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the fluids withdrawn by the stomach-pump.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for examination has been withdrawn the syphon process may be {544}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.