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ture and elasticity, the diminution of the subcutaneous fat, the flabbiness (if I may use such a word) of the areolar tissue, the softness and smallness of the muscles. The latter symptoms are closely connected with emaciation and debility, and often with physical signs such as evince kindred characters of the pulse and heart.

Of all these, however, the altered facial colour is the most obvious and important, as well as the most constant. The more characteristic variety of this change is describable as imparting to the face a kind of muddy greenish pallor, or pale earthy hue, such as can scarcely be mistaken for any other colour. The chief extremes (if we may so term them) of this symptomatic colour are jaundice on the one hand, and an anæmic whiteness on the other.

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Jaundice to have occurred in about 14 of 260 cases, a proportion rather less than 5 per cent. It may be conjectured that in about one half of these cases the jaundice was simply due to the hepatic disorganization produced by consecutive cancer of the liver.

The remainder were probably quite independent of any disease of this organ. The coloration of such jaundice appears to merge, by numerous gradations in different cases, into the ordinary hue of the cancerous cachexia. And (if we except those rare cases in which its symptoms and the date of its appearance refer it to a cause analogous to that of the jaundice which sometimes comes on in the later stages of fatal cardiac disease) it is difficult to avoid regarding it as little more than a variety of this cachexia. Such a view is especially confirmed by one or two important features it generally offers. The icteroid stain is rarely intense, indeed the conjunctiva is often but moderately yellow. The stools, again, however offensive, have neither the white colour nor the putrefying odour characteristic of true jaundice. And the skin and urine are rarely loaded with bile in anything like the usual degree.*

Pallor of skin is just as evidently a variety of the above colour in some cases, a complication of it in others. In other words, it often seems traceable to no other cause than the cachexia which it accompanies; oftener, however, is due to some of those incidents of the malady which, occurring in other diseases, would bring about a similar result. Thus hæmorrhage, suppuration, frequent vomiting, scanty ingestion of food, long confinement, and a host of circumstances (among which are recorded such rare contingencies as concurrent albuminuria) may all complicate and increase that pallor which is an element of the peculiar facial hue characteristic of gastric cancer.

With allusions equally hasty and imperfect, we must pass by the interesting subject of inquiry which the nature of this cachexia might afford us. Enough to say that, of all the provisional theories which suggest themselves, that which regards the original or pathognomonie cachexia as the result of the humoral disease which precedes and brings

A further discussion of this interesting point would lead me too far from my present subject. It may suffice to add, that without wishing to deny the analogy of this coloration to certain forms of jaundice, I am anxious to insist on its connexion with the cancerous cachexia, and its distinctness from the commoner varieties of icterus.

about the cancerous deposit, is, on the whole, the safest, as well as the most useful. According to this vague theory, there is a cachexia which, in many cases, can be verified prior to any of those local changes that afterwards rudely measure and express it. But besides this specific cachexia (the nature and date of which render it so important for pathology and diagnosis), there are a variety of conditions which closely resemble it, but bear to the total malady a relation of coincidence rather than of identity, or effect rather than of cause. Often as these latter complicate and obscure the true cancerous cachexia, pathological accuracy requires their separation in the history of the malady, nay more, so far as practicable, in any given instance. Indeed, it would be difficult to find a better illustration of the practical value of such accuracy than we may see in many cases of this malady. Contrary to what has been generally stated by authors, the cachectic aspect witnessed in gastric cancer is often imitated by mere ulcer of the stomach, sometimes so closely as really to defy distinction. But in all these cases the resemblance, however close, is easily explained. The circumstances of both diseases are such as to involve, in a large proportion of the more fully developed cases, a certain amount of cachexia-the joint product of ulceration, hæmorrhage, vomiting, pain, starvation. While in other instances a knowledge of this fact renders the symptom a valuable aid to diagnosis. Wherever cachexia precedes these circumstances, or is present in a degree utterly disproportionate to what their aggregate influence might lead us to expect, there it acquires the rank (pro tanto) of a leading (and almost pathognomonic) symptom.

Febrile symptoms seem to accompany gastric cancer much more frequently than is generally supposed. But I am not in a position to make any exact statement respecting the numerical frequency of their presence. As a rule, these symptoms rarely amount to definite hectic, but are generally limited to what is termed irritative or symptomatic fever. The tongue, often covered with a thickish white fur, which is especially distinct posteriorly, gleams through this covering, or appears at its edge of a deep red "raw" colour. The face is not unfrequently marked by injected red patches on the centre of each cheek, contrasting strongly with the pallid cachectic hue of the surrounding integuments. The urine is still more frequently of scanty amount and high specific gravity, loaded with urea and urates. The various forms of uric acid deposit are also anything but uncommon ; indeed it is perhaps in this malady that we may find the best illustrations of that pecular pink variety (or rather complication) of uric acid deposit, which has long been regarded as characteristic of constitutional malignant disease.

The import of this febrile reaction is probably very different in different cases. Ulceration, inflammation, peritonitis, suggest themselves as explanations, at least as frequently as the primary malady, or even the exhaustion it directly or indirectly produces. On the whole, however, the latter state seems to me the best clue to the nature of these symptoms in the majority of cases in which they are

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present. Especially is this explanation applicable where none of the above local complications appear to be prominent. In such instances the febrile reaction often seems strictly analogous to the feverish condition producible by starvation, exposure, or over-exertion, in persons otherwise healthy. And in consonance with this view, I think it will generally be found that its presence is a rough test of the progress of the malady-at any rate of its effect upon the constitution; and is therefore not only one element of a very unfavourable prognosis, but an indication for as much nourishment and support as the local circumstances of the malady will allow.

The state of the bowels in gastric cancer is another point on which I have no exact numerical details to offer. In most instances, however, either constipation or diarrhoea is specified as having been present during a considerable period of the malady. And in many the two states alternate with each other; constipation in the earlier months of the history being succeeded by diarrhoea towards the last few weeks of life.

Constipation, the more frequent of the two, appears to be due to the circumstances of the malady rather than to the malady itself, and in this respect is comparable with the constipation which so frequently accompanies gastric ulcer. Obstruction, vomiting, and pain, which prevent alike the distension and the movements of the intestinal canal, concur to form a ready explanation of the frequency and intensity of this symptom, which sometimes persists up to the last hour of life.

Diarrhoea seems mainly attributable to the direct irritation caused by the cancerous, purulent, or hæmorrhagic effusion which the gastric lesion introduces into the intestines. The noxious influences of these fluids are often aided by their decomposition or incipient putrefaction in their passage through the bowels. Ulceration of the cæcum, and of the neighbouring ileum and colon, is comparatively so rare, as to afford but a very exceptional explanation. The date of the occurrence of diarrhoea is generally consonant with the above view of its production; it is subsequent to ulceration, in other words, is comparatively late in the history of the malady. It thus coincides with a period at which the patient's strength is generally so far exhausted as to be very susceptible of any further depressing influence. Hence it often indicates imminent danger, and is not unfrequently the proximate cause of death.

The symptoms which more specifically betray the approach of death, offer little that is peculiar to this disease. Anasarca is by no means uncommon, and is usually accompanied by ascites. A disproportionate effusion into the belly points rather to some local cause of the dropsy, such as pressure of the cancerous tumour on the vena porta, and is hence less significant for prognosis. Jaundice, as before mentioned, appears sometimes to be a precursor of death, as is also a form of pulmonary effusion which I believe to be a mere passive congestion. Hiccough, again, is usually due to local causes acting on the diaphragm. The nervous phenomena that usher in the close of the malady are delirium, followed by coma.

The duration of the aggregate malady formed by the succession of all these symptoms may be calculated, from 198 cases, as averaging about 12 months. This average seems to differ little in the two sexes. Out of 142 cases, 107 male and 35 female, the average in the male was 12, in the female 11 months. This slight difference is rendered even less important by the smaller number of females referred to, especially in conjunction with the fact, that the deviations from the average are far more striking and less trustworthy, in the case of the longer durations than of the shorter. Indeed, as regards the longest or most chronic instances, it is curious to notice how few gradations exist between protraction to the close of the second year, and the one or two rare examples of a duration of six or seven years. Hence these extremely protracted cases are not improbably examples of dyspepsia ending in cancer, an opinion which may also be directly deduced from their symptoms.

Practically, then, we may deduce that the maximum duration of gastric cancer amounts to a period of about thirty-six months from the first appearance of the symptoms, and that very few cases survive the twenty-fourth month. The minimum is about one month. As might be inferred from the histological details before alluded to,* many of the most protracted cases are shown by necropsy to have a structure often designated "colloid" and "encephaloid," though originally scirrhus. The converse exception is much rarer, a large majority of the cancers rapidly fatal really belonging to these two intense forms of the malady.

But in noticing these facts, we must be careful not to overrate their significance. The commencement of the symptoms often has little connexion with the commencement of the disease. Pathologically, of course, it is not only absolutely impossible to fix the date of the deposit in any given instance, but probable that its material origin may be followed by all those varieties in the date of subsequent growth which we can verify in external cancers. And even that aggregate of symptoms which, for diagnostic purposes, we may make the representative of the disease, must often give a very distorted view of the real duration of the case. Slight anorexia, cachexia, or emaciation would often elude the notice of the patient; or, perhaps, would rarely (in hospital practice) cause him to seek professional advice, such as might sometimes detect and distinguish the latent cause of these earlier symptoms. Hence, in most of the cases on which the above estimate is founded, the symptoms from which the commencement of the malady has been dated are those of active gastric disturbance in the shape of pain and vomiting.

This brings us to a point on which I am anxious to be explicit, in order not only to compensate the probable bias of the above estimate, but also to explain the deceptive resemblance between cancer and ulcer of the stomach-a resemblance which it is often of vital importance for the physician to unmask. In many cases of gastric cancer, the symptoms only date from the commencement of ulceration in the British and Foreign Medico-Chirurgical Review, No. xxxvii. p. 226.

cancerous deposit:—from a time, that is, when the incurable and malignant disease offers a close analogy, in many of its circumstances, to the curable ulcer; and an analogy which necessarily brings about the closest similarity in many of the local symptoms. As a rule, it seems that, whether we explain their access as due to this cause, or view them as independent of it, the more specific and frequent varieties of vomiting and pain, as well as the occurrence of hæmorrhage, begin at a period about midway in the history of the best marked cases. Hence we may conjecture (1st) that the cancerous deposit itself generally precedes the symptoms by a period of at least some months; and (2nd) that the above estimate of the total duration of the symptoms will probably receive some extension from future clinical researches.

It may be interesting to combine the estimates we have come to respecting the frequency of the above symptoms separately, in order to determine their bearing on the diagnosis of the malady, or on the probabilities of any given case. Of the two estimates we have generally adduced for each symptom, we had better keep to the larger, both as a more direct and positive one, and as seeming to balance most exactly the two kinds of error-excess and deficiency-to which all such calculations are liable :

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Applying to these figures the simpler laws of probabilities, brings out the following statements.

The probabilities or "odds" are eleven to two against all six symptoms being simultaneously present in any given case. In other words, one or other of the six is absent in more than five out of six examples of the malady.

Supposing the least frequent-hæmorrhage-to be absent, the odds are still as many as eight to five against the concurrence of the remaining five.

It is only the absence of a second symptom-for example, cachexia -that equalizes the chances, so as to render exactly even the probabilities for and against the concurrence of the remaining four-pain, vomiting, anorexia, and tumour. In other words, the simultaneous presence of four of the above symptoms is about the average amount of evidence hitherto detected in cases of gastric cancer. The numerical frequency of anorexia and cachexia (70 to 75) is so nearly alike, that it scarcely matters which we include in this four; save that, on the whole, the presence or absence of cachexia is less mistakeable than that of anorexia. Hence supposing, in any given instance, we find pain, vomiting, tumour, and cachexia are all present, we may feel that the diagnosis, even if uncertain, is as little so as, in the majority of cases, it is likely to be.

The chances of concurrence would of course increase as the number of symptoms decreased. Thus it is 23 to 12 that pain, vomiting, and tumour are all present; 52 to 12 that pain is associated with vomiting.

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