4. Hemorrhage

Vomiting of blood is observed, according to Brinton, in about forty-two per cent of the cases of gastric cancer. The blood is sometimes ejected in sufficiently large quantity to be recognized with the naked eye. More frequently, however, it is not vomited in the pure state, but mixed with gastric juice, food, mucus; sometimes the blood has undergone many changes during its sojourn in the stomach, and then looks blackish, brownish, or presents a coffee-ground appearance. The quantity of blood ejected is, as a rule, smaller in gastric cancer than in ulcer; but while in ulcer the hemorrhage if once entirely arrested very seldom recurs, it is quite different in cancer. For here small hemorrhages appear in succession for a long time, at intervals of a few days' duration. Melsena (blood in the stool) sometimes accompanies the hemorrhage. It is found, however, less frequently than in gastric ulcer. The hemorrhage, as a rule, takes its origin from the minute vessels of the submucous plexuses or from the capillaries of the superficial layer of the mucosa covering the neoplasm. It is very seldom that a larger vessel is opened, and in that case a fatal issue results.

The hemorrhage is also caused by manifold processes of ulceration, involving the vessels of the cancerous mass.

5. Tumor

The presence of a tumor in the gastric region is one of the most reliable and pathognomonic signs of cancer. The recognition of this will depend upon its size and position. The larger the tumor, the more superficially it is situated, the more easily can it be detected. Inspection alone sometimes suffices to make us suspect a malignant growth: on looking at the gastric region, either in the standing or recumbent position of the patient, a protrusion is noticed, either below the ensiform process or at the margin of the ribs on the right or left side. The result of inspection must always be corroborated by the palpation method. The latter is much more reliable and by far more effective. The palpating fingers encounter a resistant body of varied size and shape, often presenting the appearance of a hard, irregular, nodulated mass; sometimes, however, being smooth and small, and but slightly different from a contracted abdominal muscle. The latter cases are the most difficult to recognize, and sometimes a positive diagnosis as to the presence of a tumor can hardly be made. Percussion is another means of verifying the results of palpation.

The presence of a tumor in the stomach will give a dull sound on gentle percussion, and sometimes a tympanitic note on firm percussion.

In establishing the diagnosis of tumor or neoplasm of the stomach, it is necessary to have in mind also the existence of "apparent tumors" of the abdomen,1 which may be mistaken for real growths.

The apparent tumors which I speak of here relate to swellings found cither directly in the epigastrium or the left or right hypochondrium, and have nothing to do with a neoplasm of whatever kind. In most cases of this kind a resistance may be detected by palpation, sometimes even by inspection, lying between the ensi-form process and the umbilicus, presenting a rather smooth surface and frequently pulsating. The size of these tumefactions varies between that of a hen's egg and a man's fist. Light percussion always elicits a dull sound over the area of resistance. These apparent tumors are not exactly of frequent occurrence. The apparent tumor may be poduced: (1) By a prolapse of the left lobe of the liver; (2) by exposure and thickening of the abdominal aorta; (3) by a hypertrophic condition of parts of the abdominal muscles; (4) by adhesions (?) around the lesser curvature of the stomach.

1 Max Einhorn: "On Apparent Tumors of the Abdomen." Medical Record, November 24th, 1900.

The left lobe of the liver may be the cause of the apparent tumor when it is situated in the median line directly under the ensiform process. Frequently we will get above the resistance, especially at the ensiform process, instead of liver dulness, a more tympanitic sound on percussion. The swelling in these cases is of considerable dimensions (size of a fist).

If the apparent tumor is caused by the aorta, it usually lies deep in the abdominal cavity, close to the spinal column, has an elongated shape, and pulsates strongly. The resistance is usually one to two thumbs in diameter and about two inches in length. Such a tumor is often mistaken for an aneurism.

The abdominal muscles are probably the cause of the tumor if it lies superficially and can be palpated to one side, either right or left, of the linea alba. The resistance usually runs horizontally and measures about one to one and a half inches in breadth by two to three inches in length; its surface is not globular like in tumors caused by the liver, but more flat, although it may be slightly rounded at the sides.

Adhesion of the stomach is hard to determine with certainty. The resistance felt is rather indefinite, small, lying generally at the lesser curvature of the stomach toward the pylorus, and does not show the characteristic distinctions of the three other groups. Whether the tumor belongs to one or other of the four groups is of less importance than the decision of the question whether in a given case we have to deal with a real tumor (neoplasm) or only with an apparent tumor.

In apparent tumors the swelling presents a more or less smooth surface; at all events there are no distinct nodules. The tumor is not always felt with the same degree of distinctness and sometimes may escape palpation altogether. It occupies the position described above, and a high degree of enteroptosis is usually associated with it. As further aids to diagnosis, we have the course of the disease, which usually extends over years; the age (it may occur from the time of adolescence to old age), and the malnutrition, which generally is not of recent date, but has lasted for a long time.

Whether the existing tumor belongs to the stomach or not, and also what region of the organ it occupies, can be determined by the following methods: A tumor of the lesser curvature moves slightly downward on deep inspiration, and becomes less distinct or sometimes disappears on deep expiration. On inflating the stomach with carbonic-acid gas or with air, the resistance will be found just above the gastric area. Tumors of the pylorus, if not adherent to the liver, will move down on inspiration, and if held in this position with the hand will not ascend during expiration; if adherent to the liver they will move up during the act of respiration. A tumor of the pylorus sometimes disappears when the stomach is full, on account of the different positions the stomach occupies in its empty and in its filled states. A tumor of the greater curvature will move up and down during inspiration and expiration, and will also descend when the stomach is inflated with air; it will then occupy the lowest border of the inflated area.

According to my experience, transillumination of the stomach gives the best results with regard to the recognition of the presence of tumors and the determination of their situation. The tumor, not being translucent, is visible as a dark spot within the red transilluminated zone of the abdominal wall. It appears on top of this zone when the tumor occupies the lesser curvature, and at the base of the transilluminated area when it springs from the greater curvature. The dark spot is at the right in tumors of the pylorus. In some instances transillumination discloses the presence of a tumor even when the latter is not yet accessible to palpation.