In considering the subject of hyperacidity it was stated that at the height of digestion the degree of acidity rises to 70 or 100 on Ewald's scale, that the resulting pain and discomfort abate as the stomach empties itself, and that when the stomach is empty the patient is free from all trouble. Hence it is that his symptoms so rarely occur at night.

(A) Continuous Hypersecretion

In some severe cases, however, the secretion of gastric juice continues after digestion is complete and after the stomach is empty. It occurs apparently in the absence of any stimulus, except such as is afforded by swallowed saliva and mucus.

This form of secretory neurosis, "continuous hypersecretion," is uncommon. It occurs I believe only as a late stage in cases of long-continued hyperacidity which have been imperfectly treated. There is usually a history of many years of gastric illness of the hyperacid type. It requires no separate description, but a few points may be mentioned. In the first place cross-examination of the patient will probably reveal the fact that the pain does not cease when the stomach is empty, but that it runs on to the next meal, so that it is sometimes described by the patient as being at its worst " just before a meal." As in the case of simple hyperacidity, it will have been noticed by the patient that it is relieved to some extent by food or bicarbonate of soda. In the second place the pain is very apt to occur at night, commonly between 12 and 2 o'clock. Thirdly, vomiting and consequent emaciation are more marked than in simple hyperacidity, so much so that a suspicion of carcinoma may be aroused in spite of the long history. Finally some degree of dilatation of the stomach is usually present.

The actual proof, however, of the existence of this continuous hypersecretion can only be reached by washing out the stomach clean over night, and aspirating the stomach in the morning while still fasting. In well marked cases there are obtained from the stomach 4-8 oz. of clear yellowish-green fluid with a specific gravity of about 1,005 and a total acidity between 60 and 80.

As regards the dietetic treatment nothing need be added to the outline given under hyperacidity, and the same question discussed under that heading as regards the relative advantages of an amylaceous and a protein diet comes up again here. But hypersecretion is a more severe condition than hyperacidity and much less tractable. It is more than ever important to start a course of treatment with a period of semi-starvation and the minimizing of gastric stimulation. And as there is here no healing process required, as in the case of gastric ulcer, malnutrition may be disregarded and some loss of weight need cause no anxiety. The patient will generally submit to any restrictions in his desire to recover.

The slight rest cure recommended as the first step in the treatment of hyperacidity should be extended. In certain cases it may be wise even to proceed on the lines laid down for the treatment of gastric ulcer, and to maintain an empty stomach for two or three days with the use of saline injections per rectum, while lavage is performed daily. Milk to the value of 560 calories may then be commenced, and with complete rest in bed the full milk-carbo-hydrate diet described in connexion with gastric ulcer may be reached at the end of a month. As regards the continuance of lavage, one must be guided by the degree of discomfort which persists and especially by its occurrence at night. Thenceforward the treatment must be such as has been described for hyperacidity, attention being paid to the rectifying of all the errors of diet and life which have often contributed to the production of this state. But progress will often be slow and great patience is necessary.

(B) Paroxysmal Or Intermittent Hypersecretion

This condition may be mentioned here, though it has not necessarily any connexion with hyperacidity. In its pure form it lies quite apart from that condition, having only this in common, viz., that it is clearly a neurosis independent of any change in the stomach, a manifestation in fact of some disturbance arising elsewhere, which produces its end-effect through the vagus. It may bear a close resemblance to migraine and in some cases the distinction cannot be made. Its resemblance to the gastric crisis of tabes must always be borne in mind. A single attack might be mistaken for the result of some indigestible food or an irritant poison.

Sufferers from this condition are usually young. Attacks are often met with in schoolboys. They are said to be precipitated by emotion. Certainly there is sufficient evidence to warrant the prohibition of tobacco in these patients. The boy's first attempt to smoke will often result in an attack which at any rate has the superficial character of this form of hypersecretion. I have known it to follow the smoking of an unusually strong cigar by an adult. In many cases no dietetic or other error can be discovered, and the occurrence of attacks is capricious and inexplicable.

As the name indicates, the trouble occurs in isolated attacks, the general health and the digestion being often perfect in the intervals. Occasionally there is a history of co-existing hyperacidity. It has been mentioned in connexion with hyperacidity that attacks of severe gastric pain probably due to pyloric spasm with profuse pyrosis sometimes occur. It is probable that these attacks are due to sudden purposeless secretion of gastric juice, but I know of no exact observations as to the contents of the stomach at this time, and opportunity for examination is rare, as vomiting is uncommon. In fact the proof of the nature of an attack can only come from examination of the vomit. But if an attack occurs (as is common) with an empty stomach, especially at night, the presumption is strong that it is an instance of paroxysmal hypersecretion and not a mere digestive disturbance.

The attack usually begins rather suddenly, often in the night, and in typical instances with an empty stomach. Discomfort in the epigastrium soon rises to actual pain, which may be severe. Flatulence and eructations are common, probably due to the interaction of gastric juice and swallowed saliva. Pyrosis is usually the next event, and saliva may stream from the mouth. Vomiting sets in and generally gives some relief for a time. A highly acid fluid is evacuated as in the case of continuous hypersecretion, and acid has been found to the amount of 05 per cent. Not only is there epigastric and substernal burning and pain, but in many cases from the character of the pain one must conclude that some part of the stomach-wall, probably the pylorus, is in a state of violent spasm. It may be so severe that the hands grow cold and the face pale, and the mistake may be made of confounding it with a biliary colic. Thirst is often experienced and relief may be gained by drinking alkaline water.

Such an attack usually passes off in a few hours or in a day or two, and good health is resumed, though a weakly patient may be left somewhat prostrate. It may not recur for weeks or months. Sometimes the attack is associated with or followed by severe headache, so that the resemblance to migraine may be close. I know of no case where visual phenomena have occurred.

If hyperacidity coexists, the line of dietetic treatment has already been indicated. But in the pure form of paroxysmal hypersecretion with intervals of good health there is little to be done. The diet, however, must be examined and if necessary simplified. Without any reasons to advance in favour of such a view, I believe it is well to diminish the meat taken by such patients, allowing it only at one meal in the day, preferably at the midday meal. Tobacco and alcohol should be curtailed or forbidden. Opportunity may be taken to ensure good teeth and slow mastication. I think the tendency to this condition wears out with increasing years and wisdom, as is certainly the case with migraine.