of gastric cancer. Constipation is the rule, and not infrequently there
is obstinate constipation. This is to be expected when the patient eats
little and vomits a great deal, or when there is stenosis of the
pylorus. In cancer, as in many other diseases of the stomach, the
peristaltic movements of the intestine are inclined to be sluggish.
Occasional diarrhoea is also common in gastric cancer, being present,
according to Tripier,[54] at some period or other in over one-half the
cases. Constipation often gives place to diarrhoea during the last
months or during the last days of life. In other periods of the disease
diarrhoea not infrequently alternates with constipation. In rare cases
diarrhoea is an early symptom, and it may be present exceptionally
throughout the greater part of the disease. The irritation of
undigested food sometimes explains the diarrhoea. When diarrhoea is
persistent there probably exists catarrhal inflammation of the large
intestine, or in some instances there may be diphtheritic and
ulcerative inflammation of the colon, causing dysenteric symptoms
during the last stages of cancer of the stomach.
[Footnote 54: "Étude clinique sur la Diarrhée dans le Cancer de
l'Estomac," _Lyon Méd._, 1881, Nos. 40, 41, 42.]
Black stools containing altered blood occur for some days after profuse
gastric hemorrhage. It is important to examine the stools for blood, as
bleeding may occur from cancer of the stomach without any vomiting of
blood.
There is no change in the urine characteristic of gastric cancer.
Deposits of urates are not uncommon. If there be profuse vomiting or
frequent washing out of the stomach, the urine often becomes alkaline
from fixed {551} alkali.[55] The amount of urea is diminished in
consequence of the slight activity of the nutritive processes of the
body. Rommelaere attaches unmerited diagnostic importance to this
diminution of urea. A similar diminution of urea occurs in other like
states of depressed nutrition.
[Footnote 55: According to Quincke, when the acid in the stomach is not
hydrochloric acid, but organic acid resulting from fermentation, then
vomiting and washing out the stomach do not reduce the acidity of the
urine (_Zeitschrift f. klin. Med._, Bd. 7, Suppl. Heft, p. 25).]
Albuminuria does not belong to the history of gastric cancer, although
a small quantity of albumen may be present in the urine as in other
anæmic and cachectic conditions. A larger quantity of albumen may be
due to parenchymatous and fatty degeneration of the kidney or to
chronic diffuse nephritis, which are infrequent but recognized
complications of gastric cancer. There is often an excess of indican in
the urine, to which, however, no diagnostic significance can be
attached.
The urine in gastric cancer sometimes contains an excess of aceton, or
at least of some substance which yields aceton upon the application of
various tests. This so-called acetonuria is present without any
symptoms referable to it, so far as we know. Allied to this so-called
acetonuria is that condition of the urine in which it is colored
burgundy-red upon the addition of ferric chloride in solution
(Gerhardt's reaction). It is not positively known what substance
imparts this last reaction to the urine. V. Jaksch, who has studied the
subject industriously, believes that the red coloring substance is
diacetic acid, and he proposes to call the condition diaceturia. Fresh
urine, which shows in a marked degree Gerhardt's reaction, often has a
peculiar aromatic, fruity odor, as has also the expired air. Gerhardt's
reaction has been studied mostly in diabetic urine, but it occurs
sometimes in cases of gastric cancer and in a variety of diseases. This
so-called diaceturia may be associated with a peculiar form of coma,
but it is oftener observed without any symptoms referable to it[56]
(see page 555).
[Footnote 56: The various tests for aceton in the urine are not
altogether satisfactory. They are to be found in an article by Von
Jaksch in the _Zeitschrift f. klin. Med._, Bd. viii. p. 115. For
English readers a good abstract of an article by Penzoldt on these
tests and on acetonæmia in general is to be found in _The Medical News_
of Philadelphia, Aug. 9, 1884, p. 162, but this does not consider the
corrections and additions to be found in V. Jaksch's article cited
above. Acetonuria has been observed especially in diabetes mellitus,
fevers, carcinoma, and dyspepsia.
The substance which produces Gerhardt's reaction is to be distinguished
from other substances which may be present in the urine and give a red
color with ferric chloride--first, by the fact that boiling the urine
in a test-tube for five or six minutes destroys the first-named
substance, or causes the red color to disappear in case this has been
produced by ferric chloride; and, secondly, by the fact that ether
extracts the substance from acidified urine, and that the red color
produced in the ether extract by ferric chloride (it may be necessary
to first neutralize the acid) fades away in the course of a few days
(V. Jaksch, _Zeitschrift f. Heilkunde_, Bd. iii. p. 17). Urines which
respond to Gerhardt's reaction in a marked degree yield aceton on
distillation, but aceton or an aceton-yielding substance may be present
in considerable quantity without response of the urine to Gerhardt's
test.]
Disorders of nutrition embrace an important group of symptoms, such as
loss of flesh and strength, impoverished blood, and cachectic color of
the skin. Emaciation and debility are sometimes the first symptoms of
gastric cancer to attract attention, and often the first symptoms to
arouse anxiety. More frequently these symptoms of disordered nutrition
first appear after dyspeptic ailments or pain have existed for several
weeks or months. It may aid in the diagnosis of gastric cancer to weigh
the patient {552} from time to time, as carcinoma is generally attended
by progressive loss of weight.
The patient frequently becomes morose and depressed in spirits. His
strength fails, sometimes disproportionately to the loss of flesh.
There is no disease in which emaciation becomes more extreme than in
cases of gastric cancer.
In many cases profound anæmia develops, and sometimes in such a degree
that this symptom cannot be regarded always as simply co-ordinate with
the other disorders of nutrition, but is to be regarded rather as an
evidence of some special disturbance of the blood-forming organs. The
blood may present the same changes as are observed in pernicious
anæmia, such as extreme reduction in the number of red blood-corpuscles
(to one million or even half that number in a cubic millimeter) and
manifold deformed shapes of the corpuscles (poikilocytosis). In extreme
cases the proportion of hæmoglobin in the blood may be reduced to 50 or
60 per cent. of the normal quantity.[57] There is occasionally a
moderate increase in the number of white blood-corpuscles. In one case
of gastric cancer I observed a leucocytosis in which there was one
white to twenty red blood-corpuscles without enlargement of the
spleen.[58]
[Footnote 57: The granular disintegrating corpuscles
(Zerfallskörperchen of Riess) may also be found in the blood in
considerable number. Leichtenstern has observed that toward the end of
life the relative proportion of hæmoglobin in the blood may be
increased, sometimes rapidly, and may even exceed the normal limit.
This is due to concentration of the blood in consequence of the loss of
water. In such cases the tissues appear abnormally dry and the blood
thick and tarry at the autopsy (_Ziemssen's Handb. d. spec. Path. u.
Therap._, Bd. viii. 1te Hälfte, p. 344).
It seems to me proper to distinguish two kinds of anæmia in gastric
cancer--a simple anæmia, which is present in the majority of cases, and
can be explained by the development of the cancer and the disturbance
of the gastric functions; and a pernicious anæmia, which is present
only in exceptional cases, and has the typical symptoms of progressive
pernicious anæmia.]
[Footnote 58: In a case of large medullary cancer of the stomach
reported by H. Mayer there was one white to fifty red blood-corpuscles.
The spleen was not enlarged (Bayer, _Aerztl. Intelligenzblatt_, 1870,
No. 21). A similar case is related by Lebert, in which, however, the
spleen was enlarged (_op. cit._, p. 481).]
To the pallor of anæmia is added often a faded yellowish tint of the
skin which is considered characteristic of the cancerous cachexia. At
the same time, the skin is frequently dry and harsh, and may present
brownish spots (chloasma cachecticorum). The pallid lips, the pale
greenish-yellow color of the face, the furrowed lines, and the pinched
and despondent expression make up a characteristic physiognomy, which,
however, is neither peculiar to gastric cancer nor present in all cases
of the disease. There is no cachectic appearance which is pathognomonic
of cancer; and in this connection it is well to note that there are
cases of gastric ulcer, and particularly of non-cancerous stenosis of
the pylorus, in which all of the symptoms described as peculiar to the
cancerous cachexia are met with. Nevertheless, the weight of these
symptoms in the diagnosis of gastric cancer should not be
underestimated. There is no disease in which profound cachectic
symptoms so frequently and so rapidly develop as in gastric cancer.
The profound nutritive disturbances of gastric cancer are referable
partly to the cancer as such, and partly to the impairment of the
functions of the stomach. It is impossible to separate the effects of
these two sets of causes, and distinguish, as some have done, a
cachexia of cancer {553} and a cachexia of inanition. It is the
combination of these causes which renders the cachexia of cancer of the
stomach so common, so rapid in its development, and so profound as
compared with that of cancer in other situations. The relation of
cancer in general to cachexia need not here be discussed, save to say
that there is the best ground for believing that the cachexia is
directly dependent upon the growth and metamorphoses of the primary
cancer and its metastases, and that there is not reason to assume any
dyscrasia antedating the cancerous formation.
While the failure of the general health and the gastric symptoms in
general develop side by side, it is especially significant of gastric
cancer when the symptoms of impaired nutrition are more pronounced than
can be explained by the local gastric disturbance. When, however, as
sometimes happens, gastric symptoms are absent or no more than can be
explained by anæmia and marasmus, then in the absence of tumor a
positive diagnosis is impossible. Such cases of gastric cancer during
life often pass for essential or pernicious anæmia. Otherwise,
unexplained symptoms of anæmia with emaciation and debility,
particularly in elderly people, should lead to a careful search for
gastric cancer.
Finally, it is necessary to add that there are exceptional cases of
gastric cancer in which there is no emaciation, and in which the
general health appears to be astonishingly well preserved. In most of
these cases death occurs either from some accident of the disease or
from some complication.
Slight or moderate oedema about the ankles is a common symptom during
the cachectic stage of gastric cancer. This oedema is due to hydræmia.
This cachectic dropsy in rare cases becomes excessive and leads to
anasarca, with serous effusion in the peritoneal, pleural, and
pericardial sacs. Such cases are liable to be mistaken for heart
disease, particularly as a hæmic murmur often coexists, or for Bright's
disease. Ascites may be the result not only of hydræmia, but also of
cancerous peritonitis or of pressure on the portal vein by cancer. Many
cases of gastric cancer associated with ascites have been falsely
diagnosed as cirrhosis of the liver, and sometimes the distinction is
extremely difficult or impossible.
During the greater part of the disease the pulse is usually normal;
toward the end it is not infrequently rapid, small, and compressible.
In consequence of weakness and anæmia any exertion may suffice to
increase the frequency of the pulse, and may induce palpitation of the
heart and syncope.
As might be expected as the result of anæmia, hæmic murmurs in the
heart and blood-vessels are not rare in gastric cancer.
Epigastric pulsation is often very prominent in cases of gastric
cancer, as it may be in various other conditions. This pulsation is
sometimes of a paroxysmal nature.
Venous thrombosis is not a rare complication in the last stages of
gastric cancer. It is most common in the femoral and saphenous veins,
and is rapidly followed by painful oedematous swelling of the affected
extremity. Thrombosis of the subclavian and axillary veins is much less
frequent. When it occurs there are the same symptoms of phlegmasia alba
dolens in the upper extremity as have been mentioned for the lower.
Lebert has recorded a case of thrombosis of the right external jugular
{554} vein.[59] The thrombosis is the result of marasmus, and therefore
may occur in other gastric diseases besides gastric cancer, so that
this symptom has not all the diagnostic importance for gastric cancer
claimed by Trousseau. Being an evidence of great weakness of the
circulation, marantic thrombosis in cancer of the stomach is of grave
prognostic import.
[Footnote 59: _Op. cit._, p. 394.]
The temperature is often normal throughout the course of gastric
cancer. Febrile attacks, however, are not uncommon in this disease.
Elevation of temperature may occur without any complication to explain
it. During the second half of the disease there may be either irregular
febrile attacks or a more continuous fever, which is, however, usually
of a light grade, the temperature not generally exceeding 102°. Slight
chills may be experienced. Lebert describes a light and a hectic
carcinomatous fever.
There may be subnormal temperature with collapse during the last days
of life, and in general anæmia and inactivity of nutritive processes
tend to produce a low temperature.
Dyspnoea on slight exertion may be present in gastric cancer as a
result of anæmia or of fatty heart. In a few cases of gastric cancer
have been observed symptoms pointing to a reflex vagus neurosis, such
as paroxysms of dyspnoea, oppression in the chest, and palpitation of
the heart, but these symptoms are less common in gastric cancer than in
some other diseases of the stomach. Watson[60] relates a case of
gastric cancer in which increasing dyspnoea and palpitation were such
prominent symptoms that he was led to diagnose fatty heart with portal
congestion as the sole trouble. At the autopsy the heart and lungs were
found healthy, but there was extensive cancer of the greater curvature
of the stomach. He subsequently ascertained that there had been
symptoms pointing to gastric disease.
[Footnote 60: Sir T. Watson, _Lectures on the Principles and Practice
of Physic_, vol. ii. p. 471, Philada., 1872.]
The various complications of gastric cancer which affect the
respiratory organs will be considered later.
Depression of spirits, lack of energy, headache, neuralgia,
sleeplessness, and vertigo are functional nervous disturbances which
are often the result of disordered digestion from whatever cause, and
are therefore not uncommon in gastric cancer. The theory that these
symptoms are due to the absorption of noxious substances produced in
the stomach and intestine by abnormal digestive processes is
plausible,[61] and more intelligible than reference to some undefined
sympathy between the digestive organs and the nervous system.
[Footnote 61: This theory is elaborated by Senator ("Ueber
Selbstinfection durch abnorme Zersetzungsvorgänge, etc.," _Zeitschrift
f. klin. Med._, Bd. 7, p. 235).]
The intelligence is generally not impaired in the course of gastric
cancer.
Considerable interest belongs to coma as a symptom of cancer of the
stomach, and more particularly to the occurrence of coma with the
peculiar characters which have been described by Kussmaul as
distinguishing diabetic coma.[62] The most distinctive feature in
Kussmaul's group of symptoms is the accompaniment of the coma by a
peculiar {555} dyspnoea in which, without evidence of disease of the
lungs or air-passages, the respirations are strong and deep and often
attended with a groaning sound in expiration. The breathing is either
normal in frequency or oftener moderately increased. The pulse is
usually small and frequent. The temperature is not much elevated, and
sometimes is much below the normal. Sometimes the coma is preceded by a
period of excitement, with restlessness, and perhaps with screaming.
Gerhardt's reaction in the urine may or may not be present. When it is
present in a marked degree there is often an aromatic, chloroform-like
odor to the breath and to the fresh urine. The patient may come out of
the coma, but in the vast majority of cases the coma terminates
fatally.
[Footnote 62: _Deutsches Arch. f. klin. Med._, Bd. 14, p. 1.]
It is now known that this dyspnoeic coma is not confined to diabetes
mellitus, but that it occurs also in gastric cancer and in various
other diseases.[63] Its occurrence in gastric cancer is rare. In this
disease it does not usually appear until anæmia is far advanced, but it
may occur in cases of cancer in which the patient's general health and
nutrition are still fairly good. I recently made the post-mortem
examination of an elderly man, fairly well nourished, who was found in
the streets comatose and brought in this condition to Bellevue
Hospital, where he died in about twelve hours. While in the hospital
his breathing was increased in frequency, forcible, and deep. His
temperature was normal. The urine contained a small quantity of
albumen, but no sugar. No previous history could be obtained. Uræmic
coma was suspected. At the autopsy was found a large, soft, ulcerated
cancer of the lesser curvature and posterior wall of the stomach near
the pylorus. The kidneys, brain, heart, and other organs were
essentially healthy.
[Footnote 63: Von Jaksch was the first to describe this form of coma in
cancer of the stomach (_Wien. med. Wochenschr._, 1883, pp. 473, 512).
He adopted the term coma carcinomatosum, and more recently coma
diaceticum. L. Riess has reported seventeen cases of this coma
occurring in a variety of diseases, such as pernicious anæmia, gastric
cancer, gastric ulcer, tuberculosis, which all had in common profound
anæmia. He proposes the term dyspnoeic coma (_Zeitschrift f. klin.
Med._, Bd. 7, Suppl. Heft, p. 34, 1884). Senator has described two
cases of gastric cancer with this coma. He uses the terms dyscrasic
coma and Kussmaul's group of symptoms (_ibid._, Bd. 7, p. 235). In the
cases described by Litten under the name coma dyspepticum, dyspnoea was
absent, but Gerhardt's reaction in the urine was present. In Litten's
cases structural disease of the stomach was not supposed to be present.
The patients recovered from the coma (_ibid._, Suppl. Heft, p. 81).]
We possess no satisfactory explanation of this form of coma. In
diabetes it is considered to be due to the presence in the blood of
some intoxicating agent. For a time this agent was thought to be
aceton; it is now believed by Von Jaksch to be diacetic acid. Much
stress has been laid upon the aromatic, fruity odor of the breath and
of the fresh urine, and upon the presence of some substance in the
urine which imparts to it a burgundy-red color upon the addition of
liquor ferri chloridi (Gerhardt's reaction. See changes in the urine,
page 551). Although the whole aceton question is at present in a very
confused state, there is no proof that aceton or its allies possesses
the toxic properties assumed by this theory;[64] and it is certain that
dyspnoeic coma may occur in diabetes and in other diseases without the
presence of Gerhardt's reaction in the urine. It is also true that this
reaction often occurs without any clinical symptoms referable to it.
Riess and Senator believe that in non-diabetic {556} cases anæmia is
the most important factor in the production of this coma.[65]
[Footnote 64: Frerichs, _Zeitschrift f. klin. Med._, Bd. 6, p. 3.]
[Footnote 65: Riess refers the coma to the anæmia as such, whereas
Senator thinks that, in consequence of the depraved nutrition of the
body resulting from the anæmia, some toxic substance is developed which
enters the circulation.]
Coma, probably belonging to this same variety, may occur in gastric
cancer without the peculiar dyspnoea which has been described. There is
reason to believe that this dyspnoea is not a necessary symptom of the
so-called diabetic coma.
Chronic Bright's disease terminating with uræmic coma is an occasional
but not frequent complication of gastric cancer.
Coma and other cerebral symptoms may be produced by secondary cancerous
tumors in the brain.
Stupor deepening into coma may develop during the often-prolonged
death-agony of gastric cancer.
The distribution, origin, and frequency of cancerous growths secondary
to gastric cancer are most conveniently considered under Pathological
Anatomy. Symptoms referable to certain localizations of these secondary
cancerous deposits, however, are so common, and so interwoven with the
clinical history of cancer of the stomach, that it is desirable to
consider some of these symptoms in the present connection.
Cancer of the liver is the most important of these secondary cancerous
growths. It is estimated to be present in nearly one-third of the cases
of gastric cancer, but by no means in all these cases does it produce
symptoms. As a rule, the earlier hepatic cancer forms in the course of
gastric cancer the more likely is it to be attended by symptoms. The
most important symptoms of secondary cancer of the liver are
enlargement of the liver, peritoneal exudation, and persistent icterus.
When nodular growths can be felt in the free border or surface of the
liver, the diagnosis is generally easily established. Sometimes the
liver remains of normal size or is even contracted, and then the
diagnosis is difficult or impossible. Ascites or exudative peritonitis
is present in about one-half of the cases of cancer of the liver.
Jaundice is less frequently present. It is only persistent jaundice
which aids in the diagnosis of hepatic cancer.
The various combinations of gastric cancer with secondary hepatic
cancer may be clinically grouped as follows:
1. Symptoms of gastric cancer with latent hepatic cancer.
2. Symptoms of gastric cancer followed by symptoms of hepatic cancer.
3. Symptoms both of gastric cancer and of hepatic cancer present when
the case comes under observation.
4. Symptoms of hepatic cancer with latent gastric cancer.
5. Symptoms of hepatic cancer followed by symptoms of gastric cancer.
6. Both hepatic and gastric cancer latent. Symptoms of anæmia and
marasmus, or of chronic exudative peritonitis, or of chronic pleurisy.