Objective Symptoms

On palpation the gastric region is frequently found tender on pressure, although not actually painful, this tenderness not being limited to one circumscribed spot, but to a larger area covering the greater part of the gastric region. The contour and the size of the stomach are frequently found enlarged, although this condition is by no means characteristic of the affection in question. A splashing sound can be produced after the ingestion of water or after meals, but not in the fasting condition.

On examination of the stomach with a tube in the fasting condition it is found to be empty, or only a few cubic centimetres (five to ten) of gastric juice can be obtained. One hour after Ewald's test breakfast, or two to four hours after Leube-Riegel's test dinner, the gastric contents include an abundance of hydrochloric acid and of the ferments, the acidity being, as a rule, much higher than normally (twice or three times as high). A disc of egg albumen becomes digested in the filtrate of these contents in a very short time (sometimes in half an hour). The gastric contents obtained three to four hours after the test dinner show macroscopically that the meat has been perfectly digested, while starchy substances are yet either unchanged or very little altered. The filtrate of the gastric contents, either after the test dinner or after the test breakfast, will reveal the presence of either starch or large quantities of erythrodextrin, The addition of a few drops of Lugol's solution to the filtrate will produce either a blue color or an intense dark red.

The high degree of acidity is most commonly caused by free hydrochloric acid. The difference between the amount of free hydrochloric acid (as determined by Mintz's or Toepfer's method) and the total acidity is not great, the figure very frequently being from 10 to 20.

The motor faculty of the stomach is usually not impaired; in a few instances it is rather increased. Thus two hours after the test breakfast, or six to seven hours after the test dinner, the stomach is found to be either empty or to contain but very little food. The salol test likewise shows salicyluric acid in the urine as early as an hour after the ingestion of the salol.

The degree of acidity of the urine is frequently diminished during the digestive period. This, however, is not always the case, for occasionally the degree of acidity of the urine and of the gastric contents may be found increased at the same time.

Course

At the beginning hyperchlorhydria is most frequently intermittent. The patient may suffer from this affection for several days, weeks, or even months, becoming free from the ailment for periods of time which vary from several weeks to months or even years. After this interval the trouble either recurs spontaneously without any apparent cause, or is evoked by a severe mental shock or worry. Later on the periods of remission may become shorter, the periods of hyperchlorhydria longer, and at last this condition may become permanent.

The following is a typical case of hyperchlorhydria:

N. B. O------, 23 years old, complained for the last two and a half years of digestive disturbances which consist in pyrosis, dryness in the throat, drowsiness, and constipation. These symptoms were always present and became aggravated at certain periods of time. Patient has never lost much in weight. For the last three months patient suffered from pains in the gastric region. These appear quite regularly one and a half to two hours after meals, and last for one and a half to two hours. Before meals and shortly afterward patient feels well. Appetite very good.

Present Condition

Patient looks somewhat pale. Tongue clear, with but a slight coating at the back. Gastric region not painful to pressure; stomach not enlarged.

One hour after the test breakfast: HC1 +; acidity = 100; free HC1 = 88; dextrin + traces; erythro-dextrin + very much.

In the fasting condition, the stomach is empty.

The following represents an atypical case of hyperchlorhydria:

Patient (M. A------) has been ailing for four or five years with pains in the stomach and frequent vomiting. Sometimes she has no pains for two to three weeks, at the end of which time they reappear. The pains occur immediately after meals. She also vomits large quantities of food. On examination I found that the stomach was only sensitive to pressure; otherwise nothing could be discovered. With regard to diagnosis it was questionable whether I had to deal with an ulcer or with some functional disorder of the stomach. The regular treatment for ulcer (milk diet, rest, large doses of bismuth) was instituted, but after a period of three weeks the symptoms had not abated. The pains appeared in the same severity and the vomiting persisted. The failure of the treatment made it probable that there was no ulcer. Patient was examined one hour after a test breakfast, and the following condition found: HC1 +; acidity = 100; free HC1 = 86. In the fasting condition the stomach was empty. Hyperchlorhydria was diagnosed, and the treatment arranged accordingly.

The patient now rallied very quickly and recovered entirely.

Prognosis

The prognosis in hyperchlorhydria is, as a rule, quite good, except in some cases of a very protracted and severe nature, in which the prognosis regarding the complete disappearance of this condition is bad, although even then there is no danger of a fatal issue.

Diagnosis

The diagnosis of hyperchlorhydria is made either from the subjective symptoms alone or from these in connection with the results of a chemical examination of the gastric contents. The subjective symptoms characteristic of hyperchlorhydria are:

1. Pain, appearing constantly about two to three hours after meals. Relief from the pain is felt immediately after the ingestion of an alkali, or a little while after the partaking of some food, especially albuminous.

2. Appetite and thirst are either in a healthy condition or increased.

3. No marked cachexia.

4. Constipation.

Although all the symptoms mentioned make the diagnosis of hyperchlorhydria probable, it can be made with certainty only after repeated examinations of the gastric juice.

1. On examination of the stomach in the fasting condition, the organ is either found empty, or contains only a few cubic centimetres of juice.

2. One hour after Ewald's test breakfast the degree of acidity is found greatly increased, owing to the large amount of free hydrochloric acid.

Differential Diagnosis

In making the diagnosis of hyperchlorhydria, we shall have to exclude all conditions which are liable to give similar symptoms; for instance, gastric ulcer, permanent hypersecretion, and biliary colic. The characteristic symptoms of ulcer have been described above, and we shall here limit ourselves to the remark that the pain of an ulcer, even if this is accompanied by hyperchlorhydria, does not disappear entirely after the ingestion of large doses of alkalies. Permanent hypersecretion is very frequently accompanied by vomiting, and the most intense attacks of gastric pain appear, as a rule, in the middle of the night or early in the morning. On examination with the tube, the stomach in the fasting condition is found to contain considerable quantities of gastric juice (80 to 100 c.c). Biliary colic, not accompanied by jaundice or by a considerable palpable swelling of the gall bladder, may give rise to errors as to the real cause of the pain. In biliary colic, however, the pains, as a rule, appear later than in hyper-chlorhydria (four to five hours after a meal), and are not eased by the ingestion of food or by alkalies.

Another means of differential diagnosis is that the pains in biliary colic most commonly extend over the right epigastric and hypochondriac regions, whereas the pains of hyperchlorhydria are felt more in the middle of the epigastrium, although sometimes radiating farther to the right.