CONCLUSIONS

Most of the investigators of the fractional test meal agree, that the acidity curves may run from anacidity all the way through to hyperacidity in both health and disease. Our results on proven cases confirm these observa

tions so far as ulcers of the stomach or duodenum are concerned. We conclude, therefore, that in ulcer the diagnostic value of the curves is slight.

We are indebted to Drs. Brooke, Royer, Petersen-Saunders, and Misses Goble and Erdman for assistance in carrying out this work.

(1) SCHÜLE, A.: Untersuchungen über die Secretion und Motilität des Normalen Magens, Ztschr. f. Klin. Med., 1895, xxviii, 461. (2) EHRENREICH, M.: Ueber die Kontinuierliche Untersuchung des Verdauungsablaufs mittels der Magenverweilsonde. Ztschr. f. Klin. Med., 1912, lxxv, 231.

(3) REHFUSS, M. E.: A new method of

gastric testing, with a description of a method for the fractional testing of the gastric juice. Amer. Jour. Med. Sci., 1914, cxlvii, 848. (4) REHFUSS, BERGEIM AND HAWK: Gas

tro-intestinal studies. II. The fractional study of gastric digestion with a description of normal and pathologic curves. Jour. Amer. Med. Assoc., 1914, lxiii, 909. (5) REHFUSS, M. E.: Gastro-intestinal studies. VI. The impossibility of interpreting the findings obtained by the customary examination of the test meal. Jour. Amer. Med. Assoc., 1915, lxiv, 569.

(6) CLARKE AND REHFUSS: Gastro-intestinal studies. V. The protein curve of gastric digestion in normal and pathologic cases. Jour. Amer. Med. Assoc., 1915, lxiv, 1737.

(7) TALBOT, E. S.: The examination of

normal gastric secretion by the fractional method. Jour. Amer. Med. Assoc., 1916, lxvi, 1849. (8) CROHN AND REISS: Studies in fractional estimations of stomach contents. Amer. Jour. Med. Sci., 1917, cliv, 857.

(9) HORNER, C. P.: The fractional test meal. Jour. Amer. Med. Assoc., 1917, lxix, 1931.

(10) REHFUSS, M. E.: Possibilities of fractional gastric analysis. Jour. Amer. Med. Assoc., 1918, lxxi, 1534.

(11) CROHN AND REISS: Effects of restricted (so-called ulcer) diets upon gastric secretion and motility. Amer. Jour. Med. Sci., 1920, clix, 70. (12) RYLE, J. A.: On the investigation of gastric function by means of the fractional test meal. Lancet, 1920, ii, 490.

(13) REHFUSS AND HAWK: A consideration of the gastric test meal from experimental data. Jour. Amer. Med. Assoc., 1920, lxxv, 449.

(14) LYON, Bartle and ELLISON: Clinical

gastric analysis with detail of method and a consideration of the maximum information to be obtained. N. Y. Med. Jour., 1921, clxiv, 272.

(15) RYLE, J. A.: Studies in gastric secretion. I. The hypersecretory curve and its interpretation. Guy's Hosp. Rep., Lond., 1921, lxxi, 45. (16) RYLE, J. A.: Studies in gastric secretion. IV. Some individual experiments with the gastric tube. Guy's Hosp. Rep., Lond., 1921, lxxi, 158. (17) RYLE AND BENNET: Studies in gastric secretion. V. A study of normal gastric function based on the investigation of one hundred healthy men by means of the fractional method of gastric analysis. Guy's Hosp. Rep., Lond., 1921, lxxi, 286. (18) BELL, J. R.: Notes on a consecutive series of 425 gastric analysis by the fractional method. Guy's Hosp. Rep., 1922, lxxii, 302.

(19) BELL, J. R.: Gastric ulcer and achlorhydria. Arch. Int. Med., 1923, xxxii, 663.

(20) Carlson, A. J.: The secretion of gastric juice in health and disease. Physiol. Reviews, 1923, iii, 1.

C

LINICAL hypoglycemia has recently been brought to our attention, but experimental hypoglycemia was reported by Underhill of Yale in 1908. He produced a glycosuria and hypoglycemia in rabbits by injecting normal saline intravenously. This hypoglycemia by normal saline injection could be prevented by adding calcium chloride. Later other investigators by injecting guanidin, phosphorus, etc., produced a hypoglycemia. Then in 1922 Banting's classical results with insulin popularized the subject. Still later, organic extracts and also plant extracts have been used to produce hypoglycemia with a symptom complex similar to that produced by insulin. None of these substances caused hypoglycemia when given by mouth. All were administered parenterally and numerous observers have performed the test with identical results. We have seen no published record of insulin or of preparations claiming to be like insulin being administered by mouth and causing hypoglycemia with the symptom complex of a low blood sugar, that impressed us that it was worthy of further study. We personally have tested first by animal experimentation and then clinically many of the preparations said to be as good as insulin and potent by oral administration and have not found one that repeatedly reduced blood sugar or

gave any of the symptoms or signs accompanying insulin hypoglycemia. We do not consider any preparation which fails to give symptoms of an overdose when given in large amounts as a potent remedy and, therefore, advise all who attempt to treat diabetes which cannot be controlled by diet to use only insulin administered parenterally until trained, honest observers who have nothing to sell prove oral administration of insulin, the anti-diabetic hormone, to be effective. Hypoglycemia has frequently been observed in undernutrition but it rarely, if ever, causes the symptom complex of low blood sugar subsequent to an overdose of insulin. The case of Dr. Hepmann of Johns Hopkins as reported by Joslin with a blood sugar of 17 mgm. per 100 cc. had only one symptom of hypoglycemia, and that was general weakness. Lack of other symptoms of low blood sugar caused by insulin administration was doubtless explained by the gradual reduction of the blood sugar in extreme undernutrition, that is starvation. The hypoglycemia of normal persons deserves mention. Prior to insulin fasting blood sugars in clinically normal persons as low as 40 to 50 mgm. per 100 cc. were not infrequently observed.

Gray's tables giving the fasting blood sugars of 431 clinically normal persons show: