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 Velden38 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.
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 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.
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. 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.
40 "Ueber den Magenkrebs," Volkmann's Samml. klin. Vorträge, No. 87, p. 21.