Secondary growths occur so frequently, and exert such an important influence upon the symptoms and signs of the gastric complaint, that it is necessary briefly to consider the clinical phenomena that attend their development in the principal organs of the body.

Metastases In The Liver

Secondary deposits are met with in the liver in at least 35 per cent, of all cases. In some instances only one or two nodules are discovered after death, while in others the entire organ appears to be replaced by aggregated masses of carcinoma. As a rule the size of the individual metastases is inversely proportionate to their number, and it is often observed that the hepatic affection is most marked when the primary growth in the stomach is comparatively insignificant. This latter fact helps to explain the infrequency of gastric symptoms in cases where the liver is extensively involved at an early period. The situation of the growths varies according to their mode of formation, those produced by infection of the portal system usually developing in the substance of the organ, while those that arise from infection of the lymphatics are often situated beneath the capsule. The right lobe of the liver is principally affected when the pyloric and central regions of the stomach are the seat of disease, and the left lobe in cases of primary carcinoma of the cardia. The most rapid and extensive destruction of the hepatic tissue is associated with soft ulcerated growths of the upper margin of the stomach, while a localised scirrhus of the pylorus which produces great dilatation of the stomach is the least malignant in this respect. The period at which the liver becomes affected varies greatly in different cases ; in some instances large tumours appear within three months of the onset of the gastric symptoms, while in others enlargement of the organ is detected only during the last few weeks of life. The rapid infection of the liver which so often occurs during the warm months of the year may be partly responsible for the higher death-rate from carcinoma of the stomach that obtains between May and September.

It is always difficult to differentiate between the symptoms which arise from secondary disease of the liver and those that attend the primary complaint and coexisting metastases in other organs. As a rule, however, secondary growths of the liver are accompanied by severe and constant pain in the right hypochondrium and back, which is increased by exertion and is often worse at night. In every case, also, the emaciation, cachexia, and anorexia become greatly increased when the liver is infected, while in many instances the pain after food and vomiting which previously existed tend to diminish. Contrary to the usual statements on the subject, jaundice is a comparatively rare result of the hepatic affection, only about one-fifth of the cases of icterus being directly referable to it. Ascites occurs in about 21 per cent, of the cases where the liver is affected, and in about 50 per cent, of those where there is coexisting disease of the peritoneum. In most instances it is only moderate in amount, and does not appear until the liver is already much enlarged. An excess of urobilin in the urine is supposed to accompany the destruction of the liver substance by the new growth (Tissier).

The physical signs vary according to the number and position of the secondary growths. When these are few, and situated deeply in the substance of the right lobe, the liver appears to be enlarged and presents a smooth surface and a well-defined edge, while posteriorly the area of hepatic dulness is found to be much increased. If, on the other hand, the metastases project upon the surface, they may usually be felt in the form of rounded tumours, which increase in size and are often very tender upon pressure. Scirrhous deposits are sometimes distinctly concave or ' cupped,' owing to the contraction of their fibrous substance. Carcinoma of the cardia is often associated with enlargement of the left lobe of the liver, or with a nodular growth in that portion of the organ situated in the epigastrium. A solitary tumour in the region of the gallbladder usually indicates a direct extension of carcinoma into the liver from an adherent pylorus. Among the minor indications of the disease are oedema of the legs, enlargement of the superficial veins of the abdomen, and slight albuminuria.