April 10th

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.

Dtagtiosis

In cases of ischochyraia due to stenosis of the pylorus, benign as well as malignant, symptoms of vomiting1 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 thin latter is very easily recognized and as a rule is retained in the stomach when the pylorus is1 Vomiting may sometimes be absent, notwithstanding that ische-chyniia has already developed. I at present have under observation a patient with carcinoma pylori (with dearly palpable tumor), who has been ailing for the last six mouths. The patient has never vomited nor has he 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 unstenosed. For thi6 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Whenever no chyme is withdrawn by this method, it is necessary to wash out the stomach.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.

Differential Diagnostic Points

Condition Of Gastric Contents

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:

1. The dilated or abnormally large stomach.

8. The thickened and readily palpable pylorus.

3. The peristaltic restlessness of the stomach.

4. The fermentation products.

1. The abnormal size of the stomach is pathognomonic only if the organ occupies nearly the entire lower section of the abdomen, and contains over three or four litres of fluid. Such stomachs are frequently met with in old cases of stenosis of the pylorus, and their presence at once awakens the suspicion of a narrowing of the pylorus; before this diagnosis can be made, however, the presence of ischochymia must be determined. In this country considerable weight has been placed upon this symptom; yet the absence of this diagnostic sign should not lead us astray, for it is our aim to make the diagnosis of pyloric stenosis as early as possible, while the pronounced, at once perceptible dilatation of the stomach develops only in the course of time.

2. If it is possible by means of palpation to map out the pylorus as a smooth, oval tumor, and if ischochymia is present and the disease has lasted over one and a half or two years, we can with certainty make a diagnosis of benign pyloric stenosis.

3. Peristaltic restlessness of the stomach is frequently found in cases of benign as well as of malignant stenosis of the pylorus. Inasmuch as the peristaltic restlessness of the stomach but very rarely occurs as a pure neurosis, this symptom is of great significance for the recognition of stricture of the pylorus, the more so as an examination for this purpose (simple inspection of the abdomen in the recumbent position) is not attended with any difficulty.

The presence of this symptom in connection with the existence of ischochymia speaks in favor of narrowing of the pylorus, and against simple relaxation of the gastric muscular coat; the absence of this symptom is of no consequence.

4. Fermentation products (formation of lactic acid or gases in the stomach) are observed almost constantly in all cases of ischochymia. Commonly, one or the other kind of fermentation is present, that is, either formation of lactic acid or formation of gases. The lactic acid is found in the stomach in cases in which the secretion of hydrochloric acid is considerably diminished, while the development of gas is encountered in cases in which there is an abundant secretion of gastric juice. These points, which have been especially emphasized by H. Strauss,1 I can completely confirm on the ground of my own experience.

These fermentation products may be absent, however, notwithstanding the presence of pyloric stenosis, if the stomach has been treated in a rational manner, that is, has been washed out several times.

The constant or frequent occurrence of small quantities of bile in the stomach does not in my experience militate against the existence of a narrowing of the pylorus; on the other hand, it appears to me to point to a firm rigidity of this orifice, in consequence of which the latter is never completely closed.2

Among the more recent auxiliary measures which are available in arriving at a diagnosis, the gastro-scope has been recently employed by Rosenheim and Kelling. In my opinion there is no doubt that this instrument has a great future, although at present it has not been generally utilized.

1 H. Strauss: Zeitchr. f. klin. Medicin, 1895. 2 Max Einhorn: "A Further Contribution to Our Knowledge of Ischochymia," l. c.

A protracted atony of the stomach may at times produce ischochymia; it is then, however, not constantly found and disappears soon after the regulation of diet and rational treatment. The same may be said of grave forms of chronic gastric catarrh. Here also ischochymia is liable to develop under favorable conditions. The symptom, however, disappears after a few washings of the stomach. In this way I believe that these two conditions (atony of the stomach and chronic gastric catarrh) can be distinguished without difficulty from stenosis of the pylorus, and can give no cause whatever for mistakes.