April 19th

Patient was examined one hour after Ewald's test breakfast. There was a considerable amount of bile in the gastric contents, which did not contain any food from the previous day. Chemically: HC1 = 0; no lactic acid; acidity = 22.

Diagnosis

In cases of ischochymia due to stenosis of the pylorus, benign as well as malignant, symptoms of vomiting 1 and pain are almost always present, in connection with a more or less considerable loss of weight. This condition, however, is best recognized by the examination of the stomach by means of the tube when fasting. I usually instruct the patient to have at his supper, on the night preceding the examination, besides soup, meat, and bread, some rice, as this latter is very easily recognized and as a rule is retained in the stomach when the pylorus is stenosed. For this examination the expression method alone is not always sufficient. Whenever no chyme is withdrawn by this method, it is necessary to wash out the stomach. In these cases food is then continually found in the stomach. Dilatation of the stomach is almost always present; the organ occasionally extends from the margin of the ribs far down to the symphysis.

1 Vomiting may sometimes be absent, notwithstanding that ischochymia has already developed. I at present have under observation a patient with carcinoma pylori (with clearly palpable tumor), who has been ailing for the last six months. The patient has never vomited nor has lie had much pain. His complaints merely refer to loss of appetite and obstinate constipation. The examination of the stomach in the fasting condition always reveals the presence of chyme (coarse food-stuffs are principally found). Although the patient, living on a more regulated diet, has gained six pounds within the last month, nevertheless the ischochymia remained unchanged.

Differential Diagnostic Points

Benign stenosis of pylorus.

Malignant stenosis of pylorus.

Duration of illness.

Long duration of illness (two to fifteen years).

Short duration of illness (five months to one and one-half years).

Course of the disease.

Long intervals without pain, or periods of perfect euphoria.

No periods of perfect euphoria, but constant and gradual aggravation of the symptom**.

Tumor.........

As a rule absent.......

Present in most cases.

Condition Of Gastric Contents

Benign stenosis of pylorus.

Malignant stenosis of pylorus.

Free HC1........

Present in the great majority of cases.

Nearly always absent.

Lactic acid....

Absent in the great majority of cases.

As a rule, present.

Acidity.....

Always increased....

Fluctuates between 30 and 90.

Rennet.....

Always present.....

Varies.

Odor............

Unpleasant, disagreeable

Very frequently fetid.

In the following I shall describe several symptoms which, when present, are very valuable, but whose absence does not militate against the existence of pyloric stenosis. These symptoms are: be a cancer, and could not be resected on account of the numerous adhesions, principally with the colon. Gastroenterostomy was established, and in about a month's time patient was able to leave the clinic and partake of a great variety of food. Soon, however, regurgitation of bile into the stomach appeared, and a short while afterward '"peristaltic restlessness" of this organ also developed. Both conditions made the patient feel very uneasy.

1. The dilated or abnormally large stomach.

2. The thickened and readily palpable pylorus.