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The following papers were then read and discussed:

Observations, Surgical and Pathological, with Clinical Notes and Exhibition of Patients with Specimens, Donald Maclean, Detroit.

A Case of Interscapulo-Thoracic Amputation from Tuberculosis, Schuyler C. Graves, Grand Rapids.

Purulent Pericarditis due to Traumatism, with Report of a Case, Frank W. Garber, Muskegon.

Simple Glaucoma, Eugene Smith, Detroit.

Treatment of Mallignant Growths, William E. Rowe, Allegan.

The Operation for Epithelioma of the Eye-lids, with Illustrations, Reynold J.

Kirkland, Grand Rapids.

Adjourned.

ALBERT E BULSON,

Secretary.

THE DIAGNOSIS OF GASTRIC CARCINOMA.

THADDEUS H. WALKER, M. D.,

Detroit.

We meet with cases of gastric carcinoma most frequently between the ages of 35 and 65; sometimes between 25 and 35, and 65 and 75; rarely under 25 or over 75. Both sexes seem to share alike though some give a higher percentage to the female. Heredity is thought by many to be a factor, but reliable statistics are scarce. The clinical picture varies somewhat with the site of the neoplasm. If at the cardiac end, the lumen of the œsophageal opening is soon lessened by the growth. The patient complains of fullness and pressure, however not always in the region of the invaded part. There is pain and difficulty in swallowing solid food and later liquids cause distress. Vomiting is present but consists of mucus and only such food as has not passed into the stomach. Very seldom can a tumor be palpated in this region, yet we generally have severe pain upon percussion over the xiphoid process. Difficulty in passing the stomach sound and a microscopical examination of any particles attached to the sound will confirm the diagnosis. The course of the disease is necessarily short, due to the great difficulty in nourishing the patient.

If the fundus or pyloric end of the stomach is the site of the neoplasm, symptoms develop more slowly. The pain, nausea, deranged appetite, constipation and vomiting are at first not different from those of chronic gastritis; though in a patient over 35 we may suspect carcinoma from these insidious symptoms. In many cases the patient says this is the first time he has had any marked stomach trouble, which has been accepted as a diagnostic sign. At autopsies and operations we often find the carcinoma developed upon the cicat

ricial base of an old ulcer which may have healed as long as ten or fifteen years previously. We must then think of this when clinical history shows the existence of an ulcer which may or may not have completely healed. The symptoms are all progressive. Food, especially meat, becomes distasteful. As the pyloric stenosis increases vomiting becomes more frequent and pain more intense. Finally we have vomiting of disorganized blood, namely, the familiar "coffee-grounds" vomit, soon followed by marked anæmia, cachexia, oedema, &c. Even in the last stages we cannot always palpate a tumor, for the fundus may be evenly infiltrated; the liver may completely cover a large tumor at the pylorus or upon the smaller curvature; or the abdominal wall may be too rigid even under an anæsthetic to permit us to feel any growth.

Such briefly are, the generalized symptoms known by us for some years; but we are striving for an early diagnosis which will give us a chance to apply more successfully the methods of treatment to be discussed to-day. This we may hope to accomplish by finding pathological changes in the physiology of digestion.

By the use of a soft rubber tube such as is sold for the purpose, we can obtain samples of the stomach contents. It will be readily understood that in order to obtain the results of digestion, the stomach must be free from the remains of a previous meal before we introduce our test meal. The simplest way to wash out the stomach is by the siphon method. Introduce the stomach tube and to it attach a yard of rubber tubing and a funnel; then hold the funnel higher than the patient's head and pour in water. We siphon out by quickly bringing the funnel, before all the water has flown out, down to a basin on the floor. This procedure should be repeated until the water returns clear. The test meal should consist of food which will in no wise interfere with digestive processes or whose constituents will interfere with our tests. A baker's roll and a glass of water (about 250 cc) is as simple as we can make a test meal and fulfills our requirements. Boas recommends oatmeal gruel when testing for lactic acid but this is not absolutely necessary. About one hour after

having given the test meal, which is generally given in the morning and called a test breakfast, we may introduce the stomach tube. With the tube in the stomach, we ask the patient to bear down with the abdomiral muscles (expression method) and easily obtain enough fluid for analysis, indeed the amount will indicate the muscular activity of the stomach. A large amount, 100 cc and over, indicate atony of the stomach, a condition progressing very rapidly with carcinoma. To determine the actual amount of stagnation and its results, we may give the test meal late in the evening and examine in the morning. We first filter the stomach contents and test the filtrate with litmus paper as to its acidity. This gives us the total acidity due to inorganic and organic acids and acid salts. We now wish to test for free HCL and have numerous tests we can apply for quick, practical purposes; congo paper (red) turning blue, tropæolin paper (yellow) turning brown, and by gentle heat lilac or a very delicate watery solution of methyl-violet, turning sky-blue in the presence of free HCL. However, if we are examining a suspected case of carcinoma, we may expect an absence of free HCL, which for a time was thought to be pathognomonic of carcinoma, but careful observations have since proved it not to be.

We now look for lactic acid and for this purpose employ either Uffelmann's or Boas' tests. Uffelmann's reagent consists of 10 cc ( ) 4 per cent. carbolic acid and 20 cc ( ) water and to which a few drops of a weak solution (about 1 per cent,) of ferric chloride is added, in a test tube, until we have an amethyst blue color. We now shake up some of the stomach fluid with ether, decant and add to the above solution, which turns canary yellow in the presence of lactic acid. Boas' test is applied, if no free acids are present, (test with Congo paper, etc.) by first evaporating 20 cc of the filtered stomach contents to a syrup; then allow to cool, add 100 cc ether and in half an hour decant the ether into a porcelain dish and drive off the ether on a water bath; to the residue add 50 cc water, shake well and filter; to the filtrate add 5 cc sulphuric acid and a pinch of manganese dioxide; now pour into a small Florence flask and fit a stopper with a bent

glass tube so when the flask is gently heated, the aldehyd (resulting from lactic acid splitting up under oxidizing agents) passes over into an alkaline solution of iodin and gives the characteristic iodoform reaction, smell and color; or with Nessler's reagent a reddish yellow precipitate. If free acids are present in the filtrate add an excess of barium carbonate and evaporate to a syrup; then a few drops of phosphoric acid and heat; allow to cool, extract with ether and proceed as above.

The objection to Uffelmann's test is that substances other than lactic acid give the same color reaction, such as oxalic acid, citric acid, tartaric acid, alcohol, grape sugar, etc. And as many of our foods contain these and other substances which give a similar reaction, it is well to wash out the stomach the evening before giving the test breakfast and make sure there are no remains of a previous meal. It is also very necessary that the simple test breakfast be given. Boas' reaction is sensitive to one part lactic acid in 10,000; however, we are not looking for a trace but for a large percentage. A positive reaction under Uffelmann's test under these precautions should leave little room for doubt as to the presence of lactic acid. Of course a more exact and careful analysis should be made, but the busy practitioner, thinking he has no time for elaborate examinations, does not equip himself with the necessary apparatus. Therefore these few simple tests are brought to your notice. The presence of large quantities of lactic acid is to-day considered one of the principal diagnostic signs of carcinoma. We find lactic acid many times very early in the course of the disease, but often it does not appear until the later stages. Again, with secretory and motor insufficiency we may have lactic acid, therefore the presence of lactic acid is not in itself pathognomonic of carcinoma. Still, its presence is of great value as a help in diagnosis. Even with no tumor palpable and other evidences (absence of free HCL., presence of lactic acid and characteristic physical signs) enough to weight the balance in favor of carcinoma, we can safely make an exploratory laparotomy which may reveal conditions favorable for the surgeon's knife.

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