Free IIC1 (recognizable as unbound) is not invariably, hut almost constantly, absent from the stomach-contents, save in the cases of carcinoma developing from simple ulcer, and also in the earlier stage of carcinoma in which no diffuse gastritis has resulted. An actual small secretion of IIC1 commonly takes place throughout the course of the disease, but it is so minute as to be unrecognizable by the commonly-employed tests. In cases with complete atrophy of the gastric tubules alone is it absolutely absent. Carcinoma is usually fatal before this condition occurs. There is coincident diminution in the amount of the fer ments, pepsin and lab, secreted; but these latter do not entirely disappear, as is the case in glandular atrophy, succeed ing a chronic gastritis, and in neurotic suppression of secretion.
Lactic acid commonly abounds in car cinoma stenosing the pylorus, with ab sence of free HC1 and the presence of decided delay in the passage of food into the bowel. The greater the degree of stagnation of the ingesta, the more pro nounced the lactic-acid production. To distinguish with absolute certainty lactic acid production from that derived from the food, proceed as follows: Wash the stomach thoroughly with warm water until all traces of food have disappeared. Administer a pint of moderately-thick gruel made from fine oatmeal, with the addition only of salt. Eight to ten or more hours later (the period of removal depending upon the degree of stagnation) the patient being at rest in bed and no food or drink having been taken in the interval, the gastric contents are aspirated or expressed. The filtrate, if clear, is now directly tested. If it be colored, instead, exhaust 30 to 60 cubic centi metres with five times its volume of ether, and test the aqueous extract of the etherial residue. Five to 10 cubic centimetres of an aqueous solution of ferric chloride, so dilute as to be almost colorless, is placed in a test-tube, and a few drops of the filtrate added. The faint-yellowish color of the iron solution assumes a deep-canary yellow in the pres ence of lactic acid. A less delicate and less reliable test is liffelmann's carbo lated-ferric-chloride solution (a dilute so lution of ferric chloride containing a few drops of a 5-per-cent. solution of carbolic acid). The violet hue of this is also changed to a canary yellow. (For a de tailed account of the various methods of examination of the stomach-contents, see a paper by the writer, Medical News, Feb. 18, '93, a reprint of which will be sent on application.) With the presence of large amounts of lactic acid, pyrosis is often a common symptom. •
As the case progresses, the presence in the vomit (or in the removed stomach contents) of altered. blood, rather than that of bright red, appears. The blood, because of its rather long sojourn in the stomach and mode of appearance (not as a frank hcemorrhage as is usual in ulcer), is apt to be of grumous, brownish-black or coffee-ground appearance, and will dis tinctly color the vomit or the contents removed by the tube. as in ulcer, large haemorrhages are infrequent, but the vomiting, or the presence in the re moved contents, of altered blood is com mon. Occurring also, unlike as in ulcer, the intervals between the haemorrhages or a small series of them are slight if at all apparent.
Anorexia is usually a marked symp tom. Occasionally the appetite remains remarkably good. The tongue is much like that seen in chronic gastritis, rather thickly coated, especially in the morning. The bowels are usually much constipated, especially when a high grade of pyloric stenosis and vomiting occur. The urine is more or less scanty and high colored, and of relatively specific gravity. It shows deficiency in the chlorides. There may be an increase in the amount of nitrogenous output. Indican is increased in amount, and acetone and diacetic acid may be encountered.
A tumor is frequently met with in car cinoma involving the pylorus when the case first comes under observation. It should always be painstakingly and per sistently sought for. In examination the abdomen must be relaxed and palpation made under full inspirations. Air-di- tension of the stomach, to bring the pylorus below the edge of the liver, may be necessary to disclose the presence of tumor. Its employment should never be omitted. A tumor of the lesser curva ture, palpable in the presence of a dropped stomach, tends to disappear on air-inflation. The tumor commonly has a firm feel and is painful to palpation. Evident tumor may, of course, be absent; because of this we cannot exclude car cinoma. Simple hypertrophy of the pylorus and persistent reflex cramp simu late tumor. Such cases are on record, and the writer has seen several incidents of them. Faces in the colon should not be allowed to mislead, the bowel being first thoroughly cleansed by repeated irri gation before a decision is reached. It should be remembered that pyloric tu mors are not influenced by respiration unless adherent to the liver, and that without adhesions to adjacent parts the position of the tumor may be much lower in the abdomen than is the normal pylorus.