articles by Mathieu1 and Maniage on this subject are of much interest.

The cases may be spoken of in some detail.

3

1. Norman Moore's case was a girl, aged thirteen years, who presented no special stomach symptoms, but vomiting occurred two days before death. At the autopsy a carcinomatous growth, measuring three inches in diameter, was found at the cardiac end of the stomach.

4

2. Scheffer's case. A boy, aged fourteen years (in whom the diagnosis of neoplasm of the spleen was made), complained of anorexia and pain. Vomiting of food came on only twenty days before death. A tumour was present in the left hypochondrium. Death occurred after a history of nine weeks, and after the patient had been one month under observation. The autopsy report by von Recklinghausen was encephaloid cancer of the stomach.

3. Jackson's case, quoted by Welch, was in a boy, fifteen years of age, in whom no evidence of disease existed until ten weeks before death.

6

4. Lindner's and Kuttner's case, quoted by Schiff, was in a sixteen-year-old boy.

9

5, 6, 7, 8. Cases of Koster, Dittrich, Landouzy, and Boas.10. These were all aged seventeen years. The first two showed scirrhus of the pylorus. In the case reported by Landouzy, although there was persistent vomiting without evident cause, with a tumour in the umbilical region, varying in position and character, the question of a gastric growth does not seem to have been considered. The age of the patient and the absence of pain apparently led to error. Death occurred after about seven weeks, The stomach was found dilated, with a scirrhous mass at the pylorus.

vol.

1 Du Cancer précoce de l'Estomac, Lyon, 1884.

2 Essai sur les Tumeurs malignes des Enfants, Paris, 1895.

3 Transactions of the Pathological Society of London, 1885, vol. xxxvi., p. 195.

4 Jahrbuch für Kinderheilkunde, Leipzig, 1880, vol. xv., p. 425.

5 Extracts from the Proceedings of the Boston Society for Medical Improvement, V., Appendix, p. 109.

• Centralblatt für die Grenzgebiete der Med. u. Chir., Band i., No. 12.

Centralblatt für Chirurgie, 1888, p. 372.

8 Prager Vierteljahrschrift, 1845, Band viii., p. 116.

• Bull. de la Société anatomique de Paris.

10 Diag. u. Ther. der Magenkrankheiten.

9, 10. Cases of Hirtz1 and Dittrich.2-These were both at the age of nineteen years.

3

4

11, 12, 13. Cases of Wilde, Glynn, and Dock. These are all at the age of twenty years. Wilde's case was from the records of the Pathological Institute at Kiel. In it there was a large cancerous ulcer at the cardia. Glynn's case presented symptoms for three months. There was a tumour, apparently at the pylorus. At operation involvement of the glands was found, and it was abandoned. Death followed fourteen days later.

Dock's patient had suffered about a year with pain, difficulty in swallowing, loss of strength, ascites, and oedema. There was obstruction to the passage of the stomach tube and no test meal was obtained. The abdomen was tapped and 4700 cubic centimetres of fluid removed. In this were found many cells showing caryokinetic figures and atypical mitosis. Fluid was also aspirated from both pleural cavities. Jaundice appeared later. The diagnosis was malignant disease of the peritoneum, lungs, and pleura. At autopsy cancer of the stomach involving the pylorus was found. There was involvement of lymph glands, omentum, pancreas, liver, and bile ducts. The total duration of this case was slightly over a year.

6

Dock expresses the opinion that cancer of the stomach in early life frequently runs a slow course, and cites a case reported by Mathieu in a man, aged twenty-five years, whose symptoms began three years before, but there is no proof that these were due to cancer during the whole period. While cancer of the stomach in a young individual may pursue a slow course, as at any other age, yet from the cases collected by Mathieu and from those in the present series under the age of thirty, the conclusion seems to be justified that it is more often a rapid and acute affair.

III. Cancer of the Stomach in the Third Decade.-The cases at this period are more numerous, and may present difficulties in diagnosis. The proportion-4 per cent.-in our series is unusually large. The six cases are reported somewhat

1 Quoted by Williams, Lancet, 1897, vol. i., p. 1194.

2 Prager Vierteljahrschrift, 1846, Band xiii., p. 167.

3 Ueber das Vorkommen des Krebses bei jugendlichen Individuen, Inaug. Dissert., Kiel, 1892.

4 Lancet, 1896, vol. ii., p. 1232.

5 American Journal of the Medical Sciences, N. S. 113, 1897, p. 665.

6 Semaine médicale, 1895, p. 225.

fully, since, apart from their age, they all showed features of interest, one of which was the rapid course of the disease. They are given in order of age.

No. 103.1 Rapid Course.-W. S., male, coloured (hosp. no. 14,392), aged twenty-two years, admitted November 4th, 1895, complaining of nausea and vomiting. His family history was negative. He had been healthy previously, and gave a history of lues and alcohol in moderation.

Present illness began rather acutely four months before with pain in the epigastrium after eating. Nausea and vomiting came on later. The vomiting became more frequent, and on admission he vomited after every meal. Pain had been severe.

Examination showed emaciation, a dry and harsh skin, and very pale mucous membranes. In the left hypochondrium there was distinct resistance felt on deep inspiration, which was permanent. The area of stomach tympany after inflation was increased. The result of the test breakfast was as follows: Hydrochloric acid was absent and lactic acid was constantly present. The blood showed hæmoglobin 38 per per cent., red corpuscles 4,220,000, and white corpuscles 6,800.

Course. He vomited frequently, usually soon after food. The temperature rose several times to 101° and 102° F., without any chill or discomfort. Despite some relief to the symptoms by diet and lavage he lost ground during his stay. On Dec. 23rd he was discharged. He was lost sight of, and his subsequent history is not known. The following note was made by Dr. Thayer:-" Despite the youth of the patient and the absence of palpable tumour, the history of sudden onset, the results of the test meals, and the grave anæmia appear to justify a diagnosis of gastric cancer."

No. 110. Stomach Tumour with Secondary Growth in the Umbilicus. C. D., male, white (hosp. no. 15,722), aged twenty-four years, farmer, admitted April 7th, 1896, complaining of pain in stomach. His family and previous history were negative. He had never had any stomach trouble before his present illness, which began suddenly a year and a half before, with vomiting after eating. Pain was present in the epigastrinm, and was at times very severe. Ten months before admission he noticed a tumour in the left epigastrium, which has increased in size and become very tender. Since the appearance of the tumour he has vomited every day. In spite of this his appetite has continued good. He has lost over 60 lbs. in weight.

Examination showed great emaciation, pale mucous membranes,

1 The number given first is that of the case in the present series.

and a greatly excavated abdomen. In the left epigastrium, about midway between the costal margin and the navel, was a distinct prominence, which descended visibly on inspiration. On palpation a distinct hard mass was felt, which varied in consistence, and was somewhat tubular. It was very movable, and could be swung into either a horizontal or vertical position. On April 10th Dr. Osler noted slight peristalsis visible in the mass. It could be moved quite to the

right of the middle line. Gurgling was evident in the mass. There was a tumour mass in the navel which was of stony hardness and could be grasped and moved. It was slightly tender.

The patient did not gain, the vomiting continued, and he was discharged unimproved. His subsequent history is unknown.

No. 94. Rapid Course; Tumour; Operation; Death Three Months Later.-A. B., male, white (hosp. no. 13,059), aged twenty-five years, admitted on June 16th, 1895, complaining of weakness and debility. His history was negative, and he had previously been well and strong.

Present illness began about eight weeks before, when his friends noticed that he looked yellow. Two weeks later he had a slight feverish attack, which kept him in bed for some days. The temperature did not rise above 102° F. He then had loss of appetite, and began to lose flesh. He went to New York, and there had an attack of diarrhoea. After this loss of appetite, occasional belching of gas, and a bad taste in the mouth persisted, There was no nausea or vomiting. For two weeks before admission he had lost weight rapidly-nearly 15 lbs. His physician discovered a mass in the abdomen, and for this he sought advice.

Examination showed moderate pallor, with some sallowness and emaciation. The thorax was negative. The abdomen was natural; but about two fingerbreadths below the ensiform cartilage there was a distinct elevation, which descended with inspiration and could be held down. After the drinking of fluid this was lower, and could be depressed almost to the navel. It was not painful. After inflation the stomach tympany reached nearly to the navel, and the mass was moved down and to the right. The test meal gave 80 cubic centimetres of liquid, which contained no hydrochloric acid, and gave a reaction for lactic acid. The blood showed hæmoglobin, 75 per cent.; red corpuscles, 3,996,000; white corpuscles, 8,500.

The following note was made by Dr. Osler :- "There seemed no question that this was a tumour of the stomach, and probably carcinoma. The great mobility, with varying conditions of fulness and emptiness of the stomach, seemed a very important point. Then the anæmia, the nausea, the failure of stomach digestion, the absence of free hydro

chloric acid, and the presence of lactic acid, in spite of the fact that he had only completed his twenty-fifth year, point to carcinoma of the stomach."

Operation by Dr. Bloodgood on June 18th. At a distance of an inch and a half from the pylorus, there was on the lesser curvature a group of distended veins and a patch of reddening of the serosa, with a little puckering just at the curve. This corresponded to a solid, firm mass, which appeared to extend about an inch on the anterior curvature and farther back on the posterior wall, forming a mass fully the size of an orange. Small nodules were felt on the posterior portion of the stomach.

The patient recovered rapidly from the exploratory operation. He was up in two weeks, had a good appetite, and seemed in every way better. He left for the mountains just three weeks after the operation. During the summer he grew feebler, more emaciated, and died on Sept. 25th, 1895.

The whole course of the symptoms only lasted for four months. The operation for a time seemed to have a beneficial effect on the symptoms. This improvement after an exploratory operation is referred to elsewhere.

No. 121. Rapid Course.-J. P., male, white (hosp. no. 17,801), aged twenty-six years, farmer, admitted Nov. 6th, 1896, complaining of abdominal pain and vomiting. His family and previous history were negative. He had been healthy, and had worked out of doors.

Present illness began in June 1896, with severe pain in the abdomen. This came on after he had severely strained himself by lifting a heavy weight, when, as he said, "something had given way inside." This pain continued and became very severe. It was situated about the navel, rarely in the epigastrium. Vomiting came on soon after the onset, and was usually just after eating. Twice the vomitus contained blood. He was generally very hungry, and felt that he could eat a dozen times during the day. There had been very rapid loss of weight-about 70 lbs. in five months.

Examination showed great emaciation. In the left hypochondrium there was a firm mass which moved with respiration. It extended to the median line, showed intrinsic movements, and could be felt to contract and relax under the hands. The diagnosis of contracted stomach with rather general involvement was made. The special features of the tumour will be spoken of elsewhere under that heading. The blood showed hæmoglobin 82 per cent.; red corpuscles, 5,600,000; white corpuscles, 10,000.

The patient was discharged on Nov. 16th, somewhat improved. His further history was obtained from Dr. Primrose, of New Berne,