A medical man, aged forty-three, engaged in a large practice in London, consulted us in October 1895 for indigestion. He stated that he had been perfectly well until the 9th of September, when, after attending a public dinner and eating more than was his habit, he felt very unwell and vomited a large quantity of undigested food. After taking the usual remedies and restricting his diet for a day or two, he found that instead of recovering the power of digestion he was unable to take solid food without discomfort,, and within a week was obliged to confine himself to milk and other liquid forms of nourishment. Since that time he had constantly suffered from nausea, flatulence, and acidity, had grown very weak, and had lost nine pounds in weight. On examination the stomach was found to be slightly dilated, and to contain a large excess of mucus, but no free hydrochloric or lactic acid. No tumour could be detected, nor was there any evidence of disease in the other organs of the body. But in spite of the most careful dieting and medicinal treatment, flatulence, acidity, and nausea ensued after every meal, and within a few weeks a strong aversion to food manifested itself. When seen a month later the patient was found to have lost nearly a stone in weight, and appeared extremely weak. The dilatation of the stomach was now marked, and its contents exhibited an abundance of lactic acid. There was also complaint of constant micturition, and on examining the pelvis a tender mass about the size of a walnut could be felt between the rectum and the bladder. Sis weeks later the debility had increased so much that we found him confined to bed. Nausea and vomiting ensued about an hour after every meal, and the bladder symptoms were very troublesome. The abdomen was distended and contained a small quantity of free fluid, while several indefinite tumours could be felt near the umbilicus and in the left iliac fossa. Death occurred almost exactly five months after the onset of the acute symptoms, and at the autopsy there was found colloid infiltration of the pyloric half of the stomach, with implication of the omentum and pelvic peritoneum.
(b) When acute pain constitutes the first indication of the disease, the growth is usually localised to a comparatively small area of the stomach, and is found after death to be extensively ulcerated. It is probable, therefore, that sudden sloughing of its substance was the cause of the symptom in question. Not infrequently the pain develops soon after some physical effort, when the patient feels as though something had given way in his abdomen, and is seized with faintness and vomiting. Subsequently the suffering is more or less continuous, and is especially severe after meals or upon exertion. The following case is a good example of this mode of onset.