A middle-aged woman was admitted into hospital for cancer of the stomach. She was greatly emaciated and cachectic, and suffered from constant retching and vomiting. The illness was supposed to have lasted for a year, but there was no history of haematemesis or melaena. On examination the stomach was found to be greatly dilated, and its peristaltic movements were plainly visible through the thin abdominal walls. Immediately above and to the right of the navel there was a prominent tumour the size of a large egg, which moved with respiration, was dull on percussion, and very tender. These signs, taken in conjunction with the general appearance of the patient, seemed to warrant a diagnosis of carcinoma of the pylorus, but an examination of the vomit showed that it contained an excess of free hydrochloric acid and no lactic acid. The case was consequently diagnosed as one of chronic ulcer with inflammatory thickening. At the necropsy a deep ulcer was found in the posterior wall of the stomach, close to the pylorus, surrounded by great induration of the tissues. No signs of carcinoma could be discovered.

(b) All varieties of pyloric stenosis are liable to be associated with the intermittent appearance of a tumour during the peristaltic contraction of the hypertrophied gastric wall. This condition, however, persists for only two or three minutes at a time, can often be seen as well as felt, and completely disappears as soon as the gastric movement ceases.

(c) A gall-bladder adherent to the pylorus seldom gives rise to a tumour unless it happens to contain a large calculus. When this is the case a hard non-tender mass may be detected in the right hypochondrium, in the neighbourhood of the ninth costal cartilage, which moves downwards upon inspiration but is incapable of lateral displacement. Distension of the stomach with gas shows that the pylorus is fixed to the under surface of the liver, the edge of which organ may sometimes be felt at the margins of the tumour. Less frequently a gumma or hydatid of the liver is the cause of the gastric adhesion, and the tumour then presents the general features characteristic of these diseases.

Table 32. -The Differential Diagnosis Of The Principal Conditions Which Give Rise To Stenosis Of The Pylorus