A FURTHER REPORT ON ACHYLIA GASTRICA.1 BY MAX EINHORN, M.D., NEW YORK. IN 1892 I suggested the term "Achylia Gastrica "2 for those conditions in which the stomach apparently secretes no juice and in which clinically the diagnosis of "atrophy of the gastric mucosa" seems to be justifiable. In my paper referring to this subject I endeavored to show that cases of achylia gastrica and cases of pernicious anæmia ought to be kept strictly apart. Whereas the latter, as a rule, ends fatally, the former does not necessarily endanger the life of the patient. As a proof of this view I described a case of achylia gastrica which I had under observation for four years and whose condition had, meanwhile, rather improved, and another case in which the obtained historical points made it probable that the stomach had persisted in this state of juicelessness for forty years. In this case there were no subjective symptoms present and the patient used to partake of the heaviest food with perfect impunity. In all these cases the small intestine acts vicariously and completely replaces the lack of digestion of the stomach. 3 In regard to the literature of "atrophy of the gastric mucosa the same can be found in my above-mentioned paper. I would like, however, again to pay my tribute to the excellent work done in this line by Henry and Osler and F. P. Kinnicutt. Both papers describe cases of pernicious anæmia in which the autopsy showed the disappearance of the gastric glands. Henry and Osler have given various characteristic drawings illustrating the microscopic picture of this condition. 46 The recent literature on cases of pure achylia gastrica (not complicated with pernicious anæmia) is not very extensive. Simultaneously with my article on Achylia Gastrica" Ewald published a paper entitled: "A Case of Chronic Disability of Gastric Secretion (Anadenia Ventriculi ?)." Ewald's views are in perfect accordance with mine. The patient reported in the paper had been observed by Ewald for two and a half years. Whereas this patient improved considerably in every respect and gained forty-two pounds in weight, the chemical examination of the gastric contents showed a total lack of juice. Th. Rosenheim reports a patient, aged eighteen, who presented all the symptoms of achylia gastrica in 1889, and when examined anew in July, 1894, the same condition of the stomach was found. Westphalen described a case of achylia gastrica complicated with motor insufficiency. Here the diagnosis made during life was verified by autopsy after patient's death a few days after an operation. In his text-book on 66 Diseases of the Stomach," J. Boas 8 says: "There is at present no doubt that an absolute and permanent lack of gastric secretion may be compatible with a subjectively and objectively perfect welfare. Instead of many one striking inThe patient, under observation for over three years, partakes of the heaviest foodstuffs without any discomfort whatever, notwithstanding the absolute lack of HCl and almost entire absence of the enzyms." stance. In this country Allen A. Jones' has described under Read before the New York Academy of Medicine, Section on General Medicine, May 21, 1895. Max Einhorn: MEDICAL RECORD, June 11, 1892. Henry and Osler: American Journal of the Medical Sciences, vol. 91, 1886, p. 498. F. P. Kinnicutt: American Journal of the Medical Sciences, vol. 94, 1887, p. 419 $87 C. A. Ewald: Berliner klin. Wochenschrift, 1892, Nos. 26 and 27. Th. Rosenheim: Berliner klin. Wochenschrift, 1894, No. 39. p. H. Westphalen: St. Petersburger med. Wochenschrift, 1890, Nos. 37. 38. J. Boas: Specielle Diagnostik und Therapie der Magenkrankheiten, Leipzig, 1893. p. 18. Allen A. Jones: New York Medical Journal, May 27, 1893, p. 573. the name of "Gastric Anacidity" four cases belonging to this class of affections. It would have been hardly necessary to again discuss this subject but for two new facts observed which appear to be of value for the affection in question. As yet it is uncertain whether in all cases of achylia gastrica there necessarily exists an anatomical lesion (atrophy of the glands) or not-i.e., whether cases of achylia might not perhaps occur, in which the gastric mucosa is not much altered. The question of the possible existence of achylia when there are no considerable changes of the gastric mucosa is closely connected with the further question, whether a repair of this condition be possible. The two following observations will perhaps throw some light on these questions: CASE I.-M. G. Diagnosis: Achylia gastrica, Erosiones ventriculi.-The details of this case are given in my paper1 on "Erosions of the Stomach." Here it will suffice to state that the chemical examination of the gastric contents of this patient-which analysis has been made far more frequently than described in my paper-always revealed a total absence of HCl, an acidity of four or even below that, absence of the biuret reaction, and absolute deficiency of the rennet and pepsin ferments. In this way the diagnosis of achylia gastrica had been established. In the same patient lavage, in the fasting condition, used to bring up several small pieces of gastric mucosa, which, microscopically, showed the presence of rather normal glands. (In my above-named paper on "Erosions of the Stomach" there is a drawing of the microscopic picture of a piece of gastric mucosa of the patient.) It is evident from this observation that there might exist an achylia even when the glandular layer of the stomach has not been totally destroyed. The suppression of the gastric secretion is, then, probably caused by certain nervous disturbances. CASE II.-Louis T, now twenty-eight years of age, with previous diagnosis: Achylia gastrica (reported in 1888 in the New York Medical Press, and thereafter, in 1892, in the MEDICAL RECORD)-still presented the symptoms of achylia gastrica in 1893. In 1894, however, the patient began to show a different aspect of his gastric functions. At first it was noticeable that the gastric contents consisted of a much finer mixture the solid particles being much more minute -contained the two characteristic ferments, presented a low degree of acidity (though higher than heretofore), and revealed the presence of peptone. A few months later the acidity increased to thirty, and now even free HCI could be easily detected. In this case, in testing the gastric contents in 1893, I also applied Sjoequist's method as modified by Ewald 2 in order to determine whether there was combined HCl. The result was always negative. I have applied the same method (Sjoequist- Ewald) in three other cases of achylia gastrica, and could always determine a complete absence of combined HCl, According to my belief, in cases in which the acidity has either disappeared or is so low that it does not exceed four or six for a long period of time, it is sufficient, for practical purposes, to ascertain the absence of the ferments (pepsin and rennet), of Günzburg's reaction and of the biuret test, in order to make the diagnosis of achylia gastrica. I am quite certain that one would find also in all these cases a total lack of the combined HCl, just in the same manner as I found it in the three cases I have especially examined with regard to this point. If I now return to case Louis T―, it appears quite evident that even a typical case of achylia, where this 1 M. Einhorn: MEDICAL RECORD, June 23, 1894. Proceed as follows: To 10 c. c. of the filtrate add BaCO,, evaporate to dryness, and reduce to ash. Dissolve the residue in H2O. If, on addition of a solution of Na,CO,, no precipitate is formed, it shows that no barium chloride is present, or that there was no combined HCl present. condition has remained unchanged for seven years (five years thereof under constant observation), may take a turn for the better and the stomach may slowly regain its secretory function. This fact appears to find only an explanation under the supposition that the suppression of gastric secretion in this case was not due to a total disappearance of the glandular layers, but rather to certain thus far unknown nervous disturbances. Both cases mentioned prove that achylia gastrica may exist in a person notwithstanding the presence of gastric glands. From the above it is apparent that the clinical picture of achylia gastrica does not suffice to establish the diagnosis of anadenia ventriculi (Ewald). It does not, however, by any means follow that some cases of achylia gastrica might not be complicated or rather caused by anadenia. The following case that was observed for several years, and on which ultimately an autopsy was made, will be of great interest with regard to the point in question : Mrs. Augusta G, about thirty-eight years of age, came under my care through the kindness of Dr. J. Rudisch in 1888. The patient stated she had suffered severely from the stomach for the last five years. She frequently had pains after meals. There was no vomiting. Constipation. During these five years patient had lost considerably in weight-about twenty pounds altogether. The examination of the chest organs did not show anything abnormal. Palpation of the abdomen did not reveal any tumor. There was no splashing sound in the gastric region and the contours of the stomach could not be mapped out. By abundant food and massage the condition of the patient greatly improved. She increased seven pounds in weight during the winter, and the pains were slight or absent. During the summer of 1888 I examined the gastric contents one hour after Ewald's test-breakfast. The contents obtained were small in quantity and thick. The bread particles were not minute and looked unchanged. The amount of fluid was extremely small. The filtrate showed: HCl = o ; acidity = 4; rennet = 0; biuret reaction o; erythrodextrin = 0; sugar +. In the fall of 1888 I again examined the gastric contents and obtained exactly the same result. Patient in the summer of 1889, although feeling quite well, left for Europe. She stayed a few weeks in Franzensbad, and then about two months in a hydropathic institute near Vienna. When patient returned to New York she was not not, on the whole, better than heretofore. During the winter of 1889-90 she had a severe attack of pleurisy, from which she recovered perfectly. Patient spent the summer of 1890 in the Catskill Mountains. While there she caught cold and suffered from a new attack of pleurisy with considerable exudation. After aspirating over a quart of liquid with the Dieulafois apparatus patient seemed to recover quickly. Soon afterward, however, a new serious ailment-carcinoma uteri-made its appearance and ended her life on September 11, 1891. During the last eighteen months of patient's life the gastric symptoms were not very pronounced. Patient used to eat very slowly, and always made intermissions (for about two to three minutes) after every few mouthfuls of food. She asserted that without the intermissions the food would not go down and remained in the oesophagus. Patient, however, partook of a quite manifold and varied diet (meat, green peas, spinach, asparagus, different soups, white bread and butter, milk, coffee). In order to alleviate the pains caused by the cancer-pronounced inoperable by the best gynecologists of this city-methyl-blue 0.2 once a day was administered first per os, then per rectum. This medicament was used in this case a whole year with the greatest benefit. During the entire sickness the nutrition of the patient remained quite good. About three months before death a resistancy was felt below the ensiform process which was ascribed to the stomach. It was quite natural to think of a cancerous growth in this organ also. This, however, was not the case, as the autopsy afterward showed. At the autopsy the uterus was found to be of the size of a child's head, and taken up by a scirrhous cancer. At the beginning of the colon ascendens there was a perforation (caused by the pressure of the tumor on that organ); pus in the abdominal cavity. For a better conception I give the following drawings: FIG. 2.-One part of the two inner layers highly magnified: a, mucosa; b, sub mucosa. The stomach was not adherent to the neighboring organs; it looked extraordinarily small and firm, of large pear's size, and measured 10 ctm. in length and 6 ctm. in width, the walls being about 1 ctm. thick. In opening the stomach the interior appeared quite smooth, presenting a whitish gray surface. The pylorus was not stenosed, and could be passed with the finger. From two different spots of the fundus ventriculi numerous microscopical specimens were made, showing the entire cross-cut of the wall of the stomach. No glands could be found anywhere, and instead of them. there was a thin layer consisting principally of round cells. The submucosa was greatly hypertrophied and filled with numerous cyst-like meshes. The muscularis was also very much thickened. Conclusions. In this case the diagnosis of achylia gastrica had been made three to four years before death. An abundant and well-regulated dietary regimen had considerably improved the patient's condition. The state of the stomach was bearable and remained so. A cancer of the uterus, however, developed and ended the life of the patient. At the autopsy the stomach was found to be very small in size and its walls uniformly thickened. The inner surface presented a smooth and whitish appearance; microscopically the inner layer was found to contain no glands, and consisted merely of cells and scanty fibrous tissue. The other layers of the stomach, the submucosa and muscularis, were greatly hypertrophied, not containing, however, any foreign elements. Thus, the condition of the stomach found at the autopsy corresponded to that of cirrhosis ventriculi, as described by Nothnagel,' Henry and Osler, and von Kahlden.3 In this case it seems justifiable to assume that the achylia gastrica, which was diagnosticated about three years before the exitus, was due to a real anadenia of the organ. It appears, however, more than probable that the great diminution in the size of the stomach developed in the last three or five months before death, at the time when the resistancy began to be felt at the ensiform process. Out of the entire number of my newly observed cases of achylia gastrica (they amounted to thirteen after deducting the above-narrated cases), I may be allowed to report two typical cases of this affection, one of which was interesting, inasmuch as there were no gastric symptoms whatever and the complaints appertained merely to the intestinal tract. Typical Cases of Achylia Gastrica.-The following cases are of great interest: CASE I. (October 24, 1892).-Mrs. G, aged about forty-five, complains of her stomach for the last twelve years. She is almost always troubled with pains after meals in her gastric and epigastric region. Appetite poor. Bowels inclined to be constipated. Vomiting appeared very seldom. Patient had lost considerably in weight during the first years of her ailment ; thereafter her weight remained stationary. In 1891 she visited Carlsbad, but her condition did not improve any. Present Condition.-Patient of small stature and quite thin. Panniculus adiposus looks somewhat thin. Lips and cheeks of a pale color. Tongue not coated. Chest organs in good shape. The palpation of the abdomen reveals the absence of any tumor. The epigastric region is sensitive to pressure, but not exactly painful. A splashing sound can be produced to about three fingers' width below the navel. The urine does not contain either sugar or albumin. October 27th.-Examination of the stomach one hour after Ewald's test-breakfast: HCl = 0; lactic acid = 0; acidity 6; rennet = 0; biuret reaction the = ; erythrodextrino; sugar +. The quantity of gastric contents is not large, and contains a very small amount of liquid. The bread particles are not minute. No mucus. October 30th.-When fasting: stomach empty. January 8, 1893.-Examination of the stomach one hour after Ewald's test-breakfast: HCl = o ; lactic acido; acidity = 4; rennet = o ; pepsin = 0; biuret reaction = 0; erythrodextrin = 0; sugar +. During the year 1893 several other examinations of the gastric contents had been made, with the same analytical data as just mentioned, Taking into consideration the very long period of the ailment and the result of the chemical examination of the gastric contents, achylia gastrica was diagnosticated, and cancer excluded. The further course of the patient's condition has fully verified this assumption, for the patient now (two to three years after the reported examinations) is in rather a better condition than heretofore. The treatment consisted in occasional lavage and intragastric faradization. ČASE II. (October 1, 1894)-Mrs. A. S-, aged about twenty-five, had suffered five years ago from severe diarrhoea for about three months. Eighteen months later patient had a new attack of diarrhoea lasting over a month. About a year ago she began to complain of pains after meals. complain of pains after meals. These pains, as a rule, appeared right after the partaking of food and lasted for about three hours. At times, patient would experience a mere feeling of pressure, at times, however, the pain was very intense in character. Bowels regular. For the last two years she suffered from very severe headaches. Patient had lost seven pounds during the last year. She greatly suffers from belching without any bad odor. Appetite very good. Patient, at times, feels very sleepy, at times again she is subject to fainting spells of very short duration. Present Condition.-Patient looks well nourished, though somewhat pale. Tongue slightly coated. Chest organs intact. The stomach is situated quite low (gastroptosis) and the right kidney movable. The epigastric region is sensitive to pressure, although not painful. The urine does not contain anything abnormal. October 2, 1894.—Examination of the stomach one hour after Ewald's test-breakfast. Only a small quantity of thick contents could be obtained. The bread particles are not minute and they obstruct the tube. The filtrate shows: HCl=o; reaction hardly acid; acidity = 2; lactic acid = o ; biuret reaction = 0; renneto; pepsine o; erythrodextrin = 0; sugar +. = October 4th. In the fasting condition: stomach empty. Patient is treated every other day with intragastric faradization. She feels better and can eat without pains; the headaches have meanwhile disappeared. October 17th.-Examination of the stomach one hour after Ewald's test-breakfast: HCl = o, of hardly acid reaction; acidity = 2; lactic acid not present; biuret reaction = o ; rennet = o ; pepsin o; erythrodextrino; sugar +. The bread particles not minute; small quantity of fluid; no mucus. = At the end of November, 1894, patient was dismissed from treatment. During the last two months she had gained eight pounds in weight and was believed to be perfectly well. The examination of the gastric contents of November 29, 1894, however, revealed exactly the same condition as previously described. April 5, 1895.-Patient felt well all the time without any treatment. The gastric contents were again examined and found to contain the same characteristic properties as above stated. A Case of Achylia Gastrica with Predominant Intestinal Symptoms (April 14, 1894).-Solomon Sfifty-seven and a half years of age, always enjoyed good health until August, 1892, when he had a severe attack of dysentery (patient had to stay in bed for over three weeks and felt afterward extraordinarily weak). Since that time patient had attacks of severe diarrhoea (much mucus, sometimes blood in the passages) every two to three weeks. This diarrhoea used to alternate with constipation. From August to October, 1892, patient had lost forty pounds in weight. From that time on he felt weak and miserable and complained of thirst. This condition remained unchanged during this time. He complains at present principally of extreme weakness, of intense thirst, and of very weakening diarrhoeal attacks. Present Condition.-Color of lips and cheeks very pale, anæmic. Tongue furred with a whitish coat. Chest organs intact. The stomach extends to one finger's width below the navel. A splashing sound can be easily produced in the gastric region. There is nowhere any tumor. There are no sensitive spots discoverable in the abdomen. The knee reflex is present. The urine contains neither sugar nor albumin. Patient was treated for some time, at first, with injections into the bowels (acid. tannic. 2.0 to a quart of water once daily), thereafter with the administration of peptonate of iron. All these means, however, failed to be of any benefit whatever; the tired feeling and weakness persisted, and the frequent attacks of diarrhoea likewise remained unchanged. November 21, 1894.-Examination of the stomach one hour after Ewald's test-breakfast: HCl = o ; acidity = 2; lactic acid = o ; rennet = o ; pepsin o; biuret reaction = o ; erythrodextrin = 0; sugar +. Quantity of liquid very small; the bread particles not minute; no admixture of mucus. November 23d.- When fasting: stomach empty. Achylia gastrica is diagnosticated, and the patient treated with intragastric faradization. The diet is arranged in such a manner that it does not contain very much meat, and is, instead, rich in food taken from the vegetable kingdom. Number. ! After two weeks of this treatment the sensation of ter. weakness remained away. Patient began to look betHis cheeks had a red color, the bowels were regular, and the troublesome sensation of thirst that formerly was so annoying to the patient disappeared. December 17th.-Examination of the stomach one hour after Ewald's test-breakfast: HCl = o, of neutral reaction; biuret reaction = o ; rennet = o ; pepsin = 0; erythrodextrin erythrodextrino; sugar +. Small quantity of fluid; the bread particles not minute; no mucus. Patient asserts that he feels well; he can walk great distances without feeling tired. December 20th.-One and a half hour after the testbreakfast: stomach empty. December 31st.--Patient takes one glassful of milk; one hour afterward, he takes a glassful of water, and his stomach is directly faradized for ten minutes. Then the gastric contents are obtained by means of a tube; they consist of uncurdled milk diluted with water and are of neutral reaction. Patient was examined at various times in January and February, 1895, and there was always found a complete absence of gastric juice. The absorption of the stomach was examined by means of the KJ test, and the iodine could be detected in the saliva after a lapse of eleven minutes. Patient's health was and remained thus far in very good state; his appetite is fair, bowels regular, and stools well formed; no attacks of diarrhoea. April 15, 1895.-Patient has gained ten pounds in weight. (Several examinations that have been made with regard to the acidity of the urine are here omitted, as they will be mentioned later.) Of the remaining patients with achylia gastrica I may be permitted to give in table form a short review of the subjective complaints and of the objective data found. Stomach very large; ex I tends to one hand's width below navel. Result of the Chemical Examina- Remarks. The particles of roll not minute. Stomach, when fasting, always empty. Extends to The pieces of bread not small. about one finger's width above navel. Gastroptosis. Stomach sunken down but not enlarged. In normal position and not enlarged HC o, lactic acid = o, acid- Three-quarters of an hour after The particles of bread unchanged. = 2, rennet = o, mucus. no Frequent attacks Extends to the The pieces of roll not minute and navel. Pains after meals; Gastroptosis. poor appetite; frequent diar rhoea. Pains after meals: Extends sometimes head- the navel. ache; frequent diarrhoea. unchanged. HCl = o, lactic Pains after meals: Gastroptosis. frequent belching; sometimes vomiting obstinate diarrhoea. No gastric symp toms: obstinate diarrhoea, alter nating with con stipation. Stomach larged. The pieces of bread not small. HCI o, acidity = 2, rennet en The particles of bread not mi- Right kidney movable. Stomach empty when fasting. One hour after the test-breakfast the stomach was found empty several times. Patient was under observation for a whole year and had gained seven pounds; she then died, after a short illness, with pneumonia. One hour after the test-breakfast the stomach, as a rule, used to be found empty. The absorption of the stomach was examined by means of KI; in twelve minutes iodine could be detected in the saliva. Patient was under observation for over a year. There was a decided improvement in the patient's condition. He has gained six pounds in weight: there were hardly any pains, and the diarrhoea appeared only very seldom. The chemical examination of the stomach, however, showed the same condi tion as described. Right kidney movable. Here Sjoecquist's method, as modified by Ewald, was applied in order to determine the quantity of combined HCI; no traces, however, could be detected. The treatment consisted principally in intragastric faradization. There was marked improvement. Patient gained six pounds in weight; the pains and the diarrhoea entirely disappeared. Pronounced nervous symptoms. Right kidney movable. Tongue always clean. Patient was under observation for four years. His condition has not changed in any way during this period of time. His weight remained the same, and his subjective and objective symptoms persisted in an unchanged manner. Symptomatology. Whereas the subjective complaints, as is easily apparent from the above-mentioned cases, may be of quite a manifold nature and may often be entirely absent, particularly as regards the stomach, the objective symptoms are always present. In reference to this point I expressed myself in my paper on "Achylia Gastrica" in the following way: "In all four cases the stomach contents showed, one to one and a half hours after Ewald's test-breakfast, the following peculiarities: 1. The pieces of roll are not minutely minced and unchanged. 2. The reaction very weakly acid or neutral, usually the acidity was 4 (ie., 100 c.c. of the filtrate of the stomach contents are saturated by 4 c.c. of a one-tenth standard solution of sodium hydrate). 3. Hydrochloric acid not present. 4. Lactic acid present, but could be discovered only after a thorough shaking with ether. 5. Neither propeptone nor peptone present. 6. The tests for the pepsin and rennet ferments gave negative results. The stomach contents did not smell badly, and did not otherwise give the appearance of decomposition.' 7. To these seven points I would now add as point 8, absence of mucus, and 9, the remarkably small quantity of liquid found in the stomach of these patients one hour after the test-breakfast. Aside from the fluids soaked in and around the particles of bread there is hardly any liquid at all. The gastric contents thereby acquire a peculiar, characteristic appearance, and look different from what they do in other affections of the stomach. This small amount of fluid in the gastric contents of patients with achylia may be explained in the following way: Besides the water (or tea) ingested into the stomach with the test-meal, there is no addition of juice (or liquid) during the stay of the food in this organ. As the more liquid chyme, as a rule, leaves the stomach quicker than the more solid substances these latter alone will then, after awhile (about one hour after Ewald's test-breakfast), be found present. The motor function of the stomach was not impaired or slackened in any of my patients; in some of them rather somewhat hastened (I. S and Solomon The absorption faculty of the stomach I have examined in three of these patients and did not find it in any way retarded. (In patient L. T after 0.2 KJ the reaction for iodine appeared in the saliva after eight minutes, in I. Safter twelve, and in Solomon Safter eleven minutes.) In what condition is the acidity of the urine in patients with achylia gastrica? It appeared to me of interest to pay attention to this point, and more especially to ascertain whether there is any difference in the degree of acidity of the urine passed in the fasting condition and that emptied during the act of digestion. As is well known, normally there is a decrease of the degree of acidity of the urine during gastric digestion. This is explained by the fact that at that time the acid elements are conducted, so to say, to the stomach. This point, however, does not apply to achylia gastrica, for there is no acid secretion in the stomach. For this reason it would theoretically appear correct to assume that in achylia gastrica the acidity of the urine in the fasting condition and during digestion would not vary very much. The following experiments go to show that this is really the case. The experiments were conducted in the following manner: The patient arising early in the morning empties his bladder; half an hour later he urinates and puts it in a bottle with the mark "U. I." (urine first fasting). He then takes Ewald's test-breakfast. One hour afterward he again urinates and marks the bottle with "U. II." (urine second = during digestion). His gastric contents are then obtained. All the samples are thereupon examined. In this way the rela The rennet zymogen, however, may still be found present. Etiology. With regard to the etiology of achylia gastrica it is generally assumed that same develops after preceding grave chronic catarrhal conditions of the stomach. The newer text-books on "Diseases of the Stomach" (Ewald, Boas, Bouveret) mention this affection in the chapter on Gastritis Glandularis Chronica." I certainly believe that such an origin of achylia gastrica is sometimes the case. The cases of chronic gastric catarrh in which the acidity is pretty low (10 to 20), no free HCl exists, but biuret reaction and likewise rennet are present, speak in favor of this view. They represent, so to say, the preceding stage of achylia gastrica. Notwithstanding this, it seems to me more than probable that the affection in question may establish itself also in some other way (in consequence of nervous disturbances). In such instances the glandular layers of the stomach need not, necessarily, be greatly altered, although it appears probable that after a long persistence of inactivity of the glands these may begin to atrophy. The above-mentioned cases, M. prove the possibility of a nervous G and L. T origin of achylia gastrica. Prognosis. The prognosis of cases of achylia gastrica is good quoad vitam, which view I have represented in my previous papers and is now generally accepted by most writers.. The small intestine perfectly replaces the digestive work of the stomach, and the organism is not only enabled to maintain its equilibrium but also to gain in weight. The above case of Ewald shows that very clearly (patient had gained forty-two pounds); some of my own cases likewise prove this fact. Treatment. With regard to the therapy, such will be necessary only in those cases in which there are some subjective complaints. The treatment will have to be carried out in the two following directions: 1. To stimulate the mechanical action of the stomach. 2. To arrange the diet in such a way that same is easily accessible for the intestinal digestion. The first point is best achieved by stimulating the stomach, as by lavage and, principally, direct faradization of the organ. In some of the cases I have not applied any medicaments whatever, in some I have administered condurango or nux vomica. In reference to diet it is of utmost importance to see that the food is broken into very minute particles or can be easily done so by chewing. For, on the one hand, all kinds of meat are not altered in any way in the stomach and reach the intestine in the same shape as when they entered the cardiac orifice; on the other hand, the starchy substances contained in the vegetable food cannot become converted into maltose as long as the albuminous membrane occluding them has not been opened. In the stomach of these patients starch, as such, when accessible to the action of ptyalin, undergoes conversion into sugar very rapidly. |