RARE OR OBSCURE CASES 325

SHORT NOTES O F RARE OR OBSCURE CASES

RECURRENCE OF CARCINOMA OF THE STOMACH EIGHTEEN YEARS AFTER PARTIAL GASTRECTOMY.

BY ERIC PEARCE GOULD, SUNOEON TO OUT-PATIENTS I N THE BlIDDLESEI HOSPITAL, LONDON.

W. B., male, age 58, was admitted to the Middlesex Hospital under the care of Dr. Pasteur in January, 1907, complaining of epigastric pain of four weeks' duration.

Examination revealed a freely movable mass in the epipastrium, to the right of the middle line. The patient's general condition was good, and the diagnosis of carcinoma of the stomach having been made, he was transferred to the caw of Sir Alfred Pearce Gould. The following is the record of the operation performed on Feb. 9, 1907 :-

"An incision 6 in. in length was made just to the right of the middle line through the right rectus. The bottom of the incision was in. below the level of the umbilicus.

" The abdominal cavity was opened and a growth was found extending round the pyloric end of the stomach. The first part of the duodenum was thcn clamped in two places, and the gut divided between them. The distal end of the duodenum was closed by a double row of sutures. The coronary and right gastro-epiploic arteries were then ligatured, and the gastro- hepatic omentum and part of the great omentum cut through. Clamps were placed across the stomach well above the growth, and the stomach divided between, the proximal end being closed with a double row of sutures. A posterior gastro- jejunostomy was then done, and the wound closed and dressed with gauze.

" The growth, about 24 in. in diameter, involved principally the anterior surface of the stomach and did not quite reach the pylorus. It was circular, well circuni- scribed, and consisted of one large ulcer with a much-thickened nodular base, and thickened everted edges considerably raised above the level of the stomach mucous membrane. The posterior surface of the stomach was only slightly adherent."

No glands could be felt.

Pathological &port.-Spheroidal-celled carcinoma. Apart from the development of a duodenal fistula, which closed spon-

taneously, the patient made an uneventful convalescence, and left hospital on March 15.

Nothing further was heard of him until he came to my out-patient department on Sept. 15, 1925, complaining that, having been quite well until February-that is, . eighteen years after the operation-he then began to have pains in the stomach and to be short of breath. The man, now 76 years of age, was vigorous but anremic. Abdominal examination revealed

326 THE BRITISH JOURNAL OF SURGERY

a soundly hcaled laparotomy scar, and to the left of i t a somewhat indefinite mass which was dull on percussion, moved with respiration, and was not tender. A barium meal gave the picture of a gastro-enterostomy with a small stomach cavity. The blood-count showed a pronounced degree of

secondary aniemia. The patient declined to come into hospital, but was seen from time to time, up to December, 1925, without any obvious alteration in his condition.

He was not seen again until June, 1926, when the tumour to the left of the middle line was found to he grcatly increased, form- ing a proniinence extending from the costal margin down to the navel, and to the right of the mid-line. He had lost flesh and his an- mnia was more pronounced,

His chief complaint was He was admitted to thc hospital on July 15, and slowly

Hc slept for most of the time that he was in

Flu. 23(i.--Priinaiy tumonr. ( x 75.)

but lie was still taking his €ood without pain. of weakness. sunk, dying on Aug. 9. hospital, and on no occasion required sedative drugs for pain. The following is an extract from thc post- mortem rcrord :-

“Both lobes of’ the liver were greatly enlarged by numerous soft, second- ary ncw growths, the lar- gcst of which was 4 in. in diameter. Previous partial gastrectomy, with gastro- jejunostoiriy patent. The remaining portion of the stomach was occupied by a large fungating mass of iicw growth which left little

of the growth was adhcrcnt to the under surface of thc left lobc of the liver, and continuous with the deposit in that organ. Thc head of the pancreas and the middle portion of the body were also cxtensively infiltrated. The growth within the stomach stopped short a t the junction of the jejunal mucosa, which junction was

healthy mucosa. Thc mass FIG. 437.--Pr11na~y tumour. ( ;: 860.)

RARE OR OBSCURE CASES 327

thus sharply :demarcated. Enlarged glands were present in the neighbour- hood of the stomach and on either side of the abdominal aorta, but no glandular or other recurrence was found elsewhere in the body.”

Sections of the original tumour (Figs. 236, 237) show diffuse infiltra- tion of the muscles and connective tissue by columns of spheroidal-celled carcinoma. The cells of the growth have slightly granular protoplasm, and distinct cell outline ; the nuclei are fairly constant in size and staining, and each possesses a promi- nent acidophil nucleolus. No attempts a t tubule formation could be detected.

Sections taken from the edge of the tumour found in the stomach at the post-mor- tem (Figs. 238, 239) show invasion of the surrounding

of carcinoma. The cells of the growth have clear protoplasm and indistinct cell outline. The nuclei vary much in size, shape, and depth of staining. The larger nuclei are less densely stained and show a prominent nucleolus. Portions of the growth show attempts a t tubule formation.

The diffcrcnce in the histological character of the two tumours natur- ally raises the question as to whether the second is a recurrence of the first, or whether the second is not, in fact, a true second primary carcinoma in the same organ. Whilst admitting that the his- tological differences, although definite, are slight, and would not in themselves justify acceptance of the second of the above alternatives, I feel that the clinical history of the case strongly supports this view. Unlike carcinoma

FIG. 239.-Tumour found post mortem. ( X 360.) of the breast, in which dis- ease the period of freedom

from recurrence not infrequently exceeds 10 or even 15 years, clinical experience suggests that recurrence after removal of a carcinoma of the stomach occurs, if a t all, within a 5-year period, although probably few cases of this kind have been followed for as long as 18 years. To this, the most important consideration in favour of looking upon the case as an instance

tissue by strands and masses FIG. 238.-Tumour found post morteni. ( x 76.)

328 THE BRITISH JOURNAL O F SURGERY

of a second primary cancer in the same organ, must be added the fact that, whilst the first tumour took the form of a shallow ulcer with everted indurated edges, the second was of the free-growing fungating type.

The chief interest of the case, however, lies in the remarkable prolongation of healthy life which resulted from the operation performed in the early days of partial excision of the stomach. It suggests also the value of an efficient gastrojejunostomy in lessening the pain usually associated with a rapidlr advancing gastric carcinoma.

I am indebted to Professor J. MacIntosh and his staff in the Bland- Sutton Institute of Pathology for identifying the block of tissue embedded after the original operation, for cutting further sections from this block, and for reporting upon these and sect,ions made from the tumour found in the stomach post mortem.

A LATE RESULT IN ECTOPIA VESICX. BY P. N. G. STARR,

ASSOCIATE PROFESSOR OF CLINICAL SURGERY IN THE UNIVRRSITY OF TORONTO.

WHEN I read the notes of the case reported by Drs. Foulds and Robinson,l showing the late result in one of the cases of ectopia vesicE operated upon by the late George A. Peters, it occurred to me that the case of a man living in New York State might also be of interest.

This man, when a boy 11 years of age, had been brought to Dr. Peters’ house on the day of the doctor’s funeral, having previously experienced in New York City three unsuccessful attempts to make a bladder. The case was referred to me, and on May 11, 1907, I transplanted both ureters into the rectum by the method described by Peters. On the right side the cuff slipped out of the rectum, but the other worked perfectly, and a month later I transplanted the one that had slipped. His condition was not good a t this time, and I did not ablate the remainder of the mucous membrane of the bladder, expecting to do that about a year later. He did not return until September, 1916, when I removed the mucous membrane of the bladder, and swung a flap of skin to cover the raw surface.

On May 28, 1926, he returned to see me, having developed a small inguinal hernia on the left side. Except for this he is in perfect health, he has no inconvenience from urine, and his sphincter ani muscle acts perfectly, even during sleep. Another striking thing is that the space between the symphysis pubis has become considerably narrower. He is at this time a young man of 50, carrying on as a commercial traveller, covering the New England States.

REFERENCE. Brit. Jour. Surg., 1927, xiv, 529.