The Indigestion of 
Starchy Foods. 
By Reynold W. Wilcox, n.D.,LL.D., 
Professor of Clinical Medicine and Therapeutics at the New York 
Post-Graduate Medical School and Hospital; Visiting 
Physician to St. Mark’s Hospital, New York. 
Press of 
Parke, Davis & Co. 
1896. THE SYMPTOMS AND DIAGNOSIS OF THE 
INDIGESTION OF STARCHY FOODS.* 
BY REYNOLD W. WILCOX, M.D., LL.D., 
OF NEW YORK; 
Professor of Clinical Medicine and Therapeutics at the New York Post- 
Graduate Medical School and Hospital: Visiting Physician 
to St. Mark’s Hospital 
There are many reasons why the text-books are silent upon 
the subject of this paper. The ease with which the contents 
of the stomach can be examined, the accuracy with which the 
effect of pepsin can be estimated, the zeal and energy of the 
manufacturers of digestive ferments, have placed our knowl- 
edge of gastric digestion in a very satisfactory condition. To 
one who will carefully study the accurate work of Hayem and 
Winter, and who will follow their teachings, the chemistry and 
physiology of the gastric fluids are well understood. Yet, 
after all, the gastric may be stated to be only the preliminary 
to duodenal digestion. And that gastric digestion is not even 
essential, is shown by observations of Czerny, who demon- 
strated that a dog could live for five months after his stomach 
had been removed. 
The digestion of starches, it is well known, takes place in 
the mouth and in the intestine. The older physiologists were 
of the opinion that the digestion of starches came to an end in 
the stomach. Kellogg, however, has shown conclusively that 
starch digestion can go on, under certain conditions, in the 
stomach. One hundred and forty-nine cases in which starch 
digestion was especially studied, complete conversion was 
found in 2 per cent. The conditions under which this is 
brought about will be considered at a later period. 
Starch digestion, according to Brown and Heron, may be 
represented as follows: 
* Read before the Medical Society of the State of New York, at its 
ninetieth annual session, January 29, 1896, and reprinted Irom The Med- 
ical News, 1896, Vol. LXVIII, p. 182. 2 
One molecule of gelatinous is converted into n molecules 
of soluble starch. 
One molecule of soluble starch— 
io(C12 H 2 0O j 0) 
-f8(HgO)=r. 9(ClgHS0O10) Erythro-dextrin. 
+(C12H28Oi1) Maltose. 
=2. 8(C12H20O10) Erythro-dextrin. 
+2(C12H22011) Maltose. 
=3. 7(C12H20O10) Achroo-dextrin. 
Maltose. 
And so on, the resultant being: 
= 8(C12H2201i) Maltose. 
+2(C12H80O10) Achroo-dextrin. 
We will now consider this digestion as it takes place at the 
various portions of the alimentary canal. 
The term buccal dyspepsia has been used for more than a 
score of years. It was supposed to be characterized by insuf- 
ficient nutrition, resulting in emaciation, abdominal distention, 
flatulence, and colicky pains, or abdominal distress, and was 
due to imperfect conversion of the starches in the mouth. In- 
vestigation subsequently showed that this imperfect conversion 
was but a part, and perhaps a minor part, of the causa- 
tion, the more important being hasty mastication. The hasty 
mastication resulted in (i) imperfect breaking up of the starch 
grains, (2) deficient quantity of saliva, and (3) imperfect insali- 
vation. Since the conversion of insoluble starch into soluble 
sugar depends upon not only a sufficient amount of saliva, but 
also upon trituration of the starch grains so that their capsules 
shall be thoroughly ruptured, and thorough mixture of the 
saliva with the starch, it can readily be seen how very im- 
portant is complete mastication. With these three factors in 
full play, starch conversion is practically instantaneous. Natu- 
rally a considerable portion in this form of indigestion—so- 
called buccal dyspepsia—can be cured by eating more slowly, 
on the one hand, and by limitation of the starchy foods which 
are ingested, on the other. This cause of dyspepsia is far 
more frequent than it is popularly supposed to be, and the 
neglect to properly appreciate this etiological factor explains 
some of the failures in therapeutics of those who place great 
reliance upon the results of the examination of the stomach 
contents. The careless hurrying of the carbo-hydrates into the 
stomach without their being properly acted upon by the ptyalin of the secretions of the mouth is, as I have said before, a very 
important cause of dyspepsia. Lees has recently called atten- 
tion to another prevalent error, which is frequently, I imagine, 
even encouraged by physicians. Too much amylaceous food 
is taken into the stomach soaked in tea, coffee, milk, beef tea, 
and other fluids. The result of this is that insalivation is not 
at all performed, and the ptyalin, quite likely deficient in 
amount from lack of mastication, is present in such small per- 
centage that it is practically inoperative. The stomach is not 
expected to originate the digestion of starches; it may, and 
likely does, continue the process, when commenced in the 
mouth, for about half an hour. The natural inference from 
this is that fluids of any kind should not be used while masti- 
cating amylaceous food, and the patient should be restricted 
from the too free use of tea, soups with vegetables, puddings 
with milk or cream, or boiled farinaceous foods with the same. 
The results which are obtained in practice tend to show the 
correctness of the observation. When we consider that, de- 
pending upon the dryness and hardness of the food, from one 
to three pints of saliva are secreted daily, and that the per- 
centage of ptyalin present (in mixed saliva) is according to 
Frerichs, .0141, the action of the hydrolytic ferment is by no 
means insignificant. When, from the causes above mentioned, 
the amount of carbohydrate food daily ingested, which is nec- 
essary for an adult, varying, according to Parkes, from twelve 
ounces (at rest) to sixteen or eighteen ounces in laborious 
occupation (practically about two-thirds of the total food) is 
hurried into the stomach with but little conversion, the results 
to be expected in the intestines are not far to seek. What the 
effect of the presence of a large amount of unconverted starch 
in the stomach may be on gastric digestion, is not, so far as 
I know, determined, nor, indeed, is it within the scope of this 
present investigation to inquire. 
In the stomach it is admitted that the action of the amylo- 
lytic ferment, ptyalin, may continue for about half an hour, its 
activity being finally checked by the fatty acids, or by the free 
hydrochloric acid, the latter even if in small quantity. On the 
other hand, it has been stated that when these acids are in or- 
ganic combination they may favor starch conversion. Recog- 
nizing the amylolytic changes by means of the iodine-iodide 
test (Lugol’s solution; starch, blue coloration; erythro-dextrin, 
red or purple; achroo-dextrin, brownish; the sugar, maltose or 
glucose, being detected by Fehling’s solution) Kellogg found 
3 in the series of cases above mentioned that the purple color of 
erythro-dextrin was detected in 67.8 per cent., and the brown 
color of achroo-dextrin in 17.4 per cent. The conditions under 
which this unusual digestion takes place are pronounced hypo- 
pepsia, or to be more accurate, hypopepsia with hypo-acidity. 
In fact, the state of starch digestion may be a very good index 
of the degree of total acidity. When Lugol’s solution gives a 
brown coloration or no reaction whatever, complete conver- 
sion of starch has taken place and the presence of sugar can 
be confirmed by the strong reaction given by Fehling’s solu- 
tion. A suggestion may be entertained that the prompt con- 
version of starch into sugar which takes place under these 
conditions may result in the rapid absorption of the digested 
starch so that the conditions are less favorable for the develop- 
ment of acid fermentation than in the presence of a large 
quantity of unconverted starch. With this observation by Kel- 
logg, I leave the subject of starch conversion in the stomach. 
The digestion of starches is resumed in the small intestine. 
Owing to the inherent difficulties of the subject the various 
processes have not been so thoroughly worked out. As a 
matter of fact, buccal and gastric digestion are merely pre- 
paratory to the intestinal. In addition, here, proteids and fats 
as well as starches are digested, and failure in one direction 
must necessarily result in abnormalities in the other. In 1890 
Boas attempted to study experimentally intestinal digestion in 
man. For this purpose he made use of vomited matter 
obtained by a reflux of the intestinal fluids into the stomach. 
He also made use of the stomach tube and of aspiration. 
Naturally the irritation of the stomach tube, even if the stom- 
ach had been previously irrigated, would result in some gastric 
fluid, so that unmixed intestinal fluid cannot be obtained. The 
subject was experimented with while fasting, and the reflux 
from the intestines was favored by his decubitus and by mas- 
sage of the epigastric region. Although this method is not 
applicable to the study of intestinal dyspepsia in our patients, 
yet the observations of Boas had a certain practical value in 
that they demonstrated the influence of bad gastric upon the 
intestinal digestion. Perhaps the sole result of these experi- 
ments, so far as concerns starch digestion, is the statement 
that patients suffering from hypochlorhydrie do not suffer from 
intestinal troubles; in other words, this is confirmatory of 
Kellogg’s work, which shows that under these conditions starch 
is digested in the stomach, and the opportunity for intestinal 
4 5 
disturbance from undigested starch is not presented. Another 
factor of importance in intestinal digestion is the presence of 
micro-organisms, whereas normal gastric digestion is probably 
free from them. The conditions favorable to the action of 
amylopsin are similar to those favorable to the action of 
ptyalin; namely, moderate heat, a slightly alkaline medium 
and removal of the changed material from time to time. The 
ferment in the pancreatic juice, distinctly amylolytic (amylop- 
sin), cannot be distinguished from ptyalin. The digestion of 
starches results in maltose or glucose, the latter being always 
the final result. Obviously here we must consider that the 
effect of the pancreatic fluid on starch may be practically 
inhibited by the discharge of a large amount of acid fluid 
through a patulous pyloric orifice in cases of marked gastric 
acidity—another point at which gastric and intestinal indiges- 
tion approach. The succus entericus from Lieberkuhn’s glands 
is believed to convert starch into sugar, but under what con- 
dition and to what extent physiological literature is generally 
silent. 
So far as the difference in the digestion of starches at the 
various points is concerned we may follow Kirke in stating 
that while the pancreatic and intestinal juices are able to turn 
the achroo-dextrin which remains into maltose, and maltose 
into glucose (dextrose) it is doubtful whether saliva possesses 
the same power. 
The difficulty of reaching the diagnosis of the indigestion 
of starches in the intestine is already apparent, yet we believe 
that in a given number of instances it can be arrived at with 
reasonable certainty. The importance of making this investi- 
gation is great, when we consider that to the assimilation of 
changed starch we owe much. On the other hand, we have 
proof, if proof were lacking, that the indigestion of starches is 
a frequent condition—not so frequent however, as Coutaret in 
1870 would have us believe, 60 per cent, of dyspeptics—by the 
prevalence and somewhat good repute of dyspepsia cures based 
on raw beef and hot water. And when we consider that in 
France bread has a prominent place in the dietary and in other 
European countries starchy foods are even more largely em- 
ployed, the importance of the subject is apparent. In this 
country, not only does hasty eating, but bad cooking, and the 
imperfectly raised biscuit and cakes and other pastry are often 
saturated with greasy substances, and give us reason to believe 
that starchy dyspepsia is even more frequent. 6 
Taking up the symptoms of intestinal indigestion as refer- 
able to the failure of starch conversion I would place first and 
foremost constipation, of which the cause is quite likely that 
the colloid-like unconverted starch does not so readily permit 
of watery osmosis into the intestine as does the sugar into 
which it is converted, which acts as a crystalloid. The accu- 
mulation of undigested and unabsorbed material may even be 
considerable and give rise to marked enteroptosis (Glenard). 
On the other hand diarrhea is comparatively infrequent; how- 
ever, fermentation may go on briskly so that a large amount 
of irritating material may be formed and its expulsion takes 
place. Should diarrhea exist it is likely to be diarrhea alterna- 
ting with constipation and not the persistent one which may 
characterize other intestinal conditions. 
The symptom next in importance is undoubtedly flatu- 
lence, especially that which occurs two or three hours after 
meals. The question here arises as to how much of this may 
be due to gases from the imperfect digestion of proteids in the 
alimentary canal. To clear up the question we must refer to 
the work which has been done upon various sulphur com- 
pounds. Baumann in 1880 propounded the theory that the 
combined or ethereal sulphates found in the urine were an 
index of the amount of putrefactive products absorbed from 
the intestine; these are chiefly indol, phenol and skatol; the 
latter is practically of no importance in this study since it is 
found almost exclusively in the large intestines (Filati). Indol 
by oxidation becomes potassium indoxyl-sulphate, long known 
as indican. Looking upon indol as the product of bacteria 
upon the proteids, as Kuhne and Nencki would have us believe, 
and considering with this the view of Pisenti that the amount 
of indican depends largely upon the activity of the pancreatic 
fluid, we come close to the clinical fact that clay-colored stools, 
excessive preformed sulphates, and abundant indican in the 
urine are associated with defective secretion of pancreatic fluid. 
To Herter and Smith all who study this subject must acknowl- 
edge their indebtedness for their exhaustive work upon the 
preformed sulphates and indican and their relations with intes- 
tinal indigestion. Since then we have the proteids as the 
source of sulphur compounds, the causation of flatulence can 
be determined by the increased ratio of preformed to inor- 
ganic sulphates and by the excess of indican in the urine. 
Therefore, flatulence as a symptom, when the chemical evi- 
dence of the proteid indigestion is absent, can with reasonable certainty be referred to amylaceous dyspepsia, with greater 
reason, indeed, than appears above, because the gastric hydro- 
chloric acid retards bacterial activity, and an excess poured 
into the intestine markedly interferes with the digestion of 
starches. Confirmatory of this view is the observation of Kast, 
that neutralization of the gastric juice with sodium carbonate 
was followed by an increased ethereal sulphates. Biernacki 
practically reaches the same conclusion when he says that the 
excretion of putrefactive products is large, with great decrease 
of hydrochloric acid secreted. The further suggestion can be 
made that the gases due to proteid indigestion are sulphur-con- 
taining and consequently more obnoxious than those of the 
marsh-gas series of carbo-hydrate origin. Yet it must be borne 
in mind that gluten associated with the carbo-hydrates is a sul- 
phur-containing body, so that this distinction is not so important 
as it would at first appear. Coincident with flatulence are the 
painful phenomena from heaviness, tenderness, and abdominal 
discomfort to colicky pains. Since flatulence is more marked 
with starchy than with proteid indigestion, these symptoms are 
more prominent. Further, because constipation is an import- 
ant factor; abdominal heaviness in addition to acute pain is 
frequently found. Not only are local physical signs, as full- 
ness, tenderness, and changes in percussion note more marked 
than in proteid indigestion, but the general symptoms are more 
numerous and persistent. The opportunity for absorption of 
peccant material—to use an odd term—is favored by the con- 
stipation, but as has been stated, the ptomaines of decomposed 
starch (amulon-ptomaine) are almost as injurious to the human 
body as the ptomaines of nitrogenous foods. Therefore, we 
note the lassitude, habitual malaise, general debility (partly 
from insufficient nutrition) the insomnia, the various sensory 
symptoms, headaches, vertical, frontal, or occipetal, and ver- 
tigo. The heart symptoms are prominent, due in part to gas- 
eous distention, and vary in importance from palpitation, 
cardiac distress, cardiac pain, and tachycardia to syncope. 
We have also the urticarias, the muddy complexions, cold 
hands and feet referable to this cause. We may even ob- 
serve marked mental changes, as hypochondriasis, intellec- 
tual apathy, and morbid somnolence. 
The picture is a familiar one but we all have doubtless 
failed many times in not differentiating this particular form of 
indigestion, and attributing too much importance to the gas- 
tric, to the neglect of the intestinal digestion. After all, the 
7 8 
diagnosis by exclusion, lor such must be the method employed, 
and its accuracy can be readily put to the touchstone of clin- 
ical experience. Those in whose persons starch is imper- 
fectly digested, tolerate badly the starched foods. The causes 
of indigestion of starches are: (i) excessive ingestion of carbo- 
hydrates, (2) imperfect insalivation, (3) hasty mastication, (4) 
too diluted starchy foods, (5) too great gastric acidity, (6) insuf- 
ficient or perverted secretion of pancreatic fluid, (7) excess or 
abnormal activity of micro-organisms, (8) intestinal torpor or 
exaggerated peristalsis, and (9) imperfect absorption of already 
digested foods. 
The diagnosis rests upon the positive evidence of consti- 
pation, flatulence, the sensory phenomena, the general sys- 
temic disturbances and remote painful symptoms existing in a 
marked degree, and upon the negative evidence as found in 
the ethereal sulphate ratio and the amount of urinary indican. 
The picture seems clearly outlined, and at the close of our 
study we may say that the diagnosis of the indigestion of 
starchy food should be reached with reasonable certainty. THE TREATMENT OF THE INDIGES- 
TION OF STARCHY FOODS.* 
BY REYNOLD W. WILCOX, M.D., LL.D., 
OF NEW YORK; 
Professor of Clinical Medicine and Therapeutics at the New York Post- 
Graduate Medical School and Hospital; Visiting Physician 
to St. Mark’s Hospital. 
The proper treatment of this form of indigestion takes 
into consideration its causation. As has been said at an- 
other place, the prophylaxis comprises: the limitation of the 
starches ingested; thorough mastication; which results in 
complete insalivation, because in this way is the output of 
saliva increased; and the taking of starchy foods in as dry a 
condition as possible. By giving careful attention to these 
conditions, a very considerable number of instances of the 
indigestion of starchy foods can be relieved. This is the 
extent to which the treatment of so-called buccal dyspepsia 
can go in the way of prevention. 
The treatment of the indigestion of starchy foods must 
take into consideration the acidity of the stomach contents, the 
amount and character of the pancreatic fluid, the influence of 
intestinal micro-organisms, the deficient or exaggerated peris- 
talsis, and the absorption of the converted starch. 
Too great acidity of the gastric contents is unfavorable to 
starch conversion, because: first, it limits the time during 
which the ptyalin from the salivary glands acts in the stomach, 
at best but half an hour, or abolishes it altogether; secondly, 
the outpouring of an excessively acid fluid from the stomach 
into the duodenum delays and markedly interferes with the 
re-establishment of starch conversion by the action of the 
amylopsin of the pancreatic fluid. In these cases the testing 
* Read before the Section on General Medicine of the New York 
Academy of Medicine, February 18, 1896, and reprinted from The Med- 
ical News, 1896, Vol. LXVIII, p. 393. 
9 of the stomach contents gives a ready solution to the problem,, 
and the neutralization of the excess of acid by sodium bicar- 
bonate in dose from five to a hundred grains, in time varying 
from immediately to two hours after eating, will rectify this 
error. Recent papers have shown the harmlessness of even 
the long-continued use of large doses of this drug; and, further 
than this, the favor in which this remedy is held by many 
practitioners is due, not so much to its beneficial effect upon 
gastric, as to its secondary action upon intestinal digestion. 
In these cases not only must the proper dose be ascertained 
for each individual, but the time for its administration is 
equally important. The methods for ascertaining the motility 
of the stomach have been so frequently of late the subject of 
study by clinicians that it is not necessary for me to discuss 
them at this point. In passing, it is worthy of remark that 
the action of sodium bicarbonate is solely in neutralization of 
the free hydrochloric acid in the stomach, the important cause 
of interference with starch conversion; but it is probably with- 
out effect on the acids in organic combination. 
Of disturbances of the motor functions, constipation is the 
rule in imperfect starch conversion. The best method of over- 
coming this is the administration of a saline in conjunction 
with an alkali, the latter assisting in the process of conversion. 
Further than this, as both Wohler and Miahle have pointed 
out, the administration of salines will diminish the urinary 
acidity and quite likely also increase the normal alkalinity of 
the intestinal contents. The saline, which I have used by 
preference, is sodium phosphate (the normal, not the acid 
phosphate) in from 40 to 120 grain doses, to be taken in a full 
glass of hot water on rising in the morning. To this dose is 
added 15 to 40 grains of sodium bicarbonate. The advantage 
which the phosphate possesses over the sulphate is that it is 
distinctly less disagreeable in taste. As an alternative to these 
drugs I have used cascara sagrada in various preparations, in 
sufficient dose to secure a full movement, but I am not satis- 
fied that its action is so beneficial. If gastric acidity is high, 
then we must in addition administer large doses of sodium 
bicarbonate during, or immediately after, each meal. Haiden- 
hain has shown that alkalies facilitate pancreatic digestion, and 
this is the probable explanation. 
Diarrhea is by no means common. It is generally due 
either to obstinate constipation, and alternates with it, or to 
abnormal activity of the micro-organisms. In the first case, 
10 11 
as a rule, hard masses are found in the stools; in the second, 
the passages are watery, containing mucus and are of bad 
odor. If the diarrhea is due to the irritation produced by 
hardened masses, thorough purgation by the official compound 
cathartic pill followed by the sodium phosphate mixture is 
sufficient. If it is due to fermentation, a preliminary purga- 
tion with castor oil should be followed by the use of intestinal 
antiseptics. In either case no opium or any of its alkaloids 
should be administered, for these only give temporary relief 
and lay the foundations for a worse condition than previously 
existed. The so-called intestinal astringents are equally use- 
less. When the fermentation is marked, the expulsion of gas 
And pain are prominent symptoms. The treatment for the 
associated diarrhea is given above. In addition intestinal 
antiseptics should be continually administered. Since the 
commencement of my studies in 1884, I have made use of a 
large number of drugs, and their various disadvantages have 
been determined by clinical observation, f ollowing Boucnara, 
we can say that naphtol has the best bacteriological basis for 
its therapeutic use. On the other hand, it is locally irritant, 
and it also increases the chlorine and generally the hydro- 
chloric acid of the stomach, thus interfering with starchy diges- 
tion. Bismuth salicylate is not open to these objections, but 
unless the kidneys are healthy, this, as well as the other sali- 
cylates, is contia-indicated. Another disadvantage is, that 
this decomposes in the stomach, setting free the salicylic acid. 
Further, as Gley has shown, unless the pancreatic fluid and 
bile are discharged in sufficient amount into the duodenum so 
that distinct alkalinity is secured, the breaking up of such 
compounds as salol does not take place, and thus the sali- 
cylates may be useless. Salol presents another objection 
from the carbolic acid which it contains. I have used bismuth 
naphtolate with much satisfaction in these cases; it is not 
irritant and certainly limits the amount of gas formed, the 
offensiveness of the discharges, and decreases pain when 
caused by intestinal distention of gas. The dose varies from 
ten to twenty grains two hours after eating, administered as a 
powder or in gelatin capsules. Benzoyl guaiacol has been used 
in a few instances, but not with the same success. The impor- 
tance of intestinal antisepsis does not alone lie in the preven- 
tion of gas-formation, diarrhea, and pain, but also in the 
prevention of auto intoxication from ptomaine absorption. By 
these means also the remote effects of systemic poisoning, the fecal anemia of Clark, neuralgia, vertigo, and the mental 
symptoms are obviated, and the results of the action of the 
micro-organisms of proteids resulting in indol, phenol, and 
skatol, and other aromatic bodies are minimized. The proper 
method of dealing with flatulence accompanied by pain is out- 
lined above. For impatient individuals, while we are evacu- 
ating the offending material and establishing antisepsis of the 
digestive tract, a plan for affording speedy relief, and one 
which will not interfere with tfie action of the drugs in use, 
must be adopted. This is the administration of the concen- 
trated tincture of avena sativa in a wineglassful of hot water 
every half hour until the pain is subdued. 
absorption of converted starch takes place rapidly 
enough if peristalis is normal and mucus is not present in 
inordinate quantity. The latter is reduced in amount by the 
use of the sodium phosphate mixture in the manner directed. 
The changes in character and amount of the pancreatic 
fluid have been the cause of various therapeutic expedients, 
and in obviating the results of these variations, physicians 
have found many apparently useful resources. At the outset 
pancreatin should be considered. The preparations, as found 
in the market, are often inert and, even if not, their action is 
destroyed in the stomach by contact with the acid gastric juice. 
To prevent this loss of action, Unna used pills coated with 
keratin. With this method of administration there is some 
question if these pills will not pass entirely through the intes- 
tinal tract with undissolved coating. It has been proposed to 
coat these pills with fused salol. The same objection applies 
to this practice as to the use of this drug for the establishment 
or intestinal antisepsis. The cases when it is most needed are 
those of deficient flow of pancreatic juice and diminished alka- 
linity of the contents of the duodenum, and so the salol would 
likely prove to be an impervious coating. Probably the best 
coating is an alcoholic solution of shellac, containing a suffi- 
cient quantity of balsam of tolu to impart a proper degree of 
elasticity, so that cracking of the coating during its drying is 
obviated; this was the suggestion of Flint. The use of pan- 
creatin then appears to be rather in the preparation of predi- 
gested foods than administered as a drug. 
Diastase, the maltine of Irwine (1785), Dubrunfault (1823- 
30), Payen, and of Persoz, has been the subject of much study. 
As made by Payen and Persoz, it is capable of dissolving, in 
several hours, fifteen to eighteen hundred times its weight of 
12 cooked starch. This, as other diastases, loses its property of 
converting starch in the presence of acid, but the degree of 
acidity requisite is less than the usual gastric acidity. Although 
its action is favored by alkalies and alkaline salts, yet the 
caustic alkaline solutions destroy it. As Hayem points out 
its action is best between 950 F. and 104° F., and the analogy 
between the vegetable and animal diastase (ptyalin) appears to 
be complete. The use of diastase from malt was insisted upon 
by Coutaret (1870), who claimed to obtain great benefit from its 
use. In cases of gastric hyperacidity, when the action of the 
ptyalin is suspended in the stomach and when that of the pan- 
creatic fluid is lessened or prevented, the use of vegetable 
diastase administered with an alkali (sodium bicarbonate) gave 
good results. This practice was also sanctioned by Boas. 
For this purpose the following method of preparation has been 
employed: Three ounces, i.e., three heaping tablespoonfuls of 
crushed malt, is well mixed with a half pint of cold water in 
a jug and allowed to stand from ten to twelve hours. The 
supernatant fluid was then poured off and strained through 
two or three folds of muslin until the filtrate becomes clear 
and bright. The yield is about six ounces. The disadvan- 
tages of this preparation were found in the necessity of its 
being freshly prepared. To preserve it, a few drops of chloro- 
form were added to a tightly corked bottle of the liquid. When 
required for use it should be emptied into a saucer and left in 
a warm place, when, after two or three hours, the chloroform 
would be entirely evaporated. A liquid preparation of dia- 
stase, which is permanent, has been found in the shops for 
several years. It seems to possess but little amylolytic activ- 
ity, due probably to the contained alcohol. The use of malt 
extracts in the treatment of amylaceous dyspepsia has yielded 
some very good results, but we are limited to the solid extracts. 
The liquid extracts generally contain so much alcohol and 
acids, the results of fermentation, that the action of the dia- 
stase is inhibited. At the same time, however, the feeble 
diastatic power of even the best of them, generally about five 
times their weight of dry starch, the large amount of inert sub 
stances, their deterioration with age, and the fermentation 
which the large amount of sugar (maltose) which they contain 
give rise to, are all disadvantages. Further, the pharmaceuti- 
cal difficulties in the way of using them in mixtures, are ob- 
stacles, but not insurmountable ones, to their use in elegant 
pharmacy. Some years ago (1891) I noted that a malt extract 
13 containing diastase in large percentage had been made by 
Jokichi Takamine, the Japanese chemist, but I have been un- 
able to find pure diastase of value in the market until during 
the past year. My skepticism in regard to the value of dia- 
stase in the form of a dry powder was based upon the low 
starchy converting power of a foreign preparation. When I 
found that a diastase had been isolated by Takamine, and its 
value certified to by Lascar, I again experimented with the 
substance. This preparation, according to Smith and Tonkin, 
is made as follows: Bran of ordinary wheat is sterilized by 
heat so as to destroy any and all germs which it may contain. 
After cooling it is mixed with the Japanese fungus, the eurotium 
a?yzcE, known as taka-moashi, in such proportions as experi- 
ence shows to be most favorable for the development of the 
diastatic fungus, taka koji. This mixture is kept at the same 
temperature during the whole of the forty hours it takes the 
fungus to attain its full development. The taka-koji is then 
washed in cold water, after which the pure diastase contained 
in the latter is precipitated in the form of a tasteless, odorless, 
and nearly white powder. Experiments have shown that this 
diastase possesses the remarkable power of, within ten min- 
utes, converting into sugar one hundred times its weight of 
starch (estimated in the form of a dry paste), and, within three 
hours, fifteen hundred times its weight of starch. Its activity 
is increased by raising the temperature up to 131° F., but no 
higher. This action is more marked in neutral or feebly alka- 
line solutions, but is entirely absent in acid or strongly alkaline 
media. Even when the conditions are in the highest degree 
favorable the action of the diastase ceases when a certain 
amount of sugar has been formed. On placing the solutions 
in a dialyzer, so as to remove the sugar as fast as it was 
formed, it was found that the action of the ferment more 
closely resembles the process taking place in the organism, 
and that a much larger percentage of sugar was obtained than 
without it. 
Lascar has found that he can convert with this diastase 
one hundred to one hundred and fifty times its weight of starch 
into a soluble state. Under proper conditions this first named 
amount is so thoroughly converted in four minutes that neither 
the iodine test nor the microscope can detect unconverted 
starch. The starch employed in most of his experiments was 
carefully washed arrowroot. The final result is, to a great 
extent, maltose. In this connection especial mention should 
14 be made that an undue employment of heat will destroy the 
action of diastase. The powder, as found in the market, ap- 
pears to be permanent, and is used in doses of from one to 
five grains, as a powder or in gelatin capsules, during or after 
the meal. Since there is a possibility of the activity of this 
drug being impaired in its passage through the stomach, al- 
though Thompson believes that vegetable diastase continues 
to operate in acid media, it may be administered as a pill, 
coated with an alcoholic solution of shellac, keratin, or salol, 
but the objections noted above will hold here as well. This 
method, however, I have not found to be necessary. 
The following cases, which are briefly reported, illustrate 
the classes in which we may reasonably hope to derive benefit 
from the administration of this drug: 
I. —July 2, 1895. H. E., aged fifty six years, dry-goods 
merchant, has suffered for years with dyspepsia. The attacks 
occur chiefly during his busy season, when hasty luncheons 
and irregular hours are the rule. On ascending the stairs the 
dyspnea is so severe that speech is impossible. The eyes are 
yellowish, dull headaches occur almost daily, and one to three 
nights each week The heart is irregular, both in force and 
rhythm, there is much hepatic tenderness, and the abdomen is 
resistant and painful on pressure, which gives rise to gurgling. 
Ten grains of calomel with twenty grains of sodium bicarbo- 
nate gave several copious, foul-smelling motions. A pill com- 
posed of podophyllin one-quarter grain, iridin one-half grain, 
and enonymin one grain, was ordered for each night. Bismuth 
naphtolate, five grains with taka-diastase, three grains in 
powder, was given after each meal. iqth. The passages 
being softer and no longer foul-smelling, the bismuth is now 
omitted. The sleep and palpitation are much improved. 
August 9th. The improvement continues, and although car- 
diac irregularity persists, he is not sensible that his heart is 
abnormal. September 19th. All medication is now with- 
drawn, excepting the diastase which the patient is positive is 
also unnecessary. October 5th. On accidentally meeting the 
patient he announces that he is feeling in excellent condition, 
having taken no medicine for the past week. The patient 
might be classified as a buccal dyspeptic. 
II. —July 27th. R. C., aged forty years, a merchant attend- 
ing to a large enterprise, besides representing his organization 
in attempt to influence legislation, has been a pronounced 
lithemic for several years. He has been under the care of 
several physicians, who have generally pronounced him to be 
brighlique and have prescribed a vegetable diet. He complains 
of various neuralgic pains, languor, disinclination to exertion, 
irritability of temper, constipation, and flatulence. The car- 
diac first sound is booming, the second accentuated. The 
urine of sp. gr. 1018, without albumin, sugar, or casts, con- 
15 16 
tains much calcium oxalate and broken-down epithelium. He 
is directed to make use of a mixed diet, avoiding, how- 
ever, potatoes, drink one to three pints of an alkaline water 
between meals, daily, and to take outdoor exercise, short of 
fatigue. In addition he is to receive taka-diastase in two-grain 
doses with one grain of citrated caffeine after each meal. 
August ioth. The patient reports but little change save that 
constipation and flatulence are better. September 22d. The 
temper and capacity for work are much improved, and the 
work is done with less exertion, October 30th. The urine is 
now of sp. gr. 1022, with nothing abnormal excepting some 
calcium oxalate. December 9th. The patient reports great 
improvement over his condition six months ago and feels that 
he can dispense with medicine. 
III.—July 30th. V. E., aged fifty-six, army officer, has 
been troubled for several months with morning nausea, consti- 
pation, distention of the stomach and bowels, more marked 
two or three hours after eating. There was dyspnea on exer- 
tion at all times, but after meals this became more marked, 
and with it was noticed palpitation. The patient was fleshy, a 
large eater, and was accustomed to the regular use of whisky 
in considerable amount, but never to the extent of inebriation. 
Physical examination revealed an irregular and intermittent 
pulse, a shortened, high-pitched and metallic first sound of the 
heart, an accentuated pulmonic second sound, a small liver, 
the area of flatulence being still more diminished because of 
the tympanitic percussion note which extended over the entire 
abdomen; the urine contained a trace of albumin and bile. 
The diagnosis was, fatty heart, cirrhotic liver, and duodenal 
indigestion. The patient was directed to limit his starchy 
foods, bread, potatoes, puddings, and diminish the amount of 
whisky, and at the same time dilute it. The sodium phosphate 
mixture was ordered for the morning, a pill of strychnine one- 
twentieth grain, and nitroglycerin one-hundredth grain, to be 
taken thrice daily and immediately after eating, taka-diastase 
five grains in gelatin capsules. August ioth. The patient re- 
ports that the flatulence had markedly diminished, and with it 
the palpitation and dyspnea after meals; the constipation was 
lessened. The conditions, as found on physical examination, 
are as before, excepting that the abdominal distention and 
tympanitic percussion were not so marked. September 12th. 
The improvement has continued as regards the digestion, 
although the cardiac symptoms are but little better. October 
1st. The constipation is so far relieved that the sodium phos- 
phate can be omitted. The cardiac dyspnea is marked, and 
insomnia has become a prominent symptom. Beer is now 
used to the exclusion of whisky. 14th. Albumin has increased in 
the urine, and the cardiac symptoms are more severe, although 
the patient has a better appetite and does not complain of in- 
digestion. The diastase is now reduced to two grains per 
dose. 25th. No dyspeptic symptoms are elicited upon ques- 
tioning, therefore the diastase is omitted. November 16th. 
The circulatory disturbances are increasing, necessitating fre- 17 
quent changes in treatment. About two weeks after this report 
the patient died quite suddenly. This patient suffered from 
incurable diseases of heart and liver, yet the betterment of his 
dyspeptic symptoms was too pronounced to be attributed solely 
to change in diet or to other medication. 
IV. —August 20th, W. L., aged forty, lawyer, consulted me 
to be relieved of excessive flatulence, accompanied by consti- 
pation, which had existed for four weeks. He stated that he 
was a rapid eater, fond of bread and pastry, but of good hab- 
its. Physical examination revealed nothing but a sensitive 
and tympanitic abdomen. He was thin, nervous, and ener- 
getic. The urine showed an excess of alkaline phosphates. 
The sodium phosphate mixture was given, and five grains of 
taka-diastase in capsules with meals. Besides, the food was 
to be eaten slowly, masticated thoroughly, and the fluids at 
meals limited to twelve ounces. September 24th. The patient 
has been in the country since his first report, and states that he 
is greatly improved, but that at times only is he annoyed by 
flatulence. Sodium phosphate is to be omitted. October 17th. 
The symptoms are now entirely relieved, the urine is normal, 
and the diastase is omitted. This patient suffered from buccal 
dyspepsia, and a portion of the relief, at least, was brought 
about by regulating his habits of eating. 
V. —August 3d, H. S., aged forty-four, builder, three days 
ago, while bathing, suffered from cardiac pain, oppression, and 
vertigo. For some months he had noticed abdominal pains 
after meals, flatulence, and dyspnea. At times his vertigo was 
so severe that he was unable to go about unfinished buildings. 
The patient was very stout, but his color was good. He was 
a hearty eater, and was much of his time in the open air. Be- 
yond a rapid and slightly irregular heart-beat, nothing was 
found. The abdomen was fleshy, yet gave tympanitic reso- 
nance in the epigastric region. The liver was distinctly felt 
below the ribs. The patient’s habits as regards large amounts 
of beer were corrected, and he was given taka-diastase in six- 
grain doses in capsules. 10th. The patient returns, complain- 
ing that the capsules gave rise to great irritation of the 
stomach, with nausea, followed by vomiting. The dose was 
diminished to four grains and given in powder form. One- 
sixth of a grain of mercurous iodide (yellow), was given 
each night, and a half glass of Villacabras water in the morn- 
ing. September 14th. The vertigo, flatulence, and breathless- 
ness are improved. October 27th. The iodide and mineral 
water can now be omitted. The diastase is to be diminished 
to three grains during a continuance of the improvement. 
December 14th. The patient experiences so excellent health 
that all medication is omitted. 
The foregoing cases, with a number of others,* have been 
under observation a sufficient length of time for arriving at a 
fair conclusion as to the value of the remedy. In but two 
♦See The Medical Age, 1896, No. io, p. 299. 18 
instances have been noted any markedly unpleasant results 
from the administration of diastase. One is recorded above; 
the other was of a young man who came to me suffering from 
acute intestinal indigestion from dietary indiscretion, whose 
symptons were apparently unchanged, excepting increased 
nausea, after the administration of the remedy. 
Nor am I certain as to the proper dosage; it is possible 
that one or two grains may be amply sufficient; on the other 
hand, I know of no reason why the maximum dose (six grains) 
as given above, may not be exceeded with safety. Theoretic- 
ally that amount should be ample. Personally, I have come 
to prefer its administration in the form of a powder, and in 
that form it seems to retain its properties. All important is 
the diagnosis, that it shall be exact. Accessory means for the 
relief of by symptoms should not be neglected. 
We may fairly conclude that taka-diastase is useful: 
1. In many cases in which the symptoms were wrongly 
attributed to proteid indigestion. 
2. In the vast majority of cases as a substitute for the 
inefficient pancreatic extracts, malt mixtures and various com- 
binations hitherto employed. 
3. For the same relief of amylaceous dyspepsia, which, in 
the case of proteid indigestion, is obtained by acids and pepsin. 
4. As a successful method by which the patients can pre- 
serve their nutrition upon a mixed diet. 
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