Complete Text (Part 10)

Terms : Ectasia (or ectasis) signifies dilation with motor insufiiciency. Atonic gastric ectasia signifies weakness of muscles of stomach. Hypertonic gas- tric ectasia signifies pyloric stenosis. Food should be out of the stomach in from 7 to 8 hours, no matter how heavy or large the meal. Tests which give information of gastric motility. a. Leube. A Riegel meal is washed out in 6 hours with 1 liter of water. Normal equals slight trace of food. b. Boas. A simple evening meal of meat, bread and butter is washed out the next day. If any food remains there is considerable motor insufficiency. c. Ewald-Siever's method : 1 gram of salol is given after a meal and the urine is collected every 15 min- utes for 2 hours. Test with ferric chloride for phenol, which gives violet color. Salol is broken down in the alkaline media of the small intestine into phenol and salicylates and is excreted in the urine. Difficulties of test: 1. The gastric juice acts slightly upon salol in about 15 minutes, breaking it up. 2. Small amounts of salicylic acid and phenol may be absorbed from the stomach. Normally, phenol appears in the urine in from 45 to 75 minutes and is all excreted in 24 to 27 hours. Abnormally, if not detected before 75 minutes in- dicates motor insufficiency; if not detected before 24 hours indicates stenosis. If detected in 15 min- utes an error is indicated. d. Winternitz. The method is the same as the preceding, except that iodipin is used in place of salol. Iodipin is not touched by the gastric juice, but requires pancreatic secretions and bile to free 124 iodiii. Tlie snliva is tested for iodin with si arch paste. Xormallv, it appears in from 15 to 45 min- utes. e. Sahli test meal (fat soup), (see text books for detail.) The method is incorrect if lipase is pres- ent in the stomach. f. An evening meal of substances easily recog- nized, such as raisins, rice, spinach, etc. Recover}^ of any of the meal (macroscopically or microscopi- cally) the next morning shows impaired motility of a degree depending upon the findings. g. Direct fluoroscopic examination with barium, wliich is the best method when available. Consideration oi absorption. Not of much im- poitance clinically. Penzoldt-Faber test : Two to o grains of KI are given in a capsule after a meal, which is rapidly absorbed by the mucus membrane and appears in the saliva, normally, in oO vo 40 minutes. Test the saliva every few minutes ^^'itll a fcAV drops of HX03 and a small amount of starch paste, when a positive reaction is indicated by a blue color. Indirect examinations. Where it is not possible to remove contents of stonuich, indirect methods may be used. They are not very accurate, but may give much help at times. a. (iunzberg's method: 0.2 gm. of KI are placed in the thinnest possible strongly vulcanized rubber tubing about 2.5 cm. long, which is then tied wath three threads of fibrin hardened in alcohol. Test by placing in water for 1 hour to be sure of no leak. The patient is allowed to swallow the bag three-quarters of an hour after an Ewald meal. Test saliva as in Penzoldt test. The HCl and pepsin digest the fibrin threads and free the KI which is 125 absorbed. It should appear in the saliva in three- quarters of an hour. b. Sahli's Desmoid bag. A bag of ordinary rub- ber-dam, containing a 0.05 gm. pill of methylene blue and 0.1 gm. of iodoform, tied with dried but chemi- cally-untreated catgut, which is digested by the gas- tric ferments, but not the pancreatic. The bag is swallowed after the noon meal. The methylene blue appears in the urine, normally, in 6 hours, coloring it green ; iodin in the saliva in 2 hours. Special test for carcinoma. Wolff Junghan's test. This is a soluble albumin test for carcinoma, very delicate, and applicable only to stomach contents. There should be no free HCl present and no occult blood for the successful application of the test, and it should be read within half hour after it has been set up. Positive results occurring after that time should be ignored. Reagent : Phosphotungstic acid 0.3 gm. HCl (concentrated) 1.0 cc. 96% alcohol 20.0 cc. Distilled water qs. ad. 200.0 cc. Procedure : Six carefully cleaned test tubes (cleaned with soap and water, alcohol and ether) are put in a rack and to them are added the fol- lowing : Tubes I II III IV V VI Filtered gastric contents. Ice O.o cc 0.2 cc 0.1 cc 0.05 cc 0.025 cc Dist. water 9 cc 9.5 cc 9.8 cc 9.9 cc 9.95 cc 9.975 cc Dilution equals ..1-10 1-20 1-50 1-100 1-200 1-400 After these dilutions have been made apply a clean rubber stopper to each tube and invert several times to mix. Do not use fingers as stoppers on account of errors in test. 1 cc. of the I'eagent is now carefully layered on 126 each of the tubes, which layering must be perfect. The presence of a white ring in the first three tubes is normal. A ring in the fourth is non-com- mittal. A ring in the fifth or sixth speaks for car- cinoma and is considered a positive test. Several points of clinical value : 1. High free HCl with low combined suggests liyperchlorhydria with hypermotility. 2. High (or normal) free HCl with high combined suggests hyperchlorhydria with stasis, probably spasm or stenosis. 3. Low free HCl with moderate combined sug- gests hypomotility with perhaps normal acid output. 1. HCl deficit with high combined suggests stasis with organic acid production. 5. HCl and mucus vary inversely as to their amounts. Mucus is never found with a high HCl. In gastritis, where mucus is characteristically pres- ent, HCl is low or absent. 6. Organic acids do not form if HCl is present in normal or increased amounts. 127 SPUTUM. Deriiiition : Sputum mcliides all the secretions which come from the respiratory passages. Collection of sputum. Avoid coutaminatioii from the mouth especially when making cultures. In chil- dren this can he done by stretching a piece of gauze over the finger and tickling the tliroat. The child AviJl cough and raise sputum, Avhicli will adhere to the gauze. When a quantitative examination is to be made, collect sputum in conical glass containers and look for stratification. Sometimes the gastric contents are examined in patients who swallow their sputum. Color of sputum: Gray — mucus. YelloAA' — pus ( purulent ) . Yellowish-gray — pus and mucus (muco-puru- lent) . Red — blood usually. When the lung is the source, it is frothy; when from the mouth, it its not frothy; when from the stomach, it is dark red or coffee-ground in appearance, and is never frothy. Occjurrence of hlood in the sputum {hemoptysis), 1. Pneumonia. 2. Infraction of lung. ?). Weeping aneurism. 4. Tuberculosis. 5. Tumor metastasis to lung. G. Blastomycosis. 7. Echinococcus cysts. 8. Paragonimus westermani (lung fluke). Green — resolving pneumonia, pj^ocyaneus infec- tion, rupture of subdiaphragmatic abscess. Black — coal and iron workers. White — starch granules in sputum of bakers. Various colors — dve workers. 12B An} Oil lit of spuiuni. This varies within a wide range. Large amounts are met with in : J. Branchial affections with much secretion. 1\ Bronchiectatic and tubercular cavities. 3. Pulmonary edema. 4. Perforating empyemas. Odor of sputum. Normally the sputum should have no odor. Sweetish odor — pulmonary abscess, occasionally in tbc. and oral sepsis. Foul — putrid bronchitis, gangrene, bronchiec- tasis. Cheese-like — perforating empyema. Putrefactive — stagnation in lungs or receiving cup. Macroscopic appearance. Layer formation. Top, frothy; bottom, granu- lar ; serous fluid between ; used to be consid- ered diagnostic of bronchiestasis, but it may occur whenever there are large amounts of sputum. Curshmann's spirals. These consist of a central core around which are wound strands of threads. The core is highly retractile and may be fibrin. Microscopical examination is necessary in order to make out the structure Charcot-Leyden crystals and eosinophiles are usually found with them. Dittrich's plugs. These are cheese-like masses usually about the size of a mustard seed, yel- lowish-Avhite to gray in color, sometimes form- ing casts of the bronchi or bronchioles from which they come. They are also of frequent occurrence in the crypts of tonsils of other- wise normal individuals. Upon crushing them they give a disagreeable odor. Microscopi- cally, they show large numbei^s of bacteria, 129 fatty acid crystals, fat globules and cellular detritus. Cheesy masses (rice bodies). These are small, yellowish masses varyinci- in size from that of a pin-]wint to a pea. They may be pigmented by decomposition products of hemoglobin. Upon crushing tliey do not give a disagreeable odor. They occur most frequently in tuber- culosis, also in abscess and gangrene. Fibrinous casts. In as much as not all the material making up these casts is fibrin, they are more properly called "bronchial casts.'' Many are branching and the size of the bron- chus from whicli they came. When composed of fibrin, they stain beautifully with Weigert's fibrin stain. With acetic acid they are not precipitated, and are friable in consistency. They occur in pneumonia and fibrinous bron- chitis. Bronchioliths. Tliese are calcified collections of debris and secretions. Pneumoliths. The majority of these are tuber- cttlous in origin, formed by the calcification of caseotis areas. They have a chalky or cal- carious consistency. Elastic tissue. This appears as grayish, opaqtie flakes, which are most readily recognized by ptitting the sptitum between two glass plates and looking toward the light. The other struc- tures can be dissolved away by boiling the sputum in 10% XaOH, eqtial parts of each, after which the sputum is diltited and the sediment examined. The fibrils of elastic tis- sue are not as wavy as those of fibrous tissue and are not dissolved by XaOH. Origin of elastic tissue: 1. Walls of arteries. Appear in sheets. 130 -. Bronchi. Have branches. 3. Alveoli. Appear in squares. When elastic tissue is found it means lung destruction. Echinococcus membranes. These ma}'^ be ex- pectorated in rather large masses, which are tough, thick and porcelaindike in color. 3Jicroscopically, they show laminated struc- ture. Microscopical exu in i nation. White blood cells. The ordinary ])olymorpho nuclear neutrophil is of little significance and is almost invariably found. The eosinophiles are found in asthma associated Avith Charcot- Leyden crystals. Red blood cells. These, also, are of little im- portance. Epithelial cells. J. Pavement ejnthelium coming from mouthy pharynx and upper larynx. 2. Cylindrical e]nthelium coming from nose and bronchi may be ciliated. '.. Alveolar epithelium coming from alveoli often contain coal pigment ' (phthisis melanoticaj and are found in normal sputum, especially in the morning. They are increased in any irritation of the respiratory tract. In chronic passive congestion of the lungs they often con- tain hemotoidin or hemosiderin granules, and are then known as ''heart-failure cells." iUifSitals. Patty-acid. These needle-shaped crystals occur singly or in group-. Heat changes them into fat droplets. They are soluble in ether and alkali. They occur in gangrene, putrid bron- chitis, and chronic tuberculosis. 131 Cliolcsteriii. Tliese crystals resemble steps superimposed upon one another. They occur frequently in association with fatty-acid crys- tals in empyema, chronic lung abcesses and chronic tuberculosis. Hematoidin. These crystals are rhomboid or needle-shaped, and ruby-red in color. They occur rarely in lung abscesses, empyenui, per- forating liver abscesses and old hemorrhages. Tyrosin and leucin. These crystals are of rare occurrence and are formed only by the decom- position of protein material. They occur in empyema, lung abscess or perforating liver abscess. Triple phosphates. These occur in the same conditions as leucin and tyrosin. Calcium oxalate. These occur in conditions associated A^■itll decomposition. Charcot-Leyden. These are found in association Avith eosinophiles and are probably derived from them. They occur most frequently in asthma, and less frequently in fibrinous bron- chitis and hav fever. 1 niriial pcn'osites. 1. Amoeba buccalis (A. gingivalis and A. den- talis probably the same). 2. Amoeba histolytica. This parasite ma}' occur in rupture of amoebic abscess through dia- phragm. See section on parasites. .*). Echinococcus granulosus and cysticus. The booklets, scolices, or portions of the cyst wall will diagnosticate the condition. These should be looked for in unexi^lained hemor- rhages from the lungs. 132 4. Pargonimus westermani (lung fluke). Look for the eggs of this parasite, Avhich are operculated on blunt end. They measure .1 mm. X .05 mm. This parasite is a com- mon cause of heilioptysis in Japan. Fungi. 1. Streptothrix actinomyces. The sputum with this infection is glairy and mucilaginous or purulent and contains yellowish gran- ules about the size of a pin head, the so- called ''sulphur granules." If one of these granules is placed upon a slide and crushed with a coyer-slip and examined, threads are found centrally and club-shaped proc- esses are seen peripherally. The}^ can be stained with Lugal's solution. 2. Aspergillus. Look for doubly-contoured threads with brownish pigmented spores. They are best seen after the sputum has been treated with 10% KOH. They occur occasionally in bronchiectasis and tuber- culosis. 3. Blastomyces. Treat the sputum with dilute KOH and look for yeast-like, doubly-con- toured, retractile bodies. They occur occa- sionally in systematic blastomycosis. Bacteria. I. Tubercle bacillus. Pick out grayish opaque flakes and stain with Ziehl-jN^eelsen stain: 5% carbolic acid water 90 parts Concentrated alcoholic fuchsin 10 parts Stain for three minutes, during Avhich time gently heat oyer a bunsen flame and replace the stain as it eyaporates. AYash the excess of stain off with water and decolorize witli a 2% solution of HCl in 80% alcohol. When no more stain comes off', counter- stain Ayith 1% methylene blue. The tubercle bacilli. 133 I'etain tlie red fuslisiii stain wliile tlie other elements; are decolorized and take the bine stain. It is of importance that not all acid-fast organisms are alcohol acid-fast as is the tnbercle bacillus. Allien a more careful search, is desired, the anti- formin method should be used. A good modification is that of Loeffler's : 10 to 20 cc. of sputum are mixed with an equal quantity of Sodium hypochlorite 10 grams Sodium hydroxide 10 grams Water 100 cc. Boil for not longer than 15 minutes and centri- fugal ize at high speed for from 1 to 2 hours. Make smears of the sediment and stain as above. Guinea pig inoculation should also be resorted to when in doubt. The sputum is injected intraperi- toneally. If the animal is first given a strong radia- tion with the X-ray it will succumb much more quickly than othermse. Cultivator of the tubercle baoillus. Petroff egg media: Meat infusion glycerin (500 grams of meat infused with 500 cc. of a 15% solution of glycerin in water for 21 hours) 1 part Beaten eggs (sterilize shells by pour- ing boiling water over them and break into sterile beaker and beat thoroughly. Filter through sterile gauze into sterile graduate) 2 parts Ifo alcoholic solution of gentian vio- let to make a dilution of 1-10,000 Tube in sterile test-tubes and inspissate for three consecutive days, the first at 85 deg. C till solidified and on the two remaining at 75 deg. C for one hour. An equal quantity of sputum and 134 mixed and incubated for 30 minutes to digest the former. Neutralize ^^'itll N/HCl and centrifugalize at liigli speed for 10 minutes. Inoculate the sedi- ment on to a few Petrolf tubes and seal with par- affin. Seven to ten days are required for growth. The gentian violet inhibits the growth of other organisms. ( Method of isolating the organism from the blood. Dr. Mildred C. Clough, J. H. H. Bui., Dec, 1917, page 303.) 10 to 20 cc. of the patient's blood are hemolysed in sterile distilled water and centrifugalized at high speed for 1% hours. Three-fourths of the sediment is planted upon a blood agar slant, which is then sealed with paraffin to prevent drying. A growtli appears after incubation of 7 to 20 days. The other fourtli is inoculated into a guinea pig. II. Pneumococcus. Pneumococci are divided into four groups, in accordance with their serological reactions. See Monograph of the Kockefeller Insti- tute for Medical Research No. 7, October 16, 1917. Tyi)e I. Causes about 33.3 %_of the cases of lobar pneumonia. The disease runs a severe source. The organism is practically never found in normal sputum. Type II. Causes about 13% of the cases of lobar pneumonia. The disease runs a severe course. The organism is practically never found in normal sputum. Tj^pe III. Causes about 13% of the cases of lobar pneumonia. The disease runs a most severe course. The organism is found in about 28.1% of normal persons. Type IV. Causes about 20.3% of the cases of lobar pneumonia. The disease usually runs a mild course. The organisms are found in about 18.2% of noa'mal persons. 135 Types 11-a, lib and li-x are found in about 1S.27(; of normal persons. Isolation of the pncumococcus and determination of group. 1. Mouse inoculation. Obtain a specimen of sputum as free from saliva as possible; wash in six changes of sterile salt; grind a piece the size of a bean in a sterile mortar, add sterile salt solution drop by drop till a homogeneous solution is formed that will readily pass through the needle of a small syringe. Inject 0.5 to 1.0 cc. of this emulsion intra- peritoneally into a mouse. Either wait until the mouse is dead or test by peritoneal puncture for the presence of pus, and kill if pus is found. In either case wash the peritoneal ca'ity out with 4 to 5 cc. of sterile salt solution after making pre- liminary smears and cultures on blood agar plates. Make a homogeneous suspension of the peritoneal wasliings and set up tubes as follows for agglutina- tion : TuLe 1 2 3