A man about fifty years of age was admitted into hospital for ' pernicious anaemia.' He stated that his health had been failing for seven months, during which time he had lost nearly two stones in weight and had become extremely weak. He had also grown very pale, and found that the least exertion gave rise to breathlessness and palpitation. The appetite was very bad, and after meals he had suffered from distension of the stomach, nausea, and flatulence. There had never been any vomiting or haematemesis, and the bowels were constipated.

Examination showed him to be very emaciated. The eyelids were puffy, the lips and conjunctivae pallid, and the skin a pale lemon colour. There was marked oedema of the ankles. No signs of pulmonary disease could be detected, but there was a loud systolic bruit over the base of the heart on the left side. The stomach extended to the level of the navel, and pressure over the epigastrium gave rise to pain, but no tumour or resistance could be felt. The other organs were apparently healthy. The blood showed red corpuscles 26 per cent., haemoglobin 19 per cent., well-marked poikilocytosis and a few typical megaloblasts. The gastric contents were devoid both of free hydrochloric and lactic acid. During his residence in the hospital the gastric symptoms increased, and on several occasions he vomited after meals. Emaciation made rapid progress, and the anorexia became absolute, so that the greatest difficulty was experienced in the administration of food. The temperature was slightly elevated at night but subnormal in the morning, and from time to time the constipation was replaced by diarrhoea. A few small haemorrhages also developed in the retina of the right eye. Death occurred suddenly from syncope at the end of three weeks. At the necropsy the greater part of the posterior surface of the stomach was found to be affected with an exuberant soft growth of spheroidal-celled carcinoma, which had given rise to a small encysted collection of pus behind the organ. The glands along the lesser curvature were enlarged, but there were no metastases in the liver or other organs.

(c) Ancemia with an Excess of White Corpuscles in the Blood. Alexandre and other writers have described cases of carcinoma of the stomach in which the symptoms of severe anaemia were associated with a great excess of white corpuscles (leuchaemia). Three cases of this description are included in our hospital series, and in each instance the spleen was much enlarged.

The first symptoms of ill-health consisted of breathlessness on exertion, debility, palpitation, and discomfort after meals, and the patients subsequently complained of loss of flesh, want of appetite, and at a later period of pain after food and repeated vomiting. In two cases the stomach underwent considerable dilatation, and a tumour was detected in the epigastrium, but in the other no special signs of the gastric complaint existed during life. In each the spleen was easily palpable, but it never projected more than three inches below the costal margin, and was not accompanied by enlargement of the lymphatic glands. Free hydrochloric acid was absent in the only case where the result of an examination of the gastric contents was recorded, and in every instance, in addition to a diminution of the red corpuscles, there was a marked increase in the number of white cells, the ratio of red to white varying from 70 to 1 to 12 to 1 Thrombosis of the femoral, iliac, or popliteal veins invariably occurred before death, and two cases succumbed to pneumonia. The average duration of life was about eleven months. It is interesting to note that in only one out of the three cases was a correct diagnosis made during life, the other two being regarded as examples of leucocythaemia.

Case XVI

A woman, thirty-three years of age, had complained of weakness, dyspnoea, and palpitation for nearly six months. When admitted into hospital she was markedly anaemic and thin, and exhibited a great distaste to food. The spleen was considerably enlarged, and the blood showed a vast excess of white corpuscles, the proportion of red to white being 26 to 1. The stomach was slightly dilated, and in the epigastrium an ill-defined tender tumour could be felt. About a week later she was attacked by thrombosis of the left femoral vein, and subsequently by pneumonia, which terminated fatally. After death cancer of the pylorus and lesser curvature was discovered, with secondary disease of the great omentum. The spleen was large, firm, and pale, but did not contain any secondary growths.