It is impossible to describe in any but general terms the course pursued by carcinoma of the stomach. Not only do the symptoms vary in intensity at different periods, but those which were at first most conspicuous often disappear after a few months, while others, that depend upon the fortuitous involvement of a neighbouring organ or upon structural changes in the growth itself, develop with startling rapidity and may completely change the clinical aspect of the case. But, in spite of every alteration in the symptomatology or physical signs, one fact usually stands out conspicuous and unmistakable-improvement is rare and always transitory, and the health of the patient steadily declines.
Among the special symptoms of the disease, pain usually exhibits the greatest variation, being apt to subside spontaneously after the liver has become involved, to be relieved by haemorrhage or a change of diet, and to alter in character and time of onset when the growth undergoes ulceration.
Vomiting' as an early symptom is chiefly encountered in stricture of the orifices. In disease of the cardia the dysphagia and regurgitation of food steadily increase until the obstruction becomes almost absolute, but in pyloric cases the periodic attacks of emesis are often interrupted from time to time by symptoms of acute gastritis, which persist for several days and may give rise to fatal exhaustion.
Spontaneous cessation of vomiting often occurs shortly before death, but it may ensue at an earlier period, owing to sloughing of the growth which caused the obstruction or to the establishment of a fistulous communication with the intestine.
As a rule the anemia develops gradually, and repeated examinations of the blood show a slow but steady diminution of haemoglobin and red corpuscles. Occasionally, however, cachexia develops rapidly, and attains within a few days the degree which it usually takes months to produce, or a sudden increase of pallor occurs at irregular intervals. In such cases it is a fair assumption that ulceration of the growth has been accompanied by internal haemorrhage, which, owing to the absence of a systematic examination of the evacuations, had escaped attention.
Emaciation varies in degree in different cases, but is always progressive. It is most rapid in cases of stricture of the cardiac or pyloric orifice, and in those where anorexia and vomiting are early and prominent symptoms. The loss of flesh is comparatively slow when a non-ulcerated growth occupies the wall or gradually infiltrates the entire stomach.
Temporary increase of weight is often observed in cases of pyloric stenosis which are subjected to lavage and careful feeding, and after the performance of an exploratory laparotomy or gastro-enterostomy. Renewed hope also exercises a beneficial influence upon the general nutrition, so that a patient who is assured of recovery by a new medical attendant will often regain appetite and weight for several weeks. A fictitious increase of weight usually accompanies an effusion of fluid into the peritoneal or pleural cavities, general oedema, or a rapid infiltration of the liver.
Although the course of carcinoma of the stomach depends to a great extent upon the situation of the disease and the various complications incidental to its development, there can be little doubt that it is also largely influenced by the rate of growth of the tumour at different times. In every case there probably exist certain periods of latency, the duration of which varies according to the structure of the neoplasm, its location in the stomach, and the vulnerability of the tissues. Thus, there is every reason to believe that an appreciable interval always exists between the commencement of the carcinoma and the appearance of the first symptoms of disordered digestion, which is comparatively short when a medullary or cylinder-celled growth affects the cardia or pylorus, but is often protracted in the case of a localised scirrhus of the body of the viscus. Again, it frequently happens that after the disease has pursued an acute course for the first few months the urgent symptoms abate, the rate of emaciation diminishes, and life is prolonged for many months beyond the period originally anticipated. In such it is usual to find after death either that the primary growth presents evidence of partial repair, or that it is largely composed of fibrous elements, which indicate a retrograde activity. On the other hand, cases are often met with in which, after a period of slow development, the pain, vomiting, and cachexia undergo a sudden exacerbation, the liver becomes rapidly affected by metastases, and life is cut short in a few weeks, while a necropsy shows extensive sloughing of the tumour or an exuberant growth at the edge or base of a scirrhous induration. Whether these variations of malignancy depend upon local or constitutional conditions it is impossible to say, but the fact remains that, except under certain circumstances, the course pursued by the disease is essentially irregular, and consequently impossible to predict.