Paralysis affecting the face or one side of the body was observed in 2 per cent, of our cases, and was caused either by ordinary cerebral haemorrhage, a metastatic growth in the brain, or by thrombosis of the basilar or middle cerebral arteries.
Insomnia is a frequent cause of complaint, especially towards the termination of the disease, and may be attributed partly to nocturnal attacks of pain, and partly to the cerebral anaemia that ensues from the general malnutrition. The delirium which is sometimes observed during the last few weeks of life is also probably due to the latter condition.
In contrast to the optimism displayed by the subjects of tuberculosis, mental depression is an invariable feature of gastric carcinoma, and usually induces the patient to take a serious view of his complaint long before the development of special symptoms suggests to his medical attendant the possible existence of malignant disease. Persons who possess an hereditary predisposition to phthisis or mental disorders not infrequently develop actual melancholia or suffer from delusional insanity. We have known several cases where the mental aberration was so pronounced as to necessitate the employment of special attendants or removal to an asylum. If these phenomena appear at an early stage of the disease, they often mask the gastric affection and occasion serious errors of diagnosis. Excessive pain accompanied by insomnia sometimes induces attempts at suicide. The occasional development of tetany and spinal paralysis will be discussed among the complications of the disease.
Certain cases, and especially those where the growth is extensive, the anaemia profound, and vomiting an infrequent symptom, exhibit a peculiar form of coma during the final phase of the disease. This phenomenon, to which the term ' coma carcinomatosum ' has been applied, was first described by Petters and Kaulich, and later by V. Jaksch, Riess, and Senator. According to our experience it is usually preceded by rapid failure of strength, disappearance of appetite, a fall of temperature, and occasionally by severe retching and vomiting. The patient lies motionless in bed and in a state of profound lethargy, from which he can at first be temporarily aroused, but which is soon transformed into genuine coma. In this condition the breathing is quickened, and is characterised by deep inspirations, followed by long sighing expirations. The pulse is small and of low tension, and varies in frequency from time to time. The pupils are slightly dilated, the tongue is dry and often covered with aphthae, and the surface of the body is cold and blue. The urine is retained, and the quantity secreted is greatly diminished. Occasionally the sweet smell of acetone may be recognised in the breath. Slight attacks of convulsions are sometimes observed. The duration of the coma varies from twenty-four hours to several days, but after it has become profound life is seldom prolonged more than three days. In those cases which display an extreme somnolence rather than actual coma, the patient may continue in a lethargic state for ten days, or even longer, provided that the warmth of the body and the nutrition are satisfactorily maintained. In one instance which came under our care the patient remained unconscious and unable to swallow food for seventeen days. Death usually occurs quite suddenly from failure of the respiration.
The great similarity between this form of coma and that which attends diabetes seems to indicate that it also arises from auto-intoxication. The acetone smell in the breath and the occurrence of oxybutyric acid in the urine in both forms of coma are of special interest.