a reddish or no coloration, and Fehling's solution is positive. The accumulation of the products of starch digestion increases the specific gravity of the filtrate of the contents obtained after the test-meals, unless secretion is excessive. Normally, the specific gravity of the filtrate after the testbreakfast is 1010 to 1015; after Sée's meal, 1015; after Riegel's dinner, 1015 to 1020. If a large quantity of starch products is present, either the evacuation of the stomach is too slow or absorption is diminished, or both conditions are present. Digestive products do not accumulate in the normal stomach.

The digestion of the proteids is revealed by inspection and by chemical tests, and is displayed best by the Riegel or Sée meals. The proteids may be rapidly digested as in active or excessive secretion; or they may remain undissolved and untransformed in anacidity. The methods of distinguishing syntonin, albumoses, and peptones is described elsewhere, but the biuret test gives a rough idea of the activity of peptonization. The products of proteid digestion accumulate in the stomach only when there is motor insufficiency.

The digestive work done by the stomach in the various diseases is described in the fourth and fifth sections. By mere inspection of the physical properties of the contents, information concerning the functional power of the stomach may be obtained, which is very valuable both in diagnosis and in the dietetic treatment.

CHAPTER IV.

THE BACTERIOLOGICAL SIGNS.

Ir is a remarkable clinical fact that the micro-organisms of the stomach are quite constant, and are characteristic of the qualities of the contents and of the motor function of the stomach in which they grow. As a rule, germs do not thrive in an acid medium so well as in an alkaline or a nearly neutral culture. Consequently, a large number die rapidly or degenerate, or form the more resisting spores when they remain in the acid stomach. The germicidal power of the gastric juice is important, but it is incomplete, both in health and, to a greater degree, in disease. The germs swallowed

during the period of functional rest and during the period when no hydrochloric acid is free in the stomach, may escape uninjured into the intestines and find there a persistent and favorable soil. Their passage through the stomach may be too rapid to allow time for their destruction. The healthy stomach may fail to protect the organism against invasion even by the pathogenic germs. The diseased stomach may become a breeding receptacle, particularly for the saprophytic germs. The hydrochloric acid influences only the quality of the germ growth which occurs in the diseases of the stomach accompanied by motor insufficiency.

But apart from the acid reaction, the composition of the diet exercises a great influence on the development of the lower forms of life. Each germ has its own peculiar habitat, its favorite culture soil, and dies when it can not adapt itself to the sudden changes which occur in the contents of the stomach. On the other hand, their increase is rapid in a favorable soil.

But of more influence than either the acidity and the composition of the contents of the stomach are the intermittence of the food supply and the complete emptiness of the resting organ, which, when normal, evacuates the germs along with the chyme into the duodenum. Thus the normal stomach is intermittently empty and clean and without a culture soil. Consequently, in the normal organ germs do not have time, during the short digestive period, to manifest their very active powers of growth and proliferation. The churning movements of the stomach also help to keep its contents sweet. Constant motion is very destructive to some forms of germ life.

Naturally, the flora of the stomach is dependent upon the number of germs which obtain entrance there. The supply of these is abundant,—from food and drink, from the mouth, the nose, and the throat, and probably from the intestines. The opportunities afforded by pathological conditions are readily used.

The prevailing classification of bacteria is based on their form-cocci, bacilli, spirilli. Besides these, we have other germs-the molds and the yeasts. The particular kind of germ found, with but few exceptions, is of little diagnostic value. It is probable that a more complete study and a more exact control of the conditions would extend this short limit.

The quantity of germs found denotes more favorable conditions of growth. This may be referred to the quality of

the soil, but the richness and the active growth of the flora is, also, directly and closely dependent on the delay or the failure of the stomach to empty itself.

The germs of the stomach under consideration are not pathogenic, but live on and in dead matter. Consequently, their existence is made manifest by changes in the contents on which they live. The acids, the gases, and the toxins of fermentation and putrefaction are thus developed.

The bacteriological signs consist of the kind and the number of the micro-organisms, and of the products which they form by fermentation and putrefaction. The products which are of practical importance are the organic acids, the gases, and the toxins.

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Fig. 10.-Sarcinæ ventriculi from stomach-contents, X 530; stained with methylene blue (authors' specimen).

1. The Kind of Germ.-The many kinds of germs found in the healthy stomach and in the pathological stomach have not been isolated and studied; but it will not be denied by those who frequently make a microscopical examination of the stomach-contents that the individual forms are very numerous. Only sarcina, yeast, and the bacillus geniculatus have a definite pathological meaning. And this is true of these three only when they are persistently present in large quantities and in active growth.

Many forms of sarcinæ exist in the air, and they may find their way into the stomach, and, under favorable conditions, may there proliferate. Oppler, who has best studied these cocci in the stomach-contents, succeeded in isolating five varieties, presenting distinct color and culture peculiarities. The cultures possess only a scientific interest; practically, we

are concerned only with their persistent presence in large quantities in the contents of the stomach.

These cocci are about 2.5 in diameter and appear in small cubical groups of eight, the packages or bales being marked by lines running at right angles. Larger packets may be formed. They may be found very loosely united or separated, and are small when undergoing degeneration.

Sarcinæ in large quantities are only found in benign forms of gastric stagnation or retention with free HCl. They can not live in the lactic acid contents of carcinoma. In small number they may be found in cancer, during the free HCl stage, in gastritis, in ulcer, in gastroptosis, and in the dynamic affections. Their presence in these diseases is inconstant and rare. Their persistent growth in large numbers is character

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Fig. 11-Yeast from stomach-contents; X 530 (authors' specimen).

istic of retention due to myasthenia and to non-malignant obstruction.

Yeast, which grows by budding and occurs in single cells, or in strings of cells, clear and bright, and staining yellow with iodin, is often found in the stomach-contents; but it only grows and flourishes there when there are motor insufficiency and a suitable soil. The acidity of the contents of the stomach has little influence on the growth of the yeast. It matters little whether the reaction is alkaline, neutral, or strongly acid. Even excessive hydrochloric acidity does not arrest its growth, nor does carcinoma prevent its development. Whenever there is motor insufficiency yeast may be found, but it is not very vigorous except in gastric retention, when the yeast accumulates in large quantity, and the microscope shows that the plants are growing rapidly. The proliferation of the

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yeast is proportionate to the motor insufficiency and to the richness of the diet in fermentable matter. Yeast is often present in small quantity in all the diseases of the stomach, except simple ulcer.

The bacillus geniculatus (Fig. 12) is present in very large numbers in carcinoma (Boas), and is sufficient to render a case suspicious. This bacillus consists of cells a little smaller than the bacillus subtilis, arranged often in a zigzag line, or in pairs, joined end to end so as to form an angle. It does not color with iodin, but colors homogeneously with fuchsin. It is large, devoid of motion, may be easily seen without staining, and is always present in carcinoma when the contents contain a notable quantity of lactic acid. It develops in acid-sweetened bouillon and produces lactic acid (Kaufmann).

Fig. 12.-Bacillus geniculatus from stomach-contents; X 730: a, spore-formation; oval spores in center, ends pale and indistinct; b, multiplication by cell-division; c, normal cell arranged in a zigzag line; length, 4 to 8 μ; width, about 0.7 μ (authors' specimen).

These are the only varieties-viz.: sarcina ventriculi, yeast, and the bacillus geniculatus, whose simple growth in the stomach signifies that the organ is diseased. The sarcina, in large quantities, are almost exclusively found in benign retention with free HCl. Yeast finds a most favorable soil in stagnation or retention, regardless of the kind or the degree of acidity. The bacillus geniculatus is constantly present in cancerous obstruction of the pylorus which produces retention. It is sometimes absent in other forms of carcinoma, but its persistent presence in large numbers is almost characteristic of malignant disease of the stomach.

2. The Number of Germs.-The quantity and the general character of the micro-organisms present are of diagnostic value. The normal stomach is a bad medium for bacterial