well-marked arteriosclerosis thoroughly studied by us have we found the stomach normal, but in some of the cases (which have been excluded from consideration) the chronic gastritis was in all probability due to the medication or to the advanced nephritis.

IV. DISEASES OF THE BLOOD.

The diseases of the white corpuscles (pathological leukocytosis, leukemia, and leukopenia) do not produce any special disturbances of the stomach. The enlarged spleen which accompanies leukemia may be the cause of vomiting. The enlarged liver may obstruct the venous circulation of the stomach, and interfere with the proper performance of its mechanical work. Leukemia may, however, produce symptomatic gastric hemorrhage. Leukopenia and leukocytosis do not affect the stomach, although either functional or organic disease of the stomach may result from the same cause which produces the leukopenia or the leukocytosis. The symptomatic gastric hemorrhage of scorbutus and of hemophilia need only be mentioned.

The diseases of the red corpuscles are responsible for the secondary diseases of the stomach which are due to the diseases of the blood. But not all the gastric troubles which are found in the anemias are due to the disease of the blood. The stomach disease and the blood disease may be accidental associations, or they may result from pathogenic causes which affect both, or the gastric trouble may be the effect of the medication employed against the anemia, as the iron, arsenic, and the excitant diet which it is the rule to prescribe. Eliminating, so far as possible, these disturbing factors, our investigations have led to the following conclusions:

Simple oligochromemia disturbs neither secretion nor the motor function. But this is not the case in chlorosis. In about one-third of the cases of true chlorosis the stomach symptoms predominate in the clinical history; in about onehalf of the cases there are gastric symptoms and pain. Vomiting occurs intermittently in about ten per cent. of the cases, and loss of appetite is the rule. Disturbances of secretion are more frequent than would be indicated by the complaints of the patients, as in only nine per cent. of the cases have we found secretion normal in its degree and in its evolution. Gastric secretion is sometimes normal when the patient complains of digestive trouble.

As regards the nature of the stomach trouble, in 23 per

cent. of the cases we have noted a diminution of secretionin some cases functional, in other cases due to gastritis. But we can not convince ourselves that the gastritis is due to the chlorosis and not to other causes. In 68 per cent. of the cases we have found the hydrochloric acidity excessive at some period during the digestion of the test-breakfastexcessive free HCl at the expiration of one hour in II per cent. of the cases, excessive physiological HCl (H+ C) in 32 per cent. of total cases, and an abnormality in the evolution of digestion in the remainder of the cases. No noteworthy myasthenia existed in any of the cases, the results being obtained by using the ordinary methods and by controlling them with the water-test whenever they did not give satisfactory results. Briefly, in chlorosis there may be hyperesthesia gastrica, or there may be adenohypersthenia gastrica, and in some cases there is hypersthenic gastritis. Ulcer was present in six per cent. of the total cases, and we have never seen a gastric hemorrhage in pure chlorosis that was not due to ulcer. Gastric cramps occur in chlorosis when it is accompanied by gastroptosis or hyperchlorhydria. Associated with the gastric trouble is generally found neurasthenia gastrica, which is as it should be when the influence of chronic irritation or irritable weakness of the abdominal sympathetic in the causation of chlorosis is held in mind.

The disturbing influence of oligocythemia on the stomach is far less than the influence of chlorosis. Hemorrhagic anemia diminishes secretion, and this effect is often seen in ulcer after a severe hemorrhage. But the normal secretion or the hyperchlorhydria returns as the regeneration of the blood advances. In grave oligocythemia secretion may be diminished, and the gastric glands, like the noble elements of other organs, may undergo fatty degeneration and atrophy. Ulcer is much less frequently a result of oligocythemia than of chlorosis. In the study of the effect on the stomach of oligocythemia, be it dyshematopoietic, degenerative, or hematocytolytic, we have been unable to discover a thread to guide us in the confusion. In the primary cases it is difficult to eliminate the influence of medication or to estimate the influence of the causative disease in the secondary cases, as in pyemia, in septicemia, and in the anemias due to intestinal putrefaction and auto-intoxication. In a majority of the simple cases of mild and severe oligocythemia the stomach is normal.

V. DISEASES OF NUTRITION.

The various diseases of nutrition do not disturb the stomach to an equal degree. Chronic rheumatism produces directly no particular disturbance. Obesity causes little more than diminution of the appetite, the gastric disturbances found in this disorder of nutrition being due to the mode of life and to improper treatment. But many fat people are active, enjoy good appetites, and have excellent digestion. Fasting produces diminution of hydrochloric acid secretion without diminishing the formation of the ferments. The stomach ceases to act, but retains its functional power. In chronic subnutrition there is diminution or loss of HCl secretion without a corresponding diminution of the ferments. But in prolonged subnutrition of a severe degree secretion is not simply in abeyance, but it may be permanently impaired, and the weakness of the stomach muscle is in keeping with the weakness of the general muscular system. We would, in this connection, emphasize the very important influence of emaciation and loss of muscular strength in the causation of displacements of the abdominal viscera-kidneys, liver, spleen, colon, and stomach.

Diabetes, be it constitutional (nutritive), nervous, pancreatic, alimentary, or hepatic, may disturb the stomach. In many cases there is only a diminution of HCI secretion. There is often myasthenia in cases of long standing, which may be associated with hyperchlorhydria or with hypochlorhydria, but which is most likely the result of excessive eating and drinking rather than of the diabetes. It is the rule to find no serious disturbance of the stomach in diabetes, unless there be great emaciation, advanced cardioarteriosclerosis, or nephritis. But it should be remembered that the functions of the stomach may be insufficient, and under such circumstances the diet should not be made too exclusively nitrogenous.

The gastric troubles of gout may be due to the drugs which are commonly employed, to the restricted diet, to the secondary nephritis and arteriosclerosis, or, finally, to the disease of which the uric acid precipitation is the expression. There may be an associated or, sometimes, a secondary gastritis. But the special gastric trouble of gout is myasthenia, which may be accompanied either by hyperchlorhydria or by hypochlorhydria, with or without fermentation. there be hypochlorhydria and fermentation, a vicious circle is established, for this secondary gastric trouble of gout favors

If

the conversion of the neutral into the acid phosphate of soda, and may cause uric acid precipitation.

VI. DISEASES OF THE KIDNEYS.

It is difficult to study the effects of the diseases of the kidneys on the stomach, for the usual medication of nephritis is likely to do the stomach injury, and the two organs may become diseased from the same causes. But excluding, so far as possible, these sources of error, it may be stated in a general way that the stomach troubles of nephritis are due to acute or chronic uremia. The retention poisoning may act on the central nervous system and produce vomiting, which is always a most prominent gastric symptom in uremia, whether gastritis be present or absent. The retention poisoning also leads to the elimination of ammonia compounds by the stomach, and the HCl may be neutralized, so that the analysis of the contents gives a false conception of the activity of secretion. We have frequently noticed that the hypochlorhydria of the acute exacerbations of chronic nephritis is replaced by normal secretion, or even by hyperchlorhydria, during the period of quiescence of the Bright's disease when renal sufficiency is reëstablished. Indeed, it seems that it is the rule in the early period of chronic nephritis to find the gastric irritation displayed by hydrochloric acid in excess. But later, the hyperchlorhydria is replaced by permanent hypochlorhydria symptomatic of chronic gastritis. The hydrochloric acidity diminishes during the uremic attacks, and the alkaline or nearly neutral vomit may contain ammonia (white cloud produced by vapor from a glass rod dipped in HCI). The ferments seem to be destroyed in part, or are secreted in less quantity than would be proportionate to the diminution of the hydrochloric acid secretion. Flatulency is common, although fermentation is rare, and it may possibly be due to the decomposition of carbonate of ammonia. stomach disturbance is a rough index of the degree of renal insufficiency, and the preservation of the functions of the digestive organs protects the system and the kidneys against injury by gastro-intestinal auto-intoxication.

The

Stone in the kidney may either produce no gastric trouble at all or it may excite reflex vomiting. We have sometimes found hyperchlorhydria, or, more frequently, hypochlorhydria. The painful gastroduodenal crises of movable or floating kidney are said to be common, but the disturbance certainly

originates in some cases in the cecum and colon, and in others the signs and symptoms are due to perinephritis.

VII. SPINAL DISEASES.

Myelitis, multiple sclerosis, and spinal meningitis may be accompanied by reflex vomiting, by hyperchlorhydria, and by painful gastric crises. But the gastric troubles caused in this manner are either so rare or so obviously sympathetic that they hardly deserve mention. It is not so, however, with the gastric crises of locomotor ataxia, which occur during the course of the sclerosis of the posterior columns, or which may be the first revealing sign (in about five per cent. of cases) of tabes at a period when there are no disturbances of the reflexes, of sensation, or of coordination.

The gastric crises begin suddenly, regardless of the state of repose or of functional activity of the stomach, and regardless of the quantity and the quality of the diet. There may be irregular prodromal symptoms-shooting pains, epigastric uneasiness, depression of spirits, and restlessness. The crisis is continuous, and is manifested by pain, by vomiting, and by general weakness and anxiety. In from a few hours to several days the crisis ends as suddenly and as apparently without cause as it began.

The pain is not always present, and it is variable in quality and intensity. It may be burning, stabbing, shooting, cramplike, moderately severe, or almost deadly in its agony. But the pain has always certain distinctive characteristics: it is bilateral in its radiations; it is not relieved by vomiting, by alkalies, or by albuminous food; it is only temporarily diminished by lavage, and then only in the beginning of the crisis, and morphin controls it only during the period of narcotism. Sometimes, though seldom, the pain is the only manifestation, and it may then be cramp-like, without vomiting, and with complete arrest of secretion. Furthermore, we would emphasize the fact that the quality and the intensity of the pain bear no relation whatever to the hydrochloric acidity of the contents of the stomach.

Vomiting may be absent, but usually it is present, obstinate, and accompanied by nausea and by retching. It may be the predominant symptom, and the gastric intolerance may be complete. The vomit consists of whatever may be in the stomach at the time-food, gastric juice, mucus, and, eventually, bile and pancreatic juice. The crises are usually accompanied by thirst and by complete loss of appetite.