Microscopically no sarcinae or other signs of decomposition are found. Frequently cell nuclei are met with in large numbers. In examining the patient one hour after Ewald's test breakfast, the gastric contents will be found to contain more liquid than usually, and the degree of acidity will be quite high (SO to 120). As a rule, the degree of acidity of the gastric contents is higher than that of the gastric juice when withdrawn from the stomach in the fasting condition. In examining the filtrate of the gastric contents with reference to the starchy products, it will be found that the Lugol solution will produce a deep violet or even blue color, showing that the starch has not been much changed. A thin disc of hard-boiled egg will bo digested in the filtrate at blood temperature in about half an hour to an hour. The difference as to the degrees of digestion of the albuminates and starches (the former being more quickly, the latter much more slowly digested) can be best studied after Leube-Riegers test dinner. Three to four hours after such a dinner the obtained gastric contents show hardly any meat particles whatever (all being digested), whereas particles of starchy food form the principal part of the mixture.

In this way the difference between the digestion of meats and starchy foods existing in this affection is seen at once.

Differential Diagnosis

In making the diagnosis of gastrosuccorrhoea, all organic lesions of the stomach (ulcer and stenosis of the pylorus) which are liable to be accompanied with gastrosuccorrhoea will have to be excluded. According to my experience, it is easy to exclude stenosis of the pylorus, but not an ulcer. In stenosis of the pylorus the stomach in the fasting condition is also found to contain a liquid, but this is mixed with food and the filtrate always shows the presence of starch or sugar products. But the main thing is that food articles can be seen even with the naked eye, whereas the liquid found in the stomach in case of genuine gastrosuccorrhoea does not contain any food particles, as described above. The presence of an ulcer will be suspected if there has been a preceding haematemesis or melsena or a circumscribed spot in the gastric region very painful to the slightest pressure. The absence of these symptoms will tend to justify the diagnosis of gastrosuccorrhoea.

In this respect I agree with Reichmann as to the existence of a pathological continuous gastric succor-rhoea, although I restrict this name to cases not presenting any organic lesions of the stomach. Whenever the latter exist, I deem it best to look upon the accompanying gastric succorrhoea as a consequence of the main trouble, but not as the cause of the organic lesion. According to my experience, which coincides with that of Ewald, cases of genuine gastrosuccorrhoea chronica are quite rare. They are less frequent than those of periodic gastrosuccorrhoea. During the last eight years I have met with eight cases of this affection, one of which I1 published in 1887. The following is the description of one of my recently observed typical cases of gastrosuccorrhoea:

1 Max Einhorn: New Yorker inedicinische Presse, 1887.

A. S------, 21 years old, has suffered since early youth from digestive troubles. As far back as he can remember, he has felt hungry very soon after meals (one hour). The bowels, although usually regular, were at times very constipated. Patient was always weakly, but in the last three years he has been troubled to a much greater degree. He felt extremely weak, became dizzy after meals, and was overcome by a feeling of sleepiness. The bowels became constipated' all the time. During the last six or seven months there was a sensation of extreme weakness in the hands and feet. The appetite was constantly increased, and a hungry feeling appeared very frequently. For the past three months there had been a burning sensation in the gastric region, which in-creased in severity about an hour or two after meals. From that time on the patient began to vomit frequently. The vomiting, as a rule, occurred very soon after a meal, although occasionally it took place either in the middle of the night or in the morning before breakfast.

Patient had lost lately in weight (about ten pounds).

Present Condition

Chest organs intact. On palpation, the gastric region is somewhat sensitive to pressure. There is, however, no circumscribed painful area. A splashing sound can be produced extending to about one finger's width above the navel. The tongue is thickly coated. The color of the lips and cheeks is quite good, and the patient does not look emaciated. The knee reflex is present, and the urine does not contain anything abnormal. The examination of the stomach one hour after a test breakfast showed the quantity of chyme to be small (about 30 c.c); hydrochloric acid +, acidity = 100.

The examination of the stomach in the fasting con-dition revealed the presence of a considerable quantity of pure gastric juice; 120 c.c. of a somewhat turbid liquid, not containing any food remnants whatever, were withdrawn with the tube. This fluid contained free hydrochloric acid, had an acidity of 80, gave only weak biuret reaction, while erythrodextrin, dextrin, and sugar were wholly absent. During the first three months of treatment the condition of the stomach in reference to its secretion of juice did not change in any way. Repeated examinations, which had been made in the fasting condition of the patient, always gave the same result: presence of about 100 c.c. or more of pure gastric juice.

The treatment consisted at first in regulation of the diet, and in the administration of large doses of alkalies. Later on washing of the stomach and spraying of the organ with a 1 to 2:1,000 solution of nitrate of silver was instituted. The latter means proved more effective than the former treatment, and after about two weeks it was noticed that the stomach in the fasting condition contained considerably smaller quantities of juice. Frequently but 30 or 20 c.c. of juice were found. The spraying was continued for two months, after which time the stomach in the fasting condition was usually found empty. This objective improvement was connected with a subjective amelioration of all the symptoms: the vomiting ceased, the hunger was much less marked, the dizziness subsided, and the patient felt stronger and could do his work much better. The examination of the stomach one hour after the test breakfast, however, showed that the hyperchlorhydria still persisted. In this case we frequently tried to determine the motor (transportation) faculty of the stomach. One and a half hours after Ewald's test breakfast, as a rule, the stomach was found empty, showing that this faculty was rather increased.

This is of interest, inasmuch as it shows that continuous hypersecretion need not be associated with sluggishness in the muscular action of the organ, a theory which is accepted by most investigators who have written on the subject.

The following is another typical case of continuous hypersecretion.

S------, 46 years old, has been suffering from digestive disturbances since 1893. The principal symptoms consist in pains appearing in the gastric region about three hours after meals and also early in the morning before arising. The appetite was always good. Thirst is frequently greatly marked and with it a sensation of dryness in the mouth.

The pains are almost always relieved either by food or by bicarbonate of soda. Steady brain work, strain in business, and worry greatly aggravate the condition, while a stay in the country and rest materially diminish the symptoms. There were several intermissions of the symptoms extending over a period of a few months' duration. But thus far they have always returned. Constipation exists in a high degree.

On examination the stomach is found to extend to two fingers' width below the navel; the gastric region is not painful to pressure.

One hour after test breakfast: Quantity of chyme (consisting of fine pieces of roll and a watery liquid) amounts to 500 c.c. HC1 +, acidity = 108, free HC1 = 02, ervthrodextrin + much.

In the fasting condition, the stomach contains 130 c.c. of a watery liquid not mixed with any particles of food. HC1 +, acidity = 100, free HC1 = 90, ery-throdextrin = 0.

Several other examinations gave similar results, and for quite a while the stomach in the fasting condition usually contained from 70 to 140 c.c. of clear gastric juice. The treatment consisted in the application of intragastric galvanization and spraying with nitrate of silver. The symptoms gradually subsided.

Prognosis

According to my experience, the prognosis of gastrosuccorrhoea is not bad. As a rule, most patients improve under rational treatment. Frequently, however, there are relapses. Some very obstinate cases are occasionally met with, and the trouble, although yielding somewhat to treatment, may persist for years. There is, however, no danger of a fatal issue resulting from this disease alone.

Treatment

As we have seen, gastrosuccorrhoea is always associated with hyperchlorhydria. The treatment of the latter condition in reference to diet, drugs, and mode of living will have to be resorted to here also. With reference to diet, I have only to add that it is of great importance not to permit the patient to partake of any large quantities of liquid. In this affection more stress must be laid upon this point than in hyperchlorhydria.

Medicaments

The treatment of gastrosuccorrhoea must be directed toward decreasing the undue amount of gastric secretion. With this end in view, Voinovitch 1 recommends the use of atropine in doses of 2 mgm. (gr. 1/32) daily. Bouveret prefers morphine to atropine. Following the advice of Leubuscher and Schaeffer,2 he administered as much as 2 to 3 cgm. (gr. 1/3-1/2-) of sulphate of morphine three times daily by subcutaneous injection. This author doubts, however, whether this treatment, which seems to be effective in the initial state of the affection, will prove useful in cases that have progressed further. The use of either atropine or morphine may be tried for a short time, but they should never be administered for a long period. The subcutaneous injections of morphine especially should be avoided, as the patient runs the risk of becoming an habitue of this drug.

1 Voinovitch: La Semaine medicale, April 6th, 1892.

2 Leubuscher und Schaeffer: Deutsche med. Wochenschr., 1892.

Large doses of subnitrate of bismuth (2 gm. or half a drachm in a wineglassful of water three times daily half an hour before meals) seem to have occasionally very good effects. Wolff1 recommends Carlsbad salt or:

℞ Sod. sulph.,....... 80.0

Potass, sulph.,....... 5.0

Sod. chlorat......... 80.0

Sod. carbon.,....... 25.0

Sod. bicarbon.,....... 10.0

M. f. pulv. Half a teaspoonful in half a glassful of lukewarm water three times daily: the first portion to be taken in the fasting condition, the second two hours before the midday meal, and the third two hours before supper.

Riegel2 likewise speaks highly of this mode of treatment.