This diet gives 11⁄2 liters of milk, 100 Gm. zweiback, 2 eggs. 50 Gm. butter, 125 Gm. meat, 190 Gm. potatoes, and 80 Gm. oatmeal. In other words, 110 Gm. albumen, 105 Gm. fat, 200 Gm. carbohydrates, which, as above stated, gives us the 24-hour requisite of food for an adult at rest. The general rule is to continue this diet for three days or until such time as one feels certain of the dejecta being composed of waste material from the test-meal prescribed. To make this absolute, one has only to give a capsule containing .3 Gm. of powdered carmin at the beginning and end of the test diet. The color line, as noted in the feces, is very distinct. Of great importance is the determination of the elapsed time from the intake to the excreted stool, the normal time for the small intestine averages 2 to 4 hours, whereas in the large intestine, only 1/5 the length of the former, 14 hours is required. The chief difficulty in carrying out this regime is met with the patient's unwillingness to adhere strictly to the prescribed diet, and a physician's skill is taxed often to the utmost in convincing his patient of the necessity for such measures, assuring him that for accurate information the procedure is necessary. In carrying through a fecal examination four stages are to be considered: (1) macroscopic examination; (2) microscopic; (3) chemic; (4) bacteriologic. The first three will be considered in this paper. (1) Quite the most important examination is the macroscopical. Here we observe the color and consistency, and note the odor and chemical reaction. In normal feces we find mucin, the indigestible residue of food, decomposition products, and inorganic salts. The consistency of the feces varies from fluid to semi-fluid, depending largely on the time it remains in the intestine, and the extent to which absorption of its watery portion has taken place. A pure flesh diet gives a comparatively dry feces, while substances rich in sugar yield feces with a comparatively large amount of water. The quantity of water taken has no direct influence upon that found in the feces. This amount seems to be in direct ratio to the energy of the peristalsis. The odor is due to the presence of sulphuretted hydrogen and skatol. The color is due to the altered coloring matter of the bile hydrobilirubin or stercobilin, and partly to the character of the food. Milk stools in both infants and adults are lemon-yellow in color. Spinach, cabbage, calomel, and certain bacteria give green stools. The green color of infants' feces is believed to be due to the action of butyric and lactic acids upon the biliary coloring matter. Rhubarb, senna, longwood, saffron, fuchsin and blood may give red stools. Santonin gives blood-red or yellow-colored stools, Normal stools are brown and contain no unchanged bile. Meconium contains unchanged bile. Iron, bismuth, salts, charcoal, and blood coming from the upper part of the gastro-intestinal canal impart a black color. The normal coloring matter of the feces is derived from the bile, and when this fluid is prevented from discharging into the duodenum the feces become very light or clay-colored. When blood, mucus, or pus is well mixed with the feces, the origin is high up in the intestine. When not mixed, the origin is from the lower part of the colon or the rectum. The feces of infants fed with normal breast milk, and children and adults fed largely on milk show a lemon-yellow or orange-colored stool. The golden yellow stool is evidence of an excess of carbohydrate. The total quantity discharged daily varies from 4 to 6 ounces. Among pathological findings are to be noted gross flakes of mucus, either transparent, ropy and extensive, or intimately mixed with foreign materials; blood pus, portions of tapeworm or other parasites, stones, ova, etc., are often found. Butyric acid gives rise to the distinct acid-like smell of some feces, while acetic acid gives off a biting, sour smell, and malodorous stools are due to albumen putrefaction. For a closer examination we make a broth by mixing a small selected piece of feces the size of a walnut with distilled water. The amount is divided and placed in two receptacles, one with a black and one with a white background. Here the sharp conirast produced gives us clearly outlined particles which, when placed for microscopical examination on slides, assist us in reaching our conclusions as to foreign elements present and source of difficulty. (2) The microscopical examination of a stool from an ordinary mixed diet might develop the following report: particles of food; cells-red blood corpuscles, intestinal epithelial cells, pus corpuscles or leucocytes; crystals-triple phosphate, phosphate of lime, cholesterin, fatty, and hematoidin crystals. None of these has any pathological significance. Parasites and bacteria may be found. Parasites in the intestinal tract include worms and protozoa. The worms belong either to the nematoda or to the flat worms, the latter group containing the cestoda, which are fairly common, and the flukes, which in Europe, at least, are by no means ordinarily found in man. Nematoda. (a) Perhaps the commonest of all internal parasites is the small threadworm, Oxyuris vermicularis. (b) Ascaris lumbricoides, six to eight inches long, and has a general resemblance to an earthworm. Not unfrequently its presence in children is associated with nervous disorders. (c) Ascaris mystax. a closely allied worm, is sometimes parasitic in children; the infection is acquired from cats. (d) Ankylostoma duodenale. which causes profound anemia by drawing blood from the walls of the bowel. The diagnosis is clinched by finding the ova in the motions. They exhibit a segmented yolk, enclosed in a thin shell. (e) Trichocephalus dispar, about two inches long and white, and does not seem to cause any great inconvenience. (f) Trichina spiralis. Cestoda. Seen as many varieties of tapeworm. Trematoda. (a) Distoma hepaticum is rather rare as a human parasite. When it does occur it may be found in the feces as brown-colored ova. (b) Distoma lanceolatum is considcrably smaller, and is narrower in proportion to its length. Protozoa. A number of protozoa, including members both of the Rhizopoda and Infusoria, have been found in the feces. The only one which is of undoubted clinical importance is the Amoeba dysenterie, which is present in a great proportion of cases of tropical dysentery. In addition to amoeba, dysenteric stools invariably contain bacteria, among which streptococci and the bacillus coli communis seem to preponderate. These, howcver, do not enter into the present consideration. The normal test diet stool shows a brownish mixture practically homogeneous containing the chaffy remains of oatmeal and cocoa nibs. Under pathological conditions, however, the Schmidt diet would reveal connective tissue remains and tendons from the chopped meat. They are whitish-yellow in color, thread-like in appearance, and of solid consistency. In case of doubt the addition of a drop of acetic acid destroys this appearance of the connective tissue, whereas mucus would develop this thread-like quality. rods. Muscle fragments may also be noted as small brown-colored Potato remains appear as sago granules, glassy and transparent in character. These are easily mistaken for flakes of mucus, but the addition of iodine would produce the characteristic blue color with starches. Fat remains would be denoted by their light yellow color, and the soft, small, fecal lumps. Mucus appears in large extended strips or in finely divided semitransparent yellowish particles. For further microscopical examination the chemical tests are brought into play. Three drops of prepared feces are placed at equal intervals on a slide; one is crushed into a fine layer by a cover glass; another stirred with a drop of 36 per cent. acetic acid, heated to the steaming point and then covered, and the third stirred well with a small drop of strong solution of iodopotassium iodide. The first in the normal stool will give us small granules, isolated fragments of muscle fibre with rounded edges, large and small crystals of calcium salts, flakes of fatty acids of calcium, colorless soaps, isolated potato cells, chaffy remains from oatmeal and cocoa nibs. The second preparation, the acetic acid test, serves to furnish a view of the entire fat content. When cool, this specimen shows small flakes of fatty acid; when heated, these melt into drops congealing as the preparation cools. The third preparation, which appears brownish in color, later turning to violet, gives us the potato remains. Under diseased conditions of the alimentary tract the following pathologic evidences present themselves. With preparation No. 1, large numbers of muscle fragments are seen in a good state of preservation with well-defined sharp edges, even to the detection of the crossed striations. Needles of fatty acids and soap, drops of neutral fats, numerous groups of potato cells, parasite eggs, mucus, connective tissue and pus come into the field of vision. Preparation No. 2 shows massive fatty acid flakes, while No. 3 gives the blue color of starch granules and violet fungus. spores, as well as yeast cells, the latter being colored yellow by iodine. Normal feces should be feebly acid or feebly alkaline in reaction, this test being made with the ordinary litmus paper. The sublimate test for detecting the condition of the bile shows green coloring to fecal broth when unaltered bile (bilirubin) is present, and red for the normal or reduced (hydrobilirubin) bile. The most delicate test for occult blood is known as the benzidine test, which is given below in detail, as it is little known to the general practitioner and yet a very simple execution. Saturate solution of benzidine in glacial acetic acid. (2) Fecal broth from pea size of feces in 3 cc. water. The light brown acid foamy stool with the butyric acid smel! is the fermented stool, while the putrefactive evacuation is of darker color and not likely to be foamy. The significance of these pathologic findings is the keynote of this paper, for upon these are to be determined the foods best suited to the individual case. (1) Mucus. The presence of mucus indicates inflammation of the mucous membrane, and is the sole reliable indication of this condition. Two exceptions are to be noted: in the mucuscolic incident to the nervous over-production of mucus, and the glazed-looking dry stool so often the result of the straining in constipation. When noted in large flakes the origin is to be found in the colon. Sometimes opaque and glistening, and again closely intermingled with foreign ingredients: the fine sago-looking flakes of mucus come from the small intestine, the smaller they appear the higher up we look for their origin. These are usually filled with bacteria and coloring matter. (2) Unchanged pigment. Bile pigment showing green in the sublimate test indicates too rapid passing of intestinal con tents or failure of reduction; whereas complete absence of either red or green color in the sublimate test indicates a fatty stool where the bile is completely cut off. (3) Fat occurs in all feces, normal and pathological, and may be recognized in the form of neutral fats, soaps, or fatty acids. Fatty stools, that is the "fat diarrheas" of infants, are recognized as such macroscopically, by their whitish color, often a peculiar sheen, and in liquid stools often by the presence of a thin floating layer of fatty acid crystals. Neutral fats appear either as droplets or as masses with irregularly rounded con tours. The stools may be abnormally fatty in disease of the pancreas, and in such cases when the bile is cut off from the intestine, and occasionally in disturbances of intestinal digestion as with intestinal tuberculosis and intestinal amyloid degeneration. (4) As to the meat remains, any connective tissue remains appearing in the feces indicate disturbed gastric digestion, for gastric juice alone acts upon raw connective tissue. Again, if macroscopic muscle remains appear, small intestine disturbance is evident, the stomach sharing but slightly in the solution of muscle. Occasionally connective tissue and muscle remains are found together, an indication of combined gastric and intestinal disturbance. Defective starch (5) Carbohydrate and starch remains. digestion has its origin in the small intestine, and to its juices alone do we look for complete reduction. We note small microscopic tapioca-like potato remains or even separate potato cells. The stool is soft and pappy, light brown and foamy and acid in reaction. Gastrogenic Intestinal Disorders. Acute Gastritis. In all forms of acute gastritis the removal of all food for twenty-four hours is the general rule. To quench the thirst, always a prominent symptom in the first stages of this condition, ice, ice water, or champagne in teaspoonful doses or less may be administered with impunity. It is usually wiser, however, to administer hot water for this early condition, especially during the first twenty-four hours. With the cessation of vomiting, diluted milk 4 to 1 with lime water, soda water or barley water, may be tried; not more than twenty ounces can commonly be taken in the first day. As the case progresses the materials used should be milk with decreasing amount of dilution, albumin water, whey, to all of which may be added a little sherry if necessary to bring up the body temperature. On the fourth or fifth day carbohydrates may be added in the form of arrowroot, toast or rusk, blanc-mange, one or two poached eggs, clear soup or beef tea. Boas recommends the following diet to begin about the third day. 8 a. m. : Milk (with tea), 200 Gm. Zwieback, 50 Gm. |