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presence of lactic acid were very suggestive of new growth. He improved, however, rapidly in the hospital, and when he left we were in doubt as to the nature of the trouble.

In connection with these, a case may be mentioned in which the question of cancer of the stomach arose, but which afterward was proved to be pernicious anæmia.

Insidious Onset, with gradual Failure of Strength and Loss of Colour; Stomach Symptoms; Loss of Weight; Extreme Anaemia; Cancer of the Stomach suspected; Readmission with Profound Anemia; Blood characteristic of Pernicious Anaemia.-J. K. (hosp. Nos. 10,136 and 10,261), admitted first on June 15th, 1894, complaining of weakness and vomiting. His family and previous histories were negative.

He

The present illness began insidiously about five months before. noticed that he was growing pale and that he was having pain in the back. His appetite gradually failed, and two months before vomiting began. The vomiting was generally after food. The vomitus never contained blood. He had lost over 30 lbs. in weight.

Examination showed marked pallor and some emaciation. There was nothing of note found either in the thorax or abdomen. A solid body was felt below the left costal margin on deep inspiration, which was thought to be the spleen.

Test Breakfast gave 25 cubic centimetres of yellowish fluid, neutral in reaction, and containing neither free hydrochloric acid nor lactic acid.

Blood.-Hæmoglobin, 27 per cent. ; red corpuscles, 1,048,000; white corpuscles, 4,400.

Stained specimens did not show any nucleated reds and no apparent increase in the lymphocytes (no exact differential count was noted).

He

He remained in the hospital for only three days, and the diagnosis was left open between gastric carcinoma and pernicious anæmia. was readmitted two weeks later. The only new symptoms presented were œdema of the feet and increasing weakness; otherwise his condition had been much the same.

The blood examination showed on admission: hæmoglobin, 17 per cent.; red corpuscles, 918,000; white corpuscles, 4,800.

One week later it was: hæmoglobin, 19 per cent.; red corpuscles, 970,000.

Stained specimens showed a number of typical megaloblasts along with a few normoblasts. The differential count showed polymorphonuclears 68 per cent. and lymphocytes 29 per cent.

On August 15th the count was: hæmoglobin, 48 per cent.; red corpuscles, 1,908,000. Only two nucleated reds were found, one a

normoblast and the other a megaloblast.

showed 34-4 per cent. of lymphocytes.

The differential count

The patient was in the hospital until Oct. 12th, when his count was hæmoglobin, 69 per cent. ; red corpuscles, 3,600,000.

Stained specimens were practically normal. There were no nucleated reds, and lymphocytes were 17 per cent. of the leucocytes.

In the following interesting case the patient recovered from a profound ana mia, and six years later died of cancer of the stomach.

In Hospital six years before with Pernicious Anamia; Gradual Recovery; Second Admission with loss in weight and vomiting; Presence of a Tumour in the Epigastrium and the characteristic features of Cancer of the Stomach.

W. M. (hosp. no. 16,611), who was admitted on July 9th, 1896, with gastric symptoms and a definite stomach tumour, had been in the hospital with pernicious anæmia six years previously. He was first admitted in 1890, when the diagnosis of pernicious anæmia was made. He then had a blood count of about 1,000,000 red corpuscles. After a stay in the hospital of eight months he was discharged with a red count of 4,900,000 and hæmoglobin 92 per cent. On a second admission for diarrhoea in 1892 his count was in the neighbourhood of 3,000,000. His general health was good. On his last admission he complained of "sick stomach." He gave a history of having been very well since his admission in 1892. The present trouble began only about one month before admission. He thought it had been brought on by his having drunk very cold beer when he was overheated. Vomiting began, which had been nearly continuous. Examination showed a gastric tumour, absence of hydrochloric acid, and presence of lactic acid in the stomach contents.

One or two additional points of interest may be noted. In a few cases of cancer the sallow lemon tint of the skin, so characteristic of progressive pernicious anæmia, is present. In No. 33, male, aged 69, while there was marked general anæmia, there was a curious distribution of yellow pigment over the skin. No. 49, too, presented a very yellow tint of the skin, which made us for a time suspect primary anæmia. In the case of J. R. C., aged 64, seen June 6th, 1896, with Dr. Baden, the anæmia was profound, and the whole appearance of the patient was that of a primary anæmia, the general tint of the skin being of a lemon colour. A well-marked tumour was present.

Emphasis may again be laid on the importance of accurate blood examinations, as without them the diagnosis must frequently be in doubt, while with them it is a very unusual case in which any doubt remains. In all our cases-except No. 132, which has been discussed the relationship between the number of red cells and the percentage of hæmoglobin was typical of a secondary anæmia. The hæmoglobin was reduced proportionately much more than the red corpuscles. In pernicious anæmia it is rare not to find a relatively high-colour index. The blood examination is the more important as the gastric findings in pernicious anæmia may show absence of hydrochloric acid, and so possibly suggest the presence of malignant disease.

Conclusions.-1. In a doubtful case a blood count below 1,000,000 red blood-corpuscles is strongly in favour of pernicious anæmia.

2. While nucleated red blood-corpuscles are present in all very severe anæmias, megaloblasts rarely if ever occur in cancer of the stomach.

3. Neither an increase in the leucocytes nor special variations in the forms appear to be of any moment in the diagnosis of cancer of the stomach.

4. The presence or absence of digestion leucocytosis is too uncertain to be of much assistance in diagnosis.

CHAPTER XII.

COURSE OF THE DISEASE-LATENT CANCER.

THE STATISTICS OF DURATION OF SIXTY-THREE CASES-CONDITIONS UNDER
WHICH IMPROVEMENT OCCURS-ACUTE CASES-CHRONIC CASES-LATENT

CARCINOMA OF THE STOMACH THREE GROUPS OF CASES, (a) WITH
NO LOCAL FEATURES, (b) WITH THE SYMPTOMS OF AN ASSOCIATED
LESION, (c) WITH METASTASES WHICH MASK THE PRIMARY DISEASE.

As a rule the progress of a case is steadily downwards, and the entire duration of the disease is rarely more than from a year and a half to two years. It is to be remembered that the duration of symptoms cannot be taken as synchronous with the occurrence of the growth, as will be referred to when we discuss the latent cases.

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In 63 cases of the series it was possible to estimate the entire duration in 48, under one year; in 15, above one year; in 3, above two years. More closely analysed, 16 cases ran a course from the first symptoms to death within three months; 17 cases died between the third and sixth months; 15 between the sixth and twelfth months. Of the 15 cases with a duration above one year 3 died between the twelfth and eighteenth months, 7 between the eighteenth and twenty-fourth months. The longest case lived slightly over two years and a half, the diagnosis being verified by autopsy.

Conditions under which Improvement occurs. While the course is, as a rule, downwards, there are not infrequently periods of improvement, which we have known to occur under three different conditions. A change of diet, combined with lavage, is sometimes followed by a remarkable betterment in the symptoms, local and general. Excluding 24 cases in which the stay was too short for any special treatment, of the remaining cases, 31 showed signs of marked improvement.

Of these only 8 showed any special gain in weight; 3 increased 5 lbs. ; 4 gained between 5 and 10 lbs. ; 1 gained 19 lbs. In many instances, without any gain in weight, the general and local conditions were very much improved.

A second cause of improvement, which is seen more often. in private practice, is the visit of an optimistic consultant. Some years ago a gentleman in the neighbourhood of Philadelphia had much distress after eating, progressive emaciation, anæmia and a well-defined nodular tumour on the lesser curvature of the stomach, which was only evident when the organ was full, or when he took a deep inspiration. He had been ill for some time, and had practically made up his mind that the disease was incurable. A positive diagnosis of chronic gastric catarrh by a most optimistic consultant was followed for a period of nearly three months by the most remarkable improvement in his general condition. As there was no particular change in the treatment, which had consisted of lavage and careful dieting, to the pronounced mental impression may reasonably be attributed a part at least of this change.

Thirdly, a most extraordinary improvement may follow an exploratory operation, as in the case reported by W. W. Keen and D. D. Stewart. The patient, a physician, aged 35 years, after an exploratory laparotomy, in which the body of the stomach was found "much involved," gained rapidly, and four months subsequently weighed 178 lbs., having about March weighed 115 lbs. About seventeen months following the first operation the symptoms had so far recurred that another exploratory operation was performed, after which he died of peritonitis. Two large, open, cancerous ulcers were found in the stomach. This case is, we believe, unique in the history of carcinoma of the stomach.

Acute Carcinoma of the Stomach.-This designation may be applied to the cases in which the disease runs a course within three months. There were 16 cases in our series. The following is the most acute case in the series (reported by Dr. Thayer, J. H. H. Bulletin, vol. ii., p. 162) :

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Coloured man, aged 40 years; admitted Sept. 19th, 1891. While not infrequently subject to dyspepsia, and occasionally to what he termed bilious attacks, he had been actively at work as a coachman,

1 Transactions of the Association of American Physicians, vol. xiii.

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