COXSACKIE B4 VIRUS INFECTIONS IN NEW SOUTH WALES DURING 1962

nodules". Examination of gastric washings revealed profuse carcinoma cells (F'igure Pl. Laparotomy showed an extensive carcinoma of the fundus of the stomach. with metastases in the lesser sac and along the superior surface of the pancreas. CASE II.-This male, aged 71 years, presented at the outpatient department complaining of dyspncea. He was found to be suffering from congestive cardiac failure with auricular fibrillation. Over the next two weeks he complained of progressive giddiness, together with partesthestse in his limbs, which caused difficulty in walking. At this stage he was admitted to hospital. He denied anorexia and weight loss, but complained bitterly of calf pain. On physical examination of the patient, the tendon reflexes were absent and vibration sense was absent at the ankles; Romberg's sign was present. The patient appeareel a little elisorientated. There was slight, tender hepatomegaly, but no other abdominal masses were palpable. The hremog'lobin value was 6·9 grammes per 100 rnl., and a blood smear showed erythrocytes with central pallor. His white cell count was normal. his erythrocyte sedimentation rate was 16 mm. in one hour (Westergren), and his blood urea level was 49 mg. per 100 m\. Thymol flocculation was pronounced, and the zinc sulphate turbidity was 9·5 units. The blood glucose level was 110 mg. per 100 ml. Lumbar puncture showed normal cerebro-spinal fluid pressure, and biochemical and bacteriological findings, including a Wassermann reaction, were normal. In view of the central nervous system algns, a fractional test meal examination was done, and histamine-fast achlorhydria was demonstrated. The total serum vitamln-Bs, level was 187 "Y"Y per millilitre. Radiological examination with a barium meal revealed no abnormality. Examinations of gastric washings on two occasions showed carcinoma cells (F'igu re II). The radiological examination with barium meal was repeated and showed non-c1istensnon of the mid-portion of the stomach consistent with infiltrating carcinoma. Gastroscopic examination showed no lesion. Laparotomy was performed, and the stomach felt normal. It was opened, and although no carcinoma could be seen, the surgeon noted that the mucosa appeared thicker than would have been expected in the presence of histaminefast achlorhydria. A random biopsy was taken, and the wound was closed. The biopsy, reported on by Dr. V. J. McGovern, showed carcinoma-in-situ of the gastric mucosa (Figure III). It was thought that, in view of the patient's age and physical condition, further surgerv was not indicated. It is of. interest that Schade states that "surface carcinoma may appear to the naked eye only as a discoloured mucosal area which may not be visible in the fresh unfixed operation specimen and is not palpable". He also states that "surface carcinoma may exist for several years before the tumour stage develops".