North Carolina. The mass increased rapidly in size, and an exploratory operation was decided on. However, the patient's condition was so bad that it had to be abandoned before the abdominal cavity was opened. The emaciation became extreme, the vomitus was at times bloody and grumous, the pain became so severe that morphine was required, and death followed in Dec. 1896, after a duration of about six months. No autopsy was obtained. No. 56. Rapid Course; Secondary Growth in the Liver.-A. W., male, coloured (hosp. no. 7,730), aged twenty-eight years, marble polisher, admitted July 17th, 1893, complaining of a "lump in the stomach." His family and previous history were negative with the exception of lues. Present illness only dated back for a period of three months, when he first noticed a mass in the abdomen. Soon after this he lost his appetite and began to vomit. The vomitus was scanty and never contained blood. Pain also appeared which, though not severe, had been constant. The bowels had been loose. There had not been any jaundice. He had lost over 30 lbs. Examination showed emaciation and pale mucous membranes. The thorax was negative. There was no jaundice. The abdomen was distended; the epigastrium showed an irregular nodular mass, the rounded prominences of which were distinctly visible. The lower border of this mass was within a finger's breadth of the right anterior superior iliac spine. It was hard and sharp, and could be felt to descend on inspiration. Numerous rounded prominences were felt. The liver dulness in the right nipple line began at the sixth rib, and extended a distance of 23 centimetres. The supraclavicular glands were not palpable. Test meals gave absence of free hydrochloric acid and the presence of lactic acid. Coffee-grounds" was present once in the vomitus. 66 Death and Autopsy. On August 2nd the patient complained of sudden abdominal pain, which was not specially localised. The general condition was that of collapse, from which he did not rally, and death followed in a few hours. At autopsy the stomach was somewhat dilated, with the pylorus imbedded in a mass of glands extending into the portal fissure and attached also to the colon. The stomach contained coffee-ground material amounting to about a pint. On the posterior wall, just within the pylorus, was a soft, fungoid mass, 8 by 5 centimetres, with an excavated ulcer. The glands along the lesser curvature were involved. Sections showed the growth to be typically carcinomatous, with no tendency to adenoma. The liver weighed 6,200 grammes, and reached 18 centimetres below the ensiform. The surface was studded with elevations which varied from mere points to areas 6 and 7 centimetres in diameter. The liver tissue was largely replaced by neoplasm. The duration of the disease in this case was about four months. It is striking that the symptoms first complained of were due to the secondary growth in the liver. It is an illustration of the class of cases in which the symptoms are largely those of the secondary growth, and in which the diagnosis of the primary seat may be impossible. But for the chemical findings and the vomitus it would not have been possible during life to have diagnosed the primary growth. The case further illustrates the latency of a stomach growth, and how much difference there may be between the duration of the disease and its symptoms. No. 45. Rapid Course; a Previous History of Gastritis.-P. K., male, white (hosp. nos. 627, 1,184, and 6,532), aged twenty-eight years, labourer, admitted Jan. 3rd, 1893, complaining of pain in the abdomen, with loss of weight. His family history was negative. His previous history was of interest in that he had been twice admitted to the hospital, in 1889 and 1890, with acute gastritis. There had been an interval of nearly three years since his last admission, in which time he had been fairly healthy, without any stomach symptoms during the greater part of the time. Present illness began about four months before admission, with pain and vomiting. The pain was confined to the epigastrium, continuous, and increased by pressure. His appetite had continued fairly good in spite of nausea and vomiting. He had steadily lost weight. and of late, with oedema of the legs, there had been shortness of breath, Examination showed a very anæmic man with puffy eyelids. The thorax was negative. In the abomen, below the right costal margin in the parasternal line, was a mass which descended markedly with inspiration. It extended from the right nipple line to the middle line, and the fingers could be placed between it and the costal margin. Liver flatness did not extend below the costal margin. After inflation the mass was pushed over to the right. No peristalsis was visible. The blood showed hæmoglobin 30 per cent.; red corpuscles, 3,100,000; white corpuscles, 22,000. The test meals contained blood, showed absence of free hydrochloric acid, and presence of lactic acid. The patient lost ground rapidly. His temperature was almost constantly elevated to 100° or 100-5° F. in the evening. He died on Feb. 23rd, 1893, after a duration of between five and six months. No autopsy was obtained. Remarks. In reviewing these cases two features stand out prominently—a striking abruptness of onset, and the acuteness of the course. In four out of the six the disease began with a sudden definite onset. Another (No. 94) gave a history of only six weeks' illness, and might be included under the same head. In the sixth case the enlarged liver gave the first indication of malignant disease. Comparing this group with the cases in the period of five years over thirty, no such acute onset was found in the latter. The opinion that cancer of the stomach in the young frequently runs a rapid course has already been spoken of. Mathieu1 came to this conclusion after a study of the recorded cases. The cases of this series support this view. It may be noted that all of our cases were in males. Certain symptoms may be spoken of in detail. Loss of appetite was considered by Brinton to be a marked symptom in young individuals. Mathieu holds a contrary view, and in his collected cases found that in one-half of the cases this symptom did not appear until the last four or five weeks of life. In a quarter of his cases the appetite was retained until death. He considers that this view of the supposed common absence of appetite in the young has contributed to errors in diagnosis. He suggests, in explanation of the fact that appetite is so often retained, that the mucous membrane is but little changed. In our series there was no loss of appetite in three, anorexia was present in two, and in one the point was not noted. Pain. As in cases at all ages, a certain number are free from this symptom throughout. In our series only one was free from pain. In the others it was fairly severe. Vomiting was also present in five of the cases. in whom it was absent had also absence of pain. The patient Tumour was present in five cases, in one of which it was only found at autopsy, the enlarged liver having covered it during life. Ascites was not present in any of this series. Among twenty-seven cases collected by Mathieu it was present in five, of which four were thought to be cirrhosis. Fever was thought by Mathieu to be generally absent in the young. But three of our cases had fever, and a fourth gave a history of a feverish attack shortly before admission. 1 Loc. cit. Duration. This is of special interest, and the frequent acuteness of the course in the young is borne out by our cases. Mathieu, in his series of nineteen cases in the young, estimates a mean duration of three months. In eleven cases out of nineteen the duration was within two months and a half, in six of the remainder it was within six months, and in the remaining two the course was one year. The minimum period was between five and six weeks. In our series the duration is known in four instances. None of these were over six months-two being this period and two being four months. Of the remaining two, one with a history of four months was lost sight of; but, as he had lost ground rapidly and did not improve under treatment, it seems probable that the duration would not be much prolonged. The sixth case gave a history of over eighteen months. Two of the conclusions of Mathieu may be quoted : 1. Cancer of the stomach below the age of thirty has generally a rapid progress of some months, and often ends suddenly by incidents more or less abrupt. 2. Early cancer is not latent-it is often overlooked. CHAPTER III. SYMPTOMS. OF GENERAL; SYMPTOMS ON ADMISSION- VOMITUS. IN a discussion of this part of the subject it is well to bear in mind the classical saying of Brinton that cancer of the stomach is "obscure in its symptoms." Of organs liable to cancer the stomach is the best example of the class to which the term inaccessible has been applied. In studying the disease, we must always be on the watch for unusual and unexpected features. From the typical case with anorexia, vomiting, tumour, loss of weight and strength, etc., there are all varieties to the latent form without a symptom directly referred to the stomach. Symptoms on Admission.-Taking them up in detail, it is of interest to note those of which the patients complained on admission, as they give some guide to the main subjective features. Ten gave no complaint of any stomach symptoms. Of the remaining 140, 84 complained of pain, 46 of vomiting, 38 of dyspepsia, 38 of loss of weight and strength generally with some stomach symptoms-12 of tumour, 5 of anorexia, 2 of hæmatemesis, and a number of various other conditions such as dyspnoea, jaundice, etc. The comparatively large number who complained of a tumour 1 Under this term is included a variety of indefinite stomach symptoms, such as uncomfortable full feelings, sensations of weight or distress, belching of gas, waterbrash, etc. It seems a convenient term to use, despite its uncertainty. |