ence, and the correctness of the inference is denied by some writers. It is claimed that the total quantity of the fermentation acids formed in the stomach is not great; that few of them are toxic, even in large quantity; that they are combined and diluted by the blood, that some of them are so harmless as to serve as food; and that putrefaction, which is the chief source of poisons, occurs in the stomach seldom and irregularly and, indeed, almost accidentally. Clinical and experimental evidence is not conclusive, it is true, as to the existence of gastric auto-intoxication, but it would seem that iconoclasm threatens to go too far. The toxicity of the gastric juice is much greater in some of the diseases of the stomach than in health; the toxicity of the urine is often increased in the diseases of the stomach accompanied by toxemic symptoms, although the bowels be healthy and the liver show no signs of functional insufficiency; there are often present in the diseased stomach, and, indeed, in a state of active and virulent growth, germs which produce poisons in cultures. These are conclusions deduced from our investigations. Hydrogen sulphid formed in the stomach and found in the breath and in the urine gives rise to a special symptom-group on its way through the system. Butyric acid certainly produces local irritation and systemic symptoms. Acetone is sometimes found in the stomach when oxybutyric acid and acetone are found in the urine. Moreover, the toxicity of the urine is no index of the toxemia, for gastric poisons are not eliminated by the kidneys only, and it is probable that some of them, at least, are changed into simpler and non-poisonous compounds during their passage through the body. Furthermore, the absence of a perceptible increase of the toxicity of either the gastric contents or the urine does not exclude the existence of slow, chronic self-poisoning. The denial of the existence of gastric self-poisoning is based on a simple negation, and can not be justly made in disregard of the clinical and experimental evidence which we have, however little it may be.

1. INFLUENCE ON THE INTESTINES.

The functions of the intestines may be disordered indirectly by the injurious influence of the diseases of the stomach. on the nervous system, on the liver, on the blood, on nutrition, on the circulation, and on the kidneys; but there can be no question that their most direct action is on the intestines by reflexes originating in the stomach and conveyed by the

sympathetic and the pneumogastric nerves. These influences, however, are difficult to define, and they may be dismissed with this brief notice in order that we may pass at once to the consideration of the more important disturbances which occur in virtue of the close association of the stomach and intestines in digestion, and of their being but divisions of the digestive tube with one grand work in common.

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Whenever the stomach fails to do its required digestive work an additional burden is thrown on the intestines. the nitrogenous food is not properly peptonized, and if the bundles of muscular fibers are not unbound, as is the case in insufficiency of the secretory and motor functions, the omitted work must be performed in the bowels. If the action of the saliva is too rapidly arrested in the stomach, the intestines must convert more than their share of the carbohydrates. The healthy intestines, as is well known, are capable of performing this extra work perfectly, and the digestion and the utilization of the food may be as good as when both the stomach and intestines do their work normally.

extra work is a menace to the integrity of the functions of the intestines, and their susceptibility to disease is increased.

A disease which disorders the digestive work of the stomach, disorders, as a necessary consequence, the secretion and peristalsis of the intestines. It is well known that the saliva and the products of salivary digestion are physiological excitants of gastric secretion. If the saliva be excluded from the food and its entrance into the stomach prevented, the activity of the secretion of hydrochloric acid and the two gastric ferments during the digestion of the test-breakfast is reduced to about one-half of what it should be. The products of gastric digestion, also, excite the functions of the stomach. Chyme, on the other hand, as it undergoes conversion into chyle, is the physiological excitant of intestinal secretion and peristalsis, so that an alteration of the composition of the chyme must entail an alteration of intestinal secretion and peristalsis. This alteration may be compensatory or it may be so great as to produce functional insufficiency.

Now, functional insufficiency of the intestines, whether it be produced by extra work or by disordered gastric secretion and peristalsis, favors intestinal fermentation and putrefaction, and these in turn become active enemies of intestinal health. Thus the diseases of the stomach which are accompanied by disorders of secretion (excessive or diminished) and by disorders of the motor function (excessive or diminished) produce naturally disorders and diseases of the intestines.

If the disease of the stomach be accompanied by excessive gastric secretion, the carbohydrates must be digested by the bowels, and the gastric digestion of albumin is very active. If sweets are not excluded from the diet, gastric fermentation may become active, and, continuing in the intestines, it may prevent intestinal putrefaction; but even in this condition. putrefaction is likely to begin in the cecum, where the contents first become nearly neutral or alkaline. The colonic putrefaction is not accompanied by indicanuria, but it is manifested by very foul stools, and by the excessive formation of H&S gas. If sweets be excluded from the diet, gastric fermentation may be controlled, but intestinal putrefaction then begins high up in the small bowel, and the contents become thoroughly rotten in the colon. Indicanuria is very marked, and putrefaction and pancreatic superdigestion are only favored by the excessive gastric peptonization in the same manner as when predigested foods are eaten. If the disease of the stomach be accompanied by diminished gastric secretion, salivary digestion is very active and the digestion of the albumins is thrown on the bowels. Fermentation begins high up in the small intestines (even in the stomach, if there be motor insufficiency), and continues as long as the intestinal contents contain fermentable matter. Putrefaction does not occur in the small bowel, and the fermentation is usually active enough to prevent excessive putrefaction in the colon. If gastric stagnation or retention be present, there will be intestinal putrefaction or fermentation according to the reaction of the chyle and its richness in peptones or carbohydrates. Consequently, in diseases of the stomach which are accompanied by disorders of secretion and by disorders of the motor function, intestinal secretion and peristalsis may be disturbed, the food may be lost by fermentation and putrefaction (the analysis of the stools showing only an apparently normal utilization), auto-intoxication may be produced, and enteritis, colitis, or enterocolitis may result. Diminished gastric secretion also favors enteric infection.

Finally, gastroptosis may be primary and cause enteroptosis, and this process is but little less frequent than the production of gastroptosis by the primary prolapse of the colon. Gastro-enteroptosis may induce chronic changes in the abdominal sympathetic and in the nutrition of the intestines. Enteritis membranacea may then be an ultimate effect.

II. INFLUENCE ON THE LIVER.

The manifold functions of the liver-the largest and most important gland of the body-may be disordered by diseases of the stomach.

The liver is an organ of assimilation and disassimilation. This nutritive function may be disordered by the products of abnormal digestion and by auto-intoxication, or it may be disturbed on account of the irritation, or the overwork, or the required performance of unusual work.

The liver is also a poison-destroying organ. It accumulates, eliminates, and destroys the poisons which are carried to it by the portal vein. This function can be disturbed by auto-intoxication and by the absorption (without conversion) of the products of peptonization. Peptones and digestive albumoses, when they get into the circulation without being first transformed, act as poisons.

The liver is also a digestive organ, for the bile exerts a marked influence on the intestinal digestion and utilization of food. The quantity and activity of its secretion is dependent in part on the quantity and quality of the food and on the composition of the chyme, a large mixed meal when it is normally digested by the stomach being the most active cholagogue known. This physiological and purposive secretion of bile may be disordered by the diseases of the stomach which require a modification of the diet as regards the proportion of the grand classes of food which enter into its composition, which withhold, by retention or by vomiting, the required quantity of food, and which alter by secretion, digestive transformation, fermentation, and putrefaction the normal properties of the chyme.

The liver is a blood-destroying organ, and it has probably something to do with blood building and with the maintenance of the composition of the plasma. This function may be disordered indirectly by the diseases of the stomach through their action on the blood (hematocytolysis) and through the association of disordered functions. If one function of the liver becomes disordered, the other functions. may be compromised with it.

Consequently, the functions of the liver may be disordered by disease of the stomach. Hepatic insufficiency may be thus established, or the organ may become congested and, finally, inflamed. The congestion and inflammation may be acute or chronic. It is likely that the functions of the liver

may be deranged by reflexes from the diseased stomach, in the same manner that gall-stones produce hyperchlorhydria and hyperchylia gastrica, or that they may be deranged by the action of the diseased stomach on the cardiovascular system. Carcinoma and ulcer of the stomach may produce hepatic complications.

III. INFLUENCE ON THE BLOOD.

The injurious influence of diseases of the stomach on the blood is exerted in several different ways:

1. Diseases of the stomach frequently produce inanitionanemia, which is the sequel of subnutrition. Inanition acts in two principal ways on the blood. It may produce insufficiency of the hematopoietic organs, just as it produces general functional inactivity; or it may alter the composition of the plasma so that it becomes poor in nitrogenous matter, the resistance of the red corpuscles being diminished and the development of the white corpuscles being decreased. Consequently, subnutrition may produce dyshematopoietic oligocythemia, or the dyshematopoiesis may be accompanied by hematocytolysis, as is the case in the grave anemia of atrophy of the gastric glands.

2. The diminished supply and the diminished absorption of water, and its increased elimination by supersecretion or vomiting, may produce oligemia sicca. The oligemia may be simple, the red corpuscles being normal in number, in coloring (hemoglobin), in size, in form, in resistance, and in their affinities for stains; or the oligemia sicca may mask a disease of the red corpuscles, the deception being quickly made plain by the use of the microscope.

3. The loss of blood by hemorrhage (ulcer, carcinoma, erosions) produces an acute or chronic anemia, which may be mild, severe, or grave. Oft-repeated small hemorrhages produce grave and rebellious form of anemia when the daily or frequent losses of blood exceed the quantity of blood supplied by the hematopoietic organs.

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4. Auto-intoxication does more direct and more extensive injury to the blood than it does to the nervous system, cytoplasmic poisons destroying the red corpuscles and the activity of the blood-building organs are decreased. Consequently, the anemias of auto-intoxication may be dyshematopoietic or hematocytolytic.

5. The blood may also be injuriously affected by the influ