be opposite the knots of the silk 
suture previously described. This suture is carried into 
the lumen of the small intestine, then across the edge of 
the incision taking a bite of about 1 mm. of the small in- 
testine and the stomach so that it includes all of the layers 
of both structures. The first suture is tied and then a 
continuous suture is applied with the stitches near enough 
to each other to absolutely prevent hemorrhage. This 
suture is carried to the distal end of both incisions and then 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 435 




Fig. 91. — A continuous row of fine chromicized catgut sutures extending 
through and through the mucosae of stomach and of jejunum. This catgut 
suture is begun at the opposite end from which the silk suture was started 
and the ends of both of these sutures are left long. 




Fig. 92. — Clamp removed and outer Lembert sutures in place. 



436 



CANCER OF THE STOMACH 



passed out through the wall of the stomach at a point 
opposite the distal end of the gastro-enterostomy clamps. 
The lumen of the stomach is now opened by means of 
scissors, care being taken to so cut the mucous membrane 
along the edge of the incision which has already been made, 
that all the layers of the stomach wall present a smooth 
surface. 



^3- 





X 








Fig. 93. — Showing the anterior Lembert silk stitch, which entirely sur- 
rounds the inner Connell row of sutures, and which is a continuation of the 
first row of silk sutures applied. 

It is important to be careful to sponge away any mucus 
which may be emptied upon the wound surface when the 
stomach is opened, but in doing this one should be careful not 
to loosen the mucous membrane from the overlying muscle 
and in no way to traumatize the delicate tissues composing 
the edge of this wound. The edge is then caught at three 
points with delicate fine-toothed clamps constructed for this 
purpose, so that these layers may be held in their proper 



SURGICAL TREATMENT OF CANXEE OF THE STOMACH 437 

position during the remaining steps of the operation. The 
same steps are then carried out in opening the jejunum, care 
being taken to place the fine-toothed clamps opposite those 
on the stomach wound edge. In case the mucous mem- 
brane overlying the posterior two rows of sutures does not fall 
into absolutely close apposition, it is best to place a fine 
silk, continuous suture uniting this mucous layer which, 
however, is not necessary in case there is perfect coaptation. 
The anterior opening is now closed by applying the suture 
introduced by C. H. Mayo. This is a continuation of the 
continuous catgut suture already applied. The suture is 
carried through all the lavers of the intestine from without 




Fig. 94. — Extra, stay, silk-stitches placed at each end of the anastomosis. 
Edges of opening in transverse mesocolon sutured to stomach 1 cm. from 
anastomosis, with interrupted silk sutures. 

inward, then from within outward, then across the space 
and then through the stomach wall in the same manner 
from without inward grasping all layers, then from within 
outward, then across the space to the jejunum. These 
steps are repeated until the entire anterior wound has been 
closed and the point is reached at which the catgut suture 
was begun. The end of the suture containing the needle 
is then tied to the portion of the catgut at the beginning of 
the suture which was left long for this ptu^pose. This 
suture inverts every portion of the stomach and intestinal 



438 



CANCER OF THE STOMACH 



wall so that the serous surfaces are in apposition. The 
needle containing the original suture is then taken up and a 
row of Lembert sutures is applied covering up the catgut 
suture Hne, which is continued at the point at which this 
suture was started and there tied to the ends which were 
left long for this purpose. At this point there is some 
danger of strain and in order to overcome this, two or three 




Fig. 95. — Diagram to show relations in a posterior gastro-jejunostomy. 
A, Greater curvature; B, pylorus; C, duodeno-jejunal flexure. 

interrupted silk sutures are applied, attaching the stomach 
wall to the jejunum. It is well to apply the same number 
of sutures at a point directly opposite this, because that 
point is also likely to require a little additional protection. 
At the time of tearing the opening in the transverse 
mesocolon from four to six Kocher hemostatic forceps are 
placed upon the edge of the opening in the transverse 
mesocolon at a uniform distance from each other. After 
the anastomosis betw^een the stomach and the jejunum 



SUEGICAL TREATMENT OF CANCER OF THE STOMACH 439 

has been completed, a fine silk suture is passed through the 
wall of the stomach down to but not through the mucous 
membrane or mesocolon from the suture line at points 
opposite to those indicated by the Kocher forceps. The 
edge of the tear in the transverse mesocolon is then brought 
down to the point at which this suture has been placed and 
the latter is tied about the small portion of tissue grasped 
by the Kocher forceps. This is repeated so that the 
territory in the transverse mesocolon is held in apposition 
with the posterior stomach- wall at six points 1 mm. from the 
line of suture. This will prevent a hernia through this 
opening and it will also prevent the tissues of this opening 
from causing an obstruction due to contraction following 
the operation, because union will take place between the 
raw surfaces of this opening and the posterior wall of the 
stomach immediately after these sutures have been tied. 
The stomach is then laid down in a normal position, the 
jejunum is replaced, the transverse colon and the omentum 
are placed over the jejunum and the abdominal wall is 
closed. 

Practically no unnecessary manipulation has been made 
during the entire operation so that the tissues have not 
been bruised and consequently it is not likely that adhesions 
will occur. In closing the abdominal wall great care is 
taken to evert the peritoneum in order that there may not 
be contact of raw surfaces from the line of incision with 
any of the intraabdominal structures. In this way a 
further precaution can be taken against the formation of 
peritoneal adhesions. 

It is well to perform gastric lavage immediately after 
the operation has been completed, using normal salt so- 
lution at a temperature of 105° F. in order to remove any 
mucus and blood which may have accumulated in the 



440 CANCER OF THE STOMACH 

cavity of the stomach. The warm water has a tendency 
to stimulate the patient and to overcome shock by heat, 
and by the absorption which will take place of a certain 
portion of the normal salt solution. The cleansing of the 
stomach from mucus and blood will prevent the occurrence 
of nausea and vomiting and the patient will be greatly 
benefited because of this. 

After Treatment. — In case the patient suffers from nausea 
or vomiting, or both, after the operation, gastric lavage is 
employed at once in order to again relieve the irrita- 
tion. The temperature of the lavage fluid should be 
the same as that mentioned above. Not more than 1 pint 
of water should be passed into the stomach at one time, 
and then this should be evacuated again in order not to 
overdistend the organ or place an unnecessary strain upon 
the sutures. Usually it is not necessary to perform lavage 
more than once or twice, but occasionally it may become 
necessary to repeat gastric lavage several times a day for 
a number of days. In the meantime the patient receives 
a nourishing enema every 3 hours. This consists of 1 
ounce of some concentrated predigested food dissolved in 
3 ounces of normal salt solution, and is introduced through 
a small catheter which is inserted into the rectum for a 
distance of not more than 2 or 3 inches. It is best to 
attach a funnel or the barrel of a good sized glass syringe 
to the catheter, and to permit the fluid to enter the rectum 
by its own weight. Several minutes should be consumed 
each time during the introduction of this fluid. 

In the meantime it is well for the patient to chew gum 
vigorously in order to produce saliva whose alkaline re- 
action has a beneficial effect upon the healing of the 
wound in the stomach. It will also prevent the patient 
from suffering from parotitis. The patient may take 



SUEGICAL TREATMENT OF CAXCER OF THE STOMACH 441 

small sips of very hot water from the first and increase the 
amount constantly from day to day. After the second 
day the patient may take small quantities of broth or 
water gruel everj' 2 or 3 hours. It is best to give him a 
half teaspoonful of milk of magnesia in a little water be- 
fore taking the gruel in order that the stomach may remain 
alkaline. 

After the first week small quantities of buttermilk and 
cream (3 parts of the former to 1 part of the latter) will be 
borne ver}^ well; also egg albumin in sweet orange juice. 
Later on a general liquid diet is permissible. It is best not 
to begin giving solid food for about 6 weeks. After the 
operation, if milk is given, it is well to add a teaspoonful of 
milk of magnesia or 3^^ ounce of hme water to 4 ounces of 
milk. If a patient is suffering from constipation, 2 ounces 
of castor oil may be given in the foam of beer or malt ex- 
tract am' time after the third day. Usually the milk of mag- 
nesia prevents constipation, however. 

EXCISION OF THE PYLORIC END OF THE STOMACH FOR THE 
REMOVAL OF CANCER 

The preparatory treatment is the same as that which has 
already been described. In planning the operation it is 
best to take a general survey not only of the extent of the 
growth, but also of the direction in which it has made the 
greatest amount of progress and the distribution of lymph 
nodes which show some degree of enlargement. If these 
enlarged lymph nodes extend behind the stomach into the 
space behind the duodenum so that they can be found 
below the transverse mesocolon, then their removal is of 
no use. In many of these cases the enlarged lymph nodes 
are inflammatory in appearance and may contain no 
mahgnant elements. They are due to the infection from 



442 CANCER OF THE STOMACH 

the ulcerated stomach, the infectious material having 
traveled farther than the malignant elements. In cases 
then in which the cancer is severely ulcerated, the pres- 
ence of enlarged lymph nodes, to points beyond which it 
is safe to remove these structures, does not absolutely con- 
traindicate the excision of the malignant growth. There 
is, however, always a strong probability that these glands 
contain elements of the cancer infection aside from the 
infection due to other microorganisms, and for this reason 
while it is important that a bad prognosis be made, under 
no condition should a hopeless prognosis be given. 

We have patients alive at the present time operated 
more than 8 years ago in whom many of the greatly enlarged 
glands could not be removed, but from the post-operative 
history it is plain that there were no malignant elements 
present in these enlarged glands, or that if they were present 
they have since been destroyed. The latter theory is 
quite as likely to be the correct one as the former, because 
there can be no doubt but that a large proportion of the 
malignant elements in every cancer which are carried away 
from the original growth are destroyed and do not succeed 
in causing secondary growths. By removing one of these 
lymph nodes and splitting it through the center, one can see 
the little white areas which are due to cancer with the 
naked eye, if the lymph nodes are at all severely infected 
with the malignant growth. So if there is any doubt, one 
can satisfy himself very readily. Moreover, the enlarge- 
ment due to the infiltration with cancerous tissue is much 
harder than the enlargement due to other infections. 
In cases in which the lymph nodes are hard and large along 
the coronary artery, we have never seen a case that has 
permanently recovered after gastrectomy, either partial 
or entire. But it is theoretically possible for these glands 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 443 

also to be enlarged in these cases without containing 
cancerous elements. 

The next important point is to determine the adhesions 
of the malignant growth. There may be inflammatory 
adhesions in connection with these growths in cases in 
which the cancer itself has not invaded the surrounding 
tissues, but these cases are not numerous, and as a rule if 
there are adhesions the excision is not likely to increase 
the life of the patient. The liver should be carefully ex- 
amined. If this organ contains secondary growths the 
removal of the primary cancer in the stomach will be of 
no benefit. 

In some cases, there is an involvement of the transverse 
colon and this may be quite as circumscribed as is the 
involvement of the pylorus. It is doubtful, however, 
whether any of these patients can be permanently cured 
by the removal of the pyloric end of the stomach together 
with the involved portion of the transverse colon, although 
theoretically this is possible. It is consequently proper 
that this condition should be considered from a surgical 
standpoint. After completing this examination which 
can be carried out without traumatizing any of the tissues, 
and without forcing any of the cancer infection into the 
lymphatics by manipulating the tissues with a proper 
degree of gentleness (especially if this examination is 
performed with the bare hands without gloves), the opera- 
tion should be selected which seems most suitable for 
the individual case. 

It is well to bear in mind that violence either during the 
manipulations necessary for making this examination, or 
during the operation is of great harm and no benefit to 
the patient. First, because it greatly increases the shock, 
and second, because it, undoubtedly, serves to disseminate 



444 CANCER OF THE STOMACH 

the cancerous infection. At this point, one must decide 
whether it is best to make a gastro-enterostomy, with the 
plan of reUeving the obstruction and the irritation of the 
diseased portion of the stomach, and improving the nutri- 
tion of the patient during the remainder of his Ufe, without 
interfering with the maUgnant growth itself, or whether it 
is best to perform a gastro-enterostomy as a prehminary 
operation with the plan of removing the pyloric end of the 
stomach at a later operation. The latter should be per- 
formed 2 or 3 weeks after the patient has recovered from 
the traumatism and shock of the preliminary operation 
and has gained a little because of his improved nutrition. 
Lastly, whether both operations, gastro-enterostomy and 
the excision of the pyloric end of the stomach, should be 
performed at the same time. 

It is in these cases in which experience and judgment are 
of the greatest value. Both of these elements will enable 
the surgeon to reduce the traumatism and the shock to a 
minimum, and consequently an experienced surgeon with 
good judgment can perform a more extensive operation 
than it would be safe for a less experienced surgeon to 
undertake. For example, in a case in which it would seem 
proper to remove the pyloric end of the stomach and the 
transverse colon together with the omentum, the operation 
might last an hour in the hands of a surgeon with great 
experience, while it would surel}^ last two or three times as 
long in the hands of a less experienced surgeon. The patient 
would consequently be exposed to traumatism two or three 
times as severe in the latter case. The exposure of the 
intraabdominal organs to the atmosphere during this 
time would greatly increase the shock. Many unnecessary 
manipulations would be made by the latter surgeon. In 
most instances, an inexperienced surgeon will manipulate 



SUEGICAL TREATMENT OF CANCER OF THE STOMACH 445 

tissues more violently, especially in periods during which 
some uncertainty arises as to the best method of accom- 
pUshing certain ends, and at times when he is trying to 
think. During all of this time the patient is under the 
influence of an anesthetic, the bad effects of which increase 
greatly with the length of time during which it is being 
administered. There can be no doubt but that many of 
the deaths following operations upon the stomach during 
the early period of stomach surgery were due to the fact 
that at that time no one had acquired any special skill 
and judgment in these operations; inasmuch as it was 
not possible to acquire this skill and judgment except 
through personal experience. The frequency with which 
these early cases died from pneumonia was, undoubtedly, 
due to unnecessary traumatism, to long-continued anes- 
thesia, and to long exposure of the diaphragm and the 
intraabdominal tissues to this unnecessary irritation and, 
of course, also to the fact that these patients were placed 
in bed in a horizontal position instead of having the upper 
end of the body elevated after the operation. 

Having then considered all of the conditions present, 
together with the elements connected with the individual 
patient, the further steps of the operation must be chosen. 
If it seems wise to make an excision of the pyloric end of 
the stomach, the question will arise as to whether it is 
best to perform a gastro-enterostomy first or whether it is 
better to make an excision and later make the gastro- 
enterostomy. Theoretically, both plans are equally good 
so that this may be left to the individual incUnation of 
the operator. If the gastro-enterostomy is performed first, 
the method which has ah-eady been described should be 
followed. If the excision of the pylorus is made first, there 
remains a choice between making a posterior gastro-enteros- 



446 CANCER OF THE STOMACH 

tomy or using a portion of the end of the stomach for the 
pui-pose of making this anastomosis. Both of these 
methods will be described later. 

Excision of the Pyloric End of the Stomach. — If one bears 
in mind the blood supply of the stomach, it is an easy matter 
to excise the pyloric end \\-ithout the loss of more than a 
few drams of blood. This is because the blood supply 
comes from f om* definite points : the coronar\^ arters- above to 
the left, the pjdoric artery above to the right, the gastro- 
epiploic arterj^ to the right and left below. If these four points 
are grasped between two paks of forceps at each point and cut 
and ligated immediately, "the principal blood supply of the 
portion to be removed is completely under control. Com- 
municating branches of blood-vessels are then controlled 
by the apphcation to the greater and lesser omenta of 
strong hemostatic forceps placed in pairs, the intervening 
tissue being cut and the distal portion being carefully 
Ugated. A sufficient amount of the lesser and greater 
omentimi is permitted to project beyond the hgation to 
make sUpping impossible. These vessels may be Ugated 
with catgut or fine silk. In this way, the portion of the 
stomach to be removed is entirely separated from its at- 
tachment from the greater and lesser omenta. It should 
include all of the tissues containing enlarged hmiph nodes, 
and in earl}^ cases it should extend up to the coronary 
arteries and in late cases bej^ond these arteries. On the 
side of the duodenum, the forceps should be applied to a 
point at least 3 cm. beyond the pyloric end of the malignant 
growth, but even in cases in which the growth does not 
approach the pylorus, the excision should still include 
this structm-e, because recurrence is not uncommon in the 
tissues belonging to the pylorus, while it almost never 
occm's in the tissues belonging to the duodenum. 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 447 

If there are inflammatory adhesions to the pancreas 
these are removed with great care in order to prevent injmy 
to the pancreatic tissues. If the tumor extends into the 
pancreas a portion of this organ may be removed, but inas- 
much as there have been no permanent recoveries in our 




Fig. 96. — Resection of two-fifths of tlie stomach for carcinoma at the 
lesser curvature with posterior gastro-jejunostomy (A) made as close as 
possible to the line of excision of the stomach. The anterior layer of the 
greater omentum has been divided close to the greater curvature and the 
pylorus has been doubly clamped and sectioned. Portion to be excised 
delimited by dotted lines. 

experience in any of these cases, it is doubtful whether the 
additional danger to the life of the patient caused by cutting 
into the pancreas will be compensated for by the proba- 
bility of the permanency of a cure. 

The entire portion of the stomach containing the cancer, 
together with at least 3 cm. of apparently normal tissue in 



448 



GANGER OF THE STOMACH 



the direction of the duodenum including the pylorus and 
at least 6 cm. toward the cardiac end of the stomach of 
apparently normal tissue is in this manner entirely loosened 
from all surrounding tissues. 

Especial attention should be directed toward the import- 
ance of preventing injury to the arteries supplying the 
transverse colon. In order that the latter viscus may not 
become necrotic as a result of interference with its blood 
supply, a strong stomach clamp is next applied to the 




X^ajje^naitt 



Fig. 97. — Excision of pylorus and antrum of stomach with end-to-side 
gastrojejunostomy for multiple malignant ulcers just proximal to the 
pylorus. Dotted line shows projected line of excision. Clamps in posi- 
tion for section of pjdorus. 



upper end of the duodenum. A second clamp is applied 
to the stomach at a point chosen for resection, then two other 
clamps are apphed to keep the contents of the portion to 
be removed from soiHng the peritoneal cavity when the 
portion is cut away. The intervening portion is then 
removed by cutting along the edge of the two clamps which 
were apphed first. 

The treatment of the two stumps must now be considered. 
If enough of the duodenal end is left to invert the cut end 
of this structure, this may be accomplished in various 
ways. A purse-string suture of silk or linen should be 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 449 



applied 1 cm. below the clamp and the crushed end should 
be inverted into the lumen of the duodenum while this 
purse-string suture is being tied. The surface which has 
been puckered in by the tying of this suture is then covered 
by the use of two rows of interrupted Lembert sutures of 
silk or hnen, care being taken not to leave any portion 
which is not covered with peritoneum. A gauze pad is 






Fig. 98. — Shows method of mverting stump of duodenum. 

then laid over this surface while the stump of the stomach 
is being disposed of. It seems to be a good practice to 
cauterize the portion of the stomach-wall grasped in the 
heavy clamps with the actual cautery. A strong, silk or 
linen suture or a fine, double, chromicized catgut suture is 
then used to fold in the portion of the stomach-wall which 
has been crushed into the lumen of the stomach by placing 
Lembert sutures, grasping the tissues on each side of the 

29 



450 CANCER OF THE STOMACH 

clamps successively and passing them over the clamps 
passing throughout the distance until the entu'e defect 
has been covered with these sutures. Then the clamps are 
loosened and the continuous sutures are tightened. This 
causes the crushed portion to fold into the lumen of the 
stomach, while the serous surfaces on the two sides come 
into accurate apposition. An additional stitch is added at 
the end of this line of sutures for the purpose of tying the 
free end upon which traction has been made to bring the 
surfaces in apposition. It is important to fold in the 
corners carefully with additional sutures, because these 
points represent the weak points in the closure. A fine silk 
Lembert suture is then placed over the entire line of these 
deep sutures to serve as a provision for safety in case some 
one of the stitches might not be absolute!}^ reHable. 

We now have the stomach entirely separated from the 
intestine and it becomes necessary to make a gastro-jejun- 
ostomy in order to reunite these structures. It is best to 
do this on the posterior surface of the remaining portion 
of the stomach at a suflB.cient distance from the sutm^e Hne 
just described, to insure a satisfactory blood supply so 
that there may be a rapid and perfect union between the 
stomach and the intestine. It is well to thoroughly irri- 
gate the portion of the stomach with normal salt solution 
at 105° F. before this last step is carried out. If there is 
any doubt about the safety of using the gastro-enterostomy 
clamps which were used in the gastro-enterostomy opera- 
tion described above, then the operation can be performed 
without clamps quite as conveniently as with them. A 
loop of the jejunum just below the transverse mesocolon 
is placed in the same relative position that w^as described in 
the gastro-enterostomy operation above, then the posterior 
serous suture is applied, uniting the jejunum to the pos- 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 451 

terior surface of the stomach for a distance of 5 cm. These 
sutures should grasp all the tissues down to the mucous 
membrane but not through this tissue. An incision 4 cm. 
long is then made parallel to and K cni. from this row of 
sutures extending down to the mucous membrane but not 
through it, both on the stomach and the small intestine. A 
fine, double, chromicized catgut thread in an ordinary 
sewing needle is then passed through all the layers of the 



^•*t^ '' - -^ -3Nfe^^>5t t "355^^^. 




Fig. 99. — -Showing the anterior Connell catgut stitcli. 

stomach and the intestine. The line of sutures is begun at 
the point at which the silk suture was ended and carried to 
the point at which the silk suture was begun. 

The mucous membrane is then cut, care being taken to 
first place moist gauze bands around the tissues so as to 
prevent soihng of the peritoneal cavity. Any substance 
which may come from the cavity of the intestine and the 
stomach is carefully sponged away and then the catgut 
suture is continued around the remaining portion of the 



452 



CANCER OF THE STOMACH 



opening. The Connell suture is employed for this purpose. 
It is appUed in the following manner. The suture is 
passed through the layers of the stomach wall from within 
outward, then carried over to the wall of the intestine, 
passed through all the layers from without inward, then 
from within outward and then it is carried across to the 
stomach again. These steps are repeated until the entire 




Fig. 100. — Showing method of closure of end of the stomach by a Connell 
line of catgut sutures which is then covered with a row of Lembert silk 

sutures. 

opening is closed, care being taken to remain within 2 mm. 
from the edge of the wound. As these sutures pass through 
all of the layers, there can be no hemorrhage from the 
edges of the incision. The catgut suture is then tied to the 
end which was left long at the beginning. It is well to oil 
the catgut suture with vaseline so as to have it perfectly 
smooth in order that it may not tear the tissues as it passes 
through them. 



SUEGICAL TREATMENT OF CANCER OF THE STOMACH 453 

The original silk suture is now taken up again and is 
carried on in the form of a Lembert suture around the 
anterior surface of the anastomosis to the point of its 
beginning where it is tied to the end which was left at the 
beginning of this suture. The edges of the opening in the 
transverse mesocolon are now sutm'ed to the stump of the 




^ 










, I /j f I'll 



^^,^ 







'/ ' y^fi'y] 



\ "A.' 



) h 



Fig. 101. — The greater omentum sutured with intermpted silk stitches 
to the stomach and lesser omentum. Dotted lines indicate cut end of 
stomach and the anastomosis. 

stomach and the entire surface left bare hy the removal of 
the pyloric end of the stomach is covered by uniting the 
greater and lesser omenta, or by carr^dng the stump of the 
duodenum up to the stump of the stomach and uniting 
these by means of fine silk sutures. At all events, every 
portion of the raw surface must be carefully covered with 
peritoneum. 



454 CANCER OF THE STOMACH 

In some cases the amount of available tissue for closing 
the duodenum is not so plentiful as might be desired to 
obtain a closure in whose permanency one can have 
complete confidence. In such cases it is best to provide 
for the possible occurrence of a leakage some days after 
the operation. By carrying one or two cigarette drains down 
to the closed end of the duodenum, passing these out of the 
upper end from the abdominal wound one can provide for 
this comphcation. These cigarette drains are constructed 
by roUing a pad of gauze within a piece of rubber tissue so 
that the rubber tissue overlaps the gauze. The end of the 
gauze should project a httle from each end of the rubber 
tissue. It may be well to add to this a glass drainage tube 
which will serve to keep the abdominal wound sufficiently 
open to permit any accumulations to pass out of the 
wound. 

In case the cancer involves the pylorus so that it will 
become necessary to remove 2 or 3 cm. or more of the 
upper end of the duodenum, it is often better to utihze a 
rubber drainage tube 30 cm. long and 1 cm. in diameter, 
and to draw over this a second rubber drainage tube just 
large enough to prevent the inner drainage tube from 
slipping through the outer one unless quite a little force 
is appUed. The outer drainage tube should have the length 
of 15 cm. so that the inner tube projects bej'ond it at each 
end about 7>9 cm. At one end the inner tube should have 
a number of small perforations; this end should then be 
inserted into the duodenum for a distance of 15 cm. and 
the free end of the duodenum should be closed by means of 
several purse-string sutures about this drainage tube so as 
to make a complete closure and so as to guard against 
leakage. The serous surface should be inverted and after 
three or four purse-string sutin*es have been applied, the 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 455 

edge of the duodenum should be sutured by means of from 
four to six fine, silk sutures to the outer rubber tube. Then 
this should be carried out of the upper angle to the abdominal 
wound or through a small stab wound at a point directly 
in front of the end of the duodenum. It is possible for bile 
and duodenal secretion to escape through this tube and, on 
the other hand, one may introduce into the duodenum 
through this tube a quantity of normal salt solution by the 
drop method, to which some form of concentrated food has 
been added. Adhesions will take place between the end 
of the duodenum and the abdominal wall, and after 1 or 2 
weeks the sutures holding the rubber tubing in place will cut 
through the edge of the duodenum by causing pressure- 
necrosis and then the walls of the duodenum will close 
spontaneously. Occasionally, considerable quantities of 
bile and pancreatic fluid will escape through the wound and 
this may cause excoriation of the skin. This, however, can 
be readily corrected by giving the patient the white of one 
egg every 2 hours night and day for several days and 
by covering the raw surface freely with white vaseline or 
with castor oil. The ingestion of egg albumin seems to 
prevent the formation of this irritating secretion. In 
patients who are very much depressed as a result of their 
disease and the operation, it is wise to treat the end of the 
duodenum in this way, because this enables one to supply 
the necessary amount of nourishment almost immediately 
after the operation without in any way interfering with the 
healing of the gastroenterostomy wound. Usually it is 
better to pass this duodenal rubber tube out through a 
separate opening and to suture the stump of the duodenum 
by means of a few fine, silk sutures; thus one can provide an 
additional safeguard against soiling of the peritoneal 
cavity with fluid coming from the duodenum. The closure 



456 CANCER OF THE STOMACH 

of the end of the duodenum about the rubber tubing should, 
however, be so complete that leakage cannot occur for a 
considerable period of time. By that time adhesions will 
have formed which will protect the general peritoneal 
cavity. It is, of course, of the greatest possible importance 
thi'oughout this operation that at no point will there be 
tension upon any of the tissues because all of the tissues 
are so dehcate that the sutures may not hold if subjected 
to tension. By carefully bearing in mind this additional 
principle, one can invariably provide some means of avoiding 
such difficulty. Of course, the smaller the amount of 
tissue which it is necessary to remove in the individual 
case, the less the danger from tension upon the sutures, but 
even in cases in which a very large amount of the stomach 
has been removed, it is possible to guard against this 
difficulty. Under no condition should any suspicious 
tissue be left in order to prevent tension. One can always 
improvise some other means of accomphshing this end. 

COMPLETE GASTRECTOMY 

From a technical standpoint, a complete gastrectomy is 
but sHghtly more difficult than is the operation which has 
just been described. From a practical standpoint, on the 
other hand, the operation may be looked upon as almost, if 
not entirely useless, not because of the difficulty of the 
operation itseK, but because of the fact that in cases in 
which the operation can be performed with permanent 
success, it is not required, because success can be obtained 
by means of the simpler operation which has just been 
described. On the other hand, in cases in which complete 
gastrectomy is the only operation which gives any possi- 
bihty of permanent success, there are practically always 
comphcations which will make it either impossible for the 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 457 

patient to recover permanently from the operation or 
certain that recurrence will cause the death of the patient 
in a relatively short time. 

There are certain advertising advantages in performing a 
complete gastrectomy, occasionally, because no matter 
how carefully one guards the secret of having performed 
such an operation, it is certain to be carried from mouth 
to mouth until the surgeon who has performed it gains a 
certain degree of notoriety for unusual surgical skill. 
But so far as the patient is concerned, it is doubtful whether 
in any case in which the operation was necessarj^, he had 
secured any real benefit. 

Operative Technique for Gastrectomy. — The technique 
described in the previous operation will also serve for the 
operation of complete gastrectomy with the exception 
that the entire stomach is laid bare instead of only its 
pyloric end. This is done by applying artery forceps 
behind the entire greater and lesser curv^ature to a point 
within 3 or 4 cm. of the esophagus. Stomach clamps are 
then apphed as in the previous operation, with the excep- 
tion, however, that the clamp nearest the esophagus must be 
apphed in such a direction that the stump which is left 
above it is suflacient to permit its attachment to a loop of 
the jejunum. The esophagus and small remnant of the 
stomach are then thoroughlj^ irrigated with normal salt 
solution through a stomach tube which has previously 
been inserted into the stomach and has been withdrawn 
within a point just above the apphcation of the upper 
clamp. All of the Uquid must be siphoned out carefully so 
that none of it remains in the esophagus or the httle rem- 
nant of stomach and so causes soiUng. The portion of the 
stomach between the two clamps is then removed in the 
manner described in the pre\dous operation. The end of 



458 CANCER OF THE STOMACH 

the duodenum is treated after the method which has just 
been described by inserting the double drainage tube so 
that there can be no pressure of fluid from the duodenum 
upon the jejunum. 

A loop of the jejunum, sufficiently long to be carried up 
to the stump of the stomach without tension, is passed 
through an opening in the transverse mesocolon, or it may 
be passed in front of the transverse colon. A longitudinal 
incision is made in this loop at its upper end. This in- 
cision should be 5 cm. long and the edge of the opening 
carefully sutured to the stump of the remnant of the 
stomach, one suture grasping all of the layers with the 
exception of the peritoneum, and a second row of Lembert 
sutures grasping all the layers down to, but not through, 
the mucous membrane. It is absolutely necessary that 
there should be no tension. The edge of the opening in 
the transverse mesocolon is then carefully sutm^ed about 
the duodenum. The entire defect in the peritoneum caused 
by the removal of the stomach must be covered by uniting 
the edges of the greater and lesser omenta. 

In these cases it is well to place a glass drainage tube and 
one or two cigarette drains down to the space from which 
the stomach has been removed, in order that any hquid 
which may accumulate will be carried away from the 
peritoneal cavity. In these cases it is best to pass the 
rubber drainage tube entering the duodenum through a 
separate stab-wound, in order that the distance between 
the end of the duodenum and the abdominal wall may 
be as small as possible so that the peritoneum about the 
stab-wound may be sutured to the duodenum. 

If there is any doubt about the safety of the suture line 
between the stump of the stomach and the jejunum, this 
may be strengthened by suturing over it a piece of omentum 



SUEGICAL TREATMENT OF CANCER OF THE STOMACH 459 

or a strip of fascia lata 3 era. wide and long enough to 
encircle the gastro-enterostomy without causing any 
compression. 

The after-treatment in these cases is the same as in the 
case just described. A small, soft-rubber tube may be 
carried through one nostril and down through the esophagus 
and the remnant of the stomach into the jejunum so that 
the end extends for a distance of 15 to 30 cm. into the 
jejunum. Through this tube small quantities of pre- 
digested food may be introduced into the intestine every 
2 hours. Water may also be given through this tube. 
It is well to administer liquid nourishment by rectum in 
the form of nourishing enemata every 3 hours in order 
to support the patient as well as possible; normal salt solu- 
tion may be given by the drop method. 

In case the flow of bile and pancreatic fluid does not be- 
come estabhshed normally through the loop of the jejunum 
which has been carried up to the stump of the stomach, it 
may become necessary later on to plan an entero-enter- 
ostomy between the two branches of the jejunum. This 
can best be done at a point from 3 to 5 cm. beyond the 
transverse mesocolon. This can be accompUshed by the 
application of a Murphy button or by performing an 
anastomosis 3 cm. in length after the method described for 
performing anastomosis between the stomach and the 
jejunum. 

GASTRO-ENTEROSTOMY 'FOLLOWING PARTIAL GASTRECTOMY 

BY UNITING THE JEJUNUM DIRECTLY TO THE LOWER END 

OF THE STOMACH WOUND 

Some surgeons with great experience in intestinal surgery 
prefer to make the partial excision of the stomach first 
and then to make the anastomosis between the remaining 
portion of the stomach and the jejunum directly to the 



460 QANCER OF THE STOMACH 

lower end of the wound remaining in the stomach. In 
performing this operation there is great danger of leakage 
at the point at which the jejunum is united with the suture 
line of the stomach. It is necessary to bring the opening 
in the stomach down to the opening in the jejunum, but 
if this leakage is guarded against by the proper applica- 
tion of sutures at this point, the total amount of trau- 
matism required by the operation is considerably less 
than if the operation is performed which has already been 
described. But it must be borne in mind that it requires a 
much greater amount of technical skill to execute this 
operation than the one which has been described. 

Technique of Operation. — The technique of the opera- 
tion is exactly the same as in the previous operation. 
After the clamps have been applied the remnant of the 
stomach is carefully irrigated and all of the liquid is 
siphoned out. Then a pad is placed behind the stomach; 
the portion of the stomach to be sacrificed is cut away 
and fine-toothed clamps are applied to the edge of the 
remnant of the stomach grasping all of its layers. If 
there is a bleeding point, this is caught and a fine, silk 
suture is passed through the wall of the stomach to com- 
press the bleeding vessel. The cavity of the remaining 
portion of the stomach is carefully sponged until it is 
perfectly dry and then a suture is applied uniting both 
wound edges together sufficiently far from the greater 
curvature of the stomach to determine the size of the 
opening which must remain for the purpose of making an 
anastomosis with the opening in the jejunum. It is im- 
portant to determine this at this stage, because, otherwise, 
almost invariably the opening is left too small. All of the 
layers, with thie exception of the peritoneal surface, are 
united by means of a continuous suture, or in case the 



STEGICAL TREATMENT OF CANCER OF THE STOMACH 461 



remnant of the stomach is of considerable size, a ConneU 
suture may be used for this purpose. This passes from 
the mucous membrane out through aU of the layers 2 
mm. from the edge of the wound, then across to the other 
side and through all of the layers from without inward. 
The sutm'e is then tied witliin the stomach waU, then it 
is carried out through one edge and across the wound, then 
from without inward and from witliin outward on the 








Fig. 102. — The duodenum lias been inverted and the lower portion of 
the stomach reflected upward. A loop of jejunum has been brought through 
the opening iu the trans^-erse mesocolon and point {A) sutured to the 
stomach. 

other side, then across to the other side, then from without 
inward and from within outward and across again and 
so on until the entire wound has been closed, especial care 
being taken to fold in the angle of the upper end. A. row 
of Lembert sutures is now placed over this suture line so 
that the peritoneum is once more united. The opening 
at the lower end of the stomach wound is then sutured 
into a wound of exactly the same size made in the jejunum 



462 



CANCER OF THE STOMACH 



at the point just below the transverse mesocolon tnrough 
which an opening has been torn. 

The union between this opening in the stomach and that 
in the jejunum is accomplished by two rows of sutures, the 
first grasping all of the layers with the exception of the 
peritoneum, the latter consisting of a row of Lembert 
sutures of fine silk completely covering the first row of 
sutures. From three to six additional sutures are now 




JejTziunB. 



Fig. 103. — Showing method of beginning anastomosis of end of stomach to 

side of jejunum. 

placed at the point at which the jejunum is opposite the 
suture line which is closed by the upper end of the stomach 
wound. It is important that these sutures be applied with 
great accuracy in order that there may be no leakage at 
this point. 

The opening in the transverse mesocolon is then sutured 
to the wall of the stomach 7 mm. from the gastro-enterostomy 
opening by means of six or eight fine silk sutures. The ab- 



SURGICAL TREATMENT OF CANCER OE THE STOMACH 463 

dominal wall is then closed. The jejunum is treated as 
in the previous operations. 

If this operation is performed with great skill, it has 
the advantage of placing the gastro-enterostomy opening 
at the lowest point of the stomach and of providing a 
mechanical arrangement which is ideal. Were it not for 




Fig. 104. — -The Connell line of suture being applied. A row of Lembert 
silk sutures later surrounds this. 

the great likelihood of faulty union at the one point, this 
operation would undoubtedly be the operation of choice. 



POST-OPERATIVE TREATMENT 

It is important to carry out a definite plan of post- 
operative treatment in these cases in order to prevent 
avoidable deaths. During the early times of gastric 
surgery, there were many deaths from pneumonia and 
quite a number from acute dilatation of the stomach. 
The deaths from pneumonia were due to a great extent to 
unnecessary traumatism during the operation, to infec- 



464 CANCER OF THE STOMACH 

tion during operation and to anesthesia which was pro- 
longed unnecessarily because of the incompetency and 
inexperience of the surgeon and to lack of judgment. 
These causes of pneumonia have now, fortunately, been 
eliminated because surgeons can now obtain skill by assist- 
ing those who have a vast experience. 

Another cause of pneumonia came from aspiration of 
vomitus. This is ehminated now by performing gastric 
lavage at the close of the operation and again whenever 
there is any sign of nausea. Another cause consisted in 
the tendency to hypostatic congestion of the lungs by plac- 
ing the patient in the horizontal recumbent position directly 
after the operation while the patient was still deeply 
narcotized, due to the fact that the anesthetic was con- 
tinued until the close of the operation. By permitting the 
patient to awaken thoroughly by the time the last stitches 
are inserted this cause is also eliminated, and by elevating 
the head of the bed 18 inches and placing pillows under 
the patient's head and shoulders when he returns to bed 
and permitting him to move about, the tendency to hypo- 
static congestion of the lungs is eliminated. As a result 
of these changes the percentage of cases of pneumonia 
following operations upon the stomach has been enor- 
mously reduced so that we now practically never see a case 
of this kind. 

Acute Post -operative Dilatation of the Stomach. — 
From some mechanical condition which happens occasion- 
ally after operations upon the stomach and gall-bladder, the 
patient suffers from an acute, very rapid dilatation of 
the stomach which may result in so marked a displace- 
ment of the heart that it may prove fatal. It may also 
cause a rupture of the suture hne between the stomach 
and the intestine. Since we have systematically practised 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 465 

gastric lavage at the close of these operations, we have not 
encountered this compUcation. It is, however, important 
to bear the possibihty of this condition in mind and to 
introduce a stomach tube immediately in case this com- 
pUcation occurs. This should be followed by careful 
gastric lavage with normal salt solution at 105° F. This 
should be repeated in case any SAToiptoms recur. 

The condition can be recognized by the shortness of 
breath, by the sudden increase in pulse rate and by the 
complaint of the patient that he is being smothered. Phys- 
ical examination will show a marked displacement of the 
left lung and heart. It is important to act quickly in these 
cases because death sometimes occurs within an hour of 
the beginning of the dilatation. It is consequently wise 
to instruct the nurse to perform lavage whenever there is 
any doubt. Small sips of water may be given to these 
patients almost immediately after the operation. Patients 
receive much comfort from the chewing of gum, because 
the saliva which they are able to swallow keeps the stomach 
in an alkahne condition and overcomes the severe thirst 
which is further controlled by the free administration of 
water by rectum by the drop method. It is quite as weU 
to use water as normal salt solution by rectum in these 
cases. The injection of water should be continued very 
slowly, but ver^^ constantly so long as it is being absorbed, 
then this should be interrupted for 2 full hours in order 
to give the intestine an opportunity to secure rest. It is 
best to measure the amount the patient can take com- 
fortably in this manner in order that a quantity slightly 
less than this may be given during the next proctoclysis. 
Thus this may be interrupted before the patient's hmit 
has been reached. For instance, if a patient can take 
1,000 cc. of water by rectum before feeUng any dis- 



466 CANCER or the stomach 

comfort during the first administration, only 900 cc. 
or about 30 ounces should be given during the second 
administration, always with an interval of 2 hours. It 
will be found that the saliva will flow much more copiously 
during the chewing of the gum after the patient has had 
one or more of these proctoclyses. 

Aside from increasing the comfort of the patient, the 
chewing of gum prevents the infection of the parotid gland. 
We have had no parotiditis in any case, in which we have 
directed the patient to chew gum directly after gastric 
operations, while formerly this condition occurred fre- 
quently enough to be very annoying. 

Occasionally these patients suffer from acidity of the 
stomach and eructations of sour substance. Notwith- 
standing the fact that previous to the operation there may 
have been no free hydrochloric acid present. In these 
cases it is well to give from 15 to 30 drops of milk of mag- 
nesia or 10 to 20 grains of bicarbonate of soda in 2 to 4 
ounces of water in sips every hour, so that it takes the 
patient about half an hour to take this solution and half 
an hour to rest from it. 

On the third day an ounce or two of broth or water gruel 
may be given by naouth every 2 hours. This may be con- 
tinued for 3 or 4 days, when an ounce or two of good 
buttermilk with an ounce or two of cream may be given 
once or twice during the day. The white of an egg in 2 
to 4 ounces of water may then be given and later a sufficient 
amount of orange juice may be added to this to disguise the 
egg. In each instance it is weU to give the bicarbonate of 
soda or the milk of magnesia immediately before giving 
these articles of food. After 10 days, milk with milk of 
magnesia may be given regularly and the patient may chew 
beef or mutton and swallow the juice but not the pulp. 



SUEGICAL TEEATMENT OF CANCER OF THE STOMACH 467 

It is wise to caution these patients after they leave the 
hospital never to eat any raw fruits or vegetables (espe- 
cially not those that are likely to be covered with manure) , 
like lettuce, radishes, celery, raw onion, etc. It is also well 
to give these patients a definite diet list which they may 
resort to any time when their new digestive apparatus 
refuses to digest the food contained in the regular diet list 
which should also be supphed to these patients. Thus 
it is absolutely necessary to tyrannize over this class of 
patients in order to keep them in good condition after 
these operations, because as a rule these patients are pri- 
marily erratic eaters and many of them pride themselves 
upon being able to eat fooUsh things after such operations. 
We have had a number of patients who have suffered 
severely from gastric disturbances as the result of some 
foohsh act of this kind. While many others have been 
able to digest their food normally for many years by 
adhering to a reasonable diet similar to the following: 

Diet List for Use when Normal. — Drink no water 
and no other Uquid except hot milk during meals, not for 1 
hour before or after meals. 

Drink an abundance of good water between meals. 

Drink no tea or coffee, and nothing containing alcohol. 

Eat very slowly and chew all your food for a long time. 

Eat nothing very sweet or very sour. 

Eat nothing that has been fried. 

Eat no hot bread, cake, candy, canned goods, pickles, 
pancakes, puddings, pie, pastry or pork; no raw vegetables 
or raw fruits, unless the latter are perfectly ripe and not sour, 
no bananas or raw apples, no fried onions cabbage, turnips, 
sweet potatoes, baked beans, corned beef, and no nuts. 

You may eat broiled or stewed beef and mutton, breast 
of chicken, fish, cooked vegetables, cooked ripe fruits, bread, 



468 CANCER OF THE STOMACH 

butter, toast, well cooked cereals, rice, milk or cream soups 
and vegetable soups; also soft-boiled or poached eggs. 

You may drink milk, cream and buttermilk. 

In case the milk of magnesia used in connection with 
the milk in the following diet should act too freeh' upon 
the bowels, lime water may be substituted for it, but it is 
best to add one or the other to the milk in order to prevent 
such from coagulating in the stomach and in order to 
alkahnize the milk. 

Patients should be instructed to use the following diet 
the moment they feel any distress and not to wait until the 
digestive apparatus is badly out of order before giving it 
the rest which this diet affords. 

Diet 2. — Chew all food for a long time. Eat nothing 
sweet or sour. 

Take }i pint of hot milk with 1 or 2 teaspoonfuls of 
milk of magnesia or 2 to 4 tablespoonfuls of lime water at 
6, 8, 10, 12, 2, 4, 6 and 8. Later you may take the other 
articles of food in this list at 8, 12 and 6. 

First Week. — Four pints of hot milk daih' with milk of 
magnesia or hme water; if this is not sufficient to keep 
your strength you may add from 1 to 4 raw eggs. 

Second Week. — Same as first, and 2 to 4 raw or soft-boiled 
eggs in addition. 

Third Week. — Same as second, and 2 to 6 pieces of very 
dry toast in addition. 

Fourth Week. — Same as third, and all kinds of milk or 
cream soup in addition. 

Fifth Week. — Same as fourth, and all kinds of mush or 
boiled rice in addition. 

Sixth Week. — Same as fifth, and broiled, stewed or boiled 
beef or mutton in addition, chew and swallow the juice, 
but not the fiber. 



SURGICAL TREATMENT OF CANCER OF THE STOMACH 469 

Later add cooked vegetables and cooked fruits, adding 
only one kind each week. 

Later you may swallow the beef or the mutton. 

Even after recovering fully, do not eat pastry, pie, pan- 
cakes, pickles, pork, or puddings. No cake, candy or 
canned goods. No raw vegetables or raw fruits, unless 
the latter are perfectly ripe and not sour. 

EXCISION OF THE COLON IN CASE OF CIRCUMSCRIBED INVOLVE- 
MENT OF THE TRANSVERSE COLON COMPLICATING 
CANCER OF THE STOMACH 

Very rarely a cancer of the stomach located in the lowest 
portion of the greater curvature may become adherent to 
the transverse colon during the early period of its develop- 
ment and this condition may lead to an abdominal section 
because of the obstruction of the passage of fecal material 
through the transverse colon together with the presence of 
digestive disturbance. These cases are extremely rare but 
they occur frequently enough to warrant a description of 
the operation which will be required in this case. 

The operation which one would naturally wish to perform 
would consist in the excision of the transverse colon and 
the union by means of the suturing of the two ends. This, 
however, is not a satisfactory operation because the pos- 
terior surface of the transverse colon is not covered with the 
peritoneum and a leakage may occur, moreover there is 
likely to be an obstruction to the passage of gas and feces 
at this point of union, and this added to the other conditions 
is likely to cause trouble. It is consequently far better 
to remove the cecum, the ascending colon and the trans- 
verse colon after the manner practised in Lane's operation; 
to implant the end of the ileum into the sigmoid flexure 
and to close the free end of the transverse colon at the point 
at which the section was made. 



470 CANCER OF THE STOMACH 

This operation at once removes the cancerous portion 
of the transverse colon and the portion of the omentum 
containing the infected lymph nodes and leaves a con- 
venient condition for performing a posterior gastro-enteros- 
tomy. The excision of the colon should be made before 
the operation upon the stomach is begun. The important 
points in this operation consist, first, in securing perfect 
hemostasis. This can be accomphshed by laying bare the 
peritoneum covering the inner side of the cecum and grasp- 
ing the blood-vessels supplying the cecum, and the hepatic 
flexure of the colon and the ascending colon. The ileum 
is then clamped between two powerful forceps from 5 to 
10 cm. from the cecum at a point at which it will be most 
convenient to implant the proximal end of the ileum into 
the sigmoid flexure. The distal end is then removed 
together with the cecum and the ascending colon. 

In the region of the hepatic flexure of the colon it is 
important to guard against injuring the duodenum, which 
often projects to the right toward the right kidney pouch 
and unless this fact is borne in mind it is an easy matter to 
injure this portion of the duodenum. When the hepatic 
flexure of the colon has been reached it is best to abandon 
the operation for a time, packing the space made bare 
with gauze pads and to implant the proximal end of the 
ileum into the sigmoid flexure, care being taken to close 
the space behind these structures to prevent a future hernia. 
Then the operation is again resumed in the region of the 
hepatic flexure of the colon, the duodenum is laid bare, the 
four arteries mentioned in gastrectomy are clamped and 
the pyloric end of the stomach is removed together with 
the transverse colon, care being taken to grasp the middle 
colic artery with two pairs of forceps and to cut it before 
traction is made upon it. 



SUEGICAL TREATMENT OF CAXCER OF THE STOMACH 471 

The colon is then clamped between two strong clamps at 
least 7 cm. beyond the tumor and the entire structure up 
to that point together with the pyloric end of the stomach 
and the omentum are removed together with all of the 
lymph nodes contained in this region. The duodenum and 
the stomach are then treated as in the operations described 
above. The gastro-jejunostomy is also performed after 
the method already described and the entire raw surface 
which has been produced by the removal of the portion of 
the ileum, the cecum, the ascending colon, the transverse 
colon and the pyloric end of the stomach are carefully 
covered with peritoneum and the remnant of omentum is 
sutured over this surface. The operation is completed 
after the method described in gastrectom3\ 

By carrying out this operation systematically according 
to the method just described, being careful throughout the 
operation to keep the small intestine packed away from 
the field of operation and by avoiding all unnecessary 
manipulation of the intraabdominal organs, it is possible to 
complete this operation in a relatively short length of time 
and to reduce the shock to a minimum. Xormal salt 
solution and concentrated predigested food may be given 
by rectum immediately after the operation and it is wise 
to give from 1,000 to 1,500 cc. of normal salt solution 
under the breasts directh' after the operation and to repeat 
this twice a day for 2 or 3 days until the patient can take 
fluid by mouth. 

The after-treatment is the same as that which has already 
been described. 



CHAPTER XII 
NON-SURGICAL TREATMENT 

Prophylaxis. — All patients with obstinate dyspepsia 
should be advised to submit to laparotomy at the hands of 
a competent surgeon. While experience has shown that 
there is no '^ cancer age," it is a proven fact that individuals 
above the age of 35 years are more prone to malignant dis- 
ease than are those below such age. Abdominal explora- 
tion is a safe procedure with modern operative aids. Its 
teachings are of such worth that in suspected gastric cancer 
or atypical dyspepsia, the procedure should be resorted to 
more frequently than it now is. It is a curious condition of 
the professional mind which permits argument against lap- 
arotomy, where even expert non-surgical treatment has 
failed. Patients in America are rarely greatly alarmed 
when competent authorities recommend laparotomy as a 
solution of their disturbances of digestion. On the con- 
trary, many individuals are so weary of ineffectual attempts 
to aid them by types of therapy ranging from crystal-gazing 
to almost permanent residence in hospitals or sanatoria, 
that they eagerly look forward to surgical intervention as a 
way out of their dyspeptic dilemmas. 

Individuals in middle life, who have unaccountably 
developed faulty digestion, should be carefully examined 
for anomalies of the circulatory system, the kidneys, the 
blood and the blood-forming organs or the central nervous 
system. If disease is not located in such organs, and 
infective processes can be excluded, the patient should be 

472 



NON-SURGICAL TREATMENT 473 

told the possibilities of a malignant termination of his 
ailment and advised to consult a reputable surgeon. 

Chronic, recurrent, or frequently bleeding ulcers, should 
be treated as potential or actual cancers and removed when 
possible. 

In all types of cases, diagnosis should not be withheld until 
everybody recognizes cancer but the guileless patient or 
his optimistic physician, '\^^len the patient can answer 
''yes" to all the signs and symptoms of gastric cancer set 
down in the text-books, he would do well to get his affairs 
in order, for no form of treatment is then of permanent 
avail. While scientifically conducted chnical investiga- 
tions of gastric ailments have returned facts of much diag- 
nostic worth, the doctrine that the physicians must wait 
until analysis of the gastric extracts from dyspeptics shows 
absent free hydrochloric acid before they call a disease 
cancer, has sent more people to the grave than have ab- 
dominal explorations, however poorly such may have been 
performed. When made by trained surgeons, abdominal 
section is attended by a mortality of about 3^^ of 1 per cent. 
There is a mortality of 100 per cent, in the non-surgical 
treatment of gastric cancer. 

The first aim of prophylaxis then, should be the eradica- 
tion from the human family of all potential or actual malig- 
nancy by surgical means. So long as we are in ignorance 
regarding the etiology of all cancer, and inasmuch as the 
question of its parasitic or its constitutional origin is a 
debatable one, it behooves medical men everywhere to 
urge early radical treatment of the disease. 

In view of the fact that it has been shown that cancer is 
not infrequently more prevalent in certain districts, houses 
or famihes, it would seem proper to systematically study 
such localities, dwellings or families with a hope of ascer- 



474 CANCER OF THE STOMACH 

taining etiologic information or to segregate affected in- 
dividuals as a preventive measure. Intermarriage of 
cancerous folk, especially members of cancer families, 
should be interdicted. While no one can say positively that 
hereditary transmission of cancer takes place, it is not pos- 
sible to state that certain tendencies toward malignancy 
are not transmitted from one generation to another. 

Registration of cancer cases should be required of physi- 
cians by both local, state and federal authorities. Such 
reports should fully cover the etiologic, clinical and patho- 
logic features connected with such patients. 

General Measures. — There are really three main groups 
of patients for which medical treatment is indicated. These 
comprise patients in whom external evidences of metastases 
(to lymph glands, liver, peritoneum) contraindicate sur- 
gery; those on whom operations have been performed and 
instances where surgical measures are indicated, but 
complications (hemorrhage, vomiting, exhaustion) prevent 
immediate operation. 

It is not necessary that patients know how seriously 
they are affected. Some individuals demand a statement 
of their exact condition. One should use tact in imparting 
such knowledge. To a member of the family, a blood- 
relative, or a trusted friend, the ailment and its conse- 
quences should be fully described. While no hope of non- 
surgical cure of cases of gastric cancer exists, much may 
be done to make these unfortunates comfortable. 

Care of the Teeth and Oral Cavity. — As we have pre- 
viously pointed out, many patients with malignant disease 
of the stomach have imperfect or dirty teeth. While no 
one has absolutely demonstrated the deleterious effects 
upon injured gastric mucosse of swallowed, atypic mouth 
enzymes, amino-acids {e.g., tryptophan), pus, bits of teeth, 



NON-SURGICAL TREATMENT 475 

bacteria or protozoa, it would appear safe to admit that 
such substances throw an excessive amount of unnecessary 
labor upon the body's defensive mechanism. Decayed 
teeth should be extracted and imperfect teeth repaired. 
Cancer patients usually endure extraction of teeth well. 
If properly carried out this operation requires no more 
anesthetic than a few whiffs of ether. In many instances, 
the work can be done under local anesthesia. Follow- 
ing the extraction of the teeth, hemorrhage is generally 
controlled by having the patient bite upon a firm 
gauze roll. If this does not suffice, bits of ice may be 
allowed to dissolve in the mouth, or the gums may be 
sprayed with weak adrenalin solution. Hypodermatic ad- 
ministration of morphine sulphate (gr. }i) often aids in con- 
trolling bleeding, and is a useful medicine to exhibit where 
pain is annoying or the patient is nervous. If seepage of 
blood from the torn gums continues for longer than 24 
hours, active horse serum should be administered (10 cc. 
doses, 2 or 3 times during the day usually suffice) intra- 
muscularly or intravenously. Where hemorrhage is pro- 
longed, and symptoms of shock appear, transfusion of 
human blood from a relative is indicated. In our expe- 
rience, this maneuver is most satisfactorily performed by 
the PercyrCook method (see below). 

To contract the gums after the extraction of teeth, a 
useful mouth-wash is Dobell's fluid to which has been 
added formalin to make a 1 per cent, solution. This wash 
has also hemostatic and bactericidal properties. It 
can be used after each feeding. One need scarcely men- 
tion that liquid or very soft food should be given until 
the gums have healed. Proper fitting artificial teeth should 
be inserted as soon as the gums are healed and firm. 

Oral cleanliness should be sought apart from removal of 



476 CANCER OF THE STOMACH 

decaying teeth. Oozing, soggy, pus-laiden gums should 
be freely incised. Small abscess cavities may be lightly 
swabbed with 2 per cent, solution of silver nitrate, 10 per 
cent, formalin solution or dilute tincture of iodine. Foul 
tonsils or other infected adenoid tissue should be extirpated, 
if possible. If this cannot be done, then cauterization of 
disease foci should be thoroughly performed. 

It is often astonishing to note the feeling of well-being 
which gastric cancer patients exhibit after their mouths 
have been cleaned up. Appetite may return, food may be 
eaten in abundance, gain in weight occur, and such general 
improvement supervene as to arouse hopes of a mistake 
in diagnosis or of spontaneous regression of the neoplasm. 

The toilet of the stomach should be as carefully taken 
care of as in the case of the oral cavity. This demands 
attention in all instances of gastric cancer, whether they be 
of the retention or the non-retention type. 

The reduction to a minimum of the swallowing of foul 
substances from the mouth is an important step toward 
gastric cleanliness. Even with this source of infection 
limited, the stomach is yet burdened, as a rule, with ob- 
noxious material in the form of retained food, altered blood, 
products of tissue necrosis, bacteria and foreign chemical 
compounds. Much can be done by regulating the kind 
of diet (see below). Other measures are 2 ounces of 
oleum ricini (in beer, malt extract, acid fruit juices or 
administered through a stomach tube) at least once weekly; 
lavage of the stomach with solutions of 2 per cent, formalin, 
1 per cent, salicylic acid, 0.5 per cent, thymol, 1-2,000 
quinine, or 1-3,000 alphozone (follow the medicinal lavage 
by a washing with normal salt solution at 37° C.) ; the ex- 
hibition of gtt. xxx dilute hydrochloric acid (U.S. P.) 
y^ hour after eating, or the administration of oil of eucalyp- 



NON-SURGICAL TREATMENT 477 

tus (gtt. XV — t.i.d. a.c), radium water (oj to gss on 
an empty stomach several times daily), or bismuth sub- 
carbonate (gr. XXX, when Uquid food is taken or upon the 
empty stomach, 4 times daily). 

Of all the above means of keeping the stomach clean, diet 
and frequent lavage are, undoubtedly, the most satisfactory. 
Patients readily become accustomed to the daily use of 
the stomach tube, and chng to it when they discover how 
great is their rehef from annoying sj'-mptoms by lavage. 
The best time to wash out the stomach is when the patient 
experiences the greatest discomfort. Usually a generous 
lavage before the morning meal, or the last thing at night, 
will insure the greatest measure of cleanliness and comfort. 
Patients with far advanced gastric cancer may require 
lavage several times daily. 

Diet. — Feeding is always a serious problem in this disease. 
What agrees with one patient is often unbearable to 
another. Routine diet tables will be found to have but a 
general appUcation. The type of food will frequently 
require changing in a given patient. It thus follows that 
dieting in gastric cancer is a highly individual problem. 

Not infrequently, success in feeding these unfortunates 
rests upon the correct estimation of the position occupied 
by the stomach tumor. Growths at or near the cardia 
sometimes call for administration of very soft or liquid food. 
This may have to be given through a long catheter, or a 
stomach tube of small cahber passed beyond the constric- 
tion. It may be necessary to constantly use this method 
of feeding, but not rarely growths near the entrance to the 
stomach slough extensively, and so permit periods of rehef 
from tube life. Extensive, canalized growths in the body 
of the stomach often allow the exhibition of weU-chewed, 
mixed food for a long time. The patient's desires should 



478 CANCER OF THE STOMACH 

be humored in such event. WTien early or late pyloric 
steiiosis has occurred, it may be impossible to get a proper 
quantity of nom'ishment beyond the stomach. In mild 
stenoses where the normal way of food ingestion causes 
distress or pain, or where gastric atony and dilatation result 
in the constant presence of foul stagnation products in the 
stomach, considerable relief from discomfort and sufficient 
nutriment may be obtained by metagastric (duodeno- 
jejunal) or so-called ''duodenal" alimentation. 

Metagastric alimentation is of service where it is possible 
for the bulb of the ''duodenal tube" or the end of a post- 
gastric catheter to pass beyond the pylorus. It has been 
our observation (corroborated by fluoroscopic examina- 
tions) that in many instances duodenal tubes do not pass 
through the pylorus. Unfortunately in the very class of 
case in which this mode of feeding is most desirable, there 
is mechanical hindrance to its successful apphcation. 
Not only in pyloric cancer does the bulb fail to pass into 
the duodenum, but we have learned that not infrequently 
the end of the tube gets caught between nodular projec- 
tions of the growth and material forced through it lodges 
in the stomach. Where the gastric lumen is tortuous, 
this occurrence is quite common. Ordinary duodenal 
tubes m.ust remain in situ for long periods of time. This 
renders the method an inconvenient, as well as one not 
altogether desirable, from the standpoint of cleanhness. 

The form of postgastric catheter that can be passed 
directly into the small bowel upon a silk-cord guide is, in 
our experience, the most satisfactory. One can be reason- 
ably sure that food is reaching the desired locality, the 
amount given can be computed, the patient is less incon- 
venienced by a thread being constantly present in his throat 
and mouth than by a rubber tube, and, lastly, it is possible 



NON-SUEGICAL TREATMENT 479 

to keep tubes clean that need only be present in the 
alimentarj" tract at the time food is given. 

Various nourishing mixtures may be administered by 
the metagastric method. Those commonly found useful 
are parboiled milk, cream, buttermilk, malted milk, koumiss, 
wines, cocoa, chocolate, thin purees, clear broth, egg-nogg, 
barley-water, black coffee, tea, carbonated preparations, 
predigested foods, fruit juices, sugar water, or special 
formulae. There is a wide range. From 2 to 8 ounces 
should be administered at a time. The material should 
be at 37° C. and be passed in slowly. If one can be sure 
that the distal end of the feeding-tube is alwaj^s patent, 
then nutrient mixtures may be given by a modified "drop- 
method." 

In instances where emaciation has been marked, we 
have found it useful to feed patients by the metagastric 
method, mixtures of amino-acids and maltose. Such are 
readily prepared by first digesting Witte-peptone in normal 
salt by trypsin (Fairchild) under toluol or in 0.4 per cent, 
alphozone-normal salt solution, and then adding sufficient 
maltose to make a 5 per cent, mixture. From 100 to 
.500 cc. may be administered through the post-gastric 
catheter every 3 hours. If thirst is excessive, similar quan- 
tities of normal salt solution at 37° C. should be given 
10 -minutes before the amino-acid maltose preparation. 

Where the gastric lumen is patent the essential feature of 
successful dieting is to allow only such food as will cause 
Httle irritation and will pass through the stomach leaving 
the minimum of residue. Lumps of food are hkely to in- 
jure the diseased gastric lining, produce or keep up a hemor- 
rhage and, by stagnating in the stomach, furnish a constant 
source of irritation as well as an ideal culture media for a 
host of inimical bacteria. Care should be taken that 



480 CANCER OF THE STOMACH 

foods are not too hot or too cold. Hot foods cause gastric 
congestion or even hemorrhage in cancer, while cold foods 
may be responsible for painful gastro-spasms. 

Uncooked vegetables and fruits should be interdicted, 
not only on account of the possibility of their being 
mechanical irritants, but also because they are a common 
source of infection. It has been frequently pointed out 
by Ochsner, that fann produce is generally contaminated 
by manm'e-impregnated soil. It is not essential to beUeve 
that these uncooked foods caxry a parasite capable of caus- 
ing cancer, in order to hmit their use. Anyone who has 
taken the trouble to examine microscopically or chemically, 
the dung which is ordinarily used to force, ripen or bleach 
garden products, will admit that the possibihties of such, 
when taken raw, acting as sources of infection, cannot 
be denied. It is a rather striking fact that in communities 
where an excess of uncooked vegetables or ''greens" 
comprises a good share of the diet, gastric cancer is very 
prevalent. Among city dwellers, of the well-to-do class, 
who can afford fresh garden products, the cancer rate is 
hkewise high. The interesting and valuable investigations 
of Smith relative to the production of tumors in daisies 
from bacilh isolated from ''galls" would appear to indicate 
that raw ''greens" or vegetables might be a source of gastric 
irritation. The researches of Gaylord, upon the develop- 
ment of tumors in fish that Hve in water highly contami- 
nated by their own discharges, are not without significance 
in pointing out the dangers attending ingestion of 
bacteriallj'- or chemically filthy food. 

With the increase in the population of the globe there 
has been an increase in cancer generally — particularly in 
gastric cancer. What effect, through pollution of water 
supphes and food, this increase has exerted toward causing 



NON-SURGICAL TREATMENT 481 

the disease, we can but conjecture. The end-result is 
worthy of thought. 

Rectal Feeding. — This may be required after hemorrhage, 
on account of pain, in ''coma carcinomatosa " where 
exhaustion has resulted from loss of appetite, nausea, 
vomiting, in starvation due to stenoses, or to allay thirst. 

Rectal aUmentation is best administered by the ''Murphy 
drip" method. The patient should lie with hips 
elevated upon one or two pillows. Cleansing the colon 
with normal salt solution should be performed before the 
nutrient enema is given. The clystra should be given at a 
temperature of 37° C. In ordinary cases enemata are well 
retained. If they are expelled promptly, more care should 
be taken in their administration, or gtt. v-xx of tincture 
opii and gtt. iii to x of tincture belladonna, may be in- 
corporated in every second enema. From 4 to 8 ounces of 
nutrient fluid nday be given at intervals of from 4 to 6 
hours. If these feedings are combined with nourishment 
per Oram, it is well to give but two daily. 

Various formulae for nutrient enemata are in vogue. We 
have found the following useful: 

Maltose or 30 . grams 

Alcohol (95 per cent.) or 20.0 cc. 

Peptonized milk or 100.0 cc. 

Normal salt solution q. s. ad viii or 240 . cc. 
Mix.— Heat to 37° C. 
Sig. — Administer slowly. 

Other enemata of value are parboiled milk ( 5 v every 3 
hours) ; glucose (§ij to § viii normal salt solution), egg albu- 
men and maltose (whites of 2 eggs, maltose § j in normal 
salt solution to § viii) . It is doubtful if anything of more 
use than water, salts or alcohol is absorbed from certain of 

31 



482 ,€ANCEK OF THE STOMACH 

^'nutrient" mixtures comprising eggs, starch, proprietary 
predigested foods, beef extracts and the Hke. 

To two patients we have given enemata composed of 
amino-acids and maltose with seeming benefit, but the 
procedure is still on trial. 

MANAGEMENT OF SYMPTOMS 

Anorexia is not infrequently a most annoying symptom 
in gastric cancer. The desire for certain kinds of food is 
lost. This may amount to an actual aversion. Some 
patients early lose their appetites for meat products, 
milk or sweets. The change of food desire for the in- 
dividual is not infrequently radical. The appetite is 
best stimulated by lavage, catharsis, the employment 
of hot baths, massage, attempt at change of mental at- 
titude, or by a vacation. 

Early lavage often prevents anorexia. Its effect is 
both tonic and cleansing. After the stomach has once 
been relieved of such accumulation as may exist at the 
time the patient comes under observation, it is not nec- 
essary to use medicinal remedies in the wash water. 
Normal salt solution at 37° C. acts very well in most 
instances, and is readily prepared. In cases where the 
gastric retention is very marked, or where a widely slough- 
ing growth constantly befouls the stomach, lavage with 
Carlsbad water (1 dram of Carlsbad Salts to 1,000 cc. 
of water at 37° C), 1 per cent. salicyUc acid solution or 
0.5 per cent, solution of lysol are usually of service. 

Vom.iting. — In many instances vomiting is due to im- 
proper food, overfeeding, obstruction or pain. 

If the diet is altered so that it is enticing, and care is 
taken that, with the eager attempt to regain health, the 
patient does not overload his stomach, much of the 



NON-SURGICAL TREATMENT 483 

vomiting may cease. When pain is the cause of the emesis 
(see below) simple remedies to reheve such should be 
promptly instituted. 

In cases where stenoses produce early with a constant 
amount of gastric stagnation, lavage usually takes care of 
the annoying vomiting. It may be performed fearlessly 
provided a soft stomach tube is used. Only in instances 
where there has been severe hemorrhage, is it contra- 
indicated. We have frequently observed, however, that 
hemorrhage itself may initiate a prolonged attack of 
vomiting which may not cease until the blood clots have 
been washed from the stomach. We have often thor- 
oughly lavaged a stomach within a few minutes after a 
severe hemorrhage without untoward symptoms on the 
part of the patient. 

Medicinal remedies are of but secondary value in the 
treatment of vomiting unless they attack one of its under- 
lying causes. 

We have found that severe retching, with or without 
vomiting, can be controlled by orthoform (grains 10 every 
4 hours; taken on an empty stomach), chloroform (gtt. 
10-30) administered after lavage, or potassium bromide 
(grains 30-60) per rectum. Occasionally there are cases 
where vomiting is so annoying that it is necessary to 
administer opiates. These should be given by the physician 
himself and preferably hypodermatically. 

Acidity, Pyrosis and Eructation. — Such are not rarely 
extremely annoying. Regulation of the diet combined 
with catharsis and frequent gastric lavage do much to 
prevent or relieve these symptoms. 

The administration of hydrochloric acid (gtt. 15-30 
after meals) aids in limiting intragastric fermentation, and 
in this way acts to relieve pyrosis and eructations, which 



484 CANCER OF THE STOMACH 

are largely due in this disease to fermentation and organic 
acids. If gastric lavage is not used to remove stagnant 
contents from the stomach, or if fermentation of such 
contents is not prevented, then it may be occasionally 
necessary to employ alkalies to neutralize the high com- 
bined acidity. This is a slovenly way to aid the patient, 
although at times it may prove of value in reUeving symp- 
toms. We have found that alkalies given in the form of 
bismuth subcarbonate (grains 30) and calcined magnesia 
(grains 20) prove useful in such emergencies. 

Bowels. — If constipation exists — and it frequently does — 
2 ounces of castor oil in beer or fruit juices may be given 
once or even twice weekly. There is nothing superior to 
castor oil for emptying the intestinal tract of contaminating 
and putrefying contents. Where castor oil is not well 
borne, from J^ to 2 ounces of liquid paraffin may be ad- 
ministered, preferably on an empty stomach. There are 
instances where from 3 to 5 grains of calomel given at bed 
time are useful in relieving the bowels, and at the same time 
overcoming flatulence. Mild cathartics which retain their 
activity for a long time are phenolphthalein (grains 5- 
10), cascara sagrada (gtt. 15-60 at bedtime) or compound 
jalap powder (grains 30-60 at bed time). 

Where the stools show an excess of mucus, hot Carlsbad 
water, or solutions of sodium phosphate or sodium citrate, 
should be given before the first feeding in the morning. 

Not infrequently, diarrhoea is an annoying symptom. 
There are cases where no medicinal agent, other than opi- 
ates, will be found of service. Everything else should be 
tried, however, before morphine, codein or the like are used. 

Keeping the stomach clean, putting the patient for a 
few days upon a diet of parboiled milk or buttermilk, 
rest in bed, or hot applications over the abdomen, some- 



NON-SUEGICAL TREATMENT 485 

times stop exhausting diarrhcea. TVTiere simple measures 
fail, bismuth subgallate (grains 10) may be given after each 
bowel movement. Tannigen, tannic acid, or a pill com- 
posed of opium and camphor may also be of service. 

When opiates are indicated they may be administered 
in the form of laudanum (gtt. 10-40) or paregoric, by mouth 
or in starch-water enemata. Codein or morphine should 
not be used unless absolutely necessary inasmuch as not 
infrequently they produce nausea, rapid emaciation, to- 
gether with physical and psychic unrest. 

Pain.— In but 15 per cent, of instances of gastric cancer 
is the pain sharp, cohcky or prostrating. These are cases 
where ulceration exists or perforation has taken place. 
In these emergencies, opiates should be administered 
promptly and preferably by the hypodermic needle. Pa- 
tients should be kept in bed, and after preUminary lavage, 
hot apphcations should be applied to the epigastrium. If 
hemorrhage complicates, an ice-bag or ice-coil locally should 
be used. 

Much of the abdominal distress in gastric cancer is due 
to accumulation in the stomach of gas or stagnant material. 
In such instances the stomach tube should be hberally 
employed. There are instances where improper diet causes 
epigastric pain. This error should be corrected. At times 
it will be found necessary to administer such remedies as 
chloroform water, orthoform, bismuth, creosote, or even 
opiates. 

Flatulence. — A cold enema given in the morning will be 
found of considerable value in preventing or treating this 
sometimes annoying sjmiptom. Where a patient is bed- 
ridden, and there is a constant tendency to gaseous dis- 
tention of the bowel, a rectal tube of fair caliber may be 
inserted 5 times a dav and left in situ for from 10 minutes 



486 CANCER OF THE STOMACH 

to a li hour. Where pronounced gastro-intestinal fermen- 
tation exists, alleviation may be secured by the administra- 
tion of from one to six tubes of liquid culture of Bacillus 
bulgaricus (Metchnikoff) daily. 

Hemorrhage. — It is impossible to prevent the more or 
less constant seepage of blood that occurs in certain types 
of gastric maUgnancy. The hemorrhage which it is neces- 
sary to treat is that which occurs acutely, or where constant 
seepage has produced marked anemia which prevents sur- 
gical intervention in an otherwise operable case. The acute 
hemorrhage of gastric cancer is best treated by prompt 
lavage of the stomach with normal salt solution (37° C), 
hypodermic administration of morphine (grains M-3^), 
absolute rest in bed, ice-coil to the abdomen, heat externally 
and the institution of rectal feeding. If hemorrhage does 
not cease within a few hours, horse serum in from 10 to 100 
cc. doses should be given hypodermatically. This can be re- 
peated several times in the course of 24 to 48 hours. The 
preparation known as ''coagulose" devised from the experi- 
mental work of Clowes of the Buffalo Cancer Research 
Laboratory may be found of service where horse serum has 
proven to be ineffective. We have observed that several 
instances of persistent hemorrhage were satisfactorily 
treated by the direct transfusion of human blood after the 
method of Percy and Cook. The latter describes the 
technique as follows: 

A Simple Method of Blood Transfusion. — A method of 
blood transfusion which presents many desirable features 
has been in use at Augustana Hospital long enough to 
establish its value as a means of relieving anemia and in- 
creasing resistance. 

The blood is aspirated into a specially prepared trans- 
fusion tube from a good sized vein of the donor and injected, 



NON-SURGICAL TREATMENT 487 

before it has opportunity to coagulate, into a similar vein of 
the patient. 

The Transfusion Tube. — ^The transfusion tube is made 
from soft carefully annealed German glass. It consists of 
a graduated cylinder about 16 inches long and of about 
650 cc. capacity. The lower end of this cylinder is drawn 
out at right angles to its axis to form the canula which is 
inserted directly into the vein. The upper end or mouth 
of the cylinder is drawn out at right angles to its axis but 
is perpendicular to the canula. This end is made about 
4 inches long and about % inch in diameter. Over it is 
slipped a rubber tube about 15 inches long which ends in a 
small glass tip or mouth piece. A glass tee or branch is 
inserted at about 6 inches from the cylinder, cutting the 
rubber tube in 2 parts, 6 and 9 inches long. To the side 
branch of the glass tee an ordinary rubber atomizer bulb 
is connected by a piece of rubber tubing 2 inches long. 
This rubber tube is clamped shut with an artery forceps 
while the blood is being aspirated from the donor. The 
forceps is removed and clamped above the tee when the 
transfusion tube is filled and inserted in the vein of the 
patient. 

Sterilizing and Coating Transfusion Tube. — Caution: 
Tube must be dry and free from blood. (After use, wash 
quickly with cold water adding shot if necessary to loosen 
clots, then wash with alcohol and ether separately and 
successively.) 

1. Dry Heat Method. — Wrap tube in a white cloth, 
steriUze in bacteriological steriUzer by dry air, 30 minutes 
at 175° C. Caution. — Do not overheat. Before tube be- 
comes cold pour in a couple of ounces of melted and steril- 
ized ordinary hard grocer's paraffin. Turn tube around 
(handhng it with sterile gloves or scrubbed hands) so that 



488 CANCER OF THE STOMACH 

every part is reached by the melted paraffin. The paraffin 
is then poured out of the large end of the tube. Examine 
canula (small end) to make sure that it is not closed by the 
hardened paraffin. It should be T\'ide open. If not, heat 
gently over escaping steam or a small flame and tip the tube 
so that the paraffin runs out into the large end of the tube. 
The tube may then be safely done with cold air, fanning it 
or by pouring over it sterile water, first warm then cooler 
and cooler. (No water should reach the inside of the tube 
as it will not then coat over evenly.) 

2, Steam or Autoclave Method. — Aspirate or pour about 
2 ounces of melted grocer's paraffin into tube (dry and free 
from blood), wrap loosely in a towel or cloth, sterilize 15 
minutes only at 15 pounds pressure in the autoclave. 
Turn the tube around so that every part of the tube is 
reached b}^ the paraffin, handling it with sterile gloves or 
scrubbed hands. The process of cooUng is as described 
in the previous method. The tube, properly coated, has a 
uniform gray color and the canula is wide open. The tube 
is now ready for use and may be wrapped up in a sterile 
towel and put away. 

SterHizing rubber tubing, glass tee, and mouthpiece is 
done by pulling them apart, wrapping them in a towel 
(careful not to have any kinks in the tubing) and sterihzing 
in the autoclave 15 pounds pressure for 15 minutes. (Note. 
— Use no heat for sterihzing rubber bulb. Wash with 
alcohol before using; this is sufficient.) A small arteTj 
forceps is clamped on the rubber tube between the atomizer 
bulb and the glass tee. A small piece of sterile cotton is 
inserted into the glass tee, the rubber tube connected with 
the mouthpiece is then slipped over one branch of the tee, the 
atomizer bulb is connected to the side branch of the tee and 
the rubber remaining connects the other branch of the tee 



XOX-SURGICAL TREATMENT 489 

to the mouth of the transfusion tube. The mouthpiece at 
the free end of the rubber tube is now placed in the mouth 
and an ounce of sterile Uquid parafhn is then sucked up 
through the canula tube into the tube. The mouthpiece 
is then wrapped in sterile gauze so as not to contaminate 
the sterile tube. The whole is then set aside ready for use. 
The hquid paraffin floating on top of the blood prevents the 
access of ah-, thus tending to delay coagulation. 

Procedure. — A constrictor, which may be a rubber tube 
but better a blood-pressure instrument, for the donor is 
placed high around the arm. The veins of the arm of donor 
and recipient are exposed, preferably above the elbow. 
The incision is best made from 2 to 3 inches long just above 
the bifurcation of the median vein at the elbow. Two per- 
cent, cocain is injected about the vein hyiDodermically. 
The vein is carefully dissected out, the small branches being 
clamped, ligated, and divided. 

Up to this point the operation is the same in the case of 
both donor and patient. The operation should be com- 
pleted to this extent in both persons before the vein is 
opened in either case. 

A ligature is then placed around the vein of the donor at 
its upper end. that is centrally, and tied, another ligature 
is placed at the lower part and not tied but held by the 
assistant before and while the vein is being opened by the 
operator, in order to control bleeding while the canula is 
being inserted. Sim il arly a hgatm^e is placed around the 
vein of the patient and tied at the distal part, another being 
sUpped around the vein centrally and held without t}T.ng 
while this vein is opened and the canula inserted. Both 
veins are now opened between the hgatiu'es placed as above, 
with a sharp scalpel or fine sharp scissors. A T^ide and free 
opening must be made in the vein in order that the canula 



490 



CANCER OF THE STOMACH 



may slip easily into the lumen of the vein. It is very easy 
to slip the canula between the walls of the vein instead of 
into the lumen if this precaution is not observed. 

The transfusion tube now contains an ounce of Uquid 
paraffin in it and with atomizer bulb clamped off, is taken 
up by the assistant. The mouthpiece is placed in his 




Fig. 105. — Transfusion by Percy-Cook method. Illustration shows end 
of tube in position for aspirating blood from vein of donor. _ Note paraflfin- 
lined tube, layer of liquid paraffin above blood level. Aspirating tube and 
clamp on tube leading to compression bulb. 

mouth, the upper end of the tube balanced in his hand while 
the operator sUps the canula into the vein of the donor in a 
distal direction, i.e., toward the hand. If the canula does 
not sUp readily into the vein, this may be facihtated by 
grasping and holding apart the edges of the cut vein with 
fine mouse-tooth or smaU-nosed docking forceps, or the 
canula may be guided along the channel of a grooved direc- 



NON-SURGICAL TREATMENT 



491 



tor, which has been sHpped into the vein. The canula is 
pushed home into the vein until its tapering sides just fill 
the lumen of the vein. The distal ligature is then loosened 
and the air-pressure constrictor pumped up to 60 to 90 mm. 
The blood quickly gathers from the anastomosing deep and 
superficial veins and flows through the open vein into the 




Fig. 106. — Percy-Cook method of blood transfusion. Blood being given 
to recipient. Note direction of transfusion tip in arm vein; clamp 
on aspiration tube with compression bulb under control for gradually 
emptying transfusion tube. 

canula. The assistant then sucks gently but continuously 
and the blood rapidly enters the tube. (Too hard sucking 
will collapse the vein so that no blood enters the tube.) If 
the vein has been pulled too hard by the assistant holding 
the ligature it will collapse much more quickly. If the tech- 
nique has been good the tube may be filled in 4 or 5 min- 
utes. It is not advisable to leave the canula in the vein 



492 CANCER OF THE STOMACH 

for a much longer time, however. It is better to be content 
with taking 200 or 300 cc. of blood than take 6 or 7 minutes 
to fill the tube. The rubber tube is now clamped with a 
heavy artery forceps near the mouth of the transfusion tube 
in order that blood shall not be lost in the transfer from 
donor to patient. The canula is then taken out and in- 
serted in the vein of the patient in a central direction, i.e., 
toward the heart. The large clamp is removed from 
the rubber tube near the mouth of the transfusion tube. 
The small clamp near the atomizer bulb is taken off and 
clamped above the glass tee and between it and the mouth- 
piece. Gentle pressure is now placed upon the atomizer 
bulb which forces the air into the tube, displacing the blood 
as it enters the vein. It should take about 4 to 5 minutes 
to inject the blood as a more rapid injection may cause a 
dilatation of the right heart with collapse and death. (After 
taking the canula from the donor's vein an assistant mean- 
while removes the constrictor from the arm and ties the 
distal ligature of the donor's vein.) The canula must be 
slipped out before any liquid paraffin enters the vein pro- 
ducing fat emboli. When this is done the central ligature 
on the patient's vein is tied and the skin closed over the 
vein with horse-hair stitches. 

Advantages of the Method. — 1. The blood is measured and 
a definite quantity is taken and injected in a short space 
of time. 

2. The donor is protected absolutely from any infection 
which the patient may have, as there is no contact, direct 
or indirect. There is no chance for a drop of the patient's 
blood to get into the donor's vessels. 

3. It is a venous operation, so there is no danger from 
infection to the deep structures lying about the large artery 
usually used for the purpose. There is no impairment of 



NON-SURGICAL TREATMENT 493 

the circulation as from, the Hgation of such an important 
artery as the radial. 

4. It has proved uniformly successful where care has 
been taken to insure the proper technique. 

In the treatment of the anemia following gastric hemor- 
rhage or gastric seepage, the most satisfactory remedies ap- 
pear to be salvarsan, arsenious acid, Fowler's solution or 
cacodylate of sodium. Any of these may be given alone, 
or with preparations of iron. There are numerous useful 
iron preparations. We have found to be of service, Blaud's 
mass or various forms of iron conveniently put up in ampules 
for hypodermatic administration. 

There are many cases of malignant anemia in which 
ordinary drugs are of little value. In such cases if the stool 
examination reveals the constant presence of altered blood, 
the giving of blood-building medicines may become effective 
after several hypodermic injections of horse serum or a 
transfusion of from 300 to 600 cc. of human blood. Not 
rarely, attention to these details will enable the patient to 
come to operation, or will render operative procedures of 
more marked benefit. 

X-rays. — In gastric cancer, the therapeutic value of 
Roentgen rays is uncertain. The effects appear to be 
largely influenced by the type of gastric neoplasm, the stage 
of the disease, the pressure of associated lesions (anemia, 
metastases, cardiorenal complications and the like), and 
the skill with which treatments are given. 

Cases in which the method appears to be justifiable are 
those where inoperable growths exist; where operation has 
been performed and gland involvement discovered; where 
patients are either too weak for, or refuse, surgical inter- 
vention; where recurrences have appeared, and in the in- 
terim of two-stage operations. 



494 CANCER OF THE STOMACH 

It should he especially emphasized that under no circum- 
stances other than absolute refusal of surgical measures, should 
x-ray therapy he advised in instances of suspected or early 
gastric malignancy. It is the phj^sician's duty to urge the 
benefits of laparotomy. There is no instance of pathologic- 
all}^ demonstrated gastric cancer, on record, that has been 
cured by x-v3cy treatments. 

In suitable instances, x-ray exposures may be begun 
2 or 3 days following laparotomy. Treatment should be 
to the deeper tissues, with a hard tube, and there should be 
(except in Y&ry weak patients, or those who have previously 
been treated by .x-rays) exposure of from 1.5 minutes to 
1 hour. The parts of the body adjacent to the treatment 
area must be carefully protected by lead foil. Such pro- 
cedure insures proper ^'erj^thema dose." The treatments 
should be given dailj^, or every other day for from 6 to 12 
days. A rest of a similar period should be permitted 
before the patient is again exposed. 

During actinotherapy frequent examination of the pa- 
tient's urine and blood should be made. Vigorous a;-ray 
treatment is not infrequently accompanied by the presence 
of albumin and casts in the urine. Rapid destmction of 
red blood ceUs, with a fall in the hemoglobin and an increase 
of mononuclear leucocytes at the expense of the polynuclear 
forms may follow prolonged Roentgen exposure. 

The precise way in which x-ray therapy favorably influ- 
ences certain malignant growths is not known. It would 
appear that the x-rays may destroy young cancer cells, 
split cancer-protein into ''toxic" and "'non-toxic" mole- 
cules, cause hemorrhage with liberation of enzymes capable 
of attacking neoplastic ceUs, or, by stimulating some yet 
undiscovered property' of the blood serum, formed elements 
or both, strengthen the body's defensive mechanism. 



NON-SURGICAL TREATMENT 495 

Radium, Mesothorium and Allied Substances. — In 

growths of limited extent, particularly when such are 
located at or near the cardia, it would seem that radium or 
mesothorium are of value. Such may be applied directly 
to the diseased area in protected capsules at the ends 
of sounds. The capsule should be left in situ for from 1 
to 12 hours. Only wealthy folks are able to afford such 
treatments. 

Where there is extensive involvement of the stomach by 
cancer, we have observed certain interesting results follow- 
ing the drinking of radio-active water. If from 4 to 
60 cc. are administered at intervals of from 1 to 4 times 
daily, pain appears to lessen or subside, the stomach con- 
tents become less foul, hemoglobin may increase, and the 
patient may exhibit an attitude of general well-being. Oc- 
casionally, the disease appears to remain quiescent for a 
time, or it progresses slowly. Massmann reports an in- 
stance where cancer at the cardiac orifice was held in 
check for 2 years by the ingestion of radio-active water. 
The patient finally succumbed as the result of metastases. 

Radio-active water has at least the quality of being 
comparatively reasonable in price. Its extensive use is 
thus possible. 

It should not be forgotten that, due to much pseudo- 
scientific publicity, and to the cost of treatments by x-ray, 
radium or mesothorium, a not-to-be-neglected benefit that 
may accrue from their use, has a psychic foundation. If 
the patient can afford such comfort he should be permitted 
it. On the other hand, no sacrifice or neglect of simple, 
proved and accessible therapeutic measures should be per- 
mitted in order that a patient enjoy light therapy. Not 
rarely do we see individuals who have spent their all pur- 



496 CANCER OF THE STOMACH 

suing phantom cures, die in squalor or become a burden 
upon the commonwealth, or upon charitable friends. 

Serotherapy. — In 1909, Hodenpyl reported striking re- 
sults in malignancy following the injection into those 
affected, of ascitic fluid obtained from the peritoneal sac of 
a woman in whom there seemed to have been a spontaneous 
cure of an intra-abdominal neoplasm. Unfortunately, both 
the donor of the serum and the brilliant investigator died 
when it seemed about to be shown that serum from certain 
kinds of cancer appeared to possess protective substances. 
R,. Weil made an extensive biochemic examination of the 
Hodenpyl fluid and showed that it seemed to contain a 
measurable increase of anti-cancer bodies. 

Other antisera have been proposed. The most notable of 
these is that of Berkeley and Beebe. These investigators 
claim to have made an extract of cancer tissue removed 
surgically. By successive injection of the ''specific human 
cancer extract" into alien mammals, a serum may be 
developed which when injected into the original host in 
increasing doses, is followed by ''rapid regression and dis- 
appearance" of what tumor remains. Berkeley and Beebe 
think the effect is due to cytolysis of the tumor cells. They 
report encouraging results from the use of their "anti- 
serum" in 16 cases of malignancy. 

Autolysates of human embryos have been used by Fischera 
in the treatment of malignancy. Nearly 50 per cent, of 
his cases were aided by the treatment. 

Vaccine Treatments. — This method of therapy has been 
frequently suggested, and all types of vaccines have been 
used. If removal of a metastatic gland shows sarcoma, 
then a certain beneficial effect may result from the use of 
Coley's "toxins" {Streptococcus erysipelatis and Bacillus 



NON-SURGICAL TREATMENT 497 

prodigiosus) . This remedy should be tried whenever it is 
possible. 

Suggestive "spUt-proteid^' vaccination has been carried 
on by W. Vaughan in cases of cancer. Basing his work 
upon the investigations of V. C. Vaughan on cellular pro- 
teids, W. Vaughan has prepared a "vaccine" consisting of 
aqueous solutions of the non-toxic radicle of the protein 
molecule. W. Vaughan describes the preparation of this 
vaccine as follows: 

A small piece of the tissue is first examined by frozen 
section, in order to ascertain the exact nature of the growth. 
Next, the malignant tissue is dissected as freely as possible 
from all surrounding tissues, after which it may be placed 
in absolute alcohol and kept until opportunity is given to 
carry out the following steps. All tissue should be dehy- 
drated in absolute alcohol before being split up. Next, 
the cancer material is ground as finely as possible with an 
ordinary meat grinder, but if the amount is small, loss may 
be saved by cutting with scissors and forceps, after which 
it is placed in a flask which contains about 15 times the 
volume of material of a 2 per cent, solution of sodium 
hydrate in absolute alcohol. (It will facilitate the solu- 
tion of the sodium hydrate in the alcohol if the former is 
first pulverized finely in a mortar.) The flask containing 
the material is next heated over a water-bath for from 2 to 
3 hours, depending on the amount of tissue that is to be 
split up. For safety only, the flask is connected with some 
form of condenser before heating. However, the alcohol 
should not be heated to such a degree that it actively dis- 
tils, as too much heat will absolutely destroy the activity 
of the resulting residue. At the end of 2 or 3 hoiu-s the 
tissue within the flask should appear as a finely divided 
powder. If this is not the case it is my practice to allow 

32 



498 CANCER OF THE STOMACH 

the flask to stand over night, after which time the super- 
natant fluid is decanted and a sufficient amount of the alka- 
line alcohol solution added to make up the original volume, 
heat being again applied in the same manner. 

Next the solution is filtered off and the residue washed 
upon the filter with absolute alcohol until its reaction is no 
longer alkaline. While still somewhat moist the residue is 
weighed upon the filter, a filter paper of equal weight being 
placed upon the opposite balance to offset the weight of the 
one containing the residue. Next it is transferred with a 
sterile spatula to a sterile bottle and sufficient sterile water 
added to make the desired solution. With small amounts 
of material I prefer a 1 per cent, solution, with larger 
amounts, a 2 per cent. Practically all of the residue is 
soluble in water, but if such is not the case it may be filtered. 
Lastly, sufficient phenol is added to make the given amount 
contain 0.5 per cent. This is kept as stock solution and 
injections given of the same. 

W. Vaughan states that injections of from 3 to 30 cc. 
of his solution may be made frequently. The time for 
injection is indicated by observing the relative fluctuations 
of the polymorphonuclear and the mononuclear cells in 
differential blood counts. An increase in mononuclear 
cells — particularly of the large mononuclears — appears to 
be a favorable sign. The injections should be given ''only 
at the periods during which the percentage of polymorpho- 
nuclear leucocytes is increasing." 

W. Vaughan reports numerous cases illustrative of the 
effects of using spUt-proteid vaccine. Some have encour- 
aging pointings. W. Vaughan's contributions to the effect 
of cancer residue injections upon blood morphology are 
certainly creditable and perhaps not without practical 
significance. 



XOX-SURGICAL TREATMENT 499 

Chemo -therapy. — The announcement by Wassermann 
that solutions of an eosin-selenium compound brought 
about regression or even cure of cancers in mice proved a 
rare stimulus to workers in experimental laboratories and 
to clinicians. Notable reports have come from EhrUch, 
Caspari, Xeuberg and Popov. 

These investigators have shown that certain cancers are 
cured, regress, or have their growth halted when intravenous 
injections of solutions of colloidal copper, platinum or 
selenium, eosin-selenium compounds, leech extract or casein 
are given. Robertson and Burnett have observed that 
aqueous emulsions of lecithin injected directly into tumors 
diminish the tendency to form metastases, retard the metas- 
tatic growth when it does occur, and in some instances 
retard the primary^ growth. 

It would appear that treatment of cancer by chemo- 
therapy offers alluring possibilities. The method has not 
yet proven of absolute worth. It is suggested that direct 
injection of solutions of coUoidal copper or platinum, leech 
extract, casein or emulsions of lecithin into irremovable 
gastric cancers or metastases from such might be employed 
with benefit. 

REFERENCES 

Berkeley and Beebe: New York Medical Record, 1912, March 16. 

Vaughax, W.: N. Y. Med. Jour., 1910, Oct. 15. 

Caspari and Netjeerg: Deutsck. ISIed. 'Wockenschr., 1912, Vok 
xxxviii, p. 375. 

Popov: These de Unirersite de !MontpeHer, 1913, July 26, Xo. 24. 

LoEB, McClurg, and Sweek: Loeb and Fleisher; Loeb, IMcClurg and 
Sweek; and Loeb and Fleisher, Jour. A.M.A., 1913, June 1-i, p. 1857, 
and The Interstate Medical Journal, 1912, vol. xix, Xo. 12. 

Loeb: Interstate Medical Journal, 1913, xx, Xo. 5. 

Robertson and Burnett; Jour, of Exp. Med., 1913, Xo. 3, p. 34-4. 



INDEX OF NAMES 



Abderhaldex, 230, 266, 320, 344, DaCosta, 327 



347, 349 
Adami, 371, 372 
Aschoff, 31, 50 
AscoK, 320, 348, 349 
Ascoli and Izar, 349 

Bashfoed, 96 

Beck, 421 

Beebe and Berkeley, 496, 499 

Bergmann and Meyer, 342, 344, 349 

Berkeley and Beebe, 496, 499 

Bernstein and Simons, 348, 349 

Blackford and MacCarty, 105, 109, 

362 
Blumer, 184, 185, 186 
Boas, 205 

Boas and Oppler, 211 
Bolton, 351, 352, 371 
Bonhoff, 332, 349 
Brinton, 26, 50, 98, 109, 175, 351, 

369, 371, 372 
Broders and ^MacCarty, 109 
Buday, 18, 50 
Burnett and Robertson, 499 

C.a:bot, 24, 50, 324, 326, 327, 329, 349 

Cammidge, 263, 267 

Campbell, 52, 108, 412 

Capps, 332 

Carrel, 85, 109 

Caspari, 499 

Chesnel, 358, 372 

Clendenning, 52, 108, 412 

Clowes, 486 

Coley, 496 

Connell, 425, 434, 436, 451, 452, 461, 

463 
Cook and Percy, 475, 486, 490, 491 
Coolidge, 276 
CrHe, 336 
Cuneo, 418 
Cunliffe, 327, 349 



Dare, 115, 127, 138, 324 

Dittrich, 98 

Dobell, 475 

Dock, 173, 373, 374, 381, 406, 416 

Drew, 371, 372 

Ehelich, 499 

Elsberg, Xeahoff and Geist, 338, 349 

Eisner, 190 

Emerson, 242, 267 

Ewald, 245, 246 

FeilDstein and Weil, 344, 349 
Fenwick, 24, 26, 37, 38, 44, 48, 50, 

52, 98, 107, 108, 109, 134, 147, 

175, 361, 372 
Fibiger, 39, 50, 84, 109 
Fischer, 230, 266 
Fischer and Xeubauer, 230, 231, 232, 

266 
Fischera, 496 
Fleisher and Loeb, 499 
Flexner and JobUng, 83 
Fonio, 227 
Forametti, 190 
Fox, 26, 50 

Frank and Heimann, 347, 349 
Franz, 347, 349 
Frazier, 52, 108 
Frennd and Kaminer, 339, 349 
Friedenwald, 26, 28, 50, 175, 356, 

363, 364, 372 
Fuld and Levison, 228, 229, 266 
Fiitterer, 39, 50 

Galtox, 44, 50 

Gay, 85, 109, 320 

Gaylord, 480 

Geist, Elsberg, and Xeuhoff, 338, 349 

Gies, 239, 267 

Gluzinski, 226 

Graham, 355, 363, 371, 372 



502 



INDEX OF NAMES 



Gressot, 359, 372 
Gross, 263 
Gunzberg, 202 

Hahn, 175 
Hall, 190 

Hall and Williamson, 231, 267 
Hamburger, 320 
Hansmann, 366 

Hardisty and Ruttan, 205, 266 
Hardy and Meyer, 411 
Heimann and Frank, 347, 349 
Hendly, 37 
Hie Ding Lin, 31 
Hodenpyl, 496 

Hoffman, 20, 21, 23, 25, 28, 29, 34, 
35, 50 

IzAR and Ascoli, 349 

Jackson, 190 

Jacques and Woodyatt, 367, 372 

Janeway, 190 

Jobling, 320 

JobUng and Flexner, 83 

Jones and Rous, 108 

Junghans and Wolff, 117, 142, 143, 
146, 245, 246, 247, 248, 250, 
251, 252, 253, 254, 255, 256, 
267, 368, 398 

Kaminer and Freund, 339, 349 
Kauffmann, 211, 266 
Kausch, 190 
KeUing, 190, 348, 349 
Kober and Lyle, 231, 266 
Kocher, 438, 439 
Kohlenberger, 231, 266 
Krida, 334, 335, 336, 338, 349 
Kussmaul, 171, 389, 397 
Kuttner, 190 

Lane, 469 

Lang, 334, 349 

Lebert, 98, 175, 369, 372 

Lembert, 435, 436, 438, 449, 450, 

452, 453, 458, 461, 462, 463 
Leube, 175 

Levin, 83, 108, 371, 372 
Levison and Fuld, 228, 229, 266 



Loeb, 499 

Loeb and Fleisher, 499 

Loeb, McClurg, and Sweek, 499 

Louis, 98 

Luton, 98, 109 

Lyle, 412 

Lyle and Kober, 231, 266 

MacCarty, 68, 77, 85, 86, 87, 88, 

109, 238, 352, 353, 370, 371, 

372 
MacCarty and Blackford, 105, 109, 

362 
MacCarty and Broders, 109 
MacCarty and Wilson, 67, 69, 70, 

71, 72, 73, 74, 75, 76, 109, 269, 

358, 370, 372 
Massmann, 495 
Mathieu, 374, 381 
. Mayo (C. H.), 437 
Mayo (W. J.), 428 
Mayo-Robson and Moynihan, 50 
McClurg, Loeb, and Sweek, 499 
McCrae and Osier, 38, 50, 175, 321, 

324, 326, 329, 332, 349, 356, 

372, 373, 381 
McDowell and Wilson, 370 
Melinkow, 370 
Metchnikoff, 486 
Meyer, 421 

Meyer and Bergmann, 342, 344, 349 
Meyer and Hardy, 411 
Mikulicz, 190 
Miyake, 31, 50 
Moniciion, 44, 50 
Moreschi, 97, 109 
Morris, 109 
Morris (Roger), 106 
Moynihan and Mayo-Robson, 50 
Mtiller, 230, 266, 332, 339, 349 
Miiller and Whitman, 342, 344, 347 
Murphy, 81, 85, 108, 459, 481 
Murphy and Rous, 109 
Murphy, Rous, and Tytler, 108 

Napoleon, 123 

Neubauer and Fischer, 230, 231, 232, 

266 
Neuberg, 499 
Neuhoff, Elsberg and Geist, 338, 349 



INDEX OF NAMES 



503 



OcHSNER, 33, 417, 480 

Oppenheim, 231, 266 

Oppler and Boas, 211 

Osier, 48, 358, 372 

Osier and McCrae, 38, 50, 175, 321, 

324, 326, 329, 332, 349, 356, 

372, 373, 381 

Pateeson, 359, 372 

Pelosi, 227, 266 

Percy and Cook, 475, 486, 490, 491 

Petry, 342 

Pettinkofer, 243 

Popov, 499 

Ransohopf, 348, 349 

Robertson and Burnett, 499 

Roche, 344, 349 

Rokitansky, 108 

Rokitansky and Waldeyer, 52 

Rolph, 246, 267 

Rosenbloom and Sanford, 231, 239, 

267 
Rosenheim, 190, 361, 372 
Rous, 81, 85, 95, 97, 108, 109 
Rous and Jones, 108 
Rous and Murphy, 109 
Rous, Murphy, and Tytler, 108 
Ruttan and Hardisty, 205, 266 

Salomon, 245 

Sanford and Rosenbloom, 231, 239, 

267 
Schiff and Sorenson, 138, 142, 229, 

252, 266, 367, 372 
Schoenberg, 276 
Schryver and Singer, 202, 203, 228, 

229. 266 
Senn, 423 
Shutz, 356, 372 

Simons and Bernstein, 348, 349 
Singer and Schryver, 202, 203, 228, 

229, 266 
Slye, 45, 50 
Smith, 83, 108, 480 
Snow, 83, 108 
Sorenson and Schiff, 138, 142, 229, 

252, 266, 367, 372 
Stockton, 344, 349 



Strauss, 204, 226, 366 

Sussmann, 190 

Sweek, Loeb and McClurg, 499 

TALLQtnST, 115, 118 

Tatham, 31, 50 

Topfer, 366 

Traube, 188 

Tytler, Rous, and Murphy, 108 

Uffelmann, 226, 242, 379 

Vaughan", 147 
Vaughan (V. C), 497 
Vaughan (W.), 497, 498, 499 
Virchow, 45, 50, 52, 108, 111, 184 
Virchow and Waldeyer, 111 

Waldeyer, 52 ,79, 108, 111 
Warfield, 231, 239, 240, 266, 338, 349 
Wassermann, 396, 410, 499 
Weil, 320, 334, 349, 496 
Weil and Feldstein, 344, 349 
Weinstein, 231, 233, 239, 241, 266, 

267 
Welch, 26,'50, 98, 100, 109, 327, 369, 

372, 373, 381 
Whitman, 342, 349 
Whitman and IMliller, 342, 344, 347 
Williams, 31, 33, 34, 37, 44, 48, 50 
Williamson and Hall, 231, 267 
Wilson, 89, 90, 91, 92, 107, 109 
Wilson and MacCarty, 67, 69, 70, 

71, 72, 73, 74, 75, 76, 109, 269, 

358, 370, 372 
Wilson and McDowell, 370 
Witzel, 422, 423 
Wohlgemuth, 261, 263, 267 
Wolff, 248 
Wolff and Junghans, 117, 142, 143, 

146, 245, 246, 247, 248, 250, 

251, 252, 253, 254, 255, 256, 

267, 368, 398 
Woodyatt and Jacques, 367, 372 
Wooley, 371, 372 
Wynhausen, 263, 267 

Yates, 52, 108, 412 



INDEX 



Abderhalden method for detection 
of specific ereptases, 
344 
apparatus for, 345 
technique of, 347 
Abdominal examination, 166 
catharsis before, 167 
gastric lavage before, 167 
position of patient for, 168 
preparation of patient for, 167 
inspection, 169 

change of position in, 170 
enlarged lymph nodes in, 172 
local prominences in, 169 
pelvic bones in, 169 
presence of free fluid in, 169 
respiratory movements, in, 170 
rib margins in, 169 
visible peristalsis in, 170 
pain, 132, 149 
palpation, 172 

after inflation of stomach, 177 
appearance of skin in, 173 
deep, 174 

diminished tension of abdom- 
inal wall in, 172 
hot bath before, 173 
parietes, thickness of, effect on 
palpation of abdominal tumors, 
183 
prominences, local, 169 
tumor, 154, 175 

effect of gastric inflation on, 182 
of respiratory movements on 
mobihty of, 183 
incidence, 175 
mobihty of, 179 

influence of complications on 
demonstration of, 181 
of duration of disease on 

demonstration of, 180 
of histologic type on dem- 
onstration of, 180 



Abdominal tumor, mobilitj- of, influ- 
ence of location in gastric wall 
on demonstration of, 181 

of position of patient on 
demonstration of, 181 
palpation of, tenderness [in, 
178 
effect of thickness of abdom- 
inal parietes on, 183 
position of, 176 

relation to part of stomach 
involved, 177 
size of, 178 
wall, tumors of, gastric cancer and, 
differential diagnosis, 416 
Abnormal proliferation of gland 

cells, 79 
Abnormahties in gastric outline, 
fluoroscopic examination of, 277 
Abscess of pancreas, gastric cancer 

and, differential diagnosis, 401 
Achlorhydria, Wolff-Junghans' test 

in, 253 
Achyha gastrica associated with 
gastric cancer, 47 
gastric cancer and, differential 

diagnosis, 403 
simple, Wolff-Junghans' test in, 

253 
malignant and benign, Wolft'- 
Junghans' test in, 246 
Acid salts in gastric retention ex- 
tracts, 203 
Acidity, 483 

of fasting stomach extracts, 201 
of gastric retention extracts, 225, 
366 
Gluzinski's method of de- 
termining, 226 
of stomach after operation for 
gastric cancer, 466 
Actinomycosis associated with gas- 
tric ulcer, 47 



SOS 



506 



INDEX 



After-treatment of complete gas- 
trectomy, 459 
of posterior gastro-enterostomy, 
440 
Age factor in weight loss, 165 

in etiology of gastric cancer, 27, 
354 
Air-pressure cabinet, Willy Meyer's, 

421 
Albumin, precipitible units of, 248 
soluble, Wolff-Junghans' test for, 
245, 368 
Alcohol in etiology of gastric cancer, 

37 
Alimentation, duodenal, 478 

metagastric, 478 
Altered blood, 204. See also Occult 

blood. 
Amount of gastric retention extracts, 

225 
Anaphylaxis test, Ransohoff 's, 348 
Anemia, 125, 154, 319, 365 
causes of, 320 

following gastric hemorrhage, 
treatment of, 493 
Anemias, primary, Wolff-Junghans' 

test in, 252 
Animals, experimental production of 

gastric cancer in, 84 
Anorexia, 114, 482 
Anterior gastro-enterostomy, 430 
gastrojejunostomy, 429 
wall of stomach, fluoroscopic ex- 
amination of growth on, 
281 
Roentgenographic appear- 
ance of growth in, 292 
Antitrypsin, 342 

estimation of, in Bergmann and 
Meyer's reaction, 343 
Antitryptic reaction, Bergmann and 

Meyer's, 342 
Appearance of mucous membranes, 
319 
of sclera, 319 
of skin, 319 . 

Appendix, disease of, association of 
gastric ulcer with, 384 
dyspepsia, chronic, in duodenal 
ulcer, 387 



Appetite, 150 

in duodenal ulcer, 389 

in gastric cancer in young, 376 
Ascites, 163 

in gastric cancer, 105 

incidence of, in gastric cancer, 409 
AscoU's miostagmin reaction, 348 
Asiatic cholera with gastric cancer, 

49 
Asthma with gastric cancer, 50 
Auscultation, 189 
Autolysates, treatment of gastric 

cancer by, 496 

Bacillus of Oppler-Boas, artificial 
culture of, 214 
characteristics of, 212 
cultures in beef bouillon, 216 

after forty-eight hours, 

220 
after seventy-two hours, 
221 
macroscopic examination, 222, 

223 
microscopic examination, 222, 
223 
frequency of occurrence, 224 
in gastric retention extracts, 212 
macroscopic examination, 215 
microscopic examination, 215 
staining properties of, 213 
Bacteria in gastric cancer, 43 

retention extracts, 211 
Bacterium tumefaciens, 83 
Basophile leucocytes in gastric can- 
cer, 332 
Beck's operation in gastric cancer, 

421 
Benign and malignant growths, as- 
sociation of, 371 
gastric cancer, 51 
Benzidin test for occult blood in 

gastric retention extracts, 205 
Bergmann and Meyer's antitryptic 
reaction, 342 
antitryptic reaction, apparatus, 
343 
estimation of antitrypsin, 

343 
technique of, 343 



INDEX 



507 



Bile coloring in gastric retention ex- 
tracts, 200 
effect of, on glycyltryptophan test, 
242 
on tryptophan test, 242 
Biliverdin in feces, 259 
Bleeding, 125 
Blood, 115, 154 
altered, 204. See also Occult 

blood. 
changes in gastric cancer, 321 
effect of, in glycyltryptophan 
test, 243 
in tryptophan test, 243 
in feces, 259 
in gastric cancer, 319 

extracts, relation of Wolff- 

Junghans' test to, 255 
clinical interpretation of tests 

for, 260 
in gastric cancer in young, 379, 
380 
retention extracts, 204, 226 
benzidin test for, 205 
instances of, 206 
method of determining, 
205 
negative test for, 261 
serum, deviations from normal 

shown by, 333 
shadows, 327 

transfusion by Percy and Cook's 
method, 486 
advantages of, 492 
technique of, 489 
tube used for, 487 
coating of, 487 
sterilization by dry 
heat method, 
487 
by steam method, 
488 
traumatic, in gastric retention 
extracts, 200 
Blumer's shelf, involvement of, 184 
Bright's disease in gastric cancer, 50 
Brun's glucose medium for prepar- 
ing sections of cancer tissue, 108 

Cancer cases, registration of, 474 



Cancer, gastric, 17. See also Gas- 
tric cancer 
milk, 246 
of stomach, 17. See also Gastric 

cancer. 
tissue, preparing sections, Brun's 
glucose medium for, 108 
Wilson's rapid method of cut- 
ting and staining, 107 
Capillary edema, 319 
Carcinoma colloides, 58, 94 
fibrosum, 52, 94 

gastric, 52. See also Gastric cancer. 
meduUare, 53, 94 
of pancreas, gastric cancer and, 

differential diagnosis, 401 
of pylorus, 426 

gastro-enterostomy for, 427 
two-stage operation for, 427 
Carcinomatous period, 150 

clinical, 130 
Cardia, growths near, diet in, 477 
fluoroscopic examination of, 279 
obstruction at, 100 
Cardiovascular disease, Wolff-Jung" 

hans' test in, 254 
Catharsis before abdominal exami- 
nation, 167 
Changes in leucocytes, quantita- 
tive, 327 
Chemical examination of feces, 258 
Chemotherapy in treatment of gas- 
tric cancer, 499 
Chewing gum after operation, 465 
Cholecystitis with gastric cancer, 48 
CholeHthiasis with gastric cancer, 48 
Chyle, effect of, on glycyltrypto- 
phan test, 242 
on tryptophan test, 242 
Chymification, presence of, in gas- 
tric retention extracts, 201 
Cirrhosis of liver with gastric can- 
cer, 50 
gastric cancer and, differential 
diagnosis, 411 
Classification of gastric cancer, 51 

neoplasms, 51 
Clinical consideration of gastric 
cancer, 354 
symptoms, significance of, 363 



508 



INDEX 



Coagulose, treatment of hemorrhage 

by, 486 
Coley's toxins, treatment of gastric 

cancer by, 496 
Colloid gastric cancer, 58 
Colon, excision of, in involvement 

of transverse colon in gastric can- 
cer, 469 
Color of gastric retention extracts, 

200 
Colored agar method for staining 

gastric retention extracts, 208 
Combined acidity in gastric reten- 
tion extracts, 226 
degree of, 203 
Complete gastrectomy, 456 
after-treatment of, 459 
drainage after, 458 
Complications, general, of gastric 

cancer, 100 
Conjugal state in etiology of gastric 

cancer, 35 
Connell suture, 425 
Constipation, 114, 125, 150, 484 

chronic, gastric cancer and, dif- 
ferential diagnosis, 414 

in gastric cancer in young, 376 
Constitutional diseases with gastric 
cancer, 50 

faults, gastric cancer and, differ- 
ential diagnosis, 415 
Contracting gums after extraction 

of teeth, 475 
Cook and Percy's method of blood 

transfusion, 486 
Crystals in feces, 266 
Curvature, lesser, fluoroscopic exami- 
nation of growth in, 279 
Cyst of pancreas, gastric cancer and, 

differential diagnosis, 400 

Decayed teeth, 161 

Diabetes with gastric cancer, 50 

Diagnosis, differential, 382 

early, 111 

errors in, 24 
Diarrhea, 114, 125, 154 

green, 259 
Diastase in feces, Wohlgemuth's 

method of determining, 261 



Diet after operation for gastric 
cancer, 466, 467 
after posterior gastro-enterostomy, 

441 
in etiology of gastric cancer, 35, 477 
in growths in body of stomach, 477 

near cardia, 477 
in patent gastric lumen, 479 
in pyloric stenosis, 478 
Differential diagnosis, 382 
Digestion leucocytosis, 332 

previous disorders of, in gastric 
cancer, 355 
Digestive disorders, 114 
Dilatation of stomach, post-opera- 
tive, 463, 464 
Diphtheria with gastric cancer, 49 
Disease, duration of, 148 
Drainage after complete gastrec- 
tomy, 458 
after excision of pyloric cancer, 
454 
Drug addictions, gastric cancer 

and, differential diagnosis, 416 
Duodenal alimentation, 478 
ulcer, 387 

acid dyspepsia in, 387 

appetite in, 389 

chronic appendix, dyspepsia in, 

387 
dilated stomach in, 389 
epigastric pain in, 388 

tenderness in, 389 
eructations in, 388 
facts determined upon exami- 
nation in, 389 
from history, 387 
upon Roentgen examina- 
tion in, 389 
gastric cancer and, differential 

diagnosis, 391 
glycyltryptophan test in, 238 
hematemesis in, 388 
hemoglobin in, 389 
hemorrhage in, 388 
indurated, 360 
melena in, 388 
pain time in, 388 
periodicity of complaint, 387 
plethora in, 389 



INDEX 



509 



Duodenal, ulcer, pyrosis in, 388 
seasonal relation of complaint 

in, 387 
sex in, 387 

tr^-ptophan test in, 238 
vomiting in, 388 
water-brash in, 388 
Wolff- Junghans' test in, 253 
Duration of disease, 148 

influence of, on demonstration 
of mobility of abdominal 
tumor, 180 
of malignant period, 132 
Dyspepsia, acid, in duodenal ulcer, 
387 
cbronic laparotomy in, 4:72 
Dysphagia, 114, 147 

Eczema "with gastric cancer, 50 
Edema, 162 

capillary, 319 
Edestin test of Fuld and Le^nson, 

228 
Emptj-ing power, gastric, investi- 
gation of, 194 
Enlarged lymph nodes in abdominal 

inspection, 172 
Enlargement of liver, 163 
Enteritis in gastric cancer, 106 
Eosinophiles in gastric cancer, 333 
Epigastric pain, 124 

in duodenal ulcer, 388 

tenderness in duodenal ulcer, 389 

tumor in gastric cancer in young, 
378 
Ereptases, specific, Abderhalden 

method for detection of, 344 
Ereptic ferment in gastric cancer, 

367 
Eructations, 483 

in duodenal ulcer, 388 

in gastric cancer in young, 378 
En,'sipela3 with gastric cancer, 49 
Erj"throcji;es, influence of metas- 
tases on, 322 

quantitative changes in, 321 

shape of, 326 

size of, 326 
Esophageal lesions, gastric cancer 

and, differential diagnosis, 392 



Etiologic factors in gastric cancer, 354 
Examination by fluoroscopic screen, 
275 
of abdomen, 166 

of feces, 256. See Feces, exami- 
nation of. 
of gastric function, 193 
by test-meal, 194 
of secretory' function in gastric 

cancer, 224 
physical, significance of, 365 
Roentgen, 268 
Excision, complete, in gastric can- 
cer, 418 
of colon in involvement of trans- 
verse colon in gastric cancer, 469 
of pyloric cancer, drainage after, 
454 
end of stomach, 441, 446 

care of transverse colon 

in. 448 
treatment of stumps in, 448 
Exploratory laparotomy, 382 
Extra-esophageal growths, circiun- 

scribed, excision of, 424 
Extragastric cancer, Wolff-Jung- 
hans' test in, 252 
disease association of gastric can- 
cer with, 48 
Extraglandular structures, hyper- 
plasia of, 90 
Extrapyloric cancer. 420 

circumscribed, excision of, 424 

Facial appearance, 161 

Fa mi ly incidence of gastric cancer, 

44, 45 
Farmers, gastric cancer in, 31 
Fasting stomach extracts, acidity of, 
201 
free hydrochloric aciditj^ iu, 
degree of, 202 
method of determin- 
ing, 202 
Fasting stomach extracts, total 
acidity of, 202 
determination of, 203 
Feces, bfliverdin in, 259 
blood in, 259 
cr^-stals in. 266 



510 



INDEX 



Feces, diastase in, Wohlgemuth's 
method of determining, 261 
examination of, 256 
chemical, 258 
macroscopic, 256 
microscopic, 263 
method, 264 
ferment tests of, 261 
hydrobilirubin in, 258 
leucocytes in, 266 
microscopic findings in, 265 
protozoa in, 265 
reaction of, 258 
red blood corpuscles in, 266 
tryptic digestion in, Gross-Wyn- 
hausen's method of determin- 
ing, 263 
undigested food in, 266 
Feldstein and WeU's viscosimeter, 

344 
Ferment tests of feces, 261 
Ferments, gastric, tests for, 227 
Fetor ex ore, 161 
Fibiger's rat tumors, 84 
Fibrous gastric cancer, 52 
Fistulse in gastric cancer, 103 
Fixation of stomach in gastric ulcer, 

387 
Flatulence, 485 

Fluoroscopic examination in gastric 
carcinosis, 281 
of abnormalities in gastric out- 
line, 277 
of growth at cardia, 279 

high in lesser curvature, 279 
in pars media, 279 
in pyloric region, 280 
on anterior wall, 281 
on posterior wall, 281 
of peristalsis, 282 
palpation in, 282 
screen, examination by, 275 
negative findings, 276 
positive findings, 276 
Food desire, 125 

relation of abdominal pain, 364 
remnants in gastric extract, 366 
Foreign bodies in large bowel, gas- 
tric cancer and, differential 
diagnosis, 412 



Foreign bodies in stomach, gastric 
cancer and, differential diag- 
nosis, 412 
Formol index, 229 
Free hydrochloric acidity of fasting 
stomach extracts, 
degree of, 202 
method of determin- 
ing, 202 
Frequency of gastric cancer, 17 

retention, 200 
Freund and Kaminer test, 339 
for precipitate, 341 
ingredients of, 339 
second, 341 
technic of, 341 
Frozen sections, examination of, for 

malignancy, 187 
Fuld and Levison, edestin test of, 

228 
Fundus, cancer of, Roentgenographic 
appearance, 292 

Gall-bladder disease, gastric can- 
cer and, differential diagnosis, 
394 
association of gastric ulcer with, 
384 
Gall-stones, 149 
Gall-tract, cancer of, gastric cancer 

and, differential diagnosis, 394 
Gastrectomy, complete, 456 
operative technique for, 457 
partial, gastro-enterostomy fol- 
lowing, 459 
total, prognosis after, 442 
Gastric acidity in gastric cancer in 
young, 379 
ulcer, 386 
low, Wolff-Junghans' test in, 

254 
relation of glycyltryptophan 
test to, 239 
of tryptophan test to, 240 
cancer, 17, 28 

abscess of pancreas and, differen- 
tial diagnosis, 401 
achylia gastrica and differential 
diagnosis, 403 
associated with, 47 



INDEX 



511 



Gastric cancer, acidity of stomacti 

after operation for, 466 

actinomycosis associated vrith., 
48 ' 
in etiology of, 27, 354 

alcoliol in etiology of, 37 

ascites in, 105 

Asiatic cholera with, 49 

association with other gastric 
disease, 46 

asthma with, 50 

bacteria in, 43 

Beck's operation in, 421 

benign t}"pe, 51 

blood in, 319 
changes, 321 

Blight's disease with, 50 

cancer of gall-tract and, dif- 
ferential diagnosis, 394 

carcinomatous type, 52 

care of oral ca^'ity in, 474 
of teeth in, 474 

causes, possible, 17-45 

cholecystitis with, 48 

choleHthiasis with, 48 

chronic constipation and, dif- 
ferential diagnosis, 414 

cirrhosis of Liver with, 50 

of stomach and, differential 
diagnosis, 411 

classification of, 51 

clinical consideration, 354 
differentiation from gastric 
cancer, 358 

clinically carcinomatous period 
of, 130 
developing in patients with 
years of antecedent dys- 
pepsia of peptic ulcer t%T)e, 
122 

colloid type, 58 

complete excision, 418 

conjugal state in etiology" of, 35 

constitutional diseases with, 50 
fatilts and, differential diag- 
nosis, 416 

cyst of pancreas and, differential 
diagnosis, 401 

decayed teeth in, 161 

definition, 17 



Gastric cancer, diabetes with, 50 

diagnostic errors in, 24 

diet in, 477 
after operation for, 466, 467 
in etiology of, 35 

diphtheria with, 49 

disease of pancreas and, dift'er- 
ential diagnosis, 397 

duodenal ulcer and, differential 
diagnosis, 391 

early diagnosis of, 112 

Roentgen examination in, 
273 

eczema with, 50 

edema in, 162 

enteritis in, 106 

ereptic ferment in, 367 

erA'sipelas with, 49 

esophageal lesions and, differ- 
ential diagnosis, 392 

etiologic factors in, 354 

etiology, possible, 17-45 

excision of colon in involvement 
of transverse colon in, 469 

experimental production in ani- 
mals, 84 

facial appearance in, 161 

family incidence of, 44, 45 

fetor ex ore in, 161 

fibrous type, 52 

fistulse in, 103 

foreign bodies in large bowel 
and, dift'erential diagnosis, 
412 
in stomach and, differential 
diagnosis, 412 

gall-bladder disease and, dif- 
ferential diagnosis, 394 

gastric granuloma and, differ- 
ential diagnosis, 411 
s^'p hilis associated with, 47 
ulcer and, differential diagno- 
sis, 391 

gelatinous type, 58 

general comphcations, 100 

distribution, 17 
frequency, 17 

glycyltrj-ptophan test in, 238 

gonorrhea with, 49 

gout with, 50 



512 



INDEX 



Gastric cancer, gross deviations 
from normal in, 52 
habits in etiology of, 38 
hemorrhage in, 101 
heredity in etiology of, 43, 474 
histologic deviations from nor- 
mal in, 58 
hygiene in etiology of, 41 
in cases operated for clinically 
benign gastric ulcer in whom 
cancer was microscopically 
diagnosed, 113-122 
in farmers, 31 
in Jews, 30 
in negroes, 28 

in patients in whom malignancy 
followed periods of gastric 
disturbance of irregular 
clinical type, 149-153 
who presented few clinical 
evidences of malignant pro- 
cess primary in stomach 
waU, 153-157 
who prior to onset of malig- 
nant disease had perfect 
gastric health, 134-148 
in young, 373 

abdominal tenderness in, 378 
appetite in, 376 
blood in, 379 

character of neoplasms in, 380 
clinical data in, 376 
constipation in, 376 
duration of gastric com- 
plaints in, 374 
epigastric tumor in, 378 
eructations in, 378 
gastric acidity in, 379 

emptying power in, 379 
incidence of, 373 
laboratory data in, 379 
laparotomy findings in, 380 
location of malignant process 

m, 380 
microscopic examination of 
unfiltered gastric extracts 
in, 380 
"occult" blood in, 380 
operative procedures in, 380 
outcome of, 380 



Gastric cancer, in young, pyrosis 
in, 378 

stools in, 379 

test-meals in, 379 

types of histories in, 374 

vomiting in, 378 

weight loss in, 376 
incidence of ascites in, 409 
increase in, 26 

indications for medical treat- 
ment in, 474 
infectious diseases with, 48 
involvement of transverse colon 

in, 443 
jaundice in, 106 
lack of progress in study of, 353 
la grippe with, 49 
liver metastases in, 105 
location of, 97, 368 

tables of, 99 
lung metastases in, 105 
malaria with, 49 
malignant hour-glass contrac- 
tion in, 101 

peritonitis and, differential 
diagnosis, 405 

type, 51 
management of symptoms in, 

482 
measles with, 49 
medullary type, 53 
morbid anatomy of, 51 
mortality, general increase, 20 

table of, 18-23 
mucoid type, 58 
mucous surfaces in, 161 
mumps with, 49 
nationality in etiology of, 28 
nephritis in, 106 
nervous compUcations in, 106 
non-surgical treatment of, 472 
nutrition in etiology of, 35 
obstruction at cardia in, 100 
occupation in etiology of, 31 
parasitic infections with, 49 
pathologic differentiation from 

gastric ulcer, 358 
pathology of, 370 
perforation in, 101 

perigastric abscess in, 102 



INDEX 



513 



Gastric cancer, pneumonia after 
operation for, 463 
precarcinomatous period in, 123, 

149 
preparation for operation in, 419 
previous disorders of digestion 

in, 355 
proctoclysis after operation in, 

465 
prognosis after operation in, 442 
prophylaxis in, 472 
proteid diet in etiology of, 37 
protozoal infection with, 50 
protozoic infections of bowel 
and, differential diagnosis, 
414 
pyloric obstruction in, 100 
quinsy with, 49 
rate of growth, 95 
age factor in, 96 
influence of body nutrition 
on, 96 
of location in, 97 
ratio of occurrence, 22 
raw food in etiology of, 33 
rectal feeding in, 481 
relation to gastric ulcer, 46 
sarcoma of stomach and, dif- 
ferential diagnosis, 412 
sarcomatous type, 52 
scarlet fever with, 49 
secondary to extragastric malig- 
nant process, 157 
to malignancy in other or- 
gans, 409 
Senn's operation for, 423 
seven signs of inoperability of, 

186 
sex in etiology of, 26 
significance of gastric ulcer with 
respect to, 350 
of history in, 354 
smallpox with, 49 
Smithies' percussion sign in, 188 
social status in etiology of, 34 
surgical treatment of, 417 
symptomatology, 110 
symptom-complexes of, 112 
syphilis of stomach and, differ- 
ential diagnosis, 409 
33 



Gastric cancer, thrombosis in, 106 
tobacco habit in, etiology of, 38 
toilet of stomach in, 476 
tonsillitis with, 49 
traumatism in etiology of, 39, 40 
treatment of, by autolysates, 
496 
by chemotherapy, 499 
by Coley's toxins, 496 
by mesothorium, 495 
by radio-active water, 495 
by radium, 495 
by Roentgen rays, 493 
by serotherapy, 496 
by vaccines, 496 
by Vaughan's split-proteid 
vaccine, 497 
tryptophan test in, 237 
tuberculosis of stomach and, 

differential diagnosis, 410 
tumors of abdominal wall and, 
differential diagnosis, 416 
of kidney and, differential 

diagnosis, 402 
large intestine and, differen- 
tial diagnosis, 402 
of liver and, differential diag- 
nosis, 396 
of omentum and, differential 

diagnosis, 402 
of retroperitoneal tissues and, 

differential diagnosis, 402 
of small intestine and, dif- 
ferential diagnosis, 403 
types of, 370 
typhoid fever with, 49 
ulcerating type, 54 
variation in pathologic opinion 

as to life history of, 352 
venereal disease in etiology of, 

39 
with malignancy primary in 

other organs, 48 
with pleurisy, 49 
with pneumonia, 49 
with rheumatism, 49 
with tuberculosis, 47, 48 
with yellow fever, 49 
carcinosis, fluoroscopic examina- 
tion in, 281 



514 



INDEX 



Gastric disease, association with gas- 
tric ulcer, 46 
emptying power in gastric cancer 
in young, 379 
investigation of, 194 
normal, time limit for, 196 
physiologic method of estimat- 
ing, 195 
extract, acidity of, 366 

blood in relation of Wolff- 

Junghans' test to, 255 
food remnants in, 366 
lactic acid in, 366 
microscopic examination of, 367 
occidt blood in, 367 
Oppler-Boas bacilU in, 367 
unfiltered microscopic examina- 
tion of, 380 
ferments, tests for, 227 
function, examination of, 193 

by test-meal, 193 
hemorrhage, treatment of anemia 

after, 493 
inflation, effect of, on abdominal 

tumor, 182 
lavage before abdominal examina- 
tion, 167 
lumen, patent, diet in, 479 
mucosa, hyperplasia of elements 
of, 86 
retrograde changes in, 93 
neoplasms, classification of, 51 
location of, 97 
rate of growth, 95 
outline, abnormalities in, fluoro- 
scopic examination of, 277 
residue in gastric ulcer, 387 
retention extracts, acid salts in, 203 
acidity in, 225 
amdunt of, 225 
bacteria in, 211 
bile coloring in, 200 
chymification of, 201 
color of, 200 
combined acidity, 226 
degree of combined acidity 
of, 203 
of total acidity of, 203 
examination of unstained 
preparations, 210 



Gastric retention extracts, free 
hydrochloric acid in, 225 
Gluzinski's method of deter- 
mining, 226 
lactic acid in, 226 

method of determina- 
tion of, 204 
macroscopic study of, 200, 

225 
microscopic examination of, 
206, 226 
method of, 207 
significance of, 210 
mucus in, 201 
"occult" blood in, 204, 226 
benzidin test for, 205 
instances of, 206 
method of determining, 
205 
odor of, 201, 225 
Oppler-Boas bacillus in, 211 
staining, by colored agar 

method, 208 
traumatic blood in, 200 
frequency of, 200 
syphilis associated with gastric 

cancer, 47 
ulcer, 384 

actinomycosis associated with, 

47 
alterations in gastric peristalsis 

in, 387 
area of tenderness in, 387 
association with disease of ap- 
pendix, 384 
of gall-bladder, 384 
clinical differentiation from gas- 
tric cancer, 358 
dietetic irregularities in, 384 
epigastric distress in, 384 
facts determined from history 
of, 384 
obtained by examination in, 

385 
secured by laboratory exami- 
nation in, 385 
fixation of stomach in, 387 
food relief of distress in, 384 
gastric cancer and, differential 
diagnosis, 391 



INDEX 



515 



Gastric ulcer, gastric cancer, and, 
residue in, 387 
geographic variation in inci- 
dence of, 351 
glycyltryptophan test in, 238 
hemorrhage in, 385 
hour-glass stomach in, 387 
hyperplasia in, 86 
in young, abdominal pain in, 

377 
malignant ulcer in, 361 
microscopic examination in, 386 
pathologic differentiation from 

gastric cancer, 358 
periodicity of complaint in, 384 
recurring acute infections in, 

384 
relation to gastric cancer, 46 
Roentgen-ray findings in, 387 
significance of, with respect to 

gastric cancer, 350 
simple, Wolff-Junghans' test in, 

253 
stools in, 386 
symptomatology, when disease 

is well established, 146 
symptom-complexes of, 356 
test-meal findings in, 385 
tryptophan test in, 238 
variation in accepted clinical 
complex of, 353 
in pathologic opinion as to 
life history of, 352 
vomiting in, 385 
Gastro-enterostomy, anterior, 430 
following partial gastrectomy, 459 

technique of, 460 
for carcinoma of pylorus, 427 
lavage after, 439 
opening, location of, 428 
posterior, 428 
Gastrojejunostomy, 431 
anterior, 429 
posterior, 431, 432 
Gastroscope, Sussmann, 190 
Gastroscopy, 189 
Gastrostomy, Witzel's technique of, 

422 
Gelatinous gastric cancer, 58 
General appearance of patient, 160 



Geographic variation in incidence of 

gastric ulcer, 351 
Gland cells, abnormal proliferation 

of, 79 
Gluzinski's method of determining 
acidity of gastric retention ex- 
tracts, 226 
Glycyltryptophan test, 230, 367 
effect of bile on, 242 
of blood on, 243 
of chyle on, 242 
in duodenal ulcer, 238 
in gastric cancer, 238 
organic acid in, 241 
relation of, to gastric acidity, 

239 
results, 23^237 
Smithies' modification of, 232 
summary, 244 
Gonorrhea with gastric cancer, 49 
Gout with gastric cancer, 50 
Granuloma, gastric cancer and, dif- 
ferential diagnosis, 411 
Green diarrhea, 259 
Gross- Wynhausen's method of deter- 
mining tryptic digestion in feces, 
263 
Growth of gastric neoplasms, rate of, 

95 
Gum chewing after operation, 465 



Habits in etiology of gastric cancer, 

38 
Hematemesis, 364 

in duodenal ulcer, 388 
Hemoglobin in duodenal vilcer, 389 

influence of metastasis on, 325 

quantitative changes in, 324 
Hemolytic reaction, 334, 367 

technique of, 335 
Hemorrhage, 101, 115, 147, 149, 364, 
486 

treatment of anemia after, 493 

in duodenal ulcer, 388 

in gastric ulcer, 385 

"occult," 147 

treatment by coagulose, 486 
Heredity in etiology of gastric can- 
cer, 43, 474 



516 



INDEX 



Histologic deviations from normal 
in gastric cancer, 58 
type, influence of, on demonstra- 
tion of mobility of abdominal 
tumor, 180 
History, precancerous, 355 

significance of, in gastric cancer, 
354 
Hot bath before abdominal palpa- 
tion, 173 
Hour-glass contraction, malignant, 
in gastric cancer, 101 
in gastric ulcer, 387 
Hydrobilirubin in feces, 258 
Hydrochloric acid, free, in gastric 

retention extracts, 225 
Hygiene in etiology of gastric can- 
cer, 41 
Hyperplasia in gastric ulcer, 86 
of elements of gastric mucosa, 86 
of extraglandular structures, 90 

Incidence of gastric cancer in 

young, 373 
Index, formol, 229 

peptic, 228 
Indigestion, 124 
Indurated duodenal ulcer, 360 
Infectious diseases, gastric cancer 

with, 48 
Ingredients of test-meal, 195 
Inguinal nodes, involvement of, 184 
Inspection of abdomen, 169 

of patient, 160 
Investigation of gastric emptying 

power, 194 
Involvement of Blumer's shelf, 184 

of inguinal nodes, 184 

of liver, 186 

of lymph-glands, 184 

of pyloric lymph-glands, 186 

of supraclavicular glands, 185 

Jaundice, 149 

in gastric cancer, 106 
Jews, gastric cancer in, 30 
Junghans-Wolff test for soluble 

albumin, 245, 368 

Kaminer and Freund test, 339 



Kidney, tumors of, gastric cancer 
and, differential diagnosis, 402 

Laboratory data in gastric cancer 
in young, 379 
examination, facts secured by, in 
gastric ulcer, 385 
Lactic acid in gastric retention ex- 
tracts, 226, 366 
method of determina- 
tion, 204 
La grippe with gastric cancer, 49 
Laparotomy, exploratory, 382 

findings in gastric cancer in 

young, 380 
in chronic dyspepsia, 472 
Large intestine, tumors of, and 
gastric cancer, differential diagno- 
sis, 402 
Lavage after posterior gastro-enter- 
ostomy, 439 
best time for, 477 
in post-operative dilatation of 

stomach, 465 
tube, 196, 197. See also Stomach 
tube. 
Leucocyte count, maximum, 329 

minimum, 329 
Leucocytes, basophile, in gastric 
cancer, 332 
changes in, quantitative, 327 
in feces, 266 

polynuclear, in gastric cancer, 332 
qualitative variation in, 332 
transitional, in gastric cancer, 332 
Leucocytosis, 329 

digestion, 332 
Levison and Fuld, edestin test of, 

228 
Liver, enlargement of, 163 
involvement of, 186 
metastases in gastric cancer, 105 
tumors of, gastric cancer and, dif- 
ferential diagnosis, 396 
Location of gastric cancer, 97, 368 

in young, 380 
Loss of weight, 150, 154, 163 
Lungs, metastases to, in gastric can- 
cer, 105 
Lymph-glands, involvement of, 184 



INDEX 



517 



Lymphocj-tes, large, in gastric can- 
cer, 332 
small, in gastric cancer, 332 

]Macroscopic examination of cul- 
tures of Oppler-Boas bacillus, 
215, 222, 223 
of feces, 256 

of gastric retention extracts, 
200, 225 
"Magenweg," 279 
]Malaria with gastric cancer, 49 
Malignanc}^ primarj^ in other organs, 

gastric cancer with, 48 
Malignant and benign groA;rths, as- 
sociation of, 371 
gastric cancer, 51 
period, duration of, 132 
ulcer in gastric ulcer, 361 
Management of sjTnptoms in gas- 
tric cancer, 482 
Measles with gastric cancer, 49 
Medullary gastric cancer, 53 
Melena, 364 

in duodenal ulcer, 388 
Mental attitude factor in weight 

loss, 166 
Mesothorium, treatment of gastric 

cancer by, 495 
Metagastric alimentation, 478 
Metastasis, external e^ddence of, 162 
influence on er\i;hroc}'tes, 322 

on hemoglobin, 325 
to peritoneum, 163 
Meyer and Bergmann's antitryptic 

reaction, 342 
Meyer, Willy, air-pressure cabinet 

of, 421 
Microscopic examination in gastric 
ulcer, 386 
of cidtuxes of Oppler-Boas bacil- 
lus, 222, 223 
of feces, 263 

method of, 264 
of gastric retention extracts, 
206, 226 
method of, 207 
significance of, 210 
of Oppler-Boas bacillus, 215 
findings in feces, 265 



:Milk, cancer, 246 

Miostagmin reaction, AscoH's, 348 

Mobility of abdominal tumor, 179 

]Mode of onset, in gastric cancer, 113, 
136 

Morbid anatomj', of gastric cancer, 
51 

Mortality, tables of, in gastric can- 
cer, 18-23 

Motor-meal tube, Smithies', 196, 197 

-Mucoid gastric cancer, 58 

Mucous membranes, appearance of, 
319 
surfaces,. 161 

Mucus in gastric retention extracts, 
201 

Miunps with gastric cancer, 49 

Murphy drip method of rectal feed- 
ing, 481 

]vIyeloc}"tes in gastric cancer, 332 

Xatigxalitt in etiology of gastric 
cancer, 28 

Negative test for "occult" blood, 261 

Xegroes, gastric cancer in, 28 

Xelaton tumor, 174 

Xephritis in gastric cancer, 106 
Wolff-Junghans' test in, 254 

Xers^ous comphcations in gastric 
■ cancer, 106 
signs, 163 

Non-pjdoric cancers, surgical treat- 
ment of, 420 

Xon-surgical treatment of gastric 
cancer, 472 

Xutrition, 115 

in etiologj' of gastric cancer, 35 

"Occult" blood, clinical interpreta- 
tion of tests for, 260 
in gastric cancer in young, 380 
retention extracts, 204, 226, 
367 
benzidin test for, 205 
instances of, 206 
method of determining, 
205 
negative test for, 261 
hemorrhage, 147 



518 



INDEX 



Occupation in etiology of gastric 

cancer, 31 
Odor of gastric retention extracts, 

201, 225 
Omentum, tumors of, gastric cancer 

and, differential diagnosis, 402 
Operation, chewing of gum after, 465 
in gastric cancer, preparation for, 
419 
Operative technique for gastrec- 
tomy, 457 
Oppler-Boas bacillus, artificial cult- 
ure of, 214 
characteristics of, 212 
cultures in beef bouillon, 216 

after forty-eight hours, 

220 
after seventy- two hours, 
221 
macroscopic examination, 

222, 223 
microscopic examination, 222, 
223 
frequency of occurrence, 224 
in gastric extract, 367 

retention extracts, 211, 212 
macroscopic examination, 215 
microscopic examination, 215 
staining properties of, 213 
Oral cavity, care of, in gastric can- 
cer, 474 
condition, bad, weight loss from, 
165 
Organic acid in glycyltryptophan 
test, 241 
in tryptophan test, 241 

Pain, 485 

abdominal, 132, 149 
food relation of, 364 
in gastric cancer in young, 377 

epigastric, 124 

time in duodenal ulcer, 388 

types of, 116, 364 
Palpation, abdominal, 172 

in fluoroscopy, 282 
Pancreas, disease of, gastric cancer 

and, differential diagnosis, 397 
Parasitic infections with gastric 

cancer, 49 



Pars media, fluoroscopic examina- 
tion of growth in, 279 
growth in, Roentgenographic 
appearance of, 292 
Partial gastrectomy, gastro-enter- 

ostomy following, 459 
Passage of stomach tube, technique 

of, 199 
Pathology of gastric cancer, 370 
Patient, general appearance of, 160 
after establishment of malig- 
nancy, 161 

inspection of, 160 

preparation of, for operation, 419 
Pepsin, tests for, 227 
Peptic index, 228 
Percussion, 187 
Percy and Cook's method of blood 

transfusion, 486 
Perforation in gastric cancer, 101 
Perigastric abscess in perforating 

gastric cancer, case, 102 
Periodicity of symptoms, 363 
Peristalsis, fluoroscopic examination 
of, 282 

alterations of, in gastric ulcer, 
387 

visible, in abdominal inspection, 
170 
Peritoneal cavity, presence of free 

fluid in, 185 
Peritoneum, metastasis to, 163 
Peritonitis, malignant, gastric can- 
cer and, differential diagnosis, 

405 
Phantom tumor, 171 
Physical abnormalities, 160 

examination, signiflcance of, 365 
Physiologic method of estimating 

gastric emptying power, 195 
Plethora in duodenal ulcer, 389 
Pleurisy, gastric cancer with, 49 
Pneumonia after operation for gas- 
tric cancer, 463 

gastric cancer with, 49 
Poikilocytosis, 327 
Polynuclear leucocytes in gastric 

cancer, 332 
Poor-appetite habit, weight loss 

from, 166 



INDEX 



519 



Position of abdominal tumor, 176 

relation to part of stomach 
involved, 177 
of patient for abdominal examina- 
tion, 168 
Posterior-gastro-enterostomy, 428 
after-treatment of, 440 
diet after, 441 
gastrojejunostomy, 431, 432 
wall, fluoroscopic examination of 
growth on, 281 
Roentgenographic appearance 
of growth in, 292 
Post-operative dilatation of stom- 
ach, 463, 464 
lavage for, 465 
treatment, 463 
Precancerous history, 355 
Precarcinomatous period, 123, 149 
Preparation for operation in gastric 
cancer, 419 
of patient for abdominal examina- 
tion, 167 
for operation, 419 
for Wolff-Junghans' test, 247 
of stomach for operation, 419 
Proctoclysis after operation in gas- 
tric cancer, 465 
Prognosis after operation in gastric 
cancer, 442 
after total gastrectomy, 442 
Prophylaxis in gastric cancer, 472 
Proteid diet in etiology of gastric 

cancer, 37 
Protozoa in feces, 265 
Protozoal infection with gastric 
cancer, 50 
of bowel, gastric cancer and, 
differential diagnosis, 414 
Pyloric cancer, drainage after exci- 
sion of, 454 
end of stomach, excision of, 441, 
446 
Roentgenographic appear- 
ance of growth at, 303 
lymph-glands, involvement of, 186 
obstruction in gastric cancer, 100 
region, fluoroscopic examination 

of growth in, 280 
stenosis, diet in, 478 



Pylorus, carcinoma of, 426 

Pyorrhea alveolaris, 161 

Pyrosis, 483 

in duodenal ulcer, 388 

in gastric cancer in young, 378 

Qualitative variation in leucocytes, 

332 
Quantitative changes in erythro- 
cytes, 321 
in hemoglobin, 324 
Quinsy with gastric cancer, 49 

Race in etiology of gastric cancer, 28 

Radio-active water, treatment of 
gastric cancer by, 495 

Radium in treatment of gastric can- 
cer, 495 

Ransohoff's anaphylaxis test, 348 

Rat tumors, Fibiger's, 84 

Raw food in etiology of gastric can- 
cer, 33 

Reaction, antitryptic, Bergmann 
and Meyer's, 342 
Ascoli's miostagmin, 348 
glycyltryptophan, 231, 367 
hemolytic, 334, 367 
technique of, 335 
of feces, 258 
skin, 337 
tryptophan, 231 

Reagent, Wolff's, 248 

Rectal feeding by Murphy drip 
method, 481 
in gastric cancer, 481 

Red blood corpuscles in feces, 266 

References to Hterature, 50, 108, 
266, 349, 371, 381, 416, 499 

Registration of cancer cases, 474 

Rennin, tests for, 227 

Respiratory movements, effect of, 
on mobility of abdominal tumor, 
183 

Retrograde changes in gastric mu- 
cosa, 93 

Retroperitoneal tissues, tumors of, 
gastric cancer and, differential 
diagnosis, 402 

Rheumatism, gastric cancer with, 
49 



520 



INDEX 



"Ring cancer," Roentgenographic 

appearance of, 303 
Roentgen diagnosis in earlj- gastric 
cancer, 273 
examination, 268 

class of cases for, 268 
information derived from, 287 
methods of, 27-i 
rays, treatment of gastric cancer 
by, 493 
indications for, 494 
Roentgenographic appearance of 
body of stomach, 292 
of cancer of fundus, 292 
of growth in anterior wall, 292 
in pars media, 292 
in posterior wall, 292 
of ring cancer, 303 
plates, examination by, 283 
mode of procedure, 284 
Roentgen-ray findings in gastric 
ulcer, 387 

Sarcoma, gastric, 52 

gastric cancer and, differential 
diagnosis, 412 

Scarlet fever with gastric cancer, 49 

Scirrhus, 52 

Sclera, appearance of, 319 

Secretory function of stomach, ex- 
amination of, 224 

Senn's operation for gastric cancer, 
423 

Serotherapy in gastric cancer, 496 

Seven signs of inoperability of gas- 
tric cancer, 186 

Sex in duodenal ulcer, 387 

in etiologj!- of gastric cancer, 26, 
354 

Shadows, blood, 327 

Shape of erythrocj^tes, 326 

Significance of clinical symptoms, 
363 
of physical examination, 365 
of test-meal findings, 366 

Size of abdominal tumor, 178 
of erj^hrocj^tes, 326 

Skin, appearance of, 319 
in abdominal palpation, 173 
reaction, 337 



Small intestine, tumors of, gastric 
cancer and, differential diagnosis, 
403 
Smallpox with gastric cancer, 49 
Smithies' colored agar staining 
method, 208 
method of examination of gastric 

retention extracts, 210 
modification of glycyltryptophan 
test, 232 
of tryptophan test, 233 
motor-meal and lavage tube, 196, 

197 
percussion sign in cancer of fun- 
dus of stomach, 188 
Social status in etiology of gastric 

cancer, 34 
Soluble albumin, Wolff-Junghans' 

test for, 245, 368 
Special tests, 367 
Splenic enlargement, gastric cancer 

and, differential diagnosis, 402 
Split-proteid vaccine, Vaughan's, for 

treatment of gastric cancer, 497 
Staining of gastric retention extracts, 

by colored agar method, 208 
Stomach, cancer of, 17. See also 
Gastric cancer. 
diet in growths in body of, 477 
dilated, in duodenal ulcer, 389 
examination of secretory func- 
tion of, 224 
excision of pyloric end of, 446 
post-operative dilatation of, 463, 

464 
preparation of, for operation, 419 
testing emptying power of, 275 
toilet of, in gastric cancer, 476 
tube. Smithies', 196, 197 
advantages of, 198 
description of, 197 
faiilts of ordinarj', 197 
technique for passage of, 199 
Stools, examination of, 256. See 
also Feces, examination of. 
in gastric cancer in young, 379 
ulcer, 386 
Strength of patients, 115 
Supraclavicular glands, involvement 
of, 185 



INDEX 



521 



Surgical considerations, 368 

treatment of gastric cancer, 417 
of non-pyloric cancers, 420 
Sussmann's gastroscope, 190 
Symptomatology' of gastric cancer, 

110 
Symptom-complexes of gastric can- 
cer, 112 
of gastric ulcer, 356 
Symptoms, clinical, significance, 363 

periodicity of, 363 
SypMlis, gastric, Wolff-Junghans' 
test in, 252 
gastric cancer and, differential 
diagnosis, 409 

Technique of blood transfusion, 489 

of gastro-enterostomy following 

partial gastrectomy, 460 

Teeth, care of, in gastric cancer, 474 

decayed, 161 

extraction of, contracting gums 

after, 475 
in etiology of gastric cancer, 42 
Temperature, 147 

Tenderness, abdominal, in gastric 
cancer in j^oung, 378 
area of, in gastric ulcer, 387 
of palpable abdominal tumors, 178 
Test, edestin of Fuld and Levison, 
228 
glycyltryptophan, 230, 244 
results, 234-237 
Smithies' modification, 232 
Kaminer and Freund, 339 
Ransohoff's anaphjdaxis, 348 
tr3rptophan, 231 
results, 23-t-237 
Smithies' modification, 233 
summary, 244 
typical, 234 
Test-meal examination of gastric 
function, 193 
findings, 117 

comparison of, with Wolff- 
Junghans' test, 251 
in gastric ulcer, 385 
significance of, 366 
ingredients of, 195 
in gastric cancer in young, 379 
Tests, special, 367 



Thrombosis in gastric cancer, 106 
Tobacco habit in etiology of gastric 

cancer, 38 
Tonsillitis with gastric cancer, 49 
Total acidity, degree of, in gastric 
retention extracts, 203 
of fasting stomach contents, 202 
determination of, 203 
Transfusion of blood, Percy and 

Cook's method, 486 
Transitional leucocj'tes in gastric 

cancer, 332 
Transverse colon, care of, in exci- 
sion of pj'loric end of stom- 
ach, 448 
involvement of, in gastric can- 
cer, 443 
excision of colon in, 469 
Traumatism in etiology of gastric 

cancer, 39, 40 
Treatment of anemia after gastric 
hemorrhage, 493 
of gastric cancer by autolysates, 
496 
by chemotherap}', 499 
by Coley's toxins, 496 
by mesothorium, 495 
by radio-active water, 495 
by radium, 495 
by Roentgen rays, 493 
by vaccines, 496 
medical, indications for, 474 
non-surgical, 472 
post-operative, 463 
surgical, 417 
Trj^ptic digestion in feces, Gross- 
Wynhausen's method of determin- 
ing, 263 
Tryptophan test, 231 
effect of bile on, 242 
of blood on, 243 
on chyle, 242 
in duodenal ulcer, 238 
in gastric cancer, 237 

ulcer, 238 
organic acid in, 241 
relation of, to gastric acidity, 

240 
results, 234-237 
Smithies' modification, 233 
summarj^, 244 



522 



INDEX 



Tryptophan test, typical, 234 
Tube for blood transfusion, 487 

for gastric lavage, Smithies', 196, 
197 
Tuberculosis associated with gastric 
cancer, 47, 48 

of stomach, gastric cancer and, 
differential diagnosis, 410 
Tumor, abdominal, 175 

N^laton, 174 

phantom, 171 
Tumors of liver, gastric cancer and, 

differential diagnosis, 396 
Two-stage operation for carcinoma 

of pylorus, 427 
Types of gastric cancer, 370 

of pain, 364 
Typhoid fever with gastric cancer, 49 

Ulcer, duodenal, 387. See also 

Duodenal ulcer. 
Ulcerating gastric cancer, 54 
Ulcus carcinomatosum, 54, 94, 361 

Wolff-Junghans' test in, 250 
Uncolored preparations of gastric 

retention extracts, examination 

of, by Smithies' method, 210 
Uncooked vegetables, danger from, 

480 
Undigested food in feces, 266 
Urine, 148 

Vaccine treatment of gastric can- 
cer, 496 
Vaughan's split-proteid vaccine for 

treatment of gastric cancer, 497 
Venereal disease in etiology of gas- 
tric cancer, 39 
Viscosimeter, Weil and Feldstein's, 

344 
Vomiting, in duodenal ulcer, 388 
in gastric cancer, 115, 125, 133, 
149, 365, 482 
in young, 378 
ulcer, 385 
weight loss from, 165 

Water-bkash, 114, 149 
in duodenal ulcer, 388 
Weight loss, 125, 148, 150, 154, 163, 
164 
age factor in, 165 



Weight loss, factor of mental atti- 
tude in, 166 
from bad oral conditions, 165 
from poor-appetite habit, 1 66 
from undereating, 165 
from vomiting, 165 
in gastric cancer in young, 376 
Weil and Feldstein's viscosimeter, 

344 
Wilson's rapid method of cutting 

and staining cancer tissue, 107 
Witzel's gastrostomy, technique of, 

422 
Wohlgemuth's method of determin- 
ing diastase in feces, 261 
Wolff-Junghans' test, comparison of 
other test-meal findings, with, 
251 
for soluble albumin, 245, 368 
in achlorhydria, 253 
in cardiovascular disease, 254 
in duodenal ulcer, 253 
in extragastric cancer, 252 
in gastric syphilis, 252 
in low gastric acidity, 254 
in malignant and benign achy- 
lias, 246 
in nephritis, 254 
in primary anemias, 252 
in simple achylia gastrica, 253 

gastric ulcer, 253 
in ulcus carcinomatosum, 250 
interpretation of, 248 
manifestation of, 248 
manifestations of, relation to 
location of malignant process, 
250 
mode of procedure, 248 
preparation of patient for, 247 
relation of, to presence of blood 

in gastric extracts, 255 
results of, 249 
Wolff's reagent, 248 
Wynhausen-Gross' method of deter- 
mining tryptic digestion in feces, 
263 
X-RAY examination, 268. See also 

Roentgen examination. 
Yellow fever with gastric cancer, 49 
Young, gastric cancer in, 373 



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Prentiss' Embryology 

Laboratory Manual and Text=Book of Embryology. By Charles 
W. Prentiss, Ph. D., Professor of Microscopic Anatomy, Northwestern 
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368 illustrations, 50 in colors. Cloth, $3.75 net. 

JUST ISSUED 

Prof. Prentiss' new work has many features that make it extremely valuable 
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It is the only comparatively brief text in which a large number of original 
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palate, and tongue of these embrj'os. Of the same embr^^os from which series 
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vous system. The book contains 368 illustrations, 50 in colors. 



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Mallory*s 
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Patoologic Histology. By Frank B. Mallory, M. D., Associate 
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of 677 pages, with 497 figures containing 683 original illustrations, 124 
in colors. Cloth, $5.50 net ; Half Morocco, ;^7.oo net. 

REPRINTED IN THREE MONTHS 

Dr. Mallory here presents pathology from the morphologic point of view. He 
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that may terminate in that particular end-result to the primal cause of the lesion. 
The illustrations are most beautiful. 

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Howeirs Physiology 



A Text=Book of Physiology. By William H. Howell, Ph.D., 
M. D., Professor of Physiology in the Johns Hopkins University, Balti- 
more, Md. Octavo o{ 1020 pages, 306 illustrations. Cloth, $4.00 net. 

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the same time, however, sufficient consideration has been given to the experimen- 
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his work. Illustrations have been most freely used. 

The Lancet. London 

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PATHOLOGY 



Mallory and Wright's 
Patholog»ic Technique 

Just Issued — New (6th) Edition 

Pathologic Technique. A Practical Manual for Workers in Patho^ 
logic Histology, including Directions for the Performance of Autopsies 
and for Clinical Diagnosis by Laboratory Methods. By Frank B. 
Mallory, M. D., Associate Professor of Pathology, Harvard Univer- 
sity; and James H. Wright, M. D., Pathologist to the Massachusetts 
General Hospital. Octavo of 538 pages, with 160 illustrations. Cloth, 
;^300 net. 

In revising the book for the new edition the authors have kept in view the 
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Boston Medical and Surgical Journal 

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Eyre's Ba^cteriologic Technic 

Bacteriologic Technic. A Laboratory Guide for the Medical, 
Dental, and Technical Student. By J. W. H. Eyre, M. D., F. R. S. 
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London. Octavo of 520 pages, 219 illustrations. Cloth, $3.00 net. 

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thorough was his revision that the entire book, enlarged by some 1 50 pages and 
50 illustrations, had to be reset from cover to cover. He has included all the 
latest technic in every division of the subject. His thoroughness, his accuracy, his 
attention to detail make his work an important one. He gives clearly the technic 
for the bacteriologic examination of water, sewage, air, soil, milk and its products, 
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experience. To any one interested in this line of endeavor the new edition of 
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McFarland*s Pathology 



A Text=Book of Pathology. By Joseph McFarland, M. D., Pro- 
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colors. Cloth, ^5.00 net; Half Morocco, ^6.50 net. 

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McFarland's 

Biolog(y: Medical and General 

Biology: Medical and Genera!. — By Joseph McFarland, M. D., 
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NEW (2d) EDITION 
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BACTERIOLOGY AND HISTOLOGY. 



McFarland*s Pathogenic 
Bacteria and Protozoa 

Pathogenic tSacteria and Protozoa. By Joseph McFarland, M. D., 
Professor of Pathology and Bacteriology in the Medico-Chirurgical 
College of Philadelphia. Octavo of 878 pages, finely illustrated. 
Cloth, ^$3.50 net. 

NEW (7th) EDITION, ENLARGED 

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for McFarland' s work a place in the very front of medical bacteriologies. The 
illustrations are the best the world affords, and are beautifully executed. 

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of Trinity College." 

The Lancet, London 

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v/ritten. . . . The descriptions given are accurate and readable." 

Hill's Histology and Organography 

A Manual of Histology and Organography. By Charles Hill, 
M. D., formerly Assistant Professor of Histology and Embryology, 
Northwestern University, Chicago. i2mo of 483 pages, 337 illustra- 
tions. Cloth, ^2.25 net. 

THE NEW (3d) EDITION 

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a 



book of this size. Particular consideration is given the mouth and teeth. 



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THE BEST /\ m 6 r 1 C St H standard 

Illustrated Dictionary 

Just Out— New (8th) Edition— 15OO New Terms 



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PATHOLOGY 



Stengel ^ Fox*s Pj^thology 

Pathology. By Alfred Stengel, M. D., Sc. D., Professor of Medi- 
cine, University of Pennsylvania; and Herbert Fox, M. D., Director 
of the Pepper Laboratories of Clinical Medicine, University of Pennsyl- 
vania. Octavo of 1045 pages, with 468 text-illustrations, many in 
colors, and 15 colored plates. Cloth, ^6.00 net ; Half Morocco, $7.50 net. 

JUST READY— NEW (6th) EDITION. REWRITTEN 

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175 pages has been added and some 75 new illustrations, many of them in colors. 
The work is a handsome volume of over 1000 pages. In the first portions, de- 
voted to general pathology, the sections on inflammation, retrogressive processes, 
disorders of nutrition and metabolism, general etiology, and diseases due to bac- 
teria were wholly rewritten or very largely recast. A new section on transmissible 
diseases was added ; the terata were included, with a synoptical chapter on terat- 
ology. Th« glands of internal secretion were given a separate chapter, and new 
chapters on the pathology of eye, ear, and skin were added. 



Stiles on the Nervous System 

The Nervous System and its Conservation. By Percy G. 
Stiles, Instructor in Physiology at Harvard University. i2mo of 230 
pages, illustrated. Cloth, $\.2^ net. 

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Stiles' Nutritional Physiology 

Nutritional Physiology. By Percy Goldthwait Stiles, In- 
structor in Physiology at Harvard University. i2mo of 295 pages, 
illustrated. Cloth, ^1.25 net. 

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This new work expresses the most advanced views on this important subject 
It discusses in a concise way the processes of digestion and metabolism. The 
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" It is remarkable for the fineness of its diction and for its clear presentation of the sub- 
ject, relieved here and there by a quaintly humorous turn of phrase that is altogether delight- 
ful." — Colin C. Stewart, Ph. D., Dartmouth College. 



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Jordan's 
General Bacteriology 

A Text=Book of General Bacteriology. By Edwin O. Jordan, Ph.D., 
Professor of Bacteriology in the University of Chicago and in Rush 
Medical College. Octavo of 650 pages, illustrated. Cloth, ;^3.oo net. 

NEW (4th) EDITION 

Professor Jordan's work embraces the entire field of bacteriology, the non- 
pathogenic as well as the pathogenic bacteria being considered, giving greater 
emphasis, of course, to the latter. There are extensive chapters on methods of 
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on the bacterial production of pigment, acid and alkah ; and on ptomains and 
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rhea, diphtheria, dysentery, and tetanus. The relation of bovine to human 
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This work will also appeal to academic and scientific students. It contains 
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water, food preservatives, the processes of leather tanning, tobacco curing, and 
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sanitary engineering, etc. 

Prof. Severance Burrage, Associate Professor of Sanitary Science , Purdue University. 

" I am much impressed with the completeness and accuracy of the book. It certainly 
covers the ground more completely than any other American book that I have seen. 



Buchanan's 
Veterinary Bacteriology 

Veterinary Bacteriology. By Robert E. Buchanan, Ph.D., Pro- 
fessor of Bacteriology in the Iowa State College of Agriculture and 
Mechanic Arts. Octavo, 5 16 pages, 2 14 illustrations. Cloth, ^3.00 net. 
THE BEST PUBLISHED 

Professor Buchanan discusses thoroughly all bacteria causing diseases of the 
domesdc animals. He goes minutely into the consideration of immunity, opsonic 
index, reproduction, sterilization, antiseptics, biochemic tests, culture-media, 
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B. F. Kaupp, D. V. S., State Agricultural College, Fort Collins. 

" It is the best in print on the subject. What pleases me most is that it contains all the late 
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EMBRYOLOGY. 



Heisler*s Embryology 

A Text=Book of Embryology. By John C. Heisler, M. D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
Octavo volume of 435 pages, with 212 illustrations, 32 of them in 
colors. Cloth, ^3.00 net. 

THIRD EDITION— WITH 212 ILLUSTRATIONS, 32 IN COLORS 

This edition represents all the advances recently made in the science of em- 
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a standard work. 

G. Carl Huber. M. D., 

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" I find this edition of 'A Text-Book of Embryology," by Dr. Heisler, an improvement 
on the former one. The figures added increase greatly the value of the work. I am again 
recommending it to our students." 

Bohm, Davidoff» and 
Huber's Histology 

A Text=Book of Human Histology. Including Microscopic Tech- 
nic. By Dr. A. A. Bohm and Dr. M. Von Davidoff, of Munich, and 
G. Carl Huber, M. D., Professor of Embryology at the Wistar Insti- 
tute, University of Pennsylvania. Handsome octavo of 528 pages, with 
361 beautiful original illustrations. Flexible cloth, ^3.50 net. 

SECOND EDITION. ENLARGED 

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and has been considered one of the most practically useful books on the subject 
of Human Histology. This second edition has been in great part rewritten and 
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complete students' text-book on Histology in existence. 

Boston Medical and Surgical Journal 

" Is unquestionablv a lext-book of the first rank, having been carefully written by thorough 
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manual." 



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Wells* Chemical Pathology 



Chemical Pathology. — Being a Discussion of General Pathology 
from the Standpoint of the Chemical Processes Involved. By H. 
Gideon Wells, Ph. D., M. D., Assistant Professor of Pathology in the 
University of Chicago. Octavo of 6i6 pages. Cloth, $'^.2^ net. 

NEW (2d) EDITION 

Dr. Wells' work is written for the physician, for those engaged in research in 
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to Uric-acid Metabolism and Gout. 

Wm. H. Welch. M. D. 

Professor of Pathology, Johns Hopkins University. 

" The work fills a real need in the English literature of a ver\' important subject, and I 
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Lusk*s 
Elements of Nutrition 

Elements of the Science of Nutrition. By Graham Lusk, Ph. D., 
Professor of Physiology at Cornell Medical School. Octavo volume 
of 302 pages. Cloth, ^3.00 net. 

THE NEW (2d) EDITION— TRANSLATED INTO GERMAN 

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stations. 

Lewellys F. Barker, M. D. 

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" I shall recommend it highly to my students. It is a comfort to have such a discussion 
of the subject in English." 



HISTOLOGY. u 



Daugherty's 
Economic Zoology 

Economic Zoology. By L. S. Daugherty, M. S., Ph. D., Professor 
of Zoology, State Normal School, Kirksville, l\Io., and ^I. C. Daugh- 
erty, author with Jackson of " Agriculture Through the Laboratory 
and School Garden." Part I: Field a7id Laboratory Guide, i2mo of 
237 pages, interleaved. Cloth, $1.25 net. Part II: Principles. i2mo 
of 406 pages, illustrated. Cloth, $2.00 net. 

ILLUSTRATED 



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and their actual application. The economic phase is emphasized. 
Part I — the Field and Laboratory Guide — is designed for practical instruction in 
the field and laboratorj'. To enhance its value for this purpose blank pages are 
inserted for notes. 



DrewV 
Invertebrate Zoolog'y 

A Laboratory Manual of Invertebrate Zoology. Bv Gilmax A. 
Drew, Ph.D., Assistant Director at Marine Biological Laborator\^, Woods 
Hole, !Mass. With the aid of Former and Present ^Members of the Zoological 
Staff of Instructors. i2mo of 213 pages. Cloth, 51-25 net. 

NEW 2d I EDITION 

The subject is presented in a logical way, and the type method of study has 
been followed, as this method has been the prevaiUng one for many years. 

Prof. Allison A. Smyth, Jr., Virginia Polytechnic Institute 

" I think it is the best laboratorv- manual of zooiogT.- I have yet seen. The large number 
of forms dealt with makes the work applicable to almost any locality." 



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Norris* Cardiac Patholog(y 

studies in Cardiac Pathology. By George W. Norris, M.D. 
Associate in Medicine at the University of Pennsylvania. Large octavo 
of 235 pages, with 85 superb illustrations. Cloth, ^5.00 net. 

SUPERB ILLUSTRATIONS 

The illustrations are superb. Each illustration is accompanied by a detailed 
description; besides, there is ample letter press supplementing the pictures. 

Boston Medical and Surgical Journal 

" The illustrations are arranged in such a way as to illustrate all the common and many of 
the rare cardiac lesions, and the accompanying descriptive text constitutes a fairly continuous 
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McConnelFs Pathology 

A Manual of Pathology. By Guthrie McConnell, M. D., As- 
sistant Surgeon, Medical Reserve Corps, U. S. Navy. i2mo of 523 
pages, with 170 illustrations. Flexible leather, ^2.50 net. 

NEW (2d) EDITION 
Dr. McConnell has discussed his subject with a clearness and precision of 
style that make the work of great assistance to both student and practitioner. 
The illustrations have been introduced for their practical value. 

New York State Journal of Medicine 

" The book treats the subject of pathology with a thoroughness lacking in many works of 
greater pretension. The illustrations — many of them original — are profuse and of exceptional 
excellence." 



McConneirs Pathology and Bacteriology ^%tuAe^. 

Pathology and Bacteriology for Dental Students, By Guthrie 
McConnell, M. D., Assistant Surgeon, Medical Reserve Corps, U. S. N. 
i2mo of 309 pages, illustrated. Cloth, ^2.25 net. 

ILLUSTRATED 

This work is written expressly for dentists and dental students, emphasizing 
throughout the application of pathology and bacteriology in dental study and prac- 
tice. There are chapters on disorders of metabolism and circulation; retro- 
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gressive processes, tum.ors, special mouth pathology, sterilization and disinfection, 
bacteriologic methods, specific micro-organisms, infection and immunity, and 
laboratory technic. 



HISTOLOGY. 



13 



Dtirck and Hektoen*s 

Special Patholog(ic Histology 

Atlas and Epitome of Special Pathologic Histology. Bv Dr. H. 

DiJRCK, of Munich. Edited, with additions, by Ludvig Hektoen, M. D., 
Professor of Pathology, Rush Medical College, Chicago. In two parts. 
Part I. — Circulatory, Respiratory, and Gastro-intestinal Tracts. 120 
colored figures on 62 plates, and 158 pages of text. Part II. — Liver, 
Urinary and Sexual Organs, Nervous System, Skin, Muscles, and 
Bones. 123 colored figures on 60 plates, and 192 pages of text. Per 
part : Cloth, ;^3.oo net. hi Saiindei^s' Hand-Atlas Series. 

The great value of these plates is that they represent in the exact colors the effect 
of the stains, which is of such great importance for the differentiation of tissue. 
The text portion of the book is admirable, and, while brief, it is entirely satisfac- 
tory in that the leading facts are stated, and so stated that the reader feels he has 
grasped the subject extensively. 

William H. Welch. M. D., 

Professor of Pathology, Johns Hopkins University , Baltimore. 

" I consider Diirck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very 
useful book for students and others. The plates are admirable." 

Sobotta am) Huberts 
Human Histolog(y 

Atlas and Epitome of Human Histology. By Privatdocent Dr. 
J. Sobotta, of Wiirzburg. Edited, with additions, by G. Carl Huber, 
M. D., Professor of Histology and Embryology in the University of 
Michigan, Ann Arbor. With 214 colored figures on 80 plates, 6Z 
text-illustrations, and 248 pages of text. Cloth, ^4.50 net. In 
Saimders' Hand- Atlas Series. 

INCLUDING MICROSCOPIC ANATOMY 

The work combines an abundance of well-chosen and most accurate illustra- 
tions, with a concise text, and in such a manner as to make it both atlas and text- 
book. The great majority of the illustrations were made from sections prepared 
from human tissues, and always from fresh and in every respect normal specimens. 
The colored lithographic plates have been produced with the aidof over thirty colors. 

Boston Medical and Surgical Journal 

" In color and proportion they are characterized by gratifying accuracy and lithographic 
beauty." 



14 SAUNDERS' BOOKS ON 

Bosanquet on Spirochaetes 

Spirochastes : A Review of Recent Work, with Some Original Ob- 
servations. By W. Cecil Bosanquet, M.D., Fellow of the Royal Col- 
lege of Physicians, London. Octavo of 152 pages, illustrated, ;^2.50 net. 

ILLUSTRATED 

This is a complete and authoritative monograph on the spirochaetes, giving 
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Bosanquet in this field of study makes this new work particularly valuable. 



Levy an^ Klemperer*s 
Clinical Bacteriology 

The Elements of Clinical Bacteriology. By Drs. Ernst Levy and 
Felix Klemperer, of the University of Strasburg. Translated and 
edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine, 
Philadelphia Polyclinic. Octavo volume of 440 pages, fully illustrated. 
Cloth, ^2.50 net. 

S. Solis-Cohen, M. D., 

Professor of Clinical Medicine, Jefferson Medical College, Philadelphia. 

" I consider it an excellent book. I have recommended it in speaking to my students." 



Lehmann, Neumann, anb 
Weaver's Bacteriology 

Atlas and Epitome of Bacteriology : including a Text-Book of 
Special Bacteriologic Diagnosis. By Prof. Dr. K. B. Lehmann 
and Dr. R. O. Neumann, of Wiirzburg. From the Second Revised and 
Eiilm^ged German Edition. Edited, with additions, by G. H. Weaver, 
M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical 
College, Chicago. In two parts. Part I. — 632 colored figures on 69 
lithographic plates. Part II. — 511 pages of text, illustrated. Per part: 
Cloth, ;^2.50 net. In Saunders' Hand-Atlas Series. 



PATHOLOGY, BACTERIOLOGY, AND PATHOLOGY 



IS 



Durck and Hektoen*s General Pathologic Histology 

Atlas and Epitome of General Pathologic Histology. By Pr. 
Dr. H. Durck, of Munich. Edited, with additions, by Ludvig Hek- 
TOEN,M. D., Professor of Pathology in Rush Medical College, Chicago. 
172 colored figures on 77 lithographic plates, ^6 text-cuts, many 
in colors, and 353 pages. Cloth, ^5. 00 net. In Saunders' Hand- Atlas 
Series. 

American Text-Book of Physiology second Edition 

American Text-Book of Physiology. In two volumes. Edited by 
William H. Howell, Ph. D. , M. D. , Professor of Physiology in the Johns 
Hopkins University, Baltimore, Md. Two royal octavos of about 600 
pages each, illustrated. Per volume: Cloth, ^3.00 net; Half Morocco, 
M.25 net. 

'•The work will stand as a work of reference on physiology. To him who desires to know 
the status of modern physiology, who expects to obtain suggestions as to further physio- 
logic inquiry, we know of none in English which so eminently meets such a demand "— 
The Medical News, 

Warren's Pathology and Therapeutics second Edition 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M. D., LL.D., F. R. C. S. (Hon.), Professor of Surgery, Harvard Med- 
ical School. Octavo, 873 pages, 136 relief and lithographic illustrations, 
33 in colors. With an Appendix on Scientific Aids to Surgical Diagnosis 
and a series of articles on Regional Bacteriology. Cloth, ^5.00 net; 
Half Morocco, ^6.50 net. 

Raymond's Physiology New (3d) Edition 

Human Physiology. By Joseph H. Raymond, A. M., M. D., Pro- 
fessor of Physiology and Hygiene, Long Island College Hospital, New 
York. Octavo of 685 pages, with 444 illustrations. Cloth, ^3.50 net. 

" The book is well gotten up and well printed, and may be regarded as a trustworthy 
guide for the student and a useful work of reference for the genera; practitioner. The 
illustrations are numerous and are well executed." — The Lancet, London. 



l6 BACTERIOLOGY, PHYSIOLOGY, AND HISTOLOGY. 

Ball's Bacteriology seventh Edition, Revised 

Essentials of Bacteriology : being a concise and systematic intro- 
duction to the Study of Micro-organisms. By M. V. Ball, M. D., Late 
Bacteriologist to St. Agnes' Hospital, Philadelphia. i2mo of 289 pages, 
with 135 illustrations, some in colors. Cloth, ^i.oo net. In Saunders' 
Question- Conipend Series. 

" The technic with regard to media, staining, mounting, and the lil^e is culled from the 
latest authoritative works." — T/ie Medical Times, New York. 

Budgett*S Physiology New (3d) Edition 

Essentials of Physiology. Prepared especially for Students of Medi- 
cine, and arranged with questions following each chapter. By Sidney 
P. Budgett, M. D., formerly Professor of Physiology, Washington Uni- 
versit)', St. Louis. Revised by Havan Emerson, M. D., Demonstratoi 
of Physiology, Columbia University. i2mo volume of 250 pages, illus- 
trated. Cloth, ^ 1. 00 net. Saunders'' Question- Coinpend Series. 

"He has an excellent conception of his subject. . . It is one of the most satisfactory 
books of this class" — University of Pennsylvania Medical Bulletin. 

Leroy*s Histology New (4th) Edition 

Essentials of Histology. By Louis Leroy, M. D., Professor of 
Histology and Pathology, Vanderbilt University, Nashville, Tennessee. 
i2mo, 263 pages, with 92 original illustrations. Cloth, ^i.oo net. In 
Saunders'' Question- Compend Series. 

" The work in its present form stands as a model of what a student's aid should be ; and 
we unhesitatingly say that the practitioner as well would find a glance through the book 
of lasting benefit." — The Medical World, Philadelphia. 

Barton and Wells' Medical Thesaurus 

A Thesaurus of Medical Words and Phrases. By Wilfred M. 
Barton, M. D. , Assistant Professor of Materia Medica and Therapeutics, 
and Walter A. Wells, M.D., Demonstrator of Laryngology, Georgetown 
University, Washington, D. C. i2mo, 534 pages. Flexible leather, 
I2.50 net; thumb indexed, $3.00 net. 

American Pocket Medical Dictionary ^ew (9th) Edition 

American Pocket Medical Dictionary. Edited by W. A. New- 
man Dorland, M. D., Editor "American Illustrated Medical Dic- 
tionary." Containing the pronunciation and definition of the principal 
words used in medicine and kindred sciences, with 75 extensive tables. 
693 pages. Flexible leather, with gold edges, $1.00 net; with patent 
thumb index, $1.25 net. 

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., of 
the Jefferson Medical College, Philadelphia. 




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