According to Brinton, vomiting occurs in 87.5 per cent, of all gastric cancers. Lebert observed it in 80 per cent, of his cases, while in our own series it was recorded in 87 per cent., and in 9 per cent, it constituted the initial symptom of the disease. Like pain, it varies greatly in severity, in some instances appearing only at an advanced stage of the complaint, while in others it either occurs at intervals or is so frequent as to take precedence of all the other symptoms. An analysis of our 154 cases gives the following results: no vomiting in 13 per cent., occasional vomiting in 7 per cent., frequent vomiting in 80 per cent.

(a) Complete absence of vomiting is so very exceptional that the term ' no vomiting ' must be held to imply that the symptom was so unimportant that it failed to attract the attention of the patient. In most of these cases the disease appears in the form of a localised growth upon the posterior wall or curvatures of the stomach, though occasionally a considerable area may be involved, provided the orifices are not obstructed. The stomach shown in fig. 12, p. 14, was taken from a man who vomited only twice during the whole course of his illness. It is important to observe that in all these cases pain is usually excessive, and that in many of them the liver becomes affected with secondary growths at a comparatively early period of the disease. Absence of both pain and vomiting is very rare, and was noted only once in our series of cases (0.65 per cent.).

Latency of the symptom may arise from several causes. In the first place, it is well known that the normal excitability of the vomiting centre in the medulla oblongata varies considerably in different individuals, some being affected with sickness from the most trifling causes, while in others the induction of vomiting is a matter of the greatest difficulty. Again, frequent vomiting rarely coexists with severe gastric pain, on account of the restricted diet and the constant use of opiates which the suffering necessitates. Finally, the profound general exhaustion which accompanies the progress of the malignant disease gradually depresses the nervous system and diminishes its reflex functions.

Table 26.-Showing The Relative Severity Of The Vomiting In Carcinoma Of Different Regions Of The Stomach

(b) Occasional vomiting is characterised by attacks of emesis, which recur at irregular intervals throughout the course of the disease. As a rule they do not appear until the third or fourth month, but occasionally they constitute the first symptom. The vomiting may occur quite suddenly, or it may be preceded by an increase of pain, flatulence, distension, or nausea. In the former case it often takes place in the early morning or before a meal, and results in the rejection of several ounces of viscid mucus; while in the latter it ensues after meals, and causes the evacuation of a large quantity of undigested and fermenting food. In both instances the ejecta usually contain lactic acid, but are devoid of free hydrochloric acid. The frequency of the symptom varies in different cases, in some occurring only every two or three weeks, while in others an attack is experienced every six or seven days. Its exciting cause is equally variable, an unduly large meal, indulgence in beer or wine, over-excitement, or exposure to cold or fatigue, being liable in many patients to produce sickness. In almost every instance pain, either constant or occasional, is a marked symptom, and as a rule the vomiting affords a welcome though temporary relief. A glance at Table 26 shows that occasional vomiting is most frequent when the morbid growth affects the walls or curvatures of the stomach without implication of the orifices, and it may therefore be attributed partly to local irritation of the gastric nerves, and partly to the chronic gastritis which always accompanies the disease.

(c) Frequent vomiting occurs in the great majority of cases at a late stage of the disease, and is present in some throughout its entire course. Its time of advent and its severity depend chiefly upon the situation and extent of the growth and the existence of ulceration.

The most characteristic variety is met with in stenosis of the pyloric orifice. In this condition severe pain is rarely experienced, but flatulence, distension, and acidity are always prominent symptoms. When the disease commences at the pylorus, and implicates the valve, vomiting may be present from the first; but when the growth induces rigidity of the tissues, or merely involves the outlet by a process of extension, five months or more may elapse before the sickness becomes frequent. At first the attacks are only occasional, and chiefly occur during the night or after an unduly large meal; but with the progress of the complaint they become more and more frequent, until vomiting takes place every few days. At this period the sequence of events is somewhat as follows : loss of appetite and the discomfort that ensues after meals have induced the patient to restrict himself to liquid or semi-solid food, but even under these circumstances he suffers every second or third day from abdominal distension, acidity, and nausea. In order to procure relief he will often induce vomiting by inserting his finger down the throat; but very soon the symptoms culminate spontaneously in emesis, whereby the stomach rids itself of a large quantity of sour fermenting material. Comparative comfort is enjoyed for the next twentyfour hours, after which time the symptoms of maldigestion recur, to terminate once more in vomiting. Although intense nausea may be experienced, very little effort is required to evacuate the stomach, the process being one of gentle regurgitation, which is markedly favoured by a recumbent posture. Gradually the intervals of relief become shorter, until hardly a day passes without one or more attacks of emesis. This condition may persist until the end, or it may subside a few days before death owing to profound exhaustion and inability to take nourishment.

Subsidence of the vomiting at an earlier period may ensue either from sloughing of the growth which had caused the obstruction, or from the establishment of a fistulous communication with the intestine. The former is often accompanied by severe epigastric pain and diarrhoea, and sometimes by melaena or haematemesis, after which the patient experiences much relief. Should the orifice remain patent, this amelioration may continue for some time; but if the exuberant growth recurs the former symptoms gradually reassert themselves. The formation of a fistula is a late event in the disease, and the relief it affords is usually evanescent.

The ejecta in the cases of pyloric stenosis are very characteristic. The quantity varies from three-quarters of a pint to two quarts or more, and the semi-liquid material is dark brown in colour and possesses a sour, sickly, pungent, rancid, or even an offensive smell. When filtered the fluid is found to be acid in reaction, owing to the presence of lactic acid, but free hydrochloric acid is usually absent. Occasionally acetic or butyric acid may be detected in it. The residue upon the filterpaper consists of masses of undigested food and a large quantity of mucus. One of the most important features of the vomit is the appearance in it of some article of diet which had been swallowed at a distant date, such as date or grape skins, beans, peas, currants, corn, grape-stones, or orange-pips. In one of our cases some french beans were vomited in an unaltered state nearly four weeks after they had been eaten. Microscopical examination of the sediment reveals various kinds of debris, sarcinae, torula?, micro-organisms, red corpuscles, and occasionally minute particles of the morbid growth. Offensive vomit usually denotes putrefaction of the proteid constituents of the food, but in rare cases it arises from sloughing of the growth. A faecal odour indicates intestinal obstruction or gastro-colic fistula.

The periodic vomiting of pyloric stenosis is liable to be superseded from time to time by urgent and continuous sickness, which persists for several days and entirely precludes the administration of food by the mouth. This variety is usually due to an attack of subacute gastritis, caused by retention and decomposition of the food ; but occasionally it arises from peritonitis at the base of the growth, from kinking or twisting of the duodenum, or from secondary obstruction of the colon. In rare instances the impaction of undigested material or a foreign body in the contracted pylorus leads to a rapidly fatal termination.