Thus the physician will have determined, by combining these various methods: (1) Whether the stomach is in its usual posi tion, (2) Whether it is of normal size and capacity, (3) Whether the gastric juice is of healthy characters as to the activity of pep sin and the percentage of hydrochloric acid, (4) Whether any abnormal acids are present, (5) Whether unhealthy fermentation or putre factive changes are occurring in it, and (6) Whether organisms of disease exist in it.
How these facts, read in the light of his know ledge and experience, will enable him to come to an opinion as to the nature and cause of the digestive trouble will be understood when the significance is appreciated of some few facts that will now be stated.
In ulceration of the stomach the percentage of hydrochloric acid is usually much increased, while in cancer of the stomach hydrochloric acid is much diminished, and in advanced cases absent.
In catarrhal states of the stomach, while acid and pepsin are diminished, there is much mucus present in the contents of the stomach.
In indigestion due to poorness of gastric juice, atonic dyspepsia as it is called, while the contents of the stomach show deficient acid and pepsin, excess of mucus does not exist, and the withdrawn contents show little change.
In dilated stomach, instead of 1 to 2 pints, the stomach will hold up to 4 pints and more.
In disorder of the stomach due to blocking of the outlet into the bowel, the stomach will be found to contain a large quantity of material, far more than the amount of one meal, and it will be fermenting and foul-smelling.
Incidentally the passage of the tube may reveal other things. For, if no preparation has been made, the size and alteration in the pieces of food will show whether the patient chews properly, and whether the digestion is active or feeble. The passage of the tube in morning, before any food has been taken, will show whether the stomach quite empties itself, or whether some food always remains unex pelled. In the latter case there is evidence of weak muscular power.
When the stomach-tube is used to withdraw contents for the determination of the chemical characters of the gastric juice, some prepara tion is made beforehand. A certain meal is prescribed, called a test-meal, which is taken when the stomach is quite empty, e.g. in the morning, and the tube is passed 1 to 2 hours later. To secure that the stomach is empty it is well first to pass the tube merely to wash out the stomach, the patient then takes the test-meal into the washed stomach, and this is withdrawn I to 2 hours later.
The usual test-meal or test-breakfast is that of Ewald, and consists of one Vienna roll and 15 ozs. of weak tea (three ordinary cups). It is withdrawn 1 hour after the beginning of the breakfast. A more substantial meal may be given, but it must be most thoroughly cut up and chewed, else the pieces will block the tube; and it is withdrawn 2 or 3 hours later, accord ing to its size.
The use of the stomach-tube is attended by very little discomfort to the patient. On the first occasion there is often a little fuss, retch ing and gagging, by the patient. This is largely due to inexperience, to the patient holding the breath, and to nervousness. As a rule, the second time it is used, the tube passes without difficulty, and I have frequently had patients who passed the tube themselves on the third occasion with perfect ease. It is quite certain that if the tube can be passed by the physician It can be passed still more easily by the patient, as soon as be knows how and has had it done once or twice.
No patient whose physician proposes to use this method of investigation should hinder him, as it may be found that the passage of the tube and the washing out of the stomach may be the shortest and easiest road to recovery.
Spraying the throat with cocaine, smearing the tube with glycerine and so on, are fre quently recommended as preliminaries. The tube, which must of course be of soft rubber, should shortly before use have been properly sterilized, by boiling for a minute in a 1-per cent solution of bicarbonate of soda, and should then be immersed in warm water in a perfectly clean bowl or glass vessel. The author finds the simplest and easiest way is to lift the tube out of this warm water, and without any preli minary spraying or smearing to pass it straight down.
The patient should sit on a chair, a bucket between his knees, a rubber sheet round his neck and hanging down into the bucket. At his one side is a table with the vessel contain ing the tube, and the requisite jugs with water. The patient should tilt the head slightly up, and widely open the mouth, and the tube is passed straight to the back of the throat, and then gently but quickly pushed down, while the patient goes through the act of swallowing, but breathing freely. A spurt of air, and per haps fluid, will indicate when the tube has passed into the stomach. This should occur when the length of tube passed, measuring from the teeth, is 16 inches, and at this part of the tube there should be a mark that cannot be rubbed out; a thread securely tied round the tube would do. The tube should be passed 2 inches farther, and if the stomach is in nor mal position, and of normal size, it should be possible now to empty out its contents by lower ing the outer end, while the patient takes a deep breath, holds it, and then with his hands squeezes his stomach upwards, straining with his abdominal muscles at the same time. If it is necessary to push the tube materially farther, before the contents are got, this fact shows at once that the stomach is displaced downwards or dilated.