562 GIFFIN, SANFORD, SZLAPKA: UROBILIN .AND UROBILINOGEN the estimation of urobilin and urobilinogen in THE DUODENAL CONTENTS. Bv Herbert Z. Giffin, M.D., Arthur H. Sanford, M.D., AND Tiiaddeus L. Szlapka, M.D., MATO CLINIC. IIOCIULSTER, MINNESOTA. "ith evide“ce of increased blood cm I * f • ,,ttcrnpt ‘o estimate the activitv of ! a'"1 ‘""""pan; this with the probable capacity for biood t on la 'VOrkeI? have used “s "*'l“ of blood destruc- t on the changes that occur in the contents of the bile, namely, the amount of bile pigment excreted, and especially the amount of urob! the amount of urobilinogen!!!°SC" anda"‘l urobilinUrV-V-l,n -in ^theppi stools"«er esti,natLby means''i of the Charnas spectrophotometric method and stimulated interest in this manner of estimating blood destruction, particularly in pernicious anemia for makh ’ 'T™' ■" •'“S ",ll,ltr-v a more simple procedure „ t "'"It' ,n;">"t.tative estimates of these substances has been dm ised by \\ llbur and Addis. Iiobertson, making use of the 'if' I-.ppin.'cr r< P"r'" f,"{|"1RS 1,1 CV«T "ay comparable to those The theories advanced with regard to the fate of hemoglobin after benudys's arc not well substantiated. Recent investigations ; '' hipp|e and Hooper are especially important. Their experi- cri d 7,° VCd “ FI1 <lt-al "f Carcful study over a considerable pinod of tune, and, of necessity, only on dogs. Their conclusions are ill some resects iconoclastic. If further work substantiates their findings it may be necessary to change our conception of the factors concerned in the formation of bile pigment. These authors con¬ clude, especially from their results regarding the influence of diet on bile-pigment production, that the disintegration of red blood cells is not the important factor m the production of bile pigments. They have made estimations chiefly of the amount of bilirubin. It will be interesting to learn of their results with respect to urobilin and urobilinogen, for in the clinical studies on the hemolytic anemias there is now considerable evidence from many observers that the amounts of these substances excreted are definitely increased Ibis increase, it is true, may be the result of impaired organ unction as well as of blood destruction. The quantity of bilirubin does not, however, run parallel to the quantity of urobilin and urobilinogen m pathological conditions. In our own studies we have made use of the modifications of the llbur and Addis methods recently devised and reported by GIFFIN, SANFORD, SZLAFKAI UROBILIN AND UROBILINOGEN 563 Schneider. The essential advance in technic is the application of the observations, not to stool extracts, but to the contents of the duodenum as collected by means of an Einhorn tube. In this liquid an amount of the biliary elements and their derivatives sufficient for quantitative determinations is readily obtained in a short time. M hile an estimation of the amounts of these pigments in the duodenal contents at a given time cannot be regarded as an index of the total amount excreted in twenty-four hours, objections are also advanced with respect to the values obtained in the twenty- four-hour stool in which some proportion of the substances may¬ be destroyed or changed in character. The values obtained by Schneider s method have been so definitely in accord with the clinical manifestations that there is little doubt of the existence of a relationship which it is to be hoped may be made clearer by further study. These values are also in accord with the results obtained from estimations on the stool. The technic we have used, which in all of its essentials is that described by Schneider, is pre¬ sented in detail, in order that it may be readily understood and easily followed. We wish to express our indebtedness to the originator of this method for his personal interest in our work. The Method of Obtaining the Duodenal Contents.* The tube and the metal capsule employed are similar to those of the Einhorn duodenal tube, but experience has led to the use of a somewhat stiffer tube and a capsule which, though similar in shape, is slightly larger and heavier, weighing 6.4 gin. This model of capsule was recommended by Schneider. However, an ordinary Einhorn or a Ilehfuss bucket may be used. For convenience in observing the contents of tile tube a piece of glass tubing is inserted at its end. In the preparation for the examination the patient is instructed to partake of no food for at least twelve hours, except perhaps a little tea or coffee without cream, and to take frequent sips of warm water up to the time of the examination. The nature and purpose of tin- test arc also explained, as the patient's confidence and cooperation aid in the passage of the tube. The passage of the duodenal tube is a simple procedure. The metal capsule is placed on the back of the tongue and the patient is directed to swallow hard several times in rapid succession. There is usually some difficulty as the capsule reaches the level of the cricoid, but this is overcome by deep breathing. After the capsule has passed this irritable zone, peristalsis carries it along without further discomfort to the patient and largely beyond his control. lie merely swallows from time to time, Diking a few sips of warm water and the capsule finally reaches the stomach and comes to rest at about 60 cm. from the incisor teeth. * Described by Szlnpka. 564 GIFFIN, SANFORD, SZLAPKA: UROBILIN AND UROBILINOGEN The patient is now made to lie on his right side, with the hins elevated eight or ten inches. The pyloric end of the stomach thus becomes more dependent, and gravity, aided bv gastric p“rUtaIs"s somTn)ltrPfn.mttlPa?S ^rOUghIinto P°sition m ‘he duodenum- ln-C,SOrS- In OUr exPer*ence this is accom- in t/s u' "'" """T ‘° an hour- usual|y in about forty- p e minutes At no tune is it necessary to push the tube on its wav frustrate °it!f* t|Cn< S “>>> * »P » the stomach lnistratc- its passage into the duodenum. well "r" lS Si',k;tlle cn'1 °fthe tubc is allowed to hang • . ,er the edge of the table. Gastric contents siphon out first" fwamlto6b>' th,e injccti°" of a few 'able centimeter! OI warm water As the capsule moves through the pylorus into the duodenum the fluid recovered becomes yellowish and finally a clear bmwn°b PuT ;i,1ItimiTcoflo.r f™m light .«»<>"- to chocolate Grown, lure duodenal fluid is faintly alkaline, clear, of quite alkaline “hs T V,SC“ = f‘*‘m b golden- Tlle liquid must be ,. C, vf,mere appearance is not a safe guide as to its identity although with experience one may come to recognize it readily Ihc character of the fluid collected must be observed closely as from time to time the pylorus permits the passage of gastric contents into the duodenum. This impure liquid mav he detected bv its c mnge ,1. color and its dull, cloudy, opalescent ap^aran* hmmishcd viscidity, more rapid flow, and change in reaction to S ',o„n ,?T r‘‘‘f i • * k1'0"1'1' of coursc- >« discarded, time t ,. ; '! 5°"' “I b‘,!e )ccome interrupted an unusual length of of I- thc 'nation °f a little warm water into the tube or the taking of deep breaths by the patient, will help to reestablish it The application of suction is neither necessary nor advisable „„ I 'S T C,Tnn! to c‘,lk‘ct the duodenal contents in a small of the ^dili ■' T Tr llght raUSC the raP'd transformation tnclie tist,cst whichw TT" should m Ik* l,r made°b: m immediately..; 2(1 cic- °f li( 'ui,i arc n«*ssary for Laboratory Technic.* The duodenal contents is poured into a graduated cylinder as soon I" laborator>-. a"d its gross appearance noted Normally it is a light, straw-colored, viscid fluid, and this is reported an IT ti( 11 '"i "llor may var-v to dark yellow, lmiwn it he’cnkm' f "' ‘arkrCOr''i fl,li,ls alwa-vs yield much bilirubin, ut the color of the duodenal contents does not always indicate the amount of urobilinogen or urobilin present, as these'derivatives of hihruhm are sometimes demonstrated in considerable amounts in normal yellow fluids. Occasionally, however, in cases other than pernicious anemia or hemolytic icterus a colorless, watery secretion with no biliary pigments or derivatives is collected. * Dcscrilwd by Sanford. OIFFIX, SANFORD, SZLAFKA: UROBILIN AND UROBILINOGEN 565 " I1™. c c- or more °f pIpbp duodenal contents is collected it is divided into two 10 c.c. portions in 25 c.c. graduates. To one 10 c.c. portion is added an equal amount, 10 c.e., of a saturated alcoholic solution of zinc acetate (Schlesinger’s solution).* The mouth of the graduate is closed by the thumb and the contents thoroughly nnxtrd by- vigorous shaking for about one minute. The mixture is then filtered through a single layer of coarse filter paper, the filtrate being collected in another clean, dry graduate. When exactly 10 c V,f ^tra*e *s obtained it is used for testing for urobilin and urobilinogen. _ To this mixture, which consists of 5 c.c. of duodenal a,nt^ c‘c' nl' Schlesinger’s solution, is added exactly 1 c.c. of Ehrlich’s aldehyde reagentf measured with a 1 c.c. pipette. The color of the fluid is usually significant when viewed by transmitted and reflected light. If urobilinogen is present in’ considerable amount, especially if it predominates, the fluid, on the addition of Ehrlich s reagent, becomes a cherry red, varying in intensity with the amount of chromogen present.