CASE 236.

The patient, aged 45 years, had not considered herself dyspeptic, 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 prolapsed, right and left ganglia of the sympathetic sensitive, abdominal walls. extremely flaccid. Examination of the stomach fluid gave the following figures: (A), .196; (a), .80; (T), 324; (H), 004; (C), .240.

Methyl-violet gave a slight reaction for free HCl. Uffelmann'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 H

the above figures, is A-a-T=C+ A case of hyperpepsia with hypoacidity and a deficient amount of free hydrochloric acid, or hypohydrochlorie, but without acid fermentations.

Many cases of this sort are met, and show clearly that the presence of free HCl 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.

Hyperpepsia 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 con

dition. 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 umbilicus; the abdominal walls much relaxed; considerable degree of ovarian irritability, which, however, probably had little to do with the general condition. The amount of fluid withdrawn from the stomach was 60 c. c., and examination gave the following results: (A), .280; (a), 1.03; (T), .312; (H), .004; (C), .268.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 reaction, indicating imperfect starch digestion. Rennet ferment abundant. The formula resulting from the above is as follows: A+a+T= H

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.

Ap

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. petite 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, hyperæsthesia of the lumbar ganglia of the sympathetic. At the time of examination there was impaction of the lower bowel. amount of fluid was 74 c. c. A.160, a 73, T.304, H .008, C .206. Congo-red and methyl-violet both gave slight reaction. Lactic acid test negative, peptones H

abundant. Formula: A-a-T=C+

The

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 hypohydro

A young woman aged 22 years, had been accustomed to take large quantities of fluids at meals, and had taken large quantities 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; trembling of the limbs. Physical examination 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 withdrawn 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, Aa H÷ ·T+C-- +. A case of hyperpepsia

with diminished amount of useful chemical work, as shown by C-, and hyperacidity from the excessive quantity of hydrochloric acid present, but without acid fermentation.

Hyperpepsia with deficient combined chlorine (C-) and hyperacidity (A'+)— 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 withdrawn, 150 c. C. Result of examination of stomach fluid: (A), .280; A', .252; (a), 1.14; (T), (H), .394; .166; (C), .100.

Formula derived from the above quanH+

tities: A+a+T+C—

+.

This case is nearly identical with the preceding, only differing 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 attributable 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.

Hyperpepsia with deficient combined chlorine (C) and hypoacidity 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. Examination 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, neither indicating the absence of peptones nor of albuminoids. Formula, A-a-T+ H+ =. A case of marked hyperpepC sia, as indicated by the high figure for free hydrochloric acid, yet with pronounced hypoacidity, and without acid fermen

tation. The zero value of coefficient (a) indicates the total absence of useful work on the part of the stomach.

Hyperpepsia with deficient combined chlorine (C) and hypoacidity (A'—)— with acid fermentation.

CASE 155.

The patient, aged 25 years. The stomach fluid when withdrawn was green in

In this, as in the analogous case · 199 - it is 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.

Hypoacidity of the first degree (A'— but above.100) with pseudo-hyperacidity (A' +) due to acid fermentation.

CASE 154.

The patient, aged 37 years, had suffered from stomach disorders for some time; had been addicted to the free use of tea and coffee and usual errors in diet. The stomach symptoms noted, were, distress two or three hours after eating; eructations 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; insomnia; 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), .320; (A'), .140; (a). 2.14; (T), .392; (H), .020; (C), .140. Peptone reaction slight.

Formula,

A+ (A') a +T+CHypopepsia of the first degree with hypoacidity without acid fermentation.

CASE 275.

A young woman, 25 years of age, had suffered from dyspepsia and a variety of general nervous and pelvic symptoms for a number of years. Stomach tube

A case of hypopepsia of the first degree, with hypoacidity and without acid fermentation.

Hypopepsia of the first degree with hypoacidity with acid fermentation. CASE 117.

The patient, an unmarried lady aged 33, had suffered for a number of years with stomach disorder, the prominent symptoms of which were nausea in the morning, constipation, constant occipital headache, sensation of pressure and heaviness in the head, and muscular twitching. The lower border of the stomach was two inches below the umbilicus. The right kidney was movable, hyperæsthesia of the right lumbar ganglion of the sympathetic. The quantities obtain 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. The HO formula: A a+T

C =

Hypopepsia of the second degree (A'· and below.100) - with pseudo-hyperacidity (A).

CASE 61.

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 constriction by corset wearing and tight waist bands, and the continuous use of purgatives. Had also taken chloride of gold and strychnia.

The prominent symptoms were choking, sensation of soreness in the œsophagus, fullness in the stomach, eructations of gas, nausea almost continuous, brief sensation of hunger a few hours after eating constipation, hemorrhoids, gaseous distension of the bowels, many neurasthenic symptoms, especially distress of mind and insomnia, occipital headaches, burning and pressure in head, giddiness, vertigo, sensations of chilliness, trembling, especially of the legs, muscular twitching, and palpitation of the heart. The phys

The patient, a woman aged 48 years, had suffered from digestive troubles for many years; had been addicted to hasty eating and over-eating, and to the excessive use of sweets, fats, and fluids, especially at meals, 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, eructations of gas, regurgitations of fluid frequently after eating, occasional vomiting of bile and mucus without nausea, sometimes vomiting the . entire amount eaten; the vomited matter bitter; cramps in the stomach; faintness; faint sensation in the stomach; good appetite; the patient has observed that vegetables, fermented bread, and strong acids disagree with her; bowels very inactive; stools whitish, mixed with opaque mucus, 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; noise 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 withdrawn from the stomach, 100 c. c. Result of examination of stomach fluid: (A), .012; (a), o; (T), .156; (H), .012; (C), .028.

Peptone slight. Lugol's solution gave

no reaction, showing complete digestion of starch. Rennet ferment absent. H

A

Formula, A—a T-Ccase of hypopepsia of the second degree, without acid fermentation.

Hyperpepsia of the second degree with hypoacidity with acid fermentation. CASE 13.

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; (A'), .0017; (a), 5.00; (T), .100; (H), .000; (C), .002.

HO

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, the pain 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, 2.11; T, .260; H, .040; C, .064. Formula:

H =

A'-(A) a + T-C
C-

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 anæmic 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.

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 classification.

Under appropriate treatment the patients showed marked improvement in nutrition.

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 zymogen abundant. H =)

Formula, A+ a=T=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 fermentation. The high value of (a) which is practically normal, indicates the good quality of the chloroorganic 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,

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 kidney was movable and sensitive. By means of the stomach tube, 113 c.c. of fluid was withdrawn after the usual test-breakfast, an examination of which furnished the following data: (A), .200; (a), .88; (T), .286; (H), .002; (C), .224.

Lactic acid was present, and the biuret reaction showed a considerable amount

+ In

Formula, Aa+T―C+) 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 stomach in emptying itself of its contents. CASE 94.

A man, aged 55 years. Amount of stomach fluids 110 c. c. (A), .168; (a), .87; (T), .310; (H), .050; (C), .136. Uffelmann's reagent showed lactic acid present. Peptones abundant. Formula, H=

==}

A-a+TC—a+T=(

=

A case of simple dyspepsia with C, and acid fermentation. The diminished amount of useful stomach work through the failure of chlorine to combine with albumen, and the acid fermentation which may have been greater than that shown in the value of (a) as indicated by the amount of lactic acid present, 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.