61 This theory is elaborated by Senator ("Ueber Selbstinfection durch abnorme Zersetzungsvorgänge, etc.," Zeitschrift f. klin. Med., Bd. 7, p. 235).
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.62 The most distinctive feature in Kussmaul's group of symptoms is the accompaniment of the coma by a peculiar 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.
62 Deutsches Arch. f. klin. Med., Bd. 14, p. 1.
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.63 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.
63 Von Jaksch was the first to describe this form of coma in cancer of the stomach (Wien. med. Wochenschr., 1883, pp. 473, 512). He adopted the term coma carcinomatosum, and more recently coma diaceticum. L. Riess has reported seventeen cases of this coma occurring in a variety of diseases, such as pernicious anæmia, gastric cancer, gastric ulcer, tuberculosis, which all had in common profound anæmia. He proposes the term dyspnoeic coma (Zeitschrift f. klin. Med., Bd. 7, Suppl. Heft, p. 34, 1884). Senator has described two cases of gastric cancer with this coma. He uses the terms dyscrasic coma and Kussmaul's group of symptoms (ibid., Bd. 7, p. 235). In the cases described by Litten under the name coma dyspepticum, dyspnoea was absent, but Gerhardt's reaction in the urine was present. In Litten's cases structural disease of the stomach was not supposed to be present. The patients recovered from the coma (ibid., Suppl. Heft, p. 81).
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;64 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 cases anæmia is the most important factor in the production of this coma.65
64 Frerichs, Zeitschrift f. klin. Med., Bd. 6, p. 3.
65 Riess refers the coma to the anæmia as such, whereas Senator thinks that, in consequence of the depraved nutrition of the body resulting from the anæmia, some toxic substance is developed which enters the circulation.
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.