544 DISEASES OF THE STOMACH. 



pends on obstruction of the femoral vein, and shows that, in conse- 

 quence of the retarded circulation, a clot has formed in it. More rarely 

 death occurs from a rapid peritonitis, after perforation of the stomach. 

 Still more rarely, copious haemorrhage from the stomach hastens the 

 exhaustion, or, by its extent, causes sudden death. Finally, death 

 may be caused or hastened by complications and secondary diseases. 



DIAGNOSIS. In cases where the epigastrium is painful, where there 

 is frequent vomiting, occasionally of substance looking like coffee- 

 grounds, where there is a tumor in the epigastrium, the diagnosis of 

 cancer of the stomach from chronic catarrh is easy. If these symp- 

 toms be absent, particularly the tumor, which Andral maintains is the 

 only certain sign of cancer of the stomach, the differential diagnosis 

 of these two diseases may be very difficult. In forming an 'opinion, 

 the age of the patient is important ; besides this, we often can only 

 judge from the general condition. 



The diagnosis from chronic ulcer of the stomach, also, is sometimes 

 easy, again very difficult. In one well-known case, two medical celeb- 

 rities, Oppolzer and Schoenlein, could not agree whether there was 

 cancer or ulcer of the stomach. In the differential diagnosis, the factors 

 chiefly to be regarded are the following: 1. The age of the patient; 

 in young persons, cancer may be excluded almost with certainty. 2. 

 The duration of the disease ; if it has existed more than a year, the 

 probabilities are against cancer. 3. The strength and condition of the 

 patient ; in ulcer, these are often affected but little, and not till late in 

 the disease, while in cancer they are greatly impaired very early. 4. 

 The character of the pain ; cardialgic attacks indicate ulcer rather than 

 cancer. 5. The condition of the blood vomited ; in ulcer of the stomach, 

 it is in large quantities, and hence slightly changed, while in cancer the 

 amount is usually scanty, it is black, and looks like coffee-grounds ; 

 still, in some cases of cancer, there is abundant vomiting of blood, and 

 with an ulcer of the stomach there may be ejection of black, grumous 

 masses. 6. The presence or absence of a tumor ; the former proves 

 almost certainly that there is cancer, for the cases where thickening of 

 the walls of the stomach and connective-tissue growths, in the vicinity 

 of an ulcer, cause a tumor, are exceedingly rare. But, on the other 

 hand, we must not forget that absence of a tumor does not prove that 

 there is no cancer. 



The variety of the cancer can rarely be determined with any cer 

 tainty during life. Alveolar cancer, being the rarest variety, is onlj 

 to be suspected where the disease runs a very slow course, and when 

 there is ascites. The diagnosis becomes more certain if, after tapping, 

 nodular masses can be felt in the omentum. If these symptoms are 

 absent, we must suspect scirrhus or medullary cancer. The more acute 



