or older; we must see if there is any difficulty in deglutition when partaking solid food, if a tumor is palpable, if the epigastric pain is more dull and continuous and not dependent upon taking food and not relieved by vomiting, if there is frequent fetid belching, if there is repugnance to meat. Advanced cases of gastric carcinoma are most easily recognized, but in beginning cases it is often almost impossible to find out. If there is a doubt, the contents of the stomach should be examined to determine whether they contain H.C1. If they do not, it is probably a case of carcinoma in an early stage.

To obtain the contents of the stomach for examination, the following method seems to be the best: Let the patient throw his head back slightly, open his mouth, push the soft rubber tube to the posterior wall of the pharynx without using your finger for guiding and ask the patient to swallow. The muscles of deglutition will grip the tube and it will pass without difficulty in the upper end of the esophagus and by gently pushing it will easily reach the stomach, the contents of which can then mostly be obtained by abdominal pressure.

In cases in which none of the symptoms are distinctly pronounced, but in which there is only a shadow of a doubt, we must be on our guard in making the prognosis. If we promise the patient relief and health and the case is a beginning carcinoma, the next physician who gets the case, and who is more cautious, will get the credit of having understood the disease at once, having told the patient that he could not help him much.

Cachexia is almost invariably a sign of carcinoma, but a cachectic appearance is seen in later cases of ulcer and cases of gastritis, but in the latter only if complications are present. After having excluded carcinoma we should carefully go over the case again and see if it could be gastric ulcer. Hemorrhages caused by gastric cancer occur almost invariably in the cachectic stage, never when the general appearance of the patient is good; but in ulcers of the stomach we often have severe hemorrhages when the gen

eral condition of the patient is good. In ulcer, the pain presents itself not as a continuous pain but usually in paroxysms and is often relieved by vomiting.

In palpitation of the epigastric region there can be detected invariably a point where pressure will cause sharp excruciating pain, while the same pressure on a place near this point may not produce any pain. The amount of H. Cl. is mostly increased in the contents of the stomach, and this is sometimes a valuable resource in the differential diagnosis.

If we have excluded the two most serious pathologic conditions, we may direct our attention to gastralgia which can occur at all ages. In this case there is no change in the taste of the mouth and the appetite is irregular; often hot sensations are experienced in the stomach which often change to cold; the pains can make their appearance at any time and in all forms and are frequently relieved by pressure on the stomach. The chemistry of digestion is not altered and epigastric pulsation is present. Vomiting may occur at times and consists sometimes of mucous masses, sometimes of the more or less digested contents of the stomach. Constipation is mostly present, but no fever. The main symptom of gastralgia is always the pain.

If we get a gastric disorder under our observation and feel confident after careful consideration that none of the three above-mentioned diseases are present, we can then with good conscience call the case chronic gastritis.

I do not want to say by this that all cases of chronic gastritis are pleasant for the physician, but that the prognosis is rather favorable. An examination of the contents of the stomach should be made in all these cases if opportune; and we will be able to help the patient in a great number of cases after we have ascertained as to whether the conversion of starch is more impaired, or the dissolution of the proteids. Seventy-five percent of these cases will readily yield to a rational treatment including the mechanical, dietetic and remedial resources that we have at our disposal today; which to outline does not come under the domain of my paper.

Absence of Gastric Juice-Its Significance
and Treatment

BY HENRY WALD BETTMANN, M. D., CINCINNATI
Member of the American Gastro-Enterological Society

Laboratory methods of diagnosis are making great strides in all departments of medicine. The general practician is beginning to make his own microscopic and chemical tests. The examination of the blood, sputum and urine is practiced now as a routine procedure by many progressive physicians. The study of the gastric juice is also becoming more frequent. The technic of all these examinations has become common property. It has now become of the highest importance to learn what all of these data, obtained so laboriously, actually signify. It is now understood, for example, that leukocytosis is a symptom, and must be studied with the other symptoms before its significance can be determined. Albuminuria is no longer considered a sure symptom of Bright's disease, but must be studied in its relationship to the other conditions present in the case. The same is true in regard to the gastric juice. The data obtained by chemical tests are symptoms only and must be interpreted with enlightened clinical insight before their meaning becomes clear.

The next great advance toward clinical perfection, therefore, will consist of an increased power to interpret with reasonable sureness all the data obtained by physical, chemical and microscopic methods.

Every practician who examines the gastric juice often will meet many cases in which the gastric contents give no reaction for free HCl. It was at first supposed that this absence of reaction was always a sign of cancer of the stomach. This view has been considerably modified since. Edinger in 1880 discovered that amyloid degeneration of the gastric mucosa may be characterized by absence of HC1. Fenwick, in 1887, showed that some cases of pernicious anemia are accompanied by atrophy of the gastric mucosa,

and later demonstrated that the atrophy may occur in cancer of different organs, e. g., the uterus, the breast, the bowel. Absence of HCl. from the stomach has since been demonstrated in some cases of diabetes mellitus, and cirrhosis hepatis; and Riegel has shown that it may follow gastritis of toxic origin. In all of these instances the underlying condition can usually be recognized without great difficulty, and only a careless examination would permit a pernicious anemia, or a cancer in some organ of the body to escape observation.

In daily practice absence of gastric juice is commonly found in one of three conditions: Cancer of the stomach, chronic gastritis, and that peculiar disease called by Einhorn "achylia gastrica." The special purpose of this paper is to call particular attention to this latter condition, which is by no means rare, but which has received by far too little attention by the profession.

Absence of gastric juice or achylia gastrica (to use Einhorn's term) should be carefully differentiated from anachlorhydria or absence of free HCl. The phrases have too often been used interchangeably at the expense of accuracy. We should not, in the strict sense of the word, use the term achylia except in those cases in which not only the HC1. but also the pepsin and labferment are wanting. In cases of true achylia the stomach contents removed one hour after a test-breakfast should give negative reactions for peptone, propeptone, HCl., pepsin and labferment.

In 1892 Einhorn suggested the term achylia gastrica for cases in which the stomach had apparently lost its power of secretion. This term has been somewhat grudgingly adopted, but its use has gradually become more and more general. I believe that the discovery of "achylia gastrica" as a distinct clinical entity, clearly to be differentiated from chronic gastritis and the above-named conditions, is a brilliant clinical achievement. It is true that chronic gastritis may terminate in atrophy of the gastric mucosa, and may then be confused with achylia, but this termination is cer

tainly uncommon, and the history and etiology will leave little doubt as to the nature of the case.

Achylia gastrica is characterized by a complete suspension of all gastric secretion. There is no HCl., no pepsin, no rennet; the bread crumbs of the test-breakfast ́undergo no visible change during their hour's stay in the stomach; the gastric contents when removed give no reaction for peptone or propeptone; they may be neutral or faintly alkalin or acid; the total acidity rarely rises above 4 or 6. Mucus is nearly always absent; there is no decomposition of the food, no smell, no fermentation, and no bacteria under the microscope.

This appearance of the gastric contents is so characteristic, and the chemical reactions so uniform, that confusion with other diseased conditions is hardly possible. It is important to know that "achylia gastrica" is a benign affection; that when uncomplicated it does not tend to end fatally; that the patient can usually be restored to comfortable, good health. The symptoms that accompany achylia may be few or many, or absent altogether; they may be localized in the stomach, or the stomach may apparently functionate normally, and the chief disturbance be in the bowels. The nutrition may be markedly or only slightly affected. In nearly all the cases I have seen the weight has been subnormal, and remains subnormal even after the patient's restoration to good health. A typical case is as follows:

L. M., aged 42, a manufacturer, of nervous temperament, was well up to July, 1902. He had never suffered previously from any gastric or intestinal disturbance. In July, 1902, he began to vomit a colorless, tasteless fluid about three hours after each meal. The vomiting was preceded by considerable nausea and malaise, and about 30 to 50 cc. was ejected. There was never any food in the vomited material, which was neutral or slightly acid in reaction. He lost weight and strength rapidly, being reduced from 130 to 115 pounds, and later to 110 pounds. He became nervous and as troubled with insomnia; he would often awaken at ht and vomit a small quantity of fluid. He was treated