A man, forty-one years of age, stated that for two months he had suffered from pain after meals, flatulence, and oppression at the chest. He had also vomited occasionally, but had never brought up any blood. The indigestion had been accompanied by loss of appetite and progressive debility, but he did not think that he had lost much flesh. A week before he came to the hospital he had been suddenly seized with stabbing pain in the abdomeD, which caused him to feel sick and ill, after which the stomach began to swell. On admission the abdomen was uniformly enlarged, and the superficial veins were more prominent on the right than on the left side. When he lay upon his back the signs of ascites were very obvious, but percussion over the umbilical region elicited a dull note instead of the tympanitic resonance due to floating intestine. It was also observed that the right loin was dull posteriorly, while on the left side the percussion-note was resonant from the lower ribs to the crest of the ilium. No tumour could be felt even after the evacuation of several pints of fluid. Although paracentesis afforded considerable relief, the patient's strength rapidly failed, and he died at the end of six weeks.

Necropsy. There was considerable ascites present. The colon, small intestines, great omentum, and stomach were united into a mass which was attached to the spine on the left side. The whole of the peritoneum was much thickened and covered with miliary carcinoma. The stomach was contracted and its walls greatly thickened by scirrhous infiltration, but the pylorus was not affected nor was the mucous membrane ulcerated.

Among the clinical records of the London Hospital of the last twenty years we have discovered fourteen cases in which ascites constituted the sole indication of cancer of the stomach. In six of these progressive enlargement of the abdomen, followed by oedema of the legs, was the first symptom to attract the attention of the patient; in six the ascites had been preceded for a month or two by pain or discomfort after meals, flatulence, and vomiting; while in the remaining two the gastric and peritoneal symptoms appeared to develop at the same time. It may therefore be concluded that in at least one half of all cases there is no evidence to connect the ascites with a malignant growth of the stomach.

As the disease progressed pain and distension of the abdomen, accompanied by shortness of breath and palpitation, were invariably present, but only in one third of the cases was there any complaint of pain after food or vomiting. The temperature was subnormal in every instance except one, where the peritonitis was ushered in with slight fever. A palpable tumour existed in four cases, and in each instance it was found to be due to infiltration of the great omentum. In the remainder the peritoneum was affected with miliary cancer, and the stomach was situated too deeply to be detected by palpation. Effusion into the pleura occurred in one third of the cases, and was more frequent on the left than on the right side. In one case the pericardium became inflamed immediately before death. In every instance the ascites was considerable in amount, recurred rapidly after paracentesis, and as a rule the contraction of the mesentery caused the intestines to be covered by fluid, so that the anterior aspect of the abdomen was dull instead of resonant on percussion. Occasionally adhesion of the bowel to the spine or the kidney gave rise to a tympanitic note over the lumbar region. Cases of this description run their course with great rapidity, for we find that the average duration of life in those of our series was only seventeen weeks.

The Dyspeptic Form

This occupies an intermediate position between the latent and the ordinary varieties of the disease. It is characterised by the presence of dyspeptic symptoms resembling those of an inflammatory or nervous affection of the stomach, which no form of treatment will relieve and which are accompanied by progressive loss of flesh and strength. Pain after food is rarely complained of, but there is a constant sense of uneasiness, discomfort, or distension, which is increased by liquid as well as solid food, and is attended by anaemia and obstinate constipation. Nausea is often present in the early morning or after meals, but vomiting seldom occurs and haematemesis is exceptional. At a late stage of the complaint, however, a small quantity of altered blood may sometimes be extracted from the stomach. Examination of the gastric contents after a test meal shows a marked deficiency or entire absence of free hydrochloric acid, but lactic acid may not exist until shortly before death. Careful examination usually reveals a moderate degree of dilatation of the stomach, and not infrequently a tumour in the region of the pylorus. Owing to the insidious nature of the complaint, life is often prolonged for a considerable period, and we have met with several cases where the persistent and progressive character of the symptoms seemed to indicate a duration of three or four years. In other instances involvement of the pylorus or cardiac orifice by the growth leads to the development of periodic vomiting or dysphagia, which soon brings life to an end.

It is worthy of notice that the occurrence of pregnancy almost invariably gives rise to excessive vomiting, which no treatment will allay, and which does not subside even after the induction of abortion.