A man, forty-eight years of age, was admitted into hospital under our care in 1887 for a chronic ulcer of the stomach. For more than a year he had complained of pain and sickness after meals, and on two occasions had vomited a large quantity of blood. Under treatment these symptoms eventually subsided, and he apparently became cured. In 1890 he again sought admission into hospital for severe indigestion. According to his statement he had been perfectly free from pain for more than a year, when, after a few weeks of ill-health, he began to experience a sense of weight and oppression at the chest after meals, attended by flatulence, nausea, and want of appetite. During the last two months he had lost much flesh and felt very weak. There had been no vomiting or haematemesis. On examination he was found to be very thin and markedly anaemic. The stomach was somewhat dilated, and pressure over the region of the pylorus gave rise to pain, but no tumour could be discovered. The temperature was subnormal, the urine healthy, and the blood showed a great reduction in the number of red corpuscles and of haemoglobin, with slight leucocytosis. After a test meal the contents of the stomach gave the reaction for free hydrochloric acid, but were free from lactic acid. For two or three weeks a milk diet was attended by improvement, but subsequently the discomfort after meals increased and vomiting occurred each night. The patient continued to lose flesh and strength, and on two occasions exploration of the stomach with a tube revealed the existence of altered blood in the organ. Free hydrochloric acid disappeared about the fifth month of the disease, but no lactic acid was ever detected. Shortly afterwards he was attacked by pneumonia, to which he succumbed.
Necropsy. On the posterior wall of the stomach, about two inches from the pylorus, was a chronic ulcer the size of a five-shilling piece. Growing from its lower margin and base was a large firm growth of greyish-brown colour, which on microscopical examination proved to be a spheroidal-celled carcinoma. The lymphatic glands along the lesser curvature and behind the stomach were enlarged, but there were no metastases in the liver or other organs.
A woman, aged thirty-five years, was admitted into the Westminster Hospital on April 12, 1900, suffering from what was supposed to be a gastric ulcer. She stated that in 1894, about a month after the birth of her first child, she had pain in the chest and back, coming on soon after food and relieved by vomiting, but unattended by haematemesis. This lasted for three and a half years, when the symptoms subsided, and for six months she suffered from no discomfort or inconvenience. A month before the second child was born she had another attack, which lasted nine months, during which time she frequently brought up blood, but never in large quantities. About sixteen months ago she again became pregnant, and since then had suffered constantly from gastric symptoms. The pain after meals had become more pronounced and the vomiting more frequent. She stated that, with intermissions, her illness had lasted for six years, and during the last two years she had lost flesh considerably.
On admission the patient was found to be very thin, but she presented no cachectic appearance; her weight was five stones eight pounds. She complained of a.feeling of oppression in the epigastric region, culminating in acute pain after food and relieved by vomiting. The vomited matter consisted of undigested food with a quantity of yellow frothy fluid having an acid reaction. There was very little abdominal tenderness, the stomach was only slightly dilated, and there was some thickening about the pylorus. The temperature was normal, and the urine had a specific gravity of 1020 and contained no albumin.
The patient was kept in bed and was placed on three pints of peptonised milk-five ounces every two hours-with plasmon custard; but the vomiting was so persistent that nutrient enemata with suppositories of beef peptones were substituted. These suppositories contained 50 per cent, of peptone of beef, and each weighed 72 grains. The bowels were relieved from time to time by a simple enema. On this treatment she progressed favourably until May 14, when there was a sudden rise of temperature. At 7 a.m. it was 103.4° F., and at 3 p.m. it was 104.6°, the pulse being 136. There was no sore throat, or pneumonia, or endocarditis, and apparently nothing to account for it. She was put on small and frequently repeated doses of tincture of aconite, and on the following day the temperature fell to 100° F., although henceforth it was never quite normal and ranged from 100° to 101° F. On the 16th she started an attack of diarrhoea, which proved extremely obstinate and continued until her death. There were often from ten to twelve evacuations in the twenty-four hours. The motions were loose, but not watery; they were small and greenish-brown in colour, not slimy, but very offensive. Various modes of treatment were tried, without avail, including saturated solution of camphor in alcohol (three drops every five minutes) drachm doses of carbonate of bismuth every four hours, enemata of opium (fifteen drops of the tincture in two ounces of mucilage of starch), and from time to time pill of lead and opium. That these remedies were ineffectual is shown by the fact that she had 103 motions in twenty days, exclusive of those which were too small to note. Once or twice the stools were dark in colour and contained what was apparently broken-up clot. The patient gradually lost ground, and early in May a small nodular mass was felt to the right of the middle line, midway between the umbilicus and the ensiform cartilage. The stomach was dilated, but not markedly so. On May 26 it was obvious that she was critically ill. She was losing flesh rapidly and was too weak to get out of bed. There was considerable anaemia, and the face looked almost as if it were jaundiced, although the conjunctivae were white. She was in no pain but took very little nourishment. The tongue was moist and tremulous, and there were streaks of fur in the centre. The diarrhoea continued, and there was prolapse of the rectum. There was no albumin or sugar in the urine. The stomach was more dilated, but the liver was not enlarged.
At the necropsy the stomach was found to be adherent about the pylorus to the liver. It was dilated, and at the pylorus there was an ulcer consisting of two distinct parts. One, which was directed towards the stomach, was cicatrised, and this was adherent to the liver; and the other, directed towards the pylorus, was fungoid in appearance. The two ulcers together were of about the size of a five-shilling piece. There were enlarged glands in the portal fissure and in the neighbourhood of the growth. There were no secondary deposits in the liver, which was fatty. The intestines showed melanic contents in places, and the villi were atrophied. The spleen, adrenals, pancreas, kidneys, bladder, uterus, and ovaries were normal. Microscopical examination of the growth, showed that the condition was one of spheroidal carcinoma. The muscular tissue about the pylorus was being invaded by a growth poor in cells and suggesting scirrhus. Recorded by Dr. Murrell.
(b) In about 15 per cent, of the cases the symptoms of gastric ulcer continue prominent throughout the whole course of the complaint. Pain is experienced after every meal, whether it be composed of liquids or solids, and in many instances there is a marked intolerance of milk. Vomiting occurs frequently, and is often particularly troublesome at night, while from time to time attacks of excessive retching supervene, which persist for several days and preclude the administration of food by the mouth. Pyrosis is almost always a source of complaint, and extreme thirst may be present. As a rule, the appetite gradually diminishes or is replaced by an intense craving for food, which disappears after a few mouthfuls have been swallowed. Loss of flesh is invariably a marked feature of the case, and the patient becomes exhausted after the least exertion. Profuse haematemesis is also apt to occur, and may prove fatal, while occasionally life is suddenly cut short by perforation of the stomach. Examination of the abdomen rarely affords any evidence of carcinoma, since a tumour and secondary growths are seldom encountered, while any dilatation of the stomach which may exist is usually ascribed to the ulcer. The gastric contents usually exhibit an excess of free hydrochloric acid for several months, and not infrequently the signs of hyper-secretion continue until the end. Cases of this description are extremely difficult to diagnose, and it is only by noting the disproportionate loss of flesh and strength, and perhaps a steady diminution in the secretion of hydrochloric acid, that a cancerous invasion of the ulcer can even be surmised.
(c) Complete latency of the gastric symptoms with a precocious development of secondary growths in the liver or peritoneum occurs in only about 5 per cent, of the cases. In such the ulcer of the stomach appears to undergo cicatrisation, but leaves behind it a tendency to flatulence and distension after meals, with an enfeebled appetite and great weakness. After this condition of ill-health has continued for some months attention is again attracted to the abdomen, either on account of pain in the chest or back, accompanied by signs of enlargement of the liver, or by the development of ascites. As soon as these signs show themselves emaciation progresses rapidly, pain or vomiting is experienced after meals, and the disease runs its usual course.