In the diseases accompanied by subacidity the diminution of the acidity of the urine is less than in health, and in the diseases accompanied by superacidity the diminution is greater than in health. If the superacid gastric secretion be removed by vomiting or by lavage, the diminution is still more marked, and the total urine of the twenty-four hours may be milky (phosphates), alkaline, and poor in chlorids. Gastric phosphaturia is found in chronic hypersthenic gastritis, adenohypersthenia gastrica, and in the other diseases of the stomach accompanied by superacidity or by supersecretion, whether they are or are not associated with stagnation, or retention, or vomiting.

V. INFLUENCE ON THE HEART AND CIRCULATION.

If it be borne in mind how fine and complex is the mechanism of the circulation, how numerous are the influences which control or alter the caliber of the arterioles and the action of the heart, it should cause no wonder that the heart is frequently disturbed by the pathological reflexes and the mechanical compression of an organ so closely situated and so intimately connected with it by an almost common nervesupply as is the stomach. Normal digestion increases the frequency and strength of the heart-beats, and strong excitation of the mucous membrane of the stomach makes the heart's action slow. The close anatomical and physiological relationship would seem to furnish good grounds for expecting the diseased stomach easily and frequently to disorder the heart's action. This natural expectation is only in part fulfilled by clinical observation.

Tachycardia of gastric origin is so rare that we do not remember to have seen a case. The pulse may be frequent in diseases of the stomach accompanied by fever or by an inflammatory complication, and a weak heart may be excited by normal or by pathological digestion. But the normal heart beats no more frequently in the afebrile or simple diseases of the stomach than it does in health. Moreover, a symptomatic increase of the frequency of the pulse does not constitute tachycardia, for it is essential that the neuromuscular apparatus be disordered. Arrhythmia, allorrhythmia, and asymmetry are equally as rare as gastric tachycardia, though they may occur in association with other disturbances of the heart of undoubted gastric origin. It may be possible for a disease of the stomach to produce these disturbances in

either their paroxysmal or habitual forms, but it would seem wise to ignore the possibility until better proof of their causation is given than we have been able to find. Gastric bradycardia, however, is the most common form of the slow heart. The heart-beats sometimes fall as low as 35 or 40 to the minute, but the milder form with 50 or 60 beats a minute is most frequent. The bradycardia may occur in paroxysms and be accompanied by weak action of the heart, as shown by a small pulse, pallor, cold extremities, fainting, and by loss of consciousness in severe cases; it may be intermittent, the paroxysm occurring in connection with gastric digestion or with an exacerbation of gastric irritation; or it may become chronic and habitual. It is sometimes observed in neurasthenia gastrica, but it is most common in myasthenia and obstructive retention, in ulcer, in the painful paroxysms of hypersthenic gastritis, and in gastroptosis, particularly when the gastroptosis is accompanied by retention, by neurasthenia, and by low abdominal tension.

Nervous palpitation may be the expression of a disease of the stomach, and, indeed, in either its subjective or its objective form. The subjective form is characterized by normal heart action, the complaints of the patient being due to hyperesthesia of the sensory nerves of the heart. This pseudopalpitation occurs sometimes in ulcer, adenohypersthenia gastrica, chronic hypersthenic gastritis, and gastralgia, the epigastric cutaneous nerves being at the same time hyperesthetic. Objective palpitation is characterized by perceptible overaction of the heart, the frequency of the heart-beats being commonly increased. The palpitation may have in the disease of the stomach its all-sufficient cause or only the occasion of the attack. The diagnosis of the cause of palpitation may present almost insuperable difficulties, but the source of the trouble may be located in the stomach by exclusion of the diseases of the heart and blood-vessels, and of other diseases and habits (morphinism, alcoholism, abuse of tobacco, excesses in venery, etc.) which may produce it, by the close relation of the attacks to gastric digestion, and by its control or cure under treatment of the disease of the stomach with which it is associated.

Gastrocardiovascular Symptom-groups.-A well-defined cardiovascular symptom-group of gastric origin is sometimes met with in neurasthenic or nervous patients, between the ages of twenty and forty years, who suffer from bulimia, adenohypersthenia gastrica, myasthenia gastrica, or neurasthenia gastrica. The trouble is always paroxysmal in its

first stages. The attacks, which begin and end suddenly, last from a few hours to two or three days. Usually, during the night or soon after rising in the morning, a sense of oppression and fullness is felt in the epigastrium, the heart palpitates, the pulse becomes irregular, and the patient is suddenly seized with great anxiety. The heart feels overdistended and flutters, and the abdominal aorta palpitates strongly. The patient is weak and depressed, cardiac dyspnea is marked, but there is no precordial pain and no headache. The attacks recur after varying intervals, or the trouble may become continuous and chronic, with constant epigastric distention, dyspnea, bulimia, and anxiety which is likely to produce hypochrondriasis. The disease affects almost exclusively men, and chiefly brain-workers, the attacks recurring after eating an acid or some particular fruit or food. The whole trouble seems to be produced by a reflex from the morbid mucous membrane of the stomach affecting the vagosympathetic, and probably also the vasomotor, nerves. In the severe attacks the arterioles are constricted and the left heart is dilated. During the intervals between the attacks the heart and circulation are normal. The cardiovascular paroxysms can be controlled by the proper treatment of the disease of the stomach.

Another well-defined gastrocardiovascular symptom-group, produced by a disease of the stomach, affects the arterioles of the lesser circulation and causes dilatation of the right side of the heart (Potain). These attacks are more common in neurasthenic and chlorotic girls than in men, and they may or may not be painful. The attacks are sometimes brought on by very mild gastric excitants, even solid food, like digestible meats, being sufficient to produce them. The attacks occur during gastric digestion and begin with slight dyspnea and substernal oppression. In the beginning of the attack the second pulmonary sound is accentuated and has a quick, metallic ring. Later, the heart sounds become muffled, and a distinct bruit de galop can be heard to the right of the sternum. In the severe attacks relative tricuspid insufficiency may develop, a systolic murmur being heard at the apex, propagated to the right and accompanied by a systolic distention of the right jugular vein. The heart dulness is then enlarged to the right. The attack may end in half an hour, and may or may not be accompanied by moderately severe pain extending over the thorax from the left clavicle to the umbilicus. The trouble is most common in hyperesthesia gastrica, neurasthenia gastrica, during the development of gastroptosis, and in adenohypersthenia gastrica.

The influence of the diseases of the stomach on the heart and blood-vessels should not be forgotten, for the gastrocardiovascular troubles can be cured only by the proper treatment of the disease of the stomach. An acute disease of the stomach or an exacerbation of a chronic disease of the stomach may break compensation, or give the death-stroke in organic disease of the heart, or be the exciting cause of an attack of angina pectoris. It is a good rule to watch the stomach in the management of the diseases of the heart and blood-vessels.

VI. INFLUENCE ON THE NERVOUS SYSTEM. During normal gastric digestion the nervous system is physiologically in repose. It is a natural period of mental and physical rest. The inactivity may be prevented by the use of stimulants, like tea, coffee, alcohol, tobacco, and by a lively environment. But if the mind be not forced into activity, it will seek its physiological repose, and if it be too much excited artificially, the functions of the stomach may be slowly performed. In an analogous manner, pathological digestion may destroy this natural tendency of the mind and body, and the nervous system itself may manifest the disordered digestion. Gastric headache, drowsiness, insomnia, and the many nervous symptoms of the diseases of the stomach, display the influence of the diseased stomach on the nervous system. But not only are nervous symptoms produced, but also special disorders of the nervous system. The principal disturbances of this kind are neurasthenia, vertigo, tetany, and epileptiform convulsions.

There is no question in our mind that both spinal and cerebral neurasthenia may result from the diseases of the stomach. There is no doubt that the reverse is equally true; that neurasthenia may begin in other organs or in the central nervous system and extend to the stomach. Irritable nerve weakness may readily be propagated from one division of the sympathetic system to another. Then are established the neurasthenic vicious circles of the stomach, and the stomach itself may forge this circular chain. It matters not whether the irritable weakness be caused by self-poisoning, by subnutrition, by oligocythemia (gastric), by direct propagation along the sympathetic or the pneumogastric nerves, or by the effect of the gastric trouble on the mind or on sleep. The stomach is still the creator of the trouble. The diseases of the stomach

which are most active in this respect are neurasthenia gastrica, gastroptosis, myasthenia gastrica (with hyperesthesia, hyperchlorhydria, or fermentation), obstruction of the pylorus, and all the hypersthenic painful affections of the stomach. The disease of the stomach is the primary trouble, and the secondary neurasthenia can be cured only after the control or cure of the exciting causative disease. Like other secondary diseases, the neurasthenia may acquire an independent existence, and it always requires treatment in itself. But this peculiarity is no evidence against its genesis by the disease of the stomach.

Vertigo a stomacho laeso (Trousseau) is not frequent. Gastric vertigo is in itself without characteristic features, but it occurs in association with the stomach trouble and is relieved by the cure of the stomach disease. It is sometimes possible to bring it on by sudden change of position, and to relieve it by giving a few mouthfuls of food; it is sometimes associated with nausea, sometimes with frontal headache, sometimes with vasomotor disturbances, and sometimes with hot flushes and a sense of warmth in the stomach. The attacks begin sometimes when the stomach is empty, and sometimes a few hours after a meal. The head first feels light, or heavy, or compressed, the vision becomes cloudy, there is some particular sensation referable to the stomach, and then the surrounding objects oscillate and turn about the patient, or the patient loses his sense of equilibrium and of space and feels himself in the air. Consciousness, however, is never lost, and the patient always knows that the movements are mere illusions. Vertigo is a very common symptom, and it is a symptom of many other diseases (particularly of the arteries and the circulation) besides those of the stomach. In the cases of vertigo in which we have been able to find no other cause than the disease of the stomach, the digestion has always been "slow and laborious" (Trousseau), and the myasthenia has been accompanied by butyric acid fermentation. But we are not prepared to state that gastric vertigo may not occur under other circumstances.

Tetany is a rare complication of the diseases of the stomach, and we have been able to find only 41 reported cases. But gastric tetany is frequently fatal (73 per cent.), and many cases doubtless occur without being recognized or without being reported.

Tetany is a motor neurosis characterized by bilateral paroxysmal tonic spasms affecting chiefly the flexor muscles of the extremities. The muscular cramps are painful, and con