Columbia Winihtv^ity mti)eCit|>ofi^eto|9orfe ^cIjooI of ©ental anb (Bval ^urgerp J^eference Eitirarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diagnosistreatmeOOnile THE DIAGNOSIS AND TREATMENT OF DIGESTIVE DISEASES N I LES THE DIAGNOSIS AND TREATMENT OF DIGESTIVE DISEASES A PRACTICAL TREATISE FOR STUDENTS AND PRACTITIONERS OF MEDICINE BY GEORGE M. NILES, M. D. PROFESSOR OF GASTROENTEROLOGY AND CLINICAL MEDICINE, ATLANTA MEDICAL college; GASTROENTEROLOGIST to the GEORGIA BAPTIST HOSPITAL, WESLEY MEMORIAL HOSPITAL, ATLANTA HOSPITAL; CONSULTING GASTROENTEROLOGIST TO THE ANTI-TUBERCULOSIS ASSO- CIATION, ATLANTA, GEORGIA WITH 1 COLORED PLATE AND 86 OTHER ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 2-1-7 '^mi Copyright, 1914, by P. Blakiston's Son & Co. THE. MAPLE. PRES3. TOEK. PA E. C. THRASH, M. D. and HANSELL CRENSHAW, M. D. TWO RARE SPIRITS, WHOSE WISDOM, ENCOURAGEMENT, AND PHILOSOPHY HAVE GREATLY AIDED ITS PREPARATION, THIS VOLUME IS INSCRIBED PREFACE In advancing this volume, it is not my purpose to assist in the erroneous movement for divorcing gastrointestinal diseases from the broad field of internal medicine to which they rightfully belong, but to answer, for the student and busy general practitioner, two important questions regarding these diseases, namely, "What is the disorder?" and "What should be done for it f" Not only general practitioners, but specialists in other lines, who find it necessary to keep informed in a general way concerning digestion and nutrition, have discussed with me what they desire in such a book. Briefly stated, they need a compact book, which shall contain first, concise, but easily intelligible, descriptions of the various reliable tests for the objects of study in the gastric contents, intestinal juices, and feces; second, practicable and least disturbing methods of determining the position, size, motility, etc., of the stomach, intestines, and other abdom- inal viscera; third, a succinct statement of the diagnostic methods indicated in the recognition of digestive diseases; and, finally, an exhaustive discussion of both general and special therapy as applied to these diseases. This I have endeavored to accomplish. I have, how- ever, purposely omitted lengthy arguments of unsettled etiologic questions, prolix descriptions of rare conditions which possess only academic interest, and the consideration of pathologic states of a purely surgical nature. On the other hand, remembering Herbert Spencer's words, that "To so present ideas that they may be appre- hended with the least possible mental effort, is a desidera- tum," and recognizing the importance of economizing the reader's attention, I have earnestly labored to express my- self in a clear and explicit manner. vii Vlll PREFACE In the making of this work, I have in many instances departed from the beaten track, voicing conclusions and consequent therapeutic procedures at variance with those laid down in some accepted text-books. These conclusions have been reached by years of study and observation; the therapy has been proved to my satisfaction, and can be proved to the satisfaction of others who will honestly investigate. I wish to express my appreciation and thanks to the fol- lowing named gentlemen for various courtesies extended to me in the preparation of this volume: Dr. Max Einhorn, Dr. George Roe Lockwood, Dr. Robert Coleman Kemp, Dr. Anthony Bassler, Dr. C. D. Aaron, Dr. A. B. Jamison, Dr. J. D. Albright, and Dr. J. W. Weinstein. George M. Niles. TABLE OF CONTENTS PART FIRST GENERAL DIAGNOSIS AND TREATMENT OF DIGESTIVE DISEASES DIGESTIVE DISEASES CHAPTER I Page Getting in Touch with the Patient i CHAPTER II Diagnostic Methods i5 Palpation of the Epigastric and Abdominal Surface 29 Examination of the Abdomen below the Epigastrium 35 Transillumination of the Stomach or Gastrodiaphany 41 Chemic Examination of the Stomach Contents 44 Test-meals 44 CHAPTER III Examination of the Feces 69 Microscopical Examination of the Stools 74 Intestinal Parasites 79 CHAPTER IV Examination of the Esophagus, Stomach and Intestines by the Roentgen Ray no CHAPTER V Is the Case Strictly Surgical? i59 Early Malignant Growths in the Stomach or Intestines . . . . : 160 Late Malignant Growths 160 Non-malignant Growths of the Stomach, Pylorus or Duodenum . . 162 Confirmed Atony and Dilatation of the Stomach 163 Appendicitis, Acute or Relapsing • • • 163 Gastric or Duodenal Ulcer 166 Hemorrhages from the Stomach or Upper Alimentary Tract . . . .167 Chronic and Indefinite Ills that have Resisted all Internal Treat- ment 167 ix X CONTENTS CHAPTER VI Page The Stomach-tube 170 CHAPTER VII Gastric Lavage 185 Indications for Gastric Lavage 185 CHAPTER VIII Various Methods of Local Treatment of the Stomach, Internal and External 203 Electricity 205 CHAPTER IX Orthopedic Methods of Supporting the Abdominal Walls and Viscera 222 CHAPTER X Local Treatment of the Intestines 233 Local Applications 243 CHAPTER XI Hydrotherapy in Gastrointestinal Diseases 260 CHAPTER XII Psychotherapy in Gastrointestinal Diseases 282 CHAPTER XIII General Considerations of Diet 315 Chemic Composition of Common Food Substances 325 Artificial Foods 336 Duodenal Alimentation 340 Rectal Feeding 344 Recipes for Nutrient Enemata 348 Other Methods of Nourishing the Body 349 CHAPTER XIV Drug Therapy in Digestive Diseases 351 CONTENTS XI PART SECOND SPECIAL DIAGNOSIS AND TREATMENT OF DIGESTIVE DISEASES CHAPTER XV Page Neuroses, Motor, Sensory, and Secretory 377 Motor Neuroses 381 Sensory Neuroses 384 Secretory Neuroses 387 Secretory Neuroses of the Intestines 396 General Considerations in Therapy of Digestive Neuroses .... 400 CHAPTER XVI The Gastrites, Acute and Chronic 403 Acute Gastritis 403 Acute Infectious Gastritis 406 Toxic Gastritis 407 Phlegmonous Gastritis 408 Chronic Catarrhal Gastritis 410 Achylia Gastrica 415 Treatment of Chronic Gastritis 417 Diet for Chronic Gastritis (Ewald) 420 Diet for First Week of Treatment (Einhorn) 420 Diet for Chronic Gastritis (Friedenwald and Ruhrah) 42 1 Alcoholic Gastritis 423 CHAPTER XVII Motor Insufficiency and Dilatation of the Stomach 426 Motor Insufficiency of the Second Degree 429 Acute Dilatation of the Stomach 435 CHAPTER XVIII Hematemesis — Ulcer of the Stomach 439 Ulcer of the Stomach 440 Treatment of Gastric Ulcer 445 Indications for Surgery 456 Chronic Erosions 457 CHAPTER XIX Tumors of the Stomach — Foreign Bodies in the Stomach .... 460 Diagnosis of Cancer of the Stomach 464 Medical Treatment of Gastric Cancer 477 Foreign Bodies in the Stomach 481 xii CONTENTS CHAPTER XX Page Duodenal Ulc^r — Intestinal Ulceration — Proctitis 485 Treatment of Duodenal Ulcer 491 Intestinal Ulcers 492 Proctitis 494 CHAPTER XXI Diarrhea and Dysentery 515 Treatment of Diarrhea 521 Dysentery 5^5 Amebic Dysentery 533 CHAPTER XXII Constipation ' 543 CHAPTER XXIII Intestinal Parasites 557 Vermes 55^ General Index 57i PART FIRST GENERAL DIAGNOSIS AND TREATMENT OF DIGESTIVE DISEASES DIGESTIVE DISEASES CHAPTER I GETTING IN TOUCH WITH THE PATIENT In the management of ills, to which the gastrointestinal tract is heir, the physician should never lose sight of the individual. To attempt a rational treatment of these many and ofttimes perplexing manifestations of disordered digestion, without delving into the personality underlying and permeating them all, will in very many instances prove disappointing to both patient and physician. I admit that in the acute expressions of gross dietetic errors, routine methods to cleanse the alimentary canal and relieve distress are generally sufficient. These con- ditions require but little scientific acumen, the indications for treatment being obvious. Such disorders, apart from their emergent nature and the demand for quick and in- telligent care, do not generally call for any great amount of either tact or patience on the part of the medical attendant. When, however, an indigestion, either real or supposed, passes the acute stage, and assumes the least tendency to chronicity, then it is that the whole personality of the sufferer becomes involved, and the digestion alone is no longer the only issue. When a patient requests aid for any form of gastrointes- tinal discomfort, his complaints should be received with close attention, and met with kindly interest. It matters not whether the disturbance lies in the stomach, the in- 2 GETTING IN TOUCH WITH THE PATIENT testines, or is the reflection of a disturbed mentality, it is a thing of reality to the patient; otherwise, he would not come for relief. He is naturally unable to differentiate between important and unimportant symptoms — all are important to him; and a lack of interest from the one to whom he has come for aid may impair confidence at the start, and greatly handicap the most worthy efforts. Again, the attitude of the physician toward the patient should be as far as possible optimistic. In no class of diseases, other than those purely mental, is there such a tendency toward pessimism, low spirits, or even a settled gloom, as in the digestive troubles. The sour-appearing dyspeptic, with his complaints and grumblings, his warped viewpoint of life, and his mournful introspection, has become a familiar and classic picture. These sad-visaged sufferers nearly always come with a ready-made diagnosis, whose basic supports may be built upon the most nebulous foundations, but who cannot be swerved from their false ideas by rough tactics. No matter how foolish some of these ideas may appear to the trained intellect of the medical man, or how bizarre the fancies, they must be met as if they were real pathologic entities, not ridiculed nor scoffed at. These varied symptoms do not necessarily denote a weak mentality. It appears that digestive distress, when long drawn out, affects all grades of intelligence with an almost equal blight. It seemingly spares no one. Thus, to as- sume that a patient is weak minded, because he gives way to depression and food-fear as a result of dyspepsia, is in the vast majority of instances absolutely incorrect and unjust. Furthermore, there are few cases of chronic indigestion that can be successfully managed by medical and dietetic measures alone, if administered in a routine manner, unaccompanied by any moral propulsive power. The dynamics of medicine and the dynamics of mind cannot be disassociated. It is, therefore, necessary at the very beginning of the treatment to get in close touch with the TEMPERAMENT 3 individuality of the patient; to discover, if possible, his vulnerable points both for good and ill; to probe with sympathetic interest his hopes, his fears, his aspirations. Many times in such a preliminary investigation, the whole secret is bared; the primary underlying cause is disclosed; and knowing this, the indications for treatment are clear as the noonday sun. Recently there consulted me a widow, who complained of poor digestion and extreme nervousness. She had noted that at the end of each month, as "rent-day" drew near and her depleted finances seemed insufficient to meet her imperative obligations, her digestion would become more painful. After her rent had been paid, she claimed that for several days she always enjoyed a comparative freedom, from her chronic ills. A careless or unsympathetic inquiry would not have brought out these facts, and the knowledge of them enabled me to relieve both her suffering body and her perturbed mentality. The temperament, that "climate of the mind," as it is called by Dr. Weir Mitchell, often gives important clues, if rightly read. To expect gastric neuroses in phlegmatic, unintelligent laborers, who perform physical toil requiring no mental effort, and whose bodies demand practically all of the available vitality, leaving but little for the nerves, would be foolish. On the other hand, in this strenuous march of the twentieth-century civilization, to "keep up with the procession" requires a constant tax on every bodily and nervous resource, so that in the alert and wide- awake individuals of middle age, or younger, it is sometimes almost impossible to differentiate between organic and neurotic disturbances of digestion, unless, in addition to known scientific methods of diagnosis, careful studies of both disposition and temperament are conscientiously made. Some of the most bitter complaints of various digestive ills come from young, rosy and well-nourished individuals, with no signs of cachexia, but with evident hyper-sensitive 4 GETTING IN TOUCH WITH THE PATIENT nerves. Then we often have to contend with the young or middle-aged woman of good circumstances, of refine- ment and education, but who has nothing to attract her thoughts outward; consequently, they stray inward, to her hurt. Then, and perhaps the worst, there is the suc- cessful business man, who after years of unremitting toil, retires from active participation in the serious affairs of life, expecting to enjoy in peace his well-earned rest. Unfortunately, his dreams are seldom realized. Too often his industrious mind, with no tangible daily occupation, will become short-circuited upon his digestion, and he is then liable to become a prey to the many fads and isms preached from the housetops by the various cults, each one claiming the secret of health. Such patients are frequently in the incipient stages of organic disease, the consequence of both age and previous incessant labor, and when there is superimposed an added complication of morbid introspection, the task of the medical adviser is greatly increased. These are the cases where the per- sonality of the physician counts for much, and unless he can get in close touch with such a patient, so as to treat both the disease and the individual, the results are generally unsatisfactory. Another class of patients who require careful personal study are the chronic "complainers." They are often excellent people, who lead useful lives, but who have imperceptibly fallen into the habit of magnifying every epigastric or abdominal sensation, and have gradually become convinced that they have weak and impaired diges- tive organs. They can give no good reasons for their un- ceasing complaints — they simply and automatically com- plain. These again call for careful study in order to lift them out of the doleful rut into which they have un- consciously fallen, and to place them upon the solid ground of normal thinking, acting and talking. In making up the anamnesis, and grouping the symptoms •into a coherent whole, I have to an extent followed the THE ANAMNESIS 5 general plan of Cohnheim, and for that part which I have utilized I desire to make acknowledgment. It is seldom wise to allow a patient to tell his story in his own way. If allowed, he will aimlessly enumerate all his subjective symptoms without regard for chronology, rhyme or reason, taking up valuable time to little purpose. Usually I first get a general idea of the family history, inquiring as to neurotic ancestry, intemperance, possible malignant or specific troubles, and manner of daily life. The seeds of many digestive diseases are sown before birth, and numberless unfortunates are ushered into life with weak digestive organs, brought about by parental infirmi- ties, and fostered by parental shortcomings. Many times I have noted patients with a history of poor digestion dating back to childhood, who admitted early recollections of dyspeptic parents, creating a "dyspeptic environment" from which the passage of time had not released them. These sufferers are deeply imbued with their beliefs, and ordinary methods of treatment possess for them no efficacy whatever. Next I inquire how long the present illness has been in evidence, together with the causes leading up to it. Such indefinite statements as "A long time," or "Several years" mean nothing, and are without value. To arrive at a definite starting point, the physician must learn just when the symptoms first appeared, whether the trouble developed suddenly or gradually, and whether it has been intermittent or steadily progressive. Such information at once classifies the affection as acute or chronic, and clearly points the way for further questions. Next comes the inquiry as to whether the discomfort is constant or only occasional. This is of importance, because the course and progress of the trouble, the remissions or intermissions, may in themselves name the diagnosis to- gether with the indicated treatment. Chronic gastritis, nervous dyspepsia, malignancies in or around the digestive tract, stenoses or kinks occurring 6 GETTING IN TOUCH WITH THE PATIENT along the course of the alimentary canal — all these cause a certain amount of unbroken distress. Oh the other hand, periodic pains may raise the suspicion of duodenal ulcer, gall-stones, relapsing appendicitis, gastric crises, gastralgia, cyclic vomiting, or one of the many forms of psychic indigestion. It is especially necessary to learn whether these periods of discomfort are punctuated by those of entire comfort and well-being, or are simply remis- sions, where the patient feels better, but is not entirely well. Considerations of appetite are of value. Many of the most chronic and persistent alimentary ills flourish right along in company with a normal, or even ravenous appetite, and this will point to one of two conclusions — either the presence of a neurosis, or the insistent demands of a half- starved body, tortured by a long, rigorous, and perhaps unnecessary course of dieting. These constant voicings of "cell-hunger" are frequently the unrealized factors that make for the sour disposition and clouded mental horizon so characteristic of the con- firmed dyspeptic who sticks to a limited diet for months and years. Should, however, the appetite be consistently poor, this fact may point to malignant disease, to a scanty output of digestive juices, to chronic, so-called intestinal autoin- toxication, or even to a long-standing nervous anorexia. Having disposed of this, the next question would natu- rally be in regard to swallowing. Apart from a psychic difficulty, which may be caused by disgusting sights or thoughts connected with the food, or by lack of saliva to moisten the bolus, the latter of which may come from either bodily or mental illness, an impediment to the act of deg- lutition would indicate the disease of either the esophagus or cardiac opening of the stomach. A violent emotion will sometimes as effectually inhibit the power to swallow as a mechanical obstruction. A number of years ago, I observed a healthy and robust man attempt to eat a meal while his wife was at the height THE ANAMNESIS 7 of her first labor. After several futile attempts, he de- sisted, saying that had his throat been encircled by a knotted cord, it would have been just as possible to swal- low. A few hours later, his wife having been safely deliv- ered, he had no trouble in eating a hearty meal. An intermittent difficulty might mean esophagismus or cardiospasm, but a gradual increase to where only finely comminuted food or liquids can be forced down the esopha- gus, especially in patients past middle life, would indicate either malignant growth or a gradual tightening cicatrix from previous ulcer. A stenosis following injury, or burns from corrosive substances, can generally be diagnosed from the history. The possible presence of an esophageal diverticulum should be kept in mind, particularly if there is frequent difficulty in swallowing, accompanied by a sense of dis- tention and regurgitation of portions of the food. The other diagnostic features of esophageal diverticulum cannot be discussed here. The next question would be as to the pain or other un- comfortable sensations which brought the patient for relief. This is of deep significance, because a purely functional dyspepsia never causes actual pain. There may be feelings of distress, or distention, or pressure, or desire to eructate gas, or even acute nausea, but as to pain in the strict acceptation of the term, close questioning seldom discloses it. Many patients seem unable to dis- tinguish the difference between pain and other sensory disturbances, and the physician should ever be on the alert lest error creep in. I include as pain, sensations of crampy, colicky, cutting, stabbing, boring, or burning nature, and not the various other vague and indefinite feelings of discomfort, even though they bring about decided distress. Another frequent condition that is denominated pain, unless carefully differentiated, is the globus; hystericus. This, though easily recognized, needs to^be dealt with 8 GETTING IN TOUCH WITH THE PATIENT cautiously and tactfully. The term hysteric is looked on with aversion by all, and its application to any patient is sure to excite resentment or even indignation. Many a patient has changed her doctor in anger upon being told that some of the symptoms were hysterical, and few there are who will permit this supposed stigma to be mentioned with equanimity. Really, it is seldom necessary to inform a patient that some of her or his symptoms are hysterical, and my experience has taught me to steer clear of its men- tion directly or indirectly. If pressure and discomfort alone are felt, the question arises whether they are constant, or only appearing after meals at irregular or stated intervals. Constant pressure in the abdomen, independent of the meals or the nature of the food, may indicate a gastric neurosis, pressure from a distended intestine, or encroachment upon the abdominal cavity from ascites or enlargement of some of the abdominal viscera. A pressure located in and around the epigastrium, accom- panied by fullness, distention, flatulence, malaise, heart- burn, regurgitation of sour chyme, and perhaps vertigo, will excite the suspicion of a decided hyperchlorhydria, or peptic or duodenal ulcer. It might be well to mention, however, that this train of symptoms is occasionally the reflex expression of a chronic appendicitis, or even of a disturbance in or around the gall-bladder. Pressure occurring only after taking solid food indicates chronic gastritis, while if it is in evidence after either solid or liquid food, a neurosis may be thought of. Should there be actual pain, it is well to ascertain its character, and when and where it occurs. Should it be of a colicky, cutting or boring nature, radiating backward, it may mean one of several morbid conditions. If it re- curs every few months, with periods of comparative health between, it may be cholelithiasis or some form of gastric crisis. Should it occur daily at a definite time after eating, and be relieved by vomiting or alkalies, it is probably THE ANAMNESIS 9 ulcer or perhaps only hyperchlorhydria. Should it be relieved by the escape of gas or free evacuation of the bowels, it may be an intestinal colic brought about by ordinary constipation,' by excessive protein putrefaction, or by numerous kinks and twists found in ptosed intes- tines. The importance of visceroptosis, with its train of attendant evils, has but recently been recognized and only in the last few years has the medical profession realized the excellent results obtainable by raising and straightening out these twisted and distorted intestines. Should vomiting alone relieve pain, and should the patient find that food taken many hours previously is ejected, it would indicate either a stenosed pylorus or a duodenal kink or other obstruction. The symptom of vomiting, in any of its aspects, is im- portant. Early morning vomiting from an empty stomach may indicate pregnancy, alcoholic gastritis, or gastrosuc- corrhea. Sudden and explosive vomiting immediately after eating indicates reflex excitation; a profuse vomiting of spoiled and fermented food every few days points to a dilated stomach ; the vomiting of gastric crises or the cyclic form occur between periods of good health; while if it comes on after dietetic indiscretions, it may mean only the rebellion of an insulted stomach. The condition of the patient's bowels is always worth careful inquiry. A detailed recital of their habit, character of stools, presence or absence of mucus, state of the mucus in regard to the feces, intestinal parasites, flatus, and other considerations, should never be omitted. After these special symptoms have been noted, it is then in order to obtain a grouping of general symptoms, for now the physician can give them their proper weight in making up his estimate of the whole. Great loss of flesh, progres- sive weakness, anorexia or excessive appetite, abnormal thirst, change of disposition, troubled sleep, mental de- pression or irritability — all these to the observant intellect of the careful clinician will tell their story, and ofttimes a lO GETTING IN TOUCH WITH THE PATIENT practically certain diagnosis can be made without going further, though such a diagnosis is not always satisfactory. The chief gastroenterologist of a busy Jewish clinic in New York City recently confessed that 80 per cent, of the diagnoses were made from the subjective symptoms alone. This state of affairs he did not defend, but pled the over- whelming amount of work to be accomplished in a neces- sarily brief space of time. Having made all the proper inquiries of the patient, the physical and other forms of examinations are next in order. While some patients demur at the necessary disrobing, incident to a thorough physical examination, at heart they appreciate the interest shown by the physician. Such objections can nearly always be overcome by a little tact and explanation of the purpose in view, and the more complete the examination, the more confidence will be instilled into wavering and doubting minds. Knowing how often patients come with a self-made diagnosis of digestive disease, when the trouble is elsewhere, it behooves the examiner to observe carefully the general appearance of the whole body, not neglecting the facial expression. With many, especially the uneducated, a disturbance anywhere between the neck and the symphysis pubis is denominated "stomach trouble." Not infrequently do I have women with marked ovarian disease, or men with irritations of the urinary bladder, who confidently lay the blame on that long-suffering viscus, the stomach, and are with difficulty convinced otherwise. The appearance of the skin, its ruddy or sallow hue, its firm or wrinkled "feel," its healthy moisture or harsh dry- ness, pallor, or cyanosis, cachexia or eruption — any of these will tell their story. A slight erythema of the backs of the hands, which the patient has hardly noticed, may fix the diagnosis of pellagra, while the bronze color may stamp it Addison's disease. The present state of nourishment is also of the utmost APPEARANCE OF THE PATIENT II importance, not only from a diagnostic standpoint, but from that of the nature of treatment, dietetic or otherwise, to be inaugurated. Let it not be forgotten that some of the most abject and emaciated specimens of humanity are brought to their miserable state by foolish systems of dieting. A very strict diet, in which the viands most relished are forbidden, is liable to set up first an anorexia, then a sitophobia, or fear of food. To expect the digestive organs, whose principal advisors and stimulators are the hormones, or psychic incentives, to perform their best work, when every meal is taken with indifference, disgust or gastronomic introspection, is chimerical. So, often, one after the other, loved delicacies are forbidden, while nothing appetizing is substituted, until the patient is reduced to the verge of caloric bankruptcy. Recently there consulted me an intelligent young lady, who had for two years been gradually reduced in her food intake, so that she was getting only about three hundred calories daily. She complained of "sinking spells" in her stomach, of weak and trembling knees, and a tendency to cry at the least provocation. Examination revealed fairly healthy digestive organs, and little was required besides liberal alimentation to make her strong and happy once more. Evidently the disorder for which she first sought aid had long since disappeared, but the dietetic shadow still held on, to her discomfiture. There is another class of patients, who strenuously insist on emptying the stomach at the first sign of epigastric distress, real or fancied. These are generally neurotic or hyper-sensitive individuals, who imagine that food can exert some malign effect on the stomach, if allowed to remain there too long. Without giving the meal a chance to be chymified, or ejected into the small intestine, where it can be of actual service to their body, they wildly drink warm water or some emetic, or, worse still, they contract the "stomach-tube habit," washing out the essentials of the meal before it comes into contact with any absorptive 12 GETTING IN TOUCH WITH THE PATIENT surfaces. Sometimes the obsession takes the form of de- manding a speedy evacuation of the bowels by some hy- dragogue, or copious enemas, so that the fecal current is continually accelerated, and the previously mentioned condition practically obtains. In no part of this chapter does its title apply more forcibly then to this class of sufferers. The "habitus enteropticus," so strongly stressed by Cohnheim, while of some importance, does not possess for me that overshadowing significance. I constantly observe instances of incompetence of the abdominal walls, relaxed visceral supports, and marked visceroptoses in people of normal "habitus," and I am forced to confess that the con- clusions so ably advocated by both Stiller and Cohnheim have not been altogether borne out by my experience. The appearance and general contour of the abdomen is most instructive to the practised eye. Sometimes a view of the abdominal profile will disclose the full and wavy line of a dilated and ptosed stomach; sometimes the outline of a morbid growth. A relaxed and atrophied abdominal wall may reveal increased peristalsis, or abdominal stiffen- ing of some of the muscles. Such signs are specially signifi- cant as indicating stenosis of the pylorus, or of the colon. Visible peristalsis in old or emaciated people, or. in multi- parous women of slender physique, signifies but little, and must not be confounded with true "peristaltic unrest." The appearance of the tongue is fraught with pitfalls for the unwary, and too often it is accorded undue significance. Foul and coated tongues are found in the presence of gas- trointestinal disease, and sometimes where there is normal digestion. It would appear that hasty mastication, coupled with careless "oral toilet," is responsible for most of the coated tongues. The strawberry tongue of scarlatina, the tongue denuded of its epithelium in pellagra, the sug- gestive mucous patches, and the spongy or dry and glisten- ing tongue of depressed bodily states have their import; and I should mention particularly the frequent and painful PHYSICAL EXAMINATION 1 3 little aphthous ulcers found on the tongue, sometimes called "dyspeptic ulcers." These annoying and sometimes oft- occurring little lesions seem to really have some connection with a disordered alimentary tract, though the actual re- lationship has never been demonstrated. The appearance of the tongue in disordered stomach and intestines may be accorded some corroborative weight, but, with the exceptions mentioned, should not be taken too seriously. Auscultatory or scratching percussion, electric transil- lumination, inflation with air or carbonic acid gas have their place in mapping out the stomach and intestines, but all are liable to fallacies. When practicable, the Roentgen rays afford the most satisfactory information concerning the size, character and relative location of the abdominal organs. Incidentally, these rays have considerably altered previous conceptions of the topography of this cavity. In the vast majority of cases, intelligent and careful palpation yields the most satisfactory and reliable informa- tion. Beginning with the epigastrium, the palpating fingers should deliberately and attentively examine, as far as pos- sible, the stomach, the different divisions of the colon, the sigmoid flexure, the small intestines and appendix, the liver and gall-bladder, the spleen and kidneys, the abdominal rings, the rectum, and the abdominal cavity as a whole, searching for tumors, ascites or transpositions of the viscera. In order to perform this successfully, the hands should be well warmed, the patient should be put in no cramped or uncomfortable position and by sympathetic assurances upon the part of the physician, he should be free from trepidation or fright, so that the mind will be at ease, and the abdomen properly relaxed. Palpation discloses but little when forced upon a timorous or terror-stricken subject. Due allowance should always be made, in seeking for sore or tender areas, for the mental attitude of the patient. Some give way to bitter complainings at the slightest 14 GETTING IN TOUCH WITH THE PATIENT discomfort, while others, with Spartan fortitude, minimize the most exquisitely painful sensations. The physician will simply have to judge each case according to its merits, making various qualifications as indicated by temperamental infirmities. The time and care spent in studying and determining the various phases of the patient's character, the cheery interest manifested, and the optimism brought into play, which should brighten and permeate every therapeutic procedure — all these are the necessary factors in getting into close and sympathetic touch with the discouraged dyspeptic, and, like the opening move in a campaign by a wise commander, will often decide the ultimate success or failure of the whole course of treatment. CHAPTER II DIAGNOSTIC METHODS In the proper diagnosis of the various ills and abnormali- ties of the digestive tract, there are many special methods available. A careful scrutiny of external appearances, a painstaking manipulation and palpation, a proper chemic examination of the stomach or intestinal contents, making due allowances for modifying circumstances, a microscopic examination of these contents also, together with an X-ray examination both as to topography and motility — all have their helpful place, and should be used, when necessary, by the conscientious physician. A brief mention of some of the more easily discernible points of interest is appropriate: The greater curvature of a normally distended stomach lies about i 1/2 to 2 1/2 inches above the umbilicus, where the abdominal muscles are firm and fairly taut. Some there are who possess abnormally large stomachs (espe- cially hearty eaters or drinkers, for instance), and these should not necessarily be considered as pathologic, unless noticeable symptoms are also in evidence. When a patient shows atony and relaxation of the stomach walls, with motor insufficiency, the lesser curva- ture in its normal relation to the diaphragm, while the lower border is below the level of the umbilicus, and, in addition, complains of marked gastric symptoms, we may consider it a case of dilatation of the atonic type. Again, as a result of pylorospasm, of benign or malignant stric- ture, or any obstruction to the orderly and free exit of the stomach contents, we find the so-called stenotic or ob- structive form of dilatation of the stomach. These con- 15 1 6 DIAGNOSTIC METHODS ditions should not be confounded with gastroptosis, for in the latter case the lesser curvature is also markedly below its proper position. In such prolapsed states, the suspensory ligaments of the stomach are relaxed and inefficient, and the entire viscus sinks ; occasionally so much, that the lesser curvature looks inward to the right, and the greater curvature outward to the left. The pylorus may lie below the level of the umbilicus, rendering a "kink" or torsion of the duodenum quite easy to acquire, and mechanically obstructing the outlet of the stomach. The varieties of gastroptosis and gastric dilatation are numerous, and will be mentioned again in the discussion of X-ray methods. Whenever practicable the patient should have some pre- liminary preparation for examination, as this greatly facili- tates the task of the physician. On the day or night pre- vious the bowels should be emptied by a cathartic, or the lower bowels by copious enemata. Should there be much gaseous distention, the addition of one or two ounces of milk of asafetida to the enema will decidedly aid this. It is well for the stomach to be either empty, or that only a light meal should be eaten previous to the examination. The patient should be examined in various positions, as may be indicated. Inspection. — As a general rule the first part of the examination should be made in the dorsal position, as the physician can get a better idea of the general relations of the external abdomen if the whole surface is exposed at one time. There is generally no objection to this in female patients, if the pubic region is covered by a towel or garment. In obese subjects, or those with much deposition of fat in the abdominal parietes, but little specific information can be gained from simple inspection. In thin individuals, however, or those with relaxed and attenuated abdominal walls, much can be learned. INSPECTION 1 7 Often a dilated stomach may be easily recognized by its bulging in the umbilical or hypogastric region, and under these circumstances the epigastric region is usually hollow and depressed. In such patients the artificial distentions of the stomach with carbonic acid gas frequently discloses the contour of that organ, including the peristaltic waves, with graphic accuracy. Kussmaul has noted very active peristaltic movements in the dilated stomach, especially of the stenotic type, the waves passing from the linea alba below the umbilicus in an upward direction, and to the right to the lower margin of the liver. Kemp facilitates inspection by placing the patient upon a raised table, the head toward the window, the shades being arranged so that the light enters on a plane only slightly above that of the patient, and directed from the head toward the feet. The physician, standing toward the foot of the table, and bending from side to side, can obtain much information by watching the play of shadows cast by the inequalities of the abdomen, as respiration progresses, and observing the undulations of the under- lying organs as reflected on the surface. Other interesting viewpoints may be gained by standing to one or the other sides, or even permitting the patient to face the light in a semi-recumbent position. In thin and slender multiparous women, a gastroptosis and enteroptosis may often be diagnosed by directing the patient to stand erect, and getting a side view. In this position the epigastrium will exhibit a depression, while the bulging surface of the lower abdomen will plainly show the presence of the ptosed viscera. I have many times been able to follow with tolerable accuracy the peristaltic waves of the intestines, while any tumors or abnormal inequalities were plainly visible. Percussion and Auscultation of the Stomach.— There are many factors to be considered in making out the size and position of the stomach by auscultation and percussion. l8 DIAGNOSTIC METHODS The findings may be influenced by its full or empty con- dition, by the tone of its walls, by the character of its contents (air, water, or food), by the position of the pa- tient and by the amount of subcutaneous fat present. To get the best results the stomach should contain some air, at least; and Dehio has demonstrated, both on living sub- jects and the cadaver, that if the stomach is absolutely empty, any tympanitic sounds obtained by percussion over this viscus come from the colon and not the stomach, as the latter is contracted into the left concavity of the diaphragm, and not being in contact with the anterior thoracic wall, cannot produce any tympany. Dr. Robert Coleman Kemp has devoted much time to the elucidation of this form of examination, and to him we owe many of our present methods. The patient should first be examined in the dorsal posi- tion, with the knees slightly flexed, and the abdominal walls relaxed as much as possible. The percussion hammer may be used, if desired, but it is doubtful if the hammer can ever equal the percussing fingers in delicacy, where a prac- tised touch is brought into play. Under ordinary cir- cumstances the borders of the stomach may be made out with a reasonable degree of accuracy, though, if the colon contains much gas, confusion may occur in mapping out the lower border of the stomach. The percussion sound of the colon is somewhat lighter than that of the stomach, and also lacks some of the resonance and clearness of the latter. The presence of food in the stomach or feces in the colon naturally alters the sounds, and the physician should make due allowances. It is well to map out the stomach, and, if possible, the transverse colon, while the patient is lying down. The position is then changed to a standing posture, and the changes in location noted. Quite frequently the presence of a tumor may be decided by percussion alone, for gaseous collections are sometimes confounded with real tumors by nervous and excitable individuals. METHODS OF PERCUSSION IQ Auscultatory Percussion. — This is a most satisfactory method of mapping out the stomach, and, unless the patient is very obese, is fairly accurate. An ordinary stethoscope is best in this procedure, and the chest-piece should be placed firmly upon the naked surface above the seventh rib in the left mammary line, or between the tip of the ensiform cartilage and the left costal margin, or in the same vertical line, but below these points. When decided gastroptosis is suspected, the "point of bearing" may need to be quite low on the median line of the abdomen. The physician' should first percuss near the stethoscope, lightly tapping the surface with a single finger, until the characteristic sound of that particular stomach is decided. He should then begin well away from the stethoscope and gently percuss in a straight line toward it until by the change of sound he knows the border is reached. This can be marked with a pencil or pen. He should then radiate in rather a large circle, percussing inward from each peripheral point, until the border line is reached, gently marking the points as located. In this manner the stomach can be quickly and, under ordinary circumstances, satisfactorily mapped out. The operator should remember that, when dilated or mis- placed, the tendency of the stomach is for the greater bulk to lie to the left of the median line, though occasional cases of dilation yield a tympanitic sound quite a distance to the right of the abdomen. In rare instances percussion gives valuable information concerning a tumor of the stomach wall, but, if facilities for X-ray examination are available, the latter is much more dependable. Scratch Method of Auscultatory Percussion. — This method, which was originated by Kemp, has a field of usefulness. The stethoscope is placed upon the abdomen, as in the previous method, and the surface is lightly scratched by the middle finger in about the same way as the light percussion. The stomach tympany can be fairly well brought out in this way. 20 DIAGNOSTIC METHODS "Flicking percussion" is employed by some, but has nothing special to commend it. Inflation of the Stomach with Carbonic Acid Gas. — Under proper conditions this is a useful adjunct to other means of outlining the stomach walls. It is especially useful in thin subjects with relaxed abdominal walls, and of little use in obese individuals, or those with rigid abdominal parietes. Two ordinary glasses, each full of water are needed. In one is dissolved about a dram of tartaric acid; in the other about the same amount of bicarbonate of soda. These two solutions are to be drunk quickly, one after the other, and the patient instructed to lie down quietly with the mouth closed. The inflation follows promptly, the stomach contour becoming plainly visible. This method is contraindicated when there has been a recent hemorrhage, when ulcer or cancer is present in the stomach, or in advanced arteriosclerosis. A few observers have advocated inflating the stomach with air, either with a Davidson syringe or a double bulb. A stomach tube is flrst introduced through the cardia, and the air is then pumped in ad libitum. Some advocates of this method claim that the operator can tell with tolerable exactness just how much air is being pumped in, by keeping account of the compressions of the bulb. To say the least, this is problematical. Outlining the Stomach by the Use of Water. — Dehio has investigated this method quite thoroughly, and by its intelligent use much can sometimes be learned. The patient is first percussed over the stomach, with that viscus empty, and the patient in a standing position. The phy- sician then administers about 8 ounces of moderately cold water, and percusses the area of dulness. This water is followed up by several more glasses, each time noting the percussion results. The patient then assumes the recum- bent position, and if tympanites is in evidence where dulness formerly appeared, it is proof positive that the former area of dulness corresponded to the stomach. OUTLINING THE STOMACH 21 Occasionally, in marked atony, dilatation, or ptosis, a single glass of water will cause appreciable dulness below the umbilicus. This method is not applicable in stout patients, or where there is fecal accumulation in the colon. There are many other methods of locating and delimiting the stomach, some of which are extremely complicated but not very practical. A few will simply be mentioned, though scant space will be accorded them. Leube intro- duces a stiff sound and, by moving it about in the stomach, determines the boundaries by touch. In suspected ulcer, cancer or erosions of any sort, this would be dangerous. Moreover, a method which is comparatively safe in skilled hands might subject the patient to grave risk in unpractised ones. Some go so far as to inflate the stomach with carbonic acid gas, while a double quantity is injected into the large intestine through a colon tube. It is expected that the different pitches of sound between the colon and stomach will mark the limits of each. This has been tried by me a number of times without satisfaction. Kemp's stomach whistle, in which a little whistle is attached to the end of a stomach tube, and the sound produced by short, quick, compressions of a Lockwood bulb inserted into the other end, is another novel method. This is quite interesting, and in practised hands may be useful. It will hardly, however, come into general use. Splashing and Gurgling Sounds. — These sounds may be elicited when both air and fluid are in the stomach, depend- ing largely on the state of the stomach walls. Some students of this subject consider such sounds as of no practical significance, other than denoting atony or relaxa- tion of the stomach. Some dexterity is required to produce these sounds without discomfort to the patient, and the physician should be gentle in the manipulations. The sounds are best demonstrated by rapidly tapping with the tips of two or three fingers, but without entirely removing them from 22 DIAGNOSTIC METHODS the abdominal surface. The patient should always be in the dorsal position with the abdominal walls freely relaxed. Sometimes rather energetic manipulation is re- quired, and both hands may be brought into play, shaking the two sides well until the splashing is plainly heard. In some individuals there is at frequent intervals more or less splashing, denoting no special pathologic condition. When it is found several hours after a test meal, or found in the morning hours before any food or water has been taken, it certainly denotes an abnormality. When well brought out, the splash is quite a rehable diagnostic sign as to the position of the lower border of the stomach, and it can be easily verified by changing the posi- tion of the patient, noting the varying location of the splash with each change. I have occasionally found subjects with hyperesthetic abdominal surfaces, who could not bear this manipula- tion, and whose rectus muscles would become so rigid that no sound could be elicited. These are unsuitable for this test, and the time may be put to better use in other directions. Deglutition Sounds. — These were first described by Meltzer, and in the last few years have, with the aid of the X-rays, become a diagnostic aid of considerable value. The deglutition sounds are the first, or the sound heard as the fluid enters the esophagus; and the second, which follows about seven seconds later. Both may be heard by placing the stethoscope over the ensiform cartilage, though the second sound is more distinct. In certain or suspected esophageal or cardiac obstruction, these sounds are both significant and helpful. If both sounds are absent, there is probably a decided stricture of the esophagus; while if the second sound is delayed, some obstruction to the orderly progress of food or liquid is assured. It is most interesting and instructive, when a fluoro- scopic examination is available, both to listen to the deglutition sounds, and to watch the causes of these sounds. ESOPHAGOSCOPY 23 The patient is given some milk, to which bismuth has been added, and ordered to hold it in the mouth until told to swallow. Everything being ready, the X-ray is projected through his neck, and carried down as he swallows, while simultaneously the observer is listening and watching through the fluoroscope. Unless the physician is accus- tomed to the sounds of the X-ray machine, he may become confused by the two sounds. If, however, he will keep the stethoscope closely pressed in the ears, and his auditory attention fixed upon the deglutition sounds, he will soon be able to hear them satisfactorily. Various other sounds in and about the stomach have been investigated, some of them seemingly for curiosity alone. Some have claimed to be able to hear "dripping sounds" as the fluid coursed along the stomach walls, but this is open to doubt. The succussion sound, produced by energetically shaking the whole body, is of no account as a diagnostic help. Gurgling sounds in the stomach may be brought about by the contracting of its walls on mixed contents of fluid and gas. These sounds are sometimes weird and disquieting to the patient, but have no fixed diagnostic significance. Esophagoscopy. — Efforts to examine the esophagus, and through it, the stomach, have been made for over a hundred years. In 1807 Bozini directly examined the upper end of the esophagus, and since that time many other investi- gators have industriously attempted to perfect and utilize this method of diagnosis. For several reasons esophagoscopy will probably never become popular or widely employed. It is uncomfortable to the patient ; there is often an element of danger attached to its use, unless in skilled and practised hands; and the slight view of a portion of the interior of the stomach which may at best be obtained is generally unsatisfactory. There are two kinds of instruments for the purpose: the older ones, in which the illumination is thrown down the tube from the outside (Mikulicz, Rosenheim) ; and the 24 DIAGNOSTIC METHODS more recent ones, which have Httle, "cold" electric lamps on the distal end (Einhorn, Jackson). In 1906 Jackson improved upon Einhorn's instrument, and brought out one in which the interior of the stomach could be observed rather better. This instrument, besides being larger than previous ones, contains an auxiliary tube for the drainage and suction of the secretions. In addition. Dr. Jackson devised several accessories, intended to map the stomach or esophageal walls, to make applications, or to remove foreign bodies. To quote Dr. Jackson, who deserves more consideration along this line than any other observer, I will use the fol- lowing: "The explorable area varies in the normal adult stomach from one-half to three-quarters of the total mucous membrane, the field being considerably larger in infancy, dilatation, or prolapse. Careful attention to two points eliminates most of the difficulties in gastroscopy : The first of these is that profound anesthesia is essential (in the esophagus the use of cocain is preferred) since when the tube enters the stomach straining and retching are un- controllable, annoying, and dangerous; the second point is the position of the patient, which is the most favorable one in bringing the mouth, pharynx and esophagus into a straight line. To accomplish this the patient is drawn forward until the tops of his shoulders clear the table by from 4 to 6 inches, and the mouth gag is inserted on the left side. The assistant is placed on the right side of the patient's head on a stool of appropriate height, as though on a side-saddle, his right leg beneath him in the kneeling position, his left foot supported on a stool 26 inches lower than the top of the table. His right forearm is passed beneath the patient's neck, supporting it, his right hand grasps the mouth gag, drawing it strongly at or in front of the bregma, bending it backward and exerting a certain degree of upward pressure. The foregoing points having received attention, certain difficulties remain. They lie, however, altogether above or opposite the cricoid cartilage, ESOPHAGOSCOPY 2$ and are surmountable with slight practice. Mikulicz determined i point, namely, that a gastroscope must be rigid. Rosenheim went a step further, and said that it must not only be rigid, but should be straight; now I think we are ready to add four more dicta: i. Optic appa- ratus must be abandoned. 2. The tube must be passed by sight. 3. The stomach must be examined in a collapsed state, to permit of mopping, palpation with instrument, probing, and combined endoscopy and external palpation. 4. General anesthesia is indispensable to prevent con- tractions of the diaphragm which clamps the tube, render- ing exploration impossible. "The instrument with the obturator in situ is dipped in warm water, or better, thoroughly lubricated with glycerin. The esophagoscope may be introduced without the employ- ment of a general anesthetic, although this is always pref- erable (the fear of the patient from the looks of the in- strument, and the distress incident to its passage makes a general anesthetic almost essential in most instances). Should it not be used, the patient sits in a backed chair with head thrown back and face toward the ceiling. The instrument is pushed into the esophagus without exerting any force, and introduced the length of the esophagus. The obturator is then withdrawn, the lamp lit, and in- spection begins and continues while the tube is being withdrawn. In stomach observations, it should be recalled that the most important regions of the organ for the site of pathologic lesions, the pyloric and lesser curvature — are not accessible to vision through the tube; and thus, that if nothing abnormal was noted in as much of the gastric mucosa as would be seen, that serious disease may still exist in these inaccessible regions. Both instruments should not be used, excepting where a diagnosis cannot possibly be made by the other well-known methods^ and only when for existing reasons, a diagnosis is important to be obtained quickly. It should not be used in esophageal or gastric ulcer or phlegmonous gastritis, and it should be 26 DIAGNOSTIC METHODS recollected that serious stomach disease may exist in the walls, or extra-gastric of those areas, exploration of which might not show its presence on the mucosa side. Its field of usefulness is to make or confirm the existence of early malignant disease in the esophagus or stomach (carcinoma and sarcoma), to remove foreign bodies from both organs, and to diagnose and possibly remove papil- lomata or polypi from the stomach. In my experience, better results in examining the pyloric region are obtained in women than in men ; this I believe is due to the fact that in women the vertical stomach is more commonly met with." As the secretions in the esophagus and stomach are so frequently in the way, and exercise such a disconcerting effect, obtruding as they do just as the operator is about to obtain valuable information, it is well to administer to the patient two hours before using the instrument a full dose of morphin and atropin, or atropin alone, to partly dry up some of these secretions. As a confusing factor in the use of long tubes is the reflected light on its interior, Bassler has slightly modified the Jackson instrument by having the interior of the distal end oxidized or painted black for a distance of about 15 centimeters. By the existence of this darkened zone, a darker circle is seen about the tissue at the end opening separating this from the reflex of light nearer the eye. The above somewhat detailed description will convince the reader that the esophagoscope and gastroscope are not instruments for the inexperienced or amateurs, and the physician should be chary in attempting to employ them unless he has received some special instruction, or feels that the need is very urgent. I have in more than one instance known of almost irreparable damage being inflicted by the use of these instruments in hands more zealous than experienced, and I trust this caution will be heeded. Esophageal Sounds and Bougies. — These instruments are most useful in locating foreign bodies in the esophagus or ESOPHAGEAL STRICTURE 27 cardia, diagnosing and stretching strictures, and deter- mining the presence of diverticula extending from the esophagus. There are numerous shapes and forms of these instru- ments, some not being safe nor practical. In simple stricture of moderate degree the hard-rubber sounds with rounded olive tips are sufficient. Occasionally, when the obstruction is slight, a rather rigid stomach-tube will an- swer, as it is quite safe. Often, after a stricture has been well dilated, the passing of an ordinary stomach-tube at stated intervals will be quite sufficient to keep the esoph- agus open. iiiiii*ifni «]^^ Fig. I. — -Esophageal electrode, which has different sized olives and which can also be used as an esophageal bougie. (Bassler.) Several years ago I was consulted by a lady of fifty- eight years, who could swallow nothing but liquid food, and that slowly and with difficulty. Examination disclosed a fairly tight stricture, which was dilated easily. After a few dilations she could eat any kind of food she desired, if only it was well masticated or pulverized. Since then I have passed a 20 English tube at intervals of ten days or two weeks, finding this entirely adequate to keep her esophagus freely open. A convenient form is a sound with a single coiled-wire or whalebone shaft and a number of olives of different sizes. If the shaft is too long to be conveniently carried it may be obtained in jointed form. These olives are sufficient for any permeable stricture, but occasionally those are found that are so tight and tortuous that they 28 DIAGNOSTIC METHODS cannot be penetrated. Under these circumstances Plum- mer has devised an ingenious method. The patient is directed at night to swallow 3 yards of buttonhole silk twist, with the assistance of water drunk to facilitate the passage of the thread. The following morning he is directed to swallow three more yards of the continuous thread, and if there is an opening through the stricture or diverticulum, the thread will go into the stomach and on Fig. 2. — Gastrotomy for impermeable stricture of esophagus following acci- dental ingestion of acid. Patient wears a silver tube held in place by straps, and occluded by a cork stopper. Patient in good health about fourteen years after operation. (Operation performed by late Dr W. S. Armstrong.) into the bowel, and will be firmly enough fixed to stand considerable traction. Over this thread a special form of perforated olive is passed, and with the thread as a guide, strictures that are other wise impermeable, may be safely penetrated; and by gradually increasing the sizes of olives, be satisfactorily dilated. Without a guide it is unsafe to use much force in at- tempting to penetrate or enlarge a tight or strictured esoph- agus. The operator should be careful to use but moderate force, and when his sense of touch does not assure him PALPATION 29 that he is in the esophageal channel, he should cautiously withdraw, and progress with the greatest caution. In- expert or careless handling of esophageal bougies is fraught with danger. These bougies should never be used in the presence of aneurysm of the thoracic aorta or recent hematemesis. In malignant growths on or about the esophagus or cardia, also, they should be employed only under most urgent need, and with the utmost care. PALPATION OF THE EPIGASTRIC AND ABDOMINAL SURFACE The importance of thorough and intelligent palpation of the abdomen as an aid to understanding pathologic con- ditions within cannot be overestimated. The tips of edu- cated fingers and the palms of responsive hands can carry to the mind's eye a picture both graphic and accurate. The patient should sufficiently disrobe so that the whole surface from the thorax to the symphysis pubis can be easily reached. To attempt an examination with a limited surface available, or a small area at a time is both un- satisfactory and unscientific. One word of admonition is appropriate here : the physician should be sure that his hands are warm — comfortably warm to the patient. Nothing is more provocative of resentment of the abdominal muscles, or more perturbing to the patient, than cold or clammy hands upon this sen- sitive portion of the human body. The patient should generally be placed in the recumbent position, first on the back, and in other positions as the examination progresses. The hand should be gently but firmly placed upon the abdominal surface, and permitted to remain quietly for a brief space of time, or until the abdominal walls and muscles become accustomed to its presence. It is well also to assure the patient that no pain of consequence will be inflicted, so that, as far as 30 DIAGNOSTIC METHODS possible, the element of apprehension and consequent tension may be eliminated. The palpation is made with a rotary pressing movement, permitting the hand to slide smoothly over the skin from one part of the abdomen to another. A steady, firm, press- ing movement, is much preferable to jabbing the fingers down into the soft yielding surface. By this means it is possible to press the hand deeply into the abdomen, and to detect deep-seated pathologic lesions of appreciable size. If thought necessary, the knees should be drawn up, and moderately deep and steady breathing should be en- couraged. It is also well for the physician to make an occasional remark, or to engage the patient in desultory bits of conversation, so as to draw his mind from the examina- tion. This is especially appropriate in a hysteric or neu- rotic patient, otherwise the objective findings are apt to be warped and biased by the patient's previously formed conclusions. During the various manipulations the physi- cian should carefully note the facial expression, as certain areas are palpated, for in no class of disorders than those incident to the digestive system are the lights and shadows of the countenance more suggestive. If by these means sufficient abdominal relaxation cannot be obtained, the ' patient may be put in a warm bath, or even undergo com- plete anesthesia. In the first examination, should the stomach or intestines be distended with gas, or should scybalous masses be in evidence along the course of the intestinal channel, these facts should be noted, and another examination be made after these factors are removed. "The various areas of the abdomen should be systematically explored, beginning first with the location of the stomach, then the small in- testine, the ileocecal valve, the colon, and finishing with the marginal or deep organs, such as the liver, gall-bladder, spleen, kidneys, etc. In examining the lateral portion of the abdomen, both hands should be employed, the under one sustaining the lumbar region, while the upper makes PALPATION 31 pressure upon it to note the character and consistency of the intervening tissues" (Bassler). It is well to change the position of the body from time to time, observing the difference in position of the various organs. In relaxed abdominal supports, there may be a variation of several inches in the position of some of the organs, and Dehio's methods of mapping out the stomach by the aid of drinking one or more glasses of water are appropriate. The spleen or movable kidneys may be palpable in a semi-sitting or knee-chest position, when they cannot be located in the dorsal. To find a movable kidney, I prefer the following method : with the patient on his back and in a partly sitting posture (nearly 45 degrees), I direct him to make a deep inspiration, and firmly grasp the wall of the abdomen close under the rib with my thumb in front and the other four fingers behind in the lumbar region. Holding this grip, I slowly put the patient in the recumbent position, directing him at the same time to breathe out fully. As this is done the kidney will be felt to slip upward with somewhat of a jerk, while the patient may experience rather a disagreeable sensation caused by the kidney being pressed upon. In obese patients it is sometimes necessary to turn them partly on the side, or even to follow up this manipulation in several angles of position. In the examination of women, palpation of the abdomen should be supplemented when possible by pelvic and vaginal investigation, for ofttimes many symptoms attrib- uted to the digestive system may be in reality reflexes from gynecologic disturbances. It is well also to examine the anus and rectum, and, if thought advisable, the sigmoid may be explored. Many times have I found in these unsuspected tracts the crux of the whole situation. Tenderness in the Epigastrium.— In thin and nervous subjects, particularly women, tenderness will nearly always be elicited by deep pressure in the epigastrium. This 32 ■ DIAGNOSTIC METHODS comes from the celiac plexus, and, in the absence of other symptoms, is of no significance. The upper portions of the recti are often tender after hard exercise or stress of coughing or vomiting. The fact that the tenderness is in the abdominal wall instead of the underlying organs may be proved by pinching up the muscles laterally when they are relaxed, and this is a fact well worth proving in many instances. Epigastric tenderness may also be due to dila- tion of the right ventricle, to pleuritis, to acute or chronic affections of the liver or gall-bladder, and to subphrenic abscess. There are obviously tender areas in gastric cancer or ulcer of any extent, and in many there is a hyper- esthetic condition of the epigastrium at all times. Chronic or acute gastritis, arsenical poisoning, gastralgia, phos- phorus poisoning, or chronic pancreatitis may be expressed in epigastric tenderness, and all these should be considered when this symptom is present. In catarrhal states, ten- derness is usually diffuse over the gastric region, and, except in acute gastritis, is not accompanied by much resistance of the walls. "In the local neurotic and gas- troptotic cases the tenderness is usually confined in an area just below the ensiform about the size of the palm of the hand, and as a rule is not accompanied by resistance" (Bassler). The tenderness of gastric and duodenal ulcer is generally sharply demarked, is situated below the ensiform to the right or left of the median line, and is generally accompanied by a quick and lively resistance. The same may be said of unfavorable post-ulcer conditions, though the resistance is not so act ve, nor the line of pain so well demarked. The tender spot associated with a duodenal ulcer is fre- quently to the right of the median line, while that of ulcer of the stomach is to the left. This, however, should not be taken too literally, as quite a number of gastric ulcers have manifested a tender spot to the right of the median line. Diffuse pain and tenderness is generally noted in traumatism, in localized peritonitis and perigastritis, and TUMORS IN THE EPIGASTRIUM 33 in disturbed conditions of the solar plexus of the sympa- thetic and celiac axis. Occasionally the examiner finds multiple circumscribed spots of tenderness over various parts of the epigastrium or abdomen, and these are likely to be manifestations of "nervous dyspepsia," that will-o- the-wisp of digestive disorders. Tumors or Growths in the Epigastrium.— This is a most important consideration, for the ability to rightly diagnose and weigh the significance of tumors in this region cannot be overestimated. I will enumerate a number of them, and briefly discuss their possible bearing on disturbances in the epigastric locality or the whole body. Tumors of the stomach proper, usually carcinomatous, rarely sarcomatous, or due to inflammatory infiltration and deposits around a gastric ulcer, may sometimes be felt here, especially when the patient takes a deep breath, driving the abdominal viscera down from out the cover of the diaphragmatic dome. As to the pylorus, it must not be forgotten that the normal pylorus can sometimes be felt in a child, or slender adult, as a round, finger-like mass deep in the right side of the epigastrium. The actual connection of a gastric tumor with the stomach can be proved more clearly if that viscus is inflated with carbonic acid gas, according to directions previously given. The transverse colon traverses the lower part of the epi- gastrium in many cases. Its sacculation and peristalsis can often be made out in rachitic children or thin adults, paticularly when they are flatulent or constipated. In Hirschsprung's disease, or congenital dilatation of the colon, if there is fecal accumulation, there may be an immense tumor squarely in the epigastrium. In aged people with stiffened and sclerotic intestinal walls, the colon can fre- quently be plainly palpated in the epigastrium, and its sacculated feeling may be much like a tumor. Tumors in connection with the omentum usually lie below the colon, but in tubercular peritonitis these inflam- 3 34 DIAGNOSTIC METHODS matory growths in their exuberance may extend well up into the epigastrium. The same may be said of malignant nodules. I have in mind at present two instances of this sort, one still living, in which the epigastrium showed a crowded mass of tumors originating lower down in the abdominal cavity. Swellings derived from the pancreas sometimes extend forward from the depths of the abdominal cavity, being felt vaguely in the epigastric and upper umbilical region. They are sometimes most puzzling. These tumors have the stomach in front of them and are seemingly fixed to the posterior abdominal wall. They move but little on respiration, and sometimes require complete anesthesia for their disclosure. These tumors may be carcinomatous, and may leave in their wake wasting, anemia, jaundice and death. The so-called pancreatic cysts are sometimes located here, but are in reality not pancreatic but "peripancreatic cysts," as denominated by Jex Blake. Tumors in connection with the duodenum may be felt in the right side of the epigastrium, and are usually due to primary malignant disease. Many of these are not recognized on account of the lack of careful and deep palpation, for they are deeply placed, and have to be differ- entiated from such conditions as cancer of the stomach, pylorus, pancreas, bile ducts, and portal fissure generally, not by their physical signs so much as by the general symptoms and progress of the malady. A growth on the first part of the duodenum gives rise to symptoms practi- cally like those of cancer of the pylorus — wasting, anemia, dilatation of the stomach with visible and restless peris- talsis, attacks of copious vomiting, and perhaps occasional hematemesis. Jaundice will not be present unless second- ary growths occur in the portal fissure. Malignant disease with palpable tumor in the second part of the duodenum, involving the bile ducts, soon produces a marked jaundice EXAMINATION OF THE ABDOMEN 35 of the obstructive type. Cancer in the third part of the duodenum produces duodenal stenosis, dilatation of the duodenum and stomach and troublesome vomiting. In the last-named condition, the vomitus will contain bile and pancreatic ferments. Growths in connection with the kidneys and suprarenal capsules occur in the epigastrium only after they have reached considerable size. They rise up out of the loin and flanks, and their diagnosis at such an advanced stage should cause no confusion. Sometimes enlargement of the spleen brings its blunt anterior end into the epigastrium. This, too, should be obvious when it occurs. In every region of the abdomen there is a plentiful supply of lymphatic glands, and these glands are prone to become enlarged and palpable. When such are felt the physician should be mindful of Hodgkin's disease, chronic peritonitis, tuberculous peritonitis, or malignant growths. In the epigastrium the glands may be felt as nodulated chains or masses, usually hard and rounded, but softer and even cystic if their contents caseate or break down into pus ; they occasionally calcify, becoming hard and stony. The en- larged glands appearing only on the epigastric region belong to the stomach or mesentery, and the diagnosis of their significance is always important. EXAMINATION OF THE ABDOMEN BELOW THE EPIGASTRIUM A careful examination of this region is most important, and in many instances, enlightening. In the several divi- sions of this area there is much to be noted, much to be considered. In the preparation of the following, I am greatly indebted to Dr. Jex Blake. Left Hypochondriac Region. — An abnormally lobulated liver may make a superficial tumor in this area, but it will be continuous with the main mass of that organ. A tumor 36 DIAGNOSTIC METHODS of the left lobe of the liver may also project superficially into the left hypochondrium. A part of the stomach lies normally in this region, and the presence of a gastric tumor may need to be differentiated from a splenic tumor. This may be done by noting that the stomach, being mobile, changes position with respira- tion, while the spleen is capable of but little movement. The normal spleen is not palpable in the abdomen. When it is enlarged, from the first degree on up, it can be detected by placing the patient in a recumbent position with his abdominal walls freely relaxed. The physician, standing on the patient's left side, should palpate the left hypochondrium by hooking his fingers over the costal margin about the eighth or ninth costal cartilages. The fingers are firmly tucked in during expiration, being relaxed during inspiration. The spleen can usually be recognized by the fact that it comes down under the left costal margin on inspiration, has a smooth surface and a notched upper and inner margin. Tumors of the pancreas and retroperitoneal cysts some- times extend into this region, and rarely tumors of the left kidney or suprarenal body. Right Lumbar Region. — Sometimes an abnormally lobu- lated liver may present a thin flange of liver tissue in this region, causing the physician to mistake it for a movable kidney or a dilated gall-bladder. ' The ascending colon can usually be palpated and rolled under the fingers in this region, and in aged people it may feel almost like a rod. When filled with feces it may pre- sent a doughy feel, and can be moulded by pressure. Where there is obstruction lower down, the colon may be distended, sacculatedj and exhibiting visible peristalsis. This colon may become thickened with inflammatory products, may become abscessed, or, from pericolitis, perityphlitis, appendicitis or hyperplastic tuberculosis, may form a thickened and tender mass directly under the abdominal wall. In acute conditions of this sort, the EXAMINATION OF THE ABDOMEN 37 patient may be acutely ill, though if such growths seem to be assuming a chronicity, malignancy may be suspected. Thickening of the ascending colon, with tenderness, and perhaps mucous or blood-streaked stools, may be encoun- tered in mucous colitis and dysentery. It is also found in the later stages of amebic dysentery. The ascending colon may be felt as a sausage-shaped tumor in acute and chronic ileocecal or ileocolic intussus- ception. It may appear first in the right iliac region, extended across the abdomen at or above the umbilicus, and then down the left into the pelvis. Along with this will be spasmodic abdominal pain, vomiting, passage of mucus and blood by the rectum, and tenesmus. The small intestine is rarely the cause of abdominal tume- faction, unless in the case of enteric intussusception. Tumors in connection with the right kidney usually make their appearance deep down in this region, with the ascending colon and perhaps the small intestine in front of them. The characteristic feature of such tumors is that they may be lifted forward en masse from behind by a hand placed at the back of the loin. Furthermore, the peculiar shape and consistency of a movable kidney, and the sickening sensation elicited as it is pressed upon, should be noted. Umbilical Region. — Since X-ray examinations of this re- gion after a bismuth test -meal have become so frequent, it has been discovered that the stomach is much more movable than was formerly supposed, and that even in health its lower border often extends below the level of the umbilicus. If, however, very much of the stomach is found in the umbilical area, pathologic dilatation or ptosis may be inferred. Tumors in reference to the transverse colon have been previously considered; likewise tumors in connection with the omentum. Growths arising from the duodenum, kidneys, supra- renals, pancreas, and mesentery may all be encountered 38 DIAGNOSTIC METHODS in the deeper portions of the umbilical region, usually as more or less fixed masses arising from or connected with some definite part of the posterior abdominal wall. Their satisfactory diagnosis will depend largely on the condition of the patient, the amount of adipose tissue present, and the degree of relaxation obtained. The aorta bifurcates just below and just to the left of the umbilicus. In thin and relaxed individuals this por- tion of the aorta is plain indeed, and its throbbing presence not infrequently excites suspicion of aneurysm. Aneurysm here is quite rare, and the normal aorta lacks that lateral expansion that is found in this abnormality. Left Lumbar Region.^ — The most frequent tumorous "growth in this region is an enlarged spleen. Tumors of the stomach, omentum, suprarenal, kidney or descending colon may be found in this area, and they can generally be differentiated from splenic dulness without special difficulty. Right Inguinal Region and Right Iliac Fossa. — This is a region fraught with many problems, and embracing many diagnostic pitfalls for the unwary. Swellings and growths in the inguinal region rarely are confined to it, but extend more or less into the right iliac. In this fossa may be encountered inflammatory thickenings and abscesses con- nected with the cecum and appendix, bearing in connections symptoms such as abdominal pain, fever, vomiting and constipation. The physical signs in some of these condi- tions are deceptive, and not at all commensurate with their gravity. Sarcoma or lymphosarcoma of the cecum is quite rare, and gives rise to a softer mass and more rapid growth than a cecal carcinoma. The diagnosis of appendicitis is given in full elsewhere in this book. Inflammation of the right ovary or tube, or ovarian neuralgia, may produce symptoms, especially in nervous patients, closely simulating appendicitis. A doubt under such circumstances may be cleared up by a vaginal examination. EXAMINATION OF THE ABDOMEN 39 Inflammatory swellings and abscesses in the left iliac fossa may arise in connection with psoas abscess, from the swelling or breaking down of lymphatic glands, infected from perhaps some small wound in the leg or perineum. Left Inguinal Region and Left Inguinal Fossa. — The sig- moid flexure is here, and when filled with scybalous masses forms quite a prominent swelling. This region is sometimes the seat of cancerous growth, accompanied by cachexia, the passage of blood-stained stools, and followed later by intestinal obstruction. Before leaving this subject it will be well to discuss the so-called "Head zones," which have received considerable attention in some quarters. According to Dr. Head, stimulation is excited from diseased states of internal organs, and, being transmitted by way of the sympathetics to a distinct spinal segment, are referred to sensory fibers of the skin which pass backward into the same segment. This means the existence of hyperalgesic areas on the body reflexly caused by disease of organs within, and, according to the localities on the skin in which these areas are observed, inferences of diagnostic worth should be assumed as to which of the internal organs are affected and where the lesion is situated. These zones have some value, when taken in connection with other symptoms, but too much weight must not be accorded them alone. Where certain sensitive spots are due to hysteria, uremia, neuralgia, or central nervous diseases, to separate them from the "Head zones" is an impossible task. Bassler admits that the pyloric and gall- bladder zones are more often present than the others, but even to these too much diagnostic significance should not be given. There are certain gastric conditions, however, in which pressure spots of real diagnostic worth have been located. Boas has shown that in gastric ulcer, about one-third of the cases give tender pressure points situated to the left of the spine close to the twelfth dorsal vertebra. In my experi- 40 DIAGNOSTIC METHODS ence, and that of some other American observers, this spot is generally higher up, being at or near the tenth dorsal vertebra. When present, this spot is noted as a very tender area close to the spinous process and keenly painful to deep point pressure. Some cases are seen where the char- acteristic tender spot is to the right of the spine, being suggestive of ulcer of the pylorus or duodenum. Kell- ing explains these spots as being due to the supersensitive posterior branch of the intercostal nerves, which in turn are due to a reflex hyperesthesia from the sympathetic nerves. The physician, in searching for these tender spots, must riot be misled by other tender spots (usually higher up) due to neurasthenia, disease of the spine or cord, or infectious disease. Any tender spots in the back that cover a rather large area, are perhaps on both sides of the spine, and range up, are probably the expression of a neurosis. These neurotic tender spots are inclined to shift from place to place, and do not manifest that extreme tenderness in one small spot as do the tender areas from gastric ulcer. In gall-bladder disease there is generally found a painful area in the back on the right side. This area is diffuse, though in simple, uncomplicated gall-stone disease it may be located in a rather small area to the right of the eleventh dorsal vertebra and along the course of the last ribs. In cholelithiasis a reflex area of tenderness may be found in the back of the right shoulder at the upper part of the scap- ula. This is so common that it has been noted by the laity, and referred to by them as a "liver pain." In disease of the intestines, especially where the colon is crowded with feces, there is often present a transverse dragging pain in the back. In enlargements of the spleen (malaria, leuke- mia) the dragging weight of this organ, or the tension of its fibro-elastic framework brought about by rapid swelling, may cause a somewhat acute pain midway between the spine and thoracic margin about the eighth rib. A general caution may be inserted in connection with TRANSILLUMINATION OF STOMACH 4 1 the search for tender spots on the abdomen or back: Many patients, who come to the physician for diagnosis of digestive diseases, are neurotic in the extreme, and have preconceived ideas as to their malady. These ideas nat- urally color their statements, and cause them to magnify the soreness of certain areas, while they may minimize that of other areas, perhaps more important. In such cases the examiner should be on his guard, not letting the patient know that he expects to find, nor bringing out answers by leading questions. I have in more than one instance, by suggestive inquiries purposely given, elicited a history totally at variance with the real pathologic condi- tion. I find it useful at times to direct my questions negatively, and if there is no affirmation of the symptoms sought, it may be considered fairly certain that they do not exist. For instance, in pellagra, I would not ask, "Do you have shooting pains in the limbs?" but ask instead the question "You have never been troubled with shooting pains, have you?" Some phlegmatic and matter-of-fact individuals are inclined to minimize all their symptoms, and the physician must in such cases, allow an added weight to the somewhat grudging admission of illness. These are the toilers of both sexes, who feel that they have no time for sickness, and who, only by careful questioning, will grant the examiner a full and comprehensive history of subjective symptoms. TRANSILLUMINATION OF THE STOMACH OR GASTRODIAPHANY Viewing the shape of the stomach from outside the body by means of brightly illuminating the inside of this organ has a limited use in diagnosis. By the employment of transillumination of the stomach, gastroptosis, dilatation, irregularities in contour, and occasionally, morbid growths may be recognized. Casenave, in 1845, first applied this method to living tissues, and in 1867 Milliot experimented quite extensively 42 DIAGNOSTIC METHODS with it in the stomachs of animals and cadavers. To Dr. Max Einhorn, however, we owe its availabiUty in trans- illuminating the stomachs of living humans, and demon- strating its worth. Einhorn 's instrument consists of a soft -rubber and rather small stomach-tube, through which runs a small cable, carrying at the distal end a little Edison lamp. The other end of the wires are. connected with a battery, and there is a convenient interrupter some distance from the tube. The lamp is enclosed in a small glass bulb, which both acts as a reflector and prevents the heat of the light from burning the stomach mucosa. He has the patient drink about two glasses of water, inserts the light, and examines him in a darkened room. As it was difficult to move or adjust the lamp in the stom- ach with any degree of certainty, Kemp devised a circum- scribing gastrodiaphane, in which there was used a cable about 6 inches longer than the Einhorn instrument, but about the same caliber. The cable is more flexible in the vicinity of the light, allowing rather free movement. At the base of the light is attached an extremely thin accessory cable, running parallel with the main cable, and increasing its size but little. After introducing the light as far as is desired, the accessory cable is gently drawn upon, and by slightly shifting the angle of the main cable, the light can be moved almost at will in the stomach. A little practice and care will enable the physician to get a fairly accurate idea of the stomach contour in this manner. Care should be taken that the two cables are parallel when passed into the stomach, and that the accessory cable is sufficiently relaxed before the two are withdrawn. Eight dry cells with a rheostat will afford ample strength, and this may be procured in the form of a pocket battery. It is advisable to have an extra lamp at hand in case of need. Water was the medium formerly employed, but a great advance has been achieved in the use of fluorescent media. Three such media have been found to be of value. TRANSILLUMINATION OF STOMACH 43 Bisulphate of quinin, lo grains to a pint of water, to- which may be added five drops of dilute phosphoric acid. The reaction of this solution is acid, and the fluorescence a pale violet. This fluorescence is somewhat increased by greater acidity, but disappears if the solution becomes alkaline. Esculin. — This is a preparation obtained from the ^sculus hippocastanum (horse-chestnut) indigenous to Europe. An eighth to half a grain of esculin in half a pint of an alkaline solution will give a pale blue fluorescence. Fluorescin (phthalic anhydrid, five parts) , a naphthalin product, and resorcin (seven parts), heated to 200° C. This is a reddish powder, slightly soluble in water, neutral in reaction, but not fluorescent in this reaction. In an alkaline medium it gives a beautiful green fluorescence, a liquid opal. The last is the most available agent for this purpose, and may be obtained from Merck & Co. quite cheaply. The addition of a small quantity of glycerin adds to the fluor- escence, and the contents of the stomach must be alkalin- ized. There should be given first two or more glasses of water in which about half a dram of soda has been dis- solved; this should be followed by another glass of water, in which are dissolved a dram of glycerin and half a grain of fluorescin. This method greatly enhances the value of transillumina- tion, and the fluorescin exerts no deleterious effects. On catheterization of these patients, greenish fluorescent urine is obtained an hour after the administration of the above- mentioned solution, but no albumen, sugar nor casts have been found. In order to obtain satisfactory results from gastrodi- aphany, the patient should be in a dark room, with the abdomen and back exposed to view. The lamp and tube may be introduced by artificial light, which is put out before the internal lamp is lit. When the electric current 44 DIAGNOSTIC METHODS is turned on, the patient should stand up, for in this position every outHne of the stomach is more plainly visible. With gastroptosis, the lesser curvature can be outlined, while with a dilated stomach the complete contour can often be observed. If we illuminate in the dorsal position, but little will be shown, for as Meltzing contends, there is but little of the stomach against the anterior wall of the abdomen in this position. CHEMIC EXAMINATION OF THE STOMACH CONTENTS The examination of the stomach contents after the ingestion of different test -meals is now recognized almost universally as a diagnostic method of great worth. Suit- able allowance should be made for modifying factors, and the clinical history of the case should not be disregarded, but it is admitted by all unprejudiced observers that certain conclusions may be formed from the chemic examination of test-meals that cannot be reached any other way. It has been demonstrated by physiologists that the secre- tions of the stomach begin as soon as the food enters that viscus, continuing until the chyme has passed into the intestiries, though with lesser activity toward the end of stomach digestion. It follows, therefore, that examinations at different periods of digestion will give different results, and it is best to make the examination at a definite time and during the height of digestion. For this purpose a number of test-meals have been devised, which, being extracted at different times after ingestion, naturally give different results. TEST-MEALS Riegel's Test-dinner. — This is the oldest one used, and consists of a plate of meat broth weighing from 5 to 7 ounces, i 1/2 ounces of mashed potatoes, and a plain, roll. TEST-MEALS 45 This should be extracted from the stomach four hours after eating. Ewald's.^ — -This is another of the early test-meals. It consists of 6 ounces of finely chopped meat, stale bread i ounce, and a little butter. This should be extracted in three hours. Germain-See's Test-meal. — In this test-meal the patient is given 3 to 5 ounces of white bread, 2 or 3 ounces of finely chopped meat, and a large glass of water. This is to be extracted in two hours. Ewald-Boas Test-meal. — This is the most available one, and for plain examination of the chemic functions of the stomach, is probably used more than any other. It con- sists of two slices of white bread, toasted if preferred (no butter), and a glass and a half of water. This should be extracted in exactly one hour. Boas has suggested a dry test-meal, consisting of a plain roll without any water, but this is difficult to take, and possesses no commensurate advantages. Boas' Test-breakfast. — One ounce of rolled oats boiled in I pint of water. This is indicated where an accurate test for lactic acid is desired, as it contains none of this acid. In the employment of test-meals, there are several modi- fying factors, both physical and psychic, to be considered. The meal should be an indication of what the stomach is doing and its condition at the time the test-meal is extracted. To place the patient under the influence of adverse cir- cumstances, such as change of habits or fear, defeats the object in view. So far as practicable, it is not wise to inform the patient that the stomach is to be aspirated at the next visit, and, if he asks the direct question, the phy- sician, while not deceiving him, should do all that is possible to allay his fears. It is my custom, when I desire a patient to return for a test-meal, to simply inform him that I wish him to come for "further examination." It is best that a test-meal should be taken in the morning 46 DIAGNOSTIC METHODS on an empty stomach, or at least where nothing but water has been ingested one or more hours previously. This is not always practicable, and variations from this particular time have to be resorted to. Any time up to noon the pa- tient may be required to abstain from food until the test- meal is taken; later than that, however, it is well to permit a light repast that will pass out of the stomach before the test-meal is taken. I often take test-meals at one, two or three in the afternoon, when the early morning hour is not practicable. There are many circumstances and conditions in private practice quite different from hospital practice, and the resourceful physician must meet these differences with tact and intelligence. Some observers, mostly European, use tea as the fluid of test-meals. In my opinion water is preferable, as tea irritates some stomachs, and besides has no uniform strength. The methods of extracting test-meals, and other consid- erations involved therein, are fully discussed in a separate chapter. Before chemically testing the ingesta, several points may be brought out by a microscopic examination. Some gastroenterologists advise a careful measurement of the aspirated contents, but, as I do not think it necessary to entirely empty the stomach, except for special reasons, I do not follow this procedure. If, however, a very large quantity is easily aspirated several hours after a test-meal, it would excite suspicion of hypersecretion, and a test of both the secretory and motor functions would be in order. Microscopic inspection may disclose large undigested pieces of bread ; in others remnants of bread that are nearly digested or slightly digested; in others a fine fluid mushy mass. These findings are at once suggestive. After a Riegel's test-meal the differences are more distinctive; for the mass may be fine, uniform and mushy, containing no EXAMINATION OF STOMACH CONTENTS 47 coarse elements; or there may be coarse undigested meat fibers. Mucus, frank blood or plentiful bile are readily visible. In some instances the gastric contents, when placed in a glass vessel, form three layers : at the bottom, a fine starchy, fluffy mass; next a cloudy zone; and on top a foamy layer, the last-named being evidence of gaseous fermentation. In cases of achylia gastrica, especially in senile cases, the bread is aspirated with difficulty, and presents a dry and unchanged appearance. The unresponsive and almost parched gastric mucosa of these aged patients absorbs the fluid of the test-meal, instead of secreting any juice of its own. The gross amount of mucus present may be tested by a hooked wire, which is passed through the contents and drawn up. In excessive amounts of mucus, there are long strings visible, varying in viscosity. This mucus may be clear or stained with the pathologic coloring matter in the stomach. In rare instances blood-stained mucus may be picked up on this wire. Odor. — In normal test-meals the odor is "bready" and not disagreeable. In some pathologic conditions the odor is anything but pleasant, varying from a "fermenting smell" to a distinct putrescence. In the presence of advanced carcinoma, with decided obstruction, the odor may be foul indeed. Before beginning the chemic examination proper, the contents should be filtered. The regular filter paper is preferable, though, if this cannot be obtained, several layers of gauze or cheese-cloth will answer. For practical purposes the most important feature to determine is the amount of hydrochloric acid present, free or combined, during the height of digestion. Should hydrochloric acid be present, it is necessary to ascertain whether it is normal in quantity, increased or deficient. Should it either be absent, or deficient in amount, then lowered digestive power of the stomach is proved. 48 DIAGNOSTIC METHODS When free hydrochloric acid is present in easily appreci- able amount, the determination of pepsin is unnecessary; in fact, pepsin may be present when the acid is absent; but the presence of hydrochloric acid is prima facie evidence of the presence of pepsin. In the total absence of the acid, tests for pepsin should be employed. For a complete chemic examination and analysis the following tests should be carried out : 1. Reaction. 2. Free hydrochloric acid. 3. Total acidity. 4. Combined hydrochloric acid. 5. Organic acids (lactic, acetic, butyric). 6. Propepton. 7. Pepton. 8. Pepsin. 9. Renin. 10. Dextrin. 11. Erythrodextrin. 12. Achroodextrin. 13. Occult blood. 14. Bile and intestinal juices. Before judging of abnormal conditions in test-meal find- ings, it is necessary that the examiner should be familiar with normal conditions. A normal Ewald-Boas test-meal, extracted an hour after ingestion, should show free hydrochloric acid, 15 to 25; total acidity, 50 to 60 ; propepton and pepton, small amount ; pepsin and rennin present; erythrodextrin present in small amount, or absent; dextrin absent. Some patients may have the free hydrochloric acid pres- ent within normal limits, and suffer with symptoms of hyper- acidity; others may have a marked excess of free acid, and complain of no special discomfort pointing to that con- dition. This is to a great extent a matter of individual peculiarity. EXAMINATION OF STOMACH CONTENTS 49 Reaction. — This may be determined by blue and red litmus paper. Should the filtrate be acid, it turns the blue paper red; and conversely, if it is alkaline, it turns the red paper blue. In a filtrate of neutral reaction, there is, of course, no change. For a qualitative estimate of the presence of acid in general, and free hydrochloric acid in particular, congo-red and dimethylamidoazobenzol paper may be used (the latter is usually called dimethyl paper). The presence of any acid turns the congo-red paper blue; and the deepness of the blue is to an extent an indicator of the amount of free acid in the filtrate. The dimethyl paper responds to hydrochloric acid, and turns red in its presence. A small amount of free hydrochloric acid may turn the yellow di- methyl paper only a light pink,, while a great amount will turn it a bright scarlet. While this method is by no means exact, a fairly good estimate may be made by it, which will give the doctor a "working basis" until a quantitative estimate can be made. Tests for Free Hydrochloric Acid. — Many tests for this acid have been advocated, some of which possess but little merit. Most of these tests are based upon the assumption that certain coloring matters respond to mineral acids and not to organic. About the only organic acid liable to inter- fere is the lactic, and this can be eliminated, if necessary, by quantitative check tests. Gunsburg's Phloroglucin-vanillin Test. — This reagent consists of 2 grams of phloroglucin and i gram of vanillin dissolved in 30 grams of absolute alcohol. Into a small porcelain dish are placed an equal number of drops of this reagent and gastric filtrate. The disK is then held over an alcohol lamp (not too closely) and the contents allowed to evaporate slowly. A cherry-red color appears if free hydro- chloric acid be present. If there are only traces, a rose tint appears at the margin; while if no free hydrochloric acid is present, the color of the evaporating solution varies from a yellow to a brown. 4 50 DIAGNOSTIC METHODS This test responds only to free hydrochloric acid, and not to organic acids. The disadvantage of this method lies in the instability of the solution, which must be made fresh at frequent intervals and kept in a dark place. Boas' Resorcin-sugar Test. — Five grams of resorcin and 3 grams of cane-sugar are dissolved in loo c.c. of alcohol. An equal amount of this reagent and gastric filtrate are slowly evaporated to dryness in a porcelain dish, as in the previous test. The presence of free hydrochloric acid is demonstrated by a rose-red color, which fades on cooling. This responds to hydrochloric acid only, and is preferable to the Gunsberg test. This solution is both cheaper and more stable. Toepfer's Quantitative Method. — By this method free hydrochloric acid, combined hydrochloric acid, total hydro- chloric acid, and acid salts are readily and accurately determined. Ordinary routine examinations seldom call for more than a determination of total acidity, free and combined hydrochloric acid, but when free acid is absent, the pepsin and rennin tests may be indicated. In the employment of Toepfer's method the following solutions are required: (i) A I per cent, alcoholic solution of phenolphthalein (colorless) . (2) A I per cent, aqueous solution of sodium alizarin sulphonate (brownish yellow). (3) A 0.5 per cent, alcoholic solution of dimethyl- amidoazobenzol (yellowish red). (4) A decinormal solution of NaOH (sodium hydrate) as a titrating solution. The rationale of Toepfer's method consists in the sensi- tiveness of the three-color end-reagents to the various con- stituents of the gastric juice. To judge of the different stages of color changes calls for a definite "color sense" on the part of the physician, and an inability to note the fine gradations of color, as they blend one into another, will EXAMINATION OF STOMACH CONTENTS 5 1 seriously handicap the examiner. I have known several otherwise excellent diagnosticians, who, because of their indifferent color perception, could not successfully avail themselves of this method. The decinormal solution should be of such accurate strength that i c.c. will neutralize 0.00365 hydrochlgric acid. Some use 10 c.c. of the gastric filtrate for each test, but often there is not a great amount of this filtrate avail- able, and I seldom use more than 5 c.c, but with equal ac- curacy. Into each of three beakers or small glass containers, are put 5 c.c. of the gastric filtrate. To obtain the free hydro- chloric acid two drops of the solution of dimethylamidoazo- benzol are added, and into this is titrated drop by drop the decinormal solution of sodium hydrate until the filtrate turns an orange yellow. Some examiners make the error of carrying this reaction to a lemon yellow, which is incorrect. To carry the titra- tion thus far would put an unduly large number into the class of hyperchlorhydria. Let me insist that the titration be stopped at an orange yellow. To obtain the total acidity, two drops of the phenol- phthalein solution are put into another beaker, and the decinormal solution titrated into it until the end-reaction of red is reached, or until no more redness is produced by titration. Where the gastric filtrate is scanty, another convenient method may be employed for determining the total acidity. After the free hydrochloric acid has been determined, into the same solution may be placed two drops of the phenol- phthalein solution. This produces no change in color until the titration is proceeded with, but the end reaction of red takes place just the same as in the plain filtrate, minus the dimethylamidoazobenzol. Let the titration proceed until the end reaction is reached, and the sum of the free hydro- chloric acid, plus the amount of decinormal solution 52 DIAGNOSTIC METHODS required to obtain the end reaction, will represent the total acidity. To obtain the combined acid, add to the other beaker of gastric filtrate one small drop of the sodium-alizarin- sulphonate solution. Titrate with the decinormal solution until an end reaction of a marked purple is reached. The titration may be performed with a graduated pipet, or, much preferably, a graduated buret supported on a stand. This pipet or buret should be graduated to 1/5 e.c. To obtain the combined acid, subtract the index of the end reaction from the total acidity. In making these calculations, as the degree of acidity is represented by the number of cubic centimeters of the deci- normal solution required to bring about the proper color reaction in the gastric filtrate, plus the proper indicating solution, and the figures are based on the assumption that 100 c.c. of the filtrate will be used, while in reality only 5 c.c. are used, the number of cubic centimeters of the deci- normal solution must be multiplied by 20. For instance, if I c.c. of the decinormal solution were required to color the gastric filtrate plus the dimethylamidoazobenzol solution an orange yellow, the result should read 20; and that would be within normal limits. To compute the free hydrochloric acid in percentage, multiply the first result by 20, and then by 0.00365. If 10 c.c. of gastric juice are employed, multiply the result by ID. Sometimes where the amount of the test-meal is extremely scanty as much as 5 c.c. are not available for the tests. Should only 2 c.c. be available, the result should be multiplied by 50. When as small an amount as this is examined, however, great care should be exercised in noting the color gradations, lest a decided error ensue in the final calculations. A further suggestion in making these examinations is to have beneath the glass beaker a white ground, that a good, clear light be available, and that the examiner should not permit the possible reflection of colored walls, EXAMINATION OF STOMACH CONTENTS 53 curtains, etc., to interfere with his judgment of color changes, or end reactions. Lactic Acid. — The most-used test is Uffelmann's, and is fairly accurate. It should be freshly made before each test, and is prepared as follows: lo c.c. of a 4 per cent, carbolic acid solution is mixed with 20 c.c. of distilled (or plain) water, and to this is added one drop of sesquichlorid of iron. This makes an amethyst-blue solution. Should the blue be too marked, it can be lightened by the addition of a small amount of water. To this solution add a few drops of the gastric filtrate, and, in the presence of lactic acid, a canary-yellow reaction follows. Some have de- scribed it as a "canary-green," but this does not accord with my observation. Fatty acids produce an ash-gray reaction, and inorganic acids decolorize the amethyst -blue solution. Should phosphates be present, they may give the same reaction as lactic acid, and the following modified Uffel- mann test has been proposed to eliminate that possible error. Take 5 c.c. of the filtrate plus 10 c.c. of ether, shake it in a test-tube, and allow it to stand until the ethereal solution has separated from the watery solution. Pour the ethereal part into another test-tube, and place it in a glass of hot water to evaporate. Add i c.c. of distilled water to the remaining drops, and test for lactic acid with the Uffelmann solution. If the canary color occurs, lactic acid may be considered present beyond a peradventure. Boas' Test for Lactic Acid. — Take 10 to 20 c.c. of the gas- tric filtrate, and evaporate it into a syrupy consistency over the water bath. Should free hydrochloric acid be present, neutralize it with an excess of barium carbonate. A few drops of phosphoric acid are then mixed in and the carbonic acid expelled by boiling. The fluid is then cooled, and ex- tracted two or three times with 50 c.c. of ether. After half , an hour pour off the clear ethereal layer. The ether is now evaporated, and the residue washed in a flask with 45 c.c. of water, well shaken and filtered. Concen- 54 DIAGNOSTIC METHODS trated sulphuric acid, 5 c.c, and a pinch of manganese dioxid are added to the filtrate. The mixture is then dis- tilled over a small flame, and the vapor conducted into a narrow cylinder containing about 10 c.c. of an alkaline iodin solution. This consists of equal parts of a decinormal iodin solution and the standard potassium hydroxid solution. The vapor may be conducted into the same quantity of Nessler's reagent. If lactic acid is present, it gives rise to the iodoform reaction (clouding and odor of iodoform) with the iodin mixture. If Nessler's reagent is used, yellowish-red aldehyd of mercury appears. This is a good and reliable test, but, as will be understood, requires considerable technic and great care to perform it successfully. For this reason, it is not often available to the general practitioner, and is clinically impractical. The presence of lactic acid in a test-meal may or may not possess significance. I might say, however, that when a test -breakfast or test-dinner is taken under proper condi- tions, which admit of only traces of lactic acid, and this acid is found in appreciable quantities, it is of pathologic significance, and indicates either subacidity or stagnation. The impression prevails in certain quarters that the pres- ence of lactic acid is pathologic of cancer. This is putting it too strongly. It may fairly be stated that conditions existing in the presence of cancer are favorable for the presence of lactic acid, and that finding this acid is only one of several indications that point the diagnostic finger to- ward cancer. Volatile Acids. — Fatty or volatile acids are recognized by boiling a small amount of the gastric filtrate in a test- tube. A strip of moistened blue litmus paper is held over the tube so that the vapor will come in contact with it but not the boiling filtrate. The paper turns red if volatile acid is present. Either butyric or acetic acid can be recognized by their odor in the gastric contents when present in an appreciable quantity. Such a small amount of butyric acid will throw EXAMINATION OF STOMACH CONTENTS 55 out such a characteristic odor of spoiled butter, that any other test is hardly necessary. Should the acetic acid be present in only small amount, it can be determined by Einhorn's test of neutralizing the watery residue of the ethereal extract of the gastric filtrate with carbonate of soda, and then adding neutral chlorid of iron. The presence of acetic acid is shown by develop- ment of a red color. Propeptone. — -Add to the gastric filtrate about 5 c.c. of the saturated solution of sodium chlorid. A small amount of the former is sufficient. If propeptone is present, it will be precipitated; if no precipitation occurs, add one or two drops of acetic acid, and a precipitation will take place in the presence of propeptone, which clears up on heating, but becomes turbid on cooling. Peptone. — After filtering out the propeptone, take 2 c.c. of the gastric filtrate, and make it strongly alkaline by adding sodium hydroxid solution. Then add a few drops of a weak i per cent, copper solution. Peptone gives a purple or violet-red color. Pepsin.— A thin disk of the white of a hard-boiled egg, weighing about i gram (i cm. in diameter and i mm. thick) is placed in a test-tube containing about 5 c.c. of the gastric filtrate. This should be kept at blood temperature, and a most convenient method is by the use of a thermos bottle. If free hydrochloric acid is not present in the filtrate, add two drops of dilute hydrochloric acid. The presence of pepsin will cause a disappearance of the albumen in from two to six hours. Most of the methods for quantitative determination of pepsin are too complicated for the physician, unless he has special experience in a chemical laboratory. The simplest one that has come to my notice is one devised by Henry Illoway, and which is sufficiently exact for all practical purposes. Ten cgm., exact weight, of egg-albumen (white of hen's egg) is coagulated in the following manner: -56 DIAGNOSTIC METHODS The egg is placed in a pot of cold water, which is then covered with a lid and put on to boil. It is allowed to cook for ten minutes after the water has begun to boil — in all it should be heated twenty minutes from the time it has been put on. The egg is then taken out and allowed to cool. So that the gastric filtrate may act on the albumen in the same way as food in the stomach, the cube is cut in half. The filtrate can then act on eight sides instead of four. This coagulated albumen is now put into 10 c.c. of gastric filtrate (from stomach contents extracted one hour after ingestion of an Ewald-Boas test-meal) and this is placed in a thermostat which is kept at 38° C. The time in which the 10 cgm. are digested, entirely, partially, or not at all, will give a correct idea as to the status of the pepsin secretion in the case under examina- tion. lUoway has shown that normal digestion of the albu- men requires from five to five an one-half hours. His classification is as follows : Hyperpepsinia. — Digestion requiring only from three to four hours, not in any pathologic sense necessarily, but only to indicate a secretion of pepsin greater than usual, which, however, may be the normal in that individual case. Normal Pepsinia.— Digestion of the albumen requiring from five to five and one-half hours. Hypopepsinia. — Digestion requiring more than the usual time. The degree of this condition is indicated by the number of hours required beyond the standard of time. Apepsinia. — No change in nor digestion of the albumen. Another method often used is that of Mett. This con- sists in sucking fresh egg-albumen into capillary tubes°*of I or 2 mm. in diameter, coagulating the albumen by boiling, and then cutting off portions of the tube 3 to 5 cm. long, and placing these pieces in the gastric contents. These pieces should be kept in the incubator at body temperature for ten hours. At the end of this time each end of the tube should show a lack of albumen which has been digested away, while some of the solid albumen will remain in the EXAMINATION OE STOMACH CONTENTS 57 center of the tube. Both the empty portions of the tube and the portion that is full are measured, and the activity of the pepsin digestion thus determined. The relative amount of pepsin varies according to the square of the length of the empty portion of the tube, the figures of the latter being expressed in millimeters; thus 3 mm. of digestion equals nine parts of pepsin; 2 mm. equals four parts of pepsin, etc. Rennin. — Add five drops of the gastric filtrate to 10 c.c. of fresh neutral milk in a test-tube. Some advise neutral- izing the gastric filtrate with decinormal sodium hydroxid solution, but this is not necessary. Place the tube of milk in a glass of warm water at a temperature of about 100° F., or in a thermostat. A thermos bottle will also answer, and is both cheap and convenient. Normal Rennin. — Coagulation will occur in five to fifteen minutes if the rennin content be normal. Deficient Rennin. — If five drops of the gastric filtrate give no result, add i c.c. of the filtrate to 5 or 10 c.c. of the sweet milk under the same conditions. If no coagulation occurs in fifteen to thirty minutes, rennin may be consid- ered deficient. Absence of Rennin.— When no reaction is obtained in half an hour with 5 c.c. of gastric filtrate in 10 c.c. of milk, rennin may be considered absent. It has been demonstrated by more than one observer that rennin is in nearly normal amount when pepsin is deficient or absent, and it has also been shown that rennin is one of the last elements in the process of gastric digestion to disappear. Starch Digestion. — The orderly progress of starch diges- tion can be followed and the different stages separated with probably more exactitude than any other physiologic di- vision of general digestion. In a recent trial of a murder case in Atlanta, Ga., one of the most vital factors in fixing the time of the death of the victim was the fact that starch digestion in her stomach 58 DIAGNOSTIC METHODS had reached the erythrodextrin stage. This, in addition to the fact that no free acid was present, fixed the time of her death with almost absolute certainty at less than an hour after she had eaten a carbohydrate meal. The first step in starch digestion begins in the mouth through the action of the ptyalin. It has been thought that the action of ptyalin, which transforms starch into maltose and dextrose, was halted practically as soon as there was a free secretion of acid in the stomach. Later physiologic experiments have proved that the action of the ptyalin continues uninterruptedly in that portion of the stomach contents unaffected by the acid, and does not cease until the whole contents have lost their alkaline reaction. The first of starch digestion, therefore, is denominated Amylodextrin or AmiduUn, giving a light, but distinct blue with Lugol's solution. Erythrodextrin. — Gradually, as the inversion progresses, the color produced by the Lugol's solution becomes violet blue, violet, red violet, red, or mahogany brown. This varied color change is why the continued inversion is called erythrodextrin. Achroodextrin. — With continued action of the ptyalin, a stage is reached in which Lugol's solution produces no color reaction ; this is called achroodextrin, meaning with- out color. Amylodextrin is precipitated by tannic acid and alcohol, while erythrodextrin and achroodextrin are pre- cipitated by alcohol and ether, not by tannic acid. These two dextrins do not reduce Fehling's solution, nor do they ferment with yeast. Maltose. — This is soluble in alcohol, insoluble in ether. It reduces Fehling's solution, but does not ferment with yeast. Dextrose. ^ — This is insoluble in alcohol and ether and ferments readily with yeast. These reactions are quite important, as they enable the physician to not only determine the degree of starch con- EXAMINATION OF STOMACH CONTENTS 59 version in cases of hyperacidity and hypersecretion, but also enables the observer to state with a fair degree of ac- curacy how long a meal has been taken. This, as has been noted above, may become a question of medico-legal importance. Occult Blood. — The presence or absence of occult blood in the gastric contents is of weighty diagnostic import. In several conditions, either malignant or benign, the knowl- edge concerning occult blood is sufficient to name the diag- nosis ; while in feces also its presence is suggestive of various pathologic states. There have been many tests devised for the detection of occult blood in the gastric contents and feces, and I will endeavor to give several of the most practical and reliable. The simplest test is performed with benzidin paper, which is immersed in the gastric filtrate, and then has a few drops of hydrogen peroxide poured over it. After drying a short time, the paper turns blue in the presence of occult blood. This is feasible when there is rather a large amount of occult blood present, and the paper can be kept perfectly dry. Moisture on the hands of the examiner, or a moist atmos- phere in the room renders this test unreliable. In the detection of occult blood, it is recognized that many of the red corpuscles are degenerated and broken down, especially in the feces after the blood has passed through the whole intestinal canal. The hematin crystals remain, however, and these respond to the tests. A general plan of extraction of the hematin is advisable, and this is accomplished by rubbing up with half a test-tube of the gastric filtrate, of the same amount of a watery extract of the feces, one-third its volume of glacial acetic acid and one-half its volume of ether. The mixture is well shaken, and allowed to separate. Should this be slow, a few drops of methyl alcohol will hasten the separation. The clear supernatant ether contains the hemoglobin, and should be poured off for the other examinations. It is well not to depend on any single test, but to perform 6o DIAGNOSTIC METHODS two or more with the ethereal extract, if sufficient is at hand. Guaiac Test. — This is a fairly satisfactory test, but hardly as reliable as the aloin. It is accomplished by the oxidation of the guaiaconic acid in the presence of blood into a guaiac blue. A fresh alcoholic solution of guaiac is made by scraping with a knife a few grains of old gum guaiac into a test-tube containing about 5 c.c. of alcohol. (The area of guaiac containing the yellow particles is the most sensi- tive solution for the reagent.) To the alcoholic guaiac solution is added about 2 c.c. of hydrogen peroxid, and the contents shaken. To this mixture is added i c.c. of the acetic-etherial extract, and in the presence of occult blood a blue-violet color will appear in the upper part of the mixture, or in the whole mixture if much occult blood is present. This blue will fade, if the mixture is allowed to stand for some time. In the examination of feces contain- ing blood, a purplish-brown color may be observed due to both the blood and the urobilin contained in the extract. Should no blood be present, no color would appear, unless a faint brown from the urobilin. Aloin Test. — This test is probably the most dependable of the various ones advocated. The reagent is prepared as follows: In a test-tube about one-third filled with 70-per cent, alcohol, a small amount of powdered aloin is placed (about as much as will go on the tip of a knife blade) , and allowed to dissolve. About 3 c.c. of the acetic-etherial extract is placed in a tube, to which an equal amount of the aloin solution is added. This mixture is then treated with about 2 c.c. of thoroughly ozonized turpentine, or an equal amount of hydrogen peroxide. (The turpentine is better.) Ozonized turpentine is prepared by allowing chemically pure turpentine to stand exposed to the air for about a mouth. The above mixture is thoroughly shaken, and, if blood is present, the reaction, a cherry red, will appear in the lower part or all of the solution in a short time. To make it more delicate, the ozonized turpentine EXAMINATION OF STOMACH CONTENTS 6 1 may be added drop by drop, and the color will show more deeply in the lower part of the mixture. This test must not be allowed more than fifteen minutes to develop, for after that time a reddish color may show, even if no blood is actually present in the specimen. Adler's Benzidin Test. — This is quite a satisfactory test of stomach contents after an Ewald-Boas test-meal, but is not reliable for testing the feces, as it may react from such substances as potato, milk or farina, or other cereals as they pass down the intestinal canal. This reagent is prepared by dissolving as many benzidin crystals as will lie on the end of a spatula in one-third of a test-tube of 70-per cent, alcohol. When the crystals are dissolved, an excess of hydrogen peroxide is added (about one-fourth of the amount) , and to the top of this the acetic-ethereal extract is added. When blood is present an intense green color is quickly in evidence, and when absent, only a milky white appears. Iron Test. — This test is valuable, if the patient is not taking an iron preparation. It is quite sensitive, and is produced by placing a small amount of unfiltered gastric contents in a porcelain dish, with a pinch or two of potas- sium chlorid and a few drops of concentrated hydrochloric acid, mixing these well, and heating the contents over a small flame sufficiently to drive off the water and chlorin, and obtain a perfectly dry residue. To this a few drops of a diluted solution of potassium ferrocyanide are added, and when blood is present, the color of Prussian blue is apparent. Spectroscope. — -The spectroscope is advocated by some for the detection of fresh blood in the gastric contents, but it has no advantage over the previous tests mentioned, beside being open to the possibility of gross errors if wrongly interpreted. When blood has been in the stomach or intestines any length of time, it is dark or black in appearance, and never red, unless poured out in large quantities and ejected quickly. There are few pathologic expressions more 62 DIAGNOSTIC METHODS dramatic and fear-inspiring than the appearance of blood in the vomitus or stools. Patients may put off treatment of their ailments from time to time, but when there is hematemesis or intestinal hemorrhage, aid is quickly and urgently sought. Blood in the stomach contents is found most often in gastric ulcer or cancer. It is sometimes present in benign stenosis, and occasionally in chronic gastritis from catarrhal ulcers. It may also arise from multiple erosions in the course of alcoholic gastritis, or following an alcoholic debauch. It is not uncommon in cirrhosis of the liver, and passive congestion due to portal obstruction, or heart or lung disease. It may arise from aneurysm into the esophagus or stomach, in severe anemia or hemophilia, scurvy, purpura hemorrhagica, Hodgkin's disease, typhus or yellow fever, malignant small-pox, or in pernicious malarial fever, or hemorrhagic scarlet fever. It may follow traumatism, and occult blood is not infre- quently found in the stomach contents from inexpert extraction or the use of an improper stomach tube. It must not be forgotten, also, that the blood may not orig- inate in the stomach or esophagus, but may be swallowed from a pulmonary or nasal hemorrhage. Patients have had slight hemorrhages of this sort during sleep, have unconsciously swallowed the blood, and mistaken diagnoses of diseased conditions of the stomach or intestinal tract have been perpetrated. When testing for blood, either visible or occult, the physician should ever be on the alert as to its origin, lest grave errors as to diagnosis and conse- quent treatment becloud his viewpoint. Bile and Intestinal Juices in the Stomach. — The presence of bile in the stomach may be due to stenosis of the intes- tines, to excessive vomiting in migraine, or to excessive vomiting from dietetic errors — in fact, bile will appear in the stomach after laborious vomiting from any cause. An extremely small amount of bile will show itself in the gastric contents or lavage water, and a special test is seldom necessary. Sould a test be desired, however, EXAMINATION OF STOMACH CONTENTS 63 there may be added to 2 c.c. of the gastric contents i c.c. of fuming nitric acid. The presence of bile turns this green. The examination of the intestinal juice may with pro- priety be considered under the heading of examination of the duodenal contents. There are no intestinal juices normally in the stomach, and their presence there is due to the same causes as the presence of bile. Character and Significance of Gastric Mucus. — A small amount of mucus and saliva is normally always present in the fasting stomach, and a certain amount admixed with the contents of a full stomach. The mucus in test-meals is found both well mixed with the substance of the meal and in a free form floating in coagulated lumps on the top. That finely mixed is the gastric mucus, secreted by the glands of the stomach and combined with the mucin con- stituents of the saliva. The other form of mucus is caused by irritation from the stomach-tube, or is swallowed mucus, originating in the mouth, pharynx or naso-pharynx. In patients with post-nasal catarrh there is being uncon- sciously swallowed much of the time quantities of thick glairy mucus, which is easily visible to the eye in the stomach contents. Unless this mucus is septic itself, or unless it is taken into an achylic stomach, it has but little local diagnostic significance. The detection of excess mucus in test-meals has been discussed. Examination of Duodenal Contents. — Many have been the methods for obtaining the duodenal juices, both direct and indirect. Boas first obtained them by massaging the empty stomach in the duodenal region, forcing the juice into the stomach, and extracting it with a stomach-tube. Hemmeter and Kuhn endeavored to pass a small stomach- tube directly into the duodenum, but were not very success- ful. Einhorn used the duodenal bucket with a certain measure of success, though the amount of juice secured was insignificant in quantity. He also endeavored to catheterize the duodenum. 64 DIAGNOSTIC METHODS Later on both Einhorn and M. Gross, independently, but about the same time, devised a method by which in the majority of cases the duodenal contents may be obtained. The Gross tube consists of a perforated round metal ball about twice the size of a pea, to which is attached a thin, flexible rubber tube 0.2 cm. in diameter and 125 cm. in length, marked every 10 cm. To this is attached a glass bulb, which is . connected by a< length of tubing with a mouth-piece, which the operator can use to aspirate with his own mouth, or to which an aspirating bulb may be attached. Gross advises the following method : Test-meal. — The patient is given in the morning a tumblerful of equal parts of milk and water. This mixture causes but little flow of hydrochloric acid, but contains sufficient fat to stimulate the pancreatic secretions. Half an hour later the duodenal tube is introduced. The patient should swallow the ball and tube, previously wet in water, until the mark 45 cm. reaches the lips. Then blow slightly through the tube into the stomach so as to smooth the tube out and cause it to hang freely in the stom- ach cavity. The patient should then lie down slowly, turn over on the right side, in which position, after a few minutes, the tube is permitted to glide down through the mouth without swallowing, following the pull of the ball until the 60 cm. has been reached. After five or ten minutes the aspiration may be begun, and it should show contents of a sHghtly yellow tint. The patient should remain with the mouth partly open, but should make no swallowing move- ments. The tube will gradually descend to the 65 or 70 cm. mark. A second aspiration may now be made, and usually a yellowish liquid, free from casein, will appear, giving a weakly acid reaction. By waiting a while, and making several aspirations, the yellow aqueous contents of the duodenum will usually be secured, giving a neutral or alkaline reaction, and sometimes exhibiting a greenish- METHODS OF OBTAINING DUODENAL CONTENTS 65 yellow fluorescence. Occasionally the aspirated fluid re- mains acid, perhaps due to hyperchlorhydria, and, therefore neutralization of the duodenal contents may necessarily take place lower down. As a check, give a cup of coffee with the tube in place. Aspiration should then be per- formed, and if the fluid is still green, the contents are duo- denal. By withdrawing the tube a short distance and aspirating, coffee is drawn out. Gross affirms that, unless there is some mechanical obstacle to the passage of the ball through the pylorus, that the duodenum will usually be reached and the contents successfully aspirated in an hour. Einhorn's Duodenal Pump. — This has some advantages over the one just described, in that it may be used for both aspirating purposes, for duodenal lavage, or for duodenal alimentation. The illustration makes its workings quite clear. It has three markings — 40 cm. (cardia), 56 cm. (pylorus), and 70 to 80, distance from the capsule. The duodenal contents are aspirated out by the syringe, the cock turned, they are then ejected into a vessel, and so on. Einhorn's Method. — The patient in a fasting condition drinks a cup of tea with sugar but no milk, and then about half an hour later the capsule and tube (previously lubri- cated in water) are swallowed. The swallowing may be assisted by drinking half a glass of water. To be sure that the tube is in the stomach and is not kinked, a little fluid may be aspirated to determine its reaction. A syringeful of water is then forced into the tube, followed by one of air, the tube is shut off by the stop-cock, and the thread with rubber hitched over the ear. The patient should not close the lips or teeth for a while, and should quietly wait about an hour for the tube to penetrate the duodenum. When the tube reaches about the 70 cm. mark at the lips, aspiration is begun. If the perforated capsule is in the duodenum, on aspirating there is obtained a golden- yellow watery fluid, somewhat viscid, and of alkaline reac- tion. Einhorn recommends that when the flow commences, the piston of the syringe should be removed, and by keeping 5 66 DIAGNOSTIC METHODS the barrel of the syringe low, the liquid should be siphoned out. This I have attempted a number of times without success, and, while it may be practicable in the experienced hands of Einhorn, any one less expert will find it necessary to continue the aspiration in order to obtain the duodenal juices. At times the tube coils in the stomach, and does not enter the duodenum. If the fluid obtained is acid, withdraw the tube to the 56 cm. mark, wash it out with water, blow air through it, and in half an hour the attempt may again be made. When the tube lies in the stomach, it does not collapse on aspiration; when it is in the duodenum, however, it collapses on aspiration, and the flow of fluid is much slower. As a further test, a little milk may be given, and, if no milk is aspirated, it may be safely assumed that the tube is in the duodenum. There are some stomachs in which the conformation does not lend itself to the progress of the tube into the duodenum, and in others the pylorus may be stenosed, or in other ways obstruct the passage of the tube. In the great majority of individuals a certain amount of patience and persever- ance will enable the physician to obtain the undiluted duodenal juices. Examination of the Duodenal Juices. — The test for bile has been mentioned and it may be tested in the same man- ner as in the stomach. Steapsin. — Take one drop of neutral milk, two drops of water, and two or three drops of the duodenal contents. The last named should be neutralized if the reaction is acid. Place this small amount of fluid in a small test-tube, and keep it at the temperature of the body. Put in this a mi- nute piece of blue litmus agar, and in twenty minutes this should turn red from the development of fatty acids. As has been previously mentioned, a thermos bottle will serve fully as well as an expensive incubator. Trypsin. — If the duodenal fluid is acid, neutralize it, and place in it a small piece of a hard-boiled egg. Keep this EXAMINATION OF DUODENAL JUICES 67 two or three hours at blood temperature. If trypsin is present, the albumen will be dissolved. Amylopsin. — To test for this, use a boiled starch solution or prepared starch paper. Mix the duodenal contents with the starch solution, or insert in it a narrow strip of starch paper, and leave it for a while at blood teniperature. In about an hour add a weak iodin solution, and, if dextrin is present, a red color is developed. Another test for amylopsin in which a quantity of a i per cent, solution of Kaulbaum's soluble starch, heated in an incubator to 55° c. A number of test-tubes are heated up, and 5 c.c. are put in a hot tube, to which five drops of the duodenal juice are added. This is shaken for about a minute, and 1/2 c.c. of a 250th normal iodin solution is then added. The normal iodin solution consists of an aqueous solution of equal parts of iodin, iodid of soda, iodid of potassium, and iodid of ammonium, i to 250. If no amylopsin is present, the solution becomes blue; or green if bile is present ; if amylopsin is normal, a pale pink ; if in excess, it is colorless. M. Gross has investigated the duodenal juices to a considerable extent, and has drawn certain conclusions from a microscopical examination of them. To quote him: "The microscopic inspection of the duodenal con- tents, as gathered with the aid of aspiration in the receptacle of the instrument, enables one after a short experience to draw certain conclusions as to the part of the duodenum from which the fluid emanates. Thus, in the pars superior duodeni, the contents are more likely to resemble gastric contents, although there are already all the characteristics of the duodenal contents, such as reaction, color, and oft- times ferments (secondary stomach, 'Nachmagen')- A few centimeters lower down, but still above the caruncle (papilla of Vater) they have all the properties of pure duo- denal contents, that is, they are alkaline, limpid, viscid, fluid, light yellow to green or golden yellow; in rare cases it is even possible to obtain pure duodenal secretion, or 68 DIAGNOSTIC METHODS rather intestinal secretion, i.e., without the admixture of bile. The fluid has a lighter color, scarcely yellow. In the pars inferior, a few centimeters lower still and below the caruncle, the duodenal contents may show the same char- acteristics as above the caruncle, but when the stomach is empty in irregular and infrequent intervals, the duodenal contents will contain also a wave of the characteristic bladder contents. In normal conditions, under the stimu- lation of ingested food, the inspissated bladder bile, mixed with the now abundantly secreted liver bile, flows freely into the duodenum at the beginning of digestion, and at the opening of the so-called duodeno-choledochal sphincter. When, however, this sphincter is closed, there is an obstacle to the flow of bile, compelling it to take its course through the cysticus and gall-bladder." Our practical knowledge of the various modifications of the duodenal contents and intestinal juices is far from satisfactory, and much is yet to be learned concerning their bearing on pathologic digestive conditions. The foregoing methods of examination of the stomach and upper intestinal tracts should not be taken singly, but should be correlated in all cases where the diagnosis is doubtful. To depend on any single diagnostic feature is unsafe and unscientific. Test-meals, for instance, are of high value and furnish in many instances important diagnostic facts. To make a diagnosis, however, on the simple findings of a test-meal, without taking into consideration other symptoms sub- jective and objective, may lead the examiner into decided error. In no class of diseases are isolated symptoms more fallacious and misleading than those of the digestive system, and the reader is admonished to take advantage of every aid, both clinical and laboratory, so that the diagnoses may represent a large perspective, and the liability to incorrect conclusions may be minimized. CHAPTER III EXAMINATION OF THE FECES The intelligent examination of the feces is one of the most important aids in diagnosis of gastrointestinal con- ditions, and at the same time one of the most neglected. Apart from specialists in digestive diseases, health officers, or those engaged in laboratory investigations, the exami- nation of normal or abnormal stools is infrequent and perfunctory. The general practitioner should be familiar with the various appearances of the feces, and should also acquaint himself with the normal macroscopic and microscopic appearance. In order to form a correct judgment it is necessary that a somewhat fixed standard be formed, so that deviations from this standard may be properly interpreted. To Schmidt and Strasburger we are much indebted for painstaking studies and helpful conclusions in the examina- tion of feces, and in "The Test-diet in Intestinal Diseases" by Dr. Adolf Schmidt, which has been acceptably translated by Dr. C. D. Aaron, we have a compact and excellent pre- sentation of the subject. The requirements which must be imposed on a suitable test -diet are manifold. To quote Prof. Schmidt, "It must be so selected that it can be taken by healthy persons as well as by most of those suffering with intestinal disorders ; it must be free as possible, but not absolutely free, from waste matter, in order that the stimulus ordinarily furnished by the ingesta should not be completely absent ; it must be capable of supplying the minimum, at least, of calories required by the body (at rest), and must contain the three chief groups of food-stuffs in proportionate relation to 69 70 EXAMINATION OF THE FECES each other; finally, it must be of simple com.position, easy to make and uniformly prepared. Only when all these general requirements are fulfilled, the narrower selection with regard to the methods of subsequent fecal examination can proceed." There are certain fundamentals in a test-diet, which must not be neglected, and according to Schmidt, they are as follows: 1. A certain measure of milk (1/2 to i 1/2 liters), which, however, may be boiled entirely with the foods; 2. About 100 grm. white bread (or zwieback, cakes, etc.) ; 3. A good portion (100-250) of potato-broth; 4. One-fourth pound chopped beef, a portion, at least, of which must remain raw of half raw. These articles furnish a suitably balanced dietary, and one which can be borne by any ordinary digestive tract. The following is the detailed test-diet, as recommended by Schmidt and Strasburger: In the morning: 0.5 liter milk (or if milk does not agree, 0.5 liter cocoa, prepared from 20 grm. cocoa-powder, 10 grm. sugar, 400 grm. water, and 100 grm. milk, 50 grm. zwieback. In the forenoon: 0.5 liter oatmeal gruel, prepared from 40 grm. oatmeal, 10 grm. butter, 200 grm. milk, 300 grm. water, i egg (strained) and salt to taste. At noon: 125 grm. chopped beef (raw weight), broiled rare, with 20 grm. butter, so that the interior will remain raw. With this is given 250 grm. potato-broth, made of 190 grm. mashed potatoes, 100 grm. milk, and 10 grm, butter with some salt. In the afternoon : Same as morning. In the evening : Same as in forenoon. This diet contains i 1/2 liters milk, 100 grm. zwieback, 2 eggs, 50 grm. butter, 125 grm. beef, 190 grm. potatoes, and gruel made of 80 grm. oatmeal. It contains about no grm. albumen, 105 grm. fat, and 200 grm. carbohydrates, and furnishes a total of about 2247 calories, answer- INTESTINAL TEST-MEAL 7 1 ing the minimum requirements of an adult at rest. It may be said in this connection, however, that this diet is quite a tax upon deHcate stomachs, and often it is necessary to reduce it in general quantity. This diet should be given for three days — sometimes longer — until a stool is obtained, which with a certainty comes from it. Under normal conditions this occurs at the second defecation after the inauguration of the test- diet. There is generally no difficulty in recognizing the feces arising from this test-diet, but, if desired, a capsule containing about 5 grains of carmine may be administered at the beginning and end of the test. This sharply defines the test-stool, unless there is diarrhea, in which event it is well instead to extend the diet over a rather longer period. It will be somewhat obvious that the above test-diet, in its preparation and ingestion presents some difficulties when attempted outside of a well-ordered institution, or when attempted among individuals of a mediocre intellect. To overcome this I have made a modification of the Schmidt-Strasburger test-diet, which can be easily com- prehended and applied, not only in hospitals, but also in private homes. This, too, more nearly conforms to the American custom of three daily meals, for, to vary in many particulars the habits of the patient will create an abnormal condition of the fecal evacuations, thereby de- feating the object in view. My modified test-diet is as follows : Morning, coffee, tea or cocoa with much milk, oatmeal with milk, one soft-boiled or soft-poached egg, and one roll with much butter. Noon, bouillon, if desired, 1/4 pound of lean minced beef, roasted in butter (half raw inside), a liberal plate of baked and well-mashed Irish potatoes, tea, or tea with milk, and a roll with a liberal amount of butter. Evening, oatmeal with plenty of milk, and a little sugar, if preferred, one or two eggs cooked any desired way, except 72 EXAMINATION OF THE FECES hard-fried, or, instead of the eggs, a moderate portion of roast veal or lamb, a roll with butter, and tea or milk. A sufficiency of water should be drunk with this diet, and the patient should be encouraged to drink water liberally through the day. After the second daily defecation follows the ingestion of this test-diet, the examination of the feces may generally begin. Macroscopic. — This forms the most important part of the whole examination, if carefully and intelligently made, and alone is often sufficient to enable an experienced investigator to form a judgment of intestinal conditions. It first decides if color, consistency, and odor correspond with normal feces, due allowances being made as to color, if milk or cocoa has been ingested. The former produces light-brown stool, while the latter produces a red-brown. Other deviations through disease may be shown in black, tarry feces (blood) , or sticky, clay-colored stools (fat) . The odor under normal conditions should be mildly excrementitious, with the characteristic odor of human stools. Under pathologic conditions it may give off a rancid odor (butyric acid) or a sour odor (acetic acid), or assume the vile odor of putrefaction. In the diarrhea of pellagra the feces assume a char- acteristic odor which is almost pathognomonic. Nurses, who have had considerable experience in the care of this disease, have assured me that the diagnosis could in a majority of cases be made from the odor of the stools, even if most of the other marked symptoms were absent. There may also be noted at first inspection, gross flakes of mucus, blood-stained pus, portions of tapeworm or other parasites, undigested particles of food, streaks of unmixed blood, or any other foreign bodies. Regarding the mucus, it is important to decide whether it is thoroughly mixed with the feces, or easily separated. The former condition would point to an origin of the mucus MACROSCOPIC APPEARANCE 73 high up; the latter to its origin low down in the bowel. The same may apply to pus or blood. In the next stage of the examination the entire stool may be stirred up with a spatula, and a portion about the size of a walnut placed in a small mortar. This should be well rubbed up, and, if stiff in consistency, enough water may be added to soften it to about the consistency of sauce. The ground-up specimen is then spread upon a smooth black plate, or any smooth black background. This test-diet, if normal will appear as a soft, homogeneous -mass, with minute brown or reddish points. If abnormal, there may appear as food remains, small shreds of connective tissue and tendons from the chopped meat eaten. These can be distinguished from the mucus by their whitish yellow color and their thread-like appear- ance. If in doubt, a thread is placed under a microscope and treated with acetic acid. In connective tissue the thread-like structure disappears. Remains of muscle tissue appear as small, brown-colored rods, resembling tiny splinters of wood. These can be broken up by pressure, showing their muscular structure under the microscope. An excess of undigested muscular tissue in the feces points to disturbed intestinal digestion. The potato remains appear as glassy, transparent granules, much like granules of mucus. Under the micro- scope they will show their cellular structure, and may be colored blue with iodin. The fat remains are light in color, and clay-like in con- sistency, and if in excess may show in small, light-yellow lumps. Mucus in large amounts, or even in small, may and should be recognized. Large shreds or strips, tubes, etc., as in the presence of mucous colic, may be removed before the specimen is ground up, and their identification is easy. The smaller flakes may be harder to recognize, though Schmidt affirms that there is no form of mucus found mingled with the feces, which on thorough inspection cannot 74 EXAMINATION OF THE FECES be recognized with the naked eye — especially if some of the ground-up mass is placed on a glass plate and held up against the light. The mucus will then show as glassy, transparent flakes, occasionally colored yellow by bili- rubin, with irregular, ragged outlines. If still in doubt, the microscope can always serve as arbiter, disclosing with clearness the minute structure of the mucous-flakes. Occasionally large crystals of ammonio-magnesium phos- phate are present in putrefying and malodorous feces. They grate when the specimen is being rubbed up in the mortar, show the coffin-lid shape under the microscope, and are easily dissolved by any acids. MICROSCOPICAL EXAMINATION OF THE STOOLS For this examination care must be taken in the selection of fragments, as a random search will often disclose noth- ing. In the case of parasite eggs, etc., it is well to mix the stool with water, and allow the specimen to sediment, or to centrifugalize it. Mucous particles are to be chosen if protozoa are the objects of search. In searching for blood, for instance, it often makes much difference whether or not the right particle is taken. Epithelial Cells. — These are found in squamous form in mucus which covers the stool, and comes from the anal region. Many of these cells are generally present in cases of proctitis or rectal cancer. Cylindrical cells are the commonest found. They are easily found in the lavage water of the rectum and sigmoid, and show all grades of degeneration, from well-preserved, even goblet cells to those in which the nucleus has disappeared absolutely. This often occurs in diarrhea, and sometimes the cells are so abundant that the condition is denominated "desquama- tive catarrh." Triple phosphate crystals are generaly present, ir- regularly formed as a rule. Calcium phosphate crystals occur in the same form as in the urine. There are also PLATE I. K^atharine HiU Vegetable Cells found in Feces. (After Schmipt and Strasbueger.) MICROSCOPIC EXAMINATION 75 calcium salts of still unknown acids, which are present in irregular, oval, or circular masses, sometimes fissured, sometimes with a concentric striation, and always bile stained. The calcium soaps and oxalate are also frequently- found. Cholesterin is often present, but not in typical crystal form, requiring a chemical examination for its detection. Charcot-Leyden crystals have been noted in the feces in a Fig. 3. — Normal feces. {Landois.) a, Muscle fibers; h, tendon; c, epithelial cells; d, leucocytes, e-i, various forms of plani-cells, among which are large numbers of bacteria; between h and h are yeast-cells; k, ammonium- magnesium phosphate. great variety of diseases, but most well-posted observers claim that their presence indicates some animal parasite, though it may be any, from the harmless oxyuris to the pernicious uncinaria. Remnants of undigested food form the chief part of the picture, especially the thorn-like spines from various fruits and berries. The remains of these show in spiral cells, with the veins of leaves well defined; thick cellulose shells of various cells, some resembling soap masses, some parasite eggs; and the elastic tissue from meats. These heterogene- ous objects can be readily identified only after careful and intent practice. Experience, however, will soon enable the examiner to readily recognize all the ordinary constituents 76 EXAMINATION OF THE FECES of normal or pathologic stools, and the rarer objects gener- ally require special methods for their detection. Examination for Gall-stones in the Feces. — To find gall- stones in the feces (and a careful search may continue for fifteen days after the colic) the stools are well mixed with water, and rubbed through a sieve. Sometimes no stone Fig. 4. — Boas' stool-sieve. {Hemmeler.) is found, even when there have been typical symptoms of cholelithiasis. In such a case, it may have been infection of the bile ducts and not a stone that caused the pain; or the stone may have remained in the ampulla of Vater without entirely closing the duct ; or, after engaging in the cystic duct, it may have fallen back into the gall-bladder; or it may have disintegrated in the intestine. All these considerations should be taken into account when searching for a stone without success. The size of a gall-stone varies from that of a tiny con- GALL-STONES 77 cretion to that of a pigeon's egg. The single stones are usually spherical and rough, but when multiple, they usually have well-defined facettes. When fractured they usually show their formation in concentric layers. Gall- stones are composed chiefly of cholesterin and the calcium salt of bilirubin, with traces of calcium carbonate. For analysis the stone is dried and powdered, for unless it is powdered, the mucous coating will prevent its solution. The powder may then be dissolved in alcohol and ether, and the cholesterin crystallized out as the ether evaporates. After the cholesterin is extracted, the residue is treated in the cold with very dilute KOH solution. This will extract the bilirubin, the yellow solution of which will give Gmelin's test. The solution will be blue if bilirubin is present. Pseudo Gall-stones. — These objects have been the cause of many diagnostic errors, and many have been the mistakes in naming these deceptive concretions real gall-stones. Every suspected stone should be fractured and examined chemically. Among the deceptive pseudo gall-stones may be mentioned masses of vegetable tissue, seeds of fruits, pieces of bone, enteroliths, masses of fats, and soaps of high melting point. Olive oil won its undeserved reputation as a means of removing gall-stones from the fact that many concretions of soaps, superficially resembling gall-stones are frequently passed after ingestion of a considerable quantity of this oil. Gall-sand. — The sand-like concretions found so plenti- fully in some stools are probably not from the gall-bladder. Genuine gall-sand would be likely to disappear in the bowel, but its failure to do so would not explain the large quantities of it in the stools (Nauyn). Pancreatic stones are rarely found in the stools, and, if found, would probably occur singly. They are white and consist chiefly of calcium carbonate. Enteroliths.— By enterolith is meant an incrustation of organic salts around a body which serves as a nucleus, usually a hard particle of food or a lump of hardened feces. 78 EXAMINATION OF THE FECES They are seldom passed in the stools. Their chief impor- tance is in connection with appendicitis (Emerson). Intestinal Sand. — This condition is frequently reported, mostly in nervous patients. Intestinal sand in small gran- ules about the size of ordinary sand sometimes appears in the stools in considerable quantities, even half an ounce or more. The passage of these granules may be an incident of a nervous period, and be preceded by much pain, as in the paroxysms of mucous colic. Many of these reported cases, on investigation, have proved to be instances of pseudo sand, seeds of berries, granules from the seed case of pears, concretions of altered blood pigment or bile pigment, or concretions of medicines, as salol. In other instances the sand may be real, i.e., quartz swallowed with the food. Meyer and Cook cite a case in which the granules proved to be masses containing resin and tannin, which came from the milk cells of the banana, which the action of the diges- tive juices had given a stony hardness. Eichorst describes a condition which he calls "gravel- forming enteritis," explaining it as a secretory neurosis. Chemical analysis of true intestinal sand has shown that it contains phosphates and carbonates, especially of calcium, but also of magnesium, iron, etc.; while in some of the granules calcium sulphate predominates. Practically all of them, however, contain some organic matter, many bacteria, fat, cholesterin, and urobilin (Emerson). Emerson reports two cases of real intestinal sand. In one, a young boy ill with an indefinite nervous disorder, such large amounts of fine granules were occasionally passed that the sand was the most conspicuous constituent of the stool. The other patient, a young woman with an intes- tinal neurosis, passed many granules, which seemed to be plugs of cells impregnated with carbonates. The nature of the dead cells could not be determined. This interesting condition lacks much of complete eluci- dation, and is a worthy field for exhaustive study. INTESTINAL PARASITES 79 Tumor Fragments. — Tumor fragments or the broken- down remains of polyps or intestinal growths may appear in the stools, having their origin in the rectum, colon, or even higher up. They are so altered in their passage by the intestinal contents that they ^re extremely hard to recog- nize; and require the scrutiny of one trained in such in- vestigation to identify them satisfactorily. INTESTINAL PARASITES Ameba Dysenteriae. — This pathogenic protozoon, form- erly called Amoeba coli, is now generally admitted to be the cause of amebic dysentery, a colitis characterized by a chronic course, frequent and bloody stools, a tendency to relapse, and frequent association with abscess of the liver. ■t \' /' / Fig. 5. — Amoeba coli. (Hemmeter.) Craig and other investigators in the field of tropical medicine have identified a number of different amebae, some of which they claim to be harmless. Musgrave, how- ever, doubts that there are any non-pathogenic forms of ameba, or at least, that they may not become pathogenic. 8o EXAMINATION OF THE FECES These protozoa are found with amebic dysentery. Most of them are in the floors of ulcers which undermine the mucosa of the colon and ileum, and in the burrowing tracts which radiate from these ulcers and undermine the mucosa. They are also found in the contents and walls of the liver abscesses, which complicate this disease, and in the sputum, if the abscesses have ruptured into the lungs. The ameba dysenteriae is a rhizopod, varying in diameter from 8 to 50 microns. It has a clear hyaline ectosarc, seen best in the pseudopods, a finely granular endosarc, usually Fig. 6. — E. coli. X 1,200. Cyst showing 6 nuclei. (There are 8 in the cyst, but 2 are out of focus.) (Craig.) containing some of the parasite's ingesta (red blood-cells, leucocytes, bacteria, epithelial cells, and minute particles of food), and often one or more vacuoles, which do not pulsate. Its spherical nucleus, about 6 microns in diameter, is sometimes, especially when the ectosarc contains little foreign matter, clearly seen, but as a rule not visible in the living parasite. To demonstrate the nucleus, one kills the organism with corrosive sublimate, or stains it by appro- priate methods (Emerson). To obtain a specimen for examination, little flakes of mucus or pus should be selected, or the mucus may be secured by passing a soft catheter, or through a speculum. Preferably a saline cathartic should be previously ad- ministered, and the fluid portion of the stool examined while warm. The last precaution is quite necessary, and INTESTINAL PARASITES 8 1 various devices have been suggested to keep the stool warm. A most convenient method is to employ two tin buckets, one holding a pint, the other a quart or half gallon. The patient may use the small bucket for the stool, which may be passed either in the office or a con- venient toilet. The larger bucket is partly filled with warm water, and the small one placed in this water until the specimen is examined. The slide should also be warmed, as the amebae are not motile when cold. Fig. 7. — E. Coli. X 1,200. Vegetative form showing character of nucleus. {Craig.) The organisms in different cases of amebic dysentery do not all look alike, and there is sometimes so much difference that some observers have divided them up into quite a number of varieties. The observer must endeavor to distinguish resting amebag from degenerated or swollen epithelial cells, and for this reason, only those organisms should be called amebse which unmistakably project a pseudopod, and which are to some extent motile. Others should be discarded. The ameba dysenteriae has been found in various diar- rheal conditions, and the physician should be mindful of this. Since they were first described by Losch, they have 6 82 EXAMINATION OF THE FECES been found in the stools during typhoid fever, in acute and chronic enteritis, colitis and proctitis, in pellagra, and even in the stools of apparently healthy individuals, who suffered no intestinal disturbance. Allan, of Charlotte, has so frequently found the ameba in the stools of pellagrins, that he has argued a certain relation between the two conditions. While he has not proved his contention, it must be admitted that many pellagrins suffer from amebic dysentery, and that many cases of amebiasis also suffer from pellagra. Schaudinn and Craig have positively separated the Enta- meba coli from the Entameba histolytica, the former the so- called harmless variety, the latter the pathogenic variety causing dysentery. The problem of non-pathogenic amebae Fig. 8. — Balantidium coli. a, Nucleus; b, vacuoles; c, cytostome, with pit and peristome; d, ingested material. (Tyson after Leuckart.) is of interest to the zoologist, but the physician can more safely consider every ameba he finds in the stools as pos- sibly pathogenic and possessing present or future poten- tialities for harm. Musgrave examined 300 persons in Manila, of whom 10 1 had ameb^. Of these sixty-one had dysentery, and forty had no signs of the disease. During the next five months, however, every one of these forty developed a definite dysentery. Balantidium Coll.- — -This parasite of the colon and cecum of the hog is of importance, as humans are not infrequently EXAMINATION OF THE FECES 83 20. 30. -40. 50. 60. 70. 80. 00. 10. 120. 130. 140. ISO. I60. I70. ISO. 190. 200. Fig. 9. — Parasitic bodies, ova, and lar only. 1. Larva strongyloides intestinab"s. 2. Ovum of fasciola hepatica. 3. Ovum of tEenia nana. 4. Ovum of uncinaria duodenalis. 5. Ovum of uncinaria americana. 6. Ovum of taenia saginata. 7. Ovum of taenia solium. 8. Ovum of opisthorchis sinensis. vffi met in human feces; color approximate {Tyson.) 9. Ovum of opisthorchis felineus. 10. Ovum of cotylogonimus heterophj^es. 11. Ovum of taenia cucumerina. 12. Ovum of ascaris lumbricoides. 13. Ovum of dicrocoelium lanceatum. 14. Ovum of bothriocephalus latus. 15. Ovum of trichiuris trichiura. 16. Ovum of oxyuris vermicularis. INTESTINAL PARASITES 85 infected with it. The body is oval-shaped, the anterior end is sHghtly truncated, with a short peristome, generally funnel-shaped, and opens externally near the anterior pole. When feeding it opens out and broadens, so one can see it is a mouth which leads to a gullet, and not a simple furrow. The interior structure of this parasite consists of granular substance, and it contains a nucleus and con- tractile vacuoles. Fat and starch granules, and occasion- ally red and white corpuscles may be found within the granular substance. The posterior end is rounded, contains the anus, and particles may be observed to pass from it. This parasite can change its shape, and possesses both for- ward and rotary motion. Human infection from this para- site probably occurs most frequently through the infusorium entering its host in the encapsulated state. When hog feces are dried and pulverized, the encysted forms are scattered about and come in contact with food and drinking water, and in this way the infection easily follows. The pathogenicity of these parasites to the human has been questioned by some, but it is now fairly well conceded that they may set up a severe catarrh, which may even be fatal. Henschen claims that they may cause a catarrh, which continues after they die out. Musgrave, Strong and Klimenko have furnished the most of our present informa- tion concerning them. Ascaris Lumbricoides. — This, the ordinary "round worm, " is very common, and, according to Garrison, occurs in about 0.4 of all cases. The female is about 20 to 40 cm. long, 5 mm. thick, with a straight and conical tail. The posterior end of this parasite is bent ventrally into a hook, and terminates into two spicules. The mouth of both male and female is surrounded by three papillae, and the color is gray or a dirty reddish-brown. Though it is an in- habitant of the small intestine, and is therefore most often seen in the stools, it sometimes appears in the vomitus, generally to the great alarm and consternation of the 86 EXAMINATION OF THE FECES Fig. io. — Ascaris lumbricoides : to left, male in lateral aspect; to right, female, ventral aspect, natural size. {Tyson after Railliet.) INTESTINAL PARASITES 87 patient. In fact, there is nothing more repulsive to the average individual than the vomiting of worms. The eggs of this worm are- also found in the^stools in large o. Fig. II. — Oxyuris vermicularis : to left, female; to right, male (considerably enlarged) . A, Anus; 0, mouth; v, vulva. (Tyson after Braun.) numbers, are elliptical, are 50 to 70 microns long, and 40 to 5o^microns wide. They have an unsegmented protoplasm surrounded by a thick transparent shell, which is covered 88 EXAMINATION OF THE EECES by a thick, uneven and lumpy gelatinous envelope, usually bile-stained. In searching for this worm it is well to first give santonin, which will promote both their, death and expulsion. Oxyuris Vermicularis. — (Thread- worm ; Pin-worm; Seat- worm.) This little parasite occiirs in the rectum and colon, even as high as the cecum, where it may invade the appendix and even reach the stomach. They have been known to penetrate through the uterus and tube into Douglas' cul-de-sac. Some abscesses are thought to have been caused by their boring through the intestinal walls. They are present in perhaps 0.8 per cent, of adults. The adult male is from 3 to 5 mm. long, with its posterior end bent into a ventral hook. The female is about 10 mm. long. The worms are white in color. The eggs are 50 microns long and have a characteristic symmetry. The worm leaves the rectum to lay its eggs on the skin surround- ing the anus, and it is then that the itching occurs. The eggs when deposited already contain a fairly well-developed embryo. These eggs are seldom found in the stools, except in the mucus which may coat the stool as it passes through the rectum. The eggs will not be found by a cursory ex- amination of the skin around the anus, but it will be necessary to first scrape away the surface epithelium. They can then be observed. Cestodes. — The adult parasites live in the small intestine of man; the larval forms may be found in the muscles and other organs. The most important varieties of tapeworms found in human beings are the Taenia solium, Taenia medio- canellata, and the Bothriocephalas latus. The diagnosis can only be made by the discovery of the segments of this parasite or the eggs in the stools. The tapeworm has a scolex or head, which may live for years, even when detached from the rest of its body, an oblong neck, and detachable segments (proglottides). These segments vary in size and shape and possess the power of limited motion. The worm itself is flat and lacks INTESTINAL PARASITES 89 both mouth and intestines. It grows by alternate genera- tion through germination of a pear-shaped primary host, and remains united to the latter for a time as a colony of bandlike shape. Each segment forms a sexually active individual. The proglottides gradually increase in size as they become more distant from the head, and then diminish again toward the extremity. This worm is an hermaphrodite. On its head are four sucking disks, by which it attaches itself to the mucosa of the intestines, and by means of pores it derives its nourishment from the chyme. The older and better-developed proglottides contain many fertile eggs, which are emptied into the intestinal canal and appear in the stools. The ovum contains an embryo, which requires for its development an intermediary host. After reaching the stomach the envelop is dissolved by the gastric juice. The embryo is set free, and finds its way by the lymphatics or blood-vessels to some place (usually the muscles), where it settles. It here surrounds itself with a sac, which may later be enveloped by a calcareous deposit. In this condition it is called a cysticercus or measle. When the measle reaches the stomach of a new host it opens, and its scole enters into the small intestine, where it develops into a full-grown tapeworm. Taenia Solium. — This is the armed or pork tapeworm, is not common in America, but is rather frequent in Europe and Asia. When mature it may reach the astonishing length of 10 or 12 feet. The head of this worm is smaller than the head of a pin, spherical, and provided with four sucking disks, in the middle of which is the rostellum and a double row of hooklets, from twenty-four to twenty-six in number, and from these bristling hooklets it derives its name. The neck is narrow and slender and nearly an inch long. The body is divided into segments, possessing both male and female generative organs, and at about the four hundred and fiftieth they become mature and contain ripe ova. The segments are about i cm. long and about 7 or QO EXAMINATION OP THE FECES 8 mm. wide. The worm attains its full growth in three to four months, about which time the segments begin to shed and appear in the stools. The uterus forms a straight median tube in each segment, giving off five to seven branches on each side. The eggs are rounded and covered with a thick shell. Occasionally the cysticerci (measles) are found in man, either in the muscles, brain, or skin. Fig. 12. — Head and neck, and ovum X300, of tenia solium. Embryophore surrounded by vitellus. {Tyson after Gould.) When found in the muscles, they produce pain, numb- ness, weakness, and symptoms resembling peripheral neu- ritis. In the ventricles of the brain, they cause irritative symptoms, and may produce death. Taenia Saginata. — This is the unarmed beef tapeworm, and is seen in America as well as Europe and Asia. It is longer, thicker, and wider than the armed variety, and may grow as long as 20 feet. The head measures over 2 mm. in breadth, has four large sucking disks, but no hooklets. The ripe segments are about 18 mm. in length, and 8 or 10 in breadth. The uterus consists of a median stem, with from twenty to thirty-five lateral branches. The ova are large, and the shell thicker than those of the armed worm, but the difference is not striking enough to make it easy to discriminate between the two. The measles occur in beef, INTESTINAL PARASITES 91 being smaller than the Taenia solium. This parasite is acquired in man by the eating of raw beef. Bothriocephalus Latus. — This tapeworm is found in certain districts bordering on the Baltic Sea, in Holland, Switzerland, and Japan. The very few cases found in the United States are believed to have been imported. This tapeworm is the longest of the varieties, measuring from 25 to 30 feet, or even more in rare instances. The Fig. 13. — Head and neck of taenia saginata: A, retracted: B, -extended. {Tyson after Gould.) Fig. 14. — Bothriocephalus latus. {Tyson after Leuckart.) head is elongated, almond-shaped, is about 2 mm. long and I mm. broad. It has no hooklets. The neck is narrow and^^short, about 2 cm. long, and passes at once into the body segment. The body is thin and flat. The full- grown proglottides are nearly square, and show the sexual organs in the center. The uterus shows a median dark line, with four to six lateral branches, resembling a star or 92 EXAMINATION OF THE FECES rosette. The eggs are oval and round, with a thin mem- brane and a lid. The larvse of this parasite develop in the peritoneum and muscles of pike especially, and of other Fig. 15. — Taenia nana: X 10. {Tyson after Gould.) fish, as perch or trout. Infection occurs from eating raw or insufficiently cooked fish. Echinococci are the larvse of the Taenia echinococcus of the dog. This is a tiny cestode 4 or 5 mm. long, consisting of three or four segments, of which the terminal one alone Fig. 16. — Tasnja echinococcus. {Tyson ajter Coplin and Bevan.) a, Adult; b, head from echinococcus cyst. On left a detached hooklet, as seen in fluid from cyst. is mature. The head is small, provided with four sucking disks, and a rostellum with a double row of hooklets. When these parasites are taken into the body with food or in any other manner, cysts develop in various parts of the INTESTINAL PARASITES 93 human organism, as in the Hver or muscles. These cysts contain scolices, the head of the taenia presenting four sucking disks and a circle of hooklets. These cysts have been passed from the rectum. This malady is common in Iceland, rather frequent in Europe, and rare in the United States. It is commonly written of as Echinococcus Disease. Tricocephalus Dispar (Whip -worm). — This parasite is found in the cecum and large intestine of man. It measures from 4 to 5 cm. long, the male being somewhat smaller than the female. It is easily recognized by the peculiar differ- ences between the anterior and posterior portions. The anterior forms three-fifths of the body, is thin and hair-like, while the tail end of the female is more conical and thicker, terminating in a blunt extremity. The tail end of the male is rolled somewhat like a spring. The number of these worms is variable, as many as a thousand having been counted, while sometimes only ten or fifteen are found. In some parts of Europe they are very common, but are rare in the United States. Occa- sionally profound symptoms of diarrhea and anemia have accompanied their presence, but often no symptoms appear, though many may be present. Trichina Spiralis (Trichiniasis). — The trichina in its adult form lives in the small intestine. The embryos pass from the intestines, and reach the voluntary muscles, where they become encapsulated larvae. The history of trichiniasis is interesting. In 1822 Tiedemann described the ovoid cysts in the human muscle. Later Owen named it. In 1845 Leidy described it in the pig. In i860 Zenker discovered in a young girl both the intestinal and muscle forms, and satisfactorily estab- lished their connection with the specific symptoms. The proper understanding of this parasite is most important. Man is infected with it by eating the raw or partly cooked flesh of trichinous hogs, which contain the encapsulated trichinae. These capsules are digested in the stomach, and the trichinae set free. They then pass into 94 EXAMINATION OF THE FECES Fig. 17. — Trichinella spiralis. {Tyson after Braun.) a, Gravid female "intestinal trichiura;" C, embryos; G, vulva; Ov, ovary;, 6, adult male, "intestinal trichiura;" T, testicles; C, young larva; (^, larva in musculature; e, encapsulated larva in muscle. INTESTINAL PARASITES 95 the small intestine, and about the third day become sexually mature. By the sixth or seventh day the embryos are fully developed. The young produced by each female trichina have been estimated at several hundred. The female worm penetrates the intestinal wall, and the embryos are probably discharged directly into the lymph-spaces, and thence into the venous system, whence they reach the muscles; and in about two weeks they develop into the full-grown muscle form. A myositis is then caused by their irritation, and they may become encapsulated. The trichinae may live in these cysts for many years, and they may be surrounded by a calcareous deposit. In the hog the capsule does not readily become calcified, so that the trichi- nae are not as readily visible as in man ; besides, an apparently healthy animal may be suffering from the presence of the trichina. The intestinal trichinae are visible to the naked eye — white glistening worms 4 or 5 mm. long. The male is half this size, with two little projections from the hind end. The caudal extremity is thicker than the head. The muscle trichina is only about 0.6 mm. long and coiled in the capsule, with a pointed head and rounded tail. Theodore Janeway and one or two others have demonstrated the Trichinella spiralis in the human blood, and Packard re- ports finding an embryo in the blood of a patient, and a short time later larger embryos were 'found in the muscle, not yet encysted. Strongyloides Intestinalis (Anguillula stercoralis et in- testinalis; Leptodera stercoralis et intestinalis; Rhab- domena strongyloides). — This is a small nematode worm found in the feces. It is frequent in the tropics and warm countries in cases of endemic diarrhea, and is occasionally found in this country. Thayer reports three cases from Osier's clinic. The adult female resembles a filaria, and measures about 2 mm. long and 35 microns wide. The body increases slightly and gradually in size from the head to the posterior 96 EXAMINATION OF THE FECES quarter, and then terminates suddenly in a short tail. The male is slightly smaller. These worms are abundant in the duodenum, fewer in the jejunum. The adult worms are seldom found in the stools. Fig. i8. — Strongyloides intestinalis; on the left, a gravid female from human intestine (natural size 2.5 mm.). In the middle, a rhabditiform larva from fresh fecal matter, X 120; to the right, a filariform larva from culture, X 120. {Tyson after Braun.) The rhabditiform larvae of this parasite found in the stools are quite active, and the best way to find them is to make a depression in the fecal mass, fill it with water, place the stool then in a thermostat or thermos bottle,_and INTESTINAL PARASITES 97 examine the water next day for the eel-hke worms. The eggs do occur, but rarely, and are extremely hard to distinguish from the Uncinaria duodenalis. Trematodes (Fluke Worms; Distomiasis). — Flukes are found in the lungs, liver, small intestine, and in the blood. ^ / / . / ^ Fig. 19. — Fasciolopsis buski. {Tyson after Braun.) a, Ora sucker; h, acetabulum; c, cirrus pouch; d, vitelline glands; e, "shell gland;" / and g, posterior and anterior testicles; h, ovary; i, cecum; k, uterus. They are solid worms of a leaf or tongue shape, possessing a clinging apparatus in the form of oral and ventral sucking cups, which vary in number. Sometimes they have a hook-like projection. The intestinal canal of this parasite 7 98 EXAMINATION OF THE EECES is without an anus and split like a fork. They are generally hermaphroditic. Flukes have been reported and carefully studied in the far East, especially in China, Japan, and India. Houghton reported that 8 per cent, of all male patients admitted to the Fig. 20. — Showing the sexual glands of fasciola hepatica; 5X1. {Tyson after Braun.) O, Oral sucker; D, intestinal ceca; Do, vitelline glands; Dr, ovary; Ov, uterine canal; T, testicles; Sq, "shell gland;" V, transverse vitelline duct; Gp, genital pore; S, ventral sucker. Wuhu General Hospital, Anhui, during one year were in- fected. Nearly all these patients were farmers and boatmen. Wellrmarked cases of this infection show enlarged liver and spleen, cachexia, eosinophilia, ascites, greatly ex- aggerated knee-jerks, and bloody stools. The leucocyte INTESTINAL PARASITES 99 count is not increased, but varies from 2000 to 8500 per cubic millimeter. The ova may be found in the blood, but they are noted mostly in the stools, although they are found with some Fig. 21. — Copula tory bursa of Necator americanus, showing the deep cleft dividing the branches of the dorsal ray and the bipartite tips of the branches; also showing the fusion of the spicules to terminate in a single barb. Scale i/io mm. {Stitt.) lb, Branches of dorsal ray magnified; 2a, the buccal capsule of N. americanus; 2b, the same magnified; 3a, copulatory bursa of Anchylostoma duodenale, showing shallow clefts between branches of the dorsal ray and the tridigitate terminations, spicules hair-like; 36, the dorsal ray magnified; 4a, the buccal capsule of A. duodenale, showing the much larger mouth opening and the prominent hook-like ventral teeth; ^h, the same magnified; 50, egg of N. americanus; 56, egg of A. duodenale; 6a, rhabditiform larva of strongyloides as seen in fresh feces. 6b, rhabditiform larva of hookworm in feces eight to twelve hours after passage of stool. difficulty. In size they resemble the ova of the Ascaris lumbricoides, for which, under the low power, they may be easily mistaken. The latter ova, however, are much more refractile, and, since their envelops are sticky, lOO EXAMINATION OF THE FECES gather debris in the stool and leucocytes in the blood. In the fresh stool the embryo in the egg is quiescent and shaped like a melon seed; later there is motion of the cilia. The free-swimming miracidium is seen only after the stool has stood about ten hours. It can be kept alive in water for four or five days. Among others in the trematode class may be mentioned the Fasciolopsis buski, found so far only in the far East ; the Distomum lanceolatum, a very rare parasite which hatches Fig. 22.— Tail, with expanded bursa, of male Necator americanus. {Tyson and Fussell.) only on the intestine of some intermediary host, perhaps the slug, and has been found in the intestines and biliary ducts of European and American domestic animals; the Fasciola hepatica, or liver fluke, a widely spread parasite inhabiting the bile ducts of some herbivorous mammals. These are so frequently found, that their history and detailed descrip- tion may be left to special works on parasites. Uncinaria Duodenalis; Uncinaria Americana; Hook- worm. History. — The history of our knowledge of this important parasite is most interesting. As has so often been found, where parasites of this class are concerned, members of the genus were first discovered in the lower animals, the worm being by no means confined to man. A German clergyman, by the name of Goeze, in 1792 was the first to describe it, his observations having been made on the particular species of hookworm that inhabits the UNCINARIA AMERICANA lOI intestinal tract of the badger. Seven years later Froelich discovered a somewhat similar worm in the intestinal tract of the fox, and gave to the parasite our present appellation "hookworm," being the literal translation of the German "Haakenworm." He it was who also originated the name, "Uncinaria," this being the zoological name for the genus in which this worm is still included by most writers. This worm was first observed as a human parasite in 1838 by an Italian named Dubini, and six years later he de- scribed it by the name of Anchylostoma duodenale. Ten years later both Bilharz and Griesinger proved that the profound anemia so common in northern Africa, and known as "Egyptian chlorosis" was certainly produced by this parasite. In 1878 it was shown that laborers working on the St. Gotthardt tunnel were almost all infected with the worm, and Perrocito, who discovered this, also demon- strated that the disease prevailed in the mountains of northern Italy, and was called "Mountain anemia" or "Mine anemia." Following these observations, investigators from different parts of the world began to report this worm with great frequency, and at present it is known to be prevalent in every part of the globe where climate conditions favor its development. Writings of many American physicians show beyond question that hookworm disease, the victims of which were called "dirt eaters," has prevailed in this country for at least a hundred years, and no doubt it has existed ever since the importation of slaves began. Notwithstanding this, the true nature and cause of the trouble was not recognized until recent years, and the first case of hook- worm disease, where the diagnosis was definitely estab- lished, was reported by Blickhahn in 1893. In 1902 Stiles showed that the parasite as found in America differed in some minor particulars from those found in Egypt and southern Europe, and he gave to what was supposed to be our new- world species of the worm the name of Uncinaria Ameri- I02 EXAMINATION OF THE FECES cana. At that time it was also sometimes called ' ' Necator Americanus," or the American murderer. The hookworm belongs to the order of nematodes or round worms, being related to and much resembling the small "pin worm" which is well known. On careful examination, however, the two present marked differences, which may be detected with the naked eye by one well acquainted with their peculiarities. Microscopically they differ still more. Like the pin-worm, the hookworm is small, being in the case of the female about 1/2 inch long, and about the width of an ordinary hat pin; the male is slightly smaller than the female. In the fresh state the worm is often of a pinkish gray; after death, however, it assumes a dull grayish tint. Unlike the pin- worm, this parasite is not found, except in rare instances, in the feces, and its presence in the stools plays no part in making the diagnosis of the disease. Like many other diseases or infections, while the symp- toms may point with almost a certainty to the presence of these worms in an individual, the only way to be absolutely sure is to examine the feces for the eggs. This examina- tion is a simple one, requiring only a glass slide upon which to spread the specimen of feces and a low-power microscope. As the eggs are, as a rule, very numerous, the diagnosis can usually be made quickly, although in some instances, where the number of worms is small, the finding requires a more careful study. The eggs are found in the stools either unsegmented or during the early stages of segmentation. They have a clear thin shell. While the yolk will show all stages of segmentation, it is rare to find eggs with an undivided yolk, those divided into four, eight, sixteen, or more segments being the most common. The eggs should be searched for in the feces by mixing a small amount with a drop of water on a slide. The older the feces and the warmer the weather, the more advanced will be the segmentation. To find eggs in stools, where they are not numerous, it is EXAMINATION FOR UNCINARIA IO3 well to follow the suggestions of Dock and Bass. The stool is diluted with about ten volumes of water, is strained through two or three layers of gauze in a funnel, and is then centrifugaUzed until the sediment is thrown down. The supernatant fluid is poured off, more water is added, the tube is well shaken, and the stool again centrifugaUzed. Since hookworm eggs stick to glass in a pecuHar way, a drop of the sediment is put on a glass sHde, and the sHde is gently immersed in water, which will wash off much of the sedi- ment, while the eggs will stick to the glass. Another drop of the sediment is then put on the same spot, and the immersion repeated. This being repeated several times, the eggs will be easily observed, if any are present. The disadvantage of this procedure lies in the fact that other varieties of eggs, which might be in the specimen are lost. The adult hookworms may be found in the sedimented stool after a small dose of thymol followed by oil. The adults are usually red from the blood with which they are filled. They abound in the duodenum, ileum, and jejunum, sometimes many thousands in one person, though in most instances, only a few hundred. While they do not multiply in the intestines, they may live there for years, and the clinical symptoms are not a fair criterion as to the number infesting the intestinal tract of any individual. Larvae of flies are sometimes present in stools. This oc- curs when the patients evacuate their bowels in exposed places, where the flies can deposit their eggs on or just inside the anal orifice. These larvce are sometimes passed in astonishing quantities, generally to the great consterna- tion of the patient. Their identification should present no special difficulty, and, should there be any doubt, if some of the larv£e together with a small amount of feces, are kept in a vessel over which is thrown netting or cheese- cloth, so that air may freely enter; and if this is kept in a warm place for several days, the flies will hatch out, and their particular variety be known. Plant Parasites. — Various yeasts are often present in I04 EXAMINATION OF THE FECES normal stools, though moulds are rare. Blastomycetes have been found in the stools of patients with systemic infection with this parasite. The Oidium albicans has occasionally been found in children. Sarcinse are fre- quently found in cases of dilated stomach, especially where the hydrochloric acid is deficient. When present in large numbers, they may aggravate a diarrhea by the products of their fermenting processes. Microorganisms. — These form a large portion of the stool, most of them being dead. Almost any organism may appear accidentally in the feces, but there is a flora of bacteria so constantly found, that their presence may be considered normal. Among the most important are the Bacillus coli, Bacillus lactis aerogenes, Bacillus bifidus. Bacillus aerogenes capsulatus (gas-forming), and Bacillus putrificus. The Bacillus coli is of importance in reference to the indolic type, and some observers are disposed to accord this bacillus a wide range of activity in the etiology of various diseases. The Bacillus ^rogenes capsulatus is concerned in the saccharobutyric type of intestinal putrefaction. The Bacillus lactis aerogenes causes fermentation of milk and the production of lactic acid. These lactic-acid- producing bacilli are held to be antagonistic to putrefactive changes and much investigation has been entered into under this assumption. To even partly "sterilize" the intestinal tract, however, seems rather chimerical to most individuals. The Bacillus bifidus appears to be a normal inhabitant of the nursing infant, disappearing soon after the child is weaned. When it persists, its presence would seem to be associated with certain symptoms of intestinal intoxication. Its most characteristic shape is like the letter Y, hence its name. Involution forms are most common. The greatest interest attached to this organism is that it is one of the few intestinal organisms which is not discolored by the Gram method. It is a strict an^robe. There might be mentioned also the Bacillus pyocyaneus, MICROORGANISMS IN THE FECES I05 Bacillus tetani, the Staphylococcus group, and many of the thermophilic and acidophilic organisms, but a detailed de- scription would be superfluous in a work of this character. It may be stated, however, that the present opinion is that the lower bowel, at least, is not a favorable habitat for living organisms, and that most of them found in the stool are dead. Tubercle Bacilli. — In searching for these it is not neces- sary to digest a solid stool. Mucous masses should be selected, especially the blood-stained or puriilent particles, and these treated as sputum. In intestinal tuberculosis, the bacilli are often present; still in many cases of un- doubted presence of this disease none are found. Probably many are destroyed before their exit with the stools, especially when there is much fermentation going on in the intestinal tract. When found, their origin from swallowed sputum must be considered, and the diagnosis of tuberculo- sis in children has been made this way. Page's method, as cited by Emerson, is to suspend a piece of the solid stool half the size of a pea in 1.5 c.c. of distilled water, add 54 c.c. of a mixture of equal parts of absolute alcohol and ether, and centrifugalize for ten minutes ; a smear made of sediment is fixed to the slide with a drop of egg-albumen, and stained as usual. Bacillus Typhosus. — In typhoid fever is seen the "pea- soup" stools, copious in quantity, watery, of a foul odor, alkaline in reaction, with many triple phosphates. In some patients limited to a milk diet, diarrhea is less common, and in occasional cases, constipation is present. When the stool is blood-tinged, it sometimes presages a hemorrhage, though this is not a sure indication. ■ Pus is rare in typhoid stools, unless in the presence of severe ulceration. To grow this bacillus from stools a special medium is required, and for a detailed description of the preparation of this medium, the reader is referred to special works on clinical diagnosis. One method, as shown by Peabody and io6 EXAMINATION OF THE FECES Pratt, is to first use Malachite-green bouillon as an en- riching medium. (The beef bouillon they used contained I : looo malachite green, and had an acidity of 0.5 per cent, to phenolphthalein, but the amount of dye and acidity must be determined for each preparation of the malachite green used.) While this completely inhibits the growth of Bacillus coli. Bacillus typhosus will often grow luxuriantly in it, although the dye does exercise some restraint over this organism. Tubes containing 15 c.c. of this medium are Fig. 23. — Bacillus typhosus, stained to show flagella. {Oertel after Frankel and Fjeiffer.) inoculated with one drop of the fluid stool or suspension of the stool, and are left in the thermostat eighteen to twenty- four hours, and then one drop of the culture is rubbed over the surface of a Drigalski-Conradi plate. While the positive indent ification of the Bacillus typhosus is both useful and interesting, I may be pardoned for re- marking that there are several other methods of diagnosis in this disease which are as satisfactory clinically, and are both easier and quicker. Spirillum Cholerae Asiaticae. — This is a small, curved, "comma-shaped" bacillus. It is actively motile, and has a single long delicate flagellum at one end. It does not MICROORGANISMS IN THE FECES I07 produce spores, and involution forms are common. It stains readily in all bacterial stains, and is decolored by the Gram method. It grows rapidly at ordinary room temperature on all commonly used media, in fact on some media too poor for other organisms to grow upon. It will not grow on potato at room temperature, but will in a thermostat. It is actively aerobic. It grows in a charac- teristic manner on gelatin which it liquefies, and on the gelatin plates the colonies soon appear as minute white Fig. 24. — Cholera spirilla. {PUfield.) points, resembling fragments of broken ground glass with granular irregular margins. After Hquefaction begins, the colony sinks into the little cup of liquid cloudy gelatin which surrounds it as a halo. This organism produces much indol and is sensitive to acids. The stools in severe Asiatic cholera are quite character- istic. They are copious, ejactdated from the bowel with but little effort, and the water in them, which in the main is secreted by the intestinal wall, is dotted with gray flecks, these flecks consisting of masses of epitheUal cells, cholera spirilla and fat droplets. They have but Httle fecal odor, are alkaline, sometimes blood-stained, and contain little albumen and much salt. Io8 EXAMINATION OF THE FECES There are many other spirilla, pathogenic and non- pathogenic, but their identification and differentiation require special study and equipment. Some of them can only be recognized by a specific test of inoculation of a guinea-pig or other animal. Cholera nostras gives rise to a profuse diarrhea not unlike the Asiatic variety, and in times of epidemic, it may be hard indeed to distinguish between the two. The true diagnosis of Asiatic cholera may be generally made directly from the stools, but during epidemics of this disease all severe diarrheal maladies should be regarded with extreme suspicion, whether or not any pathogenic organisms may be found in the feces. The Dysentery Bacillus (Shiga's Bacillus). — This in shape and in some of its cultural characteristics resembles the Bacillus typhosus. It is a short organism with rounded ends, is non-motile, and is inclined to involution forms. This organism stains readily in the commonly used aniline dyes, showing a tendency to polar staining, and is de- colorized by Gram's method. This organism, and others in its closely related class, which have been identified by His, Flexner, Harris and others, are the cause of "bacillary" dysentery, which may occur sporadically or in severe epidemics. This form of dysentery may begin as an acute gastroenteritis with a diarrhea, which increases in severity until the stools lose their fecal character, are frequent, scanty, and painful, and contain chiefly mucus and blood and numerous organisms of dysentery. In recognizing these organisms the agglutination tests are most important. The blood serum of a patient infected with an organism belonging to the Flexner-Harris type will agglutinate the pure culture of this organism in dilu- tions of I : looo. In the Shiga bacillus, agglutination is less complete. The physician will find that time, thought and patience in the field of investigation of feces will be well spent. This EXAMINATION OF THE FECES lOQ is in many respects a fallow field, and, as research work in it proceeds, many and valuable will be the disclosures. A test-meal from the stomach represents the normal or abnormal activities of only a small portion of the alimen- tary tract. The feces in many ways constitute an index of the workings of the whole alimentary tract, and when rightly read present a picture of the highest possible diagnostic value. CHAPTER IV EXAMINATION OF THE ESOPHAGUS, STOMACH AND INTESTINES BY THE ROENTGEN RAY Perhaps no discovery of recent times has so advanced human knowledge concerning the intimate appearance and workings of the abdominal viscera as the Roentgen or X-ray. Especially in obscure conditions of these organs has this ray come to our aid, and, where formerly it was necessary to perform an exploratory laparotomy to clear up an uncertain diagnosis, the Roentgen ray now, in many instances, points out the real pathologic condition with unerring precision. Furthermore, in no department of X-ray diagnosis have such rapid advances been made as in the examination of the abdominal organs. The ordinary classical methods of physical examination have long ago penetrated the darkness of the lungs and chest, but the abdomen has been a terra incognita in many respects, till these rays enabled us to pierce its most hidden recesses. On the other hand, however, this method requires spe- cial and expensive apparatus, expert technic, and trained judgment; there is connected with it some danger, unless proper precautions are taken, and, except where employed in hospitals or special institutions, it is quite an expensive procedure, beyond the means of individuals in ordinary circumstances. These disadvantages will probably disap- pear in the course of time. The X-ray is most useful in deciding whether or not an operation is advisable, and, while many early cases of malig- nant disease have been diagnosed and relieved, many also have been spared the misfortune of needless operations. In the diagnosis of diseased states of the esophagus, the X-ray has been partly considered. In the diagnosis of EXAMINATION OF ESOPHAGES III diverticula, or the early diagnosis of cancer of the gullet, it is invaluable. The appearance of the coursing of the bismuth and milk down this passage has been described, and any tortuous channels leading off from the esophagus are easily observed through the fluoroscope. One difficulty in forming a correct idea of the size of any possible sacculation in the esophagus has been in the rapidity with which the contents pass through into the stomach. In the normal individual, where there is no marked constriction either in the lumen of the passage or at the cardia, fluids reach the cardiac end of the gullet in from five to ten seconds and solids in about twice that length of time. To obviate this quick emptying, it is necessary, in order to obtain a sharply defined outline of the esophageal walls, to plug in some way the lower end of the tube. The best and most practicable method of accomplishing this has been devised by Bassler, and described by him in the Journal of the American Medical Association, April 26, 1913- For this purpose he uses a simple device made by Tiemann and Company, which may be described as follows: To a 120 cm. (4-foot) length of rubber tubing 4 mm. in diameter, is attached a rubber bag covered with a reinforcement of silk, and having a brass tip at its lower end to give it weight. At the upper end of the tube is a cock. An ordinary surgical syringe of about 2 -ounce capacity containing water is used to distend the bag, which, when distended is fusiform in shape, and measures about 10 cm. in its circumference. The tube is lubricated with glycerin and passed in the usual manner of a stomach-tube. Xt is allowed to go down to beyond a mark made on the tube, about 16 inches from the upper end of the bag. After the bag is in the stomach, it is filled with water by means of the syringe. This being done, the cock is closed, and the tube firmly pulled so that the elastic bag of water is drawn 112 EXAMINATION OP THE ESOPHAGUS tightly into the funnel-shaped cardiac orifice of the stomach. The patient is now told to exhale completely so as to raise the dome of the diaphragm to a high level, and the external tube held tightly at this point. It is then fastened about the forehead or around the neck of the patient with a secure knot. Sometimes an external weight is preferable to hold the bag up against the cardia, and weight of 1/2 to i pound is generally sufficient. There being a silk string inside the tube, there is no danger of its breaking. The cardiac orifice being occluded, a mixture of bismuth, acacia and water is run into the esophagus from an irrigating jar by means of an ordinary urethral catheter, a rather large one being best. About 150 c.c. of the bismuth suspension are placed in the irrigating jar, and allowed to flow in until the bismuth mixture appears in the mouth, showing that the gullet is filled. With the patient standing, radiographs are then taken in the lateral dorsal position, with the left back to the plate. Such plates show the outline of the esophagus with any changes present. By this means of examination, irregularities of the walls can be observed, and it is possible to make a diagnosis of carcinoma of the gullet long before any stenosis appears. After the plates are taken, the tube is allowed to relax so the bismuth will flow into the stomach, the cock is opened, and a slight upward tension causes the water to flow out of the bag either by pressure or siphonage, and the ap- paratus is then withdrawn from the esophagus. This method is not practicable when stenosis is present. In 1904 Rieder devised the bismuth meal, in which bismuth was given mixed with milk, oatmeal or any other pultaceous substance. This was followed by the bismuth suspension in and sedimentation by Holzknecht; after this came the double meal by Haudek, and the dis- covery of antiperistalsis by Jonas. At present barium sulphate has almost superseded bismuth, as it not only gives a more homogeneous appearance of the EXAMINATION BY THE ROENTGEN RAY "3 ^P" n 1 A V 1" j ^B 1 ^ H V H M; Jl |y 1 Fig. 25. — Stricture of esophagus from drinking acetic acid. Patient of Dr. Niles. {Dr. John S. Derr.) A, Esophagus; B, stricture; C, heart shadows. EXAMINATION OF THE STOMACH "5 Fig. 26. — Gastric carcinoma. A, Gas in fundus; B, marked involvement by new growth of the lesser curva- ture and pars pylorica; C, metastases in the outer part of the body of the stomach; D, duodenum; E, bismuth in the small intestine; F, gas in the splenic flexureof the colon. Diagnosis proven by operation in St. Luke's Hospital. Markers at the ensiform and umbilicus. (Made in the X-ray laboratory of Dr. Anthony Bassler, New York City.) EXAMINATION OF THE STOMACH II7 mass in the stomach, but interferes less with the motiHty of that organ. The double test-meal is given as follows : the patient takes the first bismuth meal at 7 a. m. Six hours later, i p. m., he presents himself at the office of the radiographer. A glance through the radioscope suffices to show the amount and shape of the bismuth residue, and give an idea of the most important point in the diagnosis — viz., the motility of the stomach. If the stomach be empty, a good idea of the motility both of the stomach and the intestines may be gained by observing the position of the bismuth head and tail in the colon. The patient then takes the second bismuth meal, consist- ing of a heavy suspension of bismuth carbonate in water. The second meal defines the shape, size and position of the organ, and completes the Roentgen diagnosis. Dr. Guido Holznecht, of Vienna, has recently furnished a very complete study of the significance of different symp- tom complexes, as disclosed by X-ray examination, and published in Archives of the Roentgen Ray. Acknowledg- ments are made to him for these groupings. Symptom-Complex I. 1. Bismuth residue after six hours. 2. Normal stomach shadow in the screen. 3. Achylia. Diagnosis. — Small carcinoma of the pylorus. This symptom group is almost always associated with stenosis of the pylorus due to a small carcinoma. There is stagnation and loss of tone, as evidenced by the bismuth residue, which may be a small one. The patient may suffer from little or no disturbance, except loss of appetite, and slight malaise. This diagnosis is made more plain, when we remember that, unless there is stenosis, in the presence of achylia there is generally hypermotility, and the stomach would empty itself in two or three hours. Ordinary atonic delay of gastric evacuation never lasts as long as six hours, and the cause must be either stenosis or spasm of the Il8 EXAMINATION OF THE STOMACH pylorus. Pylorospasm is never associated with achylia, but with hyperacidity. The above is not a mere empirical symptom- complex, but a logical one, and a decided advance in the early diagno- sis of carcinoma. Although the recognition of the achylia required the use of a test-meal and a stomach-tube, the clear conception of the stenosis and the accompanying circumstances could not have been reached so surely in any other manner. The radiological examination also shows that the new growth is small and operable, since otherwise there would be some defect in shape or extent of the bismuth shadow. Diffuse contracting carcinoma, or deep circumscribed scirrhus would also show symptoms of achylia and loss of motility. This, however, would not give a normal gastric picture, but one showing shrinkage and defective filling. Symptom-complex I (A). 1. Bismuth residue after six hours. 2. Normal shadow of the stomach. 3. Schwarz's fibrodermic capsule intact after five hours. Diagnosis. — Small carcinoma of the pylorus. Symptom-complex I (B). 1. Bismuth residue in stomach after six hours, 2 . Head of the bismuth column in hepatic flexure. 3. Normal stomach shadow. Diagnosis. — Small carcinoma of the pylorus. The examination of the stomach for such a symptom group as the above is much more practicable when the "double bismuth meal " is taken. The patient should take a Rieder meal at 7 a. m., and should see the radiographer at I p. m. A previous test-meal has shown achylia. At a glance it is observed that there is a residue in the stomach, and that the head of the bismuth column is in the splenic ilexiu"e. Carcinoma is at once suspected. The second Rieder meal is now given, an aqueous suspension of bismuth. The form, position, size, and evacuation of the EXAMINATION OF THE STOMACH 119 Fig. 27. — Carcinoma near the cardia. Patient of Dr. Niles. {Skiagraph by Dr. John S. Derr.) A, Roughening caused by malignancy of growth; C and D, peristaltic contrac- tions; B, normal cap. Marker at umbilicus. EXAMINATION OF THE STOMACH 121 Fig. 28. — Horn-shaped contracted stomach. Inoperable carcinoma. Patient of Dr. Willis Jones. {Skiagraph by Dr. John S. Derr.) A, Antrum almost obliterated by tumor; marker at umbilicus. EXAMINATION OF THE STOMACH 1 23 stomach are shown to be normal, and the radiological examination of the stomach is complete. This symptom-complex might apply to an old callous ulcer with achylia, the latter being due to alteration in the mucous membrane, and the loss of motility to invasion of the pylorus. Such a case, however, would show a snail- shaped stomach with transverse and longitudinal contrac- tions, and displacement of the pylorus to the left. Symptom -complex II. 1. No residue after six hours. 2. Marked defect in gastric shadow. 3. Horn-shaped stomach. Diagnosis.- — Carcinoma. No stenosis. Inoperable. Patients with such a picture may show no clinical symp- toms, except anorexia and loss of weight, but derive little or no benefit from gastroenterostomy. The marked defect in the gastric shadow shows clearly the presence of a tumor, but this tumor is inoperable. Haudek has shown that when the stomach has lost its hook form from contraction, and has attained the horn form, it is no longer capable of complete resection. This form of the stomach can only be due to one of two causes — hypertonicity or shrinkage. The first is ruled out by the nature of the case, since the tone of the stomach walls would be impaired by the commencing cachexia. When the palpable tumor is small, we may be sure there is something else behind, and that the shrinkage is due to some widespread infiltration, which renders the resection inadvisable. On the other hand, when the stomach retains its ordinary physiologic hook form, we may with propriety consider the case to be operable. This radiological conclusion is logical and of importance. Symptom-complex III. 1. No residue after six hours. 2 . Marked defect in the shadow in the pars media or pars pylorica. 3. Hook-shaped stomach. Diagnosis. — Carcinoma of the stomach. Operable. 124 EXAMINATION OF THE STOMACH Symptom -Complex IV. 1. Small residue after six hours. 2. Sensitive pressure-point over the stomach. 3. Normal stomach shadow. Diagnosis. — Simple gastric ulcer. This, in addition to a previous test-meal, showing either marked acidity or the presence of occult blood, makes the diagnosis fairly certain. In all cases of gastric ulcer there is a certain impairment of the motility. Haudek has never found an ulcer of the stomach without this delay in the evacuation of this organ, and no case of pyloric spasm with- out some lesion of the stomach wall. As regards the pressure-point, it is not enough to merely find a sensitive point somewhere in the epigastrium. The radiograph should show that the pressure-point falls on the lesser curvature of the stomach where an ulcer is most frequently situated, and that it moves with the stomach by pressure or indrawing of the abdominal walls (Jonas). Diagnosis of gastric ulcer by means of the X-ray, will be more fully considered later in the chapter. Symptom-complex V. 1. Small bismuth residue after six hours. 2. Pressure-point. 3. Displacement upward and to the left. 4. Snail form of the stomach shadov/. Diagnosis. — Old contracting ulcer on the lesser curvature of the pars pylorica. Symptom -complex VI. 1. Small bismuth residue after six hours. 2. Pressure-point and resistance in the pars media. 3. Transverse contraction of the pars media. 4. Diverticulum without air bubble in the smaller curvature, immovable. Diagnosis. — Callous ulcer of the pars media. Even where a sensitive pressure-point is absent, the com- bination, hyperacidity, with a small residue after six hours, EXAMINATION OF THE STOMACH 125 Fig. 29. — Gastric ulcer (chronic non-indurated). Diagnosis proven by operation in New York Polyclinic Hospital. Markers at the ensiform and um- bilicus. {Made in X-ray laboratory of Dr. Anthony Bassler, New York City.) A, Stomach; B, ulcer, in posterior wall of pars pylorica; C, pyloris; D, duodenal cap; E, cecum and ascending colon. EXAMINATION OP THE STOMACH 127 Fig. 30. — Dilated stomach, 19 hours retention due to pylorospasm. {Made in the X-ray laboratory of Dr. Anthony Bassler, New York City.) A, Gas in fundus; B, B, transversely and longitudinally enlarged stomach; C, tight pyloris; D, first part of duodenum. Markers at the ensiform and umbilicus. EXAMINATION OF THE STOMACH 1 29 is almost characteristic of ulcer, according to the radiologists. This conclusion is not yet accepted without reservation by the internists. Symptom-complex VII. Large sickle-shaped residue after six hours. Diagnosis. — Old stenosis of the pylorus, due to ulcer. This symptom is due to dilatation and secondary atonic alteration of the musculature, with great loss of motility. Symptom -complex VII (A). 1. Large residue after six hours. 2. Dilatation. 3. Loss of tone. Diagnosis.^ — ^O'ld ulcer-stenosis. The above symptoms, however, do not afford clear in- formation as to the character of the lesion — whether a simple ulcer, a callous ulcer, or a carcinoma on the base of an old ulcer. To better decide this question it is well to consider the following : Symptom-complex VIII. 1. Large sickle-shaped residue. 2. Marked defect in the filling of the pars pylorica. Diagnosis. — Carcinoma on the base of an old ulcer, with stenosis. This picture is fairly common. It has been recently advanced, and with reason, that a marked stenosis of the pylorus with dilatation and paralysis, might exist without vomiting or other severe symptoms. Vomiting might set in later, not necessarily from the stenosis, but from the commencing carcinoma. The signs of dilatation and vomit- ing, and the previous history of ulcer, all point to stenosis of the pylorus, and do not contraindicate operation. Symptom-complex IX. 1. No bismuth residue after six hours. 2. Marked defect in the shadow of the pars pylorica or pars media. 3. Transverse constriction of the greater curva- ture. 130 . EXAMINATION OF THE STOMACH Diagnosis. — Carcinoma on the base of an old ulcer. No stenosis. Symptom-complex X. 1. Stomach empty after six hours. Head of the bismuth column at splenic flexure of colon. 2. Shortening of the stomach. 3. Congestion at the cardia. Diagnosis. — Carcinoma of the pars cardiaca. Symptom I indicates hypermotility of the stomach due to hypoacidity or anacidity. This should be confirmed by a second examination three hours after the bismuth meal. Symptom II indicates a diffuse contraction, and indicates carcinoma. Symptom III points to the rapid encroach- ment and advance of the pathologic process. The achylia renders the diagnosis of ulcer untenable. The condition is probably inoperable. Symptom-complex XI. 1. Stomach empty after six hours. Head of bismuth column in the ascending colon. 2. Stomach shadow normal. 3. Pressure-point moving with the duodenum. Diagnosis. — Duodenal ulcer. Symptom -complex XII. Normal stomach. 1 . Stomach empty in six hours. Head of bismuth column in the ascending colon. 2. Stomach shadow normal. 3. No increase of peristalsis; no antiperistalsis. 4. HCl normal. This is the picture of a normal stomach, and in no case showing these signs has been found any anatomical altera- tions on operation or post-mortem examination. It should always be remembered, however, that the less number of positive symptoms, the greater care is necessary in the Roentgen examination, and the greater caution should be observed in expressing an opinion. In addition to the symptom-complexes so interestingly and clearly brought out by Holzknecht, and pointing to the EXAMINATION OF THE STOMACH 131 Fig. 31. — Six-hour residue. Pyloric Stenosis. Confirmed at operation. Patient of Drs. L. L. Andrews and E. G. Jones. {Dr. John S. Derr.) A, Six-hour residue; B, duodenum. Marker on umbilicus. EXAMINATION OF THE STOMACH 133 Fig. 32. — Gastroptosia (moderate) with hypermotility. {Made in the X-ray laboratory of Dr. Anthony Bassler, New York City.) A, Gas in the fundis; B,B, rugae; C, pars pylorica with hypermotility; D, pyloric muscle; E, normal duodenal cap; F, third part of duodenum; G, liver shadow. Markers at the ensiform and umbilicus. EXAMINATION OF THE STOMACH 13s Fig. S3- — Pyloric stenosis from adhesions to gall-bladder. Confirmed at operation by Dr. E. C. Davis. The stones filling the gall-bladder did not show in skiagraph. {Dr. John S. Derr.) A, Deformity of pylorus due to adhesions; B, deformed cap. Marker at umbilicus. EXAMINATION OF THE STOMACH 137 Fig. 34. — Atony and dilatation of stomach. Pyloric stenosis. Non-malig- nant. Diagnosis confirmed at operation. Patient of Dr. L. L. Andrews. {Dr. John S. Derr.) A, Gas in cardia; B, remains of duodenal cap; C, pylorus. Marker hidden by stomach shadow. X-RAY SIGNS OF ULCER I39 diagnosis of gastric ulcer, there have been a number of important studies and experiments in which the X-ray was employed to diagnose this condition. In 1907 Jolasse reported that he had seen a patch of bismuth showing in the skiagram of a patient suffering from gastric ulcer. In the same year Hemmeter performed a number of ex- periments on cats and rabbits, in whom he artificially produced deep ulcerations in the pylorus. These ulcers were treated with bismuth, and if the animals were kept without fluid, the bismuth spots could be seen on the screen twenty-four hours later. Later on, Haudek and Clairmont made a number of other experiments with ani- mals, and their observations corroborated Jolasse. Leaving out the very technical details which lead up to the conclusions, Haudek cites the following: 1 . A fiat ulcer of the stomach does not give any shadow, due to the deposition of bismuth on its surface. 2. Any abnormal circumference shadow, which is seen after a bismuth meal is due to the enclosure of the bismuth in a pathological pocket, or diverticulum. 3. A penetrating ulcer of the stomach may frequently give rise to a special appearance — an outgrowth or diver- ticulum of the bismuth shadow, with an air bubble at its summit. The radiological signs of a penetrating ulcer of the stomach are as follows : 1. A patch or streak of bismuth, isolated from the mass of the bismuth meal, or branching out from it, usually at the lesser curvature and in the pars media of the stomach. 2. A gas-bubble at the summit of this isolated patch. 3. Retention of the bismuth for a considerable time in this region. 4. Immobility of the bismuth patch, which is not in- fluenced by palpation or pressure. Haudek also concludes that penetrating gastric ulcer is by no means uncommon, and that the reason that they have been previously overlooked, lies in the fact that no I40 EXAMINATION OF THE STOMACH reliable diagnostic, means for their detection have been available. In the Roentgen ray we have the most convincing methods of diagnosing that interesting and sometimes confusing condition, the hour-glass stomach. This condi- tion is divided by pathologists into two groups — congenital and acquired. The existence of the former is denied by good observers like Mayo Robson and Moyihan, the latter ascribing the so-called congenital hour-glass contraction to one of three causes — gastric ulcer, adhesions in the stomach or its walls, and carcinoma. Acquired hour-glass contraction is generally the result of cicatricial contraction of a healing gastric ulcer. This ulcer is usually situated on the lesser curvature, and has extended to the long axis of the stomach ; or there may have been two ulcers, one on either side of the lesser curvature. In consequence of the resulting contraction, the stomach appears to be divided into two pouches, the larger corre- sponding to the fundus, the smaller to the pyloric end of the viscus. The sulcus separating the two in generally of considerable length, and is usually situated somewhat nearer to the pylorus than the cardia. In some cases the stomach is adherent to the pancreas or to the undersurf ace of the liver, and occasionally the pyloric portion is dilated, the result of a coincident cicatricial or spasmodic stenosis of the pylorus. Robson and Myonihan have reported two instances of the stomach being divided into three pouches by two constric- tions, making the so-called "trifid stomach." Dr. Robert Knox has contributed a valuable study on the X-ray diagnosis of hour-glass stomach, and acknowledg- ments are given for assistance in the preparation of this section. The symptoms of this condition are fairly characteristic, though at times somewhat indefinite. At first the symp- toms appear to depend on the original cause, while later on the condition itself may be diagnosed, if sufficient care EXAMINATION OF THE STOMACH 141 Fig. 35. — Hour-glass contraction of stomach. Patient of Dr. L. S. Hardin. {Dr. John S. Derr.) A, Dilated cardia; B, hour-glass contraction; C, peristaltic waves; D, antrum; E, cap. EXAMINATION OF THE STOMACH 143 Fig. 36. — Water-trap stomach. Patient of Dr. L. C. Fischer, operation. {Dr. John S. Derr.) A, Long pyloric arm. Marker at umbilicus. Confirmed at EXAMINATION OF THE STOMACH 145 and patience are exercised. The following are the char- acteristic symptoms of hoiir-glass contraction: 1. Pain after a meal, coming on at once or after some time. 2. Vomiting of the stomach contents, and some- times also blood. 3 . Emaciation slowly increasing. 4. The presence of a tumor, due to cicatrization of an old ulcer with absence of ascites and secondary nodes. These symptoms may for a time simulate stenosis of the pylorus, the condition lasting for years, and causing great suffering. Fatal hemorrhage may occur, in which all the blood enters the bowel, and the patient may die without showing any of the diagnostic signs of bleeding into the stomach. This has been denominated "hematemesis into the intestine." It will be noted that during lavage of the stomach all of the fluid fails to return. Often after an apparently thorough lavage, a further quantity of stomach contents makes its appearance. This is foul and bad-smelling, and several times, after the stomach has seemingly been washed clean, another lavage will show these signs of retained contents. Another symptom of worth is a splash on palpation of the stomach after the apparent removal of all of its contents. Sometimes, on percussing the empty stomach, and again percussing it after distention, a change in the position of the tumor may be observed. The proximal pouch is first dis- tended, then the distal pouch. Occasionally the notch between the two tumors is noticeable after distention. On dilatation, bubbling and sizzling sounds may be heard through the stethoscope some distance from the pylorus. Patients are sometimes themselves conscious of this symp- tom, as the food passes from one pouch to the other. Some years ago a middle-aged woman came under my notice, in whom the diagnosis of hour-glass stomach could 146 EXAMINATION OF THE STOMACH be made by palpation. She reported extreme fullness in the epigastrium, which was relieved as the food was emptied in the second pouch. Unfortunately I lost sight of her, and am unable to report her present condition. I was un- able at the time to get her in touch with a radiologist. An examination of the stomach after a bismuth meal affords a positive diagnosis of this trouble. The movements of the stomach may be observed, the passage of the meal may be watched as it progresses from the cardiac to the pyloric segment, and a series of radiograms may be obtained of the position and appearance of the bismuth meal at successive intervals. By this method the operator may also learn the exact time which the stomach takes to empty itself, and thus be enabled to estimate the degree of ob- struction present in a particular case. For the detection of foreign bodies in the stomach or intestines the X-ray is invaluable. Pieces of metal can be easily located, and followed during their progress, shoiild such take place. Two year ago there was sent me a girl twelve years of age, who reported swallowing an iron tap, about 1/2 inch in diameter. The tap was four-cornered, with rather sharp edges and corners, and it was hard to realize how she got it down her esophagus. An X-ray ex- amination quickly located it in her stomach, from which it was removed. Dr. C. Thurston Holland reports the radiography of a hairball in the stomach, in which the viscus was so filled by the mass of hair that the barium mixture, which was used in this instance, only left rather indistinct shadows around the walls of the stomach, though the food could be seen "flowing" through the pylorus into the duodenum. Biliary calculi are sometimes clearly brought out by radiography, but at present the radio- diagnosis of chole- lithiasis is subject to many errors, and a positive diagnosis is quite exceptional for the following reasons, as adduced by Dr. Jaugeas: ' ' Biliary calculi are as a rule exclusively organic in chem- EXAMINATION OF THE INTESTINES 147 Fig. 37. — ^Lane's kink and coloptosis. (Made in the X-ray laboratory of Dr. Anthony Bassler, New York City.) A, Cecum; B, Lane's kink; C, transverse colon; D, sigmoid; E, dilated rectum. Markers at the ensiform and umbilicus. EXAMINATION OF THE INTESTINES 149 Fig. 38. — Rectal injection of colon and appendix. Patient of Dr. G. H. Noble. {Dr. John S. Derr.) A, Appendix; B, transverse colon; C, cecum; D, splenic flexure; E, sigmoid. Marker on umbUicus. EXAMINATION OF THE INTESTINES 151 ical composition, being composed of cholesterin, biliary pig- ment, biliary acids, etc., which, owing to their great trans- parency to the X-rays, show but little contract to the ab- dominal opacity. In rare cases, however, calcium salts are added to these organic substances in such proportion as greatly to increase the density of the calculus. Between the cholesterin type and the calcareous type are a great number of intermediary forms, varying in the proportion of salts which they contain. The presence of calcium is, indeed, the sole condition of visibility. Other factors also may interefere with the radio-diagnosis, as the presence of bile in the gall-bladder, its concentration, and the thickening of the vesicular walls attenuate the contrast of the image, and may entirely efface it where the opacity of the calculus is not great." The matter is rendered even more difficult by the situation of the bile ducts on the lower surface of the liver, where they are easily confounded with the shadow of the hepatic parenchyma and the abdominal organs. To this there is, however, one exception — the common bile duct. This is frequently the seat of biliary calculi, and its image may always be clearly separated from that of the liver. Muscularity of the abdominal walls and obesity add greatly to the difficulties, but notwithstanding all the disadvantages mentioned, a radiographic examination should never be neglected when practicable, since a certain, although limited number of cases yield a positive diagnosis. The further we go down the digestive tract and away from the stomach, the less useful in some respects are the X-rays for diagnosis. The topographical aspect of the small in- testine is made out with great difficulty, the hardest part of all being the duodenum. In stenosis of the duodenum the pylorus may be seen open and pulled down. Under normal conditions only the pars superior horizontalis is seen in the duodenum, and at no time are there contractions visible; but in the case of 152 EXAMINATION OF THE INTESTINES stenosis we sometimes get the entire duodenum filled, and visible peristalsis. Haudek claims that autopsy findings have established the fact that whenever the symptoms of ulcer of the stomach were associated with hypermotility of the stomach during life, the ulcer was usually found at the duodenum. The course of the rest of the small intestine soon after a m.eal is seen only in a few bismuth spots in the hypo- gastrium; later larger masses, resembling caluiflower, are seen. In the majority of cases we observe only individual curls resembling the small intestine. Gross, with his intestinal tube, has succeeded in getting 250 cm. of bismuth injected, and has outlined the small intestine fairly well. Novak has shown that the existence of small helminthiform masses in the region of the small intestine indicates stenosis. The Colon. — The position of this gut is best studied by the bismuth bolus enema. For the functional test of the intestines the use of the Rieder meal, and watching the progress of this meal through the entire intestinal tract is more satisfactory. The distention of the colon by air is troublesome to the patient, and gives a blurred picture. The colon is usually recognized by the haustra, and the cecum cannot be separated from the ascending colon. The transverse colon does not run horizontally, but runs in a line with the greater curvature of the stomach, and the haustra are specially well marked in this portion of the gut. From the splenic flexure the descending colon takes a straight downward course, with a slight narrowing at the sigmoid flexure. The entire colon in its normal condition is quite movable. The passage of food in the presence of normal motility varies considerably, but, according to the consensus of opinion, may be located in its onward course about as follows: The small intestines are seen from a half hour after the meal is taken up to four or flve hours ; the cecum and colon are seen about four to six hours after the meal; COLOPTOSIS 153 >1 ■ r4i &1 ^ ^ I ^ -^ -« ^ ^ CI ,• cS i-i ^ i 53 •2 -Q "^ 5-. g rt I o 2 ^ a^ ■^ =^ 2 ■"^ S t>o ■^ S - X '— ■ ^