Cardiac disease : no gastric symptoms, but a palpable tumour of the stomach. A woman, fifty years of age, was admitted into the London Temperance Hospital on account of urgent dyspnoea and oedema of the legs. She had suffered from rheumatic fever in early life, but had enjoyed good health until five months previously, when she began to experience shortness of breath upon exertion and to lose flesh. She had never had any pain after meals, but occasionally complained of nausea in the early morning and exhibited a strong distaste for food. On examination the heart was found to be much dilated, and both the mitral and aortic valves were obviously incompetent. The liver was enlarged and tender, and the abdomen was distended with fluid. Treatment directed to the state of the heart led to considerable improvement, and a diminution of the ascites permitted the detection of a round and somewhat painful tumour situated immediately above and to the left of the navel. This mass increased in size and became the seat of occasional shooting pains, but there were no gastric symptoms. Death ensued quite suddenly from syncope. Post-mortem examination showed that the great curvature of the stomach was affected by a carcinomatous growth which had partially invaded the transverse colon.
(c) It is a common clinical observation that a rapid involvement of the liver usually masks the symptoms of the primary growth in the stomach, which is often found after death to be quite inconsiderable in size and may even have undergone partial cicatrisation. In such cases severe pain and vomiting after meals are usually absent, and the patient merely complains of nausea, distension, and flatulence. On the other hand, the hepatic affection is accompanied by constant pain in the epigastrium or right side of the chest, ascites, cachexia, emaciation, and sometimes by jaundice. The disease runs its course in five to seven months, and in the absence of a necropsy the patient is usually supposed to have died from primary cancer of the liver. The frequency with which this mistake is made is indicated by the fact that nearly one third of all cases which are diagnosed as ' cancer of the liver' are found after death to present a primary growth in the stomach.
Occasionally a patient will seek advice solely on account of symptoms arising from metastases in the lungs, pleurae, bones, lymphatic glands above the clavicle, or even from multiple growths in the skin. In the following case all the symptoms pointed to a primary tumour of the brain, and no suspicion of malignant disease of the stomach was entertained.