Part 92

Depression of spirits, lack of energy, headache, neuralgia, sleeplessness, and vertigo are functional nervous disturbances which are often the result of disordered digestion from whatever cause, and are therefore not uncommon in gastric cancer. The theory that these symptoms are due to the absorption of noxious substances produced in the stomach and intestine by abnormal digestive processes is plausible, and more intelligible than reference to some undefined sympathy between the digestive organs and the nervous system.

The intelligence is generally not impaired in the course of gastric cancer.

Considerable interest belongs to coma as a symptom of cancer of the stomach, and more particularly to the occurrence of coma with the peculiar characters which have been described by Kussmaul as distinguishing diabetic coma. The most distinctive feature in Kussmaul's group of symptoms is the accompaniment of the coma by a peculiar {555} dyspnoea in which, without evidence of disease of the lungs or air-passages, the respirations are strong and deep and often attended with a groaning sound in expiration. The breathing is either normal in frequency or oftener moderately increased. The pulse is usually small and frequent. The temperature is not much elevated, and sometimes is much below the normal. Sometimes the coma is preceded by a period of excitement, with restlessness, and perhaps with screaming. Gerhardt's reaction in the urine may or may not be present. When it is present in a marked degree there is often an aromatic, chloroform-like odor to the breath and to the fresh urine. The patient may come out of the coma, but in the vast majority of cases the coma terminates fatally.

It is now known that this dyspnoeic coma is not confined to diabetes mellitus, but that it occurs also in gastric cancer and in various other diseases. Its occurrence in gastric cancer is rare. In this disease it does not usually appear until anæmia is far advanced, but it may occur in cases of cancer in which the patient's general health and nutrition are still fairly good. I recently made the post-mortem examination of an elderly man, fairly well nourished, who was found in the streets comatose and brought in this condition to Bellevue Hospital, where he died in about twelve hours. While in the hospital his breathing was increased in frequency, forcible, and deep. His temperature was normal. The urine contained a small quantity of albumen, but no sugar. No previous history could be obtained. Uræmic coma was suspected. At the autopsy was found a large, soft, ulcerated cancer of the lesser curvature and posterior wall of the stomach near the pylorus. The kidneys, brain, heart, and other organs were essentially healthy.

We possess no satisfactory explanation of this form of coma. In diabetes it is considered to be due to the presence in the blood of some intoxicating agent. For a time this agent was thought to be aceton; it is now believed by Von Jaksch to be diacetic acid. Much stress has been laid upon the aromatic, fruity odor of the breath and of the fresh urine, and upon the presence of some substance in the urine which imparts to it a burgundy-red color upon the addition of liquor ferri chloridi (Gerhardt's reaction. See changes in the urine, page 551). Although the whole aceton question is at present in a very confused state, there is no proof that aceton or its allies possesses the toxic properties assumed by this theory; and it is certain that dyspnoeic coma may occur in diabetes and in other diseases without the presence of Gerhardt's reaction in the urine. It is also true that this reaction often occurs without any clinical symptoms referable to it. Riess and Senator believe that in non-diabetic {556} cases anæmia is the most important factor in the production of this coma.

Coma, probably belonging to this same variety, may occur in gastric cancer without the peculiar dyspnoea which has been described. There is reason to believe that this dyspnoea is not a necessary symptom of the so-called diabetic coma.

Chronic Bright's disease terminating with uræmic coma is an occasional but not frequent complication of gastric cancer.

Coma and other cerebral symptoms may be produced by secondary cancerous tumors in the brain.

Stupor deepening into coma may develop during the often-prolonged death-agony of gastric cancer.

The distribution, origin, and frequency of cancerous growths secondary to gastric cancer are most conveniently considered under Pathological Anatomy. Symptoms referable to certain localizations of these secondary cancerous deposits, however, are so common, and so interwoven with the clinical history of cancer of the stomach, that it is desirable to consider some of these symptoms in the present connection.

Cancer of the liver is the most important of these secondary cancerous growths. It is estimated to be present in nearly one-third of the cases of gastric cancer, but by no means in all these cases does it produce symptoms. As a rule, the earlier hepatic cancer forms in the course of gastric cancer the more likely is it to be attended by symptoms. The most important symptoms of secondary cancer of the liver are enlargement of the liver, peritoneal exudation, and persistent icterus. When nodular growths can be felt in the free border or surface of the liver, the diagnosis is generally easily established. Sometimes the liver remains of normal size or is even contracted, and then the diagnosis is difficult or impossible. Ascites or exudative peritonitis is present in about one-half of the cases of cancer of the liver. Jaundice is less frequently present. It is only persistent jaundice which aids in the diagnosis of hepatic cancer.

The various combinations of gastric cancer with secondary hepatic cancer may be clinically grouped as follows:

1. Symptoms of gastric cancer with latent hepatic cancer.

2. Symptoms of gastric cancer followed by symptoms of hepatic cancer.

3. Symptoms both of gastric cancer and of hepatic cancer present when the case comes under observation.

4. Symptoms of hepatic cancer with latent gastric cancer.

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 {557} 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. 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. 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.

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 {558} 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 (3-1/3 per cent.). 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. 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.). 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. 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. 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.

{559} As a rule, patients with gastric cancer die from gradual exhaustion. In a condition of extreme emaciation and feebleness the patient sinks into a state of collapse, accompanied often with stupor, sometimes with mild delirium. The death-agony is prolonged frequently from twelve to twenty-four hours, and sometimes even longer. On the other hand, death may occur somewhat suddenly in the last stages of gastric cancer, and without satisfactory explanation.

Death from copious gastric hemorrhage does not occur probably in more than 1 per cent. of the cases of cancer of the stomach.

In the rare cases of death from perforation of the stomach the patient is sometimes so exhausted at the time of perforation that the occurrence of this accident remains unrecognized in the absence of any complaint of characteristic symptoms.

The coma which sometimes leads to the fatal termination of gastric cancer has already been sufficiently considered.

Finally, death may be the result of certain complications more or less dependent upon the cancer. Of these the most important are suppurative peritonitis and pulmonary complications, particularly oedema, terminal pneumonia, and embolism of the pulmonary artery.

DURATION.--It is evidently impossible to determine the exact duration of a cancer of the stomach. Doubtless in all cases there is a period of growth of the tumor before it produces symptoms, and the duration of this latent period can never be determined. When symptoms appear they are often at first so mild as to be readily overlooked, and so ambiguous that even if recognized they are not clearly referable to the cancer. Gastric symptoms may have preceded, perhaps for years, the development of the cancer, so as to lead to the assumption of a longer duration of the cancer than is really the case. Estimates, therefore, of the duration of gastric cancer can be only of limited value.