Primary Carcinoma of the Head of 
the Pancreas, with Hour-glass Con- 
traction of the Stomach, Simulat- 
ing During Life Pyloric Stenosis 
BY 
D. J. MILTON MILLER, M.D. 
PHILADELPHIA, PA. 
Reprinted from the Medical Record, August 31, 1895 
TROW DIRECTORY, PRINTING AND BOOKBINDING CO 
NEW YORK 
2oi-213 East Twelfth Street 
i895 PRIMARY CARCINOMA OF THE HEAD OF 
THE PANCREAS, WITH HOUR-GLASS CON- 
TRACTION OF THE STOMACH, SIMULAT- 
ING DURING LIFE PYLORIC STENOSIS.1 
The patient, a single woman, a domestic, aged fifty- 
three, first came under observation in the wards of the 
Episcopal Hospital, in February, 1894. At that time 
she gave a history of three months' illness, the principal 
symptoms of which were epigastric pain and occasional 
vomiting ; the latter usually affording relief, and con- 
sisting of mucus and undigested food, and once of 
bright-red blood. The outlines of the stomach were 
apparently normal, and deep pressure in the epigas- 
trium elicited pain, but there was no tumor. Gunz- 
burg's test revealed the presence of free HC1, but not in 
excessive amount, z>., the reaction, though well de- 
fined, was not intensely so. She had always been an 
excessive eater and a large drinker of tea, but never of 
alcohol. There was no family history of note. Under 
rest and a diet of peptonized milk she rapidly improved, 
and within three months was discharged, a diagnosis of 
chronic catarrhal gastritis having been made. 
On November 3, 1894, she was readmitted into the 
Episcopal Hospital. It was then noted that she had 
lost considerable flesh and was quite anaemic. She re- 
ported marked increase in, and almost constant, pain 
and frequent vomiting-on several occasions of pure 
blood, or the so-called " coffee grounds" material. There 
was no tumor discernible. The outlines of the stomach, 
1 Read before the Philadelphia Pathological Society, May 8, 1895. 4 
as defined by auscultatory percussion, appeared to be 
normal, and remained so throughout the whole history 
of the case. Examination of the gastric contents after 
Ewald's test-meal gave a faint reaction with Gunz- 
burg's solution. The contents had a strongly acid 
odor, reacting promptly to blue litmus paper. By the 
latter part of December a small, immovable, ill-de- 
fined, and very tender tumor could be felt in the epi- 
gastrium, two inches below the ensiform cartilage. 
Shortly after admission peptonized milk in small quan- 
tities was ordered, and daily lavage was practised. To 
effect this, a large amount of water was used, and it was 
noticed that, although the washings were done in the 
morning, they contained quantities of food given the 
day before. This occurred even when no food or milk 
had been taken for twelve or fourteen hours. About 
the 20th of January, 1895, a light jaundice was noted. 
This grew more intense, and was accompanied by an 
increase in the hepatic dimensions, and by the develop- 
ment of an oval, elastic, and semi-fluctuating tumor at 
the tip of the ninth right rib ; this was thought to be 
the gall-bladder. 
Several examinations during the course of the disease 
failed to give constant evidence of the presence of free 
HC1. This was probably due, as the sequel will show, 
to the failure to thoroughly wash out the stomach on 
the night previous to the administration of the test- 
breakfast-a precaution that should never be omitted, 
if we desire correct results in chemical examination of 
the gastric contents. The salol-test for the motor 
function of the stomach was also employed, but with 
unsatisfactory results. 
During the latter third of the patient's life the stools 
were frequently, but unsuccessfully, examined for evi- 
dences of fat. A microscopic examination, however, 
was not made. The urine, though tested on several 
occasions, contained neither sugar nor albumin. 
By February 25th the epigastric tumor was more de- 5 
fined, and still very painful and immovable. Other- 
wise the patient's condition continued about the same. 
Sometimes vomiting daily for a period;, and then a week 
or ten days elapsing with entire freedom from this 
symptom. Pure blood was never vomited while under 
observation, though the so-called " coffee grounds" 
matter was ejected on several occasions. At this time 
Dr. D. D. Stewart kindly saw the case, and consented 
to undertake an examination of the gastric contents 
with the view of determining the absence or presence of 
lactic acid. In order to eliminate all sources of error, 
the organ, at Dr. Stewart's suggestion, was thoroughly 
cleansed prior to the administration of Boas's flour soup. 
In doing this forty-eight quarts of water were used. In 
the withdrawn contents, Dr. Stewart found a total 
acidity of 88 ; .05 of free HC1; sharp reaction with Gunz- 
burg's test ; and no lactic acid. In the light of this ex- 
amination a probable diagnosis of cicatricial stenosis 
from old ulcers was made. 
From the 25th to the 28th of February the patient 
was fed exclusively on meat broths, milk being entire- 
ly withheld ; on the latter date the stomach was again 
thoroughly washed out with a solution of soda (sod. 
bicarb., § ss. ; water, Oij.). It took but eight quarts on 
this occasion to cleanse the organ. The flour soup was 
then introduced through, and before removing, the tube, 
allowed to remain in the stomach over night, and with- 
drawn the next morning by aspiration.1 Dr. Stewart's 
examination of this was as follows : Contents received, 
360 c.c. ; strong odor of salol (given six days pre- 
viously) ; total acidity, 70 ; sharp Gunzburg ; free HC1, 
0.175 ; combined and free HC1 (Leo's method), 
0.02225 > no lactic acid ; egg disk completely dissolved 
in three and a half hours. 
On the 7th of March tympanites developed, and 
there were signs of commencing cardiac failure. 
1 These manipulations were carried on under Dr. Stewart's direc- 
tions. 6 
Various measures were employed to relieve the ab- 
dominal distention, but with indifferent success. The 
patient gradually grew weaker and died March 13th. 
It should be added that no enlargement of the supra- 
clavicular and inguinal glands was at any time pres- 
ent, and that the temperature ranged between 98° and 
99.50 F., occasionally reaching ioo° F. 
Autopsy.-Body emaciated. Skin and mucous mem- 
branes deeply tinged with bile. Pleurse adherent at 
various points. Lungs pale, except at posterior bases, 
where there is hypostatic congestion. Slight amount 
of fluid in pericardium. Heart small, muscle pale, 
valves normal. Stomach and intestines strongly dis- 
tended with gas. Stomach occupies an almost vertical 
position, the whole of the organ lying to the left of 
the median line, the lowest extremity on a level 
with the umbilicus. The pylorus is at a point midway 
between the ensiform cartilage and the umbilicus. On 
a line with the pylorus, and involving the whole cir- 
cumference of the stomach, is a constricting band, 
which divides the organ into two parts : the lower, 
consisting of about one-third of the stomach, is thus 
separated from the body of the viscus by a rather nar- 
row opening. The diameter of the stomach is lessened 
about one-half at this point. The portion above the 
constriction is of about normal capacity, while that be- 
low seems dilated. (Owing to rupture of the walls be- 
fore the removal of the stomach, the exact capacity 
could not be tested, but the constricted portion evi- 
dently held about sixteen fluid ounces, the rest of the 
organ about two pints.) The mucous membrane is 
softened (post mortem) and in a state of catarrhal 
gastritis ; but there is no evidence of cicatrization at the 
site of the constriction or elsewhere. The pyloric ori- 
fice is little, if at all, narrowed, as it admits the fore- 
finger with ease. The head of the pancreas is the seat 
of a hard tumor, about the size of a hen's egg, which 
completely surrounds and occludes the pancreatic and 7 
common bile-ducts. As a result the body of the pan- 
creas is enlarged and softened, its duct dilated and 
filled with retained secretion. Behind the obstructed 
portion, the common duct is dilated and filled with 
dark bile. The cystic and hepatic ducts are also 
dilated, while the gall-bladder is enlarged and distend- 
ed with fluid bile. The liver is enlarged, bile-tinged, 
the ramification of the hepatic duct filled with dark- 
greenish fluid. There are no secondary growths. The 
condition of the other organs is unnoteworthy. Dr. 
McFarland, pathologist to the Episcopal Hospital, ex- 
amined the pancreatic growth, and reported it to be 
carcinoma. 
This case presents many points of interest. In the first 
place, it emphasizes the value and the necessity of 
the modern methods of research in the diagnosis of 
obscure affections of the stomach and pyloric zone. 
The clinical history above narrated certainly warranted 
the diagnosis of malignant stenosis of the pylorus, with 
secondary involvement of the liver, or, at least, of the 
glands in the hepatic fissure ; but the constant presence 
of free HC1 (although by our imperfect methods this was 
often absent), and above all the absence of lactic acid, 
enabled us to exclude gastric cancer, and led us to attri- 
bute the symptoms to a cicatricial stenosis of the pylo- 
rus, hypertrophic in character, occluding the common 
duct, with possibly a concomitant carcinoma of the pan- 
creatic head. The autopsy showed the latter surmise 
to be true. There was no stenosis, but a remarkable 
constriction of the whole circumference of the stomach, 
forming the diverticulum above mentioned, and ac- 
counting for the signs of dilatation during life, and the 
difficulty in washing out the organ, the food collecting 
in the constricted portion. It explained, also, why 
auscultatory percussion failed to reveal the true dimen- 
sions of the organ, the stomach note being lost as soon 
as the space separating the two portions came under 
the percussing finger. This contraction was evidently 8 
congenital, as there was not the slightest evidence 
at the autopsy of cicatrices at the site of the constric- 
tion. Contractions of the stomach seem to be rather 
rare anomalies, as the few works we have referred to 
make little or no mention of them. This seems to be 
an instance of exaggeration of the antrum pylori (the 
lower quarter lying in front of the pylorus), which 
Ewald1 mentions as causing the stomach, without the 
action of cicatricial contraction, to assume the shape of 
an hour-glass. Another interesting feature is the con- 
firmatory evidence which our case gives of Boas's and 
D. D. Stewart's2 work on the value of the presence 
of lactic acid as a sign of carcinoma of the stomach. 
The gastric catarrh was evidently sympathetic in char- 
acter, and the weakening and dilatation of the con- 
stricted portion sequential to this. Until the onset 
of the pancreatic disease the diverticulum must have 
been able to empty itself, as there were no symptoms 
before that time. With the appearance of the carci- 
noma, however, and the consequent gastritis, the motor 
power of the stomach was impaired, and signs of dila- 
tation became evident. 
As to the pancreas, a comparatively uncommon con- 
dition is presented in the limitation of the malignant 
growth to the gland alone. In only 12 out of 127 cases 
of pancreatic cancer collected by Segre,3 was the dis- 
ease confined to that organ. It is quite possible that 
the pancreatic disease might have been detected with 
more certainty during life, had closer attention been 
paid to the presence of fat in the stools and glycosuria ; 
but owing to the prominence and interesting features 
of the gastric symptoms, the stools were not examined 
microscopically, and the urine was tested but a few 
times. 
1 Diseases of Stomach, English Translation, p. in. New York, 1892. 
2 Medical News, February 16, 1895. 
8 Osler : Practice of Medicine, p. 461. New York, 18