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ARSENIC POISONING.-Arsenic interferes with the normal metabolism, but the exact nature of the chemical changes which occur is not understood. While beneficial in very minute doses, in sufficiently large quantities it may produce inflammation in any part of the body, either applied directly or through the circulation. The stomach may be irritated by direct action, or after the arsenic is absorbed the stomach may become the seat of inflammation from the arsenic in the circulation. The arsenic in the circulation reaches all tissues. Almost all of the symptoms are produced by the action of the irritant in this manner. There can be little or no doubt that the cause of the recent Manchester epidemic was due to arsenic, because there was an absence of any other sufficient cause. Sufficient arsenic was discovered to produce the symptoms of poisoning, and the symptoms were identical with those produced by chronic arsenic taken in other ways.-T. Lauder Brunton, in Lancet.

TREATMENT OF PNEUMONIA.-Dr. Thomas R. Brown, after a short review of the various shifting modes of treatment of this disease, says that the failures of the past should not be forgotten, and that no line of treatment should be followed in which the good does not definitely outweigh the bad. Pneumonia is not a disease of the lung solely, but also a general toxemia, and thus in discussing the subject the possibilities of direct and indirect treatment should be considered. The early work of the Klemperers gave much encouragement to the hope of the probable efficacy of an antitoxin; thus far, however, the results have been problematical, but the attitude at the present time is promising. As to the advances along the indirect or symptomatic mode of treatment, the author believes that the best results are obtained by careful nursing, diet, hygiene, and by the systematic use of hydrotherapeutic measures during the entire course of the disease, cold sponging and cold packs being more practical than the full tub. Saline infusions are to be employed in the patients who have faint heart sounds and a weak pulse. One or two pints should be used. Inhalations of oxygen or medicated oxygen vapors are valuable in extreme cases. Morphine for pain, alcohol and strychnine for stimulation, are the most reliable drugs. Caution should be taken that thorough disinfection of the sputum is carried out.-Maryland Medical Journal.

INTESTINES, SARCOMA OF.--Sarcoma of the intestine is more common than text-books indicate. It much more frequently affects the small than the large intestine. The ileum seems to be its favorite location. Sarcoma rarely produces stenosis. Dilatation is more frequent. Usually it grows from one side of the bowel entirely. The diagnosis is difficult and will always remain obscure; still, if a smooth, freely movable tumor be found in the abdomen, unless it can be otherwise satisfactorily accounted for, one should be reminded of the probability of sarcoma of the intestine, especially if there is also present the general picture of sarcoma, with its peculiar anemia. C. Van Zwalenburg (Jour. Amer. Med. Association).

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Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

REPORT OF A CASE OF CANCER OF THE STOMACH.*

BY WILLIAM A. JENKINS, A. M., M. D.

Lecturer on the Practice of Medicine and Assistant Demonstrator of Anatomy in the
Kentucky School of Medicine.

T. S., male, colored; single, aged fifty years, a day laborer by occupation, came to me for treatment in December, 1900. In so far as I was able to judge from questioning him there was no direct evidence of syphilis, tuberculosis, or cancer in his family. He states that both of his parents died in a dropsical condition; patient had typhoid fever at the age of twelve. He gave a history of two or three attacks of subacute articular rheumatism.

Aside from this he was exceptionally healthy in his younger days; passed the physical examination for service in the regular army, and served for five years at Fort Sill. Patient denies syphilis, and physical examination fails to show any evidence of either syphilis or tuberculosis; states that he drank a great deal of whisky, and that he habitually took a drink before breakfast. The patient first noticed his trouble in July or August, 1900. At that time he began to have indigestion, as he termed it; his appetite was variable, and he was troubled some with constipation; there was a feeling of fullness after meals, with occasional regurgitation into the mouth of particles of food and sour material. Symptoms gradually became worse; he began to have attacks of pain in the epigastric region, increased on pressure; noticed some loss of flesh; felt tired and weak, and had no strength. He began *Read before The Kentucky School and Hospital Medical Society, January 23, 1902. For discussion see page 178.

to vomit about the first of November, 1900. At first he vomited about once in six or eight days.

This history brings the case up to December, 1900, when he first came to me. At his first visit I made a thorough and careful physical examination of the man. He possessed a large, emaciated frame. The examination of the chest was negative; heart perfectly normal, lungs sound. No evidence of arterio-sclerosis. Patient complained of an occasional difficulty in swallowing.

Abdominal examination: Inspection negative; palpation disclosed a sense of resistance; a mass just to the left of the xiphoid appendix and under the margins of the cartilages of the adjacent ribs on the left side. There was dullness on percussion in the same area, and pain on pressure. No deformities, no paralysis, no disturbance of the nervous. system; in fact, the man did not exhibit any evidence, either organic or functional, of derangement of any organ or part of the body except that group of clinical symptoms and physical signs which pointed to his stomach trouble.

Urinalysis as follows: Acid reaction; specific gravity 1,030; a sediment of urates; no albumen, no sugar; a few epithelial cells; no casts; urea 1.6 per cent; uric acid and oxalate of lime crystals present. Vomiting was now occurring every two or three days, and consisted of a pale, sour, watery fluid, containing undigested food. Never at any time throughout the case was there the least appearance of blood, coffee-ground or otherwise.

I suspected and suggested cancer of the stomach, and in my own mind diagnosed the case as such. I desired to make use of a test-meal and the stomach-tube, but the patient would not permit it. However, I obtained some of the vomitus while it was fresh, on two separate occasions. An examination of this material showed total acidity .55, free hydrochloric acid absent, lactic acid present.

The man came to me from time to time, and continued to complain of difficulty in swallowing; said that he could hardly swallow at all. I gave him some water to drink before me. He was unable to place the glass to his lips and empty it without removal, but was obliged to take a small amount of water in his mouth, swallow it, rest a moment and take another swallow, and so on. During the months of February and March, 1901, the emaciation was becoming extreme. I requested him to have himself weighed; he did so, and found that he weighed 118 pounds, his normal weight being between 160 and 170 pounds.

Some edema of the ankles made its appearance at this time. His urine was examined again and showed acid reaction; no albumen; specific gravity 1,025; no sugar; a few granular casts; uric acid and oxalate of lime crystals. He now vomited at almost any time, sometimes twice a day. The difficulty in swallowing, taken in connection with the situation of the tumor mass on examining the abdomen, led me to the opinion that the chief point of involvement was about the cardiac orifice (which conclusion the post-mortem confirmed).

[graphic][subsumed][subsumed]

A-Cardiac orifice of stomach, where esophagus was severed. B-Spleen. C-Interior of stomach. D-Pyloric end of stomach.

When the man first came to me I placed him on a liquid diet, chiefly sweet milk and broths, such as oyster, beef, mutton, and chicken broth. After feeding he was given two teaspoonfuls of the following combination: Phenolated essence of pepsin, diastatic essence of pancreaticus, ää oz. iv. During the last two months of his life I depended entirely on peptonized food, chiefly milk and liquid peptonoids, usually adding a little crushed ice, as it seemed to render the nutriment more palatable to the patient. For the nausea I used a tablet containing cocaine, gr.; oxalate of cereum, bismuth subnitratis, aa gr. iiss. The tablets were given when required. On the 7th day of May, 1901, the man died. A post-mortem was held. I removed the stomach, and present it for your

consideration in connection with the history of the case. The specimen is a very interesting one, and is well preserved, as you see. The stomach, spleen, left kidney, and the diaphragm were all adherent in one mass; also a part of the transverse colon and a small portion of the abdominal aorta were so bound up by adhesions that they had to be removed with the stomach. The greater portion of the stomach was involved, the point of least involvement being the pyloric end. The retro-peritoneal glands were enlarged and hardened; there was some involvement of the thoracic lymphatics. The cardiac orifice was so stenosed that you could hardly introduce an ordinary lead pencil into the opening. An incision was made into the stomach and its interior was examined carefully for ulcerated areas; none were found. I present some microscopical sections which were taken from different parts of the stomach and from the peritoneal glands. If you will look at them under the microscope you will see how prettily they illustrate the method of growth and the arrangement of the non-ulcerative or cylindrical cell type of carcinoma.

The chief feature of this case to me personally is that I was able to obtain a post-mortem-to see with my own eyes and examine with my hands the conditions and relations of the various abdominal organs, as well as to examine sections of the stomach with the microscope—thus confirming my diagnosis and indelibly imprinting the case on my mind. This opportunity, as you all know, is very rarely obtained in private practice.

As regards the etiology of this case I have very little to say. The medical profession are not agreed definitely on the cause of cancer. Heredity, age, abuse of the stomach from eating or drinking, germs, and the formation of cancer on an old ulcer base, are the principal things mentioned as etiological factors in the production of cancer of the stomach. I know that the patient was addicted to alcohol, and I have his statement that both of his parents died in a dropsical condition, and that is all the positive information obtainable that would tend to throw any light whatever on the cause of the trouble.

The pathology has been pretty well covered in the report of the case and by the exhibition of the specimen itself, showing very nicely the unusual amount of involvement at the cardiac orifice, the extensive adhesions and the lymphatic involvement. The stomach is markedly reduced in size.

In the series of forty-five cases reported by Osler, ulceration was present in thirty-five. Metastasis occurred in thirty-nine cases of this

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