RECENT ADVANCES IN THE DIAG- NOSIS AND TREATMENT OF SOME DISEASES OF THE STOMACH. BY L. WOLFF, M. D., PHYSICIAN TO THE GERMAN HOSPITAL OF PHILADELPHIA; DEMONSTRATOR OF CHEMISTRY IN THE JEFFERSON MEDICAL COLLEGE, ETC. FROM THE MEDICAL NEWS, September 21, 1889. [Reprinted from The Medical News, September 21, 1889.] RECENT ADVANCES IN THE DIAGNOSIS AND TREATMENT OF SOME DISEASES OF THE STOMACH.1 By L. WOLFF, M.D., PHYSICIAN TO THE GERMAN HOSPITAL OF PHILADELPHIA ; DEMONSTRATOR OF CHEMISTRY IN THE JEFFFRSON MEDICAL COLLEGE, ETC. The pathological conditions of the stomach have, during the last few years, received a great deal of attention and consideration by medical investigators, with the result of placing them in a new light and a more rational position. As pathological manifestations are but abnormal physiological functions, we will have to consider the normal gastric functions before proceeding to the abnormal. It is a well-established fact that the stomach has distinct digestive power, and it is also well known that this is due to its secretions or to part thereof. While the secretive action of the stomach, in common with all mucous membranes, results in the production of mucus, the secretion of its acid digestive fluid from the peptic glands is one peculiar to this viscus alone, 1 Read by invitation before the Atlantic County Medical Society, Atlantic City, N. J., September 4, 1889. 2 WOLFF and to this product the name “gastric juice” is com- monly given. That portion of the acid gastric juice which has a distinct influence on its digestive prop- erties has been definitely shown by Carl Schmidt to be hydrochloric acid. The proteid ferment, which is made active only by this acid, is known as pepsin, and the result of its action on albuminoid food as peptone. It has of late been questioned if the hydrochloric acid secreted by the peptic glands has only the power of rendering the pepsin active, and it is held by some (G. Bunge, Lehrbuch der physiologischen und pathologischen Chemie) that its principal value con- sists in rendering aseptic the ingested food, a fact which the attempt has been made to substantiate from the result of experiments which proved that 0.3 per cent. HC1 prevented septic change in meat fibre, while the average normal gastric juice con- tained that amount of it. Normal gastric juice undoubtedly prevents and corrects effectually septic change of albuminoid food. Felix O. Cohn, in the Zeitschidft fiir physiologische Chemie, xiv., 1, July 29, 1889, ascertains that this is not attributable to the admixture of pepsin ; that even small quantities of HC1 prevent the formation of acetic acid, and that lactic fermentation is prevented by as much HC1 as is necessary to convert into chlorides the phosphates necessary for the development of the bacillus acidi lactici. He also states that pepsin- hydrochloric acid has the same value to prevent fermentations as that without pepsin, and that HC1 united with peptones fails to inhibit or prevent fer- DISEASES OF THE STOMACH. 3 mentation, and, as is already known, to digest albu- minoid food. He further confirms Ewald’s obser- vation that HC1 is probably secreted at once with the ingestion of food, but is imbibed by and united with the albuminoids, also with the bases and salts it unites with or displaces, and that during this period there is nothing to prevent other fermenta- tions. The question of the production of HC1 in the peptic glands from the alkaline blood and fluids, is one that is of interest and value to gastric physi- ology. That HC1 must necessarily result from the decomposition of the chlorides of the blood and liquids of the body is quite apparent. As sodium chloride is the principal one of these contained in the blood and lymph, and as these also hold in solution sodium bicarbonate, it may readily be in- ferred how sodium carbonate can form with libera- tion of hydrochloric acid, as per following formula : NaCl + NaHC03 = Na2C03 + HC1. It is, undoubtedly, the characteristic secreting power of the epithelial cell to diffuse the products of this decomposition in a manner that the more alka- line salt will be returned to the blood, while the acid becomes part of the gastric secretion. It is a peculiar fact that the peptic glands of the pyloric region, which distinguish themselves even macroscopically by their paler color, secrete alkaline fluids, which, however, when acidulated with HC1, have marked peptonizing power. When comparing the anatomical structure of the peptic glands of the 4 WOLFF, pyloric and the non-pyloric region of the stomach, we find that the former have no ovoid, often called peptic, epithelial cells which we find in the tubules of the latter. It seems fair from this to deduce that the ovoid cells of the peptic glands stcrete the HC1, as already pointed out by Heidenhain. I have recently been able to arrive at similar de- ductions from experiments conducted with Dr. E. P. Davis at the Philadelphia Hospital. In a number of examinations of the gastric juice of normal infants no hydrochloric acid was found present therein, while coincident with my observations it was stated that the tubules of the peptic glands of the infantile stomach have no ovoid cells. Ludwig and Ogata deduce from experiments on dogs on which resection of the entire stomach had been practised, as well as from some in which the pylorus had been occluded and the animals fed by a duodenal fistula, that the stomach was not abso- lutely necessary as far as digestion was concerned, either as a receptacle for food or as a generator of peptic fluids. Though these experiments of Czerny, Ludwig, and Ogata prove beyond doubt the pos- sibility of nutrition without the stomach in the dog, the predigestion of food in the stomach is certainly indicated by the time it remains there, the changes it undergoes while there, and the absorption of pep- tonized food directly therefrom. That the stomach should only slowly rid itself of its chyme cannot possibly be only to the end of rendering it anti- septic by contact with its acid secretion, when the powerful peptonizing action of the chlorhydric solu- DISEASES OF THE STOMACH. tion of its secreted albuminoid principle is so well established. That different foods are much more readily acted on by the gastric juice and passed from the stomach, as shown by Beaumon*-, would also tend to establish the importance of gastric diges- tion for the nutritive process, even if impairment of the normal gastric digestion did not give rise to special pathological conditions quite characteristic as well as important in their effect upon the general nutrition of the human organism. Before proceeding to the consideration of the typical diseases of the stomach, their pathology, diagnosis, and treatment, after having learned the special digestive function of the stomach, it is well first to study, as a general pathological condition, the perverted function which must arise more or less from all gastric disorders, and which, as an impair- ment or lack of the peptic act, is, therefore, termed “dyspepsia.” Modern pathology recognizes the fact that gastric digestion is a purely chemical process due to various influences upon the secretory appa- ratus of the stomach, and the “ chemical dyspepsia” has, as such, been proclaimed in the last three Get- man Congresses for Internal Medicine, by von den Welden, Leube, Riegel, Ewald, Boas, Edinger, Jaworsky, etc. Dyspepsia. The chemical changes which take place in the stomach under abnormal conditions are the variable composition of the gastric secretion, owing to the increased, diminished, or totally absent quantity of 6 WOLFF, hydrochloric acid, for so far no absence of pepsin has been established in any of the gastric secretions yet examined, and all of them have answered the physiological digestive test if admixed with hydro- chloric acid. The diagnosis of dyspepsia, as practised to-day, is the consequence of, and was developed from lavage of the stomach, as introduced by Kussmaul about twenty years ago, and the close investigation of the matter thus washed out. Previously the contents of the stomach and its secretions were judged principally from the vomited matter, but as this is a pathological product, it cannot give any correct idea of the possible functional ability of this organ. The ingesta, besides largely diluting the gastric secretion, make its chem- ical examination very uncertain and unreliable. The withdrawal of the gastric secretion when its digestive power is the greatest, is necessary at certain periods which have been ascertained by experiment and observation. This has to be done also at a time when the presence of ingested matter shall not render the withdrawal impossible. Without dwelling on the different experiments to ascertain this period, it is now generally accepted that a special meal should be given, after which, at a certain time, the gastric secretions are withdrawn. The early meal generally employed for this purpose is known as the trial breakfast, which consists of a few pieces, altogether about two to three ounces, of bread or bun and a glass of water or a cup of tea. Jaworsky and Glu- zinski, relying on the observation that a soft-boiled egg disappears from the normal stomach in one and DISEASES OF THE STOMACH. 7 a half hours, use this instead of the above-mentioned trial breakfast. At times, however, and especially under pathological conditions, it is found that the egg is not peptonized in that period, and then, by clogging the tube and the now proven union of the free hydrochloric acid with the albuminoids, the withdrawal is rendered difficult and the results inac- curate. To obtain the gastric juice from four to five hours after a more copious “trial dinner” has no advantage, and the “ trial breakfast,” after all, is the one relied upon. Ewald and Boas express the gastric juice by epi- gastric pressure, about one hour after the trial breakfast, when it is known that in the normal state it is strongly acid from hydrochloric acid, the lac- tic acid having disappeared, and only continuing to be present in abnormal conditions. To express the gastric juice has disadvantages which may be readily avoided by the use of a suction apparatus. Germain See recommends a Potain aspirator for this purpose, partial exhaustion only being made, but an ordinary syringe answers the purpose very well, as the quan- tity for chemical analysis need only be very small, from one to two drachms sufficing to that end. The tube employed for withdrawal of gastric juice is a small-sized, ordinary stomach-tube, having two fenestrse, and, in the cases of infants and children, I have frequently used simply a small, soft-rubber catheter. After the introduction of the tube in the usual manner, the fluid is withdrawn by slowly drawing out the piston of the syringe. A sufficient quantity 8 WOLFF, is recognized by a small glass-tube connection in the rubber one ; the tube is then carefully withdrawn and emptied into a small glass vessel. The liquid so obtained is next filtered and tested, to ascertain if acid or not, with neutral litmus paper. When the acidity is thus established, the amount of acidity is determined by acidimetry with a dpcinormal solution of sodium hydrate, litmus or phenolphthalein being used as indicator. Five cubic centimetres of the filtered gastric juice are neutralized with decinormal solution of soda, as stated above, and the total acidity is expressed by multiplying the result by twenty, thus giving the number of cubic centimetres of one-tenth normal soda solution necessary to neu- tralize one hundred cubic centimetres of gastric juice. After this is done, the chemical character of the acid is investigated. To this end the lactic acid test of Uffelmann may be applied. This consists of a two per cent, solution of carbolic acid to which a few drops of neutral ferric chloride are added, suffi- cient to produce a steel-blue color. When this is added to some of the filtered gastric juice it will be decolorized if the acid is pure hydrochloric; if lactic acid is present together with hydrochloric, the color will be changed to a yellowish tint, and if the lactic acid is in excess, it may even assume a reddish-yellow; whereas, in the absence of hydro- chloric acid, it will have a more greenish tint. Though this seems to answer the purpose, it only shows the presence of lactic acid, without giving a DISEASES OF THE STOMACH. 9 distinct idea as to the presence of hydrochloric acid. For the purpose of showing the latter, Laborde proposed the use of methyl-violet; a watery solution of this is promptly changed by HC1 to a greenish- blue color, but is not affected by lactic nor the fatty acids. It has, however, the disadvantage of being not sufficiently delicate, and the color-changes with weak acidulous fluids are not distinct enough to judge of small amounts of HC1. To test with it, some of the filtered gastric juice is placed in a small glass vessel (watch-crystal) placed upon white paper, and the test solution is allowed to drop on the side of the vessel and commingle with the fluid, when the change of color can be plainly observed against the white background. In a series of ex- periments to ascertain the limit of delicacy of these tests for HC1, I have found that the methyl-violet could detect in this manner i part of HC1 in 2500 parts of water. The next test, superior in delicacy, is a saturated aqueous solution of tropeolin ; this yellow solution, when applied for the examination of gastric juice in the manner described for methyl-violet, will change to a beautiful red, or brownish-red with HC1, is but a little darkened by lactic acid, and very slightly so by the fatty acids. I have ascertained its limit of detection of HC1 to be 1 to 3500, while 1 to 500 is the greatest dilution of lactic acid that will darken its color, and it is not affected by a 1 to 100 dilution of acetic acid. A more recently introduced reagent is the phloro- 10 WOLFF, glucin-vanillin. Germain-See has made extensive experiments with this, and while it does not indicate organic acids, he claims for it a delicacy sufficient to indicate as little as i to 20,000 of HCl—a claim, however, which I have not been able to substantiate entirely from my own experiments. It was found by Wiesner that if a pine stick was dipped into a phloroglucin solution, and was then touched with strong HCl, it turned a dark-red color. This reaction is caused by the presence of vanillin in the pine wood; and, therefore, this was substi- tuted for it. The test is composed as follows : 2 grammes phloroglucin and 1 gramme vanillin dis- solved in 30 grammes absolute alcohol. This yel- lowish solution gives at once with a stronger mineral acid a dark-red color with deposition of red crystals. To apply this test to weak acid solutions, such as the gastric juice, the fluid must be evaporated at a moderate heat, not reaching the boiling-point of water, to drive off the water and leave the HCl of sufficient strength to act on the reagent. To this end a few drops of the test are mixed with a similar quantity of the filtered secretion, and then slowly evaporated to dryness. If HCl is present the dry residue assumes a red color, or if present in very small quantity may show distinct red outlines only. In my hands this test, certainly a very valuable and delicate one, failed to indicate more than 1 part HCl in 10,000 parts. The red Congo paper, as proposed by Prof. Riegel, is a most delicate reagent, and easy of ap- plication. It is readily turned of a bright greenish- DISEASES OF THE STOMACH. 11 blue color by HC1, but is also affected by lactic acid, which changes its color to a dark dirty-blue; and acetic acid will darken it with a bluish tinge. With this reagent, as obtained from Merck in Darm- stadt, I was able to detect as little as i part of HC1 in 20,000 parts of water; and while i part of acetic acid to 3000 water gave a slight change in color with bluish edges, 1 of this to 5000 did not affect it in any manner; 1 part of lactic acid in 5000 water was indicated by it in traces, but 1 to 6000 failed to elicit a change in its color. It is thus seen that the latter is perhaps the most delicate reagent we have, not alone for HC1, but as an indicator of general acidity, and that when it fails to indicate the latter a total anacidity may be fairly claimed. When it indicates acidity, the ap- plication of the other tests may become necessary, not alone to ascertain the character of the acidity, but to approximate the degree to which HC1 may be present in cases of subacidity. The gradation and limits of these reagents, as pointed out by me, may be readily utilized to this end by dilution of the secretion up to the point where either of the above tests fail, and computing the HC1 by the amount of the dilution. The excess, normal presence, diminution, or ab- sence of HC1 being thus established, the digestive power of the gastric juice is now ascertained by the physiological test. To this end a small piece of coagulated egg albumen of about 7 mm. diameter and 1 mm. thickness is digested at the temperature of the body, and the comparative time necessary for 12 WOLFF, its solution noted. With normal secretion this should be complete in from one to one and a half hours, whereas under abnormal conditions a much longer period and the addition of HC1 may be required. To classify the different phases of chemical dys- pepsia, they can be conveniently arranged as hyper- acidity, subacidity, and anacidity. Hyperacidity is the overproduction of HC1 by the peptic glands, the amount reaching as much as 0.4 to 06 per cent, of the peptic secretion. Its etiology seems still obscure, and may be attributed perhaps to the chemical condition of the blood, and to the concentric rather than peripheral stimula- tion of the secretory glands, and it is a fact that at times it is found irrespective of food ingestion. While its symptoms are quite characteristic, con- sisting of pyrosis, acid eructations which perceptibly affect the teeth, occasional vomiting, and ptyalism, under such conditions commonly termed water- brash, its diagnosis is readily made out with the tube and subsequent acidimetry, and confirming the character of the acid with methyl-violet, which is promptly changed to a distinct greenish-blue. As a chemical indication for the therapy of acid dyspepsia or hyperacidity, alkalies must rank first and foremost; amongst them the sodium bicar- bonate deserves principal consideration in massive doses of from 30 to 45 grains every four hours, and before meals. Alvine evacuations, which are more or less suppressed in this condition, should be freely promoted by Carlsbad salts, or by appropriate preparations of rhubarb in laxative doses Hot DISEASES OF THE STOMACH. 13 potations, which are often lauded in this connection, have, in my experience, proven of little avail, but free lavage with borax or sodium bicarbonate solu- tion gives the greatest relief. As physiologically indicated the diet should consist of proteid sub- stances, while carbohydrates must be studiously avoided. Subacidity. Etiology.—While in hyperacidity it was an excess of HC1 which caused rather gastric distress than suppression of the peptic act, subacidity is generally observed in the catarrhal conditions of the gastric mucous membranes which are caused by improper food, excesses in drink or chemical irri- tants, and where, through irritation, the mucosa is hyperaemic and secreting abnormal quantities of alkaline mucus, diminishing the ostia of the peptic glands, and admixing the former with the gastric juice proper, thus preventing its proper action on the food-bolus. The common acute indigestions of our summer months, attributable to excessive drink- ing of iced beverages, belong to this class. The symptoms are anorexia, thirst, slight fever, a sense of pressure and fulness in the epigastrium, occa- sional vomiting, and belching of gas, with eructa- tions of fermenting food. A dry and coated tongue is generally observed in this condition, together with a bitter taste in the mouth. The bowels may be loose or bound, and by a progressive advance of the catarrhal process to the duodenum it may be followed by icteroid appearance. Treatment.—-This class of dyspepsia calls for rapid evacuation of the stomach, either by tube or emetic, 14 WOLFF, followed by local sedatives, such as bismuth and soda; while after subsidence of the mucous hyperaemia and a continuance of subacidity, ten to fifteen drops of dilute HC1 in water prove of service given after food. During the febrile stage small pieces of ice by the mouth and iced milk diluted with some effervescent alkaline mineral waters prove most grateful and serviceable. Chronic Gastric Catarrh. The persistence or frequent repetition of ingestion of the causative elements of the acute gastric catarrh cause a chronic state commonly met with in subjects, termed “chronic dyspeptics,” and, as the chronic gastric catarrh, is the cause of subacid disturbances of the digestive function. This may be, and often really is, gastro-enteritis; and, again, it is dependent at times upon other diseases and, therefore, only secondary in character. The cause of disturbance of the chemical composition of the gastric secretion hence must be looked for either in the altered chemical composition of the blood or in the changed anatomical relations of the glands. The gastric mucous membrane in this affection is heavily coated with a grayish-white material, con- sisting largely of cast-off epithelium; the odor from the buccal cavity is, from this cause, more or less offensive, and the mucosa beneath the coating is red and hyperaemic. According to the stage of its existence, the mucous surfaces may be smooth or atrophic, and there may be an accompanying atrophy of the peptic glands and an increase of connective DISEASES OF THE STOMACH. 15 tissue between them. Not infrequently hyperplasia of the mucosa exists, diminishing the ostia of the peptic glands, the hyperplasia extending at times even to the submucous tissue. The main result of these anatomical changes con- sists in the reduction of the amount of HCl in the secretion, and with it the diminished digestive power and an insufficient inhibition of bacterial develop- ment, in consequence of which fermentation of the ingesta ensues, with copious eructation of gases and the formation of lactic, acetic, and other acids. In cases where the absence of HCl is very marked, the fermentative processes may cause vomiting, and the ejecta will often reveal to microscopic inspection yeast fungi and sarcinae ventriculi, which are, how- ever, of no special pathological consequence. A feature of the chronic gastric catarrh is the impaired peristalsis of the stomach. This is de- pendent on the diminished amount of HCl present, as we know that in the normal stomach this acid is the principal exciting cause of gastric peristalsis. In consequence thereof dilatation results, and the degree of subacidity becomes more and more marked until almost entire anacidity prevails, as I had occa- sion to observe in several instances of chronic gas- tric catarrh during a recent investigation of a'series of cases of this kind at the German Hospital of Philadelphia, made by myself and the medical resi- dent, Dr. Gerlach. As the physical examination of the stomach offers no characteristic points for diagnosis, the latter can- not well be established without the chemical exami- 16 WOLFF, nation, together with due consideration of the sub- jective and objective symptoms and exclusion of such pathological conditions which stamp the dys- pepsia as secondary to some other affection. The treatment of the chronic catarrh of the stomach as a primary affection should be largely dietetic, avoiding all food that is irritant, bulky, or slowly acted on by the gastric secretions. Thus, carbohydrates should be avoided, also fats, and principally alcoholic beverages. Milk, broths with raw eggs broken and stirred into them, and toast, should, in severe cases, constitute the principal food. As the tardy gastric digestion will favor fermenta- tive changes, which in turn act as irritants and favor the accumulation of mucous secretion, the removal of undigested food, together with such bacteria as would incite decomposition de novo in freshly added food, is indicated in all such cases, and calls for mechanical treatment by lavage, which, though little practised in this country so far, has often worked wonders with chronic dyspeptics. Amongst the remedial agents the chemical indica- tion for the use of HC1 would certainly be foremost, to correct the subacidity and promote the peptic process. When lavage is practised this indication will generally hold good, but when the milder symp- toms do not indicate the use of the tube it will do no good. The reason for this is the large amount of mucus which is coagulated by the acid, and by enveloping the food particles prevents them from being acted upon by the gastric secretions. In these cases the alkalies, and among them the sodium bi- DISEASES OF THE STOMACH. 17 carbonate, should be used, together with the vege- table bitters to excite active secretion ; of these the tine, gentian, comp., tinct. nucis vomic., tinct. Colombo, etc., will prove of good service. Gastric antiseptics and antiferments can hardly be adminis- tered in sufficient quantity to do good, and very few, if any, are germicidal enough to correct an already fermented food-bolus. The constipation, sometimes so marked in these cases, is best overcome by Carlsbad salts or by some of the laxative mineral waters, or in more obstinate cases by pil. rhei comp. Nervous Dyspepsia. The influence of the nervous system upon the gastric digestion has been regarded as of great im- portance and has led to the special classification of “nervous dyspepsia.” That the innervation of the stomach may influ- ence the gastric secretion, and that hyperacidity or subacidity may thus arise, is not to be doubted, but that special nerve influence could pervert the chemi- cal act of digestion with normal secretion in the stomach any more than in the retort is not reasona- ble. The only neuroses appreciable to our present state of knowledge must be those of either sensory or motor disturbances. The reflexes causing intense neuralgic pains of the stomach may depend primarily upon perverted digestion, with or without motor im- plication, and are, as such, known as “ gastralgia. ” In neurotic patients they may develop, even without peptic disturbances, from external influences upon 18 WOLFF, a morbid mind; but that with normal gastric secre- tion, the chymification of food should be interfered with by nerve influence can only be explained by the interference of reflexes with the motor innerva- tion—i.