THE lUU'l'ISH .JOIKNALOP

DERMATOLOGY AND SYPHILISMAY, 1<):J5.

FRACTIONAL GASTRIC ANALYSIS IN DISKASES OFTHE SKTN: FURTHER OBSERVATION IN 316

CASES, WITH SPECIAL REFERENCETO ROSACEA.

W HERBERT BROWX, Ml).,PhysR'ian fur Diseases of the Skin, Victoria Infirmary and Royal Hoapital

for Sick Children, Glasgow ;

MARY S. SMITH, -MD.,Assistant Physician, Skin litspartinent, Victoria Infirmary and Royal Hospital

fur Sick Children, Glasgow ; and

ALLISON B. McLACHLAN, M.D.,McCall Anderson Letttiirer in IX'rinatoIogy. University nf (llaagmv ; Physician

for DisPiLsea of tiic Skin, Western Intirmary anil Stdbhill, (JIHHJ OW.

RvLE and Barber(') were the first in this country to employ the frac-tional method of gastric analysis in the investigation of diseases of theskin. In their original research in. 1920 they confined themselves to theinvestigation of rosacea, the skiu-disease particularly associated withgastric disturbance. Twelve cases were examined and the results werestartling :

In 5 of the 12 cases, or 41%, there was complete achlorhydria,., 2 ,, ,, 16% „ extreme hyponhlorhydria,

i. e. in 7 of the 12 cases, or 58%, there was complete or marked hypo-chiorhydria. They obtained in addition very satisfactory results by theadministration of large doses of dilute HCl,

As a result of this couuuunication, one of us. Brown(^). pursued furtherinvestigations along siuiilar lines, and in 1928 published the findings in50 cases of rosacea, aud in 50 cases of dermatoses other than rosacea,with the followiug results :

VOL. XLVII. P

182 W. H. BROWN, M. S. SMITH AND A. D. McLACHLAN.

T A B L E I.

Elosacea. Other cases.

Complete achlorhydria . 7cases,or 14%lg^o, . 6case8,or 12%l _(,,Marked h\T)ochlorhydria 8 „ 16%( /« . 5 „ 1 0 % / ' ' °SUght ' ,, ' . 13 „ 26% . 9 „ 16%Nonnal acidity . . 18 „ 36% . 17 ,, 34%HypercUorhydria . 4 ,. 8% . 1 3 „ 26%

The cases investigated to contrast with the rosacea group were mainlyacute widespread derinatoses. They showed a definite tendency tohyperehlorhydria.

The results in the rosacea group support-cd in the rnam those of Ryleand liiirbor, 5H% having a subacidity if we include cases witli a slighthypochlorhydria. Only 30%, however, had either a complete achlor-hydria or a marked hypochlorhydria as compared with Ryle and Barber's58%, and only 14% a complete achlorliydriii as (-ninpared witli tlioir41%. The siiiali nnmber of cases examined hy Ryle and Barl)er abnostcertainly accounts for this difference in percentage results.

I t is of interest to note that Bennet and Ryle(^), in an investigation of100 healthy medical students, found 4**,, with a complete achlorhydriaand H% with hyperchlorhydria.

The arbitrary terms used in recording our results are as follows, basedin terms of N/*** NaOH ;

Complete achlorhydria . Complete absence of free HCl.Marked hypochlorhydria . Free HCl under 20.

f , •• I „ from 20 to 30.Low normal IKornml acidity . ,. from 30 to 50.Hyperchlorhydria . ,, over 50.

In Table II, Brown's figures for rosacea are compared with those oftwo more recent workers, RulisonC*) and Eastwood(^).

If wo include the cases showing only a slight degree of liypoclilorhydria(low normal of other workers), Rulison finds 70% with hypochlorhydriu.and Eastwood 48%, as compared with Brown's 56%. We think, however,that in making a comparison of our own cases with the results of otlierworkers, we will get a truer presentation of the facts it' we compareparticularly the percentage of cases with achlorhydria and marketi

FRACTIONAL GASTRIC ANALYSIS IN DISEASES OF THE SKIN. 183

Complotpachlorhydria

Marker 1hyp»H-hlorhydria

Lnw nonniilXormiil ofiilityHyperchlorhydria

Total

7

8

K)184

50

Brown.caaea.or 14%)

i.. 16% 1

,. 2fi%3fi%

» 8%

cases.

TABLE II.KMV

. 4 caeea.30%

• 1 1

. 9

. 21 „

. 5

.leases.

H-IKKl.

or 8%)30%

2 2 % )

1 8 %4 2 %1 0 %

RiillKon.7 cases.

17

H10

r>50 cases.

or 14%

3 4 %

22%2 0 %

1 0 %

hypochlorhydria, and emphasize any difference rather than include caseswith slight hypochlorhydria. Thus Eastwootl and Brown get tlie identicalresult, viz. 30% with achlorhydria and marked hypochlorhydria, andRulison the higher figure of 48%. Rulison gives a shredded wheatbiscuit and two glasses of water as the test-meal, instead of the standardoatmeal test breakfast of this country, and considers as the nonnal rangefor free HCl anything from 30 to 45. The difEerent nature nf the testbreakfast may eicplain the larger percentage with hypochlorhydria inRuUson's cases.

Since 1925 we have continued to investigate the gastric findings inrosacea, and iu the present paper record the results obtained by thefractional methotl in a further series of 150 cases of roaacea and 166 casesof dermatoses other than rosacea.

In Table III the results obtained in Brown's original 50 cases of rosaceaare compared with those of the present series of 150.

TABLE I I I .

Rosaooa (50 cascu). Rosacea (150

Complete achlorliydria . 7 cases,or 14% 1 n.^. . 18 cases,or 12%1Marked hypochlorhydria 8 ,, 16%f /" . 23 „ 16%fSlight • ., • . 13 „ 26% . 32 „ 21%Xorniiil acidity . . 18 „ 36% . fi3 „ 42%Hyprrchlorhyilria . 4 „ ' 8% . 14 „ 9%

The percentage figures are strikingly similar, and may be taken as therecords for a series of 200 cases of rosacea. Our figures are practicallyidentical witli those of Eastwood.

In Table IV the percentages for the present series and the totalpercentages, including Brown's original cases, are compared.

184 W. H. BROWN. M. S. SMITH AND A. D. McLACHLAN.

TABLE IV.

Kosacea(new series,

150cases).

RoBacea(total,

200easea).

other than Other thanrosacca rosacea

{new aeries, (total,161) cases). 216 cases).

Complete achlorhydria . 12%Marked hypockiorhydria 16%SHght „ ^ . 21%Noniial acidity . . 42%Hyperchlorhydria . 9%

28%' 13%15%

23%40%9%

28%- 16%

33%16%

19%14%33%18%

35%

It wUl be noted in the above table that the total percentages of caseswith achlorhydria or marked hypochlorhydria is actually lower in therosacea group (28%), as compared with that in other tlerniatosea in bothseries (38% and 35%). If we include the cases showing only a slighthypochlorhydria it raises the percentage in rosacea to 51%, which is 2%higher than that in the other derniatoses (49%). Bnt, as previouslymentioned, we think it is of greater importance to compare only themore marked degrees of hypochiorhydria in each series.

Since the first investigations by Ryle and Barber, and Brown, theprevalent belief has been that achlorhydria. or extreme hypochlorhydria,is a distinctive feature of rosacea. The results, as shown in Table 1\ ,seem to show that this assumption is incorrect, and that such a degreeof subacidity is just as frequent in chronic dermatoses in general.

Comparing the results in Brown's original series of dermatoses otherthan rosacea witli the present 166 cases, it will be seen that there is adistinctly higher percentage of cases with hypercblorhydria in the former—26%—as compared with 18% in the latter. Tbis difference wouldappear to arise from the fact that acute widespread dermatoses werespecially selected in the original series, while in the present series, no suchselection was made, and this group consists mainly of chronic conditions.

In Table V the findings in the dermatoses other than rosacea are shownin more detail. Apart from rosacea, the number of cases in each of thesedermatoses is too small to be of any value for statistical purposes in theseparticular affections, but, when arranged with rosacea in tabular form,according to the percentage showing achlorhydria and extreme hypo-chlorhydria, the results are striking, in that rosacea is found to occupyan inconspicuous position on the table. It is of interest to note how thediseases of allergic origin—nrticaria, Besnier's prurigo—are found towards

FRACTIONAL GASTRIC ANALYSIS IN DISEASES OF THE SKIN. 185

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186 W. H. BROWN, M. S. SMITH AND A. D. McLAOHLAN.

the bottom of the table. This is contrary to expectation, and contraryto the findings of others (Bray{*), Oliver and WilkinsonC), abst.).

Gastric analyses were carried out on more than one occasion in 41cases. The number of examinations varied from 2 to 6, and the periodof observation from 3 days to 10 years. Tbe following are tbe results.

In 27 of the 41 cases, or 66%, the results were classified in thesame group as before.

In 9 of the 41 cases, or 22%, the results were classifieil in a highergroup than before.

In 5 of the 41 cases, or 12%, the results were classified in a lowergroup than before.

The findings in the repeat analyses are given in more detail in Table VI.

TABLE VI.—Repeated Analyses. Group Urtchatu/ed (27 Cases).Mnxlmijin Mlniniiiui MaximumiiumlxT of t>*'rl">l "f iMTitMl of

oRlimiitiims. (jbHiTvntiini, nliscrvBtioii.4 . 1 moiitli . 2 years.2 . 3 davH . 10 months.

Hypertrhlorhydrift .Normal aciditySlight hypochlor-

hydriaMarkcci hypochlor-

hydriaComplete achlor-

hydria.

Sum^r of

102

2

4

9

MiiiimiimiiiimlMT II

tiittlniat l«ii22

2

2

2

2 . 5 months . 8 „

2 . 1 month . if „

4 . 3 months . 4 years.

The prominent feature in these observations was the general tendencyfor the gastric analysis to remain the same, or to show comparatively littlechange ; achlorhydria, extreme hypochJorhydria and hyperchlorhydriagenerally remained unchanged.

In 14 cases, however, in which similar observations were made, variationoccurred, necessitating putting them into a different group. The actualfigures for the free HCl content in these cases are given in Table VTI.

In 75 cases of rosacea special attention was also paid to the followingadditional points ; the presence or absence of focal sepsis in teeth ortonsils, abnormality of the scalp in the direction of excessive oiliness orscaliness, the presence or absence of menstrual disturbance in womenand the presence or absence of symptoms of gastric disturbance. Laterin the investigation the frequency with which dentures were worn becauH)apparent, and a special note was made regarding their presence or absence.The age of the patient was also noted and the duration and severity ofthe disease.

FRACTIONAL GASTRIC ANALYSIS IN DISEASES OF THE SKIN. 187

TABLE VII.—Repeated Atmlyses. Group Clianged (14 Cases).

IVriod of tMimatloii 1. KxtiuiatiiHi 2. Estlmat.iuii 3. EstiiutttiurU. EstUiiatkiii 5. EstlmatlonO.'"^'- iihscrvatioii. Frr-e HCl. FriM? HCl. Free HCl. Free Ht'l. Free HCl. Free HCI.

1 . 1 month . 42 . 582 . 1 year . 25 . 26 . 353 . 4 months . 20 . 504 . 10 „ . 15 . 305 . 10 „ . Nil . 34 . 25 . 20 . .ViV . 8fi , 9 „ . ,. . 187 . 9 , , . 10 . 308 . 4 , , . Nil . 5it . I ypar . " . Nil . Trace . 10

10 . 4 months . iK) . 30 . 381 1 . 5 . , . 55 . 3012 . 7 years . 40 . 15 . 20 . 2013 . fi „ . 35 . 27 . 26 . 2514 . 6 months . 30 . 30 . 10

From these observations we find that: '1. The majority of the patients examined were women.2. The ages ranged from 23 to 55, the average being 35.3. The duration and severity of the disease did not appear to bave

any relation to the gastric HCl content.4. The sex of the patient seemed to have an infiuence on the gastric

finding. Of the 10 men examined, 5 were found in the hyperchlorhydriagroup, which consisted of only 8 patients. This preponderance of hyper-chlorliydria in men over women is in agreement with the tindinga ofothers (Vanzant et alia(^) and Bell(")).

5. 51% of the patients showed the presence of focal sepsis in the teethor tonsils or both. (Stokes and Beernian(^°) found 51*9% with definitefocal infection in their series of 83 rosacea patients.)

6. 55% had au excessively oily or scaly scalp, more usually scaly thanoily,

7. In many the face became worse just before or during menstniation,but menstnial disturbance was present in only SO",,. (This agrees closelywith the records of Hachenburg("), who found menstrual disturbance in6 out of 26 women with rosacea.)

8. 77% had dentures or no teeth.9. Symptoms of gastric disturbance were present in 61%, being practi-

cally constant in the hyperchlorhydria gronp. The percentages for theindividual groups are given in Table VIII. (Stokes and BeermanC")found 66"5% with gastro-intestinal disturbance in their series.)

188 W. H, BROWN, M. S. SMITH AND A. D. MCLACHLAN.

TABLK V I I I .

Of the 9 cases with eomplete achlorhydria. 43% had gastric symptoms.„ 17 ,, marked hypochiorhydria 41% „ „„ 18 „ sUght " „ " 70%„ 23 ,, normal acidity 65% „ „„ 8 „ hyperchlorhydria 90% „ „

DISCUSSION.

A subacidity is frequent in rosacea and in other chronic dermatoses.It is frequent also in many other general medical conditions (BcUC),Wilkinson and Oliver. abst.(^-")- Moore( 3), etc.). It frequently followsthe infectious fevers, pneumonia, influenza, typhoid, paratyphoid, malaria,etc., and is found in sucli debilitating diseases as rheumatoid arthritis,diabetes mcllitus, tuberculosis, hyperthyroidism, hypothyroidisni, neuras-thenia, etc., and in the various toxsemtas, e.g. the toxaemias of pregnancy.In pernicious ansemia and subacute combined sclerosis achlorhydria isthe rule. It is a feature also of the type of ansemia described variouslyas naicrocytic, non-megalocytic, or simple achlorhydric ansemia (Witts(i*))-and of the condition known as gastrogenous diarrhoea and of certainglossitic and ulcerative afiections of the mouth.

According to Ryle( ) the gastric habitus of the individual is closelyrelated to the physiological habitus. He cites the findings of Campbell('®)and Oonybeare( ''), who, " examining independently the same group ofhealthy medical students by means of the fractional test-meal andradiographically were able to demonstrate a definite relationship betweenhypertonus and hyperacidity on the one hand and hypotonus and hypo-acidity on the other. They also correlated these phenomena with gastricmotility and the general phj'sique of the individual; hypertonus, hyper-acidity, and rapid emptying (barium) occurred most frequently in menof the broad-chested, vigorous, athletic type; hypotonns, low acidity andslow emptying (of barium) for the niost part in men below the averageof physical development, and not taking regular exercise. Between theseextreme types there was a much larger group showing normal tonus andnormal acidity ".

The foregoing presents one possible explanation of the subacidity foundin chronic dennatoses, since the pain, discomfort or itching of a chronicdermatosis would tend in time to produce a depressed, debilitated, hypo-tonic individual. In the allergic complaints in our series, however, e.g.

FRACTIONAL GASTRIC ANALYSIS IN DISEASES OF THE SKIX. 189

Besnier's prurigo, where one would expect the hypotonicity and thehypoacidity to be most marked owing to the long dnration and distressingnature of the complaint, the subacidity was least marked of all thedermatoses. Perhaps these were vagotonic individuals who started outwith a hyperchlorhydria.

The rosacea patient, according to Rulison, is typically a person withpoor muscle tone and a low blood-pressure ; Eastwood also noted thelow blood-pressure in many rosacea patients. On the other hand, it islikely that some degree of gastritis is always present in view of the dietaryindiscretions indulged in by the patient. Hurst(^*), in a recent article,states that in the production of achlorhydria. gastritis and constitutiomilfactors are of equal importance : "' without gastritis there is no achlor-hydria, but gastritis does not cause achlorhydria unless the patient ispredisposed by having the hypersthenic gastric constitution. Ga.stritisin the presence of the hypersthenic constitution may lead to duiMlenalulcer and gastric ulcer, and a gastric ulcer may become malignant, butachlorhydria does not develop ".

Although the duration and the severity of the disease in rosacea appearsto bear very little relation to the gastric HCl content, this may beexplained by the constitutional factor. In a hypersthenic individualwith hyperchlorhydria the presence of chronic gastritis may lead toreduction of the gastric acidity without bringing it below h^-perchlor-hydria level.

SUMMARY.

Gastric analyses have been performed in a fuither series of 150 cases ofroaacea, and the findings compared with those of a pre\-ious investigationof 50 cases. The results show a very striking similarity (see Table 111),

Our results compare very closely with those of Eastwood (see Tahle II).For comparison, gastric analyses have been performed also in a new

series of lfifi ca.ses of dermatoses other than rosacea.The figures in Brown's original paper have been added to those in the

present series, making a total of 200 cases of rosacea, and 216 cases ofdermatoses other than rosacea (see Table IV),

The percentage of cases showing achlorhydria and extreme hypochlor-hydria is lower in the rosacea group, viz. 28%, as compareil with 35% inother dermatoses.

Gastric analyses were repeated on more than one occasion in 41 cases

190 W. H. BROWN, M. S. SMTTH AND A. D. MoLACHLAN.

over periods ranging from a few days to 10 years. The general tendency-was for the gastric analysis to remain the same, though the cliaicalcondition improved or got well. In only 3 cases was there any verymarked difEerence.

Symptoms of gastric disturbance were present in 61% of a gronp of75 patients with rosacea. The severity of the symptoms varied con-siderably in degree. In some they were negligible ; in others, amountedto actual pain. The most common complaint was a sensation of fullnessafter food, with flushing of the face. The degree of flushing also variedvery much.

A much moTt? extensive study of the gastric analysis, as detailed in thispaper, has led us to conclude that marked subacidity is not a featurepecuhar to rosacea as was originally thought. A degree of subacidityseems to be a feature of chronic dermatoses in general. We have aot,however, investigated a sufficient number of cases in each particulardisease to be dogmatic on this point.

These findings do not detract from the well-established fact that strictdietetic treatment in combination with large doses of dilute HCl bringsabout marked improvement in rosacea.

REFERENCES.

(1) RYLB ami BARBER.—Lancet, 1920, ii, p. 1195.(2) BROWN.—firii. Joum. Derm, and Syph., 1925, xxxvii, p. 213.f3) BENNET and RYLE.—(?«)/'a Hosp. Sep., 1921, lxxi. p. 286.(4) RULISON.—Ani^r. .Joum. Med. Sri., 1927, clxxiv, p. 6().(5) EASTWOOD.—Brit. Joum. Derm, and Syph., 1928, xl. No. 3, p. 91, and No. 4,

p. 148.(6) BnAY.—Berent Adrnncus in Allergy. London : ("Ihiirchill, 1931.(7) OLIVER and WILKINSON.—QtiaH. Jmirn. Med., 1933. xxvi, p. 431.{8) VANZANT, ALVAREZ, EUSTERMAN, DUNN and BERKSON.—Arch. Int. Med.,

1932, xlix, p. 345.(9) BELL.—Gwy's Hosp. Rep., 1922, Ixxii, p. 302.(10) STOKES and BEERMAN.—Arch, of Derm, and Sijph., 1932, xxvi. No. 3, p. 47S.(11) HACHENBtrRO.—Derm. \Vnrhen.fi-hr., I93I, w'n, pp. 165 and 197.(12) WILKINSON and OMVEK.^LWW(•*>/, 1931, i, p. 66.(13) MOORE.—«nV. Med. Joum., 1932, i, p. 363.(14) WITTS.—(?w!/'s Hosp. Rep., 1930, Ixxx, p. 253 ; 1931, Ixxxi, p. 193.(15) RVt,E.—Lattccf, 1925, i, p. 641.(16) BAIKD, CAMPBELL and HERN.—Ou]fa Hosp. Rep., 1924, lxxiv, p. 339.(17) CAMPBELL and CONYBEARE.—Ibid., 1924, lxxiv, p. 354.(18) HuR3T.—ifn(. Med. Joum., 1934, ii, p. 665.