The general constitution must also be considered. The weaker the patient and the worse the diathesis so much more unfavorable is the prognosis.

We are only justified in prophesying a cure when we are in a position to quiet the predisposing causes. Pathology-Cases of acute or chronic cystitis are rarely seen at a post-mortem examination. We must, therefore, rely on our knowledge obtained from experiments performed on animals and from the cystoscopic study of the bladder on living subjects.

The cystoscopic study of the acute gonorrhoeal form shows that the disease is not equally dis

tributed, as it attacks the neck of the bladder and trigonum.

The inflammatory area is intensely reddened. The parallel branches of the blood vessels given off in the mucosa are dilated, making apparent all the finer branches that can not be seen in a state of health. The mucosa is swollen, the inflammatory area at the neck of the bladder can be seen shading off into the normal light orange pink mucous membrane of the bladder in figure 1.

The inflammatory area appears at the top, as the picture was taken with the No. 1 cystoscope of Nitze. In the case of cystoscopes, with the reflected light, the object is always reversed in the vertical diameter. In very acute cases extravasations of blood can be seen under the mucous membrane and exuding from it, adding to the congested appearance, as seen in figure 2.

Clumps of the degenerated epithelium that have been thrown off can occasionally be seen floating in the contents of the bladder.

When the inflammation subsides, the mucous

Fig. III.

hyperæmic, softened and swollen. The blood vessels are dilated, as shown in figure 5.

The microscopical examination of the urine shows many red blood corpuscles, many pus corpuscles, clumps of epithelium, and numerous pus cocci and bacilli, according to the nature of the disease. The bacterium coli commune is nearly always found, often in pure culture.

In catarrhus vesicæ the mucosa shows only slight alterations. The congestion and casting off of the epithelium leave no important after-changes.

In cystitis suppurativa, of which the cystitis gonorrhoica, already described, is a type, the entire mucous membrane, or only a part of the same, is deeply reddened and thickened. In the intensely reddened areas, ecchymoses may be found. In cases that begin slowly and pursue a chronic course, we find the more important alterations on the base of the bladder. The epithelium is often thrown off, even to the deepest layers, and covered with strongly adherent pus.

When the inflammation has pursued a chronic course, the mucous membrane is decidedly hyper

Fig. II.

membrane becomes paler, and the blood extravasations disappear one after the other, until we again get the appearance of the mucous membrane of the normal bladder, as shown in figure 3.

The little round elevations seen in this picture are simply air bubbles that have been introduced by an imperfect syringe.

An experimental cystitis can be caused by cantharides. According to Guyon, three stages of the inflammation can be differentiated in animals so treated. (1) The blood vessels become congested and the epithelium is thickened. (2) The epithelium, having been invaded by pus corpuscles, is cast

Fig. IV.

trophied in places. Small papillomata may be formed by the process of papillary proliferation. The small fibroma papillare (Virchow) so caused are the starting points of tumors of the bladder. Such conditions are seen often after the chronic gonorrhoeal cystitis, often the muscular layers of the bladder hypertrophy, causing a trabeculated condition. In figure 6 is shown trabeculated surface with a phosphatic concretion.

In cystitis parenchymatosa or interstitialis, we have an infiltration of pus into the submucosa and intermuscular connective tissue.

In pericystitis we have an infiltration of pus into

the subserous connective tissue. This may be the result of a spread of the cystitis parenchymatosa, or from the spread of an inflammation from neighboring organs. If an abscess is formed from a local accumulation of pus, it may empty into the bladder, rectum, vagina, or peritoneal cavity. Gravitating abscesses along the rectum are not uncommon.

Cystitis crouposa is a very rare disease, in which the wall of the bladder is covered over, with a more or less evenly measured fibrinous membrane, that can be removed without great substance losses.

Cystitis diphtheritica is caused most often from

chior has, however, shown that the acid cystitis is only exceptionally tuberculosis.

Primary tuberculosis of the bladder is very rare. Most often tuberculosis of the bladder is noticed in connection with tuberculosis of the epididymis or of the prostate. In such cases it spreads very often into both kidneys. Tuberculosis of the bladder takes its origin very seldom from a descending course. Feleki has noticed cases of tuberculosis of the kidneys lasting for years without causing tuberculosis of the bladder. König, as proof of this fact, relates his experience that often after removal of a

infection from open bladder wounds, or from the use of septic instruments, or from infection from the self-retaining catheter. Sometimes it occurs after severe infectious diseases, e.g. diphtheria, scarlet fever, and variola. It arises by contiguity from diphtheritis of the female genital organ. It has been seen in cases of paralysis of the bladder, or from infiltration of urine into a false passage made in the urethra. In all these cases the alkalinity of the urine favors a cystitis diphtheritica (Virchow). As a result of this inflammation, we have a large surface or several smaller areas of necrosis of the mucosa, leading to the formation of gangrenous grayishblack pseudomembranes, which are often encrusted with uric acid.

After these gangrenous eschars have been thrown off, either healing or a new advancing diphtheritic necrosis begins. This process may advance through ureters into the pelves of the kidneys. This process often leads to perforation of the bladder, with quick accompanying peritonitis, or to septic degeneration of the extraperitoneal connective tissue, when the point of discharge has not been at a place covered with peritoneum. In these cases we have an infiltration of the submucosa, forming abscesses in the wall of the bladder. When these interstitial

Fig. VII.

tuberculous kidney which had caused vesical catarrh the latter quickly disappeared.

A secondary infection in the case of a tuberculous individual, through metastatic deposit of the tubercle bacilli is rare.

The disease advances by continuity. Cystitis gonorrhoica or other chance causes may make a more favorable soil for the tubercle bacilli that come from the kidneys. The pathological anatomy, as well as Rovsing's experiments on animals, vouch for the correctness of this statement. In these experiments tubercle bacilli were injected into the bladder, and the urethra tied off, but a tuberculous cystitis could not be caused in this way. However, when before these experiments the mucous membrane had been injured, or when a cystitis suppurativa had previously existed, cystitis tuberculosa could be caused in this way.

Tuberculosis of the bladder occurs more often in men than in women and children, and most often between the twentieth and fortieth years of life; still it is sometimes seen in young children and in old men. Birch-Herschfeld, out of 2,565 autopsies on women performed at the Dresden Hospital, found only four cases of tuberculosis of the bladder.

As the tuberculosis of the bladder, in most cases,

which gradually increase in size, as shown in figure 7. These tubercles, through the process of cheesy degeneration, lead to ulcers. Surrounded by hyperæmic areas, as shown in figure 8. These ulcers

increase in size, and as their walls coalesce, large tuberculous sores of the bladder arise that destroy a great part of the mucosa and submucosa. The symptoms are very much the same as in any other severe chronic inflammation of the bladder. In some cases the pain is very severe (cystitis dolorosa).

The prognosis is always unfavorable.

REFERENCES.

1. Petersen: "Experimentelle Studien zur Pathogenese und Therapie der Cystitis," Inaug. Diss., Dorpat, 1874.

2. Dubelt: Archiv für experimentelle Pathologie und Pharmakologie, Bd. 5, 1876.

3. Droysen: "Zur Aetiologie des Blasenkatarrhs," Inaug. Diss., Berlin, 1883.

4. Krogius: Festschrift der Universität, Helsingfors, 1890.

5. Schnitzler: "Zur Aetiologie der Cystitis," Wien, 1892.

6. Bumm: "Die Aetiologie des puerperalen Blasenkatarrhs," I Congress der deutschen Gesellschaft für Gynäkologie, München, 1886.

7. Michaelis: Deutsche medicinische Wochenschrift, 1886, p. 492.

8. Clado: "Étude sur une bactérie septique de la vessie," Thèse de Paris, 1887. 9. Hallé:

"Recherches bact. sur un cas de fièvre urineuse." Bulletin de la Société Anatomique, 20 Oct., 1887. 10. Albarran et Hallé: "Note surune bactérie pyogène et sur son rôle dans l'infection urinaire," Bulletin de l'Académie de Médecine, 21 Août, 1888, et Semaine Médicale, 1888.

11. Albarran: "Étude sur le rein des urinaires," Paris, 1889.

12. Tuffier et Albarran: "Note sur les micro-organismes des abcès urineuses peri-uréthraux,"Annales des Maladies des Organes Genito-urinaires, 1890, pp. 5, 33.

13. Morelle: "Étude bactériologique sur les Cystites," Extrait de La Cellule, I, VII, fascicule.

14. Krogius: "Recherches bactériologiques sur l'infection urinaire."

25 WEST FORTY-FOURTH STREET.

OBSERVATIONS ON THE USE OF THE SAHLI TEST-MEAL.*

BY EDWARD A. ARONSON, M.D.,

NEW YORK,

EARLY in 1902, Sahli' described a new method for the examination of the different functions of the stomach. In his opening remarks, he truly said that by means of the present methods of examination, we are unable to determine whether there is any disturbance, separately or together, of the motor secretory or absorptive functions of the stomach.

The quantity of a test-meal withdrawn after a stipulated time is not only dependent on the motility of the stomach, but also on the amount of secretion by the stomach; the percentage acidity is no direct indication of the secretion, but is also influenced by the motility.

The principle of the new Sahli method depended on the addition to a test-meal of some substance not absorbed by the stomach, which can be quantitatively calculated. After the withdrawal of the testmeal. it was possible to determine how much passed over into the intestine, how much remained in the stomach, and how much of the withdrawn meal consisted of gastric secretion. The important considerations, however, are that the entire test-meal should be

*From the Internal Department of the Königin Augusta Hospital, Berlin, Germany. Prof. C. A. Ewald, Director.

homogeneous, that the substance which is to serve as the indicator should remain in complete admixture with the meal, and that, as v. Mering' has shown, the stomach absorbs no water. Fat was the substance selected by Sahli to serve as the indicator.

The idea of using fat for such a purpose did not originate with Sahli, but was first used by Matthieu;' v. Mering' also employed fat in the form of an eggemulsion to determine the absorptive property of the stomach.

In order to undertsand the purposes of this paper, I will briefly describe the Sahli test-meal. Twentyfive grams of ordinary flour and fifteen grams of butter are placed into an iron or other suitable vessel over a flame and allowed to become a roast brown. To this are slowly added 350 c.c. of water, and the whole is constantly stirred; a little salt, sufficient for flavoring, is also added and the mixture allowed to boil for one or two minutes. After the stomach has been thoroughly washed, the patient is given 300 c.c. of this soup, and the reaining 50 c.c. are retained as a control.

After one hour the soup is withdrawn and the quantity noted. Three hundred c.c. of water are now introduced through the tube, and the stomach is gently massaged; within a few minutes, this diluted meal is then withdrawn and its quantity noted. The acidity of the soup first withdrawn and that of the diluted are determined and according to the formulæ of Matthieu,' which are as follows, we are enabled to calculate the amount which remained in the stomach:

a the acidity of the undiluted soup. b = the acidity of the diluted soup.

x= the quantity of soup remaining in the stomach:

Three hundred c.c. of water being used to dilute the soup remaining in the stomach after withdrawal of the first, therefore

ax = b (x 300) x(a-b) 300b

X

=

300b

a-b

The amount of fat in the control and in the first withdrawn soup is now determined. This was at first done by means of the Soxhlet method, but it was found to be too tedious and too inconvenient for clinical purposes. At the suggestion of Sahli, his assistant Seiler,' introduced the Gerber' butyrometric method, which is much more simple and rapid. Seiler made comparative estimates of both methods, and found the results to vary but very little.

Having found out the amount of fat in both the control and the withdrawn meal, Sahli uses this amount as an indicator and makes use of the foling terms and formulæ to reach results:

TO = amount of test soup withdrawn + the amount found to have remained in the stomach. The amount of fat in the soup which remained in the stomach, the "residue," gives an indication as to the amount of test soup retained-so that if in 300 c.c. test soup there is 4 per cent. fat-that is, 12 grams, and if, for example, we find that in TO there are 3 grams of fat, then we can conclude that

X 300 c.c.75 c.c. remained behind of the amount of soup given to the patient. This remainder is designated by the term SU. Since TO includes soup gastric secretion, then TO — SU = MA or gastric secretion. It must not be concluded that the amount MA includes all the gastric secretion, as some of the latter, together with some of the soup, certainly passed over into the duodenum.

The motility quotient is found by using the formula, 300-Su

300 ; normally this quotient varies between and and anything above or below these figures determines a hypermotility or a hypomotility.

Acting on the suggestion given to me by Professor Ewald, I determined to apply the Sahli method to a series of cases taken from the rich material of the Polyclinic and some from the wards of the Königin Augusta Hospital, for the purpose of ascertaining its practical utility and whatever advantages it possessed.

Owing to the fact that the Gerber butyrometric method for the quantitative determination of fat requires a special centrifuge, which was not at my disposal, I employed another method, that of SchmidBondzynski, 10 for the same purpose. This is a much more delicate method than the Gerber but requires more time.

The following table as a result of my experience with this test is submitted with comparative diag

From the above we notice that the amount of the HCl varies between 3.2 per cent. and 4.4 per cent. which figures lie intermediate between that found by Pawlow' in the normal gastric juice of dogs, to be 5 per cent. and by Schüle' and Troller' in the gastric juice of patients to be 1.8 per cent. 3.6 per cent. If therefore in the application of the Sahli test-meal, the acidity per cent. of the pure secretion is found deviating one way or another from the above mentioned normal figures, we can diagnose a hyperacidity or a hypacidity.

noses, the one made according to the Sahli method, the other according to the clinical signs, together with the use of the Ewald-Boas test-meal.

In looking more closely over the table one is struck by the wide difference in many instances in the figures of the To and Acidity columns from the normal figures; again, in comparing the clinical diagnoses. with those made according to the Sahli method, we notice the lack of agreement, especially in cases Nos. 4, 6, 17, and 19. All the patients were, of course, treated in accordance with the clinical diagnosis, and under such, improved or were entirely

cured.

The very principle of the Sahli test-meal is open to criticism; it is not, as Sahli says, homogeneous for even on standing, within a very short time, there is a separation of the fat toward the surface and the thicker portion of the soup sinks to the bottom. Sahli also stated that this homogeniety was maintained by the constant churning through the peristaltic action of the stomach. This may also be objected to, for in every one of my cases, no patien was allowed to express the test-meal, but I aspirate in each case, introducing the stomach tube at var,

ous levels and very often receiving the fluid at first, followed by the thicker portion, showing that the soup did not remain homogeneous within the stomach. This latter point was also observed by Koziczkowsky," who says that the unequal distribution of fat within the stomach places the usefulness of the test in question. Bönniger," in a criticism of the Sahli method, says that there is no equal distribution of the fat within the stomach, and on this ground alone depreciates the value of the test. Another cause for criticism is the fact that, owing to the presence in the stomach of a fat-splitting ferment, as was studied by Volhard," the amount of fat remaining in the stomach after aspirating the test-meal is by the calculation entirely too small. Seiler, however, in his work investigated this point, and states that the splitting up of the fat does not yet occur within the hour the test-meal remains in the stomach.

Owing to the fact that the soup as mentioned above, and as described by Sahli, was not homogeneous, I added mucilage of acacia in amounts of 30-50 c.c. to the soup, to make an emulsion and thus distribute the fat equally. I employed this emulsion in the second ten cases of my series. On aspirating, however, the homogenity was always disturbed in all cases in which mucus in any material amount was present. This corresponded with the findings of Zweig," who says that the homogenity of the soup is disturbed in all cases of chronic gastritis with increased mucus and in cases of marked motor insufficiency.

Zweig made use of fifty-two cases, and found, as a rule, that the percentage acidity of free hydrochloric acid was considerably diminished as compared with Sahli's figures. In thirty-three cases he found vary. ing combinations indicative of disturbances of the different functions of the stomach. No one case of nervous dyspepsia existed without showing a disturbance of function according to the Sahli testmeal. He further says that in cases of subacidity and possibly anacidity, the Sahli method is not commendable, as the irritation caused by the Ewald-Boas test-meal is more marked than when using the Sahli test-meal, and where free hydrochloric acid occurs with the former, it may be absent in the latter.

If we titrate the stomach contents in patients who have received an Ewald-Boas test-meal and also the Sahli meal, we will find that the figures resulting from each do not agree, but that the acidity after a Sahli meal is invariably less than after an Ewald-Boas meal. This is probably due to the fact, as above mentioned, that the roll of the Ewald-Boas meal stimulates the stomach glands to a greater degree than the bland soup of the Sahli meal and thus causes an increased secretion.

I made comparative examinations in many of my cases and found this always to hold true. I will mention only the few following cases:

acidity then we should consider, in addition, the percentage acidity of free hydrochloric acid, as organic acids may be present in large amounts.

This test-meal serves well for the detection of lactic acid, as the soup contains none; in addition pepsin, rennet, starch digestion, etc., may be examined for in the same manner as when using other test-meals.

The application of the test-meal enables one to make a differential diagnosis between hyperacidity and hypersecretion which with the ordinary methods we are unable to do. Again, in the large number of different stomach conditions on a nervous basis which the internist sees, one can always find a disturbance of function when using the Sahli test-meal.

In the progress of clinical medicine we are continually looking for aids in order to perfect our diagnoses. Such aids, however, in order to be made use of by the general practitioner, must be practicable and not involve too much time in their employment. The Sahli test-meal certainly cannot be considered a practical aid, for no practitioner can allow himself the length of time necessary to carry out this test in the ordinary routine of practice, and therefore its use must remain limited to a hospital or sanatorium.

The Ewald-Boas test-meal has now been in use for many years, and has given satisfaction even to the specialist in gastric diseases, but this is no objection to the introduction of newer tests, which, in order to replace what we already have, must be simpler and give us at least as good results. A careful comparison of both tests fails to impress us with the results claimed by Sahli.

In summing up, I may mention:

1. When made up according to Sahli's description, the soup is not homogeneous.

2. The application of the test-meal to general practice is entirely impracticable.

3. The time consumed in determining results is incommensurable with the advantages derived from

its use.

4. The lack of agreement in every case between the clinical diagnosis and the diagnosis according to the Sahli method.

5. The possible diagnosis by means of the testmeal, of function disturbance.

6. The diagnosis between the degree of acidity and amount of secretion.

Before concluding I wish to express my sincere thanks to Prof. C. A. Ewald and Dr. L. Kuttner for the material placed at my disposal and also for the great interest shown by them in carrying out the purposes of this paper.

REFERENCES.

1. Sahli, "Über ein neues Verfahren zur Untersuchungen der Magenfunctionen," Berliner klinische Wochenschrift, 1902, Nos. 16, 17. Klinische Untersuchungs-Methoden, 1902.

2. v. Mering, Verhandlungen des Congresses für innere Medicin, 1897, Klinisches Jahrbuch, 1899, Bd. VII.

3. Matthieu, "Über ein neues Mittel die motorische Kraft des Magens und den Durchgang von Flüssigkeit durch denselben zu messen," Archiv für Verdauungskrankheiten, Bd. 1, 1896.

4. Matthieu und Remond, Société de Biologie de Paris, December, 1890, Archiv für Verdauungskrankheiten, Bd. I, S. 348.

44

5. Seiler, "Über eine neue Methode der Untersuchung der Function des Magens," Inaugural Dissertation," 1901. Deutsches Archiv für klinische Medicin, Bd. 72, Heft 5-6. 6. Gerber, "Die praktische Milchprüfung," K. J. Wyss, Bern, 1900.

7. Pawlow, "Die Arbeit der Verdauungsdrüsen," German by A. Walther, Wiesbaden, Bergmann, 1896. 8. Schüle, Zeitschrift für klinische Medicin, Bd. XXXII. 9. Troller, ibidem, Bd. XXXVIII.