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.
From this grouping it is evident that the existence of secondary hepatic cancer may aid in the diagnosis of cancer of the stomach, or may mislead, or may be without influence. The greatest assistance in diagnosis is rendered when the physical signs and the symptoms of hepatic cancer develop some time after the appearance of gastric symptoms which may previously have been equivocal. Much more difficult to diagnosticate are the cases of hepatic cancer accompanied or followed by gastric symptoms, inasmuch as cancer of the liver, whether primary or secondary, may be attended with marked disturbance of the gastric functions, including hæmatemesis. In these cases, unless a tumor of the stomach can be discovered, a positive diagnosis of gastric cancer is impossible. In view of the infrequency of primary cancer of the liver, however, there will be in many of these cases a strong probability in favor of primary cancer of the stomach. When it is remembered that over one-third of the cancers of the liver are secondary to cancer of the stomach, it is evident that in cases which appear to be primary hepatic cancer very careful attention should be given to the exploration of the stomach. But even then diagnostic errors will often be unavoidable.
Cancer of the peritoneum secondary to cancer of the stomach may produce no symptoms, and so pass unrecognized. The diagnosis of peritoneal cancer is readily made when, after the recognition of gastric cancer, secondary cancerous nodules in the peritoneum can be felt through the abdominal walls or through the vagina. There are cases of gastric cancer in which the symptoms are all referable to secondary cancer of the peritoneum. Cancer of the peritoneum is usually attended with fluid exudation in the peritoneal cavity. The chemical and the microscopical examination of this fluid withdrawn by paracentesis may aid in the diagnosis of cancerous peritonitis. Whereas in dropsical accumulations in the peritoneal cavity the quantity of albumen in the fluid is usually less than 2½ per cent., in cancerous peritonitis there is usually from 3 to 4 per cent. of albumen, the percentage rarely falling as low as 2½ per cent., but sometimes being as high as from 5 to 6 per cent. The percentage of albumen in ordinary peritonitis is usually over 4.66 Clumps of cancer-cells are sometimes to be found by microscopical examination of the fluid. These cells are large, epithelioid in shape, and often contain vacuoles and fatty granules. It is only when these cells are arranged in clumps or as so-called budding cells, and when they are present in abundance, that they are diagnostic. They are to be sought especially in fibrinous coagula. They are present only when the cancerous alveoli actually communicate with the peritoneal cavity.67 The development of cancerous nodules in the margins of an opening made in the abdominal walls by a trocar is also evidence of cancerous disease of the peritoneum. The same thickening and retraction of the mesentery and omentum may occur in cancerous as in tuberculous peritonitis. In both the exudation is often hemorrhagic.
66 The conditions under which the estimation of the quantity of albumen in the peritoneal exudation may prove of diagnostic aid are fully considered by Runeberg (Deutsches Arch. f. klin. Med., Bd. 34, p. 1). Here also are given methods for making this analysis for clinical purposes.
67 The literature on this subject is as follows: Foulis, Brit. Med. Journ., July 20, Nov. 2, 1878; Thornton, ibid., Sept. 7, 1878; Quincke, Deutsches Arch. f. klin. Med., Bd. 30, p. 580; Ehrlich, Charité Annalen, vii. p. 226; Brieger, ibid., viii.
Importance has been attached to enlargement of the supraclavicular lymphatic glands in the diagnosis of cancer of the stomach, but there are so many causes of enlargement of these glands that not much significance can be attached to this symptom, which, moreover, is absent in most cases. Still, under certain circumstances this glandular enlargement may aid in the diagnosis. The same remarks apply to enlargement of the inguinal glands, which is a common occurrence in case cancer involves the peritoneum. One must not mistake abnormal prominence of the lymphatic glands in consequence of emaciation for actual enlargement.
Gastric cancer much less frequently than gastric ulcer causes perforation of the stomach. Of 507 cases of gastric cancer collected by Brinton, perforation into the general peritoneal cavity occurred in 17 (31/3 per cent.).68 In two cases of gastric cancer reported by Ellis perforative peritonitis was preceded by symptoms supposed to be only those of ordinary dyspepsia, hemorrhage and vomiting being absent.69 Various fistulous communications like those described under gastric ulcer may be the result of perforation of gastric cancer, but with the exception of gastro-colic fistula they are much more frequently produced by ulcer than by cancer. In 160 cases of gastric cancer collected by Dittrich, gastro-colic fistula existed in 6 (3¾ per cent.).70 In 507 cases collected by Brinton this fistula existed in 11 (2.17 per cent.). In Lange's 210 cases gastro-colic fistula existed in 8 (3.8 per cent.). Of 33 cases of gastro-colic fistula collected by Murchison, 21 were caused by cancerous ulceration.71 The symptoms characteristic of fistulous communication between the stomach and the colon are the vomiting of fecal matter and the passage of undigested food by the stools. These symptoms are not present in all cases, so that a diagnosis is not always possible. Fecal vomiting is influenced by the size of the opening between the stomach and the colon. With great obstruction at the pylorus, fecal vomiting, as might be expected, is absent or infrequent, while the passage of undigested food by the bowels is common. Under these circumstances vomiting is sometimes relieved after the establishment of the fistula. Aid may be afforded in the diagnosis of gastro-colic fistula by the introduction into the rectum or into the stomach of colored or other easily recognizable substances, and determining their presence in the vomit or in the stools in consequence of their escape by the unnatural outlet. V. Ziemssen has determined in a case of gastro-colic fistula due to cancer the escape into the stomach of carbonic acid gas artificially generated in the rectum, with failure to obtain distension of the colon.72 A number of instances of gastro-cutaneous fistula due to gastric cancer have been recorded, but this form of fistula is much less common than gastro-colic fistula, and much less frequently the result of cancer than of ulcer of the stomach. Subcutaneous emphysema may precede the formation of the fistula. Other gastric fistulous communications resulting from cancer, such as with the pleura, the lungs, the small intestine, are too infrequent to merit consideration under the symptomatology of the disease.
68 Loc. cit. Lange (op. cit.) records in 210 cases of gastric cancer 12 perforations into the peritoneal cavity (5.7 per cent.).
69 Extr. fr. the Rec. of the Boston Soc. for Med. Improvement, vol. iii. p. 116, and vol. iv. p. 109.