METHODS OF PRECISION 
IN THE 
INVESTIGATION OF 
DISORDERS OF DIGESTION 
By J. H. Kellogg, m. D. 
Superintendent of the Sanitarium at Battle 
Creek, Mich., Member of the American 
Medical Association, Michigan State 
Medical Society, American Public Health 
Association, British and American As- 
sociations fwn the Advancement of Sci- 
ence, American Microscopical Society, 
American Social Science Association, 
Mississippi Valley Medical Association, 
Societl D' Hygiene of France, British 
Gynecological Society, and of the Inter- 
national Periodical Gynecological Con- 
gress. 
modern medicine PUB. CO. 
Battle Creek, Mich. 
>893- METHODS OF BREOSWN. 
IN THE 
INVESTIGATION OF DISORDERS OF DIGESTION 
READ BEFORE THE CINCINNATI MEETING OF THE MISSISSIPPI 
VALLEY MEDICAL ASSOCIATION, OCT. 13, 1892. 
BY J. H. KELLOGG, M. D. 
Superintendent of the Sanitarium at Battle Creek, Michigan, Member of the Ameri- 
can Medical Association, Michigan State Medical Society, American Public 
Health Association, British and American Associations for the Ad-, 
vancement of Science, American Microscopical Society, Amer- 
ican Social Science Association, Mississippi Valley Med- 
ical Association, Societe D’ Hygiene of France, 
British Gynecological Society, and of 
the International Periodical 
Gynecological Coijgress. 
MODERN MEDICINE PUBLISHING CO. 
Battle Creek, Mich. 
1893. METHODS OF PRECISION IN THE INVES- 
TIGATION OF DISORDERS OF 
DIGESTION. 
It is not my purpose to undertake to survey, within the 
narrow limits of this paper, the whole field of gastric pathology 
as related to diagnosis. I shall only call attention to some of 
the newer methods of diagnosis relating to functional disorders 
of the stomach, particularly disturbances of the chemico-vital 
processes of digestion, by means of which exact, rather than 
merely presumptive, data may be secured upon which to base 
a rational mode of treatment in each individual case. The 
desirability of more precise methods than those which have been 
heretofore employed, has long been felt by all intelligent prac- 
titioners. In no class of curable diseases does the physician, 
even though aided by the skill acquired by long experience, 
find himself so often completely baffled as in the treatment of 
the functional disorders of digestion. 
While it is doubtless true that the difficulty of inducing a 
patient to follow the dietetic prescriptions requisite for a cure, 
is often responsible for failure, as well as the inability of the 
physician to make an exact diagnosis of the morbid condition 
present, it is, perhaps, equally true that our inability to com- 
mand obedience on the part of our patients is not infrequently 
the result of our frequent blunders, which lessen the confidence 
of our patients in our ability to prescribe a dietetic regimen 
with efficient accuracy. 
A patient who has for weeks or months faithfully carried 
out the dietetic directions arranged for him by his physician, 
but finds himself still suffering from the same disorders as at 
the beginning, if, happily, his sufferings have not been aggra- 
vated by the experimentation to which he has been subjected, 4 
THE INVESTIGATION OF 
naturally becomes skeptical of the practical value of “dieting,” 
and perhaps loses respect altogether for the science of medical 
dietetics. It is no wonder that such patients are generally 
more ready to rely upon the results of their own observation 
and experience than upon the dictum of their physicians. 
Neither is it surprising that physicians often become disheart- 
ened in their attempts to prescribe therapeutic dietetics for 
their patients, and content themselves with the empirical em- 
ployment of various palliative antidotes or ingenious methods 
of “toning up” or “toning down” the activities of the stom- 
ach by means of stimulants or sedatives, as the case may seem 
to require, leaving the patient to manage his dietary according 
to his own tastes or judgment. 
Doubtless the late eminent Dr. Austin Flint had spent many 
years in baffled attempts to find the royal road of dietetics for 
the various classes of dyspeptics who consulted him, before he 
arrived at the conclusions which led him to give to his students 
such advice as the following, which the writer took from his 
lips, and which was doubtless heard during his lifetime by 
some of those present: “ When a dyspeptic patient asks you 
the question, What shall I eat? reply, Eat what you like. If 
he asks, How much shall I eat? say to him, Eat as much as 
your appetite demands. If he still asks, When shall I eat? 
answer, Eat when you are hungry.” Briefly stated, Dr. Flint’s 
advice to a man with a disordered digestion as regards his 
diet was, Eat what you like, as much as you like, and when 
you like. 
Since this has been the rule in diet with the great majority 
of those who seek advice for stomach disorders, it is evident 
that Dr. Flint did not recognize any important relation what- 
ever between diet and disease, —a state of skepticism in which 
many physicians have found themselves after a similarly wide 
and disappointing experience in attempting to adjust the known 
to the unknown in making dietetic prescriptions for stomach 
disorders, the nature of which could only be guessed at. 
Equally suggestive of the state of almost utter ignorance 
which has prevailed in the profession respecting the functional 
disorders of the stomach, is the enormous and indiscriminate 
consumption of pepsines, peptones, peptonoids, and digestives 5 
DISORDERS OF DIGESTION. 
and digested foods of names and forms almost too numerous to 
mention, which are administered and swallowed with the hope 
that they will do good somehow, without any clear idea as to what 
morbid condition is present, or how it is to be relieved by the 
particular agent employed. 
The demand for these digestive agents has become so great 
that even the great beef and pork packers have gone into the busi- 
ness of making pepsins, beef extracts, peptones, etc., and we 
may expect soon to see these articles sold by the grocers along 
with the pork and potatoes, beef, bread, beans, etc., that they 
are supposed to help digest. Perhaps we shall even be able to 
buy our food with the proper amount of digestive agent already 
mixed with it, so that we shall need to take no thought for our 
stomachs or those of our patients, provided we have full faith 
in the value of the products of artificial digestion. 
The great faith in pepsin, which has given rise to this enor- 
mous consumption of artificial digestive agents of various sorts, 
is an evidence of the almost universal lack of knowledge respect- 
ing the real nature of the chemical vital changes which con- 
stitute the process of digestion. 
Mosso, several years ago, called attention to the fact that 
the pepsin required for the digestion of an ordinary meal is al- 
most insignificant in amount, and that this agent is rarely ever 
found deficient in morbid conditions of the stomach. One of the 
most striking experiments made by this investigator and his col- 
leagues, consisted in passing through the stomach of a dog, two 
thousand litres of water acidulated with hydrochloric acid. 
The digestive activity of the acid solution thus treated was found 
to be sufficient to digest seventy-five kilograms (165 pounds) of 
egg albumen. In other words, the dog’s stomach is capable 
of furnishing pepsin enough to digest 165 pounds of meat at 
a single meal,— doubtless five or six times the animal’s own 
weight. 
Within recent years the important investigations respecting 
the chemistry of digestion, which have been carried out by vari- 
ous German and English physiologists, have thrown such a flood 
of light upon the digestive process that great hopes have been 
raised that more precise and exact methods might be discov- 
ered for the treatment of digestive disorders, which constitute by 6 
THE INVESTIGATION OE 
far the largest share of all the ailments that come under the oh 
servation of the general practitioner. 
Special interest was aroused by the recent excellent work of 
Ewald, whose methods of investigating functional disorders of 
the stomach by means of an examination of the stomach fluid, 
were quite generally adopted in Germany, and to some extent 
in England and this country. The interest at first aroused by 
the new methods introduced by Ewald and his collaborator, 
Boas, rapidly waned, however, when it was discovered that a 
very great and irreconcilable inconsistency existed between the 
results promised and those attained. Many of the methods 
which they proposed are most excellent, and are certainly a 
great improvement over methods which have previously been 
employed; but a single point of Vital weakness in their method 
has rendered the practical results obtained through it most 
uncertain and disappointing. 
Following the view of Bidder and Smith, they assume that 
whenever free HC1 is found present in a given gastric fluid, the 
acidity of the fluid in question is due to HC1. They accord 
ingly determine the digestive value of a given gastric fluid by 
first ascertaining the presence or absence of free HC1 by means 
of Congo-red and methyl-violet, or other color reagents, and 
then determining the total acidity by the ordinary methods of 
acidimetry. A determination of the total acidity by acidimetry 
furnishes an estimate, not only of the amount of free 1ICI 
present, but of the free Cl plus that in combination, it is 
not true that shaking the gastric contents with ether, as pro- 
posed by the method of Ewald, will remove the organic acids 
present. Each acid, whether organic or mineral, has its own 
coefficient of solution in ether, when taken in the aqueous 
solution and shaken with the latter, but a very considerable 
amount is always left behind, certainly sufficient to constitute 
a most serious source of error. This mistake any one can 
verify for himself, by a simple experiment with an aqueous 
solution with lactic acid, first washing with ether as thoroughly 
as possible, then determining by means of a decinormal soda 
solution, the amount of acid present in the ethereal residue 
and that left behind in the acid solution. DISORDERS OF DIGESTION. 
7 
This method is especially faulty in that it furnishes no good 
means of determining the amount of free HC1 present, since the 
chlorine in combination with albumen possesses the same degree 
of acidifying function as does free HC1, so that with a given 
total acidity the chlorine present may be entirely in the form 
of free HC1, or may exist only in combined form. It is cer- 
tainly a matter of great practical importance to know whether 
the chlorine in a given gastric fluid exists in a free state, or 
whether it is combined with albumen ; and whether the rela- 
tion of the combined chlorine and the free HC1 is normal, or 
otherwise. 
Hayem and Winter, of Paris, have within the last two years 
perfected a new method which places the chemistry of the stom- 
ach upon the same exact basis as that which has been elabo- 
rated for analysis of the urine. It is now possible, by the 
employment of methods perfected by these investigators, to 
determine the quality of a given stomach fluid with even 
greater accuracy than we are able to determine by chemical 
means the characters of a given specimen of urine. After 
having employed this method in the analysis of more than 
400 specimens of stomach fluid, which were furnished by 
over 300 different patients, I consider myself in a position to 
speak with some degree of confidence respecting the value of this 
method and of the practical results to be obtained from it, and 
feel no hesitancy in pronouncing the method thoroughly accu- 
rate and reliable, and by all means the greatest advance which 
has been made in the diagnosis of disordered digestion, at 
least within the last half century. I translate from a work by 
Hayem and Winter, the following brief account of the an- 
alytical method pursued : — 
“Place in three capsules, designated respectively as a, b, 
and c, 5 c. c. each of the stomach liquid previously well filtered. 
“To capsule a add an excess of carbonate of soda; then 
evaporate all the capsules to dryness on the water-bath, after 
which proceed as follows : — 
“Carry capsule a progressively and cautiously to a red 
heat, avoiding a higher temperature. To hasten destruction of 
the organic matters, and to diminish the action of the heat, 8 
THE INVESTIGATION OK 
the dried residue should be broken and stirred frequently with 
a glass rod. 
“ The capsule should be withdrawn from the heat when the 
points of ignition are no longer visible, and when the mass 
becomes pasty by the beginning of the fusion of the carbonate 
of soda. 
“The calcination should be just sufficient to produce a col- 
orless solution. After cooling, add distilled water and a slight 
excess of pure nitric acid boiled, to drive off the excess of 
carbolic acid. Then neutralize the solution, or even render it 
slightly alkaline by the addition of pure carbonate of lime or 
soda. In employing carbonate of soda, the limit of alkalinity is 
indicated by an abundant precipitation of calcareous salts, 
which carry down all the carbon. 
“ After filtration with Berzelius’s filter paper, and washing the 
residue with boiling water, the amount of chlorine present is de- 
termined by a decinormal solution of nitrate of silver in pres- 
ence of neutral chromate of potash. 
“The addition, as stated above, of a slight excess of nitric 
acid, favors the separation of the carbon. The final addition 
of the carbonate of soda in very slight excess, increases the 
sensibility of the indicator without interfering with the reaction. 
“ Proceed in the manner above described, and taking all 
the necessary precautions, absolutely constant results may be 
obtained with the same liquid. The sensitiveness of the 
method with the chromate of silver is great. 
“The figures furnished by a, and expressed in HC1, rep- 
resent the total amount of chlorine contained in the stomach 
liquid. 
“(£.) After prolonged evaporation at ioo° C., for an hour 
after the disappearance of all liquid, add an excess of car- 
bonate of soda again; evaporate again, and proceed as before 
for the determination of the amount of chlorine present. 
“The figures furnished by capsule b represent the total 
chlorine, less that which has been driven off by prolonged 
evaporation on the water-bath, that is to say, less the free 
hydrochloric acid; a — b=free HC1. 
“ By evaporation on the water-bath at ioo°, the same results 
are obtained as in an oven at no°; but if the last temperature DISORDERS OF DIGESTION. 
9 
is exceeded, even very slightly, the mass gives off white fumes, 
and the results are vitiated. So, for constant results, it is 
better to employ prolonged evaporation on the water-bath. 
“(<r.) After drying, capsule c is calcined with care, without 
the addition of soda. By breaking the residue, the calcination 
is hastened, and requires but a short time. Here, especially, 
excessive elevation of temperature must be avoided. The heat 
is arrested when the carbon becomes well dried and friable. 
The capsule should be quite deep, and only the bottom should 
be touched by the flame, the upper portion being protected by 
wire cloth. After cooling, proceed as before. 
“The figures obtained from b represent the amount of fixed 
chlorides, consequently b — c will give the amount of chlorine 
lost during the calcination of the residue ’of capsule c, that is to 
say, the combined chlorine.” 
By comparing the results of the analyses of capsules b and 
c, there is found to be a difference in favor of b, in case the 
fluid examined is a product of normal digestion ; in other words, 
the chlorine represented by b is in excess of that represented 
by c, showing that chlorine exists in the gastric juice in another 
form than that of free hydrochloric acid, and fixed chlorides. 
The investigations of Richet, published a few years ago, showed 
that a considerable amount of chlorine exists in the gastric 
fluid, combined with albumen in the process of digestion. By 
subtracting c from b, the amount of chlorine so combined is 
determined. 
The fluid usually employed in the chemical analysis is.ob- 
tained by giving the patient a test breakfast consisting of two 
ounces of stale white bread and eight ounces of weak tea or hot 
water, without sugar or cream, and withdrawing the stomach 
fluid by means of a stomach tube one hour after the patient 
begins to eat. By this method four known quantities are ob- 
tained: — 
1. The total chlorine. 
2. The amount of free chlorine. 
3. The amount of chlorine combined with albumen. 
4. The amount of fixed chlorine. 
The four quantities thus obtained — two by analysis and 
two by subtraction — are represented as follows: — 10 
THE INVESTIGATION OF 
Total chlorine, T. 
Free.chlorine, H. 
Chlorine combined with albumen, or organic chlorides, C. 
Fixed chlorine, F. 
Having determined these four quantities by chemical analy- 
sis, the total aridity, represented by A, is next determined. 
A solution of Congo-red is employed as a qualitative test for 
the presence of free acids, and methyl-violet, Giinzburg’s rea- 
gent, or the resorcine and sugar test, is used to show the pres- 
ence of free HC1. The color reactions are, of course, simply 
confirmatory of the results obtained by chemical analysis, but 
are of comparatively little practical value, as they give no very 
positive idea respecting the quantity of free acid present. 
T represents the glandular work of the stomach, including 
also the amount of sodium chloride contained in the test meal, 
which must be a known and certain quantity. 
H and C together (H -f- C) represent the chemical work of 
digestion, which consists of two parts : — 
1. The breaking up of the chemical combination of chlo- 
rine with bases, and the production of free hydrochloric acid. 
2. The combination of hydrochloric acid with albumen, the 
first step in the process of hydration by which the albumen is 
converted into peptone. 
H represents the amount of free hydrochloric acid ready for 
combination with albumen ; C, the amount already combined. 
It is evident, then, that by a comparison of the figures ob- 
tained for T, H, and C, in the case of a given stomach fluid, 
with the figures presented by a normal stomach fluid, we have 
an exact means of appreciating any modification of the normal 
digestive work which may be the result of morbid conditions. 
By a study of the results obtained upon healthy dogs and in- 
dividuals, it has been shown that the quantity II (free IIC1) 
is always small in normal digestion, as compared with C (chlo- 
rine combined with albumen or organic chlorides). It is also 
found that combined chlorine (C) contributes as much to the 
acidity of a given stomach fluid, as the same amount of chlo- 
rine would do if in the form of free hydrochloric acid (HCl). 
By careful quantitative analysis, it has been shown that the 
total acidity (A) is chiefly due to H (free HCl) and C (com- DISORDERS OF DIGESTION. 
11 
bined chlorine). Lactic acid and acid phosphates contribute 
very slightly to the total acidity of the normal conditions, hence 
the formula under normal conditions would be, practically, 
H-f C=A. 
From this formula may be derived the following : — 
A—H 
C 
This is not absolutely true, however, as A, in small part, is 
made up of acid phosphates, and in the early stages of di- 
gestion also lactic acid. There are also present, even in normal 
cases, a small proportion of neutral or ammoniacal chloro-or- 
ganic compounds, so that normally we find .86, instead of i. 
This quotient is termed the coefficient of digestion, as it is a 
means by which a most important fact respecting the quality 
of the digestive process may be determined. This quantity is 
represented by a, Mihich we may term “coefficient a.” The 
practical value of coefficient a will be recognized by studying 
the following formulae, which result from conditions to be 
named : — 
In certain morbid states, the combinations of chlorine with 
albumen, or chloro-organic compounds, are, in large part, 
neutral instead of acid. Such compounds are the result of ab- 
normal products of digestion, and of no use from a nutritive 
standpoint. These neutral substances, while contributing to 
the value C, contribute nothing to the value A, consequently, in 
a case of this sort, we should have the formula A=H-|-C—C', 
in which C' represents the neutral chloro-organic compounds, 
instead of A=H-|-C. Transposing H, and dividing both mem- 
bers of the equation by C, as before, we obtain the formula, 
A—H C' 
~c ~~a cT’ 
in which it is evident that the coefficient a will be less than 
normal; that is, less than .86, because C is below par. The 
real value of C is diminished just in proportion to the amount 
of neutral organic compounds present. In cases of this sort, 
A is always small in proportion to (H -{- C). 
It not infrequently happens, however, that A exceeds 
the sum of H and C ; in other words, we have the formula, 12 
THE INVESTIGATION OK 
A=H-j-C-{-x, in which x represents the amount which A ex- 
ceeds the sum of H and C. Transposing H as before, and 
dividing both members of the equation by C, we have, 
A—H , x 
C — a+ C ’ 
in which it is evident that coefficient a exceeds the normal 
quantity. These cases are those in which normal digestion 
is complicated by acid fermentation. 
It is thus apparent that coefficient a serves a most useful pur- 
pose in two cases, in one of which it is less than normal, which 
indicates that the value of C is diminished just in proportion 
to the amount that a is diminished ; in other words, that the 
quality of the work done by the stomach is bad, just in pro 
portion as a is less than normal. On the other hand, when a 
is above normal, the indication is that acid fermentation is 
present, and in amount just in the proportion that a exceeds 
the normal quantity. We have here, then, a means of deter- 
mining two things, which by all previous methods have been 
left undetermined : i. The real quality of the work done by the 
stomach ; 2. The proportionate amount of products of acid 
fermentation present. 
Both these facts are of the greatest practical value. C is 
the index to the actual useful work done by the stomach ; but 
C may be large, and yet the value of the work done be noth- 
ing, in consequence of the catalytic changes upon which the 
chemical work of the stomach depends having taken a wrong 
direction, so that the chloro-organic compounds formed are 
neutral instead of acid. This condition will be shown by co 
efficient a, without which it could not be definitely deter- 
mined, although it might be suspected by the diminished value 
of A. On the other hand, when A is increased by acid (er- 
mentation, the fact might be taken as an indication of hyper- 
pepsia, instead of acid dyspepsia, if reliance were placed upon 
the total acidity taken in connection with the presence of fret- 
hydrochloric acid, as shown by color reagents, as in the method 
of Ewald and Boas, and wjthout the determination of the amount 
of free and combined chlorine and the value of coefficient a. 
By long and painstaking studies of the digestive process in 
healthy men and dogs, Profs. Hayetn and Winter have estab- DISORDERS OF DIGESTION. 
13 
lished the following figures as representing the normal limits 
of variation in healthy digestion : — 
Normal variations, l 
Total acidity (A) (0.180— .200 gms.) 
Coefficient (a) (-86) 
Total chlorine (T) (0.300 — 0.340 gms.) 
Free HC1 (II) (0.025—0.050 gms.) ( lgo_ 
Organic chlorides (C) .....(0.155—0.180 gms.) j 
Fixed chlorides (F) (o. 109 gms.) 
By the use of the above exact data, it is possible to 
represent the different states of digestion. In normal digestion 
each of the symbols would be followed by the signl = ; that is, 
the quantities represented by each of the symbolic letters in the 
formula are within the limits of normal variation as follows : — 
A=«=T=J?-}=. 
In typical hyperpepsia we have equal dominance of the 
sign as in the following formula: — 
H+U 
A+tf—T-f-C-j- I 
Hypopepsia is characterized by the sign —, giving us the 
typical formula : — 
H-l 
A—a=T—C— j • 
It is evident, however, that an almost infinite number of 
variations and modifications of these formulae is possible, ac- 
cording as one or all of the different elements of the digestive 
work are exaggerated or diminished. We may have, for ex- 
ample, an increased amount of gland work on the part of the 
stomach, with diminished chemical work, in which case T 
would be -f-, and the'sum of H and C —, (H -f- C)—. 
We may also have a sufficient amount of that phase of 
chemical work which consists in a liberation of the chlorine 
from the bases, together with an abundant secretion of fixed 
chlorine, coincident with the failure of the chlorine to combine 
with albumen, in which case our formula would be — 
i 
T + S±}-. 
l Quantity of chlorine expressed as HC1 in ioo c. c. of stomach fluid. 14 
THE INVESTIGATION OF 
We may even have an excess of chlorine set free, and yet a 
very great deficiency of combined chlorine, through the failure 
of the chlorine to enter into normal combination with albumen. 
Then we should have 
cH±b; 
or we may have H -f with C —, and the sum of H and C less 
than normal, shown by the formula, 
cHi|- 
It is evident that H and C, considered separately and together, 
represent the chemical work done by the stomach, especially 
when taken in connection with the quotient or coefficient a. 
In their study of pathological cases, Profs. Hayein and 
Winter have employed the following method of classification : — 
Considered with reference to the amount of stomach work 
done, pathological cases may be divided into hyperpepsia, 
hypopepsia, and an intermediate form, simple dyspepsia. Typ- 
ical hyperpepsia is expressed by the formula already given, in 
which all the qualities are above normal, or -(-, with the ex 
ception of a. It is rare, however, to find a case in which there 
is simply an exaggeration of stomach work. There is, almost 
without exception, some qualitative modification of the diges- 
tive process, the recognition of which is of the highest impor- 
tance. This leads to the subdivision of hyperpepsia into two 
classes, quantitative and qualitative, in which the character- 
istic deviations from the normal digestive process are, respect- 
ively, a simple exaggeration of stomach work, and a qualitative 
modification of the character of the work done. 
Both these classes, qualitative and quantitative hyperpepsia, 
are again subdivided into two varieties, this division being 
based upon the simple difference in degree, the lesser degree 
being only an attenuated form of the higher degree of simple 
qualitative or quantitative with qualitative change. The term 
** attenuated ” is used to designate the less pronounced variety. 
We thus have simple quantitative hyperpepsia, and quantita- 
tive hyperpepsia attenuated, and also hyperpepsia qualitative, 
and hyperpepsia qualitative attenuated. DISORDERS OF DIGESTION. 
15 
A still further subdivision of the principal classes of hyper- 
pepsia is based upon the presence or absence of acid fermen- 
tations ; so that, in all, we have six types of hyperpepsia. 
The basis for the subdivision of cases of hypopepsia chosen 
by Hayem and Winter is a wholly artificial one. They make 
three degrees of hypopepsia, in all of which we of course find 
A —. Cases in which A is less than normal, but above ioo, 
are designated as hypopepsia of the first degree ; those in which 
A is less than ioo, and still a measurable quantity, are desig- 
nated as of the second degree. Cases in which A is nothing 
are placed in a third class, apepsia. 
These three classes are, with the exception of the third, each 
subdivided, as in the case of hyperpepsia, into two types, ac- 
cording as acid fermentation is present or absent. In the third 
class there is no acidity and hence no fermentation. 
With reference to cases of hypopepsia, the value of A be- 
comes a matter of great interest. The total acidity is not in- 
frequently found to give a very high figure, notwithstanding the 
existence of hypopepsia in a very marked degree, evidently as 
the result of the excessive acid fermentation which is very 
likely to be present in this class of cases, owing to the defi- 
ciency of free hydrochloric acid, the natural antiseptic of the 
gastric juice. Before the classification of cases of hypopepsia 
can be properly made, we must determine the true value of 
A, that is, the amount of acidity due to the normal acid ele- 
ments of the stomach fluid, the free HC1 (H), and the organic 
chlorides or chloro-albumen compound (C). 
The method of Ewald and Boas, which determines the 
quality of the digestive fluid by measuring the acidity and ascer- 
taining by color reagents the absence or presence of hydro- 
chloric acid, is thus notably defective, since it practically con- 
siders acidity to be normally due to free'HCl (H). Normally, 
as above stated, A is composed of free HC1 (H), combined 
HC1 (C), and a small amount of lactic acid and acid phos- 
phates. In pathological cases, however, the greater part of 
A may be composed of acids of the fatty series, — lactic, 
acetic, and butyric,— resulting from fermentation. 
The determination of the presence of these acids by color 
reagents is a somewhat uncertain process, and sometimes en- 16 
THF. INVESTIGATION OF 
tirely fails, while any quantitative estimation relating to fatty 
acids is quite out of the question in the examination of stom- 
ach fluids, in consequence of the small amount of material 
usually available in an individual case. 
The great advantage of the method of Hayem and Winter, 
and its remarkable exactness, is well shown in the ease with 
which it enables us to determine the true value of A. Re- 
turning to the formula, 
A —H 
= a 
C 
we have, by multiplying both members of the equation by C, 
and transposition, A = (a X C)-f-H. To ascertain the true 
value of A, which we may designate A', in any given case, we 
have only to substitute in this equation the normal value of 
a, .86; then making the simple calculation indicated by the 
formula, we have at once the true value of A. The following 
case will illustrate the value of this method in the determination 
of the true value of A : — 
In a case of very pronounced stomach disorder of long 
standing, the figures found for A were .313 mgs., and for a, 
5.14. It should be remembered that the figures for A repre- 
sent the acidity expressed in milligrams of HC1 per 100 
c.c. of the stomach fluid examined. In this same case, H 
was found to be .056, and C, .050, reaction for fatty acids 
negative. Following the method above indicated, we find the- 
value of A' to be 99, from which we discover at once that 
there is an enormous diminution of useful stomach work, 
although there happens to be a considerable amount of free 
hydrochloric acid present. The high figure of a, and the figures 
obtained for A' show at once the cause of the hyperacidity in 
acid fermentation, notwithstanding the failure of the reaction 
for fatty acids, which we have found, as doubtless have most 
other physicians who have made a careful study of the chem- 
istry of the stomach, is to a high degree unreliable. 
The classification of cases of hypopepsia is necessarily 
in part based upon the value of A', and not solely upon that 
of A. This gives rise to a sub-type of hypopepsia character- 
ized by pseudo-hyperacidity, in which A is +, although DISORDERS OK DIGESTION. 
17 
A'is—. These cases are found in the fermentative types of 
hypopepsia. 
In the careful chemical study of more than 400 cases, 
by the methods of Hayem and Winter, I have found a con- 
stant confirmation of'their results, and a demonstration of the 
great advantages presented by this method over all others. 
I have found, however, a number of interesting cases in 
which the type is decidedly different from any of those in- 
cluded in the classification of Hayem and Winter, which seems 
to require some modifications of their scheme of classification. 
This will appear more clearly after the study of a series of 
illustrative cases. 
Before presenting a series of cases illustrative of the differ- 
ent types and varieties of stomach disorders as relates to the 
disturbance of the normal chemical processes of digestion, it 
may be well to recall briefly the significance of the different 
quantities which furnish the basis of classification. These 
quantities, represented by the symbols (A), (A'), (a), (T), (H), 
and (C), each teach an important fact in relation to digestion. 
(A) represents the total acidity which is normally due almost 
wholly to free IIC1 and the combined chlorine or chloro-organic 
combinations present in the gastric juice, only a very small 
percentage of acidity being normally attributable to lactic acid 
and acid phosphates. In normal conditions, the total acidity 
is not less than .180 grams, nor more than .200 grams in 
100 c. c, of stomach liquid, the acidity being represented as 
anhydrous HC1. 
(A'). When the total acidity is greatly increased by the 
products of acid fermentation, it is important to know what 
portion of the acidity is due to normal elements, and how 
much must be attributed to lactic acid or to other members of 
the series of fatty acids. A' is found by multiplying the 
quantity C by .86, the normal coefficient, and adding H, 
as indicated by the formula, A' = (a X C) -f- H. 
(a). This quantity, obtained from the formula, 
A—H 
C “ a> 
has for its normal value, .86. A higher figure represents the 18 
THE INVESTIGATION OF 
presence of abnormal acids resulting from fermentation. A 
lower value shows the presence in the quantity C of neutral 
chloro-organic combinations having a resemblance to normal 
digestive products, but without nutritive value, and which con- 
tribute nothing to the acidity of the stomach fluid. Both of 
these facts are of great importance, especially as the information 
conveyed by them can be obtained in no other way. The value 
of a as a means of determining the quality of the chemical 
work done by the stomach will be readily appreciated. When 
below the normal figure, it indicates with certainty that the 
value C is depreciated by neutral chloro-organic compounds; 
but the amount of this depreciation is not so clearly indicated 
by the lowered value of a as is the amount of acid fermenta- 
tion by its increased value, since the neutral compounds in C 
may be, to a greater or less extent, neutralized by the products 
of acid fermentation. Thus, while we are able to say that acid 
fermentation is present whenever we find a above the normal 
figure, we cannot with equal certainty say that acid fermentation 
is not present when a is less than the normal figure. 
This fact is clearly shown by one or two remarkable cases, 
the details of which will be given later in this paper, in which 
the value of a is oc, being represented by a fraction with a 
whole number for a numerator, and zero for a denominator, 
C-) 
Here x represents the amount of acidity due to the products of 
acid fermentation. It is evident that C might in a given case 
possess such a value, although wholly composed of neutral com- 
pounds, as to mask completely the value x, thus hiding the 
presence of the abnormal acids. The amount of acidity due 
to the products of fermentation which can be hidden in this 
way, is, however, comparatively so small that this fact docs not 
materially lessen the value of a as an index to the quality of 
the chemical work done in the digestive process, and it may 
properly be regarded as the coefficient of digestive work. It 
snoukl be remembered that a represents, not a definite quantity, 
but simply the proportion which exists on the one hand between 
the acidity normally due to the chloro-organic compounds, or 19 
DISORDERS OF DIGESTION. 
C, and the increased acidity due to the presence of the products 
of acid fermentation, or the diminished acidity due to the 
presence of neutral compounds in C. When a is found to be 
zero, as we have observed in a number of instances, the indi- 
cation is positive both that acid fermentation is wholly absent, 
and that C is wholly composed of neutral and worthless com- 
pounds. a becomes oo when C is o, and when A exceeds H, 
the result obtained by subtracting H from A in this case repre- 
senting exactly the amount of acidity due to acid fermentation. 
The significance of a when found to be oo, is readily shown 
by the following formulae : — 
Recalling the formula A = H -f- C -f- x, in which x represents 
the products of acid fermentation, and the formula derived 
from the foregoing 
A — H x 
C ~ 1 + C* 
it is clear that in any case in which C = o, we shall have 
A — H x 
= — , or oo. 
o . o 
In such a case A is wholly composed of the products of acid 
fermentation, and there is no useful work done by the stomach. 
Such cases might perhaps be classed as apepsia. 
(T) represents the total chlorine, making allowance for the 
amount of chloride of sodium taken in the test-meal, and indi- 
cates the total amount of gland work done in the stomach in 
the secretion of fixed chlorine; that is, chlorine combined with 
bases. 
(H) represents the amount of chlorine which has been set 
free under the vital influence of the stomach work, and is ready 
to enter into the digestive process proper, by combining with 
albumen. 
(C) represents the amount of chlorine which, after having 
been set free from the bases, has entered into combination 
with albumen, and thus has taken part in the digestive process. 
When C has its proper acid value, that is, when a is = or 
it represents the useful chemical work done by the stomach. 
The sum of Hand C represents the total amount of chlorine set 
free from the bases, or what might be termed the preliminary 
chemical work done by the stomach. 20 
THE INVESTIGATION OK 
In considering from a therapeutic point of view the results 
obtained by the chemical analysis of stomach fluids, it is nec- 
essary especially to keep in mind the four possible kinds of 
work done in the stomach : — 
1. Gland work, represented by T. 
2. Preliminary chemical work, represented by H -f C. 
3. Useful chemical work, represented by C taken in connec- 
tion with a. 
4. Vicious chemical work, or fermentation, indicated by the 
increased value of a. 
Within the last six months, more than 600 analyses of stom- 
ach fluids have been made under the writer’s supervision in 
the Sanitarium Laboratory of Hygiene, the fluids analyzed hav- 
ing been obtained from nearly 500 different cases. The cases 
studied in this paper number 321, and the number of analyses 
413. A careful study has been made of the results obtained 
by each analysis, together with a careful comparison with 
the symptoms presented by the patient. It is not intended 
to present in this article even a brief summary of all the interest- 
ing facts which have been noted, but merely to give a suffi- 
cient number of cases to illustrate each one of the leading 
forms of disturbance in the digestive process which have 
been observed. 
Before presenting these illustrative cases, it must be stated 
that the study of this large number of cases has brought to 
light a considerable number of forms which were not noted 
by Hayem and Winter in their investigation, which involved 
only 200 analyses, and a considerably smaller number of cases. 
Vs the work progressed, the increasing number of new forms 
finally became so great as to compel me to undertake a new 
classification, the necessity for which has become more and 
more apparent by the constant discovery of a marked differ- 
ence as regards therapeutic requirements existing between 
cases grouped by Hayem and Winter in the same class. The 
classification herewith presented is certainly not above criti- 
cism, and whether or not it is any improvement upon classi- 
fications previously presented, will appear only after it has 
been subjected to the ordeal of examination by those corape- 21 
DISORDERS OF DIGESTION. 
tent to estimate its value, and the test of a longer experience. 
It is offered simply as the best attempt the writer can make at 
the present time toward grouping the various forms of disturb- 
ance in the chemical processes of the stomach in such a manner 
as to show at a glance both the therapeutic indications and the 
relation of each individual form to dissimilar or cognate forms. 
The classification offered ought not perhaps to be termed an 
entirely new one, as it recognizes many of the same principles 
as that madp by Hayem and Winter. 
As in the classification of Hayem and Winter, the term hyper- 
pepsia is used to indicate an excess of stomach work, and hypo- 
pepsia, a deficiency of stomach work ; hyperhydrochlorie, an 
excess of free HC1 (H -f), and hypohydrochlorie, a deficiency of 
free HC1 (H —) I have used the term hyperclorhydrie to indicate 
an excess of combined chlorine (C -f-), and hypochlorhydrie, a 
deficiency of combined chlorine (C—). The terms hyperacidity 
and hypoacidity are self-explanatory. The principles upon 
which the classification is based are as follows : — 
Three great classes are recognized,— 
I. Hyperpepsia, in which an excessive amount of both glan- 
dular work and chemical work are done. 
II. Hypopepsia, in which there is a notable diminution in the 
stomach work; if not always in the glandular work, in the 
chemical work. 
III. Simple dyspepsia. 
Each of these classes is again subdivided. 
Hyperpepsia is divided into three groups, the characteristics 
of which are,— 
(a.) H -J-, free hydrochloric acid in excess. Hyperpepsia 
with hyperhydrochlorie. 
(b.) H—, free hydrochloric acid deficient. Hyperpepsia 
with hypohydrochlorie. 
(c.) C —, a deficiency of combined chlorine or of useful 
chemical work. Hyperpepsia with hypochlorhydrie. 
We always find C+ in groups (a) and (b), and H-|- in group (c). 
Groups (a), (b), and (c) are each divided into sub-groups, 
in which we find, respectively, A -f, and A—, or hyperacidity 
and hypoacidity. 22 
THE INVESTIGATION OF 
We have a still further division of sub-groups into two types, 
as acid fermentation is present or absent, as indicated by 
coefficient a. 
In group (c), characterized by hypochlorhydrie (C —), or 
a failure of the free HC1 to combine with the albumen, form- 
ing thus an organic chlorhydrate, we have three sub-groups char- 
acterized respectively by (i), hyperacidity; (2), hypoacidity; 
and (3), pseudo-hyperacidity (A -}- A'—). (1) and (2) have 
each two types, with and without fermentation, (3) of course 
presenting but one type, fermentation being always present. 
Group (c) presents also a fifth sub-group, in which the amount 
of acid fermentation is so great that A -}- A'— is found. 
Hypopepsia. — The basis chosen-by Hayem and Winter for 
the classification of hypopepsia is followed, three classes being 
formed, in the first of which A or A' is less than normal but 
above . 100, and in the second, below . 100; in the third, or apep- 
sia, A is o. A' is necessarily always —,in hypopepsia. In each 
of the first and second degrees of hypopepsia, we have two sub- 
groups, A—and A-J-, or hypoacidity and hyperacidity. A — 
presents two types, as acid fermentation is absent or present. 
A-f- presents, necessarily, but one type, that of acid fermenta- 
tion. This type is conveniently termed pseudo-hyperacidity, 
as the total acidity may be high, although the value of A due 
to the normal elements of gastric juice, or A', may be small. 
As above indicated, I have found cases of pseudo-hyperacidity 
in hypopepsia of the second degree (a number of cases), 
although Hayem and Winter in their smaller number of cases 
observed this type only in hypopepsia of the first degree. 
Simple Dyspepsia.— I have divided simple dyspepsia into two 
classes : — 
(a.) Cases in which acid fermentation is absent. 
(b.) Cases in which acid fermentation is present. 
Each of these groups is divided into two sub-groups. The 
basis taken for the subdivision of group (a) is the value of 
coefficient a, which may be (1) =, or (2)—. In group (b) the 
basis of subdivision is the value of C, which is (1) -}-, and (2) —. 
The utility of this classification from a therapeutical stand- 
point will be seen when we consider the therapeutic indications 
of each of the several classes, sub-classes, and types recog- CLASSIFIED REPRESENTATION OF THE VARIOUS DISORDERS OF THE CHEMICO-YITAl 
PROCESSES OF DIGESTION * 
Prepared by J. H. KELLOGG, M. D., Superintendent Battle Creek Sanitarium 
and the Sanitarium Laboratory of Hygiene, Battle Creek, Mloh. 
Hyperacidity 
(A+) 
—a. f... A-j- ft—;=T ;= 
-j-a. f... A-|- «-{- T+ 
St i 
"t i 
si 
H- j 
C+ 
II— 
C+ 
H— 
8 5 
st i 
St 
St i 
St i 
H-; 0;=( 
II—;=; 0 | 
C-;=;+ i 
11 —;=» | 
—;=;4 ! 
H—; 0;=( 
C-; 0 I 
II—;=; 0 I 
C—; 0 I 
11=;— j 
C- 
II 0 1 
C- 
H=;—;+1 
C+; j 
11=;- l 
c+;= ! 
H=;- I 
C+ 
11= j 
c_ 
4* 
+ 
+ 
+ 
+ 
+;= 
+ 
=;+ 
—**=;+ 
—»=;+ 
—r= 
—^=j 
+;*= 
=;+;— 
“i+ 
H yperhyd rochlorie 
(H-f-) 
(Free HCI in excess) 
HYPERPEPSIA 
f—a. f... A 4- a—;=T=;-4~;— 
!+••*... A+ «+ T+;-v- 
-—-II. f . . • A*— rt— I -j-Js 
Hvpohydrochlorie 
(H—) 
(Free HCI deficient) 
Hyperacidity 
(A+) 
Hypoacidity 
. (A-) 
a. f... A— a— T=;+ 
Hyperacidity 
(A+) 
—a. f... A+ a— T+ 
-|-a. f... A+ <i+ T+;= 
//> \ 
lypucniurnyiine (t—; 
(Combined Cl deficient) 
—a. f... A— ti— f-f-jssj— 
-J-a. f... A— fl-|" T“ 
+a. f...A+ T-f-;— 
HYPOPEPSIA A'- 
1ST DEGREE 
A or A'—, but above 
.100 gms. 
(—•'•••A- - T-~+ 
+•■ <••• A- <•+ T—;=;4- 
| -f*. f. • . A*— rt_f* T'—|”j~ 1= 
—a. f... A— a—; 0 T— 
+»• f... A— *+ T— 
2ND DEGREE 
A or A'—, and below 
.100 gms. 
Hypoacidity . 
(A-) 
-j-a. f... A'— «+ T—;= 
3RD DEGREE A^O—Apepsia A 0 a 0 T— 
SIMPLE DYSPEPSIA • 
Without acid fermentation 
Typical (>=) A=;+ «= T=;+;— 
Quabtatra («—) A—;=;+/*— T=;—;+ 
With acid fermentation 
Hyperthiorhfdm A=;+;—a-\- T=;—;-f- 
HypBtWortrrtlri* (C—) A- «+ T= 
* The signs and symbols employed in this classification relate to the following quantities determined by the 
study of the digestive process in healthy subjects to be the limits of normal variation, the quantity of chlorine bring 
expressed as HC1, and the values given having relation to loo ex. of stomach fluid . — 
Total Acidity (A or AO .1S0-.200 gms. Coefficient (a) .86. 
Total Chlorine (T) .300-.340 gms. Pree HC1 (H) .oij-.ojo gms. 
Combined Chlorine (C) .155-.1S0 gms. Pixed Chlorine (P) .109 gms 
Total Chlorine set free from bases (H-f-Q . 180-22 gms. DISORDERS OF DIGESTION. 
23 
nized in this class of cases. How these therapeutic indications 
are to be met is a subject too large for consideration in this 
paper, but one which I have made the subject of long and 
varied experimentation, extending through several years, the 
results of which I shall report in another paper. The limits of 
this paper will admit of no more extended reference to this 
branch of the subject than a few brief suggestions. 
In the accompanying outline exhibiting the classification 
which I have briefly described,—a.f. means without acid fer- 
mentation ; -J- a.f., with acid fermentation. 
A great advantage offered by this classification is the fact 
that it affords a basis for a new and simple nomenclature of 
functional disorders of the stomach due to disturbance of the 
chemico-vital processes of digestion. The twenty-two groups 
which I have formed, include all of the different forms of de- 
ranged chemical processes which I have encountered in the 413 
analyses upon the study of which this paper is based —a num- 
ber sufficiently large, I think, to include practically all the 
different forms likely to be met with in practice. 
Another very great advantage presented by the classification 
and nomenclature proposed is found in the fact that the name 
of each morbid condition not only clearly identifies it by ex- 
hibiting its characteristic features, but gives at the same time 
its therapeutic indications. It is also so simple and natural 
that it can be mastered with very little study. It is only neces- 
sary to keep in mind the following points to be able to classify 
at sight any case after obtaining the necessary data by analysis, 
and representing it in a formula : — 
x. Whenever H is found, the case is one of hyperpepsia, 
unless we find also (H -(- C) —, when it may be a case of sim- 
ple dyspepsia, which will be determined by noting if all the quan- 
tities are within the normal limits, or closely approach them. 
2. Hyperpepsia also exists in some cases in which we find 
H — and C + and (H'-)- C) -|~. We may have (H -f- C) = with 
H — and C —J- in. both hypopepsia and hyperpepsia ; but if the 
case is one of hypopepsia, T will be — or = ; if it is hyper- 
pepsia, -j-. 
3. Having settled the question as to whether the case is one 
of hyperpepsia or hypopepsia, simply write down the word 24 
THF. INVESTIGATION OF 
“ Hyperpepsia ” if the case belongs to this class, then note the 
signs opposite H and C. If both are -f, then write next to the 
word “Hyperpepsia” the word “ Hyperhydrochlorie. ” If H 
is—, write, instead, “ Hypohydrochlorie ;” or if II is -f- with 
C—, write “ Hypochlorhydrie.” Next note the sign opposite A ; 
if -j-, add to the two preceding words the word “ Hyperacidity." 
If A is within the normal limits, this term may be omitted ; 
or if the figures approach close to the upper limit, “ Hyper- 
acidity ” may be written, and if the figures nearly correspond 
with the lower limit of the normal range, “ Hypoacidity ” may 
be written. One more point must be noted : Whether or not 
acid fermentation is present, which will be determined by 
coefficient a. If a -j- is found, acid fermentation is certainly 
present; if a—, fermentation is presumably absent. The 
presence or absence of acid fermentation may be indicated by 
writing after the preceding terms — a. f. or -j- a. f. as the case 
may be. Thus, the name of the first form noted in my scheme 
of classification would be hyperpepsia with hyperhydrochlorie and 
hyperacidity, without acid fermentation. 
The naming of cases of hypopepsia is simpler, as there are 
fewer subdivisions. The same principles are followed as with 
hyperpepsia. The same may be said, also, with reference to 
simple dyspepsia. By the aid of the accompanying scheme of 
classification, any one can classify any case of disturbed chem 
ical action in the digestive process after obtaining the necessary 
analytical data, with a very little practice, and even without 
going as deeply into this subject as is desirable and really 
necessary for a full grasp of it. 
I find it convenient in making notes of cases to abbreviate 
the terms employed, as follows: Hyperpepsia, Hprp.\ Hypo- 
pepsia, Hpop.\ Hyperhydrochlorie, Ifprhcl.; Hypohydrochlo- 
rie, Hpohcl.\ Hypochlorhydrie, Hpoclh.; Hyperacidity, Ilprac.; 
Hypoacidity, Hpoac. \ Pseudo-hyperacidity, Pshprac.; Acid fer 
mentation, a. f. Thus the form above referred to might be 
briefly written Hprp-Hprhcl-Hprac—a. f. 
The ingenious method of representing stomach disorders by 
means of formulae, originated with Hayem and Winter, the 
authors of the methods of analysis upon which this method of 
studying stomach disorders is based. ■DISORDERS of digestion. 
25 
Normal Digestion.— A lady aged 35 years had been for a 
few weeks under treatment for pelvic and nervous disorders, 
which required an application of the rest-cure. She had been 
recently allowed to take exercise, and was gaining rapidly in 
flesh and strength ; tongue clean, and no symptoms of dis- 
ordered digestion. The following were the quantities found : 
(A), .175; O), .85 ; (T), (H), .042; (C), .156; giv- 
ing the formula, 
Case 64. 
A T H = I 
A = 3=T==c = f =' 
In this case, the chemical processes concerned in digestion 
are evidently entirely normal. 
Hyperpepsia. —The following cases illustrate the different 
forms of hyperpepsia : — 
Hyperpepsia with hyper hydrochloric and hyperacidity — without 
acid fermentation. 
Case 39. 
The patient, a lady aged 49 years, had suffered for many 
years from disorders which had been greatly aggravated by 
the frequent use of purgatives for the relief of obstinate consti- 
pation. The symptoms relating to the stomach were, eructa- 
tions of gas, extreme acidity, frequent attacks of severe pain 
in the stomach, good appetite, heaviness at the stomach. 
Many neurasthenic symptoms were also present, including 
great mental depression, sleeplessness and vertigo, urine scanty, 
with sediment of urates and uric acid. Physical examination 
showed the stomach to be moderately dilated, great tenderness 
in both lumbar ganglia of the sympathetic, abdominal muscles 
very tense. The quantities given by analysis were as follows : 
(A), .256; O), .07; (T), .560; (H), .240; (C), .224. 
Formula: . . . H + ) , 
A+,a- T + j. + . 
Hyperpepsia with a great excess of free hydrochloric acid, 
without acid fermentation. The eructations of gas and other 
symptoms in this case would have led to the conclusion 
that the patient was suffering from simple acid dyspepsia, and 
might perhaps have suggested the employment of hydrochloric 26 
I HE 1NVESTIOATION OK 
acid as a means of suppressing abnormal fermentations, or 
remedies of a stimulating character to induce a greater degree 
of digestive activity. The gas was evidently the result, not of 
fermentation, but of the secretion of CO2 from the blood, 
which not uncommonly occurs in cases of excessive irritability 
and consequent congestion of the gastric mucous membrane. 
On the employment of means for suppressing the excessive 
amount of glandular activity shown by the high figure of T, 
the patient rapidly improved, and in a few weeks left the San- 
itarium with every evidence of permanent improvement of health. 
Hyperpepsia with hyperhydrochlorie and hyperacidity—acid 
fermentation. 
Case 226. 
A young man aged 22 years, who had been addicted to hasty 
eating, overeating, excessive use of sweets, confectionary, 
meats, drinking freely of fluids at meals, and of sedentary 
habits, had employed for relief, but without benefit, various 
mineral acids, hot water drinking, etc. He complained con- 
stantly of too abundant secretion in the mouth, burning in the 
oesophagus, fullness, distension of the stomach, eructations of 
great quantities of gas, regurgitation of hot, sour liquid, fre- 
quent attacks of sharp pain In the stomach soon after eating, 
excessive appetite, inability to digest coarse foods, such as 
cabbage, green peas, etc.; burning and heaviness at the stom- 
ach ; extreme constipation, bowels moving not more often than 
once in three days; stools hard ; gaseous distension of the 
bowels; poor memory; inability to concentrate the mind; 
dullness; hesitancy in speaking; drowsiness after meals; head- 
ache; heaviness in the head; strained feeling in the eyes; 
pain in the scalp and chest; coldness of extremities, especially 
of the knees; feverishness fifteen or twenty minutes after eat- 
ing ; specks before the eyes; occasional loss of sight; general 
feeling of weariness and exhaustion ; shortness of breath. Phys- 
ical examination showed a considerable degree of dilatation of 
the stomach. The quantity of stomach fluid removed was 125 
c. c., reddish in color, and presented a considerable quantity 
of mucus. The quantities obtained were as follows : (A), .352; 
(«), -95 > (T), .14° > (C), .224. DISORDERS OF DIGESTION. 
27 
Congo-red and methyl-violet gave strong reactions. Uffel- 
mann’s reagent showed lactic acid present in considerable 
amount. Biuret reaction showed peptones present in moderate 
amount. Lugol’s solution gave blue violet color, indicating 
but slight digestion of starch. The chemical work done by the 
stomach in this case is represented by the following formula : 
A + fl + T+C + [+• 
Case 73. 
A young woman of twenty-four years, had suffered for many 
years from stomach disorders, without finding relief, although 
a great variety of medical means were employed. The follow- 
ing quantities were obtained: (A,) .380; (a), 1.35; (T), 
.440; (H), .070; (C), .230. 
F°rmula: A+a + T+H+|+. 
Uffelmann’s reagent showed in this case a great amount of 
lactic acid, and the stomach fluid when withdrawn exhibited 
a dark brown color, probably due to the presence of a small 
quantity of blood, the result of the intense congestion of the 
mucous membrane present in the case. The hyperacidity in 
this case was certainly very remarkable, and the highest I have 
yet encountered, being nearly double the maximum amount 
presented in health. The determination of the value of A in 
this case, showed that the acidity due to the products of acid 
fermentation was equivalent to nearly .100 grams of anhydrous 
HC1 for each 100 c.c. of the stomach fluid. 
Hyperpepsia with hyperkydrochlorie and hypoacidity — without 
acid fermentation. 
The patient, a lady aged 37 years, had suffered for many 
years from a variety of stomach symptoms, which had recently 
led to a diagnosis of malignant disease. She had been assured 
that she was suffering from cancer involving the stomach, liver, 
and spleen, and that her case was hopeless. The patient suffered 
from constant pain in the stomach, flatulency, throbbing at the 
epigastrium, pain in the head, general nervousness, depression, 
Case 51. 28 
THK INVESTIGATION OF 
emaciation, and obstinate constipation. Physical examination 
showed extreme sensitiveness of the solar plexus and of both 
lumbar ganglia ; the lower border of the stomach was three 
inches below the umbilicus, the right kidney was prolapsed, 
the bowels prolapsed, the abdominal walls extremely flaccid. 
The figures furnished by analysis of the stomach fluid were 
as follows: (A), .132; (a), .38; (T), .364; (H), .048; (C), 
.224. 
Congo-red and methyl-violet both gave good reactions, and 
the biuret reaction indicated the presence of albuminoids. The 
formula representing the digestive work in this case is 
A_a-.T+»-U 
The figures for (H) are so near the maximum in this case, 
that it is evidently proper to class it with cases in which (H) 
is -+-» the case being, in all other respects, identical with those 
which fall in this group. 
Hyperpepsia with hyper hydrochlorie and hypoacidity—with 
acid fermentation. 
Case 207. 
The formula for a typical case of this form of dyspepsia 
would be, a- u+T + « + U. 
I have not yet met a typical case of this form, but have found 
cases so nearly approaching it that I expect to meet it in the 
study of a larger number of cases. It is only necessary that the 
value of C should be so small that with the addition of the prod- 
ucts of acid fermentation present in the case, the total acidity 
is still below the normal figure, a condition which is certainly 
not unlikely to occur. 
Hyperpepsia with hypohxdrochlorie and hyperacidity — without 
acid fermentation. 
Case 197. 
A lady, aged 30 years, had long suffered from severe head- 
ache, although she had experienced no special symptoms which 
she had herself attributed to the stomach. She confessed 
to careless habits of eating, eating hastily and sometimes DISORDERS OF DIGESTION. 
29 
to excess, especially in the use of flesh meats and salads, of 
which she was very fond. The patient was also subject to 
attacks of shortness of breath and impairment of vision. 
Physical examination showed foul tongue, great tenderness of 
both the right and the left ganglia and of the abdominal sympa- 
thetic. Examination of the stomach fluid gave the following 
results: (A), .204; (a), .76; (T), .332; (H), .000; (C), .268. 
Congo - red gave a good reaction ; methyl-violet, none. 
Uffelmann’s reagent showed lactic acid present, and the biuret 
reaction indicated the presence of peptones in moderate amount. 
The above figures furnish the following formula : 
A + a — T } +• 
In this case it will be noted that peptones were formed, not- 
withstanding no free hydrochloric acid whatever was present 
in the gastric juice. An abundance of hydrochloric acid was 
secreted, as shown by the high figure of T, and more than the 
usual amount of useful stomach work was done, as shown by 
the high figure of C. The diminished value of coefficient a, 
however, indicates the presence of an abnormally large amount 
of neutral compounds in C, probably a larger amount even 
than is indicated by the lessened value of coefficient a, since 
lactic acid was shown to be present, indicating a considerable 
degree of acid fermentation concealed. When C is in ex- 
cess, its quality is usually diminished, a very striking example 
of which we have already given in case 39, in which the value 
of coefficient a was only .07. 
Case 246. 
The patient, aged 43 years, had suffered for many years from 
stomach disorders as the result of hasty eating, overeating, 
irregular meals, excessive use of sweets, fats, meats, fluids at 
meals, pickles, vinegar, and tea and coffee. Bad positions in 
sitting, sedentary habits, and the traction of heavy skirts upon 
tight waistbands had aggravated her disorders. Quinine, min- 
eral waters, and a variety of laxatives and tonics had been 
tried without relief. The patient observed a metallic taste in 
the mouth in the morning, which sometimes remained dur- 
ing the entire day ; a very bad breath; eructations of gas; 30 
THE INVESTIGATION OF 
fullness in the stomach; nausea, lasting from 15 to 20 min- 
utes ; appetite variable; special craving for coffee, pastry, and 
rich food ; bowels constipated ; prolapse of rectum ; extremely 
nervous and depressed ; occasionally giddy; constant sense 
of weariness; palpitation of the heart. Physical examination 
showed a brown coat upon the tongue, and extreme tenderness 
of the sub-umbilical ganglion. Examination of the stomach 
fluid after the usual test meal consisting of ounces of 
dry unfermented bread with 8 ounces of water, gave the fol- 
lowing figures: (A), .200; (a), .71 ; (T), .376; (H), .008; 
(C), .272. 
Congo-red and methyl-violet both gave good reactions. Re- 
action for lactic acid was pronounced, as also the biuret re- 
action. Lugol’s solution showed that starch digestion had 
advanced only to the state of erythro-dextrine, as indicated by 
the light purple color; rennet ferment abundant. The above 
figures give the following formula : 
A = <i T + ” + | + • 
The acidity in this case is at the extreme upper limit of 
normal variation, and hence the case may be fairly classed as 
one of hyperpepsia with hypohydrochlorie, without acid fer- 
mentation. The following is another very interesting case of 
the same sort: — 
Case 236. 
The patient, aged 45 years, had not considered herself dys- 
peptic, and until recently had enjoyed excellent health. 
Weighed, eighteen months previously, 192 pounds; present 
weight, 108 pounds; had been accustomed to use meat, sweets, 
and coarse vegetables freely, but made little use of fruits; 
condiments, tea, and coffee had also been freely used. The 
only symptoms relating directly to the stomach, which the patient 
had noted, were, occasional vomiting when constipated, and 
burning at the stomach much of the time ; frequent attacks 
of diarrhoea ; pain in the right side ; ringing in the ears; scanty 
urine. Physical examination showed stomach and bowels pro- 
lapsed, right and left ganglia of the sympathetic sensitive, 
abdominal walls extremely flaccid. Examination of the stomach DISORDERS OF DIGESTION. 
31 
fluid gave the following figures’: (A), .196; (a), .80; (T), .324 ; 
(H), .004; (C), .240. 
Methyl-violet gave a slight reaction for free HC1. Uffel- 
mann’s reagent indicated the presence of lactic acid. Biuret 
reaction showed abundance of peptones ; Lugol’s solution 
showed imperfect digestion of starch. The formula furnished 
by the above figures, is 
A H — ) , 
A — — T_^c + j- +. 
A case of hyperpepsia with a deficient amount of free hydro- 
chloric acid, or hypohydrochlorie, and without acid fermenta- 
tion. 
Many cases of this sort are met, and show clearly that the 
presence of free HC1 is not a matter of so great importance as 
has formerly been supposed. The diminished value of (a) in 
this case, accounts in part, perhaps, for the steady loss of flesh 
observed in this patient during a series of months. The patient 
made a rapid gain in flesh after being put to bed and subjected 
to the treatment indicated for relief of her stomach disorder. 
Hyperpcpsia with hypohydrochlorie and hyperacidity — acid 
fermentation. 
Case 254. 
The patient, a young woman aged 22 years, had for two 
or three years been running down in health, suffering from 
a variety of nervous symptoms which had been attributed to 
excessive work in school, and other causes which probably had 
little or nothing to do with her condition. The patient was 
considerably emaciated, very weak, and extremely nervous. 
Physical examination showed a foul tongue; stomach dilated, 
the lower border of the stomach being an inch below the um- 
bilicus ; the abdominal walls much relaxed ; considerable de- 
gree of ovarian irritability, which, however, probably had little 
to do with the general condition. The amount of fluid with- 
drawn from the stomach was 60 c. c., and examination gave 
the following results: (A), .280; (a), 1.03; (T), .312; (H), 
.004 ; (C), .268. 
The color reagents showed the presence of free hydrochloric 
acid in abundance, also lactic acid. The biuret reaction 
showed peptones abundant. Lugol’s solution gave a purple 32 
THE INVESTIGATION OF 
reaction, indicating imperfect starch digestion. Rennet fer- 
ment abundant. The formula resulting from the above is as 
follows: • . , . _ H— ) , 
A+fl+T=c+ ;•+. 
The young woman made rapid improvement under measures 
directed to the relief of her stomach disorder. 
Hyperpepsia with hypohydrochlorie and hypoacidity — without 
acid fermentation. 
Case 151. 
The patient, a lady aged 45, had long suffered from digestive 
disturbance as the result of irregular eating, the use of pickles, 
cheese, and other harmful articles of food, waist constriction 
from corsets and waist bands, and the use of coffee. Appetite 
diminished, stools very irregular, alternation of constipation 
and diarrhoea, gaseous distension of the bowels, tenesmus of 
lower bowel, general nervous exhaustion, constricted feeling in 
the region of the heart, tongue flabby, hyperaesthesia of the 
lumbar ganglia of the sympathetic. At the time of examina- 
tion there was impaction of the lower bowel. The amount of 
fluid was 74 c. c. A .160, a T .304, H .008, C .206. 
Congo-red and methyl-violet both gave slight reaction. Lactic 
acid test negative, peptones abundant. Formula : 
A—T=C+ f+. 
Hyperpepsia with hypohydrochlorie and hypoacidity — with acid 
fermentation. 
To complete the scheme of classification, I ought to be able 
to present here a case of hyperpepsia with hypohydrochlorie 
and hypoacidity — with acid fermentation. Such a case would 
require the following formula : 
A—a-f'I -H=>— q _j_ | +r=s* 
As will be seen by reference to the chart, this formula might 
occur also in hypopepsia of the first degree, with hypoacidity 
and acid fermentation, the only thing required being a slightly 
higher value for T and for C than I have happened to meet in 
any of the cases thus far studied ; so this may be considered DISORDERS OF DIGESTION. 
33 
as the point at which hyperpepsia and hypopepsia meet and 
overlap. 
Hyperpepsia with hypochlorhydrie (C—) and hyperacidity (A-(-) 
— without ucid fermentation 
Case 129. 
A young woman aged 22 years, had been accustomed to take 
great quantities of fluids at meals, and had taken large quan- 
tities of iron, which she thought to be in part the cause of her 
condition ; suffered from regurgitations of food, especially at 
menstrual periods; had excessive appetite and a craving for 
acid foods; extremely nervous; impaired memory; loss of 
energy ; mental confusion ; inability to concentrate the mind ; 
occipital and frontal headache; general pain; distress and 
giddiness; disturbance of vision ; specks before the eyes; 
appearance of fire before the eyes ; general exhaustion ; trem- 
bling of the limbs. Physical examination showed tongue coated 
white over its whole surface ; the lower border of the stomach 
one inch below the umbilicus; solar plexus extremely sensitive ; 
abdominal walls flaccid. The amount of stomach fluid with- 
drawn was 170 c.c., more than four times the normal amount. 
The following is the result of the examination of the stomach 
fluid: (A), .256; (a), .80; (T), .360; (H), .152; (C), .130. 
Peptones abundant. Formula : 
A + a —T+“ + | + 
A'case of hyperpepsia with diminished amount of useful chem- 
ical work, as shown by C —, and hyperacidity from the ex- 
cessive quantity of hydrochloric acid present, but without acid 
fermentation. 
Hyperpepsia with hypochlorhydrie (C—) and hyperacidity 
(A-f-) — with acid fermentation. 
Case 199. 
Young woman of 28 years, who had suffered from stomach 
disorders for a number of years, the most prominent symptoms 
being acid and flatulent dyspepsia ; heaviness of the stomach; 
general weariness and confusion of thought. Quantity of fluid 34 
THE INVESTIGATION OF 
withdrawn, 150 c. c. Result of examination of stomach fluid: 
(A), . 280; A', .252; (a), 1.14 ; (T), .394 ; (H), .166; (C), . 100. 
Formula derived from the above quantities : 
a + „ + t + 5(! + j+. 
This case is nearly identical with the preceding, only dif- 
fering from the fact that acid fermentation was present. 
It is important to obtain the value of A' in these cases, so as 
to be able to form a correct judgment respecting the amount 
of actual stomach work done, as the value of A in cases of 
acid fermentation is always more or less due to the acid 
products of fermentation. By comparison of the values A' and 
A, one can form at once an estimate of the amount of normal 
chemical work done by the stomach as compared with the 
abnormal chemical work in the form of acid fermentation. 
Hyperpefsia with hypochlorhydrie ( C — ) ami hypoacidity (A—) 
— without acid fermentation. 
Case 59. 
A man of 57 years, who had for many years been accustomed 
to high living and the free use of ardent spirits. Examina- 
tion of the stomach showed marked dilatation. A chemical 
analysis gave the following figures : (A), .088 ; (a), o ; (T), .360 ; 
(H), .090; (C), .090. 
Biuret reaction very slight, indicating the absence of neither 
peptones nor albuminoids. Formula : 
A—T+?±}- 
A case of marked hyperpepsia, as indicated by the high figure 
for free hydrochloric acid, yet with pronounced hypoacidity, 
and without acid fermentation. The zero value of coefficient 
a indicates the total absence of useful work on the part of the 
stomach. 
Hyperpepsia with hypochlorhydrie (C-—) and hypoacidity (A—), 
with acid fermentation. 
Case ioo. 
Patient, a man aged 26 years. Had suffered for a number of 
years with digestive disorders, the principal symptoms of which DISORDERS OF DIGESTION. 
35 
were eructations of gas, heart-burn, headache, constipation. 
Patient had been addicted to the use of tobacco and alcoholic 
drinks, and had taken a great deal of riiedicine of various sorts 
without relief. Hyperaesthesia of the solar plexus and right 
lumbar ganglia of the sympathetic. Patient had suffered from 
various nervous disorders and sexual weakness. 
The amount of fluid withdrawn from the stomach after the 
test meal, was 120 c. c. The result of the analysis was: (A) 
172; (A') 142 ; (a) 1.21; (H) .068 ; (C) .086. 
Formula : 
a-«+t+£+ 
Biuret gave violet reaction, which showed the absence of 
peptones and the presence of albuminoids. Much mucus and 
considerable residue. The high figures for T indicated in this 
case the abundant secretion of fixed chlorine, but failure of the 
stomach to set free the proper amount of chlorine. The high 
figures for H show an excessive amount of free chlorine, not- 
withstanding the small value of C, which is due to the failure 
of the chlorine to combine with the albumen. 
Hyperpepsia with hypochlorhydrie (C—) and pseudo-hyper- 
acidity fA-f-A'—) — with acid fermentation. 
A young man, a clergyman, aged 32 years, had for many 
years suffered from disorders of the stomach, giving rise 
to headache, emaciation, languor, and diminished mental and 
physical activity. The most prominent stomach symptoms 
were morbid thirst, irritation of the throat, coughing, burning 
at stomach, constant eructations of gas, daily attacks of pain 
coming on after meals, pain variable in character, described as 
gnawing, dull, and sharp, no appetite until after beginning the 
meal, appetite increasing with the meal. Patient unable to eat 
potatoes and other vegetables and raw apples. Sensation of 
ball in the stomach, coldness and throbbing in the stomach. 
Bowels regular, stools very fetid and of a light yellow color. 
Gaseous distension of the bowels. Nervousness. Mental 
dullness. Fidgets. Drowsiness after meals. Frontal head- 
aches and disposition. to support the back of the head. Pain 
in the scalp, stomach, and under the shoulder blades. Giddi- 
Case 243. 36 
IHK INVESTIGATION Ol 
ness. Frightful dreams, sudden waking with fright. Coldness 
of extremities and between the shoulders. Burning sensation 
after eating, with flushing of face, occurring ten or fifteen 
minutes after eating. Exhaustion and w-eariness in the morn 
ing, and involuntary sighing. Tongue foul, especially at its 
back part. 
Examination of stomach showed it to be considerably dilated, 
its lower border being below the umbilicus. Quantity of fluid 
withdrawn after a test meal, 245 c. c. Color green, no mucus. 
Analysis gave the following: (A) .236; (A') .158; (a) 1.64; 
(T).26o: (H) .072 ; (C).ioo. Reaction for lactic acid nega 
tive ; peptone reaction good ; rennet ferment absent, rennet 
zymogen abundant; starch digestion very complete as shown 
by the brown color with I.ugol’s solution. Formula : 
A+A'—a+T—H+ (, 
In such a case as the above the importance of determining 
the value of (A') is very evident since it gives at once an 
estimate of the amount of acidity which is due to acid fer- 
mentation, and which can be very promptly suppressed by 
the employment of proper measures to render the stomach 
aseptic. In this case the acidity due to acid fermentation was 
found to be equivalent to .078 gms. of anhydrous HC1 for each 
100 c. c. of the stomach fluid. 
Studied by means of Kwald’s method, or, indeed, by any 
other than the precise method presented in this paper, an 
entirely wrong conception would have been formed concerning 
the character of this case, since the failure of the color re 
actions for lactic acid, and the absence of acetic acid, left no 
means of detecting the presence of acid fermentation or of 
estimating the amount of abnormal acids formed. Hut the 
determination of the value of (A') by the method previously 
described, gives us an exact measure of the amount of acid 
fermentation products present, and thus of the extent to which 
acid fermentation occurs. Studied by other methods, this case 
would be regarded as a very pronounced case of hyperpepsia 
without acid fermentation, although it is clear from considers 
tion of the value of (A'), of (T) and of (H-f-C), all of which are 
considerably below normal, that there is really a diminution of DISORDERS OF DIGESTION. 
37 
normal stomach work in all its branches; although the large 
amount of free hydrochloric acid present, nearly double the 
average amount, characterizes the case as one of hyperpepsia. 
From a therapeutic standpoint, however, this group of cases of 
hyperpepsia must be treated very differently from the typical 
forms of hyperpepsia, and hence its detection is a matter of 
very great importance. 
The cause of the fermentation in this case is clearly indicated 
by the great quantity of fluid found, which was equal to the 
total quantity taken at the test meal, and more than six times 
the normal amount. It may be supposed from the large amount 
of fluid withdrawn from the stomach, considered in connection 
with other symptoms presented by the case, that this patient’s 
stomach was seldom, if ever, empty, a fluid remnant remaining 
over from each meal to infect the next, thus keeping up a state 
of constant fermentation. 
Case 155. 
The patient, aged 25 years. The stomach fluid when with- 
drawn was green in color, indicating the presence of bile. 
Result of analysis : (A), .192; (A'), .152; (a), 2.29; (T), .404; 
(H), .128; (C), .028. 
Formula derived from the above quantities : 
A' —a + T + c + J-—. 
A case of hyperpepsia with hypoacidity, and with deficiency of 
useful stomach work, and acid fermentation. 
In this case as in the preceding it was necessary to obtain 
the value of A' in order to form a correct estimate of the 
amount of normal chemical work done by the stomach, since the 
acid fermentation present contributes more or less to the value 
of A. In the present case, A is normal, although A' is much 
below the normal value, and this notwithstanding the high value 
of H. 
Hypopepsia of the first degree (A'— but above . 100) with 
pseudo-hyper acidity (A—}-) due to acid fermentation. 
Case 154. 
The patient, aged 37 years, had suffered from stomach dis- 
orders for some time ; had been addicted to the free use of tea 38 
THF. INVESTIGATION OF 
and coffee and usual errors in diet. The stomach symptoms 
noted, were, distress two or three hours after eating; eructa- 
tions of gas ; sometimes regurgitation of food with small clots 
of blood ; vomited black clots of blood one month previous; 
burning pain ; appetite variable; bowels very inactive ; insom 
nia; general exhaustion; palpitation of the heart. Physical 
examination showed red tongue coated in the center; lower 
border of stomach below the umbilicus; great tenderness of the 
solar plexus and the umbilical ganglia ; general tenderness of 
the abdomen. Stomach tube withdrew 120 c. c. of fluid. 
Analysis gave the following figures: (A), .32o; (A'), .140; (a). 
2.14; (T), .392; (H), .020; (C), .140. 
Peptone reaction slight. Formula : 
A + (A'_)<, + T+”“ l- 
Hypopepsia of the first degree with hypoacidity - without acid 
fermentation. 
Case 275. 
A young woman, 25 years of age, had suffered from dyspep- 
sia and a variety of general nervous and pelvic symptoms for 
a number of years. Stomach tube withdrew 70 c.c. of fluid. 
Result of examination : (A), .124; (a), .73; (T), .288; (H), 
.016; (C), . 1-48. 
Peptones and rennet ferment abundant. Lugol’s solution 
gave the purple reaction of erythro-dextrine. Formula: 
A — T-cl}- 
A case of hypopepsia of the first degree, with hypoacidity and 
without acid fermentation. 
Hypopepsta of the first degree with hypoacidity — with acid fer- 
mentation. 
The patient, an unmarried lady aged 33, had suffered for a 
number of years with stomach disorder, the prominent symp- 
toms of which were nausea in the morning, constipation, constant 
occipital headache, sensation of pressure and heaviness in the 
head, and muscular twitching. The lower bonier of the stom- 
ach was two inches below the umbilicus. The right kidney was 
Case i i 7. DISORDERS OF DIGESTION. 
39 
movable, hyperaesthesia of the right lumbar ganglion of the 
sympathetic. The quantities obtained by analysis were as 
follows: Amount of stomach fluid 300 c. c.; slight amount 
of mucus present. A .140, a .89, T .202, H o, C 158. 
Formula: „ 0 , 
A — a -\-'Y —_ [•—. 
Hypopepsia of the second degree (A' — and below .106) — 
with pseudo-hyperacidity ( A -)-). 
Case 6i. 
The patient, a lady aged 29, had suffered for many years 
from indigestion, the result of irregular meals, the free use of 
sweet pickles and other indigestible articles of food, waist con- 
striction by corset wearing and tight waist bands, and the con- 
tinuous use of purgatives. Had also taken chloride of gold 
and strychnia. 
The prominent symptoms were choking, sensation of sore- 
ness in the oesophagus, fullness in the stomach, eructations of 
gas, nausea almost continuous, brief sensation of hunger a few 
hours after eating, constipation, hemorrhoids, gaseous disten- 
sion of the bowels, many neurasthenic symptoms, especially dis- 
tress of mind and inso-mnia, occipital headaches, burning and 
pressure in head, giddiness, vertigo, sensations of chilliness, 
trembling, especially of the legs, muscular twitching, and palpi- 
tation of the heart. The physical examination showed the 
stomach to be dilated, the lower border being inches below 
the umbilicus. Analysis of the stomach fluid showed the fol- 
lowing quantities : A .248, A' .087, a 2.72, T .190, H .014, C 
.086. Congo-red and methyl-violet both gave good reactions. 
Peptones abundant. Formula : 
A a+T C—| ' 
A very marked case of hypopepsia of the second degree, with 
pseudo-hyperacidity. 
Hypopepsia of the second degree with hypoacidity — without 
acid fermentation. 40 
THE INVESTIGATION OF 
Case 435. 
The patient was a lady of 28 years, unmarried. She had 
for several years been a semi-invalid, largely the result of 
irregular and hasty eating, eating between meals, excessive use 
of meats and coarse vegetables, and waist constriction. The 
symptoms present were morbid tastes, nausea, vomiting, attacks 
of pain soon after eating, “all gone” sensation in the stomach, 
gnawing pain at the epigastrium, recurrence of hunger soon 
after eating, haemorrhoids, sleeplessness, attacks of sick head- 
ache, coated tongue, decayed teeth, lower border of stomach 
one inch below umbilicus, left lumbar ganglia sensitive, right 
kidney movable and very sensitive. 
The stomach tube withdrew 40 c. c. of fluid after the usual 
test meal, of which 30 c. c. were left upon the filter as sedi- 
ment, showing an exceedingly small amount of digestive work 
done. A large amount of mucus was present. The color tests 
indicated the absence of lactic acid, free HC1 and peptones, 
and complete digestion of starch. Biuret showed a moder- 
ate amount of albumenoids. Rennet ferment abundant. The 
following figures were obtained by quantitative analysis : (A) 
.160; (a) .82; (T)-30o; (H).ooo; (C).i96. Formula: 
a -r Ho l 
A a T C-f- f 
The small amount of fluid obtained in this case was evidently 
due to the fact that the fluid was so thick and contained such a 
great quantity of mucus that its removal by means of the tube 
was unusually difficult. 
The following case of hyperpepsia of the second degree 
without acid fermentatiqn, is still more remarkable. 
Case 265. 
The patient, a woman aged 48 years, had suffered from di- 
gestive troubles for many years ; had been addicted to hasty 
eating and overeating, to the excessive use of sweets, fats, and 
fluids, especially at meals, and overwork at sewing late at night. 
Symptoms : bitter taste in the mouth in the morning, tender 
surface upon the tongue, scanty secretion in the mouth, eructa- 
tions of gas, regurgitations of fluid frequently after eating, 
occasional vomiting of bile and mucus without nausea, some- DISORDERS OF DIGESTION. 
41 
times vomiting the entire amount eaten ; the vomited matter 
bitter ; cramps in the stomach ; faint sensation in the 
stomach ; good appetite ; the patient has observed that vege- 
tables, fermented bread, and strong acids disagree with her; 
bowels very inactive ; stools whitish, mixed with opaque mu- 
cus, at times bloody and large in amount; pain at and after 
stools ; frequent ineffectual effort to relieve bowels ; gaseous 
distension of bowels, with odorless flatus; drowsiness after 
meals, also at other times ; heaviness in the head, bowels, and 
knees; pain in back and lower part of the shoulders, also in ribs 
and right side ; sciatica, giddiness, vertigo ; noises in the head, 
dreams of falling, coldness between the shoulders, also of the 
extremities; specks before the eyes; appearance of fire; 
twitching of the muscles. 
Physical examination showed moderate dilatation of the 
stomach, and prolapse of the bowels. Amount of fluid with- 
drawn from the stomach, ioo c. c. Result of examination of 
stomach fluid : (A), .012 ; (a), o ; (T), . 156 ; (H), .012 ; (C), .028. 
Peptones slight. Lugol’s solution gave no reaction, showing 
complete digestion of starch. Rennet ferment absent. 
Formula: . „ H—) 
A case of hypopepsia of the second degree, without acid fer- 
mentation. 
It is interesting to note in this case the value of a. Re- 
calling the formula : 
A—H 
= («), 
C ' 
and substituting the respective quantities, we have 
.012 .012 0 
= — = 0). 
.028 28 
The meaning of this is that although we have .028 gms. of 
combined chlorine in each 100 c. c. of stomach fluid, the 
chloro-organic compounds represented by this quantity have 
a neutral instead of an acid reaction and are of no nutritive 
value. 
The hypopepsia in this case was so marked as to approach 
very closely to apepsia. 42 
THE INVESTIGATION Ot 
Hypopepsia of the second degree with hypoacidity — witn acid 
fermentation. 
The patient, a physician aged 35 years, had recently suffered 
from an attack of la grippe which had left him with .greatly 
disordered digestion. Physical examination showed marked 
dilatation of the stomach. Stomach tube withdrew, after the 
test-breakfast, 55 c. c. Analysis gave the following figures: 
(A), .010; (AO, .0017; (a), 5.00; (T), .100; (H), .000 ;(C), 
.002. 
Formula: A . H o ) 
A — <*+ r — c_ . 
A most pronounced case of hypopepsia of the second degree, 
with acid fermentation. 
Case 13. 
Case 62. 
A lady, aged 65 years, had suffered for years from frequent 
attacks of great pain in the stomach, which occurred at such 
short intervals that the pain was nearly continuous, and 
burning in character; also suffering from pain in the region of 
the liver and in the left side and from morbid taste. The 
stomach fluid contained a considerable amount of mucus. 
The following quantities were obtained by analysis : (A), . 175 ; 
(A'), .096; (a), 2. it ; (T), .260; (H), .040; (C), .064 
Formula: . . _ H = ) 
A-a+T-C-f- 
In this case the free HC1 (H) is normal in amount, but the 
case is nevertheless one of hypopepsia of a very pronounced 
type. Such cases are rare, but do exist, and emphasize the 
importance of a method of investigation which gives exact 
rather than presumptive data. 
Hypopepsia of the third degree—apepsia.— I have observed 
two cases of this sort, the most typical one of the two being 
herewith presented. 
The analysis of the patient’s stomach fluid easily explained 
the anaemic and emaciated condition which existed, and the 
extreme exhaustion which had baffled all attempts to afford 
relief by the aid of tonics or other palliative measures. Addendum to follow page 42. 
Cask 63. 
The patient, a married lady aged 45 years, had suffered from 
dyspepsia for a number of years. The patient attributed her 
stomach disorder to the use of coffee. The principal symptoms 
were nausea and movements of the bowels occurring immedi- 
ately after eating, palpitation of the heart, sleeplessness, neural- 
gia, a great variety of neurasthenic symptoms, rheumatic pains 
in the limbs, great emaciation and anaemia, tenderness of the 
solar plexus, and of the lumbar ganglia of the sympathetic, also 
extreme hypersesthesia of the pneumogastrics, right kidney pal- 
pable and sensitive, hyperaesthesia of the spine and intercostal 
nerves. The following quantities were obtained by analysis : 
(A), o; (a), .00; (T), .130; (H), .000; (C), .060. 
Formula : . T Hoi 
A o, a o, 1 —| 
The color reagents agreed with the quantitative analysis, in 
indicating the entire absence of free hydrochloric acid, biuret 
reaction showed the entire absence of peptone, although the 
value of (C) indicates a small amount of combined chlorine. 
That this was not a normal product, however, is evidenced by 
the total absence of acidity. In another analysis made a few 
weeks later, the amount of free hydrochloric acid found present, 
was gms. .008, and the stomach fluid was found acid. 
The following case, observed since the publication of this 
paper, illustrates another very interesting form of apepsia, 
which I think has not been previously described. It is, how- 
ever, simply a variety of the preceding, the only difference be- 
ing that acid fermentation is added to the apepsia. In this 
case (No. 483) the following quantities were found : (A), .010 ; 
(a), 2.50; (T), .108; (H), .000; (C), .004. 
Formula: . . H o ) 
A — a + 1 —c_ - — 1. 
The color reactions were all negative. Lugol’s solution 
showed complete digestion of the starch. Rennet ferment and 
rennet zymogen both entirely absent. Biuret reaction for pep- 
tone, negative. It is evident that, in this case, notwithstanding 
the fact that the stomach fluid was acid, no actual work was 
done by the stomach, and that the acid was the result of fer- 
mentation. DISORDERS OF DIGESTION 
43 
Simple Dyspepsia.—The following cases, which for lack of 
space we will present as briefly as possible, represent the four 
forms of simple dyspepsia which are recognized in our classifi- 
cation : — 
Simple dyspepsia, typical, without fermentation (a=). 
Case 247. 
A young lady, aged 23 years. Amount of stomach fluid, 175 
c. c. (A), .228 ; {a), .85 ; (T), .312 ; (H), .032 ; (C), .232. 
Peptones abundant ; starch digestion moderate ; rennet zym- 
ogen abundant. 
Formula : . , rT, H = ) . 
A+ a=1 =c + ' +. 
The deviation from the normal chemism of the stomach is not 
sufficient in this case to relegate it to any of the classes of 
morbid digestion. It is simple dyspepsia without acid fer- 
mentation. The high value of (a) which is practically normal, 
indicates the good quality of the chloro-organic compounds 
represented by (C). There was moderate dilatation of the 
stomach as shown by examination, as well as by the large 
quantity of liquid present at the end of the hour, which does 
not exceed, in healthy stomachs, 40 c.c. 
Simple dyspepsia, qualitative, without acid fermentation. 
Case 53. 
Patient, a married lady of middle age, had suffered for 
several years from a variety of symptoms indicating disorders 
of digestion, which were probably the result of overwork, both 
mental and physical, and the use of stimulating medicines, 
which had been freely used. The most prominent symptoms 
were bad taste in mouth, eructations of gas, regurgitations of 
food, nausea, vomiting of food and bile, gnawing pain at the 
stomach, capricious appetite, inability to use fluids, obstinate 
constipation for several years, gaseous distension of bowels, 
nervousness and morbid fears, loss of spirits, impaired memory 
and loss of energy, fidgets, insomnia, occipital headache, heavi- 
ness and aching in the limbs, pain between the shoulders, pain 
under the ribs, pain in the lower part of the back and thighs, 44 
THE INVESTIGATION OK 
frightful dreams, nightmare, sudden waking from sleep with 
fright, coldness of extremities, sensation of burning and fever- 
ishness after meals, ringing in the ears, specks before the eyes, 
formications and numbness in limbs, weariness, palpitation of 
the heart, shortness of breath, excessive secretion of urine, 
moderate dilatation of stomach, sensitiveness of the lumbar 
ganglia of the sympathetic, prolapse of colon. 
The quantities obtained by chemical analysis after test break- 
fast were as follows: Quantity, 80 c. c.; (A).172; (a) .67; 
(T) .380 ; (H) .034 ; (C) .206 ; peptone reaction good. 
Formula: 
In this case the acidity was slightly below normal. This was 
due, not to the deficiency of the stomach work, but to the poor 
quality of the chloro-organic compounds; in other words, to an 
excessive formation*of neutral chloro-organic compounds, as is 
evidenced by the greatly diminished value of a. This is very 
clearly shown by determining the value of A' by the method 
previously described, which is . 2 j i. If the chloro-organic 
compound (C) possessed the normal value, the total acidity in 
this case would be .211 instead of .172. 
Simple dyspepsia and hyperchlorhydrie, with acid fermentation. 
Case 116. 
A lady aged 24 years, who had spent a number of years in 
boarding school, was suffering from severe constipation of the 
bowels, hemorrhoids, inability to concentrate the mind, and 
extreme nervous irritability, giddiness, sudden loss of strength, 
general exhaustion, general muscular weakness and debility. 
Her condition had usually been attributed to overwork in 
school. The patient had not considered herself a dyspeptic, 
but the physical examination showed a badly coated tongue and 
a relaxed condition of the abdominal muscles; the right kid- 
ney was movable and sensitive. By means of the stomach 
tube, 113 c.c. of fluid was withdrawn after the usual test break- 
fast, an examination of which furnished the following data: 
(A), .200; (a), .88 ; (T), .286; (H), .002 ; (C), .224. DISORDERS OF DIGESTION. 
45 
Lactic acid was present, and the biuret reaction showed a con- 
siderable amount of peptone. The following formula represents 
the chemical work of the stomach in this case : 
, , T H— ) . 
A = “+ r-C+ | +' 
A case of simple dyspepsia without hyperacidity with hyper- 
chlorhydrie and deficiency of hydrochloric acid, or hypohydro- 
chlorie, and slight acid fermentation. 
Case 89. 
The patient aged 42 years. Amount of stomach fluid, 165 
c.c.; (A), .200; (a), .89; (T), .284; (H), .020; (C), .202. 
Formula: . , rp H—) . 
A = a + 1-c+f+. 
In this case also the amount of disturbance of the stomach 
process is so slight that it may be classed as a simple dyspepsia 
with acid fermentation, probably due to the delay of the stom- 
ach in emptying itself of its contents. 
Simple dyspepsia with hypochlorhydrie atid acid fermentation. 
Case 94. 
A man, aged 55 years. Amount of stomach fluids no c. c. 
(A), .168; (a), .87; (T), .3x0; (H), .050; (C), .136. 
Uffelmann’s reagent showed lactic acid present. Peptones 
abundant. Formula : 
A —rf + T —C— [ — 
A case of simple dyspepsia with hypochlorhydrie and acid 
fermentation. The diminished amount of useful stomach work 
through the failure of the chlorine to combine with albumen, 
and the acid fermentation which may have been greater than 
that shown in the value of (a) as suggested by the strong re- 
action for lactic acid, were doubtless the result of the dilated 
condition of the stomach which prevented the complete and 
prompt emptying of the organ, and so gave rise to a slight 
degree of disturbance of the normal chemical process of 
digestion, and occasioned the setting up of a vicious chemical 
process in the form of acid fermentation. 46 
THE INVESTIGATION OE 
As the work upon which this paper is based includes, so far 
as the writer knows, the largest number of cases which have 
been studied by so exact methods of investigation, I think it 
important to present a brief summary of the results obtained, 
which will show at a glance the relative frequency of the patho- 
logical conditions which are recognized by this mode of inves- 
tigation, and as will appear, indicate that some of the current 
notions upon this subject are quite erroneous. With reference 
to the three general classes, hyperpepsia, hypopcpsia, and sim- 
ple dyspepsia, the cases were divided as follows: — 
Hyperpepsia 170 
Hypopepsia i 117 
Simple dyspepsia 34 
In considering these figures, it should be remembered that 
hyperpepsia and hyperacidity are by no means coincident con- 
ditions ; and that each of the three groups included in hyper- 
pepsia has a sub-group in which the acidity normal or below. 
The old method of analysis would place all of these cases in 
hypopepsia ; but as the cases given show, and as will appear 
still more clearly from the summary of the particular condi- 
tions observed for each group, many cases of hypoacidity are 
really cases in which there is an excess of stomach work rather 
than a deficiency, and hence belong to the class of hyperpepsia 
rather than hypopepsia. 
The accompanying tables present at a glance the particular 
facts observed as regards the relative frequency of excess, defi- 
ciency, and equality, in the figures found by analysis in rela- 
tion to the coefficient of digestive work (a), the total chlorine 
(T), the free HC1 (H), the combined chlorine (C), and the 
sum of free HC1 and combined chlorine (H-f-C), representing 
the amount of chlorine set free from the bases and prepared to 
enter into the work of digestion. 
The tables also show the relative frequency of the different 
forms of hyperpepsia, hypopepsia, and simple dyspepsia, and 
the dominant characteristics of each group. The following 
facts presented by the tables are especially worthy of note : — 
Hyperpepsia.— The 170 cases found in this class constitute 
52.9% of the total number of cases studied. DISORDERS OF DIGESTION. 
47 
Class. 
Group. 
Sub-Group. 
t 
c 
6 
£ 
Coefficient 
(a) 
Total 
(T) 
Cl 
FreeHCl(H) 
Combined 
Cl (C) 
(H+C) 
+ 
= 
— 
0 
+ 
= 
— 
+ 
= 
— 
0 
+ 
= 
— 
0 
+ 
= 
— 
Hyperhydrochlorie 
Hyperacidity (A+) without a .f. 
29 
6 
33 
27 
2 
29 
29 
29 
(11+) 
“ with a. f. 
29 
29 
29 
29 
29 
29 
i 
63 eases. 
Hypoacidity (A—) without a. f. 
5 
5 
4 
i 
5 
5 
5 
«=> 
Hypohydroehlorie 
Hyperacidity (A+) without a. f 
29 
7 
22 
11 
12 
6 
39 
29 
29 
. . 
• (H—) 
37 
37 
19 
13 
5 
37 
37 
37 
.2 
74 cases. 
Hypoacidity (A—) without a. f. 
8 
8 
3 
5 
8 
8 
7 
1 
e* 
Hypochlorhydrie 
Hyperacidity (A+)*without a. f. 
“ with a. f 
1 
9 
9 
1 
1 
8 
1 
1 
9 
1 
9 
1 
3 
6 
m 
(C ) 
Useful Work Defi- 
Hypoacidity (A—) without a. f. 
12 
8 
8 
12 
8 
7 
2 
1 
2 
12 
8 
12 
8 
1 
1 
5 
3 
e 
4 
cient. 33 cases. 
Pseudo-hyperacidity (A+A’—) with a. f. 
3 
3 
2 
1 
3 
3 
1 
2 
1st Degree. (A— 
Hypoacidity (A—) without a. f 
29 
29 
2 
3 
24 
2 
24 
3 
10 
6 
13 
8 
21 
18 
18 
3 
6 
9 
4 
13 
1 
1 
10 
1 
17 
1 
gms.) 58 cases. 
Pseudo-hyperacidity (A+A—) with a. f. 
11 
11 
3 
2 
6 
4 
7 
1 
3 
7 
4 
7 
2d Degree. (A— 
Hypoacidity (A—) without a. f. 
35 
32 
3 
1 
1 
33 
3 
28 
4 
34 
1 
35 
.2 
19 
19 
o 
4 
13 
4 
12 
3 
18 
1 
19 
Su 
gms). 57 cases. 
Pseudo-hyperacidity (A+A—) with a. f. 
3 
3 
1 
2 
2 
1 
3 
3 
CU 
D5 
SJDegree—Apepsia 
9 
9 
2 
2 
2 
2 
cT 
(AO). 2 Cases. 
f 
[ Without Fermenta- 
I Typical (a=) 
5 
5 
1 
3 
1 
1 
2 
2 
5 
4 
1 
R « 
| tion. 19 cases. 
Quatitatire (a—) 
14 
14 
1 
7 
G 
s 
6 
10 
4 
G 
7 
1 
o 
| With Fermentation. 
f nvperchlorhvdrie (C+) 
14 
14 
* * 
4 
4 
C 
9 
5 
10 
4 
5 
9 
#E 
cZ 
15 cases. 
\ llypochlorhydrio (C—) 
1 
1 
1 
1 
1 
1 
TABLE I.—SUMMARY OF THE RESULTS OF THE CHEMICAL ANALYSIS OF THE STOMACH FLUID IN 321 CASES OF 
DISORDERED DIGESTION, CLASSIFIED IN RELATION TO NORMAL QUANTITIES. 48 
THE INVESTIGATION OF 
8 
(«ROlP. 
5 
Acidity (A) 
Coefficient 
(o) 
Total Cl (T) 
Free I1C1 (H) 
Combined C1(C) 
<n+o 
6 
A 
+ 
0 
+ 
— 
0 
+ 
= 
— 
+ 
= 
— 
0 
+ 
= 
— 
0 
+ 
— 
11 vperhydrocblorie 
(H+) 
03 
58 
5 
29 
C 
28 
60 
3 
63 
63 
63 
i i 
Hvpohvdrochloritt 
* S 
(H—)... .* 
”4 
M 
8 
37 
• 
30 
33 
30 
11 
74 
74 
73 
15 
k © 
Hypochlorhydrle 
5S 
(t—) 
33 
13 
20 
20 
13 
26 
4 
3 
33 
33 
•• 
! 
1 
12 
Total 
iro 
137 
33 
86 
IS 
71 
119 
37 
14 
96 
74 
. . 
137 
33 
142 
16 
12 
1st Degn*e (A—, 
5S 
11 
47 
29 
8 
11 
39 
10 
44 
4 
12 
1C 
30 
13 
45 
i 5 
Hi IMH • 1IV 
3d Degree (A—u«i 
r a 
57 
3 
54 
22 
32 
3 
3 
■c 
48 
9 
41 
55 
r 
57 
1- 
3d Decrw — Apejv 
R - 
ill (AO) 
2 
2 
2 
2 
2 
:= - 
Total 
117 
14 
101 
o 
51 
61 
ft 
11 
17 
89 
19 
85 13 
12 
1C 
87 
r 
13 
104 
« 
Without AcKl Ker 
19 
4 
s 
5 
14 
o 
10 
7 
1 
10 
8 
15 
4 
ro 
S 
1 
1* S 
With Acid Ker- 
| s 
mentation. 
15 
5 
9 
1 
15 
4 
5 
6 
10 
5 
10 
4 
1 
5 
10 
... 
e. " 
Total 
34 
8 
15 
5 
14 
6 
15 
13 
1 
20 
,3 
25 
8 
1 
15 IS 
i 
1 
£ 
Grand Total.. 
321 
too 
IT 
142 
i 
152 
18 
146 
5 
136 
69 
116 
97 
39 
172 
13 
174 
24 
121 
2 
47 
M7 
TABLE II.-GENERAL SUMMARY OF THE RESULTS OF THE CHEMICAL ANALYSIS OF the STOMACH FLUID IN 321 
CASES. CLASSIFIED IN RELATION TO NORMAL QUANTITIES. DISORDERS OF DIGESTION. 
49 
x. Hyperpepsia with Hyperhydrochlorie (H-\~).— The first 
group of this class, hyperpepsia, with hyperhydrochlorie, or 
free HC1 in excess, presents sixty-three cases, which is 19.6% 
of the entire number of cases studied, or 37% of all the cases 
of hyperpepsia. This is by far the largest single group found. 
In this group, A is of course nearly always -{-, yet we find A —• 
in five cases, although, as will be noticed, free HC1 (H) and 
combined chlorine (C) are -f- in all the cases of this group. It 
is evident, then, that these five cases could not be properly 
classed as cases of hypopepsia. The total chlorine is found in 
excess in 60 of the 63 cases. 
An interesting fact especially worthy of note in relation to 
this group is the frequency with which a— occurs. Since the 
figures represented by a are an index to the quality of the di- 
gestive work done, or, at any rate, to the chemical quality of 
C, indicating, when deficient, the presence of neutral chloro- 
organic compounds, which are as much greater in proportion 
as a is less than normal, it is evident that in this group of hy- 
perpepsia, in which we find both H-f- and C-{-, and with rare 
exceptions A-f- and T+, or hyperacidity and excessive secre- 
tion of chlorine, the digestive product is, if not in the ma- 
jority of cases, in at least a large minority (42.8%), inferior in 
quality, a fact which accounts for the remark often made by 
this class of patients, “ Doctor, I have a ravenous appetite; I 
eat more than I ought to eat, and I seem to digest my food 
without difficulty; nevertheless, I lose in weight continually, 
and cannot gain an ounce of flesh.” 
2. Hyperpepsia with Hypohydroclilorie {H—). — In this 
group, characterized by a deficiency of free HC1, we find sev- 
enty-four cases, 23% of the total number of cases studied, or 
43-5% tfie cases of hyperpepsia. This group is only ex- 
ceeded by the preceding in the number of cases which it 
presents. 
It is noticeable that the total chlorine is in excess much less 
frequently in this group (44.6%), as compared with the preced- 
ing (95.2%). The less frequency with which hyperacidity oc- 
curs in this group, and the smaller proportion of cases in which 
the total chlorine is in excess, indicate distinctly that in this 50 
THE INVESTIGATION OE 
group the hyperpepsia is less pronounced than in the preceding. 
A careful study of the cases in this and the preceding group 
show a gradually descending scale reaching from the most 
pronounced hyperpepsia down to hypopepsia. The most at- 
tenuated cases, in fact, seem to overlap the first group of hy- 
popepsia, so that a fourth division of hyperpepsia with 
hypohydrochlorie (H — A—, -f- a. f.) would coincide with the 
first division of hypopepsia of the first degree. 
Hyperacidity is the dominant condition as in the preceding 
group, although likewise not absolutely constant; for we find 
A — in four cases, notwithstanding that the amount of com- 
bined chlorine present is in so great excess as to more than 
compensate for the deficiency of free HC1 in every case, so that 
we find in all the cases of this group (H -f- C) in excess. Evi- 
dently there is a sufficient amount of chlorine set free from the 
bases to give a figure for A in excess of the normal in every 
case. The hypoacidity is then due in these cases to the pres- 
ence of neutral chloro-organic compounds, shown by the dimi- 
nution of a. It will be noted, however, that A— occurs more 
frequently in this group (10.8%), than in the preceding (7.9%), 
while a— is slightly less frequent. 
3. Hyperpepsia with Hypochlorhydrie ( C—). — The value 
of the method of chemical investigation of stomach fluids 
to which it is the purpose of this paper to call attention, 
is especially apparent in the study of this group of cases of hy- 
perpepsia. In fact, it is only by the aid of this method that it 
is possible to discover these cases, and to form of them a distinct 
group. The older methods give their characteristic reactions 
in the presence of both free HC1 and combined chlorine, and 
hence afford no means of distinguishing between these two im- 
portant conditions of the chlorine participating in the digestive 
act; and hence a recognition of these conditions by a careful 
determination of the quantity of chlorine in each state in a 
given case, affords our only means of determining how much of 
the chlorine set free from the bases with which it is combined 
when secreted by the stomach, really enters into the digestive 
process by combining with albumen for the conversion of the 
latter into peptone. 
The 33 cases comprised in this group constitute 10.2% of 
the entire number of cases studied, or 19.4% of the cases of DISORDERS OF DIGESTION. 
51 
hyperpepsia. It will be noted that A—- occurs in nearly two 
thirds of the entire number of cases, showing at once the fact 
that the combined chlorine (C) is a more important element in 
the production of the normal acidity of the gastric juice than is 
free HC1 (H). 
The total chlorine is in excess in 78.9% of the cases, a much 
larger proportion than in the preceding group. Free HC1 is in 
excess in all the cases, although the total amount of chlorine 
set free, shown by the sum of H and C (H -{- C) is deficient in 
36.3% of the total number of cases, being in excess in only six 
cases, or less than one fifth of the entire number of cases in 
this group. 
The quality of the digestive product is also poor, however 
in a large proportion of cases, as shown by the low value of 
a, which is below normal in thirteen cases, or 39.4% of the 
total number, and also by the absence of peptones from the 
stomach fluid. It thus appears that in this group both phases 
of the chemical process are faulty. 
This group, notwithstanding the large proportion of cases of 
hypoacidity (63.6%), is evidently allied to the preceding 
groups, although the general formula furnished by the cases of 
hypoacidity in this group is also very closely allied to the 
formula found in the first group of hypopepsia. One charac- 
teristic peculiarity alone distinguishes the formulae of this group 
from those of hypopepsia of the first degree ; namely, the ex- 
cess of free HC1, or H -J-, which is always present in this 
group, associated with C—, but is never found in hypopepsia. 
It will also be noticed that in all the sub-groups of this class of 
hyperpepsia, T -j- (total chlorine in excess) occurs most fre- 
quently, T = and T — only occurring in the third and fifth sub- 
divisions of the group, its most attenuated forms, which 
approach very closely to hypopepsia, as does the third form in 
each of the preceding groups. 
Both groups may be said to touch the line of hypopepsia, 
as has been already remarked. 
4. In the total summary of the characteristics exhibited by 
hyperpepsia in its different forms, we find A -f- in 80.6% of the 
cases of hyperpepsia; A— in a little less than one fifth of the 
eases, while A= is absent. It should be mentioned, however, 
that A -(- includes a few cases in which the total acidity was 52 
THE INVESTIGATION OK 
close to the extreme upper limit of normal variation, and A — 
two or three cases in which A was close to the lower limit. 
A= is a characteristic of simple dyspepsia. 
The coefficient a is below normal in 71 (41.7%) of the cases. 
a= occurs in only 13 cases, being one of the characteristics of 
simple dyspepsia. The total chlorine is equal, or in excess, in 
156 cases (91.8% ), being found deficient in only 14 (8.2%) of 
the cases. 
H + occurs in 96 (56.5%) of the cases, and H— in 74 
(43.5%) of the cases. We find C (combined chlorine) in ex- 
cess in 137 (80.6%) of the cases, and deficient in 33 (19.4%) 
of the cases. (H-j-C) is in excess in 142 (83.5%) of the 
cases, equal in 16 (9.4%) of the cases, and deficient in 12 
(7.1%) of the cases. 
Hypopepsia. — The total number of cases of hypopepsia was 
found to be 117, 36.4% of all the cases examined, a much 
smaller number than would be supposed by the frequency with 
which hydrochloric acid is administered to patients by physi- 
cians and the great quantities of pepsin and other digestive 
agents, and digested or partially digested food substances, an- 
nually swallowed by dyspeptics. A careful study of the chem- 
istry of digestion in pathological cases shows that deficient 
digestive work is not the chief fault in the majority of cases of 
disordered digestion, but abnormal or vicious chemical work. 
My statistics show unmistakably that in a great proportion of 
cases of indigestion, the stomach is even doing an excess of 
work ; but the quality of the work done is inferior or takes a 
wrong direction, so that notwithstanding the great amount of 
labor performed by the stomach, the blood is not supplied with 
the proper amount of well-elaborated food substances, but in- 
stead receives a great amount of material which has been par- 
tially digested only, or has been subjected to deteriorating 
changes through the action of microbes and other ferments, 
and which must be destroyed by the liver and eliminated by 
the kidneys and other emunctories, along with the normal 
waste and excrementitious products of the tissues. It is this 
semi-starvation and auto-intoxication which gives rise to a 
great share of the morbid symptoms presented in various forms 
of functional stomach disorders DISORDERS OF DIGESTION. 
53 
In hypopepsia we find a still greater deficiency of well elab- 
orated food elements than in hyperpepsia, and yet it is not un- 
common to find persons suffering from a very extreme degree 
of hypopepsia who are not by any means so much emaciated as 
we should expect to find them, and sometimes even enjoying 
fair health, owing to the fact that the stomach is not the chief 
digestive organ of the body, but only a sort of antechamber in 
which the preliminary digestive work is done. So it is possible 
for very good health to be enjoyed coincident with hypopepsia, 
provided a suitable dietetic regimen is followed, and even 
though the stomach may be almost wholly inactive in the 
digestive process. 
As before stated, 1 have followed the plan of Hayem and 
Winter in grouping cases of hypopepsia, since their method, 
although wholly artificial, is as good as any that has occurred 
to me. The study of a still larger number of cases will perhaps 
enable me to find a natural and better basis of classification. 
i. Hypopepsia of the First Degree (A— or A'—, but above 
.100 gms.f —The total number of cases in this class is 58 or 
49.4% of all the cases of hypopepsia. We find here, as in hy- 
perpepsia, a few deceptive cases, although of the opposite char- 
acter. The total acidity which is usually less than normal (47 
cases, 81.1%) was found to be in excess in 11 cases (18.9%). 
As hydrochloric acid was also present in all but three of the 
cases, although diminished in quantity, these cases examined 
by the older methods would have been pronounced cases of hy- 
perpepsia ; but that they belong to the class of hypopepsia is 
evidenced by the fact of the deficiency in the total chlorine 
(T), and also in the diminished combined value of H and C (H 
-f- C), as well as the low value of H. A— appears much more 
frequently than in hyperpepsia. These cases afford another 
interesting illustration of the importance and value of the 
ingenious method of investigating stomach fluids devised and 
perfected by Hayem and Winter, and which appears to me to 
be the only one of any considerable scientific value which has 
been proposed. 
The total chlorine is in excess in but eight cases (13.8%), 
being deficient in 39 (67.2%) of the cases. Free HC1 (H) was 
deficient in 44 (75.8%) cf the cases, and entirely absent in four 54 
THE INVESTIGATION OK 
cases (6.8%). A few cases in which it was found equal were 
classified as hypopepsia because of the low values of T and 
(H -f C), showing an evident and marked diminution in both 
the secreting and chemical work of the stomach. The com- 
bined chlorine (C) was deficient in 30 (51.7%) of the cases, 
equal in 16 (27.6%), and in excess in 12 (20.7%) ; and (II -|- 
C) was minus in 45 (77.6%) and equal in 13 (22.4%) of the 
cases, never in excess. 
2. Hypopepsia of the Second Degree (.A or A'—, and below 
.100 gms.).— Total number of cases, 57, or 48.7% of the cases 
of hypopepsia. Here, as in the preceding group, we find a few 
cases (three, or 5.2%) of pseudo-hyperacidity. In each of 
these cases, as in the similar cases of the preceding group, an 
abnormal degree of acidity was present, due to acid fermenta- 
tion and the formation of a great quantity of lactic acid and 
perhaps other members of the fatty acid series. That these 
cases belong properly to the class hypopepsia, is easily ascer- 
tained by obtaining the value of A' by the method previously 
described. This value was, in the three cases of hyperacidity 
found in this group, determined to be less than .100 gms., al- 
though the acidity was in one instance found to be .413 gms., 
or more than double the normal amount, the value of A' in this 
instance being only .086 gms., or about one half the normal, 
and one fifth the total, acidity. We find A less than normal in 
54 (94.7%) of the cases, a considerably larger proportion than 
in the preceding group. T -f- occurs in this group in but three 
cases, the total chlorine being equal in only six (10.5%) of the 
cases and falling below normal in 48 (84.2%). The free hy- 
drochloric acid was normal in only nine (15.8%) of the cases, 
below normal in 41 (71.9%) of the cases, and o in seven cases. 
C was o in two cases, and below normal in 55 (96.5%) of the 
cases. The advanced state of hypopepsia in this group is 
shown by the fact that the combined value of H and C(H-f C) 
is below normal in every case, while in the preceding group 
this value is normal in 22.4% of the cases. 
3. Hypopepsia of the Third Degree (A O, or Apepsia).—Apep- 
sia was found in only two cases, 1.7% of the cases of hypo- 
pepsia, or .6% of the cases studied. In one of the two cases 
of this sort which I have met, the reaction of the stomach fluid DISORDERS OF DIGESTION. 
55 
was slightly alkaline, and the value of A was —.020. T— was 
found in both cases. Combined chlorine (C) was present in 
slight quantity in both cases. 
In this group, the stomach work reaches the vanishing point, 
a condition which not infrequently co-exists with malignant dis- 
ease, although not invariably present. When present in connec- 
tion with a perceptible thickening in the epigastric region, it 
becomes, however, a very important aid to diagnosis, as hyper- 
pepsia would not be likely to co-exist with such a condition 
except in the case of gastric ulcer accompanied by fibrous thick- 
ening. We thus have a very important means of differential 
diagnosis in a class of cases in which it is sometimes difficult 
to determine by other means whether an existing disease of the 
stomach is simple ulceration which may be cured, or a disease 
of a malignant and incurable character. 
Summarized, the facts'relating to hypopepsia are as follows: 
A— in 101 (86.3%) of the cases ; A -f- in only 14 (11.9%) ; 
total chlorine in excess (T -j-) in only 11 (9.4%) of the cases, 
and deficient in 89 (76%) of the cases. Free HC1, never in 
excess, was found deficient in 85 (72.6%) of the cases, normal 
in only 19 (16.2%), and was entirely absent in 13 (11.1%) of 
the cases. The combined chlorine was diminished in 87 
(74-3%) °f the cases, equal in 16 (13.6%), and in slight ex- 
cess in only 12 (10.2%) of the cases. The combined value of 
free HC1 and combined chlorine was also deficient in 104 
(88.9%) of the cases, and equal in only 13 (11.1%). 
Simple Dyspepsia.— This class includes 34 cases, 10.6% of 
the entire number studied. The cases grouped in this class are 
those in which there was no serious disturbance of the chemical 
work of digestion. The smallness of the proportion of cases is 
at once an indication of the importance of a careful chemical 
study of the stomach fluid in all cases of dyspepsia, to obtain a 
basis for a rational plan of treatment. 
Of the cases of simple dyspepsia the total acidity (A) was 
found to be in slight excess in nine (26.4%), equal in 17(50%), 
and slightly deficient in only eight (23.5%). The coefficient a 
was found in excess in 15 (44.1%) of the cases, as the result of 
acid fermentation, which may be properly considered as the 
principal chemical disturbance met with in simple dyspepsia, 56 
1HK INVESTIGATION OF 
there being neither a deficiency nor an excess of chemical work 
to any considerable degree, but rather a vicious chemical action 
added to the normal work of the stomach. That this vicious 
action may ultimately lead to a disturbance of the normal 
chemical work of the stomach, I have many times seen demon- 
strated by the readiness with which the normal chemical work 
of the stomach is resumed when acid fermentation is suppressed 
by lavage and the employment of antiseptic measures by pre- 
scribing a proper dietary, and when necessary, antiseptic medi- 
cation. 
We find a— in 14 (41.1%) of the cases, an evidence that a 
deterioration in the quality of the work done by the stomach 
may occur without either an increase or a diminution of the 
amount of work done; in other words, without either hyper- 
pepsia or hypopepsia. T = was found in 15 (44.1%), T -f 
in 6 T— in 13 (38.2%) of the cases. Free HC1 was 
normal in quantity in 20 (58.8%), and deficient in 13 (38.2%) 
of the cases. Combined chlorine (C) was in excess in 25 
(73.5%) of the cases. This deviation is not sufficiently serious 
in itself to characterize a case as abnormal, since C represents 
useful chemical work. An increase of combined chlorine is, 
according to my observation, a condition commonly present in 
cases in which a patient is rapidly gaining in flesh. The com 
bined value of H and C (H + C) was slightly in excess or 
equal in nearly all the cases (33, or 97%). 
General Summary.— A brief glance at the grand totals of the 
chemical facts contained in the table shows hyperacidity to be 
present in 160 (50%) of the cases; hypoacidity was found in 
142 (44.2%) of the cases. The acidity was normal or equal in 
*7 (5-2%) of the cases, and wholly absent in two (.6%) of the 
cases. 
The coefficient of chemical stomach work, shown by the value 
of a, was in excess in 152 (47.4%) of the cases, deficient in 
146 (45.4%) of the cases, equal in 18 (5.6$) of the cases, and 
o in five cases (1.6%). 
The total chlorine was in excess in 136 (42.4% ) of the cases, 
deficient in 116 (36.1 % ), and equal in 69 (21.5%) of the cases. 
Free HC1 was in excess in 97 (30.2%), deficient in 172 
k53*5%)> equal in 12.2% of the cases, and entirely absent in 13 57 
DISORDERS OF DIGESTION. 
(4-i%) of the cases. Combined chlorine (C) was in excess in 
i74 (54-2%), deficient in 121 (37-7%), equal in 24 (7.5%), 
and totally absent in two cases. The combined value of 
H and C (H-f C) appeared in excess in 157 (48.9%) cases, 
deficient in 117 (36.5%) cases, and equal in 47 (14.6%) cases. 
Acid Fermentation. — It is interesting to note the relation of 
acid fermentation to the several classes described. As indi- 
cated by the value of a, fermentation was present in 86 (50.6%) 
of the cases of hyperpepsia, in 51 (43.6%) of the cases of hy- 
popepsia, and 15 (44.1%) of the cases of simple dyspepsia; 
from which it appears that acid dyspepsia is a more frequent 
accompaniment of hyperpepsia than of hypopepsia. This fact 
would seem at first sight to oppose the opinion generally held 
that the free HC1 of the gastric juice is a natural antiseptic, 
and of great use in inhibiting abnormal fermentations. It 
seems probable, however, that in many cases, the hyperpepsia 
may be the result of glandular irritation and hyperactivity pro- 
duced by the contact with the gastric membrane of lactic and 
other acids produced in excess by abnormal fermentations. 
That free hydrochloric acid lessens the tendency to acid fer- 
mentation in the stomach is clearly shown by a comparison of 
the frequency of the occurrence of fermentation in the different 
groups of hyperpepsia. In the first group, hyperpepsia with 
hyperhydrochlorie (H -f), acid fermentation was found in 29 
(46%) cases; in the second group, with free hydrochloric acid 
deficient, although (H-f- C) was in excess, acid fermentation 
was found present in 37 (50% ) cases ; while in the third group, 
hyperpepsia with hypochlorhydrie, (H -f- C) being in excess in 
only 18% of the cases, acid fermentation was found present in 
20 (60.6% ) cases. 
Just why acid fermentation occurs less frequently in hypo- 
pepsia than in hyperpepsia, is somewhat difficult to understand. 
A remarkable concurrent fact, and one which I believe is new 
to the study of this subject, is the very complete digestion of 
starch in cases of pronounced hypopepsia, which I have ob- 
served in a very considerable number of cases. In fact, I have 
found the state of the starch digestion to be a very good index 
to the degree of total acidity. When A is large, Lugol’s solu- 
tion gives a blue, bluish purple, or purple color, showing that 58 
IHK INVESTIGATION OF 
the starch is unchanged or is partially or completely converted 
into erythro-dextrine. In well-marked cases of hypopepsia with 
hypoacidity, Lugol’s solution gives a brown color, or no reac- 
tion whatever, showing complete conversion of the starch into 
sugar, an observation which is confirmed by the strong reaction 
for sugar given by Fehling’s solution. 
Through the more prompt conversion of starch into sugar in 
the stomach in hypopepsia, the digested starch may disappear 
by absorption so rapidly that the conditions become less favor- 
able for the development of acid fermentation than in the pres- 
ence of a large quantity of partially digested starch. This 
point is of sufficient interest to be worthy of more complete 
study, and I hope to be able to elucidate it more fully in some 
future paper. 
In my studies of digestive fluids, I do not confine myself to 
a determination of the quantity of chlorine present in its differ- 
ent forms, but also employ the various color reagents, and 
the well-known tests for peptones, propeptones, and albumi- 
noids, the coagulation test for rennet ferment and for the 
rennet zymogen, and also determine the state of the starch 
digestion by means of Lugol’s solution. Tests are also made 
for lactic acid, as well as for acetic and butyric acids, and for 
bile and alcohol when the presence of these substances is sus- 
pected. Important facts are also ascertained from an ocular 
examination of the stomach fluid, from a determination of its 
quantity and the amount and appearance of the residue left on 
the filter. On the next page is a reproduction of the blank 
form which I have prepared for use in my own laboratory, and 
which I find very convenient, as it shows at a glance all the 
more important things relating to the chemical work of the 
stomach which it is possible to know. 
I also sometimes employ salol for determining the state of 
the motor function of the stomach, and iodide of potash for 
ascertaining the rate of absorption; but I find so great a dis- 
crepancy in the results obtained by these methods that I cannot 
but consider them as of less value than the information derived 
by other means, especially clapotement and the stomach-tube. 
The Acid of the Gastric Juice. — There has been an almost 
endless discussion among physiologists respecting the nature of DISORDERS OF DIGESTION. 
59 
rsj o. 
SANITARIUM LABORATORY OF HYGIENE. 
BATTLE CREEK, IV1ICM. 
J. H. KELLOGG, M D., Superintendent. 
ANALYSIS OF STOMACH FLUID. 
M 189 .. 
Test-meal. Bread, fermented, unfermented.... oz., meat, 
eggs....oz. Water, 8 oz. Breakfast. Dinner. (Lavage 
two hours previous.) Duration of Digestion hours 
minutes. 
Physical characteristics: amount c.c., color 
odor blood mucus residue gms. 
Normal variations.* 
Total acidity, (A) .... gms. (A'). .. .gms. (. 180-. 200 gms.) 
Coefficient, (a) (. 86) 
Total chlorine, (T) gms. (.300-.340 “ ) 
Free HC1, (H) gms.) ,, j (.025-.050 “)).i8o- 
Combined chlorine, (C).. “ j ( (.155-. 180 “ ) j .225. 
Fixed chlorides, (F) “ (109 gms.) 
Color reactions for HC1 : Congo-red...Methyl-violet 
Giinzburg’s reagent.... Resorcine.... Dried residue.... 
Reactions for fatty acids, etc.: Lactic Acetic or 
Formic Butyric Bile Alcohol 
Digestion of Proteids : Biuret reaction purple, violet 
Propeptones Rennet ferment! Rennet 
zymogen 
Digestion of Starch: Lugol’s solution. .blue, brown, violet, 
purple. 
H ) 
Diagnosis. Formula :A a T l 
Prescription 
* The quantity of chlorine is expressed as HC1. The values given relate to 
100 c.c. of stomach fluid. 60 
THE INVESTIGATION Of 
the acid of the gastric juice. Quite a considerable number of 
eminent chemists have maintained that the normal acid of the 
gastric juice is lactic acid, and there have been physiological 
chemists of repute who have regarded the acidity of the gastric 
juice to be due, in considerable part, to acid phosphates. The 
majority of authorities have given their adhesion, however, to the 
views of Bidder and Schmidt, who regarded the acidity of the 
gastric juice to be due to the presence of free hydrochloric acid. 
The experiments of Richet and others l«ve thrown considerable 
doubt upon this theory, however, and consequently much con- 
fusion has existed among physiologists upon a point which it 
would seem ought by this time to have been authoritatively 
settled. That lactic acid is normally present, in small amounts 
at least, in the early stages of digestion, is a fact which cannot 
be disputed ; and that it plays a part of some importance in the 
digestive process, the writer has demonstrated to his own satis- 
faction, although just what part it acts in the normal chemical 
process of digestion cannot yet be fully explained by the data 
which physiological and therapeutic experiments have placed in 
our hands. The facts which the writer desires to present, it is 
believed will be found of interest in this connection, and will 
contribute something toward the settlement of this important 
physiological question. The facts to be presented are as 
follows:— • 
1. The results observed respecting the constancy of free HCl 
in the quantitative analysis of 413 different stomach fluids. 
2. The results npted as regards the presence of lactic acid in 
the examination of stomach fluids. 
3. Experimental observations respecting the effect of the 
addition of free hydrochloric acid to meat juice. 
4. Therapeutic observations respecting the influence of lactic 
acid upon the digestive process. 
1. The Results of the Quantitative Analysis 0/413 Stomach 
Fluids.—The stomach fluids analyzed in this series of observa- 
tions, were furnished by 321 different individuals. The fluid 
was withdrawn from the stomach one hour after taking a test 
breakfast, neither food nor fluid having been taken since rising. 
The presence of hydrochloric acid was determined qualitatively 
by the use of the usual color reagents, Congo-red, methyl-vio- DISORDERS OK DIGESTION. 
61 
let, Giinzburg s reagent, and the resorcine and sugar reaction. 
Each fluid was also carefully examined quantitatively by sub- 
stantially the same method suggested by Bidder and Schmidt, 
which consists in first determining the total amount of chlorine 
present in the gastric fluid, then making a second determina- 
tion, after evaporating the liquid to dryness without* the addi- 
tion of carbonate of soda, and drying the residue for an hour 
so as to drive off all free HC1. Subtracting the figures obtained 
in the second analysis from those obtained in the first, the dif- 
ference will represent, of course, the exact amount of HC1 
existing in a free state in the fluid examined. No method of 
determining the amount of HC1 present in the gastric juice 
more accurate than this has ever been devised, and indeed this 
method seems to offer all the advantages as regards accuracy 
that could be desired. It is evident that the only chance for 
error, if any exist, would be in the representation of too small 
a quantity of free HC1, since in the first determination the free 
HC1 is wholly fixed by the carbonate of soda added, so that 
the only source of error likely to arise, will be found in neglect- 
ing to continue the evaporation of the dried residue in the sec- 
ond determination for a sufficient length of time to completely 
dissipate the free HC1 present. 
The results obtained were as follows :— 
(a) The presence of free HC1 was indicated by color 
reactions in 362 cases, or 87.6 per cent of the total number 
examined. 
(b) The presence of HC1 was determined by the quantitative 
method, and in amount sufficient to be measured, in 397 cases, 
or 96.1 per cent of the total number of fluids examined. 
It is interesting to note that free hydrochloric acid was found, 
and the amount determined by the quantitative method, in 
every single instance in which its presence was indicated by 
color reactions, although the color reagents failed to indicate 
the presence of free HC1 in quite a number of instances in 
which it was present in very appreciable quantity, as determined 
by quantitative analysis. In one instance the color reagents 
totally failed to indicate the presence of free HC1, although 
this acid was present to the amount of .020 grams of anhydrous 
acid in each 100 c.c. of sto.mach liquid. 62 
THE INVESTIGATION OF 
It appears from these results that hydrochloric acid is a very 
constant constituent of the gastric juice, even under unfavor- 
able circumstances, for nearly all the cases examined were 
persons who were suffering more or less from stomach disor- 
ders. The sixteen cases in which no free hydrochloric acid was 
found by quantitative analysis, were all cases of hypopepsia of 
a very pronounced degree. Hypoacidity existed in all these 
cases, and lactic acid was present in only three of the sixteen 
cases. 
2. Observations Relating to Lactic Acid in the Analysis of j2ft 
Stomach Fluids.— The stomach fluids examined were furnished 
232 different persons, nearly all of whom were suffering more 
or less from disordered digestion. For obvious reasons, no 
quantitative estimation of the amount of lactic acid present was 
undertaken. Uffelmann’s reagent was employed with all pos- 
sible precautions. A watery solution of the residue obtained 
by washing the liquid several times with ether, then evaporat- 
ing the ethereal extract, was used, but the presence of lactic 
acid was indicated in only 180 cases, or 54.9 per cent of the 
total number of fluids examined. 
The evidence respecting the degree of constancy of lactic 
acid as a constituent of gastric juice afforded by this fact, can- 
not be said to be absolutely conclusive on account of the want 
of a thoroughly reliable color indicator for this acid; but such 
evidence as exists, leads to the conclusion that this acid is 
much less constant as a constituent of gastric juice than is free 
HC1, and this observation still remains good, even if we con- 
sider lactic acid present in every case which presents any evi- 
dence of acid fermentation, since the addition to the figures above 
given of 59 cases of acid fermentation in which the presence 
of lactic acid was not noted, making 259 cases in all, would still 
give 21 per cent of the total number of cases examined in which 
lactic acid was observed to be absent. 
I do not know whether or not a study of this sort, including 
so large a number of cases, has ever before been made, and 
hence am not able to make a comparison of my results with 
those obtained by other observers. I ought to add, however, 
that every precaution was taken to avoid the ingestion of lactic 
acid with the food, and to exclude lactic-acid-forming ferments. DISORDERS OF DIGESTION. 
63 
To this end I discarded the use of the white raised bread com- 
monly employed for the test breakfast, and used, instead, 
unleavened water-bread composed of whole-wheat meal with 
the addition of common salt to the amount of three fifths of 
one per cent of the bread taken. 
Admitting the correctness of the above observations, it seems 
quite clearly established that free HC1 is the normal acid of the 
human gastric juice, and that lactic acid plays only a subor- 
dinate part. 
If it be suggested that the observations are inconclusive, be- 
cause the digestion was disordered more or less in the majority 
of cases from which the fluids were obtained, this objection is 
negatived by a comparison of the results obtained in cases ofi 
hyperpepsia and hypopepsia respectively. Of the total number 
of cases examined with reference to lactic acid, 182 belonged 
to the class hyperpepsia, and 123 were cases of hypopepsia. 
Lactic acid was found present in 97 cases, or 53.3 per cent, of 
the cases of hyperpepsia, and in 63, or 51.2 per cent, of the 
cases of hypopepsia, while the proportion of all the cases ex- 
amined in which lactic acid occurred, was 54.9%. If lactic 
acid is normally a prominent constituent of the gastric juice, 
we should expect to find it increased Hi quantity in cases in 
which the other elements of the gastric juice were found in ex- 
cessive proportion ; but, as shown by the above figures, this is 
not the case. We find lactic acid occurring with about equal 
frequency in cases of hyperpepsia and hypopepsia. 
3. Observations Respecting the Effect of the Addition of Free 
HCl to Meat Juice.— The fact that free hydrochloric acid is 
not found in the gastric juice of dogs that have been fed on 
meat, has been used as an argument against the theory which 
regards this acid as an essential constituent of healthy gastric 
juice. Hayem and Winter some time ago suggested that this 
fact might be due to the combination of free hydrochloric acid 
with the albuminous elements of meat, thus causing the dis- 
appearance of HCl in a free state from the gastric fluid obtained 
from the stomach of a dog during the digestion of flesh food. 
The following experiment, a modification of an experiment 
made by the authors above referred to, seems to demonstrate 
this hypothesis to be correct: — 64 
THE INVESTIGATION OF 
A quantity of meat juice was expressed from fresh beef and 
titrated with a decinortnal solution of hydrate of potash ; its acid- 
ity was found to be equivalent to.021 grams of anhydrous HC1. 
A solution of hydrochloric acid was then added drop by drop 
to an equal quantity of the same preparation of meat juice, 
testing frequently for the presence of free HC1. No indica- 
tion whatever was obtained until after .015 grams of anhy- 
drous HC1 had been added. A faint indication of the presence 
of free acid was then obtained with Congo-red paper. The 
solution was then titrated with a decinormal solution of KHO, 
and its acidity was found to be an equivalent of .035 grams of 
anhydrous HC1, showing that the HC1 added had not been 
neutralized by any alkaline substance in the meat juice, but 
that it had been simply fixed by the albumen with which it had 
formed an acid combination, it still retaining its acid function 
to the full degree. 
This experiment explains very completely the absence of free 
HC1 from the gastric juice of the dog during the digestion of 
meat, and of course answers completely the argument based 
upon this fact. 
4. Therapeutic Observations Respecting the Influence of Lactic 
Acid upon the Digestive Process.— I have made a very consider- 
able number of observations respecting the influence of lactic 
acid upon stomach digestion. Having noted the frequent ab- 
sence of lactic acid in cases of hypochlorhydrie, lactic acid 
being noted as absent in 25 (61 per cent) of the 41 cases of 
hypochlorhydrie,— cases in which free HC1 is present in the 
gastric juice in abundant quantity, but fails to combine with 
albumen to the usual extent, or, in other words, in which there 
is a deficient amount of useful work done by the stomach,— it 
occurred to me to be possible that the qualitative change in the 
character of the chemical work done by the stomach might be 
due to this notable deficiency of lactic acid, which previous 
experience had taught me to be useful in certain cases of dys- 
pepsia, although I had not before been able to predict in 
advance just which cases would be benefited by the remedy. I 
accordingly began the administration of the lactic acid in doses 
of 5-15 minims of pure acid in cases of this class, and with the DISORDERS OF DIGESTION. 
65 
most excellent results, as will be seen by the following case, 
which is a fair example of many others which might be cited : — 
A young man aged 30, a student, had suffered for eight 
or ten years from stomach disorders which had been but par- 
tially relieved by the various remedial measures which he had 
employed. Was emaciated, and suffered much from sour 
stomach. Appetite was good, but the nutritive processes were 
evidently very defective, for he was continually emaciated and 
weak, and unable to pursue his studies except under great 
difficulty. 
Analysis of the stomach fluid gave the following quantities : 
(A), .217; O), 1.00; (T), .354; (H), .090; (C), .120. 
Formula:- A+a + T+H+) 
The above figures indicate hyperpepsia with hyperchlorhydrie, 
hyperacidity, and acid fermentation. The amount of free 
hydrochloric acid is notably large — nearly double the maxi- 
mum quantity found in health ; but fermentation existed not- 
withstanding the presence of this large quantity of free HC1, 
a circumstance which I have observed in many other cases. 
The patient had occasionally found relief by the use of lacto- 
peptine. At my suggestion, he discontinued the use of this 
remedy, and used lactic acid instead—5 to 10 drops imme- 
diately after each meal, sometimes repeating the dose one half 
hour to one hour after the meal. Sept. 7, 1892, a month after 
the first analysis, another test breakfast was taken, and the fol- 
lowing figures were obtained: (A), .188; (a), .81; (T), .284; 
(H), .020; (C), .204: 
Formula:— A ™ H—) 
A=„=T-c+'= 
Uffelmann’s test for lactic acid gave no reaction. Peptones 
abundant. This formula indicates simple dyspepsia with slight 
deficiency of free HC1, without acid fermentation. It is inter- 
esting to note that under the influence of the lactic acid the 
excessive secretion of chlorine had disappeared, the fermenta- 
tion ceased, and the large quantity of free HC1 which remained 
in the stomach unused, was made to combine with the albumen,' 66 
THE INVESTIGATION OK 
and thus enter into the useful chemical work of the stomach. 
The excess of the combined albumen (C) cannot be considered 
a pathological condition in this case, as it only indicates the 
effort of nature to supply the extra quantity of nutritive mate- 
rial needed for promoting a gain in Under the influence 
of this simple remedy alone, having made no change whatever 
in his diet, the patient had gained several pounds in flesh, and 
was so greatly improved that he considered himself practically 
well. He was advised to continue the use of the lactic acid 
for some time longer. 
Similar observations respecting the therapeutic value of lactic 
acid have been made in a very large number of cases, with 
equally good results, the details of which will be recorded in 
another paper devoted to the treatment of functional stomach 
disorders. 
The following summary relating to other data than that per- 
taining to the chlorine of the gastric fluid may be of interest:— 
Sex.—Of the whole number of cases examined, 30% were 
men and 7®% women. The proportion of males to females 
found in each of the three great classes of dyspepsia is as 
follows : — 
In hyperpepsia the proportion was found to be, for males, 
34.6%; females, 65.4: in hypopepsia, for males, 24.8, fe- 
males, 75.2% : in simple dyspepsia, for males, 26.5% ; females, 
73-5%- If thus appears that men are more susceptible to hy- 
perpepsia than are women, while hypopepsia is the most com 
mon form of stomach disorder in women. 
Digestion of Proteids.— Out of 261 cases, peptones were 
abundant in 183 ; reaction for peptones was feeble in 32 cases, 
and absent in 44 cases. The reaction for albuminoids was 
also absent in 11 cases. 
The rennet ferment was present in abundance in 77.1% ; was 
entirely absent in 13.8% ; was present in the form of zymogen 
in two cases in which it could not be detected in the form of 
rennin ; and was entirely absent as rennin or rennet zymogen 
in 7.6$ of the cases. 
Starch Digestion. — In 149 cases in which starch digestion was 
especially studied, the purple color of erythrodextrine was found 
in 67.8% ; the digestion of starch shown by the blue color was DISORDERS OF DIGESTION. 
67 
present in 2% ; good digestion of starch, shown by brown col- 
oration, in 17.4%, and complete digestion, indicated by no 
reaction, in of the cases. 
Quantity of Fluid Obtained. — The quantity of fluid obtained 
in normal cases is 40 c.c. Eighty to 100 c.c. was found in 
32.3% of the cases, and more than 100 c.c. in 67.7%. 
Residue.— The residuum was found to be less than one fourth 
of the entire quantity of fluid withdrawn in 20.7%, more than 
one fourth and less than one half in 62.9%, and more than one 
half in 16.4% of the cases. 
Mucus.— Mucus was present in considerable quantity in 
45.1%, in very small quantity in 46.3%, and absent in only 
8,6%, indicating very clearly the relation of stomach catarrh, 
or excessive secretion of stomach mucus, to functional stom- 
ach disorders. 
Lactic Acid.— Lactic acid was in excess in 34.2% of the 
cases, diminished in 23.5%, and absent in 42.3%. 
Dilatatio7i of the Stomach.— Dilatation of the stomach was 
observed in 42% of the cases. 
Hyperccsthesia of the Sympathetic Ganglia.— Hyperaesthesia 
of the solar plexus and of the lumbar ganglia of the sympathetic 
was present in 29.6% of the cases. 
Kidney Displacement. — Mobility or displacement of one or 
both kidneys was found in 14.6% of the cases. 
It would also be of interest to study the relation of the data 
above presented to the several classes, groups, and sub-groups 
of dyspepsia, but this study must be deferred for a future paper. 
As regards the treatment of the various conditions with which 
we are made acquainted by a careful chemical investigation of 
the products of digestive work obtained from the stomach when 
in full activity, I have not space in this paper to do more 
than simply call attention to the fact that the requirements of 
each individual case are by this method so clearly defined, and 
so explicitly indicated, that there can be no doubt as to what 
needs to be done. After obtaining the data furnished by the 
chemical investigation, noting also the quantity of the fluid 
withdrawn, one has but to make a formula to be enabled to 
see at a glance what are the therapeutic indications in the par- 
ticular case. For example, if in a given case the formula found 68 
THE INVESTIGATION OF 
is A -f- a -}- T -}- -J-, the fact is discovered instantly that 
the case in hand is one of hyperpepsia with hyperhydrochlorie, 
hyperacidity, and acid fermentation. Whether or not the hy- 
peracidity is due to acid fermentation alone, can be readily 
ascertained by determining the value of A', which should always 
be done whenever we find a -f-. If A' is above normal, then we 
have hyperacidity due to hyperhydrochlorie, and to this is su- 
peradded the acidity resulting from acid fermentation. If the 
acidity resulting from acid fermentation is very considerable in 
amount, and especially if the quantity of fluid drawn from the 
stomach is large, we know at once that the first measure to be 
employed in the case, unless strongly contra-indicated by some 
other pathological condition, is lavage. It is surprising indeed 
how quickly acid fermentations may be suppressed by simply 
washing out the stomach, at the same time so ordering the 
patient’s dietary as to avoid the introduction or development 
of microbes ; in other words, employing an aseptic diet. 
The superiority of a method which determines, quantita- 
tively, the amount of chlorine present in the stomach fluid, and 
the exact amount of chlorine present under the several condi- 
tions in which this element is found in the stomach fluid, is 
well shown by the following case :— 
The patient (Case 68), a married lady about 50 years of 
age, had suffered for many years from stomach disorders more 
or less pronounced. The quantities obtained after the test 
breakfast were as follows : (A), .272 ; (A'), .251 ; (a), .96 ; (T), 
.384 ; (H), .058 ; (C), .224. 
The color reactions were as follows : Congo-red indicated 
the presence of free acid. Methyl-violet gave only a very 
slight reaction, indicating a very small amount of hydrochloric 
acid in a free state, notwithstanding the fact that it was actually 
present in excess. Uffelmann’s reagent indicated the presence 
of lactic acid. 
It is evident that without the quantitative chemical analysis 
in this case, the real nature of the case could not have been un- 
derstood. The slight indication of the methyl-violet reaction 
would suggest that the excessive acidity was due to the fermen- 
tation, which would be considered as confirmed by the reaction DISORDERS . OF DIGESTION. 
69 
for lactic acid. The determination of the actual quantities of 
chlorine present, however, shows us that the amount of fer- 
mentation is very slight, a being normal at .86, and that the 
quantities of free HC1 (H) and combined chlorine (C) present, 
are sufficient to give an acidity of .251, the significance of 
which is readily seen by comparing these figures with the normal 
quantity .180 to .200; in other words, the chemical investiga- 
tion affords most conclusive evidence that the hyperacidity is 
due, not to acids resulting from fermentation, but to an excess 
of HC1 secreted and set free. In the following case, the 
same point is illustrated, and an additional one of fully equal 
importance : -—- 
The patient, a married lady of 35, was a chronic dyspeptic. 
Sixty-nine c.c. of stomach fluid were obtained after a test 
meal, in which a considerable amount of mucus and residue 
were found. Analysis gave the following quantities : (A), .320; 
0a)> 1 *35 j (T)> -34°: (H), .074; (C), .182. 
Congo-red indicated the presence of free acid, but methyl- 
violet gave only a very slight reaction. Uffelmann’s reagent 
gave the reaction for lactic acid. If the color reagents had 
been relied upon without the quantitative analysis, this case, 
as the other, might have been regarded as a case of excessive 
acidity due to fermentation alone, whereas there was not only 
fermentation but also hyperpepsia of a very considerable de- 
gree, as is readily seen by comparing the above figures with the 
normal, the combined chlorine and the free HC1 (H-f C) being 
in excess, and the value of A' being considerably above normal, 
namely .231. A great amount of fermentation is also shown 
to be present, as indicated by the high value of a. This is a 
case of hyperpepsia with acid fermentation. In this case, 
however, the fermentation is the chief morbid condition, as but 
one fourth of the excess of acidity is due to normal elements. 
By no other known means could the exact conditions present 
in this case have been accurately ascertained. 
In the cases mentioned above, the fermentation was quickly 
suppressed by lavage, aseptic diet, and antiseptic medication, 
and the patient made rapid and marked improvement. 
The excess of free hydrochloric acid, and of the total chlo- 
rine, indicates usually a glandular irritation resulting in exces- 70 
THE INVESTIGATION OF 
sive secretion. There is often found (29.6%) great hyper- 
aesthesia of the solar plexus, the lumbar ganglia, and some- 
times other portions of the abdominal sympathetic, the re- 
lation of which to functional disorders of the stomach is a 
matter of great interest, but of too large proportions to be con- 
sidered in this paper. This glandular and nervous hypersesthe- 
sia or irritability must be lessened by the employment of an 
appropriate dietary, soothing remedies, such as subcarbonate 
or subnitrate of bismuth, galvanism, and the various resources 
of hydrotherapy adapted to such cases. By the aid of mas- 
sage, skillfully administered, the relaxed stomach may be emp- 
tied of its contents before fermentation has become far 
advanced. By these and other means the return of the stom- 
ach process to a normal channel may be facilitated, and gen- 
erally the vis medicatrix na/urte is competent to restore to a 
normal state the vital activity of the stomach when favorable 
conditions are applied, so that the patient quickly experiences 
wonderful relief; and the satisfaction afforded to the doctor 
by the gratitude of his patient is ample compensation for the 
painstaking investigation required to put him upon the right 
track. 
The chart which I present with this paper exhibits a classifi- 
cation of all the different forms and types of dyspepsia which 
I have encountered in a very careful study of 600 analyses, 
and shows at a glance the therapeutic indications of each. 
The best means of meeting these indications may not be in all 
cases known to us at present, although the results which I have 
obtained are such that I do not feel any hesitancy in saying to 
any patient whose stomach disorders are clearly functional, 
that he may confidently expect relief within a reasonable length 
of time by the employment of the rational measures with which 
we are acquainted, and which the precise knowledge afforded 
by accurate means of investigation enable us to employ 
with far greater satisfaction and success than heretofore. We 
have long been possessed of abundance of artillery and ammu- 
nition with which to fight the hydraheaded disease, dyspepsia, 
which is perhaps responsible for more human ills and woes than 
any other malady ; but our efforts have been often fruitless be- DISORDERS OF DIGESTION. 
71 
cause we were obliged to aim our artillery without precision, 
like firing at an enemy concealed in a fog-bank. 
The new facts which have come to us through the brilliant re- 
sults of the labors of the eminent French physiologists who 
have given to us the new method of analysis described in this 
paper, illuminates this subject with the light of a noonday sun, 
and renders interesting—I may even say fascinating — the 
study and treatment of a class of disorders which have been 
heretofore so disappointing and so baffling as to render to 
many physicians the very sight of a chronic dyspeptic, obnox- 
ious and repulsive. Although for twenty years my professional 
work has been done under such circumstances as to bring me 
in contact constantly with a very large number of obstinately 
chronic cases belonging to this class of sufferers, I confess I 
have fully shared the sentiments above expressed, with my 
medical brethren, and have only really experienced genuine 
satisfaction—I may almost say delight — in meeting an old 
dyspeptic, since I have based my treatment of these cases upon 
positive facts furnished by a rigid chemical investigation, in- 
stead of trusting to hypothetical theories, intuition, or even ex- 
perience, which is a dear school to learn in,— at least for our 
patients,— and unfortunately teaches wrongly almost as often 
as rightly. No therapeutic experience could be more interest- 
ing than to watch a bad type of indigestion gradually rising 
from the lowest depths of hypopepsia through the lesser de- 
grees of this morbid state, by and by reaching simple dys- 
pepsia, or some attenuated form of hyperpepsia, and finally 
assuming those normal characters which indicate a restoration 
to perfect health. The only possible objection that can be 
raised to this investigation of stomach disorders is the fact that 
it is inconvenient for both patient and physician. I have 
found, however, without a single exception, that patients who 
have long suffered the pangs of chronic dyspepsia, are very 
ready to submit to the slight inconvenience accompanying the 
skillful passage of a small stomach tube, and many patients find 
the operation so little disagreeable that they are inclined, from 
curiosity to learn what progress they are making, to desire the 
passage of the tube too frequently. By a general and skillful 72 
THE INVESTIGATION OK 
use of the tube, it is possible to employ it without serious dif- 
ficulty with the most delicate patients, and even children. 
As regards the inconvenience to the physician, I cannot 
speak so encouragingly, for nothing short of a very thorough, 
painstaking, and most exact chemical investigation is of the 
slightest value. Indeed, the information afforded by a careless 
investigation might be most unfortunate and damaging by giv- 
ing a wrong direction to the treatment. The most precise 
chemical methods and the most carefid and dexterous manipu- 
lation will alone give satisfactory results. A mere qualitative 
analysis is of no value whatever, as has already been shown. 
An exact quantitative determination of the chlorine in its sev- 
eral states must be made. For this, a properly equipped labo- 
ratory and a skilled chemist, or at least one who is skilled in 
the particular methods required in quantitative analysis, are 
requisite. The time required for the careful examination of a 
single specimen of stomach fluid is from three to five hours. 
Much of this time must be consumed in filtration and evapo- 
ration, and so three or four specimens can be examined at 
once without much increasing the time spent.. It must not be 
imagined, however, that when an analysis has been made and 
the diagnosis and therapeutic indications worked out. all has 
been accomplished that a stubborn case requires. It is often 
necessary to make repeated analyses, varying the character of 
the test meal and the time of the digestion. Above all, it is 
necessary that a careful dietetic prescription shall be made, 
and that the patient shall be made to carry it out. The diffi- 
culties in the way of inducing the patient to lake the dietetic 
part of his prescription, are sometimes very great, but the 
thing must be accomplished, even if it becomes necessary to 
send the patient away from home to some place where his die- 
tetic needs may be supplied, or to hire a special cook or nurse 
to supervise his dietary. At whatever cost, the thing must be 
done, and not in a half-hearted way, but most thoroughly, or 
the effort will be fruitless. I find that patients are always 
deeply interested in the results of the chemical investigation of 
the stomach fluid, and a careful physical examination of the 
stomach by clapoteinent and other means. Patients who have 
long suffered from stomach disorders recognize at once the DISORDERS OF DIGESTION. 
73 
value of this mode of investigation, and are very ready to bear 
uncomplainingly the slight inconvenience of the method, feel- 
ing that an effort is being made to reach the root of the diffi- 
culty which has occasioned them so much discomfort and suf- 
fering. The ability to represent graphically by a formula the 
exact condition of the digestive process in a given case, and to 
determine mathematically the extent of deviation from the nor- 
mal condition, relieves the subject of functional disorders of 
the stomach from the mystic vagueness with which it has been 
surrounded heretofore, and illuminates every case thus investi- 
gated with a light which renders the study really a fascinating 
one to both patient and physician. The graphic character of 
the method and its exactness have suggested that it might be 
termed the “ algebra of the stomach.” Certainly no algebraic 
problem could be more interesting than are the problems, in 
digestion which this method enables one to solve readily, and 
with a high degree of precision. 
In my own experience, I think I have demonstrated that 
most of the therapeutic indications encountered in functional 
disorders of the stomach may be fully met by careful and intel- 
ligent regulation of the diet with the aid of the information 
afforded by the chemical investigation of stomach fluids, and 
by a skillful application of the various therapeutic means af- 
forded by hydrotherapy, massotherapy, electrotherapeutics, and 
a few medicinal agents. Peptones, pepsine, and other digested 
foods and digestants I have almost wholly discarded, and I be- 
lieve with advantage. Indeed, in reviewing the results in the 
treatment of more than 10,000 cases of stomach disorders, I 
can find very few instances in which more than temporary bene- 
fit has been derived from the use of these agents. I hope to be 
able soon to publish a report of the results of a series of exact 
experiments which clearly define the precise value of this class 
of remedies. 
There is still, however, a great dearth of knowledge respecting 
the dietetic properties of various food substances and prepara- 
tions. The observations of Beaumont upon the stomach of 
Alexis St. Martin afford about the only reliable information 
possessed by the profession at the present time ; but unfortu- 
nately, this ingenious investigator was unacquainted with the 74 
INVESTIGATION OF DIGESTIVE DISORDERS. 
facts which have been developed by modern physiology, and 
especially by bacteriology, and hence his observations were 
necessarily crude and his results conflicting and uncertain. As 
a matter of fact, we know almost nothing about the digestibility 
of foods or the special therapeutic values of different food sub- 
stances. I am now engaged in an extensive series of experi- 
ments upon healthy persons, which I trust will afford definite 
and positive information, since the exact chemical methods 
which we now possess enable us to study the digestive process 
in all its stages with nearly the same precision that the assayer 
studies the handful of crude ore brought him by the prospector, 
and with results as brilliant as those which sometimes reward 
the mine hunter among the mountains of the West. 
The results of my studies, together with an outline of the 
methods of treatment which I have found successful in the 
management of functional disorders of the stomach, I shall 
make the subject of other papers.