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.
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 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 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.