Jan., 1942] ACHLORHYDRIA AND ANAEMIA: BHENDE 13

Table I ACHLORHYDRIA AND ANJEMIA 84 cases An analysis of 79 cases Diagnosis Number of By Y. M. BHENDE, m.d. (Bom.) cases (From the Department of Pathology, P. G. Singhanee Anaemia 79 Hindu Hospital, Bombay) Chronic gastritis 2 Chronic 1 ' appendicitis inormal gastric juice contains hydrochloric Dyspepsia' 2 acid, pepsin, rennin and the intrinsic factor of Castle. The secreting function of the stomach It is seen at once that the, bulk of the cases may be investigated by means of a fractional is formed by the anaemia group; in fact, it was test meal. As ordinarily performed, the the anaemic state of these patients that neces- examination gives information only as to the sitated their admission to the hospital for hydrochloric-acid formation; the presence of investigation. A detailed analysis of these pepsin and rennin can be recognized by in vitro 79 cases of anaemia, with special reference to test, but for the detection of the intrinsic the state of their gastric secretion, forms the factor in vivo tests are necessary. basis of this communication. each case a detailed Davis (1931) by using the histamine test Procedure.?In clinical was taken. The blood was meal was able to demonstrate that the failure history scrutinized of all the absolute a the stomach function was probably progres- minutely, recording indices, van den and the red cell sive; his investigations (confirmed by many Bergh reaction, fragi- Wassermann or Kahn tests were done others) established the fact that, as a general lity test; rule, the ferment factors of the stomach fail as a routine and, wherever indicated, other A marrow after the hydrochloric acid; and whenever there bio-chemical studies. sternal biopsy is was done as a routine in all the cases. The absence of free hydrochloric acid, one may were a presume some diminution in the ferments as well. urine and the faeces subjected to detailed Consequently, in clinical practice, it has become examination in every case, and the faeces very customary to study only the acid secretion of carefully searched for parasitic ova. For the the stomach. In the study of anaemia, the gastric analysis, in the first instance, a frac- determination of the of tional oatmeal gruel test was employed and, if acid-secreting capacity ' the this no free' the stomach has become an established proce- displayed acid, procedure dure; the finding of complete absence of acid was repeated by the method recommended by Jn use the stomach contents has assumed a diag- Castle and Minot (1936); this entails the nostic importance in the differentiation of the of dilute alcohol as the test meal and histamine anjemias and may be of some value in their as the special stimulus. treatment. Results.?Tables II and III show the arrange- ment of the cases under the headings of true By achlorhydria is meant the absence of free and false achlorhydria and their diagnoses in hydrochloric acid in the as gastric juice, judged detail :? by the production of a when yellow colour, Table II dimethyl-amino-azo-benzol ' ls (Topfer's reagent) added to a specimen of the secretion. The True achlorhydria term 44 cases achylia gastrica was introduced by Einhorn to indicate the absence of both acid and of ferment.11892) Since the Number actual measurements of the Diagnosis cases ferment pepsin are rarely made in clinical prac- tice, the terms achlorhydria and achylia gastrica Pernicious anaemia 13 anajmia with com- have become synonymous. In this we Pernicious subacute 6 paper, bined degeneration of the cord. have used the term to indicate the ' achlorhydria macrocytic ansemia 13 absence of Tropical free' acid (di-methyl); to those Idiopathic hypochromic anaemia (Witts') 5 cases ' which do not show free' acid even after Normocytic anaemia of varied origin .. 4 a maximum histamine we have Ankylostomiasis 1 stimulus, given 1 the name true to which do Pellagra achlorhydria; others Carcinoma stomach 1 n?t show 'free' acid with the usual fractional ?atmeal gruel test, but do so after the histamine stimulus, we have applied the term false achlor- Table III hydria. False achlorhydria Material.?In view of the above in 35 cases a criteria, series of 418 medical we have general cases, Number of pome across 84 with The patients achlorhydria. Diagnosis cases. Percentage in our series works out to 20.09; and ~h*s figure agrees with that of and anaemia .. 31 Dhayagude Tropical macrocytic _ (1939) for Bombay. Table T gives Idiopathic hypochromic anaemia (Witts') 1 the||hadilkar .. 2 classification of the cases to the Normocytic anaemia of varied origin according anaemia: cirrhosis liver 1 ^agnosis :? Normocytic 14 THE INDIAN MEDICAL GAZETTE [Jan., 1942

Discussion.?Seven, out of the 79 cases, sec- Oppler in 1895. Hurst (1923), Christian 1 reted free' acid when the gastric analysis was (1925), Eggleston (1931) and others believe repeated with the alcohol meal without the that achlorhydria is a precursor of pernicious histamine stimulus; consequently, they have been grouped under false achlorhydria. It Table IV that 28 of the 72 is worth noting cases?38.8 True achlorhydria per cent?showed the achlorhydria to be of the 44 cases false type, and the results strikingly illustrate of the histamine the importance using stimulus Number of in years for the demonstration of the true of Ages cases ' inability the stomach to secrete free' acid. Pernicious anaemia contributes the largest 11 to 20 i figure to the true achlorhydria group. Cahn 21 to 30 11 and von Mehring (1886) were the first to 31 to 40 .13 41 to 15 the absence of acid in the 50 demonstrate stomach 51 to 60 4 contents in pernicious anaemia. The invariable occurrence of true achlorhydria in that disease was fully established by Hurst. However, we anaemia, combined sclerosis, chronic arthritis and carcinoma would like to emphasize the fact that some stomach. Table V shows the pre- undoubted cases of genuine tropical macrocytic valence of the gastro-intestinal symptoms in our anaemia do exhibit a true achlorhydria; though, cases:? to the small number of cases we owing studied, Table V refrain from drawing any percentage figures. This is quite contrary to the usual orthodox 79 cases teaching after Wills; it means that the final differentiation of tropical macrocytic anaemia Symptom True achlorhydria False achlorhydria from pernicious anaemia cannot be made by the alone. The factors that gastric analysis help in Total cases ..*1 44 cases 35 cases cases are difficult cases?and such not very rare Stomatitis or a; 15 10 ??are (a) unequivocal signs of involvement of previous history of it. the central nervous system, (6) a sternal marrow Loss of appetite 4 9 and response to liver extracts. We biopsy, (c) Vomiiing .. 3 5 believe that an unequivocal demonstration of Diarrhoea or a 7 10 the affection of the central nervous a previous history ' system,' preponderance of the haemoglobinized megalo- of it. blasts in the marrow fluid, and a quick and ready response to the purer brands of liver extracts In assessing the significance of achlorhydria the anahaemin for to be in (of type, instance), with ansemia, one has to be very particular in favour of the diagnosis of a case of macrocytic considering which of the conditions?lack of anaemia as pernicious. acid or ansemia?is the primary. Apperly The occurrence of true in idio- (1936) states that when the red blood cell count achlorhydria ' pathic hypochromic anaemia has oeen observed is about half the normal figure, free' acid dis- by many workers. Witts (1930), Davis (1931) appears from the stomach. Alvarez and Carlson and Hartfall (1934) have shown that true (1936) found that when the haemoglobin falls is found in over 80 cent of the achlorhydria per below 75 per cent free acidity is reduced, cases. In this condition at least one can say McRobert, Reddy and Subramanium (1940) that the impaired gastric secretion with its record recoveries from histamine-fast achlor- consequent loss of appetite, indigestion, and im- hydria with improvement in the associated of iron the ? proper absorption determines anaemic anaemia. However, no definite conclusions can conditions. be drawn, for the present,' regarding the pro- The increased frequency of true achlorhydria duction of any ill-effects by the achlorhydria, in the upper decades of life has been commented though most clinicians agree to the exhibition of on by many (Faber and Lang, 1908; Davies hydrochloric acid in promoting recovery. and James, 1930; Bloom and Poland, 1933). It will be seen from table IV that the largest ; Siwimary number of true achlorhydrias falls in the ages between 41 and 50. (1) An analysis of 79 cases of achlorhydria ? is given. . ? Whether achlorhydria, per se, leads to any gastro-intestinal symptoms has not been defi- (2) It is stressed that the histamine stimulus must true nitely settled. Faber and Lang (1908) mention always be employed to distinguish from false epigastric distension, nausea, vomiting, gases, achlorhydria. It is out some cases of nervous symptoms of all sorts, diarrhoea, and (3) pointed that tropical anaemia do exhibit true mucus in the stools. A more definite syndrome, macrocytic ascribed to achlorhydria, is often referred to as achlorhydria. ' gastrogeaous. diarrhoea ', first described by (Concluded on opposite page) ! ; (Continued from previous page) I thank all my colleagues at the hospital for their co-operation; to Dr. J. C. Patel, especially I am grateful for constant help and many suggestions. I also thank Dr. R. Row, m.d., D-sc. (Lond.), the Director of our hospital, for the permission to publish this paper, and much guidance in its preparation.

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