COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANpARD HX641 30622 RC803 .G41 A manual of modem g N:V "VXC Sol) v=r Columbia ^nibersiitp mt6eCitpofi5ctD|9ork Coflege of ^ftpsitcians; anb #)urgeon£f 3^ef erente Xibrarp A MANUAL OF MODERN GASTRIC METHODS Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofmoderngaOOgill [Photo by J. Hume Paterson. Fig. 1.— Auto-lavage. (See page 119.) A MANUAL OF MODERN GASTRIC METHODS CHEMICAL, PHYSICAL, AND THERAPEUTICAL BV A. LOCKHART GILLESPIE M.D., F.R.C.P.E., F.R.S.E. Lecturer on Materia Medica and Therapeutics in the School of Medicine of the Royal Colleges, Edinburgh ; Post-Graduate Lecturer on Modern Gastric Methods, Edinburgh ; Medical Registrar, Royal Infirmary, Edinburgh Author of "The Natural History of Digestion" (Contemporary Science Series) WITH A CHAPTER UPON' THE MECHANICAL METHODS USED IN YOUNG CHILDREN JOHN THOMSON, M.D., F.R.C.P. Ed. Assistant Physicia7z, Royal Hospital for Sick Children, Edinburgh NEW YORK WILLIAM WOOD & COMPANY 1901 Wt) The symbol a, therefore, represents the quotient ob- tained by dividing the figure for the total acidity, minus that for free hydrochloric acid, by the amount of combined chlorine. If no organic acids are present, or acid salts, a should have a value of i. Normally it varies between 0'8 and 0'g2. The presence of the organic acids of fermentation and of an excess of acid salts raises the value of A, and thus a may correspond to a value above the figure I. 64 METHOD OF HAYEM AND WINTER Example of Hayem and Winter's Method. Sample of stomach contents removed two hours after Benger's Food, in a case of gastrostomy for occlusion of the oesophagus. Contents (slight gastric smell) were in a well-digested form. After filtering, 5 c. c. were placed in three crucibles — a, b, and c. To a sodium carbonate was added in excess. The three crucibles were then heated on a water-bath until an hour had elapsed after their apparent thorough drying. Deci-normal sodium hydrate solution and a drop of phenol- phthalein was added to another 5 c. c. N Total acidity = 6-5 c. c. NaHO — , or 0-4745 per cent, or 130. 10 The dried contents of crucible b were dissolved in a little distilled water, carbonate of soda added, and the solution dried again as before. The contents of a, b, and c were now ignited over a naked flame at a dull red heat, the resulting ash dissolved in water, rendered slightly acid with nitric acid, heated to expel carbonic acid, and filtered. The filtrates were titrated with deci-normal nitrate of silver solution, and chromate of potassium. a. Total chlorine, . 6'6 c. c. A0NO3 — , or 0-4818 per cent. b. Chlorine after eva- poration, . . 6-0 c. c. ,, „ or 0-4380 „ c. Inorganic chlorine, . 1-6 c.c. ,, ,, or o"ii68 „ 1. Total acidity, .... 0-4745 per cent, or 130 = A 2. Total chlorine {a), . . . 0-4818 „ = T 3. Free chlorine ((Z — i5) . . 0-0438 „ =H 4. Fixed chlorine (c) . . . o-ii68 ,, = F 5. Combined chlorine {b—c) . 0-3212 „ = C 6. Acidity not due to chlorine (1-3+ 5), • • • • 0-1095 or 30. ^A— H>^ _ 0-4745-0-0438 ^ ^ (^) = 0-3212 toepfer's method 65 The figures obtained show practically normal amounts of chlorine, and a high total acidity, much of it not due to hydro- chloric acid. 7'his circumstance is explained by the fact that the patient at the time was taking dilute phosphoric acid after her food. {d.) Toepfers Method. — A method has been de- scribed by Toepfer * which is easily performed, and is said to be fairly accurate. Toepfer first estimates the total acidity by means of phenol-phthalein and a deci-normal solution of soda in the*usual way-f He then uses a i per cent, solution of sodium-alizarin- sulphonate in water. This body is stated to be unaffected by hydrochloric acid in combination with proteid. A third indicator is also used, 0*5 per cent, solution of dimethyl -amido-azo -benzol in alcohol, which reacts to free mineral acids, and is not affected by organic acids, unless present in greater pro- portion than 0"5 per cent. The second reagent is termed for brevity alizarin, and is used in a similar manner to phenol-phthalein, deci-normal soda being added until a permanent pure violet colour results. This tint should be compared with that formed on the addition of 3 or 4 drops of the alizarin solution to 5 c. c. of a I per cent, solution of sodium carbonate. The third indicator, or dimethyl, has a yellow colour if no free hydrochloric acid be present, red if there be some in the contents. The deci-normal solution is added until this red colour disappears. By this method we obtain, first, the total acidity ; second, with the alizarin, the acidity minus the combined hydrochloric acid. No. 2 subtracted from No. i gives the amount of combined hydrochloric acid present. * Zeitschr.f. Phys. Chernie^ Bd. xix., pp. 104-222. t But see p. 68. E 66 toepfer's method The amount of soda used in titrating No. 3 gives the free hydrochloric acid. Adding the figures obtained for the combined and the free hydrochloric acid will give the total proportion of that acid present ; and subtracting that from the total acidity will give the acidity due to organic acids and acid salts. The advantages of this method are, that it takes up a short time and requires no complicated apparatus, the addition of the soda solution to equal parts of the contents after the addition of the three indicators being all that is necessary. With regard to Toepfer's method, Mohr * states that good results may be ob- tained after the operator has had some practice with it, but that at first it is difficult to decide the exact point at which the end reactions occur. There is a danger, to his mind, of the quantity of free hydro- chloric acid found being too high. Hoppe-Seyler f recommends it, while Strauss | remarks that the end reaction with the dimethyl is determined with difficulty. Hari, § discussing it, is not quite sure if the alizarin is to be absolutely depended upon for the estimation of the combined hydrochloric acid, while he recom- mends the portion to which this indicator has been added to be shaken thoroughly until the violet colour produced by the alkali has disappeared, when a thin layer of the fluid is looked through. Dimethyl-amido- azo-benzol appears to be ten times more delicate than Gunzburg's reagent and than Congo red, in the * Zeitschrift f. Phys. Chemie^ Bd. xix., No. 6, p. 647. i" Miinchener Med. Wochensc/irift, 1., 1895. J Deutsche Arch.f. klin. Med., Ivi., p. I, 287. § Archivf. Verdauwigskrankkeiten, Bd. ii., Heft 2. toepfer's method 67 detection of free h}'drochloric acid, and twenty times more delicate than Congo red with regard to organic acids. The experience of this method which the writer has had does not lead him to recommend it as being very accurate. The presence of free organic acids along with free hydrochloric acid causes the dimethyl to record too high a figure, in the same way as Gunzburg's reagent ; while he cannot accept it as proved that it is entirely uninfluenced by hydrochloric acid in proteid combinations. Artificial mixtures of albumin with a very small portion of hydrochloric acid, which did not lose acidity on drying, and in which both Gunzburg's and Liebermann's tests were negative, coloured the dimethyl solution pink or orange, and, if this reagent be accurate, contained some free mineral acid. It is so delicate, as regards free hydrochloric acid, that it is almost certain that it must react in some degree to that acid in its combined form. Its end reaction is also difficult to determine with certainty. If a drop be added to 5 c. c. of deci-normal hydrochloric acid solution, and an exactly correspond- ing amount of deci-normal solution of soda added, before the acid has been neutralised, the bright red colour changes to orange, then to brownish yellow, becoming light yellow on exact neutralisation. This light yellow tint must, therefore, be reached in titrat- ing specimens of stomach contents before the absence of free hydrochloric acid is certain. But the orange colour mentioned above seems to be given to the dye by dilute organic acids, and by combined hydrochloric acid. Sodium-alizarin-sulphonate is supposed to be un- 68 toepfer's method affected by this combined hydrochloric acid, while reacting to all other acid bodies. When tested in the same way as dimethyl, its colour, greenish yellow in the presence of acids, became violet at the point of neutralisation, using deci-normal solutions of hydro- chloric acid and soda. With excess of proteid, the violet colour did not appear until a considerable quantity of alkali was added, more than was repre- sented by any acid salts in the albumin solution, or free acid as shown by dimethyl. Toepfer recommends that the titration with phenol- phthalein and deci-normal soda should be carried on until the colour produced is not deepened by further addition, instead of regarding the first permanent pink tinge as the end reaction. Equal quantities of acid and alkaline deci-normal solutions when mixed together produce no coloration of phenol-phthalein, a trace of the soda in excess causes a permanent pink, the depth of which varies greatly with the quantity added. A dark red only appears when the fluid is of considerable alkalinity, while excess of the indicator yields a perman- ent degree of redness where the usual smaller quantity only gives a pink, capable of further intensification. Example of Tocpfej's Method. Contents removed from a case of slight excess of h3'drochloi ic acid, two hours after a light meal. Have no smell, fluid clear, food well digested. Used unfiltered. r. Total acidity. 10 c. c. titrated with deci-normal soda and phenol-ptha- lein. 8' I c. c. used until solution became pink — 8'i X o'oo365 = o"295 per cent., or 8x. 8'5 c. c. used until solution became red — 8'5 X o'oo365 = o'3io per cent., or 85. toepfer's method 69 2. Free hydrochloric acid. 10 c. c. titrated with deci-normal soda and 2 drops of 0-5 per cent, alcoholic solution of dimethyl-amido-azo- benzol. 4'6 c. c. added when solution became orange — = 0"i679 per cent., or 46. 5*1 c. c. added when solution became light yellow — = 0'i86i per cent, or 51. 3. Acidity minus tJiat due to combined hydrochloric acid. 10 c. c. and 3 drops of the watery solution of alizarin- sodium-sulphonate : titrated as above. 7'8 c. c. used before solution became violet and corre- sponded to tint of the indicator in a 3 percent, solution of sodium carbonate — • 7"3 c. c. X 0-00365 =0-2847 per cent., or 78. Result. j 0-295 per cent., or 81 Total acidity i ^ ' ^ (0 •^ (.0-310 ,, ■^" ^ ^ 5:5 Combined HCl I °'°^°^ " " l (1-3) 1 0-0255 „ „ 7 ^ ^' Organic acids ( o-ii68 ,, ,,- 32 r . x-, and acid salts ( 0-0985 ,, „ 27 ^-^K ^n Total hydrochloric j 0-1782 per cent, or 49 acid, free and combined ( 0-2 1 16 ,, „ 58'-" ^ 3jJ Phloroglucin-vanillin gave the free HCl as only 0-09 per cent. (^.) Martins and Lilttkes Method. — This method is based upon the theory that, when the gastric contents are ignited at a low heat, below the point at which chlorides volatilise, the hydrochloric acid present is driven off, leaving the chlorine which is in combination with bases. It, in fact, rests upon the same proposi- JO MARTIUS AND LUTTKE S METHOD tion which Hayem and Winter have advanced for part of their process. The only difference hes in the fact that the dried contents are not subjected to so high a temperature. Indeed, the method has been elabo- rated for the purpose of estimating the chlorine present without destroying the organic substances which are contained in the fluid tested. Reagents required (Volhard's Method). 1. A deci-normal silver solution, containing nitric acid and persulphate of iron. This solution is made by dissolving 16-997 grm. of dried and pure nitrate of silver in about 900 c. c. of dilute nitric acid, con- taining "25 per cent, of the acid, adding 50 c. c. of the liquor ferri persulphatis, and diluting the mixture with distilled water to the volume of 1000 c. c. 10 c. c. of this solution represents 0'0365 grm. HCl. 2. A deci-normal solution of ammonium sulphocyanide. 7*6 grm. of this salt is dissolved in distilled water and the solution made up to 1000 c. c. The solution must be stand- ardised against the foregoing solution of nitrate of silver. To do this 10 c. c. of the silver solution are measured out into a beaker and about 200 c. c. of water added. The sulphocyanide solution is then added from a burette until a permanent reddish colour appears. If the solutions are exactly correct, 10 c. c. of the sulphocyanide solution will be neces- sary. If, say, 9'6 c. c. are required, 960 c. c. of the sulphocyanide solution must be diluted up to 1000 c. c. This diluted solution should again be tested against the deci-normal silver. The Process of Analysis. 10 c. c. of the unfiltered stomach contents are poured into a graduated flask of 100 c. c. capacity. The con-- tents should be well shaken before being measured. Then 20 c. c. of the deci-normal acid silver solution are added to this, the whole well shaken and set MARTIUS AND LtJTTKE S METHOD 7 I aside for ten minutes. If the contents are strongly coloured, they may be decolorised by the addition of 5 to lo drops of a solution containing i part of potassium permanganate in 15 parts of water. This is rarely necessary, and the addition should only be made after all the chlorine has combined with the silver, as permanganate of potash decomposes free hydrochloric acid and liberates chlorine. After chlorine has combined with silver this action does not occur. The contents of the flask are then diluted with distilled water to the 100 c. c. mark, and filtered through a dry filter paper into a dry vessel. 50 c.c. of the filtrate are placed in a beaker, and the quantity of silver is determined by the use of the sulphocyanide solution. The number of c.c. of this solution used is multiplied by 2, and the figure ob- tained is subtracted from the 20 c.c. of silver solution originally employed, and gives the amount of silver re- quired to combine with the total chlorine, and, there- fore, the amount of total chlorine in 10 c. c. of the gastric contents. The sulphocyanide solution is acted on by the nitrate of silver uncombined with chlorine, and is unaffected by the chloride of silver formed from the chlorine in the stomach contents. This part of the process gives the total quantity of chlorine present in the contents. Other 10 c.c. of the gastric contents are evaporated to dryness in a platinum capsule either on a water- bath or an asbestos slab. They are then ignited over a naked flame until the residue no longer burns with a luminous flame, care being taken not to heat the cap- sule too strongly and to thereby drive off some of the chlorine. After the incineration the residue is mois- 72 MARTIUS AND LUTTKE S METHOD tened with distilled water and thoroughly rubbed up with it by means of a glass rod. It is then treated with hot distilled water and filtered, the precipitate on the filter being washed once or twice with hot water to make sure that all the chlorides have been removed from the carbon and insoluble ash of the residue. The whole filtrate is then mixed with lo c. c. of the deci-normal silver solution, and the excess of silver nitrate remaining determined, as before, by means of the sulphocyanide solution. The figure obtained, subtracted from the lo c. c. of the silver solution originally added, gives the amount of silver required to combine with the chlorine in the inorganic chlorides of 10 c.c. of the gastric contents. From the first analysis we have found the total chlorine present, in the second the chlorine which is in the form of inorganic salts. If the second figure be subtracted from the first, we obtain the exact amount of chlorine present in the form of hydrochloric acid in lo c.c. of the gastric contents. Example of Martius and Liittke's Method. Stomach contents from a case of chronic fermentative dys- pepsia with intestinal putrefaction ; sour smell ; food ill-digested; a number of organisms under the microscope ; removed two and a half hours after a liffht breakfast. Total Acidity = 0"25 per cent., or yo (unfiltered). No free hydrochloric acid present with vanillin-phloroglucin. Acetic and lactic acids present with Uffelmann's reagent. 10 c.c. of unfiltered contents were placed in a loo c.c. flask, and 20 c.c. of the deci-normal and silver solution added. After diluting to lOO c.c. and filtering, 50 c.c. were titrated with the deci-normal ammonium sulphocyanide solution. MARTIUS AND LUTTKE S METHOD J ^^ 6'2 c. c. were added before a permanent reddish colour ap- peared. That is, I2"4 c. c. of the silver solution were contained in the filtrate of loo c. c, but 20 c. c. were added, 7*6 c.c. therefore remained on the filter paper. 7'6 c.c. = (i c. c. = 0"00365 grm. HCI) 0-02774 gi'™- HCl in 10 c. c, or 0*02774 per cent. The total chlorine present was 0-2774 P^'" cent. Other 10 c.c. were dried in a crucible and carbonised over a naked flame. The residue was well washed with distilled water and filtered. 10 c. c. of the acid silver solution were added, and the amount made up to 100 c.c. After filtration, 50 c.c. were taken and titrated as above. 2"5 c.c. of the sulphocyanide solution were required, or 5 c. c. in the 100 c. c. 5 c. c. subtracted from the original 10 c. c of the silver solution left 5 c. c. remaining on the filter as chloride of silver, or OT825 per cent, as hydrochloric acid. The inorganic chlorine present was o-i825 per cent. Result — - Total acidity, . . . o"25 per cent. Total chlorine, . . . 0*2774 » (Free chlorine, o-oo per cent.) Inorganic chlorine, . . o'i825 per cent. Chlorine combined with proteids, 0-0949 „ Therefore, Acidity due to other factors, . 0-J551 ,, The results from this analysis were checked by using 25 c.c. of the two filti-ates which remained, adding to them dilute hydrochloric acid in excess, and throwing the chloride of silver formed on ash-free filter papers. The precipitates were then washed with water and alcohol, dried, incinerated in weighed capsules, and the amount of chloride of silver present deter- mined by weighing. The precipit;ite of chloride of silver was so finely divided that some sodium chloride had to be added in addition to the acid, and the precipitate on the filter could not be thorough!}' washed. After incineration, therefore, when the silver chloride remained in a more compact state, any soluble 74 MARTIUS AND LUTTKe's METHOD chlorides present were washed awa}^ with distilled water, before finall}^ drying and weighing. Thus in the estimation of the total chlorine the 20 c. c. of the silver solution added represents 0-34 grm. AgNOj or 0-287 gfm. AgCl (170 : I43'5). In 25 c. c. of the filtrate -0438 grm. of silver chloride was found, or 0'i752 grm. in the 100 c.c. Subtract- ing this from 0-287 grm. we get o-iiiS grm, of silver chloride, which corresponds to the chlorine left on the filter paper in 10 c.c. of the contents. 0-1118x0-25427 = 0-028427 grm. HCl in 10 c.c, or 0-2842 per cent. From 25 c.c. of the second filtrate, o-oi8 grm. of chloride of silver was obtained, or 0*072 in the total fluid, to which 10 c.c. of the silver nitrate solution had been added, equal to 0-1435 grm. AgCl. The amount of AgCl remaining on the filter paper was therefore 0-1435-0-072 = 0-0715. This multiplied as above gives 0-1807 per cent., for the inorganic chlorides as HCl. Resiclt. Titration. Gravimetric. Total chlorine, . . 0-2774 P^'" cent. 0-2842 per cent. Inorganic chlorine, . 0-1825 ,> 0-1807 ,, Hydrochloric acid, . 0-0949 ,, 0-1035 „ (/[) The Auihoj'S Method. — This method was devised as a simple and ready means of obtaining most of the information afforded by the many and complicated chemical manoeuvres of the two pre- ceding methods. Instead of estimating the chlorine, as Hayem and Winter recommend, the acidity before and after evaporation is determined. Ten c. c. of the filtered or unfiltered gastric contents are placed in an evaporating basin, and other 10 c. c. in a beaker. The evaporating basin is placed on a water-bath and the contents evaporated to dryness at the boiling point. The basin is left for an hour or more after the author's clinical method 75 contents seem to be dry. A small quantity of distilled water is then added, and a drop of the solution tested with vanillin-phloroglucin. If free hydrochloric acid be shown to be still present, it is again evaporated. In cases where there is much proteid material and a high percentage of free hydro- chloric acid, it is as well to add water to the dried residue and evaporate again at least three times. Ultimately the dried residue is dissolved in distilled water and well stirred. The total acidity of the lo c. c, previously placed in a beaker, is determined by means of a deci-normal soda solution and phenol- phthalein. The acidity of the lo c. c, which have been dried and re-dissolved in water, is similarly determined, and gives the acidity remaining after volatilisation of any free volatile acid. Numerous determinations of the results of this method, performed upon artificial digestive mixtures, show that the results obtained are very accurate. In the practical analysis of the gastric contents, the total acidity may be com- posed of hydrochloric acid in its two forms, volatile organic acids, non-volatile lactic acid, and acid salts. The acidity of the portion after evaporation may be made up of combined hydrochloric acid, lactic acid, and acid salts. As a rule, if there is much free hydrochloric acid present, the organic acids are either absent, or present in very small quantities. When the contents in the evaporating basin are heated, the volatile fatty acids, such as acetic and butyric acids, are first driven off. Free hydrochloric acid, however, does not volatilise until almost all the water has disappeared. In fact, before the end of the evaporation, if free hydrochloric acid be 76 author's clinical method present, it becomes so concentrated that any proteid bodies in the contents are charred. This char- ring develops a dark violet coloration which is known as Liebermann's reaction, and serves to indi- cate, almost as well as Giinzburg's test, the presence of the acid in a free state. The violet colour is prob- ably due to the formation of a colouring matter, from the proteids present, similar to the body known as tryptophan, one of the normal products of the tryptic digestion of albuminous bodies. Hydrochloric acid forms a combination with this pigment. We have now obtained the acidity of the 10 c. c. which have been dried, and that of the 10 c. c. before evaporation. If the figure for the acidity after evapo- ration be smaller than that obtained in the other portion, some acid must have been driven off during the process of evaporation. If this be hydrochloric acid, a violet coloration of the dried residue ap- pears ; if it be due solely to volatile fatty acids, no such change in colour results. If the acidity of the two portions, before . and after evaporation, be the same, no volatile acid can be present. It is not contended that this procedure is absolutely accurate, but it affords an easy and rapid way by which the constituents which go to form the acidity of the gastric contents can be ascertained. The evaporation of the second portion can be carried out, if no water-bath is handy, on the top of hot pipes, such as are used for heating purposes, or an ordinary pan may be half filled with water, boiled on a gas jet, over or close to a fire, and the porcelain basin containing the contents floated on the surface of the water. No doubt some time elapses before the portion is thor- AUTHORS CLINICAL METHOD "]"] oughly dried, but while it is drying one can easily attend to other matters, as the evaporation requires little or no actual supervision. Now let us consider what information we have derived from the results of the analysis in this process. \A''e have estimated the total acidity of the stomach contents; we have determined, more or less accurately, the amount of acid which is volatile ; and we have remaining the proportion of acid which cannot be driven off by heating to dryness at the boiling point. We have been afforded evidence by the presence or absence of Liebermann's reaction whether free hydro- chloric acid is contained, or not, in the specimen analysed. No one can cavil at the result obtained from the estimation of the total acidity, while even if the proportion for the free acid obtained be a little over or slightly under the real amount, we have learned whether it contains any hydrochloric acid, or only volatile fatty acids. The acidity remaining after evaporation can only consist of hydrochloric acid com- bined with proteid bodies, lactic acid and acid salts. The presence of lactic acid in such quantity as to indicate abnormal chemical changes during the course of gastric digestion, may easily be determined by means of Uffelmann's test, or any of the other tests detailed under the section in which the methods of detecting this acid are detailed (page 43). The acid salts are seldom present in sufficient quantity to vitiate any arguments based on the quantity of non- volatile acidity found in this way. If the tests for lactic acid be negative, or if they give only a slight reaction, the acidity remaining after evapora- tion may be regarded as almost entirely consisting of yS author's clinical method hydrochloric acid in combination with proteid bodies. The free acid — that is, the acid driven off during the process of evaporation — may of course consist of both hydrochloric acid and volatile fatty acids. It is well to remember, as already mentioned, that the presence of free hydrochloric acid, within normal limit, generally contra-indicates the presence of fatty acids due to fermentative changes. Thus, if by means of Giinzburg's reagent, or by the colour produced by drying, a considerable percentage of free hydrochloric acid is shown to be present, a trace of the fatty acids means little. On the other hand, a trace of the free mineral acids with a considerable proportion of free acidity may indicate the occurrence of fermentative changes due to the presence of the mineral acid in insufficient quantity to exercise antiseptic influences. The tests already mentioned on page 45 will serve to indicate whether these volatile fatty acids are present in any large amount. The significance of the amounts of free hydrochloric acid, and of that acid in combination with proteid bodies, lies in the fact that the free acid may be looked upon as an active force in further digestion, and in the prevention of fermentative changes ; while the combined portion of this acid represents the amount of work done, — the expended force, — towards the digestion of the proteids contained in the food. Any conclusions based upon the proportions of these two forms in which the hydrochloric acid is found must include the consideration of the time after the last meal and the characters of the food taken in it. But this method is capable of further expansion. If the acidities be determined in fireproof porcelain AUTHOR S CLINICAL METHOD 79 crucibles, and a third portion of the contents (lo c. c.) be placed in another crucible, the total chlorine present can be determined after the total acidity has been cal- culated in portion No. i by adding a small excess of carbonate of soda, and then by drying the contents on a water-bath, incinerating at a dull red heat, and deter- mining the amount of chlorine present in the residue in the usual way {vide Hayem and Winter, page 59). After estimating the acidity contained by the 10 c.c. in crucible No. 2, — that is, the acidity after eva- poration, — carbonate of soda may likewise be added, and the chlorine which remains calculated as in the last. In the third crucible the contents are simply dried without any addition, incinerated as before, and the amount of chlorine in the ash determined. If it is wished to find out the percentage of solids in the contents, crucible No. 3 may be weighed before- hand, weighed after the 10 c.c. have been thoroughly dried, and again after incineration. The difference between the second weighing and the first gives the amount of total solids in 10 c.c. ; the first weighing subtracted from the third gives the percentage of ash ; while the ash deducted from the total solids gives the proportion of organic material present. The determination of the chlorine is thus very similar to the method advocated by Hayem and Winter, or by Martius and Liittke. The heat employed in the incineration of the contents of the crucibles should never be raised above that of a dull red ; if this degree of heat be continued for some time and not exceeded, the carbon of the residue may be driven off without volatilisation of the inorganic chlorides. The 8o author's clinical method process of incineration in the first and second crucibles need not go so far as this, nor need the carbon be altogether driven off from a third crucible, unless it is wished to obtain the exact amount of inorganic ash present in the contents. Owing to the addition of the excess of soda before drying and incinerating the first two specimens, the residue remaining after incineration is strongly alka- line, and, therefore, after solution in distilled water, should be carefully neutralised by the addition of dilute nitric acid, to prevent any fallacy arising from the presence of phosphates and to facilitate the dis- integration of the ash. If the amount of carbon left after incineration be considerable, it tends to render the end reaction of the quantitative test for chlorine, by means of silver nitrate and chromate of potassium, indefinite and difficult to determine with exactitude. In such a case, after adding distilled w^ater to the residue, it may be thrown upon a filter, washed several times with distilled water to extract all the chlorine, and the filtrate tested without the carbon which has been left on the filter paper. It may be advisable, in such a case, to use Volhard's method in the estimation of the chlorides, a method w^hich has been already described in the consideration of IMartius and Liittke's process. The figures obtained from these processes represent the total chlorine present in lO c.c. (crucible No. i) ; the chlorine left in the contents after evaporation at ioo° C. (crucible No. 2); and the proportion of chlorine present in the form of inorganic compounds with bases. As in the process of Hayem and Winter, the figure obtained from crucible No. 2 when subtracted from author's clinical method 8 1 that of crucible No. i gives the quantity of chlorine driven off by evaporation ; while the figure which represents the inorganic chlorine, obtained from crucible No. 3, if subtracted from that of crucible No. 2, will give the amount of chlorine which has not been driven off by drying at the boiling point, but which is burned off during incineration. The figures obtained in the two sections — that is, those for the acidities and those for the chlorine — may with advantage be expressed in each case in terms of hydrochloric acid per cent. They are then exactly comparable, and the amount of free acid can be con- trasted with that of the free chlorine, and similarly the percentage of the combined acid with that of the chlorine in combination with organic bodies. The free chlorine determined in this way consists of hydrochloric acid and of any chloride of ammonia present ; and the combined, of hydrochloric acid and other chlorine compounds with organic bases. Some difficulty may be experienced in determining the exact point at which the end reaction occurs in the estimation of the acidity after evaporation. Often the residue left is highly coloured. The best way to proceed is to divide the solution obtained, after dissolving the residue in distilled water, into two equal parts, and to use one without the addition of soda as a means of comparison with the other, to which soda has been added, so that the point at which the phenol-phthalein, becoming pink, affects the tint of the solution, may easily be determined. 82 author's clinical method Example. Stomach Contents removed from a case of nervous dyspepsia with delayed digestion, heartburn, and intestinal symptoms. Removed two and a quarter hours after breakfast of minced meat, toast, and water. Fluid turbid ; meat partly digested ; smell sour ; no scum. 1. Total Acidity. N 10 c. c. titrated with — soda solution and phenol-phthalein. 10 r r 7-8 c. c. used (7-8xo-oo365) = o-02847 = o-2847 percent., or 78. 2. Acidity after Evaporation. 10 c. c, 7" 3 c. c. ^ soda used. 7"3 X 0'00365 = 0'026645 grm. HCl = ov2664 per cent., or 73. Faint trace of violet colour in contents of capsule after drying. 3 . Volatile A cidily •. 0"5 c. c. (i — 2) = (o-5 xo"00365) o'ooi825 grm. HC1 = 0'0i825 per cent., or 5. Tested with vanillin-phloroglucin, a faint red colour developed on drying. Tested with Uffelmann's reagent, the presence of lactic acid was shown. Such forms the ordinary clinical method, but for the purposes of illustration the further processes available were carried out. 4. Total Chlorine. The 10 c. c. of capsule i, after neutralisation, and after the addition of a pinch of sodium carbonate to ensure excess of the alkali, were dried, and ashed at a dull red heat. The resulting ash was dissolved in water, filtered, the filter paper washed with distilled water, and the filtrate tested as in Hayem and Winter's method, after neutral- ising with nitric acid. In this instance a solution of silver nitrate was used, 9*5 c. c. of which corresponded to 10 c. c. of deci-normal hydrochloric acid solution, or to C"0365 grm. of HCl. AUTHOR S CLINICAL METHOD 8-3 c. c. of the silver solution was added before the potas- 1 * 1 * I ^ J 0-0365 x8-3 Slum chromate befran to be acted on, or — ^ — = ■ = 9-5 0*03 188 grm. HCl in 10 c. c, or 0'3i88 per cent. 5. Non-volatile Chlorine. The contents of No. 2 were similarly treated, after testing the acidity. 8'i c. c. of the silver solution were required, or = o'03ii2 grm. HCl in 10 c. c, or o'3ii2 per cent. 6. Volatile Chlorine. The result of No. 5 subtracted from that of No. 4 gives only 0-2 c. c. of the silver solution as the equivalent of the volatile chlorine, and this is equal to 0-0076 per cent, of free hydrochloric acid. 7. Inorganic Chlorine. Other 10 c. c. were dried without addition in a capsule, incinerated at a low red heat for a considerable time, and the ash treated as before. 4*4 c. c. of the silver solution sufficed to combine with all grm. HCl, or the chlorine, or 0-0365 X 9-5 -43 =.0-01 0-1689 psi" cent. suit.— Total acidity. Re. I. 0-2847 per cent. 2. Non-volatile acidity. 0-2664 ,, 3- Volatile acidity, . 0-01S25 ,, 4- Total chlorine, . 0-3188 ,, 5- Non-volatile chlorine, 0-3112 ,, 6. Volatile chlorine, 0-0076 ,, 1 • Inorganic chlorine, . 0-1689 ,, 8. Organic non-volatile chlorine, or chlorine combined with pro- i teids(5-7) . 0-1423 9- Total chlorine apart i 1 from inorganic chlo- rides (6 + 8) . 0-1499 < (4-5) ■ Chlorine com- bined with pro- teids. 'I'otal chlorine, as HCl, free and combined. 84 author's clinical method ^, , . ,. , ( Total acidity due 10. iotal acidity not due \ ^ ■ ' -j^ , , . -^ , . „ -< to organic acids to chlorine (1-9) =0-1348 per cent, "j ^^^ ^^ ^^j^^_ 11. Non-volatile acidity .^^^^.^ ^^.^ ^^^ not due to chlorine I -j 1^ ' acid salts. (2-8) . . =0-1241 12. Volatile acidity not ( Volatile organic due to chlorine < acid = acetic (3-6) . . =0-01065 » i ^cid. The figures obtained show the presence of a very small quan- tit)' of free hydrochloric acid, not sufficient to check the lactic acid fermentation, a moderate amount of combined hydrochloric acid, a comparatively large quantity of lactic acid, and a trace of a volatile organic acid, probably acetic. 4. Quantitative Tests for the Organic Acids, If the organic acids be volatile the amount present may be estimated by titration of the distillate of a known quantity of the contents. If partly volatile, z.e., acetic and butyric acids, and partly non-volatile, z'.s., lactic acid, titration of the distillate and of a watery solution of the residue of an ether extract of the fluid remaining in the retort will give the total amount of organic acids present fairly accurately (zn'de p. 42.) 5. Other Methods. Contejean's Method. — Contejean* suggests the use of hydrocarbonate of cobalt, added in excess to the stomach contents, as a qualitative test for the acids in the gastric contents. The mixture is shaken or stirred frequently, and * Journ. d. /. Phys, et. d. I'Anat., No, i, 1893. OTHER -METHODS 85 becomes pink in the course of a few hours if some oxide of cobalt be formed and dissolved, while the residue after filtering and drying is blue. If absolute alcohol be now added, any chloride of cobalt present is dissolved by it, and can thus be separated from the lactate, which is insoluble in alcohol. The chloride of cobalt solution is of a pink colour when cold, turning to blue on heating. On evaporation rectangular crystals of this salt may be obtained, and serve as irrefragable evidence of the presence of hydrochloric acid. To ascertain the positive presence of lactic acid, he advises that the stomach contents should be shaken up several times with ether, the ether removed, evaporated, and the residue dissolved in distilled water, to which zinc oxide has been added. This mixture has to be kept for some time at a mild heat, when, if lactic acid be present, crystals of lactate of zinc may be found under the microscope on eva- poration of the solution. Hoffmann's Method. — Hoffmann* has suggested that the amount of free hydrochloric acid in the gastric contents may be estimated by the degree of inversion of cane sugar, measured by the polarimeter, brought about by its action. Or by the splitting of methyl-acetate into methyl-alcohol and acetic acid, by the action of free hydrochloric acid, and titration of the acetic acid formed. Brauns Method.j — The total acidity of 10 c.c, or any other fixed quantity of the stomach contents, is determined in the ordinary way, and then i c.c. more of the deci-normal solution of soda is added. * Centralblatt f. klin. Med., No. 16, 1889. f See Leube, Specielle Diagnostik, etc., p. 234, 1889. 86 MIERZYN ski's METHOD Dry and incinerate. Then as much of a deci-normal solution of sulphuric acid is added as is required to neutralise the' soda used. Warm the mixture to get rid of carbonic acid, and titrate with deci-normal soda again. The quantity of the solution used repre- sents the amount of hydrochloric acid originally present. Mierzynski's Gas Volumetric Method* - — Five to 15 c. c. of the stomach contents, after filtration, are mixed with an excess of carbonate of barium in a porcelain crucible, dried, and incinerated. The ash is dissolved in boiling water, and filtered. It often contains, in addition to the soluble chloride of barium, some of the hydrate, owing to reduction of the car- bonate during incineration. If this is the case, a drop of phenol-phthalein will colour the solution pink. To get rid of the hydrate all that is necessary is to blow air through a glass tube until the pink colour dis- appears, and filter once again. To the filtrate ammonium chromate is added in slight excess, the solution heated, and the precipitate which forms caught on a filter paper. This is then washed with very dilute hot ammonia to remove any remaining chromate. The lower end of the filter is now pierced, and the precipitate washed through with i in 20 hydrochloric acid solution in excess, to which 10 c. c. dilute sulphuric acid is finally added. The solution is now placed in a ureameter, 5 to 10 c. c. of a 2 per cent to 2'5 per cent, peroxide of hydrogen solution mixed with it, shaken for half a minute, and the quantity of oxygen evolved calculated from the height of the water in the tube of the apparatus. * Ceniralblatt f. vinere Med., No. 15, s. 1073, 1894. TABLE OF METHODS Sy 2HCH-BaC03=CO, + H<,0 + BaCl, BaCl2 + (NH;)2Cr04 = 2NH,Cl + BaCr04 2BaCrO,+ 5H20 + 5H2S04=2BaSO,+ Cr2(SOJ3 + ioH,0 + 80 Therefore, 2HCl = BaCl2 = BaCr04 = 40. The result is then corrected for temperature and pressure, and the number of c. c. multiplied by half the molecular weight of HCl. For example — -lo c. c. of stomach contents gave 22"4 c. c. of oxygen at 742 mm. pressure, and 16° C. To correct for temperature and pressure 22*4 must be multiplied by 0-o8io6 (from Baumann's Tables), and by i8'i85, or half the molecular weight of HCl. This gives 33'Oi8 m. grm. in 10 c. c, or 3-3 per thousand. Table of the Methods used for the Detection and Estimation of the Acids present in the Stomach Contents. I . Qualitative. a. Simple acidity only. Litmus. b. Form of acid present. 1. Free hydrochloric acid. a. Vanillin-phloroglucin. b. Resorcin. c. Sulphocyanide of potassium and acetate of iron. d. Dimethyl-amido-azo-benzol. 2. Free acids of any kind. a. Congo red. ' . b. Tropseolin 00 {L Orange Poirier). c. Benzo-purpurin. 88 TABLE OF METHODS d. Methyl-violet e. Emerald green (Vert Brilliant). f. Fuchsin. Z. Leo's method. Organic acids. a. Carbolic acid and perchloride of iron. b. Dilute perchloride of iron. c. Co-efficient de partage. d. Alcohol and sulphuric acid, with formation of ethers. Quantitative. a. Total acidit}', titration with deci-normal sodium hydrate, and phenol-phthalein or litmus. b. Acids forming the total acidity. 1. Hydrochloric acid only. a. Free HCl only. ]\Iintz's method. b. Hydrochloric acid, free and combined with proteids. Sjoqvist's method. 2. All the acids present. a. Cahn and Von IMering. b. Mintz-Boas c. Hayem and Winter. d. Toepfer. e. Li.ittke and Martius. / ^Modified Hayem and Winter. 3. Organic acids alone. 1. Distillation and titration of distillate. 2. Titration before and after ether. TABLE OF METHODS 89 3. Otha^ less knoivn inetJiods* 1. Contejean's methods. Qualitative. 2. Hoffmann's method. Quantitative for free hydrochloric acid. 3. Braun's method. Quantitative for total hydrochloric acid. 4. Mierzynski's gas volumetric method, for total hydrochloric acid. * See Appe7tdix^ p. 161. CHAPTER VL GENERAL CONSIDERATION OF THE DIFFERENT CHEMICAL METHODS DESCRIBED. The various methods for the estimation of the hydrochloric acid and fatty acids in the stomach contents, which have been described in the preceding chapters, may be divided into two classes. The first class contains those methods in which the proportion of hydrochloric acid is determined irrespective of the chemical state in which it is present ; the second, those in which the amount of acid, both in a free state and combined with proteids, is determined. The first class consists of the methods of — 1st. Cahn and von Mering. 2nd. Sjoqvist. ^7-d. Leo. 4///. Martius and Liittke. The differentiation of the hydrochloric acid present into that which is free and that which is combined with proteid bodies, is carried out by the processes of— 1st. Mintz. 2;?^. Mintz and Boas. 2,rd. Toepfer. 4///. Hayem and Winter ; and St/i. Of the Author. CONSIDERATION OF METHODS QI If one wishes to ascertain the total quantity of chlorine present as hydrochloric acid in a sample of stomach contents, no process can be more accurate than that of Sjoqvist. If one desires to determine the quantity of chlorine combined Avith inorganic salts, and in the form of hydrochloric acid, free and combined together, Martins and Liittke's method affords good results. The method of Cahn and von Mering may be at once dismissed, because, as has already been noted, it is both costly and difficult. The method of Sjoqvist requires much skill in chemical analysis, while that of Martins and Liittke, although accurate, does not yield all the information which may be of use. On the other hand, the simple method of Mintz and Boas quickly indicates the proportion of free hydrochloric acid in the contents, accurately if it is the only acid present, slightly in excess of its real value if organic acids are also present. The method of Hayem and Winter affords much more information, and appears to be fairly accurate. By it the total acidity, the free hydro- chloric acid, the hydrochloric acid combined with proteids, and the inorganic chlorides, are all deter- mined. It is, however, somewhat tedious to carry out, and requires considerable chemical skill in the estimation of the chlorine present. Toepfer's method is easy and does not take up much time, nor does it require any costly apparatus. It may be warmly recommended for the ordinary clinical examination of the stomach contents. The figures obtained are not, in all probability, absolutely accurate, but for clinical work the accuracy of the analytical chemist is not required. What we wish to know is how acid the 92 SIGNIFICANCE OF ACIDITIES stomach contents in any given case are, and what this acidity is made up of. The modification of Hayem and Winter's method, used for some years past by the author, is likewise attended with the possibiHty of some error ; the process, however, is simple and easy, and in his hands has afforded so much information with little trouble, and has been of so much use in the diagnosis and treatment of cases of dyspepsia of all kinds, that he is disposed to recommend it for employment in clinical work. By it we obtain infor- mation as to the total acidity and as to the acidity left after evaporation ; while coupled with the ordinary quantitative tests for the presence of free mineral acid or of the fatty acids, the process affords all the information required to diagnose the faulty chemistry which may underlie gastric affections. After the performance of many of the processes detailed above, in which the principal point aimed at is the estimation of the chlorine present, the presence of the fatty acids, and, if required, the amount of these acids in the contents, may be determined by the use of the various tests described in Chapter IV. The Significance of the different Acidities obtained in the Stomach Contents. In an artificial digestion experiment, in which nothing but hydrochloric acid, pepsin, and proteid bodies are present, until the acid has been added up to a certain proportion, namely, to about 7 per cent, of the proteids, no free hydrochloric acid appears in the fluid. It has all combined with the proteids present. It gives no coloration with Giinzbure's or with SIGNIFICANCE OF ACIDITIES 93 Mohr's reagent, but still retains the same acid value in titration which it possessed before combination. That is to say, that if 10 c. c. of a deci-normal solu- tion of hydrochloric acid be added to a solution of any proteid in which the proteid is in excess, no free acid can be detected, but the mixture, provided it is neutral before the addition of the acid, is exactly neutralised again by the addition of 10 c. c. of deci- normal soda. This combination of hydrochloric acid with proteid bodies represents the first stage in their digestion, and therefore the amount of the acid in combination may be regarded as an index of work already done. Further, if in our artificial digestion experiment more acid be added, none of it will be found to be present in a free state until from 7 to 9 per cent, of the acid, when compared with the proteid, is contained in the fluid. During the decom- position of the native proteid molecules, however, simpler proteid bodies are formed which have a greater afiinity for the acid ; and a solution of albumin, which contains at the commencement of digestion a small quantity of free hydrochloric acid, may, as digestion proceeds, exhibit no trace of it ; that is to say, the lower proteids resulting from the digestive act are able to combine with more of the acid than the native albumin from which they are derived. Thus, the albumoses appear to be capable of combining with from II to 15 per cent, of hydrochloric acid, and pure peptone with about 19 to 20 per cent. If these facts be remembered, the amount of combined hydrochloric acid obtained by any of the methods described above, will indicate the ability of the gastric glands to secrete sufficient hydrochloric acid not only to act upon and 94 SIGNIFICANCE OF ACIDITIES combine with all the proteids of the food, but to provide the slight excess of free acid which enables the process of decomposition of the proteid bodies to go on to its natural termination. The presence of free hydrochloric acid in the contents, remembering what we have just said, in- dicates a power of further digestion on the part of the gastric juice. Its absence may denote diminished activity of the gastric glands, unless the contents have been removed shortly after a heavy proteid meal. A low total acidity after food composed largely of carbohydrates, does not invariably indicate diminished digestive powers. The gastric glands appear to be able to regulate the amount of acid secreted, not so much in relation to the combined acid present, but in connection with the proportion of free hydrochloric acid in the contents. So we may say that a low acidity with little combined acid and the normal amount of free mineral acid is by no means abnorm.al, if the food has contained a small proportion of albuminous material ; on the other hand, a very high acidity, even 0"4 to 0*45 per cent. (HCl) with or without free hydrochloric acid, does not necessarily indicate hyperacidity if the contents have been remioved after a food chiefly consisting of proteids. But if with a low acidity no free hydro- chloric acid can be detected after a meal of carbo- hydrates, or if the acidity some time after proteid food is normal but does not similarly contain any free hydro- chloric acid, we are justified in diagnosing a diminished secretion of acid in the gastric juice. Again, if in the first instance, after carbohydrates, there is a normal total acidity almost entirely composed of SIGNIFICANCE OF ACIDITIES 95 free mineral acid ; or in the second, that is, after proteid food, the total acidity be very high with the same proportion of combined acid as should normally be present but with a greater quantity of free acid, we may look upon the patient as suffering from hyperchlorhydria, — in other words, too great a secre- tion of hydrochloric acid from the gastric glands. CHAPTER VII. THE ACTIVITY OF THE GASTRIC JUICE. Tests for the Activity of ihe Gastric Juice — Egg Albumin — Giinzburg's and Sahli's Iodide of Potassium Test — Oppler's Test — Rennet — The Identification and Estimation of the Forms of Proteid present — Sugar and Starch — Saliva — Toxines. Tests for the Activity of the Gastric Juice. To obtain an indication of the activity of the gastric juice, the white of one or two eggs, apart from the yolk, are mixed with 4 oz. of water, and the solution heated to the boiling point, with constant stirring. The albumin is, in this way, coagulated in fine par- ticles. After cooling, it is given to the patient, and b}- means of the stomach-tube removed from the stomach in half an hour to three-quarters of an hour afterwards, after the addition of 4 or 5 oz. of water. The stomach should be empty before the white of eg<^ mixture is given, or, if it is not empty, should be washed out beforehand. Examination of the fluid removed will show whether the digestion of the albumin has proceeded to a termination or not. The egg-albumin, as yet unaltered, can be separated by boiling the fluid, with the addition, if necessary, of acetic acid, and filtering. The acid albumin is re- moved after precipitation with an alkali close to ■ ACTIVITY OF GASTRIC JUICE 97 the neutral point. The presence of albumoses or peptone in the filtrate can then be ascertained by means of the biuret reaction. The acidity and the constituents of the acidity can be readily determined by any of the methods described above, and the presence of pepsin investigated by an artificial diges- tion experiment. The degree of acidity of the fluid obtained in this way will be equal to one-half only of the true acidity of the stomach contents, since an equal part of water has been added to the contents before they are withdrawn. This method is a very accurate means for determin- ing the activity of the gastric secretion in health or disease. Egg-albumin is readily digested in the stomach, and does not, during its digestion, give rise to any organic acids. If a considerable proportion of the albumin given has been altered, and is no longer in the coagulated form at the end of one-half to an hour, the gastric digestion may be regarded as normal. If, however, very little of the albumin has been rendered soluble, that is to say, has been converted into lower proteid forms, and the contents removed are only slightly acid, we have good evidence of a defective secretion of gastric juice. Gunzburg and Sahli * have proposed another method to ascertain the rapidity of the gastric diges- tion of albumin and fibrin. A small quantity of iodide of potassium, O'l to 0"2 grm. (gr. iss. to iij.) is enclosed in an envelope of fibrin or in a thin gum packet fastened with a string of fibrin. The salt may also be given, placed in a short piece of thin indiarubber * Deutsch. med. Wochenschr., 1889, No. 41, and Correspondenzblatt der Schweizer Ae7'zte, 1889, p. 402. G 98 ACTIVITY OF GASTRIC JUICE tubing, the ends of which are firmly closed with plugs of fibrin. The iodide can only be absorbed by the mucous membrane of the stomach when the envelope of fibrin has been digested. The length of time re- quired for the appearance of the salt in the saliva (see page 12) is regarded by them as an indication of the rapidity of gastric digestion. The time taken for the absorption of iodide of potassium is very variable, and the rapidity with which the fibrin enveloping the salt is dissolved bears no direct relation, in many cases, to the presence of free hydrochloric acid in the con- tents, as it is often digested as rapidly in the absence as in the presence of this acid in a free state. The time taken, also, for its digestion will vary with the contents present along with it in the stomach. A simple way of determining the presence or absence of pepsin and free hydrochloric acid in the stomach contents may be performed in the following manner : — Small discs of coagulated white of egg may be cut by means of a double-bladed knife, and the sections thus obtained punched with a cork-borer or other similar instrument, so as to produce discs of albumin equal in size and thickness. These discs may be preserved in glycerine till required. An equal quantity of the filtered stomach contents is then placed in four test-tubes and one or two discs of the albumin placed in each. To the first nothing further is added ; to the second, two drops of the dilute hydrochloric acid of the Pharmacopoeia to each 5 c. c. of the stomach contents ; to the third, 0'2 to 0"5 grm. (gr. iij. to vij.) of pure pepsin is added ; and to the fourth, both the acid and the ferment. The test-tubes are then placed in an incubator, the temperature of ACTIVITY OF GASTRIC JUICE 99 which is kept at about 100'' F., or in any other warm and suitable place. The rapidity of the solution of the albumin discs informs us whether digestion can take place without the addition of hydrochloric acid or pepsin, or whether one of these bodies or both are necessary. The actual digestive power of the contents upon albumin may be ascertained by adding a known quantity of pure egg-albumin, coagulated or un- coagulated, to 10 c. c. of the stomach contents, and by weighing the albumin which can still be coagulated by the aid of heat on a weighed filter paper. The percentage of loss will give the digestive activity of the specimen examined. It should be remembered, with regard to these tests, that a perfectly normal and active sample of the stomach contents may exert no digestive action on albumin, unless free hydrochloric acid be added, owing to the fact that all the hydrochloric acid present has combined with proteid bodies originally present. In such a case the contents will have prob- ably been removed before the height of digestion. Oppler* has lately described a nev/ method of esti- mating the activity of pepsin. An hour after a test- breakfast the contents of the stomach are expressed, and the organ washed out with a small quantity of distilled water. The contents and washings are then diluted to I or 2 litres, as may be, with distilled water and dilute hydrochloric acid added until the total acidity stands at 77 = 0'28i per cent. A 2"i per cent, solution of egg-albumin is prepared, and the nitrogen of it estimated by Kjeldahl's method. Twenty c. c. of the albumin solution are then added to * Cenlralblatt f. hinere Med., February I, 1896. TOO RENNET 50 c.c. of the diluted stomach contents, and the mix- ture digested at 375° (for three hours). After coagu- lation and precipitation of the albumin and acid- albumin remaining, and removal of them by filtration, the nitrogen of the proteids in the filtrate is estimated and the percentage of albumin acted on calculated. He finds that the formation of pepsin is diminished in chronic gastritis, carcinoma of the stomach, especi- ally if situated on the body. When the pylorus is the seat of the disease th^ ferment persists longer than the hydrochloric acid, but gradually diminishes. In atony and dilatation pepsin is only secreted in less quantity if catarrh be present with diminished acid. Pepsin is increased in gastric ulcer, acid dyspepsia, chronic hypersecretion {Reichniaini's Magensaftjluss), and sometimes in chlorosis. Nervous dyspepsias and secondary affections of the stomach with lessened acidity are accompanied by diminished pepsin for- mation. The activity of pepsin secretion runs parallel with that of the hydrochloric acid, but the correspondence is not always complete. • Rennet. To ascertain whether the milk-curdling ferment is present, a small quantity, say 10 c. c, of boiled milk of neutral reaction, is mixed with an equal amount of neutralised and filtered stomach contents. If the mixture be kept at a temperature of 100° F. for a short time, the milk generally coagulates in about ten to fifteen minutes. Leo * adds only two to five drops '^ Diagnoztik, 1 890, p. 1 19. TESTS P-QR PROTEIDS lOI of the stomach contents to lo c. c. of raw milk without neutraHsing the former, on account of the relatively small quantity of it added to the milk. Raw milk is recommended by him because it coagulates ten times more rapidly than milk which has been boiled. Neutralisation of the stomach contents is rendered necessary in the first method by the fact that, if it be even moderately acid, the milk coagulates in the absence of rennet, the coagulation in such a case being flaky or lumpy, unlike the characteristic cake or layer of casein floating in the whey when formed by the action of rennet. Tests for tlie Identification and Estimation of the Proteids Present in the Gastric Contents. In some cases it may be desired to ascertain whether the products of the peptic digestion of the native proteids of the food are present or not, or, again, to estimate the quantities of each form con- tained in solution. Before applying any of the requisite tests the contents must be thoroughly filtered. If there be much mucus present, filtration through paper is a slow and tedious business. It is best to first strain them through well-washed muslin, and then filter through thin white filter paper. If speedy filtration be desired, an exhaust pump may prove of advantage. A certain quantity of the filtrate, say lO c. c, is measured out by means of a pipette, and deci-normal soda solution cautiously added. If any acid albumin be present, the fluid gradually becomes opalescent shortly before neutralisation, and the addition of one 102 TESTS FOR PROTEIDS or two drops more of the soda brings down a floccu- lent precipitate of this proteid. The precipitate is filtered off, on a weighed filter paper if desired, and washed with distilled water. The filtrate is still slightly acid in reaction, but no further precipitate comes down when a drop or two of the soda solution is added to it. The filtrate is now boiled, and at the boiling point made slightly acid with acetic acid. All the coagul- able proteids fall and may be filtered off, and the precipitate washed with boiling distilled water. The proteids remaining in this second filtrate con- sist of albumoses and peptone. The biuret test may be applied to a small portion of the filtrate for the purpose of detecting the presence of these bodies in it. To this end a drop of i per cent, sulphate of copper solution is added to a portion in a test-tube, giving it a slight greenish-blue tinge, which changes to a more or less bright pink on the addition of a small amount of liquor potass^, or of a 40 per cent solution of caustic potash, indicating the presence of albumose or peptone. Fehling's solution may be similarly used, a small drop being added by means of a glass rod, and a little potash if needful. Fehling's solution may also be used in bulk, some of the filtrate being floated on its surface, when a pink ring at the point of contact appears if these bodies be contained in the liquid. This is not nearly so delicate a method, and seldom a negative proof, if the proteids be small in amount, requiring corroboration by other means. The biuret reaction, it should be remembered, can- not be obtained in any solution to which phenol- TESTS FOR PROTEIDS IO3 phthalein has been previously added, the alkali giving that dye a colour similar to the pink caused by the lower proteids. The xantho-proteic reaction may also be em- ployed. A small quantity of the liquid is heated in a porce- lain basin with strong nitric acid, allowed to cool, and some ammonia added. If proteids are present a reddish-orange colour appears. These last tests only serve to tell us whether albu- moses or peptones are present. To ascertain whether the proteid be of the nature of an albumose or of a peptone, or if both are contained in the liquid, the filtrate after the removal of the albumin is boiled, rendered slightly acid, and saturated at the boiling point with neutral sulphate of ammonium [(NH4)2 SO^.] The albumoses are precipitated, and can be separated from the still soluble peptone by filtration, and wash- ing the precipitate on the filter paper with hot saturated ammonium sulphate solution. The persistence of the biuret and xantho-proteic reactions in the filtrate denotes the presence of peptone. If the nature of the albumoses caught on the filter paper is of moment or interest, they may be dissolved up in hot water, the resulting solution concentrated and saturated with chloride of sodium. The primary albumoses are precipitated, proto- and hetero-albumose ; the secondary albumose, deutero- albumose, remains in solution. The ammonium sulphate and chloride of sodium may be removed by dialysis from both solutions, and the proteids obtained in a nearly pure state. Hetero- I04 TESTS FOR PROTEIDS albumose can be separated from proto-albumose by- taking advantage of its insolubility in distilled water, in which the latter is soluble. The precipitation of hetero-albumose by the removal of salts from the solu- tion is rendered more complete by the application of heat. A rapid and easy method to ascertain the forms of proteid bodies in the stomach contents is : — i. To test for acid albumin as above. 2. To add an equal quantity of 10 per cent, trichloracetic acid (C2HCI3O.2.) This precipitates proto-albumose in the cold, and coagulates all albumins and globulins. If the solution now be boiled and filtered while hot, the proto-album.ose dissolves up and passes through along with deutero-albumose and peptone. The usual tests will reveal their presence or absence. On cooling, the proto-albumose in the filtrate again separ- ates out. Mucin and nucleo-albumins may be present in the filtrate when the acidity is low and the digestive power weak. In fluids obtained, or regurgitated, from oesophageal pouches, the presence of mucin in con- siderable amount may aid in the diagnosis. The addition of a very small quantity of acetic acid, just enough to render the solution acid, precipitates mucin. The specimen to which the acid is added should be allowed to stand for twenty-four hours, when the precipitate, if any, will be apparent. This precipitate is insoluble in excess of the acid. A similar precipitate from the nuclein in nucleo- albumin occurs, but this is soluble in excess. Nucleo-albumins are acted on by active gastric juice, the proteid portion being digested like other SALIVA 105 albumins, the nuclein left. As this is insoluble in an acid medium, it does not appear in the filtered contents of the stomach. Tests for Sugar and Starch in the Stomach Contents. It will not be necessary to enter into all the particulars of the tests for sugar, or for starch, in this place. Sugar is at once detected by the reduction of Fehling's solution when boiled with some of the filtered contents, deprived of proteid bodies ; starch, by adding a drop of the contents to a mixture of iodine, iodide of potassium, and v/ater, when the appearance of a blue colour indicates its presence, of a violet, erythrodextrin. Saliva. In some instances it is of importance to know whether the fluids vomited or removed from the stomach are composed of gastric secretion, or of saliva which has been swallowed and regurgitated, as in cases of water- brash, or with oesophageal pouches. If chiefly com- posed of saliva the reaction will be slightly alkaline, neutral, or perhaps very slightly acid. A few c. c. added to some starch solution, and kept at 38'^ C. for about twenty minutes, will convert some of the starch into dextrins or maltose, as evidenced by the colour produced on the addition of the iodine and iodide of potassium solution ; and lastly, the addition of dilute perchloride of iron to some of the fluid, . which should be first rendered slightly acid with the merest I06 TOXINES IN GASTRIC CONTENTS trace of hydrochloric acid, causes the development of a red colour owing to the presence of sulphocyanide of potassium. This red colour disappears on the addition of mercuric chloride, unlike the similar colour yielded by meconic acid in cases of opium poisoning. Colosanti * advocates precipitation of the saliva with alcohol, filtration, evaporation of the filtrate to dryness, solution of the residue in water, and the addition of copper sulphate. If sulpho- cyanide of potassium be present, a bright emerald green develop es. Toxines in the Gastric Contents. For the separation and study of the toxines present in the stomach contents, Turck 7 recommends the withdrawal of the stomach fluid either before break- fast or after a preliminary washing out, and the introduction of starch or albumin onh'. The fluid obtained is filtered through a sterilised Pasteur filter, and the filtrate concentrated under a vacuum pump. The degree of concentration is measured, and a quantity corresponding to i c.c. of the original fil- trate injected into an animal for each 1000 grammes of its body-weight. This proportion is gradually increased. The unused portion of the fluid is now heated to 136^ or 158'' F. under a vacuum for four hours. The proteids coagulated by this temperature, which does not destroy bacterial products, are filtered off, and the new filtrate injected as before. The products of the growth of the organisms grown from the con- * yioXy^s Jahresbei- ., xix, 72, 1890. J AW York Med. Journ., Feb. 22, 1896, p. 233. TOXINES IN GASTRIC CONTENTS lOj tents, and cultivated in boullion, are similarly treated and injected. The toxic effects of the filtered and sterile stomach contents are due to two factors : to albumoses, or other protelds in them, or to bacterial products.* * Vide also Cissaet et Terre, Coinpt. Rend. d. I'Soc. d. Biologie, 1894, pp. 532 and 633. CHAPTER VIII THE DETERMINATION OF THE MOTILITY, SIZE, AND POSITION OF THE STOMACH. The Motility — Salol (Ewald, Ruber) — Oil (Klemperer) — Gastrograph (Einhorn) — Kymograph (Hemmeter) — Power of Absorption — Potassium Iodide (Penzoldt) — Rhubarb — Size and Position — Fill- ing Stomach with Water — With Gas— With Air — Clapotement — Determination of the exact quantity of the Stomach Contents. The Motility of the Stomach. Several tests have been devised for the purpose of determining the motor function of the stomach. Leube has suggested that the presence or absence of soHd contents a definite period of six to seven hours after a large meal, or of two to two and a half hours after Ewald's test-breakfast, might serve as an indication of the power of that organ to empty the food into the duodenum. That is to say, if the stomach is empty at these hours, its motility may be regarded, according to him, as normal ; if there is still some solid material in it, the motility is weakened. This method, however, is subject to fallac}', depends upon the nature of the food taken, requires the use of the stomach-tube, and takes no account of the process of absorption as well as that of motility. Ewald * has proposed the use of salol. Salol is a " Therapeiitische Monatshefte, August 18S7. MOTILITY OF THE STOMACH IO9 compound of carbolic and salicylic acids, a phenol- ether of salicylic acid, which is said not to be changed by acid solutions, but to be converted in alkaline fluids into salicylic acid and phenol. Ewald imagined that, if this supposition was true, salol would prove an ex- cellent means for determining how rapidly substances pass into the duodenum from the stomach, and, in addition, might help to show if the action of the pancreas and the intestinal cells were normal, as the salol would not be affected by the acid of the gastric juice, but would be split up in the duodenum ; its derivatives absorbed and excreted in the urine. When salol has been decomposed into the two acids above named, the salicylic acid, absorbed into the blood, appears in the urine as a further decomposition pro- duct, viz., salicyluric acid. Normally, salicyluric acid can be detected in the urine forty to sixty, or, at most, seventy-five minutes after gr. 15 (i grm.) of salol has been given during the course of digestion. Any delay in the appear- ance of the acid in the urine will indicate some re- tardation of the time taken by the stomach to empty itself. The salol is best given in gelatine capsules, to guard against any action of the alkali in the saliva on it, and which readily dissolve in the stomach. Salicy- luric acid may be recognised by the violet colour, similar to that produced in the formation of Uffel- mann's reagent, on the addition of a neutral solution of perchloride of iron. To detect the first trace of the acid some of the urine should be rendered acid with hydrochloric acid, shaken up with ether, and the ether extract tested with the iron solution, as the salicyluric acid readily combines with the ether used. no MOTILITY OF THE STOMACH A simple method, recommended by Ewald, is to place a drop of the urine on a filter paper and then let a drop of lo per cent, solution of chloride of iron fall upon the moistened spot. Where the iron solution touches the moistened surface, a violet colour appears if there is even the smallest trace of salicyluric acid present. This test, however, is of little practical value. Ewald, indeed, states that the reaction is obtained, in the great majority of a large series of experiments, between sixty to seventy-five minutes after the salol has been taken. Other observers, however, have obtained very various results, and if Stein's observation is correct,* viz., that salol is absorbed by the mucous membrane of the stomach, although it is not decom- posed in that organ, and that it may appear in the urine in the form of salicyluric acid before its entrance into the bowel, the method can hardly be regarded as accurate. Stein has obtained this reac- tion in dogs with duodenal fistulse before the con- tents of the stomach reached the bowel, and in cases where there was no evidence of any decomposition of the salol in the stomach. Huber t estimates the motility of the stomach wall by the same drug, but in a different manner. He determines how long the salicyluric acid reaction in the urine lasts. He finds that traces of this acid may be found in healthy people for 24 hours after inges- tion, while in those in whom enfeeblement of the muscles of the stomach wall is present salicyluric acid can be detected 48 hours or even longer after "'' Wien. med. Wochen. 43, 1892. J MiiJich. med. Wochen., 1887, No. 19, MOTILITY OF THE STOMACH I I I administration. Here, again, it is difficult to say what portion of the time taken is dependent on the move- ments of the stomach wall, and what portion on delay of intestinal absorption. To carry out Ruber's test, the urine should be examined 24 to 30 hours after the salol has been given, and if salicyluric acid is still present at the latter period (or later), we may infer that there is some disturbance of the motor activity of the stomach. Klemperer"^ has proposed still another method for determining the motor activity of the stomach. He introduces a definite quantity, looc. c. (a little more than 2 oz.) of pure olive oil into the empty stomach, which may be washed out beforehand if necessary. Two hours afterwards the oil is removed by the stomach-tube as completely as is possible, and the difference between the quantity originally introduced and that obtained after the two hours is regarded by him as an indication of the gastric motility. This method is of doubtful value, and to many patients very objectionable. Einhorris Gastrograph.\ — One of the many instru- ments introduced by Einhorn, the gastrograph, consists of a stomach-tube with a hollow ball at the lower end containing a free ball of platinum. (Fig. V.) By the movements of the stomach walls the platinum ball is moved about in the bulb, coming in contact with the terminals of an electric circuit therein, and by break- ing and making the current, signals the occurrence of gastric movements on a suitable apparatus outside. Heminetei''s KymograpJi. — Einhorn's gastrograph * Deutsche med. Wochenschr., 1887, No. 47, t Zeitschr.f. klin. Med., xxvii. 3I4, s. 242. 112 PO^YER OF ABSORPTION only records the acti\-e movements of the stomach, and Hemmeter has devised another method for test- ing both the active and passive gastric peristalsis. Moritz of ]\Iunich has independently conceived and described a similar apparatus. A deglutable elastic stomach-shaped bag of thin rubber is attached to the end of a stomach-tube. It is introduced while collapsed, and then blown up with air. The outer end of the tube is then attached to a manometer or tambour, and the movements of the stomach walls, however slight, can be registered on paper attached to a revolving drum. A time record is also kept on the paper, and, as the movements of respiration affect the size of the stomach, a separate line indicates the respiratory movements, as recorded by a pneumograph (see p. 162). The methods recommended for the determination of the motility of the stomach can seldom be em- ployed, except in cases where the motor insufficiency gives rise to such characteristic symptoms that the evidence they afford can, as a rule, be only corrobora- tive. The Po-wer of Absorption of the Stomach. The absorptive power of the gastric mucous mem- brane may be tested with potassium iodide. Penzoldt* recommends small doses of this salt, o*i grm. (gr. i|), enclosed in gelatine capsules. A capsule is given, and the time which elapses before iodine appears in the saliva is determined by means of the ordinary reaction with starch paste'. To perform this test a filter paper should be moistened with starch paste * Penzoldt and Faber, Berliner klin, Wochenschr.^ 1882, No. 21. Fig. 5. — Einhorn's Gastrograjjli. (See page 111.) Fig. 6.— Einhorn's Gastric Spray. (See page 121.) Fig. 7. — Einhorn's Deglutable Electrode. (See page 127.) SIZE AND POSITION OF STOMACH I 1 3 and dried, and every five minutes after the capsule has been taken, a drop of the saliva placed upon it. The addition of a drop or two of fuming nitric acid will cause the appearance of a blue colour when iodine is secreted in the saliva. The time which elapses before this reaction can normally be obtained varies from ten to fifteen minutes, but may be delayed from thirty minutes to a whole hour, or even longer, when the absorptive power of the gastric mucous membrane is diminished. It should be remembered in connection with the test that, if the capsule be given without food, it may pass almost at once, indeed before solu- tion of the gelatine, into the duodenum. It should, therefore, be always administered with or soon after food. Another test makes use of rhubarb. Two grains of powdered rhubarb are given, and fifteen minutes afterwards the addition of liquor potassje to the urine should cause the formation of a red colour. Before using any of these tests in which the appear- ance of the drug in the urine is noted, it is necessary to be sure that the patient has not emptied his bladder immediately beforehand. Tlie Size and Position of the Stomach, A description of the usual clinical methods for the determination of the size and position of the stomach does not enter into the scheme of this book. There are several methods, however, which may be legitim- ately described under this heading, without trenching on the purely clinical aspect. One of the earliest instruments suggested for the determination of the lower margin of the stomach H 114 SIZE AND POSITION OF STOMACH consisted simply of a rigid bougie, the point of which could be felt, after introduction, through the abdo- minal wall. This method was found to be not unat- tended with risk, and has consequently been aban- doned. Einhorn's Gastrodiaphanoscope and Turck's Gyro- mele are described elsewhere (pp. 132, 161). When instruments cannot be used, Dehio* directs that the patient should be percussed both when lying down and when erect, after drinking various quan- tities of water. He says that the normal stomach when empty is entirely within the thorax, and is not percussible ; that a quarter of a litre of water produces a dull area, extending 1 1 J cm. below the xiphi-sternum, in the erect posture ; and that a second draught of the same amount lowers the dullness to 27 cm. A litre causes it to reach to almost the level of the umbilicus, generally to within an inch of that spot. On the other hand, Jaschtschenkof avers that the empty and normal stomach is percussible, and that filling it with water causes an upward, not a down- ward, extension of dullness. In cases where much difficulty is experienced in distinguishing the percussion note of the stomach from that of the colon, the stomach may be filled with water, and the colon with air per aiinin, when the sharp demarcation between the dull note of the stomach and the tympanitic resonance of the bowel can readily and accurately be determined. If the colon be loaded, the reverse method may be used. The patient is given some bicarbonate of soda * Separat Abdruck aus den Verkandlufigen des Congresses f. innere Med. ■\ Si Petersburg nied. Woc/i., 29, 1888. SPLASHING SOUND I I 5 in solution, and then a corresponding amount of tartaric acid. The evolution of carbonic acid gas, which resuhs, expands the stomach, and renders the percussion note over it tympanitic, in marked contrast to the dull note of the loaded colon. Another way is to pass the stomach tube and expand the stomach by blowing down it, and has the merit of being quite free from risk. Fleming * suggests a method of combined percus- sion and auscultation, whereby the slightest change in the note can be • detected by a stethoscope placed over the stomach region, where it is uncovered save by the abdominal wall. Splashing Sound, or Clapotement. The sound caused by the movements of the gastric contents when the body is shaken, or the abdominal wall over the stomach strongly percussed, indicates the presence of both fluid and gas in it. It is often obtainable in healthy subjects, and indicates nothing unless the sounds be abnormally loud, or ob- tainable by percussion below the normal lower limit of the stomach. Percussion for this purpose is best performed with the edge of the hand ; but in some cases of dilated stomach, with thin and lax parietes, tapping with the finger may suffice to produce it. Normally, percussion elicits a splashing sound not lower than midway between the sternum and the um- bilicus, and then it is only feeble. In atonic condi- tions the splashing sounds are heard in the same region, but may persist for four to six hours after a * Edin.-Hosp. Reports^ Vol. I. Il6 EXACT QUANTITY OP^ meal, denoting delayed emptying. In simple enlarged stomach — Ewald's megalogastria — the splashing sound may be produced as far down as the umbilicus, while in cases of pronounced dilatation it may be elicited more or less over the whole of the anterior abdominal surface. The localisation of splashing sounds to a somewhat circumscribed, area about the umbilicus and below it, and the absence of these sounds higher up, are suggestive of possible gastro- ptosis. But it must be remembered that forcible percussion of one part of the abdomen often suffices to elicit splashing sounds, although the stomach does not occupy a position directly beneath it. The actual spot under which the sound is produced can in some cases be more accurately determined by combining auscultation with percussion. Another point to be kept in mind is the frequent disappearance of " clapotement " sounds after the first few strokes, owing to the resultant stimulation of the muscles in the gastric walls, and their consequent contraction. The Determination of the exact quantity of the Stomach Contents. As a rule the quantity of chyme can be estimated from the amount of fluid obtained through the stomach tube. In many cases, especially where the stomach walls are lax, all the fluid cannot be with- drawn. Mathieu and Remond * suggest that in such, circumstances a small portion of the contents should be removed through the stomach tube, and, without removing the tube, a measured amount of water * Sec. de. Biologic, Nov. 8, 189c. STOMACH CONTENTS I I 7 poured down it. The patient now, by shaking him- self, etc., mixes the water and the stomach contents, a sample of which is withdrawn. The difference between the acidities of the undi- luted and the diluted samples affords evidence of the total quantity present. Thus, if b represent the undiluted portion ; a, its acidity ; q, the amount of water added, and a the acidity of the diluted contents : ax = c'lq + ax aq , , aq or X = — -, so that x = b + — — , a - a a - a That is, the quantity of the original contents is equal to the number of c. c. of water added, multi- plied by the acidity present after its addition, divided by the result of subtracting the second acidity from the first, and adding the portion withdrawn on the first occasion. Example. Ten c. cm. withdrawn with an acidity of 0"365 per cent. 200 c. cm. of water added, and another sample withdrawn with an acidity of 0-3285 per cent. o'32 85,x 200 . X = 10 + ~^> — ~ pr- = 1810 c. cm. 0-365 -0-3285 CHAPTER IX. THE MECHANICAL METHODS USED IN THE TREATMENT OF THE DISEASES OF THE STOMACH^ Lavage — Auto-lavage — Friedlieb's Apparatus — Gastric Spray (Einhorn) — Needle Douche (Turck) — Treatment by Electricity — Apparatus — External Electrisation — Internal Electrisation — Illumi- nation of the Stomach — Diaphanoscope (Einhorn) — Other Instru- ments — Gyromele (Turck, Boas) — Massage. The Process of Washing Out the Stomach (Lavage). The method of introducing the stomach tube has already been described. It only remains, therefore, to add a few particulars concerning the process of washing out the stomach. After the tube has been passed down and some of the contents of the stomach removed for the purpose of analysis, warm water is introduced into the stomach, until the patient signifies uneasiness from distension of the organ. The funnel is then depressed, and the fluid with the remaining portion of the contents syphoned off into a pail or basin. This process is repeated until the water re- turning through the tube is clear. As, in many instances, the pouring of the water into the funnel carries down a considerable proportion of air with it into the stomach, often causing the patient much pain LAVAGE I I 9 and discomfort, and as this air is frequently expelled through the tube again at unexpected moments, it is a good plan to hold the funnel in the left hand, and, compressing the tube just below with the little finger, to only allow the water to pass slowly down when the funnel is full. - If this is not done, and the water is allowed to run down as fast as it is poured in, much air is carried down with it. If the return flow of water from the stomach is checked at any time, generally owing to blocking of the eyes of the tube with solid particles in the contents, the funnel should be raised, a little more water poured down to dislodge the obstruction, and the funnel again depressed. Usually some small portion of the fluid introduced remains behind when syphonage alone is relied on to empty the stomach. In this case expression by pressure over the epigastrium may be resorted to. Several solutions have been recommended to be used for washing out the stomach. The best seems to be one made by adding a few drops of a solution of permanganate of potash to warm water until it be- comes light pink in colour. A 3 per cent, solution of boric acid, 2 to 4 per cent, of bicarbonate of sodium, or a I per cent, solution of common salt may also be used. The permanganate of potash solution has this advantage over the others, that when the stomach is thoroughly washed out and all the contents re- moved, the returning fluid retains a pink colour ; but should any of the contents still remain, the fluid re- turned is of a brown hue. Aiito-lavage. — The foregoing method cannot be used by the patient himself When a patient, there- fore, is instructed to personally continue the process I20 AUTO-LAVAGE of lavage, another method is called for. In this, the stomach tube is connected bv a glass T or Y tube to a rubber tube running from a reservoir filled with the warm solution to be used, and to another leading into the receiving pail (Frontispiece). The rubber tube Heading from the reservoir is furnished with a pressure clip close above the upper limb of the T or Y tube, and a similar clip is placed on the corresponding part of the lower tube, rather further away from the glass connection (see p. 165 Appendix). The reservoir, for which an ordinary metal douche- can may be advantageously employed, capable of con- taining at least two litres, is filled with the warmed solution and hung on to a nail fixed in the wall a little above the level of the patient's head when sitting down. The clip on the tube leading from it must be closed beforehand. The tube leading from the lower limb of the T is conducted into a pail placed on the floor, or directly into a sink, if con- venient. The clip upon this tube is also closed. The patient now introduces the stomach tube, attaches the upper end to the free limb of the T tube, and pressing the clip on the tube leading from the reservoir, allows the warm water to enter the stomach. When the stomach is full of fluid, the lower clip is opened a short time before the upper is closed. The water from the reservoir at once fills the lower tube in preference to that going to the stomach, following the path of least resistance, and if the upper clip be now closed, syphon action — sufficient to empty the stomach through the lower tube — is started. This process is repeated until the outgoing fluid is clear or almost clear. AUTO-LAVAGE 121 - Friedlich's Apparatus. — Another very simple method by which auto-lavage can be satisfactorily performed is by' Friedlieb's apparatus. This consists of a stomach tube jDrovided with a bulb at a part sufficiently far from the end of the tube to remain outside the lips after introduction of its extremity into the stomach. Compression of the bulb, followed by closure of the tube beyond it by pressure of the fingers, causes, by its succeeding expansion, the stomach contents to be drawn up into it. Closure of the tube between the bulb and the lips and com- pression of the bulb forces the contents out through the funnel at the distal end. The bulb need only be used if ordinary syphonage proves to be insuffi- cient. Einhorn's Gastric Spray* This instrument consists of a stomach tube in which the usual eyes are re- placed by a terminal bulb, having at its extremity a small aperture (Fig. VI.). The tube is introduced into the stomach, which must be empty — ie., after lavage or fasting— the outer end attached to a spray- producer, and the indiarubber pump compressed in the ordinary way. The spray should be set in action whenever the nozzle has entered the cardiac orifice ; that i.s, when the tube has been passed in beyond the teeth of the patient for a distance of i8 inches (45 cm). Antiseptic, analgesic, and astringent solutions may be used for spraying the stomach in this manner. The inventor employs a i to 2 per thousand solution of silver nitrate, 10 c.c. at a sitting, in cases of gastric * New York Afed.Journ., Sept. 1892. 122 LAVAGE - erosions,* or of hypersecretion with hyperchlor- hydria.-j- Tiirck's Needle-Douche. — Dr Turck demonstrated an apparatus which he called a ' stomach needle- douche ' at the meeting of the American Medical Association in May 1895. Two tubes are attached to each other, side by side. One is of smaller calibre than the other, and is only intended to reach the stomach cavity immediately beyond the cardiac orifice. The larger is continued further, and should extend as far as the lowest part of the larger curvature. The smaller and shorter tube is supplied with a small per- forated bulb at its extremity, or is perforated by minute holes towards the lower end, where it termin- ates in a blind extremity. The ball or bulb possesses the advantage that it can be removed and cleaned, and that the tubes may be used without it, a nebulizer being employed instead. Hot or cold water, or both alternately, are forced through the smaller tube under the pressure of a force-pump. A shower bath is thus produced in the stomach, and, if considerable pressure be employed, mucus and adherent material can be removed from the walls, and a powerful vasomotor and muscular stimulating action induced. The larger tube serves to drain off the fluid introduced, and thus to prevent any overdistension of the stomach {c.f. Fig. XIV., p. 164). Indications for Lavage. Lavage is of service, apart from its value for diag- nostic purposes, whenever stagnation of food in the * Berlin, klin. Wochejisck., 20-21, 1895. t Med. Record, Nov. 23, 1895. INDICATIONS FOR LAVAGE 1 23 stomach is present, when there is much mucus in the organ, in cases of hyperacidity, and in many of the various forms of nervous dyspepsia. In cases of nervous origin the mere act of washing out the stomach is often followed by a great amelioration of the symptoms, owing more, perhaps, to stimulation of the nervous system and to mental suggestion than to the actual removal of contents which are often normal in character. Some recommend lavage in the morning before or after breakfast ;• others prefer the evening before bed- time. In severe cases of dilated stomach with hyper- secretion, it may be required before breakfast and before the evening meal, to remove the stagnating remains of food and to permit of the digestion of the food under as favourable circumstances as possible. If the patient suffers from insomnia or restlessness during the night from auto-intoxication due to absorp- tion of the products of gastric fermentation, lavage before going to bed is often followed by marked relief As a rule the best hour of the day, should sleep be un- disturbed, is before breakfast, when as much nourish- ment has been extracted from the ingesta as possible. If sleep is not affected the fermentative processes are seldom very active or deleterious. After lavage, some light nourishment should at once be taken ; liquids such as milk and potash water, or bovril, may be ad- ministered by the tube before withdrawal. If lavage is practised more than once daily, care must be taken to avoid emptying the stomach shortly after each meal. Absorption, in most of the cases in which lavage is beneficial, is slow, and the regular removal of the food within four or five hours of its 124 TREATMENT BY ELECTRICITY ingestion practically starves the patient. Patients, hov/ever, with largely dilated stomachs, due to non-malignant contraction and narrowing of the pyloric orifice, in whom little or nothing can -pass into the duodenum, may derive much relief from the artificial removal of the contents before each meal. Lavage is contra-indicated under the same condi- tions noted already as rendering the passage of the tube inadvisable or dangerous. When. the tube is easily tolerated, however, lavage may be practised in conditions which forbid the use of the stomach tube, because its passage occasions violent retching and dis- comfort. Treatment by Electricity. The application of the Faradic and Galvanic currents is often of service in the treatment of some forms of dyspepsia. The application may be made in two ways :— 1. Both electrodes may be placed upon the skin. 2. One electrode may be introduced into the stomach, the other applied to the skin. Apparatus Required. I. The Battery. — The best form of cell for generat- ing the current is the Leclanche-Barbier, as recom- mended by Herschell. In this cell the outer case is made up of zinc, a cone of carbon occupies the centre, and the space between is filled with a jelly containing chloride of ammonium. The carbon cone is hollow, and when the jelly becomes too dry, it may TREATMENT BY ELECTRICITY 1 25 be moistened by the introduction of a solution of chloride of ammonium into its cavity. 2. A Dial Collector, or a Rheostat. — The first should be so constructed that the cells used can be taken from any part of the series. The rheostat, by diminish- ing the resistance, allows the gradual application of an increased current to the part treated. 3. A Galvanometer. — The best form for use is what is known as a ' dead-beat ' galvanometer, in which the needle moves back at once to its original position without oscillation. 4. De Watteville s Key. — This is necessary to allow of a reversal of the current, or a change in the form of electricity. , 5. A Faradic Coil. — With a key for turning the current on, and two or three cells for generating it. 6. Conducting Cords {Rheophores) and Electrodes. — The conducting cords should be of considerable length. Many forms of electrodes have been recommended, both for external and internal use. I. External Electrodes. (a^ For use where both electrodes are placed on the skin.— For the purpose two large flat electrodes are employed. The one is applied to the anterior . abdominal wall over the gastric region, the other placed on the side close by. Or, if it is desired to apply the current to the sympathetic in the cervical region, the electrode placed on the skin over it should be smaller — i.e., two and a half by one and a quarter inches. Ziemssen got good results by using electrodes of 126 TREATMENT BY ELECTRICITY about 500 to 600 square centimetres in area (80 to 100 square inches), a strong galvanic current, and brief faradisation of the skin of the abdomen, chest, and back. The surface of the electrodes for applica- tion to the skin should be covered with flannel, spongio-piline,.or better, a sponge may be used. A serviceable electrode consists of a sponge about five inches in diameter carried on in a wooden base (Herschell) ; another, of a sponge about three inches .across, in a vulcanite cup. The advantages which accrue from the use of a sponge electrode consist in the greater ease with which it can be cleaned, and in the power it affords the operator of gradually increasing the strength of the current by increasing the pressure whilst applying it. {b.) For 7ise when one electrode only is applied to the skin. — In this case the best results are obtained with large electrodes. A flat electrode, six inches by four, covered with spongio-piline, answers very well. It is placed over the epigastrium. 2. Electrodes for Direct Use in the Stomach. , (<^.) The simplest form of electrode for use in the \stomach consists simply of an ordinary red-rubber stomach tube of large diameter, perforated with several small openings close to the end; if it has a lateral eye, this should be situated nearer the extremity than in the ordinary tube. A flexible metallic rod is also provided, with a rounded bulb at the lower end, very similar to that of an oesophageal bougie. This bulb fills up the lumen of the tube TREATMENT BY ELECTRICITY 12/ completely when passed down it, and is of sufficient length to extend from the tip of the tube up to and beyond the terminal eyes. The rubber tube is passed into the stomach in the usual wa}'. If it is made with one lateral eye of the ordinary size it can be used to wash out the organ and to introduce the water beforehand j the metallic rod is now intro- duced down the lumen. During the progress of the rod the patient should throw back his head as far as possible to straighten the curve of descent, as, although flexible, a metallic rod exerts considerable pressure outwards at the convexity of its curve, thus causing increased pharyngeal discomfort. {b.) EinJiorn's Deglntabk Stomach Electrode. — Ein- horn of Xew York has devised a novel form of electrode, in the shape of an ovoid hard-rubber capsule about the size of an almond. The capsule is perforated with numerous e}-elets (Fig. VII.) and con- tains a small button electrode. The electrode is con- nected with a delicate wire covered with indiarubber, which is continuous with the rubber of the capsule. To use it, the patient drinks a glass of water, when fasting, or after a light meal, then opening his mouth widely the capsule is placed far back on the root of the tongue. Taking a mouthful of water and swallowing, the capsule passes easily over the pharynx, and iinds its way into the stomach. A mark on the rubber cord, 1 6 inches (40 cm.) from the capsule, serves to denote when the electrode has reached the stomach — i.e., when the mark comes to the teeth. Once in the stomach the connecting wire is joined to the negative pole of the batter}-. If on withdrawal of the capsule any resistance be 128 TREATMENT BY ELECTRICITY felt at the cardiac orifice of the stomach, no force should be used. Let the patient swallow once or twice, and at the moment when the larynx rises during deglutition, slight traction will serve to withdraw the electrode. (c.) Ewald has modified Einhorn's electrode, and in- vented a .very useful instrument. It consists of a hollow sound of rubber, about the size of a Nekton's catheter No. 13, through which the wire is dra^vn. The wire terminates in an electrode very similar to that suggested by Einhorn, but the greater rigidity of the connecting tube renders it possible to exert some force on the electrode should its passage down be arrested in the oesophagus, as sometimes occurs dur- ing the use of Einhorn's instrument. Details of the Application. External Electrisation. I. Galvanisation. — The electrodes used should be thoroughly soaked with warm salt and water, and it is as well to wash the skin with soap and water beforehand. The connecting wire from the negative pole of the battery is attached to the electrode placed over the epigastrium in the direction of the long axis of the stomach. This electrode should be as large as pos- sible. The positive and smaller electrode is applied on the left side of the abdomen, close to the first. If the patient be a male he can hold the larger electrode in position himself, and a sponge electrode may be used. In female patients the dress need only be TREATMENT BY ELECTRICITV I 29 loosened, and an electrode covered with flannel used. The pressure of the clothes suffices to keep it in position. The sitting should not last longer than from five to ten minutes, and the current used should be strong enough to cause marked contractions of the abdominal muscles, apart from the causation of pain. The positive electrode may be placed on other parts of the body if desired ; over the sympathetic in the neck, as Baradini * has recommended ; or over the spinal cord, when the electrode may be slowly passed up and down the spine, or it may be fixed in one position. 2. Faradisation. — In applying this form of elec- tricity two small electrodes may be employed, placed one or two inches apart over the stomach region ; or a large flat electrode may be placed over the stomach, and another on some insensitive part, as over the buttocks. The application may last ten minutes, and the current used should be strong enough to cause muscular contractions. It is often advisable, especially in neurasthenic cases, to apply the current to the spinal region. The smaller electrode should then be slowly passed up and down the spine, and especial attention paid to the left side in the cervical region, to stimulate the left pneumogastric nerve which chiefly goes to the stomach. The electric brush can be used if a more stimulat- ing effect is desired, when the current should be just strong enough to produce sparks betv\-een the brush and the skin. The skin must be dried thoroughly beforehand. * Journ. de la Soc. Scz'ent., 1891, No. x., p. 97- I 130 treatment by electricity Internal Electrisation. As noted above, the application of the electric current directly to the stomach should only be under- taken after fasting, or after washing out the organ. To prevent any direct contact between the mucous membrane and the actual electrode, the stomach must be partially filled with water. If the case be one of great gastric dilatation, a considerable quantity of water may be required, as the current only affects those parts of the viscus in contact with the water. Galvanisation. — The large electrode placed on the abdominal wall is connected with the positive pole, and should be moved about over the stomach region. The current used is of a strength equal to from 15 to 20 milliamperes, and should not be continued for more than eight minutes at each sitting. Faradisation. — The external electrode should be kept in motion over the skin of the gastric region, and current used as rapidly interrupted as possible. In this way the application is rendered much smoother. As before, the strength of current em- ployed must be such as to cause muscular contractions without giving rise to pain. Indications for the Use of Electricity. In atony of the stomach walls. — Faradisation, both internal and external, acts most beneficially. If the atony be an accompaniment of neurasthenia, the continuous current should also be used. In dilatation of the stomach. — The evidences of its effects here are very conflicting, but it acts beneficially in cases of moderate enlargement, especially if associ- ated with nervous symptoms. TREATMENT BY ELECTRICITY I3I Gastralgia. — For this it may be used externally first, and, if necessary, directly to the stomach wall afterwards. Hypochlorhydria. — The internal application of the interrupted current acts better in such cases than the use of the galvanic stream, or external electrisation. Illumination of the Stomach. Einhorn has invented an instrument for the direct illumination of the stomach cavity, by means of which a slightly luminous area, corresponding to the portion of the stomach uncovered by other tissues save the abdominal wall, can be seen on the anterior wall of the abdomen in a darkened room (Fig. VIII.). The Gastrodiaphanoscope, or, as it has been more lately christened, the Gastrodiaphane, consists of a soft rubber tube, such as is usually employed in lavage, bearing at the end an Edison lamp of hard glass. The electric lamp is connected with a battery by two wires enclosed in the tube. The lamp is connected with the" stomach tube by means of a metal mounting. The lamp and the mounting are of the same diameter as the tube. Before using the instrument on the human subject, it is as well to attach it to a battery, and, immersing the lamp in water, to test its stability by passing through it a somewhat higher current than is used when in the stomach. The patient should drink one or two full tumblers of water beforehand. To avoid all untoward consequences, the stomach should be almost full of water. When the current is turned on in a darkened room, a feebly-illuminated area of the abdominal wall may be seen. This area, in healthy people, corresponds to the portion of 132 OTHER INSTRUMENTS the stomach uncovered save by the abdominal walls, and is situated below, and a little to the left of the xiphi-sternum. In dilatation of that organ, or in gastroptosis, the illuminated area takes a lower position, and a more rectangular shape. In some cases, under favourable circumstances- — that is, when the abdominal walls are thinly clothed — thickenings and tumours of the gastric walls may be shown by a local decrease in translucency, or by an altered form of the luminous area. (Figs. IX-XI.) It is evident that this instrument can only prove of value under favourable conditions. If the patient be stout, little or nothing can be seen, while a pyloric tumour is only perceptible when the end of the tube is able to be introduced below and behind it, as in a dilated stomach, where the greater curvature hangs down to a lower level than the tumour. Other Instruments. Turck's Gyroniele. — Fenton B. Turck * describes in this journal an instrument which he had invented some time previously. Designed to indicate the position, shape, and size of the stomach, it is called the ' Gyromele,' and consists of a tube containing a cable, with a sponge at its extremity. An apparatus for producing rapid rotation of the cable and the sponge attached to its lower extremity is attached to the outer end. After introduction of the tube into the stomach, if the cable be passed onwards down it,, the rotating sponge glides over the mucous membrane of the larger curvature, turns up towards the pylorus, and then along the smaller curvature. The positions '^.New York Med. Jourti.^ Feb. 22, 1896. Fig. 8. — Einhorn's Gastro-Diaphanoscope. (Seepage 131.) Fig. 9. — Normal transillumined area. (See page 132.) Fig. 10. — Area transillumined in Dilatation. (See page 132.) Fig. 11. — Area transillumined In Gastroptosis. (See page 132.) OTHER INSTRUMENTS 1 33 of the cable and sponge can be easily felt through the abdominal wall if rotated rapidly. When cables of different flexibility are used, the distensibility of the stomach walls can be gauged. Thus a very flexible cable is used first and pushed in until it meets with resistance at the lesser curvature. The length intro- duced is noted. The revolving sponge is at the same time palpated through the abdominal wall, and the depth of descent ascertained. A stiffer cable is now used in the same way, and the difference between the length of the stiff cable which has been introduced before the resistance is felt and that of the more flexible one, serves to indicate the power of distension of the walls. (Fig. XII.) The movements of the gyromele can sometimes be felt behind the liver, and in thin subjects the rotatory movements of the sponge can even be seen through the abdominal wall. If the stomach be prolapsed the sponge can be felt as it follows the lesser curvature below the margin of the liver. The revolving sponge acts also as a curative agent by removing any mucus adhering to the mucous membrane, can be used for the direct application of therapeutic substances, or as an electrode capable of applying the electric current topically to various parts of the organ. The vibratory effects arising from its use are often of service in cases of dilated stomach ; the motor power of the stomach is stimulated, and the mucous membrane becomes more vascular from its rubbing or massage-like action. Boas * uses a modified gyromele in which the sponge is attached to the end of a soft solid bougie, * Cenlralbl. f. iimere Med.^ Feb. 8, 1896. 134 MASSAGE and the apparatus rotated as in Turck's instru- ment. Massage of the Stomach. Little need be said here about massage for stomach diseases. It is especially indicated in cases of dilated stomach, nervous dyspepsia, and, indeed, all cases with delayed motility. It may with advantage be combined with electrical treatment. At first the patient should be placed on his back with, his legs bent and his head slightly raised, two or three hours after a meal. Massage of the abdominal wall over the stomach is then begun, from the cardia towards the pylorus. The patient is then placed on his right side and petrissage per- formed from over the pylorus towards the cardia. The sitting should last about fifteen minutes. It has been found to shorten the duration of emptying of the stomach — by an hour in some cases. In cases of moderate stagnation of the stomach contents, good may often accrue if the patient be told to lie on his right side at night, and to person- ally rub the epigastric region from the left side up- wards and to the right. CHAPTER X. THE MECHANICAL METHODS USED IN YOUNG CHILDREN. By JOHN THOMSON, M.D., F.R.C.P. Ed. Gavage — by the Nose — by the Mouth — Indications ; Lavage — Method — Indications. The mechanical treatment of the stomach in young children may be considered under two heads — (i) Forced Feeding, or Gavage ; (2) Stomach Washing, or Lavage. Both these measures are simple of application and of great value in suitable cases as therapeutic measures. At present, however, the use of the latter as an aid to diagnosis is limited to excep- tional cases. 1. Forced Feeding, or Gavage. MetJiods and Appai'-atus. — There are a great many devices by the use of which fluid food and medicine can be introduced into the stomach of a child who is unable or unwilling to swallow them in the ordinary way. In some of these the nose is used as the way of access to the pharynx, while in others the food is passed through the mouth. {a) Nasal Feeding. — Of this there are several 136 GAVAGE methods. The first of these, and the simplest, consists in pouring a bland form of liquid nourish- ment into one nostril, through which it rapidly finds its way into the pharynx and is inevitably swallowed. In doing this, the child should be kept lying on his back, and his head must be held steady. The food given must, of course, be quite unirritating in char- acter {e.g. milk). It is poured into the nose by means of a glass or rubber ear-syringe, over the nozzle of which a short piece of indiarubber tubing has been fitted ; or a special spoon may be used, the sides of which are folded over near the point, so as to form a kind of narrow spout. The process of feeding must take place slowly, and regular pauses must be made to allow of swallowing. , The second method resembles the first in all respects, except that the rubber tube attached to the nozzle of the syringe is long enough in this case to reach through the nasal cavity to the nasopharynx. It is used when the fluid to be given is of such a nature as to irritate the delicate mucous membrane of the nose. When the fluid is bland, the first method is preferable, as the pressure of the rubber tube is itself a cause of irritation. The third method consists in the passage of a tube through the nose, pharynx, and gullet into the stomach. For this a soft rubber catheter. No. 12 or No. 1 3 (French), is suitable. It is thoroughly oiled and passed backwards through the nose into the pharynx. This may be done with the patient lying on his back; but often, in older children especially, the sitting posture is preferable When the end of the catheter reaches the pharynx, there is often retching, and GAVAGE 137 some resistance is felt. The patient's head should then be inclined slightly forward and the tube pushed gently on. When it gains the oesophagus it generally ceases to irritate the pharynx ; and, soon after, the passage of gas and liquid from its upper end indicates that it has reached the stomach. The catheter occasionally passes into the larynx ; this is not common, and its occurrence is at once announced by the onset of cough and dyspnoea. Much more frequently it finds its way forward into the mouth, and this is very apt to happen if there is much coughing or retching while the end of the catheter is passing the pharynx. When the catheter has reached the stomach and the retching has stopped, the food is introduced into it by a funnel or syringe. Probably the best funnel for the purpose is a glass syringe of moderate size from which the piston has been removed. It fits into the catheter easily, and, should any obstruction occur in the process of feeding, the piston can be replaced and used to clear it away. While the catheter is being with- drawn, its end must be tightly compressed, lest the few drops remaining in it should get into the larynx in passing. {b) Forced Feeding by the Month. — This is generally carried out by the passage of an oesophageal tube into the stomach. The apparatus required is the same as that used for stomach-washing, namely : a soft rubber catheter, connected by an inch or two of glass tube, and a foot and a half of rubber tubing with a vulcanite funnel, large enough to hold from 3 to 6 oz. The catheter should have one or two extra eyes, and its 138 GAVAGE size varies with the size of the child from Xo. 14 to No. 18 (French). The child is placed flat on his back, his head being held steady by an assistant. 1 he left forefinger is then placed lightly on the tongue to depress it, while with the right hand the catheter, well oiled, is passed down the phar3'nx for 8 or 10 inches. The stomach being reached, the funnel is raised for a few moments to allow the escape of gas. The food is now poured into the funnel and rapidly finds its way into the stomach. When the funnel empties, the tube is tightly compressed, and rapidly, but gently, with- drawn. If the withdrawal of the catheter is done slowly or carelessly, it is apt to excite vomiting. In infants who have no teeth, or only one or two, no gag is required. In older children some sort of gag is necessar}^, as there is otherwise danger of the tube being bitten. In them, however, the process is much more difficult than in babies, and not nearh- so generally useful. A simpler form of forced feeding (first recom- mended by ]\Ir Scott Battams) often proves of great value. For this all that is necessary- is an ordinary glass or ball s}-ringe, to the nozzle of which four inches of rubber tube are attached. The child, who is refusing food, or who for some reason ought not to be allowed to suck in the ordinar}' way, is laid on his back, the tube is passed towards the back of the mouth, and the liquid is gently injected. In older children who close their teeth, the tube may easily be passed backwards inside the cheek, and the liquid thus readily reaches the pharynx. GAVAGE 139 Indications for Forced Feeding. In children these are many and various, and the method chosen must depend on the requirements of the case in hand and on the nature of the fluid to be administered. The following are perhaps the most important conditions in which forced feeding proves valuable. 1. In the rearing of preniaUire infants, periodic feeding, either through the nose with a spoon or by means of a catheter passed through the mouth, has been found of great use. It was first made use of by Prof Tarnier of Paris. 2. Similarly, in young infants and others who are so weak that the effort of sucking and swallowing exhausts them, great benefit may be got from forced feeding either through the nose, or preferably through the mouth by Mr Scott Battams' method. 3. In some cases of prostration {e.g. in typhoid) there is obstinate refusal of all food and medicine to an extent which seriously endangers life. These cases may be effectually treated by one of the methods of nasal feeding or by the syringe and short tube. 4. The same methods are very serviceable when swallowing is interfered with by pain due to ulce^'ation of the mouth or throat. 5. A few years ago, Dr Kerley drew attention to the fact that regular forced feeding by means of an oeso- phageal tube passed into the stomach was extremely useful in persistent vomiting in infants. Babies who are not able to retain even a teaspoonful of fluid swallowed in the ordinary way, can usually retain a much larger amount of nourishment if it is I4Q LAVAGE IN YOUNG CHILDREN poured into the stomach through a catheter. The explanation of this remarkable fact is obscure, but of the value of its application in practice there can be no doubt whatever. 6. When in cerebral cases, in cases of narxotic poisoning, and in convulsive conditions such as tetanus, the process of swallowing is interfered with, life may be prolonged and sometimes saved by forced feeding with a tube either through the nose or mouth. In the same way, in cases oi diphtheritic paralysis affecting the pharynx, feeding through a tube is of the greatest value in keeping the patient alive until the part recovers its function. 2. Stomach Washing, or Lavage. Methods and Apparatus. — A soft rubber catheter connected with a vulcanite funnel by i8 inches of tubing, such as is used for ordinary gavage, consti- tutes the best apparatus for stomach washing. The catheter used should be the largest that can be easily passed, and should have two or three eyes. Plain luke- warm water is probably as good as any other fluid. The child is made to sit or lie on his mother's knee with his face looking towards her left side, and with his clothes and hers duly protected by a mackintosh sheet. A slight pressure on the chin generally makes him open his mouth, and the catheter is then passed gently backward over the tongue, and down the oesophagus, as already described in speaking of gavage. When the stomach is reached and the funnel has been momentarily raised to allow any gas present there to escape, the water is poured into it from an ordinary jug. Jn doing this one must be careful, LAVAGE IN YOUNG CHILDREN 14[ especially in weakly children, not to over-distend the stomach by running in too much water at a time, or by holding the funnel too high. When a sufficient amount of water has been introduced, the funnel is lowered, and the contents of the stomach rapidly fill it by syphon action, and are allowed to run away. The tube is then pinched to prevent the entrance of air, the funnel raised again and refilled with water, and the process repeated. The washing -out should be continued until fragments of curd, etc., cease to be found in the returning fluid. Indications for Stomach Washing. 1. In so-called ' sinmner diarrhcea' or ' iniik infec- tion'^ stomach washing, combined with irrigation of the lower bowel, constitutes the most rational and successful preliminary treatment. When first intro- duced it was supposed that it should only be em- ployed in those children who were not very weak. It is now recognised that the weaker the infant the more important is it to wash out his stomach without delay, because the very active poisons to which the most alarming symptoms are due can be partially removed in this way. The process itself is practically without danger if carefully carried out. 2. In all forms of chronic vomiting of gastric origin in children, irrigation of the stomach may be useful ; but owing to the practical difficulties met with in its application to older children, its use is mainly confined to babies. In a great many cases one washing-out is sufficient to initiate improvement in the symptoms ; in others, the process may have to be repeated daily for several days. Not infrequently in an infant who 142 LAVAGE IN YOUNG CHILDREN has been vomiting several times a day for weeks, the symptom will cease altogether after one washing-out of the stomach. This may be the case even when, owing to blocking of the tube with curd, the irrigation has been so imperfectly carried out that no improve- ment is expected. Further, it has been found that in some cases mere passing of the stomach tube, and holding it in position for a minute or two, seems to exert a favourable influence and stop the vomit- ing. The writer is not prepared to give a satisfactory explanation of this curious fact, but has observed it sufficiently often to be sure that the improvement which follows in these cases is more than a mere coin- cidence. References. W. Scott Battams. — Lancet, June 16 and 23, 1883. L. Emmett Holt. — New Yorh Med. Record, April 28, 1894. Chas. G. Kerley. — Archives of Pediatrics, February 1892. CHAPTER XL CLASSIFICATION OF GASTRIC CONDITIONS. In Relation to the Variations in the Acidities — To the Digestive Power — To the Duration of Digestion. Classification of Gastric Conditions in relation to the Acidities Present. I. Acidity Normal. Total acidity rising to 0"2 5-0'35 per cent. HCl. Free hydrochloric acid present up to O'l per cent. Lactic acid in traces in early stages. Hydrochloric acid combined with proteids, increasing until third stage, 0"2-0"3 per cent. No free HCl in first stage, unless food be free of proteids. In health. (Free HCl may be absent during most of digestion, if the food taken be in large bulk, and chiefly of proteids.) In dyspeptic symptoms, and haemorrhage, from congestion of the liver. Gastric erosions (occasionally). Carcinoma of the cardiac end, or of the oesophagus. 144 CLASSIFICATION OF Sometimes in pyloric carcinoma, especially if arising after previous ulceration. In many cases of nervous dyspepsia, and dyspepsia accompanying anaemia, or chlorosis. 2. Increased Acidity. Hyperacidity. (a.) Due to an ina^ease of Hydrochloric Acid. Total acidity high, 0"3-0"45 per cent. Free hydrochloric acid in excess, 0'2-0'3 per cent. Combined hydrochloric acid normal. Free HCl appears early. First stage, therefore, short, and lactic acid may be absent. After a large proteid meal acidity may rise to a high point. In most cases of gastric ulcer, and of gastric erosions. From nervous causes. (Simple hyperchlor- hydria.) In some cases of dilated stomach. Hypersecretion of gastric juice. (Gastro- succorrhoea continua periodica, vel chronica. Reichmann's disease; Gastro- xynsis. Rossbach's disease.) {b.) Due to an increase of Organic Acids along with lessejied secretion of Hydrochloric Acid. Total acidity high but variable, 0"3-0"8 per cent. Free hydrochloric acid absent or only in traces. GASTRIC CONDITIONS 1 45 Combined HCl generally small in amount. First stage long, lactic acid present. Lactic and volatile fatty acids present during later stages. In carcinoma of the pylorus and adjacent parts. Dilatation of the stomach ; a, with pyloric obstruction ; b, with atony of walls. Atonic dyspepsia, and chronic gastric catarrh. In some cases of nervous origin, functional in character. In the later stages of chronic ulcer, owing to- catarrh. 3. Hypoacidity. {a.) Acidity composed cJiiefly of Hydrochloric Acid. Total acidity low, 0-05-OI5 per cent. Free HCl absent, or in traces. Combined HCl small in amount, o-05-o-i per cent. All stages prolonged; lactic acid present ia first, or throughout. Traces of volatile organic acids present. In Hypochlorhydria, without fermentation. Acute gastritis, during recovery, or at com mencemen t. Carcinoma of the stomach, without bac- terial fermentation. Cirrhosis ventriculi. In moderate dilatation of the stomach without fermentation. During acute or chronic febrile and sup- purative disorders. K J 46 CLASSIFICATION OF ((5.) Acidity due to Organic Acids. In extreme cases of atrophy of the mucous membrane of the stomach ; in cancer ; waxy degeneration ; cirrhosis ; phleg- monous gastritis ; and in the most acute stages of febrile diseases. Here little or no hydrochloric acid is secreted, and any acidity which may be present is due to the organic acids of fermentation. From the table given above, it will be seen that different conditions may accompany the same disease or form of gastric disorder. The variations are due very largely to the absence or presence of bacterial fermen- tation, and, in a less degree, to the existing amount of motility possessed by the stomach walls. The main indications consist in the recognition of the amount of acidity per cent, of the contents, and the determination of the proportion of the total acidity, which is composed of hydrochloric acid, free or combined. The nature of the acids producing the acidity not due to hydrochloric acid affords a means of recognising the nature of the fermentative process at work in each individual case. Classification in Relation to Digestive Po"wer. I. Normal or Increased. Hydrochloric acid and pepsin may be increased. In health. Gastric ulcer, and gastric erosions. Hyperchlorhydria. GASTRIC CONDITIONS 1 47 Many cases of nervous dyspepsia. Many cases of cancer of oesophagus and cardiac end of stomach. Early stages of catarrh. Early stages of dilated stomach from pyloric obstruction, not due to cancer. Hypersecretion. 2. Diminished. {a.) Due to diminution of Hydrochloric Acid. Cancer of pylorus and body, earlier stages. Chronic catarrh, early stages. Severe nervous depression. Dilated stomach. {b^ Both Hydrochloric Acid and Pepsin diminished or absent. Atrophy of mucous membrane. Cancer of pylorus and wall in the later stages. Chronic catarrh, later stages, or with atrophy of cells. Dilated stomach if accompanied by catarrh. Acute gastritis. Acute fevers. Phthisis, especially towards the end. Cirrhosis of stomach. Speaking generally, in functional disorders of the stomach there is seldom any marked diminution in the secretion of pepsin, although the amount of hydrochloric acid may be much lessened. In organic diseases the secretion of the acid is affected before that of the pepsin, but the latter is markedly dimin- ished in the course of time. 148 CLASSIFICATION OF GASTRIC CONDITIONS Classification in Relation to the Duration of Digestion. 1. Normal. In health. Megalogastria. Gastroptosis without dilatation (may be slightly delayed). Gastric ulcer (may be shortened). Hyperchlorhydria (may be shortened), and hypersecretion. Gastric erosions. 2. Lengthened. (a.) From decreased motility. Dilated stomach. Cancer of pylorus, early stages. Many cases of nervous dyspepsia. {b}) From decreased digestive pozver. Atrophic catarrh. Acute gastritis. Cancer of walls and cardiac end. {c.) From both causes. Cancer of p}'lorus, later stages. Cirrhosis of stomach, and dilated stomach with catarrh. Many cases of nervous dyspepsia. CHAPTER XII. THE APPARATUS AND REAGENTS REQUIRED IN THE EXAMINATION OF THE STOMACH CON- TENTS. Apparatus — Reagents — Tables of Standard and Deci-normal Solutions — and of their Equivalents. I. Apparatus. (rt.) For the usual clinical methods^ ivitJwut special arrangements. Pipettes to hold 2, 5, and 10 c. c. Pipettes are usually more accurately gradu- ated and satisfactory than the ordinary measure-glasses. Measure graduated in cubic centimetres to hold 50 or 100 c. c. Two or three urine glasses. Iron tripod and copper gauze. Porcelain evaporating basins, to hold 20 to 100 c. c. Glass beakers, as thin as possible, to hold 50, 100, and 1000 c. c. Spirit lamp, or Bunsen burner. Glass funnels, 3 and 6 inches in diameter. Test tubes. Filter papers. Glass rods. Two burettes to hold 50 c. c, graduated in 5ths of a c. c, preferably with Shellbach's band. 150 APPARATUS Burette stand, double. Water bath. This may be dispensed with when evaporating fluids, by floating the evaporating dish on water in a larger basin ; the addition of some common salt to the water in the outer basin hastens the process of evaporation as its boiling-point is raised. Half-a-dozen fireproof porcelain crucibles, to hold 20 c. c. Microscope. (b.) WheJi special analytical facilities are accessible. In addition to the apparatus detailed above : — Drjnng chamber, capable of being kept at a constant temperature : 100° or 110° C. Separating funnels. Sand-bath. Balance, to weigh to O'OOi grm. Nickel, or platinumx capsule. Carbonic acid apparatus. Bacteriological requisites. Gas-volumetric apparatus, for Mierzynski's method. 2. Solutions. Colour Reagents. Alcoholic. 1. Phenol-phthalein, 2 to 4 per cent, 2. Congo red, saturated. 3. Gunzburg's. Phloroglucin, 2 grm., gr. xxx. Vanillin, i grm., gr. xv. Absolute alcohol, 30 c.c, §j. APPARATUS 151 4. Boas' reagent. Resorcin, 5 grm., gr. Ixxv. White sugar, 3 grm., gr. xlv. Dilute alcohol, 100 c.c, §iijss. 5. Dimeth}4 -amido - azo - benzol, 0'5 per cent, in absolute alcohol. 6. Cochineal. 7. TropKolin OO, i in 30. Water}-. 1. Litmus. (A more delicate solution of this dye is that termed Azolitmine. Powdered litmus is extracted with boiling water, eva- porated to small bulk, acidified with acetic acid, further evaporated almost to dryness, and then precipitated with 85 per cent, alcohol. The precipitate is collected, dissolved in water, and a drop of chloroform added to pre- serve it. * 2. Benzo-purpurin. Saturated solution. 3. Mohr's reagent. 10 per cent, solution of potassium sulpho- cyanide, 2 c. c, 5ss. Solution of acetate of iron (neutral),. 0'5 c. c, nx viij. Distilled water, 20 c. c, 5vj. 4. Perchloride of iron, diluted with water until almost colourless. 5. Uffelmann's reagent. A few drops of a dilute perchloride of iron solution. 10 c.c. of 2 to 5 per cent, carbolic acid (sijss). * Pharmaceul.Jovni., vol. Ivi, March 7, 1896. 152 SOLUTIONS 6. Sodium-alizarin-sulphonate, i per cent, in water. •Other Solutions. 1. Lugol's solution. Iodine, OT grm., gr. iss. Potassium iodide, 02 grm., gr. iij. Distilled water, 200 c. c, §vj., 3vj. 2. Deci-normal solutions of: — Caustic soda, 4-0 grm. in lOOO c. c. Hydrochloric acid, 3'65 grm. in lOOO c. c. Silver nitrate, lyo grm. in lOOO c. c. Sulphocyanate of ammonium, y6 grm. in 1000 c. c. 3. Standard Solutions. 1. Silver nitrate, 29-075 grm. in lOOO c.c, i c.c. 001 grm. NaCl, or 0'Oo624 grm. HCl. 2. Fehling's solution, loc. c. =0-05 grm. glucose; and sulphate of copper, 5 per cent. Caustic soda, 10 per cent. Hydrochloric acid. Acetic acid. Nitric acid. Trichloracetic acid, 10 per cent. Tables of Standard Solutions and Equivalents used in the Different Methods. Normal and Deci-normal Solutions. Normal solutions of all chemical bodies for use in analysis contain in each litre the exact amount of each substance in grammes which corresponds to its molecular weight. STANDARD SOLUTIONS I 53 Deci-normal solutions are formed from normal solu- tions by diluting them ten times with distilled water. . Thus sodium hydrate with a molecular weight of 40 (23 + I + 16) forms a normal solution in water when each litre contains 40 grammes, or a deci-normal solution when the litre contains 4"0 grm. A known quantity of a normal solution of one substance is exactly equivalent to the same quantity of a normal solution of another. Thus a normal solution of hydrochloric acid contains 36-5 (i + 35'5) grm. in each litre, or 3-65 grm. in the same quantity of its deci-normal solu- tion. 1000 c. c. of either solution exactly neutral- ises 1000 c. c. of the corresponding solution of sodium hydrate. If the substance used be dibasic or tribasic, the amount in each litre of its normal solution is only one- half or one-third of its molecular weight. So as H2SO4 is dibasic, its molecular weight being 98 (2 -h 32 + 64) , only 49 grm. are contained in each 1000 c. c. of its normal solution. Similarly, oxalic acid (126) forms a normal solution with 63 grm. per litre. Deci-normal solutions are generally employed in the analysis of gastric contents. To make a deci-normal solution of sodium hydrate, for example, a little more than 40 grm. of caustic soda should be dissolved in about 900 c. c. of distilled water, and more water added up to the 1000 c. c. It is then titrated against a standard deci-normal solution of an acid, of which a small quantity of guaranteed accuracy can be obtained from a chemical laboratory. If 10 c. c. exactly 154 STANDARD SOLUTIONS neutralise lO c. c. of the acid solution, the solution is of the proper strength. If, however, gS c. c. suffice to turn litmus or phenol-phthalein blue or pink respec- tively, 2 c. c. of water must be added to each 9-8 c. c, or 20 c. c. to each 980, to correct the error. When more of the soda solution than of the acid is used, it is too weak, and more soda must be added. It is easier to add an excess at once, and then to calcu- late the additional water required, than to try to add the exact amount of soda. The solution as corrected must again be standard- ised against the acid, and any necessary correction made. If the solution of soda be used uncorrected, as for instance when 9'8 c. c. corresponds to 10 c. c. deci- normal acid, the proper result of a titration with it can be obtained by regarding each 9'8 c. c. as equal to 10 c. c. of the acid. So if hydrochloric acid be used, and 9-8 c. c. of the soda neutralises 10 c. c. of the acid, 9-8 c. c. is equivalent to 0'0365 grm. HCl. If the quantity of the stomach contents titrated be 10 c. c, the amount of acid equivalent to the number of c. c. of deci-normal soda solution added, multiplied by 10, will give the acidity per cent, in terms of the acid value made use of in the calculation. If 5 c. c. are titrated the amount obtained is multiplied by 20, or if only 2 c. c, by 50, to obtain the percentage acidity. Thus 10 c. c. of a stomach contents required N 7'5 c. c. — soda = 0-02737 grm. HCl. 5 c. c. „ 375 c. c. ,, =0-013687 grm. HCl. 2 c. c „ 1-5 c. c. „ =0-00547 grm. HCl. STANDARD SOLUTIONS 03 IMultiplying the first by lo, the second by 20, and the third by 50, the acidity/^;- cent, as HCl is 0-2737. Table to show the Acidity per cent, in terms of HCl when 10 c. c, 5 c.c, and 2 c. c. of the stomach con- tents are titrated in relation to the quantit}^ of Deci-normal Sodium Hydrate Sokition used. N ^. ^^^ HCl per cent. — NaHO. 10 HCiin ^raimies. 10 c. c. titrated. 5 c. c. titrated. 2 c. c. titrated, j •I 0-000365 0-00365 0-0073 0-01825 •2 "0007 3 0-0073 00146 0-0365 •3 o*ooi095 0-01095 0-0219 0-05475 •4 0-00146 0-0146 0.0292 0-073 •5 0-001825 0-01825 00365 0-09125 •6 0-OC2I9 0-0219 0-0438 0-1095 7 0-002555 0-02555 0-0511 0-127 •8 0-00292 0-0292 0-0584 0-146 ■9 0-003285 0-03285 0-0657 0-164 i-o 0-00365 0-0365 0-073 0-1825 I -I 0-004015 0-04015 0-0803 0-20075 1-2 0-00438 0-0438 0S76 0-219 1-3 0-004745 0-04745 0-0949 0-23725 I '4 0-00511 0-0511 0-1022 0-2555 I'd 0-005475 0-05475 0-1095 0-2737 1-6 o-oo5?4 0-0584 O-I16S 0-292 17 0-006205 0-06205 O-I24I 0-31 1-8 0-00657 0-0657 0-1314 O-32S 1-9 0-006935 0-06935 O-I3S7 0-346 2-0 0-0073 0-073 0-146 0-365 3-0 o'oio95 0-1095 0-219 0-5475 4-0 0-0146 0-146 0-292 0-73 5-0 0-01825 0-1825 0-365 0-9125 6-0 0-0219 0-219 0-438 1-095 7-0 o'02555 0-2555 O-51I — 8-0 0-0292 0-292 0-584 — 9-0 0-03285 0-3285 0-657 — lo-o 0-0365 0-365 0-73 — 156 STANDARD SOLUTIONS When the acidities are expressed in terms of hydro- chloric acid, it is convenient, for purposes of compari- son, to express the chlorine values in the same way. Mohr's Standard Silve?^ Nitrate Solution. This solution contains 29-075 grm. of pure nitrate of silver in the litre, and each cubic centimetre corre- sponds to '006 grm. of chlorine, or 'Oi grm. of sodium chloride, or "00624 grm. HCl : — Thus '029 X "2088 — "006 grm. chlorine. ' '029 X '3441 = "01 grm. NaCl. •029 X -2147 = -00624 grm. HCl. To express chloride of silver in terms of hydro- chloric acid, its weight is multiplied by 0-25427. Solutions used in Martius and Liittke's Method. Deci-nornial Acid Sohition of Silver Nitrate. 17 grm., or, more exactly, 16-997 grm. of dry and pure nitrate of silver, are dissolved in 900 c. c. of a 25 per cent, pure nitric acid solution. 50 c. c. of the ' liquor ferri sulfurici oxidati ' of the German Pharmacopoeia are added, the same quantity of the liquor ferri persulphatis, B.P., may be substituted for this — and the mixture made up with distilled water to 1000 c. c. ; or more than 17 grm. of the silver nitrate may be used, and the solution standardised against an exact deci-normal solution of hydrochloric acid. Each cubic centimetre of the solution is equivalent to one c. c. of deci-normal HCl, or 0-00365 grm. STANDARD SOLUTIONS ■ 1 57 Deci-norinal Avimoniuin Stilphocyanate Solution. When correct, this solution should contain y6 grm. of pure NH^ CNS in each litre. To make it, 8 grm. of the salt are dissolved in looo c. c. of distilled water, and the mixture standardised against the acid silver solution. For this purpose a burette is filled with it, and lo c. c. of the silver solution placed in a beaker and diluted with distilled water to about 200 c. c. The sulphocyanate solution is run in until a permanent red colour results. If only 9-5 c. c. are required, 950 c. c. of the sulphocyanate solution must be made up to 1000 c. c. with distilled water. The new solution is now titrated a second time against the silver solution. If the difference between them be small, the number of c. c. required for 10 c. c. of the silver solution is noted, and the correct result of any subsequent titrations worked out by cal- culation. If correct, i c. c. corresponds to i c. c. of the silver solution. Deci-norinal Solution of Nitrate of Silver. 170* grm. (AgN03==i7o) in the litre forms a normal solution, therefore a litre of the deci-normal solution contains 17 grm. I c, c. of this, or -017 grm. AgNOg, corresponds to •00365 grm. HCl. That is, I grm. of AgNOg corresponds to -2088 grm. of chlorine. I grm. do. -2147 grm. of HCl. I grm. do. '3441 grrn- of NaCl. * 169-97 grin- to the litre is the absolute and exact amount necessary 158 STANDARD SOLUTIONS Table showing the percentages of Chlorine in lo c. c. of a fluid when tested with the Deci-normal Solution. C.c. of Deci- normal Silver Chlorine HCl NaCl Nitrate used. per cent. per cent. per cent. I •0355 •0365 •0585 2 •071 •073 ■117 3 •1065 •1095 •1755 4 •142 •146 •234 5 •1775 •1825 •2925 6 ■213 •219 ■351 7 •2485 •2555 ■4095 8 •284 •292 ■468 9 •319s •3285 •5265 lO •355 ■36s •585 To transform the figures for chlorine directly into those for HCl, they should be multiplied by 1-028, and into those for NaCl, by 1-64.8. If the solution of nitrate of silver employed be of known strength but not deci-normal, the amount of the silver salt in the number of c. c. used may be mul- tiplied by '2088 to give the amount of chlorine present, by "2147 for HCl, and by '3441 to express the result in terms of chloride of sodium. STANDARD SOLUTIONS 159 E "^ B ° 2 o o b go o o ° E-2 1^ ° O -- o ^ + I' -o ^ + a -—TO ^^ I— I .H ^ y %'^ ■ "^ '^00 j.-e -g o .+ O •GO ao ■GO o