Some cases require more careful dieting than the former, and various modes of dietetic treatment have been adopted. They must therefore receive some consideration. Two important indications arise during the course of the disease which assist us in deciding upon the kind of diet which is most suitable. One point is the fermentation which so commonly occurs in the stomach and the irritation arising from the products of the fermentation. Sugar not only irritates the stomach by its local effect, but it may undergo fermentation and give rise to acidity. The starches in all cereal foods also undergo fermentation and produce acids. Butter contains such an acid ready formed. The other point is : the deficiency of hydrochloric acid in the gastric juice. This deficiency leads to considerable delay in the digestion of meat, fowl, fish, and all other substances which are called protein foods. The normal proportion of hydrochloric acid in the gastric juice is sufficient to act as a germicide or disinfectant. But when the proportion of this acid is deficient the bacteria and fungi which cause the fermentation of the food flourish amazingly.

Let the last point be considered first. The patient must have some proteins regularly. If his food contains none he draws the necessary supply from his muscles, and this piecemeal removal of the muscles leads to a rapid enfeeble-ment of the body and other consequences, which are more unpleasant than merely wasting away. The amount of proteins usually considered necessary is 100 grammes (approximately 3 1/2 ounces) a day. But Chittenden has shown that we can live on half that amount, and it is now usually accepted that 80 grammes a day is enough for a man or woman who does no manual labour. A diet consisting of 4 pints of milk a day would contain 84 grammes of protein. Some physicians therefore treat their bad cases of chronic gastric catarrh by keeping them in bed and giving them a milk diet for two or three weeks. It is given in tumblerful doses every two hours from 7 a.m. to 11 p.m., and an extra glassful in the night, making altogether ten tumblersful. It is a remarkably good method of treating some cases, especially when the disease is due to alcohol. The patient does not like it at first, but he soon becomes accustomed to it, and gets well in a moderately short period of time. But it does not agree with everybody. If it does not appear to be borne very well, let some bicarbonate of soda or potash be put into the milk. This will neutralize the acidity of the stomach, and prevent the formation of large and hard curds. If it does not agree in this form the milk should be fortified by the addition of dried milk powders, such as Plasmon, Tilia, or Sanatogen, and then reduced to its proper bulk by mixing with it some Perrier, Apollinaris, soda-water, or other gaseous water. If this does not agree with the patient we can fall back upon peptonized milk or soured milk, the latter being prepared by tablets containing the lactic-acid ferment. When opportunity occurs the treatment can be carried out by giving whey or buttermilk to the patient. They are exceedingly useful, and have this advantage: they do not form large curds in the stomach, but light and flocculent curds, and they contain a minimum of fat. A generation ago Niemeyer strongly recommended buttermilk for the treatment of chronic gastritis; he wrote thus" When the patient is hungry let him eat buttermilk; when he is thirsty let him drink buttermilk". But the proteins may be derived from carefully cooked fish, fowl, tender meat, and poached eggs, and some farinaceous food must then be given to replace the sugar which exists in the milk. As a general rule these foods should consist of Benger's Food, or other invalid's food, fine oatmeal - baked until it is like biscuit powder - arrowroot, blancmange, and sago or tapioca pudding, all of which are made with milk, and a small amount of dry toast or torrefied bread. Too much farinaceous food should not be allowed, because it may lead to fermentation and thereby aggravate the condition which we wish to improve. The persistence of flatulence, heartburn, and acidity would be considered a sufficient indication to reduce the amount of these foods or to put the patient on a milk diet with some meat or fish.

The second point has been partly considered in the foregoing. But while the digestion of proteins in the stomach is defective owing to the diminution of hydrochloric acid, the digestion of farinaceous foods may be perfect. This suggests that the diet should contain more farinaceous food and less protein. With this mode of treatment the ordinary animal foods should be abstained from. Milk and milk powders may be given. Benger's, Savory and Moore's, Mellin's, and other farinaceous foods will be valuable. Therefore the patient should be kept on these foods for a few days. The recipes given for these foods in the treatment of acute gastric catarrh may be usefully employed. Iceland moss jelly, agar-agar jelly, and ordinary jellies, if not too sweet, will soothe the stomach and be suitable food. Sugar must only be used very sparingly because of its influence in increasing the mucous discharge. Butter and cream should be avoided, not only because of the acidity of the former, but because they check the secretion of gastric juice. After a few days we may cautiously add to the diet a poached egg or a little steamed fish (sole, plaice, whiting, or fresh haddock). If these are borne without pain or discomfort we may, in another day or two, give some scraped meat, chicken panada or soufflee, and any other meat which has been passed through a mincer or sieve. After these we can give in rotation, mashed potato, spinach, vegetable marrow, or some vegetable puree; and, finally, the breast of chicken, guinea fowl or pheasant, tender mutton, and under-cut of beef.

The fermentation of food by yeasts, fungi, and bacteria is considered by many authorities to be far more important than the deficiency of hydrochloric acid in the gastric juice, although the latter is acknowledged to be the main reason for the constant fermentation. These authorities therefore allow very little carbohydrate (starch and sugar) during the treatment. Leube gives the following course of treatment -

(a) The diet should consist at first of clear soup or broth, solution of meat, milk, eggs - boiled or raw - and plain or aerated water.

(b) After a few days he adds boiled chicken, calves' brains, and boiled milk and bread.

(c) At a later stage he adds a small amount of bread and butter, and some scraped beef-steak, quickly cooked and underdone.

(d) Finally, he allows ordinary beef (underdone), roast chicken or partridge, macaroni, cooked green vegetables or fruit, and a small amount of wine.

Leube's solution of meat is prepared as follows: Mince 2 lb. of plain meat, place it in a porcelain vessel (a glass jar will do as well) with 1 3/4 pints of water, and add 3/4 ounce of pure hydrochloric acid. Place this vessel into a pan of water and boil it for ten or fifteen hours. It should now be turned out of the vessel and rubbed down to a paste with a pestle and mortar, returned to the vessel, and the latter put back into the pan of water and boiled again for fifteen or twenty hours. The substance should now be neutralized by the addition of 1 ounce of bicarbonate of soda, which will convert the hydrochloric acid into common salt. It should then be evaporated in a saucepan on the hob until it is of a syrupy consistence. This food is now ready for use. It may be given in doses of 2 ounces. It is almost ready for absorption and requires scarcely any digestion in the alimentary canal. It should be taken lukewarm; a little salt being added if necessary. It is an extremely useful food for cases of chronic catarrh, ulcer, or cancer of the stomach.

Lavage of the stomach is a valuable aid in the treatment of this disease. It should be done each morning before breakfast. When it is done at home the solutions used generally consist of bicarbonate of soda and common salt, boracic acid, or permanganate of potash. At the various Spas the water of the district is used alone. All these liquids should be used at a moderate temperature. By means of lavage the mucous membrane is cleansed and refreshed, mucus and food residues are removed, bacteria and fungi are washed away, the circulation through the bloodvessels is improved, and the muscles stimulated to activity. If the patient refuses to have his stomach washed out daily, he should be encouraged to take an emetic at least once a week, and thereby produce the effects of lavage in a minor degree.

A moderate degree of exercise is essential for all patients who can take it. Golf is useful for both men and women. If they are unable to take exercise of this character they must be encouraged to walk for half an hour twice a day. They may also exercise their arms, back, and abdominal muscles by the simple exercises taught to school children. Those persons who suffer from cardiac debility may be taught to do the Schott exercises as practised at Nauheim.

Change of air is likewise beneficial. A warm, moist air is useful in some cases, a drier atmosphere in others. This is a matter which the medical attendant must carefully consider; a warm, moist climate being suitable for the debilitated and aged; a drier climate for those who have passive congestions and copious discharges from the mucous surfaces; and a dry bracing air for those who have a relaxed state of the system generally, especially when combined with neurasthenia. He will know best whether the patient requires a moist air like that of Devonshire, the drier air of Bournemouth, Brighton, Algiers, or Egypt, or a cool and bracing air like that of Harrogate, Ilkley, Buxton, Matlock, or Malvern. Each of these climates is considered good for chronic gastric catarrh, but the constitution of the patient and the nature of the primary complaint will make one place more suitable than another for each individual case.