2. The term "acute infectious epiglottitis" is suggested for this condition as being more scientific, and more fully explaining its probable nature. It is of course understood that the inflammation and oedema involve only the anterior surface of the epiglottis.

172 WASHINGTON AVENUE.

BIBLIOGRAPHY

1. Mainwairing. Medical Facts and Observations for the Year 1791, Vol. I. (See Marsh's article).

2. Home, Sir Everard. Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, 1808, Vol. 3. (Marsh).

3. Burne. London Medical Gazette, May 22, 1830, p. 313.

4. Marsh, H. Cases of Acute Inflammation Confined to the Epiglottis. Dublin Med. and Chir. Journal, Sc., Vol. 13, March 1, 1838, p. 1-23.

5. Tomkins. Fatal Enlargement of the Epiglottis, Lancet, London, 1841-2, V. I. p. 705. 6. Louis. Sur l'inflammation de l'epiglotte. Gaz. d'hop., 1843, T. 2, p. 357.

7. Kesteven, W. B. On Epiglottitis. London Med. Gazette, Vol. 8, May 4, 1849, p. 761-763. 8. Larsen. Schmidt's Jarbücher für 1852, p. 315.

9. Wunderlich. Handbuch der Pathologie und Therapie, 1856, S. 110.

10. Gibb, G. D. Case of Acute Epiglottiditis, Transactions Path. Soc., Lon., 1863, Vol. 15, P. 50.

11. Windsor, J. Case of Epiglottitis, or Acute Inflammation and Enlargement of the Epiglottis, British Medical Journal, Jan. 30, 1864, pp. 120-122.

12. Crisp. Acute Inflammation of the Epiglottis, Transactions Pathological Society London, Vol. 17, p. 28, 1866.

13. Pel. Nederlandsch Tydschrift voor Geneeskunde, 1878, S. 452.

14. Michel. Centralbl. für medicinische Wissenschaften, 1878, No. 2.

15. Moure, E. J. Oedeme aigu primitif des replis aryteno-epiglottiques. Rev. mens. de laryngol., 1880-1, V. I., p. 27.

16. Fredet. Epiglottide suppureé avec cedeme dela glotte. Mort par asphyxie, Soc. de med. leg. de France, Bull., 1882, Vol. 7, pp. 91-93.

17. Wesseler, C. Edema of the Epiglottis, Proc. St. Louis Med. Soc., 1881, Vol. 3, p. 43. 18. Störk. Klinik d. Kranheiten d. Kehlkopfes, 1880, p. 200.

19. Moll, A. C. H. Medisch. Weekbl., Vol. 5, No. 38.

20. Ruault, A. Epiglottide oedemateus, circonscrite primitive. Rev. mens. de laryngol, 1887, Vol. 7, pp. 673-676.

21. Schmidt, H. Cricumscriptes entzündtliches odem der Epiglottis, 1889.

22. Gottstein, J. Die Krankheiten des Kehlkopfes, 1893, . 109.

23. Hajek, M. Schnitzler, klinischer Atlas, 1894. S. 52.

24. Park, W. H. The Bacteria Present in the Human Throat, etc., N. Y. Med. Record, Jan. 27, 1894.

25. Veillou. Recherches sur l'etiolgie et la pathogiene des angines aigues non diptheritiques, Arch. de med. experiment, Vol. 6, 1894.

26. Kuttner. A. Larynx odem und subumcöse Laryngitis, Virchow's Archiv, Vol. 139, Heft, 1, 1895.

27. Semon, Sir F. On the Probable Pathological Identity of the Various Forms of Acute Septic Inflammations of the Throat, etc. British Med. Journal, April 27 and May 18, 1895.

28. Levi, L., and Laurens, G. Un cas'd œdeme aigu primitif du larynx. Arch. gen de med., Dec., 1895.

29. Bayliss, E. B. Acute Edema of the Larynx, N. Y. Med. Record, Nov. 16, 1895.

30. Arnold J. Burnett's System of Diseases of the Ear, Nose and Throat, 1896, p. 312. 31. Schmidt, Moritz. Krankheiten d. oberen Luftwege, s. 153 U. 232.

32. Ibid. II. Auflage, 1897, 8. 283.

34. Meyjes, W. P.

33. Browne, Lennox. The Throat and Nose and their Diseases, 1897, p. 468. Angina Epiglottidea Anterior, Journal of Laryngol, March, 1897, Journal of Laryngol. Sept., 1897.

p. 112.

35. Milligan, Wm.

36. Kyle, D. B. A Text-Book of Diseases of the Nose and Throat, 1899. p. 514. 37. Welch, W. H. Johns Hopkins Hospital Bulletin, December, 1892, p. 135.

CARCINOMA OF THE STOMACH WITH REPORT OF CASES SHOWING INCREASED HYDROCHLORIC

ACID.*

BY ANDREW MACFARLANE, M. D.,

Clinical Professor of Physical Diagnosis, Albany Medical College.

It is only a few years ago that the diagnosis of carcinoma of the stomach was entirely a matter of scientific interest and had no practical significance. The prognosis was without hope; the treatment of no avail and strictly symptomatic. The belief in its hopelessness was so prevalent that even an attempt to make an early diagnosis seemed chimerical.

To-day, however, surgery of the stomach has made such advances that the complete removal of this organ is among the successful operative procedures while palliative operations have added much to the comfort and life of patients.

That the stomach is not an organ absolutely essential to life is shown by the fact that people who have complete absence of the gastric secretion are often unaware that there is any abnormality in their digestive system as the intestinal digestion compensates for this failure of the stomach.

Since operative procedure is the only hope it is the duty of the physician in all suspicious cases to make at the earliest possible moment a highly probable, if not an absolutely certain diagnosis in order that his patient may have this one chance for recovery.

Doubt has been thrown upon the possibility of making an early diagnosis in cancer of the stomach because the attempt has too often been made to diagnosticate carcinoma from the presence of one symptom alone which symptom has usually been due not to the carcinomatous process itself but to one of its secondary effects. There are diseases in which the presence of a single idiopathic symptom is sufficient upon which to base an absolutely correct diagnosis as the bacillus of tuberculosis in sputum, the gonococcus in an urethral discharge and the plasmodium malariæ in the blood. In the vast majority of diseases however the physician is satisfied not with one symptom alone no matter how characteristic, but seeks a complete picture of the disease entity and from the resultant of all the symptoms deduces his diagnosis. Medical history is full of failures due to the efforts from limited

*Read before the Medical Society of the State of New York, January 30, 1900.

observation to make the presence or absence of a certain single symptom pathognomonic for the presence or absence of a distinct disease. Diseases of the stomach have been no exception and cancer of the stomach from the inherent difficulty of its early diagnosis has frequently suffered in this respect. As practically all the symptoms of carcinoma are due not directly to the cancer itself but to the secondary effects induced, the symptoms in any case will vary with these secondary effects which are not always the same and many of which may be the result of other pathological conditions. The mobility of the stomach may be practically normal or very seriously affected; the gastric secretion may be markedly modified or unchanged; the cancerous growth may be flat, infiltrating and therefore imperceptible to touch, or rough, nodular and easily palpable; the mucous membrane slightly affected or ulcerated with the presence of blood, pus and particles of cancerous tissue in the gastric contents. The difficulties of diagnosis and the reason for the seeming contradictions in the symptoms thus become evident. The general symptomatology. of cancer is therefore of little value unless the symptoms are classified with the condition which induces them.

The symptoms of carcinoma of the pylorus are very different from those of cancer involving other parts of the stomach, the signs of a diffuse growth different from those of a localized tumor, the evidence of an ulcerating tumor very different from that of one which has not ulcerated, the symptoms of a primary growth different from those where the tumor has secondarily developed. The significance then of the presence or absence of retention, hydrochloric acid, lactic acid, blood, pus, sarcinæ, yeast should not be applied indiscriminately to all cancerous conditions but to the selected cases in which the inducing condition is present.

The time allowed will not permit this paper to deal in detail with the diagnostic value of all the symptoms which may be associated with carcinoma of the stomach. I desire however to bring to your attention a series of cases sixteen in number in which what is ordinarily considered the most characteristic symptom of carcinoma-absence of hydrochloric acid-was not present. Since 1879 when Van der Velden1 announced that the absence of hydrochloric acid in pyloric stenosis was due to carcinoma, although he did not regard it as a pathognomonic symptom, no

question in medicine has aroused more discussion than this relationship of hydrochloric acid to carcinoma and its diagnostic significance. While some have claimed that the absence of hydrochloric acid was pathognomonic of cancer, it certainly has always been of the highest diagnostic significance. Kollmar," Biach,3 Eisenlohr, Tapret," Pignal," Koch," Ewald, and Bouveret have reported cases showing that the presence of hydrochloric acid is not necessarily inconsistent with the diagnosis of cancer.

8

The absence of hydrochloric acid in carcinoma is believed to be due to a gastritis, the direct result of the cancerous invasion or of the action of the toxines produced. The reason for its presence has aroused some difference of opinion. It probably always indicates a more or less intact mucous membrane. Many of these cases have been found to be cancerous growths upon the base of an old ulcer, the hyperacidity due to the ulcer being carried over as it were in the cancerous condition. The history, duration and course of the disease often make clear this sequence. Other cases are circumscribed cancerous nodules with no marked involvement of the rest of the mucous membrane or possibly carcinomata which have developed upon a condition of previous hyperacidity. The theory that as the oxyntic cells which are supposed to secrete hydrochloric acid are not situated at the pylorus, a cancerous growth affecting strictly this area should not interfere with the secretion of hydrochloric acid is not plausible since fifty per cent. of the cancers of the stomach affect the pylorus and only five to eight per cent. show the presence of hydrochloric acid.

Of the sixteen cases here reported, in twelve of which the diagnosis was confirmed by operation or post-mortem examination, six have clinical histories highly suggestive of a preceding ulcer. Hydrochloric acid was continuously present in thirteen and for a time found in the other three where it was later replaced by lactic acid. The pylorus was involved in seven cases, the pylorus and lesser curvature in two, the lesser curvature alone in one, and the growth was diffuse in one case. Lactic acid was present late in four patients, in three replacing the hydrochloric acid and in one associated with it. All suffered greatly from vomiting, retention determined by the presence of sarcinæ or food was well marked, emaciation and loss of strength were striking in every case and the appetite was poor in most of the cases.

The duration of the gastric symptoms varied from a few months to some years. In nine cases it was less than a year and in seven extended over a year, in several over a number of years. In seven cases pain was a prominent symptom while burning and distress were mentioned in two. These sixteen cases included eleven men and five women and their ages varied from thirty to seventy-two years. Three were in the fourth decade, seven in the fifth and the remainder, six, over fifty.

The object of this paper is not to add to the difficulties of diagnosis but to impress the importance of a possibility in a considerable number of cases of the absence of this the most characteristic symptom of carcinoma and the necessity of judging each case by itself. Statistics are of great value but necessarily of no assistance in determining the condition in an individual case and of course can never take the place of a careful, thorough examination.

The question to-day is not the necessity of making an absolutely certain diagnosis of gastric carcinoma, for many hold that that certainty is only possible when a tumor is present and then the time for successful operative procedure is probably past, but a highly probable diagnosis, after a thorough, painstaking examination, based upon the presence of some gastric symptoms of carcinoma together with the constitutional evidences of malignancy-progressive emaciation, anæmia, cachexia. Exploratory operations I believe, are in such cases even more justifiable than in many other obscure abdominal conditions where the surgeon does not hesitate to make his diagnosis after his incision.

The following histories taken from the case records of Dr.. Boas' private and polyclinic, Berlin, illustrate this condition-the presence of hydrochloric acid in carcinoma of the stomach. These histories have intentionally been condensed in order to emphasize the gastric condition. Some are not as complete as would be desirable because the records of dispensary patients cannot always be made so comprehensive as those patients in hospital wards.

The writer desires to take this opportunity to acknowledge his indebtedness to Dr. Boas for many kindnesses and in this instance for the privilege of examining and using his case records.

C. H., aet. 54, laborer. For the past eight weeks has every three or four days great pressure in the stomach and vomits food eaten the day before; appetite is good and has no distaste towards