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 THE CHEMICAL INVESTIGATION Ol- 
 
 GASTKIC AND INTESTINAL 
 
 DISEASES 
 
THE CHEMK AL IJNVES I KiA TION Or 
 
 GASTRIC Aro INTESTINAL 
 DISEASES 
 
 BY THE AID OF TEST MEALS 
 
 BY 
 
 VAUGHAN HARLEY, M.D.Edix. 
 
 M.kc.r., F.c.s. 
 
 rRori:ss()R of pathological chemistry, 
 
 UNIVERSITY COLLEGE, LONDON 
 
 FRANCIS W. GOODBODY, M.D.DunL 
 
 M.R.C.P. 
 
 ASSISTANT PROFESSOR OF PATHOLOGICAL CHEMISIKV, 
 LNIVERSITY COLLEGE, LONDON 
 
 LONDON 
 EDWARD ARNOLD 
 
 41 & i3 MADDOX STREET, BOND STREET, W 
 1906 
 
 [All rishls reserved] 
 
0*^' 
 
 ^%^ 
 
 
 ^■^1> 
 
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 CONTENTS 
 
 INTRODUCTION 
 
 PART I— DISEASES OF THE STOMACH 
 
 CHAPTER I 
 Mkthod of obtaining Gastric Contents and Ti:st Mioals . . ■- 
 
 C II ARTE K II 
 Macroscopic AND Microscopic Examination of Gastric Contents I.' 
 
 CHAPTER III 
 Chemical Examination op Gastric Contents— Total Aciditv. 
 
 Volatile Acidity -* 
 
 CHARTER IV 
 
 Chemical Examination op Gastric Contents (continued)— 
 Qualitative and Quantitative Methods for the Recogni- 
 tion of Free Hydrochloric Acid 
 
 CHAPTER V 
 Chemical Examination op Gastric Contents (continued)— 
 Lactic Acid, Butyric acid, Acetic Acid 
 
 171680 
 
vi CONTENTS 
 
 CHAPJ'ER YI 
 
 PACE 
 
 Chemical Examination of Gastric Contents (continued)— 
 
 Gastric Ferments 36 
 
 CHAPTER VII 
 Chemical Examination of Gastric Contents (continued)— 
 
 Gas Fermentation in Stomach 
 
 CHAPTER VIII 
 Organic Diseases of the Stomach — Acute, Chronic and 
 
 Alcoholic Catarrh, Achylia Gastrica 43 
 
 CHAPTER IX 
 Organic Diseases of the Stomach (continued)— Gastric Ulcer . 57 
 
 CHAPTER X 
 Organic Diseases of the Stomach (continued)— Gastric Car- 
 
 CHAPTER XI 
 Functional Diseases of the Stomach — Secretory Neuroses, 
 
 Hyperhydrochloria, Gastro-Succhorea, Hypohydrochloria 70 
 
 CHAPTER XII 
 Functional Diseases of the Stomach (continued) — Motor 
 
 Neuroses, Hypermotility and Hypomotility ... 81 
 
 CHAPTER XIII 
 Functional Diseases of the Stomach (continued)— Sensory 
 Neuroses, HYPERiESTiiEsiA, Gastralgia, Anaesthesia and 
 Vomiting Neurosis 88 
 
CONTENTS 
 
 PART II— DISEASES OF THE INTESTINES 
 CHAPTER XIV 
 stigation of i> 
 Milk, Schmidt's, Mixed, and Meat Dikts . . . .9:3 
 
 CHAPTER XV 
 Quantity op F.eces, Colour, Conslstency and Odour . . 99 
 
 CHAI'TEK XVI 
 General Examination op F.eces, Macroscopic and Microscopic 110 
 
 CHAPTER XVII 
 Chemical Examination of F.eces— Reaction, Water and Solids 116 
 
 CHAPTER XVIII 
 Chemical Examination op Faeces (continued)— Nitrogen, Alp.u- 
 
 MEN, ALBUMENOSE, PEPTONE AND MUCUS 12? 
 
 CHAPTER XIX 
 Chemical Examination of F.eces (continued)— Fat . . .142 
 
 CHAPTER XX 
 Chemical Examination op F.eces (continued) — SuciAR and 
 
 Carbohydrates i.V2 
 
 CHAPTER XXI 
 Chemical Examination of F.eces (continued) — Phenol, Indol, 
 
 AND Skatol 158 
 
 CHAPTER XXII 
 Chemical Examination of F.eces (continued)— Bile, Urobilin, 
 
 AND Blood 104 
 
viii CONTENTS 
 
 CHAPIEK XXIII 
 
 I'AGE 
 
 MoTOE Power of the Intestinal Teact— Diaeehcea akd Con- 
 stipation 171 
 
 CHAPTEIl XXIV 
 Intestinal Dyspepsia 1<J6 
 
 CHAPTER XXV 
 Intestinal Catabrh, Acute and Chronic ; Enteeitis Ceouposa . 202 
 
 CHAPTER XXVI 
 Colitis— Mucus, IJlceeatiye (Acute and Chronic), and Mem- 
 branous .... 211 
 
 CHAPTER XXVII 
 Intestinal Atrophy 224 
 
 CHAPTER XXVI 11 
 Intestinal Ulceration 230 
 
 CHAPTER XXIX 
 Intestinal Carcinoma 233 
 
 CHAPTER XXX 
 Sprue (Psilosis) 240 
 
 CHAl'TER XXXI 
 Intestinal Concretions, Gall-stones, Pancreatic Calculi, 
 Enteroliths, and Intestinal Sand 243 
 
 APPENDIX -251 
 
 INDEX -253 
 
INTRODUCTION 
 
 Modern Medicine has advanced along scientific lines, so that 
 to-day the clinician is compelled to call Science to his aid in the 
 investigation of disease. Just as the surgeon requires X-rays 
 to elucidate certain problems, and bacteriological methods of 
 investigation are imperative in the diagnosis of some diseases, 
 so the physician, in treating diseases of the stomach and bowels, 
 requires the aid of chemical analyses for making an accurate 
 diagnosis. More especially is this the case in functional diseases 
 in which there may be no physical signs, and in which the 
 symptoms may be very misleading. 
 
 The methods of investigating diseases of the stomach and 
 bowels are very numerous, and it is impossible in a book like 
 the present to enter at all fully into the subject. We will, there- 
 fore, confine our attention for the most part to chemical methods 
 which we have ourselves employed for some twelve years with 
 more or less useful results. The results summed up in this 
 work must not be regarded as conclusive, but merely as a pre- 
 liminary to more careful chemical investigation of stomach 
 and bowel diseases. We shall only cursorily mention micro- 
 scopic appearances as these have not been especially investi- 
 gated : and bacteriology we shall leave entirely alone, not 
 because we under-rate its importance, but because its import- 
 ance is so great that it ought only to be described by 
 bacteriologists themselves. 
 
 It was originally intended to discuss more or less completely 
 the views held by other observers, but as the work progressed, one 
 found the results to be so numerous and so conflicting, that to 
 deal with them at all would make a book far too unwieldy for 
 practical use ; it has, therefore, been our endeavour to keep 
 the book within clinical limits, and to lay stress only on those 
 points which have especially come within our own cognisance. 
 Chemical methods for ordinary analyses are fully given, while 
 
2 INTRODUCTION 
 
 those methods which we only occasionally use have been merely 
 sketched, or reference made to works where they are fully 
 described. All the methods described in this book have been 
 tested again and again by us and our pupils, and are as reliable 
 as we describe them to be. 
 
 It is practically impossible to diagnose many of the functional 
 diseases of the stomach from the symptoms alone, and the clini- 
 cian who does not call chemical tests to his aid is bound to mass 
 together under one or another heading, various functional dis- 
 orders which ought to be kept entirely separate. Thanks to 
 the introduction of the stomach- tube, one is now able to obtain 
 the contents of the stomach, and find out what chemical changes, 
 if any, are present, thus enabling one to draw conclusions as 
 to the sub-division of the various functional diseases of the 
 stomach. 
 
 In organic diseases of the stomach, chemical analysis is not 
 nearly so important, since in these there are several signs and 
 symptoms which point in one direction or the other. 
 
 It must be understood that the results obtained from the chemi- 
 cal analysis of the gastric contents can never alone be sufficient 
 for the formation of a definite diagnosis of the various forms 
 of gastric dyspepsia ; each case has to be carefully considered 
 in connection with the various symptoms and physical signs 
 present, and the stomach analysis is merely to be regarded as 
 an aid in making a more careful and detailed diagnosis. 
 
 The idea that any one chemical factor is pathognomonic of 
 any special condition must also be at once put aside. The 
 diagnosis of carcinoma of the stomach from the absence of free 
 hydrochloric acid in the gastric secretions has now to be regarded 
 as non-conclusive, unless the history and physical signs support 
 the diagnosis. This is analogous to the fact that the presence 
 of albumen in the urine is not pathognomonic of Bright's disease 
 unless one has negatived its attribution to cardiac, digestive, 
 or other causes, and has, in support of the Bright's disease theory, 
 various other symptoms with possibly other chemical results, 
 which point in that direction. The fact that albumen is not 
 pathognomonic of Bright's disease does not, however, detract 
 from the value of the urine analysis. 
 
 The chemical methods now employed in the diagnosis of 
 stomach diseases have opened up a large field in the various 
 
INTRODUCTION 3 
 
 functional disorders of the stomach. The more one studies 
 the chemistry of the stomach the more one reahses what a vast 
 number of dyspeptics there are who suffer from functional 
 disturbance of the stomach, the number of such patients being 
 out of all proportion to the number of those who suffer from 
 structural diseases of the stomach. It would appear that in 
 everyday practice, where we have to deal with functional 
 disease of the stomach more than with organic, it is practically 
 essential to use chemical methods if we hope to arrive at 
 a correct diagnosis. It is not sufficient, in cases of gastric 
 dyspepsia, to say that the individual is suffering from acid 
 dyspepsia ; before one can hope to do any good by treatment 
 of such a condition, one must isolate the particular form of acid 
 dyspepsia present, whether it is due to increased hydrochloric 
 acid, or to increased volatile acids. It must also be remembered 
 that in cases of dyspepsia where the secretion of the gastric 
 juice is found to be perfectly normal, the motor-power of the 
 stomach may be found to be abnormal, leading to certain 
 chemical changes in the gastric contents which account for the 
 indigestion. In other cases again, where the chemistry and 
 the motor-power of the stomach appear to be in no way out of 
 order, the patient may, owing to alterations in the sensibihty 
 of the stomach, be suffering from various symptoms of indi- 
 gestion, and the analysis of the gastric contents will, in such 
 cases, enable one to make a diagnosis of gastric hyperaesthesia. 
 
 The investigation of intestinal diseases is complicated by 
 the necessity of employing fixed diets of known composition, 
 as the kind of diet taken has so great an influence on the normal 
 appearance of the stools. If one examines the motions with 
 merely a rough idea of the food which has been taken by the 
 patient, one may be considerably misled in the conclusions 
 arrived at, and further, it is imperative in the more comphcated 
 cases, to examine several motions on a fixed diet, since the com- 
 position — and more especially the quantity — of the normal 
 faeces may vary from day to day, with the result that a true 
 knowledge of the normal appearance of the stools can only be 
 gained after a period of from three to five days. 
 
 For instance, in slight cases of catarrh of the bowels, only 
 whitish mucus may be seen — possibly not in sufficient quantity 
 to be considered pathological — while, if a series of motions 
 
4 INTRODUCTION 
 
 are examined, mucus may be found, in some of the specimens, 
 so loaded with epitheUal cells and leucocytes as to lead to an 
 undoubted diagnosis of catarrh of the bowels. 
 
 Or again, in ulcerative colitis, unless there is very extensive 
 ulceration, one may not find blood in all the motions, and, 
 perhaps, only occasionally, leucocytes or sloughs in sufficient 
 quantity to enable one to be sure of making a correct diagnosis. 
 Such being the case in organic diseases of the bowel, one 
 naturally expects to have a yet more varied picture in functional 
 disturbance, making the necessity of a long period of observation 
 more important. 
 
 In describing the alterations in the faeces in various diseases 
 of the bowel, we have given analyses of cases on different diets 
 by way of illustration ; we have included the urine analyses in 
 order to give a rough idea of how the general metabolism is 
 influenced. We have not discussed the results of the urine 
 analysis, as it appeared to open up too large a field in general 
 metabolism to be admissible in the present work, but the results 
 given are of value in trying to gain a scientific insight into the 
 general chemical changes which occur in the organism. 
 
 The results found in the chemical analyses of the fseces are 
 discussed as showing the alterations produced in the different 
 diseases of the bowel under consideration, and must only be 
 taken as types to give a general idea of the conditions found. 
 Our present knowledge of the alterations produced in the fseces 
 in disease of the intestine does not allow of more definite conclu- 
 sions, but when more facts have been accumulated in this con- 
 nection, one may hope to be able to classify, not only the organic 
 diseases of the bowels, but also the functional alterations which 
 may occur in the intestines or secretions, just as is now possible 
 in the case of the stomach. 
 
PART I 
 DISEASES OF THE STOMACH 
 
 CHAPTER I 
 
 METHOD OF OBTAINING GASTRIC CONTENTS AND TEST 
 MEALS 
 
 The investigation of the alterations produced in the stomach 
 by disease when one only had the vomited matter to examine 
 was most unsatisfactory, and it was not until other methods 
 of obtaining the gastric contents were introduced that the 
 physician was able to gain accurate knowledge of the changes 
 occurring in the stomach when that organ is deranged. Kuss- 
 maul ^ first made use of the stomach-tube as a means of 
 obtaining the gastric contents for clinical diagnosis, and to this 
 method is due all our present knowledge of the different forms 
 of functional dyspepsia. 
 
 The idea that patients object to swallowing the tube has 
 been found by all who employ it to be entirely fallacious. The 
 majority of patients do not make the slightest objection, and 
 even those few who do at first very soon become accustomed to 
 it. In neurotic patients especially, where the stomach analysis 
 is most valuable in making a diagnosis, one finds that the tube 
 is easily swallowed in the majority of cases. i 
 
 It is unnecessary in a book like the present to describe the 
 stomach-tube in detail, as those who read these pages will be 
 already famihar with the various tubes ordinarily employed, 
 and it is only necessary to mention a few points which we 
 have found useful. American tubes differ from the English 
 ones in having the lower opening larger than the other eyelet. 
 The size of the stomach-tube employed in practice is 19-23 of 
 
 1 Dmtl. Archil'. Klin. Mvd., vol. vi. p. 455. 
 
6 rxASTRIC DISEASES 
 
 the English scale, and it is advisable to use the largest size, as 
 it diminishes the sensation of retching, owing to the oesophagus 
 more easily contracting on the tube, and preventing any of the 
 gastric contents coming up outside. Several operators have 
 preferred having the stomach-tube and funnel made out of one 
 piece of rubber, and in such a case, the complete apparatus will 
 be 180 cm. long. The disadvantage of the continuous rubber 
 tube is the impossibility of noting the stomach contents as they 
 pass along. The most convenient form in practice is a piece 
 of glass tubing about 8 cm. in length, inserted into the ordinary 
 stomach-tube ; from this a suitable piece of tubing, about 70 
 cm. long, is connected with a large glass funnel. This form 
 of apparatus is easily cleaned, and when not in use can be taken 
 to pieces so that each part can be kept hanging straight. This 
 is an important point, as all tubes should be kept straight, and 
 not rolled. After use, the stomach-tube with rubber attachment 
 should be washed by passing a large quantity of hot water 
 through it, then some disinfectant, such as perchloride of 
 mercury (1 in 1000), and finally, a stream of cold water, after 
 which it should be hung up in some cool place until required for 
 further use If it is merely desired to obtain the gastric contents 
 for purposes of analysis, it is unnecessary to have a fresh tube 
 for each patient if the foregoing precautions with regard to 
 cleansing have been taken. In cases of long-continued lavage 
 of the stomach, it is desirable for the patient to have his own 
 tube, and, needless to say, special tubes must be kept for 
 syphilitic and tubercular patients. 
 
 Insertion of the Tube. — When inserting the tube, 
 it is very important that the operator should make, no fuss, as 
 the patient is apt to become nervous in such a case. If one 
 takes the tube quietly, and dips it into warm water, and passes 
 it down the patient's throat, the tube is in his stomach before 
 he realises what is going on. Most of the difficulties one hears 
 of in practice are caused by the doctor going through an elaborate 
 process of oiling and greasing the tube, or other preparatory 
 measures previous to its passage. In our experience, it has 
 never been found necessary to use any form of lubrication 
 except dipping the tube into warm water. In very rare cases 
 it may be necessary to spray the patient's throat with a 5 
 per cent, solution of cocaine. The patient should be made 
 
GASTRIC CONTENTS AND TEST MEALS 7 
 
 to sit upright, and it is convenient to have tied round his neck 
 an apron of waterproof material long enough to reach the slop- 
 pail ; by this means, the saliva will run down to the pail and 
 prevent the soiling of the floor or the patient's clothes. The 
 patient is directed to bend his head a httle forward, and cautioned 
 against throwing his chin up when attempting to swallow the 
 tube. The natural tendency to throw the head back should 
 be discouraged, as it narrows the opening of the oesophagus 
 instead of widening it. The tube is then passed over the tongue 
 to the back of the throat, and the patient told to swallow ; 
 while he is in the act of swallowing, slight pressure engages the 
 tube in the oesophagus, and, by its muscular force, the tube is 
 carried on into the stomach. In the event of any difficulty 
 being experienced in getting the tube into the oesophagus, 
 it is better to withdraw it at once and try again, as the 
 patient is apt to become nervous if the tube does not go down 
 quickly. The ordinary passage of the tube will occupy only a 
 few seconds. 
 
 Obtaining- the Stomach Contents. — If the stomach 
 contents do not begin to flow when the tube reaches the stomach, 
 it is advisable to move the tube slightly up and down so as to 
 make sure that it has not doubled on itself, and that it has reached 
 the level of the fluid. The patient is then directed to take some 
 deep respirations, and if this is insufficient, to bear down with 
 his abdominal muscles. If these methods are not efficacious, 
 some operators have advised massage of the front of the abdomen, 
 by which means, peristalsis appears to be set up and the stomach 
 contents voided. Aspiration must at times be employed, and 
 frequently it is sufficient merely to grasp the stomach-tube with 
 the left hand, and with the right hand press out the air in the 
 lower part of the rubber tubing ; the fingers of the right hand 
 are then tightly closed on the tube, and the left hand loosened. 
 By repeating this manoeuvre several times, a sufficient vacuum 
 is obtained to raise the stomach contents to the level of the 
 patient's mouth, when the syphon action begins. Boas ^ re- 
 commends a bulb tube for this purpose ; the proximal end of 
 the tube, after its introduction into the stomach, is pressed 
 and the bulb squeezed, when the distal end is clamped and the 
 bulb allowed to expand. By this method, a partial vacuum 
 1 Boas, " Diagnostik unci Therapie der Magenkrankheiten," 3rd Auf, p. 128. 
 
8. GASTRIC DISEASES 
 
 is produced in the tubing, and the gastric contents will begin 
 to flow. 
 
 The simple apparatus of Rosenau ^ has many advantages 
 over other more complicated apparatus. It consists of a 
 graduated bottle with a capacity of 200-300 cm., which can 
 be connected to an ordinary stomach-tube and closed by an 
 india-rubber stopper. The stopper has three valved apertures, 
 any of which can be opened by a rotary movement, and com- 
 municate with an elastic bag, so that the atmospheric pressure 
 within the bottle can be exhausted or increased at will. 
 
 The objections to using methods of aspiration in obtaining 
 the stomach contents are that it comphcates the apparatus, 
 making the patient imagine that the operation is more important 
 than it really is, and the danger of causing too great a vacuum 
 and so sucking some of the mucous membrane of the stomach 
 into the eyelets, and detaching it from the stomach wall, thereby 
 leaving a raw surface. With the apparatus described above, 
 the suction can be regulated, so that the latter danger is avoided . 
 It must always be borne in mind that if one is to obtain gastric 
 contents in a suitable condition for analysis, no water whatever 
 must be added. It is perfectly impossible to obtain correct 
 results where this has been done ; however carefully the quantity 
 of water put into the stomach is measured, one can never be 
 sure what allowance to make for the quantity of water added, 
 as it is extremely difficult to empty the stomach completely. 
 
 It has frequently been stated that the use of the stomach- 
 tube is attended with danger, but in our opinion it can, under 
 certain conditions, be used with impunity in practically all 
 cases. One must naturally use common sense, and not employ 
 it in advanced valvular disease when compensation has failed 
 if there is the slightest straining on the part of the patient. It 
 is probably better not to use the stomach-tube in cases of 
 arterio-sclerosis with high tension ; in aortic aneurism, one 
 certainly ought to beware of using it, as also in some lung condi- 
 tions, severe bronchitis, and pulmonary tuberculosis in the 
 advanced stages. In cases of gastric ulcer where there has been 
 recent haemorrhage, the tube should not be used ; but, in doubt- 
 ful cases, no harm will probably arise from its use. When one 
 considers how soft the rubber tube is, one would hardly expect 
 
 1 Bril. Med. Jouni., April 23, 19 C4, y. 1^8. 
 
GASTRIC CONTENTS AND TEST MEALS 9 
 
 it to cause much damage to tlic mucous membrane. In short, 
 it may be said that, under ordinary conditions, there is not the 
 least danger incurred in passing the tube. 
 
 Capacity of the Stomach.— After having obtained 
 the stomach contents by means of the stomach-tube, the estima- 
 tion of the capacity of the stomach can be conveniently carried 
 out by one or other of the following methods : 
 
 (1) Before removing the tube, one can fill the stomach with 
 a measured quantity of water from the funnel until the patient 
 complains of feehng distended. The drawback to this procedure 
 is that the water presses the larger curvature of the stomach 
 downwards, and tends to enlarge the capacity of that organ, 
 while there is no certainty that the water has reached the cardiac 
 end of the stomach when the patient complains of distension. 
 In fact, the feeling of discomfort and pressure may cause 
 attempts at vomiting when the stomach is not completely 
 filled, and individual idiosyncrasies may lead to feehngs of dis- 
 comfort before the stomach is really distended with water. 
 
 (2) To obviate the disadvantage and discomfort of the water 
 method of estimating the capacity of the stomach, it has been 
 proposed to introduce air by means of the Boas bulb, or by 
 attaching a Higginson's syringe in order to distend the stomach 
 and determine the position and capacity by means of percussion. 
 In this case also, the condition of the stomach wall prevents an 
 accurate apphcation of the method. In cases of atony, the 
 stomach wall very easily becomes over-distended, although only 
 slight pressure has been produced as measured by means of the 
 manometer. 
 
 (3) Various chemical methods have been employed for dis- 
 tending the stomach, such as giving the two portions of a seidlitz 
 powder dissolved in water one after the other, or a small 
 quantity of citric acid in water is administered to the patient, 
 and immediately afterwards a solution of sodium carbonate. 
 The liberated carbonic acid distends the stomach, and, by means 
 of percussion, 02ie is able to estimate its capacity. 
 
 Ost ^ has collected the results of various observers with refer- 
 ence to the capacity of the stomach, and he gives a table as 
 follows : 
 
 1 " Beitriige zur Bestiiiiinung dcr Capacitiit lies Magens," quoted from Boas' 
 " Magcnkrankheiten," i. p. 10. 
 
10 GASTRIC DISEASES 
 
 Ewald 250-1680 cm. 
 
 Luschka 1500-2000 „ 
 
 Schiiren 2430 „ 
 
 Benckc 3000 „ 
 
 Brinton 3130 „ 
 
 Soemmering ...... 2500-5500 „ 
 
 Henle 2500-5500 „ 
 
 Kussmaul found the capacity of the stomach to b3 2600 cm. 
 It must be remembered that a correct estimation of the capacity 
 of the stomach depends, to a great extent, on the condition of 
 the patient, whether he is nervous or the reverse, whether he 
 is famihar with the stomach-tube, or, in the case of chemical 
 means being used, accustomed to the sensation of being distended. 
 All these points have to be taken into consideration before one 
 is in a position to express an opinion as to the stomach being 
 pathologically enlarged or not. As a general rule, one may 
 say that if the stomach will contain more than 3000 cm. of 
 water, it is probably dilated. The condition in which it is most 
 important to obtain an idea of the size of the stomach is when 
 it is uncertain whether the resonance found on percussion in 
 the region of the umbihcus is due to a dilated stomach, or to 
 an enlarged transverse colon. Any of the methods mentioned 
 can be used to determine the approximate size of the stomach, 
 while by means of a long rectal tube, the transverse colon can 
 be filled with air, and the percussion note will decide whether 
 the clear note varies during the latter procedure or not, and 
 one can tell whether one has to deal with a tympanitic note 
 due to dilated colon or to a dilated stomach. 
 
 TEST MEALS 
 
 It must be remembered that different food materials, as shown 
 by Pawlow, excite the secretion of gastric juices in different 
 proportions, and it is, therefore, very important, if one wishes 
 to compare one analysis with another, to note exactly what 
 diet the patient has taken, and the period of time since he took 
 it ; otherwise, the chemical analysis is worthless. The experi- 
 ments of Pawlow ^ show that different kinds of food have a 
 corresponding definite hourly rate of secretion, and call forth 
 characteristic alterations in the proportion of the juice. On 
 
 1 Pawlow, " The Work of the Digestive Glands," translated by W. H. Thomp- 
 son, p. 35. 
 
GASTRIC CONTENTS AND TEST MEALS 11 
 
 a meat diet, tlie maxiinuni rate of secretion occurs during the 
 first and second hours, and in both, the quantity of gastric juice 
 is approximately the same. Bread gives a maximum secretion 
 of gastric juice during the first hour, wliile in the case of milk 
 it occurs during the second and third liours. On the otlier 
 hand, the most active formation of juice occurs with meat during 
 the first hour, with bread during the second and third hours, 
 and with milk during the last hour of secretion. Vie thus see 
 that the maximum out-fiow, as well as the whole curve of 
 secretion, is characteristic for each diet. 
 
 These valuable results of Pawlow show how important it 
 is, in comparing one case with another, to have a fixed diet 
 for patients. It is practically immaterial what diet one uses, 
 but for the sake of convenience, we have preferred to use a test 
 breakfast. 
 
 In giving a test meal, it is important to see that the stomach 
 is empty, otherwise, the analysis may be vitiated ; if the 
 remains of food from the previous day are still present in the 
 stomach, one cannot obtain a proper quantitative analysis 
 representing the juice excreted for the new meal. 
 
 The various test meals employed in practice for the diagnosis 
 of stomach diseases can now be described. 
 
 (1) Test Breakfast.— EwakP long ago recommended, 
 as a test breakfast, that the patient should take one roll of 
 white bread about 35 grams and 400 c.c. of water or weak 
 tea without milk or sugar, and, that one hour afterwards, 
 the contents of the stomach should be syphoned off for 
 examination. 
 
 In practice we find it more convenient to give two cups of 
 weak tea Avith a little milk, and two slices of dry toast. The 
 advantage of either of these meals is that one is able to 
 obtain the stomach contents one hour afterwards ; the semi- 
 fluid contents easily flow up the tube without any blocking 
 which is apt to occur when the larger ingesta, more especially 
 meat, are given. The meal can be also taken by patients with 
 weak digestions or intolerant stomachs. The disadvantage is 
 that the meal has a very slightly stimulating effect on the 
 gastric secretion, but this is negatived when one remembers 
 that the object of its use is to obtain comparative results. 
 
 1 Ewald, " Klin, der Verdauuiigskratikheiten," ii. IS'.tS. p. 285. 
 
12 GASTRIC DISEASES 
 
 (2) Boas' s Test Meal.^— This consists of a teaspoonful 
 of rolled oats and iOOO c.c. of water boiled down to 5(J0 c.c. 
 and given with the addition of niilk, but without any salt. The 
 stomach contents are removed for examination one hour later. 
 The meal was introduced by Boas with the special object of 
 estimating the quantity of lactic acid present in the stomach 
 with particular reference to carcinoma. The bread or toast 
 given in the ordinary test breakfast always contains some 
 lactic acid, and such meals are, therefore, not suitable when the 
 quantity of lactic acid present in the stomach has to be estimated. 
 
 The following precautions must be observed before the Boas 
 test meal is given if one is to obtain a satisfactory analysis. 
 The previous night, the stomach must be washed out with 
 water until the fluid returns absolutely clear, and this process 
 should be repeated just before giving the test meal. Otherwise, 
 there is a great chance of some of the lactic acid from the 
 previous meal being retained in the stomach, thus vitiating 
 the results. 
 
 (3) RiegeFs Test Meal." — The patient takes, while fast- 
 ing, a soup-plateful of bouillon or broth, 150 to 200 grams of 
 beef steak, and 50 grams of 'puree of potatoes. In order to 
 prevent the lumen of the tube becoming obstructed, it is advis- 
 able to have the meat finely minced. 
 
 Leube ^ has recommended a similar meal, passing the stomach- 
 tube after seven hours. If one finds the stomach then empty, 
 one can consider that the motor-power is not delayed, but one 
 obtains no evidence as to whether the gastric secretion is normal. 
 In many pathological conditions, when the ingesta are passed 
 on into the duodenum in the normal, or even a shorter space 
 of time, chemical analysis proves that the gastric contents have 
 either a deficiency or excess of hydrochloric acid. It would 
 appear that the time for passing the tube after this meal varies 
 in different individuals. In some cases, it can be passed after 
 two or three hours, while in others, one has to wait for five or 
 six hours before the results are obtained. Riegel states that 
 he finds four hours after the ingestion of the meal the best time 
 for carrying out the first diagnostic examination. If the stomach 
 
 1 Zeilschr. f. Klin. Med., vol. xxv. 
 
 2 Riegel's " Magenkrankheiti-ii," \\ S2. 
 
 3 Dvulsch. f. Klin. Med., vol. v. p. 33. 
 
GASTRIC CONTENTS AND TEST MEALS 13 
 
 is found to be empty by that time, one has learnt that the motor- 
 power is normal, if not accelerated, but no information whatever 
 is obtained as to the hydrochloric acid or peptic digestive power. 
 In those cases where the stomach empties itself in four hours, 
 it is necessary to repeat the meal and pass the tube at an earlier 
 time, preferably two hours after the meal. On the other hand, 
 if at the end of four hours, there is still a large amount of diges- 
 tive material in the stomach, one repeats the operation at a 
 later period. In no case ought one to be content with only 
 one investigation for the drawing of conclusions. 
 
 The disadvantage of this test meal is that, if one wishes 
 to make a chemical examination, one has very mixed gastric 
 contents to deal with, and the comparative results, in our own 
 experience, have not been very satisfactory. On the other 
 hand, for microscopical examination, this method is very valuable 
 in showing starch granules or muscular fibres in a more or less 
 digested condition, undoubtedly, the principal value of the 
 meal is in showing the motor-power of the stomach, and not 
 the estimation of the gastric digestive power. 
 
 (4) Salzer's Test Meal.^ — Salzer's test meal consists 
 of giving two meals, one after the other. The first consists of 
 30 grams of finely minced cold roast beef, 250 c.c. of milk, and 
 50 grams of rice with one soft-boiled egg. Four hours later, a 
 second meal of tea and roll as in Ewald's test breakfast, is 
 given, the contents of the stomach being syphoned ofi one hour 
 after the second meal. In this method, Riegel's test meal 
 is combined with the test breakfast. As has been already 
 shown, the stomach which possesses normal motility would be 
 empty in about five hours after Riegel's meal, so that, if the 
 motor-power is normal or slightly in excess, there ought to be no 
 remains of the first meal in the stomach contents, but merely 
 the residue of the test breakfast for analytical purposes. 
 
 The disadvantage of this method is that complication in the 
 gastric stimulation is caused by the administration of two meals 
 so closely following each other, as we have shown to be pointed 
 out by Pawlow in liis experiments. It is also found that the 
 comparison of the analyses obtained in different cases does not 
 give very constant results. We therefore prefer to use Riegel's 
 test dinner for investigating the motor-power of the stomach, 
 1 Boston, " Clinical Diagnosis," p, 310. 
 
14 GASTRIC DISEASES 
 
 and not to complicate it with the analysis after the test break- 
 fast, leaving the latter till another occasion. 
 
 (5) Klemperer's Test Meal. — The patient takes 
 while fasting, 500 c.c. of milk, and two rolls of white bread, the 
 stomach contents being removed two hours later. It is essential, 
 if one wishes to obtain maximum results on a milk diet, to 
 remove the gastric contents at a longer interval than one hour, 
 since the secretion has not reached its maximum by that time ; 
 Pawlow having found in his careful investigations that milk 
 does not give its maximum stimulation to the gastric contents 
 for two or three hours. In this diet, therefore, one has no 
 advantages over the ordinary test breakfast, and in maldng 
 comparisons, one must remember that the quantity of hydro- 
 chloric acid will be higher than that obtained when the simple 
 test breakfast is given, 
 
 (6) German See Test Meal. ^— The patient takes, while 
 fasting, 100 to 150 grams of bread, 60 to 80 grams of finely 
 minced meat and one glass of water, the stomach contents 
 being removed two hours later. 
 
 When employing tins diet, one obtains gastric contents which 
 are stimulated by proteid (meat, the gastric secretion of which 
 would be at its highest in two hours), and by carbohydrates 
 (bread, which would give its maximum stimulation in the 
 first hour). And the diet appears to us to have no advan- 
 tages over the others described. 
 
 X Acad, de J\Icd., Paris 1888, 3rd series xix. p. 72. 
 
CHAPTER II 
 
 MACROSCOPIC AND IMICROSCOPIC EXAMINATION OF 
 CASTRIC CONTENTS 
 
 The gastric contents having been obtained after any of the test 
 meals described, should be inspected, and the appearance, 
 colour, and odour noted. For this purpose, it is advisable to 
 place the contents in a conical vessel, noting the various layers 
 which form, and isolating, by means of a pipette, specimens from 
 these layers for separate examination. 
 
 The test breakfast yields gastric contents which form three 
 distinct layers in the vessel, the lowest, consisting of a dense 
 mass of finely divided starch residue, above this, a deeper layer 
 of turbid fluid, while the uppermost layer consists of clear liquid 
 with some frotji on the surface, and showing bubbles of gas 
 slowly rising on the top. Increased gas fermentation will be 
 found to occur in all cases of motor insufficiency, leading to 
 stagnation of the gastric contents. In cases of motor insuf- 
 ficiency, it is not at all uncommon to find the lowest layer contain 
 distinct lumps of toast, in spite of mastication having been 
 well carried out. One of the functions of the motor-power of 
 the stomach is its churning action, allowing the gastric juice 
 to act more easily on the ingesta and thus break them up, so 
 that any diminution in the movements of the stomach will be 
 shown by the insufficient breaking-down of the toast. 
 
 Reigel's test dinner gives gastric contents, in which — if they 
 are removed before the stomach is empty — one finds in the 
 lowest layer a dense precipitate of partially digested pieces of 
 meat. In those cases where there is excessive digestive activity, 
 the lower layer may be almost converted into fluid, and only 
 some remnants of muscular fibres and a few starch granules 
 are to be seen by the naked eye examination. A rough idea 
 of the digestive power of the stomach can be obtained by inspec- 
 tion. The gastric contents in some cases give no reaction for 
 
16 GASTRIC DISEASES 
 
 free hydrochloric acid, and in spite of its absence, one finds only 
 finely broken-up residue ; while, in other cases, one finds a large 
 quantity of coarsely divided food. The quantity and the 
 breaking-down of the two classes of gastric contents show very 
 great differences, for in the first case, the peptic digestion is 
 far better than in the second. In the first, the stomach very 
 nearly approaches the normal, the proteids having been digested, 
 although the gastric secretion has not gone quite far enough 
 to form free hydrochloric acid. In the second case, the 
 production of free hydrochloric acid has been much below the 
 normal, as shown by the large quantity of undigested or partially 
 digested pieces of meat, and if this gastric contents had been 
 examined chemically, one would have found a very marked 
 diminution in the quantity of hydrochloric acid. 
 
 The conical vessel allows one to see if there is any blood, 
 mucus, bile, or pus present in the gastric contents, specimens 
 of which can be obtained for further examination by means of 
 a pipette. 
 
 It is very important in all cases of stomach disease to take 
 special note of the odour of the gastric contents obtained after 
 the employment of one or other of the test meals. In normal 
 gastric contents after a test breakfast, there ought to be no 
 objectionable smell present, whilst in pathological conditions, 
 it may vary from a shghtly sour to a more or less putrid stinking 
 odour. The irritating smell of butyric acid is most characteristic, 
 and, as mentioned later, practically does away with the necessity 
 of chemical examination for this substance. In cases of atony 
 of the stomach, where there is long-continued stagnation 
 of the gastric contents, one may obtain a definite smell of 
 sulphuretted hydrogen, and occasionally, a sufficient quantity 
 of this substance is present to blacken moist lead paper. In 
 malignant disease, it is not uncommon to have a distinctly 
 putrid smell in cases where the gastric carcinoma has ulcerated. 
 In cases of intestinal obstruction, or where an abnormal connec- 
 tion between the stomach and intestine has arisen, one may 
 obtain a fa}cal odour. 
 
MACROSCOPIC AND MICROSCOPIC EXAMINATION 17 
 
 MICROSCOPIC EXAMINATION OF THE GASTRIC 
 CONTENTS 
 
 The microscopic examination of the contents removed from 
 the stomach after any of the various test meals is not so important 
 as the macroscopic, and far less so than the chemical examination. 
 It has already been pointed out that, if the gastric contents are 
 put in a conical vessel, one can, by means of a pipette, separate 
 any portions desired for microscopic examination. 
 
 One finds in some cases after Riegel's test meal that the 
 muscular fibres still retain their cross striation, and have been 
 little acted on by the gastric juice. The chemical analysis will 
 prove the absence or diminution of hydrochloric acid, and 
 probably, a decrease of pepsin. In other cases, one finds 
 microscopically that the muscular fibres have been well digested, 
 but that the starch digestion has not proceeded at an equal 
 rate. In these cases, one generally finds that one has to deal 
 with hyperhydrochloria. The deficiency of starch digestion 
 is very easily demonstrated by means of the microscope if one 
 uses a solution of potassium iodide and iodine, which stains the 
 starch a blue colour. 
 
 Quantities of fat are sometimes recognised in the stomach 
 contents by aid of the microscope, but they have little patho- 
 logical significance. 
 
 Epithelial cells will be found in the sediment, but they are 
 not of much diagnostic value, although in rare cases cancer cell 
 nests may be found in the particles of the sediment of gastric 
 contents. We, however, agree with Riegel that these are of 
 very rare occurrence. 
 
 In washing out the stomach with water after having removed 
 the gastric contents by syphoning, or in washing out a fasting 
 stomach, it is not uncommon to find in the wash-water small 
 pieces of gastric mucosa. Einhorn ^ has made a special study 
 of these, and gives in his book numerous plates showing the 
 various forms found in this way ; the conclusions to be drawn 
 from the examination of such specimens are, however, unrehable, 
 as Einhorn himself has stated. 
 
 In some cases the microscope may reveal the presence of blood 
 corpuscles ; very small quantities can be distinguished by this 
 
 1 Einlioni, " Diseases of tlic Stomach," p. 78. 
 
 B 
 
18 GASTRIC DISEASES 
 
 means where no positive chemical reaction can be obtained. 
 And it must not be forgotten that blood in such small quantity 
 may come from the pharynx, owing to shght bruising or 
 straining with the tube, and may have little significance. 
 
 It is unnecessary here to describe the various micro-organisms 
 which may be recognised by the aid of the microscope. Oppler 
 and Boas^ have drawn special attention to a form of bacillus 
 which they consider to be present in the gastric secretion in 
 cases of carcinoma. This bacillus is easily recognised by its 
 large size and immobility, and Kaufmann has shown that it 
 possesses the power of converting various sugars into lactic acid. 
 The question of the presence of lactic acid in mahgnant disease 
 will be discussed later on, but it is important to remember that 
 in most cases of carcinoma one finds this lactic acid bacillus. 
 
 The view that the stomach is not essential for the digestion 
 of proteids, and that the hydrochloric acid present in the gastric 
 secretion really acts as an inhibitor of the various micro-organ- 
 isms which have been swallowed by the mouth, is strongly held 
 by Bunge ^ and others. It has, however, been definitely proved 
 that the addition of hydrochloric acid to the gastric contents 
 does not entirely destroy micro-organisms, and there are 
 numerous cases in which, in spite of an excess of hydrochloric 
 acid, micro-organisms are present. At the same time, it will 
 be found in these cases that the condition is accompanied by 
 diminished motility of the stomach. In all probabihty, the 
 hydrochloric acid does inhibit, to a certain extent, the micro- 
 organisms present in the stomach, provided that it is performing 
 its functions healthily. The cholera bacillus, certain strepto- 
 cocci, &c., are Idlled by the gastric juice, while others, especially 
 spores, are not acted upon. Also gastric juice diminishes the 
 action of certain toxalbuminj , such as tetanotoxin and diphtheria 
 toxin, as has been shown by Nencki, Sieber, and Schomiow.' 
 Under pathological conditions, the hydrochloric acid — owing 
 to itb weak action — is insufficient to be of material service. 
 
 Numerous varieties of sarcinse have been described, but the 
 cultivation of the different varieties is of more scientific than 
 practical interest. The presence of sarcinse in the stomach 
 
 1 Deut. Med. Wochenschr., 1895, No. 5. 
 
 2 Lehrbuch der physiol. Chemie, 1887. 
 
 3 Ccnlralb. /. liactcriul, vol. x.xiii. 
 
MACROSCOPIC AND MICROSCOPIC EXAMINATION 19 
 
 indicates the retention of stomach contents, whether the reten- 
 tion is due to atony of the stomacli, gastritis, or even structural 
 obstruction, while, in malignant disease, as shown later, they 
 are absent. 
 
 Crystals of cholesterin, leucin, oxalate of lime or ammonium 
 magnesium phosphate may be recognised microscopically, but 
 they have no clinical significance. 
 
CHAPTER III 
 
 CHEMICAL EXAMINATION OF GASTRIC CONTENTS— TOTAL 
 ACIDITY, VOLATILE ACIDITY 
 
 The quantitative estimation of the amount of acidity in a 
 given quantity of gastric contents is among the most useful 
 analytical data we have in making a diagnosis in gastric diseases. 
 
 Total Acidity. — Ewald ^ describes a method for estimating 
 the acidity due to hydrochloric acid, organic acids and acid 
 phosphates, which is generally known as " total acidity." 
 
 Method : — Ten c.c. of filtered gastric contents are measured 
 into a small beaker, and 20 to 30 c.c. of distilled water added, 
 and, as an indicator, three drops of 1 per cent, alcohohc solu- 
 tion of phenolphthalein. The solution is kept constantly 
 stirred, during which time a decinormal solution of sodium 
 hydrate is allowed to run, drop by drop, into the beaker until 
 the red colour which at first appears does not deepen on the 
 addition of a further drop. The number of c.c. of sodium 
 hydrate used is then read off, and this multiplied by ten will 
 give the quantity of decinormal sodium hydrate required to 
 neutralise 100 c.c. of gastric contents. This number is that which 
 is generally known as " total acidity " in modern books on 
 diseases of the stomach. It must, however, be remembered, 
 as we have stated above, that this is really the amount of total 
 acids in 100 c.c. of gastric contents, and should never be taken 
 to represent the amount of hydrochloric acid actually present, 
 being in reahty only the total acidity due to hydrochloric acid, 
 the various organic acids and acid phosphates present in the 
 stomach. In describing the method of estimating the quantity 
 of volatile acids, we will show how the total amount of volatile 
 
 1 Klinik dcr Verdammgskrankheiien, vol. ii. 1893, p. 34. Proceeding first 
 recommended by Geigel and Blass, " Procentuale mid absolute Aciditat des 
 Magensaftes," Zeitschr. /. Klin. Med., vol. xx. No. 3, and also by Geigel and 
 Abend, " Die Salzsam'C Secretion bei Dyspepsie Nervosa." Virchow's Archiv. 
 vol. cxxx. No. 1. 
 
EXAMINATION OF GASTRIC CONTENTS 21 
 
 acids can be estimated, and, by subtracting the acidity due to 
 volatile acids from the total acidity found by the above method, 
 we have the acidity which is represented by the quantity of 
 hydrochloric acid and acid phosphates ; and, since the acid 
 phosphates are, as a rule, only small in amount, this quantity 
 may be taken as roughly representing the total acidity due to 
 hydrochloric acid. 
 
 The normal acidity in the gastric contents as estimated by 
 the above method, is found, after taking a test breakfast, to 
 vary between 40 and 60. 
 
 The lowest total acidity that we have met with amongst a 
 large number of stomach analyses, was 14, when 13-6 of the 
 acidity was found to be due to volatile acids. This was in a 
 case of malignant disease at the cardiac end of the stomach. 
 
 As a general rule, the total acidity is found not to be less than 
 from 18 to 20 in cases of hypoliydrochloria, with volatile acids 
 varying from 2 to 3-5. 
 
 In cases of hyperhydrochloria, which are very much more 
 frequent than cases of hypohydrochloria, the acidity as a rule 
 varies from 80 to 100, although it is not at all uncommon to get 
 a total acidity as high as 120 or even higher. 
 
 Volatile Acidity. — Gastric contents have always been 
 found to contain, after any test meal, volatile acids in greater 
 or smaller quantities. 
 
 Butyric acid, acetic acid, and fatty acids are probably the 
 chief volatile acids present in the stomach contents, and they 
 are especially increased if there is any stagnation ; and as 
 will be shown later, they may be present in increased quantities 
 when free hydrochloric acid exists in normal quantity, or even 
 in excess. 
 
 The recognition of these acids is generally a simple matter, 
 owing to the intensely acid smell which one notices when obtain- 
 ing the gastric contents by means of the stomach- tube. 
 
 If some of the gastric contents are placed in a test-tube and 
 a strip of blue litmus paper (previoubly moistened), stretched 
 over the top, one finds, on gently heating the tube, reddening 
 of the paper, owing to the liberation of the volatile acids. 
 
 For the estimation of the volatile acids, Hermann Strauss ^ 
 introduced a method by which fresh unfiltered gastric contents 
 
 1 Deut. Med. Wochcnschr., 1896, No. 38. 
 
22 GASTRIC DISEASES 
 
 were poured into large sterilised fermentation tubes. The 
 fermentation tubes were then placed in an incubator at 37° C. 
 for twenty-four hours. The proportionate amount present is 
 estimated as follows : 
 
 One or more bubbles of gas Very slight fermentation. 
 
 Tube filled to one fifth with gas Slight fermentation. 
 
 Tube filled between one fifth and I 
 
 one half f Moderate fermentation. 
 
 Tube filled between one half and) ,^ , . 
 
 three-quarters j' ^^"^^i fermentation. 
 
 It is obvious that this method cannot be very accurate, as 
 the gastric contents are under totally different conditions from 
 the normal, being removed from the modifying influence of 
 gastric secretions, saliva, and mucus. 
 
 Other methods have been introduced, none of which appear 
 to be very satisfactory. Some ten years ago, a method which 
 has been found to yield very satisfactory results, was introduced 
 in the Department of Pathological Chemistry, University College, 
 London. The method has the merit of being feasible for clinical 
 work. 
 
 Harley's Method of estimating the Total Vola- 
 tile Acids in the Gastric Contents. — A certain quantity 
 (preferably about 25 c.c.) of unfiltered gastric contents is 
 poured into a distillation flask, and 100 or more c.c. of water 
 added. A current of superheated steam is driven through the 
 flask, and a small flame placed underneath it. The superheated 
 steam, raising the contents to boiling-point, drives off the volatile 
 acids which distil over through a condenser into an Erlenmeyer 
 containing about 10 c.c. of decinormal solution of sodium 
 hydrate. After about thirty minutes, the Erlenmeyer is removed 
 and a few drops of neutral solution of litmus added to the sodium 
 hydrate solution. The fluid is then titrated by rapidly running 
 into it a decinormal solution of sulphuric acid until a neutral 
 reaction is obtained. The quantity of decinormal solution of 
 sodium hydrate neutralised by the volatile acids is then easily 
 obtained. Multiplying the number by four, if 25 c.c. of gastric 
 contents were taken, will give the quantity of volatile acids in 
 100 c.c. of gastric contents. 
 
 This method is somewhat similar to that originally employed 
 by von Mering, in which the gastric contents with water arc 
 
EXAMINATION OF GA8TRIC CONTENTS 23 
 
 distilled, and when boiled down to about one-third of their 
 volume, a fresh quantity of water is added, and again boiled 
 to about one-third ; this process is repeated some four or five 
 times, the liberated volatile acids being collected by means of 
 a condenser in a decinormal solution of sodium hydrate and 
 titrated as above. The von Mering method has possibly the 
 same accuracy as the one which we have described, but it is 
 more difficult to carry out, and needs more looking after. 
 
 Both these methods have one possible cause of error, — some 
 of the organic matter, as proteids or fat, may be broken up by 
 the superheated steam, and lead to too high a quantity of 
 volatile acids. At the same time, even if this should be the 
 case, the quantity broken up when control analyses are done 
 is equal, for w^e have found the control analyses to be sufficiently 
 accurate for all diagnostic purposes. 
 
 As an example of the accuracy of this method for the 
 quantitative estimation of the volatile acids expressed in c.c. 
 of one-tenth Normal NaOH,^ the following results may be given : 
 
 1 . . . . 3-0 2-8 control. 
 
 2 . . . .3-2 2-8 „ 
 
 3 . . . .70 7-5 „ 
 
 ■4 . . . . 70 7-0 „ 
 
 In the above we have illustrated two analyses with a small 
 quantity of volatile acids, and two analyses with a large 
 quantity of volatile acids, and it appears that the results are 
 very close, and are certainly sufficiently accurate, as before 
 stated, for all diagnostic purposes. 
 
 The normal amount of volatile acids, as estimated by Harley's 
 method, varies from 2 to 5, although we have found as much 
 as 11 in an individual apparently suffering from no gastric 
 disturbance. In all cases where we have found a larger quantity 
 than this, there have been definite symptoms of dyspepsia, and 
 as a rule, in those cases where the quantity is above 5, the patient 
 is suffering from symptoms of acid dyspepsia. 
 
 In one case we found 16 with a total acidity of 62, and in 
 another, 25 with a total acidity of 60. Both these patients 
 had neurotic histories, and showed signs of delayed motility 
 with some dilatation of the stomach. 
 
 In a case of chronic tubercular disease of the lungs (healed), 
 
 1 Harley and Leney, B.M.J., Oct. 27, 1899, p. 1271 
 
24 GASTRIC DISEASES 
 
 where there was marked increase of mucus in the gastric con- 
 tents, and evidently chronic gastric catarrh, we found volatile 
 acids varying from 18 to 30, with a total acidity varying from 
 40 to 70 in some ten analyses after test breakfasts. 
 
 In a case of mahgnant disease of the cardiac end of the 
 stomach, we found 22-4 volatile acids with a total acidity of 47. 
 
 In hypohydrochloria, we found volatile acids 14 with a total 
 acidity of 30. 
 
 It will thus be seen that the quantitative estimation of volatile 
 acids is of considerable importance in determining how much 
 of the total acidity is due to volatile acids. 
 
 In hyperhydrochloria it will be found that, even where the 
 total acidity is considerably increased, one may get an increase 
 in the quantity of volatile acids. As a general rule, however, 
 in marked cases of hyperhydrochloria, the volatile acids are 
 only shghtly, if at all, increased. 
 
 In some cases where the total acidity is higher than normal — 
 say, 70 to 90— it may be found to be due, not to the increase 
 of hydrochloric acid, but to marked increase in the quantity 
 of volatile acids, so that increased total acidity is really only 
 an apparent increase in consequence of the great increase in 
 the volatile acids. 
 
CHAPTER IV 
 
 CHEMICAL EXAMINATION OF GASTRIC CONTENTS (continued)— 
 QUALITATIVE AND QUANTITATIVE METHODS FOR THE 
 RECOGNITION OF FREE HYDROCHLORIC ACID 
 
 (1) Methyl-Violet.^ — A very diluted watery solution of 
 methyl-violet is placed in two test-tubes, each about one- 
 third full. To one of these, one c.c. of filtered gastric contents, 
 and to the other, an equal quantity of distilled water, is added. 
 The two test-tubes being held up to the light, one notices the 
 appearance of a violet colour if free hydrochloric acid is present, 
 the colour gradually changing to blue on standing. 
 
 The methyl-violet test can also be employed by allowing a 
 drop of filtered gastric contents to come in contact with a drop 
 of methyl-violet solution in a porcelain capsule, thus obtaining 
 a violet colour changing to blue on standing, at the junction 
 of the two fluids. 
 
 This test is mainly of historical interest, V. d. Velden 
 having employed it for detecting the presence of free hydro- 
 chloric acid in his classical work on " Carcinoma of the Stomach." 
 The test is not a delicate one. 
 
 (2) Congo Red. — A watery solution of congo-red or filter- 
 paper previously soaked in congo-red solution, is dried and kept 
 in stock, cut up into strips. 
 
 A drop of gastric contents placed on congo-red paper gives 
 an intense blue colour if free hydrochloric acid is present. 
 
 A drop of gastric contents and one drop of congo-red solution 
 arc allowed to come in contact with each other in a porcelain 
 capsule, when, in the presence of free hydrochloric acid, a blue 
 colour will appear at the junction of the two fluids. 
 
 The congo-red solution is a very sensitive reaction for free 
 hydrochloric acid. 
 
 (3) Tropaolin 00. — A solution of tropaohn, or filter-paper 
 
 1 V. d. Velden, Dent. Arch. /. Klin. Med. 1879. Bd. x.\iii. 49. 
 
20 GASTRIC DISEASES 
 
 previously soaked with tropaolin, is used in the same manner 
 as the congo-red solution ; in the presence of free hydrochloric 
 acid, one obtains a lilac or blue colour. 
 
 This method is not so sensitive as congo-red, and only acts 
 with free hydrochloric acid, the organic compounds of hydro- 
 chloric acid not giving the reaction. 
 
 (4) Giinzburg's Solution/ — The solution employed 
 by Giinzburg consists of : 
 
 Phloroglucin 
 
 2 grams. 
 
 Vanillin 
 
 1 gram. 
 
 Absolute Alcohol . 
 
 . 30 grams. 
 
 This solution must be kept in a dark glass bottle, as light 
 easily decomposes it. 
 
 A few drops of Giinzburg's solution are added to a few drops 
 of filtered gastric contents in a porcelain capsule, and gently 
 heated over a small flame. If free hydrochloric acid is present, 
 a bright red colour appears at the margin, gradually extending 
 over the whole surface. It is advisable to hold the capsule 
 in the fingers in order to avoid over-heating, and consequent 
 charring, as, should this be the case, a yellow colour appears, 
 and no conclusions can be drawn. This is a very pretty test 
 and used to be considered the most delicate for clinical purposes : 
 it is useful for demonstration purposes. 
 
 (5) Dimethyl-amido-azo-benzol. — The method for de- 
 tecting the presence of free hydrochloric acid by the use of 
 0.5 per cent, of alcohohc solution of dimethyl-amido-azo-benzol 
 was first introduced by Topfer.- 
 
 One or two drops of dimethyl-amido-azo-benzol solution, 
 when added to gastric contents, will yield a beautiful crimson 
 colour in the presence of free hydrochloric acid, while if free 
 hydrochloric acid is not present, one merely observes a dirty 
 yellow colour. 
 
 This method of Topfer is undoubtedly the most valuable 
 we have at the present moment for demonstrating the presence 
 of free hydrochloric acid. Its advantages are : 
 
 (a) A solution of dimethyl-amido-azo-benzol keeps for a con- 
 siderable time. 
 
 (h) It is by far the most easily applied test for recognising 
 
 1 Cvntrdlhlatt. f. Klin. Med., 1887, No. 40. 
 
 2 Zeitsrhr. /. Physiol. Chcmie, Bd. xix. Heft 1. 
 
EXAMINATION OF GASTRIC CONTENTS 27 
 
 the presence of free hydrochloric acid of all those in common 
 use. It is the most certain in reaction, as neither excess of lactic 
 acid nor the presence of acid phosphates will cause the colour 
 to appear, and t alone is all that is necessary for clinical purposes 
 in definitely clinching the presence or absence of free hydro- 
 chloric acid. 
 
 (c) It is not necessary to filter or prepare the gastric contents 
 in any way. 
 
 QUANTITATIVE ESTIMATION OF HYDROCHLORIC 
 ACID 
 
 As hydrochloric acid is the most important acid secretion of 
 the stomach, it has been thought that the knowledge of the 
 quantity present in pathological conditions is of great import- 
 ance in the proper diagnosis of diseases of the stomach, and a 
 great number of investigators have carried out researches in 
 the subject. Numerous methods for the quantitative analysis 
 of free hydrochloric acid have been introduced, and each has 
 its own supporters. We have repeatedly tried most of these 
 methods, and have found one or other more or less useful. But 
 after some years teaching, and after the experience gained in 
 seeing the manner in which the methods have been employed 
 by advanced students, we have slowly come to employ only 
 two methods, which appear to us to be the most accurate and 
 most easily carried out. 
 
 (1) Leo's Method/— This method depends upon the fact 
 that all the acids, including the proteid combined hydrochloric 
 acid, present in the gastric contents, are neutralised by calcium 
 carbonate, while the acidity due to the acid phosphates and 
 other alkaline substances is not altered, so that one titrates 
 one portion of the fluid direct, and the other after treating it 
 with calcium carbonate. 
 
 To ten c.c. of gastric contents, five c.c. of chloride of calcium 
 solution are added, a few drops of phenophthalein being used 
 as an indicator ; one titrates with one-tenth normal solution 
 of sodium hydrate. A further fifteen c.c. of gastric contents 
 are treated with one gram of dry powdered calcium carbonate 
 and filtered through ash free filter-paper. Ten c.c. of the filtrate 
 
 1 Hoppc-Seylcr's C'hemitchcr Analyse, 1903, p. 519. 
 
28 GASTRIC DISEASES 
 
 are then taken, and after passing a stream of air through to 
 remove any excess of carbonic acid, five c.c. of concentrated 
 calcium chloride solution are added, using phenojihthalein as 
 an indicator, and again titrated with one-tenth normal solution 
 of sodium hydrate. 
 
 The difference between the two results obtained gives the 
 total acidity, provided that the stomach contents do not contain 
 lactic acid or volatile fatty acids. In these cases, it is necessary, 
 previous to carrying out the analysis, to extract the lactic acid 
 and volatile fatty acids with ether. 
 
 (2) The Prout-Wynter Method.— The unfiltered gastric 
 contents are measured off, and one must see that the quantity 
 is sufficient to allow of its being divided into three equal parts 
 for this analysis ; it is advisable to employ not less than fifteen 
 c.c, and in practice we prefer thirty c.c. 
 
 (a) Ten c.c. of unfiltered gastric contents are placed in a 
 platinum capsule, and ten to twenty drops of saturated solution 
 of sodium carbonate added. The capsule is then placed on 
 a sand-bath, and gradually evaporated to dryness, care being 
 taken that none of the contents are lost through " spitting." 
 When thoroughly dry, the contents are incinerated, and after 
 all the organic matter has been burnt off, the capsule is heated 
 to redness. The contents are then washed into a beaker by 
 means of a small quantity of distilled water, and labelled, 
 No. 1. 
 
 {b) A further ten c.c. of unfiltered gastric contents are 
 measured into a second platinum capsule, and dried down on 
 a sand-bath until all the fluid has disappeared ; just before 
 charring begins, ten to twenty drops of sodium carbonate solution 
 are added, run over the whole surface, and the "fluid again 
 evaporated to dryness. The contents are then incinerated, 
 raised to red heat, and washed with distilled water into a beaker 
 labelled. No. 2. 
 
 (c) A third ten c.c. of gastric contents are placed in a platinum 
 capsule, carefully dried down on the sand-bath, incinerated and 
 raised to red heat, the residue being washed with distilled water 
 into a beaker labelled, No. 3. 
 
 To each beaker a few drops of nitric acid are added, until 
 effervescence ceases, and fifteen c.c. of decinormal solution of 
 silver nitrate. 
 
EXAMINATION OF GASTRIC CONTENTS 29 
 
 The contents are filtered into beakers correspondingly 
 numbered, and the residue washed three or four times with 
 distilled water. 
 
 To the filtrate a few drops of iron alum solution are added 
 as an indicator. It is then titrated by rapidly running in a 
 solution of decinormal potassium sulphocyanide, quickly stirring 
 until a salmon-pink appears, and remains for a minute. 
 
 Each c.c. of decinormal silver nitrate equals a c.c. of decinormal 
 sulphocyanide of potassium, and each c.c. represents 0003(55 
 grams of hydrochloric acid. 
 
 The number of c.c. of decinormal sulphocyanide of potassium 
 used in each case is read off, subtracted from the quantity of 
 decinormal solution of silver nitrate originally taken, and the 
 remainder multiphed by 000365, by which means one obtains 
 the quantity of hydrochloric acid contained in each ten c.c. of 
 gastric contents. 
 
 The rationale of the method is as follows : 
 
 To the first capsule one adds sodium carbonate in order to 
 convert all the hydrochloric acid present into sodium chloride, 
 none of which chlorine will be driven off by heating, and the 
 number of c.c. of potassium sulphocyanide required gives the 
 total amount of hydrochloric acid present. 
 
 The contents of the second capsule are dried before the sodium 
 carbonate is added ; therefore, all the hydrochloric acid present 
 as free hydrochloric acid is driven off, while the addition of the 
 sodium carbonate prevents the hydrochloric acid combined 
 with the proteids from being driven off. 
 
 The third capsule only gives the amount of hydrochloric acid 
 present in the form of mineral salts, as in drying down, the free 
 hydrochloric acid is lost, and in incinerating, the hydrochloric 
 acid combined with the proteids is driven off, so that only the 
 chlorine combined with the mineral salts is left. Therefore, 
 
 No. 1 Capsule = total hydrochloric acid. 
 
 No. 1 minus No. 2 = free hydrochloric acid. 
 
 No. 2 minus No. 3 = proteid hydrochloric acid. 
 
 No. 3 — mineral hydi'ochloric acid. 
 
 This method is very accurate, as shown by comparison of the 
 results obtained with control analyses. The following table 
 of four analyses may be taken as an average specimen of the 
 results one may expect to find in normal gastric contents : 
 
30 
 
 GASTRIC DISEASES 
 
 TABLE I.— SHOWING THE ACCURACY OF THE PROUT-WYNTER 
 METHOD 
 
 Total HCl. 
 
 Free HCl. 
 
 Proteid HCl. 
 
 Mineral HCl. 
 
 (1) 0-32 
 
 0-31 (Control) 
 
 0-020 
 
 0-010 (Control) 
 
 0-23 
 
 0-23 (Control) 
 
 0070 
 
 0-070 (Control) 
 
 (2) 0-32 
 0-32 
 
 0-020 
 0-020 
 
 0-25 
 0-24 
 
 0-050 
 0-050 
 
 (3) 0-30 
 0-28 
 
 0-006 
 0-006 
 
 0-27 
 0-25 
 
 0-025 
 0-025 
 
 (4) 0-32 
 
 0-31 „ 
 
 0-004 
 0-007 
 
 0-27 
 0-27 
 
 0-050 
 0-040 
 
 If many stomach analyses have to be done, it is as well to 
 have at least three capsules. It is possible to use the same 
 capsule for the three separate analyses, but much time is 
 thereby lost, and the method becomes very tedious. 
 
 (3) Topfer's Method.^ — In this method, filtered gastric 
 contents have to be employed, and one must have sufficient to 
 divide into three quantities. 
 
 (a) Ten c.c. of filtered gastric contents are placed in a beaker, 
 and a few drops of alcoholic solution of phenophthalein 1 per 
 cent, added as an indicator ; titration with a decinormal solution 
 of sodium hydrate is then carried out in exactly the same way 
 as previously described in the estimation of total acidity. 
 
 (b) Ten c.c. of the same gastric contents are placed in a beaker, 
 and a watery solution of alizarin 1 per cent, (monosulphate 
 of sodium) used as an indicator. One titrates with a decinormal 
 solution as before. The end point is reached when the colour, 
 which at first was yellow, turns to violet. Since ahzarin does 
 not act with proteid hydrochloric acid, the difference between 
 (a) and (6) will indicate the amount of proteid hydrochloric 
 acid. 
 
 (c) To ten c.c. of filtered gastric contents, an alcoholic solution 
 of dimethyl-amido-azo-benzol 0-5 per cent, is added, and the 
 
 1 Loc. cit., ]). 20. 
 
EXAMINATION OF GASTRIC CONTENTS :'.l 
 
 mixture is titrated with one-tenth normal solution of sodium 
 hydrate. This will give the quantity of free hydrochloric acid. 
 
 The difference between («) and (b) -i- (c) will give the acidity 
 referable to organic acids and acid salts. 
 
 This method of Topfer is much more rapidly performed than 
 that of Prout-Wynter, but it has the great disadvantage that 
 the end colour mth each titration is not sharply defined, and 
 hence may lead to great personal variations. 
 
 It has been found, in a class of advanced students, that while 
 the results obtained with the Prout-Wynter method tend to 
 be more or less in accordance, those obtained with Topfer's 
 method seldom, if ever, agree. 
 
 If one individual, however, is carrying out a research, he 
 becomes in time so skilled, and in his hands the end reaction 
 is so sharp that he obtains, by means of the Topfer method, 
 correct results as compared with control experiments. In such 
 a case, the method is accurate and useful for comparing different 
 stomach analyses, but for those who only occasionally do quanti- 
 tative stomach analyses, it is undoubtedly better to rely on the 
 more tedious method of Prout-Wvnter. 
 
CHAPTER V 
 
 CHEMICAL EXAMINATION OF GASTRIC CONTENTS (co7itimied)— 
 LACTIC ACID, BUTYRIC ACID, ACETIC ACID 
 
 C H^ 
 I 
 LACTIC ACID— c H (OH) 
 
 I 
 
 C O H 
 
 The recognition of lactic acid in the gastric contents is made 
 by employing Uffelmann's reaction. 
 
 Chemical Test for Lactic Acid.— A few drops of 
 perchloride of iron solution are added to a test-tube of water, 
 so that the solution is so pale as to be almost colourless. 
 The solution is then divided equally between two test-tubes, 
 and to each tube one adds a few drops of 2 per cent, carbohc 
 acid solution, which has for some time previously been exposed 
 to the air, this rendering it more sensitive. The solution when 
 ready for testing should be pale amethyst blue. One adds a 
 few drops of filtered gastric contents to one of the test-tubes, 
 when, in the presence of lactic acid, a marked yellow or greenish- 
 yellow colour will be observed. This colour is easily recognised 
 by comparing it with that of the control test-tube. 
 
 Since alcohol, sugar, and phosphates give Uffelmann's reaction, 
 it is better to take five c.c. of gastric contents and shake them 
 with thirty c.c. of pure ether, free from alcohol. The separated 
 ether is then evaporated, and the residue dissolved in a httle 
 water, and tested with Uffelmann's reagent. 
 
 Quantitative Estimation of Lactic Acid (Boas's 
 Method)/ — " Ten c.c. of filtered gastric contents (which, in the 
 case of free hydrochloric acid being present, must be evaporated 
 to a syrup after the addition of barium carbonate) are taken, 
 and a few drops of phosphoric acid added, the carbonic acid 
 removed by boiling and the residue extracted on cooling with 
 
 1 Simon, " Clinical Diagnosis," p. IGO. 
 
EXAMINATION OF GASTRIC CONTENTS 33 
 
 100 c.c. of pure ether free from alcohol. The ether is evaporated 
 after separation, and the residue shaken up with forty-five c.c 
 of distilled water, and treated with sulphuric acid and manganese 
 dioxide. The flask is closed by a doubly perforated stopper ; 
 through one aperture, a bent tube passes to the distilling appara- 
 tus, and a straight tube provided with a piece of rubber tubing 
 clamped of? through the other. The mixture is then distilled until 
 about four-fifths of the contents have passed over, excessive heat 
 being carefully avoided, or the aldehyde will be decomposed. The 
 distillate is collected in an Erlenmeyer containing twenty c.c. 
 of one-tenth normal solution of iodine, and mixed with twenty 
 c.c. of 5-G per cent, solution of potassium hydrate. The mixture, 
 after being well shaken, is allowed to stand for a few minutes. 
 In order to liberate the hypiodite and the iodine in combination 
 with the potassium not used in the reaction, twenty c.c. of 
 hydrochloric acid and an excess of sodium bicarbonate in sub- 
 stance (some of the latter should remain undissolved at the 
 bottom), are added, and the excess of iodine determined by 
 titration with one-tenth normal solution of sodium arsenite. 
 The titration is carried to the point of decolourisation, when 
 freshly prepared starch solution is added, and the mixture again 
 titrated with one-tenth normal solution of iodine until the blue 
 colour is permanent. The number of c.c. of one-tenth normal 
 solution employed {i.e., twenty), minus the number of c.c. of one 
 tenth normal solution of sodium arsenite, will indicate the number 
 of c.c. of the former required for the formation of iodoform, i.e., 
 the amount of lactic acid present in ten c.c. of gastric contents. 
 As one c.c. of one-tenth normal solution of iodine has been found 
 to indicate the presence of 0003388 grams of lactic acid, it is 
 only necessary to multiply the number of c.c. used by this figure 
 and the result by ten, in order to obtain the percentage." 
 
 According to numerous observers, this method of Boas is 
 sufficiently accurate for clinical purposes, but we have found 
 it too tedious for general use. 
 
 The presence of lactic acid in the gastric contents after the 
 usual test meals is of little importance chnically, since the lactic 
 acid may be produced by the action of bacteria in the mouth, 
 or even be preformed in the diet. It will be found that lactic 
 acid is present in small quantities after all ordinary test meals, 
 so that if one wishes to examine especially for this substance 
 
 c 
 
34 GASTRIC DISEASES 
 
 in the gastric contents, it is necessary to go through a special 
 technique. 
 
 The stomach having been previously washed out, the patient 
 is given a Boas meal of oatmeal soup, and one or two hours 
 later, the stomach contents are obtained by means of the stomach- 
 tube. The gastric contents under normal conditions will be 
 found, under these circumstances, to give no reaction with 
 Uffelmann's reagent. If lactic acid is present, one gets a very 
 distinct reaction, and it has been shown by Boas that the 
 Uffelmann reaction only occurs in cases of carcinoma of the 
 stomach. The presence of lactic acid after the oatmeal diet 
 in carcinoma of the stomach is due to the fact that the lactic 
 acid bacillus is present. The question of why carcinoma should 
 cause the presence of the lactic acid bacillus has not, up to the 
 present, been satisfactorily settled. The chnical importance, 
 however, is very great, as anything which helps to recognise 
 carcinoma of the stomach in its early stages — when one may 
 hope to do some good by surgery — is very valuable, and it is 
 considered that lactic acid is present in the very early stages 
 of carcinoma of the stomach, before the disease can be recognised 
 by any other means. 
 
 C H3 
 I 
 BUTYRIC ACID— (C H.,)., 
 I 
 C H 
 
 Increased fermentation occurs in the stomach whenever there 
 is stagnation of the gastric contents, and in these cases one finds 
 butyric acid. 
 
 For chnical purposes, it is, as a rule, sufficient to recognise 
 the presence of butyric acid by the rancid, butter-hke odour 
 of the gastric contents. 
 
 Chemical Test for Butyric Acid. — An ethereal 
 extract of gastric contents is obtained by shaking ten c.c. wth 
 an equal volume of ether, and slowly evaporating it in a glass 
 capsule. After the disappearance of the ether, there will be left 
 a few drops of water which have been extracted from the gastric 
 contents. If necessary, a few more drops of distilled water may 
 be added, and then some small pieces of calcium chloride. After 
 well stirring the solution, one observes numerous oil-drops floating 
 
EXAMINATION OF GASTRIC CONTENTS 35 
 
 on the surface of the liquid, and these give ofE a characteristic 
 odour of rancid butter. 
 
 The cHnical significance of the presence of butyric acid corre- 
 sponds to that of voLatile acids, since it occurs, as already stated, 
 where there is fermentation going on in the stomach, which is 
 especially apt to take place where there is retention of the 
 stomach contents for any length of time. In some cases one will 
 find that the increase of butyric acid accounts for the marked 
 acidity complained of by the patient, when there is no increase 
 in the hydrochloric acid in the stomach contents. 
 
 C TT 
 
 ACETIC ACID— I ' 
 
 C O H 
 
 Amongst the volatile acids which may be present in cases 
 of gastric stagnation, one has to include acetic acid. 
 
 Chemical Test for Acetic Acid.— Ten c.c. of gastric 
 contents are shaken up with ether, and the ether pipetted ofi 
 and filtered. The residue is shaken up with distilled water, and 
 neutralised with a solution of sodium hydrate, when, on the 
 addition of a drop of perchloride of iron, a dark red colour is 
 obtained if acetic acid is present. 
 
 The presence of acetic acid has practically the same significance 
 as that of butyric acid. 
 
CHAPTER VI 
 
 CHEMICAL EXAMINATION OF GASTRIC CONTENTS {contimied)— 
 GASTRIC FERMENTS 
 
 The gastric juice contains, under normal circumstances, three 
 ferments — pepsin, rennin, and lipase. 
 
 Pepsin. — The most important of the three ferments present 
 in the gastric contents is pepsin or its enzyme, pepsinogen. 
 
 Pepsin is recognised by its power, in the presence of free acids 
 (more especially hydrochloric acid), of converting coagulated 
 proteid into soluble albumen. 
 
 Coagulated Egg Albumen Test for Pepsin.— 
 The white of a hard-boiled egg is cut into cubes of roughly 0-5 
 cm., which can be easily done with a double-bladed knife. Three 
 test-tubes are prepared as follows : 
 
 (1) Four c.c. of filtered gastric contents. 
 
 (2) Two c.c. of filtered gastric contents and two c.c. of four 
 per mille hydrochloric acid solution. 
 
 (3) Two c.c. of distilled water and two c.c. of four per mille 
 hydrochloric acid solution. 
 
 Into each of these test-tubes is placed a cube of egg albumen, 
 and the tubes are put into a thermostat or water-bath at 37° C. 
 In the presence of pepsin of sufficient quantity, the whole of 
 the proteid will be converted into soluble albumen in from half 
 an hour to an hour, so that the fluid becomes quite clear in 
 test-tubes Nos. 1 and 2. If the albumen has been properly 
 coagulated, it will remain unaltered in test-tube No. 3, and 
 this is the object of its use — as a control tube. 
 
 The gastric contents, when they contain an insufficient quantity 
 of hydrochloric acid, or when only pro-enzyme is present, will 
 only show digestion in test-tube No. 2, an additional quantity 
 of hydrochloric acid having been added to make up for the 
 deficiency of hydrochloric acid present In the case of 
 
EXAMINATION OF GASTRIC CONTENTS 37 
 
 pepsinogen only being present, the free hydrochloric acid which 
 has been added has converted the pepsinogen into active pepsin. 
 
 Carmine -Red Fibrin Test. — Some fibrin from bullock's 
 blood is quickly washed free from all traces of colouring-matter, 
 this being important so as to avoid decomposition of the fibrin. 
 The fibrin is then dried with alcohol and ether, and stained with 
 an alcoholic solution of carmine-red until the colour does not 
 deepen. Any excess of carmine is removed by washing in water, 
 and the fibrin thus prepared is kept in glycerine. 
 
 Method of carrying out Test. — Three test-tubes are 
 prepared as follows : 
 
 (1) Four c.c. of filtered gastric contents. 
 
 (2) Two c.c. of filtered gastric contents and two c.c. of a four 
 per niille hydrochloric acid solution. 
 
 (3) Two c.c. of filtered gastric contents and two c.c. of distilled 
 water. 
 
 A small piece of carmine fibrin wliich has been washed clear 
 of glycerine is placed in each of the test-tubes, wliich are then 
 placed in a water-bath at 37° C, being taken out and shaken 
 every two or three minutes. The time when the fluid is 
 first coloured by carmine is noted. Pepsin, in the presence 
 of hydrochloric acid, dissolves the fibrin, converting it into 
 soluble fibrin, thus hberating the carmine which becomes 
 diffused through the fluid, and indicates that digestion has 
 commenced. 
 
 If pepsin and hydrochloric acid are present in the gastric 
 contents in normal amounts, it will be found that test-tube 
 No. 1 will show a red colouration in from three to five minutes. 
 In the event of tlie hydrochloric acid in the gastric contents 
 being normal, the additional quantity of hydrochloric acid in 
 test-tube No. 2 will tend to make it excessive, and thus 
 hinder digestion. 
 
 In hypohydrochloria, or in cases where the proenzyme and 
 not pepsin is present, test-tube No. 2 will show a red colouration 
 before the other test-tubes. 
 
 In hyperhydrochloria, it will be found that test-tube No. 3, 
 which has been diluted with water, will show distinct digestion 
 of the fibrin before test-tubes Nos. 1 and 2, since the pep'iin will 
 not act as rapidly if hydrochloric acid is in excess in the gastric 
 contents. 
 
38 GASTRIC DISEASES 
 
 As examples of these three conditions, we will give three 
 typical cases. 
 
 (A) Euchlorhydria. 
 
 (1) Red colouration in 3 to 5 minutes, 
 
 (2) Red colouration in 3 to 5 minutes. 
 
 (3) Red colouration in 5 to 10 minutes. 
 
 (B) Hyperhydrochloria. 
 
 (1) Red colouration in 7 to 15 minutes. 
 
 (2) Red colouration in 3 to 7 minutes. 
 
 (3) Red colouration in 3 to 12 minutes. 
 
 (C) Hypohydrochloria. 
 
 (1) Red colouration in 10 to 30 minutes. 
 
 (2) Red colouration in 5 to 30 minutes. 
 
 (3) Red colouration in 30 to 120 minutes. 
 
 In practice we find that this carmine fibrin test is easily carried 
 out, and gives a great insight into the powers of digestion of the 
 gastric contents. Another advantage is the fact that the fibrin 
 can be prepared and kept for a long time, provided it is covered 
 with plenty of glycerine. 
 
 Quantitative Estimation of Pepsin. — For the 
 quantitative estimation of pepsin, more accurate methods are 
 required than the foregoing digestive method. 
 
 Leube's Method. — Two test-tubes of filtered gastric con- 
 tents are taken, and to each is added either carmine fibrin or 
 egg albumen, and to one a httle pepsin. If the proteid is 
 more rapidly digested in the test-tube to which pepsin has been 
 added, it shows that an insufficient quantity of pepsin is present 
 in the gastric contents. 
 
 In some cases in which hydrochloric acid is absent from the 
 gastric contents, the stomach appears to be excreting no pepsin, 
 though in reality pepsin is present in the form of its enzyme, 
 pepsinogen. Jaworsky ^ has recommended in such cases the 
 introduction, into the stomach of the fasting individual, of 200 
 c.c. of one-tenth normal hydrochloric acid solution ; half an 
 hour later, the stomach contents are removed, and the fluid 
 thus obtained tested for pepsin. 
 
 1 Zeitschr. /. Klin. Med., Bd. xi. p. 113. 
 
EXAMINATION OF GASTRIC CONTENTS 30 
 
 Mett's Method of Estimating- the Quantity of 
 Pepsin/ — A solution of white of ogg is sucked up into fine 
 glass tubes of 1 to 2 mm. lumen, and quickly coagulated by 
 plunging the tubes into hot water at 95° C. The tube thus 
 prepared is cut into small lengths, and placed in one or two 
 cm. of the fluid to be investigated. The whole is kept in a 
 thermostat at 37° C. After the termination of ten hours, the 
 length of the pieces of tube and that of the undigested remains 
 in the proteid column is measured off by the aid of a milUmetre 
 scale, a microscope of low-magnifying power being employed. 
 The difference gives the length of the digested proteid in milli- 
 metres and fractions of a millimetre. The quantity of pepsin 
 is the square of the albumen column dissolved in the same time. 
 If one of the fluids digests a column of 2 mm. of proteid, and 
 the other a column of 3 mm., the relative quantity of pepsin 
 in each is not expressed by the figures 2 and 3 respectively, 
 but by the squares of these figures, i.e., by 4 and 9. The second 
 fluid is, therefore, two and a quarter times stronger than the 
 first. 
 
 Rennet Ferment or Rennin. — The ferment next in 
 importance to pepsin is rennin, the analysis of which has been 
 very little utiHsed in the diagnosis of gastric diseases. 
 
 Hammarsten's Method. — Ten c.c. of unboiled milk 
 of neutral reaction are placed in a capsule, adding one or 
 two c.c. of previously filtered and neutralised gastric contents. 
 It is necessary not to add too great a quantity of gastric con- 
 tents, as the dilution of the milk may either hinder the rapidity 
 or interfere with the proper coagulation. The mixtiire is kept 
 at body temperature, and if rennin is present, the milk will in 
 ten to twenty minutes be coagulated into a sohd mass, without 
 any alteration in its chemical reaction. If the milk has been 
 too much diluted, there will be no firm clot even in the presence 
 of rennin, but only masses of floccuh settled at the bottom 
 of the vessel. 
 
 The diminution or absence of rennin in gastric catarrh has 
 been shown by Boas and Bouveret " to demonstrate how far 
 the gland tissue has been destroyed, and may be of value in 
 
 1 Pawlow's " The Work of the Digestive Glands " (translated by W. H. 
 Thompson), 1902, p. 26. 
 
 2 Gaz. Med. de Paris, 1893, No. 22. 
 
40 GASTRIC DISEASES 
 
 coming to a conclusion as to the degree of recovery one may 
 expect in such cases from proper treatment. It is found that 
 the quantity of rennin as a general rule rises and falls with 
 the quantity of pepsin. Up to the present, most cHnicians 
 have been content with estimating the peptic action of the 
 gastric contents, and have neglected the rennet ferment. 
 
 Lipase : Fat-splitting Ferment of the Stomach. — 
 The normal stomach contains, in addition to pepsin and rennin, 
 the ferment hpase, which is capable of breaking up neutral fat 
 into fatty acids and glycerine. Some of the fat acids are then 
 further saponified in the stomach. 
 
 Recognition of Lipase. — Some ohve-oil is shaken up 
 with sodium hydrate in a test-tube, and the oil decanted so that 
 it has an alkaline reaction, since ordinary ohve-oil generally 
 contains some free fatty acids. Litmus solution or some other 
 indicator is added to some of the neutral ohve-oil in two test- 
 tubes ; to one of these some previously filtered and neutrahsed 
 gastric contents are added, and to the other an equal quantity 
 of water. The two test-tubes are then well shaken and placed 
 in a water-bath at 37° C, the tubes being periodically shaken. 
 If lipase is present, the test-tube containing the gastric contents 
 and the olive-oil will gradually show an acid reaction by turning 
 the litmus red. So far, no experiments have been done on the 
 presence or absence of lipase in different diseases of the stomach. 
 
CHAPTER VII 
 
 CHEMICAL EXAMINATION OF GASTRIC CONTENTS {continued)— 
 GAS FERMENTATION IN STOMACH 
 
 Under normal conditions, a certain amount of air is swallowed 
 with the food, and apparently some carbonic acid is given off 
 from the blood-vessels of the stomach wall itself, while it is 
 possible that some gas passes from the intestine through the 
 pylorus into the stomach. The quantity of gas present in the 
 stomach under ordinary circumstances is so small that it is 
 unnoticed by the individual. The swallowing of gas, on the 
 other hand, may cause the patient to eructate large quantities, 
 this being especially seen in nervous eructation. In such cases, 
 the air is swallowed cither into the CESophagus or into the 
 stomach itself, and later eructated with loud reports. This 
 nervous eructation is one of the manifestations of a neurotic 
 taint, and can be easily recognised by the facts that the repeated 
 gas has neither taste nor odour, and that on placing a cork 
 between the molars, the eructation ceases. 
 
 The gases found in the stomach are nitrogen, carbonic acid, 
 oxygen, and sometimes, hydrogen, while under pathological 
 conditions, sulphuretted hydrogen or marsh gas may occur. A 
 rough analysis of the gases of the stomach can be easily carried 
 out. 
 
 A eudiometer is filled with gastric contents, inverted over 
 water — or better, mercury — and kept for twenty-four hours 
 at 37° C. The gas which collects in the eudiometer can be first 
 examined for carbonic acid by inserting a strong solution of 
 sodium hydrate, and measuring what amount of gas has been 
 absorbed. Some pyrogallic acid is then added, which will dis- 
 solve any oxygen present, and if necessary, the hydrogen 
 can be estimated by sparking (after the addition of some pure 
 oxygen), and the nitrogen estimated by the residue . Sulphuretted 
 hydrogen can be recognised by inserting some lead acetate 
 
42 GASTRIC DISEASES 
 
 paper, which will become distinctly blackened if this gas is 
 present. 
 
 The chemical examination of the gases of the stomach is of 
 little importance for clinical purposes. 
 
 The formation of gas in the stomach, or gas reaching the 
 stomach from the intestine, may be so much increased as to 
 produce marked symptoms — sometimes becoming even the 
 chief symptom complained of by the patient. 
 
 In pyloric stricture, owing to the putrefaction of the proteids 
 in the stomach, one may obtain large quantities of sulphuretted 
 hydrogen which may be very objectionable to the patient on 
 account of the odour. As a pathological novelty which has 
 several times been observed, a patient may eructate inflammable 
 gas, and cases have been described where patients have been able 
 to ignite the eructated gas at the end of a cigar-holder. Boas ^ 
 states that sulphuretted hydrogen is more often present in 
 benign disease of the stomach, while, where there is gas formation 
 due to mahgnant disease, it is almost invariably absent. 
 
 In some cases the patient eructates marsh gas, this gas being 
 formed by the decomposition of the cellulose ; but it is still a 
 question whether it can be formed in the stomach itself, or 
 whether — as seems more probable — it reaches the stomach from 
 the intestines, 
 
 1 Deut. Med. Wochenschr., 1892, No. 49. 
 
CHAPTER VIII 
 
 ORGANIC DISEASES OF THE STOMACH— ACUTE, CHRONIC AND 
 ALCOHOLIC CATARRH, ACHYLIA GASTRICA 
 
 Gastric catarrh is very commonly diagnosed, and probably in 
 practice many cases of fmictional disease of the stomach have 
 been erroneously included under this heading. 
 
 True gastric catarrh is accompanied by structural changes 
 in the stomach wall, so that one has an inflammatory process 
 to deal with. In the mildest forms, it may be merely an 
 inflammatory desquamation of the epithelium covering the 
 mucous membrane of the stomach, while in more severe cases 
 the inflammation extends into the glandular parenchyma. In 
 even more advanced cases, it extends into the fibrous tissue of 
 the stomach wall itself. 
 
 Gastric catarrh may, for the sake of convenience, be divided 
 into acute and chronic, according to the intensity and duration 
 of the disease, but it must be remembered that the dividing-line 
 between the two is purely arbitrary. 
 
 The general symptoms of gastric catarrh have not here to be 
 dealt with, but merely the alterations in the activity of the 
 secretions of the stomach, as shown by the examination of the 
 vomited matter, or more definitely and accurately determined 
 by the analysis of the gastric contents after a test meal. 
 
 In the normal stomach, neither the vomited matter nor the 
 gastric contents after a test meal contain mucus in any large 
 quantity. Schlile ^ considers that mucus is present in the 
 normal stomach on a carbohydrate diet, while Heidenhain has 
 shown that mucus only occurs in very small quantities in 
 carnivora, and in larger quantities, in herbivora. 
 
 The normal quantity of mucus present in a healthy stomach 
 cannot be easily recognised in the gastric contents obtained 
 after an ordinary test breakfast. Where there is a diminution 
 1 Zeitschr. /. Klin. Med., Bd. xxviii. p. 481. 
 
44 GASTRIC DISEASES 
 
 of hydrochloric acid, Schmidt ^ has shown that one finds glassy 
 swollen lumps resembling saliva, while, if hydrochloric acid is 
 present in normal, or even increased quantities, the mucus 
 has a filamentous, flocculent, or shreddy appearance. It has 
 been shown that nmcus takes twice the time for digestion that 
 an equal quantity of albumen requires. 
 
 It is necessary to make certain that the mucus found in the 
 stomach contents really comes from the stomach, and not from 
 the other passages. The mucus from the back of the pharynx 
 or nares can easily be recognised by its darkened colour, being 
 stained more or less by carbon in town-dwellers, while that 
 coming from the sahva will be found, not intimately mixed 
 with the gastric contents, but distinctly separate. In all cases 
 of gastric catarrh, one will find more mucus than the mere 
 trace found in a healthy stomach, and much more than is found 
 in any other stomach disease, except possibly mucoid gastritis, 
 (if it is considered desirable to separate tliis from the ordinary 
 chronic gastritis). In the majority of cases of gastritis, one may 
 expect to find the gastric secretions — with the exception of 
 mucin — to be decreased, the ferments being also decreased. 
 When atrophy of the mucous membrane has set in, not only 
 hydrochloric acid, but also ferments, entirely disappear from 
 the gastric contents. In consequence of the decrease of hydro- 
 chloric acid and pepsin in cases of gastric catarrh, the proteid 
 digestion is diminished. In most cases of catarrh, hydrochloric 
 acid is not entirely absent, and there is a small quantity of pepsin 
 present, which explains the partially digested food in the vomit ; 
 the digestion of starch taken in the diet is little, if at all, 
 interfered with. As already stated, the excretion, of remiet 
 ferment, as a rule, runs parallel with that of hydrochloric acid 
 and pepsin, and, according to Boas and Bouveret," the quantity 
 of rennin present in gastric catarrh is of very great clinical 
 importance in deciding the intensity and prognosis of the disease. 
 The organic acids tend to be slightly increased in cases of catarrh 
 of the stomach, and these acids are very considerably increased 
 when, in addition to the catarrh, one has some stagnation of the 
 gastric contents. In hardly any cases of simple catarrh of the 
 stomach is there a large quantity of lactic acid found, though 
 
 1 Ikulsch. Archiv. Klin. Med., vol. Ivii. p. 72. 
 
 2 Loc. cit. i>. 39. 
 
ORGANIC DISEASES OF THE STOMACH 45 
 
 there is considerable increase of butyric and other fatty acids ; 
 and this distinguishes simple catarrh of the stomach from catarrh 
 accompanying malignant disease of the stomach. 
 
 ACUTE GASTRITIS 
 
 The vomit in acute gastritis consists of undigested residue 
 of food mixed with mucus, and often has an unpleasant taste, 
 even when the emesis does not occur until some hours after the 
 last meal. If the vomiting has been frequent, the residue of 
 food becomes less and less, until the later vomits may consist 
 entirely of mucus, more or less bile-stained. 
 
 The chemical examination of the vomit in acute gastritis 
 shows an acid reaction, although the total acidity is never verv 
 high ; and in cases where there has been frequent vomiting, the 
 later vomits may be neutral, or even faintly alkahne. The 
 tests for free hydrochloric acid, as a rule, are negative, although 
 one sometimes obtains a feeble reaction. On the other hand, 
 the organic acids, more especially butyric and acetic acids, will 
 be found to be increased. Bile is often present, and when the 
 emesis has been frequent the vomit may contain merely bile- 
 stained mucus, which gives a very distinct reaction ^vith cold 
 nitric acid for bile pigments. 
 
 Blood in small quantities is not uncommonly found in acute 
 gastric catarrh. The gastric juice, by its action on the haemo- 
 globin, has, however, generally converted most of the blood 
 present into hsematin, and when only small quantities are 
 present, it may be impossible to recognise it without chemical 
 means. If some of the brown mass is collected in a pipette, and 
 dissolved in sodium hydrate, after filtration and the addition 
 of ammonium sulphide, it can be examined by the spectroscope 
 for hsemochromogen, when, in an alkahne solution, one obtains 
 two absorption bands — a marked band between D and E (550-4 
 wave length), and the second band, which is not so dark, between 
 E and b (520-4 wave length). 
 
 The first severe symptoms having passed of?, a more thorough 
 analysis of the alterations in the gastric secretions can be obtained 
 after the administration of a test breakfast. The toast appears 
 very little altered, and looks as if it had been simply swallowed, 
 mixed with a certain amount of mucus. 
 
46 
 
 GASTRIC DISEASES 
 
 The breaking up of particles of food in the healthy stomach 
 is in great part due to the churning movements of the stomach 
 wall, by means of which the gastric secretions are intimately 
 mixed vnth. any sohd contents, the mechanical action at the 
 same time kneading the contents into a homogeneous consistency. 
 In acute catarrh of the stomach, there is a deficiency of both 
 the gastric secretions and motor-power of the stomach wall- 
 hence the appearance of the gastric contents. 
 
 TABLE 11. 
 
 ANALYSIS OF GASTRIC CONTENTS IN ACUTE 
 GASTRIC CATARRH 
 
 Case. 
 
 Qualitative. 
 
 Quantitative. 
 
 D 
 
 gestion 
 
 i 
 1 
 
 y 
 
 ■6 
 1 
 
 ^3 
 3 2 
 
 
 ■3 ? 
 
 ^1 
 
 
 HCl. 
 
 inmiuutes b). 
 
 "5 
 
 I 
 
 i 
 
 1 
 
 S 
 
 1 
 
 2 
 
 3 
 
 C. .5.5 
 F. 60 
 W. 89 
 
 acid 
 acid 
 acid 
 
 
 
 
 
 + 
 + 
 + 
 
 + 
 + 
 + 
 
 + 
 + 
 
 + 
 
 24 
 30 
 
 44 
 
 7 
 7 
 11 
 
 0-16 
 0-19 
 0-28 
 
 O'OO 
 0-00 
 0-00 
 
 0-02 
 0-04 
 0-18 
 
 0-14 
 0-1.5 
 
 0-10 
 
 
 10 
 
 
 
 
 4 
 
 
 
 15 
 
 
 (a) Expressed in c.c. of ^ N. solution of NaOH. 
 (6) 1. Filtered Gastric contents and carmine fibrin. 
 
 and equal quantity 0-4 p.c.HCI. 
 „ of water. 
 
 In Table II. the analysis after a test breakfast of three cases 
 of acute gastric catarrh is given. In these three cases it so 
 happens that the reaction is acid, although it is not uncommon 
 to find it neutral. 
 
 Qualitative Analysis. — The chemical tests for free hydro- 
 chloric acid gave no reaction in any of the three cases, which 
 is what is to be expected in acute gastritis, though one occasion- 
 ally obtains a trace. 
 
 Lactic acid is, as a rule, found to be present where the ordinary 
 test breakfast has been given, and it is essential to give Boas's 
 oatmeal soup if one wishes to compare the results Avith what 
 will be found in cases of carcinoma of the stomach. Butyric 
 acid was present in the three cases given above, and this is the 
 general rule, although we have sometimes known it absent. 
 
 Mucus is found to be present in considerable quantities ; in 
 
ORGANIC DISEASES OF THE STOMACH 47 
 
 some cases it is extremely frothy, and the gastric contents 
 contain bubbles in the mucus, while on other occasions, one 
 finds not so much gas, though the mucus is always intimately 
 mixed throughout the fluid. 
 
 Quantitative Analysis. — The total acidity will be found 
 after test breakfasts to be always, comparatively speaking, low, 
 varying in the three cases which we have given as types from 
 24 to 44. 
 
 The volatile acids are, as a rule, increased, varying from 5 
 to 15, while in the cases we have given, they vary from 7 
 to 11. In cases of acute gastric catarrh, where there are 
 complications, such as pyloric obstruction with considerable 
 stagnation of the gastric contents, the volatile acids may be 
 very much higher than these figures. 
 
 Quantitative Analysis of Hydrochloric Acid.— The 
 Prout-Wynter method shows that the total quantity of hydro- 
 chloric acid varies from O'lG to 0'28 per cent., the tendency being 
 towards the lower figure. In the three cases we have used as 
 types, free hydrochloric acid was absent, and if present, the 
 quantities will be extremely small. Hydrochloric acid combined 
 with proteids is seen in the first two of these cases to be low, 
 0-02 and 0-04 per cent., and only in the last case, where there 
 is the highest total acidity, does the proteid acidity reach 0-18 
 per cent. The chlorine combined with the minerals is large in 
 amount in the first two cases, 0"14 and 0'15 per cent., while in 
 the last case, where the total hydrochloric acid was found to be 
 highest, it is 0"10 per cent. In fact, in the first two analyses, 
 nearly all the chlorine present in the stomach contents is com- 
 bined with the minerals. 
 
 Digestion. — One at once obtains a clue as to the presence or 
 absence of pepsin or pepsinogen in making digestive tests with 
 carmine fibrin. In two of the cases given, we find that there is 
 no digestion of the fibrin in any of the tubes even up to the 
 lapse of thirty minutes, so that we can say that neither pepsin nor 
 pepsinogen was present in these two cases. In the other case, 
 test-tube No. 1 (containing gastric contents and fibrin alone), 
 showed the first signs of digestion after ten minutes, while test- 
 tube No. 2 (containing gastric contents and an equal quantity 
 of four per mille hydrochloric acid) showed the first appearance 
 of digestion in four minutes. In test-tube No. 3 (to* which an 
 
48 GASTRIC DISEASES 
 
 equal quantity of water was added), digestion was delayed for 
 fifteen minutes. It is seen that in this case the hydrochloric 
 acid was diminished, and digestion did not occur at all rapidly 
 except with the addition of hydrochloric acid ; but since digestion 
 did occur in test-tubes 1 and 3 after a certain length of time, 
 pepsin was present as pepsin and not only as pepsinogen, the 
 delayed digestion being entirely due to the lack of hydrochloric 
 acid. The fact that in the case in which most hydrochloric acid 
 was present there was no digestion with the fibrin test, is of 
 interest, as it shows that neither pepsin nor pepsinogen were 
 present. In this case the analysis was carried out during 
 an attack of acute catarrh in a patient who was probably 
 suffering from chronic alcoholic catarrh ; hence the difference 
 of analytical results in this case from the first two, in which there 
 was only simple acute gastric catarrh. 
 
 CHRONIC GASTRITIS 
 
 The quantity of the vomit in chronic gastritis is never very 
 large, and considering the regularity of the vomiting, is quite 
 remarkable for its smallness. In severe cases, one finds remnants 
 of undigested food looking as if they had been simply swallowed ; 
 the particles are intimately mixed with mucus, so that the thick 
 slimy gastric contents can only with great difficulty be poured 
 from one vessel to another, and in some cases where the vomit 
 is very small in amount, it will adhere so firmly to the vessel 
 that the latter can be turned upside down without upsetting 
 the contents. The mucus produced in the stomach is always 
 intimately mixed with the fluid together with some balls or 
 flakes, while the mucus coming from the mouth, pharynx, or 
 nares floats in stringy masses in the gastric contents. Only in 
 washing out an empty stomach does one find, in chronic gastritis, 
 flocculi of mucus which have been washed away from the stomach 
 wall, and deposited at the bottom of the vessel receiving the wash- 
 water. Not only is the examination of the gastric contents 
 after a test meal of importance in chronic gastritis, but it is well 
 also to examine the morning vomit or the water used in washing 
 out the fasting stomach. This will be found to be rich in mucus, 
 with a feebly acid or neutral reaction, as a rule containing no 
 free hvdrochlorio acid. 
 
ORGANIC DISEASES OF THE STOMACH 49 
 
 The microscopic examination of the vomit may reveal numerous 
 epithehal cells and nuclei mixed up in the mucus, and, in some 
 cases, fragments of gland tissue may be found. Einhorn^ lays 
 great stress on the presence of small particles of mucous mem- 
 brane in the wash- water, which are not due to any injury pro- 
 duced by the stomach-tube, but are the products of a special 
 form of catarrh of the stomach accompanied by erosion. In 
 some cases one finds pus on microscopic examination, and it 
 is important to consider whether the stomach itself is the source. 
 In severe infectious diseases, such as puerperal fever, empyema, 
 &c., it is possible that interstitial purulent inflammation of the 
 stomach may be present ; still further, where a tumour has 
 been felt in the region of the stomach and has become smaller 
 or disappeared, one may have to deal with gastric abscess or 
 perforation of an abscess, or perforation of an abscess from 
 some neighbouring viscus into the stomach. 
 
 In cases of chronic gastric catarrh, there is often a certain 
 amount of diminished motility, which will produce objective 
 signs in the vomit or test meal, such as the remains of former 
 meals. In rare cases one gets increased motility, causing the 
 ingesta to pass on to the intestine in a shorter period than 
 normal. In such cases, on passing the tube at the ordinary 
 time after a test meal, the stomach will be found to be empty. 
 
 The quantity of gastric contents after a test breakfast will be 
 found to vary very much, according to whether there is delayed 
 motility or not. In the five cases which we have taken in 
 Table III. to illustrate the condition, the quantity varied from 
 70 to 200 c.c. ; the general tendency, however, is for the 
 quantity to be small. 
 
 The reaction in most cases will be found to be feebly acid, 
 although on occasion it may be neutral (such cases have not 
 come under our observation). 
 
 Qualitative Analysis. — The test for free hydrochloric 
 acid gives, as a rule, a very feeble reaction, and generally fails, 
 as in three of the cases given. 
 
 If Boas's oatmeal soup has been given, lactic acid is absent, 
 
 or in any case, will be very small in amount. This is of great 
 
 importance when we consider that many chronic gastric catarrhs 
 
 yield chemical analyses very closely resembling those of catarrh 
 
 ^ Einhorn, " Diseases of the Stoniuch," 2nd edit. 189S. 
 
 D 
 
50 
 
 GASTRIC DISEASES 
 
 accompanying carcinoma of the stomach ; while in the latter, 
 the presence of excessive quantities of lactic acid will help to 
 confirm the diagnosis, the absence or small quantity of lactic 
 acid will enable one to recognise a case of simple chronic gastric 
 catarrh. 
 
 TABLE 
 
 IIL- 
 
 -ANALYSIS 
 
 OF GASTRIC CONTENTS IN 
 
 CHRONIC 
 
 
 
 
 GASTRIC CATARRH 
 
 
 
 
 Qiu 
 
 ilitat 
 
 ve. 
 
 
 Quantitative. 
 
 Digestion in 
 minutes (6). 
 
 
 
 
 
 
 
 
 
 Case. 
 
 1 
 1 
 
 
 12 
 
 1 
 
 1 
 
 H 
 
 
 
 If 
 
 HCl. 
 
 
 Total. ^ 
 Free. 
 
 Proteid. 
 Mineral. J 
 
 1 
 
 2 
 
 3 
 
 H. K. 3 
 
 acid 
 
 
 
 + 
 
 + 
 
 + + 
 
 22 
 
 16-6 
 
 0-17 0-01 
 
 1 
 0-08l0-08 
 
 
 
 17 
 
 
 
 C. .-iO 
 
 acid 
 
 
 
 + 
 
 + 
 
 + 
 
 45 
 
 5-2 
 
 o-is' 0-00 
 
 0-05 
 
 0-10 
 
 
 
 15 
 
 
 
 P. 38 
 
 acid 
 
 + 
 
 - 
 
 + 
 
 -t- 
 
 54 
 
 11 
 
 0-25 0-01 
 
 0-17 
 
 0-07 
 
 12 
 
 10 
 
 
 
 D. 71 
 
 acid 
 
 - 
 
 - 
 
 + 
 
 + 
 
 54 
 
 6 
 
 0-25 Trace 
 
 0-18 
 
 0-07 
 
 14 
 
 3 
 
 17 
 
 U. 79 
 
 acid 
 
 
 
 - 
 
 + 
 
 + + 
 
 20 
 
 11 
 
 0'26 U-00 
 
 1 
 
 0-06 
 
 0'20 
 
 
 
 22 
 
 
 (a) Expressed In c.c. ol ^^ N. solution of NaOH. 
 (fi) 1. Filtered Gastric contents and carmine tibrin. 
 
 2. „ 
 
 3. 
 
 and equal quantity 0'4 p.c. IICI. 
 „ „ of water. 
 
 In most cases of chronic gastric catarrh, butyric acid is found 
 to be j)resent in the stomach, sometimes in fairly large amounts. 
 
 In all cases, as has already been stated, mucus in excessive 
 quantity is found. 
 
 Quantitative Analysis. ^The total acidity varies from 20 
 to 54 in the cases which we have chosen as examples ; the 
 tendency is to be low, and when one considers how much of tliis 
 acidity is due to volatile acids, one sees that the total quantity 
 of hydrochloric acid and acid phosphates is very small indeed. 
 
 The volatile acids are increased, varying from 5-2 to 16-6 : 
 where there is delayed motility, a larger quantity of volatile 
 acids is generally found. 
 
 Quantitative Analysis of Hydrochloric Acid. — 
 The total hydrochloric acid, as estimated by the Prout-Wynter 
 method, is low, varying from O'lS to 020 per cent. Free hydro- 
 chloric acid is, as a rule, not present, although it may be as much 
 as OOl per cent. The general tendency in cipcs of chronic 
 
ORGANIC DISEASES OF THE STOMACH 51 
 
 gastric catarrh is for the hydrochk)ric acid combined with tiie 
 proteids to be extremely low (although not so much so as is found 
 in acute catarrh), the amounts varying between 005 and 0'18 
 per cent. The ihlorine combined with the minerals is not found 
 to be increased, varying from 007 to O'lO per cent., and only in 
 one case is it as high as 0'2() per cent. 
 
 Digestion. — The carmine fibrin test shows the digestive 
 powers in all cases to be decreased ; in the majority of cases, 
 there is no digestion whatever of carmine fibrin, except with the 
 addition of four per mille hydrochloric acid. In two of the 
 examples which we have taken for illustration, there was 
 digestion in twelve to fourteen minutes, and with the gastric 
 contents alone. There was no digestion in test-tube No. 3 (in 
 which the gastric contents were diluted with water), except in 
 one case where there were signs of digestion after seventeen 
 minutes. In the cases which we have taken as types, we find 
 the digestion in test-tube No. 2 (to which four per mille hydro- 
 chloric acid was added), to vary from three to twenty-two 
 minutes. It would, therefore, appear that in all these cases 
 either pepsin or pepsinogen was present, although in some cases 
 of chronic gastric catarrh — more especially those which have 
 advanced very considerably — even pepsinogen may be absent, 
 and in these cases, rennin will also be absent. 
 
 Further examination of these cases showed that in one case 
 blood in small amount was present (being only identified by 
 chemical means), and the microscopic examination showed, in 
 some cases, masses of epithelial cells entangled in mucus. 
 
 ALCOHOLIC CATARRH 
 
 We can now discuss four cases of chronic catarrh in alcoholic 
 subjects. These are of interest as showing analyses differing 
 from those of ordinary catarrh, and if further observers confirm 
 these results, they will be of value in helping to diagnose chronic 
 gastric catarrh of alcohohc origin. 
 
 The quantity of gastric contents in these four cases, see 
 Table IV., was small, as one finds in ordinary catarrh. 
 
 The reaction in all cases was acid. 
 
 Qualitative Analysis. — Free hydrochloric acid was found 
 to be present, giving a distinct reaction. 
 
 The volatile acids, acetic and butyric, were found to be in- 
 
52 GASTRIC DISEASES 
 
 creased. Lactic acid was not especially sought for by Boas's 
 oatmeal soup, but butyric acid was very evident by the odour 
 and was also demonstrated by chemical tests. 
 
 As in all cases of ordinary gastric catarrh, mucus was present ; 
 but in these cases it seemed to be thicker and of a more tenacious 
 consistency than is foimd in simple catarrhs. 
 
 TABLE IV.— ANALYSIS OF GASTRIC CONTENTS IN 
 ALCOHOLIC CATARRH 
 
 
 
 Qualitative. 
 
 
 Quantitative. 
 
 
 
 
 
 
 
 
 
 
 Diijestiou ia 
 miuutes (6). 
 
 
 
 
 
 
 
 
 
 
 Case. 
 
 o 
 1 
 
 o 
 
 .a 
 1 
 
 
 § 
 
 s 
 
 S 
 
 
 If 
 
 HCl. 
 
 
 
 1 
 
 
 1 
 
 1 
 
 i 
 
 1 
 
 2 
 
 3 
 
 P. 24 
 
 acid 
 
 + 
 
 — 
 
 + 
 
 + + 
 
 88 
 
 11 
 
 0-32 
 
 0-02 
 
 0-15 
 
 0-15 
 
 7 
 
 5 
 
 ' 
 
 K. 36 
 
 acid 
 
 + 
 
 - 
 
 + 
 
 + + 
 
 76 
 
 IG 
 
 0-27 
 
 0-02 
 
 0-18 
 
 0-07 
 
 5 
 
 5 
 
 8 
 
 G. 91 
 
 acid 
 
 + 
 
 - 
 
 + 
 
 + + 
 
 88 
 
 12 
 
 0-37 
 
 0-02 
 
 0-26 
 
 0-09 
 
 5 
 
 8 
 
 4 
 
 H. 95 
 
 acid 
 
 + 
 
 - 
 
 + 
 
 1 
 
 7 
 
 0-36 
 
 0-01 
 
 0-25 
 
 0-10 
 
 13 
 
 12 
 
 15 
 
 (a) Expressed in c.c. of ^ N. solution ol NaOH. 
 0) 1. Filtered Gastric contents and carmine tibrin. 
 
 2. „ „ „ „ 
 
 3. 
 
 equal quantity 0'4 p.c. HCl. 
 ,, of water. 
 
 Quantitative Analysis. — The total acidity varied from 
 76 to 88, showing a distinct increase, even when one com- 
 pares it with the normal gastric contents, the increase being 
 more marked in comparison with the total acidity wliich one 
 finds in simple chronic catarrh. 
 
 The volatile acids varied from 7 to 16, showing an increased 
 fermentation in the stomach. 
 
 Quantitative Analysis of Hydrochloric Acid. -The 
 total quantity of hydrochloric acid varied in the four cases from 
 0'27 to U"37 per cent., corresponding with what one usually finds 
 in the analysis of normal gastric contents. The quahtative 
 analysis for free hydrochloric acid gave a distinct reaction, and 
 the quantitative analysis of all the cases indicated the figure 
 0"02 per cent., except one (001 per cent.), a peculiar coincidence, 
 showing only a very slight decrease from the quantity of free 
 hvdrocliloric acid one usuallv finds in health after a test break- 
 
ORGANIC DISEASES OF THE STOMACH 53 
 
 fast. The quantity of chlorine combined with proteids varied 
 from 0"15 to 0"2() per cent., resembhng the quantity of proteid 
 hydrochloric acid found in healthy individuals, and which we 
 have found in cases of ordinary gastric catarrh. The quantity 
 of chlorine combined with the minerals varied from 0'07 to ()'15 
 per cent. 
 
 Digestion. — In three of the four cases one sees that the 
 digestion was fairly rapid, in fact, two of the test-tubes showed 
 digestion well within normal limits, and from the results obtained 
 by the digestion of fibrin alone, one certainly would not be able 
 to detect the presence of any pathological condition. In one 
 case the digestion was distinctly delayed, and in test-tube No. 2, 
 even after the addition of four per mille hydrochloric acid, it 
 took twelve minutes as against tube No. 1 with gastric contents 
 alone, which required thirteen minutes. So one sees that the 
 delayed digestion is not due to pepsinogen only being present, 
 but to a decrease in the activity of the pepsin. This case is 
 of especial interest as it occurred in a beer taster. 
 
 It would appear that in chronic gastric catarrh of alcoholic 
 origin, there is a greater proportion of mucus than can be ac- 
 counted for by the diminution in the quantity of gastric secretion, 
 as indicated by the quantity of hydrochloric acid or pepsin. We 
 have a tendency to mucus catarrh, if one is to consider that such 
 a thing exists, and if there is destruction of the glandular cells in 
 the stomach in alcoholic catarrh, it would appear that the active 
 cells secrete hydrochloric acid and pepsin to an excessive degree. 
 One can consider that in alcohoUc catarrh there is, in addition 
 to the catarrhal process going on in the stomach, a hyper- 
 hydrochloria which accounts for the results obtained by analysis. 
 
 ACHYLIA GASTRICA 
 
 Chronic gastric catarrh may be completely cured or may 
 slowly pass, with destruction of the glandular elements of the 
 mucous membrane, into atrophy of the stomach, Fen\vick ' 
 considered that there is a form of atrophy of the stomach as 
 a disease — sui generis — leading to a condition very much 
 resembling pernicious anaimia. Einhorn " states that the 
 microscopic examination of the debris found in the wash-water 
 1 Lancet, 1877. 2 '• Diseases of the Stomach," 2nd edit. 1898. 
 
54 
 
 GASTRIC DISEASES 
 
 of cases of achylia gastrica reveals portions of mucous membrane 
 with some normal glands still present. He describes a case 
 which lasted for five years, and then slowly recovered ; the 
 secretory acidity increasing so that the food was more or less 
 digested, and hydrochloric acid gradually appearing in the 
 gastric contents. He attributes this case of achylia gastrica, 
 not to total absence of the gastric secretory glands, but to 
 nervous disturbance, inhibiting for the time being the secretion 
 of both hydrochloric acid and pepsin. 
 
 The gastric contents, after a test breakfast, have a brownish- 
 white colour, and on standing, quickly separate into two layers, 
 the upper an almost colourless fluid, and the lower a brown mass 
 of solid particles of food, the toast being distinctly irregular in 
 shape, and appearing not to have been acted on by digestion. 
 There is very little finely divided material such as one finds in 
 healthy gastric contents after a test breakfast, and as a rule. 
 
 TABLE V, 
 
 -ANALYSIS OF GASTRIC CONTENTS IN 
 ACHYLIA GASTRICA 
 
 
 
 Qualitative. 
 
 
 
 
 QuantitUive. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 IJigestion in 
 minutes (6). 
 
 
 
 
 
 
 ^ 
 
 ^ 
 
 
 
 
 Case. 
 
 .1 
 
 s 
 
 "3 
 
 1 
 
 X 
 
 s 
 
 2 
 
 2 
 
 e4 
 
 
 HCl. 
 
 
 
 
 
 
 
 
 
 
 
 
 ? 
 
 K 
 
 ■■g 
 
 
 9 
 
 
 
 — • 
 
 (J 
 
 .s 
 
 s 
 
 
 
 
 
 W 
 
 
 a 
 
 3 
 
 
 ? 
 
 cS 
 
 t 
 
 ii 
 
 •; 
 
 ^ 
 
 1 
 
 2 
 
 3 
 
 
 
 
 '"' 
 
 « 
 
 
 o 
 
 ^ 
 
 H 
 
 
 £ 
 
 % 
 
 
 
 
 
 T. 49 
 
 acid 
 
 
 
 
 
 
 
 
 
 15 
 
 3-6 
 
 
 — 
 
 — 
 
 — 
 
 
 
 
 
 C.49 
 
 acid 
 
 
 
 + 
 
 + 
 
 + 
 
 40 
 
 - 
 
 0-15 
 
 0-00 
 
 0-0 7 
 
 0-08 
 
 
 
 
 
 
 
 M. 66 
 
 icid 
 
 trace 
 
 
 
 
 
 + 
 
 40 
 
 6 
 
 0-10 
 
 -00 
 
 0H13 
 
 0-«7 
 
 30 
 
 20 
 
 
 
 (rt) Expressed in c.c. of ^-^ N. solution of NaOH. 
 (i) 1. Filtered Gastric contents and carmine fibri 
 
 ecjual quantity oi p.p. HCl. 
 „ of walcr. 
 
 there is no increase in the quantity of mucus. The odour is 
 not at all unpleasant, resembling in fact the food before it was 
 introduced into the stomach. 
 
 In the above table we have given three cases, illustrative of 
 achylia gastrica. The first is a typical case of the condition, which 
 was verified by post-mortem three years later. The last case, 
 although the analysis is not entirely in favour of achylia gastrica. 
 
ORGANIC DISEASES OF THE STOMACH 55 
 
 has been included because the blood examination in this patient 
 showed results exactly similar to those one finds in pernicious 
 ansomia, and therefore the case ought to be included in this group. 
 
 Tiie reaction in most cases will be found to be very feebly acid. 
 
 Qualitative Analysis. — In typical cases of achylia 
 gastrica no reaction for free hydrochloric acid will be obtained, 
 although in the third case given above, the analysis showed a 
 trace of hydrochloric acid ; in two previous analyses, however, 
 of the same individual, no free hydrochloric acid had been found. 
 
 As a general rule the volatile acids are found not to be in- 
 creased unless there is delayed motility. Lactic acid, if present 
 at all, will be found only in traces. This is an important factor 
 in distinguishing achylia gastrica from carcinoma. In both con- 
 ditions we have a diminution or possible absence of hydrochloric 
 acid, but in malignant disease, one finds lactic acid in increased 
 quantities, whereas in achylia gastrica it is usually absent, or 
 only present in traces. Of the three examples, lactic acid was 
 only found to be present in one — after Boas's oatmeal soup. 
 
 Butyric acid appears to be, as a rule, absent, and is only 
 present in one of the three cases in our table. 
 
 Mucus, if present, is intimately mixed with the food, and 
 occasionally one sees long stringy masses which come from 
 the posterior nares or back of the throat. It should be 
 remembered that these patients often suffer from relaxed 
 throats, and in noting the amount of mucus present in the 
 gastric contents, this fact should be borne in mind. 
 
 Quantitative Analysis.- -The total acidity will be found 
 to be decreased. In cases where the condition has advanced to 
 complete atrophy of the mucous membrane of the stomach, the 
 total acidity may be as low as 4. In the case which was veri- 
 fied at the autopsy, the total acidity was found to vary from 
 10 to 16, and in the analysis given it was 15 ; in the other 
 two cases in which the disease was not so advanced, it was 40. 
 
 In achylia gastrica, the quantity of volatile acids is not, as a 
 rule, increased. In some cases, accompanied by dilatation of 
 the stomach, there may be an increase of volatile acids, but 
 even this would appear to be of rare occurrence. 
 
 Quantitative Analysis of Hydrochloric Acid. — 
 The Prout-Wynter method shows cither total absence of 
 hydrochloric acid in all its forms, or marked diminution. 
 
56 GASTRIC DISEASES 
 
 Unfortunately, in the case which was verified by post-mortem 
 later, a quantitative analysis was not done ; in the other two 
 cases we see that the total quantity of hydrochloric acid varied 
 from O'lO to 0*15 per cent. Free hydrochloric acid was 
 absent in both cases, and the proteid hydrochloric acid was 
 in one case only 03, while in the other it was 07 per cent. 
 
 The chlorine combined with the minerals was very low, being 
 0-07 and 0-08 per cent. 
 
 Digestion. — The carmine fibrin test showed, in the first and 
 second cases, a total absence of pepsin and pepsinogen. In the 
 third case, there was only very slight digestion in thirty minutes 
 in the test-tube containing gastric contents and fibrin alone, while 
 on the addition of four per mille hydrochloric acid, there was 
 digestion after twenty minutes. From the chemical analysis 
 alone, one might at first consider that this was a case of malignant 
 disease of the stomach, although against such a diagnosis was 
 the fact that the volatile acids were only slightly increased, and 
 still further, in three separate analyses, lactic acid was absent. 
 The general symptoms of the patient and a more detailed 
 examination of the urine and blood indicated pernicious anaemia, 
 while the fact that he Hved for five years after the analysis shows 
 the importance of taking into account all the symptoms and 
 other methods of diagnosis, since from the chemical analysis 
 of the stomach contents alone, a diagnosis of carcinoma of the 
 stomach imqlit have been made. 
 
 The motor-power of the stomach is, as a rule, normal. In the 
 first case after Riegel's test meal, the stomach was found to be 
 completely empty between the fourth and fifth hours, and this 
 patient suffered as a rule from no symptoms of indigestion, 
 except occasionally from flatulency. 
 
 On washing out a fasting stomach in an individual suffering 
 from achylia gastrica, it is not uncommon to find traces of blood 
 or particles of mucous membrane, showing that the stomach 
 walls are more easily wounded by the stomach-tube than in 
 health, and this was especially marked in the first case tabulated. 
 Schmidt^ and Riegel " state that large quantities of mucus may 
 be present in cases of achylia gastrica, but in the cases which 
 have come under our observation, this has not been confirmed. 
 
 1 Deut. Arch. /. Klin. Med., vol. Ivii. 
 
 2 Die Erkranknngcn des Mogcns, 18'J7, p. 61G. 
 
CHAPTER IX 
 
 ORGANIC DISEASES OF THE STOMACH {continued)— 
 GASTRIC ULCER 
 
 The symptoms of pain and vomiting in gastric ulcer, although 
 not strictly chemical, are of such importance as to necessitate 
 a few remarks before discussing the chemical analysis. 
 
 The typical pain of gastric ulcer is commonly supposed to 
 occur immediately after the food has been taken, while in practice 
 it is found that the pain occurs at various times ; it may be 
 immediately after food, or it may be delayed for two or three 
 hours. Numerous cases of undoubted gastric ulcer occur, in 
 which the first symptom is the vomiting of blood without any 
 pain, and therefore pain can only be considered as one of many 
 symptoms of ulceration of the stomach. 
 
 There is a tendency for the emesis to occur at the height of 
 the pain, whether it occurs immediately or two or three hours 
 after the ingestion of food, and unlike the emesis Avhich occurs 
 in hyperhydrochloria, the vomiting causes almost immediate 
 rehef. The vomiting in gastric hypersecretion, occurring as 
 it does at irregular intervals, and that of gastric ulcer occurring 
 at a more or less constant interval after the taking of food in 
 each special case, helps to differentiate these conditions, in spite 
 of the similar chemical analyses. 
 
 The vomit in cases of gastric ulcer shows a diflterent appearance 
 according to the quantity of food or the period of time which 
 has elapsed since it was taken. The longer the interval between 
 the taking of the food and the vomiting, the better digested 
 the stomach contents appear to be, the food often being very 
 finely broken up, thus indicating a good motility as well as an 
 active secretion. The vomit has a very acid taste, so that the 
 patient may complain of the sourness. 
 
 Haematemesis is of so great importance in the diagnosis of 
 gastric ulcer that one may regard it as the most ini])ortant sign, 
 
58 GASTRIC DISEASES 
 
 and unless it is present, or tlie history of a previous haemorrhage 
 has been obtained, it is difficult to diagnose a case as one of 
 gastric ulcer. We must remember that the finding of blood, 
 even in comparatively large quantities, is not invariably a sign 
 of gastric ulcer, as it may be due to circulatory changes either 
 in the stomach wall itself or the lower end of the oesophagus, 
 such as one finds in cirrhosis of the liver. 
 
 Blood, when present in large quantities in the vomit, may have 
 a normal bright red appearance, while if in small quantities, or 
 if it has been retained in the stomach for some time after the 
 heemorrhage has occurred, one gets the well-known coffee-ground 
 appearance. And in the latter case it may sometimes be neces- 
 sary to make a chemical analysis in order to recognise that it is 
 blood. Blood in gastric ulcer is, as a rule, present in more or less 
 large quantities, the ha3morrhage being generally accompanied 
 or preceded by some pain ; in a few cases, however, as already 
 mentioned, thexe may be hsemorrhage without any previous 
 symptoms to lead one to suspect the possibility of ulceration. 
 
 The total acidity of the vomited matter is generally increased, 
 and the tests for free hydrochloric acid give a very marked 
 reaction. When vomiting occurs immediately after the food 
 is taken, the hydrochloric acid is naturally not so much increased, 
 but even in these cases one obtains a reaction. Gastro-succhorea 
 not infrequently occurs with gastric ulcer, and may possibly 
 explain the reaction for free hydrochloric acid immediately after 
 the taking of food. 
 
 It is generally considered that the stomach-tube should not 
 be employed in cases of gastric ulcer, and it should not, as a rule, 
 be used immediately after a hemorrhage has occurred, although 
 in some cases of repeated haemorrhage the washing-out of the 
 stomach may be of great service. Possibly it is better not to 
 use it at all if a diagnosis can be made without it, but in 
 doubtful cases it would appear that there is little objection to 
 using it, provided ordinary care is taken. The chances of 
 injury are small, and there is certainly less danger of injury 
 being occasioned by a soft rubber tube than by the violent 
 retching caused by vomiting. 
 
 The stomach contents after a test breakfast — unless the ulcer 
 is situated at the pyloric end of the stomach, causing dilatation 
 of that organ — are not at all large in quantity. 
 
ORGANIC DISEASES OF THE STOMACH 
 
 59 
 
 In all cases a distinctly acid reaction is present. 
 
 Qualitative Analysis. -The test for free hydrochloric 
 acid shows an unmistakal>lc reaction, enabling one at once to 
 recognise that it is present, and in the majority of cases, the 
 test alone will indicate that it is in excess. 
 
 TABLE VI.— ANALYSIS OF GASTRIC CONTENTS IN 
 GASTRIC ULCER 
 
 
 
 Qu.'ilitativ 
 
 [?. 
 
 
 
 Quantitative. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Digestion in 
 minutes (6). 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 Ciifc. 
 
 1 
 
 5 
 
 1 
 
 1 
 
 
 1 
 
 2 
 
 1 
 
 2 
 1 
 
 
 IICl. 
 
 
 
 
 
 1 
 
 1 
 
 a 
 
 iS 
 
 1 
 
 2 
 
 3 
 
 H. 15 
 
 acid 
 
 + 
 
 
 
 ' 
 
 
 
 64 
 
 13-6 
 
 0-28 
 
 0-01 
 
 0-18 
 
 0-09 
 
 5 
 
 4 
 
 6 
 
 IT. 28 
 
 uiarkeil 
 acid 
 
 + + 
 
 
 
 
 
 
 
 94 
 
 3 
 
 0-42 
 
 0-02 
 
 U-29 
 
 0-11 
 
 4 
 
 4 
 
 4 
 
 F. 45 
 
 acid 
 
 + 
 
 - 
 
 + 
 
 + 
 
 118 
 
 15 
 
 0-40 
 
 0-12 
 
 0-20 
 
 0-08 
 
 2 
 
 4 
 
 2 
 
 E. 76 
 
 acid 
 
 + 
 
 - 
 
 + 
 
 + 
 
 88 
 
 6 
 
 0-40 
 
 0-04 
 
 0-28 
 
 0-08 
 
 2 
 
 2 
 
 2 
 
 H. 102 
 
 acid 
 
 + + 
 
 + 
 
 ^ 
 
 
 
 87 
 
 6 
 
 0-42 
 
 U-04 
 
 0-32 
 
 0-06 
 
 10 
 
 7 
 
 5 
 
 {fi) Expi-esscd ih c.c. of y'^f N. solution of NaOH. 
 (h) 1. Filtered (iristric contents and carmine libriu. 
 
 and equal (luantity (i-4 p.c. HCI. 
 „ „ of water. 
 
 The absence or presence of lactic acid in cases of gastric ulcer 
 seems of little importance. If Boas's oatmeal soup has been 
 given, lactic acid will not be present, though after an ordinary 
 test breakfast, a reaction may be obtained. Butyric acid is, as 
 a rule, absent, but in some cases — especially where dilatation 
 of the stomach accompanies the ulceration — one may obtain a 
 reaction. 
 
 As a rule mucus is not present in gastric ulcer, although 
 in some few cases it may be found ; it is never, however, present 
 in anything like the quantity accompanying gastric catarrh. 
 The cases in which mucus does occur can also be easily distin- 
 guished from gastric catarrh by the high total acidity which 
 occurs in gastric ulcer. 
 
 Quantitative Analysis. — In all cases where ulceration of 
 the stomach has been found to be active — as in the cases in the 
 
GO GASTRIC DISEASES 
 
 above table which have been demonstrated by operation during 
 the process of a gastro-enterostonomy — the total acidity is 
 found to be high, varpng from 87 to 118. In one case, in 
 which the gastric ulcer was latent, it is only 64 ; unfortunately 
 this case was not confirmed by operation, but haemorrhage and 
 other symptoms of gastric ulcer had preceded the analysis. 
 
 The volatile acids as a rule are very shghtly increased, although 
 in some cases where there is dilatation of the stomach, there 
 is a marked excess, as in two of the cases given above, which were 
 13-6 and 15 respectively. In the other cases, the volatile acidity 
 is seen to vary from 3 to 6. 
 
 Quantitative Analysis of Hydrochloric Acid.— In 
 all the cases of gastric ulcer which were confirmed by operation, 
 hydrochloric acid is present in large quantities. In the four 
 certain cases we find from 0-40 to 042 per cent., while in the case 
 in which no operation was performed, and the last haemorrhage 
 had occurred one month previously, the hydrochloric acid 
 was only 0-28 per cent. Free hydrochloric acid is always present, 
 and in the cases above given it varies from 01 to 012 per 
 cent. The quantity of hydrochloric acid combined with proteids 
 shows a considerable increase, the variations in the above cases 
 being from 0-20 to 0-32 per cent. ; only in the exceptional case is it 
 less, 0- 18 per cent. The general tendency appears for the chlorine 
 combined with the minerals to be, comparatively speaking, low ; 
 in the above cases it varies from 0-06 to Oil per cent. 
 
 Digestion. — The carmine fibrin test in cases of gastric ulcer 
 shows a tendency to increased rapidity of digestion. This is 
 generally more marked in the test-tube containing gastric juice 
 alone than in the tube to which four per mille hydrochloric acid 
 has been added ; the additional hydrochloric acid tending to hinder 
 rather than to increase digestion. In the cases given as examples, 
 it will be noted that the digestion is sometimes apparent in two 
 minutes, and in only one case was it as slow as ten minutes in 
 the test-tube containing gastric juice alone. In this latter case, 
 the digestion, when hydrochloric acid was added, was more rapid, 
 taking only seven minutes. The tube to which water had been 
 added digested in five minutes ; the explanation is difficult to 
 give. In the other cases, it is seen that the dilution with 
 water did not cause very marked alterations in the activity 
 of the pepsin. 
 
ORGANIC DISEASES OF THE STOMACH (.1 
 
 In cases of gastric ulcer where a Riegel's test meal has been 
 given, one finds the stomach empty in a normal period, and it 
 is not at all uncommon to find after a test breakfast the stomach 
 almost empty in the space of one hour, so that it would appear 
 that in some cases of gastric ulcer, especially when the ulceration 
 does not occur towards the pyloric end of the stomach, there 
 is a tendency to increased motihty. 
 
CHAPTER X 
 
 ORGANIC DISEASES OF THE STOMACH {continued)— 
 GASTRIC CARCINOMA 
 
 In malignant disease of the stomach, the situation of the 
 growth gives rise to certain characteristic symptoms which are 
 indicated in the gastric contents. In carcinoma of the cardiac 
 end of the stomach, when the growth has increased so as to cause 
 stenosis, true vomiting does not occur, but one sees regurgitation 
 of food, mixed with large quantities of mucus which accumulate 
 in the lower end of the oesophagus immediately above the narrow- 
 ing. The vomit in these cases occurs with great regularity, 
 and as a rule, immediately after the taking of food. In such 
 cases, the position of the growth can be demonstrated by means 
 of the stomach-tube, and portions of the growth are occasionally 
 found in the eye of the tube ; these will be invaluable in making 
 a diagnosis by microscopic examination. The examination of 
 the patient by X-rays is of very great service, especially if milk 
 containing bismuth sub-nitrate has been given, and its passage 
 watched along the oesophagus. 
 
 In carcinoma of the pyloric end of the stomach, when the 
 growth has advanced so far as to cause narrowing of the pylorus, 
 so that the gastric contents can only with difficulty pass into 
 the duodenum, dilatation of the stomach is gradually produced, 
 and it is not at all uncommon to see distinct peristaltic waves 
 on inspection of the patient's abdomen. The vomiting in such 
 cases is very obstinate, occurring every few days, or sometimes 
 daily, and as time goes on the periods between the vomiting 
 diminish in length. It is found that in pyloric carcinoma, the 
 vomiting usually occurs in the afternoon or evening, thus dis- 
 tinguishing it from the vomiting of simple gastric catarrh, which, 
 as a rule, occurs in the early morning. The quantity of vomited 
 matter in pyloric carcinoma is as a rule large, from half to one 
 litre, which also distinguishes it from gastric catarrh, where a 
 
ORGANIC DISEASES OF THE STOMACH G3 
 
 small quantity of vomited matter is noted. The vomit consists 
 mostly of food in an undigested or semi-digested condition, and 
 often the remnants of the food of previous days. 
 
 Carcinoma of the stomach may exist for long periods without 
 any vomiting, and this is especially apt to occur when the smaller 
 or larger curvature or posterior wall of the stomach are involved 
 in the malignant growth. In some cases where there has been 
 frequent vomiting, and carcinoma either of the cardiac end of 
 the stomach, or the lower portion of the oesophagus, has caused 
 such constriction that not even the finest stomach-tube can be 
 passed, the passage will suddenly become free and the vomiting 
 cease. This is due to the fact that the growth has ulcerated, 
 causing disappearance of the stenosis, and it will then be found 
 that a large tube can be easily passed into the stomach. Simi- 
 larly, in cases of carcinoma of the pylorus accompanied by 
 obstinate vomiting, the intervals may become longer and longer, 
 until the vomiting altogether ceases, owing to the softening and 
 sloughing of the tumour. 
 
 The appearance of the vomited matter varies according to 
 the food taken ; in all cases, however, it shows a marked want 
 of efficient motihty and of breaking up of the food, even in 
 spite of peristaltic waves being noted on examination of the 
 abdominal wall ; and remnants of food from previous days are 
 generally present. Bile is practically never found in malignant 
 disease of the stomach, but there are often large quantities of 
 mucus, intimately mixed with the stomach contents. In nearly 
 all cases, blood in small quantities will, sooner or later, be found 
 in the vomit. But the blood in carcinoma, as distinguished 
 from that found in ulceration, is small in amount, since it comes 
 from small superficial abrasions, and to demonstrate its presence 
 it is often necessary to resort to chemical tests. In rare cases, 
 owing to the breaking-down of the growth, there may be erosions 
 of large vessels leading to copious hsemorrhage which may be 
 difficult to distinguish from those of gastric ulcer. 
 
 Chemical Examination of the Vomited Matter 
 in Carcinoma of the Stomach. — In a case of carcinoma 
 of the stomach verified by autopsy, Golding Bird,^ of Guy's 
 Hospital, first showed in 184:2 that the free hydrochloric acid, 
 
 1 "Contribution to Chemical Pathology of some Forms of Morbid Diges- 
 tion," Lond. Med. Gaz., 1842, vol. ii. p. 391. 
 
64 GASTRIC DISEASES 
 
 which was present in considerable quantities in the early stages 
 of the disease, gradually diminished in amount as the strength 
 of the patient decreased, and that the organic acids gradually 
 increased as the free hydrochloric acid diminished. 
 
 Van den Velden ^ in 1879 again drew attention to the fact that 
 in carcinoma of the pylorus, free hydrochloric acid was absent 
 from the stomach contents. Since this period, a number of 
 writers both for and against the absence of free hydrochloric 
 acid have taken the field. The discrepancies in the opinions 
 of the various writers are partly due to their not recognising the 
 difference between free and combined hydrochloric acid. The 
 diminished secretion of hydrochloric acid and the absence of free 
 hydrochloric acid are not, however, pathognomonic of carcinoma ; 
 it was long ago shown by Van den Velden that both in gastritis and 
 fever, one may find absence of- free hydrochloric acid. Riegel ^ 
 has further shown that in amyloid disease of the mucous mem- 
 brane of the stomach, toxic gastritis, atrophic catarrh, and 
 certain forms of nervous disease — and sometimes even in phthisis 
 and heart disease — free hydrochloric acid is absent from the 
 stomach contents. In most cases, the other signs and symptoms 
 help one to diagnose whether its absence is due to malignant 
 disease or other causes, and it must be remembered that one 
 would rarely venture to diagnose carcinoma of the stomach 
 from an analysis of gastric contents alone. 
 
 The question of how soon in carcinoma of the stomach hydro- 
 chloric acid disappears is a very difficult one to settle ; it 
 certainly seems that, as the disease advances, the quantity of 
 hydrochloric acid diminishes, and in some cases free hydro- 
 chloric acid is entirely absent at a very early sta^e when no 
 other signs or symptoms of carcinoma are present. On the 
 other hand, there are certain cases of carcinoma in which one 
 finds free hydrochloric acid to be present for a long time, and 
 further one even occasionally gets hyperhydrochloria. Those 
 cases in which hydrochloric acid remains present throughout — 
 even, it may be, in increased quantity — are usually associated 
 with ulceration, partaking of a carcinomatous nature. 
 
 Thiersch ^ described a very interesting case in which free hydro- 
 chloric acid was present, and at the autopsy, cancer was found 
 
 iLoc. cit, p. 2r). 2 Vic ErkrunkiuKjcn dcs Mayois, 1897, p. 788. 
 
 ■i Miinchaier Med. Wochcnschrifl, 188G. 
 
ORGANIC DISEASES OF THE STOMACH 05 
 
 to be growing on the site of an old gastric ulcer. We can say 
 with confidence that, when the signs and symptoras point to 
 malignant disease, the absence of free hydrochloric acid from 
 the vomit is a very great factor in confirming the diagnosis 
 of carcinoma, and, unless there is some evidence to lead one 
 to suspect the presence of gastric ulcer, the presence of free 
 hydrochloric acid in such cases would negative such a diagnosis. 
 
 Microscopic Appearance of the Vomited Matter 
 in Carcinoma of the Stomach. — In examining the 
 sediment obtained from the vomit or washings of the stomach 
 in mahgnant disease of that organ, it is not at all uncommon 
 to find epithcHal cells, sometimes arranged in the character- 
 istic nests found in carcinoma. Rcinboth^ describes how 
 in small blood clots obtained from the washing out of a mahgnant 
 stomach, small particles of the growth are sometimes found. 
 Unfortunately, the microscopic recognition of carcinoma is 
 not, in most cases, possible till the later stages of the disease, 
 and the diagnosis may be made earlier by other means. 
 
 In the vomited matter of carcinoma of the stomach, one 
 generally finds remains of muscular fibres, vegetable cells, starch 
 granules, and fat globules, which are easily recognised. Sarcinse 
 are usually absent, and Oppler - has shown that if one introduces 
 pure cultures of sarcinae into a carcinomatous stomach, they 
 disappear within twenty-four hours, a dilated malignant stomach 
 being a very bad nourishing chamber for these organisms ; this 
 is contrary to what occurs in ordinary atonic dilatation of the 
 stomach. It is not at all uncommon to find yeast cells in the 
 stagnated contents of a carcinomatous stomach. In almost all 
 cases of carcinoma, one finds long filamentous bacilU which are 
 productive of lactic acid. 
 
 Boas ^ has observed more or less large quantities of pus cells 
 in mahgnant disease of the stomach, but Riegel ^ considers that 
 these are more often due to accidental contamination than to 
 the malignant disease itself. 
 
 Chemical Examination of the Gastric Contents 
 after a Test Breakfast. — The appearance of the gastric 
 
 1 Deulsch. Archiv. /. Klin. Med., Bd. Iviii. 8i). 
 
 2 Miinchen. Med. Wochcnichr., 1894, No. 29. 
 
 3 Dingnostik u. Therap. der Magenkrankheiten II., Theil, 1890, p. 184. 
 
 4 Die Erkrankungen des Magens, 1897, p. 788. 
 
C6 
 
 GASTRIC DISEASES 
 
 contents obtained after one hour in malignant disease varies 
 very considerably according to the position of the growth. 
 When the disease occurs towards the pylorus, leading to 
 obstruction, one has the complication of a more or less dilated 
 stomach, which does not occur when the growth is at the 
 cardiac end. Unless special precautions are taken in cases 
 where the mahgnant disease is in the pylorus and dilatation is 
 present, it is not uncommon to find mixed with the tea and 
 toast some remains of the previous day's food. And if one 
 
 TABLE VII.— ANALYSIS OF GASTRIC CONTENTS IN 
 GASTRIC CARCINOMA 
 
 Case. 
 
 Qualitative. 
 
 Quantitative. 
 
 Dig 
 
 estioii in 
 
 Re- 
 marks. 
 
 1 
 Pi 
 
 
 1 
 
 1 
 
 ■6 
 
 1 
 
 .S 
 
 s 
 
 9; 
 
 1 
 
 1 
 
 
 HCl. 
 
 minutes (//). 
 
 s 
 
 H 
 
 d 
 
 f 
 
 Pi 
 
 i 
 
 1 
 
 2 
 
 3 
 
 B. 10 
 
 acid 
 
 
 
 + 
 
 
 
 + + 
 
 — 
 
 — 
 
 - 
 
 — 
 
 - 
 
 - 
 
 
 
 
 
 
 
 Cardiac 
 
 C. 67 
 
 acid 
 
 
 
 + 
 
 + 
 
 + 
 
 IT 
 
 - 
 
 0-13 
 
 0-00 
 
 0-02 
 
 0-11 
 
 
 
 
 
 
 
 Cardiac 
 
 G. 13 
 
 acid 
 
 
 
 + 
 
 + 
 
 
 
 40 
 
 15 
 
 0-22 
 
 - 
 
 - 
 
 - 
 
 
 
 25 
 
 
 
 Pyloric 
 
 J. 85 
 
 acid 
 
 
 
 + 
 
 + 
 
 + 
 
 47 
 
 22-4 
 
 0-32 
 
 0-00 
 
 0-16 
 
 0-16 
 
 
 
 
 
 
 
 Pyloric 
 
 (a) Expressed in c.c. of yL X. solution of XaOH. 
 (&) 1. Filtered Gastric contents and carmine librin. 
 
 and equal quantity 0-4 p.c. HCl. 
 ..of water. 
 
 wishes to obtain a proper gastric analysis in such cases, it is 
 necessary to wash out the stomach on the evening or morning 
 before the test breakfast is given. 
 
 The quantity of gastric contents varies considerably according 
 to the situation of the carcinoma. In early cases of malignant 
 disease at the cardiac end while the tube can still be passed, 
 there is a tendency to decrease in the quantity of gastric con- 
 tents, which is apparently due, not so much to increased motor- 
 power, as to the difficulty of removing the contents, for, on 
 washing out with water, one continues to obtain contents for 
 some time, showing marked difficulty in thoroughly cleaning 
 the stomach. Scarcity of pure material often hampers analysis. 
 
 In the above table we give four cases of malignant disease 
 
ORGANIC DISEASES OF THE STOMACH 07 
 
 of the stomach, which, soon aft«r analysis, were verifi-nl by 
 autopsy. In the first two cases, the carcinoma was either 
 at the f^reater curvature or towards the cardiac end. In the 
 two latter, there was malignant disease involving the pyloric 
 orifice. 
 
 The gastric contents in all the cases showed large particles 
 of toast which had been little broken up, mixed with a certain 
 amount of mucus in three of the cases. In no case was any 
 blood found. 
 
 The reaction was in all these cases distinctly acid, and it would 
 appear rare to obtain a neutral reaction in carcinoma. In these 
 four cases, the various tests for free hydrochloric acid were 
 negative. In describing the vomited matter in cancer of the 
 stomach, we have remarked how sometimes free hydrochloric 
 acid may be present, and the repetition of these remarks is 
 unnecessary. 
 
 In all cases, the test for lactic acid gave a marked reaction. 
 We have already mentioned the fact that long filamentous 
 baciUi which produce lactic acid are considered by Boas to be 
 always present in malignant disease. It would appear that in 
 carcinoma there is a greatly increased quantity of lactic acid 
 after a test breakfast, and that even when Boas's oatmeal soup 
 has been given, lactic acid will be found. Its presence is a very 
 early symptom in carcinoma, and is, therefore, of great diag- 
 nostic value. At the same time, Hammerschlag ^ has shown 
 that it is not uncommon to find lactic acid only slightly increased 
 in those cases of malignant disease where the proteid digestion 
 is normal, or only very slightly reduced. 
 
 One finds butyric acid present in most cases of carcinoma. 
 Even when there is no obstruction to the pylorus, there appears 
 to be a tendency to stagnation of the contents in the stomach, 
 so that butyric acid occurs in the early stages of malignant 
 disease. Of the four cases given above, butyric acid was easily 
 recognised in all except one ; in this case, there was a suspicion 
 of its presence, though the quantity of material was not sufficient 
 to allow of a very detailed analysis. 
 
 Mucus is, as a rule, present in carcinoma, this being due to 
 the fact that a certain amount of catarrh generally accompanies 
 the disease. Undoubtedly there are cases of malignant disease 
 1 Archiv. f. V erdauiuujskrankhviten, vol. ii. part i. 
 
68 GASTRIC DISEASES 
 
 in which mucus is not increased, and in one of the cases described 
 above it was absent. 
 
 The total acidity in carcinoma is, as a rule, decreased, as is 
 well illustrated in the examples taken. In rare cases, where 
 the carcinoma has followed upon gastric ulcer, one may fnd, 
 as has been described, no decrease in total acidity. 
 
 In all cases of carcinoma in which we have been able to do a 
 quantitative analysis of the volatile acids, we have found them 
 increased. Of the four cases which were verified by autopsy, 
 there were sufficient gastric contents in only two to allow of 
 an estimation of the volatile acids, and in these two cases, they 
 amounted to 15 and 22-4 respectively. 
 
 The total quantity of hydrochloric acid in most cases of 
 carcinoma of the stomach is decreased. In one of the cases 
 given above, the total hydrochloric acid was 032 per cent., but 
 in this case the analysis was done some months before the 
 autopsy, at which a tumour was found extending towards the 
 pyloric orifice ; in the other cases it is seen that the total hydro- 
 chloric acid is decreased. 
 
 In all uncomplicated cases, free hydrochloric acid is absent ; 
 one has to remember, however, the cases where gastric ulcer 
 precedes the mahgnant disease, when this will not be the case. 
 
 In the majority of cases, it would appear that the combined 
 hydrochloric acid is decreased, and in some cases entirely absent. 
 We see in the table that in the one case in which the total 
 quantity of hydrochloric acid was apparently normal, no less 
 than 0"16 per cent, was combined with the proteids. 
 
 The mineral hydrochloric acid is, as a rule, very large in 
 amount. In the two cases in which analyses were carried out 
 it was 0"11 and 016 per cent., resembling what one finds in 
 acute gastric catarrh. 
 
 The carmine fibrin test shows for the most part absence of 
 digestion. The diminution of pepsin is not pathognomonic of 
 the disease, since in all cases of secondary gastritis or atrophy 
 of the stomach there is a tendency to diminution of pepsin 
 and pepsinogen, as well as of other ferments. In mahgnant 
 disease of the stomach, one finds both pepsin and rennin as a 
 rule diminished, and it is not at all uncommon to find both these 
 ferments entirely absent. In three of the four cases given in 
 the table, this was the case. In only one case was there a slight 
 
ORGANIC DISEASES OF THE STOMAOTI GO 
 
 digestion after twenty-five minutes in test-tube No. 2 to which 
 four per mille hydrochloric acid had been added. 
 
 Wc see that the chemical analysis of the gastric content? 
 after a test breakfast in cases of malignant disease of the stomach 
 yields very valuable results in helping to make a diagnosis. At 
 the same time, it must be remembered that the symptoms and 
 general examination of the patient should in all cases be very 
 carefully weighed together 'with the analytical results before 
 any definite conclusions can be drawn. 
 
CHAPTER XI 
 
 FUNCTIONAL DISEASES OF THE STOMACH— SECRETORY NEU- 
 ROSES, HYPERHYDROCHLORIA, GASTRO-SUCCHOREA, HYPO- 
 HYDROCHLORIA 
 
 In functional dyspepsia one is now able, thanks to the intro- 
 duction into general practice of the stomach-tube, to recognise 
 the changes produced in the gastric secretion, as well as the 
 changes in the condition of the stomach wall itself, so that one 
 can classify the pathological state with a certain amount of 
 scientific accuracy. 
 
 The majority of cases of chronic gastric dyspepsia which come 
 under the notice of medical men will, when careful chemical 
 examination of the stomach contents has been made, prove to 
 be due to functional disturbance and not to organic disease. 
 Functional disturbance of the stomach may, for the sake of 
 convenience, be divided into three groups, due to alterations in : 
 
 (a) The secretions of the stomach. 
 
 (b) The motor-power of the stomach. 
 
 (c) The sensibility of the stomach. 
 
 It will be found in all cases of functional disease of the 
 stomach that the more often one is able to obtain an analysis 
 after a test meal, the more accurate will be the diagnosis ; in 
 looking through our notes of gastric analyses the importance 
 of having a series of analyses is very apparent. In all cases 
 where this has been possible, there has not been the slightest 
 difficulty in classifying the condition of the stomach, while 
 in those cases where only a few, or possibly only one analysis 
 has been made, one may easily be led into error in diagnosis, 
 especially when the results of chemical analysis are not very 
 typical of the condition present. 
 
 It is important also, in diagnosis by means of chemical analysis, 
 not to diagnose functional disease of the stomach until organic 
 disease has been negatived by a very careful examination 
 
FUNCTIONAL DISEASES OF THE STOMACH 71 
 
 of the symptoms and physical signs present. Functional 
 dyspeptics, as a rule, show other nervous symptoms, such as 
 neurasthenia, &c., which help one in making a diagnosis, but 
 on this account, the error nmst not be made of overlooking 
 possible organic disease in a neurotic patient. 
 
 Functional dyspepsia is especially prevalent in the upper 
 and middle classes who are in the habit of cultivating their 
 brains more than their bodies, and one finds many instances 
 of it in the legal and medical professions, and in over- worked 
 business and hterary men, &c. The condition is found most 
 frequently in persons of active middle life, rather than in the 
 young or old, and secretory dyspepsia would appear to be more 
 common in men than in women, while motor derangement of 
 the stomach is more frequently met with in women than in 
 men. One would naturally expect that a single fmiction of 
 the stomach would seldom be alone at fault, and in practice 
 it is not at all uncommon to have two or three functions dis- 
 turbed at the same time in the same individual, so that hyper- 
 hydrochloria, together with hypersesthesia and atonic dilatation 
 of the stomach, may be present in the same patient. 
 
 When the motor-power of the stomach is interfered with, one 
 gets various groups of symptoms, according to the part of the 
 stomach especially affected ; in some cases, pyloric spasms 
 seem to be the principal symptom, in others increased peristalsis, 
 and in others again, loss of tone may give rise to atonic dilatation. 
 
 With these prefatory remarks, we may now go on to sub- 
 divide the various forms of functional dyspepsia met with in 
 practice, and illustrate them with analyses of cases. The 
 analysis given in each table is a single one chosen from a series 
 of analyses of a separate case, as illustrating the condition 
 generally found ; by this means one gets a better picture of the 
 condition present in that particular disease. 
 
 As an example, we will take one case of hyperhydrochloria 
 in which a series of analyses was carried out. It will be seen 
 in this case (Table VIII.) that the various analyses correspond in 
 general and enable one to recognise the case as one of purely 
 functional disease. On two occasions mucus was present, and 
 the volatile acids were sometimes increased ; these analyses 
 alone might lead one to beheve that there was some gastric 
 catarrh, but on looking at the analyses as a whole, one sees 
 
72 
 
 GASTRIC DISEASES 
 
 that no catarrh was present, and that it was a case of 
 hyperhydrochloria, the increased volatile acids being due to 
 temporary motor insufficiency. The lactic acid wliich is shown 
 to be present in all the analyses was only found in very small 
 quantities, and is due to a test breakfast only being employed, 
 and not Boas's oatmeal soup. 
 
 TABLE VIII.— ANALYSIS OF GASTRIC CONTENTS IN 
 A CASE OF HYPERHYDROCHLORIA 
 
 
 Qualitative. 
 
 
 
 Quautitative. 
 
 
 
 1 
 
 
 
 
 
 — 
 
 
 
 
 Digestion in 1 
 mimites (0). \ 
 
 
 
 
 
 
 ^ 
 
 
 
 Date. 
 
 1 
 
 o 
 
 X 
 
 -6 
 1 
 .2 
 
 i 
 
 .2 
 
 i 
 
 ^ 
 3 
 § 
 
 o 
 
 IICl. 
 
 
 
 
 
 s 
 
 s 
 H 
 
 1 
 
 p 
 
 ' 
 
 2 
 
 3 
 17 
 
 7-11-98 
 
 acid 
 
 + 
 
 + 
 
 u 
 
 u 
 
 93 
 
 5-2 
 
 0-365 
 
 0-058 
 
 0-215 
 
 0-091 
 
 10 
 
 11 
 
 14-11-98 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 92 
 
 6-5 
 
 0'37 
 
 0-05 
 
 0-21 
 
 0-10 
 
 6 
 
 11 
 
 17 
 
 14-12-98 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 u 
 
 84 
 
 12-4 
 
 U-3G5 
 
 0-069 
 
 0-181 
 
 0-115 
 
 6 
 
 9 
 
 14 
 
 29-12-98 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 + 
 
 8,5 
 
 12-8 
 
 0-336 
 
 0-033 
 
 0-186 
 
 0-117 
 
 9 
 
 8 
 
 15 
 
 11-1-99 
 
 acid 
 
 + 
 
 + 
 
 
 
 
 
 7-4 
 
 C-4 
 
 0-354 
 
 0-0G9 
 
 0-183 
 
 0-102 
 
 G 
 
 8 
 
 16 
 
 20-1 -9 9 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 81 
 
 8-0 
 
 0-376 
 
 0-022 
 
 0-245 
 
 0-109 
 
 5 
 
 7 
 
 11 
 
 26-1-99 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 88 
 
 14-0 
 
 0-398 
 
 0-073 
 
 0-215 
 
 0-110 
 
 5 
 
 5 
 
 11 
 
 30-1-99 
 
 acid 
 
 + 
 
 + 
 
 
 
 
 
 81 
 
 5-2 
 
 0-39 
 
 0-02 
 
 0-25 
 
 0-12 
 
 5 
 
 7 
 
 12 
 
 3-2-99 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 + 
 
 9U 
 
 12-8 
 
 0-38 
 
 0-04 
 
 0-23 
 
 0-11 
 
 7 
 
 8 
 
 14 
 
 («) Expressed in c.c. of j^^ N. solution of NaOH. 
 (6) 1. Filtered Gastric coiiLeuts aud carmine fibrin. 
 
 3. 
 
 and equal (luantity (i-4 ]).c. HCl. 
 " of water. 
 
 SECRETORY NEUROSIS OF THE STOMACH 
 
 That the secretions of the stomach are under the control of 
 the nervous system has long been beheved, and naturally so, 
 since other secretory glands have been demonstrated to be under 
 the control of the nerves. Numerous observers have tried to 
 show how the nervous secretions of the stomach are influenced 
 by stimulation or inhibition, but no experiments on cither the 
 vagus or sympathetic seemed to give any definite and constant 
 results in animals. 
 
FUNCTIONAL DISEASES OF THE STOMACH 73 
 
 It was not until Pawlow and his pu})i]s, with their more refined 
 methods of experimenting and their careful use of antiseptics, 
 showed that gastric secretion was under the control of the vagus, 
 that our knowledge from the experimental side was established. 
 In dogs in which he had made oesophageal and gastric fistula), he 
 Wciii able to prove that the mere psychological stimulus of seeing 
 food, (fee, sufficed to cause secretion of the stomach juice. That 
 the gastric juice really came from the psychological stimulus, 
 he demonstrated by his ingenious method of dividing the stomach 
 into two parts, so that he had a small stomach isolated from 
 the oesophagus with a gastric fistula in it. By feeding these 
 dogs — when there was no possibility of food entering the 
 stomach from the oesophagus — he was able to collect absolutely 
 pure gastric juice from the small isolated stomach. Section of 
 the vagi with certain precautions caused complete absence of any 
 psychological secretion in dogs thus fed, and still further, stimula- 
 tion of the peripheral end of the vagus produced a distinct flow 
 of gastric juice. Pawlow^ was thus able to demonstrate that 
 the secretory nerve of the stomach was the vagus, and that it pro- 
 bably contained not only stimulating, but also inhibitory fibres. 
 
 All Pawlow's w^ork is so inteuesting and so experimentally con- 
 clusive, that we must refer our readers to the book itself, since it is 
 of great importance in enabhng us to understand how functional 
 changes produced in the stomach may account for dyspepsia. 
 
 Eicheto had under observation a patient with obstructed 
 oesophagus and gastric fistula in whom, after chewing flavoured 
 food — although none of it reached the stomach — he found a 
 copious flow of gastric juice, just as has been now demonstrated 
 in animals by Pawlow. 
 
 Having seen that the gastric secretion is so easily influenced 
 by psychological stimulation, we can readily understand how 
 in disease either stimulation or inhibition of the vagus may act 
 on the gastric glands so as to aft'ect the secretions. The 
 chemical reflex caused by gastric secretion may be found to 
 play an important role in the pathological alterations of the 
 composition of the gastric juice, but the subject is too recent 
 to be discussed here.a In cases of stimulation of the vagus, 
 
 1 Loc. cit. p. 10. 
 
 2 Journ. de VAnntom. cl dc la PhijsioL, iii. No. G. 
 
 3 Starling, Croonian Lectures, June 1905. 
 
74 
 
 GASTRIC DISEASES 
 
 one would expect increased gastric secretion, leading to hyper- 
 hydrochloria when food is taken, or, when such stimulation 
 occurs in the fasting individual, gastro-succhorea. While, on 
 the other hand, in cases where inhibition of the vagus occurs, 
 one may get hypohydrochloria. 
 
 Pathologically, hypersecretion of the gastric juice may occur 
 
 TABLE IX.— ANALYSIS OF GASTRIC CONTENTS IN 
 HYPERHYDROCHLORIA 
 
 
 
 Qualitative. 
 
 
 
 
 Quantitative. 
 
 
 Digestion 
 in minutes (i). 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 Case. 
 
 o 
 1 
 
 5 
 
 .2 
 
 1 
 
 P> 
 
 p 
 S 
 
 .■2 
 
 •2 
 o 
 
 
 HCl. 
 
 
 
 ■i 
 
 
 1 
 
 g 
 
 1 
 
 2 
 
 3 
 
 V. 6 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 92 
 
 6 
 
 0-37 
 
 0-05 
 
 0-21 
 
 0-10 
 
 6 
 
 U 
 
 17 
 
 V. 10 
 
 acid 
 
 + + 
 
 + 
 
 
 
 
 
 108 
 
 ■1 
 
 0-41 
 
 0-06 
 
 0-28 
 
 0-07 
 
 8 
 
 5 
 
 5 
 
 T. 12 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 106 
 
 8 
 
 0-42 
 
 0-02 
 
 0-29 
 
 0-10 
 
 13 
 
 9 
 
 15 
 
 C. 17 
 
 acid 
 
 4- 
 
 + 
 
 
 
 
 
 75 
 
 3 
 
 0*34 
 
 0-01 
 
 0-23 
 
 0-10 
 
 10 
 
 5 
 
 5 
 
 S. 23 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 116 
 
 9 
 
 0-36 
 
 0-02 
 
 0-26 
 
 0-08 
 
 4 
 
 4 
 
 6 
 
 C. 32 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 102 
 
 6 
 
 0-40 
 
 0-03 
 
 0-30 
 
 0-07 
 
 2 
 
 6 
 
 3 
 
 C. 51 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 125 
 
 9 
 
 0-48 
 
 0-02 
 
 0-29 
 
 0-17 
 
 2 
 
 3 
 
 5 
 
 P. 63 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 + 
 
 100 
 
 4 
 
 0-36 
 
 O'Ol 
 
 0-28 
 
 0'07 
 
 5 
 
 4 
 
 6 
 
 L. 76 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 + 
 
 94 
 
 
 
 0-37 
 
 0-01 
 
 0-30 
 
 0-06 
 
 2 
 
 2 
 
 3 
 
 (rt) Expressed iu c.c. of jJ^ N. solution of XaOH. 
 (6) 1. Filtered Gastric contents and carmine fibrin. 
 
 2. 
 
 3. 
 
 ind equal quantity 0-4 p.c. HCl. 
 „ ,, ■ of water. 
 
 in two forms, that present during digestion, which is recognised 
 as hyperhydrochloria, and that from a fasting stomach, which 
 is known as gastro-succhorea. 
 
 HYPERHYDROCHLORIA 
 
 The condition of hyperhydrochloria is best defined as an 
 excessive secretion of gastric juice occurring during digestion, 
 either the gastric secreting cells or the secretory fibres of the 
 vagus being more sensitive than is normal, so that the excitation 
 
FUNCTIONAL DISEASES OF THE STOMACH 75 
 
 of the food causes an excessive secretion of juice. The analysis of 
 such gastric contents will show not only increased total acidity, 
 but also an increase in both free and combined hydrochloric 
 acid. In this condition the ferments, pepsin and rennin, are 
 usually increased, as well as the acids normally present in the 
 gastric juice. 
 
 In all cases of functional disease of the stomach, it is important, 
 as already stated, to have a series of analyses ; in this way one 
 obtains more definite results than is possible when one attempts 
 to make a diagnosis from a single analysis. In Table IX. we 
 have put together the results of nine analyses of different indivi- 
 duals as types of the various forms of hyperhydrochloria which 
 one meets with in everyday practice. 
 
 The quantity of gastric contents found after a test breakfast 
 is, as a rule, somewhat increased in cases of hyperhydrochloria ; 
 at the same time, this is not always demonstrated, owing to 
 the fact that the condition is often accompanied by increased 
 motihty, so that one does not obtain such a large quantity of 
 gastric contents after the hour's interval as one would expect 
 to find where there is excessive secretion of gastric juice. 
 
 Qualitative Analysis. — A markedly acid reaction is 
 present in all cases of hyperhydrochloria. 
 
 One would naturally expect to find a very marked reaction 
 with the various tests for free hydrochloric acid in cases where 
 there is a hypersecretion of gastric juice, and in cases of hyper- 
 hydrochloria, one will find that the reaction for hydrochloric 
 acid is always very distinct. 
 
 When the ordinary test breakfast has been given, one generally 
 obtains a slight colour reaction with the test for lactic acid, 
 but when Boas's oatmeal porridge has been given as a test diet, 
 the test for lactic acid will be negative. 
 
 Butyric acid is often found in hyperhydrochloria ; the condition 
 is accompanied by some diminution in the motor-power of the 
 stomach, the butyric acid being due to this delayed motility. 
 
 In uncomplicated cases, mucus is not, as a rule, present, 
 although in some cases we have found it in a single analysis ; 
 when, however, several analyses have been carried out, we have 
 found that the presence of mucus was not constant, and was 
 apparently accidental. One sees, on comparing a series of 
 analyses of the same individual, that mucus is, as a rule, absent 
 
70 GASTRIC DISEASES 
 
 in cases of hyperhydrochloria, while in cases of catarrh of the 
 stomach, it is always present. It would appear that in simple 
 hyperhydrochloria, mucus is not so often present as it is in cases 
 complicated with gastric ulcer. 
 
 Quantitative Analysis. — The total quantity of acid 
 present in hyperhydrochloria varies from 60 to 130, or even 
 more. In the series of cases which we have given as types, it 
 varies from 75 to 125. In most cases of uncomplicated hyper- 
 hydrochloria the acidity will be about 100, and it should be 
 considered that any increase above GO of acidity verges on 
 hyperhydrochloria. The line of demarcation between normal 
 gastric secretion and the slight excess which occurs in mild 
 cases of hyperhydrochloria is difficult to define, as the symptoms 
 may be very marked in some cases where the acidity is only 
 slightly increased, owing to hypersesthesia being also present. 
 Conclusions as to the class of functional diseases of the 
 stomach in which such cases are to be • placed can only be 
 made by a series of analyses. 
 
 In hyperhydrochloria, the volatile acidity will be found to 
 be normal, while there is a tendency in some cases for it to be 
 increased. In three of the cases it was increased to as much 
 as 9. This increase in the volatile acidity will generally be 
 found to be due to diminished motility accompanying the 
 condition. 
 
 Quantitative Analysis of Hydrochloric Acid.— 
 The total hydrochloric acid is always increased. In the 
 series of analyses given, the lowest figure is 0"34: per cent., 
 and the highest 0'48 per cent., the analyses generally tending 
 towards the higher figure rather than the lower. 
 
 Free hydrochloric acid, as already stated, is always found 
 by chemical tests to be present. The quantitative analysis 
 varies in the cases given from 0"01 to 0'06 per cent., though 
 higher figures may occasionally be reached. 
 
 The quantity of hydrochloric acid combined with proteids 
 will always be found to be increased, varying from 0-21 to 0'30 
 per cent, in the examples quoted. 
 
 The quantity of chlorine combined with the minerals in 
 hyperhydrochloria varies, but the general tendency is for the 
 quantity not to be markedly increased. In the examples 
 given, it varies from 000 to 0*10 per cent. 
 
FUNCTIONAL DISEASES OF THE STOMACH 77 
 
 Digestion. — In liyperhydrochloria, one finds, with the 
 carmine fibrin test, rapid digestion, so that in some cases the 
 fibrin is dissolved and the carmine Uberated in as short a time 
 as two minutes. The addition of hydrochloric acid to the 
 gastric contents in test-tube No. 2 may, in some cases, tend 
 to delay digestion owing to the excess of hydrochloric acid 
 hindering the action of the pepsin. The general conclusion 
 to be deduced from the examination of several cases of liyper- 
 hydrochloria is that pepsin and pepsinogen are present in 
 normal or even increased quantities. 
 
 The examination for rennin, when the gastric secretion has 
 been previously neutralised, will also show a tendency to in- 
 creased activity. 
 
 The chemical analysis in cases of liyperhydrochloria is seen 
 to correspond with that of gastric ulcer, and this is not remark- 
 able when one considers that in gastric ulcer one has a condition 
 of hypersecretion. The differential diagnosis between gastric 
 ulcer and hyperhydrochloria is therefore extremely difficult, 
 and can only be arrived at by considering the symptoms and 
 chnical history. In cases where one gets an undoubted history 
 of hoematemesis, the diagnosis is comparatively easy, but in 
 other cases one must rely on the general history and symptoms, 
 and it would appear that the stomach-tube is of very little aid 
 in coming to definite conclusions. 
 
 GASTRO-SUCCHOREA 
 
 In healthy individuals, a resting stomach contains no gastric 
 secretion, so that on passing the stomach- tube in a fasting 
 individual, no gastric contents should be obtained. It is 
 important before making a diagnosis of gastro-succhorea, when 
 one finds gastric contents in a fasting individual, to wash out 
 the stomach the previous night in order to be sure that the 
 gastric contents are not due to the excitation of remnants of 
 food or secretion which has irritated or stimulated the stomach. 
 If, having previously washed out the stomach, one still finds 
 gastric contents on passing the stomach-tube, one may safely 
 consider that the patient is suffering from gastro-succhorea. 
 
 The frequency of this condition would appear to vary con- 
 siderably according to different observers, and the countries 
 
78 
 
 GASTRIC DISEASES 
 
 in which the observations have been made. It appears to 
 be quite common in Norway amongst badly fed individuals, 
 and Dr. Grieg, of Bergen, who worked in our laboratory, was 
 good enough to send us a series of analyses of patients suffering 
 from gastro-succhorea. The analyses simply show normal 
 gastric juice, and it is unnecessary to reproduce them here. 
 Not only is hydrochloric acid present in such cases, but also 
 pepsin and generally rennin. 
 
 HYPOHYDROCHLORIA 
 
 We have already shown that hyperhydrochloria is due to 
 excitation of the secretory fibres of the vagus nerve, the con- 
 
 
 TABLE 
 
 X.- 
 
 -AN 
 
 ALY 
 
 SLS 
 
 OF 
 
 GASTRIC CONTENTS 
 
 IN 
 
 
 
 
 
 
 
 HYPOHYDROCHLORIA 
 
 
 
 
 
 
 Qualititi 
 
 fC. 
 
 
 
 
 Quantitative. 
 
 
 D 
 
 gestion 
 
 Case. 
 
 i 
 1 
 
 5 
 
 1 
 
 2 
 
 3 
 
 1 
 
 1 
 1 
 
 HCl. 
 
 
 
 (b). 
 
 1 
 
 1 
 
 2 
 
 i 
 
 1 
 
 2 
 
 = 
 
 E. 11 
 
 acid 
 
 
 
 + 
 
 + 
 
 + 
 
 ,. 
 
 10 
 
 0-26 
 
 0-00 
 
 0-13 
 
 0-12 
 
 
 
 
 
 
 
 1'. 53 
 
 acid 
 
 « 
 
 + 
 
 + 
 
 
 
 30 
 
 ' 
 
 0-09 
 
 0-00 
 
 0-01 
 
 0-07 
 
 
 
 15 
 
 • 
 
 C. 55 
 
 acid 
 
 
 
 + 
 
 + 
 
 + 
 
 21 
 
 
 0-16 
 
 O'OO 
 
 0-02 
 
 O'U 
 
 
 
 2 
 
 
 
 J. 62 
 
 acid 
 
 
 
 + 
 
 + 
 
 
 
 40 
 
 
 0-25 
 
 0-00 
 
 0-07 
 
 0-18 
 
 
 
 5 
 
 
 
 C. 78 
 
 add 
 
 
 
 + 
 
 + 
 
 
 
 22 
 
 
 0-13 
 
 0-00 
 
 0-05 
 
 0-08 
 
 
 
 30 
 
 
 
 U. 79 
 
 acid 
 
 
 
 + 
 
 -- 
 
 + -f- 
 
 20 
 
 11 
 
 0-2(i 
 
 0-00 
 
 0-06 
 
 0-20^ 
 
 
 
 22 
 
 
 
 P. 102 
 
 faint 
 acid 
 
 
 
 
 
 
 
 
 
 18 
 
 
 0-16 
 
 0-uo 
 
 0-01 
 
 0-12 
 
 
 
 
 
 
 
 (a) Expressed in c.c. of ^^ N. solution of NaOlf. 
 (6) 1. Filtere.i Gastric contents aud carmine fllii-in. 
 
 and equal iiuantity 4 p.c. HCl. 
 „ of water. 
 
 trary condition — diminished secretion of gastric juice or hypo- 
 hydrochloria — being produced by the excessive action of the 
 inhibitory fibres of the vagus nerve. The diminished secretion 
 which occurs in gastric catarrh or in carcinoma of the stomach 
 must at once be separated from this purely neurotic condition 
 of hypohydrochloria- In the former cases, there is often abso- 
 
FUNCTIONAL DISEASES OF THE STOMACH 79 
 
 lute destruction of the gastric juice secreting glandular cells 
 of the mucous membrane, while functional hypohydrochloria 
 is accompanied by no destruction of the secreting cells, ])ut 
 merely inhibition through the vagus nerve causing diminislicd 
 secretion. Hypohydrochloria is found in practice to be a much 
 more rare complaint than the opposite condition of hyper- 
 hydrochloria. This is only what one would expect on physio- 
 logical grounds, since the inhibitory function is not so strongly 
 represented in the vagus nerve as the excitatory function. 
 
 In Tabic X. we have put together seven cases illustrative of 
 this condition. It is found that after a test breakfast a large 
 quantity of gastric contents is, as a rule, obtained, showing that 
 delayed motility usually accompanies the condition. 
 
 Qualitative Analysis;— The reaction in all cases of 
 hypohydrochloria which have come under our notice has been 
 acid or feebly acid ; in no case have we obtained a neutral 
 reaction . 
 
 In hypohydrochloria the ordinary tests for the presence of 
 hydrochloric acid occasionally give a reaction, but in more 
 numerous cases, free hydrochloric acid is absent. 
 
 Lactic acid has been found to be present in nearly all the cases 
 we have examined after the ordinary test breakfast, but when 
 Boas's oatmeal porridge has been given, it is very often absent, 
 and never found in any increased quantity. This is of con- 
 siderable help in distinguishing this condition from that of 
 maUgnant disease of the stomach, in which one finds the exces- 
 sive quantity of lactic acid already mentioned. 
 
 In the majority of cases, butyric acid will be found to be 
 present, though in some few cases it is absent. 
 
 In typical hypohydrochloria, mucus is absent, though in 
 taking a series of analyses — as in hyperhydrochloria — one may 
 occasionally find it present. The importance of a series of 
 analyses in these cases in helping one to distinguish the condition 
 from carcinoma of the stomach is very apparent, for, in carci- 
 noma of the stomach, the majority of analyses will reveal the 
 presence of mucus, whereas in hypohydrochloria, it will be 
 absent. 
 
 Quantitative Analysis — In hypohydrochloria the total 
 acidity is foimd to vary from 18 to 40 in the cases we have taken 
 as types, and some show an even smaller acidity. 
 
80 GASTRIC DISEASES 
 
 In uncomplicated hypohydrochloria one would expect the 
 volatile acidity to be normal. In the cases which we have 
 taken as examples, it has occasionally been almost normal, but 
 in the majority of cases it tends to be increased, from 8 to 
 11. This is partly due to delayed motility causing the 
 stagnant gastric contents to ferment, the inhibitory action of 
 the hydrochloric acid being no longer sufficient to stop the 
 action of bacteria. This is what one would naturally expect, 
 if the views of Bunge and others, who hold that hydrochloric 
 acid acts merely as an inhibitor of bacterial action, are correct. 
 In no case of hypohydrochloria where there has not been delayed 
 motility, have we been able to find any morbid increase in the 
 volatile acidity. 
 
 Quantitative Analysis of Hydrochloric Acid. — 
 The total hydrochloric acid in cases of hypohydrochloria 
 varies in the cases we have given from 0-26 to 0-09 per cent. 
 The majority of cases, however, vary from 0-12 to 019 per 
 cent. 
 
 In some cases, a trace of free hydrochloric acid may be present, 
 although, as a rule, one finds total absence of this substance. 
 
 The quantity of chlorine combined with the proteids is always 
 low, the quantity varying from 001 to 0-13 per cent. Unhke 
 what one finds in organic" disease of the stomach, we have never 
 come across a case of hypohydrochloria of purely neurotic 
 origin where proteid chlorine was entirely absent. 
 
 The chlorine combined with minerals varies very much. In 
 some cases the quantity is low — 0"07 per cent. — while in others 
 it is increased, and may reach as much as 0*20 per cent. 
 
 Digestion. — In hypohydrochloria there is a tendency 
 for the digestion to be distinctly delayed, so that no digestion 
 occurs until one has added a four per mille solution of hydro- 
 chloric acid to convert the pro-pepsin present into active 
 pepsin. But in some cases digestion does occur even without 
 the addition of hydrochloric acid. It would appear from diges- 
 tion experiments that the ferments are rarely absent, and that 
 the delayed digestion is due to the diminished quantity of 
 hydrochloric acid ; at the same time, we have seen undoubted 
 cases of functional hypohydrochloria in which pepsin and 
 pepsinogen were entirely absent, in some of these cases rennin 
 also having been absent. 
 
CHAPTER XII 
 
 FUNCTIONAL DISEASES OF THE STOMACH (continued)— MOTOR 
 NEUROSES, HYPERMOTILITY AND HYPOxMOTILITY 
 
 The motility of the stomach being under the control of the 
 nervous system, both as regards its activity and muscular tone, 
 this function can be altered in two directions : 
 
 (a) Hypermotility, or increased functional activity, which may 
 affect the whole organ and sometimes causes a condition of 
 peristaltic restlessness, or may excite rumination. The in- 
 creased motihty may be limited to different parts of the stomach, 
 such as the pyloric or cardiac region, leading to muscular spasm. 
 
 (b) Hypomotility, which includes the loss of both motor-power 
 and tone through deficient nerve impulses. The former, when 
 affecting the body wall of the stomach, produces atonic dilatation 
 of that organ ; the latter, if the insufficiency is limited to the 
 cardiac end, may cause regurgitation of food, or if the pyloric 
 region is affected, leads to pyloric insufficiency. 
 
 (a) Hypermotility. —General hypermotility of the stomach 
 may in some individuals be habitual, so that the food taken is 
 more rapidly passed on into the duodenum than occurs in a 
 healthy individual. In one case which we had under observa- 
 tion — that of a surgeon-major in the Indian army — we found 
 that after a test breakfast the stomach was always empty within 
 twenty minutes ; on washing out the stomach after this interval 
 no remains of toast, &c., could be obtained. A meat meal was 
 also found to leave the stomach very rapidly, so that it would be 
 found empty in one hour. Unfortunately, only a few experi- 
 ments could be carried out in this case, as the patient, being 
 perfectly well, objected to the use of the stomach- tube. As a 
 general rule, we may consider that hypermotility is accompanied 
 by no disagreeable sensations, and in the case in question, the 
 individual did not even feel hungry in consequence of the rapid 
 emptying of the stomach. The diagnosis is easily made by 
 
82 GASTRIC DISEASES 
 
 passing the stomach-tube at various intervals after a test meal. 
 In a pure case of hypermotility, one will find the stomach con- 
 tents perfectly normal if the interval after the test meal has 
 been taken is short enough. In many cases, however, one finds 
 other gastric functions disturbed, more especially the secretory 
 functions, leading to — in the majority of cases — hyperhydro- 
 chloria. 
 
 A condition of the stomach known as peristaltic restlessness, 
 has been described by Kussmaul ^ in which the muscular dis- 
 turbance of the stomach wall was due to the peristaltic nerve 
 apparatus being upset ; in fact, a true motility neurosis. The 
 peristaltic movements, in these cases, occur early in the morning, 
 so that the fasting stomach which only contains air is felt by 
 the patient to be in a state of unrest, and the peristalsis can in 
 some cases be observed by the physician. The condition is 
 increased to a marked extent after taking food. Unfortmiately, 
 we have no record of analyses showing the chemical composition 
 of the gastric contents under such circumstances ; it would, 
 however, appear that peristaltic restlessness is very often 
 accompanied by gastro-succhorea. 
 
 Increased peristalsis, causing sensations of pain in the stomach, 
 may also occur when there is stenosis of the pylorus or duodenum, 
 but this can hardly be considered as purely functional. 
 
 Rumination, although partly due to insufficiency of the 
 cardiac spliincter, can probably be included under hypermotiUty, 
 since in a pure case of rumination the gastric contents are 
 brought up by the muscular contraction of the stomach wall. 
 Sometimes the cardiac sphincter of the stomach remains under 
 the will-power of the patient, who, whenever he pleases, can 
 bring up the food into his mouth. In other cases it appears 
 that the will-power has not sufficient control, and the patient 
 is periodically troubled with rumination. In the analyses of 
 ruminating patients, we have on occasion found the gastric 
 contents to be of normal composition, although it is not un- 
 common to find the secretions functionally altered, generally 
 tending in the direction of hyperhydrochloria. 
 
 Spasm of the cardia may occasionally occur, causing a painful 
 cramp. The condition of cardiac spasm is easily recognised 
 when one attempts to pass the stomach-tube ; it will suddenly 
 
 1 Volkmann's ,SV(w?«/. Kliu. Vortnii/r, No. 181, 1S80. 
 
FUNCTIONAL DISEASES OF THE STOMACH 
 
 83 
 
 stop in its passage along the oesophagus, and if one attempts 
 to force it, it will tend to turn on itself. While— as distinguished 
 from what would occur in organic disease — if one allows the 
 tube to remain a few minutes above the constriction, the cramp 
 suddenly relaxes, and the tube slips into the stomach. 
 
 Spasm of the pylorus causes a distinct cramp in the pyloric 
 ref^ion of the stomach which may lead to sensations of faint- 
 ness. When such spasm lasts for any length of time, one may, 
 after a test breakfast, find an excessive quantity of gastric 
 contents. Spasm of the pylorus is not uncommonly accom- 
 panied by hyperhydrocliloria, and it is necessary in such cases 
 to be very careful in making a diagnosis so as not to confound 
 them with gastric ulcer, leading to narrowing of the pyloric end 
 of tlie stomach. 
 
 (6) Hypomotility — Diminished motility of the stomach may 
 be either a temporary or a more or less permanent condition. 
 One of us, together with Dr. Leney,^ has already published an 
 account of a patient, who under ordinary circumstances had a 
 normal motor-power with normal gastric secretions, but who, 
 when suffering from migraine with some nausea, evinced marked 
 delay in the motor-power of the stomach. 
 
 TABLE XI.— DELAYED MOTILITY DUE TO MIGRAINE 
 
 Analysis. 
 
 Total 
 HCl. 
 
 Free 
 HCl. 
 
 Pi-Oteid 
 HCl. 
 
 MiiH-ral 
 HUl. 
 
 Proteid 
 + Free 
 HCl. 
 
 \'olatile 
 Aciillty in 
 c.cm.jVN. 
 
 NaOH. 
 
 1 
 2 
 3 
 4 
 
 0-330 
 0-310 
 0-335 
 0-345 
 
 0-010 
 0014 
 0-015 
 0-042 
 
 0-270 
 0-235 
 0-2G5 
 0-225 
 
 0-050 
 0-005 
 0-050 
 0-080 
 
 0-280 
 0-249 
 0-280 
 0-2G7 
 
 100 
 
 11-0 
 
 8-0 
 
 GO 
 
 Average 0-330 
 
 0-020 
 
 0-249 
 
 0-OGl 
 
 0-209 
 
 100 
 
 The above table illustrates this point by four different analyses. 
 
 1 " An Experimental En(iuiry into the Quantity of Volatile Acids in the 
 Stomach." L. Leney and Vaiighan Harley. — Brit. Med. Journ., ^lay 1899. 
 
84 
 
 GASTRIC DISEASES 
 
 The chemical analyses of the gastric contents in this 
 patient showed that, in spite of delayed motility, there was 
 no variation from the normal in the secretion of hydro- 
 chloric acid. The volatile acidity, on the other hand, was very 
 markedly increased, the total in four analyses varying from 
 G to 16. 
 
 Permanent hypomotihty, or atonic dilatation of the stomach, 
 is a condition very frequently met with in practice. These are 
 among the cases in which one finds the well-known stomach 
 splash, the patients so often complaining that they feel as if 
 they had a hot-water bottle inside them. 
 
 TABLE 
 
 XII 
 
 —ANALYSIS OF GASTRIC CONTENTS IN 
 
 MOTOR 
 
 
 INSUFFICIENCY 
 
 
 
 Qualitative. 
 
 Quantitative. 
 
 Digestion in 
 minutes (//). 
 
 
 
 
 
 
 ^ 
 
 
 Case. 
 
 1 
 
 ci 
 
 pi 
 
 a 
 
 .2 
 
 hi 
 
 
 3 
 
 2 
 
 1 
 
 2 
 1 
 
 IICl. 
 
 
 H 
 
 1 
 
 1 
 
 
 1 
 
 1 
 
 3 
 3 
 
 B. 55 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 96 
 
 6 
 
 0-41 
 
 0-03 
 
 0-24 
 
 0-14 
 
 2 
 
 C.54 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 + 
 
 lUO 
 
 7 
 
 0-41 
 
 0-U3 
 
 0-28 
 
 0-10 
 
 3 
 
 2 
 
 4 
 
 M. 2 
 
 acid 
 
 
 
 + 
 
 + 
 
 
 
 58 
 
 7-2 
 
 0-24 
 
 0-00 
 
 0-12 
 
 0-12 
 
 8 
 
 9 
 
 16 
 
 M. 59 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 37 
 
 9-8 
 
 0-18 
 
 0-UO 
 
 0-10 
 
 0-08 
 
 
 
 35 
 
 
 
 A. 68 
 
 acid 
 
 -1- 
 
 H- 
 
 + 
 
 + 
 
 98 
 
 12 
 
 0-34 
 
 U-U3 
 
 0-24 
 
 0-08 
 
 2 
 
 3 
 
 5 
 
 S. 26 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 CO 
 
 12-6 
 
 0-24 
 
 0-01 
 
 0-23 
 
 0-0 
 
 8 
 
 7 
 
 9 
 
 S. 43 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 8U 
 
 16 
 
 0-28 
 
 U'U2 
 
 0-16 
 
 0-11 
 
 3 
 
 h 
 
 5 
 
 1'. 98 
 
 acid 
 
 -1- 
 
 + 
 
 + 
 
 + 
 
 58 
 
 17 
 
 0-25 
 
 froo 
 
 0-18 
 
 0-07 
 
 
 
 11 
 
 
 
 T. 75 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 u 
 
 44 
 
 18 
 
 0-17 
 
 0-UO 
 
 0-11 
 
 0-06 
 
 40 
 
 12 
 
 
 
 N. 4 
 
 acid 
 
 + + 
 
 + 
 
 + 
 
 62 
 
 18-8 
 
 0.3, 
 
 O'OO 
 
 0-17 
 
 0-14 
 
 25 
 
 12 
 
 1 ' 
 
 (II) Kxpresscd in c.c. of Jg N. solution of NaOII. 
 (h) 1. Filtered Gastric contents and carmine librin. 
 
 and equal (juantity O'l p.c. TICI. 
 of water. 
 
 In Table XII. we have given ten cases with their analyses 
 as types of the condition of uncomplicated dilatation of the 
 stomach. In most cases one finds an increased quantity of 
 gastric contents after a test breakfast. 
 
FUNCTIONAL DISEASES OF THE STOMACH 85 
 
 Qualitative Analysis. — The reaction in nearly all cases 
 of true motor insufficiency which we have come across has 
 been distinctly acid ; in few cases have we foimd even a 
 neutral reaction. 
 
 Free hydrochloric acid is present in the majority of cases, 
 although a negative reaction is sometimes obtained. 
 
 Lactic acid would appear to be increased in most cases, and even 
 when Boas's oatmeal porridge has been given, lactic acid will 
 generally be found, though never in any great quantity, thus 
 helping to distinguish the condition from that of gastric car- 
 cinoma. 
 
 Butyric acid is seen to be present in all the cases of hypo- 
 motility which we have given in the table, and this is due to 
 stagnation of the gastric contents leading to butyric fermenta- 
 tion. 
 
 Mucus is sometimes found in cases of atonic dilatation of the 
 stomach, although in the most typical cases it is absent. In 
 the table we see that the latter occurred in six cases out of ten. 
 
 Quantitative Analysis. — The total acidity in motor 
 insufficiency varies very considerably, some analyses showing 
 excessive acidity, while in others it is diminished, according to 
 the direction in which the secretory functions are affected. In 
 the cases given, the total acidity varies from 37 to 100. 
 
 The volatile acids in cases of atonic dilatation of the stomach 
 appear always to be increased ; in some cases the increase is 
 shght (in these it is generally found that hyperhydrochloria 
 is marked), and the excess is never to be compared with what 
 one finds in organic constriction of the pyloric region, leading 
 to dilatation of the stomach. In the cases in the table, the 
 volatile acids are seen to vary from 6 to 18'8. 
 
 Quantitative Analysis of Hydrochloric Acid. — 
 The total hydrochloric acid in these cases of atonic dilata- 
 tion of the stomach varied from 0-17 to 0-41 per cent., so that 
 the same wide range which we found in the total acidity 
 occurs also in the quantity of hydrochloric acid in the gastric 
 contents. 
 
 In some cases there is an entire absence of free hydrochloric 
 acid, while in others it may be as high as 0'03 per cent. 
 
 The amount of chlorine combined with the proteids varies 
 very much, but in no purely functional case that we have seen 
 
86 GASTRIC DISEASES 
 
 has there been an entire absence of hydrochloric acid combined 
 with proteids. In the table, it ranges between O'lO andO'28 
 per cent. 
 
 The quantity of chlorine combined with the minerals varies 
 as much as the other chlorides ; in the cases given, from 06 
 to 0"14 per cent. 
 
 Digestion — The digestion experiments with carmine 
 fibrin show the same differences as have been found in the 
 substances already mentioned. In only two cases was the 
 ferment in the form of pepsinogen, requiring the addition of 
 hydrochloric acid before it became active. In other cases the 
 digestion is practically normal, while in others again there is a 
 tendency to delay. In no case, however, of atonic dilatation 
 of the stomach have we noted an absence of both pepsin and 
 pepsinogen. 
 
 It will thus be seen that the quantitative analysis gives us 
 little assistance in making a diagnosis, except so far as the 
 volatile acids are concerned. The chemical analysis in cases 
 of atonic dilatation of the stomach or motor insufficiency shows 
 that the condition may be accompanied by either hyperhydro- 
 chloria or hypohydrochloria. In spite of the chemical analysis 
 not enabling us to make a diagnosis, the use of test meals is 
 invaluable. For by this means, we are able to recognise delayed 
 motility even when a test breakfast only is given, while the 
 recognition is even more simple when a test meal containing 
 meat is given and one finds considerable delay in the passage 
 of food from the stomach. 
 
 Insufficiency of the cardiac end of the stomach may lead to 
 regurgitation so that, for no apparent reason, the food suddenly 
 returns into the mouth. The chemical analysis in such cases 
 not uncommonly shows hyperhydrochloria, although one does 
 sometimes find regurgitation where only very shght alterations 
 in the gastric secretions occur. In a group of cases of psychical 
 regurgitation, the gastric contents may be found by chemical 
 analysis to be perfectly normal, the regurgitation being due 
 to some perij^heral or central stimulation of the vagus leading 
 to inhibition of the nerves of the cardiac end of the stomach. 
 
 Insufficiency of the pylorus is not often perceptible to the 
 patient, and is, therefore, seldom brought to the notice of the 
 doctor. When sodium carbonate and citric acid are given so 
 
FUNCTIONAL DISEASES OF THE STOMACH 87 
 
 as to form carbonic acid, or when the stomach is distiuided with 
 air, one finds that, instead of the stomach being blown out as 
 in a normal manner (so that one can easily map it out by per- 
 cussion), the gas keeps on passing into the intestine, and no 
 tympanitic area can be obtained. The analysis of the gastric 
 contents in some cases of insufficiency of the pylorus shows 
 nothing abnormal, although, as a rule, the secretory functions of 
 the stomach are altered. 
 
CHAPTER XIII 
 
 FUNCTIONAL DISEASES OF THE STOMACH (cow^niwerf)— SENSORY 
 NEUROSES, HYPER.ESTHESIA, GASTRALGIA, AN/ESTHESIA, 
 AND VOMITING NEUROSIS 
 
 Hypek^sthesia, or increased sensibility of the stomacli, can 
 be divided into liyperaesthesia causing general sensations de- 
 scribed by the patient as dyspepsia, and the more exaggerated 
 condition known as gastralgia. Hyperaesthesia ought to 
 include all sensations of indigestion— whether of pain or dis- 
 comfort — in cases where one does not find sufficient alteration:; 
 in the stomach or its contents to account for such sensations ; 
 since the process of digestion ought to be insensibly carried on. 
 
 In Table XIII. we have placed together, under the heading 
 of Gastric Hyperaesthesia, eight cases in which the patient 
 suffered from very severe pain or discomfort at periods varying 
 from one to two hours after food, or in the middle of the night. 
 Examination of the motor-power of the stomach showed no 
 real delay in motility. 
 
 The quantity of gastric contents after a test breakfast varies 
 very considerably, and gives no definite information. 
 
 Qualitative Analysis.— The reaction in all cases was 
 distinctly acid, and in no cas-.i was there even a neutral reaction. 
 Free hydrochloric acid was absent in two of' the cases, the 
 other six giving a distinctly positive reaction. 
 
 Lactic acid was present after the ordinary test breakfast, 
 but in no case was there any apparent excess. 
 
 Butyric acid was absent in four of the cases, and in those 
 in which it was present there was never a very large quantity. 
 Mucus was found in two of the cases, but it was not constant. 
 Quantitative Analysis.— The total acidity in these 
 cases, as would be expected from our definition, was prac- 
 tically normal. In one of the cases it was as much as 77 
 which would allow of its being classified as hyperhydrochloria ; 
 
FUNCTIONAL DISEASES OF THE STOMACH 
 
 80 
 
 at the same time, the degree of pain and discomfort in this case 
 was altogether out of proportion to the amount of acidity when 
 we consider that the stomach may have an acidity of 100 without 
 any marked symptoms of dyspepsia, and it is, therefore, as well 
 to include the case in hyperaesthesia, especially as there was no 
 increase in the volatile acids. The rest of the cases show a 
 practically normal acidity. 
 
 TABLE XIII.— ANALYSIS OF GASTRIC CONTENTS IN 
 GASTRIC HYPER.ESTHESIA 
 
 
 Qualitative. 
 
 
 
 Quantitati\ 
 
 e. 
 
 
 Diy-estion in 
 
 
 
 
 
 
 -< 
 
 ^ 
 
 
 
 
 minutes (h). 
 
 Case. 
 
 i 
 
 1 
 
 3 
 
 3 
 
 .2 
 
 1 
 
 1 
 .2 
 
 1 
 
 i 
 
 3 
 
 1 
 "a 
 1 
 
 1 
 
 HCl. 
 
 
 
 
 3 
 
 a 
 
 1 
 
 i 
 
 1 
 
 2 
 
 3 
 
 31. 2 
 
 acid 
 
 
 
 + 
 
 + 
 
 
 
 52 
 
 5 
 
 0-28 
 
 O'ou 
 
 U-17 
 
 U'll 
 
 
 
 « 
 
 
 
 S. 
 
 acid 
 
 A- 
 
 + 
 
 + 
 
 
 
 G3 
 
 4 
 
 0-30 
 
 U-02 
 
 0-15 
 
 0'12 
 
 10 
 
 8 
 
 18 
 
 B. 27 
 
 acid 
 
 + 
 
 + 
 
 
 
 + 
 
 77 
 
 2 
 
 U-20 
 
 u-ul 
 
 0-15 
 
 0-0 4 
 
 5 
 
 4 
 
 
 J. 39 
 
 acid 
 
 + 
 
 + 
 
 + 
 
 
 
 58 
 
 5 
 
 U-29 
 
 U"02 
 
 0-17 
 
 0-10 
 
 4 
 
 i 
 
 7 
 
 S. 48 
 
 acid 
 
 
 
 + 
 
 + 
 
 + 
 
 50 
 
 4 
 
 0-20 
 
 0-00 
 
 0-13 
 
 0-07 
 
 20 
 
 8 
 
 
 
 N. 50 
 
 icid 
 
 + 
 
 + 
 
 
 
 
 
 4 
 
 4 
 
 lJ-28 
 
 0'04 
 
 0-12 
 
 ()-12 
 
 6 
 
 4 
 
 8 
 
 M. 61 
 
 acid 
 
 + 
 
 + 
 
 
 
 
 
 OG 
 
 3 
 
 0-27 
 
 0-02 
 
 U-21 
 
 -It 1 
 
 2 
 
 3 
 
 2 
 
 B. 64 
 
 acid 
 
 + 
 
 + 
 
 
 
 
 
 56 
 
 2 
 
 U-25 
 
 0-01 
 
 0-18 
 
 0-06 
 
 15 
 
 4 
 
 2.-. 
 
 (rt) Expre.-sed in c.c. of ^\ N. .solution of NaOH. 
 (6) 1. Filtered G.istiic contents and carmine librin. 
 
 uid ("(jual quantity tfl p.c. HCI. 
 ,, ,, of water. 
 
 The volatile acids are seen to be not much increased, only in 
 two cases amounting to 5. We have often noted that an 
 increase of butyric acid or of the volatile acids causes an exces- 
 sive degree of pain, and if the pain in these cases was caused 
 by ever so small an amount of acidity, one sees that a sensa- 
 tion of pain is very easily set up in a hyper-sensitive stomach 
 by this irritant. 
 
 Quantitative Analysis of Hydrochloric Acid.— The 
 total hydrochloric acid can be regarded as normal in all the cases, 
 free hydrochloric acid being present in all but two of them. 
 
90 GASTRIC DISEASES 
 
 The quantity of hydrochloric acid combined with proteids 
 was, in all cases, what one would expect to find in normal gastric 
 contents, and shows nothing of interest. 
 
 The chlorine combined with the minerals was what one finds 
 in stomach analyses where there is not much the matter. 
 
 Digestion. — The experiments with carmine fibrin showed 
 that in all but one case pepsin was present, and even in this case, 
 digestion occurred in eight minutes with the addition of four 
 per mille hydrochloric acid, showing that pepsinogen was present. 
 In all probabihty, rennin is also present in the majority of cases. 
 
 It would appear from the consideration of these analyses 
 that when the motor-power of the stomach is found to be normal, 
 one must recognise that, under certain circumstances, a condition 
 of hypersesthesia may exist. The fact that the analysis is 
 negative makes it all the more valuable, as it precludes the 
 possibility of any gastric disease accounting for the symptoms 
 of indigestion. The testimony of a normal gastric juice secretion 
 justifies one in considering the case to be one of gastric hyperajs- 
 thesia of the mucous membrane, and treating it as an entirely 
 neurotic condition. Still further, seeing that the digestion is 
 really normal in these cases where the patients complained of 
 indigestion, it is best in the matter of diet not necessarily to 
 order that which is the most easily digested and assimilated, 
 but rather to give a generous diet, and ensure th: patient's 
 ialdng a proper amount of nourishment, thus educating the 
 tier V ous system to stand a stimulating and normal diet. 
 
 GASTRALGIA 
 
 Cases where one gets acute pain, sometimes described as 
 agony, and almost resembling that which occurs in gastric ulcer, 
 may be diagnosed as gastralgia. In such cases, it must be 
 remembered that unless one finds the gastric contents normal 
 in a series of analyses, one is not justified in calling it gastralgia. 
 Where hyperhydrochloria accompanies the condition, one will 
 be prepared to diagnose it as a case of gastric ulcer, wliile in 
 cases where hypohydrochloria is found, one might be led_to 
 diagnose carcinoma of the stomach. So that, in gastralgia as 
 in hypera^sthesia, the chemical analyses, although they give 
 normal results, are of great value in helping to make a diagnosis. 
 
FUNC'TIONAL DISEASES OF THE STOMACH 1)1 
 
 GASTRIC ANESTHESIA 
 
 Tlio condition of diminished sensibility of the stomach is 
 difficult to recognise in cases where the gastric contents arc 
 found to be normal, since, in the normal stomach, digestion is 
 carried on so peacefully that no inconvenience is attached to 
 it, and no sensations of either pain or discomfort are experienced 
 after the taking of food. This being the case, we can see that 
 the healthy individual has a non-sensitive stomach. On the 
 other hand, chemical analysis will show that there are cases 
 in which this non-sensibility of the stomach is carried to 
 extremes. In the examination of healthy individuals, such 
 as students in the laboratory, &c., it is not at all uncommon 
 to find that after the taking of a test meal, the stomach contents 
 are anything but normal, although the patient has suffered from 
 no symptoms of indigestion, and is rather indignant at being 
 told that his stomach is not secreting normal gastric juice. We 
 have come across several cases where hyperhydrochloria existed 
 to a considerable extent in an individual suffering from no 
 gastric symptoms whatsoever. In Table XIV. we give one 
 case of gastric anaesthesia to illustrate this condition. 
 
 TABLE XIV.— ANALYSIS OF GASTRIC CONTENTS IN 
 GASTRIC AN/ESTHESIA 
 
 
 Qualitative. 
 
 
 
 
 Quantitative. 
 
 
 DifiPstiou in 
 minutes (6). 
 
 
 
 
 
 
 
 _; 
 
 
 
 Case. 
 
 i 
 
 
 2 
 
 '% 
 
 
 -• 
 
 ■a 
 
 HCI. 
 
 
 
 
 i 
 
 ^ 
 
 o 
 
 
 s 
 s 
 
 ^ 
 
 i 
 
 
 
 ~ 
 
 -■ 
 
 
 
 
 
 1 
 
 
 ^ 
 
 
 t^ 
 
 CS 
 
 ^ 
 
 ? 
 
 t 
 
 ■S 
 
 
 1 
 
 2 
 
 3 
 
 
 
 
 
 « 
 
 
 ^ 
 
 o 
 
 H 
 
 * 
 
 £ 
 
 s 
 
 
 
 
 B. 52 
 
 acid 
 
 + 
 
 + 
 
 
 
 
 
 118 
 
 C 
 
 0-47 
 
 0-04 
 
 0-27 
 
 0-11 
 
 3 
 
 4 
 
 6 
 
 (a) Kxprcsscd in c.c. of j-\, N. solution of Na OH. 
 {b) 1. Filtered Gastric caiitoiits and carmine librin. 
 
 and e(iual ([uantity (Vl i).c. IlCl. 
 
 „ ,, of W.ltcT. 
 
 In a healthy doctor, aged thirty, the analysis of the gastric 
 contents after a test breakfast showed a condition of hyper- 
 hydrochloria with shghtly increased volatile acids. On looking 
 at the table, one sees that otherwise the digestion was carried 
 
92 GASTRIC DISEASES 
 
 on well, and in spite of this hyperhydrochloria, the patient 
 suffered from no symptoms of indigestion whatsoever. When 
 one remembers that hyperhydrochloria with a total acidity of 
 about 100 will sometimes cause considerable symptoms of acid 
 dyspepsia, one must recognise that, in addition to a condition 
 of hypersesthesia, which has already been illustrated, there is 
 also a condition of gastric analgesia. 
 
 VOMITING NEUROSIS 
 
 A full description of neurotic vomiting need not be given here, 
 but a few words must be said mth regard to the vomiting due 
 to nervous causes, as it is of great importance in making a 
 diagnosis to recognise that such cases are due to nervous influ- 
 ences, and are not true dyspepsia. Cerebral vomiting, due to some 
 lesion in the brain, is not at all uncommon, and at the commence- 
 ment of a case of cerebral vomiting, one finds that the gastric 
 contents contain a considerable quantity of butyric acid, due 
 to delayed motility. When the vomiting has been frequent, 
 the later vomits no longer contain butyric acid, and may consist 
 simply of bile-stained fluid, containing a little mucus. In cases 
 where one has been able to give a test breakfast, one finds the 
 gastric analysis to differ very Httle from what one expects 
 to find in health. In spinal lesions, the same is found, and 
 the gastric crisis of tabes dorsahs is also illustrative of this 
 condition. In neurasthenia it is not at all uncommon for 
 neurotic vomiting to occur periodically, while in hysteria, one 
 gets hysterical vomiting. In these cases, which are apparently 
 due to irritation of the vomiting centre, the chemical analysis 
 of the vomit is not sufficiently pathological to account for the 
 condition, and the diagnosis must be made by careful investiga- 
 tion of the symptoms and other signs of the disease, a detailed 
 analysis being of little use to the clinician, who must take each 
 case on its own merits. 
 
PAP.T 11. DISEASES OF THE 
 INTESTINES 
 
 CHAPTER XIV 
 
 TEST MEALS FOR THE INVESTIGATION OF INTESTINAL DISEASES 
 —MILK, SCHxMIDT'S, MIXED AND MEAT DIETS 
 
 Apparently for aesthetic reasons, the examination of the fajces 
 has been very much neglected by medical men in general, and 
 in spite of the fact that it is impossible to diagnose some of the 
 diseases of the bowel without a thorough examination of the 
 faeces, our knowledge of the chemical composition of the stools 
 under pathological conditions is very much less than our know- 
 ledge of the stomach contents in gastric disease. It is un- 
 fortunate that such should be the state of affairs, since many of 
 the slighter forms of intestinal dyspepsia lead to alterations in 
 the faeces, and the recognition of these is a considerable aid in 
 making a diagnosis. 
 
 As a consequence of investigations into the fa3ces having been 
 made so scantily, our knowledge is most imperfect, and it will 
 be impossible for us to give more than a sketchy outline of the 
 general alterations which occur in the stools in certain patho- 
 logical states. 
 
 The fffices, as we know, consist of undigested and indigestible 
 substances taken in the food ; at the same time, they also 
 consist of more or less changed digestive secretion which is 
 poured into the alimentary canal, together with numerous 
 bacteria, the bacteria of the faeces having been shown by 
 Strasburger ^ to represent in health no less than one-third of the 
 dry substance, while imder pathological conditions the propor- 
 tion may be very much larger. 
 
 1 Zeit. /. Klin. Med., -10, 1902, p. -113 and 48 ; 1903, p. 495. 
 
94 INTESTINAL DISEASES 
 
 Thanks to Strasburger and Schmidt, we have an excellent 
 work " Die Fsoces des Menschen," which comprises the general 
 facts at present known as regards the analysis of the fseces. 
 
 The diet has a very marked influence on the appearance of 
 the faeces, and in comparing the stools under pathological con- 
 ditions, it is absolutely essential to have some fixed diet. We 
 all know how widely the stools of an individual on milk 
 alone differ from those of an individual on an ordinary mixed 
 diet, and if the normal white stool which one sees on a milk 
 diet occurred on a mixed diet, it would be pathological. The 
 proper investigation of the faeces, therefore, necessitates certain 
 diets being given, comparison being made of the fa3ces on these 
 diets only. It is further necessary to keep the patient on the 
 same diet for a period of three to five days, so as to obtain a 
 normal motion on the special diet. In all chemical investigation 
 of the faeces, whether in health or disease, it is necessary to 
 collect all the motions belonging to a three- to five-day period, 
 giving some indicator so as to isolate — both at the commence- 
 ment and at the end of the period during which the diet is being 
 taken — the stools passed on the fixed diet. The faeces are then 
 collected from the first appearance of the indicator up to the 
 time when the second dose is seen to appear in the stools. All 
 the motions passed during this period are either separately 
 analysed, or to save time, the whole may be analysed together 
 alter being thoroughly mixed. 
 
 With regard to the choice of diets for analysis, it is necessary 
 to have a selection, so that one may suit individual requirements 
 in the various pathological conditions. One must also bear in 
 mind the necessity of providing the various ingredients (carbo- 
 hydrates, fat, and proteid) in convenient quantities, and in a 
 form which will be more or less easily utihsed by the ahmentary 
 canal. 
 
 The diets which we have found the most useful for analytical 
 purposes are four in number ; these are found to simplify the 
 normal standards for comparison, while providing sufficient 
 variety to enable one to deal with patients suifering from divers 
 diseases, in some of which a more substantial diet could not be 
 tolerated. 
 
INTESTINAL CONTENTS AND TEST MEALS 95 
 
 L— MILK DIET 
 
 Milk is the simplest of all diets, containing as it does, proteid, 
 fat, and carbohydrates in a form comparatively easily absorbed, 
 thus affording a diet which can be employed in cases of severe 
 intestinal derangement where no other food could be given. 
 
 The milk is best given at two-hour intervals, the quantity 
 being varied according to the weight and general condition of 
 the patient. As a rule, ten ounces of milk every two hours 
 from 8 A.M. to 10 p.m. — making a total of four pints in the 
 twenty-four hours — ^is a suitable diet, and this contains 85-00 
 grams of proteid, 84*00 grams of fat, and lOG-40 grams of carbo- 
 hydrates, so that the individual receives a total of 15G1-8-A 
 Calories in the twenty-four hours. 
 
 In cases where the patient is unable to take milk, and as pre- 
 digested milk cannot be employed in the investigation of absorp- 
 tion, one must endeavour to get over the difficulty by decreasing 
 the quantity, gi^dng it hot or cold according to the idiosyncrasy 
 of the patient, or adding a small measured quantity of hme 
 or barley-water to each glass of milk. When the latter plan 
 is adopted, it must be remembered that barley-water contains 
 a certain amount of carbohydrates, and the carbohydrates 
 thus obtained must be added to those contained in the milk 
 itself in calculating the total Calories. In cases where the bulk of 
 fluid is the patient's difficulty, the amount of nourishment in a 
 given quantity of fluid may be increased by evaporating the milk 
 to one-third its volume over a water-bath. 
 
 II.— SCHMIDT'S DIET^ 
 
 7-30 A.M.— Milk 17J oz. (or if milk is very badly borne, 
 cocoa made from f oz. cocoa-powder, 3- oz. sugar, I oz. water, 
 3| oz. milk), and 6 biscuits.^ 
 
 9 A.M. — Gruel made from U oz. oatmeal, ^ oz. butter, 7 oz. 
 milk, 10| oz. water, 1 egg, and 2 biscuits. 
 
 1 P.M. — 4| oz. (raw weight) minced beef, lightly fried in 
 ^ oz. butter (so that the interior remains raw), and potato 
 
 1 Die Funktionspriilu7i(j dcs Dunnes miUcls der Prohckost, &c. Wiesbaden 
 1904, p. 7. 
 
 2 Schmidt gives rusks, but we find it more convenient to cnii)l()y Mackenzie's 
 toast biscuits, the analysis of which is given in tiie Apiwndix. 
 
96 INTESTINAL DISEASES 
 
 piLr4c made from 7 oz. mashed potatoes, 7 oz. milk, I oz. 
 butter. 
 
 4-30 P.M.— Milk 17| oz. 
 
 7-30 P.M.— Same as at 9 a.m. 
 
 This diet contains 118-00 grams proteid, 104-86 grams fat, 
 and 204-48 grams carbohydrates, so that the total quantity 
 given each day will be 2297-37 Calories.^ 
 
 The advantage of Schmidt's diet over a simple milk diet is 
 that it gives us various constituents of food more resembling 
 a normal diet ; at the same time, the food has not been so altered 
 in the cuhnary process that the ingredients are difficult to 
 recognise microscopically. 
 
 The faeces which are passed on Schmidt's diet can be very 
 easily examined both microscopically and chemically, and it 
 is undoubteilly a very useful diet in the investigation of most 
 intestinal corr.] laints. On the other hand, the diet has che very 
 serious disadvantage that Enghsh patients, as a rule, object to 
 taking it for many consecutive days. It cannot, therefore, be 
 called a suitable diet for making metabolism observations. 
 
 III.— MIXED DIET 
 
 The mixed diet, which, after twelve years of experimental 
 work on human metabohsm, we find to yield the best results 
 for the investigation of absorption and general metabolism 
 of patients suffering from malnutrition, is as follows : 
 
 8 A.M. — 10 oz. hot water. 
 
 9 A.M. — 3 oz. whiting, 4 Mackenzie's toast biscuits, J oz. 
 butter, 10 oz. tea, 2 oz. milk. 
 
 12 noon. — 10 oz. hot water. 
 
 1 P.M. — 3 oz. mutton, 3 oz. cabbage, rice pudding {\ oz. 
 rice 10 oz. milk),^ 4 biscuits, \ oz. butter. 
 4-30 P.M. — 10 oz. tea, 2 oz. milk, 2 biscuits. 
 
 6 P.M. — 10 oz. hot water. 
 
 7 P.M. — 3 oz. plaice, 3 oz. chicken, 3 oz. spinach, rice 
 pudding (i oz. rice 10 oz. milk), 2 biscuits, I oz. butter. 
 
 1 Schmidt gives 102 grams proteid, 111 grams fat. and 101 grams carbo- 
 hydrates, with a cakn-ic value of 22:}-4 Calories, hut our tigures are the results of 
 repeated analyses of tho food-stuffs we employ. 
 
 2 'I'hisriec pudding is very fluid unless carefully piepared, and re(piires extra 
 tinu! in cooking; so that sometimes it is preferable to use only S oz. milk. 
 
INTESTINAL CONTENTS AND TEST MEALS 97 
 
 10 P.M.— 10 oz. milk. 
 
 This diet contains 13081 grams proteid, 72-19 grams fat, and 
 119'35 grams carbohydrates, so that 1697"03 Calories are given 
 in the twenty-four hours. 
 
 According to the weight and appetite of the patient, the diet 
 may be increased to 4 oz., or decreased to 2 oz. If it is 
 desired to increase the Calories in a certain direction, the easiest 
 way is to add a measured quantity of milk, taking as a 
 standard that 10 oz. of milk contain 10'63 grams proteid, 
 10'50 grams fat, and 1330 grams carbohydrates, making a 
 total of 195-20 Calories. 
 
 For purposes of analysis, we give in the Appendix an ana- 
 lytical resume, of the various food-stuffs employed in the mixed 
 diet given for metabolism experiments. The tables given 
 are based on averages obtained in numerous analyses, specimens 
 of each article of diet having been taken before administration 
 to the patient. By substituting another food-stuff for any 
 article of food given in the above diet, the individual idiosyncrasies 
 of patients may be suited. 
 
 The faeces on this mixed diet can easily be compared with 
 one another, and for quantitative chemical analyses, it would 
 appear to be the best suited. The diet is a more desirable one 
 than Schmidt's, as the patients can be kept on it for a much 
 longer period Avithout being nauseated, and the results are, 
 therefore, more accurate. The disadvantage of the diet is that 
 in cooking, &c., the food is so much altered that microscopic 
 examination does not give such definite results as are obtained 
 in Schmidt's simpler diet. 
 
 We find it advisable in many cases to put the patient for a 
 short period on Schmidt's diet, in order to give an opportunity of 
 making a microscopic examination, and having a quahtative 
 chemical examination of the faeces, and to follow this by a 
 second test period on a mixed diet, during which a quantitative, 
 as well as a quahtative, analysis can be carried out. 
 
 IV.— MEAT DIET 
 
 In some cases where the condition of the patient does not 
 allow of Schmidt's diet or a mixed diet, and where one cannot 
 give milk on account of some individual idiosyncrasy, we have 
 
 G 
 
98 INTESTINAL DISEASES 
 
 found a simple meat diet to be useful. The patient takes I to 
 J lb. of finely minced beef every tliree or four hours, and one 
 hour before each meals, 10 oz. of hot water. 
 
 The disadvantage of this diet is that the patient objects to 
 taking large quantities of meat, and for this reason it is difficult 
 to give sufficient Calories in the twenty-four hours to keep up 
 the weight. By giving J lb. of meat every three hours, one gets 
 a total of 1 lb. of minced beef per diem, and this diet consists of 
 145-5 grams proteid, 31-08 grams fat and no carbohydrates, 
 yielding a total of 885*59 Calories in the twenty-four hours. 
 
CHAPTER XV 
 
 QUANTITY OF F.ECES, COLOUR, CONSISTENCY, AND ODOUR 
 
 In the organism of a healthy individual there are various 
 factors which have a great influence on the Cjuantity of faeces 
 passed. V. Oefele ^ shows that a single motion may contain from 
 100 to 250 grams with thirty to forty grams of sohds, while 
 Lynch ^ describes a case of prolonged constipation in which no 
 less than twenty kilos were passed. 
 
 The quantity of motion passed under ordinary circumstances 
 varies from day to day, so that no conclusions can be drawn 
 from the examination of a single stool, it being essential to take 
 the average of a period of observation ; the longer the period, 
 the more accurate Avill be the conclusions drawn as to the average 
 daily quantity. Individual sensations must not be taken as 
 any indication of the quantity of stools passed, for it will be 
 found that in most people the estimation of the quantity of faeces 
 is influenced by the hardness of the motions, thus leading to a 
 false and often exaggerated idea of the quantity passed. 
 
 The faeces, even during a period of fasting, are found to show 
 individual variations. Cetti, during a ten days' fast, passed 
 an average of no less than 22 grams of fresh faeces per 
 diem, the faeces containing 3-4 grams of dried substance ; while 
 Breithaupt, during a six days' fast, passed 9-5 grams of fresh faeces 
 containing 2 grams of dried substance (Fr. Miiller).^ 
 
 The age of the individual under observation has a marked 
 influence on the quantity of faeces passed, as is shown in 
 table XV. 
 
 It is seen that there is a general tendency to an increase in 
 the daily cj[uantity of faeces progressive mth the age of the 
 
 1 Statistische. Vergleichstabdlen zur practischen Koprolojie, &c., Jen. G> 
 Fischer, 1904, S. 58. 
 
 2 Coprologia Tesis, Buenos Aires, 189G, p. 38. 
 
 3 Berlin, Klin. Wochenschr., 1887, p. 434. 
 
100 
 
 INTESTINAL DISEASES 
 
 patient under observation. It will be noticed that a child on 
 ordinary cow's milk tends to pass a larger quantity of faeces 
 than when sucking the breast. This is in great part due to 
 the quantity of nourishment given ; when artificial feeding is 
 properly arranged, it has been found that the addition of cream 
 in a child being reared on cow's milk will make the fa3ces more 
 closely resemble those found on mother's milk. 
 
 TABLE XV.— INFLUENCE OF AGE ON THE QUANTITY OF FAECES ' 
 
 
 
 Averao-eiiuautity 
 
 
 Ago. 
 
 Diet. 
 
 of fresh fasces 
 per diem. 
 
 Observer. 
 
 1 month 
 
 Mother's milk 
 
 3"3 grams 
 
 Camerer & Hartmann 2 
 
 2-3 months 
 
 „ 
 
 6-5 
 
 „ 
 
 2-3 months 
 
 Cow's milk 
 
 51-6 
 
 Escherich 3 
 
 7 months 
 
 According to the food 
 
 15-56 „ 
 
 Various 
 
 9 months 
 
 Cow's milk 
 
 59 
 
 Camerer * 
 
 f-2 years 
 
 Mixed 
 
 77 
 
 
 4 years 
 
 
 101 
 
 Camerer & 
 
 6 years 
 
 „ 
 
 134 
 
 „ 
 
 9 years 
 
 
 117 
 
 „ 
 
 I 1 years 
 
 
 128 
 
 ,, 
 
 Adult 
 
 
 131 
 
 Pettenkofer and Voit o 
 
 The frequency of the motions has a marked influence on the 
 total quantity of faeces passed, and a diet which causes frequent 
 motions tends also to increase the total quantity. It is well 
 known that in health the kind of diet has a great influence on 
 the stools, a diet rich in meat tending to cause constipation, 
 while a diet rich in vegetables tends to increase the peristalsis 
 of the bowel, causing more frequent stools and a larger quantity 
 of faeces. 
 
 I We have already shown how we prefer to employ one of four 
 diets for the purpose of examination of the faeces under patho- 
 logical conditions, and it is only necessary for us to describe 
 the quantity of faeces found on these four diets, leaving further 
 details, which are purely physiological, out of consideration. 
 
 1 Strasburger and Schmidt, Die Faeces des Mcnschcn, p. 1 1. 
 
 2 Zeitschr. /. Biologic, xiv. 1878, p. 383. 
 
 3 Jahrb. f. Kinderheilkunde, xxvii. 1888, p. 104. 
 i Zeitschr. f. Biologic, xxxix. 1899, p. 37. 
 
 f. Ibid. xvi. 1888, p. 33. 
 e Ibid. ii. 1800. p. 488. 
 
i ^i: 
 
 QUANTITY OF F^ECE8 
 Quantity of Faeces on a Milk Diet. 
 
 ^^^ 
 
 III iudividualfi 
 
 on a milk diet, the quantity of faeces varies, acclitiirng^t/)/-cjij^ . 
 analyses, from GO to 288 grams, the average being i:33-;rgraTm*:-~, 
 The quantity of milk given has a very marked influence on the 
 quantity of faeces passed. 
 
 TABLE XVI.— QUANTITY OF F.ECES ON MILK DIET 
 
 Pints. 
 
 Cases. 
 
 Hi-hcst iu 
 
 Lowest iu 
 
 Average in 
 
 
 
 fjrams. 
 
 grams. 
 
 grams. 
 
 4 
 
 8 
 
 277 
 
 60 
 
 135-2 
 
 4.1 
 
 6 
 
 288 
 
 79 
 
 142-6 
 
 5 
 
 2 
 
 159 
 
 144 
 
 151-5 
 
 G 
 
 2 
 
 142 
 
 1.34 
 
 138-0 
 
 In Table XVI. we have put together observations in which 
 the patient took 4, 4|, 5 or 6 pints of milk per diem, and it is 
 
 seen that the quantity of faeces passed on these quantities 
 shows a tendency to increase with the increased quantity of milk. 
 Quantity of Faeces on a Schmidt's Diet.— On 
 this diet, the quantity of faeces varies from 56 to 135 grams, 
 the average being 89-8 grams, thus showing that Schmidt's diet 
 tends to cause a smaller cj^uantity of faeces than a simple milk 
 diet. 
 
 TABLE XVII.— QUANTITY OF F.ECES ON SCH.MIDTS DIET 
 
 Cases. 
 
 Highest in 
 grains. 
 
 Lowest in 
 gr.iiis. 
 
 Average in 
 grams. 
 
 8 
 
 135 
 
 56 
 
 89-8 
 
 Quantity of Faeces on a Mixed Diet.— The faeces 
 on an ordinary mixed diet show a variation from 30 to 282 grams 
 per diem, the average being 102-8 grams. 
 
 TABLE XVIII.— QUANTITY OF F.ECES ON MIXED DIET 
 
 Cases. 
 
 Highest iu 
 grams. 
 
 Lowest in 
 grams. 
 
 Average in 
 grams. 
 
 118 
 
 282 
 
 30 
 
 102-8 
 
102 
 
 INTESTINAL DISEASES 
 
 In discussing mixed diets in connection with examination 
 of the bowel, we mentioned that the introduction of milk was 
 the easiest method of increasing the Calories ; it is as well, 
 therefore, to give here the effect of increasing the quantity of 
 milk in a mixed diet on the quantity of faeces. In Table XIX. 
 the effects of the addition of 1^ pints, 2 pints, 2 J pints and 
 3 pints respectively are separately given. 
 
 TABLE XIX.— QUANTITY OF F.ECES ON MIXED DIET + INCREASING 
 QUANTITIES OF MILK 
 
 Piuts. 
 
 Cases. 
 
 Highest in 
 
 Lowest in 
 
 Aver i-e in 
 
 
 
 gnims. 
 
 
 
 H 
 
 35 
 
 314 
 
 52 
 
 117-3 
 
 2 
 
 24 
 
 283 
 
 55 
 
 101-6 
 
 2^ 
 
 12 
 
 282 
 
 82 
 
 137-6 
 
 3 
 
 5 
 
 225 
 
 65 
 
 139-4 
 
 It is seen that on IJ pints of milk the quantity of faeces varied 
 from 52 to 31 -i grams, j-ielding an average of 117-3 grams. When 
 2 pints were added to the ordinary mixed diet, the quantity 
 of faeces varied from 55 to 283 grams, giving an average 
 of 101 '6 grams, showing a sHght tendency to decrease in the 
 average quantity. When 2| pints of milk were added to the 
 diet, the quantity of faeces varied from 82 to 282 grams, yielding 
 an average of 137 6 grams, while on the 3 pints of milk, the 
 quantity of faeces varied from 65 to 225 grams, averaging 139-4 
 grams. In making a general comparison of results, it will be 
 seen that there is a tendency to increase in the quantity of 
 faeces in proportion to the increased quantity of milk given. 
 
 Quantity of Faeces on a Meat Diet. — The quantity of 
 faeces on a meat diet varied from 41 to 72 grams, the average of 
 six cases being 54-5 grams. It will be noticed that this is a 
 much smaller quantity than those found on the other diets 
 which we employ in the investigation of diseases of the bowel. 
 TABLE XX.— QUANTITY OF F^CES ON A MEAT DIET 
 
 Cases. 
 
 Hij?liest in 
 grams. 
 
 Lowest iu 
 grrams. 
 
 Average in 
 graas. 
 
 6 
 
 72 
 
 41 
 
 54-5 
 
QUANTITY OF F^CES 103 
 
 COLOUR, CONSISTENCY, AND ODOUR 
 
 Colour.— The colour of the interior of the fseces is not 
 always the same as that found on the surface, so that it is 
 important, when noting the colour, to have the motions 
 thoroughly broken up. 
 
 The normal colour of the stools is in part due to the diet. On 
 a mixed diet, the tendency is for the motions to be of a definite 
 brown colour, while if meat preponderates in the diet, the colour 
 may be blackish-brown, or even almost black. On a mixed diet 
 containing a large quantity of vegetable matter, the colour tends 
 to be hght brown or greenish-brown. In the majority of cases, 
 the green colour is due to chlorophyll which occurs when large 
 quantities of cabbage, salad, or more especially spinach, are 
 taken. Quincke has also shown that the hghtness of colour 
 on a vegetable diet is partly due to bubbles of gas which are 
 entangled in the large amount of residue left. The green colour 
 may be due to bacteria, while under pathological conditions, 
 it can be caused by bile. 
 
 The colour of the faces is also influenced to a certain extent 
 by the length of time they have remained in the large intestine, 
 since the normal absorption of water which occurs in the large 
 intestine especially influences the surface of the fa)ces ; so that 
 one may note a darkening of the outer layer (due to the greater 
 drying) and on moistening, the colour becomes distinctly lighter 
 (Fleischer). 
 
 On a milk diet, on the other hand, the fseces are white or 
 pale orange colour. 
 
 The colour of the faices is not influenced b}' bile as such, since 
 bile, as bilirubin cr bihverdin, does not occur in normal motions. 
 The colour is in great part due to urobilin, which has been formed 
 from the bile in its passage along the inte;itine after it has reached 
 the ca}cal valve. On extracting the faces with acid alcohol, one 
 is able to remove the greater part of the urobilin, which is easily 
 recognised by means of the spectroscope ; but even after repeated 
 extraction, the residue still has some colour. 
 
 As already stated, bilirubin as such is never normally present 
 in the stools of adults, although in early infancy it is always 
 present. In the ordinary breast-fed child, one gets a yellowish- 
 coloured motion due to bilirubin which is very easily converted 
 
lot INTESTINAL DISEASES 
 
 into biliverdin, and excreted as such when there is any disturb- 
 ance of the digestion, in which case we get the green motion 
 so commonly noticed in children. The conversion of the bili- 
 rubin into biliverdin would appear to be due to the acids (acetic 
 and butyric acid) which are formed by the disturbed digestion. 
 The green motions seen in children may, however, be due, not 
 to biliverdin, but to the products of a special bacteria causing 
 a green pigment. 
 
 In adults, bihverdin is never found in the motions except 
 after calomel or under pathological conditions. 
 
 In cases where the bile duct is obstructed, one gets the well- 
 known pipe-clay coloured stool which is in part due to the 
 absence of urobihn from the faeces. The Hght-coloured stool 
 found in jaundice is also partly due to the large amount of fat 
 present in the stools ; on extracting the fat with ether, one 
 obtains brownish-coloured faeces due to the heematin residue 
 of the meat diet. 
 
 That colourless stools may occur in the absence of obstruction 
 of the bile duct was shown by Walker^ in two cases, in both of 
 which it was demonstrated that the bile ducts were patent ; and it 
 would appear that the absence of the pancreatic juices explains 
 the deficiency of colour. 
 
 Dr. Walker drew attention to the fact that one may have 
 colourless stools without any jaundice. In fact, the normal 
 brown colour of the stools is due to the action of the pancreatic 
 juice on the bile pigments. He described two cases : 
 
 (1) T. W., a medical practitioner, passed colourless stools 
 for some twenty-four years. The stools were .described as 
 large, colourless stools with a peculiar putrid, rather than faecal, 
 odour. In course of time, the dejecta were accompanied by 
 free oil or fat which floated either as liquid or sohd substance 
 on the surface of the water, and the stools themselves were 
 greasy. During many years, the patient remained in good 
 health, and then had a slight attack of pneumonia, during which 
 he had s^me jaundice, with deep staining of the conjunctiva, 
 skin, and urine, thus conclusively showing that when real ob- 
 struction to the bile ducts appeared, jaundice occurred. When 
 on an Exclusively milk diet, the motions were snow-white ; they 
 were usually the large, rather relaxed putrescent, greasy, clay- 
 
 1 Med. Chir. Trans., 1880, vol. Ixxii. p. 257. 
 
QUANTITY OF F/ECES 105 
 
 coloured stools noted at the commencement of the disease. At 
 the age of ninety-one he died. At the autopsy, the liver was 
 normal, the pancreatic duct was dilated, and, at lh3 entrance to 
 the duodenum, was blocked by an irregular calculus. 
 
 (2) The second patient passed some colourless stools, and 
 at the autopsy, there was found to be no obstruction of the bile 
 ducts, but the opening of the pancreatic duct was blocked by a 
 duodenal cicatrix. 
 
 In some cases where there is no obstruction to the bile duct, 
 and apparently no increased quantity of fat to cause a colourless 
 motion, it would appear that the urobihn normally present in 
 the faeces has been converted into leuko-urobilin which is 
 colourless, and after exposure to the air, gradually becomes by 
 oxydation reconverted into urobilin, giving a coloured motion. 
 
 Medicaments may influence the colour of the stools. As 
 is well known, one gets, after bismuth, black faeces ; this used 
 to be considered due to the sulphide of bismuth, but as Quincke^ 
 has now shown, it is really due to the reduction of the bismuth 
 sub-nitrate to bismuth sub-oxide. Calomel also influences 
 the faeces by causing an increased excretion of bile, hastening 
 the bile along the alimentary canal and, in some cases, allowing 
 the bihverdin to be eliminated as such, instead of as urobihn. 
 Rhubarb, senna, and satonin cause yellowish-coloured stools 
 which, on being rendered alkaUne, become more red. 
 
 Consistency. — The consistency of the faeces, in absencs 
 of disease of the bowel, depends on : (1) The amount of water 
 present ; (2) the amount of fat present ; (3) the amount of mucus 
 present ; (4) the amount of indigestible remains of vegetable 
 matter. 
 
 The stools may be formed, and if hard, are more or less in 
 the shape of sausages, the size of the sausage depending upon 
 the size and tone of the anal orifice. If the rectum is narrowed 
 by stenosis, one may get pencil or ribbon-like motions. It has 
 been shown by Boas - that in true stenosis of the bowel, it is much 
 more common to get a pultaceous motion containing some long 
 or short pencil-like cyhnders than the narrow faeces alone. This 
 
 1 Vortrag in der Sitzung des physiolog. Vcreins zu Kiel am, 13, vii. 96. — 
 Refcrirt Miinch, med. Wochenschr., 1896, p. 854. 
 
 2 Diagnostik u. Tkempie der Darmkrankheiten, Leipzig, 1898 ; vo'. i. pp. 95 
 and 96. 
 
106 INTESTINAL DISEASES 
 
 alteration in shape is not conclusive evidence of narrowing of 
 the rectum or anal orifice ; in simple muscular spasm of the 
 muscles of the rectum or the anal orifice, or in paralysis of the 
 lower part of the large intestine, one gets some appearance of 
 pencil-like motions. The diagnosis is at once cleared up by the 
 insertion of the finger into the rectum. 
 
 Large, sausage-like motions are often found to be made up 
 of small balls massed together, w^hile in other cases one has a 
 cylinder with one or two balls pressed into it. These scybala 
 coming from the sacculi coli are remains of some previous days' 
 food, this being easily demonstrated when charcoal has been given. 
 
 The formed motions in constipation tend to be less and less 
 sausage-shaped, and more and more hke sheeps' motions, the 
 fsecal balls having facets, while in chronic constipation the balls 
 may become more and more isolated until one gets distinct 
 round balls or typical scybala. These scybala are due to the 
 long delay in the large intestine, and point to imperfect powder 
 of contraction of the muscles of the large intestine. 
 
 Loose motions may be divided into pultaceous motions 
 like those passed by cows, and watery motions which one 
 gets in cases of diarrhoea. There may be all kinds of gradations 
 between the pultaceous and the serous exudations which one 
 gets in cholera. It can be easily understood that, in cases of 
 diarrhoea, it is not at all uncommon to find a pultaceous, or 
 even a fluid, motion mixed up with some scybala, the explana- 
 tion of which has already been given. 
 
 It must be recognised that the pultaceous motion, when not 
 due to excess of fruit or vegetables in the diet, fat in the stools, 
 or aperients, is always pathological. The quantity of fat or 
 mucus in the stools has a great influence on the softness of the 
 motions, but these alterations will be considered in discussing 
 the pathological cases. 
 
 The brittleness of the motion depends, to a certain extent, 
 upon the equal mixture of its constituents. When milk is well 
 digested, one gets a very tenacious motion, while, when lumps 
 of casein are left owing to imperfect digestion, the motions 
 become leos coherent. Again, in fasting or on a pure meat diet, 
 the motions are very coherent. Where vegetables are given, 
 leaving a large amount of cellulose residue, one often gets more 
 or less brittle faces. 
 
QUANTITY OF FiKUES 107 
 
 Oiour The distinctive smell of faeces is due to the skatol 
 
 and small degree of indol normally present in them. Skatol 
 and indol are derived from the putrefaction of protsids in the 
 large intestine, and therefore the degree of odour present in the 
 faeces is dependent on the quantity of proteids in the diet, and 
 the quantity of putrefactive bacteria present in the large intes- 
 tine. On a milk diet in health, smell is almost absent in con- 
 sequence of the very small quantity of proteid reaching the 
 large intestine. A milk diet, when fermentation takes place 
 in the intestine, is very apt to cause acid-smelling faeces, due 
 to the presence of acetic and butyric acid. 
 
 Motions which contain a large amount of mucus often have 
 a seminal smell, which is very characteristic, though difficult 
 to explain. 
 
 Under certain conditions, the faeces have a putrid smell, quite 
 distinctive from indol and skatol ; this very often occurs in 
 maUgnant disease of the bowel, and also in dysentery. 
 
 Having briefly described the general characteristics of the 
 faeces so far as colour, consistency, and odour are concerned, 
 we can now group together the macroscopic appearance of the 
 faeces in individuals taking one or other of the four diets which 
 we employ in observation of bowel disease. 
 
 Colour, Consistency, and Odour on a Milk Diet.— 
 The colour of the faeces on a pure milk diet tends to be yellowish- 
 white or white tinged with orange. As a rule, the faeces are not 
 so well formed as those on an ordinary diet, and the rolls show 
 a tendency to have small lumps cemented together, while in 
 other cases the firm sausage-shaped stool is accompanied by 
 some soft paste. The hard white faeces passed on a milk diet 
 very often show a distinct pink shade of colour in patches on the 
 outside of the lump ^ or rolls, due to the products of bacteria. 
 
 In constipation,, the faeces on a milk diet take the form of 
 sheeps' motions or isolated scybala. Where the latter are 
 present, they are often so hard that they rattle like stone:; 
 when in a jar, and on breaking them up in a mortar they show 
 marked resistance, the pieces fljdng apart as though dry clay 
 pellets were being broken up. In such cases, it is not at all 
 uncommon to notice a definite earthy smell. 
 
 In diarrhoea on a milk diet, the appearance of the faeces 
 resembles Devonshire cream, the consistency being such that 
 
108 INTESTINAL DISEASES 
 
 they can be poured from the jar into a capsule in a thick, s'imy 
 mass, leaving a considerable quantity sticking to the glass. 
 Bubbles of gas are seen on the surface, and on shaking the 
 faeces, they will become very frothy. The odour of fseces in 
 diarrhoea often resembles that of decomposed cheese, while 
 in other cases they may smell like putrid proteid. 
 
 Colour, Consistency, and Odour on a Schmidt's 
 Diet. — The fajces, on a Schmidt's diet, are generally of a hght, 
 brownish-yellow colour, tending to a darker colour on the outside 
 than is found in the interior. Usually they are well-formed 
 rolls, while in some cases there are formed lumps or scybala. 
 The odour of the faeces on Schmidt's diet is pecuharly earthy. 
 The faeces are frequently brittle, and are easily broken up into 
 a fine powder on drying. In fact, they are more brittle and 
 more easily broken up than any fseces we have examined. 
 
 In constipation, the faeces on Schmidt's diet consist of lumps 
 massed together into sheep-hke motions, or scybala faceted 
 or isolated as in other diets. 
 
 In diarrha'a, the fseces on a Schmidt diet resemble those 
 found on a milk diet. 
 
 Colour, Consistency, and Odour on a Mixed Diet. 
 — The faeces on a milk diet are generally nut-brown or ohve- 
 green in colour. The latter is, as has already been explained, 
 due to the chlorophyll from the vegetables given in the 
 food. From day to day the colour varies considerably ; for 
 instance, in one day on a mixed diet, one may get distinctly 
 brown faeces, and on another day green, or perhaps a mixture 
 of the two, while, on a third day, they may be a dirty slate 
 colour. The motions on a mixed diet are generally in the form 
 of a sausage about 1| in. in diameter, and it is not at all un- 
 common to find, joined to these rolls, small round or flattened 
 lumps firmly embedded in the mass. On being dried, the 
 firm normal faeces on a mixed diet are rather brittle, easily 
 broken up and ground down in a mortar. On the other hand, 
 when one gets pasty or fluid faeces on a mixed diet, they tend 
 on drying, to become hard and glassy, with almost the appear- 
 ance of flint, and can only be ground down with great difficulty. 
 
 In constipation, the faeces on a mixed diet are dark brown 
 or black scybala, showing pressure facets ; mucus is generally 
 found in the crevices between these lumps. In some cases. 
 
QUANTITY OF F.^CES 109 
 
 the scybala are so hard that they resemble stones, and rattle 
 like the constipated faeces on a milk diet. The lumps are ex- 
 tremely difficult to break down when well-formed scybala are 
 present. The odour of these faeces is generally not very distinc- 
 tive of skatol and indol. 
 
 In diarrhoea, the faeces are very dark-brown, nearly black ; 
 the consistency is that of thick paste, and floating about in this 
 thick paste are small rolls or scybala about one to two inche;; 
 in diameter. The faeces are very sticky, and sometimes adhere 
 closely to the glass jar. Soft paste and fluid motions present 
 on a mixed diet have generally a very offensive odour. 
 
 The faeces in a mixed diet to which considerable quantities 
 of milk have been added in order to raise the Caloric value, tend 
 to be of a hght-brown colour, and according to the quantity 
 of milk added, resemble more and more the faeces seen in a milk 
 diet. The consistency is never so firm as that of faeces in an 
 individual on a mixed diet, without the addition of milk. 
 
 Colour, Consistency, and Odour on a Meat Diet. 
 — The colour of the faeces on a meat diet is very dark brown, 
 almost black. The consistency tends to be very firm, the 
 rolls varying in length. As a rule they are not longer than 
 two or three inches, and are generally quite separate from each 
 other. The odour on a pure meat diet is that of skatol and 
 indol, and under normal circumstances, is not very offensive. 
 
CHAPTER XYI 
 
 GENERAL EXAMINATION OF F^CES, MACROSCOPIC AND 
 MICROSCOPIC 
 
 After having noted the colour, consistency, and odour of the 
 faeces, it is necessary to make a general examination, and for 
 this purpose, it is advisable, after well mixing the faeces, to divide 
 them up, reserving the greater part for chemical analysis and 
 a smaller portion for macroscopic and microscopic examination, 
 
 MACROSCOPIC EXAMINATION 
 
 A portion about the size of a walnut is put into a mortar, and 
 by slowly adding water and grinding, the whole is brought to a 
 pea-soup consistency. It is well to have a glass dish, one half of 
 which is coloured black, and to pour the pea-soup-like mixture 
 into the dish. On running it about over the surface, one gets a 
 very good idea of the residue or particles of mucus that may be 
 left after breaking up the faeces. The examination Avill show 
 particles of mucus, fibrin, &c., connective or muscular tissue, and 
 any remnants of vegetable matter, and the particles can be taken 
 out if desired, and mounted on a slide for microscopic examination. 
 
 Mucus will only be recognisable under pathological "conditions, 
 and if found to be coloured yellow with bilirubin, it will indicate 
 that the mucus comes from the small intestine, while that coming 
 from the large intestine or the rectum will be very slightly yellow, 
 or more probably white. Floating about in the faeces may be seen 
 small sago-like bodies resembhng frog-spawn, which used to 
 be attributed to mucus coming from the intestinal follicles, but 
 are now known to be the remains of vegetable matter. These 
 sago-like bodies have only been found by us after a mixed diet ; 
 and in individuals who have been taking a large quantity of 
 vegetables, they are almost invariably present in the faeces. 
 They have no pathological significance. 
 
GENERAL EXAMINATION OF F^CES 111 
 
 Connective tissue or remains of tendon will be [found in 
 some cases where minced meat has been given, or a diet con- 
 taining under-cooked meat. The macroscopic appearance of this 
 connective tissue very much resembles that of mucus, but if 
 small particles are put under the microscope, they can be dis- 
 tinguished from mucus by the addition of acetic acid, which 
 removes the striation from connective tissue, while in the case 
 of mucus it produces striation. Small quantities of connective 
 tissue are occasionally found under normal conditions, but when 
 large quantities are present, it points to insufficient digestive 
 power of the stomach. The residue of muscular fibres can 
 occasionally be seen by the naked eye as small brown or reddish- 
 brown points, which will be immediately recognised under the 
 microscope. If large quantities of meat have been given in 
 the diet, these remains of muscle will be found in normal diges- 
 tion, but on the ordinary test-diet, more especially the mixed 
 diet, any muscular tissue which can be easily recognised by the 
 naked eye must be considered pathological, and points to dis- 
 turbance of the digestive power of the small intestine. 
 
 Ammonium magnesium phosphate, or triple phosphate 
 crystals are, in some cases, so large as to be seen macroscopically. 
 They are not present on an ordinary test-diet, if the faeces 
 examined are perfectly fresh ; if, however, the faeces have been 
 passed one or two days before examination, they are nearly 
 always present, especially if the fseces tend to be alkaline, or if 
 there is increased putrefaction. They probably have no patho- 
 logical significance. 
 
 Blood or pus can often be recognised in the thin layer floating 
 on the black half of the dish, or on the transparent half, if held 
 up to the light. Remains of undigested particles of food, bones, 
 bits of egg-shell, cellulose, or intestinal worms can also be recog- 
 nised by the naked eye. 
 
 MICROSCOPIC EXAMINATION 
 
 For the microscopic examination of the fa3ces, it is well to 
 prepare three or four shdes to receive the pea-soup-like mixture. 
 
 Muscular fibres will be easily recognised imder the micioscope , 
 their significance, when large quantities of meat have been given 
 in the diet is very slight, but when only small quantities of meat 
 
112 INTESTINAL DISEASES 
 
 have been taken, their presence is indicative of disease of the 
 aUmentary canal. If muscular fibre is found distinctly striated, 
 it is evident that intestinal digestion is hindered. 
 
 The recognition of connective tissue under the microscope is 
 merely confirmatory of its observance by the raked eye. 
 
 On a milk diet, when the digestion is disturbed, it is not at 
 all uncommon to find small flocculi of casein which will be easily 
 recognised, showing a distinct tendency to disturbed intestinal 
 digestion. 
 
 Yellow lumps, as described by Nothnagel, are very often 
 found. They can sometimes be seen by the naked eye, having 
 the appearance of small yellow points the size of a small pin's 
 head. Under the microscope, they will be seen to consist of 
 irregular-shaped masses of structureless yellow substance, very 
 often surromided by mucus. On the addition of sodium hydrate 
 they slowly dissolve, the solution being much hastened by heat- 
 ing. On the addition of acetic acid, these structureless masses 
 swell up, and if ferrocyanide of potassium is added, yield a 
 white precipitate. On the addition of Millon's solution and 
 heating, one obtains a red colour. 
 
 From the microchemical examination of these yellow lumps 
 it would appear that they are of an albuminous nature, and 
 coloured with bihrubin. The fact that they are coloured with 
 bihrubin, and not with urobilin, shows that a noimal reduction 
 of bile is not being carried on in the intestine, and, since the 
 yellow mas:es are so often embedded in mucus, and since they 
 do not occur in normal motions, they are evidently significant 
 of some inflammatory affection of the small intestine accompanied 
 by mucus formation. 
 
 Fat, if present in large quantities, would be recognised 
 macroscopically ; microscopically, one can recognise smaller 
 quantities, and in nearly all specimens of fa;ces, a certain amount 
 will be found to be present. If the fat has a low melting-point, 
 one will find it in the form of drops, while the higher melted fats 
 will be in regular flakes. On heating the slide, the neutral fat 
 will melt, and, on cooling again, form drops which will be easily 
 dissolved by hot alcohol, ether or chloroform, and will be un- 
 altered by the addition of sodium hydrate. 
 
 Fatty acids will be found partly in flakes, but much more 
 easily recognised in the needle-like crystals, which will give the 
 
GENERAL EXAMINATION OF FJEVEH 1 1:3 
 
 same reaction as the neutral fat, except that they are easily 
 soluble in cold alcohol and sodium hydrate. The soaps also 
 appear in the ftcces, partly in flakes and partly in crystals. Soap 
 flakes are less shiny, of a firmer consistency, and have sharp 
 corners, so that, practically, one is able to distinguish them from 
 the fatty acid or neutral fat flakes. They are easily dissolved 
 in hot water or alcohol, and on warming the preparation, they 
 melt in the same manner as the fatty acids and the neutral fats. 
 Under normal circumstances, one finds, on a meat diet, some 
 fat drops, while crystals of fat or fatty acids are rarely present 
 on the ordinary test-meals ; the presence of soaps is also not 
 characteristic of any special pathological condition, unless we 
 find them coloured with bihrubin, instead of urobihn ; thi^ 
 condition will indicate diminution in the reduction of bile in 
 the intestine. 
 
 It is not at all uncommon to find remnants of starch in the 
 faeces by the aid of the microscope, on using chemical tests. 
 The ordinary method of testing for starch is by adding a solution 
 of potassium iodide iodine, when the starch will become indigo 
 black. When any quantity of potato or other starchy food is 
 given in the diet, one obtains a very distinct colour reaction 
 with iodine. It is extremely difficult to say what degree of starch 
 in the fseces one ought to consider pathological, and a diagnosis 
 of want of carbohydrate absorption or breaking-up is probably 
 better made by Schmidt's fermentation test. 
 
 Ammonium magnesium phosphates are the commonest 
 crystals found in faeces, and are never coloured by bile ; and, as 
 we said when discussing the triple phosphate crystals macro- 
 scopically, they are in some cases so large that they can be 
 detected in the process of grinding. Crystals of triple phosphate 
 are easily soluble in dilute acetic or other acids, and on the 
 addition of ammonium solution, the crystals reappear. They 
 are uninfluenced by the addition of ammonium carbonate f^olution 
 and are thus distinguished from the basic magnesium phosphate. 
 Neutral phosphate of hme crystals (di-calcium-phosphate) are 
 not at all uncommon in the faeces, and are occasionally stained 
 by the bile pigments, which never occurs with the ammonium 
 magnesium phosphate crystals. They are soluble in all acids and 
 ammonia. Their significance seems to be practically the same 
 as that of the ammonium magiiesimn phosphates. 
 
 K 
 
114 INTESTINAL DISEASES 
 
 Calcium oxalate crystals are extremely common on a mixed 
 diet. In fact, if large quantities of vegetables are given, 
 one finds in nearly all instances these characteristic crystals in 
 the faeces. On a meat or milk diet they are usually absent. 
 Therefore, when large quantities of vegetable have been taken 
 in the diet, they have no pathological significance, but if no 
 considerable quantity of vegetable has been given, their presence 
 in any great number points to some intestinal dyspepsia. 
 
 Cholesterin crystals are very often recognised in the f8?ces 
 by the aid of the microscope ; they are so characteristic tha": 
 the chemical reaction need not here be given. ^ The more careful 
 the c xamination of the faeces, the more often cholesterin will be 
 found, and it would appear that, in all cases where there is any 
 great increase in mucus excretion, cholesterin is always present. 
 
 Charcot-Leyden's crystals, which are so easily recognised 
 by their characteristic shape, are often found in the iseces, 
 embedded in mucus. It used to be thought that the presence 
 of these crystals was especially characteristic of the presence 
 of intestinal parasites, but this is not the case. One finds 
 intestinal worms when Charcot-Leyden's crystals are not to 
 be recognised, and vice versd. Charcot-Leyden's crystals are 
 also found not uncommonly embedded in the mucus of mem- 
 branous enteritis, and they would appear to have no special 
 significance. 
 
 Various forms of epithehal cells and leucocytes are found in 
 the faeces, and these are of great value in helping to make 
 a diagnosis. When mucus-containing faeces, microscopically 
 examined, show that the mucus contains numerous leucocytes 
 or epithehal cells, one obtains very conclusive evidence of catarrh. 
 In some cases where the epithehal cells show very httle sign of 
 breaking down or digestion, one may consider that the catarrh 
 is in the rectum or lower part of the bowel, while in cases 
 where the epithehal cells are very much broken up, one may 
 make a diagnosis of catarrh in the small intestine. In our 
 experience, the examination of the epithehal cells found micro- 
 scopically in the faeces has been of little use in helping to 
 locate the position of the catarrhal process ; the presence or 
 absence of bile-stained mucus is a much better indicator of 
 the situation of the catarrh. It will be found that in catarrh 
 
 1 The cheDiical tcslw for clioleslerin will be fouiul iiiuler Ciall Stones. 
 
GENERAL EXAMINATION OF F^CE8 115 
 
 of the small intestine — unless there is constipation — mucus or 
 some of the soaps present in the fseces will be coloured with 
 bihrubin, or in some cases, with biliverdin. 
 
 It is unnecessary to describe the other tissue substances or 
 foreign bodies which may be present in the faaces, as one's own 
 common sense tells one that any undigested residue swallowed 
 by the mouth will in process of time and under ordinary circum- 
 stances, appear in the fscces ; the pathological significance, there- 
 fore, of such substances as small particles of bone (more especially 
 fish-bone) being found in the faeces is nil. It would appear 
 that it is possible for some of the finer bones to be absorbed or 
 broken up in their passage along the alimentary canal, but as 
 the quantity of bone capable of being thus absorbed cannot 
 be determined, the recognition of fish-bones in the fseces yields 
 no evidence of diminished digestion. 
 
CHAPTER XVII 
 
 CHEMICAL EXAMINATION OF F.ECES— REACTION, WATER, 
 AND SOLIDS 
 
 In investigating diseases of the intestine, the chemical analysis 
 of the fa3ces is most important. It is unnecessary for us here 
 to discuss the various chemical processes wliich go on in the 
 intestinal tract, and the alterations which take place in the 
 food in its passage along the bowel, due to the action of the 
 bile or pancreatic secretions or intestinal juices. For, although 
 it is of great importance to know what is going on in the intestine 
 itself, we are only here interesting ourselves in making a 
 diagnosis on the alterations which are found to occur in the 
 faeces, due to pathological changes in the intestine. 
 
 Reaction. — The reaction of the faeces varies, according 
 to the diet taken, both in health and disease, and although the 
 reaction itself is not of great importance in making a diag- 
 nosis, it gives certain evidence of changes going on in the bowel 
 itself, the knowledge of which may be useful. At the present 
 moment, our knowledge of the reaction of the feeces is very 
 Hmited, and it is considered sufficient to know whether the 
 feeces are alkaline, acid, or neutral. Quantitative alterations 
 in the acidity oralkalinity have not up to the .present been 
 much utihsed. 
 
 Method. — In the examination of the f feces, it is necessary 
 to remember that the reaction of different parts of the motion 
 varies, and it is not at all uncommon to find that the surface 
 reaction is quite different from that of the centre, so that, in 
 making any observations on the reaction of a stool, it is necessary 
 to mix the fsoces thoroughly before testing. Certain changes 
 take place in the stool on keeping, and the reaction may become 
 more acid or more alkahne as the case may be ; it is therefore 
 essential in noting the reaction of a motion to examine it as 
 fresh as possible. 
 
CHEMICAL EXAMINATION OF FyECES 117 
 
 If the fseces are fluid, it will be sufficient simply to mix them 
 well, but in the case of solid motions, it is as well to rub up the 
 fseces in a mortar with distilled water until they assume a pea- 
 soup consistency, and use this mixture for testing the reaction. 
 It will then only be necessary to dip a glass rod into the mixture, 
 and apply it to some red or blue htmus paper which has been 
 previously moistened ; one can then easily note the reaction 
 on the reverse side of the paper. 
 
 The different indicators, such as cochineal, methyl orange, 
 phenophthalein, &c., being very sensitive to certain bases or 
 acids, will often give a reaction entirely at variance with that 
 fomid with htmus. At the same time so httle has been done 
 in practice with the different indicators that for ordinary pur- 
 poses, the litmus reaction is considered sufficient. 
 
 Quantitative Estimation of Alkalinity or Acidity. 
 —Twenty to fifty grams of fresh fseces are well mixed and 
 ground up in a mortar, as described in the macroscopic 
 examination of the faeces, ten volumes of water being added. 
 The mixture thus prepared is then titrated by allo\ving one 
 tenth normal solution of sodium hydrate or one-tenth normal 
 hydrochloric acid solution — according to whether the fseces 
 have previously given an acid or an alkahne reaction — to run 
 in with frequent stirring, rmtil, by employing a glass rod, the 
 litmus paper gives a neutral reaction. The tested acidity or 
 alkalinity can easily be calculated by multiplying by five if 
 twenty grams of fresh fseces have been used, or by two if htty 
 grams have been employed. 
 
 Reaction in Health.— There is a variation in reaction 
 even in normal stools. As a rule, however, they deviate only 
 very slightly from the neutral reaction. 
 
 Meconium, or fasting stools — which may both be regarded 
 as the normal products of the excretions from the ahmentary 
 tract unvitiated by any food residue — give a faintly acid re- 
 action, owing to the large quantity of fatty acids which they 
 contain. 
 
 The diet has a great influence on the reaction of the fseces, 
 so it will be well to make a few observations with regard to the 
 normal reaction found on the four test diets which we employ 
 in the "examination of the fseces for the investigation into the 
 condition of the intestinal tract. 
 
118 INTESTINAL DISEASES 
 
 Reaction on a Milk Diet.— The reaction of infants' 
 faeces differs according to whether they are fed with hiiman 
 or cows' milk. The normal reaction of the faeces of a breast- 
 fed child is faintly acid owing principally to the preponderance 
 of lactic acid, and in less degree, of the other volatile fatty acids. 
 The fseces of a child brought up on the bottle usually give a 
 neutral or very faintly alkaline reaction, owing to the increased 
 amount of casein present in cows' milk. At the commencement 
 of most of the minor intestinal troubles in children, one gets a 
 very marked acid reaction, owing to the formation of lactic 
 and butyric acid. In more comphcated intestinal disease 
 such as enteritis, intestinal tuberculosis, typhoid, dysentery, 
 and cholera, the faeces of a child give a distinctly alkahne reaction 
 owing to the putrefaction of the proteids causing an excess of 
 ammonia, and, at the same time, are very foul-smelhng. 
 
 The normal faeces yielded by a milk diet in an adult give a 
 neutral or very faintly alkahne reaction. Pathological altera- 
 tions in the bowel cause, in adults, similar changes in the reaction 
 of the faeces to those found in children. 
 
 Reaction on Schmidt's Diet.— The reaction of the 
 faeces on Schmidt's diet is neutral or very faintly acid, where 
 there is a healthy condition of the intestine. In cases where 
 there is a tendency to intestinal fermentation, causing imperfect 
 breaking-down of the carbohydrates and the formation of lactic 
 and butyric acids, the stools, as a rule, are acid. In increased 
 putrefaction, where the effect of the bacteria in the large intestine 
 is to cause excessive breaking down of the proteids with increased 
 formation of ammonia, the faeces will give a distinctly alkahne 
 reaction. 
 
 Reaction or a Mixed Diet.— On an ordinary mixed 
 diet with a fair digestion, the reaction of the faeces is very uniform, 
 and there should be only a very shght deviation from the neutral, 
 or very faintly alkahne reaction. The tendency to alkaline 
 reaction on a mixed diet is due to the putrefaction of the proteid, 
 which causes formation of ammonia. An acid reaction is, how- 
 ever, produced where there is any increased breaking down of 
 carbohydrates, leading to excess of lactic or butyric acids. 
 Schmidt ^ found that on a diet rich in starch, the total acidity 
 equalled 80, while the same stool, after standing in a hot-air 
 
 1 Schiuidt and Strasburger, Die Fceccs dcs Mcnschoi. p. 108. 
 
CHEMICAL EXAMINATION OF F/ECES 110 
 
 cupboard at 37° C. for twenty-four hours, showed an acidity of 
 320. This illustrates the importance of examining the iscces 
 in a fresh condition. Increased quantities of fat in the diet, or 
 insufficient absorption of fat, often lead to an acid reaction of the 
 faeces, owing to the excess of fatty acids in the stools. 
 
 In diseases of the stomach, if not complicated by intestinal 
 disorder, the reaction of tlie faeces remains neutral. Obstruction 
 of the bile-ducts causes a markedly acid stool, owing to the 
 decreased absorption of fat. When the pancreatic secretion 
 is absent — although there is an increased quantity of fat in 
 the stools, due to the greatly decreased breaking up and 
 absorption of the fats — the presence of the excess of fatty 
 acids, which would otherwise cause an acid reaction, is masked 
 by the increased putrefaction of the proteid, so that the stools 
 are strongly alkaline. In intestinal disturbance resulting from 
 the imperfect digestion of carbohydrates, leading to the forma- 
 tion of lactic and butyric acids, one obtains an acid reaction. 
 
 Reaction on a Meat Diet. — On a meat diet, the re- 
 action of the faeces is, as a rule, faintly alkaline, or it may 
 be markedly so, owing to the increased c^uantity of ammonia 
 formed by the breaking down of proteid in the large intestine. 
 
 WATER AND SOLIDS 
 
 The casual examination of the faeces gives a very misleading 
 idea of the quantity of water present in any specimen, for one 
 sees more or less fluid motions due to the increased quantity 
 of mucus, or even to some of the low-melting fats, which are 
 accompanied by no increase in the quantity of water as evidenced 
 by analysis. 
 
 Method of Estimating the Quantity of Water in 
 the Faices. — The estimation of the quantity of water in 
 the faeces is not so simple as would at first sight appear. The 
 faeces have to be dried down to some constant temperature 
 which must not be too high, as otherwise, in obtaining dryness, 
 one is apt to drive off volatile substances, and the weighing of 
 the residue gives no true indication of the actual loss of 
 weight which is due to water alone. In practice, it is advisable 
 to take a small quantity of well-mixed fa3ces in a capsule and 
 dry them over a water-bath with continual stirring. When 
 
120 INTESTINAL DISEASES 
 
 they have thus been rendered as dry as possible, the capsule 
 should be placed in an oven kept at some fixed temperature 
 for a certain number of hours, after which it is placed over 
 sulphuric acid in a desiccator, allowed to cool, and then 
 weighed. This is repeated till the capsule remains at constant 
 weight. We obtain the best results by keeping our drying 
 cupboard at 60' C, using this as our constant temperature 
 for obtaining standards of comparison. 
 
 If the faeces contain a large quantity of fat, it will not be 
 possible to dry them by this method ; it is essential in such 
 cases to mix the faeces, previous to drpng, with a weighed quantity 
 of sand, which has been prepared by extracting with water, 
 alcohol, and ether. This addition of sand will greatly simplify 
 the drying, the method being otherwise as above described. 
 
 Quantity of Water in the Faeces under Normal 
 Conditions — The quantity of water in the faeces is in- 
 fluenced by the activity of the large intestine and the diet 
 taken, so that, before discussing the quantity of water present 
 in the faeces on our test meals, it is necessary to make a few 
 remarks on the factors influencing the dryness of the faeces. 
 
 A diminution in the quantity of water in the faeces is produced 
 by any stagnation of the intestinal contents in their passage 
 along the large intestine, since the greater quantity of water 
 is absorbed from the faeces during its passage along the colon. ^ 
 
 Stagnation of the intestinal contents may be due to diminished 
 peristalsis or insufficient stimulation of the mucous membrane. 
 This takes place when the food leaves Httle residue, as, for example, 
 in fasting, on a pure meat diet, or milk diet. Diminished 
 peristalsis of the large intestine may also be attributable to the 
 insufficient action of the muscles of the bowel, such as occurs in 
 simple neurasthenia, or want of accustomed exercise in people 
 confined to bed from whatever cause. Dryness of the faeces 
 may also be due to increased absorption of water by stimula- 
 tion of the epithelium covering the mucous membrane of the 
 large intestine ; this is the apparent explanation of the dry 
 faeces which occur in some cases at the commencement of taking 
 certain alkahne springs.^ 
 
 1 Vaiighan Harlc}-, " The Influence of the Removal of the Large Intestine 
 and Increased Quantities of Fat in the Diet on General Metabolism in Dogs " — 
 Proc. Roy. Soc, vol. Ixiv. 1898. 
 
 2 Hoppe-Seyler. — Physiol. Chemie, Berlin, 1881, p. 3t)3. 
 
CHEMICAL EXAMINATION OF F/ECES 121 
 
 An increased quantity of water in the faeces may be due to 
 diminished absorption of water, arising from insufficient activity 
 of the water-absorbing function of the epithehum of the mucous 
 membrane of the large intestine. Insufficient activity of the 
 epithelium of the large intestine may be produced in mal- 
 nutrition, and also when the chymus has been pathologically 
 altered so that salts with high water co-efficient are present in 
 the intestine, or when certain medicinal salts are taken which 
 cause an increased quantity of water in the faeces. 
 
 All abnormal intestinal contents appear to stimulate peristalsis, 
 and the more irritable the mucous membrane of the intestine, 
 the less the stimulant necessary to cause increased peristalsis, 
 so that in inflammatory or in nervous (central) conditions, one 
 frequently obtains an increased quantity of water in the faeces. 
 
 In all inflammatory conditions of the mucous membrane of 
 the intestine, one sees, in addition to increased peristalsis, a 
 tendency to an increased excretion of fluid from the mucous 
 membrane itself, and at the same time, a secretion of mucus, 
 which together give rise to an increased quantity of water in 
 the faeces. In diseases of the small intestine, inflammatory 
 products are often no longer recognisable in the faeces ; one 
 gets an increased quantity of water, and it is impossible to say 
 whether it is due to exudation or to transudation. The increased 
 quantity of water in the stools of cholera— Schmidt ^ describes 
 cases in which only V2 to I'S per cent, of dry substances were 
 found in the stools — is considered to be principally due to trans- 
 udation, in the same way as the watery stools which occur after 
 taking senna appear to be due to exudation. If one finds, 
 together with an increased quantity of water in the f»ces, inflam- 
 matory products from the mucous membrane, such as epithelial 
 cells, mucus, pus, or blood, one may consider the condition 
 to be probably due to exudation, while, if one finds increased epi- 
 thehal cells and flocculi of epithelial cells (as in cholera) indi- 
 cating the destruction of the surface layers of the mucous mem- 
 brane, one may consider the condition to be due to transudation. 
 
 With these preliminary remarks, we may now go on to 
 consider the quantity of water usually found in fresh faeces. 
 In the cases which we have examined, the quantity of water 
 has varied from 57-8 to 93-9 per cent., and in health on 
 
 1 Strasbur^cr and Schinidt. Die Fcerc.i dcs Men.schcii, \>. 113. 
 
122 
 
 INTESTINAL DISEASES 
 
 ordinary diets one may consider tliat the quantity varies from 
 70 to 80 per cent., giving an average of about 75 per cent. 
 
 Quantity of Water present in the Faeces on a 
 Milk Diet — As we have already shown, the quantity of 
 water in the faeces is partly dependent on the amount of 
 residue left in the chymus ; on a milk diet, therefore, which 
 leaves very httle residue, one would expect a decrease in the 
 quantity of water. At the same time, milk contains a large 
 quantity of fat, and this has an influence on the quantity of 
 water in the faeces, increased quantities of fat tending to increase 
 the total quantity of water in the faeces. ^ 
 
 TABLE XX.— PERCENTAGE OF WATER NORMALLY PASSED 
 IN THE F.ECES ON A MILK DIET 
 
 M.Ik iu 
 
 Number 
 
 Highest per 
 
 Lowest per 
 
 Average per 
 
 piuts. 
 
 of cases. 
 
 cent. 
 
 cent. 
 
 cent. 
 
 4 
 
 G 
 
 81-23 
 
 73-45 
 
 76-99 
 
 u 
 
 4 
 
 83 -90 
 
 71-74 
 
 76-00 
 
 5 
 
 2 
 
 83-93 
 
 74-71 
 
 79-32 
 
 6 
 
 2 
 
 73-52 
 
 73-06 
 
 73-29 
 
 We have put together in Table XX. the results obtained 
 on a milk diet in individuals who apparently suffered from 
 no intestinal derangement. It will be seen that the quantity 
 of milk daily taken causes an alteration in the quantity of 
 water pr,>sent in the faeces. When four pints of milk were 
 given daily, the largest quantity of water found in the faeces 
 was 81 "23 per cent., and the lowest quantity 73 '45 per cent., 
 the average of the six cases being 76-99 per cent. In four 
 normal individuals taking 4| pints of milk per diem, the 
 highest quantity of water present in the faeces was 83-96 
 per cent., and the lowest 71-74 per cent., the cases yielding an 
 average of 76-00 per cent. In these cases, the increase of -| pint 
 of milk per diem had no tendency to increase the average quantity 
 of water in the fa3ces. In two individuals to whom five pints 
 ot milk were given daily, the highest quantity of water found 
 in the faeces was 83-93 per cent., while the lowest quantity was 
 74-71 per cent., giving an average of 7932 per cent., thus showing 
 
 1 V'aughan Harlev, loc. cil. p. 283. 
 
C1IKMICAL EXAMINATION OF K/EOKS 123 
 
 a tendency to increased (quantity of water in the f»ces when 
 the increased quantity of milk was given in the diet. In two 
 further individuals, the quantity of milk was increased to six 
 pints per diem, when the maximum quantity of water in the 
 feces was 73-52 per cent., and the minimum quantity 73-0() 
 per cent., giving an average of 73 29 per cent., so that, in these 
 two cases, there appeared to be no increased quantity of water 
 in the faeces consequent on the increased quantity of milk given 
 in the diet. In reviewing all the cases, we note a general tendency 
 to increase in the quantity of water in the faces, consequent 
 
 TAB1.1-: XXI.— PERCENTAGE OF WATER NORMALLY PASSED IN 
 THE F.ECES ON SCHMIDT'S DIET 
 
 Number of cases. | Higlicst pin- i-ent. 
 
 Lowest per cent. 
 
 Average per cent. 
 
 t 
 6 1 83-15 
 
 71-66 
 
 75-95 
 
 on increased quantities of milk given in the diet. This is 
 probably partly explained by the increased quantity of fluid 
 taken, which undoubtedly has some influence on the quantity 
 of water in the faeces, but the increase is principally due to the 
 increased amount of fat taken in the diet, leading to an increased 
 quantity of water in the stools. 
 
 Quantity of Water in the Faeces on Schmidt's Diet. 
 — We have put together in Table XXI. the results obtained 
 on a Schmidt's diet in six individuals who apparently suffered 
 from no intestinal disorder. We see that the maximum quantity 
 of water found in the faeces was 83-15 per cent., while the 
 minimum quantity was 71-66 per cent., the cases yielding an 
 average of 75-95 per cent. In discussing the Schmidt diet, we 
 have already shown that it is a diet very easy of assimilation 
 and absorption, and, therefore, one leaving little residue to 
 cause stimulation of the bowel and increased peristalsis. At 
 the same time, this diet is not so rich in fat as a milk diet, and 
 this is the partial explanation of a smaller average of water 
 being found in the faeces on a Schmidt diet than on a residue- 
 free diet, such as milk. 
 
 Quantity of Water in the Faeces on a Mixed Diet. 
 — In eighty-seven cases (Table XXII.) en an ordinary mixed diet 
 
124 
 
 INTESTINAL DISEASES 
 
 in which no milk was given as such, but merely in the form of 
 puddings, &c., the maximum quantity of water in the faeces was 
 83-21 per cent., and the minimum quantity 67-60 per cent., the 
 cases giving an average of 75-72 per cent. It is thus seen that 
 
 TABLE XXII.— PERCENTAGE OF WATER PASSED IN THE F.ECES 
 ON A MIXED DIET 
 
 Xumber of cases. 
 
 Highest per cent. 
 
 Lowest ])er cent. 
 
 Average per ceut. 
 
 87 
 
 83-21 
 
 67-60 
 
 75-72 
 
 on the mixed diet which we employ in the examination of the 
 bowels, there is very little residue to stimulate intestinal peri- 
 stalsis, with the result that the quantity of water found in the 
 faeces very much resembles that found on a Schmidt diet. 
 
 Quantity of Water in the Faeces on a Mixed Diet 
 and Increasing- Quantities of Milk. — We have already 
 pointed out that fat has an influence on the quantity of water 
 present in the faeces, and it is necessary, in comparing the 
 quantity of water found in the faeces of patients on a mixed 
 diet, to have some idea of the increase caused by adding milk 
 to the diet, when this has been done to increase the Caloric 
 worth of the patient's rations. 
 
 TABLE XXIIL— PERCENTAGE OF WATER PASSED IN THE F.ECES 
 ON A MIXED DIET + INCREASING QUANTITIES OF MILK 
 
 Milk in 
 
 Nnmber 
 
 Highest per 
 
 Lowest per 
 
 Average per 
 
 pints. 
 
 of cases. 
 
 cent. 
 
 cent. 
 
 cent. 
 
 H 
 
 28 
 
 82-65 
 
 65-42 
 
 74-57 
 
 2 
 
 21 
 
 81-09 
 
 68-45 
 
 73-79 
 
 2^ 
 
 11 
 
 82-18 
 
 68-10 
 
 74-30 
 
 3 
 
 5 
 
 83-21 
 
 74-80 
 
 79-19 
 
 In twenty-eight cases (Table XXIII.) in which IJ pints of 
 milk were given in addition to the ordinary mixed diet, the 
 maximum quantity of water in the faeces was found to be 82-65 
 per cent., and the minimum quantity 65-42 per cent., the cases 
 giving an average of 7457 per cent. 
 
CHEMICAL EXAMIXATrON OK F/ECES 125 
 
 On increasing the quantity of milk to two pints daily, in twenty- 
 one cases, the highest quantity of water in the faeces was 81-09 
 per cent., and the lowest 08-45 per cent., the average in these 
 twenty-one cases being 73-79 per cent. 
 
 A further increase of milk to 2 J pints daily in eleven cases 
 was seen to yield a maximum quantity of water of 82-18 per 
 cent., and a minimum of G8-10 per cent., the eleven cases giving 
 an average of 74-30 per cent, of water found in the faeces. 
 
 In five cases the quantity of milk was increased to three pints 
 per diem, and in these cases the highest quantity of water 
 found in the faeces was 83-21 per cent., and the lowest 74-80 per 
 cent., the average being 79-19 per cent. 
 
 On reviewing these cases in which increasing quantities of 
 
 TABLE XXIV.— PERCENTAGE OF WATER NORMALLY PASSED IN 
 THE F.ECES ON A PURE MEAT DIET 
 
 Number of cases. 
 
 Highest per cent. 
 
 Lowest per cent. 
 
 Average per cent. 
 
 6 
 
 80-97 
 
 68-59 
 
 74-26 
 
 milk were added to an ordinary mixed diet, we find a general 
 tendency to increase in the quantity of water found in the faeces, 
 if we take into consideration the progressively diminishing 
 number of cases on increased quantities of milk, which causes 
 individual variations to play a greater part than if we had a 
 larger number from which to make our average. 
 
 Quantity of Water in the Feeces on a Meat Diet. 
 — In the preUminary discussion on the absorption of water 
 from the intestine, we showed that the quantity of residue 
 in the diet had a considerable effect on the stimulation of the 
 large intestine, and that resulting stagnation of the contents 
 might be produced by the diminished residue, leading to deficient 
 stimulation. A meat diet, yielding as it does, a stool reseaibhng 
 that of the fasting individual, is, therefore, very apt to cause 
 constipation. In the cases we have examined, constipation has 
 sometimes been present, but not always, and this is probably due 
 to the fact that the large quantity of water given with the diet 
 hindered the constipating effect of the small residue. 
 
 In the six examples given in Table XXIV., all the cases of 
 
126 INTESTINAL DISEASES 
 
 constipation have been eliminated, the results including only 
 those in which no constipation or other apparent bowel trouble 
 had arisen. The maximum quantity of water present in the 
 faeces was found to be 80 97 per cent. ; considering that the diet 
 given yielded so little residue, this is high, but as there was appa- 
 rently no intestinal derangement to account for such a large 
 quantity of water in the faeces, we have included it in the hst. 
 The percentage of water found in the other cases was 68-86 per 
 cent., 78-43 per cent., 75-95 per cent., 72-76 per cent, and— the 
 lowest — 68-59 per cent., making an average for the six cases 
 of 74-26 per cent. It is thus seen that, on a pure meat diet, there 
 is a distinct tendency to a small quantity of water being ehminated 
 in the faeces, and this is all the more marked when we consider 
 that we have included one case with a particularly high excretion 
 of water. We may, therefore, say that the average amount 
 of water excreted in the faeces tends to be less on a meat diet 
 than on any of the other diets which we employ for the obser- 
 vation of diseases of the bowels. 
 
CHAPTER XVIII 
 
 CHEMICAL EXAMINATION OF F/ECES {conliiuicd)—'SlTRO(iEN, 
 ALBUMEN, ALBUMENOSE, PEPTONIC, AND MUCUS 
 
 Our knowledge of the total nitrogen in the faeces is very com- 
 plete since Voit's School at Munich made its numerous observa- 
 tions in general metabolism, and V. Noorden apphed the same 
 methods to metabolism in disease. The value, however, of 
 the estimation of the total nitrogen in the faeces, in the diagnosis 
 of intestinal diseases, has not been found to be so great as was 
 at first hoped. It is possible that want of sufficient accuracy 
 in comparing results on diiTerent diets has crippled the use of 
 the knowledge in diagnosis, and that with extended knowledge 
 we shall find it of real value. 
 
 Method of Estimating- the Total Quantity of 
 Nitrogen in the Faeces — Kjeldahl's method for estimating 
 the nitrogen in the faeces is the one most usually employed, and 
 as it yields very good results, it seems to be all that is required. 
 
 A weighed quantity of fresh faeces can be employed in 
 estimatirg the quantity of nitrogen in the faeses by Kjeldahl's 
 method, although in practice we prefer to use a weighed 
 quantity of dried faeces. 
 
 The daily quantity of faeces is thoroughly mixed, or in the 
 case of an analysis of a period being carried out, the total three 
 to five days faeces are thoroughly mixed, so that one obtains 
 a fair average specimen. In practice, we generally prefer to 
 make a daily analysis, in order to avoid the danger of losing any 
 nitrogen from the faeces on standing. The weighed quantity 
 of faeces is placed in a capsule, and one-tenth normal sulphuric 
 acid solution poured over it in the proportion of 15 to 20 c.c. to 
 each hundred grams of moist faeces ; this is to prevent any 
 loss of ammonia in the process of drying. The capsule is then 
 placed over a water-bath and, with frequent stirring, is allowed 
 to dry, until the faeces are fairly hard. The capsule is then 
 
128 INTESTINAL DISEASES 
 
 removed, placed in a hot-air oven at 60° C. for two hours, 
 and cooled over sulphuric acid in a dessicator, as in the method 
 for estimating the total quantity of water in the faeces. The 
 contents of the capsule, when cool, are transferred by means 
 of a spatula into a mortar, and ground until all visible lumps 
 have disappeared, and a fine powder remains. 
 
 One gram of the powder is placed in a Kjeldahrs destruction 
 flask with 25 c.c. of strong sulphuric acid and one gram of sodium 
 pyrophosphate added to hasten oxydation. The flask is allowed 
 to stand for a few hours (if immediately heated, the contents 
 are apt to foam), and then heated over a Bunsen burner ; it is 
 necessary to have the flask placed well on its side, and it is of 
 great assistance to have a small conical glass stopper (Fig. 1), 
 which will arrest any of the boihng sulphuric acid which may 
 spit, and allow it to flow back into the flask. The heating must 
 at first be gentle, and a full power of gas used 
 later, otherwise, there will be too much foaming. 
 The contents of the flask, having been heated 
 till they become perfectly colourless, are allowed to 
 cool. The rationale of the process is the conversion 
 of all the nitrogen present in the faeces into 
 ammonium sulphate, and the destruction of all the 
 organic matter by oxydation. 
 Pj^, ^ The cold contents of the flask are carefully 
 
 washed, rinsing three or four times with about 
 GOO c.c. of water, into a large distillation flask.^ Some granules 
 of zinc are added to prevent much bumping when distillation 
 is carried on, and a strong solution of sodium hydrate added 
 until the contents of the distillation flask are ajkahne. The 
 sodium hydrate will, by this method, liberate any ammonia 
 from the ammonium sulphate, and it is only left to collect the 
 ammonia by distilling. The distillation flask is connected so 
 that the liberated ammonia can be distilled over into a 
 measured quantity of deci-normal solution of sulphuric acid. 
 The distillation is carried on until all the ammonia wliich is 
 present in the distillation flask has been driven over into the 
 one-tenth normal sulphuric acid, and has formed there 
 ammonium sulphate. The measured quantity of sulphuric acid 
 is now titrated with deci-normal sodium hydrate solution, using 
 
 1 Flasks can now be obtained which do for botii dostniction ^.nd distillation. 
 
CHEMICAL EXAMTNATFON OF F.ECKS Il".i 
 
 neutral litmus as an indicator, until one f>;ets a neutral reaction. 
 The quantity of deci-nornial sodium hydrate solution required 
 to neutralise the measured quantity of deci-normal sulphuric- 
 acid having been subtracted from the original amount, the 
 remainder^will give the quantity of sulphuric acid which has 
 been neutralised by the ammonia distilled over, and the calcula- 
 tion of total nitrogen is easily made. 
 
 Quantity of Nitrogen in the Normal Faeces. — 
 Formerly it was considered that the nitrogen found in the stools 
 was the remains of undigested proteid, but it is now generally 
 
 TABLE XXV.— DAILY EXCRETION OF NITROaEN IN THE F.ECE.S 
 IN FASTING 1 
 
 Cetti 0-31() gmins 
 
 Breithaupt O-lUi 
 
 Obstruction of the Oesophagus . . 0'44(j „ 
 
 First fasting lunatic .... 0'223 „ 
 
 Second fasting lunatic . . . 0'17 „ 
 
 I Average .... 0'254 grams nitrogen 
 
 recognised that the amount of nitrogen left over from digestion, 
 in cases where the food is well prepared and easily assimilated, 
 does not play the only role ; we have also to deal with the 
 nitrogen from the human body itself. EpitheHal layers of 
 mucous membrane are being continually shed, and these, 
 together with the mucus and intestinal secretion, create a certain 
 amount of nitrogen residue. In addition to this, we have the 
 bile and pancreatic secretions thrown into the intestine, and 
 these nitrogenous constituents, when not absorbed, add their 
 quantum. The numerous bacteria normally present in the 
 intestine also yield no inconsiderable quantity of nitrogen ; 
 some of this nitrogen, being due to the breaking-up of proteid 
 by the bacteria in the intestine, yields nitrogenous residue as 
 well as a certain amount of indol and skatol. And a not in- 
 considerable quantity of nitrogen is normally due to the bacteria 
 present in the intestines themselves. In fact, Schmidt and 
 Strasburger - consider that, on a diet yielding only a small residue, 
 the quantity of nitrogen which may be put down as derived 
 from bacteria is no less than ^ to \ of the total nitrogen present 
 in the stools. 
 
 1 Schmidt and Strasburger, Bit Fences dcs Menschoi, p. 119. 
 
 2 Ibid. p. 120 ; 
 
130 INTESTINAL DISEASES 
 
 Our knowledge of the amount of nitrogen derived from the 
 intestines themselves in human beings has, of late years, been 
 greatly amplified, thanks to the observations of Fr. Miiller on 
 the fasting individuals, Cetti and Breithaupt. 
 
 In Table XXV. one sees that there is a considerable quantity 
 of nitrogen daily ehminated in fasting individuals ; the enormous 
 individual variations in the quantity of nitrogen excreted are 
 also very clearly brought out, so that one must remember, in 
 calculating the quantity of nitrogen in the faeces, to take into 
 account individual variations. The latter are even greater in 
 metabolism experiments, for it is found that the same individual 
 on the same diet during different periods excretes varying 
 quantities of nitrogen. These individual variations, and the 
 variations in the same individual from time to time, render the 
 results obtained by analysis, as to the quantity of nitrogen in 
 the faeces, difficult to deal with.^ The way the varying quantity 
 of uric acid in the urine is known to fluctuate is analogous to 
 the nitrogen fluctuation found amongst individuals in the faeces. 
 
 The quantity of nitrogen shown in Table XXV. only holds 
 good in absolute fasting, for it has been shown by Rieder ^ in 
 three experiments in which he gave nitrogen-free diets, that no 
 less than 0-73 grams of nitrogen were excreted in the faeces per 
 diem. The fact that the quantity of nitrogen excreted by the 
 ahmentary canal is larger when food is taken than in fasting, 
 has been shown by several observers, as also the fact that pro- 
 gressive increase in the quantity of non-nitrogenous diet causes 
 a progressive increase in the quantity of nitrogen excreted in 
 the fasces. This is merely what one would expect when one 
 considers that the digestive secretions would be greatly increased 
 by taking a non-nitrogenous diet, compared with the secretions 
 in a fasting individual. The greater the quantity of the non- 
 nitrogenous diet, the greater the quantity of secretion required 
 for its digestion, and, therefore, the greater the (piantity of 
 nitrogen left in the residue. 
 
 Having shown that a certain quantity of the nitrogen present 
 in the stools is undoubtedly derived from the ahmentary canal 
 itself in fasting or on a nitrogen free diet — the quantity vary- 
 ing according to whether digestive secretions are required or 
 
 1 V. Noorden, Lehrbuch dcr Pathologic dts Staff wechsds, Berlin, 1893, p. 39. 
 ■« Zdtschr. i. Biolocjie, vol. xx. 1884, p. 378. 
 
CHEMICAL EXAMINATION OF FMCE^ 
 
 131 
 
 not — we now go on to see wliat influence diet has on the 
 nitrogenous residue. It has been clearly shown by experi- 
 ments that when food is properly prepared, so that it yields 
 only a very small residue, and requires a minimum amount 
 of digestive juice for its absorption, the quantity of nitrogen 
 eliminated is small. In human beings, one always finds on 
 a meat diet (which is the best absorbed of all diets),, some 
 undigested muscular fibres in the stools. Rubner ' showed that 
 on a pure meat diet, ri2 to 1-2 grams of nitrogen were ex- 
 creted per diem. 
 
 When a diet contains a good deal of residue, more especially 
 cellulose, the (quantity of nitrogen is naturally very much in- 
 creased. 
 
 TABLE XXVI.— NITROGEN IN DIET YIELDING RESIDUES 
 
 Food. 
 
 Daily excretion 
 of nifrog-en. 
 
 1 
 Percentage of ; 
 nitrogen in Author, 
 dried faeces. 
 
 Potatoes (3078 grains) . . 3-G9 grams 
 Black bread (1360 grams) . 4-2G „ 
 Peas (600 gi-ams) . . . 3-57 „ 
 Carrots (5133 grams) . . 2-52 „ 
 Savoy cabbage (3831 grams) . 2-4 
 Generous Vegetarian Diet . 3 46 
 
 401 „ 
 
 3.93 
 3 08 
 7-35 
 301 
 3-39 
 
 Rubner 
 
 Voit 
 ( Rumpf and 
 ( Schunim 
 
 In Table XXVI. we see that the quantity of nitrogen daily 
 excreted in the faeces on diets which contained a certain amount 
 of cellulose — and, therefore, greatly increased residue — is quite 
 considerable. In fact, the quantities are, as will be found later 
 on, above those observed on our ordinary test meals. 
 
 It would seem that the larger the quantity of nitrogen taken 
 in the diet, the less the proportion found in the faeces, so that 
 an increased quantity of nitrogen in the diet would appear to 
 aid digestion. As a matter of fact, this is not really the case ; 
 the digestion is not improved, but the total quantity of nitrogen 
 excreted from the ahmentary canal being falsely considered 
 as the nitrogen given in the proteids (whereas only a given 
 
 1 Zciischr. f. Biologie..,\o\. xv. 1879, p. l.')9. 
 
 - Schmiilt and Strasburger, Dit Fcec(sda< Mennchoi. p. 122. 
 
132 
 
 INTESTINAL DISEASES 
 
 quantity is taken in the diet), makes it appear too high ; while, 
 if one is giving such a diet as meat, where nearly all the proteid 
 is absorbed, the increased quantity of nitrogen taken in the food 
 yields a relatively smaller quantity of nitrogen in the faeces. 
 
 TABLE XXVII.— INFLUENCE OF INCREASED QUANTITY OF DIET 
 ON THE NITROGEN IN THE F^CES i 
 
 Diet. 
 
 Daily excretion of nitrogen. 
 
 Meat (884 grams) .... 
 
 1-2 
 
 „ (1435 „).... 
 
 112 
 
 White bread (689 grams) 
 
 1-95 
 
 (1327 ., ) . . 
 
 2-44 
 
 Peas (600 grams) .... 
 
 3-57 
 
 „ (960 „ ) .... 
 
 9-09 
 
 On the other hand, when a diet yielding more residue is taken, 
 such as a diet of white bread or peas, the quantity of nitrogen 
 excreted in the faeces increases with the quantity taken in the 
 diet, as shown in Tabl/ XXVII. (Rubner) 
 
 On diets relatively free from residue, the quantity of nitrogen 
 found in the faeces is very small, as shown by Table XXVIII. 
 
 TABLE XXVIIL— QUANTITY OF NITROGEN IN THE F.ECES ON 
 RESIDUE FREE DIETS 2 
 
 Food. 
 
 Daily excretion of 
 nitrogen. 
 
 Percentage of 
 
 nitrogen in dried 
 
 fteces. 
 
 Macaroni (695 grams) 
 White bread (689 grams) . 
 Rice (638 grams) 
 Maize (750 grams) 
 
 1-86 grams 
 1-95 „ 
 213 „ 
 
 2-27 „ 
 
 6-88 
 8-30 
 
 7-85 
 4-6 
 
 The quantity of nitrogen present in the fa3ces is seen to be 
 influenced by the amount of residue left in the faeces, together 
 with the different kinds of diets given, and still further, by 
 individual variations. 
 
 It is now necessary for us to consider the quantity of nitrogen 
 present in the faeces when individuals are on one or other of the 
 four diets which we are in the habit of using for the investigation 
 of intestinal disease. In all the cases, the numbers given are 
 
 1 Schmidt a 
 
 2 11,1,1. p. I: 
 
 d Strasburgpr, Die Faces dcs Mcnschcn, \. 123. 
 
CHEMICAL EXAMINATION OF FyECKS 
 
 \-x 
 
 the result of a series of analyses extending over a period of at 
 least three, and generally five days, so that although the number 
 of cases investigated is not great, the results may be considered 
 sufficient for the deduction of general conclusions. 
 
 Quantity of Nitrogen in the Faeces on a Milk Diet. 
 — In breast-fed children, less nitrogen is excreted in the 
 faeces than in children fed on cows' milk. Biedert ^ made 
 calculations from a large number of cases, and found in breast- 
 fed children 0-15 grams of nitrogen in the fseces, and in children 
 fed on cows' milk, 0--41 grams of nitrogen in the faeces. 
 
 In adults, Schmidt and Strasburger considered that the 
 quantity of nitrogen present in the fajces on a milk diet was 
 about 1-11 grams per diem, but this is a larger quantity than 
 we have found in the cases which have come under our notice. 
 
 TABLE XXIX.— QUANTITY OF NITROGEN IN THE FAECES AND 
 ABSORPTION OF THE SAME ON A MILK DIET 
 
 Milk in 
 l.ints. 
 
 Niiiiibur 
 of cases. 
 
 Hig 
 
 liesr. 
 
 Lowest. 
 
 Averaoc. 
 
 Nitrogen 
 in grams. 
 
 Absorbed 
 pur cent. 
 
 Nitrogen 
 in grams. 
 
 Absorbed 
 per cent. 
 
 Nitrogen 
 in griinis. 
 
 Absorbed 
 per cent. 
 
 4 
 
 H 
 
 5 
 
 6 
 5 
 2 
 
 117 
 1-20 
 1-20 
 
 95-37 
 96-53 
 94-59 
 
 0-63 
 0-53 
 0-92 
 
 91-39 
 9216 
 92-94 
 
 0-84 
 0-76 
 1-06 
 
 93-82 
 95-03 
 93-76 
 
 In Table XXIX. it is seen that when four pints of milk were 
 given daily, the largest quantity of nitrogen excreted per diem 
 was 1-17 grams, and the lowest quantity, 0C)3 grams, the cases 
 giving an average of 0-84 grams per diem. If one calculates 
 the quantity of nitrogen given in the food, and subtracts from 
 that the quantity of nitrogen found in the fseces, one obtains 
 a general idea as to the amount of nitrogen absorbed, although, 
 as has already been shown in the general discussion of nitro- 
 gen in the faeces, a considerable quantity of the nitrogen is due 
 to the residue of the digestive secretions, epithelial cells, and 
 bacteria, &c., so that absorption calculated by this method is 
 not absolutely correct. As at present we have no means of 
 estimating the quantity of nitrogen eliminated by the human 
 
 1 Die Kinderndhrun'j im Saiijlinjsrdkr, &c. iv. Au/l., Stiittgirt, F. Enkc, 
 1900, p. 59. 
 
13i 
 
 INTESTINAL DISEASES 
 
 being himself, it is essential in these calculations to take for 
 granted that all the nitrogen present in the faeces represents 
 the nitrogen which has not been made use of by the organism. 
 It is seen that in these cases the highest absorption of nitrogen 
 was 9537 per cent., and the lowest 91-39 per cent., so that 
 the average absorption of proteid in the six cases was 93 82 per 
 cent. 
 
 Five cases of individuals who were taking 4^ pints of milk 
 per diem were investigated, and it was found that the maximum 
 quantity of nitrogen present in the faeces was 120 grams, and 
 the minimum quantity, 0-53 grams, making an average of 0-76 
 grams of nitrogen excreted per diem. On making a calculation 
 of the absorption on this diet, it was found that the highest 
 absorption was 96 53 per cent., and the lowest, 92-16 per cent., 
 giving an average absorption in the five cases of 95-03 per cent. 
 
 TABLE XXX.— QUANTITY OF NITROGEN IN THE F.^CES AND 
 ABSORPTION OF THE SAME ON A SCHMIDT'S DIET 
 
 Number 
 of cases. 
 
 Higlicst. 
 
 Lowest. 
 
 Average. 
 
 Xitrog:en 
 in grams. 
 
 Absorbed 
 per cent. 
 
 Nitrogen 
 in grams. 
 
 Absorbed 
 per cent. 
 
 Nitrogen 
 in grams. 
 
 Absorbed 
 per cent. 
 
 11 
 
 1-90 
 
 97-77 
 
 0-43 
 
 89-94 
 
 0-88 
 
 95-29 
 
 On increasing the diet to five pints of milk per diem, only two 
 cases were investigated. The highest quantity of nitrogen 
 excreted was found to be 1-20 grams, and the lowest, 0-92 grams, 
 giving an average of 1-06 grams per diem. The absorption in 
 these two cases was 9459 and 9294 per cent, respectively, 
 giving an average of 93"76 per cent. 
 
 We see, therefore, that on a milk diet the quantity of nitrogen 
 present in the faeces is considerably less than the results obtained 
 by Schmidt and Strasburger on the same diet. 
 
 The absorption of nitrogen on a milk diet seems to vary 
 between 94 and 95 per cent., which is a very good absorption, 
 especially when one remembers that most of the nitrogen present, 
 as previously mentioned, is due to that derived from the mucous 
 membrane, digestive secretions, &c., thus masking the real 
 absorption of the nitrogen taken in the diet. 
 
CHEMICAL EXAMINATION OF F.ECES 
 
 135 
 
 Quantity of Nitrogen in the Fseces on Schmidt's 
 
 Diet.— Eleven cases, in wlioni there was no sii^n of <j;astro- 
 intestinal disturbance, were investigated on a Schmidt's diet. 
 
 In Table XXX. it is seen that the highest quantity of nitrogen 
 eliminated in the faeces was TOO grams per diem, and the lowest 
 quantity 0"4.'} grams per diem, giving an average of 088 grams 
 per diem. It is thus seen that the average quantity of nitrogen 
 present in the faeces on Schmidt's diet is slightly larger than 
 that found on a milk diet, except when large quantities, such 
 as five pints per diem of milk, were taken. 
 
 The highest absorption of nitrogen on this diet was 97 77 
 per cent., and the lowest 89*94 per cent., the cases giving an 
 average of 95*29 per cent. This is higher than any of the 
 absorptions on the milk diet, and is explained by the fact that 
 the quantity of nitrogen eUminated by the bowel is masked 
 by the increased quantity of nitrogen in the food. 
 
 Quantity of Nitrogen in the Faeces on a Mixed 
 Diet — No less than seventy-five cases taking a mixed diet 
 (without the addition of milk, except in the form of puddings, 
 &c.) were investigated, none of the cases showing signs of any 
 gastro-intestinal derangement. 
 
 TABLE XXXI.— QUANTITY OF NITROGEN IN THE F.ECES AND 
 ABSORPTION OF THE SAME ON A MIXED DIET 
 
 Xuiiiber 
 of c:iscs. 
 
 Highest. 
 
 Lowest. 
 
 Average. 
 
 Nitrogen 
 iu gvamF. 
 
 Ahsorbud 
 per cent. 
 
 Nitrogen 
 iu grams. 
 
 Absorbed 
 • per cent. 
 
 Nitrogeu 
 in grams. 
 
 Absorbed 
 per cent. 
 
 75 
 
 1-55 97-07 
 
 0-30 
 
 90-12 
 
 0-97 
 
 93-46 
 
 In Table XXXI. it is seen that the highest excretion of nitrogen 
 was 1-55 grams, and the lowest 30 grams, the cases yielding 
 an average of 0'97 grams of nitrogen in the faeces per diem. It 
 is seen that the quantity of nitrogen on this diet is considerably 
 larger than that found on either the milk or Schmidt's diet, and 
 this is explained by the increased amount of residue, especially 
 the cellulose residue from the cabbage in the diet. 
 
 The highest absorption on a mixed diet was seen to be 97-0. 
 per cent., and the lowest 9012 per cent., the average of the cases 
 
130 
 
 INTESTINAL DISEASES 
 
 being 93'46 per cent. ; these amounts very closely resemble 
 those found on a milk diet, and are considerably less than those 
 obtained with Schmidt's diet. 
 
 Quantity of Nitrogen in the Faeces on a Mixed 
 
 Diet + Increasing" Quantities of Milk The effect on 
 
 the nitrogen in the faeces of adding increasing quantities of milk 
 to a mixed diet, is brought out in the following table : 
 
 TABLE XXXII.— QUANTITY OF NITROGEN IN THE FAECES AND THE 
 ABSORPTION OF THE SAME ON A MIXED DIET f 
 INCREASING QUANTITIES OF MILK 
 
 
 
 Hiyhost. 
 
 Lowest. 
 
 Average. 
 
 
 
 
 
 
 
 pints. 
 
 of eases. 
 
 Xitroseii 
 
 Absorbed 
 
 Nitrogen 
 
 Aljsorbed 
 
 Xitrogeu 
 
 Absorbed 
 
 
 
 in grauis 
 
 per ceut. 
 
 iu grauis. 
 
 per eeuf. 
 
 III grams. 
 
 per cent. 
 
 u 
 
 26 
 
 200 
 
 i)7-34 
 
 0-57 
 
 90-10 
 
 1-11 
 
 93-84 
 
 2 
 
 21 
 
 1-60 
 
 97-55 
 
 0-68 
 
 93-13 
 
 0-94 
 
 94-99 
 
 n 
 
 10 ■ 
 
 2-14 
 
 <Hv(56 
 
 0-85 
 
 93-41 
 
 1-30 
 
 94-60 
 
 3 
 
 5 
 
 2-39 
 
 97-20 
 
 0-64 
 
 93-23 
 
 1-44 
 
 94-71 
 
 It is seen that when 1| pints of milk daily were added to the 
 diet of twenty-six cases, who showed no sign of intestinal trouble, 
 the highest quantity of nitrogen excreted in the fseces was 2-00 
 grams, and the lowest 57 grams, the cases yielding an average 
 of l-ll grams per diem. This average is greater than that found 
 in any of the previous diets, and the range between the lowest 
 and the highest figures is also considerably wider than noted 
 in the other diets, being due to individual variations. 
 
 The absorption in these twenty-six cases varied from a 
 maximum of 97*34 per cent, to a minimum of 90-10 per cent., 
 the cases giving an average of 93*84 per cent. 
 
 On a mixed diet to which two pints of milk were added per 
 diem, twenty-one cases were investigated. The highest quantity 
 of nitrogen was seen to be 1*60 grams, and the lowest 0'68 
 grams, the cases yielding an average of 0*94 grams of nitrogen 
 excreted per diem in the faeces. It will be noticed that when 
 two pints of milk were added to the diet, the fluctuations were 
 not so great as with 1| pints of milk, and the average quantity 
 of nitrogen in the faeces was also not quite so high. 
 
 The absorption of nitrogen, when two pints of milk were 
 
CHEMICAL EXAMINATION OF F^CES ]'M 
 
 addedto the mixed diet, is seen to vary from 97-55 per cent, to 
 *.);M;3 per cent., the cases averaging 9499 per cent, per diem. 
 
 On a mixed diet when 2 J pints of milk were added, ten cases 
 were investigated. The maximum excretion of nitrogen was 
 found to be 2T4 grams, and the minimum excretion 0'85 grams, 
 the average of the cases being no less than 1 -30 grams of nitrogen 
 excreted per diem in the stools. Here we have a larger quantity 
 of total nitrogen in the fseces than in either of the previous diets. 
 
 The absorption in these ten cases on a mixed diet with two 
 pints of milk added daily, varied from 9f)-G() per cent, to 93-41 
 per cent., the average proteid absorption in the cases being 
 94-GO per cent, in the twenty-four hours. 
 
 On a mixed diet when three pints of milk were taken daily, 
 we only have the analyses of five cases. The highest quantity of 
 nitrogen found in the faeces was 2-39 grams, and the lowest 0-f)4 
 grams, the cases giving an average of 1-44 grams of nitrogen 
 in the fseces per diem, this being a greater quantity than had 
 been seen in any of the diets which we have just discussed. 
 
 'The highest absorption was 97-26 per cent, and the lowest 
 93-23 per cent., the cases yielding an average of 94-71 per cent. 
 
 On glancing over these cases on a mixed diet with the addition 
 of milk, one sees a distinct tendency to increase in the quantity 
 of nitrogen corresponding with the increase in the quantity 
 of milk given. In the case of two pints of milk being given, it 
 is seen that there was no increase in the quantity of nitrogen 
 excreted, but individual variations have to be considered, and 
 one must draw general conclusions from the results as a whole, 
 regarding the non-increase of nitrogen on two pints of milk as 
 an exception. 
 
 The absorption of nitrogen tends also to increase with in- 
 creasing ([uantities of milk in the diet. 
 
 Quantity of Nitrogen in the Faeces on a Meat 
 Diet — Table XXXIII. gives the results in five cases which 
 were investigated on a pure meat diet. 
 
 It is seen that the maximum quantity of nitrogen excreted 
 was 0-79 grams, the minimum being very low, only 0-26 grams, 
 and the average 0-52 grams, while the average quantity of 
 nitrogen in the fseces in fasting has already been shown to be 
 025 grams in the twenty-four hours. 
 
 The absorption of nitrogen on a purely meat diet varied from 
 
i;58 
 
 INTESTINAL DISEASES 
 
 97-16 per cent, to 91-48 per cent., the average of the cases being 
 95-32 per cent. 
 
 Since a meat diet yields very httle residue, and is even better 
 absorbed than a milk diet, there is a tendency for the quantity 
 of nitrogen in the faeces to be extremely low ; at the same time, 
 
 TABLE XXXIII.— QUANTITY OF NITROGEN IN THE F^CES AND 
 ABSORPTION OF THE SAME ON A PURE MEAT DIET 
 
 Number 
 of cases. 
 
 5 
 
 Hi-hest. 
 
 Lowest. 
 
 Averajre. 
 
 N'itrojien 
 in gi-aiiis. 
 
 Absorbed 
 ]ier cent. 
 
 Xitrogon 
 in fjrauis. 
 
 Absorbed 
 per cent. 
 
 Xitroi^en 
 in firams. 
 
 Aljsorbed 
 per cent. 
 
 0-79 
 
 97-16 
 
 0-26 
 
 91-48 
 
 0-52 
 
 95-32 
 
 owing to the large quantity of nitrogen relatively present in 
 the diet, the absorption of nitrogen is very good. 
 
 ALBUMEN, ALBUMENOSES, AND PEPTONE 
 
 The tests for albumen, albumenoses, and peptone, can be 
 roughly considered together. 
 
 Test for Albumen Fresh faeces -should be well mixed 
 
 with water, and then rubbed up in a mortar, filtered through a 
 folded filter paper, and the filtrate tested for albumen. If the 
 fseces are alkaline, one also gets, in solution, casein and mucus, 
 which can be prevented by previously using dilute acetic acid. 
 
 (1) To the bottom of the filtrate in a test-tube a layer of cold 
 nitric acid is run in, when a white precipitate forms at the 
 junction of the liquids if albumen is present. 
 
 (2) The upper layers of the watery extract of the faeces are 
 heated in a test-tube, when a precipitate will form. Two to 
 three drops of dilute acetic acid can be added, and, if albumen 
 is present, the precipitate remains, and sometimes increases in 
 quantity. 
 
 Test for Albumenoses and Peptone : Hofmeister's 
 Method.'— To well-rubbed-up faeces ()l volumes of con- 
 centrated hydrochloric acid are added; then phosphorstungstic 
 acid and hydrochloric acid are alternately added until no more 
 
 1 Hoppc-Scylor'.s Chnnischc An<tbjsc. Edited by TlKerfulkM-, 7tli edition. 
 ]). 4.^)4. 
 
CHEMICAL EXAMINATION OF F.ECES 13!) 
 
 precipitate is formed; after gently heating, the thick precipitate 
 is collected on a filter-paper, which is well washed with water, 
 and dissolved in sodium hydrate solution. The r.^sulting deep 
 blue liquid is hoated over a flame on a gauze until it turns a 
 dirty yellow ; some of the fluid is then poured into a test-tube, 
 cooled, and tested for th^ biuret reaction, the propeptone or 
 albumos3 giving a violet or reddish colour. 
 
 Presence of Albumen — In healthy children there ought 
 to be no albumen present in the faeces, but when there is any 
 enteritis or summer diarrhoea, albumen is always found to be 
 present in the f?eces. 
 
 In adults on ordinary diets albumen is not to be found in the 
 fgeces under normal conditions. It is difficult to distinguish 
 between unabsorbed albumen and that which is derived from 
 the alimentary tract itself. The albumen present in cases of 
 simple diarrhoea or jaundice seems to be due to the unabsorbed 
 residue of the food. On the other hand, the albumen found in 
 the stools in cases of cholera may be derived from the ah- 
 mentary tract itself ; also when mucus, blood, or pus, are present 
 in the motion, albumen may be due to these substances. One 
 has to remember that the large intestine will absorb considerable 
 quantities of albumen, and, therefore, when albumen appears in 
 the fseces, there must be great disturbance of the ahmentary 
 tract. In pathological conditions, such as enteritis and coUtis, 
 one finds a very marked quantity of albumen. In chronic 
 mucoid conditions of the bowel, there is generally a shght 
 albumen reaction. In chronic constipation, as a rule, one finds 
 a mere trace of albumen, or it is absent. In all cases of diarrhoea, 
 from whatever cause, it would appear that there is a marked 
 reaction for albumen in the fseces. 
 
 MUCUS 
 
 Mucus, as glycero-proteid which can be broken up into proteid 
 and carbohydrates, is distinguished from the neucleo-proteids 
 or nuclein by th? latter containing phosphorus. Small particles of 
 mucus can be easily recognised in the faeces, and can be picked 
 out with forceps, and shaken in a test-tube with 2i per cent. 
 alcohoUc subhmate solution, so as to break up the larger particles ; 
 if necessary, a glass rod may be used to disintegrate any large 
 
UO INTESTLNAL DISEASES 
 
 fiocciili. It is then allowed to sediment, and is washed with 
 distilled water, after which a few drops of Ehrlich Brondi tri- 
 aoid solution ^ are poured over it. With this reagent, the . 
 flocculi of mucus, if not containing fat and epitheUal cells, are 
 stained green or blue-green, all other tissue substances except 
 nuclein being red. 
 
 Chemical Test for Mucus : Hoppe-Seylers Method.— 
 Fresh faeces are well mixed with lime-water, and the hme-water 
 extract precipitated with acetic acid. The mucus thus pre- 
 cipitated must be free from phosphorus, and, on heating with 
 7"5 per cent, hydrochloric acid, will yield a reducing substance. 
 The reducing substance is tested by neutrahsing the filtrate 
 with sodium hydrate, and boiling with a few drops "of copper 
 sulphate solution, when a reduction of the copper is obtained. 
 
 Ordinary mucus in the faeces is often so much mixed up with 
 fat and epithelial cells that it can only, with great difficulty, be 
 dissolved in lime-water. This Hoppe-Seyler method has the 
 disadvantage that it also precipitates nuclein and nucleo-pro- 
 teids, and in order to make sure that one is dealing with 
 mucus, it is necessary to ascertain that the precipitate contains 
 no phosphorus, and to see that one is able to obtain a reducing 
 substance from it after boiling with acid. As a general rule, 
 mucus can be recognised macroscopically and microscopically 
 with sufficient accuracy to justify one in dispensing with chemical 
 analysis. 
 
 The mucus found in membranous enteritis is always so 
 mixed with epitheUal cells and fat, that it is insoluble in lime- 
 water, and only soluble in strong sodium hydrate solution. 
 
 Presence of Mucus — The normal faeces .contain no 
 mucus except in very early childhood. In adults, a small 
 quantity of mucus may coat a solid motion even in health, 
 and in constipation, one always finds a certain amount of shmy 
 mucus between the lumps or scybala. 
 
 1 Khrlich Brondi three-coloured mixture consists 
 
 of satur 
 
 ■ated soli 
 
 ition of 
 
 Orange G. acid fuehsin and me 
 
 thyl green, as follows : 
 
 
 
 
 Saturated solution i 
 
 of Orange C . 
 
 . 24 
 
 27 c.c. 
 
 
 Acid fuchsin 
 
 
 . Hi 
 
 -:3:} c.c. 
 
 
 Methyl green 
 
 
 
 35 c.c. 
 
 
 Water 
 
 
 
 (50 c.c. 
 
 
 Absolute alcohol 
 
 
 
 40 c.c. 
 
 
 Glycerine 
 
 
 
 20 CO. 
 
 
 (The mixttire should be allowed to stand for one or two weeks before using.) 
 
CHEMICAL EXAMINATION OF Fi^CES 141 
 
 The fate of the mucus secreted by the various portions of the 
 gastro-intestinal tract can he briefly summarised as foUows : 
 
 Mucus derived from the stomach is never present in the stools, 
 owing to its being easily digested. 
 
 Mucus derived from the small intestine is only present in 
 the faeces when increased peristalsis is hastening it along the 
 large intestine. It is recognised as coming from the small 
 intestine by the fact that it is usually coloured with bile, and 
 more or less intimately mixed with the faeces. 
 
 Mucus which is found to be intimately mixed with the faeces, 
 and is not coloured by bile, is derived from the upper part of 
 the large intestine. 
 
 Mucus found between the scybala or coating rolls of faeces 
 is derived from the lower part of the large intestine, probably 
 in most cases from the rectum. 
 
 If, on examination, the mucus present in the stools is found 
 to be mixed with epithelial cells, it indicates catarrh of the 
 bowel. 
 
 The mucus of membranous enteritis is nearly always found 
 to have mixed with it numerous epitheUal cells and fat drops. 
 It would appear that the mucus accompanying acute catarrh 
 is probably due to hypersecretion from a secretory neurosis, 
 and not to true inflammation of the bowel. 
 
CHAPTER XIX 
 
 CHEMICAL EXAMINATION OF F.^iCES {continued)— ¥AT 
 
 The qualitative reaction of fat in the faeces is of very little 
 importance, since, in all cases, a certain quantity of fat will be 
 found in the stools. 
 
 The total ether extract is, as a rule, taken to represent the 
 fat in the estimation of its quantity in the faeces, and the thorough 
 isolation of the fatty acids, soaps, neutral fats, and cholesterin 
 has not so far been found to repay the trouble entailed. 
 
 Quantitative Estimation of Fat — A weighed quantity 
 of finely powdered dry faeces, after having been dried down 
 with sulphuric acid, as in the estimation of total nitrogen, 
 or with the addition of 1 per cent, of hydrochloric acid, is 
 taken for the estimation of the fat. It is necessary to dry 
 down the faeces with an acid so as to spht up any of the soaps 
 present, and render them soluble in ether. The powder is 
 placed in a fat-free filter-paper in a Soxhlet apparatus, connected 
 with a reflux cooler, and extracted with ether until no further 
 fat is obtained on extraction. The ether extract, after being 
 dried, is dissolved in water-free ether, and filtered into a weighed 
 Erlenmeyer, the ether evaporated off, and, when dried, weighed. 
 The increased weight thus obtained yields the total ether 
 extract, and for all purposes of analysis is sufficiently accurate 
 to be called fat. 
 
 Chemical Analysis to Estimate the Quantity of 
 Neutral Fat, Fatty Acids, and Soaps.^— Some fieces, 
 after being well mixed, are dried at 90° C, placed in a 
 Soxhlet apparatus, and extracted with ether until all the 
 soluble matter is dissolved. The ether mixture is then dried 
 and redissolved in absolute ether, sp. gr. 720, and filtered 
 
 1 Vaughan Harley, " On the Breaking-up of Fat in the Alimentary Canal 
 under Normal Circumstances and in the Absence of the Pancreas."— Proc. 
 Jiuy. Sac, vol. Ixi. " 
 
CHEMICAL EXAMINATION OF F.^CES 
 
 li: 
 
 through a fat-free filter-paper into a weighed vessel, in which 
 it is dried and afterwards weighed. 
 
 The ether residue thus obtained is then treated with a watery 
 solution of sodium carbonate, which converts free fatty acids 
 into soaps ; after again drying, the neutral fat, cholesterin, &c., 
 are extracted from this by means of ether filtered through a 
 fat-free filter-paper and weighed. The difference between this 
 and the first weighing is taken to equal the quantity of free 
 fatty acids present. 
 
 The neutral fat present in the last ether extract is then 
 
 TABLE XXXIV.— QUANTITY OF FAT PRESENT IN THE F.ECES IN 
 FASTING INDIVIDUALS! 
 
 
 rcrceut- 
 
 a?e of fat 
 
 in dried 
 
 fasces. 
 
 Total fat pur 
 dieui. 
 
 Neutral 
 fats and 
 clioles- 
 terin. 
 
 Tat acids. 
 
 Soaiis. 
 
 Cctti . 
 Breithaupt . 
 Case of obstruc- 
 tion of oesophagus 
 
 35-46 
 
 28-42 
 
 26-3 
 
 1-21 grams 
 0-57 „ 
 
 1-14 „ 
 
 55-02 "o 
 47-0 "„ 
 
 37-65 % 
 41-5 % 
 
 7-33 °'o 
 11-5 0^ 
 
 saponified by the addition of alcoholic sodium hydrate solution 
 and evaporated to dryness, when it is again extracted with 
 ether. It is necessary to repeat this saponification with alcoholic 
 sodium hydrate solution until all the neutral fats are removed. 
 The ether extract left will contain cholesterin. 
 
 The original substance which was extracted with ether is 
 treated with dilute hydrochloric acid in order to liberate from the 
 soaps any fatty acids which may be present. It is then dried 
 at 90° C, and when completely dry, again extracted with ether. 
 The quantity of ether extract which is then obtained represents 
 the fatty acids present in the form of soaps. 
 
 Fat in Normal Faeces — In discussing the nitrogen in 
 the normal faeces, we showed that a certain quantity of the 
 nitrogen in the stools has nothing to do with the diet taken, 
 and, in the same way, we find in the normal faeces that a certain 
 amount of fat is derived from the excretions of the alimentary 
 canal itself. This fat represents not only the quantity of fat 
 
 1 Schmidt and Strasburger, Die Fcecea des Menschen, p. 155. 
 
144 
 
 INTESTINAL DISEASES 
 
 contained in the digestive juices, but also that derived from 
 the mucous membrane in the breaking-up of the epitheUal cells 
 which are continually thrown oif from the intestinal wall. 
 
 Fr. Miiller carried out a series of analyses of the quantity of 
 fat in the fseces of fasting individuals, similar to those which 
 have been already described in the case of nitrogen. 
 
 It is seen in Table XXXIV. that the average excretion of 
 fat in a fasting individual is no less than 0-79 grams per diem. 
 It is also seen that the daily excretion of fat varies very consider- 
 ably in different individuals, the maximum being 1-21 grams, 
 and the minimum 57 grams in the twenty-four hours. We 
 
 TABLE XXXV.— INFLUENCE OF MELTING-POINTS OF FATS ON THE 
 PERCENTAGE ABSORPTION i 
 
 Kiudof fat. 
 
 Melting-poiut ° C. 
 
 Percentafjc 
 excreted. 
 
 Stearin 
 
 60 
 
 91-86 
 
 Mixture of stearin and almond oil 
 
 55 
 
 10-6 
 
 Mutton suet 
 
 52 
 
 915 
 
 Mutton suet ..... 
 
 49 
 
 7-4 
 
 Bacon fat 
 
 43 
 
 2-58 
 
 Pork fat 
 
 34 
 
 2-5 
 
 Goose fat 
 
 25 
 
 2-5 
 
 Olive oil 
 
 Liquid 
 
 2-3 
 
 thus see that there is great individual variation in the quantity 
 of fat daily excreted from the alimentary canal in fasting 
 individuals, and in all analyses on the quantity of fat in the 
 fa3ces, we must bear in mind these individual variations, just 
 as we had to do in the case of nitrogen. 
 
 Kobert and Koch ' examined a patient with an artificial anus 
 at the commencement of the ascending colon, and they were 
 able to wash out daily from the large intestine 0'97 grams of 
 dry substance, which contained from frS to 9-3 per cent, of fat. 
 This would yield about 0-09 grams of fat per diem excreted 
 from the large intestine itself, so that when we compare the 
 quantity of fat in a fasting individual with the quantity of fat 
 which is evidently excreted from the large intestine, we see 
 
 Schmidt and Strasburger, Die Fcecis dcs MtHnchcii, p. 156. 
 Dtutscht Med. Wuchcmchr., 1894, No. 47. 
 
CHEMICAL EXAMINATION OF F.ECES J I' 
 
 that the greater portion of the fat must be excreted by the small 
 intestine or in the bile and pancreatic juice. ^ 
 
 The quantity of fat excreted by the alimentary canal also 
 appears to be influenced by the diet taken, irrespective of the 
 diet containing any fat, for Rubner found on a fat-free diet 
 consisting of bread and dumpling, no less than 31 to <)0 grams 
 of fat daily excreted in the fioces. 
 
 Influence of Melting-points of Different Fats on 
 Absorption. -Tlie fats taken in the diet vary very much 
 as regards their melting-points, and the facility of absorption 
 is thereby very considerably influenced. 
 
 It is seen in Table XXXV. that the lower the melting-point, 
 the better the absorption of fat. It has also been found that 
 the better the fat is emulsified in the process of digestion, the 
 better it is absorbed ; so that butter and other pure fats are 
 more easily digested than, for instance, mutton suet. There 
 would appear to be individual variations in the assimilation of 
 fat, since Hultgren and Landergren - found, on a similar diet, 
 individual diiTerences in the quantity of fat absorbed. On 
 margarine, from 95'5 to 92-3 per cent, of fat was absorbed, 
 while when butter was given, 97.3 to 93'7 per cent, was absorbed. 
 The quantity of fat present in the food has an influence on 
 the quantity absorbed. In a diet containing a small quantity 
 of fat, it is not at all uncommon to find more fat in the fseces 
 than had been taken in the food. It is easily understood that 
 part of this large quantity of fat found in the faeces is derived 
 from the excretions of the body itself. 
 
 Malfatti ^ found in an individual on a diet of peas, which 
 contained only 4"()G grams of fat, that he was able to recover 
 4"51 grams in the f»ces in twenty-four hours. V. Hosslin ^ 
 on taking r2 grams of fat in the food, found that he obtained 
 r71 grams of fat in the faeces, and in another case when 36 
 grams of fat were given in the diet, no less than 3"7r) grams of 
 fat were found in the faeces. 
 
 1 The composition of the excretion of the loop of the hirge intestine is given 
 in " The Influence of Removal of the Large Intestine and Increasing Quintities 
 of Fat in the Diet on General Motaholisin in Dogs." — Vaiighaii H;;rl:-y, Proc. 
 Roy. Sec., vol. Ixiv. 
 
 2 Pflilger Archives, vol. Ix. 
 
 3 Quoted by J. Kiinig, Chcmie dcr mensrid. Xahrungs u. Genus.smittd, 1889, 
 iii., aufl. i. p. 3(5 ff. 
 
 4 Virchoivs Archiv, vol. Ixxxix., 1882, p. 95. 
 
 K 
 
146 INTESTINAL DISEASES 
 
 Increasing quantities of fat in the diet are shown to give 
 relatively better absorptions of fat. V. Noorden^ found that 
 when he gave 4 "2 grams of fat in the diet, 57 "1 per cent, 
 of it appeared in the faeces, while when he increased the 
 fat in the diet to 42 '2 grams, the quantity of fat in the faeces 
 was lO'O per cent., and on still further increasing the fat 
 in the diet to 80 "2 grams, only (r36 per cent, of the fat was 
 lost. 
 
 It will be seen from these results that it is impossible when 
 a small quantity of fat is given in the diet, to come to any conclu- 
 sions as to its absorption ; at the same time, when an ordinary 
 diet is taken, containing a fair amount of fat, we may consider 
 that the excretion from the human body itself remains more 
 or less constant, and we are, therefore, justified in making a 
 calculation of the absorption by estimating the quantity of fat 
 found in the faeces. 
 
 Rubner considered that the assimilation of fat reached its 
 maximum when 350 grams of fat (butter) were taken in the diet 
 per diem. 
 
 We now come to consider the quantity of fat present in the 
 faeces on the various diets which we employ for the examination 
 into intestinal diseases. 
 
 Quantity of Fat in the Faeces on a Milk Diet. — 
 Breast-fed children yield from 10 to 20 per cent, of dry substance 
 in the faeces as fat, while the amount on cows' milk is from 14 
 to 23 "8 per cent. The absolute quantity of fat lost in the faeces 
 on cows' milk is greater than that on mother's milk, owing to 
 the larger quantity of faeces. Uffelmann reckoned that 0*8 
 to 0"9 grams of fat were excreted per diem on cows' milk, as 
 against 0"44 grams on mother's milk. 
 
 In adults, the quantity of fat found in the faeces varies with 
 the quantity of milk taken, Schmidt and Strasburger stating 
 that from 97 to 93 per cent, of the fat given in the diet is 
 absorbed, the average being 93-93 per cent. ; the daily quantity 
 of fat excreted in the faeces, according to these observers, is 
 15 to 7 '5 grams per diem. It may be roughly stated that on 
 a milk diet in infants, 949 to 93 per cent, of the fat given is 
 absorbed, while in adults from 95-6 to 93*4 per cent, of the fat 
 given in the food is absorbed. 
 
 1 LvJirhuch dcr Pathologic dcs Stoffwcchscls, Berlin, 1893. 
 
CHEMICAL EXAMINATION OF F.^CES 
 
 147 
 
 We will now give the results of some analyses illustrating 
 what we have found on a milk diet. 
 
 TABLE XXXVI.— QUANTITY OF FAT IN THE F.ECES AND ABSORP- 
 TION PER CENT. ON A MILK DIET 
 
 3Iilk iu 
 pints. 
 
 Xumljcr 
 of cases. 
 
 Hi', 
 
 host. 
 
 Lowest. 
 
 Av( 
 
 rase. 
 
 Fat iu 
 grams. 
 
 Absorbed 
 per cent. 
 
 Fat iu 
 grams. 
 
 Absorbed 
 per cent. 
 
 Fat in 
 •rraras. 
 
 Absorbed 
 per cent. 
 
 4 
 
 H 
 
 5 
 
 
 6 
 2 
 
 314 
 5-40 
 5*22 
 
 98-67 
 97-73 
 95-19 
 
 1-12 
 1-14 
 5-05 
 
 96-26 
 93-23 
 95-03 
 
 2-18 
 2-95 
 5-13 
 
 97-40 
 95-82 
 95 11 
 
 In Table XXXVI. it is seen that six cases taking four pints 
 of milk per diem were analysed, there being no gastro-intestinal 
 disturbance. The highest quantity of fat in the faeces was 3-14 
 grams, and the lowest ri2 grams, the cases yielding an average 
 of 2 "18 grams of fat daily excreted in the faeces. 
 
 The absorption in these cases on four pints of milk varied from 
 98"67 per cent, to 96"26 per cent., the average absorption of 
 fat per diem being 97 "40 per cent. The absorption of fat is 
 thus better than the absorption of proteid on a milk diet. 
 
 Analyses of six cases on 4| pints of milk per diem show the 
 highest quantity of fat in twenty-four hours to be 5 "40 grams, 
 and the lowest ri4 grams, giving an average of 2"95 grams of fat 
 in the faeces per diem. 
 
 The highest absorption on 4| pints of milk was 97*73 per cent., 
 and th lowest 93*23 per cent., the average absorption of fat 
 per diem being 95-82 per cent. 
 
 In two further cases, analyses were carried out, the individuals 
 taking five pints of milk per diem. These cases yielded 5"22 
 grams and 5*05 grams of fat in the faeces respectively, the 
 average being 5*13 grams. 
 
 The absorption in these two individuals taking five pints of milk 
 daily, showed a maximum absorption of 95'19 per cent., the 
 minimum absorption being 9503 per cent., giving an average 
 of 95'11 per cent, of fat daily absorbed. 
 
 On looking through these cases on a milk diet, we see that 
 there is a general tendency to an increase in the quantity of 
 fat in the faeces on increased quantities of milk. This is only 
 
148 
 
 INTESTINAL DISEASES 
 
 what one would expect, as the increased quantity of fat con- 
 tained in the increased quantity of milk would, in all probability, 
 lead to increased residue. On the other hand we see that with 
 an increased quantity of milk the tendency is for the absorption 
 of fat to decline, so that there is apparently a tendency to 
 decrease in actual absorption with increased quantities of 
 milk, contrary to what one finds when fat is increased in an 
 ordinary mixed diet. 
 
 Quantity of Fat in the Faeces on Schmidt's 
 Diet. — On Schmidt's diet, ten cases were examined, none of 
 whom evinced any tendency to intestinal derangement. 
 
 TABLE XXXVIL— QUANTITY OF FAT IN THE F.ECES AND ABSOPvP- 
 TION PER CENT. ON SCHMIDT'S DIET 
 
 Numlji;!" 
 of discs. 
 
 II iL 
 
 llfSt. 
 
 Lowest. 
 
 Ave 
 
 rai>e. 
 
 Fat in 
 
 •i'l-ains. 
 
 Absorbed 
 per cent. 
 
 Fat in 
 grams. 
 
 Absorbed 
 \wr cent. 
 
 Fat in 
 grams. 
 
 Absorbed 
 per cent. 
 
 10 
 
 r)-47 
 
 97 -55 
 
 2-12 
 
 94-63 
 
 4-20 
 
 96-15 
 
 In Table XXXVIL the highest quantity of fat in the faeces 
 is seen to be 6-47 grams per diem, and the lowest 212 grams, 
 giving an average, in the cases examined, of 4*26 grams of fat 
 excreted in the faeces per diem on Schmidt's diet. The variation 
 in the quantity of fat is very considerable when one takes into 
 consideration the fact that the diets given were exactly the 
 same, and it shows how great individual variations may be. 
 
 The absorption of fat in these ten cases on Schmidt's diet 
 showed a maximum of 97-55 per cent., and a minimum of 94.63 
 per cent., making the average daily absorption of fat 96-15 per 
 
 TABLE XXXVIIL— QUANTITY OF FAT IN THE F.ECES AND ABSORP- 
 TION PER CENT. ON A MIXED DIET 
 
 Number 
 of cases. 
 
 Uiu 
 
 best. 
 
 I.owesl. 
 
 Av 
 
 Fat in 
 grams. 
 
 ■rage. 
 
 Absorbed 
 per cent. 
 
 Fat in 
 ^;ranis. 
 
 Absorbcul 
 per cent. 
 
 Fat in 
 grams. 
 
 Absorbed 
 per cent. 
 
 79 
 
 6-07 
 
 98-51 
 
 113 
 
 !)()-19 
 
 3-29 
 
 95 •05 
 
CHEMICAL EXAMINATION OF F^.CE^^ 
 
 MO 
 
 cent. We see that the absorption of fat on »Schniidt\s diet 
 very closely resembles that found on a milk diet. 
 
 Quantity of Fat in the Faeces on a Mixed Diet.— 
 On a mixed diet, in which no milk was given except in the 
 form of puddings, &c., seventy-nine cases were investigated. 
 
 In Table XXXVIII. results of the seventy-nine cases are 
 given. The maximum quantity of fat excreted was G07 grams, 
 and the minimum ri3 grams, the cases giving an average of 
 3 '29 grams of fat in the fsBces per diem. 
 
 The absorption in these seventy-nine cases taking a mixed 
 diet varied from 98'51 to 90"I9 per cent., and yielded an average 
 daily absorption of 95 05 per cent. The absorption, therefore 
 on a mixed diet was not so good as the absorption on either 
 Schmidt's or the milk diet. 
 
 Quantity of Fat in the Faeces on a Mixed Diet 
 with the Addition of Increasing Quantities of 
 Milk. — The influence on the fat in the faeces of increasing 
 quantities of milk in the diet was investigated in a series of cases, 
 and in Table XXXIX. the highest and lowest results found in 
 the analyses of some sixty-two cases, together with the average 
 absorption obtained on these diets, are given : 
 
 TABLE XXXIX.— QUANTITY OF FAT IN THE F.ECES AND ABSORP- 
 TION PER CENT. ON A MIXED DIET + INCREASING 
 QUANTITIES OF MILK 
 
 Milk in 
 pints. 
 
 Number 
 of cases. 
 
 Highest. 
 
 Lowest. 
 
 Average. 
 
 Fat in 
 grams. 
 
 Absorbed 
 per cent. 
 
 Fiit in 
 grams. 
 
 Absorbed 
 per cent. 
 
 Fat in 
 grams. 
 
 Absorbed 
 per cent. 
 
 u 
 
 2 
 3 
 
 26 
 
 21 
 
 10 
 
 5 
 
 7-85 
 6-85 
 5-41 
 5-27 
 
 98-28 
 98-43 
 98-18 
 97-64 
 
 1-96 
 1-71 
 2-39 
 2-50 
 
 91 -37 
 91-77 
 91-86 
 95-11 
 
 3-75 
 3-35 
 4-24 
 3-75 
 
 95-62 
 96-20 
 95-47 
 96-68 
 
 It is seen that when 1| pints of milk were added to the 
 ordinary mixed diet, the highest quantity of fat found in the 
 fseces was 7 "85 grams, and the lowest Vdi) grams, the cases 
 giving an average of 3"75 grams of fat in the faeces per diem. 
 It is interesting to notice the very large individual variations 
 in the quantity of fat eliminated on an ordinary mixed diet 
 
150 
 
 INTESTINAL DISEASES 
 
 with the addition of 1| pints of milk, when there was 
 apparently no intestinal trouble. 
 
 The absorption of fat on a mixed diet with IJ pints of milk 
 varied from 98-28 per cent, to 91-37 per cent., the average of 
 the twenty-six cases being 95-62 per cent. 
 
 On a mixed diet to which two pints of milk were added, twenty- 
 one cases were investigated, and showed a maximum of 6-85 
 grams of fat in the faeces, a minimum of I'Tl grams, and an 
 average daily excretion of 3-35 grams. 
 
 The absorption on a mixed diet with the addition of two pints 
 of milk varied from 98-43 per cent, to 91-77 per cent., making 
 an average absorption of 96-20 per cent, per diem. 
 
 On a mixed diet to which 2| pints of milk were added, ten 
 cases were investigated, and these showed a maximum fat 
 excretion of 5-41 grams and a minimum of 2-39 grams, the 
 average daily excretion of fat in the faeces being 4-24 grams. 
 
 TABLE XL.— QUANTITY OF FAT IN THE F.ECES AND ABSORPTION 
 PER CENT. ON A PURE MEAT DIET 
 
 Xumbur 
 of cases. 
 
 Hig 
 
 hest. 
 
 Lowest. 
 
 Average. 
 
 Fat ill 
 grams. 
 
 Absorbed 
 per cent. 
 
 Fat in 
 grams. 
 
 Absorbed 
 per cent. 
 
 Fat in 
 grams. 
 
 Absorbed 
 per cent. 
 
 5 
 
 2-43 
 
 96-90 
 
 0-53 
 
 92-40 
 
 1-22 
 
 94-77 
 
 The absorption of fat on a mixed diet with 2^ pints of milk 
 varied from 98 18 per cent, to 91-86 per cent., making an aver- 
 age daily absorption of 95-47 per cent. 
 
 On a mixed diet to which three pints of milk were, added daily, 
 five cases were analysed, and of these the highest quantity of 
 fat found in the faeces was 5-27 grams, and the lowest 2-50 grams, 
 giving an average of 3-75 grams of fat excretion per diem. 
 
 The absorption of fat on the mixed diet when three pints of 
 milk were added varied from 97-64 per cent, to 95-11 per cent., 
 the average daily absorption of fat being 96-68 per cent. 
 
 On looking over these results, we notice a tendency for the 
 quantity of fat to be increased in the fajces when increased 
 quantities of milk were given in the diet. At the same time, 
 the increase is not nearly so marked as when the milk was 
 increased, and no other diet taken. 
 
CHEMICAL EXAMINATTOX OF F.ECES i:.l 
 
 The absorption of fat when increasing quantities of milk were 
 added to a mixed diet seems to be Httle influenced when one 
 compares the results of analyses given. 
 
 Quantity of Fat in the Faeces on a Meat Diet.— 
 In five cases in whom the bowels appeared to be perfectly 
 healthy, analyses were carried out on a pure meat diet, and 
 the results are tabulated in Table XL. 
 
 We see that in the five individuals on a pure meat diet, the 
 maximum quantity of fat found in the faeces was 2-43 grams, 
 and the minimum 0'53 grams, the average excretion being 
 1-22 grams per diem. 
 
 The absorption in these five cases on a meat diet varied from 
 96-90 per cent, to 92 -lO per cent., the average daily absorption 
 being 9-I'77 per cent. This low absorption of fat is due to the 
 small quantity taken in the diet and has already baen explained. 
 
CHAPTER XX 
 
 CHEmCAL EXAMINATION OF F/ECES {cont in vccl)—HV GAR AND 
 CARBOHYDRATES 
 
 SuCxAE can be examined for either with fresh or dry fgeces. 
 
 Alcoholic Method of Estimating Sugar.— A 
 weighed quantity of either fresh or dried faeces is placed in an 
 Erlennieyer, and ten volumes of absolute alcohol added ; after 
 having been thoroughly mixed and filtered, the residue is washed 
 with alcohol containing a little water. The alcoholic filtrate 
 is evaporated to dryness in a capsule, and the residue dissolved 
 in water. By this means, the albumen and albumoses are 
 removed from the sugar-containing solution. If a quantitative 
 analysis is to be made, it is desirable to allow the faeces to stand 
 in contact with absolute alcohol for at least two or three days 
 with frequent shaking before filtration, so that the proteids 
 may form a more insoluble precipitate with the alcohol. The 
 filtrate can be tested for sugar either by Fehling's solution or 
 by fermentation. 
 
 Blauberg's Lead Acetate Method.^ — Some dried 
 faeces, which have been extracted with ether, so as to render 
 them more or less free from fat, are extracted with Thymol 
 water by heating on a water-bath, filtered, and washed with 
 Thymol water. The filtrate is precipitated with lead acetate 
 or basic acetate of lead. The excess of lead is removed by 
 passing a stream of carbonic acid through it. and the fresh 
 filtrate is tested for sugar. 
 
 Either of these methods may be employed, but we have found 
 in practice the alcoholic method to be the more convenient. 
 
 Presence of Sugar — In children fed on milk, a small 
 quantity of sugar is found in the fajces. In children taking 
 the breast, Pusch and Callomon " found by means of the fermen- 
 
 1 Quoted by Schmidt and Strasburger, Die Fasces de.'i Mcn/ichcii, p. 172. 
 
 2 Experirnenlelle und Jcritische Studien iiber SauglingsfceceSjBerVm, ISUT, p. .'{il. 
 
CHEMICAL EXAMINATION OF F.ECE8 ir.3 
 
 tation test, a fair quantity of sugar even in cases wheiv there 
 was no marked diarrhcca. 
 
 Cohnheim^ found sugar present in the f;eces in individuals 
 suffering from diarrhea. 
 
 Under ordinary circunistanees it is found that the fa>ces 
 contain no sugar. In fact, so far as our experience has gone, 
 we have never recognised any sugar in the fseces, and similar 
 results have been found by Rubner,"' Uffelmann/' &c. 
 
 CARBOHYDRATES 
 
 Starch is, as a rule, easily recognised in the fa>ces by the aid 
 of the microscope, especially when a solution of iodine and 
 potassium iodide has been employed, and, for ordinary purposes 
 we have found this ample {see p. 113). 
 
 Method of Estimating the Carbohydrates in 
 the Faeces. -^A weighed quantity of either fresh or dried 
 fa3ces free, as far as possible, from any mixture of mucus, is 
 placed in a flask to which 2 per cent, solution of hydrochloric 
 acid is added. The flask is connected with a reflux cooler, and 
 heated on a sand-bath for one or two hours. The filtrate, 
 having been neutralised with sodium hydrate, is tested for sugar 
 by Allihn's method. 
 
 To about 100 c.c. of filtrate, GO c.c. of Fehling's solution is 
 added in a small flask, and after covering with a watch-glass, 
 well boiled. 
 
 Alhhn's glass tubes require to very carefully filled with 
 asbestos, the asbestos having been previously prepared with 
 boiling water and afterwards with alcohol and ether. It is 
 essential in fiUing the Alhhn tube with asbestos to be very 
 careful, otherwise there may be difficulty in the filtration. It 
 is well first to use long pieces of asbestos, carefully packing them 
 with a glass rod, and then washing on to the top of the packed 
 asbestos some finely cut asbestos suspended in water so as to 
 make a fine surface on the top, which will prevent any of the 
 copper oxide from coming through the filter. It is important 
 in stopping these filters to take care not to pack them too 
 tightly, as otherwise there will be great difficulty in filtration. 
 
 1 Vorselungen icber allgemeine Pathologic, 1882, Bd. ii. p. 140. 
 
 2 Zcitschr. f. Biologie, vol. xv., 1879, p. 130. 
 
 3 P/liigcrs Archii\, vol. xxix.. 1882, ]k 3.")(). 
 
154 
 
 INTESTINAL DISP:ASES 
 
 The Allihn tube, having been carefully prepared, is dried and 
 weighed. The sugar-containing solution, after being well 
 boiled with Fehling's solution, is then filtered by the aid of a 
 suction pump through the asbestos filter, the flask being well 
 washed with boiling water, and all the copper oxide washed on 
 to the asbestos by means of a glass rod tipped with rubber. 
 
 ALLIHN'S TABLE.!— QUANTITY OF SUGAR CALCULATED FROM 
 THE WEIGHT OF COPPER OR COPPER OXIDE 
 
 Sugar. 
 
 Copper. 
 
 Copper oxide. 
 
 Sugar. 
 
 Copper. 
 
 Copper oxide. 
 
 6.25 
 
 18-94 
 
 
 36 
 
 82-4 
 
 92-8 
 
 12 
 
 32-8 
 
 36-8 
 
 37 
 
 84-4 
 
 95-1 
 
 13 
 
 34-9 
 
 39-2 
 
 38 
 
 86-5 
 
 97-4 
 
 14 
 
 37-0 
 
 41-6 
 
 39 
 
 88-5 
 
 99-7 
 
 15 
 
 39-1 
 
 43-9 
 
 40 
 
 90-5 
 
 101-9 
 
 16 
 
 41-2 
 
 46-3 
 
 41 
 
 92-6 
 
 104-2 
 
 17 
 
 43-3 
 
 48-7 
 
 42 
 
 94-6 
 
 106-5 
 
 18 
 
 45-4 
 
 51-0 
 
 43 
 
 96-6 
 
 108-8 
 
 19 
 
 47-5 
 
 53-4 
 
 44 
 
 98-6 
 
 111-1 
 
 20 
 
 49-6 
 
 55-8 
 
 45 
 
 100-7 
 
 113-4 
 
 21 
 
 51-7 
 
 58-1 
 
 46 
 
 102-7 
 
 115-7 
 
 22 
 
 53-8 
 
 60-5 
 
 47 
 
 104-7 
 
 118-0 
 
 23 
 
 55-9 
 
 62-9 
 
 48 
 
 106-7 
 
 120-2 
 
 24 
 
 58-0 
 
 65-2 
 
 49 
 
 108-8 
 
 122-5 
 
 25 
 
 00-1 
 
 67-6 
 
 50 
 
 110-8 
 
 124-8 
 
 26 
 
 62-1 
 
 69-9 
 
 51 
 
 112-8 
 
 127-1 
 
 27 
 
 64-2 
 
 72-2 
 
 52 
 
 114-9 
 
 129-4 
 
 28 
 
 66-2 
 
 74-5 
 
 53 
 
 116-9 
 
 131-7 
 
 29 
 
 68-2 
 
 76-8 
 
 54 
 
 119-0 
 
 134-0 
 
 30 
 
 70-2 
 
 79-1 
 
 55 
 
 121-0 
 
 136-3 
 
 31 
 
 72-3 
 
 81-3 
 
 56 
 
 123-0 
 
 138-6 
 
 32 
 
 74-3 
 
 83-6 
 
 57 
 
 125-1 
 
 140-9 
 
 33 
 
 76-3 
 
 85-9 
 
 58 
 
 127-1 
 
 143-2 
 
 34 
 
 78-4 
 
 88-2 
 
 59 
 
 129-2 
 
 145-5 
 
 35 
 
 80-4 
 
 90-5 
 
 60 
 
 131-2 
 
 147-8 
 
 After washing with hot water, alcohol, and ether, the tube is 
 sucked as dry as possible, after which a stream of hydrogen 
 is allowed to pass through it, and while passing through the 
 asbestos, the asbestos part of the tube is heated in a flame to 
 redness. By this means the copper oxide will be reduced to 
 metallic copper. On cooling, the tube is again weighed, and 
 from the quantity of reduced copper found in the tube, the 
 quantity of sugar is calculated by referring to Allihn's table. 
 
 1 Schmidt and Strasburger, Die Faeces des Mensehen, j). 170. 
 
CHEMICAL EXAMINATION OK VM'KH 
 
 155 
 
 Strasburger prefers to use Volliard-Pfliiger's C()[)per Cyanide 
 Method because, in the above-described method, there may 
 be, besides the collection of copper on the Allihn's filter, some 
 impurities from the filtrate in the faeces collected on the asbestos. 
 Most of these foreign substances, however, would be burnt during 
 the heating of the tube in the flame, as well as which the method 
 of estimating carbohydrates in the focces by converting them 
 into sugar by boiling with dilute hydrochloric acid is not accurate, 
 because other substances besides carbohy- 
 drates, such as mucus, can hardly help being 
 broken up in the process, thus yielding copper 
 reducing substances, and tending to make 
 the results obtained by the method of ana- 
 lysis too high. 
 
 Method of Estimating- Carbo- 
 hydrates by Schmidt's Fermen- 
 tation Tests. — Schmidt ^ has introduced 
 an ingenious method of estimating the amount 
 of fermentation going on in the fseces, thus 
 obtaining a rough idea of the quantity of 
 carbohydrates present in the stool. 
 
 About five grams of fseces, or if very fluid, 
 a quantity sufficient to yield about one gram 
 of dry substance, is put into fermentation 
 tube A (Fig. 2), and well mixed with water. 
 An indiarubber stopper connected with tube 
 B is inserted into the fermentation tube, 
 avoiding any bubbles of gas, tube B having 
 been previously filled with water and con- 
 nected with tube C which has a small 
 opening at the top, and contains no water. 
 The apparatus, put together as seen in Fig. 
 2 is then allowed to stand in an oven at 
 37° C. for twenty-four hours ; the gas formed in the faeces 
 passes up into tube B and drives the water over into tube C. 
 
 If, from a given quantity of starch, a given quantity of gas 
 
 was developed, this method would be very accurate for the 
 
 quantitative estimation of carbohydrates in the fseces, but, 
 
 unfortunately, this is not found to be the case. Schmidt 
 
 1 Schmidt and Strasburger, Die Freccs' des Menschen, p. 178. 
 
15G 
 
 INTESTINAL DISEASES 
 
 considered that by this fermentation method one ought not to 
 get normally more than one-quarter of B filled with gas from 
 one gram of dried faeces. In employing this method, we have 
 found it essential to use very fresh faeces, otherwise, the process 
 seems to be most inaccurate. 
 
 Presence of Carbohydrates. — The presence of starch 
 in the faeces, although of undoubted importance, has not, 
 unfortunately, been investigated by us so thoroughly as the 
 presence of nitrogen and fat, partly because of the difficulty 
 of carrying out the methods with sufficient accuracy to draw 
 definite conclusions, and partly because the micro-chemical 
 reaction has seemed to us to be sufficient for making a diagnosis 
 when the alternative is working with inaccurate methods. 
 
 When finely prepared starch is given in the diet, such as 
 white bread made from very finely ground flour, only a very 
 small quantity of carbohydrates, if any, is found in the fa?ces. 
 
 TABLE XLI.— INFLUENCE OF THE FINENESS OF PREPARATION 
 OF THE FOODi 
 
 Kind of food. 
 
 Carbo- 
 hydrates in 
 the food. 
 
 Carbo- 
 hydrates m 
 the f jeces. 
 
 Author. 
 
 Fine white flour 
 
 Medium flour . 
 
 Wholemeal . 
 
 Bread made from ground rye 
 
 Bread made from whole rye 
 
 Rice .... 
 
 Dumplings 
 
 Maize .... 
 
 Peas .... 
 
 
 528-8 
 
 507-9 
 
 504-5 
 
 515-6 
 
 481-6 
 
 493 
 
 557-5 
 
 563 
 
 587-9 
 
 5-83 
 13-10 
 37-23 
 45-7 
 01-4 
 
 4 
 
 9-0 
 18-0 
 41-0 • 
 
 Riibner 
 
 Wicke 
 Riibner 
 
 In Table XLI., the influence of fineness of preparation of the 
 carbohydrates on the quantity present in the fa>ces is well 
 illustrated. 
 
 It has been shown by Riibner that when 528-8 grams of white 
 Hour were given, only 5"8.'i grams of carbohydrates were found in 
 the faces; while, when 481 "G grams of whole rye were given, 
 no less than 61 '4 grams of carbohydrates were found in the 
 fffices. 
 
 1 Schiiiidl and Sin 
 
 rgor, Die F(rri\'^ dcs Mcnf<cfu'ii, p. ISI. 
 
CHEMICAL EXAMINATION OF F.ECES ir,7 
 
 The quantity of carbohydrates taken in the diet has also a 
 considerable influence on the quantity found in the faeces. 
 
 TABLE XLII.-INFLUENCE OF THE QUANTITY OF CARBO- 
 HYDRATES IN THE FOODi 
 
 Kin.lof r.K.l. 
 
 C.irlpoliydnitcs 
 ill the" food. 
 
 C-irlioIiydnites 
 in the ficces. 
 
 j 
 Autlior. 
 
 White brciid 
 
 Peas, GOO-0 grams . 
 „ 959-8 „ . 
 
 391 1 
 
 (i701 
 3.-)7-(> 
 
 587 -9 
 
 G-0 
 
 5-0 
 
 12-9 
 
 41-0 
 
 RiibnCr 
 
 In Table XLII. it will be seen that^when white bread was given, 
 the quantity of bread made no difference in the quantity of 
 carboliydrates found in the faeces, while, on the other hand, 
 when peas, which are more difficult to digest, were employed, 
 the effect of increasing the carbohydrates in the diet was to 
 cause a very marked increase in the quantity of carbohydrates 
 found in the faeces. 
 
 1 Scliniidt and Strasburgcr, Die Fceccs des Menschen, p. 182. 
 
CHAPTER XXI 
 
 CHEMICAL EXAMINATION OF F.ECES (continued)— PHENOL, 
 INDOL, AND SKATOL 
 
 The three substances, phenol, indol, and skatol, which are 
 derived from the breaking-down of the proteids by the action 
 of bacteria in the large intestine, can well be described in a 
 group. 
 
 Hoppe-Seyler's Method of Analysis/ — The specimen 
 of feeces to be examined is mixed with water until it forms a 
 paste, and, after adding more water, is placed in a distillation 
 flask which is connected with a cooler and heated over a free 
 flame, and distilled to one-third its volume. The distillate 
 (1) will contain free fatty acids, phenol, indol, and skatol. This 
 distillate is mixed with sodium carbonate solution in order to 
 convert the free fatty acids into sodium soaps, and thus render 
 them no longer volatile. After the further addition of water, 
 it is again distilled, and this time phenol, indol, and skatol will 
 come over in the distillate (2). 
 
 The distillate (2) is rendered strongly alkahne by the addition 
 of caustic potash and again distilled, when indol and skatol 
 will be distilled over, the phenol remaining behind. Since 
 indol is not so volatile in steam as skatol, the first portion of 
 the distillate will contain the most skatol, and by fractional 
 distillation, one is able to separate the indol from the skatol. 
 
 OH 
 
 H— C CH 
 PHENOL.— CgH^OH = I II 
 
 H— C CH 
 
 \ / 
 C 
 H 
 
 Phenol forms long needles which are soluble in fifteen parts 
 of water, melts at 40° C, and boils at 181° C. 
 
 1 Handbuch dcr Phy.fial. ti. Pathol. C/ioni.'^cJtcn Anah/.^i\ vii. Aufl. lUO;}, 
 pp. 217-240. 
 
CHEMICAL EXAMINATION OF F^CES 159 
 
 Tests for Phenol. — (1) On heating a solution containing 
 phenol with Millon's reagent, one immediately obtains a red 
 colour or red precipitate. 
 
 (2) On adding bromine water to a solution containing phenol, 
 one obtains a milky cloud, which slowly forms a yellowish-white 
 precipitate consisting of silky shiny needles or cheesy flakes 
 of tribromphenol. 
 
 \0 H 
 
 (3) On adding a few drops of perchloride of iron solution to a 
 solution containing phenol (which must have a neutral reaction) 
 one obtains a violet colour, quickly changing to blue. 
 
 H 
 
 HC C— NH\ 
 
 INDOL.— C^H.N =1 II CH 
 
 HC C— CH/- 
 
 \ / 
 CH 
 
 Indol crystallises from hot water as small shiny leaves, with a 
 distinctly fa?cal colour, easily soluble in hot and less soluble in 
 cold water. Indol has a melting-point of 52° C. and a boiling- 
 point of 245° C. 
 
 Tests for Indol. — (1) A solution containing indol, on 
 adding nitric acid which contains some nitrous acid, gives a red 
 colour, and eventually a precipitate of nitrate of nitrosoindol 
 CyH(iN (NO). Nitrosoindol is slightly soluble in water, easily 
 soluble in alcohol, and insoluble in ether : on heating to dryness, 
 it explodes. 
 
 (2) An alcohohc solution of indol, into which a chip of pine- 
 wood moistened with hydrochloric acid is inserted, gives a 
 cherry-red colour, nitrosoindol. 
 
 (3) LegaVs Test.~^To a solution containing indol one adds a 
 very dilute solution of sodium nitro-prusside, and, on the further 
 addition of a few drops of sodium hydrate, one obtains a deep 
 violet colour which turns to blue on the addition of hydrochloric 
 acid or acetic acid. 
 
IGO INTESTINAL DISEASES 
 
 H 
 
 HC C— N]l\ 
 
 SKATOL.-(/o METHYL rNDOL).—f"nH,N = l_ il ^^<^"H 
 
 HC C — C // 
 
 \ / CH3 
 CH 
 
 Skatol crystallises in colourless leaves which have a foetid 
 odour and, as we have already said, is less soluble in water and 
 more easily distilled than indol. The crystals of skatol have a 
 melting-point of 95° C. and a boiling-point of 265° C. Skatol 
 readily unites with hydrochloric acid, forming crystals (CyHgN^) 
 HCl., which are insoluble in ether and water and readily soluble 
 in alcohol. 
 
 Tests for Skatol. — (1) A solution containing skatol, 
 when nitric acid containing nitrous acid is added, does not give 
 a red colour as when the acid is added to the indol solution, but 
 merely a whitish cloud. 
 
 (2) A solution containing skatol on the addition of concen- 
 trated hydrochloiic acid gives a violet colour. 
 
 (3) An alcoholic or water solution of skatol on the addition of 
 a chip of pine-wood moistened with hydrochloric acid gives no 
 red colour, -as distinguished from indol. If a chip of pine-wood 
 is put into a hot alcoholic solution of skatol and then into cold 
 concentrated hydrochloric acid, one gets a cherry-red colour 
 which changes into a dark violet. 
 
 (4) On the addition of diluted sodium nitro-prusside and a 
 further addition of sodium hydrate, a solution containing 
 skatol gives a yellow colour which, on adding a half-volume of 
 glacial acetic acid and heating to boiling, turns a violet colour. 
 
 (5) On warming a solution of skatol with sulphuric acid one 
 gets a purple-red colour. 
 
 The above-described methods of recognising the presence of 
 phenol, indol, and skatol may occasionally be of interest, but 
 for diagnostic purposes they are of very httle use. 
 
 The quantitative estimation of phenol, indol, and skatol is 
 extremely comphcated, and we personally have no experience in 
 the matter. The methods are described by Schmidt and Stras- 
 burger,^ and those who desire to carry on the research are referred 
 to these authors. 
 
 1 Schmidt and .Strtusbuigor, Die Fceces dcd Mciidchcn, p. 144. 
 
CHEMICAL EXAMINATION OF F.^CES 101 
 
 For clinical purposes one can obtain, by the examination of 
 the urine, very valuable information as regards the increase of 
 intestinal putrefaction in connection with the formation of 
 phenol, indol, and skatol. By estimating the quantity of aro- 
 matic sulphates in the urine one obtains direct evidence as to 
 whether these aromatic substances are increased or not, as 
 well as which the examination for indican gives satisfactory 
 evidence of the increase or the reverse of this substance. To 
 test for indican in the urine, the following method is sufficient 
 for all clinical purposes. 
 
 Test for Indican in the Urine. — To a specimen of 
 urine in a test-tube, concentrated nitric acid is added to the 
 bottom of the test-tube by means of a pipette. A reddish ring 
 appears at the junction of the two layers if indican is present. 
 If it is only slightly in excess, a pink colour appears in five to 
 ten minutes. Excessive indican in the urine is shown by the 
 appearance of the reddish colour immediately the acid is added, 
 w^hicli deepens within two or three minutes. When a very 
 marked increase of indican is present in the urine, this red 
 colour becomes almost black on standing. 
 
 In making a series of analyses in our laboratory on the amount 
 of indican in the urine as indicated by the nitric acid method, 
 and comparing it with the methods of Jaf!e, &c., we have found 
 the nitric acid test to be all-sufficient for clinical purjjoses. 
 
 Presence of Phenol, Indol, and Skatol. — The 
 quantity of phenol, indol, and skatol in the faeces under various 
 pathological conditions has been very little investigated, the 
 subject being a difficult one owing to the want of easy quanti- 
 tative methods of analysis. On the other hand, it is easy to form 
 an idea of the amount of intestinal putrefaction going on in the 
 ahmentary canal, and leading to the production of phenol, indol 
 and skatol by estimating the indican or the aromatic suljjhates 
 in the urine. But it must be remembered that the estimation of 
 the quantity of indican or aromatic sulphates in the urine gives 
 no absolute indication of the amount of phenol, indol, and skatol 
 formed in the alimentary canal, since we do not know what cir- 
 cumstances influence its rate of absorption from the bowel : we 
 therefore only gain definite evidence as to the increase of indican 
 or aromatic sulphates in the urine. There may be no increase in 
 indican or aromatic sulphates in the urine together w^ith in- 
 
 L 
 
1G2 INTESTINAL DISEASES 
 
 creased formation of phenol, indol, and skatol in the ahmentary 
 canal, in cases where there is hindered absorption of these sub- 
 stances. 
 
 Phenol, indol, and skatol, according to Senator,^ are not 
 present in meconium, and when one considers that these sub- 
 stances are derived from the breaking-up of proteid by the action 
 of bacteria in the intestine, one would not expect them to be 
 present in meconium, since we know that bacterial putrefaction 
 does not go on in the bowels of the foetus. The fasting indi- 
 vidual, as we have already shown, normally passes a certain 
 amount of faeces which are derived from the digestive secretions 
 in the intestinal canal, the formation of mucus, and the residue 
 of epithehal cells which are continually thrown of? from the 
 ahmentary tract. These substances, which are more or less rich 
 in proteid, lead to a certain degree of intestinal putrefaction, 
 i.e., phenol, indol, and skatol, which have always been found 
 present in the stools of fasting individuals. 
 
 Normal faeces, according to numerous observers, contain a 
 varying quantity of phenol, indol, and skatol, according to the 
 quantity of bacteria present in the intestine — the latter being 
 influenced by the rapidity of transit of food along the alimentary 
 canal and also by the composition of the diet. The diet given 
 to the individual under observation would naturally tend to 
 have a very marked influence on the quantity of phenol, indol,. 
 and skatol formed, since we know that these substances are 
 principally derived from the proteid in the food. A diet rich 
 in carbohydrates and poor in proteid would, under normal con- 
 ditions, tend to form very little of these aromatic substances. 
 On the other hand, a milk diet, though it contains a considerable 
 quantity of proteid, causes a very small quantity of aromatic 
 substances to be present in the faeces, owing to its being made 
 rapid use of in the ahmentary canal and leaving a very small 
 residue in the bowels for the action of bacteria. On a purely 
 meat diet, with its increased quantity of proteid, and its 
 tendency to cause constipation, one gets, relatively speaking, 
 a very marked increase in the quantity of phenol, indol, and 
 skatol. The rapid transit of food along the alimentary canal 
 also tends to diminish the quantity of phenol, indol, and skatol, 
 and it is found that even in slight cases of increased peristalsis 
 
 1 Zcitschr. /. Physiol. Chcm'.e., iv. 1880, p. 1. 
 
CHEMICAL EXAMINATION OF F.^CE8 Ui[\ 
 
 due to nervous causes there is a marked tendency to decrease 
 in the quantity of aromatic sulphates in the urine as well as in 
 the quantity of indican. A smart purge, such as any of the 
 sahnes, owing to its effect of hastening the food along the alimen- 
 tary tract, leads to a diminution in the quantity of phenol, indol, 
 and skatol in the faeces. The most marked reduction of these 
 substances occurs when calomel is given : in such cases we not 
 only have the increased peristalsis tending to cause a diminution 
 in the amount of phenol, indol, and skatol, but we have in addi- 
 tion the action of the calomel on the bacteria of the bowel, as 
 calomel seems, of all drugs, to be the best of the intestinal 
 antiseptics. 
 
 In constipation, or where the action of the bowel tends to be 
 sluggish, we should expect to find an increase in the quantity of 
 phenol, indol, and skatol, and it is found in most of these cases 
 that the indican and aromatic sulphates are increased in the 
 urine. 
 
 In would appear from the observations of Nothnagel that 
 phenol, indol, and skatol are not so markedly increased in 
 diseases of the large intestine as they are when the disease 
 occurs in the small intestine. 
 
CHAPTER XXII 
 
 CHEMICAL EXAMINATION OF F.ECES {contimicd)— BILE, UROBILIN, 
 AND BLOOD 
 
 Bile, in the form of bile acids or pigments, may occasionally 
 occur in the faeces, and a few remarks on the subject are necessary 
 here. 
 
 Glycocholate and taurocholate of soda are the two principal 
 substances present in the human bile in their passage along the 
 intestine. They are, however, for the most part, absorbed in the 
 small intestine, only a very small proportion of the bile acids pass- 
 ing through the ileo-caecal valve. The bile acids, on reaching the 
 large intestine, are acted upon by the putrefactive bacteria and 
 broken down into glycocol and taurin ; and the cholalic acid 
 united with the soda forms chelate of soda. Consequently, 
 under normal circumstances, no bile acids appear in the fseces. 
 
 Cholate of soda, however, is normally present in the stools ; 
 but, its pathological significance up to the present being negative, 
 it is unnecessary to describe it here. The method for its recog- 
 nition is given by Hoppe-Seyler.^ 
 
 Method of Testing for Bile Acids. — In cases where 
 bile acids are present in the faeces, one is able to obtain Petten- 
 koifer's reaction. A small portion of faeces is placed on some 
 white porcelain, adding a little sugar or a very dilute solution of 
 furfurol, and allowing some concentrated sulphuric acid to 
 come in contact with the faeces on the plate — care being taken 
 that heating does not cause charring. In the presence of bile 
 acids, one obtains a bright crimson colour. This test is not 
 very accurate, however, as the albumen, &c., present in the 
 faeces often mask the reaction. 
 
 Presence of Bile Acids. — As already said, the bile 
 acids, under normal conditions, are absorbed or broken up in 
 their passage along the intestine, so that none appear in the 
 
 I Handhuch der Physiologisch und Pathologisch Chcmischcn Analyse, Aufl. vii, 
 1903, p. 271. 
 
CHEMICA.L EXAMINATION OF FAECES 105 
 
 stools. In cases, however, of very rapid passage of the alimen- 
 tary contents along the bowel, allowing little time for the action 
 of putrefactive bacteria in the large intestine, bile acids may 
 be found in the fa3ces. 
 
 Bile Pigment. — The recognition of bile pigments in the 
 fseces is a great deal easier than that of bile acids, and conse- 
 quently is much more generally utihsed in practice. In using, 
 in the later parts of this book, the term bile as being present 
 in the faeces under pathological conditions, we refer to bile pig- 
 ments and not to bile acids. Bile pigments may be recognised 
 in the faeces either as bilirubin or biliverdin. 
 
 Methods of Recognising Bile Pigment: (1) 
 ScJniiidt\s Reaction. — This is, undoubtedly, the most decisive 
 method of recognition of bile pigments in the faeces. On the 
 addition of a concentrated solution of corrosive sublimate to 
 either dry or wet faeces, a bright green colour will be obtained if 
 bile is present. This green colour may be obtained even with 
 very small particles of faeces, so that the test can be used as a 
 micro-chemical one. The green colour produced by the subli- 
 mate is due to the bihrubin being converted into bihverdin. 
 
 (2) Gmelin's Test. — Some faeces are smeared on a white tile, 
 and a few drops of nitric acid containing nitrous acid are run 
 on to the edge of the faeces, when, in the presence of bile pig- 
 ments, a play of colours is produced. Green must be recognised 
 among the colours before one can definitely say that bile pigment 
 is present. If the faeces are coloured green by chlorophyll or 
 bacteria, it is necessary to make a watery extract and allow a 
 drop of nitric acid to come in contact with a drop of the watery 
 solution, when a play of colours will appear if bile is present. 
 
 (3) Huppert's Test.—Ahont fifteen grams of moist faeces are 
 well mixed with milk of lime and, after shaking, filtered : the 
 precipitate is washed with water until no more colour appears 
 in the filtrate. The precipitate is then collected and extracted 
 with hot alcohol which has been previously acidulated with sul- 
 phuric acid. The extract, in the presence of bile, will have a 
 light green colour, due to biliverdin. 
 
 Presence of Bile Pigment. — The bile pigments which 
 reach the intestine in their passage along the bowel undergo 
 certain transformations. It is found that the contents of the 
 bowel in the upper third of the small intestine are of a yellowish 
 
166 INTESTINAL DISEASES 
 
 colour, due to bilirubin ; and it has been shown by one of us ^ 
 that the contents in the middle third are of a white or greyish 
 colour, the green colour only appearing again in the lower third 
 of the small intestine. Under ordinary circumstances, when 
 the ileo-csecal valve is passed, the normal colour of the fseces 
 appears, the bile pigments having been converted by the action 
 of putrefactive bacteria into urobilin. It would appear that 
 in health the bile pigments in the middle third of the small intes- 
 tine are present in some chromogenic form until they are coloured 
 green after reaching the lower third of the small intestine. Since 
 bile pigments are converted into urobihn after their passage 
 into the large intestine, and, in some cases, even into the lower 
 part of the jejunum, no bile pigment under normal circumstances 
 is present in the faeces. In cases of diarrhoea, more especially 
 the so-called jejunal diarrhoea of Nothnagel, bile pigment is 
 always present in the stools, 
 
 UROBILIN 
 
 The colouring-matter, urobihn, as it is found in the faeces, 
 has been known by the name of hydrobihrubin or stercobihn ; 
 but since the urobihn found in the faeces, when properly 
 purified, has been demonstrated to be identical with the 
 urobihn, when equally purified, that is found in the urine, 
 it seems a pity to comphcate matters by giving them dif- 
 ferent names. We shall, therefore, refer to urobilin in the 
 faces under the head of urobilin, and not of hydrobihrubin 
 or stercobihn. 
 
 Test for Urobilin in the Faeces: Schmidfs Test.— 
 When a concentrated solution of perchloride of mercury is 
 apphed to either wet or dry faeces, a bright red colour is developed 
 in the space of a few minutes if urobihn is present. The rose- 
 colour extract, when separated and examined with the spectro- 
 scope, shows an absorption band of urobihn between F and b. 
 It is possible by this method to recognise very small quantities 
 of urobihn. The colour is distinctly visible on a fragment of 
 faeces after treatment with perchloride of mercury when examined 
 under the microscope. If urobihn is present in very marked 
 
 1 Vaughan Harlcy, " Formation of Urobilin."— i>;v't. Jlcd. Journ., Oct. 3, 
 1896. 
 
CHEMICAL EXAMINATION OF FAECES 1G7 
 
 excess, the pink colour will be very distinct within five minutes, 
 while, in only shght excess, the colour appears within five to 
 fifteen minutes : if only a very little urobiHn is present it may 
 be thirty minutes or longer before one gets a reaction, and the 
 most marked reaction will be seen at the end of some twenty- 
 four hours. This test for urobilin is so satisfactory that it is 
 unnecessary to describe the older methods of recognising urobilin 
 in the fopces. 
 
 Presence of Urobilin.— In discussing bile pigments 
 we showed how bile pigments are converted into urobiUn in the 
 large intestine. The greater part of the urobihn present in the 
 intestinal contents or in the faeces is probably in the form of the 
 chromogen urobiHnogen, since we find that in some cases, larger 
 quantities of urobilin are found in the faeces when they have 
 stood for some time. In the case of new-born children, no 
 urobilin is present in the stools or in the urine, meconium being 
 always found to be entirely free from urobiUn. In healthy 
 adults, it would appear that under normal conditions urobihn 
 is not found in the bowel until it has reached the ileo-caecal valve. 
 In autopsies, as a general rule, perchloride of mercury will give 
 a red colour to urobihn in the intestinal wall in the same way as 
 it gives to the faeces a pink colour.^ 
 
 By this method one is able to see where the urobilin is first 
 formed. We have found that, as a general rule, it is not formed 
 until it has passed the ileo-caecal valve, while in exceptional cases 
 the urobilin formation extends some way up the jejunum. 
 
 It has been shown by Gerhardt - that in cases of complete 
 obstruction of the bile-duct, the faeces contain no urobihn. In 
 fact, as long as the bile-duct is obstructed, urobihn is absent from 
 the faeces, except in some few cases which are possibly explained 
 by the absorption of bile from the gall-bladder, and the excretion 
 of it into the bowel. That urobilin does not appear in the faeces 
 in obstruction of the bile-duct is of interest in diagnosis. We 
 may describe one case, that of a man with marked jaundice 
 whose iscces contained no trace of urobilin : he was given daily 
 by means of the stomach-tube from 25 to 125 grams of pigs' 
 bile absolutely free from urobilin : on the second day after its 
 administration, urobihn appeared in the faeces, and on the third 
 
 1 Loc. cit. p. 166. 
 
 2 Ueher Hydrohiliruhin und seine Bcziehunqcn zum Ikieriis. — Inaug. Diss, 
 Berlin, 1889. 
 
168 INTESTINAL DISEASES 
 
 day, it was detected in the urine : when the administration of bile 
 ceased, urobihn disappeared from the fseces and urine. This 
 clearly demonstrates that the urobilin present in the faeces is 
 derived from the bile in the individual, and, under ordinary 
 conditions, one expects to find urobilin present in the faeces. In 
 cases of increased intestinal putrefaction, there is a tendency to 
 an increase in the quantity of urobilin in the faeces. 
 
 The quantity of urobihn in the urine is, to a certain extent, 
 indicative of the quantity formed in the stools, but we must 
 remember that the amount of absorption going on at any time 
 is not exactly proportionate to the amount of urobihn in the 
 bowel, just as the amount of indican does not definitely indicate 
 the amount formed in the intestine. 
 
 In meconium, urobilin is always absent and bile pigments only 
 found present. In the case of colourless stools unaccompanied by 
 any jaundice, it is often found that urobilin is absent as such and 
 only urobilinogen is to be recognised ; the latter can, by exposure 
 to the air, be converted into urobilin, the faeces then becoming 
 coloured. In the colourless faeces sometimes seen in fat stools, 
 urobilin is present, as a rule, in normal quantities, the colour only 
 being masked by the excess of fat : removal of the fat by ether 
 will at once reveal the colouration. 
 
 BLOOD 
 
 In blood which is derived from the stomach or from the 
 upper part of the small intestine — unless there is extremely 
 rapid peristalsis and the haemorrhage is considerable— the 
 oxyhaemoglobin is entirely converted into haematin in its 
 passage along the bowels. In haemorrhages which occur low 
 down in the bowel, such as the rectum, or when the haemorrhage 
 occurs in the large intestine and there is increased peristalsis, 
 oxyhaemoglobin itself may be present. 
 
 Methods of Recognition. — (1) As a general rule, when 
 fresh haemorrhage occurs and the blood has not been altered by 
 the process of digestion, it can be recognised by the naked 
 eye ; or doubtful specimens can be examined under the micro- 
 scope and red blood corpuscles recognised. If the blood is 
 present in the form of oxyhaemoglobin and the doubtful specimen 
 is dissolved in water, examination with the spectroscope will 
 
CHEMICAL EXAMINATION OF FMCES IG^) 
 
 reveal the two characteristic absorption bands between D 58!)-3 
 to 577-8 wave-length and E 55()-2 to 5288 wave-length. 
 
 (2) Guniacum Test.— To a watery extract of faeces which appear 
 to contain blood, a few drops of turpentine which has been exposed 
 to the air for some time or some ozonic ether are added. On 
 the addition of a little freshly prepared tincture of guaiacum, one 
 obtains a bright amethyst-blue colour. This test is not very 
 satisfactory for faeces, since they may themselves contain suffi- 
 cient oxygen carriers to complete oxydation in the absence of 
 blood-corpuscles. 
 
 (3) Teichnmnn's Hcemin Tes^.— When the stools contain blood 
 so altered that it is already formed into haematin it is necessary 
 to use further tests, and Teichmann's is one of the most useful. 
 A small specimen of fa3ces containing blood is placed on a warm 
 glass slide and rubbed up with glacial acetic acid, a trace of 
 sodium chloride being added. After warming over a flame, 
 being careful to avoid over-heating, the preparation is dried, 
 and if examined by the microscope there will be seen, in the 
 presence of blood, the characteristic haemin crystals as irregular- 
 sized rhombic crystals of a brownish or reddish-brown colour. 
 
 (4) ^^^eheis Test}— A portion of faeces, after being extracted 
 with ether and all excess of fat removed, is mixed with water 
 and one-tliird its volume of acetic acid : it is then rubbed up into 
 a fluid consistency, placed in a large test-tube, and ether added. 
 The ether, in the presence of blood, takes up the haematin and 
 becomes a brownish-red colour, and if separated can be easily 
 examined with the spectroscope, when it shows the four absorp- 
 tion bands of acid haematin : a small marked band in the red 
 between C and D i. 654-7 to 652-6 wave-length, and two fainter 
 bands between D and E ii. 589-3 to 577 8 wave-length and 
 iii. 553.3 to 536-6 wave-length, with a broad band at F iv. 
 516-8 to 490-6 wave-length, which is very often difficult to see. 
 
 Presence of Blood in the Stools. — It is stated 
 that when Weber's test is employed, one obtains a reaction if 
 blood sausages or underdone meat have been taken in the diet. 
 With the ordinary tests, unless raw meat or blood has been 
 taken in the diet, the results are certainly negative. In haemor- 
 rhages from the stomach or small intestine, the blood is intimately 
 mixed with the faeces, and, as already stated, is present in the 
 
 1 Berl. klin. Wochenschr., 1893, Xo. Ii'. 
 
170 INTESTINAL DISEASES 
 
 form of hfematin. In some cases of haemorrhage from typhoid 
 or tubercular ulceration of the bowel accompanied by diarrhoea, 
 one gets oxyhsemoglobin even when the haemorrhage occurs 
 in the small intestine, the blocd being intimately mixed with 
 the motions. In hoemcrrhages from the large intestine, the 
 blood is not so intimately mixed with the faeces, especially if 
 it comes from low down in the bowel ; and it is generally 
 found to be more or less mixed with mucus, pus, or some 
 intestinal sloughs from the bowel. 
 
CHAPTER XXIII 
 
 MOTOR-POWER OF THE INTESTINAL TRACT— DIARRHCEA AND 
 CONSTIPATION 
 
 Before discussing diarrhoea and constipation, it is important to 
 consider the general motility of the bowel. 
 
 The frequency of the action of the bowels varies very con- 
 siderably in different individuals, this being partly due to the 
 mode of life and the diet taken. Any diet leaving a large residue 
 in the bowel tends to cause more or less bulky stools accompanied 
 by frequent motions ; so that on a large vegetable diet, or more 
 especially amongst vegetarians, it is not at all uncommon to 
 find a habit of passing two or three motions daily. On the other 
 hand, a diet leaving very little residue, such as milk or meat, 
 tends to diminish the frequency of the motions, so that one 
 may only have an action of the bowels once in two or three days. 
 The knowledge of the peristaltic condition of the alimentary 
 tract is of very great importance to the physician both in the 
 diagnosis and treatment of diseases of the bowels. By noting 
 the time it takes for any easily recognised substance to reappear 
 in the faeces after having been taken by the mouth, one gets 
 an idea of how long it takes for food to pass from the mouth 
 to the anus ; but one obtains no clue, in cases of delay, as to 
 how much of the delay is due to want of motor-power in the 
 stomach. In discussing the motility of the stomach, we have 
 already shown how the motor-power of the stomach can be 
 easily investigated ; and if the motility of the stomach has been 
 found to be normal, any delay in the appearance of food in the 
 faeces must be attributed to the bowels. On the other hand, 
 if we have found delayed motility of the gastric contents, the 
 amount of delay occurring in the stomach must be subtracted 
 from the total delay in the passage along the alimentary tract, 
 and we shall thus learn how much delay is incurred in the passage 
 along the bowels. In order to make more decisive calculations 
 
172 INTESTINAL DISEASES 
 
 with regard to the motor-power of the alimentary canal, a diet 
 well mixed with bismuth sub-nitrate has been given and the 
 course of food along the alimentary tract observed by means of 
 X-rays. Sicard and Infroit ^ found by this method that the food 
 took seven hours to pass along the small intestine and reach 
 the ileo-caecal valve : another period of fourteen hours was 
 required for the passage of food along the caecum and ascending 
 colon, the rest of the large intestine taking a further period of 
 three hours. The question of whether the large or small intestine 
 is responsible for the delayed motor-power cannot be settled by 
 any method at present known which is applicable to ordinary 
 practice. 
 
 In cases of increassd peristalsis, one gets, by examination of 
 the faeces, some idea whether the increased peristalsis is in the 
 large intestine ; for it is found that when mucus, stained with 
 biliverdin, is present in the faeces, or when, by chemical methods, 
 bile is recognised in the stools, one may conclude that the in- 
 creased peristalsis is in the large intestine : otherwise, the bile 
 would have been converted into urobilin in its passage along 
 the greater bowel. 
 
 Investigation of the motor-power of the alimentary tract by 
 means of the recognition of different particles of food in the 
 faeces is not very satisfactory. The regularity of the motions 
 has long been known by investigators in metabolism not to 
 indicate the rate of passage of substances along the bowel, for it 
 has been found that the faeces passed on any occasion are not 
 necessarily derived from the food taken during the preceding 
 twenty-four hours, and that it is not uncommon to find par- 
 ticles of a former day's food which have remained behind in 
 the sacculi of the colon and have not been passed in the stools 
 which had previously appeared. It is, therefore, necessary in 
 metabolism experiments, where one wishes to separate the 
 stools of the different diets given, to have some means of recog- 
 nising the faeces belonging to each period. For this purpose, 
 finely ground bone was given by Voit, charcoal and carmine 
 having been given by other investigators. It appeared to us 
 that this method of separating the stools on different diets could 
 be well applied to investigating the motor-power of the alimen- 
 tary tract, and for the purpose, we have used either finely ground 
 1 La Presse Mcdicale, 1903, No. 99. 
 
MOTOR-POAVER OF INTESTINAL TRACT 173 
 
 vegetable charcoal or cachets containuig carmine in five-grain 
 doses, the former having been found by us to be the more con- 
 venient. Two drachms of vegetable charcoal are dropped into 
 a wineglassful of water and allowed to stand over-night, the 
 charcoal thus getting into fine suspension, benig both mixed 
 and swallowed more easily than when simply stirred in milk or 
 water. The mixture is given before breakfast and the motions 
 collected, noting the time when each is passed. A point which 
 makes the charcoal more valuable than the carmine method is 
 that in very dark-coloured motions it is sometimes difficult to 
 recognise the carmine, whereas small particles of charcoal can 
 be easily detected by microscopic examination. The charcoal 
 method of investigating the motility of the bowels has been 
 employed by us for over twelve years, during which time a 
 great number of cases have come under our observation. 
 
 In the chart which follows we have put together the results in 
 diseases. One notices the wide range of hours which elapse in 
 different individuals before the reappearance of charcoal in the 
 fgeces. In no less than four cases it appeared within the first 
 hour after its administration, and this from examination of the 
 patient's symptoms and the chemical analyses was found to be 
 due to increased peristalsis of nervous origin, accompanied by no 
 organic changes in the bowel. On the other hand, we have 
 fourteen cases of chronic constipation in which the charcoal took 
 from 100 to 165 hours to reappear in the faeces : in none of these 
 cases was there any real obstruction in the bowel, and the delayed 
 peristalsis appeared to be due to sluggish action of the bowel 
 from purely functional causes. In rare cases the delay is a great 
 deal longer than this, but we have made no special investigations 
 on this subject, it having been our habit to use enemata or some 
 other means of obtaining the faeces in cases of delay beyond 
 100 hours. 
 
 It is well known that in normal individuals living an ordinary 
 life on a mixed diet there is a tendency to pass a motion every 
 twenty-four hours : it would appear that, by training from 
 youth upwards, the nervous motor-controlling influences of the 
 bowel have become accustomed to operating every twenty-four 
 hours, and thus the habit is produced. We see this very markedly 
 in some individuals who, if they are hindered from relieving their 
 bowels at the usual hour, have to wait till the same hour next 
 
174 INTESTINAL DISEASES 
 
 day before they can get relief. In the chart we have dra\^Ti up, 
 the interesting fact is brought out that there is a tendency — 
 even in cases where there is great delay in the passage cf food 
 along the alimentary tract — for the bowels to act at intervals of 
 twenty-four hours. Of the 518 cases examined, the charcoal 
 reappeared in the faeces between the twenty-third and twenty- 
 eighth hours in no less than 174 cases : that is to say, 33 59^ 
 per cent, of the individuals observed passed their motions within 
 this period. During the second period of twenty-four hours, of 
 the 279 cases who passed the charcoal at a longer interval than 
 twenty-eight hours after its administration, no less than 100 
 had an action of the bowels at periods varying from forty-seven 
 to fifty- two hours : that is to say, 35 "48 per cent, had an action 
 of the bowel during the second period. During a third period 
 in which 124 cases did not pass their charcoal till after fifty-two 
 hours, the charcoal appeared in no less than thirty-seven of the 
 cases between seventy-one and seventy-six hours : so that 29"83 
 per cent, passed the charcoal during the third period. During 
 a fourth period, out of thirty-six cases in whose faeces the charcoal 
 did not appear for seventy-six hours, no less than eight, or 22*22 
 per cent., passed their charcoal during the ninety-sixth hour 
 after its administration by the mouth. 
 
 This periodicity of the action of the bowels — even after so long 
 a delay as seventy-six hours — is most interesting and suggestive, 
 as it shows how important it is, in cases of faecal accumulation 
 where there is no real obstruction, and w^here one wants to get 
 maximum results with a minimum drug stimulation, to administer 
 drugs or enemata so that they shall act during one of these 
 twenty-four-hour periods. 
 
 In some of the above cases where there has been long-delayed 
 appearance of the charcoal, the patients have, in the interval, 
 passed one or more motions belonging to the previous diet. 
 One meets with numerous cases in practice where the patient says 
 that he or she has no constipation since there is a regular action 
 of the bowels. By means of the charcoal method, however, 
 one finds that the passage of food along the alimentary canal 
 requires a longer period than under normal conditions ; and 
 only by this method is it possible to recognise that, in spite of 
 the daily motion, there is a long delay in the transit of food 
 along the ahmentary canal. In several cases where the 
 
MOTOR-POWER OF INTESTINAL TRACT 175 
 
 chemical examination of the urine and the symptoms of the 
 patient have led one to believe that there was stercoral 
 poisoning, this charcoal method has shown that such was not 
 the case, but that there was a delay in the passage of food along 
 the bowel, in spite of a daily motion having occurred. It will 
 also be found by the charcoal method that scybala, blackened 
 with charcoal, will appear three or more days after the charcoal 
 has been given, and that, in the meantime, stools of normal colour 
 which have evidently passed along the bowel without carry- 
 ing with them the blackened scybala, have been obtained. 
 
 DIARRHOEA 
 
 The term diarrhoea does not apply to the frequency of the 
 motions, for we all know of individuals who have three or four 
 motions of a solid consistency daily : the term diarrhoea is more 
 rightly reserved for motions of liquid or pultaceous consistency. 
 
 The factors which cause a pultaceous or hquid stool may be 
 grouped under four headings : 
 
 (1) The pultaceous or fluid motion due to the increased quan- 
 tity of water in the fseces, this being a true diarrhoea stool. 
 
 (2) The pultaceous motion due to the increased quantity of 
 fat in the faeces, this condition being known as " fat diarrhoea." 
 
 (3) The pultaceous motion caused by the increase of mucus. 
 
 (4) The pultaceous stool which one gets in various pathological 
 conditions of the bowel, due to organic disease of the mucous 
 membrane of the bowel itself. The latter condition will be 
 described later in treating of various organic diseases. 
 
 Diarrhoea Due to the Increased Quantity of Water 
 in the Faeces. — An increased quantity of water in the faeces, 
 rendering them pultaceous, can be produced by any factor 
 which leads to increased peristalsis and rapid hurrying of food 
 along the large intestine. The normal condition of the large 
 intestine with regard to the absorption of water may also be 
 interfered with and thus, without increased peristalsis, give 
 rise to an increased quantity of water in the stools, due to in- 
 hibition of the water-absorption power of the large intestine. 
 In cases where there is a rapid hurrying of food along the large 
 and the small intestine, the motions will probably contain some 
 bile pigment which has not been converted into urobilin. 
 
176 INTESTINAL DISEASES 
 
 In functional diarrhoea there would appear to be always in- 
 creased peristalsis, and, if the opportunity arises to administer 
 charcoal, it will be found to appear in the stools very shortly 
 after its administration 1 y the mouth (we have found it in as 
 short a period as fifteen minutes). 
 
 General Appearance of the Stools in Diarrhoea. 
 — The motions may vary in colour from a very pale cream 
 to dark chocolate-brown, according to the cause of the diarrhcBa, 
 and in some degree, to the diet taken. 
 
 The consistency of the motions varies between pultaceous 
 masses and almost pure water. In cases where the diarrhoea is 
 of short duration, it is not uncommon to find some scybala mixed 
 up with the pultaceous motions. 
 
 The odour of the stools in diarrhoea vaiies very considerably. 
 At the commencement of the attack, or where there has been 
 delay in the large intestine, the motions are, as a rule, extremely 
 offensive. But where there is marked peristalsis with frequent 
 motions, the odour steadily diminishes, and in cases of pure 
 jejunal diarrhoea, there may be scarcely any faecal odour at all. 
 
 Chemical Examination of Diarrhoea Stools. Mucus. 
 — In most cases of functional diarrhoea mucus in sufficient 
 quantity to be recognised by the naked eye (as described in the 
 macroscopic examination of the faeces) is found to be present. 
 In all cases where there is increased peristalsis of the large intes- 
 tine, involving the rapid elimination of the contents of the small 
 intestine, mucus will be found intimately mixed with the fseces; 
 and it is not at all uncommon to find it stained more or less green 
 by bihverdin. 
 
 Albumen. — In all the cases of diarrhoea which we have ex- 
 amined, we have always found a marked quantity of albumen in 
 a watery extract. 
 
 Blood. — In simple diarrhoea, blood or its pigments are not 
 found in the faeces : if it is present, it arises from some extraneous 
 source, such as haemorrhoids, or it indicates organic disease of 
 the bowel. 
 
 Bile. — In cases of diarrhoea, the reaction for bile is not always 
 successful. Bilirubin or biliverdin will be found to give a marked 
 reaction in cases where there has been a very rapid passage of 
 the intestinal contents along the bowel, more especially in 
 cases of jejunal diarrhoea. As already mentioned, it is not 
 
MOTOR-POWER OF INTESTINAL TRACT 
 
 uncommon to find mucus stained with bile ]iigmonts where there 
 is increased peristalsis in the large and small intestine. 
 
 Urobilin. — The chemical examination of the faces for urobilin 
 will, in most cases of diarrhoea, show only a slight reaction, though 
 at the commencement of the diarrhoea, urobilin may be present in 
 increased quantities. In true cases of jejunal diarrhoea, however, 
 no urol)iliu reaction will l)e obtained. 
 
 Microscopic Appearances.— The microscopic examina- 
 tion of the fa3ces shows an increased residue of food, vegetable 
 
 TABLE XLIII.— DISEASE— SIMPLE DIARRHCEA 
 
 Diet : ^lixecl + milk, containing 32-82 grams nitrogen, 88-91 grams fat, 131-58 
 grams carbohydrates, 2207-35 Calories, 2520 c.c. lliiid. 
 
 Date, Dec. 1900 
 
 7 
 
 8 
 
 9 
 
 10 
 
 Average. 
 
 Weight in kilos 
 
 01-8 
 
 61 -8 
 
 62-3 
 
 62-0 
 
 61-9 
 
 Calories per kilo 
 
 35-30 
 
 35-30 
 
 35-02 
 
 35-17 
 
 3519 
 
 Urine . 
 
 Quantifative Ana 
 
 lysis 
 
 
 
 Quantity 
 
 2300 
 
 1400 
 
 2130 
 
 1620 
 
 1863 
 
 Specific gravity 
 
 1021 
 
 1022 
 
 1021 
 
 1022 
 
 1022 
 
 Nitrogen 
 
 32-31 
 
 23-28 
 
 35-06 
 
 23-97 
 
 28-66 
 
 Urea .... 
 
 GO-GO 
 
 45-22 
 
 67-13 
 
 45-31 
 
 54-57 
 
 Uric acid. 
 
 0-86 
 
 0-71 
 
 0-87 
 
 — 
 
 0-81 
 
 Ammonia 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 Phosphates (P.^O-) . 
 
 — 
 
 3-43 
 
 4-96 
 
 3-59 
 
 3-99 
 
 Chlorides. 
 
 10-00 
 
 7-00 
 
 10-48 
 
 6-64 
 
 8-53 
 
 2 /-Total 
 
 "1 1 Alkaline (A) 
 
 222 
 
 4-25 
 
 6-14 
 
 4-31 
 
 4-23 
 
 1-96 
 
 4-04 
 
 5-85 
 
 414 
 
 4-00 
 
 ^ni Aromatic (B) . 
 jg I Ratio A: B 
 
 0-26 
 
 0-21 
 
 0-29 
 
 0-17 
 
 0-23 
 
 7-5:1 
 
 19-2 : 1 
 
 20-0 : 1 
 
 24-3 : 1 
 
 .17-4:1 
 
 Fceces : 
 
 Quantitative Ana 
 
 ysis 
 
 
 
 Date, Dec. 1900 
 
 8 
 
 9 
 
 10 
 
 11 
 
 Average 
 
 No. of Motions 
 
 2 
 
 2 
 
 3 
 
 2 
 
 4 days. 
 
 Quantity 
 
 361 
 
 306 
 
 344 
 
 118 
 
 282 
 
 Water per cent. 
 
 82-97 
 
 83-91 
 
 84-85 
 
 7700 
 
 82-18 
 
 Nitrogen 
 
 273 
 
 2-16 
 
 2-48 
 
 1-21 
 
 214 
 
 Fat . . . . 
 
 6-58 
 
 5-50 
 
 6-24 
 
 3-03 
 
 5 41 
 
 Absorbed nitrogen per cent. 
 
 — 
 
 — 
 
 — 
 
 — 
 
 93-48 
 
 fat per cent. 
 
 ~ 
 
 ~ 
 
 ~ 
 
 ~ 
 
 93-91 
 
 cells, muscular fibres, and increased quantities of fat and 
 starch. Crystals of calcium salts of bile acids, calcium 
 oxalates, and ammonium magnesium phosphate crystals are 
 generall)/- found. The most important microscopic observation 
 
 M 
 
178 INTESTINAL DISEASES 
 
 in the Jkces of diarrhoea is the fact that the mucus present 
 contains few, if any, epitheUal cells— this fact enabling one to 
 diagnose the case as one of simple diarrhoea, as against catarrh 
 of the bowels, 
 
 Quantitative Analysis of the Faeces in Diarrhoea. 
 —The quantitative analysis of the faeces in cases of diarrhoea 
 may be considered of minor importance. In ordinary shght 
 cases there is usually no increase in the excretion of nitrogen, 
 while in acute cases, more especially those of jejunal diarrhoea, 
 one may expect to find an increased quantity of nitrogen. In 
 children, even in the mildest forms of diarrhoea, such as that 
 accompanpng dentition, an increased quantity of fat will be 
 found in the stools. 
 
 Simple Diarrhoea. — We had the opportunity of observ- 
 ing in some metabohsm experiments an individual who suffered 
 from an attack of diarrhoea during the period of analysis. 
 
 In the above case. Table Xldll., a male, aged thirty-seven, 
 suffering from traumatic neurasthenia without any marked 
 intestinal symptoms, had an attack of diarrhoea as indicated by 
 the frequency of the stools and their unformed semi-fluid consis- 
 tency. During the period of four days' analysis, the first charcoal 
 given took no less than fifty-two hours to appear in the stools, the 
 motion at that time being well-formed rolls, coloured black by 
 charcoal. Six hours later, a brown, unformed, pultaceous motion 
 was passed, and, in the next two days, the patient passed two or 
 three motions daily. The second charcoal was given on the 
 fourth day, and took sixty hours to appear in the motions. The 
 last motions before the appearance of the second charcoal were 
 dark-brown formed rolls of a normal consistency. It is seen on 
 looking at the table that the last-formed motion contained only 
 77 per cent, of water : on the previous day, on which there were 
 three motions, the percentage of water was 84-85 per cent. The 
 analysis of the first day was rather vitiated by the fact that the 
 second motion, which was unformed, was mixed with the first 
 charcoal-formed motion and the two analysed together. We see 
 that in this case the quantity of faeces was very markedly increased 
 during the time that the diarrhoea occurred, as also the quantity 
 of water — since on an ordinary mixed diet, with the addition of 
 milk, the average percentage of water in the faeces is found to be 
 74 per cent. 
 
MOTOR-POWER OF INTESTINAL TRACT 179 
 
 The quantity of nitrogen in the faeces is seen to be increased on 
 the days of diarrhoea, being more than 2 grams per diem, while 
 on the last day of normal faeces the nitrogen was only 1-21 grams. 
 We have shown that the average daily quantity of nitrogen present 
 in the faeces on a mixed diet with the addition of milk is about 1 
 gram, so that in this case of diarrhoea from no apparent cause 
 
 TABLE XLIV.— DISEASE— SIMPLE DIARRHCEA 
 
 Diet : Milk, containing 15-77 grams nitrogen, 92-82 grams fat, 99-96 grams 
 carbohydrates, 1G77-09 Calories, 2380 c.c. fluid 
 
 Date, July 1904 
 
 17 
 
 18 
 
 19 
 
 20 
 
 Average. 
 
 Weight .... 
 
 82-01 
 
 82-67 
 
 81-45 
 
 
 81-71 
 
 Calories per kilo . . \ 
 
 20-45 
 
 20-53 
 
 20-59 
 
 
 20-52 
 
 Urine : 
 
 Quantitative Analysis 
 
 
 Quantity 
 
 440 
 
 570 
 
 570 
 
 
 527 
 
 Specific gravity 
 
 1026 
 
 1030 
 
 1027 
 
 
 1028 
 
 Nitrogen 
 
 10-74 
 
 14-42 
 
 14-24 
 
 
 13-13 
 
 Urea .... 
 
 22-76 
 
 28-96 
 
 30 09 
 
 
 27-27 
 
 Uric acid. 
 
 0-19 
 
 0-36 
 
 0-41 
 
 
 0-32 
 
 Anamonia 
 
 0-78 
 
 1-27 
 
 1-65 
 
 
 1-23 
 
 Phosi^hates (P.O.) . 
 
 2-49 
 
 3-05 
 
 2-46 
 
 
 2-69 
 
 Chlorides. 
 
 2-21 
 
 2-86 
 
 2-86 
 
 
 2-64 
 
 g /-Total 
 
 2 1 Alkaline (A) 
 
 1-89 
 
 1-96 
 
 1-85 
 
 
 190 
 
 1-73 
 
 1-75 
 
 1-63 
 
 
 1-70 
 
 ;S-'| Aromatic (B) . 
 ^ iRatio A : B 
 
 0-16 
 
 0-21 
 
 0-22 
 
 
 0-20 
 
 10-8 : 1 
 
 8-3 : 1 
 
 7-3: 1 
 
 
 8-5:1 
 
 FcBCcs : 
 
 Quantitative A nalysis 
 
 
 
 
 
 
 
 Average 
 
 Xo. of motions. 
 
 2 
 
 4 
 
 1 
 
 1 
 
 3 days. 
 
 Quantity 
 
 972 
 
 713 
 
 174 
 
 426 
 
 742 
 
 Water per cent. 
 
 93-25 
 
 94-85 
 
 94-68 
 
 9510 
 
 94-47 
 
 Nitrogen 
 
 2-23 
 
 1-25 
 
 0-31 
 
 0-79 
 
 1-53 
 
 Fat .... 
 
 4-75 
 
 2-67 
 
 0-67 
 
 1-69 
 
 3-26 
 
 Absorbed nitrogen per cent. 
 
 — 
 
 — 
 
 — 
 
 — 
 
 89-92 
 
 „ fat per cent. 
 
 — 
 
 
 ~ 
 
 ~ 
 
 96.49 
 
 and probably entirely due to increased peristalsis of the intestine, 
 the quantity of nitrogen excreted was increased to double its 
 normal amount. Instead of the normal proteid absorption of 
 about 95 per cent., the average in this case was 93-48 per cent. — 
 not a marked decrease when one considers the quantity of nitrogen 
 present in the fseces. The fat in the stools during the time that 
 the diarrhoea lasted was large in amount, being 6 grams per diem, 
 
180 INTESTINAL DISEASES 
 
 wliile on the fourth day, on which one motion only was 
 there was only 3 03 grams of fat. On referring to the normal 
 absorption on such a diet, we see that the last day corresponds 
 with what is usually found in normal cases, while on the other 
 days it is diminished. The normal absorption on such a diet 
 is, roughly, 9G per cent., while in this case the absorption is 
 diminished, being 93-91 per cent. 
 
 The analysis of the urine is given in the table, but it is un- 
 necessary to go into details. 
 
 We will now consider a case of simple diarrhoea (Table XLIV.) 
 which lasted throughout the period of observation, the patient 
 being on a milk diet. 
 
 In this case, on the two occasions on which charcoal was given 
 — at the commencement and end of the period of three days — 
 the charcoal appeared in the faeces in two hours the first and in 
 three and three-quarter hours the second time of administration. 
 The colour of the faeces (when not blackened by charcoal) was 
 creamy-yellow, and, although the bulk of the charcoal was 
 passed in the two motions of the first day, traces were still to 
 be found on the second day. The consistency of the motions 
 throughout was pultaceous, and the odour very offensive. 
 
 The chemical examination of the faeces showed a marked 
 increase of mucus and of albumen : no blood or bile was present 
 and throughout, the urobilin was in excess. 
 
 The microscopic examination showed very few epithelial cells 
 mixed up with mucus ; so that this case, in spite of the frequent 
 motions and their fluid consistency, could not be diagnosed as 
 catarrh of the bowel. The history and progress of the case 
 confirmed the diagnosis of simple diarrhoea. 
 
 The urine analysis showed nothing to help the diagnosis of 
 the bowel disorder except a tendency to increased intestinal 
 putrefaction, and the daily quantity of urine was very small. 
 On the same diet, when no diarrhoea was present, this patient 
 passed an average of 1285 c.c. of urine per diem. 
 
 The quantitative analysis of the faeces, on the other hand, 
 showed a very marked excess in the quantity of water. Instead 
 of the normal average of 76 per cent., we have the high average 
 of 9447 per cent, of water, due, in all probability, to hyperaemia 
 accompanying the increased peristalsis. 
 
 There was a distinct increase in the daily elimination of 
 
MOTOR-POWER OF INTESTINAL TRACT 181 
 
 nitrogen by the bowel, so that the absorption, instead of being 
 normal — i.e., 95 per cent, on a milk diet — was only 89-92 per 
 cent. The fat in the stools showed a slight tendency to 
 increase, averaging 3-2G grams, and there was only a slightly 
 diminished fat absorption, the average being 96-49 per cent. 
 
 Nervous Diarrhoea. — Having discussed a case of simple 
 diarrhoea, due to increased peristalsis, with probably no vasa- 
 motor changes in the intestine leading to hypera3mia and hence 
 only a slight increase in the quantity of fluid in the motions, and 
 a second case accompanied by hyperaemia, we now pass on to 
 purely nervous diarrhoea which would appear to be accompanied 
 by — in addition to increased peristalsis — marked vasomotor 
 changes in the large intestine, leading to hyperaemia and causing 
 an excessive flow of water into the bowels. It would appear 
 that nerve shock or fright causes in certain individuals a sudden 
 fluid motion ; and in others the anxiety of railway traveUing 
 when no lavatory carriage is supplied and other mental con- 
 ditions are known to all of us to cause diarrhoea. 
 
 We now give a very interesting case of a naval officer, aged 
 fifty, who suffered from general nervousness and complained of 
 flatulent dyspepsia, accompanied by severe belching, which was 
 cured by a cork.^ He was periodically troubled with severe 
 attacks of diarrhoea, and we were able to get some analyses on 
 these occasions. Taking one day's record, we find that he had 
 motions as follows : 
 
 Bowels moved. 
 
 Bowels nioved, preceded by a great deal of belching. 
 
 Bowels moved. 
 
 Bowels moved, with some intestinal flatulency. 
 
 Bowels moved. 
 
 Bowels moved. When massaged, said he felt the wind 
 
 very badly, nearly choking him. 
 Bowels moved. 
 
 2.2.") 
 
 A.M. 
 
 6 
 
 A.M. 
 
 9.25 
 
 A.M. 
 
 9.40 
 
 A.M. 
 
 10.15 
 
 A.M. 
 
 1.15 
 
 P.M. 
 
 2.45 
 
 P.M. 
 
 4 
 
 P.M. 
 
 4.45 
 
 P.M. 
 
 510 
 
 P.M. 
 
 6 
 
 P.M. 
 
 6.15 
 
 P.M. 
 
 7.15 
 
 P.M. 
 
 8.10 
 
 P.M. 
 
 9.20 
 
 P.M. 
 
 10.0 
 
 P..M. 
 
 11.0 
 
 P.M. 
 
 1 -See p. 41. 
 
182 
 
 INTESTINAL DISEASES 
 
 On some occasions when lie complained of a great deal of 
 wind in the stomach, very little was found on examination : on 
 other occasions the stomach was distended. During the re- 
 maining days of the period of observation, there were only two 
 or three motions, and then there would be periods of freedom 
 from diarrhoea. Charcoal was given on six occasions, and 
 was found to appear in the motions as follows : 
 
 1st Charcoal appeared 2|- hours after administration. 
 2nd ,, ., 1 hour ,, 
 
 3rd 
 4th 
 oth 
 6th 
 
 4 hours 
 25 minutes 
 2 hours 
 15 minutes 
 
 The motions were of uniform consistency, coloured black by 
 charcoal and containing a little mucus. In the intervals between 
 
 TABLE XLV.— DISEASE— NERVOUS DIARRHCEA 
 
 Diet: Milk containing 19-48 grams nitrogen, 114-66 grams fat, 123-48 grams 
 carbohydrates, 2069-76 Calories, 2920 c.c. fluid 
 
 Date, January 1902 . 
 
 19 
 
 i 
 
 20 
 
 21 
 
 Average. 
 
 Weight in kilos 
 
 80-78 
 
 80-33 
 
 79-88 
 
 80-33 
 
 Calories per kilo 
 
 25-62 
 
 25-77 
 
 25-91 
 
 25-77 
 
 Urine : 
 
 Quant iiative A nalysis 
 
 
 
 Quantity 
 
 1820 
 
 1040 
 
 730 
 
 1197 
 
 Specific gravity 
 
 1020 
 
 1018 
 
 1023 
 
 1020 
 
 Nitrogen 
 
 2111 
 
 10-82 
 
 12-12 
 
 14-68 
 
 Urea .... 
 
 36-95 
 
 19-57 
 
 23-21 
 
 26-58 
 
 Uric acid 
 
 0-50 
 
 0-39 
 
 0-58 
 
 0-47 
 
 Ammonia 
 
 0-35 
 
 0-68 
 
 0-81 
 
 0-61 
 
 Phosphates (P.O.) . 
 
 4-00 
 
 2-70 
 
 3-29 
 
 3-33 
 
 Chlorides. 
 
 9-10 
 
 3-85 
 
 2-95 
 
 5-31 
 
 S /-Total 
 J J Alkaline (A) 
 c-1 Aromatic (B) . 
 
 3-55 
 
 2-14 
 
 2-01 
 
 2-57 
 
 3-40 
 
 2-04 
 
 1-83 
 
 2-42 
 
 0-15 
 
 0-10 
 
 0-18 
 
 0-15 
 
 ^ iRatio A : B 
 
 22-7 : 1 
 
 20-4 : 1 
 
 10-2 : 1 
 
 16-1: 1 
 
 FcEces . 
 
 Quantitati 
 
 ■e Analysis 
 
 
 Average 
 
 No. of motions 
 
 14 
 
 15 
 
 14 
 
 3 davs. 
 
 Quantity 
 
 545 
 
 1181 
 
 1307 
 
 1011 
 
 Water per cent. 
 
 91-15 
 
 93-39 
 
 93-68 
 
 92-74 
 
 Nitrogen 
 
 1-49 
 
 2-42 
 
 2-55 
 
 2-16 
 
 Fat .... 
 
 6-23 
 
 10-11 
 
 10-70 
 
 9-01 
 
 Absorbed nitrogen per cent. 
 
 — 
 
 — 
 
 — 
 
 SS-91 
 
 ,, fat ])cr cent. 
 
 — 
 
 
 ~ 
 
 92-14 
 
MOTOR-POWER OF INTESTINAL TRACT 183 
 
 the charcoals the motions Avere thin and hquid, of a light 
 yellowish-brown colour, sometimes containing mucus (though 
 never in any large quantity) : albumen and urobilin were always 
 present, and occasionally a biliverdin reaction was obtained. 
 There was no blood and, microscopically, there were remnants 
 of food, with a few crystals but no marked increase of epithelial 
 cells. 
 
 In Table XLV. it is seen that during the three days of analysis 
 on a milk diet there were very numerous motions — fourteen and 
 fifteen per diem. The first charcoal given appeared in two and 
 a half hours, while the last appeared in one hour. The urine 
 analysis showed no increase of aromatic sulphates, and, in spite 
 of the great degree of diarrhoea, there was no marked decrease in 
 the quantity of urine passed daily ; but this is accounted for by 
 the large quantity of fluid taken. On the three days when the 
 faeces were analysed the average quantity per diem was no less 
 than 1011 grams, containing 92-74 per cent, of water. The 
 nitrogen in the fseces ^.veraged 2-16 grams, so that the absorption 
 was very markedly decreased, being only 88-91 per cent. The 
 fat in the faeces varied considerably on the different days, the 
 average being 9"01 grams per diem : the average absorption of 
 fat was also diminished, being only 92-14 per cent. 
 
 The patient was then put on a pure meat diet (Table XLVL), 
 the quantity he was able to take being very small — only 9*16 
 Calories per kilo, body-weight. During this time he steadily lost 
 weight, though the loss was, comparatively speaking, slight. 
 Analysis of the urine showed that more nitrogen was daily 
 eliminated than was taken in the diet. The uric acid was larger 
 than that found on the milk diet, though certainly not above a 
 normal average. The aromatic sulphates remained the same as on 
 the milk diet. The analysis of the faeces showed the motor-power 
 of the alimentary tract to be not quite so accelerated as on the 
 milk diet, since the first charcoal did not appear until four hours 
 after its administration by the mouth — the second charcoal, on 
 the other hand, appearing in as short a time as twenty-five 
 minutes. The quantity of faeces on this pure meat diet was 
 considerably diminished, the motions varying in number from 
 one to five per diem, but the quantity averaging only 178 grams. 
 The stools were reddish brown, consistency fluid paste, con- 
 taining some mucus and a considerable quantity of albumen. 
 
181 
 
 INTESTINAL DISEASES 
 
 TABLE XLVL— DISEASE— NERVOUS DIARRHCEA 
 
 Diet : ]Meat, containing 14-72 grams nitrogen, 3fv68 grams fat, grams carbo- 
 liydrates, 718-32 Calories, ]()80 c.c. Huid 
 
 Date, January 1902 . 
 
 24 25 26 
 
 27 
 
 Average. 
 
 Weight in kilos 
 
 78-75 78-53 78-30 
 
 78-30 
 
 78-47 
 
 Calories per kilo 
 
 9-12 9-15 919 
 
 9-19 
 
 916 
 
 Urine . 
 
 Quantitative A nalysis 
 
 
 
 Quantity 
 
 950 
 
 940 
 
 840 
 
 840 
 
 893 
 
 Specific gravity 
 
 1028 
 
 1027 
 
 1028 
 
 1026 
 
 1027 
 
 Nitroeen 
 
 
 
 21-53 
 
 19-57 
 
 19-24 
 
 2011 
 
 Urea .... 
 
 44-45 
 
 39-05 
 
 38-22 
 
 37-38 
 
 39-78 
 
 Uric acid. 
 
 0-43 
 
 0-45 
 
 0-33 
 
 0-82 
 
 0-51 
 
 Ammonia 
 
 0-42 
 
 0-23 
 
 0-26 
 
 019 
 
 0-28 
 
 Phosphates (P.pr) . 
 
 2-60 
 
 1-89 
 
 2-18 
 
 1-00 
 
 2-07 
 
 Chlorides. 
 
 0-87 
 
 1-69 
 
 0-77 
 
 1-34 
 
 117 
 
 S [Total 
 
 J 1 Alkaline (A) 
 
 c-l Aromatic (B) . 
 ^ I Ratio A : B. . 
 
 4-08 
 
 3-91 
 
 3-98 
 
 4-11 
 
 402 
 
 3-90 
 
 3-75 
 
 3-84 
 
 3-98 
 
 3-87 
 
 0-18 
 
 0-16 
 
 0-14 
 
 0-13 
 
 0-15 
 
 21-7: 1 
 
 23-4: 1 
 
 27-4: 1 
 
 30-6 : 1 
 
 25-8 : 1 
 
 Faeces : 
 
 Quant itativc A n alys is 
 
 
 
 
 
 
 
 
 Average 
 
 No. of motions 
 
 4 
 
 5 
 
 2 
 
 1 
 
 4 days. 
 
 Quantity 
 
 418 
 
 98 
 
 132 
 
 62 
 
 178 
 
 Water per cent. 
 
 93-82 
 
 91-33 
 
 91-33 
 
 91-33 
 
 91-95 
 
 Nitrogen 
 
 1-42 
 
 0-48 
 
 0-63 
 
 0-29 
 
 0-70 
 
 Fat ... . 
 
 5-14 
 
 1-69 
 
 2-27 
 
 1-07 
 
 2-54 
 
 Absorbed nitrogen per cent. 
 
 — 
 
 — 
 
 — 
 
 
 95-24 
 
 ,, fat jicr cent. 
 
 — 
 
 - 
 
 — 
 
 
 93 07 
 
 Bile pigments could not be demonstrated, and urobilin was 
 always found present. The water was very largely increased, 
 being no less than 9r95 per cent., while we have foimd the 
 average quantity of water on this diet to be 74 per cent. There 
 was no great increase in the quantity of nitrogen, but the fat 
 was double the quantity which we have found in our normal 
 cases. The absorption of proteid was apparently increased, 
 being 95*24 per cent., while the fat absorption was decreased to 
 93-07 per cent. 
 
 During a third period another analysis of the same individual 
 was done on a mixed diet (Table XLVIL), when he took thirteen 
 Calories per kilo, body- weight ; and on this small diet he increased 
 slightly in weight. During this period it was found that he was 
 
MOTOR-POWER OF INTESTINAL TRACT 
 
 185 
 
 TABLK XLVIL— DISEASE— NERVOUS DIARRHCEA 
 
 Diet: Mixed, containing 1900 grains nitrogen, 47*1G grams fat, 40'J3 grams 
 carbohydrates, 1064-99 Calories, 1200 c.c. fluid 
 
 Date, February 1902 
 
 13 
 
 14 
 
 15 
 
 16 
 
 .\verage. 
 
 Weight in kilos 
 
 77ti2 
 
 77-41) 
 
 7S-30 
 
 78-30 
 
 77-90 
 
 Calorics per Uilo 
 
 13-72 
 
 13-7() 
 
 13-00 
 
 13-60 
 
 13-67 
 
 Urine : Qunnlitativc- Analysis 
 
 
 
 Quantity 
 
 500 
 
 lOBO 
 
 950 
 
 880 
 
 847 
 
 S])ccific gravity 
 
 
 1028 
 
 1032 
 
 1031 
 
 1029 
 
 1030 
 
 Nitrogen 
 
 
 ior,7 
 
 23-58 
 
 19-48 
 
 17-16 
 
 17-69 
 
 Urea . 
 
 
 ! 18 -(it) 
 
 43-14 
 
 33-06 
 
 28-16 
 
 30-76 
 
 Uric acid 
 
 
 0-48 
 
 1 37 
 
 0-90 
 
 0-88 
 
 0-90 
 
 Ammonia 
 
 
 0-61 
 
 1-0(5 
 
 0-93 
 
 0-97 
 
 0-86 
 
 Phosphntcs(P,0,) 
 
 
 1 1-20 
 
 2-76 
 
 2-35 
 
 2-20 
 
 212 
 
 Cliloridcs. 
 
 
 1 2-74 
 
 5-30 
 
 6-46 
 
 5-19 
 
 4-92 
 
 S |- Total 
 
 5 1 Alkaline (A) 
 
 
 1-85 
 
 5 03 
 
 3-38 
 
 3-11 
 
 3-34 
 
 
 1-72 
 
 4-72 
 
 3-13 
 
 2-93 
 
 3-12 
 
 3'j Aromatic ( B) 
 ^ I Ratio A : B. 
 
 
 0-13 
 
 0-31 
 
 0-25 
 
 0-18 
 
 0-22 
 
 
 13-2 : I 
 
 15-2: 1 
 
 12-5: 1 
 
 16-2 : 1 
 
 14-2 : 1 
 
 Fceccs : QiKoitilalive Ann 
 
 lysis 
 
 
 
 
 
 
 
 
 Average 
 
 Xo. of motions 
 
 2 
 
 2 
 
 1 
 
 2 
 
 4 days. 
 
 Quantity 
 
 
 89 
 
 129 
 
 70 
 
 204 
 
 123 
 
 Water, per cent. 
 
 
 89-78 
 
 89-78 
 
 89-78 
 
 88-55 
 
 89-41 
 
 Nitrogen 
 
 
 0-55 
 
 O-80 
 
 0-44 
 
 1-38 
 
 0-74) 
 
 Fat 
 
 
 1-01 
 
 2-34 
 
 1-27 
 
 4-02 
 
 2-31 
 
 Absorbed nitrogen per cent. 
 
 — 
 
 — 
 
 — 
 
 — 
 
 95-84 
 
 „ fat per cent. 
 
 — 
 
 
 
 " 
 
 95-10 
 
 practically on nitrogen equilibrium, in spite of having a tendency 
 to diarrhoea, the motions being hardly increased in frequency, 
 but the quantity of fluid being above the normal. On the two 
 occasions on which charcoal was given, the first appeared in 
 two hours and the second in fifteen minutes. It is interesting 
 to note in this individual, during the three periods of analysis, how 
 considerably the rates varied at which the charcoal passed 
 through the alimentary tract ; and as there was no evidence, in 
 the examination of the faeces, of pathological changes to account 
 for this, the case appears to us to be a typical one of nervous 
 diarrhoea. 
 
 Stercoral Diarrhoea. — In patients suffering from habitual 
 constipation, it is not at all uncommon to find periodical 
 
186 
 
 INTESTINAL DISEASES 
 
 attacks of diarrhoea. In some of these cases it would appear 
 that the stagnated faecal masses set up a local catarrh from some 
 mechanical pressure, thus causing diarrhoea. There are cases, 
 however, without any organic alterations in the bowel where 
 the liberation of marsh and other gases from the faecal lumps 
 cause, by their stimulation, increased peristalsis of the bowel. 
 
 TABLE XLVIIL— DISEASE— STERCORAL DIARRH(EA 
 
 Diet: Mixed + milk, containing 17"41 grams nitrogen, 124"21 grams fat, 
 
 12r96 grams carbohydrates, 2105-93 Calories, 1710 c.c. fluid 
 
 Date, June 1904 
 
 12 
 
 13 
 
 14 
 
 Average. 
 
 Weight in kilos 
 Calories per kilo 
 
 75-60 75-15 
 
 27-85 28-02 
 
 75-15 
 
 28-02 
 
 Urine : Quantitative Analysis 
 
 ty 
 
 Quantity 
 Specific gravi 
 Nitrogen 
 Urea . 
 Uric acid. 
 Ammonia 
 Phosphates (P^O-) 
 Chlorides . 
 
 © /-Total . 
 
 3 I Alkaline (A) . 
 
 ^'j Aromatic (B) 
 
 r? V Ratio A : B . 
 
 1800 
 
 1300 
 
 1540 
 
 1290 
 
 1014 
 
 1020 
 
 1019 
 
 1022 
 
 13-50 
 
 14-01 
 
 16-92 
 
 14-97 
 
 2G-28 
 
 26-91 
 
 32-18 
 
 29-54 
 
 0-40 
 
 0-38 
 
 0-17 
 
 0-24 
 
 0-09 
 
 0-25 
 
 0-42 
 
 0-51 
 
 2-14 
 
 2-27 
 
 3-29 
 
 2-76 
 
 9-00 
 
 '7-58 
 
 6-33 
 
 7-65 
 
 2-59 
 
 2-75 
 
 3-11 
 
 2-81 
 
 2-40 
 
 2-57 
 
 2-94 
 
 2-61 
 
 0-19 
 
 0-18 
 
 0-17 
 
 0-20 
 
 12-6: 1 
 
 14-3 : 1 
 
 17-3: 1 
 
 13-0: 1 
 
 FcEces : Qiinntitalivr Anali/fis 
 
 Date, June 1904 
 No. of motions . 
 Quantity . 
 Water per cent. 
 Nitrogen . 
 
 Fat . . . . 
 
 Absorbed nitrogen ]i.c. 
 ,, fat per cent. 
 
 13 
 
 14 
 
 15 
 
 17 
 
 18 . 
 
 1 
 
 2 
 
 2 
 
 2 
 
 1 
 
 216 
 
 74 
 
 40 
 
 344 
 
 229 
 
 77-90 
 
 82-28 
 
 74-30 
 
 96-61 
 
 i)3-29 
 
 2-77 
 
 0-76 
 
 0-60 
 
 0-68 
 
 0-89 
 
 12-40 
 
 3-40 
 
 2-67 
 
 3-03 
 
 4-00 
 
 - 
 
 - 
 
 - 
 
 - 
 
 - 
 
 75-12 75-25 
 28-03 27-98 
 
 1475 
 
 1019 
 
 14-85 
 
 28-73 
 
 0-30 
 
 0-32 
 
 2-61 
 
 7-64 
 
 2-81 
 
 2-63 
 
 0-18 
 
 14-3 : 1 
 
 Average 
 
 4 days. 
 
 226 
 
 84-84 
 
 1-43 
 
 6-38 
 
 91-78 
 
 93-25 
 
 In Table XL VIII. a case of stercoral diarrhoea is exhibited. 
 The motions, on ordinary occasions, were formed rolls made up 
 of masses of scybala, and were only passed at intervals of three 
 or four days — or at even longer intervals when no drugs were 
 taken. The patient had, in consequence of this constipation, 
 been in the habit of taking purgatives, and even then was unable 
 to obtain a daily evacuation. When the attack of diarrhoea 
 
MOTOR-POWER OF INTESTINAL TRACT 187 
 
 occurred, motions of unformed paste, containing a few scyl)ala, 
 were passed, and this continued for two or three days, after 
 wliich there was a return to the constipation. The analysis of 
 the urine merely showed an increase of indican, and no albu- 
 men or sugar was present. On referring to Table XVLIIL, 
 it is seen that the aromatic sulphates were not increased. The 
 quantity of phosphates was normal, while the chlorides were 
 seen to be increased. In spite of the patient taking an ordinary 
 mixed diet with the addition of milk, the uric acid excretion 
 was remarkably small, although the output of nitrogen and 
 urea was normal. The ammonia excretion progressively 
 increased. 
 
 In the analysis of the fa?ces the first charcoal was found to 
 appear in twenty-eight hours after its admmistration, while the 
 second charcoal took no less than forty-one hours. On testmg 
 the motility of the bowels on an earher occasion, when there was 
 no tendency to diarrhoea, the charcoal did not appear till seventy 
 hours after its administration. 
 
 The ordinary motions were short, dark-brown rolls, either 
 made up of scybala intermixed with mucus, or separate scybala. 
 The first motion passed after the charcoal consisted of black, 
 unformed soft paste, containing numerous scybala and of an 
 extremely offensive odour. The subsequent motions were 
 greenish-brown paste (that passed on the seventeenth being 
 almost fluid) and contained some formed rolls or scybala, the 
 odour being very offensive. 
 
 Mucus was increased in all the motions, and the albumen re- 
 action was very marked. Blood was occasionally present, while 
 bile was absent and urobihn increased. The microscopical 
 appearances included numerous vegetable cells, muscular fibres 
 and starch granules, numerous crystals of ammonium magnesmm 
 phosphate, calcium salts of bile acids, a few epithehal cells, and 
 some leucocytes. 
 
 The quantitative analysis of the fseces showed that the daily 
 quantity varied from 40 to 344 grams, containing from 74-30 to 
 96-61 per cent, of water. The faeces contained a varying quan- 
 tity of nitrogen, and on the day on which the greatest quantity 
 of ffeces, with the greatest quantity of water, was passed, only 
 0-68 grams were present, while on the first day, no less than 2-77 
 grams of nitrogen were contained in the fa-ces, the daily average 
 
188 INTESTINAL DISEASES 
 
 being 1-43 grams. The quantity of fat varied from 2-67 to 12-40 
 grams in the twenty-four hours, the average being 6-38 grams. 
 The absorption of both nitrogen and fat was very markedly 
 decreased, being respectively 91-78 and 93-25 per cent. 
 
 The only remarkable point in the analysis is the presence of 
 blood in the motions ; otherwise, the analysis is very similar 
 to that of ordinary diarrhoea. It was considered, however, 
 that the blood was not due to ulceration or very advanced 
 catarrh, since there was no evidence of pus cells and only a very 
 few epithelial cells and leucocytes were present : the case may, 
 however, be put down as on the borderland. 
 
 Dyspeptic Diarrhoea. — Under the heading of dyspeptic 
 diarrhoea may be grouped certain attacks of diarrhoea which 
 are due to errors in diet. Some of these cases are probably due 
 to the diet, from mechanical reasons, causing increased peristalsis 
 of the bowel, while in other cases, increased peristalsis of the 
 bowel may be excited by the products of the fermentation of 
 the carbohydrates, leading to the excessive production of irritable 
 acids, such as butyric, lactic, and acetic acids. Further, from 
 the putrefaction of the proteids, sulphuretted hydrogen or other 
 gases may be h berated and cause increased intestinal peristalsis 
 (Bokki). In so-called "fat-diarrhoea" Tschernoff^ describes a 
 case in which the quantity of fat was increased even to 48 per cent. 
 These attacks of dyspeptic diarrhoea are especially common after 
 taking certain articles of food ; turnips, cabbages, pickles, fresh 
 fruit (especially if unripe), are all liable to set up this form of 
 diarrhoea. The chemical examination of the motions shows 
 nothing of great importance, and we have never had an oppor- 
 tunity of doing a quantitative analysis in a typical case of the 
 kind. 
 
 CONSTIPATION 
 
 In discussing intestinal motility, we showed that in normal 
 individuals, the bowels tended to act every twenty-four hours, and 
 that the passage of food along the small intestine was very 
 rapid, the delay occurring in the descending colon and sigmoid 
 flexure, the fjcces remaining there until expelled at twenty-four- 
 hour intervals into the ampulla of the rectum, where they 
 produce a sensation of desire for defecation. In cases cf long 
 
 1 Jahrhuch I. KiinhrhrHkniidc, vol. xxviii. 18SS, p. 1. 
 
M0T0R-P()WP:R of intestinal tract 18D 
 
 retention in the ampulla of the rectum, masses of scybala may 
 cause tenesmus. Physiological variations in the frequency of 
 action of the bowels are very considerable, and some people 
 have an action only once in two or three days, while Reichmann^ 
 describes cases of normal individuals feeling perfectly well, and 
 having an action of the bowels only once in two or three weeks 
 or at even longer intervals. It is impossible for us to discuss 
 here all the various causes of constipation. Obstinate con- 
 stipation may of course arise when there is a physical obstruction 
 pressing on the bowels themselves, or when there are physical 
 changes in the muscular structure of the bowel, such as 
 atrophy ; or, in rare cases, where there is great lengthening of 
 the large intestine. 
 
 The functional cases of constipation due to delayed peristalsis 
 may conveniently be considered here, since the action of the 
 bowel in health is dependent on the peristalsis of the muscles 
 of the bowel, together with the action of the extrinsic muscles 
 which are called into play in the act of defecation. The peri- 
 stalsis of the bowel is stimulated to a certain extent by the 
 composition and amount of residue present in the intestine, so 
 that diet plays a very important role in this stimulation. A 
 diet consisting principally of vegetable material, since it contains, 
 a large quantity of cellulose, leaves a large residue in the bowel,, 
 which from its mechanical size alone tends to stimulate peris- 
 talsis. On the other hand, a diet consisting of meat or milk, 
 both of which are easily digested, and leave a very small amount 
 of residue to stimulate the bowel, are apt to cause sluggishness. 
 A carbohydrate diet, even if finely prepared, causes the formation 
 of various acid products, such as butyric, lactic, and acetic acids, 
 and although there is very httle residue left for mechanical 
 stimulation, yet these acids appear to stimulate peristalsis. 
 The extiinsic muscles which act in defecation may lose a certain 
 amount of tone from giving up any habitual exercise, such as 
 riding or walking, or any exercise which makes one use the 
 diaphragm, and in some cases the taking of regular physical 
 exercise helps the bowels to act. At the same time, constitu- 
 tional variations must be borne in mind, since one finds habitual 
 constipation in individuals who lead a healthy out- door life 
 with plenty of exercise. In neurasthenia, just as there is a 
 
 ^ Quoted Xotlmagers Darmhranl-hciten. 
 
190 INTESTINAL DISEASES 
 
 tendency to dilatation of the stomach or gastroptosis due to 
 want of muscular tone, so there may be enteroptosis and loss of 
 tone in the large intestine, leading to constipation. 
 
 Constipation Faeces. — The stools in constipation are 
 very varied in form, from hard rolls to scybala matted together 
 in sausage-shaped masses like sheeps' motions, or separate small 
 lumps of scybala varying in size from a pea to a nut. These 
 scybala are sometimes so hard that they rattle in a pan with a 
 distinct metallic sound ; they are often coated with a mucus 
 of a very thick and tenacious consistency, and it is not at all 
 uncommon to find streaks of blood in the mucus. The colour 
 of the scybala varies from dark brown to almost black, except 
 when the patient is on a milk diet, when one finds a slaty-grey 
 colour. 
 
 Markedly delayed motihty is easily recognised by giving 
 charcoal, and, in some cases, there is a very long interval between 
 its administration and the appearance of the charcoal in the 
 stool. If charcoal does not appear after about 100 hours, 
 one has obtained sufficient information on the point, and the 
 patient can be reheved by enemata or purgatives. The odour of 
 ordinary scybala, considering the length of time they have 
 been retained in the bowel, is not, as a rule, very offensive. 
 If there is no catarrhal affection of the bowel, and no 
 greatly increased intestinal putrefaction, there may be little 
 or no odour in scybala even after long retention. If, however, 
 the above conditions are present, one gets increased formation 
 of indol, phenol, and skatol, leading to a very foul stool. This 
 lack of odour is partly due to the dryness of the faeces, and in 
 constipation cases, where the motions have been accelerated 
 by purgatives, foul-smelling faeces are often found. 
 
 The chemical analysis of the faeces in constipation shows that 
 mucus is nearly always present, but the mucus coats the faeces, 
 and is not intimately mixed with the scybala as one finds in 
 catarrh. 
 
 Albumen is not, as a rule, obtained in the watery extract of 
 constipation faeces. 
 
 Blood, as already mentioned, is not uncommonly found in 
 streaks, generally arising from injury in the passage of the 
 motions. In cases of congestion of the liver, where one has 
 venous engorgement of the intestine, so often accompanied by 
 
MOTOR-POWER OF INTESTINAL TRACT l'.)l 
 
 chronic constipation, one sometimes finds blood pigment 
 intimately mixed with the stool ; also, in cases of duotlenal 
 ulceration or ulceration of the stomach, the same may occur. 
 But, in functional constipation, no blood is found intimately 
 mixed with the scybala. 
 
 The examination of the fseces for bile invariably gives a 
 negative reaction. When examined for urobilin, the scybala 
 generally show a tendency to excess. 
 
 The microscopic appearances in constipation fa)ces appear 
 to be of httle importance. According to the diet, one finds a 
 certain amount of partially digested muscular fibre. On a 
 Schmidt's diet, one always finds some muscular fibre, and 
 generally some starch granules, with a few fat drops, or even 
 fat crystals. On an ordinary mixed diet, remains of vegetable 
 cells, epithelial cells and leucocytes are found, the latter especially 
 if there is any tendency to catarrh of the bowel, or retention 
 of the scybala, causing irritation of the mucous membrane. 
 
 Crystals of ammonium magnesium phosphate, and, in some 
 cases, of oxalate of lime, are present, and it is not at all 
 uncommon to find numerous cholesterin crystals. 
 
 The quantitative analysis of the fseces shows, as a rule, a very 
 marked decrease in the quantity of water, which varies from 
 50 to 70 per cent. The total nitrogen and fat in the fseces are, 
 as a rule, found to be perfectly normal, and one may say also 
 that the absorption of nitrogen and fat does not vary very much 
 from what we have already stated to be the normal absorption ; 
 and this, in spite of the long retention in the bowel. 
 
 Simple constipation may have httle effect on the patient, 
 while in other cases, individuals are so susceptible to the retention 
 of fseces that if they miss a daily action of the bowels, they suffer 
 from headache or other symptoms all day, these being due to 
 auto-intoxication from the absorption of products of putre- 
 faction from the bowel. 
 
 We will now describe two cases, one of habitual constipation 
 in which no symptoms were produced by the constipation itself, 
 and another in which marked symptoms accompanied it. 
 
 A lady suffering from Graves' Disease, but with no symptoms 
 of indigestion, had always had a tendency to constipation. 
 Analyses were carried out during two periods. The first char- 
 coal appeared in 108 hours and 10 minutes after its administra- 
 
192 
 
 INTESTINAL DISEASES 
 
 tion, and three days later, carmine was given as an indicator, 
 the latter appearing in the faeces in 1G5| hours. The charcoal 
 mostly appeared in the first motion five days after being given 
 by the mouth, the motion consisting of 26 grams of scybala, 
 only partially matted together. Between the first appearance 
 of charcoal and the carmine appearance on the tenth day, four 
 
 TABLE XLIX.— DISEASE— CHRONIC CONSTIPATION 
 
 Diet : Mixed, containing 15"88 grams nitrogen, 77'69 grams fat, 85"78 grams 
 carbohydrates, I483'(54 Calories, 1400 c.c. fluid 
 
 Date, May 1904 
 
 23 
 
 24 
 
 25 
 
 26 
 
 27 
 
 2S 
 
 Aver- 
 age. 
 
 42-43 
 
 Weight in kilos . . 
 
 43-20 
 
 42.53 42-41 
 
 42-30 
 
 42-30 
 
 41-86 
 
 Calories per kilo . 
 
 34- 11 
 
 34-88 34-98 
 
 35 07 
 
 35-07 
 
 35-43 
 
 34-82 
 
 Ur 
 
 ne : Quantitative Analysis \ 
 
 Quantity . 
 
 1040 
 
 950 
 
 1260 
 
 1000 
 
 1030 
 
 1120 
 
 1093 
 
 Specific gravity . 
 
 1020 
 
 1020 
 
 1020 
 
 1022 
 
 1022 
 
 1018 
 
 1020 
 
 Nitrogen . 
 
 15-70 
 
 — 
 
 20-29 
 
 17-42 
 
 17-20 
 
 16-24 
 
 17-37 
 
 Urea .... 
 
 29-74 
 
 33-80 
 
 39-69 
 
 31-50 
 
 34-09 
 
 32-48 
 
 33-55 
 
 Uric acid . 
 
 0-94 
 
 0-60 
 
 0-82 
 
 0-78 
 
 0-67 
 
 — 
 
 0-76 
 
 Ammonia . 
 
 0-60 
 
 0-33 
 
 0-63 
 
 0-43 
 
 0-52 
 
 0-55 
 
 0-51 
 
 Phosphates (P^O^) 
 
 2-23 
 
 1-96 
 
 2-61 
 
 2-23 
 
 213 
 
 2-05 
 
 2-20 
 
 Chlorides . " . 
 
 5-72 
 
 4-75 
 
 5-17 
 
 4-10 
 
 4-22 
 
 414 
 
 4-68 
 
 i r Total 
 
 -§ I Alkaline (A) 
 
 3-0(5 
 
 2-92 
 
 3-59 
 
 3-19 
 
 2-83 
 
 2-87 
 
 3 08 
 
 2-98 
 
 2-86 
 
 3-33 
 
 3-08 
 
 2-73 
 
 2-79 
 
 2-96 
 
 -=1 Aromatic (B) 
 = I Ratio A : B 
 
 0-08 
 
 0-06 
 
 0-26 
 
 0-11 
 
 0-10 
 
 0-08 
 
 0-12 
 
 37-3:1 
 
 47-7:! 
 
 12-8:1 
 
 28-0:1 
 
 27-3:1 
 
 25-0:1 24-6:11 
 
 F 
 
 ceces : Quantitative Ajialysis 
 
 Date, May 1904 
 
 
 26 
 
 27 
 
 29 
 
 30 
 
 Average 
 
 No. of motions 
 
 
 2 
 
 1 
 
 1 
 
 1 
 
 6 days. 
 
 Quantity 
 
 
 65 
 
 27 
 
 200 
 
 195 
 
 81 
 
 Water per cent. 
 
 
 54-78 
 
 53-82 
 
 74-23 
 
 74-23 
 
 64-27 
 
 Nitrogen 
 
 
 1-39 
 
 0-68 
 
 2-42 
 
 2-36 
 
 1-14 
 
 Fat 
 
 
 6-02 
 
 2-92 
 
 10-53 
 
 10-26 
 
 4-96 
 
 Absorbed nitrogen per ce 
 
 nt. 
 
 — 
 
 _ 
 
 — 
 
 — 
 
 92-82 
 
 ,, fat per cent. 
 
 
 — 
 
 ■ — 
 
 — 
 
 — 
 
 93-62 
 
 small motions were passed, the total containing 123 grams, 
 and the quantities varying from 16 to 43 grams. The scybala 
 were dark greenish brown and extremely hard, the fseces being 
 found to contain only 55-86 per cent, of water. 
 
 Another period of six days was analysed, the patient ha^^ng, 
 in the interval, received massage, which somewhat diminished 
 the constipation. In Table XLIX. the results are given. 
 
MOTOR-POWER OF INTESTINAL TRACT I'.KJ 
 
 During the period on a mixed diet when 34-82 Calories per 
 kilo were taken, the patient did not gain weight, and it is seen 
 that the average quantity of nitrogen in the urine and faeces 
 was greater than the intake. The nitrogen and urea in the 
 urine varied considerably, the quantity of uric acid being practi- 
 cally normal, while the ammonia was increased. 
 
 The first charcoal appeared in 85 hours, and the second in 
 61 1 hours. Despite this delay, the urinary analysis showed 
 no increase in aromatic sulphates, though there was some in- 
 crease of indican. The fgoces were greenish brown, and consisted 
 of hard lumps matted together so as to form rolls, having the 
 appearance of sheeps' motions, and, considering their dryness, 
 they were very offensive. Mucus was increased, and albumen 
 was found to be present. No blood or bile could be recognised. 
 The urobilin was slightly increased, although, on some days, 
 only a shght reaction was obtained. The microscopic appear- 
 ances included nothing of note, only a few epithehal cells being 
 present, so that there was evidently no marked catarrh. 
 
 The daily quantity of fseces varied considerably, and the motions 
 obtained on the 29th and 30th occurred after the administration 
 of a pill. The first natural motions contained 54-78 and 53-82 per 
 cent, of water, while those after the pill contained 74-23 per cent. 
 
 The nitrogen in the normal motions varied from 1-39 to 0-68 
 grams, and the fat from 1-02 to 2-92 grams in the twenty-four 
 hours. In spite of the administration of the pill, the average 
 quantity of nitrogen was 1-14 grams, and that of fat 4-96 grams. 
 The absorption during the period was considerably decreased. 
 
 The second case was that of a male, aged forty-six, who 
 suffered from general debility, his skin having the markedly 
 yellow tinge so often noticed in chronic constipation. It had 
 been considered that he might be suffering from malignant disease 
 and marked anaemia. He gave a history of constipation of 
 many years standing, and a tendency to a weak heart. The 
 heart was found to be somewhat dilated with soft blowing 
 murmurs in the mitral area, but no other signs of cardiac failure 
 could be detected. The blood count, in spite of the markedly 
 ansemic appearance, was as follows : 
 
 Hiiemoglobin ....... 78 
 
 Red blood corpuscles ..... 4.380,000 
 
 Leucocytes 9,000 
 
 Ratio , 487 : 1 
 
 N 
 
194 
 
 INTESTINAL DISEASES 
 
 The patient was put on an ordinary mixed diet, and on the 
 evening previous to the administration of charcoal, he was given 
 a PiL Col. et Hyoscy. The first charcoal did not appear in the 
 faeces for 78 hours, and the second charcoal, which was given 
 at the end of five days, did not appear for 51 hours and 20 
 minutes, and was only then obtained by giving a Pil. Col. et 
 Hyoscy. During the period of five days the patient only passed 
 three motions, of which the first two only can be regarded as 
 constipation stools, the third appearing after a pill had been 
 given. 
 
 TABLE L.— DISEASE— CHRONIC CONSTIPATION 
 
 Diet: Mixed + milk, containing 21"14 grams of nitrogen, 111'60 grams fat, 
 
 145-30 grams carbohydrates, 2087-30 Calories, 1790 c.c. fluid 
 
 Date, March 1905 
 
 13 
 
 14 
 
 15 
 
 16 
 
 17 
 
 Aver- 
 age. 
 
 Weight in kilos . 
 
 80-10 
 
 79-88 
 
 81-00 
 
 80-78 
 
 80-78 
 
 80-51 
 
 Calories per kilo . 
 
 26-06 
 
 26-13 
 
 25-77 
 
 25-84 
 
 25-84 
 
 25-93 
 
 Urine : Quantitative Analysis 
 
 
 Quantity . 
 
 1120 
 
 1330 
 
 1090 
 
 1580 
 
 1130 
 
 1250 
 
 Specific gravity . 
 
 1020 
 
 1022 
 
 1024 
 
 1020 
 
 1022 
 
 1020" 
 
 Nitrogen . 
 
 17-14 
 
 18-09 
 
 20-60 
 
 18-64 
 
 20-10 
 
 18-91 
 
 Urea 
 
 35-73 
 
 36-31 
 
 34-66 
 
 38-55 
 
 35-37 
 
 36-12 
 
 Uric acid . 
 
 0-62 
 
 0-81 
 
 0-65 
 
 0-33 
 
 0-62 
 
 0-51 
 
 Ammonia . 
 
 0-55 
 
 0-23 
 
 0-53 
 
 0-66 
 
 0-45 
 
 0-48 
 
 Phosphates (P.O5) . 
 
 2-32 
 
 2-26 
 
 2-94 
 
 3-64 
 
 2-37 
 
 2-71 
 
 Chlorides . 
 
 4-14 
 
 5-45 
 
 4-47 
 
 7-90 
 
 5-65 
 
 5-52 
 
 ^ r Total . 
 
 1^ 1 Alkaline (A) 
 
 3-18 
 
 3-72 
 
 4-10 
 
 4-11 
 
 3-50 
 
 3-72 
 
 2-97 
 
 3-52 
 
 3-85 
 
 3-86 
 
 3-31 
 
 3-50 
 
 -g,"! Aromatic (B) 
 1 I Ratio A : B 
 
 0-21 
 
 0-20 
 
 0-25 
 
 0-25 
 
 0-19 
 
 0-22 
 
 14-1 : 1 
 
 17-6 : 1 
 
 15-4 : 1 
 
 15-4 : 1 
 
 17-4: 1 
 
 16-0 : 1 
 
 Fc 
 
 eces .- Quantitative Analysis 
 
 
 Date, March 1905 
 
 
 16 
 
 17 
 
 ■ 18 
 
 Average 
 
 No. of motions 
 
 
 
 1 
 
 1 
 
 1 
 
 5 days. 
 
 Quantity . 
 
 
 
 101 
 
 132 
 
 203 
 
 87 
 
 Water per cent. . 
 
 
 
 66-60 
 
 69-22 
 
 80-08 
 
 71-97 
 
 Nitrogen . 
 
 
 
 1-42 
 
 1-71 
 
 1-70 
 
 0-97 
 
 Fat . 
 
 
 
 5-48 
 
 6-60 
 
 6-57 
 
 3-73 
 
 Absorbed nitrogen per c 
 
 ent. . 
 
 
 — 
 
 — 
 
 — 
 
 95-41 
 
 „ fat per cent. . 
 
 
 
 — 
 
 — 
 
 — 
 
 !H)-33 
 
 The urine analysis in this case (Table L.) showed an increased 
 quantity of urobihn and indican. The aromatic sulphates are 
 seen to be increased, and since tliis patient suffered from head- 
 aches, &c., there was evidently auto-intoxication. Microscopi- 
 
MOTOR-POWER OF INTESTINAL TRACT 195 
 
 cally, the presence of calcium oxalate crystals gave credence to 
 the idea of the digestion not being quite normal, but otherwise, the 
 quaUtative analysis showed nothing abnormal. During the period 
 of five days the patient took 25-93 Calories per kilo, and the 
 weight remained more or less constant. The nitrogen output 
 in the urine was fairly equal, and the quantity in the urine and 
 faeces showed that the patient was practically on nitrogen 
 equilibrium. On turning to the analysis of the faeces, it was 
 found that the patient passed hard rolls composed of masses 
 of scybala. The odour was very offensive only after the pill 
 had been given, the first two motions being noted as of moderate 
 odour. Chemically, mucus was found to be increased and 
 mixed with the lumps, some of the scybala being coated with 
 it. Albumen, blood, and bile were absent ; the stools showed 
 excess of urobilin by the perchloride of mercury test. Micro- 
 scopically, vegetable cells, starch granules, some partially digested 
 muscular fibres and a few fat drops could be recognised. The 
 mucus contained a few epithelial cells and some leucoc}i;es 
 were seen, cholesterin crystals being also present. 
 
 The quantitative analysis of the faeces showed the first two 
 motions, which occurred without a pill, to consist of 101 and 
 132 grams respectively, containing 66-60 and 60-22 per cent, of 
 water. The stools contained 1-42 and 1-71 grams of nitrogen 
 per diem, and 5-48 and 6-60 grams of fat respectively. 
 The third stool (obtained after a pill had been given) con- 
 sisted of 203 grams, and contained 80-08 per cent, of water ; 
 the quantity of nitrogen was 1-70 grams, and the quantity 
 of fat 6-57 grams, so that the j)ill, although it increased the 
 quantity of water, did not have any effect on the amount 
 of nitrogen and fat excreted. The average output of nitrogen 
 and fat, for the five days on which the patient was examined, 
 corresponded with what one normally finds on this diet. 
 The absorption of nitrogen w^as 95-41, and that of fat 96-33 
 per cent., which was about normal on this diet. The after- 
 history of this case negatives carcinoma, and with regular 
 bowel treatment, the constipation was cured, and he now feels 
 perfectly well. 
 
CHAPTER XXIV 
 
 INTESTINAL DYSPEPSIA 
 
 Although dyspepsia literally means disturbance of tlie peptic 
 digestion, the expression " intestinal dyspepsia " has gradually 
 crept in to describe those forms of indigestion which arise in 
 the bowel from functional derangement leading to alterations 
 in the succus entericus. In discussing diseases of the stomach, 
 we have shown how simple functional changes in the secretion 
 of the gastric juice can produce a varied group of symptoms, 
 and it is not to be wondered at that alterations in such an 
 important secretion as that of the succus entericus should cause 
 symptoms of indigestion. Faber,^ in a very able paper, has 
 shown how various symptoms which used to be described as 
 gastric can really arise from disturbance in the bowel itself. 
 It must, however, be realised that our knowledge of the pathology 
 of the succus entericus is extremely limited, and we can only 
 now generalise, hoping that, in the future, problems will be 
 unravelled by careful analyses of the stools, just as they are now 
 being solved by the stomach-tube in gastric pathology. 
 
 Intestinal dyspepsia, for all chnical purposes, can be divided 
 into two classes : (1) Excessive fermentation of the carbo- 
 hydrates in the bowel, and (2) Excessive putrefaction of the 
 proteid in the bowel. 
 
 Excessive Fermentation of the Carbohydrates 
 in the Bowel. — Schmidt and Strasburger ^ have specially 
 investigated the excessive fermentation of the carbohydrates 
 which occurs in the ahmentary canal in cases of intestinal 
 dyspepsia. If, on employing Schmidt's fermentation tube, 
 one obtains on the test diet more than one-third volume 
 of gas from the faeces in twenty-four hours, one may con- 
 sider that there is carbohydrate fermentation ; and at the 
 
 1 Archiv. Vcrdanumjskrankhcitcn, vol. viii. p. 15. 
 " Die FcFCes dcs ilcnschcn, p. 198. 
 
INTESTINAL DYSPEPSIA 107 
 
 same time, the faeces themselves become more acid during the 
 process of fermentation by the development of lactic and butyric 
 acids, &c. 
 
 We will now describe a case which seems suitable for demon- 
 stration of the intestinal dyspepia due to excessive fermentation. 
 
 A male, aged thirty, when over-worked or worried, was subject 
 to periodical attacks of pain in the bowels, coming on in the 
 middle of the night, the patient having suffered in the same way 
 three years previously. Taking hot water or food had no influ- 
 ence on the pain, which he described as not a true gripe, 
 but rather discomfort with flatulency and gurgling going on 
 in the intestines. There was some tendency to sluggishness of 
 the bowels, though no marked constipation. 
 
 During a period of four days, analyses were carried out on a 
 mixed diet with the addition of milk. 
 
 The quahtative analysis of the urine showed a shght increase 
 of indican ; some few uric acid and calcium oxalate crystals 
 were found microscopically. On boiling, phosphates were 
 precipitated in the urine ; at the same time, on referring to 
 Table LI., it will be seen that there was no real increase in the 
 daily quantity of phosphates. The quantitative analysis of the 
 urine showed that it was almost normal, the aromatic sulphates 
 not being increased. 
 
 The qualitative analysis of the faeces may be now described. 
 The first charcoal appeared in 26 hours, and the second charcoal, 
 which was given on the fifth day, did not appear until 51 hours 
 later, in spite of there having been a daily action of the bowels. 
 
 The colour of the faeces except when charcoal was present 
 was, throughout the period, dark brown or greenish brown. 
 The consistency was formed rolls with some small lumps which 
 could hardly be called scybala. The odour was noted to be 
 offensive throughout. 
 
 Examination of the faeces showed an excess of mucus both 
 on inspection and when rubbed up with water. 
 
 The watery extract of the faeces gave a distinct albumen 
 reaction. 
 
 Blood and bile were absent in all the motions. 
 
 The urobihn appeared to be increased in spite of the fact that 
 the urine analysis showed no increase of urobilin. 
 
 On microscopic examination of the faeces, some partially 
 
198 
 
 INTESTINAL DISEASES 
 
 digested muscular fibres, a few starch granules and fat drops, 
 together with some remnants of vegetable cells were found. 
 There were a few epithehal cells in the mucus, but not sufficient 
 to allow of a diagnosis of intestinal catarrh. 
 
 TABLE LI.— DISEASE— INTESTINAL DYSPEPSIA 
 
 Diet : Mixed + milk, containing 18-72 grams nitrogen, 100-86 grams fat, 
 126-24 grams carbohydrates, 1839-60 Calories, 2130 c.c. fluid 
 
 Date, March 1905 . . 
 
 5 
 
 6 
 
 . 7 
 
 8 
 
 Average. 
 
 Weight in kilos 
 Calories per kilo . 
 
 70-76 
 
 70-88 
 
 71-10 
 
 70-43 
 
 70-79 
 
 26-60 
 
 25-95 
 
 25-87 
 
 26-12 
 
 25-99 
 
 Urine 
 
 .- Quantih 
 
 dive Analysis 
 
 
 
 Quantity 
 
 960 
 
 1520 
 
 1240 
 
 1420 
 
 1231 
 
 Specific gravity 
 
 1022 
 
 1024 
 
 1023 
 
 1023 
 
 1023 
 
 Nitrogen 
 
 Urea .... 
 
 
 — 
 
 18-97 
 
 14-64 
 
 17-80 
 
 24-56 
 
 46-36 
 
 34-97 
 
 27-12 
 
 28-35 
 
 Uric acid 
 
 i 0-18 
 
 0-78 
 
 0-76 
 
 0-28 
 
 0-50 
 
 Ammonia 
 
 ; 0-04 
 
 0-41 
 
 0-32 
 
 0-38 
 
 0-29 
 
 Phosphates (P.OJ - • 
 
 2-14 
 
 4-59 
 
 3-41 
 
 2-69 
 
 3-21 
 
 Chlorides . ' . 
 
 4-80 
 
 7-60 
 
 3-50 
 
 5-25 
 
 5-29 
 
 1 /-Total . 
 
 je I Alkaline (A) . 
 
 2-37 
 
 3-92 
 
 3-76 
 
 2-56 
 
 3-15 
 
 2-24 
 
 3-63 
 
 3-56 
 
 2-40 
 
 2-96 
 
 3" Aromatic (B) . 
 ^ I Ratio A : B . 
 
 013 
 
 0-29 
 
 0-20 
 
 0-16 
 
 0-19 
 
 17-2: 1 
 
 13-6: 1 
 
 17.8:1 
 
 15-0: 1 
 
 16-1: 1 
 
 Fcece 
 
 ? ; Quant 
 
 'f alive An 
 
 alysis 
 
 
 
 Date, March 1905 . 
 
 6 
 
 7 
 
 8 
 
 9 
 
 Average 
 
 No. of motions 
 
 1 
 
 1 
 
 1 
 
 1 
 
 4 days. 
 
 Quantity 
 
 1 oo 
 
 36 
 
 89 
 
 117 
 
 91 
 
 Water per cent. . 
 
 72'73 
 
 71-41 
 
 71-41 
 
 75-16 
 
 72-68 
 
 Nitrogen 
 
 1-43 
 
 0-44 
 
 1-09 
 
 1-25 
 
 1-05 
 
 Fat ... . 
 
 5-22 
 
 1-62 
 
 4 00 
 
 4-57 
 
 3-85 
 
 Absorbed nitrogen p. c. . 
 
 — 
 
 — 
 
 — 
 
 — 
 
 94-39 
 
 fat per cent. . 
 
 
 ~ 
 
 
 
 96-18 
 
 Quantitative Analysis of the Faeces.— As already 
 mentioned, the patient passed a motion each day, and it 
 fvill be seen that the daily average quantity of faeces was 91 
 grams, containing 72-68 per cent, of water. The quantity of 
 nitrogen excreted per diem was 1-05 grams, and of fat 3-85 grams 
 so that the daily average absorption of nitrogen and fat 
 respectively was 94-39 and 96-18 per cent. Thus we see that 
 in this case there was no indication of want of absorption or 
 marked organic disease of the intestine. 
 
INTESTINAL DYSPEPSIA 
 
 19D 
 
 On Schmidt's diet, the motions were of a Hght yellowish-brown 
 colour, principally rolls, although some soft scybala were massed 
 together in irregular lumps. There was apparently no marked 
 increase of mucus, and the chemical analysis corresponded with 
 that on the mixed diet. On the other hand, with Schmidt's 
 fermentation tube, five grams of fseces yielded no less than two- 
 
 TABLE LII.— DISEASE— INTESTINAL DYSPEPSIA 
 
 Diet : Mixed, containing 16"88 grams nitrogen, 77-10 grams fat, 127'97 grams 
 carbohydrates, 1(570-39 Calories, 1270 c.e. lluid 
 
 Date, March 1903 
 
 15 
 
 10 
 
 17 
 
 18 
 
 19 
 
 Average 
 
 Weight in kilos . . 
 
 73-80 
 
 73-80 
 
 73-88 
 
 73-80 
 
 73-91 
 
 73-84 
 
 Calories per kilo . . 
 
 22-70 
 
 22-70 
 
 22-69 
 
 22-70 
 
 22-68 
 
 2269 
 
 Ur 
 
 ine : Quantitativ 
 
 e Analy^ 
 
 is 
 
 
 
 Quantity . 
 
 1460 
 
 1440 
 
 1400 
 
 1460 
 
 1290 
 
 1410 
 
 Specific gravity . 
 
 1021 
 
 1021 
 
 1018 
 
 1020 
 
 1021 
 
 1020 
 
 Nitrogen . 
 
 16-35 
 
 16-56 
 
 16-94 
 
 17-23 
 
 18-83 
 
 17-18 
 
 Urea 
 
 34-16 
 
 34-85 
 
 33-09 
 
 34-75 
 
 33-93 
 
 34-15 
 
 Uric acid . 
 
 0-90 
 
 0-90 
 
 0-91 
 
 0-92 
 
 0-97 
 
 0-92 
 
 Ammonia . 
 
 0-65 
 
 0-63 
 
 0-29 
 
 0-60 
 
 0-63 
 
 0-50 
 
 Phosphates (P.jOj) 
 
 2-57 
 
 2-63 
 
 2-51 
 
 2-54 
 
 2-49 
 
 2-55 
 
 Chlorides . " . 
 
 7-33 
 
 5-33 
 
 7-00 
 
 8-03 
 
 5-81 
 
 6-70 
 
 S C Total 
 
 5 I Alkaline (A) 
 
 5-71 
 
 4-13 
 
 3-42 
 
 3-62 
 
 3-88 
 
 4-15 
 
 5-49 
 
 3-11 
 
 3-17 
 
 3-35 
 
 3-01 
 
 3-90 
 
 ^1 Aromatic (B) 
 jg I Ratio A : B 
 
 0-22 
 
 0-22 
 
 0-25 
 
 0-27 
 
 0-27 
 
 0-25 
 
 25-0 : 1 
 
 17-8:1 
 
 12-7:1 
 
 12-4:1 
 
 13-4:1 
 
 15-6 : 1 
 
 Fa 
 
 ces : Quantitativ 
 
 s Analys 
 
 is 
 
 
 
 Date, March 1903 
 
 15 
 
 17 
 
 19 
 
 20 
 
 21 
 
 Average 
 
 No. of motions . 
 
 2 
 
 I 
 
 1 
 
 1 
 
 1 
 
 5 days. 
 
 Quantity . 
 
 333 
 
 66 
 
 52 
 
 88 
 
 68 
 
 121 
 
 Water per cent. . 
 
 83-36 
 
 73-39 
 
 69-39 
 
 71-36 
 
 69-12 
 
 73-32 
 
 Nitrogen . 
 
 1-88 
 
 0-60 
 
 0-54 
 
 0-86 
 
 0-71 
 
 0-92 
 
 Fat. 
 
 9-12 
 
 2-89 
 
 2-62 
 
 4-15 
 
 3-46 
 
 4-45 
 
 Absorbed nitrogen p.c. 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 94-55 
 
 ,, fat per cent. 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 94-23 
 
 thirds volume of gas, and on some occasions, even more. At 
 the fermentation test, the reaction was found to have become 
 markedly acid. It would, therefore, appear that this case can 
 well be put down as more or less typical of intestinal dyspepsia, 
 due to fermentation of the carbohydrates. 
 
200 INTESTINAL DISEASES 
 
 Intestinal Dyspepsia Due to Excessive Putre- 
 fraction of the Proteid in the Bowel.— A male, aged 
 thirty-six, suffered from periodical attacks of marked depres- 
 sion accompanied by a certain amount of pain in the loins 
 and shoulders. He was very nervous, complained of frequent 
 headaches, and said he had suffered for years from so- 
 called nervous dyspepsia, for which he had been treated two 
 years previously by Leube. The bowels acted irregularly, 
 tending to constipation, though he often suffered from attacks 
 of diarrhoea of a few days' duration. The patient was put on 
 an ordinary mixed diet, and a five days' analysis carried out. 
 
 The quahtative analysis of the urine showed increase in 
 urobilin and indican, otherwise nothing special was noted. 
 The Quantitative urine analysis merely showed a tendency to 
 increase in the quantity of aromatic sulphates. 
 
 The qualitative analysis of the faeces (Table LII.) showed that 
 the first charcoal appeared in six hours and twenty-five minutes 
 after its administration, and it is quite possible that in this case, 
 the patient being distinctly neurotic, the increased peristalsis was 
 purely psychological. On the first day, the patient passed two 
 motions, and on the other four days, one motion daily. The second 
 charcoal took forty-nine hours and fifteen minutes to appear in 
 the fseces. The motions on the five days of analysis were always 
 formed ; on the first day they are described as " soft formed with 
 some liquid," and on the last as " formed rolls mixed with scybala 
 massed together in the form of sheeps' motions." The colour, 
 except when charcoal was mixed with the stool, was dark brown 
 or greenish brown. There was a good deal of mucus mixed up 
 in the stools, and the odour was throughout very offensive. 
 
 The chemical examination of the fseces showed' an excess of 
 mucus in all the motions. 
 
 Blood and bile were absent throughout. 
 
 Urobilin was present in excess. 
 
 The microscopic examination showed nothing remarkable, 
 and the number of epithelial cells, mixed up with the mucus, 
 was so small that this case could not be put down as catarrh 
 of the bowels. 
 
 The quantitative analysis of the faeces shows a daily excretion 
 varying from 52 to 333 grams. On the first day when there was 
 increased peristalsis, the percentage of water was 83-36, while 
 
INTESTINAL DYSPEPSIA 201 
 
 it is seen on the other days to vary from 09 to 73 per cent, 
 only, the daily average of faoces being 121 grams, containing 
 73-32 per cent, of water. The nitrogen in the faeces showed 
 an average of 0-92 grams, and the fat an average of 4-45 grams. 
 The absorption of nitrogen was, therefore, normal, though the 
 absorption of fat showed a tendency to decrease, being only 
 <)4-23 per cent. 
 
 During another period, Schmidt's diet was given, and the 
 motions examined by Schmidt's fermentation-tubes. In this 
 case, the fermentation test showed a volume of gas of a httle 
 over one-third ; at the same time, a neutral motion, on one 
 occasion, became alkaline during the process of fermentation, 
 and, on the other occasions, the alkalinity which was present at 
 the commencement seemed to increase. 
 
 In 'considering the urine in this case, we find that there is an 
 increase of urobilin and indican, together with an increased 
 quantity of aromatic sulphates. 
 
 With regard to odour, the motions were extremely foul, and 
 contained a large amount of indol, phenol, and skatol. The 
 increased intestinal 'putrefaction in this case is seen, however, 
 not to be accompanied by decrease in the absorption of proteid 
 as indicated by ordinary analysis. At the same time, we must 
 remember that in this case there was an excessive quantity of 
 mucus, and it has been generally demonstrated that increased 
 intestinal putrefaction is more apt to occur in cases where there 
 is excess of mucus, blood, or pus in the bowel than in cases 
 where the increased proteid of the stool is due to deficient 
 absorption. 
 
 The patient suffered from comparatively sHght fermentation 
 when compared with what one sees in corresponding cases of 
 intestinal dyspepsia due to fermentation of the carbohydrates. 
 This is owing to the fact that indol, phenol, and skatol do 
 not irritate the bowel, and cause increased peristalsis, or so 
 large an increase of gas, as is the case in fermentation of the 
 carbohydrates, where lactic and butyric acids act as irritants 
 on the mucous membrane of the bowel. 
 
CHAPTER XXV 
 
 INTESTINAL CATARRH, ACUTE AND CHRONIC; ENTERITIS 
 CROUPOSA 
 
 Catarrh of the bowels would appear to be a more common 
 disease than catarrh of the stomach ; at the same time, it is 
 doubtful whether it is as common as is generally supposed, since 
 certain cases of diarrhoea from nervous or other causes are 
 undoubtedly popularly called catarrh of the bowel, when, as a 
 matter of fact, there is no organic change in the intestine. It 
 seems that enteritis, when a more systematic examination of 
 the fseces is undertaken, will be found not to play so important 
 a I'ole in the pathology of bowel disease, just as gastric catarrh, 
 since the introduction of the stomach-tube, is often found not 
 to be present, the symptoms being due to functional derange- 
 ment of the stomach only. 
 
 Catarrh of the bowels may be produced by various causes. 
 Chemical substances in some cases directly irritate the mucous 
 membrane of the intestine, setting up a true catarrh, while in 
 other cases certain articles of food taken in excessive quantity — 
 so that the digestive functions are not sufficient to carry out 
 the proper preparation of the food — irritate the mucous mem- 
 brane of the bowel, either by reason of the bulk of the food or 
 the products of decomposition. In other cases again, the food 
 itself may be tainted, and directly irritate the mucous membrane 
 of both the stomach and bowel, setting up a gastro-intestinal 
 catarrh. 
 
 Certain bacteria may undoubtedly set up a true enteritis, i.e., 
 cholera, typhoid, and probably, in some cases, the bacillus coli 
 themselves. In certain individuals, cold is apt to set up true 
 catarrh of the bowels just as in others cold sets up catarrh 
 of the respiratory tract. 
 
 Since it is only our intention here to discuss the chemical 
 changes produced in the fsoces by the process of catarrh, it is 
 
INTESTINAL CATARRH, ACUTE AND CHRONIC 203 
 
 unnecessary for us to divide it into the various sub-divisions 
 according to the cause of the enteritis ; it will suffice for our 
 purposes to divide it into two forms, acute and chronic catarrh, 
 treating colitis separately. 
 
 ACUTE CATARRH OF THE BOWELS 
 
 Acute catarrh of the bowels, unless it is very hmited in 
 extent, is practically always accompanied by a certain degree 
 of diarrhoea ; this is partly due to the increased quantity of 
 water present in the faeces, and partly to the excessive amount 
 of mucus thrown ofE from the inflamed bowel. It has to be 
 remembered that the consistency and not the frequency of the 
 stools must be designated as diarrhoea. The motions will 
 vary in frequency from 1 to 20 per day. In cases where 
 the catarrh involves both the small and the large intestine, 
 there is a tendency to frequency of motions. When the 
 catarrh is limited to the large intestine, especially the lower 
 end of it, the motions may be as many as 20 or more per diem, 
 while on the other hand, in cases of intestinal catarrh limited 
 to the small intestine, it is not at all unusual to have only one 
 motion passed daily. The first motion may be of a semi-sohd 
 nature, quickly followed by more or less hquid stools, the later 
 motions tending to be frothy and extremely slimy. It is not 
 at all uncommon to find amongst the liquid stools a certain 
 quantity of scybala, which are really the retained motions of 
 previous days. 
 
 The colour of the faeces in adults varies from hght brown 
 to a greenish colour. An absolutely green colour in adults is 
 only present in rare cases, and is always due to the presence of an 
 increased quantity of bihverdin. In children, on the other hand, 
 it is quite common to find green stools even in the sHghter cases 
 of catarrh, and this may be due either to biliverdin or the pro- 
 ducts of bacteria themselves. The odour of the faeces varies 
 very much according to the cause of the catarrh and the fre- 
 quency of the motions. The first motions in acute catarrh 
 are, as a rule, very offensive, but if there are numerous motions 
 with excessive transudation into the bowel, causing a washing- 
 out of the bacteria and their products from the large intestine, 
 the odour may become practically inoffensive. Where the 
 
204 
 
 INTESTINAL DISEASES 
 
 motions are less frequent, so that the bacteria have time to 
 multiply in the excessive exudation, the odour is extremely- 
 offensive. In cases of catarrh of the bowel on a milk diet, one 
 finds an acid odour owing to the excessive quantities of lactic, 
 butyric, and acetic acids. 
 
 We may now consider a typical case of catarrh of the bowels, 
 using it as an illustration of what one may expect to find in 
 ordinary cases of acute catarrh of the bowel, not affecting the 
 large intestine. 
 
 A male, aged twenty-three, had periodical attacks of diarrhoea 
 set up either by chill or slight errors in diet, and often accom- 
 panied by slight fever. 
 
 The qualitative analysis of the urine showed an increase of 
 indican and urobilin, but nothing else of note. 
 
 TABLE LIII.— DISEASE— ACUTE CATARRH OF THE BOWELS 
 
 Diet: Mixed, containing 18-30 grams nitrogen, 114-44 grams fat, 126-71 
 
 grams carbohydrates, 2051-49 Calories, 1510 c.c. fluid 
 
 Date, October 1904 . . 
 
 6 
 
 7 
 
 8 
 
 9 
 
 Average. 
 
 Weight in kilos 
 
 66-37 
 
 66-37 
 
 67-50 
 
 67-50 
 
 06-94 
 
 Calories per kilo . . 30-91 
 
 30-91 
 
 30-54 
 
 30-54 
 
 30-73 
 
 Urine : Quant 
 
 tative An 
 
 alysis 
 
 
 
 Quantity . . .1300 
 
 1290 
 
 1430 
 
 1490 
 
 13-78 
 
 Specific gravity 
 
 1026 
 
 1024 
 
 1023 
 
 1022 
 
 1024 
 
 Nitrogen 
 
 18-75 
 
 19-35 
 
 22-58 
 
 21-38 
 
 20-49 
 
 Urea . 
 
 39-52 
 
 37-73 
 
 39-04 
 
 38-89 
 
 38-80 
 
 Uric acid 
 
 0-35 
 
 0-70 
 
 0-88 
 
 0-86 
 
 0-70 
 
 Ammonia 
 
 0-72 
 
 0-64 
 
 0-60 
 
 0-17 
 
 0-53 
 
 Phosphates (P.fir,) 
 
 3-02 
 
 2-91 
 
 313 
 
 3-28 
 
 3-09 
 
 Chlorides 
 
 7-41 
 
 7-65 
 
 8-48 
 
 9-37 
 
 8-23 
 
 S r Total . 
 1 J Alkaline (A) 
 0-1 Aromatic (B) 
 
 3-76 
 
 3-56 
 
 3-42 
 
 i-07 
 
 3-70 
 
 3-63 
 
 3-37 
 
 3-23 
 
 3-83 
 
 3-51 
 
 0-13 
 
 0-19 
 
 0-19 
 
 0-24 
 
 0-19 
 
 jg I Ratio A : B 
 
 . i:7-9:l 
 
 17-7: 1 
 
 170: 1 
 
 16-0: 1 
 
 19-7: 1 
 
 Fferes : Qiutnti 
 
 latire An 
 
 tlysis 
 
 
 
 Date, October 1904 
 
 - i 
 
 7 
 
 8 
 
 9 
 
 Average 
 
 No. of motions 
 
 
 
 1 
 
 1 
 
 I 
 
 2 
 
 4 days. 
 
 Quantity 
 
 
 
 211 
 
 92 
 
 42 
 
 65 
 
 102 
 
 Water per cent. 
 
 
 
 84-88 
 
 77-53 
 
 70-98 
 
 76-46 
 
 77-46 
 
 Nitrogen 
 
 
 
 1 -69 
 
 1-10 
 
 0-65 
 
 0-81 
 
 1-06 
 
 Fat . 
 
 
 
 5-48 
 
 3-59 
 
 2-09 
 
 2-63 
 
 3-45 
 
 Absorbed nitrogen ]).c. 
 
 
 — 
 
 — 
 
 — 
 
 — 
 
 94-23 
 
 „ fat percent. 
 
 
 — 
 
 — 
 
 — 
 
 — 
 
 96-99 
 
INTESTINAL CATARRH, ACUTE AND CHRONIC 205 
 
 The quantitative analysis of the urine (Table LIIL), which 
 was carried out during a slight febrile attack, shows an excess 
 in the quantity of nitrogen eliminated above that taken in the 
 diet, the uric acid being also increased. 
 
 The analysis of the faeces shows that the first charcoal appeared 
 two hours after its administration ; the second charcoal, which 
 was given on the fifth day appearing four hours later. During 
 the four days of observation, the patient passed one motion 
 daily, except on one occasion, when there were two motions. 
 They consisted of soft, sHmy paste, occasionally tending to the 
 formation of soft rolls, but no scybala were present. The motions 
 appeared frothy from excessive formation of gas, and the odour 
 was extremely offensive throughout. 
 
 Chemical Analysis of the Faeces.— On inspection 
 of the stools, it was at once seen that mucus was present in 
 large excess. In all cases of catarrh of the bowel one finds this 
 excess of mucus, and in this case, on spreading some of the 
 faeces on a plate for thorough examination, the mucus was 
 found to be intimately mixed with the faeces ; and in some of 
 the specimens, gelatinous lumps or strips of mucus were found. 
 
 The watery extract of the faeces gave a marked albumen 
 reaction. 
 
 At no time was blood found to be present, and this would 
 appear to be the rule in the majority of cases of acute catarrh. 
 In some few cases, very minute quantities of blood may be 
 noticed, and when this occurs, some of it is usually mixed with 
 the mucus. 
 
 This case gave no reaction for bile pigments, though in some 
 cases of catarrh of the bowel with frequent motions one may 
 find even in adults a distinct bile reaction, and, in many cases, 
 the mucus is found to be stained by bile pigment. 
 
 The examination of the faeces for urobilin showed a marked 
 excess, and this has been our general experience. 
 
 Microscopically, the faeces showed partially digested muscular 
 fibres, together with vegetable cells, a few starch granules and 
 fat drops. The microscopic examination of the mucus showed 
 that it contained numerous epithelial cells, together with a 
 few isolated leucocytes ; in all specimens examined, the epithelial 
 cells were prominent. If one is to diagnose catarrh of the bowel, 
 it is essential that one should find numerous epithelial cells 
 
20G INTESTINAL DISEASES 
 
 mixed up with the mucus, as the mere presence of mucus is not 
 in itself sufficient evidence that there is true catarrh going on. 
 If ulceration is not also present, very few leucocytes will be 
 found. 
 
 The quantitative analysis of the fseces showed that in spite 
 of their being so soft, and apparently of such a watery con- 
 sistency, the actual quantity of water was not increased to any 
 great extent. Only on the first day was it as much as 84-88 per 
 cent., the average for the four days being 77-46 per cent. The 
 quantity of nitrogen present in the faeces averaged during the four 
 days 1-06 grams, and the fat during the same period averaged 
 3-45 grams. The absorption of nitrogen was 94-23 per cent, 
 (being a slight decrease), while that of fat was 96-99 per cent. 
 It would appear that this is, as already stated, a more or less 
 typical case of catarrh of the bowel, in which the large intestine 
 is not involved to any marked extent, the important point 
 being the fact that the motions did not contain any marked 
 increase of water although the increased quantity of mucus 
 very considerably altered their consistency from the normal 
 standard ; and it is also to be noted that the frequency was 
 not increased, whereas in many cases one finds a distinctly 
 increased number of motions. But, as we have already 
 remarked, this is largely dependent upon the extent to which 
 the lower end of the large intestine is involved. 
 
 CHRONIC CATARRH OF THE BOWELS 
 
 The difference between acute and chronic catarrh of the bowels 
 is one chiefly of degree, and many cases can be described as 
 acute catarrh, verging on sub-acute, and sub-acute verging 
 again on chronic, without its being possible to say definitely 
 what distinguishes one from the other. Generally speaking, one 
 may consider that in acute catarrh there is a tendency to 
 diarrhoea, while in chronic catarrh there is more apt to be a 
 tendency to constipation. The latter varies very much ; some- 
 times there may be two or three days constipation followed 
 by more or less diarrhoea, while in other cases one gets diarrhoea 
 motions of a semi-solid consistency alternating with sohd motions. 
 There is a tendency in chronic catarrh for the quantity of faeces 
 to be larger than normal, and considering the tendency to 
 
INTESTINAL CATARRH, ACUTE AND CHRONIC 207 
 
 constipation, this is remarkable, though it may be partly ex- 
 plained by the increased quantity of mucus which accompanies 
 the chronic catarrhal process. 
 
 The condition of the faeces in chronic catarrh can well be illus- 
 trated by taking a case and founding our description on what 
 was found in this individual. 
 
 TABLE LIV.— DISEASE— CHRONIC CATARRH OF THE BOWELS 
 
 Diet : Mixed + milk, containing 22-15 grams nitrogen, 83-79 grams fat, 
 
 102-59 grams carbohydrates, 1708-43 Calories, 1740 c.c. fluid 
 
 Date, May 1904 . 
 
 17 
 
 18 
 
 19 
 
 20 
 
 Average. 
 
 Weight in kilos 
 
 81-73 
 
 81-90 
 
 81-56 
 
 82-13 
 
 81-78 
 
 Calories per kilo . 
 
 21 -04 
 
 21 -(50 
 
 21-68 
 
 21-53 
 
 21-61 
 
 Urine 
 
 .- Quani it alive An 
 
 alysis 
 
 
 
 Quantity 
 
 1120 
 
 1920 
 
 1270 
 
 1340 
 
 1413 
 
 Specific gravity 
 
 1020 
 
 1022 
 
 1024 
 
 1022 
 
 1022 
 
 Nitrogen 
 
 14-90 
 
 29-76 
 
 24-10 
 
 24-12 
 
 23-72 
 
 Urea .... 
 
 27-55 
 
 62-21 
 
 48-01 
 
 49-31 
 
 46-77 
 
 Uric acid 
 
 0-73 
 
 1-11 
 
 1-00 
 
 0-98 
 
 0-96 
 
 Ammonia 
 
 0-16 
 
 0-84 
 
 0-85 
 
 0-67 
 
 0-63 
 
 Phosphates (P.O5) . 
 
 1-95 
 
 3-03 
 
 3-59 
 
 2-87 
 
 2-86 
 
 Chlorides 
 
 4-59 
 
 7-10 
 
 5-21 
 
 5-50 
 
 5-60 
 
 1 f Total . 
 
 rf 1 Alkaline (A) . 
 
 2-73 
 
 5-97 
 
 4-48 
 
 4-42 
 
 4-40 
 
 2-53 
 
 5-57 
 
 4-23 
 
 414 
 
 4-12 
 
 ^"1 Aromatic (B) . 
 .^ I Ratio A : B . 
 
 0-20 
 
 0-40 
 
 0-25 
 
 0-28 
 
 0-28 
 
 12-7 : 1 
 
 14-0 : 1 
 
 16-9: 1 
 
 14-8 : I 
 
 14-7 : 1 
 
 Face. 
 
 ' .- Quant 
 
 itative Ar 
 
 alysis 
 
 
 
 Date, May 1904 . 
 
 
 21 
 
 23 
 
 25 
 
 Average 
 
 No. of motions . 
 
 
 1 
 
 2 
 
 1 
 
 4 days. 
 
 Quantity . 
 
 
 261 
 
 343 
 
 138 
 
 186 
 
 Water per cent. 
 
 
 70-84 
 
 79-61 
 
 86-86 
 
 7910 
 
 Nitrogen , 
 
 
 3-73 
 
 3-43 
 
 0-89 
 
 2-01 
 
 Fat 
 
 
 9 02 
 
 8-29 
 
 215 
 
 4-87 
 
 Absorbed nitrogen per ccn 
 
 t. 
 
 — 
 
 — 
 
 — 
 
 90-93 
 
 „ fat per cent. 
 
 
 ~ 
 
 " 
 
 ~ 
 
 94-24 
 
 A male, aged thirty-six, had periodically indulged in alcohol 
 to excess. He was said to have frequent attacks of indigestion 
 together with constipation, this condition having lasted for some 
 years. The patient passed a motion regularly for several days 
 and then, for no apparent reason, he would become constipated. 
 He had been in the habit of taking drugs when constipated for 
 more than two days, so as to avoid a longer period of constipation. 
 
208 INTESTINAL DISEASES 
 
 During the time of observation, a four days' analysis was carried 
 out on a mixed diet with the addition of milk. The qualitative 
 analysis of the urine showed an increase in the quantity of indican 
 and urobilin, but no sugar or albumen ; nothing else of interest 
 was noted. 
 
 The quantitative analysis of the urine (Table LIV.) showed, 
 comparatively speaking, a large qivintity of urea, and the nitrogen 
 in the urine was shghtly in excess of that given in the diet, the 
 total daily excretion of uric acid being high, and the aromatic 
 sulphates increased. 
 
 The examination of the faeces during the period showed that 
 the first charcoal appeared in 95 hours 45 minutes after its 
 administration, and the charcoal given on the fifth day appeared in 
 51 hours, so that we have in this individual a decided tendency to 
 delayed motor-power of the alimentary tract, this being the usual 
 condition found in chronic catarrh of the bowels. The patient, 
 during the four days of analysis, passed motions on alternate 
 days, there being on the second alternate day two stools. The 
 faeces consisted of formed rolls with a tendency to scybala 
 matted together like sheeps' motions, while, on one day, the 
 stool was unformed, and of a pasty consistency. The colour 
 was dark greenish, and the odour throughout the period was 
 very offensive. In simple chronic catarrh, one nearly always 
 finds very offensive motions, and they are always more offensive 
 than those of simple constipation. 
 
 The chemical examination of the faeces showed a marked 
 excess of mucus, which on careful inspection was found to be 
 intimately mixed with the faeces. Albumen was found to be 
 present in the watery extract of the faeces, this being what we 
 have found in all the cases of chronic catarrh which we have 
 investigated. Neither blood nor bile was present, and this 
 would appear to be the rule in such cases. The reaction of all 
 the motions passed was alkaline, and the addition of perchloride 
 of mercury solution to the faeces showed a very marked excess 
 in the quantity of urobilin. 
 
 In cases where the catarrh involves the large as well as the 
 small intestine, fragments of muscular fibres are found, by 
 microscopic examination, to be more numerous than usual. 
 When, however, connective tissue is also present, it shows, 
 according to Schmidt, that the stomach is implicated. Numerous 
 
INTESTINAL CATARRH, ACUTE AND CHRONIC 209 
 
 vegetable cells were noticed in this case, and fat drops were also 
 present. The presence of an increased quantity of fat in the 
 stools is not at all uncommon in chronic catarrh of the bowels. 
 Crystals of ammonium magnesium phosphate and calcium salts 
 of bile acids were observed, and numerous epithelial cells were 
 intimately mixed with the mucus, but no leucocytes could be 
 found. 
 
 The quantitative analysis of the faeces showed that on one day 
 no less than 343 grams were passed, while the average for the 
 four days was 186 grams, this being higher than normal on 
 such a diet. The quantity of water present in the faeces was 
 comparatively speaking, small, the average output being 79'10 
 per cent., thus making the large quantity of fajces the more 
 remarkable. The nitrogen in the foBces averaged no less than 
 2-01 grams per diem, and the fat 4-87 grams. We see, therefore, 
 a very marked diminution in the quantity of nitrogen absorbed, 
 90 '93 per cent., while there was also a diminution ni the 
 absorption of fat, 94-24 per cent. 
 
 As already stated, this case can be taken as a general type 
 of chronic catarrh of the bowel. At the same time, we must 
 remember that analyses vary very much, and, in some cases, 
 the absorption of both nitrogen and fat is found to be almost 
 normal, while in the majority of cases it is diminished, often 
 markedly so. In one case of catarrh of the bowels occurring 
 in a possibly tubercular individual, who passed from 3 to 4 
 motions per diem, we found the absorption of nitrogen to bo 
 66-40, and that of fat 82-50 per cent. 
 
 ENTERITIS CROUPOSA 
 
 The pathological condition recognised as enteritis crouposa 
 or, as it is more often called, diphtheritic enteritis, is a rare 
 disease. It is certainly extremely rare when diphtheria bacilli 
 themselves are the cause of the condition, and to avoid mis- 
 apprehension it would appear to be better to call it enteritis 
 crouposa except when the Loeffler bacillus is the cause of the 
 disease. 
 
 This condition is met with in cases of mercurial poisoning, 
 either surgical or medical, and it seems especially to occur in 
 people who are run down from any cause. Of late years, it has 
 
 o 
 
210 INTESTINAL DISEASES 
 
 been not infrequently found where serous cavities have been 
 washed out with perchloride of mercury. 
 
 In various infectious diseases, such as pneumonia, general 
 septicaemia, scarlatina and smallpox, it is not unusual to find 
 croupous enteritis. The pathological condition of dysentery is 
 also included in this group. 
 
 The faeces will be found to be passed more frequently than 
 usual ; there is, as a rule, a good deal of tenesmus, and the 
 motions are extremely watery. 
 
 The faeces will be found to be mixed with mucus, blood, and 
 pus ; in fact, they may consist of the latter material alone, and 
 not uncommonly they contain shreds of tissue. 
 
 Under the heading of " blennorrhcea intestinahs," a group 
 of cases may be classed, which are more chronic than the 
 ordinary enteritis crouposa ; as seen in tubercular or carcino- 
 matous patients, or other cachectic individuals, the liquid 
 motions are grey or almost white, and appear to be nothing but 
 pus, mucus, and water. 
 
 It must be especially noted, as pointed out by Nothnagel, 
 that purulent faeces are not found in proper catarrh of the 
 intestine, but merely in the croupous form of inflammation 
 of the bowel. Unfortunately, we are unable to give any 
 metabohc analyses of the condition of enteritis crouposa. 
 
CHAPTER XXVI 
 
 COLITIS— MUCUS, ULCERATIVE (ACUTE AND CHRONIC) AND 
 MEMBRANOUS 
 
 Of late years, colitis has been especially brought to the notice 
 of medical men as a disease sui generis and for this reason we 
 consider it advisable to discuss it separately from catarrh. The 
 pathological condition of the bowels in true cohtis is of a very 
 varied nature. In some cases where the cHnical symptoms 
 have been characteristic, the autopsy reveals very limited 
 changes in the intestines. In describing the chemical conditions 
 foimd in cohtis, it is as well for us to make three sub-divisions 
 of the disease : («) Mucous Cohtis. (6) Ulcerative Cohtis (acute 
 and chronic), (c) Membranous Cohtis. The demarcation hne 
 between one and the other may, in some cases, be very narrow. 
 
 {a) MUCUS COLITIS 
 
 The form of cohtis most frequently met with in ordinary 
 practice is probably mucus cohtis. Its etiology varies very 
 much in different cases, although we do not agree with Lockwood 
 that it is generally consequent on appendicitis. A great number 
 of cases undoubtedly follow appendicitis, but this fact does not 
 necessarily imply that the appendicitis is responsible for the 
 condition. It may rather be that the attention of the doctors 
 had not been drawn to the faeces until the appendicitis had 
 asserted itself. In fact, the case which we are using to illustrate 
 mucus colitis is one of those in which mucus was never wof/ce(Z in 
 the motions until after an attack of appendicitis, followed by 
 operation. Of course, we do not mean to imply that the removal 
 of the appendix set up mucus colitis, but that the underlying 
 pathological condition which caused the appendicitis was 
 probably the same as that which caused the cohtis to appear 
 
212 INTESTINAL DISEASES 
 
 later, and that the removal of the offending appendix was not 
 sufficient to hinder the progress of the colitis. . \ \ 
 
 The etiology of mucus cohtis is difficult to define, and pathol- 
 ogists incline to divide into three groups : (1) those who 
 hold that mucus colitis is a purely nervous disease arising 
 from nervous alterations in the secretions of the colon ; (2) those 
 who consider the condition to be one of organic disease, having 
 a distinct anatomical pathology ; (3) those who attribute the 
 condition partly to nervous and partly to anatomical changes. 
 It appears to us that pure hypersecretion of mucus, arising from 
 imperfect nervous control of the secretions of the bowel in 
 neurotic and hysterical individuals, is sufficient to explain the 
 condition in many cases. 
 
 The symptoms occurring in mucus cohtis vary very consider- 
 ably, and, in some cases, one gets a bizarre picture, the general 
 weakness and lassitude of the patient, and the degree of wasting 
 and malnutrition evinced being altogether out of proportion 
 to the amount of nourishment taken, and further, to the amount 
 of absorption shown by metabolism analysis. On the other 
 hand, there are cases in which a large amount of mucus is dis- 
 charged by the bowel, and where the general symptoms are so 
 little marked that the mucus cohtis is only discovered by accident. 
 The ordinary signs of the condition, when looked for in these 
 cases, are tenderness in various parts of the colon (ascending 
 or descending, or more rarely the transverse), together with a 
 certain amount of rigidity of the muscles over the tender area. 
 In describing the chemical conditions found in mucus cohtis, 
 we will again take one case as an example, and base our 
 description on this. 
 
 A lady, aged thirty-six, who was distinctly neurotic, though 
 in no way an invahd, and who was leading an ordinary society 
 Hfe, had always fussed about her general condition, and had 
 been in the habit of frequently examining her motions. She 
 was first seen in 1900 for indigestion Avith a tendency to con- 
 stipation, though the latter condition was not very marked. 
 There was no mucus present at that time. In 1903 she had 
 an attack of appendicitis, for which the appendix was removed. 
 Some time afterwards, when entirely recovered from the appendi- 
 citis, she first noticed the presence of mucus in her motions ; 
 eighteen months later, she complained of pain along the 
 
COLITIS 
 
 213 
 
 whole course of the ascending and transverse colon, and general 
 lassitude, having great difficulty in getting through her ordi- 
 nary engagements. She stated that for the last year or more 
 she had noticed mucus in more or less large quantities in her 
 motions, and that she had periodical febrile attacks. The 
 patient was put on an ordinary mixed diet with the addition 
 of milk, and analyses carried out. 
 
 The qualitative analysis of the urine showed an increase of 
 indican, but no marked increase of urobilin, the urine being 
 otherwise normal except for the presence of some calcium 
 oxalate crystals. 
 
 TABLE LV.— DISEASE— MUCU.S COLITIS 
 
 Diet : ^Mixed + milk, containing 18-92 grams nitrogen, 88-18 grams fat 
 108-00 grams carbohydrates, 1777-69 Calories, 1680 c.c. fluid 
 
 Date, March 1905 
 
 2 
 
 3 
 
 4 
 
 Average. 
 
 Weight in Ivilos 
 
 
 48-60 
 
 48-60 
 
 48-60 
 
 48-60 
 
 Calories per kilo 
 
 
 36-58 
 
 36-58 
 
 36-58 
 
 36-58 
 
 Urine 
 
 .- Qua 
 
 ititativc A7i 
 
 alysis 
 
 
 
 Quantity . 
 
 
 ' 1400 
 
 1370 
 
 1150 
 
 1307 
 
 Specific gravity . 
 
 
 1016 
 
 1016 
 
 1023 
 
 1018 
 
 Nitrogen . 
 
 
 11-48 
 
 15-21 
 
 18-06 
 
 14-92 
 
 Urea 
 
 
 18-76 
 
 24-52 
 
 32-13 
 
 25-10 
 
 Uric acid . 
 
 
 0-11 
 
 0-33 
 
 0-07 
 
 0-17 
 
 Ammonia . 
 
 
 0-18 
 
 0-26 
 
 0-52 
 
 0-32 
 
 Phosphates (P.,0-) 
 
 
 1-62 
 
 2-14 
 
 2-44 
 
 2-07 
 
 Chlorides . " .' 
 
 
 5-30 
 
 5-62 
 
 5-18 
 
 5-37 
 
 % r Total . . 
 1 1 Alkaline (A) 
 
 
 ; 2-34 
 
 3-06 
 
 3-36 
 
 2-92 
 
 
 1 2-26 
 
 2-91 
 
 3-20 
 
 2-79 
 
 &.1 Aromatic (B) 
 ^ I Ratio A : B 
 
 
 ! 0-08 
 
 0-15 
 
 0-16 
 
 0-13 
 
 
 ; 28-3 : 1 
 
 19-4 : 1 
 
 20-0 : 1 
 
 21-5:1 
 
 Faces 
 
 : Qua 
 
 ntUative Ai 
 
 alysis 
 
 
 
 Date, March 1905. 
 
 3 
 
 4 
 
 5 
 
 6 
 
 Average 
 
 No. of motions 
 
 1 
 
 1 
 
 1 
 
 1 
 
 3 da vs. 
 
 Quantity . ' . 
 
 106 
 
 115 
 
 65 
 
 37 
 
 108 
 
 Water per cent. 
 
 8(5 -9e 
 
 78-21 
 
 66-95 
 
 72-75 
 
 76-23 
 
 Nitrogen 
 
 0-81 
 
 1-48 
 
 1-27 
 
 0-59 
 
 1-38 
 
 Fat " . 
 
 1-81 
 
 3-28 
 
 ■ 2-81 
 
 1-32 
 
 3-07 
 
 Absorbed nitrogen p.c. . 
 
 — 
 
 — 
 
 — 
 
 — 
 
 92-71 
 
 ,, fat per cent. . 
 
 — 
 
 
 ~ 
 
 ~ 
 
 96-52 
 
 The quantitative analysis of the urine showed, as will be seen 
 in Table LV., a tendency to decrease in the quantity of nitrogen ; 
 
214 INTESTINAL DISEASES 
 
 unfortunately, however, the analysis was begun immediately 
 the patient was put on the diet instead of three or four days 
 later, and hence the small quantity of nitrogen on the first day 
 (11-48 grams). In spite of the patient taking 36-58 Calories 
 per kilo, there was no gain of weight during the period of analysis 
 and, as will be shown later, this could not be entirely explained 
 by the want of absorption. 
 
 The quantitative analysis of the fseces showed the first charcoal 
 to appear in 25i hours after its administration by the mouth, the 
 second charcoal taking 37 hours to appear. 
 
 During the three days of analysis, the patient passed one 
 motion daily, consisting of unformed paste of a brownish green 
 colour and with an extremely offensive odour. Some of the 
 motions tended to consist of formed rolls, but, as a rule, they 
 were quite pultaceous. 
 
 In a certain number of cases of colitis, one sees a tendency 
 to diarrhoea of a mild type, the charcoal appearing in 6 to 8 
 hours after its administration. In such cases the patient may 
 have one or more motions daily, some of them consisting of 
 almost pure mucus ; in other cases, there is a distinct tendency 
 to delay in the appearance of the charcoal in the faeces, varying 
 from 48 to 150 hours. These patients may pass more or less 
 solid motions mixed with mucus in varying amounts, and as a 
 rule, the motion is of the normal sausage shape with an occa- 
 sional tendency to scybala, the sausage motion being, however, 
 always much softer than normal. It would appear that the 
 tendency to an excessively putrid odour is not so great as in 
 simple catarrh. 
 
 The chemical examination in the case we .are discussing 
 showed a very marked excess of mucus, it being not only inti- 
 mately mixed with the fasces, but also in separate masses m the 
 pultaceous motion. The quantity of mucus varied very much 
 from day to day, the porridge-hke motion being very slimy, 
 and adhering to the sides of the vessel. The mucus itself was 
 of a yellowish colour, occasionally tending to be streaky, though 
 there was never any appearance of membranous casts. 
 
 In mucus colitis, as we have previously said, one finds large 
 quantities of mucus separate from the motion, as well as some 
 intimately mixed with the ordinary stool. The mucus, as a 
 rule, is shiny white, and not uncommonly it has the appearance 
 
COLITIS 215 
 
 of boiled sago. The white sKmy mucus varies so much in its 
 consistency and quantity that one sometimes finds it difficult 
 to distinguish mucus colitis from the condition which we shall 
 later describe as membranous cohtis. 
 
 The watery extract of the faeces in this case showed no 
 albumen reaction ; in some cases, however, of mucus cohtis, one 
 finds a distinct albumen reaction in the watery extract of the 
 faeces, although — unlike catarrh of the bowels — it is not at all 
 common. 
 
 Blood and bile were absent from all the motions, and this 
 would appear to be the universal rule in cases of simple mucus 
 cohtis. 
 
 In the majority of cases of mucus cohtis, the reaction for 
 urobilin both in the faeces and urine is normal, w^hile in catarrh 
 of the bowel there is a tendency to increase of urobihn. 
 
 The microscopic examination showed some shght increase 
 of muscular fibre, a few starch granules, and some fat drops, 
 together with crystals of ammonium magnesium phosphate 
 and calcium oxalate. The mucus under the microscope was 
 seen to consist of transparent matter containing only a very 
 few leucocytes, and here and there epithehal cells. 
 
 In mucus cohtis, in addition to the quantity of mucus present 
 in the stool, it is worthy of note that the mucus contains no 
 large number of epithelial cells and leucocytes, thus at once 
 distinguishing it from catarrh of the bowels. 
 
 The quantitative analysis of the faeces showed that during the 
 four days when stools w^ere passed (representing the three days' 
 diet, as isolated by charcoal) the quantities varied from 37 to 
 115 grams, the average quantity of faeces per diem being 
 108 grams. The quantity of water present in the faeces is 
 also seen to vary very considerably, from 6G*95 to 86*99 per cent, 
 the average being 7623 per cent. The daily quantity of nitrogen 
 fluctuated, the average being 1'38 grams, while the average 
 cjuantity of fat per diem was 3 '07 grams. The absorption of 
 nitrogen was 92"71 per cent., showing a distinct tendency to 
 decreased absorption, while that of fat was 96-52 per cent., 
 which one may regard as normal. In many cases of mucus 
 cohtis, it would seem that the absorption tends to vary very 
 little from the normal, although one finds variations which are 
 difficult to explain. In this case, some of the increase in the 
 
210 INTESTINAL DISEASES 
 
 quantity of nitrogen in the fasces can doubtless be explained 
 ]jy the increased cpantity of mucus, so that the real absorption 
 of the proteid taken in the diet -was probably larger than would 
 appear from the analysis. 
 
 ULCERATIVE COLITIS 
 
 Under the heading of ulcerative cohtis, we have to include 
 the two conditions, acute and chronic ulceration of the colon, 
 the latter being very frequently met with in practice. 
 
 Acute Ulcerative Colitis. — Acute ulcerative colitis 
 occurs both as tropical dysentery and sporadically. In true 
 dysentery, the chemical analysis shows abundance of mucus, and 
 one always obtains an albumen reaction, in addition to which 
 peptone is generally present. Mucoid sanguinolent stools, con- 
 taining numerous scybala, are frequently passed, the motions 
 being accompanied by considerable pain and almost constant 
 tenesmus. In severe cases, the discharge from the bowels becomes 
 thinner and thinner, and of a more greenish colour, until at last 
 one may obtain stools looking very much like the wasliings of 
 meat. Microscopic examination of the motions reveals, together 
 with numerous bacteria which we need not here describe, a large 
 quantity of leucocytes and epithelial cells mixed up in the 
 mucus. 
 
 Asylum dysentery has been very ably described by Mott and 
 Durham.^ The motions passed in this asylum dysentery very 
 closely resemble those passed in ordinary dysentery, and the 
 diagnosis has to be mainly based on the fact of having blood 
 together with large amounts of mucus in the stools. In a 
 really typical motion one may obtain, as in dysentery, a mixture 
 of blood and mucus with very little else, though one generally 
 finds some scybala. According to the degree of bowel affection, 
 the proportions of liquid and solid faecal material vary, so that 
 in some cases one may have difficulty in recognising blood and 
 mucus ; careful examination will, however, generally reveal its 
 presence. In some cases of asylum dysentery, it would appear 
 that the patient does not continuously pass typical stools consist- 
 ing of blood and shme ; one gets on one day a typical stool, on 
 the next, merely a loose motion, and on the third and fourth 
 1 " Report on Colitis and Asylinn Dysentery," May 1900, p. lo. 
 
COLITIS 217 
 
 days a constipated motion ; but in the latter event, the motions 
 will be coated with shreds of blood and patches of slime. 
 
 The mucus present in asylum dysentery is generally somewhat 
 tenacious, and consists of a jelly-like material, translucent or 
 slightly opaque ; the colour is whitish (except when blood is 
 present to redden .it), or it may have a greenish hue. Micro- 
 scopically, numerous leucocytes will be found in the stools, and 
 as a general rule, only a few epithelial cells. 
 
 Chronic Ulcerative Colitis.— Under the heading of 
 chronic ulcerative colitis, one ought to include the various 
 chronic ulcers wliich may occur in the large intestine as the 
 result of tubercular or syphihtic disease, carcinoma, or any 
 other morbid condition. The differential diagnosis between 
 one and the other cannot, however, be arrived at by mere 
 chemical analysis, so that we A\dll content ourselves with 
 describing the form which occurs in stercoral ulceration as a 
 type of ulcerative colitis. 
 
 It would appear that scybala, from mere pressure or from 
 the production of chemical irritants, are apt to cause ulceration 
 of the large intestine. These scybala are especially inclined to 
 be retained in the caecum, hepatic, splenic or in the sigmoid 
 flexure, and it is, therefore, in these positions that one most 
 commonly finds stercoral ulceration. 
 
 Stercoral ulceration is very often accompanied by mucus 
 coHtis. That the scybala are the cause of the mucus colitis 
 seems doubtful. It would appear much more likely that in 
 those cases of mucus colitis in which there is chronic constipa- 
 tion or retention of scybala in certain positions, the scybala 
 are the cause of the ulceration, and the mucus colitis is a mere 
 accident. 
 
 The symptoms of chronic ulcerative colitis caused by faecal 
 retention vary very much according to the degree of constipation 
 present, and also to the degree in which the individual reacts 
 to the constipation. As we have already said, even slight con- 
 stipation causes, in some people, ver)^ marked toxic symptoms. 
 
 In cases of stercoral ulceration we find by the charcoal 
 method that there is, as a rule, great delay in the passage of 
 charcoal along the alimentary tract. There are, however, 
 cases in which the patient shows no delayed bowel action, and 
 yet there is stercoral ulceration. In those cases where there 
 
218 
 
 INTESTINAL DISEASES 
 
 is no absolute delay in the passage along the alimentary canal, 
 one finds that, in spite of the bulk of the charcoal appearing at 
 the end of twenty-four hours or so, some of it tends to be 
 eliminated in the next two or three days. It would appear that 
 in these cases, most of the faeces pass along the ahmentary canal 
 fairly rapidly, while certain scybala are retained in the sacculi 
 of the large intestine for a longer period, some of these scybala 
 setting up the ulceration. 
 
 We will now describe a case illustrative of the general condi- 
 tion. A male, aged thirty-four, had suffered from chronic con- 
 stipation for many years ; he complained of general abdominal 
 discomfort and tenderness over the caecum and sigmoid, pressure 
 over other parts of the bowels revealing no tenderness. 
 
 TABLE LVI.— DISEASE— CHRONIC ULCERATIVE COLITIS 
 
 Diet: Mixed + milk, containing 21-57 grams nitrogen, 120-75 grams fat, 
 ] 43-60 grams carbohydrates, 2522-97 Calories, 2070 c.c. fluid 
 
 
 
 1 1 
 
 
 
 Aver- 
 
 Date, May 1903 . . 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 8 
 
 age. 
 
 Weight in kilos . 
 
 59-85 
 
 59-79 
 
 59-85 
 
 61-09 
 
 60-41 60-13 
 
 60-12 
 
 Calories per kilo. 
 
 42-33 
 
 42-30 
 
 42-33 
 
 40-50 
 
 41-92 42-12 
 
 41-93 
 
 • Urine : Quantitative Analysis 
 
 
 Quantity . 
 
 1820 
 
 1580 
 
 2140 
 
 1120 
 
 1840 
 
 2340 
 
 1807 
 
 Specific gravity . 
 
 
 1016 
 
 1018 
 
 1017 
 
 1023 
 
 1014 
 
 1016 
 
 1017 
 
 Nitrogen . 
 
 
 20-5G 
 
 14-85 
 
 24-82 
 
 17-92 
 
 17-49 
 
 28-50 
 
 20-69 
 
 Urea 
 
 
 
 
 29-70 
 
 53-07 
 
 37-07 
 
 32-38 
 
 54-99 
 
 41-84 
 
 Uric acid . 
 
 
 0-62 
 
 0-58 
 
 0-98 
 
 0-89 
 
 0-69 
 
 0-86 
 
 0-77 
 
 Ammonia . 
 
 
 0-47 
 
 0-21 
 
 0-34 
 
 0-49 
 
 0-68 
 
 0-67 
 
 0-44 
 
 Phosphates (P.jOj) 
 
 
 3-46 
 
 2-61 
 
 3-96 
 
 2-61 
 
 2-98 
 
 4-12 
 
 3-29 
 
 Chlorides . 
 
 
 8-30 
 
 4-32 
 
 7-81 
 
 5-62 
 
 7-37 
 
 11-74 
 
 7-53 
 
 i [Total . . 
 -g 1 Alkaline (A) 
 
 
 3-94 
 
 2-42 
 
 5-00 
 
 3-41 
 
 3-67- 
 
 5-76 
 
 4-03 
 
 
 3-73 
 
 2-29 
 
 4-77 
 
 3-21 
 
 3-47 
 
 5-44 
 
 3-82 
 
 -g, ~| Aromatic (B) 
 1 iRatio A : B 
 
 
 0-21 
 
 0-13 
 
 0-23 
 
 0-20 
 
 0-20 
 
 0-32 
 
 0-21 
 
 
 17-7:1 
 
 17-6:1 
 
 20-7 : 1 
 
 16-0 : 1 
 
 17-3:1 
 
 17-0:1 
 
 18-2:1 
 
 Faces : Quantitative- Analysis 
 
 
 Date, May 1903 
 
 7 
 
 8 
 
 9 
 
 
 10 
 
 Average 
 
 No. of motions 
 
 
 2 
 
 2 
 
 2 
 
 
 2 
 
 6 days. 
 
 Quantity 
 
 
 95 
 
 163 
 
 100 
 
 
 279 
 
 106 
 
 Water per cent. 
 
 
 63-23 
 
 05-16 
 
 65-4 
 
 5 
 
 76-70 
 
 67-64 
 
 Nitrogen 
 
 
 1-50 
 
 2-44 
 
 1-4 
 
 8 
 
 2-80 
 
 1-37 
 
 Fat 
 
 
 5-33 
 
 8-76 
 
 5-3 
 
 2 
 
 10-02 
 
 4-91 
 
 Absorbed nitrogen percen 
 
 t. 
 
 — 
 
 — 
 
 — 
 
 
 — 
 
 93-65 
 
 fat per cent. 
 
 
 " 
 
 ~ 
 
 
 
 
 93-75 
 
COLITIS 219 
 
 The patient was put on a mixed diet with the addition of milk, 
 containing no less than 41 1)3 Calories per kilo, and on this diet 
 he increased in weight. During a period of six days, metabolism 
 analyses were carried out. 
 
 The qualitative analysis of the urine showed a marked increase 
 in the quantity of indican, and an excess of uric acid crystals 
 was noted in the sediment. 
 
 The quantitative analysis of the urine (Table LVI.) showed 
 no marked increase in uric acid, although it was deposited in the 
 urine. It is seen that the quantity of nitrogen daily excreted 
 varied very considerably, the average, however, showing nitrogen 
 equilibrium. 
 
 The analysis of the fa?ces showed the first charcoal to appear 
 in 102 hours 55 minutes, while the second charcoal given on 
 the seventh day appeared in 50 hours 15 minutes. 
 
 During the six days of analysis, motions corresponding to 
 the diet were passed on only four days, there being two motions 
 on each of these days. During the first three days on which 
 the patient passed two motions daily, the quantities of each 
 stool varied from 45 to 110 grams; on the last day when the 
 motions were passed immediately after each other, the quantity 
 was the largest noted, owing to the fact that a water enema was 
 given (on account of there being some tenesmus from the retention 
 of scybala in the rectum). As soon as the motion was obtained 
 the water was poured off, the motion being analysed as free as 
 possible from water. It was noticed that some charcoal-contain- 
 ing scybala appeared the day after the charcoal was first recog- 
 nised in the faeces, that is to say, six days after its administration. 
 The stool consisted of hard round lumps and rolls composed 
 of numerous scybala massed together. At the same time, there 
 were some separate scybala, and, on one occasion, the motion 
 consisted entirely of separate scybala stuck together with thick 
 mucus, stained with blood. Small coagula of blood were also 
 found between the scybala. In addition to the mucus between 
 the lumps, some of the scybala were coated with a layer of mucus 
 as if they had been smeared over with vasehne, this layer of 
 mucus being often distinctly tinged with blood. The odour 
 was noted on all occasions to be extremely offensive. 
 
 The scybala in these cases of chronic ulcerative colitis are 
 generally found to be more or less rounded, varying in size from 
 
220 INTESTINAL DISEASES 
 
 a small bean to a large walnut. In cases where mucus colitis 
 is present in addition to the stercoral colitis, one finds firm 
 shellac-hke mucus coating the scybala, and large quantities of 
 slimy mucus of a bright yellow or dirty red colour are found to 
 be mixed up in the stool. 
 
 The chemical examination of the fa^-ces showed, as already 
 described, a great excess of mucus. On breaking up the motions 
 with water, only a httle mucus was found mixed up in the scybala 
 themselves. The watery extract of the faeces gave no albumen 
 reaction, though in some cases of stercoral ulceration we get 
 a distinct albumen reaction. In this case, small quantities of 
 blood were found in clots adherent to the mucus or to the scybala. 
 Bile was not found in any of the motions, and in no case of 
 stercoral ulceration have we ever obtained a bile reaction. 
 
 In this case, perchloride of mercury shoAved a very feeble 
 reaction for urobilin, although in the majority of cases of ster- 
 coral ulceration, we have found a tendency to an increased 
 urobihn reaction. 
 
 The microscopic examination showed some partially digested 
 muscular fibres, together with numerous vegetable cells, calcium 
 salts of bile acids, and a few crystals of ammonium magnesium 
 phosphate. The gelatinous mucus was found to contain 
 numerous epithelial cells and leucocytes, and round some of 
 the clots there appeared to be some fibrous tissue containing 
 leucocytes ; but distinct sloughs, which could be recognised 
 as such, were not found. 
 
 The quantitative analysis of the fasces showed various quanti- 
 ties per diem ; in spite of there being two motions on each of 
 the four days belonging to the diet of six days, the daily quantity 
 was not very large, and most of the delay in this case was 
 probably present in the rectum itself, since a large quantity 
 of faeces was obtained by giving a water enema, which hastened 
 the expulsion of the fseces by two or three days. It is seen that 
 the water varied from 63-23 to 65-45 per cent, during the first 
 three days on which no enema was given. In spite of the fact 
 that the water was poured off as soon as the motion was obtained, 
 some f must have remained behind, thus accounting for the 
 increase of water in the fasces (to 76-70 per cent.), on the last 
 day of analysis. The daily quantity of nitrogen fluctuated 
 from 1-48 to 2-80 grams, the average for the six days being 
 
COLITIS 221 
 
 1-37 grams, showing a slight increase of nitrogen on this 
 diet. The quantity of fat is seen to be very large, varying from 
 5-32 to 1002 grams, making a daily average of 4-91 grams. It 
 is seen that the absorption of proteid was 93- 65 per cent., 
 while that of fat was 93 75 per cent., the absorption of both 
 proteids and fat being below the normal. 
 
 MEMBRANOUS COLITIS 
 
 It has long been recognised that the passage of distinct mem- 
 branes or casts occurs in certain neurotic individuals. White- 
 head^ gives a veiy inll resume of the literature on the subject, 
 elating the observations of these casts by the early observers. 
 It has been found in the few instances where autopsies have 
 been carried out in individuals suffering from this membranous 
 colitis that there were practically no anatomical changes to 
 account for the condition. Between the periods of attack, 
 the patient may suffer from no special intestinal troubles except 
 possibly constipation. Colicky pains of more or less severity 
 are followed in two or three days by the passage of membrane 
 after Avhich the patient feels very much better until the re- 
 currence of a similar attack. In some cases, the stools consist 
 almost entirely of shreds or tubular casts of membrane, which 
 have a more or less faecal odour ; sometimes they are colourless 
 when mixed with the fajces, and on washing they are always 
 found to be grey or transparent white. The membranous 
 material can take most fantastic forms, though careful examina- 
 tion generally reveals, on floating in water, an almost complete 
 tube ; at other times branched pieces of membrane are observed. 
 Microscopic examination of the mass shows a glassy structure 
 which on the addition of acetic acid gives a cloudy striation. 
 One sometimes sees in the membrane numerous epithelial cells, 
 while in other cases practically none are present. The mem- 
 brane appears in some cases to be in distinct layers, between 
 which it is not uncommon to find remains of undigested food 
 or faeces. The membrane may contain numerous crystals of 
 ammonium magnesium phosphate and cholesterin, and, occa- 
 sonally, Charcot-Leyden crystals. The chemical analysis of 
 the membrane when washed free from epithehal cells is found 
 1 British Medical Journal, 1871, February 11 and 18. 
 
222 INTESTINAL DISEASES 
 
 to consist principally of mucus, Leathes ^ considered that 
 these casts were not mucus, since, when free from epithelial 
 cells, they gave no reaction for proteid, and appeared to be 
 composed of chitin derived from the carbohydrates. Fibrin 
 has been described by Guttmann" as present in considerable 
 quantities, though other observers appear to differ on this point, 
 and to consider that the presence of fibrin is to be regarded as an 
 exception. The appearance of the fa3ces in cases of pure mem- 
 branous colitis practically differs in no way from that in ordinary 
 constipation. At the same time, there are numerous cases of 
 mucus coUtis in which one periodically observes membranous 
 casts. We have never been able to obtain any metabolism 
 analyses during which the patient has suffered from the cohcky 
 pains and passed casts, although we have had cases under 
 observation where membrane has been voided at various times. 
 The most marked case which has come under our notice is 
 that of a lady, aged forty-one, who had suffered from " weird " 
 abdominal symptoms for some twelve years. On occasions, 
 she would get girdle-like pains in the abdominal region which 
 would become very tender, and on the same day or the day 
 after, a membranous mass would be passed. Some of these 
 membranes were described by the patient as 3 ft. long, though 
 the specimens which came under our observation were never 
 more than 2 ft. in length when floated out in water. The mem- 
 branes on different occasions varied from 1 to 2 ft. in length, 
 and were about 1| in. in diameter. As a rule, they were 
 extremely thin, although sometimes the walls were consider- 
 ably thickened and distinct layers were evident. The mem- 
 branes tended to be more or less colourless, although the white 
 colour was sometimes masked by faeces. The tub^s were, as a 
 rule, passed separate from the faeces, or only contained very small 
 quantities of faecal matter. When washed free from faeces, they 
 were perfectly colourless, and on no occasion did we find any 
 staining from bile. No urobihn reaction was obtained except 
 when contaminated by faeces, and blood was never present. The 
 microscopic examination showed the membrane to consist of a 
 colourless, structureless, glass-like substance containing a few 
 leucocytes, and sometimes epithelial cells, which always showed 
 marked fatty degeneration were found. In fresh specimens, 
 
 1 Lancet, 1905, vol. ii. 
 
 2 Dcutsch. Med. Wochenschr., 1887, No. 27. 
 
COLITIS 223 
 
 ammonium magnesium phosphate crystals were never present, 
 though, on some occasions, when the specimens were examined 
 af tsr some days' delay, numerous triple phosphates were found to 
 be present. Charcot-Leyden crystals were never seen, although 
 in old specimens cholesterin crystals were present. The 
 chemical examination of the washed membrane gave a biuret 
 reaction, and a pink colour with Millon's reagent. On the 
 addition of acetic acid, the mass became more opaque, and on 
 further addition of the acid, almost fluid. The membrane, after 
 digestion with pepsin and hydrochloric acid, yielded a precipitate 
 which contained phosphorus. On boiling with dilute acid and 
 subsequent neutralisation, one obtained a reducing substance. 
 
 From these chemical tests, it is evident that the membranes 
 consisted of a proteid containing both nucleo-albumen and true 
 mucus. 
 
 In the intervals between the attacks, the patient was never 
 well, suffering from chronic constipation alternating with attacks 
 of diarrhoea, the chemical analysis showing that she had chronic 
 mucus colitis. She described the occasional passage of liquid 
 motions resembling " pigs' wash," with an extremely offensive 
 odour and an acid smell, and of a dirty greyish-white colour. 
 On several occasions we were able to make a chemical analysis 
 of this patient's motions, which were found to vary greatly in 
 quantity ; the motor-power of the alimentary tract was also 
 found to show considerable variations, the charcoal appearing 
 on one occasion in 25J hours, and on another in 73| hours. On 
 other occasions when it was given, the time of its reappearance 
 varied between these limits, but purgatives or enemata had to 
 be given when there was considerable delay, as the patient 
 became very nervous if the constipation was of long duration. 
 The urine analysis showed nothing of note, and the faeces 
 analyses always gave results which would lead one to diagnose 
 mucus colitis. The absorption of nitrogen varied from 84-65 
 to 96-68 per cent., and the absorption of fat from 88*40 to 96-56 
 per cent, on a mixed diet during four different periods of meta- 
 bolism analyses in the course of two years. The worst absorp- 
 tion occurred immediately after an attack of so-called " pigs' 
 wash," when the motions were extremely offensive, and con- 
 tained a large excess of mucus. On this occasion, some blood 
 was found mixed up with the stools, which appeared at that 
 time to indicate ulceration of the bowel. 
 
CHAPTER XXVII 
 
 INTESTINAL ATROPHY 
 
 Atrophy of the intestine can be j)atliologically sub-divided 
 according to its anatomical situation, there being atrophy either 
 of the mucous membrane, folhcles, sub-mucosa, or of the 
 muscular coat of the intestines. Clinically, it is extremely 
 difficult to diagnose the site of the anatomical changes in 
 atrophy of the bowel. It would appear, however, that with 
 proper examination of the faeces, one can clinically sub-divide 
 atrophy of the bowel into : 
 
 (a) Atrophy of the mucous membrane of the bowel, dis- 
 regarding the question of its affecting the follicles or the general 
 mucous membrane. 
 
 (b) Muscular atrophy of the bowel. 
 
 In illustration of atrophy of the bowel, we select two cases 
 from those which have come under our notice, which may be 
 classified under the above heads. 
 
 (a) Atrophj of the Mucous Membrane of the Intestme. — A 
 male, aged seventy-one, had a distended colon, for which he 
 had been treated three years previously in Germany. During 
 the last year, he had periodically passed blood and mucus six 
 or seven times a day, and unless drugs were employed, the 
 diarrhoea was more or less continuous. He had previously 
 weighed fourteen stone, but when he came under observation he 
 weighed only eleven stone one pound. The patient had a slight 
 aortic murmur, and some arterio sclerosis ; otherAvise, there was 
 nothing of special note in his condition except the abdominal 
 symptoms. The abdomen was very distended and pendulous, and 
 the colon on percussion and palpation seemed to fill up the whole 
 belly, yielding a splash not only over the csccum, but through- 
 out its entire length. There was distinct pain on pressure in 
 the umbilical region, but nothing further of moment could be 
 detected. During the time he was under observation, he passed 
 
INTESTINAL ATROPHY 225 
 
 frequent motions, sometimes no less than sixteen or eighteen 
 in the day, when he was taking no drugs. During a period of 
 five days, he was put on a milk diet and analyses carried out. 
 The qualitative analysis of the urine showed only a mere trace 
 of albumen. 
 
 TABLE LVII. 
 
 -DISEASE— ATROPHY OF THE MUCOUS MEMBRANE 
 OF THE BOWEL 
 
 Diet: Milk, containing 18-55 grams nitrogen, 109-20 grams fat, IIT^OO grams 
 carbohydrates, 2073-06 Calories, 2800 c.c. fluid 
 
 Date, June 1901 . . 
 
 " 
 
 7 
 
 8 
 
 9 
 
 10 
 
 \vcrage 
 
 Weight in kilos . 
 
 70-05 
 
 70-20 
 
 69-98 
 
 69-75 
 
 09-75 
 
 70-07 
 
 Calories ]icr kilo 
 
 27-90 
 
 28-08 
 
 28-17 
 
 28-20 
 
 28-20 
 
 28-13 
 
 Ui 
 
 ine : Quantitath 
 
 e Analysis 
 
 
 
 Quantity . 
 
 2000 
 
 2000 
 
 2100 
 
 1740 
 
 1820 
 
 1944 
 
 Specific gravity . 
 
 1010 
 
 1011 
 
 1011 
 
 1011 
 
 1013 
 
 1011 
 
 Nitrogen . 
 
 12-77 
 
 15-40 
 
 15-54 
 
 14-02 
 
 10-38 
 
 14-94 
 
 Urea .... 
 
 2.3-08 
 
 20-80 
 
 28-98 
 
 27-14 
 
 30-70 
 
 27-35 
 
 Uric acid . 
 
 0-33 
 
 0-34 
 
 0-17 
 
 0-24 
 
 0-24 
 
 0-20 
 
 Ammonia . 
 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 Phosphates (P,,0-) 
 
 3-30 
 
 4-20 
 
 4-20 
 
 3-83 
 
 3-46 
 
 3-80 
 
 Chlorides . 
 
 7-02 
 
 400 
 
 5-40 
 
 0-09 
 
 3-40 
 
 5-45 
 
 1 { Total 
 
 2 1 Alkaline (A) 
 
 2-14 
 
 2-70 
 
 — 
 
 3-11 
 
 2-25 
 
 2-57 
 
 1-91 
 
 2-44 
 
 — 
 
 2-88 
 
 1-99 
 
 2-31 
 
 3 1 Aromatic (B) 
 ^ iRatio A: B 
 
 0-23 
 
 0-32 
 
 — 
 
 0-23 
 
 0-20 
 
 0-26 
 
 8-3 : 1 
 
 7-0: 1 
 
 — 
 
 12-5: 1 
 
 7-7: 1 
 
 8-9 : I 
 
 Fee 
 
 CCS : Qi 
 
 antilaliv 
 
 3 Analys 
 
 is 
 
 
 
 Date, June 1901 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 Average 
 
 No. of motions . 
 
 15 
 
 13 
 
 14 
 
 14 
 
 •14 
 
 5 days. 
 
 Quantity . 
 
 133 
 
 204 
 
 203 
 
 255 
 
 70 
 
 173 
 
 Water per cent. 
 
 70-03 
 
 70-05 
 
 84-88 
 
 84-33 
 
 85-43 
 
 81-00 
 
 Nitrogen . 
 
 1-04 
 
 1-00 
 
 1-59 
 
 2-00 
 
 0-55 
 
 1-30 
 
 Fat .... 
 
 3-73 
 
 5-00 
 
 3-76 
 
 4-99 
 
 1-19 
 
 3-73 
 
 Absorbed nitrogen p.c. 
 
 — 
 
 — 
 
 — 
 
 
 — 
 
 9207 
 
 ., fat per cent. 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 90-58 
 
 The quantitative analysis of the urine (Table LYII.) showed 
 a diminution in the quantity of nitrogen relative to the quantity 
 taken in the diet. There was a low uric acid excretion, and, 
 considering that the patient was suffering from diarrhoea, the 
 aromatic sulphates were markedly increased. 
 
 The motor-power of the alimentary tract, as tested by means 
 of charcoal, was found to be delayed, for in spite of the frequent 
 
 p 
 
226 INTESTINAL DISEASES 
 
 motions (there being on the first morning of analysis no less than 
 nine, while six occurred in the afternoon and night, and on the 
 following day, eight in the morning, and five in the afternoon 
 and night), the first charcoal did not appear till 48 hours after 
 its administration by the mouth, and the second charcoal, given 
 on the sixth morning, did not appear until 36 hours after its 
 administration. During the five days of analysis, the motions 
 varied in number from 13 to 15 per diem, and in quantity from 
 70 to 255 grams. The motions consisted of unformed paste 
 of a porridge-like consistency, and only on a few occasions con- 
 tained any faecal lumps. The colour varied from chocolate to 
 reddish brown, and on the third and fourth days some pure 
 blood was observed in the motions. The odour was most offensive 
 throughout, giving the impression of large quantities of indol, 
 phenol, and skatol. At the same time, a distinct smell of sulphu- 
 retted hydrogen was noted, this being also chemically recognised. 
 The chemical analysis of the faeces showed that some of the 
 motions contained practically no increase of mucus, while in 
 others there was some slight increase ; in fact, the quantities 
 of mucus alone seemed to negative the diagnosis of mucus colitis. 
 The mucus which was found was of a more or less yellowish 
 colour tinged with blood. The watery extract of all the motions 
 examined gave a distinct albumen reaction. During the period 
 of frequent motions, blood was found to be present on the third 
 and fourth days of faeces analysis, and, in some of the motions, 
 blood corpuscles in large quantities were recognised. No bile 
 pigments were obtained in any of the motions, while the stools, 
 when tested for urobilin, showed a marked excess. 
 
 Microscopically, the fa3ces contained a certain amount of 
 casein and fat globules, together with crystals ' of ammonium 
 magnesium phosphate and some salts of the fatty acids. On 
 the occasions when blood was found, numerous blood corpuscles 
 were present, as already stated, together with a few leucocytes 
 and epithelial cells. No shreds of mucus could be recognised, 
 so that a diagnosis of ulcerative colitis was negatived. 
 
 The quantity of faeces varied very considerably, from 70 to 255 
 grams being passed in the twenty-four hours, and it is seen on 
 referring to the table that the quantity of water present in the 
 faeces also varied, from 76-03 to 85-43 per cent. When one 
 considers the frequency of the motions, the average of faeces 
 
INTESTINAL ATROPHY 227 
 
 per diem was not very high, being 173 grams, containing 81-(iO 
 per cent, of water, the latter also not being so high as one would 
 have expected to find from the apparent markedly diarrhoea. 
 The nitrogen in the faeces varied from 55 to 2 00 grams per 
 diem, the average being 1-3G grams, and the quantity of fat varied 
 from 1-19 to 5-00 grams per diem, with an average of 3-73 grams. 
 The absorption of nitrogen was 92-67 percent., and that of fat 
 96-58 per cent. It is, therefore, seen that in spite of the frequency 
 of the motions, and in spite of their very fluid appearance, the 
 amount of fluid was not very great, nor the absorption much 
 diminished, the proteid absorption being principally affected. 
 During the period of observation, the patient took 28-13 Calories 
 per kilo, and was kept entirely in bed, there being a loss of 
 weight in the six days from 70-65 to 69-75 kilos. 
 
 The patient remained under observation another three weeks, 
 although no further quantitative analyses were carried out. On 
 several occasions, he passed blood in the motions, the quantity 
 steadily increasing. There was considerable flatulency, and 
 towards the end the patient was constantly troubled with hiccough. 
 
 The autopsy showed atheroma of the aortic valves with old 
 pleural adhesions. On opening the abdomen, the large intestine 
 bulged out, and the caecum was larger than a man's head. The 
 large intestine appeared to be greatly distended, and it was so 
 thin that, on trying to remove it, it burst in several places. A 
 small villous growth was found in the sigmoid flexure, and on 
 examination it was seen to be ulcerated at the extremity, which 
 explained the periodical attacks of haemorrhage. Two erosions 
 were found in the large intestine, and the mucous membrane 
 appeared to be more red than normal. 
 
 Dr. WakeUn Barratt was good enough to make a microscopical 
 examination of the large intestine, and reported that the sur- 
 face was free from epithehal cells, this being probably due to 
 post-mortem changes. The mucous membrane was distinctly 
 thinner than normal, and it would appear that the case may be 
 taken as an example of general atrophy of the mucous membrane 
 of the large intestine. Nothing of note was found in the other 
 organs, which were fairly normal except in the particulars 
 described. The haemorrhage in this case was a pure accident 
 so far as the atrophy of the bowel was concerned. The general 
 symptoms, such as frequency of motions and pultaceous 
 
228 
 
 INTESTINAL DISEASES 
 
 consistency of the fgeces may, however, be attributed to atrophy 
 of the mucous membrane of the large intestine, leading to 
 diminished absorption of water together \A'ith diminished absorp- 
 tion of proteids, the fat absorption being httle affected, since this 
 is only to a very hmited extent carried on in the large intestine. 
 
 TABLE LVIII.— DISEASE— MUSCULAR ATROPHY OF THE BOWEL 
 Diet: Mixed, containing 8-03 grams nitrogen, 33-99 grams fat 39-68 grams 
 
 carbohydrates, 683-02 Calories, 
 
 700 c.c. fi 
 
 uid 
 
 
 Date, January 1902 . . 
 
 22 
 
 23 
 
 24 
 
 25 
 
 Average. 
 
 Weiglit in kilos 
 
 65-48 
 
 65-03 
 
 64-80 
 
 64-65 
 
 64-99 
 
 Calories per kilo 
 
 10-43 
 
 10-50 
 
 10-54 
 
 10-57 
 
 10-51 
 
 Urine : Quantitative Analysis 
 
 
 
 Quantity 
 
 730 
 
 840 
 
 750 
 
 800 
 
 780 
 
 Specific gravity 
 
 1023 
 
 1022 
 
 1024 
 
 1024 
 
 1023 
 
 Nitrogen 
 
 10-14 
 
 12-56 
 
 11-76 
 
 12-99 
 
 11-86 
 
 Urea .... 
 
 18-93 
 
 23-52 
 
 23-07 
 
 25-22 
 
 22-69 
 
 Uric acid 
 
 0-65 
 
 0-69 
 
 0-64 
 
 0-62 
 
 0-65 
 
 Ammonia 
 
 0-51 
 
 0-41 
 
 0-34 
 
 0-64 
 
 0-41 
 
 Phosphates (PoO^) 
 
 1-61 
 
 1-85 
 
 1-80 
 
 1-76 
 
 1-76 
 
 Chlorides . " . 
 
 3-36 
 
 4-20 
 
 3-81 
 
 3-65 
 
 3-76 
 
 £ r Total . 
 
 1 1 Alkaline (A) . 
 
 2-10 
 
 2-35 
 
 2-28 
 
 2-35 
 
 2-27 
 
 1-94 
 
 2-17 
 
 2-13 
 
 2-16 
 
 2-10 
 
 '^\ Aromatic (B) . 
 ^. I Ratio A : B . 
 
 0-16 
 
 0-18 
 
 0-15 
 
 0-19 
 
 0-17 
 
 12-1 : 1 
 
 12-0: 1 
 
 14-2: 1 
 
 11-3: 1 
 
 12 4: 1 
 
 Face 
 
 s .- Quantitative Ai 
 
 alysis 
 
 
 
 Date, January 1902 . 
 
 
 24 
 
 25 
 
 26 
 
 Average 
 
 No. of motions . 
 
 
 1 
 
 1 
 
 1 
 
 4 days. 
 
 Quantity . 
 
 
 34 
 
 50 
 
 65 
 
 37 
 
 Water per cent. . 
 
 
 74-32 
 
 74-32 
 
 74-32 
 
 74-32 
 
 Nitrogen . 
 
 
 0-53 
 
 0-78 
 
 1-02 
 
 0-58 
 
 Fat . 
 
 
 2-64 
 
 3-97 
 
 .5-05 
 
 2-92 
 
 Absorbed nitrogen per ccn 
 
 t.. 
 
 — 
 
 — 
 
 — 
 
 92-78 
 
 water per cent. 
 
 
 — 
 
 — 
 
 — 
 
 91-65 
 
 (?)) Atfophj of the Muscles of the Intestine. — We now come to 
 the description of a case which may be classed under the above 
 heading. A male, aged sixty-nine, had suffered from chronic 
 constipation (which had gradually been getting worse), together 
 with marked flatulency, for some twelve or thirteen years. The 
 heart was described as galloping and fluttering, and there was 
 considerable arterio sclerosis, for which the patient had been 
 treated at Nauheim. The flatulency when constipated was. 
 
INTESTINAL ATROPHY 229 
 
 so severe that he woke in the night with considerable breath- 
 lessness, and some tendency to syncope. On examination of 
 the abdomen, the colon was found to be distended and soft, 
 the rectal examination showing considerable ballooning. There 
 appeared, however, to be little retention of faeces in the rectum, 
 and the constipation was apparently due to the general weakness 
 of the colon itself. A four days' period of analysis was under- 
 taken, during which the diet had to be very limited owing to 
 the patient's dislike for food : and the most one was able to give 
 was lO'Sl Calories per kilo. The qualitative analysis of the 
 urine showed nothing of note. 
 
 The quantitative analysis of the urine is of interest (Table 
 LVIII.), since we see that, although the patient was taking only 
 8 grams of nitrogen, no less than 11-86 grams were excreted 
 per diem. In spite of this, very little weight was lost during 
 the period. It is also seen that, considering the small quantity 
 of urea and nitrogen, the uric acid was excessive ; otherwise, the 
 analysis calls for no special mention. 
 
 The motor-power of the alimentary tract showed some delay, 
 the first charcoal appearing in 49 hours 45 minutes, and the 
 second in 33-J hours. Motions were passed on only three of 
 the days corresponding to the period of four days when the diet 
 was given. The quantity of fseces varied from 34 to 65 grams 
 per diem, making an average of only 37 grams during the period. 
 The stools consisted of thin rolls mixed with some paste and a 
 little mucus of a brownish colour, the odour being noted as very 
 offensive. The average quantity of water in the fseces was only 
 74-32 per cent. The chemical analysis of the faeces showed that 
 mucus was present, but no albumen, blood, or bile, the urobilin 
 being only slightly increased. The daily quantity of nitrogen 
 averaged 0-58 grams, and that of fat 2-02 grams per diem. In 
 spite of there being a normal quantity of nitrogen and fat in 
 the faeces, we find that the patient had a very small absorption 
 of proteid, 92-78 per cent., and a still worse absorption of fat, 
 only 91-65 per cent. In this case, it would appear that the 
 constipation was due to atrophy of the large intestine, which 
 was distended throughout, and seemed to have lost its con- 
 tractive power. Unfortunately, this must remain supposition, 
 since we were unable to have an autopsy to verify the diagnosis, 
 the patient being still aUve. 
 
CHAPTER XXVIII 
 
 INTESTINAL ULCERATION 
 
 In ulceration of the intestines, one has to include duodenal 
 ulcers as well as the various ulcerative conditions which may 
 arise in the intestine, such as tubercular, syphilitic, carcino- 
 matous and ui'semic ulcers. The differential diagnosis between 
 the various ulcerative conditions which may occur has to be 
 made by careful analysis of the patient's history and symptoms, 
 as well as by bacteriological methods. So far as chemical 
 analysis of the faeces goes, we may say that it alone will not 
 enable us to differentiate between the various forms of ulcera- 
 tion ; all we can expect from it is aid in making a diagnosis of 
 intestinal ulcer, regardless of its etiology. The text-book 
 theory that the diagnosis of duodenal ulcers arising from extensive 
 burns, emboli, or thrombosis is easily distinguished from that 
 of gastric ulceration by noting the lapse of time between the 
 taking of food and the attack of pain, with various other symp- 
 toms, is, as a matter of fact, more theoretical than practical. 
 In considering the alterations which may occur in the faeces in 
 cases of duodenal ulcer, one is at once confronted by the fact 
 that in some cases one gets diarrhoea, and in others — and in 
 the more numerous cases, it would appear — constipation is 
 present. So long as there is no haemorrhage, one niay say that it 
 is practically impossible from the examination of the fseces to 
 make a diagnosis of duodenal ulcer, the diminution of faeces 
 observed in some cases being due to the small quantity of food 
 taken owing to the patient's fear of consequent pain. If 
 haemorrhage occurs, blood will be recognised in the faeces, the 
 appearance of the blood being practically the same as that 
 found in gastric ulcer. 
 
 The generally accepted idea that diarrhoea accompanies 
 ulceration of the intestines — more especially of the large intes- 
 tine — is only partially correct. The diarrhoea is supposed to be 
 
INTESTINAL ULCERATION 231 
 
 due to the intestinal ulcer exposing parts of the bowel to the 
 irritation of the fa3ces, thus producing increased peristalsis ; in 
 addition to which there is an increased quantity of water in the 
 stools, owing to the diminution of the water-absorbing surface 
 from the destruction of parts of the mucous membrane of the 
 bowel by ulceration, so that theoretically one would have an 
 increased quantity of water and increased intestinal peristalsis 
 to produce diarrhoea. But in spite of this, one often finds in 
 practice cases of even extensive ulceration of either the large 
 or small intestine where no diarrhoea is present. We all know 
 that constipation is a not infrequent symptom in extensive 
 typhoid ulceration. It would appear that, in ulceration of the 
 bowel, one may have either constipation or diarrhoea except in 
 cases where the ulceration occurs in the sigmoid flexure or 
 ractum. 
 
 The most important sign in the examination of the fseces for 
 intestinal ulceration is undoubtedly the presence of blood. In 
 fact, if no blood is found in the motion, it is impossible to diag- 
 nose ulceration of the intestine from the examination of the faeces. 
 We have already said that in duodenal ulcer there is fairly 
 extensive haemorrhage in the majority of cases, while in ulcera- 
 tion of the large intestine, the amount of blood present at one 
 time is usually very limited. The quantity of blood is often 
 so small that it cannot be recognised by the naked eye, and is 
 only discovered on microscopical or chemical examination. In 
 cases of possible ulceration of the bowel, the discovery of blood 
 in the faeces together with pus and some fibrous tissue, is sufficient 
 to justify one in considering that one has ulceration of the bowel 
 to deal with. When, on the other hand, blood is not found in 
 th3 faeces, it is not sufiicient to negative ulceration of the bowel 
 unless repeated examinations of the faeces have been made. 
 
 In addition to blood as an aid in diagnosing ulceration of the 
 intestine, we have also the fact that one often finds a certain 
 amount of pus present. In some cases one finds distinct sloughs 
 even on macroscopic examination of the stools. The presence 
 of pus in the bowel in any large quantity is, however, in favour 
 of a diagnosis of croupous enteritis rather than of simple ulcera- 
 tion. The value of the recognition of pus in attacks of ulceration 
 of the bowel is also very much lessened by the fact that the 
 higher up the ahmentary tract the ulcer is situated, the more 
 
232 INTESTINAL DISEASES 
 
 likely one is to find no pus present, as the greater part of it is 
 digested in its passage along the bowel. 
 
 In cases of ulceration, especially in carcinoma, occurring in 
 the lower part of the colon or rectum, it is not uncommon to 
 find equal quantities of pus, blood, and mucus. On the other 
 hand, as pointed out by Nothnagel, one obtains similar motions 
 containing pus, blood, and mucus in cases of dysentery. By 
 earlier observers, it was thought that follicular ulceration could 
 be diagnosed by the presence of mucus resembling frogs' spawn 
 in the stools, but it is now known that this frogs' spawn appear- 
 ance is due to altered vegetable matter, either starch or small 
 pieces of fruit, and not to mucus, and undoubtedly it is not 
 significant of follicular ulceration of the bowel. 
 
 The chemical examination of the fseces, in cases of ulceration 
 of the intestine, is, therefore, only of qualitative value, and 
 careful quantitative analyses are practically useless. 
 
CHAPTER XXIX 
 
 INTESTINAL CARCINOMA 
 
 In the lesser diseases of the bowel, more especially in catarrhs 
 and functional derangements, a careful examination of the 
 faeces, both chemical and microscopic, is essential in arriving 
 at a definite diagnosis. In carcinoma of the intestine, on the 
 other hand, whether it is the small or the large intestine or the 
 rectum which is involved, the symptoms and physical signs 
 are of much greater importance than the chemical or microscopic 
 examination of the faeces. It is, therefore, only necessary for 
 us to briefly describe what is found chemically and microscopi- 
 cally in such cases, recognising that it is far more important 
 to make a careful analysis of the patient's symptoms and 
 physical signs in the early stages of mahgnant disease of the 
 bowel. 
 
 In cases of carcinoma in the intestine, as in cases of carcinoma 
 elsewhere in the body, the fact of the blood-count showing an 
 increased quantity of leucocytes is undoubtedly of very great 
 importance in helping to make a correct diagnosis, and an 
 increased quantity of uric acid in the urine will also be of use. 
 
 The early stages of carcinoma, which are the most important 
 to recognise if one hopes for any success in treatment by surgical 
 interference, produce practically no alterations in the faeces. 
 If there is carcinoma of the bowel, causing some obstruction to 
 its lumen, one gets the symptoms of obstruction as a natural 
 sequence, but until the carcinoma itself has begun to ulcerate, 
 nothing pointing to the malignity of the growth can be detected 
 in the faeces. 
 
 The presence of blood and pus in the faeces should always lead 
 to suspicion of ulceration of some malignant growth of the bowel, 
 unless it is found that the patient is suffering from ulcerative 
 colitis or dysentery. 
 
 Constipation is a very frequent accompaniment of carcinoma 
 
234 INTESTINAL DISEASES 
 
 of the bowel. When the obstruction is situated in the rectum 
 or low down in the large intestine, the motions may be of peculiar 
 shape, either ribbon-like or pencil-shaped. One must remember, 
 however, that it is not unusual to find such motions in cases 
 where there is no real obstruction of the bowel ; in fact, these 
 narrow motions are as commonly found in cases of simple spasm 
 of the bowel as in cases of obstruction. Boas^ has shown that in 
 malignant disease of the bowel it is much more common to find 
 a liquid motion containing some of these pencil-like ejecta than to 
 have the latter alone. In some cases, the constipation is reUeved 
 by the occurrence of ulceration, and if, in such cases, the con- 
 stipation has been of long duration, one gets a series of very 
 copious motions, of a very offensive nature. In advanced cases 
 of carcinoma, where there is very considerable ulceration, it is 
 not at all uncommon for the faeces to have a distinctly cadaveric 
 odour, which is very characteristic of carcinoma of the bowel. 
 
 Diarrhoea alternating with constipation is one of the most 
 frequent symptoms in carcinoma of the bowel, though there are 
 apparently some cases where diarrhoea is more or less constant 
 without any constipation. We thus see that in intestinal 
 carcinoma either constipation or diarrhoea may be present. In 
 cases where the growth obstructs the lumen of the bowel, the 
 charcoal may take a very long time to appear in the faeces. 
 The colour of the stools is not at all distinctive ; the longer the 
 constipation, the greater the tendency towards dark stools. 
 As already mentioned, the odour of the stools is always very 
 offensive, and when ulceration of the growth takes place, there 
 is a tendency for the normal odour of phenol, indol, and skatol 
 to be masked by the cadaveric odour. 
 
 The examination of the mucus in the faeces will often show 
 that there is some catarrh of the bowel present. In most cases, 
 the watery extract of the faeces gives an albumen reaction. 
 
 The presence of blood in the stools is of great importance 
 in diagnosing malignant disease of the bowel. It may sometimes 
 be recognised in the comparatively early stages, and it seems 
 that blood which appears in the faeces before there is definite 
 evidence of ulceration of the growth is due to oozing from the 
 malignant growth itself. As a rule, the blood is small in quantity, 
 and in cases where it is derived from oozing, it may be very 
 
 DiiKjnoKtil: h. Thrapic dcr Darwkr<inlchcitcn., T.cipzig, ISOS, vol. i. p. OG. 
 
INTESTINAL CARCINOMA 235 
 
 intermittent. Where this is observed, it must be considered 
 of great importance, as indicating the possibiUty of early- 
 malignant disease. The presence of bile in the motions of 
 patients suffering from carcinoma of the bowel is of little signifi- 
 cance except in those cases where the growth is so situated that 
 it obstructs the common bile duct. In most cases of intestinal 
 carcinoma, it will be found that the urobilin tends to be increased^ 
 The microscopic appearances in cases of carcinomatous 
 disease of the bowel are only of importance in the later stages, 
 where one has ulceration of the malignant growth. In some 
 cases, as already stated, blood is found even before ulceration 
 has taken place ; on the other hand, pus is not present until after 
 the ulceration has occurred, so that the presence in small quanti- 
 ties of both blood and pus is of very great importance in making 
 a diagnosis of malignant disease of the bowel. In rare cases, 
 where the growth has ulcerated extensively, one may find 
 particles of the growth in the motions. 
 
 Chemical analyses on different diets appear to be of little 
 use in carcinoma of the bowel. In the few cases where we have 
 been able to carry them out, the results have varied very con- 
 siderably. One interesting case, however, came before our 
 notice. A barrister, aged forty-eight, had weighed 12 stone 
 two years previous to coming under our observation, when he 
 was found to weigh only 9| stone. A year previously, he had 
 suffered from periodical attacks of vomiting at night, and 
 an exploratory laparotomy was made. The caecum showed 
 markedly increased peristalsis, and a malignant tumour was 
 found obstructing the hepatic flexure of the colon. The 
 growth was so closely adherent to the omentum, intestines, and 
 surrounding organs, that it was impossible to remove it ; 
 communication was, therefore, made between the ascending 
 and transverse colon, and the patient made a good recovery 
 from the operation. The tumour, however, steadily grew, 
 though the patient gained strength and weight for two months : 
 after which he began to lose weight, and a hard lump, the size of 
 an orange, was felt in the region of the caecum. The liver was 
 enlarged to of in. in the nipple line, and the growth in the caecal 
 region extended up to the liver. 
 
 The patient was put on a milk diet, and an analysis carried out 
 during a period of four days. The first charcoal appeared in 
 
23G 
 
 INTESTINAL DISEASES 
 
 2J: hours, the second taking 48 hours to appear in the faeces. 
 The quaHtative analysis of the urine showed a uric acid ring 
 with cold nitric acid, and the microscof>e revealed numerous 
 uric acid crystals and urates in the sediment. 
 
 TABLE LIX.— DISEASE— INTESTINAL CARCINOMA 
 
 Diet : Milk containing 1-4 -84 grams nitrogen, 87-36 grams fat, 94-( 
 carbohydrates, 1578'44 Calories, 2240 c.c. fluid 
 
 Date, May 1905 . 
 
 20 
 
 21 
 
 22 
 
 23 
 
 Average. ! 
 
 1 
 
 Weight in kilos 
 
 60-98 
 
 60-53 
 
 60-08 
 
 60-08 
 
 60-42 
 
 Calories per kilo . 
 
 25-00 
 
 26-07 
 
 26-27 
 
 26-27 
 
 26-13 1 
 
 Urii 
 
 le: Quan 
 
 litative A 
 
 lalysis 
 
 
 
 Quantity 
 
 2070 
 
 1850 
 
 1620 
 
 1600 
 
 1785 
 
 Specific gravity 
 
 1013 
 
 1011 
 
 1012 
 
 1013 
 
 1012 
 
 Nitrogen 
 
 15-U 
 
 14-06 
 
 14 90 
 
 16-00 
 
 15-02 
 
 Urea .... 
 
 27-53 
 
 24-05 
 
 27-70 
 
 26-40 
 
 26-05 
 
 Uric acid 
 
 012 
 
 0-17 
 
 0-26 
 
 0-19 
 
 0-18 
 
 Ammonia 
 
 0-31 
 
 0-17 
 
 0-26 
 
 0-21 
 
 0-24 
 
 Phosphates (Pp^). 
 
 2-H) 
 
 2-15 
 
 3-40 
 
 2-40 
 
 2-54 , 
 
 Chlorides . ' . 
 
 9-:53 
 
 6-85 
 
 6-64 
 
 5-92 
 
 7-18 1 
 
 o ( Total . 
 
 2-48 
 
 2-37 
 
 2-63 
 
 2-80 
 
 2-57 , 
 
 J 1 Alkaline (A) . 
 
 2-li 
 
 2-17 
 
 2-34 
 
 2-50 
 
 2-28 1 
 
 "^''i Aromatic (B) . 
 
 0-37 
 
 20 
 
 0-29 
 
 0-30 
 
 0-29 
 
 j5 [ Ratio A : B . 
 
 5-7 : I 
 
 10-9 : 1 
 
 8-1 : 1 
 
 8-3 : 1 
 
 8-1: 1 
 
 Fa'ce 
 
 .- Quant 
 
 'talive Ai 
 
 nhjsis 
 
 
 
 Date, May 1903 . 
 
 21 
 
 22 
 
 23 
 
 24 
 
 Average 
 
 No. of motions 
 
 1 
 
 1 
 
 1 
 
 1 
 
 4 days. 
 
 Quantity 
 
 90 
 
 105 
 
 97 
 
 75 
 
 92 
 
 Water p3r cent. 
 
 71-97 
 
 76-61 
 
 76 61 
 
 74-25 
 
 74-86 
 
 Nitrogen 
 
 0-98 
 
 0-96 
 
 0-88 
 
 0-75 
 
 0-89 1 
 
 Fat .... 
 
 G-48 
 
 6-30 
 
 6-00 
 
 4-96 
 
 5-94 
 
 Absorbed nitrogen p.c. . 
 
 — 
 
 — 
 
 — 
 
 — 
 
 94-00 
 
 ,, fat per cent. 
 
 - 
 
 — 
 
 — 
 
 — 
 
 93-20 j 
 
 The quantitative analysis of the urine (Table LIX.) showed 
 that the patient was eliminating more nitrogen in the urine than 
 he was receiving in the diet, and during the period of analysis 
 he gradually lost weight, in spite of taking 26-13 Calories per kilo. 
 The uric acid, alhough it was precipitated by cold nitric acid, was 
 shown to be small in amount, the average being 0-18 grams per 
 diem. (In another period on milk, the daily average was 039 
 grams, and on a mixed diet 0-85 grams.) The aromatic sulphates 
 are seen, however, to be increased in quantity. 
 
INTESTINAL CARCINOMA 237 
 
 The examination of the fa3ces showed the stools to be only 
 partly formed, and on some occasions, a few scybala were 
 mixed up in the unformed paste. On two occasions, the motions 
 contained some blood, and blood-stained mucus was recog- 
 nised macroscopically. The microscopic examination showed, 
 together with debris, some blood corpuscles and numerous 
 leucocytes. The mucus was found to contain both epithelial 
 cells and leucocytes. 
 
 The chemical analysis of the fcieces showed an increased 
 quantity of mucus, together with albumen, and as already 
 stated, blood was present in two out of the four motions 
 analysed. The urobilin was markedly increased. During the 
 period of observation, the patient passed a motion each day, 
 the quantity varying from 75 to 105 grams, the average 
 being 92 grams per diem. In spite of the motions being of a 
 very soft consistency, we see that the water in the faeces only 
 amounted to 74"86 per cent., the softness of the faeces being 
 evidently due to the increase of mucus and fat. The stools 
 contained an average of 0'89 grams of nitrogen per diem, and no 
 less than 5-94: grams of fat. We thus see that there was only a 
 slight diminution in the absorption of proteid, 94"00 per cent., 
 of which the probable explanation is that the quantity of mucus 
 increased the proteid in the stools. The fat showed a very 
 marked diminution, being only 93"20 per cent. 
 
 A three days' analysis on a mixed diet was also carried out. 
 when the same low absorption of fat was observed, being 93-08 
 per cent., the proteid absorption being not quite so good as 
 on the milk diet, the average on this occasion being only 92 '89 
 per cent. 
 
 In another case of early malignant disease of the bowel, in 
 which a growth in the upper part of the rectum (not large enough 
 to encroach on the lumen of the bowel), was later found at the 
 autopsy, an analysis on a mixed diet with the addition of milk 
 was carried out. 
 
 In this case there was no distinct increase in the quantity 
 of uric acid present in the urine, but the aromatic sulphates 
 were increased. The first charcoal appeared in 26} hours 
 and the second 521 hours after its administration by the mouth. 
 The stools consisted of unformed faeces of a greenish black 
 colour, the chemical examination showing excess of mucus 
 
238 
 
 INTESTINAL DISEASES 
 
 together with albumen, but no blood or bile ; urobilin was 
 present in excess. The green colour of the motions was found 
 to be due to chlorophyll. 
 
 TABLE LX.— DISEASE— INTESTINAL CARCINOMA 
 
 Diet : ^lixed + milk, containing 15--18 grams nitrogen, 67'C9 grams fat, 
 123-04 grams carbohydrates, 1.535-66 Calories, 1900 c.c. fluid 
 
 Date, July 1901 
 
 Weight in kilos 
 Calories per kilo . 
 
 Quantity 
 Specific gravity 
 Nitrogen 
 Urea . 
 Uric acid 
 Ammonia 
 Phosphates (F.,0^) 
 Chlorides 
 g / Total . 
 J I Alkaline (A) 
 ^ j Aromatic (B) 
 ^ [ Ratio A : B 
 
 5S-27 58-50 59-13 58-81 58-68 
 26-37 26-27 25-99 2613 1619 
 
 Average. 
 
 Urine : Quantit:dive Analysis 
 
 1200 
 
 1650 
 
 1820 
 
 1650 
 
 1018 
 
 1011 
 
 1013 
 
 1012 
 
 15-12 
 
 12-24 
 
 14-41 
 
 12-87 
 
 27-63 
 
 21-2< 
 
 26-93 
 
 22-26 
 
 0-57 
 
 0-58 
 
 0-65 
 
 0-58 
 
 221 
 
 1-81 
 
 2-36 
 
 2-06 
 
 4-92 
 
 4-95 
 
 6 13 
 
 5-26 
 
 1 2-70 
 
 2-57 
 
 2-91 
 
 2-51 
 
 1 2-44 
 
 2-33 
 
 2-63 
 
 2-24 
 
 ' 0-26 
 
 0-24 
 
 0-28 
 
 0-27 
 
 , 9-4:1 
 
 9-6: 1 
 
 9-4: 1 
 
 9-4: 1 
 
 FcECcs : Quanfifafive Analysis 
 
 Date, July 19)1 
 No. of motions 
 Quantity . 
 Water per cent. 
 Nitrogen . 
 Fat '. 
 Absorbed nitrogen p.c, 
 ,, fat per cent. 
 
 15 
 
 16 
 
 17 
 
 18 
 
 19 
 
 2 
 
 1 
 
 4 
 
 3 
 
 4 
 
 96 
 
 108 
 
 141 
 
 81 
 
 94 
 
 74-76 
 
 69-93 
 
 74-16 
 
 77-83 
 
 74-72 
 
 1 -09 
 
 1-45 
 
 1-63 
 
 0-80 
 
 1-06 
 
 3-93 
 
 5-26 
 
 5-90 
 
 2-91 
 
 3-85 
 
 1580 
 1013 
 13-66 
 24-76 
 0-59 
 
 2-11 
 5-31 
 2-67 
 2-41 
 0-26 
 9-4: 1 
 
 Average 
 
 4 days. 
 
 129 
 
 74-28 
 
 1-51 
 
 5-46 
 
 90-25 
 
 91-93 
 
 During the time of observation (Table LX.) it is seen that 
 the patient passed from 1 to 4 motions per diem ; the stools 
 were very small in amount, varying from 14 to 65 grams, except 
 on one occasion, when there was one motion of 108 grams. 
 The daily total quantity of faeces averaged 129 grams, and in spite 
 of their pultaceous appearance, only 74-28 per cent, of water was 
 found to be present. The nitrogen in the stools averaged 
 rSl grams daily, and the fat 5'46 grams. The absorption of 
 proteid in this case was 9025 per cent., a marked diminution, 
 and the absorption of fat was 91-93 per cent., also a great 
 
INTESTINAL CARCINOMA 239 
 
 diminution. At the autopsy, a malignant growth wliich was 
 not large enough to cause any occlusion of the bowel, was 
 found just below the junction of the sigmoid flexurj and the 
 rectum. A very shght amount of force tore the bowel com- 
 pletely through the infiltrated area. The patient had frequently 
 complained of straining with motions, but rectal examination 
 during hfe had revealed nothing to account for it. During 
 the time of analysis, no blood was found in the motions. The 
 history of this case was difficult to obtain, as unfortunately 
 the patient suffered from considerable mental derangement. 
 
 We have given these two analyses of carcinoma of the bowel, 
 though they show nothing very definite except that in each 
 case the absorption of both nitrogen and fat, especially the 
 latter, was diminished. It remains to be seen whether from a 
 larger number of quantitative analyses of the faeces one may 
 be able to draw any definite conclusions. 
 
CHAPTER XXX 
 
 SPRUE (PSILOSIS) 
 
 The fgeces in sprue are sufficiently distinctive to require a 
 separate description. The chronic form of the disease is 
 occasionally met with in this country, and the acute form seems 
 to differ from the chronic chiefly in degree. 
 
 Illustrating the condition found we will now give a 
 description of a case of sprue which came under our notice. 
 A lady, aged forty-seven, who had hved for some years 
 in the tropics, was suffering from an attack of sprue accom- 
 panied by sickness, diarrhoea, and tenderness of the abdomen. 
 The ordinary symptoms of sprue — marked anaemia with a 
 waxy appearance, considerable wasting and raw tongue — 
 were present. The motions varied in number from 1 to 8 per 
 diem, the average being two or three motions daily. The 
 patient was extremely emaciated, weighing only 5 stone 9 
 pounds when she came under observation, and she was put 
 on a pure milk diet. During the period of analysis, the quahta- 
 tive analysis of the urine showed a marked increase of indican 
 with some increase of urobilin, otherwise nothing abnormal 
 was noted. During a period of three days the motions were 
 collected and analysed. 
 
 The quantitative analysis of the urin (Table LXI.) was 
 only carried out on the first two days of the period, owing to an 
 accident. The quantity of nitrogen taken in the food was 12'99 
 grams, and it is seen in the table that the average quantity 
 excreted in the urine was only 8-93 grams. At the same time, 
 when we take into consideration the relatively large quantity 
 found in the fseces, there was a very fair proportion excreted 
 in the urine. There was also only a slight relative increase 
 in the aromatic sulphates. 
 
 On turning to the examination of the faces, it was found 
 that the first charcoal appeared 24 hours after its adminstra- 
 
SPRUE (PSILOSIS) 
 
 241 
 
 tion. During the first day only two motions were passed, one 
 comparatively large, and the other small. On the second 
 day, no less than five motions were passed, and on the third, 
 only one. The second charcoal, given on the fourth morning, 
 appeared in 5 liours and 35 minutes. 
 
 TABLE LXI.— DISEASE— SPRUE (PSILOSIS) 
 
 Diet : Milk, containing I2-!)!) grams nitrogen, 7fi"44 grams fat, 82"32 grams 
 carbohydrates, 1381-14 Calories, 1900 e.e. Huid 
 
 Date, June 1904 . 
 
 20 
 
 27 
 
 28 
 
 Average. 
 
 Weight in kilos 
 
 30-93 
 
 30-90 
 
 36-73 
 
 30-87 
 
 Calories per kilo . 
 
 37-40 
 
 37-37 
 
 37-60 
 
 37-46 
 
 Urine 
 
 Qunntilalt 
 
 (■" Analysis 
 
 
 
 Quantity 
 
 1 100 
 
 1000 
 
 
 
 10.50 
 
 Specific gravity 
 
 1010 
 
 1013 
 
 — 
 
 1012 
 
 Nitrogen 
 
 8-37 
 
 9-49 
 
 — 
 
 8-93 
 
 Urea .... 
 
 16-80 
 
 
 — 
 
 10-80 
 
 Uric acid. . 
 
 0-07 
 
 0-08 
 
 — 
 
 0-08 
 
 Ammonia 
 
 0-30 
 
 0-47 
 
 
 
 0-44 
 
 Phosphates (P.,0.) . 
 
 1-20 
 
 1-34 
 
 
 
 1-27 
 
 Chlorides 
 
 4-07 
 
 3-70 
 
 
 
 3-89 
 
 o rTotal . 
 1 1 Alkaline 
 
 1-32 
 
 1-01 
 
 _ 
 
 1-47 
 
 1-21 
 
 1-48 
 
 — 
 
 1-35 
 
 3 'j Aromatic 
 
 ^ iRatio A : B . 
 
 0-11 
 
 0-13 
 
 
 
 0-12 
 
 11-0: 1 
 
 11-4: 1 
 
 - 
 
 11-3: 1 
 
 Date, June 1904 . 
 
 27 
 
 2S 
 
 29 
 
 Average 
 
 No. of motions 
 
 2 
 
 .1 
 
 1 
 
 3 days 
 
 Quantity 
 
 208 
 
 337 
 
 120 
 
 255 
 
 Water per cent. 
 
 79-94 
 
 80-20 
 
 77-08 
 
 79-46 
 
 Nitrogen 
 
 1-28 
 
 2-02 
 
 0-.-)2 
 
 1-47 
 
 Fat .... 
 
 31-28 
 
 03-83 
 
 12-74 
 
 35-92 
 
 Absorbed nitrogen p.e. . 
 
 — 
 
 — 
 
 — 
 
 88-68 
 
 „ fat per cent. 
 
 
 — 
 
 — 
 
 53-01 
 
 The motions, as a rule, consisted principally of paste with 
 some thin badly formed rolls of a very soft consistency. The 
 colour when not stained with charcoal was greyish-green, some- 
 times tending to be greyish- white. The odour throughout 
 was most offensive. 
 
 The chemical analysis showed an increased quantity of mucus 
 and some albumen, but no bile or blood pigments could be 
 recognised in any of the motions. In spite of the faeces being 
 so colourless, there was a distinct urobiHn reaction. 
 
242 INTESTINAL DISEASES 
 
 It is difficult to make any definite statements as to the 
 chemical condition generally found in sprue, but the description 
 here given may be taken as an example of what one may 
 expect to find on macroscopical examination. The chemical 
 examination has been very much neglected, and from the 
 reports which one finds on the subject, the results of various 
 observers differ considerably. The subject is one well worthy 
 of further attention. 
 
 The microscopical examination in this case showed nothing 
 abnormal, except a possible increase of epithelial cells. 
 
 The quantitative analysis of the faeces is of interest. The 
 quantity of the separate motions fluctuated, the smallest being 
 only 31 grams, while the largest was 174 grams, the daily 
 quantity varpng from 120 grams to 337 grams, yielding an 
 average of 255 grams. In spite of the apparent hquid con- 
 sistency of the motions, it was found that there was no great 
 increase of water, the average being 79-46 per cent. The 
 quantity of nitrogen daily excreted varied considerably accord- 
 ing to the number of motions, the average being 1-47 grams, 
 showing a distinct tendency to increase. The fat is still more 
 remarkable, since the quantity found in the stools varied from 
 12'74 to 63*83 grams in the twenty-four hours — the average 
 quantity for the three days being no less than 35-92 grams. 
 It is seen, therefore, that there was a distinct tendency to an 
 increased quantity of nitrogen in the fseces, the absorption 
 being only 88-68 per cent., while the fat absorption was still 
 more hindered, being only 53-01 per cent. This marked 
 diminution in absorption partly explains why the patient did 
 not gain weight in spite of taking a diet containing no less than 
 37-46 Calories per kilo. In the subsequent eight weeks, during 
 which the motions became less frequent, and altogether more 
 normal in appearance, the gain in weight was only 1| pounds. 
 
CHAPTER XXXI 
 
 INTESTINAL CONCRETIONS, GALL-STONES, PANCREATIC CALCULI. 
 ENTEROLITHS, AND INTESTINAL SAND 
 
 INTESTINAL CONCRETIONS 
 
 Amongst the concretions found in the faeces, one has tn 
 include gall-stones as well as pancreatic calculi. In the 
 examination of calculi, the qualitative analysis seems to be 
 the more important, and the quantitative analysis is, up to 
 the present, of pathological interest only. The first step in 
 the analysis of intestinpJ concretions is to see how far they 
 consist of organic matter, and for this purpose a small portion 
 of the substance is placed on a platinum spatula and burnt. 
 It is stated that pancreatic calculi on heating yield a peculiar 
 aromatic odour. 
 
 GALL-STONES 
 
 For the examination of a gall-stone, it is first necessary to 
 reduce it to a powder, and then extract all that is soluble by 
 the aid of boiling water. The residue is further extracted 
 with equal volumes of alcohol and ether. If carbonate of 
 lime is present, the residue will give off bubbles of gas on 
 the addition of hydrochloric acid. 
 
 A chloroform extract is made of the residue which, on 
 evaporation of the chloroform, can be tested for bile pig- 
 ments by the addition of cold nitric acid ; if l:)ile pigments are 
 present, one obtains a play of colours. 
 
 The easiest method of recognising the presence of urobilin 
 is by the examination of the watery extract by the aid of 
 the spectroscope. 
 
 Cholesterin can be easily recognised by evaporating the 
 alcoholic ether extract, care being taken that the evaporation 
 is not too rapid ; otherwise, the cholesterin is apt to crystal- 
 lise out in needles, and not in the distinctive crystalline form 
 
244 INTESTINAL DISEASES 
 
 so easily recognised by the microscope. The crystals of 
 cholesterin thus obtained, if not recognised microscopically, 
 can be chemically tested. 
 
 Cholesterin Tests. Salkowski. — A chloroform solution 
 of cholesterin treated with an equal volume of sulphuric acid 
 becomes bluish-red, gradually turning to violet red. 
 
 Liehermann — Burchard. — A chloroform solution of cholesterin 
 with ten drops of acetic anhydride and sulphuric acid added 
 drop by drop gives a red, then blue, and finally a green colour ; 
 if very httle cholesterin is present, the green colour may appear 
 at once. 
 
 The analysis of the various inorganic substances is of httle 
 importance, but if desired, it can be easily carried out by refer- 
 ring to any qualitative chemical book. 
 
 Gall-stones can be roughly divided into three groups : 
 
 (1) Pure cholesterin calculi of a more or less white or 
 yellowish colour, with a smooth or waxy surface ; on fracture, 
 they are seen to consist of radiating or concentric layers of crystals. 
 
 (2) Cholesterin pigment calculi, often showing facets, coloured 
 brown or greenish, on analysis found to be composed partly 
 of cholesterin, and partly of calcium bilirubin. 
 
 (3) Bile pigment calculi, which are, as a rule, smaller than 
 the other calcuh, and of a more or less dark colour. They will 
 be found to contain very little cholesterin, and consist princi- 
 pally of bilirubin hme, though, in some cases, one finds biliverdin, 
 bilifucsin, or bihcyanide. Iron and copper seem to be regular 
 constituents of these calculi. 
 
 PANCREATIC CALCULI 
 
 Pancreatic calcuh are, as a rule, very small, about the size 
 of a Unseed seed, of a greyish- white colour with a rough surface, 
 in some cases faceted and of a mortar-hke consistency. 
 Chemically, they are found to consist principally of carbonate 
 and phosphate of lime, together with a certain amount of organic 
 matter, albumen, fat acids, neutral fat, soaps, and pigments. 
 
 ENTEROLITHS 
 
 Intestinal calcuh are fairly common in herbivora, but rare in 
 man and carnivora. In man, they are generally oval or round 
 
INTESTINAL CONCRETIONS 24r, 
 
 and when more than one is present, sometimes faceted. The 
 colour is yellowish or brownish-grey, and on section, they are 
 found to consist of concentric layers mainly comjiosed oE 
 ammonium magnesium phos])hate or calcium phosphate. On 
 extraction with ether and alcohol, one finds varying amounts 
 of fat and pigment present ; in contra-distinction to gall-stones, 
 the pigment is found to be principally urobilin, although some- 
 times bile pigments themselves may be present. The nucleus 
 is generally found to be some foreign matter, especially fruit 
 stones, fish-bones, and even shreds of vegetable fibre. These 
 concretions are usually formed in the large intestine, more 
 especially in the csecum or sacculi of the colon, occasionally in 
 the rectum, and rarely, if ever, in the small intestine. 
 
 Another variety of intestinal concretion, which is very common 
 in countries where oat-bran is a principal article of diet, resembles 
 the hair-balls of herbivora. These calculi consist of the remains 
 of oat-bran arranged in concentric layers around some foreign 
 body as a nucleus. They are extremely light, and largely 
 composed of organic matter as will be seen on calcining them. 
 They may contain some calcium magnesium phosphate, together 
 with small quantities of soaps and fats. Hammarsten^ gives 
 as their composition : 
 
 Calcium magnesium phospliate . . . 7(1 per cent. 
 
 Oat-bran ....... 15-18 per cent. 
 
 Soaps and fat . . . . . .10 per cent. 
 
 DRUG CALCULI 
 
 The habitual use of certain drugs is not uncommonly followed 
 by the formation of calculi, wliich are found in the motions. 
 The most common of these are undoubtedly those found after 
 taking Salol tabloids (Marshall and Treves). Benzoic acid 
 or shellac sometimes cause calculi, and the habitual use of water 
 containing carbonate of lime may produce small calculi. 
 
 INTESTINAL SAND 
 
 The presence of substances resembling sand in the faces is 
 not at all uncommon, these particles being, in some cases, the 
 seeds of fruits (such as figs, gooseberries, strawberries), not to 
 1 Lehrbiich d. Physiologie Chemic. 
 
24G INTESTINAL DISEASES 
 
 take into account larger substances (such as orange-pips, &c.), 
 in fact, all kinds of foreign matter ; and in nervous patients who 
 are fond of examining their motions, the discoveries of peculiar 
 diseases are numerous. Such cases, however, are easily recog- 
 nised as spurious, and it is hardly worth while to call them 
 instances of false intestinal sand. 
 
 A bona-fide case of false intestinal sand has, however, been 
 brought before the British public by Garrod,^ a case due especially 
 to the sclerenchymatous particles of pears which became en- 
 crusted with earthy salts. These inorganic salts are easily 
 dissolved in acid, and then, under the microscope, they are seen 
 to be composed of " woody cells, the thick transparent walls 
 of which are traversed by channels running from the narrow 
 cell cavities towards the surface." 
 
 Black, sand-like material in the motions is described by 
 American observers as occurring in people who have eaten 
 bananas. 
 
 True Intestinal Sand. — True intestinal sand is not at all 
 uncommon, if looked for in the motions. It occurs mostly 
 in patients who have mucus colitis, although it has been described 
 m neurotic individuals, unaccompanied by mucus colitis. It 
 generally occurs in women, but we have seen it in both men and 
 women, and one man came "under our observation who had no 
 bowel trouble whatever, but suffered from chronic gastric ulcer, 
 and was in the habit of passing intestinal sand when on a milk 
 diet. It appears to be much more common in individuals who 
 are taking a milk diet, and, as far as our experience goes, we 
 have never found true intestinal sand in any case where the 
 patient has not been taking a diet large'ly composed of milk. 
 
 The sand varies in colour from greyish to yellowish brown, 
 and when washed free of debris, is gritty, and to the touch 
 resembles sea sand. Chemically, it is found to contain a large 
 quantity of calcium and phosphorus, together with traces of 
 magnesium and iron. It is insoluble in potassium hydrate 
 solution, and soluble in strong nitric acid with the liberation 
 of bubbles of gas. The organic matrix left behind is soluble in 
 alkalies. 
 
 Garrod found in one case of his that the sand contained, in 
 
 ' Duckworth and (Jarrod, '" Stucly of Intestinal Sand."' — Med. Cliir. Trans., 
 vol. Ix.Kxiv. 1). 389, I'JOl. 
 
INTESTINAL CONCRETIONS 
 
 addition to urobilin (which is always present), a purple pigment 
 giving a spectrum not resembling any of the now-known ])ig- 
 ments. It would appear that true intestinal sand is probably 
 formed in the region of the csecum, and some observers consider 
 that it is an excretion from the intestinal mucous membrane. 
 On the other hand, it is quite possible that it is simply the 
 inorganic calcium salts in the milk crystallising under certain 
 pathological conditions. Its importance, except as a curiosity, 
 is very small, as although one gets in some cases colicky pains 
 preceding the passage of the sand, it seems not at all unusual 
 for the patient to have no symptoms whatever during the time 
 that the sand is passed. 
 
 Chemical analyses, in the cases of some observers,^ give the 
 following results : 
 
 (1) 
 
 Duckworth and Gar rod : 
 
 
 
 
 Water 
 
 
 . 12-40 
 
 
 Organic material 
 
 
 . 2t)()f) 
 
 
 Inorganic material 
 
 
 . 61-31 
 
 
 Calcium oxide 
 
 
 54-98 
 
 
 Phosphorus pentoxide . 
 
 
 . 42 -.T. 
 
 
 Carbon dioxide . 
 
 
 2-21) 
 
 
 Residue, containing traces of 
 
 magnesium and iron . 0-47 
 
 (2) 
 
 Matliieu and Richaud : 
 
 
 
 
 
 Case 1 
 
 Case 2 
 
 
 Organic material 
 
 . 30-800 . 
 
 . 4.5-80 
 
 
 Tricalcic phosphate 
 
 (;4-20(i 
 
 40-68 
 
 
 Calcic carbonate . 
 
 . :v4is . 
 
 514 
 
 
 \'arious mineral substances 
 
 1 •.•)7() . 
 
 2-38 
 
 {■>) 
 
 Thomson and Ferguson : 
 
 
 
 
 Organic matter . 
 
 
 . 28-5 
 
 
 Inorganic matter 
 
 
 . 71-5 
 
 
 Calcic carbonate . 
 
 
 . 11-7 
 
 
 Tricalcic phosphate 
 
 
 . 87-3 
 
 
 Insoluble residue (silica) 
 
 
 1.0 
 
 (4) 
 
 Berlioz : 
 
 
 
 
 Water 
 
 . 
 
 . 1 1 -25 
 
 
 Nitrogenous organic materia 
 
 of fa?cal origin . 
 
 . 22-24 
 
 
 Fatty substances 
 
 
 . Traces 
 
 
 Phosphoric acid . 
 
 
 . 17-56 
 
 
 Lime .... 
 
 
 . 26-22 
 
 
 Magnesia 
 
 
 14 05 
 
 
 Silica 
 
 
 . 8-68 
 
 1 Duckworth and Garrod, loc. cit. 
 
248 INTESTINAL DISEASES 
 
 (5) Marquez : 
 
 Organic matter of animal origin . .. . .72 
 
 Inorganic matter, consisting of caleimu phosphate 
 
 and traces of carbonate . . . . .28 
 
 (6) Biaggi: 
 
 Organic material (by difference water, iron) . . 29'2S 
 
 Magnesium phosphate . . . . . .26-82 
 
 Calcium carbonate ...... 43'90 
 
 Two specimens of sand were examined in our laboratory 
 by Dr. 0. T. Williams. The material was practically insoluble 
 in water, and on heating a small quantity with Millon's reagent, 
 a red colour was seen, and a positive result obtained with the 
 Xantho-Proteic and Biuret reactions. 
 
 The organic material contained 10 per cent, of substance 
 soluble in ether. This ethereal extract contained : 
 
 22-5 per cent, as free fatty acids. 
 
 13 '4 ., combined fatty acids. 
 
 After extraction with ether, the remaining sand was acidified 
 and again extracted with ether, and yielded 8 per cent, of fatty 
 acids combined with soaps. The chemical analysis yielded : 
 
 Combustible material (organic). 
 Incombustible material . 
 
 The inorganic residue contained 
 
 Calcium present as Ca.jP.^O^ 
 Calcium not present as Ca-.P^Og 
 Iron calculated as Fe.jO.. 
 Magnesium calculated as MgoO 
 Phosphates calculated as PoO-, 
 Carbonates 
 Sulphates 
 Chlorides 
 
 A specimen of both samples 
 pinky- white flame. 
 
 An investigation was made (and is still continuing), to find 
 the nature of the material from its organic point of view. 
 
 In Specimen II. 10 per cent, of the material was soluble in 
 ether. Of this ethereal extract, 22-5 per cent, was present as 
 free fatty acid, and 13'4 per cent, as combined fatty acid. The 
 remaining portion of this first ethereal extract (/.c.,unsaponifiable) 
 gave an iodine absorption value (Hube's method) of 117 per cent., 
 which is higher than that of Oleic acid, and lower than that 
 of Linoleic acid — so that it is possible that this portion 
 
 . .55-6 
 
 per 
 
 cent. 
 
 . 44-t 
 
 1 . 
 
 
 " 
 
 15 5 
 
 per 
 
 cent. 
 
 14-34 
 
 
 
 2-96 
 
 
 ., 
 
 0-07 
 
 
 „ 
 
 10-5 
 
 
 
 1-5 
 
 
 ., 
 
 0-6 
 
 
 ., 
 
 Trace 
 
 
 
 3n combustion 
 
 burnt with 
 
INTESTINAL CONCRETIONS 211) 
 
 (unsaponifiable matter) consists of a mixture of these two acids 
 or their salts. (This is being further investigated in a specimen 
 found since going to Press.) 
 
 After the above extraction with ether, the remaining sand 
 was acidified and again extracted with ether, which yieUled 
 8 per cent, of the sand, showing the presence of cS per cent, of 
 soaps insohible in ether. (These are still under investigation 
 and will probably turn out to be stearic acid, &c.) 
 
APPENDIX 
 
 The (luantities of the different constituents of the diets used 
 for diagnostic purposes have been given in the text. In practice 
 it is found necessary to vary the quantities of the different 
 ingredients to suit individual patients, and for the sake of 
 convenience in calculation, we have found it useful to have 
 tables giving the quantities of nitrogen, fat, carbohydrates, and 
 calories in given quantities of the different articles of diet. 
 
 When first carrying out experiments in metabolism, separate 
 analyses of the diets employed in each case were made, but 
 after an experience of a large number of different analyses, we 
 find it now sufficient to take periodical samples, and compare 
 them with the results we obtained in our early experiments. 
 In this way we have accumulated a large number of separate 
 analyses, and find that, dealing constantly with the same 
 tradespeople, the discrepancies in the results found are well 
 within the limits of experimental error. In the case of foods 
 which we rarely use, we have given the results obtained by 
 Konig. The analytical figures of London milk are those of 
 Professor Kenwood, and are based on the average of several 
 thousand cases, and the figures correspond with what we have 
 found in some seventy analyses during the last ten years. The 
 figures quoted of other articles of diet are those which we have 
 ourselves obtained in a series of analyses, and with the data given 
 in the subjoined table, calculations as to the quantity of nitrogen, 
 fat, and carbohydrates, as well as calories, can be rapidly made. 
 This table is not only of use for the purposes of analysis, but 
 we have found it of great help when alterations in the diet are 
 necessary for the purposes of treatemnt ; by this means, the 
 desired number of calories can be easily introduced, and the 
 food altered as to its richness in proteid, fat, or carbohydrates. 
 
252 APPEN^DIX 
 
 the calories in the diet being kept the same, increased or de- 
 creased according to exigencies. 
 
 TABLE SHOWING THE QUANTITY OF NITROGEN FAT, CARBOHY- 
 DRATES, AND CALORIES IN DIFFERENT ARTICLES OF DIET 
 
 Diet. 
 
 Nitro- 
 
 o-Cll. 
 
 Fat. 
 
 Car- 
 hoby- 
 (Initcs. 
 
 Calorics. 
 
 AntlKir. 
 
 Plaice (cooked, I oz.) 
 
 0-93 
 
 014 
 
 
 
 2513 
 
 iHarley am 
 
 Whiting (cooked, 1 oz.) 
 
 
 0-78 
 
 0-52 
 
 
 
 24-81 
 
 J Goodbody 
 
 Sole (uncooked, 1 oz.) 
 
 
 0-73 
 
 0-43 
 
 
 
 22-96 
 
 Konig 
 
 Beef fillet (roast, 1 oz.) 
 
 
 1-16 
 
 0-.C.7 
 
 
 
 38-75 
 
 1 Harlev and 
 
 Beefsteak (raw. I oz.) 
 Mutton (roast, 1 oz.) 
 
 
 0-70 
 I 1-22 
 
 2-2« 
 3-67 
 
 
 
 
 39-14 
 65-14 
 
 - Goodbody 
 
 Chicken (roast, 1 oz.) 
 
 
 1-14 
 
 0-95 
 
 29 
 
 38-24 
 
 
 Egg (boiletl, one) . 
 
 
 1-20 
 
 6-80 
 
 
 
 93-99 
 
 J Konig 
 
 Egg (uncooked, one) 
 
 
 1-25 
 
 5-9.T 
 
 
 
 86-08 
 
 Cabbage (cooked, 1 oz.) 
 
 
 0-16 
 
 0-23 
 
 0-45 
 
 8-08 
 
 \ Harley and 
 1 Goodbody 
 
 Spinach (cooked, 1 oz.) 
 
 
 0-27 
 
 0-45 
 
 2-95 
 
 23-20 
 
 Potatoes (uncooked. 1 oz 
 
 •) 
 
 0-05 
 
 0-03 
 
 5-35 
 
 23-49 
 
 Kunig 
 
 Cauliflower (cooked, 1 oz 
 
 •) 
 
 0-22 
 
 0-20 
 
 2-00 
 
 18-16 
 
 Corlette 
 
 Rice (uncooked, 1 oz.) 
 
 
 0-32 
 
 0-20 
 
 21-73 
 
 99-15 
 
 ,- Kdnic 
 
 Oatmeal (uncooked, 1 oz 
 
 • ) 
 
 0-49 
 
 1-80 
 
 20-77 
 
 116-45 
 
 "'o 
 
 
 
 
 
 
 Harley and 
 
 Biscuit (Mackenzie's toast, one) 
 
 0-OG 
 
 006 
 
 3-00 
 
 14-40 
 
 (Joodbody 
 
 Milk(Ioz.) . . . . 
 
 0-17 
 
 105 
 
 1-33 
 
 19-52 
 
 Kenwood 
 
 Pudding (1 oz. rice, 20 oz. 
 
 
 
 
 
 
 milk) . . . . 
 
 3-68 
 
 21-20 
 
 48-33 
 
 489-61 
 
 
 Pudding (I oz. rice, 16 oz. 
 
 
 
 
 
 Harley and 
 
 milk) . . . . 
 
 3-04 
 
 17-00 
 
 43-00 
 
 411-06 
 
 Goodbody 
 
 Pudding (i-oz. rice, 12 oz. 
 
 
 
 
 
 
 milk) . . . . 
 
 2-20 
 
 12-70 
 
 26-83 
 
 283-82 
 
 
 Butter (1 oz.) 
 
 
 
 23-00 
 
 
 
 213-90 
 
 KiJnig 
 
 Barley water (1 oz.) 
 
 
 
 
 
 
 0-62 
 
 2-54 
 
 Corlette 
 
50 
 
 vV 
 
 ^ 
 
 i23aSG18 9 1 2 3 '4- S S 1 8 
 
 30 no 
 
 • 1 2 3 a B 6 7 S a 1 Z3 '7 S 
 
 J50 IGO 
 
-ffouis a/Ur AdinAi\x€traXiorv 
 
 CHART SHOWING HOURS AT WHICH CHARCOAL WAS PASSED. 
 
INDEX 
 
 AuscKS-<i.-. oastrir. 49 
 Aljsorption. .vt< Fat mid Nitrogen 
 Aci'tir Arid. 
 
 Formula for, 35 
 
 Gastric contents, in, 35, 45, 51 ; 
 test for, 35 
 Acid dyspepsia. 23 
 Acidit\' 'i| ■_:,l^l^ic content'^, .Mct Total 
 
 Ai idilv uikI \'olatile Acidity 
 Ai-iiyli.i -Msirica. 53-56 
 Aljc, intliiiiirc of, on quantity of 
 
 Albumen in f;et'es, 
 
 Pathological fffices, in, 170, 
 180, 187. li)3. 197. 205, 
 208. 215, 21G, 226, 237, 238, 
 241 
 Significance of, 139 
 Test for, 138 
 All)umenoses in fa?"es. 138-139 
 Alcoholic catarrh, 51-53 
 Alimentary canal, 
 
 Fat excreted by, 143-145 
 Nitrogen in stools from, 130 
 Alimentary tract, motor power of, 171- 
 
 175, 223, 225-22G, 229 
 American stomach tubes, 5 
 Ammonia, formation of, in faeces, 118, 
 
 119 
 Ammonium magnesium phosphate 
 crystals in faeces. 111, 113, 191, 
 209, 215, 221, 22(j 
 Ana'sthesia, gastric, 91-92 
 Analgesia, gastric, 92 
 Acrtic aneurism, 8 
 Aortic yalves, atheroma of, 227 
 Ai)])endicitis, mucus colitis following. 
 
 211 
 Aromatic sulphates in urine, in- 
 cicasiuii- ((uantity of, in certain 
 |,ath(«logic:d conditions, 194, 200, 
 201, 225, 23(5, 237, 240, 241 
 Artcrio-sclerosis, 8, 228 
 Aspiration, 8 
 
 Asylum dyseutery, 21(>-2i7 
 Atony of' stomach, odour of gastric 
 
 contents in, IG 
 Atr(>])liy. intc^tinal, 224 ct -seq. 
 
 Bactkria, 
 
 Faeces, of. 93, 104. 107 
 Intestinal, 129. 1(32 
 Bananas, in false intestinal sand, 24(i 
 Barratt, Dr. Wakclin, cited, -l-ll 
 Beef fillet, food value of, 252 
 Beefsteak (raw), food value of, 252 
 Beneke, cittd, 10 
 
 Benzoic acid, calculi formed by, 245 
 Berlioz, analysis of intestinal sand by. 
 
 247 
 Biaggi, analysis of intestinal sand by, 
 
 248 
 Biedert, c/^■(Z, 133 
 Bilirubin, 103, 104, 112, 113. 115, 1()5. 
 
 160. 170 
 Biliverdin, 103, 104, 115. 165, 17(>.203 
 Bile, 
 
 F;T3ces, in, 170-177,205. 215, 235 ; 
 Absence of, from normal 
 fieces, 103 
 Fat excreted in. 145 
 Gastric contents, in, 45, 03 
 lleduction in intestine,diminution 
 in, 112, 113 
 Bile acids in faces, 164-165, 209 
 Bile duct, obstruction of, stools in, 104, 
 
 119, 107 
 Bile ijigment calculi, 244 
 Bird, Golding, cited, 03 and note 
 Bismuth, colour of stools after, 105 
 Jilciuiorrhcea intestinalis. 210 
 Blood, 
 
 Fwces. in. 1()8-170. 17(i, 187. 188. 
 
 190-191, 205, 215, 216, 220, 224, 
 
 226, 227, 231. 232, 234-235, 237 
 
 (iastric contents, in, 45, 51, 56. 
 
 63 
 
 Blood corpu.scles in faices, 22(i, 237 
 
 Blootl count in case of constipation. 
 
 193; in intestinal carcinoma, 233 
 Boas, bulb stomach tube of, 7, 9 ; 
 test meal of, 12 and nole^; quan- 
 titative estimation of lactic acid, 
 32-33 ; cited, 42 and note, 65 and 
 nolei, 67, 105 and note 2, 234 
 Boas and Bouveret, cited, 39 and note 2, 
 44 and noic'^ ' 
 
INDEX 
 
 AHSfEssK-. tvastric, 4i) 
 Absorption, .sec Fat (tnd Nitrogen 
 Acetic Acid, 
 
 Forimila for, 35 
 
 Gastric contents, in, 35, 45, 51 ; 
 test for, 35 
 Ac'id dyspepsia, 23 
 Acidity of gastric content^, -sec Total 
 
 Acidity qnd Volatile Acidity 
 Acliylia gastrica. 53-50 
 Anc itillucnrc of, ou (luantity of 
 
 fjcLcs. !l!l-10l) 
 Albumen in fteees, 
 
 Pathological faeces, in, 17G, 
 180, 187, 193, 197, 205, 
 208. 215, 21(5, 220, 237, 238, 
 241 
 Significance of, 139 
 Test for, 138 
 Albunienoses in fapces. 138-139 
 Alcoholic cataiTh, 51-53 
 Alimentary canal. 
 
 Fat excreted by, 143-145 
 Nitrogen in stools from, 130 
 Alimeiitarv tract, motor powerof, 171- 
 
 I 75. 2i':'{, 225-220, 229 
 American stomach tubes, 5 
 Ammonia, formation of, in frcces, 118, 
 
 119 
 Ammonium magnesium phosphate 
 crystals in faeces. 111, 113, 191, 
 209, 215, 221, 220 
 Anesthesia, gastric, 91-92 
 Analgesia, gastric, 92 
 Aortic aneurism, 8 
 Aortic valves, atheroma of, 227 
 Appendicitis, mucus colitis following, 
 
 211 
 Aromatic sulphates in iirine, in- 
 creasing quantity of, in certain 
 pathological conditions, 194, 200, 
 201, 225, 230, 237, 240, 241 
 Arterio-sclerosis, 8, 228 
 Aspiration, 8 
 
 Asylum dysentery, 210-217 
 Atony of" stomach, odour of gastric 
 
 contents in, 10 
 Atrophy, intestinal, 224 et seq. 
 
 Bactj^ria, 
 
 Fffices, of, 93, 104, 107 
 Intestinal, 129, 102 
 Bananas, in false intestinal sand, 240 
 Barratt, Dr. Wakelin, cited, 227 
 Beef fillet, food value of. 252 
 Beofsteak (raw), food value of, 252 
 Beneke, cikd, 10 
 
 Benzoic acid, calculi formed by, 245 
 Berlioz, analysis of intestinal sand bj', 
 
 247 
 Biaggi, analysis of intestinal sand by, 
 
 248 
 Biedert, cit-d, 133 
 Bilirubin, 103, 104, 112. 113. 115, Ki.".. 
 
 100, 170 
 Bihverdin, 103, 104, 115, 10.5, 170.203 
 Bile, 
 
 FiBces, in, 170-177, 20.5. 215, 235 ; 
 Absence of, from normal 
 fisces, 103 
 Fat excreted in. 145 
 Castric contents, in, 45, 03 
 Reduction in intestine,diniinution 
 in, 112, 113 
 Bile acids in f^ces, 164-165, 209 
 Bile duct, obstruction of, stools in, 104, 
 
 119, 107 
 Bile jjigment calculi, 244 
 Bird, Golding, cited, 03 and note 
 Bismuth, colour of stools after, 105 
 Blennorrhoea intestinalis. 210 
 Blood, 
 
 Fieees, in. l(iS-170, 170, 1S7. 188. 
 
 1 90- 191, 205, 2 1 5, 2 K), 22i », 224, 
 
 226. 227, 231,232.234-235,237 
 
 (Jastric contents, in, 45, 51. 5(>. 
 
 03 
 
 Blood corpuscles in faeces. 22(), 237 
 
 Blood count in case of constipation. 
 
 193; in intestinal carcinoma. 233 
 Boas, bulb stomach tube of, 7, 9 ; 
 test meal of, 12 and note^; (pian- 
 titative estimation of lactic acid, 
 32-33 ; citrd, 42 and note, 65 and 
 nolei, 07, 105 and note 2, 234 
 Boas and Bou veret, cited, 39 and note 2, 
 44 and note- ' 
 
254 
 
 INDEX 
 
 Bokki, cited, 188 
 
 Boston " Clinical Diagnosis," cited. 
 
 13 note 
 Bowels, 
 
 Atrophv of mucous membrane of, 
 224-228 ; muscular atrophy, 
 228-229 
 Catarrh of, see that title 
 Frequency of action of, 171 
 Motility of. 171-175, 191-194. 
 197, "200. 208, 214, 217-218, 
 219. 237 
 Periodicity of action of. 173-174, 
 
 188-189 
 Peristalsis of, effect of diets on. 
 
 189 
 Stenosis of, 105-106 
 Bread, black, nitrogen excretion on 
 
 diet of, 131 
 Bread, rye. 15(5 
 
 Bread, white, diet of, 11, 132, 157 
 Bieithaupt, fast of, 09, 129, 130, 143 
 Bright's disease, 2 
 Brintor, cited, 10 
 Bronchitis, 8 
 
 Bunge, cited, 18 and note 2, 80 
 Burchard, cited, 244 
 Butter, food value of, 252 
 Butyric acid. 
 
 Ffeces, in, 118. 119 
 Formula for. 34 
 Gastric contents, in. 
 
 Clinical significance of, 35 
 Odour of, 16 
 
 Pathological conditions, in, 
 45, 46, 50, 51-52, 54, 55, 
 59, 66, 67, 72, 74, 75, 78, 
 79, 84, 85, 88, 89, 92 
 Test for. 34 
 
 Cabbage. 
 
 Food value of, 252 
 Nitrogen excretion on diet of, 131 
 Caecum, 247 
 Calcium salts of bile acids in faeces, 
 
 220 
 Calcium oxalate crystals in fjeces, 
 
 114, 215 ; in urine, 195, 197, 213 
 Calomel, 104, 105, 163 
 Calories, number of, in various articles 
 
 of diet, 252 
 Camerer, cited, 100 a7id notes 'i^, 6 
 Camerer and Hartmann, cited, 100 
 
 and note 2 
 Carbohydrates, 
 
 Faeces, in, 153-157 
 Fermentation of, excessive, in 
 
 the bowel, 196-199 
 Peristalsis of intestine caused by 
 diet of, 189 
 
 Carbohydrates — continued 
 
 Quantities of, in various articles 
 of diet, 252 
 Carbonic acid in gastric contents, 41 
 Carcinoma of stomach 
 
 Differential diagnosis by lactic 
 acid reaction, 18, 34. '46, 49- 
 50, 55, 67 
 Gastric contents after test break- 
 fast, 65-69 
 Hydrochloric acid, free, absence 
 
 of, in, 2, 64-65 
 Hypohydrochloria. differential 
 
 diagnosed from, 79 
 Odour of gastric contents in. 16 
 Situation of growth, 62, 66 
 Test meal for investigating. 12 
 Vomited matter in, see Vomited 
 matter inCarcinoma of Stomach 
 Vomiting in, 62-63 
 Carcinoma of intestine, 233-239 
 Carmine Red Fibrin test for pepsin, 
 
 37-38, 47, 51, 56, 60, 68, 77 
 Carnivora, 43 
 Carrots, nitrogen excretion on diet of. 
 
 131 
 Casein in faeces, 112, 226 
 Catarrh of the bowels. 
 Acute, 203-206 
 Causes of, 202 
 Chronic, 206-209 
 Stools of, diagnosis by, 3-4. 141 : 
 diagnosed from diarrhoea. 178. 
 from mucus colitis, 215 : 
 diagnosis of situation by. 114- 
 115 
 Cauliflower, food value of, 252 
 Cellulose, nitrogen excretion on diet 
 
 containing. 131 
 Cerebral vomiting, 92 
 Cetti, fast of, 99, 129, 130, 143 
 Charcoal, use of, in investigating 
 
 motility of bowels, 172-175 
 Charcot-Leyden's crystals in faeces, 
 
 114,221 
 Chicken (roast), food value of. 252 
 Chlorine, combined, in gastric con- 
 tents, 47. 50, 52-53, 56, 60. 76. 
 80, 85-86, 90 
 Chlorophyll in faeces, 103, 108. 238 
 Cholate of Soda, 104 
 Cholera, stools of, 121, 139 
 Cholera bacillus, effect of gastric juice 
 
 on, 18 
 Cholesterin. 
 
 Fseces, in. 114 and note, 143. 191. 
 
 195, 221, 223 
 Gall-stones, recognition of, 243- 
 244 
 Coagulated egg albumen test for ^lep- 
 sin, 36-37 
 
INDEX 
 
 255 
 
 Cohnheim, cited, 153 and nolv i 
 Colitis, 
 
 Albumen in faeces of. 139 
 Membranous. 221-223 
 Mucus. 21l-21() 
 
 Ulcerative, acute. 21G-217 ; 
 chronic, 217-221 
 Colon. 
 
 Affection of, in mucus colitis. 212 ; 
 
 in intestinal atrophj-. 224 
 
 Ulceration of. 2 Hi ct -scg., 232 
 
 Congo red test for free hydrochloric 
 
 acid, 25 
 Connective tissue, residue of. in fa>ces, 
 
 111, 112 
 Constipation. 
 
 Accompanying intestinal dis- 
 eases, 200-207, 223. 228, 229, 
 230, 231, 233-234 
 Delayed peristalsis in, 173 
 Fseces of, 106. 139, 140, 190-195 ; 
 on different diets, 107, 108, 
 192-195 
 Periodical diarrhoea alternatmg 
 
 with, 185-188 
 Some causes of, 125. 188, 190 
 Urine of. 1G3 
 Corlette, cited, 252 
 Croupous enteritis, 231 
 
 Def.tccatiox, 189 
 Diarrhoea, 
 
 Accompanvins diseases of in- 
 testines," 203. 20(i, 214. 223, 
 224, 230-231, 234 
 Definition and classes of, 175 
 Dyspeptic, 188 
 Faces of. lOG, 139. 166, 176-178 ; 
 
 on different diets. 108, 109 
 Nervous, 181-185 
 Simple, 177-181 
 Stercoral, 185-188 
 Water in faeces, from increased 
 quantity of. 175-176 
 Diets, 
 
 Faeces, influence on, 94 
 
 Food value of different articles, 
 
 252 
 Special, for analysis, of faeces, 
 94-98 ; for gastric analyses, 11- 
 14 
 Digestion in — gastritis, acute, 47-8, 
 chronic, 51 ; alcoholic catarrh, 53; 
 achylia gastrica, 56 ; gastric ulcer, 
 60-61; hyperhydrochloria, 76-77; 
 hypohydrochloria, 80 ; motor 
 insufficiency, 86-87 ; gastric hyper- 
 resthesia, 89. 90 
 Dimethyl-amido-azo-benzol, testing 
 for free hydrochloric acid bv, 26-27 
 Diphtheritic enteritis, 209-2 lo' 
 
 JJidease.i of thMomuch, -see Einhorn 
 
 Drug calculi. 245 
 
 Drugs, colour of faeces after different. 
 105 
 
 Duodenal ulcers, 2.30, 231 
 
 Duckworth and Garrod " Study f>f 
 Intestinal Sand," cited, 246 noli. 
 247 
 
 Dumplings, 156 
 
 Dysentery. 216, 232 
 
 Dyspepsia, functional, 70-71 ; intes- 
 tinal. 114. 196-201 
 
 Dyspeptic diarrhoea, 188 
 
 Eggs, food value of, 252 
 
 Ehrlich Brondi triacid solution, 140 
 
 and 7iole i 
 Einhorn " Diseases of the Stomach." 
 
 cited, 17 and note, 49 and note, 
 
 53 and note ~ 
 Empj^ema, 49 
 Enteritis, 139, 202 
 Enteritis crouposa, 209-210 
 Enteritis membranous, 141 
 Enteroliths, analysis of, 244-245 
 Epithelial cells in faces, 114,205-206. 
 
 242 
 Eructation, nervous, 41 
 Escherich, cited, 100 and note^ 
 Euchlorhydria, action of carmine 
 
 fibrin test for pepsin in, 38 
 Ewald, cited, 10, 20-21, test breakfast 
 
 of, 11 and note 
 
 Faber, cited, 196 and note 
 Faeces, 
 
 Albumen in, 138-139 
 
 Albumenoses and peptone in, 
 138-139 
 
 Analysis of, in — diarrhoea, 176- 
 179 ; nervous diarrhoea, 182- 
 185 ; stercoral diarrhoea, 186- 
 187; constipation, 190-195; 
 intestinal dyspepsia, 197-201 ; 
 catarrh of bowels, acute, 203- 
 206, chronic, 207-209 ; enteri- 
 tis crouposa, 210 ; mucus colitis, 
 212-216 ; ulcerative colitis, 
 216-221 ; membranous colitis, 
 221-223; intestinal atrophy, 
 224-229 ; intestinal ulceration, 
 230-232 ; intestinal carcinoma, 
 233-239 ; sprue, 240-242 
 
 Bile acids and pigments in, 164- 
 166 
 
 Blood in, see under Blooil 
 
 Carbohydrates in, see th'it title 
 
 Colour of, 103-105; on different 
 diets, 107-109; in diarrhoea, 
 176, 178, 180, 183 ; in con- 
 stipation, 190-193 ; in intes- 
 
250 
 
 INDEX 
 
 Ffecei — continued 
 
 tinal dyspepsia, 197, 200 ; in 
 acute catarrh of bowels, 203, 
 in chronic catarrh of bowels, 
 208, in colitis, 214-216; in 
 asylum dysentery, 217 ; in 
 carcinoma of bowels, 234, 237 ; 
 in sprue, 241 
 Colourless stools, 103, 104-105, 
 
 1G8 
 Consistency of, 105-107 ; in 
 various pathological conditions, 
 175, 176, 183. 190, 197, 206, 
 214, 215, 217, 219, 220, 226, 
 227, 229, 237, 238, 241, 242 
 Diet, influence of, on, 94 
 Examination of, importance of, 
 
 93 
 Fat in, see Fat in Fseces 
 Intestinal sand in, 245-249 
 Macroscopic examination of, 110- 
 
 111 
 JMicroscojiic examination of, 111- 
 
 115 
 Mucus in, see under Mucus 
 Nitrogen in, see under Nitrogen 
 Normal, 93, 99-100, 117 
 Odour of, see under Odour 
 Oxyhsemoglobin in, 168, 170 
 Phenol, indol and skatol in, see 
 
 those titles 
 Quantity of, normal, factors in- 
 lluencing, 99-100 ; influence of 
 diets on, 101-102; in diarrhoea, 
 183, 187 ; in constipation, 139 ; 
 in intestinal dyspepsia, 200 ; in 
 chronic catarrh of bowels, 206- 
 207, 208, 209 ; in colitis, 215, 
 
 219 ; in stercoral ulceration, 
 
 220 ; in intestinal atrophy, 
 226-227, 229 ; in carcinoma, 
 238 ; in sprue, 242 
 
 Reaction of, 116-117, 201, 208; 
 influence of diet on, 117-119 
 
 Sugar in, 152-153 
 
 Urobilin in, .see binder WrohWxn 
 
 Water in, method of estimating, 
 
 119-120; normal quantity, 
 
 factors influencing, 120-121 ; 
 
 after test meals, 122-126 
 
 Fasting individuals, stools of. 99, 162 
 
 Fat, 
 
 Absorption of, and influence of 
 melting-points of fats on, 144, 
 145-146; on test diets, 146-151 ; 
 in membranous colitis, 223 
 
 Absorption and excretion of, on 
 dinVrcMt diets, 146-151 ; in 
 (liarrh(ea, 177, 179-181, 184, 
 188; in constipation, 191-195; 
 in intestinal dyspepsia, 198, 199, 
 
 Fat — continued 
 
 201 ; in acute catarrh of bowels, 
 204, 206 ; in chronic catarrh 
 of bowels, 209 ; in mucus co- 
 litis, 215 ; in stercoral ulcera- 
 tion, 218. 220-221 ; in intes- 
 tinal atrophy. 227, 228, 229 ; in 
 carcinoma, 237-238 ; in sprue, 
 242 
 Diet, in. 
 
 Reaction of fseces from, 119 
 Water in stools from, 122, 123, 
 124 
 Drying of faeces containing, 120 
 Faeces, in, 112-113 ; quantitative 
 estimation of, 142 ; in fasting 
 individuals, 143-144; in nor- 
 mal faeces, 143-145. (<Sec also 
 above. Absorption and Excre- 
 tion) 
 Quantities of, in various articles 
 of diet, 252 
 " Fat-diarrhoea," 188 
 Fatty acids, in faeces, 112-113; 
 quantitative estimation of, 142- 
 143 
 Fenwick, cited, 53 and not''^ 
 Fibrin in membranous colitis, 222 
 Fish-bones in faeces, 115 
 Flatulency, 227, 228-229 
 Flour, influence of fineness of, in 
 food on excretion of carbohydrates, 
 156 
 
 Gall-stones, analysis of, 243-244 
 Gastralgia, 90 
 
 Gastric carcinoma, see Carcinoma 
 Gastric catarrh, 39-40, 43-45 
 Gastric contents. 
 
 Acetic acid in, see Acetic Acid 
 
 Analysis of, after test breakfast, 
 in — catarrh, 44; acute gastritis. 
 45-48 ; alcoholic catarrh, 51-53 ; 
 achylia gastrica, 53, 54 ; car- 
 cinoma of stomach, 66-69 ; 
 motor insufficiency, 84-87 ; 
 hypera?sthe.sia, 88-90 ; gastral- 
 gia, 90 ; anaesthesia, 91-92 ; 
 value of normal results in diag- 
 nosis, 90 
 
 Butyric acid in, see that title 
 
 Ddbris from, in achylia gastrica, 
 53 
 
 Diagnosis by chemical analysis 
 of, 2 
 
 Ferments in, sec Pepsin. Rcnnin, 
 Lipase 
 
 Free hydrochloric acid in, sec 
 Hydrochloric acid, free 
 
 Gases in, 41-42 
 
 Lactic acid in, see Lactic acid 
 
INDEX 
 
 257 
 
 <jii3tric Q.onteAtfi— continued 
 
 Macroscopic examination of, 15- 
 
 10 
 iSrethod of obtainine;, 7-S 
 Microscopic examination of, 17-11) 
 Munis in, see under Mucus 
 Quantity of, after test breakfast 
 in — chronic gastric catirrh, 4!) ; 
 alcoholic catarrh, ol ; gastric 
 ulcer. oS ; carcinoma, 66 ; 
 hypL'rhydrochloria, 75 ; hypo- 
 hydrochloria. 70 : pyloric 
 spasm, 83 ; motor insufficiencv, 
 84 
 Rsiction of. 41). 4S. 4!). 5\ 51. 5:). 
 
 66. 67. 75. 7!). 84-85 
 Retention of. l!)-35 
 Stagnation of. acids pres3nt in, 
 
 34-35 
 Test meals in investigating, 10- 
 
 14 
 Total acidity of, sae that title 
 Volatile acidity of, see th'it title 
 Gastric hypsrajsthesia, 88-90 
 Gastric juice, bactericidal action of, 
 
 18 
 Gastric mucosa from empty or fasting 
 
 stomach. 17-18 
 Gastritis, acute, 45-48 ; chronic, 48-51 
 Gastro-succhorea. 74. 77-78, 82 
 Geigel and Abend, cited, 20 notz 
 Geigel and Blass, cited, 20 note 
 Gerhardt, cited, 167 cnii note- 
 German. See Test Meal, 14 and note 
 Glycoeholat3 of soda. 164 
 Glycocol, 164 
 Gmelin's te.st for bile pigments in 
 
 fseces. 165 
 Grieg, Dr., 78 
 Guaiacum test for blood in faeces, 
 
 169 
 Giinzburg's solution for testing for 
 
 free hydrochloric acid. 26 
 Guttmann, cited, 222 an I ntt: - 
 
 H.EMATEJiESis in gastric ulcer, 57-58 
 H.-ematin, 1()S, 1()9, 170 
 Hpemorrhage.s from intestinal tract, 
 
 168, 169-170 
 Hammerschlag, cited, 39-40, 67 and 
 
 note, 245 
 Harley, Vaughan, cited, 22-24, 123 and 
 
 note'i^, 142 note, 145 no/ei, 166 and 
 
 note, 167 note 
 Harley and (Joodbody, cited, 252 
 Harley and Loney. cited, 23 note 
 Heidenhain. cited, 43 
 Henle, cited, 10 
 Herbivora, 43, 244, 245 
 Hiccough, 227 
 
 Hofmeister's test for albumcnoscs and 
 
 ])eptone in f;eces. 138-139 
 Hoppe-Sevlcr, Chetnischr A ii<i'i/sf. 
 cited,' 21 notei, 120 not-. 138 nolv. 
 1.58 note, 164 note ; test for mucus 
 in faeces. 140; for indol. i>henol 
 andskatol, 158-160; for bile aci, Is. 
 164 
 V. Hiisslin. cited. 145 and note* 
 Hultgren and Landergren, cited. 145 
 
 and note 2 
 Huppert's test for bile pigments in 
 
 feces, 165 
 Hydrobilirubin. 16() 
 Hydrochloric acid in gastric contents. 
 Acidity due to, method of estima- 
 ting. 21 
 Function of, 18. 80 
 Qu;uititative analysis of. in patho- 
 logical conditions, 46. 47. 5!). 
 52-53, 54, 55-56. 59. (iO. (56. (>8. 
 72, 74, 75, 76, 80, 83. 84, 85. 
 89-90 
 Hydrochloric acid, free, in gastric 
 contents. 
 Absence of, 2, 16. 63-64 
 Pathological conditions, in. 45, 46. 
 47, 49, 50. 51. 55, 59, 6(5. 67. 68. 
 72. 74, 75, 76. 79, 80, 84, 85, 88. 
 89 
 Qualitative and quantititive me- 
 thods for recognition of. 25-31 
 Hydrogen in gastric contents, 41-42 
 Hyperemia, 180. 181 
 Hyperesthesia, gastric, 3 
 Hyperhydrochloria, 
 Acidity in, 21, 24 
 Accompanying gastric diseases, 
 
 53, 82, 83, 85, 86, 90, 91-92 
 Analysis of gastric contents in. 
 
 71-72, 74-76 
 Carmine fibrin test for jjcpsin in. 
 
 37. 38 
 Definition of. 74 
 Diagnosis between gastric ulcer 
 
 and, 77 
 Digestion in, 76-77 
 Hyper motility of stomach. 81-83 
 Hypersecretion, gastric, vomiting in, 
 
 57 
 Hypohydrochloria, 
 
 Accompanying gastric diseases, 
 
 86, 90 
 Acidity in, 21, 24 
 Analysis of gastric contents in, 78. 
 
 80 
 Carcinoma diagnosed from, 79 
 Carmine tibrin test for pepsin in, 
 1 37, 38 
 
 I Digestion, in, 80 
 
 i Functional and organic, 78-79 
 
258 
 
 INDEX 
 
 Hypomotility of stomach, 81, 83-87 
 Hysterical vomiting, 92 
 
 Indican in urine. 187. 194. 197. 200. 
 
 201, 208, 213 ; test for. 161 
 Indol, phenol and skatol, characters 
 and formulae for. 158. 159; in faeces, 
 107. 158, 159, 201, 22G 
 Intestinal concretions, 243 et seq. 
 Intestinal diseases, test meals for in- 
 vestigating, 3, 93-98 
 Intestinal dyspepsia, see Dyspepsia 
 Intestinal obstruction, odour of gastric 
 
 contents in, 16 
 Intestinal tract, see Alimentary tract 
 Intestine, large. 
 
 Activity of, factors influencing, 
 
 120-121 
 Bile acids in, 164 
 Bile pigments converted into uro- 
 bilin in. 167 
 Catarrh of, frequency of motions 
 
 in, 203 
 Passage of food along, 172 
 Peristalsis, increased in, 172. 175- 
 
 176, 181 
 Post-mortem appearance in atro- 
 phy, 227-228 
 Ulcers, chronic, in, 217 
 Intestine, small. 
 
 Bile acids absorbed in, 164 
 Bile pigments in. 165-166 
 Catarrh of, frequency of motions 
 
 in, 203 
 Exudation and transudation in 
 
 121 
 Fat excreted by, 1 45 
 Passage of food along, 172 
 Intestines, see also Bowels 
 Bacteria in, 129 
 Ulceration of, 230-232 
 
 Jaundice, 104, 139 
 Jaworsky, cited, 3 and note 
 
 Kauf.maxx, cited. 18 
 
 Kenwood, Prof., cited, 251, 252 
 
 Kjeldalil's method of estimating ni- 
 trogen in faeces, 127-129 
 
 Klemperer, test meal of, 14 
 
 Robert and Koch, cited, 144 and note 2 
 
 Kiinig. cited, 251, 252 
 
 Kussmaul, cited, 5 and note, 10. 82 
 and note 
 
 Lactic Acid, 
 
 Faeces, in, 118, 119 
 Formula for, 32 
 
 Gastric contents, in, 12, 18, 32- 
 34, 44, 46, 49-50, 51-52, 54, 55, 
 
 Lie tic Acid — continued 
 
 59, 65, 66, 67. 72, 74, 75, 78, 70. 
 84, 85, 88, 89 
 
 L?athes, cited, 222 
 
 Legal's test for indol in faeces, 159 
 
 Leney and Harley, cited, 83 and note 
 
 Leo. method for quantitative analy- 
 sis, of free hydrochloric acid, 27-28 
 
 Leube, quantitative estimation of 
 pepsin by, 38; test meal of, 12 
 and note 3 
 
 Leucocytes, in faeces, 114 
 
 Leuko-urobilin, 105 
 
 Liebermann, cited, 244 
 
 Lime, neutral phosphate of crj'stals 
 of, in faeces, 113 
 
 Lipase in gastric contents, 40 
 
 Lockwood, cited, 211 
 
 Loeffler bacillus, 209 
 
 Luschka, cited, 10 
 
 Lynch, cited, 99 and note 2 
 
 Macaroni, 132 
 
 Mackenzie's toast biscuits, 95 note-. 
 
 252 
 Maize, 132, 156 
 Malfatti, cited, 145 and note 3 
 Marquez, analysis of intestinal sand 
 
 by, 248 
 Marsh gas. eructation of, 42 
 Mathieu and Richand, analysis of in- 
 testinal sand by, 247 
 Meconium, 161-162, 167, 168 
 Membranous colitis, 221-223 
 ]\Iercurial jDoisoning, 209 
 V. Mering, cited, 22-23 
 Methyl-Violet test for free hydro- 
 chloric acid, 25 
 Metabolism, fixed dieis for the study 
 
 of, 94-98 
 Mett's quantitative estimation of pep- 
 sin by, 39 
 Meat diet for metabolism, 97-98 
 
 Gastric juice secretion after, 11 
 
 Faeces from, characters of, 102. 
 
 1,03, 109, 119, 125-126, 131, 132, 
 
 137-138, 150-151, 162, 183-185 
 
 Fat absorption and excretion on, 
 
 150, 151 
 Nitrogen excretion and absorp- 
 tion on, 131, 132, 137-138 
 Sluggishness of bowels due to, 
 171, 189 
 Migraine, 83-84 
 Milk diet for metabolism, 95 
 
 Cow's milk, influence of, on faeces. 
 
 100, 118, 133, 140 
 Fa^'cs from. 
 
 Characters of 101, 103, 107- 
 108, 117-118,122-123, 162 
 
INDEX 
 
 259 
 
 Milk diet for metabolism — conliuiicd 
 Intestinal sand in. 24(1-247 
 Fat absorption and cxcrotion on, 
 
 140-148 
 Food value of. 252 
 Gastric juice secretion aflcr, 11. 14 
 Mctabniism on. 17it-lS2. 22."), 
 
 23t)-2:{7, 240-242 
 Nitr^uen excretion and ahsor])- 
 
 fioii on. i;5:m:u 
 
 SItli;L^^'hncss of bowels due to. 
 17 1. 1S9 
 Mixed diet for metabolism. !)(>-97 
 
 F;eces from, charac^ters of, 101 ■ 
 
 U)X 108-1 Oil. 118-1!!). 12.'M24 
 
 Fat absorption and excretion on 
 
 148, 140 
 Metabolism, 13o-137, 149-1.")], 
 
 191. 192. 199, 200-201. 237 
 Nitrogen excretion and absorf)- 
 tion on, 135-130 ; on mixed 
 diet with increasing quantities 
 of milk, 136-137 
 Mixed diet -I- milk, for metabolism. 
 97. 102. 177, 178- 180. 180, 194. 
 198, 213. 218. 237- 239; water 
 percentage in fteces from. 124- 
 125 
 Motions, shape of, in intestinal carci- 
 noma. 234 
 Mott and Durham, cited, 2\& and note ^ 
 Mucous membrane, particles from 
 
 achylia gastrica, 50 
 Mucus, 
 
 Casts of, in membranous colitis. 
 
 222 
 Digestion of. 44 
 
 FiPces, in, 107. 109. IIO. 139-141 ; 
 in pathological cotiditions, 170. 
 17«. 180. 1N7. 190. 193, 195. 
 Iit7. 20(1. 2(11, 2(M-2(»0. 208-209. 
 214-215. 21(). 219-220, 224. 220. 
 229. 232. 234. 237-238, 241 
 Gastric contents, in. 43-48, 52-55. 
 59, 00-08, 71, 72, 75-70, 79, 84, 
 85 88 89 
 Mucus colitis! 211-217, 223, 246 
 Miiller. Fr.. cited, 99 and notei, 130, 144 
 -Muscular fibres, residue of, in fteces, 
 
 111-112. 208. 215. 220 
 Mutton, roa^t. food value of. 252 
 
 Xencki, Sieber and .Schounow, cited, 
 
 18 mid note 3 
 Nervous diarrhoea, 181-185 
 Neurasthenia. 92. 189-190 
 Neurotic taitit, symptom of. 41 
 Neutral fat in faeces, (piantitative esti- 
 mation of, 142-143 
 Nitrogen, 
 
 Absorption of, on clillercnt diets. 
 
 Nitrogen — ronliniud 
 
 133-130 ; in mcmbr^mous co- 
 litis, 223 
 
 Absorption and excretion of. on 
 test diets in— diarrlxca. 177. 
 178-179, ISI. 187-188; con- 
 stipation. 191-195; intestinal 
 dyspepsia. 198. 199. 201 ; 
 catarrh of bowels, 204. 20(i, 
 209; mucus colitis. 215-210; 
 stercoral ulceration, 218, 220- 
 221 ; intestinal atrophy, 227. 
 228. 229; carcinoma, 237; 
 si)rue, 241, 242 
 
 Elimination of. in in-inc of— con- 
 stipation, 195; acute catarrii 
 of bowels, 205; colitis, 213- 
 214, 218, 219; intestinal atro- 
 l)hy, 225, 228, 229 : carcinoma, 
 230, 2.38 
 
 FiTOes,in, 127-138 (wr cdso ahnir. 
 Absorption and Excretion) 
 
 Gastric contents, in. 41 
 
 Quantities of. in various articles 
 of diet. 252 
 V. Noorden, cited, 127. 130 iiolr'^-, 140 
 
 and note 
 Norway, 78 
 
 Nothnagel. cited, 112. 103, 1(50, 189 
 note. 210. 232 
 
 Oat bran. 245 
 
 Oatmeal (uncooked), food value of. 
 
 OcFour. 
 
 Fa;ces, of. 
 
 Normal faeces, 107 
 Pathological fanes. I7(i. 180, 
 187. 190. 195, 197, 200. 
 201, 203-205. 208, 214, 
 219, 220. 229. 234, 241 
 Gastric contents in jiciiylia gas- 
 trica, of, 54 
 Oefele, v., cited. 99 and iiott i 
 Ol)pler, cited, (io and note'^ 
 Oppler and Boas, cited, 18 and note i 
 Ost. table of estimations of stomach 
 
 capacity quoted, 9 and note, 10 
 Oxalate of lime crystals in fa-ces, 191 
 Oxygen in gastric contents. 41 
 Oxyha'inoglobin in fa'ces, KiS. 170 
 
 Pain, 
 
 Butyric or volatile acids, due to 
 
 increase of, 89 
 Gastralgia, of, 90 
 Gastric idcer, of, 57 
 Pancreatic calculi, 244 
 Pancreatic juice, 119. 145 
 Pawlow, cited. \0 and note-W. 14. 39 
 note 1, 73 and note i 
 
2(50 
 
 INDEX 
 
 Peas, diet of, and excretion of — nitro- 
 gen. 131, 132; fat, 145; cuho- 
 iiydratc, 156, 157 
 Pepsin in gastric contents. 
 
 Pathological conditions, in. 47-48, 
 51, 53, 5G, ()(). B8. 75, 77. 80. 
 86, 90 
 Quantitative estimation of (me- 
 thods), 38-39 
 Tests for, 36-37 
 Pepsinogen in gastric content.', 36. 37. 
 47-48. 51, 53, 56. 68, 77. 80, 86, 90 
 Peptone in faeces, 138-139. 216 
 Peristalsis of stomach, increased, 82 
 Peristalsis of intestines, increased, 189, 
 
 192-193 
 Pettenkofer and Voit, cited, 100 and 
 
 note 6 
 Phenol, see Indol Phenol and Skatol 
 Physiol, chemie, BevWn, cited, 120 note ^ 
 Plaice, food value of, 252 
 Potatoes, food value of, 252 ; nitro- 
 gen excretion on diet of, 131 
 Proteids (see also Nitrogen- Absorp- 
 tion) 
 Digestion of, 18 ; in gastric ca- 
 tarrh, 44 
 Odour of faeces from diet of, 107 
 Prout-Wynter Method for quantita- 
 tive analysis of free hvdrocliloric 
 acid, 28-30, 31, 47, 50, o^i 
 Puerperal fever, 49 
 Pus, 
 
 Chronic gastritis, in, 49 
 Faeces, in, 231-232, 235 
 Malignant stomach, in. 65 
 Pusch and Calloraon, cited, 152 and 
 
 note 
 Pylorus, 
 
 Insufficiency of, 86-87 
 Spasm of. 83 
 Stenosis of, 82 
 Stricture of, 42 
 
 Quincke, cited, 103. 105 and note i 
 
 Rectum, ulceration of. 232 ; malig- 
 nant disease of, 237-9 
 
 Eegurgitation. 86 
 
 Reichmann, cited, 189 and note 
 
 Reinboth. cited. 65 and note"^ 
 
 Rennin in gastric contents, 39-40, 44, 
 51, 68, 75, 77, 80, 90 
 
 Rice, 132, 156, 252 
 
 Richet, cited, 73 and note 2 
 
 Rieder, experiments of, cited. 130 and 
 note 2 
 
 Riegel, cited, 56 and note ~, 64 and note 
 ii5 and note*; test meal of, 12 and 
 jiote ^-\4: ; gastric contents yielded 
 by, 15, 17 
 
 Rosenan, apparatus for obtaining 
 stomach contents, 8 and note 
 
 Rubner. cited, 131 and note. 132, 145, 
 146, 153 and note^, 156, 157 
 
 Rumination. 82 
 
 Runipf and Schumm, cited, 131 
 
 Salkowski. cited, 244 
 
 Salol tabloids, calcidi caused by, 245 
 
 Salzer, test meal of, 13-14 
 
 Sand, intestinal, 245-249 ; true. 246 : 
 false. 246 
 
 Sarcinaj, 18-19, 65 
 
 Schmidt, cited, 44 and note, 56 f/wrf 
 note'i-, 208; method of estimating 
 carbohydrates in faeces, 155-156 ; 
 bile pigments, 165 ; urobilin, 166- 
 167 
 
 Schmidt's diet for metabolism, 95 and 
 notes Ql ; metabolism on. 101, 108. 
 118, 123, 134, 135, 148-149, 191. 
 199, 201 
 
 Schmidt and Strasburger. Die Faeces 
 des Menschen, cited, 94, 100 note i, 
 118 and note, 121 note, 129 and 
 notesi and2, 131 7iote2, 132 7iotes, 133, 
 134, 143 and notes, 144 noteK 146, 
 152 Jiote^, 155 note, 156 note, 157 
 7iote, 160 and note i, 196 and note - 
 
 Schiile, cited, 43 and note 
 
 Schiiren, cited, 10 
 
 Senator, cited, 161 
 
 Shellac, calculi caused by, 245 
 
 Sicard and Infroit, cited, 172 note 
 
 Simon. " Clinical Diagnosis," cited. 
 32 note 
 
 Skatol, see Indol, Phenol, and Skatol 
 
 Sloughs in faeces, 231 
 
 Soaps m fseees, 113, 142-143 
 
 Soemmering, cited, 10 
 
 Sole (uncooked), food value of, 252 
 
 Spinach, food value of. 252 
 
 Spinal lesions, vomit of, 92 
 
 Sprue (Psilosis), 240-242 
 
 Starch in faeces, 113 
 
 Snarling. Croonian Lectures, cited. 73 
 and note 3 
 
 Stenosis of the bowel, 105-106 
 
 Stercobilin, 166 
 
 Stercoral diarrhoea, 185-188 
 
 Stercoral ulceration, 217-221 
 
 Stomach, 
 
 Atrophy of. 53 
 
 Capacity of. 9-10 
 
 Cardiac end. diseases of, 24. 82- 
 
 83, 8() 
 Dilatation, atonic of, 84-87 
 Functional diseases of (see also 
 
 names of diseases), 70 et seq. 
 Cias fciiiicntation in, 41-42 
 
INDEX 
 
 261 
 
 Stomach — continued 
 Jlotor power of. 
 
 Achylia gastrica. in, oO 
 Functional dcrangcinpnts of, 
 
 70. 71.81 cf-oeq. 
 Gastric contents in cases of 
 
 insufficiency of. l.j 
 Gastritis, acute, in. 4() 
 Test meals for investigating. 
 
 12-14 
 Ulcer, gastric, in. (>l 
 Xcm'oses, motor. 81 el seq. ; sec- 
 retory. 72-80 : sensory, 88-92 ; 
 vomiting. 92 
 Organic diseases of (.<(< also name;; 
 
 of diseases), 43 it •s*//. 
 Peristalsis, increased. 82 
 Pylorus, see that fit'c 
 Secretions, nervous control of. 
 72-74. 78 
 Stomach tube, use of — different forms, 
 etc., 5-9 ; use of, in gastric ulcer, 58 
 Strasbiu"ger, cifecl. 93 find note. 155 
 Strasburger and Schmidt, see Schmidt 
 Strauss, Hermann, cited, 21-22 
 Succus entericus. 196 
 Sugar in faeces. 152-153 
 
 Tabes dorsalis, gastric crisis of, 92 
 Taurin. 164 
 
 Taurocholate of soda in faeces, 164-165 
 Teichmann's Ha?min test for blood in 
 
 faeces, 169 
 Test meals for investigating gastric 
 
 diseases, 11-14; importance of 
 
 using, 19-11 
 Test diets for investigating intestinal 
 
 diseases, see Diets 
 Thiersch, cited, 64 and note 3 
 Thomson and Ferguson, cited, 247 
 'i'liroats, relaxed, 55 
 Tiipfer, detection and analysis of free 
 
 hydi-ochloric acid, 26-27. 30-31 
 Total acidity of gastric ((.ntcnts. 46, 
 
 47, 50, 52, 54, 55. .".s. -'.M. (id. (i(i. 68, 
 
 72, 74, 75, 76, 78. 7!i. S4. s.'.. S8-89; 
 
 method of estimating, 20-21 ; 
 
 average value of, 21 
 Toxalbumins, action of gastric juice 
 
 on. 18 
 Tropiiolin test for free hydrochloric 
 
 acid, 25-26 
 Tschernoff, cited, 188 
 Tubercular disease of lungs, 23-24 
 Tumours, gastric, 49 
 
 Uffelmann, CiVcrf, 32, 34. 146, Xo^and 
 
 note 3 
 Ulcerative colitis, 4, 216 et seq. 
 Ulcers, gastric, 8, 57-61, 77 
 
 Ulcers, intestinal, 230-232 
 
 Urea in urine, 208 
 
 Uric acid in urine, 197. 205.225,236. 
 
 237 
 Urine, 
 
 Albumen in. 2 
 Indican in, see Indican 
 Quantitative analyses of patho- 
 logical urines, 177. 179. 182, 
 184. 186. 187, 192-194, 198. 
 199, 201). 201, 204, 2(»5. 207, 
 208, 213, 218, 219, 225, 228- 
 229, 236. 238. 240, 241 
 Urobilin in, 168. 194. 208, 240 
 Urobilin, 
 
 Absence of, from ficnes, 167- 16S 
 Enteroliths, in, 245 
 Fa'ces, in. 
 
 Normal. 103, 105. 166-168 
 Pathological, 177, 187, 191, 
 193, 195, 197. 200, 201. 
 205, 215, 220, 226, 229, 
 235, 237, 238, 241, 247 
 Urine, in, 168, 194.208,240 
 Urobilinogen, 167, KiS 
 
 Vagus nerve, gastric secretion con- 
 trolled by. 73-74. 78 
 Vege cable diet. 
 
 Colour of faeces on, i03 
 Frequency of motions on, 171 
 Nitrogen excreted on, 131 
 Peristalsis stimulated by, 189 
 Remains of, in fajces, 1 10 
 Velclen, V. de, cited, 25 and note, 64 
 
 and note' 
 Virchow's Archiv, cited, 20 note, 145 
 
 note' 
 Voit. cited, 131, 172 
 Voit's school at Munich. 127 
 Volatile acidity of gastric contents, 
 46.47. 50, 52, 54, 55, 59, 60, 68, 71, 
 72. 74. 76, 78, 80, 83-84, 85. 89 ; 
 estimation of, 21-24; normal value 
 of, 23 
 Vomited matter in carcinoma of 
 
 stomach, 62-65 
 Vomiting, 
 
 Gastric ulcer, from, 57-58 
 Neurotic. 92 
 
 Walker. Dr.. cases of, cited. 104-105 
 Weber's test for blood in faeces, 169 
 Whitehead, cited, 221 note 
 Whiting, food value of. 252 
 Wicke, cited. 156 
 Williams, Dr. 0. T., cited, 248-249 
 
 Yeast cells in carcinomatous stomach, 
 65 
 
Piintedby 
 
 Balla.vtyne &■ Co. Limited 
 
 Tavistock Street, London 
 
MR. KDWARD ARNOLDS 
 MEDICAL l>UBLICATK)NS 
 
 FOOD ^ THE PRINCIPLES 
 OF DIETETICS 
 
 r.v 
 ROBERT HUTCHISON, M.D. Edin., F.R.C.P. 
 
 Assistant Physician I 
 
 the London Hospital and to the Hospital for Sick Chiklren, 
 Great Ormond Street. 
 
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 NEW AND REVISED EDITION 
 
 OUTLINE OF CONTENTS. 
 I. The Nature, Nutritive Constituents, and Relative Values of Foods. 
 II. The Amountof Food required in Health. 
 HI. On the InHuence of various Conditions upon the Amount of Food 
 
 required. 
 IV. Animal Foods. 
 V. Jellies— Fish. 
 VI. Soups, Beef- Extracts, Beef-Juices, Bee f- Tea ; and Beef- Powders. 
 VII. Milk. 
 VIII. Foods derived from Milk. 
 
 IX. Cheese, Eggs, and Egg .Substitutes. 
 X. Vegetable Foods. 
 XI. The Cereals : Wheat— Bread. 
 XII. Bread (,-,w////wrt')— Other Cereals, 
 
 XIII. The Pulses — Roots, and Tubers. 
 
 XIV. Vegetables— Fruits— Nuts— Fungi— Alga; and Lichens. 
 
 XV. Sugar, Spices, and Condiments. 
 XVI. Mineral Constituents of the Food. 
 
 XV 11. Water and Mineral Waters. 
 XVIII. Tea, Coffee, and Cocoa. 
 XIX. Alcohol. 
 
 XX. Alcoholic Beverages: Spirits and Malt Liquors. 
 XXI. Alcoholic Beverages {continued) : Wines. 
 XXII. The Cooking of Foods. 
 XXI II. The Digestion of Food in Health. 
 X.XIV. I he Principles of Feeding in Infancy and Childhood: Iluni.in 
 
 Milk. 
 XXV. The Principles of Feeding in Infancy and Childhood (con/in ucJ ) ; 
 
 Substitutes for Human Milk. 
 XXVI. The Principles of Feeding in Infancy and Childhood (<•<'«//«//(•</) ; 
 Other Substitiues for Human Milk (IVptonized Milk, Con- 
 densed Milk, Proprietary Foods) ; Feedmg oJ Older Children. 
 XXVI I. The Principles of Feeding in Disease. 
 XXVni. The Principles of Feeding in Disease (6(?»//n?/f</). 
 XXIX. Artificial and Predigested Foods and Artificial Feeding. 
 
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