system, in chlorosis, in anemia, in the arthritic, and in the neuropath. Gastric hyperesthesia may be the first and only symptom of uremia. It may be a monosymptom of hysteria or may coexist with other manifestations of this psychosis. It may be excited by irritant foods and drinks, by tea, coffee, tobacco, excesses in venery, onanism, and masturbation. It is a common sign of narcotic drug habits, and may be produced by chloroform narcosis. It is a symptom of absinthe alcoholism, is not rare during convalescence from exhausting diseases, sometimes precedes and sometimes follows gastralgia nervosa, and may be induced by prolonged fasting and by the protracted use of an exclusive and insufficient diet. Hyperesthesia gastrica is a common result of an insufficient or exclusive diet, but the basis of the trouble is most frequently a neuropathic or an arthritic soil.

Clinical Description. In the mild form, immediately after the introduction of food there is a peculiar uneasiness and discomfort, a feeling of local irritation, and tingling, shooting pains. These symptoms continue throughout the period of digestion, and disappear with the evacuation of the stomach.

In the well-developed form the contact of food produces immediate pain, which, when severe, may excite nausea and vomiting. The symptoms are excited alike by fluids and by solids; indeed, fluids containing an excitant seem to produce a more diffused pain. The pain, often preceded and accompanied by a sensation of weight and fullness, continues throughout the period of gastric activity; and nausea, a sensation of cold and heat, conscious gastric arterial pulsation, and vomiting convince the patient of the existence of a very serious organic disease. When water is introduced through the tube into the stomach, retching and vomiting are immediately and almost invariably excited. Through fear of pain, one article of food after another is refused; through vomiting the supply of nutriment may be reduced below the needs of nutrition, and emaciation may become progressive. There may be no emaciation, or there may be emaciation proportionate to the quantity of food lost by vomiting and to the insufficiency of the diet. Gastric hyperesthesia is the forerunner of anorexia nervosa and of habitual vomiting.

During the period of gastric repose there is often a sensation of emptiness, often decidedly unnerving and unbearable, and associated with slight vertigo and faintness. A peculiar form of hyperesthesia gastrica is manifested by short, painful paroxysms (fifteen to thirty minutes), which occur as soon as the stomach becomes empty. The pain may be relieved by

food, but it is not relieved by soda, the sodium chlorid formed increasing the pain and often exciting nausea. It is probable that the pain is produced by the action of free HCl on the oversensitive gastric mucosa, secretion continuing after the evacuation of the contents of the stomach into the duodenum. In some cases sensation is dissociated, either in the periphery or in consciousness. There may be a morbid sensibility to slight changes in the temperature of the food, the painful impression of contact being momentarily less pronounced; or the gastric contents may produce now a sensation of cold, now burning, now pain, and these sensations are sometimes spontaneous and perceived when the stomach is empty.

In hyperesthesia gastrica the skin over the epigastrium is often very sensitive. Deep pressure reveals the morbid sensibility of the whole stomach, there being no circumscribed painful points. The area of diffused tenderness is sharply limited and corresponds closely with the size and form of the stomach. By moderate vertical pressure with the fingers the size and position of the stomach may frequently be determined with exactness.

The secretory function of the stomach is normal. The contents, after the test-breakfast, reveal normal chemical, microscopical, and bacteriological signs. There may be inconstantly a small excess or a slight diminution of free HCl, which may be plausibly explained by the accompanying vasodilatation.

Diagnosis. The pain due to contact, and occurring immediately and invariably after the ingestion of food, or as soon as the stomach is empty, and with the associations detailed in the clinical history, and with the normal functional signs, leave little room for doubt as to the nature of the trouble. The etiology may also aid in the diagnosis. The pain is excited by the contents of the stomach-the food, digestive products, and the free hydrochloric acid. Consequently the symptoms are digestive, occur regularly, and for a number of days or weeks after meals, or at the moment when the stomach first becomes empty. Hyperesthesia gastrica, consequently, differs widely from the paroxysms of gastralgia nervosa.

Differential Diagnosis.-The only diseases likely to be confounded with hyperesthesia gastrica are atypical ulcer, adenohypersthenia gastrica, and hypersthenic gastritis. In adenohypersthenia and in the hypersthenic form or stage of gastritis, the pain does not occur so soon after the ingestion of food, and the stomach only becomes intolerant toward the height of secretion. The pain is also in strict relation

with the quality of the food, and is relieved by albuminous foods and by alkalies. In hyperesthesia the pain is immediate, and is due to contact and not to functional excitation, and is produced by all sorts of food. The abnormal chemical signs characteristic of functional and organic adenohypersthenia are absent.

Ulcer may be manifested only by pain, but the ulcer pain has distinctive features. Cases where the pain does not occur immediately after taking food present no difficulty. But hyperesthesia may be a complication of ulcer. Even in the absence of the characteristic relations of the pain of ulcer to the quality of the food, to the evolution of secretion, to the movements and repose of the body, and even in the absence of the characteristic circumscribed epigastric and dorsal pressure-points the abnormal functional signs of ulcer would still be conclusive. Both diseases are frequent in the same class of patients, and if there is doubt after weighing all the signs, the case should be treated as ulcer.

Treatment. It is best to put these patients at once to bed. The more absolute the repose of body and mind, the more rapid will be the cure. Sedative galvanization, applied as in the treatment of gastralgia, but with the current of very low density-as two milliamperes with an electrode 100 sq. cm., daily sittings. A cold compress (Winternitz's compress is the best) should be kept constantly over the abdomen. Nitrate of silver is the best medicine, and often acts with remarkable efficiency. One grain shouldbe dissolved in two ounces of distilled water, and one or two teaspoonsful should be given three times a day on an empty stomach. It is often unnecessary to continue the drug longer than two or three days. A more efficient method is to spray or douche the stomach with a solution of nitrate of silver. In our experience, the bromids do no good.

The diet should be non-exciting and indifferent in its physiological action on the stomach. For a short period a pure milk diet or milk and lime-water should be employed; as soon as the pain is controlled, cereal gruels, soft-boiled or poached eggs, and meats, vegetables, and other foods should be added, in the order given in the chapter on Diet (Section III, chap. 1). Or it may be best to employ exclusive rectal feeding for a few days.

The etiological treatment will demand attention, and consists in medication directed against the hysteria, anemia, chlorosis, neuropathic or arthritic constitution, and the correction of excesses and of bad habits.

CHAPTER II.

THE DYNAMIC AFFECTIONS OF SECRETION.

SOME authors deny the existence of persistent disorders of secretion which are not produced by an anatomical lesion of the gastric mucosa, and the majority of writers consider all the dynamic affections of secretion to be neuroses. In our opinion both these contentions are erroneous. There is no doubt that persistent abnormalities of secretion are frequently functional signs of the anatomical diseases of the stomach. No one will deny that secretion may be disturbed through the nerves which control it. Prolonged study and careful investigation have led us irresistibly to the conclusion that the disorders of secretion are not always due to an alteration of the mucosa or to a neurosis of the vagosympathetic system.

It is, furthermore, the custom to describe a very special condition of the stomach as a distinct disorder of secretion, or neurosis of the stomach. This condition has been named ".continuous secretion," or gastrosuccorrhea, or Reichmann's disease, and it may be either periodical (gastrosuccorrhea periodica) or continuous (gastrosuccorrhea continua chronica). We are unable to convince ourselves that continuous gastrosuccorrhea exists as a dynamic affection. This condition of secretion may be met with as an episode in obstruction of the pylorus, in myasthenia with secretory irritation due to the retention of the contents of the stomach, or in the hypersthenic form of chronic gastritis. It is not a distinct morbid entity, but is a special symptom-a mere complicating condition. Continuous secretion, in our opinion, is not a severe form of supersecretion without an anatomical lesion of the mucous membrane, nor is it a delayed reaction of the secretory nerves to the excitation produced by the meals. The normal stomach does not secrete when it is empty, and, at most, only 10 to 20 c.c. of gastric contents can be removed when the tube is introduced into the normal stomach in the early morning before breakfast; but sometimes when the tube is introduced at this time (even when the stomach has been thoroughly washed out the evening before and left empty) it will be found that the stomach contains much more than 20 c.c. of a liquid rich in hydrochloric acid

and the digestive ferments. This is considered the characteristic functional sign of continuous secretion. The sign exists, but we maintain that its interpretation is wrong. The secretion has merely accumulated in the stomach (myasthenia, pyloric obstruction), or it has been formed as a result of hypersthenic gastritis, or, in case the stomach has not been washed out, it may have been excited by retained food and digestive products. The evening lavage, or lavage followed by a few days of rectal feeding, or the water test, considered in combination with the clinical history and with the other objective signs, will reveal the cause of the gastrosuccorrhea and demonstrate its non-existence as a dynamic affection of the stomach. It is always due to retention, or to hypersthenic gastritis, or to both.

Unfortunately, the words in common usage are unsuitable for designating the dynamic affections of secretion. Superacidity (or the mongrel word, hyperacidity) denotes abnormal increase of the acidity of the contents, whether it be due to hydrochloric or to organic acids. Hydrochloric superacidity is more exact, but the term is also used to denote the functional sign of certain anatomical diseases of the stomach. The same objections apply to subacidity. Supersecretion denotes an increase of the quantity of secretion, whether it be a particular morbid process or a functional sign. Hyperchlorhydria and hypochlorhydria denote a pathological increase or decrease of hydrochloric acid in the filtrate of the gastric contents at the acme of digestion, and do not embrace all the secretory disturbances which are found in the two classes of the dynamic affections. In order to avoid confusion and to embody an exact conception of their nature, we shall divide the dynamic affections of the stomach into two large classes, and describe them, in keeping with references in other parts of this book, as adenohypersthenia gastrica (aðýýív, gland, nép, excessive, and vos, strength; excessive glandular activity) and adenasthenia (à, a, and vos) gastrica. These terms denote the morbid processes which are manifested by the disturbances of secretion, and stand in clear relief with the similarly formed terms, myasthenia gastrica and neurasthenia gastrica.

1. ADENOHYPERSTHENIA GASTRICA.

Adenohypersthenia gastrica is a dynamic affection characterized by the secretion of a gastric juice which is abnormally