Medicine 359

RECENT LITERATURE.

CRITICAL SUMMARIES AND ABSTRACTS.

MEDICINE.

By JOHN D. COMRIE, M.A., B.Sc., M.B., F.R.C.P.,

Assistant-Pathologist, The Royal Infirmary.

Recent Developments in Gastric Tests.

Tests for Hydrochloric Acicl.?The most delicate tests hitherto devised for detecting the presence of free hydrochloric acid in the contents of

the stomach are that by heating to dryness, with Giinzburg's reagent, consisting of phloroglucin and vanillin dissolved in alcohol, and the use

a weak watery solution of methyl-violet. Of these the former will

give a brilliant red in the presence of '05 per cent. HC1., while the latter will give a distinct blue colouration with 0*2 per cent. HC1.

Recently Steensma1 has found that the substitution of phlot'idzin for the same amount of phloroglucin renders Giinzburg's test even more delicate than before.

A new reaction proposed by Simon2 depends upon the ability of

Nitric acid to turn guaiac resin solution blue. The test solution consists of guaiac resin dissolved in a mixture of spiritus setheris nitrosi (10 parts) and rectified spirit (40 parts). A quantity of this is poured above 5 c.cm. of filtered stomach contents, so as to form a layer. At the meeting place of the fluids a white ring forms, which, after a few seconds, becomes blue if free hydrochloric acid is present, through its combina- tion with the nitrous ether to form nitric acid. The test is a useful

one for practical purposes. To avoid the criticism of acid estimation that the acid may in a

given case be secreted so slowly that it is neutralised at once, Schaly3 conducts the estimation by introducing into the stomach bouillon

acidulated with a known amount of HC1. and withdrawing samples at 'ntervals. From the increase or decrease he obtains a more correct

gauge of the secretive action of the stomach. He finds that the acidity varies greatly in the same person from day to day.

In cases where the use of the stomach-tube is undesirable, it has been recommended by Schwarz4 to give the patient 4 grammes of bismuth subnitrate in a Sahli's capsule, and by the help of a Roentgen screen to examine four or five hours after the swallowing of the capsule m order to determine whether the bismuth has escaped. The opening of the capsule indicates the presence of a moderate amount of free

hydrochloric acid. Pepsin Estimation.?As the amount of hydrochloric acid present in

the stomach varies within wide limits in different cases of the same

360 Recent Literature

disease, e.g. in gastric cancer, attention has been directed more of late to the estimation of the pepsin. The determination of the degree to which the ferments have been diminished forms a better criterion of

the retrograde changes in the mucous membrane than does the mere estimation of the amount of acid secreted. The standard method hitherto has been that of Mett, of which an improved scheme is given as follows by Sailer and Farr5:?"For filling the tubes we employ the whites of two or three eggs, well mixed to render the fluid as homo-

geneous as possible. Thick-walled tubes of a calibre of 1 to 1*5 mm. are preferable to those of thinner walls and larger calibre, as they fracture more accurately and yield more uniform albumin columns. Sections of tubing, suited in length to the vessel to be employed in

boiling, are filled with fluid egg-white by suction, and plugged with little balls of bread. When a sufficient number of tubes has been

prepared they are dropped into a pan containing warm water, which is rapidly brought to the boiling point. This temperature should be maintained for five minutes. After drying, the tubes are hermetically sealed with sealing-wax or paraffin and allowed to ripen for several

days. The tubes remain in good condition for a long time, being practically sterile. When needed for use these tube lengths are cut into sections, 2 to 3 cm. in length, with a triangular file." Onec.cm. of

stomach contents is added to 15 c.cm. of normal HC1., and into this two of the tube sections are laid away to digest in the incubator at 37? C. for twenty-four hours. At the end of this period the number of millimetres to which the column of albumin has been digested is

measured, and this figure squared gives the relative peptic activity of the sample of gastric juice.

Two other methods have been introduced for estimating pepsin. One, known as the ricin test, is described by Solms.6 For this a filtered

solution of 1 per cent, ricin and 5 per cent, sodium chloride in water

is acidified by HC1. which renders the solution milky. This milkiness

is cleared up by peptic digestion, and it is to be determined to what

extent the gastric juice may be diluted and still retain its power to

clear up the solution. Solms fixes the standard at 100 pepsin units per c.cm. of gastric contents, when the ricin solution is just cleared up after three hours in the incubator by 1 c.cm. of a 1 per cent, dilution of the

gastric fluid. He found that the normal peptic power of the stomach varied between 100 and 200 units. In cases where there was no acid

or very little acid the pepsin fell to 10 or 20 units; on the other hand, when the acidity is much increased it does not appear that there is a

corresponding rise in pepsin ; in cases of carcinoma there is always a

very low peptic power. Witte7 gives the results of testing this method upon 50 patients, and regards it as not only easier to work and quicker than Mett's method, but as very simple and practical. The most

powerful gastric juice which he encountered was 500 pepsin units, and

Medicine 361

this was found along with moderate acidity. He also found that

although the peptic power tended to rise with the acidity, there was 110 definite relation between them.

Wolff and Tomaszewskis using another method, the Edestin test, arrived at much the same conclusions. In normal states of the

stomach the activity amounts to about 100 pepsin units, and it sinks

and rises with the acidity, though there is no definite parallelism between the two. This test, introduced by Fuld,9 consists in adding stomach contents suitably diluted to a 1 per cent, solution of Edestin in weak hydrochloric acid. Edestin still unchanged by the action of

pepsin at the end of its period in the incubator is precipitated by the addition of ammonia as an indicator.

A still simpler and very rapid method of pepsin estimation has

been introduced by Gross.10 It depends upon the fact that casein is

readily precipitated by weak acetic acid, while the products of its

digestion, caseoses, are not. 10 c.cm. of casein solution with HC1. are

placed in each one of a row of test-tubes. These are warmed in the

Uicubator, and increasing quantities of the stomach contents to be

examined are added along the row. After a quarter of an hour in the

mcubator the tubes are again removed, and to each is added a few

drops of concentrated solution of acetate of soda. Any undigested easein is precipitated, and thus one finds the smallest quantity of

gastric juice that in 15 minutes will digest all the casein.

Various observers have performed confirmatory observations upon the value of this method of gastric diagnosis, and it seems likely that the examination for pepsin will, in future, to a large extent, replace the estimation of hydrochloric acid in cases where it is essential to

gauge the functional power still rem aining to the gastric mucous mem- brane. The estimation of pepsin is also preferable to the somewhat uncertain method of estimating the rennin by the milk-curdling power of various dilutions of gastric juice, introduced some years ago bj7. Boas.

Sahli's Desmoid Reaction, introduced some years ago as a test of

the secretory function of the stomach, has lately been the subject of a great deal of research by various workers who have criticised it both

favourably and adversely. The principle of the method consists in

administering substances like salol, methylene blue, and potassium iodide, in gutta-percha bags, made from a square of gutta-percha tissue 4 cm. by 4 cm., tied up with a desmoid of raw catgut. This substance,

consisting of fibrous tissue, is soluble only in the gastric juice, and when the bag opens out as the catgut dissolves the absorption quickly follows of the contents, which can be demonstrated in the urine or

saliva. These desmoid capsules are swallowed immediately after the

midday meal or a test meal with a draught of water. The urine

passed 5 hours and 7 hours later, and again next morning, is examined

362 Recent Literature

for the presence of blue discolouration, which should by this time have appeared. Its earlier appearance is supposed by Sahli to indicate

hyperacidity, and its non-appearance within 13 hours either decreased acidity or decreased motility of the stomach. The answer as to the

value of this test turns upon the question whether catgut may be dissolved in the intestine as well as in the stomach, or whether, if the

capsule opens, this can only have taken place under the action of the gastric juice. Sahli holds that catgut is soluble only in the stomach, and that if the capsule enters the intestine unopened it will pass

right through without setting free its contents. On the other hand, Lewinski,11 as the result of clinical trial and laboratory work, maintains that the method is untrustworthy, because digestion of connective tissue takes place in the intestinal juices. Among those who support the value of the desmoid reaction may be mentioned Frauenberger,12 Robin,13 and Tottmann.14

Frauenberger, as the result of a large clinical experience, concludes that the test is a valuable one for use in cases where for any reason the

use of the stomach tube is undesirable, and where one wishes informa-

tion regarding the secretion in sufficient quantity of hydrochloric acid. Robin in over 100 cases compared the result of the desmoid reaction

with that obtained through examination by means of the stomach tube. He found that the only conditions in which the desmoid reaction was negative were achylia gastrica and cancer of the stomach, so that the negative result may be taken as a sign of failure to secrete gastric juice. He concludes that the time of appearance of the green colour in the

urine bears no relation to the degree of acidity of the gastric juice. He makes the proposal that the desmoid capsules should be given always after a meal of definite constitution (two soft-boiled eggs, two rolls and a cup of tea), so as to obtain results comparable with one another from different patients.

Tottmann, as the result of conducting upon 60 patients a com-

parison of the desmoid reaction, Schmidt's test diet and the examination of stomach contents removed by the tube, concludes that the first and second are both pleasanter and afford a greater degree of information than the last. He particularly values the information obtained from a

negative result (thus agreeing with Robin), as indicative of a failure by the stomach to secrete.

Apparently this test places in our hands a valuable diagnostic method, which, in contrast to the use of the stomach tube, is quite unobjectionable. It has, it is true, a liability to fallacy, and must be used only in conjunction with other diagnostic methods. A positive result is of value only when the green colour appears in the urine within 8 hours, and it may then be taken to indicate, in the absence of definite gastric symptoms, that the function of the stomach is

normal.

Medicine 363

Einhorn's Digestive Bead Test.?Einhorn 15 has recently published the

results of further researches with his digestive beads. These are recom-

mended by various writers as constituting a simple and convenient Method of testing the power of the digestive function, and one, further, which is quite unobjectionable and suitable even for cases in which a special test diet cannot be tolerated. Six beads, to which are attached different food substances, are strung and tied upon a silk thread. One

has a piece of catgut threaded and tied round it. The second has a

fish-bone from a pickled herring similarly attached. The third has a

bundle of muscle fibres, previously hardened in alcohol, bound to it by a silk thread. The fourth has a piece of sweetbread, similarly hardened and wrapped in a little square of gauze, attached to it. The fifth has

been dipped in melted mutton fat. The sixth bears a small piece of potato with skin still attached. The bead string is placed in a gelatin capsule, and so readily swallowed. If the beads appear in less than

24 hours there is an accelerated intestinal motility; if after 48 hours

the motility is retarded. Catgut and fish-bone should be digested in

the stomach, the remaining four in the intestine, and the presence of remnants on the beads helps to indicate the site of the digestive error. ?A-S nuclei are specially digested by the pancreatic juice, the appearance ?f nuclei, upon microscopic examination of the contents of the gauze hag on bead No. 4, indicates defective secretion by this organ. If it

ls desired to make the string shorter, two or more of the substances may of course be strung upon one bead.

Gastric Motility.?The various methods in vogue of testing the period during which food remains in the stomach depend upon mixing with

substances like salol or iodopin, which are broken up on reaching the intestine, with the formation of substances which are rapidly excreted. These can be recognised in the urine or in the saliva, and thus the time spent in the stomach discovered in a roundabout way. Strauss and Leva1(5 have recently elaborated a method depending upon a simpler principle. It consists in giving, as a test breakfast, 50 grammes ?f a special bread baked with milk, so that this quantity contains about 5'3 grammes of fat, which of course is not digested by the stomach. After an hour the stomach is washed out and the fat computed. They found that with normal motility the amount of fat still in the stomach was 0-8 to 2'5 grammes, with decreased motility up to 5 grammes, and with excessive motility under 0*8 gramme. The authors of the method

recommend it as relatively simple and speedily learnt. Supino17 has devised a simple instrument for measuring the pressure

that the musculature of the stomach wall is capable of exerting. He

connects an ordinary soft rubber stomach tube by means of a T-canula

with an indiarubber double bellows and with a glycerine manometer. By pumping air into the stomach this is distended up to a point where the height of the manometer remains constant and can be read oft.

364 Recent Literature

Normal motor activity gives a pressure of 5 to 7 upon his scale, and in dilatation of the stomach it is diminished to from 2 to 4. In cases of hypersecretion spasmodic contractions are indicated by sudden rises alternating with falls. The method is notable for ingenuity rather than for actual practical utility.

References.

1. Steensma. Nederland Tijdschr. v. Geneesk. P. 203. 1908. 2. Simon. Berliner klin. TVocliensclir., 44. 1907. 3. Schaly. Arcliiv. des Malad. de I'appareil digest. 1908.

4. Schwarz. Kongress der deut. Roentgen Gesellsch. April 1908. 5. Sailer and Farr. Progressive Medicine. P. 24. December 1907. 6. Solms. Zeitsclir. f. hlin. Med. Vol. lxiv. P. 159. 7. Witte. Berliner ldin. TVocliensclir., 42. 1907.

8. Wolff and Tomaszewski. Berliner hlin. TVocliensclir., 22. 1908.

9. Fuld. Vereinf. Inn. Med. July 1908. 10. Gross. Berliner hlin. TVocliensclir., 13. 1908.

11. Lewinski. Muenchener med. TVocliensclir., 9. 1907.

12. Frauenberger. Wiener med. TVocliensclir., 30. 1907.

13. Robin. Medycyna, 38,39. 1907.

14. Tottmann. Muenchener med. TVocliensclir., 52. 1907.

15. Einhorn. Jour. Amer. Med. Assoc. 2nd February 1907. Arcliiv. /? Verdciuungskr. P. 475. 1907.

16. Strauss and Leva. Deut. med. TVocliensclir., 29. 1907.

17. Supino. II Policlinico, xiii., p. 365. 1907.