A stool which might microscopically be full of undigested starch would

not show a corresponding large amount of glucose when analyzed by diastase methods. Digestion and absorption of food takes place mainly in the small gut within six to eight hours after ingestion. Food remnants remain in the large intestine from fifteen to twenty hours. The large intestinal bacterial flora is such that protein, fat and starch can be destroyed. Bacteria have been isolated from saurkraut and manure that will break down starch to acetone and both volatile and involatile

organic acids. These facts having come to our attention, we attempted to measure the volatile acids present in stools of diabetics by distillation of these stools in the presence of acid sodium phosphate. Here too unsatisfactory results were obtained. Finally, we have attempted to measure, by the method of McClure, the strength of the duodenal enzymes as removed by the duodenal tube. The study of a few cases by this method has shown remarkable deficiencies in the digestive enzymes of greatly undernourished diabetics. We are not ready to report on this

phase of the work, but what has been done confirms the microscopical findings in the stool.

Our present methods for estimating the ability of the patient to digest the food fed is as follows: First, the microscopical examination of the stool. The amount of undigested starch, fat, and muscle fiber are roughly estimated and indicated by the signs to ++++. Second, the duodenal tube is passed on the fasting stomach and a sample of duodenal contents is removed and

enzymes estimated by the method of McClure. Third, the food calories fed are compared to the gain in weight. Our experience has been

that when 800 to 1000 calories are fed in excess of the basal requirement, the patient should gain at least 5 to 7 pounds a month. This holds for a patient up and about a small ward, resting at least half the day.

Of the first 10 undernourished diabetics studied by these methods. 8 showed definite inability to digest food. The duodenal enzymes were strength of those found in the normal only one-quarter to one-half the individual. The weight gained was either none at all or only a few pounds. The stools were more or less full of undigested food.

Some of these patients showed considerable improvement in digestion after a month or more of insulin

treatment. The amounts of undigested material in the stools decreased. In some instances the strength of the duodenal enzymes increased, in others very little change was noted. The rate at which weight was gained usually increased after some weeks of insulin treatment.

The results of this work are what would be expected. Strange to say very little has been done concerning the ability of the undernourished diabetic to digest food. Even in the latest works on the subject of diabetes, nothing is mentioned about it. We feel that is it of importance only because so much fallacy has crept into the diabetic literature as a result of the disregard of the stools.

One might draw the erroneous conclusion, for instance, that high fat diets break down the tolerance of patients, because after putting undernourished patients on high fat, they require more and more insulin. We feel that no study of the metabolism of undernourished diabetics can be of real value unless the stools are studied and the digestive factor receives due consideration.

Ο

UR knowledge of the gastric residuum has been gained largely from a study of the gastric contents removed from the stomach in the fasting state by means of the ordinary stomach tube.

According to Loeper (1), Kemp (2), Riegel (3), Gaither (4) and others the quantity of residuum obtained from the normal fasting stomach should not exceed 20 to 25 cc., according to Boas (5), 50 to 100 cc.; while all agree that it should not contain food remnants. Some doubt was cast upon the truth of these figures by the observations of Harner and Dodd (6), who demonstrated by means of the X-ray that the complete removal of the residuum from the stomach was not always possible by means of the ordinary stomach tube. This fact This fact has been confirmed by Rehfuss and his co-workers (7) who removed the fasting gastric contents by means of the Rehfuss tube and found that the quantity of contents in 100 normal cases averaged 52.14 cc., the largest 160 cc., and the smallest 23 cc. The total acidity noted averaged 29.9, the highest being 77.6; the lowest 2.4, the free HCl averaged 18.50, the highest 65.8, the lowest 0. Micro

1 From the Gastro-Enterological Clinic of the Department of Medicine, University of Maryland.

Read at the meeting of the American Gastro-Enterological Association, Atlantic City, May 5, 1924.

scopically, no food residue or meat fibers were noted, though leucocytes were almost always observed. The residuum was colorless in 43 per cent of these cases, and yellow or green in 56 per cent. These observers were thus able to demonstrate that the usually accepted limit of the normal residuum of 20 to 25 cc. is incorrect. They furthermore showed, that the fasting contents always presented the qualities of a physiologic active secretion, and that these appeared even in the absence of a normal stimulus.

Having convinced ourselves of the impossibility of obtaining the entire fasting contents of the stomach with the ordinary stomach tube, we concluded to study the residuum by means of the Rehfuss tube. The tube was swallowed without water and the gastric contents aspirated while the subject was placed in various positions. When aid in swallowing was necessary the tube was coated with a film of mineral oil. Observations were made upon 10 normal individuals, and upon 50 patients affected with various disorders.

Table 1 presents the normal cases in which a comparison is made of the results obtained by employing the Rehfuss tube, and results obtained by employing the ordinary stomach tube, as to the amount of residuum obtained. A similar comparison following a fractional analysis and an Ewald test meal, was obtained in the same

individual. In all instances in which fractional analyses were made in order to obtain more accurate results, advantage was taken of the mixing of the contents before withdrawal, as has been advised by White (8) as well as by Friedenwald and Gantt (9).

These figures indicate that the average volume of residuum obtained with the Rehfuss tube is 58 cc., the maximum amount 95 cc., the minimum 20; the average of free HCl is 13; maximum 32; minimum 0; the average total acidity is 26; maximum 50 and minimum 6. These figures are considerably higher than those obtained under similar conditions with the ordinary tube as may be observed in the table.

It has been suggested by Kopeloff (10) and others that there is a daily variation in the total amount of fasting contents obtained from the same individual.

Table 2 presents the daily variations. in the volume of the residuum obtained in 3 normal individuals.

These tables indicate that the daily variations in the volume of the residuum as well as in the free HCl and total acidity of this secretion are not marked when obtained under identical conditions; the maximum variation in volume in the 3 examinations was 12 cc.; the minimum 2 cc.; the maximum variation in free HCI 12; minimum 2; the maximum variation in total acidity is 12, minimum 2.

be separated; differing in this respect from that observed in pathological conditions as will be noted later.

On microscopic examination, the normal residuum presents cell nuclei in larger or smaller numbers, either free or arranged in clumps produced by the action of the digestive fluids upon the epithelial cells. In addition, normal epithelial cells are noted, which are derived from the mouth, respiratory tract, or the stomach itself. In cases of duodenal regurgitation round or cubical cells may frequently be observed and occasionally bile-stained columnar epithelium derived from the biliary tract may be seen. Leucocytes in small numbers are always seen in the fasting contents, but when present in large numbers they indicate disease. A frequent finding is the presence of the spiral cells first described by Jaworski, which are actually produced by the precipitation of mucin by the hydrochloric acid of the gastric secretion. Bacteria of various types always occur in the fasting secretion, but are only found singly or grouped in small masses. Gross or microscopic food residues in the form of meat or vegetable fibers are never noted under normal condition.

In our study of the residuum of various digestive disturbances the fasting contents were examined in 50 cases in which 2 were cases of chronic gastritis, 8 of cancer of the stomach, 10 of ulcer of the stomach and duodenum, 12 of achylia gastrica, 4 of dilatation with pyloric stenosis, 5 of gastric neuroses including hypersecretion, 4 of chronic cholecystitis, 2 of secondary gastric disturbances due to pulmonary tuberculosis, and 3 of enteroptosis.