arsenic may be required by anemia. The infusion of condurango seems to be the most beneficial bitter. Small doses of the bromids (sodium or strontium) often undoubtedly do good for a short time. It may be advisable or necessary to use soporifics. The constipation is best treated by massage, oil or glycerin injections, electricity, and a proper diet. The common practice of frequently irritating the stomach with socalled reconstituent drugs can not be too strongly condemned in the management of neurasthenia gastrica.

The etiological treatment should receive careful consideration. Enteritis, intestinal irritation (tape- or other worms), enteroptosis, movable kidney, anemia, disease of the genital or urinary organs, associated gastric troubles (particularly gastroptosis), and whatever has prepared the soil or occasioned the genesis and aided the evolution of the affection, should have proper attention, in keeping with a fundamental principle of therapeutics.

CHAPTER V.

MYASTHENIA GASTRICA.

MYASTHENIA (ę, muscle, and à0veía, weakness) gastrica is a dynamic affection of the stomach, characterized by diminution of the elasticity and strength of its muscular layer. The stomach does not empty itself within the normal period, and is distended more easily by its contents, on which it retracts with less than its normal force. Myasthenia is primarily and essentially an independent dynamic affection of the stomach. Pathologically, many claim for it a place among the nervous affections of the organ. The nervous system may play a part in its genesis, but essentially it is a muscular affection. The muscle is everything, and is insufficient because it is weak or degenerated.

In its course the disease may pass through all degrees of motor insufficiency, varying from a slight deviation from health to absolute gastric retention. Clinically, the evolution of the disease may be divided into two periods: the one being characterized by stagnation, the stomach slowly emptying itself completely between meals or during the night only; the other by retention, the stomach always containing food.

Etiology. Myasthenia is the most frequent dynamic affection of the stomach, occurring regardless of sex and at all ages.

The predisposition to the disease may be hereditary, persons being born with weak muscles as with weak nerves or mucous membranes. Whole families may have it, yet it may be impossible to attribute it to a common dietetic error or mode of life or to other common pathogenic influences. The causes of myasthenia are exceedingly numerous, and it is very difficult to determine precisely its relation to heredity. The very frequent occurrence of the disease in families possessing an undeniable hereditary taint-the neurotic, the arthritic, and in families afflicted with the series of diseases characterized by slow and imperfect catabolism-would seem to indicate that a myasthenic predisposition may be inherited. The disease is more frequently acquired, and it is rare that a myasthenic person can pose with much show of reason as a victim of heredity. A mild, and often a temporary, form is produced by mental fatigue and by depressing moral causes. The shock of fear, of accidents, or of grave misfortune may be the cause of the relaxation of the voluntary and involuntary muscular systems; and myasthenia gastrica can be thus produced, particularly if the shock comes during gastric digestion. Prolonged mental and physical fatigue can have the same result. But myasthenia gastrica produced in this acute manner is most frequently mild in degree, and recovery may be rapid; but under conditions favorable to its further development the disease may become progressive and serious.

Myasthenia gastrica is an almost constant sequel of severe acute diseases. During convalescence, when the appetite represents more closely the needs of nutrition than the functional power of the stomach, the weak organ is often overloaded, and the gastric myasthenia frequently persists in spite of the improvement in the general strength and in nutrition. Typhoid fever, influenza, and diphtheria deserve particular mention in this connection, though many other adynamic diseases leave the stomach in the same condition.

Many chronic diseases are predisposing or efficient causes. It is one of the gastric affections of the initial stage of pulmonary tuberculosis. Diseases of the heart, of the lungs, and of the liver, accompanied by congestion of the portal circulation, often cause myasthenia gastro-intestinalis. It is very common in gout, in uricemia, in biliary lithiasis, in diabetes, in severe anemias, and after severe hemorrhages. All dis

eases accompanied by malnutrition or subnutrition are predisposing causes.

Myasthenia may be a complication of many of the diseases of the stomach, and its development renders the situation much more serious. Among the many causative gastric diseases may be mentioned chronic gastritis (chiefly hypersthenic form), displacements of the stomach, and carcinoma.

The disease may also be caused by dietetic errors, particularly intemperance in eating and drinking, the overtaxed gastric muscle becoming fatigued, insufficient, and less retractile. Very large and bulky meals, large quantities of effervescent drinks, large drafts of water in summer, rapid and excessive beer-drinking, and the drinking of large quantities of hot water or of mineral waters are common errors, which, repeated often, may directly produce myasthenia. Myasthenia, according to its severity, may be accompanied by stagnation or by retention of the gastric contents.

1. MYASTHENIA WITH STAGNATION.

Clinical Description.-Myasthenia with stagnation is very variable in its severity. The degree of stagnation measures precisely the degree of myasthenia. The period of gastric digestion (which naturally varies with the quality and the quantity of the meal) may be but slightly prolonged, or the stomach may get a short rest only in the early morning. Two forms should be clearly separated, the one being mild and the other severe. In the mild form of stagnation myasthenia the stomach is empty later than it normally should be, but the evacuation of the contents of the stomach is complete between meals. In the severe form of stagnation myasthenia the stomach is not empty before the midday nor before the evening meals, but is empty for a short period before breakfast. The inability of the stomach to evacuate its contents during the twenty-four hours characterizes the retention form of myasthenia, in which form the stomach always contains food under the circumstances imposed by ordinary dietetic customs. Both mild and severe stagnation myasthenia may be latent, the disease being expressed only by its physical signs. The stomach empties. itself later than in health, remains flaccid, as evidenced by splashing, throughout the digestive period, and distends excessively under the weight of a moderate quantity of contents. The balance of nutrition is maintained, but it is impossible to increase the weight of the body. The patient

does not complain, but is exposed to digestive disorder when a very large meal is eaten, or when the usual quantity of food is taken while the body and mind are fatigued.

This latent period may last a number of weeks, or even years, before the clinical period develops. This is the common mode of development when the predisposing cause is heredity, or when the myasthenia follows acute or chronic disease, or when it is due to faulty digestive hygiene. The clinical period may appear suddenly, after shock or depressing emotions, or physical or mental fatigue, or after a dietetic

error or excess.

The symptoms of the clinical period are digestive, the short intervals when the stomach is empty being passed without discomfort. Soon after food is taken the stomach feels full and heavy, and the air swallowed and the carbon dioxid set free from the carbonates of the food and the saliva by the secreted hydrochloric acid distend the stomach, often to such a degree that the clothing must be loosened. The gas is removed by frequent belching, bringing with it often a little fluid into the esophagus or mouth; and this is one of the most constant symptoms of the trouble. The distention of the stomach is thus diminished, but the sensations of weight and fullness only gradually disappear as the stomach lazily empties its contents into the duodenum. If the meal be large the gastric distress may become greater and greater, until the stomach empties itself by copious vomiting, after which there is no more trouble until another meal is eaten. The duration and the intensity of the symptoms are dependent on the quantity of food eaten, and in the mild cases the symptoms may appear only after the chief meal. In the severe form the muscular elasticity is still further diminished, and the discomfort may occur after each meal, and may, indeed, sometimes be produced by drinking a glass of water. The appetite, which is usually good before meals, may be quickly satisfied. A symptom of differential value is the relation of the gastric symptoms to the quality of the food, the symptoms being excited by both fluid and solid food, fluids often producing as much distress as an ordinary mixed meal. This symptom is exceedingly rare. other uncomplicated disease of the stomach. Such is the simple form of stagnation myasthenia, characterized by digestive symptoms in close relation with the quantity and the fluidity of the food; by belching and regurgitation; by a mere maintenance of the balance of nutrition; by physical and mental exhaustion after moderate exercise or effort; and by the physical and functional signs of myasthenia.

But the disease does not always remain so mild and simple. The stagnation is a favorable condition for fermentation, and the regurgitations may have the odor and taste of organic acids; but we would particularly emphasize the fact that fermentation is rare even in the severe form of stagnation myasthenia. In some cases, however, it does occur irregularly and intermittently. To the symptoms already enumerated may be added gastralgia, pain, often nausea and vomiting, headache, sometimes insomnia, and mental, moral, and physical depression, vertigo, peripheral and central disorders of the circulation, erythema, urticaria, slow and labored action of the heart, with a reduplication of the second sound.

In consequence of the prolonged sojourn of the contents in the stomach (and, rarely, of fermentation), the gastric glands may become irritable, and secretion may continue for a short time after the evacuation of the chyme into the intestines, or there may be simple hyperchlorhydria. This condition is expressed by gastric pain, hydrochloric heartburn and pyrosis, thirst, and sometimes a sharp appetite and headache. In still other cases the secretion may become continuous during the day, and the uninterrupted irritation may produce the hypersthenic form of chronic gastritis, which is a most serious sequel of myasthenia.

In stagnation myasthenia the bowels are usually constipated, but when myasthenia intestinalis (a common complication or association) becomes well marked, the whole clinical aspect of the case is changed. The nervous and constitutional symptoms (attributed wrongly by some authors to gastric auto-intoxication) appear; and there is constipation, insomnia, headache, neurasthenia, oligocythemia, chlorosis, disorders of the circulation, and hepatic congestion. The intestinal myasthenia may become the most prominent trouble and be manifested by periodical colalgia, localized colitis, spasm alternating with localized dilatations, intestinal supersecretion, and the discharge of muco-albuminous membranes infected with bacteria. When the intestines become involved malnutrition begins, and may lead to extreme emaciation and intestinal cachexia.

The preservation of the strength, the weight, and the appearance of good health is a marked characteristic of simple myasthenia gastrica with stagnation. The disease itself has no influence on general nutrition, the food being eventually as well utilized as in health. If emaciation occurs, it is due to an insufficient or an improper diet or to a complication. The symptoms being digestive, and increasing in pro