Progress

of tbe flDeCucal Sciences. MEDICINE.

*ric Analysis.?The value We of a.

Ca

o^g11

COrnpare

foijQSe^

of analysis of test meals and only be appreciated properly provided findings with a sufficiently large number

can

the

normal an(i abnormal conditions to furnish averages. Panton and Tidy1 have published studies in gastric analyses, which may be tabulated

stanHrVations r d?Wn, and at varying intervals. fUn^us> which lies beneath the left dome of the and always contains gas, passes into the body of stomach at the level of the cardiac orifice. In the ^rticai1 position the body is nearly of uniform width, is situated *? the left of the middle line, and is either vertical or

of*

?

'

?

?itbd?e' plafGr

lying

^ragm,

?

^cli

curv

...

shghtly t

It is separated from the pyloric to the right. stomach by the incisura angularis on the lesser

(the pre-pyloric sphincter4). The pyloric part Pyloric vestibule (or antrum), which is directed ^Pw 1 as ^ passes to the right of the middle line and the i>yl0y-s n? Ca^al1 which is about one inch in length, passes backwards

c?n,a?re

PROGRESS OF .THE MEDICAL SCIENCES.

254

lS

upwards, and to the right, ending in the duodenum, and normally empty from contraction of the sphincter, even when

the stomach is full. With the X-rays an) D in the or abnormality position shape of the stomach can observed, but it must be borne in mind that the skiagram ^vl. show a material difference in the position of even a norifl stomach, according to the vertical or horizontal attitude of patient. Hour-glass contraction can be readily recognise and a functional contraction of this nature may be distinguish6 from the organic form by the fact that in the latter the.nec does not pass from the most dependent part of the upPe the

rest

of

'

segment.

{

leading to fixation or deformity of some par1, the stomach can be recognised with the X-rays, but they Atonic and obstruct! no signs distinctive of cancer. dilatation, with or without ptosis, are clearly displaye a Hypertonus, a sign commonly caused by duodenal ulcer, ia the rarely present in gastric ulcer, is easily diagnosed by 1 Adhesions

'

that the greater curvature does not reach the umbilicus the vertical position. ^ The activity of peristalsis can be.determined by X-rays, well as the rate of evacuation of the stomach. The glycyl tryptophane test for the diagnosis of ?aS er

carcinoma has been again reported upon favourably by Neubau Normal gastric ju and Fischer,5 who conclude as follows : The stomach contents tl does not split glycyl-tryptophane. definite carcinoma gives almost regularly a positive reaction (84 per cent, of cases verified by autopsy, 75 per cent of vv Other diseases of the stomach diagnosed clinically). as a rule negative." ts The tryptophane test6 depends on the power of present in the cancer juices to break down proteins into 01 acids. ^ Tryptophane is an amino-acid which is split out protein molecule by trypsin and by the autolytic tissue cells, whether they be normal or cancer cells ; but ^ pepsin of normal gastric juice does not disintegrate proteins ^ far as the amino*acids, and hence tryptophane is not fouu When disintegrating cancer t1 normal stomach contents. is present in the stomach, autolytic enzymes may be preseu ^ the gastric contents, and may set free tryptophane \s 1 digesting protein. If it has not already been formed, necessary to add a compound of tryptophane, glycyl-tryF 1 for tW the filfprprl filtered QtnmQrh to tHp stomach rnnfptitc and lnmhcifp incubate foT contents Qnrl phane, tn LV7"cylgK the four hours before testing. During incubation tryptophane is split into glycin (amino-acetic acid) "

"

ferIIie-n0 af1^e enzyn1?5^

frort1^

tryptophane.

tryptophane is made by adding bromine sto cautiously, drop by drop, to 3 or 4 c.c. of the incubated The test for

^

ter ^

MEDICINE.

255,

to which few drops of 3 per cent, acetic acid have ^?ntents, een added. A reddish violet colour indicates the presence of The tryptophane reaction is not characteristic ^yptophane. cancer unless the of the ferment a

the pancreas

possible

presence

proteolytic

intestine is excluded. claims to have shown that the or

Weinstein7 yptophane is superfluous Pr?ducing enzyme in gastric

use

of

glycyl

for the detection of tryptophanecontents. Gastric contents always ?ntain proteoses and peptones that are readily convertible by ncer enzyme into their corresponding simpler peptides and mi^o acids,

Austin

8

including tryptophane.

considers the tryptophane test the most availablene for cancer that can be used in a clinic. is doubtful how far this test depends on the presence 0? gastric carcinoma. Walker Hall and Scott Williamson *? ,

inH

a

recently Smithies10) have suggested that it nothing else than the presence of blood serum.

more

Jcate

Symptomatology

of

Gastric

and

Duodenal

may

Ulcers.?From

study of one thousand cases of ulcers of the stomach JJreful duodenum Friedenwald draws the following conclusions.. In patients suffering from various gastric disturbances 11

Per cent, are affected with ulcers. The largest proportion of ulcers occur between the entieth and fiftieth year of age. 3More than twice as many males are affected as femalesAnaemia is present in a large proportion of the cases of 2-

mCe^'

5; A history of over-indulgence in food or drink can be amed in almost half of the number of cases of ulcer. Acidity. The greatest proportion of cases of ulcer pr a normal acidity, i.e. 46 per cent., 30 per cent, a hypery' 23 Per cent- a subacidity. Hyperacidity is proporti0 more frequently observed in males and subacidity in S" acu^e ulcers and those accompanied by recent hem thp ?rFhages the acidity is very high, while in chronic forms acidity is low. The average duration of symptoms is twelve years. 8 The most prominent symptom of ulcer, pain, occurs ^6r centcases, and pain is most frequent in cases Cla^ed with a high acidity. Pain appears sometimes y after food (gastric ulcer) or long after food (duoH ulcer). Varying periods of intermission of pain as ^vell as the other symptoms may occur. ePigastric tender area is present in at least 90 per cent uc- of all cases, a dorsal tender area in 32 per cent. Vomiting is a very prominent symptom occurring in 67

0,

acSents

feJ^/^y ?

asso^-

n?'

per cent, of

cases.

.256

PROGRESS OF THE MEDICAL SCIENCES.

Hasmatemesis is present in 22 per cent, of cases and Melsena is more than twice as frequen as gastric hemorrhage. Occult blood is present in 81 per centof the cases. 12. Of the one thousand cases 52 per cent, are duodena and 40 per cent, gastric, the largest proportion occurring in males (58 per cent.). 13. Acidity in duodenal ulcers : 48 per cent, present norm*1 acidity, 35 per cent, hyperacidity, and 16 per cent, hyperacidity being more frequently observed in males an subacidity in females. an 14. Pain is present in 96.5 per cent, of duodenal ulcers, is most prominent in cases with hyperacidity. 15. Distinct periods of intermission from pain and otn a symptoms, varying from one to twelve months or more, exceedingly common in this affection. 16. Epigastric tenderness is present in 89 per cent, ofJduodenal cases ; a tender area to the right or left of the media line in 7 per cent. an j 17. Vomiting occurs in 21 per cent, of duodenal cases, is more frequent in those accompanied by high acidity. ^ 18. Melsena occurs in 54 per cent, of duodenal cases, an ?occult blood is present in 83 per cent. 11.

melsena in 51 per cent.

,

,

subacid^ 1

.

Sensibility of the Alimentary Canal.?Hertz,11 after

inV?sjJs

gating the sensibility of the alimentary canal to stimuli of vario^ kinds, has arrived at the following interesting conclusions The mucosa from the upper end of the oesophagus to 1. junction of the rectum with the anal canal: Tactile stimul negative. 2. (Esophagus and anus : Thermal stimulus, positive?

3.

Stomach and intestines : Thermal stimulus, negativ (Esophagus and stomach : Dilute HC1. and organ

?

acids, negative.

Rectum

:

Glycerine, negative.

Anus : Glycerine, positive. Whole mucosa : Alcohol, positive (sense of heat)The surface of ulcers (gastric and intestinal) is no 4. ?sensitive to tactile, thermal, and chemical stimuli than the m mucosa.

ct

.

?

^

^en 5. The sense of fulness is due to slow increase in ate ?exerted on the fibres of the muscular coat. There is an adeq ^ tension which is constant for each segment. The ?contents required to produce this tension varies with the ?of the muscle fibres. ^ 6. The sense of fulness in the rectum has a special chara by virtue of which it produces the call to defacation. ma of 7. Hunger is a combination of the general sense

vo^urn^one

SURGERY.

weakness with the local ^nd after sense is due to the

sense

of

257 an

empty stomach.

The

periodical motor activity of stomach and intestines during fasting, in which a condition of muscular '^ypertonus and. nervous hyperexcitability exists. 8. The only immediate cause of true visceral pain is tension

Exerted capsule

the muscular coat of hollow organs and on the fibrous of solid. In the alimentary canal pain is experienced hen there is a more rapid or greater increase in the tension of muscular fibres than that of the adequate tension for the Sense of fulness (see above, No. 5). 9? Pain in diseases of the alimentary canal, although true visceral pain, is sometimes due to the spread of lsease to surrounding tissues or tension on peritoneal attachIrient, or pain of nervous origin referred to skin, muscles and on

r

requently

c?nnective ,

.

l0-

tissue.

Tenderness

*ln> muscles and

-j.

generally depends

on

hyperalgesia

of the

connective tissue supplied by the same e?ment of the central nervous system. External pressure may Clease the tension referred to in No. 9. .Il- All these various sensibilities may be exaggerated by

lning

in neurasthenia.

J.

A. Nixon.

REFERENCES. *

Panton

and Tidy, Quart. J. Med., 1910-11, iv. 449. 3 Hutchison and Rainy, Clinical Methods, 5th Edition, p. 85. i. 225. 4 Hertz, Brit. M. J., 1912, J. Physiol., 1911, xlii. 93. 5 med. Wchnschr., 1911, lviii. 674. s ^eubauer and Fischer, Miinchen. /? Am. M. Ass., 1911, lvii. 1305. 7 g /. Am. M. Ass., 1911, lvii. 1420. Med. Rec., 1911, lxxx. * M.-Chir. J., 1911, xxix. 96. 10 11 J. Am. M. Ass., 1912, lix. 539. Am. J. M. Sc., 1912, cxliv. 157. Goulstonian Lectures, London, 1911. S 3 L Z, I/OUW, Kadner, Epitome of New Work cccxv, 20;, IVcLVlllCl, V^t's JllHtU., Jahrb., 1912, the tysiology and Pathology of the Digestive Organs.

Cathcart,

yVeinstein,

'^u?tin,

pmithies, ^ertz-

|"rieden\vald,

p?7

'

on

Medicine.

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