^:x- (o o ^t&^ % ^"*VI /■' r ON THE MORBID ANATOMY AND SYMPTOMS OF CANCER OF THE PANCREAS. BY J. DA COSTA, M.D. "4: r\i^Qc, ''.ZLOllA'* [Extracted from the Proceedings of the Pathological Society of Philadelphia.] PHILADELPHIA: J. B. LIPPINCOTT & CO. 1858. J~ ON THE MORBID ANATOMY AND SYMPTOMS OP CANCER OF THE PANCREAS. Dr. Da Costa presented the following paper on Cancer of the Pan- creas.__At a former meeting of the Society I exhibited a specimen of primary cancer of the pancreas, and was requested to report more fully on the occurrence of this affection, and on the symptoms by which it is marked. In accordance with this wish, I beg leave to present this paper, accompanied by a table of thirty-seven cases, derived from various sources, and including two brought before the Society. I have not endeavored to swell the number by instances adduced from the older writers; I have not included in the subjoined table the three cases of Morgagni, the five cited by Bonetus, or the thirty-six obser- vations on scirrhus of the pancreas, which Lieutaud bas collected; nor have I referred to the oft-mentioned, but exceedingly unsatisfactory ac- counts given by Ileberden; but I have attempted to bring together the cases of pancreatic disease which have been published by authors still living, or not long deceased, and such as seemed to have been undoubt- edly cancer of the organ. The great difficulty, indeed, in studying cancer of the pancreas is, that, while the older writers have most evidently confounded all chronic altera- tions of the pancreas under the title of scirrhus, many of the later phy- / 4 CANCER OF THE PANCREAS. sicians have taken the ground that cancer does not affect this gland, that all the observations, certainly those of primary cancer, are erroneous, and have brought about a skepticism with reference to the whole subject, which, in connection with the rarity with which the organ is carefully inspected in post-mortem examinations, has tended much to retard our knowledge of its morbid states. Yet there are (leaving out the descriptions of the older writers) a sufficient number of well-authenticated cases of disease of the pancreas on record, not only to prove that the gland is frequently the seat of cancer, but also that, in all probability, cancer is the most common of its chronic affections. These very cases, too, demonstrate that the malignant diseases of the organ are not always, as has been affirmed, secondary, but that cancer may commence in the pan- creas and be confined to it, or else extend from it to surrounding tex- tures. (See cases recorded in the Table.) When the pancreas becomes cancerous the disease usually attacks its right extremity. The whole gland may be equally affected, or only the middle portion and the splenic end suffer (Case 31;) but this is not frequent. For the most part the cancerous change takes place mainly, if not solely, at the head, the other portions remaining healthy, becoming indurated, or undergoing a fatty degeneration. The disease shows a great tendency to spread to the adjacent lymphatic glands, and a cancer of the pancreas often in reality consists of the transformed head of the organ, so closely blended with these glands, as to have occasioned an apparently uniform tumor of considerable size, which, by pressure, produces obstruc- tion of the ducts leading from the liver, or changes in structure in the surrounding tissues. Scirrhus and encephaloid are both met with in the pancreas, and run the same course as in other organs. Colloid deposits, too, have been described as occurring. (Dr. Wilks; see Table, Case 32.) The natural structures disappear entirely, and the microscope exhibits nothing but abnormal cells, or else the cancer may be infiltrated through the regular gland-tissue. The form and size of the pancreas are materially modified by the cancer- ous disease, especially is the size. Enlargement almost invariably occurs, and the organ may exceed three or four times its natural bulk. Dupon- chel* relates the case of a soldier who died at Cadiz after a long and obscure disease of the abdomen, and in whom a large tumor, of the size of a child's head, consisting of a brownish matter resembling coagulated blood, and of a broken-down cerebral-like substance, was found occupying the place of the pancreas, of the glandular structure of which not a ves- * Bulletin de la Society Med. d'Emulat. Mars, 1824. CANCER OF THE PANCREAS. 5 tige remained. A mass of similar size occurred in the case of a woman described by Caspar.* The pancreatic duct often becomes implicated in the disease. Some- times it remains pervious, but at others it is entirely obliterated. It may be pervious in the diseased mass, or where it opens into the intestine, while at the more healthy portions of the gland it is obliterated. Again, the reverse takes place ; it permits the pancreatic secretion to flow, until it reaches the diseased portion of the pancreas, but here and at its mouth it is closed. Cruvelhierf met with what appeared to be a cyst in the pancreas, but which, on closer examination, was proved to be the much- dilated pancreatic duct, the duodenal extremity of which was strongly compressed by a scirrhous degeneration of the head of the pancreas. A still more remarkable case happened a few years ago in the clinical wards of Professor Bamberger.£ The duct, by pressure at a part of its course, was dilated into a cyst, containing a yellowish-red fluid, of the size of a man's fist. True cysts, however, occur in cancer of the organ; their walls are thin and translucent; their contents may be a bloody serum, (Case 19,) or blood mixed with broken down tissue. (Duponchel, loc. cit.) The effects of pancreatic cancer show themselves chiefly on the adjacent organs. Secondary cancers in the brain are not described, nor do the thoracic viscera become often affected. Albers mentions a case in which the lungs were filled with small, yellowish cancerous de- posits; Bennett (Clinical Lectures) one, in which gelatinous-looking masses in the lung proved, when microscopically examined, to be cancer; and it is not improbable that the "pulmonary consumption" in Sewall's case (Case 3) was cancer of the lung, as it did not come on until a long time after the pancreatic disease was fully developed. The stomach, intestine, and liver, from their proximity to the pancreas, are the organs which suffer most. The stomach may be perfectly healthy, or it may be adherent to the pancreatic tumor and thickened, especially near the pyloric ex- tremity. The thickening is due to a simple increase of the normal struc- ture, or to a cancerous deposit in the coats of the organ. The pyloric orifice may be narrowed, and so pressed upon by the tumor as to be nearly obliterated, (Case 2.) The mucous membrane of the stomach is found in a state of softening, or of thickening, but for the most part it is perfectly healthy. The viscus may be much distended, or contracted. Its inner surface has been observed to be covered with a dark slimy fluid, or to contain blood, or even as much as a gill of pus, derived (Case 22) * Caspar's Wochenschrifft, No. 9; quoted in Canstatt's Jahresbericht, 1844. j- Essai sur l'Anat. Pathol., tome i., p. -86, 1816. J Vol. vi. Virchow's Path, and Therap., p. 667. 6 CANCER OF TIIE PANCREAS. from a perforation of its coats, through which the pancreatic mass com- municated with the stomach. Such cases of perforation have been several times noticed. The perforation occurs at the seat at which the stomach adheres to the morbid mass; the rupture may be at one, or at several places. (Hasenohl.) The duodenum presents the same changes as are met with in the sto- mach. It may be adherent to the pancreas, thickened and contracted, or distended; its calibre may be nearly obliterated by pressure, (see Case 23,) its mucous membrane softened, and one or several ulcerations communi- cating with the pancreas exist in it. The other parts of the intestine generally remain healthy; yet they, too, have been noted to have been greatly contracted, to have been ulcerated, (Case 15,) to have contained (Case 23) small cancerous masses, or to have been nearly filled with blood. The colon has been observed to be much contracted, and its coats thickened and covered with small patches of lymph, (Cases 17 and 18.) There seems, indeed, to be a very great tendency to fibrinous deposits, and to an increase and thickening of the cellular textures of the body, as witnessed in the intestines, and also in a cirrhosed state of the liver. The liver is very variously affected. It remains healthy, becomes the seat of cancerous deposits, or exhibits abnormal changes with reference to size, density, and color. One of the most frequent appearances is to find it enlarged, and of a peculiar greenish hue. Dr. Bright, in an oft-quoted case, describes it as resembling "dark greenstone porphyry." It may be softer than natural in consistency, but is frequently denser, owing, in some instances, to a thickening of its cellular tissue. Well-marked examples of cirrhosis (Cases 26 and 34) have also been observed. In common with all the other organs in the body, it is at times pale and devoid of blood, (Cases 7 and 29.) The biliary ducts may be normal, or have their calibre greatly increased. The hepatic duct, as well as the cystic and common duct, are at times in some parts nearly obliterated, while in others they are much dilated; or one duct is dilated and the other compressed. Again, both the hepatic and cystic duct may be expanded, and the com- mon duct be barely pervious, (Case 9.) In a case described by King,* the hepatic and choledoch duct above the seat of their compression were dilated to the size of the ileum of an infant. Toddf had a young girl under his care, in whom the hepatic and common duct were so distended as to form a distinct swelling in the epigastric region, which was tapped during life, and was found to contain several quarts of bile. The cystic duct alone may be closed; but the duct which most frequently suffers is the * Medico-Chirurg.Review, 1827, (See Table, Casel.) •j- Dublin Hospital Reports, vol. i. CANCER OF THE PANCREAS. 7 common duct. It is evident, however, that the exact spot of its occlusion, or the state above the seat of compression of it, or of the cystic and hepatic duct, will depend much upon the shape and size of the pancreatic tumor. The gall-bladder, in cases of compression of any of the ducts connected with the biliary function, is enlarged and greatly distended. Its coats have been observed to be much thickened, and its mucous membrane slightly ulcerated, (Case 23.) Its contents are a dark, inky bile, or an inodorous, colorless fluid, (Cases 1 and 15,) which King (loc. cit.) tells us has no resemblance in chemical composition to bile. The other structures situated in the abdomen do not often become affected in consequence of a pancreatic cancer. The omentum may be implicated in the disease; the spleen remains healthy. The supra-renal capsules were involved in a case described by Dr. Bright* The diseased mass may press upon the nerves and narrow the aorta, as in a case quoted by Mondiere from Portal, f In another instance, the latter author has observed an aneurism to have been produced by the pressure of a scirrhous tumor of the pancreas. The age and sex of those suffering from cancer of the pancreas may be seen from the following table of thirty-seven cases:— Ace. Males. Females. 14 to 22.......- 2 24 to 28...... 2 1 33 to 36.......3 40 to 46......4 2 48 to 58.......8 4 58 to 68......2 4 68 to 78.......- 2 Not stated...... 3 22 15 These figures certainly show that cancer of the pancreas conforms, in respect to age, to the general laws of cancerous disease. It will be per- ceived that the majority of cases occurred after the fortieth year. The youngest (Case 21) was a girl 14 years of age, the eldest a woman of 76. Rokitansky has mentioned an instance of the pancreas having been found scirrhous at birth. With reference to sex, the majority of cases are met with in men. Of the fifteen female cases, two occurred in colored women. Dr. Walshe's statements concerning sex do not agree with my deductions. He thinks the disease is more frequent in the female. J * Med-Chirurg. Transactions, vol. xviii., Case 7. It may not be without interest to state that in this case no bronzy color of the skin is mentioned. ■f- Traite* de l'Apoplexie. J Walshe on Cancer, p. 321. 8 CANCER OF THE PANCREAS. The exact duration of the affection it is not possible to ascertain. Like all chronic diseases, its commencement cannot be accurately fixed. It would seem that, although it may last for several years, and occasion prolonged suffering, it may also run a more rapid course. It is, in- deed, in not a few of the cases specially noted, that the patient had been, up to a certain time,—not a year before his death,—in excel- lent health. In several instances, no marked symptoms appeared until four or five months before death, and a case has been reported in which the disease seemingly commenced with acute symptoms, and ran on, in eleven weeks, to a fatal termination, (Case 36.) In one patient it was ushered in by jaundice, in another by a febrile attack, (Case 7.) In one case it is recorded that it followed a sudden disappearance of tumefaction of the parotid and submaxillary glands, (Case 9,) in another, (Case 28,) that it was produced by continual pressure against the stomach. Death usually takes place from gradual exhaustion. But it may occur after he- morrhage, or by the development of cancer in other parts of the body, or with the symptoms of an adynamic fever, (Case 8.) The patient mentioned by Dr. Campbell (see Case 22) expired suddenly, after a sound like something bursting. The stomach had been perforated, and was found to contain a large quantity of pus. The symptoms of cancer of the pancreas are not always the same; they are mostly produced by the effects of the disease on other organs. The affections of the pancreas themselves give rise to few, if any, special symptoms ; to none which are constant. Local Signs.—Amid the local signs, one of the most important is the ex- istence of a swelling, or a tumor. In thirteen cases out of the thirty-seven recorded below, a tumor is specially noticed ; in one, there was fulness at the epigastrium ; and in one at the left hypochondrium; in one fullness at the epigastrium, with resistance to touch ; in one, an indistinct hardness at the pit of the stomach, and in another, at the right side of the abdomen, making eighteen cases in which the pancreas had given rise to perceptible signs of its enlargement. The situation of the tumor is mostly noted as in the epigastric region, or between this and the umbilicus. It may extend into the right hypochondrium, or into the left, or (Case 22) into both. It may be fixed or movable, (Case 35,) with limits not definable, or capable of being accurately determined by the touch and by percussion. In some instances it is painful on pressure; in others not. In several very inter- esting cases it was accompanied by pulsation and a blowing sound, and might thus have been readily mistaken for an aneurism. In Dr. Bat- tersby's patient (Case 17) there was an apparent systole and diastole ; the pulsation ceased in two months, but the bruit and the tumor remained. In the patients of Sandwith, Fletcher, Tessier, and McClurg, (Cases 20, 24, CANCER OF THE PANCREAS. 9 27, and 28,) the pulsation continued as a permanent phenomenon. Both pulsation and blowing sound may be accounted for by the tumor lying across, and compressing the abdominal aorta. In Dr. Battersby's case, however, the blowing sound may have been produced by the deposits which covered the inner coat of the abdominal aorta. An epigastric tumor of a different nature may be caused by disease of the pancreas, and lead to singular errors of diagnosis. Petit* ope- rated on a case of what he thought to be a strangulated hernia of the stomach or colon. The tumor was soft and compressible, and accompa- nied by vomiting and hiccough. The operation demonstrated that it was the stomach, pressed forward by an enlarged pancreas; whether cancer- ous or not, was not determined. In another case already cited, (See Case 21,) an epigastric tumor was not the cancerous pancreas itself, but a dila- tation of the hepatic and choledoch duct produced by it. Pain is a very constant symptom : it is mentioned in thirty-two out of thirty-seven cases. The seat of the pain is, in most instances, the epigas- trium. In twenty of these thirty-two cases it seems to have been there most marked, although it was not always confined to this seat, but ex- tended to the right side, or to the left, or to the back, or to the umbilicus and lower part of the abdomen. In one case it was an intermitting pain confined to the lower part of the abdomen. In two or three others it extended equally over the whole abdomen. In four cases it had its seat of greatest intensity in the back, but in one of these there was also deep- seated epigastric pain, a constant pain in the lower part of the abdomen, and pains extending to the arms. In another case they radiated to the left half of the chest, and to the abdomen. In three cases the pain was mainly felt in the sides, and extended into the back. The character of the pain is very various. In the majority of the cases it is severe, in some excruciating, and in paroxysms of several days du- ration. It is, at times, much like colic; or again it is described by the patient as "a deathly distress," (Case 29,) or (Case 19) as a "hot sensa- tion extending into the back." In some cases it is very slight, more of an undefined uneasiness (Case 9) than actual pain. In Andral's patient at La Pitie,f the pains were like blows of a hammer, or like the perforating dart of a dagger, and increased at night. The pancreatic tumor was found, on post-mortem examination, to have compressed the nervous plexus which spreads around the abdominal aorta. The pain is not, as a rule, increased by taking food, for this is only noted in very few of the cases, (see 18 and 29;) on the other hand, there are instances * Discours sur la Medecine du Coeur: Lyons, 1806. ■j- Lancette Francaise, No. 16. 10 CANCER OF THE PANCREAS. in which it is specially stated that it was not. The pain may become duller (Case 32) as the disease advances; it may or may not be increased on pressure. It may be suddenly augmented by turning in bed from side to side, (Case 14.) In not a few cases is it increased by the erect po- sition, and hence we find patients seeking relief by stooping, and curving their body forward so as to relax the abdominal parietes, (see Cases 2, 3, 5, 13, 28.) Vomiting is a symptom, the frequency and importance of which it is difficult to determine, for it is obvious that in those cases in which much disease of the liver or cancer of the stomach were superinduced, it can- not be established in how far the symptom may be placed in connection with the disease of the pancreas. In the thirty-seven cases below noted, vomiting is mentioned in twenty-one ; but in two of these it was a transi- tory phenomenon, lasting a very short time, and occasioned in one, by eat- ing indigestible food. In one case it came on after an attack of hepatitis, which happened seventeen years before any symptoms of pancreatic dis- ease developed themselves; in three others, it occurred in patients in whom considerable disease of the liver and stomach was, after death, detected. Leaving out these six cases, we still find it in fifteen. In nearly all of them it was a late symptom, and in only a few constant. In one patient (Case 20) it did not appear until six weeks, and in another not until ten days before death, (Case 23,) although in him the pylorus was found greatly contracted. The narrowed state of the pylorus, caused by the pancreatic disease, or the pressure of the tumor on the stomach will ex- plain the vomiting in several instances. In a case mentioned by Dr. Heni'y Lee,* at the Royal Medico-Chirurgical Society, in which vomiting was among the symptoms, the stomach was perforated by the head of the pancreas, which had produced ulceration by pressure. In another case, (22,) in which ulceration of the stomach occurred, nausea and vomiting became prominent symptoms as the pancreatic tumor increased. The vomited matter consists either of the food that is swallowed (in many cases there is neither nausea nor vomiting until shortly after food be taken) or else (Case 18) of a substance like bran and water, of a bilious fluid, (Case 9,) of fluid of a glairy character, or of a watery, colorless fluid, (Cases 29 and 37 ;) or, again, the ejection may contain blood, (Cases 9 and 16.) The watery fluid that is sometimes discharged may be very abundant. It is thought by some to be the pancreatic secretion itself, and not to be derived from the stomach at all; others regard it as an increased salivary flow. The vomited matter is stated in one case, (23,) in which the pylorus was greatly contracted, to have been like coffee- * Lancet, 1842. CANCER OF THE PANCREAS. 11 grounds. But the coffee-ground vomit, so often seen in cancer of the stomach, is evidently here but exceptionally met with. In the case kindly communicated to me by Dr. Harris, there was in the vomit a distinct black- ish sediment; this was proved to be stove coal, of which the patient was in the habit of consuming daily about half a pint, eating it in the form of cinder. The condition of the bowels is usually that of constipation. In thirty-four cases constipation is mentioned in nineteen; in four the bowels were regular; in three diarrhoea occurred as a late symptom ; one patient passed blood and pus by stools ; two others, at times blood; in the other cases diarrhoea existed, or alternated with constipation. The faeces are mostly hard, and vary in color according to the presence or absence of the biliary secretion. Hemorrhage into the bowels, which has been observed as occuring in several cases, will explain the black, bloody stools sometimes voided. Dr. Bright has directed attention to the presence of fatty stools in cases of pancreatic cancer which he has published (loc. cit.;) they were noticed in three cases. But he is far from having af- firmed, as subsequent writers wish us to believe, that they are of constant occurrence. He himself speaks of cases of scirrhous pancreas without fatty discharge, and, although he thinks that it is connected with " dis- ease probably malignant of that part of the pancreas which is near to the duodenum, and ulceration of the duodenum itself," he does not, by any means, lay this down as positive, since, at the end of his paper, he suggests that the symptom might be diagnostic " of the nature of the diseased action rather than of its seat." Many observers have since brought forward instances of fatty discharges in which no disease of the pancreas existed, and, on the other hand, to the cases of Bright, but few others have been added in which these discharges were associated with affections of this gland.* A desire to bring the physiological teachings of the present day in connection with morbid anatomy may have prompted many to accord so much importance to the occurrence of fatty stools in pancreatic disease. But pathological anatomy seems to contradict the as- sertion that the pancreatic secretion possesses alone the power to emul- sify, and to render the fatty matters fit for absorption. It can certainly not be the only agent. The cases of Dr. Bright would lead rather to the conclusion that, for fat not to be acted upon, the duodenal secretions must also be vitiated, and the flow of healthy bile interfered with. For * Dr. Eisemann, Viertel Jahreschrifft fur'die praktische, Heilk, 1853, (quoted in the Med. Examiner, 1855,) speaks of several cases of pancreatic disease, with abundant fatty discharge, but in the case which came under his own care there was none. Da some of the instances quoted the oily evacuations had ceased, although the pancreas was so indurated as to have rendered the performance of its function impossible. 12 CANCER OF THE PANCREAS. in all of them there were also ulcers in the intestine, and the ducts through which the bile flows were compressed or nearly obliterated. Jaundice constitutes, in a large proportion of cases, one of the most prominent symptoms ; it is persistent, and resists all treatment. In most instances it does not appear until the pancreas has enlarged considerably, in other words, not until late in the disease ; but in a few cases it is noted among the early signs. It usually increases as the disease progresses, and the skin becomes of a deep-yellow, or of a greenish hue, (Cases 1 and 36.) Dyspeptic symptoms are a class of symptoms which are found in pan- creatic cancer, in a very varying degree. From the vague manner in which the term is made to embrace different states, it is difficult to ascertain the exact nature of these symptoms in the reported cases. They are noted in twenty-five out of thirty-seven cases, some as of early, some as of late occurrence; but of these twenty-five cases there are several in which the signs of indigestion had been evidently present at a time long anterior to the other symptoms of the disease, and probably to the disease itself. Acid eructations were troublesome in five cases ; in two cases there was much pain after eating ; in five cases there was considerable flatulency, incon- trollable in one, but not dependent upon taking food, (Case 30.) A feel- ing of weight and oppression at the stomach are noted in three cases ; of sinking, relieved by food, in one ; of great irritability of the stomach in two. Constant thirst is mentioned in six cases, but in one of these dia- betes existed. The appetite fluctuates in every conceivable way; it frequently remains good even to the last; it is sometimes capricious, although the patient (Case 7) can take a great deal of food; anorexia is noted in seven out of the twenty-five cases in which dyspeptic symptoms are mentioned. Hiccough was in two cases (28 and 34) an exceedingly annoying inci- dent. The tongue is not often alluded to ; from which it may be inferred that it does not often present any peculiarity. It is stated in four cases to have been dry; in two, it was covered with a yellowish coat; in one, with a brown fur ; it remained clean throughout in one, and its cleanness and great moisture are especially commented on in two interesting cases (17 and 18.) The ptyalism, which sometimes takes place, will give rise to this macerated appearance of the tongue; but, although it may be both very abundant and exceedingly offensive,* the occurrence of this salivary discharge is not frequent, and its importance in diagnosis, there- fore, less than some authors state it be. Dropsy is met with in the advanced stages of pancreatic cancer. It was present in sixteen out of thirty-seven cases; yet, although many of *- Mondiere. Archives Generates de Medecine, 1836. CANCER OF THE PANCREAS. 13 these were complicated with hepatic derangement, in none was it very marked; in most, ascites was present; in some, ascites and anasarca; in one case, marked anasarca of the upper and lower extremities, (Case 17,) and only slight ascites; and in another, (27,) oedema of the feet was seen disappearing and reappearing. Emaciation and debility are both very striking and constant symptoms. The emaciation is great and progressive. In a case, reported by Sand- with, the patient was so emaciated that the spine could be distinctly traced through the abdominal parietes. Debility usually goes hand in hand with the perceptible loss of flesh, but it may not be as extreme ; and, again, it is sometimes prominent among the earlier symptoms. In ex- ceptional cases the loss of flesh is slight, and debility not marked. The countenance is usually pallid, and has a distressed look; the features be- come pinched, and the face is expressive of suffering and anxiety. The skin is sallow, of a bloodless hue, or jaundiced, or more rarely it is straw- colored, (Case 28.) The pulse is not often noted, when it is, it is stated to have been quicker than in health. A tendency to hemorrhage must also be alluded to ; blood was lost from the stomach, bowels, and lungs, in several cases. The main symptoms, then, of pancreatic cancer, are a tumor in the epigastric region, pain there, «or in the back, constipation, progressive emaciation and debility, and obstinate jaundice and occasional vomiting, as the disease advances. The diagnosis is possible, if these symptoms be present, and provided we are able to exclude with certainty the diseases of the stomach and of the liver. I shall not attempt to decide in how far the symptoms may be shared by other chronic affections of the pancreas. Tubercle of that organ is rare, and is associated with tubercle of the lung or of the brain.* Chronic pancreatitis gives rise to many of the same phenomena; but, taking the cases which I have met with in pursuing this inquiry as my standard, I should say that those signs which indicate a tumor, and the symptoms which show its marked growth and pressure upon other organs, are not often present; that pain does not occur to such a marked degree ; that the falling off in health is very gradual, and the disease slower of progress, and also that the bowels are not as constipated, but are, on the contrary, more fre- quently relaxed. It is, however, fair to state, that Dr. Claessen, in a work on Diseases of the Pancreas, (Cologne, 1842,) remarks that constipation in chronic pancreatitis is urgent and enduring. * Wiirtemberg. Med. Correspond. Blatt. By whom and where reported. ■ Ki"iiK: Rledico-Chi- rurg. He- view, 1827; horn a case under the care of Du- puytrcii. Age and .Sex. 2 Pewall. Med. and Physical Journal, i xxxi. p. "J1 3 Sewall. lb. 45; male. Not men- tioned; but up- wards of four months. Local Signs. State of Bowels. Jaundice. Kmacia- tion and Debility. Dropsy. Not men- tioned. About one year. Tumor in epigastrium. "A young A few years. Not men- tioned. Not men- tioned. Not men- jNot men- tioned, jtioned, ex- jcept that during the day before death, stools of black and bloody ap- pearance passed in- volunta- rily. Severe, deep- seated, epi- gastric pain, increased by the erect po- sition: hence patient al- ways in a curved posi- tion of the body. Deep-seated, epigastric pain, in- creased by the erect position; hence always a curved position. Almost constant. Present. Consti- pated. Not men- tioned. Very great(skin of a green- ish-yellow color) oc- curred up- wards of four months before death. Not men- tioned. Emacia- tion mode- rate; debi- lity not men- tioned ; (excepting as noticed after an operation for cata- ract; then, also, ten- dency to syncope, in the per- pendicu- lar posi- tion.) Both great. Verv slight ascites; (post- mortem. Not men- Great ema-Slight as- tioned. ciation; jcites: no debility ; oedema. not noted. Dyspeptic Other Symp- Symp- toras, and toms. Remarks. Post-mortem Appearances. Cataract of Pancreas was large; a por- some years' tion of it forming, with a standing. cluster of scirrhous glands, a tumor, by which the com- mon duet was much com- pressed, but its mouth re- mained pervious. The pan- creatic duct was free; so was the cystic duct. The hepatic and eholedoch duct, above the seat of their compres- sion, were distended to the size of the ileum of an in- fant, and filled with gas. The gall-bladder.besides gas, contained au inodorous, co- lorless fluid, which had no resemblance, in chemical composition, to bile. Liver was large and green. Large intestines contained coagu- lated blood. Acid eruc- Disease pre- '. Pancreas was nearly three tations; ceded by tu- times its natural size; hard great irri- mefactiou of throughout, irregular, and tability of parotid and unyielding. Its right ex- stomach, 'submaxil- tremity pressed firmly on ilary glands, the duodenum, and on the' which sucl- small extremity of stomach, denly sub- thereby nearly obliterating sided. [the pyloric orifice. Other organs healthy. i i Great A pulmo- I Pancreas—only one of the acidity; no nary con- abdominal viscera, which food ex- ;sumption jwas diseased, was enlarged, cept milk jcame on two and scirrhous, particularly could be (months be- its right extremity, which retained 'fore death. embraced the duodenum,and on sto- pressed so firmly on the py- mach. yet lorus that its orifice would appetite scarcely admit of the intro- remaiued duction of a common-sized good. catheter. Stomach and in- testines were greatly con- tracted. Liver healthy. Lungs hard and unyielding, and in many places ulce- rated, and affected with tu- bercle. 4' Martland. |Edinb. Med. and Surg. Journal, 1825. Abernethy. In a lecture delivered at St. Bartholo- mew's Hos- pital. Lan- cet, April 21st, 1827. 60; female. 6 Abercrom- bie. "Dis- cs of the Stomach," p 412. Am. ed Abercrom- bie. lb. " A man of ad- vanced age." Six months. 56; male. 35; male. region of the tumor. Not men- tioned. Two years Eighteen months. Hard tumor,' In and Not men- about the about the tioned. size of the palm of the hand, at scro- biculus cor- dis and right side, below the margin of the ribs; very painful on pressure, and en- larging to- ward the end of the complaint. None. Pain in the Not men- epigastric re- tioned. gion, gradu- ally extend- ing, and in- creased by pressure, by erect pos- ture; hence patient con- stantly stooping forward. He had also to be propped up in bed, to lessen pres- sure. 1 Not men- Pain in the None. tioned. '. left hypo- j chondrium, extending into back. Not men- tioned. Regular; | Most in- j Great and stools very white, Consti- pated. Regular. As a late Sometimes epigastric region. in and transi- I tory symptom. constipa- tion, at others diarrhoea. tense; Iprogres- came on a ' sive debil- few weeks ■ ity, and after first I extreme manifesta- emacia- tions of the | tion. disease. None; Increas- Not men- Tain after (counte- ing debil- tioned. eating. nance had ity. a distress- ed appear- ance, even from com- mence- ment, but was never jaun- diced.) Occurred Both pre- ' Not men- : Symp- only a few sent; died! tioned. tomsofin- weeks be- gradually ] I digestion fore death. I exhausted, j present. Not men- tioned. Anorexia; great thirst: furred and 'dry tongue. Pulse be- tween 80 and 100. None; (counte- nance re- markably pale.) Both pre- sent to a marked degree, and pro- gressive. Not men- tioned. Present appetite capri- cious; took a good deal of food. | Pancreas. The head formed |a scirrhous tumor about the size of a hen's egg. In this tumor was lodged the ductus communis, which was al- most impervious, and was still more obstructed by a small calculus. The cystic and hepatic ducts were con- siderably dilated. Gall-blad- der much enlarged. Liver studded with small, distinct tubera, which were con- fluent opposite the gall- bladder. Pancreas in a state of com- plete disorganization and ulceration from end to end. State of other organs not mentioned. Strong ac- tion ofheart; throbbing in head; dis- ease com- menced with a febrile at- tack ; fre- quent per- spirations at night. Pancreas, in parts, hard; in others soft, and composed of yellowish and white mat- ter. Mass attached to spine. Liver enlarged and soft. Other organs healthy. Pancreas considerably en- larged, and of nearly carti- laginous hardness, except some spots, which were soft, with the appearance of me- dullary sarcoma. Pylorus thicker than normal, and adherent to pancreas. Other organs healthy, but very devoid of blood. O* i1 By whom and where Age and Sex. Duration. Local Signs. Pain. Vomiting. State of Bowels. Jaundice. Emacia-tion and Dropsy. Dyspeptic Symp- Other Symp-toms, and Post-mortem Appearances. a reported. Debility. toms. Remarks. 8 Andral. 54; Four Fullness in Intense Not men- Diarrhoea None. Not men- None. Extreme Insomnia; i Pancreas enormously en- Archives female. months; left hypo- pains in dor- tioned. as a very tioned ; disgust for febrile signs; larged, and transformed into Generates de previous chondrium, sal ren-ion, late (face pale, taking patient died a tumor, which seemed a Medicine, health but no extending to symptom. expressive food; with all the combination of scirrhus, en- 1831; or good. tumor per- the left half of suffer- tongue symptoms of cephaloid, and tubercle. (?) Lancette ceptible. of the chest, ing-) had a an adynamic This mass compressed the franc, T. Y. or through yellowish fever. aorta, and the plexus of No. 216. abdominal region; more fre-quent at night, last-ing from several hours to-several days at the time. coat. nerves which surrounds it. Other organs healthy. A sanguineous effusion into the pericardium. g Becourt. 45; Four Pain on Above Nausea; Costive; Occurred Great Slight Great At times Pancreas—head scirrhous, Quoted by male. months. pressure at a umbilicus; also vomit- hard early, and debility; ascites. thirst; passive he- rest converted into fat; liver Andral, small point abdominal ing, in last stools, at became also ema- appetite morrhage. of an olive-color, and con- Pathol. between cramps; two times intense; ciation. good; taining a few cancerous Interne. umbilicus at times months, white. slight cardial gia spots. Gall-bladder dis- Tome ii. p. and violent pains bilious, jaundice, flatulency. tended, containing very 283. curvature of stomach; heat over stomach. over stomach, extending over whole abdomen. sometimes sanguino-lent ejec-tions. with feel-ing of op-pression at the epigas-trium, were in-deed the first symptoms. dark bile; hepatic and cystic ducts enlarged; common duct very much compressed, and barely pervious. Sto-mach healthy. 10 Percival. "Middle Three Epigastrium Not men- Bilious Blood and Present. Emacia- Anasarca "Disordered Liver " much diseased." (Transact, of College of aged months. distended; tioned. vomiting. pus passed tion and toward secret, of Pancreas scirrhous, contain- man." tumor felt by stools. much the end. urine." ed a considerable abscess. Physic, protruding debility. Ductus com. choled. closed, Ireland,) from middle, in the parts adjacent to the Vol. ii. p. pancreas. Gall-bladder full; 132. cystic duct pervious. OS 11 Dr. Bright's Cases. Vol. xviii. Med.- Chir. Transact., 1833. Case I. 12 Dr. Bright. Case n. lb. 49; male. 50; female. One year, Not ascer- tained ; certainly not less than seven or eight months, perhaps some years. None. None. Pain in loins. No pain on pressure; some pain at lower part of abdomen, relieved by pressure, and occur- ring only at intervals. Not men- tioned. Retching and vomiting for seventeen years; increased much within the seven months before death. Stools copious and light- colored ; for the last two months fasces con- tained a yellowish, fatty matter, and bowels were much relaxed. Rather costive; evacua- tions whitish; a few dark motions like pitch; a week be- fore death large coagula of blood; while under ob- servation for three months, fatty matter noticed in her dejec- tions. Present; com- menced six months after first symptoms of disease, Very great; gradually increasing; did not occur as a permanent symptom until four or five months before death. Great debility, and ema- ciation, continu- ally increasing, Progres- sive and great debility; general emacia- tion, cheeks much sunken, but some fat on abdomen. Slight ascites; legs very slightly oedema- tous. None. Great thirst and appetite. Not very marked. Marked enlargement of liver; frequent urination; diabetes; acute pleurisy two weeks before death. Good health until seven or eight months be- fore death. Seventeen years ago severe hepatitis; she became very drowsy during the last days of her life. Pancreas hard and carti- laginous to the touch; of a bright-yellow color; its head formed, with the surround- ing glands, a hard, globular mass; at junction of pan- creas with duodenum ulcers had taken place. Liver re- sembled dark greenstone porphyry, and contained hard, circumscribed masses; its ducts were enlarged; common duct dilated, but terminated by a ciilrde-sac in diseased part of pancreas. Signs of jaundice pervaded many structures; serum olive-colored; coating of fib- rine on pleura- Pancreas hard and carti- laginous ; its head enlarged and glued to duodenum, andcommunicatingthrougli an ulcerated spot with this. Common gall-duct pervious, but evidently had been com- pressed; biliary ducts dis- tended. Liver cancerous. Lungs healthy, but firmly bound down posteriorly by strong, adhesive bands. CO By whom Age and Sex. State of Bowels. Emacia- Dyspeptic Other Symp- £ and where Duration. Local Signs. Pain. Vomiting. Jaundice. tion and Dropsy. Symp- toms, and Post-mortem Appearances. » reported. Debility. toms. Remarks. 13 Dr. Bright. 21; Decided Indistinct No pain Not men- Rather | Slight; Emacia- Anasarca; Not men- Out of Pancreas—hard mass near lb. female. illness for hardness on mentioned. tioned. bound, but increased tion not also some tioned. health for its head; another near the Case III. two right side of subse- towards great, but ascites. two years; spleen; intervening portion months. abdomen. quently evacua-tions were copious, fatty, and thin. close of life. great debility; restless-ness. slight cough; preferred lying in a raised position. seemed more healthy; mass-es of yellow color. Ulcers in the intestine; some ulcers communicating with glands in the meso-colon; mesente-ric glands and supra-renal capsules diseased; also, bron-chial glands; slight deposit of round size at apex of lung. Liver enlarged, of a dark-olive color; hepatic and cystic duct enlarged, but common duct becoming much constricted before en-tering duodenum. 14 Dr. Bright. 76; Thirteen None. Severe pain Vomiting Consti- Jaundice Great and Among Weight Palpitation Pancreas large and in a 26. female. months; in the sides, not men- pated at only increasing the late and dis- of the heart. scirrhous condition, involv- Case VI. good extending to tioned; the latter latterly lassitude symp- tension of ing the ductus choledochus health the back; nausea as portion of present. and toms stomach. in the diseased structure. before pain also im- a late the dis- debility. anasarca; The common duct was dila- attack, mediately under right mamma; acute pain in turning from left to right side; pain in the side became very fixed. symptom. ease; clay-colored stools. also some ascites. ted up to its termination, where it was found com-pletely obliterated; near the duodenum it formed a com-plete culrde-sac. Liver small, but gorged with bile. Gall-bladder enormously distend-ed. Duodenum thickened, and somewhat contracted. 00 16 Dr. Bright. lb. Case VII. Dr. Bright. lb. Case VIII. 35; male. 43; male. Thirteen months. Ten months. Tumor above umbilicus, reaching not quite to pit of stomach. Indistinct hardness at pit of stomach. Not men- tioned. At pit of stomach. Not men- tioned. Towards end of life; severe vomiting of a dark- col ored fluid shortly before death. Consti- pated; stools became, subse- quently, clay- colored and yeast- like; a few days before death very dark. Relaxed at first; clay- colored stools, then varying in color. As a late symptom. Jaundice appearing suddenly and early; became persistent. Both present to a marked degree; at first greater debility than ema- ciation. Both markedly present; debility as an early symptom. Not present. Not present- Not men- tioned. Flatu- lency. A tumor below umbilicus. Appetite unusually great; itching over body; frequent drowsiness; tendency to hemorrhage. Pancreas—malignant dis- ease towards its middle; its splenic and hepatic heads not infiltrated; its duct per- vious. Its middle portion was involved and continuous with a large, movable mass, connected with the lower tumor seen during life. This tumor consisted of masses, which surrounded the aorta and iliacs, and, passing up the spine, involved the pan- creas and renal capsules. Upper tumor was a movable mass in the omentum. A few scirrhous tubera in liver. Gall-bladder distended. Ori- fice of cystic duct very nearly closed; hepatic duct and common duct both some- what contracted; colorless fluid in gall-bladder and cystic duct. Small, malig- nant tumor attached to sur- face of the heart. Pancreatic duct seemed obstructed in healthy part of pancreas; in other parts pervious. Pancreas not enlarged, but its head formed a large yel- low mass, with neighboring absorbent gland; pancreatic duct greatly enlarged. Liver full of yellow spots, of vary- ing size; liver enlarged; all the ducts involved in can- cerous masses; hepatic duct enlarged, and filled with colorless fluid. Stomach full of dark, grumous fluid. Se- rum in chest of dark-yellow color. Ulcer in duodenum. CD By whom and where reported. Age and Sex. 18 Dr. Batters- by. Dublin Medical Journal, Vol. xxv. 1844. Case I. Dr. Batters- by. lb. Case II. About 58; female. 24; male. Duration. Sick twenty- five months; marked for thirteen months. Four years. Local Signs. Pain. Deep-seated pulsating tumor in epi- gastrium, having a well-marked bruit de soufflet; the pulsation ceased in two months, but the bruit and the tumor remained; fullness in epigas- trium. None. Severe pains in back, extending to arms; then uneasiness and deep- seated pain in the epi- gastrium, increased by pressure; also, con- stant pain in the lower part of abdomen. Severe pain in stomach, coming on generally after meals; subsided after vomiting; sometimes appearing in the middle of the night. Vomiting. State of Bowels. Jaundice. Present; sometimes of dark fluid, sometimes like bran and water. Very sluggish; attended with violent straining and intense distress; faeces generally watery, deficient in bile. Severe con- stipation ; diarrhoea at end of life. Present, but not to a great degree. Not men- tioned ; (skin sallow.) Emacia- tion and Debility. Both pre- sent; ema- ciation extreme. Emacia- tion; features pinched; debility not men- tioned. Dropsy. Slight ascites; very marked anasarca of upper and lower extremi- ties, which increased much at later portion of disease. Ascites and anasarca, both as late symp- toms. Dyspeptic Symp- toms. Eructa- tions ; appetite nearly gone, hut this not until last month of no thirst; tongue pale and clean. Other Symp- toms, and Remarks. Ptyalism; mouth always full of saliva; dysphagia. Cleanness and great moisture of tongue. Post-mortem Appearances. Pancreas enlarged and hard throughout; every trace of its natural structure had disappeared. At its lower edge existed a thin cyst, about the size of a wal- nut. Duodenum extremely contracted, and adherent to pancreas; pancreatic duct was pervious for about an inch only from the duode- num. Liver small, of a dark- gray color, and dense; owing, apparently, to a thickening of its cellular tissue. The common duct and hepatic duct were not interrupted; colon and cardiac orifice of stomach much contracted; cellular tissue increased and hard. Mesenteric vessels and nerves involved in the scirrhous mass; gastro-he- patic omentum dense, hard, and thickened; aorta dis- eased by deposits in its en- tire course through the ab- domen. Pancreas dense and carti- laginous ; confounded some- what with surrounding structures. Liver healthy. Stomach and intestines dis- tended. The sub-mucous coat of ileum and colon thickened; also covered with small patches of closely-ad- hering lymph. to © r* fed o *A 1-3 W ni >• 19 Crompton. Birming- ham Path. Society; in Prov. Med. Journal, Dec. 1842. 60; male. 20 Sandwith Ed. Med. and Surg. Journ, Vol. xvi. p. 380. 21 Todd. Dublin Hospital Re- ports. Vol.i 67; female. Upwards of two years. 14; female. Not men- tioned. Some months. Pulsation, left side, below carti- lage of false ribs. Tense swelling in epigastric region, extending to right hypo- chondrium ; it was tapped, and a greenish fluid escaped. Constant pain below the ensiform cartilage; sometimes " a hot sen- sation," sometimes pain extend- ing into the back. Continual pain in epi- gastrium, extending to hypochon- drium ; at times most intense; increased on pressure. In epigas- trium ; increased on pressure; at times severe and very acute. None, until last month, then only for two days, after eating in- digestible food. Not until six weeks before death, then very constant and dis- tressing; every- thing she swallowed was rejected. Not men- tioned. Tolerably regular; at times somewhat relaxed; dejections of good color. Costive. Not men- tioned. Slight and not perma- nent. None. (Com- plexion sallow.) Deep orange- colored skin. Extreme and pro- gressive emacia- tion; (a peculiar pallid ap- pearance of counte- nance noted.) Both; eyes had a peculiar expres- sion of anxiety; emaciation was ex- treme; spine could be traced through abdominal parietes, Great debility and ema- ciation. None. Not men- tioned. Ascites and ana- sarca. Appetite irregular; suffered more after a full meal; mouth generally clammy; tongue constantly covered with a brown fur at the base, and down the centre. Loss of appetite. Pulse some- what quick; Bkin dry and harsh. Great agita- tion, tore the bed- clothes, etc. Spasms and convulsions; had had, for a long time, pains in the abdomen; development of disease followed; a fever, with relapses. Pancreas hard as carti- lage; its left side distended by a large cyst, containing a bloody fluid. Many of the mesenteric glands enlarged and hardened. Liver small; scirrhous tubercles scattered through its substance; cys- tic duct obliterated by a de- posit. A few calcareous deposits in lungs. Other organs healthy. Pancreas presented usual signs of scirrhus. Stomach erythematous. Splenic ar- tery imbedded in scirrhous matter. Pancreas; head and glands around it converted into a hard, solid mass; its duct obliterated. Stomach some- what thickened. Liver healthy; cystic duct dilated, but at its juncture with hepatic it was impervious; remaining portion natural. to 23 Age and Sex. 72; female. Dr. Greene. Dublin Journal of Medical Science. Vol. xxv. 1844. Male; age not stated. Not men- tioned. Local Signs. Tumor like large orange in epigas- trium, extending into both hypochon- driac re- gions. Nine None, save months, fullness in epigastrium. Pain in epi- gastrium ; two months previous to death became very distressing. Pain in epigastric region, and over umbi- licus, some- times like colic. Vomiting. State of Bowels. Nausea and ■ vomiting as tumor increased. None, except ten days before death, then coffee- ground matter. Not men- tioned. Consti- pated. Jaundice. Emacia- tion and Debility. Dropsy. Not men- tioned. Jaundice intense. Both to a high degree. Not men- tioned. Dyspeptic Symp- toms. Other Symp- toms, and Remarks. Post-mortem Appearances. Expired Buddenly, after sound like something bursting. Anorexia; thirst; acid eruc- tations; signs of indiges- tion were the earliest symptoms. A week before his death delirium; died in that state. Pancreas much enlarged; altered in structure, except- ing at left extremity; tumor at the right oxtremity, with pus on surface, and ruptured entrance, which communi- cated with a cavity in its interior, and with a rupture in the rear of the stomach. This viscus, containing a gill of pus, was softened towards pyloric extremity. At the greater extremity thicken- ing of its coats. Duodenum, near pancreas, was softened. Liver small, and very dense, of darker hue. Gall-bladder much distended; cystic duct distended; duct com. choled. occluded by tumefaction and induration of duodenum. Wursungian duct only seen at left extremity, and here its calibre obliterated. Pancreas.—Its head was bound down, with the as- cending and descending co- lon, into a cancerous mass, with which the duodenum was also connected; cystic and hepatic duct obstructed by the malignant growth. >Iucous coat of gall-bladder ulcerated in several spots. Cancerous masses in several parts of the small intestines. Stomach dilated; pylorus hard, thick, and firm, and its calibre greatly contract- ed. to to 241 Dr. Fletcher. Birmingham Path. So- ciety: Jan. 20th, 1844. Prov. Med. Journal. 25 52; female. Not men- tioned ; (under treatment for two months.) Albers. Rheim. Corresp. Blatt, 1843; or, Can- statt's Jahres- bericht, 1849, Vol. ii. 50; male. Hardness and in- creased space of dullness, extending from the right hypo- chondrium into the epi- gastrium; pulsations felt there and in the left hypo- gastric region; and a distinct bruit de souffiet at- tended each impulse when the patient was in the recum- bent posi- tion. Upwards Fullness of of one epigastric year; (pre-;region; Intense, ex- Vomiting cruciating generally pain in in about region of half an stomach; in- hour after creased on taking pressure; pain ex- tended to right hypo- chondrium, and down to the umbili- cus. viously in good health.) a tumor with an irregular surface felt there, and in the right hypochon- driac region; and a pear- food; con- stant nausea. movable body be- tween twelfth rib and the anterior superior spinous pro- cess of the ileum. Above umbi- licus, and extending to right hypo- chondrium ; subsequently pain in the left side, ex- tending to ensiform cartilage, and to umbi- licus; also, dorsal pain; pain not constant; also, pain over spinous processes of all lumbar vertebra; at least on pressure; (these verte- brae were very promi- nent. As a late symptom; matter vomited; yellowish- green, then dark matter. Costive; scanty evacua- tions twice or three times daily in an advanced stage of the disease. Not men- tioned. Soft, white stools; very late in the disease black stools. emacia- tion. AscitM; [Irritable bowels stomach; above very great tympani- .thirst; tic. i tongue dry and red. Present, and in- creased ; occurred as an early symptom Present. Not men- tioned. The whole surface of abdomen was tender; pulse small and feeble, 120 per minute. Pancreas.—Entire organ carcinomatous; its head very much enlarged, wrapping around the duodenum, and inclosing that intestine in its diseased structure, so as to produce a stricture just below the pylorus. Liver studded with carcinomatous tubercles; other organs were healthy. Eructa- tions of a bitter fluid; also, clear, yel- lowish, green, and acid fluid expecto- rated; appetite good; very fetid breath. Dullness on percussion on left side of chest; dis- position to lie on the back; saliva- tion for three months, after taking ^ij. of calomel; urine dark color, con- taining cho- lesterine; passed with some diffi- culty. Pancreas.—Its head hard and degenerated, forming a yellowish tumor, which, mi- croscopically examined, showed irregular cells, with several nuclei. Similar cells are seen in the small, yel- lowish deposits in the left lung, and in the liver; pan- creatic duct pervious, and could be traced to the mid- dle of the gland. Gall-blad- der much dilated. The en- trance of the common duct could not be found. Pan- creas adherent to duodenum, and at seat of adhesion an ulcer in the latter. to CO By whom and where reported. State of Bowels. Emacia- Dyspeptic Other Symp- £ CD Age and Sex. Duration. Local Signs. Pain. Vomiting. Jaundice. tion and Debility. Dropsy. Symp-toms. toms and Remarks. Post-mortem Appearances. 26 Caspar. Cas-par's Wo-chenschrifft, 40; Not men- Tumor could Not men- Present At times Present. Present. Ascites as None. Vomiting Pancreas, the size of a female. tioned. be felt, whose tioned. mainly af- Btools con- disease ad- commenced child's head, and in a state edge extend- ter taking taining vanced. after de- of scirrhous degeneration; No. 9; quoted in Canstatt's ed along me-dian line to food. dark blood livery. cirrhosis of the liver; gall-bladder much distended. Bericht, umbilicus. 1844; 3. 27 Tessier, 33; Not men- Hard, pulsat- Present; Not men- Constipa- Doubtful; Not men- (Edema of Not men- Pulse be- Pancreas.—Whole of the Journal de male. tioned ; ing tumor when the tioned. tion. pale-yel- tioned ; feet, disap- tioned. came small; organ converted into a can- Medic, de (appeared, extending oedema ap- lowish but great pearing face altered; cerous mass, which com- Lyon, Nov, 1847. when first from ensi- peared there com- debility is and reap- extremeties pressed the aorta; a few seen, in form cartil- was violent plexion. noted as pearing. cold two days mesenteric glands around tolerably age to um- pain extend- perceived before death. the tumor cancerous. In good bilicus; ab- ing to the d suddenly the pancreas a few softened ' health.) domen pro-minent. In the last stages abdo-men con-stantly rising, and simultane-ously so with pulse, each movement accompanied by a sound audible some distance from patient, (glou-glou.) feet. two days before death. spots. Other organs were healthy, except the stomach, which was much dilated and filled with fluids. (This sup-posed to he the cause of the gurgling "glou-glou"sound.) to m: j. r. McClurg. Medical Ex- aminer, Phil, 1851. 50; male. Eight months. Fullness in epigastric re- gion, and to the touch the feel of a thickened condition; decided pul- sation in the epigastric region; great tender- ness there on pressure. Pain com- menced early, and was constant and very in- tense ; some- times most in the region of the sto- mach, then in the left side, or in the back; no pain in the right side, excepting a month or two before death. None. Costive. None; (skin dry, of a straw color; counte- nance had a wild, anxious look.) Progres- sive de- bility and emacia- tion. Ascites and ana- sarca four weeks be- fore death. Anorexia; feeling of oppression at epigas- trium ; tongue covered with a thick, yel- low coat. Great rest- ..ssness; pa- tient unable to lie in bed; also inability to stand erect; bent forward so as to relax abdominal muscles; at one time fever; pulse, 90. In the last month of the dis- ease hic- cough be- came an al- most con- stant symp- tom. The patient thought his disease had been pro- duced by having car- ried, two years pre- vious to his last sickness, a load of coal in a tub, which press- ed hard against the stomach, giving him pain at the time, and ever after some uneasi- ness or a tired feeling at the epigastrium Pancreas.—The whole of the organ was converted in- to a cancerous mass, which also embraced the smaller curvature of the stomach, surrounded the solar plexus, the aorta, and accompany- ing vessels, and adhered to the diaphragm, the liver, the arch of the colon, and omen- tum. Liver was enlarged, hard, and " tuburculated;" gall-bladder healthy. to 0 By whom Age and Sex. v State of Bowels. Emacia- Dyspeptic Other Symp- £ and where Duration. Local Signs. Pain. Vomiting. Jaundice. tion and Dropsy. Symp- toms, and Post-mortem Appearances. © reported. Debility. toms. Remarks. 29 Dr. Knee- 64; About Hard tume- "Constant Present, Consti- No jaun- Extreme Not men- Continual Pancreas enlarged and land. New male. eighteen faction in deathly dis- and as an pated. dice. emacia- tioned. vomiting hard; adherent to stomach; York Jour- months. epigastric tress," con- early tion; (skin of food; converted, with the portion nal of Medi- region; not fined princi- symptom; of a dingy, occasional where it was adherent, into cine. Vol.xi. tender on pally to matter pale, vomiting one mass of scirrhus, of a 1853. pressure. epigastric region; in-creased by nourish-ment; suffer-ing, indeed, much greater when he did not rejeot whatever he swallowed. vomited colorless; of a saltish taste. bloodless hue.) and sink-ing sensa-tion about the sto-mach were very early symptoms. uniformly dull or yellowish-white color, and of a homo-geneous structure. Liver, spleen, and kidneys anaemic in appearance. The mucous membrane of the stomach had retained its normal structure; the viscus was much contracted. 30 John S. An- 52; "Several Indistinct Continuous Present, Rather Never Increas- Not men- None. Abdomen Pancreas.—Its head en- trum. Asso- female. years." fullness in epigastric but rarely, irregular marked; ing debil- tioned. Food became, in larged to the size of a ciation Med. epigastric pain, as a and only and irri- skin ity and readily the last goose egg, by a cancerous Journal, region, in the very early as thedis- table; gradually emacia- digested; stages, tym- deposit in its tissue. Simi- 1855. later stages; symptom; at ease ad-- stools became tion; had uncon- panitic; lar deposits in the smaller also, indis- first relieved vanced, natural, slightly had at- trollable right thigh end, and in neighboring lymphatic glands. Pancreas tinct dullness by change of and then except yellow and tacks of flatulence, became on percus- air and appeared when defi- muddy. debility but not swollen, and not adherent. Pyloric end of stomach, near pancreas, sion ; at one tonics; later to arise cient in for several dependent femoral vein time a cir- more severe, from dis- bile; years. on taking tender in thickened by a deposit of cancer, apparently colloid; cumscribed and extend- tension by nothing food; pain several parts spot, an inch ing to the wind; like fat in the of its course. deposit ceased abruptly at square, be- right groin, never a passed, not earlier Death took the pylorus; dark, black, low the edge and to the black even when stages re- place from slimy mucus, as is often of the liver, back. appear- cod-liver lieved by inanition. ejected in cases of cancer of tender on deep pres- ance of vomit. oil was taken. taking food; the stomach, covered the py-lorus. Other viscera, as far sure, was noticed. seemed more a sensation of ex-haustion. as examined, healthy. 31 Haldane. Male; Seven None. Not men- Not men- Costive; Intense, Present, No ana- For seven Gradually, Pancreas cancerous, (by microscope) but disease was not at the head of the organ, which was healthy. Retro-grade cancer-spots in liver, and in the mesentery. Gall-bladder much distended; ductus communis com- Month. Journal of Med. Science, Edinb., 1854. age not stated. months or upwards. tioned. tioned. clay-colored stools during jaundice; previously dark and scybalous; not fatty. but occur-ring as a late symp-tom. and both continu-ally in-creasing. sarca; but ascites, with much tympa-nitis. months. before death, sank into asthenic coma. pressed, and involved in the disease. to 32 Dr-Wilks. Transactions | of the Pathol. Society of London, Vol. vi. 1855. 56; male. 33 Dr. Da Costa, Proceed, of Path. Society of Philadel- phia, p. 8; or, North Am. Med.- Chir.Re- view, Janu- ary, 1858. Six months. Abdomen felt rigid in the last stages of the disease, but no tumor perceptible. 45; male. Seven months. In middle of back and in abdomen, varying in intensity; very severe at first; became dull, and lessened much as disease advanced. Obsti- nately con- stipated, but stools through- out nor- mal. None. Pain across Occa- epigastrium, sional, and but not severe; ex- tending to back. not at com- mence- ment of Consti- pated ; dejections are clay- colored, not fatty. Very marked; occurred rather early in the dis- ease, and continu- ally in- creased. Emacia- tion steady and pro- became extreme; debility not spe- cially men- tioned. Slight ascites, as a late symptom. Appetite bad, but not capricious. Both present, but neither to a marked degree. Patient I Pancreas changed into a when first cancerous mass; in part fi- slen did not brous and hard, in part anne'ar very gelatiniform. The head still appear very ktllined somehealthy struc. ture. The duct, close to the duodenum, was pervious, but quite impervious when run- ning through the diseased gland-. The pancreas was closely adherent to the duo- denum and stomach. A few of the gastric absorbent glands were partly infil- trated with morbid matter, but they were not connected with the diseased pancreas. The omentum was drawn up, and converted into a hard cancer. In it, and in the pancreas, were found well-marked cancer-cells. No cancer existed in other parts of the body. Very slight symptoms of indiges- tion. Hemorrhage from the lungs. Pancreas enlarged; its head and surrounding glands con- verted into a hard tumor, which, microscopically ex- amined, proved to be a can- cer; middle portion in a state of fatty degeneration. Pan- creatic duct pervious. Liver enlarged, green and mottled, with irregular and large pig- ment masses in its struc- ture; hepatic and common duct much compressed; cys- tic duct dilated; a few can- cer-spots in liver; other or- gans healthy. All the cellu- lar tissues were extremely yellow. The lower lobes of the lungs were voluminous and engorged; the seat of the hemorrhage could not be detected. to —, "Rv whnm State of Bowels. Emacia- Dyspeptic Other Symp- and where reported. Age and Sex. Duration. Local Signs. Pain. Vomiting. Jaundice. tion and Debility. Dropsy. Symp-toms. toms, and Remarks. Post-mortem Appearances. 34 Dr. Agnew. 56; One year; None. Pains of fly- Present; Very tor- Very Both None. Signs of in- Troublesome Pancreas enlarged to four Proc.ofPath. male. previously ing charac- matter re- pid; evacu- slight, if markedly digestion hiccough; he times its size; its structure Society, p. 84, or North in good ter, passing jected was ations any; present; were the was a good replaced by cancerous mass- health. through ab- of a glairy clay- (counte- | weight, first mark- liver, and es; also a deposit of can- Am. Med.- domen to the character, colored ; nance pale when first ed symp- had, for a cer at cardiac orifice of sto- Chirg. Rev., July, 1858. right and very sometimes and blood- attacked, toms; long time, mach, (both examined with shoulder; no offensive. greenish. less; color 250 lbs.; nausea; had slight the microscope;) liver cir- pain on pres- Nausea of skin in- at time of flatulency; dyspeptic rhosed; the ducts pervious; sure; feeling was among dicating a death, a feeling symptoms, kidneys also seemed granu- of fullness the earliest cancerous 120 lbs. of fullness which be- lar. The enlarged mass of and weight symptoms, cachexia.) over the came, rather the pancreas pressed on the in epigas- but vomit- stomach. suddenly, thoracic duct. trium. ing oc-curred only as the case pro-gressed. much aggra-vated ; at the time they became so he was much depressed in spirits. 35 Dr. Bennett. 50; One year; Tumor in Pain severe Present; Not men- None. Both pre- None. No appe- Tenderness Pancreas. — Its head in- " Clinical male. previously epigastrium and con- occurred tioned. sent and tite; py- over liver; volved with the surround- Lectures," in good perceived by stant ; is epi- at first oc- pro- rosis as a pulse small ing mesenteric glands, and " p. 449. health. patient him- gastric, but casionally; gressive. very early and weak; a mass compressing the py- self three not increased later, be- symptom; slept but loric extremity of the sto- months and on taking came con- food could little; urine mach in a cancerous tumor. a half before food. stant; he not be re- normal; pro-,This mass was seated in the death; tu- vomited tained on longed ex- smaller curvature, and pro- mor very matter re- stomach; spiration, jected into the stomach. painful on sembling thirst only feeble and The remaining portions of pressure; coffee- occasion- harsh respi- the pancreas were healthy, could be grounds, ally; ratory mur- but the duct was obliterated. moved up- mostly one tongue mur in A cyst in the right kidney; wards and to hour to an and gums lungs. liver felt hard and nodu- the right. It hour and a dry. lated ; lung presented gelati- was distinct- half after nous-looking masses, which, ly felt, two meals. microscopically examined, inches below proved to be cancer. the ensiform cartilage, and three above um- bilicus. to 00 36 37 Dr. Bennett. "Clinical Lectures," p. 462. Case com- municated to me by Dr. Harris. 50; male. 44; colored woman. Eleven weeks. Upwards of thirteen months. None. Gnawing pain in epi- gastrium, (was the first symptom of disease;) alsi acute grind- ing pain in the region of the liver. Constant, dull, and ex- tending over abdomen. No vomit- ing; food excited Of watery fluid, de- positing a blackish sediment; never of food; was not as con- stant as disease ad- vanced ; indeed, at one time ceased for several months. Consti- pated stools of a lead color; at times dark- green. Regular. Yellow tinge of skin ap- peared four weeks after first symp- toms; jaundice steadily increased; finally skin be- came of a dark, green tint. Yellow- ish con- junctiva, but not early in disease, and never very marked. Emacia- tion not mention- ed, but progres- sive ex- haustion. Both present and pro- gressive. Loss of appetite; tongue slightly furred, moist, but became dry; con- siderable thirst; food ex- cited nausea. Present from the first, in- creased with the disease; loss of ap- petite marked; tongue re- mained clean through- out; some flatulency. Two weeks after he felt gnawing pain, was overworked; drowsiness, loss of appe- tite, ano- rexialippear- ed, soon fol- lowed by jaundice. Died of ex- haustion. Pancreas—right extremity converted into a cancerous tumor, rest of the organ indurated; contained a few small cysts. The portion of the common duct which passed through the tumor barely admitted a small probe. Behind this con- striction the common, cys- tic, and hepatic ducts, were greatly enlarged; liver of a green color; its bile-ducts dilated; some cancerous spots in liver, as also in kidney; gall-bladder dis- tended, containing two gall- stones, supposed, by their passage from the liver, to have occasioned the grind- ing pain over the organ. Pancreas converted into a cancerous mass the size of a fist, and having the gene- ral characters of encepha- loid. Its right extremity was mainly diseased; the liver was slightly enlarged, had a few small, cancerous tumors on its external sur- face. The stomach was per- fectly healthy, so were also the other abdominal organs; common duct, pervious. o in o H w Ti to o