The reason why starch can be given to these patients is, first, that even if it does not change so quickly (the acid gastric secretion when reaching a certain height, checks the ptyalin action of the saliva, in the stomach), the pancreatic juice contains a very active ferment for the conversion of starch into sugar and ferments for the conversion of fats and albuminates; and if the starch digestion is inhibited in the stomach it will be finished further on in the digestive tract. Another reason is that if the acidity is so great as to prevent the change of starch into sugar, we can give these patients alkalies to diminish the acidity, and that is better than to take away the starch; it is better to give a remedy than to take away the food.

So the diet in these cases of hyperchlorhydria should be a liberal one. We must take away all highly spiced substances, and not give them too much of the tougher meats, such as beef, pork, venison, but a liberal diet of chicken, lamb chops, or the tender meats, and plenty of milk, butter and eggs, bread and cereals, and rather restrict potatoes and other starchy substances.

We will now consider those cases where there is continuous hypersecretion, the group in which the stomach continues to secrete juice even if there is no food present. Usually we find this condition in ulcers of the pylorus; rarely, in cases of neurotic disturbances, either due to organic nervous diseases, central lesions, or sometimes merely functional in character.

What will you do in this group? Here frequent eating is of great importance. Try to make use of the gastric juice which is given by the stomach anyway. It irritates the mucous membrane and makes the patient uncomfortable - but if you put in some food, and especially albuminates which have a tendency to enter into combination with the acid - the acidity in the stomach is diminished and that gives them relief. These patients tell you that they have pain three hours after eating. If they eat, the pain is better. The acidity is reduced by the ingestion of food. The water and the albuminates in the food bind the acid, so that it is not only diminished (diluted) but some is taken away (partly neutralized). Some of these patients wake up early in the morning. The acidity is too great for the stomach. If they put in food - eat breakfast, they feel all right. So frequent eating is a cardinal point in the treatment of these cases.

Fats have a tendency to inhibit gastric secre-tion, and are to be recommended in all these classes of hyperchlorhydria, and continuous hypersecretion.

Now, we will take up the cases in which the gastric secretion is normal. The symptoms may be of a high character. The patient complains of all kinds of things - pain, eructations, loss of appetite, etc. This is the group designated as nervous dyspepsia. The symptoms are distressing, but still we find nothing radically wrong. We cannot find any deviation from the normal, and still the patient complains, and so we ascribe the condition to some nervous phenomena which we do not exactly understand. These cases have to be treated differently. They can eat anything, and should be made to eat everything; they should be given a liberal diet; no restrictions at all in these cases. Very often these patients with nervous dyspepsia eat lightly, and if kept away from food they would never get well; but if you change their habits of eating, the change should not be made too abruptly. If patients have been on a strict diet for a long time, you cannot bring on a change in a day. A patient who has been living on milk and crackers for two years if put at the table and given a good meal - even if the stomach is good - will have trouble. The stomach is not used to it. You should take a few days, or even a week, and gradually change the diet, until the patient is put in such a condition that he eats everything. All of these cases of nervous dyspepsia should eat everything, but make the change to the regular way of living slowly.

Now, we come to the third group, in which just the reverse of the first group exists; the gastric secretion is diminished - and ultimately we will take the group in which there is no gastric juice at all.

In chronic gastric catarrh there is a diminution of the acidity, and in functional nervous disorders, disorders of a depressed character, the stomach works poorly and the acidity is diminished. In all these cases the vegetable foods should predominate, and not much meat should be given. Meat should be restricted, and fats as such should not be given in large quantities, for they have a tendency to inhibit secretion. Meat, on the other hand, has a tendency to increase secretion, but if too much is given it creates a disturbance - so we give enough meat, and less fat.

Now, all these questions have been worked out by the physiologists, but we cannot take their findings right away into the clinic and say, "We go according to them." It is only if they have been proven to do good in practice that we can adopt them. Until then, we cannot go by them alone. In Germany especially, many clinicians act too much on these physiological experiments. They at once give a diet according to these rules. But that is not the best way. It is best to go by what we find to be of clinical value, and to leave the theories, as such, alone. If we find something practical, and this corresponds to a certain physiological theory, so much the better.

Now we come to the class of cases in which there is no gastric secretion, achylia gastrica. That is a large group. These patients have no organic disease, and yet have distressing symptoms. It is the result of something else. The condition is easily managed and the dietetic treatment here plays a great part. The food is changed very little in the stomach in these cases, for there is no gastric juice. Not only the albuminates but also the starch and fats are unchanged. Starch as such would change in such a stomach, but the starch is usually enclosed in a membrane of plant albumin, and this little membrane or coating which surrounds the starch is usually opened by the gastric juice; but in cases of achylia there is no gastric juice, and the ptyalin cannot reach the starch and enter it; and that is the reason why starch cannot change in cases of achylia. If you want the starch changed, you must see that the particles of food are entirely broken up, pulverized almost; that has a tendency to open up the little cells in such a way as to reach the secretion.