Complete Text (Part 8)

requiring a study of Motility. 4. That of a place of absorption, requiring a study of Absorption. AVe shall limit ourselves to the knowledge obtain- able from a study of the gastric contents and leave to other departments the additional important in- formation to be gained by direct abdominal examin- ation and X-ray. The condition of the gastric contents may be studied from the vomitus or by emptying the stom- ach by means of the stomach tube. By this means we may study the activity of the stomach — as to its powers of secretion, ferment formation, motility, and absorption. I. Secretions. A. Vomitus. Vomitus consists of stomach con- tents plus mucus and saliva. It represents no defi- nite phase in gastric digestion; it is, therefore, of much less value along certain important lines than the gastric contents artificially removed. Much val- uable information can be gained from its study, how- ever, especially in the following particulars : 1' Time of vomiting. 2. Amount. 3. Keaction. 4. Odor. 5. Color. 6. Macroscopical contents. 7. Microscop- ical examination. . 100 Types of Tomiting. 1. Cerebral. a. Organic brain changes (no nausea, projec- tile). b. Drugs. Apomorphine. 2. Systematic. a. Local. Drugs, emetics, acute gastritis. b. Psychic — unpleasant sights or smell. c. Toxic. Uraemia, pregnancy, ethyl, alcohol. d. Keflex. Gastric crises, acute inflammation of gastrointestinal tract, renal colic. e. Obstructions. Points of special interest. 1. Time. Morning (alcoholism, pregnancy, hypersecre- tion). After meals (ulcer, esophageal obstruction, pyloric obstruction). Definite time (neurotic). 2. Amount (relation to food and water intake). Large (stasis-atony or obstruction — shows food remains). Hypersecretion has little or no food present. 3. Reaction. The reaction is acid, with the fol- ing exceptions : 1. Esor>hageal obstruction. 2. Presence of intestinal contents (bad retching). 3. Occasionally in achylia. 4. Alkali poisoning, or therapy. 4. Odor. 1. Fecal (obstruction, paralytic ileus, perito- nitis with complete motor insufficiency). 2. Almonds (hj^drocA^anic poisoning). 3. Garlic (arsenated hydrogen). 4. Sour (uraemic, acetone), etc.). 101 5. Color. Varies Avith presence of: 1, food; 2, bile; 3, blood; 4, poisous; 5, fungi. 6. Macroscopic appearance. 1. Bile (retching). 2. Food (retention). 3. Blood (dark red or coffee ground). 4. Fecal. 5. Cancer tissue. 6. Mucus. 7. Microscopical examination, (see under Fast- ing stomach), 8. Chemical analysis (see under Test meals). B. Stomach tube. It is better taken if ice cold and lubricated with oil. Some cases warrant cocain- izing the throat. 1. Factors regarding patient. He should be sit- ting upright or lying on side. A rubber apron should be tied around neck so as to prevent soiling clothes. False teeth should be removed and other foreign bodies. He should be instructed to breath normally. 2. Passage of tube. Hold as a pen, avoid pressing on tongue, and push back to posterior wall and then down. A swallowing movement at this point helps. Kesistance is encountered on the floor of the stom- ach, 40 cm. or 18 in. in adults, 9 in. in child). Re- move tube if there is great pallor or cyanosis. 3. Emptying stomach. Have patient cough, or bear down with abdominal muscles or use Politzer or Boas bags. Indications for the passage of the stomach tube. 1. Emptying the stomach in poisoning, disten- tion or stasis. 2. Lavage in stasis, fermentation, mucus, hic- coughs, post-operative vomiting or chronic ulcer with high acidity. A pint of warm water is usually safe for an adult with 102 sodium bicarbonate or HCl, as the case demands. Beware of habit formation. 3. Gavage. Coma, forced feeding, local mouth conditions, pyloric stenosis (infancy). 4. Medication. Castor oil, salts, emetics, silver nitrate, etc. Contraindications for the passage of the stomach tube. 1. All general conditions in which excitement and retching are associated with harmful results to the patient. 2. Local conditions in which trauma associated with its passage might be dangerous as aneurism, esophageal vacicosities, bleeding ulcer, corrosive poisons, etc. C. Fasting stomach examination. The patient should be instructed to eat a supper in which rice or some other easily recognized food is included, such as spinach, raisins, prunes, etc. After this meal nothing should be eaten until after the passage of the stomach tube the following morn- ing. 1. Normal findings. a. Macroscopic. 10 — 100 cc. fluid, often bile tinged from retching. There may be a few streaks of blood from injury to the mucus membrane. No food remains should be present. b. Microscopic. An occasional starch granule and a few bacteria. No yeasts, no Oppler- Boas bacilli, no sarcinae, no food remains. c. Chemical. The gastric contents should be slightly acid (usually test for free HCl). No lactic acid should be present and is not tested for a^ a routine unless suspected. Guiac test should be negative and is not 103 tested for as a routine. Hoiiseiiiann's test should be negative. This test is used to determine retention and is carried out in the following manner : Allow the gastric contents to stand in a conical container for about 30 minutes; pour off the supernatent fluid, add 10 — 15 drops of Lugal's solution or iodine to the sediment and water till transparent. Starch granules show up blue and are in- dicative of retention. 2. Abnormal findings. a. Macroscopic. Food remains, large amount of fluid (hypersecretion), body tissues (cancer fragments, blood, pus, mucus), foreign bodies (rarely), parasites. b. Microscopic. Oppler-Boas bacilli, B. Bul- garicus, sarcinae, yeasts, infusoria, pro- tozoa (amoeba, flagellates), eggs and worms. Food remains (meat fibers, starch, fats). Crystals, fatty acid, triple phos- phates, calcium oxalate, bile crystals (leu- cin, tyrosin, cholesterin). Body cells r.b.c, w.b.c, cancer cells). D. Test meals. The advantage of giving test meals and then obtaining the gastric contents is that a study can be made of the effects of various meals on normal individuals and a standard can be obtained by which we can judge deviations in the abnormal conditions. Test meals should be of such a character as to (1) produce a normal, psychic and chemical flow of gastric juice; (2) be easily taken by even ill people; (3) be easily recovered (not ob- structing stomach tube). 104 Ewald test meal. 40 grams of bread (without crust because of color) well masticated. 400 cc. of water. (Tea as a substitute not ad- visable on account of interference with guiac test.) Remove in one hour. ]^ormal findings : 30 — 50 cc. fluid with residual bread. Free HCl 20—40%. Total acidity 40— G0%. Disadvantages : a. Little psychical stimulation. b. Some lactic acid introduced. Dock modification. 1 shreaded wheat biscuit in place of bread. (More palatable.) Boas test meal. Oatmeal (1 liter of water, 1 tablespoonful oat- meal boiled to 500 cc.) This modification eliminates the introduction of lactic acid. Remove in one hour. !Xormal findings : Ver}^ little residual material, acidity? Riegel test meal. Mid-day heav}' meal : 400 cc. soup, 200 gm. beefsteak, 150 gm. potato, 1 glass of water. Remove in three to four hours. Advantages : a. Good psychicial stimulation of gastric juice. b. Longer period before removal, hence more information. 105 Disadvantages : a. Too heavy for many conditions. b. Blocks tube. 4. Fisher test meal. Bread and tea (modified Ewald). % pound chopped, seasoned, lean beef. Remove in 3 hours. Advantages same as Riegel. Disadvantages : Too heavy for many cases. 5. Salzer test meal. Double meal. Breakfast: Meat, milk, rice and egg. Four hours later : Stale bread and water. Remove one hour after second meal. Normal findings : No remains of first meal. Advantages : Especially adapted for study of motility. G. Sahli test meal. A fat savory soup of which 250 cc. are given and 50 cc. kept for comparison. Remove gastric contents 1 hour after taking in 2 portions : a. As much as can be obtained directly. b. With a known amount of water wash out the remaining. By reckoning the per cent of fat content (method of Mathieu and Remond- Webster, pg. 58) of the various specimens it becomes possible to determine quantitatively the amount of gastric contents in the stomach at the time of its removal; then by reckoning the acidity per cent it becomes possible to tell the actual amount of acid in the stomach and not merely its per cent. 106 E. Examination of recovered gastric contents. 1. Amount. Ewald 30 — 50 cc. ^Vlore in stasis or livper .secretion. 2. Reaction. Acid, rarely alkaline. Duodenal re- gurgitation and a few acliylias may produce an alka- line reaction. Generally su^cient organic acid is present to cause acidity. 3. Odor, Same as for vomitu?. (Uraemic, rancid, acetone, fecal, etc.) 4. Color. Limited also by previous emptying to bile and blood, fresh or coffee-ground. 5. Macroscopic. Layer forination. Xormal. Fluid and food residue. Abnormal. Retained food (not removed by pre- vious emptying). Blood, fresh or old. Con- sider possibility of trauma from stomach tube, also rule out blood from nose, mouth, throat and lungs. Pus. L'lcerated carci- noma, ruptured abscesses, pyorrhea. Tissue. Especially in carcinoma. Mucus. Gastritis. (I. Microscopic, (See Fasting stomach.) 7. Cliemical analysis. a. Routine. 1. Presence or absence of HCl. 2. Amount of HCl present. 3. Amount of combined acid. 4. Organic acids, especially lactic. 5. Occult blood. b. When indicated. 1. Ferments. 2. Special tests (especially for cancer, which are taken up under that subject). For the acid determination the necessity of devis- ing methods for the differentiation of organic and inorganic acids is obvious. When we speak of a test as specific for HCl it really means for inorganic acids in general, but acids other than HCl are elimi- 107 Hated from consideration. Most of the tests we use as specific for HCl Avill, unfortunately, give suspici- ously positive results with organic acids if they are in high enough concentration. 1. Qualitative tests for HCl. 1. Litmus. Turns red from any acid. 2. Congo red paper (filter paper dipped in acids it gives an orange to a pinkish Congo red, alcohol solution, and dried). It is supposed to differentiate organic from inorganic acids ; deep blue with HCl , bluish red with organic acids. AVith suffi- cient concentration organic acids will also give a definite blue. 3. Topfer's (dimethyl amido azo benzol, 5% alcoholic solution). This is the most gen- erally used reagent. It gives a yellow color in alkaline solutions, and with HCl it gives a deep red to a pinkish orange, depending upon the concentration. With organic acids it gives an orange to a deep pinkish orange, depending upon the concentration. It is sensitive to .02 parts of HCl in 1000 cc. It gives suggestive positive reactions with organic acids in concentrations above 5%. 4. Gunzberg's (2 gm. phloroglucin, 1 gm. vanil- lin in 30 cc. of absolute alcohol or in 100 cc. 80%). Keep in dark bottle. Ivoact,^ with no organic acids nor acid salts re- gardless of concentration. Sensitive to .05 parts of HCl in 1000 cc. Method of performing test : 1 drop of reagent is allowed to dry in a porcelain dish. (Heating is permissible without burning.) 1 drop of gastric contents is placed over the drop of the dried reagent and also dried with great care. lo: HCl gives a purple red color. ( Miutz mod- ilication of Gunzberg. 5. Boas. 5 gm. resorcin, :j gill, caiie sugar, 100 cc. 95% alcohol. More stable tban Gimzberg's, with similar delicacy and same color reactions. 0. Tropeolin. Saturated alcoholic solution Tropeolin. Use as Gunzberg's. Less delicate and color ditference between organic and inorganic is too close to be of practical value. II. Quantitative Tests for Free HCl. 1. 10 cc. of gastric contents well mixed and un- filtered. (Filtering causes some H2O loss and, therefore, HCl concentration.) If much mucus is present, filtering will be necessary regardless of slight error associated with it. Avoid including food in the 10 cc. Technique of perfonning test. To 10 cc. of gastric juice add a drop of Topfer's reagent. If a deep pink color results, proceed with quantitative determination. If a i)inkish orange color results, stop at once and do a Gunzberg test to determine the presence of any HCl. A. Should the resulting color be a deep pink or red color, add from a buret, drop by drop, with con- stant stirring, enough ^syi^ XaOH to change the color to a definite Jeinon color. Calculation: Xo. cc X/10 XaOH X 10 = acidity per cent. B. Should The resulting color with the Topfer's be a pink orange and although only one drop were used, a fresh 10 cc. of gastric contents will be neces- sary, for the presence of Topfer's reagent gives a false positive witli Gunzberg's reagent. If tlie qual- 109 itative test with Gunzberg's shows no HCl present, it will be unwise and impossible to carry ont the test. If the fresh gastric contents gives a positive (hmzberg test, then from a buret add, very care- fully, VIO XaOH to 10 cc. of the gastric contents and test with Gunzberg's reagent after the addition of each 1 — 2 drops, for there is not much free HCl present and the end j^oint must not be passed for accurate determination. Calculation : Same as with Topfer's. Note: Normal acidity is .'2 to .0%, probably as high as .5%, when just out of the gland, but quickly falls to .2 to .8% from contact with (1) mucus of gastric glands, (2) protein combination, (3) alka- line duodenal regurgitation. Expression of acidity: 1. In terms of acidity per cent, which is the no. of cc. of N/IO XaOH necessary to neu- tralize 100 cc. of gastric contents. 2. Actual amount of HCl present based upon the fact that 1 cc. of N/IO NaOH is equal to .00365 gm. of free HCl. Determine 100 cc. .2 to .3% equals 20 to 10 acidity per cent. Definition of terms : Euchlorhydria, when free HCl is .2 to .3% or 20 — 10 acidity pex* cent. Hypochlorhydria, when free HCl is decreased .1%. [Chronic gastritis ( subacute), incipient cancer, fe^'ers, severe anaemias, many mental diseases, c.p.c. chronic nephritis, etc.] Anachlorhydria, absence of free HCl. (Cancer, pernicious anaemia, neurasthenia, etc.) Aclijlia, absence of HCl and ferments. Hyperchlorhydria, free HCl from .2 to .9%. (Ulcers, chlorosis, reflex, migraine.) (Surmont- Dahon, defective XaCl output, compensation.) 110 E-,timation of HCl deficit. To 10 cc. of gastric contents add 1 drop of Topfer's reagent, Tvliicli should not give positive reaction. Confirm absence of free HCl with Gnnzberg's test. Into the 10 cc, with Topfer's reagent as an indica- tor, add, drop by drop, X/10 HCl, stirring con- stantly, nil til a definite positive reaction is obtained. For more accurate determination control end point with Gnnzberg's reagent. Calculation: Xo. cc. of X/10 HCl required X 10 =: acidity per cent. III. Combined Acid. In order to calculate the entire HCl acidity per cent, one must determine, in addition to the free HCl, the HCl combined with foods, especially the proteins. The amount of combined HCl can be de- termined by one of two methods : 1. Einhorn method. This method is simple, quick and sufficiently accurate for clinical work. Method of performing test: To 10 cc. of gastric contents add a drop of Top- fer's reagent. Titrate with X/10 XaOH and de- termine the free HCl. When the end point of the above determination is reached add a drop of phe- nolphthalein and continue to add X/10 XaOH until a definite pink color is obtained lasting at least 30 seconds. Calculation: Xo. cc. XVIO XaOH required to bring about reaction after the free HCl has been neutral- ized X 10 =: acidity per cent for combined acid. In cases where no free HCl exists, i. e., negative Topfer's and Gnnzberg's reaction, the HCl deficit and combined HCl should be determined, which will require two 10 cc. portions. Determine the HCl deficit as above. The combined HCl is determined by adding the i)henolphthalein at once and titrating with the X/10 XaQH, The fallacies of this method Ill are obvious, for such a determiuation of conibiued acids includes: 1, combined HCl ; 2, acid salts; 3, organic acids. When the free HCl is high and there is no evidence of stasis, the bulk of combined acid determined will be represented by combined HCl, but where the free HCl is low or absent, especially when associated with stasis, acid salts and organic acids will often comprise the greater part of this acid calculation. 2. Topfer's method. This method is of value in differentiating between the constituents above enu- merated. Procedure : A. Determine total acidity, including free, com- bined, and salts, using phenolphthalein as indicator. (10 cc. gastric contents plus 1 drop of indicator plus ^NyiO XaOH till end point). Calculate acidity per cent. B. Determine free acid, both HCl and organic, and salts as follows : To 10 cc. of gastric contents add 2 — 3 drops of a 1% aqueous solution of alizarin monosulphonate of sodium, which turns yelloAv with acid and violet with alkali. This indicator reacts with free acids, organic and HCl, and salts, but does not react with organically bound HCl. Titrate with N/10 XaOH till a pure violet color not growing darker with the addition of more alkaU. Cal-culate acidity per cent. C. Determine free HCl with Topfer's or Gunz- berg's reagent. Calculate acidity per cent. Explanatory example: A = 80 acidity % (includes all acids, free, salts, and combined). B = 22 acidity % (includes all acids and salts not organically bound). C = 20 acidity % (includes only free HCl). A — B = 58 acidity % = combined HCl (also com- bined organic acids if HCl is insufficient for lactic 112 acid being weaker will not combine as long as HCl is present to do so). B — C = 2 acidity % ^ organic acids and salts. (A— B) plus C = total HCl, or 78 acidity %. In cases where there is a free HCl deficit and organic