Part 90

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. 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 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.

The tests for free hydrochloric acid are most satisfactorily applied to the fluids withdrawn by the stomach-pump. After a sufficient quantity for examination has been withdrawn the syphon process may be {544} substituted.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.

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. 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.

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.

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. 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.

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. 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.

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. 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.

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, spasm of the muscular coat near a cancer or an ulcer of the stomach may produce a false tumor or enlarge a real tumor.

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.