THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
LOS ANGELES
GIFT OF
Dr. Jimil Bogen
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if-A-zi^/'/^
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N
DIAGNOSIS
OF THE
MALIGNANT TUMORS
OF THE
ABDOMINAL VISCERA
BY
PROFESSOR RUDOLPH SCHjMIDT
PR0FP:SS0K of medicine in the MNIVEKSITY of INNSBRUCK
AUTHORIZED ENGLISH VERSION
BY
JOSEPH BURKE, ScD., M.D.,
ATTENDING SURGEON, BUFFALO HOSPITAL OF THE SISTERS OF CHARITY,
CONSULTING SURGEON, EMERGENCY HOSPITAL,
BUFFALO, N. Y.
NEW YORK
REBMAN COMPANY
herald square BUILDING
141-145 West 36th Street
COPYHIGHT, 1913, BY
R E B M A N CO M P A N Y
New York
All Rights reserved
PRINTED IX AMERICA
Biomedical
lib'-ary
TABLE OF CONTEXTS
A. GENERAL PART
PAGE
Physical Examination of the Abdomen for the Presence of ]\Ialignant
Tumor-Masses and Their Resultant Manifestations 1
1. External Examination 1
2. Internal Examination 6
3. X-ray Examination 7
Pseudo-Malignant Abdominal Diseases 10
Chemical Demonstration of Blood in the Feces 1-t
The Diagnostic Significance of Vegetable and Bacterial Organisms of
the Gastro-Intestinal Tract 20
Ehrlich's "Diazo" and "Aldehyde" Reaction 30
Symptomatology of Cachexia and General Symptoms 37
Etiology of Malignant Tumors 45
Cell Disposition 47
Etiology in its Narrower Sense 49
Etiologically Important Factors in the Taking of Case Histories
of Malignant Neoplasms 55
Prophylaxis of Malignant Tumors 57
Local Hygiene 58
General Hygiene 59
B. SPECIAL PART
Cancer of the Stomach 63
Early Symptoms ' 63
Physical Examination for Gastric Cancer 76
V
f;^fii094
vi TABLE OF CONTENTS
PAGE
Accompanying Symptoms from Other Organs 83
Feces and Stomach Contents 90
Types of Disease, Course and Duration 97
Suspicious Factors and Differential Diagnosis 99
Carcinoma of the Large Intestine 106
Early Symptoms 106
Physical Examination for Carcinoma of the Large Bowel 113
Feces and Stomach Contents 117
Accompanying Symptoms from Other Organs 119
Course, Duration and Types 121
Suspicious Factors and Differential Diagnosis 121
Primary and Secondary Cancer of the Liver 125
Early Symptoms 125
Physical Examination of the Liver 127
Accompanying Symptoms from Other Organs 129
Suspicious Factors and Differential Diagnosis 130
Carcinoma of the Gail-Bladder 133
Early Symptoms 133
Physical Examination for Cancer of the Gall-Bladder 136
Accompanying Symptoms from Other Organs 138
Course, Duration and Types 14-0
Suspicious Factors and Differential Diagnosis 141
Carcinoma of the Pancreas 14-5
Early Symptoms 1-15
Accompanying Symptoms from Other Organs 149
Suspicious Factors and Differential Diagnosis 151
Malignant Tumors of the Kidney 153
Early Symptoms 153
Physical Examination of the Kidneys . 156
Accompanying Symptoms from Other Organs 158
Course, Duration and Types 160
TABLE OF CONTENTS vii
PACE
Suspicious Factors ,'ind Differential Diafrnosis 101
"Ati/pical" Malignant Abdominal Grozcths 165
C. CASE HISTORIES
Carcinoma of the Stomach 174
Carcinoma of the Lar^e Intestine 261
A. Cecum 261
B. Hepatic Flexure 265
C. Splenic Flexure 270
D. Si^noid Flexure 271
E. Rectum 281
Primary Carcinoma of the liiver 293
Secondary Carcinoma of the Liver 302
Carcinoma of the Gall-Bladder, Including the Biliary Passages and
Papilla of Vater 304
Carcinoma of the Pancreas 327
Malignant Tumors of the Kidneys 334
APPENDIX
Atypical Malignant New-Growths in the Abdomen 343
Index 357
\
A. GENERAL PART
Author's Preface
The difig-nosis of a malicrnunt new growth ranks among the most
important decisions in the domain of abdominal diseases. Depending on
the stage of the disease, it may mean a saving of life, or it may mean a
death sentence.
It behooves the physician to avoid, as far as possible, the reproach
of not having recognized in time the malignant nature of the disease,
making a life-saving operation impossible ; but, on the other hand,
the patient should not be subjected to unnecessary alarm and a useless
operation through an erroneous assumption of a malignant process.
To choose the right path between these two extremes of possible error
belongs to the most difficult problems of internal medicine.
Here it will seem proper to bridge over the chasm existing between
the deep knowledge of the clinician and the wide field of the general prac-
titioner. In the lattcr's hands lies the early diagnosis of cancerous
diseases, for it is his judgment that the patient seeks in the first place.
During my activities of more than ten years in the clinic of my
honored teacher, Hofrat Professor Dr. E. v. Neusser, and in my present
capacity, I have had abundant opportunity to gather manifold expe-
riences in regard to malignant diseases of the abdominal organs. I was
further in a favorable position most carefully to examine the various
cases, some of which have been briefly sketched among the case histories ;
these cases being in connection with medical post-graduate work, I was
able to compare the diagnostic results with the outcome of operative
interference and autopsies.
Thus the case histories to be appended include, almost throughout,
the counter-findings of the surgeon, but especially those of the anatomist.
That these findings come from the latter is due to the sad fact that
most cases of cancerous disease reach the clinic when it is too late.
In going over the history of the symptoms in these cases, one gains
the conviction that an early diagnosis would have been possible had it not
been for the fact that the medical adviser, through no fault of his own,
lacked experience. As already mentioned, we are here concerned with
one of the most difficult chapters of internal medicine, in which some de-
gree of certainty can be acquired only after years of special study and
continued control by means of autopsies and operations. From this
point of view I believe that a book which deals with this subject, not as
a compilation, but from the author's experience of many years, ought not
to be without benefit.
X AUTHOR'S PREFACE
The nature of the subject, through the numerous diseases entering
into differential diagnosis and a consideration of the different methods of
examination, accounts for the fact that the scope of the discussions be-
came somewhat broadened, so that the underlying work partly includes a
diagnostic study of abdominal diseases in general, yet has in view par-
ticularly the malignant processes.
In planning the book, I believe I have everywhere been mindful of the
problem of the earliest possible diagnosis, especially in the case of gastric,
intestinal and renal neoplasms.
In the case histories, the symptoms appearing first have received sharp
emphasis, and I considered it important to give detailed discussion to the
diagnostic value of the subjective phenomena which so frequently are the
forerunners of the objective findings.
As it is precisely in the domain of malignant neoplasms that prob-
ability very often precedes certainty in the making of a diagnosis, I
considered it to the point, from case to case, to emphasize the most im-
portant factors of suspicion, especially in so far as they resulted from
the condensation of simple and brief reflections. In connection with this
it seemed important to me alwaj^s to include in the calculations the con-
stitutional peculiarity of the patient. In view of the wide range of this
subject, exhaustive references to the literature relating to it would have
been impossible and useless.
At the same time, it seemed proper here and there to gratify the de-
sire for further information.
The current efforts at cancer diagnosis, by means of serum reactions,
have not been included in this work.
These experiments, such as Brieger's anti-trypsin determination,
Pfciffer's anaphylaxis test, AscolVs mejostagmin reaction, Crile's isolysin
demonstration, etc., have partly been recognized as not available for can-
cer diagnosis, or this recognition is on the way.
I do not wish to detract from their theoretical interest.
In the differential diagnostic discussions it seemed of great practical
importance to discriminate between the existing malignant disease and
benign affections, at the same time giving especial attention to the rela-
tive frequency of possible mistakes.
As multiplicity should be avoided in diagnosis it has been my con-
stant endeavor, in the differential diagnosis, to point out the most acces-
sible, briefest and most certain route.
In composing this book, my happiest anticipation was that it might,
in a modest measure, assist in early diagnosis, and so in saving the life
of a patient.
Beyond this individual interest, however, there was also before my
eyes the great question of the cancer problem. The more improbable the
assumption of a specific cancer excitant becomes, the more improbable
also the assumption that the cancer problem could be satisfactorily
cleared up in the more narrow domain of laboratory research. In those
cases where questions of congenital peculiarity, hereditary influences,
dyscrasias, etc., and their relations to the genesis of cancer, are awaiting
\
AUTHOR'S PREFACE xi
solution, an advance in knowledge can be expected only from the active
co-operation of the entire profession, and especially from the physician
engaged in active practice.
So, I may say, that beyond the individual case it is the object of this
book to promote, in a modest way, the general interest in cancerous dis-
ease, thus placing the question of cancer research on the broadest pos-
sible basis.
DR. RUDOLPH SCHMIDT.
Vienna.
Translator's Preface
Our close personal association with Professor Schmidt duriny- a two
and one half years' (1899-1902) service in the clinic of the late Hofrat
Professor Edward v. Neusser, gave us ample opportunity to attest with
appreciation the thoroughness of scientific detail and the almost uncanny
diagnostic ability characteristic of both Ncussei' and Schmidt. One could
not help being impressed with the fact that diagnosis was always of para-
mount interest and the greatest aim of a clinic whose chiefs were Skoda,
Bamberger, Kahler and Neusser; it remained for Schmidt, however, as
assistant to Neusser, in the Vienna General Hospital and later, as Attend-
ing Physician to the Empress Elizabeth Hospital, to specialize in the
study and diagnosis of abdominal neoplasms.
We were so impressed with the importance of Professor Schmidt's
book, particularly with its great clinical value to the general practitioner,
whom the cancer patient first consults, that we determined to translate
it into English.
We trust our efforts will be appreciated and that the translation will
get the same cordial reception in America as the original did in Europe.
We wish to express our most cordial and sincere thanks to Dr. Otto
Rebescher, without whose aid w^e could not possibly have completed the
work.
JOSEPH BURKE.
Buffalo, N. Y.
Physical Examination of the Abdomen for the
Presence of Malignant Tumor-Masses and
their Resultant Manifestations
External Examination
Various methods of external examination aim at removing, at least
partially, the obstacles which the abdominal walls place in the way of
palpation. Each one of these methods strives to overcome the contrac-
tion of the abdominal nmscles, be it active or reflex.
Active tension of the abdominal muscles is easily caused by the patient
lying on his back and raising his head in order to see the palpating hand
of the physician.
Hence the first rule: The head of the patient should rest without a
pillow on the same level as the rest of the body. I consider it quite to
the point to request the patient to press his head down upon the table.
In this way one most effectively overcomes the inclination of the patient
to lift his head, and at the same time it diverts his attention from the
abdomen.
Drawing up the legs may sometimes favor relaxation of the abdominal
walls, but under certain conditions may also have the opposite effect
if the legs of the patient are in a position that is too tense.
Examination in a warm bath has the advantage of a thorough relax-
ation of the abdominal walls, but it has also disadvantages : the head of
the patient is elevated, the forearm of the examiner cannot be conven-
iently placed on the abdomen. It may further not be amiss to place a
thermophore upon the abdomen some time before the examination. In
this way considerable relaxation of the belly-walls can be induced even
without the bath.
As all anesthetics may be dangerous to the life of the patient, no
matter how carefully administered, one will hardly resort to this extreme,
though radical, method for purely diagnostic reasons ; less objection
might be raised against the subcutaneous administration of morphin.
Whoever knows how to palpate well will, rarely need much artificial
help in producing relaxation of the belly-walls.
The most frequent cause of a resistant, tense belly-wall is found in
a harsh method of palpation which is unseemly and faulty.
The art of palpation is often looked upon as a matter of course and,
as compared to percussion and auscultation, is practised altogether too
little.
1
2 TUMORS OF THE ABDOMINAL VISCERA
Aside from the technique of palpation there are also certain cases
in which conditions are such that palpation elicits pain, hence muscular
"defence," conditions whicli vary from time to time. Thus, for instance,
palpation of the lower abdominal wall may be very painful, owing to a
distended urinary bladder, hypertrophy of the prostate, etc. ; hence the
rule: first empty the bladder, especially when palpating per rectum or
per vaginam.
Even aside from the above, the condition of fulness inside of the
abdomen, particularly of the gastro-intestinal tract, is of great im-
portance.
In cases of gastric ulcer one can easily convince one's self that the
greatest tenderness on pressure is observable- when meteorism of the
stomach is present, but when the distended walls of the stomach are
enabled to relax through belching of gas or vomiting, the tenderness
often disappears entirely.
This is a law which holds good in all ulcerating conditions of the
gastro-intestinal tract, and is therefore also applicable to gastro-intes-
tinal carcinoma.
Here is the place to say a word in regard to the practice of using
effervescent mixtures, etc., in an effort to distend the stomach, a practice
which is still considerably in vogue.
In my opinion these procedures are usuall}^ unpleasant and often
dangerous to the patient ; they can almost always be omitted without
detriment to a diagnosis, especially when it is feasible to make an exam-
ination of stomach or bowel contents. In my own practice I have not
resorted to this method of stomach inflation, -even once, in a great
many years.
As previously mentioned, palpation becomes painful when there is
distention of the stomach or part of the intestine which has been subject
to ulcerative changes, and thus is rendered more difficult by the reflex
spasm of the abdominal walls. In this way hemorrhage, and even per-
foration, may occur. Frequently inflation is resorted to in order to
see whether and how a tumor-mass shifts. However, when a tumor-mass
is located in the gastro-intestinal tract and is freely movable, its "wan-
dering" can be determined by making examinations at different times,
on an empty stomach and after meals, and if necessary one may carefully
give food which causes formation of gas, such as bread.
Neither is inflation necessary to determine the presence of coils of
intestine in front of a tumor-mass, since one can usually detect by palpa-
tion a piece of gut which is resting upon a solid base such as the kidney,
spleen, etc., especially in a contracted state.
In my opinion, therefore, there is hardly ever a reason for producing
meteorism by artificial inflation. On the contrary, though, it will fre-
quently be found necessary to remove spontaneous meteorism by some
active measures or through vomiting, defecation, etc., because it increases
abdominal rigidity when there are ulcerative processes in the gastro-
intestinal tract. The presence of gas also causes much tenderness.
It seems important to me to emphasize the fact that the customary
PHYSICAL EXAMINATION 3
office hours of physicians are very unfavorable for palpating gastric
tumors. Many a tumor which can be demonstrated easily after the small
morning collation cannot be so detected in the afternoon on account of
the full and inflated condition present. In cases that are suspicious
because of abdominal enlargement, I consider it important to examine
while the patient is fasting, and where cancer is suspected it might be
well to examine immediately after emptying the stomach of the patient
through vomiting or by means of the stomach-tube.
It is also well to see that fermentable food be avoided as far as pos-
sible, and milk may be classed as such at times.
When there is insufficient emptying of the bowels it will be advisable
to soften an}' hardened scybala by means of oil enemata, and then admin-
ister a cathartic (phenolphthalein, .5:1.0; ricini ca., 15, etc.). In this
way one can also best guard himself against wrong inferences due to
old sc^^bala and any spastic contractile conditions in the region of the
large bowel. One can also prevent meteorism from interfering with
palpation b}' means of wet packs over the abdomen, warm sitz baths,
the introduction of a soft rectal tube, or the administration of warm
carminative teas, etc.
The less the stomach and intestine are distended with gases the more
successful will be tb.e palpatory examination of the abdomen.
One point which, in my opinion, is too little borne in mind, in the
technique of abdominal palpation, is the method of breathing.
During the entire time of palpation it should be of a diaphragmatic
type. Only in this way can one make comparative estimates of the
so-called "respiratory" mobility.
It must seem evident to every man that the "respiratory" mobility
of one and the same tumor must vary according to whether the dia-
phragm moves extensively downward during respiration or moves but
little, as is the case during breathing which is chiefly costal. Hence it
would be more proper to speak of "diaphragmatic respiratory" mobility,
in order to emphasize, even in the nomenclature, that the unhindered
action of the diaphragm here pla3^s an important role.
A most efficacious way of inducing diaphragmatic breathing is to
place one's own or the patient's hand on his epigastriimi, requesting him
to breathe in such a way that the hand is raised during inspiration.
With all those enlargements that are subject to movement by the dia-
phragm, palpation is to be carried out in a rliythmical way ; that is,
during inspiration as well as expiration the palpating hand should move
in a direction opposite to that in which the underlying part is moving.
Where, for instance, one is dealing with a, transversely situated cylin-
drical tumor of the pylorus, the palpating fingers are laid with gentle
pressure just underneath tlie suspected place, and then request is made
for deep diaphragmatic inspiration. The descending cylindrical tumor
is now forced against the palpating finger-tips which finally come to
rest over the tumor. During this entire performance the fingers will
remain in the same place, or they may glide upward over the descending
supposed tumor with little change of place.
4 TUMORS OF THE ABDOMINAL VISCERA
During expiration, the tumor returning upward, the fingers, which
are making even pressure in the opposite direction (as when one tears
the stem from a cherry), should move downward. In this even, rhythmical
way the tumor should be examined during several inspirations and expi-
rations as to its form, size, consistency, etc. This rhythmical method
of palpation has the great didactic advantage of getting the hand of the
beginner accustomed to rest, thus avoiding that aimless boring and
punching Avhich is too often seen, even among more advanced practi-
tioners.
The significance of forced diaphragmatic breathing lies also in the
fact that during the forced downward movements certain tumors lying
behind the xiphoid process or the ribs become accessible to palpation.
Of great importance is palpation in different positions. This enables
one to determine the degree of mobility and to obtain a desirable relaxa-
tion of the muscles of the abdomen, thus thinking of it as a barrel, the
floor of which carries the largest burden.
There are quite prevalent cei'tain fallacies in regard to the diagnostic
value of ballottement, as found among others in kidney tumors.
The larger tumors of the cecum or the spleen can be made to ap-
proach the palpating hand in front intcrmissively in the antero-posterior
direction from the loins. The symptom, after all, depends upon the
antero-posterior diameter of the tumor-mass and its more lateral situ-
ation. Contact of the same with the back is a particularly favoring
factor. Corset lobes of the liver not seldom produce the phenomenon
of ballottement, of course more in a slanting direction from the flanks
(axillary line) forward, although ballottement may be occasionally elic-
ited from behind with an organ displaced downward or through inter-
position of downward dislocated kidney. We count ballottement of
stomach tumors among the greatest rarities, yet even there it may come
under observation.
If there is a suspicion of a malignant neoplasm in the abdomen, the
chief object is to determine the existence of a tumor-mass; then other
symptoms resulting from its presence will have to be taken into con-
sideration.
It is well at the first examination to pay attention to the existence
of tender pressure points, since they often correspond to the seat of the
neoplasm.
As far as stomach and intestinal carcinoma are concerned, strict
attention must be paid to disturbances in the calibre of the canal and
the resultant signs. Thus we meet with splashing sounds, which, when
localized in circumscribed portions of the intestine, e.g., in the ascending
colon, may occasionally be of the utmost importance. As local shaking
is in many cases painful, I recommend that the examination be made
after the fashion of a succussio Hippocrates, in such a manner that the
physician takes hold with both hands in the region of the anterior supe-
rior spine of the pelvis and shakes evenly, the abdomen being parallel
with the table. The ear being brought near to the abdomen, one can
easily determine the place of origin of the splashing sounds.
PHYSICAL EXAMINATION 5
By moans of the broadly iin[)osccl hand one can often more easily
identify localized flatulence, as well as mild peristalsis, whether it be
in the stomach or in a circumscribed portion of the intestine, than by
inspection, especially when there is bad illumination.
I count percussion as among the least de|)endable aids in physical
examination for malignant tumors of the abdomen.
It is often entirely impossible to establish lines of demarcation on
account of the close and irregular juxtaposition and even intermingling
of air-free and air-filled tissue-masses and organs.
Attention may here be called to the fact, which to my knowledge
has not received cognizance, that in dilatation of the stomach, hence in
pyloric stenosis, liver dulness is greatly diminished without assuming
the interposition of intestine between the anterior surface of the liver
and the belly-wall or border of the liver palpable under the costal arch.
Only in cases of extensive air-free tumor-masses is there any pros-
pect of obtaining resonance which belongs to the tumor-mass, and even
then it will require firm application of the pleximeter, or several fingers,
in order to compress the interposed gut, light percussion being made over
the central part in order to avoid neighboring portions of the stomach
and intestines. It has already been mentioned that slight differences
in the sound obtained in the flanks, on change of position, are not to be
emplo3^ed in the diagnosis of "ascites."
As far as changes in the abdominal wall itself are concerned, when
there is a suspicion of a neoplasm, particularly if enlargement has already
been demonstrated, and ascites is present, one should never omit an
examination of the umbilicus for carcinomatous infiltration. There is
no other symptom which might so surely and easily determine the dif-
ferential diagnosis between "malignant," "tubercular" and "cirrhotic"
ascites ; even though this is not one of the common symptoms, yet in
cases of ascites an experienced diagnostician will never neglect looking
for it.
The finding of epigastric venous enlargements may be very signific;int.
These are most frequently found in connection with periportal cirrhosis,
but ma}" also occur with malignant processes w^hich are mostly intra-
hepatic or ad portam. They are of especial diagnostic value if the ma-
lignant tumor-mass is centrally located in the liver and the organ itself
shows no enlargement. One must not forget that the cirrhoses of Laennec
are not rare as a complication of extra-hepatic malignant abdominal
diseases.
It seems to me that altogether too little notice is taken of auscul-
tatory phenomena. Full attention should be given to systolic murmurs
heard in the epigastrium in gastric and hepatic carcinoma, occurring
oftcncst, according to my ow^n observation, at the end of expiration,
the origin of these murmurs being traced partly to the abdominal aorta,
partly to the arteries and veins supplying the larger oi-gans. Neither
should one omit examination for localized peritoneal friction-sounds so
frequently occurring in tliis region with stomach and intestinal carcinoma
and liver-metastases.
6 TUMORS OF THE ABDOMINAL VISCERA
Finally — for the sake of completeness — mention must be made of the
sense of smell which can afford diagnostic aid through its perceptions.
Thus Boas singles out the fact that in cases of carcinoma of the rectum
the parts of clothing near the anus give off not merely a fecal but a
fetid odor, the reason for same being obvious.
If in cases of stenosing gastric carcinoma there is a belching of gas,
it can be immediately recognized as SH2 (the odor of rotten eggs). In
these cases there is usually the growth of sarcina*. In carcinoma of the
esophagus, the expired air may be of a fetid character.
Internal Examination
Digital examination per rectum or per vaginam should never be
omitted in a case of suspected malignant tumor in the abdomen, or
when this diagnosis has already been established. This examination is
not limited to cases which show signs of a neoplasm growing in this
region; it must therefore be made regardless of sucli signs, since the
ovaries as well as the peritoneum in the pouch of Douglas are not seldom
the seat of metastases, and the prognosis of a case or the question of
operability is not rarely decided in this way. One must not lose sight
of the fact also tliat carcinoma of the rectum may remain rather latent
for a long time, and that for this reason alone digital examination of
the rectum appears as indicated when there is only a slight suspicion
of such a malignant condition. We find carcinoma of the rectum in
very young individuals, even in those in the twenties, is not of the
greatest rarity.
Rectoromanoscopy
Especiall}^ in those cases where tenesmus, tenderness on pressure over
the sigmoid flexure, the presence of blood, pus and mucus in the feces
point to a deep-seated catarrhal ulcerative disease, whose chronic nature
raises the suspicion of a malignant groAvth, rectoromanoscopi/ ^ will conic
into its rights, particularly if digital examination prove negative.
In this way many a case of polypi, catarrhal ulceration, etc., in the
lowermost portion of the intestine has been properly recognized ; under
its guidance it will also be possible to excise portions for microscopical
examination. One must not forget, however, that the danger in this
method of examination grows commensurately with the distance one
tries to reach higher up in the bowel (romanoscopy), as there are even
cases reported in the literature " in which expert examiners have thus
brought on fatal perforation, not only in ulcerated, but also in normal
areas of the intestinal walls.
Romanoscopy,^ therefore, is indicated only when there is great prob-
ability of gaining a decided advantage for the patient. It would be
desirable to consider romanoscopy as belonging to the domain of sur-
' Compare Schreiber, Sammlung zwangl. Abhandl. a. d. Geb. d. Verd. — u. Stoff-
wechselerkr., Albu. I. Bd., H. 1/2, 1908.
' For obvious reasons similar cases are unfortunately but rarely reported.
^ For such a case see Anschiitz, Beitrage zur Klinik des Dickdarmkrebses. — Mitt.
;ius d. Grenzgeb. d. Medizin u. Chirurgie. III. Supplementth., Jena, 1907, p. 508.
PHYSICAL EXAMINATION 7
gerj, so that in case of rupture, life-saving laparotomy could be per-
formed immediately.
Profuse intestinal hemorrhage as well as acute inflammator}' pro-
cesses should always be regarded as contraindications to instrumental
examination.
X-Ray Examination
With respect to the value of radiological examination in regard to
abdominal diseases in general, and gastro-intestinal affections in par-
ticular, it would seem that at the present time there are prevalent some
rather exaggerated notions, not only among the laity, but also in the
medical profession.
Whoever occupies himself with a single method of examination will
ride his hobb}- to the danger of esteeming it too highly.
It would be commendable to allow for this psychological factor in
radiological publications.
Indiscriminate X-raying of the abdomen in any and every case can
only lead to quackery or — because of the frequency of useless negative
results — bring discredit on this method of examination, in both instances
equally regrettable. Therefore, as in operative interference, so also
in radiographic examinations, one should not proceed without indica-
tions. This course is justified, since the method itself is not without
danger, as besides local burns, deaths have occurred from the admin-
istration of the customary doses of bismuth (30-50 g.).
In deciding upon the indications, one will have to bear in mind that
a thick belly is less adapted for X-ray examination than a lean one.
Where it is a question of shape, location and size of the stomach,
the sovereign method, certainly the most convenient for the operator,
is the X-raying of the bismuth-filled stomach.
After these findings have been settled upon, however, very little or
nothing — with some exceptions — has been gained that will aid in the
final diagnosis, especially as far as the three most important diagnoses
are concerned, namely: ulcer, carcinoma, neurosis.
The diagnosis of ulcer, and that with which we are here concerned,
viz., carcinoma of the stomach, will have to be made from consideration
of the sum total of our clinical findings, A particular value is ascribed
in the clinical picture to occult intestinal hemorrhages, because a repeated
negative finding makes a recent ulcerative process in the stomach im-
probable.
If an exhaustive clinical examination offers nothing to support the
probability of carcinoma then the X-ray will hardly disclose anything
further.
If the presence of a gastric tumor,"* together with persistent occult
hemorrhage and the remaining symptoms, is clear, one can well save the
patient the annoyance of a bismuth meal.
Quite different are those cases in which there is slight or moderate
* Its recognition is not so diflBcult a* occasionally described in radiological works.
8 TUMORS OF THE ABDOMINAL VISCERA
probability of gastric cancer and where careful clinical analyses yield
no further data. In such cases it would be of the greatest importance
if the clinical work could be actually benefited by radiograph}'.
This, however, is generally not the case, as is shown by the recog-
nition of the symptoms which make the radiologist suspicious of car-
cinoma. The fact must not be overlooked that as sources of error in
methods of examination, radiology ranks among those that head the
list. When reference was made to the radiologist's suspicion of car-
cinoma it was really saying too much.
Observation of the bisnmth mass in the stomach and observation of
peristalsis in the greater curvature will occasionally yield the following
diagnostic points: 1. Processes altering the lumen existing in the wall,
or in or outside the stomach cavity. 2. Stenosis at the pylorus. 3. Ex-
clusion of a portion of the wall in the normal peristalsis. How and
where arc these details of observation applied in cancerous disease of
the stomach?
1. Not seldom cancers are ulcer-like and may attract attention by
occult intestinal hemorrhages, but without causing any alterations in
the calibre of the organ. Even advanced cancers may spread on the
surface without encroaching upon the lumen of the part. As a rule, it
will be only in far-advanced cases of gastric cancer that we can find a
decided encroachment upon the hunen with eventual filling of the antrum
or contraction with formation of an hour-glass stomach and deficient
expansibility of the cardia. It is from such cases that the illustrations
in the literature '' have been obtained.
In such advanced cases one may eventuall}' succeed, in carcinoma
of the pars media for instance, in demonstrating an hour-glass stomach
which in itself may, of course, be benign. In differential diagnosis, for
that matter, regard nmst also be had for the "spastic" hour-glass stom-
ach due to a local lesion of the stomach-wall, such as erosion, but which
may be purely functional at the time of the examination.
In addition to clinical phenomena, such as difficulty in swallowing
and in the introduction of the stomach-tube, advanced carcinoma of
the cardia may, by means of the X-ray, show deficient expansion.
Defective "filling-in" of the antrum pylori will have to be judged
cautiously, inasmuch as it is only seldom a real expression of narrowing
in the early stage of pyloric cancer.
Conditions would be simple if the stomach were a U-shaped tube
with a smooth wall, of definite shape with easily movable contents. But
the inner wall is much convoluted in changing, and at times spastic,
states of contraction, and the contents tenacious.
The above makes apparent the necessity of the greatest scepticism in
regard to anomalies in the state of fulness and the border of the shadow
in the antrum pylori, the shape of which is not always a definite one.
Besides, in order to obtain the best unfolding, one must help by
means of right-sided position, massage, etc., factors whose efficiency
''See E. Shiifz, Weiner Klin. Wochensch., 1906. No. 14..
PHYSICAL EXAMINATION 9
varies from time to time. Naturally the ability to unfold may be en-
hanced by bending, spasms, and compression from without.
Far-advanced diffuse infiltrating, scirrhus carcinomata of the stom-
ach, which, for that matter, will also give characteristic clinical data,
will show up in the X-ray a stomach much diminished in size.
2. jNIanifestation of pyloric stenosis does not figure among the early
symptoms of pyloric cancer; on the other hand, clinically they may be
diagnosed with great probability from the subjective symptoms as shown
by me in the treatise of colic from pyloric stenosis.''
However, according to the latest observations, it seems that spasms
of the p3'lorus ~ (without any anatomical stenosis) can give the same
results.
Only a positive finding is — with caution — of value. Even in cases
of clinically genuine pyloric stenosis, "antiperistalsis" may be missing.
As a result of solid infiltration, or cicatricial induration, especially
when the anatomical process has already penetrated the muscularis,
there is a theoretic possibility that a circumscribed portion of the stom-
ach, e.g., the antrum pylori, may not take part i"n peristalsis. Even
here, for that matter in most cases, one may be dealing with advanced
cases of cancer of the stomach.
The foregoing deductions are not intended to discourage radiological
examination *^ as useless when there is suspicion of a gastric cancer, but
rather to point out its proper limits of employment and to warn against
undue expectations.
In classifying, according to merit, the diagnostic measures that will
aid in the determination of gastric cancer, radiology finds a place at
the bottom of the list. The clinical methods of examination come first.
After they have been exhausted then may come cases in which there
is an indication for X-ray examination.
Still less are there prospects of real gain for diagnosis in malignant
diseases of the large bowel, although during their entire course there
may be demonstration of their existence.
The best chance for radiological findings may be in the cases of ring-
shaped, obstructing neoplasms especially peculiar to the sigmoid flexure.
Neoplasms of the liver, the gall-ducts, pancreas, as well as retro-
peritoneal enlargements, find no place in these considerations.
Where one faces a diflFerential diagnosis of "attacks of colic resulting
from nephrolithiasis or of a neoplasm in the kidney," it would be ad-
visable to employ the X-ray because of the easy demonstration of stones
in the kidney (uratic calculi included).
*i?. Schmidt. Die Schmerzphenomene bei inneren Krankheiten, etc.. AV. Brau-
mueller, 1906, page 142.
' R. Bauer, Beitrage zur Symptomatologie des Ulc. Ventric, Wiener nied. Wocli.,
1910, No. 15.
' Grosse Verdienste iim die Rontgen Diagnostic der Magenkrankheiten hat sich
die Wiener Schule erworben., Vgl. Hohknecht, Wiener Klin. Rundshau, 1905, Nos.
16 to 23.
10 TUMORS OF THE ABDOMINAL VISCERA
It is well known that gall-stones can be demonstrated with a degree
of certainty in only a small percentage of cases.
PSEUDO-MALIGNANT ABDOMINAL DISEASES
When in connection with the triad of general symptoms, viz., pale-
ness, weakness and emaciation, and simultaneously there occur abdom-
inal manifestations, such as digestive disturbances, etc., one will very
easily suspect malignant disease even without a demonstrable tumor.
Pernicio us A n einia — Senile
Tuberculosis — .4 ddison Icterus
Here it will be well to think of pernicious anemia and senile tuber-
culosis, more or less of the rather latent type, as well as Addison's
disease, always bearing in mind that neuropathic individuals may become
greatly emaciated under a diet which is self-imposed or ordered by a
physician. The same is true of jaundiced individuals In whom the stasis
of bile need not be due to malignancy.
Not infrequently tumor formations may arouse the suspicion of
malignancy, nnich more so when characterized by much hardness. In
these cases the greatest caution will have to be exercised, especially when
they run their course without the above-mentioned trio of general
symptoms.
Scyhala
Thus it may often be rather difficult at the first examination to
distinguish hard, round fecal masses in the region of the sigmoid flexure
from malignant tumors, glands, etc. These inspissated, stony scybala
are not often mouldable; pressure upon the same is not infrequently
painful. It is never sufficient to rest content with the mere knowledge
of the presence of scybala. We should inquire into the causes that
lead to their formation.
Thus I recall a case in which cancer of the stomach proved to be
the cause of obstipation, and another case of a deaf and dumb patient
in whom witliout anamnesis I was led to think of cancer of tlie stomach
by remembering the first-mentioned case, my suspicion in the latter being
verified at autopsy.
Corset Lohes of the Liver
Naturally a deep-seated stenosis will be thought of (sigmoid flexure).
In female patients it will be well not to forget the possibility of "corset"
lobes of the liver, even when the presence of a tumor in the ileocecal
region has been established. On account of induration these lobes may
feel very hard and, where a deep "corset" groove has resulted, the con-
nection of such a lobe with the liver may not be easily made out.
Extraordinarily hard tumors may be produced by the deposition of
lime, and which, at times, may be mistaken for a malignant enlargement.
In a case under my own obsem^ation, in which there was left-sided
hemorrhagic pleuritic effusion, there was found under the left costal
PSEUDO-MALIGNANT DISEASES 11
arch an extremely hard mass wliich I was Inclined to consider as the
priniar}^ focus. Autopsy, however, disclosed cancer of the lung. The
hard mass under the costal arch on the left side corresponded to the
anterior pole of the spleen displaced downward, and in the capsule of it
there had formed a qiiite large calcareous deposit.
Stone-hard consistency must always be considered cautiously; it is
such a degree of hardness that malignant tumors do not attain.
Tncholtezoar
When the patient happens to be a young woman with hysterical
tendencies, an epigastric enlargement should remind us of trichobezoar,
i.e., a hair tumor, which may result from the swallowing of hair during
a period of man}^ years.
The possibility of mistaking conditions like the above for cancer is
proved by the case of Bollinger,'* which was accompanied by severe
cachexia and in which was found a mass of hair weighing 900 g. The
appearance of hair in the feces, in the vomit or in the stomach lavage,
above all an exact history of chewing the hair braid, absence of occult
intestinal hemorrhage, and finally the incongruity of a tumor with an
otherwise healthy general condition, will guard us against mistaking hair
tumors for malignant gastric conditions. More frequently mistaken
diagnosis of floating kidney, spleen, and tumors of the omentum appear
to have slipped in.
PJifjfohezoar
Equally rare are tumefactions of the stomach composed of plant
fibres (phytobezoar) which are occasionally observed after the habitual
use of black root or shellac stones (due to drinking polish).
Suhmticous Lipomata
Lipomata of the colon are extremely rare ; much more so are fatty
tumors which reach the size of a man's fist, developing in the submucosa
of the stomach. They may lead to threatening manifestations by invag-
ination, and also provoke colic and other bowel disturbances such as
obstipation, diarrhea, meteorism, etc. Circumstances of this kind may
excite suspicion of a malignant growth when a tumor is palpable. How-
ever, the absence of cachexia and emaciation will be important factors.
Nelaton Tumors
In the differential diagnosis of malignant abdominal tumors we may
occasionally have to deal with those growths known as "^Nelaton tumors,"
which seem to occur especially in females between twenty and thirty years
of age, though they are but very rarely seen.
Being fibromata or fibro-sarcomata they are characterized by a tough
consistence, and eventually also knobby excrescences, two important
characteristics of malignant neoplasms. If they are located in the deep
pre-perltoneal layers of the belly-wall, they act just like intra-abdominal
tumors in that they disappear upon contraction of the abdominal muscles.
'Bollinger, Miinchener mcd. Wochenschr., 1891, No. 22.
1^ TUMORS OF THE ABDOMINAL VISCERA
CASE from my own observation: F. N., 24 years of age, female.
The patient has for six months been complaining of pains to the left
of the umbilicus, where there is a palpable tumor ; pains occur one hour
after eating. During two months the quantity of urine has been dimin-
ished, the color darker. On the left side, underneath the costal arch,
there is a hard and irregular tumor-mass, which is tender on pressure,
and disappears when the patient sits up.
In view of the misleading subjective symptoms the following possi-
bilities presented themselves, whether looked at from the medical or
surgical point of view: Cicatrized ulcer, kidney tumor, enlarged glands,
carcinoma of flexura lienalis of the colon.
The operation disclosed a ^'Nelaton tumor" behind the abdominal
muscles.
The above case illustrates very well iiow misleading such a tumor
of the belly-walls may be.
In these cases, again, it will be well to include the absence of cachexia
as an important factor in our calculations.
Such a decision as to the malignant origin of a palpable mass in
the abdomen is so far-reaching in its consequences that we should always
carefully consider the possibility of an inflammatory exudative process.
It is an easy diagnostic rule to think of tuberculosis and actinomy-
cosis in tumors of the ileocecal region, if they are hard, slightly painful,
and accompanied by moderate temperature rise. Regard must also be
had to masses of exudate due to appendicitis, which sometimes, espe-
cially in their later stages, may i)e very hard. If in these cases of
delayed resolution the patient happens to be advanced in years — and
this apparently is not seldom the case — the suspicion of malignancy is
often well founded. Only the most exact histor\^ (sudden febrile begin-
ning when the patient has been enjoying the best of health) can guard
against errors. Moreover, the possibility of a secondary paracolitic
abscess resulting from cancer of the cecum must be borne in mind, espe-
cially after prodromal cachectic symptoms.
Gland Tuberculosis in the Abdomen
Tuberculous processes in the epigastrium are met with much more
rarely than in the ileocecal region; but even there, under certain cir-
cumstances, may lead to enlargements from omental tuberculosis, sup-
puration of glands with the formation of cold abscesses, etc.
F. S., 65 years of age, widow. Had nine children ; had transitory
hemoptysis, violent cough and great weakness. Began about one and
one-half years ago, January, 1903, by feeling weak, very sleepy toward
evening.
In April, 1904, had sudden and severe stomach cramps which lasted
through the entire night. Since then, during the last two months, there
is cough with rather copious expectoration, accompanied by pain under-
neath the costal arches. Lost 6 kg in weight since the winter of 1903-
1904.
Status presens: June 7, 1904 (Clinic Xeusser), mass under the costal
PSEUDO-MALIGNANT DISEASES 13
arcli on tlie left side which in extent and configuration is similar to the
spleen, if same could be thought of as extending to the umbilicus. This
tumor is quite hard, without tenderness on pressure, easily shaken by
pulsation. Over the central portion of the tumor, as well as in Traube's
space, there is dulness on percussion.
Infiltration of the apex of the right lung. Edema over the sacrum.
Temperature of 39.4° C. on one day only, otherwise afebrile.
Blood: 3,900,000 erythrocytes, G0% hemoglobin; 14,600 leucocytes.
Urine: slightly diazo reaction.
Stomach: After a test-breakfast of a roll and tea there was no free
HCl.
Result of operation (Clinic Hochenegg, Docent Dr. Alhrecht) : The
spleen-like tumor in the epigastrium extensively adherent to the belly- wall.
Also adhesions to the small intestines.
Puncture: yellowish green, thin pus (cold abscess!).
Liver Gumma
In the case of an apparently malignant tumor of the liver there is
always the question of a gunmia, and accordingly a Wassermann test
is in order.
Tumors of Omentum
Special attention should be paid to those inflammatory omental tu-
mors which are observed particularly after partial resection of the
omentum (herniotomy), and also after pelvic peritonitis. If the follow-
ing symptoms appear within a few weeks after section of the omentum,
as most frequently happens — severe local pains, signs of peritoneal irri-
tation, occasional signs of intestinal stenosis, moderate rises in tempera-
ture, and above all the enlargement — there wall be hardly any difficulty
in the recognition of these cases. ^'^
Far greater is the danger of making a mistake when the inflammatory
omental swelling comes on spontaneously, i.e., without surgical inter-
ference.
This, though very seldom, seems to occur in those cases where por-
tions of the omentum remain in the hernial sac for a long time, or where
inflammatory peritoneal processes have taken place around some of the
abdominal organs (especially about the female genitalia).
A correct interpretation will be rendered difficult even then, when
the inflammatory swelling of the omentum shows up years after the
operation.
In this way there may develop swellings up to the size of a child's
head, sometimes in the epigastrium, in the median line or to the right
and in the periumbilical or lower abdominal region — in short, without
any definite topography. In this connection we find adhesions to the
belly-wall among the frequent occurrences.
^"Compare Dennii G. Zesae Deutsche Zeitschr., f. Chir., 1909, Vol. 98, page 503.
14 TUMORS OF THE ABDOMINAL VISCERA
CHEMICAL PROOF OF BLOOD IX THE FECES
Whenever there are reasons for suspecting the existence of a malig-
nant disease of the gastro-intestinal tract, the eventual finding of blood-
coloring matter in the feces will be of great diagnostic interest.
Chemical analysis of the stomach contents (whether vomited or washed
out) is mostly superfluous, because fresh blood or decomposed blood
(coffee-groundlike masses) can easily be made out by inspection, and
preserved, or pale erythrocytes can easily be distinguished under the
microscope, as they are often found alongside of clumps of brown blood
pigment.
The color peculiar to the feces is due partly to the changed coloring
matter of the bile, partly to the food taken in (blood-coloring matter
of meat and plant pigment), or to medicaments (bismuth, iron, silver,
hemoglobin preparations, etc.) ; from which it follows that blood coming
from the upper segments cannot be demonstrated microscopically.
Only wlien the blood comes from tlie lower segments of the gut (anal
opening, ampulla or sigmoid flexure) can it be demonstrated, as in the
stomach, macroscopically or at least microscopically. In all other cases
we must have recourse to clicmical analysis."
Gastro-intestinal liemorrhages of this kind (including liemorrhage
from the esophagus) are at present often designated as "occult." ^^
It seems to me, that with the numerous methods of chemical analysis
too little regard is given to the practical diagnostic points, and yet
unnecessary efforts are made to add to the detail of existing methods.
Thus the fact is overlooked that the professional chemist aims at dis-
covering the minimum trace of a certain substance, although the diag-
nostician takes no interest in such minimum traces. So also hei-e.
That method will jueld the most valuable results which shows a clear,
positive reaction when there is question of more than a mere trace of
blood-coloring matter.
Besides, it seems important to me to employ the same method every
time and alwaj^s in the same manner in order to gain data for com-
parison.
The van Deen-Weber test is probably best adapted for the purpose,
but I recommend absolutely the use of h^'drogen peroxide only as oxidiz-
ing agent.
The following are the details of the method as it has been practised
in my department for many years, and which on account of its simplicity
would seem to merit general adoption :
Method of Testing for Blood
By means of a glass rod place a quantity of fecal matter, about
" Only very exceptionally, where there is very rapid passage through the bowels*
can erythrocytes, coming from gastric hemorrhage, be demonstrated in the feces, and
then occasionally the cells appear enlarged and glistening like wax.
" In my ojiinion it would be commendable to have some regard for grammar and
simply speak of "chemical" hemorrhages; to call something "occult" when it can be
clearly demonstrated at anv time, does not seem rational.
BLOOD IN THE FECES 15
the size of a hazel-nut, upon the bottom of a test-tube and add an
approximately equal volume of glacial acetic acid. Thoroughly mix the
feces and the glacial acetic acid by stirring with the glass rod, this
being done in order to provide access for the acetic acid to the blood-
coloring material and to effect its change into acid hematin.
Then, in order to dissolve the acid hematin which has formed, add
2 to 3 ccm alcohol ^^ and stir again with the glass rod. In another test-
tube place an equal quantity of guaiac-resin, finely powdered, and pour
over it 1 to 2 ccm alcohol, shaking this mixture until a saturated solution
has been obtained, when there will remain some undissolved guaiac-resin.
Decant the upper portion of the saturated solution (the undissolved
portion of the guaiac remaining behind) into the first testing glass ^^
and add a little hydrogen peroxide. In the presence of a large amount
of blood there immediately appears a deep dark blue color. When
smaller quantities of blood are present the color may be only dark
green; upon the addition of a little water and some chloroform (about
as much as the top of the test-tube will hold) the chloroform will assume
a violet to blue color from the coloring matter that has formed. It is
always advisable to repeat the test after about two minutes as a control,
because a positive reaction, as shown by the blue color, may be more
clearly observed.
If the Weber test is carried out in this way it will hardly take more
than a minute, requires only two test-tubes and one glass rod, wherefore
it is particularly adapted for use during office hours.
This, however, is of the greatest importance, for an early diagnosis
of gastric or intestinal cancer rests largely in the hands of the practical
physician. When the chemical examination for blood-coloring matter
in the feces proves positive, the following questions Avill suggest them-
selves :
"AUmentarii" Melena
1. May not tlie blood-coloring matter come from meat taken in as
food ^•' or from medicines containing hemoglobin (puro, hemotogen,
etc.).^
If a positive blood reaction in the feces is to be of any diagnostic
value it will be necessary that the patient take into his stomach no kind
of blood-coloring material for three days. The use of meat and sausage
is to be forbidden ; other restrictions in diet, however, are not insisted
upon.
Microscopic control should always be made of the fecal matter which
"Ether may be used as well; but I have always observed a perfect parallelism
in the result of reaction, whether alcohol was used or ether. T prefer alcohol, because
it seems to extract more rajiidly. 1 consider the objections made in the literature to
the use of alcohol as being entirely without foundation.
"Whoever desires may pour off the alcohol or ether layer into another test-tube
and use it for the test. I do not consider it necessary, in fact there is a possi-
bility of losing blood coloring matter that has not yet been extracted.
" Ham, sausages, and bloody meats are especially to be considered, as they may
cause a positive reaction as late as the third day after their elimination from diet.
16 TUMORS OF THE ABDOMINAL VISCERA
has been used for the blood test so as to discover possible muscle fibres. ^^
With sluggish intestinal function it may be possible to find such muscle
fibres as late as the third day after the discontinuance of a meat diet.
In such cases it may be desirable at the outset to administer a light laxa-
tive (e.g., pulv. rad. rhei) in order to remove any accumulations of
fecal material.
This microscopical examination will be of value also in so far as it
may reveal clumpy, dark brown blood pigment, packed together, due
to hemorrliages higher up in the gut, in this way confirming the chemical
findings.
Microscopic demonstration of blood pigment is made easier and diag-
iiostically more valuable in tliose cases where the diet consists of milk,
excluding all pigment.
Origin of Hemorrhage
2. If the first question be answered in the negative, there arises the
second (juestion as to the origin of the hemorrhage.
Theoretically there is a great variety of possibilities, but as a rule
there is a definite symptom-complex wliich will favor localization.
Nose — Gums
Accidents, such as hemorrhage from the nose or from the gums, are
ruled out by the fact that a single examination is never deemed sufficient,
the feces being repeatedlv tested for blood during a considerable period.
Sputum
The same holds good of hemorrhagic sputuiii that may have been
swallowed.
Beclal Mucosa
Hemorrhage from piles will probably be visible to the naked eye in
most instances. Should the stools be solid and coated with bloody mucus,
the chemical analysis could, in cases of suspected gastric hemorrhage,
be performed with portions taken from the centre of the fecal mass with
the help of two teasing needles.
In obscure cases the condition of the rectal nmcous membrane may
be worthy of attention. Just as there are individuals with easily bleeding
gums, so also the rectal mucosa may occasionally display hemorrhagic
tendency, of which fact one can easily be convinced during a rectoscopic
examination by lightly touching the mucosa with a sound covered with
cotton.
Parenchymatous bleeding from the gastric mucosa also deserves full
consideration.
Gastric Crises
We may here leave out of consideration those certainly extremely
'" If the patient is told that disobedience in regard to prescribed diet will lead
to a mistaken result and therefore to "wrong treatment," the regulations in regard
to diet will probably be observed; still the microscopic control must be made.
BLOOD IN THE FECES IT
rare cases of gastrostaxis in wliicli, without anatomical basis, there may
occur the severest hematemesis and mclena.
Much more important are those cases in whicli the vomiting of coffee-
gi-ound material may take place as the result of extreme and persistent
vomiting attacks, such as occur in gastric crises. If the patient is first
seen after the attack, the chemical demonstration of blood in the feces
might lead one to think of an ulcerative process in the stomach.
La cage
In like manner caution must be exercised in judging of chemical
blood findings in the feces immediately after stomach lavage, as in these
cases there is a possibility of gastric hemorrhage due to spasmodic con-
traction during vomiting or to the stomach-tube itself.
Cicalricial Pyloric Stenosis
P^ven with benignant cicatricial pyloric stenosis, parenchymatous
bleeding from the gastric mucosa may take place, and thus lead to blood
in the feces. One may be inclined to assume severe hyperemia as the
cause, resulting from irritation due to disintegrated stomach contents
in the presence of venous stasis, since the high intra-gastric pressure can
easily effect compression of the intra- and epigastric venous plexuses.
Boirel Stenosis and Acute Peritonitis
This might also explain the coffee-ground vomiting, accompanied by
high degrees of meteorism occasionally observable in cases of deep-seated
stenoses of the intestines, which we also observe in diffuse acute peri-
tonitis.
Hemorriiagic Diathesis
Parenchymatous bleeding from the gastro-intestinal tract may also
be due to a general hemorrhagic diathesis resulting from unknown in-
juries or from sepsis, severe icterus,^" etc. The bleeding may also be
due to extreme portal congestion, cancer of the liver, thrombosis in the
portal veins, etc.
Terminal Findings
Terminal and preterminal findings, therefore, will have to be utilized
with the utmost caution.
Thus in the late stages of cancer of the pancreas, gall-bladder, etc.,
it may be possible to discover blood in the feces because of invasion of the
duodenum, portal congestion, or as a result of hemorrhagic diathesis.
If, therefore, theoretically our calculations were based, in a one-sided
way, upon a positive blood reaction in the feces, there would be a large
number of diagnostic possibilities, especially with the existence of paren-
chymatous gastro-intestinal hemorrhages.
Practically, however, conditions are, as a rule, much more simple.
Through the mass of clinical symptoms the possibilities are nar-
^' With pronounced icterus the absence of uroi)ilinogen in the stools seems also
to make the demonstration of small quantities of blood not depending on ulceration
easier, so that the greatest cantion is here to be observed.
18 TUMORS OF THE ABDOMINAL VISCERA
rowed down very much, so that stomach aihiaents which may be sus-
pected of carcinoma mostly require differentiation from gastric neurosis,
constitutional "achylia," peptic ulcer or chronic gastritis.
Within these narrow limitations the chemical finding of blood in the
feces is, in and of itself, highly significant.
Whenever we are confronted with the above limited possibilities for
differential diagnosis and continual blood-tests of the feces turn out to
be constantly or repeatedly positive, we must always think of some ulcera-
tive process, and may, therefore, eliminate gastric neurosis, achylia and
chronic gastritis. In view of the clinical similarity between some cases
of esophageal cancer (with absence of difficult swallowing) and cancer of
the stomach it would be well not to forget this possibility.
In what quantity and Avith what frequency a given case of carcinoma
of the stomach contributes to the admixture of blood in the feces de-
pends in part upon the anatomical character of the tumor.
The softer the cancer, the more it inclines toward disintegration, the
easier it may lead to severe protracted hemorrhages, in this way yield-
ing permanent positive blood-tests in the feces. When the carcinoma is
of a fibrous character, severe hemorrhages may often be absent for many
days.
Burdensome Tests
In these cases (as well as those of benignant ulcerations which do not
bleed) it may be important to use proper precautions in employing bur-
densome tests (Belastungsproben). As such I consider the administration
of mechanically irritating coarse brown bread, hot fluids, physical exer-
cise, harsh palpation, occasional!}' also moderate inflation of the stom-
ach by means of effervescent mixtures. If, despite all this, the chemical
test of the feces proves constantly negative, the possibility of an ulcera-
tive process may be excluded from our differential diagnostic calcula-
tions as highly improbable. But the reverse may also afford diagnostic
elucidation.
Arrest of Hemorrhage
When during the treatment of gastric ulcer (rest in bed, milk diet,
etc.) where we strive to prevent all mechanical and chemical irritation of
the stomach, the blood disappears rapidly from the feces ^^ and does not
recur even with overloading of the stomach, malignant ulceration will be
highly improbable.
Gastric Melena withovt Blood in
the Stomach Contents
The significance of the chemical blood demonstration in the feces, so
far as gastric ulcerations are concerned, gains in importance through
the fact that lavage of the stomach may bring to light gastric contents
that do not contain blood, whereas examination of the feces will yield
a positive result. We are probably dealing with hemorrhages which oc-
" Even with abundant hemorrhages from benign gastric ulcer the blood-test in
the feces is occasionally negative after one week.
BLOOD IN THE F?:CES 19
curred, for example, the day previous or which, occurring in small amounts
and at short intervals, show up in the feces through summation accord-
ing to the principle "gutta cavat saxum."
Good motilit}^ of the stomach, as may occasionally exist even in cases
of cancer of the stomach, favors the flow of blood downward.
Intestinal Diseases
The considerations detailed above permit us to proceed to those cases
in which diseases of the intestine require differential diagnosis. Here,
also, we may generally say that repeated positive blood findings in the
feces argue against a simple catarrhal condition, and with otherwise
corresponding symptoms speak for an ulcerative disease of the bowel.
Besides carcinoma of the large bowel there are practically only two
other ulcerative processes that will have to be considered most fre-
quently, viz., tubercular ulcerations and duodenal ulcer.
In this matter of chemical blood analysis in the feces every man will
have to gather his own experiences with a constant method, in this way
securing an important diagnostic aid, especially in the diagnosis of gas-
tro-intestinal carcinoma.
It seems to me of little value to collect positive and negative findings
from the literature, for, as already stated, the particular method of
analysis must be taken into account.
Whoever, for example, utilizes large amounts of feces to obtain blood
coloring matter will have positive results oftener than he, as I recom-
mend it, who carries out the test in a coarser way. To search for the
smallest traces of blood is senseless and to no purpose.
Recapitulation
In conclusion, it may be well to repeat some of the most important
points of the foregoing considerations.
1. Feces containing admixtures of blood or pus which can be recog-
nized macroscopically, or in which muscle fibres are demonstrable micro-
scopically are not adapted for chemical blood tests, since a positive result
is generally not of diagnostic value. ^^
2. If the examination of feces for blood coloring matter is to be of
diagnostic value, it will be commendable wlfen obstipation exists, to re-
move the old stools by means of a mild laxative (e.g., pulv. rad. rhei)
or very careful enemata (avoiding injury), and to enjoin a meat-free
diet for three days. Positive blood findings on the first or second day
are to be utilized with caution. Negative findings are not, of course,
significant.
3. When the blood findings are negative and suspicious clinical signs
point to an ulcerative gastro-intestinal process, we may proceed to make
"Belastungsproben" (use of bran bread, light gymnastics, etc.). When
the stools are of a firm consistence, with blood on the surface only, cen-
" Clear pus yields exquisitely positive van Deen reaction. A positive result of
reaction in stools containing pus would not, for that matter, lead to error, since
purulent admixtures occur exclusively in cases of perforation or ulcerative processes,
hemorrhages usually occurring with such conditions.
20 TUMORS OF THE ABDOMINAL VISCERA
tral portions should be utilized. An expert will occasionally be able to
determine whether the degree of a positive blood reaction corresponds to
the number of muscle fibres, but on this point great caution is in order,
4. In case of positive blood findings we must determine whether, with
bland diet and rest in bed, the blood does not disappear very soon from
the feces, since in the differential diagnosis of benignant and malignant
gastric ulceration we may decide to assume the former condition.
5. Even with negative findings in the stomach contents, obtained by
lavage, blood in the feces may be of gastric origin.
THE DIAGNOSTIC SIGNIFICANCE OF VEGETABLE AND
BACTERIAL ORGANISMS OF THE GASTRO-INTES-
TINAL TRACT
In cases in which there is suspicion of malignant disease in the gas-
tro-intestinal tract, the microscopical examination of the stomach and
bowel contents should not be made without considering in their general
aspect vegetations that ma}' be present. In this way we not rarely ob-
tain symptoms which are of especial significance as a foundation for the
final diagnosis, since they make its limitations comparatively narrow.
The diagnostic value of a symptom, however, is inversely propor-
tionate to the scope of its limitations.
A concrete example. The demonstration of an abundant "lactic-
acid bacilli" vegetation in the feces possesses an incomparably higher
value than the demonstration of an achlorhydria, because the latter
symptom, in its causative interpretation, affords room for dispropor-
tionately more possibilities.
It does not seem useless to me to emphasize that there exists a vast
difference between the diagnostic value of saprophytic and infectious
germs, which difference is based partly upon the fact that the former are
effect, the latter cause.
Whilst, under certain circumstances, infectious germs are of much
significance even when occurring singly, saprophytic organisms are of
value only when present in numbers. Only their abundant occurrence
excludes the possibility of accidental presence and proves that certain
conditions for their favorable growth were present at the site of their
development.
From this there follow certain deductions for the diagnostic valua-
tion of saprophytic findings.
1. It is apparent that it remains a matter of personal experience to
know the limitations within which the occasional discovery permits of
diagnostic acceptance.
2. The demonstration of a certain saprophyte by culture can never
be a question of prime import, hence there is no sense in culture methods.
The weight of the diagnosis rests much more upon the unstained or
dry cover-glass preparation, as it alone enables us to make an exact
estimate as to the deciding quantitative conditions.
Theoretically, an immediate examination of stomach and bowel con-
VEGETABLE AND BACTERIAL ORGANISMS 21
tents would be required in order to exclude subsequent increase of sa-
prophytic germs. But in so far as "lactic-acid bacilli" and "sarcina ven-
triculi Goodsir^'' arc concerned, such apprehensions are out of place,
since their multiplication within a few hours outside of the body and at
room temperature need not be taken into consideration.
3. Since only quantitative conditions decide, special precautions are
not necessary in obtaining the material for examination.
Gastric Vegetations appearing
in the Feces
Even in those cases when clinical signs point to a malignant disease
of the stomach it will be advisable to examine the feces providing there
are no vomited stomach contents at hand. For as far as sarcina ven-
triculi Goochir, or an abundant growth of lactic-acid bacilli are con-
cerned, the conclusions are nearly identical whether the findings have
been made in the stomach contents or in the feces.
The examination of the feces for gastric vegetations is of importance
for another reason.
I have observed cases of gastric cancer in which on certain days the
stomach contents revealed an extraordinarily abundant vegetation of lac-
tic-acid bacilli, whereas on other days the findings were hardly sufficient
to be of diagnostic value ; the findings in the stools, however, remained
constant. shoM'ing abundant growth of lactic-acid bacilli.
On the other hand, there may be cases in which, under the influence
of a cancer that is developing upon the site of a cicatrix, the sarcina?
vegetations disappear from the stomach, to be replaced by a growth of
lactic-acid bacilli, in which cases the last "stragglers" of the sarcinas maj^
still be found in the feces.
Fresli Preparation
For practical diagnostic purposes examination of the fresh prepara-
tion is to be recommended most. A small drop of Lugol's solution is
placed upon the slide and as small a quantity of feces or stomach con-
tents is stirred into it by means of platinum loop or needle. An effort
should alwaj's be made to obtain a floating portion of feces, as this adds
to the ease of observation.
A very good view is also obtained in the thin portions of the border
of a hanging drop. The Lugol solution will stain not only food rem-
nants like starch, muscle fibres (through imbibition with bilirubin green
coloring), but also imparts color to saprophytic germs such as clostria?,
leptothrix varieties, and "large-celled" sarcinae.
The experienced observer will often be able to content himself with
looking over the fresh preparation, since the morphological details are,
as a rule, entirely sufficient.
Where time will permit or with insufficient experience in this domain,
it is advisable to make Gram stained dry preparations, at least in so far
as rod-shaped bacilli, cocci or spirochetes are diagnostically concerned.
Take a loopful of stomach contents or feces and smear it over a cover-
22 TUMORS OF THE ABDOMINAL VISCERA
glass, avoiding a smear that is too thick, dry it in the air and fix it by
passing it through the flame three times ; then stain according to Gram.
Only the micro-organisms become fixed, as the foodstuffs, because of their
greater size, are carried away during washing.""^ This, however, affords
an excellent view of the growths fhat may be present.
Only very exceptionally does it become necessary — at least for the
experienced observer — to make a plate culture. This might enter into
consideration when the feces contain numerous Gram-positive rod-shaped
bacilli and there is a doubt whether we are dealing with lactic-acid bacilli.
Even here special propagative measures, culture methods, etc., are prac-
tically quite superfluous. For, if it be question of a scant number of
lactic-acid bacilli, they have no diagnostic sigiiiflcance, but if they are
present in large numbers, they will without difficulty thrive on 2% grape-
sugar agar.
In the cultivation of stomach and bowel contents I always reconmiend
the streak procedure by means of a platinum spatula, because in this
way we can succeed in immediately recognizing contaminations from the
air, especially air sarcina*, by their topographical position between the
streaks.
With stomach contents it will be possible to bring the platinum spat-
ula in direct contact before making the streak, but for culture from
feces it is advisable to float one to three loopfuls in a bouillon tube, then
immerse the spatula, remove excess by swinging and proceed to make the
streak; without this precautionary measure confluent areas of colon ba-
cilli are obtained, which renders it almost impossible to discover isolated
colonies of lactic-acid bacilli.
It will now be in place to briefly discuss the different findings in the
gastro-intestinal bacterial and vegetable growths in so far as the interest
of clinical diagnosis requires it.
A. Lactic- A rid BaciUi
Synonyms: Boas-Oppler B., "long'' B., B."" lilifornis. B.. jjeniculatus de Bary.
In a work published in 1886* from KnssmauVs clinic, Dc Bart/ '- has
described, among others, cases of cancer of the stomach in wliich the
, stomach contents contained great numbers of long and short rod-shapes
which were immotile. Their length varied from 4 to 20 [^.. In ap-
pearance the bacillus resembled that of anthrax. The number of rod-
shapes showing up in the microscopic field was enormously large ; every-
thing else stepping into the background (page 253).
There is not the least doubt that in this case De Bary had under the
'"The same fate may at times easily befall sarcinae that are present; wherefore,
as already emphasized, the examination of the fresh preparation is absolutely neces-
sary to determine the presence of this saprophyte.
'' An inappropriate designation. The length varies from cocci-like rods (dwarf
forms) to long threads (giant forms). The width is more constant; they are always
"thin" bacilli.
^^ Dp Barif. Beitrag zur Kenntniss der niederen Organismen im Mageninhalte.
Arch. f. Experim. Pathol, ii. Pharm., 1886, XX.
VEGETABLE A\U BACTERIAL ORGANISMS 23
microscope an abundant pure culture of lactic-iicid l)acilli. However,
with his method of cultivation on nutritive media that were fluid and did
not contain sugar Hie lactic-acid bacillus could not tiu-ive and l)e Bury
confused a "Subtilisart" in an abundant superficial mould with the lac-
tic-acid bacilli seen in the fresh preparation.
Later on, Boas (1892) and Oppler (1895) again called attention
to the occurrence of an abundant vegetation of rod-shaped bacilli in the
stomach contents in cases of gtistric carcinoma, without obtaining a
culture.
ir. Schlesinger and Kaufman -^ were the first to carry out the plate
cultures of the rod-shaped bacilli, which up to this time had been only
moi-phologicall}' characterized, and the}^ found the important fact that
the addition of 2% grape-sugar to ordinary sugar brings about a good
growth at incubator temperature.
Stenosing cancers of the pylorus, accompanied by "coffee-ground"
vomiting, furnish the largest yield of lactic-acid bacilli in the stomacii
contents as well as in the feces.-* One who is not sufficienth^ familiar
with gastro-intestinal bacterial growths would do well to preserve speci-
mens of the stomach contents and feces from such "extreme" cases for
purposes of comparison when making tests, -"^ in order to recognize
growths of lactic-acid bacilli when these latter show' up less clearly.
Whilst vegetations of rod-shaped bacilli in the feces consist mostly of
forms that are short and of equal length, we find in the picture furnished
by a stool of the above description (see Plate Fig. 2,) that there are
considerable differences in the length of the rod-shaped bacilli; they are
thin, occasionally amounting to threads; their protoplasm seems to con-
tain granules here and there, never contains spores ; the shorter bacilli
often meet at angles.
The above-described picture occurs in isolated form in the stomach
contents ; in the feces it appears as if it had sprouted.
By floating the stomach contents or feces in Lugol's solution, the
above-described lactic-acid bacilli do not show any blue or violet stain.
This distinguishes them from those usually long, thick, plump forms
of leptothrix which, because they cannot grow under aerobic conditions,
are found in enormous quantities in the tartar about the teeth,-" and
which are occasionally demonstrable in the feces, especially when the lat-
ter are acid in reaction — as a separate type of vegetation.
Tlie forms of leptothrix, just referred to, take on — even though not
"^Schlesinger and Kaufman. Uber einen Milchsaiirebildenden Bacillus \ind sein
Vorkommen im Magensaft. Wiener klin. Rundschau, 189fi, Nov. 15.
"jR. Schtnidt. Mitt. d. Ges. f. innere Med. in Wien., 1903, Nov. 5.
-'With the addition of a few drops of forniol such sjiecimens may be pre'^erved
in glass-stoppered bottles for an indefinite period.
"^ In the bacteriological examination of the tartar about the teeth we find, for that
matter, gradual transitions from the typical forms of lej>tothrix that stain blue with
iodin to slender rod-shaped forms which entirely resemble the lactic-acid bacillus
morphologically; however. 1 have never succeeded in making a culture. Still T con-
sider it very probable that this is the parent form of the lactic-acid bacillus which
has come into its present state through adoption of the leptothrix form of the oral
cavitv to the conditions in the stomach (mostly a cancerous stomach).
24 TUMORS OF THE ABDOMINAL VISCERA
constantly — a blue violet stain if the Lugol solution works its way into
the oftentimes granulated protoplasm, but care must be taken to see
that the material to be examined is thorouglily stirred in the drop of Lu-
gol, so that the iodin solution actually comes into contact with the
threads of leptothrix.
In regard to Gram staining, the lactic-acid bacilli and forms of lep-
tothrix are in perfect accord, that is, they are Gram-positive except when
in the case of outgrown, older and evidently degenerate forms, the pro-
toplasm has ceased to be partly or entirely alcohol-fast and hence shows
up, in contrast, color that is Gram-negative.
Gram-positive Bacilli in the Feces
As far as the Gram picture in the feces is concerned the lactic-acid
bacilli have two doubles, whose frequent presence lead to Gram-positive
bacilloses in the feces.
Filiform Type with Granular Reaction
1. Filiform type with granule reaction.-^ Under this term I have
registered cases in which the long, thick. Gram-positive forms of lepto-
thrix, just referred to, predominate in the stool.
This picture of a vegetation is not frequent. It ma}- occasionally be
found in "intestinal fermentative dyspepsia" {A. Schmidt), hence in
evacuations that are acid in reaction, light yellow in color, soft in consis-
tency, and have the odor of butyric acid; sometimes I have found it in
intestinal and peritoneal tuberculosis, never so far in malignant processes
of the large bowel.
The differentiating characteristics from the lactic-acid bacillus may
here be summarized once more: throughout conspicuously long plump
threads, curled here and there like a whip, staining frequently "with iodin,
cannot be cultivated aerobically. Stomach contents contain no analogous
rod-shapes, but do not infrequently show absence of HCl (achylia gas-
trica) when "intestinal fermentative dyspepsia" is present.
"Pseudo-colon" Type
2. "Pseudo-colon" type. This is a Gram-positive bacillosis in the
feces described by me, being rod-shaped bacilli,-'^ Gram-positive, anaero-
bic, occurring in large numbers, and in contrast with the colon bacillus
stand out through their more glistening appearance.
Whoever wishes to procure test stools containing this ty^e of vegeta-
tion should be guided by the description given under 1, of stools that are
acid, light yellow, having the odor of butyric acid, often foamy, which,
according to my experience, occur most frequently — though seldom —
in neuropathies with gastro-intestinal atony, which at times is accom-
panied by achylia. For a stool having the qualities in question the pseudo-
colon type is almost obligatory and stands at the summit of its develop-
mental possibilities. Less pronounced approaches to this type are fre-
"See Plate, Fig'. 3.
" See Fig. 4. The examinations of Professor Ghon show that this is a type of
streptothrix.
Fig. I.
Microscopic appearance of a growth of the foces
(Grnm staining) in a case of anatomically ami
functionally perfect gastro-intestinal tract.
Fig. II.
Slicroscopic appearance of a growth of the feces
(Gram staining) in a case of carcinoma of the
stomach. One sees numerous firampositive „laetic
acid bacilli".
Fig. III.
Microscopic appearance of a grovrth of the feces
(Gram staining): „Filiform type" with granulose
reaction.
Fig. IV.
Microscopic appearance of a growth of the feces
(Gram staining): pseudo-colon type.
These figures are equally magnified.
Rebman Company, New York.
VEGETABLE AND BACTERIAL ORGANISMS 25
quently found with the many different — mostly chronic — processes in the
large intestine ; however, they have no particular significance.
Here, also, it may be well to emphasize the points of difference from
the lactic-acid bacillus :
Gram-positive, short rod-shapes, without differences in length, can be
cultivated anacrobically only. Stomach contents reveals no analogous
growths, but may show absence of HCl (achylia gastrica).
Bearing in mind what has been said above it should not be difficult to
properly recognize a growth of lactic-acid bacilli even in the feces ; in
the stomach contents conditions are much simpler, since, if there be pres-
ent Gram-positive rod-shapes, having the previously discussed morpho-
logical character, the lactic-acid bacillus is practically the onW one that
deserves consideration.
Culture Demonstration of Lactic-
Acid Bacilli
Nevertheless, should culture demonstration be desirable or easily
feasible in one or the other case, it will generally be sufficient to start a
growth on plates of grape-sugar agar, as indicated previously. After
24 or at most 48 hours (at incubator temperature only) very small
colonies will appear, which remind one of streptococci, and which do not
increase in size. The border of the colonies is wavy, after the fashion of
the anthrax bacillus. Only on very dry agar may the colonies some-
times have a sharp outline, and then they are composed mostly of very
short rod-shapes that have not grown to be threads.
The morphological character of the colonies, especially in so far as it
belongs to the first-mentioned type, which is the standard, is sufficient
for their sure recognition among gastro-iiitestinal bacterial growths.'^
Diagnostic Significance of Lactic-
Acid Bacilli Findings
As regards the diagnostic significance of findings of lactic-acid ba-
cilli, be they in the stomach or in the feces, it is of course no question of
a specific symptom of gastric cancer.
Specific symptoms, belonging only to a certain definite disease process,
count among the greatest of all rarities, and in the entire symptoma-
tology of malignant neoplasms there is no specific symptom. Between
specific symptoms and inconsequential manifestations of disease there are
a number of gradations.
And not only here, but in many other domains of symptomatology
as well, there ought not to be carried on the idle strife in regard to
specificity and non-specificity, rather there should be an agreement as to
what place a certain symptom occupies in the line of diagnostic value.
Concerning the vegetation of lactic-acid bacilli I can maintain, by
^' In regard to separation of a morphologically similar disease producer observed
by me (Gram-positive ulcerative mvcosis of the stomach), see jR. Schmidt. Mitt, aus d.
Grenzgeb. d. Med. ii. Chir., 190fi, 'Vol. XV, Copy 5, i>age 705.
26 TUMORS OF THE ABDOMINAL VISCERA
reason of inan3' years' experience, that we are here dealing with a symp-
tom which is of no consequence.
It seems to me quite to the purpose to reiterate in a few sentences
the essence of my personal experience.
1. The absence of lactic-acid bacilli vegetation can never be used as
against the diagnosis of carcinoma of the stomach, since advanced cases
ma}'^ occasionally go on without this finding.
2. At times one must figure on variation in the quantities of such
vegetation in the stomach, whilst in the feces they remain constant.
3. An abundant vegetation of lactic-acid bacilli in the stomach con-
tents always leads to the occurrence of analogous bacterial growths in
the feces, and the latter, as has just been stated, may, despite their gas-
tric origin, at times surpass the former in intensity.
4-. In very rare exceptional cases an abundant vegetation of lactic-
acid bacilli in tlie feces may also be of intestinal origin. In my observa-
tions, extending over more than ten \'ears, I have met with but two such
cases, one being a case of lymphosarcoma of the small bowel, the other
a case of cicatricial stenosis on a tubercular basis in the lowermost por-
tion of the ileum."'"
5. A growth of lactic-acid bacilli in the stomach contents is prac-
tically alwa^'s of gastric origin, and in the majority of cases coincides
with the existence of carcinomatous disease of that organ.
6. From my observations during more than ten years I can recall
but three exceptional cases in which there was no carcinomatous disease
of the stomach :
a. Cicatricial pyloric stenosis following HCl erosion (operution).
b. Carcinoma of the gall-bladder (autopsy).
c. Cicatricial pyloric stenosis with synchronously existing kidney
tumor of Grau'itz.
In all of these cases there was pyloric stenosis and "coffee-ground"
vomiting.
7. Isolated lactic-acid bacilli, be they in the stomach contents or in
the feces, must be used with utmost precaution for diagnostic purposes,
especially when dealing with "agonal" conditions, such as sepsis and
peritonitis, which cases are occasionally accompanied by coffee-ground
vomiting.
8. The absence of lactic-acid bacilli when there is "coffee-ground"
vomiting (as in hyperacidity, benignant pyloric stenosis, gastric crises,
intestinal stenosis, peritonitis, congestive catarrhal conditions, etc.), may
generally be constinied as against the diagnosis of gastric carcinoma.
B. Sarcince of the Stomach
As a result of my examinations I have become convinced that the ex-
aminations of gastric sarcinae, made by Oppler in his day, are entirely
erroneous.
"*R. Schmidt. Beitriige zur abdominalen Diagnostik. Med. Klin., 1909, No. 2,
page 7.
VEGETABLE AND BACTERIAL ORGANISMS 27
Those sarcinfc which can ahiiost without exception he demonstrated
in hirge nunihcrs, hoth in the stomach contents and in the feces in every
case of benignant organic stenosis of the pylorus, have nothing in com-
mon with tlie different kinds of pigment-forming sarcina' of the air.
Entirely different in shape and size, the stomach sarcina' do not ad-
mit of cultivation in customary nutritive media. Their abode within
the human organism is in the stomach ; only from here do they gain ac-
cess to the feces, without ever settling primarily in the feces, never ap-
pearing in the urine, and never in the air-passages. The appearance of
gastric sarcina? is therefore limited to the stomach, in perfect contrast to
the ubiquitous presence of the various kinds of air sarcin.e; the question
of its origin remains entirely unsolved. ^^
Despite the impossibility to cultivate stomach sarcina?, it is perhaps
never difficult, with some experience in the domain of gastro-intestinal
vegetations, to properly recognize them because of their size and con-
spicuous bale shape. Also, as already emphasized, one can easily pro-
cure gastric contents containing stomach sarcinae, which can be preserved
by keeping air-tight after the addition of a few drops of formol.
Morphologically, two forms are to be distinguished :
Large-Celled Form (lodin Positive)
1. A large-celled form. The dice formation is mostly very exact, and
with Lugol's solution there appears an extensively yellow coloration
(iodin positive forai).
Small-Celled Form {Iodin Negative)
2. A small-celled form. There is a tendency to the formation of more
irregular, globular masses, the individual sarcinae are really smaller, and
sometimes have spore-like inclusions that are able to shut off the light.
There is no coloration with iodin (iodin negative form). The irregular
masses often appear honeycombed or like the spawn of frogs.
Since both forms are constantly to be found — though one n\a.y be
more prevalent than the other — I think that we are simply concerned
with different stages of development of one and the same species, though
the iodin positive form seems to require the more favorable conditions of
life.
In the bowel the sarcinas coming from the stomach undergo degen-
erative changes, and the large-celled sarcina? often appear as if washed
out and shadowy, comparable to red cells of the same description oc-
curring in nephritic urinary sediment ; there may also be observed dis-
integrating processes in the outline (bale, dice) itself. As regards the
diagnostic utilization of stomach sarcinje, I would like to summarize the
results of my experience, as follows :
a. For the diagnostic application, it makes no difference whether the
stomach sarcina" are found in the stomach contents or in the feces ; for
in the latter case they originate in the stomach.
'' In an older work from the year 1849, Virohow's Arohiv, page 331, O. W. Simon
has expressed the opinion that stomach sarcinae represented a stage of development
of yeast-cells. T consider this opinion worthy of discussion.
28 TUMORS OF THE ABDOMINAL VISCERA
b. Vegetation of stomach sarcinfe occurs only in connection with a
high degree of stagnation of stomach contents. If the finding is constant
it proves, almost always, the existence of organic stenosis in the neigh-
borhood of the pylorus or duodenum.
c. The finding of a malignant tumor-mass in the supra-umbilical
parts of the abdomen, besides the demonstration of the stomach sarcinse
in the stomach contents or feces, suggests, in the first place, carcinoma
of the pylorus ; besides this, we most frequently have to consider carci-
noma of the head of the pancreas or the gall-bladder, with secondary ste-
nosis of the stomach outlet.
d. Constant finding of sarcinje in cases of stomach disease which is
of short duration — say several months — usually due to a malignant
process (most frequently pyloric cancer) ; the same is true of the com-
bination : sarcin<e-vegetation -|- growths of lactic-acid bacilli.
e. The occurrence of stomach sarcin<E without stenosis of the pylorus
counts among the greatest rarities ; in the course of many years I have
been able to observe only a few such exceptional cases, although I was
always on the lookout for same ; once a case of deep-seated carcinoma of
the esophagus and in another of accretion of the stomach in tuberculous
peritonitis. In both cases the occurrence of sarcinae was not permanent,
but only temporary.
C. Further Findings
The diagnosis of malignant diseases of the gastro-intestinal tract
frequently meets Avith so many difficulties, that one will occasionally avail
himself of symptoms wliich do not possess the value that attaches to lac-
tic-acid bacilli and stomach sarcinfe vegetations.
Megastoma Entericum
Here, as belonging to the realm of gastro-intestinal bacterial and
plant vegetation, we must take into consideration the finding of cer-
c-omonas intestinalis (Lamhl) s. Megastoma entericum (Grassi),^'- in so
far as it is met with in the stomach contents.
These parasites, belonging to the flagellates, have so far been found
in the stomach almost exclusively in connection with carcinomatous dis-
eases, though on the whole their occurrence is quite rare. They are of a
pear-shaped form, about twice the size of a red blood cell, with two eye-
like nuclei in the broad end of their body.
The conditions favoring their multiplication in the stomach seem to
be as follows :
1. Alkaline reaction.
2. Presence of special hiding-places on the inner surface of the stom-
ach, as established chiefly by papillary cancer proliferations.
The cases observed so far always showed non-obstructing neoplasms,
located for the most part in the fundus of the stomach; being in definite
^^ Hensen, Deutsches Arch. f. Klin. Med., Vol. 59, page 450 (first observation);
Cohnheim, Deutsch. med. Wochenschr., 1903, page 230, illustration, page 206; Zabel,
Wiener Klin. Wochenschr., 1904, 38 (illustrations).
VEGETABLE AND BACTERIAL ORGANISMS 29
contrast to the appearance of the hvctic-acid bacilhis, whicli doubtless has
special preference for carcinoma at the pylorus.
The eventual finding of a megastoma vegetation in the stomach con-
tents ^^ deserves particular attention, because of the scanty symptoma-
tology of non-obstructing cancer of the fundus, and because a palpable
tumor is mostly absent.
Of unequally less diagnostic import is such a finding in the feces ;
here the parasites appear mostly encysted and at rest, and are of oval
formation. Occasionally they might be of gastric origin, but, as a rule,
when the stomach contents are negative with reference to parasitic find-
ings, we are dealing with an autochtomous intestinal growth that has
come to development coincident with the existence of gastric hypoacidity,
a condition Avhich, for that matter, is almost the rule in the case of other
parasites, such as tenia?. It seems that the gastro-intestinal tract is more
accessible to parasitic invasion when, due to weakness, it is functionating
below the normal.
Bacterium Coli
In cases of carcinoma of the stomach the colon bacillus and related
species (e.g., bact. lactis aerogenes) show up more pronouncedly in the
Gram-picture or in the respective plate cultures when extensive disinte-
gration of the new formation has taken place, and such cases may,
through the local establishment of a kind of intestinal vegetation even
without connnunication with the gut, exliibit fecal stomach contents. In
connection with lactic-acid fermentation in carcinomatous stomach con-
tents, the microbes mentioned above might be of more real import than
the so-called lactic-acid bacilli.
According to ni}^ observation,^'* it seems that colon bacilli vegeta-
tion, so far as its abundant occurrence is concerned, is a peculiarity
with those rarer forms of gastric carcinoma in which there takes place a
uniform diffuse infiltration of the stomach-walls in toto, without any
proper tumor- formation (so-called linitis plastica Brinton). In the fresh
preparations from these cases the colon bacilli were conspicuous for their
small size, and appeared almost like cocci. In the streak cultures there
were close areas of colon bacilli.
Vegetation in Feces in Connection ivith
Neoplasms of the Bowel
So far as neoplasms of the intestinal tract are concerned, the picture
afforded by vegetation in the feces does not show any findings that are
nearly as important as, for instance, the lactic-acid bacillus is in cancer
of the stomach.
The following three findings, however, seem to me to deserve atten-
tion, as they occur only in cases of severe organic lesions of the bowel.
1. Lively motile rod-shaped forms. If the smallest possible particle
^^ For this jnirpose it might be especially well to examine the sediment of the
irrigation fliiid.
** Uber Mesentericus. ii. Colihacillose des Magens. Wiener Klin. Wochenschr.,
1901, 2.
30 TUMORS OF THE ABDOMINAL VISCERA
of stool is floated in a drop of water and observed under the microscope,
the rod-shaped bacilli that are to be examined show throughout an in-
dolent molecular motion in one and the same place, or passive motion due
to currents of fluid. Automotion, in the sense that individual rod-shapes
"shoot about," cross the microscopic field, etc., is an extremely rare oc-
currence. According to my observations, it is found only with the severer
organic bowel lesions, among others — carcinomata.
2. Abundant presence of spirochetes. As compared to the spirocheta
pallida of Schaud'mn, the intestinal spirochete, with its scanty and bold
curves, is easily recognizable even unstained, especially at the edge of
a hanging drop, also with the Gram or Giemsa preparation ; its abundant
presence coincides mostly with severe catarrhal conditions of the large
bowel, among others with carcinoma of the large intestine.
3. In some cases of cancer of the large intestine I have been im-
pressed with the abundance of cocci that show up with the Gram stain,
and arc arranged in large heaps. Exulcerating surfaces may, of course,
occasionally serve as nutritive media for the development of pus or-
ganisms. Still, the finding is far from being constant or specific.
I note the especial copiousness of cocci in the feces in many cases
of pernicious anemia.
Ehrlich's ''Diazo"" and ''Aldehyde^' Reaction
For many years I have given full attention to both of the above
urinary reactions, even in connection with the malignant diseases here
under discussion, and I have repeatedly made use of them with diagnostic
advantage. I give space for their separate discussion because as yet
they have received too little appreciation from physicians in general, al-
though the simplicity of their performance makes them accessible for
every man.
For the diazo reagents I employ the following, according to Frieden-
xvaJd — -Ehrlich :
1. Paramidoacetophenon 1.0
Acid, hydrochlorici concentrati 50.0
AqujE Destillatc-e 1000.0
II. Natrii nitrosi 0.5
Aqua? Destillata? 100.0
Pour into a test-tube about 3 cm^ of reagent I and add one to two
drops ^^ of reagent II; mix with an approximately equal quantity of
urine and add about 1 cm^ of ammonia.
The reaction can be considered as positive only when the foam that
is generated by shaking has an undoubted red color (not brown). Light
rose = weakly positive; scarlet red = strongly positive.
Ehrlich's original observation,^^ according to Avhich the "diazo" re-
*' An excess of reagent II may lead to a falsely negative reaction.
"P. Ehrlich. Uber eine neiie Harnprobe. Zeitschr. f. Klin. Med.. 1883, page
285; Charite Annalen, 1883, page 140.
VEGETABLE AND BACTERIAL ORGANISMS 31
action is absent in afebrile processes, hence also in cancer, is quite jus-
tified in so far as it lays down a rule which has not many exceptions.
Certainly the fever as such has nothing to do with the occurrence of
the reaction. For, as Ehrlich already emphasized, these are infectious
processes with liigh fever, which are only exceptionally accompanied by
diazo reaction, e.g., croupous pneumonia, acute articular rheumatism,
diphtheria, whilst otlier infectious processes with much less fe])rilc va-
riation show an almost constant diazo reaction in the urine, e.g., miliary
tuberculosis, typhoid, morbilli.
These facts seem to indicate that the febrile metabolism, as such,
plays a lesser part in the causation of the diazo reaction than the kind of
toxin operating at the time.
And this manner of conception explains those cases, indeed very rare,
which are occasionally accompanied b^^ a strong diazo reaction, although
the course of the disease is afebrile or only subfebrile.
For abdominal non-malignant pathological processes I would like to
set up the following scale of frequency taken from my observation :
I. Reaction almost always positive and mostly maximal.
a. Tuberculosis of the peritoneum ; including cases which are afebrile
or have only slight elevations in temperature. In these cases the reaction
has no palpable prognostic meaning, and its occurrence does not depend
on pulmonic complications,
b. Enteric fever: The reaction not rarely becomes obscure about a
week prior to the disappearance of the fever.
c. Parametritis with post-puerperal streptoccean reaction."'
II. Intermittentl}^ positive, often only moderate reaction.
(t. Tubercular ulcers of the intestines and tubercular tumor of the
cecum ; also tuberculosis of the female genitalia and general tubercular
adenitis of the abdomen.
Since all these affections rarely appear by themselves, but are mostly
in combination, and are often also accompanied by foci in the bones and
in the lungs, it is difficult to estimate the influence of the individual
lesion. As a rule, the reaction is so much more pronounced as the general
infection overshadows the local anatomical process, in w^hich cases, for
that matter, higher fever temperatures may be entirely wanting.
/). Cholangitic Infections. ^^
Ulcerative processes of the duodenum with ascending infection of the
biliary passages may, in this way, occasionally go along with diazo reac-
tion ; similarly, some cases of cholelithiasis are accompanied by diazo
reaction, which in such cases, however, is usually very moderate and of
short duration.
^' According to my own observation, cases of general staphylococcus infection run
their course, as a rule, without any diazo reaction. The maximal constant diazo
reactions in streptococcus sepsis stand in peculiar contrast to the almost constantly
negative reaction in acute articular rheumatism.
^'* With positive reactions in these cases, streptococci and colon bacilli niiglit be
particularly considered analogous to other observations. 1 woiild consider the ex-
istence of diplococcus or staphylococcus infection of the bile-jiassage as highly im-
probable in the jiresence of a jHisitive diazo reaction.
32 TUMORS OF THE ABDOMINAL VISCERA
III. Reaction constantly negative.
Cirrhosis of Laennec, myeloid leukemia, ascites due to cardiac and
portal congestion, catarrhal jaundice, chronic gastro-intestinal catarrh,
simple ulcer. ^''
Diazo lieaciion Neoplasms
In the scale of frequency and intensity of the diazo reaction, as out-
lined above, I would include malignant diseases of the abdomen between
groups I and II : reactions seldom and even then feebly positive.
The tumor process, as such, could hardly give rise to a positive diazo
reaction. I lean to the belief that when malignant diseases of the abdo-
men occur with diazo reaction, we are probably always dealing with
secondary infections (streptococci, colon bacilli).
Accordingly, in the cases where there was a positive reaction (and
they were rare) in connection with stomach cancer, I found that the lat-
ter was mostly of the medullary type and exulcerating very much. Fi-
brous forms, ulcerating but little, seem almost never to be accompanied
by diazo reaction.
The observation that cancer of the bile-passages, particularly the
gall-bladder and terminal portion of the ductus choledochus, also the
papilla of Voter, yields about the most frequent positive results, also
leads me to the assumption that in cases of malignant abdominal diseases
the diazo reaction is dependent upon secondary infection. Here the con-
ditions for secondary infection, considered as belonging to the cholan-
gitic processes, are particularly favorable.
Here, as- in typhoid, it is possible that complications, such as the oc-
currence of purulent peritonitis, may cause the reaction to disappear.
Even though I am inclined to look at the diazo reaction in malig-
nant diseases as a symptom of secondary infection, its diagnostic value
seems to me really greater than that of findings of eventual rises in tem-
perature. For, leaving aside the fact that the latter may easily be ab-
sent as the result of cachexia, the diazo reaction has, as already
previously emphasized, a specific meaning, even though it be within wider
limits, and, indeed, certain highly febrile infectious processes (pneu-
monia, malaria, etc.) at times run their course without this urinary
finding.
Diagnostic Value of Diazo Reaction in
Malignant Processes of the Abdomen
As regards the specific diagnostic value of the diazo reaction in the
province of malignant diseases of the abdomen, the following points of
view seem to me worthy of special mention :
1. The combination of ascites with a strongly positive diazo reac-
tion permits the exclusion of an uncomplicated cirrhosis of Laennec, as
^' An exception to this is a case of Gram-positive mycosis of the stomach, so
far observed by myself alone, which showed a constant diazo reaction. See Sitz.-Ber.
d. Ges. f. innere Med. ii. Kinderheilk., February 25, 1904, and Zeitschr. f. Heilk.,
1905, Vol. XXVI, Copy 7; Abteil. f. prakt. Anat., Copy 3.
VEGETABLE AND BACTERIAL ORGANISMS 33
well as cardiac congestion. For differential diagnosis there really re-
main only tuberculosis of the peritoneum and ascites resulting from a
malignant neoplasm, tlie latter assumption, however, being highly im-
probable.
2. Ascites without diazo reaction makes peritoneal tuberculosis very
improbable. In this case the probabilities are about evenly divided be-
tween cardiac and portal congestion and neoplasm.
3. In the differential diagnosis of gastro-intestinal cancer on tbe one
hand and gastric or intestinal catarrh on the other, a positive diazo reac-
tion would favor the assumption of the former.
4. In the differential diagnosis of carcinoma and tubercular tumor
of the cecum a positive diazo reaction makes the latter much more
probable.
5. In the differential diagnosis of senile tuberculosis and gastric can-
cer, a clearly positive diazo reaction makes much more for the first
assumption.
Aldeliy'de Reaction
Another reaction, which like EJirlich's diazo reaction and because of
its simplicity and diagnostic import deserves to become the common prop-
erty of medical men, is the aldehyde reaction, also inaugurated by
Ehrlich.
At first misinterpreted ^ ** as to its causative significance, the investi-
gations of Poppenhelm, Neubauer and Bauer "^^ demonstrated that the
occurrence of this reaction, as well in the urine as in the feces, is syn-
chronous with the presence of urobilinogen.
For the performance of this test I recommend the following solution,
which is a little at variance with the original prescription :
Dimethylamidobenzaldehyde 2.0
Acidi hydrochlorici concentrati 100.0
Sig. Aldehyde reagent; to be added drop by drop.
The reagent is added drop by drop to the urine that is to be exam-
ined, whereupon an intensive red color appears if there be present a
large amount of urobilinogen, the color disappearing upon addition of
an excess of the reagent ; hence the addition of drop after drop, though
not too timorously. When urine is exposed to sunlight for a length of
time any urobilinogen that may be present is converted into urobilin,
which latter does not react with the reagent, hence might arise the theo-
retic requirement to obtain freshly voided urine which only contains uro-
bilinogen. Practically, this requirement is modified by the fact that this
conversion takes place very slowly under ordinary external conditions.
The same is true of feces, which in their fresh state mostly contain
urobilinogen only, which also in this case but slowly changes into urobilin.
In the examination of feces for urobilinogen, it is advisable to mix a
*" Ehrlich^s dimethylamidobenzaldehvcl reaction. Zeitschr. f. Physiol, u. Chemie,
1900-1901, No. 31, p. 520.
"Dr. R. Bauer. Zentralhl. f. innere Med., 1905, No. 34.
34 TUMORS OF THE ABDO:\IIXAI. VISCERA
portion about the size of a pea (at times only a few loopfuls) with 2 to
3 cm^ 60% alcohol in a porcelain dish by means of a glass rod, then
adding the reagent to this alcoholic extract (filtration is superfluous).
If an equal quantity of feces and alcohol are used we are enabled to make
a quantitative estimate.
In decided contrast to the previously discussed diazo reaction, which
must be considered as pathological even if of slight degree of intensity
(light rose- red coloration), moderate degrees of a positive aldehyde re-
action in the urine are hardly of value. They manifest themselves through
slight and mostly delayed red coloration in from one to two minutes.
Indeed, there are many instances in which even this slight degree of a posi-
tive reaction is wanting.
At any rate, the reaction becomes of full diagnostic value, then, only
when it turns out strongly positive, which is determined by its rapid
onset and intense red coloration.
As already mentioned, the significance of a strongly positive alde-
hyde reaction in the urine is identical with that of a pronounced urobili-
nogenuria.
The question arises, therefore, as to the general significance of this
manifestation and its special diagnostic value within the limits of the
topic in which we are here interested.
My opinions are as follows :
Origin of Vrohilinogen
1. The intestine (large bowel) is practically considered as the place
of origin of urobilinogen, and bilirubin of the bile as the material from
which it springs.
2. Normally, a portion of iiitestin;d urobilinogen reaches the liver
through resorption into the portal vein, and from the liver it is almost
quantitatively eliminated into the bile and with it again returns to the
bowel ("small circulation"').
Causo of its Passage into the Urine
3. If for any reason (thick consistency of the bile, moderate vis a
tergo, obstacles to evacuation on account of swelling of the mucous mem-
brane, occlusion, etc., of the bile-passages) the flow of bile be impeded,
it is possible, probably because of the overloading of the liver-cells with
bile coloring matter, for a portion of the urobilinogen normally resorbed
from the bowel to pass the liver-cells, gain access to the large circulation,
thence to be excreted by the kidne3's.
If the boAvel be the place of formation of urobilinogen, then the liver
is the organ which, because of partial disturbance in its function of
biliary elimination, determines the transition of intestinal urobilinogen
into the circulation and from there through the kidneys into the urine.
According to this view, every urobilinogenuria of high degree would
ultimately have to be interpreted as an hepatic symptom.
VEGETABLE AND BACTERIAL ORGANISMS 35
Febrile Urohilinogenuria
Indeed, it is illogical to speak of a febrile urohilinogenuria, since the
fever, as such, is never the cause of this phenomenon, it being well known
that high febrile diseases, as is most often the case in typhoid, run their
course witliout urohilinogenuria.
In these cases also the clinical observations, for example, in pneu-
monia, absolutely speak for the hepatic origin of the symptom, pre-
sumably, in the way of an accompanying cholangitis.
Hematogenous (?) Urohilinogenuria
If, with the existence of a general hemorrhagic diathesis, there are
multiple hemorrhages from the skin, mucous membranes and muscles,
there is also here no cogent reason to speak of "hematogenous" uro-
hilinogenuria.
These diseases are rather such in which there is present chronic alco-
holism, or in which we are concerned with the toxic ejffects of infection,
intestinal diseases, etc. ; so that, also, in these instances the assumption of
pathological conditions of the liver is to hand and actuall}^ too, objective
changes in the organ are not seldom found.
Clinically, therefore, I adhere to the principle: without disturbances
of the liver function there is no pathological urohilinogenuria. The na-
ture of the disturbance, however, seems to me to be the drainage of bile.
"Aldehyde" Reaction: Biliary Ohstruction
Malignant diseases of the abdomen not infrequently have their origin
in the liver or involve the bile-passages secondarily (carcinoma of the
duodenum, pancreas, secondary carcinoma).
The significance of the aldehyde reaction lies in the fact that, because
of its simplicity, it enables the practitioner to clearly acquaint himself
Avith the conditions of the bile drainage from the intrahepatic bile-ducts.
Especially the demonstration of just beginning or very slight biliary
congestion in particular is successful only by means of the testing of the
urine for urobilinogen. If there already exist a definite subicteric or
icteric discoloration, then the reaction — at least in the urine — loses in
significance.
If in such cases the reaction is positive, it proves nothing more than
the skin discoloration. "*" If the reaction is negative — and according to
my own experience this is not rare in cases of moderately severe jaun-
dice — it admits of no further conclusions. It would be entii*ely wrong to
assume total biliary occlusion because of the continued absence of the
formation of urobilinogen in the bowel. One can easily convince himself
that in such cases of incomplete biliary obstruction urobilinogen is
clearly demonstrable in the feces, although there is no aldehyde reaction
in the urine.
The following explanation seems to fit these somewhat paradoxical
cases :
" With obscure subicteric discoloration it is, indeed, a welcome confirmation of
what is found on inspection.
36 TUMORS OF THE ABDOMINAL VISCERA
Biliary congestion is undoubtedly a factor favoring the appearance
of urobilinogen in the urine. Therefore, subicteric discoloration almost
always goes along with a strong aldehyde reaction. But as the biliary
congestion, through its increasing intensity, diminishes the amount of
bilirubin in the bowel, hence also the material from which urobilinogen is
formed, there is at the same time a factor which, in its normal develop-
ment (complete biliary obstruction), to a certain extent halts the forma-
tion of urobilinogen in its incipiency.
Now, it seems that these forces residing in the process of biliary con-
gestion but working in an opposite direction may accumulate, so that,
despite the existing congestion of bile and despite the presence of uro-
bilinogen in the bowel contents, the urine show5 normal conditions as far
as the aldehj'de reaction is concerned, in other words, it reacts negatively.
Since, therefore, the investigation of the urine with reference to alde-
hyde reaction has little meaning where a definite jaundice is present, the
examination of the feces in these cases becomes so much more valuable.
Only in this way can we expect to arrive at a reliable conclusion as
to the quantity of bilirubin that has gained access to the bowel.
If there be total occlusion of the ductus choledochus the testing of
the feces for urobilinogen may result entirely negative, or there may be
found only traces of urobilinogen, derived from that bilirubin which
has come into the bowel with the secretions of the intestinal mucous
membrane.
IMere inspection of the stools may lead to gross errors, as the color
of the feces is influenced by several factors, such as nutriment, admixture
of blood, medicaments, etc.
Aldehyde reaction in stomach contents that have been vomited or ob-
tained by means of the stomach-tube proves only the presence of bile,
which even under normal conditions contains urobilinogen.
Recapitulation
With reference to the diagnosis and differential diagnosis of malig-
nant diseases of the abdomen, the following points of view should receive
special prominence.
1. The aldehyde reaction in alcoholic extract of feces, like the bili-
rubin test in urine, permits of the uninterrupted estimate of bile drain-
age into the bowel ; the icteric color of the skin is not reliable as a
graduator, because it may outlast for a longer time the reopening of the
bile-passages. Complete drying up of the biliary secretion, as happens
particularly with malignant stenosing processes (cancer of the head of
the pancreas), is shoAATi in the feces by complete or nearly complete
absence of the aldehyde reaction.
2. Slight degrees of a positive aldehyde reaction in the urine (mostly
delayed appearance of a light red coloration) have no real significance
in so far as they are transient findings.
3. A strongly positive aldehj^de reaction in the urine is always a
sign of impeded drainage of bile; in these cases precisely the mildest
forms of biliary congestion give rise to a strongly positive reaction,
SYMPTOMATOLOGY OF CACHEXIA 37
even before the appeurance of a subicteric coloration, whilst medium and
high degrees of icterus frequently run along with aldehyde reaction.
4. We must also take into consideration whether the reaction in the
urine is constant or only transient/'* whether it is stationary, increasing
or decreasing. Malignant processes not rarely distinguish themselves by
a rapid increase.
5. Among the afebrile diseases of the abdomen a strong aldehyde
reaction is an almost regular accompaniment of acute enlargement of the
liver and of Laennec's cirrhosis, as long as same progresses without
ascites.
6. In cases of chronic congestion of the liver with secondary indura-
tion, and in cases of Laennec's cirrhosis together with ascites, the alde-
hyde reaction may occasionally be absent in the urine. With chronic in-
duration of the liver resulting from the proliferation of firm connective
tissue the conditions might be more unfavorable for compression of the
biliary passages through congestion of the blood-channels.
7. In definitely ascertained malignant disease of the abdomen a con-
tinued or progressive aldeh^^de reaction in the urine becomes a decidedly
important symptom, which will always demand a most exact examination
of the liver ; it may stand in relation to a secondary or primary neo-
plastic disease of the liver itself or to glandular affections about the
liver, providing there be no complications, such as cirrhosis, etc. Still,
precaution must be exercised, because in just such cases we may meet
with aldehyde reaction even without severe anatomic disease of the liver.
8. The absence of the aldehyde reaction in the urine in a case of
demonstrable disease of the liver is a remarkable finding; but it may
never be used as an argument against disease of the liver. To what ex-
tent an affection of the liver gives rise to urobilinogenuria will depend on
the degree of intrahepatic biliary congestion produced b}^ the process.
9. As in all qualitative tests, the result of the aldeh3^de reaction
should have reference to the specific gravity and the daily quantity of
urine. In case of poh'uria with low specific gravity a negative finding
is correspondingly less weighty, w^hilst a positive finding is correspond-
ingly more weighty.
SYMPTOMATOLOGY OF CACHEXIA AND GENERAL
SYMPTOMS
The name "Cachexia" (from the Greek "y.ay.o;," bad, and "I^t;,"
to be or to behave), which in and of itself means little, ought to he used
in those cases only where there is a combination of general symptoms,
namely, the trio : emaciation, adynamia and an unhealthy color of the
face.
With this definite limitation, cachexia, even in its early stages, be-
*^ Appearance of a strong aldehyde reaction was occasionally observed by me in
cases of pregnancy. In view of the frequency of postpuerperal cholelithiasis it would
be very desirable to institute repeated tests with the aldehyde reaction during the
course of pregnancy.
38 TUMORS OF THE ABDOMINAL VISCERA
comes a directly valuable symptom, particularly in the diagnosis of ab-
dominal neoplasms, since its limitations are logically essentially narrower
than that of its component factors. These latter will now be discussed
separately as to their significance in differential diagnosis.
1. Emaciation
Emaciation
Whenever a malignant abdominal process enters the diagnostic field,
the anamnesis and continued observation will keep sharply in view the
body- weight. Occasionally those surrounding the patient have noticed
the falling in of the cheeks, prominence of the zygomatic arches, and the
"pointed" appearance; the patient himself, who formerly had a "belly,"
notes the looseness of his trousers and vest, women call attention to the
fact that their arms are becoming thinner, that their corsets close more
easily. Rings that former!}' fitted snugly have become loose.
Thus we can by retrospection inform ourselves with much certainty
in regard to emaciation, that is, the loss of flesh and, later on, of muscle
tissue, providing the patients do not present themselves with the precise
figures of their weight.
Weighing
During subsequent observation it will bo of the greatest importance
to watch the body-w^eight at intervals of one to two weeks, using a re-
liable scale (Sanatorium, Apothecary's, etc.).
Urinary analysis cannot in the least compare in practical significance
with the clear and simple speech of the scales. Aside from the fact that
the urinary analyses, as a rule, cover a period of only twenty-four hours,
and do not take into consideration the loss of flesh, the figures of the
usual urinary analysis are therefore very problematical, as the X-content
of the food and the N-output in the feces is mostly disregarded.
The symptom of emaciation ought always to be considered in relation
to the physical and ps^^chical personality of the patient.
Mind and Emaciation
There exist intimate relations between mind and body-weight. In
the case of neuropathic individuals great caution should be observed in
appraising the symptoms of emaciation.
We arc all aware of the considerable and rapid loss of weight in pa-
tients suffering from progressive paralysis, melancholia, mania, etc. But
even patients afflicted with simple "irritable weakness" may show signs of
failing in weight, and under the influence of exciting and depressing
mental affections there may result considerable losses in weight in a
short time, which losses disappear with the cessation of the causative
factors, so that if we were to represent this condition by curves we would
get a sharp incline following a sharp decline. Occasionally, however, it
may happen that following such a neurotic crisis in weight there ensues
a permanent decrease in the body-weight.
Thus I saw a patient in July, 1905, whose weight up to a short time
SYMPTOMATOLOGY OF CACHEXIA 39
previous luul been 111 kg-; ho luid lost J30 kg; his attending physicians
tlioiight of curcinonia of the pancreas.
Only recently, iVIay, 1910, I saw the patient again; aside from neu-
rasthenic complaint and arteriosclerosis, he is perfectly well, but his
weight has permanently come down to 74 kg.
Such cases will the more easily awaken the suspicion of malignant
abdominal disease if, as is frequently the case with neurotics, there are at
the same time gastro-intestinal symptoms, such as anorexia, gastralgia,
etc. In these cases the cause of the emaciation frequently lies in under-
nutrition, be it because the patient restricts his diet and makes it mo-
notonous for fear of trouble, or because he has had prescribed for him
by his physician a very restricted diet on the strength of the erroneous
diagnosis of gastric ulcer. On account of under-nutrition, however, the
"irritable weakness" of the nervous system increases, and this condition
gives rise to the symptoms which complete the vicious circle.
In such cases a single examination often makes it really difficult to ex-
clude malignant disease, and if the patient notices any such suspicion
from the actions of the physician or his own surroundings, then the basis
for a new aggravation of his general nervous condition is established.
Here it is often most desirable to simply ask "therapeutic questions."
After occult hemorrhages have been ruled out, the patient should be
treated as a neurasthenic, he should be told to abstain from work and be
removed from his uneasy surroundings ; place him in a favorable climate
and on a favorable diet, discontinue the solicitous regime of diet, and
frequently in two to three weeks the patient will be on the road to
recovery.
Hence, in making estimation of the diagnostic value of the symptom
of emaciation the state of the mind and immediate circumstances, sucTi
as care, excitement, etc., deserve full consideration.
The more forceful the personality, the smaller will be the chances for
unpleasant psychic emotions, and the greater will have to be the valua-
tion of emaciation existing in a given case.
The psychical side of the patient's personality is to be considered,
especially in so far as it is not indifferent whether the supposed malig-
nant disease is lodged in an individual with little, or in one with much,
adipose tissue. In the latter case emaciation is more conspicuous and
is made much more explicit by actual figures.
Accordingly, the initial losses in weight are often more considerable;
if the body-weight has already dropped very much, it usually diminishes,
not suddenly but gradually.
Increase in Weight
Here I may note with emphasis that weight increases not due to mere
retention of fluids such as take place in hydrops or anasarca, but real
increases from the addition of fat and muscle tissue may occasionall}'
be observed in the course of malignant diseases of the abdomen. This
can be easily understood if one keeps in view the general pathogenesis
of emaciation in malignant diseases.
40 TUMORS OF THE ABDOMINAL VISCERA
Pathogenesis of Emaciation
In the vast majority of cases the pathogenesis ultimately rests on
disturbances in assimilation, which in their turn depend in a large measure
on disorders of "external" digestion in the gastro-intestinal tract. In
almost all cases of emaciation macroscopic or microscopic examination
reveals the fact that the food has been but poorly used up, there being
present an abundance of muscle fibres, soaps, neutral fat, etc. The fre-
quent worrying losses in weight that occur with benignant forms of jaun-
dice are remarkable.
The influence on "internal digestion," which undoubtedly is at the
bottom of the emaciation in certain forms of diabetes mellitus, and which
is employed in accounting for the emaciation that follows administration
of thyroid gland substance, acute infectious diseases, etc., could hardly
be considered as playing a real part in cancerous diseases.
Whoever has observed even once how rapidly the weight increases
after a simple gastro-enterostomy in cases of stenosing pyloric cancers —
without removing the neoplasm — will hardly venture to ascribe the pre-
ceding emaciation to hypothetical cancer toxins.
Even otherwise it is not difficult to realize that the emaciation de-
pends above all on the relation of the new growth to the digestive tract.
Tims it happens that occasionally cancer of the uterus, breasts, kidneys,
etc., run along with the external appearance of blooming health.
And from this point of view it can be well comprehended why within
the digestive tract carcinoma of the rectum most frequently is accom-
panied by a good state of nutrition.
Besides direct local functional disturbance and its general effects on
the entire digestive tract, it is found that precisely with malignant new-
growths inside of the chylef active system it is largely the ulcerative
process which considerably hastens the process of emaciation through
chronic loss of body fluids, absorption of rotten disintegrated tissue mat-
ter and septic infections.
Excluding a specific toxic cause of emaciation, after what has been
said it must at once become apparent that even in cases of malignant
new-growths increases in weight can be brought about in such cases
where rest — rest in bed — takes the place of occupational exertion, be it
physical or mental, where a suitable dietetic regime is chosen and where
the effort is made to readjust functional disturbances by physical and
medicinal means.
However, it must be emphasized that these gains in weight stay Avithin
moderate limits and mostly represent a rapidly transient occurrence.
2. Color of the Face and Pigment Anomalies
Among the integral distinguishing signs of the cachexia found in con-
nection with malignant neoplasms we count alterations in the color of the
face, which, at times, are the first indication of a malignant disease.
Before all, we should give consideration to the "teint paille jaune,"
that light yellow discoloration of the face which is perhaps most fre-
SYMPTOMATOLOGY OF CACHEXIA 41
quently found with cancer of the stomach. Despite its yellow tint, it
has not the least in common with icterus, and in numerous cases in which
I examined the urine I found neither bilirubin nor urobilinogen. It is
possible that we are here dealing with a deposit of some derivative from
the blood coloring matter similar to deposits not infrequently found in
internal organs in connection with various dyscrasias.'
While, on the one hand, this "straw-colored" tint in question is found
in only a small percentage of malignant neoplasms, we also find it with
non-malignant processes, as in severe cases of tuberculosis, chronic puru-
lent conditions, and especially in processes that incline to amyloidosis.
The complexion, in pernicious anemia, too offen is in perfect accord with
the above. In spite of this, it would be wrong to look for the cause of
this peculiar color in the physical changes of the blood only, since car-
cinoma, with "straw-colored" face discoloration, often yields almost nor-
mal blood findings. Chloranemic findings also are not rare. Ulcerating
gastro-intestinal carcinomata probably most often lead to the peculiar
complexion in question.
Paleness
The already mentioned incongruity between the complexion and
blood findings applies also to those more frequent cases of malignant tu-
mors, which are accompanied by a light-gray paleness of the countenance.
In these cases the blood picture shows nearly normal conditions, par-
ticularly as far as the coloring power of the blood is concerned.
In cases of this kind, w^eakness of the peripheral circulation ^"^ might
be looked upon as the cause of facial paleness, similarly in some cases of
asthenic constitution and certain forms of arteriosclerosis (lues!) and
in tabes. The acute peripheral circulatory weakness and poor per-
meability of the blood in fainting spells has, to a certain extent, been
permanently explained.
As the color of the face is an integral component part of the con-
stitutional peculiarity of every individual, and as already mentioned, cer-
tain constitutions are noted for their pale countenances even when in
perfect health, the anamnesis will have to allow for this fact when there
is suspicion of cancer. In most cases, the women-folk will be able to
offer the best information in regard to any changes in the appearance of
the patient.
This individual characteristic also deserves consideration, in so far as
certain individuals, especially those of asthenic neuropathic constitu-
tions, who are frail of countenance and who easily collapse, are concerned.
On the contrary, there are powerful constitutions inclined to plethora,
that occasionally show a healthy red color of the face, even with ad-
vanced malignant disease.
The cachectic color of the face seems to be absent most frequently in
cases of non-ulcerating neoplasms, such as primary cancer of the liver,
melanocarcinoma, carcinoma of the pancreas, etc.
^ « — ■ — — — — - —
" In this respect, regard must be had for the capillary dilatations so frequently
seen on the cheeks 'of cancer patients and probably due to arteriosclerosis.
42 TUMORS OF THE ABDOMINAL MSCERA
Figment Anomalies
With the color of the face, peculiar to individuals, there sometimes
are associated other pigment anomalies of the skin, especially Addison-
like discolorations. In these cases we must be on our guard against a
too hasty diagnosis of suprarenal disease, be it primary or secondary.
Whoever has in mind to demonstrate a lesion of the suprarenal bodies at
autopsy may often succeed, in so far as metastases in these organs, cal-
lous induration of same, etc., are not rare in connection with malignant
new-growths of the abdomen. Yet we often enough find these pigmenta-
tions when the suprarenals are completely intact. There are three sepa-
rate possibilities that must be considered here:
a. The pigmentations similar to Addison discoloration, at times seg-
mentall}'' arranged on the trunk alongside of depigmented areas, are pre-
existent, and date back many years, even as far as childhood. As in
pernicious anemia, so also with malignant neoplasms, they are to be
considered as a constitutional stigma. In most of these cases we are
dealing with asthenic constitutions, and in some families such occurrences
are frequently observed.
b. The pigmentations may be synchronous with the development of
carcinoma, and are to be looked at as a hemochromatosis of Reckling-
hausen. Its appearance seems to be favored by an abundance of pigment
in dark-haired individuals, with darkly pigmented iris and dark com-
plexion, as well as by factors which in and of themselves induce hyper-
pigmentation, such as strong sunlight when working in the fields, etc.
Carcinoma of the pancreas is among the neoplasms most frequently
accompanied by pigmentation of the skin.
To this group there probably also belong those skin discolorations
occasionally observed in severe pulmonary tuberculosis or in splenomegaly
as a result of chronic splenic tuberculosis, in which cases we may be in-
clined to agree with v. Netisser in assuming toxic injuries to the sympa-
thetic nervous system as being the cause.
c. With combined high urobilinogen content in the urine, as, for in-
stance, in liver metastases and cirrhotic complication, it would be proper
to take into consideration whether the hyperpigmentation of the skin
might not, at least in part, have some connection with the rich urobili-
noe-en content of the tissue fluids.
3. Adynamia
Adynamia
All other things being equal, this symptom will appear earlier and
more pronouncedly in asthenic constitutions and vice versa manifest
itself late in stronger constitutions. In man^' cases it will be judicious to
make a functional test by trying out the patient's ability to perform
certain regulated amounts of work. ,
Adynamia shows itself, for that matter, not only in general fatigue
but also in a lowering of circulatory force.
SYMPTOMATOLOGY OF CACHEXIA 43
Edema
This at least is one of the M^ays in which the occurrence of edemas
comes about, and these — after exchision of cardioreual disease — become
of considerable diagnostic import.
\yhenever there is suspicion of malignant neoplasm of the abdomen,
one should never neglect to examine the space behind the internal mal-
leolus b}' making pressure on it with the finger. In malignant disease
edema is often encountered in this place, even though the tibias are
entirely free from it.
Examination over the os sacrum is equally important — especially in
bedridden patients in whom mild edemas around the ankles easily dis-
appear.
Latent Edema
Latent edemas, such as have disappeared with rest in bed or such as
have not yet made their appeai-ance, may, according to my own observa-
tions, be elicited by means of a hot foot-bath.
We can find all stages of transition from dropsical swellings of high
degree that appear early, and present the picture of a severe parenchy-
matous nephritis, to the other extreme, namely, that of mummification.
In one place shrinkage, in the other swelling.
In general, it may be said that soft, strongly ulcerating and bleeding
neoplasms, like medullary cancer of the stomach, lymphosarcoma of the
small intestine, etc., frequently lead to severe dropsies.
With fibrous forms of carcinoma (gall-bladder, pylorus, etc.),
edemas are, from general causes, much less frequent, and stomach can-
cers which, on account of severe pyloric stenosis or diffuse contraction of
the stomach, cause frequent vomiting, at times lead to progressive exsic-
cation of the tissues.
In this edema and ascites may again disappear.
In no case and in no stage might the absence of edema be construed
as an argument against a malignant growth ; so it happens that occa-
sionally enormous liver metastases run their course without even a trace
of edema.
It is certain also that in these combinations the individual peculiari-
ties of the skin and the subcutaneous connective tissue play a part. The
softer and more succulent the skin, the easier there will occur in it ac-
cumulations of fluid; the tenser and dryer it is (extremes of this would
be cases of congenital icthyosis), the less will be the tendency to edema-
tous swellings.
Congestion from Local Causes
Besides the edemas due to general weakness of the peripheral circu-
lation, or to a general dyscrasia, there also frequently exist in cases of
abdominal neoplasms local causes for dropsical engorgement, and they
give rise mostly to edema of one leg, hence dii*ect compression of the
venous trunks, thrombosis and rupture into the venous channel.
44. TUMORS OF THE ABDOMINAL VISCERA
Body Temperature
Variations from the normal temperature of the body are to be met
with frequently in connection with abdominal neoplasms.
As far as subnormal tempei*atures of 36° C, and even less, are con-
cerned, they are of little diagnostic interest, since they are only a par-
tial expression of the general cachectic lowering of the vital energy.
Far more interest attaches to elevations in body temperature, though,
generally speaking, the lowest level of the fever curve in cachectic sub-
jects naturally possesses lower diagnostic value. Personally, I do not
consider that it has been proved that there is a specific fever, i.e., a fever
emanating from the activity of the tumor cells.
The frequency scale of febrile phenomena, with reference to the type
and seat of the neoplasm, favors the view, that we are dealing with a
secondary infection. ^^
Thus medullary ulcerating forms of gall-bladder cancer, not infre-
quently, run their course with fever, at times accompanied by herpes
and a mild diazo reaction ; the same is true of duodenal carcinoma with
which ascending infections of the bile-passages can easily take place.
Cholecystitis and cholangitis or cholangitic abscesses are the original un-
derlying factors of the fever that is seen with intra-hepatic malignant
processes.
In ulcerating forms also of stomach and bowel cancer there is plen-
tiful access for the exciting agents of infection and, indeed, it is sur-
prising that febrile temperature-rises occur singly and sporadically, and
are of such mild degree.
Here, also, we are concerned with complications such as perigastric,
subphrenic or pericolitic purulent foci, especially when the febrile move-
ments continue over a longer period of time.
Complicating infectious processes may thus occur and give rise to
chills, which, however, are mostly isolated, or follow each other at longer
and irregular intervals.
When they are accompanied by severe collapse, there will always en-
ter into serious diagnostic consideration the possibility of a beginning
peritonitis due to perforation. Aside from this, chills may; according to
my own observation, result from internal hemorrhage in cases of car-
cinoma of the stomach.
If the febrile rises in temperature are accompanied by night-sweats,
which occasionally is the case in connection wdth malignant abdominal
tumors, there might arise the false suspicion of a tubercular process,
especially when supported by an occasional diazo reaction.
From what has been said we may deduce two diagnostic rules which
are not unimportant :
1. With obscure febrile conditions in older individuals the possibility
of malignant new-growths, especially of the gastro-intestinal tract, should
not be forgotten.
*"' In regard to similar and opposite \iews, see F. Fromme, Deutsche med. W.,
1907, No. 14; A. Alexander, Deutsche med. W., 1907, No. 5.
ETIOLOGY OF MALIGNANT TUMORS 45
2. In the diagnosis of cases that give the suspicion of stomach or
intestinal cancer, do not fail to give attention to the behavior of the
bod>^ temperature ; in the differential diagnosis from chronic catarrhal
conditions elevations in temperature may occasionally merit serious con-
sideration and, under circumstances, may argue in favor of a malignant
ulcerative process.
ETIOLOGY OF MALIGNANT TUMORS
In their ultimate causes all processes of growth are traced back to,
and become merged with, the problem of life itself, and will therefore re-
main problematic to scientific research which is based on sensible per-
ception ; indeed, when considered with reference to their final causes they
are no longer a problem of natural science but of metaphysics.
It is a psychologically easily explainable characteristic of etiological
research that in dealing with disease processes there is a tendency to trace
a morbid condition to one single cause, as in ctiologically tracing syphilis
we justly lay it to the entrance of the spirocheta pallida of SchaiuVinn.
This tendency was nurtured above all by the brilliant results of bac-
teriological research and its establishment of specific causes for disease,
without the effects of which a given disease is not conceivable. If ever
such an interpretation of a single cause can claim practical title it cer-
tainly can do so in the realm of infectious diseases.
Yet, even in this domain the conviction is always gaining more ground
that, in a pathological occurrence, besides the one specific cause, i.e., the
infectious excitant, many other factors, e.g., of a constitvitional type,
come into play.
In a philosophical sense there is really no uniform cause of a "hap-
pening," every cause being at the same time an effect.
Though such foresightedness in every single case would be imma-
terial and useless, I feel justified in warning against the other extreme of
too great nearsightedness.
Three factors are especially significant in the causative perception of
disease processes :
1. That more frequently they do not have specific causes than that
they do have them.
2. That the causes decidedly do not always correspond to the pres-
ent time of the pathological process, but occasionalh^ date very far back,
as the single individual is nothing exclusive in himself, but, merely rep-
resents the latest link in the chain of his ancestors.
3. That accordingly the causes of disease, or at least a part of them,
ought not always to be sought after in the external world, but in many
ways also in the internal world of living matter.
4. That strict distinction is to be made between a specific cause of
disease, without which the disease process in question is inconceivable,
and non-specific causative factors, which at times may act against and
represent one another and very often prodifce effects only through being
combined in manifold groupings. *
46 TUMORS OF THE ABDOMINAL VISCERA
As pathological processes of cell-proliferation, at least in their ele-
mentary causes, certainly have points of contact amongst themselves
as well as with physiological processes of growth, a consideration of
them in these wider limits can only favor an understanding of the genesis
of malignant processes of growth.
Ovum
That which, to us, is the greatest riddle in this domain, is quite self-
evident — the development of the ovum, according to a definite plan, into
a completed organism after fecundation by the spermatozoon.
If the spermatozoon be here considered as the cause of the l>egin-
ning cell-proliferation one will be satisfied that it is a cause which cannot
measure up with the effect, since, doubtless, the ovum possesses an innate
force which as a cause comes much more into consideration.
An infinitely complicated machinery which, as if through removal of
some restraint, runs along as if conscious of its destination.
Fecundation Theory of Klehs
and Others
The physiological example of the fecundated ovum has led to the
fantastic cancer theory of Klehs — a theory now largely forsaken —
according to wliich epitlielial cells are fecundated by the entrance of
leucocytes.
Full consideration is due the enormous power of division belonging to
the ovum, and which, as an elementary property, is transmitted to the
descendant cells in varying degree and according to the need for cell-
replacement.
Internal Secretion Groivth
Very remarkable are the manifold relations of glands with internal
secretion and processes of cell-multiplication and cell-growth.
The shedding and growths of horns in cervides, the enlargement of
the breasts during pregnancy, the changes in acromegaly, etc., are
throughout processes of growth which are undoubtedly at least elicited
by the entry of certain products of internal secretion into the circula-
tion, since here also we can assume as cause a latent proliferative ability
residing in the growing cells themselves, and that in accordance with a
definite plan of construction. Here, also, belong the relations of the
thyroid gland to the skeletal system.
Diatheses
This group of observations seems to me to caution against denying
a priori that the development of neoplastic processes is influenced by
eventual alterations in the bulk of body fluids giving rise to certain
diatheses (gout, diabetes, etc.).
The gross errors of the old humoral pathology in regard to the gene-
sis of cancer have led to a inaction which in its denial of the influences
of dyscrasias probably goes beyond the bounds of truth.
ETIOLOGY OF MALIGNANT TUMORS 47
Exogenous Injuries Exciting
Inflammation
Moreover, all those chiefly exogenous injuries which are al^le to excite
inflannnation have an influence in eliciting cell-proliferation.
Beginning with the mechanical injury of a pressing shoe, and pass-
ing (iver soot, paraffin, etc., to the spirocheta pallida of Schaudinn and
the X-rays, there is an infinite number of special causes. This group of
biological irritants is undoubtedly most intimately related to the genesis
of cancer, even if they are not considered as specific causes, and their
operation in eliciting malignant cell-proliferations can be assumed only
through their combination with other causative factors, particularly
those of an endogenous nature. Finally, Ave nuist be mindful of those
processes of growth which result from increased functional demands, as
when a muscle is made to do more work.
In the formation of an opinion as to the genesis of malignant tumors
two points of view seem to me very worthy of note.
1. The circumstance that malignancy in many ways is, as it were,
superimposed on a benign tumor. Therefore, it will hardly do to pre-
sume that there are totally different kinds of origin for benignant and
malignant new-grow'ths, hence, also, the study of tumor-formations with
reference to the etiology should really begin with the benignant forms
which frequently are the first steps of the malignant ones.
2. The probability of a tumor theory must rest on the hypothesis
that it does not apply to epithelial grow^ths alone, but will also be able
to explain the malignant connective-tissue growths, the more so, as even
here transitions seem to occur.
Comparable to a nihilistic attempt against the stability of the state,
malignant tumors offer occasion :
1. To deal with the person who makes the attempt, that is, definite
cell-groups or areas of organs from which the growth originates, and,
furthermore :
2. To search for those influences which led to the attempt, at times
converting a normal citizen into a pathological criminal.
I. Cell Disposition •
CeU Disposition
Cohnheim's Theo ry
Many of the theories that endeavor to explain the genesis of ma-
lignant new-growths, really limit themselves to making plausible some
local cell disposition, thus, especially, Cohnheim-'s theory of embryonic
displacement of cells.
Resuming the former comparison: The nihilistic criminal probably
is bom a criminal, he is a degenerated individual abnormally disposed
from his birth.
48 TUMORS OF THE ABDOMINAL VISCERA
Similarly, we are inclined to consider those cell-groups, from which
malignant new-growths are developed, as being abnormally disposed from
the start, having remained and become degenerated in an earlier stage of
development ; still, it is also possible that long-continued external in-
juries, through their influence, may generate a state of depravity, and
that the more easily, of course, when they find their point of attack in
individual cells which are ali-ead^^ abnormal or which were originally of
low grade and little differentiated.
There is no doubt that, as far as the origin of certain malignant new-
growths is concerned, we are actually dealing with displaced embryonal
cells. This is particularly true of the kidney tumors of Grawitz, der-
moids, certain retroperitoneal swelling formations, emanating from rests
of the Wolffian bodies, etc.
Precisely this group of malignant neoplasms are the most striking
argument against the parasitic theory of cancer genesis. ^"^ We are to
believe that the cancer excitants, as if by selection, will produce their
effects from the blood-current and leave intact all other tissue-cells.
Even here, for that matter — with reference to the displaced cells —
we are not dealing with a sine qua non, with no essential or even specific
cause. Otherwise, for instance, it would be entirely inconceivable why
carcinoma of the small intestine should be so extremely rare in compari-
son to carcinoma of the stomach, as if scarcely any displaced cells should
be at hand. Perhaps, there is hardly an individual who does not have
somewhere in his anatomy embryonic displaced cell-masses (n.-Evi, etc.).
This point alone is therefore surely not a sufficient explanation.
Cohnheim's theory probably rests upon the consideration that it is
difficult to imagine how highly differentiated cells can sink to such a low
biological state and become so estranged from the entire organism, as is
true of the anarchistic malignant tumor-cells.
One way to evade this difficulty would be by assuming that the tumor
does not originate from the fully differentiated cells but from germinal
centres {Schaper's Indifference Zones),'*" which are composed of cells that
are imperfectly differentiated and approaching more the embryonic
state.
Rihhert's Theory
Equally unsatisfactory is Ribherfs theory of post-fetal epithelial
displacements brought about b3' chronic inflammation in connective tissue.
It must jcertainly be granted that cell-masses thus injured and grow-
ing under abnormal conditions of life may occasionally become the point
of origin of new-growths. The disposition of the cells to malignancy
may in some cases be in part actually conditioned by their topographical
and functional separation from the normal cell-connection.
Certainly there is justification for the theory — and it is supported
^^See: Umfrage iiber Aetiologie des Carcinoma, Med. Klinik, 1905, page 409, 496,
544. Aiisserungen von L. Aschoff, E. Ziegler, Marchand.
" Schaper and Cohen, Beitrage zur Anatomic des tierischen Wachstums. Arch. f.
Entwickelungsmechanik, XIX, 3, 1905.
ETIOLOGY OF MALIGNANT TUMORS 49
bj histological findings — that without such anatomical displacement
chronic irritation may lead to a loss of higher cell-functions, may pro-
duce a disturbance in the functional equilibrium of the cell, and thus
bring about the appearance of the most original function of the cell,
namely, its ability to divide.
Hansemann's Anaplasia
In his doctrine of "anaplasia" of cancer-cells, v. Hansemann has tried
partly to furnish anatomical foundation for this view of cell-depravity.
II. Etiology in its Narrower Sense
Etiolorjy in Its Narrower Sense
As all probability seems to point against the assumption of a specific
cause in the nature of a microbe for malignant neoplasms, the causative
relations Avill have to be investigated from case to case.
Here, then, we will again have to consider (a) endogenous factors as
well as (b) exogenous irritants. ,
a. Endogenous Causes
Endogenous Causes
Changes in the organism due to age count among the most apparent
factors in this domain. Even though malignant proliferative processes
may occur congenitally or take place during the years of development,
their relations to a more mature age are well knowTi and justify our
speaking of cancer as a disease of advanced years. This is a peculiarity
which does not apply to a single one of the many known infectious
processes and therefore serves as another argument against the parasitic
theory of cancer.
Age
Of what kind arc the elementary relations between age and malignant
new- growths ?
Disturbances in the plan of construction which from the constant
changing of cells can be assumed to exist also in post-embryonic life,
are surely conceivable in view of the unequally rapid aging of the differ-
ent tissues, e.g., epithelium and connective tissue. On this is based the
theory of Thiersch, who supposes a disturbance of the static equilibrium
between epithelium and stroma as a predisposing factor in the develop-
ment of cancer.
It may also seem exceedingly plausible to assume that in more ad-
vanced age, under the influence of local circulatory disturbance, cell-
complexes may at times degenerate, thereby losing their higher charac-
teristic properties, and instead there comes to the fore, unhindered, a
tendency — corresponding to an elementary function — to multiply, be-
ing, as it w^ere, an "irritable weakness."
But also alterations in the metabolic processes of the entire organism
enter into consideration.
50 TUMORS OF THE ABDOMINAL VISCERA
Be that as it may, changes in age undoubtedly figure as a causative
factor in the genesis of carcinomatous new-growths in particular. Ma-
lignant proliferative changes here go hand in hand with benign ones,
especially so in the aging skin, and point to a common causative source.
Attention may here be called to those tiny angiomatous formations
of the skin, which, as a general thing, first appear more numei'ousl}- in
old age and have been pointed out, erroneously, as marks of malignant
new formations.^* Still, it is a remarkable fact that in advanced years
the skin does incline to manifold benign proliferative processes.
Constitution and Cancer of the Stomach
With reference to constitutional peculiarity, I would like to sum-
marize my own personal views, at least so far as the most frequent in-
ternal neoplasm — cancer of the stomach — is concerned. 1. As far as
cases in advanced age are concerned they are mostly individuals of very
robust constitution, who were "never sick," have had but little if any in-
fectious disease, have never been troubled with disturbances of digestion,
and, in most instances, come from very healthy, long-lived parents. They
are, in many ways, individuals in whose cases one would be tempted to
speak of "excessive well being," which, for that matter, may amount to a
cause, owing to the fact that such persons are able to expose themselves
much more to dietetic indiscriminations witliout liarmful results for a long
time. 2. As far as younger people arc concerned, say those between 30
and 40 years, the reverse is true, the patients frequently being individ-
uals inclined to weakness, and having a general aspect that is decidedly
phthisical, pallor of the face, etc. This is particularly true of individ-
uals becoming afflicted with U'mpho-sarcomatous processes.
Heredity
Any typical findings amongst relations and ancestral lines are en-
tirely out of the question. Longevity and health of the parents I con-
sider the most common. In group number 2, Ave do indeed not infre-
quently find tuberculosis among ancestors, and individuals with healed
tubercular foci are predisposed to cancer in a somewhat higher degree.
Personally, I do not consider transmission in a similar sense, at least, as
far as gastric cancer is concerned, to be of frequent occurrence. Yet,
many an ancestral tree that has been studied, scarcely leaves room for
doubting the possibility of direct transmission.'*'*
Here we may dismiss the notion that gastric cancer, as such, is trans-
missible. It would seem, however, that functional debility of an organ
(weak stomach, varicose veins, hemorrhoids, etc.), are hereditary in some
families, and this certainly holds good also of constitutional anomalies
of dyscrasia, such as gout, diabetes, etc.
It must also be borne in mind that certain neoplasms are especially
frequent, this being true of cancer of the stomach; so if the patient shows
*'^ Leser, Munchener Med. Wochenschr., 1901, No. 51.
■"See: ,/. Wolff. Die Lehre von der Krebskrankheit, u.s.w. 1907, page 361.
Verlag von Gustav Fischer.
ETIOLOGY OF MALIGNANT TUMORS 51
a disposition to nialij[>iiant disease, the probable chance of affecting one
of the more fretjuent phices, e.g., the stomach, are in, and of themselves,
very great.
Diatheses
Diatheses, as met with in cases of gout, diabetes, and constitutional
adiposity, seem to be of especially frequent occurrence among the ances-
tors and relatives of cancer patients.
But, even in cancer patients themselves, it is not altogether too rare
that we meet with the anomalies of metabolism just referred to.''"
Uratic Diathesis
Personally, I hold that rheumatic antecedents in all stages up to
genuine gout are of very frequent occurrence. It seems remarkable to
me that those previously mentioned small angiomatous formations of the
skin in my experience frequently coincide in large numbers with a uratic
diathesis. It is quite conceivable that alterations in the body fluids
might stimulate growth of cells predisposed thereto, or unfavorably in-
fluence causatively considered chronic inflammatory processes of the
mucous membranes, preventing their cure.
It is possible that a chemical irritant, taken in with drinking-water
and exerting its influences by way of the body fluids, might be at the bot-
tom of adenomatous formations in endemic goitre. Attention might also
be called to the relations of diabetes to xanthomatous tumor formations.
Internal Traumas
Long-combined internal traumas, produced by an abnormal mixture
of different body fluids, seem to me exceedingly worthy of attention as
predisposing causes of malignant cell-proliferations.
The objection that this would have to lead to numerous multiple
growths falls flat. As in other instances, a dyscrasia can confine itself to
one locality (e.g., isolated affection of the large toe- joint in gout). Aside
from that, we are here dealing, as already mentioned, with only an occa-
sional cause which presupposes the existence of other local causes in com-
bination with which alone it becomes effective.
With such extensive limitations it seems to me that the dyscrasia doc-
trine of Rokitansky and others was not entirely erroneous. The notion
of "internal cell-injuries" due to abnormal body fluids will be forced upon
us in those cases, for instance, where in the same individual there is a
multiple occurrence of benign and malignant tumors which are entii-ely
independent of each other, or where malignant proliferative processes
occur in different parts of the same system (lymphatic and myeloid sys-
tems, both ovaries, both suprarenal bodies, etc.).
Cirrhosis of the Liver
Furthermore, attention seems to be due the relations between cir-
rhotic processes and such as develop outside of the liver, e.g., intestinal
■"See: Boas, Uber Carcinom und Diabetes. Berliner Klin. Wochenschr., 1903,
page 243.
52 TUMORS OF THE ABDOMINAL VISCERA
carclnomata. Aside from some dyscrasia resulting from restricted func-
tions of the liver we would here also have to consider local congestion as
a favoring factor.
Climatic Injuries
In numerous articles it is proven that conditions of the soil may,
under circumstances, cause the frequency of cancer cases. This is said
to be true of clay and mud soils, of the location of dwellings along streams
where frequent inundations take place, of damp houses, etc.
Opposed to this it seems that in dry, hot countries, malignant new-
growths are rare — such is the claim made for Tunis and Algiers. The
first-mentioned influences are decidedly calculated, through their interfer-
ence with the function of the skin, to induce and promote disturbances in
the nature of a dyscrasia such as "rheumatic" diathesis, and it appears to
me personally the kind of a connecting link that is far more probable
than the conclusion which is usually drawn from it as to the presence of
a specific cancer parasite.
Mind
If trouble and worry — psychical factors — are at times jointly ac-
cused, it seems to me deserving of note that these are influences which
may ultimately lead to a retardation and. alteration of metabolism.
Thus our forefathers looked upon a phlegmatic temperament as one
of the causes of cancer. Temperament and metabolism may indeed bear
relations to each other as far as changes are concerned.
Whoever looks at constitutional and dyscrasic factors as a partial
cause, at least in some cases, will not permit infectious processes to pass
unheeded, since they are capable of imparting to the body fluids a last-
ing characteristic (agglutination phenomena, Wassermann reaction), and
may certainly lead to an alteration of the entire organism, as is demon-
strated in cases where persons have only once passed through a certain
infectious disease, especially in childhood.
An analysis of my observations along this line ^^ has convinced me
that in a conspicuously large percentage of cases the past history of can-
cer patients very rarely or never discloses any infectious diseases, and
this is true principally of the infectious diseases of childhood.
"Never was sick" is the surprisingly frequent response often elicited
from cancer patients who are far advanced in age.
Should this observation of mine be bonie out later on, and I am in-
clined to think it will, then I can see only two explanations.
1. Attacks of infectious diseases, especially infectious diseases of
childhood, afl'ord a certain protection against subsequent disease from
malignant neoplasms. From this there would follow a mighty prophylac-
tic perspective. Or
2. Individuals, whose congenital constitutions later on incline to ma-
lignant neoplasms, have a certain immunity particularly against infec-
tious diseases of childhood.
" Krebs und Infektionserkrankungen. Med. Kllnik, 1910.
ETIOLOGY OF MALIGNANT TUMORS 53
Cancer and Tuberculosis
Since Rokitansky promulgated his theory of antagonism between can-
cer and tuberculosis, basing his opinions on dyscrasias, numerous works
have been written on this theme. I would like to sum up my own opinions
by saying that individuals with well-developed progressing tuberculosis
of the lungs are extremely unlikely to have carcinoma. On the contrary,
healed apical lesions and other stationary healed tubercular processes,
or such as incline to healing, especially those of glands and bones, are
decidedly not rare in cancerous patients.
Lues
In regard to the fi-equenc}' of lues in the past history of cancer pa-
tients there is no agreement. My personal impression is that so far as
the clinical study of malignant neoplasms is concerned luetic antecedents
are not frequent.
b. Exogenous Local Causes
Exogenous Local Causes
The presence of concretions in the gall-bladder figures among the
best known local causes of malignant proliferative processes.
Gail-Stones
All statistical observations agree in this respect that in the vast ma-
jority of cases the development of cancer in the gall-bladder coincides
with the presence of concretions. That the latter are pre-existent is ap-
parent in many cases from the data of the past history. Whether we
are here concerned with a purely traumatic irritant must remain an open
question. In this connection there may enter into consideration the
chemical composition of bile and preceding chronic inflammatory
processes of the gall-bladder mucosa.
Gastric Ulcer
With reference to the much-discussed relations between gastric ulcer
and cancer of the stomach I take the personal stand that in only a small
percentage of cases does cancer of the stomach become superimposed on
a gastric ulcer, but not seldom during the course and even in the begin-
ning of a malignant process ulcer-like defects develop in the mucous mem-
brane of the stomach, and it seems that A'cry often these have led to the
anatomical diagnosis of "cancer on an ulcerated base." ^^
In many such cases which I saw on the operating table a most exact
anamnesis had not furnished the least ground on which to assume a pre-
existing ulcer.
Mechanical Traumas
Mechanical traumas in and of themselves, without simultaneous chemi-
cal irritants, could hardly ever be a causative factor of any importance,
and least of all when there is question of but a single acute trauma.
^''See: Hauer, Uber Magengeschwiire unci Carcinom. Miinchener med. Wochen-
schr., 1910, No. 23.
54- TUMORS OF THE ABDOMINAL VISCERA
Chemical Irritants
Long-combined chemical irritants are undoubtedly more significant.
As far as the skin is concerned their causative effect displays itself in
manifold plastic ways, the epitheliomas observed in chimney-sweeps, tar
and paraffin workers being classic witnesses.
The application of such observations to the mucous membranes of
the alimentary tract is obvious. There is hardly a doubt that cancer of
the esophagus occasionally stands in some relation with imbibition of
whiskey, which explains its prevalence in male individuals.
The particular frequency of rectal carcinoma is probabl}' explained
by the especially favorable conditions for mechanical and chemical in-
juries.
Here, also, the previously mentioned internal chemical irritants,
such as altered body fluids, disturbance of nutrition from local arterio-
sclerosis, venous congestion, etc., may act conjointly with other factors.
Roentgen Rays
Recently, also, the Roentgen rays have come to figure among those
injuries which under the circumstances may be looked upon as predis-
posing causes of skin cancer.
Chronic Inflammation
Despite their individual differences, a common feature unites the
exogenous injuries just discussed: with proportionate degree of severity
and proportionate duration of their action they all end in a chronic in-
flammatorij condition of the affected tissue.
It seems that, on such a foundation, degeneration into a malignant
tumor-cell takes place most easily.
Taken in this sense — as excitants of inflammation — it may be that
now and then this or that microbe enters into only a subordinate causal
relation to tumor formation, which is exemplified when under certain cir-
cumstances tubercular or luetic tissue processes seem to afford favorable
preliminary conditions for malignant cell-proliferation.
None of the influences formerly discussed, whether of an endogenous
or exogenous nature, are entitled to be classed as a specific cause. Pos-
sibly there is no such cause for malignant neoplasms. Many components,
changing from case to case with regard to origin and severity, unite in
producing the resulting malignant cell-proliferation.
Each single case has its particular place with reference to causative
influences, and requires separate analysis.
ETIOLOGICAL NOTEWORTHY FACTORS 55
ETIOLOGICAL NOTEWORTHY FACTORS IN THE TAKING
OF HISTORIES OF MALIGNANT NEOPLASMS
Since all probabilities indicate that a specific and uniform cause for
malignant neoplasms does not properly exist, but that from case to case
there is an underlying combination of endogenous and exogenous bio-
logical irritants and dispositions, in connection with the previously de-
tailed discussions as to the etiology of malignant neoplasms, I would like
to sum up in a superficial manner the points which seem important to me
in the recording of case histories.
While fully appreciating local exogenous causes of disease, I wish to
lay especial stress upon congenital peculiarities and the possibility of
congenital transmission. Information from the patient as to the follow-
ing points will be of service.
1. Maternal, at times paternal, organism? Longevity of parents?
Dyscrasias in parents, such as gout, adiposity, diabetes? Malignant
neoplasms or tuberculosis? In the same manner ascertain the same facts
concerning patient's own brothers and sisters, the maternal grandmother
and her descendants.
2. Constitution of patient during childhood. Weak? Strong?
Scrofulous and rachitic?
3. What infectious diseases of childhood have been passed through?
What infectious processes later on? Tuberculosis? Lues? ]\Ialaria?
Typhoid? Pneumonia?
4. Is the individual one who has always enjoyed robust health?
5. Is there anything in the patient which might give the impression
of constitutional inferiority?
a. What place does the patient occupy in line of seniority
with reference to other children? How old was the mother
at time of patient's birth?
h. Enteroptosis?
c. Epilepsy? Migraine?
6. Constitutional characteristics at and before beginning of disease:
a. General appearance? Temperament? Color of hair? Fall-
ing out of hair? Gray early? Arcus senilis of the cornea?
h. Circulatory anomalies: Tendency to varicose veins and
hemorrhoids (hereditary conditions?) congenital inclination
to epistaxis? Arteriosclerosis? Blood-vessel tumors in the
skin (angioma) ?
c. Skin: Psoriasis vulgaris? Chronic eczema? Ichthyosis?
d. Does anything in the patient suggest a gouty diathesis or
other allied conditions? {Heherden's nodes? Hallux val-
gus as analogous to similar deviation in metacarpo-
phalangeal articulations? Sciatica, Lumbago?) Diabetes,
adiposity, thyroid-gland anomalies?
56 TUMORS OF THE ABDOMINAL VISCERA
7. Is there a general tendency to the occurrence of new formations,
e.g., angiomas of the skin or cysts, myomas, etc., about the female
genitals .''
8. Have chronic injuries of mechanical or chemical nature been at
work in the site of the disease .'' (Concretions, pressure upon the epigas-
trium by leaning up against tools, etc., abnormalities of diet?)
9. Was the affected organ anatomically and functionally up to or be-
low par prior to the disease.'^ (Gastric ulcer.'' Gastric neuroses .-^ Achy-
lia gastrica.'^ Hemorrhoidal conditions.'' Cirrhosis .^ Cholelithiasis.'')
In conclusion, brief mention may be made of those points which on
the strength of personal impressions I consider worthy of note. Where
we are concerned with such an extremely difficult question as is embodied
in the disposition to cancer, the individual observer can never arrive at a
definite conclusion but can only gain impressions which, be they ever so
convincing to the observer himself, cannot be proved objectively. Yet,
their probability may be gradually augmented through similar experi-
ences of others, and finally amount to certainty. Thus impressions which
originally partook more of an ingenious significance may come nearer
being observed facts fully qualified for natural science.
With reference to cancer of the stomach, this being by far the most
frequent of internal cancers, my fairly abundant experience in this do-
main and observation centred thereon have given me the following im-
pressions :
1. The majority of patients are robust individuals, very often de-
scended from long-lived parents, and in fact coming from a very healthy
family, the patients often declaring that they have been healthy all their
life. Frequently one would be tempted to speak of "excessive well-being"
and to assume that also in this direction a certain normal state cannot
be overstepped with impunity. Very often infectious diseases of child-
hood are denied, and also the number of subsequent infectious diseases,
in so far as they affect the entire organism, is very slight in this group
of cases. Opposed to this there are often at hand the marks of a uratic
diathesis, and accordingly the history often discloses arthritic and neural-
gic disease processes. Neither is it rare that these latter shortly precede
the beginning of the malignant disease. There are also cases in wliich espe-
cially the skin of the family stock appears as if sprinkled with dotlike
angiomas.
With this type arteriosclerosis is a frequent finding. The}^ are usually
individuals who enjoyed very good digestive powers.
The anamnesis not seldom elicits the fact that the hair has turned
gray prematurely. The eyebrows are often conspicuous because of their
enormous development.
2. In partial contradistinction to the type of cases just described,
which occur mostly in the later years of life ("dynamic type"), there is
another category of patients who often are attacked by gastric cancer
PROPHYLAXIS OF MALIGNANT TUMORS 57
while still in the thirties and forties ("adynamic type"). Their consti-
tution very frequently exhibits marks of congenital inferiority, as shown
by features that arc "phthisical" and enteroptotic. Not rarely in these
cases does the tuberculin test point to latent tubercular foci (mediastinal
glands, etc.), or there exist manifest signs of arrested tubercular foci
(glands, bones, pulmonary apices, etc.). Arteriosclerosis is mostly absent,
the blood-vessels have a delicate feel, anamnesis not seldom draws out the
fact of a tendency to epistaxis from early childhood. Very often they
are individuals who have suffered their life long from a "weak stomach,"
whose nervous "irritable weakness" also exhibited itself in their digestive
energy.
To this "adynamic" group also belong most cases of pre-existing gas-
tric ulcer. Achylia gastrica might also be said to be pre-existent in these
cases. Among their ancestors we not seldom meet with tuberculosis. The
eyebrows frequently are only indicated.
PROPHYLAXIS OF MALIGNANT TUMORS
Clinical observations would seem to justify one speaking of cancer
prophylaxis, and the thought that there is a hygiene which protects to
a certain extent against taking disease from malignant tumors, deserves
to be carried from the physician's office to the laity.
The prophylactic measures naturally proceed from our notions as to
the causes of the different malignant diseases of organs, and as has been
made clear in our former discussions,^^ in addition to positive exogenous
injuries there will also come into consideration those rather hypothetical
endogenous irritants.
Many of these irritants are undeniable as predisposing causes, many
are based on personal opinion, hence prophylactic advice will partly
bear a personal stamp.
Are those immediately surrounding a cancer patient to protect them-
selves in any way against contact with the patient or his personal uten-
sils.'^ Does there exist the danger of infection.'^
Danger of Infection
Following observations on animals (transmission of canine vaginal
sarcoma to the dog's penis after coitus),^* and similar confirmed observa-
tions of very experienced clinicians (cancer a deux), this question will
have to be answered in the affirmative.
Even though one be an absolute opponent of the theory of a specific
cancer e!xcitant, one can find an explanation in the assumption that under
circumstances tumor cells can, through their extensive emancipation from
the parent organism and their great biologic independence — analogous
to unicellular microbes — in case they become liberated through ulceration
and immediately gain access alive to other organism, take root and —
" See page 49.
"Zeitschr. f. Krebsforschung. VIII, 3, 4., page 5Q5.
58 TUMORS OF THE ABDOMINAL VISCERA
comparable to inoculation experiments in mice — continue to proliferate
in a characteristic manner.
Thiersch has found that during the process of transplantation even
normal epithelial cells may take root in a different organism.
It will, therefore, surely be advisable not to use an uncleaned spoon of
a patient having cancer of the stomach, to avoid kissing him, etc.
Among internal carcinomas, those that are ulcerating near the oral
and anal openings will demand special precautions.
Everything, however, indicates that the danger of direct transmission,
especially as far as carcinoma of the digestive tract is concerned, is
almost insignificant, and could be compared to the probability there
would be of a railroad collision when one makes but a single short trip.
Another practically important question would be: Is there a prophy-
laxis — naturally a relative one only — for those individuals who have been
successfully operated on for gastro-intestinal cancer or individuals who,
because of the frequent occurrence of cancer among their ancestry, fear
analogous disease.''
This question also must be unconditionally answered in the affirma-
tive. Putting it briefly, the prophylaxis seems to me to consist of a local
and general hygiene.
I. Local Hygiene
Local Hygiene
Since irritants which lead to a chronic inflammation undoubtedly enter
into consideration as predisposing causes in many cases of malignant
disease of internal organs, the prophylaxis will have to be rather
strenuous.
Individuals who have had gastric ulcer or those who have been surgi-
cally freed from cancer of the stomach, will have to subject themselves
to a diet devoid of mechanical, thermic or chemical irritants that are
liable to produce trauma. From this point of view it will be advisable to
exercise painstaking care of the mouth and teeth.
Whiskey drinkers ought to be cautioned of the danger of esophageal
cancer, and even in the case of other patients, providing they are not
of too apprehensive a nature, it may not be amiss to point out the greater
likelihood of cancer if the hygienic advice is not observed.
The more the natural lessons of hygiene become impressed on the
popular mind, especially with reference to diet, the fewer will be the cases
of gastric cancer and vice versa.
If, as is borne out by my personal observation, previously robust
constitutions arc afflicted with gastric cancer, I can see one of the causes
for it in the scorning manner in which these "stomach athletes" break
the rules of gastric hygiene.
Nutritional excesses may in one or the other case undoubtedly become
predisposing causes.
PROPHYLAXIS OF MALIGNANT TUMORS 59
II. General Hygiene
General Hijgiene
Whoever shares my personal view of "internal cell traumas" brought
about by conditions of dyscrasia such as uratic diatheses and other meta-
bolic disturbances, and in fact whoever is of the opinion that the general
constitutional level of the organism is not without influence from case
to case as a predisposing cause, will have due regard for these factors
after operative removal of malignant tumors as well as in cases hered-
itarily disposed toward malignancy.
It does not seem too remote a thought to occasionally place such
individuals under different climatic conditions (hot and dry) in which
malignant neoplasms appear to be rare (Tunis, Algiers). On the other
hand, to take them out of places which, perhaps, through favoring the
disease by promoting dyscrasias have often been accused etiologically
(damp dwellings along streams, damp clay and mud soils).
Change of quality and excitation of metabolism by means of nuld
diaphoresis, mild drink cures, etc., will suggest themselves in addition to
appropriate dietetic measures.
Harmful psychical factors also (carcinomaphobia) will have to be
eliminated as far as possible.
B. SPECIAL PART
Cancer of the Stomach^
EARLY SYMPTOMS
One is so accustomed to see malignant new-growths of internal organs
at so late a stage of their development, that the notion of a gastric
cancer being the size of a millet seed sounds rather strange to the diag-
nostician.
And yet every tumor which later on impresses us so forcibly on
account of its dimensions must develop from the minutest size.
We are probably justified in assuming that these initial stages will
forever remain inaccessible territory to clinical diagnosis.
For even if we grant the possibility that the development of cancer
cells can change the bulk of the body fluids in any specific way, and this
specific change could be demonstrated, it would still be more than doubt-
ful that such a specific dyscrasia should accompany the very first develop-
ment of cancer.
At what time, then, does carcinoma of the stomach enter the field of
internal diagnosis, since its first initial stages interest only biologists
and histologists.'*
This question permits of the following answers:
1. When it ulcerates and leads to the presence of blood-coloring mat-
ter in the stomach contents and feces.
2. When it begins to disturb the function of the affected organ.
Blood in the Feces
If, for example, we allow two years for the average duration of cancer
from its very beginning, the question arises: When (on the average)
does the cancer begin to ulcerate.''
If we remember that the mucous membranes of the stomach and duo-
denum are particularly inclined to ulcerative processes and which ex-
plains the foregoing, unlike almost any other area of mucosa is con-
stantly subjected to chemical, thermal and mechanical irritants, the
assumption surely lies near at hand that in case of malignant disease
ulceration will set in early.
For the much-desired early diagnosis of gastro-intestinal cancer the
following urgent postulate will apply: In cases of gastro-intestinal dis-
^ The numbers in the text and in the foot-notes refer to the respective case his-
tories. — Here I have in mind those quantitatively small hemorrhages which cannot at
all be made out macroscopically nor demonstrated with desirable certainty under the
microscope, but whose presence can be proved by the chemical test.
63
64 TUMORS OF THE ABDOMINAL VISCERA
ease repeated clieniical examinations of the feces for blood-coloring mate-
rial are absolutely necessary.
In such cases one might think of demonstrating a gastric hemorrhage
by washing out the stomach. Still, it must be remembered that exam-
ination of the feces yields an approximately twenty-four hour result,
whereas lavage of the stomach — barring the presence of stagnation —
will only determine whether a hemorrhage has occurred at or shortly
before the time of lavage; at the same time we will also have to reckon
with the possibility of artificially produced hemorrhage brought about
by the introduction of the stomach-tube, straining, etc.
For this and other reasons the Salomon test" seems but little com-
mendable. It proceeds from the supposition that bloody serous fluid
containing albumin transudes from the ulcerating surface, and aims at
demonstrating albumin according to Esbach or through N-determination
in the reflow (Kjehlahl). It is said that if there be over 20 mg N in
100 cm.*^ reflow (400 cm.^ being the total), it involves suspicion. The
same is said of -Ke— "1/2% Esbach.
It is certain that a positive outcome may result even without cancer
of the stomach, there being various possibilities, such as peptic ulcer,
chronic gastritis, swallowed sputum, etc. A negative result may occur
even in advanced carcinoma.
In view of the small results obtained this test is not likely to become
clinically prevalent, because it requires a second introduction of the
stomach-tube ; the food remnants are washed out in the evening and the
following morning 400 cm^ of water are introduced and withdrawn
twice, thus subjecting the patient to three washings, including that after
the test-breakfast.
In advanced gastric cancer accompanied by stagnation, the test will
certainly often turn out positive, but in such cases it will give way to
methods of examination that are simpler and admit of fewer interpre-
tations.
Disturbances of Motility and
Its Consequences
For diagnostically obscure cases I consider the above test as too
uncertain in its results — both negative and positive — to be of any real
value in aiding and determining diagnosis.
Thus it happens that of the various functions of the stomach, and
incidentally those of the bowel, the motor function is in many cases the
first to suffer.
If the cancer be situated in the pyloric or prepyloric portion of the
stomach, then, in addition to the impeded onward movement of gastric
contents on account of direct encroachment of the tumor-mass in the
lumen, there also come into consideration swellings of the mucosa and
^ H. Salomon, Deutsche med. Wochenschr., 1903, No. 31. — The frequent localization
of gastric cancer at the pylorus or in its immediate vicinity (curv. minor., prepyloric)
makes it apparent that stagnation of the stomach contents not seldom belongs to the
early symptoms.
CANCER OF THE STOMACH 65
pyloric spasms ; but even if otherwise situated the tough infiltration of
even only a circumscribed area cannot be without effect on peristalsis.
Also, ptosis of a carcinomatous stomach, due to the disappearance
of intra-abdominal adipose tissue, may favor stagnation, and thus aug-
ment the resultant subjective sensations such as pressure in the stomach.
Adjustment of the ptosis through pressure from below upward will then
afford relief.
In the same measure that the expulsion of the ingested food becomes
gradually more and more retarded, and the foods that do not gain
access to the bowel in time are subjected to bacterial decomposition,
there results a set of symptoms which must often be construed as direct
evidence of increasing stagnation. These symptoms may now be discussed
in the order in which they frequently follow each other as early symptoms.
a. Pressure in the Stomach
The more or less painful sensation of fulness in the epigastrium after
eating is in many cases the first signal for alarm.
The pathogenesis of the symptom is made clear by the fact that the
evacuation of the gaseous and thickly fluid stomach contents through
belching or vomiting affords immediate relief. Not infrequently does it
happen that at the time of this pressure in the stomach the epigastrium,
through spontaneous inflation, bulges somewhat and becomes tense like
an air-cushion.
The interference with the emptying of the stomach leads partly
through fermentations, to abnormally high burdening of the stomach-
walls, and it is this increased internal pressure in the first place that
causes the symptom.
Not infrequently it precedes the objectively demonstrable stagnation
b}^ a considerable period of time, and therefore merits serious consid-
eration.
Topography
Wliilst the sensation of pressure in the stomach is most often dif-
fusely localized in the epigastrium, there are cases in which it is felt
in the region of the pylorus,^ or behind the xiphoid process, or in the
back.^ N'ot seldom stabbing sensations are experienced on both sides
under the costal margins.
Time and Appearance
With reference to the time of its appearance, this symptom is mostly
intermittent ; it is related to the time of eating, sometimes appearing
immediately, but most often in the following two hours, and lasting
about one hour; yet there are cases in which it exists more or less con-
tinuousl3\'
^No. 33. *No. 69. » Nos. 35, 41.
66 TUMORS OF THE ABDOMINAL VISCERA
Causation
Its causation is dependent upon the quantity and qualit}'' of the
food, and in the individual case after the fashion of a well-prepared
experiment, is strictly adherent to rule and may be proved to be so.
This point deserves attention in contradistinction to similar but more
capricious sensations in gastric neuroses. Though according to rule and
unchanging in one and the same case, the conditions for its occurrence
in different observations are not entirely identical. Although always of
an alimentary nature, there will be differences with respect to quality of
the badly agreeing foods.
The severest sensation of pressure is produced chiefly by the intake
of solid foods, especially meat. Cooked beef, above all, is tolerated worst.
Yet here, as in all dietary questions, individual peculiarities will play a
part. Thus it happens occasionally that certain kinds of meat which are
hard to digest,*' such as pork, are well tolerated, whereas farinaceous
foods give rise to severe sensation of pressure; in other cases sweets'
and vegetables ^ are badly borne.
Diagnostic Import
Can the symptom of pressure in the stomach, which we are able to
elicit by alimentation, be utilized for the diagnosis of an incipient gas-
tric cancer.'*
We find it frequently in those digestive neurasthenics whose gastro-
intestinal canal labors under "irritable weakness," and is not seldom met
with at the time of the menopause ; it often precedes gall-stone colic by
months and years ; it accompanies benign ulcerations of the stomach and
cardiac congestions. Acute dyspepsia after indigestion, every increase
in the volume of neighboring organs of the stomach which narrows space
(tumors of the liver and spleen, echinococcus and pancreatic cysts, etc.),
may manifest themselves subjectively by the sensation of pressure in
the stomach.
The symptom may therefore result from quite heterogeneous organic
conditions. Nevertheless, it deserves full consideration as an aid in
diagnosis.
Most of the enumerated organic processes are easily excluded ; prac-
tically we are concerned only with gastric ulcer and neurotic disturbances
of gastric function.
If the symptom rests on the following premises it will lead us to
suspect cancer of the stomach :
1. Unaccountable and pronounced occurrence in individuals who have
always had strong stomachs ("stomach athletes") and have arrived at
the age of cancer.
2. Regularity of its occurrence after a certain quantity or quality of
food with repeated experimental control (in contradistinction to gastric
neurosis !).
«Nos. 18, 66. 'No. 81. » No. 59.
CANCER OF THE STOMACH 67
3. Striking persistence of the symptom and but slight therapeutic
results, when apparently it can be accounted for by a single dietetic error.
•i. Unchecked progress in the intensity of the symptom : The sensa-
tion of pressure coming on in the beginning after abundant, later after
slight ingestion of food ; in the beginning intermittent, later continuous ;
in the beginning mild, later very painful.
The first point which takes into account the individuality of the pa-
tient seems to me especially important.
A "stomach athlete" who suffers from gastric disease must be ap-
praised differently than a "stomach weakling."
Only a powerful etiological factor can disturb the functional equi-
librium in the former case. Even when the trouble is laid to an error in
diet, the greatest scepticism is in order, particularly so if a return to the
normal condition is not soon established. Behind the "spoiled stomach"
and the "acute gastric catarrh" of the "stomach athletes" there lurks but
too often a cancer." Other tilings being equal, "stomach athletes" are
more open to the suspicion of cancer than "stomach weaklings," as they
are found among cancer patients in far greater numbers.
b. Phenomena of Regurgitation
From the same source as the above subjective symptom, namely, from
stagnation of the contents of the stomach, there arise the symptoms
which will be discussed presently, and which from a common point of view
I would like to designate as "phenomena of regurgitation."
They var}^ all the way from occasional eructation of gas to continued
copious vomiting.
Their appearance is partly spontaneous, and partly brought about by
stooping, which leads to a compression of the abdominal contents.
Eructation of Gas
This phenomenon may be easily misleading when it is very noisj' and
explosive-like. One is accustomed, and justly so, to make this observation
in the cases of gastric neurotics (aerophagia). But it does occur also —
rarely indeed — in cases of cancer of the stomach.*'
"Like the whistling of a locomotive" is the comparison a patient
makes in one of the case histories (36).
In the beginning the regurgitating gases are mostly odorless, but
with further progress they can be recognized as SH2 by their odor of
rotten eggs.^'^ The presence of this odor is usually concomitant with
the microscopic finding of sarcina ventriculi. The stomach sarcina may
be considered the most frequent excitant of SH2 fermentation in the
stomach contents.
Therefore in the valuation of this symptom a higher appraisal will
be demanded if it occurs in individuals who formerly had strong stomachs.
In contradistinction to the eructation of neuropathic individuals two
points seem to me deserving of note:
»Nos. 2, 36. "Nos. 23, 36, 45, 49, 51, 56, 61.
68 TUMORS OF THE ABDOMINAL VISCERA
Neurotics almost never complain of bad-smelling eructations.
Eructations of gas, as a result of an organic gastric lesion, frequently
attract attention by nocturnal disturbance.
"Sour" Eructations ("Heartburn")
Belonging to the early period of gastric cancer, and frequently con-
comitant with a good appetite, this symptom also owes its existence to
motor insufficiency of the stomach. Favored by stagnation and often also
by hypochlorhydria, there occur processes of decomposition which lead
to the formation of organic acids, such as lactic, butyric and acetic acids.
It is to these acids that the existence of the symptom can be ascribed in
cancer of the stomach.
Nothing could be more erroneous than to infer a hyperchlorhj'dria.
The sensation of heartburn here discussed extends upward along the
esophagus and occasionally also leads to sensations in the throat, which
must not be interpreted as "globus hystericus" and eventually "gastric
neurosis."
The appearance of the symptom is not seldom synchronous with the
expulsion period, and therefore frequently occurs two to three hours
after the noonday meal, and occasionally also sets in at night.
The use of bread sometimes seems to cause it promptly.
Watery Eructation
Instead of sour eructation, or alternating with it, we sometimes meet
with regurgitation of mouthfuls of watery, tasteless, or slightly salty
tasting masses ^' (HCl free gastric juice.''), or a slimy glaring fluid. ^-
It will be necessary not to confuse this with the flow of saliva, which
can occasionally be observed as a reflex symptom in gastric cancer (1-i).
Vomiting
Vomiting stands at the head of the phenomena of regurgitation.
Hence its frequent occurrence is often first found in advanced stages of
the disease, but may also be permanently absent.
In cases of diffuse scirrhus cancer of the stomach,^ ^ with extreme
narrowing of its lumen, there is mostly frequent and copious vomiting,
often even after the use of small quantities of fluids.
Fibrous cancers, limited to the pylorus and resulting in much stenosis
with secondary gastrectasia, lead to less frequent but therefore more
copious vomiting.
Non-stenosing medullary cancers, which often are of enormous extent,
not seldom run along without vomiting, so that one must not be misled
in diagnosis by the apparent contrast of a large tumor and no vomiting.
With reference to the time of day, the vomiting not seldom occurs
about the time of the expulsion of the food (about two hours after eat-
ing), but frequently also prefers the midnight hours.
Its first appearance is often attributed by the patient to some
dietetic error.^^ In the case of individuals with strong stomachs, who
" Nos. 69, 74, 99. " No. 40. " Nos. 2, 25, " No. 5.
CANCER OF THE STOMACH 69
have never vomited before, such attempts at explanation should always
be considered with doubt. Only too often the dietetic error is merely the
exciting cause, the fundamental cause being a developing cancer.
It seems that sometimes the use of Karlsbad water ^^ or the use of
cold drinks^^ provokes the vomiting. Liquid foods often act more unfa-
vorably than solid ones (76).
A fact frequently observed is that the vomiting and the accompany-
ing nausea as well as the milder symptoms of regurgitation, such as
eructation of gas and heartburn, occur and are made worse when lying
on the right side,^"
These throughout are cases in which the cancer affects the pyloric
portion of the stomach where it has led to a more or less severe stenosis
of the outlet.
The right-sided vomiting attitude indicates — generally speaking — a
local process at the pylorus and is mostly a sign of organic disease.
The vomitus is mostly of an alimentary character, and frequently
brings to liglit old remains of food.
Vomiting of bile is rare with pyloric stenosis, and more frequent with
cancer of the fundus ; yet, development of cancer at the pylorus may lead
to insufficiency of the outlet, in which case there is nothing to prevent a
backward flow of bile.
Seldom does gastric cancer make its first appearance with vomiting
of blood or melena (19, 67), and even in later stages copious bleedings
are rare.
The well-known coffee-ground vomiting deserves full attention when
accompanied by abundant vegetation of lactic-acid bacilli.
Otherwise it is found also with icterus gravis, acute peritonitis, gas-
tric crisis, agonal vomiting in sepsis, pneumonia, etc.
Feculent and fetid vomiting may be due to putrid ulcerations (90,
94), gastro-colonic fistula (18), or complicating ileus.
c. Phenomena of Pain
The development of gastric cancer is, in its clinical appearance, very
frequently ushered in by pains.
To a large extent they emanate from the same source as the symp-
toms hitherto discussed, namely, from impeded evacuation of the stomach
contents, in connection with which there may occur, under the influence
of peristaltic waves, severe stretching of the stomach walls.
This conception of the pathogenesis of the pain is proved by the fact
that the belching of gas or thorough emptying of the stomach contents
through copious vomiting immediately cuts short the phenomena of pain ;
it is also proved by the frequent and synchronous occurrence of balloon-
like bulging and tension of the epigastrium (gastric meteorism). Again,
it is proved by the fact that phenomena of pain are found first and fore-
most with those cancers which spring from the pylorus itself or from
its immediate vicinity.
» No. 35. '' No. 21. " Nos. 21, 27, 49, 50, 7(5.
70 TUMORS OF THE ABDOMINAL VISCERA
Pain produced in this manner seems to play an important part so
long as there is no extreme and permanent dilatation of the stomach and
so long as the intake of food is yet sufficient ; in the initial stages the
persistence of HCl secretion might also be a factor augmentating the
pain, perhaps, through the excitation of peristalsis or provoking spasms
of the pylorus.
To arrive at a diagnosis of gastric cancer in its early stages, it is
essential to give careful consideration to the pain phenomena which have
their seat in the epigastrium.
The frequent false, shameful diagnoses of acute or chronic gastritis
in gastric cancer will become fewer, if more attention is paid to the fact
that the latter affections are not usually accompanied by painful phe-
nomena.
The curve of pain-phenomena during the course of cancerous disease
rises in the beginning, but later on drops often to zero, which is in
peculiar contrast to the underlying anatomical condition.
Attacks of pain which, in the begiiming, are of daily occurrence,
later on often become much rarer ^** and may finally disappear entirely.
This might be explained by accommodation of the stomach through
dilatation to the raised internal pressure, diminution of peristaltic power
and a reduced intake of food, as well as the gradual cessation of HCl
secretion.
In the symptomatology of gastric cancer two groups of pain-phe-
nomena may be distinguished, viz. :
"Distention Pains" of the Stomach
In those cases where pyloric stenosis has occurred, which in the early
stages may be due to spasms, the pains are of a pronounced colicky na-
ture and are identical with "colic of pyloric stenosis" as described by
me.^*^
As is true of distention pains in other organs (gall-bladder, uterus,
aorta), it is also the case here that with increased internal pressure there
is pronounced tendency to radiation.
Thus different types of pain arise:
1. Eight-Sided Type ("pseudo gall-stone colic"). — The pains occur
on the right side underneath the arch of the ribs and radiate spasmod-
ically toward the right loin and right scapula. ^^
2. ^^Girdle pain^^ ^yp^-
The pains begin underneath the xiphoid process and radiate sym-
metrically toward both sides, along the arches of the ribs, into the flanks
and back (51), or the pains converge from both sides toward the epi-
gastrium.
3. Left-Sided Type,-^ similar to gall-stone colic. — The pains radiate
"Nos. 11, 14.
'* R. Schmidt, Die Schmerzphaenomene bei Inneren Erkrankungen, etc. W. Brau-
niueller, Wien und Leipzig. Second Edition, 1910.
^»Nos. 11, 44, 58, 80.
" Nos. 56, 60, 68, 73, 83.
CANCER OF THE STOMACH 71
from the epigastrium toward the left breast and into the left scapula and
axillary portions of the left side of the thorax.
■i. Crossed Type (rare). — Radiation from the right side beneath the
costal arch toward the left scapula or the reverse (13, 61).
As with all pains that have a central point of origin and peripheral
extensions, it also happens in these cases that the peripheral extensions
may be separated from the ensemble of pain and occur independently,
which renders their interpretation difficult.
Abortive Pains
Among the rather infreqtcent abortive painful conditions the follow-
ing might be mentioned according to their topography :
1. Pains in the back.
Occasionally they can be elicited experimentally through artificial in-
flation of the stomach, and accordingly they are found in those sponta-
neous distentions of the stomach-walls which frequently exist in pyloric
stenosis. They frequently coincide with a severe sensation of pressure an-
teriorly in the epigastrium and occur when the latter become maximally
increased, but can also occur by themselves (11, 57).
Alimentary provocation,-- and hence their appearance after meals,
distinguishes them from those continuous pains in the back which some-
times accompany retroperitoneal glandular metastases and involvement
of the pancreas from cancer of the stomach. Pressure on the gastric
tumor or certain movements, such as sitting up, sometimes lead to exacer-
bations (15).
2. Vertebral column.
As in gastric ulcer, so also in carcinoma of the stomach, we may elicit
circumscribed areas of tenderness by striking the vertebral column as we
do in percussion. This tenderness may be intrascapular (11) or on a
level with the angle of the scapula (15) or correspond to the twelfth
dorsal vertebra (25).
In no case do such local hyperesthesias of the vertebral column alone
justify our thinking of metastatic involvement of the same.
3. Pains over the lower third of the sternum (83) or to the left of it.
4. Right or left lumbar region.
If occasionally there be isolated pains in this region they may give
rise among others to the false suspicion of a renal affection (18, 63).
5. Lower abdominal regions and periumbilical regions.
This kind of localized pain is seldom met with in cancer of the stom-
ach; in most instances it might be attributed to secondary disturbance
of the bowel or peritoneal complications (4, 55).
In the production of the pain phenomena so far discussed alimentary
influences show themselves clearly. Precisely for the correct interpreta-
" No. 81.
72 TUMORS OF THE ABDOMINAL VISCERA
tion of the last-named isolated radiations, it will be of great importance
to determine in how far they are dependent on alimentary influences.
If the pains appear immediately after eating (46), or, as frequently
happens, in the course of the next two or three hours, the correct in-
terpretation will not be difficult. Often, however, the interval is a very
long one (six to seven hours), which is probably due to the delayed ex-
pulsion of stomach contents as a result of motor-insufficiency (58, 72).
In no case does such a state of affairs justify us in thinking that the
neoplasm is situated in the duodenum. Not infrequently there are noc-
turnal aggravations of these complaints which is in line with the tendency
of all colicky pains to appear at night.
The quality of food is not without consequence, and frequently there
exists particular intolerance for solid foods, especially meat.
Only in rare cases can the intake of food allay pain (16). This is
most apt to be the case with milk, etc. (13), or if the food stimulates the
stomach to empty itself. Thus the use of coffee or sour wine may at
times afford r-elief.
Exquisite hunger pain, similar to that in gastric ulcer, may also be
observed.
It has already been mentioned, and significance attaclied to it, that
anything which unburdens the stomacli-walls, such as belching and vom-
iting, causes alleviation and often sudden cessation of the s^nnptoms of
pain just discussed.
The attitude of, as well as the changes in, the position of the body
frequently play a great part, especially at the time of the painful
attacks.
Thus lying on the right side often causes an increase of pain and an
increase in the phenomena of regurgitation.
This behavior is exhibited above all in those gastric cancers which
have involved the pylorus.
In cases of cancer of the fundus and cardia, lying on the left side is
badly tolerated (13, 45, 66), and even otherwise there occasionalU^ exists
severe left-sided pain (66).
A c company in g Symptoms
Of the symptoms that accompany the pain-phenomena just discussed,
the following are most frequently observed according to their mode of
origin :
Active gurgling as evidence of stenosis due to spasm or occlusion ;
hardening of the epigastrium, var3ang increase of resistance, especially
underneath the left border of the ribs, and at times a swelling in that
area ; all of these being manifestations of peristaltic efforts to overcome
the obstruction at the pylorus ; furthermore, hiccough, eructation, vomit-
ing. A rare accompanying symptom is defective vision during an attack
of pain (26).
The pain phenomena hitherto discussed have for their anatomical
basis ulceration in the vicinity of the pylorus.
To a great extent they proceed from the mechanical factor of dis-
CANCER OF THE STOMACH 73
tention of the stomach-walls which is at the bottom of the sensation of
pressure in the stomach, so frequent in the beginning of the disease.
They are frequently found in the early stages of gastric cancer, and
are of valuable service in differentiating from such painless affections as
chronic gastritis.
But they may also afford valuable aid in differentiating gastric neu-
roses that are accompanied by pain.
With reference to the foregoing, two points of view are to be borne
in mind :
1. The more mechanical factors, such as position of the body, etc.,
take part in the production of gastralgia, the greater the probability of
ulcerative disease.
2. Nocturnal occurrence of gastralgias, awakening the patient from
sleep, is generally peculiar to organic ulcerative conditions.
Even though a consideration of the pain phenomena does not in and
of itself lead up to the diagnosis of "gastric cancer," it w^ill in many cases
render an ulcerative disease probable.
In most instances the diagnosis of an ulcerative condition is a pre-
requisite for the diagnosis of cancer of the stomach, at least in that phase
of the disease which proceeds without positive findings on palpation.
Whilst so far we have been concerned with symptoms of pain which
often occur spontaneously, after the manner of colics, there exist also
pains which can be mechanically evoked, especially by pressure on the
epigastrium.
T enderness on Pressure
In very many cases of cancer of the stomach the epigastrium is sen-
sitive to pressure even in the first stages of the disease.
As in gastric ulcer, the cause for this may lie in the intragastric in-
crease of tension. If the balloon-like tense stomach is brought to col-
lapse through copious belching of gas or through vomiting, the erstwhile
pronounced epigastric tenderness often suddenly disappears. Evacua-
tion of the bowels also seems to relieve such a tense ballooned stomach
occasionally.
But the tumor-mass, as such, may also be the point of origin of pain-
ful sensations, particularly when inflammatory peritoneal complications
arise which may occasionally be demonstrated by the peritoneal fric-
tion rub.
Localized tenderness on pressure, therefore, always deserves atten-
tion, and may sometimes confirm an indistinct finding obtained by pal-
pation.
Where we are dealing with movable tumors, the point of tenderness
will vary with the migrations of the tumor. The wandering and pulling
of the tumor incidental to body movements may produce localized pain,
often giving rise to a sensation of painful turning over.
In all cases Avhere pa.lpation does not yield definite findings, such sen-
74 TUMORS OF THE ABDOMINAL VISCERA
sations should be carefully considered, especially in the cases of intelli-
gent patients.
The mechanical trauma of pressure which goes with palpation of the
epigastrium may a,lso produce pain when brought about in another form,
as in straining of the belly-walls during defecation (40), or in lifting
heavy burdens (65), or by pressing against a load when carrying it (28).
Setting the body in vibration, as happens when going down hill, etc.,
must be taken into account as a mechanical factor. Thus even motion
may occasionally aggravate the pains ; if the latter be localized over the
lower part of the sternum, it might lead to confusion with angina pec-
toris (43).
So far it has been pointed out that cancerous conditions of the stom-
ach not seldom announce themselves by phenomena of pain and also sub-
sequently run a painful course, which is in contradistinction to chronic
gastritis and in accord with benign ulcerations of the stomach.
It is true that in rai*e cases the beginning of cancerous disease may
be signalled by the disappearance of formerly existing painful conditions.
Thus some cases of gastric ulcer run along with a painful feeling of hun-
ger on an empty stomach, which at any time can be promptly cut short by
alkalies, and which undoubtedly is due to excess of hydrochloric acid or
hyperesthesia from hydrochloric acid. If in such cases there develop a
cancer having the ulcer for its base, it may, through cessation of HCl
secretion, have the effect of a permanently administered massive alkalido-
sis. The pains disappear (96), and in this way an apparent improvement
in the ailment really marks the beginning of the lethal disease.
d. Appetite, Thirst and Tolerance of the Stomach
It must be a priori evident that with the great individual differences
of gastric function, even as existing within physiological limits, cancerous
disease of the organ will manifest great variability with reference to ap-
petite, feeling of thirst and tolerance for food.
A "stomach athlete," a "heavy eater" will be thrown out of his stride
with greater force when cancer takes hold of his functionally powerful
stomach than will a "stomach weakling."
Even though anorexia may be the rule, exceptional cases are fre-
quently found in which the appetite is preserved, and even meat is well
tolerated.-^
Thus, for instance, medullary carcinoma (8) may be accompanied
by bvit little disturbance of appetite at a time when the tumor has at-
tained enormous size. In view of such cases one would be tempted to say:
The greater the tumor the better the appetite and the fewer the com-
plaints.
Absence of stenosis because of rapid ulceration might in part explain
the insignificance of the complaints.
Ea'cu cases of gastro-colonic fistula may run along with a relatively
good appetite (31).
"Nos. 3, 8, 11, 17, 2-2, 27, 33, 39, 56, 66, 69, 72, 77, 78, 81, 86.
CANCER OF THE STOMACH 75
Not infrequently it is only the fear of suffering that induces the
patient to eat little (51, 66, 83).
In no case, therefore, is a well-preserved appetite a finding which
can be construed against the diagnosis of cancer of tlie stomach.
Mention deserves to be made of the fact that cancer of the stomach
may make its debut with a voracious appetite. This, however, is extremely
rare and, according to my experience, is observable in neuropathic in-
dividuals only.
Thirst
The demand for liquids is frequently' increased (1, 2, 8, 28). This
symptom seems to me to deserve attention, since in gastric neurosis, which
often must be differentially diagnosticated, the feeling of thirst seems
often to have dropped below normal, giving rise to oligodypsy.
Polydypsy occurs in cases of cancer that progress without vomiting.
Severe anemia seems occasionally to be a favoring factor, analogous to
such behavior in primary anemias. Sensations of heat in the stomach
sometimes seem to provoke the feeling of thirst.
Anofpxia
If in cases of gastric cancer we analyze the sensations, that we term
anorexia, we very frequently encounter a particular aversion toward
meat, and oftenest it is cooked beef that excites the greatest repugnance.
This anorexia produced by meat is, however, by no means an infrequent
symptom in connection with other lesions of the stomach, such as achylia
gastrica, peptic ulcer, etc., and conditions of general weakness resulting
from tuberculosis, anemia, etc.
It is evident that meat, especially unappetizing cooked beef, makes
the greatest demands on the digestive energy of the stomach.
Intohrance
Accordingly, the intolerance of the stomach affects meat food in the
first place, subjective symptoms, especially feeling of pressure in the
epigastrium, resulting from its use.
The consistence of the food plays a large part, hard foods particu-
larly being badly tolerated.
The curve of tolerance often drops rapidly, and soon the digestive
power is able to cope with a liquid diet only (milk, soup, etc.).
In view of the pronounced individual peculiarities of gastric function
there can be little wonder if the above general rules are subject to numer-
ous exceptions.
Thus the tolerance for milk is extremely variable, even under physio-
logical conditions. Frequently cancer patients cannot tolerate it be-
cause it sours and causes belching gas. Soup also is not always well borne
(67, 73).
Disgust for meat may be absent even in advanced stages (78). Oc-
casionally minced meat agrees best of all (77). It is not subject to fer-
mentative processes to the same extent as carbohydrates, and hence
76 TUMORS OF THE ABDOMINAL VISCERA
would seem indicated in those cases where fermentative processes are
actively going on.
From the above we would expect that occasionally there would be
decided intolerance for foods prepared with flour and yeast (48, 66, 81).
If at times solid food is better tolerated than liquid (76, 96), it may
be explained by the more compact form of the first mentioned, which im-
poses less of a mechanical burden upon the stomach.
By way of a resume, I would like to emphasize once more that with
regard to the symptoms just discussed great caution is to be observed
with reference to their diagnostic worth; individual peculiarities are
decisive.
PHYSICAL EXAMINATION FOR GASTRIC CANCER
Since in the vast majority of cases the pyloric orifice, as a result of
its topographical relation to cancer of the pylorus, is subjected to more
or less spasms, occlusion from swollen mucous membranes or direct en-
croachment on the lumen, the physical examination must aim to find
those signs which can be construed as indications of disturbed canali-
zation.
Balloon-Lil-e Stomach
The phenomenon of a "balloon-like" stomach may pass for such a
symptom.
The abnormal decomposition of stagnating contents produces a sort
of "spontaneous inflation" of the stomach, the relation of which to vari-
ous subjective symptoms has already been discussed in detail. This in-
flation may affect the right or left portion (26, 28) in greater degree.
To what extent this pathological condition of the organ can be demon-
strated either by palpation alone or also by inspection will depend on
the degree of infiltration as well as the state of the abdominal mus-
culature.
With little inflation and good tonus of the abdominal musculature
the finding can often be shown by palpation onl3\
It is advisable to palpate interruptedly, especially on the left side
under the arch of the ribs, having the fingers in extension and palpating
perpendicularly or at least at an acute angle in order to recognize the
stomach in its inflated state, in Avhich it much resembles a cystic forma-
tion. With a relaxed belly-wall and high intragastric pressure one will
be able to make out the stomach, which appears like an air-cushion.
Pressure on same often immediately produces phenomena of regurgita-
tion, such as belching of gas, heartburn, etc. Through the upward escape
of gas in belching, the inflated stomach collapses like a punctured balloon.
Examination by succussion very often elicits loud splashing sounds.
Visible Gastric Peristalsis
Concomitant with the symptom of "balloon stomach" we frequently
observe visible gastric peristalsis, the peristaltic waves travelling the
CANCER OF THE STOMACH 77
extent of the organ accompanied by hiccough (3, 5), and usually with-
out pain (27, 50). When peristalsis has attained its height there fre-
quently ensue phenomena of regurgitation.
Epigastric Pulsation
Among the findings on inspection which must be taken into considera-
tion in cases of gastric cancer, we count the phenomenon of epigastric
pulsation. Tumor-masses developing in the epigastrium and spreading
toward the spinal column frequently come into contact with the abdomi-
nal aorta and often pulsate, this phenomenon sometimes disappearing
when the movable tumors are displaced on changing the position of the
body (32). Hence in determining the antero-posterior dimensions of
such an epigastric tumor certain significance is attached to the presence
of pulsation.
Without a palpable tumor epigastric pulsation is not of diagnostic
import. It can frequently be found in connection with gastroptosis.
The "balloon stomach" above referred to is capable of transmitting aortic
pulsation anteriorly. Auscultatory findings, which will be discussed later,
can enhance the significance of epigastric pulsation.
Abscess of Ahdominal Wall
Abscesses of the ahdominal walls count among the findings that can
be easily determined by inspection in cancer of the stomach. They are
very rare, occurring most frequently with those gastric cancers that
have become intimately adherent with the anterior belly-wall."^
In one of these cases (34), at the summit of the swelling, there ex-
isted splashing which could be heard and felt, pulsation, and tympanitic
sound when lying on the back, which gave way to dulness when lying on
the side. This sufficiently identified the internal origin of the abscess
and excluded the danger of confusion Avith an abscess springing from the
belly- walls themselves.
Hernias in the Linea Alba
Among the most frequent findings on inspection in gastric cancer
we count those hernias made up mostly of preperitoneal adipose tissue
and being the size of a pea or nut, which might occasionally be taken as
the cause of existing stomach complaints. Otherwise they are a rather
inconsequential finding, and I Avould warn explicitly against taking them
into account as an etiological factor in stomach complaints, especially if
there be no compelling reasons for doing so. They are probabl}'^ pre-
existent in cases of cancer, appearing more prominently on account of
the emaciation of the abdominal walls.
Positive findings by palpation may be permanently absent ; this, how-
ever, applies to only a small percentage of cases, providing the proper
technique be employed. As to the length of time intervening between
ulceration (demonstration of blood in the feces) and palpability of the
" See R. Segfiel. Uber die Milbeteiligung der vorderen Bauchwand beim Magen-
carcinom. Miinchener med. Wochenschr., 1899, page \(\\\.
78 TUMORS OF THE ABDOMINAL VISCERA
tumor, there are present no certain facts for one's guidance; naturally,
there will be great variation.
At the same time, it is more than probable that cancerous disease of
the stomach reveals itself to chemical investigation much earlier than to
physical examination. Some of the causes for continued latency of gas-
tric tumors would be :
1. Adhesions to the lower posterior surface of the liver.
2. Localization in the immediate vicinity of the cardia.
3. Surface infiltration.
Palpation
The greatest care should be taken in palpating the line between the
xiphoid process and the umbilicus. Here the recti are often split, and
we do not have to contend with an intervening musculature. The ex-
amination should be made with the body in various positions (also stand-
ing), and the breathing should be very deep, i.e., diaphragmatic."' Only
in this way can tumors be felt that are concealed behind the xiphoid
process. "
One should never omit to examine with the body on the right side, as
in palpation of the spleen, in order to determine tumors which are lying
in the left hypochondrium.
Spasms of the Pylorus
Tumors belonging to the pyloric region not infrequently display a
peculiar behavior in that their consistence often undergoes sudden changes
during palpation, frequently accompanied by squirting sounds. The pa-
tients themselves occasionally are aware of a sudden and at times pain-
ful occurrence of tautness that feels like a cord, which again disappears
(6, 13, 20, 107) ; this cord may have the circumference of the index
finger (13).
Nothing would be wider of the mark than to infer from such a find-
ing that there was a functional spastic disease of the pylorus (Kauss-
maul).
In these cases we are usually dealing with fibrous and scirrhus forms
of gastric cancer accompanied by much hypertrophy of the pyloric mus-
culature. That which is felt is the result of two things:
1. Hypertrophied musculature which is in a state of peristaltic
unrest, and,
2. Cancer mass. It is upon the first of these that the change during
palpation depends.
It is true that analogous contractile conditions can be felt in the
pyloric region of the stomach in cases of gastric neuroses, thus among
others, in achylia. The evidence of prompt motility and a constantly
negative blood finding in the feces will, however, put us on the right track
in these cases, which, after all, are extremely rare.
" See page 3.
CANCER OF THE STOMACH 79
Tumor Types
Corresponding- to the varied localization and form of the tumor-
masses tlie different types of gastric cancer may be distinguished as
follows :
Globular, Cyst-Like
These are rounded, often quite smooth tumors up to the size of an
apple, which not rarely cause a protuberance of the belly-walls. They
are similar to cystic enlargements.^*'
Situated, as a rule, to the right of the median line, they are often
best felt when the patient is lying on his left side.
Its identity with the stomach is often indicated by the fact that
pressure upon tlie tumor produces regurgitation of stomach contents ;
also there are often audible loud and persistent squirting sounds over
the tumor.
Light percussion over the central portions of the tumor-mass yields
a tympanitic sound.
Tumors in the Begion of the Spleen
These are usually knobby and much harder than a chronic tumor of
the spleen, and, with the patient lying on his right side, are often pal-
pable only at a point where otherwise the anterior pole of an enlarged
spleen is demonstrable ; in the erect position the tumor in some cases
moves downward from the splenic location and can then be distinctly felt,
but on lying down disappears again behind the arch of the ribs (62).
The particular hardness of cancerous tumors is a sufficient mark of dis-
tinction from a palpable anterior pole of the spleen. I recall a case
which was beset with difficulties : on the left there was a malignant pleu-
ral effusion ; and also on the left side beneath the costal arch a stony-
hard tumor could be felt. Autopsy disclosed the anterior pole of the
spleen, which had been forced dowTiward ; the peculiar consistency was
due to massive deposits of lime salts in the capsule of the spleen.
Cylindrical Tumors Lying
Transversely
This tj'pe is counted among the most frequent, and includes chiefly
cancers springing from the pylorus itself or from its immediate vicinity
in the lesser curvature. They are frequently situated in the median line
or a little to the right of it.
It is these that give rise to the phenomena of contraction above de-
scribed. They are mostly fibrous carcinomas.
Surface Tumors
Tumors extending along the surface, often the size of a child's head.
At times these have the umbilicus for their central point and are occasion-
ally adherent to the anterior abdominal wall (8).
" Thus in Case 33, competent surgical opinion prior to operation was to the efiFect
that there was a possibility of a cystic swelling.
80 TUMORS OF THE ABDOMINAL VISCERA
They are mostly medullary, non-stenosing carcinomas, which, there-
fore, give rise to but few gastric manifestations. It is in these cases that
the paradox applies : the greater the cancerous tumor, the better the
appetite. Frequently there is pronounced pulsation.
Contracted Stomach
Stomach contracted and felt in toto, without circumscribed tumor-
formations, in a state of active peristalsis. This type is found in those
cases which in the literature are described as benign gastric affections:
"linitis plastica Brinton,^'' but whose malignant nature is now generally
recognized (2).
Tumors originating in the stomach usually possess a high degree of
mobility.
In part, these changes in place occur spontaneously without our co-
operation, and are frequently noticed by the patients themselves. They
will give the information that without changing the position of the body,
the tumor is at one time more to the right and at another more to the
left (11, 44). This wandering probably depends in the first place on the
state of fulness with occasional spontaneous inflation of tlic stomach. In
case of doubt as to whether a palpable tumor in the epigastrium belongs
to the liver or the stomach, the phenomenon of spontaneous wandering
will decide against the former.
These tumors, providing they have not become firmly adherent, may
also be displaced actively, only their movability is least in a downward di-
rection analogous to an object suspended from above (64, 90).
If the tumor can be well grasped from above it is possible to con-
stantly locate it during every respiration, but if such is not the case the
tumor will glide away from luider the hand during expiration and move
upward. The tumor cannot be fixed during expiration.
The preceding phenomenon is therefore of a secondary nature and
does not deserve that significance which is generally ascribed to it. The
physical strength of the examiner would be more than a sad thing, if it
were not sufficient to hold the tumor even during expiration, providing,
of course, that the tumor can be grasped from above. Only the last pos-
sibility or impossibility is of diagnostic interest with regard to free
movability or adhesions.
The movability can be indirectly determined by having the patient
assume different body positions. The movability in this way often proves
very great.-"
Ballottement
Ballottement figures among the rarest findings in cancer of the stom-
ach (61); enteroptosis, left-sided location of the tumor and a consider-
able diameter are favoring factors.
" Thus in Case 62, the tumor is found behind the left arch of the ribs with the
patient on his back, but wanders into the region of the umbilicus when the patient
changes to his right side.
CANCER OF THE STOMACH 81
In many cases where gastric cancer has been positively diagnosed and
tumors in the region of the stomach are demonstrable, other rarer pos-
sibilities enter into our calculations : thus we may be dealing with infil-
trated omentum reflected onto the upper surface of the liver (94), or
with groups of glands along the lesser curvature ; there also come into
consideration mesenteric gland metastases (66), and naturally also me-
tastases in the left lobe of the liver.
Percussion
Percussion plays a rather subordinate part in the determination of
gastric tumors ; at any rate, it may be of importance in differentiating
cystic tumors, in which case light percussion must be made over the
central portions of the tumor-mass, having the finger or pleximeter in
firm apposition. If the result be a completely tympanitic sound, it is
always possible that the tumor springs from some air-containing organ
(stomach or gut).
With the presence of pyloric stenosis or dilatation of the stomach,
the liver dulness is frequently more or less diminished and in its place
we find a tympanitic sound.
Percussion may also be employed for detecting abdominal areas that
are tender to pressure and to blows. Where we have to determine whether
the cause producing the pain is deeply or superficially situated, percus-
sion becomes of differential diagnostic significance (61).
Auscultatory Findings
Among the findings on auscultation, splashing sounds as signs of dila-
tation due to pyloric stenosis deserve attention in those cases where they
are present in the morning on an empty stomach (22), or where they can
be obtained at almost any time and with ease. It is always advisable to
elicit this phenomenon after the manner of Hippocratic succussion by
grasping the right and left sides of the pelvis and shaking.
Gastric Borhorygmi
Completely analogous to intestinal borborygmi occurring in stenosis
of the bowel, there may also occur similar auscultatory phenomena (gas-
tric borborygmi) with stenosis of the pylorus. If of but slight inten-
sity, they can be heard only when the ear is applied to the epigastrium,
but later on frequently become audible at a distance and are noticed by
the patient himself. The more they are found to be present and the
louder they become, the greater should be the attention given them as an
expression of pyloric stenosis. Their occurrence may be considerably in
advance of the characteristic objective symptoms of pyloric stenosis.
Peritoneal Friction-Sounds
Among the phenomena of auscultation peritoneal friction deserves
very careful attention (9, 18) ; if limited to the epigastrium, it is most
frequently due to perigastric or perihepatic complications (ulcerating
gastric cancer and liver metastases). I have never been able to observe
82 TUMORS OF THE ABDOMINAL VISCERA
it in cases of gastric ulcer. Frequently recognizable on palpation by its
crepitating sound, it is much increased by diaphragmatic breathing.
'More frequent are these systolic murmurs heard in the epigastrium,
mostly in a circumscribed area, whose genesis is not perfectly clear but
whose origin is in the circulation.-^ I believe that I was the first to empha-
size the peculiarity of their expiratory increase.-'"* They are found in
gastric as well as hepatic cancer.
They seem to have four rules in common :
1. Their occurrence is synchronous with the arterial pulse or if, as
is exceptionally the case, they are constant, there is a pronounced sys-
tolic increase.
2. At the end of expiration they gain in intensity and occasionally
are clearly demonstrable then, only if at this time, i.e., the end of expi-
ration, the patient holds his breath.
3. They are usually confined to a small area.
4*. Firmer apposition of the stethoscope usually increases the inten-
sit}'^ of the murmurs ; in rarer cases they become audible onl}^ when the
stethoscope is applied with pressure. In most instances they can be made
out without any piressurc by simply applying the ear.
"Epigastric circulator}^ murmurs," aside from the extremely rare
cases of aneurysm of the abdominal aorta, really come into consideration
only in Laetmec cirrhosis, and even here they are rare enough.
At times, therefore, practical significance attaches to them as indica-
tors of malignant growths in the abdomen, regardless of the theoretical
question as to their cause.
They may be of especial value in those cases which yield obscure find-
ings on palpation.
Their pathogenesis is, perhaps, not a uniform one. If the epigastric
tumor is lying upon the abdominal aorta (cancer of the pancreas), one
could imagine that pressure upon same, especially if reinforced by pres-
sure with the stethoscope from the outside, would produce a mild stenosis
of the abdominal aorta which would give rise to a systolic murmur. Dur-
ing expiration the antero-posterior diameter of the epigastrium is small-
est, the belly-wall is nearest to the vertebral column, and with the inter-
position of a tumor the conditions for compression of the aorta would
be most favorable.
However, this explanation will not obtain in those cases of cancer
metastases in the right lobe of the liver where the murmurs are audible
over the infiltrated area, and there only (46, 59, 82). In the latter case
we can only take into consideration compression of the larger venous or
arterial trunks, and in those cases in which there are present constant
murmurs becoming increased during systole, the origin is most likely in
the venous current.
=» Nos. 2, 8, 11, 13, 37, 47, 53, 62, 63, 64, 65, 73, 78, 86, 98.
^' Med. Klin., 1909, No. 2.
CANCER OF THE STOMACH 83
ACCOMPANYING SYMPTOMS FROM OTHER ORGANS
These will be discussed here in so far only as they are more or less
peculiar to carcinoma of the stomach. Their relation to malignant dis-
ease in general has already been discussed in another place (page 37).
Particular consideration will here be given to those findings which
may occasionally appear as early symptoms.
Oral Cavity
There can be no wonder that such a far-reaching process as malig-
nant disease of the stomach should make itself felt throughout the entire
digestive tract.
Atrophy of Lingual Mucosa
As worthy of note I consider those atrophic alterations of the lin-
gual mucosa which up to the present time have received but little atten-
tion. In these cases the mucosa is partially (especially in its middle por-
tion) or entirely smooth, shiny, and "paper-like" ; '^'^ similar atrophic
conditions are not infrequently met with in pernicious anemia, but in the
latter case they are often accompanied by the formation of painful blis-
ters, which is of rare occurrence in connection with gastric cancer.
Coated Tongue
Coated tongue is an inconstant finding, being notoriously frequent in
neuropathic individuals without any appreciable digestive disturbances,
and may be entirely absent even in advanced cases of gastric cancer. In
some cases this may be explained by the atrophic processes of the lingual
mucosa above referred to, as in the latter case decided desquamation of
the atrophic epithelial layers does not take place.
This may also explain why occasionally the coating of the tongue is
unilateral only, there being atrophy of the mucosa on the other side.
Teeth, etc.
Very defective teeth, tendency to the formation of tartar, and a bad
condition of the oral cavity in general are frequent findings. In so far
as these conditions favor the development of abundant bacterial growths
and the foods reach the stomach after most imperfect mastication, we
might in some cases consider them as predisposing factors of cancerous
disease.
Salivation, Deglutition Dijflculties
Salivation may at times become a prominent symptom (9T). Diffi-
cult deglutition — mostly of mild degree — may occur especially in those
cases where we are dealing with a diffuse infiltrating scirrhus cancer (10)
or where the cancer development originates in the fundus.
">See Nos. 8, 10, 14, 23, 38, 41, 59, 69.
84 TUMORS OF THE ABDOMINAL VISCERA
Intestinal Tract: Obstipation
Obstipation figures among the most frequent accompanying symptoms
on part of the intestine ; or the evacuation of the bowel may be irregular,
obstipation alternating with diarrhea.
Diarrhea
Cases that run along with diarrhea and are otherwise suspicious of
cancer, not seldom turn out to be pernicious anemias.
In passing it may be mentioned, that diarrheas may sometimes be
initially produced by hemorrhage into the bowel (67, 76).
In later stages of the disease profuse diarrhea may also be due to
disintegration of the neoplasm or its transmission to the colon with the
establishment of a gastro-colic fistula (18, 31, 54).
Obstipation as an Early Symptom
Obstipation may be put down as the rule in the early stages of gas-
tric cancer as also in its subsequent course. It may be the first symptom
of a developing gastric cancer and precede all other symptoms. When
unaccountable obstipation occurs in individuals who have previously al-
ways had good bowel action we must take into account etiologically the
possibility of cancer, and among other things institute chemical tests for
occult blood in the feces. The presence of large fecal masses in the sig-
moid flexure should constantly remind us of the possibility of gastric
cancer (100).
With reference to the pathogenesis of this kind of obstipation, it is an
interesting observation that gastro-enterostomy may entirely remove it.
Accordingly, we are no doubt concerned with "stomachal obstipation."
Intestinal Peristalsis
Mild intestinal peristalsis, limited to the lower abdominal region and
occurring above Poupart's ligament, is, according to my observation,
not a rare finding ^^ in those cases which run along with rigidity of the
stomach, even though there be no anatomical hindrance within the bowel.
Possibly we are here dealing with some kind of associated movement of the
intestine. ^-
In other cases pronounced intestinal stenosis may be present in the
rectum, dependent upon peritoneal metastases in the pouch of Douglas,
as in Case 10 (scirrhus), in which a stenosis was demonstrable 4 cm above
the anus, and in Case 92, which presented the clinical picture of bowel
stenosis.
This rectal type of gastric cancer frequently is accompanied by ascites
resulting from carcinoma of the peritoneum.
There is danger of mistaking carcinoma of the rectum, unless atten-
tion be paid to the intact condition of the mucosa that overlies the tumor-
"Nos. 11, 14, 36, 39, 85, 100.
^^ In reviewing tiie literature in connection with the publication of this work, I
found a notice in regard to this, which is in accordance with my observations. See
Anschiitz, Mitt. aus. d. Grenzg. d. Med. u. Chir., Ill Supplement b., 1907, page 516.
CANCER OF THE STOMACH 85
masses producing stenosis from without. The diagnosis might also re-
solve itself by left-sided supraclavicular glandular metastases.
In cases of subphrenic suppuration as a result of gastric cancer, in-
flammator}' adhesions may lead to intestinal peristalsis (7). Pronounced
meteorism may be due to retroperitoneal gland metastases (60, 66).
Peritoneum
The peritoneum may become altered through local inflammation in
the region of the tumor-mass and give rise to fibrinous exudation, which
is occasionall3' demonstrable as peritoneal friction (leathery rub).
Juvenile forms of gastric cancer tend to general distribution over the
peritoneum.
Thus I saw a case of general carcinosis of the serous membranes in
an 18 year old girl; point of origin: medullary carcinoma of the greater
curvature (autopsy).
In such cases there is the constant danger of erroneously diagnosing
tubercular serositis, which may be even the anatomist's verdict at the first
hasty glance.
Aside from the above, we find that diffuse infiltrating scirrhus cancers
of the stomach (so-called linitis plastica Brinton) frequently give rise to
metastases in the peritoneum.
Ascites
A fairl}^ constant accompanying symptom of carcinosis of the peri-
toneum is ascites (12, 51), which is mostly of hemorrhagic or "milky"
character ; the latter condition is peculiar, especially to those cases which
run along with extensive mesenteric and retroperitoneal glandular metas-
tases (85).
Leaving aside the hydropic-anemic forms, ascites in connection with
gastric cancer may also be due to engorgement of the portal vein in con-
sequence of metastases in the liver.
Subphrenic Abscesses
Among the inflammatory complications we might emphasize the occa-
sional occurrence of left-sided subphrenic abscess : ^^ much tenderness to
pressure below the left arch of the ribs and in the lateral portions of the
lower intercostal spaces of the left half of the thorax with occasional
transition of the process to the left pleura.
If in the final stages of gastric cancer there occurs peritonitis due to
perforation, it is usually manifested by chills, sudden collapse, and great
tenderness of the abdomen.
Liver
A rather severe icterus figures among the rare occurrences in connec-
tion with gastric cancer. ^^ Secondary cancer of the liver usually runs
its course without icterus.
"Nos. 7, 18, 34.
'Mn 124 cases under my own observation, I find icterus only twice; in one case
there was cancerous infiltration of lig. liepato-duodenale, in the other there were metas-
tases in the liver.
86 TUMORS OF THE ABDOMINAL VISCERA
If in connection with symptoms that are suspicious of cancer there
also exists a distinct icterus, it will always be commendable to take into
consideration the possibility of pancreatic or duodenal carcinoma.
Hepatic enlargement and increase in the consistency of the liver may
be dependent upon fatty infiltration (31).
One should be cautious in attributing unevenness of the liver surface
to metastases, as it may be due to corset lobe formation (64).
Whilst the formation of metastases in the liver may run along with-
out pain, there are on the other hand cases in which such intense painful
phenomena set in that one may be led to suspect cholecystitis, abscess
of the liver, etc., especially if accompanied by fever (46).
If the metastases have occurred in the left lobe of the liver and cause
a displacement of the border downward, it may easily happen that the
tumor-mass lying under the supposed elongation of the right lobe of the
liver may be mistaken for the tumor itself.
Circulatory System
The occasional local relations to the circulation and the resulting
auscultatory phenomena have already been discussed in another place
(page 81).
Bradycardia is not an altogether too seldom finding, at least in those
cases of cancer of the stomach which exhibit a tendency to exsiccation
of the tissues, and in which the blood findings may be more or less nor-
mal (3). In these cases there are usually underlying rather fibrous fonns
with stricturing of the pylorus. By way of mummification there results
a reduction of cardiac motor force with consequent atrophy, and this,
together with a state of inanition and secondary general weakness of
organs, seems to me the most frequent cause of occasional bradycardia.^^
In the anemic-hydropic type of gastric cancer (23) there is mostly
present tachycardia with venous noises ^^ and anemic heart murmurs. In
addition there may often occur, especially over the sternum, decidedly
rasping and grating systolic murmurs, which even autopsies have not
been able to account for, and which might be put down clinically as
pseudo- pericardial nmrmurs.
From my own experience I would regard valvular lesions (post-endo-
carditic) as extremely rare complications of malignant neoplasms. Per-
haps this may be explained by the rarity of infectious diseases in the
previous history of cancer patients.'^*'*
Atheromatous changes in the arterial system, peripheral as well as
central, are of frequent occurrence (1, 7). Thus I can remember cases
of youthful individuals who showed very pronounced atheromatous
changes (9, 38).
In Case 38 severe constant pains in the large toe were due to endar-
teritic process in the anterior tibial artery.
^= Nos. 3, 25, 35, 49, 50.
'«Nos. 19, 28, 51, fi3, 71.
^a i?. Schmklf. Krebs mid Tnfectionski'ankheiten. IMed. Klinik, 1910.
CANCER OF THE STOMACH 87
Those capillai-y dilatations in the cheeks, so often seen in patients
who have arteriosclerosis with hypertension, are frequently met with in
cancer patients.
Thrombosis of the crural veins (8, 73) are frecjuent accompani-
ments in the later stages of the disease; it will be well to bear this in
mind when there is pain in the lower extremities, e.g., in the calves, to-
gether with unilateral or symmetrical edema (4)7).
As a curiosity I will mention a case in which (via ductus thoracicus.^)
there occurred thrombosis of the left subclavian vein.
In a small percentage of cases intumescence of the spleen may occur,
but it rarely extends below the arch of the ribs. These are cases that
are accompanied by rather severe anemia, and the tumor may be desig-
nated an anemic tumor; moreover, I have seen splenic tumors in cases in
which the cancer of the stomach developed in the hilum of the spleen
(66), Avhich would lead us to think of local congestion resulting from
pressure on the splenic vein as the cause of the condition.
Atrophy of the spleen is of much more frequent occurrence than
enlargement.
It may be put down as a diagnostic axiom that when there is sus-
picion of gastric cancer and the spleen is distinctly enlarged, the first
thouglit should be of pernicious anemia.
Lympliatic System
In cases where gastric cancer is suspected, one should never omit to
examine the left supraclavicular space, and also the left axilla. It is
true in advanced cases only do we find "Virchow's gland" above the
clavicle, and even then the percentage of positive findings is not large.
They coincide almost constantly with retroperitoneal glandular metas-
tases, and are mostly hard, indolent glands.
I can recall but one single case of gastric cancer in which the glands
were of soft consistence, the patient being 30 years of age (89).
Quite exceptionally there may occur inflammatory, and even purulent,
processes in the glands in which metastases have taken place (79, 105),
and possibly the infectious agents are carried in by way of the thoracic
duct at the same time with the cancer-cells.
However, there may be pre-existent disease such as tuberculosis, and
then it is possible to demonstrate anatomically both processes side by
side.
Metastases into the right supraclavicular space are among the great-
est rarities, and I can remember but one such case (43).
Tuberculous lymphomas of the neck are sometimes also of extremely
tough consistence, yet they are seldom strictly unilateral, often recurring
in large numbers, and extend upward along the neck. Very frequently
the history is decisive (many years' duration) ; at times we can also
find scars after suppuration.
Caution must be observed not to confuse carcinomatous glands of the
neck with laterally situated calcified strumous nodules.
The latter have an angular surface feel and arc of bony, hard con-
88 TUMORS OF THE ABDOMINAL VISCERA
sistence: two findings which will perfectly safeguard the differential
diagnosis.
I have never observed metastases in the inguinal glands. Very ex-
ceptionally I have seen inflammatory swelling in connection with second-
ary purulent processes in the pouch of Douglas (7). The palpable
tumor-masses present in the epigastrium in cases of gastric cancer not
seldom owe their existence to gland metastases (60) ; with retroperi-
toneal extension they may even lead to compression of the aorta, and
thus give rise to murmurs.
Diffuse bone metastases may run a perfectly latent course. When
making direct examination for bone tenderness, however, it will fre-
quently be possible to elicit positive findings in such exposed parts as
the sternum, ribs, pelvic bones, and in this way gain information which
will strengthen the suspicion of metastases into these parts (Tl).
I recall a case of suspected osteosarcoma of the right trochanter,
in which autopsy disclosed a gastric cancer as the primary focus.
Genito-Urinary System
Polyuria, with the quantity of urine ranging between 2,000 and 3,000
cm^, not infrequently accompanies the anemic forms of gastric cancer
(8, 65, 84), even during part of the dropsical stage; in these cases we
are dealing mostly with medullary, non-stenosing forms. Here the poly-
uria is to be interpreted as anemic poh'uria, which is also found in severe
chlorosis or pernicious anemias.
Case 54 is characteristic: without the administration of a diuretic,
there was a sudden diuresis of 51, with simultaneous retrogression of
the edema.
Case 90 illustrates the possibilit}' of a confusion with renal and gas-
tric tumors.
Metastases into both ovaries (71, 72, 74), mostly bilateral, is not a
very rare complication ; in most cases there is coexistence of ascites
as a result of carcinomatosis of the peritoneum.
Thus there mav come to exist a gynecological type of gastric cancer
and the ovarian findings may be the occasion for useless operations.
Occasionally it also happens that the symptoms of an incipient gas-
tric cancer are referred to some accidental tumor of the genitalia which
bears no relation to the cancer, and in this Avay also operations are
undertaken on the strength of false suppositions (71).
The genesis of pleural complications may be manifold. Thus there
may be inflammatory pleural effusions in connection with subphrenic
abscesses (7), accompanied by much tenderness on pressure in the inter-
costal spaces ; hemorrhagic exudations are frequently found with diffuse
infiltrating scirrhus forms with ascites, and in youthful individuals they
can easily arouse false suspicion of tubercular serositis.
Aspiration after operation may lead to gangrene of the lung, and
thus to sanious exudate (55).
Pleural complications almost throughout belong to the later stage of
CANCER OF THE STOMACH 89
gastric cancer; when pleural effusions accompany the beginning of can-
cer development the etiology nmst be sought for in other directions.
Thus in Case 92, in addition to gastric cancer, there was present a
right-sided tubercular pleuritis.
Among the findings that affect the parenchyma of the lungs mention
must be made of the frequent occurrence of atelectasis in the left lower
lobe. The same can be associated with the oft-existing dilatation of the
stomach, and occasionally with carcinomatous infiltration of the dia-
phragm. The pulmonary parenchyma may also become the seat of
miliary metastases,^" presenting the clinical picture of a miliary tuber-
culosis minus the infectious elements. Thus in Case 95 there was present
extreme air-hunger, together with a slight left-sided hemorrhagic effu-
sion, microscopic examination of which gave reason to suspect malig-
nancy. During life the diagnosis of pulmonary carcinomatosis had
been made.
Nervous System
Contracted pupils and tardy reaction to light are not infrequent
findings ; together with rigidity of the vessels of the iris they may appear
as an accompanying manifestation of a general angiosclerosis.
In some cases insomnia is prominent even in the initial stages with-
out being dependent upon pain or similar causes.
The painful phenomena evoked by the local condition have already
been discussed in detail elsewhere (page 69).
Furthermore, many complications such as metastases in the liver,
endarteritic processes (38), venous thromboses, metastases in bones,
perforative peritonitis, etc., can give rise to intense pain.
As a curiosity I would like to cite a case of streptococcic meningitis
(54), in which the bacteriology furnished ground for suspecting intes-
tinal origin of the excitant of the disease ; an unimpaired sensorium was
clinically striking.
Tetanic attacks are among the greatest rarities in connection with
pyloric stenoses.
Shin
Edematous alterations in the subcutaneous connective tissue may
often be permanently absent. With fibrous and scirrhus forms of car-
cinoma of the stomach there may even result a sort of mummification of
the organism.
Opposed to this are the dropsical types whose external aspect stimu-
lates the picture of an acute nephritis ; in these cases there are often
present general edemas, even in the region of the sternum, belly-wall,
eyelids, etc. Here we are concerned mostly with medullary forms.
When there is suspicion of carcinoma we must always be on the look-
out for the presence of edemas ; especial attention should be given to the
region behind the internal malleolus and over the sacrum.
" See H. Lippman. Uber einen Fall von akuter haematogener Carcinomntose.
Zeitschr. f. Krebsf., Bd. Ill, page 290.
90 TUMORS OF THE ABDOMINAL VISCERA
Occasionally the edemas are latent, appearing only after protracted
walking or after a hot foot-bath.
The gravisli pale color of the face reminds us to a certain extent
of the appearance of the tubercular patients, and being partly yellowish
it bears resemblance to the color seen in pernicious anemia.
As not only bilirubin, but also urobilinogen, is frequently absent from
the urine, there is no evidence for the hepatic oi'igin of this color.
Under the influence of cancer development there may be at times —
though rarely — an Addison-like pigmentation (8, 81),. but exposure to
the sun's rays may also be a favoring factor. It is possible that nutri-
tive or toxemic disturbances of the sympathetic nervous system play a
part in this connection, since melanosis of the skin occurs with processes
that are accompanied by cachexia, such as cancer of the pancreas, peri-
toneal tuberculosis, etc.
Whoever believes that constitutional factors predispose to cancerous
disease will not be heedless of congenital pigmentary anomalies.
Thus in Case 89 the trunk showed depigmented zones arranged in
girdle fashion, which is occasionally observal)le in pernicious anemias.
Night-sweats sometimes count among the early symptoms of gastric
cancer and might lead one to the wrong diagnosis of tuberculosis (88).
Motor Apparatus
The occurrence of hallux valgus (3, IT, 63) and Heberden's nodes
(75, 78) as constitutional marks, as well as the anamnestic determina-
tion of arthritic antecedents, are to be considered worthy of attention.
FECES AND STOMACH CONTENTS
The examination of stomach contents and feces is not a condition
sine qua non for tlie diagnosis of gastric cancer; moreover, the cases
are not rare in which the chemical and microscopical examinations are
ornamental rather than practical, of complementary rather than funda-
mental significance. Naturally this is especially true in advanced stages
of the disease when a distinct tumor can be felt.
If, for didactic reasons or for the sake of the greatest possible cer-
tainty, a microscopic or chemical finding is desirable, it will be well to
examine the feces in the first place.- The principle that such methods
of examination should be employed first as are most sparing to the patient
ought to gain more recognition. Lavage of the stomach, when ulcera-
tion and disintegration is going on, is not an indifferent matter, and
includes the danger of hemorrhage, even of perforation. This, however,
should not deter one from performing lavage when it is necessary for
diagnosis ; statistically the danger of complications is slight.
But even in these cases I would recommend that the feces be exam-
ined first. There are three questions for which an answer must be found
in the chemical and microscopic investigation of feces or stomach con-
tents :
CANCER OF THE STOMACH 91
1. Is there hemorrhage of the stomach?
2. Is there stagnation of stomach contents?
3. In what state are the secretions of the gastric mucosa?
(Janlfic HemorrJiage
Gushing hemorrhages with elimination per os or per anum are, gen-
erally speaking, foreign to the clinical picture of gastric cancer, although
such ulcerous Ijchavior may occasionally mark the beginning or end of
the process. It is well known that those small hemorrhages which lead
to coifee-ground vomiting are incomparably more frequent. To a cer-
tain extent they may come from a gastric mucosa that has not under-
gone carcinomatous alteration, but is in a state of active or passive
h^'peremia.
Analogous coffee-ground vomiting is sometimes fqund without ulcer-
ation in the terminal stages of pneumonia, diabetes, sepsis, icterus gravis;
furthermore, in gastric crises and intestinal stenoses. These quantita-
tiveW slight gastric hemorrhages, which are the rule in cancer of the
stomach, do not give rise to characteristic tar-colored stools ; they re-
main macroscopically "'occult," but are chemically demonstrable. It has
already been stated elsewhere (page 14) that these "chemical bleedings"
in the feces have great significance, even for the early diagnosis of gas-
tric cancer.
Is a positive chemical blood finding in the feces a constant, regular
accompaniment of gastric cancer?
This question, which is of great diagnostic import, I would like to
answer conditionally only, namely, on the supposition that my technique
of examination for blood-coloring material be used. The same is, as has
been previously stated, designedly coarse. By the use of large quantities
of feces and very thorough extraction, positive results may certainly be
obtained in cases where by the use of my very much simplified technique,
which I have reconmiended for practical diagnostic purposes, a negative
finding is the result. As emphasized on a former page, the diagnostician,
in contradistinction to the professional chemist, is interested in chemical ,
substances — in this case blood-coloring material — not for their own sake,
but because of their diagnostic value, i.e., their presence in certain pro-
portions.
The above question may be answered by saying that, especially with
a palpable tumor, the demonstration of blood is constantly successful
and only exceptionally negative. Furthermore, I would not look upon a
negative result as being opposed to the diagnosis of gastric cancer, pro-
viding such negative findings be not absent for weeks at a time.
Positive findings will have to be utilized with much greater precau-
tions if they are obtained with more sensitive tests.
Symptoms of Gastric Stagnation
in the Feces
Since in many cases impaired motor function of the stomach figures
among early symptoms of gastric cancer, we have already discussed on
92 TUMORS OF THE ABDOMINAL VISCERA
a former page those symptoms of the disease which are referable to ob-
struction of the pyloric passage and stagnation of the stomach, namely,
such manifestations as visible gastric peristalsis, balloon-stomach, SH2
fermentation, colic of pyloric stenosis, etc.
The history (vomiting foods of the previous day) also will some-
times lead to the assumption of gastric stagnation. We can also infer
the presence of gastric stagnation from examination of the feces, partic-
ularly with reference to vegetations.^*
Probable and almost certain evidence of stagnation can be inferred
from the presence of stomach sarcince, which from man}'^ years' experience
along these lines I consider a separate species.^^
Sarcinfe in the feces are always of gastric origin and equivalent to
the demonstration of sarcinje in the stomach itself.
But sarcinse develop in the stomach only when there is present stag-
nation of high degree ; their constant presence during continued observa-
tions almost always coincides with the existence of organic stenosis at
the pylorus or duodenum.
There seems to be some relation between the formation of SH2 and
the presence of sarcinjE.
Malignant pyloric stenoses are accompanied by sarcince vegetation,
especially so long as the HCl secretion persists.
The persistent finding of sarcinas in the feces almost always is jus-
tification for assuming gastric stagnation of high degree which is de-
pendent on pyloric stenosis.
The assumption of rather intense stagnation of stomach contents is
also close at hand in those cases where the lactic-acid bacilli are promi-
nent in the feces.
Extreme cases of this kind, in which the colon bacillus is forced into
tlic background, are usually cases of cancer of the pylorus. Here the
changed appearance of the bacteriological picture of the stool is due to
the transition of abundant lactic-acid bacilli from the stomach into the
bowel. At the "Naturforscher" Congress in Meran in 1906, I had occa-
sion to point out the fact that under pathological conditions even the
small intestine could become the brooding-place for lactic-acid bacilli,
so that with diseased conditions of the same — which, however, are rare —
there may be an abundant vegetation of lactic-acid bacilli in the feces.
A finding having such a genesis I observed in a case of lympho-
sarcoma of the small intestine and in a case of chronic, deep-seated and
severe stenosis of the small gut.
These cases are very rare exceptions to the general rule, that an
abundant vegetation of lactic-acid bacilli in the feces points in the first
place to the stomach as their source, and in general coincides with the
finding of cancer of the pylorus.
Besides the ulcerative process, stagnation and deficiency of hj^dro-
'^ See page 20.
'"See R. Schmidt, Med. Klinik, 1909, No. 2. Mitt. d. Ges. f. innere Med.. Vienna,
III, page 240. Mitt, aus den Grenzgebieten der Med. und Chirurgie, Vol. XV. 5.H.,
1906.
CANCER OF THE STOMACH 93
chloric acid are the two fundamental causes for the development of lactic-
acid bacilli in the stomach, and the numerical strength of the lactic-acid
bacilli that arrive at development is mostly in direct proportion to the
quantitative extent of both these factors.
This determines the diagnostic value. Lactic-acid bacilli, appearing
sporadically, are of no value for diagnosis ; it is only their grouping in
a "vegetation picture" that renders them diagnostically valuable. The
correct estimate of this numerical strength will of course depend upon
personal experience. Whoever is not in a position to avail himself of
the latter, will do better, in the beginning of his observations, not to
include in his diagnostic considerations the gastro-intestinal bacterio-
logical findings, since mistakes may result only all too easily.
It would also be a great mistake to rule out a gastric cancer because
of the absence of lactic-acid bacilli.
State of Secretions
Since the time of V. Velden, in 1879, the absence of HCl in gastric
cancer passed as a sort of axiom.
How^ever, cases of gastric cancer are not rare in which, even in ad-
vanced stages of the disease, there is persistence of HCl secretion.'**^ The
mucous membrane of the cancerous stomach seems to respond for a long
time with HCl secretion, especially to the severe irritation produced by
the products of decomposing stomach contents obtained in the morning
from a fasting stomach.
After lavage of the stomach, how^ever, the mild irritation of a tea
and roll breakfast is not sufficient to stimulate HCl secretion anew.
Occasional, persistence of HCl secretion, despite far-advanced car-
cinoma of the stomach, proves that there can be no direct connection be-
tween cancer of the stomach and achlorhydria. A causative link is
necessary, and it would seem like forcing things w^ere we to look for this
link elsewhere than in the chronic gastritis that accompanies the devel-
opment of cancer.
In this way we can also explain those cases in which achlorhydria
continues after resection of the stomach. "^^
At times, of course, even factors of dyscrasia may have an influence
on the state of secretions of the gastric mucosa.
Persistence of HCl secretion is also met with in cases in which there
is no ground whatever for svipposing a pre-existing ulcer. There would
be really no reason why a cancer having an ulcer for its base should act
differently in this respect. In general, the conditions for persistence of
HCl seem to be especially favorable if the cancer is limited locally, ex-
tending in depth rather than along the surface.
A positive finding of HCl, therefore, especially when occurring in
medium or even subnormal quantities, must not deter us from the diag-
nosis of gastric cancer, providing there are other sufficient grounds for
*°Nos. 13, 22, 48, 56, 66, 67, 72, 76, 79, 80.
*^H. Mafti, Deiitsche Zeitschr. f. Chiriirgie, Vol. 77 (107 Falle von Magenreaktion).
94 TUMORS OF THE ABDOMINAL VISCERA
it clinically. More important than a single finding will be the determina-
tion of the HCl curve, which at times declines rapidly (52).
Chemical Analysis of Stomach
Contents
In determining the secretory conditions, the analysis of stomach con-
tents will always be of prime importance.
If vomited stomach contents are not available, or examination of
same has not already yielded more or less decisive findings, such as stag-
nating food remains of the previous day, areas of lactic-acid bacilli, etc.,
it will be advisable to wash out the stomach after a test breakfast of
water and a roll (about 400 cm^ of unsweetened tea, or water, and one
roll). Withdrawal to take place about % "^ ^^^ hour after taking,
RiegeVs test dinner had better be avoided on account of the fre-
quently existing intolerance for meat, and it offers no other advantages.
The evening before the test breakfast the patient should eat prunes
or some ham, so that in case of pronounced motor insufficiency plant-
cells or muscle fibres may show up in the withdrawn test breakfast.
For qualitative as well as quantitative purposes, we would recom-
mend Toepfer's HCl reagent,^- i.e., a 57f alcoholic solution of dimethyla-
midoazobenzol. By blotting the stopper of the reagent bottle on a small
folded filter-paper there results a yellow circular disk. Dip the end of
a glass rod into the test breakfast that has been withdrawn and streak
over half the yellow disk. If the color remains yellow, or becomes light
red, it indicates that free HCl is absent or is present only in minimal
quantities.
The total acidity is estimated in the well-known way by means of a
1% alcoholic phenolphtiialein solution and /4() • . .Na OH.
Further determinations, such as combined HCl, organic acids, pepsin,
active principles of glands, steapsin, have no decisive diagnostic sig-
nificance.
The same is true of lactic-acid tests still so much in vogue. With-
out stagnation there is no formation of lactic acid in the stomach. If,
as is prescribed in cases of stagnation, the stomach is thoroughly washed
out before giving the test breakfast, and then the test breakfast is given,
Uffelmann's test will prove negative even in cases of advanced gastric can-
cer, providing no contents remained in the stomach after lavage. The
excitants of lactic-acid formation in the stomach — among which strains
of colon bacilli certainly also play a part — are simply not able to gen-
erate sufficient quantities of lactic acid from the carbohydrates of the
test breakfast in the short space of % of an hour.^^
The demonstration of lactic acid, which attains the highest value
when occurring in stagnating stomach contents, is nothing more than a
chemically demonstrable partial evidence 'of stagnation in case of de-
ficient HCl secretion ; but stagnation is frequently indicated macroscopi-
^^M. Toepfer, Zeitschr. f. physiol. Chemie, 1894, Vol. 19, page 104.
*^ Boas, Uber das Vorkomnien und die diagnostische Bedeiitung der Milchsjiure
im Mageninhalt. ' Miinchener nied. Wochenschr., 1893, No. 43.
CANCER OF THE STOMACH 95
cally, especially also microscopically, by the absence in the test break-
fast of food remains, such as muscle fibres, plant tissues, etc., ** and also
finds particular microscopical expression in the colonization of vegetable
and animal parasites.^''
Microscopical Examination of
Stomach Contents
Order of microscopical examination of vomited or withdrawn stom-
ach contents: One loopful of stomach content is placed upon a slide
together with one drop of alcoholic solution of Sudan HI, then thor-
oughly mixed with one drop of Lugol's solution. One loopful of this
mixture is taken for examination.
In examining same the following 3 groups of findings must be con-
sidered, similar to those in fecal examinations:
/. Alimentary findings:
a. Muscle fibres ; after test breakfast these are a certain proof of
great stagnation. The Lugol solution has colored them yellowish-brown
or green (presence of bilirubin).
b. Starch granules, stained blue with Lugol solution. Normal find-
ing after a test breakfast.
c. Neutral fat and soap needles. The neutral fat is stained red with
Sudan III ; the soap needles are unstained. These and fatt}^ acid needles
must not be confused with the "long" bacillus. After a test breakfast
these findings are signs of stagnation, providing the patient has not
taken any milk before it.
d. Plant tissues, coming from currants, cranberries, prunes, etc.,
eaten the evening before and found in the test breakfast, are always a
sign of stagnation.
//. Anatomical findings, depending upon anatomical alterations of
the gastric mucosa :
a. Evidence of hemorrhage, as shown by erythrocyte shadows ^'' or
granules of brown-colored blood pigment detritus, in which the nuclei of
leucocytes are most often visible.
b. Pus. Found mostly in far-advanced and much ulcerating cancers,
and then only seldom.
c. Admixtures of mucus (best studied macroscopically).
d. Tumor particles. ^'^ The appearance of the latter probably al-
ways denotes an advanced stage of the disease and is not a frequent find-
ing. In order to avoid mistaking these for shreds of normal nmcous
membrane an exact histological examination is required.
** For this reason it is advisable to give the patient currants, cranberries, prunes,
etc., the evening before the test breakfast.
*-^ Coni]iare Gastro-intestinal GroMths, page 20.
^" This finding indicates that the hemorrhage is not of recent date, at least has not
occurred during the withdrawal of the food.
*' See Reineboth, Deutsches Arch. f. klin. Med., 1897, Vol. 58, page 6-2.
96 TUMORS OF THE ABDOMINAL VISCERA
///. Bacterial ^^ and vegetable growths.
a. Lactic-acid bacilli not stained by Lugol solution.
b. Leptothrix forms ; long, but plump rod-shapes and mostly stained
violet blue by Lugol.
c. Forms of colon bacilli.
d. "Stomach" sarcina- ; the large-celled type staining yellowish brown
with Lugol, the small-celled type remaining unstained.
e. Yeast-cells ; when pathologically increased these are sometimes
stained dark brown (glycogen reaction.'').
/. Mycelium threads of mould fungi.
g. Megastoma entericum.
Signs of HypoclilorJiydria in
the Feces
As far as the determination of deficient HCl in the gastric juice is
concerned, certain probable conclusions may also be drawn from exami-
nation of the feces.
Alimentary findings would come into consideration in so far as we
are dealing with remnants of muscle fibres. Yet in the using up of food-
stuffs there are different factors that must be taken into consideration,
such as quality of the meat food, its manner of connninution ; gastric and
intestinal juice, pancreatic secretion, motility of the gastro-intestinal
tract, etc. This multiplicity of influential factors renders the interpreta-
tion of alimentary findings in the feces more or less illusory and there-
fore would make it appear needless to carry out a test diet, which for
that matter would be impracticable in view of the much limited food
tolerance in connection with gastric cancer. In cases where with fairly
regular bowel movements and without any particular bowel atony and
moderate intake of meat (once a day) there are more or less abundant
muscle fibres whose transverse stria? are well preserved in the feces, it
will generally be permissible to assume a diminished hydrochloric-acid
secretion.
I consider the experiment of Sahli, i.e., digestion of catgut {SaldVs
desmoidrcaction)^" of diagnostic value in those cases where it proves
negative, i.e., where the urine does not become colored. In these cases
HCl is always diminished or entirely absent.
It is advisable to carry out the test in the following way : One half
hour after taking the breakfast, consisting of tea and a roll, the patient
swallows a little sack made of India-rubber, which contains the reagent
and is tied up with very fine raw catgut; the contents is a methylene pill
(.05 medicinal methylene blue together with extr. and powder liquir.
aa .04).^<^
My own experience has convinced me that permanent absence of blue
** Especial regard should lie had for vomited material and also the sediment of
the irrigation fluid.
« 7?_ Fravenheryer, Sahli's Desmoidreaktion, etc. Wiener med. Woch., 1907, No. 30.
M Pi-epared by the firm of G. Pohl in Schonbaum, District of Danzig.
CANCER OF THE STOMACH 97
discoloration of the urine always justifies us in assuming at least a hypo-
chlorh^'dria ; frequently we are dealing with achlorhydria.
Positive findings (blue discoloration of the urine after several hours)
I do not consider of value, as among other things such accidents as im-
perfect tying of the sack, etc., may cause the India-rubber sack to open.
The abundant occurrence of lactic-acid bacilli in the feces is, as has
previously been stated, a finding which in most cases is concomitant with
achlorhydria.
Another finding in the feces which I consider highly suspicious of
achlorhydria or subacidit}', is the presence of animal parasites, such as
megastoma entericum (4), tjenia, ascarides, etc. In this connection it
seems to me that the subacidity is not the result but the cause of mod-
erate parasitic invasion. In most instances, for that matter, we are here
concerned with chronic forms of subacidity, such as achylia gastrica.
TYPES OF DISEASE, COURSE AND DURATION
Despite the biological and anatomical similarity of the underlying
condition, the clinical pictures afforded by cancerous disease of the stom-
ach-wall vary within wude limits, and individual types can easily be
recognized.
Mummifying Type
Thus there is a "mummifying" type, observed most frequently in
advanced age, especially if the carcinoma be of a fibrous character and
encircles the pylorus. In these cases edemas almost never occur. As a
result of continued losses of fluids through massive evacuation of the
highly elastic stomach there ensues severe exsiccation of the tissues. The
vomiting is mostly "coffee-ground," containing abundant lactic-acid ba-
cilli. The heart is small, with now and then bradycardia.
Hydropic- Anemic Forms
The very opposite to the above is the hydropic-anemic form,^^ which
is frequently found at a less mature age, being characterized by the
development of a general dropsy of the skin, besides effusions into the
serous cavities. These are mostly medullary, severely ulcerating and
constantly bleeding, extensive tumor-masses which produce little or no
stenosis.
Not infrequently the stomach contents contain lactic-acid bacilli in
only moderate quantity, vomiting is rare, and appetite and tolerance of
the stomach are often very good. The heart is dilated, there are present
anemic murmurs and venous hums, tachycardia.
Anemic Type
In the early stages of this form anemia sets in without anasarca or
dropsies, so that this "anemic" tj'pe in its external aspect reminds one
" Nos. 23, 41.
98 TUMORS OF THE ABDOMINAL VISCERA
chiefly of the picture of pernicious anemias. The color of the face inclines
to yellow, which may be dependent upon hemochromatosis; even Add'uon-
like pigmentations may occur with this form.
Peritoneal and Pleural Forms
Finally, I would like to designate as "peritoneal-pleural" forms those
cases in which peritoneal or pleural metastasis occurs early, thus in most
instances leading to hemorrhagic or "milky," turbid ascites. Edemas of
the skin are not characteristic of this form.
This type is led up to especially by scirrhus carcinomas which dif-
fusely infiltrate the stomach and lead to its contraction."- Vomiting or
eructation of gases is very prominent, the vomiting is not copious, but
in conformance with the small lumen of the stomach occurs in small quan-
tities.
This form can easily be mistaken for tubercular serositis, because
by way of the lymphatic current it leads to metastases of the serous sur-
faces, omentum, ligamentum teres, and often also the umbilicus : ^'"^ the
liver, as a rule, remains free from the more extensive metastases.
The classification of the four types just discussed was the result of
general impressions gained by inspection.
Various other types could be singled out, based on prominent detailed
symptoms, so that we might speak of "rectal," "gynecological" and other
types of gastric cancer.
Such classification, however, seems to me more or less artificial and
arbitrary. The facts concerning same will be discussed in the chapter
on "Differential Diagnosis."
Course of the Disease
With regard to the course of the disease it seems to me particularly
worthy of note that the disease curve is not a progressively increasing
one, but frequently shows remissions, which are partly spontaneous and
partly the result of treatment.
It will have to be borne in mind that the complaints of the patients
are not referable directly to the tumor itself but rather are due to chronic
gastritis, stenosis of the pylorus, hemorrhages, etc. The stenosis may
be diminished through ulceration or it may be overcome by compensatory
hypertrophy of the musculature of the stomach. Chronic gastritis is
amenable to therapeutic influences, the hemorrhages may cease, etc.
Nothing would be more erroneous than to allow such deceitful improve-
ments to throw one off the track to the right diagnosis.
Even the Karlsbad cures, which ordinarily rather increase the com-
plaints of gastric cancer patients, are sometimes accompanied by good
results (65, 79). The stomach complaint may even disappear sponta-
neously for a long time (8, 31, 44). Existing pains may become less
" Nos. 2, 6, 12, 53, 60, 70, 81.
" See, Qti^nu et Longuel, Du cancer secondaire de ronibilic. Revue de Chirurgie,
1896, XVI, page 96.
CANCER OF THE STOMACH 99
or vanish entirely; in tliese latter cases the cessation of HCl secretion
and the diminished food intake are the determining factors.
In this way the body-weight may, even without the occurrence of
edema, be considerably increased shortly before death (58).
After operative interference, even when there remain behind cancerous
tumor-masses, the body-weight may undergo a temporary increase (59).
Duration
The duration of the disease manifestations from their first appearance
to their ending by death naturally varies within wide limits.'"'^ Only in
a single case (66) of my histories is there a probability of 3 years' dura-
tion. Not infrequently cases are found that extend over 2 years and
several months. In many cases, of course, the first symptoms of the
disease as shown by ananmesis date back only a few months prior to death.
However, cases that run over a period of two years are not rare, and
they are the cases in which on retrospection one can say : it would have
been possible to make the diagnosis at the beginning of the disease. Pes-
simism with regard to the possibility of an early diagnosis, therefore,
seems to me out of place. Of course, there are cases having an apparently
long period of latency.
Period of Latency
But the period of latency can be influenced, and I hope that also the
present work will contribute to its abbreviation in this or that case.
A physician who is well instructed in the symptomatology of cancer dis-
eases will not seldom find suspicious factors of malignant disease in those
cases which, as far as the less experienced observer is concerned, are still
in their "latent period."
On the other hand, it is the duty of physicians to make clear to
their patients that stomach complaints of milder degree, especially when
occurring in individuals with otherwise strong digestive organs, should
never be underestimated.
I am also convinced that continued clinical study of the cancer
problem will bring to light a decided disposition on the part of certain
individuals to cancerous disease and will also yield the details *by which
to recognize it.
What we are accustomed to designate as period of latency is certainly
not a time during which there are no symptoms, but rather a time dur-
ing which, either through the fault of the patient or his medical adviser,
the existing symptoms are not observed ; this can and will be changed.
SUSPICIOUS FACTORS AND DIFFERENTIAL DIAGNOSIS
That a tumor in the epigastrium plus stomach contents deficient in
free HCl but richly laden with lactic-acid bacilli, arouses the suspicion
of gastric cancer, needs no special mention.
'^ See Case History, ad 9.
100 TUMORS OF THE ABDOMINAL VISCERA
We have already discussed in detail the suspicious factors in so far
as they form a part of the symptomatology. The diagnosis will result
from the correct grouping of all the symptoms in a given case.
Here it may be permissible to call attention to several brief, rather
general considerations and combinations of ideas which may give rise to
the suspicion of cancerous disease of the stomach, even in its incipiency.
Such suspicious factors would be among others :
1. Unaccountable occurrence after the 30th year of gastric s^^mp-
toms, such as pressure in the stomach, eructation, etc., in an individual
previously favored with a healthy gastro-intestinal tract ("gastro-intes-
tinal athletes").
2. Given the same gastro-intestinal individuality, a disproportion be-
tween cause and effect in so far as the accused dietetic error gives rise
to strikingly stubborn stomach complaints.
3. Rapid diminution of gastric tolerance in a "stomach athlete," e.g.,
when soon only milk and soup are well borne.
4. Long duration of occult intestinal hemorrhage in suspected ulcer
despite proper treatment with prolonged rest in bed.
5. As certain forms of gastric cancer begin and continue with the
typical subjective symptoms of peptic ulcer, and as the treatment of
ulcer will also produce apparent cures in these cases, it will always be
advisable to make the diagnosis of gastric ulcer with reservation.
Personally I consider this reservation especially appropriate in cases
where we are dealing with strong ''"' individuals previously enjoying good
digestive energy, between the ages of 40 and 50. Such patients should
be warned of the possibility of a malignant ulceration, so that they place
themselves under continued observation.
6. Finding of sarcinae in the stomach contents or feces when the
stomach ailments are of short duration, denoting a rapid development of
pyloric stenosis. ^^
7. Stubborn obstipation in an individual who has hitherto been reg-
ular.^'^
Differential Diagnosis
The foregoing and similar associations of ideas will frequently awaken
the suspicion of carcinomatous disease of the stomach and give occasion
for further differential diagnostic considerations.
As a measure of prime importance in differential diagnosis I regard
repeated examinations of the feces for "occult" hemorrhages.^^ If the
findings prove constantly negative, a gastric cancer is highly improbable.
^^ Simple gastric ulcer seems generally to be more common in weak individuals with
phthisical appearance, irritable vaso-niotor weakness and enteroptosis. See Mitt. d.
Ges. f. innere Med. u. Kinderheilk., 1910, page 87.
''"Nos. 16, 22, 35, 52, 56, 72.
"Nos. 37, 39, 40, 42, 91.
^^ See page 16.
CANCER OF THE STOMACH 101
Chronic Gastriiis
Pr()l);ihly one of tlio most frequent erroneous diaf^noses is "chronic
gastric catarrh." This diagnosis seems to be made as extremely frequent
as it is extremely seldom justified, for "chronic gastritis" is much more
of an anatomical than a clinical conception. The severest "chronic gas-
tritis" may he observed post mortem, whereas during life there were
only extremely mild or not any gastric symptoms. This contrast is fa-
miliar to anybody who has witnessed many autopsies, I do not think that
during the course of an entire year I have had a single occasion among
my patients to diagnose "chronic gastritis" as the sole cause of existing
gastric complaints.
In cases where pains become prominent, where they are mechanically
influenced by position, etc., in short where there exist rather serious di-
gestive difficulties, this diagnosis of "chronic gastritis" must be made
cautiousl3^ It is the greatest enemy to the early diagnosis of gastric
cancer.
Gastric Ulcer
As long as there is no distinct tumor at hand,*^^ confusion with a
benign ulceration of the stomach is not only conceivable but at times
unavoidable.
Common to both above all else is the demonstration of blood in the
feces.
To my mind the only reliable criterion is the course of the disease
and the therapeutic test ; but even here great caution should be exercised,
since the subjective complaints of carcinoma also may often be favorably
influenced by the gastric ulcer treatment, especially with rest in bed.
The rapid occurrence of severe stagnation, persistence of "occult melena,"
despite a rest cure of many weeks, may decide in favor of malignancy.
Anorexia is not a rare accompaniment of gastric ulcer, and even the chem-
istry ^" of the gastric juices is frequently alike in so far as the findings
of HCl are normal.
Gastric Neuroses
Gastric neuroses occurring, for instance, at the time of the menopause,
frequently awaken the suspicion of carcinoma because of the severe ano-
rexia, continued gastric pressure and rapid emaciation.
Acute Gout
I have also seen acute attacks of gout run a course of man}' weeks
accompanied b}'^ severe anorexia and a particular disgust for meat.
Trichohezoar
"Hair tvnnors" of the stomach are probably a rare cause of mistaken
diagnosis.
^' Perigastric tumors with gastric ulcer count among the greatest rarities.
'" The cases of gastric ulcer observable in Vienna, as a rule, show no hyper-
chlorhydria. *
102
TUMORS OF THE ABDOMINAL VISCERA
Tuberculosis
Consumptives often suffer from anorexia, and the suspicion of can-
cer in these cases may be strengthened by the more or less high degree of
cachexia produced by the underlying ailment. Aside from that, many
cases of tuberculosis are accompanied by subacidit}^ and even achlorhy-
dria ; furthermore, in senile phthisis the pulmonary symptoms are not
prominent or are obscured by an accompanying emphysema.
The motor function of the stomach, however, is usually intact. The
absence of "occult" melena deserves particular and full attention.
Pernicious Anemia
The same is true of pernicious anemias, which from their general
aspect may easily awaken the suspicion of gastric carcinoma. Among
the symptoms which occasionally are common to both we might mention :
emaciation, pronounced feeling of weakness, pallor, anorexia with dis-
gust for meat, achlorhydria, sporadic lactic-acid bacilli in the feces,
epigastric tenderness to pressure (in pernicious anemia being due to hy-.
peremia of the liver), epigastric resistance (enlargement of the liver and
spleen !).
For a rapid differentiation we might consider the following:
"Anemic" Type of Gastric Cancer.
Obstipation.
Tumor of the spleen rare.
Rarely any tenderness to pres-
sure over the lower half of the
sternum.
Occult "melena."
Lactic-acid bacilli in the
often very abundant.
fe(
Pernicious Anemia.
Diarrheas often dating back a
number of years.
Tumor of the spleen frequent.
Blood test of feces negative.
Few lactic-acid bacilli in the feces;
often abundant presence of
cocci.
In this way the differential diagnosis may frequently be made with
great probability even without a blood examination.
Tuhercular Serositis
Confusion with tubercular serositis may occur, especially in case of
the peritoneal-pleural types (see page 98) of gastric cancer, and that
so much the easier when we are dealing ^^nth youthful individuals, in
whose cases we are less apt to think of malignant diseases.
Thus I recall the case of a girl, 18 years of age. During life The.
serosarum was thought of. Autopsy disclosed a soft carcinoma of the
greater curvature, lymphatic metastases into the peritoneum and pleura
with hemorrhagic effusions.
Such cases sometimes run a moderately febrile course and occasion-
ally are accompanied by diazo-reaction, as so often almost regularly hap-
CANCER OF THE STOMACH 103
pens in tuberculosis of the peritoneum. Carcinomatous infiltration of the
umbilicus (5.*J), good motility of pleural effusions, "occult melena,"
copious vegetations of lactic-acid bacilli in the feces and strongly hem-
orrhagic or "milky" character of the ascitic fluid may occasionally be
findings which rapidly decide in favor of the diagnosis of carcinoma.
Abscess of the Liver
Uniform diffuse metastasis into the liver (40, 82) may also be very
misleading, especially if accompanied by nmch painfulness and fever.
Here there is a possibility of making the wrong diagnosis of abscess of
the liver, cholangitis, echinococci, etc.
On the other hand, cases of gastric or duodenal ulcer with secondary
abscesses of the liver may easily lead to the assumption of gastric car-
cinoma with metastasis in the liver.
Neurasthenia
Where a gastric cancer develops in a neuropathic individual there is
danger of confusing an organic with a functional disease.
Thus in one case the disease manifested itself with a voracious appe-
tite ; another complained of burning in the stomach, "as if a lamp were
in it."
The symptom picture in such cases readily assumes neuropathic traits.
Organic lesions of the nervous system may come into the foreground
and obscure the primary disease process.
Neuralgias
Hemiplegia
Thus in one case there existed very severe neuralgias which were the
result of metastases in the spinal column ; in another case there was hemi-
plegia due to embolism from an ulcerating endocarditis (infection from
the ulcerating surface.'').
Senile Tuberculosis
It has already been stated that in cases of senile tuberculosis one may
easily be falsely suspicious of cancer of the stomach. But mistakes can
also be made in the opposite direction.
I have in mind a case in which tuberculosis was thought of on ac-
count of hemoptysis, and the autopsy revealed metastases in the lungs ;
in another observation there was a combination of pulmonary cavity and
gastric cancer. I have also observed multiple caries of bones and can-
cer of the stomach. Mediastinal gland metastases may provoke delusory
attacks of asthma, or the finding of a purulent left-sided pleural effusion
may cause one to overlook the primary disease of the stomach. Early
carcinomas, occurring about the fortieth year, are very frequenth' accom-
panied by healed tubercular foci.
Addison
Adynamia, together with bronzed discoloration of the skin, may lead
us to think of Addison's disease when there is really a gastric cancer
(see page 47).
104 TUMORS OF THE ABDOMINAL VISCERA
Intestinal Stenosis
The symptoms of secondary intestinal stenosis may also obscure the
clinical picture of carcinoma of the stomach. Thus increased gastric
peristalsis frequently exists with moderate rigidity of the bowel; but
there may also be real stenosis of the bowel even to the occurrence of
ileus, due to metastases in the pouch of Douglas, invasion of the colon or
metastasis in the mesentery of the small intestine together with con-
traction.
Endocarditis, etc.
Occasional cardiac complications are ulcerating endocarditis and
peritonitis, in which cases we are apt to consider the ulcerating surface
as the source of the infectious excitants.
Meningitis
A complicating infectious process that I saw in one case was the
occurrence of streptococcic meningitis (54).
Complications of this kind are apt to attract the entire attention of
the observer.
Perforating Peritonitis
The same holds good of perforative peritonitis (23, 74) occurring
acutely with chills and abdominal pains.
Abscess of Abdominal Walls
Abscesses of the abdominal walls should always be investigated with
reference to their possible connection with carcinoma of the stomach.
In the differential diagnostic considerations so far we have dealt with
the possibility of mistake between gastric cancer and non-neoplastic dis-
eases of organs.
There still remains to be considered the possibility of mistakes be-
tween gastric cancer and other neoplasms.
Carcinoma of the Esophagus
Deep-seated carcinoma of the esophagus might be considered first. If
this condition, as is often the case, causes no difficulties in swallowing,
then the sum of the clinical symptoms — including demonstration of blood
in the feces — very often entirely answers the description of gastric can-
cer, only there is no palpable tumor. The subjective complaints are fre-
quently referred to the epigastrium. A wrong diagnosis in these cases
could easily lead to a useless operation ; this possibility, therefore, must
always be reckoned with when the findings by palpation are deficient.
However, the reverse error is also possible where a gastric cancer is
situated high up where a scirrhus carcinoma infiltrating the entire stom-
ach causes stenosis of the cardia (10).
CANCER OF THE STOMACH 105
Carcinoma of the Colon
Tumors situated in the median line of the epigastrium ought never
to be referred to the colon, but rather to the stomach, as the middle por-
tion of the transverse colon almost never becomes carcinomatous.
Rectal Carcinoma
At times rectal carcinomas are erroneously assumed in these cases
where we are dealing with stenosis caused by gastric cancer metastases in
the pouch of Douglas.
Cancer of the Gail-Bladder
Moreover, carcinoma of the gall-bladder when running its course with-
out icterus and stenosing the pylorus may easily be mistaken for cancer
of the pylorus. Under these circumstances there may even occur "cof-
fee-ground" vomiting and copious vegetation of lactic-acid bacilli. A
history of cholelithiasis and the occasional unusual degree of gastric dila-
tation will admonish one to be cautious.
Ovaries
Ovarian metastases may be mistaken for a primary tumor.
Bone Tumors
It is extraordinarily rare that metastatic bone tumors give occasion
for confusion with primary bone tumors.
I remember a case in which the assumption was osteosarcoma of the
thigh. Autopsy: primary carcinoma of the stomach.
The combination of gastric ulcer and tumors of Grawitz, which I
can remember having met, can easily give rise to the wrong diagnosis of
a gastric neoplasm. In one case there was present even "coffee-ground"
vomiting with copious vegetation of lactic-acid bacilli and achlorhydria.
Autopsy: Cicatricial benign stenosis of the pylorus and Grawitz tumor.
Renal Neoplasms
Case 90 illustrates the possibility of confusion between gastric and
renal neoplasms. This mistake is occasionally favored by the fact that
the painful sensations in gastric cancer, even though seldom, may be to
a greater extent localized posteriorly in the left or right kidney region.
Carcinoma of the Large Intestine
Stenosis,*'^ secondary catarrh of the large intestine and ulceration are
the factors which, from internal necessity, comprise the entire sympto-
matology of carcinoma of the large bowel, at least in so far as the intes-
tinal tube as such is concerned. From this there also results the varie-
gated row of symptoms which are designated as early symptoms and
which will be discussed in the following pages.
EARLY SYMPTOMS
1. Fain Phenomena
In many cases they introduce the clinical manifestations and precede
the objective findings. An exact estimate of their value in a given case
belongs to the most important requisition of an early diagnosis in this
domain.
Atiacl's of Colic
Attacks of colic, otherwise unaccountable or apparently caused by a
dietetic error, are not seldom the first signal of alarm.
In these cases the first important thing is to correctly interpret the
character of the colicky attacks and discover their intestinal origin. In
this respect the fullest attention is due to the auscultatory phenomenon
of "borborygmi," often increasing to the extent of "bowel roaring," and
also in the taking of histories it would be well to make inquiries in regard
to this when there is question of colicky attacks.
This auscultatory phenomenon often precedes visible peristalsis by a
long interval. The attacks of colic that are observed in connection with
intestinal carcinoma are mostly due to obstruction and increased peristal-
tic efforts of the portion of intestine lying ahead of the point of ob-
struction.
Topography
I consider radiation of pain toward the anal opening occasionally ac-
companied by rectal tenesmus "- a very important mark of recognition,
belonging especially to carcinoma of the large intestine.
Another factor that will speak for the intestinal origin of the pains
" Functionally equivalent to stenosis we must consider disturbed motility or entire
cessation of it in a circumscribed portion of gut invaded by carcinoma.
*^ Ca. flex, sigm., 1, 5; Ca. recti, 6.
106
CARCINOMA OF THE LARGE INTESTINE 107
is that they occur iinmedijitcly l)cfore or together with bowel evacuation
or are accompanied by violent tenesmus.
Less certain than the criteria just mentioned and sometimes directly
misleadincr are other topographical relations of intestinal colics.
Thus with deep-seated carcinoma the radiation may occasionally oc-
cur in tiie left testicle (Ca. recti, 11).
As a rule, we find it localized around the umbilicus or spread diffusely
over the lower abdominal region.
In some cases the situation of the intestinal colic corresponds to the
seat of the disease, the colicky pains being locally limited, and if cor-
rectly diagnosed as intestinal colic this local situation will lead one to
think of a local cause which most frequently turns out to be a carcinoma.
Thus, when the carcinoma is situated in the hepatic flexure, the colics
may be located to the right of and above the umbilicus (Ca. flex, hepat.,
3), or if the descending colon and sigmoid flexure be affected, they are
more localized on the left side, the point of emanation being in the left
half of the epigastrium or the left lower abdominal region (Ca. recti, 9).
Radiations into the back and loins count among the most fi'equent ob-
servations.
Influences
Alimentary influences sometimes figure in the provocation and con-
trol of colicky attacks ; such fermentable foods as bread, dumplings,
legumes, etc., being chiefly blamed.
AVith this in view it occasionally may be advisable for diagnostic rea-
sons to undertake experimental tests along these lines.
Frequently it is impossible from the history to determine a definite
relation to the mode of nutrition, as there exist seemingly paradoxical
relations, such as improvement in the subjective complaints after the in-
take of foods "^"^ which are difficult to digest, e.g., sauerkraut, probably
because of their laxative action.
The general pathogenesis of intestinal colics, in which ovcrdistcntion of
the bowel-Avalls by gas plays an important part, will account for the fact
that the elimination of feces and gases in most instances affords prompt
relief from pain.
In one case, for instance (flex, hepatic, 1), colic was regidarly pro-
voked by lying down immediately after eating.
I also recall a case of carcinoma of the hepatic flexure in which un-
covering of the legs or walking on a cold floor sufliced to induce colic.
This behavior was of decisive significance for the differential diagnosis of
gall-stone colic and intestinal colic.
A Karlsbad "drink cure" may, under some circumstances, also occa-
sion colics in case of latent carcinoma of the large bowel (flex, lienal, 1).
The fact that colics set in or become aggravated with certain posi-
tions of the body may be important, since such behavior points to a local
cause.
" Ca. flex, hepat., 1.
108 TUMORS OF THE ABDOMINAL VISCERA
Thus in one case (Ca. fiex. lienal, 1) lying on the left side caused in-
creased severity of the colicky pains.
Also in this domain there are "painful attitudes" which have long
ago been recognized in the symptomatology of gastric ulcer.
Time of Occurrence
The time relations of the colics offer practically no diagnostic advan-
tages and can rather be misleading.
Thus I recall a case (Ca. ceci, 4) in which the pains began imme-
diately after the intake of food and were localized in the epigastrium;
in another case (Ca. flex, hepat. 1) the interval amounted to five hours.
This, in conjunction with gastric symptoms, such as vomiting, sour eruc-
tation, hiccough, could be misleading if too much diagnostic value is at-
tached to relation in time between food intake and beginning of pain,
unmindful of the fact that, figuratively speaking, the gastro-intestinal
tract acts like a worm, which, when irritated in one place, will twist and
turn throughout its length. The intake of food is just such an irrita-
tion, and in case of an irritable condition of the large gut ma}' elicit such
immediate reaction.
Intestinal colics share in the general preference of all colics, includ-
ing physiological uterine pains, to appear at night.
In contradistinction to other colics (gall and kidney stones), the
colics observed with carcinoma of the large intestine are but seldom ac-
companied by chills (Ca. flex, hepat., 3) ; whereas moderate rises in tem-
perature are frequently met with; they originate in the ulcerating process.
If in connection with cancer of the large intestine we make the obser-
vation that at times attacks of colic are absent unto the end, whilst in
other cases they are the first manifestations of the disease, it is quite
analogous to other diseases (e.g., gall-stones) in which we expect to find
colics.
In the later stages it is chiefly the organic stenosis which is at the
bottom of the colics ; in the beginning, but also later on, the same effect
is produced functionally by disturbed motility of the portion infiltrated
by cancer or by spastic contractile conditions of the same ; secondary in-
flammatory complications of the large intestine augment the disposition
to painful attacks. At any rate, the intestinal colics just discussed often
precede by a long interval the objective symptoms of stenosis, such as
visible peristalsis, cessation of fecal and gaseous elimination, fecal vomit-
ing, etc., and herein lies their importance, which cannot be overestimated
for the early diagnosis of intestinal cancer. While frequently occurring
at the height of obstipation, they sometimes also set in when there is
fairly regular bowel evacuation (Ca. flex, lien., 1).
However, they may also be absent with the severest obstipation (Ca.
recti, 5), not occur at all (Ca. ceci, 2), or set in only during the later
stages of the disease (Ca. flex, lien., 1; ceci, 1). This is simply an evi-
dence of the caprice characterizing the relation of colicky attacks for the
processes on which they depend. The absence of colics, therefore, can
CARCINOMA OF THE LARGE INTESTINE 109
never be construed against the diagnosis of a possible carcinoma of the
large intestine.
In a subsequent chapter those factors will be summed up which would
seem suitable to impart to intestinal colics an especial value for the
diagnosis of intestinal cancer.
The pain phenomena hitherto discussed were more or less diffuse and
characterized by their colicky character.
The development of cancerous growths in certain sections of the bowel
also leads to localized, more circumscribed sensations of pain without
definite nuance, which deserve careful attention as local symptoms.
Tenderness on Pressure
In every abdominal examination at least the cecum and the three
flexures should be tested for any possible tenderness to pressure, and it
will be advisable to palpate the splenic flexure, as in palpation of the
spleen, with the body lying on the right side. Neoplasms of the in-
testine are almost always more or less tender to pressure.
Carcinoma of the sigmoid flexure not infrequently occasions localized
spontaneous pains, in connection with which radiation may occasionally
be observed along the left spermatic cord into the left testicle ; bowel
movements at times afford relief.*'"'
Lumbar Pains
Continued pains in the back do not occur according to my expe-
rience even with deep-seated intestinal cancer (Flex. sigm. and rectum)
as frequent findings. If they occur at all they have less connection with
the neoplasm as such and are not to be looked upon as a local symptom.
Not rarely, however, they fall within the area of the radiations of
attacks of colic and occur synchronously with them ; therefore, the}' also
evince occasional dependence upon alimentary influence (Ca. flex, sigm.,
5). Even with very extensive metastases in the retroperitoneal glands,
they may be entirely absent (Ca. flex, sigm., 2). Occasionally they seem
to have some connection with ascites and disappear after its removal.
Emaciation as such may sometimes elicit them, this being a well-known
phase of antifat-cures. They may, furthermore, depend on accumu-
lation of fecal masses, the removal of which is followed by their temporary
disappearance. Finally these symptoms may also be occasioned by metas-
tases in the liver just as they give rise to painful sensations in the epigas-
trium. Pains in the sacral region seem to me to be more closely related
in a causal way to deep-seated intestinal carcinoma, such pains also being
met with in hemorrhoidal conditions.
Painful Positions
"Painful position" may be brought about in several ways. They may
be caused by the weight of tumor-masses, which lose their points of sup-
port when the body assumes certain positions.
" Ca. flex, sigm., 2, 4.
110 TUMORS OF THE ABDOMINAL VISCERA
Thus in tumors of the cecum, left-sided decubitus causes especial
discomfort and there is observable a painful pulling toward the left, or
with certain lateral decubitus there may ensue colicky pains (increase of
the stenosis through pressure, kinking, etc.).
But also severe tension of the abdominal walls from meteorism some-
times seems to prohibit lateral decubitus, this being almost invariabl}'^
so when there have been added acute peritonitic complications.
These would be suspected, especially when the pains set in acutely
above the symphisis, and are accompanied by chills, collapse, and severe
rigidity of the abdominal walls. (Ca. recti, 2.)
2. Disturbances of the Motor Function of the Bowel
From this there result in the first place symptoms on the part of
the bowel ; furthermore in a great number of cases there are also gastric
symptoms.
a. Intestinal Symptoms
There is a close analogy between carcinomas which develop in the
sigmoid flexure and carcinomas of the pylorus, severe stenosis being of
frequent occurrence. The more solid consistence of the feces in this
terminal portion of the large intestine may be considered a favoring
factor for the occurrence of stenosis manifestations. Deep-seated car-
cinomas of the large intestine, therefore, more frequently lead to severe
stagnation of fecal masses, i.e., obstinate obstipation.
In these cases, especially when there is circular extension and the
cancer is of a scirrhus nature, there easily ensues severe organic stenosis.
It is important to know that obstipation due to carcinoma of the large
intestine not infrequently shows deceptive remissions (Ca. flex, sigm., 4).
These may be explained by compensatory hypertrophy of the portion
of bowel above the stenosis or to an opening of the passage through
ulceration ; occasionally there may come into consideration causative fac-
tors which act as curative in habitual constipation, such as diet, move-
ments, general improvement of bodily constitution through sojourn in the
country, etc.
In the later stages of the disease, often the initial obstipation occurring
with cancer of the rectum and sigmoid changes to the opposite, at least,
in so far as copious evacuations occur accompanied by violent tenesmus.
Indeed, the stagnation of fecal masses continues undiminished, and it
would be fallacious in these instances to speak of "diarrhea"; examination
per rectum and externally discloses the presence of old, caked scybala.
The evacuations are frequently not fecal discharges but consist of mucus,
blood and pus.
It is very noteworthy that these copious evacuations are scarcely ever
influenced by therapeutic measures directed against chronic intestinal
catarrh such as diet, rest in bed, astringents, opium preparations, etc.,
and this may occasionally serve as a diagnostic reminder.
With carcinoma of the rectum we also meet with disturbances of mo-
CARCINOMA OF THE LARGE INTESTINE 111
tility, such as incontinence. During the course of a long-continued obsti-
pation there may suddenly occur irresistible tenesmus and involuntary
bowel movement.
The separate evacuation of urine and feces is also frequently inter-
fered with.
Similarly retention of larger enemas becomes impossible and prolapses
may easily occur (Ca. recti, 2).
Cancers developing in the cecum, in the hepatic and splenic flexures,
are less frequently accompanied by severe obstipation than the deep-
seated neoplasms just discussed.
As the lumen of the bowel in the former is larger, the cancers are
often mural, not circular, and leave an open passage as a result of ulcer-
ation ; moreover, the contents of the upper portion of the large intestine
are less consistent. Infiltration of the bowel as such may in a functional
way be equivalent to a stenosis, and if in addition to this there occur
acute insufficiency'"'-'* of the section of bowel lying ahead, the conditions are
at hand for the occurrence of ileus.
Just as obstinate obstipation is not frequent with this kind of cancer
of the large intestine, so also profuse diarrheas are not the rule.
Mild obstipation alternating with mild diarrheas is probably more fre-
quent, the variations from the normal often being very slight (Ca. flex.
hep., 1; flex, sigm., 2).
This is one of the chief reasons why those cancers situated in the
first two-thirds of the large intestine are so easily overlooked.
h. Gastric Symptoms
These deserve full attention, because not infrequently they may mis-
lead in diagnosis and deceive one into assuming an independent gastric
disease.
Such a mistake is likely to occur ^*' if besides anorexia there occur
epigastric pains, heartburn, eructation of gas, inmiediately after the
intake of food.
In one of my cases there was intolerance for sour foods, ingestion
of which being followed by instant vomiting and troublesome belching.
In discussing the pain phenomena it has already been pointed out that
with carcinoma of the large bowel, the appearance of intestinal pain may
follow immediately the ingestion of food.
A portion of the gastric symptoms, e.g., heartburn, is evidently re-
ferable to stagnation of stomach contents, which in its turn represents
only an extension of intestinal stagnation.
From it there results decomposition of stomach contents and re-
gurgitation upward which manifests itself by eructations (tasteless, sour
or foul smelling), heartburn, nausea and vomiting, as well as anorexia.
In the case of carcinoma of splenic and hepatic flexures, local ad-
hesions may give rise to disturbances of gastric motility.
'° The same may frequently be due to acute overdistention of the bowel-wall.
•• Ca. ceci, 3.
112 TUMORS OF THE ABDOMINAL VISCERA
Vomiting is mostly scant and less of an alimentary nature than in
the case of gastric cancer, occurring mostlj'^ in occasional form only, but
sometimes characterized by special stubbornness (Ca. recti, 14).
It sometimes occurs especially after the use of sour foods (Flex, lien.,
2), or after prolonged walking (Cecum, 4) and sometimes is separated
by a constant interval of time (2 hours), from the time of eating (Flex,
lienal, 2).
During the course of the symptoms of stenosis "coffee-ground" vom-
iting may also occur (Flex, sigm., 5) ; this might be attributed to severe
distention of the stomach which impedes the venous flow.
Since the gastric symptoms originate in disturbed intestinal function,
it is easily understood that they should be subject in an especial degree
to influences that are calculated to regulate bowel function (bowl washes,
cathartics, etc.), more so than is the case in gastric cancer.
The occurrence of hiccough (Ca. flex, lienal, 2), which sometimes exists
to a pronounced degree without any peritonitic complications might, as
in pyloric stenosis, be of gastric origin.
Together with these symptoms of gastric origin there also is expe-
rienced a "sensation of pressure" in the epigastrium, which is occasionally
found regardless of the location of cancer of the large intestine. It
sometimes sets in inunediately after the ingestion of food and may be ex-
plained by the impeded emptying of the stomach.
In these cases it would also be well to determine whether there might
not be intumescence of the liver as a result of metastasis. Also local
states of distention of the large intestine above the diseased portion of
the bowel may manifest themselves by a more or less painful sensation
of epigastric pressure, and it has already been pointed out that, espe-
cially with deep-seated cancer of the bowel, the origin of the attacks of
colic is not infrequently situated in the epigastrium (Ca. flex, hepat,, 2).
The appetite frequently remains remarkably good (Ca. recti, 5, 12;
Ceci, 2) ; occasionally it is only the fear of aggravation of the feeling
of abdominal distress which, despite good appetite, keeps the patient
from ingesting larger quantities of food (Ca. flex, sigm., 10) ; in other
cases there exist anorexia, which sometimes is limited, as in gastric cancer
especially, to the use of meat (Ca. flex, hepat., 1).
3. Hemorrhage
Copious hemorrhages from the ulcerating neoplasm are probably of
extremely, rare occurrence with intestinal carcinoma and then almost al-
ways occur in rectal or sigmoid cancer; but even in these cases there is
a far more frequent discharge of blood-colored mucous masses resembling
that of dysentery.
Tar-colored stools are never observed.
In carcinoma of the cecum and both upper flexures the stools mostly
give no macroscopic hint of blood ; only the admixture of mucus not
infrequently shows a dark red color. As cancer of the large intestine
is often complicated with hemorrhoidal conditions, it becomes very diffi-
CARCINOMA OF THE LARGE INTESTINE 11. 'J
cult, at times, to decide how cheinicnlly demonstrable blood may be traced
to its source.
Precisely in these cases, the uselessness of those methods which en-
deavor to prove even the minutest traces of blood, is made clear and
the advantages of a coarser technique of examination become apparent.
With regard to this, reference may be made to former discussions. A
constantly negative finding of blood coloring matter would at any rate
admonish to greatest caution in making the diagnosis of cancer of the
large intestine, especially if, at the same time, the supposedly ulcerating
surface be mechanically irritated by the ingestion of food rich in cellu-
lose, such as bran-bread.
PHYSICAL EXAMINATION FOR CARCINOMA OF THE
LARGE INTESTINE
1. Palpation
Simplest of all, is the demonstration by palpation of deep-seated rectal
carcinomas ; wherefore, the frequenc}- of wrong diagnosis in this domain
presents a glaring contrast.
Diagnoses like "hemorrhoids," "chronic catarrh of the large bowel,"
are of daily occurrence.
Omission of digital examination of the rectum is, in many of these
cases, a punishable offence.
Uncommon size of the empty ampulla^'^ may occasionally be a suspi-
cious factor in carcinoma situated high up in the rectum or deep-seated in
the flexure, and urge to repeated digital exploration. For the height —
particularly the depth — of these cancers changes and depends, in part,
upon the degree of abdominal meteorism and the suprastenotic accumula-
tion of feces. ''^ Hence, not one but several examinations.
For the rest, when there is suspicion of carcinoma of the large in-
testine, particular attention will have to be shown the angles of the
imaginary square represented by the large bowel (cecum and the three
flexures), the more so when in the general orientation one of these places
displays special tenderness to pressure. Severe tension of the abdominal
walls, through gaseous distention of the intestine, often adds to the
difficulties of palpation and should always be eliminated as far as pos-
sible.«'-^
The situation of the tumors usually corresponds to their point of
origin.
It is probably very rare that carcinomas of the rectum (Ca. recti,
8) give occasion for the appearance of cancerous tumors that can be
felt through the abdominal walls.
Cancers of the sigmoid flexure are removed from the belly-wall, and
especially with ascites can only be reached by intermittent deep palpa-
" Hochenegg, Wiener klin. Wochenschr., 1897, No. 32.
"' In regard to instrumental examination, see page 6.
•" See page 2.
114 TUMORS OF THE ABDOMINAL VISCERA
tion. They may occasionally be located almost in the median hnc of
the lower abdominal region (Ca. flex, sigma., 6) and sometimes, analogous
to tumors of the pylorus, exhibit the phenomenon of "wandering." In
case of scirrhus, circular cancers of the sigmoid, which in fact are not
palpable because there is no real tumor formation, it can easily happen
that the fecal masses which become caked into hard balls, may be mis-
taken for the tumor.
Cancers of the splenic flexure, on account of their hidden position,
could most easily escape discovery; in the examination of this flexure it
would seem to me most proper to examine, after the manner of splenic
palpation, and also bimanually, as for kidney tumors.
Carcinoma of the hepatic flexure, on account of adhesions, frequently
does not permit of difl"ercntiation from the border of the liver.
Palpation should also always include observation of any pulsations
in the tumor-masses ; their presence usualh^ indicates that the tumor-
masses extend backward toward the abdominal aorta, or have come into
contact with the latter through metastasis into the retroperitoneal glands
(Ca. ceci, 1; flex, hepat., 1).
Carcinoma of the cecum and ascending colon, exhibit frequently
ballottement by bimanual examination, providing they extend far back
into the lumbar region; less critical interpretation of this s^^nptom might
result in falsely diagnosing tumors of the kidne}'.
Respiratory mobility of tumors of the cecum is usually very slight,
but never entirely absent.
Besides the discovery of tumor-masses, other findings as well must
be taken into consideration, when thei'c is suspicion of intestinal cancer.
Thus the state of rigidity of the abdominal wall.
In this respect the flanks deserve especial attention, to acquaint one's
self with the amount of distention of the ascending and descending colon,
if there is no ascites. Thus deep-seated carcinomas (Ca. flex, sigm., 1, 9)
sometimes lead to marked distention of the descending colon, stenoses of
the splenic flexure lead to increased tension on the right side. The most
suitable method of testing for it is interrupted palpation with the flatly
imposed hand.
By means of the gently imposed hand, one can recognize also those
first degrees of increased intestinal peristalsis whose waves the eye cannot
clearly detect on the surface, the peristaltic distention of the bowel-loops
which manifests itself through alternating increase and decrease, be it
local or diff'use, of abdominal tension, at the same time simultaneously
occurring intestinal noises can often be better identified with the palpat-
ing hand than with the ear.
2. Inspection '"
The visibility of increased intestinal peristalsis naturally depends
upon the intensity of the latter and also the degree of muscular hyper-
'° In regard to instrumental examination of the lower bowel segments (Recto-
Romanoscopy), see page 6.
CARCINOMA OF THE LARGE INTESTINE 115
trophy, but espccifilly upon the condition of the belly-walls also. The
more relaxed ^ley are, the more easily they can be made to stand out by
distended segments of gut, and the more easily also they adapt them-
selves to their movements.
If the abdominal musculature be tense and well developed, increased
peristalsis may occasionally lead to only a sudden increase in the size
and tension of the abdomen, but without the appearance of isolated seg-
ments of gut, the intestinal noises alone calling attention to peristaltic
processes. The rapid appearance and disappearance of such a "balloon
belly" is proof of its origin. It may also happen that distended portions
of gut arc visible, but there cannot be noticed any movements of the
same.
The following factors are of importance for the diagnosis of peristal-
sis of the large intestine and thus of some obstruction in its course.
a. Projection of the contour of the large intestine.
In April, 1908, a woman, 63 years old, was received in my division
(k.k. Kaiserin Elizabeth Hospital). Inspection of the abdomen led to
immediate diagnosis, viz., stenosis in the region of the hepatic flexure of
the colon. The first thing to strike the eye was peristalsis of the small
intestine localized around the umbilicus, and in addition to that, as a sort
of culmination, the ascending colon stood out with all its contour, so that
this portion of the gut could be recognized beyond a doubt. Autopsy
performed on May 10, 1908 (Professor Dr. Fr. Schlagenhaufer) con-
firmed the localization of the stenosis. Cause: Carcinoma vesicae felleje.
This case illustrates that it is of the greatest importance to deter-
mine, if possible, where the peristalsis ends.
The width of the intestinal loops is of no value for localization, since
loops of the small intestine too often ai'e subject to maximal distention;
it might carry some meaning when, with very thin belly-walls, there were
doubts as to whether the peristalsis was physiological or pathological;
the former takes place in small loops of intestine.
h. Isolated peristalsis and distention of the sigmoid flexure.
This will have to be thought of if an intestinal loop projects above
Poupart's ligament on the left side, this loop collapsing with spontane-
ous or artificial (rectal tvibe) discharge of flatus. In one case, for in-
stance (Ca. flex, sigiu., 8), the peristaltic projection was concurrent with
increased filling of the left Yen. epigastr. inf.
c. Particular state of tension of the belly-wall along the course of the
ascending or descending colon. This symptom is of value only in the
absence of ascites, and gains in importance if it be unilateral.
Bulging in the usual topographical area of the transverse colon, i.e.,
above the umbilicus, may occasionally also depend upon severe distention
of the small intestine, and if the transverse colon does not stand out
prominently, great caution is in order; this is especially true if there is
absent increased tension on the right side or on both sides.
d. Capacity of the ampulla.
e. Radiation of the colicky pains into the rectum.
/. Tenesmus.
116 TUMORS OF THE ABDOMINAL MSCERA
3. Auscultation
With distended loops of intestine, as met with in carcinoma of the
large bowel, even when there is no stenosis, the heart-sounds become clearly
resonant and are heard over large areas of the abdomen. Where the
question of meteorism is of interest, I consider this symptom very worthy
of attention. It is more reliable than the size and state of tension of the
abdomen.
Full attention, moreover, is due those rumbling, oft metallic, squirt-
ing sounds, which are brought about through the movements of fluids in
the large gas-containing recesses of greatly distended loops of the intes-
tine, when assailed by the peristaltic waves. It will be well to note its
localization, as this is occasionally in relation to the seat of the stenosis.
Thus, in one case of carcinoma of the cecum (2), their seat was princi-
pally in the left half of the abdomen ; in a case of carcinoma of the sig-
moid flexure (9) they occurred mostly along the course of the descending
colon. It is of advantage to auscultate directly with the ear, without a
stethoscope.
Furthermore, attention should be paid to peritoneal friction-sounds ^^
in the area of the tumor masses, because in difl'erential diagnosis between
the latter and kidney-tumors, they exclude the latter. These peritoneal
friction-sounds are sometimes palpable by their sound, which resembles
crunching of snow.
An auscultatory phenomenon but little heeded is intestinal splashing,
which is to be distinguished from the gurgling sounds, which latter are
quite insignificant.
In order to obtain this splashing sound I recommend indirect suc-
cussion by taking hold of the iliac bones and shaking to and fro. In the
presence of marked dilatation of intestinal loops, which occur only with
stenosis and paralytic conditions (peritonitis), there result difl'use, often
rumbling, splashing sounds, and the ear can often approximately deter-
mine the seat of their origin.
Particular attention should be given to unilateral splashing in the
flanks, e.g., in the region of the ascending colon, which is occasionally
found with carcinomatous diseases of this portion of the bowel.'-
Sometimes the ascent and descent of the diaphragm produce enough
agitation, leading to "inspiratory" bowel splashing (Ca. flex, hepat., 3).
J/.. Percussion
Its significance, in the cases of disease here under consideration, ex-
hausts itself in the demonstration of ascites. The percussion-note tells
us nothing: in regard to the situation of a tumor in the intestinal wall,
because tumors that are externally adjacent to the bowel-wall or such as
are covered by the intestine, yield identical findings on percussion.
Liver dulness is often greatly diminished on account of existing
meteorism.
" See Ca. ceci., 1.
" Ca. ceci, 1 ; flex, hepat., 1 ; recti, 6.
CARCINOMA OF THE LARGE INTESTINE 117
FECES AND STOMACH CONTENTS
Feces
The quality of the bowel evacuations in cancer of the large intestine
varies within wide limits and depends upon different influences, such as
the scat of the neoplasm, ulceration, accompanying catarrh of the large
bowel, etc.
Dysenlevy-Like
Carcinoma of the rectum and of the sigmoid flexure more than others
offer findings of diagnostic import. Here we meet with stools that are
"dysentery-like," i.e., composed of bloody mucus and sparse fecal masses
or of the former alone, frequently accompanied by tenesmus, which should
always be the occasion for a careful examination of the lower portions of
the bowel. They may be provoked by cathartics. If we are dealing with
individuals of advanced age, there are usually underlying, deep-seated
ulcerating cancers of the rectum. ^^ The copious evacuations in such cases
cannot, for apparent reasons, be controlled by diet or astringents.
It is with these deep-seated neoplasms more than others, and even here
not often, that we find the discharge of large quantities of blood which is
liquid and partly coagulated (Ca. recti, 6, 10; flex, sigm., 5).
Knotty and Rihhon-Lil'e
Naturally, there may also be absent copious evacuations with deep-
seated cancers of the large intestine and, instead, there may be present
most obstinate obstipation with the discharge of marble-like stools (Ca.
recti, 3). This last-mentioned form of stool, as well as ribbon-like stools,
as is well known, has nothing to do with stenosis of the bowel. Feces
resembling that of sheep are very frequently found with idiopathic chronic
obstipation ; ribbon-like stools are mostly attributed to spasm of the
sphincter.
I am inclined to attribute it more to relations between the closing of
the sphincter and the expulsive forces, since this shape of stool is also
found with spasm of the sphincter.
IcJiorous
In the case of the neoplasms situated higher up in the bowel (cecum,
hepatic and splenic flexures) the stools are indeed never well formed,
being mostly pulpy, soft, smeary, but in no way are they characteristic.
Their macroscopic appearance affords no hint of blood, except such small
quantities as may come from coexisting hemorrhoids ; chemical analysis,
however, often yields constantly positive evidence of blood-coloring mate-
rial. Only exceptionally do we meet with fluid, foamy evacuations with a
penetrating stinking odor (Ca. flex, hepat., 2).
" See Ca. flex, sigm., 5, 6 ; flex, hepat., 4.
118 TUMORS OF THE ABDOMINAL VISCERA
The reaction of the stools is, as a rule, decidedly alkaline, correspond-
ing to the preponderance of processes of decomposition.
Microscopy of the Feces
Microscopically, the following findings deserve attention:
1. Bacterial growths.
2. Alimentary findings.
3. Cytological findings.
Ad 1. As gastric carcinoma gives rise to the presence of noteworthy
vegetative findings (lactic-acid bacilli, sarcinae, etc.), so we also expect
analogous findings with cancer of the large intestine. Yet, the conditions
here are far more complicated, because pre-existing bacterial growths must
be taken into account.
Though specific findings may be absent, a review of the fecal vegeta-
tion in the native or "Gram preparation '' may sometimes afford informa-
tion which puts the physical and chemical conditions underlying normal
intestinal vegetation into an altogether different light. Thus, I remem-
ber a case of cancer of the large bowel (Ca. ceci, 4), which was conspicu-
ous for the large number of very motile short rod-shapes which crossed
the microscopic field in all directions. Such a finding is decidedly patho-
logical. The rod-shaped bacteria of normal feces do not exhibit any
spontaneous movements, but show only the well-known molecular move-
ment.
In other cases there occur spirochetes in large numbers, which also
are foreign to the normal picture of the stool. I can also recall observa-
tions in which the stool was characterized by the appearance of Gram-
positive cocci in large quantities ; in fact, they were present in such
quantities as I have otherwise observed only in pernicious anemias. Lac-
tic-acid bacilli, also, may occasionally occur in larger quantities (Ca.
ceci, 2 ; flex, hepat., 1 ).
To attach proper meaning to these and similar findings among the
symptoms of cancer of the large intestine, is a matter of personal experi-
ence. Whoever is but little acquainted with vegetative findings, will do
better to leave them out of his calculations. The expert will often find
them valuable aids.
Alimentary Findings
Ad 2. Carcinomatous disease of the large bowel is attended by severe
functional disturbance of the entire digestive tract.
This is evidenced by the frequent finding of poorly digested muscle-
fibres which can often be found in large quantities and which show well-
preserved transverse striation. Also fat digestion may be considerably
impaired, as I remember that, in cases of sanious diarrheas (Ca. flex,
hepat., 2), in addition to fatty acid, I also found neutral fat (pancreas
intact, no icterus). The stools contained fat with a paradoxical, strongly
alkaline reaction !
CARCINOMA OF THE LARGE INTESTINE 119
Cytological Findings
Ad 3. Among the cellular elements I would call attention to eosinophile
cells, which are not infrequently present, especially with deep-seated neo-
plasms of the large bowel, though not indeed in such vast numbers as occa-
sionally happens in amebic dysentery.
Gastric Findings
Chief among the gastric findings is the frequent persistence of HCl
secretion (Ca. ceci, 4; flex, sigm., 10).
In the course of stenotic conditions, among others with perforative
peritonitis (Ca. flex, sigm., 9), there may occur "coffee-ground" vomit-
ing (Ca. flex, lien., 1; flex, sigm., 5), but in these cases the vomitus does
not exhibit the vegetation of lactic-acid bacilli, so peculiar to carcinoma
of the stomach.
If, during the course of stenosis attacks, the feces are prevented
from passing for a long time, there often ensues the vomiting of yellow
masses containing bilirubin, in which colon bacilli turn up in rapidly in-
creasing quantities, as also Gram positive rod-shapes and cocci, so that
we finally have the picture of intestinal bacterial growths. These bac-
teriological findings precede fecal vomiting and therefore deserve serious
attention.
ACCOMPANYING SYMPTOMS ON THE PART OF
INDIVIDUAL ORGANS
Urinary Bladder
In so far as carcinomas of the cecum, the sigmoid flexure, or the
rectum are concerned, symptoms of the urinary bladder count among the
not infrequent accompanying symptoms. Thus pressure of the tumor-
masses, distended loops of intestines, etc., upon the urinar}' bladder may
produce increased desire to urinate ; or there may occur the entrance of
colon bacilli from the bowel with secondary cj^stitis. Then we often have
tenesmus of the bladder with pains radiating into the penis. The tenes-
mus may become so violent, that incontinence results (carcinoma flex,
sigm., 8). Sometimes there is also a disturbance in the separate voiding
of stool and urine, so that with urination there occurs simultaneous stool
evacuation (Ca. flex, sig., 4; recti, 12).
Finally, there may even be established a vesico-rectal fistula so that
feces gain entrance into the urinary bladder (Ca. flex., sigm., 3; recti,
11). In these cases the patients refer to characteristic gurgling sounds,
occurring during urination, which are due to the presence of intestinal
gases in the bladder. Examination of the urinary sediment reveals, among
other things, muscle fibres and intestinal bacteria ; a finding most charac-
teristic of these are the yeast-like clostrides which stain blue with Lugol,
since their occurrence in the body is limited to the bowel exclusively. Th*^
portions of urine voided last contain the largest proportion of feool
matter.
120 TUMORS OF THE ABDOMINAL VISCERA
The subjective symptoms in sucli cases of vesico-rectal fistula are
sometimes quite confusing, because of their insignificance.
These and similar observations emphasize the fact that, with the
presence of bladder symptoms, especially in advanced age, the intestinal
proximity of the urinary bladder must not be left out of consideration.
Varicocele
Attention must also be called to the occasional occurrence of a left-
sided varicocele, with radiating sensations into the left testicle; this is
most frequently found with carcinoma of the rectum and sigmoid.
Peritoneum
Diffuse metastasis onto the peritoneum, with a general peritoneal car-
cinosis, does not belong to the frequent findings. When carcinoma of
the large intestine is accompanied by severe ascites, we must, in the first
place, think of hepatic complications. We arc dealing cither with metas-
tases in the liver, or with the not rare cirrhotic complications (Ca. flex,
hepat., 4; flex, sigm., 1, 9).
Extensive metastases in the retroperitoneal glands may lead to con-
gestion of chyle, and thus to the occurrence of a "milky" ascites (Ca.
flex, hepat., 4).
Liver
Liver metastases are most frequently found with cancer of the rec-
tum and sigmoid, the enormous enlargement of the organ in these cases
often standing in sharp contrast to the small size of the primar}" focus.
This seems to be almost a rule. Large secondary cancers mostly issue
from a small cancerous focus! Accompanying perihepatitis may lead to
very extensive radiations of pain (Ca. recti, 12). Even very diffuse
liver metastases lead to only mild subicteric discoloration, but not to a
pronounced icterus. If icterus does occur, it may under certain circum-
stances again disappear (Ca. recti, 4).
Lymph Glands
Metastasis into the external lymph-glands (inguinal, supra-clavicu-
lar axillary) is almost never observed. Where we find enlarged glands,
as, for instance, in observation 2 (Ca. ceci), it will be well to think of
another etiology, e.g., tuberculosis.
Sheletal System
Bone metastases also are quite extraordinary. Case 1 (Ca. ceci)
is an exception in this respect. Through metastasis into the cervical
vertebra, in this instance, there resulted an ascending paralysis of the
various extremities. In this very exceptional case, metastases occurred
even in the scalp, which in the beginning surgeons had erroneously looked
upon as atheromas.
Generally, however, carcinoma of the large intestine docs not exhibit
any special tendency to the formation of metastases, and it is this as
well as its good accessibility to the surgeon that renders its diagnosis of
CARCINOMA OF THE LARGE INTESTINE 121
practical iiiiportaiict'. In view of the fact, that in cases of cancer of the
hirge bowel, the intake of food and its assimilation do not suffer for a
long time, especially when the cancer is low down, and since we are often
dealing with vigorous individuals who have always enjoyed the best health,
there can be little wonder that the general state of nutrition sometimes
remains good for a time. With prolonged duration of ulceration, how-
ever, there results also in these cases t^'pical cancerous cachexia, often
accompanied by extreme pallor, and frequently there is also the ten-
dency to moderate edemas.
Fever, Night-Sweats
Febrile movements (Ca. ceci, 3, -1; recti, 13) and night-sweats are
frequent accompanying manifestations.
COURSE, DURATION AND TYPES
A fact, recognition of which is important, because it might lead to
the abandonment of a suspicion that has already been formed, is the
oft intermittent and remittent course of the clinical manifestations.
Thus, for several days there may be present stools of a d^^senteric
character, which are succeeded for a long time by regular bowel move-
ments and general well-being, until new attacks again set in (Ca. flex,
sigm., 5).
With improved appetite the body-weight may become considerably
increased ; thus in- one case, for instance, there was a gain in weight of
14 kg (Ca. flex, hepat., 2).
Obstinate obstipation may be followed by fairly regular bowel move-
ments. In the beginning, after their first appearance, colics may be ab-
sent for months.
The duration of that stage of intestinal cancer, in which clinical
symptoms manifest themselves, seems to me to be shorter than that of the
average gastric cancer, so far as the dates can be determined from the
patient's history.
I, for my part, consider a two-years' duration as exceptionally long.
In this respect, however, there is a great divergence of opinions among
different observers. ^^
SUSPICIOUS FACTORS AND DIFFERENTIAL DIAGNOSIS
As far as the localization of the neoplasm in the bowel is concerned,
there are certain indications that frequently come into the foreground
and are specially adapted to guide us in the right diagnostic path. Apart
from the general symptoms,"*^ tliey will here be summarized in groups.
'"Thus Kraske (Samml. klin. Vortr. Xeiie Folge, Nos. 183, 184., 1897) estimates
the average duration of rectal cancer as four to five years.
" See page 37.
122 TUMORS OF THE ABDOMINAL VISCERA
1. Discharge of blood and mucus accompanied by violent tenesmus.
Such "dysentery-like" stools must always remind one of the possibility
of a deep-seated carcinoma of the rectum or sigmoid flexure. One should
never content himself with the mere findings of hemorrhoids, as these
frequently are only an accompanying manifestation of deep-seated car-
cinoma.
On the other hand, one must be on his guard in making the diagnosis
of "dysentery" (Ca. flex, sigm., 5), especially when dealing with a spo-
radic case. Retrogression of the symptoms is not sufficient ground for
exclusion of the diagnosis of cancer.
2. Intestinal colics with meteorism, so-called "wind colics" (Ca. flex,
hepat., 1, 2; recti, 3, 6, 9 ; flex, sigm., 3). Occurring after a dietetic
error (the use of gas-forming foods, etc.), or spontaneously, they fre-
quently arc the clinical debut of cancer of the large intestine. In the
beginning they may set in at intervals of several months, but, later, they
come on with increasing frequency. They deserve the most serious con-
sideration, especially where we are dealing with individuals of "strong
bowels," who have previously never had any bowel complaints, as it is
just from this class that a large percentage of patients is recruited.
Prolonged obstipation seems to be a frequent eliciting factor, so much so,
that one could often speak directly of obstipation colics. But, since it is
not in the nature of "habitual" obstipation to provoke violent colics,
such "obstipation colics" must, among other things, always arouse the
suspicion of a malignant disease of the large intestine. In view of the
fact that obstipation also accompanies other colics, particularly gall-
stone and renal colics, these latter processes will haVe to be excluded
after a very careful analysis of the pains. After that has been done, in-
testinal colics will have to be diff"ercntially diagnosed from the more fre-
quent affections, such as chronic saturnismus, intestinal tuberculosis,
appendicitis, incarcerated hernias, etc.
Especially the differentiation from appendicitis may occasionally be
difficult, not only in the case of carcinoma of the cecum but also in deep-
seated rectal cancers, in which cases there may result severe distention
and sometimes even perforation of the cecum (Ca. flex, sigmoid, 1).
On the other hand I have repeatedly observed, after appendicitis in
older individuals, remarkably firm exudates accompanied with very slight
febrile movements and slight tenderness to pressure, in which cases it
was only the fact of absolute health up to the time of the attack and the
further course of the disease, that guarded against confusion with car-
cinoma.
The diagnostic difficulties are so much the greater, since cancers of
the large intestine may lead to secondary pericolitic suppurations.'*'
With cancer of the hepatic flexure (3) there is sometimes danger of
confusion with cholelithiasis. Deep-seated cancers of the rectum may
also lead to sensations radiating into the left testicle (Ca. flex, sigm.,
3), which might lead to the erroneous diagnosis of urethral colic.
" Tu-fjier, Semaine medicale, 1904. No. 25.
CARCINOMA OF THE LARGE INTESTINE 123
3. Unaccountable obstipation in an individual without previous in-
testinal complaints. The symptoms of obstipation may become more sig-
nificant when considered with reference to the "bowel individuality" of
the patient. Frequently we are dealing with individuals whose intestinal
function was always perfectly regulated (Ca. flex, sigm., 4; recti, 5),
"like a clock," the patients will often say ; suddenly, apparently without
cause, stubborn obstipation sets in ! In such cases, we are compelled to
think of the possibility of cancer of the large bowel. Also in these cases,
as has already been emphasized elsewhere, deceptive remissions may occur,
the bowel movements becoming regular for a long time.
The paradoxical combination of obstipation with occasional violent
tenesmus and incontinence (Ca. recti, 5) must seem particularly sus-
picious.
■i. Acute ileus.
Whilst the occlusion of the bowel may frequently be introduced by
the above-mentioned attacks of colic, it may occasionally also occur as
the first symptom in the midst of apparently good health. Here the his-
tory must aim at finding s^nnptoms dating farther back, which, of course,
may often be of rather inconsequential nature, and besides incarcerated
hernias, intestinal tuberculosis, etc., the possibility of carcinoma of the
large intestine will have to be considered.
5. Obscure febrile conditions in older individuals, though accom-
panied by only slight abdominal symptoms, must urge us to think of the
possibility of cancer of the large bowel, since these cases are often ac-
companied by chronic febrile conditions with irregular rises in tempera-
ture but occasionally also with chills (Ca. ceci, 3).
6. Tumor-masses in the topographical area of the large intestine.
Definite palpatory findings do not, of course, belong to the early
symptoms, which justifies us in assigning to them the last place among
the factors of suspicion. They may be permanently absent when we are
dealing with circular stricturing cancers, %s is the case especially in the
region of the sigmoid flexure. In these cases hard and impacted sc^'^bala
are frequently mistaken for tumors.
Tuberculosis of the Cecum
At the cecum it is the tumor-forming type of ileocecal tuberculosis
that enters into differential diagnostic consideration ; the tumors may be
extraordinarily firm. The guiding viewpoints in these cases are: a most
careful examination of the pulmonary apices, determination of the diazo
reaction in the urine, and demonstration of tubercle bacilli in the stool.
Corset Lobes
One must be cautious not to mistake corset lobes of the liver which
are sometimes observed in the cecal region in enteroptotic women.
Kidney Tumors
Tumors belonging to the ascending and descending colon not seldom
exhibit slight ballottement, and this might lead one to think of kidney
tumors (Ca. flex, hepat., 3). Peritoneal friction over the tumor would
124^ TU:\10RS OF THE ABDOMINAL VISCERA
speak against a tumor of the kidney. If belonging to the bowel, the his-
tory will reveal intestinal symptoms, and there will also be the objective
demonstration of "occult" intestinal hemorrhages, occasionally it might
also be well to institute a dietetic test. With solid retroperitoneal tu-
mors, the portions of bowel overlying them anteriorly can be rolled to
and fro, which would serve as a further distinguishing criterion.
Gastric Carcinomas
In case of carcinoma of the ascending colon, there is sometimes diffi-
culty in deciding whether the tumor does not belong to the stomach (Ca.
flex, hepat., 2). Gastric symptoms, such as anorexia, heartburn, vomit-
ing, etc., are frequently met with. Among others, protracted diarrheas
would here argue much more in favor of the diagnosis of cancer of the
intestine.
Mistaken diagnosis seems to me most likely to occur with carcinoma
situated at the splenic flexure (carcinoma Hex. lienal, 2).
In regard to the occurrence of "coffee-ground" vomiting, this has
already been discussed in another place.
Tumors of the Gall-Bladder and Liver
Tumors of the hepatic Hexure, especially when adherent to the liver
and leading to subicteric discoloration and febrile movements, may occa-
sion confusion with tumors of the gall-bladder and liver.
Cylindrical tumors lying transversely in the middle of the epigastrium
almost always belong to the pylorus ; beginners like to refer these to the
transverse colon.
Greatest reserve ought to be maintained with respect to palpatory
findings in the region of the sigmoid flexure. What is here felt from
without is but rarely a carcinomatous tumor. Even when a cancer is
present, that which is felt is most often the impacted scybala or the flex-
ure itself which lias become hjpertrophicd or altered by chronic inflam-
mation. It is well known that cancers of the flexure frequently cannot
be palpated because they are ring-shaped and scirrhus.
Cancer of the rectum naturally is most apt to be confused with ma-
lignant processes which produce stenosis from without, thus above all
certain forms of gastric cancer with metastasis in the pouch of Douglas,
occasionally also ovarian cancers.
Intactness of the mucosa overlying the tumor-masses is probably an
important criterion, in connection with which it must only be borne in
mind that also cancers of the flexure high up can be palpated through
the intact mucosa of the lower portions of the bowel.
Even with sarcoma of the rectum, according to Kraske,'' there is
little tendency to ulceration, so that the mucosa may be found intact.
" P. Kraske, Samnihing klinischer Vortrage. New Series, Nos. 183, 184, 1897.
Primary and Secondary Cancer of the Liver
With the various differently situated cancer-tumors (gastro-intcs-
tinal, thyroid gh\nd, breasts, etc.) it is always of importance to deter-
mine whether metastasis has already taken place in the liver-tissue, posi-
tive findings being a strict contraindication for radical surgical pro-
cedure.
On the other hand, no therapeutic or prognostic significance attaches
to the decision whether a carcinomatous alteration in the liver takes its
origin from the liver-tissue itself or is carried in from some primary
focus; therefore, it seems justifiable to me, that both forms be clinically
considered in common, the more so, since the assumption of a primary
cancer of the liver can be arrived at only by exclusion.
The diagnosis of cancer of the large glands (liver, pancreas) is ren-
dered especially difficult by the fact that,^ even with extensive cancerous
infiltration of these organs, recognizable disturbances in function are
often absent. So, for instance, in carcinoma of the liver, in the primary
as well as secondary forms, a distinct icterus does not occur in most
instances.
A further difficulty lies in the fact that pain phenomena mostly occur
first at a time when the peritoneal covering of the organ becomes in-
flamed through subperitoneally located cancer-masses. If the cancerous
proliferation develops from central portions it may, through lack of con-
tact with the peritoneum, easily run its course without s3'mptoms. This
may explain why precisely primary cancers of the liver are frequently
not detected until the last stages of the disease have set in.
EARLY SYMPTOMS
If, from the beginning, cancerous nodules develop subperitoneall}",
that is, in the peripheral layers of the liver-tissue — which is especially
true of the secondary forms — it is possible that phenomena of pain will
be among the first symptoms. They will, therefore, deserve serious atten-
tion when there is thought of liver metastases. Reversal of this rule would
not, of course, obtain. Even very extensive cancerous infiltrations of the
liver with enormous enlargement of the organ may run along without
spontaneous or artificially evoked pains (1, 3), and it is often surprising
to note the degree of adaptation of which the liver is capable.
In other cases, however, diflfuse or circumscribed exquisite pain can
be elicited over the organ in the epigastrium by pressure or by the more
readily regulated percussion stroke. With this there may occur — though
125
126 TUMORS OF THE ABDOMINAL VISCERA
seldom — radiations into the right shoulder and shoulder-blade (7), as
they sometimes also occur spontaneously.
INIovements such as stooping, pulling off the shoes, etc, which bring
about pressure upon the organ, also the sitting attitude, are painful.
Tenderness to pressure is frequently found in the region of the right loin.
Special attention is due to tenderness localized in certain areas of the
liver surface. This would point to some localized process distributed in
the liver, in connection with which, aside from gummata and abscesses,
there especially enters into consideration the existence of carcinoma.
Here, however, it must be borne in mind that also with diffuse altera-
tions of the organ (e.g., congested liver), the greatest tenderness on per-
cussion is met with mostly in the linea alba.
Intumescence of the organ leads to exceedingly unpleasant sensations
of pressure and fulness in the epigastrium, which frequently last for a
long time, frequently also become exacerbated, especially after meals,
and by their increase and decrease occasionally resemble attacks of colic.
In accordance with their peritonitic character, perihepatic compli-
cations may lead to the severest paroxysms of pain (Sek. Ca. hepat., 1),
which, quite analogous to pleuritic pains, are characterized by "stab-
bing sensations."
If the entire peritoneal covering of the liver is acutely inflamed, any
change in position may become exceedingly painful, and, as in acute peri-
tonitis, the patients are immobilized and compelled to remain in one
position.
Medullary gastric cancers seem to be the most frequent to give rise
to this "forme douloureuse" of secondary cancer of the liver; it may be
that the pronounced ulceration favors the importation of the excitants
of inflammation.
In this way wc may get pictures of disease which make us think of
some acute infectious process in the liver (liver abscess, cholangitis, lues,
etc.), rather than carcinoma, pain being the most prominent symptom.
This form of secondary carcinoma of the liver in which the phenomena
of pain are the controlling feature, is among the rarest exceptions. With
primary cancer of the liver it is observed still more rarely. Though of
secondary importance, the painful phenomena due to perihepatic condi-
tions often become very noticeable.
Similar to pleuritic pains, they depend partly upon the body position,
and occasionally set in very acutely (Prim. Ca. hepat., 2) ; change of po-
sition, coughing, etc., frequently provoke exacerbations.
They are usually localized on the right side under the costal arch, but
occasionally are also noticed on the left side or extend in girdle-like
fashion above the umbilicus toward the back; in rare cases they radiate
from the epigastrium into the right and sometimes also into the left
shoulder.
Whilst carcinoma of the gall-bladder and biliary passages, discussed
elsewhere, leads, in the majority of cases, to icterus, this does not obtain
in the primary and secondary cancers of the liver here under consid-
cration.
CANCER OF THE LIVER 127
Absence of Icterus
The absence of pronounced icterus may here be put clown as a rule
(a rule with exceptions).
Bearing' in mind that primary carcinoma may remain locali/X'd as a
focus and that metastatic cancer-nodules often are scattered in the liver-
tissue, this rule will excite but little wonder.
The absence of icterus is often surprising in cases. where the liver,
in toto, has been replaced by cancer-tissues. Why does compression of
the bile-ducts and secondary icterus not occur?
Compression of the bile-ducts probably does occur; if, in spite of
this, icterus is ^ibsent, it' may be due to two factors :
1. The channels of resorption (lymph and blood vessels) may be
compressed.
2. The production of bilirubin may be greatly diminished.
A sign indicating biliary congestion far more frequently than a dis-
tinctly jaundiced skin, are the light stools and dark urine containing
abundant urobilinogen, and in regard to the significance of Ehrlich's
aldehyde reaction we must refer to what has been previously said of it.'^
PHYSICAL EXAMINATION OF THE LIVER
Collateral Portal Circulation
Notw^ithstanding the acute course of cancer of the liver, there may
occasionally occur — as in benign processes accompanied by compression
of the portal vein — the development of external collateral veins, the rec-
ognition of which is rated among the most important and most signifi-
cant findings on inspection.
Coughing or pressure will bring them into greater prominence. They
extend in an upward direction, mostly in the middle of the epigastrium
(Prim. Ca., 1, 2), over the lower part of the sternum, or they cross the
right costal arch.
It has been tried to interpret this finding of collateral veins in pri-
mary cancer of the liver as evidence of a pre-existing chronic cirrhotic
process ; however, secondary cancerous infiltrations of the liver also are
accompanied by analogous formation of collateral veins without any
cirrhotic disease, which rules out the above assumption.
The determination of a collateral portal circulation is of particular
diagnostic significance, especially in those cases where the carcinomatous
process is accompanied by ascites or where the enlargement of the liver
is very moderate, thus in both cases yielding unsatisfactor}- findings on
palpation.
"Soft" Hepatic Cancer
With reference to the four cardinal points of examination by pal-
pation, namely, size, shape, surface and consistence, it must be empha-
sized that — though indeed very rarely — the consistence of the portions
"See page 33.
128 TUMORS OF THE ABDOMINAL VISCERA
infiltrated with cancer, which, as a rule, distinguish themselves by their
especial hardness (board-like), may also be more or less soft (Prim.
Ca., 5). With secondary cancer of the liver, this, for instance, is true
of primary foci in the testicle or in the thyroid gland.
Liver Surface
In order to exactly palpate the surface of the liver, it is highl}^ com-
mendable to make the examination with lateral decubitus (left-sided po-
sition for the right lobe and vice versa), at the same time making an
effort to reach as far as possible upward under the costal arch and the
xiphoid process, which is best accomplished with forced diaphragmatic
breathing.^''
The finding of nodular protuberances will call mostly for differential
diagnosis from gummata.
With a smooth surface it would have to be determined whether the
increase in consistence is diffusely even or limited to a certain area of
the liver.
Here the occasional presence of "corset lobes" ^'^^ would have to be
ruled out.
Border of the Liver
In ascertaining the location of the hepatic border, which is particu-
larly adapted for determining the consistence of the liver, care must
also be had not to mistake a "corset groove" for the border. Also, the
lower border of a cancerously infiltrated ligamentum gastro-colicum
might be mistaken for the border of the liver.
A rapid increase in the size of the organ counts among the most im-
portant findings, and it may be necessary to note the location of the
lower border of the liver by one or more marks. ^^' ^-
Pain Phenomena
Palpation of the organ ought always to include examination for pain-
ful phenomena that can be elicited by various mechanical means, such as
percussion, change in position, stooping, etc.
Aitsc^dtation
Systolic Murmurs
Auscultation in some cases affords evidence for assuming a compres-
sion of the hepatic arter}^ or its branches. In this manner we must in-
terpret systolic murmurs (Prim. Ca., 1,6) in so far as they can be heard
over the liver, especially in the region of the right lobe and not too near
the median line. Their localization seems to stand in intimate relation
with the spread of carcinomatous infiltration in the liver-tissue.
According to our own observation, they reach their greatest inten-
sity toward the end of expiration. Epigastric systolic murmurs occur-
ring near the median line, even when audible over the liver, are much
■^ See page 3.
'" See page 10.
*", ^- Best done by producing a linear scratch mark with a needle.
CANCER OF THE EI\ EK 129
more difficult of interpretation as to their origin. Here there is a pos-
sibility of their originatinf;- in the abdominal aorta. Tviuiors lying exter-
nal to the liver (pancreas, stomach, glands, etc.) may cause more or
less compression of the aorta, and in and of themselves or through
atheroma of the vessel give rise to systolic murmurs.
Combined examinations Avill frequently disclose the fact that the
systolic murmurs just referred to become weaker and finally disappear.
In such cases the assumption is close to hand that the compression af-
fected smaller arterial trunks and that, through progressive cancer pro-
liferation, a stenosis was succeeded by complete occlusion of the blood-
vessels, thus bringing about a cessation of the murmurs.
There is no relation between the spread of the malignant process in
the liver and the occurrence of these murmurs. It seems to be simph' a
matter of accident, because often very diffuse neoplasmatic infiltrations
of the liver run along without murmurs, whilst circumscribed areas, on
the other hand, may occasion loud murmurs.
Perihepatic Friction
Auscultation may offer elucidation in still another direction: through
the finding of perihepatic friction-sounds, sometimes recognized on pal-
pation as "snow crepitation," it may point to a local focus in the liver,
thus from the start preponderatingly narrowing down the differential
diagnostic field to carcinoma, lues and cholangitic abscess formation.
ACCOMPANYING SYMPTOMS FROM OTHER ORGANS «^
Gastro-In testinal
It deserves to be emphasized that gastro-intestinal disturbances may
be absent in primary cancer of the liver until the last stages of the dis-
ease (1, 2, 5).
In other cases, besides the occurrence of obstipation, there may set
in early anorexia for meat and meat intolerance, the patient complaining
of an uncomfortable sensation of pressure in the epigastrium after the
ingestion of food (3).
Accordingly, the chemical findings of the gastric contents will vai'^',
showing perfectly normal conditions of secretion (3) or a cachectic
aclilorh3'dria (2).
Terminally, under the influence of increasing portal congestion, there
may occur "coffee-ground" vomiting and melena (T).
Ascites
Ascites is an inconstant symptom ; it seems to occur more often with
moderate enlargement of the liver than with great intumescence, which
might occasionally have some connection with pre-existent cirrhotic
processes. Particular attention should always be given to a hemorrhagic
or "milky" character of the ascites.
*^ Only the primary tumor formations of the liver will here be taken into con-
sideration.
130
TUMORS OF THE ABDOMINAL VISCERA
Spleen
Great enlargement of the spleen, so that the organ extends below the
costal arch, does not seem to be of frequent occurrence in connection with
primary cancer of the liver ; swellings of lesser degree are sufficiently ex-
plained by the oft coexisting portal congestion.
Leucocytes
The blood may show moderate increase of leucocytes rather than
leucopenia, a fact which would enter into consideration at times in the
differential diagnosis from the cirrhosis of Laennec.
Melanin
In respective cases, besides the aldehyde reaction, the urine would
also have to be watched for melanin (Prim. Ca., 7).
SUSPICIOUS FACTORS AND DIFFERENTIAL DIAGNOSIS
The realm of differential diagnosis varies, among others, according
to the anatomical distribution and form of the cancerous infiltration of
the liver.
Cirrhosis of Laennec and Fatty Liver
If the same is diffuse, extending over both lobes and not accompanied
by nodular protuberances on the surface, it affords a palpatory finding,
which, providing the enlargement of the organ remains within moderate
limits, leads one to think of a cirrhosis, and, since icterus is mostl}' ab-
sent, particularly a cirrhosis of Laennec (first stage), the fatty liver of
drinkers sometimes also feels very firm, and may thus enter into the
differential diagnosis.
Some of the more important differential diagnostic points will here
be given brief review :
Diffuse Carcinoma. Infiltration
with Smooth Surface without
Icterus.
Cachexia, progressive loss of
strength and enlargement of
liver, pains, perihepatic fric-
tion.
Systolic vascular murmurs.
Ascites frequent, at times becoming
chylous or hemorrhagic.
Liver hard, like a board.
Moderate leucocytosis.
Occult bowel hemorrhage (in pri-
mary gastro-intestinal cancer).
Often after the 60th year of life.
Cirrhosis of Laennec {First Stage),
at Times Fatty Liver.
Appearance good, condition re-
mains stationar}' ; no pain.
Auscultation mostly negative or
venous hums, after the type of
the "Bruit de diable."
Ascites mostly absent or serous.
Consistence less firm.
Leucopenia.
Mostlv before the 60th A'ear of life.
CANCER OF THE LIVER
131
It must be mentioned, however, that any one of these distinguishing
marks may be absent.
Thus, especially in so far as primary neoplasms of the liver are con-
cerned, cachectic appearance may be absent even with enormous swell-
ing of the liver (Prim. Ca., 7) ; cancerous disease may, though it is rare
with diffuse infiltration, run its course without pain, the consistence may
be soft or at least appear only tensely elastic, so that in the latter case
there may arise the suspicion of a cyst. This is true not onl}- of pri-
mary cancer of the liver, but also of metastatic infiltration, especially
when the primary focus consists of a soft tumor-mass (testicle, adrenal,
thyroid, etc.). Esophageal varices, hemorrhoids may also give rise to
bowel hemorrhages in connection with the cirrhoses of Laemiec, and it
must be borne in mind that gastro-intestinal cancers may occasionally
develop in individuals afflicted with cirrhosis, the congestion existing in
the portal system perhaps inducing a sort of predisposition. Ulcers of
the stomach may also develop in connection with such congestion. All
this may, with cirrhosis, lead to a positive blood-test in the feces.
Amyloidosis
Where we are dealing with a cavernous tuberculosis, chronic suppu-
rative processes, etc., a diffusely enlarged hard liver, even when very
voluminous, can hardly be interpreted in any other way than as an amy-
loidosis. It might, however, be mistaken for a carcinomatous process
where the cause of the amyloidosis is rather latent (e.g., contracted kid-
ney, tubercular intestinal ulcers, etc.).
Biliary Cirrhosis
Those generally rare cases of primary or secondary cancer of the
liver ^^ which are accompanied by diffuse enlargement of the organ, a
smooth surface and icterus, will, among benign diseases, have to be dif-
ferentiated especially from biliary cirrhosis.
Increased. Carcinoma, Infiltration
xclth Smooth Surface; zcith Icterus.
Acute course.
Often after the 60th year of life.
Systolic vascular murmurs over the
liver.
Ascites frequent.
Occult bowel hemorrhages in pri-
mary cancer of the esophagus,
stomach or bowel.
Spleen extending to the costal arch
or small.
Enlargement of the liver progres-
sive.
Biliary Cirrhosis.
Chronic course, with epigastric
complaints dating far back.
Seldom after the 60th year of life.
Ascites very rare.
Spleen often extending consider-
ably beyond the costal arch.
Plemeralopia frequent.
Enlargement of the liver station-
ary.
" In regard to carcinoma of the gall-bladder, see page 133.
132 TUMORS OF THE ABDOMINAL VISCERA
Where a localized alteration of the liver with distinct protuberances
on the surface is demonstrable, the field of differential diagnosis is a com-
paratively narrow one.
Hepatic Gumma
If the alteration affects the left lobe of the liver, and there is no pro-
nounced icterus, the possibility of a gummatous process especiall}' will
have to be reckoned with and iodine therapy instituted. Other tertiary
manifestations of lues (bone and dermal scars, defects in the nasal sep-
tum, the gums, choroiditis, etc.) should always be looked for; the Was-
sermann reaction in these cases is almost always strongl}'^ positive. ^^
Those cases of syphilis of the liver are most apt to lead to confusion
which exceptionally run their course accompanied bj^ icterus and ascites
and severe edemas, especially when occurring at an advanced age.
Unilocular echinococcus cysts will be mistaken extremely seldom be-
cause cachexia is absent, their consistence is more elastic, and subjective
epigastric symptoms (sensation of pressure, etc.) often date far back;
it is only when the disease leads to severe icterus — which is extremely
rare in connection with unilocular echinococcus cysts — that there is dan-
ger of erroneously assuming a malignant process of the liver.
Multilocular echinococcus cysts might offer the most serious difficulty
because the syndrome of symptoms confronting us here may be of a de-
cidedly malignant complexion, thus exceedingly firm consistence (mostly
in the right lobe of the liver), uneven contour, ascites, icterus.
As compared to Bavaria, Switzerland and Wiirtemberg, Austria con-
tributes only a small percentage of this disease.
Pleuritis
The perihepatic pains and the fact that they are influenced by breath-
ing, coughing, etc., may, at least in the initial stages of cancer of the
liver, be mistaken for pleuritic processes.
Having made certain the diagnosis of a carcinomatous infiltration of
the liver, the further question as to its primarj' or secondary nature is of
purely theoretical interest.
The following, among others, are probable grounds for assuming a
primary cancer of the liver :
1. Exclusion of primary foci situated outside of the liver, in which
connection such rare localities as lungs, breasts, testicles, thyroid and
suprarenal glands would have to be taken into consideration. Constantly
negative blood findings in the stool will render cancer of the esophagus,
stomach or intestine improbable.
2. Decided swelling of the spleen. This deserves attention in so far
as it may be a symptom of a synchronously existing cirrhosis.
3. Very youthful age. Statistics show that primary cancer of the
liver attacks young people with relative frequency.
4. Severe icterus renders a primary cancer of the liver highly im-
probable.
*'i?. Bauer, Lues iind innere Medizin. Franz Deuticke, 1910.
Carcinoma of the Gall-Bladder
EARLY SYMPTOiAIS
On comparing the functions of the gall-bladder to tliose of other or-
gans, the stomach, for instance, in which latter case there are also pres-
ent other sources of irritation, we find that conditions in the former organ
are far more simple, its activity being restricted mainly to the reception
and forwarding of the .secretion furnished by the liver-cells. Accordingly,
one might expect that the gall-bladder would be the last among the organs
likely to become the seat of cancer, were it not for the fact that occasion-
ally it has to suffer grave mechanical injuries from concretions.
Since functional disturbances of the gall-bladder have much less op-
portunity of coming to the surface either in a subjective or objective
way, than is the case in such organs as the stomach, it cannot be won-
dered at that the first symptoms of cancer of the gall-bladder, at least as
far as the anamnesis discloses them, appear at a comparatively late date
and often only a few months before death.
In the majority of cases the first symptoms are those of pain, and the
correct interpretation of these painful phenomena counts among the pri-
mary requisites for an early diagnosis.
Phenomena of Pain
The beginning of cancer of the gall-bladder consists in anatomical
changes of the organ itself, such as hardening (tumefaction) with in-
crease of intravesical pressure, cholecystitis, etc., or it may be perihepa-
titis of a portion of the liver, which is adjacent to or continuous with
the gall-bladder.
The symptoms of pain can be classified in two groups.
a. Those without colic.
These are frequently stabbing or oppressive pains restricted to the
gall-bladder, which are mostly dependent upon mechanical causes and
frequently appear in the sitting or stooping attitude, whereas they are
felt but little or not at all in the erect position, i.e., standing up.
Rapid walking, coughing, sneezing and lying on the right side cause
exacerbation of the painful symptoms, hence the danger of confounding
them with pleuritic pain. As in pleurisy, it is found that lying on the
healthy side is intolerable and causes the sensation of pain travelling
from right to left in the painful area (3). The region of the gall-bladder
is often tender. Pains in the back are also observable and the}' radiate
to the front in girdle fashion, sometimes being more localized on the
right side. At the same time there may be tenderness over the spinal
column in the interscapular region.
133
134 TUMORS OF THE ABDOMINAL VISCERA
If the liver capsule becomes inflamed, either diffuse or circumscribed,
as a result of cholangitic complication, such as abscess, etc., the organ
becomes tender and displacement of it, such as occurs during breathing,
change of position, etc., proves very painful (7) ; likewise pain is elicited
by percussion over the linea alba, where the organ, by simultaneous sepa-
ration of the recti, is found most immediately. Stasis of bile or can-
cerous infiltration may render the liver tender to touch and percussion.
b. Colicky symptoms.
Just as the presence of concretion in the gall-bladder is looked upon
as the primary cause of cancer in the organ, so also, conversel}^ it is
found that the development of cancer in the gall-bladder gives rise to
gall-stone complaints in so far as it provokes gall-stone colic. Often the
gall-stone disease remains latent up to this time and the developing can-
cer provokes the first attack.
Secondary cholecystitis, together with interference in the flow of bile,
may be considered last in causing attacks. There is, therefore, sudden
and severe colic, localized in the epigastrium or in the region where the
gall-bladder may be, the pains radiating into the loins and upward into
the right shoulder. Percussion of the liver in the linea alba and striking
of the right loin with the fist are most often painful. L3'ing on the side
is barely tolerated.
Accompanying symptoms : vomiting of bile, chills.
Sometimes the painful attacks are of an abortive type, but by their
nocturnal appearance betray their colicky nature. Whilst in uncompli-
cated gall-stone colic we find jaundice, if it occurs at all, making its ap-
pearance within a few succeeding days, we find with complicating gall-
bladder cancer that stasis of bile shows up several weeks later.
In uncomplicated cholelithiasis the incident anorexia passes away
with the attack, whereas in cases complicated with cancer the anorexia
becomes more permanent.
Bile Stasis
As the evacuation of bile can go on even without a gall-bladder, as-
happens after resection, it is obvious that jaundice may be permanently
absent,**^ occur very late, or show itself in the last phases of the disease
even when there is a diffuse carcinomatous infiltration of the wall of the
gall-bladder.^^ This is especially true in the scirrhus forms of gall-
bladder cancer, in which cases there is considerable shrinkage of the
organ, eventually leading to stenosis of the pylorus or the hepatic flexure
of the colon.
In the matter of an early diagnosis, then, not much significance can
be attached to the presence of a decided jaundiced skin or discoloration
of the mucous membranes or the demonstration of bilirubin in the urine.
More important, however, because appearing earlier, is the demonstra-
tion of increasing quantities of urobilinogen in the urine. For this test
'^Nos. 10, 11, 12, 13, 11, 17,
" Nos. 2, 7, 19, 21.
CARCINOMA OF THE GALL-BLADDER 135
I recommend solely Ehrlich's aldehyde reaction, as it cannot be sur-
passed in simplicity. *^^
Negative reactions in the urine should not be used for diagnosis.
Constantly positive findings will always call careful attention to \\n- liver,
as they generally coincide with mild grades of biliary stasis.
The reaction, like albumin and sugar tests, is of sufficient importance
to become a routine test with all physicians. In obscure abdominal cases
I consider the neglect of the examination for urobilin a great mistake.
Of greatest importance is the failure of the reaction in alcoholic ex-
tract of stool with existing jaundice, since this is a positive indication of
a complete obstruction of bile.
If in a case of cancer of the gall-bladder there be stasis of bile, caus-
ing urobilinogenuria and finally the elimination of bilirubin in the urine
and jaundice, then we may consider several possibilities.
a. The cancer in the continuous course reaches the ductus choledochus
and occludes it. In this way there occur the most intensive forms of
jaundice, the so-called "Schwarzsucht." These are cases in which the
urobilinogen disappears entirely from the feces; the jaundice becomes
stationary and rarely subject to change.
b. The jaundice depends partly or entirely upon cholangitic com-
plications. Accordingly, the body temperature is usually increased, chills
may occur, the peritoneum of the liver becomes inflamed, we may have
peritoneal friction rubs.
Cholangitic infectious processes not rarely lead to the appearance
of Ehrlich's diazo reaction in the urine. With this pathogenesis of the
jaundice variations of the latter are easily explained.
c. Cholelithiasis, so often occurring synchronously with cancer of the
gall-bladder, can give rise to the appearance of jaundice. The infectious
process often accompanying cancer of the gall-bladder elicits colic of
the organ, and in this way there occurs the expulsion of concretions into
the ductus choledochus, resulting in jaundice due to obstruction. Or
there may be jaundice lasting but a day or two, coming on together with
the painful attacks, this jaundice depending on swelling (infectious or
vasomotor) of the mucous membranes lining the gall-ducts, or it may de-
pend upon hyperemia of the liver.
Those cases in which icterus makes its first appearance several weeks
after a gall-bladder colic, seem to me especially suspicious of carcinoma
of the gall-bladder (3, 4).
The complications discussed under &, and c make it appear compre-
hensible that also with carcinoma of the gall-bladder the biliary stasis
and its resultant manifestations in the urine, such as elimination of bili-
rubin or urobilinogen, and skin discoloration, may be subject to more or
less pronounced variations. The skin discoloration as such is less adapted
as an indicator of the momentary biliary congestion, because the disap-
*' Compare No. 38.
136 TUMORS OF THE ABDOMINAL VISCERA
pearancc of the bile-pigment in the skin, especially if it has reached a
high grade and has lasted a long time, is much slower than the retro-
gression of the biliary congestion.
Edematous infiltration of the skin may lead to a local diminution of
the jaundiced discoloration (3). If, as is not seldom the case, the icterus
diminishes toward the end (9), it may occasionally be due to a reduced
production of bile-coloring material.
PHYSICAL EXAMINATION FOR CANCER OF THE GALL-
BLADDER
The early diagnosis of cancer of the gall-bladder presupposes that
the examiner is in the habit of making a detailed exploration of the gall-
bladder region in every abdominal case. I believe I am not wrong in
assuming that this is frequently omitted.
Inspection
There are cases of carcinoma of the gall-bladder (though they are
those of much-emaciated patients) in which the gall-bladder can be rec-
ognized by mere inspection (3). It bulges forward like a globular forma-
tion, and with diaphragmatic breathing exhibits exquisite movability.
Palpation
In most instances, however, palpation is required, and this should be
tried also in the lateral decubitus.
Where the belly-walls are very much relaxed it is possible — though,
of course, seldom — to grasp the border of the liver from above between
the thumb and the fingers, thus also feeling the great distention of the
gall-bladder.
The findings differ very much. The gall-bladder may be transformed
into a very thin tumor (21), which is globular or pear-shaped, the sur-
face sometimes almost angular and facetted (1, 15), (adapting itself to
concretions!) ; but the walls may also feel soft (4). Besides ascertaining
the size, consistence and shape, one should also always look for tenderness
to pressure.
In differential diagnosis it is only the lower pole of a deeply located
kidney that comes into consideration.
Gall-Bladder or Kidney?
The often difficult distinction will be based especially on the follow-
ing considerations :
1. By gliding the palpating fingers downward over the lower pole of
the kidney it is possible, if the organ be movable, to cause it to spring
upward after the manner of a cherry-stone, this being a procedure which
is impossible of accomplishment with respect to the gall-bladder fixed in
its place. The kidney which has thus been dislocated upward can again
be displaced downward if the patient stands upright.
CARCINOMA OF THE GALL-BLADDER i:JT
The relations of the lower pole of the kidiuy to the bortler of the
liver are variable, those of the gall-bladder are fixed.
2. Accordingl}', it is in a large measure possible to penetrate between
the border of tlie liver and a (juestionable tumor when wo are dealing
with the lower pole of the kidney ; the pathologically altered gall-bladder
is frequently fixed to thi- hepatic border, and penetration is therefore
impossible.
3. A tumor of the gall-bladder is usually adjacent to the anterior
abdominal wall, and occasionally even bulges out.
■i. The movability of gall-bladder tumors with diaphragmatic breath-
ing is particularly prompt.
5. Differences in consistence are not always present, as very elastic
tension and diffuse carcinomatous infiltration may be the equivalent of
the normally existing difference; frequently, however, the gall-bladder
feels softer, and then there is slight trace of fluctuation.
6. With very much enlargement its pear-shape becomes conspicuous,
as also the good lateral motion on the diminishing pedicle, when there is
absence of upw^ard or downward mobility.
While the normal gall-bladder is not, as a rule, palpable, it is fre-
quently possible, wath carcinomatous disease of the organ, to feel it. The
cause for this does not always lie in an enlargement of the organ ; some-
times even the reduced and contracted gall-bladder is demonstrable. The
cause seems rather to be in the increased consistence, which in its turn
may be due to increased internal pressure or to thickening of the
walls.
"Corset Lobes."
Unfortunately, even the gall-bladder with enlarged volume is fre-
quently not palpable. This is due to the frequency with which so-called
"corset lobes" are present with cholelithiasis and cancer of the gall-
bladder.
The anterior portion of the border of the right lobe of the liver is
stretched out flat like an apron, separated from the rest of the organ
by a more or less deep groove running in a horizontal direction on a level
with the costal arch, and behind this "corset lobe" there is concealed the
gall-bladder, at times much enlarged, not accessible to palpation. Only
very exceptionally is the left lobe of the liver stretched out in a similar
manner, and then it may suggest a splenic tumor if sufficient attention is
not paid to the sharp free border.
The "corset lobes" derived from the right half of the liver may lead
to a series of diagnostic errors. If these lobes are marked off bj^ a deep
groove, one is very apt to assume that the hepatic border lies along this
groove; this the more so, as the continuation of the groove toward the
left actually leads to the border of the left lobe of the liver.
On account of the small sagittal diameter of the "corset lobe," it
usually yields a tympanitic sound, as it rests upon the bowel like a plexi-
meter. Again, it offers but little resistance to the palpating fingers, and
therefore easily escapes detection by palpation, particularly when the
138 TUMORS OF THE ABDOMINAL VISCERA
examination is undertaken in the dorsal decubitus and not in both lateral
positions.
Furthermore, when such "corset lobes" extend far down, they give
rise to resistances in the ileocecal region, so that they occasionally sug-
gest even tumors of the cecum ; the consequent deep location of the gall-
bladder may, in painful affections, lead among others to the danger of
confusion with appendicitis.
Corset lobes are not seldom subject to distinct ballottement, which,
however, can be obtained better in the axillary line of the lumbar region
than directly from the back.
As a result of connective-tissue induration, the consistence in the
proximity of the "corset groove" is fi-equently increased, so that one
might easily imagine a cirrhotic or even carcinomatous process going on.
As carcinoma of the gall-bladder very frequently spreads by con-
tinuity, the portions of the liver immediately adjacent should be carefully
examined as to consistence, character of the surface, etc.
This regional invasion is not without meaning for the diagnosis of
cancer of the gall-bladder.
Often it is only the area immediately surrounding the gall-bladder
which is infiltrated and feels hard as a board, or there are present promi-
nent cancer nodules, or it is possible upon auscultation and even pal-
pation to demonstrate peritoneal friction. ^'^
It may occasionally occur in connection with cancer of the gall-blad-
der that metastasis gives rise to tumors of the large omentum, which may
be easily misleading.
ACCOMPANYING SYMPTOMS FROM OTHER ORGANS
Gastric manifestations, such as anorexia, dilatation, gastric peris-
talsis, vegetation of sarcinae and lactic-acid bacilli, "coffee-ground" vomit-
ing, achlorhydria, etc., may come so prominently into the foreground
that they obscui'c the primary disease. This refers above all to those
cases of cancer of the gall-bladder which lead to stenosis of the pylorus
or duodenum.^'* Confusion with primary gastric affections is so much
more easily possible, as we are frequently dealing with cancer of the gall-
bladder which is of the scirrhus type, confined to the gall-bladder and
running its course without icterus.
But even without such mechanical complications disturbances of the
stomach are frequently met with. The syndrone, icterus and continued
anorexia, occurring in advanced age, will always make us think of the
possibility of cancer of the gall-bladder.*^^ The anorexia and intolerance
frequently are limited to meat.
The biliary stasis as such probably has nothing to do with the ano-
'''Nos. 2, 6, ]0, 20.
'"Nos. 1, 2, 11, 15, 17, 19.
w No. 4.
CARCINOMA OF THE GALL-BLADDKR 139
rcxia, for frequently the anorexia occurs as the initial syinptoiii without
icterus. '^^
In view of the individual differences in functionating power of the
organ ("stomach athletes" and "stomach weaklings"!), there can be lit-
tle wonder if in some cases the appetite remains.''-' Even in such cases
the intake of nutrition is often limited, as it easily causes a sensation of
discomfort in the epigastrium (3, 19).
Similarly as in gastric cancer, it is possible that in the beginning of
the disease formerl}'^ existing gastric complaints, such as pyrosis, may
disappear (10), which is probably due to a decline in the HCl curve.
Boivel
Cases beginning with anorexia (2, 11) are usually accompanied by
obstipation, yet a sluggish bowel is of far less frequent occurrence with
cancer of the gall-bladder than it is with cancer of the stomach. Even
regulation of formerly tardy bowel movements may be observed (8) which
may have some connection with the poor absorption of fat as a result of
biliary stasis.
In rare cases carcinoma of the gall-bladder leads to severe stenosis of
(11, 14), and may invade the hepatic flexure of the colon (20).
Ascites
Ascites, which sometimes becomes very prominent (2), deserves at-
tention as a peritoneal symptom. It may be the result of metastasis in
the peritoneum (19, 20), and thus be due to carcinomatous peritonitis
or be traceable to a congestion (metastases ad portam hepatis!). The
occurrence of local areas of inflammation such as pericholecystitis and
perihepatitis with fibi-inous exudation and consequent peritoneal fric-
tion, has already been mentioned. Diff'use metastasis into the liver-tissue
with ver}^ much enlargement of the organ (7) does not count among the
frequent occurrences. Often the metastasis is very slight or takes place
largely by continuity in the immediate proximity of the gall-bladder.
Not infrequently the enlargement of the organ is due to the congestion
of bile, which may also lead to increased consistence — though, indeed,
moderate^ — of the organ.
Retroperitoneal Glands
Formation of metastasis in the retroperitoneal glands may occasion-
ally give rise to compression of the inferior vena cava, thus inducing a
thrombosis of that vessel (3).
Tachycardia
Despite prolonged and pronounced biliary congestion, carcinoma of
the gall-bladder, and analogously also carcinoma of the papilla of Vater,
"Nos. 2, 6, 11, 13, 14, 15, 19, 21.
»' Nos. 3, 10, 12, 20.
140 TUMORS OF THE ABDOMINAL VISCERA
are frequently accompanied by tachycardia, thus being in certain contra-
distinction to benign forms of icterus. This behavior, however, does not
depend upon the cancerous nature of the disease as such. Thus the
"mummifying" types of cancer of the gall-bladder are not seldom accom-
panied by ictcrus-bradycardia. But when the peripheral resistance is in-
creased through the occurrence of dropsy in the skin and cavities, or
when cholangitic infectious processes are added, tach^'cardia is present,
even with chronic and intense icterus.
Spleen
Swellings of the spleen may come into being under the influence of a
chronic icterus, through congestion or cholangitic infections.
These, however, always remain within moderate limits, hardly ever
exceeding the costal arch, and very seldom does the organ attain the de-
gree of hardness met with in cirrhosis.
COURSE, DURATION, TYPES
"Acute" Begimiing
Here, as in cancer of the stomach or intestine, the patients frequently
describe an acute beginning. An attack of "gall-stone colic" is not sel-
dom the first link in the chain of symptoms, and naturally is an occur-
rence which impresses itself in the memory of patients better than pre-
ceding indefinite complaints.
Duration
The clinical duration of the disease (the duration of the anatomical
process cannot be judged) is a strikingly short one, at any rate really
much shorter than, for instance, in gastric cancer. I would assume an
average duration of six months and consider as unusually long a duration
of one year.
Two factors might here be adduced by way of explanation.
In the first place, the relative inferiority in functioning power of the
organ may possibly cause a longer period of latency.
Again, the frequently existing biliary congestion with its resulting
phenomena, such as cholemia, cholangitis, etc., may injure the entire
organism, which hastens the lethal course.
Types
From among the polymorphous clinical forms of manifestation of
cancer of the gall-bladder, several types may be more sharply outlined.
These may here be briefly noted.
1. "Hepatic" Type
Most intense icterus, stationary, painless, with blackish-green dis-
coloration, extreme emaciation and mummification, afebrile, found mostly
in very old women: scirrhus of the gall-bladder.
CARCINOMA OF THE GALL-BLADDER 141
2. "Cholang'dic" Ti/pe^^
This runs a febrile course mostly with moderate rises in temperature,
but which may reach considerable elevation (6, 10). Diazo reaction in
the urine; leucocytosis, often very considerable.
Icterus of medium severity, variable ; liver enlarged, tender to pres-
sure, often localized perihepatic friction. ]\Iostly younger individuals
(40-50 years) : Medullary carcinoma (villous cancer) and cholecystitis.
This type, more so than type No. 1, is frequently marked by an attack
of gall-stone colic in the beginning of the disease or during the course of it.
3. "Peritoneal" Type,
in its clearest form without icterus, accompanied by ascites, produced by
peritoneal metastasis and portal congestion.
4. "Stomachic" Type^^
Its most distinct form is represented by those cases in which icterus
is absent and the symptoms of a pyloric stenosis are present. This type,
as a rule, exhibits the usual marks of a benign stenosis (HCl sarcinse),
but may also, though seldom, be accompanied by achlorhydria, "coffee-
ground" vomiting and growths of lactic-acid bacilli.
5. "Intestinal" Type
Intestinal peristalsis as a result of stenosis of the hepatic flexure of
the colon (14).
SUSPICIOUS FACTORS AND DIFFERENTIAL DIAGNOSIS.
Suspicious Factors
So far as suspicious factors are the result of simple and uncom-
plicated considerations they may here be briefly grouped :
1. Chronic severe icterus in very old age, especially when occurring
in female patients, is in the first place always suspicious of carcinoma
of the gall-bladder.
2. If gall-bladder colic is followed after several weeks by icterus
(3, 4) it will suggest the possibility of carcinoma of the gall-bladder;
the same counts among the inducing causes of gall-bladder colic and must
always be considered etiologically, especially in advanced age ; as a gen-
eral thing it will be advisable in gall-stone patients to keep watch in
this direction.
3. "Gall-stone colics" are so much more suspicious of cancer when
they first occur in old age without apparent cause and are accompa-
nied by continued anorexia.
4. Pains below the right costal arch, manifesting themselves espe-
»*Nos. 1, 11, 19.
»=Nos, 6, 8, 10, Ifi.
142 TUMORS OF THE ABDOMINAL VISCERA
cially when patient is seated, sliould always be the occasion for a care-
ful examination of the gall-bladder.
5. A rapidly and painlessly developing pyloric stenosis with persis-
tence of HCl secretion and vegetation of sarcin<T is suspicious of carci-
noma of the gall-bladder, the more so, when at the same time indications
of a stenosis of the hepatic flexure of the colon exist.
Dijferential Diagnosis
The field of differential diagnosis varies according to the existing
type of disease, with respect to which we refer to former discussions.
Icterus Catarrhalis
So far as the "hepatic" or "cholangitic" types, which are accompanied
by icterus, are concerned, it will be well to keep in mind that icterus
catarrhalis is rare after the fortieth year of life.
Biliary Cirrhosis
Neither are "biliary cirrhoses," frequently met witli in older age,
say after the 50th year. In doubtful cases hemeralopia would speak in
favor of Hanoi's cirrhosis, ascites in favor of carcinoma, providing the
liver be enlarged and intense icterus be present. A splenic tumor extend-
ing below the costal arch and accompanied by leucopenia corresponds
more to the picture of a biliary cirrhosis.
Primary Cholangitis
Chronic icterus as a result of primary infectious cholangitis is decid-
edly rare; far more frequent is infection of the biliary passages associating
itself with neoplasms of the biliary passages (gall-bladder and papilla
of Vater). A high febrile course with hyperleucocytosis (10) and diazo
reaction must not deter us from suspecting a neoplasm being thus situated.
Impaction of Calculus
Icterus due to occlusion of the ductus choledochus bj' a calculus almost
always sets in immediately after a severe attack of colic.
Ucliinococcus
Echinococcus cysts only very exceptionally lead to severe icterus ;
this extraordinarily rare possibility must, however, be borne in mind,
because comparatively eas}^ surgical interference may in these instances
be life-saving.
Perihepatic Friction
This is met with much more frequently in connection with malignant
icterus than with benign forms.
Among the malignant processes accompanied by icterus gravis besides
cancer of the gall-bladder we have practically to take into consideration
only carcinoma of the head of the pancreas and carcinoma of the papilla
of Vater.
CARCINOMA OF THE GALL-BLADDER
143
Gall-Bladder.
Icterus curve rarely in-
termittent.
Febrile course ; at times
diazo reaction and
high leucocytosis,
cholangitic accompa-
nying manifestations
such as perihepatitis,
etc.
Gall-bladder at times
contracted, infiltrat-
ed with cancer; ex-
ceptionally soft, en-
larged.
"Corset lobes" very
frequent.
Cholelithiasis, at times
a previous history of
typhoid.
Trypsin test (feces)
positive.
Head of the Pancreas.
Icterus curve rising or
stationary.
Mostly afebrile ; no
cholangitis.
Glycosuria spontane-
ous or alimentary
(rare).
Gall-bladder enlarged.
Trypsin test ^*^ in the
feces at times nega-
tive.
Systolic murmur over
the abdominal aorta
in the epigastrium.
Papilla of Vater.
Icterus curve often in-
termittent.
Febrile course very fre-
quent, likewise cho-
langitic accompany-
ing manifestations.
Gall-bladder enlarged.
Bowel hemorrhages,"^ if at all, oc-
curring only late.
Occult bowel hemorrhage as an
early symptom.
The foregoing tabulation is designed throughout to meet cases ac-
companied by intense biliary congestion, hence severe icterus.
Just as there are no iron-clad rules in differential diagnosis, so also
here the distinguishing marks possess only conditional value.
^ In view of the uncertainty as to what extent the pancreas is responsible for
functional disturbances analogous to achylia gastrica, negative findings will have to be
used cautiously; positive findings, though, may be estimated higher in value.
*" Here negative findings are much more important than positive ones. The lack of
urobilinogen seems to have some bearing on the fact that often even very slight amounts
of blood in alcoholic stools yield a strongly positive chemical blood test. Here only
larger admixtures of blood are of value for the diagnosis of ulcerative processes. Such
admixtures of blood may be recognized macroscopically at times by the brownish color
which they impart to the feces that are free from urobilinogen, and microscopically by
the presence of amorjihous flakelike blood pigment.
144 TUMORS OF THE ABDOMINAL VISCERA
Cancer of the Pancreas
Carcinomas of the pancreas often remain free from ulcerative proc-
esses for a long time, and this explains the mostly afebrile course of the
disease, which is in particular contradistinction to the cholangitic infec-
tious processes often occurring early with carcinoma of the papilla of
Vater (ascending infection from the ulcerating surface).
In not too far advanced stages the demonstration of occult hemor-
rhages in the feces is at times certainly significant for the assumption
of a cancer of the papilla of Vater. Just prior to death it is possible
that also with cancer of the gall-bladder (12) and of the head of the
pancreas there may occur intestinal hemorrhage due to portal congestion
and penetration of the pancreatic cancer into the duodenum,
Indican
I do not attach any particular diagnostic significance to the result
of the indican reaction in the urine. It may, for example, be perma-
nently absent in cancer of the gall-bladder (15), without any demon-
strable lesion in the pancreas or its excretory channels.
In Case 7 the reaction was for a long time negative, and became
positive only with the appearance of peritonitic symptoms.
Neutral Fat
The appearance of neutral fat in the feces does not seem to have
any other meaning than that the biliary occlusion is a very severe one.
Diazo Reaction
Hyperleucocytosis
It seems to me that like cholangitic complications, so also diazo reac-
tion and hyperleucocytosis (6) are much less frequent with cancer of
the head of the pancreas.
Laennec's Cirrhosis
As far as forms of gall-bladder cancer which run their course without
icterus are concerned, the cirrhosis of Laennec in the first stage will
occasionally enter into differential diagnosis. Lack of corresponding
swelling of the spleen, circumscribed tenderness on pressure (correspond-
ing to subperitoneal cancer masses), at times with perihepatic friction
sounds in the painful area, febrile movements, ascites, etc., would be
findings pointing rather to malignancy.
Pyloric Stenosis
Pyloric stenosis would have to make us think of cancer of the gall-
bladder as the cause, when the symptoms date back but a short time
(several months) and peristalsis goes on painlessly despite persistence
of HCl. Neither condition applies to stenosis resulting from internal
ulceration. The previous history in these cases usually dates back many
years, and, under the influence of HCl irritation, peristalsis goes along,
mostly accompanied with violent colics.
Carcinoma of the Pancreas
The colorlessness of the pancreatic secretion is a factor which in and
of itself — as compared to analogous diseases of the liver — renders the
diagnosis of carcinoma of the pancreas difficult ; the main difficult}',
however, arises from the concealed location of the organ.
There are chiefly two ways in which the cancer proliferation may
make its clinical appearance already in the early stages, even though
the anatomical limits of the organ have not been exceeded, namely:
o. Compression of the channels of elimination within the gland: duc-
tus choledochus and ductus pancreaticus. This possibility applies at
least to cancers located in the head of the pancreas.
&.' Irritation of pancreatic nerves and nerve plexuses with secondary
phenomena of pain.
EARLY SYMPTOMS
Phenomena of Pain
a. Phenomena of Pain.
Though there is the undoubted possibility that cancer proliferations
in the pancreas lead to the early appearance of painful phenomena, it
must, on the other hand, be emphasized that sensations of pain referable
to the pancreatic tumor itself are often absent (1, 3, 4).
At any rate, pains that are constant, felt deep in the epigastrium and
located posteriorly in the back, of great severity and at times depending
upon body position, will occasionally awaken the suspicion of a new
formation in the pancreas. Of course, the same ensemble of pains may
be observed also in other retroperitoneal malignant new-growths (such
as gland metastases, lymphosarcoma), its intensity being in proportion
to the extent of the retroperitoneally located malignant process. Ex-
tension of the malignant process to the vertebral column, of course,
affords specially favorable conditions. The objective examination for
pain in such cases will easily elicit tenderness deep in the epigastrium,
and at times also along the spinous processes of the lumbar vertebra?
and the sacrum (2, 6).
Other painful phenomena occurring during the course of carcinoma
of the pancreas are of such nature as rather to divert attention from
the underlying process.
Thus, for example, there may often be great tenderness to pressure,
and also spontaneous pains in the region of the gall-bladder if it is
greatly distended because of compression of the ductus choledochus in
145
146 TUMORS OF THE ABDOMINAL VISCERA
the head of the pancreas (3, 5). Or there may occur hepatalgias result-
ing from perihepatitis due to cancerous infiltration of the liver, or dis-
tention of the liver capsule due to biliary congestion or cholangitic
processes.
If, as a result of duodenal or pyloric stenosis, the walls of the stom-
ach are overtaxed, there may occur gastralgias, which occasionally also
radiate into the back (2). Relieving the stomach of excessive internal
pressure, be it by means of belching of gas, vomiting or bowel evacua-
tions, usually has a verv favorable efl'ect on this kind of pain in the
back.
Stasis of Biliary and Pancreatic
Secretion
b. Stasis of Biliary and Pancreatic Secretion.
Even with quite diffuse cancerous infiltration of the pancreas, the
ductus choledochus may escape compression ; without further comment,
this is comprehensible when the new-growth is located in the tail or
middle portions. The predominating occurrence, however, of cancer
proliferation in the head of the pancreas accounts for the fact that
biliary congestion, and hence icterus, count among the frequent symp-
toms of cancer of the pancz-eas.
In this respect it will be of importance to recognize the biliary con-
gestion in its incipient stages, in regard to which we refer to previously
given details (page 35). Great practical significance attaches also here
to Ehrlich's aldehyde reaction.
"Pancreatogenous" Icterus
If pronounced icterus has set in, special attention should be given
to the following findings, in order to make a rapid differential diagnosis :
a. Decided enlargement of the gall-bladder, the demonstration of
which often meets with difficulties, especially in the presence of "corset
lobes" of. the liver.
b. The icterus often sets in without pain ; at least, there is no severe
colic (as compared to gall-stone colic with an occluding calculus in the
ductus choledochus).
c. The icterus is mostly unaccompanied by fever, at least so long
as there is no ulceration extending into the duodenum (blood-coloring
matter in the feces), which latter, if present, might indeed easily lead
to ascending infections of the biliary passages.
d. Hardly any variations in the icterus, but rather constant progress-
iveness up to a melanotic icterus with complete biliary occlusion, and at
times absence of the aldehyde reaction in alcoholic extract of stool.
Ohstr acted Flow of Pancreatic Juice
and Its Demonstration
Those cases of cancer of the head of the pancreas accompanied by
complete obstruction to the flow of bile are probably also accompanied
CARCINOMA OF THE PANCREAS U7
by total shutting off of the flow of pancreatic juice; but it is also
within the realms of possibility that there be an isolated blocking of
the secretion of the "abdominal salivary gland."
The question, therefore, arises as to what criteria we have for assum-
ing a cessation of external secretion of the pancreas into the duodenum.
Trypsin Demonstration
1. Absence of the normal proteolytic digestive energy in the super-
natant portion of feces.
The briefest and, at the same time, most reliable procedure is Miiller
and Schlechfs^^^ modification of Sahli's "capsule method."
Here the effects of the proteolytic ferments of the feces are exerted
upon properly hardened gelatine capsules that contain charcoal (Capsul.
geladurata? c. carb. ligni 0.3, original filling by the firm of G. Pohl,
Schonbaum, Danzig).
According to Stanick,''^'^ spontaneously evacuated stools may be mixed
with an equal quantity of 1% soda solution, thoroughly rubbed up and
then used for the test, thus doing away with the necessity of a test diet.
The capsule is dissolved in the supernatant liquid of normal stools in
1/^ to 1 hour; if it does not go into solution after the lapse of 24' hours,
the test is to be considered as entirely negative.
If diluted with 10% glycerin water, 1 : 100 solution results 20 to 24<
hours at 37° C.
As it is the complete absence of any proteolytic action that is of
chief diagnostic importance, it will frequently be possible to confine one's
self to an examination of the original supernatant liquid of the stools.
The test is best performed in the incubator at a temperature of
37° C. (higher temperature would in and of itself cause the capsule to
go into solution), and in order to avoid any action on the part of bac-
terial ferments a little chloroform or a few crystals of thymol may be
added.
The test may also be carried out at the higher room temperatures
(proximity of the stove).
It must be borne in mind that large admixtures of blood or a high
fat content may induce an attenuation of the contained ferments. In
the latter case, if the finding proved negative, it would be advisable to
dissolve out the fat with ether.
Large admixtures of pus practically enter into but little considera-
tion. They could, however, in and of themselves produce proteolytic
fermentative action.
If in a case otherwise clinically suspicious of carcinoma of the pan-
creas, there results a totally negative outcome of the Miiller and Schlect
capsule test, additional ground strengthening the suspicion has been
gained. A positive outcome admits as very probable the conclusion that
the pancreatic secretion is flowing into the duodenum, but naturally does
not permit the assumption that the pancreas is intact.
'«Med. Klinik, 1909, Nos. 16 and 17.
"^aMed. Klinik, 1910, No. 26,
148 TUMORS OF THE ABDOMINAL VISCERA
Through the complete failure of the Cammidge reaction,'''^ to which
we cannot attribute any diagnostic significance in the semiology of pan-
creatic cancer, the methods of "trypsin" demonstration have gained in
interest.
2. Simultaneous serious impairment of fat and albumin reduction.
Steatorrhea and Azotorrhea
This may bring about the presence in the feces of abundant neutral
fat globules and intact transversely striated muscle fibres. An entirely
negative result of qualitative analysis for indican in the urine indicates
that there is complete cessation of albumin reduction in the bowel.
Maximal interference with such reduction may naturally also lead to
specially copious stools, as in fact they are much observed in connection
with carcinoma of the pancreas.
Even the rapidly progressive and severe cachexia may be partly in-
terpreted as cachexia due to inanition.
With respect to the alimentary findings of steatorrhea and azotorrhea
in the feces, as just referred to, it must be emphasized that apparently
even with complete occlusion of the excretory passages of the "abdominal
salivary gland," there are no macroscopical or microscopical findings
deviating to any great extent from the normal. It would seem that with
appropriate conditions in the digestive tract there is a possibility of
more or less perfect compensation. Negative findings, therefore, do not
have any diagnostic significance.
On the other hand, in those cases which are accompanied by dimin-
ished reduction of albumin and fat, the explanation for these findings
is to be undertaken only after a control diet and after a consideration of
various possible causes.
If at all possible, it Avill always be advisable to place an individual with
normal digestive energy upon a like diet, though I do not wish to inti-
mate that this should be a rigid test diet.
With severe biliary congestion, as often found in connection with
cancer of the pancreas, it is hardly ever possible from the fat contents
of the stools to determine with certainty whether the fatty stools are
due only to deficiency of bile in the intestine or also to lack of pancreatic
secretion.
Amorphous or globular neutral fat is found in the severer forms of
steatorrhea even without participation of the pancreas, and on the other
hand soap needles may be present in the affections of the pancreas with
occlusion of the excretory channels, showing up abundantly in the feces
under the microscope, this being due to the fact that the fat splitting
may take place under bacterial influence.
Steatorrhea may be of diagnostic value when occurring without
biliary congestion, or at least when its intensity is strikingly dispropor-
tionate to the slight degree of bile stasis.
In such cases the microscopic finding of amorphous or globular neu-
'" Compare O. Schiimm and C. Heijler. Miinch. nied. Woch., 1909.
CARCINOMA OF THE PANCREAS 149
tral fjit would be significant, as it is always an indicator of an especially
deficient fat reduction.
If, however, the unabsorbed amount of fat is so small that it has
been perfectly split up so that only soap needles are visible under the
microscope, great caution will have to be observed even when biliary
stasis is absent.
Such findings are met with among others in diarrheas (e.g., per-
nicious anemia), in processes of the mesenteric glands, severer grades
of intestinal atony, in purulent and ulcerating gastro-intcstinal processes.
Obviously, in judging of the deficiency of fat in the feces, it will be
necessary to know the amount of fat that has been introduced per os
and at times per anum in the form of oil enemas and suppositories.
Muscle Fibres
With equal precaution and discretion we must interpret the micro-
scopical finding in the feces of transversely striated muscle fibres.
Besides gastric affections, which are accompanied by subacidity,
atonic gastro-intestinal conditions must be taken into consideration as
causative factors ; similarly also increased peristalsis as occurring in
diarrheas.
ACCOMPANYING SYMPTOMS FROM OTHER ORGANS
Anorexia
Aside from anorexia, which may occur as an accompanying symp-
tom of any disease leading to cachexia, gastric manifestations frequently
set in during the course of carcinoma of the pancreas which have their
origin in the topographical relation between the head of the pancreas
and duodenum and are caused by stenosis of the latter.
Sarcince Vegetation
Thus under certain circumstances there is an abundant growth of
sarcinae in the stomach (2) which are eliminated in the feces; dilatation
of the stomach with prolonged splashing sounds, peristaltic unrest of
the antrum pylori (2), a feeling of fulness and belching of gas (1) are
resultant manifestations of difficult emptying of the stomach.
Melena
In the final stages of cancer of the pancreas there may be invasion of
the duodenum leading to continued "occult," that is, onh^ to chemically
demonstrable melena or even to copious bowel hemorrhage (3). Pro-
liferation of carcinomatous masses into the mesentery may also give rise
to ulcerated changes in the bowel (1).
Invasion of the portal vein also may lead to bloody stools in the
terminal stages, the more so if under the influence of a chronic icterus a
hemorrhagic diathesis has been established.
150 TUMORS OF THE ABDOMINAL VISCERA
Liver
The frequency of the scirrhus form of cancer of the pancreas prob-
ably accounts for the comparative rarity of voluminous metastases in
the liver ; the enlargement of the liver usually remains within moderate
bounds and frequently depends in great measure upon biliary stasis.
The importance of a visible and greatly distended gall-bladder has
already been mentioned.
Spleen
Pressure of cancer-masses on the splenic vein may lead to a hard
splenic tumor (4), which, however, generally does not extend below the
costal arch.
Ascites
Metastasis in the peritoneum usually produces ascites, which makes
it impossible to feel the primary tumor.
Simultaneous cancerous infiltration of the great omentum may give
rise to tumor-masses in the left half of the epigastrium.
Skin Pigmentation
The occasional occurrence of bronze-like discolorations of the skin,
similar to that of Addison''s disease, is common to carcinoma of the pan-
creas and other processes leading to cachexia (gastric cancer, pernicious
anemia, tuberculosis of the pancreas, etc.).
Individuals who are rich in pigment seem to be more predisposed to
this hemochromatosis of HeckVmghmisen ■ accidental causes are occasion-
ally found in factors which are able even physiologically to produce in-
creased cutaneous pigmentation (eflfects of sunlight, etc.).
Abdominal Aorta
The topographical relation of the pancreas to abdominal aorta and
the possibility of compression of tiie latter affords a natural explanation
for the occasional occurrence of systolic epigastric murmurs.^*'" This
auscultatory phenomenon should constantly be borne in mind when we
are trying to determine any resistance that is obscure and corresponds
to the head of the pancreas.
Olycosuria
Similarly, we should always examine for glycosuria. However, in
view of the fact that conditions of dyscrasia, as has been experienced,
may have been pre-existent, the symptom will have to be interpreted with
caution.
Doubtless there are cases in which the history or continuous obser-
vation enables us to determine a clear relation between the glycosuria
and the diseased condition of the pancreas.
^""See No. 88.
CARCINOMA OF THE PANCREAS 151
SUSPICIOUS FACTORS AND DIFFERENTIAL DIAGNOSIS
It will be advisable to take into consideration the possibility of pan-
creatic cancer, especially if the following premises are fulfilled.
Suspicious Factors
1. Melanotic icterus with enlarged gall-bladder.
2. Glycosuria in advanced age, with anorexia and pains in tlie back.
3. Glycosuria with painful attitude (4).
4. Continued and abundant finding of sarcina- in gastric contents
with concomitant icterus.
5. Violent pains in the back with epigastric, systolic murmurs.
6. Cachexia and melanodermia.
7. Cachexia and ascites from unknown causes.
8. Violent pains in the back not yielding to therapeutic measures.
These and similar considerations ought always to be the occasion for
a careful palpatory examination deep in the epigastrium, and in order
to exclude, as far as possible, all gastro-intestinal meteorism, the exami-
nation should be made on a fasting stomach or after a transient absten-
tion from food and evacuation of the gastro-intestinal contents.
Being situated retroperitoneally, pancreatic tumors will be mostly
immobile ; but if they extend far anteriorly they may, similar to kidney
tumors, reach a certain degree of respiratory mobility.
Auscultation should always go hand in hand with deep exploration
of the epigastrium ; a systolic vascular murmur, at times produced by
compression of the aorta, may be an important symptom confirming the
assumption of a deep-seated aggressive neoplasm in that location.
Differential Diagnosis
With a clearly demonstrable hard retroperitoneal tumor-mass in the
epigastrium, the field of differential diagnosis is not a large one.
Retroperitoneal Gland Tumors
Lymphosarcomatous gland processes and metastatic gland tumors
would have to be taken into particular consideration. This last kind of
misinterpretation is easily conceivable, especially in those cases where
the primary neoplasm runs a latent course, e.g., carcinoma of the testicle
without any enlargement of the organ.
If a definite swelling corresponding to the location of the pancreas
cannot be felt, which is true probably of the majority of cases, the field
of differential diagnosis will depend upon the existing accompanying
symptoms.
Icterus Catarrhalis Biliary Cirrhosis
Ohstructing Calculus
If icterus is present, then cachexia sets in so rapidly that confusion
with benign forms of icteinis, such as icterus catarrhalis, biliary cirrhosis,
stone occlusion of the ductus choledochus, will hardly occur. In con-
152 TUMORS OF THE ABDOMINAL VISCERA
tradistinction to the two first-mentioned diseases, there is, above all, the
frequent considerable enlargement of the gall-bladder, which will serve
as an important guide.
Occlusion of the ductus choledochus by a calculus will be ushered in
by at least one severe attack of colic in the midst of general good health.
This may, of course, be in perfect agreement with an enlarged gall-
bladder.
Cicatrix of the Duodenum
Among other benign affections occasionally to be considered are
ulcerating cicatricial processes in the duodenum, as they also may lead
to the syndrome of "gastric stagnation with biliary stasis." But here the
previous history dating far back will, in most instances, permit of a dif-
ferentiation, because an acute course is generally the rule in carcinoma
of the pancreas. A duration of six months may be considered as very
long.
Carcinoma at the Papilla
of Vater
Duodenal carcinoma, particularly at the papilla of Vater, may easily
pass as a sort of double among the malignant diseases.
The most important marks of differentiation are the early occur-
rence of febrile cholangitic processes and the early appearance of occult
intestinal hemorrhages.
So long at least as carcinomas of the pancreas do not ulcerate into the
duodenum, they run along afebrile, and there is no occasion for bowel
hemorrhages.
Diabetes Mellitus
Cases accompanied by glycosuria but without icterus may occasion-
ally be straightway taken for diabetes mellitus ; if one makes it a rule to
examine the region of the liver and pancreas carefully, there will be less
danger of an erroneous diagnosis.
Genital Tumor
Metastases in tlie peritoneum and so into the pouch of Douglas make
confusions with gynecological affections conceivable, as is shown in
Case 6.
Ascites with obscure etiology — especially those forms accompanied
by hemorrhagic or "milky" effusion — should always remind us of car-
cinoma of the pancreas.
Malignant Tumors of the Kidney
In contradistinction to analogous diseases in the chylo-poetic sys-
tem, the intake of nutrition is very often not disturbed in connection
with malignant new-growths of the kidney, so that with intact function
of the chylo-poetic system there is lacking one of the chief conditions
for cachexia, namely, undernutrition.
In addition to this we are dealing with a paired organ, and hence
the possibility of perfect compensation when only one side is affected.
Both of these factors perhaps account for the regrettable fact that
early diagnosis of malignant new-formations of the kidney is so infre-
quent, but this should also be a mighty spur to strive for an early diag-
nosis, so that the patient while still in the best of health may receive the
benefit of the live-saving operation.
EARLY SYMPTOMS
1. Pain phenomena.
Though by no means specifically indicating the kind of disease, care-
ful study of the subjective sensations of the patient may here, as in so
many other cases, materially hasten early diagnosis in so far as the renal
nature being recognized, it gives occasion for an exact detailed examina-
tion of the organ and its excretion.
Whilst the presence of the tumor-mass, as such, subjects the renal
capsule to increased tension, there becomes added to this the fact that
renal tumors frequently are extraordinarily rich in blood-vessels, so that
further intracapsular increases in pressure may occur through active
and passive hyperemia, hemorrhage, etc.
Intrarenal painful sensations elicited in such manner are mostly con-
tinuous, and do not have that paroxysmal intermittent character peculiar
to ureteral colics. Not rarely they confine themselves to the seat of the
disease, therefore localized in the lumbar region (3).
"Pseudo" Lumbago
There is always the constant danger that they be interpreted as
muscle pains in the nature of a lumbago, the more so, as movements such
as stooping, lifting, etc., aggravate them or evoke their initial occur-
rence (3).
Contraction of the belly-wall leads to venous congestion in the abdo-
men, and this, as well as any kind of compression of the abdominal con-
153
154 TUMORS OF THE ABDOMINAL VISCERA
tents, may have the effect of eliciting pain at the locus minoris resis-
tentirT.
As opposed to lumbago and analogous affections there will be the
occasional unilateral localization, the particular stubbornness of the
pains and, last but not least, the findings with reference to kidneys and
urine.
The existence of a "painful attitude" ^-'^ also should be looked for in
suspected cases. The oftentimes great mobility of renal tumors favors
its occurrence.
"Renal" Iscliias
Particular attention will be called for if the lumbar pains are ac-
companied by neuralgic sensations in the lower extremity of the same
side (1). Also isolated neuralgias may appear, due to reflex action
("renal" ischias!).
Scrotal Pain
The scrotum may become the seat of permanent violent pains due to
varicocele coexistent with and dependent upon the kidney tumor, and in
this way lead to the performance of semi-castration, as mentioned in a
case observed by Alhrecht.^^^^
Ureteral Colics
The passage of clotted blood or tissue-shreds through the ureter
furnishes a new source of pain, and there may occur attacks^"-'^ which, in
opposition to the pain phenomena so far discussed, distinguish them-
selves by their acute appearance and acute course, in other respects re-
sembling the attacks occurring in connection with nephrolithiasis and
which must be looked upon as ureteral colics.
The more numerous the symptoms with reference to the urine and
urinary elimination, the more pronounced the characteristic radiations
into the genital region and the lower extremities, the easier it will be to
correctly interpret the attacks as ureteral colics.
Ch olelithiasis, Appendicitis
Intense appearance of gastric symptoms, such as vomiting and local
limitation of the pains, may render differential diagnosis from chole-
lithiasis, appendicitis, etc., rather difficult.
2. Hematuria and other urinary findings.
Large admixtures of blood to the urine are not seldom met with in
connection with new formations of the kidneys, and are explained in
part by the abundance of blood-vessels in the tumors (hj^pernephromas !)
and their soft consistence. A prerequisite in most cases is invasion of
the pelvis of the kidney.
">' See Case 1.
^■^P. Albrecht, Beitrage ziir Klinik und pathologisch. Anatomie der malignen Hy-
pernephrome. Arch. f. Klin. Chir., Vol. 77, No. 4.
"'a See Case 1.
MALIGNANT TUMORS OF THE KIDNEY 155
Every severe renal hemorrhage, therefore, must remind us of the
possibility of a malignant process.
"Renal" Hematuria
The question is: How can the renal origin of tlie hemorrhage be
recognized?
The most exact way, probably, is by separate catheterization of the
ureters.
Of diagnostic value also are thin and long worm-shaped blood-clots
representing casts of a ureter, combined with synchronously occurring
unilateral ureteral colics. These two premises admit of conclusions
which are just as certain as ureteral catheterization, and besides may be
confirmed by the previous history.
Certainly one will also think of a renal hemorrhage when the admix-
tures of blood appear after a somewhat brisk palpation of a kidney tumor
or the resistance suspected of being such.
There are cases in which it is even advisable to cautiously question
the patient along these lines.
Also strong contraction of the belly-wall, such as straining at stool,
may, by way of venous abdominal stasis, lead to severe hemorrhages.
On the other hand, profuse renal hemorrhages from renal tumors,
similar to the hemoptysis of tuberculars, are more or less incalculable ;
they ma}' set in, pass by rapidly, and be repeated sometimes only after
many months or years.
^Microscopically, these hemorrhages behave no different than vesical
hemorrhages : The erythrocytes are mostly unchanged, not reduced to
shadows.
"Occult" Renal Hemorrhage
Comparable to the "occult" hemorrhages occurring with gastro-
intestinal carcinoma, the quantities of blood mixed with the urine in cases
of renal neoplasms may be so small that they escape detection with the
naked eye. The urine may be clear, transparent, even surprisingly
light.
If there be at hand other indications of a renal neoplasm, such urinary
findings must under no circumstances be used as a ground for exclusion.
Moreover, if an effort be made to obtain a sediment from such macro-
scopically unsuspicious urine, it Avill not seldom be possible to demon-
strate the presence of erythrocyte shadows.
These slight hemorrhages are very likely not to be explained in the
way of blood-vessel erosion, but rather as parenchymatous bleedings.
They may come about partly through congestion or capillary tears, but
may also be partly due to inflammatory alterations in the neighboring
renal tissue. Hence also we are here dealing mostly with erythrocyte
shadows, a finding which in and of itself speaks for their renal origin.
The liberated blood-coloring material, ingested by leucocytes, may occa-
sionally be eliminated as crystals of hematoidin.
156 TUMORS OF THE ABDOMINAL VISCERA
Nephritic Sedimentary Findings
On the other hand the erythrocytes may occasionally show a cylin-
drical arrangement, which is a further mark of their renal origin. Even
other nephritic sedimentary findings may occur in connection with renal
neoplasms, though we need not necessarily be dealing with a nephritis in
a clinical sense. At times there are present only partially inflamed areas
in the proximity of the malignant tissue process.
With reference to typical polymorphous epithelia which are at times
present, I. Israel ^^^ admonishes, and rightly so, to greatest precaution.
It seems that tumor-tissues are cast off only in the rarest cases (Case 6).
Classified in the order of importance, the newer methods of "func-
tional kidney tests" come considerably after palpatory examination of
the kidneys and the urinary findings just discussed.
Valuable as is catheterization of the ureters in order to test sepa-
rately the urine from each kidney for formative elements, blood-coloring
material and albumin, just so uncertain are the conclusions based on
methods like the phloridzin-mcthylcne blue test, cryoscopic examina-
tion, etc.
PHYSICAL EXAMINATION OF THE KIDNEYS
Much would be gained for the early diagnosis of renal neoplasms if
it were to become customary to attempt palpation of the kidneys with at
least every initial examination of the abdomen.
It is a fact that with reference to examination by palpation the kid-
ney counts among the most neglected organs, so much so that even when
the organ is in a diseased condition, e.g., nephritis, hardly any effort is
made at palpation. The psychological explanation for this lies in the
fact that the effort at palpation is unsuccessful in a large percentage of
cases, particularly in so far as we are dealing with individuals having a
deep abdomen and without enteroptosis.
With neoplastic diseases of the kidney the conditions are naturally
far more favorable, and it is therefore a self-evident requirement, but
which I consider worthy of repeated emphasis : With every initial ab-
dominal examination the effort must be made to palpate the kidneys.
Where the findings on palpation, though obscure, are suspicious, it
will occasionally be necessary first to prepare the patient for examina-
tion.i'^^
Artificial Dislocation of the
Kidney Doivnicard
As enlarged kidneys are most often abnormally movable, it may be to
the point to let the patient spring from a foot-stool in order to dislocate
the kidney downward. For the same purpose it will be advisable to have
'"'Z. Israel, Chirurgische Klinik der Nierenkrankheiten. Aug. Hirschwald, 1901.
^"* See page 1.
MALIGNANT TUMORS OF THE KIDNEY 157
the patient breathe purely diaphragniatically in order to obtain the
greatest possible downward displacement of the kidney.
Respiratory Mobility
It is decidedly erroneous to refer to kidney tumors as not having
respiratory mobility. The respiratory mobility of large kidne^'-tumors,
e.g., congenital cystic kidneys, may occasionally be determined by mere
inspection.
Lateral Decuhitus
In order to relax the belly-wall on the side aflfected, it may be ad-
visable to make an examination with the patient lying partly or entirely
on his side {Israel, I.e.).
It should always be our endeavor to diminish the sagittal depth of
the abdomen by means of broad and effective counterpressure from the
respective lumbar region, so that the kidney, which may be considered as
lying at the bottom of the abdomen, may be better reached from in front.
Ballottement
In this connection I would not attach any particular diagnostic sig-
nificance to the possibility of bringing a tumor which can be felt an-
teriorly nearer to the palpating hand by pressure in the loin, that is,
ballottement.
Larger tumors of the spleen, being in contact with the lumbar region,
show this symptom almost regularly ; the same is true of "corset lobes'*
of the liver. In this case, however, the pressure is more effective if made
laterally on the right side and in a forward direction than directly from
the back on the same side, because the "corset lobe" is more intimately
in contact with the belly-wall in the axillary portions than it is in the
paravertebral area.
In very exceptional cases even tumor-masses belonging to the stom-
ach, providing they be situated on the left side below the costal arch,
may show ballottement. Naturally, the ballottement will here depend
upon the relation of the tumor-mass to the lumbar region.
A kidney tumor which exhibits this phenomenon in the dorsal de-
cubitus may not do so at all in the lateral decubitus. ^"^'^
Situation of the Colon and Its
Determination
As in the case of ballottement, I would not attach too much im-
portance to the position of the colon with reference to its relation to a
questionable tumor-mass.
Even though a kidney tumor, as compared to splenic tumors, gen-
erally has the colon anterior to it, there are many and varied exceptions.
Very frequently the patient can be spared the annoyance of a distention
of the colon ; the same should always be omitted when there is any sus-
picion of an ulcerous gastric or intestinal lesion, as it is not without dan-
ger under such circumstances (hemorrhage! perforation!).
"^ See Case 2.
158 TUMORS OF THE ABDOMINAL VISCERA
Intestine overlying the tumor-mass anteriorly will occasionally be
recognizable by the fact that one can roll a cylindrical structure (con-
tracted coil of intestine) to and fro on the surface of the tumor. If,
however, the portion of bowel lying in front of the tumor is sponta-
neously distended, palpation will disclose that in this region the tumor is
not adjacent to the abdominal wall, and there will be present splashing
sounds or local spontaneous bowel noises.
Peritoneal friction over a tumor-mass always indicates direct con-
tact with the parietal layer of the peritoneum, hence excludes anterior in-
terposition of intestine.
Diiferentiation from Gall-Bladder
and Splenic Tumors
One should always try to see whether it is possible in some position
or other to grasp the tumor from above, as this excludes the possibility
of gall-bladder and splenic tumors.
Soft Consistence
In palpating enlargements of the kidney it will be well to bear in
mind that malignant tumors of the kidneys, and this is particularly
true of the most frequent species, i.e., hypernephromas, very often are
of a soft, elastic consistence on account of their abundance of blood-
vessels, which is frequently also seen in the metastases from it, e.g., in
the liver.
Hardness and nodular outline, which are otherwise such frequent
attributes of malignant tumor formations, are here met with compara-
tively seldom.
Auscultatory Findings
The abundance of blood-vessels in a hypernephroma justifies the
assumption that an auscultatory phenomenon should occur more fre-
quently than would be surmised from reports hitherto made by observers
who probably paid no attention to it.
This is a loud-blowing systolic murmur, as it, for instance, was audible
in Case 3, especially in the flanks.
It will be advisable to look for it, not only anteriorly but also in the
lumbar region and in the flanks.
ACCOMPANYING SYMPTOMS FROM OTHER ORGANS
In view of the great frequency of hypernephromas and their ten-
dency to the formation of bone metastases, every enlargement of the
kidney ought to lead to a careful examination of the skeletal system,
but reversely also a spontaneous fracture, a bone tumor would be the
occasion for a most careful examination of the kidneys and urine.
The vault of the cranium, femur, clavicle, scapula, rib, etc., may in
a similar manner become the seat of metastases, which, in accord with
their abundant supply of blood-vessels, occasionally exhibit definite
pulsation.
MALIGNANT TUMORS OF THE KIDNEY 159
Early Metastases
P. Alhrecht ^^^ has called particular attention to the occurrence of
singular hone metastases, surgical removal of which was followed hy rela-
tively good health often for many years (6Vi> years in one of his cases).
Here, then, we occasionally have to deal with the very exceptional
case in which operation is indicated for removal of a metastatic growth.
Late Metastases
On the other hand, the danger of bone metastases remains present for
many years after the successful removal of a hypernephroma of the
kidney.
Thus in one of the cases of the author just cited, there occurred a
metastasis in the vertebral column as late as seven years after.
The formation of metastases probably occurs chiefly by way of the
blood-current, a predisposing factor being the frequent penetration of
the tumor-masses into the renal vein.
Thus occasionally also the brain may become the seat of metastasis, ^*^'''
and not rarely there are metastases in the lungs.
I recall a case in which a carcinoma of the tongue had been diagnosed;
autopsy, however, disclosing a hypernephroma as the primary focus. In
Case 5 there had occurred metastases in the vaginal wall and ulceration.
All of these secondary tumor formations, in so far as we are dealing
with hypernephromas, have a peculiar soft marrow-like consistence, a
circumstance which itiay render diagnosis difficult, especially in the region
of the liver.
Lymphogenous Metastasis
Propagation by way of the lymph current is probably to be looked
upon as a rare exception to the rule of hematogenous metastasis.
In this regard great interest attaches to Clairmonfs ^"^ observation
of a metastasis in the bronchial lymph-nodes, causing death ten years
after extirpation of a hypernephroma.
While we have so far considered chiefly the remote symptoms result-
ing from the formation of metastasis, we must also remember those phe-
nomena which are connected with the local spread of the tumor-mass.
Varicocele
Here belongs the occurrence of a varicocele as occasionally observed,
especially when the tumor is situated on the left side. It would alwa^'s be
of great importance to determine from the history or by observation
how rapidly it develops. Since various cases of renal tumors, whose rela-
tion to the renal vein and internal spermatic vein are similar, are not
characterized by the occurrence of a varicocele, the assumption is close
at hand that a certain predisposition on the part of the venous plexus
is required to produce this condition.
'"* Arch. "f. klin. Chir., 1905, Vol. 77, No. 4.
'"■ See Case 5.
^'*f. Clairmont. Verhaiidl. des 32 Kongr. d. deiitsch. Ges. f. Chir., 1903, p. 196.
160 TUMORS OF THE ABDOMINAL VISCERA
Bladder Symptoms
Bladder symptoms, such as retention of urine or tenesmus, arc prob-
ably to be looked upon partly as reflex symptoms, as they may also be ob-
served in connection with acutely occurring infarcts of the kidney ("renal
dysuria").
Stomach
The violent appearance of gastric symptoms, such as vomiting, epi-
gastric sensation of pressure, anorexia for meat, etc., may at times be
misleading. Partly also these sjmiptoms are to be interpreted as reflex
processes, particularly the vomiting, just as it accompanies ureteral
colics.^"'* The symptoms may also have their origin in the general
cachexia, or may be traced to pressure exerted by the tumor-mass. In
case of bilateral disease they might also be due to uremia.
Fever
Chills have occasionally been observed during the course of renal neo-
plasms ; one would incline to connect them with complicating pyelitis.
Thrombus formation in the renal veins and the inferior vena cava,
hence phlebitic complication, will also have to be thought of.
According to Israel (I.e.), febrile accompanying manifestations be-
cloud the prognosis of operative interference.
COURSE, DURATION, TYPES
Whilst a large proportion of the disease symptoms produced by
malignant new formations in the chylo-poetic system are due to the severe
injury to the digestive mechanism, malignant diseases of the kidneys
aff'ord an opportunity to determine the effects of malignant tumors as
such on the organism.
Numerous observations are at hand which would make malignant new
formations of the kidney — and this seems particularly true of the fre-
quently occurring tumors of Grawitz — appear comparatively benign, at
least so far as the duration of the disease is concerned.
A very striking illustration of this fact is the case of P. Albrecht,
already cited, in which, the primary tumor remaining, the patient was
alive 61/^ years after successful surgical removal of a metastatic bone
formation, and then came to autopsy, which showed a kidne^^-tumor of
Grawitz and multiple metastases.
Although other observers have repeatedly reported cases with a dura-
tion of ten years and longer, they are probably cases in which loss of
blood through hematuria occurred either not at all or only shortly before
death.
If hematuria sets in, the prognosis as to the duration of life, provid-
ing the surgeon does not promptly interfere, is decidedly unfavorable.
. '""See Case 1.
MALIGNANT TUMORS OF THE KIDNEY 161
The same holds good also of the relatively frequent renal neoplasms
of children,^ ^*' even though, as is the rule, hematuria is ahsent. Here
tile average duration of the disease seems to be onU' seven to eight
months.
Other things being equal, the malignant renal neoplasms of adults
probably admit of a far better prognosis.
In these cases there may even be observed, during the course of the
disease, quite appreciable gains in weight.^ ^^
Late metastases seem to be a peculiarity of hypernephromas, which
casts a gloom on the prognosis even after successful extirpation of the
primary focus.
The metastatic deposits may be latent for many years and only then
awaken to malignant growth.
Here we may again call attention to P. Chiirmont's interesting obser-
vation, in which ten years after extirpation of the kidney death occurred,
due to metastatic proliferation in the bronchial lymph-nodes.
For the clinician there are two main types of malignant renal neo-
plasms, and they arc :
1. The "infantile" renal neoplasms, w^hich counts among the most
important and most convincing arguments in favor of Colinlieim''s tumor
theory, as it is observed even in the new-bom, and in its entire structure
(striped muscle fibres, cartilaginous and osseous tissue) exhibits the fetal
predispositioji (Anlage). It makes its appearance in the first ^-ears of
life and may appear up to the end of the first decade.
Its characteristics are: enormous growth, slight tendency to forma-
tion of metastases, hematuria rare, rapid course.
2. Tumor of Grawitz ("hypernephroma"). Being by far the most
frequent of renal neoplasms, this also is a crown witness in favor of Cohn-
lieitns tumor theory.
Its characteristics are: tendency to hematuria ; in the absence of hema-
turia relative benignancy, with a course at times extending over many
years; occasional absence of cachexia, good appearance; tendency to
singular and at times pulsating bone metastases, late metastases.
SUSPICIOUS FACTORS AND DIFFERENTIAL DIAGNOSIS
Prevalence in the Male Sex
. Other things being equal, factors of suspicion will carry more weight
in male individuals ; for statistics agree that malignant processes, in
striking contrast to tuberculosis of the kidneys, are far more frequent in
the male sex.
Given the four fundamentals in the diagnosis of malignant processes
in general, i.e., tumor, hemorrhage, cachexia, pain, it will in most in-
stances not be difficult to draw the proper conclusion.
"" T. Oshima. Wiener klin. Wochenschr., 190", No. 4.
"' See Cases 3 and 4.
162 TUMORS OF THE ABDOMINAL VISCERA
Difficulties arise when one of these premises is more prominently
realized. Having correctly recognized a hematuria with reference to its
renal origin and its source from one kidney, and dealing with a profuse
hemorrhage, the chief conditions entering into differential diagnosis will
be nephrolithiasis, tuberculosis of the papillae of the kidneys and — in the
order of frequency after a long interval only — "parenchymatous" ^^-
hematuria.
The discharge of blood-clots and clot formation in the urine generally
indicates hemorrhage from erosion and makes a "parenchymatous" hem-
orrhage improbable.
"Parenchymatous" Unilateral Belial
Hemorrhage
"Parenchymatous" unilateral renal hemorrhages generally also dis-
tinguish themselves by their constancy and uniformity as opposed to the
often rapidly arrested hemorrhages from erosion.
The pain phenomena, such as ureteral colic, may be entirely identical
in connection with profuse hemorrhages resulting from tuberculosis of
the papilla' of the kidneys, neoplasm and nephrolithiasis ; even unilateral
"parenchymatous" renal hemorrhages may — probably as a result of acute
congestion of the respective kidney — be accompanied by violent uni-
lateral pains, but it seems that a painless course is far more frequently
the case in these instances.
N ephrolithiasis
Renal Tuberculosis
Hemorrhage in nephrolithiasis, for that matter, seldom becomes se-
vere, and just as little do profuse hemorrhages in connection with tuber-
culosis of the renal papilhe count among the frequent occurrences, yet
they may occasionally appear clinically as an early symptom, unaccom-
panied by pyuria.
It is remarkable that — quite analogous to conditions in the lung —
slight, easily overlooked tuberculous alterations in the renal papillas
may lead to severe hematuria, whilst extensive destructions of the same
kind may go along without hemorrhage.
Painless renal hemorrhage would generally speak against nephro-
lithiasis, though rare exceptions may occur even here ; if the calculus
remains stationary in one place and through pressure necrosis leads to
erosion of a blood-vessel, then we have the exceptional case just re-
ferred to.
"^ It is not within the scope of this treatise at this juncture to tatce part in the dis-
pute about "essential" unilateral renal hemorrhage from a "healthy kidney." In a great
number of cases in which a pathological and anatomical examination was made — and
only such can be admitted as evidence — inflammatory alterations were demonstrated.
It is true they were so slight that it may be doubtful wliether they explain the profuse
hematuria in Individual cases. Undoubtedly we are here not dealing with hemorrhages
due to erosion, but rather with "parenchymatous" hemorrhages, and it seems to me
that this contrast, with stress on the "onesidedness," is more important than the unpro-
ductive discussion as to genesis.
MALIGNANT TUMORS OF THE KIDNEY 163
Systolic Vascular Murmurs
Attention should always be given to systolic vascular murmurs in the
region of the kidneys. When these can be referred to the kidneys they
will, in the first place, make us think of malignant renal disease.
Findings on Palpation
Neoplasms of the kidneys accompanied by hemorrhage will probably
in most cases yield positive findings on palpation, and it will be well to
look for nodular prominences on the surface of the kidneys ; if only small
areas of the kidney are involved or if they are situated in the upper pole
of the kidney, every objective finding naturally may be absent.
There is some danger that the low situation of the inferior pole of
the kidney may be considered harmless in those cases where the low situa-
tion is in reality due to increase in the long diameter, be it that this in-
crease has taken place at the superior or inferior pole of the kidney.
In such cases — if there be tumor formation in the lower pole of the
kidney — the particular ease with which ballottement can be elicited might
call attention to the increased antero-posterior diameter of the appar-
ently intact pole of the kidney (/. Israel, I.e.).
When the findings on palpation are entirely negative, local pains in
the region of the kidney, accompanied by bone metastases, might lead
one onto the right track.
Bone Tumors
Malignant bone tumors ought, under all circumstances, to suggest
the possibility particularly of renal tumors of Grawitz. In these cases
most careful microscopical examination of the urinary sediment will be
indicated even though the macroscopic findings are entirely unsuspicious.
Nephritis
Occasionally w,e meet with nephritic sedimentary findings, such as
blood-casts, waxy casts, etc., derived from inflamed portions of the kid-
ney-tissue in the immediate proximity of the tumor-mass.
Splenic Tumor
Kidney tumors on the left side will occasionally have to be differen-
tiated from the larger splenic tumors. Pronounced diminution of the
leucocyte count would speak in favor of a splenic tumor, as pseudoleu-
kemia, for instance, and Banti's cirrhosis are most often accompanied by
leucopenia. The constant findings of a strongly positive aldehyde reac-
tion would have to be construed in the same way. The physical findings
are by no means always sufficient for a differentiation. If it is possible
in any position to grasp the tumor from above, then we have a weighty
argument against the assumption of a splenic tumor.
Sarcomas originating retroperitoneally and in the immediate neigh-
borhood of the kidne}'^, also pararenal embryonic tumors, may imitate
kidney tumors in all the physical details ; the same is occasionally true of
echinococcus cysts.
The differentiation from suprarenal tumors and the so-called "para-
164 TUMORS OF THE ABDOMINAL VISCERA
renal" tumor forms (from rests of the Wolffian bodies or displaced su-
prarenal tissue) may encounter the greatest difficulty.
Suprarenal Tumor
According to Israel,^^^ also suprarenal tumors situated outside of
the kidney as well as hypernephromas may lead to hematuria through cir-
culatory disturbances in the inferior vena cava and renal vein.
Analogous to renal tumors, they can be felt underneath the costal
arch, but generally occupy a more median situation ; they are said to lead
to prolonged neuralgias in the lumbar plexus earlier than h^^pernephro-
mas. Israel has noted atypical febrile movements surprisingly often in
his nine observations, and only in one case was there Addison-like pigmen-
tation.
If the tumor is recognized as belonging to the kidney, the field of dif-
ferential diagnosis is not a large one.
Pyonephrosis
Pyonephroses, if they be open, are easily excluded by the demonstra-
tion of pyuria, which occurs practically never in connection with malig-
nant neoplasms of the kidneys. The demonstration of a renal enlarge-
ment in the absence of secretion from the respective ureter (ureteral
catheterization) would generall}'^ speak against a renal neoplasm and in
favor of a closed hydro- or pyonephrosis.
Cystic Kidney
Congenital cystic kidneys, met with also in later life in the form of
large nodulated tumor-masses, are generally characterized by their bi-
lateral occurrence.
It remains to be mentioned that particularly in the case of non-bleed-
ing renal neoplasms — especially hypernephromas — even in the stage of
metastasis formation, cachexia does not count among the integral com-
ponent parts of the symptom complex.
"'/. Israel, Zur Diagnose der Nebennierengeschwiilste. Deutsche med. Wochenschr.,
1905, No. 44.
"Atypical" Malignant Abdominal Tumors
Practical considerations have prompted me to add this section.
It is advisable to separate in one's memory the frequent from the
rare, keeping in mind the scale of frequency for the purpose of arriving
at a clear differential diagnosis ; this requisite should also receive consid-
eration in descriptive treatises.
Only if after a detailed diagnostic analysis of the individual case
reasons present themselves which speak against the assumption of one
of the hitherto discussed "typical" kinds of neoplasms, arc there indica-
tions for thinking of the rare possibilities here to be touched upon, whose
range naturally cannot be defined.
Sarcoma
The rarity may have some connection with the histological structure
of the tumor (sarcoma!).
So far as glandular enlargements, splenic neoplasms and new forma-
tions of the small intestine are concerned, it will occasionally be possible
clinically to make the diagnosis of sarcoma.
Spleen
If, for example, in view of the cachexia, the nodular structure, the
rapid growth at times accompanied by severe pains and a blood-count ex-
cluding leukemia, we are able to make the diagnosis of a malignant tumor
of the spleen, there results from the pathological anatomy quite auto-
matically the diagnosis of sarcoma.
Retroperitoneal Glands
The same is true of those cases in which the conclusion has been ar-
rived at that the malignant process takes its origin from the retroperi-
toneal glands (5) or the lymphatic sj^stem in general.
If sarcomatous tumors develop along the gastro-intestinal tract —
and l^'mpho-sarcomas are first to be considered — the decision whether it
is a sarcoma or a carcinoma is practically beyond the pale of diagnostic
possibilities.
Lymphosarcoma and Constitution
So far as l^'mphosarcomas are concerned, it seems to me important
not to leave constitutional factors unheeded.
The existence of a congenital factor such as status l^'-mphaticus,
status hypoplasticus and status thymicus would always have to be taken
into consideration, and symptoms such as hyperplasia of the external
glands, the follicles of the base of the tongue (Kundrat), scrofulous ante-
165
166 TUMORS OF THE ABDOMINAL VISCERA
cedents with homologous diseases of the eyes may suggest the presence
of a lymphosarcomatous process. As tuberculosis frequently develops in
individuals with similar congenital predisposition, it cannot be surpris-
ing that not infrequently there is actually a coincidence of lympho-
sarcoma and tuberculosis. It is even possible that the tubercle bacillus^
through its local presence or by way of tuberculous dyscrasia, occasion-
ally furnishes an impulse to the development of lymphosarcomatous
processes.
It seems to me that we are here concerned chiefly with individuals in
whose cases it is the Ij^iiphatic system rather than the pulmonary that
reacts to tuberculosis, so that florid pulmonary tuberculosis is hardly
ever observed, not rarely, however, glandular tuberculosis and healed or
stationary pulmonary foci.
Accordingly, we are frequently dealing with individuals having a pale
facial color, reddish blond hair,'^^ paralytic thorax, and at times an en-
teroptotic abdomen. It seems that not seldom relatively young persons
in the thirties and forties are afflicted with lymphosarcomatous processes.
Among the very rare sarcomatous diseases occurring within the chylo-
poetic system lymphosarcomatosis of the small intestine is most apt to
admit of diagnosis. ^^''^ Here, in striking contrast to all other localities,
lymphosarcomas are nmch more frequent than carcinomas, so that when
the presence of a malignant disease in the small intestine has been estab-
lished it makes a lymphosarcoma very probable. In view of what has
been previously said in regard to congenital anomalies, the assumption —
corroborated in practice — is close to hand that especially tubercular dis-
eases, such as tubercular peritonitis and tubercular intestinal ulcers, will
enter into differential diagnostic consideration. It is worthy of note that
ascites in connection with lymphosarcomatosis of the small intestine does
not, as in peritoneal tuberculosis, occur more or less isolated, but is in
most instances a partial manifestation of a general edema and dropsy
of the serous cavities. Diagnosis is very much hampered by the fact that
as a result of the rather diffuse infiltration, often extending over wide
areas of the intestine, circumscribed tunior-masses are frequently absent,
in addition to which meteorism and ascites often act as obstacles in the
way of palpation. If tumor-masses can be felt, their soft consistence
might occasionally, even though conditionally only, be interpreted as
speaking against carcinoma. The tendency to diffuse infiltration of the
walls and the soft consistence of the tumor-mass probably account for
the fact that lymphosarcoma of the small intestine, in contradistinction
to scirrhus carcinoma of the small bowel, does not, as already pointed out
by Kundrat, produce stenosis,^ ^" on the contrary, even causes dilatation
"^ So far as the clinical material available in Vienna is concerned, I have found
that individuals with a congenital tendency to tuberculosis not rarely are characterized
by «i dark-brown head of hair whilst the mustache is of a foxy-red color ("hair dis-
harmony") ; I have seen this peculiar combination very often with tuberculosis of the
peritoneum and also in connection with Ivmphosarcomatous processes.
"=See Cases 9, 10, 11.
"* Case 9 illustrates that adhesion and coalescence of adjacent intestinal loops maj^
lead to severe stenosis.
"ATYPICAL" MALIGNANT ABDOMINAL TUMORS 167
of the intestinal tube in the diseased area. No significance attaches to
this criterion in the case of the large intestine, because there even carci-
nomas, especially the easily ulcerating medullary forms, may go along
without stenosis.
As shoAvn in the epicrisis of Case 11, the bacterial growth may at
times become an important diagnostic criterion in lymphosarcoma of the
small intestine.
The increase of the large mononuclear cells of the blood may amount
to at least a suspicious factor in lymphosarcomatous processes.
Sarcoma of the Stomach
If, in connection with sarcomatous processes of the digestive tract,
reference is occasionally made to the slight tendency to hemorrhage, it
would seem to me to be more of a theoretical postulate based on the sub-
mucous origin of the new-growth; the actual fact is that severe ulcera-
tion of the mucous membrane is often met with. Case 7 is an example
of a fatal gastric hemorrhage as an early symptom of lymphosarcoma
of the stomach.
Splenic tumors also are to be interpreted with the greatest precau-
tion ; they may be absent, or their presence in connection with gastro-
intestinal carcinoma may be accounted for in divers ways (anemia, com-
pression of the splenic vein, etc.).
The same is true of the exorbitant size of tumor-masses, which ac-
tually applies, for instance, to some gastric sarcomas, but which in and of
itself can never be decisive.
The more experience one gathers, the more cautious one will become
in these decisions, and so much more one will learn to respect those limits
where logical recognition ends and guessing begins.
"Atypical" Localization
Malignant growths of the abdominal cavity may be "atypical" and
rare with regard also to their localization.
Diaphragmatic Tumors
Thus I recall a case of metastatic sarcoma of the left pleura, in which
a nodular tumor-mass was palpable just below the left costal arch. In
view of a constant strongly positive aldehyde reaction, liver metastases
were thought of. Autopsy showed that the tumor-masses belonged to
the left half of the diaphragm, which had been forced downward.
Cancer of the Small Intestine
Here we may also mention the decidedly rare, mostly scirrhus can-
cers of the small intestine; as they are not palpable on account of the
small size of the tumor, a certain diagnosis will hardly ever be made. The
combination : Severe obstructive symptoms and diarrheas could easily lead
one to think that the stenosis affects a portion of intestine in which the
contents, on account of their fluid character, maj^ easily pass even a
stenosis of high degree.
168 TUMORS OF THE ABDOMINAL VISCERA
Duodenal Cancer
Carcinomatous diseases of the duodenum ^^^ also count among the
relatively rare occurrences.
Their correct recognition during life is beset with great difficulties,
arising already from the fact that frequently, on account of their deep
situation or their small size (this is especially true of the periampullar
forms), a tumor cannot be felt.
"Periampullar"
If in spite of this precisely the periampullar forms are more easily
accessible to medical diagnosis, it is due to their limited topographical re-
lation to the terminal portion of the ductus choledochus. They enter into
differential diagnostic consideration in every case of "malignant" icterus,
in regard to which we refer to previous discussions.^^'* A large gall-
bladder, without alterations in its walls, occult intestinal hemorrhage,
pronounced appearance of at times high febrile cholangitic processes with
perihepatitis, abscesses of the liver, etc., may count as most important
attributes.
"Parapyloric"
"Prejejunal"
The high up parapyloric and low down prejejunal duodenal neo-
plasms will frequently run their course under the clinical picture of a car-
cinoma of the pylorus. At the same time, it must always be borne in
mind that there are far more chances in these cases for the persistence
of HCl secretion; also that in the prejejunal forms the conditions for
regurgitation of bile and pancreatic juice into the stomach are more
favorable. Carcinoma of the pylorus is only very exceptionally accom-
panied by vomiting of bile ; the withdrawn stomach content in particular
very seldom contains bile-coloring matter.
Cancer of the Appendix
Malignant tumors of the appendix ^^'* — carcinomas come into first
consideration — do not admit of diagnosis on account of their small size.
As apparently they do not lead to metastases and do not show unlimited
growth, they can hardly be looked upon as "malignant" tumors in a clin-
ical sense, even though they bear their histological characteristics.
Omental Tumors
On account of their relative rarity, malignant tumors of the omen-
tum ^-" (almost always secondary!) may give rise to error. Thus, when
correspondingly situated underneath the right costal arch, the lower free
border may be easily mistaken for the border of the liver.
"' See Cases 22, 23, 24 and 25.
"* See page 144.
"'See W. Vassmer, Deutsche Zeitschr. f. Chiriirgie, 1908, Vol. 91 (compilation of
95 cases).
"" See Case 1.
"ATYPICAL" MALIGNANT ABDOMINAL TUMORS 169
Remarkable is their smooth, lamelliform expansion in the perium-
bilical situation as well as in varying other situations.
Ovaries
Testicle
In conclusion, we will refer to one more group of neoplasms which
are looked upon as rarities, by internists at least, namely, malignant
growths of the genital organs, ^"^ especially the testicle and ovaries. They
enter the domain of medical diagnosis when, like testicular neoplasms, for
example, they have led to retroperitoneal tumor formations, or, after the
manner of ovarian tumors, develop far upward and lead to ascites. Those
examiners who, in every obscure case of abdominal neoplasm, examine both
testicles, so that they may at the same time ascertain proper descent
and on the other hand also examine per vaginam, will run little risk of
overlooking these growths. It must, however, be noted with stress that .a
primary neoplasm of the testicles may at times be very small and that
intumescences of the ovaries may be brought about by metastasis (gas-
tric cancer!).
In diagnostically obscure cases of apparently "malignant" ascites in
females we must always consider the possibility of ovarian carcinoma.
Pseudo-symptoms of pregnancy (pigmentation of the nipples, etc.), may
occasionally, as in Case 2, lead one in the right direction.
Other accompanying symptoms, especially in so far as they affect the
gastro-intestinal tract, such as slight manifestations of stenosis, are rather
calculated to mislead one. Retroperitoneal tumor-masses occurring in
males, even though situated in the epigastrium, should always be examined
with reference to their possible relations to primary neoplasms of the
testicle.
"' See Cases 1, 2, 3, 4.
C. CASE HISTORIES
C. Case Histories
111 the following accounts it will be my endeavor to present short case
histories taken from my own experience. Ahiiost throughout they are
cases which I had occasion to discuss in post-graduate courses, so that
I can speak for the correctness of the previous history and the objective
findings. In the presentation of the cases I am guided by notes made |or
my personal use immediately after each lecture. Most of the cases in-
clude the notes of the surgeon or pathological anatomist, and occasion-
ally both. I have tried to omit everything that was superfluous in order
to afford a rapid general view. For this same reason it seemed proper to
arrange the dates according to definite viewpoints, so that the material
may be reviewed easily in one direction or another.
The arrangement is as follows :
1. Ancestry and relationship.
2. Congenital peculiarities, metabolic diseases, etc.
3. Previous infectious diseases.^
4. Previous history of the digestive tract.
5. Other previous history.
6. Initial symptoms and further course.
7. Objective symptomatology.
8. Dates of events ^ and duration of disease.
9. Findings at autopsy or laparotomy.^
The greater portion of the clinical material here to be discussed is
taken from the II. Medical Clinic in Vienna (Hofrat Professor Dr. E. V.
Neusser) ; the lesser portion from my division at the K.K. Kaiserin Eliza-
beth Hospital. The autopsies were performed at the Pathological Ana-
tomical Institute (Hofrat Professor Dr. A. Wnch.selbaum) and in the
prosector's department of K.K. Kaiserin Elizabeth Hospital (Professor
Dr. Fr. Schlagenhaufer) . The operations were performed in the clinic
of Hofrat Professor Dr. Gussenhauers and (after April 2, 1904- ) his suc-
cessor, Hofrat Professor Dr. J . Hoclienegg.
M. D. C. = Infectious Diseases of Childhood.
^ The date of "Status presens" generally corresponds to the day on which I had occa-
sion to present the case clinically. The date of the "beginning" has always been inferred
from the previous history of the patient, and naturally possesses limited validity, just
like the information as to the "duration" of the disease.
^ Given in epitomized form only.
173
Carcinoma of the Stomach
Case 1. — B. G., 53 years, M.^ Conductor.
ad 2.— Had two attacks of gout in the spring of 1898; swelling in
the joint of right great toe, occurring at night; after a week the same
joint in the left side was affected.
ad 4. — Always had a preference for acid foods.
ad 6. — Anorexia since October, 1898 ; now and then "false" hun-
ger. Sensation of pressure after eating. Often attacks of dizziness
upon arising in the morning. Sensation of "fire" in the stomach with
much thirst.
ad 7. — Transversely running tumor in the epigastrium. Tongue
heavily coated. Vomiting extremely seldom, only three times of late.
Frequent belching of gas, only once having the odor of rotten eggs. Ob-
stinate constipation. Emaciation, losing 20 kg. Second aortic sound
very loud, murmur-like. Hypertension,
Urine: Indican reaction {Obermayer) strongly positive.
ad 8. — Beginning: October, 1898.
Status presens: October 23, 1900.
Autopsy: February 18, 1900.
Duration : About 2 years, 4 months.
ad 9. — Autops}^ (Professor Dr. A. Ghon) : Infiltrating gastric car-
cinoma, chiefly in the pyloric portion of the stomach, with severe stenosis
of the pyloris. Atheromatosis of the aorta in high degree, especially in
the ascending portion and at the arch, with dilatation of the ascending
portion ; beginning contraction of the kidneys as a result of arterio-
sclerosis.
Eplcrisis: Possibility of relationship between gout and cancer! The
dragging course (2 years, 4 months) might be dependent on the severe
atheromatous disease in the circulatory system. The possibility of such
influence leading to a poorer nutrition of the cancerous tissue is held by
French clinicians, among others Bard.^
Case 2. — J, S., 62 years, M.
ad 1, — Father died in advanced age, much emaciated (Ca..'').
Mother died of old age.
ad 2. — Tubercular habitus,
ad 3. — Erysipelas.
*M = Male; F = Female.
^ Bard. La semaine medicale, 1904, No. 34.
174
CARCINOMA OF THE STOMACH 175
nd 4. — Since 1879 stomach suft'ercd; trequent bitter vomiting early
in the morning when stomach was empty, and eructation of gas during
many years; took tlie Karlsbad cure in 1887 and 1888 with good results.
For a long time obstipation, frequently sheep-like stools.
ad 5. — No drinker, moderate in eating. Liking for hot foods, par-
ticularly for very hot soup, no abuse of acid foods.
ad 6. — Since January, 1899, appetite very poor. Nourished him-
self since Septeml)er, 1899, with milk and rolls, lately only with milk. Se-
vere burning in the epigastrium. Relief after belching. Continuous
thirst.
ad 7. — Stomach small, in continual peristaltic unrest. Continued
explosive belching without particular odor, with slightly sour taste.
Tongue dry. Systolic murmur in the epigastrium. Obstinate constipa-
tion. Emaciation in highest degree. Retromalleolar edema and on the
sacrum.
Vomit: Fat globules, very small rod-shapes (Culture: bact. coli), no
lactic-acid bacilli, no sarcin«.
ad 8. — Beginning: January, 1899.
Status presens : April 26, 1900.
Autopsy: May 5, 1900.
Duration: About 1 year, 4 months.
ad 9. — Autopsy (Docent Dr. K. Landsteiner) : Scirrhus carcinoma
of the stomach with infiltration and contraction of the whole stomach-
wall. Ulcer scar at the pylorus. Carcinoma of the peritoneum and the
reginal lymph-glands.
Epicrisis: A typical case of diffuse scirrhus of the stomach! These
are without doubt cases which are looked upon as benign, on account of
lack of a definite tumor formation and failure of metastases, being re-
ferred to in the literature partly under the name "linitis plastica Br'ni-
ton:'
Characteristics of this form of stomach cancer: Small stomach, peri-
staltic unrest, continual regurgitation (gases), bact. coli-growth.^ The
symptom of explosive eructation present could in itself easily lead to
error (hysteria). The strong gas formation might be due to the pres-
ence of the bact. coli and the exclusive milk diet (fermentation). The
many years of previous stomach complaints were probably due to the ulcer
at the pylorus.
Case 3. — J. K., 65 years, M. Laborer.
ad 1. — Father and mother lived to old age, brothers and sisters all
healthy.
ad 2. — Suffered since childhood from ichthyosis. At the age of
29 he became ill and had painful swelling in the joints of both great toes
without fever, nightly occurrence of the affection. Later participation
of the ankle and knee joint, then the hip and the joints of the right arm
'See B. Schmidt. Wiener klin. Wochenschr., 1901, No. 2.
17(5 TUMORS OF THE ABDOMINAL VISCERA
and forearm. He was confined in bed one-half year and suffered from
nocturnal exacerbations of pain. In Karlsbad, arthritis urica was diag-
nosed. Since that time, in spring and autumn, frequent slight joint pains.
At the age of 46 he suffered another severe attack. Was in the hospital
nine weeks. Nodules, which disappeared, formed in the forearm. At
that time was operated on for hallux- valgus.
ad 3. — At the age of 31, fever attacks every second day with
chill, feeling of heat and sweat, received "bitter" powders. Perhaps
malaria.
ad -i. — Always had very good appetite.
ad 5. — Hard drinker.
ad 6. — In the night of April 7, 1900, sudden nausea and vomiting.
Appetite good, has eaten meats until lately, although at night he always
vomited copiously. Complains of burning pains in stomach, particularly
after eating, also sour and bitter eructations.
ad 7. — Tongue slightly coated, teeth very defective, ^'isible gas-
tric peristalsis accompanied by hiccough. Considerable vomiting, par-
ticularly in the middle of the night. By assuming the right lateral posi-
tion severe eructation and rather severe vomiting. Constipation. Tym-
panitic sounds in the region of the liver. Pulse 44, hypo-tension. No
edema.
Stomach contents: Lactic-acid bacilli most profuse, no hydrochloric
acid.
Blood: Ugh., 70%; erythrocytes, 4,500,000; leucocytes, 10,000.
ad 8.— Beginning: April, 1900.
Status presens : June 12, 1900.
Epicrisis: Remarkable is the presence of a constitutional defect as
expressed by ichthyosis and uric acid diathesis.'^ Hallux-valgus appears
to me in many cases to be a sign of latent uric-acid diathesis. The case
deserves interest from the standpoint of the connection between skin and
metabolism. Tympanites, in place of the liver dulness, is a frequent find-
ing in cases of pyloric stenosis. When the pyloric orifice is stenosed, the
severity of the regurgitation often increases, by assuming the right lateral
position (eructation, vomiting).
Case 4. — F. W., 55 years, M. Laborer.
ad 2. — Was alwa^^s healthy.
ad 5. — At the close of 1896, after lifting a heavy load, pains in
the region of the umbilicus of three weeks' duration.. Abdomen distended.
Loss of appetite and frontal headache ; otherwise there occurred no at-
tacks of nausea, no vomiting, bowels were regular. No alcoholism ; led
regular life.
ad 6. — In January, 1899, loss of appetite and drawing pains be-
gan in the lower abdomen, which occurred twice daily, now and then at
night. Since that time often no stool for from six to seven da^^s. Feel-
' Compare Case 1.
CARCINOMA OF THE STOMACH 177
ing of pressure in the stomach after eating, fi'equently odorless eruc-
tations of gases and heartburn. Distaste for boiled beef.
ad 7. — Tongue only slightly coated. Teeth very defective. Tu-
mor of the pylorus palpable. Considerable "coffee-ground" vomiting,
with abundant lactic-acid bacilli and sarcina\ No edema.
Feces: Abundant cercomonas intestinales.
ad 8. — Beginning: January, 1899.
Status presens: May 16, 1900.
Duration : About 1 year, 4 months.
Epicrisis: The abdominal complaints which occurred in 1896 (after
the lifting of a heav}^ load) could possibly have been the expression of an
ulcer of the stomach.
We are justified in speaking here of a "gastric" obstipation. The ob-
stipation is indeed frequently an early symptom of gastric cancer. The
"monadenfauna" ^ is here an intestinal one, as it sometimes is met with
in cases of achylia gastrica. This finding in the feces brings to mind the
idea of an insufficient secretion of hydrochloric acid. There never oc-
curred a gastric monadenfauna in pyloric carcinoma, although not sel-
dom in carcinoma of the cardia.
Case 5. — G. J., 43 years, M. A mother-of-pearl worker.
ad 3. — At the age of 2 had smallpox (the smallpox scars visible).
ad 4. — Never had stomach complaints.
ad 5. — Was always healthy.
ad 6. — In the fall of 1899 vomited six or seven times. In Febru-
ary severe vomiting after eating "goulash," from then on daily. No
pains. Was very much weakened by a Karlsbad cure. Loss of weight
of about 40 kg! Acid eructations, burning in the throat.
ad 7. — Tongue thickly coated, teeth defective. Distinct gastric
peristalsis with accompanying hiccough. Doughy consistence of the skin,
so that after pressure of the finger upon the abdomen and also over the
sternum there remains a small depression. No edema over the tibia, no
retromalleolar edema.
Stomach contents: "Coffee-grounds," no free HCl, abundant lactic-
acid bacilli.
ad 8.— Beginning: Fall, 1899.
Status presens: July 18, 1900.
Autopsy : June 22, 1900.
Duration: About 1 year, 10 months.
ad 9. — Autopsy : Polypoid carcinoma of the pylorus, constricting
in high degree. Small metastases in the regional serosa, numerous metas-
tases in the liver as large as hazel nuts.
Epicrisis: In the diagnosis of stomach diseases one has always to
consider the individuality of the patient. With "stomach athletes" who
always had enjoyed the best digestion, nearly every severe gastric dis-
* Compare, among others, A. Cohnheim, Deutsche med. Wochenschr., 1908, No. .%
and U. Gwastalla, Wiener klin. Wochenschrift, 1909, No. 45.
178 TUMORS OF THE ABDOMINAL VISCERA
turbance, if it is not cured in a very short time, must awaken the sus-
picion of malignancy ; also the bad result of a Karlsbad cure should cause
us always in analogous cases to think of carcinoma.
The pitting of the skin over the abdomen and over the sternum is here
not caused by edema but by a peculiar lo.s-s of elasticity of the skin which
one not seldom finds in constricting stomach carcinoma with copious loss
of fluid as result of continuous vomiting.
Case 6.— N. N., 78 years, F.
ad 5. — Twelve children.
ad 6. — In October, 1898, vomiting and odorless eructations began,
revulsion against meat. Since the beginning of October, 1899, the abdo-
men became gradually larger.
ad 7. — In the epigastrium one feels a transversely situated, very
hard roll, but which in the next moment feels soft; at the same time loud
gurgling. Ceaseless vomiting. Stomach contracted and in continuous
peristaltic unrest. Severe ascites, which toward the end disappears en-
tirely. Water can be taken only by the teaspoonful, but these small
quantities come back again immediately.
Obstipation in the last months ; feces lead pencil-like. Four centi-
metres above the anus a uniformly circular constricted point, over which
the mucous membrane is drawn unchanged (stenosis from without!).
Sudden occurring painful swelling of the left leg. Left-sided, slightly
sero-sanguineous pleural effusion.
Blood: 4,500,000 erythrocytes ; 26,000 leucocytes.
In the last days almost complete retrogression of the ascites, of the
left pleural effusion and of the edema in the left lower extremity. High-
est temperature, 37.3° C. In the terminal coma aspiration movements
(expression of an enormous feeling of thirst!),
ad 8. — Beginning: October, 1898.
Status presens: October 30, 1899.
Autopsy: November 15, 1899.
Duration : About a year,
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Scirrhus carcinoma of
the stomach, with carcinomatosis of the peritoneum.
Epicrisis : An analogue to Case 2 ! No circumscribed tumor forma-
tion, but a diffuse, uniform infiltration of the whole stomach-wall with
enormous constriction of the lumen.
Continuous peristalsis with resulting high-grade changes in the con-
sistence of the palpable stomach-canal (stone hard to soft!), and abso-
lute intolerance of even the smallest amount of fluid.
The patient can take to herself from without no fluid, since even the
smallest amount is immediately vomited. She drinks, therefore, toward
the end from her owm internal fluid depots (ascites, pleural exudate,
edema of the left leg), and there occurs a mummification of the former
dropsical patient. Even in the coma, movements of aspiration, as if she
would drink.
CARCINOMA OF THE STOMACH 179
Case 7. — Sch. U., 65 years, F. Laboring woman.
ad 6. — 111 since the beginning of September, 1899. There began
pains in the stomach, particularly after eating. Bitter and sour eructa-
tions, vomiting. From beginning, severe constipation. Severe tender-
ness to pressure underneath the left costal arch and in the left axillary
line over the lower intercostal spaces. Inguinal glands on left side painful,
ad 7. — Tongue coated, the right side more than the left. Meteor-
ism of moderate degree; tumor not palpable. Lower abdominal region
very tense. In the lower left quadrant, bowel peristalsis visible.
A gland in the left groin swollen, painful, later becomes smaller and
less painful. Left-sided pleural effusion after friction in the left axilla.
Aspiration: Cloudy effusion, with very numerous leucocytes. Severe
retromalleolar edema. Second aortic sound ringing. Highest tempera-
ture in the last days, 39.6° C.
ad 8. — Beginning: First part of September, 1899.
Status presens: November 4, 1899.
Autopsy: November 13, 1899.
Duration: Two months (.'').
ad 9. — Autopsy (Professor Dr. H. Albrecht) : Carcinoma of the
stomach of both the small and greater curvatures, without stenosis of
the pylorus with secondary carcinomatosis of the peritoneum. Sub-
phrenic abscess, about the size of an apple, between the spleen, stomach
and diaphragm; some pus in Douglas cul-de-sac. Fibrinous suppurative
pericarditis and left-sided pleuritis. Multiple contraction of the bowel
through the carcinomatous infiltration. Ascending aorta very athero-
matous and dilated. Chronic tuberculosis of lymph-glands of the neck.
Epicrisis: Carcinoma of the stomach as the cause of left-sided sub-
phrenic abscess and of left-sided suppurative pleuritis and fibrinous peri-
carditis ; in the beginning as the result of cachexia, no essential tempera-
ture rise.
Case 8. — N. N., 40 years, M. Machinist.
ad 6. — In the beginning of November, 1897, stomach trouble began
suddenly ; eructations, very sour vomiting, one-half hour after taking
food. July, 1898, a palpable tumor in the epigastrium. Winter of
1898-99, the stomach difficulties disappeared entirely, he could eat every-
thing, except large portions. Since April, 1899, severe edema of the
lower extremities. Bowels always regular. Since June, 1899, strong feel-
ing of thirst as result of a feeling of internal heat. Moderate polyuria.
Appetite and stool with essential disturbances. By assuming a left lat-
eral position, he experiences the feeling as if a heavy mass sank towai-d
the left. Feeling of hot and cold along the spine. Increase of the pains
in the back by pressure upon the tumor.
ad 7. — A tumor about the size of the palm of the hand, in the
centre of which lies the navel ; the tumor is hard, uneven, pulsates strong.
Over the same a systolic murmur is audible ; slight respirator}' mobility,
also, by diaphragmatic breathing. The tongue not coated. Bronze-
180 TUMORS OF THE ABDOMINAL VISCERA
like pigmentation in the face, on the forehead, neck and extensor surfaces
of the upper extremities. Pigment spots on the soft palate and on the
mucous membrane of both cheeks.
Blood: Hemoglobin, 30% ; 2,800,000 erythrocytes: 18,000 leucocytes,
among which were 8% cosinophiles.
Urine: Slight polyuria, traces of sugar.
Stomach contents: For the first time, toward the end, vomiting, and
about two litres of blood, lactic-acid bacilli very profuse,
ad 8. — Beginning: November, 1897.
Status prcsens: November 9, 1899.
Autopsy: November, 1899.
Duration : Two years,
ad 9. — Autopsy : High-grade ulcerative soft, carcinoma corre-
sponding to the pylorus, without stenosis. Tumor grown to the abdomi-
nal wall, the left lobe of the liver and attacking the pancreas, the head of
which is infiltrated.
Spleen enlarged. Thrombosis of tiie right crural vein.
Ejncrisis: It is not a seldom occurrence that in very large stomach
tumors, as we have here, stomach complaints are absent for a long time,
almost entirely. Disturbances on the part of the stomach exist in the
above reported case, only in the beginning and toward the end. One can
truly say, the fact somewhat underlined: the greater the stomach tumor,
the less the stomach complains ! The explanation for this seems to me
to be in the absence of a stenosis.
The large soft carcinomas, as was here the case, ulcerate very se-
verely, so that it does not come to a lasting stenosis. The pyloric out-
let becoming free, the stomach symptoms existing in the beginning dis-
appear again completely ; so also here. By an anatomical progressive
process a disappearance of the s^'mptoms can functionally take place.
The constipation in carcinoma of the stomach could result perhaps
partly from a pyloric stenosis and gastric stagnation; it was perma-
nently absent. Of interest is the peculiar skin and nmcous membrane pig-
mentation, combined with eosinophilia of the blood; pigment anomalies,
which are found in affections accompanied by severe cachexia (stomach
cancer, tuberculosis, and cancer of the pancreas, etc.), of course not fre-
quently (v. Recklinhausen's hemochromatosis).^
Case 9.— J. S., 36 years, M. Tailor.
ad 1. — One sister died of cancer of the stomach {?).
ad 4. — Beginning of gastric illness, five years ago ; the patient vom-
ited almost every week once after eating, without experiencing pain.
Frequently the feeling of ("setting up") in the epigastrium (as if a
worm were in the abdomen). The appetite always good.
ad 6. — Since two years ago the vomiting became more frequent.
The patient became pale and lost weight. For the past six months almost
"Compare W. Mar/er. Skin Melanosis in Diseases of the Pancreas. Zentralbl. f.
Grenzgeb. d. Chir., IV, page 2-25.
CARCINOMA OF THE STOMACH 181
every day stomach craiups, radiating into the left half of the thorax and
"up as far as the head."
ad 7. — The tongue thickly coated. A tunior-niass palpable in the
epigastrium, over which friction-sounds were audible. Second aortic tone
ringing,
ad 8. — Beginning: December, 1897.
Status presens: December 2, 1899.
Autopsy: February 10, 1900.
Duration: 2 years, 2 months,
ad 9. — Autopsy (Professor Dr. H. Alhrecht) : Ulcerating carci-
noma of the fundus and of the cardiac end of the stomach, with metastases
in the regional lymph- glands and in the head of the pancreas. Jejunos-
tomy, February 3, 1900. Atheroma of the abdominal aorta with numer-
ous thrombi in the walls; from here emboli of the right iliac artery and
of the left femoral artery.
Epicrisis: The severe atheroma of the abdominal aorta in a 36-year-
old patient deserves to be reported as remarkable.
This affection was the terminal cause of death, there being sudden
manifestations of a blood-vessel closure of the large arteries of the lower
extremities (the patient was in the clinic of the Hofrat Professor E. Al-
bert, after laparotomy. (Embolism of the right iliac artery and of the
left femoral artery !) The severe atheromatous disease of the abdominal
aorta is etiologically unexplained.
Case 10. — F. J., 57 years, M. Carpenter.
ad 1. — Mother died from a pulmonary disease.
ad ^. — Appetite was always good.
ad 5. — Suffered much since early childhood from cough, particu-
larly in bad weather. During the past year "pulmonary catarrh," with
night-sweats ; remained in the house about five months.
ad 6. — The patient noticed in 1899 a tumor between the navel and
the lower end of the breast-bone; since then has frequently the feeling
that in swallowing something sticks, this being accompanied by nausea
and pressure in the stomach. After several minutes the food passes down-
ward. Appetite good, though alv/ays pressure and feeling of tension in
the stomach after nourishment.
ad 7.- — Tongue coated, mucous membrane somewhat atrophic in
spots. Swallowing of fluid difficult, sensation of sticking; finely masti-
cated meat is swallowed better. No vomiting. Blowing systolic murmur
in the region of a large liver metastasis. Frequent thoracic breathing,
with soft respiratory murmurs. Severe retromallcolar edema.
ad 8. — Beginning: 1899.
Status presens : February 13, 1900.
Autopsy: March 13, 1900.
ad 9. — Autopsy (Professor Dr. O. Stoerk) : Scirrhus and infil-
trating carcinoma originating in the smaller curvature near the cardia and
infiltrating a large part of the stomach with extensive metastases in the
liver; many small metastases in the left pleura.
182 TUMORS OF THE ABDOMINAL VISCERA
Epicrisis: As a result of stenosis of the cardia, deglutition difficulties
became very prominent. Remarkable is a loud systolic murmur in the
region of the liver metastases.
Case 11. — J. M., 50 years, M. Cabinet maker.
ad 3.- — At the age of 34 had a left-sided pneumonia, which lasted
three weeks, otherwise always healthy.
ad 6. — Beginning of August, 1899, pain in the epigastrium be-
gan, radiating from both sides toward the middle, "as if a crab had
pinched with both claws." Burning pains in the right upper quadrant of
the abdomen and feeling of heat in the back, one-half hour after eating;
at the same time, to the right above the umbilicus, a sausage-like projec-
tion. Eructation of bitter and sour food. Such attacks daily in the
beginning, later only two or three times in the week.
November, 1899, the attacks of pain became less frequent, pains in
the back continuous.
October, 1899, fourteen days' irregular fever and emaciation. Appe-
tite good. Increase of the symptoms in the right lateral position. Vom-
iting after potatoes, bread, coffee, sour and hot edibles.
February, 1900: Pains only after inappropriate nourishment, and
when in the right lateral position.
April, 1900: Back pains disappeared. Appetite good; predilection
for meat. Antipathy against acid foods.
May, 1900: Pains in the abdomen, particularly toward midnight. Ap-
petite very good, also appetite for meat. No s3Mnptoms after taking
nourishment. Spinal column very sensitive to pressure, corresponding
to third and twelfth dorsal vertebra?.
July, 1900: No pain in the epigastrium, only pains in the back. Ap-
petite poorer. Severe sensitiveness to pressure of the spinal column be-
tween the shoulder-blades.
ad 7. — February, 1900: Tongue very heavily coated, teeth very
defective. Tumor not palpable in the epigastrium, pain upon pressure
below the xiphoid process. Indican reaction (Obermayer) strongly posi-
tive. No edema. On the mucous membrane of the cheeks and hard palate
on both sides brownish pigment spots.
April, 1900: Indistinct resistance in the liver region. Systolic mur-
mur in the epigastrium most distinctly audible, particularly at the end
of expiration. The patient feels a protuberance ( Aufstellung) in the
epigastrium, accompanied by gurgling. Now and then slight intestinal
peristalsis above Poupart's ligament. Severe retromalleolar edema.
May, 1900: The patient himself feels individual tumors in the epi-
gastrium, and remarks that they change their position. Underneath the
xiphoid process is a tumor, which in the left lateral position can be dis-
placed down and to the left. jMetastases palpable on the surface of the
liver. Severe anemia, 25% Hemoglobin. No edema,
ad 8. — Beginning: August, 1899.
Last status presens: July, 1900.
Duration : About one year.
CARCINOMA OF THE STOMACH 183
Epicrisis: The ck'inent of pjiin appears strongh' in the foreground
in the above observation and lends the case an ulcer-like symptom com-
plexion. Doubtlessly the process began as cancer of the pylorus. The
appetite remained good for a long time and meat was borne well. I
have observed fre()ueiitly in stenosis of the pylorus^'* slight intestinal
peristalsis (accompanying movements of the intestines.'').
The systolic "epigastric murmur" occurs in this case before the pal-
pability of the tumor.
Case 12.— D. F., 42 years, M. Carpenter.
ad 1. — No hereditary diseases.
ad 2. — Phthisical habitus.
ad 5. — Was always healthy until January, 1900.
ad 6. — .January, 1900, pains in the whole abdomen, soon there-
after stomach symptoms, vomiting, emaciation.
ad 7. — Tongue moist, somewhat coated. Ascites of moderate de-
gree, milk-like cloudiness ("chyliform").
ad 8. — Beginning: January, 1900.
Status presens : November, 1900.
Autopsy: December 13, 1900.
ad 9. — Autopsy (Hofrat Professor Dr. yi. Weichselbaum) : Dif-
fuse scirrhus of the whole stomach, with strongly contracting metastases
in the peritoneum, particularly in the small and large curvatures of the
stomach, growing on to the left musculus quadratus lumboinim and psoas
with stenosis of the pyloric orifice. Hemorrhagic ascites, bilateral hydro-
thorax. Individual calcified tubercles in the right upper lobe. Hyper-
trophy of the middle lobe of the prostate with hypertrophy of the bladder
and cystitis. Numerous metastases in the spinal column, in the ribs, in
the thigh.
Epicrisis: Similar cases, with ascites and pleural exudate in patients
of phthisical habitus, can easily be mistaken for tuberculosis of the serous
membranes. In the differential diagnosis observe particularly: "milky"
character of the effusion, afebrile course, the absence of the diazo
reaction.
Case 13.— A. L., 34 years, M. Office clerk.
ad 1. — Father died in old age.
ad 2. — Phthisical habitus.
ad 4. — Always had a good appetite. Preference for spic}' and
sour foods.
ad 5. — "Was always healthy."
ad 6. — In the beginning of 1899 occurrence of burning pains in
the region of the gall-bladder, radiating into the epigastrium, back and
lateral portions of the thorax, also into the left shoulder. In the begin-
^^ Compare Anschiitz, Grenzgebiete fiir Chirurgie und interne Medizin, 1907, III.
Suppl., page 516.
1H4< TUMORS OF THE ABDOMINAL VISCERA
ning eructations, which afforded relief, later sour eructation. In the be-
ginning amelioration of the complaints through ingestion of warm soup,
warm milk, cataplasms ; later all this without avail. High fever and
diarrhea for some days. Intolerance for sour foods. Impossible to lie
on right side during attack of pain ; when free from pain position made
no difference.
October, 1899 (daily lavage of the stomach during the evening)^
even on a mixed diet no gastric complaints.
November, 1899, feeling "as if there were no room in the stomach."
Continuous pains in the epigastrium, radiating into the back. Anoi'exia.
Pains in the back increasing and diminishing with the pains anteriorly in
the epigastrium.
ad 7. — September 6, 1900: Tongue moist, slightly coated. Abdo-
men not tender to pressure; indistinct transverse swelling in the epigas-
trium. The patient himself has on occasion of an attack of pain felt a
transverse cord. The attacks of pain are accompanied by gastric peri-
stalsis. Pressure over the pylorus elicits prolonged borborygmi. Pale
yellow coloration. Skin dry, peeling off". HCl positive in gastric con-
tents withdrawn from fasting stomach.
October, 1900: Cylindrical tumor, having the diameter of the index
finger, about 4 cm below the xiphoid process. Nominal tenderness to
pressure. Soft, blowing systolic murmur in the epigastrium. Edema.
HCl positive on fasting stomach, sarcina?. Patient has no complaints.
November 12, 1900: Tumor more distinct, sensitive to pressure. Bow-
els regular. Retromalleolar edema.
ad 8. — Beginning: Early part of 1899.
Status presens: September 6, 1900. October 4-, 1900. No-
vember 12, 1900.
Autopsy: November 14, 1900.
Duration: About 1 year, 10 months,
ad 9. — Autopsy: Carcinoma of the pyloric region of the stomach.
Epicrisis: In this case also the element of pain comes into the fore-
ground in the beginning and during the further course of the disease.
Here we have those wide radiations peculiar to the "colic of pyloric
stenosis" described by me.^^ The long persistence of HCl secretion is at
any rate a factor promoting pain. The patient's own observation that a
transverse cord could be felt in the epigastrium (pyloric spasm before the
stenosis) is worthy of note.
Case 14.— H. T., 52 years, F.
ad 1.- — Father died probably of cancer at 53, one sister died of
tuberculosis.
ad 2. — Meagre stature.
ad 3. — Passed through several diseases of childhood.
ad 4. — Always had a good stomach, could tolerate everything well.
" R. Schmidt. Die Schmerzphanomene bei inneren Krankheiten, etc. Second edi-
tion, 1910.
CARCINOMA OF THE STOMACH 185
ad 5. — Always healthy; menstruation absent for one year.
ad 6. — Emaciation since October, 1900. Poor appetite since De-
cember, 1900. Hitlierto no vomiting. "Water often runs together in
mouth." Sensation of pressure in stomach.
ad 7. — Mucosa of the tongue smooth in the middle portions, shiny,
atrophic. Hard tumor at the pylorus. Light peristalsis of intestinal
loops above Poupart's ligament. Pale yellow color of face. No edema.
Stomach contents: No HCl, abundance of lactic-acid bacilli and yeast-
cells.
ad 8. — Beginning: October, 1900.
Status presens: April 23, 1901.
Duration : About 7 months.
Epicrisis: In regard to "stomachal" intestinal peristalsis, we refer to
Case 11.
Case 15.— S. J., 46 years, F.
ad 2. — First menstruation at 17 years of age.
ad 3. — Measles at 4; pulmonary disease at 34, received 16 of
Koch's injections, remained in bed 3 months.
ad 4. — Stomach complaints for past 10 years.
ad 5. — In May, 1899, fell from stairs, striking region of the stom-
ach. In 1899 was treated for articular rheumatism. Has not eaten
meat for one year.
ad 6. — Last menstruation March, 1900. In lower abdominal region
frequent sensation of contraction. Dorsal vertebra^ very tender on per-
cussion, especially at the height of the angle of the scapula. For-
merly for a long time pains in back in dorsal position, now only when
sitting.
ad 7. — Sensitive tumor in the epigastrium. Liver metastases. Se-
vere edema of the lower extremities and over the sacrum.
ad 8. — Beginning: March, 1900.
Status presens: September 21, 1900.
Autopsy: October 22, 1900.
Duration : 7 months ( ?).
ad 9. — Autopsy (Professoi Dr. H. Glion): Soft carcinoma in the
wall of the stomach near the lesser curvature, superimposed on a round
ulcer, invading the pancreas, which had grown to the posterior wall of
the stomach. Multiple metastases in the liver.
Epicrisis: The localized sensitiveness on percussing the vertebral col-
umn at about the level of the angle of the scapula is worthy of note ; the
phthisical antecedents could easily awaken the suspicion of a beginning
spondylitis. Undoubtedly, however, we were dealing with a gastric reflex
symptom, which often appears also in gastric ulcer.
Cessation of the menstrual periods might count among the early
symptoms.
About one year previous to the beginning of the cancerous disease a
trauma to the epigastrium.
186 TUMORS OF THE ABDOMINAL VISCERA
Case 16. — J. K., 57 years, M. Cabinet maker.
ad 2. — Ton^e indented.
ad 3. — No I. D. C. ; at 13 was unconscious for 4 weeks (Ty. 2).
ad 4. — Appetite always good, bowels regular; never had pains in
the stomach. Preference for highly salted and spiced foods; was com-
pelled always to eat rapidly.
ad 5. — No alcohol ; no nicotine.
ad 6. — In May, 1900, without preceding indigestion, whilst at work
was taken with cutting, burning pains in the region of the stomach, dis-
tention of that organ; the pains lasted one to two hours, limited to the
epigastrium. These pains subsequently occurred daily. During the at-
tack the patient found relief by pressing wnth his hand over the region of
the stomach. Later on he noticed an erectile feeling and hardening in
the pit of the stomach. Eructation brings relief, likewise sometimes the
ingestion of food. Constipated since May, 1900. Appetite good, but
distress immediately after meals. No vomiting. Pains occur more easily
when stomach is empty; daily odorless eructation and heartburn. Posi-
tion exerts no influence. Very frequent nocturnal pains in the epigas-
trium, together with hardening of the same.
ad 7. — Teeth defective. Tumor underneath the left costal arch.
Hoarseness since appearance of stomach complaints, cannot speak loud
any more. Frequent hiccough. In the morning on arising nausea and
vomiting. Since June, 1900, often swelling of the feet during the day,
regress at night.
ad 8. — Beginning: May, 1900.
Status presens: October 15, 1900.
Autopsy: March 26, 1901.
Duration: About 11 months.
ad 9. — Autopsy: (Professor Dr. H. Ghon) : Disintegrating papil-
lary carcinoma of the pyloric portion of the stomach, with stenosis of the
pylorus and dilatation of the stomach. Tuberculosis in the left pul-
monary apex, with small hazelnut size cavity.
Epicrisis: "Colics of pyloric stenosis" precede demise by about eleven
months. A rapidly occurring pyloric stenosis is, almost always, of ma-
lignant origin. Benign ulcerous processes require a long time to produce
stenosis by way of cicatricial contraction.
Case 17.— B. A., 52 years, M.
ad 1. — No cancerous disease in the family.
ad 2. — In 1884, 16 years ago, attack of gout. Pains on both sides
in the great toe- joint, in the left knee and left thumb. Pains occur espe-
cially at 5 P.M. and 3 a.m. These attacks were repeated during three
years, up to 1887, after which the patient was entirely free from com-
plaints.
ad 3.— No I. D. C.
ad 4. — Stomach always unusually good. Preference for strongly
peppered and sour foods.
CARCINOMA OF THE STOMACH 187
ad 6. — Since November, 1899, intolerance for meat. Headaches
after eating- meat or bread. Since then has lived on milk and soup. In
April, 1900, first pain in the epigastrium, and that particularly after eat-
ing; sensation ""as if a stone were lying in the stomach." Since then
odorless eructation, no vomiting. Since the beginning of November, 1900,
there is present the feeling as if the stomach on the left side, underneath
the costal arch, becomes erectile and hard; with it "rolling," which, when
it becomes strong, affords relief. There might be appetite for meat, but
patient fears the consequences.
ad 7. — Distinct gastric tumor, hard, little painful. Stomach, be-
ing spontaneously distended, is palpable. Spleen can be felt, moderately
tough ; no edema. Hallux valgus on both sides of high degree.
Stomach contents: Stasis, no HCl.
ad 8. — Beginning: November, 1899.
Status presens: November 22, 1900.
Epicrisis : Development of cancer in a gouty individual ! The sig-
nificance of hallux valgus as a constitutional defect at times has already
been pointed out. Initial symptom is intolerance of meat. Eating of
meat provokes headache, later on, there follow the subjective and objec-
tive symptoms depending upon constriction of the pA^loinis.
Case 18.— F. B., 52 years, M.
ad 3. — Of I. D. C. had only measles. During military service fell
into the water and suffered for eight months from articular rheumatism.
No lues.
ad 4. — Formerly never had stomach complaints. Preference for
highly seasoned foods.
ad 6. — In December, 1899, beginning of pressure sensation about
% to % hours after eating. Duration: about one hour. No vomiting;
bitter eructation and heartburn. Anorexia; particular intolerance for
farinaceous foods, meat and sharply seasoned foods. Constant increase
of the complaints. Some improvement after taking soda bicarb. Percus-
sion caused pain on the right side, posteriorly, over the base of the lung
and underneath the right costal arch.
ad 7. — Tongue slightly coated. Tumor-mass on the left side in
the epigastrium ; later on, friction in the same place and much tenderness
to pressure. Vomiting only toward the end. Previous to death, fecal
vomiting (containing triple phosphates!), diarrheas. Tongue verv drv.
Chill, five days before death. Traube's space narrowed; on the left side,
posteriorly, dulncss from the angle of the scapula, respiratory sounds
weakened, slightly bronchial.
Urine: Since 1^ years scanty, much sedim. laterit.
ad 8. — Beginning: December, 1899.
Status presens: December 19, 1900.
Autops} : January 7, 1901.
Duration: 1 year, 1 month.
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Diffuse, ulcerating
carcinoma of the stomach, especially of the greater curvature, with
188 TUMORS OF THE ABDOMINAL VISCERA
diminution of the gastric lumen ; an ichorous, walled-off abscess, the size
of a head, underneath the left half of the diaphragm, between stomach
and transverse colon, extending on the right up to the suspensory liga-
ment of the liver. Abscess perforating near the curvature into stomach
and colon, so that there is a communication. Carcinomatosis of the pa-
rietal and visceral peritoneum, metastases in the liver, in the retroperi-
toneal and inguinal lymph-glands.
Epicrisis: As in Case 7, so also here, a left-sided subphrenic abscess,
which, perforating the stomacli and colon, established a gastro-intestinal
fistula.
Result: Fecal vomiting with triple phosphate crystals and ichorous
diarrheas. The change in urination noted by the patient IVo years prior
to death (oliguria with copious uric-acid sediment) probably coincides
with the development of cancer.
Case 19.— W. M., 60 years, M. Coachman.
ad 2. — Ten j^ears ago inflannnation in joints of both hands, lasting
three weeks.
ad 3.— No I. D. C.
ad 4. — Had an "excellent stomach"; fat, also, was tolerated in
large quantities. Preference for sour and hot foods.
ad 5. — Three years ago was treated during fourteen days for morb.
macules, Werlhofii.
ad 6. — In November, ]9()(), vomited blood, filling a cuspidor, with-
out prodromes ; simultaneous black coloration of the stool. After this
vomiting of blood, pains began. Anorexia since the end of January,
1901 ; disgust for meat. Feeling of pressure in the stomach after eating;
pains to the left of the navel, with left lateral position ; the point of pres-
sure moves the width of three fingers to the left, the same with right lat-
eral position to the right. If the patient eats at noon the pains appear
about 6 or 7 o'clock; they make the right lateral position impossible.
Chief complaints after the ingestion of meat.
ad 7. — Tongue not much coated. Hard, nodular tumor in the left
half of the epigastrium. No vomiting. Hiccough daily in the fore-
noon. Has lost 15 kg in weight during the last two months. No
edema.
Stomach contents: HCl absent, lactic-acid bacilli abundant.
ad 8. — Beginning: November, 1900.
Status presens: April 29, 1901.
Duration: 6 months.
Epicrisis: The joint affection occurring at the age of 50 might be
interpreted as a metabolic disturbance, rather than a pure infectious dis-
ease. Relations between carcinoma and metabolic anomalies! As is fre-
quently the case, so also here, we are dealing with a "stomach athlete."
A rare initial symptom : hematemesis. The right-sided "painful position"
speaks for the pylorus as the place of origin.
CARCINOMA OF THE STOMACH 189
Case 20.— J. B., 57 years, M. Porter.
ad 1. — Father died at TO of old age. oNIother succumbed to some
pulmonary disease.
ad 2. — Phthisical habitus.
ad 3. — No I. U. C. ; typhoid (?) at 9 years of age.
ad 4. — Never had stomach complaints.
ad 5. — Always led a regular life, "like a clock."
ad 6. — In December, 1900, burning in the gullet after eating,
later on nausea and vomiting after every meal. Pain in the region of the
stomach after the intake of solid foods. Rowels regular in the beginning,
but later became irregular, hard. In May, 1901, "coffee-ground" vom-
iting. In June, 1901, despite visible peristalsis, not much pain.
ad 7. — In March, 1901, the patient himself became aware of an
enlargement in the epigastrium, which seemed to become erect and move,
accompanied by gurgling. Tumor at the pylorus. Visible peristalsis with
hiccough. Yellowish coloration of the face. Distinct retromalleolar
edema. "Coffee-ground" vomiting without HCl, with presence of pure
culture of lactic-acid bacilli.
ad 8. — Reginning: December, 1900.
Status presens: June 13, 1901.
Duration : 6 months.
Epicrisis: The initial symptoms, such as heartburn, nausea after every
meal, etc., may be interpreted in many ways. They gain in importance,
however, when they occur in an individual who has had a "strong stomach"
and not disappearing very soon. In such cases one must always think of
gastric cancer.
Case 21. — F. P., 50 years, M. House servant.
ad 1. — Mother, four sisters and brothers healthy.
ad 3. — No I. D. C. Malaria at 17, since then always healthy.
ad 4. — Appetite always good and bowels regular; preference for
sour and spicy foods.
ad 6.^ — Loss of appetite without apparent cause since January,
1901, particularly, disgust for boiled beef and fat. Feeling of pressure
after eating meat. Since that time constipation. Since then has lived
on sour milk, eggs, brain with Ggg. Since February, 1901, sour eructa-
tion, vomiting at first only after drinking cold water, but later also after
soup, least after milk. Recently cramp-like pains in the region of the
pylorus. With right lateral position rather severe eructation, vomiting
lighter, pains more severe.
ad 7. — Early in August, 1901, palpable resistance in the epigas-
trium. Transverse firm tumor as thick as the middle finger. No edema.
"Coffee-ground" vomiting, with pure culture of lactic-acid bacilli.
ad 8. — Reginning: January, 1901.
Status presens: August 6, 1901.
Autopsy: September, 1901.
Duration : About 8 months.
190 TUMORS OF THE ABDOMINAL VISCERA
ad 9. — Autopsy: Constricting infiltrating carcinoma of the py-
lorus with peritoneal and hepatic metastases. Slight cicatricial changes
in both pulmonary apices.
Epicrisis: Disgust, especially for boiled beef, is frequently found as an
initial symptom, and in cases when gastric digestion had been good must
be considered seriously. The vomiting at the start was elicited especially
by cold water.
The localization of the process at the pylorus is indicated by the
right lateral "painful position," which also causes exacerbation of eruc-
tation and vomiting.
Case 22. — J. B., 58 years, M.
ad 1. — Father and mother died of old age.
ad 3. — No I. D. C. Typhoid at 16 years of age.
ad 4. — Always has good appetite, bowels regular.
ad 5. — Always healthy.
ad 6. — In beginning of October, 1901, without apparent cause,
immediately after noonday meal, violent burning pains in the middle of
the epigastrium, with heartburn. Duration: 1^ hour; thereafter dizzi-
ness and vomiting (mucoid, dark, sour). Since then, if he eats at 12
o'clock, has burning pains at about 2 or 2.30 p.m. Appetite still good in
the early part of September, 1901. When in pain the patient doubles
up, and with his hand presses against the region of the stomach, which
alleviates the pain somewhat. Eructations "like rotten wood." He is
aware of splashing sounds earl}'' in the morning, without having had any-
thing to drink.
ad 7. — Tongue slightly coated, teeth very defective. Tumor in the
epigastrium, with occasional gastric rigidity. No edema. After test-
breakfast, 1.3% HCl. Few sarcinae. Splashing sounds in stomach early
in the morning, on a fasting stomach. Vomiting about three to four
hours after meals.
ad 8. — Beginning: Early in October, 1901.
Status presens : November 4, 1901.
Operation: December 18, 1901.
Duration: 21/) months (?).
ad 9. — Operation (Dr. H. Salzer) : Pylorus and pyloric portion of
the stomach-wall changed into a hard tumor. Greatest length at the
greater curvature, 12 cm; at the small curvature, 8 cm. Resection of the
pylorus, gastro-enterostomy. Dismissed as cured January 23, 1902.
Anatomical finding: Infiltrating carcinoma of the stomach superim-
posed on a gastric ulcer.
Epicrisis: For the purpose of differentiation from a benign stenosis of
the pylorus (HCl sarcinae), it seems to me important that the stenosis
has developed after a very short duration of stomach symptoms. This
speaks generally for malignancy of the stenosis. The existing painful
attacks are to be interpreted as "colics of pyloric stenosis."
The anatomical finding refers to a chronic ulcer jis the basis of the
cancer formation. Clinically, there is not the slightest evidence of a
CARCINOMA OF THE STOMACH 191
chronic ulcer. Tliis incongruity is found so often as almost to justify the
suspicion that the changes anatomically' appearing as a chronic ulcer
have developed in the course of the cancer development (thrombosis?).
Moreover, in this case there was for a long time persistence of HCl
secretion, which is commonly accepted as characteristic of ulcer carci-
noma, although there is no compelling reason for it.
Case 23.— J". N., 42 years, M. Tailor.
ad 1. — Father died at H-i of old age. Mother living and healthy.
ad 3. — No I. D. C. ; scorbutus (?) at 13 years of age.
ad 6. — Says that in October, 1899, he spoiled his stomach at a
death wake ; since then stomach is sensitive, now and then some pressure
in the stomach and constipation. In the spring of 1900 felt exhausted,
had a pale ("j-ellow") color. Varying appetite; now and then vomiting
immediately after meals. Ei*uctations having the odor of decomposed
eggs. In the autumn of 1900 a "chronic gastric catarrh" was diagnosed.
Karlsbad cure, followed by some improvement. During the course of
1901 no vomiting; in the autumn of 1901 appearance of edema in the
lower extremities. Since appearance of gastric symptoms patient no
longer has headaches, which he had before. Since Fcbiiiary, 1900, sensa-
tion of pressure on both sides along the costal arches and in the middle
of the epigastrium ; now and then pains in the back. Pain in stepping
Avith the left leg, pain being behind the internal malleolus and in the
popliteal space; entire leg strongly edematous (thrombosis of the left
crural vein).
ad 7. — Lingual mucosa, especially in its middle portion, smooth,
atrophic. Soft carcinomatous nodules can be felt in the epigastrium.
Pulse 12-i, small, bounding. Loud, raspy, systolic murmur audible over
the sternum. Emaciation covered up by diffuse dropsical swellings ; ex-
treme pallor. Hemoglobin 12%, numerous normoblasts.
December 9. — After defecation, severe pains in the belly, collapse,
died at midnight.
ad 8. — Beginning: October, 1899.
Status presens: December 2, 1901.
Autopsy: December 10, 1901.
Duration : 2 years, 2 months.
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Polypoid carcinoma,
being the size of a man's fist, in the pyloric region, with papillary sur-
face. Recent perforation toward the base of the liver with beginning
diffuse, fibrinous peritonitis. Escape of stomach contents into belly cav-
ity (pure culture of streptococci in the peritoneal cavity). Severe gen-
eral anemia.
Epicrisis: Wherever a single dietetic error is accused of being the
cause of protracted gastric ailments, the greatest doubt should be main-
tained.
Very frequently these are cases of gastric cancer in which a dietetic
error probably precipitates the appearance of a latent carcinoma. The
diagnosis of "chronic gastric catarrh" should always be made with great-
192 TUMORS OF THE ABDOMIXAI. VISCERA
est scepticism and after careful deliberation; for how often a gastric
cancer is concealed behind this pseudonym !
A "chronic gastric catarrh" is anatomically very frequent, but clin-
ically enormously rare as the sole cause of severe or even painful gastric
symptoms.
The disappearance of a chronic cephalalgia with the appearance of
gastric cancer is interesting.
This case illustrates the "hydropic-anemic" type of gastric cancer;
the same is always accompanied by tachycardia and very often also
conspicuous, raspy, systolic murmurs, especially over the sternum, which
may be easily referred to the pericardium. Autopsies offer no explana-
tion ; they are probably only anemic murmurs.
Case 24.— W. F., 42 years, F.
ad 1. — Father living and healthy; mother died a year ago of
gastric cancer.
ad 3.— No I. D. C.
ad 4. — Fifteen years ago had stomach trouble, lasting one year.
Stabbing pains on the left side, underneath the costal arch, with great
sensitiveness to pressure. Increase of the complaints after ingestion of
foody frequently vomiting two hours after meals. These symptoms dis-
appeared entirely after one year.
ad 5. — Menstruations began at 15. Had 7 confinements.
ad 6. — Since the beginning of November, 1900, constant gastric
pains and vomiting. Anorexia. Disgust for meat; could eat nothing but
milk. The patient herself felt a tumor, which increased rapidly in 9 weeks.
ad 7. — Tumor the size of a walnut in the umbilical depression. No
edema. Color of face, pale. Transient temperatures up to 38° C.
Stomach contents: Abundant lactic-acid bacilli. HCl absent.
ad 8. — Beginning: November, 1900.
Status presens: December 7, 1901.
Operation: December 13, 1901.
Duration : About 1 year, 1 month.
ad 9. — Operation: Firm tumor the size of a hen's egg belonging
to the p3'lorus (Histol. cylindrical cell cancer). Transverse mesocolon
grown to the tumor.
Epicrisis: Mother and daughter taken with gastric cancer in rapid
succession. The gastric affection of 15 years ago ma^^ probably be diag-
nosed even at a subsequent date as an ulcer. The occasional rises in tem-
perature must be referred to the carcinoma, in fact it Is advisable when
there is suspicion of gastro-intestinal neoplasms to pay attention to the
behavior of the temperature.
Case 25. — H. J., 36 years, M. Laborer.
ad 1. — Parents living and healthy.
ad 4. — Always had a good stomach, preference for sour and spicy
foods ; eructations for quite some time past. Since six or seven years
constipation and hemorrhoids.
CARCINOMA OF THE STOMACH 193
ad 6. — Since January, 1900, often has pain and pressure in stom-
ach after catin^r; these disturbances started without cause. Often vom-
iting (immediately after ingestion of food) and belching of odorless
gases. Since December, 1900, the abdomen began to enlarge. Gastric
pains, especially 1 to ll/i hours after meals; often epigastric pains at
night; vomit ameliorates condition. Pain anteriorly at tiie xiphoid proc-
ess and posteriorly at a point corresponding to the 12th dorsal vertebra.
Tenderness to pressure in right lumbar region. (Autopsy: right-sided
hydronephrosis as a result of cancerous infiltration of the right ureter.)
Since two days ago slight difficulty in deglutition. Appetite not so very
bad ; yet onl}' milk is tolerated;, one or two spoonfuls of soup, water in
teaspoonfuls, otherwise immediate vomiting. It takes the patient half
a day to drink one-half litre of beer. A mouthful seems too much, comes
back immediately.
ad 7. — Ascites. Nodular tumor-masses in the left half of the epi-
gastrium ; spontaneous alterations of same in position, change in distinct-
ness of palpation. Umbilicus infiltrated with cancer (since the beginning
of the disease hardening and enlargement noticed around the umbilicus,
gradually become larger and harder). Severe retromalleolar edema. Bi-
lateral pleural effusion. Pulse 44<, threadlike.
ad 8. — Beginning: January, 1900.
Status presens: January 4, 1902.
Autopsy: January 14, 1902.
Duration: 2 3'ears.
ad 9. — Autopsy (Professor Dr. H. Alhrecht) : Infiltrating scirrhus
of the stomach with considerable diminution in size of same and uniform
hypertrophy of the muscularis. Secondary carcinoma of the entire peri-
toneum with complete atrophy of the large omentum and multiple con-
strictions of the large bowel. Coprostatic ulceration of the cecum, with
perforation of same in three places, the size of a lentil. Serofibrinous
peritonitis. Stenosis of the right ureter, due to cancerous infiltration
and right-sided hydronephrosis. Cancerous infiltration of the skin of
the umbilical region.
Ejncrisis: A typical example of that type of gastric cancer which
leads to contraction of the stomach and early ascites. Precisely these
cases not infrequently run their course with umbilical metastases, a find-
ing which permits of the most rapid and most simple differential diag-
nosis from tuberculosis of the peritoneum. Inability of the stomach to
retain even very small quantities of fluids is characteristic. In order to
consume one-half litre of liquids the patient requires half a day! The
unaccountable appearance of gastric symptoms, where previously there
was a good stomach, is, as always, worthy of attention. Ulcerlikc pains
accompany the process of the disease. Pronounced bradycardia !
Pulse 44.
As a rare complication of a gastric cancer there develops (through
cancerous infiltration of the right ureter) a right-sided hydronephrosis
with tenderness on pressure in the right kidney region.
194 TUMORS OF THE ABDOMINAL VISCERA
Case 26. — J. Z., 59 years, M. Prison guard.
ad 2. — Articular rheumatism for 19 months at the age of 47, had
started in the joint of the great toe; fever for one month.
ad 3.— No I. D. C.
ad 4. — Always a good stomach; preference for strongly seasoned
foods.
ad 5. — Moderate in drinking and smoking.
ad 6. — Since January, 1900, nausea and sour eructations. Since
September, 1901, severe gastric pain, mostly about 4 o'clock in the after-
noon and at night. The pain often begins in the lower abdominal region
on the left, and extends to the xiphoid process ; belching brings relief.
During an attack of pain right lateral decubitus is tolerated badly,
dorsal decubitus is impossible ; vision is poor during attack of pain.
ad 7. — Tongue much indented. Stomach distended like an air-
cushion, particularly in its right pyloric portion. Hard, nodular tumor
of the pylorus. For the past 14 days very copious vomiting in the
evening, formerly at evening only a feeling of pressure and regurgitation
of "sour water." Eructation having the odor of decomposed eggs
(SH2). During the attack of pain, erectile feeling in the region of the
pylorus, pupils somewhat contracted, reacting slowly ; P. T. R. increased.
No edemas. Pulse, 56. HCl negative after test-breakfast.
ad 8.— Beginning: January, 1900.
Status presens: January 15, 1902.
Operation : February 25, 1902.
Duration: 2 years, 1 month.
ad 9. — Operation (Dr. H. Salzer). Firm tumor at the pylorus the
size of a small apple. Typical resection of the pylorus after Billroth (1).
Dismissed as cured, March 15, 1902.
Epicrisis: This is a type of the "fibrous" gastric cancer limited to
the pylorus and producing much constriction; bradycardia (pulse 56)
as a frequent accompanying manifestation in these cases. The history
reveals no infectious diseases of childhood. At 47 years of age the
patient had a joint affection which, in view of the fact that it started
in the joints of the great toe, and the further fact that infectious articu-
lar rheumatism almost never occurs for the first time at this age (47
years), may be looked upon as "gouty."
The functional ability of the stomach had been a very good one before
the disease.
Eructation of sulphurous fluids in the presence of achlorhydria is
alwaj's highly suspicious of a constricting cancer of the pylorus.
Case 27.— F. P., 43 years, M. Servant.
ad 3. — Had smallpox and measles; at the age of 15 had malaria
for five months.
ad 4. — Alwa3's had a sensitive stomach, fat in particular being
badly tolerated.
ad 6.- — In November, 1901, appearance of anorexia; subsequent
CARCINOMA OF THE STOMACH 195
improvement of appetite. Even now has appetite for meat, no pains.
Meat is tolerated. With right lateral decubitus there is burning as high
up as the throat. The patient nmst lie on his left side.
ad 7. — Tumor at the pylorus. Visible (painless) gastric peri-
stalsis. Three to four hours after meals there is vomiting, light and
gushlike (having set in during past three months). No edemas. HCl
absent ; sarcina- in addition to lactic-acid bacilli,
ad 8. — Beginning: November, 1901.
Status presens : January 16, 1902.
Autopsy: March 9, 1902.
Duration: 4 months(.'*).
ad 9. — Autopsy (Professor Ur. A. Ghon) : Scirrhus of the pylorus,
probably an ulcer base, with stenosis. Flat scirrhus infiltration of the
peritoneum and omentum.
Epicrisis: Here we have the unusual case of a "stomach weakling"
contracting cancer of the stomach. This is much more frequent in
"stomach athletes," so much so that one is often tempted to say : Gastric
cancer is a disease of "healthy people."
The anatomist suspects a pre-existing ulcer, clinically there is no
typical history of an ulcer, yet it might be possible that the sensitive-
ness of the stomach, extending over many years, has some connection
with a latent, cicatricized ulcer.
Edemas do not usually appear^ — not even terminally — in connection
with fibrous cancer of the pylorus and copious vomiting. The profuse
vomiting leads to desiccation of the organism.
The tolerance for meat remaining up to within a few months of death
is remarkable.
Case 28. — J. N., 51 years, M.
ad 2. — A weak individual.
ad 3. — No infectious disease.
ad 4. — Constipated for past seven years.
ad 5. — No alcohol; heavy smoker (pipe).
ad 6. — In November, 1901, loss of appetite and slight pains in
the upper abdominal region ; formerly sour eructations now and then.
While carrying a trunk, pressed same against the belly, producing sharp
pains in the epigastrium. Epigastrium somewhat tender on pressure,
otherwise no pain. Great thirst during past five weeks.
ad 7. — Tongue heavily coated. Epigastrium distended, especially
on the left side, where there is tensely elastic consistence, loud splashing.
Cancer nodules palpable in the epigastrium. Waxy yellow color of the
face. No edema. Loud venous hums.
Stomach contents: HCl negative, enormously abundant lactic-acid
bacilli.
ad 8. — Beginning: November, 1901.
Status presens : March 3, 1902.
Duration: 4* months(?).
Epicrisis: Great thirst is not infrequently met with in gastric cancer;
196 TUMORS OF THE ABDOMINAL VISCERA
the symptom deserves consideration in so far as gastric neuroses are
frequently accompanied by a strikingly diminished feeling of thirst.
A trauma, pressing against a trunk, in this case elicited epigastric
pain, evidently at a time when the carcinoma already existed (November,
1901). It is indeed not rare that traumas permit neoplasms, hitherto
more or less latent, to manifest themselves.
Case 29.— F. W., 65 years, M.
ad 3. — No I. D. C. In 1887 left-sided pleurisy for six weeks.
ad 4. — Five years ago loss of appetite with sour eructation and
vomiting after ingestion of meat. A swelling is said to have existed
between the left costal arch and the navel, but which subsequently
disappeared; at the same time pain posteriorly in left lumbar
region.
ad 5. — Otherwise always health3\
ad 6, — Since November, 1901, sour burning eructations. Vomit-
ing, especially two to three hours after eating, frequently also at 3 a.m.
Constipation since this illness started. Often a sensation of "rolling"
in the stomach. Appetite would be good, but he was afraid to
eat.
ad 7. — Doughy, firm consistence at a place corresponding to the
pylorus, of varying distinctness. Left half of the epigastrium distended
with meteorism. Evidence of atelectasis posteriorly, lower left side,
traces of retromalleolar edema.
Stomach contents: Traces of HCl, severe stagnation, abundant sar-
cinae, besides lactic-acid bacilli.
ad 8. — Beginning: November, 1901.
Status presens: March 17, 1902.
! Operation: March 23, 1902.
Duration : About 5 months.
ad 9.— Operation (Docent Dr. P. Albrecht) : Carcinoma of the
stomach, corresponding to the posterior portion of the pylorus and the
posterior wall of the stomach along the lesser curvature ; at the latter
place adherent to the left lobe of the liver; wall of the stomach at this
site shows cicatricial changes; contracted; probably cancer in a cicatrix.
Gastro-enterostomy. Dismissed as cured April 7, 1902.
Epicrisis : The previous history of the case would seem to justify the
opinion of the operator that the carcinoma was superimposed on an ulcer
base.
In 1897, five years prior to surgical interference, there was present
a disease which, in view of the then existing swelling, anorexia, meat
intolerance, etc., could easily have been mistaken for a carcinoma. It
is highly probable that it was an ulcer tumor of inflammatory origin.
Evidences of atelectasis in the region of the left lower lobe are not
rarely met with in connection with gastric cancer, and very likely are
explained by the high position of the left half of the diaphragm as a
result of g-astric meteorism.
CARCINOMA OF THE STOMACH 197
Case 30. — J. R., 50 years, M. Clerk.
ad 1. — Father reached high old age.
ad 3.— No I. D. C.
ad 4. — Gastric comphiints for past three years.
ad 5. — Always was healthy; transient sciatica-like pains in 188.5.
ad 6. — Since autumn of 1901, increase of gastric complaints;
since then anorexia and severe emaciation. At present cramp-like pains,
especially after eating, radiating from the epigastrium into the left
lumbar region and upward along the sternum ; at the same time in-
creased tension in the left half of the epigastrium (gastric peristalsis).
Severe sensation of pressure after eating meat, also pains in epigastrium
when straining hard at stool.
ad T. — Tongue not coated. Large cylindrical tumor on the left
side, below the costal arch. Frequent hiccough. No edemas. Spleen
distinctly palpable.
Stomach contents: Very abundant, short lactic-acid bacilli,
ad 8. — Beginning: Autumn, 1901.
Status presens : June 2, 1902.
Operation: June 8, 1902.
Autopsy: June 10, 1902.
Duration: About 9 months(.'').
ad 9. — Autopsy (Docent Dr. J. Bartel) : Carcinoma of the pylorus
encroaching on the lesser curvature upward almost to the cardia, down-
ward to the middle of the greater curvature. Resection of almost entire
stomach.
Epicrisis: This case affords occasion for pointing out the fact that
infectious diseases of childhood in particular are strikingly seldom re-
corded in the history of cancer patients. There will be repeated oppor-
tunities for emphasizing this point.
"Colics of pyloric stenosis"^- prevail in the ensemble of subjective
phenomena. "Lactic-acid bacilli" are present in abundance, but not in
the usual form of long threads, rather as Gram-positive rod-shapes
("dwarf forms"), a morphological type occasionally also found in cul-
tures on sugar agar, particularly when the nutritive medium is dry.
The colonies are then circular and do not exhibit the t^'pical curled
border reminding one of anthrax colonies.
Case 31.— H. J., 38 years, M. Miner.
ad 2. — Tubercular habitus.
ad 3. — No I. D. C. At 17 had pneumonia for 5 weeks.
ad 5. — Frequent sufferer from pulmonary catarrh and morning
sweats (autopsy: lungs normal).
ad 6. — June, 1900: Pressure in stomach after eating meat, loss of
appetite; mild constipation. Epigastrium tender. Condition became
improved.
'- See page 70.
198 TUMORS OF THE ABDOMINAL VISCERA
December, 1901 : Repetition of same manifestations. Condition much
improved.
April, 1902: Tho,se around him became aware of the ill-smelling
vomitus. Bowel movements improved the appetite. Vomiting two to three
hours after ingestion of food. No tenderness to pressure under the left
costal arch.
Beginning of May, 1902: Copious discharge of mucus at stool.
June 10, 1902: Sudden violent cramplike pains around the umbilicus,
abdomen very rigid, dulness in the flanks, tenderness on pressure (au-
topsy: perforating peritonitis).
ad 7. — Tongue moist, somewhat coated. A hard, nodular tumor-
mass can be felt under the left costal arch, but only with patient in right
lateral position. Liver larger and harder (autopsy: fatty liver). Severe
edema of right lower extremity. No vomiting, hardly any eructation.
Withdrawal of stomach contents 3Melds fecal content with bacterial
\egetations.
Blood: •i,.500 leucoc3ftes. Hemoglobin, 40 'X .
ad 8. — Beginning: June, 1900.
Status prescns: June 5, 1902.
Autopsy: June 11, 1902.
Duration : About 2 years,
ad 9. — Autopsy (Professor Dr. O. Stoerk): Extensive carcinoma
of the greater curvature in the fundus of the stomach and wide perfora-
tion into the splenic flexure. Recent perforation of the colon in this
region through its wall infiltrated with carcinoma into the abdominal
cavity with beginning peritonitis. Metastatic infiltration of the omen-
tum ; here and there liver metastases. Fatty infiltration of the liver of
high degree.
Epicrisis: Transient improvements in the gastric complaints, as in
this case, do not belong to the rare occurrences in the course of a gastric
cancer. Ignorance of this fact may permit them to mislead one, causing
the abandonment of suspicion, probably correct in the first place. It
must never be forgotten that the functional disturbances of the organ,
occurring in connection with gastric cancer, are in many ways not directly
due to the cancer as such, but are brought about through pyloric steno-
sis, chronic gastritis, constipation, etc. These, however, are variable and
may show improvements. Thus, the pyloric stenosis may become less
through ulceration of the constricting tumor, the chronic gastritis and
the constipation are partly amenable to therapy.
Thus we have here also the statement of the patient that the appetite
improved wdth the occurrence of diarrheas.
Spontaneous diarrhea is not a frequent occurrence in gastric cancer;
if accompanied by copious discharge of mucus, as in the case at hand,
they w^ould suggest the possibility of a secondary participation on part
of the colon (gastro-colonic fistula) ; the same holds good of fecal vomit-
ing with the microscopic finding of bacterial vegetation. Only in severely
ulcerating soft gastric cancer is the latter occasionally met with without
the existence of a communication with the bowel. Strange, yet easily
CARCINOMA OF THE STOMACH 199
explained by tlic discovery of a gastro-colonic fistula, was in this case the
inability to obtain a clear reflow. Diffuse uniform enlargement of the
liver with moderate increase in consistence may also be due to fatty
infiltration.
Case 32. — I. E., 68 years, M. Coppersmith,
ad 3— No I. D. C.
ad 5. — Always was healthy.
ad 6. — Since June, 1901, diminished appetite. December, 1901 :
intolerance for cooked beef and strongly seasoned foods; since has no-
ticed a tumor in the abdomen, which is painful only on pressure; since
this time there often is eructation, no vomiting. Severe emaciation of
late.
ad 8.^ — Nodular tumor-mass in the epigastrium. Pronounced pul-
.satory vibration of same, disappearing entirely in the left lateral posi-
tion. Edemas existed formerly when the patient was walking about.
Stomach contents: HCl negative, vomitus contained blood, abundant
lactic-acid bacilli.
ad 9. — Beginning: June, 1901.
Status presens : June 8, 1902.
Duration: About 1 year.
Epicrisis: The disappearance of the intense pulsatory vibration in the
epigastrium in the left lateral position is explained by the displacement
of the movable epigastric tumor-mass belonging to the stomach, which
transmits aortic pulsation to the belly-wall only when the patient is lying
on his back. If the tumor-mass were firmly attached rctropcritoneally the
lateral position w^ould produce no change.
The edemas in this case are latent ; they have regressed since the
patient remains in bed.
Case 33.— G. B., 63 years, M.
ad 3. — Thirty years ago had a left-sided pleurisy, lasting 8 days.
ad 4. — Always had a very good appetite.
ad 5. — Always healthy.
ad 6. — Beginning of complaints, June 26, 1902; pressure in the
region of the stomach, located on the right side, especially after ingestion
of food. Symptoms became aggravated during the following two months.
Appetite at the start perfectly good, even meat being well tolerated.
No eructations. Bowels regular. Two months later anorexia and belch-
ing of SHj. Pressure in stomach, particularly after intake of evening
meal, lasting until 2 a.m., pains radiating into both hypochondriac re-
gions. Great intensity of pains with left lateral position. Dorsal de-
cubitus tolerated best. Of late the patient can partake only of soup
and eggs.
ad 7. — Tumor as big as an apple in the right half of the epigas-
trium, demarcation from liver not possible (surgical diagnosis: cyst.'').
Pigmented spots on mucous membrane of both cheeks.
Stomach contents: HCl negative; abundant lactic-acid bacilli.
200 TUMORS OF THE ABDOMINAL VISCERA
ad 8. — Beginning: June, 1902.
Status presens : October 22, 1902.
Operation: November 1, 1902.
Autopsy: November 4, 1902.
Duration : About 5 months,
ad 9. — Operation (Docent Dr. D. Pupovac) : Large cancerous
tumor on the posterior wall of the pylorus, adherent to the liver, pancreas
and transverse colon.
Autopsy: Confirmation of above finding (disintegrating medullary
carcinoma).
Epicrisis: Prolonged SH2 fermentation (eructation giving the odor
of "rotten eggs") is always a sign of an organic lesion, and very fre-
quently coincides with the presence of sarcina ventriculi, upon which in
my opinion this kind of gastric fermentation depends in most cases. It
is above all in benign pyloric constrictions succeeding ulcer of the stom-
fich that there is subjective complaint of SH2 and objective finding of
sa.rcina ventriculi.
However, malignant stenosis also may be accompanied by the same
subjective and objective finding.
The aggravating effect on the pain with left lateral position, though
the process is localized at the pylorus, is worth}' of note. It is conceiv-
able that the gastro-hepatic adhesions in this case play an essential part.
Case 34.— M. W., 59 years, M.
ad 4. — Appetite formerly always good.
ad 6. — Since November, 1901, anorexia and fre(juent eructation of
"sour water" ; no vomiting. Had to be careful in his diet during the
past weeks. Three weeks ago there began "internal" pains in the left
half of the epigastrium; 14 days ago the skin in this locality became
reddened and in the course of a few days there developed a swelling as
big as a fist, bulging outwardly. Frequent attacks of dizziness, severe
emaciation of late.
ad T. — Bulging, the size of a fist, in the left half of the epigas-
trium, belonging to the abdominal wall, protruding on coughing, fluctu-
ating distinctly in one place; no respiratory movability. Distinct thrill
with pulsation. Skin in bulging area firmly infiltrated, hot, red ; edema
in the neighborhood. Over the top of the swelling a high tympanitic
sound, which disappears in lateral position ; splashing audible and palpa-
ble here and there on percussion. Traces of retromalleolar edema. Slight
elevation of body temperature.
ad 8. — Beginning: November, 1901.
Status presens: November 11, 1902.
Operation: November 13, 1902.
Autopsy: November 18, 1902.
Duration : About 1 year.
ad 9.- — Autopsy (Professor Dr. A. Ghou) : Putrificd and ulcer-
ating carcinoma of the lesser curvature of the stomach, near the p^dorus,
with constriction of the pyloric portion ; adhesion of the lesser curvature
CARCINOMA OF THE STOMACH 201
with the border of the left lobe of the liver and perforation of the
carcinoma. Putrifying, subphrenic abscess in the area of the left lobe
of the liver and the spleen. Putrifying phlegmon of the retroperitoneal
connective tissue of the left side of the abdomen and testicle. Arterio-
sclerosis of high degree. Aspiration of the subphrenic abscess.
Epicrisis: In this case ^^ we were dealing with a subpiirenic, gas-
containing putrefactive process in the epigastrium preparing to dis-
charge outwardly, emanating from a gastric tancer. Hasty examination
might in such cases easily lead to the diagnosis of abscess of the abdom-
inal wall, in this way overlooking the more deeply seated origin.
Case 35. — L. F., 49 years, M.
ad 1. — Father and mother died of old age.
ad 3. — In 1891 pain in limbs and head, with fever ("influenza").
ad 4). — In 1893, 10 j-ears ago, on getting up in the morning very
profuse vomiting of red blood; gastric ulcer was assumed present. Black
coloration of stools. No gastric pains. Cured in 8 weeks. Patient
then remained healthy until autumn of 1899. Preference for sour foods.
ad 5. — In autumn of 1899 repeated gastric complaints, feeling of
pressure about one hour after meals and moderate acid eructations.
Particular intolerance for potatoes and cereal foods. Anorexia. Com-
plaints disappeared only in March, 1900. From the autumn of 1900
to ]\Iarch, 1901, and again from the end of 1901 to the early part of
1902, repetition of the same SA^nptoms. In spring of 1902 quite well
again.
ad 6. — November, 1902, beginning of anorexia, accompanied by a
constant feeling of fulness in the stomach. No vomiting. In January,
1903, "gastric catarrh" was diagnosed and Karlsbad cure prescribed.
As long as he took the cure had to vomit profusely in the evening, the
vomitus being like coffee-grounds. After 8 days stopped drinking Kai'ls-
bad water and the vomiting ceased. During the painful attacks the
right lateral decubitus is badly tolerated ; sour, rancid eructation after
eating.
ad 7. — Hard, uneven tumor at the pj^lorus, visible gastric rigidity.
Pulse 54.
Stomach contents: "Coffee-grounds," HCl negative, abundant lactic-
acid bacilli. Melena.
ad 8. — Beginning: November, 1902.
Status presens : March 13, 1903.
Duration: About 4< months(.'^).
Epicrisis: Longevity of parents. This is a statement recurring fre-
quently in the previous history of cancer patients. In this case there is
a clear historj^ of ulcer dating back ten A^ears with numerous intervals
free from symptoms and repeated relapses. It is one of those forms
of ulcer in which the clement of pain is more or less absent, prone to
"See R. Sepc/eL Uber die Mitheteiligung der vorderen Bauchwand beim Magencar-
cinom. Miinchener med. Wochenschr., 1898, page 664.
202 TUMORS OF THE ABDOMINAL VISCERA
hematemesis in the midst of good health, and in which, pain not being
present to act as a deterrent, traumatic injuries may very easily come
about through ingested food.
This case is another illustration of the ominous erroneous diagnosis
of "gastric catarrh." The imbibition of Karlsbad water in this case
provokes continued "coffee-ground" vomiting.
Case 36. — S. B., 60 years, M. Forester.
ad 1. — Father and mother re<ached the age of 70; father died of
pulmonary tuberculosis.
ad 2. — Always frail, which exempted him from military service.
Otherwise healthy up until 1879. In November, 1902, and February,
1903, suffered from "gouty" complaints in the left, later also in the
right foot.
ad 3. — No infectious diseases.
ad 4. — In 1879, he suffered from loss of appetite, disgust for
meat and severe emaciation ; at that time twice vomited enormously pro-
fuse quantities of richly brown-colored mucoid material. Disease passed
over painlessly. Subsequently could tolerate everything very well ; in
fact, had a very good stomach ; "I could have eaten stones and lead."
Bowels also were regular.
ad 6. — In November, 1902, patient noticed distention of the gas-
tric region, had feeling of pressure after intake of nourishment. This
lasted until February, 1903. Then there set in eructations with the
odor of decomposed eggs (SH2), loud, "like the whistle of a locomotive."
"Erection" of the stomach, severe constipation. Disinclination toward
meat, desire for farinaceous foods, which formerly he did not like. On
account of the occurrence of severe flatulence, he cannot take the latter.
No pain.
ad 7. — The indistinct tumor can be felt, corresponding to the py-
lorus. Distinct gastric peristalsis, painless, appearing especially on mov-
ing about. Mild intestinal peristalsis also visible. Yellowish coloration
of the face, no edemas, severe emaciation. Since three weeks ago profuse
vomiting every third da}', often at night.
Stomach contents: "Coffee-grounds," abundance of lactic-acid bacilli.
ad 8. — Beginning: November, 1902.
Status presens: May 27, 1908.
Operation : June -1, 1903.
Autopsy: June 16, 1903.
Duration: About 8 months.
ad 9. — Operation (Docent Dr. D. Pupovnc) : A carcinoma, taking
in the pylorus and lesser curvature, adherent to the under surface of the
liver and the head of the pancreas.
Autopsy (Professor Dr. A. Glion) : Ulcerating, infiltrating cancer of
the pylorus. Gastro-enterostomy June 4.
Epicrisis: In November, 1902, therefore synchronous with the first
symptoms of the developing cancer, "gouty" symptoms are said to have
appeared in the left foot.
CARCINOMA OF THE STOMACH 203
It is c'liiiic'.illv certain that exogenous irritants take ])art in the causa-
tion of cancerous proliferations. The assumption lies close to liand also
that endogenous irritants exerted through their chronic effect on the
body secretions by metabolic anomalies, may act similarly as an etiologi-
cal factor.
Here also is the case of a "stomach athlete." "Stones and lead I
could have eaten." Similar expressions are frequently heard from cancer
patients.
The belching of gas in this case is of an explosive character ("like
the whistle of a locomotive"), more frequently observed in gastric neu-
roses (aerophagic, etc.).
The odor of the belched gases (SH2) guards against confusion.
Case 37.— B. M., 47 years, M. Contractor.
ad 1. — Parents lived to old age; 8 brothers and sisters healthy.
ad 2. — Very corpulent, 102 kg before being taken sick.
ad 3. — No infectious diseases ; no lues.
ad 4. — Foods difficult to digest always well borne; preference for
very sour and highly seasoned foods, also liked hot foods. Bowels always
regular.
ad 5. — Never was sick.
ad 6. — At Christmas, 1902, still well, could eat and drink any-
thing. Constipation had set in some time before Christmas (formerly
quite regular). About New Year's, 1903, the appetite diminished, 14<
days later already "coffee-ground" vomiting and black stools. Pressure
in stomach, especially after eating meat, and that, immediately after
eating. The patient became pale and rapidly emaciated. Early in May,
1903, Karlsbad Miihlbrunn and Sprudel salt were prescribed for one
month. The condition became worse. Frequent eructation with very
sour taste. Since the beginning of the vomiting, pains, especially under-
neath the right costal arch.
May, 1903 (after Karlsbad cure) : Severe pains radiating from the
epigastrium upward to the middle of the sternum, and especially to the
right over the region of the liver.
June, 1903: Pain, especially to the right, in the epigastrium, from
there extending upward over the lower anterior portions of the thorax,
where there is an internal "feeling of heat," a sort of "raging," particu-
larly before vomiting and after eating. Right lateral position impos-
sible during attack of pain.
ad 7. — Tumor-masses in the region of the liver and underneath the
border of the liver. "Peritoneal" friction in the epigastrium, especially
during expiration. Pale yellow coloration of the face (without icterus)
since January, 1903. No edemas. Frequent profuse vomiting of "cof-
fee-ground" masses without HCl, with abundant lactic-acid bacilli.
ad 8. — Beginning: December, 1902.
Status presens : June 6, 1903.
Duration : About G months.
204. TUMORS OF THE ABDOMINAL VISCERA
Epicrisis: Constipation, where formerly the bowels were regu-
lar, seems to have been the first symptom of beginning cancer of the
stomach.
The subjective symptoms, such as "colics of pyloric stenosis," come
prominently into the foreground.
An important physical sign, the determination of which is too fre-
quently forgotten in abdominal diseases, is "peritoneal" friction in the
epigastrium.
Case 38.— M. F., 56 years, F.
ad 2. — At 9 years of age attacks of headache on right side with
"cramps of the jaw," particularly when excited; improved on bromides.
Otherwise was always healthy.
ad 3. — No infectious diseases.
ad 6. — In the spring of 1901, beginning of stomach coniplaiiils ;
after ingestion of food, pressing pains, radiating from the epigastrium
toward the esophagus, especially if moving about immediately after meals.
Decrease of appetite ; no vomiting, no eructation.
October, 1902: Great sensitiveness to pressure in the abdomen on the
left side, constipation, could eat almost nothing. Operation in the clinic
of Hofrat Professor Dr. K. Gussenhauer.
March, 1903: Must vomit everything. In October, 1902, pricking
pains in left great toe (Autopsy: Atheromatosis of the anterior tibial
artery), accompanied by feeling of cold. June, 1903, these complaints
are so bad that the patient cannot sleep. The pain extends up to the
ankle-joint. The pains set in especially after moving. The left foot feels
colder, livid discoloration. Slight relief while rubbing the painful places
with the hand.
ad 7. — Extensive tumor-mass underneath the left costal arch.
Lingual nmcous membrane slightly atrophic at the lateral borders. Pale
yellow coloration of the face (without icterus), no edemas.
ad 8. — Beginning: About March, 1901.
Status presens: flunc 9, 1903.
Autopsy: June 24', 1903.
Duration : About 2 years, 3 months.
ad 9. — Autopsy (Professor Dr. 0. Sfoerk) : Flat, ulcerated carci-
noma, involving the entire region of the pylorus. Severe atheromatosis
above the bifurcation of the aorta ; at the latter place thrombus forma-
tion. Atheroma of high degree of both crural arteries; the left ante-
rior tibial artery especially seems to be greatly affected and throm-
bosed.
Epicrisis: Remarkable are the great atheromatous changes in the ab-
dominal aorta and in the arteries of the legs discovered at autopsy ; clin-
ically, the symptoms of an impending gangrene of the toes stand promi-
nently in the foreground. It is conceivable that the endogenous injuries
which produced the severe vascular diseases might also take part in the
causation of the cancer development.
CARCINOMA OF THE STOMACH 205
Case 39. — F. K., 39 years, M. Dairyman.
ad 1. — Fnther died at 50 of pulmonarv tuberculosis.
ad 2. — Between the ages of 12 and 15 had one "epileptic" attack
every month.
ad 3. — No infectious diseases in childhood. At 18 had malaria
for 3 months (lived on the Thaya). At 20 years of age iiad pneumonia
for 6 weeks. In 1902 had erysipelas for 3 months. Two years ago lues
(treatment by mouth and by injections).
ad 4. — Always had a very good stomach, tolerating also fat, bow-
els regular. Preference for sour foods.
ad 5. — Heavy smoker and drinker.
ad 6. — In September, 1902, beginning of gastric complaints. In
the morning on a fasting stomach heartburn and sour eructation, stool
was formerly regular, now at times constipated, at times diarrhcic. In
February, 1903, the patient started vomiting, in the beginning only after
the noonday meal, two or three times during the week, later on also
after breakfast and after the evening meal. In March, 1903, cutting
pains in the umbilical region, radiating from there horizontally to the
right and left, especially on a fasting stomach in the morning and after
vomiting also at night. Since April, 1903, pain especially when turning
about to the right, a feeling as if something becomes displaced to the
right. Right lateral position impossible during an attack of pain. In
June, 1903, intolerance for milk and fat foods. No disgust for meat.
Appetite not bad.
ad 7. — A hard, rough tumor as big as an apple somewhat to the
right and above the navel ; gastric peristalsis visible. Now. and then also
intestinal peristalsis above Poupart's ligament. No edemas. Pulse under
60. Vomiting usually ten minutes after intake of food. HCl negative.
Abundant lactic-acid bacilli.
ad 8. — Beginning: September, 1902.
Operation: June 27, 1903.
Duration: About 10 months.
ad 9. — Finding at operation (Docent Dr. D. Pupovac) : Tumor
(cancer) of the pylorus, about the size of a child's fist; adhesion of the
anterior surface of the stomach to the transverse colon. Retroperitoneal
gland metastases at the upper border of the pancreas (gastro-enteros-
tomy retrocol).
Epicrisis: Disturbances of formerly regular bowel evacuations (con-
stipation alternating with diarrhea) count also in this case among the
initial manifestations.
No disgust for meat, no anorexia (June, 1903!). Very definite pain-
ful position of the right side corresponding to the localization at the
pylorus.
Also in this case of pathologically increased and visible gastric peri-
stalsis there could be noticed peristalsis of the bowel. ^^
" See Jiiige 84.
206 TUMORS OF THE ABDOMINAL VISCERA
Case 40.— J. B., 64 years, M.
ad 2. — In December, 1902, pains in the right shoulder-joint; had
to stay in bed for 14 days.
ad 3. — No infectious diseases in childhood. In 1893 had "bloody
dysentery" for 8 days.
ad 4. — No gastro-intestinal disturbances. Bowels always regular;
hemorrhoids for some years.
ad 5. — Always was healthy.
ad 6. — In December, 1902, whilst still enjoying good appetite, the
bowels began to be tard}^ movements obtainable only through irrigation.
Straining at stool alreadj^ at that time accompanied by pressing pains
in the epigastrium. Soon after eructation, feeling of distention, disgust
for boiled beef, sensitive to strong odors. Condition made worse b}- cures
in Karlsbad and Luhatschowitz. Since the end of June, 1903, severe
emaciation; since then also a feeling of pressure in the epigastrium to-
gether with a sensation "as if wind and stool must come through the
mouth." Moist compresses cause discharge of wind and afford relief. In
right lateral position increase of the pressing pains, raising of the lower
abdominal region upward brings relief.
ad 7. — A transversely running sausage-shaped resistance in the
region of the pylorus palpable now and then. Abdomen sunken. Pale
yellowish coloration of the face (without icterus). Vomiting only of late.
Frequently about half a spittoonful of mucoid glassy fluid without odor
or taste is discharged through the mouth.
Stomach contents: HCl negative; sarcina> and rather abundant very
long lactic-acid bacilli.
ad 8. — Beginning: About December, 1902.
Status prescns: Julv 27, 1903.
Operation : July 29*, 1903.
Autopsy: August 13, 1903.
Duration: About 7 months,
ad 9. — Operation (Clinic Hofrat Professor Dr. A'. Gussenhauer) :
Very large carcinoma at the pylorus, adherent to the liver. No ascites.
Gastro-enterostomy performed with difficulty.
Autopsy (Professor Dr. A. Ghon) : Infiltrating carcinoma of the py-
lorus (scirrhus) with much constriction. Secondary carcinoma of the
serosa in the region of the diaphragm.
Epicrisis: Constipation following formerly regular bowel movements
as an initial symptom !
Similar to some cases of ulcer the presence here of carcinoma provokes
pain in the epigastrium when the abdominal wall is brought into action
(straining at stool). Right "painful position."
The vomiting of surprisingly large quantities of mucous (odorless and
tasteless) is worthy of note.
Case 41. — B. J., 46 years, M. Day laborer.
ad 1. — Parents died of pulmonary' tuberculosis. Five brothers and
sisters are alive and well.
CARCINOMA OF THE STOMACH 207
ad 3. — No infectious diseases.
ad 5.— During ciiildhood, and also later, always healthy; moderate
drinker, heavy smoker; tiie present disease is his first.
ad 6. — He says that in the autumn of 1901 he spoiled his stomach,
and since then on and off has indefinite diffuse pains in the rl'gion of the
stomach, vomited several times. Otherwise felt quite well. Only in March,
1902, the appetite became worse. The patient began looking pale. Con-
stant uncomfortable feeling in the epigastrium, witiiout being particularly
influenced by ingestion of food. In the beginning of the disease moderate
eructation, no heartburn. Nausea without vomiting. The patient worked
until Christmas, 1902, at which time he noticed a swelling of the feet,
about the ankles. In the summer of 1903 the stools became diarrheic,
since then four to five bowel movements daily. Since June, 1903, tiie legs
are edematous ; the patient has lost but little in weight. No actual pains,
ad 7. — Tongue coated, nmcous membrane slightly atrophic. A
tumor-mass, the size of an apple, on the right above the navel ; over it
tympany, as also over the region of the liver. Very severe, soft, pale
edema in the lower extremities, on the back and especially in the scrotum ;
also edema of the belly-walls.
Stomach contents: Abundant bacterial flora, consisting of bacteria
coli, lactic-acid bacilli and sarcinjB (sporadic). HCl negative,
ad 8. — Beginning: Autumn, 1901.
Status presens : August 4, 1903.
Duration: About 2 years.
Epicrisis: So frequently the case, absence of infectious diseases in the
previous history ! This case belongs to the "anemic-hydropic" type of
gastric cancer.
We are dealing with a soft ulcerating carcinoma at the pylorus with-
out much constriction. Therefore the element of pain is almost absent
and the subjective symptoms on the part of the stomach, despite the large
size of the tumor, are slight.
Colon bacilli, in large quantity, is a frequent finding in just these soft,
severely ulcerating forms of gastric cancer; no doubt it takes part in the
formation of lactic acid.
Case 42. — J. W., 35 years, M. Farmer.
ad 1. — Father died at 60 years of age from stomach and liver dis-
ease (Ca.'*). Mother, brothers and sisters are healthy.
ad 2. — At from 15 to 16 years of age often had nose-bleed (dura-
tion up to one day) especially in summer; after marriage this is said to
have stopped.
ad 3. — When 12 years old had malaria from May to October; sub-
sequently always well.
ad 4. — Stomach always very good, could tolerate everything; liked
to eat hot foods.
ad 5. — Heavy drinker and smoker.
ad 6. — In March, 1903, appearance of pains in the epigastrium,
partly at night, partly during the day. Epigastrium became sensitive
208 TUMORS OF THE ABDOMINAL VISCERA
to pressure; constipation. Three weeks after appearance of pain the
appetite became less. Meat was no longer tolerated, only milk and soup.
Bowels often did not move for a week. Until August, 1903, no vomiting,
often sour, bitter, ill-smelling eructation. Bitter taste in the mouth.
Now and then slight bulging in the epigastrium accompanied by bor-
borygmi. In the beginning the pains were somewhat assuaged after
drinking coffee or sour wine. Later on were continuous night and day.
Increase of pains, especially in right lateral position.
ad 7. — No distinct tumor palpable. Frequent squirting sounds in
the pyloric region, pyloinis not particularly sensitive to pressure. No
edemas. Severe anemia: erythrocytes 1.2 millions, Hgb. 207c, leucocytes
6,100, pulse 10-1, venous hums. "Coffee-ground" vomiting, abundant
sarcin.T and yeast. HCl negative,
ad 8. — Beginning: March, 1903.
Status presens: August 8, 1903.
Operation: August 14-, 1903.
Duration: About 6 months,
ad 9. — Operation (Docent Dr. D. Pupovac) : Pyloric carcinoma
fixed to the pancreas. Glands affected.
Epicrisis: Gastralgias mark the clinical beginning of the disease,
anorexia following afterward. Constipation (absence of bowel movements
for a week) in this case counts among the early symptoms.
Right-sided "painful position."
The use of coffee or sour wine affords relief from pain in the begin-
ning, probably by promoting evacuation of the stomach.
The subsequently existing continuous pains, uninfluenced by intake
of food, might be due to encroachment of the tumor on the pancreas.
Case 43. — F. D., 72 years, M. Coachman.
ad 1.^ — Several children died of tuberculosis.
ad 3. — No infectious diseases.
ad 5. — Never was sick — except for a "cold," after which severe
catarrh, and since then frequent coughing. Heavy drinker. Pain over
the lower portion of tiie sternum and in the epigastrium on walking.
Anorexia.
ad 7. — Numerous hard glands in the right supraclavicular fossa.
Left pulmonary apex slightly dull, with few, moist rales. Left brachial
plexus very sensitive to pressure. Cachectic color of the face; no edemas.
ad 9. — Autopsy, November 9, 1903 (Hofrat Professor Dr. A.
Weicliselhaum) : Nodular and infiltrating carcinoma of the stomach with
metastases in the lesser and greater curvatures, in the large omentum, in
the mesenteric and retroperitoneal as well as in the right bronchial and
supraclavicular lymph-glands. ^Metastases in the pleura on both sides.
Small partial aneur^^sm of the heart with atheroma of the coronary
arteries.
Epicrisis: In this case during life the possibility of a pulmonary
carcinoma was thought of. ^Metastasis in the right supraclavicular glands
CARCINOMA OF THE STOMACH 209
is very unusual in connection with gastric cancer. In this case it may
by explained by hii abnormal right-sided course of the thoracic duct.^'
Besides right-sided involvement of the glands there was also involve-
ment of the pleura. Apical dulness, due to fibrous tuberculosis, is not
a rare finding in gastric cancer, and this finding may easily be mislead-
ing, the more so, as gastric disturbances often accompany tuberculosis.
Case 44.— 0. A., 62 years, F.
ad 1. — Parents died in advanced age.
ad 3. — No infectious diseases.
ad 4. — Never had stomach complaints.
ad 5. — Had 12 children, of whom 3 only are living. She herself
was never sick.
ad 6. — In January, 1903, cramp-like pains started underneath the
right costal arch, radiating into the right back. Appetite became worse.
In August, 1903, had to vomit several times. Very painful attacks in
the beginning, often 5 to 6 times a day, lasting 2 to 3 hours. In the
beginning the attacks came on daily, since 2 months ago has no more
pains. For the past 5 or 6 months rather pressing pains in region of
the tumor. There might be an appetite, but the patient is afraid to eat.
ad 7. — Tumor the size of an apple, in the region of the pylorus
(noticed since August, 1903). The tumor shifts spontaneously, now
somewhat to the right and then somewhat to the left, with left lateral
position, becomes displaced to the left. On making pressure over the
tumor the gastric contents escape from above. Since two months ago
frequent vomiting; bowels constipated.
Stomach contents: "Cofifee-grounds," HCl negative, abundant lactic-
acid bacilli.
ad 8. — Beginning: January, 1902.
Status presens : December 30, 1903.
Duration : About 1 year.
Epicrisis: The previous history, as is so frequently the case, yields the
trio: "Never any infectious disease; never any disease at all; stomach
always in perfect condition !"
A "colic of pyloric stenosis" (type of "pseudo-gall-stone colic")
introduces the disease. Then there follows the deceptive remission of
the pain phenomena. In some cases this is explained by the freeing of
the pyloric passage as a result of ulceration ; the cessation of HCl secre-
tion also enters into consideration, the development of the cancer having
the same effect as continued large doses of soda bicarbonate ; finally the
preservation of the stomach, involuntarily effected by the increasing
anorexia, must also be taken into account.
Spontaneous wandering of tumor-masses in the epigastrium are, in and
of themselves, a fairly certain indication that they belong to the stomach,
and their diagnosis may be very important in order to differentiate them
from firmly fixed tumors of the liver.
^^Hosch, Grenzg. der Med. und Chir., Vol. 18, page 489.
210 TUMORS OF THE ABDOIMINAT. VISCERA
The wandering is explained by the changed condition of distention
of the stomach and perhaps also of the transverse colon.
The patients themselves often call attention to the fact that at dif-
ferent times they feel the tumor in different places.
Also the fact that pressure upon the tumor leads to immediate regurgi-
tation upward, makes the diagnosis of the swelling certain.
Case 45.— B. K., 65 years, F.
ad 2. — Between the ages of 17 and 2-i there were present nmltiple
small ulcers on both lower extremities, which issued from small infiltra-
tions. Had six children, abortion in the third month only with the
seventh.
ad 3. — No infectious diseases.
ad 4. — Stomach always very good ; only eggs were badly borne.
ad 6. — Since 1902, constipation, appetite became irregular. Since
November, 1903, now and then nausea and inclination to vomit; on and
off eructation having the odor of SH2 ; complete anorexia, continued con-
stipation; very often biliary vomiting. Pain in the belly on both sides;
increasing after ingestion of food, improvement after bowel movements.
Right lateral position better tolerated.
ad 7. — Tongue slightly coated. Belly distended, sensitive to
pressure ; ascites. Hard, uneven tumor-masses in the epigastrium.
Tumors varying from the size of a hazelnut to a walnut can be felt
through the posterior vaginal wall. Slight retromalleolar edema. Reflow
in gastric lavage very bloody. Never any "coffee-ground" vomiting.
Urine: Indican test (Obermeyer) strongly positive.
ad 8. — Beginning: 1902.
Status prcsens : January 25 and March 1, 1904.
Autopsy: March 19, 1904.
ad 9. — Autopsy (Decent Dr. K. Landsteiner) : Crater-like car-
cinoma immediately below the cardia with scirrhus metastases in the
peritoneum and omentum ; numerous liver metastases.
Epicrisis: One of those cases of gastric cancer in which there is also
present a positive gynecological finding (tumors palpable through the
posterior vaginal wall!). Mistakes may be made, especially in those
cases where the metastases take place in the ovaries.
As the neoplasm did not, as is usual, lie in the neighborhood of the
pylorus, but just below the cardia, vomiting of bile resulted, which is
not commonly observed in pyloric constrictions. Right lateral decubitus
is even better tolerated than left.
Case 46. — L. G., 42 years, M. Coachman.
ad 1. — No hereditary taint.
ad 3. — Varicella at 7 years of age; typhoid at 23 (8 weeks).
ad 4. — Never had gastro-intestinal disturbances.
ad 6. — About the middle of November, 1903, a feeling of pressure
came on in the epigastrium after every meal, especially after eating solid
CARCINOMA OF THE STOMACH 211
foods, disappearing three-fourths of an liour afterward. Intolerance for
boiled beef, sour wine and beer. No pain on a fasting stomach. Pain in
the epigastrium immediately after ingestion of food ; duration, one-half
hour.
Accompanying manifestation: belching of air with relief. No vomit-
ing, no nausea. Inci-ease of pain by being shaken up while riding in a
wagon and when in left lateral position. Such painful conditions until
January, 1904. From then on continuous pains in the left side of the
epigastrium not related to intake of nutrition. Turning from the back
to the side is painful. Changing over to the left side is almost impos-
sible. Appetite good until January, 1904.
ad 7. — Liver somewhat enlarged, tough, sensitive to pressure upon
percussion over the left lobe; a distinct systolic murmur audible over the
liver. Mild subicteric discoloration.
Urine: In the beginning urobilinogen only, later bilirubin also demon-
strable.
Blood: Leucocytes, 19,000. Hgb. 75%.
ad 8. — Beginning: November, 1903.
Status. presens : February 24, 1904.
Autopsy: March 5, 1904.
Duration: 3^ months (?).
ad 9. — Autopsy (Docent Dr. J. Bartel) : Scirrhus carcinoma of
the lesser curvature, central ulceration, diffuse and uniform carcinomatous
infiltration of the liver.
Epicrisis: The initial attacks of pain, elicited b}' intake of food, are
of gastric origin and are connected with the development of cancer in
the stomach itself.
The pains appearing toward the end of January, not affected by in-
take of food, are of hepatic origin and are probably referable to an
accompanying perihepatitis and capsular tension resulting from car-
cinomatous infiltration of the liver.
In such cases the patients are frequently compelled to assume the
dorsal decubitus, as the lateral positions, especially turning over to the
left side, cause most violent pain due to the pulling of the liver, which
has increased in weight, on inflammatory adhesions, suspensory ligaments,
etc. The process of infiltration in the liver also reveals itself on auscul-
tation by a systolic murmur, moreover by abundant elimination of uro-
bilinogen in the urine, later followed by bilirubinuria.
Case 47.— V. C, 63 years, M.
ad 1. — Mother died at 75 of old age.
ad 3.^ — At 18 had typhoid for 6 weeks; at 28, pneumonia for 2
weeks.
ad 5. — Since 2 years ago weakness in legs, for the past 3 years
paresthesias in the fingers (Autopsy: Syringomyelia). Heavy smoker.
ad 6. — Since ]\Iarch 21, 1904, feeling of pressure in the epigastrium
after eating. Aery slight subjective complaints during the entire course;
the patient eats meat up to the last.
212 TUMORS OF THE ABDOMINAL VISCERA
ad 7. — Hard, cylindrical tumor, transversely situated in the epi-
gastrium ; over it "snow treading" sound is palpable and friction can be
heard. Now and then eructation of "cofFee-ground" masses containing
abundant lactic-acid bacilli. Stubborn constipation. HC1.{ absent.
Urine: Usually over 2,000 cm a day.
Blood: Erythrocytes, 5,100,000; hemoglobin, 60% ; leucocytes, 4,200.
Edema of the lower extremities. Right calf hard, hot, painful.
(Autopsy: Thrombosis of the right crural vein.)
ad 8.- — Beginning: end of March, 1904".
Status presens: August 30, 1904.
Autopsy: December 22, 1904,
Duration: about 9 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Ulcerating carcinoma
of the pylorus and stenosis of same, together with adhesions to the
under surface of the liver. Secondary carcinoma of the regional lymph-
glands. Dilatation of the stomach. Induration of left pulmonary apex
from tuberculosis, left-sided walled-off cheesj'^ pleuritis. Multiple tuber-
cular caries of the ribs. Syringomyelia throughout the entire spinal
cord with distinct formation of cavities in the gray substance of the cer-
vical and dorsal portions of the cord.
Epicrisis: The subjective symptoms of the patient, who at the same
time was suffering from syringomyelia, were extremely mild.
When there is suspicion of carcinoma of the stomach attention should
always be paid to "peritoneal friction" showing itself on palpation as
"snow squeaking." Especially with an indistinctly palpable tumor it is a
very significant diagnostic phenomenon.
Case 48.— G. A., 38 years, M.
iid 1. — Both parents living and well.
ad 3. — Varicella at 6 years of age ; otherwise always healthy.
ad 4. — Stomach was always very good; preference for strongly
sour foods, which also now are well tolerated.
ad 6. — In October, 1902, the appetite diminished with respect to
all foods. No disgust for meat ; a little later, constipation set in. Since
July, 1903, a feeling of distention after eating and sour eructation.
Pain 14 to 1 hour after intake of nutrition ; in left lateral position eructa-
tion affording relief. Feeling of pressure, particularly after meat. At-
tacks of pain often at midnight. Intolerance for meat and flour foods
prepared with yeast. Among others beer, wine and fat are tolerated.
ad 7. — Tumor of the pylorus palpable, especially with left lateral
position, of varying consistence; distinct gastric peristalsis.
Stomach contents: HCl demonstrable on a fasting stomach, abundant
sarcinfe. HCl negative after lavage and test-breakfast.
ad 8. — Beginning: October, 1902.
Status presens: April 14, 1904.
Operation: April 22, 1904.
Duration: About ll/o years.
ad 9. — Operation: Gastric carcinoma with metastases.
C'ARCIXOMA OF THE STOMACH 213
Epicrisis: The cliJinf^ing coiisistenci' of i\\v pyloi-ic tumor ;is noted hy
the palpating- finf)vrs is accounted for by the chan<re in contraction atul
relaxation of the pyloric musculature.
Such findings by no means justify us in assuminf^ a j)urely spastic-
functionjil natui-e of the disi'ase.
HCl is found in the sta<rnating stomach contents, evidently resulting
from former strong irritants (products of decomposition of ingested
food?). After emptying and lavage of the stomach the mild irritation
produced by the test-breakfast is not sufficient to elicit HCl secretion.
Such behavior is not seldom met with in cancer of the stomach.
Case 49.— F. D., 41 years, M. Worker in Gold.
ad 1. — Mother died of tuberculosis, brothers and sisters of chil-
dren's diseases.
ad 3. — Measles in childhood, otherwise always healthy,
•xd 4,, — Always had a good stomach; was in the habit of eating hot
foods and rapidly. Severe constipation since childhood.
ad 5. — Has to stoop while seated at his work, in pulling wire it
frequently happened that the instrument slipped from the hand and hit
against the epigastrium.
ad 6. — Stomach trouble since August, 1903. After eating "gou-
lash," pressure in the stomach and nausea, appearing often 1 to ll/^> hours
after eating. Sour eructations, now and then having the odor of "rotton
eggs." Since the end of February, 190-1, vomiting soon after meals. A
feeline- as if the stomach were "too narrow." After ingestion of food
the patient cannot lie on his right side because it excites nausea. iSo
pain, only feeling of pressure in the epigastrium.
ad 7.- — Hard, uneven tumor at the lesser curvature. Stomach in
the left half of the epigastrium bulging like an air-cushion. Pulse 54.
"Coffee-ground" vomiting containing abundant lactic-acid bacilli.
Urine: Strong indican reaction {Ohermeyer).
ad 8. — Beginning: August, 1903.
Status presens: April 20, 1904.
Operation: April 26, 1904.
Autopsy: April 27, 1904.
Duration : About 8 months,
ad 9. — Operation: Carcinoma of the pylorus encroaching on the
lesser curvature, stomach enormously hypertrophied, only slightly di-
lated, firmly fixed posteriorly.
Autopsy: Carcinoma on the basis of a gastric ulcer.
Epicrisis: One of those not rare cases in which the anatomical find-
ing speaks for a preceding ulcer, whilst clinically there are no grounds
for assuming such to be the case.
With reference to the "irritation theory" it would have to be borne
in mind that the patient was in the habit of eating things rapidly and
when they were hot. Also he had to stoop a great deal while sitting at
his work, the epigastrium being at the same time exposed to manifold
traumas.
2U TUMORS OF THE ABDOMINAL VISCERA
Right lateral position is badly tolerated, not because it elicits pain
but because it excites nausea (carcinoma at the pylorus!).
Case 50. — F. W., 32 years, M. Coachman.
ad 1. — Mother died of some pulmonary disease.
ad 3. — Varicella at 6 years of age; no lues.
ad 4. — Always had a good stomach ; preference for sour and spicy
foods.
ad 5. — Moderate drinker and smoker.
ad 6. — Toward the end of May, 1904, feeling of pressure after eat-
in "• boiled beef. Frequent stabbing on both sides underneath the costal
arches accompanied by a feeling of distention in the epigastrium; later
on vomiting, two hours after meals. Half an hour after ingestion of
food pressure and contracting pains in the stomach which lasted until
vomiting occurred. In riglit lateral position there is a feeling as if somc-
tliing fell over to the right side, at the same time there is nausea.
ad 7. — No distinct tumor can be felt. Visible gastric peristalsis
without actual pain. Pulse 48.
Stomach contents: HCl negative; abundant lactic-acid bacilli.
ad 8. — Beginning: End of May, 1904.
Status presens: August 30, 1904.
Operation: September 3, 1904.
Duration : 3 months.
ad 9.^ — Operation (Docent Dr. A. Exner) : Constriction of the
pylorus by a sjiarply circumscrii)ed carcinoma. Glands enlarged both
at tlie lesser and greater curvature. Resection of the pylorus and gastro-
enterostomy.
Epirrisis: The intolerance of the carcinomatously diseased stomach is
frequently first exhibited toward "boiled beef," the use of same, so
prevalent in A'ienna, ividently taxes tlie digestive energy of the stomach
very much.
Here, also, there exists a right-sided "vomiting position." Brady-
cardia is a peculiarity of the ratlier fibrous carcinomas constricting the
pylorus, in connection with which there are losses of large amounts of
fluid as a result of copious vomiting, and frequently there occurs a sort
of mummification of the organism. The heart in these cases is small
and atrophic.
Case 51.— P. M., 30 years, W.
ad 1. — No tuberculosis In the family.
ad 2. — Tubercular habitus.
ad 3. — No infectious diseases ; was always healthy.
ad 4. — Since 16 years of age repeated occurrence of gastric trouble,
especially after sweet flour foods producing flatulence, mostl}' I/4 to l/o
hour after eating, accompanied by moderate feeling of pressure and heart-
burn.
ad 6. — About the middle of August, 1903, slight pains began
below the xiphoid process, especially upon making pressure and fasten-
CARCINOMA OF THE STOMACH 215
ing the skirts; pain also underneath both costal arches, lb is said that
puhnonary catarrh was diagnosed at that time. Two weeks hiter, again
stabbing pains below the xiphoid process, radiating into both sides under
the costal arches, into the back and flanks. Five to ten minutes after
eating feeling of pressure in stomach, nausea and "perturbation" in the
entire abdomen. Large quantities of fluid are particularly badly tol-
erated. Now and then eructation of sour fluid or gases (having the odor
of "rotten eggs"). Vomiting of tenacious, white mucous, which affords
relief. In the summer of 1904; the vomiting subsided. She could tolerate
only milk and eggs, all other food being vomited. In the beginning of
September, 19()-t, the abdomen gradually enlarged, during the last 8 days
spontaneous diarrheas. Recently swelling of the lower extremities. Sen-
sitiveness to pressure in the epigastrium ; appetite would be good, but the
patient is afraid to eat.
ad 7. — Ascites. Epigastrium filled with hard, gland-like tumors,
which rise with pulsation and yield a tympanitic sound; even on slightly
pressing the stethoscope in the epigastrium it is possible to elicit a sys-
tolic murmur. Slight edema in the lower extremities. Right-sided pleural
effusion. Venous hums. The vomited stomach contents contain abun-
dant, ver}' long lactic-acid bacilli. The same bacteriological finding in
the feces, which latter also contains numerous pus-cells, some of them
eosinophiles.
Urine: Very strong diazo reaction, which disappears synchronously
with the occurrence of purulent peritonitis, 7 days prior to death.
Blood: Leucocytes, 13,000.
ad 8. — Beginning: About August 15, 1903.
Status presens: September 14, 1904.
Autopsy: October 14, 1904.
Duration : 1 year, 2 months,
ad 9. — Autops}^ (Docent Dr. J. Bartel) : Enormous medullary ul-
cerating carcinoma of the pars pylorica of the stomach and the lesser
curvature with perforation and diffuse peritonitis. jNIetastases in the peri-
portal lymph-glands and infiltration of the pancreas with carcinoma.
Struma cystica. Pylorus not much constricted.
Epicrisis: This patient was referred to the clinic with the diagnosis
"tuberculosis of the peritoneum." This is probably the most frequent
erroneous diagnosis in cases where gastric cancer attacks vouthful in-
dividuals and is accompanied by ascites.
In this 30-year-old patient there w^as, in addition, a very intense diazo
reaction, which is ver}^ rarely met with in gastric cancer, but almost reg-
ularly observed in tuberculosis of the peritoneum.
The result of the feces examination was the first reason for changing
the diagnosis : lactic-acid bacilli ! Only during the subsequent course did
vomiting occur, yielding identical bacteriological findings.
Case 52.— H. J., 51 years, M.
ad 3. — No I. D. C. Typhoid at 9 years (duration, 6 weeks). In
1900, left-sided pneumonia.
216 TUMORS OF THE ABDOMINAL VISCERA
ad 4<.—T- Always had a good appetite.
ad 6. — In the beginning of July, 190-4, frequent heartburn after
eating bread; appetite good at the start. In August, 1904, beginning of
pain in the stomach. Since August, 1904, continuous pressing, now and
then cramp-like pains in the region of the stomach, sometimes brought
about by movements, such as stooping. Feeling of gastric pressure, es-
pecially after eating meat. Appetite became bad. Pain, especially 2 to
3 hours after eating. Sour eructation in horizontal position.
September, 1904: Copious vomiting of strongly sour and strongly
mucoid masses. "Rolling" in the region of the stomach and visible gas-
tric peristalsis.
ad 7. — No distinct tumor. Epigastrium little sensitive, , loud
splashing, visible gastric peristalsis. Small hernia in the linea alba, little
painful. Yellowish pale face coloration. Sarcinae in stools and stomach
contents. Food rests after withdrawal of contents from fasting stomach
show 157o and after test-breakfast 1% HCl.
ad 8.^ — Beginning: June, 1904.
Status presens : October 3, 1904.
Operation: October 21, 1904.
Duration : 41/^ months,
ad 9. — Operation (Docent Dr. A. Exner) : Carcinoma at the py-
lorus (hard tumor, the size of a nut), encroaching on the pancreas.
Epicrisis: Heartburn, especially after eating bread, in this case ap-
pears as an early symptom, and is present also during the further course
(favored by horizontal position).
Hernias in the linea all)a must be accepted with greatest resei've only
as the cause of existing gastric disturbances ; they are not rare, accom-
panying manifestations in cases of gastric cancer.
As repeatedly emphasized, the appearance of symptoms of pyloric
constrictions (residues from the previous day, sarcina', visible peristal-
sis, colic of pyloric stenosis) with stomach complaints of only several
months' duration, is always highly suspicious of malignancy.
As in Case 48, so also here, the stomach contents withdrawn in a fast-
ing condition show a greater HCl content than those obtained after a test-
breakfast (with previous lavage).
Case 53.— M. J., 57 years, M.
ad 1.- — Father living and well.
ad 3. — Scarlatina at 10 j^ears of age (at 19 had general edema
for 17 weeks).
1901 : Chills with bloody expectoration, same in 1903.
ad 4. — Vomiting now and then, simultaneous with occurrence of
headache. Bowels always regular.
ad 6. — May, 1904 : Loss of appetite, disgust for meat ; could only
take liquid food.
August, 1904: Frequent heartburn, severe vomiting after every meal.
Bowels irregular, mostly constipated.
ad 7. — Distinct ascites ; navel toughly infiltrated, corresponding
CARCINOMA OF THE STOMACH 217
to the liganicntuiii tores, a finn cord running upward. Uneven tumor-
masses in the cpigastriinn ; over this covering a large area "peritoneal"
friction. Traces of retromalleolar edema,
ad 8. — Beginning: Ma}^ 1904.
Status presens : October 4, 1904.
Autopsy: November 11, 1904.
Duration: About 6 months,
ad 9.^ — Autopsy: Pyloric portion of stomach diffusely infiltrated,
diminishing the lumen of the stomach and greatly constricting the py-
lorus. No dilatation of the stomach on account of the rather uniform
infiltration. Metastases in the peritoneum, particularly also contraction
in the mesentery. Navel carcinomatosis of the peritoneum. Often also
the ligamentum teres can be felt as a toughly infiltrated cord. Extensive
"peritoneal" friction-sounds, audible in the epigastrium, also betrays
peritoneal involvement.
Absence of gastric dilatation, despite severe pyloric stenosis with
continuous vomiting, may be due to diffuse infiltration of the gastric
walls.
Case 54.— Z. F., 39 years, M.
ad 1. — IMother died of intestinal cancer.
ad 2. — Between the ages of 15 and 24, frequent epistaxis.
ad 3. — No I. D. C. As a child, always well and strong.
ad 4. — One morning, when 22 years of age, felt slightly unwell,
whilst riding, felt a mild diffuse stabbing anteriorly in the chest, fell to
the ground unconscious ; is said to have been unconscious for 8 days, on
awakening nose and mouth filled with blood. He was told that "an artery
had burst." Had no gastric or pulmonary complaints; after 14 days
felt perfectly well.
In the autumn of 1892, when 27 years of age, had for some days
anorexia; on the third or fourth day, jaundice appeared, and a few days
later there were colic-like pains in the right half of the abdomen. Dur-
ing the past 8 years, on and off, chills without any other accompanying
symptoms.
ad 6. — In January, 1904, a lump of clotted, black blood was dis-
charged with the stool, being enveloped in thick mucous and accom-
panied by some tenesmus. In May, 1904, the appetite grew worse; im-
mediately after eating stabbing, cramp-like pains underneath the left
costal arch, especially also on deep breathing. Stomach is said to have
been somewhat distended frequently. Since May, 1904, his weight
dropped from TO kg to 50 kg. Tendency to frequent fluid bowel evacua-
tions. Stools of a very bad odor. In right lateral position there is a
feeling of something shifting from left to right. After one glass of milk
immediate stabbing underneath the left costal arch and a feeling of im-
peded breathing. These symptoms last four to five minutes, then there
follow colic-like pains in the left lower abdominal region. One to two
hours after the noonday meal, fluid bowel evacuation. No eructation, no
heartburn, no vomiting. For the past month pains underneath the left
218 TUMORS OF THE ABDOMINAL VISCERA
costal arch on deep breathing, stooping, reaching for some object with
the left hand. During the past weeks colicky pains in the left half of
the abdomen, accompanied by loud gurgling; left half of the abdomen
distended and tense.
Immediately after defecation, severe pains in the left half of the abdo-
men. In the beginning of December, 1904, the appetite improved, had
predilection for sour potato salad. The patient is aware of peculiar,
continuous splashing sounds underneath the left costal arch, which pre-
vent him from sleeping.
ad 7. — Tongue slightly coated. Uneven, hard tumbr-mass under-
neath the left costal arch, respiration movable, over it a tympanitic
sound. Pale yellowish facial color.
Stomach contents: After test breakfast, total acidity, 44-%. No sar-
cinae, no lactic-acid bacilli. Distention of the colon produces pain un-
derneath the left costal arch.
Feces: Blood-coloring matter present; abundant cocci, gathered to-
gether in heaps.
January 9, 1905: Overnight, spontaneous diuresis of 5 litres, and
furthermore, disappearance of the edemas (lower extremities, sacrum).
Leucocytes, 9,630. During the concluding days of life, violent headache
and meningeal manifestations without any particular disturbance of con-
sciousness.
ad 8. — Beginning: January, 1904.
Status presens: October 15, 1904.
Autopsy: February 12. 1905.
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Carcinoma of the
transverse colon ^*^ the size of a man's fist, ulcerating, situated on the
upper wall, extensively perforating it in many places. Diffuse purulent
meningitis with the formation of a scant cloudy exudate (more abundant
only at the base and distinctly purulent).
Bacteriological finding (Professor Dr. A. Ghon) : Capsule- forming
streptococcus. Analogous finding in the contents of abscess lying be-
tween the stomach and colon.
Epicrisis: The non-involvement of the pylorus (carcinoma of the
greater curvature) accounts for the fact that symptoms of regurgitation
(eructation, vomiting) are permanently absent. Clinically, one is strongly
inclined to assume that the episode occurring at 22 years of age (severe
unconsciousness with hemorrhage from mouth and nose) was an internal
hemorrhage from a gastric ulcer latent up to that time, which later be-
came the base of the developing cancer.
Like the ulcer, the carcinoma subsequently ran a latent course. Only
involvement of the colon produces in January, 1904, the first alarming
symptom: discharge of a lump of clotted blood in the feces with slight
tenesmus. The ulcerative process in the splenic flexure, moreover, ac-
counts for the tendency to copious liquid bowel evacuations and the
'" It was impossible to determine whether the colon or the stomach was the place
of origin.
CARCINOMA OF THE STOMACH 219
peculiarity of the intestinal flora (pronounced appearance of large heaps
of cocci!). As the pyloric passage remains latent there is no growth of
lactic-acid bacilli.
The sudden appearance of spontaneous polyuria (5,000 cm) about
one month prior to demise, with regress of the edemas, nuist be put down
as a fact ; it is difficult to account for it in any satisfactory way.
The last stage of the disease process, a meningitis, due to capsule-
forming streptococci, may have been of abdominal origin.
Case 55. — A. N., 53 years, F.
ad 1. — Mother died of some pulmonary disease.
ad 3. — No I. D. C. ; later also ahvays well.
ad 6. — In July, 1903, one-quarter hour after eating meat, violent
pain in the lower half of the abdomen ; the pain becoming worse after
another quarter of an hour; vomiting of the ingested foods, together
with much mucous and some bile ; vomiting afforded immediate relief. If
the patient eats nothing there is bulimia; as soon as she begins to eat
the sensation of hunger ceases.
ad 1 .■ — Hard tumor at the p>'lorus. Left low^er abdominal re-
gion and left flank decidedly bulging, corresponding to the greatly di-
lated stomach, which is in peristaltic unrest. Collapse of the bulging
portions after severe eructation of gases. The vomitus contains abun-
dant lactic-acid bacilli. Some time after operation, appearance of a
putrid exudate in the left pleural space, containing abundant colon ba-
cilli. Leucocytes, 29,000.
ad 8. — Beginning: July, 1903.
Status presens: October 23, 1904.
Operation : November 3, 1904.
Autopsy: November 29, 1904.
Duration : 4 months.
ad 9. — Operation f Docent Dr. H. Lorenz) : Carcinoma as big as a
fist at the pylorus. Pea-size metastases in the left lobe of the liver and
metastases in the great omentum.
Autopsy (Professor Dr. 0. Stoerk) : Carcinoma of the pylorus, en-
circling same (gastro-enterostomy anterior 17 days ago) ; here and there
metastases in the liver. Pneumonic areas in the left lower lobe and a
gangrenous cavity the size of a hazel-nut perforating into the pleural
space. Walled-off putrid exudate.
Epicrisis: Exquisite intolerance for meat. The localization of the
pain produced in the epigastrium by eating meat is somewhat unusual,
though it might have some connection with the low situation of the greatly
dilated stomach. The terminal putrid pleural empyema was not, as
might have been suspected, an abdominal extension, but originated in a
gangrenous area in the lung (aspiration.'').
Case 56. — J. H., 46 years, M.
ad 3.- — No I. D, C. ; as a child, always healthy,
ad 4. — Never had stomach or intestinal complaints.
220 TUMORS OF THE ABDOMINAL VISCERA
ad 6. — Since Januar}', 1904, frequent violent pain in the region
of the stomach, radiating from the epigastrium toward the left breast.
Appetite became bad. Now and then eructation with the odor of SH2.
September 8-9, very severe pains to the right, in the region of the gall-
bladder, lasting uninterruptedly for two days.
January 13, 1905: Appetite good of late. Pain increased on motion,
radiating toward the anterior portion of the thorax and toward the back,
ad 7. — Indistinct resistance in the midline of the epigastrium (No-
vember 17, 1904). Tenderness to pressure on the right side, underneath
the costal arch, in the region of the gall-bladder. Stomach dilated, can
be felt because of increased tension of the walls. HCl 2% (after test-
breakfast) : abundant sarcinre.
January 13, 1905: Distinct tumor to the right of the umbilicus and
traces of HCl (after test-breakfast) ; abundant sarcinjE.
ad 8. — Beginning: January, 1904.
Status presens: November 11, 1904, and January 13, 1905.
Operation: January 19, 1905.
Duration : About 1 year,
ad 9. — Operation (Docent Dr. A. Earner): Tumor the size of a
fist, of cartilaginous hardness, extending from the greater curvature to
the pylorus ; infiltration of glands of the greater curvature.
Epicrisis: Even though in November, 1904 (operation: January,
1905) the chemical and microscopical findings (Hcl and sarcina^) cor-
responded to a benign stenosis, the consideration that the stenosis (sar-
cinae ! gastric meteorism !) developed in a short time would speak for the
malignant nature of the disease. Despite the persistence of HCl secre-
tion, there was no clinical ground to think of a pre-existing ulcer. After
the stomach complaints had run along for one year tlie appetite was
still well preserved.
Case 57. — K. W., 51 years, F. Washerwoman.
ad 3. — In childhood had cholera and variola.
ad 4. — Never had gastro-intestinal disturbances.
ad 5. — Always was well.
ad 6. — In July, 1904, pains began in the back, especially at night
and when doing hard work. Since the middle of October, 1904, continu-
ous pains in the epigastrium, worse at night and after eating. After the
pains had lasted one hour there followed nausea and vomiting, partly
biliary, once "coffee-grounds." Increase of symptoms after eating solid
foods. Of late, therefore, the patient takes onU' soup, milk and tea.
Since the beginning of the gastric pains anorexia and constipation ; since
then also paleness of the face and emaciation.
ad 7. — Tumor in the epigastrium, transmitting a strong pulsatory
thrill. Much tenderness on pressure along the right costal arch and in
the region of the right kidney. "Coffee-ground" vomiting, abundant lac-
tic-acid bacilli.
Urine: Strong indican reaction {Ohermeyer) . Death following hema-
temesis.
CARCINOMA OF THE STOMACH 221
ad 8. — Beginning: July, 19()4<.
Status prescns : NovcnibL-r 15, 19()4.
Autopsy: May 11, 1905.
Duration: 10 months,
ad 9. — Autopsy (Dr. K. Wiesiwr) : Constricting cancer with border
like a wall (ulcer.'') at the pylorus, extensive metastases in the periportal,
mesenteric and retroperitoneal lymph-glands. Intergrowth of stomach
with anterior belly-wall, with the liver and with the pancreas. Fresh
fibrinous pleuritis over the left lower lobe.
Epicrisis: Also in this case the phenomena of pain come strongly into
the foreground. The initial symptom is pain in the back, and its noc-
turnal aggravation is worthy of note. So also the attacks of pain sub-
sequently occurring in the epigastrium and doubtless of gastric origin,
exhibit similar relations to the hours of the night.
Early adhesions to the pancreas may enter into the production of the
pains in the back.
Sensitiveness on the right side posteriorly in the kidney region is not
seldom met with in connection with painful lesions of the pylorus.
Case 58. — J. B., 51 years, M. Machinist.
ad 1. — Parents died from weakness of old age.
ad 3.— No I. D. C.
ad 4. — Stomach was always inclined to be weak ; milk poorly tol-
erated.
ad 5. — Always was healthy. His work required him frequently to
brace instruments against the epigastrium.
ad 6. — Since February, 1904, at intervals of 2 to 3 days, stabbing
pains in the middle of the epigastrium, thence radiating to the right an-
teriorly into the nipple of the breast and at the same time into both sides
of the back ; duration of attacks mostly 3 hours ; often accompanied by
feeling of chill and hiccough. In the beginning of September, 1904, very
violent pains, the patient vomited 3 litres (?) dark, coagulated blood.
Remained in the hospital four weeks and was discharged as "cured."
Eight days later he returned to work. The appetite grew worse. From
December 3d to December 24th gained 3 kg in weight. Bowels always
regular. Appetite good. Feeling of soreness in the mouth. After break-
fast at 8 o'clock pains follow at 9 o'clock; frequent attacks of pain toward
7 P.M. During the painful attack the patient acquires relief by walking
about or assuming the left lateral position.
ad 7. — Indistinct resistance in the region of the pylorus ; there
and underneath the right costal arch great sensitiveness to pressure. Per-
cussion in the linea alba (epigastrium) painful. Tenderness in the right
axillary line at points corresponding to the sixth and seventh intercostal
spaces. The vertebral column is sensitive to pressure, two finger breadths
below the level of the angle of the scapula and thence downward. Splash-
ing in the stomach, which the patient himself has noticed since the begin-
ning of the disease, splashing occurring while walking about. Pale yel-
lowish f.ace coloration (no icterus).
222 TUMORS OF THE ABDOMINAL VISCERA
Blood: 2,400,()()() erythrocytes, 4,800 leucocytes, 40% hemoglobin,
ad 8. — Beginning, Februarys 1904.
Profuse hematemesis : September, 1904.
Status presens: February 4, 1905.
Autopsy: February 14, 1905.
Duration: About 1 year,
ad 9. — Autopsy (Docent Dr. J. Bartel) : Ulcerating carcinoma of
the cardiac end of the stomach perforating below, and ulcer of the stom-
ach. Escape of stomach contents into the abdominal cavity. Lapa-
rotomy two days ago with establishment of a jejunal fistula.
Ejncrisis: Chronic trauma in the epigastrium through bracing instru-
ments against it.
Beginning of the disease with pyloric colic (type: pseudo-gall-stone
colic) ; hiccough as an accompanying symptom.
Seven months after the beginning of the first symptoms there occurs
a profuse hemorrhage. Two months prior to death there is an increase
in weight of 3 kg. Death occurs with hematemesis.
Anatomical diagnosis : Ulcus carcinomatosum.
Clinically, in view of the short duration of the entire disease (one
year), unaccompanied by symptoms of ulcer, the thouglit obtnides itself,
whether the coming of the ulcer was not associated with some malig-
nant factor, so that such cases would have to be classified as "ulcerous
cancer."
For differential diagnosis in these and similar cases, only one rule
seems to me applicable. If, under continued ulcer therapy (rest in bed,
regulation of bowel movements by means of enemas, diet, etc.), the hemor*
rhage does not cease, a malignant ulceration nuist be thought of.
Case 59. — F. P., 32 years, M. Baker,
ad 3.— No I. D. C.
ad 5. — Was always healthy.
ad 6. — In March, 1903, decrease of appetite; especially after in-
gestion of vegetables, feeling of fulness in the stomach and eructatipn,
with the odor of decomposition. No pains. Six months later began to
vomit about one-half hour after meals, bowels constipated.
November, 1903 : Resection of the pylorus ! The patient could again
eat everything, bowels became regular, gained 10 kg in one month; felt
well until November, 1904. Appetite again became bad, eructation and
vomiting of bile. After meals, pain underneath the xiphoid process and
on both sides along the costal arches.
February 16, 1905: Second operation, with transient improvement,
ad 7. — Tongue conspicuously red, smooth, shiny. Extensive
metastases in the liver ; systolic murmur over the left lobe,
ad 8. — Beginning,* March, 1903.
. First operation : November, 1903.
Second operation: February 16, 1905.
Status presens: jMarch 15, 1905.
Duration : 2 years.
CARCINOMA OF THE STOMACH 22'S
ad 9. — Finding at operation: Liver filled with tuiuor nodules; stom-
ach could not be hroufrht into view on account of nunurous adlicsions.
Kpicrisis: The impeded evacuation of the stomach leads to the usual
ascending scale of symptoms: feeling of fulness — eructation — vomiting.
Deserving of note is the "rotting" odor of the regurgitated gases in con-
tradistinction to the odorless eructation in nervous dyspepsias.
Atrophic changes in the lingual mucosa are not seldom met Avith in
cancer of the stomach, similarU^ as in pernicious anemias. Over the car-
cinomatously infiltrated liver a systolic vascular murmur. Although after
the first operation there evidently remained behind some carcinomatous
tissue (relapse after three months), the patient gained 10 kg in weight.
Case 60.— M. S., 61 years, F. '
ad 3. — No infectious diseases.
ad -1. — For the past 15 years frequent digestive disturbance after
fat foods, grain Hour foods, etc. ; after a fcAV days of careful dieting
rapid improvement. Chronic constipation.
ad 5. — Never seriously sick; had four normal confinements.
ad 6.— Since the end of March, 1905, now and then, stabbing in
the left hypochondrium. One morning in the early part of April, 1905,
sudden unaccountable severe pain along the left costal arch, stabbing
and cutting; patient could rest only on her back. Increase of pain after
eating soup or milk. On the same day, twice vomiting of coloi-less mucus.
Since then these pains are constant, now and then worse at night ; in-
crease after ingestion of sour foods. Feeling "as if a stone were lying in
the stomach." Pains radiating from the left costal arch into the left lum-
bar region, often upward behind the sternum, so that the patient could
hardly breathe. Constant pains in the left side of the back, also in the
region of the sacrum. Appetite bad, bowels constipated. Eructation of
mucus or air.
ad 7. — A tumor-mass can be felt to the left under the costal arch
when patient is in right lateral position.
Seventh and eighth intercostal spaces on the left somewhat sensitive
to pressure; likeAvise the left lumbar region. Traces of retromalleolar
edema. HCl negative. Neither the vomitus nor the feces show lactic-acid
bacilli in larger quantities.
Urine: Indican reaction strongly positive. Slight indication of a
diazo reaction.
ad 8. — Beginning: End of March, 1905.
Status presens: May 8, 1905.
Autopsy: June 8, 1905.
Duration : 2 months.
ad 9. — Autopsy (Docent Dr. J. Bartel) : Ulcerating medullary
gastric carcinoma (not stenosing) of the lesser curvature wnth large gland
metastases (= palpatory finding), retroperitoneal and mesenteric.
Metastases. in the liver. Left-sided pleural effusion. Struma of the left
lobe of the thyroid gland.
Epicrisis: The location of the main tumor-mass underneath the left
224 TUMORS OF THE ABDOMINAL VISCERA
costal arch corresponds with the left-sidedness of the painful phenomena.
At the same time the left lumbar region, as well as the seventh and eighth
intercostal spaces (axillary), are sensitive to pressure. As a result of
gastric dilatation due to impeded evacuation (despite a patent pyloric
passage) there occur left-sided radiations of pain. Growth of lactic-
acid bacilli is absent.
The tumor palpable during life did not correspond to the gastric can-
cer itself but to the metastatic glandular infiltration in the lesser cur-
vature.
Case 61.— H. H., 37 years, F.
ad 1. — Parents are living and healthy; mother has gravel in the
urine.
ad 3. — Measles at 5, whooping cough at 7. After the fourth con-
finement pains in the abdomen, chills, icterus, inflammation of both knee-
joints; duration: 4< months.
ad 4. — From 28 to 30 years of age, almost daily vomiting of mu-
cus and poor appetite (formerly had a very good stomach). No nervous
complaints. Frequent heartburn and odorless eructation. Pains, stab-
bing in character, underneath the left costal arch, radiating into both
shoulder-blades. Pains also when perfectly at rest. After same a swell-
ing is said to have been often palpable underneath the left costal arch,
often disappearing suddenly (peristalsis.'*). Sour, gas-forming and spicy
foods were avoided. Perfect cure after Karlsbad cure. During the fol-
lowing 5 years pain in the stomach occurred seldom, now and then, prior
to menstruation.
ad 6. — Since November, 1904, frequent pains underneath the left
costal arch. Since January, 1905, pallor and emaciation; anorexia and
constipation. Frequent eructation with odor of SH2. In January, 1905,
albumin found in the urine ; since the middle of May, 1905, edema in both
lower extremities.
January, 1905: Tenderness on pressure underneath the left costal
arch so that the patient could no longer wear her abdominal bandage.
In February, 1905, the pains became more intense, were also located
posteriorly on the right side at a point corresponding to the lower limits
of the lung, and radiated from the back into both scapulae. Pain, espe-
cially at 7 p.^r., sometimes lasting through the whole night, accompanied
by a feeling of pressure and tension, extending upward toward both
scapulfe; relief after eructation or discharge of gases. Anesthesia inter-
nally had a favorable effect on these painful conditions.
ad 7.- — Indistinct, somewhat firm resistance underneath the left
costal arch ; much sensitiveness underneath the left costal arch on light
percussion (May 26, 1905).
June 6, 1905: No tenderness underneath left costal arch; tumor more
distinct, cylindrical, permits of slight ballottement. Extreme pallor.
Feces: Abundant sarcinjp.
Urine: Indican reaction strongl}^ positive. Albumin 3%, few hyaline,
granular and small waxy casts.
CARCINOMA OF THE STOMACH 225
Blood: Hemoglobin, 30%, leucocytes, 19,800; few normoblasts,
ad 8. — Beginnincr: November, 1904.
Status presens: ^lay 26, 1905.
Autopsy: June 27, 1905.
Duration: About 8 months,
ad 9. — Autopsy (Professor Dr. O. Stoerk) : Ulcerating carcinoma
of the pyloric region of the stomach, having a chronic ulcer for its base.
Purulent thrombophlebitis of the portal vessels. Diffuse purulent peri-
tonitis. Severe parenchymatous nephritis and thrombosis of the left
renal vein and all its branches within the kidney.
Epicrisis: From the differential diagnostic point of view it deserves
to be mentioned that the patient was referred to the clinic by a very com-
petent man with the diagnosis of a "left-sided malignant tumor of the
kidney." In the history-, the patient stated that from 28 to 30 years of
age she had been treated for a floating kidney on the left side. A careful
anal^'sis of the s^^mptoms at that time inclines one to the belief that it
was a gastric ulcer. The nephritic finding in the urine was something
quite unusual in connection with gastric cancer; furthermore, this left-
sided tumor was ballottable.
On the other hand, the ensemble of pain had decided gastric earmarks.
Two findings in particular were of diagnostic importance :
1. Anesthesin, given internally, had a remarkable effect on the exist-
ing pain, Avhich, in view of its local anesthetic action, speaks decidedly
against renal painful conditions. 2. The feces, on microscopic ex-
amination, showed abundant sarcin.T, which is a pre-eminent gastric
finding.
These were the two main arguments against the surgical diagnosis of
renal neoplasm, and they at the same time enabled a correct diagnosis
of gastric cancer.
Case 62.— J. S., 57 years, F. Cook.
ad 1. — Parents died in advanced age.
ad 3. — In childhood had scarlatina.
ad 4. — Bowels always regular.
ad 6. — Since autumn of 1904 pallor of the face, emaciation, fa-
tigue, anorexia with disinclination toward meat. In June, 1905, transient
improvement in appetite, but the patient eats onl}' vegetables and soup.
In right lateral position drawing pains on the left side and moderate sen-
sitiveness on pressure underneath the left costal arch.
ad 7. — Cylindrical tumor underneath the left costal arch, best pal-
pable when standing and in right lateral position, when the tumor is in
the region of the navel. With dorsal decubitus the swelling disappears
behind the costal arch and can only be felt somewhat like an enlarged an-
terior pole of the spleen when that organ is moderately enlarged. Over
the tumor a short systolic murnmr. Slight edema in the lower extremi-
ties and over the sacrum.
Stool: Few long lactic-acid bacilli.
Urine: Diazo reaction temporarily positive.
226 TUMORS OF THE ABDOMINAL VISCERA
ad 8. — Beginning: Autumn, 1904<.
Status prescns: July 20, 1905.
Operation: July 27,' 1905.
Duration: About 10 months,
ad 9. — Finding at operation (Dr. R. Schmarda) : Carcinoma origi-
nating in the minor curvature, infiltrating the anterior wall of the stom-
ach, extending backward in cone-shape ; pyloric portion free.
Epicrisis : This case illustrates how important it is to palpate in dif-
ferent body positions. When standing, the tumor is easily felt under-
neath the left costal arch, whereas it disappears behind the costal arch
in the dorsal position. Examination in different positions of the body at
the same time informs us of the degree of mobility, which in the present
case was extraordinarily great.
The systolic vascular murnmr frequently heard over gastric tumors
was observed also in this case.
Case 63.— M. D., 47 years, F.
ad 1. — Father died at 60 of a chronic pulmonary disease, mother
died of heart disease.
ad 2. — Since childhood a great deal of headache, except for the
past two years. Two years ago an "epileptic" attack with unconscious-
ness. Hallux valgus.
ad 3. — Had measles, scarlatina and varicella.
ad 4. — Always had a "weak" stomach.
ad 6. — Since the end of 1903, pains in the left lumbar region, bor-
ing, deep, occurring suddenly now and then. Duration, about one-half
hour. Since the summer of 1905 pale appearance, fatigue, fasj:ening
skirts is painful. In August, 1905, black, liquid stools. Feeling of
fulness after meals, induced vomiting by tickling the throat. Heartburn.
Tenderness to pressure in the epigastrium and posteriorU' on the left
side, in the region of the kidney.
ad 7. — Tumor of the pylorus with enormous dilatation of the stom-
ach and varying tension of the gastric walls. Toward the end of expira-
tion a distinct sj'stolic murmur in the epigastrium, ^'enous hums and
anemic heart murmurs, ^'omiting a quarter of an hour after every meal;
"coffee-grounds," HCl negative, abundant lactic-acid bacilli.
Stool: Abundance of lactic-acid bacilli.
Blood: Hgb. 30%.
ad 8. — Beginning: End of 1903.
Status presens : October 5, 1905.
Operation : October 16, 1905.
Duration: About 1 year, 9 months.
ad 9. — Finding at operation (Docent Dr. A. Exner) : Carcinoma
at the pylorus, almost occluding the lumen ; glands in the immediate
proximity somewhat enlarged.
Epicrisis: Cessation of an habitual cephalalgia with the beginning of
cancerous disease. The pains localized in the left lumbar region may be
considered the initial symptom ; even during the further course, the left
CARCINOMA OF THE STOMACH 227
lumbar region remains sensitive to pressure. Whilst radiation of epigas-
tric pain into the left lumbar region is nothing rare in gastric cancer, a
limitation of the pain to this area, as here in the beginning, is not a fre-
quent observation and may easily be misleading.
Hallux valgus as a sign of abnormal (uratic?) metabolism has been
repeatedly referred to.
Case 64. — F. D., 53 years, F. Servant.
ad 1. — Parents died at a very old age.
ad 2.- — No cutaneous angiomas. Two years ago had intlammation
of the right shoulder- joint with swelling and painfulness, restored to
health in 6 weeks.
ad 3.— No I. D. C.
ad 4*. — Since end of September, 1905, diminished appetite, no an-
tipathy to meat, can eat only small quantities, othenvise feeling of pres-
sure ; often odorless and tasteless eructation. In the latter part of Sep-
tember, 1905, noticed in the epigastrium a swelling as big as a little fist,
firm, painless, movable. Tumor not tender to pressure.
ad 7. — A tumor the size of a fist in the epigastrium semi-globular,
movable in all directions, least so downward ; pulsatory vibration ; tym-
panitic sound over the tumor. Underneath the xiphoid process during
expiration loud systolic blowing is audible. No distinct gastric peristal-
sis. Border portions of the liver uneven (operation: "corset lobe"). No
edema of the legs. Subfebrile course, now and then 38° C. Lactic-acid
bacilli in the stools.
ad 8. — Beginning: End of September, (?) 1905.
Status presens : October 26, 1905.
Operation: November 16, 1905.
Duration: 1^^ months {?).
ad 9. — Finding at operation (Uocent Dr. A. Exner) : Tumor the
size of a fist at the lesser curvature, easily movable in all directions; the
entire omentum thrown back and in some places adherent to the anterior
surface of the tumor; at the greater curvature several nut-size carcino-
matous glands, the same along the lesser curvature, up to the cardia;
metastasis in the liver bigger than a nut in size. No evidence of stenosis.
Epicrisis: If the statements of the patient be correct, we would have
to assume in this case a long period of latency. Here we must also take
into consideration the absence of pyloric constriction.
In this case also we may apply the paradox set upon a former page:
The larger the gastric tumor, the less the gastric complaints.
Even very movable tumors are for obvious reasons but little moval)lc
in a downward direction.
Systolic epigastric vascular murmur!
Two years ago there was an inflammation in the left shoulder-joint.
Case 65. — F. K., 44 years, M. Farmer.
ad 1. — Mother died of an abdominal tumor.
ad 2. — Always strong and healthy.
228 TUMORS OF THE ABDOMINAL VISCERA
ad 3. — Malaria at 8, lasting 2 months,
ad 4. — Never had gastric disturbances or constipation,
ad 6. — Beginning in March, 1905, after an error in diet (sauer-
kraut and pork) : the following day the stomach was distended, there was
pain and loud gurgling, especially on the right side. A "gastric catarrh"
was assumed, a Karlsbad cure improved the condition a little.
May 18, 1905: Whilst lifting a heavy load had sudden violent pains in
the region of the stomach, somewhat to the right of the middle line. At
that time, the attending physician found a swelling on the right side in
the epigastrium. Emaciation, pallor and feeling of weakness ; frequent
night-sweats. From March to May, 1905, daily, one or two attacks of
pain with distention of the stomach, lasting one to two hours, occurring
at different times of the day without any definite relation to the intake of
food. Appetite good, even for meat, excepting that pork is badly tol-
erated. No heartburn or vomiting. Bowels regular. Pains often cramp-
like, radiating toward the back and right shoulder ; pain in the back only
when the pain anteriorly, in the epigastrium, is severe. With left lateral
position the pain becomes worse, together with a sensation as if a tunior
was sagging to the left. Feeling of painful pulsation in the epigastrium,
ad 7. — Cylindrical tumor in the middle line of the epigastrium,
hard, somewhat nodular, very sensitive to pressure. Systolic "epigas-
tric" vascular murmur.
No gastric peristalsis. Pale yellowish facial color ; no edemas. Poly-
uria (quantities of urine up to 3,900 c.c).
Gastric contents: T>actic-acid bacilli, short forms preponderating.
Blood: 3,600,000 erythrocytes, 8,400 leucocytes, 25% hemoglobin,
ad 8. — Beginning: March, 1905.
Status presens: November 4, 1905.
Operation : November 18, 1905.
Autopsy: December 11, 1905.
Duration : About 9l/o months,
ad 9. — Autopsy (Hofrat Professor Dr. A. Weichselbaum) : Ul-
cerating carcinoma of the pyloric portion of the stomach. Severe gen-
eral anemia.
Epicrisis: As is so frequently the case, a dietetic is the cause of the
first severe symptoms; even at that time (March, 1905) the medical at-
tendant should have been urged to caution by the simple consideration
that an individual, possessing a sound stomach and intestines so far,
could not possibly acquire such a stubborn gastric disease from a single
error in diet.
Diagnosis : "Gastric catarrh."
Treatment : Karlsbad cure.
Moreover, the prominent appearance of pain phenomena ought always
to speak against the diagnosis of gastric catarrh.
The lifting of a heavy load provokes intense pain, which is an occur-
rence also frequent in cases of ulcer.
Tli^e polyuria observed in this case is very likely of anemic origin
(Hgb. 25%).
CARCINOMA OF THE STOMACH 229
Case 66.— G. R., 50 years, M.
ad 1. — I'iitlKT diid of tuberculosis.
ad 3. — No I. 1). C. ; at l-i years of age bone sup})uratioii in the
right leg and thigh and right humerus, lasting for three years (Tb.?).
Later was healthy.
ad 6. — Toward the end of 1902, three years ago, vomiting early in
the morning accompanied by cramp-like pains, relief after drinking milk.
At that time the appetite was good, the bowels regular; since then some-
what inclined to be constipated. Since the end of November, 1905, fre-
quent feeling of pressure in the left half of the epigfistrium, especially
after farinaceous foods, much less after meat, even pork. Impossible to
lie on the left side because it causes the appearance of pain. Pains in
the stomach 15 minutes after ingestion of hard foods. Appetite good,
but the patient fears the pain. Continuous pains in the left lower ab-
dominal region, left flanks and lumbar region, radiating into the lower
axillary portions of the thorax (on the left).
ad 7. — Very firm, uneven, tumor-mass in the epigastrium, the size
of an apple. Ascites of moderate degree. Hard splenic tumor, extending
to the costal arch. No edema.
After test-breakfast : Total acidity 40%, HCl 30%.
Pepsin 4* mm. Mette.
Blood: 4,700,000 erythrocytes, 10,500 leucocvtes, 70% hemoglobin,
ad 8.— Beginning: End of 1902.
Status presens: December 21, 1905.
Autopsy: February 4, 1906.
Duration : About three years,
ad 9. — Autopsy: (Professor Dr. 0. Stoerk) : Ulcer-like carcinoma
situated in the fundus with wall-like borders, perhaps springing from an
ulcer, advancing toward the hilum of the spleen ; large glands in the
mesentery.
Epicrisis: Cancer in an individual who, to all appearances, in his
childhood suffered from multiple caries. Arrested tubercular processes
are not seldom met with even in cancer patients, but active progressing
tuberculosis is extremely seldom.
The first symptoms of disturbed gastric function date far back ( about
3 years).
Shortly prior to death normal secretory conditions of the gastric
mucous membrane.
The intumescence of the spleen is explained in the way of a congestion
(development of carcinoma in the hilum of the spleen with compression
of the splenic vein).
Case 67.— K. K., 55 years, M. Farmer.
ad 1. — Fatlier died at 6.5 from some stomach disease.
ad 2.- — Tubercular habitus ; was alwavs hcalthv.
ad 3.— No I. D. C.
ad 4. — Tolerated also fat aud sour foods; l)owcls always regular.
ad 6. — In the beginning of November, 1905, sudden diarrhea with-
L>30 TUMORS OF THE ABDOMINAL VISCERA
out cause, having 7 to 8 tarry stools (had worked up to the previous
day) ; the diarrhea lasted 14 days. No hunger, no thirst. Since then
constipation ; the patient can only drink milk.
December, 1905 : Lavage of the stomach, which, it is said, brought to
light grape seeds, which must have been there since October {?). One
hour after eating soup, a sensation of acidity in the stomach; very sour
eructation.
ad 7. — Psoriasis lingual, upper surface of the tongue cracked. A
transversely situated tumor in the epigastrium as thick as a thumb, hard,
somewhat uneven, giving a thrill on pulsation. Stomach dilated, spon-
taneously distended. Pale j'ellowish face coloration.
Vomitus, from fasting stomach: 1,500 c.c.
72% total acidity.
40% HCl.
Abundant sarcinae.
After test-breakfa.st (lavage preceding) : 6% total acidity.
36 Vt HCh
After test-l\reakfast (without removal of residue) : 72'/t total aciditv.
36% HCl.
Withdraimi stomach contents (fasting stomach) : 96% total aciditv.
58% HCl.
ad 8. — Beginning: Early in November, 1905.
Status presens: January 4, 1906.
Operation : January 6, 1906.
Autopsy : January 7, 1906.
Duration : 2 months,
ad 9.- — Autopsy (Docent Dr. K. Landsteiner) : Carcinoma of the
stomach, probably superimposed on a round ulcer. Congenital luxation
of the right hip-joint and deforming arthritis of the vertebral column
with the formation of exostoses.
EpicHsis: Diarrhea due to internal hemorrhage as the first symptom!
Providing the statements of the patient are correct, the cancer had.
up to that time, run a latent course.
As in former observations, so also here, the stagnating stomach con-
tents contain HCl, showing a high total acidity. After a test-breakfast
taken on an empty stomach, HCl is absent and the total acidity very
small.
Clinically, there is no indication of a pre-existing ulcer.
Case 68.— N. N., 60 years, M.
ad 2. — Has had repeated attacks of rheumatism and sciatica.
ad 3. — Of infectious diseases had only pericarditis.
ad 4. — Since 1898, following a dietetic error, sensitiveness of the
stomach with respect to fat and sour foods ; previous to that he "could
have eaten gravel." Since then occasional epigastric complaints ascend-
ing to the throat and choking. Bowels regular. Improvement at
Karlsbad.
ad 6. — August 18, 1909, is given as the date on which the present
CAKCIXOMA OF THE STOMACH 2:n
stouKU-h troubK' Ix-ojin ; at tliut time hi- had stoiiiacli fi-amps la.stiii<4- for
several minutes after (lrinkiii<^ ehanipagiie or Bordeaux. Appetite is good,
even at present (April, 1910) ; nevertheless, he has lost 10 kg in weight.
Chief complaint is pain having a pressing character, appearing almost
always when the stomach is empty, thus at 4- to 5 o'clock in the morning,
11 o'clock in the forenoon and 6 o'clock in the afternoon. The pain is
somewhat alleviated by belching of gases, higestion of food or a drink of
mineral Avater. Position exerts no influence. Moving about in the fresh
air has a favorable effect. No vomiting; eructation mostly tasteless and
odorless, only on three occasions during the disease was it somewhat sour-
sweet. After eating there is a feeling of pressure "as if he had a dry
roll in his stomach." After taking acidol-pepsin the eructations and
other symptoms are somewhat less ; Karlsbad water had a transient good
effect. Bowels somewhat tardy. Those around the patient are struck
by his bad appearance and a yellowish tint in the color of his face. Dur-
ing a rest cure of 14 days (May, 1910) gained V^ kg in weight. On and
off short stabbing in the region of the costal arches and other parts of
the abdomen at about 4 o'clock in the morning (after taking bismuth)
and in the afternoon between 4 and 6 o'clock.
April, 1910: Indistinct resistance in the region of the pylorus; pres-
sure in that region somewhat painful and radiating toward the left costal
arch. Withdrawal of stomach contents after breakfast of tea and a
roll: Alkaline reaction ! Negative bacteriological finding. No food resi-
due from previous day. On one occasion the withdrawal was accom-
panied by a discharge of small fragments of mucosa and at the end, an
admixture of blood.
Feces: On a diet free from hemoglobin the chemical test for blood
coloring matter was constantly positive. After ingestion of moderate
quantities of fat many soaps were microscopically demonstrable,
ad 8.— Beginning: August 18, 1909.
Status presens: April 20, 1910.
Operation: May 28, 1910.
ad 9. — Finding at operation (Primarius Dr. Palla) : A scirrhus
carcinoma almost encircling the pylorus, without adhesions to surround-
ing parts, pylorus much stretched in an upward direction. The cancer
encroaches more on the lesser than on the greater curvature.
Epicrisis: Here again we are dealing with an individual who has al-
ways had a "powerful stomach." He "could have eaten gravel," a state-
ment so frequently made by patients suffering from cancer of the stomach.
Clinically this case could be considered as of the "sensible" type in con-
tradistinction to the "motor" type in which latter symptoms of stagna-
tion, resulting from impeded motility, come into the foreground.
In this case there are hardly an}' demonstrable symptoms of disturbed
mobility. No vomiting, no food residue from the preceding day, no lactic
acid bacilli. The evacuation of the bowels also is but little retarded.
Appetite pretty good.
On the other hand "lumger pains" occur about tliree times a day, and
these pains being interpreted so frequently as gastric neurosis or hyper-
232 TUMORS OF THE ABDOMINAL VISCERA
acidity, are often misinterpreted. For in the preponderating majority of
these cases we are dealing with ulcerative diseases of the stomach mostly
of a benign nature. But this case and similar ones show that also with
malignant ulcerations, and with absence of HCl, an empty stomach may
lead to pain, and food intake may bring relief.
Emaciation in spite of a good appetite is worthy of note. This might
be attributed to secondary disturbances in the digestive tract (pancreas?
intestinal secretions.'^). The deficient fat reduction is a not infi*equent
finding demonstrable also in this case (with moderate ingestion of fat
and without diarrhea), shown under the microscope by the presence of
soaps in the feces.
Case 69.— M. W., 56 years, F,
ad 1.^ — Mother died at 45 of tuberculosis, father died at 70.
Brothers and sisters living and well.
ad 3. — Typhoid at 15 ; articular rheumatism at 22, lasting 3
months.
ad 4. — Stomach trouble for the past 15 years. Intolerance for
sour and fat foods and heavy vegetables ; frequent feeling of pressure
relieved by eructation, improvement after taking magnesia usta.
ad 5. — Six confinements; 12 years ago hemorrhages from a myoma
( histerectomy ) .
ad 6. — For the past two years pain in the back when cooking,
washing or baking. Since Christmas, 1905, without error in diet, feeling
of fulness in the stomach "as if it had to burst," feeling of pressure be-
hind tlie xiphoid process and posteriorly in the back; since then constipa-
tion. Appetite unchanged. Frequent hiccough ; now and then regurgi-
tation of a "mouthful of water without taste." At night often severe
nausea. Lingual mucosa on the left side somewhat atrophic.
ad 7. — Tumor in the epigastrium sensitive to pressure, the size of
a nut, transversely situated. No edemas.
ad 8. — Beginning: February, 1904.
Status presens: February 9, 1906.
Operation: February 17, 1906.
Duration : About 3 years.
ad 9. — Finding at operation (Docent Dr. A. Exner) : Stomach
contracted to the size of a small sausage-shaped tumor, involving the
entire stomach, except a small portion of the greater curvature ; besides,
hard glands, the size of beans, up to the cardia.
Epicrisis: One of those rather rare instances in which the carcinoma
attacks "gastric weaklings," in whom there is, as a result, the absence of
the rapid decline in the function of the stomach which in "gastric ath-
letes" suggests in and of itself the thought of gastric cancer.
Stabbing pains in the back, as they existed also when the disease
was fully developed, may here be considered the initial symptom. Stub-
born hiccough always deserves attention ; aside from neuroses, it is not
seldom found in constricting processes of the pylorus. This case also
exhibits atrophic changes of the lingual mucosa (on one side).
CARCINOMA OF THE STOMACH 233
Case 70.— A. B., 50 years, F.
Hcl 1. — Father died at 30 of some thoracic disease, mother and 2
sisters healthy.
ad 3. — Measles in childhood; severe influenza in 1890, also high
fever and bronchitis in May, 1905.
ad 4. — Alwaj's had a sensitive stomach, was a small eater; feeling
of pressure after ingesting a big meal. In 1871 severe gastric trouble
though having a good appetite; for one year, between 2 and 3 p.m. daily
complaints ; aggravated by smoking.
ad 5. — Frail in childhood, often had catarrh.
ad 6. — For the past year and a half unusual noises in the abdomen.
In May, 1905, feeling of pressure in the epigastrium after eating. Appe-
tite became bad. Slight tenderness, on pressure, in the abdomen.
ad 7.- — Ascites. No distinct tumor palpable. Pale yellowish facial
color. Temperature mostly 36°C. Left-sided apical infiltration; apex
of the heart displaced toward the middle line. Soft, pale edemas of the
lower extremities and over the sacrum. On and off, liquid bowel evac-
uations.
ad 8. — Beginning: August, 190-i.
Status presens: February 26, 1906.
Autopsy : March 7, 1906.
Duration: About 1 j^car, 7 montlis.
ad 9. — Autopsy (Docent Dr. K. Landsteiner) : Scirrhus carcinoma
of the p3'loric portion of the stomach, infiltrating a portion of the fundus
and constricting the pylorus. Scirrhus metastases in the peritoneum
with contraction of the mesentery. Granular tuberculosis of the lungs.
Cavity in the right upper lobe, induration in left upper lobe containing
cheesy foci. Adenoma and cholesterin containing cyst of the thyroid
gland.
Epicrisis: The previous stomach disease is hard to judge; it may have
been an ulcer. One could hardly make a mistake in dating the beginning
of the cancer development at the time of the appearance of the abnormal
noises in the abdomen. A stomach which is the seat of a scirrhus^" is
usually in great motor unrest, easily giving rise to borborygmi.
As frequently happens in scirrhus cancer, so also here, the possibility
of tubercular peritonitis was taken into consideration, the more so, as in
addition to ascites (without a palpable tumor) there was present tuber-
culosis of the pulmonary apices.
The entirely afebrile course was remarkable and of differential diag-
nostic importance.
Case 71.— L. W., 42 years, F.
ad 3. — Had scarlatina and measles.
ad 5. — Since the beginning of December, 1905, abdominal com-
plaints; at the end of that month a left-sided ovarian tumor ("edematous
fibroma"), about the size of a child's head, was removed; dismissed as
" See Cases 2, 6 and 12.
234. TUMORS OF THE ABDOMINAL VISCERA
cured on January 11, 1906; a few days later violent pains limited to the
left side, yielding to electrical treatment in 14 days.
ad 6. — In the early part of March, 1906, stabbing pains in the left
ischium, also in the right, constant, worse at night ; turning in bed im-
possible. Since then no appetite. Bowels regular. Anterior superior
spine on both sides \eyy sensitive to pressure, likewise the lower portion
of the sternum.
ad 7. — No tumor in the epigastrium. Spleen extends to the costal
arch, is moderately firm. Venous hums and loud anemic murmurs over
the heart. Pale color of the face; no edemas. Small glands in the left
supraclavicular fossa. Blood: Erythrocytes, 3,050,000 ; leucocj^tes,
5,400; Hgb., .50%. No nucleated red cells'
ad 8. — Beginning: INIarch, 1906.
Status presens: March 26, 1906.
Autopsy: April 23, 1906.
Duration : About 2 months.
ad 9. — Autopsy (Docent Dr. A'. Lnnrlsteiner) : Callous ulcer scar
with carcinoma in the region of the pylorus, large metastatic glands in
the lesser curvature, likewise in the left supraclavicular fossa. Severe
general anemia. Bilateral hydrothorax. Femur the seat of many
metastases! Absence of uterus and its adnexa (removed threi- months
ago).
Epicrisis: One of those cases of gastric cancer in which the first clin-
ical symptoms are produced by metastases. May not the ovarian tumor
removed in December, 1905, have been a metastatic formation? From
the history it was impossible to decide with certainty.
Clinically there entered into the foreground the pains in the bones
of the pelvis which, as compared with the sternal pains, frequent also in
this case and hardly ever met with even in very severe anemias. Therefore
bone metastasis was much more likely to be thought of than "anemic"
pains in bone. The glands in the left supraclavicular fossa pointed to
gastric carcinoma in the first place.
Case 72.— L. Th., 40 years, F.
ad 3. — No infectious diseases. In childhood and later on always
healthy.
ad 4. — Fat and sour foods always well tolerated; bowels mostly
constipated.
ad 6. — In August, 1905, without any dietetic error gastric com-
plaints started; nausea; no pains, no vomiting. Appetite good until
now. No disgust for meat. August 25, 1905 : Patient was operated on
for a left-sided ovarian cyst ; stomach complaints temporarily improved.
In October, 1905, again stomach trouble; nausea and pain after
eating.
In December, 1905, beginning of vomiting, mostly at about 7 p.m.
Increased emaciation. Feeling of pressure about 6 hours after the noon-
day meal ; soar eructation and nausea.
ad 7. — Transversely situated swelling, about as thick as a thumb.
CARCINOMA OF THE STOMACH 235
underneath the xiplioid process, without tenderness. Surcinrc present in
feces and stomach contents.
On a fasting stomach: 300 cm^ residue. 50% total acidity. HCl
positive. Lab and pepsin positive.
Test-hreaKfast (after lavage) : 10% total acidity. HCl negative,
ad 8. — Beginning: August, 1905.
Status presens: March 31, 1906.
Operation: April 5, 1900.
Duration: About 8 months,
ad 9. — Finding at operation (Docent Dr. P. Albrecht) : Carcinoma
of the anterior wall of the stomach near the pyloric portion, being about
15 cm long and 8 cm wide, also encroaching both the greater and lesser
curvatures. Resection of the p3dorus and posterior gastro-enterostomy.
Epicrisis: In this case again the initial complaints resulting from the
cancer of the stomach were probably ascribed to the secondary ovarian
tumor, and led to a useless operation. The rapid development of pyloric
stenosis (sarcinae) in and of itself must have suggested a malignancy.
As in former cases, ^* the residue obtained in the morning from a fasting
stomach shows a higher total and HCl acidity than the contents with-
drawn after a test-breakfast with preceding lavage of the stomach ; in
the latter case there is achlorh^'dria.
Appetite was constantly present; no disgust for meat.
Case 73.— A. W., 33 years, F.
ad 3. — No infectious diseases,
ad 5. — Always was healthy.
ad 6. — In June, 1904, there began attacks of pain in the epigas-
trium, together with distention and radiation of the pains into the left
lumbar region and left scapula; at that time also hematemesis. Since
June, 1905, anorexia. Recently black stools ; on one occasion the patient
could see nothing for five minutes. Constipation. Belching of gas with-
out any sour taste. Intolerance particularly for meat ; also for sour
and gas-forming foods — e.g., cabbage. Only milk is well tolerated. For
the past few days pains in the left calf, and on motion also in the out-
ward side of the left hip.
ad 7.— A palpable tumor, about the size of a nut, in the region of the
pylorus, likewise underneath the left costal arch; at the latter place a
blowing systolic murmur, especially at the end of expiration. Gastric
peristalsis is visible when the attacks of pain have reached their height.
Great pallor of the face, no edemas. Slight rises in temperature up to
38" C. On the left side, posteriorly below, crepitation of atelectasis.
Vomiting of "coffee-grounds," abundant lactic-acid bacilli.
Stool: Abundant lactic-acid bacilli.
Urine: Diazo reaction positive.
Blood: 24,000 leucocytes.
Muscles of the left calf sensitive to pressure, swollen, with increased
>'See Case 67.
236 TUMORS OF THE ABDOMINAL VISCERA
temperature in that area; likewise painfulness on pressure in the outer
left hip.
ad 8. — Beginning: June, 1904.
Status presens: June 4, 1906.
Autopsy: June 13, 1906.
Duration: About 2 years,
ad 9. — Autopsy (Docent Dr. J. Bartel) : Soft constricting carci-
noma of the pylorus with infiltration of the regional glands, three car-
cinomatous nodules in the liver. Severe anemia. Thrombosis of the left
crural vein.
Epicrisis: One of those rather rare cases in which hematemesis counts
among the initial sj^mptoms.
Two years before death painful attacks after the type of "colic of
pyloric stenosis," with left-sided localization.
Findings of atelectasis over the left lower lobe are not rarely met
with in connection with gastric dilatations. As often before, a systolic
"epigastric vascular murmur."
Positive diazo reaction ! This finding is rare in gastric .cancer, and
then seems to occur most frequently with the medullary forms, likewise
a high leucocyte count (24,000).
Case 74.— R. K., 58 years, F.
ad 3. — Typhoid at 1-5 years of age.
ad 4. — Stomach always very good ; fat and sour foods also were
always w^ell tolerated.
ad 5. — Was always healthy.
ad 6. — In August, 1905, while stooping, she noticed that gases or
fluids regurgitated; the latter Wfis mostly tasteless, at times somewhat
sour; since then constipation. In the beginning, despite the eructation,
could tolerate everything, except that she had a little pressure in the
epigastrium. At present only milk and broth are well borne. No pain,
no tenderaess on pressure.
ad 7. — Ascites ; edema in the lower extremities. Tumor not pal-
pable.
Stomach contents: Abundant lactic-acid bacilli.
Urine: Indication of a diazo reaction.
July 18th: During the night sudden severe pains, abdomen painful
on pressure, pulse cannot be felt, no increase in temperature ; death in
the evening.
ad 8. — Beginning: August, 1905.
Status presens : June 26, 1906.
Autopsy: July 18, 1906.
Duration: About 11^/2 months,
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Diffuse infiltrating
carcinoma, springing from the pylorus. Bilateral nodular metastatic in-
filtration of the ovaries. Acute fibrinous peritonitis resulting from per-
foration of the stomach (at the point of perforation an ulceration, the
size of a penny, not x>i carcinomatous origin).
CARCINOMA OF THE STOMACH 237
Epicrisis: Aiuoiig the initial symptoms of the case we find the peculiar-
ity that in stooping the pressure exerted on the stomach leads to a
regurgitation of gastric gases and fiuids ("expressible stomach").
The diazo reaction is remarkable. Both ovaries are the seat of meta-
static formations. Death as a result of a non-carcinomatous small gastric
perforation.
Case 75.— M. L., 67 years, F.
ad 1. — Of 5 brothers and sisters, -i died of pulmonary tuberculosis
between 40 and 50 years of age.
ad 2. — Two 3'ears ago there appeared what seemed to be nodes of
Hebcrden in the terminal phalanges of the fingers, accompanied by pain,
ad 3. — Xo infectious diseases.
ad 4. — Appetite always good, bowels regiilar.
ad 5. — Was always healthy; climacteric at 50 years of age.
ad 6. — Since the end of November, 1905, little appetite, great dis-
inclination toward meat. Bowels tardy. Since April, 1906, she noticed
a swelling in the right side of the abdomen; right lateral position impos-
sible; after every meal a painful feeling of pressure; pains in the back
on the right side, especially when Ij'ing down, less so when sitting up ;
therefore sits up many nights. For the past week general eczemas.
ad 7. — Extensive nodular tumor-masses in the right half of the
abdomen, vibrating with pulsation, and over them a tympanitic percus-
sion sound ; similar tumor-masses also on the left side, underneath the cos-
tal arch. Umbilicus firmly infiltrated. Severe edema of both lower ex-
tremities.
Blood: Leucocytes, 10,800; large mononuclear forms, 18%; hemo-
globin, 70%.
ad 8. — Beginning: November, 1905.
Status presens : June 27, 1906.
Autopsy: June 28, 1906.
Duration: 8 months,
ad 9. — Autopsy (Professor Dr. 0. Stoerli) : Diffuse medullary in-
filtration of the pylorus, general metastasis in the peritoneum and regional
glands (liver free from metastases). Histological finding: Carcinoma.
Epicrisis: The appearance of the nodes of Heberden would seem to
coincide in time with the beginning of the cancerous disease or precede
it shortly. This, as well as the general eczema, appearing a short time
before death, may be looked upon as a "dyscrasia."
The violent pains in the back, especially on the right side, are refer-
able to the carcinomatous finding.
The tough infiltration of the umbilicus ^^ deserved to be mentioned as
a partial manifestation of the general peritoneal metastasis.
The high percentage of large mononuclear forn>« is worthv of note,
as it is found much more frequently in lympho-sarcomatous processes.
"See Case 53.
238 TUMORS OF THE ABDOMINAL VISCERA
Case 76.— C. W., 62 years, F.
ad 1. — Father died of pulinonary tuberculosis.
ad 3. — No infectious diseases.
ad 4. — Always had good digestion, bowels regular.
ad 5. — Always was healthy.
ad 6.- — In the beginning of April, 1906, sudden profuse diarrhea,
lasting about one week, without pain ; general health good. Since the
end of April, 1906, at first 2 hours, later 5 to 7 hours after meals, heart-
burn ; at the same time constipation began. Since then also copious vom-
iting, preceded by cramp-like pains in the lower abdomen, extending to
the epigastrium and radiating into the dorsal and lumbar regions ; daily
vomiting. Stubborn constipation (lasting up to 10 days!). Liquid food,
e.g., milk, oggs, is more easily vomited, solid food being generally better
tolerated.
The following are tolerated: Soup, green vegetables, some beefsteak,
broilers, light flour foods, tea, cocoa. With right lateral decubitus in-
crease of pain and radiation along the esophagus, this leading to vomiting
more easily.
ad 7. — Superficial tumor at the level of the umbilicus. Frequent
gurgling in the stomach. Loud 5»plashing. Color of the face pale, no
edemas. "Coffee-ground" vomiting with a total acidity of 50% ; HCl,
30% ; pepsin, 10 mm.
Blood: Hgb., 50%; erythrocytes, 4,400,000; leucocytes, 10,000.
ad 8. — Beginning: Early part of April, 1906.
Status presens: June 27, 1906.
Operation: July 5, 1906.
Duration: About 3 months.
ad 9. — Finding at operation (Docent Dr. H. Lorenz) : A fairlv
movable tumor, the size of an apple, tough, nodular. Colon transversum
fixed to the tumor; glandular metastases in the omentum and mesocolon.
Gastro-cnterostomy retrocolica posterior.
Epicrisis: As among others in Case 75, where four brothers and sis-
ters died of tuberculosis, so also here there is a record of tuberculosis,
namely, in the father; my personal impression coincides with that of other
observers, namely, that tuberculosis is frequent!}^ met with among the
ancestors and relations of cancer patients.
Among the initial symptoms we find unaccountable diarrhea, soon giv-
ing way to most stubborn constipation. The latter Ix'havior may be con-
sidered the rule in gastric cancer.
Belonging to the early symptoms of the case, we also find heartburn,
which may probably be considered as a symptom of stagnation ; during
the further course there are "colics of pyloric stenosis." HCl secretion
is demonstrable even shortly before operative interference. The exceed-
ingly large quantity of pepsin is deserving of note.
Case 77.— E. Z., 57 years, M.
ad 1. — Father died in advanced age.
ad 4. — Had a very good stomach, could tolerate the heaviest foods.
CARCINOMA OF THE STOMACH -239
;ul (). — Sincx' uhout July, 1904, increasing anorexia and weakness
of tlie stomach ; had to he very careful, because otherwise f^astric pres-
sure would set in.
Januar}^, 1905: .\ttack of pain in the epigastrium, about three
hours after the noon-day meal, radiating toward the left, sometimes also
toward the right costal arch, lasting several hours. Frequent heartburn.
\() vomiting. Bowels moved daily. Since May, 1906, distention of the
alxlomen synchronous with the attacks of pain, the distention disappear-
ing with the pain. White meat, chopped into snifUl bits, is tolerated best.
Left lateral position proves most comfortable during an attack of pain.
ad 7. — A hard, very sensitive resistance in the middle of the epi-
gastrium. No edemas. Melena.
Blood: Erythrocytes, 3,100,000; leucocytes, 5,600; Hgb., 48'/f • Aery
numerous blood platelets.
ad 8.- — Beginning: July, 1904.
Status presens: July 7, 1906.
Operation: July 13, 1906.
Duration: About 2 years.
ad 9.- — Finding at operation (Docent Dr. A. Exner) : At about
the middle of the lesser curvature a cicatricial contracted spot, the size
of a nut, which has undergone hardening (carcinoma). In the mesentery
of the colon transversum, hard glands, bigger than hazelnuts, and thence
a diffuse infiltration of the mesocolon transversum. No stenosis of the
pylorus. Inoperable.
Epicrisis: This case runs its course without vomiting and without
constipation. The absence of both symptoms might, in part, be at-
tributed to the lack of a constriction of the pyloinis. It is well known
that pyloric constrictions are almost always accompanied by constipation.
Even without actual stenosis of the pylorus, the propulsion of the
gastric contents may be seriously interfered with when a portion of the
wall is put out of commission functionally, and then there may occur
attacks of pain which are, par excellence, characteristic of pyloric sten-
osis.
In this case there is no anorexia toward meat ; in fact, white meat,,
appropriately minced, is tolerated best. •
Case 78.— F. A., 75 years, F.
ad 1. — Both parents died at a very old age.
ad 2.- — Eight years ago had pains in the terminal phalanges of
the fingers, at present these bones are swollen after the manner of Hcber-
den's nodes.
ad 3.— No I. D. C.
ad 4. — At 50 A'^ears of age mild gastric complaints, e.g., poor tol-
erance for sausage; in other respects the stomach was very good, even
fat and sour foods being well borne.
ad 5. — Up to the time she was 15 years of age, suffered much from
hcadiiche, had to wear a green eye-shield. Later was always well, strong
240 TUMORS OF THE ABDOMINAL VISCERA
and looked well. For many years has had large varicose veins in the
legs.
ad 6. — At Christmas, 1905, beginning of periumbilical burning
pains, radiating toward the pit of the stomach ; pains irregular, now
and then remaining absent for several days, and even weeks. Good appe-
tite then as now; tolerates everything. No eructation, no vomiting.
Since April, 1906, the patient noticed a swelling, about the size of an
apple, in her abdomen, and at a place corresponding to the swelling, daily
pains radiating into the back. Continuous pains, at times becoming ag-
gravated and accompanied by gurgling, radiating from the umbilicus
toward the epigastrium and extending from there into the back. Appe-
tite good ; never vomited.
ad 7. — Somewhat prominent tumor, about the size of an apple, to
the right of the umbilicus, hard, nodular, possessing respiratory mobil-
ity, tympanitic resonance, decided pulsatory vibration. Systolic vascular
murmur underneath the xiphoid process. Traces of retromalleolar edema.
Temperature often over 37° C.
Feces: Abundant lactic-acid bacilli.
ad 8. — Beginning: December. 1905.
Status presens: July 13, 1906.
Operation : July 23^, 1906.
Duration : About 7 months.
ad 9. — Finding at operatfon (Docent Dr. P. Alhrecht) : Lesser
curvature extending almost to the level of the navel, taken up in its lower
portion by a firm, rough tumor, being about the size of an e^g, reaching
almost to the pylorus, firmly adherent to the head of the pancreas.
Epicrisis: Here, also,-" we have Heberden's nodes as a stigma of
dyscrasia. Periumbilical attacks of pain as early symptoms. Systolic
"epigastric" vascular murmur. Appetite conserved until immediately
before the operation, no meat anorexia.
Case 79.— S. G., 48 years, M.
ad 3.— No I. D. C.
ad 4. — Never had any gastric complaints, was not a strong eater;
'ate many onions and garlic.
ad 5. — Always was healthy.
ad 6. — In November, 1905, after having ingested an unusually
large amount of food, had a feelino; of pi'cssurc in the stomach ; later,
also, after a smaller intake of food. Appetite became diminished, but
could still eat everything. Ill-smelling eructation. In April, 1906, he
began to frequently vomit brown masses, even without having eaten anv-
thins". In the summer of 1906 he went to Karlsbad, after which he felt
considerably improved. In September, 1906, several glands, which sup-
purated. aDpeared in the left supraclavicular fossa and also in the left
axilla. The patient was sent to an iodin bath in Galicia. At that time
Compare Case 75.
CARCINOMA OF THE STOMACH 241
the appetite was already bad. Vomiting once a week. Constipation since
November, 1906.
ad 7. — A hard tumor, about the size of a nut, underneath the right
costal arch. Much dilatation of the stomach and distinct gastric peri-
stalsis. Glands on the left side of the neck and one gland deeply situated
behind the left clavicle, moderately firm bunch of glands in the left axilla,
suppurated. No edemas ; no angiomas.
Stomach contents, fasting: 500 cm^, dark brown, bad odor.
41% total acidity.
20% HCl.
Repeated withdrawal (fasting): 38% total acidity.
8% HCl.
After test-hreakfast: 12% total acidity.
3% HCl.
Microscopic examination: Many sarcIn.-E and a few single lactic-acid
bacilli. Constant hiccough and eructation of SH2.
ad 8. — Beginning: November, 1905.
Status presens : November 7, 1906.
Operation: November 19, 1906.
Duration: About 1 year,
ad 9. — Finding at operation (Docent Dr. H. Lorenz) : Constrict-
ing carcinoma of the pylorus. Posteriorly the pylorus is adherent to the
pancreas, superiorly with the ligamentum hepato-gastricum. Gastro-
enterostomy retrocolic.
Epicrisis: The commonplace symptom of gastric pressure introduces
the manifestations of disease. Whenever this occurs in an individual
previously having a sound stomach, it should never be neglected, the more
so when it exhibits distinct progressiveness (in the beginning only after
large quantities and later after even smaller quantities of food). As is
so frequently the case, the patient was sent to Karlsbad instead of to the
surgeon. The patient says there was considerable improvement! Such
improvements of a transitory kind, though exceptionally, do occur; evi-
dently it is the gastritis, often accompanying the cancer, which experi-
ences the improvement.
The appearance of glands in the left supraclavicular fossa and in the
left axilla probably suggested a tubercular process ; the patient was or-
dered to an iodin bath.
Metastases in the glands of the left supraclavicular fossa are not an
altogether rare finding in the later stages of gastric cancer, at any rate
not so rare as metastases in the axillary glands.
One is strongly inclined in this case to think of gland metastases ;
the suppuration of the glands, though, is strange, as it is practically
never observed in carcinomatous glands. Two possibilities suggest them-
selves. Either there was a transportation of pus-cells from the ulcerat-
ing tumor at the same time that the cancerous cells were transported or
there may have been pre-existing tubercular glands in which the cancer
metastasis gave rise to suppuration.
There is persistence of HCl secretion. It is most clearly demonstrable
242 TUMORS OF THE ABDOMINAL VISCERA
in the stagnating masses withdrawn from the fasting stomach (irritant
effect of the products of decomposition!), the mild irritation of the test-
breakfast elicits only HCl secretion.
Sarcin^e prevail among the vegetations.
Case 80.— D. D., 58 years, F.
ad 3. — Measles at 7, otherwise no I. D. C.
ad -i.- — Has had stomach trouble since she was 30 years of age ; fre-
quent gastric pressure, especially in winter, less in summer. Complaints
come on after prolonged fasting, but also after eating; sitting is un-
favorable, motion favorable. Intolerance toward milk (better borne when
taken with coffee) and grain flour foods ; often induces artificial vomiting
after meals. Constipation began when 50 years of age.
ad 6.— Since the middle of September, 1906, increase of the former
stomach complaints. Heartburn. Attacks of pain radiating from the
epigastrium into the right thorax, especially one or two hours after the
noonday meal, relief after vomiting; during tlie painful attack right
lateral position is impossible. Constipation. Disgust for meat; nourishes
herself with milk, soup and vegetables. Slight tenderness on pressure to
the right, above the navel.
ad 7. — Stomach dilated, splashing sounds and spontaneous bor-
borygmi. No visible peristalsis.
Stomach contents: Abundant sarcinse, HCl distinctly demonstrable.
Feces: Tarry, containing abundant leptothrix threads,
ad 8. — Beginning: September, 1900.
Status presens: November 14, 1906.
Operation: November 21, 1906.
Duration: About 2 months,
ad 9. — Operation (Decent Dr. P. Albrecht) : Carcinoma constrict-
ing the pylorus, involving the duodenum to the extent of one cm and ad-
herent to the pancreas. Gastro-entcrostomia rctrocolica posterior.
Epicrisis: One of the comparatively rare cases in which the cancer
does not develop in the midst of the best health, but seems to be brought
on after years of gastric symptoms (ulcer.'').
Though inspection does not reveal increased gastric peristalsis, the
existence of lively spontaneous stomach roaring points to the hindrance
at the pylorus, which is made evident by the finding of sarcinae. The
right-sided "painful position" also is of pyloric origin.
Persistence of HCl secretion.
Case 81.— Th. J., 55 years, F.
ad 3.- — Diphtheria, scarlatina, measles.
ad 4.— Appetite always very good ; never any stomach complaints,
-ad 6.^ — Since January, 1906, feeling of pressure in the epigastrium,
especially after ingestion of sweet foods. Appetite good at the start, no
eructation. Since October, 1906, has vomited about 30 times. During
the last few months there appeared, especially on the anterior portion of
the thorax, a brownish discoloration in spots. Severe emaciation of late.
CARCINOMA OF THE STOMACH 243
After intake of food pains in the back, particularly when there is simul-
taneous feeling of pressure in the epigastrium.
ad 7. — A hard, uneven tumor-mass can be felt underneath the left
costal arch, especially when the patient is in right lateral position. The
liver is tender on percussion, enlarged, and has a nodular surface; a "cor-
set lobe," filled with nodules, yields distinct ballottement. The spleen
extends to the costal arch. No edemas. The skin, especially over the
anterior portion of the chest, is pigmented dark brown,
ad 8. — Beginning: January', 1906.
Status presens: January 5, 1907.
Autopsy: February 11, 1907.
Duration : About 1 year.
ad 9. — Autopsy (Hofrat Professor Dr. A. Weichselbaum) : Dif-
fuse scirrhus carcinoma, involving the greater part of the stomach, to-
gether with contraction and diminution in its size. Metastases in the
neighboring lymph-glands, in the great omentum, peritoneum and pleura,
also in the liver. Compression of the portal vein and the ductus chole-
dochus by contracting cancer tissue. Hydrops-ascites. Icterus. Atrophy
of the right adrenal body and partial incrustation of its capsule. Brown
discoloration of the skin of the thorax.
Epicrisis: The pigmentations of the skin, which formed in the last
months of the disease, are worthy of note. As they were of an Addisoni-
an character, attention was given to the condition of adrenals at autopsy,
and it was found that the right adrenal body had become contracted
through imbedding in indurated cancerous tissue. Quite analogous pig-
mentations, however, are also met with in connection with other neoplasms
leading to cachexia (especially pancreas) ^^ without any changes in the
adrenal bodies.
As almost always happens with the scirrhus type of gastric cancer, so
also here, there is carcinomatosis of the peritoneum.
There are present lumbar pains which depend on the intake of food,
and are of the same genesis as the epigastric feeling of pressure.
Case 82.— L. Sch., 42 years, M.
ad 3. — Smallpox and diphtheria.
ad 6. — Since March, 1906, feeling of pressure in the epigastrium,
especially after eating, lasting about 14 of ^^ hour, in the beginning ap-
pearing at intervals of one week ; gradual increase of this feeling of
pressure. Often three to four Huid stools. Of late anorexia, constipa-
tion. During the last three weeks, rapidly increasing bulging in the
region of the liver; for several days past feverishness and herpes labialis.
During the last few days could tolerate only right lateral position with
knees drawn up, every change in position exceedingly painful. Often sud-
denly occurring pressing pains in the epigastrium, at the same time also
in the back.
ad 7. — Liver distinctly enlarged, very sensitive to pressure, bor-
" See page 44.
244 TUMORS OF THE ABDOMINAL VISCERA
der very firm; distinct systolic vascular murmur audible over the liver.
Dilated veins cross the right costal arch. Pallor of the face ; no edemas.
Transient temperature of 39.4° C. and herpes labialis.
Urine: much urobilinogen.
Blood: 11,000 leucocytes.
ad 8. — Beginning: March, 1906.
Status presens : January 5, 1907.
Autopsy: January 22, 1907.
Duration: About 10 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Soft, medullary carci-
noma of the stomach at the lesser curvature, not constricting, in the form
of papillary proliferations. Diffuse metastases in the liver with peri-
hepatitis. Several polypi in the gastric mucosa. General icterus.
Epicrisis: Symptoms referable to the liver came so prominently into
the foreground that for a time the possibility of a cholelithiasis with
abscess formation as well as an echinococcus infection was thought of.
On account of the perihepatitis, the patient had to remain immo-
bilized in the right lateral position, every change in position being ex-
tremely painful.
High fever up to 39.4, accompanied by an herpetic eruption, could
lead one to think of an infectious process in the liver. Chemically, the
metastasis in the liver found expression in the urine by the appearance
of a strongly positive aldehyde reaction (urobilinogen).
Case 83.— F. L., 50 years, F.
ad 3. — Had scarlet fever at 5 years of age.
ad 6. — Since the middle of September, 1906, pains during meals
behind the lower third of the sternum, later on along the left costal arch
and to the left of the sternum; relief after vomiting. The patient was
hungry, but did not eat for fear of the pain. Pain in the back on motion,
ad 7. — Tongue very much coated. Epigastrium somewhat ten-
der on pressure, so also the region of the spleen ; no palpable tumor. No
edemas; particular abundance of angiomatous formations.
Gastric contents: Abundance of lactic-acid bacilli.
Urine: Strongly positive aldehyde reaction,
ad 8. — Beginning: September, 1906.
Status presens: January 16, 1907.
Autopsy: January 29, 1907.
Duration: About 4l/o months,
ad 9. — Autopsy (Hofrat Professor Dr. A. Weicliselhaum) : Diffuse
scirrhus of the stomach with constriction of same and diminution in size.
Metastases in the great omentum and peritoneum with much contraction
of the mesentery of the small intestinal loops. Sero-fibrinous peritonitis
and a fresh pleurisy on the left. Numerous concretions in the gall-bladder
which was about the size of a goose egg.
Epicrisis: As an early symptom the previous history records retro-
sternal sensations occurring after meals, which might occasionally be mis-
interpreted as angina pectoris.
CARnXOMA OF THE STOMACH 245
The strongly positive aldehyde reaction in the urine in this case is
not explained by the metastases in the liver, but in the accompanying
cholelithiasis.
Case 84.— Sch. S., 40 years, M.
ad 3. — Malaria at 8 (lasting 6 months). In 1879, 30 years ago,
syphilis (inunction treatment).
ad 4. — Up to six years ago never had any gastro-intestinal disturb-
ances. Six years ago the appetite became bad ; after eating sauerkraut
or "fisolen" there was a feeling of fulness in the stomach followed by
vomiting, later also intolerance toward meat and flour foods.
ad 6. — Since March, 1906, there are pains of a pressing character
and vomiting after every meal. During the painful attacks the epigas-
trium is distended and loud rolling is audible. Constipation, alternating
with diarrhea. During the last three weeks the vomiting has ceased;
since then there is a disinclination toward tobacco ( formerly 30 cigarettes
daily). For the past three weeks a small swelling is noticeable in the
epigastrium. During the past six months cramp-like pains, especially
after the intake of solid foods.
ad 7. — A transversely running cord can be felt underneath the left
costal arch. Manifestations of atelectasis on the left side posteriorly
below. No edemas.
After test-breakfast: HCl, negative; total acidity, 2%. Mo N. Na.
OH. No lactic-acid bacilli.
Blood: 5,900,000 erythrocytes, 7,600 leucocytes, 75% Hgb.
Quantity of urine: Between 2,000 and 3,000 cm^.
ad 8. — Beginning: March, 1906.
Status presens : January 17, 1907.
Operation : February 9, 1907.
Duration: About 11 months,
ad 9. — Finding at operation (Docent Dr. H. Lorenz) : Anterior
wall of the stomach partly occupied by firm uneven tumor, which extends
into the pyloric region and encroaches on the posterior wall of the
stomach. Numerous glandular metastases in the small and large omentum.
Epicrisis: Dilatation pains of the stomach, together with distention
of same and "rolling," play an important part from the beginning also
in this case. Lactic-acid bacilli are absent, despite the advanced stage
of the disease.
Atelectasis in the left lower lobe of the lung. Tendency to polyuria;
edemas are absent.
Case 85.— W. B., 42 years, M.
ad 1. — Mother alive, 73 years old.
ad 3. — No infectious diseases.
ad 4. — Always had a good appetite, bowels regular; also fatty, sour
and gas-forming foods were well borne ; always had a preference for
strongly spiced foods.
246 TUMORS OF THE ABDOMINAT. VISCERA
ad 5. — On account of bodily weakness was exempted from military
service ; is said to have coughed up blood for several weeks, 17 years ago.
ad 6. — Since October, 1906, feeling of pressure after eating, often
sour eructation, constipation. Only milk and soup are tolerated. ]\Ieat
is immediately vomited.
Feeling of pressure in the region of the stomach, radiating under the
costal arches on both sides.
ad 7. — With left lateral position a tumor can be felt deep under-
neath the right costal arch, sensitive to pressure. Dilatation of the
epigastric veins. Epigastrium bulging, tense. A hard, enlarged gland
in the left supraclavicular fossa. No edemas, ^'omitus contains sar-
cin«e and a moderate abundance of lactic acid bacilli.
ad 8. — Beginning: October, 1906.
Status presens : February 25, 1907.
Operation: February "28, 1907.
Autopsy: March 27,^1907.
Duration : About 6 months.
ad 9. — Operation (Docent Dr. H. Lorenz): Cancer at the pylorus
with metastases in the mesocolon and mesentery. Chylous ascites.
Autopsy (Professor Dr. O. Stoerk) : Carcinoma of the pylorus en-
croaching on the duodenum with severe stenosis at that place. Gastro-
enterostomy 14 days ago. Extensive metastases on the peritoneum, in
the liver, in the mesenteric and retroperitoneal lymph-glands. Ascites
chylosus. Scars in the left pulmonary apex.
Epicrisis : In his youth the patient had been alHicted with a mild form
of tuberculosis (hemoptysis), the remains of whicii showed up at autopsy
as an induration in the left pulmonary apex.
Here again the disease begins in the midst of good health with "gas-
tric pressure."
The syndrome "ascites and left-sided supraclavicular hard gland"
soon informs us of the nature of the process. The "milky" character
of the ascitic fluid desei-ves attention.
Case 86. — A. H., 39 years, M. Mason.
ad 3. — Varicella.
ad 4. — At 14 years of age, after eating meat, had violent stomach
cramps (sick for 10 days) ; since then intolerance toward blackbread,
hard meat, fat. Appetite always good. Bowels regular.
ad 6. — Beginning about the middle of February, 1907, with
troublesome sour eructations, appetite then, as now, was good, bowels
regular up to the present time. For the past 14 days pain on the left
underneath the costal arch ; cannot lie on his left side. Pain after every
intake of food, even after milk. Epigastrium very sensitive to pressure.
ad 7. — On the left, underneath the costal arch, a firm tumor about
the size of a walnut ; over it a loud systolic blowing during expiration.
Numerous enlarged glands in the left supraclavicular fossa, but none
anywhere else.
After test-hreakfast: HCl negative, a few short lactic-acid bacilli.
CARCINOMA OF THE STOMACH 247
Blood: 5,900 kucocytcs.
Urine: Diazo reaction positive.
ad 8. — Beginning: February, 1907.
Status presens: May, 1907.
Operation: June 6, 1907.
Duration : About 3 months,
ad 9.^ — Finding at operation (Doccnt Dr. P. Albrecht) : Hard
tumor about the size of an egg, springing from the lesser curvature of tlie
stomach, intergrown with the under surface of the liver; retroperitoneal
gland metastases.
Epicrisis: The combination of the two symptoms, epigastric vascular
murnmr and diazo reaction, almost make certain the diagnosis of a malig-
nant disease, and to these there is still added the presence of one of \'ir-
chow's glands. Appetite good; bowels regular.
Case 87.— L. W., 45 years, M.
ad 1 . — Father died at 70, mother at 68 years of age ; neither cancer
nor tuberculosis in the family.
ad 2. — As a child inclined to be weak.
ad 3. — No infectious diseases of childhood ; in 1885 had a "menin-
geal typhoid" for 8 weeks.
ad -i. — Since having typhoid there is an intolerance toward bloat-
ing foods and fat meat; no heartburn, but often gastric pressure and
bowel troubles.
ad 6. — Since January, 1909, therefore for about II4 years, often
flatulence and borborygmi, pain in the lower abdominal region, easily con-
stipated. Appetite bad, frequent eiaictation, of late having the odor of
"rotten eggs." Since the end of February, 1910, appetite completely
vanished, much distention in the epigastrium, much rumbling in the belly.
On deep breathing there are painful sensations in the epigastrium, also
frequent attacks of cramps lasting only a few seconds, coming on about
two to three hours after meals, occasionally appearing also at night so
that the patient is awakened from sleep. From February 19th of this
year to INIarch 31st the patient has lost 8 kg. Never any vomiting.
ad 7. — Color of the face not cachectic, no edemas, a very distinct
arcus senilis. Tongue not coated. Epigastrium somewhat tender to
pressure, especially in the middle line ; no splashing sounds. No resistance
can be felt even after repeated examination. Cutaneous tubercular re-
action positive. Frequent temperature over 37° C.
Gastric contents (after tea and roll breakfast) March 18th: Total
acidity, 4% ; Mo N. Na OH. Free HCl is absent. No food residue
from the previous day. Abundance of lactic-acid bacilli, partly devel-
oped into verv long threads. No sarcinae.
March 27th: Total acidity, 6%; Mo N. Na OH. No food residue;
sporadic rod-shapes reminding one of leptothrix buccalis.
Stool: Presents almost constantly a pure culture of typical, partly
very long lactic-acid bacilli. Fairly abundant soap needles (after moder-
ate intake of fat!). Blood-coloring material in very small quantity.
248 TUMORS OF THE ABDOMINAL VISCERA
Blood: Ugh., 90-100%; leucocytes, 15,000.
ad 8, — First symptoms : January, 1909.
Status presens: March 20, 1910.
Operation : April 5, 1910.
Duration : About 1 year, 3 months,
ad 9. — Operation (Primarius Dr. Fr. Schopf) : Extensive carcino-
matous infiltration, particularly of the posterior surface of the stomach,
originating in the lesser curvature, with a suggestion of an hour-glass
stomach. Gastro-cnterostomy.
Epicrisis: The chief interest in this case lies in the comparison be-
tween the gastric and intestinal bacteriological findings.
Whilst the feces remaining constantly the same and showing at every
examination abundant presence of typical lactic-acid bacilli made one
think, in the first place, of the existence of a gastric cancer, the stomach
contents showed a changeable finding.
At the first examination a typical bacteriological finding: abundant
lactic-acid bacilli, among them many giant forms.
At the second examination only a few rod-shapes but little character-
istic as to their morphological details.
This case speaks for the greater constancy of the fecal vegetative
findings as compared to the gastric flora, which latter may, under circum-
stances, be subject to considerable variations, corresponding probably to
the varying degree of stagnation.
It is worthy of note that neither at tlie first nor second examination
was there any food residue from the previous day ; nor were there any
indications of a pyloric stenosis (no peristalsis, no dilatation, never any
vomiting) .
No tumor could be felt corresponding to the extension of the cancer
along the surface.
Here, in addition to the finding of decided hypoacidity, the presence
of an abundant vegetation of lactic-acid bacilli in the stomach contents
and especially in the feces formed an integral part of the diagnostic cal-
culation.
Furthermore worthy of note were the continued anorexia, cramps dur-
ing the period in which the stomach was emptying itself (about 2 hours
after eating), and sour eructation.
The blood showed a leucocytosis of 15,000.
The very pronounced arcus senilis (early senility?) in a man onl}' 45
years of age was remarkable.
Case 88.— J, H., 64 years, M.
ad 3. — No infectious diseases.
ad 6. — Began with pain in the stomach, vomiting and diarrhea ;
now and then night-sweats. Epigastrium sensitive to pressvire.
ad 7. — A resistance of cartilaginous hardness, the size of a walnut,
in the pyloric region. Distinct gastric peristalsis. Loud systolic mur-
mur over tlic aortic valve. Pulse 50.
CARCINOMA OF THE STOMACH 249
ad 9. — Autopsy (Professor Dr. Fr. Schlagenhaufer) March 15,
1908: Infiltrating fibrous carcinoma of the pyloric region with stenosis.
Aortic insufficiency and stenosis.
E.picrisis: Night-sweats occasionally appear as an early s^^mptom of
malignant diseases ; the bradycardia existing in this case permitted from
the start the exclusion of a progressive tubercular process as the cause of
the night-sweats.
Case 89.— R. H., 30 years, F. '
ad 1. — Parents are living and well, so, also, brothers and sisters,
ad 3.— No I. D. C.
ad 6. — Since June, 1906, increasing pallor and loss of appetite
especially for meat. Since June, 1907, there is a hard, painless swelling
underneath the left costal arch. Bowels mostly constipated; frequent
eructation of bile. Of late frequent colicky pain underneath the left cos-
tal arch and around the umbilicus, said to be independent of intake of
food. Lumbar pains.
ad T. — In the epigastrium on the left side a tough, hard tumor-
mass, distinctly movable with respiration. Soft glands in the left su-
praclavicular fossa. No symptom of pyloric stenosis.
Pigment anomalies of the skin, hyperpigmented areas alongside of
non-pigmented ones. At the waistline where the skirts are fastened there
is a girdle-like depigmented broad stripe encircling the trunk. Mild
edema of the eyelids. Irregular slight increases in temperature.
Feces: Abundant vibrios.
Blood: Hgb., 20%.
ad 8. — Beginning: June, 1906.
Status presens : June 1, 1908.
Autopsy: June 15, 1908.
Duration : 2 j^ears.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Ex-
tensive, ulcerous disintegrating carcinoma of the pyloric region of the
stomach, enormously extensive glandular metastases retroperitoneally, in
the posterior mediastinum and also in the region of the thymus ; the
supraclavicular glands on both sides have undergone necrotic softening.
Severe anemia.
Epicrisis: An early cancer at the age of 30, being according to rule
with regard to its duration (two years).
The pigmentary anomalies, arranged in segments, found also in perni-
cious anemias, deserve attention as signs of an abnormal constitution.
Virchow's glands in this case are of exceptionally soft, medullary con-
sistence. The glandular metastases, the liver remaining entirely free,
is remarkable.
The feces exhibit a well-developed growth of vibrio which is foreign to
a normal stool.
The edema of the eyelids may in part be due to the formation of
metastases in the mediastinal glands.
250 TUMORS OF THE ABDOMINAL VISCERA
Case 90.— A. A., 76 years, F.
ad 1. — Parents were healthy, died at a very old age (over 80).
ad 3. — Measles ; otherwise no I. D, C.
ad 5. — Always was healthy ; inflammation of varicose veins at 25.
ad 6. — Since July, 1908, after meals vomiting and foul smelling
eructation ; disgust for food. Diarrhea alternating with constipation.
For the past 2 years treated for floating kidney (.'').
ad 7. — Extensive, hard tumor-mass at about the level of the umbili-
cus, movable in all directions, except that the downward movability is
limited. Vomitus contains intestinal flora.
ad 8. — Beginning: July, 1908.
Status presens : September 27, 1908.
Autopsy: September 28, 1908.
Duration : 2 months.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Car-
cinoma, about the size of a man's fist, originating in the lesser curvature
of the stomach, put rif active.
Epicrisis : One is inclined to suspect that the supposedly floating kid-
ney for which this 76-year-old patient was treated for two years was
identical with the gastric tumor which remained movable up to the last.
Decomposition of gastric cancer is not of very frequent occurrence. It
is necessary, however, to recognize this possibility, as otherwise in case of
fecal vomiting accompanied by intestinal flora one may in similar cases
be misled into thinking of intestinal processes (bowel stenosis, etc.) or at
least assuming a gastro-colonic fistula.
Case 91. — J. S., 61 years, M. Wood turner.
ad 1. — Father died at 45 from pulmonary hemorrhage, mother died
of old age ; 3 brothers and sisters are well.
ad 2. — Hair turned gray onl}' during last 10 years, formerly had
black hair like the other members of the family. No rheumatism.
ad 3.— No I. D. C. No lues.
ad 4. — Never had stomach pain ; could eat very fat foods ; bowels
always regular.
ad 5. — No alcohol, no tobacco; was always perfectly healthy; the
present disease is his first.
ad 6. — Constipation since October, 1908. In the summer of 1909
those around him noticed his pale appearance. In July, 1909, continuous
feeling of cold. Coughing began ; the appetite became bad. Intolerance
toward meat. Immediately after eating meat abdominal cramps lasting
two hours. Emaciation only during the last weeks. No vomiting up to
the end, frequent einictation, great thirst,
ad 7.- — A transverse cylindrical tumor-mass in the epigastrium,
somewhat to the left and above the level of the umbilicus ; tenderness to
pressure at that place. Yellowish coloration of the face (no jaundice).
No edemas (October 30, 1909) ; severe edema (December 1, 1909). Pos-
teriorly on the right side below a pleural effusion measuring the width of
CARCINOMA OF THE STOMACH 'Jol
a h.uul (slightly licinorrhugic). Pulse 120 (36° C.)- No angiomas on
the skin. Frequent temperature of 38° C.
Stool: Constant presence of abundant blood-coloring matter; no lac-
tic-acid bacilli.
Urine: No diazo reaction; aldehyde reaction absent in the beginning,
later continuously strongly positive. Indican reaction negative.
Blood: Hgb. 60-70% (October 30, 1909).
ad 8. — Beginning: October, 1908.
Observation : October-December, 1909.
Autopsy: December, 1909.
Duration : About 1 year, 2 months,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Ul-
cerating medullary carcinoma of the pyloric region of the stomach, non-
stenosing. Right-sided fibrinous hemorrhagic pleuritis. A gangrenous
area about the size of a fist in the left upper lobe (aspergillosis!).-- No
metastases in the liver nor at the porta hcpatis.
Epicrisis: A pyloric carcinoma running its course without vomiting!
In contradistinction to the fibrous forms, medullary cancers of the stom-
ach, rarely constricting because of severe ulceration, yield but few local
symptoms (anemia, edemas, cachexia) appear very prominently. A yd-
lowish discoloration of the face is peculiar, especially to the medullary
forms of gastric cancer. Constipation was the very first symptom. Pro-
nounced elimination of urobilinogen in connection with gastric cancer is
not an absolutely certain criterion of formation of metastasis in the liver
or ad portam hepatis. It must, however, cause one to think of same.
Ohfrmeyer's indican reaction was negative (pancreas normal).
The right-sided moderate hemorrhagic pleural effusion was due to
tuberculosis; the area of disintegration in the left upper lobe (contents
odorless) owes its origin to an aspergillus invasion.
Case 92. — A. S., 54 years, M.
ad 1. — Father and mother died of some stomach disease.
ad 3. — Had pneumonia once; no I. D. C.
ad 6. — In March, 1908, beginning of stomach trouble; the patient
could not eat anything, had to vomit everything; with it there was eruc-
tation without bad taste. In August, 1908, was operated on for sus-
pected rectal cancer; a general carcinomatosis of the peritoneum was
found to be present. It is said that at that time there was obstipation,
often lasting 8 days, frequent foul-smelling, even fecal vomiting.
ad 7. — Tensely elastic abdomen with intestinal peristalsis and loud
rumbling. Rectum : At the anterior circumference a semicircular, bonj--
hard mass of infiltration covered bv mucous membrane.
'* In the cavity in the Innjr there is peculiar network, ajiparently made up of hlood-
vessels, the trabeculae beinp: substituted by a mortar-like mass; contents have no bad
odor. These mortar-like masses consist of a thick weaving of mycelia. Histologicallv,
the pleura is found to be tubercular.
252 TU.AIORS OF THE ABDOMINAL VISCERA
Feces : Very light colored, containing much neutral fat and fatty acid
needles.
ad 8. — Beginning: March, 1908.
Status prcsens: October 1, 1908.
Autopsy: October 11, 1908.
Duration: About 7 months,
ad 9. — Autopsy (Pros. Professor Dr. Fr. ScJilagenhaufer) : In-
filtrating carcinoma of the stomach and general carcinosis of the peri-
toneum ; stenosis of the ileum. Ileus. Metastases about the rectum ; dis-
tention of the large gut.
Epicrisis: Father and mother had also died of gastric cancer.
During the latter course manifestations of intestinal constriction oc-
cupied the foreground (intestinal peristalsis, fecal vomiting, severe con-
stipation), so that, as the history states, in view of a tumor-mass which
could be felt through the rectum the false diagnosis of a rectal cancer was
made. Of late there were present fat-containing stools which, for lack
of a corresponding finding in the liver or pancreas, must be considered
as of intestinal origin (disturbed absorption).
Case 93.— J. G., 61 years, F.
ad 1. — Father died of pulmonary catarrh.
ad 3. — Measles at 6; typhoid at 11; had pneumonia once.
ad 4. — Formerly had so good a stomach that she "could have eaten
pebbles."
ad 6. — For the past four years has had stomach trouble: vomiting
and extremely foul-smelling eructation. Constipation. Lost over 20 kg
in weight during one year.
ad 7. — Daily vomiting of "coffee-grounds," containing sarcinas.
ad 8.— Autopsy: November 10, 1908.
ad 9. — Autopsy (Pros. Professor Dr. Fr. ScJilagenhaufer) : Cir-
cular constricting carcinoma of tlie pylorus with great dilatation of the
stomach and consequent dystopia of the pylorus (pylorus on a level with
the bifurcation of the abdominal aorta).
Epicrisis: The drastic expression with which this patient characterizes
her former digestive power, "I could have eaten pcbV)les," recurs fre-
quently in the statements of patients suffering from cancer of the stom-
ach. As already emphasized, it seems that "stomach athletes" are more
disposed to gastric cancer than stomach weaklings. Foul smelling eruc-
tation always deserves very earnest attention.
Case 94.— F. S., 61 years, M.
ad 3.— No I. D. C.
ad 6. — Pale face color for the past year ; for the past 7 weeks
even the smallest spoonful of soup is vomited. Constipation since the
beginning of the disease.
ad 7. — Ascites. On the left side underneath the costal arch a tumor-
mass can be felt. (Autopsy: Omentum thrown back over the upper surface
CARCINOxAIA OF THE STOMACH 253
of the liver.) The patient vomits fetid pus, containing lactic-acid bacilli
of enormous length, besides colon bacilli,
ad 8.- — Beginning: December, 1907.
Status presens : December 7, 1908.
Autopsy: December 10, 1908.
Duration: About 1 year,
ad 9. — Autopsy (Pros, Professor Dr. Fr. Schlagenhaufer) : Con-
stricting carcinoma of the pylorus, ulcerating very much; few scattered
metastases in a cirrhotic liver. Omentum infiltrated in toto and thrown
back on the upper surface of the liver. Abscess in the left upper lobe of
the lung.
Epicrisis: Increasing pallor of the face counts among the early symp-
toms of carcinoma. It may be due to diminished hemoglobin content
(hemorrhage!), but it may also be that there enters into consideration,
as a causative factor, a decrease in the force of the circulation due to
cachexia, analogous to the acute pallor in transient indispositions of
fainting spells. Vomiting of macroscopically recognizable pus belongs
to exceedingly rare findings in gastric cancer; the pus flora ("giant
forms" of lactic-acid bacilli) in this case were of value for a rapid diag-
nosis.
The tumor that could be felt corresponding to the omentum thrown
back on the upper surface of the liver.
Case 95.— M. H., 36 years, F.
ad 6. — Cough since November 2, 1908; appetite became less, fre-
quent nausea, now and then vomiting. Three weeks ago a feverish feeling
(chilliness), rather severe coughing and stabbing in the left chest and
back, especiall}^ on breathing. No expectoration ; of late no feverishness.
ad 7. — A well-nourished individual with a somewhat pastj^ coun-
tenance, pale facial color, slightly cyanotic. Temperature, mostly 36° C»
Pulse, 114-126. Very great dyspnea and tachypnea with extreme air
hunger. For want of breath the patient cannot lie down, but must sit
up. Pain on pressure over the base of the left lung and in the axillary
portions ; there was also dulness over an area about the width of a hand,
and bronchial breathing; on the right shai*p vesicular breathing, with
here and there an indication of crepitation. In the left supraclavicular
space small, soft glands, the size of a bean. Cardiac findings normaL
Aspiration on left side posteriorly below: Hemorrhagic eflFusion, con-
taining remarkably large cells with nuclei rich in chromatin and large
cell-conglomerations, much variegated forms.
Gram stain: Diplococci.
ad 8. — Beginning: About November 15, 1908.
Status presens: January 15, 1909.
Autopsy: January 20, 1909.
Duration: About 2 months,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Mili-
ary, lymphogenous carcinomatosis of both lungs (macroscopic appear-
ance reminding of miliary tuberculosis), originating from a small ulcer-like
254 TUMORS OF THE ABDOMINAL VISCERA
carcinoma of the stomach. In fresh sections of the lung one can see
innumerable grayish-white nodules, from the smallest size to that of a
lentil, which are united by extremely fine threads. This diffuse infiltra-
tion of the pulmonary tissue can also be made out very distinctly with
the fingers. The lymphatic channels of the pleune are filled with can-
cerous masses ; in the left pleural cavity there is a hemorrhagic effusion.
Epicrisis: As a result of the peculiar miliary formation of metastases
in the lungs the gastric cancer in this case ran its course in a way that
would remind one of miliary tuberculosis.-"^
The following points were decisive in making during life the diagnosis
of "miliary carcinomatosis of the lungs": The extreme dyspnea (cardiac
findings normal and no other etiology present) could by exclusion be
interpreted only as pulmonary.
Against miliary tuberculosis: afebrile course, absence of diazo reac-
tion. Aside from the small pleural effusion no objective pulmonary find-
ing and yet maximal disturbance in function ! This contrast reminded
one of the similar behavior in miliary tuberculosis. The microscopical
finding in the hemorrhagic fluid obtained by aspiration was highly sug-
gestive of malignant disease. It is true there were Gram staining diplo-
cocci present, but this was explained by way of an intercurrent infection.
The finding of glands in the left supraclavicular fossa confirmed the as-
sumption of a malignant process. All this taken together led to the diag-
nosis of a "miliary carcinomatosis of the lungs" which was actually veri-
fied at autopsy.
Case 96.— N. N., 60 years, F.
ad 4. — Stomach ailments for the past four years ; there were present
exquisite "hunger pains" of a burning character, spreading also over the
lower portion of the sternum. The pain ceased immediately after drink-
ing milk, so also after dinner, but recurred after two hours. No tender-
ness on pressure. Slight improvement at Karlsbad.
ad 6. — For the past half year there is no longer any "hunger
pain" ; not even when the patient goes without food all day are there any
pains. Milk is poorly tolerated, causes sour burning and belching of
gas ; often gurgling noises along the esophagus. Solid foods, such as
ham sandwich with caviar, are better tolerated than liquids. Ham eaten
at night is at times vomited the next morning. During the last half
year has lost 20 kg in weight.
ad T. — Transversely running, very firm cylindrical tumor under-
neath the xiphoid process, ascending and descending with respiration.
No splashing; no peristalsis.
After test-hreakfast: HCl absent, pepsin absent; flora: lactic acid and
colon bacilli.
ad 8. — Beginning: Middle of April.
Status presens: October 10, 1904.
Operation : Short time after.
" See H. Ifippman. Uber einen Fall von akuter hamatogen. Carcinosis. Zeitschr.
f. Krebsforschung, 1905, page 290.
rARCINOMA OF THE STOMACH 255
ad 9. — OporHtion : Extensive gastric cancer necessitating almost
total resection of the stomach. Relapse after one year.
Epicrisis: The appearance of the cancer in this instance is marked
by the cessation of pain.
During the benigni stage of the disease, which was probably an ulcer,
hunger promptly elicited pain which was cut short by the ingestion of
milk (neutralization of HCl in the gastric juice!).
As the cancer l)rought about the permanent cessation of HCl secretion
it led to permanent disappearance of the "hunger pain." Pronounced
eructation of air with gurgling noises along the gullet, as met with in this
case, may easily mislead, and particularly when other neuropathic stig-
mata are at hand ma}- cause one to think of functional gastric disturbance
(aerophagy, etc.).
Case 97.— N. N., 60 years, M. Capuchin.
ad 4. — Formerly could tolerate ever3^thing well.
ad 6. — For the past year anorexia, intolerance toward meat, con-
stipation.
ad 7. — P'xtreme, pulsating tumor-mass underneath the left costal
arch. Pale yellowish color of the face. Continuous salivation.
ad 8. — Beginning: January, 1905.
Status presens: January 8, 1906.
Epicrisis: The continuous salivation deserves mention as an unusual
symptom.
Case 98.— H. E., 38 years, F.
ad 1. — Father died of epilepsy.
ad 3. — As a child had measles; at 11 had malaria.
ad 5. — Six confinements, last one in summer of 1901.
ad 6. — About Christmas, 1901, the patient noticed an enlargement
of her abdomen ; preceding that there had been night-sweats affecting
particularly the head, and frequent vomiting of food immediately after
eating. The enlargement of the abdomen ran along without pain. In
March, 1902, first appearance of sensitiveness to pressure in the left
lower quadrant. Severe constipation, intervals between movements up to
eight days. The patient claims to have noticed a swelling synchronous
with pain in the left side on a level w'ith the umbilicus ; this swelling soon
disappeared. Great emaciation.
ad 7. — Yellowish pale coloration of the face. Ascites of moderate
degree, bilateral hydrothorax, especially on the right. Temperature ele-
vations up to 37.8° C. Hard tumor-masses can be felt per vaginam,
especially through its posterior wall. Rectum somewhat narrowed an-
teriorly.
Blood: 2,800,000 erythrocj^tes, 8,000 leucocytes, 30% hemoglobin.
Urine: Indican and urobilinogen very abundant.
ad 8. — Status presens: End of March, 1902.
Autopsy: April 12, 1902.
256 TUMORS OF THE ABDOMINAL VISCERA
ad 9. — Autopsy (Professor Dr. H. Albrecht) : Carcinoma of the
pylorus superimposed on a chronic round ulcer, with moderate stenosis
of the pylorus. Secondary colloid carcinoma of the great omentum, the
parietal peritoneum, the entire peritoneum in the pouch of Douglas with
infiltration of the urinary bladder, parametrium and both ovaries.
Secondary carcinoma of the right costal pleura. Bilateral chylous hydro-
thorax.
Epicrisis: This 38-year-old patient had been referred to the clinic
with the diagnosis "tuberculosis peritonei." The history brought out the
fact of night-sweats, there Avas ascites and a right-sided pleural effusion,
the course of the disease being afebrile. But the facial color itself spoke
against the assumption of a tubercular disease of the peritoneum. There
was present a pronounced "yellowish" discoloration ("teint paille jaune").
Furthermore, the pleural effusion was easily movable. Hard tumor-masses
could be felt through the vagina.
The case illustrated the "peritoneal-pleural" type of gastric cancer
and is remarkable because of the prominence of the gynecological findings.
Case 99.— N. N., 50 years, M.
ad 2. — In June, 1904, inflammation of the shoulder- joint and at
the same time an inflamed condition in the large toe-joint. Cure in
Pystian.
ad 4. — Stomach always in order; could eat fat and sour foods
without trouble.
ad 6. — In February, 1906, sudden occurrence of stomach troubles,
rapidly growing worse, so that at present only a little tea and kephir is
tolerated. Stooping easily induces vomiting of watery-salty masses.
Constipation since February, 1906. A short time after eating a feeling
of pressure in the epigastrium and underneath the left costal arch. Very
soft eggs are well borne. Very severe burning after taking hydrochloric
acid solution.
ad 7. — A tumor of the pylorus, the size of a child's fist, movable
especially toward the left. Blood-vessels rigid, slight insufficiency of the
aortic valves.
ad 8. — Beginning: February, 1906.
Status presens: June 28, 1906.
Epicrisis: Uratic diathesis with an attack of gout about a year and
a half prior to the appearance of the first symptoms of cancer. "Ex-
pressible" stomach with regurgitation on stooping.
Case 100. — M. D., 69 years, M. Gardener's assistant.
ad 6. — Since October, 1908, attacks of colic-like pains in the ab-
domen, occasionally accompanied by vomiting. Since November, 1908,
decided emaciation. Even during his stay at the hospital (February,
1909) appetite was good at the start; plentiful ingestion of food.
ad 7. — An irregular, firm, small tumor-mass in the epigastrium.
Hard, i-ound tumors in the region of the sigmoid flexure ; these later dis-
CARCINOMA OF THE STO:\IACH 257
appeared and the flexure could be felt as a contracted cord. On and off,
feeble appearance of small intestinal loops, especially in the ileocecal re-
gion. Hernia in the linea alba. Pale, cachectic face color. Pulsating
carotids. No edemas ; temperature often 36° C.
Urine: Indican not increased; no aldehyde or diazo reaction.
Stool: Blood-test constantly positive,
ad 8. — Beginning: October, 1908.
Status presens: February 24, 1909.
Autopsy: April 22, 1909.
Duration: About 7 months,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Med-
ullary carcinoma of the stomach-wall in the region of the lesser curva-
ture, with severe constriction at the pylorus. Very small metastases in
the liver and the pleura. Slight atheroma of the aorta.
Epicrisis: The objective examination of this deaf and dumb patient
yielded as the first finding hard tumors in the region of the sigmoid flex-
ure, which were soon diagnosed as fecal accumulations. In and of
itself rare, this finding is occasionally met with in gastric cancers as an
indication of severe constipation ; thus in this case it gave the first occa-
sion for thinking of a gastric cancer.
Visible bowel peristalsis as described above (small loops of intestine,
moderate rigidity) is, as already repeatedly emphasized, not at all a rare
finding in connection with pyloric constrictions.^^
Case 101.— N. N., 60 years, M.
ad 4. — Always has had a sensitive stomach. Since May, 1905,
pain two hours after dinner, one hour after breakfast; often also on a
fasting stomach, in which latter case the ingestion of milk affords imme-
diate relief.
ad 6. — Since December, 1906, disgust toward meat, constipation.
Since February, 1907, complete anorexia. Even two years ago there was
found great hypoacidity. The severe pains existing formerly have
ceased, but painful sensations are still present in the epigastrium and be-
tween the shoulder-blades, somewhat more on the left side. Frequent
eructation of gas.
ad 7. — Moderately firm resistance in the epigastrium, about the
size of a walnut, resting on the aorta, felt best in the dorsal position.
Stool: Chemical blood-test constantly positive.
August, 1907: Uncontrollable hematemesis and death,
ad 8. — Beginning: December, 1906.
Status presens : May 13, 1907.
Existus: August, 1907.
Duration : About 9 months.
Epicrisis: As in Case 96, so also here, there was present "hunger
pain," which could be aborted by the use of milk.
="03868 11, 14, 36, 39.
258 TUMORS OF THE ABDOMINAL VISCERA
During the further course, probably througli the cessation of HCl
secretion, this symptom disappears.
This may have been a case of a carcinomatous ulcer.
Case 102.— N. N., 60 years, M.
ad 4>. — Stomach trouble for the past fourteen years ; before that
was in the habit of always eating rapidly and hot foods. Often pain
three hours after eating, excitement aggravated the complaints. A ner-
vous stomach disease was diagnosed. Withdrawal of stomach contents
some years ago showed normal secretory findings.
ad 6. — In 1906 there was found a deficiency of HCl. In April,
1907, severe hematemesis. Frequent eructation and vomiting of sour
masses ; often pressure in the stomach and hiccough. Appetite slight,
but even meat can be eaten.
ad 7. — Resistance and tenderness to pressure in the region of the
pylorus.
ad 8. — Beginning: 1906.
Status presens : September 7, 1907.
Exitus: October 1, 1907.
Epicrisis: The "nervous" stomach ailment may have been an ulcer,
and the final disease a carcinomatous ulcer.
Case 103.— J. K., 46 years, M. Locksmith.
ad 1. — One sister died of gastric cancer.
ad 3. — As a child had "miliary fever"; in 1869 had typhoid, being
sick for three months.
ad -1. — Never had stomach trouble; bowels always regular.
ad 6. — About August, 1900, the patient frequently experienced a
kind of "hungr}^ feeling" in the stomach, but there was no appetite. Great
feeling of thirst set in.
Later sour eructation, especially at night. In June, 1901, there were
added, sick feeling after eating, pressing, and now and then colicky pain
in the epigastrium. Felt good when the stomach was empty. Every
lateral position was badly tolerated. In August, 1901, the patient had
lost all appetite, vomiting occasionally up to two litres. His weight
dropped from 65 to 46 kg. On November 15, 1901, hematemesis ("about
two litres of blood"). Gastro-cnterostomy performed on November 22,
1901. Subsequent gain in weight and perfectly free from complaints
until April, 1902. Decrease of appetite, meat intolerance, pain in the
middle line of the epigastrium, about one hour after eating.
ad 7. — Since July 4, 1902, swelling of the left arm and the left side
of the neck; supraclavicular pain on the left side, in the left upper arm
especially along the course of the brachial artery ; pressing pains also
in the neck, on the left side, extending over the left half of the occipital
region. Gradual retrogression of the objective findings and the sub-
jective complaints, so that on July 30, 1902, there was neither swelling
nor painfulness.
CARCINOMA OF THE STOMACH 259
ad 8. — Beginning: August, 1900.
Operation: November 22, 1901.
Status prcsens: July, 1902.
Autopsy: August 17, 1902,
Duration : About 2 years,
ail 9. — Operation : Tumor at the pylorus extending toward the
fundus.
Autopsii (Professor Dr. H. Albrecht) : Infiltrating carcinoma of the
pylorus and the posterior wall of the stomach with constriction of high
degree. Secondary carcinosis of the peritoneum. Hemorrhagic ascites.
Mural thrombosis in the thoracic duct; old thrombosis of the left in-
nominate vein and a more recent tlirombosis of the left subclavian and
jugular veins.
Epicrisis: The initial subjective symptoms were sensations of hunger
with coexisting anorexia. Subsequently the typical crescendo of re-
gurgitation phenomena. After the carcinoma had existed for one year,
there occurred profuse hematemcsis.
The coincident processes of thrombosis in the thoracic duct and the
left subclavian and jugular veins are of interest.
Similarly as typical metastases in the left-sided supraclavicular glands
occur through the thoracic duct, the thought obtrudes itself whether the
thrombosis of the left subclavian vein was not brought about in this way.
Accordingly we would be dealing with a clinical equivalent of "Virchow's
glands." The thrombosis in the left innominate vein was by no means
due to compression b}^ external glands.
Case 104. — K. M., 73 years, M. Assistant lacemaker.
ad 3.— No I. D. C.
ad 4. — Never had an}' digestive disturbances.
ad 5. — Was alwaj's in good health.
ad 6. — Since Januar}', 1909, irregular bowel movements, at times
no movement for three days, then again, three movements in one day. Since
this time now and then cramps even at night in the lower abdominal region
and as high up as the umbilicus together with slight distention of the
belly. Duration one to two hours. Appetite very good, "agreeable"
eructation, ingestion of food has no appreciable influence on the pain.
On and off pain after bowel movements.
ad 7. — A hard tumor about the size of a nut, in the region of the
gall-bladder and to the left of it. During the further course great en-
largement of the liver. "Leather creaking" in the epigastrium which can
also be felt. Over the left lobe of the liver, especially at the end of ex-
piration, a loud, blowing, systolic murmur (normal auscultatory findings
at the cardiac apex). During the last days of life this murmur disap-
peared. Radial artery much sclerosed. No edemas. Dirty pale color
of the face. Vomiting only twice during the course of the disease. Sahli's
desmoid reaction negative.
Stool: No indican reaction after repeated examinations. Aldehyde
reaction distinctly positive. No diazo reaction.
260 TUMORS OF THE ABDOMINAL VISCERA
ad 8. — Beginning: January, 1909.
Status presens: February 22, 1909.
Autopsy: July 5, 1909.
Duration : 5 months,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Nut-
size, deeply ulcerating carcinoma of the greater curvature, situated 5 cm
above the pylorus; liver metastases very numerous. Ascites. Chronic
inflammation of the splenic capsule.
Epicrisis: Attacks of colic and bowel irregularities usher in the disease,
gastric symptoms associating themselves much later.
Even at a time when the palpatory finding in the epigastrium was yet
obscure, the auscultatory and palpatory finding of an epigastric friction
noise ("leather creaking") made certain the diagnosis of a process going
on in this place. During the further course there appeared over the
left lobe of the liver a systolic, blowing murmur, which disappeared only
a few days before death (murmur due to arterial compression).
The face color was dirty-gray, not showing that yellowish tint often
peculiar to gastric cancer. Obermeijer's indican reaction proved con-
stantly negative after repeated examinations, though autopsy did not
reveal any lesion of the pancreas.
Case 105.— N. N., 60 years, M.
ad 3. — Had yellow fever.
ad 4. — Formerly had a very good stomach.
ad 6. — Beginning in July, 1908, with attacks of dizziness ; since
then anorexia, disinclination toward meat. Often very foul-smelling
"sweetish-rotten" eructation, after which the patient felt somewhat re-
lieved ; occasionally pain underneath the left costal arch, e.g., after eating
grapes. Oil and soda bicarb, yield slight improvement. Gi'eat tendency
to sleep. During the night sometimes cramp-like sensations in the arms
and legs, sweats. Severe emaciation and very sensitive to cold.
ad 7. — On an empty stomach with right lateral position nodular
masses, about the size of nuts, can be felt underneath the left costal arch.
In the middle line the pylorus now and then stiffens into a hard cord,
about as thick as a finger, which disappears again under the palpating
fing-ers. A hard ffland in the left axilla.
Stool: Abundant lactic-acid bacilli.
ad 8. — Beginning: June, 190.5.
Status presens: September 14, 1908.
Epicrisis: Formation of metastases in the glands of the left axilla
belongs to the very rare exceptions ; the same is true of conditions of
tetany as shown in this case. Spastic conditions set in at the pylorus, so
that for a few moments, the latter can be felt as a firm cord, at the same
time that there are squirting noises.
Carcinoma of the Large Intestine
A. Cecum.
Case 1. — N. N., 58 years, F.
ad 6. — About Xoveniber, 1897, there began complaints at the pres-
ent (November, 1899) site of the swelling, namely, a dull drawing, press-
ing sensation above Poupart's ligament on the right side ; these complaints
lasted several weeks and retrogressed. Even at that time left lateral
decubitus was found uncomfortable because it produced a feeling as if a
heavy body fell to the left. For the past three months the bowels have
been irregular, constipation alternating with diarrhea, now and then
colicky pain about the navel. Of late, no appetite. Mild manifestations
of cystitis. Not much emaciation. For the past two years has had
constant pain in the back, somewhat aggravated by stooping.
ad 7. — A very firm, nodular tumor, about the size of an infant's
head, in the ileocecal region, which can be well outlined, especially on the
inner and upper surface, outwardly becoming a more diffuse, painful
resistance. Also over the central portions of the swelling there is a
muffled tympanitic sound. Distinct respiratory mobility, otherwise
mobility is slight. No distinct intestinal peristalsis. Later on, loud
peritoneal friction over the tumor-mass ; mild intestinal rigidity visible
in the epigastrium; splashing zone over the ascending colon.
November 23, 1899: Total paraplegia, with bladder and rectal dis-
turbance, disturbed sensation extending upward as high as the breasts.
No superficial patellar reflex. Violent pain in the right shoulder though
the mobility is unhindered, tender places over the sternum. Very slight
edema in the lower extremities. Mild febrile movements of late ; slight
jaundice. No particular emaciation.
ad 8. — Beginning: About November, 1897.
Status presens : November 1, 1899.
Autopsy: November 28, 1899.
Duration : About 2 years.
ad 9. — Autopsy (Hofrat Professor Dr. Weichselboum) : Ulcer-
ating, stenosing carcinoma of the cecum with metastases in the retro-
peritoneal and mesenteric lymph glands. One gland perforated into the
inferior vena cava. Metastases in both kidneys, in the left suprarenal
gland, in both ovaries, peritoneum, pleura, lung, liver, dura mater, vault
of the cranium, vertebral column with compression of the dorsal portion
of the cord, in the right humerus, sternum and in the hairy scalp.
Splenic tumor.
261
262 TUMORS OF THE ABDOMINAL VISCERA
Epicrisis: As left lateral decubitus produced disagreeable sensations
in the ileocecal region even two years before death, one is inclined to
assume that a tumor was here present even at that time.
Lumbar pain was a constant symptom. At no time during the course
of the disease were there any distinct symptoms of stenosis. The peri-
toneal friction sounds found over the tumor are deserving of note; they
are found much more fi-equcntly with ulcerating tumors of the stomach
or intestine than, for example, with kidney tumors and could occasionally
be used for this differential diagnosis.
Shortly before death perforation into the blood current had led to
hematogenous metastases in almost all the organs, the skeletal system
sharing in it to a particular extent. One metastasis in the vertebral
colunm led to paraplegia and ascending paralysis. The metastases in
the scalp were most unusual, and they had been surgically diagnosed as
atheromas. Besides the skeletal metastases (among others in the cranial
vault) there were also metastases in both ovaries, but without appreciable
enlargement of these organs.
Case 2.— W. T., 32 years, M. Agent.
ad 2. — A weakly individual, reddish-blond mustache. Between the
ages of 9 and 19 often had severe epistaxis. I^eft testicle very small, in
the inguinal canal.
ad 5. — Never was seriously sick.
ad 6. — Since November, 1906, conspicuous pallor. Since June,
1907, cardiac palpitation on exertion. Appetite generally good; no colics.
ad 7. — A tumor-mass in the right iialf of the abdomen, extending
upward as high as 2 finger breadths above the umbilicus, posteriorly as
far as the mammillary line, downward as far as 3 finger breadths below
the umbilicus, extending across somewhat the middle line ; firm consistence ;
slight tenderness on pressure. Over the tumor-mass there is a muffled
tympanitic sound, bowel noises being constantly audible, having a metallic
sound, and limited to the right half of the abdomen ; some indication of
ballottement. Veins of the right abdominal wall standing out promi-
nently. Glands in the right axilla. Extreme pallor of the face. Left
leg edematous, calf and thigh of the same leg very tense; small cutaneous
hemorrliages on the anterior and internal surface of the right thigh.
Blood: 2,300,000 erythrocytes, 14,500 leucocytes, 30-40% hemo-
globin.
Pulse: 108. Chills on and off with temperature elevations up to
39.6° C.
Feces: Thin fluid, very foul odor, lactic-acid bacilli moderately abun-
dant (confirmed by culture).
ad 8. — Beginning: About November, 1906.
Status presens: November 13, 1907.
Autopsy: March 7, 1908.
Duration : About 1 year, 4 months.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlogenhaufer) : Car-
cinoma of the cecum with great dilatation of the lumen, adhesion to ad-
CARCINOMA OF THE LARGE INTESTINE 263
jacent loops of small bowel. Right testicle fixed in the ingiiinal canal.
Old thrombi in both veins of the thigh, Splenic enlargement, red bone
marrow in the right femur. An ulcer at the lesser curvature in the py-
loric portion of the stomach (about 2l/> cm in diameter) adhei'ent to the
liver. Tubercular lymplioma in the right axilla.
Histological examination of the cecal tumor: colloid carcinoma.
Epicrisis: In this instance the cancer attacked a youthful individual
of a general tubercular-lymphatic appearance. Tuberculosis of the
axillary lymph glands on the right side. Severe epistaxis during youth.
During the entire course there were no symptoms of stenosis.
Extreme pallor was the dominant feature of the disease, so much so
that the case was presented to me as one of pernicious anemia.
The dilatation of the veins in the right half of the abdomen in and
of themselves had to remind one of a local abdominal process. The
accompanying sporadic chills are probably to be interpreted as sympto-
matic of ulceration (secondary infection).
The subjective symptoms on part of the digestive tract were very
slight, adynamia and anemia occupying the foreground.
Case 3.— N. K., 60 years, F.
ad 3. — Had measles as a child.
ad 6.- — In October, 1906, had some obscure, febrile condition last-
ing one week (influenza.?) ; to this there became associated stomach com-
plaints, namely, loss of appetite, later on pain immediately after intake
of food, localized chiefly in the left side of the epigastrium ; frequent
heartburn and eructation of gas. Painful attacks, often accompanied by
loud rumbling. Stool usually regular, except on one occasion, at a time
when there was very severe pain, it was hard and the bowels moved only
with the aid of an enema.
ad 7. — April, 1907: Subjectively the above-described symptoms;
subfebrile condition, temperature often going over 37° C. No distinct
tumor can be felt. July, 1907: A hard tumor, about the size of a walnut,
palpable in the ileocecal region ; tendency to diarrhea. Frequent pain in
the lower abdominal region, followed by tenesmus, which is very urgent.
Temperature frequently above 38° C. (During the course of the disease,
three chills without accompanying pain.) Quiet heart action, not in-
creased in frequency. Color of the face yellowish cachectic with capillary
dilatations in the cheeks.
ad 8. — Beginning: October, 1906.
Status presens : April and July, 1907.
Operation: July, 1907.
ad 9. — Operation (Hofrat Professor Dr. Hochenegg) : Carcinoma
of the cecum. Resection.
Epicrisis: In this case the alarming symptom was the fever of very
irregular type, occasionally becoming so much exacerbated as to induce
chills. The pain in the epigastrium often immediately after ingestion of
food, accompanied by heartburn, could lead one to erroneously suspect
a gastric lesion.
264 TUMORS OF THE ABDOMINAL VISCERA
Only in the later course of the disease did the colic of the large bowel
and tenesmus occur. The quiet pulse, never becoming rapid, spoke against
the assumption of any kind of occult purulent focus as the cause of the
fever and the chills. Never any symptoms of intestinal constriction.
Case 4. — A. V., 45 years, M.
ad 1. — No cancerous disease in the family; mother is healthy, 74
years of age.
ad 2. — Habitus quadratus ; hair blond, bristly, iris blue. Numer-
ous angiomas. Four months ago had a painful swelling of the dorsum
of left foot, lasting three and a half months.
ad 3. — Smallpox at 6 years of age.
ad 4. — Always intolerant toward fat foods.
ad 5. — Was always healthy ; heavy smoker.
ad 6. — About May, 1904, the patient's attention was called to his
pale facial color; on weighing himself found that he had lost 20 kg. Be-
came irritable. Since September of this year the bowels are somewhat
irregular, now and then fluid, following that again, constipated; the
stools became very bad smelling. Of late, now and then, griping and
some rumbling in the lower abdominal region. For the past month fre-
quent sick feelings with vomiting of sour, greenish masses, especially
toward 9 and 11 a.m. Frequent heartburn, decrease of appetite. For
the past two weeks vomiting and dizziness on walking about for some
time ; a month ago night-sweats, some cough and fever. No pain in the
back. Tenderness to pressure on the right side of the abdomen. With
lateral position mild drawing sensation in the abdomen in a direction
from right to left.
ad 7. — Uneven tumor-masses in the ileocecal region, with but little
respiratory mobility, thrill on pulsation; on and off, slight gurgling over
the tumor mass. Splashing in the stomach several hours after breakfast.
HCl positive after test-breakfast.
Feces: Strongly alkaline reaction, very foul smelling; a few spiro-
chetes, abundance of very actively motile rod-shapes.
Blood: 3,000,000 erythrocytes, 4,200 leucocytes, 407o hemoglobin.
Urine: Indican reaction strongly positive.
ad 8. — Beginning: About Ma}-, 1904.
Status presens : October 3, 1905.
Operation: October 9, 1905.
ad 9. — Operation : I^arge carcinomatous tumor in the region of the
cecum.
Epicrisis: Just as in Case 3, so also here, the gastric symptoms come
prominently into the foreground: heartburn, biliary vomiting, anorexia.
Also here, though rather intercurrently, there is fever accompanied by
night-sweats. Slight disturbances on part of the bowel: never any symp-
toms of constriction, only mild irregularities in bowel movements, light
colickv pain in the lower abdominal region, accompanied by rolling.
Bacteriologically the stools contain a few spirochetes and in addition
very actively motile rod-shapes.
CARCINOMA OF THE LARGE INTESTINE 265
The rod-shapes in normal stools show only molecular motion and never
exhibit any active movements.
Pallor and emaciation in this instance count among the initial symp-
toms, at least so far as the history shows.
B. Hepatic Flexure
Case 1.— C. G., 53 years, F.
ad 1. — Father died of tuberculosis,
ad 3. — No infectious diseases.
ad 5. — Always healthy until the spring of 1904.
ad 6. — In the spring of 1904 beginning of cramp-like pain in the
belly, occurring now and then, especially if the patient lay down imme-
diately after dinner or supper. If dinner was taken at 12 o'clock the
pain began at 2 o'clock ; the pain occurring in the evening often lasted till
midnight. The quality and quantity of the food are said to have made
no difference; after eating sauerkraut she felt better. Painful attacks
often accompanied by loud rumbling.
In the autumn of 1904; the appetite became bad, there came on a dis-
inclination toward meat.
In November, 1904, a swelling was noticed in the right side of the
abdomen. Of late frequent bitter tasting vomitus ; bowel movements
fairly regular during this entire time, except that occasionally there would
be no movement for two days at the longest. Now and then pain in the
back ; no fever.
ad 7. — Upper surface of the tongue smooth, atrophic, dry. On
the right side in the mammary line, continuous with the border of the
liver, there is a hard, protuberant, uneven tumor-mass, vibrating with
pulsation, and freely movable with respiration. Over the tumor-mass
there is a muffled tympanitic resonance, and anterior to it no intestinal
loop can be felt. The tumor-mass cannot with certainty be marked off
from the hepatic border. On and off, periumbilical peristalsis ; at the
same time there appears a portion of gut corresponding in locality to
the cecum over which splashing can be elicited. Color of the face pale
yellowish; no edemas. Transient temperature elevations of 38° C.
Feces: Mucous shreds saturated with blood, increase of the Gram-
positive flora.
Urine: Indican not increased.
Blood: 7,300 leucocytes, 40% hemoglobin,
ad 8. — Beginning: About March, 1904.
Status presens: January 11, 1905.
Operation: January 19, 1905.
Autopsy: January 21, 1905.
Duration : About 10 months,
ad 9. — Operation (Clinic Hofrat Professor Dr. J. Hochenegg) :
A carcinoma, as big as a child's head, in the hepatic flexure with great
constriction and ulceration. Cecum much distended. The tumor reached
to the duodenum from which it had to be dissected. In addition to this,
266 TUMORS OF THE ABDOMINAL VISCERA
autopsy disclosed metastases in both ovaries (size of a child's fist) and in
the retroperitoneal glands.
Epicrisis: This is another case in which secondary gastric symptoms
are not lacking: vomiting, meat anorexia, pains occurring two hours
after dinner. The latter, despite the short interval of time, are probably
to be interpreted as intestinal colics, and in another place^'' I have
pointed out with emphasis the fact that the interval of time between the
intake of food and the occurrence of pain can only with great difficulty
be employed for the purpose of localizing a painful process.
Bowel movenjents fairly regular.
The cecum takes part in the intestinal peristalsis, and over it distinct
splashing can be heard.
The pulsatory vibration of the tumor in the colon is worthy of note;
the bridging over toward the aorta being established, as shown at au-
topsy, by retroperitoneal glands. The lingua mucosa showed atrophic
changes.
The feces contained numerous Gram-positive rod-shapes reminding
one of lactic-acid bacilli.
Case 2.— F. R., 32 years, M.
ad 2. — Of a somewhat weakly constitution, but otherwise healthy.
ad 3. — Has had no infectious diseases.
ad 5. — Was always healthy.
ad 6. — In September, 1907, there began pressure in the stomach,
colicky pains came on in the epigastrium, accompanied by hiccough, so
violent that morphine injections were necessary. The appetite dimin-
ished. In December, 1907, the appetite again improved, and it is said
that during the months of January, February, and March, 1908, the
patient gained 14 kg in weight. In the beginning there was constipation,
later on diarrhea with discharge of blood and mucous. In October, 1908,
a swelling, as big as a hen's egg, was found in the abdomen on the right
side; this is said to have disappeared again {?). In January, 1909, re-
currence of severe pain in the epigastrium and anorexia, accompanied by
heartburn ; stool inclined to diarrhea.
ad 7. — A slender, much emaciated individual with a slightly en-
larged abdomen, great feeling of weakness and severe retromalleolar
edema. On the right side, on the level with the umbilicus, a tumor-
mass, as big as a child's head, with a tympanitic sound over its central
portions ; no vascular murmurs ; metallic borborygmi often audible over
the area of the swelling. No bowel peristalsis. Tympanitic resonance
over the liver. Heart-sounds are clear. Subfebrile course (often over
37° C, on and off 38° C).
Feces: Gray, putrid, somewhat foamy, strongly alkaline, mostly fluid,
containing brown-colored mucous ; blood-coloring material demonstrable
" R. Schmidt. Die Schmerzphanomene bei inneren Erkrankungen, etc. II. Edition,
1910, Wilhelm Braumuller.
CARCINOMA OF THE LARGE INTESTINE 267
only by chemical test. Microscopic examination: pus-cells, many fatty
acid needles and neutral fat.
Urine: Suggestion of a diazo reaction.
Blood: 27,()()() leucocytes. Sahli's desmoid reaction negative,
ad 8. — Beginning: September, 1907.
Status presens : January 11, 1909.
Autopsy: February 16, 1909.
Duration: About 11/2 ycfii'>>-
ad 9. — Autopsy (Prosector Professor Dr. Fr. Schlagenhaufer) :
Circular, ulcerating carcinoma of the hepatic flexure of the colon (in this
area adhesions to the anterior abdominal wall and stomach) ; multiple
metastases in the liver.
Epicrisis: As is usual in those cases in which carcinomas develop at
a relatively young age, so also here we are concerned with a constitu-
tion that has been rather weak from childhood. Also here at the begin-
ning and during the further course of the disease there were present
pronounced gastric symptoms, such as anorexia and heartburn ; the
initial attacks of colic appeared in the epigastrium and were accom-
panied by hiccough. When in the early part of 1908, about a year
before death, the appetite came back again, the patient gained 14 kg in
weight. Manifestations of constriction were lacking during the entire
course. Neither was there ever any vomiting.
The particularly bad reduction of fat was shown by the appear-
ance of neutral fat (pancreas unchanged at autopsy).
The considerable leucocytosis (27,000) is worthy of note.
ad 4. — Irregular bowel movements for the last three or four
Case 3.— M. K., 66 years, F
years.
ad 5. — In 1893 decided enlargement of the abdomen ; in the sur-
gical clinic of Hofrat Professor Dr. E. Alberts 13 litres of fluid were
withdrawn and a tumor extirpated (ovarian cyst.'') ; the patient recov-
ered rapidly and was healthy until the summer of 1901.
ad 6. — In July, 1901, after eating fruit and cucumber salad, vio-
lent colicky pain ; in this connection the attending physician is quoted
as saying that a portion of gut in the upper right quadrant became
erect, exhibiting a horizontal and a vertical limb. When this disap-
peared there was also a disappearance of the pain. Since then there is
anorexia. Up to the present time there have been six or seven attacks
of pain; the first attack occurred at 5 p.m., the others often at night.
The patient helps herself during these attacks by massaging these erected
parts; with it there is great noise, a sort of "driving about." During
the painful attacks there is a cessation of bowel movements and dis-
charge of flatus.
Discharge of flatus aff'ords immediate relief. After the attacks of
pain now and then there is vomiting, on one occasion smelling very bad ;
often also odorless eructation. Stools often are fetid, contain mucus
in rather large quantities, no blood. Great feeling of weakness, emacia-
268 TUMORS OF THE ABDOMINAL VISCERA
tion to the extent of 20 kg. Since the beginning of the disease decided
falling out of the hair. Of late, especially since the end of December,
1901, the attacks of pain follow each other closely, mostly half an hour
before the bowels move, after which tenesmus continues ; pain especially
in the right upper quadrant, without radiation. When the pain becomes
very intense there is a slight chill without subsequent feeling of heat.
When lying on the left side there is a feeling as if something in the
abdomen would sink to the left ; the patient, therefore, rests on her
back, with the legs drawn up.
ad 7. — A somewhat uneven, hard tumor, not clearly definable
against the border of the liver, possessing respiratory mobility, sensitive
to pressure ; over same there is tympanitic resonance, and here and
there bowel noises are audible, especially on deep inspiration. No bal-
lottement. Diarrhea with tenesmus. Edema over the sacrum and some
indication of it behind the internal malleolus. Frequent moderate tem-
perature elevations over 37° C. during the attacks of pain, reaching
39° C.
Feces: Much mucus. Increase of Gram-positive cocci.
Urine: Strongly positive indican reaction, abundant urobilinogen.
Blood: 3,500,000 erythrocytes, 7,500 leucocytes,
ad 8. — Beginning: July, 1901.
Status presens: March 12, 1902.
Autopsy: August, 1902.
Duration: About 13 months,
ad 9. — Autopsy (Professor Dr. O. Stoerk) : Ulcerating carcinoma
of the hepatic flexure of the colon with multiple perforations into the
upper part of the duodenum and the pylorus. Atheroma of the aorta
with parietal thromboses.
Epicrisis: In the previous history of the patient we encounter a
swelling formation, which was treated surgically, and which to all ap-
pearances was an ovarian cyst.
In July, 1901, i. e., thirteen months prior to death, the carcinoma
made its appearance with colicky pain and localized peristalsis in the
region of the hepatic flexure, provoked by an error in diet.
From this time on there is on the average one attack of colic every
month ; pain localized chiefly in the right upper quadrant, accompanied
by loud "rolling," by symptoms of regurgitation such as vomiting, eruc-
tation, by mild chills and temperature up to 39° C.
Of late the intestinal nature of the pain is betrayed by the fact that
it is associated with bowel movements which are accompanied and out-
lasted by tenesmus.
Left lateral position causes a feeling in the belly as if something
were drawn to the left.
The stools are mostly fluid, containing much mucus, but never any
blood which can be recognized macroscopically.
Since the beginning of the disease falling out of the hair.
CARCINOMA OF THE LARGE INTESTINE 269
Case 4. — P. Ch., 59 years, M. Hatmaker.
ad 1. — Parents died at a very old age.
ad 5. — Always was healthy ; for several years, on and off, there
has been diarrhea, occurring without apparent cause. It is stated that
four years ago, after eating spoiled pork, there was jaundice for two
days.
ad 6. — At the end of October, 1903, rapid increase in the cir-
cumference of the abdomen; during the past months much emaciation.
Swelling in the legs without any cardiac complaints. No pain in the
back. Appetite bad for the past month. Alcohol is admitted.
ad 7.- — No icterus. Abdomen greatly distended, epigastric venous
plexus. Ascites. Liver dulness small, in streaks. Severe retromalleolar
edema on the inner side. Tendency to subnormal temperature below
36° C. Long terminal coma with slowing of respiration and heart ac-
tion ; just before death there was vomiting of blood.
Aspirated fluid: "IMilky" turbidity, without cellular elements, sp. gr.,
1008.
Urine: No urobilinogen; strong indican reaction.
Stool: "Dysentery-like," containing much mucus and some blood.
Blood: 11,000 leucocytes.
ad 8.^ — Status presens: December 12, 1903.
Autopsy: December 31, 1903.
ad 9. — Autopsy (Professor Dr. A. Ghon) : Atrophic cirrhosis of
the liver, with splenic tumor and esophageal varices. Colloid carcinoma
of the hepatic flexure of the colon (large glandular metastases around the
pancreas, lymph-vessels dilated, metastases in both suprarenal bodies
and both pleur;e. Metastases in the peritoneum and in the osseous sys-
tem). Chylous ascites.
Epicrisis: This case illustrates the not altogether too rare complica-
tion of a liver cirrhosis with a malignant neoplasm of the bowel. L^nusual
for the assumption of a simple cirrhosis was the rapid course from the
beginning of the ascites (October, 1903) until death (December, 1903) ;
also unusual was the "milky" nature of the ascites, which was explained
by a compression of the chyle vessels (metastases in the radix mesen-
terii) ; furthermore, there was absent leukopenia (11,000 leucocytes) fre-
quently met with in cirrhosis of Laennec.
The terminal stage of the disease had the marks of a cirrhosis : throm-
bosis of the portal vein, hematemesis, hepatic coma.
Despite the serious disease of the liver, urobilinogen was absent in
the urine, perhaps as a result of poor absorption of urobilinogen from
the bowel due to thrombosis of the portal vein.
The intestinal disease manifested itself by "dysentery-like" stools.
S3nnptoms of constriction were permanently absent.
As is so frequently the case in malignant diseases, the previous his-
tory mentions longevity of the parents.
270 TUMORS OF THE ABDOMINAL VISCERA
C. Splenic Flexure of the Colon
Case 1. — R. M., 41 years, M.
ad 3.— No I. D. C.
ad 5. — Was always healthy.
ad 6. — Since January, 1906, anorexia and rapid emaciation, says
that he lost 30 kg in weight. Otherwise no initial complaints. In ]March
of this year diarrhea set in, two movements a day, which became intense
about the end of June this ^^ear. Toward the end of May of this year
a Karlsbad cure was recommended, but he could not stand it. At that
time there appeared the first attacks of colic, which since then have
recurred very often at intervals of one or two days. They extend over
the entire abdomen and are ushered in hy loud rumbling; they occur
especially at night. Bowels move once a day, though not very copiously,
and not containing any large admixtures of mucus or blood. Very often
there is odorless eructation per os, but little gas is discharged per anum.
Lying on the left side more easily provokes colick\' pain. In September
of this year the appearance was not yet suspicious of cancer. The
patient is said to have vomited "coffee grounds" once.
ad 7. — Abdomen often suddenly much distended, exhibiting bulg-
ing areas resulting from the protulx>rance of inflated intestinal loops;
no distinct tumor can be felt. Succussion yields loud splashing sounds.
Retromalleolar edemas.
Rectal finding: Ampulla conspicuously wide.
Urine: Much sediment.
Feces: Abundance of very thin. Gram-negative rod-shapes,
ad 8. — Beginning: January, 1906.
Status presens: October 11, 1906.
Operation and autopsy: October, 1906.
Duration: About 10 months,
ad 9. — Autopsy: Soft ulcerating carcinoma of the splenic flexure
of the colon. Perforating peritonitis.
Epicrisis: Anorexia and emaciation are the first clinical manifesta-
tions (January, 1906). Only several months later (May-June, 1906)
do bowel sj^mptoms appear, namely, fluid bowel movements and colicky
pain. The latter is accompanied by loud rumbling, and occurs particu-
larly at night ; lying on the left side favors their occurrence. This
peculiarity points to some localized cause of same.
In September, 1906, there existed distinct symptoms of bowel con-
striction ; dilatation of the bowel with general splashing and intestinal
peristalsis ; bowel moved daih' and were for the most part fluid.
Transiently there was "coffee-ground" vomiting, which is sometimes
peculiar to bowel stenoses.
The abnormal width of the ampulla is worthy of attention ; according
to Hochenegg, it is an accompanying manifestation of low-down con-
strictions of the large gut.
CARCINOIMA OF THE LARGE INTESTINE 271
Case 2.— K. K., 73 years, M.
ad 3. — Kcincnibers having had typhoid.
ad 5. — Otherwise was never sick.
ad 6. — Chiims to have lost 20 kg in weight since April, 1908 ; com-
plains of eructation, vomiting after sour foods, weakness and great fa-
tigue. Whilst in bed from September 28th to October 19th, gained 2.5
kg in weight and felt perfectly well. In December, 1908, recurrence of
loss of appetite, vomiting about two hours after eating. Bowels con-
stipated. No spontaneous pain, no tenderness to pressure in the abdo-
men. On and off slight increases in temperature. Just before death
torturing hiccough ; everything is vomited.
ad 8. — Beginning: April, 1908.
Autopsy: January 3, 1909.
Duration: 9 months.
ad 9. — Autopsy (Pros. Professor Dr. Fr. ScJilagenhaufer) : Ul-
cerating colloid cancer of the transverse colon at the splenic flexure in-
vading the tail of the pancreas and a loop of small intestine. Hemoside-
rosis of the spleen ; arteriosclerosis.
Epicrisis: Gastric symptoms dominate the clinical picture of the
disease and usher it in : eructation, vomiting, anorexia of varying de-
gree. Tendency to constipation is the only intestinal symptom. No
symptoms of stenosis.
D. Sigmoid Flexure
Case i. — J. B., 45 years, M. Lithographer.
ad 1. — Father died at 62 of tuberculosis.
ad 4. — Bowel irregularities since 1883.
ad 5. — At 15 enlarged cervical glands; at his work had to handle
lead and anilin dyes.
ad 6. — Since 1898 noticed a sensitiveness of the bowel, so that pain
occurred after errors in diet, but this pain soon disappeared. In January,
1899, occurrence of urinary difficulties, with tenesmus and pain in the
pelvis, urine having a foul odor. On February 22, 1899, after drinking
ice-cold beer, there was severe abdominal pain, accompanied by feverish
feeling and vomiting; at the same time constipation, no discharge of
flatus. Appendicitis was diagnosed.
ad 7. — March 5, 1900: Abdomen distended, lively diffuse peristal-
sis with loud squirting sounds, especially in the epigastrium. There is
a bulging in the left lower quadrant ; here and underneath the umbilicus
the tension of the abdominal walls is at its maximum ; left flank some-
what more tense than the right. Heart-sounds can be distinctly heard
also in the right flank. No edemas.
March 31, 1900: Pale yellowish discoloration, tongue very dr}'. Ex-
treme meteorism, in consequence of which peristalsis is less clearly visibhi
than formerly'; loud bowel noises. Hiccough. Attack of colic accom-
panied by lumbar pain. Colic radiates into the anus. Immobilization
in dorsal position. Mild rctromalleolar edemas.
272 TUMORS OF THE ABDOMINAL VISCERA
Urine: Great urobilinuria.
Feces: Pulpy, yellowish-brown, very fetid, foamy. Microscopically:
Numerous heaps of cocci, staining blue with Lugol. Toward the end:
Chills, collapse (April 6th).
April 7, 1900: The patient feels better, the bowel noises have ceased,
but the abdomen is very rigid; in the forenoon still had a fluid bowel
movement; afternoon, collapse and death,
ad 8.— Beginning: 1898(?).
Status presens: March 5 and March 30, 1900.
Autopsy: April 7, 1900.
ad 9. — Autopsy (Docent Dr. K. Landsteiner) : ring-shaped car-
cinoma of the sigmoid flexure, 50 cm above the anal opening, with many
adhesions of the intestines in the region of the true pelvis and metastases
in the liver. Great hypertrophy of the entire large and small intestine,
enormous dilatation of the cecum with perforation of same, and mani-
fold diastasis of the serosa about the large bowel, particularly the cecum.
Purulent perforative peritonitis. Bullous edema of the vesical mucosa.
Thrombosis of the left femoral vein and edema of the left leg. Embolism
in the larger branches of both pulmonary arteries.
Epicrisis: The beginning of the disease cannot be definitely ascer-
tained. Nevertheless, it is very probable that the attacks of pain occur-
ring in connection with the dietetic errors in 1898 are to be referred
to the carcinoma.
It is well known that the first symptoms of gastric or intestinal car-
cinoma frequently manifest themselves after such unintentionally pro-
duced alimentary tests. Early diagnosis will gain much if similar tests
are designedly undertaken in a given case of suspected cancer.
The symptoms of cystitis appearing in January, 1899, may also
have been of intestinal genesis.
The "appendicitis" diagnosed in February, 1899, is very probably
to be referred to the cecum ; it was at this site that the last stage of the
disease developed through the occurrence of perforation due to over-
distention ahead of the constriction. The particularly strong tension
in the left flank could lead one to think of a low down colon afl'ection ;
likewise the radiation of the colicky pain toward the anal opening.
Case 2. — B. J., 42 years, F. Teacher.
ad 1. — Mother is living and well.
ad 2. — In April, 1900, had pain in both wrist-joints, lasting two
weeks, without fever.
ad 3. — As a child had smallpox.
ad 5. — Otherwise "was always healthy.
ad 6. — In May, 1900, had pain in the back, sacrum tender on
pressure. Even in the month of April feeling of pressure in the epigas-
trium ; in walking the patient stooped forward ; could' eat but little, as
otherwise there was a feeling of great pressure in the epigastrium. At
that time there was severe constipation ; even after taking cathartics
CARCINOMA OF THE LARGE INTESTINE 273
the feces came in the shape of small, oval pieces covered with mucus.
Now and then involuntary discharge of hlood-streaked mucus. The
act of defecation was accompanied by pain and tenesmus.
In July, 1900, a swelling was felt in the epigastrium; at that place
there was pain on pressure, also on coughing and deep breathing. Since
the beginning of the disease there is emaciation, fatigue, the appetite
remaining good. No vomiting. Menstruation has ceased since the be-
ginning of the disease.
September 21, 1900: Intense pain on the right side of the thorax
on coughing, sometimes radiating over the lumbar region and even the
outer side of the thigh ; pain also on inclining forward, or when lying
on the right side. On the right side posteriorly about a hand's breadth
below the angle of the scapula a sensitive area. Troublesome dry cough
without expectoration. Great feeling of pressure immediately after in-
take of food. Tenderness on deep pressure about Poupart's ligament,
ad 7. — Enormously diffuse enlargement of the liver, the organ
feeling very firm ; over it a blowing, systolic murmur. Peritoneal fric-
tion over the left lobe of the liver, where it can also be felt, on the right
side audible only. Ascites and bilateral pleural effusion. Venous dila-
tations on the right side, posteriorly, below, alongside the vertebral col-
umn, and on the left side anteriorly over the abdomen. Very severe
edema in the lower extremities. The lower abdominal region greatly
distended by meteorism. Pain after every intake of solid or liquid food.
Toward the end gallop rhythm with pseudo-pericardial friction (due to
perihepatitis !).
ad 8. — Beginning: April, 1900.
Status presens: September 21, 1900.
Autopsy: September 26, 1900.
Duration : 6 months,
ad 9. — Autopsy (Professor Dr. H. Albrecht) : Ulcerating carci-
noma of the sigmoid flexvire, with cancerous thrombosis of the left iliac
vein and vena inf. cava. Enormous enlargement of the liver as a result
of metastases. Numerous metastases in both lungs and in the retro-
peritoneal lymph-glands. Complete compression of both low^er lobes
from hydrothorax. Chylous ascites. Chronic perihepatitis.
Epicrisis: Only those symptoms will here be mentioned which do not
emanate from the metastatic processes in the liver, but which have a
connection with the intestinal carcinoma.
The following points are worthy of note: Tenderness on deep pres-
sure over the sigmoid flexure, mucus, bloody stools associated with great
pain and tenesmus, occasionally involuntai*y discharge of blood-colored
mucus ; meteorism in the lower abdominal region. From the primary
focus there had occurred proliferation into the left iliac vein, and subse-
quently thrombosis of the inferior vena cava.
Worthy of note are the arthritic manifestations in both wrist- joints,
being the first in the row of symptoms.
At no time were there symptoms of constriction ; likewise there were
absent disturbances on part of the stomach. The ascites had a "milkv"
274 TUMORS OF THE ABDOMINAL VISCERA
character ; there were found extensive retroperitoneal glandular metas-
tases.
Case 3. — J. T., 54 years, M. Silk weaver.
ad 1. — Mother died from weakness of old age.
ad 5. — Was always healthy.
ad 6. — In September, 1899, on and off "wind colic," relief after
discharge of flatus. Stool somewhat retarded ; after bowel movements,
"pain in the bowels." Appetite very good. About July, 1900, there
began continued dull pain in the left inguinal region, radiating into the
left testicle ; the left testicle and left spermatic cord became painful on
pressure. The attending physician diagnosed a left-sided varicocele.
At the same time there began diarrhea and pain in the anus ; since July,
1900, often hourly evacuation, consisting mostly of mucus; after bowel
movement great feeling of fatigue. Emaciation. \o pain in the back.
ad 7. — Face pale yellow, somewhat bloated. On the left side above
Poupart's ligament, particularly on intermittent palpation, a tumor as
big as a nut can be felt, painful to pressure.
Per rectum: A tumor can be felt high up, having some connection
with the tumor palpable from the outside.
Epigastrium distended as a result of great enlargement of the liver;
the left lobe in particular is very hard and uneven; circumscribed tender
areas on the upper surface of the liver. Profuse diarrhea, subjective
sensation of bowel distention, continued bowel noises.
Feces: Enormous quantities of nmcus, often blood-colored.
No edemas, often profuse night-sweats. Ascites. During the sub-
sequent course burning at urination, the last portions of urine being
fecal; gurgling noises during urination (discharge of flatus per ure-
thram!). Toward the end severe edema in the lower extremities and over
the sacrum.
October 22: During the night sudden pain on the left side, above
Poupart's ligament, together with great tenderness to pressure and
much tension; severe pain in the lower abdominal region when sitting
up. Chill. Pulse very small.
October 23: Erysipelatous redness over the painful area on the left
side below.
October 25: Exitus.
ad 8.-^Beginning: September, 1899.
Status presens : September -i, 1900.
Autopsy: October 26, 1900.
Duration : About 1 3'ear.
ad 9.— Autopsy (Hofrat Professor Dr. A. Welch selboum) : Car-
cinoma in the sigmoid flexure with perforation into the bladder ; metas-
tases in the liver.
Epicrisis: The appearance of flatulent colic should always put us
on the alert for a possible beginning neoplasm of the bowel ; not seldom
this is the first manifestation of the disease.
In the beginning there was mild constipation, with a feeling of internal
CARCIN03IA OF THE LARGE INTESTINE 275
pain after defecation ; only about two months prior to death did symp-
toms of a deeply seated colon disease make their appearance : frequent
evacuations of small quantities, often consisting of nmcus only. As in
left-sided renal neoplasms, so also here obstruction to the venous flow
led to a left-sided varicocele and tenderness to pressure in the left
testicle. Subsequently occurrence of a vesico-rectal fistula with discharge
of flatus per urethram during urination, accompanied by gurgling noises.
Case 4. — F. V., 65 years, M.
ad 2. — Mother lived over TO years.
ad 3. — In 1857 had typhoid for four or five weeks.
ad 4. — Bowels always regular, one movement in twenty-four hours,
"like a clock."
ad 5. — Always led a temperate life ; no hemorrhoids ; at the age
of 46 had icterus for 3 weeks.
ad 6. — In January, 1900, sudden constipation for 14 days, bowels
moving at intervals of five days ; stool was very hard, in small lumps.
After that the evacuations again became regular, there being no com-
plaints during the summer of 1900. Since the early part of November,
1900, beginning of fluid stools, dark in color, "clear as eggs," totalling
up to twelve stools a day, the individual stool small in quantity. A few
minutes before the stool evacuation takes place there is loud rumbling
coming from the epigastrium toward the symphysis. Great feeling of
thirst, decrease of appetite, eructation after meals. No appreciable
emaciation. Of late there have come on difficulties in urination, viz.,
burning, voiding of urine possible only with simultaneous bowel evacua-
tion. No pain in the back, no colicky pain. Since about October, 1900,
a burning sensation is experienced on the left side deep down above Pou-
part's ligament, this burning being somewhat relieved after bowel evacua-
tions. The inguinal glands on the left side arc somewhat tender to
pressure.
ad 7. — A freely movable, hard tumor, about the size of a nut, can
be felt on deep palpation above Poupart's ligament on the left side ; no
visible peristalsis. Dilatation of the inferior epigastric vein. Slight re-
tromalleolar edema.
February 9th : Abdomen very tense, especially below the umbilicus, in
the same region there is pain, particularly on the left side. Repeated
chilliness, nausea and vomiting, very small pulse. Continued tenesmus.
At 5 P.M. sudden death.
ad 8.^ — Beginning: January, 1900.
Status presens : January 31, 1901.
Autopsy: February 11, 1901.
Duration: About 1 year, 1 month.
ad 9. — Autopsy (Professor Dr. //. Albrccht) : Polypoid and in-
filtrating adenocarcinoma of the upper portion of the rectum with be-
ginning ulceration and moderate stenosis. Great dilatation of the large
bowel with hypertrophy of the muscularis. Beginning peritonitis.
Epicrisis: In view of the "bowel individuality" of the patient (stool
276 TUMORS OF THE ABDOMINAL VISCERA
regular "like a clock") we may assume with great probability that the
constipation in January, 1900, lasting for 14 days, falls within the
period of the cancerous disease and was due to it.
Hypertrophy of the bowel ahead of the constriction may, in the
summer of 1900, have compensated for the obstruction.
In November, 1900, the symptoms of ulceration appear in the form
of frequent, mucosanguineous evacuations accompanied by tenesmus.
Such manifestations of constriction as visible peristalsis and colics
are absent during the entire course of the disease. The burning pain
corresponding in location to that of the tumor and which let up some-
what after bowel evacuation, are worthy of note.
Case 5. — J. H., 57 years, F. Washerwoman.
ad 3. — Never had any diseases of childhood, and later on was al-
ways healthy.
ad 4. — Bowel movement every other day as long as she can re-
member.
ad 6. — In August, 1901, the patient was taken sick overnight with
violent pain in the abdomen, there being four or five nmcosanguincous
stools with tenesmus and vomiting. This she attributed to drinking bad
water. The blood in the stools was fluid and red, disappearing after
two days, after which only large quantities of mucus were discharged.
The attending physician diagnosed the case as "dysentery." After three
weeks the patient resumed her work and felt cured.
In November, 1901, likewise in February and April, 1902, the same
painful attacks were repeated with the same accompanying manifesta-
tions, lasting from 2 to 3 days ; the attacks of pain were associated with
very loud bowel noises. In the intervals the bowel movements are said
to have been normal and regular.
In May, 1902, there occurred painful attacks of a colicky character,
accompanied b}^ loud bowel noises.
In July, 1902, there was no bowel movement for eight days ; subse-
quently bowels would move only by means of enemas. The attacks of
pain grew constantly stronger and more frequent. Bowel peristalsis
became visable.
At the present time (November 11, 1902) patient says she has had no
bowel movement for 15 days. For several weeks often eructation, odor-
less; bitter vomiting after larger intake of food. Appetite would be
good, but by way of precaution the patient takes only milk, red wine and
soup. Attack of pain in the abdomen diffuse without definite point of
origin, now and then radiating into the back, increased by ingestion of
solid or liquid food. When the colicky attack is at its height several
mouthfuls of biliary fluid are vomited. Bowel noises, especially on the
right underneath the costal arch. Nowhere any tenderness to pressure.
The colicky pain often radiates into the anus, so that there is a feeling
as if the bowels would have to move.
ad 7.^ — Tongue is moist, not coated. Abdomen much distended by
CARCIX0:MA of the large intestine 277
mefcorism, tension often beconjes suddenly increased accompanied by
loud intestinal noises. Tympanitic resonance over the liver and both
loins. Abundant atelectatic creaking on both sides over the lower por-
tions of the lungs. Indication of retromalleolar edema; also over the
sacrum. No appreciable emaciation. "Coffee-ground" vomiting with-
out any kind of vegetation in the vomitus.
Feces: \eYy small lumps.
ad 8. — Beginning: August, 1901.
Status presens : November 11, 1902.
Operation: November 19, 1902.
Duration : About 1 year, 3 months,
ad 9. — Operation : Carcinoma, formed like a signet ring, at the
sigmoid flexure.
Epicrisis: In this case the first clinical symptoms (intestinal hemor-
rhage, tenesmus, pain) were attributed to dysentery. According to the
statement of the patient the first attack (August, 1901) was accom-
panied by a loss of blood about l/o litre in quantity, light red in color;
such copious hemorrhage is not usually associated with dysentery.
The intervals between the single attacks which were free from com-
plaints must have seemed peculiar and naturally easily misleading. The
painful attacks with their characteristic radiation toward the anal open-
ing were always accompanied by loud "rolling," this being an important
symptom for determining their origin.
The increasing constriction shows itself in the greater intensity and
frequency of the colicky attacks, occurrence of stubborn constipation
and visible peristalsis.
There occurs also regurgitation per os : eructation, biliary vomiting
when the painful attacks are at their highest, later on "coffee-ground"
vomiting.-^
As very frequently in malignant neoplasms, so also here : "Never was
sick, nor did he have any infectious diseases of childhood."
Case 6. — F. W., 44 years, M. Assistant locksmith.
ad 1. — Father died of cancer of the tongue, mother of old age.
ad 3. — Twenty 3'ears ago had S3'philis (inunction treatment) ;
neither in childhood nor adult life any infectious diseases.
ad 6. — Since about January-, 1908, rapid loss of 56 kg in
weight (.'*). For the past six months bloody diarrhea, six to ten times a
da}^ with tenesmus. Five months ago is said to have had peritonitis, ac-
companied by severe edema of the legs. Now and then there is the appear-
ance of a swelling on the left side above Poupart's ligament, which moves
from the outer side to the middle. Tenderness on pressure, especially in
the middle of the lower abdominal region.
ad 7. — A tumor can be felt on deep palpation in the lower ab-
dominal region, uneven and sensitive to pressure. Bloody stools,
"See Splenic Flexure, 1.
278 TUMORS OF THE ABDOMINAL VISCERA
ad 8. — Beginning: About January, 1908.
Status presens : October 28, 1908.
Operation : November 3, 1908.
Autopsy: November 8, 1908.
Duration : About 10 months.
ad 9. — Finding at operation (Primarius Dr. Fr. Schopf) : Skin
incision from the umbilicus to the symphysis. At the promontory one
can immediately feel a hard tumor, as big as a man's fist, belonging to
the sigmoid flexure*.
Autopsy: (Pros. Professor Dr. Fr. Schlagenhaufer) : Decomposing
carcinoma of the sigmoid flexure.
Epicrisis: The enormous emaciation (56 kg) may be explained by the
fact that this patient originally was of pathologically heavy weight due
to adiposity.
Bloody diarrhea and tenesmus dominate the clinical picture ; it seems
that once during the course of the disease there was present a symptom
complex similar to that of peritonitis.
The patient himself claims to have noticed in the left lower quadrant
a swelling moving from the outer side to the middle line. Upon examining
the patient the tumor belonging to the flexure was palpable in the middle
line of the lower abdominal region.
Case 7. — F. H., 50 years, M. Shoemaker.
ad 1. — Mother is living, 75 3'ears of age.
ad 3. — Measles at 17, had pulmonary catarrh twice.
ad 6. — In January, 190-1, pain appeared in tlie lower abdominal
region, since then there is constipation ; never diarrhea. The attacks
of pain are cramp-like, localized on the left side and extend into the
lumbar region ; they become aggravated with increase in constipation.
In January of last year the patient had to urinate very often ; had to
hurry every time, otherwise could not retain the urine. This condition
lasted one month. Since the end of February of this year the attacks
of pain are accompanied by visible peristalsis with lively "rolling" in the
bowels. Emaciation to the extent of 10 kg. Attacks of pain come on,
especially when the bowels have not moved for a long time; they are also
promptly elicited by eating bread and fermentable foods ; they are not
accompanied by nausea or vomiting, except that sometimes there is sour
eructation.
ad 7. — Hard, changeable, fecal tumors can be felt in the region of
the sigmoid flexure; intestinal peristalsis with protuberance of the sig-
moid flexure which collapses immediately after discharge of flatus. With
spontaneous distention of the sigmoid flexure during the course of the
peristalsis the left inferior epigastric artery beoomes prominent. In
the epigastrium there is present a strange reverberating tympanitic
sound. No tenderness to pressure anywhere in the abdomen. Continued
atelectatic crepitus over the left lower lobe. No edemas.
Feces: ^Nlacroscopically no mucus, no blood.
CARCINOMA OF THE LARGE INTESTINE 279
April 5: Hiccough for some days- Beginnint^ of tlie peristaltic
protuberance always in the left half of the epigastrium,
ad 8. — Reginiiiiig: January, 19()-4.
Status presens: March 'I'l, 1904.
Operation : April 7, 1904.
ad 9. — Operation (Docent Dr. A. Exner): Circular constricting
scirrhus carcinoma of the sigmoid flexure, as big as a walnut ; freely
movable. No metastases demonstrable.
The tumor-masses felt in the flexure were feces, the carcinoma itself
had not been palpable.
Epicrisis: ^'isible peristalsis is preceded by attacks of colic," which
undoubtedly are explained by the beginning constriction and are, there-
fore, to be looked upon as constriction colics. They are located more
on the left side, radiate toward the left lumbar region, depend on the
degree of constipation and are influenced in an alimentary way by the use
of fermenting foods ; on and ofl' they are accompanied by sour eruc-
tation.
These constriction colics represent the first symptom of the disease.
Simultaneously there appear bladder symptoms, which it is difficult to
interpret, but which may bo looked upon as symptoms of proximity.
The peristalsis always begins in the left half of the epigastrium, and
in the course of it the sigmoid flexure stands out distinctly, there being
at the same time engorgement of the left inferior epigastric vein. Aside
from its location the sigmoid flexure can be recognized by the fact of
immediate collapse after discharge of flatus.
The scirrhus cicatricial character of the carcinoma explains both
the early appearance of constriction symptoms and the lack of blood
admixtures in the stool.
Case 8.— M. F., 52 years, M.
ad 3. — At 22 had a soft chancre ; otherwise no infectious diseases.
ad 4. — Always had a good appetite.
ad 5. — Alwaj^s enjoyed the best of health; about November, 1901,
i.e., 3 years ago, the appetite became diminished; there set in an itching
of the skin ; the urine became darker. He felt tired, looked bad, the
sclera? showed a yellow discoloration.
During the winter of 1902-1903 increase of these manifestations.
Lost 10 kg in weight. Bowels regular. At Karlsbad the jaundice re-
ceded somewhat, appetite improved, the itching of the skin became less.
ad 6. — Since about August, 1904, feeling of tension in the belly,
stool often "lead pencil-like' ; discharge of mucus. Defecation is often
preceded by cutting pain about the umbilicus. Frequent bowel noises
beneath the left costal arch.
ad 7. — Hemorrhagic ascites ; left flank somewhat more tense than
the right. Liver enlarged and firm, likewise the spleen.
Urine: Urobilinogen very abundant, no bilirubin.
Blood: 4,400,000 erythrocytes, 7,600 leucocytes, hemoglobin, 78%.
Toward the end severe edema.
280 TUMORS OF THE ABDOMINAL VISCERA
ad 8. — Beginning: August, 190'i.
Status prescns : November 26, 1904.
Autopsy: February 3, 1905.
Duration : About 6 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Ulcerating carcinoma
of the sigmoid flexure with mild stenosis, secondary carcinoma of the
peritoneum with hemorrhagic ascites. Singly scattered carcinomatous
nodules in the liver. Secondar}' carcinoma of the pleurae, the brain and
the osseous system. Atrophic cirrhosis of the liver and chronic splenic
tumor. Chronic endarterites deformans.
Epicrisis: The history of the disease resolves itself into a longer
period belonging to the cirrhosis and a shorter period during which the
cancerous disease exerts its influence.-'
The question, whether cirrhotic processes, either by way of a dyscra-
sia or through circulatory disturbances in the bowel, do not establish
an increased predisposition toward cancer, seems to me worthy of further
attention.
The following could be interpreted as suspicious of an intestinal neo-
plasm situated low down : "Lead pencil-like" stools with copious discharge
of mucus ; very lively bowel noises, localized and having a metallic
sound, attacks of pain before bowel evacuations, left flank very tense
(dilatation of the descending colon!), hemorrhagic ascites and short
course of same (probably 3 months).
Case 9.— M. H., 55 years, M.
ad 1. — Father and motlicr died at a very old age.
ad 3. — No infectious diseases in childhood.
ad 5. — Was alwa3fs healthy and strong.
ad 6. — About December, 1904, general weakness, emaciation and
difficulty in breathing. Since the beginning of the disease sluggish bowel
action, no diarrhea, no cramps. In January-, 1905, the abdomen began
to enlarge, but without pain. Appetite would be good l)ut the patient
is afraid to eat on account of increasing tenseness.
ad 7. — Tongue indented. Liver enormously enlarged, very firm
and uneven ; over it there is a systolic vascular murmur ; peritoneal fric-
tion over the left lobe. Dilatation of veins over the epigastrium. No
ascites. On the left side above Poupart's ligament a hard resistance
can be felt on intermittent palpation. Numerous atheromas on the
head (developed during the past 6 years). Pupils medium, tardy re-
action to light. Edema over the sacinim. Findings in stool are nega-
tive. HCl positive. Leucopenia.
April 28th : Sudden, very violent pain in the belly, collapse, hemate-
mesis before death.
ad 8. — Beginning: December, 1904.
Status presens: April 17, 1905.
Autopsy: April 29, 1905.
Duration : About 5 months.
" See Case 4, page 275.
CARCINOMA OF THE LARGE INTESTINE 281
ad 9. — Autops}' (Professor Dr. 0. Stoerk) : Carcinoma at the pos-
terior wall of the sigmoid flexure (the lower part of same), centrally
perforated toward the pouch of Douglas. Circumscribed purulent peri-
tonitis in the true pelvis and a recent diffuse peritonitis. Enormous
metastases in the liver (weight of liver 10.7 kg).
Epicrisis: As so frequently: Longevity of the parents, the patient
himself always having been well.
Aside from the terminal perforating peritonitis the primary car-
cinoma runs its course practically without symptoms.
Besides the proniinent appearance of cachexia there stand in the fore-
ground the metastases in the liver which lead to the enormous hepatic
enlargement. Appetite is well conserved, HCl secretion persists.
E. Rectum
Case 1.— M. A., 59 years, M. Tailor.
ad 1. — Mother suffering from some pulmonary disease, father died
at 84<.
ad 5. — Six years ago suppuration started in three places over the
sternum, associated with severe cough and night-sweats ; the process
lasted three years.
ad 6. — Since November, 1899, diarrhea (8-12 stools a day) with
copious discharge of mucus. In December, 1899, short breath on
mounting stairs and rapid walking. Since May, 1900, attacks of dizzi-
ness, swelling of the lower extremities. No abdominal pain.
ad 8. — Ascites. Continued diarrhea with incontinence (tannalbin
given hourly, without effect). Toward the end considerable pale edema
of the lower extremities.
Feces: Fluid, very rich in mucus.
Urine: Urobilinogen very strongly positive. Afebrile course.
ad 8. — Beginning: November, 1899.
Status presens: May 20, 1900.
ad 9. — Autopsy (Docent Dr. K. Landsteiner) : Ring-shaped rectal
carcinoma, ulcerating in many places, beginning 8 cm above the anus,
with extensive metastases in the liver; pulmonary metastases. Multiple,
ring-shaped tubercular ulcers of the small and large intestine. Bilateral
induration of the pulmonary apices. Ascites, anasarca. Perirectal sup-
puration, beginning peritonitis.
Epicrisis: The caries of the sternum and the induration of the pul-
monary apices during life had suggested tubercular intestinal ulcers as
the cause of the bowel symptoms, and these were actually also found at
autopsy. But outside of that there also existed an ulcerating carcinoma.
Referable to the latter were the following: Particular frequency of the
stools, occasional incontinence, evacuation of very copious, colloid-like
masses of mucus, and the appearance of severe edema in the lower ex-
tremities. The large quantity of urobilinogen might have some con-
nection with the metastases in the liver.
282 TUMORS OF THE ABDOMINAL VISCERA
Case 2.— W. J., 64 years, M.
ad 1. — Parents long lived.
ad 3. — No infectious diseases, neither in childhood nor later,
ad 4. — Stool always perfectly regular,
ad 5. — Always healthy, never was sick.
ad 6. — Since August, 1899, two to three bowel movements daily.
In January 1900, severe night-sweats, so that a change of shirts was
often necessary ; no cough, no fever.
Since March, 1900, one fluid bowel evacuation every two to three
hours; bloody colored mucus discharged in small quantities accompanied
by violent tenesmus; now and then bowel incontinence. Appetite became
diminished.
In May, 1900, extraordinary feeling of weakness.
Since the beginning of June of this year (1910) edema of the lower
extremities. No vomiting, no eructation. All foods are well tolerafted,
diet has no influence on the diarrhea. Urine comes after prolonged
straining. No pain in the back.
ad 7. — No cachectic appearance. Tongue dry over its middle por-
tion. Liver enlarged, very firm, having flat nodules on the surface, not
any appreciable tenderness on pressure. Severe edema of the leg below
the knee and over the sacrum. Now and then temperature up to 38° C.
After enemas of water there is prolapse. Ampulla very wide ; a circular
cancer mass can be felt at the promontory.
Blood: 4,000,000 erythrocytes, 7,000 leucocytes, 50% hemoglobin.
Feces: Large quantity of blood-streaked mucus.
Toward the end sudden pain over the symphysis with feeling of heat
and sweat-covered brow and great sensation of tension in the belly when
lying on the right or left side.
ad 8. — Beginning: August, 1899.
Status presens: June 12, 1900.
Autopsy: July 4, 1900.
Duration: About 11 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Papillary ring-shaped
carcinoma of the rectum with constriction ; a smaller papillary carcinoma
above the first. Polyposis of the bowel. Dilatation of the large bowel,
the bowel wall being separated in places and perforating into the sig-
moid flexure. Putrid diffuse peritonitis. Secondary carcinoma of the
liver.
Epicrisis: Longevity of the parents! Has had no disease! Tenes-
mus and occasional incontinence at an advanced age must always remind
us of rectal cancer and demands a most careful digital examination, even
when, as in this case, the appearance of the patient is good.
If we are dealing with individuals who all their life have had regular
bowel movements, the appearance of bowel irregularities must always
cause us to look for intestinal cancer.
Profuse night-sweats may also be explained by carcinomatous disease.
The copious bowel evacuations due to rectal cancer cannot be influenced
by diet or astringents.
CARCINOMA OF THE LARGE INTESTINE 283
Case 3. — J. A., 36 years, M. Foreman.
ad 1. — Mother lives and is hefllthy, likewise four brothers and
sisters.
cid 2. — From childhood until July, 1899, averaged one nose-bleed
every two weeks.
ad -it. — Appetite poor as long as he can remember,
ad 5.- — Two years ago the patient began to vomit every morning
after his coffee; this kept on for almost one year.
ad 6. — In February, 1900, constipation set in, intestinal colic and
vomiting after every intake of food; the appetite diminished. In April,
1900, the vomiting ceased, the appetite is said to have improved after
taking nux vomica, cinchona bark and soda bicarbonate. Never any
diarrhea. During the past weeks frequent prolapse of the rectum.
Since the latter part of August, 1900, the patient complains of
pressure and fulness in the region of the stomach; on account of this
feeling of pressure he cannot eat much; the liver is said to have become
larger.
Since February, 1900, lost 15 kg in weight. Pain in the back only
after lying down for a longer time.
Severe pain in the back from the top of the scapula to the costal
arches. No exacerbation on motion, decrease after defecation.
ad 7. — Face color, pale yellow. Liver enormously enlarged, hard,
uneven, not tender on pressure. Dilated veins, crossing the right costal
arch. Distinct ballottcment of the liver. Ascites; severe retromalleolar
and scrotal edema. Atelectatic crepitation over the right lower lobe
of the lung.
Feces: Bowel movements fairly regular, containing large quantities
of mucus.
Urine: No bilirubin.
Rectum: About 8 cm above the anal opening there is a protruding
hard tumor with an opening which admits the introduction of one finger.
Now and then temperature elevation up to 38° C.
ad 8. — Beginning: February, 1900.
Status presens: September 10, 1900.
Autopsy: October 13, 1900.
Duration: About 8 months,
ad 9. — Autopsy (Professor Dr. H. Albrecht) : About 8 cm over
the anus there is a small, moderately constricting carcinoma with enor-
mous metastases in the liver (weight 8,700 g). The vena cava and por-
tal vein are free. Edema of the lower extremities and the scrotum.
Hemorrhagic erosions in the stomach.
Epicrisis: The tendency to epistaxis deserves mention as a constitu-
tional peculiarity; during the cancerous period it ceased. Constipation,
intestinal colic and vomiting count among the initial symptoms.
The pain in the back is decreased after bowel movements, and are
independent of motion.
The epigastric symptoms occurring during the later course of the
disease (feeling of pressure, etc.) are due to the metastases in the liver.
28^ TUMORS OF THE ABDOMINAL VISCERA
In addition to ascites there is present severe edema of the legs and the
scrotum. •
Case 4.— J. R., 60 years, M.
ad 6. — Since about April, 1908, profuse diarrhea, now and then
vomiting; emaciation since about August, 1908. Transient icterus in
the course of the disease.
ad 7. — Liver greatly enlarged, hard, uneven. An ulcerating can-
cer can be felt through the rectum.
ad 8. — Beginning: About April, 1908.
Status presens: October 23, 1908.
Autopsy: November 11, 1908.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Gela-
tinous carcinoma in the rectum. Multiple metastases in the liver
(3,770 kg).
Case 5.— L. N., 49 years, M.
ad 1. — Parents arc healthy.
ad 4. — Bowels always perfectly regular.
ad 5. — Was always healthy.
ad 6. — Since about January, 1907, very stubborn constipation,
occurring H})parently without cause and M'ithout any cliangc in the mode
of living. During a stay in the country in the summer of 1907 the bowels
again became regular. During the past year has lost 10 kg in weight.
Appetite very good, no eructation, no vomiting. At present (January,
1908) again constipation ; bowels move only after taking phenolphthalein ;
Avithout cathartics there is often no bowel movement for five days. De-
spite constipation there is now and then tenesmus with involuntary bowel
movements ; this happened twice during the past year. On and off dis-
charge of some nuicus and blood. Pmemas arc not retained. No colics,
no sensations of metcorism. On and off pain in the region of the sacrum.
A surgical examination made in 1907 yielded negative results.
ad 7. — Carcinoma projecting into the ampulla with very narrow
lumen (January 14, 1908).
ad 8. — Beginning: About January, 1907.
Status presens: January 14, 1908.
Operation: January, 1908.
ad 9. — Operation (Hofrat Professor Dr. J. Hochenegg) : Car-
cinoma of the rectum ; total extirpation no longer feasible.
Epicrisis: The patient, who at the time of my examination (January
14, 1908) Avas still fulfilling the duties of his strenuous occupation as a
court officer, gave so typical a history that even before the rectal exam-
ination the diagnosis could be made almost with certainty.
Particularly Avorthy of note is the contrast : stubborn constipation
<'ind Avith it occasional incontinence ! The isolated discharge of blood
and mucus is also abvays highly suspicious of an ulceration Ioav down.
It is easilv seen AA'hy enemas are not retained when there is an ob-
struction loAv doAvn in the boAvcl. I^naccountable constipation AA^here
CARCINOMA OF THE LARGE INTESTINE 285
formerly the bowels were regular ought ahva^-s to bring to mind the pos-
sibility of a gastric or intestinal cancer.
It is strange that pal})ati()n made by a very competent surgeon in
August, 1907, yielded a negative result. It is probable that at that
time the tumor was high up, whereas at the time of my examination it
liad been displaced downward.
Case 6.— J. W., 61 years, M.
ad 3. — No infectious diseases,
ad 4. — Bowels always regular, appetite good.
ad 6. — About March, 1901, beginning of fatigue and general
malaise.
End of March, 1901 : Mild abdominal colic two or three times a
month, mostly toward 6 p.m. Diffuse pain, not very severe, some radia-
tion toward the anus, accompanied by lively noises.
Toward the end of jNIay, 1901, constipation began.
From July to October, 1901, the patient is said to have been treated
with poultices for a swelling on the left side above Poupart's ligament
(fecal tumors?). Stool mostly hard, thick as a small finger. After
taking cathartics (bitter Avaters) there is often blood and mucus in the
stool, blood partly clotted, partly fluid. In the beginning of ^March, 1902,
about three quarts {?) of light red blood are said to have been discharged.
The bowel movements are said to have become regular for a time, on a
milk diet, while staying in the country. Loss in weight '20 kg, increasing-
pallor and fatigue. No pain in the back.
ad 7. — Tongue dry. Visible peristalsis with very wide loops of gut,
splashing especially in the flanks, lively bowel noises. Ascites, no edemas.
Hemoglobin, 30%.
Per rectum: Firm tumor, easily reached, cauliflower-like, projecting
into the lumen with a central opening.
ad 8. — Beginning: About March, 1901.
Status presens : March 17, 1902.
Epicrlsis: Intestinal colics, occurring periodically two to three times
a month, usher in the clinical picture. They deserve attention, the more
so as we are dealing with an individual previously possessing a sound
stomach and bowel. Radiation of the colicky pain toward the anus
must always suggest a deep-seated intestinal process as the cause of same.
As a result of copious hemorrhage from the ulcerating tumor severe
anemia has supervened (30% hemoglobin).
In this instance the cancer had led to exquisite manifestations of
constriction with visible peristalsis ; there were splashing zones in the
flank corresponding to the dilated colon.
Case 7.— F. G., 61 years, M.
ad 2. — For several years, especially in winter, pain in the knee
and ankle joints, without fever.
ad 3. — ]Meas]cs at 9; at 30 had a left-sided pneumonia..
ad 6. — In April, 1904, without apparent cause, violent tenesmus,.
286 TUMORS OF THE ABDOMINAL VISCERA
there being up to 16 evacuations a day, consisting mostly of bloody
mucus. It is said that "catarrh" was diagnosed, the disease being at-
tributed to the existing hemorrhoids. Even at that time there was
present loud "rolling" in the abdomen. Appetite much diminished, later
on disgust toward meat. In the evening frequent mild febrile movements
accompanied by sensations of heat and cold. Severe emaciation and
feeling of weakness. No pain in the back.
ad 7. — Face full, reddened ; no cachectic discoloration. No
edemas.
Feces: Bloody mucous masses.
Rectal finding: Typical portio-like projecting rectal cancer,
ad 8. — Beginning: April, 1904.
Status presens: March, 1905.
Duration: About 1 year.
Epicrisis: The severe tenesmus accompanied by bloody mucous evac-
uations and loud inimbling in the bowels should have led to the right
diagnosis in April, 1904). Unaccountable appearance of gastro-intes-
tinal disturbances always deserves most serious consideration with refer-
ence to the possibility of a malignant neoplasm. As is not seldom the
case in malignant diseases, so also here there exists "rheumatic" ante-
cedents, namely, recurring afebrile arthridites.
Good facial appearance with fulness and a red color is frequently
met with precisely in connection with rectal cancer and is probably due
to the fact that with good appetite there is a good absorption of food,
often for a long time.
Case 8.— F. R., 13 years, F.
ad 1. — Parents are healthy,
ad 3. — Has had no infectious diseases.
ad 6. — About December, 3904, colicky pain appeared in the abdo-
men, bowels became constipated. The appetite was always good.
January, 1905: Enlargement of the right side of the abdomen and
later of the entire belly; no appreciable emaciation. Of late continuous
diarrhea. Pain in the region of the sacrum.
ad 7. — Dulness and hard tumor-masses in the ileocecal region, simi-
lar hard uneven tumor-masses in the left half of the abdomen. Liver is
hard and enlarged. Friction can be felt in the right half of the abdomen.
Belly very tense and distended ; extensive venous dilatations over the
middle of the epigastrium. External glands not affected. Edema in
the lower extremities and over the sacrum.
Blood: 3,400,000 erythrocytes, 13,200 leucocytes, 557^ heiiioglobin.
Urine: No aldehyde reaction.
ad 8. — Beginning: About December, 1904.
Status presens: INIarch 18, 1905.
Autopsy: April 3, 1905.
Duration : 4 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Medullary malignant
tumor of the rectum in its upper part with ulceration in form of several
CARCINOMA OF THE LARGE INTESTINE 287
imislirooin-sliapt'd lur^c iiodulcs uloiig^side of cucli other. Secondary
tumors in the lyniph-ghinds, as also in tlie mesocolon, encroaching on the
posterior wall of the uterus. Two large metastases in the liver.
Histological finding: Alveolar sarcoma.
Epicrisis: Here we have sarcoma of the rectum in a 13-year-old girl.
It began with colics and tendency to constipation ; during the latter
period continuous diarrhea. The whole lower abdomen was filled with
tumors, so that one would not be naturally led to suspect a neoplasm
originating in the rectum. The epigastric venous dilatations were ex-
plained by the extensive metastases in the liver; urobilinogen was not
demonstrable in the urine.
Case 9.— M. P., 60 years, M.
ad 1. — Father died at 76 from weakness of old age, mother died
of gastric cancer at 78.
ad 3. — Twenty-four years ago acquired syphilis.
ad 5. — Otherwise always healthy.
ad 6. — In March, 1903, there began attacks of colic in the lower
abdominal region. They were usually ushered in by "running together
of salty water in the mouth," after which there appeared loud bowel
noises, the belly became tense, pain being somewhat more severe in the left
lower abdominal region, and often there occurred vomiting of yellowish
masses ; the attacks concluded with a discharge of dark fluid stools, after
which there was immediate relief; At the start such attacks occurred
but once in two months, later, however, became more frequent. About
nine weeks ago, toward the end of January, 1905, there occurred another
such attack, but not particularly violent, followed by icterus which per-
sists to the present time. Appetite was fairly good until the appearance
of icterus. Never any mucus or blood in the stool. Of late great fatigue
and insomnia.
ad 7. — Liver enlarged, hard, uneven ; over it there can be heard a
loud systolic murmur, especially toward the end of expiration. Icterus
of medium intensity. Tenderness to pressure on the left side above Pou-
part's ligament. Dilated veins in the epigastrium. Severe retromalleo-
lar edema.
Feces: Abundance of soap needles, otherAvise nothing unusual. Two
to three bowel movements daily.
ad 8. — Beginning: About March, 1903.
Status prcsens : March 27, 1905.
Autopsy: April 13, 1905.
Duration : About 2 years.
ad 9.- — Autopsy (Docent Dr. K. Landsfeiner) : Carcinoma of the
lectum high up, ring-shaped ulceration. Metastases in the liver, with
perforation in the cystic duct and ductus choledochus, together with oc-
clusion of same by a soft, large tumor nodule. Severe icterus. Ob-
solete tuberculosis.
Epicrisis: The attacks of colic occurring in ]March. 1903, i.e., two
288 TUMORS OF THE ABDOMINAL VISCERA
years prior to death, were the first clinical manifestations of the car-
cinoma. Their situation in the lower abdominal region, accompanied by
loud rumbling in the bowels and distention of the abdomen sufficiently
characterized them as intestinal colics and as constriction colics in par-
ticular, so that even the icterus accidentally occurring after one of these
attacks — the same as after a gall-stone colic — could not dissuade us
from the first opinion. The more left-sided localization of the colics ac-
companied by tenderness on pressure at that place seems very worthy of
note as it corresponds to the seat of the disease.
Remote symptoms accompanying the attacks were a sort of sali-
vation (regurgitation from the stomach?) and occasionally also vomiting.
The appetite remained undisturbed for a long time.
The stools in this case offered no clue to a carcinoma of the rectum.
The dilated veins in the epigastrium pointed to an obstruction in
the portal circulation which was found to be due to extensive cancer
metastases. These also gave occasion for the occurrence of a sj^stolic
vascular murmur over the liver.
Case 10. — A. R., 59 years, M.
ad 3. — Contracted syphilis at 28 ; otherwise no infectious diseases.
ad 5. — Was always healthy, strong and well nourished. Five years
ago (1900) the patient noticed that drops of his urine falling on dark
trousers left stains. He became emaciated, felt weak, had severe thirst ;
on his left forearm there developed a phlegmon, and after an alxlominal
massage multiple abscesses made their appearance in the abdominal
skin. Following this 6% sugar was found in the urine. In June, 1903,
there was 2.5%.
ad 6. — For the past year and a half (about iNIay, 1904*) the bowels
were irregular, the patient often had to take cathartics, and during the
last half year these were required daily. When the bowels do not move
for some length of time there ensues eructation and vomiting of bile,
which symptoms disappear immediately after the bowels have moved.
About JNIay, 1905, for the first time there was a discharge of clotted
blood after sudden tenesmus had set in during the night ; since then fre-
quent discharge of clear blood or blood mixed with feces. Burning in
the rectum. Since the middle of September, 1905, two to three bloody
stools a day. Before each bowel movement there are severe cramp-like
pains about the navel, radiating into the region of the bladder and ac-
companied by tenesmus. After eating a roll or a dumpling the abdomen
becomes greatly distended and there are present cramp-like pains in the
lower part of the belly. Appetite good. Of late frequent very loud
rolling in the belly.
ad 7. — Sallow face color. Liver enlarged, hard, somewhat uneven.
Subfebrile temperatures, often above 37° C. No edemas.
Rectal finding: Ulcerating fixed carcinoma.
Feces: INIuco-sanguineous, strongly alkaline.
CARCINOMA OF THE LARGE INTESTINE 289
Urine: No sug'ar, not even after eatin<;- 50 g wliite bread,
ad 8. — Beginning: About May, 1904.
Status prcsens: October 4, 1905.
Duration: About 1^2 yc^rs.
ad 9.- — Diagnosis: Rectal carcinoma and metastases in the liver;
diabetes mellitus (latent).
Epicrisis: Gradually increasing constipation counts among the ini-
tial manifestations of the disease ; exacerbations of same are accompanied
by gastric symptoms, such as eructation and biliary vomiting.
During the subsequent course there follow tenesmus, discharge of
blood and colics in the lower abdomen, which precede bowel movements.
Diabetes mellitus was recorded in the history; at the time of the examina-
tion the urinary finding was negative.
Case 11.— W. R., 49 years, M. Miller.
ad 3. — During 1878, while in Bosnia, had malaria for over a half
year ; otherwise has had no infectious diseases.
ad 4. — Formerly the bowels were regular ; had hemorrhoids.
ad 6. — Since about July, 1905, frequent evacuations, often ten
times a day ; since then there are also night-sweats. Appetite always
good, no vomiting. For the past four weeks insomnia, has lost 20 kg in
weight during the past few weeks. Of late distention of the lower ab-
dominal region ; dorsal decubitus only is tolerated, lying on either side
is painful. Stools always dark, often containing rather large quantities
of mucus. For the past fourteen days there are gurgling noises at the
end of urination "as if from wind." No pain in the back. Tenderness
on pressure in the inferior abdominal region. Pain toward the end of
stool evacuations, radiating into the left testicle.
ad 7. — Pale yellow face color, inferior abdominal region much dis-
tended and rigid. No edemas. Mildly febrile course with temperature
rises up to 38° C.
Feces: Fluid, much mucus; contain pus cells and erythrocyte
shadows.
Urine: Pyuria with intestinal flora; muscle fibres in the sediment!
Subjectively there is slight tenesmus, slight burning at urination.
Blood: 9,400 leucocytes.
liectoscopic examination: Ulcerating carcinoma on the anterior wall,
situated at the juncture of the rectum and sigmoid flexure, occupying
two-thirds of the circumference.
ad 8.- — Beginning: About Jul}^, 1905.
Status presens: December 12, 1905.
ad 9. — Diagnosis: High up ulcerating cancer of the rectum with
vesical fistula.
Epicrisis: In this case the rectal cancer runs its course with very fre-
quent mucous evacuations from the start. Worthy of note are the pains
associated with bowel movements and radiatins; into the left testicle.
290 TUMORS OF THE ABDOMINAL VISCERA
The history itself (gurgling noises during the act of urination) permits
us to assume a recto-vesical fistula, the existence of which is confirmed
by the findings in the sediment (intestinal flora and muscle fibres).
The subjective bladder symptoms are slight. Night-sweats are pres-
ent among the initial symptoms.
Case 12. — J. N., 66 years, M. Locksmith.
ad 1. — Father died at 60, mother at 82 3'ears of age.
ad 2. — In lOOJ^ had rheumatic pains in the shoulders, particularly
the right.
ad 3. — Has not had any infectious diseases.
ad 4. — Bowels were always regular.
ad 5. — Was always strong and healthy. Claims that eight years
ago he once noticed blood in the stool toward the end of defecation.
ad 6. — Two weeks before Christmas of 1905 the present illness
began with severe pain in the region of the left, later also the right
clavicle, the pain extending downward to the abdomen ; stabbing pains
on breathing. Right lateral position provoked pain on the left side and
vice versa. On sitting up there were very severe pains in the back, also
pain anteriorly in the right thigh. If the patient urinates without having
previously emptied the bowels the stool and urine are discharged simul-
taneously. Bowel evacuations are copious, several times a day ; often
distention due to metcorism. Appetite always good, even for meat. Pain
in the back on\y when sitting up. Flexion of the right thigh on the ab-
domen is painful, and therefore the patient brings up the thigh with his
hand.
ad 7. — IJver much enlarged, firm, uneveii. Slight ascites, traces
of edema behind the malleolus and at the sacrum. HCl positive.
Feces: Bloody, clear as eggs.
Blood: 10,800 leucocytes.
Rectal finding: Typical rectal carcinoma.
ad 8.^ — Beginning: December, 1905.
Status presens : February 27, 1906.
ad 9. — Diagnosis : Carcinoma of the rectum ; metastases in the
liver.
Epicrisis: Worthy of note is tlie latent course of the rectal cancer until
the appearance of metastases in the liver which, on account of distention
of the capsule, lead to radiations of pain as far distant as the shoulders
and also lead to limited motion in the upper thigh.
The patient must retain his urine until the bowels have moved, as
otherwise the stool is discharged simultaneously with the urine.
The bowel evacuations are copious, muco-sanguineous. As fre-
quently is the case, so also here, we have a patient attacked by cancer, who
1. comes from lo«ig lived parents;
2. has had no infectious diseases ; and
3. was always healthy.
CARCINOMA OF THE LARGE INTESTINE 291
Case 13. — J. U., 34 years, M. Day laborer.
ad 1. — Mother is living cind well.
ad 3. — As a child had measles ; at 9 years of age had pleurisy.
ad 6. — In the spring of 1904, after eating fat meat, there occurred
diarrhea, which lasted four "days. During the summer of 1904< no com-
plaints. In November, 1905, renewed diarrhea, at first two to three times,
later four to seven times a day. In January, 1906, twelve to fifteen evac-
uations per day ; in the beginning they were painless. Appetite very good,
food is without influence on the number of evacuations. Later there were
eight day intervals between stools, after which there occurred very co-
pious bowel movements accompanied by severe pain; in addition to this,
feculent eructation. Since January of this year (1906) often twelve to
sixteen movements a day, consisting mostly of a little bloody mucus ;
tenesmus. After ingestion of food often immediate distention in the
epigastrium ; no vomiting. For the past three months offensive odor in
the mouth, "as if he had washed the mouth with urine." During two y^ars
the patient has lost only 4 kg in weight. No pain in the back.
ad 7. — Yellowish pale color of the face. Splashing sounds in the
epigastrium. Hard scybala in the sigmoid flexure. Mildly febrile course
with temperature elevations between 37° C. and 38° C.
Bowel evacuations: Muco-sanguineous masses, containing abundant
spirochetes.
Rectoscopic examinations: Nine cm above the sphincter there is a
hard tumor-mass on the anterior wall.
Histological examinations: Adenocarcinoma.
ad 8.- — Beginning: Spring, 1904 (?).
Status presens: March 20, 1906.
ad 9. — Diagnosis : Ulcerating carcinoma of the rectum.
Epicrisis: The diarrhea occurring in the spring of 1904, apparently
caused by a dietetic error, and repeated later on, even though after long
free intervals, may have been due to the cancerous disease. During the
subsequent course of the disease there were often long periods during
which no bowel movements occurred, accompanied by feculent eructation,
and ending with very massive evacuations attended by very severe pain.
The appetite remains good for a long time, which would account for
the slight loss in weight (4 kg in two years). The patient was only 34
years of age.
Case 14.— Th. R., 64 years, M.
ad 5.- — Never was sick.
ad 6. — In the autumn of 1906 there began diffuse abdominal pains
and diarrhea. Stools very often discolored wnth blood ; since November,
1906, there is vomiting after almost every intake of food.
ad 7.* — Pale yellow face color. Inferior abdominal region slightly
sensitive to pressure on both sides. Soft edema, extending over the
thigh and belly-wall, including the sacrum. After a test-breakfast of tea
and a roll there is no HCl.
292 TUMORS OF THE ABDOMINAL VISCERA
Stool evacuations: Mucus, pus, blood.
Rectoscopic examination: At the height of 14-15 cm there begins a
bleeding neoplasm, having a hard border, circular, completely ul-
cerating.
ad 8. — Beginning: Autumn, 1906.
Status presens: March 30, 1907.
ad 9. — Diagnosis : See rectoscopic finding.
Epiciisis: Gastric symptoms appear prominently in this case; vomit-
ing after every intake of nutrition, absence of HCl. Yet the character
of the stools (bloody, purulent masses of mucus) speaks for deep situa-
tion of the disease.
Primary Carcinoma of the Liver
Case 1. — F. J., 64 years, M. Metal grinder.
ad 4. — Never had any ga.stro-intestinal disturbances.
ad 5. — Never was seriously sick. In July, 1904), had pain an-
teriorly over the chest together with dyspnea, occurring especially when
walking rapidly.
ad 6. — In the beginning of November he accidentally noticed a
hard resistance above the umbilicus, not painful on pressure. The
appetite remained good, stool somewhat retarded. Particularly in the
evening hours there was a feeling of distention and fulness in the ab-
domen. No eructation, no vomiting, no colics. Rapid growth of the
epigastric tumor-mass ; during the past six weeks has lost 10 kg in
weight. Of late, frequent bleedings from the gums. Perfectly pain-
less course.
ad 7. — No icterus ; no ascites. Liver greatly enlarged, extraor-
dinarily hard, not painful on pressure ; dilatation of veins. Systolic
murmur over the liver. Spleen just about palpable, hard. Afebrile
course. Double murmur over the aorta, pulse rapid.
Urine: Urobilin positive; no diazo reaction.
Blood: 4,900,000 erythrocytes, 14,500 leucocytes, 60% hemoglobin.
Slight polychromasis, few normoblasts.
November 30, 1904: At 9 p.m. sudden loud screaming, jerkings in
the right half of the face, loss of consciousness. After half an hour
the patient regains partial consciousness, renewed attack; death.
ad 8. — Beginning: Early part of November, 1904.
Status presens : November 28, 1904.
Autopsy: December 1, 1904.
ad 9. — Autopsy (Hofrat Professor Dr. A. Weichselhaum) : In-
tense diffuse atheroma of ascending and descending aorta with great
dilatation of same. Insufficiency of the aortic valves. Left-sided
hemorrhage of the cerebrum. Carcinomatous cirrhosis of the liver with
metastases in the retroperitoneal and bronchial lymph-nodes as well
as in the visceral layer of the peritoneum. Slight hydrops, ascites.
Epicrisis: The unusually intense atheroma of the thoracic and ab-
dominal aorta might lead one to think of an underlying dyscrasia.
The differential diagnosis was really limited to a cirrhosis of Laennec
(first stage). This could be ruled out by the rapid increase in the size
of the liver as stated in the patient's history. Neither was there a
leucopenia so frequently met with in cirrhoscs of Laennec, but rather
a moderate leucocytosis (14,500).
The process ran a painless course, without icterus, without jaundice.
293
294 TUMORS OF THE ABDOMINAL VISCERA
Case 2.— W. F., 62 years, M.
ad 3. — 111 1867 had typhoid for seven weeks ; in 1904< erysipelas
of the face.
ad 4. — Since childhood had a tendency to "colds" and diarrhea,
ad 5. — Was always healthy and strong. In 1879 a rapidly
transient attack of hemiplegia (left side).
ad 6. — Since about June, 1904, on and off mild twingeing in the
region of the liver. In August, 1904, while working in a stooping
position sudden extremely violent pain underneath the right costal arch,
had to sit down immediately. The pain continued with great intensity
for one hour and since then has never ceased entirely. It is present
especially when coughing and when lying on the left side, now and then
radiating backward into the region of the kidney. No vomiting, no
chill. Even now the appetite is very good (October, 1904). Bowels
are regular. Since about July, 1904, has emaciated from 92 to 66 kg.
Weakness and fatigue.
ad 7. — October 8, 1904: No icterus, no ascites. Cachectic color
of the face with capillary dilatations on the checks. Tenderness to
pressure underneath the right costal arch. Liver much enlarged, pro-
jecting from underneath the right costal arch, very hard. Over the
riglit lobe there is a blowing systolic murmur. Corresponding to the
hepatic flexure of the colon there is bowel gurgling luiving a metallic
sound. The spleen extends to the costal arch, and is firm. No venous
dilatations over the epigastrium. Systolic murmur over the heart and in
the carotids; moderate lime deposits in the radial artery. No edemas;
temperature mostly 36° C.
Urine: No urobilin, no aliimntary glycosuria.
Blood: 10,800 leucocytes.
January 2, 1905 : Severe fvscites, venous dilatation in the epigas-
trium. Systolic murmur over the right hepatic lobe has disappeared.
Severe, soft edema in tlie lower extremities and at the sacrum. Afebrile
course, 36° C.
Urine: Abundance of urobilin; no diazo reaction.
Stomach: Total acidity, after test-breakfast, 9%, ho N. Na OH.
HCl negative.
Feces: Alternately ribbon-shaped and well formed; bowel movements
regular.
ad 8. — Beginning: June, 1904.
Status presens : October 8, 1904, and January 2, 1905.
Autops}': January 16, 1905.
Duration: About 6 months,
ad 9. — Autopsy (Docent Dr. J. Bartel) : Carcinoma of the right
hepatic lobe with metastases in the liver, periportal lymph-nodes and in
the lungs. Ascites clndosus. Healed endocarditis of the aortic valve
with insufficiency of same. Atheroma of the arch of the aorta and severe
atheroma of the peripheral arteries with much calcification.
Epicrisis: The cancer proliferation in this case affected chiefly the
right hepatic lobe, leading to much thickening and other chronic in-
PRIMARY CARCINOMA OF THE LIVER 295
ri;uiiiiuit()ry altcrjitions of the pcritoncjil covi-riiio- of the liver. To this
local peritonitic process may be referred tlie pain which ushered in tlie
disease and accompanied it practically throughout tlie entire course.
This exquisitely painful course of the disease constituted in itself
a distinguishing mark against the assumption of a cirrhotic process.
The latter was also ruled out by the auscultatory finding of a blowing,
strictly systolic murmur over the right hepatic lobe, wiiich subsequently
disappeared (murmur due to arterial compression!). The absence of
urobilinogenuria is, according to my personal experience, found much
more seldom in cirrhotic diseases of the liver than in localized malignant
processes. The rapid increase of urobilinogenuria from zero to a con-
siderable amount (January, 1905) may have some connection with the
acuteness of the underlying process.
"Milky" ascites is found far more frequently with malignant diseases
of the abdomen than with benign conditions. In this case we were very
likely dealing with congestion of chyle due to glandular metastases
(around the pancreas). The coincidence of a large liver and large ab-
domen (as a result of ascites) could also be interpreted as a malignant
syndrome.
The perfectly afebrile course did not well accord with the assump-
tion of a tumor formation springing from the biliary passages.
The intestinal flora was throughout Gram-negative. Such behavior
is unusual with gastric or intestinal neoplasms. Gastric cancers at
least in a large percentage of cases in the later stages lead to the ap-
pearance of Gram-positive lactic-acid bacilli in the stools ; intestinal
neoplasms are frequently accompanied by Gram-positive cocci.
The radial vessels were found to be much sclerosed.
Case 3. — J. B., 55 years, M. Tailor's assistant.
ad 1. — Mother succumbed to a pulmonary disease at 68; like-
wise a brother at 33.
ad 3. — Has had no infectious diseases.
ad 5. — Admits moderate use of alcohol.
ad 6. — In October, 1904, the former excellent appetite became
diminished, there set in a particular disinclination toward meat, the use
of which was followed by pressure in the stomach. Stool became re-
tarded, now and then being very light in color. The patient became
pale, emaciated to the extent of 10 kg. Afebrile course.
March, 1905: Swelling of the legs. Facial color pale, no icterus,
moderate ascites.
ad 7. — Liver moderately enlarged, firm, not painful; no vascular
murmurs. Soft, pale edema of the legs; edema at the sacrum. Afebrile
course.
Stomach contents: Total acidity after test-breakfast, 80'/r, HCl
40%. Pepsin and eff'ect of rennet normal. Toward the end "coffee-
ground" vomiting, few sarcina^.
Urine: One-quarter per cent, sugar. Strong aldehyde reaction.
Toward the end both findings negative (thrombosis of the portal vein).
296 TUMORS OF THE ABDOMINAL VISCERA
Blood: Eighty per cent, hemoglobin, 7,900 leucocytes.
' Ascitic fluid: sp. gr. 1015, "milky," cytological finding negative,
ad 8. — Beginning: October, 1904.
Status presens: March 16, 1905. •
Autopsy: April 1, 1905.
Duration : 6 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Primary carcinoma
of the liver (weight 2450 g) in an atrophic cirrhosis with green dis-
coloration of the tumor-masses ; thrombosis of the branches of the por-
tal vein after the tumor had perforated into same. Ascites, splenic
tumor, venous dilatations in the stomach and the lower end of the
esophagus. "Coffee-ground" contents in the stomach and bowel. In-
durations in the right pulmonary apex.
Epicrisis: Similarly as in Case 2, the right hepatic lobe was affected
also in this case. The rapid course (6 months) and the early appear-
ance of cachectic general symptoms (emaciation, facial pallor, weak-
ness, edema) spoke against a cirrhosis of Laennec. Meat anorexia be-
longed to the early symptoms, although the chemical findings of the
stomach proved normal. This case illustrates, among other things, the
diagnostic rule that preagonal gastric findings, as in this case "coffee-
ground" vomiting and the presence of a few sarcina?, are to be adjudged
lightly.
The urobilinogenuria, existing originally (strong aldehyde reac-
tion), and glycosuria, disappeared during the terminal stage, possibly
under the influence of the developing thrombosis in the portal vein.
Case 4. — S. E., 63 years, F. Seamstress.
ad 3. — Has had no infectious diseases,
ad 4. — Never had any gastric complaints.
ad 6. — In October, 1908, there began pain in the region of the
stomach and sour eructation. Almost at the same time the abdomen be-
came enlarged. No vomiting.
ad 7. — No icterus ; ascites, edema of the legs. Numerous small
tumor-masses (like glands) can be felt in the right half of the abdomen.
Urine: Suggestion of an aldehyde reaction; diazo reaction negative.
Feces: Test for blood-coloring matter is negative,
ad 8. — Beginning: October, 1908.
Status presens : November 23, 1908.
Autopsy: November 29, 1908.
Duration : 2 months,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer).
Epicrisis: Tumor-masses in a "corset lobe" are easily misinter-
preted ; the "corset" groove may pass as the border of the liver and
owing to the slight resistance which a "corset lobe" offers to the pal-
pating hand one easily gains the impression of greater relative mobility
of the tumor-masses.
The constantly negative finding in the feces, in testing for blood-
PRIMARY CARCIxNOMA OF THE LIVER 297
coloring matter, rendered an ulcerative process in the gastro-intestinal
tract higlily improbable.
The rapid course of the disease in particular spoke against a cir-
rhosis of Laennec, syphilis, etc.
Without doubt precisely primary cancers of the liver may for a
long time remain latent as far as the subjective symptoms in the patient
are concerned, which may also in part explain the usually acute clinical
course of the disease.
Case 5. — A. Sch., 65 years, M. Lacemaker.
ad 3. — \'aricella at 9 years of age ; otherwise no infectious
diseases.
ad 4. — During childhood often had colicky pain in the belly at
intervals of 18 to 24 days; bowels always regular. Never any icteinis.
Appetite always very good. Constant tendency to flatulence. For the
past twenty years the stools are said never to have been dark-brown
but always of a light yellow color, otherwise mostly regular and well
formed. Even very solid stools were usually colored light yellow.
ad 5. — Fifteen years ago the thyroid gland began to enlarge.
ad 6. — Bad appearance for the past tAvo years. In May, 1901,
the abdomen enlarged, and there appeared edema in the legs and scro-
tum. Dyspnea. These complaints again retrogressed. In July, 1901,
the patient noticed that the region on the right side underneath the cos-
tal arch bulged somewhat and was tender on pressure. Appetite good.
Bowels regular. Toward the end of January, 1903, he noticed in the
mouth, at a place corresponding to the ramus of the lower jaw, a pain-
less swelling, which grew to the size of a walnut and during the past
few days (April, 1903) began to bleed. On coughing there is a stabbing
pain in the back and in the region of the liver; on standing erect there
is a sensation that something in the right side of the abdomen is pulling
downward. Since the middle of March of this year (1903) there is
swelling of the legs.
ad 7. — No icterus ; no particular cachexia. Underneath the right
costal arch in the region of the liver there is a greatly projecting
tumor formation, about the size of an apple, having a tensely elastic
consistence. Liver slightly enlarged in toto, only little tender on pres-
sure. Spleen is palpable, extending to the costal arch, ^'enous dilata-
tions over the lower part of the sacrum. In the oral cavity, on the
ramus of the low^er jaw, there is a tumor the size of a walnut, discolored
dark red, soft, apparently fluctuating, bulging also externally. Soft,
retromalleolar edema.
ad 8. — Beginning: May, 1901.
Status presens: April 21, 1903.
Autopsy: May 16, 1903.
Duration : About 2 years.
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Adenocarcinoma of
the right hepatic lobe with metastases in the lungs and the left ranuis of
298 TUMORS OF THE ABDOMINAL VISCERA
the lower jaw. General arteriosclerosis, struma cystica of the right
lobe of the thyroid gland. Arteriosclerotic contracted kidney.
Epicrisis: As in Cases 2 and 3, so also here it was chiefly the right
hepatic lobe that was the seat of the cancer proliferation. One might
be tempted to connect the abnormally light color of the stools twenty
years ago with a disturbance in the biliary secretion and attribute it to
a pre-existent adenomatous formation of the liver.
Exceptionally the hepatic tumor-mass was not tough- but of a tensely
elastic consistence.
The metastasis situated in the ramus of the lower jaw showed exactly
the same consistence.
Case 6. — H. B., 18 years, M. Machinist apprentice. ^^
ad 1. — Father is living and is well ; mother was treated at the clinic
in 1897 for cancer of the stomach.
ad 2. — Since childhood has been inclined to headaches, radiating
from the occiput to the front.
ad 3. — Has had none of the diseases of childhood.
ad 5. — Was always healthy; in childhood had a tendency to ca-
tarrh of the respiratory passages during the cold seasons of the year.
ad 6. — About January 1, 1899, feeling of pressure in the epi-
gastrium after eating soup. Vomiting. Subsequently pain anteriorly
on a level with the umbilicus, girdle shaped, with tenderness on pressure
in both hypochondriac regions ; increase of the complaints on motion
and when lying on the side. Anorexia ; bowels regular.
ad 7. — Frail individual. No hairs in the axilla, infantile testicles.
Rachitic cranium. Sub-icteric discoloration. Liver moderately en-
larged, firm, with a protuberance in the epigastrium about the size of a
walnut, very sensitive to pressure. Blowing systolic murmur, especially
on the right side underneath the costal arch, also demonstrable in the
right middle axillary line. Venous dilatations over the abdomen. Spleen
palpable, hard. No ascites, no edema.
Urine: Abundance of urobilin; bilirubin negative.
Blood: 5,100,000 erythrocytes, 9,300 leucocytes, 80% hemoglobin.
During the further course there were continued pain, occasionally
radiating toward the right shoulder ; appearance of ascites ; frequent
vomiting; diarrhea. Only toward the end there was bilirubin in the
urine. Temperature ranged between 36° C. and 37.3° C.
ad 8. — Beginning: Early part of January, 1899.
Status presens: January 15, 1899.
Autopsy: January 28, 1899.
ad 9. — Autopsy (Professor Dr. H. Albrecht) : Adenocarcinoma
of the liver, with enormous intumescence of the liver and spleen in an
old pylephlebitic cirrhosis ; thrombosis of the portal vein. Metastases
in the lungs. Icterus. Fresh fibrinous purulent peritonitis.
"^ See E. Lindner. Wiener Klin. "Wochenschr., 1899, No. 44.
PRIMARY CARCINOMA OF THE 1,1 VKK 299
Ejncrisis: Primary cancer of the liver in an 18-year-ol(l individual
with numerous indications of a hypoplastic constitution (absence of
hairs in the axilla, infantile testicles, meduUated nerve-fibres at the pa-
pilla, multiple small f^landular swellings).
The disease began suddenly', accompanied by gastric symptoms and
hepatalgias (radiation toward the right shoulder!); during the further
course there occurred diarrheas (thrombosis of the portal vein). Only
toward the end did bilirubin appear in the urine; at the start there was
great urobilinuria. According to the opinion of the anatomist the
adenocarcinoma was superimposed on a pylephlebitic cirrhosis; clini-
cally this disease had inin a symptomless course and only the large
splenic tumor could remind one of a pre-existent cirrhotic disease. The
anatomical beginning of the cancer was probably at an earlier date than
the appearance of the clinical symptoms (hardly a month prior to
death) would permit one to assmne.
Case 7.— S. P., 29 years, M.
ad 1. — Parents are living and well.
ad 3.— Aside from disease lasting 5 days, to be mentioned later,
has had no febrile condition.
ad 4. — At 22 years of age suffered from some stomach trouble
for about three weeks, which was accompanied by pressure in the stomach
and vomiting.
ad 5. — Was othei-Avise healthy until September, 1905. At that
time while in Dischibuti (French coast of Somali in Africa) was taken
with ja^llow fever (up to -il" C.) ; this disappeared in five days under
quinine therapy.
ad 6. — In April, 1906, pain in the epigastrium, when sitting up
or turning from the left side to the right. Cold compresses had a favor-
able effect. Digestion normal at the start.
Middle of May, 1906: Sudden stabbing and burning pain above the
umbilicus and on both sides of the back. Pressure on the epigastrium
causes pain in the right shoulder. Pain in the right scapula. The pain
is least when the patient is lying on the back with knees drawn up.
Middle of June, 1906: Attacks of fever for five days.
June 19-26, 1906: Pain especially on the right side below the costal
arch, also to the left of the umbilicus. No icterus, color of the urine
strikingly dark since the beginning of May of this year (1906).
Night-sweats.
In the middle of May, 1906, a tumor-mass was for the first time
found to the left of the umbilicus. According to the statement of the
patient, the physician in attendance suspected echinococcus or liver
abscess.
ad 7. — No cachectic appearance, no edemas, no ascites, no
icterus. Both lobes of the liver equally much enlarged, very firm, sur-
face smooth, not sensitive to pressure. No vascular nuirmurs, no venous
dilatations. Spleen not enlarged.
300 TUMORS OF THE ABDOMINAL VISCERA
Urine: On exposure to the air became pronouncedly black! This
black discoloration could also be produced by adding drops of fuming
HNOa,' by a solution of ferric chloride and tincture of iodine. In per-
forming Legal'.s acetone test on addition of sodium nitro-prusside and
KOH the urine took on a purple-violet color, on the addition of glacial
acetic it turned blue ! Aldehyde reaction positive. Diazo reaction
present in traces.
Blood: 4,064,000 erythrocytes, 15,400 leucocytes, hemoglobin 80%,
namely :
Polynuclears, 76%.
Lymphocytes, 12%.
• Large monon, 11%.
Mast cells, 0.1%.
Eosinophiles, —
Toward the end bloody stools and bloody vomiting.
ad 8. — Beginning: April, 1906 (September, 1905.'').
Status presens : July 5, 1906.
Autopsy: August 12, 1906.
Duration: 4 months,
ad 9. — Autopsy (Professor Dr. A. Glion) : Melanosarcoma of
the liver, with enormous hypertrophy of same and thrombosis in the
ramifications of the portal vein. Melanosarcoma of the lymph-nodes at
the porta of the liver and in the retroperitoneal lymph-nodes. Slight
icterus. The liver weighs 8 kg, 50 dkg. Surface smooth.
Epicrisis: This is a case of melanosarcoma of the liver with typical
urinary findings, which comes under the discussion of primary cancer
of the liver inasmuch as there is no demonstrable point of origin out-
side of the liver (chorioidea, najvus, etc.).
At the time of his entrance the patient brought with him a urinary
report bearing the remark : tannic acid positive.
This peculiar finding — the patient denied ever having taken medica-
ments containing tannic acid — together with the enormous intumescence
of the liver immediately aroused the suspicion of a melanosarcoma, which
was confirmed even by a hasty examination of the urine.
The addition of ferric chloride actually caused a black discoloration
of the urine, and this had led to the assumption of tannic acid in the
urine.
But other oxidizing influences had the same effect, thus exposure of
the urine to the air, addition of a few drops of fuming nitric acid or of
tincture of iron. Legal's test for acetone yielded a blue color on the
addition of glacial acetic.
Hence we were dealing not with tannic acid but with melanin.
It was surprising that despite the enormous enlargement of the liver
(8 kg) there was no real cancerous cachexia and no edemas. This may
have contributed to the fact that — as stated by the patient — an echino-
coccus infection or liver abscess had been thought of.
The latter assumption may have been strengthened by the patient's
previous sojourn in the tropics and the occasional attacks of fever.
PRIMARY CARCINOMA OF THE LIVER 301
The autopsy did not disclose any complications which would account
for the febrile movements and very likely they were dependent on the
malignant process which had perhaps set in even in September, 1905
(first febrile attack). The process was ushered in by perihepatic pain
and the fact that pressure in the epigastrium elicited pain in the right
shoulder, desel'^'es attention.
As in most cases of primary and secondary neoplasms of the liver,^^
so also here, there appeared a distinct icterus.
The patient was 29 years of age.
" Exclusive of the forms originating in the gall-bladder and biliary passages.
Secondary Carcinoma of the Liver
30
Case 1.— N. N., 42 years, M.
ad 3. — Had smallpox and diphtheria.
ad 6. — In March, 1905, there began a feeling of pressure in the
epigastrium which became increased after ingestion of food; at the start
it would often be absent for one week. Duration mostly one-quarter of
an hour. Constant increase of the symptom during the course of the
disease.
In the middle of December, 1905, the epigastrium began to bulge;
the bulging increased rapidly during the past three weeks. The urine
became darker, the stools light.
Since the end of December, 1905, the patient can lie only on his
right side with legs drawn up ; every change in position is exceedingly
painful. On and off increasing and decreasing feeling of pressure in
the epigastrium, at the same time pain in the back. Anorexia, consti-
pation.
ad 7. — Facial color pale, no icteinis, no ascites. The patient con-
stantly occupies the right lateral position. The liver is enlarged, very
firm ; a systolic murmur can be heard in the area of the right lobe ;
venous dilatations across the right costal arch. Spleen is not enlarged.
No edemas.
January 6, 1906: Temperature elevations up to 39.4° C. ; herpes
labialis.
Urine: Strongly positive aldehyde reaction.
Blood: 5,136,000 erythrocytes^ 11,000 leucocytes, hemoglobin 77%.
ad 8. — Beginning (stomach) : March, 1905 (liver) : middle of
December, 1905.
Status presens: January 5, 1906.
Autopsy: January 22, 1906.
ad 9. — Autopsy (Professor Dr. A. Glion) : Medullar}', non-
stenosing carcinoma of the stomach; diffuse metastases in the liver,
partly nodular, partly diffusely infiltrating, with enlargement of the
liver. General icterus. Perihepatitis and perisplenitis.
EpicHsis: This case shows that metastases in the liver, which fre-
quently may run an almost painless course, though the liver be enor-
mously enlarged, may exceptionally be accompanied by unusually severe
'" I confine myself to the presentation of one atypical case, in which the phenomena
of pain and febrile manifestations stand clinically in the foreground.
302
SECONDARY CARCINOMA OF THE LIVER 303
pain, nanicl}' in those cases where a diffuse acute perihepatitis super-
venes.
According to my observation the niedulhiry, severely ulcerating can-
cers of the gastro-intestinal tract are the ones which with synchronous
metastasis in the liver most frequently occasion severe perihepatitis.
Very likely we are here dealing with a simultaneous invasion of inflam-
mator}' excitants from the ulcerating surface. On account of the severe
perihepatitis, which was accompanied b}^ high rises in temperature and
herpes labialis, the patient was inunobilized in the right lateral position.
There are cases in which one could easily erroneously suspect inflam-
matory infectious diseases of the liver (cholangitis, abscess of the liver,
cholelithiasis, syphilis, etc.).
Carcinoma of the Gall-Bladder, Including the
Biliary Passages and the Papilla of Vater''
Case 1.— N. N., 60 years, F.
ad 6. — Beginning of the symptoms at Christmas, 1897, with
icterus, which at the start was of varying intensity. No pain. For sev-
eral months there has been moderate vomiting, of late vomiting of
"coffee-ground" masses.
ad 7. — Ictcinis. Hard, almost angular tumor corresponding to
the gall-bladder; surrounding it are button-like hard nodules. Dilata-
tion of the stomach. The gastric contents contain abundant sai'cinae,
only a few isolated lactic-acid bacilli ; of late there is diarrhea,
ad 8. — Beginning: Christmas, 1897.
Status presens: End of August, 1898.
Autopsy: End of August, 1898.
Duration: About 8 months,
ad 9. — Autopsy: Carcinoma of the gall-bladder (cholelithiasis).
Epicrisis: The carcinoma of the gall-bladder had led to a stenosis
of the pylorus and thus to the occurrence of sarcins in the stomach con-
tents ; at the end, as a result of parenchymatous hemorrhages from the
gastric mucosa, there occurred also "coffee-ground" vomiting.
When with a general cachexia, there is a coexistence of icterus and
sarcinae we should think not only of cancer of the pancreas but also of
cancer of the gall-bladder.
An angular form and especial hardness is peculiar to gall-bladders
that are contracted and filled with calculi.
Case 2. — 0. Th., 67 years, F. Housekeeper.
ad 2. — At 60 years of ago had a severe acute articular rheuma-
tism affecting all the joints and lasting three months,
ad 5. — Was always healthy.
ad 6. — In September, 1899, the patient lost her appetite, was
nauseated by meat. Constipation set in.
About October, 1899, her attention was called to the yellow color
of her skin. Appetite again improved.
In November, 1899, there appeared pain in the back, radiating an-
teriorly in a girdle shaped manner. For the past four weeks the abdomen
=' See Cases 23, 24, 25.
304
CARCINOMA OF THE GALL-BLADDER :J()5
is enlarged, since then tiie patient has become greatly emaciated. At
present (January, 1900) there is no pain, only toward the end there was
pain in the right half of the abdomen. Continued anorexia.
ad 7. — Icterus of mild degree. Ascites and bilateral hydrothorax
(worse on the left side). Numerous hard nodules can be felt in the re-
gion of the gall-bladder and in the right hepatic lobe ; the right hepatic
lobe is drawn out into a "corset lobe" and marked off by a deep "corset
groove." Peritoneal friction in the region of the gall-bladder. Arythmia
without bradycardia.
Urine: Bilirubin negative; urobilinogen present.
Blood: 13,000 leucocytes, hemoglobin, 707c.
No itching of the skin, a few cutaneous hemorrhages. Retro-
malleolar edema. Afebrile course. Lactic-acid bacilli and stagnating
remains of muscle fibres are transiently demonstrable in the vomitus.
ad 8. — Beginning: September, 1899.
Status presens : January 4, 1900.
Autopsy: January 23, 1900.
Duration: About 5 months,
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Fibrous cancer of
the gall-bladder superimposed on a cholelithiasis (about two dozen
small, facetted, dark calculi and one light colored in the neck of the gall-
bladder, as big as a dove's Qgg) with regional metastases in the par-
enchyma of the liver and the lymph-nodes in the hilum of the liver.
The hepatic flexure of the colon is adherent to the gall-bladder. Con-
striction of the corresponding portion of the duodenum. Hydrops, as-
cites, hydrothorax. General severe icterus.
Epicrisis: The beginning of the disease (anorexia, nausea toward
meat) bore a gastric impress; a month later there already appeared
biliar}' congestion.
The very rapid course of the disease is worthy of note: death five
months after appearance of the first s3^mptoms.
There had never existed any painful attacks such as occur with
cholelithiasis ; autopsy disclosed a small, contracted gall-bladder filled
with calculi.
The metastases were situated in the region immediately surrounding
the gall-bladder, the left hepatic lobe being almost entirely free from
metastases, this latter being of frequent occurrence with carcinoma of
the gall-bladder.
The duodenum was greatly narrowed ; during life there had been
symptoms of stagnation, lactic-acid bacilli al^o being demonstrable.
The ascites had been so considerable tliat distinct palpation was possi-
ble only after aspiration of the fluid. Seven years before the appearance
of the cancerous disease, the patient being 60 years old, there had boon
an articular rheumatism for 3 months.
Case 3. — A. S., 43 years, M. Machinist.
ad 1. — Father is living and well.
ad 3. — Has had typhoid.
306 TUMORS OF THE ABDOMINAL VISCERA
•ij 5. — One day in September, 1900, at 5 p.m. severe colicky
pain, without apparent cause, in the inferior abdominal region, accom-
panied by chill; no icterus. Afterward anorexia for two or three days.
One month later (October, 1900) icterus appeared and the patient
noticed slight stabbing pain in the region of the gall-bladder (at his
work was compelled frequently to stoop and also to brace instruments
against the region of the liver). Since then could not lie on the left
side because it produced a sensation as if something in the abdomen was
drawn over to the left side. Appetite good; but there is a feeling of
fulness in the stomach. No vomiting, no eructation, meat is well tol-
erated. Bowels regular, daily movement. Despite a good appetite there
is emaciation to the extent of 3 kg. Afebrile course.
ad 6. — Pain in the back on stooping; the vertebral column
slightly tender on pressure between the shoulder-blades.
ad 7. — Icterus of medium degree. The gall-bladder can be seen
through the abdominal wall as big as a cherry ; above it there is a firai
nodule in the liver tissue. Liver somewhat enlarged all around, with
some increase in consistency, the right lobe being tender on percussion.
No edema (December 11, 1900), no indications of a hemorrhagic dia-
thesis.
December U), 1900: Painful swelling in tlie bend of the left elbow,
the veins in that locality being dilated and painful (thrombosis at
autopsy!) ; similar pain over the right lower leg. The saphenous vein of
the left lower extremity is very painful, and can be felt as a cord;
later on, severe edema of the left lower extremity with great attenuation
of the icteric coloration over that area; mucli cyanosis. Circumference
of the calf on the right side 33 cm, the thigh on the left side 49 cm, the
right 38 cm. During the further course there occurred gangrene of the
toes of the left foot.
ad 8. — Beginning: September, 1900.
Status presens: December 11, 1900.
Autopsy: January 4, 1901.
Duration: About 4 months.
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Carcinoma of the
neck of the gall-bladder with metastases in the liver and the lymph-
nodes at the hilum of the liver. Tremendous dilatation of the biliary
passages and severe icterus. Compression of the inferior vena cava by
retroperitoneal carcinomatously infiltrated lymph-nodes, together with
thrombosis of the inferior vena cava and both crural veins. Beginning
o-angrene of the left foot. Severe hemorrhage from the nasal mucous
membrane. The gall-bladder, as big as a plum, is filled with very numer-
ous concretions, the neck being !/> cm in thickness ; a milky secretion
can be scraped from the cut surface.
Epicrisis: Also in this case the clinical duration of the disease is a
verv short one, being only about four months. The attack of typhoid,
referred to in the history, may in its day, by way of a cholecystitis,
have o-iven the impulse to the formation of biliary calculi. As in Cases
1 and 2, so also here, the previous history offers no clue to suspect
CARCINOMA OF THE GALL-RLADDKll 307
gall-stone colics. The first attack is provoked evidently by the inci-
pient development of the cancer.
The development of a painful left lateral position is worthy of note,
and is not seldom found in connection with affections of the gall-bladder.
The metastasis in the liver was very slight, the organ being enlarged
as a result of biliary congestion, and therefore felt firm.
Glandular metastases lead to the compression of the inferior vena
cava ; the latter, as well as the veins of the lower extremity, being throm-
bosed.
Case 4. — L. K., 64 years, M.
ad 5.— Was always healthy until April 7, 1901.
ad 6. — On April 7, 1901, early in the morning there occurred
sudden pain around the umbilicus, lasting twenty-four hours, associated
with pain in the back and nausea; three weeks later the urine became
dark brown, and the attending physician diagnosed icterus. Then the
yellow discoloration increased in intensity. Since the appearance of
icterus there is loss of appetite, the bowel evacuations are frequently
fluid. Since the end of June, 1901, the pain has increased, being local-
ized partly in the region of the umbilicus and partly corresponding
to the right hepatic lobe.
ad 7. — Severe icterus, distinct ascites, great emaciation. Febrile
course. Liver enlarged downward about the width of one hand; on the
right side below the costal arch nodules can be felt, corresponding to the
location of the gall-bladder there is tenderness to pressure. Spleen
slightly enlarged. Severe edema behind the malleoli and over the tibias.
ad 8. — Beginning: April 7, 1901.
Status presens: August 7, 1901.
Autopsy: August 21," 1901.
Duration : 4 to 5 months.
ad 9. — Autopsy (Professor Dr. H. Albrecht) : Contracting car-
cinoma of the cystic duct encroaching on the ductus choledochus and great
dilatation of the gall-bladder. Diphtheritic cholecystitis. Severe icterus.
Very small metastases in the liver. Ascites and bilateral hydrothorax.
Severe hemorrhage in the gastro-intestinal canal from hemorrhagic ero-
sions in the stomach. No biliary calculi.
Epicrisis: Similarly as in Case 3 the disease in this instance begins
suddenly with an attack of colic lasting twenty-four hours, which, very
likely, is to be interpreted as a gall-bladder colic and has some connec-
tion with the development of cancer in the neck of the gall-bladder.
Concretions are absent. Autopsy disclosed an enlarged gall-bladder.
Common to Cases 3 and 4 is the fact that the icterus does not im-
mediately follow the initial attack of pain, but sets in about a month
later.
808 TUMORS OF THE ABDOMINAL VISCERA
Case 5.— F. Z., 74 years, M.
ad 1.— Father died at 61 years of age.
ad 5. — Was always healthy ; three years ago had mild gastric
complaints with eructation.
ad 6. — Since the middle of January, 1904, attacks of cutting
pain in the right hypochondrium ; the pain comes on at intervals of two
to three hours, and is worse at night. For the past two weeks the pain
has been particularly intense, with now and then mild chills. Since the
same time there has been constipation. From the beginning of the dis-
ease anorexia, disinclination toward meat and vegetables, predilection
for flour and milk foods. The duration of the icterus is not known.
Great emaciation since the beginning of the disease; vomited onl}' once,
in the early part of February of this year.
ad 7. — Icterus gravis, but without itching of the skin and with-
out hemorrhagic diathesis. No ascites. Liver slightly enlarged, very
tender on percussion in the middle line, gall-bladder not palpable, the
j'egion of the gall-bladder not tender on pressure. Pulse small, ir-
regular. Tonometer (Gartner) 50 mm Hg. No edemas. Tempera-
ture mostly over 37° C. ; February 9, 38.1° C. ; February 15, 39.6° C.
Death early on the morning of February 16.
ad 8. — Beginning: Middle of January', 190-i.
Status presens: February 14, 1904.
Autopsy : February 16, 1904.
Duration: About 1 month.
ad 9. — Autopsy (Professor Dr. O. Stoerk) : Papillary carcinoma
of the gall-bladder, which was diminished in size, and isolated metastases
in the ductus ciioledochus at the juncture with the cystic duct. Cholan-
gitic abscesses especially in the left hepatic lobe.
Epicrisis: The subjective symptoms of the disease made their first
appearance about one month prior to death, and analogous to observa-
tions in Cases 3 and 4 they consisted of colicky pain in the hepatic
region, which after the manner of colicky pain was attended by noc-
turnal exacerbations.
Nothing could be said with certainty regarding the duration of the
icterus. The chills and the febrile course were explained anatomically
by the cholangitic abscesses in the left hepatic lobe.
The beginning of the symptoms was associated with meat anorexia.
As in Case 4 no concretions could be found.
Attacks similar to cholelithiasis and occurring for the first time in
old age are always suspicious of carcinoma of the gall-bladder.
Case 6.— S. W., 46 years, F.
ad 1. — Father living, 79 years old, is healthy.
ad 3. — Has had no infectious diseases.
ad 5.^Frail in childhood, but otherwise healthy; later on anemic;
is said to have expectorated foamy blood in the summer of 1903, like-
wise in 1902.
CARCINOMA OF THE GALL-BLADDER JJ09
ad 6. — In tlie fall of 1903 general indisposition, easily fatigued,
anorexia. Two weeks before Christmas, 1903, her color became very
yellow for several days, accompanied by very frequent vomiting of white
mucous masses. There was disgust toward meat and soup.
In January, 1904, pain set in in the right h;df of the abdomen,
where a swelling could be noticed. The urine became darker, the bowels
remained regidar as formerly.
In May, 1904', edemas appeared in the lower extremities.
ad 7. — No icterus. The right lobe of the liver drawn out into a
"corset lobe," downward as far as the ileocecal region ; this portion of
the liver very hard, uneven, the border being blunt and indented. The
tumor-mass permits of ballottcment from the right flank to the front.
"Corset groove" just underneath the costal arch, where also peritoneal
friction (snow creaking) can be felt and a distinct knot with a depres-
sion, can be demonstrated. Pale, soft edema in the lower extremities
and at the sacrum. Temperature mostly between 38° C. and 39° C.
Urine: Continued strong diazo and aldehyde reaction; no bilirubin.
Blood: 24,600 leucocytes, 2,100,000 erythrocytes,
ad 8. — Beginning: Autumn, 1903.
Status presens : June 6, 1904.
Autopsy: June 18, 1904.
Duration : About 9 to 10 months,
ad 9. — Autopsy (Docent Dr. J. Bartel): Carcinoma of the gall-
bladder, originating in the fundus (gall-bladder small, full of calculi,
which partly also occupy the cystic duct) ; tremendous enlargement down-
ward of the right hepatic lobe (metastases!). Tuberculosis of both
pulmonary apices with induration.
Epicrisis: Though the characteristic hepatic symptom of abnormal
skin discoloration, i. e., icterus, was absent, the abnormally dark color
of the urine, together with the strong aldehyde reaction, must, from
the very beginning, have suggested the possibility of an hepatic disease.
The course was a highly febrile one and was accompanied by a
strong diazo reaction, which can probably be traced to an associated
infection of the biliary passages, the same as the leucocytosis (24,600).
Identification of the tumor-mass as part of the liver was not without
difficulty, as it was separated from the liver by a deep "corset groove,"
so that for a time, on account of its proximity to the true pelvis, there
was even thought of a possible ovarian tumor. "Corset lobes" are
frequently met with in connection with cholelithiasis, hence also car-
cinoma of the gall-bladder, and I consider them partly as congenital,
similar to the "indented" tongue, which, according to my experience,
is frequently observed with cholelithiasis. Here also the metastases are
regional, affecting particularly the neighborhood of the gall-bladder. An
attack of cholelithiasis with rapidly retrogressing icterus ushers in the
clinical picture ; as so frequently, it is the first attack of gall-stone colic,
the disease being latent until the appearance of the cancer.
The gastric symptoms that deserve note are: Disgust toward meat
and soup, and mucous vomiting.
310 TUMORS OF THE ABDOMINAL VISCERA
Case 7.— M. S., 54 years, F.
ad 1. — Both parents died from weakness of old age.
ad 3. — As a child had t^'phoid, was otherwise healthy.
ad 5. — Two years ago (1900) at 10 p. m., after eating bad butter,
there occurred severe cutting pain in the epigastrium, somewhat more
to the right and radiating into the back; chill, biliary vomiting; could
not lie on the right side. On the second day the urine was dark brown,
on the third day the sclerae became yellow. On the right side under-
neath the costal arch, a resistance could be felt which was as big as a
fist. The icterus lasted three weeks, after which there were no further
complaints.
ad 6. — In the beginning of November, 1902, after eating a pear
there occurred severe pain in the epigastrium, radiating to the right;
the patient could not keep herself erect, could not walk. No chill. The
epigastrium enlarged, and underneath the right costal arch there was a
palpable swelling which was painful on pressure. The urine was dark red.
ad 7. — December 23, 1902: Subicteric discoloration. The right
hepatic lobe extends far downward, in the middle line it extends midway
between the umbilicus and xiphoid process ; the border of the liver is
very firm. Spleen hard, extending to the costal arch. Liver very sensi-
tive to pressure.
Urine: No urobilinogen.
January 16, 1903: The liver is tremendously enlarged, very firm, sur-
face uneven. Friction can be distinctly felt over the left hepatic lobe, pain
on pressure and on deep breathing. Venous dilations in the epigastrium.
Pulse small, frequent. Pvdenia behind the malleoli and at the sacrum.
Urine: Abundant urobilinogen.
Stomach contents: One per cent. HCl.
Toward the end respiration became slow, the pulse raj)id. Suhnormal
temperatures during the last days.
ad 8. — Beginning: November, 1902 (?).
Status prcscns: December 23, 1902.
Autopsy : January 23, 1903.
ad 9. — Autopsy (Docent Dr. A'. Landsfeiner) : Polypoid car-
cinoma of the gall-bladder, which was filled with calculi. Diffuse, nodular
metastases in the liver ("corset lobe").
Epicrisis: Two years before death there occurred a typical attack of
gall-stone colic ; the second attack occurred about two months before
death. This attack ushers in the clinical period of the cancer. At the first
examination there could have been doubt as to whether we were not deal-
ing with a cirrhotic disease because of a synchronously existing splenic
tumor. After a short period of observation, however (December 23 to
January 16), the progressiveness of the manifestations was apparent and
pointed to a malignant process.
Urobilinogen, which was originally absent from the urine, appeared
in large quantities, the liver enlarged and became distinctly uneven,
peritoneal friction appeared over the left hepatic lobe, findings which are,
in and of themselves, unusual with cirrhoses.
CARCIXO:\IA OF THE GALL-BLADDER 311
The gastric secretion of HCl persisted, neither was there any other
o-round for suspecting- a })i iniary gastric cancer. On tlie other hand one
could with great probability infer from the history the existence of a
cholelithiasis (after typhoid?).
The configuration of the liver, together with the downward extension
of the right lobe, corresponded to a "corset lobe," which is so frequently
concomitant with the presence of gall-stones. The patient was descended
from long-lived parents.
Case 8.— K. B., 67 years, F.
ad 1. — Mother lived to be 76 years old; the father also attained an
old age.
ad 2. — Was healthy until 52 years of age ; at that time she was
taken sick Avith a febrile articular rheumatism, at the beginning in the
neck, later localized particularly in the knee-joint. Duration: 6 months,
ad 3. — No infectious diseases in childhood.
ad 6. — In September, 1904, while lifting a load, there occurred
cramp-like pain in the right side of the abdomen. After several days the
urine was dark, stool light, skin yellow. Anorexia since the beginning of
the disease but without eructation or vomiting, severe emaciation. Before
the disease the bowels were constipated, now they are more regular.
ad T. — Icterus of high degree ; severe ascites. Soft edemas in the
lower extremities and at the sacrum. Liver slightly enlarged. INIildly
febrile course.
Feces: Many neutral fat globules and soap needles. No urobilinogen.
Urine: No indican reaction.
Blood: 4,000 leucocytes.
January 19, 1905 : Profuse hematemesis and appearance of perito-
nitic symptoms.
ad 8. — Beginning: September, 1904.
Status prcscns: January 10, 1905.
Autopsy: January 21, 1905.
Duration : 4 to 5 months.
ad 9. — Autopsy (Docent Dr. A'. Landsieiner) : Papillary car-
cinoma in the fundus of the gall-bladder (gall-bladder full of calculi,
calculi also at the end of the ductus choledochus) ; abscesses in the left
hepatic lobe, one of these abscesses perforating into the abdominal cavity:
peritonitis. Metastases ad portam hepatis. Icterus gravis. Healed
tuberculosis of the pulmonary apices.
Epicrisis: Here again we find longevity of the parents! At the age
of 52 there occurred for the first time a severe attack of articular rheuma-
tism, which would suggest a metabolic anomaly as the cause. The first
attack of cholelithiasis (four months prior to death) was probably elicited
by the carcinomatous disease in the gall-bladder. The cancer mobilizes
the calculi ! The severe icterus is due to the complete occlusion of the
ductus choledochus b}' concretions ; therefore there resulted a greatly
disturbed fat reduction with neutral fat in the stools and complete absence
of urobilinogen. The secondary abscess formation is accompanied by
312 TUMORS OF THE ABDOMINAL VISCERA
leukopenia (4,000), and gives rise to an acute peritonitis which leads
to hematemesis.
The disease began and ended with anorexia.
Case 9.— R. T., 52 years, F.
ad 1.- — Father died from weakness of old age, mother died at 65.
ad 3. — Has had no infectious diseases.
ad 4. — Constipation since childhood.
ad 5. — Was always healthy ; has had eleven confinements. [Meno-
pause ten years ago. For several ^^ears she has had frequent attacks
of cramps in the pit of the stomach at intervals of several daj^s to a
few weeks, not influenced by ingestion of food. P'or the past year these
attacks have ceased.
ad 6. — In October, 1904, there began pain vinderneath the right
costal arch and in the back. The appetite disappeared, the patient
emaciated, and took on a pale appearance. Vcr^^ severe lumbar pain,
somewhat worse on the right side; decrease of pain after bowel evacua-
tions.
ad 7. — [Moderate jaundice, diminishing toward the end, pale facial
color. The right lobe of the liver drawn out into "corset lobe," extend-
ing far downward and liaving a somewhat firm consistence; surface, how-
ever, is smootli. A tumor-mass, as big as a nut, can be felt underneath
the costal arch. In palpating the hepatic border from above the gall-
bladder can be felt at the under surface of the liver; no appreciable en-
largement demonstrable. No edemas. IMild febrile course.
Urine: Strong aldchvde reaction ; nnich sediment lateritium.
Blood: 12,000 leucocytes.
ad 8. — Beginning: October, 1904.
Status presens: February 24, 190.5.
Autopsy: April 13, 1905.
Duration : 6 to 7 months.
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Carcinoma of the gall-
bladder and of the ductus choledochus, with contraction and occlusion
of the cystic duct. Purulent hydrops of the gall-bladder (gall-bladder
full of concretions) ; isolated metastases in the "corset lobe." Omental
metastases (corresponding to the tumor palpable on the left side). Cancer
thrombi of the ramifications of the portal vein in the liver. Hydrops,
ascites. General icterus. IMultilocular cyst, the size of a child's head,
belonging to the right ovary.
Epicrisis: Longevity of the parents; never any infectious diseases;
always in good health ! It seems to me that these three factors are pre-
disposing to malignant disease. For several years there were frequent
attacks of gall-stone colics, which suddenly ceased about one year before
death from cancer of the gall-bladder. Just a few months before death
gall-bladder pain again set in. The jaundice diminished somewhat
toward the end of the disease ; a palpable tumor on the left side under-
neath the costal arch was due to a metastasis in the omentum. The con-
tinuation of a cholelithiasis and a "corset lobe" was characteristic also
CARCINOMA OF THE GALL-BLADDER 313
ill this case. The firm consistence of the tumor was much more dependent
on connective tissue induration than metastases.
Case 10.— L. G., 46 years, M.
ad 1. — Mother died of cancer, one brother died of pulmonary
tuberculosis.
ad 3. — Has liad no infectious diseases of childhood. In 1887 had
a soft chancre with suppuration of glands.
ad 4. — Bowels always regular ; often had heartburn, so much so
that he always carried sodium bicarbonate with him.
ad 5. — Otherwise was always healthy. Eighteen years ago, when
twenty-eight years of age, there occurred sudden cramp-like pain in the
region of the liver; an inflammation of the liver capsule was diagnosed.
ad 6. — Since the end of March, 1905, there has been pain under-
neath the right costal arch when walking rapidly, on coughing, when
lying on the right side and sitting up. Formerly had frequent heart-
burn one hour after meals, especially after eating sour or spicy foods.
Since the beginning of the disease there has been none of these symptoms ;
appetite good even now. Despite this the patient has emaciated to the
extent of 13 kg during the past few weeks. The former color of the
face has become pale ; the urine has become dark.
ad 7. — No icterus ; sallow complexion. Liver exhibits a "corset
lobe," is enlarged, hard, uneven, everywhere tender to pressure ; peri-
hepatic friction can be felt. The gall-bladder is not palpable. No
edemas. Febrile course with temperatures over 38° C.
Urine: Aldehyde reaction distinctly positive.
Blood: 24,900 leucocytes.
ad 8. — Beginning: End of March, 1905.
Status presens : May 2, 1905.
Autopsy: June 15, 1905.
Duration: 21/0 months.
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Carcinoma of the gall-
bladder with regional diffuse infiltration of the liver. Lithiasis of the
gall-bladder with impaction of calculus in the neck.
Epicrisis: Aside from an "inflammation of the liver capsule" (?) at
28 years of age, the patient had always been well, except that he experi-
enced frequent heartburn. This symptom disappeared with the coming
of the cancer (decrease of HCl secretion.''). The latter is ushered in with
pain in the region of the liver, the pain being easily influenced mechani-
cally (sitting, rapid walking, coughing, lying on the right side).
It might be due partly to the objectively demonstrable fibrinous
perihepatitis. The entire liver is very sensitive to pressure.
The perihepatitis is probably of cholangitic origin, as well as the
fever and the high leucocytosis (24,900).
The appetite remained good on account of which the emaciation was
so much more significant. The liver shoAved the formation of a "corset
lobe." Icterus was absent; the dark color of the urine was due to
urobilin.
314 TUMORS OF THE ABDOMINAL VISCERA
Case 11.— M. M., 57 years, F.
ad 5. — Was always healthy.
ad 6. — Since March, 1906, supposedly after a dietetic error
anorexia, nausea and constipation. Great feeling of thirst, continuous
headaches.
ad 7. — No icterus. Stomach greatly dilated, visible gastric peri-
stalsis, in connection with which there appear bulgings to the right and left
of the umbilicus. Loud splashing on succussion of the abdomen. No
edemas. Copious vomiting; abundant growth of sarcina?. Total acidity
70%, HCl acidity 38%, 1-10 N. NaOH.
ad 8. — Beginning: March, 1906.
Status presens: April 27, 1906.
Autopsy: May 3, 1906.
Duration: 2 months,
ad 9. — Autopsy (Professor Dr. A. Glion) : Fibroid carcinoma of
the gall-bladder (gall-bladder contracted, containing one calculus) only
regionally infiltrating the liver; encroaching on the pylorus and severely
constricting it ; slight stenosis at the hepatic flexure of the colon. Chronic
endarteritis.
Epicrisis: This is one of those cases of cancer of the gall-bladder
in which the original disease is easily misinterpreted. Icterus is absent.
Gastric symptoms, namely those of a pyloric stenosis, dominate the
clinical picture: Growth of sarcinae, persistent HCl secretion, visible
gastric peristalsis.
This makes one think of cicatricial constriction of the pylorus (after
an ulcer), or even of a cancer of the pylorus.
At any rate the short duration of the symptoms in the above case
was very striking.
A cicatricial constriction of the pylorus of similar intensity (follow-
ing an ulcer) would lead us to expect symptoms dating back a number
of years.
The absence of colics from pyloric constriction, despite persistence of
HCl secretion, was remarkable because the acid secretion usually exerts
a painful influence on the pylorus when it has undergone cicatricial or
ulcerative changes.
The synchronous presence of a stenosis of the hepatic flexure of the
colon also was suggestive of a fibrous cancer of the gall-bladder.
Finally it is possible that a very careful examination of the region
of the gall-bladder and the adjacent area of the liver might lead one on
the right track.
Case 12.— F. K., 54 years, F.
ad 1. — No hereditary tendency toward carcinoma.
ad 3. — Has had no infectious diseases.
ad 4. — Four 3'ears ago had a typical attack of gall-stone colic;
jaundice two days after the attacks, lasting two weeks.
ad 6. — In the summer of 1907 the clothes became too big. At
Christmas, 1907, while walking the patient experienced a feeling of
CARCINOMA OF THE GALL-BLADDER 315
fulness and tension in the region of the liver; soon after there occurred
severe pain in the same phice, especially at night. The abdomen, as
well as the right leg, gradually enlarged. Since the middle of January,
1908, the patient has been bedridden. No gastro-intestinal symptoms,
ad 7. — No jaundice; pale color of the face. Ascites of moderate
degree. Liver-shaped like a "corset lobe," very much enlarged, very firm,
sensitive to pressure. Edema of the right leg and also of the sacrum.
July 2: Tarry black stools.
Urine: Aldehyde reaction positive,
ad 8. — Beginning: Summer of 1907.
Status presens : February 25, 1908.
Autopsy : March 9, 1908.
Duration : 7 to 8 months.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Car-
cinoma of the neck of the gall-bladder supervening on a cholelithiasis.
Numerous confluent metastases, especially in the right hepatic lobe.
Congestion of the mucosa of the large intestine. Moderate ascites. Cal-
careous tubercular focus in the upper lobe.
Epicrisis: The previous history mentions a typical attack of cholelith-
iasis. Objective examination discloses "corset lobe" shape of the liver,
enlargement and hardening of the organ without jaundice and with
ascites. A liver tender to pressure is a rare finding in cirrhosis of Laennec
but frequently found in cancer of the liver. Likewise the combination
of enlarged liver and ascites is rare in cirrhosis but frequent in cancer.
In this case also the right lobe of the liver shares in the metastases
to a far greater extent than the left lobe.
The terminal melena must be looked upon as a symptom of con-
gestion (cardiac insufficiency and congestion of the portal vein as a result
of carcinoma of the liver).
Autopsy disclosed no evidence of an ulcerative process in the gastro-
intestinal tract.
Case 13.— M. S., 74 years, F.
ad 6. — Sick since September, 1907; since then has become greatly
emaciated ; of late has taken only milk and soup ; complains of severe
cough.
ad 7. — No icterus ; pale facial color. Gall-bladder palpable, soft ;
the adjacent portion of the liver is exceedingly firm, sensitive to pressure,
a nodule as big as a cherry can be felt in the organ. Soft edema on the
dorsal surfaces of the feet and behind the malleoli.
Urine: Traces of an aldehyde reaction. Dyspnea and orthopnea;
small, rapid pulse. Foamy, fetid sputum.
ad 8.^ — Beginning: September, 1907.
Status presens: April, 1908.
Duration : About 7 months.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Sehlagenhnufer) : Car-
cinoma of the gall-bladder (cholelithiasis!) invading the adjacent liver
tissue; nodule-shaped metastases in the left hepatic lobe. Old apical
316 TUMORS OF THE ABDOMINAL VISCERA
tuberculosis; fetid bronchitis. Infiltration of the right lower lobe, where
there is a gangrenous area. Arteriosclerotic contracted kidney.
Epicrisis: Also this case ran its course without icterus. It was only
the fact that the carcinomatous infiltration and the formation of a
cancer nodule, confined to the immediate proximity of the enlarged gall-
bladder, which called to mind the possibility of a carcinoma of the gall-
bladder.
Case 14.— J. P., 63 years, F.
ad 6. — In April, 1908, was taken suddenly with colicky, severe
pains in the abdomen. The attacks of cramps often were of but a few
minutes' duration ; during the attacks the abdomen became larger and
harder and there occurred lively noises which the patient compared to
the "running of water." Since then these attacks have recurred often,
but without pains. The bowels move daily just as formerly. Appetite
is bad. Great emaciation during the past few weeks.
ad 7. — No jaundice. Very great emaciation and munnnification.
At times very lively intestinal peristalsis (not painful), loops of small
intestine appearing first around the umbilicus and the ascending colon
coming into plain view toward the last. The peristalsis ends at the
hepatic flexure. In the latter place a large and exceedingly firm swell-
ing can be felt at the border of the liver. The right flank bulges, is very
rigid, the left flank is depressed. Bigeminal pulse. Severe edema at the
sacrum.
Fece.i: Small scybala ; blood-coloring material negative,
ad 8. — Beginning: April, 1908.
Status presens: May 8, 1908.
Autopsy: May 10, 1908.
ad 9.-^Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Fi-
brous carcinoma of the gall-bladder (cholelithiasis). Adhesions to the
hepatic flexure leading to constriction of the lumen of the bowel. Hyper-
trophy and dilatation of the entire small intestine and the ascending
colon.
E picrisis : This case is a parallel to Observation No. 11. As in that
case, without icterus, as a result of fibrous cancer of the gall-bladder
there supervened the greatest constriction of the pylorus, so here there
developed great constriction of the colon in the region of the hepatic
flexure. Here also the symptoms date back only a short time, the stenosis
apparently having been compensated for a long time.
The rigidity of the ascending colon, which can easily be recognized
by mere inspection of the protuberant coils, is worthy of note.
The histor}^ does not reveal any attacks of cholelithiasis.
Case 15.— F. L., 77 years, F.
ad 6. — Since the middle of April there have been stomach com-
plaints; anorexia and a feeling of pressure in the epigastrium. After
CARCINOMA OF THE GALL-BLADUER lUl
four weeks there was a siulden appearance of jaundice. Tlie former
regular bowel movements were now followed by constipation. The patient
never suffered from colicky pains.
ad 7. — Severe icterus. Liver not enlarged; the portion of the
hepatic border in the region of the gall-bladder is of a particular hard-
ness, and in the gall-bladder a facetted concretion can be felt. Dis-
tinctly visible gastric peristalsis and splashing in the stomach. Transient
temperature elevatfons over 38° C.
Feces: No neutral fat globules.
Urine: Indican reaction (Obermayer) negative after repeated tests,
ad 8.— Beginning: Middle of April, 1908.
Status presens: May, 1908.
Autopsy: May 21, 1908.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Con-
tracting carcinoma of the gall-bladder; cholelithiasis. Carcinomatous
infiltration of the duodenum and great constriction of same. Pancreas
free. Severe jaundice.
Epicrisis: As a connnon cause for the syndrome "visible gastric peri-
stalsis and severe icterus" there entered into first consideration a pancreas
or gall-bladder affection. Carcinoma of the pylorus is only very ex-
ceptionally accompanied by great jaundice; carcinoma of the duodenum
is a rarity.
Objective examination revealed an abnormal consistence of the hepatic
border corresponding to the gall-bladder ; on palpation a facetted con-
cretion could be demonstrated in the gall-bladder. Absence of indican
reaction — even without a lesion of the pancreas — is not a rare finding
with icterus gravis.
Case 16.— N. N., 71 years, F.
ad 1. — One sister died of "abdominal cancer," another of cancer of
the uterus.
ad 6. — On February 24, 1905j after the patient had suffered a fall
on her back a swelling was noticed in the right half of the abdomen ;.
seven weeks later there appeared severe pain in the back, radiating on
both sides into the epigastrium. Duration : About ten days. Anorexia.
Toward the end of September, 1905, the patient's attention was
called to the existence of jaundice.
Christmas, 1905 : Severe colicky pains with diarrhea, stool whitish ;
since then the jaundice is said to have diminished. In January, 1906,.
severe itching of the skin.
March 10, 1906: Liver enlarged, very hard, surface uneven. Spleen
greatly enlarged.
June 12, 1906: Occasional pain in the right half of the abdomen.
Sitting up causes great pain in the region of the liver. Spleen greatly
enlarged. Edema of the legs. Continued fever ranging between 37° C^
and 40° C.
Blood: 16,400 Icucoc^^tes.
318 TUMORS OF THP: ABDOMINAL VISCERA
ad 8, — Beginning: February, 1905.
Autopsy : June, 1906.
Duration : 1 year, 5 months,
ad 9. — Autopsy: Primary carcinoma of the gall-bladder with per-
foration into the duodenum. Suppurative articular inflammation (by
metastasis from the suppurative area around the gall-bladder).
Epicrisis: A distinct splenic tumor and varying icterus, in connec-
tion with a diffuse enlargement and increased consistence of the liver,
for a time suggested the possibility of a biliary cirrhosis.
Aside from the age of the patient, at which biliary ciri'hosis count
among the great rarities, the entire ensemble of symptoms spoke in favor
of a carcinomatous process. The splenic tumor was sufficiently ex-
plained by the chronic icterus and the severe cholangitic infection, the
latter also accounting for the varying intensity of the icterus.
• Toward the end there supervened pyemic joint metastases from a
pericholecystitic purulent focus. The gall-bladder had perforated into
the duodenum.
Case 17.— H. G., 46 years, M. Metal pourer.
ad 3. — At 11 years of age had ''abdominal typhoid."
ad 5. — During military service had dysentery; was healthy until
1882. At that time was sick with anorexia, heartburn, feeling of gas-
tric pressure; bowels constipated. The patient was strikingly pale.
Duration of the disease: About two years. During the following years
felt well but looked pale.
1894: Lead colic! Rapid convalescence.
August, 1900: Recurrence of stomach trouble, together with constipa-
tion and biliary vomiting. No colic.
ad 6. — In the beginning of February, 1901, appearance of pain
underneath the right costal arch, on coughing, sneezing and on motion.
Since then the patient felt exhausted ; no fever, no appreciable emacia-
tion. About the middle of February the abdomen enlarged somewhat,
the stools became lighter in color, the urine darker. Decreased appetite
for meat ; no eructation or vomiting.
ad 7. — Moderate jaundice. Abdomen enlarged, venous dilatations
in the epigastrium. Liver enlarged, particularly in its right lobe, ex-
tremely firm, painful on percussion, especially in the linea alba. Severe,
soft edema in the lower extremities extending up to Poupart's ligament ;
edema of the scrotum. Afebrile course.
ad 8.^ — Beginning: Februar}', 1901.
Status presens: March 11, 1901.
Autopsy: March 22, 1901.
Duration: About 2 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Cancer of the neck
of the gall-bladder invading the liver and diffuse cancerous infiltration
of same. Secondary carcinoma of the regional lymph-nodes.
Ejncrisis: The first symptoms, pain in the gall-bladder region on
CARCINOMA OF THE GALL-BLADDER 319
congliing, sneezing and moving about, precede death by hardly two
months.
Venous dilatations in the epigastrium point to the disturl)ance in the
portal vein.
Typhoid infections, even without the connecting link of calculus for-
mation, could predispose to local cancerous disease by giving rise to a
chronic cholecystitis.
Case 18. — K. D., 46 years, M. Shoemaker.
ad 1. — Father died of tuberculosis.
ad 4. — From 18 to 38 years of age the patient frequently had
"stomach cramps," especially after eating sour, strongly seasoned or
gas-producing foods. Often there occurred severe burning and pressing
pain in the stomach, about one-quarter to two hours after meals, last-
mg half an hour; in order to gain relief the patient would usually lie
with his belly on a bolster; frequent pyrosis. After a severe attack ki
1894 the attacks are said to have ceased, and since then all foods have
been well tolerate^!.
ad 6. — Beginning of the sickness in the early part of November,
1901, after a liberal imbibition of wine. During the following days loss
of appetite, pain after eating fat meat. The pain appeared mostly
one to two hours after meals, was of a stabbing and pressing char-
acter, being localized especially in the region of the pylorus ; they
became exacerbated when lying on the right side, accompanied by a
feeling "as if everything in the stomach was alive." When lying on
the left side there was a feeling as if something in the abdomen was
drawing from right to left.
In December, 1901, a hard swelling was found in the epigastrium.
No vomiting, but frequent sour eructation; feeling of fulness in the
stomach. Decrease in weight (November, 1901, to February, 1902)
10 kg.
ad 7.- — Subicteric discoloration ; on the right side, underneath the
costal arch, a tumor-mass which is hard, possessing very distinct respira-
tory mobility, over the tumor an empty sound on percussion. In this
locality also pain on deep breathing and tenderness on pressure. Stom-
ach not dilated. No edemas.
Stomach contents: After test-breakfast 1% HCl; bacteriological find-
ings negative.
Urine: Urobilinogen positive ; traces of bilirubin.
ad 8. — Beginning: Early in November, 1901.
Status presens : February 28, 1902.
Operation: March 16, 1902.
ad 9. — Finding at operation (Clinic of late Hofrat Professor Dr.
A'. Gussenbauers, Professor Dr. 0. Foederl) : Carcinoma of the gall-
bladder, encroaching on the left lobe of the liver. Pylorus drawn up-
ward.
Epicrisis: This case ran its course entirely under the aspect of a
gastric disease. The stomach cramps existing for a numlx>r of years
320 TUMORS OF THE ABDOMINAL VISCERA
and related to food intake, as referred to in the history, suggested a
gastric ulcer. But also the symptoms occurring since November, 1901,
lead one to think in the first place of a disease located at the pylorus.
The pain appeared mostly two hours after eating, hence coincided with
the expulsion period of the stomach and became increased with right
lateral position, etc.
Laparotomy also actually disclosed a lesion in the region of the
pylorus but only in the form of a displacement upward toward the
carcinomatously diseased gall-bladder, which could, indeed, give rise to
kinking and constriction. The urine contained traces of bilirubin. This
case, therefore, belongs to the gastric types ^~ of carcinoma of the
gall-bladder.
Case 19. — F. R., 57 years, M. Street cleaner.
ad 3. — No infectious diseases during childhood, was always healthy,
ad 4. — Appetite always good, could tolerate all kinds of foods;
bowels always regular.
ad 5.— Two years ago (1901) while doing heavy work had pain
on and off on the right side underneath the costal arch, lasting only two
to three days at a time.
ad 6. — In January, 1903, there began slight stabbing pain under-
neath the right costal arch.
In February, 1903, this pain became severer, the bowels becoming
irregular.
The patient followed his work until March 9, 1903. The appetite
remained good but the patient dared not eat nmch because it produced
a feeling of pressure. The above-mentioned pain appeared especially when
sitting. Left lateral position is badly tolerated because it produces a
feeling as if something in the alxiomcn was drawing from right to left,
ad 7. — Jaundice (appearing ]March 24, then increasing rapidly).
Resistance underneath the right costal arch, the liver there being of a
bony hardness, somewhat uneven on the surface. Peritoneal friction
can be heard in the region of the gall-bladder, also constant squirting
sounds. No ascites, no edema. Afebrile course.
Stomach contents: HCl negative after test-breakfast.
Urine: Abundant urobilinogen, later also bilirubin. Toward the end
there was ascites.
ad 8. — Beginning: January, 1903.
Status presens : March 26, 1903.
Autopsy: May 9, 1903.
Duration : About 4 months,
ad 9. — Autopsy (Professor Dr. A. Ghon^ : Scirrhus carcinoma of
the gall-bladder, invading the liver and the transverse colon with per-
foration into the latter. Secondary carcinoma of the liver and the
lymph-nodes at the hilum. Biliary calculi in the neck of the bladder,
'^ See Case 11.
CARCINOMA OF THE GALL-BLADDKK IV2\
in tlic cystic duct and in the ductus choledochus. Severe icterus. Chronic
tumor of the spleen. General hydrops. Chronic apical tul)erculosis.
Epicrisis: Peritoneal friction in the region of the gall-i)ladder ! In
the same place there also existed pain, which appeared especially when
sitting down. Distinct icterus first occurred six weeks before death,
and then was rapidl}' progressive. It was ushered in by abundant elimi-
nation of urobilinogen. Toward the end ascites also set in.
Case 20.— N. N., 70 years, F. Farmer's wife.
ad 1. — Husband died of gastric cancer.
ad 2. — During the past few years she has had frequent rheumatic
pain in the finger-joints.
ad 4. — Now and then suffers from stomach cramps for a short
time after copious drinking of water.
ad 6. — In the beginning of February, 1908, appearance of stab-
bing pain in the axillary line over the liver, on deep breathing. Hot
compresses relieved this pain. Since then there is present anorexia.
The patient eats only soup.
ad 7. — Subicteric discoloration with severe itching of the skin.
The gall-bladder can be felt as a very firm tumor; above it the adjacent
liver-tissue is infiltrated and hard as a board.
ad 8. — Beginning: Early part of February, 1908.
Status prescns: March 13, 1908.
Death: A short time after.
Epicrisis: There were indications of dyscrasia, such as chronic pain
in the finger-joints, recurring repeatedly during the past years. Pains
in the axillary region of the liver occurring with deep respiration, are
mentioned as initial symptoms.
The gall-bladder can be distinctly felt as a tumor, the seat of
metastases being in the immediately adjacent portions of the liver-
tissue.
Case 21.— R. E., 67 years, M.
ad 3. — At 24 had malaria for two years.
ad 4. — Never had any gastro-intestinal disturbances.
ad 6. — The disease began in August, 1897, with pressing pain
in the right flank just underneath the costal arch, especially when sitting;
when walking or lying down there were no complaints. Jaundice being
of varying intensity in the beginning. After ingestion of food there was
a feeling of distention; since November, 1907, disgust toward meat and
fat ; desire for sour and sweet foods. Since then remarkable dryness of
the tongue. Severe emaciation since the beginning of the disease.
ad 7. — The left half of the tongue shows an atrophic mucous mem-
brane. Liver diffusely much enlarged, of moderately firm consistence.
The gall-bladder is palpable. Bigeminal pulse.
Afebrile course. Toward the end severe edema around the ankles
(coming on suddenly after a warm foot bath); likewise great ascites
and hvdrothorax. Afebrile course. Death with mild hematemesis.
322 TUMORS OF THE ABDOMINAL VISCERA
ad 8. — Beginning: August, 1897.
Status prcsens : January 7, 1898.
Autopsy: March, 1898.
Duration : About 8 months.
Ad 9. — Autopsy: ^'illiform cancer of the gall-bladder (gall-bladder
much enlarged and tense) ; carcinomatous masses in the ductus chole-
dochus and at the outlet of the cystic duct. No appreciable metastasis
in the liver; enlargement due to biliary congestion. Blood in the stomach
and duodenum from a ruptured vein in the esophagus.
Epicrisis: The initial pains, occurring like those in Case 20 when
in the sitting position, are very probably referable to disease in the gall-
bladder itself, the location of which corresponds to the place of the
pain. The pressure exerted on the gall-bladder in the sitting position
may, w^th a sensitive organ, be looked upon as a pain-provoking factor.
The jaundice in the beginning showed a variation in intensity, which,
however, was later followed by a constant progressiveness. During the
last months there was present meat anorexia with a preference for sweet
and sour foods. The atrophic conditions of the lingual mucosa arc
worthy of note. They have been noticed repeatedly with other forms of
visceral cancer.
The enlargement of the liver was dependent solely upon biliary con-
gestion, and accordingly the consistence was only moderately increased.
The terminal hematemesis was due to a ruptured varix of the esopha-
gus. Latent edemas in connection with cachectic processes may make
their appearance after hot foot-baths.
Case 22.— A. S., 73 years, M.
ad 2. — Since 1884 there have been repeated attacks of articular
rheumatism involving many joints, including the finger- joints, and ap-
pearing mostly in the spring of the year; for the past three years the
attacks have diminished in intensity.
ad 3. — Appetite and bowels always regulated, except that dur-
ing the past four years without any dietetic error there has appeared
on and off a feeling of epigastric pressure and eructation; during this
time the patient vomited only four times ; after vomiting the complaints
usually ceased for a rather long time. For the past four or five years
there exists intolerance toward fat foods,
ad 5. — The use of alcohol is admitted (5 litres beer daily).
ad 6. — Was taken sick early in the morning of October 29, 1904< ;
chill, pain over the lower part of the sternum and to the right of it,
accompanied by nausea and bitter eructation ; breathing caused pani an-
teriorly on the right side of the thorax, and also between the shoulder-
blades ; stabbing in the region of the heart.- On the folloAving day re-
peated chill, followed by a feeling of heat. About November 5, 1904,
the stools became light in color, the urine dark red. Of late (entered
hospital November 26, 1904) feeling of exhaustion and insomnia.
Anorexia. jNIoderate loss of weight.
ad 7. — Icterus of mediinii degree, subsequently increasing. Liver
CARCINOMA OF THE GALL-liLADDKR ;j23
slightly enlarged, also the spleen. Gnll-blatlder enlarged, walls soft,
tender on pressure. Pulse 52. Afebrile course. \ ery slight edema of
the legs.
Urine: Diazo reaction negative in the beginning, later constantly
positive.
Blood: 0,800 leucocytes.
December 14, 190-i: Severe hematemesis ; ten bowel evacuations, con-
sisting of blood, containing only a few preserved erythrocytes,
ad 8.— Beginning: October 29, 1904.
Status presens : November 26, 1904.
Autopsy: December 16, 1904. ,
Duration: IY2 months,
ad 9. — Autopsy (Professor Dr. A. Ghon) : Carcinoma of the termi-
nal portion of the ductus choledochus, proliferating into the duodenum;
at the latter place ulceration above the papilla of Vater and hcmorriiage
from a branch of the pancreatic-duodenal artery. Fresh blood in the
small and large intestine. Very small metastases in the liver. Chronic
tumor of the spleen. Great dilatation of the gall-bladder and the
ductus choledochus. Small calculi in the gall-bladder. Chronic en-
darteritis deformans, especially in the periphery.
Epicrisis: Recurring articular rheumatism, probably in the nature of
a dyscrasia ! The clinical beginning of the disease is acute (October 29),
with pain and chill, with manifestations of a gall-stone colic ; several days
later, icterus. It may be assumed w^ith the greatest probability that
the flow of bile was halted at that time, and this, together with the
presence of concretions, led to a sort of "constriction colic" of the biliary
passages.
Changes in the wall of the gall-bladder were not demonstrable by
palpation.
Diazo reaction was absent in the beginning but later was constantly
positive (cholangitic infection?).
Despite existing indications of a general hemorrhagic diathesis (cuta-
neous hemorrhage! epistaxis!) the terminal hemorrhage was correctly
interpreted as an erosion hemorrhage, high up. Its situation high up was
indicated by the almost entirely negative finding of preserved cells of
the blood; at the same time this finding I'uled out diffuse parenchymatous
bleeding from the intestinal mucosa. The enormous quantity of the
hemorrhage pointed to an erosion of one of the larger blood-vessels.
Case 23.— M. T., 52 years, M.
ad 1.- — Longevity of both parents.
ad 3. — Typhoid at 4 3'ears of age; in 1873 was sick with pneu-
monia for 9 weeks.
ad 4. — Appetite always good, bowels regular.
ad 5. — As a child was strong, and also otherwise well.
ad 6. — On May 3, 1903, the patient had jaundice, same lasting
about three months, i.e., up to the beginning of August, 1903, but
324 TUMORS OF THE ABDOINIINAL MSCERA
without pain and without an\^ gastro-intestinal symptoms; only now and
then there was a feeling of heat and cold.
At the end of July, 1904, the patient felt perfectly well, except that
on and off there were night-sweats, so much so that it was necessary to
change shirts.
About one year later, in September, 1904, after eating "goulash,"
nausea and vomiting came on during the night, without pain ; four days
later the sclera? became yellow and increasing jaundice appeai'ed.
On November 28, 1904, there was general good laalth, so that the
patient left the clinic.
On December 14, 1904, "in the evening there appeared sudden ex-
tremely intense headache, accompanied by nose-bleed. At the same
time fever set in, reaching 38° C. in the evening hours. Painless course,
ad 7. — November 4, 1904: Icterus of medium degree. The right
hepatic lobe extends somewhat farther downward and feels somewhat
more resistant. The gall-bladder is not palpable. The spleen is slightly
enlarged, soft. Pulse 50 ; no edemas, no fever.
Urine: Abundant urobilinogen; indican reaction positive; no alimen-
tary glycosuria.
Feces: Urobiltnogen positive.
Stomach contents: After test-breakfast total acidity 64V', 1-10 N.
NaOH. No hcmcralopia.
December 24, 1904: Status fcbriles; tongue very dry. Pulse 90,
dicrotic, great tachypnea. Perihepatic friction. No edema.
Blood: 14,000 leucocytes, increasing up to 20,000.
Toward the end, epistaxis, thinly fluid sanguineous stools, hema-
temesis; severe chills.
ad 8. — Beginning: May, 1903.
^ Status presens: November 4, 1904, and December 24, 1904.
Autopsy : December 29, 1904.
ad 9. — Autopsy (Dr. R. t*. Wiesner) : Carcinoma of the papilla
Vateri with stenosis and congestion of the eliminating bile channels.
Multiple cholangitic abscesses with adhesions between the surface of the
liver and the diaphragm. Fresh fibrinous pericarditis. Icterus gravis
with hemorrhagic diathesis. Subacute splenic tumor.
Bacteriological finding in the pus from abscesses ; staphylococcus
pyogenes.
Epicrisis: Worthy of note is the course of the icterus, coming and
going three different times.
First period: May 3, 1903, to August, 1903.
Second period: September, 1904, to November, 1904.
Third period: November, 1904, to December, 1904.
This behavior, in connection with the febrile course, must have sug-
gested, in the first place, a recurring cholangitic process. Without
doubt such a complication was also present and accounted for the
great variations in the course of the disease. The pus taken from the
cholangitic abscesses after death showed staphylococci. Accordingly
during life there was a high Icucocytosis (up to 20,000) and diazo re-
CARCINOMA OF THE GALL-BLADDER 325
action was absent."'"' The infection may have conic from the ulcerating
carcinoma at the {)apilla of ^'ater and at any rate was favored by the
biliary congestion produced by the carcinoma. The existing cholangitis
during the later course led to an objectively demonstrable perihepatitis.
During the last stage of the disease there was complete biliary occlusion
(no urobilinogen in the stool). Gall-bladder large, soft.
The absolutely painless course of the disease, as compared to the
usual behavior in cancer of the gall-bladder, is worthy of attention.
In and of themselves such cases, at least in their initial stages, could
easily be mistaken for catarrhal jaundice. Experience teaches, how-
ever, that after the fiftieth year of life catarrhal jaundice counts among
the greatest rarities.
Case 24. — F. J., 59 years, M. Letter carrier.
ad 3. — Measles at 10; at 28 had tonsillitis for eight weeks; in
March, 1905, had a left-sided pneumonia for four weeks,
ad 4. — Appetite always good, bowels regular,
ad 6. — In the beginning of June, 1905, the patient began to feel
bad: Exhaustion, anorexia and disgust toward meat, sour eructation
after larger meals, headache and mild jaundice. On June 10, the patient
had to take to his bed. The jaundice increased. Bowels moved daily.
No kind of pain. In the beginning of July, 1905, had chills.
ad 7. — Severe jaundice. Moderate enlargement of the liver, con-
sistence not appreciably increased. On palpating from above down-
ward the gall-bladder can be felt ; its walls are soft, little tender to
pressure. The spleen extends almost to the costal arch, is soft. Numerous
angiomatous formations. Temperature elevations up to 39.6° C. Very
severe retromalleolar edema.
Urine: Indican reaction strongly positive; no aldehyde reaction.
Feces: Many neutral fat globules; in the fat globules there is blood
pigment ! Blood-coloring material is chemically demonstrable,
ad 8. — Beginning: Early in June, 1905.
Status presens: July 15, 1905.
Autops}' : August 5, 1905.
Duration : About 2 months,
ad 9. — Autopsy (Professor Dr. A. Ghoji) : Medullary tumor about
the size of a nut, at the papilla of Vater with compression of the ductus
choledochus and pancreaticus ; dilatation of the latter as well as the
hepatic duct and its branches in the liver. ^Multiple abscesses in the liver
and general icterus of high degree. Multiple fat necrosis of the pancreas.
General obesity and fatty heart.
Histological cxomination: Papillary carcinoma.
Epicrisis: It is possible that ulcerating cancers at the papilla of
Vater frequently lead to an ascending infection of the bile-ducts from the
ulcerating surface. In this case also the body temperature occasionally
rose to 39.6° C, autopsy disclosing small cholangitic abscesses. When
'' According to my observntion, general staphvlococcvis infections, in contradistinc-
tion to streptococcus infections, are not, as a rule, accompanied by a diazo reaction.
326 TUMORS OP^ THE ABDOMINAL VISCERA
the ditferential diagnosis wavers between cancer of the head of the
pancreas and cancer of the papilla of ^'ater it seems to me that a high
febrile course favors the latter diagnosis.
Fat intolerance, met with in the histories of a large percentage of
cases of cholelithiasis, was not found in this case ; neither was there the
frequently accompanying symptom of constipation. Besides this the wall
of the gall-bladder could be felt and was soft.
The early appearance of jaundice argued against a gastric cancer
despite the existing meat anorexia ; furthennore, the vegetations in the
feces consisted almost exclusively of Gram-negative rod-shapes, lactic-
acid bacilli, therefore, being absent. Despite stenosis of the pancreatic
duct (autopsy showed great dilatation) the formation of indol in the
intestinal canal was rather increased and the urine yielded a strongly
positive indican reaction.
The existence of a macroscopicall}- occult melena could be shown under
the microscope, in so far as the neutral fat globules in the stool were
filled with amorphous Ijrown blood pigment.
Case 25.— N. N., 73 years, M.
ad 6.- — Since about April 24, 1908, continuous })ain in the epigas-
trium, anorexia and constipation. No eructation, no vomiting. Emacia-
tion. There is a feeling as if solid foods were caught at about the height
of the manubrium of the sternum.
ad 7. — No jaundice. Tongue nmch indented. Liver greatly en-
larged, moderately firm; perihepatic friction. Only near the end was there
"coft'ee-ground" vomiting, in which HC'l was clearlv positive. Repeated
chills (up to 39.9° C).
Stomach contents: Desmoid reaction positive after five hours.
Feces: Chemical blood-test constantly positive.
Blood: 4,300 to 9,960 leucocytes.
ad 8.— Beginning: About April 24, 1908.
Status presens: May 8, 1908.
Autopsy: May 29, 1908.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlangenhaufer) : ul-
cerating carcinoma of the duodenum (old ulcer base.'*) with efosion of one
of the larger blood-vessels and suppurative phlebitis. Phlebitic metas-
tases in a branch of the portal vein and secondary putrefaction of several
cancerous nodules, numerous cancerous metastases in the liver. Slight
adhesion of the stomach to the liver.
Epicrisis: As in Cases 24 and 25, so also here, the carcinomatous
proliferation in the duodenum runs its course accompanied by high tem-
peratures (39.9° C.) and chills. Autopsy reveals putrid abscesses in the
liver. At times there was leucopenia (5»000, 4,300), only near the end the
leucocyte count was somewhat increased (9,900). The accompanying peri-
hepatitis pointed to the infectious process in the liver. Jaundice was absent.
Blood-coloring matter was constantly chemically demonstrable in the
feces. The stomach contents vomited toward the end distinctly showed
free HCl.
Carcinoma of the Pancreas
Case 1. — M. C, 64 years, M.
ad 6. — Since the beginning of January, 1900, there lias been ano-
rexia. On January 16, 1900, there occurred sudden pains, not cramp-like,
in the right axillary line, corresponding to the costal arch, radiating
into the right side of the abdomen. They lasted three weeks, bore no rela-
tion to intake of food and became exacerbated at night. No febrile move-
ments. Later, pain came on half an hour after eating, and this pain let
up somewhat when the patient maintained a partly stooping position.
Often odorless eructation, seventeen to eighteen times in succession. Since
about Ma}^ 20, 1900, icterus is present, which now (June, 1900) is in-
tense. No vomiting; no nausea. Appetite is slight. No pain in the back;
the epigastrium tender on pressure.
ad 7. — Great emaciation; jaundice. Epigastrium bulging, tense,
like an air-cushion, liver slightly enlarged ; on the right side, underneath
the costal arch, pea-size nodules can be felt on the surface of the liver
when the patient is lying on his right side, the same on the left. Gall-
bladder enlarged. Retromalleolar edema, later on ascites.
Toward the end "coffee-ground" vomiting with few lactic-acid bacilli.
ad 8. — Beginning: Early in January, 1900.
Status presens : June 5, 1900.
Autopsy: June 24, 1900.
Duration: About six months.
ad 9. — Autopsy (Professor Dr. A. Ghon) : Scirrhus cancer of the
tail of the pancreas, invading the posterior wall of the pyloric portion of
the stomach and uppermost portion of the duodenum, perforating both.
Constriction of the pylorus and the ductus choledochus immediatelj below
the outlet of the cystic duct. Icterus gravis. Secondary scirrhus cancer
of the liver and the large omentum, with contraction of same, of the
retroperitoneal and mesenteric lymph-nodes and the peritoneum. Invasion
and perforation of isolated cancer nodules of the mesentery in the small
and large intestine, with the formation of ulcers. Hemorrhagic peri-
tonitis.
Epicrisis: On the one hand there was jaundice and enlargement of the
gall-bladder ; on the other hand there was the stomach distended like an
air-cushion and frequent successive eructations.
Coincident congestion of bile and stagnation of stomach contents, to-
gether with cancerous cachexia, would always make us think of a possible
carcinoma of the pancreas.
337
328 TUMORS OF THE ABDOMINAL VISCERA
The pain in the axillary line appearing quite early may have been due
to metastases in the liver or to distention of the gall-bladder. Pain in the
back was absent.
There was a diffuse carcinomatosis of the peritoneum with shrivelling
of the mesentery, which led to intestinal ulcers ; the tumor-mass showing
small nodules, which could be felt underneath the costal arch, belonging to
the omentum which was the seat of carcinomatous infiltration.
Case 2.— M. K., 36 years, F.
ad 2. — Since her 20th j^ear has had headache three to four times a
month, appearing especially toward evening and followed by a feeling of
weakness the next day.
ad 3. — As a child had measles.
ad 5. — In December, 1899, sudden pain in both wrist-joints, several
days later swelling in the joint of the left thumb, together with redness
and a feeling of heat. No fever.
Duration of the illness : one month.
In January, 1900, painful swelling in both knee-joints. Duration:
several days.
ad 6. — In February, 1900, there began particularly severe pain in
the back, lasting until the present time (November, 1900); besides also
pain in the hips.
In June, 1900, the patient began to emaciate (at present, in Novem-
ber, 1900, weighs -10 kg; two years ago, 08 kg). The pain in the back
constantly increased.
In September, 1900, occurrence of icterus.
Stomach complaints began in October, 1900. Feeling of fulness after
eating, vomiting of mucus, eructation. Bowel movements remained reg-
ular. There are pains in the back which become exacerbated when lying
on the belly, are somewhat relieved when lying on the right side, and also
relieved by defecation and discharge of gases. Anteriorly in the region
of the umbilicus now and then colicky pain, and when these come pn the
pain in the back becomes worse.
ad 7. — A greatly emaciated, jaundiced patient; gall-bladder en-
larged and visibly protuberant. Dilated stomach extending to the level of
the umbilicus, splashing.
Stomach contents: HC'l positive, many sarcina?. A hard, uneven tumor-
mass can be felt in the. epigastrium deep between recti muscles which have
become separated ; the tumor is not movable. Anterior to it and resting
upon it, a round contracted cord, as thick as a finger, can be felt, which
after a short time, accompanied by a squirting sound, gives up its con-
traction and becomes soft (contractions of the p3'lorus!). In the epigas-
trium also a systolic murmur is audible when the ear or stethoscope is
gently and without pressure placed against the belly-wall. Strong aortic
pulsation in the epigastrium. Tenderness to pressure over the sacrum, the
left crest of the ilium, the left trochanter and also the vertebral column,
from the second lumbar vertebra downward ; the left thigh is held flexed,
extension of the left leg is painful. The pains in the back persist despite
CARCINOMA OF THE PANCREAS 329
2.0 g pyramidon per day. The spleen is not palpable. Profuse bleeding
from a small scratcli wound in the right cubita.
Urine: Indican reaction negative; no glycosuria. Afebrile course,
ad 8. — Beginning: February, 1900.
Status presens: November 21, 1900.
Autopsy^^ : January 27, 1901.
Duration: About 1 year,
ad 9. — Autopsy: Scirrhus of the pancreas, proliferating into the
ductus choledochus. Adhesions to the abdominal aorta and narrowing of
same. Metastases in the left pleura, in the left lung, left suprarenal body.
Ascites, anasarca.
Epicrisis: About three months prior to the appearance of the first
symptom (pain in the back) of cancer of the pancreas there had de-
veloped in this 36-year-old patient an afebrile articular rheumatism
(dyscrasia.'^).
This order of succession is not altogether too rare, and probably
justifies the question whether "internal traumas" in the nature of a
dyscrasia are not capable of giving to cells, predisposed that way, the
impulse to cancerous proliferation.
It is highly probable the pains in the back appearing early in Febru-
ar}', 1900, were misinterpreted as "rheumatic" ; as late as June and
July, 1900, they were treated, naturally without results, by means of mud
baths. These pains, probably to a great extent, were dependent on the
retroperitoneal tumor-mass, and later also influenced by the dilated stom-
ach (relief after defecation, discharge of flatus!). The inefficacy of an-
tineuralgics (2 g p3'ramidon per day) is worthy of note and occasionally
of diagnostic value.
Analogous to Case 1, we have also here coincident stagnation of bile
and stomach contents, the former shown by the icterus, the latter by the
gastric dilatation and presence of sarcinjE. HCl persists and is explained
by the fact that pyloric constrictions produced by malignant processes
from without (cancer of the pancreas and gall-bladder) usualh' run along
with the symptoms of a benign stenosis (persistence of HCl and sarcinte).
Retroperitoneal tumors in the epigastrium not seldom account for the
fact that the pyloric portion of the stomach is displaced forward, so that
in its resting state and particular!}' when in a contractile state it becomes
distinctly palpable. In this case the pj'lorus could at one time be felt as
a soft cord and at another as a round, tense cord, similarly as in func-
tional "peristaltic unrest."
The systolic vascular murmur in the epigastrium owed its existence to
a compression of the abdominal aorta, as shown at autopsy. Such con-
strictions of moderate degree are usually compensated so that there re-
sults no anomaly of the crural pulse.
The urine yielded no positive indican reaction, a finding for that
matter which in and of itself carries with it no special significance.
^Performed in the Prosektiir des K. K. Garnisonsspitales, No. 1, Vienna.
330 TUMORS OF THE ABDOMINAL VISCERA
Case 3. — J. S., 40 years, M. Innkeeper.
ad 1. — Mother died of a pulmonary disease.
ad 3. — Had no febrile disease in childhood ; at 22 had erysipelas.
ad 5, — Alcohol to excess.
ad 6. — In the beginning of November, 1901, there came on a con-
tinued feeling of pressure, at first underneath the xiphoid process, later
radiating to the right, along the costal arch, and subsequently localized
particularly in the region of the gall-bladder. At night the patient lay on
his right side with the arm under him so as to protect the painful region
of the gall-bladder from pressure. When U'ing on the left side there was
a feeling of pulling toward the left. At the start there were chills now and
then at night together with breaking out of a cold sweat. No vomiting;
good appetite until the end of January, 1902; half an hour after drink-
ing milk there was a feeling of distention in the belly. Jaundice present
since the middle of December, 1901. No pain in the back.
ad 7. — A greatly emaciated cachectic individual; jaundice. Epi-
gastrium distended. Liver hard, enlarged downward about the width of
one hand, with a protuberance as big as a cherry, in the middle line. Gall-
bladder is large, its long axis opposed obliquely to the iicpatic border,
distinctly palpable. Spleen slightly enlarged, extending to the costal arch.
Severe retromallcolar edema ; scratches inclined to bleed easily. No
bradycardia.
Toward the end moderate melena, the bowel evacuations consisting
partly of red blood and partly of hard clots. Pneumonia and pericarditis
as terminal complications.
Vomited stomach contents: Isolated lactic-acid bacilli.
ad 8. — Beginning: Early in November, 1901.
Status presens: January 29, 1902.
Autopsy: February 10,' 1902.
Duration: About 3 months.
ad 9. — Autopsy (Professor Dr. A. Ghon) : Carcinoma of the head
of the pancreas, projecting into the duodenum ; compression of the ductus
choledochus and the duct of Wirsung in their lowermost portions. Severe
icterus. Splenic tumor. Several small cancer nodules in the liver. Bilat-
eral encapsulated apical tuberculosis. Adenomatous nodules in the right
lobe of the thyroid gland. Arteriosclerosis of the coronary arteries.
Epicrisis: This 40-3'ear-old patient had had no infectious diseases
during childhood, a statement made by surprisingly many cancer patients
under my observation.
This patient's illness began with a feeling of epigastrium pressure
(November, 1901), to which subsequently there was added continuous
pain in the region of the gall-bladder ; the gall-bladder was palpable and
on autopsy was found to be greatly distended.
Jaundice appeared soon after the initial subjective complaints (mid-
dle of December, 1901). The terminal discharge of blood with the feces
could suggest a primary ulcerative process in the stomach or duo-
denum ; the fact was that the cancer of the pancreas had invaded
the duodenum.
CARCINOMA OF THE PANCREAS 331
Autopsy disclosed healed tuberculosis of the j)uliiH)iuiry apices, a find-
ing not rare in coiuieetion with carcinoma, especially at a younger age.
Case 4. — L. A., 64 years, M.
ad 1. — Mother died from weakness of old age; obesity a family
trait.
ad 3. — At eight years of age, while living in a flooded district had
fcA'er for a year and a half.
ad 5. — Was otherwise always healthy.
ad 6. — On October 23, 1905, suddenly became sick with dizziness,
nausea and vomiting; lost consciousness for half an hour. Before that he
had become very much excited and had worked seventeen nights in suc-
cession. Since then there is great thirst (drinks 3 to 4 litres daily) and
correspondingly increased diuresis ; likewise constipation. Eructation
after every intake of food or fluid. There is a feeling of pressure in the
right half of the abdomen, and when lying on the left side there is the un-
pleasant sensation of something sinking toward the left side. Since the
beginning of the disease, languor and easy fatigue. Emaciation to the
extent of 26 kg in ten weeks. Anorexia.
ad 7. — Habitus apoplecticus, reddening of the face. Right half of
the abdomen moderately sensitive to pressure. The right portion of the
liver extending downward three finger breadths, very hard. Spleen hard,
extends to the costal arch. Tongue slightly indented. No edema at the
ankles.
Urine: Averages 4.9% dextrose, after fasting 2.3%. Acetone abun-
dant. Acetic acid reaction present. Patellar reflex absent.
ad 8.— Beginning: October 23, 1905.
Status presens: January 13, 1906.
Autopsy: February 1, 1906.
Duration: About 3 months,
ad 9. — Autopsy (Docent Dr. A'. Landsfeiner) : Carcinoma in the
tail of the pancreas ; confluent metastases in the right portion of the
right hepatic lobe. Splenic tumor due to congestion.
Epicrisis: After an acute attack of syncope there appeared in this
64-year-old individual with inherited obesity, diabetic symptoms, viz.,
polydypsia and polyuria and rapid loss of weight.
The tongue showed indentations, a symptom which I am inclined to
look upon generally as a stigma of constitutional inferiority.
Malignant disease was from the start suggested by the following:
1. Anorexia, which in a diabetic patient is always a remarkable
symptom.
2. The existence of a left-sided "painful position" in so far as lying
on the left side produced extremely unpleasant sensations in the right
half of the abdomen; moreover, lying on tlie right side was also painful,
evidently on account of direct pressure on the cancerously diseased liver.
332 TUMORS OF THE ABD0:MINAL VISCERA
Case 5.— A. H., 67 years, M.
ad 3. — Had sniallpox at 12 years of age.
ad 5. — Was otherwise always healthy.
ad 6. — First felt sick in the beginning of November, 1908. There
began pain undet-neath the right costal arch and in the lumbar region,
there supervened vomiting and chill.
ad 7. — Severe icterus. Gall-bladder greatly enlarged, visible !
Moves dowTiward and inward with respiration, and with the patient in left
lateral position it seems to lie partly to the left of the middle line. Ten-
derness to pressure in the middle of the epigastrium underneath the costal
arch. Tongue indented. Afebrile course. No edemas.
Urine: Abundance of bilirubin; aldehyde and indican reaction is
negative.
Feces: Colored brown (with icterus of high degree!) ; cause of brown
coloration : abundant blood-coloring matter. Besides soap-needles also
neutral fat globules.
ad 8. — Beginning: Early in November, 1908.
Status presens : November 21, 1908.
Autopsy: December 12, 1908.
Duration : About 1 month,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufcr) : Car-
cinoma of the head of the pancreas invading the descending and horizontal
portions of the duodenum and ulcerating in the latter places. Metastases
in the liver and the ligament between tlie liver and duodenum. Compres-
sion of the ductus cholcdochus. Icterus.
Epicrisis: The patient was first brought to a realization of his disease
by the appearance of pain underneath the costal arch produced by vomit-
ing and chill and the occurrence of jaundice.
The gall-bladder was found to be greatly enlarged and could be seen
behind the abdominal wall, following the excursions of the diaphragm.
Despite severe jaundice and despite a negative aldehyde reaction in
alcoholic extract of stool, the feces were colored almost a normal brown.
Chemical examination of the feces furnished the explanation : blood-
coloring matter constantly strongly positive. Autopsy: Carcinoma of the
pancreas perforating into the duodenum and there ulcerating. Indican
reaction absent from the urine.
As in Case 4, so also here, "indented" tongue.
Case 6.— U. P., 39 years, F.
ad 5. — For the past six years has been "ailing in the lower ab-
domen" ; had frequent genital hemorrhages, which ceased after curette-
ment. She claims that since that time she has a purulent discharge from
the vagina.
ad 6.- — In the beginning of December, 1909, there appeared severe
pain in the back and in the abdoBien ; lately severe vomiting, disturbed
sensorium. The husband of this patient noticed a certain rigidity of the
spinal column. On account of a suspected meningitis the patient was
CARCINOMA OF THE PANCREAS 333
transferred to my division from the gynecological division where, until
very recently, she had been treated for a right-sided infiltration.
ad 7. — Pale color of the face with a yellowish tint; temperature a
little over 38° C. ; sensorium slightly disturbed. Dry tongue. Abdomen
distended, vc#y sensitive to pressure ; dulness in both flanks. The patient
always maintains the dorsal position. Legs edematous, the left more so
than the right. Slight hematemesis.
Urine: Pyuria containing bacteria coli. Diazo reaction entirely nega-
tive; so also aldehyde reaction.
Stool: Blood-test negative; neither neutral fat globules nor soap-
needles.
Blood: 33,000 leucocytes. Toward the end erysipelas of tiie fac(f.
ad 8. — Beginning: Early in December, 1909.
Status presens : December 28, 1909.
Autopsy: December 30, 1909.
Duration : 1 month,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Car-
cinoma of the pancreas ; very extensive metastases in the mesentery and
the entire retroperitoneal cellular tissue through which the vena cava
and aorta take their course. Metastases in the pouch of Douglas, the
right parametrium, the left ovary, perforation into the renal pelvis. In-
filtration of the right suprarenal body. Serosanguineous ascites.
Epicrisis: The resistance in the right parametrium which evidently,
in view of the repeated gynecological diseases, had been considered as of
inflammatory nature, was in reality a cancer metastasis. And the pain
lately existing in the back and in the lower abdomen, which were also re-
ferred to the genitalia, were due to the extensive retroperitoneal tumor-
masses.
The high fever and the hyperleucocytosis (33,000) were explained by
the subsequent terminal erysipelas.
Notwithstanding the extensive carcinomatous infiltration of the pan-
creas the ductus choledochus had remained intact.
The bile-ducts were perfectly free; there was not even a trace of a
positive aldehyde reaction. Examination of the feces did not offer the
least clue for assuming a disease of the pancreas.
This case had given the appearance of a gynecological disease, a mis-
take which may occasionally occur also in the visceral forms of cancer
(stomach-intestine-gall-bladdcr !) when metastases occur in the true pel-
vis giving rise to tumor-masses which can be palpated through the vagina
or through the rectum.
Furthermore, as a result of the erroneous assumption of an inflam-
matory gynecological process in the parametrium there was close to hand
the thought of a purulent peritonitis.
Malignant Tumors of the Kidneys
Case 1.— E. D., 44 years, M.
ad 1. — Both parents died of apoplexy.
ad 2. — At three years of age had cervical adenitis, at the same
time had an eruption of the scalp.
ad 5. — At 24 had gonorrhea and orchitis ; otherwise was always
well. Six years ago suffered a fall on his back.
ad 6. — Since about October, 1900, frequent pain along the outer
side of the right lower extremity, especially in the evening after having
moved around a great deal during the day. One day in February, 1902,
after eating there was severe pressure anteriorly in the abdomen at about
the height of the umbilicus ; this was relieved by vomiting and the next
day he felt perfectly well. Eight days later there was a similar attack.
On March 3, 1902, after eating he experienced a violent attack of cramps
in the right half of the abdomen at the height of the umbilicus; vomiting
followed and kept on through the entire night; in the morning the pain
disappeared, the patient felt very much exhausted during the next
two days.
On March 6, 1902, at 11 p.m., extremely violent cramp-like pain,
radiating into the right testicle with a sensation of a swelling in that
organ ; urine dark, pronounced by a physician to contain blood. In the
morning at 6 o'clock the pain disappeared quite suddenly and the patient
felt well until the end of July, 1902. At that time thei'e gradual!}' ap-
peared pain in the back, especially on the right side ; continuous dull
pressing pain in the right half of the abdomen. The pain increased so
much that the patient could neither stand, nor sit, nor walk about ; he
felt best when resting quietly on his back. When lying on the left side the
symptoms become extremely severe : an unbearable "pulling" occurs in
the right half of the abdomen, "as if something heavy was pressing
toward the middle." The urine is remarkably dark on and off. Decrease
of appetite, great emaciation (IT kg in a few weeks) and feeling of
weakness.
ad 7. — Cachexia : edema only toward the end. Corresponding to
the right kidney there can be felt a round, hard tumor, the lumbal region
being tender on pressure and percussion. At times there is pain in the
back, occasionally stabbing sensations in the right thigh.
October 18, 1902: During the night sudden extremely violent pain in
the left hypochondrium accompanied by vomiting and discharge of bloody
334
MALIGNANT TUMOKS OF THE KIDNEYS 3:i5
urine. Discliarge of worm-like clots. Blood pressure 80 inin Hg.
(Gartner).
October 26, 1902: Retention for twenty-four hours; 500 cm" ""cotfee-
ground-liive" urine were withdrawn by means of a catheter; biliary
I vomiting.
I Vrinarij sediment: October 27, 1902: Many casts, including some hav-
!ing a wax-like appearance; besides hyaline casts and cylindroids ; granu-
ilar casts covered with renal epithelium and erythrocytes. Fat droplets
and fatty acid needles.
! ad 8. — Beginning: February, 1902.
I Status presens: October, 1902.
I Autopsy: October 28, 1902.
; Duration : About 8 months.
ad 9. — Autopsy (Hofrat Professor Dr. A. Weichselbaum) : Pri-
mary alveolar sarcoma of the right kidney, grown into the right renal
vein and the inferior vena cava and metastases into both pleurse, into the
bronchial lymph-nodes and into the lymph-nodes at the hilum of the
kidney. Old hemorrhages in the pelvis of the right kidney and blocking
of the opening into the right ureter. Acute parencli3aiiatous nephritis on
the right side. Continued thrombosis of the vena cava inferior and
iliac vein.
Epicrlsis: Even though the existence of a hypernephroma could first
be told with certainty in February, 1902 (right-sided ureteral colic),
there is yet the suspicion that the neuralgic sensations experienced on the
outer side of the right lower extremity about two years before death,
were radiating pains of renal origin.
The disease of the right kidney manifests itself violently in February,.
1902, at first by rather indefinite cramps in the right side of the abdomen,
accompanied by vomiting; then, however, there supervene characteristic
radiation into the right testicle and hematuria. From March until the
end of July, 1902, there follows a deceptive intermission, during which
the patient feels w^ell.
Only in October, 1902, the cachectic appearance and the demonstra-
tion of a palpable hard renal tumor compels us to make the right diag-
nosis of a renal neoplasm after having previously diagnosed the case as
nephrolithiasis.
The existence of a left-sided "painful position," with distinct sensa-
tions of pulling in the abdomen are worthy of note.
The finding in the sediment is that of a chronic parenchymatous
nephritis (waxy casts, fat droplets and fatty acid needles!); there is
lacking, however, hypertrophy of the left side of the heart, and the blood-
pressure is below normal.
The pain in the left side of the back occurring in October, 1902, is
perhaps referable to the thrombosis found at autopsy in the left renal
vein, and edema of the legs occurring two days before death are very
likely due to thrombosis in the inferior vena cava. Death was accom-
panied by uremic manifestations.
336 TUMORS OF THE ABDOMINAL VISCERA
Case 2. — J. M., 66 years, M. Mining inspector.
ad 1. — Parents died at a very old age.
ad 3. — Is said to have had typhoid (?) for two weeks during
childhood.
ad 5. — In 1873, at the age of 36, during violent headache, sudden
syncope ; soon after profuse vomiting of blood (about 2 litres !). Later on,
while staying in Hungary, had malaria for nine months ; when 53 years
of age had one leg amputated on account of caries of the ankle-joint.
He says that in 5s^ovember, 1902, his stools were tarry and fluid.
Anorexia with much eructation after meals.
Since January, 1903, cutting pain in the left half of the epigastrium,
accompanied by "rolling," with occasional bulging at the point of the
pain. Emaciation from 64- to 52 kg; great feeling of weakness.
ad 6. — Toward the end of April, 1903, the patient noticed a swell-
ing underneath the left costal arch, since which time it has become larger.
Lying on the left side is very badly tolerated.
ad 7. — Sallow complexion, with capillary dilatations on the cheeks;
no edemas. On the left side, underneath the costal arch, a tumor can be
felt after the manner of an anterior pole of the spleen, the surface being
somewhat uneven ; this tumor can be displaced 3 finger breadths over the
middle line toward the right; when the patient is lying on his back the
tumor is distinctly ballottable, but this is not possible when lying on the
right side ; there is good respiratory mobility. A muffled tympanitic
resonance on percussion over the tumor-mass. With maximal right lateral
position of the patient it is possible to penetrate between the tumor-mass
and the left costal arch, and in this way grasp the tumor from above.
No tenderness on pressure or on percussion over the right hmibar region.
Blood pressure subnormal.
Urine: Negative finding.
Blood: 4,500 leucocytes.
ad 8.— Beginning: End of April, 1903.
Status prescns : May 29, 1903.
Operation: June 5, 1903.
ad 9. — Finding at operation (Clinic of the late Hofrat Professor
K. Gussenhauers; Docent Dr. D. Pupovac) : Tumor, as big as a child's
head, springing from the inferior pole of the kidney. Histological exam-
ination : Tumor of Grawitz.
Epicriftis: Descended from longlivcd parents, this 66-year-old-patient
had had malaria, in 1873 had acquired an ulcer of the stomach, and at
the age of 53 had been operated on for caries of the ankle-joint. In
November, 1902, there seems to have been renewed hemorrhage from ulcer
with the addition of gastric symptoms bearing an ulcerous stamp. At
first one would have been inclined to look upon the palpable tumor under
the costnl nrch as springing from the stomach. Still, there was distinct
ballottement, at least with the patient in the dorsal position ; in the right
lateral position the tumor left the lumbar region and moved toward the
median line, so that in this position ballottement was not obtainable.
The fact that the tumor could be grasped from above distinguished
MALIGNANT TUMORS OF TIIK KIUXEVS 337
it from a palpuhlc jjole of the spleen, also there was absent a correspond-
ing splenic dulness. The examination of the urine proved negative, both
chemically and microscopically.
Case 3.— M. W., 47 years, M. Peddler,
ad 1. — No hereditary taint,
ad 3. — Typhoid at 5 years of ago.
ad 5. — At 26 had jaundice for tvi^o months.
ad 6. — In March, 1899, while pulling a heavy hand sleigh, experi-
enced a sudden stitch in the right lumbar region; for the following three
months he still noticed that on stooping there was a stabbing pain in that
region covering an area about the size of the palm of the hand. After
that he felt entirely well.
In February, 1903, without any external provocation, dragging })ain
in the right hip corresponding to the course of the sciatic nerve. Dura-
tion : 1 month.
About the middle of ^Nlarch, as a result of carrying heavy loads, pain
in the right lumbar region the same as in March, 1899. When working
in a stooped attitude he could straighten himself only with difficulty and
had to walk about in a stooped position for some time. This pain has
continued since then.
Since the middle of April, 1903, about a quarter of an hour after
every big meal there are pressing pains in the epigastrium, lasting about
two hours; aggravated by motion and left lateral position. Frequent sour
eructation. Appetite good, bowels regular. The epigastric sensation of
pressure depends only on the quantity of digested food, and is uninflu-
enced by the quality of it. From the spring of 1903 until October, 1903,
the loss in weight amounted to 5 kg.
On September 7, 1903, despite tenesmus, inability to urinate, only
after several minutes of much straining the voiding of urine takes place;
urine not bloody.
ad 7. — Facial color is cachectic, with a yellowish tint ; no edemas.
On the right side, underneath the costal arch, there is a palpable tumor-
mass corresponding in its form to the lower pole of the kidney, being
smooth, not sensitive to pressure, of moderately firm consistence; distinct
ballottement ; in front of the tumor a soft cord can be felt (colon!). A
distinct systolic murmur is audible above the tumor. Right lumbar region
slightly tender to pressure; on the right side at base, a dry catarrh.
The spleen extends one finger's breadth beyond the costal arch. Slight
aortic insufficiency. Bilateral varicocele. Temperature often subnormal
(36° C).
Urine: Quantity normal, color very light. No serum-albumin, not even
in traces.
Sediment: Extremely scanty, finely flocculent. Isolated erythrocyte
shadows ; in two preparations there was found a single cast composed of
discolored erythrocytes and renal epithelial cells. Continued finding of
uric acid sediment, transiently many oxalates.
Stomach contents: HCl positive.
338 TUMORS OF THE ABDOMINAL VISCERA
Blood: 4<,6{)(),00() erythrocytes, 5,600 leucocytes, TO'/c hemoglobin.
November 5, 1903: During the past weeks has gained 4.5 kg in weight ;
no edemas. Only on walking mild pain in the right flank ; at the place
where the tumor is distinctly palpable there is a loud systolic murnmr.
ad 8.— Beginning: March, 1899 (?).
Status presens : October 3, 1903.
Autopsy: November 20, 1903.
Duration : Over 4> years,
ad 9. — Autopsy (Professor Dr. 0. Stoerk) : Extirpation of the
right kidney on account of a tumor of Grawitz eleven days ago. Tumor
metastases in the lungs and the retroperitoneal lymph-nodes. Tumor
thrombosis in the ascending cava from the entrance of the renal vein up-
ward. Atheroma of the aorta and insufficiency of the semilunar valves.
Epicrisis: One is inclined to assume that the pains in the right lumbar
region occurring in March, 1899, and continuing for three months were
of renal origin, according to which tiie duration of the disease would ex-
ceed four years.
In the case of hypernephromata in particular, it is a cert;iin fact that
they may for a long time act like benign new formations.
In February, 1903, there also appeared sciatic pain on tiie right side.
In March, 1903, there was a repetition of the right-sided lumbar pain
occurring in 1899. Stooping becomes extremely painful. A troublesome
feeling of pressure comes on especially after big meals (obstruction of
the pyloric passage on part of the tumor-mass.'').
The systolic murmur which can be heard in the right flank over the
tumor is very worthy of note; it is probably due to the vascularity of the
tumor-mass itself.
The color of the face with its yellow nuance is reminiscent of findings
frequently met with in especially gastric cancers ("Teint paille jaune").
Blood and serum-albumin were absent from the urine until the end ;
while the quantity of the urine was normal, its color was remarkably
light.
This case shows how important it is in such cases to make an exact
microscopical examination, even though the chemical findings are negative.
In the extremely scanty sediment there were fovnul erythrocyte shadows
indicating "occult" bleeding, and there was also found one cast covered
with erythrocytes and renal epithelial cells.
During the very last days the patient had gained -tl/) kg in Avcight
without the appearance of anasarca or hydrops.
Autopsy disclosed a finding which is frequent in connection with
hypernephromata, namely rupture into the corresponding renal vein and
thence into the inferior cava.
Case 4. — J. K., 53 years, F.
ad 1. — Father is 73 years of age.
ad 3. — Has had no infectious diseases of childhood.
ad 5. — Hemopt^^sis at 43 years of age (about ^ litre of blood) :
since then often has cough during the cold seasons.
MALIGNANT TUMORS OF THE KIDNEYS JiJii)
ad 6. — At Cliristnias, 1904, tliere began stveio pain, without colicky
character, radiating from the sacrum toward the lumbar region and the
gluteal region, sometimes to the right, sometimes to the left. When the
pain is on the left side the patient walks about inclining toward the left
and the reverse. When the pain is on the left side, left lateral position is
better tolerated. During the attack of pain the urine is said to be colored
brown, at which times the patient usually urinates about three times dur-
ing the night, whereas otherwise she never voids urine at night. When the
pain is very intense it radiates toward the shoulder-blade. Since Christ-
mas, 1904, emaciation to the extent of 5 kg.
In May, 1905, the patient left the clinic, felt quite well and gained
4 kg in several weeks. She worked and felt no weakness.
On July 20, 1905, there again began pain in the left flank "like
toothache." The pain became very severe, extending downward into
the right thigh (as far as the knee), upward to the left shoulder-
blade, anteriorly into the epigastrium. No cramp-like pain, sensa-
tion of burning. With severe pain there was a breaking out of
sweat, repeated urgent desire to urinate, only a few drops being
voided, accompanied by burning, at times also nausea. The pain in-
creased when lying on the right side, so that the patient rests on the
painful side. At present (July, 1905) the pain is continuous, becoming
increased in the evening.
In May, 1905, entirely analogous pain had existed on the right side.
Good appetite for meat.
ad 7. — May 20, 1905: Afebrile course; no edemas. Corresponding
to the left kidney, especially when lying on the right side, a very firm,
uneven tumor can be felt. The left lumbar region yields dulness on per-
cussion, on the right there is tympany. The urine is very light, contains
no trace of serum- albumin or blood,
July 29, 1905 : Tumor is very slightly tender on pressure, distinctly
ballottable, hard percussion of the left lumbar region is not painful. In
front of the tumor, bowel splashing is audible. No edemas.
Urine: Abundant urobilin (chronic constipation!). The sediment con-
tains a moderate abundance of pus-cells, which partly contain yellowish
crystals (hematoidin?), and partly brown pigment granules. No ery-
throcytes. 1/4% serum-albumin.
Ureteral catheterization: Urine from the left ureter: traces of al-
bumin, finely flocculent, brownish sediment consisting of heaps of ery-
throcyte shadows and granulated detritus.
Urine from the right ureter : Traces of albumin ; very scanty, finely
flocculent sediment without distinct coloration ; extremely scanty ery-
throcyte shadows.
ad 8. — Beginning: Christmas, 1904.
Status presens : May 20, 1905, and July 29, 1905.
Autopsy: August 31, 1905.
Duration : About 9 months,
ad 9. — Autopsy (Decent Dr. J. Bart el) : Partial extirpation of a
tumor of the left kidney.
340 TUMORS OF THE ABDOMINAL MSCERA
Histological exaniination (Professor Dr. A. Ghon) : Vascular spindle-
cell sarcoma.
Epicrisis: In this case the phenomena of pain appear prominently in
the foreground ; being localized in the left side of the abdomen, they be-
tray their renal origin by occasional radiation into the thigh of the same
side, tenesmus, and change in the color of the urine. In accordance with
their intrarenal genesis they lack a colicky character. There is present a
left-sided "painful position." The not inconsiderable gain in weight
(4 kg) during the course of the disease is deserving of note. The relation
of the bowel to the tumor-mass is made clear by the presence of splashing
in front of the tumor. The changes in the urine arc very slight : We find
traces of albumin and erythrocyte shadows, for the first time, toward the
end of the disease, particularly in tiie urine obtained from the left kidney.
Case 5. — K. P., 53 years, F.
ad 5. — Was always healthy, the only sickness she had was pneu-
monia.
ad 6. — In the beginning of April of this year (1908) tiiere ap-
peared severe headaches, accompanied by dizziness ; there followed weak-
ness and loss of sensation in the right upper extremity, so that she could
not retain her grasp on objects. Soon there followed analogous manifes-
tations in the riglit lower extremity. The weakness soon changed into
complete paralysis ; inability to speak. Consciousness remained unclouded.
About the middle of April of this year (1908), two weeks after the ap-
pearance of paralysis, a })r()fuse hemorrhage occurred from the vagina
during defecation.
ad 7. — Pale color of the face; sensorium unaffected, crying mood.
Relaxed paralysis of the right arm and the right leg; Babinski's reflex
positive on the right side; patellar reflex weaker on the right. Indication
of cervical rigidity. The head greatly everted to the left. Slight spasms
in the left upper extremity. Crater-like ulcer on the left side at the en-
trance to the vagina. Loud, almost grating systolic murmurs over all the
cardiac orifices; arteries delicate, blood-pressure normal. On the right,
under the costal arch, the liver is drawn out after the manner of a "corset
lobe," consistence but little increased, surface smooth.
Blood: Hemoglobin 1007^ ; leucocytes 9,600.
Toward the end, temperature up to 40° C.
ad 8. — Beginning: Early part of April, 1908.
Status presens: May 15, 1908.
Autopsy: May 19, 1908.
Duration: About 6 months,
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schlagenhaufer) : Tumor
of Grawitz, as big as a fist, belonging to the left kidney (inferior pole)
with multiple metastases in the liver, in both lungs, in the right kidney,
in the glands of the hilum. Several metastases in the cerebrum and cere-
bellum and in the posterior wall of the vagina.
Epicrisis: This case illustrates how a tumor of Grawitz may occa-
sionally, as a result of metastases* in the brain, make its appearance
MALIGNANT TUMORS OF THE KIDNEYS 3-H
under the aspect of a gradual paralysis. The metastasis situated in tlie
right lobe of the liver was of extraordinary soft consistence, which ren-
ders the recognition of such metastases difficult during life.
The combination of hemiplegia and hemorrhage per vaginani had in-
duced me to think of the possibility of a malignant process of the geni-
talia with metastases in the brain. Examination of the genitalia actually
revealed a crater-like ulcer on the left side in the vaginal entrance. It
was only at autopsy that the primary focus in tiie lower pole of the
kidney was found.
Case 6.— N. N., 61 years, M. Laborer, "^s
ad 1. — No hereditary taint.
ad 2. — Physical development retarded until his seventeenth year,
ad 3. — Had malaria from 1855-1858 while in Hungary; since then
has been well.
ad 5. — Toward the end of 1894 the color of his face gradually be-
came pale, he felt exhausted, and glandular swellings appeared on the
neck.
ad 6. — In the spring of 1895 there were added pain in the back,
which radiated particularly into the right lower extremity.
On September 14, 1895, blood appeared in the urine; the admixture
of blood disappeared in two days.
In October, 1895, there was swelling of the lower extremities. Pro-
gressive emaciation since the summer of 1895.
ad 7.- — General swelling of glands ; the glands are modcrateh^ firm,
not adherent to each other, in some places attaining the size of a hen's
Ggg. The spleen is hard, extends three finger breadths beyond the costal
arch. On the right side corresponding to the kidney, there is an uneven,
ballottable tumor.
Blood X October 16, 1895) : 3,450,000 -erythrocytes, 96,000 leuco-
cytes, hemoglobin 50%.
Differential leucocyte count: Mononuclears, 82.3%; polynuclears,
15.67c.
February 27, 1896: 48,000 leucocytes, viz.: 51% mononuclears, 457o
mononuclears.
Urine: Albumin positive; much sediment composed of leucocytes.
December 30, 1895 : Hematuria without pain.
January 11, 1896: Discharge of a worm-shaped clot about 10 cm long.
February 20, 1896: Discharge of a particle of tissue w^hich was 1.5
cm long and 1/;^ cm wide, which after microscopic examination (Professor
Dr. A. Kolisko) was diagnosed as a shred from a disintegrating neoplasm.
ad 8. — Beginning: Spring of 1895.
Status presens : October, 1895.
Autopsy: March 20, 1896.
Duration : About 1 year.
Compare Mdrinrhlcr. Wiener Klin. Wochensciir., 1896, No. .10.
342 TUMORS OF THE ABDOMINAL VISCERA
ad 9. — Autopsy (March 20, 1896) : Perithelioma carcinomatodes
supraglaiuhihire of the riglit kidney with proliferation into the ureter
and the inferior vena cava, metastases in the liver, in the lungs and in the
spinal column. Leukemic hyperplasia of the spleen and the various lymph-
glands. Right kidney almost completely replaced by a very soft, almost
deliquescent, vascular tumor as big as the head of a small child, rupturing
into the renal vein and projecting into the lumen of the iiifirior vena
cava like a very soft plug.
Microscopical examination: Typical picture of a tumor of Grawitz.
Ejncrisis: In this 61-year-old patient the right-sided renal tumor of
Grawitz was associated with a lyin})hatic leukemia, both diseases perhaps
having sprung from a congenital constitutional defect. Until his seven-
teenth year this patient's development had been retarded. Upon repeated
examination of the urine I found in it in February 20, 1896, a shred of
tissue which Professor Dr. A. KoUsko diagnosed as coming from a malig-
nant tumor. The assumption of a right-sided malignant renal tumor har-
monized with the renal hemorrhage which occurred in September, 1895.
In January, 1896, a vermiform clot (uretei-al cast) had been voided. The
leucocyte count in the blood fluctuated during the course of the disease —
perhaps under the influence of the malignant process in the kidney — the
mononuclears being, toward the end of the disease, fewer in number than at
the beirinninir-
APPENDIX
"Atypical" Malignant Tumors of the Abdomen
Case 1.— F. A., 38 years, F.
ad 6. — Beginning of disease in December, 1899, with constipation;
up to four day intervals between stools. At the same time profuse night-
sweats. Menses had ceased since December, 1899, and the patient states
that the supervening enlargement of the abdomen (ascites!) was attrib-
uted to pregnancy. Since the appearance of the ascites there has been
pain in the back only on stooping; it disappeared after tapping. At
the start the appetite became good, becoming diminished only when there
were long intervals between stools. Only since February of this year
(1900) anorexia, eructation of gas, now and then vomiting in the morn-
ing, especially after drinking cold water. Since, frequently loud bowel
noises, accompanied by pain.
ad 7. — Severe cachexia and edema of the legs. Great ascites, to-
gether with a left-sided pleural effusion over an area as big as a hand.
At the height of the umbilicus a crescent-shaped firm lamina can be felt,
its convexity being downward, having a sharp border with numerous in-
dentations in it, continuing to the left up to the costal arch; anterior to
it there is a protuberance as big as a nut. The vertical diameter of this
tumor-mass is about three finger breadths, being about two hand breadths
wide. In the region of this tumor-mass distinct peritoneal friction can be
heard and felt. Percussion elicits a muffled tympanitic note. Above this
crescent-shaped lamina there are small, firm, nodule-shaped tumors
(glands in the meso-colon !).
Blood: 24-, 000 leucocytes.
Vaginal examination: Distinct tumor-masses are palpable in the para-
metrium on the left side.
Rectal examination: Nodular tumor-masses can be felt through the
unaltered anterior wall of the rectum.
Abdominal fluid from tapping; "milky" turbidity.
March 23, 1900: Pleural friction posteriorly on the right side below.
Venous dilatations around the umbilicus and over the right half of the
abdomen. Frequent temperature elevations above 38° C. without painful-
ness in the abdomen (section: purulent peritonitis!).
Since March 18, 1900. severe "white" edema of the legs in the lumbar
region and the lateral belly-wall.
343
344 APPENDIX
Toward the end vomiting of bile and "coffee-grounds."
ad 8. — Beginning: Early in December, 1899.
Status presens : March 8 and March 23, 1900.
ad 9. — Autopsy (Docent Dr. A'. Landsteiner) : Carcinoma of the
ovaries, having for its base papillary ovarian cysts (size of eggs) with ex-
tensive metastasis in the peritoneum. The omentum is thickly infiltrated,
and on the serosa of the bowel and the mesentery there are numerous bed-
like plaques of tumor-masses. The uterus is surrounded by tumor-masses
and partly studded by them. Fibrinous purulent peritonitis, left-sided
hydrothorax. P'resh thrombosis of the portal vein.
Epicrisis: Worthy of attention are the profuse night-sweats appear-
ing as the first symptom of the malignant disease in the ovaries. Given
the same clinical picture, these sweats might occasionally suggest tuber-
culosis of the peritoneum. The tumor-mass corresponding to the situa-
tion of the transverse colon and extending, in the shape of a crescent,
from one costal arch to the other, was shown at autopsy to belong to the
great omentum.
Among the early symptoms there was also constipati(j!i, w liich wa.-. ac-
companied by mild symptoms of stenosis (loud bowel rumbling) and which
was very likely due to moderate compression of the lowermost segment of
the bowel. The gastric symptoms (vomiting, eructation) nngiit likewise
be traced to this congestion from obstruction.
Toward the end there supervened vomiting of bile and "coffee-grounds"
due to a painless })eritonitis, which may have been brought on by j)uncture
incident to tapping.
Case 2.— M. Z., 17 years, F.
ad 1. — IMother died of tuberculosis.
ad 6. — Since the beginning of August there has been anorexia, oc-
casional vomiting, pressing, dull pain in the abdomen after eating, bitter
eructation ; constipation.
From November, 1900, to March. 1901, cessation of menses.
Finding on November 17, 1900: A tumor-mass extending two finger
breadths above the umbilicus, occupying the entire width of the abdomen;
ascites not demonstrable.
On the right side, luulerneath the umbilicus, there is a portion of the
tumor-mass as big as the head of a child, firm, hard, globular, merging
with the softer portions near the umbilicus. The tumor is fixed against
the pelvis. No pain in the back.
Genital finding: Infantile genitals; tumor-masses can be felt through
the posterior fornix.
In April, 1901, after treatment with potassium iodide, no tumors are
said to have been demonstrable (?).
In July, 1901, the patient again entered a gynecological clinic. A
nodular tumor-mass was felt to the left of the umbilicus ; painfulncss on
pressure in the epigastrium and on the right side underneath the cos-
tal arch.
"ATYPICAL" TUMORS OF THE ABDOMEN 345
On July 25, 1901, an incision was made in the posterior wall of the
vagina and about 1/4 litre of a yellowish, later reddish, fluid was evacuated,
ad 7. — August 3, 1901 : No pain in the back. Patient complains of
severe pain on the outer side of the right tiiigh. Abdomen extremely ten.se,
dulness anteriorly, together with fluctuation ; venous dilatations also over
the sternum. Linea alba much pigmented, areola? of the nipples large and
likewise much pigmented. ^ ery little indurated edema of the legs below
the knees. Afebrile course.
ad 8. — Beginning: Early in August, 1900.
Status presens : August 3, 1901.
Autopsy: August 14, 1901,
Duration : About 1 year,
ad 9. — Autopsy (Professor Dr. H. Alb,recht) : Medullar}', mostly
necrotic sarcoma of the ovaries, bigger than the head of a man.
Eplcrisis: In this 17-year-old girl, descended from a tuberculous
mother, a gynecologist had thought of tuberculosis of the peritoneum.
At the time the patient was received into the clinic (August, 1901)
the rigidity of the abdominal wall was so great that it was impossible to
obtain any finding by palpation.
The appearance of the disease with the symptoms of pseudo-pregnancy
seemed remarkable to me, and this constituted my chief reason for making
the diagnosis of a neoplasm springing from the ovaries.
Pigmentations of the linea alba as well as of the areolje of the nipples
had occurred in the very beginning and the menses had been absent for
several months. In view of this ensemble of symptoms, a relative of the
patient had, in the beginning, thought of pregnancy. The stubborn vomit-
ing also could be explained in this way.
The enormous tumor-mass springing from the ovary fills almost the
entire abdomen, which explains the appearance of external collateral veins
(also over the sternum!). The neuralgias in the right thigh are probably
to be looked upon as symptoms of compression ; pain in the back was
permanently absent. There was no ascites, neither was there any severe
edema. The tumoi*-mass had not been tender to pressure.
Case 3.— F. K., 36 years, M. Waiter.
ad 6. — In Septcmbei-, 1900, rapid enlargement of the left testicle,
which had been injured (blow) in Januar}^ 1900. Taken for a hydrocele
in the beginning; later resection.
Since the middle of January, 1901, frequently constipated for three
or four days ; often, especially at night, colicky pain at the height of the
umbilicus, particularly on the left side, accompanied by borborygmi ; if
the pain lets up anteriorly it becomes worse in the back. Flatus-produc-
ing vegetables, such as cabbage, are poorly tolerated. Appetite very good,
no vomiting. Frequent parietal headaches, which let up after movement of
the bowels.
ad 7. — Left inferior epigastric vein somewhat dilated. Situated
chiefly in the left half of the abdomen there is a very hard and uneven
tumor-mass, bigger in size than the palm of a hand and firmly fixed behind
346 APPENDIX
the peritoneum, extending about tliree finger breadths above and below the
umbilicus, reaching the mammary line on the left, and going one finger
breadth to the right of the median line. A loop of intestine can be rolled
to and fro on this tumor-mass. Pain in the back appears only at the
time of intestinal colics. Inguinal glands not enlarged. No edemas. Pain
in the back only on stool retention, immediate cessation after bowel
evacuation.
From the decursus:
March 30, 1901 : Temperature rise up to 38.5° C. and appearance
of glands in the left axilla accompanied by pain and diffuse swelling at
that site. Iodine therapy caused a retrogression of these manifestations.
April 20, 1901 : Attacks of pain due to flatulence, accompanied by
bradycardia, nausea and rectal tenesnms, breaking out of sweat over the
whole body, pallor of tiie face, feeling of pressure in the abdomen; all
these symptoms relieved after discharge of flatus. During the attack the
patient inclines forward and compresses the abdomen,
ad 8. — Beginning: September, 1900.
Status presens: March 0, 1901. and June 20. 1901.
Autopsy: July 6, 1901.
Duration: About 10 months,
ad 9. — Autopsy (Docent Dr. A'. Landste'iner) : Sarcomatosis of the
lymph-glands following a primary sarcoma of the testicle (extirpation
of the left testicle about a year ago) ; large tumors of the lymph-glands
with inclusion of the large vessels, compression of the left kidney and the
small intestine. Compression of the left lobe of tiie thyroid gland and
jugular vein by a big tumor. Compression of the superior vena cava and
dilatation of the cutaneous veins in the upper half of the body.
Epicrisis: In this 36-year-old patient the left testicle had been extir-
pated in September, 1900 (diagnosis: round cell sarcoma).
About the middle of January, 1901, there appeared colicky pains on
the left side which, without doubt, are related to the {)resence of left-sided
retroperitoneal glandular metastases and are to be interpreted as flatulent
colic.
These secondary bowel symptoms were the leading subjective com-
plaints until the end and gave rise to peculiar manifestations accompanied
by seizures of collapse.
Autopsy showed that in different places the bowel was adherent, lead-
ing to disturbances in canalization. The retroperitoneal situation of the
tumor-mass was shown by its respiratory immobility ; also loops of intes-
tine were demonstrable in front of it.
During the further course of the disease there supervened metastases
in the glands of the left axilla, accompanied by manifestations of severe
inflammation, which, however, rapidly retrogressed.
Glandular metastases also occurred in the supraclavicular space and
anteriorly lying on the trachea.
In cases of tumor-masses situated rctroperitoneally it will, therefore,
be commendable occasionally to think of the possibility of a primary
neoplasm of the testicle.
"ATYPICAL" TUMORS OF THE ABDOMEN 347
Case 4. — J. T., 50 years, M.
ad 3. — Has luid no diseases of cliildhood.
ad 5. — Was always healthy. For the past six or eight years there
is present an intumescence of" the right testicle.
ad (). — Toward the end of March, 1904, the appetite hecanie had
and moderate constipation set in. There appeared a tendency to flatu-
lence. On Api-il 1(), 1904, while walking, there suddenly appeared an enor-
mous swelling of the left leg, the limb becoming black and blue and was
very painful to pressure for two weeks.
ad 7. — Cachectic appearance; edema of the left lower extremity, at
present no tenderness on pressure. Abdomen very tense, but not appre-
ciably enlarged. P^pigastrium bulging; dilated veins cross the left ligament
of Poupart and are also present posteriorly on the right side near the
spinal colunui. A tensely elastic tumor-mass can be felt in the epigastrium,
having an oval shape with a horizontal diameter of about one dm, and a
vertical diameter of about four cm. The tumor is raised on pulsation,
fluctuates, and over it a soft systolic murmur is audible. Firm, nodular
tumor-masses about the umbilicus extending to the right Poupart's liga-
ment. The tumor-masses possess respiratory mobility. Corresponding
to the ileocecal region there is an isolated firm knot as big as a nut. Right
testicle moderately enlarged.
Stomach contents (vomited) : HCl positive.
Blood: 12,100 leucocytes.
Urine: About ^% serum-albumin, few granular casts in the sediment,
many colon bacilli.
ad 8.— Beginning: End of March, 1904.
Status presens: May 6, 1904.
Autopsy : May 30, 1904.
Duration: 2 months,
ad 9.— Autopsy (Professor Dr. A. Ghon) : Sarcomatous teratoma
of the right testicle, about the size of a fist. Secondary medullary sar-
coma of right-sided inguinal, iliac, retroperitoneal and mesenteric lymph-
glands, together with perforation into the inferior vena cava. Secondary
sarcoma in form of little knots on the peritoneum and numerous knots as
big as hazelnuts in the liver.
Epicrisis: The palpable, tensely elastic tumor-mass in the epigastrium,
on account of its retroperitoneal location, at first raised the suspicion
whether it might not belong to the pancreas.
The right testicle was not at first thought of as the point of origin,
because of the patient's statement that the intumescence of the right
testicle had been present for from six to eight years and had not under-
gone any change.
Still it was remarkable that between the tiunor-mass in the epigas
trium and the right testicle there extended tumor-masses like a bridge
toward the ileocecal region.
Corresponding to the ileocecal region itself, a tumor-mass as big as
a nut could be felt. The epigastric tumor-mass vibrated with pulsation :
the systolic murmur audible over the tumor probably originated in the
348 APPENDIX
aorta (the aorta passed through the tumor-masses). Despite their retro-
peritoneal location the tumor-masses distinctly exhihited moderate respira-
tory displaceability.
Pain in the back or other neuralgic pain was wanting during the entire
course.
The initial symptoms had been anorexia, moderate constipation with
tendency to meteorism, and acute occurrence of a venous thrombosis in
the left leg (while taking a walk).
Case 5. — J. L., 51 years, M. Shoemaker.
ad 8. — Had variola at '22: denies syphilis.
ad 6.^ — About March, 1899, loss of appetite set in. Antipathy to
meat, belching of odorless gases. Vomiting did not occur. The abdomen
was distended and tense, especially after meals. There were present con-
tinual severe pains in the back, even when resting cjuietly and irrespective
of motion ; originally they had been elicited and aggravated by motion.
Almost synchronous with these symptoms there appeared, in the left
supraclavicular fossa, a painless glandular swelling, which decreased in
size after the application of hot compresses.
In August, 1899, there also ;i])peared glands in the right supraclavicu-
lar fossa; in September, 1899, slight difficulties in deglutition were no-
ticed at the height of the second rib.
ad 7. — Cachectic, pale gray color of the face; great emaciation.
Soft gland tumors on both sides in the supraclavicular foss;e. Ascites
(aspiration fluid): "milky" turbidity.
Blood: 3,100,000 erythrocytes, \07< hemoglobin, 14,-J()0 leucocytes
with only 4.7% lymphocytes.
During the course of a terminally intercurrent infection (perforative
peritonitis) the cervical glands diminished considerably in size and be-
came very soft; at the same time the pains in the back became less,
ad 8. — Beginning: INIarch, 1899.
Status prcsens: October, 1899.
Autopsy: November, 1899.
Duration: About 9 months,
ad 9. — Autopsy (Professor Dr. H. Alhrecht) : Lympho-sarcoma-
tosis of the glands in the greater curvature of the stomach and in the
mesocolon, extending to the root of the mesentery and into the spleen,
with consequent ulceration at the greater curvature of the stomach and
slight constriction of the splenic flexure of the colon. Lymphoma in the
neck, in the axillary space, in the inguinal region of both sides and retro-
peritoneally. Old tuberculosis of the glands in the left mediastinum and the
mesenter}'. Chylous ascites and right-sided chylothorax.
Epicrisis: In view of the fact that among abdominal neoplasms gas-
tric cancers most frequently lead to metastases in the left supraclavicular
fossa, this possibility had to be taken into consideration in this case also.
The more so as anorexia and disgust toward meat counted among the
early symptoms. While, however, the appearance of "Virchow's glands"
is always amongst the late s3^mptoms of .gastric cancer, the appearance
"ATYPICAL" TUMORS OF THE ABD0:MEX 349
of supraclavicular gland swelling in this case coincides with the first oc-
currence of gastric s3'niptonis. Remarkable also was the soft consistence
of the glands, which was, later on, accentuated under the influence of an
intercurrent infection when the glands were reduced in size and the pains
in the back strangely decreased. The appearance of glandular swellings
in the right supraclavicular fossa also had to be looked upon as a very
rare happening in connection with gastric cancer.
The original retrogression of the glandular swelling after the appli-
cation of compresses was likewise worthy of note.
All of this, even during life, compelled the assumption that we were
dealing wath a primary glandular process affecting particularly the
retroperitoneal glands, which had given rise to the severe pains in the back
and, through pressure on the chyle chaiuiels, had led to a "chylous" as-
cites. From here there had occurred, via the thoracic duct, intumescence
of the supraclavicular glands. The temporary difficulties in deglutition
also were due to intumescence of the glands in the neighborhood of the
upper portion of the esophagus.
Case 6.— F. J., 37 years, F.
ad 1. — Father died of cancer of the stomach.
ad 3. — Had varicella and measles.
ad 5. — In April, 1900, while going through a confinement, a tumor
was discovered on the right side of the true pelvis. During the following
pregnancy, Csesarean section was performed on March 31, 1901, because
the tumor, which was assumed to spring from the connective tissue of the
pelvis or from the right kidney, prevented normal labor.
ad 6. — About the middle of May, 1900, there appeared also pain
in the liver, and the patient was troubled with dyspnea. Frequent vomiting
supervened, and there was disgust toward meat. Since October, 1901,
there was also vomiting of "coffee-grounds."
ad 7. — Mild subicteric discoloration; very slight edema about the
ankles. Liver enlarged downward more than the breadth of one hand,
the anterior surface being covered with very prominent elevations about
the size of apples ; they feel in part, softly elastic, and in part fluctuating.
Dilated veins cross the epigastrium and are continued onto the sternum.
Urine: Abundant urobilin.
Blood: 13,700 leucocytes.
Vaginal examination: A very firm, fixed tumor-mass, as big as an
apple, can be felt on the right beside the portio.
November 10, 1901 : Sudden appearance of general clonic contrac-
tions with trismus ; duration about ten minutes. After this attack the
power of speech was disturbed. On and off the patient is not able to recall
certain words ; thus she cannot remember her own name. When reading
there are certain words which she cannot pronounce ; the less she thinks
during reading, the better. The patient understands perfectly the words
thf^t aro sy)oken to her. Eye ground is normal. Headache occurring only
toward the end.
350 APPENDIX
ad 8. — First symptoms: May, 1900.
Status presens: November 11, 1901.
Autopsy: February 2, 1902.
Duration : About 9 months.
ad 9. — Autopsy (Professor Dr. H. Albrecht) : The liver enor-
mously enlarged (10.3 g), presenting on its surface numerous cystic
tumors as big as a man's fist, some of which bulge out considerably and
siiow distinct fluctuation. On section the liver shows cystic cavities every-
where, their size varying from that of a walnut to that of a man's fist.
Between the cysts there are solid tumor-masses, consisting of soft tumor-
tissue in which numerous hemorrhages have taken place. In the island
of Reil and in the third frontal convolution there is a round, dark-red
tumor-mass measuring on cross-section 5 cm in diameter.
Epicrisis: Clinically we were dealing with a very peculiar malignant
cystic alteration of the liver, which had led to great enlargement of the
organ. The tumor had given rise to structurally analogous metastasis
in Broca's speech area. This accounted for the repeated epileptiform
attacks and for the motor aphasia. Headache, chiefly on the left side,
supervened later.
The histological examination made by Professor Dr. H. Albrecht
showed that we were dealing with a primary cylindrical cell carcinoma of
the liver springing from the bile radicals.^
Case 7.— Th. S., 39 years, F.
ad 5. — Was always healthy until about August, 1908.
ad 6 — In August, 1908, there began i)urning pain in the epigas-
trium, occurring mostly one hour after intake of food ; anorexia. This
condition lasted about one week, after which the patient felt entirely well
again. During the night of Septemln-r 29-30, 1908, profuse hematemesis
occurred, which caused death on October 5th.
ad 7. — October 2, 1908: Light brown hair; eyebrows feebly de-
veloped; great pallor, tachycardia. An area of tenderness underneath the
left costal arch.
ad 8. — Beginning: August, 1908.
Status presens : October 2, 1908.
Autopsy: October 6, 1908.
Duration: 2 months.
ad 9. — Autopsy (Pros. Professor Dr. Fr. Schhigenhoufer) : Lym-
phosarcoma of the stomach in the shape of two tumors, each as big as a
hen's ego;, on the posterior wall of the stomach, extending to the lesser
curvature, with extensive ulceration. ^Metastases in the right kidney, al-
most entirely replacing same. Ulceration in the region of the hepatic
flexure. Bowel filled with coagulated blood. Severe anemia.
Epicrisis: While lymphosarcomatous diseases, as a rule, exhibit little
^ See Transactions of the German Association of Surgery, 1897, 26th Congress, page
137. — r. Hnherer. Zur Frage der nicht parasitaren Lebercysten, Wiener Klin. Wochen-
schrift, 1909, No. 51.
"ATYPICAL" TUMORS OF THE ABD()Mi:\ 351
tendency to bleeding, a fatal heniatcniesis occurred in this case, and that
but a short time after the appearance of ulcerous symptoms.
The extensive metastasis in the kidney deserves attention ; at times
this may impose as a primary renal neoplasm.
Case 8. — M. W., 56 years, M. Innkeeper.
ad 1. — Mother died at a very advanced age,
ad 5. — Had always been healthy.
ad 6. — In November, 1904, the appetite diminished; appearance
became bad. Even at that time a tumor as big as a fist was found in the
abdomen. Xo pain.
Since the end of February, 1905, there have been light sweats ; one
fluid bowel evacuation daily; the color of the urine became somewhat
darker. Great emaciation,
ad 7. — Pale-yellowish color of the face, no edemas, A firm tumor as
big as the head of a child can be felt in the left half of the belly, corre-
sponding in its location to a renal tumor. In front of it, running in a ver-
tical direction, there is a cord-like displaceable structure (bowel loop.'') ;
the ascending colon when distended lies anterior to the tumor. In the left
flank there is dulness coming from the tumor-mass. The tumor exhibits
moderate respiratory displaceability and is movable also in a lateral direc-
tion. From the lumbar region it does not permit of dislocation forward,
but does so from the flank. In the left lumbar region there is no dulness
and no increased resistance. The tumor admits of demarcation from the
left costal arch. There is no audible systolic vascular murmur over the
tumor. The right half of the abdomen is distended with meteorism and
isolated loops of intestine distended with meteorism are indistinctly pal-
pable. Tumor not sensitive to pressure. A big unilateral varicocele
(left) ; testicles normal.
Urine: Distinct diazo reaction; no serum-albumin, no casts.
Feces: Fluid, light yellow, foamy, acid reaction; containing abundant
Gram-positive leptothrix forms partly staining blue with iodin ; isolated
soap needles.
Stomach contents (after test-breakfast): Total aciditj^, 2%; %o N.
NaOH ; HCl negative.
ad 8. — Beginning: November, 1904,
Status presens : March 8, 1905,
Operation : March 23, 1905,
Duration: About 5 months,
ad 9. — Operation (Hofrat Professor Dr, J. Hochcncgg) : Oblique
lumbar incision about 20 cm long; after severing the muscles the uneven
tumor comes into view ; few adhesions ; hilum cannot be found, so that the
diagnosis of a renal tumor must be discarded. After extirpation of the
tumor, the apparently entirely normal kidney can be seen in the upper
end of the wound.
Dissection: A lobulated tumor, as big as the head of a child, covered
with small nodules, not sharply excapsulated ; on cross section grayish-
white ; consistence pretty firm.
352 APPENDIX
Histological examinution: Small spindlc-cell sarcoma.
Epicrisis: In its location the tumor-mass resembled a renal tumor so
perfectly that even during the operation, after the tumor had been laid
bare, it was impossible to distinguish with certainty. Only when it was
impossible to find a hilum, the diagnosis of renal tumor had to be dropped,
tile intact kidney coming to light after the operation had been performed.
It is true that aside from a positive diazo reaction the urinary finding
had been perfectly negative, which was remarkable in view of the size of
the tumor-mass.
On the other hand, there were manifestations on the part of the bowel,
such as mcteorism, fiuid foamy evacuations having an acid reaction, con-
taining a peculiar type of vegetation (abundance of leptothrix fornis).
The complete absence of any admixture of blood in the stools, however,
argued against the assumption that the tumor might belong to the trans-
verse colon.
This case illustrated that in the differential diagnosis of malignant
new-growths of the abdomen, one has to reckon with the possibility —
though indeed rarely — that tlie tumor does not spring from any organ
whatever.
Case 9. — J. S., 47 years, M. Innkeeper."
ad 1. — Father and mother are living and are well, so also four
brotliers and sisters.
ad 3. — Has had no infectious diseases.
ad -i. — Digestion perfect until 1882, at which time the patient
thinks he spoiled it by drinking cold beer. Since then there has been fre-
quent diarrhea, sometimes twenty stools a day, especially after eating
cheese or flour foods, no tenesmus, no pain; since then also tendency to
flatulence.
ad 6. — On October 30, 1897, took sick suddenly after drinking
black coffee, falling to the ground ; appearance of colicky pain in the ab-
domen. Since then the abdomen is distended; the bowel evacuations are
light in color and fluid. Colicky pain in the belly every two or three
minutes ; the}^ start in the epigastrium, sometimes radiate into the back
and are accompanied by lively gurgling. The use of coffee elicits them
promptly. Pressure on the abdomen sometimes aborts the pain. Increased
feeling of thirst, no vomiting.
Since the beginning of January, 1898, severe swelling of the legs.
Great emaciation during the past two months (November-December,
1897).
ad 7. — Color of the face pale and anemic, face bloated, capillary
dilatations in the cheeks. Hair of the head brown, mustache red. Severe
pallid edema of the lower extremities. Abdomen greatly distended with
meteorism, including the lateral portions ; splashing sounds are also
audible. Skin of the abdomen is tense, shiny. On and off big S-shaped
'See R. Schmidt, Ein Beitrag zur Lymphosarcomatosis des Diinndarmes. Wiener
Klin. Wochenschr., 1898, No. 21.
"ATYPICAL" TUMORS OF THE ABDOMEN 353
intestinal loops, about 1 dcni In width, bulge out above and to the left
of the umbilicus, disappearing on both sides under the costal arches.
Small areas of dulness in the flanks, moving with change in position.
No tumor-mass can be felt anywhere.
Feces: Constantly fluid, very putrid, containing nuuRrous lumps of
mucus as big as lentils.
Blood: N^o leucoc^^tosis, erythrocytes 4,000,000, hemoglobin 75%.
From January 9 to 12 there was a gain in weight amounting to
7 kg as a result of rapid increase of edema. Death occurred on January
30, 1898, the diarrhea (up to 14 stools a day) persisting up to the end.
ad 8. — Beginning: End of October, 1897.
Status prcsens: January 7, 1898.
Autopsy: January 30, 1898.
Duration : 3 months,
ad 9. — Autopsy: "Multiple, partly ulcerating, partly healed
(cicatricized) lymphosarcoma of the small intestine; adhesions between
two loops of bowel, corresponding to one ulcerating sarcomatous nodule,
and consequent stenosis at that site."
E picrisis : In this 47-year-old patient the symptoms that are with cer-
tainty referable to the lymphosarcoma extend over a period of about
three months. jNIany years previous there had existed a great disposition
to diarrhea which was provoked by alimentation, which disturbed the gen-
eral health but little. About three months prior to death there appeared
colics due to bowel constriction ; rigidity of the bowel could be demon-
strated objectively and there was constant diarrhea. The external aspect
of the patient presented a severe general anasarca and called to mind the
picture of the hydropic form of parench3'matous nephritis.
Although the rapid course of the disease urged the assumption of a
malignant process there was no reason for thinking at once of a Lympho-
sarcoma of the small intestine. For, as Kiindrat had already pointed out,
lymphosarcomas do not usually run along with narrowing but with dila-
tation of the intestinal tube.
As autopsy showed, the stenosis was due to adhesion between two
loops of intestine, corresponding to an ulcerating sarcomatous nodule.
The localization of the stenosis also met with difficulties ; the areas of
splashing in the flanks could suggest the possibility of dilatation of the
colon and thus of a stenosis low down (sigmoid flexure .'*) ; the coils of intes-
tine rearing with peristalsis were characterized by particular breadth.
Autopsy, however, showed that the stenosis was situated in the upper
ileum and "permitted of passage of only one finger." The sarcomatous
infiltration of the small intestine had not been palpable during life.
Case 10.— B. C, 25 years, M.
ad 1. — Father died of hemoptysis at 36.
ad 2. — The riglit eye bears evidence of a former keratitis paren-
chymatosa ; Hutchinson teetli.
ad 3. — During childhood had smallpox ; three years ago acquired
syphilis.
354 APPENDIX
ad 5. — Was otherwise healthy.
ad 6. — In February, 1895, there began stomach coniphiints, namely
pain in the epigastrium in connection with meals, lasting about one hour.
Appetite good, bowels regular.
About the middle of March, 1895, edema was noticeable in the feet,
soon also in the legs and thighs. The appetite disappeared; on and off
yellow biliary vomiting. Emaciation.
ad 7. — A pale appearing, frail individual. On the right side of the
neck there is a large, moderately hard, indolent gland. Diminished reson-
ance over both pulmonary apices. Abdomen distended, moderately tense,
not sensitive to pressure; a striking tympanitic resonance over the epi-
gastrium. The spleen passes two finger breadths below the costal arch.
Edema of the belly-wall from the umbilicus downward.
Blood: 2,100,000 erythrocytes, 307r hemoglobin, slight leucocytosis ;
no eosinophile cells can be found.
Stomach contents (vomited) : HCl positive.
Subfebrile course with a single rise of temperature to 38.4- C.
ad 8. — Beginning: February, 189.5.
Status presens: IMay 7, 1895.
Autopsy: May 23, 1895.
Duration: About 4 months.
ad 9. — Autopsy: The upper portion of the jejunum for a distance
of about 60 cm changed into a wide, thick-walled, rigid tube as a result
of Infiltration of the bowel-wall by a milky white, unconunonly soft ma.ss
winch in the portion toward the bowel lumen has partly undergone necro-
tic softening, the intact knobs bulging out. The respective mesenteric
glands are greatly enlarged, uncommonly soft, exhibit pseudo-fluctuation.
Enlargement of all the solitary follicles.
Anatomical diagnosis: Lymphosarcomatosis of the upper end of the
jejunum. Tuberculosis of the lymph-glands. Infiltration of the left pul-
monary apex.
Epicrisis: In this 25-year-old tubercular patient one was tempted to
interpret the abdominal findings as a bowel or peritoneal tuberculosis.
As in Case 1, a tumor-mass was not palpable here, which is probably
explained by the more uniform surface infiltration of the bowel-wall and
by the particular softness of the infiltrating pseudo-mass. The rapid
course of the disease, however, as well as the early appearance and rapid
development of the edemas (thigh and abdominal wall), were remarkable.
BoAvel symptoms did not appear at all, symptoms of constriction es-
pecially being absent ; the epigastric localization of the disease manifes-
tations (pain after meals with much local meteorism) could simulate a
gastric disease, but at autopsy were shown to be due to greatly dilated,
lymphosarcomatous coils of small intestine.
It seems to me that this case illustrates that, In remarkably rapid
cases of apparent peritoneal tuberculosis, accompanied by severe edemas,
the possibility of lymphosarcomatosis of the small Intestine should al-
wavs be borne in mind.
"ATYPICAL" TUMOllS OF THE ABDOMEN 355
Case 11.— Ch. K., 28 years, M. Merchant.'
ad 1. — Mother died of "hardening of the hver" at 4-8.
ad 2. — In cliiidhood always had a pale appearance, swelling of the
cervical glands, intlannnation of the eyes.
ad 8. — Had no infectious diseases of childhood. It is said that in
Deceniher, 1905, he had an eruption on the head, back, scrotum and anus,
with formation of a crust; ulcers also in the mouth. A ten-day inunction
with mercurial ointment and potassium iodid therapy produced im-
provement.
ad 4i. — Always had a disinclination toward fatty foods; they pro-
duce diarrhea. Otherwise the appetite is good and bowels regular.
ad 6. — About the end of September, 1900, there began cramp-like
pain in the abdomen, being localized about the umbilicus ; the abdomen
became somewhat sensitive to pressure. Defecation and urination were
somewhat difficult. The patient himself noticed knobby tumors in the belly.
Toward the end of December, 1906, biliary vomiting. ^leat anorexia
since the end of November (the patient likes to eat ham only). Otherwise
the appetite is good.
ad 7. — January 27, 1907 : Color of the face whitish-gray, no yel-
lowish tint. Hair dark brown ; teeth good. Nodular tumor masses occupy-
ing the greater portion of the inferior abdominal region ; they vibrate
with pulsation, especially those on the left side ; there is also a systolic
vascular murmur. Diffuse splashing in the bowel ; no bowel peristalsis.
No distinct ascites. Anemic heart-murmurs, venous hums, jumping pulse.
No enlarged glands. Retromalleolar edema. Slight temperature rises over
37° C.
March 1, 1907: Severe ascites with hydrothorax and great pallor;
soft edema of the leg and thigh and in the lumba'r region. Tumor-mass
soft, slightly uneven, situated around the umbilicus, covering an area
bigger than the palm of a hand ; over this there is tympanitic resonance.
Extensive splashing on succussion. No symptoms of bowel constriction.
Temperature, as a rule, a little over 37° C.
Feces: Bowel movements daily, copious, of gray color and fatt}' lustre
(no icterus) ; no admixture of mucus or pus. The bowel flora consists
almost exclusively of lactic-acid bacilli, which also yield a rapid growth
on culture.
Urine: Diazo reaction frequently very distinctly positive.
Stomach contents (vomited) : Only isolated rod-shapes resembling
lactic-acid bacilli ; tubular yeast cells.
Blood: 60% hemoglobin, 9,600 leucocytes, of these 17% are large
mononuclear forms.
ad 8. — Beginning: End of September, 1906.
Status presens: January 27, 1907, and March 1, 1907.
Autopsy: April 4, 1907.
Duration : About 6 months.
' See Mitteil. d. Ges. f. innere Med. u. Kinderheilk., Wien, 1907, page 107.
356 APPENDIX
ad 9. — Autopsy (Professor Dr. A. Ghon) : Dilatation, about the
size of a child's head, in the uppermost part of the jejunum; the bowel-
wall in that locality lymphosarcomatously infiltrated. The spleen is small,
the follicles of the tongue not swollen. Kidney is lobulated, the aorta
somewhat narrowed, the thickness of its walls being diminished. Chylifonn
ascites and chronic peritonitis. Chyliform right hydrothorax. Throm-
bosis of the femoral vein.
Epicrisi.s: The following three findings during life prompted me to
make the diagnosis of lymphosarcoma of the small intestine:
1. The presence of soft tumor-masses in the abdomen, the malignant
nature of which could hardly be doubted in view of the accompanying
ascites, severe edemas, etc.
2. The finding of a very abundant flora of lactic-acid bacilli in the
feces with almost negative bacteriological findings in the stomach contents.
This suggested that the peculiar intestinal vegetation was not, as is
mostly the case, of gastric, but of intestinal origin. Combined with the
first finding it led to the assumption of an intestinal neoplasm.
3. The absence of all symptoms of constriction when there were indi-
cations of dilatation of the bowel (constant, extensive bowel splashing on
succussion of the abdomen).
It is well known that precisely lymphosarcomas frequently go along
without symptoms of stenosis.
In addition there was the youthful age of the patient (28 years) ; the
fact that during youth there had been signs of lymphatismus (swelling of
glands! eye inflammations) also entered into consideration.
Autopsy also disclosed congenital peculiarities, in so far as the kidne\'s
were peculiarly lobulated and the aorta was found to be narrow and thin-
walled.
The copiousness of the stools, as well as their fat content, are prob-
ably to be attributed to poor absoi*ptive conditions; for that matter
there was neither diarrhea nor constipation.
Admixtures of mucus, pus and blood were absent, it being hardly
possible to demonstrate any ulceration in the infiltrated area of the
bowel.
The syndrome : "Ascites and diazo reaction," which in other cases is
usually referable to tubercular peritonitis, was in this instance due to
lymphosarcoma.
The high percentage of large mononuclear forms in the blood is de-
serving of note ; it is a symptom which is at least suspicious of lympho-
sarcoma.
The finding of hyperplasia of the follicles at the base of the tongue,
not rare in these cases, was not present in this instance.
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Index
Abdomen, physical examination of, 1
pseudo-malignant diseases of, 10
Abdominal tumors, atypical malignant, 165
Abscess, cold, 12
of abdominal wall In gastric cancer,
77, lot
subphrenic, in gastric cancer, 85
Achlorhydria, 93, 129
Actinomycosis, ileocecal, 12
Addison's disease, icterus in, 10
Addison-like discolorations, 43, 90, 103
Adynamia, 42
Age, 132, 141
in etiology of malignant growths, 49
Aldehyde reaction, 33, 36, 130
in biliary obstruction, 35
significance of, 36, 37
Alimentation, effect of, on pain, 71
Amyloidosis, 131
Anemia, pernicious, 10, 87
Anesthetics, 1
Angiosderosis, 89
Anorexia, 75, 129, 149
Aorta, abdominal, 5
in cancer of the pancreas, 150
origin of murmurs, 5
Appendicitis, 122, 154
Appendix, cancer of, 168
Appetite in gastric cancer, 74
Ascites, 5
examination of umbilicus in, 5
in cancer of the gall-bladder, 139
in cancer of the pancreas, 150, 152
in gastric cancer, 85
in hepatic cancer, 129
in ovarian tumors, 169
Atelectasis of lungs in gastric cancer, 89
Atheromatous changes in gastric cancer, 86
Atrophy of lingual mucosa, 83
Auscultation, in gastric cancer, 81
in cancer of large intestine, 116
in renal neoplasms, 158
Azotorrhea, 148
Bacilli, lactic-acid, 20, 24, 92
Back, pains in, 71
Bacterium coli, in gastric cancer, 29, 92
Balloon-like stomach, 76
Ballottement, 4
in corset lobes of liver, 4, 138
in stomach timiors, 4, 80
of kidney tumors, 157
Biliarj' congestion, 35, 134
Biliary obstruction, 35
Bladder, urinary, 2
in intestinal" cancer, 119
in kidney tumors, 160
Blood in feces, chemical i)roof of, U
in gastric cancer, 63, 91, 132
Bone tumors, 105, 120, 163
Borborygiui, 81
Bradycardia, 86
Breathing, diaphragmatic, 3
Cachexia, 37
Calculi, 142, 151
Cammidge reaction, 148
Cancer and tuberculosis, 53
Carcinomaphobia, 59
Cecum, tuberculosis of, 123
Cell disposition, 47
Cercomonas intestinalis, 28
Chemical irritants, 53
Cholangitis, 31, 142
Cholelithiasis, 31, 135, 154
Circulatory system in gastric cancer, 85
Cirrhosis, Laennec's, 5, 32, 130, 144
biliary, 131, 142, 151
enlargement of epigastric veins in, 5
in etiology of cancer, 51
Climate, 52, 59
Coated tongue, 83
Cocci, in neoplasms of the bowel, 30
in pernicious anemia, 30
Coffee-ground vomiting, 69, 91, 112, 129
Cohnheim's theory, 47
Colic, attacks of,' 106, 122, 134
gall-stone, 140
Collateral circulation, portal, 127
Colon bacillus, 30, 92
Colon, carcinoma of, 105
Colon, in renal tumors, 157
Color of face, 40
Constipation, 84, 123, 139
Course of gall-bladder cancer, 141
Course of gastric cancer, 98
Course of intestinal cancer, 121
Course of kidney tumors, 160
Crises, gastric, 16
Cystic kidney, 164
Danger of infection in cancer, 57
Deglutition, difficult, in gastric cancer, 83
Desmoidrcaction, Sahli's, 96
Diabetes mellitus, 152
Diagnosis of gastro-intestinal cancer, early,
63
Diaphragmatic tumors, 167
357
358
INDEX
Diarrhea in jrastric canci-r, 84
Diathesis, heinorrliagic, 17
in etiology of growths, Ki, 51
Diazo reaction, 30, 32, 144
Differential diagnosis, in cancer of gall-
bladder, i:}(), 141, 14i2
in cancer of large intestine, l-2\
in cancer of liver, 130
in cancer of pancreas, 151
in cancer of stomach, 99
in kidney tumors, 161
Digital examination of the rectum, 113
Discolorations of the skin, A3
Distention i)ains in gastric cancer, 70, 73
Disturbances of gastric motility, 64
Ductus cl)oled(K-hus, 135, 152
Duodenal cancer, 168
Duodenum, in cancer of the i)ancreas, 152
Duration of gastric cancer, 98
of cancer of tiie gall-bladder, 140
of cancer of the large intestine, 121
of kidney tumors, 160
Echinococcus cysts, 132, 142
Edema, 43, 88 '
latent, 43, 90
Effervescent mixtures, 2
Effusion, hemorrhagic ])leural, 10
Emaciation, 38, 40
Endocarditis, 104
Endogenous causes of neoplasms, 49
Enteric fever, diazo-reaction in, 31
Epigastric jnilsation, in gastric cancer, 77
Eructation of gas, 67
pjsophageal varices, 131
Esophagus, carcinoma of, 104
Etiology of malignant tumors, 45
Exogenous injuries exciting inflammation,
47
Exogenous local causes of neoplasms, 53
Exudate, inflammatory, 12
in appendicitis, 12
Face, color of, 90
Febrile urobilinogenuria, 35
Fecal vegetation in neoplasms of the
bowel, 29
Feces and stomach contents in gastric can-
cer, 90
Feces in cancer of the large intestine, 117
Fecundation theories, 46
Fever, 44, 121, 123, 135, 160
Fibroma, 11
Fibrosarcoma, 11
Fistula, rectovesical, 12, 119
Friction, perihepatic, 142
Friction-sounds, peritoneal, 5, 81, 129
Fulness, gastric, 65
Gall-bladder, 158
carcinoma of, 105, 124, 133
early symptoms in cancer of, 133
physical examination of, 136
Gall-stones, 53
Gastralgia, 73, 146
Gastric cancer, beginning of, 163
Gastric stagnation, symptoms due to, 65
Gastric ulcer, 53, 101
Gastritis, chronic, 93
Genito-uriiiary system in gastric cancer, 88
Glycosuria, in cancer of the pancreas, 150
Gout, acute, 101
Gram-positive bacilli in feces, 24
Gumma, liver, 13, 132
Gurgling, 72
Hallux valgus, 90
Hausemann's anaplasia, 49
Heartburn, 68
Heberden's nodes, 90
Hematogenous urol)ilinogenuria, 35
Hematuria, 154, 155
Hemiplegia, 103
Hemorrhage, occult intestinal, 8
after lavage of stomach, 17
arrest of, improl)abilitv of malignancy,
18
from gums, 16
from nose, 16
from i)iles, 16
in cancer of large intestine, 112
in cancer of jiancreas, 149
in cicatricial jnloric stenosis, 17
Hemorrhagic diathesis, 17
Heredity, 50
Hernias in linea alba, in gastric cancer, 77
Hi)i|>ocratis, succussio, 4
Hydrochloric acid, 70, 74, 93, 96
Hygiene, general, in cancer, 89
local, in cancer, 58
Hyperleucocytosis, 144
Hy])ernephroma, 154, 158
Hyi>ochlorhydria, signs of, in feces, 96
Icterus, catarrhalis, 151
in cancer of the ]>ancreas, 146
in gall-bladder cancer, 135, 141, 142
in gastric cancer, 85
in hepatic cancer, 127, 132
Ileus, acute, 123
Increase in weight, 39
Indican, 144, 148
Infectious diseases in etiolog}' of cancer,
52, 56, 86
Inflammation, chronic, in etiologj'^ of can-
cer, 54
Inflation of stomach, 2
Insomnia, 89
Intestinal peristalsis, in gastric cancer, 76»
84
Intestinal tract, sjinptoms from, in gastric
cancer, 84
Intestine, large, carcinoma of, 106
Iris, 89
Irritants, chemical, 54
Kidney, artificial dislocation of, 156
cystic, 164
malignant tmnors of, 153
physical examination of, 156
INDEX
359
Kidney, respiratory iii<>l)ility of, 157
thherciilosis ot. Hi J
urinary sediment in tumors of. IM
Klel)S, fecundation tiieory of. Hi
Lactic-acid bacilli, 21, 22, 23
culture of, 25
diagnostic significance of, 25
Gram stain, 24
Large intestine, carcinoma of, 106
early symptoms in cancer of, 10(5
feces and stomach contents in cancer
of, 117
physical examination in cancer of, 113
Latency of gastric tumors, 78, 99
Lavage, 17, (U, 90
Leptothrix, 23, 24
Leucocytes, in hepatic cancer, 130
Lingual mucosa, atro])hy of, 83
Linitis plastica Brinton'. 29, 80, 85
Lipoma, submucous, 11
Liver, abscess of, 103
carcinoma of, 125
corset lobes of, 10, 123. 137
fatty, 130
gastro-intestinal svuijitoms in cancer
of, 129
in cancer of the pancreas, 150
in gastric cancer, 85, 89
in intestinal cancer, 120, 124
physical examination of, 127
Local hygiene in cancer, 58
Loss of weight, 38
Lues, in etiology of cancer, 53
I-umljago, "pseudo," 153
Lumbar region, pain in, 71, 109
lAmgs, in cancer, 89
LjTnphatic system in gastric cancer, 87
Lymph-glands in intestinal cancer, 120
Lymphogenous metastasis, 159
LjTiiphosarcoma, 1(55
Mechanical traumas in etiologv of cancer.
53
Megastoma entericum, 28
Melanosis, 90
Melanin, 130
Melena, alimentary, 15
in cancer of the pancreas, 149
Meningitis, 104
Mesentery, 81
Metastases, in gastric cancer, 88, 89
in kidney tumors, 159
lymph-giands, 120, 139
Meteorism, gastric, ()9
Microscopical examination, of stomach con-
tents, 95
of feces, 118
Mind and emaciation, 38
Mind, in etiology of cancer, 52
Moliihty of gastric tumors, 80
of gall-l)ladder tinnors, 137
Motility, disturbances of gastric, (54
Motor ap])aratus. 90
Motor fimction of bowel, disturbed, 110
.MiunniificatiMii, H!), i»7
Murmurs in renal tumors, 158, 1(53
Murmurs, systolic, in gastric and liej>atic
cancer, 5, 82, 8(5, I2H
systolic, in cancer of pancreas. 150
Musclc-fil)res in tVct-s, U!)
Nclaton tumor, II
Nei)hritic sedimentary findings, 15(»
Nephritis, 1(53
Nepiirolithiasis, 1(52
Nervous system in gastric cancer, 89, 90
Neuralgia, 103
Neurasthenia, 39, 103
Neuroses, gastric, 101
Neutral fat, 144, 148
Night-sweats, 44, 90, 121
Obstijiation in gastric cancer, 84
in gali-l)ladder cancer, 139
in intestinal cancer, 123
Occult renal hemorrhage, 155
Omentum, infiltrated, 81, 138
sj)ontaneous swellings of, 13
tiunors of, 1G8
tumors of, after herniotomy, 13
tiunors of, after pelvic peritonitis, 13
Ovaries, tumors of, 105, 169
Ovum, 46
Pain, cessation of, in beginning cancer, 74
in cancer of the pancreas, 145, 151
in gall-bladder cancer, 133, 141
in gastric cancer, 69
in bcjiatic cancer, 128
in intestinal cancer, 106
Paleness, 41
Palpation, 1, 2
in gall-bladder cancer, 136
in gastric cancer, 78
in intestinal cancer, 113
of ividney tumors, 163
Pancreas, carcinoma of, 144, 145
Pancreatic juice, obstructed flow of, 146
Papilla of Skater, 144, 152
Percussion, 5
in gastric cancer, 81
in intestmal cancer, 116
Peristalsis, visible gastric, 76
intestinal in gastric cancer, 84
in intestinal cancer, 114
Peritoneum in gastric cancer, 85, 101
in intestinal cancer, 120
Pernicious anemia. 102
Pigment anomabes, 40, 42 ♦
Pigmentation of skin in cancer of ])an-
creas, 150
Plethora in cancer, 41
Pleural complications in gastric cancer. 88
Pleuritis, 132
Polypi, 6
Polyuria, 88
Portal veins, co-ieestion of bleeding in. 17
thrombosis of lileeding in. 17
Positions, painful. 109
3(50
INDEX
Primary cholangitis, 142
Prophylaxis of malignant tumors, 57
Pulsation of tumors, 114
epigastric, 77
Pylorus, cancer of, 9-2
liver dulness in stenosis of, 5
spasms of, 78
stenosis of, 5, 17, 144
Pyonephrosis, 1()4
Questions in history-taking of cancer pa-
tients, 55
Radiology, 7, 8
and quackery, 7
dangers in, 7
in etiology of cancer, 54
psychological factor in, 7
Hectoronianoscopy, 6
Rectum, carcinoma of, 105, 113, h22, 124
Regurgitation, ))hcnomena of, 67
Renal hematuria, 155, 162
Renal ischias, 154
Renal neoplasms, 105, 123
Respiratory mobility, 3, 157
Retrojieritoiieal ghi'nds, 139, 151, 165, 169
Rihbert's theory, 48
Riegel's test, 94
Sahli's desmoid reaction, 96
Salivation, in gastric cancer, 83
Saproi)hytes, 20
Sarcinae, 6
diagnostic significance of, 27, 67
Good sir, 21
in cancer of the pancreas, 149
of the stomach, 26, 92
Sarcoma, 165, 167
Schaper's indiftVrcnce zones, 48
Scrotal pain in kidney tumors, 154
Scyhala, 3, 10
Secondary infections, 32
Secretions, state of, in gastric cancer, 93
Skin, in gastric cancer, 89
Skin pigmentation in cancer of pancreas,
150
Small intestine, cancer of, 167
Smell, in diagnosis, 6
"Soft" hepatic cancer, 127
Specific causes of disease, 45
symptoms, 25
Spirochetes, in neoplasms of the bowel, 30
Splashing sounds, 4
Spleen, tumors of, 165
in cancer of pancreas, 150
in gall-bladder cancer, 140
in gastric cancer, 87
in hepatic cancer. 130, 132
in tumors of the kidney, 158, 163
Sputum, hemorrhagic, 16
Squirting sounds, 78
Stagnation, gastric, 91
Stasis of biliary and pancreatic secretions,
146
Status Ivmphaticus, 165
Steatorrhea, 148
Stomach, carcinoma of, 63
constitutional peculiarities in cancer of,
76
contents, examination of, 95
contents in gastric cancer, 90, 117
early symptoms in cancer of, 63
hour-glass, 8
in kidney tumors, 160
physical examination in cancer of, 76
resection, 93
sarcoma of, 167
spastic hour-glass, 8
Stools, in cancer of large intestine, 117
Strumous nodules, 87
Suprarenal disease, 42
Suprarenal tumor, 164
Symjitomatology of cachexia, 37
Symptoms, gastric and intestinal in gall-
bladder cancer, 138
gastro-intestinal in hepatic cancer, 129
Syphilis, in etiology of cancer, 53
Tachycardia, Sd, 139
Teeth, in gastric cancer, 83
Teint jniille jaunc, 40
Tem])eraturc of body in malignant condi-
tions, 44, i;{5
Tenderness on pressure, 73, 109, 126
Test. Esbach's, 64
Mueller and Schlecht, 147
Salomon's, 64
Weber's, 15
Testicle, timiors of, 169
Tetanic attacks, 89
Theories of fecundation, 46
C'ohnlieim's. 47
Ribbert's, 48
Thiersch's, 49
Thermophore, 1
Thirst, in gastric cancer, 75
Thrombosis, in gastric cancer, 87
Toepfer's reagent, 94
Tongue, coated, 83
Transmission of gastric cancer, 50
Traumas, in etiology of cancer, 51, 53
Trichobezoar, 11, 101
Tubercular serositis, 102
Tuberculosis, senile, 10, 103
gland, in abdomen. 12
in differential diagnosis, 102
of peritoneum, 3
omental, 12
predisposing to cancer, 50, 53
renal, 162
Types, of gall-bladder cancer, 140
of gastric sarcinae, 27
of gastric tumors, 79, 88, 97
of intestinal cancer, 121
of kidney tumors. 160
of lactic-acid bacilli, 24
of pain in eastric cancer, 70
INDEX
361
Uffelmann's test, 94
Ulcer, gastric, 2, 53, 101
Uratic diathesis, 51
Ureteral colics, 154
Urinary analysis, 38
Urobilinogen," 33, 42, 34
Urobilinogenuria, 35, 135
Valvular lesions in gastric cancer, 86
Varicocele, 120, 159
Vegetations, gastric, in feces, 21, 29
Veins, enlargement of epigastric, 5
Vena cava, conij)ression of, 139
Vertebral column, pains in, 71
Virchow's gland, 87
Visible gastric peristalsis, 76
\'oiiiitiiig, ((iflcc-ground, 69, 91, 112, 129
feculent, 69
in gall-hladder cancer, 134
in gastri<' cancer, 68, 91
in intestinal cancer, 112
Warm bath in examination of abdomen, 1
Watery eructation, 68
Weight, 38
X-rav examination, 7
Midsummer, 1913
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