It may be situated close to the pylorus or in the region surrounding the en trance of the choledoch- and pancreatic ducts or close to the jejunum, and the symptoms will vary accordingly. In addition to other manifestations there are anorexia, nausea, vomiting, and pain. When a tumor becomes palpable it will be found in the right upper quadrant of the abdomen, and it is, as a rule, fixed, and little, if at all, mobile upon manipu lation or with the movements of respira tion. Pain, when present, has a corre sponding localization, but it is likely to occur at a later period after the ingestion of food than that of malignant disease of the stomach. When the first or pyloric portion of the duodenum is the seat of the new growth the symptoms may simu late those of pyloric obstruction, among the most distinctive of which are dilata tion of the stomach, with vomiting peri odically of vast amounts of fluid and partly-disintegrated food, some of which may have been ingested days before. If the neoplasm develop close to the point of entrance of the biliary and pancreatic ducts into the duodenum,—i.e., in the ampullar portion,—jaundice will almost certainly be a symptom in consequence of obstruction to the flow of bile. If the disease be situated beyond this point,— tha t is, in the jejunal portion,—the vomited material will contain bile and intestinal matters.
Primary cancer of the duodenum has, in the great majority of cases, an an nular form, and thus most frequently produces stenosis, the stenotic symptoms varying according to the level at which the growth occurs. Above the ampulla of Vater the neoplasm develops in the first portion of the duodenum and pre sents a symptomatology almost identical to that of pyloric cancer. In that below the ampulla, besides the symptoms ac companying stenosis of the pylorus there are signs indicating a reflux of bile and pancreatic juice into the stom ach, while in that developing about the ampulla the symptoms approach more or less one or the other of the above forms. When diagnosis is impossible, explora tory laparotomy constitutes the first measure necessary for surgical interven tion, which, however, in the greater number of instances, cannot be more than palliative. Pic (Revue de 'MM., Jan., '95).
Carcinoma of the aecum is commonly attended with symptoms resembling those that have been more fully detailed in the consideration of typhlitis: pain in the right iliac fossa, with constipation (perhaps diarrhea), tympanitis, im paired appetite, coated tongue, bad taste, nausea, and vomiting.
Carcinoma of the ciecum is not rarely a most chronic condition that may exist for years without giving rise to symp toms other than slight constipation and the presence of a tumor. Matlakowski (Deut. Zeit. f. Chir.. B. 33, h. 4, 5, '92).
The ileo-efecal region is a point of predilection for the development of ma lignant tumors, mostly in the form of carcinoma and local intestinal tubercu losis. The lumen of the gut is dimin ished and the glands much enlarged.
The onset of malignant disease is very insidious, the symptoms being usually those of typhlitis and coprostasis. As
regards treatment, resection and reunion of the divided parts are necessary, but symptoms of acute obstructions are contra-indications. Simple enterostomy is here called for, with resection later on. The extent of the tumor and ad vanced cachexia are also contra-indica tions. Norte (Deut. Zeit. f. Chir., B. 40, H. 5, 6, '95).
The tumor that develops, with dull ness on percussion, will be found in the right lower quadrant of the abdomen, though capable of a certain range of movement. As obstruction becomes marked, attacks of colic will occur, in consequence of the augmented expulsive efforts of the proximal bowel, which at first undergoes hypertrophy, with subse quent atrophy and atony and dilatation, while the distal intestine becomes col lapsed and empty.
The symptoms of carcinoma of the colon differ principally in localization from those attributable to like disease in the ctecum.
Case of primary cancer of the colon reported in which the digestive process continued normal without hmmorrhage. 3latiguor (Jour. de Sled. de Bordeaux, Dec. 24. '90).
The subjective symptoms of cancer of the large intestine may be divided into four classes: (1) those in which local signs arc absent for a long time or throughout, the progressive cachexia be ing the only thing to arouse suspicion; (2) those in which the local symptoms, are indefinite; (3) those of deep-seated stenosing carcinoma in which colicky pains are accompanied by tenesmus and strangury, as frequently seen in cases of rectal cancer; (4) cases in which symp toms of Bens appear in the midst of ap parent health or after prodromes of not alarming character. Of greater value than the subjective symptoms is the presence of a palpable tumor. Contrary to the teaching of the text-books. the tumor is not always movable. The oc currence of stricture is a symptom of the greatest value. 1. Boas (Deut. med. Woch.. Feb. 15 and 22, 1900).
A suggestive diagnosis of this condi tion is alone possible. The symptoms that may be taken as fairly suggestive of this syndrome are: (I) the promi nence of digestive derangements in asso ciation with other symptoms indicative of colon disease; (2) these symptoms arise in connection with the bowel, primarily, and in connection with the stomach, secondarily; (3) the symp toms associated with obstruction of the hepatic flexure are more acute than those situated farther along the colon, and usually do not occur until the pa tient has already shown signs of con stitutional disease; (4) pain is more common and more acute in disease of the cfecum, ascending colon. and hepatic flexure than when the growth involves other segments of the large intestine, and the pain is usually felt over the seat of the disease; (5) while the symp toms may suggest disease of the colon np to and including the hepatic flexure, the absence of any tangible growth in the right iliac and lumbar regions will point to implication of the hepatic flexure. A. E. Maylard (Edinburgh Med. Jour., May, 1902).