completely arrest it, unless putrefaction occurs; but the gasforming fermentation recommences with the resumption of a mixed diet. A diet rich in carbohydrates increases the fermentation. The test should be made while the patient is on a mixed diet, is taking no germ-destroying drugs, and is employing no remedies to control the fermentation. The vitality of the germs and the degree of stagnation or of retention will thus be displayed most clearly.

The fermentation test may be made by using a Dunbar tube, a urine saccharometer, a Botkin bottle, or the stoppered test-tube of Moritz. The apparatus of Moritz is simple, easily cleaned, and readily filled. An ordinary test-tube is fitted with a perforated rubber cork. Through the perforation a glass tube, which is bent at two right angles or in a half circle, passes to the interior of the test-tube. The sterilized test-tube is filled with the well-mixed, unfiltered, and sweetened contents containing peptones or albumoses, the cork is pushed in, and the glass tubing is thereby filled with the displaced contents. The apparatus is inverted in a beaker and placed in the thermostat at 37° C. The gas, as it forms, collects in the test-tube. The mixture of gases may be analyzed chemically, but the quantity and the rapidity of its formation have a much greater diagnostic significance than has the composition of the mixture of gases. Some information as to the nature of the germ-growth may be obtained by examining a hanging drop prepared from the contents of the test-tube, and by comparing the result with the predominant forms of germs found in the contents soon after their removal from the stomach.

The other products formed by germs in the stomach have no diagnostic value. The study of the toxicity of the contents is of great interest in the pathology of the stomach, and the bacteriological examination is a fruitful field for original research. The ordinary methods of bacteriology may be readily modified so as to meet the special requirements.

CHAPTER V.

THE ANATOMICAL SIGNS.

THE direct anatomical signs of the diseases of the stomach are very few. They may be found in the vomit, in the expressed contents after a test-meal, and in the water used to wash out the stomach. These anatomical signs are blood, epithelia, leukocytes, pieces of the mucous membrane, and small fragments of neoplasms.

The presence of blood in the contents or in the washings of the stomach may very readily lead to false conclusions. A small quantity signifies very little (unless it is present persistently or very frequently), and may be due to retching, to the introduction of the tube, to a temporary or a chronic congestion. Gastric hemorrhage occurs also in severe anemias and in cirrhosis of the liver. But the hemorrhagic diseases of the stomach are ulcer and carcinoma. Small quantities of blood are often found mixed with mucus in cases of gastritis, and this occurs so frequently as to be of some diagnostic value.

If the macroscopic and microscopic examinations of the contents do not make the presence of blood clear, it is necessary to use special tests. Spectroscopic examination is not clinically practicable. The two best tests for blood in the stomach-contents are those of Weber and Jaworski. It should not be forgotten that blood may be eaten with the food, or that iron (as a drug or as a compound of the food) may be swallowed.

Weber's test is a modification of Van Deen's. To ten c.c. of the filtered contents about three c.c. of glacial acetic acid are added, and the coloring matter of the blood is extracted by shaking with about five c.c. of ether. If blood is present, the ether extract is brownish; if the ether extract is uncolored, there is no blood. The separation of the ether may be facilitated by the addition of a few drops of alcohol. Add to the brownish decanted ether extract ten drops of fresh tincture of guaiac and about 20 drops of old spirits of turpentine or a small quantity of peroxid of hydrogen. After vigorously shaking the mixture for a while it becomes dark blue if blood is present. If there is no blood present, the mixture often becomes reddish-brown with a tinge of green. When the reaction is not clear, a little water should be added, and the coloring

matter extracted with chloroform. If blood is present, the chloroform extract is colored blue.

The iron test of Korcynski and Jaworski is made in the following manner: A small piece of the colored and suspected sediment is placed in a porcelain capsule, with a pinch of chlorate of potash and one or two drops of concentrated HCl, and is slowly and gently heated to drive off the chlorin. The procedure is repeated, after the addition of another drop of HCl, until the residue of evaporation is decolorized. The addition of one drop of a one per cent. solution of potassium ferrocyanid gives a Prussian-blue color if blood is present.

In the morning washings of the normal stomach are found a few single cylindrical cells, and, rarely, a few lymphocytes. If the fasting stomach contain free hydrochloric acid, which is a pathological sign, the spiral bodies of Jaworski and groups of the nuclei of leukocytes may often be found. In gastritis with excessive secretion these cell nuclei are numerous, and are mixed with the mucus, with the chief cells, and with mononuclear leukocytes. In asthenic and atrophic gastritis no spiral bodies are found, and no nuclei of cells the protoplasm of which has been digested, but numerous cylindrical cells and mononuclear leukocytes and sometimes beaker cells. Rarely, groups of cancer cells are detected. In suppurative gastritis and in perigastric abscess, large numbers of polynuclear leukocytes in the morning washings or in the vomit may reveal the nature of the trouble.

Exfoliated pieces of the mucous membrane are sometimes found in the morning washings, and this anatomical sign is most frequent in ulcerative gastritis (erosions). Pieces of the mucous membrane or of tumors may sometimes be found in the expressed contents, having been scraped off by the tube. This regrettable accident occurs very rarely when the velveteye tube is used, but the little fragments should always be searched for in the contents, and should be utilized for diagnostic purposes. The fragments rarely extend through the glandular layer, but sometimes do so, and, when hardened, cut, stained, mounted, and examined with the microscope, may give the anatomical diagnosis in a manner which leaves no room for doubt; but it should be remembered that a normal piece of the mucous membrane does not exclude anatomical disease of another part of the stomach, and that different forms of gastritis may coexist in the same stomach. The functional signs must make clear the predominant features of the inflammation, which may be asthenic or hypersthenic. Gastritis may also be a complication of ulcer or of cancer.

Bile and pancreatic juice are sometimes found in the contents, whether vomited or removed after a test-meal, and in the morning washings before breakfast. This may occur when the stomach is normal. Pathologically, the regurgitation of bile may recur persistently, and this would make obvious the easy passage of the pylorus and suggest the possibility of an obstruction of the duodenum below the opening of the common duct; but under such circumstances it should not be concluded that the pylorus is not the seat of an anatomical disease, for the pylorus may remain patent, like a rigid tube, in cancer, in cases of ulcer, and in cicatricial deformity.

The anatomical or dynamic or exact nature of a disease of the stomach may often be made plain by the results of treatment, even when all other signs fail to clear away the obscurity. This constitutes the therapeutic diagnostic test, which is applicable to both the primary and the secondary diseases of the stomach. The principles of the test are very simple. If the hypothetical diagnosis be correct, certain results should be obtained by a particular method of treatment, which would not give the same results in another disease; or the effects of treatment may be better or may be worse than would be obtained if the hypothetical diagnosis

were true.

SECTION III.

GENERAL MEDICATION.

THE revelations of the diagnostic methods, together with our knowledge of the genesis and evolution of the diseases of the stomach, furnish the indications to be met by medication. Corresponding to the modern methods of diagnosis are the modern methods of treatment. The more accurate and complete knowledge of physiology, of pathology, and of the action of remedies has increased our ability to do good or to avoid doing harm. The pathology of the stomach, it is true, seems to have a greater charm for the lover of research than has the treatment of its diseases; but the interest of the patient begins with the medication intended to cure or to give relief.

The combination of remedies to meet the special indications of the particular diseases will be considered in Sections IV and V. The general medication consists in the use of remedies suggested by the condition of the patient and by the information given by the various diagnostic methods. The subject will be discussed under the following divisions : 1. Digestive hygiene.

2. Diet.

3. Physical remedies.

4. Symptomatic treatment.

5. Physiological treatment.
6. Bacteriological treatment.

7. Chemical treatment.

All curative treatment demands the removal or the control of the cause of the disease. This general principle of therapeutics has a very extensive application in the treatment of the diseases of the stomach; for a large number of these diseases are secondary, and the particular cause or causes of the primary diseases are often revealed by the clinical history. A man's stomach is no better and no worse, as a rule, than he himself makes it.