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Cancer of the stomach with special reference to its incidence, diagnosis and treatment
CANCER
OF THE STOMACH
WITH SPECIAL REFERENCE TO ITS INCIDENCE, TREATMENT
DIAGNOSIS AND
J. SHELTONHORSLEY,M.D., LL.D., P.A.C.S. RICHMOND,VA. INCIDENCE
T
HE Iast census reports avaiIabIe for the estimation of the mortahty from cancer in the United States show that in the year 1927 there were 103,578 deaths from cancer in the Registration Area of the United States. Of these, 36,879 were from cancer of the stomach and Iiver. As primary cancer of the Iiver is very rare, and as deaths are Iisted according to the origina site of the cancer, it seems probabIe that at Ieast 35,000 are from cancer that originated in the stomach. In Virginia there were during 1929, 1686 deaths from cancer as against 1567 in 1927, with 560 deaths from cancer of the Iiver and stomach in 1929 and 516 in 1927, probabIy more than 90 per cent of this combination being from cancer of the st0mach.l Deaths when sudden and spectacuIar attract much attention, as from the explosion of an airship, a raiIway coIIision, an automobile accident or the sinking of a ship. But the fact that more than IOO,OOOpersons perish quietIy in the United States every year from cancer (one-third of them from cancer of the stomach) causes but IittIe comment. Cancer of the stomach is responsibIe for far more deaths than cancer of any other singIe organ. When we consider that maIignant tumors from a11 other regions, such as the coIon, rectum, pancreas, kidneys, bIadder, prostate, breast, ovaries, uterus, mouth, neck, brain, skin, muscIe and bone make up the baIance which is scarceIy two-thirds of the tota mortahty from cancer, we can readiIy see how seriousIy cancer of the stomach shouId be considered. 264
CANCER OF THE STOMACH CAUSES
OF
DEATH
FROM
GASTRIC
2%
CANCER
In a recent articIe by SaItzstein and Sandweiss of Detroit, there is an analysis of 365 consecutive deaths from cancer of the stomach coIIected from the Cancer Division of the Department of HeaIth of Detroit. It incIudes a11 the deaths registered as due to cancer of the stomach from a popuIation of 1,730,000 during one and a haIf years. Of this number, onIy 28, or 7.7 per cent, had resections of the stomach for cancer, and of these onIy I I, or about 3 per cent, recovered from the operation. It is obvious that many of this smaI1 group operated upon came Iate and were desperate risks. Margaret Warwick,3 in a report of 176 necropsies on cancer of the stomach from the Department of PathoIogy of the University of Minnesota, extending over a period of twenty years, shows that the deaths from cancer of the stomach occupy a tota of about 30 per cent of a11 the Department’s necropsies on cancer. Her report brings out many interesting facts. The age varied from thirty-two to eighty-two years, but the average age was fifty-nine years. The Iargest number of deaths in any decade (35 per cent) occurred in the sixth decade, and the next Iargest number (29 per cent) in the fifth decade. Cancer of the stomach was found much more frequentIy in men than in women, and was often Iocated in the pyIorus (42.2 per cent). It is interesting to know, too, that in onIy 43.4 per cent of the cases of this series was uIceration present, and of this number 5 I per cent showed perforation and in about one-third of these the perforation was pIugged. In two-thirds of the cases with perforation death from peritonitis occurred. The most frequent fata compIication was peritonitis. There was no emaciation in about 18 per cent of the cases. In 23 per cent, or 40 of the fata cases, there was no metastasis, the growth at the time of death being confined entireIy to the stomach. In many of these cases the death was due to peritonitis. This brings up the subject from a new angle. The fact that of this series of 176 deaths from gastric cancer 23 per cent (40)
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of the cases had no metastasis, the growth being conjked to the stomach at the time of death, and yet in the larger series of Saltzstein and Sandweiss (365 cases) resection was done on only 7.7 per cent (28 cases), shows that many opportunities for cure must have been missed. In some of the 23 per cent the cancer was probably located in the inaccessible cardiac regions, but it is more common at the accessible pylorus than elsewhere. Cancer of the stomach presents variabIe forms. We are often accustomed to think of it as an uIcerating necrotic mass and yet the statistics of Warwick show that in onIy 43.4 per cent of these necropsies was uIceration present. ETIOLOGY
The cause of cancer is a subject which the Iimit of space wiI1 not permit us to discuss except to say that the theory that seems more probabIe now than any other is that cancer is not due to a parasite or any microorganism, but that it springs from a derangement of one or more IocaI ceIIs in the tissues. This derangement resuIts in a freeing of the ceIIs from the norma contro1 of the surrounding tissues, which aboIishes the restraint of going through the norma bioIogic processes of growth. These ceIIs after acquiring this attribute of unrestrained growth can transmit it to their own offspring. The fact that cancer in mice can be produced in the Iaboratory by frequent painting of the mice with tar, and that the resuIting cancer wil1 metastasize and can be transpIanted, shows that some irritant is primariIy responsibIe for the neopIasm. It may be, of course, that some microorganisms act indirectIy by causing irritation, but that cancer is primariIy due to bacteria or a microscopic parasite in the same sense that typhoid or tubercuIosis is, is hardIy tenabIe. Certain tissues of the body are Iess IiabIe to cancer than others. The cause of this comparative immunity is not known, but very obviousIy exists. It may be due to the natura1 stabiIity of the tissue. I have never seen a primary cancer of the paIms of the hands or the soIes of the feet, yet cancer of the mouth,
CANCER OF THE STOMACH
267
tongue and Iips is common. Cancer of the stomach is aIso common, and as has been stated, is one of the greatest causes of mortaIity from cancer, and yet cancer of the duodenum is extremeIy rare, aImost a surgica1 curiosity. It is necessary, then, to have some cause besides irritation. So far as we know, from observabIe regions of the body, cancer never springs directIy from norma tissue. If this hoIds in the face, tongue, rectum or uterus that can be observed, it seems highIy probabIe that the same genera1 ruIe shouId obtain in the stomach which is diffIcuIt of direct inspection. It wouId be an anomaIy if the irritation in the stomach caused by peptic ulcer did not occasionaIIy at Ieast produce cancer, whereas irritations of the mouth and Iip of peopIe of the same age are known to be one of the chief causes of cancer. UIcer of the stomach is much Iess frequent than uIcer of the duodenum, in the ratio of probabIy about I to 4, but the duodenum, Iike the paIms of the hands, seems aImost immune to cancer. In fact, the number of cases of peptic uIcer of the stomach corresponds in a genera1 way to the number of cases of cancer of the stomach. Much stress has been Iaid upon the size of the uIcer of the stomach, the Iarge uIcers being more IikeIy to be cancerous than the smaIIer ones. My own experience, however, shows that whiIe this in a genera1 way is true, there are many exceptions to it. I have had severa cases of Iarge uIcers of the stomach 5 or more centimeters in diameter that were benign, and one case at Ieast of a smaI1 uIcer of the stomach, not more than 1.5 cm. in diameter, that proved to be maIignant. No set ruIe can be made for this, but the marked tendency is for the Iarger gastric uIcers to be cancerous. SYMPTOMS
The symptoms of cancer of the stomach are not typica1. The most important thing to bear in mind is that there is no typica history or symptom of cancer of the stomach. It is more frequent in men. In SaItzstein and Sandweiss’ anaIysis of 365 cases it was found that about one-fourth of a11 the
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HORSLEY
cases gave a history of proIonged attacks of stomach troubIe, and about one-third of this number gave a fairIy typica cIinica1 history of peptic uIcer. It must be recaIIed, however, that gastric peptic uIcer is not infrequentIy found without a so-caIIed typica history. The Iarge gastric uIcers may cause more or Iess discomfort with no connection with food reIief, and sometimes the first symptom is hemorrhage. Hemorrhage is a rather infrequent symptom in cancer of the stomach, probabIy Iess than 2 per cent (I .4 per cent in SaItzstein and Sandweiss’ cases). When it is considered that, according to Warwick, onIy 43 per cent of cancers of the stomach showed uIceration, we can see that hemorrhage is by no means as common in cancer of the stomach as is usuaIIy supposed. The examination of the gastric contents in cancer of the stomach usuaIIy shows a Iow hydrochIoric acid content or, not infrequentIy, a compIete absence of hydrochIoric acid. This, however, is by no means a universa1 finding, as earIy gastric cancer may occur with normaI hydrochIoric acid in the gastric juice. BIood and Iactic acid in the gastric juice may be suggestive, but shouId not be depended upon too much. In about three-fourths of the cases there are no prehminary symptoms, but the cancer arises in otherwise apparentIy heahhy individuaIs and goes on steadiIy toward death. There are, however, many cases of antecedent Iong-drawn-out histories of stomach troubIe extending over periods of years. In one of my patients whom I operated upon at the age of seventy years, there had been intermittent stomach troubIe with some food reIief for forty years, and at operation there was cancer of the pyIorus, not very advanced, but producing partia1 obstruction. In the three-fourths of the cases of gastric cancer in which there are no such preIiminary symptoms, the situation is more serious because by the time symptoms from the cancer have arisen the growth may be we11 advanced. In many of these instances the cancer is in the so-caIIed siIent areas of the stom-
CANCER
OF THE
STOMACH
269
sch. PhysioIogists have shown that the Iesser curvature contains tissue acting somewhat Iike the neuromuscuIar tissue of the heart, and initiating peristaIsis; an uIcer or Iesion in this region usuaIIy produces symptoms because of the spasm and interference with the motor function of the stomach. Of course, at the pyIorus obstruction occurs earIy. In many cancers of the stomach (about 42 per cent according to Warwick) the tumor is at the pyIorus and wiI1 cause earIy symptoms of obstruction. Because three-fourths of gastric cancers arise in apparentIy heaIthy persons without preIiminary symptoms and march on to inevitabIe death unIess the cancer is removed, it does not mean that there was not a preIiminary Iesion. As has been mentioned before, cancer eIsewhere in the body aIways starts from abnorma1 tissue, and it is reasonabIe to expect this to be true in the stomach. Necropsies and roentgenoIogic examinations not infrequentIy show uIcers of the stomach or heaIed ulcers that have given no symptoms. Lesions aIong the greater curvature or in the cardiac portion of the stomach may exist without causing any symptoms unIess perforation or hemorrhage occurs, or unIess the growth is so Iarge as to produce obstruction. In a case of my own (Mrs. S.), a cancer of the coIon was removed which had given symptoms onIy for a few months, though the growth must have been present much Ionger, and there were severa benign adenomas in the region of the cancer. It seems highIy probabIe, then, that some Iesion such as a symptomIess adenoma or uIcer has been the preceding cause of the cancer of the stomach that arises without preIiminary symptoms. It is we11 known that in the coIon and rectum benign adenomas and papiIIomas that have existed for years often degenerate into cancer. MiIIer, EIiason and Wright4 have recentIy reported eight cases of their own in which carcinomatous degeneration of a poIyp of the stomach occurred. They think this condition is much more frequent than is usuaIIy beIieved, and have found it in 35 per cent of a11 gastric poIyps they have fuIIy studied. These poIyps were adenomas or papiIIary adenomas, and were
270
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HORSLEY
usuaIIy found in men. The chief symptoms were hemorrhage and intermittent obstruction. In some of their cases the hemorrhage was sIight but frequent, and caused profound anemia resembIing pernicious anemia. According to SaItzstein and Sandweiss, of 2 13 patients who died of cancer of the stomach when the onset was from previous good heaIth, in 74 the first symptom was “indigestion,” pain in the epigastrium in 21, a history of uIcer in 20, vomiting in 15, gastric hemorrhage in 3, diffIcuIty in swaIIowing in 5, gnawing sensation in the epigastrium in 3, distended abdomen in 3, and fuIIness in the stomach in 3. Of the atypica1 symptoms there was Ioss of weight and weakness in 37, Ioss of appetite in 14, atypica1 pain (not in upper part of abdomen) in I I, anemia in 2 and diarrhea in 2. It is readiIy seen, then, that there is no typica symptom for cancer of the stomach, either when it resuIts from the changing of a gastric uIcer into cancer or when it arises in individuaIs who are otherwise apparentIy heaIthy. It is significant to note, however, that in a Iong history of stomach compIaint when the symptoms change and become constant instead of intermittent, or when the appetite begins to disappear and the patient Ioses weight, or when vomiting of bIood occurs, there often seems to be a transition from a benign condition into maIignancy. I am trying to avoid the use of emaciation, paIpabIe tumor, vomiting bIood and cachexia as symptoms of gastric cancer, because these are often the termina1 stages and too frequentIy the patient with these symptoms may have gone beyond hope. Even in such patients, however, there may occasionaIIy be some chance for cure or at Ieast paIIiation by operation. If we recaI1 the fact that, according to Warwick, in 40, or 23 per cent of, necropsies for cancer of the stomach the cancer was Iimited to the stomach itseIf, it appears possibIe to have a and some cachexia whiIe the paIpabIe tumor, hemorrhage cancer is stiI1 confined to the stomach. This, of course, does not mean that we shouId wait for termina1 symptoms, but it does mean that there are some apparentIy advanced cases
CANCER
OF THE
STOMACH
271
that may occasionahy be saved. PaIpabIe Iymph nodes in the Iower portion of the neck, especiaIIy on the Ieft side, referred to as Virchow’s gIands, in the presence of cancer of the stomach indicate that there are metastases through the chest and in the supracIavicuIar region. Such cases, of course, are obviousIy inoperabIe from any standpoint of cure, and this may be one of the termina1 symptoms. When the cancer of the stomach is of very great maIignancy, metastases may occur in the Iymph nodes of the neck before the Iesion in the stomach has progressed very far. The most dependabIe means of diagnosis of cancer of the stomach is a roentgenoIogic examination by a competent roentgenoIogist. Nothing requires more care and responsibiIity than the examination of the stomach by -y-ray. WhiIe pictures of fractures can be easiIy taken, a competent roentgenoIogic examination of the gastrointestina1 tract requires great skiI1. I have not infrequentIy had x-ray pIates referred to me with a diagnosis of cancer of the stomach when the defect was due to the pressure of the spine upon the plates whiIe the patient was Iying prone. One who does much gastric surgery wiI1 be abie to recognize this type of x-ray pIates rather easiIy and save the patient an unnecessary operation. FIuoroscopic examination is as important as the pIates, and shouId be interpreted by a competent roentgenoIogist. In the hands of a weII-trained roentgenologist, a diagnosis of cancer of the stomach can be made rather positiveIy in about 90 per cent of the cases; on account of the Iocation of the Iesion and for other reasons in about IO per cent the diagnosis cannot be made even by the best roentgenoIogist. The chief thing that I wish to impress is that if a patient, particuIarIy a man, begins having symptoms of so-caIIed indigestion or stomach troubIe, after thirty-five years of age, and it cannot be cIeared up by ordinary simpIe remedies and reguIation of diet in two or three weeks, the patient shouId be referred to a competent roentgenoIogist for a thorough examination of the gastrointestina1 tract. If an uIcer of the
272
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HORSLEY
duodenum is found and is in an earIy stage, it shouId be treated medi&IIy for at Ieast severa months, or even Ionger if there is no compIication. Many peptic uIcers of the duodenum can be cured by carefu1 medica treatment. It is only when they resist medica treatment and recur, or when there is perforation, that operation is indicated. In hemorrhage or obstruction, the persistent types, however, or when the uIcer is very Iarge, operation is the best treatment. In an uIcer of the stomach the probIem is different. UIcers of the stomach are more difEcuIt to cure by medica treatment and, in addition to that, the tendency for uIcers of the stomach to degenerate into cancer, which occurs to aImost no extent in uIcers of the duodenum, is a very serious factor. If the uIcer of the stomach has been giving symptoms for onIy a few weeks, and can be treated satisfactoriIy and appears to be heaIing after six to-eight weeks, the medica treatment may be continued Ionger, but if it is not heaIing it shouId be operated upon. W. J. M. Scott5 has caIIed attention to the fact that even x-ray examinations at intervaIs of a few weeks do not ahvays show the actua1 facts, because sometimes the infihration of a smaI1 Iesion may fiII out a niche, when as a matter of fact the cancer is stiI1 progressing. He has reported cases with gastric symptoms five to ten years and negative x-ray findings for cancer, and yet with cancer shown at operation. TREATMENT
There is onIy one treatment for cancer of the stomach, and that is excision. The sooner it is done the better. With modern technique and carefu1 preparation, and with the choice of anesthetics, frequentIy either spina or Iocal, the mortality can be greatIy diminished. The empIoyment of the continuous intravenous injection of dextrose in Ringer’s soIution is very heIpfu1, both as a temporary measure during the operation to prevent shock and foIIowing the operation to rest the stomach. Gastroenterostomy in gastric cancer is rareIy justified. A carefuIIy done partia1 gastrectomy wiI1 carry aImost as Iow
CANCER a mortahty.
OF THE
STOMACH
273
If the cancer is so extensive that it cannot be resected, usuaIIy gastroenterostomy is contraindicated. There may be, however, occasiona instances in which this operation is indicated. SaItzstein and Sandweiss state that: “ It is being appreciated IateIy that gastric resection, if at a11 feasibIe, is a better paIIiative procedure than gastroenterostomy; patients are more comfortabIe foIIowing it, and patients with noduIes in the Iiver have Iived three years after gastrectomy for cancer. ” For the past seven years I have been using a technique which is a modification of the BiIIroth I partia1 gastrectomy.6 This consists in uniting the Iesser curvature of the stomach to the upper border of the duodenum, flaring open the anterior waI1 of the duodenum to prevent obstruction, which was a great objection to the origina BiIIroth I, and foIding in the redundant portion of the stomach aIong the greater curvature. In this way the so-caIIed “deadIy triangIe” of BiIIroth is avoided. OccasionaIIy, if the stomach is smaI1, the duodenum may be flared open enough to make an end-to-end anastomosis. When the cancer is too extensive for partia1 gastrectomy, a tota gastrectomy may sometimes be done. In the case of Mrs. L. J., this operation was performed and the jejunum was united to the esophagus. UnfortunateIy in Iifting up the stomach much of its contents regurgitated into the esophagus and when the cIamp was removed from the esophagus after detaching the stomach the upper portion of the abdomina1 cavity was contaminated by the reflux from the esophagus. Though the peritoneum had been packed off with gauze, infection resuIted and the patient died five days after operation. Examination of the stomach showed the cancer aImost throughout the stomach, though necropsy did not revea1 evidences of maIignancy eIsewhere. In one patient, Mrs. B. H. H., a paIpabIe tumor in the upper abdomen had been noticed by her for more than a year before she wouId submit to operation. A partia1 gastrectomy done according to the technique described resuIted in immediate recovery. The patient Iived in comfort for nearIy three
274
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HORSLEY
years, and died of metastases in the chest and axiIIa with apparentIy no recurrence in the stomach. This shows that cases with paIpabIe tumors are not necessariIy inoperabIe. In 1928 I pubIished an articIe’ on gastric cancer in the aged, reporting 5 patients over seventy years of age on whom this partia1 gastrectomy was done. In 2 of them part of the coIon had to be resected. The operative mortaIity was one, the patient dying as a resuIt of resection of the coIon. The oIdest patient was seventy-seven years of age, and died nine months after operation of nephritis. No necropsy was heId, but there was no evidence of recurrence of the cancer. The other patients Iived comfortabIy from six months to two years, deveIoping metastases usuaIIy in the Iiver. In spite of the fact that a11 of these cases were far advanced, two of them necessitating resection of the coIon, and a11 of the patients over seventy years of age, the resuIts in proIonging Iife and estabIishing comfort may be considered as not unsatisfactory. I have had one patient, Mrs. L. E. H., seventy years of age, who had had symptoms for fifteen years. The symptoms were increased before entering the hospita1. A partia1 gastrectomy was done and a rather smaI1 uIcer was found aIong the Iesser curvature of the stomach. It seemed to have been irritated and caused marked spasm. On microscopic examination of the Iesion one area was found in which there were two definite acini of cancer. This patient has been in exceIIent heaIth since operation nearIy two years ago (December IO, 1928) and wiI1 probabIy make a permanent cure. It is in patients such as this in whom the maIignant Iesion is found in the earIy stages that the best resuIts are obtained. SUMMARY AND CONCLUSION SaItzstein and Sandweiss have shown that in Detroit, with its abundant hospitaIs, onIy 7.7 per cent of patients with gastric cancer have a partia1 gastrectomy. It seems probabIe that the percentage is even Iower in Virginia. As partia1 gastrectomy is the onIy known cure for cancer of,the stomach,
CANCER
OF THE
STOMACH
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this means that onIy about one patient in tweIve with cancer of the stomach is given any chance for a cure. PartiaI gastrectomy in earIy gastric cancer shouId give cures comparabIe to those after the radica1 operation for cancer of the breast, and even in the more advanced cases it often brings reIief and proIongation of life. WhiIe it is necessary to study the earIy stages of any unusua1 gastric disorder in patients, particuIarIy men, over thirty-five years of age, it is aIso we11 to remember that about one-fourth of the cases of gastric cancer are subsequent to some other gastric Iesion giving symptoms for a Iong time (usuaIIy uIcer), and practicaIIy a11 of these cases shouId be recognized and operated upon in the earIy stages. In the other 75 per cent of cases, prompt attention to the first symptoms and a partia1 gastrectomy as soon as the diagnosis of gastric cancer is made wiI1 often resuIt in the proIongation of Iife and sometimes in cure, whereas otherwise there is no hope. REFERENCES I. VIRGINIA BUREAU OF VITAL STATISTICS,ANNUAL REPORT. Virginia Healtb Bull., 22: (Jan.) 1930. 2. SALTZSTEIN, H. C., and SANDWEISS, D. J. The probIem of cancer of the stomach. Arch. .hg., 21: 113-127 (JuIy) 1930. 3. WARWICK, M. AnaIysis of 176 cases of carcinoma of the stomach submitted to autopsy. Ann. Surg., 88: 216-226 (August) 1928. ~.:MILLER, T. G., ELIASON, E. L., and WRIGHT, V. W. M. Carcinomatous degeneration of poIyp of the stomach: report of eight personal cases with a review of twentyfour recorded by others. Arch. Int. Med., 46: 841-878 (Nov.) rg3o. 5. SCOTT, W. J. M. The reIationship of carcinoma and callous gastric uIcer. Surg. Gynec. Obst., 46: 199-212 (Feb.) 1928. 6. HORSLEY, J. SHELTON. Operative Surgery. Ed. 3, St. Louis, Mosby, 1928. PartiaI gastrectomy. Surg., Gynec. Obst., 44: 214-220 (Feb.) 1927. 7. HORSLEY, J. S. Cancer of the stomach in patients over seventy years of age. Ann.
Surg., 88: 554-564 (Sept.) 1928.
OF THE STOMACH
WITH SPECIAL REFERENCE TO ITS INCIDENCE, TREATMENT
DIAGNOSIS AND
J. SHELTONHORSLEY,M.D., LL.D., P.A.C.S. RICHMOND,VA. INCIDENCE
T
HE Iast census reports avaiIabIe for the estimation of the mortahty from cancer in the United States show that in the year 1927 there were 103,578 deaths from cancer in the Registration Area of the United States. Of these, 36,879 were from cancer of the stomach and Iiver. As primary cancer of the Iiver is very rare, and as deaths are Iisted according to the origina site of the cancer, it seems probabIe that at Ieast 35,000 are from cancer that originated in the stomach. In Virginia there were during 1929, 1686 deaths from cancer as against 1567 in 1927, with 560 deaths from cancer of the Iiver and stomach in 1929 and 516 in 1927, probabIy more than 90 per cent of this combination being from cancer of the st0mach.l Deaths when sudden and spectacuIar attract much attention, as from the explosion of an airship, a raiIway coIIision, an automobile accident or the sinking of a ship. But the fact that more than IOO,OOOpersons perish quietIy in the United States every year from cancer (one-third of them from cancer of the stomach) causes but IittIe comment. Cancer of the stomach is responsibIe for far more deaths than cancer of any other singIe organ. When we consider that maIignant tumors from a11 other regions, such as the coIon, rectum, pancreas, kidneys, bIadder, prostate, breast, ovaries, uterus, mouth, neck, brain, skin, muscIe and bone make up the baIance which is scarceIy two-thirds of the tota mortahty from cancer, we can readiIy see how seriousIy cancer of the stomach shouId be considered. 264
CANCER OF THE STOMACH CAUSES
OF
DEATH
FROM
GASTRIC
2%
CANCER
In a recent articIe by SaItzstein and Sandweiss of Detroit, there is an analysis of 365 consecutive deaths from cancer of the stomach coIIected from the Cancer Division of the Department of HeaIth of Detroit. It incIudes a11 the deaths registered as due to cancer of the stomach from a popuIation of 1,730,000 during one and a haIf years. Of this number, onIy 28, or 7.7 per cent, had resections of the stomach for cancer, and of these onIy I I, or about 3 per cent, recovered from the operation. It is obvious that many of this smaI1 group operated upon came Iate and were desperate risks. Margaret Warwick,3 in a report of 176 necropsies on cancer of the stomach from the Department of PathoIogy of the University of Minnesota, extending over a period of twenty years, shows that the deaths from cancer of the stomach occupy a tota of about 30 per cent of a11 the Department’s necropsies on cancer. Her report brings out many interesting facts. The age varied from thirty-two to eighty-two years, but the average age was fifty-nine years. The Iargest number of deaths in any decade (35 per cent) occurred in the sixth decade, and the next Iargest number (29 per cent) in the fifth decade. Cancer of the stomach was found much more frequentIy in men than in women, and was often Iocated in the pyIorus (42.2 per cent). It is interesting to know, too, that in onIy 43.4 per cent of the cases of this series was uIceration present, and of this number 5 I per cent showed perforation and in about one-third of these the perforation was pIugged. In two-thirds of the cases with perforation death from peritonitis occurred. The most frequent fata compIication was peritonitis. There was no emaciation in about 18 per cent of the cases. In 23 per cent, or 40 of the fata cases, there was no metastasis, the growth at the time of death being confined entireIy to the stomach. In many of these cases the death was due to peritonitis. This brings up the subject from a new angle. The fact that of this series of 176 deaths from gastric cancer 23 per cent (40)
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of the cases had no metastasis, the growth being conjked to the stomach at the time of death, and yet in the larger series of Saltzstein and Sandweiss (365 cases) resection was done on only 7.7 per cent (28 cases), shows that many opportunities for cure must have been missed. In some of the 23 per cent the cancer was probably located in the inaccessible cardiac regions, but it is more common at the accessible pylorus than elsewhere. Cancer of the stomach presents variabIe forms. We are often accustomed to think of it as an uIcerating necrotic mass and yet the statistics of Warwick show that in onIy 43.4 per cent of these necropsies was uIceration present. ETIOLOGY
The cause of cancer is a subject which the Iimit of space wiI1 not permit us to discuss except to say that the theory that seems more probabIe now than any other is that cancer is not due to a parasite or any microorganism, but that it springs from a derangement of one or more IocaI ceIIs in the tissues. This derangement resuIts in a freeing of the ceIIs from the norma contro1 of the surrounding tissues, which aboIishes the restraint of going through the norma bioIogic processes of growth. These ceIIs after acquiring this attribute of unrestrained growth can transmit it to their own offspring. The fact that cancer in mice can be produced in the Iaboratory by frequent painting of the mice with tar, and that the resuIting cancer wil1 metastasize and can be transpIanted, shows that some irritant is primariIy responsibIe for the neopIasm. It may be, of course, that some microorganisms act indirectIy by causing irritation, but that cancer is primariIy due to bacteria or a microscopic parasite in the same sense that typhoid or tubercuIosis is, is hardIy tenabIe. Certain tissues of the body are Iess IiabIe to cancer than others. The cause of this comparative immunity is not known, but very obviousIy exists. It may be due to the natura1 stabiIity of the tissue. I have never seen a primary cancer of the paIms of the hands or the soIes of the feet, yet cancer of the mouth,
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tongue and Iips is common. Cancer of the stomach is aIso common, and as has been stated, is one of the greatest causes of mortaIity from cancer, and yet cancer of the duodenum is extremeIy rare, aImost a surgica1 curiosity. It is necessary, then, to have some cause besides irritation. So far as we know, from observabIe regions of the body, cancer never springs directIy from norma tissue. If this hoIds in the face, tongue, rectum or uterus that can be observed, it seems highIy probabIe that the same genera1 ruIe shouId obtain in the stomach which is diffIcuIt of direct inspection. It wouId be an anomaIy if the irritation in the stomach caused by peptic ulcer did not occasionaIIy at Ieast produce cancer, whereas irritations of the mouth and Iip of peopIe of the same age are known to be one of the chief causes of cancer. UIcer of the stomach is much Iess frequent than uIcer of the duodenum, in the ratio of probabIy about I to 4, but the duodenum, Iike the paIms of the hands, seems aImost immune to cancer. In fact, the number of cases of peptic uIcer of the stomach corresponds in a genera1 way to the number of cases of cancer of the stomach. Much stress has been Iaid upon the size of the uIcer of the stomach, the Iarge uIcers being more IikeIy to be cancerous than the smaIIer ones. My own experience, however, shows that whiIe this in a genera1 way is true, there are many exceptions to it. I have had severa cases of Iarge uIcers of the stomach 5 or more centimeters in diameter that were benign, and one case at Ieast of a smaI1 uIcer of the stomach, not more than 1.5 cm. in diameter, that proved to be maIignant. No set ruIe can be made for this, but the marked tendency is for the Iarger gastric uIcers to be cancerous. SYMPTOMS
The symptoms of cancer of the stomach are not typica1. The most important thing to bear in mind is that there is no typica history or symptom of cancer of the stomach. It is more frequent in men. In SaItzstein and Sandweiss’ anaIysis of 365 cases it was found that about one-fourth of a11 the
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cases gave a history of proIonged attacks of stomach troubIe, and about one-third of this number gave a fairIy typica cIinica1 history of peptic uIcer. It must be recaIIed, however, that gastric peptic uIcer is not infrequentIy found without a so-caIIed typica history. The Iarge gastric uIcers may cause more or Iess discomfort with no connection with food reIief, and sometimes the first symptom is hemorrhage. Hemorrhage is a rather infrequent symptom in cancer of the stomach, probabIy Iess than 2 per cent (I .4 per cent in SaItzstein and Sandweiss’ cases). When it is considered that, according to Warwick, onIy 43 per cent of cancers of the stomach showed uIceration, we can see that hemorrhage is by no means as common in cancer of the stomach as is usuaIIy supposed. The examination of the gastric contents in cancer of the stomach usuaIIy shows a Iow hydrochIoric acid content or, not infrequentIy, a compIete absence of hydrochIoric acid. This, however, is by no means a universa1 finding, as earIy gastric cancer may occur with normaI hydrochIoric acid in the gastric juice. BIood and Iactic acid in the gastric juice may be suggestive, but shouId not be depended upon too much. In about three-fourths of the cases there are no prehminary symptoms, but the cancer arises in otherwise apparentIy heahhy individuaIs and goes on steadiIy toward death. There are, however, many cases of antecedent Iong-drawn-out histories of stomach troubIe extending over periods of years. In one of my patients whom I operated upon at the age of seventy years, there had been intermittent stomach troubIe with some food reIief for forty years, and at operation there was cancer of the pyIorus, not very advanced, but producing partia1 obstruction. In the three-fourths of the cases of gastric cancer in which there are no such preIiminary symptoms, the situation is more serious because by the time symptoms from the cancer have arisen the growth may be we11 advanced. In many of these instances the cancer is in the so-caIIed siIent areas of the stom-
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sch. PhysioIogists have shown that the Iesser curvature contains tissue acting somewhat Iike the neuromuscuIar tissue of the heart, and initiating peristaIsis; an uIcer or Iesion in this region usuaIIy produces symptoms because of the spasm and interference with the motor function of the stomach. Of course, at the pyIorus obstruction occurs earIy. In many cancers of the stomach (about 42 per cent according to Warwick) the tumor is at the pyIorus and wiI1 cause earIy symptoms of obstruction. Because three-fourths of gastric cancers arise in apparentIy heaIthy persons without preIiminary symptoms and march on to inevitabIe death unIess the cancer is removed, it does not mean that there was not a preIiminary Iesion. As has been mentioned before, cancer eIsewhere in the body aIways starts from abnorma1 tissue, and it is reasonabIe to expect this to be true in the stomach. Necropsies and roentgenoIogic examinations not infrequentIy show uIcers of the stomach or heaIed ulcers that have given no symptoms. Lesions aIong the greater curvature or in the cardiac portion of the stomach may exist without causing any symptoms unIess perforation or hemorrhage occurs, or unIess the growth is so Iarge as to produce obstruction. In a case of my own (Mrs. S.), a cancer of the coIon was removed which had given symptoms onIy for a few months, though the growth must have been present much Ionger, and there were severa benign adenomas in the region of the cancer. It seems highIy probabIe, then, that some Iesion such as a symptomIess adenoma or uIcer has been the preceding cause of the cancer of the stomach that arises without preIiminary symptoms. It is we11 known that in the coIon and rectum benign adenomas and papiIIomas that have existed for years often degenerate into cancer. MiIIer, EIiason and Wright4 have recentIy reported eight cases of their own in which carcinomatous degeneration of a poIyp of the stomach occurred. They think this condition is much more frequent than is usuaIIy beIieved, and have found it in 35 per cent of a11 gastric poIyps they have fuIIy studied. These poIyps were adenomas or papiIIary adenomas, and were
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usuaIIy found in men. The chief symptoms were hemorrhage and intermittent obstruction. In some of their cases the hemorrhage was sIight but frequent, and caused profound anemia resembIing pernicious anemia. According to SaItzstein and Sandweiss, of 2 13 patients who died of cancer of the stomach when the onset was from previous good heaIth, in 74 the first symptom was “indigestion,” pain in the epigastrium in 21, a history of uIcer in 20, vomiting in 15, gastric hemorrhage in 3, diffIcuIty in swaIIowing in 5, gnawing sensation in the epigastrium in 3, distended abdomen in 3, and fuIIness in the stomach in 3. Of the atypica1 symptoms there was Ioss of weight and weakness in 37, Ioss of appetite in 14, atypica1 pain (not in upper part of abdomen) in I I, anemia in 2 and diarrhea in 2. It is readiIy seen, then, that there is no typica symptom for cancer of the stomach, either when it resuIts from the changing of a gastric uIcer into cancer or when it arises in individuaIs who are otherwise apparentIy heaIthy. It is significant to note, however, that in a Iong history of stomach compIaint when the symptoms change and become constant instead of intermittent, or when the appetite begins to disappear and the patient Ioses weight, or when vomiting of bIood occurs, there often seems to be a transition from a benign condition into maIignancy. I am trying to avoid the use of emaciation, paIpabIe tumor, vomiting bIood and cachexia as symptoms of gastric cancer, because these are often the termina1 stages and too frequentIy the patient with these symptoms may have gone beyond hope. Even in such patients, however, there may occasionaIIy be some chance for cure or at Ieast paIIiation by operation. If we recaI1 the fact that, according to Warwick, in 40, or 23 per cent of, necropsies for cancer of the stomach the cancer was Iimited to the stomach itseIf, it appears possibIe to have a and some cachexia whiIe the paIpabIe tumor, hemorrhage cancer is stiI1 confined to the stomach. This, of course, does not mean that we shouId wait for termina1 symptoms, but it does mean that there are some apparentIy advanced cases
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that may occasionahy be saved. PaIpabIe Iymph nodes in the Iower portion of the neck, especiaIIy on the Ieft side, referred to as Virchow’s gIands, in the presence of cancer of the stomach indicate that there are metastases through the chest and in the supracIavicuIar region. Such cases, of course, are obviousIy inoperabIe from any standpoint of cure, and this may be one of the termina1 symptoms. When the cancer of the stomach is of very great maIignancy, metastases may occur in the Iymph nodes of the neck before the Iesion in the stomach has progressed very far. The most dependabIe means of diagnosis of cancer of the stomach is a roentgenoIogic examination by a competent roentgenoIogist. Nothing requires more care and responsibiIity than the examination of the stomach by -y-ray. WhiIe pictures of fractures can be easiIy taken, a competent roentgenoIogic examination of the gastrointestina1 tract requires great skiI1. I have not infrequentIy had x-ray pIates referred to me with a diagnosis of cancer of the stomach when the defect was due to the pressure of the spine upon the plates whiIe the patient was Iying prone. One who does much gastric surgery wiI1 be abie to recognize this type of x-ray pIates rather easiIy and save the patient an unnecessary operation. FIuoroscopic examination is as important as the pIates, and shouId be interpreted by a competent roentgenoIogist. In the hands of a weII-trained roentgenologist, a diagnosis of cancer of the stomach can be made rather positiveIy in about 90 per cent of the cases; on account of the Iocation of the Iesion and for other reasons in about IO per cent the diagnosis cannot be made even by the best roentgenoIogist. The chief thing that I wish to impress is that if a patient, particuIarIy a man, begins having symptoms of so-caIIed indigestion or stomach troubIe, after thirty-five years of age, and it cannot be cIeared up by ordinary simpIe remedies and reguIation of diet in two or three weeks, the patient shouId be referred to a competent roentgenoIogist for a thorough examination of the gastrointestina1 tract. If an uIcer of the
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duodenum is found and is in an earIy stage, it shouId be treated medi&IIy for at Ieast severa months, or even Ionger if there is no compIication. Many peptic uIcers of the duodenum can be cured by carefu1 medica treatment. It is only when they resist medica treatment and recur, or when there is perforation, that operation is indicated. In hemorrhage or obstruction, the persistent types, however, or when the uIcer is very Iarge, operation is the best treatment. In an uIcer of the stomach the probIem is different. UIcers of the stomach are more difEcuIt to cure by medica treatment and, in addition to that, the tendency for uIcers of the stomach to degenerate into cancer, which occurs to aImost no extent in uIcers of the duodenum, is a very serious factor. If the uIcer of the stomach has been giving symptoms for onIy a few weeks, and can be treated satisfactoriIy and appears to be heaIing after six to-eight weeks, the medica treatment may be continued Ionger, but if it is not heaIing it shouId be operated upon. W. J. M. Scott5 has caIIed attention to the fact that even x-ray examinations at intervaIs of a few weeks do not ahvays show the actua1 facts, because sometimes the infihration of a smaI1 Iesion may fiII out a niche, when as a matter of fact the cancer is stiI1 progressing. He has reported cases with gastric symptoms five to ten years and negative x-ray findings for cancer, and yet with cancer shown at operation. TREATMENT
There is onIy one treatment for cancer of the stomach, and that is excision. The sooner it is done the better. With modern technique and carefu1 preparation, and with the choice of anesthetics, frequentIy either spina or Iocal, the mortality can be greatIy diminished. The empIoyment of the continuous intravenous injection of dextrose in Ringer’s soIution is very heIpfu1, both as a temporary measure during the operation to prevent shock and foIIowing the operation to rest the stomach. Gastroenterostomy in gastric cancer is rareIy justified. A carefuIIy done partia1 gastrectomy wiI1 carry aImost as Iow
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If the cancer is so extensive that it cannot be resected, usuaIIy gastroenterostomy is contraindicated. There may be, however, occasiona instances in which this operation is indicated. SaItzstein and Sandweiss state that: “ It is being appreciated IateIy that gastric resection, if at a11 feasibIe, is a better paIIiative procedure than gastroenterostomy; patients are more comfortabIe foIIowing it, and patients with noduIes in the Iiver have Iived three years after gastrectomy for cancer. ” For the past seven years I have been using a technique which is a modification of the BiIIroth I partia1 gastrectomy.6 This consists in uniting the Iesser curvature of the stomach to the upper border of the duodenum, flaring open the anterior waI1 of the duodenum to prevent obstruction, which was a great objection to the origina BiIIroth I, and foIding in the redundant portion of the stomach aIong the greater curvature. In this way the so-caIIed “deadIy triangIe” of BiIIroth is avoided. OccasionaIIy, if the stomach is smaI1, the duodenum may be flared open enough to make an end-to-end anastomosis. When the cancer is too extensive for partia1 gastrectomy, a tota gastrectomy may sometimes be done. In the case of Mrs. L. J., this operation was performed and the jejunum was united to the esophagus. UnfortunateIy in Iifting up the stomach much of its contents regurgitated into the esophagus and when the cIamp was removed from the esophagus after detaching the stomach the upper portion of the abdomina1 cavity was contaminated by the reflux from the esophagus. Though the peritoneum had been packed off with gauze, infection resuIted and the patient died five days after operation. Examination of the stomach showed the cancer aImost throughout the stomach, though necropsy did not revea1 evidences of maIignancy eIsewhere. In one patient, Mrs. B. H. H., a paIpabIe tumor in the upper abdomen had been noticed by her for more than a year before she wouId submit to operation. A partia1 gastrectomy done according to the technique described resuIted in immediate recovery. The patient Iived in comfort for nearIy three
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years, and died of metastases in the chest and axiIIa with apparentIy no recurrence in the stomach. This shows that cases with paIpabIe tumors are not necessariIy inoperabIe. In 1928 I pubIished an articIe’ on gastric cancer in the aged, reporting 5 patients over seventy years of age on whom this partia1 gastrectomy was done. In 2 of them part of the coIon had to be resected. The operative mortaIity was one, the patient dying as a resuIt of resection of the coIon. The oIdest patient was seventy-seven years of age, and died nine months after operation of nephritis. No necropsy was heId, but there was no evidence of recurrence of the cancer. The other patients Iived comfortabIy from six months to two years, deveIoping metastases usuaIIy in the Iiver. In spite of the fact that a11 of these cases were far advanced, two of them necessitating resection of the coIon, and a11 of the patients over seventy years of age, the resuIts in proIonging Iife and estabIishing comfort may be considered as not unsatisfactory. I have had one patient, Mrs. L. E. H., seventy years of age, who had had symptoms for fifteen years. The symptoms were increased before entering the hospita1. A partia1 gastrectomy was done and a rather smaI1 uIcer was found aIong the Iesser curvature of the stomach. It seemed to have been irritated and caused marked spasm. On microscopic examination of the Iesion one area was found in which there were two definite acini of cancer. This patient has been in exceIIent heaIth since operation nearIy two years ago (December IO, 1928) and wiI1 probabIy make a permanent cure. It is in patients such as this in whom the maIignant Iesion is found in the earIy stages that the best resuIts are obtained. SUMMARY AND CONCLUSION SaItzstein and Sandweiss have shown that in Detroit, with its abundant hospitaIs, onIy 7.7 per cent of patients with gastric cancer have a partia1 gastrectomy. It seems probabIe that the percentage is even Iower in Virginia. As partia1 gastrectomy is the onIy known cure for cancer of,the stomach,
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this means that onIy about one patient in tweIve with cancer of the stomach is given any chance for a cure. PartiaI gastrectomy in earIy gastric cancer shouId give cures comparabIe to those after the radica1 operation for cancer of the breast, and even in the more advanced cases it often brings reIief and proIongation of life. WhiIe it is necessary to study the earIy stages of any unusua1 gastric disorder in patients, particuIarIy men, over thirty-five years of age, it is aIso we11 to remember that about one-fourth of the cases of gastric cancer are subsequent to some other gastric Iesion giving symptoms for a Iong time (usuaIIy uIcer), and practicaIIy a11 of these cases shouId be recognized and operated upon in the earIy stages. In the other 75 per cent of cases, prompt attention to the first symptoms and a partia1 gastrectomy as soon as the diagnosis of gastric cancer is made wiI1 often resuIt in the proIongation of Iife and sometimes in cure, whereas otherwise there is no hope. REFERENCES I. VIRGINIA BUREAU OF VITAL STATISTICS,ANNUAL REPORT. Virginia Healtb Bull., 22: (Jan.) 1930. 2. SALTZSTEIN, H. C., and SANDWEISS, D. J. The probIem of cancer of the stomach. Arch. .hg., 21: 113-127 (JuIy) 1930. 3. WARWICK, M. AnaIysis of 176 cases of carcinoma of the stomach submitted to autopsy. Ann. Surg., 88: 216-226 (August) 1928. ~.:MILLER, T. G., ELIASON, E. L., and WRIGHT, V. W. M. Carcinomatous degeneration of poIyp of the stomach: report of eight personal cases with a review of twentyfour recorded by others. Arch. Int. Med., 46: 841-878 (Nov.) rg3o. 5. SCOTT, W. J. M. The reIationship of carcinoma and callous gastric uIcer. Surg. Gynec. Obst., 46: 199-212 (Feb.) 1928. 6. HORSLEY, J. SHELTON. Operative Surgery. Ed. 3, St. Louis, Mosby, 1928. PartiaI gastrectomy. Surg., Gynec. Obst., 44: 214-220 (Feb.) 1927. 7. HORSLEY, J. S. Cancer of the stomach in patients over seventy years of age. Ann.
Surg., 88: 554-564 (Sept.) 1928.