The Early Recognition and 
Management of Malignant 
Disease op the Digestive 
. 1 System. 
BY 
MAX EINHOKN, M. D. 
KBPBINTEU FROM THE 
Weto Yorfe .ptctncal 3ouvn:al 
for July 29, 1899. Reprinted from the New TorJc Medical Journal 
for July 29, 1899. 
THE EARLY RECOGNITION AND 
MANAGEMENT OF MALIGNANT DISEASE OF 
THE DIGESTIVE SYSTEM.* 
MAX EINHORN, M. D. 
Malignant diseases or growths of the digestive 
tract comprise the different types of cancer and sar- 
coma. As the latter are much less frequent, and usu- 
ally present similar symptoms and consequences as the 
former, we will limit our remarks to cancer. 
Cancer has always been recognized as the gravest 
of diseases, bringing with it the surest prospect of 
death. This axiom remains true even to-day, with the 
only difference that we must add, “ if not interfered 
with surgically.” 
Surgery has indeed achieved its greatest triumphs 
in the removal of malignant diseases (tumors) in their 
early period of development, thus checking their fur- 
ther spread. Cancer of the breast and of the uterus 
are nowadays operated upon usually with a fair chance 
of non-recurrence of the growth. 
* Read before the Fifth District Branch of the New York State 
Medical Association, at its fifteenth annual meeting, held in Brooklyn, 
May 23, 1899. 
Copyright, 1899, by D, Appleton and Company- 2 
MALIGNANT DISEASE OF DIGESTIVE SYSTEM. 
These successful operations show that cancer is 
primarily a localized and not a systemic disease, as was 
formerly believed. 
The more deeply the malignant growth is situated, 
the more difficult becomes its recognition and the less 
fruitful, even its surgical treatment. For cases of non- 
recurrence of malignant diseases of the digestive tract 
(with the exception of the anus and rectum) are as yet 
extremely few. This, however, is not the surgeon’s 
fault, but rather that of the clinician. For, judging 
from analogy, malignant tumors, if discovered early 
enough, should be just as successfully removed from 
the digestive tract as elsewhere. It is, therefore, the 
just aim of the clinician to perfect his diagnostic abil- 
ity with regard to malignant disease. 
The stomach tube, and in conjunction with it the 
chemical analysis of the gastric contents have marked 
a decided advance in this direction; transillumination 
of the stomach may also, in favorable instances, be 
of some service. But we must concede that our meth- 
ods are still comparatively crude, and as a rule per- 
mit us to recognize the malignant affection at a stage 
when it has already progressed to a considerable 
extent. 
Before discussing the diagnosis it may not be amiss 
to make a few remarks with regard to aetiology. 
The aetiology of cancer has been investigated by 
numerous scientists all over the world. But, unfor- 
tunately, the goal has not as yet been reached. Cohn- 
heim’s theory of the origin of tumors by embryonic cells 
which have remained dormant and at a certain period 
awake with renewed energy to attain gigantic devel- 
opment, is known to us all. A similar theory has been MALIGNANT DISEASE OF DIGESTIVE SYSTEM. 
3 
recently propounded by Eibbert, who assumes that a 
tumor develops from cells which accidentally have 
stm-ed from their place of origin and have been carried 
into some other tissue. Being foreign elements they 
extend their growth, not heeding the neighboring or- 
gans. Neither of the two theories has found general 
acceptance. Sporozoa have been believed by some 
writers (Pfeiffer, Hutchinson, Park, Metschnikoff) to 
be the cause of cancer. But these so-called parasites 
which have been discovered in cancerous tissue are most 
probably nothing else than degenerated and dried-up 
portions of cells, and nothing has as yet proved their 
real parasitic nature. 
One factor which, though not directly concerned in 
the origin of cancerous tumors, creates a decided pre- 
disposition for their development, is repeated irrita- 
tion. This [etiological factor has been established 
through numerous statistics, and it seems to me to be 
most pronounced in the digestive tract. Those places 
along the digestive canal which are subjected to the 
most marked mechanical irritations are also most often 
the seats of malignant disease. Thus the stomach, 
which receives the food in a comparatively coarse state 
and is exposed to great mechanical as well as chemical 
irritations, is, according to Virchow, the organ most 
often attacked with cancer. And here, again, the car- 
dia, and especially the pylorus, are chiefly involved. 
The cardia is subjected to the friction of the food pass- 
ing through it, while the pylorus is constantly irritated 
by the acid chyme as well as by some coarse particles 
of food which, by the churning motions of the stomach, 
are constantly carried toward that outlet without pass- 
ing it. The small intestine, through which the chyme 4 
MALIGNANT DISEASE OF DIGESTIVE SYSTEM. 
passes in its greater part in liquid form, is very seldom 
attacked with cancerous disease; while the large bowel, 
in which the fascal matter assumes a more solid consist- 
ence, shows already a greater percentage of cancerous 
disease. These relations are best demonstrated by the 
statistical data given by our worthy president, Dr. J. D. 
Bryant. In a hundred and ten autopsies of patients 
suffering from intestinal cancer this writer found the 
neoplasm located six times in the small intestine, seven 
times in the csecal and ileo-ctecal regions, nine- 
teen times in the transverse colon, and seventy-eight 
times in the sigmoid flexure and rectum. 
I shall now describe in a cursory manner under 
what conditions the diagnosis of cancer of the different 
parts of the digestive apparatus is justifiable; 
I. Oesophagus and Cardia.—Gradually developing 
dysphagia and the presence of a stricture in the oesoph- 
agus, especially if a particle of tumor showing the char- 
acteristics of cancer has been brought up with the tube, 
or the above symptoms, with frequent small haemor- 
rhages, make the diagnosis of malignant disease posi- 
tive. 
11. Stomach and Pylorus.—With reference to the 
stomach and pylorus I * have suggested the following 
rules upon which to base a positive diagnosis of can- 
cer : 
1. If particles of tumor are found (in the wash wa- 
ter or in the tube) which under the microscope reveal 
the characteristic picture of a malignant growth. 
2. The presence of a more or less large tumor with 
an uneven surface, belonging to the stomach and asso- 
ciated with dyspeptic symptoms. 
* Max Einhorn. Diseases of the Stomach, first edition, p. 273, MALIGNANT DISEASE OF DIGESTIVE SYSTEM. 
5 
3. The presence of a tumor associated with frequent 
hasmatemesis. 
4. Constant pains, frequent vomiting, ischochymia, 
emaciation—all these symptoms being quite permanent 
and not extending over too long a period of time (six 
months to a year). 
5. Tumor and ischochymia. 
6. Emaciation, ischochymia, presence of lactic acid. 
7. Constant anorexia and pains, not yielding to 
treatment, accompanied by frequent small hemorrhages 
of coffee-ground color. 
111. Small and Large Intestines.—For the small 
and large intestines the following points will prove of 
service in making the diagnosis of cancer: 
1. If by abdominal or rectal palpation a tumor can 
be detected which is situated in the small or large 
bowel, and accompanied by symptoms of cachexia and 
disturbances of defecation. 
2. The presence of a tumor as just described, and 
the discovery of small particles of the neoplasm in the 
evacuation giving microscopically the appearance of a 
cancerous growth. 
3. Gradually increasing disturbances of the bowel 
for a few months in a heretofore healthy person, accom- 
panied by cachexia and symptoms of a beginning or 
already developed stricture of the bowels, and the pres- 
ence of a small particle of growth in the stools giving, 
as above, microscopically, the picture of cancer. 
After having thus summarized the conditions under 
which a positive diagnosis of malignant disease of the 
digestive system can be made, let us see how the diag- 
nosis can be established early. There are no new points 
which I can suggest for this purpose. A thorough 6 
MALIGNANT DISEASE OF DIGESTIVE SYSTEM. 
examination of the physical state of the patient—pay- 
ing strict attention to all our usual methods in this 
direction—and a full knowledge of the history of the 
case, will permit us to discover malignant disease 
comparatively early. In quite a number of instances 
we shall not be able to make a positive diagnosis of 
cancer, hut our suspicions of a malignant trouble will 
be aroused. Here frequent examinations and further 
observation of the case are of intrinsic value. Some- 
times examination under narcosis may afford better 
results. In rare cases, in which a probable diagnosis of 
malignant disease can be made, an exploratory laparot- 
omy with the view of establishing the diagnosis and 
performing a radical or palliative operation will be re- 
quired. 
Having made the diagnosis of malignant disease, 
the question arises, What shall be done for the patient ? 
The following may be given in brief as an answer ap- 
plicable to the digestive system in general: 
1. Whenever the tumor is accessible for operation, 
and there is the slightest hope of curing the patient, 
the complete extirpation of the growth should be per- 
formed. 
2. If the tumor is not accessible for operation, or 
the entire removal of the malignant disease is practical- 
ly impossible, palliative operations which serve to allevi- 
ate suffering and prolong life should be undertaken in 
cases requiring them. 
3. Cases of malignant disease operated upon, as well 
as those without operation, require for their treatment 
and management a skillful physician, who is able to 
lessen suffering and nearly always also to lengthen life, 
even under the most trying conditions. MALIGNANT DISEASE OF DIGESTIVE SYSTEM. 
7 
After these general statements, permit me to say 
a few words with regard to the special management 
of malignant disease in the different portions of the 
digestive tract. 
Cancer of the oesophagus and cardia does not for 
the present permit of any radical operation. As soon 
as the diagnosis is positive and the dysphagia is such 
that the patient is not able to partake of sufficient 
liquid and semiliquid food, in order to maintain his 
weight, gastrostomy should be performed wherever 
feasible. 
Cancer of the stomach and the entire intestinal 
tract should be operated (i. e., removed), if discovered 
early enough. Practically the outlook for a cure after 
a radical operation of some portion of the intestinal 
canal becomes less encouraging the farther away from 
the anus the tumor is situated. Malignant disease of 
the pylorus can often he recognized quite early through 
the ischochymia which it usually produces. In these 
instances a laparotomy should be performed as soon as 
possible and the pylorus resected, with establishment of 
a new communication between stomach and duodenum 
if possible; if not, a gastroenterostomy alone should be 
made. The latter operation is in many cases of decided 
benefit, facilitating nutrition and rendering the pains 
less. 
Cancer of the lesser curvature of the stomach or of 
the posterior wall is usually recognized quite late, ren- 
dering radical operations practically impossible. If 
cardia and pylorus are not involved, there will be no 
need of any operation, and the usual palliative reme- 
dies should he administered. The same may he said 
also of cancer of other portions of the stomach not in- 8 
MALIGNANT DISEASE OF DIGESTIVE SYSTEM. 
volving either cardia or pylorus, in which a radical oper- 
ation does not appear possible. 
Cancer of the rectum can be recognized at an early 
stage, and resection of the neoplasm is here accompa- 
nied by brilliant results. If the tumor is located farther 
up in the large bowel or the small intestine the results 
of an operation are not so promising, for here the recog- 
nition of the growth is possible only at an advanced 
period, and by that time often adhesions with other or- 
gans and cancerous infection of the glands have already 
taken place. 
Excision of the tumor and resection of the intestine 
in the neighborhood of the neoplasm, with an end-to-end 
anastomosis, should be practised whenever feasible. In 
case, however, total resection is impossible, an entero- 
enterostomy or enterocolostomy, or, if the cancer is situ- 
ated in the rectum, a colostomy (artificial anus) will be 
of benefit. These operations are palliative in nature 
and prolong life, at the same time making it more 
comfortable. They are intended to allay the symptoms 
of obstruction and to carry the faecal matter over a new 
route, not passing through, and thus not irritating the 
cancerous area. In some instances of inoperable can- 
cer of the rectum curettage, followed by the application 
of the thermo-cautery, may be of benefit for a short 
period. 
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