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On the Gastric Juice During Pregnancy
ARZT:
ON THE GASTlUC JUICE DURING PREGNANCY
879
mal patient will withstand prolonged anesthesia to the point of complete pupillary dilatation, the occasional abnormal patient does so only with grave danger. It is, moreover, a tacit admission of ignorance or of lack of attention to permit the full appearance of retraction and the necessity for sublethal anesthesia. The bag, therefore, in itself, as an agency for the induction of labor, is inadequate: ·Where it may be successfully employed, it is often unnecessary; expectancy is as certain and more logical. Where necessary, the bag merely precedes manual dilatation, and its use must be recognized as being strictly limited to the production of dilatable cervix. 361
STATE STREET.
ON THE GASTRIC JUICE DURING PREGNANCY*
By
FRAxz ARZT,
M.D.,
ST. I.JOUIS,
Mo.
(From the Department of Ob stetrics, Washington Unil'ersity School of Medicime)
digestive disturbances during pregnancy as well as the changes T inHEappetite and peculiar desires for certain foods, have all been well known and recorded very early in the history of medi cine. Nausea and vomiting early in pregnancy, morning sickness so-called, are classified in most textbooks under the heading of the presumptive signs of pregnancy. However, in spite of these well-knovm clinical facts, very little work has been done on t he analysis of the gastric juice during pregnancy, even to the present time. Kehrer, in 1905, reports the examination of the stomach contents during pregnancy. His findings suggest that there is a decrease in the amount of gastric hydrochloric acid, which he considers usual for pregnancy. His work precedes the introduction of the Rehfuss tube and the present-day fractional method of analysis. Before starting this work about a year ago, I found no reference in the literature dealing with fractional analysis of the gastric juice during pregnancy. Since this work was started, Tetsutaroo Nakai reported in the Tokio Journal of B£o-Chernl:st1·y, October, 1925, some recent work on the gastric juice in pregnancy. This journal came to my attention two weeks ago, and since my findings practically coincide with his, I thought it would be well to present these data immediately, although I had hoped to carry the work further before presenting it. Nakai studied the gastric juice in six cases of early pregnancy (first five months) and in eight cases during late pregnancy. From this work he concludes that during pregnancy the free acidity and total acidity of the gastric juice are lower than in nonpregnant cases, and that this deficiency is more marked during the first half. *Rpacl Anril 6, 19~6, b e fore the meeting- of the 'Washington University Medical Society, St. Louis, Mo.
880
THE AMERICAN JOURNAL OF OBSTETRI CS AND GYNECOLOGY
As I have mentioned, my work on the study of the stomach contents during pregnancy was started a year ago. It was suggested to me by Dr. Otto H. Schwarz, who had previously noted a decrease in the hydrochloric acid in three cases of early pregnancy in which the gastric contents had been examined. I have attempted to examine by the fractional method the gastric juice of the pregnant woman early in pregnancy at a time when the digestive symptoms are most marked, and again in late pregnancy after these symptoms have usually disappeared. Only cases in which the tube was inserted with comparative ease are considered. The existing nausea and vomiting make it difficult in some instances for the patient to swallow the tube, and whenever any difficulty was encountered, such cases were not used. METHOD OF ANALYSIS
The pl'egnflllt wUlIlan to Le examinell was instructeu tu eat llothillg after 6 P.M. the day before, and to drink nothing after 6 A.1r. the next day, when between nine und ten 0 'clock she swallowed a Rehfuss stomach tube, through which all of the stomach contents were removed. The tube Wll,S allowed to remain in the stomach and was fastened with adhesive t ape so that it could neither slide farther down 01' be pulled out. She then ate a test meal consisting of a shredded wheat biscuit anll 300 C.c. of water. Fractions of approximately fifteen c.c. w ere r m e oved 45, 60 and 75 minutes after the patient actually started eating the meal. Five or ten c.c. of each sample were examined quantitatively by Toepfer 's method for free hydrochloric acid and using phenolphthalein as an ind icator for total acid titrating against tenth normal sodium hydroxide. Interesting r esults were obtained as shown in Tables I and II.
Nausea and vomiting in early pregnancy, as the term" morning sickness" implies, occurs most commonly in the morning, usually just after the patient gets out of bed. It is a well-known fact that if the patient before arising, eats a few crackers or a piece of toast and then does not get out of bed until forty-five minutes or an hour later, the nausea and vomiting in a great many cases may be prevented. Now, if we consider the results as outlined in the chart, it will be seen that in both early and late pregnancy there is a marked deficiency of hydrochloric acid in the stomaeh, and that this hypochlorhydria is more pronounced the first three or four months, the time when nausea and vomiting are most commonly found. It will also be noted that the acidity of the gastric contents is greatest approximately one hour after eating, and it is at this time that the patient is instructed to get out of bed and that the vomiting does not occur. This would suggest some relation between the vomiting and the acidity of the gastric contents. We therefore administered hydrochloric acid in a series of twenty cases of early pregnancy complaining of digestive symptoms, with astonishing results. A patient, E. M., twenty-nine years of age, gravida iv, two months pregnant, had been vomiting each morning after getting out of bed, and three or four times during the day for three weeks, during which time the patient lost twelve pounds in weight. She was given ten drops of dilute hyc1rochloric acid in a half glass of
ARZT:
881
ON THE GASTRIC JUICE DURING PREGNANCY
water just before getting out of bed in the morning and before each meal. The patient returned to the clinic) three days later and had not vomited since she started taking the acid. Two weeks later, the last time the p:>.tient was seen in the -clinic, she still had not vomited. Another patient, B. B., age thirty-eight years, gravida iv, approximately two months pregnant, complaining of vomiting each morning and "heart-burn" after eating, was given ten drops of dilute hydrochloric acid before getting out of bed in the morning and before each meal. She returned to the clinic two weeks later, telling us that she vomited ill the morning on two occasions since she started taking hydrochloric acid, and that both mornings she forgot to take her medicine. The "heart-burn" had disappeared. Using dilute hydrochloric acid, 10 to 15 drops in one-half glass of water before getting out of bed in the morning and before meals, we have treated twenty consecutive cases of early nausea and vomiting of pregnancy in our prenatal clinic. These patients have varied ill the number of pregnancies from primipara to gravida viii; in ages from seventeen to thirty-eight years, and include both colored and white. I
TABLE
GASTRIC ACIDITY IN EARLY PREGNANCY TOTAL ACIDITY
FREE Hcl PT.
M. T. F . s. L. D. R. T. B. s. M. c. J. D. M. s. G.N. A. P.
I.B. M.B. F. H. L. c. C. c. A. D. E. B. A. S.
DURATION OF PREGNANCY
FAST
2 mo. 2 1h " 3 " 2 " 2% " 1% " 2% " 2% " 2 " 2 " 4 " 2 " 2% " 2% " 2 1h " 2¥2 " 2 " 2 "
4 0
0 0 0 0
2
'1
0 6 0 tj
0 0 8 0 0 0
45
1
MIN.
- 17- 0 0 7 0 6.7 3 0 0 0 0 12 10 0 4 0 8 0
1
HR. AND HR. 15 MIN.
l i l -1-12 0 11 6 11.1 14 0 0 4 1 15 16 0 7 0 0 0
0 0 5 27 6 4 8
. .
10
17 18 0 9 0
I
.
0
FAST
45
MIN.
1
1
HR.
HR. AND 15 MIN.
-3-0- ~ -32-- ~ 30 14 21 8.8 20 14 20 15 23 6 20 14 6 25 8.5 13 16
20 15 28 17 30 30 10 25 24 10 38 38 15 14 13 15 20
15 10 28 8 18 14 10 16 11 7 34 24 7 11 12 17.5 14
16 8.5 18.5 41 23 18 24
*
27
*
45 37.1) 16 23
14
*
19
"No fractIOn obta ined. TABLE
II
GASTRIC ACIDITY IN LATER PREGNANCY FREE Hcl DURATION
OF
PT.
FAST
PREGNANCY
Mrs. M. R. T. M. C.
F. s.
G.
J.
N.
E.
8 7 5
6 1h 71h 8
mo.
" " " " "
"No fractIOn obta ined.
45
12 18 6 0 0 7.5
TOTAL ACIDITY MIN.
I
1
11
HR. AND HR. 15 MIN .
FAST
45
MIN.
-6- ---ril -2-5- 2 3 - 1-6 28 19 23 20 26 12 22 * * * 12 17 21 4 10 10 16 2 0 30 37.5 12 0 0 0
1
1
HR.
HR. AND 15 MIN.
28:"5" 33 26 26 10 13.7
3-332
*
32 15 15
882
THE AMERICA N JOU RNAL OF OBSTETRICS AND GYNECOLOGY TABLE
III
RESULTS NUMBER OF CASES
- - - -----
-
SYMPTOMS
RE SU LTS
Xausea and vomiting.
Nausea and vomiting completely stopped. -~ a lls ea and vomiting. 7 Nausea and vomiting greatly r elieved. Now vomit once a week or less. _. .- - -- - _ ...._ . 1 Nausea in A.M. --and --after Nausea completely stopped. meals. -- ---- - - - - - -- --H eart-burn after mea Is, H eart-burn and nausea 1 greatly improved. Now some nausea, no vomiting. occasional. ---- - 1 Na usea frequent; vomiting No improvement. two or three times a week. 10
--
-- - --_."-------_._ ---- --------,-_ . _ . _ - - - - --
--
----._ - --
At the suggestion of Dr. Duff Allen of the Department of Surgery of Washington Universit~" \\"110 is at present working on the formation of CO 2 in the stomach, chloride determinations were made on eight cases of this series. Dr. Allen is of the opinion that this gas is formed chiefly by the regurgitation of th e tluodenal contents, due to r everse peristalsis. The sodium carbonate of j be dnodm(ll contents r eacts with the hydrochloric acid of the gastrie contents to form sodium chloride, carbon dioxide and watcr . On h('aring of my \york, Dr. Allen felt that this low acidity might be due not to actual deficiency in the hydrochloric acid contents of t he stOll1l1eh. but (l1w to a TI('lltl"alization of the aciel , TABLE
IV
TOTAL CHLO RIDE OF STOMACH CO~TEN'r s IN P REG NANCY
PT.
D. M. S. 1. B. ;T.
M. B.
F. H.
F. s. G. M. M. c.
DURATION OF PREGNANCY
2% mos.
2%
"
h
" " "
" " 1 2 h " 1 4 2
6
7 1h 5
--F ASTING CONTENTS
- -(;6- - 7;; 80.3 69.7 flil.5 52.7 90.9 85.0
45
I
1
MIN.
41 23 56.1 61.2 57 .8 50.8 46.7
---_
HR.
44
22
.. -.
69.7 68.0 68.0 56.1 78.2 96.9
I
1
--
BR. AND 15 MIN.
51 37 80.9 69.7 74.8 67.6 113.2
with the formation of sodium chloride as a result of r egurgitation of the duodenal contents. If this be the case, the gastric contents should, in spite of the low free hydrochloric acid contain a normal, or possibly an increased amount of total chlorides. In eight determinations of total chlorides carried out by Dr. Allen on these cases, it will be seen that the total chlorides were normal, or eyen increased (see Tabl e IV ) . Although the r esults outlined represent data from only a few cases, they tend to show that free hydrochloric acid in the stomach contents is not due to an actual deficiency of secretion, but to the n eutralization of the acid by alkaline salts regurgitated from the duodenum into the stomach. It is suggested
DANFCRTH:
REFERRED PAIN IN RUPTURED TUBAL PREGNANCY
883
by Dr. Allen that the reverse peristalsis causing the regurgitation might be reflex from irritation from the early pregnant uterus. This has been previously suggested by Alvarez. CONCLUSIOKS 1. That the free hydrochloric acid and total acid of the stomach contents are lower in pregnancy than in the nonpregnant, and that this deficiency is more marked early, at the time that nausea and vomiting are most common. 2. 'rhat dilute hydrochloric acid Oy mouth is indicated in preventing early nausea and vomiting of pregnancy in certain cases. REFERENCES Alvarez, W. C.: The Mechanics of the Digestive Tract, Paul B. Hoeber, New York City, 1922, p. 126. Baird and Campbell: Guy's Hospital Reports, lxxiv. Nakai Tetsutaroo: The Tokio Journal of Bio-Chemistry, October, 192;;, v, No.3.
R,EFERRED PAIN IN THE SHOULDER IN RUPTURED TUBAL PREGNANCY By W. C. DANFORTH, B.S., M.D" F.A.C.S., EVAKSTON, ILL. means of rendering differential diagnosis easier and clearer is A NYof value. The diagnosis of unruptured tubal pregnancy is often
difficult. The recognition of ruptured ectopic pregnancy is, in the majority of cases easy. 'W hen the loss of blood has not been extreme and the signs of hemorrhage, as pallor and increased pulse rate, are consequently not so marked, error may occur. The possibility of such error is evidenced by the two ca~es reported hen', as well as the possibility of avoiding error by the consideration of the :;;ignificance of pain in one or both shoulders which oecasionally occurs in intra abdominal hemorrhage from ruptured tubal pr egnancy. All who have made use of transtubal insufflation to determine the patency of the fallopian tubes have noted the frequency of pain in one or both shoulders in those cases in which normally patent tubes permit the passage of gas into the abdomen. This occurs after the woman assumes the sitting posture, after insufflation. The gas seeks the highest point in the abdomen and finds its way betvveen the diaphragm and the superior surface of the liver, causing the falciform ligament to be pulled upon. The consequent stimulation of the phrenic nerve, and its relation with n erve trunks springing from the third, fourth and fifth cervical cord segments, causes pain to be felt in the shoulders. If the woman lies down, particularly if the lower part of the body be elevated, the pain soon ceases as the g~s leaves the subphrenic space. In rupture of the pregnant tube, particularly if considerable intraabdominal hemorrhage occurs, blood may enter the subphrenic space
ON THE GASTlUC JUICE DURING PREGNANCY
879
mal patient will withstand prolonged anesthesia to the point of complete pupillary dilatation, the occasional abnormal patient does so only with grave danger. It is, moreover, a tacit admission of ignorance or of lack of attention to permit the full appearance of retraction and the necessity for sublethal anesthesia. The bag, therefore, in itself, as an agency for the induction of labor, is inadequate: ·Where it may be successfully employed, it is often unnecessary; expectancy is as certain and more logical. Where necessary, the bag merely precedes manual dilatation, and its use must be recognized as being strictly limited to the production of dilatable cervix. 361
STATE STREET.
ON THE GASTRIC JUICE DURING PREGNANCY*
By
FRAxz ARZT,
M.D.,
ST. I.JOUIS,
Mo.
(From the Department of Ob stetrics, Washington Unil'ersity School of Medicime)
digestive disturbances during pregnancy as well as the changes T inHEappetite and peculiar desires for certain foods, have all been well known and recorded very early in the history of medi cine. Nausea and vomiting early in pregnancy, morning sickness so-called, are classified in most textbooks under the heading of the presumptive signs of pregnancy. However, in spite of these well-knovm clinical facts, very little work has been done on t he analysis of the gastric juice during pregnancy, even to the present time. Kehrer, in 1905, reports the examination of the stomach contents during pregnancy. His findings suggest that there is a decrease in the amount of gastric hydrochloric acid, which he considers usual for pregnancy. His work precedes the introduction of the Rehfuss tube and the present-day fractional method of analysis. Before starting this work about a year ago, I found no reference in the literature dealing with fractional analysis of the gastric juice during pregnancy. Since this work was started, Tetsutaroo Nakai reported in the Tokio Journal of B£o-Chernl:st1·y, October, 1925, some recent work on the gastric juice in pregnancy. This journal came to my attention two weeks ago, and since my findings practically coincide with his, I thought it would be well to present these data immediately, although I had hoped to carry the work further before presenting it. Nakai studied the gastric juice in six cases of early pregnancy (first five months) and in eight cases during late pregnancy. From this work he concludes that during pregnancy the free acidity and total acidity of the gastric juice are lower than in nonpregnant cases, and that this deficiency is more marked during the first half. *Rpacl Anril 6, 19~6, b e fore the meeting- of the 'Washington University Medical Society, St. Louis, Mo.
880
THE AMERICAN JOURNAL OF OBSTETRI CS AND GYNECOLOGY
As I have mentioned, my work on the study of the stomach contents during pregnancy was started a year ago. It was suggested to me by Dr. Otto H. Schwarz, who had previously noted a decrease in the hydrochloric acid in three cases of early pregnancy in which the gastric contents had been examined. I have attempted to examine by the fractional method the gastric juice of the pregnant woman early in pregnancy at a time when the digestive symptoms are most marked, and again in late pregnancy after these symptoms have usually disappeared. Only cases in which the tube was inserted with comparative ease are considered. The existing nausea and vomiting make it difficult in some instances for the patient to swallow the tube, and whenever any difficulty was encountered, such cases were not used. METHOD OF ANALYSIS
The pl'egnflllt wUlIlan to Le examinell was instructeu tu eat llothillg after 6 P.M. the day before, and to drink nothing after 6 A.1r. the next day, when between nine und ten 0 'clock she swallowed a Rehfuss stomach tube, through which all of the stomach contents were removed. The tube Wll,S allowed to remain in the stomach and was fastened with adhesive t ape so that it could neither slide farther down 01' be pulled out. She then ate a test meal consisting of a shredded wheat biscuit anll 300 C.c. of water. Fractions of approximately fifteen c.c. w ere r m e oved 45, 60 and 75 minutes after the patient actually started eating the meal. Five or ten c.c. of each sample were examined quantitatively by Toepfer 's method for free hydrochloric acid and using phenolphthalein as an ind icator for total acid titrating against tenth normal sodium hydroxide. Interesting r esults were obtained as shown in Tables I and II.
Nausea and vomiting in early pregnancy, as the term" morning sickness" implies, occurs most commonly in the morning, usually just after the patient gets out of bed. It is a well-known fact that if the patient before arising, eats a few crackers or a piece of toast and then does not get out of bed until forty-five minutes or an hour later, the nausea and vomiting in a great many cases may be prevented. Now, if we consider the results as outlined in the chart, it will be seen that in both early and late pregnancy there is a marked deficiency of hydrochloric acid in the stomaeh, and that this hypochlorhydria is more pronounced the first three or four months, the time when nausea and vomiting are most commonly found. It will also be noted that the acidity of the gastric contents is greatest approximately one hour after eating, and it is at this time that the patient is instructed to get out of bed and that the vomiting does not occur. This would suggest some relation between the vomiting and the acidity of the gastric contents. We therefore administered hydrochloric acid in a series of twenty cases of early pregnancy complaining of digestive symptoms, with astonishing results. A patient, E. M., twenty-nine years of age, gravida iv, two months pregnant, had been vomiting each morning after getting out of bed, and three or four times during the day for three weeks, during which time the patient lost twelve pounds in weight. She was given ten drops of dilute hyc1rochloric acid in a half glass of
ARZT:
881
ON THE GASTRIC JUICE DURING PREGNANCY
water just before getting out of bed in the morning and before each meal. The patient returned to the clinic) three days later and had not vomited since she started taking the acid. Two weeks later, the last time the p:>.tient was seen in the -clinic, she still had not vomited. Another patient, B. B., age thirty-eight years, gravida iv, approximately two months pregnant, complaining of vomiting each morning and "heart-burn" after eating, was given ten drops of dilute hydrochloric acid before getting out of bed in the morning and before each meal. She returned to the clinic two weeks later, telling us that she vomited ill the morning on two occasions since she started taking hydrochloric acid, and that both mornings she forgot to take her medicine. The "heart-burn" had disappeared. Using dilute hydrochloric acid, 10 to 15 drops in one-half glass of water before getting out of bed in the morning and before meals, we have treated twenty consecutive cases of early nausea and vomiting of pregnancy in our prenatal clinic. These patients have varied ill the number of pregnancies from primipara to gravida viii; in ages from seventeen to thirty-eight years, and include both colored and white. I
TABLE
GASTRIC ACIDITY IN EARLY PREGNANCY TOTAL ACIDITY
FREE Hcl PT.
M. T. F . s. L. D. R. T. B. s. M. c. J. D. M. s. G.N. A. P.
I.B. M.B. F. H. L. c. C. c. A. D. E. B. A. S.
DURATION OF PREGNANCY
FAST
2 mo. 2 1h " 3 " 2 " 2% " 1% " 2% " 2% " 2 " 2 " 4 " 2 " 2% " 2% " 2 1h " 2¥2 " 2 " 2 "
4 0
0 0 0 0
2
'1
0 6 0 tj
0 0 8 0 0 0
45
1
MIN.
- 17- 0 0 7 0 6.7 3 0 0 0 0 12 10 0 4 0 8 0
1
HR. AND HR. 15 MIN.
l i l -1-12 0 11 6 11.1 14 0 0 4 1 15 16 0 7 0 0 0
0 0 5 27 6 4 8
. .
10
17 18 0 9 0
I
.
0
FAST
45
MIN.
1
1
HR.
HR. AND 15 MIN.
-3-0- ~ -32-- ~ 30 14 21 8.8 20 14 20 15 23 6 20 14 6 25 8.5 13 16
20 15 28 17 30 30 10 25 24 10 38 38 15 14 13 15 20
15 10 28 8 18 14 10 16 11 7 34 24 7 11 12 17.5 14
16 8.5 18.5 41 23 18 24
*
27
*
45 37.1) 16 23
14
*
19
"No fractIOn obta ined. TABLE
II
GASTRIC ACIDITY IN LATER PREGNANCY FREE Hcl DURATION
OF
PT.
FAST
PREGNANCY
Mrs. M. R. T. M. C.
F. s.
G.
J.
N.
E.
8 7 5
6 1h 71h 8
mo.
" " " " "
"No fractIOn obta ined.
45
12 18 6 0 0 7.5
TOTAL ACIDITY MIN.
I
1
11
HR. AND HR. 15 MIN .
FAST
45
MIN.
-6- ---ril -2-5- 2 3 - 1-6 28 19 23 20 26 12 22 * * * 12 17 21 4 10 10 16 2 0 30 37.5 12 0 0 0
1
1
HR.
HR. AND 15 MIN.
28:"5" 33 26 26 10 13.7
3-332
*
32 15 15
882
THE AMERICA N JOU RNAL OF OBSTETRICS AND GYNECOLOGY TABLE
III
RESULTS NUMBER OF CASES
- - - -----
-
SYMPTOMS
RE SU LTS
Xausea and vomiting.
Nausea and vomiting completely stopped. -~ a lls ea and vomiting. 7 Nausea and vomiting greatly r elieved. Now vomit once a week or less. _. .- - -- - _ ...._ . 1 Nausea in A.M. --and --after Nausea completely stopped. meals. -- ---- - - - - - -- --H eart-burn after mea Is, H eart-burn and nausea 1 greatly improved. Now some nausea, no vomiting. occasional. ---- - 1 Na usea frequent; vomiting No improvement. two or three times a week. 10
--
-- - --_."-------_._ ---- --------,-_ . _ . _ - - - - --
--
----._ - --
At the suggestion of Dr. Duff Allen of the Department of Surgery of Washington Universit~" \\"110 is at present working on the formation of CO 2 in the stomach, chloride determinations were made on eight cases of this series. Dr. Allen is of the opinion that this gas is formed chiefly by the regurgitation of th e tluodenal contents, due to r everse peristalsis. The sodium carbonate of j be dnodm(ll contents r eacts with the hydrochloric acid of the gastrie contents to form sodium chloride, carbon dioxide and watcr . On h('aring of my \york, Dr. Allen felt that this low acidity might be due not to actual deficiency in the hydrochloric acid contents of t he stOll1l1eh. but (l1w to a TI('lltl"alization of the aciel , TABLE
IV
TOTAL CHLO RIDE OF STOMACH CO~TEN'r s IN P REG NANCY
PT.
D. M. S. 1. B. ;T.
M. B.
F. H.
F. s. G. M. M. c.
DURATION OF PREGNANCY
2% mos.
2%
"
h
" " "
" " 1 2 h " 1 4 2
6
7 1h 5
--F ASTING CONTENTS
- -(;6- - 7;; 80.3 69.7 flil.5 52.7 90.9 85.0
45
I
1
MIN.
41 23 56.1 61.2 57 .8 50.8 46.7
---_
HR.
44
22
.. -.
69.7 68.0 68.0 56.1 78.2 96.9
I
1
--
BR. AND 15 MIN.
51 37 80.9 69.7 74.8 67.6 113.2
with the formation of sodium chloride as a result of r egurgitation of the duodenal contents. If this be the case, the gastric contents should, in spite of the low free hydrochloric acid contain a normal, or possibly an increased amount of total chlorides. In eight determinations of total chlorides carried out by Dr. Allen on these cases, it will be seen that the total chlorides were normal, or eyen increased (see Tabl e IV ) . Although the r esults outlined represent data from only a few cases, they tend to show that free hydrochloric acid in the stomach contents is not due to an actual deficiency of secretion, but to the n eutralization of the acid by alkaline salts regurgitated from the duodenum into the stomach. It is suggested
DANFCRTH:
REFERRED PAIN IN RUPTURED TUBAL PREGNANCY
883
by Dr. Allen that the reverse peristalsis causing the regurgitation might be reflex from irritation from the early pregnant uterus. This has been previously suggested by Alvarez. CONCLUSIOKS 1. That the free hydrochloric acid and total acid of the stomach contents are lower in pregnancy than in the nonpregnant, and that this deficiency is more marked early, at the time that nausea and vomiting are most common. 2. 'rhat dilute hydrochloric acid Oy mouth is indicated in preventing early nausea and vomiting of pregnancy in certain cases. REFERENCES Alvarez, W. C.: The Mechanics of the Digestive Tract, Paul B. Hoeber, New York City, 1922, p. 126. Baird and Campbell: Guy's Hospital Reports, lxxiv. Nakai Tetsutaroo: The Tokio Journal of Bio-Chemistry, October, 192;;, v, No.3.
R,EFERRED PAIN IN THE SHOULDER IN RUPTURED TUBAL PREGNANCY By W. C. DANFORTH, B.S., M.D" F.A.C.S., EVAKSTON, ILL. means of rendering differential diagnosis easier and clearer is A NYof value. The diagnosis of unruptured tubal pregnancy is often
difficult. The recognition of ruptured ectopic pregnancy is, in the majority of cases easy. 'W hen the loss of blood has not been extreme and the signs of hemorrhage, as pallor and increased pulse rate, are consequently not so marked, error may occur. The possibility of such error is evidenced by the two ca~es reported hen', as well as the possibility of avoiding error by the consideration of the :;;ignificance of pain in one or both shoulders which oecasionally occurs in intra abdominal hemorrhage from ruptured tubal pr egnancy. All who have made use of transtubal insufflation to determine the patency of the fallopian tubes have noted the frequency of pain in one or both shoulders in those cases in which normally patent tubes permit the passage of gas into the abdomen. This occurs after the woman assumes the sitting posture, after insufflation. The gas seeks the highest point in the abdomen and finds its way betvveen the diaphragm and the superior surface of the liver, causing the falciform ligament to be pulled upon. The consequent stimulation of the phrenic nerve, and its relation with n erve trunks springing from the third, fourth and fifth cervical cord segments, causes pain to be felt in the shoulders. If the woman lies down, particularly if the lower part of the body be elevated, the pain soon ceases as the g~s leaves the subphrenic space. In rupture of the pregnant tube, particularly if considerable intraabdominal hemorrhage occurs, blood may enter the subphrenic space