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A. B., a male infant weighing ten pounds, was born Most textbooks describe gastric cancer under on Dec. 25, 1904, in the most favorable surrounding one type the pyloric cancer. Tumor, dila- and with good inheritance. The labor had been short, tation, absence— of hydrochloric acid, presence the delivery easy with low forceps. A slight ecchy- of lactic acid, coffee vomit, continual was on middle of grounds mosis noticed at birth the finger the are the hand. On the the cried loss of weight and cachexia symptoms right following day baby and are so that the and vomited some mucus. An portrayed, typical diagnosis considerably bloody is But an under the chin and on the back made by the laity. only early diagnosis ecchymosis appeared such of the neck. On the third day several more hemor- gives a therapeutic chance, and to arrive at rhagic spots appeared and when the child was sixty it must be remembered that gastric cancer pre- hours old copious bleeding began from the base of the sents a picture in its early stages which is definite, cord at the navel. At this same time also is passed a and depends strictly upon its location. large, tarry stool made up of decomposed blood, it Two clinical types are to be distinguished vomited fresh blood, bled slightly from the nose and cancer and cancer of the lesser curvature.— from a minute scratch on and several pyloric the scrotum, to the old view cancer is as common in more on the The tem- Contrary ecchymoses appeared body. the latter as in the former and its char- was 101°. The child now a des- situation, perature presented acteristic demands perate appearance, and the outlook was of the very symptomatology recognition. worst. The symptoms of pyloric cancer also vary Nitrate of silver in the solid stick was applied to the according to the mode of origin, whether it forms bleeding points at the navel, and styptic iron was also on the base of a simple ulcer or is primary. The used. Both had only a temporary effect, and the carcinomatous ulcer is accompanied frequently blood soon poured out again through the black clots. from beginning to end with hyperacidity, con- Continuous pressure with the thumb alone served to tinuous or Late if the A of alimentary hypersécrétion. stop bleeding. heaping teaspoonful gelatin ever is there diminution in the Motor dissolved in an ounce and a half of was then acidity. water while lactic acid to the infant from a bottle, and was taken, insufficiency develops early, given eagerly late if at all. Pain is as a rule and a 1 to 1,000 solution of adrenalin was to appears severe, applied in the navel. Pressure with the thumb was kept up from and it is this form of cancer that hemorrhage time to time. The same amount of gelatin was given is most frequently profuse. twice more at intervals of two hours. The bleeding The primary pyloric cancer, on the other hand, at the navel ceased after two hours, no more ecchymotic often presents but slight motor insufficiency at spots appeared, the bleeding from the nose and from the start, but this seldom wholly fails. Free the stomach did not recur, and at the end of twelve acid falls and after several a movement of normal hydrochloric slowly gradually hours, tarry stools, as is shown by weekly tests. A relative acid color was passed. The temperature at this time had which Gluzinski fallen to 99.6° and after this became normal. insufficiency is present, showed Recovery was an cancer. was and the career of the important sign of beginning He uninterrupted subsequent " infant has been normal. demonstrated this by testing the stomach fast- ing "; again, after an albumin test breakfast (two Hemorrhagic disease of the newborn is generally hard boiled, finely divided eggs and 100-200 cc. admitted to be an infectious, self-limited disease, water); and third, after a test midday meal, all tending to death or recovery in a few days, and given on the same day. If hydrochloric acid was generally, as in this case, accompanied with fever. absent one or more times it was suggestive. Where the hemorrhages are so profuse and occur Tabora considers this test most helpful. The from so many different tissues the outlook is test is less valuable for the ulcer type of cancer, generally bad. How much of the good result because there hypersécrétion is often present. can be attributed to the gelatin, it is impossible The positive result of the test, therefore, speaks to say, but the prompt recovery after its use is for cancer, but the negative is not against cancer. certainly suggestive. The benefit from the local Slowness of secretion of hydrochloric acid is often use of adrenalin is also worth noting. manifest, and constitutes another peculiarity of gastric cancer, though not of so much value as the relative insufficiency of Gluzinski. The acid Medical progress. may form during the night, and so be found in the fasting stomach, and yet be absent even for PROGRESS IN GASTRO-INTESTINAL DISEASES. one or two hours after a test meal. On account BY ELLIOTT P. JOSLIN, M.D., BOSTON. of the motor insufficiency and disturbed secre- tion lactic acid is formed. Hemorrhages are THE pathology of gastric cancer. frequent, but less profuse than in carcinomatous Tabora ' reviews the cases of gastric cancer in ulcer and of the coffee ground variety. Pain is. the late Professor Riegel's Clinic at Giessen in an less severe, a palpable tumor fails generally at instructive manner. We recommend those es- the start, which is the opposite of carcinomatous pecially interested in this subject to read the entire ulcer, in which a clear resistance in the pyloric article. His opinions are based on a study of region is more common. This is due to the infil- 212 cases treated in the hospital during the last trated margin of the ulcer, the adhesions and five years, and of some others seen transitorily. pyloric spasm. In both forms of pyloric cancer These cases came under observation as a rule at early loss of weight occurs on account of the an unusually early stage on account of the in- early disturbance of motility, but cachexia may fluence of Riegel. fail, especially in carcinomatous ulcer. 1 Deut. Med. Woch., 1905, p. 576. Though it may be impossible to differentiate The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at MCGILL UNIVERSITY LIBRARY on June 28, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. between an ulcer and a cancer at the pylorus, in or function are most prone to develop cancer. very many cases it is possible to distinguish In the stomach two portions are so exposed, the between a beginning carcinomatous ulcer and a pylorus and the lesser curvature. In the hyper- primary cancer of the pylorus. Hypersécrétion, acid or normal stomach the pylorus opens only whether continuous or alimentary, is almost at intervals when a certain grade of acidity is pathognomic of the former. In the late stages reached, and the food collects near it and here when the hydrochloric acid has decreased, sepa- exercises its chemical and mechanical irritation. ration may be difficult. A positive history of This explains why cancer may develop not only ulcer is of value, but a negative history is not, at the pylorus, but also in the prepyloric portion. because it is so common for ulcer at the pylorus The case is different in the aehylic stomach. In to be latent. The similarity of the symptoms it the pylorus is an open door and the food is in ulcer and carcinomatous ulcer at the pylorus known to leave the stomach more quickly than is due to the similarity of the histological structure normal. The pylorus remains little disturbed, of the pylorus in the two conditions. (Boekelman.) but the lesser curvature, which we now know to The hydrochloric acid secreting cells are increased be almost perpendicular in the erect position, is in both conditions. In a primary pyloric cancer subject to continued irritation, and on account they are as a rule diminished. of its rich blood supply offers a good field for the Cancer of the lesser curvature of the stomach development of cancer. In a normal stomach, is most difficult to diagnose. In the majority of to be sure, the lesser curvature suffers as much, instances it is primary, accompanied with achylia but the pyloric portion suffers still more. The from the start and the motility is intact. By the place of predilection in the aehylic stomach is progress of the growth the stomach may become therefore the lesser curvature, in the normal rigid, and peristalsis be lost though tonic con- stomach the pylorus. Achylia in cancer of the traction of the stomach remains possible. Finally, lesser curvature is not a result of the cancer, and motor insufficiency may supervene, but with it so this symptom in these cases loses much of its the almost paradoxical condition of pyloric importance. insufficiency due to the rigid pyloric ring. This Lactic acid depends on hyperacidity and stasis is demonstrated by distention of the stomach simultaneously. It is most common in the sec- with air. Lactic acid formation is more frequent ondary anacidity of pyloric cancer, but also than in pyloric cancer, but is by no means an met with in cancer of the lesser curvature. This early symptom. A tumor is only to be felt where is because in the latter instance a slight stagna- the lesser curvature is low enough to permit tion can take place in the folds and recesses of palpation.

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