& Q Vol 286 No 1 Mic Abstract Factors influencing the density of stools from 83 healthy subjects (nine had floating and 24 sinking stools) and six patients with steatorrhea were investigated. All floating stools sank when their gas volume was compressed by positive pro: sure. Thus, to float, stools must contain gas. ‘Alter degassing, previously tloating and sinking stools had similar specific gravities, indicating that the floating or sinking propensity of such stools depends upon differences in gas rather than “TL 8 soot that oats in. the tie i times xed sign of steatorrhéa, Compared to its less Duoyant connterpatt, such a floating stool snust cone tain an excess concentration of material that is Tess dense than water. Although this mate monly assumed to be fat, such an assumption seems somewhat tenuous hectuse 10 to 15 per cent of healthy subjects consistently pass stools that float (unpublished observation by ‘Levitt. and Duane): That such a large proportion “of the apparently healthy population has stestorshea appears highly improbable. There is, however, another low-density component of stool that has received little attention = the gaseous component. We therefore studied the relative importance of fatus versus fat in the gene sis of the floating stool Mernops Stool specimens were collected from 33 apparent- Iy healthy subjects. Nine of these subjects were se- lected because they stated thit their stools sually floated. The other 24 stated that their stools very rately or never floated. Stool specimens were also obtained from six patients with steatorthea (17 to 38 of stool fat per day), ‘A portion of stool was gently phiced in a fas containing, distilled water at room temperiture (2 to 27°C), and its floating or sinking disposition noted. Ifa stool floated, positive pressure was applied to the flask and the minimal positive pressure re- quired to induce sinking Ceritical sinking pres: sure”) was determined. For sinking stools, the mini mal nexative press wired to induce Masting (Ceritical floating pressure”) was measured. Density: determinations were made with the use of a standard, 60.ml pyknometer. A cube of stool, 5 to 10 x, was ent from the specimen hy means of a wire blide (more commonly used for shieing cheese). Preliminary attempts to cut such a sexment with Wy knife or scalpel apparently squeezed fats ont of the stool since stich seuments consistently: Ind specific yravitien® of appreciably sreater th rom Denim of Medicine, Universiy of Minne tables Sanpited hy 1 gran’ (© ROL ANIINGDY.D4) from the U.S. Publis Specie gravity seprseny the tof Uae ety su a in BLOATING SLOOLS-LEVEPT AND DUANE ors FLOATING STOOLS — FLATUS VERSUS FAT D. Levier, M.D. ayo Wi jae C, Duanr, MD. fat content. A high stoot gas content (and. hence a floating stool} in healthy subjects appeared related to colanic methane production Steatormheie stools had a relatively normal gas content. The density of their nongaseous fraction was less than normal, but resulted primarily trom increased water rather than fat content, Thus, stools float because of an increased content of gas or water (or both); the floating stool should not be considered a sign of steatorrhea, 1.000 as measured in the pyknometer even thous the precut stool specimen floated. ‘The cube of stool was very ently placed in the pyknometer, and a specific. gravity determination ‘cis performed by standard technics. After the dense ity of the stool in is native (aseous) state had heen tneasured, we removed gin fiom the sample. by hhomoenizing the specimen in the pyknometer and then applsing a negative prensne of ont 4) of mercury fo the pyknometer for ive minutes. Densi- ty messurements. were then repeated on the de- sasved stool “The pressure and density measurements were car- ried ont within three hours of the passage of the tool, ind. the remainder of most specimens was Subsequently analyzed for fat concentration by the srivimetric technic of Friedner and Mober! “The possibility that colonic methane (CH,) prov duction would influence the density of stools was investigated because one of us (W.CD.), who cone sistent had floating stools, was fortuitously noted to have a CH, exeretion rate of néar record propor tions. Therefore, end-alveolar CH, concentration wat determined” in each subject’ as previously reported* and recorded. a8 parts. per million (ppm) vive atsphesie CH, ‘concentration. (about 13 ppm " aastly, the CH, and hydrogen content of stools of four heaithy subjects wae determined by homagen! zation of a known weight of stool {about 30 in « Sealed 00-m Aask that contained 200 ml of water And 800 rl of air. The air phase was then analyzed Tor CH, and hydrogen concentration’ by" xas chro: inatography. The partition cocficients between wa ter and gas for Hydrogen ‘and CH, are such. that tore than 99 per vent of each of these gases would the contained in the as phase. The quantity ofc oF these eaves present inthe stool could he cilealat fl from the volume of the yas space and. the con- entrition of each jas in this spice. ‘The total vol time of ais in the. stool specimen was calehted fram the increase in density that resulted when the specimen vas dejinsed Resunrs All floating: stools sank upon application of posi tive pressine, The critical sinking, pressure of stools from normal subjects ranged from 20-t0 140 mim of mercury. Four of the six stetorrheie stools floated, card Okom THE NEW ENGLAND JOURNAL OF MEDICINE with evitieal sinking pressures ranging fiom 3040 380) mim oF mercury All sinking stools could he made to float upon application of negative pressure, with ctitical Aoating pressures ranuing from —80 to —600 mm of mercury, Accurate: measitrement of critical floating pressures was difficult hecatise of the tendency of specimens to lose gas when subjected to neyative Dressure. The specific gravity of stools before and after degassing is shown in Figure 1. Floating stools from healthy subjects had a specific gravity. of 0.9876 + (0.0066 (aean © 1 S.E.), which increased to, 1.0896 = 0.0081 after degassing. Sinking stools of healthy 1209) Sy Specitie Grovi “Figs Shing Steaioreie Seat See ta Figure 1. Specific Gravity (Mean = 1S) of Stools in Nav tive (Gaseous) State (@) and alter Degassing (0). subjects had a mean specific geavity of LOS64 = 0.0040, which increased upon degassing to 1.0921 = 0.0034) a value virtually identical to that of the de- gassed floating stools The specific gravity of steatortheic stools in. creased from 0.864 to 1.0435 after yas removal The specific wravity of the nongaseous portion of the steatortheic stools. was significantly Less (p Tess than O01) than that of healthy subjects The fat concentration of the stools expressed as per cent wet and per cent dey weight is shown in Table I. There was no significant difference in the fat concentration of floating and sinking stools from healthy subjects, ‘The fat concentration of stools from subjects with steatorrhea was significantly greater thin normal when expressed as per cent wet Weight (p less than 0.05) of per cont dry weight (p Tess than 0.01), The mean concentration of CH, in expired air was much greater in the healthy subjects with Rating, stools (252 = 4.6 ppm) thaw in those with sinking stools (182 = 0.3 ppm), Eight of the nine ‘Table 1. Fat Concentiation of Stools from Healthy Subjects nd Patients with Steatortnea * Scan ‘SrneSieerouan astos | astost 5630) wes ob wes May 4 12 subjects with floating, stools had a breath CH, eo centration of greater than, 7 ppin whereas only two of the 24 subjects with sinking. stools hid « breath concentration greater than 7 ppm. Only one of the four subjects with steatorrhea snd floating stools hcl a breath CH, concentration of greater than 7 pp, The CH, aid hydrogen content of four stools was measured. ‘CH, comprised 64 per cent and 72 per cont of the sas present in two floating. stools ob- tained from high methane exeretors, whereas. this sas represented less than I per cent of the stoot gas of sinking stools obtained from two non-CH, pro: ducers. Hydrogen made up less than 2 per cent of the sas present in each of the four stools tested, Discussion. The question of the relative importance of flatus brersus fat as the cause of floating stools appears to he resolved in favor of flatus} Stools obviously must ‘contain & certain critical voTome of gas to float as evidenced by the fut that all floating specimens Sank when their gus volume was compressed by application of positive pressure. "The question remains, however, of the extent to which an increased fat content might assist in this Floating tendency Tt is clear that fat content has no role in determin ing whether stools from healthy subjects float or sink. After degassing, previously floating and sink- ing stools had similar specific gravities, indicating that the differences in buoyancy of these. specimens in ther native. state was entirely. attributable to differing ‘gis contents. This observation was confirmed by the finding that there was no relation hetween fat concentration and the floating or sink ing disposition of normal stools Why some. healthy subjects, should consistently have an ‘excessive quantity of gis in their stools I. hence, have floating. stools appears to be larke- is'explained by stool CH, content. GH, is a hacte al product produced in the eolon®absorbed into the blood snd then excteted by the lungs. With the use of breath CH, as an assay’ of colonic production, it has been shown that some subjects. consistently produce larte quantities of this sais whereas others produce little or none? Most normal subjects who pass Hosting stools produce large quantities of CHy. Some of which hecames entrapped in the fecal am ter. The failure to Rnd appreciable quantities of fecal hydingen, another bacterial product, is due to the act that normal, formed stoals lack the fermentable Dhiline homogenate of stool froma CTTprodueing Subject. produces CI whereas hydrogen is not formed dtil a fermentable sugar is added to the homuogenite.t "Althowgh the question was not sthalied, itis possible that patients. with ‘earbohy Grate malabsorption would hive appreciable quanti ties of hsdrowen in their took. The lave desnity of foeal specimens from patients with steatorthea resulted fran combination of & mean sew concentration roughly” similar to. that ob- Served in sinking stools of healthy subjects and a hhomaaseons portion af stood that had a specific kravéVol, 286 No. ty (mean of 1.0135) significantly less than that ob- served for normal subjeets (mean of 1.0916). The low density of this nangascons fraction coutd result from an increased concentration of water oF fat. The averige fat concentration. of steatorrheie stools averaged about 5 per 100 x more than that of normal stools. Assuming a density for fat of 0,805 (the density of oleic acid at 21°C), one et caleulate that this excess fat reduced the specifi gravity of the nongaseous fraction from a theoretical Value of 1.0538 to the observed value of 1.0495, Thus, the low density of the nongaseous portion of steatorsheie stools was apparently attributable larg Isto an increased. water rather than fat content. Theoretically, it would be almost impossible for a stool to float solely on the basis of its fat content without the assistance of yas. The quantity of stool passed per day by normal subjects is highly vari- able, averaging 125 4 in one study.* Since the specific gravity of the nongaseous component of Stool ig about 1.0916, approximately 125 x of fat would have to he added to this daily specimen to vce its density to less than that of water, Although the stools of patients with malabsorption LOCAL, ANESTHESIA—COVINO 5 probably have am inerewsed tendeney to Hlout, the clinical valve of this information must be tempered by the knowledge that itis primarily the gv and water content rather,than the fat that promotes this buoyaney, and that(Aoating stools are. frequently Jobserved in healthy subjects, primarily those who excrete large quantities af CH, o Mes. Jean Brandt for technical assit- We are inde ance with this project RerEnENces FriednerS, Moterg S: Determination of total fac! lis includ tne mediamehaintelycenden Cin Chm acta Weh45 38), 1967 Med anaes8e 1 5. Lest! MD: Proton and excretion of hydrogen as in mu! N eg) Meg 201:102-197, 1969 4. Lest MD, Donaldson RM Use of respiratory hysroven Seton o detect carbohydrate melabsorpion. J Lab Clin Med Soares 190 5. Skit Krondl'A, Vulrnosé Mets: Composition of fees in Seaorthea of diferent tology: mala telalonship between the ‘olume of fees wate dry mater” srogen, and fat content. AS J Big Ba Hh 0a2T2, Tae MEDICAL PROGRESS LOCAL ANESTHESIA (First of Two Parts) Bexyasun G. Covino, Px.D., M.D. [OCA mesthesa is defined as toss of foting of Sensation that is confined to a circumscribed area of the body. This loss of sensation most com: monly results from an inhibition of the conduction process in peripheral nervous tissue. Nerve condi tion can be altered by many different means — e.g, mechanical trauma, low temperature, anoxia and variety of chemical irritants such as alcohol or phenol. In clinical practice pharmacologic agents usually employed produce ‘a transient and completely reversible state of anesthesia in the area where loss ‘of sensation is desired. Local-anesthetic agents dilfer considerably from most other classes of digs, For example, local-an- cesthetic agents are applied directly to the region of the body in which they exert their desived pharma- cologic action wheres most other dns are admin: istered parenterally or orally and then transported by the ‘circulatory system to their target organ, which is, Tocated at some distance from the site of idiministration. In addition, localsmnesthetic sol tions are administered _most commonly by trained clinicians on an aeute basis — e., patients usually fare exposed to local anesthetic agents in a hospital Or office setting, on one decasion and may never be exposed again or only after a gonsiderable time has chipsed. Because of these peculiar features chemical Componnds that frequently possess Tower thers sequcay shuld he altessed to Dr, Cevin. peutic ratios than normally would be considered Clinically desirable have heen “employed for the produetion of regional anesthesia. Considering this relatively narrow safety margin and the widespread tise in both the medical and dental professions, the frequency of adverse effects associated with local anesthetic agents is remarkably low. For example, retrospective and prospective studies™ of peridural find spinal anesthesia involving more than 10,000 patients per study and a variety of anesthetic agents have demonstrated complications associated with the anesthetic procedure in 0.3 to 1.4 per cent. A review of the world literature for peridural anesthe- sia conducted hy Dawkins in 1969 involving more than 60,000 cases revealed a 0.2 per cent frequency of toxic reactions Since many of the adverse reac tions reported in these surveys are attributable to the anesthetic technic itself or other fuctors unre lated to the localanesthetic agents employed, true ding toxicities must be even Tess frequent than the Fixures reposted above. Although local anesthesia has heen an accepted, clinical procedure for many years and the use of Tocalanesthetic aents has heen widespread in the ener population, basic pharmacologic knowledge about this group. of agents has, been relatively Sparse until recent years. The purpose of this repo is to review the currently available information com coming local anesthesia and the pharmacodynamic, pharmacokinetic and tesicologie properties of agents Commonly employed for regional anesthesia,