OH THE PRACTICAL VALUE 
OF THE 
I 
NEWER METHODS OF EXAMINATION IN 
THE DISEASES OF THE STOMACH 
WITH A CONSIDERATION OF THE INDICATIONS GIVEN FOR 
DIET AND TREATMENT BY SUCH EXAMINATIONS 
BEING PART OF A DISCUSSION ON THE NEWER METHODS OF 
DIAGNOSIS AND TREATMENT OF STOMACH AND INTESTINAL DISEASES 
BY ( 
HENRY L. ELSNER, M. I)., 
PROFESSOR OF CLINICAL MEDICINE',’ SYRACUSE MEDICAL COLLEGE ; 
PHYSICIAN TO ST. JOSEPH’S HOSPITAL ; 
CONSULTING PHYSICIAN TO ST. ANN’S HOSPITAL, SYRACUSE, N. Y. 
REPRINTED FROM 
THE NEW YORK MEDICAL JOURNAL 
FOR MA 7 6 AND 20, 1893 
NEW YORE 
L). APPLETON AND COMPANY 
1893 OH the practical value 
OF TITE 
NEWER METHODS OF EXAMINATION IN 
THE DISEASES OF THE STOMACH 
WITH A CONSIDERATION OF THE INDICATIONS GIVEN FOR 
DIET AND TREATMENT BY SUCH EXAMINATIONS 
BEING PART OF A DISCUSSION ON THE NEWER METHODS OF 
DIAGNOSIS AND TREATMENT OF STOMACH AND INTESTINAL DISEASES 
BY 
HENRY L. ELSNER, M. D., 
PROFESSOR OF CLINICAL MEDICINE, SYRACUSE MEDICAL COLLEGE ; 
PHYSICIAN TO ST. JOSEPH’S HOSPITAL ; 
CONSULTING PHYSICIAN TO ST. ANN’S HOSPITAL, SYRACUSE, N. Y. 
REPRINTED FROM 
THE NEW YORK MEDICAL JOURNAL 
FOR MAY 6 AND 20, 1893 
NEW YORK 
D, APPLETON AND COMPANY 
1893 Copyright, 1893, 
By D. Appleton and Company. ON THE PRACTICAL VALUE OF 
THE NEWER METHODS OF EXAMINATION IN 
THE DISEASES OF THE STOMACH. 
The subject which by your courtesy it is ray privilege 
to introduce for discussion to-day is one which is so full of 
interest and so important alike to the physician and the 
surgeon that I approach it with fear and a consciousness 
of weakness, which increases as I compare ray feeble efforts 
with those which others might have made for your greater 
enlightenment. Having accepted your invitation, I shall 
discuss the practical value of the newer methods of exami- 
nation in diseases of the stomach, and the indications given 
by such examinations for diet and treatment, impartially, 
with the view of formulating such conclusions as may ap- 
pear justified, and a desire to stimulate in the profession a 
more careful and scientific study of the available methods 
of diagnosis in stomach diseases. 
The great aim of the modern scientific physician is to 
understand symptoms so thoroughly that it becomes possi- 
ble for him to localize lesions exactly, or to detect faulty 
functions with equal certainty. 
* Read before the Medical Society of the State of New York at its 
eighty-seventh annual meeting. 4 
NEWER METHODS OF STOMACH EXAMINATION. 
With the discovery of free hydrochloric acid in the gas- 
tric mucus by Prout in 1824, and the demonstration of 
pepsin by Schwann in 1836, the first data for an ultimate 
and more thorough understanding of the physiological and 
chemical functions of the stomach were given. These dis- 
coveries, with those of Reaumur and Spallanzani, formed 
the foundation upon which ultimate gastric pathology was 
to rest, and upon which a structure has been erected to 
which modern medicine points with just pride. 
“ The way to pathology is through physiology,” says 
Ewald (1) in his well-known work, and the more we deal 
with this subject the firmer is the truth of that statement 
impressed upon our minds. It is not the study of the pep- 
tonizing function alone which claims our attention, hut it is 
the proper understanding of the entire work which is per- 
formed in this human laboratory, including a large part of 
the alimentary canal, and a thorough appreciation of the 
relations which each function hears to the others, that makes 
a rational anatomical diagnosis and indications for treat- 
ment possible and in many cases positive. 
While we may not he able from this discussion to draw 
positive conclusions, it will be the endeavor of all who take 
part in it to treat the subject without prejudice, for the bet- 
ter understanding of the profession generally, which has 
not yet given it sufficient thought or the study which is 
needed to estimate the relative values of these newer meth- 
ods of examination to the diagnostician of internal dis- 
eases. 
History.—Though it is a fact established beyond con- 
troversy that the stomach tube had been used for various 
purposes before 1869, it was Kussmaul (2) who during that 
year became the pioneer in the treatment of stomach dis- 
eases by the use of the stomach pump and tube. He took 
advantage of the instrument which had for some time been NEWER METHODS OF-STOMACH EXAMINATION. 
5 
used in America for emptying the thoracic cavity in cases 
of empyema (Kussmaul (2), Martius (3)). 
Liebenneister (4), in commenting on this subject, 
prophesied that the manoeuvre of Kussmaul would proba- 
bly mark an epoch in the treatment of chronic diseases of 
the stomach. 
In 1871 Leube first recommended the stomach tube for 
purposes of diagnosis, since which time a band of earnest 
workers in Europe, headed by Leube, Kussmaul, and Rie- 
gel, with recruits such as Ewald, van den Yelden, v. Noor- 
den, Sticker, Honigman, Boas, Leo, and others in Germany, 
Hayem and Winter in France, and in our own country such 
men as Kinnicut, Einhorn, and Stockton have done much to 
clear the way for a thorough discussion of the questions 
with which we are to-day dealing. 
A genuine impulse was given when, in 1874, Ewald sub- 
stituted the soft, flexible tube for the stiffer, less elastic one 
which until that time had been used. 
Physiological Data.—For the better understanding of 
this discussion you will bear wTith me if 1 hurriedly rehearse 
a few physiological data which must serve to make clear the 
digestive activity of the stomach. 
I. The fact may be accepted as proved by Miller (5) 
that the saliva is brought in contact with micro-organisms 
in the food, and others wdiich find a habitat in the mouth. 
It is supposed that there are two groups of these organisms, 
which, both in the mouth and in the stomach, give rise to 
actual fermentation. The one group, in the presence of the 
saliva, decomposes carbohydrates with the formation of an 
acid ; the other causes a disorganization of albuminoids with 
alkaline products. The first class is said to give rise to the 
production of lactic and fat acids, which in turn, according 
to Bokai (6), even in small quantities, particularly the for- 
mer, have a salutary effect in stimulating intestinal peristal- 6 
NEWER METHODS OF STOMACH EXAMINATION. 
sis. Whether the presence of lactic acid in the secretions 
after leaving the buccal cavity is ever normal we will con- 
sider later in this chapter. 1 mention the matter here to 
remind you that modern physiologists and pathologists are 
attributing more than a simple amylolytic action to the 
saliva. 
II. The amylolytic action continues, as a rule, for some 
time after the changed starch is introduced into the stomach, 
particularly if accompanied by albuminoids. The further 
conversion should cease in the normal stomach with the in- 
crease of hydrochloric acid secretion, and after the forma- 
tion of syntonin or acid-albumin (Wesner (7), While (8), 
Boas (9)). 
III. The introduction of saliva into the stomach has a 
direct stimulating effect on the gastric mucous membrane 
(Sticker (10)). 
IV. It may be stated almost with certainty that, as a rule, 
the normal stomach is empty during the fasting period, its 
membrane is pale, covered with a layer of mucus, either 
neutral or alkaline. It contains no gastric juice. If hydro- 
chloric acid is present, it is a remnant of a former digestive 
process, or the passage or presence of the tube has caused 
it (Wille (11), Ewald (12), Foster (13), Kinnicut (14)). 
Y. Variation in the functional activity of the stomach 
must be expected according to the character of the food ingest- 
ed. (This is one of the fundamental rules of modern gastric 
physiology, and must always be considered when engaged 
in the diagnosis of stomach diseases.) 
VI. Direct irritation of the mucous membrane of the stom- 
ach is necessary for the secretion of the gastric juice. Nor- 
mally, it is the food which causes activity immediately upon 
its entrance into the stomach. 
VII. Lactic acid is never present in the stomach after the 
first period of digestion; upon this conclusion all writers NEWER METHODS OF STOMACH EXAMINATION1. 
7 
seem to agree. There is said to be an intermediate stage 
during which it is held that lactic acid is present with hy- 
drochloric acid (Ewald(15)). 
This lactic acid is not to be considered as a result of 
glandular secretion, but it is due to a process of fermen- 
tation already described, accompanying the digestion of 
carbohydrates or the ingestion of meat (Pasteur (16), 
Huppe (l?)). Lactic acid is not present when pure egg 
albumin alone is taken. 
With the establishment of an abundant hydrochloric- 
acid secretion, and ultimate free hydrochloric acid in the 
stomach, lactic acid disappears (Miller (18), F. Cohn (19)). 
As the result of experiment with a pure meat diet I have 
been able to verify the truth of Boas’s statement that lactic 
acid is occasionally present shortly after the beginning of 
digestion in very small proportion. In contradistinction to 
what is taught in all the newer text-books, Martius (20), in a 
recently published work dealing alone with the gastric juice, 
holds that in “ the normal process of digestion other acids 
than HC1 are not to be taken into consideration ”—in other 
words, are not present; that lactic-acid fermentation to any 
discoverable extent is always pathological. He opposes the 
division of the digestive process into three periods, as made 
by Ewald and Boas (21) : 
1. Period in which lactic acid is found. 
2. Period in which lactic acid and IIC1 are found. 
3. Period in which HC1 alone is present. 
The safest conclusion for us to accept with our present 
knowledge is that lactic acid is not normally present in the 
stomach during the digestive period, unless the ingested 
food contains carbohydrates in a process of fermentation— 
i. e., the fermentation lactic acid or the sarcolactic acid as 
introduced by meat. 
VIII. It may be taken for granted that the most important 8 
NEWER METHODS OF STOMACH EXAMINATION. 
constituent of the gastric juice which the physician is called 
upon to take into consideration in conjunction with the chem- 
ical analyses of the stomach contents for purposes of diagno- 
sis is hydrochloric acid. While the chemical analysis is 
usually confined to the detection of the presence or absence 
of free IICl, it must not be forgotten that the free acid found 
in the later stages of digestion is but a remnant left after 
the thorough combination of IIC1 with the albuminoid ele- 
ments of the food and other bases (Martius (22)). 
IX. HCl is secreted free, molecule for molecule, by the 
glandular structures of the stomach. It is quickly brought 
in contact with the food and other secretions in the stom- 
ach, when the period of its utility begins without delay 
(Bidder and Schmidt (23), Martius (24)). 
This statement is made in contradiction of the opinion 
of the French school, as represented by Hayem and Winter, 
which holds that absolutely no IIC1 is secreted as such, but 
that it results from a combination ultimately formed by a 
chemical change of the chlorides, more particularly the 
chloride of sodium, during the process of digestion. 
X. HCl with the pepsin secreted by the peptic glands 
forms the agent which is instrumental in the ultimate pepto- 
nization of the albuminoids, and this is the most important 
function of the gastric juice. 
XI. It may be taken for granted that the average time 
when free HCl can be detected in the stomach contents after the 
ingestion of food is about one hour. With large meals and 
coarse food it may be considerably later, depending largely 
upon the quantity and quality of the food ingested (Rie- 
gel (25)). The largest amount of free IIC1 is present two 
hours after the ingestion of the ordinary trial meal, when it 
comprises, as it does at the height of the digestive process, 
the largest part of the acid constituent of the gastric juice 
(Lowenthal (26)). NEWER METHODS OF STOMACH EXAMINATION. 
9 
This fact has been emphasized by me for some time 
past, and we now find that Lowentbal’s (27) experience 
verifies the truth of the statement made above. He found 
that with the trial meal of Riegel, with the total acidity of 
56'5, there was present 35’5 free HC1 one hundred and 
twenty minutes after the taking of the meal. 
(This physiological fact leads me, in practice, to express 
the stomach contents somewhat earlier than has ordinarily 
been recommended, and taken in conjunction with the fact 
that the amount of free HC1, as well as the total acidity, 
are subject to variations, it would lead to repeated ex- 
aminations at corresponding periods of digestion, on dif- 
ferent days, to determine the working condition of the 
stomach.) 
XII. The peptogenic function of the stomach may be di- 
vided into three stages, in each of which the changed albumi- 
noid can be studied, and gives characteristic reaction. The 
first combination resulting gives rise to an acid albumin or 
syntonin, simply a more thorough combination of albumin 
with the acid. The second is the stage in which propeptone 
is found; this leads to a third stage, when normally the 
process of peptonization is ended and peptone has become 
the final product of albumin digestion, ready to be absorbed 
or pushed onward to meet its fate in the duodenum. 
XIII. The percentage of free HCl present in normal gas- 
tric juice averages between O'15 and 0m22 per cent. Any 
considerable deviation from these figures may be consid- 
ered abnormal. 
XIV. Rennet is present in the gastric juices and, like pep- 
sin, is a constant constituent (Raudnitz (28), Boas (29), 
Johnson (30), Klemperer (31), Rosenthal (32)). 
XV. The presence of bile in the stomach interferes with 
the free performance of gastric digestion. 
XVI. The normal digestion of starch precludes the possi- 10 
NEWER METHODS OF STOMACH EXAMINATION. 
bility of the presence of achroodextrin, maltose, or dextrose, 
after one hour of stomach activity (Ewald (33)). 
XVII. Normally, evidences of absorption from the mu- 
cous membrane of the stomach should be found on chemical 
analysis to have taken place in from fifteen to twenty minutes 
after the ingestion of food or drugs (Penzoldt and Faber 
(34), Ewald (35), Wesener (36)). 
XVIII. Normally, the stomach is empty, the changed 
food having passed the pylorus between six and seven hours 
after the beginning of its digestion (Leube (37), Riegel (38), 
Wesener (39)). The motor function normally ought to 
force a bolus, which is not digested in the stomach, into 
the small intestine before the end of seventy-five minutes 
after taking it, as has been demonstrated by Ewald (40), 
also Klemperer (41). 
The following chart shows the changes which are dem- 
onstrated by the newer methods of examination in the se- 
cretory, motor, and absorptive functions of the stomach, 
with a tabulation of the diseases with which such changes 
are often associated. 
1. The qualitative changes are usually dependent upon a 
process of abnormal fermentation. These are accompani- 
ments of the various forms of indigestion which have also 
well-marked quantitative changes in the gastric juice, more 
particularly associated with a deficiency of the acid of the 
secretion. 
2. Quantitative changes. 
a, 1 and 2. The deficient secretion of the gastric juice 
is, as a rule, attended with a greater lack of free HC1 than 
of the pepsin element. With this lack of sufficient free 
IIC1 it may be taken for granted that the period of diges- 
tion is materially prolonged, that fermentation is likely to 
take place, and that the albuminoids are tardily and faultily 
digested. In the fluid taken from a stomach in which 1. Qualitative 1. With abnormal fermentation—usually associated with quantitative changes. 
2. C a, 1. Anaemia, general and local neuroses. 
f a, 1. Deficiency of the r . , (Tubei culosis, 
secretion and free s 1 Diabetes 
HC1 production. Beginning chronic gastritis, mental diseases, acute febrile diseases, diseases of 
the heart, lungs (emphysema, bronchitis), chronic nephritis. 
' «, 2. Physiological in early stages of digestion. 
Cancer of stomach, chronic catarrh of stomach, atrophy of gastric follicles, re- 
gurgitation of bile, secondary changes due to impeded circulation. 
( Tuberculosis, Amyloid diseases, Diabetes mellitus, 
„ _ Constitutional diseases. Syphilis, Addison’s disease, Leucocytosis. 
. ecie- j a, 2. Anacidity. - (Cancer (?), Pernicious anaemia, 
, 0IJ i | J Uterine disorders and those of annexa. 
c an& s. Quanti- ' Cancerous disease of liver, pancreas, duodenum, and colon [Boas (42)]. (Denied 
tative. by Leube (43) and by the author as result of clinical experience.) 
Alkaline and caustic poisons—also with large doses of alkalies not poisonous 
[Boas (44)]. 
i tt . • r. T •,, b. Gastric neurosis, ulcer of stomach and duodenum, polypoid gastritis, cicatricial 
' ua'ntitv" \)f laise with central ulceration (stomach). 
, . . . • 1 Gastric ulceration resting on a carcinomatous base, without far-reaching infil- 
gastnc Juice. [ tration. 
c. Hyperacidity and hy- j c. Neuroses (gastric), ulcer of stomach, gastroxynsis [Rossbach, Reichman (45)]. 
persecretion. ) Gastrorrhoea acida simplex (Jaworski), non-cancerous gastrectasia. 
, TT .. d. Rarely found alone, occasionally with alcoholic gastritis. 
[ <1. Hypersecret,on. j Usualfy accompanies hyperacidity. 2. f a. Hysteria, neurasthenia, idiopathic form of nervous vomiting [Leyden (46)], 
tormina ventriculi [Kussmaul (47)] (peristaltic unrest), rapid emptying (i. e., 
a. Increased motor activity. < hypermotility) of ingesta into the duodenum [Leo (48)]. Spastic closure of 
cardia [Poensgen (49), pylorismus, spastic closure of pylorus [ZLemssen (50), 
Kussmaul (51)]. 
f Anaemia, chlorosis, improper diet, phthisis, leukasmia, 
6,1. Weakened motor J alcoholism, diabetes mellitus, amyloid degeneration, 
force. Atony. | syphilis, acute infection (typhoid, etc.), cholera, puer- 
[ peral fever, chronic catarrh of the stomach. 
2. Motor J [ Obstruction (usually at pylorus, carcinomatous, cicatri- 
changes. j cial, non-malignant tumor). 
2. Changes in the Gastrectasia. 
b. Diminished motor activity. - stomach. Ulcer, cancerous degeneration of stomach wall. 
Hypertrophy of muscular coat with congenital narrowing 
[ of pylorus. 
f Tumors pressing on pylorus. 
„ „ , , . Adhesions to neighboring organs (gall bladder), liver, 
3. Extra gastric , , ® n a \o n ■> 
a pancreas, dnocleniim. 
pres.suie. , Ljgamen^ous i)ands. 
[ Hernia [Boas (52)]. 
• (a. and 6. 
Diseased gastric mucous membrane (often accompanied with atrophy of the 
3. Absorp- «■ Tardy absorption. gastric follicles). 
tive ] ] Connective-tissue overgrowth in stomach wall, 
changes. Cancerous infiltration. 
b. Complete absorptive failure. Amyloid disease. 
Impeded circulation from whatever cause. NEWER METHODS OF STOMACH EXAMINATION. 
13 
there is deficient HC1 after a trial meal we find the meat 
undigested, its fibers slightly swollen, but little changed. 
Lactic acid and other organic acids are present after we 
have reason to expect an active digestive period. 
There may be either reduced HC1, or the quantitative 
change may show anacidity. 
b. Hyperacidity with normal quantity of gastric juice. 
This change we often find in both acute and chronic 
diseases of the stomach. With Iteigel, we consider these 
cases as including only those in which the hyperacidity can 
be demonstrated during the digestive period. Any excess 
of HC1 above 0*3 per cent, may be considered as belong- 
ing to this class. In contradistinction to the anacid or 
deficient IIC1 gastric secretion, we find with hyperacidity 
the albuminoids well and rapidly digested in the majority 
of cases. In some cases, and these have been carefully de- 
scribed by Sticker, we find the meat digestion tardy, owing 
to the disproportion between the pepsin and I1C1. 
c. Hyperacidity and supersecretion. 
We classify under this division such cases as are sup- 
plied with a gastric juice of good digestive quality, but in 
which there is an overactivity of the secretory glands, giv- 
ing rise to an almost continuous acid secretion independent of 
the digestive period. 
It is possible, therefore, to express from the stomachs 
of these patients, long after digestion has ceased, a fiuid 
which is free from all remnants of ingested foods, but on 
examination is found to be sufficient to digest albuminoids. 
This condition can only be diagnosed after emptying the 
stomach thoroughly, and allowing a period to lapse with- 
out the ingestion of food, when the tube is introduced 
and a fiuid extracted with the characteristics already men- 
tioned. As a rule, the motor function of the stomach in 
these cases is faulty ; there remain in the stomach undi- 14 
NEWER METHODS OF STOMACH EXAMINATION. 
gested starch and undivided bread particles; but, as a rule, 
the meat has been thoroughly and completely digested, 
and fermentation is not likely to occur. 
d. Super secretion. 
It is a question whether there is a simple supersecretion 
which is unattended by hyperacidity. Riegel’s experience 
emphasizes the statement that hyperacidity can occur alone, 
while supersecretion, in its most pronounced forms, is, as a 
rule, which is almost without exception, accompanied with 
hyperacidity. 
2. a and b. Motor disturbances may be considered to 
be due to secondary changes. There may be overactivity 
or motor weakness. The more severe cases of the latter 
are found with some impediment to the free emptying of 
the stomach at the pylorus, when there may be simple dimi- 
nution of the motor function, or it may be almost com- 
pletely abolished. Believing, as I do, that a disturbance of 
the motor function is rarely found without some fault in 
the gastric chemical function, I am anxious to impress 
upon you the importance of gaining positive evidence of 
the motor strength, and giving to each abnormity of mo- 
tion its proper significance. The clinical evidences which 
this paper is to furnish will, I think, in conjunction with 
what Professor Stockton shall offer in detail, on this sub- 
ject, prove the value of a thorough understanding of the 
motor function of the stomach. In very many doubtful 
cases, indeed, I hold that, when coupled with absorptive 
disturbances, it furnishes data of equal if not greater im- 
port than are supplied by a study of the secretory function 
alone; for if the latter be at fault, we may still hope, with 
a sufficient motor function, to advance the food into the 
duodenum, for its ultimate digestion and absorption there. 
3. a and b. Absorptive changes. 
Tardy or complete failure of the stomach to absorb NEWER METHODS OF STOMACH EXAMINATION. 
15 
must be taken into account for the better understanding of 
the condition of the mucous membrane of that organ. 
If the accompanying chart is carefully studied it will 
be found that here, as in most diseases which require thor- 
ough physical examination for their accurate diagnosis, 
there is no one change in either secretion, motion, or ab- 
sorption which is pathognomonic or which justifies a posi- 
tive diagnosis. 
The practical value of the newer methods of examina- 
tion of the stomach and its contents lies in the knowledge 
which we gain of the changes in the functional activity of 
that organ, as epitomized above, and the addition of such 
information to our other subjective and objective symptoms. 
Our fondest hope can not make the results more than con- 
firmatory, while the study of these methods emphasizes the 
importance of adding every detail which all cases present. 
Absence of Free HCl.—Within the past few years the di- 
agnostic value which had been accorded to the absence of 
free HCl from the stomach during the height of digestion 
has been materially modified, and we are daily leaning more 
toward the conclusion that it points more directly to a dis- 
turbed function and less to any one diseased condition of 
the stomach. 
The diagnostic value of the absence or diminution of 
free HCl in the stomach secretion, associated more particu- 
larly with pyloric cancer and ultimate dilatation, was first 
systematically investigated by R. von den Velden at the 
clinic of Kussmaul in Strassburg. 
It seems strange that the knowledge of this fact, which 
was given to the profession as long ago as 1842 by Golding 
Bird (53), did not lead to its application for diagnostic pur- 
poses. Bird’s patient was a man, aged forty-two, with py- 
loric cancer and dilatation. The diagnosis was verified by 
autopsy. Bird made three chemical analyses in about three 16 
NEWER METHODS OF STOMACH EXAMINATION. 
weeks, and concluded that “ during the more irritative stage 
of the disease free HC1 is present in the vomit in consider- 
able quantities ; hut it gradually diminishes in proportion to 
the patient’s loss of strength, and the organic acids increase 
proportionally as the free HCi diminishes.” 
It has been held that the absence or diminution of HCI 
from the gastric secretion is an almost constant attendant 
of all forms of cancers, regardless of their location or histo- 
logical structure. That this is not true I am able to state 
positively as the result of experimentation during the past 
two years in eight cases of cancer — three uterine, two 
omental, with ultimate secondary nodules in the liver, two 
recurring cancers of the breast, and one medullary cancer 
probably of the right kidney after removal of the right tes- 
ticle for the same disease about one year previous. In all 
of these eight cases Leube-Riegel test meals were given and 
repeated chemical examinations were made with positive re- 
sults. HCI was present, both combined and free, in over 
ninety per cent, of the tests. In the case of cancer of the 
right kidney IIC1 was absent at times, owing to the regur- 
gitation into the stomach of the bile, due to extra-intestinal 
pressure and constriction. 
In conjunction with the study of the importance of free 
HCI as a diagnostic sign, we must remember that in not a 
few cases a feeble digestive process has progressed without 
the characteristic color reaction at the height of digestion. 
It must not be taken for granted that digestion begins at 
the moment when the secretion is expected to react to these 
tests; but let the clinician note that at that time a large part 
of the stomach work has been done and digestion is almost 
ended (Martius (54)). “ Free IICl ” might then more prop- 
erly be spoken of as “ surplus IICl.” It is, in fact, the rem- 
nant left after all affinities have been satisfied. 
Cancer of the Stomach.—The pathological condition with NEWER METHODS OF STOMACH EXAMINATION. 
17 
which absence or diminution of IICl has been most frequent- 
ly associated by clinicians is cancer of the stomach. With 
your permission I will spend a few minutes in considering 
the diagnosis of this condition, with special reference to the 
newer methods of examination of the stomach contents. 
The positive statement is made by Riegel (55) (after 
emphasizing the fact that our examinations must be oft-re- 
peated and made with accuracy and reliable reagents before 
formulating conclusions) “ that the constant presence in a 
gastric juice of free HCl and a normal peptic strength al- 
lows the exclusion of cancer of the stomach with certainty, 
regardless of the other symptoms, however strongly they 
point to that disorder.” 
If we accept the statement of Riegel, we are forced to 
determine the factor which causes the changed secretion and 
functional inactivity. That there is nothing in the cancer 
per se to check the HCl secretion is shown by innumerable 
cases of cancerous diseases of other organs, as already men- 
tioned, in which free IICl is almost always present in the 
gastric juice. It has been the experience of others that in 
a few cases of cancer of the stomach free HCl continues in 
the gastric secretion, and within the past three years the 
writer has had a similar experience in two cases in which 
free HCl could always be demonstrated at the height of di- 
gestion. In all of these cases there has been a functionally 
active gastric juice. In both of my cases the autopsies re- 
vealed the presence of cancer of the stomach, but without 
the usual accompaniment of far-reaching atrophy or degen- 
eration of the gastric follicles. The writer has notes of an 
autopsy made during the winter of 1890 in a case of pneu- 
monia ending in three days where the patient was also in 
the early stages of cancer of the stomach. In this case 
there was always presence of free IICl. The post-mortem 
showed a small scirrhous nodule at the pylorus ; the mucous 18 
NEWER METHODS OF STOMACH EXAMINATION. 
membrane of the stomach was hut little changed ; the mi- 
croscope gave evidences of unchanged peptic glands. 
Without dilating too long on the causes of anacidity in 
cancer of the stomach, it may be assumed with great cer- 
tainty that the prime factor in its causation is the infiltrat- 
ing character of carcinoma, involving the glandular elements 
of the stomach in a process of atrophy with more or less ad- 
ditional gastritis. 
Jaworski and Gluczinski (56) held that in cancer of the 
stomach there was no free HC1, little pepsin, and no pep- 
tones. Their study of the subject seemed to them sufficient 
to justify the conclusion that with free HC1 and normal di- 
gestive faculty carcinoma should be excluded. To this view 
Ewald (57) also subscribes. How contradictory are the 
statements of Cahn and v. Mering (58), who conclude that 
“ with cancer of the pylorus the presence of HC1 is the rule, 
its absence the exception ” ! 
The largest' number of examinations have been made by 
Riegel (59), who reports two hundred and seventy-four 
analyses in thirteen cases. Free HC1 was never detected. 
He (Riegel (60)) reported three cases of cancer of the stom- 
ach in which a feeble IIC1 reaction took place early in the 
disease. 
Rosenheim (61) reports sixteen cases, in fourteen of 
which there was an absence of free IIC1; in the other two 
there was a transitory presence of free HC1 and hyperacid- 
ity, respectively. 
Kinnicut (62) reports eight cases with one hundred and 
thirty-two analyses. Free HC1 was demonstrable only in 
two cases, in one of which a trace was detected in two ex- 
aminations out of twelve ; in the second a feeble HC1 reac- 
tion was once obtained. 
In ten cases under my own observation with one hun- 
dred and twenty tests, free HC1 was absent in 92-7 per NEWER METHODS OF STOMACH EXAMINATION. 
19 
cent, of the tests, and present, as a rule feebly, in 7‘3 per 
cent. 
Thiersch (63), in an interesting article On the Presence 
of Free IIC1 in the Gastric Juice in Beginning Cancer of the 
Stomach, reports a case in which HC1 was present, and 
Krause (64) has established beyond doubt the fact that IIC1 
may persist in cases of ulcerating carcinomata of the py- 
lorus. A continuous absence of HC1 is found in all cases 
in which there is atrophy or amyloid degeneration of the 
mucous membrane of the stomach accompanying cancer 
(Levy (65), Edinger (66)). 
In considering the diagnosis of gastric cancer from the 
chemical analysis of the stomach contents, it must be re- 
membered that in most forms of gastritis (Boas (67), Ja- 
worski (68)) HC1 is reduced (from 0*22 per cent., 028 per 
cent., to 0T217 per cent.). 
Boas has found that in marasmus, Riegel (69) in fever, 
Honigman in regurgitated bile (a fact to which I have al- 
ready referred in my own statistics) free HC1 is absent, and 
Grundzach (70) has shown that in perfectly healthy indi- 
viduals with normal digestion there may be a transitory 
deficiency of free HC1. 
With such data before us no one will assert that we are 
justified in diagnosticating cancer of the stomach from the 
absence or presence of free 1IC1 alone, while in the majority 
of cases of cancer of the stomach, as shown by the results 
of the tests made by Riegel, Rosenheim, Kinnicut, and my- 
self, absence of HC1 has been demonstrated ; “ the diagnos- 
tic value of this circumstance is materially lessened by the 
occurrence of this same deficiency in other diseases with 
similar symptoms.” Ewald (71) concludes: “But granting 
this, the proposition which I was the first to announce is 
still true, that the demonstration of the presence of HC1 
points with very great probability against the existence of 20 
NEWER METHODS OE STOMACH EXAMINATION. 
cancer of the stomach, for the cases of this disease in which 
there is a positive reaction to the carefully applied tests 
are so rare that they have very little hearing on the ques- 
tion.” 
1. Latency of Gastric Cancer.—The frequent examina- 
tion of the stomach contents has demonstrated, to my mind, 
at least, the fact that in a large number of cases there are 
periods of latency during which there remains a certain 
amount of functional inactivity, but in properly managed 
cases immunity from many of the painful and depressing 
symptoms of the original disease. 
Latent gastric cancer has not been generally recognized, 
and in many cases the first and correct diagnosis has been 
changed by the unsuspecting physician, owing to this 
period of latency with evident improvement and deviation 
from the ordinary course of the disease. I have in mind 
at this time a number of cases, and in most of them, if 
seen sufficiently early, there is decreasing 1IC1 in the secre- 
tion, a tardy absorption, with more or less motor involve- 
ment, according to the location of the tumor and the 
amount of secondary dilatation with the period of latency. 
The examination of the stomach contents shows no im- 
provement, neither does the amount of IICl vary mate- 
rially from that found at the beginning of the period of 
latency. 
In many of these cases the olive-oil and salol tests 
prove increasing motor strength, and in those patients who 
have accompanying glandular atrophy and yet show general 
improvement it may he assumed that constriction does not 
exist to any great degree, and that the duodenum and in- 
testines are performing their functions with sufficient ac- 
tivity to nourish the patient. It follows, therefore, that 
the cases in which we most frequently find latent gastric 
cancer are either those with localized tumor without much NEWER METHODS OF STOMACH EXAMINATION. 
21 
constriction and ultimate gastrectasia, or the infiltrating 
variety, with only moderate thickening at the pylorus. 
It is surprising to note the length of time during which 
the disease remains latent and the long duration of the dis- 
ease as a result of these periods of latency. 
I have at the present time a case under observation 
which has continued for almost six years—that of a woman, 
now sixty years old, which, seven years ago, commenced with 
vague symptoms of indigestion and anorexia. For two 
years there was an increase of these symptoms, with the 
characteristic changes in the blood found in cancerous dis- 
eases, as shown by microscopic examination. Four years 
ago she had coffee-ground vomit, and later considerable 
hsematemesis. Three years ago there was almost complete 
absence of HC1, with tardy absorption and weakened motor 
strength. With these symptoms no tumor could be felt, 
neither was there gastrectasia. At that time she com- 
menced to improve; trial meals showed absence of HC1, 
but the motor function had improved so that gradually the 
stomach learned to empty itself, to allow of the more thor- 
ough digestion in the small intestine. The subsequent 
history shows periods of exacerbation and latency until 
now, when we find a well-marked tumor in the anterior 
stomach wall, as shown by distending that organ, and sec- 
ondary nodules in the groin, and probably in the liver. 
Some may say that this was originally a case of ulcer 
which now has a carcinomatous base. This is not proba- 
ble, for there has been no time when there was hyperacid- 
ity or supersecretion, always deficient IICl; at no time was 
the secretion of the stomach competent to digest albumi- 
noid foods, while the seat of the tumor, with the early 
cachexia and blood changes, preclude the presence of an 
original ulcus ventriculi. In these cases of latent cancer 
without tumor formation the disease strongly resembles 22 
NEWER METHODS OF STOMACH EXAMINATION. 
pernicious anaemia; but here the microscope comes to our 
aid and the experienced haematologist will have no trouble 
in distinguishing. 
Henry (72), in a clinical lecture on diagnosis of cancer 
of the stomach, says: “I had under my care at the same 
time two cases—one with pernicious anaemia, the other with 
cancer of the stomach. The latter was far more emaciated, 
far more feeble than the former, while the red blood-cor- 
puscles were four or five times as numerous. Surely nothing 
in the whole held of clinical medicine can be more diag- 
nostic than such facts. In carcinoma of the stomach the 
reduction of the number of red blood-corpuscles does not 
keep pace with the cachexia; in pernicious anaemia the 
cachexia does not keep pace with the reduction of the red 
blood-corpuscles.” 
2. Infiltrating cancer of the stomach without distinct 
tumor formation is not of infrequent occurrence. Unless 
the intiltration or new tissue formation in the neighbor- 
hood of the pylorus is sufficient to cause constriction with 
more or less dilatation, the diagnosis between this con- 
dition and atrophy of the gastric follicles becomes very 
difficult. 
Here again our tests will come to our assistance if 
made, for physical signs will not avail until secondary 
changes have taken place. In both, IIC1, pepsin, and ren- 
net may be absent. In atrophy there is never hsemateme- 
sis, while the presence of altered blood and pigment gives 
the stomach contents a characteristic color in carcinoma 
(Ewald (73)). 
With infiltrating cancer we find— 
a. During fasting, the presence of the food taken the 
day before in the stomach. 
b. With trial meal, absence of free 1101. 
c. Lactic acid present. NEWER METHODS OF STOMACH EXAMINATION. 
23 
d. Progression of disease, never an improvement of 
functional activity of the stomach. 
3. Pyloric Carcinoma, Stenosis, and Gastrectasia.—In 
these cases the symptoms gradually appear. If the patient 
presents early, there is complaint of occasional vomiting, 
with more or less sternal and epigastric distress. As the 
disease advances, even before the tumor is palpable, per- 
cussion elicits a changed note over or near the normal loca- 
tion of the pylorus. 
The examination of the stomach contents after a test 
meal shows acidity due to the organic acids, lactic mainly. 
The food taken during the previous day is found in the 
stomach. As a rule, free IIC1 is absent; if not entirely 
absent, is reduced in quantity. As the disease advances 
there may still be presence of pepsin in a reduced quantity, 
while rennet may or may not be present, also peptone and 
propeptone. 
It may he taken for granted that if, on repeated exami- 
nation with the tube and with a proper diet, composed in 
part of albuminous food, the stomach retains the ingesta, 
but slightly changed and undigested for more than seven 
hours, a constriction is present at the pylorus; and if free 
HC1 is absent, with the absorptive function of the stomach 
deranged, the chances are decidedly in favor of carcinoma. 
Dilatation is usually present under such circumstances; if 
not, it will not be long in showing itself. The amount of 
fluid expressed through the tube gives an approximate idea 
of the degree of the constriction and the amount of gas- 
trectasia. 
4. Carcinomatous Infiltration ofi the Base of Old Ulcers 
(particularly at the Pylorus).—From seven to nine per cent, 
of all gastric cancers are located in and take their origin 
from ulcers (Haberlin (74), Rosenheim (75)). 
In a private communication from Professor Billroth, to 24 
NEWER METHODS OF STOMACH EXAMINATION. 
which I will again refer, he writes: “ I consider the differ- 
ential diagnosis of an ulcer of the stomach with cicatriza- 
tion and beginning carcinomatous infiltration from primary 
cancer as very difficult and usually impossible—ofttimes 
impossible when the fresh specimen is before us and cut 
into, only possible after many and large sections have been 
microscopically examined.” It may be said at this junc- 
ture that given a case (Rosenheim (76)) in which there is 
tumor formation, pain, anorexia, and rapid emaciation, 
with the characteristic blood changes of cancer, free HC1 
constantly present at the height of digestion, with possibly 
hyperacidity and ultimate gastrectasia, we may conclude 
with a considerable degree of certainty that we are dealing 
with a cancerous infiltration of the base of an old gastric 
ulcer. Here, too, we must be careful to exclude extra- 
gastric growths, which cause compression of the pylorus 
and dilatation in consequence, and may at the same time 
have accompanying hyperacidity. Such cases have been 
reported by Plawski (77), who dilates very fully on this 
subject in his article. 
5. Localized cancers without constriction and with but 
little glandular atrophy occasionally occur, and HC1 may 
continue to be present in the secretion until within a short 
time before death. 
Here the diagnosis requires a thorough physical exami- 
nation. The stomach must be outlined after the method 
of Piorry and allowance must be made for absorptive and 
motor functions according to the location of the neoplasm 
and the extent of the change in the mucous membrane as 
the disease progresses. 
6. Non-malignant and Fibrous Stenoses of the Pylorus.— 
In this connection it must not be forgotten that there are 
cases of non-malignant and fibrous stenoses of the pylorus. 
In many of these cases we have a previous history of ulcer, NEWER METHODS OF STOMACH EXAMINATION. 
25 
with attending hyperacidity, characteristic pain, and haemor- 
rhage. In other cases the stenosis is gradually formed, 
the aetiology remains obscure, and a differentiation from 
cancerous obstruction becomes necessary. 
In fibrous stricture we find IICl present, in some cases 
in excess, peptic action slow, but ultimately satisfactory. 
In thirty-three cases studied by Riegel (78), he found O'lO 
to 0'46 per cent, of IICl, and in twenty cases titrated by 
Ewald (79) he found 0'17 to 0'30 per cent, of the acid. 
As a rule, after the Ewald test meal, I have found 
hyperacidity, similar to the experience of Einhorn, as re- 
lated to me in a personal communication of great value. 
Free IICl is present, food is held in the stomach longer 
than normal, while albuminoids are changed and partially 
digested, while the organic acids, particularly lactic acid 
and butyric acid, are present and in the ascendency, dis- 
placing in some cases the free HC1, which is again found 
after thorough disinfection and washing out of the stomach. 
In most of the modern works on carcinomatous diseases 
of the stomach it appears to the writer that too little im- 
portance has been placed on a more careful study of the 
motor and absorptive function of the stomach, while the 
IICl estimation has been constantly placed in the fore- 
ground. 
The newer methods of diagnosis must include in the 
diagnosis of gastric cancer the frequent examination of the 
blood for haemoglobin as dwelt upon by Ilaberlin (80) in 
his monogi'aph, and the examination of the urine for 
indican (Rosenheim (81)), in order to give valuable in- 
formation. 
In association with the subject of cancer of the stom- 
ach, with your kind permission I will report two cases 
which show the value of examination of the stomach con- 
tents as an aid in differential diagnosis: 26 
NEWER METHODS OF STOMACH EXAMINATION. 
Case I.—On the 27th of May, 1891, I was called to see 
Ellen R., aged forty-two, unmarried, with a negative family 
history. For several months she had been complaining of a 
feeling of distress after taking food, pains radiating through, the 
upper half of the abdomen, progressive but gradual emaciation, 
with increasing muscular enfeeblement and considerable anaemia. 
The pains bore no relation to the ingestion of food, though 
she complained of flatulence about two hours after her meals. 
She had vomited at various times during the preceding two 
months, never blood, usually a light-yellow, sour-tasting, but 
not foul-smelling fluid. 
At times the vomited matter had been of a darker, almost 
brown color. There wei’e no other subjective symptoms save 
a chronic constipation. Ovarian and uterine functions were nor- 
mal, though she gave a vague history of a pelvic peritonitis, for 
which she had been treated about two years before the begin- 
ning of the symptoms of which she now complained. There was 
also a slight accentuation of the mitral sounds over that area. 
With these symptoms, the character of the pain, the vomiting, 
more particularly the occasional ejection of a brownish, almost 
coffee-colored fluid, malignant disease of the stomach or duo- 
denum was strongly suspected. 
Physical examination of the abdomen at the first visit failed 
to give satisfactory evidence of the existence of such a lesion. 
On pressure over the epigastrium there was increased tender- 
ness, while percussion was normal all over the abdomen. The 
size of the stomach was tested after the method of Piorry and 
Penzoldt, and was found to be normal. After this she refused 
the trial meal, preferring treatment for a number of days before 
the reintroduction of the tube. An examination of the urine 
at this time showed it to be normal, with a specific gravity of 
P024. During the week following, the patient's condition did 
not change materially. On the 5th of June, about nine days 
after my first visit, the patient was given a Leube-Riegel test 
meal, which was expressed after five hours by means of a soft 
tube, when it was found that most of the albuminoid food had 
been digested. The extracted remnant contained neither starch 
nor any of its products, gave positive evidence of the presence of NEWER METHOD!? OF STOMACH EXAMINATION. 
27 
HOI with Congo paper and the Gunzburg test, as well as 
that of Boas. The amount of HOI was 0’25 per cent. The 
Uffelmann test failed to show the presence of organic acids. 
The test for pepsin and rennet showed a good digestive fluid. 
The result of this examination, after the strong suspicion of 
gastric cancer, was surprising and puzzling. The test of the 
motor function with salol, and the absorptive function also, 
showed normal motor and absorptive activity. Gastric cancer 
was at once excluded, though I now leaned very strongly, 
strengthened by the increasing emaciation and antemia of the 
patient, to the diagnosis of malignant disease of some one of 
the abdominal viscera other than the stomach. No positive 
diagnosis was made. 
The subsequent course of the case proved the correctness of 
that view. During the following month a distinct nodule could 
be felt in the epigastric region, near the normal position of the 
pylorus. To localize this nodule more exactly the stomach was 
inflated, when it was found that the nodule was situated behind 
its posterior wall. The diagnosis of retroperitoneal or pan- 
creatic cancer seemed justified. In the course of the next few 
weeks it became evident that there were cancer nodules in the 
omentum and in the retroperitoneal folds and the pancreas. 
The addition of glycosuria to her other symptoms several 
weeks before her death led me to conclude that the nodule felt 
in her epigastrium was connected with the pancreas, though 
there was no fat in her stools at any time. 
On the 31st of July, 1891, she was suddenly taken with a 
profuse diarrhoea, and died in collapse during the following 
night. 
The post-mortem examination, made by Dr. Curtin, showed 
cancer nodules involving the retroperitoneal glands and omen- 
tum, with a large cancerous mass occupying the normal seat of 
the head of the pancreas. This organ was adherent to the 
stomach, and the latter organ was found entirely free from 
disease. 
In this case it may be said that the chemical analysis 
was of great value in distinguishing and in a measure locat- 28 
NEWER METHODS OF STOMACH EXAMINATION. 
ing the seat of the disease. Without the examination, but 
with the presence of a tumor ultimately in the epigastric re- 
gion, palpable, with the symptoms already given during the 
period preceding the glycosuria, no physician would have 
leaned as strongly to any other diagnosis as to that of gas- 
tric cancer. 
The absence of fat from the stools, in spite of the 
persistence of glycosuria, would have had no material bear- 
ing in the diagnosing of the case without the positive evi- 
dences of a normally acting stomach, such as we obtained 
from our chemical analysis. 
This case is one of many which might be related to 
convince the most skeptical of the truth of the statement 
that we possess in the newer methods of examination aids 
of practical value for the differential diagnosis of diseases 
which have a great similarity to the organic stomach dis- 
turbances. The cases which have given me the greatest 
satisfaction have been those in which 1 have been able by 
these methods to exclude almost positively the existence of 
organic disease of the alimentary tract when there were 
present well-marked evidences of some serious organic dis- 
sease. In such cases, in spite of the fact that there are 
symptoms referable to the stomach, it may be said, indeed 
we may be almost justified in formulating the rule, that with- 
out marked change in the contour of the stomach, without a 
tumor which can with certainty be located in the stomach 
wall, without unequivocal signs of organic disease of the 
stomach, with, on chemical analysis, the evidences of normal 
secretory, motor, and absorptive functions, organic disease of 
the stomach can be excluded with certainty. The cases in 
which nodules in the epigastrium or its immediate neigh- 
borhood connected with the liver, gall bladder, pancreas, or 
omentum require accurate differentiation are constantly 
coming to us, and require all of the skill and acumen of the NEWER METHODS OF STOMACH EXAMINATION. 
29 
careful and painstaking diagnostician. In a recent per- 
sonal communication from Boas I was pleased to note that 
he expressed his belief in the fact that one of the most im- 
portant achievements of the chemical analyses of the stom- 
ach contents was the certainty with which they permit of 
the exclusion of the diseases of the stomach. 
Case II.—In a case which recently came to my notice there 
was a small nodule in the lower right corner of the epigastrium, 
which followed in about ten months after the removal of the 
right testicle for medullary cancer in a man aged thirty-seven. 
There were some symptoms which made the exact localization 
of the tumor impossible. There was repeated vomiting at first 
of an acid mucus. As the nodule increased in size it was found 
that the stomach symptoms grew worse. An examination of 
the stomach contents after a trial meal failed to show any 
change in the functional activity of that organ ; as a result, gas- 
tric cancer was excluded. 
In the course of a few weeks, as the tumor enlarged, it was 
found that at times so much bile was present in the stomach, 
regardless of the digestive period, that a constriction of the in- 
testine below the entrance of the common duct was strongly 
suspected, thus causing a regurgitation of the bile into the stom- 
ach. When the stomach was thoroughly emptied and all bile 
removed, the reactions were normal after a test meal at the 
height of digestion. The subsequent hi.-tory, I think, justified 
the diagnosis of a growth connected with the right kidney, by 
pressure almost, occluding the duodenum at a point below the 
entrance of the ductus choledoclius. Unfortunately, no post- 
mortem was allowed. 
Atrophy of the Gastric Follicles.—The pathological con- 
dition which can be diagnosticated with the greatest amount 
of certainty by our newer methods of examination is atrophy 
of the gastric follicles, or, as Ewald calls it, anadenia. 
This may be either an independent lesion or an accom- 
paniment of cancer, or it may complicate the later stages 
of chronic gastritis. 30 
NEWER METHODS OF STOMACH EXAMINATION. 
Einhorn (82) lias spoken of a similar condition as 
“ acliylia gastrica ” in a very able article, preferring this 
term—meaning lack of gastric juice—to any other. 
Fenwick (83) was the first to call the attention of the 
profession to this condition in 1877, while Ewald (84), 
Kinnicut (85), and Boas (86) have added important data, 
which, in conjunction with those of Nothnagel (87), Osier 
(88), and Eisenlolir (89), show the clinical picture of the 
disease to correspond very closely with that of pernicious 
anaemia. 
It is still an unsettled question whether the progressive 
anaemia always precedes the atrophy of the gastric follicles, 
or whether the latter is in a large measure due to the same 
underlying vice which gives rise to the former condition. 
It is certain, however (and Eisenlolir (90) has recently 
written an article which gives abundant clinical data), that 
several forms of anaemia and various system diseases of the 
cord are intimately associated with the anadenia of Ewald. 
This fact was first insisted upon by Lichtheim (91), 
who never found the cord normal in cases of atrophy of 
the gastric follicles with pernicious anaemia. 
In these cases the stomach is usually empty while fast- 
ing ; the expressed contents, after a trial meal, contain 
neither mucus, IIC1, pepsin, nor rennet. In all of these 
cases, where there is atrophy and attending absence of pep- 
sin, Jaworski’s method of administering a diluted IIC1 
solution (200 to 300 c. c..), and siphoning it from the stom- 
ach in half an hour after its administration, during which 
time it should have stimulated the secretion of pepsin, and 
then testing the fiuid as to its digestive power, will demon- 
strate the complete inactivity of the same. This test gives 
positive evidence of changed or unproductive peptic glands. 
This is a very valuable point in the differentiation between 
atrophy and carcinoma. In the latter there is usually, with NEWER METHODS OF STOMACH EXAMINATION. 
31 
similar treatment, a small quantity of pepsin present. These 
cases require for their more thorough study a microscopic 
examination of the blood, when poikilocytosis as well as 
microcytes with characteristic granular and large cells, as 
described by Ehrlich (92), will be demonstrated. 
With an active motor function in the early stages of 
these cases, and an active digestion in the duodenum and 
intestines, these patients remain in a fairly well nourished 
condition. In most cases, however, which have come to 
my notice, the process of atrophy extends to the intestinal 
glands and duodenum, when the disease runs a rapid 
course. 
While the diagnosis of atrophy of the gastric follicles 
in the majority of cases can be made after a number of 
weeks of careful watching and chemical examination, 
Ewald (93), in his recent publication, mentions the diffi- 
culty experienced in distinguishing this condition from 
carcinoma and some of the more severe gastric neuroses. 
The form of carcinoma which is most readily confounded 
with simple atrophy is the infiltrating variety. Here 
physical signs avail little, for aside from the compensatory 
hypertrophy of the muscularis there may be no constric- 
tion at the pylorus, and consequently no gastrectasia. In 
these cases the microscopical examination of the expressed 
fluid will afford data for distinction ; the carcinomatous 
stomach contents will, as a rule, contain altered blood pig- 
ment, though hyematemesis be absent, while with atrophy 
its presence is unknown. 
All of the chemical characteristics mentioned in con- 
junction with the study of atrophy may be present in cases 
of grave neuroses, or nervous anachlorhydria ; indeed, these 
cases may assume such a serious aspect as to simulate infil- 
trating carcinoma. Ewald, in the article above quoted, 
after mentioning some of the differential points already re- 32 
NEWER METHODS OF STOMACH EXAMINATION. 
hearsed, says that “ for the differentiation of anadenia from 
severe neuroses there are as yet no characteristic symp- 
toms.” 
The neuroses simulating achylia are usually associated 
with general disturbances of the system, so that it is pos- 
sible to recognize evidences of hysteria, neurasthenia, or 
spinal irritation, and thus establish the neuro-psychic ele- 
ment. 
As able a diagnostician as Ewald reports the case of a 
woman in whom he had all of the symptoms which seemed 
to justify the diagnosis of nervous anacidity, and which he 
made after long-continued watching. The woman under 
treatment improved, and returned from Berlin to her home 
in Russia, where, after a few weeks, a tumor of the liver 
was palpable and another in the epigastric region. The 
early symptoms were undoubtedly connected with develop- 
ment of the case. 
Gastritis.—The large quantity of mucus removed by 
the tube in the average cases of gastritis must serve, in con- 
junction with the chemical examination of the stomach con- 
tents, to make the that disease comparatively 
easy. In the milder cases of gastritis free hydrochloric 
acid is present in reduced quantity at the height of the 
digestive process. 
With a progression of the disease there is usually en- 
tire absence of free IICl, traces of peptone, rennet absent, 
propeptone present. With the waning of free HC1, pepsin 
is absent in like proportion. In many of the more severe 
cases peptonization may still progress, until in the later 
stages, if the disease is unrelieved, complete atrophy, with 
its characteristic anomalies, finish the picture of the dis- 
ease. 
In these cases the reaction of the stomach contents is 
strongly acid, a condition produced by the presence of the NEWER METHODS OF STOMACH EXAMINATION. 
33 
organic acids (lactic, acetic, butyric, and fatty acids), main- 
ly due to the fermentation of the carbohydrates. 
Usually the motor function is found disturbed ; there is 
an atony corresponding with that so often found in the 
bladder muscle (Rosenheim (94)), which may be functional 
or due to interstitial overgrowth, or degeneration of the 
muscular coat. As the disease advances, the absorptive 
function gradually gives way with the destruction of the 
epithelial elements. 
Hyperacidity.—The disease with which hyperacidity is 
most frequently associated is ulcer of the stomach. There 
is a condition of superacidity and hypersecretion, to which 
we will also refer later in this article, which may exist with- 
out ulceration of the gastric mucous membrane. 
Riegel (95) was the first to call our attention to the fact 
that with ulcer of the stomach there is, as a rule, a con- 
spicuously high percentage of HC1, and Van den Velden 
(96) has demonstrated beyond controversy that in many 
cases of ulcer of the stomach the chyme contains an ab- 
normally great amount of the acid. In considering the 
diagnosis of simple typical ulcer of the stomach before an 
assemblage of educated physicians, I feel that I will be sus- 
tained in making the assertion that in the majority of these 
cases there are sufficient data to make clear the diagnosis 
without recourse to the chemical examination of the stom- 
ach contents which we are to-day considering. The age of 
the patient, the characteristic anaemia, the microscopical 
appearance of the blood, the menstrual anomalies, ofttimes 
the haematemesis, the character of the pain, with the time 
of its occurrence—all these give sufficient data in the ordi- 
nary case to make the diagnosis clear. 
On the other hand, there are cases in which the usual 
symptoms fail to clear the field for an easy and positive 
diagnosis. The case may be atypical, or there may be a 34 
NEWER METHODS OF STOMACH EXAMINATION. 
combination of circumstances with symptoms which make 
differentiation difficult, and we are consequently forced to 
resort to our tests for a solution of the question. 
It is safe to teach that in all cases of ulcer of the stom- 
ach the stomach tube should not be used without great 
caution, and only in cases where its use is made imperative 
for the purpose of diagnosing the existing condition when 
other means fail. 
Ewald, in his work, asks the question whether it is 
justifiable or necessary in a case of gastric ulcer to intro- 
duce the stomach tube. In answering, be says: “You 
know that until recently this question was answered in the 
negative. The introduction of the soft, flexible tube has re- 
duced the dangers very materially, but they are by no 
means overcome; and when we consider how easily vomit- 
ing and retching are provoked, the tube will not be intro- 
duced without a thorough appreciation of the facts enu- 
merated, and the adoption of means to prevent accidents 
which may lead to serious results.” In no case of stomach 
disease, no matter what lesion we suspect, would it be wise 
to resort to the use of the tube for purposes of diagnosis 
during the persistence of haimatemesis; or the presence of 
symptoms which arc suggestive of acute localized perito- 
nitis or acute gastritis. In these cases the stomach remains 
a noli me tangere (Rosenheim (91)). It may be concluded 
that in cases of ulcer in wThich there is no gastrectasia the 
motor function is usually good, as is also the absorptive; 
that the secretory function in the great majority of cases 
(as shown by Van den Velden (98), Riegel (99), and Ja- 
worski (100)) is associated with hyperacidity. 
As a rule, and this has many exceptions, according to 
my experience, HC1 is present in quantity to exceed 0‘3 
per cent, after a simple test breakfast, and with a full Rie- 
gel-Leube meal it may reach as high as 0’6 per cent. In NEWER METHODS OF STOMACH EXAMINATION. 
35 
one third of the cases of ulcer the acidity is found normal 
(Rosenheim (101)), while in other cases the quantity of 
IIC1 may be markedly reduced. In the latter, cancerous 
degeneration of the base of an ulcer may he strongly sus- 
pected, when an ultimate anacidity may be expected before 
death, or there may he with reduced IIC1 beginning in- 
volvement of the glandular elements of the mucous mem- 
brane (Rosenheim (102)). 
Riegel (103) reports three hundred and eighty-two 
analyses of the stomach contents in forty-two cases of ulcer 
of the stomach, in which he found the percentage of free 
HC1—at the height of digestion abnormally high—values 
of 0'4 to 0'5 per cent. 
Gerhardt (104) reported twenty-four cases of gastric 
ulcer with presence of HC1, as shown by the color test in 
seventeen, while in seven there was no response. 
Rosenheim (105), in eight cases, was able to demon- 
strate hyperacidity in two only; in four, 1IC1 was within 
normal limits; in two there was subacidity. 
Kinnicut (106) reports four cases, in all of which HC1 
was found, with thirty-one examinations after test meals, 
values of 0T7 per cent, to 0'23 per cent. 
My own experience in six cases of ulcer of the stomach, 
with repeated examinations during the past three years (forty 
tests), leads me to conclude that in the majority of cases 
free HC1 is present; that in two thirds of all cases there is 
an excess of I1C1, and in one third there are normal and 
subnormal percentages. 
With these facts and the statistics before us, we must 
conclude that in cases of ulcer the gastric juice always con- 
tains HCl, and usually an excess of it (Ewald (107)). 
The chemical analyses in a case of stomach disease in 
which there are symptoms of both ulcer and cancer be- 
comes of the greatest value to the physician and surgeon 36 
NEWER METHODS OF STOMACH EXAMINATION. 
alike. The constant presence of free HC1, in a case where 
such differentiation becomes necessary, may be regarded as 
strong evidence in favor of ulcer of the stomach and ab- 
sence of cancerous infiltration. The greatest difficulty in 
practice is ofttimes experienced in distinguishing between 
gastric ulcer, gallstone colic, and duodenal ulcer. A case 
which has been under treatment during the past winter 
demonstrated that fact very forcibly. Without giving de- 
tails of the case, it may be said that the patient was a man, 
aged eighty-one years, who had renal colic during the active 
years of his life, and for seven years has had more or less 
severe pain in the epigastrium, usually more severe during 
the afternoon about four o’clock. No one tender spot could 
be found; the entire epigastrium seemed hypersensitive to 
pressure. He had consulted prominent physicians in the 
East and West, with almost as many different diagnoses as 
physicians consulted, but without relief. For five weeks 
before he consulted me he resorted to morphine without 
benefit. At the first visit nothing could be elicited from 
the history which aided in making the diagnosis, but in 
examining the vomited matter, six hours after a meal of 
milk only, we found more free HC1 than is normally pres- 
ent at the height of digestion after an ordinary trial meal 
(0-4 per cent.). The fluid contained both pepsin and ren- 
net. After a trial meal of milk and egg albumin, it was 
found that there was marked hyperacidity (0'6 per cent.). 
This gave us abundant evidence, in conjunction with the 
examination of the vomited matter, to diagnosticate both 
hyperacidity and supersecretion. Close questioning revealed 
the fact that the patient, seven years before, had a well- 
marked intestinal haemorrhage, which fact he forgot to give. 
The diagnosis was clear—duodenal ulcer with supersecre- 
tion. It would not have been made without chemical exami- 
nation. Morphine, after a short struggle, was discontinued. NEWER METHODS OF STOMACH EXAMINATION. 
37 
Lavage with alkalies, resorcin, arsenious acid, and a suit- 
able diet, rigorously followed, were substituted for his 
previous treatment. The aged patient is well, at least 
without a symptom, in the full possession of his faculties, 
relieved from the slavery which would soon have made him 
more wretched than the disease from which he was suffering. 
Bucquoy (108) lays great stress in the diagnosis of 
duodenal ulcer on the following points: 
1. “Sudden intestinal haemorrhages in apparently 
healthy people, which tend to recur and produce a profound 
anaemia (haemorrhage of the stomach may precede or ac- 
company the melaena).” 
2. “ Pain in the right hypochondriac region coming on 
late, two or three hours after eating.” 
3. “ Gastric crisis of extreme violence, the haemorrhage 
being more apt to occur about the time of these attacks.” 
4. Osier (109) says: “The point upon which the great- 
est stress has been laid in the diagnosis of duodenal ulcer is 
the occurrence of melaena without haematemesis.” To which 
I would add the great importance and value in doubtful 
cases of chemical examination to determine the degree of 
acidity and the amount of secretion. 
Gastric Neuroses.—After a very thorough clinical con- 
sideration of the more frequent neuroses which were for- 
merly included in the chapter of “ nervous dyspepsia ”—a 
term which Leube (110) still insists upon using—I am fully 
satisfied that, with hut few exceptions, and to these I will 
refer later, the newer methods of chemical examination have 
added little to make the diagnosis easier, or in any way ex- 
plain the many vagaries of these disorders, whose symptoms 
are as variable as the colors of the chameleon. 
Leube holds that the diagnosis, or rather the suspicion 
that the disease is of nervous origin, is made a certainty by 
the examination of the stomach with the tube. He lays 38 
NEWER METHODS OF STOMACH EXAMINATION. 
down the rule that, seven hours after the trial meal, the 
stomach is invariably empty. To this many take excep- 
tion, and it appears to me with reason; while Leube grants 
that there are rare exceptions, he says “these ought not to 
upset the rule.” 
Super secretion and Hyperacidity.—It is certain that 
these conditions exist oftener than has been suspected in the 
past. These conditions are usually associated. When we 
speak of supersecretion we include that pathological con- 
dition in which the excessive secretion gives a functionally 
active juice not only during the digestive period, but long 
after the stomach has been emptied of its food. In other 
words, it is not so much an increase during digestion as it 
is a continuous secretion, entirely independent of the di- 
gestive act. 
Reichman (111) was the first to call our attention to this 
condition. Since his publication, Riegel (112) and Van den 
Velden (113) have added valuable reports of cases to our 
literature on the subject. 
The examination of the vomited matter in these cases 
is of the utmost importance, for it not only reveals the 
presence of the hypersecretion when the stomach should 
be empty, but the hyperacidity as well. This must be the 
“ exception ” to which Riegel (114) refers when speaking of 
the value of the examination of the vomited matter in dis- 
eases of the stomach. 
The symptoms in these cases are well marked. If long 
continued, we ultimately have motor insufficiency, in some 
cases almost complete atony of the muscular coat. 
Gastralgia, recurring at intervals after great mental emo- 
tion or other excitement, is a prominent symptom. 
Kinnicut (115) says: “ I have fixed as high a limit as 
fifty cubic centimetres of gastric juice as a basis for a diag- 
nosis of hypersecretion.” NEWER METHODS OF STOMACH EXAMINATION. 
39 
Ill a case which recently came to my notice I found, 
after washing out the stomach the previous night, on the 
following morning before food had been taken two hundred 
cubic centimetres of an acid fluid, with 0T5 per cent. IIC1, 
pepsin, and rennet, as shown with the milk test. In this 
case there were repeated gastralgic attacks, requiring hypo- 
dermics of morphine, which have entirely ceased since the 
recognition of the disease and its proper treatment. 
Sahli (116) found this condition present in the gastric 
crisis of tabes; it has also been observed in cases of melan- 
cholia, hysteria, neurasthenia, and many other neuroses. 
The diagnosis is made, as above mentioned, by express- 
ing the secretion after having washed out the stomach six 
or seven hours before, the patient fasting during the inter- 
val. It will be found that the fluid digests albumin readi- 
ly, is without organic acids and peptone, has free HC1, is, 
as Kinnicut says, “hyperacid gastric juice.” 
It has been held by Talma (11'7) and also Suyling (118) 
that there is a neurosis which shows itself in a hypersesthe- 
sia of the gastric mucous membrane, more particularly to 
IIC1. Lowenthal (119) has failed to show, by the adminis- 
tration of HC1 in large doses to perfectly healthy subjects, 
that there is such hypermsthesia, and his experiments with 
subjects who have diseased stomachs, some of them ulcers, 
with HC1 administration have been negative. The same 
he found to be true also with the organic acids, mainly lactic 
acid, with healthy subjects and those suffering from organic 
diseases. 
It may be taken for granted that, in cases where there 
is pain after eating, which ceases when the gastric juice is 
neutralized by alkalies, or diluted with water, or removed, a 
gastric ulcer may be strongly suspected, and not a neurosis 
or liypersesthesia to I1C1. 
If gastric ulcer can he eliminated with certainty, we must 40 
NEWER METHODS OF STOMACH EXAMINATION. 
suspect in these cases with supposed hyperaesthesia to HC1 
that the gastralgia is due to haemorrhagic erosions. 
The more the simple neuroses are studied, the more 
firmly and indelibly are impressed the facts that their recog- 
nition must depend largely on the presence of a well de- 
fined neurotic habit, evidences of a combine of symptoms 
which, for want of a better and more scientific term, we 
must call neurasthenia—in many cases a faulty metabolism 
—and, excepting the supersecretion and hyperacidity with- 
out changes in the mucous membrane of the stomach and, 
as Klemperer has pointed out, reduced motor force, we can 
not rely for definite information upon the examination of 
the stomach contents. 
From what has been said of the practical results of the 
examination of the stomach contents, you are able, without 
further infliction from me, to draw your own conclusions. 
Certain it is that by these newer methods we are made to 
understand just what the stomach is doing—a knowledge 
which is necessary in every doubtful case. No case of 
chronic disease of the stomach, in which the diagnosis can 
not positively be made, should fail to be examined, that 
the physician may thoroughly acquaint himself with the 
workings of that organ, not only for his own enlighten- 
ment, but for the greater satisfaction and benefit of his 
patients. 
While the statement of Hirschfeld (120)—that “the 
chemical method of investigating the stomach has been to 
diseases of that organ what the ophthalmoscope is to the 
diseases of the eye ”—may be somewhat exaggerated, the 
tempered conclusions of Ewald (121) may be readily accept- 
ed. He says: “ I consider the diagnostic importance of 
the expression method to be so great and the safety to be 
absolute, a very few cases excepted, that I would reproach 
myself had I neglected to resort to it in any doubtful case.” NEWER METHODS OF STOMACH EXAMINATION. 
41 
INDICATIONS FOR TREATMENT AND DIET MEDICAL AND 
SURGICAL. 
Medical.—It naturally occurs to us, in considering the 
question of the practical value of the chemical examinations 
in diseases of the stomach, to inquire into the indications 
which have been offered for diet and treatment as an out- 
come of such study. 
It may be said, and I think with a considerable degree 
of certainty, that the dietetics and therapeutics of gastro- 
intestinal diseases have been placed on a more solid and 
scientific basis by these newer methods. 
It is not within my province to dilate upon these sub- 
jects, but I wish to add a few observations which seemed 
to me indicated after considering the work which we have 
been doing in this domain. 
First, it needs no comment to prove that an exact diag- 
nosis has therapeutic advantages; second, we have learned 
from our recent studies that the most important treatment 
of stomach diseases must always remain dietetic, and must 
depend for its successful administration upon the chemical 
constitution of the digestive fluid, whether anacid, hyper- 
acid, or normal. 
Without such knowledge we are groping in the dark, 
unscientifically and unsuccessfully. What the dietetic rules 
are each case will indicate for itself, if the stomach contents 
are macroscopically, microscopically, and chemically ex- 
amined. 
The satisfaction which a physician feels in outlining a 
diet which he knows will positively find a suitable reception 
and ultimate assimilation must be sufficient recompense for 
the extra time which he has taken to study his case. It 
would be as nonsensical to give a patient with hyperacidity 
a diet composed of starchy food as it would be unwise and 42 
NEWEK METHODS OF STOMACH EXAMINATION. 
fatal to give a meat diet to one without a digestive fluid 
containing the necessary HC1 for its digestion. 
Another much-abused method of treatment has been the 
lavage of the stomach. How often have we heard of its 
use when absolutely no indications demanded it! Useful 
and beneficial only when indicated, the tube must be used 
only with caution and judgment. (See Rosenheim’s (122) 
exhaustive article, Ueber die Magendousche, Tlierap. Monats- 
hefte, August, 1892.) 
Ever since the discovery of the fact that pepsin and hy- 
drochloric acid are the important constituents of the gastric 
juice, physicians have been giving these drugs, in many 
cases without reference to the pathological condition of the 
stomach or the chemical constitution of the secretion which 
they were expected to modify or supplement. 
To-day, when it is comparatively easy to inform one’s self 
of the condition of stomach digestion, drugs, more particu- 
larly pepsin and IICl, are administered empirically to the 
detriment of the patient, and in many cases their long-con- 
tinued use has given rise to a glandular inactivity or true 
atrophy of disuse which can never be remedied. 
If we take into consideration the results which have 
been recently obtained from repeated experiments with 
alkalies and acids in healthy stomachs, we can readily 
epitomize the indications for their administration and ex- 
plain the statement which is made by Leube (123) when 
speaking of the effect of Carlsbad water. He says : “ Car- 
bonate of soda not only overcomes the superfluous acidity 
of the stomach, but, what is more important, it has the 
power of stimulating the mucous membrane to renewed 
energy and a further secretion of gastric juice. 
The truth of that statement is demonstrated by Jaworski 
(124), and also by Geigel and Abend (125), who found, 
after repeated experiments on healthy and diseased stom- NEWER METHODS OF STOMACH EXAMINATION. 
43 
achs, that moderate doses of the sodium salt (one to two 
grammes) neutralize a part of the gastric juice; but the 
alkaline reaction which first follows their administration is 
soon followed by an acid secretion in excess of that preced- 
ing the administration of the alkali (Mesnil (126)). 
Small doses (0’5 gramme) are more likely to neutralize 
a normal acid secretion, while with hyperacidity we must 
use the larger doses of the sodium salt in conjunction with 
our mechanical treatment, 'for we have not only the original 
hyperacidity to overcome, but must administer sufficient 
to neutralize the excess of the free acid secreted as a result 
of the stimulation by the alkali. From the foregoing it is 
clear that the alkaline treatment of stomach diseases must 
he limited to such cases as have an excess of IICl, or a de- 
ficiency of the acid with glandular structures intact, or a 
sufficient remnant to respond to stimulus. (Subacidity, 
chlorosis, and nervous dyspepsia with subacidity—Ritter 
and Ilirsch (127), Manassein (128), Cahn and Mering 
(129).) 
On the other hand, HC1 increases the pepsin but not 
the IIC1 (Mesnil (130)). Excess of HCl is very likely to 
reduce the secretion of the-gastric juice and the percentage 
of HC1 (Jaworski (131)). HCl does not increase the secre- 
tion in proportion to the size of the dose administered. 
HCl and pepsin are therefore of the greatest value in those 
cases where the mucous membrane and glands are diseased, 
as we find in catarrhal inflammation, glandular atrophy, and 
amyloid degeneration (here in small doses only to protect 
the remnant of glands still functionally active). Also in 
carcinomatous disease, nodular and infiltrating. 
If IIC1 could be administered in sufficiently large doses 
without corroding the mucous membrane of the stomach, 
it would at once relieve the severest case of hyperacidity 
by checking the secretion of the gastric juice. 44 
NEWER METHODS OF STOMACH EXAMINATION. 
To improve or influence the absorptive function of the 
stomach, we possess no agent, unless it be electricity. 
The motor function will be considered by another more 
worthy and competent to enlighten you with the result of 
his ripe experience. 
Surgical.—It has occurred to me, in considering this 
question, to consider the value of the newer examinations as 
related to surgery. The literature on this subject has un- 
til recently been very meager, and, as the study of my 
cases was intended for diagnosis and medical treatment 
only, I felt justified for the preparation of this paper in 
consulting many of the leading surgeons of this country, 
England, Germany, and Austria for an unbiased opinion on 
this important question. To them I sent circular letters 
asking for a response to the following questions, and such 
other information as they might offer relating to the clini- 
cal data and to the literature of the subject. (Forty such 
letters were written, to which I have received thirty-eight 
replies. At this time and place I thank those earnest 
workers who so kindly and fully answered and aided me in 
my work.) * 
I. Have you in any case been, led by a chemical exami- 
nation of the stomach contents to operate for disease of 
that organ ? 
II. Do you believe that such analysis will aid in the 
early recognition of malignant diseases and thus lead to 
early radical operations for their removal ? 
III. Have you formed any opinion of the practical 
value of the chemical analysis of the stomach contents in 
the recognition of stomach disease ? 
As a rule, the answers were not separately given. The 
majority have held, in answer to the first question mainly, 
that while chemical analyses give evidence of great impor- 
tance, they can be considered as confirmatory only, and can NEWER METHODS OF STOMACH EXAMINATION. 
45 
not be relied upon alone in deciding the question of opera- 
tive interference. 
Those consulted who had no personal experience, or in- 
sufficient to warrant conclusions, were Sir Joseph Lister, Sir 
William MacCormac, McBurney, Davies-Colley, and Van- 
der Veer. 
Billroth writes : “ It is true that free HC1 is more often 
absent from the gastric juice in gastric cancer than in ulcer ; 
but this phenomenon is not sufficiently constant and may be 
physiological. It is not sufficiently definite to be of prac- 
tical value.” 
Among those who would not rely on chemical analysis 
for surgical indications we find besides Billroth, Thomas 
Bryant, Jessett, of London ; Klemperer, Willy Meyer, Leo, 
Marcey, Leube, Goodliart, W. II. IL. Jacobson (London), 
Boas, Mayo Robson, Lange, of New York, Weir, and Hal- 
sted. 
Most of these grant the fact that the results can only be 
considered confirmatory, a link in the chain of evidence 
which at times is of great importance as an adjunct. Senn, 
who might be included in the foregoing, writes: “ I would 
never rely on chemical examination in deciding upon the 
propriety of operative interference. I regard chemical 
tests of value in making an early differential diagnosis be- 
tween ulcer and carcinoma.” Senn recognizes the great 
value of these methods without relying upon them exclu- 
sively. The answers of Keen and Bull to the questions 
asked correspond very closely to those of Senn. Weir, 
after his large experience, says : “ I have received help, 
but never relied upon chemical gastric evidences alone in 
considering the question of surgical interference in carci- 
noma of the stomach.” 
Pilcher reports a case in his answer which shows a fail- 
ure of the tests. In his case there was pyloric stenosis, 46 
NEWER METHODS OF STOMACH EXAMINATION. 
with all chemical tests indicating non-malignant disease; 
he did a gastroenterostomy, finding a typical scirrlius. 
Czerny, of Heidelberg, besides his answer, in which he 
grants a confirmatory value to the chemical tests, sends his 
monograph, taken from the Beitrdge zur Jclinischen Chirur- 
gie, in which he reports twenty resections of the pylorus 
for cancer and thirteen exploratory laparotomies, in most 
of which the tests were considered and were of value in the 
process of differentiation. 
In Case IX he found IIC1 absent at one time after a 
test meal, and present at another in the vomited matter, 
with tumor and constriction at the pylorus. The growth 
was due to a simple ulcer with enormous hypertrophy and 
consequent stenosis. Czerny afterward upbraided himself 
for paying so little attention to the results of his chemical 
tests. 
Unless I mistake the meaning of the answers received 
from Roswell Park, Einhorn, Stockton, Ewald, and even 
Riegel and Kinnicut (the latter has written a valuable paper 
on this subject in conjunction with Bull), they do not wish 
to rely in doubtful cases on the chemical tests alone. I 
judge still further that Riegel, Kinnicut, Ewald, Stockton, 
and Einhorn are positive in their belief that in the majority 
of doubtful cases, where repeated examinations are made 
and free IIC1 is absent, that the diagnosis of cancer is jus- 
tified, and they probably agree with Boas that with such 
anacidity and the presence of two classical symptoms, such 
as emaciation, oedema, or tumor, the chances are decidedly 
in favor of cancer, and the surgeon has ample indications 
for an exploratory laparotomy. 
This exploratory operation (from an extended study of 
the literature of this subject with which it is useless to bur- 
den you), we are positive, is as a rule without danger, and 
can ultimately lead only to the saving of many lives which NEWER METHODS OF STOMACH EXAMINATION. 
47 
arc now sacrificed for want of a consideration of all the di- 
agnostic means wliicli ought to he used for the conscientious 
study of these cases. 
It may be held that while the surgeon is not justified in 
making a diagnosis from the chemical examination alone, 
he ought not to operate without a thorough understanding 
of the working ability of the stomach which claims his at- 
tention. 
So far as the simple diagnosis of pyloric stricture is con- 
cerned, no method can equal in value the revelation made 
by the stomach tube. 
It is not within the province of this paper to dilate upon 
the results or advantages of the different operations for the 
removal of gastric cancer. This can he studied from the 
statistics of Rydigier, Czerny, and McArdle. Suffice it to 
say that in sixty-two pylorus resections twenty-seven (or 
43'5 per cent.) were cured (Rosenheim (132)). 
In fifty-one per cent, of all cases of gastric cancers 
(Ewald (133)) the growth is situated at the pylorus; the 
medical treatment of this condition gives an absolutely hope- 
less prognosis; the surgical offers some hope, as seen from 
the above statistics and also from a further study of all the 
cases reported in Virchow and Hirsch’s Jahresberichte dur- 
ing the past six years. The consensus of opinion of all con- 
sulted tends to strengthen the conclusion that pyloric can- 
cer is a purely surgical affection ; its diagnosis, if it can be 
made early, must be sufficient indication for surgical treat- 
ment. 
The modern surgeon has learned two valuable points 
from a consideration of this subject: 
1. Without the possibility of emptying the stomach into 
the duodenum it is impossible to live. 
2. The obstruction at the pylorus removed, chemical 
analyses have proved beyond doubt the ability of the stom- 48 
NEWER METHODS OF STOMACH EXAMINATION. 
ach after a few months to regain its motor activity when the 
duodenum carries on the further digestion. 
With methods which wonld lead to the earlier recog- 
nition of these cases, why are we not justified in hoping 
for results which will approximate those which follow 
the early removal of cancers from other organs of the 
body ? 
Appreciate if you will the positive fact that no operator 
has, after the removal of the pylorus or any part of the stom- 
ach for cancerous disease, had a functionally active stomach 
left, but that after removal of the pylorus the motor func- 
tion of the stomach, as shown in Mikulicz’s Klinik (134), 
also by Rosenheim (135), is sufficiently improved in three 
months to empty the stomach of its contents in five hours 
and a half, that the duodenum and small intestines assume 
the stomach’s work, and you have sufficient data to justify 
you in concluding that in no field of medicine is concerted 
action of the physician and the surgeon more necessary for 
the benefit of mankind. 
While at present we are forced to repeat that our tests 
are strongly confirmatory, we are certainly working in the 
right direction. With a larger experience and more exact 
methods of examination which must be evolved from the 
present, we entertain for the future a well-founded hope of 
diagnosticating malignant diseases of the stomach before 
adhesions are formed, before the tumor becomes of a size 
which makes it easily palpable with its surroundings infil- 
trated. 
When the skilled physician reaches such a stage of pro- 
ficiency in the art of diagnosis, the surgeon as his helpmate 
will no longer be charged with making autopsies in vivo, 
many lives will be prolonged, possibly saved, and medicine 
will have become more nearly an exact science. NEWER METHODS OF STOMACH EXAMINATION. 
49 
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NEWER METHODS OF STOMACH EXAMINATION.’ 
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51 
47. Kussraaul. Volkmann’s Sammlung Min. Vortrdge, No. 
181. 
48. Leo. Deutsche med. Woch., 1889. 
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Strassburg, 1882, p. G6. 
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No. 15. 
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