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
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.
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 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.