CASE LXII. Cancer of Stomach.-Martin F—, æt. 65, admitted into Guy's, Aug. 8th, 1856, and died November 23rd. He was admitted with the ordinary symptoms of cancerous disease of the stomach, and gradually sank.

Inspection was made thirty-two hours after death. On opening the abdomen, the intestines and stomach were found to be collapsed; at the lesser curvature of the stomach were several hard glands, some adherent to the stomach, others to the pylorus; some of these were softening in the centre. On opening the stomach, the pylorus was found to be very much contracted, its walls of a yellowish white colour, and soft consistency, replacing the ordinary muscular and mucous coats. It was evidently cancerous. The muscular coat was not hypertrophied as we generally find in obstruction at the pylorus, showing that the passage had remained tolerably free. Near the lesser curvature one of the tumours was beginning to protrude.

At the upper part of the œsophagus the mucous membrane appeared as if it were affected with cancer; numerous oval slightly raised spaces were of a whitish colour, and firm in consistency; they did not contain the elements of cancer; the apices of the lungs were adherent, and presented some grey induration at that part; other tissues healthy, except two small cancerous masses in the liver.

I have introduced this case to show by the inspection after death, that the hypertrophy of the muscular coat is sometimes very slight, although the disease had existed at the pylorus.

The preceding cases indicate-1. That the symptoms of cancerous disease of the stomach may be exceedingly slight, and the disease easily overlooked. 2. That the indications are more marked where the orifices are affected. 3. That in most cases death takes place from exhaustion or asthenia. 4. Fatal hæmorrhage and perforation are more rare than in ulceration of the stomach. 5. That the absorption of degenerating cancer structure sometimes leads to symptoms resembling pyæmia. 6. That some of the distressing symptoms may be alleviated; but that over-active treatment appears to hasten the fatal termination.

CHAPTER IV.

FUNCTIONAL DISEASES OF THE STOMACH.

THE imperfect action of the organs of digestion arises from very varied causes, and its several forms are generally associated together under the term dyspepsia.

It is very frequently found at the commencement of serious organic changes in the stomach, which steadily advance to a fatal termination. In by far the larger number of instances its symptoms pass off, or are mitigated after a longer or shorter period; and where the immediate cause of death has arisen from other diseases, we are often unable to find any structural change in the stomach, either in its secretions or component parts, although dyspepsia may have existed for some time; these cases constitute what are ordinarily regarded as functional diseases of the organ, the conditions being either transient or of such a character as to be beyond our sphere of observation.

Dyspepsia arises, 1. From abnormal condition of the mucous membrane and its secretion; 2. From the muscular movements being impeded ; 3. From the state of the vascular supply; 4. From the condition of the nervous system; and lastly, From the character and changes which take place in the food. Several of these causes of dyspepsia may be combined; some lead to disease of a very transient form, others are irremediable.

1. Dyspepsia from abnormal condition of the mucous membrane and its secretion.

The experiments and observations of Dr. Beaumont on Alexis St. Martin have pointed out the state of the mucous membrane which sometimes exists after improper food or stimulants; the surface of the stomach he found in such cases much injected, or

erythematous. The secretion diminished, and during this period more or less discomfort was generally produced; this condition entirely ceased in a short time, and the surface presented its usual appearance; but if death had taken place from some other cause during that condition of dyspepsia, this abnormal state would have disappeared, and no structural lesion have been discovered on careful or even microscopical inspection. The deficiency of gastric juice may be a relative rather than an actual one. A greater amount of food being taken than is needed for the system, or than can be dissolved, it remains in its undigested state and acts as an irritant, becoming a very fertile source of dyspepsia; the crude substance not only disturbs the stomach and its secretions, but if it be allowed to pass the pylorus acts upon the whole canal; or fermentative changes are set up, which we shall afterwards have to notice.

Where excess of this kind is habitual more permanent results follow, which resemble those found in some cases from diminished secretion.

In describing the various forms of dyspepsia which have their origin in an abnormal condition of the gastric juice, we may divide them as follows:-1st. It may be deficient in quantity; 2nd. Irregularly secreted; 3rd. In excess; 4th. Changed in character, as in pyrosis, in gout, or lithic acid diathesis, or in albuminuria.

The deficient secretion produces varied symptoms, and may arise from many causes. After intemperance, either in eating or drinking, the gastric mucous membrane becomes over stimulated, the portal system engorged, and the liver congested and disordered; in this state secretion does not take place in the stomach, and dyspepsia is produced.

The complexion becomes slightly sallow, the tongue furred, the appetite impaired, occasionally slight nausea or vomiting, thirst, mental depression or headache, in some cases pain at the scrobiculus cordis, and between the shoulders or in the bowels supervenes, and there may be diarrhoea.

Where excess is habitual the same symptoms are produced, but modified; the patient is hypochondriacal; he often believes himself to be the subject of serious disease of the liver, the bowels are constipated or irregular; flatulence, spasmodic

pain or cramp in the abdomen, pain across the chest, or tenderness at the scrobiculus cordis are produced; the tongue is furred, or its papillæ are distinct and injected, the pulse compressible; there is often a sense of exhaustion and imaginary physical fatigue or loss of muscular power. Sometimes there is severe headache, vomiting, disturbed vision, loss of sleep, or dreams. In this condition food taken into the stomach remains undigested, and there is a sense of weight or "load at the chest."

Where these symptoms result from totally different causes they are greatly modified. The deficient secretion does not arise from vascular plethora, but the reverse; sedentary occupations, want of exercise, mental distress, over excitement, anxiety, or insufficient food. Here we find loss of appetite or a fastidious one, pain in the head, the tongue slightly injected in its papillæ, and whitish fur upon it, though in many cases the tongue is clean, large, and indented; there is sometimes nausea, or actual vomiting, the bowels are constipated or irregular; a sense of oppression or weight comes on after eating, sometimes followed by a throbbing sensation in the abdomen and almost over the whole body, with languor or drowsiness; at other times there is faintness, and where undigested food passes into the pylorus and duodenum, violent cramp or spasmodic pain is produced.

Ingesta may be retained in the stomach many hours, and in some cases even days in a crude state; the secretion is not sufficient to dissolve what is placed in the viscus; the irritation produced by the retained food aggravates the ailment, and fermentation or decomposition is set up, with flatulence, pain, heartburn, or severe gastralgia. This, however, may arise from excess of food rather than diminished solvent power, as we have previously noticed.

In the treatment of this form of dyspepsia, arising from repletion, an emetic is advisable; if more chronic effects have been produced, small alterative doses of blue pill, with rhubarb and magnesian purgatives; by these means the portal system becomes freed from engorgement, and proper secretion takes place; should sense of exhaustion then continue, it is well to give hydrochloric or nitro-hydrochloric acids with infusion of gentian or calumba.

The character and quantity of the food is a most important

a bean; these were soft, gelatinous, and of a red colour. The sac of the lesser omentum contained similar tubercles as the general cavity of the peritoneum, and was distended with fluid. The cavity of the stomach was small, its parietes thickened; and at the lesser curvature from the œsophagus to the pylorus, the mucous membrane was irregularly raised, and presented an appearance of cells distended with clear gelatinous fluid. The larger curvature was healthy. Liver small, and of a deep bilious colour; the hepatic cells contained very little fat. The pancreas and the small and large intestines were healthy, but at the commencement of the rectum was a small nodule of cancerous growth; this had led to thickening of the mucous and muscular coat, and the intestine at that part would scarcely admit the index finger. Preparation No. 181330.

The microscopical examination showed well-marked characters of colloid cancer. The growths on the peritoneum consisted of large compound nucleated cells, and a delicate intervening fibrous tissue. In the omentum, there was a greater quantity of fibrous tissue between the cells, some of the cells contained four or five large nuclei, rendered very distinct by acetic acid. The mucous membrane of the stomach presented similar structural elements. The affection of the rectum in this case was an interesting association of disease.

CASE LIX.-Medullary Cancer of Stomach, and Liver, Lungs, &c.— William C―, æt. 60, admitted into Guy's Feb. 12th, and died March 7th. He was a patten-maker at Woolwich, and of temperate habits. Three months before his death he began to experience pain at the scrobiculus cordis, and in the loins, but had no vomiting till a short time before his death, when he brought up coffee-ground substance. On admission he was feeble, emaciated, and anæmiated; his pallor, however, increased; and it was evident that he was rapidly sinking. At the right hypochondriac and epigastric regions a large tumour could be felt.

Inspection was made eleven hours after death. On removing the liver and bringing the stomach into view a large cluster of malignant glands were seen at the lesser curvature, one being the size of an egg. From the great amount of disease, and the enlargement of the liver, the cancerous tubera in the two parts came into contact. When the stomach was opened, a large tumour was found within it, occupying the lesser curvature. It was sloughing, of a greenish brown colour, and very offensive, and its tissue broken up; it was very vascular, and had no doubt been the source of hæmorrhage. It was nearer to the œsophageal opening than the pylorus, and occupied about half the length of the lesser curvature. The stomach was elsewhere healthy, and contained a light brownish fluid. At the seat of the growth the walls of the stomach were beginning to slough.

The liver was much enlarged by carcinomatous growths throughout the substance; the cancer was soft, red, and very vascular.