In the second place there are different views on a more important point, viz. the relative advantages of an amylaceous and a protein diet. The dilemma may be stated thus. (1) It is certain that in hyperacidity digestion of starch in the stomach is quickly brought to an end by the early rise of acidity and the appearance of free acid. In fact in some cases the discomfort is largely due to the presence of large quantities of starch in the stomach which cannot be dealt with. On the other hand protein food is not only quickly digested, but it fixes and combines with acid in the process, and protein food will often relieve the discomfort, which is the chief feature of the malady. So that it would appear obvious at first sight that the diet should be mainly protein, carbo-hydrate food being administered only as sugar or, if as starch, only in very small quantity. (2) On the other hand it is equally certain that protein is a far greater stimulant to the acid secretion than carbo-hydrate food. Car-nivora have more acid in the gastric juice than herbivora. Hemmeter has shown that the acidity of the secretion in car-nivora can be diminished by feeding on a carbo-hydrate diet for a long time. It has been said also that hyperacidity is rare among Eastern races who live mainly on carbo-hydrates. So that it may be argued that by insisting on a protein diet, we relieve the symptoms, but perpetuate the malady.

It is clear that the amylaceous diet has a curative aim, while the protein diet is directed to relief of a symptom. There are advocates for both diets in their entirety. It is possible to take a middle course. I believe that the protein diet, dealing as it does with symptoms alone, is the most suitable for, and should be confined to the third class of patient mentioned above, generally a clerk, who is so placed in his work that no attempt at a complete cure can be made. But even to him some starch should be allowed - and I do not think he suffers from the addition of 3/4 oz. of thin toast or rusk at his three chief meals, or from 2 oz. of milk pudding at his evening meal. To him also may be recommended the palliative taking of milk, meat lozenge, bicarbonate of soda or the bismuth lozenge when the pain comes on at his work. Chewing gum with resulting flow of saliva and consequent neutralization of some acid in the stomach is permissible with the same object. But as a curative line of treatment I believe that in the long run a simple mixed diet with preponderance of milk gives the best result, if it is remembered that no meal should be a large one, that several small meals are better than two large ones, and that good mastication, slow eating, rest, exercise and moderation in the use of alcohol and tobacco are essential parts of the treatment.

The following is an outline of such a diet: -

Diet For Hyperacidity

Half an hour before breakfast hot water 8 oz., with a small dose of Carlsbad salt.

8.30 a.m. . . . Cocoa made with milk, 10 oz. (or freshly made tea with half milk). Graham or wholemeal bread toasted, 2 oz. Butter, 2/3 oz. Honey, 1/2 oz. One or two eggs cooked in any way.

11 a.m..... Milk diluted (6 to 1) with soda-water, 6 oz.

1 p.m..... Meat (preferably veal, mutton or ham), 2 oz.

(or fish, chicken, game, sweetbread or savoury omelette). Milk pudding, 2 oz. (or custard). Toast, 1 oz. Butter, 1/3 oz. Cheese, 1/2 oz. Milk diluted, 6 oz. (or water plain or aerated).

5 p.m..... Milk diluted, 6 oz.

Toast, 1 oz. (or rusk). 7.30 p.m. . . . Milk-soup flavoured with celery, turnip or onion, 6 oz.

Fish or meat as at lunch.

Potato-puree, 1 oz. (or lentils).

Milk pudding, 2 oz. (or blancmange, jelly, custard).

Toast, butter, cheese as at lunch (or cheese-straws).

Milk diluted, 6 oz. (or water plain or aerated). Bed time . . . Milk diluted as at 11 a.m.

Finally when it appears that gastric secretion has returned to normal limits the diet may be tentatively altered and extended. Fish or fat bacon may be added to the breakfast. The 11 o'clock milk may be omitted. A variety of vegetables may be taken such as vegetable marrow, Brussels sprouts, lettuce, cauliflower, spinach. Savouries may be added and more elaborate puddings. But simplicity, though it is monotonous, should still be the object. Only when a cure is complete should any alcohol be allowed. Whisky 1 1/2 oz. diluted with at least 7 oz. of soda-water may be taken at lunch and dinner, or claret, hock or Moselle diluted with one third part of soda-water, or light lager beer. Under no circumstances should any alcohol be used in greater strength than in these drinks, and no alcohol is permissible apart from meals.

As an example of a diet based on the use of protein for hyperacidity, that of Wegele may be quoted: -

Morning . . . Tea with milk, 100 grms.

Two soft-boiled eggs. Forenoon . . . Raw ham, 100 grms.

Cream, 50 grms.

Aleuronat meal broth, 200 grms.

Or oatmeal broth, 250 grammes. Noon .... Beef-steak, 150 grms.

Mashed potato, 200 grms.

White wine with Saratoga, Vichy or Biliner water, 100 grms. Afternoon . . . Tea, 100 grms.

Cream, 150 grms. Evening . . . Cold meat, 50 grms.

Two scrambled eggs.

Wine, 100 grms. 10 p.m. . . . Milk, 250 grms.

At meal times aleuronat toast, 100 grms. This diet yields 2,400 calories.