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PRIMARY SARCOMA OF THE STOMACH.
463 due merely to an exaltation of virulence in the organism2 On the whole, and judging from the cases which I have seen, which unfortunately include no epidemic cases, I think the answer must be in the affirmative. The clinical symptoms obviously differ considerably without any corresponding alteration in the pathological or bacteriological features, and the main differences between the organism of Weicbselbaum and the organism found in these cases in England seem to be quite msufficient to establish them as distinct species. If this view is accepted we shall henceforth look upon posterior basic meningitis as a disease comparable in certain points to pneumonia, which, while as a rule a sporadic disease, occasionally presents itself in epidemic form. The causes which determine this variation I have to thank are in both cases still to be discovered. Dr. Lees, Dr. Penrose, and Dr. Garrod for permission to make u
is often prolonged for some distance along the curvatures in the form of thick stria3 or bands. In almost every instance, whether the pylorus is stenosed or not, the cardiac portion of the stomach is dilated and its mucous membrane shows signs of chronic inflammation. In about one-sixth of the cases the entire organ was infiltrated by the new growth, which also tended to invade,the first part of the duodenum and the lower end of the oesophagus. The walls of the viscus were greatly thickened and its cavity contracted, and its inner surface was sometimes extensively ulcerated. In only two instances out of the entire number did the disease appear as a circumscribed tumour in the wall of the viscus, with secondary nodules in the surrounding mucous membrane. On microscopical examination the aisease is found to commence as a round-cell infiltration of the sub-mucosa, which subsequently spreads into the muscular coat through its interstitial connective tissue and finally destroys and replaces the contractile fibres. At first the mucous membrane is merely stretched by the subjacent growth and many suggestions. Bentinek-street, W. atrophies from pressure, but at a later stage it is often invaded by the disease and may undergo ulceration. Schlagenhaufer and Redtenbacher have shown that a diffuse PRIMARY SARCOMA OF THE STOMACH. infiltration of round cells in the mucous membrane may extend far beyond the apparent confines of the disease. Like the other forms of sarcomata, this variety is,prone to BY W. SOLTAU FENWICK, M.D., M.R.C.P. LOND., PHYSICIAN TO THE EVELINA HOSPITAL FOR SICK CHILDREN, ETC. undergo softening and degeneration, with the formation of small cavities in its substance or perforation of the wall of the stomach. DURING the last few years the opinion has been steadily gain2. Spindle-cell or fibro-sarlJorna.-This comes next in ing ground that many of the morbid growths of the stomach frequency of occurrence and constituted 12 out of the 53 which have hitherto been regarded as carcinomata are really cases, or 22 per cent. It presents itself as a round or sarcomatous in character and that the clinical description oval circumscribed tumour of the wall of the stomach and it of malignant disease of the viscus requires to be revised is utually situated near the great curvature. As it grows it more and more beneath the serous coat and exerts from a new pathological standpoint. This opinion is founded projects so much traction upon its point of origin that it not only partly upon the discovery that many specimens which are drags the whole stomach downwards but often acquires a described in museum catalogues as examples of carcino- pedunculated appearance. These tumours sometimes grow matous or fibroid tumours present the characteristic features to an enormous size (12 lb., Oantwell), and may fill the of round-cell or spindle-cell sarcoma when examined with greater part of the abdominal cavity. When small they are the microscope, and partly upon the large number of cases smooth and firm on section, but as their bulk increases they of sarcoma of the stomach which have been published since often become knotty and irregular in shape, and their tissue cystic degeneration. These latter changes are special attention was directed to the subject. Thus, Perry undergoes and Shaw found four instances of sarcoma among 50 ’, seldom accompanied by the formation of adhesions, but specimens of malignant disease of the stomach, while in occasionally give rise to perforation of the stomach the course of 23 consecutive necropsies upon persons who (Ewald). 3. Myo-sarcomata.-These are much rarer than either of had died from primary neoplasms of the organ I observed two well-marked examples of round-cell sarcoma. It may also the preceding, only five examples having been recorded up to be noticed that whereas Schlesinger in 1897 was only able the present time. They form smooth or slightly nodular to collect 30 cases of the disease, in November, 1900, the masses in the substance of the gastric wall near the great number of published cases exceeded 60, of which 53 curvature and frequently show signs of cystic degeneration. possessed sufficient details to permit of analysis. Although Like the fibro-sarcomata, they may attain enormous it is impossible to make any absolute statement as to the dimensions, Brodowski having met with one which relative frequency of the disease it is probable the sarcomata weighed 12lb. 4. Angio-sa’l’lJoma.- This has been recorded twice (Bruch constitute from 5 to 8 per cent. of all primary neoplasms and Kosinski). In one case it formed a tumour of the size of the stomach. Gastric sarcoma may appear either as a primary growth or of an infant’s head with many cysts due to interstitial as a secondary deposit. The former is by far the most haemorrhages scattered through its substance. Each variety is apt to give rise to secondary growths in common if exception be made of those not infrequent cases where the organ is involved by a lympho-sarcoma Six ’ organs more or less remote from the primary disease, but the Thus out of varieties of the primary affection have been described up to round cell is by far the most malignant. the present time-namely, round-cell sarcoma, spindle-cell 23 cases of the latter in which full details are given, 16 sarcoma, fibro-sarcoma, myo-sarcoma, myxo-sarcoma, and or 70 per cent. are stated to have exhibited metasIn almost every instance the lymphatic glands angio-sarcoma. Of these the spindle-cell and the fibro- tases. sarcomata are probably identical, while the single example immediately connected with the stomach were enlarged and of myxo-sarcoma appears to have been originally a case of in nearly 50 per cent. they were sarcomatous ; while in a few cases the retro-peritoneal, mesenteric, and even the the round-cell type which had undergone degeneration. mediastinal, cervical, and supra clavicular glands were MORBID ANATOMY. affected. One or both kidneys presented secondary deposits 1. -BoMm-ceK sa’l’corna -Round-cell sarcoma, or as it is in 28 per cent. ; the liver, ovaries, pancreas, adrenals, and I often termed " lympho-sarcoma," is the varietv most omentum each in 14 per cent.; and the lungs, diaphragm. met with and was observed in 33 out of 53 cases, or in pleurse. oesophagus, intestines, and mesentery in about 7 per It is also important to notice that As a rule it cent. of the cases. about 62 per cent. of the entire number. presents itself in the form of a dense infiltration of the nodules of growth were present in the skin of the abdomen, pyloric third of the stomach, which transforms the coats of thorax, or back in about 12 per cent. of the entire number. this portion of the viscus into a homogeneous, yellowish- The spindle-cell variety was accompanied by metastases in white mass of rigid consistence and considerable thickness. the perigastric glands in 37 per cent. of the cases, and in the The peritoneal aspect is often covered with recent lymph, skin, liver, and diaphragm in about 12 per cent. of the while the inner surface may be slightly uneven or distinctly cases, while in two out of the five cases of myo-sarcoma nodular and is occasionally superficially ulcerated. If the secondary growths were found in the liver. A further study of the morbid phenomena of gastric sarcopylorus is greatly thickened its orifice may be partially stenosed, as in cases of spheroidal-cell carcinoma, but as a mata brings to light several other points of distinction rule the rigidity of its tissues renders it patent and the valve between them and the carcinomata which may prove of incompetent rather than contracted. The growth gradually service in their clinical differentiation. Owing to the infreshades off as it approaches the centre of the organ, but it quent infection of the peritoneum there is usually a notable
If
usually
464 absence of the elongated and nodular epigastric tumour < me-sixth of the cases and is usually dependent upon which is so often present in cancer of the stomach, owing to ssecondary growths in the kidneys. If vomiting is a proinfiltration and adhesion of the great omentum. Again, in iminent feature of the case the bowels may be confined, but about 15 per cent. of the cases of round-cell sarcoma the iin many cases of the round-cell type diarrhoea is a noticespleen is so much enlarged as to project below the costaliable feature. With regard to the local symptoms which accompany margin. This increase in size is not due to the existence of a morbid growth in its substance, but to congestion andasarcoma of the stomach it should be noticed in the first place hyperplasia of the splenic pulp-a condition which never1that they may be entirely absent during the whole course of occurs in carcinoma. Kundrat observed enlargement of the 1the disease. In the case related by Baldy the appetite tonsils with occasional swelling and ulceration of theicontinued good and there was no complaint either of pain follicles of the tongue, and laid considerable stress uponor vomiting, although practically the entire stomach was their diagnostic significance. Perforation of the stomachinvolved in an enormous tumour. In another instance followed by general peritonitis occurs far more often than (Oantwel1) where the growth weighed 12 pounds the in cases of cancer (11 per cent ), owing probably to the digestive functions were apparently normal, while in that frequent softening of the morbid growth and to the absence recorded by Robert the first and only indication of an of protective adhesions. On the other hand, localised peri- extensive growth was an attack of hsematemesis. In about gastric abscess has not been observed up to the present. 76 per cent. of all cases abdominal pain is experienced durDeath from hasmorrhage has only been recorded once ing some period of the disease. It varies greatly, however, (Robert), and in one instance the disease gave rise to a both in its character and severity. As a rule it does not gastro-colic fistula (Chernjaeff). True carcinoma was twice amount to more than a sense of fulness and oppression after meals such as ensues from. gaseous distension of the stomach, found associated with round-cell sarcoma. Secondary sarcomata of the stomach are usually lympho- but in 15 per cent. of the recorded cases it was described as sarcomatous in their nature and have been observed as the having been severe and increased by the ingestion of food. result of disease in the retro-peritoneal glands (Maier, Perry), It is interesting to observe that in most of thefe the body of the stomach was either extensively infiltrated or there was a csecum (Beck), neck. pharynx, gums (Kundrat), rectum, superior maxilla, and in cases of general sarcomatosis considerable invasion of the pancreas or retro-peritoneal (Malmsten, Carry). When the mischief spreads by con- glands. The solid tumours (fibro- and myo-sarcomaia) are tiguity the pyloric region is often affected in the same more often accompanied by sensations of weight or dragging manner as in the primary affection, but when the original than by actual pain. growth is more remotely situated the metastases usually Vomiting is usually a later symptom unless the pylorus is appear as rounded tumours or thick wheals in the sub- contracted. At first it occurs at intervals, but as the stomach mucous tissue. These deposits often soften and ulcerate and becomes dilated it is repeated more frequently and the ejects are found to present the usual features which characterise may even undergo partial cicatrisation. stagnation and decomposition of the food. Vomiting ETIOLOGY. occurring soon after meals and preceded by pain usually At present there are few facts that bear directly upon the indicates ulceration of the growth, while the attacks of etiology of the disease. The round-cell sarcoma seems to incessant retching, attended with the expulsion of mucus, affect both sexes with equal frequency and to develop at which are apt to appear from time to time, and are often so any age. Nevertheless, there is a distinct tendency for it to severe as to preclude the administration of food, result from occur at an earlier period of life than carcinoma, since the secondary inflammation of the mucous membrane. In the The spindle-cell case of the large solid tumours vomiting is a less frequent mean age of 29 cases was only 34 years. variety, on the other hand, is five times as frequent in phenomenon (48 per cent.) and seldom appears until after the women as in men, the average age of the collected cases lapse of from five months to seven months. Faecal vomiting at the time of death being 51 years. The one recorded is usually an indication of a gastro-colic fistula. by Finlayson of sarcoma in a male child, three and a half Haemorrhage from the stomach is seldom a prominent years old, appears to be an exception to this rule, but the symptom of round-cell sarcoma owing to the comparative description of the microscopical features of the tumour is infrequency of ulceration of the growth. It is probable, somewhat vague. The myo-sarcomata were usually met with however, that capillary oozing is of constant occurrence, in men in the prime of life. That a sarcoma, like carcinoma, since the gastric contents removed by a tube are often found is prone to attack scar-tissue in the stomach is well illus- to be mixed with coffee-ground material,-while careful trated by a case published by Brooks, where a round-cell examination of the stools may demonstrate the existence growth developed in the cicatrix of an old bullet wound of of altered blood (Schlesinger). In the spindle-cell variety the lesser curvature. In a case which came under the writer’s of the disease repeated attacks of boematemesis were observation a large secondary melanotic growth was found observed in nearly half the cases, and in two instances a in the base of a simple chronic ulcer situated near the severe haemorrhage was the first symptom to attract. attention. pylorus. PHYSICAL SIGNS. SYMPTOMS. A palpable tumour connected with the stomach is an The general symptoms of sarcoma of the stomach are essentially the same as those which accompany other forms inconstant sign of round-cell sarcoma and was only observed In most of malignant disease. One of its earliest and most striking in about 30 per cent. ot the recorded cases. features is progressive emaciation with failure of physical instances it is produced by a local thickening of the power. This is usually most conspicuous in young persons gastric wall in the region of the pylorus, and was and in cases where the growth causes early contraction of described as a round or oval mass, occupying the right the pyloric orifice. When the neoplasm only affects a com- hypochondriac or epigastric region, smooth on the surface, paratively small portion of the viscus, as in the spindle-cell somewhat tender upon pressure, and often freely moveand myo-sarcomata, the loss of flesh is chiefly observed in able. Rapid increase in size can sometimes be observed. the later stages of the complaint or after ulceration has In other instances the tumour consists of the entire stomach Acaemia is always present and gradually and more than once the concomitant enlargement of the taken place. becomes profound, but if there is continued fever or repeated spleen has been mistaken for a malignant mass. In the haemorrhage its progress is very rapid. It is characterised fibro- and myo.sarcomata a tumour is almost always present by a great diminution both of haemoglobin and red and is often so large as to occupy the greater part of the corpuscles and in one of the cases recorded the abdominal cavity. If the growth is situated near the colouring matter only amounted to 15 per cent. of great curvature it is usually detected in the umbilical the normal. Slight leucocytosis may sometimes be observed, left hypochondriac or lumbar region, where it forms but the increase of white corpuscles which normally a smooth, firm, painless mass which is dull on perand freely moveable in all directions. occurs after meals (digestion-leucocytosis) is usually absent. I cussion This As a rule the appetite is greatly diminished and there is a latter peculiarity affords a marked contrast to the behaviour special distaste to meat, but occasionally the desire for food of a carcinomatous growth in the same position, which is continues unimpaired throughout (Rasch, Baldy) or only invariably fixed by extensive adhesions to the neighbouring declines during the last few weeks of life (Maass, Fleiner) ; viscera. In two cases where the tumour was attached to the thirst varies with the severity of the anaemia. When the posterior wall of the stomach it filled the lesser sac of the neoplasm grows very rapidly or its tissues undergo degenera- peritoneum and was consequently covered by the stomach tive changes the patient often exhibits slight but continuous and transverse colon, but being somewhat pedunculated its pyrexia (from 99° to 101° F.). Albuminuria occurs in about could easily be moved from side to side.
465
Dilatation of
the stomach can be detected in every case of swollen or ulcerated. 5. Secondary deposits in the skin occur pylorus, and when the orifice is contracted in a notable proportion of the cases and permit of excision ,peristaltic movements of the enlarged viscus are usually and microscopical examination. It should be remembered, visible. When the organ is affected by diffuse infiltration however, that sarcomatosis has been met with in true its cavity is contracted and its outlines are obscured by the cancer of the stomach (Leube). 6. A large nodular tumour due to infiltration of the omentum or a greatly enlarged transverse colon. Metastatic deposits in the skin constitute an important liver with secondary growths in its substance are rarely met 7. Persistent albuminuria is often observed in feature of the disease. As a rule they appear in the form of with. sarcoma but is exceptional in cancer. 8 The discovery of one or two small nodules in or around the umbilicus, but occasionally they are very numerous and are scattered all pieces of morbid growth in the vomit renders the diagnosis over the abdomen, chest, and back. They vary in size from certain (Riegel, Westphalen). The spindle-cell and myo-sarcomata are chiefly charac.a millet seed to a small bean, and at first are freely moveable in the subcutaneous tissue ; but after a time they become terised by their comparatively slow growth, the smooth, firm, adherent to the skin and may even give rise to ulceration. and moveable tumour, the frequent absence of pain, vomitEnlargement of the supra-clavicular and cervical glands is ing, and anorexia, and the tendency to repeated haemorrhage. rarely observed, while sarcomatous infiltration of the tongue TREATMENT. is still less common. In one case a correct diagnosis was of the recorded cases have been subjected to surgical made by the discovery of a secondary growth in the rectum. Many ’Generalisation of the disease is occasionally accompanied by treatment with considerable success so far as the immediate objects of the operation were concerned. Torok, Dock, the symptoms of purpura (Redtenbacher). Oheullcal examination of the contents of the stomach Schopf, and others have removed considerable portions of the affords similar results to those met with in gastric cancer. stomach affected by the round cell growth, and in at least Free hydrochloric acid disappears at an early stage of the one case (Schopf) there was no recurrence at the end of a complaint (Fleiner, Schlesinger) and fermentation of the year. The solid tumours are especially favourable for food often produces an excess of lactic acid (Dreyer, Maass, extirpation, as they are often pedunculated and involve a comparatively small area of the gastric wall. Hartley vIammerslag). Sctrcinae may or may not be present and removed a large fibro-sarcoma and Kosinski a cystic angioSchlesinger was able to demonstrate the presence of the sarcoma with apparent success, while in Cantwell’s case bacillus is to occur in cases which Oppler- Boas only supposed ot cancer. The sulphocyanide of potassium in the saliva the excision of spindle-cell sarcoma weighing 12 lb. gave to the patient for eight months. If one may grd.dually diminishes as the disease progresses and finally great relief judge from the morbid anatomy ot the disease the surgical disappears about one month before death. treatment of sarcomata of the stomach wi’l prove far more DURATION AND COMPLICATIONS. successful than can ever be expected in carcinoma, but it is h is difficult to estimate the exact duration of a disease too early yet to discuss the prospects of a permanent cure. which commences so insidiously and is often unaccompanied .BtNMfC[p/M/.—Baldy :Journal of the American Medical Association, by definite physical signs for many months. It would 1898. vol. i., p 523. Brodowski: Virchows Archiv, vol. lxvii. Brooks : Medical News, 1898, p. 617. Bruch : Diagnose der B6sartigen Ge-appear, however, from a study of the recorded cases that schwilste, Mainz, 1847 Cantwell : Annals of Surgery, 1899, vol. ii., p. although the round-cell sarcomata often run their course in 596 Cayley: Transactions of the Pathological Society of London, 1869, three or four months the average duration of the disease is vol. xx. Chernjaeff : Ejened Klin. Gaz., St. Petersburg, 1886, vol. vi., .about 15 months; while in the case of the spindle-cell p. 665 Dock: Journal of the American Medical Association, vol. xxxv., Ueber das Magensarcom, Inaugural Dissertation, .and myo-sarcomata life is prolonged on the average for p. 156. , Drever: 1894. Drobt: Ueber Prinoare Sarcomatose des Magens, two years and eight months. It will be observed that in tottingen, Inaugural Dissertation, Munchen, 1894. Ewald: Klinik der Verdauungsboth instances the duration of the disease is greater than krankheiten, Theil ii., p. 354. Finlayson: Brit. Med. Jour., 1899, that of cancer, a result which probably depends upon its vol. ii., p. 1535. Fleiner : Lehrbuch der Krankheiten der VerdauungsTheil i., p. 295. Hadden: Transactions of the Pathological lesser malignancy and its lesser liability to produce ulcera- organe, Society of London, 1885, vol. xxxvii., p. 234. Hammerslag : Archiv fur tion of the mucous membrane and stenosis of the pylorus. Verdauungskrankheiteo, Theil ii.. Heft 1, Beobachtung 10. Handford: Death usually occurs from exhaustion and is often preceded Transactions of the Pathological Society of London, 1888, vol. xl., 89. Hardy: Gazette des Hôpitaux, 1878. Hartley: Annals by a semi-comatose state lasting for several days. Perfora- p. of Surgery. 1896, vol. xxiii., p 609. Kehr- Langenheck’s Archiv, tioj of the stomach followed by general peritonitis occurs Iviii.. 3. Kosinski : Bericht uber die Verhandlungen der Deutschen Kundrat : Wiener Klinische in about from 10 per cent. to 12 per cent. of the cases of Gesellschaft fiir Chirurgie, 1892. round-cell sarcoma and may even take place in the spindle- Wochenschrift, 1893, p. 12. Legg: Transactions of the Pathological Society of London, vol. xxv., p. 121. Lowe: Brit. Med. Jour., 1886, - cell form (Ewald), but owing to the absence of adhesions a vol. ii., p. 1033. Maass : Deutsche Medicinische Wochenschrift, 1895, is abscess Fatal is Meier: Archiv fiir Heilkunde, 1871, Heft 2. Mintz : Berliner p. 34. perigastric exceptional. haemorrhage 1900, xxxii., p. 708. Perry : Glasgow Medical very rare. In two instances general sarcomatosis tended to Klinische Wochenschrift, 1883, p. 215 Perry and Shaw : Guy’s Hospital Reports, 1892, shorten the period of life, while in one an attack of tetany, Journal. p. 48. Rasch : Hospitaltidende, 189t, p. 849. Redtenbacher : Jahrbuch similar to that met with in cicatricial stenosis of the pylorus, der Wiener Krankenanstalten, 1894, p. 560. Riegel : Die Erkrankungen wts immediately responsible for the fatal termination des Magens, ii., p. 874. Robert : Allgemeine Medicinische Central1894, p. 1153. Sobepelern : Hospitaltidende, R. ii., 1, p. 35. Fleiner). Excessive ascites, albuminuria, portal thrombosis, Zeitung, : Zeitsehrift fur Klinische Medicin, 1897, p. 179. Schopf : and pneumonia all accelerate the natural course of the Schlesinger Centralblatt fiir Chirurgie, 1899. p. 43. Torok : Centralblatt fiir disease. Chirurgie, 1892. Virchow : Die Krankhaften Geschwulste, 2. Weissblum : Ueber Primare und Secundare Magensarcom, Inaugural DisserDIAGNOSIS. tation, Greifswald, 1886. Westphalen: Petersburger Medicinische So far as the recognition of the malignant nature of the Wochenschrift, 1893, xlv., p. 403. disease is concerned the sarcomata do not offer any particular Devonshire-street, W. dimculty. The intractable character of the gastric symptoms, coupled with the progressive emaciation, physical FOREIGN BODY IN THE ABDOMEN. debility, and cachexia, indicate a profound disturbance of the processes of digestion and assimilation, while the disBY ERNEST H. ELLISON, M. A., M.R C.S. ENG., covery of a growing tumour connected with the stomach or L.R.O.P. LOND. of metastases in other viscera demonstrates at once the existence of a neoplasm. A more interesting question is the clinical differentiation of sarcoma and carcinoma. A As illustrating the importance of the well-known axiom ,diagnosis of round-cell sarcoma of the stomach may that all instruments and sponges should be counted prior to often be made by attention to the following facts :in the interior of the abdomen I 1. The disease usually occurs before 35 years of performing operations the case which occurred in my practice following .age, so that the younger the patient the greater append the probability that the malignant affection is sarco- recently. ,matous in character. 2. In many cases there is slight A man, aged 49 years, sent for me in consequence of severe but continuous pyrexia accompanied by rapid and profound pain which he referred to the region of the umbilicus. This anaemia, while in carcinoma fever is always absent during on examination proved to be due to the presence of a foreign the early stages of the complaint and the cachexia much body which protruded through the integuments about three more gradual in its development. 3. Simple enlargement of inches below and to the left of the umbilicus. All efforts to the spleen is by no means infrequent, but is never met with remove the foreign body without a cutting operation-to in cancer unless the organ is involved in the growth. which the patient refused his consent-being futile I suc4. According to Kundrat the tonsils are apt to enlarge and ceeded in breaking off the most dependent portion of what the follicles upon the sides of the tongue may become on inspection presented the appearance of being the blades ’sarcoma
of the
is often prolonged for some distance along the curvatures in the form of thick stria3 or bands. In almost every instance, whether the pylorus is stenosed or not, the cardiac portion of the stomach is dilated and its mucous membrane shows signs of chronic inflammation. In about one-sixth of the cases the entire organ was infiltrated by the new growth, which also tended to invade,the first part of the duodenum and the lower end of the oesophagus. The walls of the viscus were greatly thickened and its cavity contracted, and its inner surface was sometimes extensively ulcerated. In only two instances out of the entire number did the disease appear as a circumscribed tumour in the wall of the viscus, with secondary nodules in the surrounding mucous membrane. On microscopical examination the aisease is found to commence as a round-cell infiltration of the sub-mucosa, which subsequently spreads into the muscular coat through its interstitial connective tissue and finally destroys and replaces the contractile fibres. At first the mucous membrane is merely stretched by the subjacent growth and many suggestions. Bentinek-street, W. atrophies from pressure, but at a later stage it is often invaded by the disease and may undergo ulceration. Schlagenhaufer and Redtenbacher have shown that a diffuse PRIMARY SARCOMA OF THE STOMACH. infiltration of round cells in the mucous membrane may extend far beyond the apparent confines of the disease. Like the other forms of sarcomata, this variety is,prone to BY W. SOLTAU FENWICK, M.D., M.R.C.P. LOND., PHYSICIAN TO THE EVELINA HOSPITAL FOR SICK CHILDREN, ETC. undergo softening and degeneration, with the formation of small cavities in its substance or perforation of the wall of the stomach. DURING the last few years the opinion has been steadily gain2. Spindle-cell or fibro-sarlJorna.-This comes next in ing ground that many of the morbid growths of the stomach frequency of occurrence and constituted 12 out of the 53 which have hitherto been regarded as carcinomata are really cases, or 22 per cent. It presents itself as a round or sarcomatous in character and that the clinical description oval circumscribed tumour of the wall of the stomach and it of malignant disease of the viscus requires to be revised is utually situated near the great curvature. As it grows it more and more beneath the serous coat and exerts from a new pathological standpoint. This opinion is founded projects so much traction upon its point of origin that it not only partly upon the discovery that many specimens which are drags the whole stomach downwards but often acquires a described in museum catalogues as examples of carcino- pedunculated appearance. These tumours sometimes grow matous or fibroid tumours present the characteristic features to an enormous size (12 lb., Oantwell), and may fill the of round-cell or spindle-cell sarcoma when examined with greater part of the abdominal cavity. When small they are the microscope, and partly upon the large number of cases smooth and firm on section, but as their bulk increases they of sarcoma of the stomach which have been published since often become knotty and irregular in shape, and their tissue cystic degeneration. These latter changes are special attention was directed to the subject. Thus, Perry undergoes and Shaw found four instances of sarcoma among 50 ’, seldom accompanied by the formation of adhesions, but specimens of malignant disease of the stomach, while in occasionally give rise to perforation of the stomach the course of 23 consecutive necropsies upon persons who (Ewald). 3. Myo-sarcomata.-These are much rarer than either of had died from primary neoplasms of the organ I observed two well-marked examples of round-cell sarcoma. It may also the preceding, only five examples having been recorded up to be noticed that whereas Schlesinger in 1897 was only able the present time. They form smooth or slightly nodular to collect 30 cases of the disease, in November, 1900, the masses in the substance of the gastric wall near the great number of published cases exceeded 60, of which 53 curvature and frequently show signs of cystic degeneration. possessed sufficient details to permit of analysis. Although Like the fibro-sarcomata, they may attain enormous it is impossible to make any absolute statement as to the dimensions, Brodowski having met with one which relative frequency of the disease it is probable the sarcomata weighed 12lb. 4. Angio-sa’l’lJoma.- This has been recorded twice (Bruch constitute from 5 to 8 per cent. of all primary neoplasms and Kosinski). In one case it formed a tumour of the size of the stomach. Gastric sarcoma may appear either as a primary growth or of an infant’s head with many cysts due to interstitial as a secondary deposit. The former is by far the most haemorrhages scattered through its substance. Each variety is apt to give rise to secondary growths in common if exception be made of those not infrequent cases where the organ is involved by a lympho-sarcoma Six ’ organs more or less remote from the primary disease, but the Thus out of varieties of the primary affection have been described up to round cell is by far the most malignant. the present time-namely, round-cell sarcoma, spindle-cell 23 cases of the latter in which full details are given, 16 sarcoma, fibro-sarcoma, myo-sarcoma, myxo-sarcoma, and or 70 per cent. are stated to have exhibited metasIn almost every instance the lymphatic glands angio-sarcoma. Of these the spindle-cell and the fibro- tases. sarcomata are probably identical, while the single example immediately connected with the stomach were enlarged and of myxo-sarcoma appears to have been originally a case of in nearly 50 per cent. they were sarcomatous ; while in a few cases the retro-peritoneal, mesenteric, and even the the round-cell type which had undergone degeneration. mediastinal, cervical, and supra clavicular glands were MORBID ANATOMY. affected. One or both kidneys presented secondary deposits 1. -BoMm-ceK sa’l’corna -Round-cell sarcoma, or as it is in 28 per cent. ; the liver, ovaries, pancreas, adrenals, and I often termed " lympho-sarcoma," is the varietv most omentum each in 14 per cent.; and the lungs, diaphragm. met with and was observed in 33 out of 53 cases, or in pleurse. oesophagus, intestines, and mesentery in about 7 per It is also important to notice that As a rule it cent. of the cases. about 62 per cent. of the entire number. presents itself in the form of a dense infiltration of the nodules of growth were present in the skin of the abdomen, pyloric third of the stomach, which transforms the coats of thorax, or back in about 12 per cent. of the entire number. this portion of the viscus into a homogeneous, yellowish- The spindle-cell variety was accompanied by metastases in white mass of rigid consistence and considerable thickness. the perigastric glands in 37 per cent. of the cases, and in the The peritoneal aspect is often covered with recent lymph, skin, liver, and diaphragm in about 12 per cent. of the while the inner surface may be slightly uneven or distinctly cases, while in two out of the five cases of myo-sarcoma nodular and is occasionally superficially ulcerated. If the secondary growths were found in the liver. A further study of the morbid phenomena of gastric sarcopylorus is greatly thickened its orifice may be partially stenosed, as in cases of spheroidal-cell carcinoma, but as a mata brings to light several other points of distinction rule the rigidity of its tissues renders it patent and the valve between them and the carcinomata which may prove of incompetent rather than contracted. The growth gradually service in their clinical differentiation. Owing to the infreshades off as it approaches the centre of the organ, but it quent infection of the peritoneum there is usually a notable
If
usually
464 absence of the elongated and nodular epigastric tumour < me-sixth of the cases and is usually dependent upon which is so often present in cancer of the stomach, owing to ssecondary growths in the kidneys. If vomiting is a proinfiltration and adhesion of the great omentum. Again, in iminent feature of the case the bowels may be confined, but about 15 per cent. of the cases of round-cell sarcoma the iin many cases of the round-cell type diarrhoea is a noticespleen is so much enlarged as to project below the costaliable feature. With regard to the local symptoms which accompany margin. This increase in size is not due to the existence of a morbid growth in its substance, but to congestion andasarcoma of the stomach it should be noticed in the first place hyperplasia of the splenic pulp-a condition which never1that they may be entirely absent during the whole course of occurs in carcinoma. Kundrat observed enlargement of the 1the disease. In the case related by Baldy the appetite tonsils with occasional swelling and ulceration of theicontinued good and there was no complaint either of pain follicles of the tongue, and laid considerable stress uponor vomiting, although practically the entire stomach was their diagnostic significance. Perforation of the stomachinvolved in an enormous tumour. In another instance followed by general peritonitis occurs far more often than (Oantwel1) where the growth weighed 12 pounds the in cases of cancer (11 per cent ), owing probably to the digestive functions were apparently normal, while in that frequent softening of the morbid growth and to the absence recorded by Robert the first and only indication of an of protective adhesions. On the other hand, localised peri- extensive growth was an attack of hsematemesis. In about gastric abscess has not been observed up to the present. 76 per cent. of all cases abdominal pain is experienced durDeath from hasmorrhage has only been recorded once ing some period of the disease. It varies greatly, however, (Robert), and in one instance the disease gave rise to a both in its character and severity. As a rule it does not gastro-colic fistula (Chernjaeff). True carcinoma was twice amount to more than a sense of fulness and oppression after meals such as ensues from. gaseous distension of the stomach, found associated with round-cell sarcoma. Secondary sarcomata of the stomach are usually lympho- but in 15 per cent. of the recorded cases it was described as sarcomatous in their nature and have been observed as the having been severe and increased by the ingestion of food. result of disease in the retro-peritoneal glands (Maier, Perry), It is interesting to observe that in most of thefe the body of the stomach was either extensively infiltrated or there was a csecum (Beck), neck. pharynx, gums (Kundrat), rectum, superior maxilla, and in cases of general sarcomatosis considerable invasion of the pancreas or retro-peritoneal (Malmsten, Carry). When the mischief spreads by con- glands. The solid tumours (fibro- and myo-sarcomaia) are tiguity the pyloric region is often affected in the same more often accompanied by sensations of weight or dragging manner as in the primary affection, but when the original than by actual pain. growth is more remotely situated the metastases usually Vomiting is usually a later symptom unless the pylorus is appear as rounded tumours or thick wheals in the sub- contracted. At first it occurs at intervals, but as the stomach mucous tissue. These deposits often soften and ulcerate and becomes dilated it is repeated more frequently and the ejects are found to present the usual features which characterise may even undergo partial cicatrisation. stagnation and decomposition of the food. Vomiting ETIOLOGY. occurring soon after meals and preceded by pain usually At present there are few facts that bear directly upon the indicates ulceration of the growth, while the attacks of etiology of the disease. The round-cell sarcoma seems to incessant retching, attended with the expulsion of mucus, affect both sexes with equal frequency and to develop at which are apt to appear from time to time, and are often so any age. Nevertheless, there is a distinct tendency for it to severe as to preclude the administration of food, result from occur at an earlier period of life than carcinoma, since the secondary inflammation of the mucous membrane. In the The spindle-cell case of the large solid tumours vomiting is a less frequent mean age of 29 cases was only 34 years. variety, on the other hand, is five times as frequent in phenomenon (48 per cent.) and seldom appears until after the women as in men, the average age of the collected cases lapse of from five months to seven months. Faecal vomiting at the time of death being 51 years. The one recorded is usually an indication of a gastro-colic fistula. by Finlayson of sarcoma in a male child, three and a half Haemorrhage from the stomach is seldom a prominent years old, appears to be an exception to this rule, but the symptom of round-cell sarcoma owing to the comparative description of the microscopical features of the tumour is infrequency of ulceration of the growth. It is probable, somewhat vague. The myo-sarcomata were usually met with however, that capillary oozing is of constant occurrence, in men in the prime of life. That a sarcoma, like carcinoma, since the gastric contents removed by a tube are often found is prone to attack scar-tissue in the stomach is well illus- to be mixed with coffee-ground material,-while careful trated by a case published by Brooks, where a round-cell examination of the stools may demonstrate the existence growth developed in the cicatrix of an old bullet wound of of altered blood (Schlesinger). In the spindle-cell variety the lesser curvature. In a case which came under the writer’s of the disease repeated attacks of boematemesis were observation a large secondary melanotic growth was found observed in nearly half the cases, and in two instances a in the base of a simple chronic ulcer situated near the severe haemorrhage was the first symptom to attract. attention. pylorus. PHYSICAL SIGNS. SYMPTOMS. A palpable tumour connected with the stomach is an The general symptoms of sarcoma of the stomach are essentially the same as those which accompany other forms inconstant sign of round-cell sarcoma and was only observed In most of malignant disease. One of its earliest and most striking in about 30 per cent. ot the recorded cases. features is progressive emaciation with failure of physical instances it is produced by a local thickening of the power. This is usually most conspicuous in young persons gastric wall in the region of the pylorus, and was and in cases where the growth causes early contraction of described as a round or oval mass, occupying the right the pyloric orifice. When the neoplasm only affects a com- hypochondriac or epigastric region, smooth on the surface, paratively small portion of the viscus, as in the spindle-cell somewhat tender upon pressure, and often freely moveand myo-sarcomata, the loss of flesh is chiefly observed in able. Rapid increase in size can sometimes be observed. the later stages of the complaint or after ulceration has In other instances the tumour consists of the entire stomach Acaemia is always present and gradually and more than once the concomitant enlargement of the taken place. becomes profound, but if there is continued fever or repeated spleen has been mistaken for a malignant mass. In the haemorrhage its progress is very rapid. It is characterised fibro- and myo.sarcomata a tumour is almost always present by a great diminution both of haemoglobin and red and is often so large as to occupy the greater part of the corpuscles and in one of the cases recorded the abdominal cavity. If the growth is situated near the colouring matter only amounted to 15 per cent. of great curvature it is usually detected in the umbilical the normal. Slight leucocytosis may sometimes be observed, left hypochondriac or lumbar region, where it forms but the increase of white corpuscles which normally a smooth, firm, painless mass which is dull on perand freely moveable in all directions. occurs after meals (digestion-leucocytosis) is usually absent. I cussion This As a rule the appetite is greatly diminished and there is a latter peculiarity affords a marked contrast to the behaviour special distaste to meat, but occasionally the desire for food of a carcinomatous growth in the same position, which is continues unimpaired throughout (Rasch, Baldy) or only invariably fixed by extensive adhesions to the neighbouring declines during the last few weeks of life (Maass, Fleiner) ; viscera. In two cases where the tumour was attached to the thirst varies with the severity of the anaemia. When the posterior wall of the stomach it filled the lesser sac of the neoplasm grows very rapidly or its tissues undergo degenera- peritoneum and was consequently covered by the stomach tive changes the patient often exhibits slight but continuous and transverse colon, but being somewhat pedunculated its pyrexia (from 99° to 101° F.). Albuminuria occurs in about could easily be moved from side to side.
465
Dilatation of
the stomach can be detected in every case of swollen or ulcerated. 5. Secondary deposits in the skin occur pylorus, and when the orifice is contracted in a notable proportion of the cases and permit of excision ,peristaltic movements of the enlarged viscus are usually and microscopical examination. It should be remembered, visible. When the organ is affected by diffuse infiltration however, that sarcomatosis has been met with in true its cavity is contracted and its outlines are obscured by the cancer of the stomach (Leube). 6. A large nodular tumour due to infiltration of the omentum or a greatly enlarged transverse colon. Metastatic deposits in the skin constitute an important liver with secondary growths in its substance are rarely met 7. Persistent albuminuria is often observed in feature of the disease. As a rule they appear in the form of with. sarcoma but is exceptional in cancer. 8 The discovery of one or two small nodules in or around the umbilicus, but occasionally they are very numerous and are scattered all pieces of morbid growth in the vomit renders the diagnosis over the abdomen, chest, and back. They vary in size from certain (Riegel, Westphalen). The spindle-cell and myo-sarcomata are chiefly charac.a millet seed to a small bean, and at first are freely moveable in the subcutaneous tissue ; but after a time they become terised by their comparatively slow growth, the smooth, firm, adherent to the skin and may even give rise to ulceration. and moveable tumour, the frequent absence of pain, vomitEnlargement of the supra-clavicular and cervical glands is ing, and anorexia, and the tendency to repeated haemorrhage. rarely observed, while sarcomatous infiltration of the tongue TREATMENT. is still less common. In one case a correct diagnosis was of the recorded cases have been subjected to surgical made by the discovery of a secondary growth in the rectum. Many ’Generalisation of the disease is occasionally accompanied by treatment with considerable success so far as the immediate objects of the operation were concerned. Torok, Dock, the symptoms of purpura (Redtenbacher). Oheullcal examination of the contents of the stomach Schopf, and others have removed considerable portions of the affords similar results to those met with in gastric cancer. stomach affected by the round cell growth, and in at least Free hydrochloric acid disappears at an early stage of the one case (Schopf) there was no recurrence at the end of a complaint (Fleiner, Schlesinger) and fermentation of the year. The solid tumours are especially favourable for food often produces an excess of lactic acid (Dreyer, Maass, extirpation, as they are often pedunculated and involve a comparatively small area of the gastric wall. Hartley vIammerslag). Sctrcinae may or may not be present and removed a large fibro-sarcoma and Kosinski a cystic angioSchlesinger was able to demonstrate the presence of the sarcoma with apparent success, while in Cantwell’s case bacillus is to occur in cases which Oppler- Boas only supposed ot cancer. The sulphocyanide of potassium in the saliva the excision of spindle-cell sarcoma weighing 12 lb. gave to the patient for eight months. If one may grd.dually diminishes as the disease progresses and finally great relief judge from the morbid anatomy ot the disease the surgical disappears about one month before death. treatment of sarcomata of the stomach wi’l prove far more DURATION AND COMPLICATIONS. successful than can ever be expected in carcinoma, but it is h is difficult to estimate the exact duration of a disease too early yet to discuss the prospects of a permanent cure. which commences so insidiously and is often unaccompanied .BtNMfC[p/M/.—Baldy :Journal of the American Medical Association, by definite physical signs for many months. It would 1898. vol. i., p 523. Brodowski: Virchows Archiv, vol. lxvii. Brooks : Medical News, 1898, p. 617. Bruch : Diagnose der B6sartigen Ge-appear, however, from a study of the recorded cases that schwilste, Mainz, 1847 Cantwell : Annals of Surgery, 1899, vol. ii., p. although the round-cell sarcomata often run their course in 596 Cayley: Transactions of the Pathological Society of London, 1869, three or four months the average duration of the disease is vol. xx. Chernjaeff : Ejened Klin. Gaz., St. Petersburg, 1886, vol. vi., .about 15 months; while in the case of the spindle-cell p. 665 Dock: Journal of the American Medical Association, vol. xxxv., Ueber das Magensarcom, Inaugural Dissertation, .and myo-sarcomata life is prolonged on the average for p. 156. , Drever: 1894. Drobt: Ueber Prinoare Sarcomatose des Magens, two years and eight months. It will be observed that in tottingen, Inaugural Dissertation, Munchen, 1894. Ewald: Klinik der Verdauungsboth instances the duration of the disease is greater than krankheiten, Theil ii., p. 354. Finlayson: Brit. Med. Jour., 1899, that of cancer, a result which probably depends upon its vol. ii., p. 1535. Fleiner : Lehrbuch der Krankheiten der VerdauungsTheil i., p. 295. Hadden: Transactions of the Pathological lesser malignancy and its lesser liability to produce ulcera- organe, Society of London, 1885, vol. xxxvii., p. 234. Hammerslag : Archiv fur tion of the mucous membrane and stenosis of the pylorus. Verdauungskrankheiteo, Theil ii.. Heft 1, Beobachtung 10. Handford: Death usually occurs from exhaustion and is often preceded Transactions of the Pathological Society of London, 1888, vol. xl., 89. Hardy: Gazette des Hôpitaux, 1878. Hartley: Annals by a semi-comatose state lasting for several days. Perfora- p. of Surgery. 1896, vol. xxiii., p 609. Kehr- Langenheck’s Archiv, tioj of the stomach followed by general peritonitis occurs Iviii.. 3. Kosinski : Bericht uber die Verhandlungen der Deutschen Kundrat : Wiener Klinische in about from 10 per cent. to 12 per cent. of the cases of Gesellschaft fiir Chirurgie, 1892. round-cell sarcoma and may even take place in the spindle- Wochenschrift, 1893, p. 12. Legg: Transactions of the Pathological Society of London, vol. xxv., p. 121. Lowe: Brit. Med. Jour., 1886, - cell form (Ewald), but owing to the absence of adhesions a vol. ii., p. 1033. Maass : Deutsche Medicinische Wochenschrift, 1895, is abscess Fatal is Meier: Archiv fiir Heilkunde, 1871, Heft 2. Mintz : Berliner p. 34. perigastric exceptional. haemorrhage 1900, xxxii., p. 708. Perry : Glasgow Medical very rare. In two instances general sarcomatosis tended to Klinische Wochenschrift, 1883, p. 215 Perry and Shaw : Guy’s Hospital Reports, 1892, shorten the period of life, while in one an attack of tetany, Journal. p. 48. Rasch : Hospitaltidende, 189t, p. 849. Redtenbacher : Jahrbuch similar to that met with in cicatricial stenosis of the pylorus, der Wiener Krankenanstalten, 1894, p. 560. Riegel : Die Erkrankungen wts immediately responsible for the fatal termination des Magens, ii., p. 874. Robert : Allgemeine Medicinische Central1894, p. 1153. Sobepelern : Hospitaltidende, R. ii., 1, p. 35. Fleiner). Excessive ascites, albuminuria, portal thrombosis, Zeitung, : Zeitsehrift fur Klinische Medicin, 1897, p. 179. Schopf : and pneumonia all accelerate the natural course of the Schlesinger Centralblatt fiir Chirurgie, 1899. p. 43. Torok : Centralblatt fiir disease. Chirurgie, 1892. Virchow : Die Krankhaften Geschwulste, 2. Weissblum : Ueber Primare und Secundare Magensarcom, Inaugural DisserDIAGNOSIS. tation, Greifswald, 1886. Westphalen: Petersburger Medicinische So far as the recognition of the malignant nature of the Wochenschrift, 1893, xlv., p. 403. disease is concerned the sarcomata do not offer any particular Devonshire-street, W. dimculty. The intractable character of the gastric symptoms, coupled with the progressive emaciation, physical FOREIGN BODY IN THE ABDOMEN. debility, and cachexia, indicate a profound disturbance of the processes of digestion and assimilation, while the disBY ERNEST H. ELLISON, M. A., M.R C.S. ENG., covery of a growing tumour connected with the stomach or L.R.O.P. LOND. of metastases in other viscera demonstrates at once the existence of a neoplasm. A more interesting question is the clinical differentiation of sarcoma and carcinoma. A As illustrating the importance of the well-known axiom ,diagnosis of round-cell sarcoma of the stomach may that all instruments and sponges should be counted prior to often be made by attention to the following facts :in the interior of the abdomen I 1. The disease usually occurs before 35 years of performing operations the case which occurred in my practice following .age, so that the younger the patient the greater append the probability that the malignant affection is sarco- recently. ,matous in character. 2. In many cases there is slight A man, aged 49 years, sent for me in consequence of severe but continuous pyrexia accompanied by rapid and profound pain which he referred to the region of the umbilicus. This anaemia, while in carcinoma fever is always absent during on examination proved to be due to the presence of a foreign the early stages of the complaint and the cachexia much body which protruded through the integuments about three more gradual in its development. 3. Simple enlargement of inches below and to the left of the umbilicus. All efforts to the spleen is by no means infrequent, but is never met with remove the foreign body without a cutting operation-to in cancer unless the organ is involved in the growth. which the patient refused his consent-being futile I suc4. According to Kundrat the tonsils are apt to enlarge and ceeded in breaking off the most dependent portion of what the follicles upon the sides of the tongue may become on inspection presented the appearance of being the blades ’sarcoma
of the