the clinical EXAMINATION OF STOOLS.1

G. Hely-Hutchinson Almond, M.A., B.M., B.Ch. M.R.C.S.

(Eng.),

L.R.C.P.

(Oxon.),

(Lond.),

Honovary Pathologist to the Royal Mineral Water Hospital, Bath Hon. Assistant Pathologist to the Royal United Hospital, Bath.

Regarded

;

standpoint, the examination of stools is a method of investigation that does not always receive the attention it deserves. A positive diagnosis of disease of the alimentary canal or its appendages, functional, catarrhal, or malignant, may be withheld solely from neglect ?f fecal analysis. Moreover, although our knowledge of the ultimate effects of intestinal bacterial activity is not targe, some striking illustrations of the possibilities of treatment as the result of this line of research have already been demonstrated. from

a

clinical

I propose to describe a routine method of examination, attention only to the more important tests at our

drawing

disposal, as as

and

it is taken.

indicating briefly A

specimen

stoppered glass

significance

of each

should be selected with

free from contamination

preference be collected in

the

a

bottle with

step

some care,

possible, and it should for clean, wide-mouthed, tightly-

as

a

of from four to

capacity

Sl* ounces.

The colour, reaction, smell and physical condign should be noted, and the presence or absence of

any extraneous matter. stercobilin?a derivative

*he nature of the

normal

colour

is

due to

to

the

biliary pigment?and by certain drugs, by of the alimentary secretions and mucosa, flora, the reaction, and the quantity of

nature of the food.

blood, by the state

The of

It is modified

A paper read before the Bath Clinical

Society.

()6

G.

DR.

HELY-HUTCHINSOX ALMOND

Meat, red wine, and dark-red fruit berries make

moisture.

the colour darker,

fibre

paler, chlorophyl greener pale orange. Chocolate, logwood, rhubarb, senna, santonin and gamboge have a tendency to turn it reddish brown, ferric iron very dark, ferrous dark only after exposure to the air, bismuth usually a slaty, sheeny grey-black. Blood if reduced and plentiful the darkens colour, and if excessive it gives it the appearance The bile pigments bilirubin and biliverdin if not of tar. vegetable

olive, milk diet white

or more

reduced

or

turn the motion green ;

diarrhoea,

as

this

occurs

in

lienteric

the result of the action of certain bacteria,

calomel, and from the presence of bismuth watery stool is, ceteris paribus, paler than a hard, constipated one ; an acid one may be pale from the presence of gas bubbles, demonstrable by the fact that it will float; alkalinity has a tendency to turn it reddish brown ; fat, if largely unabsorbed, makes the stool pale and pasty ; if bile is absent emulsification is retarded, hence the grey-white stool of jaundice ; if the pancreatic juice fails, saponification is interfered with, and the stool is pale

from the action of in certain

and as

cases.

yellow

;

A loose,

if food is not absorbed from

mucous

in sprue, the colour is pale or orange-red. Normally the reaction to litmus is amphoteric.

tation

produces

catarrh, Fermen-

putrefaction alkalinity.

acidity,

The

characteristic odour is due to indol, skatol, and

methyl mercaptan (Herter). a

meat

diet, still

more so

with

It is

more

perhaps also pronounced with

putrefaction,

in infants it is

very faint or absent. A fermented stool has an acid smell due to the presence of volatile fatty acids (butyric, formic,

etc). Mucus in large quantities gives it dysentery that of lime. A cholera stool

the odour of

serum,

is odourless.

investigation with the naked eye should be discovering the microscopic remains of food

The further directed

stuffs,

to

of mucus, pus, concretions and intestinal

parasites.

THE CLINICAL EXAMINATION OF STOOLS.

If the stools

they

are

97

they should be carefully looked at before glass bottle, because frequently

fluid

out of the

are

emptied opalescent masses of mucus can be seen lying at the bottom on the surface of* the glass. The most convenient small

Method of search for

ferring

from

one

the under surface of which has been

painted

and one-third white.

or water

and the faeces

fragments

A little saline

then rubbed down with "

tissue,

a

mucus, pus,

"

sand

or

should if present be picked out

for

"

by transglass plate,

one-third black is then

pestle meat-fibre, starch, cellulose, fat,

are

of

is

heterogeneous particles

to three grams of faeces on to

a

or

added,

spatula,

connective

other

suspicious particles microscopical examination.

Sand,"

if found, may be collected by shaking up the final rerrtainder of the stool in the glass bottle with repeated of water, and gathering it from the surface or from the bottom of the vessel, according as it sinks or floats.

bashings A

microscopical

greater

importance

examination is in many respects of than that of the naked eye. For since

Masses of food which have been imperfectly masticated and

bolted

may escape the action of the alimentary enzymes, the amounts of unaltered food in the homo-

Presence of excessive

geneous parts of the stool may offer direct evidence of their

absence.

In

proceeding,

a

geneous portion should be put

?fass

well

smear.

pressed

down

platinum loopful on

to a

so as to

Examination will reveal

pale, amorphous

f?od remains, Muscle

detritus.

mucus,

Fibres

glass

make a

a

of

a

slide and

homoa

cover

thin, transparent

considerable

quantity

Search should be made for

inorganic granules, crystals, be

etc.

their fine

easily recognised by They may be present as small, detached Sc}nare 0r oblong fragments, or in masses clustered together 0r ranged in parallel. Their presence in any but minute Quantities denotes one of the three following conditions :? can

Cr?ss striations.

!?

Rapidity

of the passage of food

through

the intestinal

?gS

DR.

tract, such of

a

as

G.

HELY-HUTCHINSON ALMOND

occurs

in diarrhoea

after the administration

or

purgative.

hydrochloric acid in the gastric juice. The connective tissue surrounding the fibres remains unacted upon, and hence the proteolytic enzymes are unable to penetrate to the muscle fibres. In such cases careful nakedeye examination should be made on the plate for connective tissue, which, over the dark ground, is seen to have a fibrous 2.

Deficiency

of

structure, which clears up It may be 3.

distinguished

Deficiency

or

the addition of acetic acid.

on

from

by its

mucus

absence in the

firmer structure.

alimentary

canal of the

pancreatic juice. In such cases the nuclei may be well preserved, and should be stained with millon followed by the application of heat or with methylene blue. Vegetable Remains.?Cellulose in the form of cellular shells

are

be

run

under

also

are

small

spirals

or

vegetable

well-marked If starch is suspected Lugol's solution should the slide, or another preparation mixed with

hairs formed of central canal.

quite

common, so

a

homogeneous

the solution should be be made from starch

material with

a

prepared. Clear differentiation must granules and small particles of black

bismuth which may be present, and which should have been previously observed. The presence

due to charcoal, iron

or

of starch in any quantity is one of the indications of pancreatitis, and it is also present in the stools of certain children who do not thrive a

or

fact that

can

as a

result of

be rectified

pancreatic deficiency,

treatment with diastase

by

malt. Fat in

stools.

some

form

Occasionally

or

by

invariably present

there may be

both in diarrhoea and in be detected

other is

large

pancreatitis

the naked eye

are

fat

small

by

no

in the

concretions, and masses

that can

means rare.

In

THE CLINICAL EXAMINATION OF STOOLS.

Certain conditions

Pasty

and

99

to be considered later the stools may be

obviously fatty.

stool small glistening beads ?f neutral fat be made In order to identify out. may usually them half a gram of faeces should be put into a test tube,

Microscopically in the normal

a

drop

of

acetic acid added if the stools

alkaline

are

or

neutral, and one c.c. of a saturated solution of Sudan iii. in 7? per cent, alcohol poured in and the mixture well shaken UP and allowed the fat

to stand for some hours.

will

globules

appearance, a

while

pinkish yellow.

ln a.

fresh

be

When their

recognised by

bright pink

fatty

acids will

Fatty

acids can, however, be

be

examined,

yellow,

and soaps

easily

seen

by the peculiar shape of their needles, and crystals can be seen clustered together in cases of pancreatitis and in sprue. The normal quantity of fat in a healthy stool is from 25 to Masses

smear

of these

33 per

cent, of the dried solid constituents. The proportion ?f neutral fat and free fatty acid on the one hand and com-

bined fatty In

acids

or

certain

ahmentary canal

soaps on the other is roughly half and diseases of the liver, pancreas and

both the total

quantity

ably increased and the proportions altered, the

and

case

it is of the utmost

proportional

llntil

in

^iccator,

ari ln

a

quantitative

30 grams of the faeces are water bath in a fume cupboard

20 to

porcelain dish on a absolutely dry. The dish a

P?\vder in a Two 50

that

estimate should be made.

For this purpose from

^ied

importance

may be considerand if this should

and the dried faces

is then transferred to are

then

ground

a

to a fine

mortar. c.c.

measured

glass

tubes

are

then taken, and

half gram of the powder is placed Into one of them 10 c.c. of 33 per cent. is then poured, and the mixture heated on a water

accurately-weighed each tube.

bath

for half

an

hour.

All the combined

fatty acids,

or

in

100

G.

DR.

HELY-HUTCHINSON ALMOND

other words the soaps, are by this method converted into free fatty acids. The mixture is then cooled and methyl ether is

in up to the 50 c.c. mark. Into the other tube 10 c.c. of distilled water is run,

run

and

then ether to the 50 c.c. mark. The ether in this case only takes up the fat and free fatty acids, whereas in the first tube all the fatty acid radical present is dissolved. Twenty c.c.

of the ether extract is

pipetted

off into

beaker, and the ether evaporated off This is done in each

weighed again.1 the

quantities

the

10 c.c.

an

allowance of

of HC1

or water

ether added must be reckoned

2 c.c.

38

weighed glass

and

case.

beaker working out the

In

of ether dissolved

must be as

a

made,

i.e. the

111

total

per cent, and not 40.

commonly seen under ammonio-magnesium or triple

Crystals of the alkaline earths the

are

microscope. Calcium and phosphates are the more usual. Calcium oxalate is found especially after large vegetable diet, such as spinach, etc. Intestinal Sand is fairly frequent in mucous colitis The and varies in colour from a brick red to a dirty white. with are of calcium particles composed chiefly phosphate, traces of calcium oxalate, salts of magnesium, iron silicates, and organic matter, etc., coloured with stercobilin. Sand "

"

"

also exists in the form of calcium soap, and both these forrflfrom vegetable sand," whi^1 "

have to be differentiated

usually floats,

and which has

pathological significance-

no

It may consist of the seeds of fruits of wooden fibre. Intestinal

Concretions

are

or

not

other small

often

masses

found, hut

Biliary concretions disintegrate easily. They are usually laminated, and are formed maiub of cholesterin and calcium-bilirubin. Pancreatic concretion

should be searched for.

(calcium carbonate)

are

rare.

formed from substances taken 1

The beaker in each case

having

by

been

Concretions may also be the mouth, e.g.

magnesiutf1

carefully

dried in the

dessieato1-

CLINICAL EXAMINATION

THE

Carbonate

OF STOOLS.

IOI

and

phosphates, bismuth, salol, shellac and ?ccasionally fat, especially in oil cures. Intestinal Parasites should in all suspected cases be Searched for. If not actually found the presence of their would are

known

denote

to infect

their

existence.

Eighty-one species

man.

Endomyces have been obtained from the stools of n?rmal individuals and those suffering from chronic intestinal

leases (sprue, etc.). Castellani has isolated no less than Slx varieties from stools and intestinal scrapings. Mucus

may be secreted from any part of the small or A coating of mucus to a well-formed stool

^rge intestine. denotes

origin in the rectum or pelvic colon, or, if mixed lntimately, higher up in the large or small intestine. In case of loose stools this generalisation fails, but it may usually inferred that the smaller the particles of mucus an

higher

is their

origin. Macroscopically mucus may fat or of hyaline vegetable matter. particles ^croscopically it has the appearance of long streaky

^Semble

small

Similar semi-transparent beads. ^ ttiucus should be spread out on

^Vlth

^U]nbers e

a

slide,

bead

fixed and stained

a

blue.

leucocytes

are

present

surmised.

pus, if

present in considerable quantities, points

^erforating srnnii

If the cells

abscess.

amount and

by

are

the aid of the

only

tUs-cells does

^compose Occult

not

preclude an ulcer, fragment.

to some

to be found in

the probut the absence of

microscope,

bity is that there is some ulceration ;

^

a

in any catarrhal condition at its seat of formation may

methylene

If

For confirmation

because the cells

are

apt

and

Blood.?If

be searched for ^?uld Und should be fixed

malignancy small

is

masses

and stained.

suspected the stools of growth, which if Such findings are,

102

DR.

G.

rare, and

however,

HELY-HUTCHIXSOX ALMOND

far the most

by

procedure

important

is the test for occult blood. The

test should first be

guaiacum

the benzidene

positive

If the latter is it is

just

negative

well to do

as

and if this

&

and Hoist's

(Schlesinger no

applied,

occult blood is

method). present, though

control.

a

A diet of under 40 grams of meat is not sufficient to give the benzidene reaction, but a special meat free diet for three

previous days is to be preferred. The benzidene perborate method (Colwell and MacCormac) will give a positive reaction with the minutest traces of blood (one part in a million)and which will not react to any enzyme and which will, moreover, react even if

or

to iodide of

inhibitory

potash/

substances

present. In any doubtful case this test should certainty be performed. In suspected gastric or duodenal ulceration the test should be undertaken (if negative) on several different are

occasions. Guaiacum Test.?Extract with of ether.

equal parts

floating few

a

on

the

drops

acetic acid. of water.

to pus,

or

piece of

a

saliv'a

three times the

walnn*' Boil and cod-

faeces the size of

quantity of water.

Filter if necessary, and add to benzidene solution. solution.

Add

of

glacial

c.c.

Add

and then ozonic ether-

guaiacum

possibly blood, but may be due

Benzidene Test.?Take

3

solution

of the ether

equal parts

Add

matter.

organic

Add two

some

and mix with

of tincture

Positive test, or

top

Take

glacial

3 per cent,

a

knife

solution

of

Benzidene

of benzidene

point

acetic acid.

a

Add 5 to

H202

so

as

10

(Merck) to 2 drops to 3 c.c.

to

make

mixtine

opalescent. Benzidene Perborate Test.?Mix 0.1

of sodium

Take 5

c.c.

of

in

perborate liquid faeces (or

10

0.1

c.c.

half

gram of

benzidene'

aci^' glacial gram of solid) and ^ of

acetic

THE CLINICAL EXAMINATION OF STOOLS.

103'.

5 C.c. of glacial acetic acid. Shake or mix well, and add 10 c.c. ?f ether. Pipette off 5 c.c. of ethereal extract into a white

dish, and evaporate off ether. perborate solution, and another 1

Add

evaporating benzidene

Positive

of

if necessary.

reaction, intense blue.

Stercobilin.?A

considerable amount of

and intestinal disorders

test

c.c.

1 c.c.

for stercobilin.

in

help

hepatic

very often be obtained by the The bilirubin and biliverdin of the bile can

gradually become reduced by the aid of bacteria.

to stercobilin

(intestinal urobilin) portion is mixed in d test tube with three or four times the quantity of a Saturated solution of perchloride of mercury a pink reaction, ^Ue to the formation of its mercuric compound, should result lri about twenty minutes in normal stools. In diminished 0r total absence of bile this reaction is delayed or absent. In the so-called saccharo-butyric form of intestinal ^erttientation the reaction is very marked. In diarrhoea, on the other hand, the pigments may be passed unchanged, and the reaction is green owing to the formation of mercuric

^ydro-bilirubin

If

a

small

and biliverdin.

The value of the stercobilin fat and

^stances

of

Allowing

table.

guaiac tests

in certain

and

pancreatic mischief, together with microscopical findings, will be made clearer by the

s?

hepatic

A great deal of work has been done in recent years on bacterial flora of the intestine, and though much of it has

far proved fruitless, a considerable value has accrued from it.

amount of

knowledge

Roughly speaking, about one-third of the solids of the Sto?ls consists of living and dead bacteria. The quantity is ?reater in diarrhoea and less in constipation. The number that can be cultivated is about 1 per cent., but this is not ecluivalent to the percentage of living bacteria, which is Pr?bably somewhat larger. The difficulty is that many of

,

?

0

111

given type

Reaction.

Odour. Muscle Starch Fibre.

Total Fats.

Saponi-

0/ /o

?/ /o

fied.

104 Un-

saponi-

Emulsion.

fied. 0/ /o

Saponification.

Stercobilin.

White.

Obstruction of pancreatic duct.

Pale Yellow,

of both Obstruction ducts. Ampulla of Vater

White.

some-

times alk.

Putrid and

60

O

40

sour.

Alk.

Primary Pancreatic Achylia.

Normal

to Red.

1

Dark Brown.

.

P. S.

Cammidge. 1

Putrid.

+

+

60

4-10

50-56

N

Putrid.

+

+

60

4-10

50-56

O

O

O

40

35

N

29-32

5-28

N

12-15

12-15

N

times acid.

Pale.

Orange

Sprue1

some-

'M.alYgnaTvt

2

ulcer.

Acid.

Faint acid.

+

34-57

Amph.

Faecal

o

25-30

;

1

N

HELY-HUTCHINSON

Acid, Obstruction of the bile duct.

G-

DR-

Colour.

ALMOND

the

figure.

lipase. the is alone latter the of absence The and ferments amylolytic or proteolytic the of more or one absence the be may there achylia pancreatic primary In only. approximate are table above the in figures The

Fats.

N

N

3 Stone?no wasting. Secondary cholangitis. Carcinoma?wasting and cachexia. Tissue wasting. Duodenal ulcer. "N normal0=absent; -V ?excess.

THE CLINICAL EXAMINATION OF STOOLS.

the anaerobic vation.

the number of varieties is

Though found as

to

do not survive

organisms

predominate.

By making

attempts

105 at culti-

large, certain types a

thin

transparent

are

film

detailed above, and

staining with

a

staining this with gram and counterweak acid fuchsin solution, a very fair estimate

?f their nature and

proportions

can

be made.

In order to

obtain uniform results the gram stain should be applied for four minutes, the iodine for half a minute, and .the alcohol for one minute : if this is not done confusion may result. In

an

ordinary healthy

gram +ve and gram

?ve

adult

on a

organisms

mixed diet the ratio of is about

equal.

The

Preponderating gram +ve bacteria are the B. bifidus and B. icidiphilus, which both attack carbohydrate food or their

cleavage

products, and the large and small subtiloid bacilli, xvhich attack proteids and their products. The chief gram

?ve

pyogenes,

the B. coli group with the B. lactis the B. coli having the largest representation of

organisms

are

ariy form. Besides these there sPores.

are

The streptococcus almost always present.

many others, bacilli and cocci and fcecalis, described by Andrews, is

Most of the bacteria referred

to above are in the propor-

tions present perfectly harmless. There is an acquired and an hereditary immunity, and the liver has probably large detoxicating powers. They are even beneficial, for they lnhibit the growth of pathogenic forms. Under certain Clrcumstahces, however, as in stasis following obstruction, fhe B. coli, for instance, may get out of hand, and along with ^he others become extremely toxic through their products. It is not, however, only in acute disease that they may Prove harmful to these parts, for carbohydrate and protein cleavage may through their influence or through that of extraneous organisms become a cause of chronic mischief. ^?L. XXXIII.

10

No. 128.

106

DR.

G.

HELY-HUTCHINSON ALMOND

Herter, whose work in this respect is second differentiates three main

of ultra

types

and his method of classification has all workers

on

the

or

now

to

none,

vicious been

cleavage, adopted bv

subject.

The Indolic Type.?This is characterised caused

proteolytic decomposition

by

by

excessive

members of the B. coli

group and probably B. putrificus. In the gram-stained field the gram ?ve bacteria predominate. The urine gives a

strong

indican reaction. ethereal

sulphates

The ratio of

in the urine, instead of

inorganic sulphates and occasionally the indol \ or acetic reaction is strongly +ve (red colourisation of urine on addition of HC1, and if necessary a few drops of 2 per cent, sodium nitrite). the normal

becomes

The Saccharo-Butyric form of fermentation is due to the presence and action of a very large number of anaerobic butyric acid producing bacteria in the lower ileum and the colon.

The chief

organism

capsulatus (gram +ve). gram +ve predominate.

concerned is the B.

aero genes

Hence

a gram field in which the The stercobilin reaction is very

marked. The Combined Indolic This form leads to neurasthenia.

rapid

and

Saccharo Butyric Type.?

fall in health

accompanied by

Herter and Kendal have shown how it is

possible to modify the flora by alteration in the diet. On a protein diet the coli group (gram ?ve) were shown to be markedly predominant, and both large and small subtiloid gram +ve bacteria were present in fair numbers. The ratio gram +ve and gram ?ve was about even. But on a carbohydrate diet gram +ve organisms became

markedly predominant,

the B. coli

(?ve) diminishing

very

THE CLINICAL EXAMINATION OF STOOLS.

greatly

and the B.

acidiphilus (?ve)

coming prominent.

irrespective

The

significant feeding

of the normal

it was manifested

equally

and B.

fact

was

107

bifidits ( + ve)1

be-

that this occurred

habits of the

animal,

for

in carnivorous and herbivorous

animals. Treatment based on these researches offers a very fair field for advance, and some promising results have

already

been

published

of the treatment of

cases

of rheu-

matoid arthritis, colitis and pernicious anaemia by starving the offending organism. But much more work on the subject is

required,

our

and it is to be

knowledge

hoped

that

by adopting

these lines

and treatment of many chronic diseases may

be furthered

REFERENCES.

General. Schmidt and

Strasbnrger : Die Fceoes des Menschen. 1905. Diagnostic Methods. 1911. Harley and Goodbody: Chemical Investigation of Gastric Intestinal Diseases. 1906. O. T. Williams : Liverpool Med.-Chir. J., 1911, xxxi. 362. Proc. Roy. Soc. Med. : Discussion on Alimentary Toxaemia," vol. Sahli's

"

and

vL

1913-

Occult Blood. A.

J.

Clark :

St. Bartholomew's

Cohvell and MacCormac :

Hospital Reports, vol. 45, 1909, p. 97. of Middlesex Hospital, vol. 23, 1911.

Arch,

Pats.

Begg

Sprue, its Diagnosis and Treatment, 1912. Hurtley : Quart. J. Med., 1912-13, vi.

:

Garrod and

242.

Bacteriology. Herter

:

Herter

:

Common Bacterial Lectures

on

Infections of the Digestive Tract, Pathology, 1902.

1907.

Chemical

Herter and Kendal :

J.

Andrews and Horder

:

Biol. Chem., 1909, x. 203. Lancet, 1906, vol. ii. p. 708.

1

A slight indol acetic reaction was found to be rarely absent in seven eight hundred investigations of the urine of patients suffering from chronic disease at the Royal Mineral Water Hospital, but it is not often

?r

very marked. It is sometimes intense in acute disease,

appearing

and

disappearing on the day

very suddenly. In a case of pneumonia it suddenly appeared after the crisis, and disappeared completely in five days.

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