The depression that invariably accompanies the disease is very liable to pass into melancholia, which may be attended by suicidal tendencies. Less frequently delusional insanity develops during the course of the gastric complaint, or symptoms of acute mania suddenly manifest themselves. Among the 160 cases recorded by Dittrich, five were insane and two suffered from violent mania.
are met with in about 1.5 per cent, of all cases, and are principally due to metastases in the brain or spinal cord, thrombosis of vessels, or to direct invasion of the vertebral column by the morbid growth. Examples of the latter kind have been recorded by Brun, Lagrange, and others, in which destruction of the dorsal or lumbar vertebrae was attended by an intense girdle pain and by partial or complete paraplegia.
In 1886 Oppenheim and Siemer. ling drew attention to the occasional development of peripheral neuritis in carcinoma accompanied by profound cachexia ; and Klippel found degeneration of the nerves of the lower extremities in two cases of cancer of the stomach. More recently Auche and Miura have described typical examples of the nervous affection which appeared to have resulted from absorption of toxic substances from the diseased stomach.
It was formerly believed that tetany was solely encountered in cases of pyloric obstruction due to the cicatrisation of a simple ulcer, but Trevelyan has recorded an instance in which it attended a carcinomatous stricture of the duodenum, which had given rise to dilatation of the stomach.1
The principal feature of this interesting complaint is the occurrence of a tonic spasm affecting the voluntary muscles of the body. Its onset is usually quite sudden, and often follows an attack of vomiting or diarrhoea. In typical cases the elbows and wrists are partially flexed, the forearms strongly pronated, the fingers adducted and firmly bent over the thumbs, while the palms are hollowed by the approximation of the thenar and hypothenar eminences. In the lower limbs, the legs are rigidly extended, the soles of the feet turned inwards, and the heels drawn up. Considerable pain is often experienced during the continuance of the spasm and the affected parts are sometimes cold and blue. The condition of the superficial reflexes is variable ; but the deep reflexes are much exaggerated, and the muscles react more readily than usual to the interrupted current. Sometimes an attack may be induced by percussion of the epigastrium, by the administration of an enema, or by compression of the main artery of a limb.
1 See Author's Ulcer of the Stomach and Duodenum, p. 311.
The other phenomena associated with this condition are neither uniform nor of great importance. The pupils are often contracted during the attack, but they still react both to light and accommodation. Severe headache is a frequent cause of complaint, and occasionally profuse perspirations are observed. Retention of urine occurs in the majority of the cases, and when the fluid is drawn off by a catheter it is often found to contain a trace of albumin. Sugar and acetone are occasionally detected in it. Cutaneous sensibility rarely undergoes any noticeable alteration, but in a few instances temporary hyperesthesia or anesthesia has been observed. The pulse is full and regular, the breathing quick and shallow, and the face and extremities usually show signs of cyanosis. The temperature is often depressed at first, but in fatal cases it usually rises, and may reach 109° F. before death. The intellect generally remains unaffected.
In almost every instance the first attack is followed within a short time by several others, but occasionally the initial seizure is separated from the second by an interval of several weeks. The actual duration of the spasm is also liable to considerable variation; in some instances it lasts from five minutes to several hours, while in others it remains almost constant for three or four days.
Occasionally the condition of simple tetany is complicated by the occurrence of general convulsions, which affect the muscles of the neck, jaw, back, and face. The attacks are intermittent and last from a few minutes to half an hour, disappearing as suddenly as they commenced, and leaving the muscles in a state of semi-rigidity. During their continuance the patient is unable to open his mouth or to swallow, and sometimes suffers from opisthotonos. This form of convulsions must therefore be regarded as a species of tetanus. Finally, in a small proportion of the cases the initial tetany is followed by convulsions that are indistinguishable from epilepsy. Gastric tetany is a very dangerous complaint, and is probably always fatal when it attacks the subjects of carcinoma. It appears to be due to the absorption into the general circulation of some toxic substance generated in the dilated stomach.