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.