CHAPTER IX. STUDY OF THE TUMOUR (continued). TUMOURS OF THE PYLORIC REGION-SOME COMMON FEATURES-THREE GROUPS.I. WITH THICKENING AND INDURATION-CASES-ESTIMA- ADHESIONS.-III. THE large number of cases, and the frequency of secondary conditions, make the tumours of this region of special interest. Among the 1300 cases tabulated by Welch, the pyloric region was involved in 61 per cent. Of the 45 cases of this series coming to autopsy, this part was involved in 24. There were also 6 cases of general involvement, which makes a total of two-thirds. of the cases in which the pylorus was the seat of disease. The growth in 63 cases of the 115, in which a tumour was felt during life, was thought to be in the pyloric region. In the majority of cases the tumour is not restricted to the pylorus itself, but invades the adjacent stomach wall to a greater or less extent. Of the 24 autopsy cases, in only 3 was the growth strictly limited to the pylorus. Next to tumours of the anterior wall those of the pylorus are the least likely to escape recognition, yet of the cases coming to autopsy there were 4 in which a pyloric tumour was not felt during life, although in each a diagnosis of carcinoma was made. Two cases in which the pylorus and lesser curvature were involved were latent. Ascites or an enlarged liver may mask a growth. Even a tumour which, post mortem, looks as if it should have been readily palpable, may escape observation during life. Thus, in No. 31, with moderate dilation, a diagnosis of malignant disease was made, but no tumour could be felt. At autopsy a hard mass was found which, with adjacent glands, was as large as a hen's egg. The secondary effects have already been discussed in Chapter VII., and the important feature of mobility has been fully referred to. The tumour itself may be dealt with under three headings: Thickening and induration. Tubular and small nodular tumours. I. Thickening and Induration.--The tendency of many pyloric tumours, as already noted, is to invade the adjacent stomach walls; and this, with hypertrophy following as a result of stenosis, may produce a large mass. In such cases the recognition of the growth is usually easy. The tumour, as a rule, lies to the right of the median line; it may, however, as already stated, show great mobility. It generally lies lower than the ordinary situation of the pylorus, and is frequently in the umbilical region. A typical case may be given :— No. 28.-M. S. (hosp. no. 3,654), male, aged 36 years; admitted Aug. 15th, 1891. The course was acute, as the symptoms had only lasted about three weeks. There were marked pallor and emaciation. The abdomen was retracted. In the epigastrium, about midway between the ensiform cartilage and navel, was a large irregular mass, which extended to the right almost to the costal margin, and to the left beyond the median line. It descended freely with inspiration. The lower edge was distinct, and could be raised by the finger. The patient rapidly lost ground, and died on Sept. 16th, after a course of about three months. No special change in the tumour was noted. Autopsy showed slight dilatation of the stomach, and a large mass in the pyloric region, involving the ring, which was contracted. The growth extended from the lesser curvature on each wall nearly to the greater curvature. The muscular coats were much thickened. It must be borne in mind that enlarged adherent glands may partially account for an indurated tumour, or there may be other organs attached. In the following case the colon, duodenum and omentum were adherent to the pyloric end of the stomach, and with enlarged lymph glands made a large mass which was felt above and to the left of the navel. No. 113.-H. C. (hosp. nos. 15,222 and 16,191), male, aged 44 years; admitted first on Feb. 13th, 1896, complaining of abdominal pain. The principal symptoms were pain and vomiting. Examination of the abdomen showed a tumour mass above and to the left of the navel. It descended markedly with respiration. On inflation the mass was carried downwards and to the right. The lower border of stomach tympany was 4 cm. below the navel. He was discharged on March 13th somewhat improved, and readmitted on May 25th in worse condition than before. The tumour was much as previously noted. The patient died on June 27th, 1896. Autopsy showed a dilated stomach, and the pyloric end occupied by a firm hard mass, which extended along the stomach wall. The colon and duodenum (and omentum) were adherent to the pyloric region, and ulceration had occurred into their cavities. The margins of these openings were firm and indurated. The adjacent lymph glands were enlarged. This case will be referred to again when the question of perforation is discussed. It may be noted that there were no symptoms pointing to this condition. In No. 52 a large mass was present in the epigastrium, extending on each side to about the parasternal lines. At autopsy this was found to represent a mass composed partly of a growth involving the pylorus and the stomach wall for 10 cm., with the adherent omentum, duodenum, and pancreas. Caution is required in coming to an opinion as to the extent of the growth. In cases with much hypertrophy it is impossible to say how widely the infiltration has extended; this may not be possible even when the abdomen is opened. In judging of the extent and size of a gastric tumour, it is to be remembered that in a majority of cases the tumour is larger than appears by external examination. For this cause, after abdominal section, a contemplated excision may have to be abandoned. Examination under an anæsthetic may show a larger growth than was supposed. In case No. 23 a mass was felt in the parasternal line below the right costal margin, which descended with inspiration, could be moved about, was very tender, feeling about the size of a walnut. After an anæsthetic was given the tumour was felt to be much larger. It was 7 cm. long and 5 cm. wide, readily movable, and felt firm and hard. In connection with the subject of pyloric tumour, two conditions require special consideration-(1) the thickening about a gastric ulcer, and (2) simple hypertrophic cirrhosis of the pylorus. Induration about a Gastric Ulcer is particularly apt to lead to error in diagnosis. The history, symptoms, and physical diagnosis may all point to malignant disease. The tumour may resemble a malignant growth, and even after the abdomen is opened it may be impossible to speak with certainty. A histological examination may be required. The stenosis and induration may follow the healing of a gastric ulcer, or there is marked thickening and induration about the ulcer itself. The history may suggest gastric ulcer, and the chemical findings show excess of free hydrochloric acid, but it cannot be said with certainty that cancer has not arisen in a previous simple ulcer. In other cases there may be absence of free hydrochloric acid, and the patient lose ground under careful diet. Four of these cases are on our records, and may be abstracted briefly. In the first two the tumour was nodular in character. The first case is mentioned in Osler's Lectures on Abdominal Tumours as M. G. on page 34. The second case is as follows: : Three admissions; Diagnosis of Cancer on the first two; on the third Death and Autopsy; Gastric Ulcer.-L. F. (hosp. no. 9,473), male, aged 45 years, admitted first on March 22nd, 1894, complaining of dyspepsia and loss of weight. His family history was negative. He had used alcohol freely, and had had syphilis. His present illness began about six months before with pain and vomiting, which were present every day. The vomitus never contained blood, and was never large in amount. The pain was severe, situated in the epigastrium, and eased by pressure. His weight had fallen from 130 to 84 lbs. Examination showed marked pallor and emaciation. No tumour was felt in the abdomen. Several test meals showed absence of HCl. No lactic acid was found. The hæmoglobin was 45 per cent., the red corpuscles 4,352,000 and the white 6000 per c.mm. The patient remained in the hospital for a month, and gained nearly 10 lbs., in weight, though the blood condition did not improve. No tumour was felt, but the sudden onset, persistent stomach symptoms, anæmia, and continued absence of HCl, all seemed to point to a diagnosis of malignant disease. Second admission.-June 16th, 1894. The patient had been fairly well until two weeks before, when the pain and vomiting returned. He had vomited " coffee-grounds" material. The general condition was much the same. In the epigastrium there was marked tenderness just to the right of the median line. Between the navel and the right costal margin a small nodular body was felt. The blood condition was unchanged. A faint reaction for HCl was got in the test meals. He remained in the hospital for six weeks, and gained 6 lbs., in weight. There was some doubt felt as to the correctness of the diagnosis of cancer. Since his discharge he had 26th he was kicked in the Third Admission.-Sept. 11th, 1894. the same symptoms as before. On Aug. left lumbar region. Early in the morning of the next day he vomited half a wash-basin of dark blood. On Aug. 30th and Sept. 1st he vomited about the same amount, and also passed blood by the bowels. Examination showed marked emaciation and pallor. The blood showed hæmoglobin about 12 per cent., red cells 1,012,000, and white cells 40,000 per c.mm. No mass was felt, but the abdominal walls were held tensely. The patient died suddenly on Sept. 13th. Autopsy showed a large gastric ulcer on the posterior wall measuring 11 by 5 cm. It was old, cicatrised at the edges, and involved all the coats of the stomach. Perforation had occurred, but numerous firm adhesions had walled off the peritoneal cavity. The floor of the ulcer was formed by the pancreas. Ulceration had opened the splenic artery. A thrombus in the splenic artery had extended into the cœliac axis and abdominal aorta. In both these cases the tumour, as felt, was nodular in character, and so they might perhaps have better been given under the second heading of small nodular tumours, but it seemed more convenient to quote all together here. In the other cases the tumour was larger and involved more of the stomach wall. Gastric Tumour; Diagnosis of probable Carcinoma; Operation; Pneumonia, Autopsy.-J. C. (hosp. no. 20,039), male, aged 57 years, admitted July 17th, 1897, complaining of pain and dyspepsia. There was nothing of note in his family or previous history. He had suffered from stomach trouble for eight years, with occasional attacks of gastric distress followed by vomiting. These occurred irregularly, perhaps once or twice a month. One year before admission these became much worse. They were more frequent and more severe. Of late he had vomited once or twice every day. The vomitus was the food previously eaten, and never contained blood. Pain was nearly constant, localised to the epigastrium, and made much worse by pressure. He had lost about 15 lbs. in weight, and much strength. Examination showed emaciation and pallor. The abdomen was |