Part 91

Sometimes the tumor eludes discovery on account of special obstacles to the physical examination of the abdomen, such as a thick layer of fat in the abdominal walls or a large quantity of ascitic fluid. Every aid in the physical examination of the abdomen should be resorted to. The patient should be examined while lying on his back with the utmost possible relaxation of the abdominal walls. If necessary, he should also be examined while standing or in the knee-elbow position. Sometimes a deep inspiration will force down a previously concealed tumor. The emptying of a dilated stomach by means of a stomach-tube will sometimes bring to prominence a gastric tumor.

The inflation of the stomach by the development in it of carbonic acid gas may render valuable assistance in the diagnosis of tumors of this organ and of surrounding parts. This method has been recommended by W. Ph. H. Wagner among others, and especially by Rosenbach. From 20 to 30 grains of bicarbonate of soda and from 15 to 20 grains of tartaric acid may be introduced into the stomach. The soda, dissolved in lukewarm water, may be given first and followed by the acid in solution, or, better, the mixed powders may be swallowed in the dry state and followed by a tumblerful of water. Some persons require a larger quantity of the powder in order to inflate the stomach. Occasionally the introduction of the effervescing powder fails to produce any appreciable distension of the stomach. This negative result may be due to the escape of the gas into the intestine in consequence of incontinence of the pylorus--a condition which Ebstein has observed and described especially in connection with pyloric cancer. When this pyloric insufficiency exists the resulting tympanitic distension of the intestine is a hindrance to palpation of tumors of the stomach. Failure to secure distension of the stomach is not always due to this cause. It may be necessary to make repeated trials of the effervescing mixture. It is well to have a stomach-tube at hand to evacuate the gas if this should cause much distress.

In some respects simpler and more easily controlled is the method of {550} distending the stomach by injecting air into it through a stomach-tube, as recommended by Runeberg. For this purpose the balloon of a Richardson's spray apparatus may be attached to a soft-rubber stomach-tube. In this way the desired quantity of air can be introduced and at any time allowed to escape through the tube.

When the stomach has been inflated the contours of tumors of the pylorus often become surprisingly distinct in consequence of the changes in the position and the shape of the stomach. When the tumor is fixed by adhesions, it may be possible to follow the contours of the stomach into those of the tumor. False tumors produced by spasm of the muscular walls of the stomach may be made to disappear by this distension of the organ. This procedure enables one to distinguish between tumors behind and those in front of the stomach, as the former become indistinct or disappear when the stomach is inflated. By bringing out the contours of the stomach the relations of the tumor to surrounding organs may be rendered for the first time clear. Assistance in diagnosis may also be afforded by distension of the colon with water or with gas or with air, per rectum, in order to determine the course of the colon and its relations to abdominal tumors (Mader, Ziemssen, Runeberg). A manifest contraindication to distension of the stomach or of the colon with gas exists if there is a suspicion that the coats of these parts are so thinned by ulceration that they might rupture from the distending force of the gas. There have been no cases recorded where such an accident has happened.

Only in exceptional cases are the bowels regular throughout the course 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, 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.

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. 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.

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 (see page 555).

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. 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.

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.]

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. 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.

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 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.

The various complications of gastric cancer which affect the respiratory organs will be considered later.