DISCUSSION.

DR. SHROPSHIRE: I am afraid it is proverbial in this Association that I cannot hear malaria mentioned without rising to discuss it. Nevertheless, I must ask permission to say a word or two, because I believe nothing could be of more value to the members of the Association than papers such as we have just heard. All of us come in contact with malarial subjects every day, and there is no more vital or important question than how to cure the disease. Dr. Moore has given us data for the comparison of two remedies-one tried and old and known to be good, and the other new but very much lauded by its champions. The facts he has laid before us are extremely valuable. I can corroborate what he has said in many respects, while there are other points on which I have arrived at different conclusions. He spoke of two forms of malaria, but there is a third form on which he did not touch, and that is the form in which methylene blue is said to be most useful. Personally, I have found it quite as efficient as quinine in most cases of malaria, though not so quick in its action; but in the case of pregnant women, where the effect of quinine is feared, methylene blue has a special use. My experience has led me to believe that the affinity of the drug for the malarial parasite constitutes its greatest value to us, and possibly quinine acts in the same way. I have had a few cases-one a tuberculous one-in which the quinine failed to eradicate the parasites from the blood. Temporarily the symptoms disappeared, but the moment the quinine was stopped the parasites returned. This may have been due to the toxines of tuberculosis. However, when I tried the methylene blue it proved more efficacious. I have been requested, while on the subject, to ask Dr. Moore whether he has ever used a combination of methylene blue and quinine?

DR. MOORE: I have never tried any combination of the two drugs. There are a number of other points on which I should like to have dwelt if time had permitted. I quite agree with the doctor as to the value of the methylene blue in the case of pregnant women.

ACHYLIA GASTRICA.

J. W. MCLAUGHLIN, M. D.,

AND

S. M. MORRIS, M. D.,

GALVESTON, TEXAS.

While we are all familiar with the conception that a deficiency of gastric juice, both in quantity and quality, often exists, it comes rather as surprise to many of us to have our attention called to the fact that cases are by no means infrequent in which there exists an absolute absence of gastric secretion, and, furthermore, that these cases often enjoy fairly good health for long periods of time and exhibit few or no symptoms whatever referable to the stomach, and may finally consult the physician for troubles apparently due to other causes. We desire, therefore, to add our small contribution to the literature of this very interesting condition.

By the term achylia gastrica, which was first proposed by Einhorn, of New York, we refer to that condition of the stomach in which it fails to respond to the normal stimulus of the food by a secretion of gastric juice, whether this condition be due to organic disease of the stomach or to a disturbance of the nervous mechanism of secretion or as a complication of some other disease. We are aware of the fact that this is not a wholly scientific manner of discussing the subject, but our apology lies in the fact that we believe that at the present time it is impossible to differentiate between a primary and a secondary achylia in the majority of cases one meets with.

PATHOLOGY.

As these cases rarely die of the affection and come to the autopsy table, but little is definitely known concerning the pathology. It appears, however, that there may exist an atrophy of the glands of the stomach due to or associated with a growth of connective tissue

between the tubules, or the glands may undergo atrophy or destruction secondarily and in connection with the various cachexias, such as those resulting from Bright's disease, carcinoma, tuberculosis, pernicious anemia, etc. In cases of profound anemias associated with gastric atrophy, we do not think it can be definitely settled which is the primary trouble in most cases. It may happen sometimes that small pieces of the gastric mucosa are washed out during lavage, and microscopical examination may enable one to form some opinion of the nature of the anatomical changes which are going on at least in part in the mucosa. We believe, also, that the disease may be purely functional, but as very little is definitely known concerning the nervous mechanism of the gastric secretion it is impossible to even venture an opinion as to how this occurs.

ETIOLOGY.

About this we confess we know almost absolutely nothing.

SYMPTOMS.

It appears that this condition may exist for a variable length of time with no symptoms whatever, but usually some disturbance of the digestive functions exists; but it is rarely of such a character as to enable one to make a diagnosis of the condition therefrom. We shall, therefore, only discuss the symptomology briefly. Patients may complain after eating of a heaviness, distress or even of actual pain over the region of the stomach usually appearing immediately and lasting for an hour or so. There may be nausea, occasionally vomiting, and a little belching of gas. A very prominent feature in many cases is a tendency to frequent, sharp and sometimes obstinate attacks of diarrhea, particularly in those cases in which the motility of the stomach is impaired. Headaches and neuralgias may be present, and neurasthenic symptoms be prominent and varied in character.

DIAGNOSIS.

This can only be definitely established by giving to the patient a test meal and examining chemically the contents of the stomach.

A number of test meals have been proposed by different authors, of varying degrees of complexity and demanding more or less digestive work of the stomach; but in our experience the Ewald test meal of bread and water is wholly satisfactory in the great majority of cases of stomach trouble. This consists of two and a half ounces of stale wheat bread and 350 c. c. of water, and is taken upon a strictly empty stomach, best in the morning. Each mouthful of the bread should be thoroughly masticated before being swallowed and the water taken between mouthfuls. One hour exactly after the beginning of the meal the stomach tube is introduced and the patient instructed to strain, which usually results in expelling a portion of the contents of the stomach through the tube into a glass provided for its reception. This is marked No. 1 and set aside for examination. Two hundred c. c. of water are poured next into the stomach through a funnel attached, syphoned out, poured back and syphoned out again, with a view to thoroughly mixing the water with the remaining contents of the stomach. This is collected in a vessel, allowed to settle thoroughly, and the clear supernatent fluid afterwards examined for the amount of its total acidity. Contents No. 1 is measured, filtered and examined for the various elements of normal gastric secretion, such as free HCl, combined HCl and the acid salts, each of these factors being determined quantitatively, then examined for pepsin, the milk curdling ferment or so-called lab ferment, and if necessary also for their zymogens; and if necessary for the products of the digestion of these ferments, such as syntonin, peptones, maltose and the presence or absence of starch. Often also, it is necessary to look for the presence of abnormal substances resulting from fermentative changes in the stomach, such as acetic, butyric and lactic acids, and for bacteria, fungi, blood, etc. Since these methods are fully described in all works on this subject, it would be unprofitable to describe them here further than to say that the filtered gastric juice is titrated with a deci-normal solution of sodium hydrate with di-methylamido-azo-benzol as indicator for the free HCl, and in the presence of phenol-phthalein for the combined acid and the acid salts, the sum of the two titrations representing the total acidity. The nor

mal gastric juice one hour after the test meal has an acidity of 15 to 20 for the free HCl—that is, requires from 15 to 20 c. c. of the deci-normal alkali to neutralize the free HCl in 100 c. c. of the gastric juice, and has a total acidity of 55 to 60. In achylia gastrica, however, we find an absence of HCl, either free or combined, and only a faint total acidity, varying between 3 and 10, an amount of acidity which the bread and water alone will often show with phenol-phthalein as indicator, showing that absolutely no HCI whatever is being secreted by the stomach. No traces of the pepsin or the milk curdling ferments can usually be found. Owing to the absence of the HCl, salivary digestion goes on unimpeded in the stomach and tests for starch are negative, while the tests for maltose are very pronounced. The quantity of gastric juice obtained by expression is also usually very small, 10 to 20 c. c., and is obtained with difficulty. Inspection of it shows that the bread has undergone practically no digestion or solution and appears to have been simply mechanically ground up with the water. The acidity of the diluted sample which had been set aside for examination is next determined with phenol-phthalein as indicator, and by comparison of this with the acidity of the expressed sample we can calculate the amount of fluid which was left in the stomach before the water was poured in. This added to the quantity expressed gives us the quantity of gastric juice in the stomach at the expiration of the hour. Normally this averages about 125 c. c.; but in achylia it is much smaller, the motor power of the stomach being usually well preserved. The differential diagnosis between a nervous achylia and an atrophic gastritis, whether primary or secondary, is according to most authorities made from the examination of the filtered gastric juice for the lab ferment and its zymogen. It is contended that in atrophic gastritis the glands which secrete this ferment, or rather zymogen, are the last to be attacked and destroyed, and so long as it can be demonstrated present the atrophy is not complete or does not necessarily exist at all, and when it is absent the total secreting structure of the stomach is destroyed and no hope can be entertained of even a partial restoration of secretion by treatment. Our experience, however, is opposed