is best and most certainly made known by an examination of the stomach contents one hour after the test meal of Leube, which consists of 10 oz. of hot water or weak tea and 3 oz. of bread. Where this is inconvenient, we may judge by the fol lowing symptoms. When the patient is under thirty years old, rather thin and pale, tongue clean with red edges, urine scanty, alkaline or neutral in the morning, when he complains of pain on pressure at the epigastrium, of occasional heartburn, eructations, much thirst and very nervous, we may, in the absence of fever, make a provisional diagnosis of an irritative condition with increased HCl, and should try a sedative diet and medication; if this gives relief, our diagnosis is reasonably certain.

So, in a person over thirty years of age, who had deranged digestion for many years, and complains of pressure at the epigastrium after meals, with occasional "bilious attacks," who has a coated tongue, sluggish bowels, urine free, and highly acid, we may safely guess it, a depressed condition with diminished HCl, and atrophy of the secreting glands, these subjects often have a good color and weight, but lack endurance, they need a stimulating diet.

Sedative diet.-A sedative diet is one which excites the least amount of HCl secretion which is necessary for its digestion. When any albuminoid article of food is taken into the stomach, HCl is secreted, a certain amount combines with the albumen, fibrin or casein; what is left over is unnecessary, often harmful.

"Hayem found in the stomach of dogs, after feeding with meat, and in the stomachs of healthy infants after a milk diet, no free hydrochloric acid. This shows not that no HCl was secreted, but that it had quickly combined with the food and none was left over.

'Prof. Rugel said at the last Carlsbad Congress that there has been no medicine hitherto used which had a marked effect in reducing the quantity or strength of the gastric secretion. He had found from experiments in dogs with a Pawlow stomach (one in which a part of the stomach is shut off from the remainder and provided with a fistula) that atropia diminishes the strength of the gastric juice to one-third or one-half of normal, and the quantity to one-sighth or one-tenth of the normal amount.

It seems then that in irritative conditions we must depend principally on sedative diet. The fats have in the last few years been found to diminish greatly excessive HCl formation and other irritative conditions.

⚫ Wirschillo (Wrotsch Russian, No. 3, 1899) finds from investigations on fifteen children, that ol. morrh diminishes the HCl and pepsin secretions; also, other fats do equally well.

"Ziasko (Wien klin. Wochenshiff, No. 18, 1897) finds that nutrient enemata diminish the excessive HCl of stomach.

Strauss (Zeitsdrift fur diet und Physical Therapeut.) finds that a butter fat diet is advantageous in those motor derangements which are with excessive HCl.

"Wolkowitsch (Gesehellshaft der Russich Aertze, St. Petersburg Wratsch, No. 13, 1898) found fat diet to have a restraining effect on the secretions of HCI.

'Aldor and H. Strauss (in Essay on Dielo-Therapec. by Hyperaciditst, Berlin, 1893) find that a fatty diet is very beneficial in + HCl.

"Akin Pereby (Wratsch, No. 4, 1878) found large doses almond oil, 50-100 grammes daily, curative of the pains and + HCl. 'Dr. Wold Bachman, working in the medical clinic of Prof. Runeberg Helsingfors, from experiments on twelve persons with hyperchlorhydria and irritative conditions, finds no advantage for an exclusive vegetable or animal diet. He finds that fat, butter, cream, added to other foods lessens markedly the excessive HCI secretion.

The starchy foods when insufficiently chewed are irritating; when well-chewed and insalivated they are much less so, and pass out of the stomach quicker.

The following table taken from Van Valzah shows how much of a 3 per 1000 solution of hydrochloric acid is able to combine the following foods:

The power of different articles of food to stimulate hydrochloric acid formation in the stomach varies. When the test12 breakfast of Loube, consisting of 3 oz. of bread and 10 oz. of hot water or weak tea, is taken in health, then withdrawn, in one hour gastric juice contains 4 parts per 10,000 of free hydro

chloric acid (Hayem) with a total acidity of 2 parts per 1,000. Bread, therefore, causes the secretion of more hydrochloric acid than its contained albuminoids can combine; it passes out of the stomach in two hours. Milk is at the head of the list of sedative foods, because it causes the secretion of only as much HCl as it can combine. There is no free HCl present during its digestion, and the stomach should be empty 90 minutes after taking.

Arranged in the order of their producing free HCl in the stomach in one hour: Milk, none; fish, very little; chopped meats, white meats, red meats, eggs, and bread, more; cornmeal, white grits, potatoes, most of all.

Consequently, milk is the most sedative, and potatoes are the most exciting articles of food. But this does not imply an exclusive milk diet, and avoidance of starchy foods in irritative conditions of the stomach, and the first stage of chronic gastritis. The quantity of milk to maintain nutrition would be too great-two gallons. Fine division of fish and meat causes a quicker and more complete combination with the HCl, and leaves less free HCl. Just enough starchy food in the form of corn bread (best), wheat bread (hard), rice, wheaten mush, to preserve nutrition must be taken. Potatoes must be avoided, or taken sparingly; and all spices, condiments, salt food prohibited.

Where milk produces a sense of weight after taking, it is due to a too rapid and firm coagulation, from a great excess of acid in the stomach. This trouble may be avoided by curdling the milk by rennet, or Fairchild's essence of pepsin which contains it; the curd is then broken up finely by beating with an egg-beater. In this finely divided state it is free from the stimulating effects of acid koumiss or buttermilk.

Milk peptonised by pancreatic extract is the most sedative of all milk preparations, for, on account of its not being coagulated by the acid of the stomach, it passes out probably in less than thirty minutes.

Fine division is the most important sedative quality that foods can have. Milk, by its fluidity, has this quality. Boiled or baked fish is an excellent food because it disintegrates so easily in the mouth. Those starchy foods which digest most easily are those which are partly dextrinized by thorough baking, like cracker, French bread, or those which, like corn-bread, disin

tegrate easily in chewing. The following table, from my own experiments, published in the PACIFIC MEDICAL JOURNAL, October, 1899, shows the action of the saliva on various starchy foods:

TABLE I.

Foods mixed and rubbed with saliva to form thin paste, kept 30 minutes at 100° F.

Where the food is chewed slowly without drinking, the division is not as fine, nor the mixture so intimate as by rubbing in a mortar, and consequently the action of the saliva is not as great, as shown by Table No. II.

In hasty eating, when, instead of the food being chewed to a paste, it is washed down into the stomach by frequent draughts of liquid, the conversion of the starch is much less, perhaps not half as much as in Table No. II.

TABLE II.

Foods chewed soft enough to swallow, then kept 30 minutes at 100° F.

The second table we may take as the normal amount of conversion of starchy food by the saliva.

The above tables show the great importance of the fine division of the food for digestion. Those foods which disintegrate into fine particles like corn bread and crackers, showing the greatest amount of action of the saliva. The presence of albumen or gluten, makes the action of the saliva more difficult,

and is probably the reason why wheat bread and crackers are not acted on so well as corn bread.

Boiled rice when eaten is not much broken up in the mouth by chewing, and the action of saliva on it is far less than when intimately rubbed up in a mortar.

Where the secretion of HCl is lessened, or absent, without derangement of the motor function, the diet should be stimulating; should consist of koumiss or butter-milk, roast meats, with condiments, salt and spices, salted and smoked meats and fish should be used freely. Mineral waters containing salt should be used as drinks, especially Bitter Kissingen, or Carlsbad in small doses much diluted.

Koumiss, or fermented milk, is in these cases the most valuable animal food. According to George Hayem, it contains from 3 to 6 parts per 1,000, of lactic acid, which can, to a certain extent, replace HCl in digestion. It also contains albumose, propeptone, and peptones from the partial digestion by the lactic acid, of the casein. Hayem finds it of the greatest benefit given in doses of 6 to 10 ozs. just before meals.

Where there is a motor derangement with the depressed condition of the stomach, the foods must be such which leave the stomach in the shortest possible time, the conditions which cause a quick evacuation of the stomach are best, fine division, neutral or slightly alkaline reaction, absence of fementative qualities.

The following tables from Penzoldt" should guide us in this respect:

LEAVES THE STOMACH IN ONE TO TWO HOURS.