Vomiting is an equally constant and perhaps even more important symptom, being met in nine-tenths of the cases. When the growth involves the pyloric end the vomitus is copious in amount, while the intervals between attacks of vomiting are relatively long. When the more central areas of the stomach are affected and its capacity is thus reduced vomiting is more frequent, usually following soon after taking of food, and the amount of vomitus is consequently less. In general the character of the vomited material depends upon the length of time it has been retained, upon the possible presence of bile or blood, the presence of small amounts of blood giving to it a somewhat characteristic appearance, indicated by the term “coffee-grounds.” As the ulceration proceeds the amount of blood may be increased, and it may even come up fresh and red. The degree of actual ulceration will be indicated by the odor and the more or less putrefactive character of the materials ejected.
Too much reliance has been placed upon examination of the stomach contents. The amount of hydrochloric acid present therein depends in large measure upon the area involved. The same is true of pepsin. The glands which produce these digestive materials are found especially in the more central area, and when this is involved their amounts will be much reduced, whereas as long as these are free they are not necessarily so affected. The presence or absence, then, of hydrochloric acid may prove most misleading. The Oppler-Boas bacilli are perhaps of more significance, but even here the surgeon is often deceived. I regret thus to appear to belittle the significance of features upon which internists place so much reliance, but I have so frequently seen their unreliability that I think it is a sad error to wait for weeks in order to make a diagnosis by means of material secured through a stomach tube.
McCosh believes that for diagnostic purposes the stagnation test is of greater value than any examination of stomach contents. This consists simply in the discovery by lavage of food within the stomach when it should have left it. Thus an ordinary meal should pass out of the stomach within five hours, but if after six hours undigested food still remains there it denotes sluggishness of digestion. Food remaining ten hours makes positive the fact of stagnation. This being once established it should be determined whether it is from atony, spasm, pyloric stenosis, peritoneal adhesions which kink the opening, or cancer. In all of these except the first, surgical intervention is necessary.
Tumor in the stomach region, in connection with symptoms already mentioned, is corroborative. In nearly every case it can be felt sooner or later. Too many have waited, however, for this corroborative symptom before considering the case a surgical one, or even one of unmistakable cancer. Anyone can make a diagnosis when he can discover the tumor. What is needed is recognition of the condition before it has advanced to that stage. When it escapes detection it is usually because it is situated in the posterior stomach wall, high up, or else because the abdomen is enormously fat. The tumor when felt will be found firm and usually tender, sometimes regular in outline, sometimes quite the reverse, usually movable, but occasionally firmly attached either to the abdominal wall or to the viscera, usually the liver. Such a tumor, changing its position with the change in shape of the stomach produced by its inflation with carbonic dioxide, may be regarded as almost certainly a cancer of this organ. One rarely detects lymphatic involvement through the abdominal wall, but in many instances it may be noted at the root of the neck. The tumor usually rises or falls with respiration. Occasionally it will not be discovered until the stomach has been washed out and completely emptied.
However, further aids to diagnosis may be furnished, for instance, by the discovery of cancer cells in the vomitus or washings, by the presence of adventitious materials, such as lactic acid, whose especial significance is rather that of stagnation and motor paresis.
It is of great importance, when possible, to decide as between ulcer and actual cancer. In general the following aids to diagnosis may be considered: Ulcer is a disease of the earlier years of life, cancer rather of the later; in ulcer the pain is direct and boring (extending to the back), in cancer it may be widely referred to the shoulders; in ulcer the vomited blood is usually fresh, in cancer it furnishes the so-called “coffee-grounds;” in ulcer there is ordinarily no tumor present, in cancer this is a late but sure sign; the history of a case of ulcer will often be a long one, that of a case of cancer is rarely long, but steadily progressive; in ulcer there may be distinct anemia, whereas in cancer it assumes rather the type of a peculiar cachexia; and the free hydrochloric acid which is increased in ulcer is usually diminished or absent in cancer.[56]
[56] Sahli has suggested what he calls a desmoid test for free hydrochloric acid. A small amount of methylene blue is enclosed in a small gutta-percha bag, and this is tied by means of a small strand of raw catgut. This catgut will not be affected by pancreatic juices, and will only dissolve in the stomach in case there be free hydrochloric acid present. The fact of its solution and the liberation of the methylene blue is made evident by the peculiar color given to the urine in a short time. If, therefore, this appears within an hour or so after the material has been swallowed one maybe sure there is free hydrochloric acid present in the stomach. The test is not absolutely accurate, but will often serve as a fairly reliable one and a substitute for the more disagreeable and ponderous method of a test meal and lavage. In some respects it is perhaps even more reliable.
The question in cases of gastric ulcers is whether they have yet advanced to actual malignancy. Probably no surgeon has ever attacked a case of gastric cancer which has not been under treatment for a time for so-called “dyspepsia or indigestion,” perhaps with a more definite diagnosis. Too many internists have waited for the discovery of a tumor before thinking of surgery. It is the business and the duty of every surgeon to impress upon the profession that the only way to treat cancer successfully is to treat it radically, and the only way to do this is to operate early. This applies equally well to the viscera or to the external portions of the body. Gastric cancer is essentially a surgical disease, and could it be recognized early and treated radically it could often be cured.
What are we to do then in the absence of early and indicative symptoms? The following rule may be laid down as one to which there is no exception: A well-founded suspicion of cancer of the stomach (or of any part of the alimentary canal) justifies an exploratory operation for its detection and recognition, which then should be extended into an operation for its complete removal should circumstances justify it. If this rule were followed we would not hear of cases of this description remaining for months or years under drug treatment, and then perhaps being finally turned over to the surgeon for relief of pyloric obstruction at a period when strength is so reduced that no operation should be seriously considered.
Gastric cancer is, then, at least in its earlier stages, a surgical disease. How is it to be recognized? By exploratory incision when there is serious doubt as to the nature of dyspepsia or indigestion which fails to promptly improve under suitable treatment. In an early stage even this might not be easy, especially for the inexperienced. Nevertheless any cancer of the stomach which produces distinct disturbances of digestion will have advanced to a degree of infiltration and thickening which will permit of its recognition by the touch of a practised operator. The discovery, then, of thickening in the stomach wall will imply the presence therein of either an ulcerated or cancerous area, which will in either event demand relief. In such a case the stomach may be opened and the mucosa exposed to sight and touch. Should the lesion prove to be malignant the same rule will apply with greater force, with the sole difference that the area should be much larger and that the surgeon should keep clear of suspicious tissue. This may necessitate a more or less complete removal of a considerable portion of the stomach. The greatest care should be exercised in the discovery and removal of all infected lymph nodes, which will be found especially along the curvatures and within the peritoneal fold. When retroperitoneal lymph involvement is discovered a hopeless aspect is put upon the case. Life may be prolonged for two or three years, even under such circumstances, and the patient is certainly entitled to whatever can be afforded him. If the cancerous process has advanced to a point or a degree making radical removal impossible, one may at once select the other alternative and perform a gastro-enterostomy at a point of election, by which relief may be afforded for at least a number of months.