Reprinted from the Therapeutic Gazette, February 15, /8gj. 
A Consideration of Some Modern Thera- 
peutic Agents in the Treatment of 
Diseases of the Stomach. 
By David D. Stewart, M.D., 
Lecturer on Clinical Medicine in tHe Jefferson Medical College. 
AS an indication of the therapeutic measures 
that I consider the most important in 
the treatment of gastric diseases, I may say 
that, if I were compelled by force of circum- 
stances to restrict myself to a single remedy, 
and were permitted to make a choice, I should 
unhesitatingly name lavage as that better meet- 
ing general indications than any other. Of 
course there would then be left untreated cer- 
tain reflex gastric disturbances,—those of ner- 
vous anacidity and atony,—and cases also of 
ulcer and atrophy of the mucosa; but since 
the last of these is practically incurable, and 
ulcer requires no treatment, save recum- 
bency and rectal feeding,—indirect thera- 
peutic measures,—and the other ailments are 
only reached by attention to another viscus or 
to the correction of a neurosis, the remedy 
chosen would be applicable to nearly all other 
affections of the stomach, such as the various 
forms of catarrh, to dilatation, to cancer, and 
to cases of hyperacidity. 
My second choice would be HC1. Not 
second because I consider it of less value than 
the stomach douche, but because its use would be much more restricted; for now only the 
various forms of catarrh, and dilatation not 
arising from pyloric stenosis, and cases of atony 
with lessened acidity would be amenable to 
treatment. Following the selection of lavage 
and HC1, I would make, as a third choice, the 
antacids, as indicated in a large group of gas- 
tric disorders to which attention has only in 
very recent years been called, and in which, 
in place of subacidity, hypersecretion of HC1 
is the chief symptom, resulting often in imper- 
fect gastric digestion and always in pronounced 
intestinal ingestion, with emaciation and marked 
impairment of the general health. 
Succeeding antacids, again, I should speak 
for other remedies, besides HC1 and the douche, 
influencing secretion and propulsion, such as 
nux vomica or its alkaloid strychnine, and the 
intragastric application of electricity. The 
actual utility of the last is still sub judice, 
but apparently has a promising though lim- 
ited field in ailments characterized by im- 
paired motility without obstruction a fronte, in 
those of diminished secretory activity without 
decided atrophy of the mucosa, and in the 
neuroses of the stomach. I should then speak 
for a digestive ferment, such as pancreatic ex- 
tract,—an indirect remedial agent of great ser- 
vice in certain gastric affections. Pepsin I 
should not ask for, as I can think of no indi- 
cation where it can be especially of value. 
Lavage is of utility both as a cleanser of the 
gastric mucosa and as a correcter of abnormali- 
ties in the various gastric functions. Whether 
used simply to free the stomach from accumu- 
lated mucus in cases of gastric catarrh, mild or 
severe, with lessened or heightened acidity, or 
2 3 
for the removal of masses of mucus and decom- 
posing material, the concomitants of gastritis, 
of dilatation, and of atony, the stomach douche 
is invaluable, and can be replaced by no other 
remedy. The utility in this direction has be- 
come the more apparent with the recently-ac- 
quired knowledge that various morbid condi- 
tions hitherto regarded as having origin and 
seat in parts remote from the stomach, and due 
to incompetence of other organs and tissues, 
actually arise from gastric auto-intoxication; 
for so now can be explained certain forms of 
cerebral disorder, such as neurasthenia, head- 
ache, insomnia, and epileptiform convulsions, 
and rheumatoid affections, such as arthritis de- 
formans, and also diffuse neuralgic and rheu- 
matic pains. That many-sided condition, too, 
termed lithsemia or uricacidaemia, of which so 
much has been written and so little is actually 
known, is suspected on more than slight evi- 
dence to have its origin in auto-infection from 
the stomach, as Bouchard has pointed out and 
Stockton has urged.* 
Indeed, so-called lithaemia, undeveloped or 
American gout, may now, in light of recent 
'research, better be termed American dyspepsia, 
in which absorption from the stomach of the 
products of decomposition is the more likely 
cause of the varied complex of symptoms than 
the much-abused uric acid. 
Ewald has asserted that at the age of forty 
there is rarely encountered normal glandular 
tissue in the stomach; this, true in Germany, 
* See the latter’s valuable paper, “ Misconceptions and 
Misnomers revealed by Modern Gastric Research” (Med. 
News, May 28, 1892). is probably equally so elsewhere, and likely no- 
where more than in this country, in which 
abuse of the stomach begins with life itself and 
ceases only with its extinction. In these days 
of hurried living, with little or no attention to 
stomach hygiene, rare is he who at a much 
earlier age escapes a mild chronic dyspepsia, 
evidences of which are ever ready to appear on 
slight deterioration in general health. The fre- 
quency of this,—gastric catarrh,—with no spe- 
cial symptoms referable to the stomach, can only 
be determined by gastric examinations in the 
supposed healthy. In instances in which I have 
been able to make observations on these,—not 
done with this as an object, but to determine 
the normal acidity at varying stages of diges- 
tion,—the frequency with which sub- or hyper- 
production of HC1 was encountered, associated 
with such evidences of catarrh as the presence 
of quantities of mucus, mingled with the re- 
moved stomach-contents, has forcibly impressed 
me with the probable rarity of a healthy mu- 
cosa. Lavage in some of these, to determine 
the fasting condition of the stomach as regards 
the presence of mucus, showed a similar state 
of affairs, especially marked in the morning 
succeeding a late supper, even though ingested 
without other alcoholic beverage than a glass 
of beer. True, my studies on the supposed 
healthy have not been numerous, and the de- 
ductions therefrom are based on data derived 
from a class paying no special attention to gas- 
tric hygiene; but that same class comprises by 
far the majority of humankind, and is encoun- 
tered in all conditions of life. Beaumont’s ob- 
servations on the robust young Canadian St. 
Martin long ago showed the extraordinary ease 
4 5 
with which decided macroscopic evidence of 
gastritis will appear on slight provocation and 
frequently without symptoms referable to the 
affected organ.* That attacks of these acute 
affections, frequently repeated, eventually lead 
to chronic catarrh there can be no doubt. 
The utility of lavage in these abnormal gas- 
tric conditions where no very marked catarrhal 
symptoms exist, but in which exterior ailments 
of gastric origin are often present, is as unques- 
tionable as in the more pronounced cases of 
catarrh with ectasia. Daily morning douching 
to remove mucus and muco-pus in those in whom 
a dyspeptic tendency exists will serve to pre- 
vent the advent of chronic catarrhal gastritis. 
So much am I an advocate of the tube that I 
recommend its use to all those who, having dys- 
peptic symptoms, are given to late suppers or to 
even slight alcoholic indulgence.f 
Apart from the utility of lavage in cases of 
simple catarrhal gastritis as a cleanser of the 
mucous membrane, the importance of which 
cannot be overestimated, it has a special effect, 
direct and reflex, upon secretion and motility. 
Its utility in gas.trectasia is too well known to 
necessitate more than passing mention; no com- 
bination of remedies can approach it in effects. 
By lavage alone ectasic symptoms are promptly 
• * Such as generalized erythematous, aphthoid, and ul- 
cerated patches, associated with secretion of mucus or 
muco-pus. 
f Similar results cannot be obtained from the ingestion 
of hot water or hot alkaline drinks. It is true that mu- 
cus, muco-pus, and food remnants may be thus swept 
into the duodenum, but solution of their products or de- 
composition is thus favored, and before extrusion of these 
through the emunctories takes place, toxic results occur. 6 
relieved, and in dilatation due to simple atony 
of the muscularis, without decided degenera- 
tion of the same, a cure often results; though 
the latter may be also hastened by the intragas- 
tric use of electricity and by nux vomica and 
hydrochloric acid. Regarding lavage, I have 
elsewhere* stated that not only are the symp- 
toms occasioned by stagnation of food ameli- 
orated or removed and more or less tone restored 
to the relaxed and overstretched muscle, but the 
gastric absorbent and secretory functions, often 
profoundly affected, are stimulated to renewed 
activity. In consequence of these beneficial 
effects, even in cases of incurable stenotic dila- 
tation, which prior to commencement of lavage 
have been emaciated and cachectic in appear- 
ance to a high degree, an extraordinary change 
for the better may appear in the course of a 
few weeks or months, though the amount of 
food taken has been but slightly in excess of 
that formerly ingested. 
In cases of hyperacidity, with or without 
hypersecretion, brilliant results are also often 
obtained by lavage with simple water, or that 
containing antacids. Cases of this sort so 
cured are perhaps sufficiently common not to be 
detailed. I may here, however, speak of two, 
both of which are more than ordinarily in- 
structive from several points of view. 
In one, a robust male, S. T., aged thirty- 
two, gastric symptoms were somewhat in the 
background and only elicited by direct inquiry. 
The ailment for which I was consulted was gen- 
eralized neuralgia. For about ten years the 
attacks had been limited to the head. They 
* Hare’s “System of Therapeutics,” vol. ii. p. 965. occurred irregularly bi-weekly, affecting indif- 
ferently either side. The pain was always of 
great severity, often accompanied by undue 
prominence of the eye, by unilateral sweating, 
and by a smaller pulse on the affected side. 
Compressing the nucha always diminished the 
pain. Subsequently, while it continued to affect 
the head, as before, vague neuralgic pains oc- 
curred in various parts of the body ; at one time 
in a limb, at another in the loins, and again 
and most obstinately in the testicles.* The 
appetite was always large and often voracious, 
especially at the time of headache. Eating 
diminished, temporarily, the cephalalgia. Other 
gastric symptoms—of which he had little, when 
the extent of the acidity is considered—were 
burning pain in the epigastrium, occurring an 
hour or so after meals, diminished by eating or 
by large draughts of water; sour eructations soon 
after meals; constipation. The stomach during 
fasting was always found to contain from twenty- 
five to one hundred cubic centimetres of a 
fluid with an acidity of from twelve to thirty- 
five, which responded decidedly to Giinzburg’s 
solution, and showed no evidence of lactic acid. 
One hour after Ewald’s test meal the acidity f 
was extraordinary,—on one occasion 180, with 
0.60 per cent, of free HC1. Organic acids 
were usually absent. He at first refused to sub- 
7 
* The testicular neuralgia was supposed by a surgeon, 
to whom I sent him for examination as to the urethral 
condition, to be due to irritation from a very slight strict- 
ure and urethral hyperaesthesia. Systematic bougieing 
was practised, but with only temporary benefit. 
f One hour after Ewald’s trial breakfast the normal 
acidity, due almost entirely to free HC1, should be 
between 40 and 60. 8 
mit to lavage, and was treated with antacids in 
full doses, carefully-regulated diet, daily morn- 
ing use of sodium sulphate and bicarbonate in 
hot water. The improvement was but tempo- 
rary. Subsequently, on the appearance and 
persistence of the diffuse neuralgia, especially 
the testicular (only temporarily benefited by 
the various measures tried), systematic daily 
lavage was instituted, at first with sodium bicar- 
bonate, one drachm to a pint of hot water, and 
subsequently with unmedicated warm water. 
No headaches or other neuralgic pains have 
occurred since the douche was regularly em- 
ployed. 
The second case—D. McV., aged sixty-three 
—was quite similar as regards the gastric condi- 
tion. The stomach contained free HC1, which 
also existed in decided excess after a trial meal. 
Symptoms of gastric disorder had been present 
for about two years. He had lost twenty-five 
pounds in weight in four months, due in all 
probability to duodenal indigestion occasioned 
by the hyperacidity, and had been compelled 
to abandon work (as an engineer) several 
months before placing himself under treatment. 
He was debilitated ; heart was feeble and radials 
rigid. His symptoms were chiefly gastric. 
There was severe pain in the epigastrium, oc- 
curring two hours after eating, and at night, in- 
dependent of food. There were also sour eruc- 
tations, obstinate constipation, troublesome 
flatulence, and pronounced insomnia. He was 
melancholic, and believed his ailment incura- 
ble. Full doses of sodium bicarbonate, three to 
four hours after a meal, and a daily laxative dose 
of a mixture of sodium sulphate, phosphate, and 
bicarbonate were at first prescribed. He im- proved, but the improvement was not main- 
tained, though treatment was continued. Daily 
morning lavage was then instituted with warm 
alkaline water. The amelioration, or indeed 
cure, was instantaneous. No gastric symptoms 
have occurred since douching was begun several 
months ago. Lavage is still continued. The 
patient has since continued in robust health. 
The occasional untoward effects from lavage* 
occur so rarely that though the likelihood of 
their occasional incidence should always be 
borne in mind, fear of them should not deter a 
resort to the douche in any case in which its 
use seems indicated. I have never seen ill re- 
sults from the use of the tube, though I have 
employed it in all varieties of cases, including 
ulcer, for diagnostic purposes. It should not 
be used for lavage in ulcer, and should rarely 
be employed for diagnostic purposes in the 
same, especially if a tendency to hemorrhage 
exists. In cases of feeble heart, large amounts 
of fluid should not be introduced or removed 
suddenly. 
In a sphere more limited than lavage there 
is no remedy more distinctly useful than HC1, 
and conversely none more provocative of harm 
if the indications for its administration are not 
carefully attended to. Its utility as a therapeu- 
tic agent has long been recognized, but for a 
9 
* Recently reviewed by Fenwick in The Practitioner, 
April, 1892. Such as convulsions in the hysterical and 
tetany in gastrectasia, syncope and sudden death in the 
predisposed as a result of abrupt alteration in the intra- 
abdominal pressure, perforation in cases of ulceration, 
from straining attending violent vomiting, and hemor- 
rhage in and from the same and as a result of variation 
in intragastric tension. considerable period its employment was alto- 
gether empirical, until the discovery that HC1 
was a natural constituent of the gastric juice, 
and essential for vigorous peptonization. Sub- 
sequently, though more enlightened notions 
governed its administration, based on these 
data, its hap-hazard employment was still gen- 
eral,* until the brilliant application of the 
stomach-tube to diagnosis by Leube paved the 
way for its more rational application. The 
investigations of Leube having shown that a 
deficiency of HC1 was very common in gastric 
disorders, its use became general in all cases of 
so-called, dyspepsia, many of which were prob- 
ably those of hypersecretion of HC1, a sensory, 
secretory neurosis not then recognized, but sub- 
sequently discovered by Reichmann (gastro- 
succorrhoea) and carefully studied by him, by 
Jaworski (hyperacidity with, or oftener without, 
hypersecretion), and others. 
Prior to the discovery of these secretory 
neuroses great difference of opinion naturally 
existed as to the utility of HC1, it probably 
very frequently being employed in cases of 
hyperacidity, as well as in those of diminished 
secretion, as examination of the stomach con- 
tents was not then general, the methods em- 
ployed lacking the convenience and exactness 
of those of to-day and the soft tube being then 
unknown. The recognition of the existence of 
these neuroses, in which harm only could result 
from its use, and of certain other ailments, such 
10 
* Thus, Trousseau, though convinced of its great 
utility in certain forms of stomach-disorder, could formu- 
late no better indication for its use than to recommend 
recourse to it in those cases in which alkalies failed. 11 
as atrophy of the mucosa, in which little benefit 
could accrue, has, without diminishing its ex- 
traordinary utility in certain cases, narrowed 
the indications for its employment, as it has 
also rendered necessary the application of the 
tube for their revelation. 
When one considers the ease with which an 
insight may be obtained into gastric disorders 
by the above-named measure, by methods in 
themselves most simple of manipulation, and 
the intelligent therapeutic application that can 
be made of these, the lamentable ignorance 
yet existing regarding diagnosis and treat- 
ment of stomach-diseases is a matter of won- 
der. The acceptance of the statement by 
many, that the use of the tube is necessary 
to arrive at the indications for the admin- 
istration of HC1, would doubtless lead to the 
withdrawal of this remedy from their armamen- 
tarium, and yet this would be better than that it 
should be indiscriminately prescribed in all cases 
of so-called dyspepsia.* Certain common tokens 
* As an indication of the bearing of gastric-juice ex- 
aminations on HC1 therapy I may mention my own case. 
Early in the autumn I had suffered from impaired diges- 
tion, through diminished secretion, greatly relieved by 
doses of dilute HC1 after meals. The symptoms eventually 
disappeared; HC1 was discontinued. Recently dyspeptic 
symptoms recurred. These were, especially, epigastric 
sensations of weight, discomfort, and acidity, appearing 
about an hour after meals. The tongue was flabby, 
showing the imprints of the teeth, as was usual. These 
symptoms were supposed to represent diminished secre- 
tion of HC1 with presence of organic acid fermentation. 
Without a stomach examination, HC1 was again begun, 
but at once discontinued on an aggravation of the symp- 
toms occurring. On the day following two .examinations 
of the gastric contents were made. Three hours after a 12 
of impaired gastric digestion, when present, 
may be said to furnish general indications for its 
administration. These are a sensation of weight 
in the epigastrium occurring shortly or immedi- 
ately after a moderate meal of proteids, suc- 
ceeded, perhaps, by gaseous, rancid eructations; 
anorexia or an easily-satisfied appetite, with nau- 
sea succeeding eating; a coated, flabby tongue 
showing the imprints of teeth. These symptoms, 
common, with a variety of others, in gastric 
atbny and catarrh signify deficient gastric secre- 
tion, and yet all may be absent and a state of 
subacidity exist, and several present with normal 
or hypersecretion of HC1. 
Though it is generally accepted that the only 
indication for the employment of HC1 is defi- 
ciency in its secretion, therapeutists are by no 
means in accord as to the precise mode of 
action, the tendency in Germany being to 
doubt the utility of its administration as a 
digestant if secretion of HC1 be much dimin- 
ished, any benefit then resulting being sup- 
posed to accrue from its antiseptic action or 
through its effect on gastric motility and its 
stimulating influence on gastric secretion. As 
an antifermentative and antizymotic HC1 takes 
lunch of bread and butter and panned oysters, the total 
acidity was 90, with very marked HC1 response (Giinz- 
burg’s). No quantitative estimation made. On the same 
day, two and a half hours after a dinner of beef-stew, 
corn, bread and butter, sherry, and a cup of tea, the total 
acidity was 108. Gtinzburg’s response was decided up to 
thirty dilutions. Mintz’s test = 0.32 per cent, free HC1; 
but a trace of lactic acid; no acid salts. Subsequent 
examinations, made daily for a short time, always showed 
increased HC1 hyperacidity. Here, within a few months, 
a complete reversion of the secretory condition had 
occurred. 13 
high rank. Putrefactive changes in the stom- 
ach originating through stagnation of food with 
deficient secretion, permitting the develop- 
ment and multiplication of bacteria, with the 
presence of irritating organic acids and poison- 
ous leucomaines, cannot occur with a small 
excess of free HC1. The growth of pathogenic 
fungi, such as the bacillus of cholera and of 
enteric fever, are similarly inhibited by traces 
of this acid, the life of the organisms ceasing 
when the amount of the latter equals a certain 
percentage.* 
The influence of HC1 on the gastric’peristole 
is still sub judice. Leube’s experiments led him 
to believe that the increased acidity towards 
the termination of gastric digestion was the 
main cause of the onward progress of the 
chyme into the duodenum. The observations 
of others in this direction, notably Fleishner,f 
do not support Leube’s contention, and it is 
also negatived by several clinical facts.| 
The ability of HC1 to aid in the transforma- 
tion of pepsinogen into active pepsin, and lab- 
* Kitasato (Zeitschrift f Hyg., Bd. iii.) found that the 
development of cholera bacilli ceased in an acid reaction 
0.06 per cent, to 0.08 per cent. HC1. Typhoid bacilli 
required a much greater percentage,—IJ. Hamburger’s 
figures (Centralbl. f Klin. Med., 1890, No. 24) are 
much smaller than the last. It would appear that 
Kitasato had used bouillon, the albuminoids and salts 
of which combined with the free HC1. (See also Reich- 
mann and Mintz, Wiener Klin. Woch., June 23, 1892.) 
J Berlin. Kim. Woch., No. 7, 1887, quoted by Reich- 
mann and Mintz, Wien. Klin. Woch., June 23, 1892. 
| HC1 hyperacidity is occasionally met with in atony 
with stagnation of the ingesta. In certain cases of 
hyperacidity the raised acidity causes spasm of the pylorus 
and retention of the chyme. 14 
zymogen into lab-ferment, is well known, and 
its utility as a direct stimulator of its own and 
pepsin secretion has in recent years also been 
urged, but on no direct evidence ; it being, how- 
ever, accepted that, in those with simple dimi- 
nution in secretion, after a course of treatment 
by HC1, the digestion continues to improve 
after its withdrawal. 
Reichmann and Mintz, believing this practi- 
cally the only result to be obtained by the ad- 
ministration of HC1, undertook a series of ex- 
periments to determine this point, a recently- 
made preliminary report of which is favorable.* 
In a series of cases in which little or no free 
HC1 existed (one in a half-hour after Reich- 
mann’s trial breakfast), increased secretion re- 
sulted in most of them on the administration 
of HC1 after meals for some days. Examina- 
tions were made before taking and after dis- 
continuing the HC1. They note that but one 
other experiment of this sort—that of Riegel’sf 
—has been reported. . In Riegel’s case free 
HC1 had been constantly absent, even after 
several months of lavage; but by the adminis- 
tration of full doses of HC1 for fourteen days, 
free HC1 eventually appeared in the contents 
of the fasting stomach. 
Regarding the utility of HC1 as a digestant, 
the trend of opinion seems to be against it, but 
on very inadequate evidence, the notion pre- 
vailing that sufficient cannot be taken when 
secretion is much diminished to exert any di- 
gestive action, the dose administered, though 
large, disappearing in forming combinations with 
* Loc. cit. 
f Deutsche Arch. f. Klin. Med., Bd. xxxvi. the albuminoids and salts of the food, and not 
manifesting itself as free acid even shortly after 
its ingestion. Reichmann,* convinced of this 
as the result of experiments which he regards 
as conclusive, but which were, however, evi- 
dently made on cases with atrophy of the gas- 
tric tubules,f no longer uses HC1 as a digestant. 
My own opinion has been entirely contrary to 
this view, because of practical results obtained 
by the administration of HC1 in cases of nervous 
dyspepsia and chronic gastritis, in which little 
or no free HC1 has usually been present in the 
gastric secretion. I have frequently found in 
cases in which, after a trial meal, the total 
acidity was trifling, and the test for free HC1 
negative or slight, that immediate relief was 
obtained from symptoms of indigestion, such 
as weight in the epigastrium and nausea after 
food, by a full dose of acid. Instantaneous re- 
lief thus obtained could only be explained on 
the supposition that the acid exerted some di- 
gestive action. In these cases a certain amount 
of HC1 is of course secreted, but often barely 
sufficient to more than wholly combine with 
the albuminoids and salts present in the food. 
The excess being furnished artificially, and 
slight continued secretion occurring, digestion 
advances more rapidly than it otherwise would. J 
I have recently undertaken some experiments 
to discover if this view, contrary to that of 
15 
* Loc. cit. 
f Deutsche Aled. Woch., No. 7, 1889. 
| I have cases under observation, in which much di- 
minished secretion of HC1 is habitual, that have been 
taking HC1 for months. The immediate relief from 
symptoms of indigestion always obtained by it causes 
them to continue taking it. 16 
Reiehmann, Boas, and others, but the result of 
extensive clinic experiments, is not correct; my 
observations, though yet but preliminary and 
based on only three cases, bear out my assump- 
tion. Two of these are cases of chronic gastric 
catarrh, the third one of nervous sub- or an- 
acidity. In each of the former free HC1 is 
often not to be obtained in the gastric secre- 
tion one hour after Ewald’s trial breakfast. 
When present it exists in minute traces. In 
the third case, a response to tests for free HC1 
could never be obtained, even after this acid 
had been administered for months.* 
Case I.—Miss M. A. ; chronic gastric ca- 
tarrh, with atonic gastrectasia. 
December 23, i8q2.—One and one-sixth 
hours after Ewald’s test breakfast withdrew 
thirty cubic centimetres of moderately well dis- 
solved roll, containing much mucus. Congo 
paper browned; total acidity 18; HC1, by 
Giinzburg’s solution, present; Mintz’s test = 
0.009 per cent, free HC1. Lactic acid and 
erythrodextrin decided ; acid phosphates pres- 
ent ; lab test positive; Three other earlier . 
observations, made at weekly intervals, substan- 
tially agreed with the above. 
December 24, 1892.—Withdrew forty-five 
cubic centimetres one and one-sixth hours after 
Ewald’s breakfast, at the termination of which 
40 drops of dilute HC1 had been taken. Con- 
tents more fluid; flow more readily through 
the tube. Congo paper markedly blued; total 
acidity 26. Giinzburg’s solution, decided re- 
sponse up to eleven dilutions. Mintz’s test 
* Tests, of course, being always made several days after 
its discontinuance. = 0.047 Per cent, free HC1. Lactic acid = 
faint trace; acid phosphates present; lab test 
positive. 
December 25, 1892.—Forty-five cubic centi- 
metres withdrawn. Conditions same as above ; 
45 drops dilute HC1 taken one hour before with- 
drawal ; total acidity 30; 0.036 per cent, free 
HC1; traces of lactic acid ; lab test positive. 
Case II.—Mrs. F. ; chronic gastric catarrh, 
with incipient atrophy; atonic dilation. 
December 24,1892.—-One and one-sixth hours 
after Ewald’s breakfast withdrew sixty cubic 
centimetres of moderately well dissolved roll, 
with little mucus. Congo paper very faintly 
blued; total acidity 25. Giinzburg’s solution 
= response ceased at third dilution. Mintz’s 
test = 0.01 per cent, free HC1; digestion test 
negative ; lab test positive ; lactic acid in abun- 
dance ; acid phosphates and erythrodextrin 
present. In this case previous observations 
had been made at intervals of six to fourteen 
days for four months; the latter ones agreed 
substantially with the above, with the excep- 
tion that no free HC1 existed in that of six 
days before. The acidity then was 43, due to 
lactic acid and acid salts. 
December 25,1892.—One and one-sixth hours 
after Ewald’s test breakfast and 30 drops dilute 
HC1, forty-five cubic centimetres withdrawn. 
Roll well dissolved ; but little mucus. Congo 
paper decidedly blued ; total acidity 32. With 
Giinzburg’s solution, response up to thirteen 
dilutions. Mintz’s test — 0.077 Per cent, free 
HC1. Digestion test positive, though retarded ; 
no lactic acid ; traces only of erythrodextrin ; 
lab test positive. 
17 18 
Case III.—Nervous anacidity. Mrs. S. R. E. 
December 22, 1892.—Withdrew thirty cubic 
centimetres thick, only partly dissolved roll one 
and one-fourth hours after Ewald’s breakfast. 
Congo paper unchanged ; total acidity 6; no 
response to Giinzburg’s solution, though fil- 
trate concentrated. Starch, erythrodextrin, 
and lactic acid absent; acid salts, traces ; lab 
test negative ; that for lab-zymogen decided ; 
digestion test negative, though HC1 added 
until it could be recognized as free acid. 
Three previous examinations were made in this 
case with similar results; not even the faintest 
traces of free HC1 could at any time be de- 
tected. Acidity always lay between 5 and 8. 
The contents withdrawn were but partly fluid, 
and clogged the tube. Frequent examina- 
tions were impossible because of the discomfort 
and prostration the use of the tube occasioned 
in the patient, who is an hysterical neuras- 
thenic. 
December 29, 1892.—Withdrew sixty cubic 
centimetres of quite fluid contents one and a 
quarter hours after Ewald’s test breakfast. One 
and a half teaspoonfuls of dilute HC1 had been 
taken,—the first dose immediately after eating 
the roll, the second fifteen minutes later. Congo 
paper faintly blued ; total acidity 20. Marked 
response to Giinzburg’s solution. Mintz’s test 
= 0.018 percent, free HC1; lactic acid ab- 
sent ; acid phosphates decided; erythrodex- 
trin present; lab test negative, as before, but 
that for lab-zymogen decided; digestion test 
positive without the addition of HCl, but very 
retarded. 
Comment on these cases is unnecessary ; evi- 
dence is so apparent of the utility of HC1 ad- ministered for the purpose in which its efficiency 
is mooted.* 
Whether similar results could be obtained 
after a more extensive meal than Ewald’s trial 
breakfast, especially that consisting largely of 
albuminoids, is yet to be determined. I am 
now investigating that point. In all likeli- 
hood the amount of acid administered would 
have to be increased, unless the direct influ- 
ence of the food taken promoted additional 
secretion. 
Still, even should the latter not occur, these 
experiments show that HC1, administered in 
medicinal doses in certain cases of even pro- 
nounced diminution in secretory activity, 
may be relied upon not to disappear from the 
stomach, contrary to the prevalent opinion, 
and may, therefore, in these be expected to 
assist digestion. But, under such circumstances, 
were its recognition as free acid impossible, 
secretion of HC1 not being entirely in abey- 
ance,—as occurs probably only in advanced 
atrophy of the tubules,—benefit may still be 
expected from the administration of HC1, and 
its trial should not be omitted. For, apart from 
its stimulating effect on the secretory function, 
which may tend to delay the advent of atrophy, 
it must also assist in the saturation of the albu- 
minoids of the food, and thus, also, in the par- 
19 
* Case III. had taken HC1 in full doses irregularly 
for one and a half years, with marked subjective evidence 
of benefit. Nausea and distress after meals were inva- 
riably relieved by it. Prior to each stomach examina- 
tion, HC1 was discontinued for a week; previous to the 
last examination none was taken for fifteen days. Evi- 
dences of its utility as a digestant are most manifest in 
this, the least promising of the three cases. tial peptonization of the latter. For, as Ewald 
first showed, even though a certain percentage 
of free HC1 may be essential for active and 
complete digestion, at least partial peptoni- 
zation may occur without it, that imbibed 
by the albuminoids sufficing for the latter 
purpose. 
Regarding the dose and time of administra- 
tion of HC1, a word must be said. If used as 
an antizymotic or antifermentative, because of 
combinations formed with albuminoids and 
salts of the food, a larger amount is, of course, 
necessary on the full stomach than when this 
viscus is empty. Notwithstanding this, for ob- 
vious reasons, its utility is greatest as an anti- 
fermentative when administered after food, ex- 
cept in cases of total suppression of secretion, 
when, if resorted to, it should be ingested fast- 
ing ; for after food a quantity too large for ad- 
ministration would be necessary to show itself 
in any efficient percentage as free acid. After 
meals, in such cases, a second antizymotic, such 
as one of the naphthols, should be chosen. 
When indicated as a secretory stimulant, HC1 
may be administered in small doses before 
meals,* or, preferably, in much larger post- 
prandial ones, that advantage may be also 
taken of its ability to synergize digestion. 
When actually indicated for the latter pur- 
pose, it is useless to administer less than a 
drachm of the dilute acid, in divided doses, 
largely diluted in water, at intervals of from 
ten to twenty minutes, the initial dose being 
taken at the termination of the first half-hour 
20 
* Alone, or in combination with common salt or with 
strychnine, both of which also promote secretion of HC1. after meals. This last is important, that sac- 
charification of starches be not too early im- 
peded. I regard a drachm of the dilute acid 
so taken as a moderate dose, and frequently 
prescribe upward of 2 drachms where decided 
diminution in free HC1 exists. No harm can 
result from these doses in cases of subacidity. 
It is, perhaps, needless to remark that nothing 
can be expected from a single dose of 10 to 15 
drops of the dilute acid, so often prescribed, 
combined with a correspondingly enormous 
quantity of pepsin. This much at least may 
be said of these small doses, that if no good 
obtains from them, at least no great harm can 
result, even when given, as they often unwit- 
tingly are, in that form of disordered digestion 
which we now know is caused by much height- 
ened secretion of HC1. 
In cases of hypersecretion of HC1,* with or 
without succorrhoea, no one remedy is of such 
distinct utility as lavage, especially with alka- 
linized water, as has already been detailed. 
The symptoms also often disappear in the less 
severe cases, without lavage, by the protracted 
use of antacids. These may be administered 
as soon after food as indications of hyperacidity 
appear, such as epigastric burning and pain, 
with acid eructations. Antacids are more dis- 
tinctly useful, when symptoms do not especially 
21 
* It must not be forgotten that a neurosis very fre- 
quently underlies these. This must itself receive atten- 
tion if permanent curative effects are to be obtained. 
Among the drugs indicated, bromides, which may be 
combined with antacids, are often of service; especially 
strontium bromide, as that least irritating. Cannabis in- 
dica and cocaine, alone or in various combinations, are 
also beneficial for the local hypemesthetic condition. demand their earlier employment, towards the 
completion of gastric digestion, about four or 
five hours after a varied meal, as the food is 
entering the duodenum. Though their admin- 
istration soon after a meal is often demanded by 
the severity of the symptoms, the ill results of 
complete neutralization of the gastric juice at 
this time must be borne in mind. Small doses 
only should then be given; subsequently, benefit 
rather than harm results from complete satura- 
tion of the gastric acid. Neutralization of the 
alkaline intestinal fluids is thus prevented, and 
more complete duodenal digestion of starches 
and fats, habitually imperfect in these cases, is 
thus promoted.* 
The utility of faradism and galvanism in the 
treatment of diseases of the stomach I have so 
lately considered elsewhere f in some detail, that 
little remains to be here stated. The measure of 
exact value of electricity, unlike that of the 
other therapeutic mehns considered, is still un- 
determined, experiments with the direct appli- 
22 
* Albuminoids are also incompletely peptonized in 
cases of hyperacidity in which hypermotility exists. 
This latter combination of hyperacidity and hypermo- 
tility is not uncommon, heightened peristalsis, as well as 
symptoms of local sensory irritation, being often origi- 
nated by the irritating effects of the superacid gastric 
secretion. In these cases, before peptonization has far 
advanced, the neutralization of the gastric acid by the 
alkali of the intestinal mucous membrane and of the 
pancreatic secretion causes precipitation of both the gas- 
tric and pancreatic ferments, with permanent cessation 
of proteolysis. 
f Hare’s “ System of Therapeutics,” vol. ii. pp. 923 
et seq., 963 et seq. The full technique, which is simplicity 
itself, with the recently-devised gastric electrodes, is 
there given. cation being of too recent date and too limited 
to permit the formation of definite conclusions 
as to immediate value and permanence of result 
in all save a limited number of gastric ailments 
in which it has been tried. It is accepted, how- 
ever, that the intragastric application of both 
faradism and galvanism influences the secre- 
tory, motor, and absorbent functions. 
The faradic current is apparently especially 
valuable as a secretory and motor stimulant, 
and is well worthy of trial in cases of lowered 
acidity, whether of inflammatory or nervous 
origin, not yielding to ordinary treatment, and 
especially in cases of nervous sub- or anacidity 
with atony, in which, if secretion is not stimu- 
lated, motility may be, and thus, as in atrophy 
of the mucosa, if decided degeneration of the 
musculature has not occurred, the preservation 
of propulsive power permits fair nutrition 
through duodenal digestion. In simple atonic 
dilatation no remedy is apparently of greater 
value than an intragastric application of fara- 
dism, combined with other approved measures, 
such as lavage and the administration of HC1; 
a cure, with renewed secretory activity, may in 
most cases be expected. In cases of obstinate 
gastralgia, direct gastro-galvanization has 
seemed of service, after other measures adopted 
to relieve have failed.* 
In that class of cases of total anacidity or of 
pronounced subacidity, such as is encountered 
in advanced gastric catarrh, in typical atrophy 
of the tubules, and in certain of the neuroses 
of the stomach, in which there is reason to 
23 
* See Emhorn's recent paper, New York Medical 
Record, January 30 and February 6, 1892. 24 
believe that the administration of HC1 is use- 
less as a secretory stimulant or as a digestant, a 
great deal can be done, both symptomatically 
and to obviate the ill results of undue retention 
of undigested food in the stomach,—atony and 
perhaps subsequent dilatation,—by the admin- 
istration after meals of an active pancreatic 
preparation. In these cases of diminished or 
absent acidity, through saccharification of such 
carbohydrates as the ptyalin comes into contact 
with, through the process of partial solution of 
food by mastication, insalivation, and by the 
aid of fluids ingested, ultimately more or less 
completely occurs in the stomach, a certain 
amount of the starches in vegetable food remain 
bound by a glutinous envelope, the unaided 
intragastric solution of which may be impos- 
sible because of deficient or absent secretion. 
In cases such as these an active pancreatic ex- 
tract, which ordinarily would be operative but 
for a short time if administered after meals, 
may be expected to exert its triple action 
throughout the whole digestive phase, and not 
only to complete the transformation of starch 
into sugar, but also to peptonize proteids and 
to digest fats. Nor is a limitation here reached 
for pancreatic extracts.'* 
In cases of enfeebled gastric digestion in 
which HC1 is secreted in diminished amount,and 
yet in which peptonization, though very incom- 
plete, occurs, HC1 should not be omitted from 
the therapy, but a pancreatic preparation may 
still be given. The latter must then be ad- 
ministered immediately before or during the 
* Apart from their ability to predigest foods, which I 
shall not here touch upon. early part of the meal. Under these circum- 
stances it will exert digestive activity for an 
hour or more, depending upon the amount and 
variety of food taken, until extinguished by the 
subsequent presence of traces of hydrochloric 
acid.* 
Should the initial dose of the latter be de- 
layed until a half-hour or longer after a meal, 
a fair opportunity will have been afforded for 
complete starch digestion and partial solution 
of albuminoids. 
A word remains to be said regarding the ad- 
ministration of pepsin. Judging from its pop- 
ularity as a remedy for indigestionf, the neces- 
sity for it seems great indeed. And yet its 
wholesale prescribing, so general in this coun- 
try, J rests upon a delusion without other foun- 
25 
* It must be borne in mind that normally, in the early 
stage of gastric digestion, acidity is low and due to acid 
salts and to a small percentage of lactic acid, so that 
digestion of starches begun in the mouth, not being per- 
ceptibly interrupted by these conditions, continues, ceas- 
ing, however, when the acidity due to free HC1 reaches 
a few thousandths of one per cent. This, after a gener- 
ous and varied meal, does not occur for an hour or more. 
The period of lessened acidity is often much prolonged 
in conditions in which secretion of free HC1 is dimin- 
ished, and may continue through the whole course of gas- 
tric digestion in certain ailments, such as in nervous an- 
acidity and in atrophy of the tubules, in which cases no 
free HC1, and often-no traces of the organic acids, are 
present. 
f And especially largely prescribed alone, or, as curi- 
ously, in combination with soda, bismuth, lactic acid, 
pancreatin, or very minute doses of dilute HC1. 
J I have recently been informed by one of the largest 
drug-manufacturing houses in this country, the purity 
and activity of whose pepsin takes high rank, that 
pepsin is gaining in favor with the medical profession 26 
dation than total misapprehension of certain 
physiological facts. 
Though it is unquestionable that both pepsin 
and acid are essential' for proteolysis, and that 
neither can display digestive activity without 
the other,* the inutility of pepsin adminis- 
tration in conditions demanding a synergist to 
digestion is indicated by the facts that the pep- 
sin-secreting cells, unlike those forming HC1, 
are very numerous and widely distributed in 
the stomach. As a consequence, though HC1 
is often either much diminished or totally 
absent from the gastric secretion in various 
affections of the stomach, pepsin is never habit- 
ually so except in advanced atrophy of the 
tubules, in which latter condition the admin- 
istration of neither HC1 nor pepsin can be of 
service as a digestant. In cases in which HC1 
is absent from the stomach, other than those of 
complete tubular atrophy, pepsin can still be 
readily obtained from its secreting glands in 
quantity sufficient to act as a digestant by 
means of hydrochloric acid, as Jaworskif first 
pointed out. 
daily, so that its present consumption in this country is 
at least one hundred per cent, greater than it was two 
years ago. 
* Except as regards the formation of syntonin and a 
small amount of protoalbumose by HC1 alone. 
f See Dent. Med. Woch., 1887, Nos. 36, 37; Munch. 
Med. Woch., 1887, No. 33. Jaworski’s diagnostic test 
for atrophy of the stomach is founded on this fact. Two 
hundred cubic centimetres of A HC1 solution is intro- 
, 10 
duced into the stomach and removed in half an hour. 
Secretion of pepsin and lab-ferment, or transformation of 
their proenzymes into the active ferments, is so readily 
produced by this measure, that should evidences of these 27 
Pepsin does not pre-exist in the cells of the 
gastric glands, but is secreted as a proenzyme 
pepsinogen or propepsin, requiring but the 
stimulating action of hydrochloric acid to pro- 
mote ready conversion of the ever-present 
proenzyme into the active ferment. 
A consideration of the foregoing, together 
with the additional fact that pepsin acts by 
mere catalysis, possessing extraordinary con- 
tinuous activity, little being consumed in the 
digestive process, unlike the case with hydro- 
chloric acid, shows that the modern extensive 
prescribing of pepsin is, to say the least, largely 
one of supererogation. It also indicates the 
absolute inutility and unscientific use of this 
enzyme alone or even without conjunction with 
full doses of hydrochloric acid. 
The benefit, therefore, supposed to result 
from its administration, when not of psychical 
origin, due to the delusion that a sovereign 
panacea for indigestion is being taken, prob- 
ably usually accrues either from the dietetic 
regimen coincidently prescribed, or from the 
ingredient—acid or alkali—with which pepsin 
is combined. 
When amelioration in symptoms results after 
use of pepsin with an alkali,* such as sodium 
bicarbonate, with which it is often unscien- 
not now be found, a diagnosis of atrophy of the mucosa 
is justifiable. This test is described in Verhandl. des vii. 
Congress, f Innere Med., 1888, p. 272. 
* An utterly incompatible combination, since pepsin 
is thus promptly destroyed. It requires the presence 
of but 0.05 per cent, of sodium carbonate to render pep- 
sin permanently inert. (See Chittenden, Medical News, 
February 16, 1889.) tifically prescribed, the case is in all prob- 
ability one of hypersecretion of hydrochloric 
acid. In such, of course, pepsin, as well as 
hydrochloric acid, is already present in. abun- 
dance in the gastric juice, so that neither is 
indicated as a remedy. The soda is, however, 
of great utility as an antacid. Subsidence of 
discomfort thus produced is, however, errone- 
ously attributed to pepsin. 
This much, however, may be said for the 
administration of pepsin, that, though it may 
be superfluous, it is also innocuous, except 
in so far as it is substituted for another 
remedy, such as hydrochloric acid, actually 
indicated. 
2620 North Fifth Street, Philadelphia. 
28