422 



STOMACH AND INTESTINE. 



date, and more considerable in amount. After 

 the disease has thus fused into one mass the 

 muscular and mucous coats, thedistention and 

 vascular disturbance undergone by the latter 

 gradually effects its disorganization. Its epi- 

 thelium becomes detached; its surface ulce- 

 rates or sloughs ; and more or less haemor- 

 rhage is excited. At this time, if not before, 

 the cancerous process is generally so far mo- 

 dified, as to give rise to the deposit of the 

 medullary instead of the scirrhous variety. 

 The eroded surface of the tumour thus be- 

 comes the site of a bleeding fungous growth ; 

 the haemorrhage from which, more or less 

 altered by the fluids of digestion prior to its 

 being ejected from the stomach, gives rise to 

 the characteristic coffee-coloured vomiting 

 which is almost always present in the latter 

 stages of the disease. The metamorphosis of 

 the cancerous mass is generally followed by 

 sloughing or ulceration, either of which may 

 end in the perforation of the organ. But this 

 event is sometimes prevented by the adhesion 

 of the peritoneal surface of the stomach to 

 neighbouring structures; and is, perhaps, still 

 more frequently staved off by the continuous 

 deposit of new cancerous matter beneath and 

 around the ulcerating mass. The perforation 

 of the gastric parietes may give rise to an abnor- 

 mal communication between the stomach and 

 some neighbouring segment of the canal : for 

 example, the transverse colon, or some part 

 of the small intestine. Or it may even open 

 on the exterior of the belly ; or penetrate the 

 thoracic cavity. 



The medullary form of cancer, which is not 

 unfrequently seen as a secondary deposit at 

 the surface and margins of the scirrhous mass, 

 sometimes occurs independently, as a con- 

 tinuous or discrete deposit in the submucous 

 areolar tissue. It offers its ordinary charac- 

 teristic structure and appearance. 



The areolar form is also more frequently 

 secondary than primary. It is by no means 

 uncommon to find the hard scirrhous texture 

 of the centre of the cancerous pylorus merge 

 into a fibrous network as it approaches the 

 inner surface of the organ; a network the 

 large meshes of which are filled with a ge- 

 latinous mass. The fibres which constitute 

 these meshes are generally long, pale, and ex- 

 tremely delicate ; and their narrow outline is 

 here and there bulged by persistent develop- 

 mental cells. The gelatinous mass which 

 they enclose consists of cells, which are often 

 large and compound ; sometimes caudate, or 

 pigmentary. It is possible that this structure 

 is to some extent produced by a true me- 

 tamorphosis of the previous scirrhus : its 

 fibres being multiplied, at the same time 

 that they are enlarged and distended by 

 the deposit, between and amongst them, 

 of a soft mass of cells. In some instances 

 we find evident traces of a development of 

 new fibres, which gradually break up the 

 primitive loculi into secondary cells. The 

 most superficial or internal of these loculi 

 project from the mucous surface into the ca- 



vity of the stomach; where they often become 

 the seat of a medullary or fungous growth, 

 which undergoes ulceration and haemor- 

 rhage. 



Stricture of the intestine. The most fre- 

 quent cancerous affection of the large intes- 

 tine is a scirrhous deposit, which more or 

 less encircles the tube, The extent to which it 

 passes round the circumference of the canal is 

 determined chiefly by its primary or secondary 

 nature. In the former case, it is a complete 

 circle. In the latter case, it generally forms 

 but part of a circle ; and occupies that side of 

 the intestine, which is nearest to the gland or 

 other neighbouring texture, from which the 

 disease may have been derived. 



In either kind of scirrhous stricture, the 

 deposit may subsequently extend, for a va- 

 riable distance, in the direction of the length 

 of the canal. But so long as it remains li- 

 mited to a simple annular mass of gristly 

 scirrhus occupying the submucous tissue, its 

 chief effect is that of narrowing the canal. 

 The influence of this narrowing on the 

 neighbouring segments of the bowel is at first 

 merely the mechanical obstruction which it 

 offers to the transit of the intestinal contents. 

 Where this obstruction amounts to a complete 

 occlusion, it is speedily fatal : the intestine 

 above the stricture becoming enormously dis- 

 tended by its contents; and undergoing in- 

 flammation, gangrene, or even rupture, as the 

 result of this distention. A slower process 

 of constriction, or a less complete obstruction, 

 generally give rise to a combination of a si- 

 milar dilatation, with a variable degree of 

 hypertrophy; the latter change being often 

 carried to such an extent as greatly to increase 

 the thickness of all the coats of the bowel, 

 and especially of the muscular tunic. 



The obstruction is often increased by the 

 way in which the diseased part of the in- 

 testine becomes abnormally united with neigh- 

 bouring viscera or walls of the belly, In the 

 secondary form of scirrhus, the mass is of 

 course attached and fixed, almost at the very 

 commencement of the process of deposit. But 

 in the primary form, it may remain free until 

 a comparatively late period of the disorder; 

 when the weight of the tumour often causes 

 the bowel to gravitate into a more or less 

 unnatural position. In either case, its oc- 

 currence often alters the course of the canal, 

 by bending it at an acute angle opposite to 

 the adherent part. The bowel is thus placed 

 at a still further disadvantage for the trans- 

 mission of its contents. 



The subsequent progress of the disease 

 requires little notice. The growth of a me- 

 dullary fungus, or the deposit of a colloid or 

 areolar mass upon the surface of the ulce- 

 rated stricture, may of course increase the 

 obstruction which the latter produces. Or, 

 conversely, its sloughing or ulceration may 

 restore the permeability of a previously al- 

 most occluded canal. Finally, the exten- 

 sion of the disease upwards, into the dilated 

 segment of intestine above the stricture, may 



