grief, anxiety, disappointment, which were once considered important
causes of cancer, exert any such influence. Cancer of the stomach
occurs as {537} frequently in those of strong as in those of weak
constitution--as often among the temperate as among the intemperate.
If, as has been claimed (D'Espine), gastric cancer is relatively more
frequent among the rich than among the poor, this is probably due only
to the fact that a larger number of those in favorable conditions of
life attain the age at which there is greatest liability to this
disease. No previous condition of constitution, no previous disease, no
occupation, no station in life, can be said to exert any causative
influence in the production of gastric cancer.
It will be observed that the obscurity which surrounds the ultimate
causation of gastric cancer is in no way cleared up by the points which
have been here considered and which are usually considered under the
head of etiology. It is impossible to avoid the assumption of an
individual--and in my opinion a local--predisposition to gastric
cancer, vague as this assumption appears. All other supposed causes are
at the most merely occasional or exciting causes. The attempts to
explain in what this predisposition consists are of a speculative
nature, and will be briefly considered in connection with the
pathenogenesis of gastric cancer.
SYMPTOMATOLOGY.--We may distinguish the following groups of cases of
gastric cancer:
First: Latent cases, in which the cancer of the stomach has produced no
symptoms up to the time of death. Many secondary cancers of the stomach
belong to this class. Here also belong cases in which a cancer is found
unexpectedly in the stomach when death has resulted from other causes.
I have found a medullary cancer, slightly ulcerated, as large as a
hen's egg, seated upon the posterior wall and lesser curvature of the
stomach of a laboring man suddenly killed while in apparent health and
without previous complaint of gastric disturbance. These cases, in
which life is cut short before any manifestation of the disease, are
without clinical significance, save to indicate how fallacious it is to
estimate the duration of the cancerous growth from the first appearance
of the symptoms.
Second: Cases in which gastric symptoms are absent or insignificant,
whereas symptoms of general marasmus or of progressive anæmia or of
cachectic dropsy are prominent. Cases of this class are frequently
mistaken for pernicious anæmia, and occasionally for Bright's disease,
heart disease, or phthisis. It is difficult to explain in these cases
the tolerance of the stomach for the cancerous growth, but this
tolerance is most frequently manifested when the tumor does not invade
the orifices of the organ.
Third: Cases in which the symptoms of the primary gastric cancer are
insignificant, but the symptoms of secondary cancer, particularly of
cancer of the liver or of the peritoneum, predominate. In some, but not
in all, of these cases the primary growth is small or has spared the
orifices of the stomach.
Fourth: Cases in which the symptoms point to some disease of the
stomach, or at least to some abdominal disease; but the absence of
characteristic symptoms renders the diagnosis of gastric cancer
impossible or only conjectural.
Fifth: Typical cases in which symptoms sufficiently characteristic of
{538} gastric cancer are present, so that the diagnosis can be made
with reasonable positiveness.
It is not to be understood that these groups represent sharply-drawn
types of the disease. It often happens that the same case may present
at one period the features of one group, and at another period those of
another group. Nor is it supposed that every exceptional and erratic
case of gastric cancer can be classified in any of the groups which
have been mentioned.[35]
[Footnote 35: In the thesis of Chesnel may be found many curious
clinical disguises which may be assumed by cancer of the stomach, such
as simulation of Bright's disease, heart disease, phthisis, chronic
bronchitis, cirrhosis of the liver, etc. (_Étude clinique sur le Cancer
latent de l'Estomac_, Paris, 1877). Layman (_Med. Annals Albany_, 1883,
p. 207) reports a case of gastric cancer in which extra-uterine
foetation was suspected.]
A typical case of gastric cancer runs a course about as follows: A
person, usually beyond middle age, begins to suffer from disordered
digestion. His appetite is impaired, and a sense of uneasiness,
increasing in course of time to actual pain, is felt in the stomach.
These symptoms of dyspepsia are in no way peculiar, and probably at
first occasion little anxiety. It is, however, soon observed that the
patient is losing flesh and strength more rapidly than can be explained
by simple indigestion. He becomes depressed in spirits. The bowels are
constipated. Vomiting, which was usually absent at first, makes its
appearance and becomes more and more frequent. After a while it may be
that, without any improvement, the vomiting becomes less frequent,
comes on longer after a meal, but is more copious. In the later periods
of the disease a substance resembling coffee-grounds and consisting of
altered blood is often mingled with the vomit. By this time the patient
has assumed a cachectic look. He is wasted, and his complexion has the
peculiar pale yellowish tint of malignant disease. Perhaps there is a
little oedematous pitting about the ankles. During the progress of the
disease in the majority of cases an irregular hard tumor can be felt in
the epigastrium. While one or another of the symptoms may abate in
severity, the general progress of the disease is relentlessly downward.
Within six months to two years of the onset of the symptoms the patient
dies of exhaustion.
Too much stress should not be laid upon any so-called typical course of
gastric cancer. This course is modified by many circumstances, such as
the situation of the cancer, its size, its rapidity of growth, the
presence or absence of ulceration, the existence or non-existence of
secondary tumors, the presence of complications, and the individuality
of the patient. It is necessary, therefore, to consider in detail each
of the important symptoms of gastric cancer. But in thus fixing
attention upon individual symptoms one must not lose sight of the
clinical picture as a whole. It is not any single symptom which is
decisive; it is rather the combination, the mode of onset, and the
course of the symptoms, which are of most importance in diagnosis.
Impairment of the appetite is the rule in gastric cancer. Anorexia is
sometimes a marked symptom before pain, vomiting, and other evidences
of gastric indigestion are noted. There is often a special distaste for
meat. The appetite may be capricious; it is very rarely even increased.
There are exceptional cases in which the appetite is preserved
throughout the greater part or even the whole course of the disease.
This seems to {539} be more frequent with cancer of the cardia than
with cancer of other parts of the stomach. Loss of appetite is a much
more common symptom in gastric cancer than in gastric ulcer. In cancer,
as well as in ulcer, the patient sometimes refrains from food less on
account of disrelish for it than on account of the distress which it
causes him.
Pain is one of the most frequent symptoms of cancer of the stomach. If
the pain begins early in the disease, and continues, as it often does,
with increasing severity, it renders gastric cancer one of the most
distressing affections. The pain is usually felt in the epigastrium,
but it may be more intense in the hypochondria. It is sometimes felt in
the interscapular region, the shoulders, or even in the loins.[36] With
cancer of the cardia it is often referred to the point of the xiphoid
cartilage or behind the sternum. In general, however, there is so
little correspondence between the site of the cancer and the exact
locality of the pain that no weight can be attached to the situation of
the pain in diagnosing the region of the stomach involved in the
growth. Nor does any import attach to the quality of the pain, whether
it is described as burning, gnawing, dull, lancinating, etc. Severe
gastralgic paroxysms occur, although less frequently than in gastric
ulcer.
[Footnote 36: The pain in cases of gastric cancer may be felt in parts
of the body remote from the stomach. Thus, in a case of cancer of the
cardia reported by Minot the pain was felt, not in the epigastrium, but
in the left shoulder, the back of the neck, and the pharynx. In several
instances the pain has been interpreted as of renal origin. In a case
of gastric cancer reported by Palmer each attack of vomiting was
invariably preceded by pain in the middle of the shaft of the left
humerus (_Extr. fr. the Records of the Boston Soc. for Med.
Improvement_, vol. iv. p. 217).]
The pain is usually aggravated by ingestion of food, although it may
not become severe until the process of digestion is far advanced. Pain,
however, occurs independently of taking food, and is occasionally a
marked symptom when there are no evidences of dyspepsia. There can be
no doubt that the cancer, as such, produces pain by involvement of the
nerves of the stomach, but there is no specific cancerous pain, such as
has been described by Brinton and other writers. There is usually
tenderness on pressure over the stomach, and this tenderness is often
over the tumor, if such can be felt.
In general, it may be said that the pain of gastric cancer, as
contrasted with that of simple gastric ulcer, is often less dependent
upon taking food, less intense, less circumscribed, less paroxysmal,
less often relieved by vomiting; but there is so little constancy about
any of these points that no reliance is to be placed upon any
peculiarity of the pain in the diagnosis of gastric cancer.
The observation of several cases of gastric cancer without pain as a
marked symptom leads me to emphasize the fact that absence or trifling
severity of pain throughout the greater part or the whole of the
disease, although exceptional, is not extremely rare. The frequency of
painless gastric cancers is given by Lebert as 25 per cent., and by
Brinton as 8 per cent., of the whole number. For many reasons,
numerical computations as to the frequency of this and of other
symptoms of gastric cancer are of very limited value.[37] Absence of
pain is more common in {540} gastric cancers of old persons and in
cancers not involving the orifices of the stomach than it is at an
earlier period of life or when the gastric orifices are obstructed.
[Footnote 37: Gastric cancer cannot be considered as a disease with
uniform characters. It is irrational to group together cancers of the
pylorus, of the cardia, of the fundus, of the curvatures, cancers hard
and soft, ulcerated and not ulcerated, infiltrating and circumscribed,
and to say that pain or vomiting is present in so-and-so many cases of
cancer of the stomach. There is not a sufficient number of recorded
cases in which the symptoms are fully described with reference to the
peculiarities of the growth to enable us to apply to gastric cancer the
numerical method of clinical study with valuable results. The great
discrepancy between Lebert's and Brinton's statistics as to the
frequency of painless cancers of the stomach illustrates the present
inadequacy of the numerical method, which is misleading in so far as it
gives a false appearance of exactness.]
The functions of the stomach are almost invariably disordered in
gastric cancer. Sometimes, especially in the early stages, this
disorder is only moderate, and is manifested by the milder symptoms of
indigestion, such as uneasy sensations of weight and fulness after a
meal, nausea, flatulent distension of the stomach relieved by
eructation of gases, and heartburn. With the progress of the disease
the uneasy sensations become actually painful; watery fluids, and
sometimes offensive acrid fluids and gases, are regurgitated; and
nausea culminates in vomiting. The breath is often very fetid. The
eructation of inflammable gases has been observed in a few cases.
The most troublesome symptoms of indigestion occur with those cancers
which by obstructing the pyloric orifice lead to dilatation of the
stomach. Cases of gastric cancer in which the distressing symptoms of
dilatation of the stomach dominate the clinical history are frequent.
These symptoms are in no way peculiar to cancer of the stomach, but
belong to dilatation produced by pyloric stenosis from whatever cause,
and will be described in the article on DILATATION OF THE STOMACH.
Various causes combine to impair the normal performance of the gastric
functions in cancer of the stomach. Chronic catarrhal gastritis is a
factor in not a few cases. The destruction by the cancer of a certain
amount of secreting surface can be adduced as a sufficient cause only
in exceptional cases of extensive cancerous infiltration. Of more
importance is interference with the peristaltic movements of the
stomach, particularly in the pyloric region, where the cancer is most
frequently situated. As already mentioned, dilatation of the stomach is
a most important cause of indigestion in many cases. Of great interest
in this connection is the discovery by Von den Velden[38] that as a
rule (to which there are exceptions) the gastric juice in cases of
dilatation of the stomach due to cancer contains no free hydrochloric
acid, and that this gastric juice has comparatively feeble digestive
power, as proven by experiments. As this alteration of the gastric
juice interferes particularly with the digestion of albuminous
substances, it is explicable why many patients with gastric cancer have
an especial abhorrence for meat.
[Footnote 38: _Deutsches Arch. f. kl. Med._, Bd. 23, p. 369.]
During the progress of the disease the dyspeptic symptoms may improve,
but this improvement is usually only temporary. In exceptional cases of
gastric cancer dyspeptic symptoms, as well as other gastric symptoms,
may be absent or not sufficiently marked to attract attention.
Hiccough, sometimes very troublesome, has been observed not very
infrequently during the later periods of the disease.
There is nothing noteworthy about the appearance of the tongue, which
is often clean and moist, but may be furred or abnormally red and dry.
In the cachectic stage, toward the end of the disease, aphthous patches
{541} often appear on the tongue and buccal mucous membrane. An
increased flow of saliva has been occasionally observed in gastric
cancer as well as in other diseases of the stomach. Thirst is present
when there is profuse vomiting.
Vomiting usually appears after other symptoms of indigestion have been
present for some time. It may, however, be one of the earliest symptoms
of the disease. At first of occasional occurrence, it increases in
frequency until in some cases it becomes the most prominent of all
symptoms. Vomiting may occur in paroxysms which last for several days
or weeks, and then this symptom may improve, perhaps to be renewed
again and again, with remissions of comparative comfort. There are rare
cases of gastric cancer in which the first symptom to attract attention
is uncontrollable vomiting, accompanied often with pain and rapid
emaciation. Such cases may run so acute a course that a fatal
termination is reached within one to two months.[39] In these cases,
which have been interpreted as acutely-developed gastric cancers, it is
probable that the cancer has remained latent for weeks or months before
it gave rise to marked symptoms.
[Footnote 39: For example, Andral relates a case in which death took
place thirty-seven days after the onset of the symptoms, these being
obstinate vomiting, severe gastralgic paroxysms, marasmus, and, about
ten days before death, profuse black vomit. There was found a fungoid
tumor the size of a hen's egg projecting into the cavity of the stomach
near the pylorus. In this situation the walls of the stomach were
greatly thickened by colloid growth (_Arch. gén. de Méd._, June, 1823).
Here may also be mentioned the fact that in several instances pregnancy
has been complicated with gastric cancer. Here the uncontrollable
vomiting which often exists has been referred to the pregnancy, and has
led to the production of premature labor.]
The situation of the cancer exerts great influence upon the frequency
of vomiting and the time of its occurrence after meals. When the cancer
involves the pyloric orifice, vomiting is rarely absent, and generally
occurs an hour or more after a meal. As this is the most frequent
situation of the cancer, it has been accepted as a general rule that
vomiting occurs at a longer interval after eating in cases of gastric
cancer than in cases of simple ulcer. But even with pyloric cancer the
vomiting may come on almost immediately after taking food, so that it
is not safe to diagnose the position of the cancer by the length of
time between eating and the occurrence of vomiting. As the cancer in
its growth obstructs more and more the pyloric orifice, the vomiting
acquires the peculiarities of that accompanying dilatation of the
stomach. The vomiting comes on longer after a meal--sometimes not until
twelve or twenty hours or even more have elapsed. It may be that
several days elapse between the acts of vomiting, which then present a
certain periodicity. The patient then vomits enormous quantities
containing undigested food, mucus, sarcinæ, and gaseous and other
products of fermentation. Sometimes, especially toward the end of the
disease, the vomiting ceases altogether. This cessation has been
attributed to reopening of the pyloric orifice by sloughing of the
growth. It is not necessary to assume such an occurrence, as a similar
cessation of vomiting sometimes occurs in dilatation of the stomach due
to persistent stenosis of the pylorus. Cessation of vomiting in these
cases is by no means always a favorable symptom.
Next to pyloric cancer, it is cancer involving the cardiac orifice
which is most frequently accompanied by vomiting. Here the vomiting
occurs often immediately after taking food, but there are exceptions to
this rule. {542} If in consequence of stenosis of the cardiac orifice
the food does not enter the stomach, it is shortly regurgitated
unchanged or mingled simply with mucus. It is this regurgitation rather
than actual vomiting which in most common and characteristic of cardiac
cancer. Even in cases in which the passage of an oesophageal sound
reveals no obstruction at the cardiac orifice it sometimes happens that
food, including even liquids, is regurgitated almost immediately, as in
a case reported by Ebstein in which cold water was returned at once
after swallowing.[40] In these cases Ebstein with great plausibility
refers the regurgitation to reflex spasm of the oesophagus induced by
irritation of a cancer at or near the cardia through contact of food or
liquids, especially when cold, with its surface.
[Footnote 40: "Ueber den Magenkrebs," _Volkmann's Samml. klin.
Vorträge_, No. 87, p. 21.]
When the cancer is seated in other parts of the stomach and it does not
obstruct the orifices, vomiting is more frequently absent or of only
rare occurrence. Vomiting is absent, according to Lebert, in one-fifth,
according to Brinton in about one-eighth, of the cases of gastric
cancer. Absence of vomiting is sufficiently frequent in gastric cancer
to guard one against excluding the diagnosis of this disease on this
ground alone.
Although in many cases the vomiting of gastric cancer can be explained
on mechanical grounds by stenosis of the orifices, this is an
explanation not applicable to all cases. Mention has already been made
of spasm of the oesophagus as a cause of regurgitation of food in some
cases of cardiac cancer. A similar spasm of the muscle in the pyloric
region may explain the vomiting in certain cases in which during life
there were symptoms of pyloric stenosis, but after death no or slight
stenosis can be found. There is reason also to believe that atony of
the muscular coats of the stomach may cause stagnation of the contents
of the stomach and dilatation of the organ. In exceptional cases of
gastric cancer in which the stomach is so intolerant as to reject food
almost immediately after its entrance a special irritability of the
nerves of the stomach must be assumed. It is customary to refer this
form of vomiting to irritation of the ulcerated surface of the cancer
by analogy with a similar irritability of the stomach observed in some
cases of simple gastric ulcer. But there is little analogy between the
ulcerated surface of a cancer in which tissues of little vitality and
irritability are exposed and the surface of a simple ulcer in which the
normal or slightly altered tissues of the stomach are laid bare.
Finally, in the existence of chronic catarrhal gastritis is to be found
another cause of vomiting in many cases of gastric cancer.
The presence of fragments of the cancer in the contents removed by
washing out the stomach with the stomach-tube has been observed by
Rosenbach[41] in three cases of gastric cancer, and utilized for
diagnostic purposes. A cancerous structure could be made out in these
fragments by the aid of the microscope. Hitherto, the presence of
particles of the tumor in the vomited matter has been considered as
hardly more than a curiosity, and I have not been able to find a
well-authenticated instance in which such particles in the vomit have
been recognized by microscopical examination. According to Rosenbach,
the fragments of the tumor in the washings from the stomach can be
recognized by the naked eye by the red, reddish-brown, or black specks
on their surface, due to recent or old hemorrhages which have aided in
the detachment of the fragments. {543} By this means such particles are
distinguished macroscopically from bits of food. By employing
soft-rubber tubes and the syphon process there is no danger, in washing
out of the stomach, of detaching pieces of the normal mucous membrane,
which, moreover, can be distinguished from the fragments of the tumor
by the aid of the microscope and usually by the naked eye. It remains
to be seen how frequently such fragments of the tumor are to be found
in the fluids obtained by washing out the stomach. It is not probable
that they will be found so often as Rosenbach anticipates. According to
the experience of most observers, they are very rarely present. They
would naturally be most readily detached from soft, fungoid, and
ulcerating cancerous growths. In this connection may also be mentioned
the occasional separation of bits of the tumor by the passage of the
stomach-tube in cases of cancer of the cardia. The eye of the tube as
well as the washings from the stomach should be carefully examined for
such particles.
[Footnote 41: _Deutsche med. Wochenschr._, 1882, p. 452.]