CANADA

MUSEUM OXFORD

MEDICAL & SURGICAL JOURNAL

JUNE, 1879.

Original Communications.

THREE CASES OF MALIGNANT DISEASE

BY RICHARD MACDONNELL, B.A., M.D., M.R.C.S., ENG. Assistant Demonstrator of Anatomy, McGill University, Montreal.

(Read before the Medico-Chirurgical Society of Montreal.)

I propose to read to you this evening the histories of three cases of scirrhus cancer, and I hope by them to illustrate three points in the clinical history of malignant disease.

1. The insidious progress of cancer of the upper part of the rectum and sigmoid flexure.

2. The irregular course of symptoms of cancer of the stomach. 3. The rare co-existence of pregnancy and malignant disease of the breast.

CASE I.-Mary B., exact age unknown, apparently about 70 years of age for many years a widow; of fair complexion, thin but not emaciated. Has been an inmate of the Church Home for many years.

I was sent for on the 28th June, 1878, to visit her. A slight cough, to which she had been subject for many years, was rather worse than usual, and for the first time she noticed the sputa tinged with blood. She had a fairly strong pulse and did not feel ill at all. The hæmoptysis was very trifling. I prescribed rest, cold food, and a mustard poultice to the chest. She was to take a pill of acetate of lead and opium every four hours until I saw her again.

NO. LXXXIII.

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The next day there was no return of the hæmorrhage. There was increase resonance on percussion. Large moist râles over chest generally. Heart sounds normal.

On the third day of the illness there was a slight return of the hæmorrhage. Altogether she had taken three lead and opium pills, for I gave her ergot.

She complained to me that day that her bowels were confined, and I ordered a enema of soap and water.

On the following day she was thought to be quite well, and she resumed her ordinary occupation.

Two days after she was apparently in the best of health, and was doing her daily work in the institution.

Five days after her recovery I received a message to hurry to see Mrs. B. I was out at the time the messenger arrived, and did not get to the Church Home for two hours afterwards. Mrs. B. was just dying; insensible; extremities cold. She died within a few minutes of my arrival,

I was told that that morning she had been uneasy in her bowels, and complained of distension with gradually increasing pain, and that her abdomen had become distended. Turpentine stripes had given momentary relief.

Post-mortem appearances. - Abdomen much distended with gas. The colon was very large, as large as a quart bottle, and dark in colour from congestion. Beginning at the sigmoid flexure and involving the upper part of the rectum was an indurated stricture which almost occluded it. The gut itself was much thickened, and was constricted on the outside.

The colon above contained a large quantity of semi-fluid faces. There were no other lesions except those found in the old cases of bronchitis with emphysema.

The site of the disease affords a definite reason for the absence of pain. Those who have read Mr. Hilton's admirable lectures on" Rest and Pain," will perhaps remember his remarks on this very point.

"Little sensibility and easy dilatibility are the physiological characteristics of the rectum, except at the lowest part, where

great sensibility, difficult dilatation, and enduring power traction are the normal physiological features."

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As practitioners you have no doubt noticed the extreme degree to which this part of the bowel can be distended without even causing inconvenience to the patient, and Mr. Hilton mentions the almost painless operation of tapping the bladder through the rectum, and of applying nitric acid to prolapsed gut. It is still very remarkable that this woman should have been the subject of such serious disease without the existence of premonitory symptoms.

CASE II.-Maria B., æt. about 70. For many years a widow. No family constitutional disease. One sister died of hypertrophy of heart. Two sisters living.

Always enjoyed excellent health. On February 18th, 1878, she first came under my care. She was suffering then from constipation for which the usual remedies were prescribed. On the 18th of April she complained of pain and distension of the abdomen, constipation and loss of appetite.

On that day I thoroughly examined the chest and abdomen, and beyond noticing that the latter was slightly tympanitic, I could find nothing to account for the symptoms. She was greatly relieved by a pidophyllin pill, and by the application of stupes of turpentine to the abdomen.

In the first week of May this pain in the left hypochondrium was very troublesome. It was more a sense of distension, I think, than actual pain. The patient could not localize it; it was not increased by pressure, nor was it influenced by posture. It was not constant, and it had a tendency to become worse at certain hours of the day. It was certainly unconnected with the taking of food, or with its quantity or quality.

There were then only two symptoms, tympanites and pain. The general health was tolerably good. At this time I repeatedly examined the chest and abdomen. The urine neither contained sugar nor albumen. Bowels generally confined. I thought then that the symptoms were due to flatulent distension of the colon.

On the 12th of May I had the benefit of a consultation with Dr. Craik. At his suggestion salicylic acid in small doses was used, with a view to assist fermentation. A great improvement in the symptoms followed, but it was merely temporary.

One day in the latter end of May she caught cold, and during the week ending 1st June, 1878, she suffered from lung symptoms, which were thought by Dr. Craik and myself to arise from a slight pneumonia.

After this attack the old symptoms returned, and then I began to suspect malignant disease. In the middle of June Dr. Howard did me the honour of examining the case with me. We examined the chest, abdomen, rectum, vagina, and urine, but still no light was thrown on the diagnosis.

The pain and typanites continued as obstinate as ever until the 14th of September, when she went under homoeopathic treatment. On the 14th of October I resumed charge of the case again. Much emaciated. Pulse very weak. For the next month she improved rapidly and was soon able to spend her day in a chair. The treatment consisted of anodynes, food and stimulants. The abdomen being now very flaccid, it afforded us (for I had benefit of frequent consultations with Dr. Howard) abundant opportunities for careful examination.

We became day by day more convinced that we had malignant disease of the colon, or of part of the intestine to deal with. For my own part, I did not even suspect the stomach until I had seen, through Dr. Howard's kindness, the autopsy of a patient of his, whose symptoms were all referred to in the intestines, and in whom, after death, the seat of the disease was found to be entirely confined to the stomach, the fatal event being caused by perforation of the pericardium.

The consideration of this case prevented me excluding from my list of possibilities, the existence of extensive organic disease of the stomach.

From the 14th of October to the 26th of November, she was entirely free from pain, but suffered from weakness and constipation. In fact the bowels now never acted spontaneously.

On the 28th of November she had a sharp attack of diarrhoea,

brought on by an overdose of mineral water. It was noticed that the stools were black. They continued so until the 2nd of December. Dr. Howard was of the opinion that the dark colour was due to blood. The pulse was frequent, and she became very anæmic. The pain in the left hypochondrium not so severe as it used to be, but more periodic, generally occurring at 4 P.M. Appetite very capricious. Occasionally slight vomiting, but merely the contents of the stomach were ejected. Never vomited blood. Diarrhoea and tenesmus were present in the month of December. The pulse gradually weakened as the disease advanced, being always regular. Tongue is now dry, brown and fissured.

On the 26th of December, Dr. Howard detected in the left hypochondrium a small movable tumour which was smooth and rolled under the fingers. Throughout the whole course of the disease this tumour afforded us ground for conjecture, but from the fact that at times it could not be found, we hesitated at giving a decided opinion.

At this time pain was very severe, but in the course of a month or so it wore away. She complained greatly of an uneasy sinking sensation in the left hypochondriac region. In March, 1879, hiccough appeared, and refused to yield to treatment.

In the beginning of April oedema, firstly of the feet, and subsequently of the hands, set in. The asthemia became more and more marked, and she died worn out.

Post-mortem Appearances.-Extreme emaciation, oedema of the ankles and hands. Abdomen shrunken and flattened; no tumour could be felt.

On opening the abdomen the lesser curve of the stomach appeared to be puckered and red. An ulcer as large as, and the shape of, the human ear, was found encircling the lesser curve, about an inch from the pylorus. The edges of the ulcer were raised, thickened, and much indurated. The centre of it was very thin, so thin that on slight manipulation a rent was made in it.

Dr. Howard, who was present at the autopsy, thought that it was a large gastric ulcer which had taken on malignant action. We found no other lesion in the body except senile changes.