The presence of new growth in the vomit or in the fluid removed by lavage is, of course, of prime importance, but it can only rarely be found, and it is quite unjustifiable to attempt to obtain it by mechanical means, such as scraping or brushing away portions from the gastric wall.
The discovery of the Oppler-Boas bacillus, a long, non-motile bacillus of the shape of a base-ball bat, is said by various authorities to be an indication of carcinoma, but while its presence is presumptive evidence in favour of carcinoma its absence has no negative value. This bacillus is usually found when lactic acid is present in the lavage.
The presence of yeast cells and sarcinas is common to dilatation of the stomach with retention, both in simple and in malignant disease.
The discovery of blood cells may be due to ulcer or cancer ; it is therefore simply a sign of serious organic disease.
The motor functions of the stomach are best tested by examination of the stomach after a test meal ; such impairment may be due to pyloric stenosis from any cause, or due to cancer of the body of the stomach, or even to chronic gastritis, but in neurosis the motility of the stomach is increased. The stomach ought to be always found empty the first thing in the morning after a meal taken at 10 p.m., but in health there should be no food present in the stomach six hours after the last meal.
In advanced carcinoma there is usually little difficulty in making a diagnosis, the only mistakes that would be likely to occur being either the mistaking of an inflammatory tumour associated with ulceration, or the mistaking of a syphilitic tumour for a malignant growth. In the latter case the history and the result of specific treatment afford clues to the diagnosis. In the former, induration around an ulcer, the long history, the tenderness on manipulation, and the presence of free HCl in the vomit or in the lavage should be of assistance; but all surgeons who have had any experience must have found a difficulty at times in deciding on a diagnosis between inflammatory disease and growth, even when the abdomen is opened.
In several patients of this kind on whom I have operated for large growths at the pylorus, or in the body of the stomach with extensive adhesions rendering removal impossible, and with enlargement of the glands rendering malignant disease extremely probable, I have performed gastroenterostomy with the idea of giving relief ; yet ultimately complete and perfect recovery has occurred, and the patients are living and well years later, showing that the supposed cancer was evidently only inflammatory thickening around an ulcer, which was cured by setting the parts at rest.
The presence of numerous adhesions, the discrete character of the enlarged glands, which are softer than cancerous ones, the absence of secondary deposits in the viscera, and the absence of funga-ting growths in the tumour itself are, when taken with the former-mentioned points, in favour of simple tumour, but as acknowledged by Osier, Halsted, Finney, and many other workers, it is impossible in some cases without a microscopic examination to distinguish between simple imflammatory tumour and cancer. Fortunately operation is of service in both conditions, therefore no harm, but only good, should result from the performance of gastro-enterostomy in either disease ; and even if the pylorus be removed for chronic ulcer thinking it to be cancer, and a new healthy passage into the bowel be established, the patient should be the gainer.
Hypertrophic stenosis of the pylorus is comparatively rare at the age in which cancer is usually found, and it has only once happened to me to mistake this condition for a neoplasm, the pylorus forming a perceptible tumour. On opening the abdomen I found the pyloric tumour smooth and uniform, and on exploring the stomach I found a chronic ulcer, which, by keeping up a state of irritation over a long period, had led to spasm and hypertrophy of the pylorus and to gastric dilatation. The excision of the ulcer and the performance of gastroenterostomy cured the patient and led to the subsidence of the hypertrophy of the pylorus. Boas (5) has called attention to three cases of this kind in which the irritation gave rise to a mistaken diagnosis. It is, however, in the early stages that errors in diagnosis are most likely to occur, leading to a fatal delay in cases that, if diagnosed early, can be cured by a radical operation; for it is undoubtedly proved that at first the disease is purely local and that its complete removal may be absolutely curative.
Medical treatment may be considered in a few words : it cannot cure, and can do very little even to prolong life ; it therefore applies only to cases too advanced for surgical treatment or where operation is declined. It aims at nourishing the patient as much as possible, and at relieving pain or other symptoms as they arise.
Surgical treatment offers the only chance of relief and the only possible chance of cure, and in order that the best results may be obtained, the physician and surgeon must act in concert, so that by a timely diagnosis an operation may be undertaken at the earliest possible date. There is ample evidence to show that for some length of time cancer is a purely local disease; and just as in the breast, the tongue, and the uterus, we can point to patients living comfortable and happy lives years after the removal of the disease, so in gastric cancer it is reasonable to assume the same possibilities. Here, however, we are faced with the difficulty of a sufficiently early diagnosis being made, and it is not only necessary for us to appeal for an early, exhaustive, and persistent investigation into suspicious stomach cases, but that when the suspicions are becoming confirmed an early surgical consultation may be held, and, if needful, an exploratory operation carried out to complete the diagnosis. Whenever a patient at or after middle age complains somewhat suddenly of indefinite gastric uneasiness, pain and vomiting-followed by progressive loss of weight and energy, and associated with anaemia, the possibility of cancer of the stomach should be recognised, and in a suspected case, if no improvement takes place in a few weeks at most, and if repeated examinations of the stomach contents after test meals show diminished digestive power with a diminution or absence of free HCl and the presence of lactic acid, an exploratory operation is more than justified. As Professor Osier says, the important aid of an exploratory operation should be more frequently advised.