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BENIGN TUMORS OF THE

JAMES F. MINNES, M.D., AND CHARLES F. GESCHICKTER, M.D. (From the Surgical Pathological Laboratory, Department oj Johns Hopkins Hospital)

Benign tumors of the stomach, though of more infrequent occurrence than malignant growths of that organ, are sufficiently common to warrant atten­ tion. In recent years an extensive literature has accumulated on their inci­ dence, pathological and clinical features, and roentgen diagnosis. They are frequently confused clinically with malignant and inflammatory , and may give rise to complications which demand immediate surgical intervention. It is the purpose of this paper to review briefly the literature and to present the clinical and pathological features of 50 benign tumors of the stomach recorded in the Johns Hopkins Hospital from 1889 to the present day.

TYPES AND INCIDENCE Benign tumors may arise from any of the several coats of the stomach: the mucosa, submucosa, muscularis, or serosa. According to the of origin they may be divided into two groups: epithelial and mesenchymal. Among the epithelial tumors are , adenopapillomas, adenomyomas, and fibro-adenomyomas. Chief among the mesenchymal tumors are the leio­ myomas, , , neurofibromas, and the rare and osteo­ mas. Finally there is a group of lesions which are not truly neoplastic but are usually included with tumors. These include -simple blood or lymph cysts, dermoid and echinococcus cysts-and rarely embryonic rests of the pancreas. The absolute incidence of these benign tumors, as well as their relative frequency as compared with malignant gastric tumors, is difficult to determine. Eusterman and Senty reported a series of 27 benign tumors, which represented 1.3 per cent of all gastric operated on at the Mayo Clinic between 1907 and 1921. In 1932 Lockwood stated that nearly 1,000 cases had been reported; his series of 12 constituted 4.5 per cent of all gastric neoplasms seen in a period of seven years. This is in accord with the findings at the University of Minnesota, where it has been estimated that 5 per cent of all gastric tumors are benign. In 1925 Eliason and Wright were able to collect 560 cases, to which they added 50 of their own, making a total of 610. Because of the confusion of nomenclature in the literature it is even more difficult to state the exact incidence of the individual types of benign tumor. The term" " has been employed frequently to describe any peduncu­ lated tumor either actually or apparently arising from the mucous layer. It refers only to the gross morphologic characteristics of the rather than to the more intimate histopathological structure. It is therefore suggested that this term be rejected and the more accurately descriptive terms and adenopapilloma be adopted. 136 BENIGN TUMORS OF THE STOMACH 137

In 1928 Szokoblow reported 182 gastric polyps of probable adenomatous structure, to which 8 polypoid adenomas have been added. In 1925 Eliason and Wright collected from the literature 44 adenopapillomas and 31 adenomas, to which they added 16 and 5 cases respectively. In 1930 Ackman collected 88 cases of multiple from the literature and added one of his own. Among the benign tumors of mesenchymal origin the are by far the most common. Eliason and Wright found 321 cases, to which they added 4 of their own. In 1927 Nigrisoli collected 211 cases. Since then Balfour and Henderson have reported 23 tumors arising from and muscle, and 16 additional cases have been recorded by various authors. Two fibromyomas have been reported.

TABLE I; Incidence of Benign Tumors Gathered from the Literature Epithelial Polyps 182 (19.5%) Papillomata...... 89 (9.5%) Adenomata...... 42 (4.5%) Polyposis...... 16 (1.7%)

Mesenchymal Leiomyomata . 341 (36.6%) Neurofibromata . 102 00.9%) Fibromata . 42 (4.5%) Lipomata . 32 (3.4%) Osteomata . 1 (0.1%) Osteochondromata . 1 (0.1%) Myomata . 3 (0.3%)

Endothelial Hemangiomata . 15 (1.6%) Lymphadenomata . 14 (1.5%) Endotheliomata . 12 (1.2%)

Cysts Simple . 29 (3.2%) Dermoid . 5 (0.5%) Echinococcus . 4 (0.4%)

TOTAL ..•.••...... •...... •.•.•.•••...•..••••.• 931

Eliason and Wright collected 28 lipomas from the literature and added one case of their own. In 1926 Bianchi, in France, found only 11 reported cases and added one more. Three additional cases have since been reported. Neurofibromas are not infrequent. Harild reviewed the literature in 1931 and found 100 cases, to which he added one of his own. One other case has been reported. are much rarer. Ten have been collected by Eliason and Wright, to which 5 recent cases may be added. The same authors found 23 fibromas, and added 6 of their own. Thirteen cases have since been recorded. In one case, reported by Nelson, the tumor had become partially ossified. Twelve cases of " endothelioma" of the stomach were reported by Dahlgren in 1934. Cysts apart from simple cysts (29 cases have been reported) are extremely rare. There are on record 5 dermoid cysts, one reported by Ruysch in 1732, 138 JAMES F. MINNES AND CHARLES F. GESCHICKTER one by Love, and the remainder by Balfour and Henderson. Echinococcus or hydatid cysts are reported by Oehlecker and by Bachlendorf, Castelvi, and Pelares. There are reports of 3 pancreatic rests in the wall of the stomach. The above review of the literature is summarized in Table I.

PATHOLOGY In the present series of 50 cases the following types were found: neuro­ , 1; fibroma, 1; , 1; leiomyomas, 16; polyps, 31; adeno­ myomas, 9; adenopapillomas, 11; multiple papillomas (polyposis), 2; un-

FIG. 1. PHOTOMICROGRAPH OF A SHOWING !!'(TERLACING BUNDLES OF MUSCLE FIBERS The cells are elongated and spindle-shaped, and have plump, oval nuclei. Autopsy No. 2247. classified, 9. In over half of the cases, 26, the polypoid tumors were multiple, 2 instances of so-called polyposis being observed. Benign tumors show no strong predilection for anyone part of the stomach, but are slightly more common in the pyloric region than elsewhere. Nineteen of the 50 cases in our series occurred in the pylorus, 12 at the cardia, 10 in the fundus, and 1 in the posterior wall. In 5 instances where the tumors were mul­ tiple they were scattered diffusely throughout the mucosa. In 8 instances the location was not accurately recorded. The majority of the lesions were small, the size of a pea or smaller. Only two tumors were as large as a hen's egg, one a neurofibroma occurring at the cardia and the other an adenoma located in the pyloric region. The mesenchymal tumors may be sessile or pedunculated. They lie within the wall of the stomach, project into its lumen, or remain subserous and FIG. 2. LOW-POWER AXD HIGH-POWER PHOTOMICROGRAPHS OF AN ADENOMA OF THE STOMACH The low-power shows a greatly thickened gastric mucosa and cystic dilatation' of the gastric and crypts. The high-power shows greatly dilated glands lined by an orderly row of gastric . The lumina of the glands are filled with mucus. Autopsy No. 9300.

139 140 JAMES F. MINNES AND CHARLES F. GESCHICKTER project into the peritoneal cavity. They are usually small but sometimes grow to a tremendous size. Scharapo and Pendl described fibromas of the stomach weighing 5,500 grams and 3,600 grams respectively. Occasionally, by virtue of their size and position, they cause embarrassment of the circula­ tion to the supra-adjacent mucosa, resulting in and ulceration. Rarely do they undergo hyaline, cystic, or malignant change. (Fig. 1.) The epithelial tumors may be divided into two groups, the adenomas and the adenopapillomas. The adenomas arise from the mucosa as reddish, friable, button-like or lobulated masses. Microscopically they represent localized areas of hypertrophy and of the gastric epithelium rest­ ing upon a broad connective-tissue and base. The stroma is extremely vascular and is seen to contain relatively large blood vessels stuffed with red blood cells, and there is an extensive cellular infiltration of lympho­ cytes, mononuclears, eosinophils and plasma cells. The glands are enlarged, usually dilated and cystic. They are lined by an orderly row of columnar or cuboidal epithelium. In some instances several layers of cells are found to line a single or crypt. When the connective-tissue or muscular ele­ ments predominate over the glandular structure, the tumor is designated a fibro-adenoma or adenomyoma. Menetrier distinguished two varieties of adenoma, depending upon whether the ducts or the fundus of the gland were involved. In the former variety the tumor is distinctly lobulated and the cysts are large and numerous. In the latter there is little or no lobulation and the cysts are either few in number or entirely absent. Menetrier called growths of the former type polyadenomes polypeux, and of the latter poly­ adenomes en nappe. (Fig. 2.) The adenopapillomas form cauliflower-like projections of varying size within the lumen of the stomach. They are friable and not infrequently ul­ cerated. It is this type of tumor that may cause pyloric obstruction. The pedicle is generally quite slender and through it run delicate bands of fibrous connective tissue which arborize frequently. Superimposed on this fibrous connective-tissue stalk is an orderly row of tall columnar epithelium. The normal peristalsis of the stomach probably acts as a contributing factor to the pedunculated nature of these papillomas and continues to exaggerate the deformity. (Fig. 3.) The term" polyposis," although frequently used in the literature, is like " polyp" a poor descriptive word. It is here used to signify multiple, minute epithelial tumors either of an adenomatous or papillomatous character scat­ tered diffusely throughout the gastric mucosa. There is considerable evidence in the literature to show that benign ade­ nomas and adenopapillomas may develop into . In 1930 Miller et al reported 8 cases out of 23, or 35 per cent, as showing carcinomatous changes; to these they added 24 cases gathered from the literature. Ackman in 1930 stated that '15 per cent of reported cases of adenopapillomas had shown malig­ nancy. Benedict and Allen in 1934, reviewing a series of 17 cases of ade­ nomatous polyps in the Massachusetts General Hospital, found microscopic evidence of in 7 cases, or 41.2 per cent. In the present series of 31 gastric adenomas and papillomas malignant change had occurred in 3. Microscopically the malignant tissue shows epithelial cells lining the FIG. 3. LOW-POWER AND HIGH-POWER PHOTOMICROGRAPHS OF A OF THE STOMACH The pedunculated character of the growth is seen in the- low-power picture. The high-power photomicrograph shows columnar epithelial cells resting upon a delicate, arborizing, connective­ tissue stalk which is infiltrated by numerous small round cells. Path. No. 45290.

141 FIG. 4. PAPILLOMATOUS TUMOR oz TilE STOM,\CH WITH EARLY CARCINOMATOUS CHANGE The gastric glands are dilated, the mucosa is greatly thickened, and the epithelium is migrating down into the underlying submucosa and muscularis. The high-power photomicrograph shows the area outlined in the low-power view. The malignant character of the tumor is indicated by the hyperchromatic appearance of the nuclei and the of the surrounding connective tissue by the cells lining the gastric glands. Autopsy No. 5170.

142 BENIGN TUMORS OF THE STOMACH 143

gastric glands and crypts, breaking through the , and invading the submucosa and muscularis. The individual cells have lost their polarity in relation to adjacent cells, and numerous mitotic figures are present. (Fig. 4.)

CLINICAL OBSERVATIONS In the present series of benign tumors 26 occurred in white and 23 in colored patients. The 16 leiomyomas were equally distributed between the two races. Since, however, the ratio of colored to white patients in Johns Hopkins Hospital is 1:6, the incidence in the former is approximately six times that in the latter. This is in harmony with the high incidence of other mesen­ chymal tumors in the colored race. The proportion of males to females was 39 to 11. The age distribution is given in Fig. 5, which shows the age of the patients at the time of death. The youngest patient was twenty-one, the oldest ninety-four; the majority of tumors occurred during the fifth and sixth decades, with a maximum incidence between seventy-five and eighty years.

FIG. 5. CHART SHOWING AGE hCIDENCE IN 50 CASES OF BENIGN GASTRIC TUMORS

Symptomatology: As indicated by Table II, little reliance can be placed upon the clinical features in arriving at a diagnosis. In 36 of the 50 cases the tumors gave no indication of their presence. The complaints on admission and the causes of death were quite independent of the gastric lesion. In 5 in­ stances there was some concomitant lesion elsewhere in the gastro-intestinal tract, as of the and esophagus. In these cases it was im­ possible to determine whether the gastric symptoms were primary in the stomach or reflex from some other portion of the digestive tract. In 4 cases there were associated lesions of the stomach: cancer in three instances and a chronic gastritis accompanying pernicious in the fourth. In only four patients did it seem likely that the gastric tumors produced symptoms. These cases are reported in detail below. Symptoms when present are dependent upon the development of some complication such as obstruction, ulceration, or hemorrhage. The size and position of the tumor are important. A large tumor situated at the pyloric 144 JAMES F. MINNES AND CHARLES F. GESCHICKTER

TABLE II; Summary of Cases

Race, Path. No. Lesion Sex, Location Clinical Features Cause of Death Age ------.------1------tA-3753 Neurofi­ \V.M.78 Cardia Asymptomatic Ruptured bladder broma A-2159 Fibroma \V.F.42 Fundus Asymptomatic Pyelonephritis A-1287 Hemangi­ \V.M.55 Pylorus Pain, vomiting, mass, Gastric cancer oma loss of weight A-11265 Leiomyoma C.M. 20 Asymptomatic Tetanus A-11706 Leiomyoma W.M.77 Posterior Pain, vomiting, consti­ Sigmoid cancer wall pation A-10227 Leiomyoma \V.M.72 Asymptomatic Heart disease "A-10404 Leiomyoma C.F. 80 Fundus Pain, filling defect, stool Gastric cancer benzidine positive A-I0604 Leiom yoma \\i.M.60 Cardia Asymptomatic cancer A-7205 Leiomyoma W.F.44 Pylorus Diarrhea, loss of weight, Pellagra anorexia "A-7739 Leiomyoma W.F. 51 Pylorus Asymptomatic Heart disease "tA-7799 Leiomyoma C.M. 94 Pylorus Asymptomatic Pneumonia A-5004 Leiomyoma C.F. 43 Asymptomatic Heart disease "A-4000 Leiomyoma C.M. 57 Cardia Asymptomatic Uremia "A-2247 Leiomyoma C.M. 39 Cardia Asymptomatic Heart disease and pylorus "A-372R Leiomyoma C.M. 40 Pylorus Indigestion, pain, ano­ Prostatic disease rexia "A-927 Leiomyoma C.M. 54 Cardia Asymptomatic Heart disease and fundus "A-930 Leiomyoma W.M.63 Pylorus Asymptomatic Tuberculosis "tA-969 Leiomyoma W.M.46 Pylorus Pain, loss of weight, weakness A-1931 Leiomyoma W.M.47 Cardia Asymptomatic Bladder cancer "A-I 1584 Polyposis W.M.61 Diffuse Asymptomatic Pneumonia A-11993 Papilloma W.M.71 Cardia Nausea, vomiting Rectal cancer and uremia tA-10102 Adenoma W.F. 75 Pylorus Asymptomatic Cerebral hemorrhage "A-9300 Adenoma C.M. 65 Diffuse Asymptomatic Cerebral hemorrhage "A-R7R4 Papilloma C.F. 5R Fundus Anorexia, fatigue, pain, Gastric cancer tarry stools "tA-7479 Adenoma W.M.50 Pylorus Weakness, indigestion, Pernicious anemia anemia No free hydrochloric acid "A-7992 Papilloma C.M. 63 Asymptomatic Pneumonia A-6072 Papilloma W.M.79 Fundus Asymptomatic Bronchial pneumonia "tA-5170 Papilloma C.M. 50 Nausea, vomiting, diar­ rhea, weakness, mass, anemia, filling defect A-4030 Papilloma C.M. 63 Pylorus Asymptomatic Heart disease tA-4250 Papilloma C.F. 49 Pylorus Morning nausea Syphilitic aortitis "tA-331O Adenoma C.M. 65 Diffuse Vomiting Gastric cancer A-3341 Papilloma W.M.76 Pylorus Asymptomatic Heart disease "tA-225t Adenoma C.M. 52 Diffuse Ascites Syphilit ic cirrhosis of "A-2575 Adenoma C.M. 48 Cardia Asymptomatic Tuberculosis and fundus "tA-2619 Polyposis W.M.75 Diffuse Asymptomatic Obstruction of lower ileum BENIGN TUMORS OF THE STOMACH 145

TABLE II (Continued)

Race, Path. No. Lesion Sex, Location Clinical Features Cause of Death ARe

A-2622 Adenoma C.M. 57 Asymptomatic Heart disease *tA-2762 Adenoma C.M. 52 Pylorus Asyrn ptomatic Rectal cancer cardia *A-2786 Adenoma W.M.39 Diffuse Asymptomatic Heart disease A-1162 Papilloma \V.F. 60 Fundus Gastric symptoms Heart disease tA-1180 Polyp M. 55 Cardia Asymptomatic Heart disease *A-1206 Polyp C.F. 65 Pylorus Asymptomatic Heart disease tA-1275 Polyp W.F. 75 Asymptomatic Gangrene of lung *A-1348 Polyp C.M. 39 Pylorus Asymptomatic Tuberculosis *tA-1433 Polyp W.M.54 Fundus Asymptomatic Cirrhosis of liver cardia A-1677 Polyp C.M.55 Cardia Asymptomatic Meningitis tA-2811 Polyp W.M.57 Fundus Asymptomatic *A-515 Polyp \V.M.61 Pylorus Asymptomatic Cirrhosis of liver *A-489 Polyp \V.M. Pylorus Asymptomatic Esophageal carcinoma *tA-45290 Papilloma \Y.M.65 Pylorus Indigestion, loss of Postop. pneumonia and weight fundus No free hydrochloric acid

* = Multiple lesion. t = Lesion greater than 1 em. valve may prolapse through it and cause obstruction. Size alone, however, is not a determining factor. Two of the largest tumors in this series, each about the size of a hen's egg, were entirely symptomless. Scharapo describes a fibroma weighing 5,500 grams excised from the stomach of a women who had had no other symptoms than a feeling of weight in the abdomen, while Pendl reports a fibroma of the stomach in a man who died of bronchial pneu­ monia, which weighed 3,600 grams and which had apparently been symptom­ less. Loss of weight, emaciation, epigastric pain, anorexia, nausea and vomit­ ing, hematemesis, melena, and a severe secondary anemia are occasionally observed, depending upon the location, size, and condition of the lesion. Although these symptoms are suggestive, they are by no means diagnostic. The tumor is rarely large enough to be palpable through the anterior ab­ dominal wall. Not infrequently tenderness and muscle spasm in the epigas­ trium are noted. The determination of the hydrochloric acid content of the gastric juice is of equivocal value. Usually it is diminished or entirely absent, but cases are reported in which it has been increased. There is one group of patients who present themselves complaining only of breathlessness, weakness and fatigue, arising from anemia and consequent to melena. In such ex­ ceptional cases the clinical picture may suggest a correct diagnosis. Roentgen Findings: Although a few isolated cases of benign tumor have been accurately diagnosed preoperatively by microscopic examination of a fragment of the tumor found in the gastric contents (Semenza and others), little reliance can be placed on the clinical findings in arriving at a correct diagnosis. With expert radiological examination of the stomach a greater number of correct diagnoses have been made. Pansdorf and Determann re­ port 4 cases of benign tumor all of which were diagnosed correctly by x-ray and confirmed at operation. Ackman diagnosed a case of multiple adeno- 146 JAMES F. MINNES AND CHARLES F. GESCHICKTER papilloma and reports 3 similar cases that had been diagnosed by x-ray. Moore asserts that benign tumors present certain roentgenologic signs which differentiate them from malignant or inflammatory lesions. He says: "If these signs are not characteristic they are at least suggestive: " 1. They produce a filling defect that is circumscribed and punched-out in appearance. " 2. The filling defect is usually on the gastric walls, leaving the curvature regular and pliant. "3. While the rugae are obliterated in the immediate area of the tumor, just as in inflammatory and malignant lesions, the rugae surrounding a benign tumor are more nearly normal in their arrangement and distribution. "4. They cause little or no disturbance in peristalsis, and retention is uncommon except when the lesion is at, or very near, the pylorus. " 5. They do not reveal a niche, nor is there any incisura or other evidence of spasm. " 6. They are rarely sufficiently large to be palpated. " Probably the most essential feature in the examination is the close and complete approximation of the walls of the barium-filled stomach. . . . "Differentiation roentgenologically, of benign tumors and other gast.ric lesions can seldom be absolute, but in many instances the roentgenologic signs warrant an attempt at such a distinction."

CASE REPORTS

1. PAPILLOMA WITH MALIGNANT CHANGE (AUTOPSY No. 5170): H. H., a fiftv-vear­ old colored male, was admitted to the hospital May 8, 1917, complaining of sweliiIi'g of both legs. His illness had begun ten months earlier, with nausea, vomiting, diarrhea, and weakness. During the month before admission the diarrhea had become more severe. The patient was emaciated, and considerable ascites was present. There was no blood in the stool, but there was a severe secondary anemia. The red blood count was 2,774,000; the hemoglobin 28 per cent. On May 19 a firm, rounded mass was felt two fingers breadth below the left costal margin. This was thought to be the spleen or the left lobe of the liver. On May 24 there was a bulging over the 8th and 9th ribs in the left axillary line, and a mass was discovered in the left flank. There was no distinct edge to the mass. The percussion note over it was not flat. Abdominal pain and tenderness were severe. The area of splenic dullness was not increased. The tumor was thought to be connected with a hollow viscus rather than with the spleen or kidney, and because of the anemia, asthenia, and diarrhea, a of the stomach was suspected. The gastric test meal showed a free hydrochloric acid of 14, total acidity 60. There was no blood and no evidence of retention in the gastric contents. On repeating the examination a large blood clot was removed. A roentgenogram showed a "fish-hook type" of stomach with a large filling defect involving nearly the entire body of the organ except the pylorus. There was no obstruction. The patient became progressively weaker and died on June 6. At autopsy there was found a chronic hypertrophic gastritis with benign and malignant polypi. Microscopically the section showed a greatly thickened mucous membrane with enlarged glands. These were frequently cystic. In the region of the polyp the mucous membrane suddenly became tremendously increased in thickness. The glands were greatly dilated, frequently cystic, and were lined by high columnar epithelial cells. The epithelium everywhere was benign in appearance. Sections through the large cauliflower-like polyp on the greater curvature of the stomach showed a mucous membrane quite similar to that described above, which suddenly passed over into smaller masses of epithelial cells arranged in imperfect glandular fashion. A portion of the surface showed necrosis and ulceration. Malignant epithelial cells invaded the musculature and extended into the surrounding tissue. BENIGN TUMORS OF THE STOMACH 147

II. PAPILLOMA WITH MALIGNANT CHANGE (AUTOPSY No. 8i04): E. B., a colored female aged fifty-eight, was admitted June 2, 1925, complaining of "stomach trouble." Her past history was irrelevant apart from a loss of 50 pounds in weight during the ten months prior to admission. Her illness had begun two months previously with anorexia, fatigue, loss of energy, and an abrupt onset of pain in the right lower quadrant. The pain had been steady and gnawing in character. One month before admission there had been gaseous eructations, occasional vomiting, and tarry stools. Constipation had been slight. On physical examination the abdomen was found to be tense and tender but there was no muscular rigidity. The tenderness was most marked in the right lower quadrant. Ex­ amination of the blood showed 4,160,000 red cells; hemoglobin 52 per cent. The stool was positive for blood. A barium meal showed the stomach to be actively irritable. There was a probable defect of the pylorus. A diagnosis of carcinoma of the pylorus was made and a Polya operation was performed July 27, 1925. The patient died Aug. 6 from pulmonary embolus. At autopsy there was found in the wall of the stomach, about 5 cm. above the point of anastomosis, a small papillomatous tumor which on section appeared to be benign. Asso­ ciated with this larger papillomatous mass were two or three small projecting masses of mucosa about 1 em. from the larger one. The appearance of this papilloma suggested that the which was resected might have been of the malignant papillomatous type. The tumor had a velvety and papillary surface. It had not extended through the wall of the stomach. The peritoneal wall was smooth and uninvolved. The edges of the tumor were not heaped up or undermined. When a section was made through the entire mass numerous areas were seen where the tumor substance was thrown into folds. The presence of other types of papillomatous tumors of benign character in the remaining unresected portion of the stomach suggested that the primary growth was a malignant papilloma. No metastases were found. Microscopically the section showed a papillary growth with a characteristic adcnomatous arrangement. The base, however, showed invasion of the submucosa by epithelial cells which had broken through the basement membrane and were migrating downward. III. DIFFUSE ADENOMAS WITH MALIGNANT CHANGE (AUTOPSY No. 3310): 1 T. N.. a male mulatto sixty-five years old, was admitted Nov. 1'i , 1906, with swelling of the abdomen. The past history was irrelevant except that the patient was a ship's cook and up to two years before had been a steady drinker. When on shore he drank three to four glasses of beer and a half pint of whiskey a day. He had no liquor at sea but went on a " spree" whenever in port. Two years previously he had stopped drinking. The patient had always had a good appetite, the bowels were regular. He had never had any colic or pain in the abdomen. About twenty months before admission he began to have occasional attacks of vomiting in the morning, and these had occurred once every two or three weeks up to the time of admission. He had not noticed blood in the stools. Physical examination showed the abdomen to be tense and swollen. Because of the presence of ascites there was no palpable mass and no tenderness. Examination of the blood showed moderate secondary anemia. The red cell count was 4,492,000; hemoglobin 82 per cent. Three months later the red cell count was 4,000,000 and the hemoglobin 60 per cent. The clinical diagnosis was cirrhosis of the liver. subcutaneous angiomatous nodules, ichthyo­ sis simplex, and chronic gastritis and colitis. The patient died Dec. 15, 1909. Post-mortem examination showed the pylorus to be thickened and the surface of the stomach covered with blood-stained mucus. The entire surface of the mucosa was studded with polyp-like masses of varying size, differing greatly in appearance and showing every gradation from small sessile masses 0.5 em. in diameter to definitely stalked tumors, with cauliflower-like extremity, and a diameter of 2 or 3 em. Some of the largest nodules had no pedicles. Sections through the masses showed them to be quite superficial, involving only the mucosa and submucosa. In two tumors the underlying muscularis was thickened and firmer in consistency, with translucent or colloid strands invading and separating the muscle bundles. This involvement of the muscularis extended only about 2.5 em. beyond

1 This case was reported in full by M. C. Winternitz and Thomas R. Boggs: A unique coinci­ dence of multiple subcutaneous hemangio-endothelioma, multiple lymphangio-cndothelioma of the intestinal tract and multiple polypi of the stomach undergoing malignant changes ; associated with ~cneralized vascular sclerosis and cirrhosis of the liver, Johns Hopkins Hosp. Bull. 21: 203, 1910. 148 JAMES F. MINNES AND CHARLES F. GESCHICKTER

the base of the polyp. These polypi were associated with the gastritis, simple hypertrophy, benign and malignant adenoma, and cancer, with extensive invasion from multiple points of origin. IV. LEIOMYOMA WITH PARTIAL OBSTRUCTIO~ (AUTOPSV No. 3728): F. L., a colored male aged forty, was admitted May 11, 1912, complaining of "misery in the stomach and bladder." The principal lesion was prostatic, and to this death was due. Two weeks prior to admission the patient began to complain of anorexia and pain in the stomach three to four hours after meals. There was also a feeling of distention in the epigastrium. On physical examination the abdomen was found to be slightly distended. The hemo­ globin was 65 per cent. At autopsy a small, rounded, elevated area about 0.5 em. in diameter was found on the anterior surface of the stomach near the pyloric valve. On incision it was found to be a grayish white structure with concentric whorls situated in the muscle coats. This tumor had apparently caused partial obstruction of the pylorus.

PATHOGENESIS The occurrence of benign gastric tumors has been ascribed to several factors. Some authors believe that they are congenital in origin, arising from some anlage separated during early fetal life. This theory would ex­ plain the familial tendency that is sometimes observed. Others maintain that chronic irritation, either physical, chemical, or bacterial, gives rise to a low­ grade inflammatory disorder of the mucosa resulting in hypertrophy. This initial process is followed by a drawing out and elongation of the hyper­ trophied tissue produced by peristalsis of the stomach and the mechanical passage of food, thus giving rise to a pedunculated tumor. In this manner the so-called polyps are supposedly formed. In support of this latter theory Scaglia has produced typical cystic gastritis and polypoid adenomatous out­ growths of the mucosa in dogs by the injection of scharlach red into the mucosa. Although it is maintained by many that a chronic gastritis is the immediate underlying factor in the production of these tumors, microscopic examination usually shows small localized tumors arising from areas of other­ wise normal gastric mucosa which is entirely free from evidence of inflam­ mation. Likewise there are many cases of chronic gastritis which show no true neoplasia. We may therefore conclude that, although chronic irritation and chronic inflammation may be contributing factors in the production of gastric tumors, they are by no means essential etiological agents.

PROGNOSIS AND TREATMENT Benign tumors are seldom fatal, but in rare instances the sudden devel­ opment of a complication such as hemorrhage may cause death. Because these tumors may at any time give rise to annoying and even dangerous symptoms or complications, and because the tumors of the epithelial group not infrequently become malignant, they should be removed as soon as rec­ ognized. If the tumor is single and circumscribed, simple excision with a good margin of healthy tissue will suffice. If the tumors are multiple, how­ ever, and scattered diffusely over the gastric mucosa, as in polyposis, as much stomach should be resected as is consistent with the complete removal of the diseased area. BENIGN TUMORS OF THE STOMACH 149

CONCLUSIONS 1. An attempt has been made to evaluate the absolute and relative inci­ dence of benign tumors of the stomach. 2. The clinical and pathological features of SO cases have been reported. 3. Benign gastric tumors rarely give rise to symptoms, but when symptoms do occur, they demand instant surgical attention. 4. The only chance of a correct preoperative diagnosis is provided by radiological examination.

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