fast. It requires not so much skill to determine that the stomach is the seat of disease, as to differentiate this disease from many other undeveloped diseases of the stomach. Of the many diseases which may simulate chronic gastritis in their symptoms, perhaps none are more apt to mislead than the neuroses.

The age of the patient will give us some evidence on this point, as nervous dyspepsia is a disease nearly always confined to the young or middle-aged. In differentiating between chronic gastritis, and carcinoma of the stomach, Ewald lays much stress on one symptom, viz: the bloody color of the stomach contents in the latter disease, due to the presence of blood pigment, which he thinks is almost invariably observed, even when hæmatemesis has not occurred; he says, however, that the diagnosis of a true gastritis can be reached only by exclusion i. e. after ulcer, carcinoma, dilatation and the neuroses are thrown out, then the residue so to speak is gastritis. Of the chemical and microscopical examinations, the following results are accepted as indicating the different forms of this disease. In simple chronic gastritis while fasting, the stomach only contains a small quantity of watery mucous fluid, frequently tinged yellow, or yellowish green, from mixture of bile. On standing a sediment of epithelial cells, round cells, and free nuclei, remnants of food, starch granules, muscle fibrilae, and vegetable cellular tissues, is found.

After a test breakfast the acidity is variable, but never increased, hydrochloric acid lessened, pepsin and renuet small in amount. In chronic mucous gastritis there is an abundance of mucus in the stomach contents, either while fasting or after taking food, so that acetic acid always gives a marked mucin reaction.

Trial digestion (in test tube) occurs only after adding hydrochloric acid, and then is slow, curdling by rennet slow, or absent, wash water after lavage contains small, frequently bloody fragments of the epithelial mucous membrane.

When atrophy has occurred the stomach while fasting is found to be empty, and the chyme expressed after test breakfast contains neither mucus, hydrochloric acid, pepsin nor rennet, and no tissue elements of the glandular parenchyma are to be found in a totally atrophied stom

ach.

Although these methods of diagnosis may seem like an innovation to the general practitioner, they are neither complicated nor difficult, and should be resorted to whenever an accurate diagnosis cannot be reached in any other way, as the success or failure of treatment depends as much upon the accuracy of diagnosis as upon the remedies employed; what might be serviceable in the first form, would as likely prove ineffective in the third, and vice versa.

Again, the sooner a diagnosis is made out, the greater the probability of relief or cure.

Hence when such a case presents itself to us, no means within our reach should be neglected, as it may mean a complete restoration to health of our patient.

PROGNOSIS.

The prognosis depends upon the age, general condition, and moral stamina of the patient, as well as upon the form or progress of the disease. In simple chronic gastritis, or chronic mucous gastritis, when un complicated and the patient found willing and capable of co-operating

with us, a cure can be promised in a great majority of cases, but the patient must be made to understand that as much depends upon his behavior, as upon our skill.

When the stage has progressed to the stage of atrophy of the mucous membrane, the most that can be hoped for is relief for a longer or shorter time, depending upon the extent of the destruction of the mucous membrane, for when the case is not seen until the secretory function of stomach is suspended, the case is a short one at best, and nothing is left for us but palliation.

TREATMENT.

In no disease has there been a greater multiplicity of remedies recommended than in the one under consideration.

And what one author relies upon as his best and surest remedy, is merely mentioned as of doubtful efficacy by another of equal eminence and skill.

Ewald divides the remedies to be employed into three groups, viz those which aim to directly replace the deficient gastric secretion, those which are to stimulate the depressed functions of the stomach, and those which are capable of counteracting the irritant substances introduced from without.

As there is always a diminished amount of hydrochloric acid in this disease, and as it plays so important a role in the process of digestion, not only by its direct action, as a digestive agent, but as an antiseptic, reducing to a minimum the ever-present tendency to fermentation, it is only rational and natural that we should place it foremost among our remedies.

It should be given not too largely diluted and in full doses, each dose divided into three and given at intervals of twenty minutes, the first immediately after the completion of the meal,-the ordinary precautions for the protection of the teeth should of course be observed. The use of pepsin, so universally given on general principles in ordinary doses seems to have no good effect in the first two forms of this disease, and in larger doses the action is doubtful, but when general atrophy of the mucosa has taken place and no pepsin is present in the stomach, even after the administration of hydrochloric acid, then full doses (5 to 8 grains) may be relied upon to some extent. Next to hydrochloric acid as an antiseptic I have found the salicylates-either salicylate of bismuth or salicylate of sodium.

The former is the more soothing to the mucous membrane. The latter while possessing the anti-fermentative properties of the former, has the additional power of neutralizing the lactic and fatty acids usually present. Another remedy recently introduced is dermatol, which has given very satisfactory results.

It is best given in five grain doses, repeated every two or three hours, when the secretion of mucous is abundant or when vomiting is very troublesome, both of which it usually relieves after a few days' use. When these remedies have failed the administration of ten grain doses of inspissated ox gall, three times a day, directly after meals, has proved of value in two cases which recently came under my observation. Nux vomica and strychnine are valuable agents when the muscular fibres of the stomach have lost their tone, and there is a tendency to dilatation. Their combination with hydrochloric acid makes an admirable

remedy in selected cases. Since the approved apparatus for washing out the stomach has simplified the process so much, lavage has come into more general use, and with the most gratifying results. It not only increases glandular activity, but detaches and removes masses of mucous and undigested and putrefied food, and frequently relieves gastric pain and distress which have resisted the most powerful anodynes. Usually clear warm water is first introduced, followed by alkaline solutions, if much mucus is present, or antiseptic solutions if indicated, leaving a small amount in the stomach after removing the tube. The introduction and removal of the tube are said to increase peristalsis and strengthen muscular activity. While Ewald, Jaworski, and Stuart speak of this remedy with positive assurance, other contemporary writers of eminence do not mention its use.

In atony of the stomach massage has been tried with good results. Enihorn's electrode is introduced into the stomach, which is nearly filled with water in order that the current may be more diffuse, the circuit being closed by a flat electrode over the epigastrium. Other measures directed to excite the stimulation of glandular secretion are the bitter tonics, of which quassia, gentian, columbo and condurango are the most active. Thompson attributes much virtue to columbo, while Ewald combined condurango with hydrochloric acid. Their modus operandi is not quite settled, Jaworski claiming they lessen the amount of secretion, while Marcone asserts they increase it, and third authority thinks their beneficial effect is due to their increasing peristalsis. However it is generally conceded that they have a stimulating effect on the digestion. Fowler's solution, nitrate of silver, ipecac, resorcin and bisulphite of carbon