It is extremely difficult to distinguish between functional and organic gastric disease, not in the recondite sense that any functional disorder is probably attended by an actual but inappreciable lesion, but with allusion to the difficulty of diagnosing slight organic lesions that would be perfectly apparent, even macroscopically and certainly microscopically, if the stomach could be exposed for examination.

On the one hand, not exactly normally but practically inevitably, there are always slight inflammatory or degenerative processes going on in the gastric wall as the result of mechanic, thermic, bacterial, and chemic insults incident to ordinary habits of eating and drinking as well as waste and repair of tissue, including the shedding of epithelium. On the other hand, pathologic lesions, unless of considerable extent or severity, do not manifest themselves readily. Hence, the functional terms are retained only as a matter of convenience, for immediate therapeutic purposes.

As a rule, hypochlorhydric states are attended by sluggish motility, hyperchlorhydric by excessive motility but the latter may be and often are complicated by, if not induced by obstruction at the pylorus so that the excess of motility is unavailing and a state of stagnation exists. Later, the continued resistance to peristalsis causes motor failure, even degeneration of muscle and dilatation.

In Hypochlorhydria, in addition to the indication for hydrochloric acid, sodium chlorid, from which the acid is formed should be used freely, yet not excessively, since its presence in the stomach in too great a proportion, checks digestion.

The diet should be reasonably varied, to stimulate secretion reflexly through the appetite, but should exclude coarse vegetables, pastry - though there is usually no objection to the inside of good pies or even to the upper crust, if light and not too "short" - ; fried foods should be used cautiously though a little fried bacon or ham or egg may usually be taken without harm. Fruit should be used moderately. Milk may be employed if well mixed with cereals etc. Tea and coffee should be taken weak, if at all, and comparatively little water should be used with meals. Three or four hours after meals, water should be drunk at intervals, so as to administer 200 or 300 c.c. three times a day. There is a difference of opinion as to nuts, seedy fruits and vegetables rich in cellulose. On the one hand, the hard particles and shreds of indigestible material tend to stimulate secretion and peristalsis; on the other hand, they may remain too long in the stomach and favor bacterial activity, gas production, exhaustion of muscle and hence the production of catarrh and dilataion. This difference of opinion is doubtless due to difference of result in different cases, so that the decision must depend upon empiricism in the individual case.

A very important principle, corroborated by Pavvlow but long known, is that each food tends to stimulate the secretion needed for its digestion and to inhibit those not needed. Hence, fats and carbohydrates should be reduced to or below the ordinary standard minimum while proteins especially meats, should be given in relatively large amount, 100 - 150 grams (corresponding to 1 - 1 1/2 pounds of meat) a day.

Hyperchlorhydria occurs much less frequently than hypochlorhydria (the former in 10 - 20%. of a miscellaneous series of gastric cases) its symptomatology is very closely imitated in inflammation of the appendix, gall stones, cholecystitis and even by neuralgia or neuritis of the soinach itself, some other viscus or the body wall. Nine-tenths of cases of acute "sour stomach" are hypoehlorhydric with formation of vegetable acids. Even when the stomach contents are analysed, the hydrochloric acidity is often exaggerated ten or fifteen degrees by reading the acidity at the final discharge of color from dimethyl-amido-azo-benzol instead of at the change from cherry to orange. Thus a very false impression has arisen as to the frequency of hyperchlorhy-dria.

Hyperchlorhydria should not be diagnosed unless the hydrochloric acidity is more than 50 degrees with small quantities of chyme or at least 40 degrees if the stomach contents are approximately equal to or in excess of the amount ingested.

The dietetic indications are almost exactly opposite to those for hypochlorhydria and, while drugs may be of benefit to relieve pain or to depress secretion, the essential treatment is dietetic, at least if alkalies are included as articles of diet. Excluding ischo-chymic cases with lesion at the pylorus, this treatment is curative in the immediate sense and, barring a rather marked tendency to recurrence, even in the ultimate sense.

Sodium chlorid should be restricted as much as possible.

Spices, condiments and sapid foods should be interdicted.

Proteins are theoretically indicated to combine with HC1, con-traindicated on account of their tendency to excite further secretion. Frequent meals are indicated to keep the gastric juice at work on ingesta rather than on the stomach, contraindicated because they call forth more secretion. Continuous supersecre-tion (known by the etymologic horror, gastrosucorrhoea) is now generally held to indicate actual ulcer. Unless, as in ischochymia with hyperchlorhydria, there is a tendency to saprophytosis, fats and sugars should be given freely as they tend to reduce the secretion, in accordance with the general principle already enunciated.

These various indications and contraindications are met by excluding meats, especially viscera, but by allowing a rather liberal use of milk, eggs, custards, cereals, on account of their protein, fat meat, cream, starchy vegetables such as potatoes, sweet potatoes and bananas, juicy fruits free from seeds, core and skin, and considerable sugar and syrup.

Tea and coffee should not be allowed but weak cocoa with milk and sugar may be used. Cold, even ice water, or cold saccharine but not alcoholic nor carbonated drinks, are advantageously used at the time when gastralgia indicates the appearance of a high degree of acidity, usually 1 - 2 hours after meals. It should be remembered that unless a true hydrochloric acid excess has actually been demonstrated, the symptoms may be misleading. The relative excess of secretion from the stomach renders the chyme abnormally liquid, so that little or no fluid should be taken with the meal.