Chapter XXXIII: Front Matter (33)

[Footnote 29: Bordier, _La Geographie médicale_, Paris, 1884, p. 464. Livingstone speaks of the infrequency of cancer among the negroes in Africa.]

The question as to what rôle is played by heredity in the causation of gastric cancer belongs to the etiological study of cancer in general. Probably in about 14 per cent. of the cases of cancer it can be determined that other members of the family are or have been affected with the disease.[30] {536} The influence of inheritance, therefore, is apparent only in a comparatively small minority of the cases. As suggested long ago by Matthew Baillie, this hereditary influence is better interpreted as in favor of a local predisposition (embryonic abnormality?) in the organ or part affected than in favor of the inheritance of a cancerous diathesis. It has been claimed by D'Espine, Paget, and others that cancer develops at an earlier age when there is a family history of the disease than when such history is absent.

[Footnote 30: This statement is based upon the collection of 1744 cases of cancer analyzed with reference to this question. Of these, a family history of cancer was determined in 243 cases. The cases are obtained from statistics of Paget and Baker, Sibley, Moore, Cooke, Lebert, Lafond, Hess, Leichtenstern, Von Winiwarter, and Oldekop. There is extraordinary variation in the conclusions of different observers upon this point. Velpeau asserted that he could trace hereditary taint in 1 in 3 cancerous subjects; Paget, in 1 in 4; Cripps, in 1 in 28. My conclusions agree with those obtained at the London Cancer Hospital (Cooke, _On Cancer_, p. 11, London, 1865).

The most remarkable instance of inherited cancer on record is reported by Broca (_Traité des Tumeurs_, vol. i. p. 151, Paris, 1866): 15 out of 26 descendants over thirty years of age of a woman who died in 1788 of cancer of the breast were likewise affected with cancer. As is well known, Napoleon the First, his father, and his sister died of cancer of the stomach.]

It may be considered established that cancer sometimes develops in a simple ulcer of the stomach, either open or cicatrized. It is most likely to develop in large and deep ulcers with thickened edges, where complete closure by cicatrization is very difficult or impossible. It is difficult to prove anatomically that a gastric cancer has developed from an ulcer, and hence such statements as that of Eppinger, that in 11.4 per cent. of cancers of the stomach this mode of development existed, are of no especial value.[31] No etiological importance can be attached to the occasional association of cancer with open or cicatrized simple ulcers in different parts of the same stomach. Of the comparatively few cases in which strict anatomical proof has been brought of the origin of cancer in simple gastric ulcer, probably the most carefully investigated and conclusive is one studied and reported by Hauser.[32] It is, however, by no means proven that Hauser's view is correct, that cancer develops from the atypical epithelial growths often to be found in the cicatricial tissue of gastric ulcer. In a few instances both the clinical history and the anatomical appearances speak decisively for the development of cancer in a simple gastric ulcer;[33] and the establishment of this fact is of clinical importance.

[Footnote 31: _Prager Vierteljahrschr._, vol. cxiv.]

[Footnote 32: _Das chronische Maqengeschwür_, Leipzig, 1883, p. 61. See also Heitler, "Entwicklung von Krebs auf narbigen Grunde in Magen," _Wien. med. Wochenschr._, 1883, p. 961. It seems to me that at present there is a tendency to exaggerate the frequency with which cancer develops from gastric ulcer.]

[Footnote 33: A particularly satisfactory case of this kind is reported by Lebert, _op. cit._, p. 503.]

Many other factors in the causation of gastric cancer have been alleged, but without proof of their efficacy. This is true of chronic gastritis, which was once thought to be an important cause of gastric cancer, and is even recently admitted by Leube to be of influence.[34] Certainly the majority of cases of cancer of the stomach are not preceded by symptoms of chronic gastritis. Although in a few instances gastric cancer has followed an injury in the region of the stomach, there is no reason to suppose that this was more than a coincidence.

[Footnote 34: In _Ziemssen's Handb. d. spec. Path. u. Therap._, Bd. vii. p. 134, Leipzig, 1878.]

Few, if any, at present believe that depressing emotions, such as grief, anxiety, disappointment, which were once considered important causes of cancer, exert any such influence. Cancer of the stomach occurs as {537} frequently in those of strong as in those of weak constitution--as often among the temperate as among the intemperate. If, as has been claimed (D'Espine), gastric cancer is relatively more frequent among the rich than among the poor, this is probably due only to the fact that a larger number of those in favorable conditions of life attain the age at which there is greatest liability to this disease. No previous condition of constitution, no previous disease, no occupation, no station in life, can be said to exert any causative influence in the production of gastric cancer.

It will be observed that the obscurity which surrounds the ultimate causation of gastric cancer is in no way cleared up by the points which have been here considered and which are usually considered under the head of etiology. It is impossible to avoid the assumption of an individual--and in my opinion a local--predisposition to gastric cancer, vague as this assumption appears. All other supposed causes are at the most merely occasional or exciting causes. The attempts to explain in what this predisposition consists are of a speculative nature, and will be briefly considered in connection with the pathenogenesis of gastric cancer.

SYMPTOMATOLOGY.--We may distinguish the following groups of cases of gastric cancer:

First: Latent cases, in which the cancer of the stomach has produced no symptoms up to the time of death. Many secondary cancers of the stomach belong to this class. Here also belong cases in which a cancer is found unexpectedly in the stomach when death has resulted from other causes. I have found a medullary cancer, slightly ulcerated, as large as a hen's egg, seated upon the posterior wall and lesser curvature of the stomach of a laboring man suddenly killed while in apparent health and without previous complaint of gastric disturbance. These cases, in which life is cut short before any manifestation of the disease, are without clinical significance, save to indicate how fallacious it is to estimate the duration of the cancerous growth from the first appearance of the symptoms.

Second: Cases in which gastric symptoms are absent or insignificant, whereas symptoms of general marasmus or of progressive anæmia or of cachectic dropsy are prominent. Cases of this class are frequently mistaken for pernicious anæmia, and occasionally for Bright's disease, heart disease, or phthisis. It is difficult to explain in these cases the tolerance of the stomach for the cancerous growth, but this tolerance is most frequently manifested when the tumor does not invade the orifices of the organ.

Third: Cases in which the symptoms of the primary gastric cancer are insignificant, but the symptoms of secondary cancer, particularly of cancer of the liver or of the peritoneum, predominate. In some, but not in all, of these cases the primary growth is small or has spared the orifices of the stomach.

Fourth: Cases in which the symptoms point to some disease of the stomach, or at least to some abdominal disease; but the absence of characteristic symptoms renders the diagnosis of gastric cancer impossible or only conjectural.

Fifth: Typical cases in which symptoms sufficiently characteristic of {538} gastric cancer are present, so that the diagnosis can be made with reasonable positiveness.

It is not to be understood that these groups represent sharply-drawn types of the disease. It often happens that the same case may present at one period the features of one group, and at another period those of another group. Nor is it supposed that every exceptional and erratic case of gastric cancer can be classified in any of the groups which have been mentioned.[35]

[Footnote 35: In the thesis of Chesnel may be found many curious clinical disguises which may be assumed by cancer of the stomach, such as simulation of Bright's disease, heart disease, phthisis, chronic bronchitis, cirrhosis of the liver, etc. (_Étude clinique sur le Cancer latent de l'Estomac_, Paris, 1877). Layman (_Med. Annals Albany_, 1883, p. 207) reports a case of gastric cancer in which extra-uterine foetation was suspected.]

A typical case of gastric cancer runs a course about as follows: A person, usually beyond middle age, begins to suffer from disordered digestion. His appetite is impaired, and a sense of uneasiness, increasing in course of time to actual pain, is felt in the stomach. These symptoms of dyspepsia are in no way peculiar, and probably at first occasion little anxiety. It is, however, soon observed that the patient is losing flesh and strength more rapidly than can be explained by simple indigestion. He becomes depressed in spirits. The bowels are constipated. Vomiting, which was usually absent at first, makes its appearance and becomes more and more frequent. After a while it may be that, without any improvement, the vomiting becomes less frequent, comes on longer after a meal, but is more copious. In the later periods of the disease a substance resembling coffee-grounds and consisting of altered blood is often mingled with the vomit. By this time the patient has assumed a cachectic look. He is wasted, and his complexion has the peculiar pale yellowish tint of malignant disease. Perhaps there is a little oedematous pitting about the ankles. During the progress of the disease in the majority of cases an irregular hard tumor can be felt in the epigastrium. While one or another of the symptoms may abate in severity, the general progress of the disease is relentlessly downward. Within six months to two years of the onset of the symptoms the patient dies of exhaustion.

Too much stress should not be laid upon any so-called typical course of gastric cancer. This course is modified by many circumstances, such as the situation of the cancer, its size, its rapidity of growth, the presence or absence of ulceration, the existence or non-existence of secondary tumors, the presence of complications, and the individuality of the patient. It is necessary, therefore, to consider in detail each of the important symptoms of gastric cancer. But in thus fixing attention upon individual symptoms one must not lose sight of the clinical picture as a whole. It is not any single symptom which is decisive; it is rather the combination, the mode of onset, and the course of the symptoms, which are of most importance in diagnosis.

Impairment of the appetite is the rule in gastric cancer. Anorexia is sometimes a marked symptom before pain, vomiting, and other evidences of gastric indigestion are noted. There is often a special distaste for meat. The appetite may be capricious; it is very rarely even increased. There are exceptional cases in which the appetite is preserved throughout the greater part or even the whole course of the disease. This seems to {539} be more frequent with cancer of the cardia than with cancer of other parts of the stomach. Loss of appetite is a much more common symptom in gastric cancer than in gastric ulcer. In cancer, as well as in ulcer, the patient sometimes refrains from food less on account of disrelish for it than on account of the distress which it causes him.

Pain is one of the most frequent symptoms of cancer of the stomach. If the pain begins early in the disease, and continues, as it often does, with increasing severity, it renders gastric cancer one of the most distressing affections. The pain is usually felt in the epigastrium, but it may be more intense in the hypochondria. It is sometimes felt in the interscapular region, the shoulders, or even in the loins.[36] With cancer of the cardia it is often referred to the point of the xiphoid cartilage or behind the sternum. In general, however, there is so little correspondence between the site of the cancer and the exact locality of the pain that no weight can be attached to the situation of the pain in diagnosing the region of the stomach involved in the growth. Nor does any import attach to the quality of the pain, whether it is described as burning, gnawing, dull, lancinating, etc. Severe gastralgic paroxysms occur, although less frequently than in gastric ulcer.

[Footnote 36: The pain in cases of gastric cancer may be felt in parts of the body remote from the stomach. Thus, in a case of cancer of the cardia reported by Minot the pain was felt, not in the epigastrium, but in the left shoulder, the back of the neck, and the pharynx. In several instances the pain has been interpreted as of renal origin. In a case of gastric cancer reported by Palmer each attack of vomiting was invariably preceded by pain in the middle of the shaft of the left humerus (_Extr. fr. the Records of the Boston Soc. for Med. Improvement_, vol. iv. p. 217).]

The pain is usually aggravated by ingestion of food, although it may not become severe until the process of digestion is far advanced. Pain, however, occurs independently of taking food, and is occasionally a marked symptom when there are no evidences of dyspepsia. There can be no doubt that the cancer, as such, produces pain by involvement of the nerves of the stomach, but there is no specific cancerous pain, such as has been described by Brinton and other writers. There is usually tenderness on pressure over the stomach, and this tenderness is often over the tumor, if such can be felt.

In general, it may be said that the pain of gastric cancer, as contrasted with that of simple gastric ulcer, is often less dependent upon taking food, less intense, less circumscribed, less paroxysmal, less often relieved by vomiting; but there is so little constancy about any of these points that no reliance is to be placed upon any peculiarity of the pain in the diagnosis of gastric cancer.

The observation of several cases of gastric cancer without pain as a marked symptom leads me to emphasize the fact that absence or trifling severity of pain throughout the greater part or the whole of the disease, although exceptional, is not extremely rare. The frequency of painless gastric cancers is given by Lebert as 25 per cent., and by Brinton as 8 per cent., of the whole number. For many reasons, numerical computations as to the frequency of this and of other symptoms of gastric cancer are of very limited value.[37] Absence of pain is more common in {540} gastric cancers of old persons and in cancers not involving the orifices of the stomach than it is at an earlier period of life or when the gastric orifices are obstructed.

[Footnote 37: Gastric cancer cannot be considered as a disease with uniform characters. It is irrational to group together cancers of the pylorus, of the cardia, of the fundus, of the curvatures, cancers hard and soft, ulcerated and not ulcerated, infiltrating and circumscribed, and to say that pain or vomiting is present in so-and-so many cases of cancer of the stomach. There is not a sufficient number of recorded cases in which the symptoms are fully described with reference to the peculiarities of the growth to enable us to apply to gastric cancer the numerical method of clinical study with valuable results. The great discrepancy between Lebert's and Brinton's statistics as to the frequency of painless cancers of the stomach illustrates the present inadequacy of the numerical method, which is misleading in so far as it gives a false appearance of exactness.]

The functions of the stomach are almost invariably disordered in gastric cancer. Sometimes, especially in the early stages, this disorder is only moderate, and is manifested by the milder symptoms of indigestion, such as uneasy sensations of weight and fulness after a meal, nausea, flatulent distension of the stomach relieved by eructation of gases, and heartburn. With the progress of the disease the uneasy sensations become actually painful; watery fluids, and sometimes offensive acrid fluids and gases, are regurgitated; and nausea culminates in vomiting. The breath is often very fetid. The eructation of inflammable gases has been observed in a few cases.

The most troublesome symptoms of indigestion occur with those cancers which by obstructing the pyloric orifice lead to dilatation of the stomach. Cases of gastric cancer in which the distressing symptoms of dilatation of the stomach dominate the clinical history are frequent. These symptoms are in no way peculiar to cancer of the stomach, but belong to dilatation produced by pyloric stenosis from whatever cause, and will be described in the article on DILATATION OF THE STOMACH.

Various causes combine to impair the normal performance of the gastric functions in cancer of the stomach. Chronic catarrhal gastritis is a factor in not a few cases. The destruction by the cancer of a certain amount of secreting surface can be adduced as a sufficient cause only in exceptional cases of extensive cancerous infiltration. Of more importance is interference with the peristaltic movements of the stomach, particularly in the pyloric region, where the cancer is most frequently situated. As already mentioned, dilatation of the stomach is a most important cause of indigestion in many cases. Of great interest in this connection is the discovery by Von den Velden[38] that as a rule (to which there are exceptions) the gastric juice in cases of dilatation of the stomach due to cancer contains no free hydrochloric acid, and that this gastric juice has comparatively feeble digestive power, as proven by experiments. As this alteration of the gastric juice interferes particularly with the digestion of albuminous substances, it is explicable why many patients with gastric cancer have an especial abhorrence for meat.

[Footnote 38: _Deutsches Arch. f. kl. Med._, Bd. 23, p. 369.]

During the progress of the disease the dyspeptic symptoms may improve, but this improvement is usually only temporary. In exceptional cases of gastric cancer dyspeptic symptoms, as well as other gastric symptoms, may be absent or not sufficiently marked to attract attention.

Hiccough, sometimes very troublesome, has been observed not very infrequently during the later periods of the disease.

There is nothing noteworthy about the appearance of the tongue, which is often clean and moist, but may be furred or abnormally red and dry. In the cachectic stage, toward the end of the disease, aphthous patches {541} often appear on the tongue and buccal mucous membrane. An increased flow of saliva has been occasionally observed in gastric cancer as well as in other diseases of the stomach. Thirst is present when there is profuse vomiting.

Vomiting usually appears after other symptoms of indigestion have been present for some time. It may, however, be one of the earliest symptoms of the disease. At first of occasional occurrence, it increases in frequency until in some cases it becomes the most prominent of all symptoms. Vomiting may occur in paroxysms which last for several days or weeks, and then this symptom may improve, perhaps to be renewed again and again, with remissions of comparative comfort. There are rare cases of gastric cancer in which the first symptom to attract attention is uncontrollable vomiting, accompanied often with pain and rapid emaciation. Such cases may run so acute a course that a fatal termination is reached within one to two months.[39] In these cases, which have been interpreted as acutely-developed gastric cancers, it is probable that the cancer has remained latent for weeks or months before it gave rise to marked symptoms.

[Footnote 39: For example, Andral relates a case in which death took place thirty-seven days after the onset of the symptoms, these being obstinate vomiting, severe gastralgic paroxysms, marasmus, and, about ten days before death, profuse black vomit. There was found a fungoid tumor the size of a hen's egg projecting into the cavity of the stomach near the pylorus. In this situation the walls of the stomach were greatly thickened by colloid growth (_Arch. gén. de Méd._, June, 1823). Here may also be mentioned the fact that in several instances pregnancy has been complicated with gastric cancer. Here the uncontrollable vomiting which often exists has been referred to the pregnancy, and has led to the production of premature labor.]

The situation of the cancer exerts great influence upon the frequency of vomiting and the time of its occurrence after meals. When the cancer involves the pyloric orifice, vomiting is rarely absent, and generally occurs an hour or more after a meal. As this is the most frequent situation of the cancer, it has been accepted as a general rule that vomiting occurs at a longer interval after eating in cases of gastric cancer than in cases of simple ulcer. But even with pyloric cancer the vomiting may come on almost immediately after taking food, so that it is not safe to diagnose the position of the cancer by the length of time between eating and the occurrence of vomiting. As the cancer in its growth obstructs more and more the pyloric orifice, the vomiting acquires the peculiarities of that accompanying dilatation of the stomach. The vomiting comes on longer after a meal--sometimes not until twelve or twenty hours or even more have elapsed. It may be that several days elapse between the acts of vomiting, which then present a certain periodicity. The patient then vomits enormous quantities containing undigested food, mucus, sarcinæ, and gaseous and other products of fermentation. Sometimes, especially toward the end of the disease, the vomiting ceases altogether. This cessation has been attributed to reopening of the pyloric orifice by sloughing of the growth. It is not necessary to assume such an occurrence, as a similar cessation of vomiting sometimes occurs in dilatation of the stomach due to persistent stenosis of the pylorus. Cessation of vomiting in these cases is by no means always a favorable symptom.

Next to pyloric cancer, it is cancer involving the cardiac orifice which is most frequently accompanied by vomiting. Here the vomiting occurs often immediately after taking food, but there are exceptions to this rule. {542} If in consequence of stenosis of the cardiac orifice the food does not enter the stomach, it is shortly regurgitated unchanged or mingled simply with mucus. It is this regurgitation rather than actual vomiting which in most common and characteristic of cardiac cancer. Even in cases in which the passage of an oesophageal sound reveals no obstruction at the cardiac orifice it sometimes happens that food, including even liquids, is regurgitated almost immediately, as in a case reported by Ebstein in which cold water was returned at once after swallowing.[40] In these cases Ebstein with great plausibility refers the regurgitation to reflex spasm of the oesophagus induced by irritation of a cancer at or near the cardia through contact of food or liquids, especially when cold, with its surface.

[Footnote 40: "Ueber den Magenkrebs," _Volkmann's Samml. klin. Vorträge_, No. 87, p. 21.]

When the cancer is seated in other parts of the stomach and it does not obstruct the orifices, vomiting is more frequently absent or of only rare occurrence. Vomiting is absent, according to Lebert, in one-fifth, according to Brinton in about one-eighth, of the cases of gastric cancer. Absence of vomiting is sufficiently frequent in gastric cancer to guard one against excluding the diagnosis of this disease on this ground alone.

Although in many cases the vomiting of gastric cancer can be explained on mechanical grounds by stenosis of the orifices, this is an explanation not applicable to all cases. Mention has already been made of spasm of the oesophagus as a cause of regurgitation of food in some cases of cardiac cancer. A similar spasm of the muscle in the pyloric region may explain the vomiting in certain cases in which during life there were symptoms of pyloric stenosis, but after death no or slight stenosis can be found. There is reason also to believe that atony of the muscular coats of the stomach may cause stagnation of the contents of the stomach and dilatation of the organ. In exceptional cases of gastric cancer in which the stomach is so intolerant as to reject food almost immediately after its entrance a special irritability of the nerves of the stomach must be assumed. It is customary to refer this form of vomiting to irritation of the ulcerated surface of the cancer by analogy with a similar irritability of the stomach observed in some cases of simple gastric ulcer. But there is little analogy between the ulcerated surface of a cancer in which tissues of little vitality and irritability are exposed and the surface of a simple ulcer in which the normal or slightly altered tissues of the stomach are laid bare. Finally, in the existence of chronic catarrhal gastritis is to be found another cause of vomiting in many cases of gastric cancer.

The presence of fragments of the cancer in the contents removed by washing out the stomach with the stomach-tube has been observed by Rosenbach[41] in three cases of gastric cancer, and utilized for diagnostic purposes. A cancerous structure could be made out in these fragments by the aid of the microscope. Hitherto, the presence of particles of the tumor in the vomited matter has been considered as hardly more than a curiosity, and I have not been able to find a well-authenticated instance in which such particles in the vomit have been recognized by microscopical examination. According to Rosenbach, the fragments of the tumor in the washings from the stomach can be recognized by the naked eye by the red, reddish-brown, or black specks on their surface, due to recent or old hemorrhages which have aided in the detachment of the fragments. {543} By this means such particles are distinguished macroscopically from bits of food. By employing soft-rubber tubes and the syphon process there is no danger, in washing out of the stomach, of detaching pieces of the normal mucous membrane, which, moreover, can be distinguished from the fragments of the tumor by the aid of the microscope and usually by the naked eye. It remains to be seen how frequently such fragments of the tumor are to be found in the fluids obtained by washing out the stomach. It is not probable that they will be found so often as Rosenbach anticipates. According to the experience of most observers, they are very rarely present. They would naturally be most readily detached from soft, fungoid, and ulcerating cancerous growths. In this connection may also be mentioned the occasional separation of bits of the tumor by the passage of the stomach-tube in cases of cancer of the cardia. The eye of the tube as well as the washings from the stomach should be carefully examined for such particles.

[Footnote 41: _Deutsche med. Wochenschr._, 1882, p. 452.]

The habitual absence of free hydrochloric acid in the gastric fluids in dilatation of the stomach due to carcinoma of this organ was noted by Von der Velden.[42] He found in eight cases of dilatation due to cancer of the pylorus that the fluids removed by the stomach-pump were free from hydrochloric acid, whereas in ten cases of dilatation due to other causes, such as cicatrized simple ulcer of the pylorus, free hydrochloric acid was only temporarily absent from the gastric juice. Von der Velden therefore attributes to the presence or the absence of free hydrochloric acid in the gastric juice in these cases great diagnostic importance. The observations which have followed Von der Velden's publication are not yet sufficient to justify us in drawing positive conclusions in this matter. Recently, Kredel[43] has reported from Riegel's clinic seventeen cases of simple dilatation in which free hydrochloric acid was only exceptionally and temporarily absent from the gastric fluids, and nineteen cases of cancerous dilatation in which, with very rare exceptions, free hydrochloric acid was continuously absent. Cases, however, have been observed by Ewald, Seeman, and others in which free hydrochloric acid has been found in stomachs dilated from gastric cancer. It is to be noted that free hydrochloric acid is absent from the stomach in other conditions than in gastrectasia due to cancer; of which conditions the most important are fever, amyloid degeneration of the stomach (Edinger), and some cases of gastric catarrh. Free hydrochloric acid is also usually absent during the first twenty minutes to an hour after a meal. We have not sufficient information as to the presence or absence of free hydrochloric acid in cases of gastric cancer without dilatation of the stomach. To Von der Velden's symptom no pathognomonic value can be attached, but it may prove, in connection with other symptoms, an aid in diagnosis. The presumption is against gastric cancer if free hydrochloric acid be found continuously in a dilated stomach. Less importance can be attached to the absence of free hydrochloric acid unless the observations extend over several weeks and fever and amyloid degeneration are excluded.

[Footnote 42: _Deutsches Arch. f. klin. Med._, Bd. 23, p. 369, 1879.]

[Footnote 43: _Zeitschrift f. klin. Med._, Bd. 6, p. 592, 1884.]

The tests for free hydrochloric acid are most satisfactorily applied to the fluids withdrawn by the stomach-pump. After a sufficient quantity for examination has been withdrawn the syphon process may be {544} substituted. Tests may also be applied to vomited material, although here the admixture of secretions from the nose, mouth, and throat may render the results less conclusive. Edinger's method of swallowing bits of sponge enclosed in gelatin capsules and attached to a string, by which they can be withdrawn, may also be employed. The sponge should be free from sand, deprived of alkaline carbonates by hydrochloric acid, and rendered perfectly neutral by washing in distilled water.

For clinical purposes the most convenient tests are those which depend upon certain changes in color produced in reagents which enable us to distinguish inorganic from organic acids. In the gastric juice the only inorganic acid which comes into consideration is hydrochloric acid, and the most important organic acid is lactic.

1. Saturated aqueous solutions of tropæolin, marked in the trade OO (Von Miller, V. d. Velden). The solution should be perfectly clear and of a lemon-yellow color. This solution is colored red by the addition of hydrochloric acid even in very dilute solution (0.01 per cent.). A similar change in color is produced by lactic acid in somewhat less dilute solution (0.06 per cent.), but the red color produced by lactic acid disappears upon shaking with ether, while that produced by hydrochloric acid remains, unless the acid was present in very minute quantity. Tropæolin is therefore a very delicate test for free acid in general, but it does not distinguish so well as some other tests hydrochloric from lactic acid.

2. Aqueous solution of methyl-violet (an aniline dye) in the strength of 0.025 per cent. (Witz, Maly). The solution should be of a violet color, and in a test-tube should allow the light to pass readily through it. The addition of hydrochloric acid in dilute solution changes the violet to a blue color, in stronger solution to a greenish tint. With lactic acid in stronger solution methyl-violet gives a similar but less distinct reaction. Methyl-violet, while a less delicate test than tropæolin, is better adapted for distinguishing hydrochloric from lactic acid.

3. Ferric chloride and carbolic acid test (Uffelmann). Mix 3 drops of liquor ferri chloridi (German Pharmacopoeia, specific gravity 1482), 3 drops of very concentrated solution of carbolic acid, and 20 ccm. of distilled water. The addition of even very dilute solutions of lactic acid (0.05 per cent.) changes the amethyst-blue color of this test-fluid to a yellow color, with a shade of green. Dilute solutions of hydrochloric acid produce a steel-gray, and stronger solutions a complete decolorization of the fluid. When both hydrochloric and lactic acids are present the effect of the lactic acid predominates unless only a mere trace of it is present. This is therefore a good test for lactic acid. It is necessary to prepare the test-fluid fresh each time before using.

4. It is well to test the digestive power of the filtered fluid from the stomach by suspending in the fluid a floccule of washed fibrin and keeping the fluid at a temperature of about 100° F. If free hydrochloric acid be present in moderate quantity, in a short time the fibrin will begin to be dissolved, but if the acidity be due to organic acid the fibrin will be dissolved very slowly or not at all.

In applying these various tests the fluids from the stomach should be filtered and the filtrate used. It is best not to rely upon a single test, but to employ them in combination. The fluids may be mixed in a test-tube. The reaction is sometimes most distinct when the fluids are allowed {545} to mingle upon a white porcelain dish. It is sometimes of advantage to concentrate the mingled fluids by evaporation. The fluid obtained by the stomach-pump five or six hours after a meal is the most suitable for diagnostic tests. The presence of peptones and of dissolved albumen makes the tests less delicate for the gastric fluids than for simple aqueous solutions of the acids.[44]

[Footnote 44: For further information on this subject consult Von der Velden, _loc. cit._; Uffelmann, _Deutsches Arch. f. klin. Med._, Bd. 26, p. 431; Edinger, _ibid._, Bd. 29, p. 555; and Kredel, _loc. cit._]

It is important to distinguish between the slight and the copious hemorrhages of gastric cancer.

The admixture of a small quantity of blood with the vomit, giving to the latter the so-called coffee-grounds appearance, is a very common occurrence in gastric cancer. Melænamesis, as the vomiting of brown or black substance resembling coffee-grounds is called, is estimated to occur in about one-half of the cases of cancer of the stomach. It is observed particularly in the cachectic stage, in which it is not rare for some brown or black sediment to be almost constantly present in the vomit. The brown or black color is due to the conversion by the acids of the stomach of the normal blood-coloring matter into dark-brown hæmatin.

The presence of blood in the vomited matter can generally be recognized by the naked eye. By the aid of the microscope red blood-corpuscles, more or less changed, especially decolorized red blood-corpuscles (the so-called shadows), can usually be detected. Sometimes only amorphous masses of altered blood-pigment can be seen. The spectroscope may also be employed, in which alkaline solutions of hæmatin produce an absorption-band between C and D, usually reaching or passing D. The presence of blood-coloring matter can also be readily detected by the production of hæmin crystals.[45] The slight hemorrhages are in most cases the result of ulceration of the cancer, by which process a little oozing of blood from the capillaries is produced.

[Footnote 45: Hæmin crystals may be produced by boiling in a test-tube a little of the suspected fluid or sediment with an excess of glacial acetic acid and a few particles of common salt. After cooling, a drop from the lower layers will show under the microscope the dark-brown rhombic crystals of hæmin in case blood-coloring matter was present in not too minute quantity.]

Copious hemorrhages from the stomach are not common in gastric cancer. They occur probably in not over 12 per cent. of the cases (Lebert). According to Lebert, they are more liable to occur in males than in females. Blood vomited in large quantity is either bright red or more or less darkened in color according to the length of its sojourn in the stomach. Following profuse hæmatemesis, some dark, tarry blood is usually passed by the stools, constituting the symptom called melæna. Copious hemorrhages from the stomach hasten the fatal termination and may be its immediate forerunner. Cases of gastric cancer have been reported in which death has occurred from gastrorrhagia before there has been time for any blood to be either vomited or voided by stool. As might naturally be expected, patients with gastric cancer do not usually rally as readily from the effects of gastric hemorrhage as do most patients with simple ulcer. Profuse gastric hemorrhage, if it occur, is most common in the late stage of gastric cancer, but I have known a {546} case of cancer of the stomach in which copious hæmatemesis was the first symptom, with the exception of slight dyspepsia.[46]

[Footnote 46: In a case of cancer of the lesser curvature observed by Laborie fatal hæmatemesis occurred before there had been any distinct symptoms of gastric cancer (Bouchut, _Nouv. Éléments de la Path. gén._, ed. 3, p. 288).]

Profuse hæmatemesis is more common with soft cancers than with other forms. The source of profuse hemorrhage is in some large vessel eroded by the ulcerative process. The same vessels may be the source of the bleeding as have been enumerated in connection with gastric ulcer. Cancers situated near the pylorus or on the lesser curvature are the most likely to cause severe hemorrhage.

While it is true that coffee-grounds vomiting is most common in cancer, and profuse hæmatemesis is most common in ulcer of the stomach, it is important to remember that either disease may be attended by that form of hemorrhage which is most common in the other.

Dysphagia is one of the most important symptoms of cancer of the cardia. Dysphagia is sometimes one of the first symptoms to attract attention, but it may not appear until late in the disease. It is usually accompanied with painful sensations near the xiphoid cartilage or behind the sternum, or sometimes in the pharynx. The sensation of stoppage of the food is usually felt lower down than in ordinary cases of stenosis of the oesophagus. Stenosis of the cardia can be appreciated by the passage of an oesophageal bougie, but it is important to bear in mind that dysphagia may exist in cases of cancer of the cardia in which the oesophageal bougie does not reveal evidence of stenosis. Dysphagia may be a prominent symptom in cancer occupying parts of the stomach remote from the cardia.[47] The dysphagia here considered is not likely to be confounded with the difficulty in swallowing which is due to weakness or to aphthous inflammation of the throat and gullet, which often attends the last days of gastric cancer.

[Footnote 47: A case in point has been reported by J. B. S. Jackson. The cancer occupied the pyloric region (_American Journ. of Med. Sci._, April, 1852, p. 364).]

From a diagnostic point of view the presence of a tumor is the most important symptom of gastric cancer. In the absence of tumor the diagnosis of gastric cancer can rarely be made with positiveness. A tumor of the stomach can be felt in about 80 per cent. of the cases of cancer of the stomach (Brinton, Lebert). With all of its importance, it is nevertheless possible to exaggerate the diagnostic value of this symptom. It is by no means always easy to determine whether an existing tumor belongs to the stomach or not, and even if there is proved to be a tumor of the stomach, there may be difficulty in deciding whether or not it is a cancer. Many instances might be cited in which errors in these respects have been made by experienced diagnosticians. The value of tumor as a diagnostic symptom is somewhat lessened by the fact that it often does not appear until comparatively late in the disease, so that the diagnosis remains in doubt for a long time. It is to be remembered also that tumor is absent in no less than one-fifth of the cases of gastric cancer.

In order to understand in what situations cancers of the stomach are likely to produce palpable tumors, it is necessary to have in mind certain points concerning the situation and the relations of this organ.

The stomach is placed obliquely in the left hypochondrium and the epigastric regions of the abdomen, approaching the vertical more nearly {547} than the horizontal position. The mesial plane of the body passes through the pyloric portion of the stomach, so that, according to Luschka, five-sixths of the stomach lie to the left of this plane. The most fixed part of the stomach is the cardiac orifice, which lies behind the left seventh costal cartilage, near the sternum, and is overlapped by the left extremity of the liver. The pyloric orifice lies usually in the sagittal plane passing through the right margin of the sternum, and on a level with the inner extremity of the right eighth costal cartilage. The pylorus is less fixed than the cardia. When the stomach is empty the pylorus is to be found in the median line of the body; when the stomach is greatly distended the pylorus may be pushed two and a half to three inches to the right of the median line. The pylorus is overlapped by a part of the liver, usually the lobus quadratus or the umbilical fissure. About two-thirds of the stomach lie in the left hypochondrium covered in by the ribs, and to the left and posteriorly by the spleen. The highest point of the stomach is the top of the fundus, which usually reaches to the left fifth rib. The lowest point of the stomach is in the convexity of the greater curvature to the left of the median line. The lower border of the stomach varies in position more than any other part of the organ. In the median line this border is situated on the average about midway between the base of the xiphoid cartilage and the umbilicus, but within the limits of health it may extend nearly to the umbilicus. The lesser curvature in the greater part of its course extends from the cardia downward to the left of the vertebral column and nearly parallel with it. The lesser curvature then crosses to the right side on a level with the inner extremity of the eighth rib, and in the median line lies about two and a half fingers' breadth above the lower margin of the stomach. The lesser curvature and the adjacent part of the anterior surface of the stomach are covered by the left lobe of the liver.

It follows from this description that only the lower part of the anterior surface of the stomach is in contact with the anterior abdominal walls. This part in contact with the anterior abdominal walls corresponds to a part of the body and of the pyloric region of the stomach, and belongs to the epigastric region. The remainder of the stomach is covered either by the liver or by the ribs, so that in the normal condition it cannot be explored by palpation.

It is now evident that tumors in certain parts of the stomach can be readily detected by palpation, whereas tumors in other parts of the organ can be detected only with difficulty or not at all. Cancer of the cardia cannot be felt by palpation of the abdomen unless the tumor extends down upon the body of the stomach. Cancers of the fundus, the lesser curvature, and the posterior wall of the stomach often escape detection by palpation, but if they are of large size or if the stomach becomes displaced by their growth, they may be felt. Cancerous tumors of the anterior wall or of the greater curvature are rare, but they can be detected even when of small size, unless there are special obstacles to the physical examination of the abdomen. Cancerous tumors of the pylorus can be made out by palpation in the majority of cases notwithstanding the overlapping of this part by the liver. The pyloric tumor may be so large as to project from beneath the border of the liver, or the hand may be pressed beneath this border so that the tumor can be felt, or, what is most frequently the {548} case, the weight of the tumor or the distension of the stomach drags the pylorus downward. The pylorus may, however, be so fixed by adhesions underneath the liver, or the liver may be so enlarged, that tumors of this part cannot be reached by palpation.

The situation in which cancerous tumors of the pylorus can be felt varies considerably. The usual situation is in the lower part of the epigastric region, a little to the right of the median line, but it is almost as common for these tumors to be felt in the umbilical region, and it is not rare for them to appear to the left of the median line.[48] Brinton states that the tumor is in the umbilical region more frequently in the female sex than in the male, in consequence of the compression exercised by corsets. Occasionally pyloric cancers produce tumors in the right hypochondrium. Exceptionally, pyloric tumors have been felt as low as the iliac crest or even in the hypogastric region.

[Footnote 48: According to Jackson and Tyson, pyloric cancers are felt more frequently to the left than to the right of the median line.]

Cancers of the stomach do not usually attain a very large size. Sometimes they form visible protuberances. An important criterion of cancerous tumors of the stomach is their gradual increase in size by progressive growth.

The consistence of cancerous tumors of the stomach is nearly always hard, as appreciated by palpation through the abdominal walls. The surface of the tumor is usually nodulated or irregular, but exceptionally it is smooth. The tumor may be movable or not, but in the majority of cases it is rendered immovable by adhesions. Mobility of the tumor, however, does not exclude the presence of adhesions. The tumor sometimes follows the respiratory movements of the diaphragm, especially when it is adherent to this structure or to the liver, but more frequently the tumor is not affected or but slightly affected by the movements of the diaphragm. If the tumor is not fixed by adhesions, it may change its position somewhat according to the varying degrees of distension of the stomach or in consequence of pressure of intestine distended with gas or feces. In consequence of these movements or of an overlying distended colon the tumor may even disappear temporarily. It is possible that the tumor may lessen or disappear in consequence of sloughing of the growth.[49] It is not rare for a certain amount of pulsation to be communicated to the growth by the subjacent aorta. This pulsation is most common with pyloric tumors.

[Footnote 49: Symptoms which have been considered as diagnostic of sloughing of stenosing cancers of the pylorus are diminution in the size of the tumor, alleviation of the vomiting, hemorrhage, replacement of obstinate constipation by diarrhoeal stools which often contain blood, increased pain after eating, and rapid progress of cachexia.]

The percussion note over the tumor is usually tympanitic dulness. Sometimes there is very little alteration over the tumor of the normal tympanitic note belonging to the stomach; on the other hand, exceptionally there is absolute flatness over the tumor.

It is often of assistance in determining that a tumor belongs to the pylorus to find dilatation of the stomach. An abnormal fulness of the epigastric and umbilical regions may then be observed, and through the abdominal walls, if thin, may be seen the peristaltic movements of the stomach. Other signs and symptoms aid in the diagnosis of dilatation of the stomach, and will be described in connection with this disease.

{549} It is to be noted that what one takes to be the primary tumor of the stomach is not so very rarely a secondary cancerous mass in the stomach or in adjacent lymph-glands or in the peritoneum. Such nodules may also increase the apparent size of the original tumor. As has been pointed out by Rosenbach,[50] spasm of the muscular coat near a cancer or an ulcer of the stomach may produce a false tumor or enlarge a real tumor.

[Footnote 50: _Deutsche med. Wochenschr._, 1882, p. 22.]

The cancer, instead of appearing as a circumscribed tumor, may infiltrate diffusely the gastric walls, and so escape detection. When the greater part or the whole of the stomach is the seat of this diffuse cancerous infiltration, a sense of abnormal resistance may be appreciated by palpation in the epigastric region. In these cases the stomach is often much shrunken in size. The outlines of the thickened organ can sometimes be made out, but the physical signs do not suffice for the diagnosis of cancer.

With cancer of the cardia there is usually more or less atrophy of the stomach, which is manifested by sinking in of the epigastric region.

Sometimes the tumor eludes discovery on account of special obstacles to the physical examination of the abdomen, such as a thick layer of fat in the abdominal walls or a large quantity of ascitic fluid. Every aid in the physical examination of the abdomen should be resorted to. The patient should be examined while lying on his back with the utmost possible relaxation of the abdominal walls. If necessary, he should also be examined while standing or in the knee-elbow position. Sometimes a deep inspiration will force down a previously concealed tumor. The emptying of a dilated stomach by means of a stomach-tube will sometimes bring to prominence a gastric tumor.

The inflation of the stomach by the development in it of carbonic acid gas may render valuable assistance in the diagnosis of tumors of this organ and of surrounding parts. This method has been recommended by W. Ph. H. Wagner among others, and especially by Rosenbach.[51] From 20 to 30 grains of bicarbonate of soda and from 15 to 20 grains of tartaric acid may be introduced into the stomach. The soda, dissolved in lukewarm water, may be given first and followed by the acid in solution, or, better, the mixed powders may be swallowed in the dry state and followed by a tumblerful of water. Some persons require a larger quantity of the powder in order to inflate the stomach. Occasionally the introduction of the effervescing powder fails to produce any appreciable distension of the stomach. This negative result may be due to the escape of the gas into the intestine in consequence of incontinence of the pylorus--a condition which Ebstein[52] has observed and described especially in connection with pyloric cancer. When this pyloric insufficiency exists the resulting tympanitic distension of the intestine is a hindrance to palpation of tumors of the stomach. Failure to secure distension of the stomach is not always due to this cause. It may be necessary to make repeated trials of the effervescing mixture. It is well to have a stomach-tube at hand to evacuate the gas if this should cause much distress.

[Footnote 51: W. Ph. H. Wagner, _Ueber die Percussion des Magens nach Auftreibung mit Kohlensäure_, Marburg, 1869; O. Rosenbach, _Deutsche med. Wochenschr._, 1882, p. 22.]

[Footnote 52: W. Ebstein, _Volkmann's Samml. klin. Vorträge_, No. 155.]

In some respects simpler and more easily controlled is the method of {550} distending the stomach by injecting air into it through a stomach-tube, as recommended by Runeberg.[53] For this purpose the balloon of a Richardson's spray apparatus may be attached to a soft-rubber stomach-tube. In this way the desired quantity of air can be introduced and at any time allowed to escape through the tube.

[Footnote 53: J. W. Runeberg, _Deutsches Arch. f. kl. Med._, Bd. 34, p. 460, 1884.]

When the stomach has been inflated the contours of tumors of the pylorus often become surprisingly distinct in consequence of the changes in the position and the shape of the stomach. When the tumor is fixed by adhesions, it may be possible to follow the contours of the stomach into those of the tumor. False tumors produced by spasm of the muscular walls of the stomach may be made to disappear by this distension of the organ. This procedure enables one to distinguish between tumors behind and those in front of the stomach, as the former become indistinct or disappear when the stomach is inflated. By bringing out the contours of the stomach the relations of the tumor to surrounding organs may be rendered for the first time clear. Assistance in diagnosis may also be afforded by distension of the colon with water or with gas or with air, per rectum, in order to determine the course of the colon and its relations to abdominal tumors (Mader, Ziemssen, Runeberg). A manifest contraindication to distension of the stomach or of the colon with gas exists if there is a suspicion that the coats of these parts are so thinned by ulceration that they might rupture from the distending force of the gas. There have been no cases recorded where such an accident has happened.

Only in exceptional cases are the bowels regular throughout the course of gastric cancer. Constipation is the rule, and not infrequently there is obstinate constipation. This is to be expected when the patient eats little and vomits a great deal, or when there is stenosis of the pylorus. In cancer, as in many other diseases of the stomach, the peristaltic movements of the intestine are inclined to be sluggish.