II. Original Communications

Cph GASTRIC HYPERACIDITY (HYPER- Qt> 1 ? nirJlKA^luii I ^n. x r jc.iy-

^ORHYDRIA), its nature, diagnosis and is

DIAGNOSIS AND

TREATMENT 1 KHA 11VIH, IN I

Russell, M.D., F.R.C.P.Ed., Assistant Physician, Edinburgh i)(jj / ^nfirmary ; Lecturer on Pathology, Medical College for Women,

p Urgh; Examiner in Pathology in the University of Edinburgh;

lib-. Examiner in Medicine in the University of St Andrews ft* *u

examiner in Medicine in the University ot St Andrews cENt

tatj0 Papers and discussions on dyspepsia and gastric dila-

tory . which have appeared either in full or in abbreviated

<W*n ^he British Medical Journal have led me to add my for <jQ.

0n to a subject of very wide interest. My excuse

pojnts lr]? so is the belief that my observations may clear up

^ere .ln connection with gastric disorders regarding which much uncertainty and confusion.

^iver 1S not many years since it was generally taught and

^$en y believed that gastric hyperacidity was due to the e of organic acids, the products of the fermentation of

196 GASTRIC HYPERACIDITY (HYPERCHLORHYDRIA)

food in the stomach, the fermentation being caused by orgaI^ isms. This widely-accepted view was probably appropi^^ from the knowledge of the condition of the stomach contents in pyloric obstruction. The inference that the gastric conteI^ underwent fermentation whenever unduly retained came

t?

applied to all, or nearly all, gastric disturbances. It beca

a fundamental proposition, a practically unquestioned assU^e tion. In more recent years, with greatly increased knowle

?

of digestive processes, it has, however, been recognised there is a gastric hyperacidity which is due not to the tation of food stuffs in the stomach, but to a true excess the amount of the special acid normally secreted by the or?

This excess of hydrochloric acid is suitably, if not e^cfaI10ll, termed hyperchlorhydria or hyperchylia, and it is to this

dition that I propose in this paper to confine myself. ^ This hydrochloric acid excess is, in my experience, a

111

more common cause of dyspepsia, and ultimately of gaS

dilatation, than is at present recognised. It is the prl fault in many cases that are classed as nervous, neurotic irritation indigestion, and not infrequently it stands in^jjr same relation to cases named gastric catarrh or gastric ^ tation. I find that of the cases of dyspepsia I have sfet]^e the Royal Infirmary I have placed about 25 per cent. in^eI) category of hyperchlorhydria. The private cases I have

show an even higher proportion of cases of hyperacidity-

Symptoms. ^

It requires patience and method to obtain an a?cUjef, record or a true picture of the symptoms in gastric dis?r^c, The plan I have developed is simple, scientific and P

^ tical, and gives satisfactory results. I begin by *nCJUl

^e how my patient feels on getting up in the morning; ijy hour at which he breakfasts, and of what that meal

u ^

consists ; how he feels after breakfast, and if any pain ^

comfort or other symptom is experienced during the i?re

and the hour at which these come on, how long they whether they continue up to the time of taking the

&1 , \

meal. If symptoms continue up to the midday y ascertain the effect that meal has upon them?

are at once aggravated, or materially relieved, or e

removed, at least for the time. I then inquire as to the

BY DR WILLIAM RUSSELL 197

Position of the midday meal. This is followed by inquiries to ^e symptoms during the afternoon, and so on until bed-

the^ an^ ^ater ^ necessary. This method I have found to be

Only way to obtain exact knowledge of symptoms, and the Ptoms so obtained are of the greatest value in helping to de-

rftiine the part of the digestive process which is at fault. Occa-

ally an observant patient gives all this without detailed

^ stioning, but such patients are rare ; the majority give a Scription which is usually irrelevant and confused, symptoms, es> and explanations being intimately interwoven and mixed.

^ ^he history thus obtained is often so characteristic as to

ej^rant the diagnosis of hyperchlorhydria without the chemical s ^nation of the gastric contents. The facts brought out in

a history are somewhat as follows: The patient feels

the e We^ *n morning, and has no discomfort until during

^ forenoon some time. He can often state the hour at which

L 0rnfort begins?one to two or two and a half hours after

"?the time varying in different cases, and even in the e

case. The pain, after lasting an hour or two, may pass if, f 1 ' " ? ' ??

th' ? reaPPear an hour or longer after the midday meal. If

^n continue right up to the time of taking the midday 0f

' Partaking of this meal removes it for a time, the period of varying from half an hour to an hour. The duration

c0ri^.e lnterval of comfort depends upon the severity of the and the composition of the midday meal. This

nce of events?meals, intervals of relief, recurrence of

the ri

r ^^scom^ort?may be maintained throughout the rest of

ti^ ay* If the last meal of the day be taken near bed-

Pa^ent may he wakened from sleep by pain and

ttyQ syniptoms which may keep him awake for an hour or

"-^he pain or discomfort varies within wide limits; it e Severe and acute, and described as grinding, gnawing,

sion burning, or the sensation may be of dragging, oppres- trjllr^0r distension. The pain is usually referred to the epigas- ?t ^

' ^ut it may go through to the back near the spine ; ^ he present behind either shoulder blade, or be most

'iver *n the normal position of the pylorus, or over the

Vn The measure and the site of the pain depend Oti *^e duration and severity of the condition more than

'^ed neuroPathic tendency in the individual. There is, ' no department where so much is attributed to dis-

198 GASTRIC HYPERACIDITY (HYPERCHLORHYDRIA)

ordered or disturbed innervation, as in gastric disorders, ^

the exaggeration of the factor tends to relegate to a subsid^ place the part taken by diet and altered secretion in the Pr^ duction of the symptoms. Symptoms due to one or other

both of these are referred to as nervous, as if a nerve cond1 were the primary and essential factor, when it is but the sens0

index of disordered chemistry. In addition to pain, tn

may be epigastric tenderness, but this is only present ^ pronounced cases of considerable duration. The tenderness quite superficial, and is readily overcome by gently rubbing handling the skin, and then deep palpation can be Practl^e without causing pain. Other symptoms referred directly

t0

stomach are flatulent distension, gaseous eructations, heart ^ and acid eructations. The eructation of gas or of a sn^t quantity of acrid material gives relief, temporary usually* often very marked and out of all proportion, one would

t

^ to the amount eructated. The bowels are constipated, or'^eflts if there be daily action, the removal of the intestinal c?n

^g} is incomplete. In severe cases there is sometimes great and mental misery, coming on or attaining their worst when

1

^

symptoms are at their height. The most prominent of ^ is a sense of physical and mental exhaustion, langour, vvearin;ilcl and weight in the lower limbs, and inability to apply ^' jjy or body to any work. Another symptom has been graP (( ^ described by Sir W. Roberts under the designation of

^

oxysmal pyrosis," and he regarded it as an " abortive &n s

complete act of vomiting." While agreeing with him that

^ special symptom only occurs during the presence f aji acid in the stomach, I think, that, instead of its beifl

abortive act of vomiting, it is a pyloric phenomenon.

The Explanation of the Symptoms. To understand the symptoms of gastric disorder it

sary to postulate precise knowledge and a clear compre of digestive processes in the stomach. Our food consists so*ceS great classes of nutriment?starch, proteid, fat. The mai

.

of starch are cereals, including rice, and potatoes ; of pr tarCheS meat, milk, eggs ; of fat are butter, milk, meat. The

^ f0r are prepared for food by baking and boiling, being ^ human food in an uncooked state. The object of

c?? ^c^ to break the starch capsules and to disintegrate

the

BY DR WILLIAM RUSSELL 199

the^C^eS SO as to exPose ^em to the amylolytic enzymes of

^ saliva and of other secretions. The longer the cooking

ch^a Proper temperature is continued, the greater are the

Co^n^es in the starch and the better the prospect of its speedy theVerS'?n" convers'oneffected in the first instance by

actsPtyalin of the saliva, and this under favourable conditions

Wt 'Wlt^ vi-our anc^ promptness, converting the disintegrated t(..

lnsoluble starch into soluble starch, a long chain of dex-

tin S' an<^ finally 'nto maltose. This amylolytic process con-

^es ^ the stomach until by the pouring out of hydrochloric ^

the gastric contents acquire an acidity of 0*003 Per cent.

3CC?rc^ng to Chittenden and Smith. At all events when the

but reaches a certain degree the digestion of starch ceases,

cele^e ^^es^on proteids, which has already begun, is ac-

p rated by the increasing secretion of hydrochloric acid and

tj ln?gen. These three chemical phenomena?starch diges-

^Po' arrest starch digestion, proteid digestion?are those

n which the unconscious comfort or the conscious dis-

^ ?rt of digestion primarily and essentially depends. When

llai C'lern'ca^ equilibrium and balance during this period is

On nta'nec*> the stomach works without obtruding its existence l ?Ur notice. The full significance of this equilibrium has,

rela^Ver' realised ; it means the existence of a " correct

0|. l0n

"

between the amount of proteid food and the amount

Pofstnc secretion. There ought to be no more gastric juice

^P ?U^ ^an can satisfy the needs of?that is, can be taken

Pro^e'^- When this is satisfied, the secretion of

HQr ric juice ought to cease, and we cannot doubt that under

conditions this must be the case. If this arrest of

it! ret'?n does not occur, equilibrium is upset, and the result-

7^ Perturbation depends upon the measure of the excess.

^ement in the secretion which is the disturbing factor is

^rochloric acid, and not the special enzyme. The

this hyperchlorhydria upon the gastric contents is

of ^0rthy, and requires explanation. The proteid elements e food are digested with promptness and even with

fo0(j^?nal alacrity ; and it might be thought that the other

hreadSubstances, especially the finely-divided starch food, as

and oatmeal porridge, would readily pass out of the

h^p ac^ with the dissolved proteids, but this is not what ns- What does occur is that a considerable portion of

200 GASTRIC HYPERACIDITY (HYPERCHLORHYDRIA)

unaltered starch is kept back and retained in the stofli*1 ^

This I have frequently found to be the case. The effec* this retained and unaltered starch is to keep up the gaS

^ secretion while presenting no constituent with which it

j combine. The physiological concept is that the undigeS^e starch is readily passed into the duodenum, and its digeS

1

^ completed in the intestine. Even in such conditions as I a

now considering, the undigested starch is, as a rule, ultima ^ passed on, but this only after much local and often geIie discomfort, but it may be finally rejected by vofliitin? Another interesting observation I have made in this connec

^ is that not only the unaltered starch may be thus retained* a considerable amount of the fat of milk may also be retalI1^j( I have several times noted this when all the casein of the

had disappeared. I have seen this both when plain milk and 1r

tonised milk had been taken. When it occurs, the fat 0

milk is found diffused through the acid fluid removed r

the stomach, but partly floating upon it, presenting atl Qf

pearance as if it were a mass of mucus. When the

milk is thus retained, it seems to me that it also keeps up ^ gastric secretion, and, presenting no element with w^'C^|0r- hydrochloric acid can combine, the discomforts of hyperC ^ hydria emerge. A third important factor in determining severity of the symptoms, is the kind of proteid food a

^ The general law is, that the less stimulating and the ^

easily digested proteids, cause less discomfort than do

of a contrary character. In all three conditions there is a common factor ?

tinued gastric secretion, continued beyond what is re^seCre- therefore beyond what can be utilised. This continued 5

tion when the stomach contents are examined, Pr

marked evidence of free hydrochloric acid, and a nig ^

centage of acidity. At this stage the stomach contend

only measure from one to a few ounces of very acrid rria(js of mainly fluid, containing starch, some milk fat, and shre

undigested material according to the kind of food ,

lC

tafeft- been taken. The main residue in ordinary cases is

^ \

At this period the gastric symptoms are very severe,

have frequently obtained the contents of the organ w

foe symptoms were at their height, and have been amaze ^ smallness of the amount in view of the intensity

BY DR WILLIAM RUSSELL 201

^flptoms. Why a residuum of finely divided although un-

^?ested starch should remain in the stomach when other

Ph* ^aS Passe<^ *he Pylorus is difficult to explain. The

jjj '?^?Sical position is roughly this, that the fate of starch e stomach is of relatively little importance, as it is digested

is f S destine > an^ this, from the nutritive standpoint alone,

anC* exP^a'ns t^ie ^act ^iat sufferers from hyperchylia do

to L??Se ^esl1 unless they adopt a starvation policy in regard tr

e*r food. But this physiological truth is one of those

^ s which has led to a total misapprehension of the phe-

deaj6na of disordered function such as the physician has to

With. The interpretation which seems to me to be in

^c, with my clinical observations is that we have to

st n?wledge that the unaltered starch is delayed in the

Pr and that is so even when broken up and digested

s,. lc?s have escaped. Being thus delayed it continues to

pr .

e the gastric secretion, and there being no more

which to combine the secretion accumulates and t0 hyperacidity in question. That this hyperacidity is

p0^toa true hypersecretion is proved by the great peptonising Qncer the filtered contents when tested in the usual way.

c0 the residuum in the stomach becomes hyperacid its

acidihUe,d retention is explained by the fact that the hyper- sD ^ keeps the pyloric sphincter closed, or even causes

Rsm of it.

Etiology. c ??king in the next place, at the etiology of hyperchylia,

^ich ?urse^ves face to face with terms and designations

, 0nly obscure the position. The favourite place in

dys find it described is under gastric neuroses, nervous

is ^epsia> gastric irritation, gastrodynia, or gastralgia. It

by always clear what writers on gastric disorders mean

to ^0rne ?f these terms. Whether the idea which is sought

%je .Conveyed is that the pain and discomfort are merely C 1Ve nervous phenomena, or that an assumed neurotic

*cid CS*S determines an increased secretion of hydrochloric tl?e underlying idea seems to be that the nervous

^naniSm is the part of the system which is primarily This conception I hold to be erroneous and

?yste ?f evil consequences. We all possess a nervous

' lri some more finely tuned and more responsive than

202 GASTRIC HYPERACIDITY (HYPERCHLORHYDRIa) aIc

in others, and we all grant and recognise the important r

played by it. All deviations of secretion from an avera?

standard, all increases of secretion, all modifications of chemic0^ vital reaction, are not to-day accepted as explained or by the word

"

neurotic," and it is time that the word and idea were relegated to a less prominent place when cons ^jS disturbances of stomach function. In opposition to

. j neurotic view I would submit as a result of my c^inl

.

experience and the examination of gastric contents that cer ^

persons are prone to secrete over-much gastric juice, and ^ possibly the constituent which is primarily at fault is

^ hydrochloric acid. I have been impressed with the occurre of severe hyperacidity in some gouty and rheumatic sudJ ^ ^ and by its occurrence in some persons as a consequence diet rich in nitrogenous substances. I think, indeed, there.

little doubt that we might add to our list of constituti0 conditions an acid dyscrasia. To regard the intense

m t0

of severe hyperchylia as a mere neurosis is an impertinent^ some of the victims of the condition. Apart, however, ^ that aspect of the case I hold the merely neurotic view ^ disproved by the following phenomena which I have freque ^ observed : the instantaneous relief obtained by removing'

,

ounce or two of acrid stomach residuum ; a like relief 0 rg

by neutralizing the acid by means of alkalies ; and the ^

^ js

of relief obtained by mere dilution. That the over-sec1"^ more a chemical and a diathetic error than a neurosis is -^l strongly supported by the experience that the mec

removal of the hyperacid residuum in severe caseSjjcjfl^ promptly overcomes the attack than any dietetic or

me . ^

measure?as if the removal of the acid removed an 0

^0[ which otherwise is difficult to arrest, and which ^gai11 removed looks as if it were absorbed and again an

resecreted. . of a

Further Local Effects.?The retention in the stomal

hyperacid residuum gives rise further to catarrh and to

^gii dilatation. In fact, so-called

" atonic dilatation " is veI^uydda'

not primarily an atonicity, but due to a hyperc bTf>: The steps of this process are too apparent to nee

.

words. In some severe cases relief is ultimately a

^ad a

vomiting. Within the last six months I have tvvice

man under my care suffering from intense hyperchy

BY DR WILLIAM RUSSELL 203

contents when brought up by vomiting were green in

re ?Ur from admixture with bile, but were never green when

^?ved by the stomach tube. What evidently happened here

fr S ^hat with the onset of nausea there was a reflux of bile 111 tile duodenum which seemed to determine active vomiting.

the

Treatment.

The treament to be selected depends upon the severity of

pr- cpnditi?n and the history of the case, and only the general tyj

Clp*es can be indicated here. In mild degrees, associated

?th C.?ns^Pa^on' ^e correction of this may be sufficient. In r instances an alkali taken some time before food neutralizes

st acid residuum and facilitates the transformation of the

obtC e^ements of the next meal. In other instances relief is

ky the administration of even a small dose of an

bee 1 as soon as discomfort begins. This has for some time

p t0 me a c^ear practical fact, and it has now the support of

W ?VV S work on the secretions of the digestive glands. I

Co no success with the administration of acids in this

^ith n' a^ough in some other gastric disorders I use them

jj. good effect. As regards diet this also has to be deter-

pr .. , by the severity of the symptoms. In some cases the

n ?f the more common forms of starch such as potato

i^^toasted bread is sufficient; in others still greater care

c^rh exerc'sec^ in the selection of the most readily digested

dis ^^rates. Another class may get past their immediate

pr ^f?rt by the use for a day or two of readily digested pure ^ ̂iet, and the gradual addition to this of the most

e carbohydrates available.

WJjq weeks ago I promptly gave relief to a young woman

^ore been sent to me with pain coming on an hour or

, after every meal, and so severe that she was almost

eggs to touch food of any kind. A couple of days on raw

&ve' and then the Sradual addition of suitable carbohydrate

ofthC*e relief. In the severest cases I find the removal e frao4.?: * ?' '? ?

of temporary cure. gastric residuum the speediest means

ys ternporary, for as I hold the conditio! dySc emporary, for as I hold the condition to be a chemical

*Ppr aS'a' an<^ no^ a neurosis, permanent cure or anything to c?acllirig it can only be looked for from a dietary adapted itself?Unteract or P^vent the chemical dyscrasia manifesting

204 0N HAND disinfection

The considerations determining the dietary are (0 * 6

proteids ought to be reduced to a physiological minim1^' and ought to be so selected and cooked as to be easy and i"ea

of digestion ; (2) the starches should be as much altered ^ possible;1 (3) the quantity of food should not exceed

physiological requirements. Proceeding on these broad ^ we may have every confidence in assuring our patients recovery, and that continuance on the lines indicated will

ca

with it the reward of physical and mental wellbeing.

daily u5e' 1 Of these there are now several on the British market suitable for ordinary