Complete Text (Part 12)

in rapid peristalsis the soluble sodium and ]30tassium soaps nuiy occur. Neutral fats indicate the absence of lipase. Fatty acid increase indicates an excess of fat in the diet over that Avhich can be absorbed or hyperperistalsis. In the decreased secretion of bile an excess of fats occur also. 147 DIFFEREXTrATTOX OF FATS, FATTY ACIDS & SOAPS. Test. Heat Ether Xeutral fat. Melted Dissolved Fatty acid. Melted Dissolved Soap. 0 0 Sudan III Stained Crystals Globules 0 + 0 Osmic acid Scharlack R. H,0 1 Stained 0 Stained 0 1 0 Xa. & IC. dis- solved Ca. & :M.g-. un- ' dissolved KOH 0 Carbol fuchsin 0 + + 0 Soaps can be broken np with acetic acid and tbcn stained with Sndan I IT. Some fatty acids with a h)w nieltino- ])oint appear in globnbir form and stain with Sudan ITT. Sugar and starch. These are not nsnal. Occa- sionally tliey come thronj^h in a cellubir envelope. Test with iodin Avhich turns starch granules blue, and Benedict's solution which is reduced by sugar. Tf. Tnte^stinal tract secretions. Bile. Occult bile never seen in the adult. To de- termine the presence of bilirubin or hydrobilirubin emulsify about 2 or :> cc. of the stool in a concen- trated solution of mercuric chloride. Allow to stand 24 hours and examine microscopically. Green sig- nifies the presence of bilirubin ; red indicates hydro- bilirubin. UrobUui. This is normal in certain amounts, but large amounts are pathological. To determine its presence use Schlessinger's test as follows : Make an acid-alcohol extract of the stool, add a few drops of Lu gal's solution, 1 or 2 cc. of XH^OH, and an equal volume of an alcoholic solution of zinc acetate. Filter and examine the filtrate for a greenish fluo- rescence. Spectroscopic examination of the intesti- nal fluid normally is positive in dilutions up to 1 to 9,000. In higher dilutions than this it is patho- logical. 148 Mucus. When mucus is abundant it means catar- rhal inflammation. In a disease resembling asthma one may get complete casts of the colon, which are usually passed between stools. To test for mucus is usually unnecessary. Ferments. These are usually tested for in order to determine whether the pancreas is functioning normally or whether the pancreatic secretion is en- tering the intestine. Since trypsin and lipase are more easily destroyed by bacteria and each requires actiyation to show its maximum efliciency, and also since proteolytic action of the intestinal bacteria may complicate the tindings, the study of the dias- tase of the stools is probably the best means of obtaining this information. Method of performing test: 1. The patient is given a light meal and a high enema the night before. 2. At 7 A. M. the next day, 750 cc. of milk are given. 3. At 7.30 and 8.00, half an ounce of Epsom salts. 4. At 8.30, a glass of Avater containing a tea- spoonful of bicarbonate of soda. Save all stools up to 2 P. M. in a vessel contain- ing 2 ounces of toluol and keep in the ice-chest or cool room. If less than 400 grams of cc. are ob- tained, an enema of a pint of water is given. From 400 to 1,100 cc. are to be expected. Titration of the diastase: Dilute the stool with enough water to make 3,000 cc. Dilute 2 cc. of this Avith 48 cc. of isotonic salt, which gives a dilution of 1 to 25, and then centrifugalize to clear. Set up tubes as folloAvs : 1 2 3 4 5 6 1 cc stool 1 cc stool 1 cc stool 1 cc stool 1 cc stool 1 cc stool 1-25 1-50 1-100 1-200 1-400 1-800 Add 2 cc of 0.1% starch solution, after dilutions 149 are made, to each. Incubate at 37 cleg. C. for half hour and add a few drops of a 1% solution of iodin to each tube. Blue shows the presence of undi- gested starch. Calculation : % cc. of 1-25 diluted stool digests 2 cc. of 0.1% starch. 1 cc. of 1-25 diluted stool digests 4 cc. of 0.1% starch, or 0.4 cc. of a 1.0% starch solution. 1 cc. of undiluted stool digests 10 cc. of a 1% starch solution. Tlie unit is the digestion of 1 cc. of a 1% starch solution by 1 cc. of undiluted stool. The minimum of normal is 600 units. (See article by Dr. Brown in Boston Med. and Surg. Jour., :N"ov. 30, 1916, Vol. CLXXV, pages 775 to 784.) Schmidt and Strasburger diet for pancreatic effi- ciency : 1. Morning: 500 cc. of milk and 50 grams of zweibach. 2. Forenoon: 500 cc. of oatmeal gruel com- posed of: Oatmeal 40 gm. Butter 10 gm. Milk 200 cc. Water 300 cc. 3. Noon: 125 gm. (raw weight) of chopped beef, broiled rare and 20 gm, of butter. 250 gm. of potato broth composed of : Mashed potato 190 gm. Milk 100 cc. Butter 10 gm. 4. Afternoon : Give same as for forenoon. 5. Evening : Give same as for dinner. This diet should be given three days or longer in order to obtain stools in which it is present. In 150 pathological conditions there will be food remnants of all kinds. ITT. Decomposition products. Gasses: H,S, CH^, ^\ H, and CO,, which are the products of fermentation and putrefaction. Crystalline bodies : Tndol and skatol. These give the feces their characteristic odor. IV. Bacteria. These make up about one-third by weight of the stool. A. Those ^^'hich normally occur: The majority of these belong to the colon group, among which the more common ones are: B. coli, including B. fecalis alkaligenes, and B. acidi lactici ; B. lactis aerogenes, B. subtilis, B. proteus vulgaris, etc. A few strep- tococci and staphylococci are sometimes found. B. Those Avhich occur under j)athological condi- tions. 1. Bacillus typhosus. This organism occurs in the stools of typhoid patients and of typhoid car- riers. One of the best ditferential culture media for identification is Endo's media, which is made, ac- cording to Robinson and Rettger's modification, as follows : Agar 25 grams . Meat extract 5 grams Pepton 10 grams Water 1000 cc. Dissolve the agar, pepton and meat extract, and autoclave at 15 pounds pressure for 30 minutes. Filter through cheese cloth and cotton, add 10 cc. of 10% sodium carbonate, adjust reaction to # plus 0.1 phenoli)hthalein, put in 100 cc. containers and autoclave at 10 pounds for 10 minutes. 151 When ready to use, add to each 100 cc. of agar: 20% lactose solution (Arnoldized) 5 cc. 10% freshly prepared anhydrous sodium sulphite sol. (sterile) 1 cc. Saturated alcoholic fuchsin (basic) 0.5 cc. Pour plates and allo\y to harden without the covers upon them. # Plus 0.1 phenolphthalein means the addition of 0.1 cc. of N/HCl to 1000 cc. of the medium after the neutral point of the solution has been determined with phenolphthalein as indicator. The basic fuchsin is colorless in an alkaline me- dium, but turns red in acid solution. Since the typhoid bacillus does not ferment lactose, the typhoid colonies will remain colorless, while the colon colonies will turn red because the colon bacillus ferments lactose. An emulsion of the stool is made in isotonic salt solution and a loopful of the emulsion is transferred to an Endo plate. With a bent wire the surface of the plate is streaked, and, without flaming, a second plate is treated likewise. Incubate 24 hours and pick colonies. In order to be relatiyely sure that a colony picked is a typhoid one, microscopic aggluti- nation can be done in the following way: A low dilution of anti-typhoid serum is made (1-100), and one drop of this is placed upon a clean slide. A drop of salt solution is placed upon the same slide near the drop of serum, and in it an emulsion of one of the suspicious colonies is made. The two drops are now coalesced, and within 2 or 3 minutes, if the colony picked is one of typhoid, deflnite clumps can be made out. One must be sure in this pro- cedure to haye the drops large enough to prevent drying, which would give false readings. If the colony picked gives agglutination, the remainder is inoculated upon agar for further identification. If 152 one should titrate specific sera with typhoid, para- typhoid (a) and paratyphoid (b), one could deter- mine the dilution of each, wliich Avould agglutinate the organism for Avhich it was specific and not those which it agglutinates in lower dilutions. By this rapid slide agglutination one can, by properly dilut- ing the sera, sometimes determine which of the typhoid group of organisms he is dealing with. 2. Dysentery bacilli. These are a group of bacilli which are resj)onsible for some forms of dysentery and which are differentiated by sugar reactions and agglutination tests. Their isolation can be accom- plished by the use of Endo's media or brilliant green media, for which see Park and Williams Bacteri- ology. These are short gram negative rods, with little or no motility. The colonies are not as large nor as opaque as the typhoid or colon and most of the groups are colorless on Endo's media. They also appear later than the foregoing. By use of the polyvalent serum they can be detected by macro- scopic slide agglutination, and then transferred to other media for more careful study. In making cultures it is desirable to pick the bloody flakes of mucus, 3. Tubercle bacillus. These are occasionally swal- lowed and must be excluded. The smegma bacillus must also be differentiated, which is . not alcohol acid-fast. Particles of blood-stained mucus are most likely to show the organisms. The antiformin method is not very satisfactory unless the organisms are present in large numbers. 4:. Cholera spirillum. This organism can usually be diagnosed from morphology and serum reactions. It can grow in a media too alkaline for the growth of other organisms. In fluid media it seeks the surface where oxygen is most abundant. It liquifies gelatin slowly, unlike S. metchnikovi. 153 Y. Animal i:>arasites. See section on parasitology. VI. Foreign bodies. 1. Gall stones. Tliese may be large or small. Stones as large as the gall bladder itself may ulcer- ate into the intestine and cause obstruction. Smaller stones must be differentiated from cartilage, insolu- ble soaps, enteroliths and fecal masses, >Yhich can be done by crushing, dissolving in ether and allow- ing to crystallize out. In the case of gall stones, one will find cholesterin crystals. 2. Intestinal sand. This is mucus impregnated with calcium salts. These smaller particles may become matted together into larger enteroliths. 3. Objects sTvallowed. Coins, buttons, safety pins, hair, etc. 4. Objects left in the abdominal cavity during operation. Clamps, sponges, knives, etc., may ulcer- ate through the bowel and be passed per rectum. A'll. Tumor fragments. If these come from any distance they are digested beyond recognition. Oc- casionally they aid in the diagnosis of tumor. VIII. Pus cells. A few occur normally. When in very great numbers they may arise from ruptured abscess. When seen in clumps they may indicate some ulcerative process, such as dysenter}', ulcera- tive colitis, syphilis, carcinoma, tuberculosis or typhoid. IX. Blood. That coming from the mouth must be excluded. If the blood is at the bottom of the stool its source must be low down in the intestinal tract; if on top, its source is higher up. If blood comes from high up in the intestinal canal, it will be dark and give the stool a characteristic tarry appearance, although its source may be high up and appear dark red if there be rapid peristalsis. Blood from the stomach gives a tarry black appearance. Blood occurs in any ulcerative condition of tlie 154 iutestinal tract, such as typhoid, ch^sentery, carci- noma, ulcer, etc. It also occurs as a result of rup- ture of blood vessels into the stomach or intestine, as in Banti's disease, aneurism or hemorrhoids. Tests for Mood. The best is the guiac test. Make a watery emulsion of the stool, add a few drops of glacial acetic acid, extract T\dth ether and perform in the same manner as with the urine. The benzi- dine test can be carried out in the same manner. A good preliminary test is the following : Make a smear of the stool upon a glass slide, and before it dries add a solution of benzidine in glacial acetic acid plus an equal volume of hydrogen-perox- ide. The absence of a green color shows that no blood is present. If the material turns a green color, a more accurate test, such as the above, should be performed, X. Crystals. 1. Fatty acid. Long or short needles singly or in groups. 2. Calcium phosphate. Wedge shaped in rosettes, or singly. 3. Magnesium phosphate. Rhombic plates. 4. Triple phosphates. Coffin-lid crj^stals. 5. Calcium carbonate, sulphate and oxalate. (See urine.) G. Calcium lactate. Radiating needles in sheet-like masses. Found in children on milk diet. 7. Cholesterin. Usually occur as steps, one superimposed upon the other. In doubt- ful cases test with concentrated sulphuric acid. The color changes from yellow to blood red, violet, green and, finally, blue. 8. Charcot-Leyden crystals. These are color- less, double-pyramid crystals. 155 9. Hematoidin crystals. These are reddish yel- low, rhombic plates, groups of needles or amorphous masses. Color of stool. The normal color is brownish, due to h^Tlrobilirubin. Bilirubin occurs in children, but never in adults. The color also depends upon exposure to the air and the character of the diet as well as medication. Milk gives a light-brown color; meat, dark brown; bismuth, black; senna and rhubarb, yellow, and calomel, a green, which is due to bilirubin not changing into hydrobilirubin. Blood gives all shades from bright red to black. Clay- colored stools occur in pancreatic disease due to excessive amount of fat, the action of bacteria re- ducing bile pigments, or the absence of bile due to the occlusion of the bile duct. Yellowish-green stools often occur in hypermotility of the intestine. Odor of stool, formally it depends upon the presence of indol, skatol, methane and hydrogen sulphide gas. The odor is most marked on a heavy meat diet and less marked on a vegetable or milk diet. It is almost lost during fasting. An excess of fermentation over putrefaction will give a sour odor. In some cases of severe dysentery- and carci- noma of the large bowel the stool has an intensel}^ disagreeable odor. Number and amount. There are great individual variations. There may be a normal number of stools and yet be constipation. Xormally from li0 to 250 "vams are excreted a da v. 156 STOOLS IN DISEASE. There are no characteristic stools in disease, but the stools of some diseases are of some diagnostic help. 1. Obstructive jaundice. (Due to stone in the common or hepatic duct, carcinoma at the head of the pancreas, or duodenitis with temporary closure of the common duct.) The stool is strictly acholic and clay-colored if the obstruction is complete and fat globules and crystals are seen. Clay-colored stools resembling this are sometimes found where no obstruction to the bile excretion exists, but where bilirubin appears in the form of a leukobase and can be demonstrated by the bilirubin test. Clay- colored stools associated with nausea and vomiting and jaundice give a complete picture. If there is a history of colics, search, at least for three days, for stone. If one is found, confirm by crushing, extract with ether, evaporate and examine for cholesterin crystals. 2. Iancreatic disease. (May be associated with stone shutting off the pancreatic duct.) The stools are ver}^ large and have an abundance of neutral fat. They may resemble vaseline or freshly-fallen snow. They may be odorless or sour. Besides the great quantity of neutral fat, fatty acids are found and great quantities of undigested meat fibres. 3. Carcinoma of the stomach. There is usually associated hyperperistalsis, but occasionally anti- peristalsis. In the cases with hyperperistalsis there occurs a copious diarrhea. If no blood is present, they are pale or yellow in color, but if blood is present, they are brown to black. The odor is usually foul. On microscopical examination one finds undigested meat fibres more frequently in this disease than any other. 4. Carcinoma of the rectum. The stool may be 157 normal in size, shape and consistenc^N', or, if the growth has caused a stricture, they may be ribbon- like. They may show a coating of blood if ulcera- tion has taken place, and mucits. Occasionally tis- sue fragments are found. 5. Annular carcinoma of the sigmoid. The groAvth may constrict the lumen and cause obstruction. There is usually constipation, distension, much gas, and there may be hyperperistalsis. Metastasis oc- curs late and the prognosis is usually good. 6. Amyloid disease. Abundant and frequent stools with little odor, ]!^o tenesmus, pain, blood nor mucus. Diarrhea continuous. 7. Hypoacidity. Foul-smelling, abundant diarrhea, with meat particles, much mucus, and blood if asso- ciated with carcinoma. Often a little hydrochloric acid will relieve condition. 8. Mucus colitis. The cause may be due to a for- eign protein, much like asthma. Charcot-Leyden crystals and eosinophiles are found. 9. Sprue. There is irritation of the whole gastro- intestinal tract. There is stubborn diarrhea and pain. 10. Metallic poisoning. (Arsenic and mercury.) These drugs cause a gaj^tro-enteritis. Mercury is excreted in the colon and causes an intense irrita- tion and watery stool. n, StricLiire of the rectum. This may be due to any of a number of causes: syphilis, carcinoma, and sometimes a congenital malformation. Kibbon stools are characteristic. If there is ulceration, as in carcinoma and lues, there will be an excess of mucus and pus. Eibbon stools always indicate rectal ex- amination. J 2. Constipation. There is a diminution in the number of stools, large appetite, a feeling of depres- sion, and usually headache. This