Although I do not favor strict and severe dietetic rules, nevertheless I deem the above-mentioned remarks as going too far. Unlike the normal healthy condition, in which instinct shows us the right measure to eat, neither too little nor too much, stomach patients very of ten have lost the feeling of self-regulation, and as a rule partake of too small quantities of food. (Only in a few cases of bulimia there may be an increased desire for food, and in connection with it the quantity of food taken may sometimes be too large.) It is therefore necessary to instruct the patients to eat more, or to give them exact figures of the quantity of food required. As this varies with every individual it is most practicable to let the patient weigh himself once a week and to see whether he keeps his weight. If the patient does not lose any it is the best sign that he takes sufficient nourishment. As good instances of a sufficient amount of food contained in the diet we give the following bills of fare which have been suggested by C. von Noorden: 1

I. A Princepally Milk Diet With Addition of Carbohydrates In Liquid Form

1C. von Noorden: Berl. Klinik, 1838, J. 35. 2 10 gm. albumose is contained in 90 cc of Denayer's peptone preparation or in 23 of Kemmerich's or in 30 of Koch's.

II. Principally Milk Diet With The Addition Of Carbohydrates And Fat In Pap Form And Soups

III. Milk Diet With Addition Of Light Pastry And Broths

IV. Milk With Tender Meat, Pastry, Butter, And Soups

V. Rich, Not Irritating Diet

Besides the importance of a sufficient diet, we must remind patients to lead a regular life, to eat slowly (bow many, especially in our country, sin against this natural law!), and to chew well and triturate the food. One must avoid either extremely cold or extremely warm food. Too copious and too complicated meals must be strongly forbidden.

I have made it a rule not to forbid anything, except what is, according to my conviction, obnoxious in the given case. In this way the patients have a great variety in their food and run less risk of subnutrition. Likewise we need not change the number of meals nor the hours appointed unless there should be especial indications for such a proceeding.

Among the laity, as well as often among medical men, there are prejudices against certain forms of food. Thus, for instance, until recently it was customary to forbid all kinds of fat, even butter, in all dyspeptic conditions. Fat, however, belongs to the group of food-stuffs which has the largest number of heat units, and besides, is not bulky as a nourishment (butter). Undecomposed fat passes the stomach without molesting the latter, and is digested in the small intestine. There is, therefore, no reason for forbidding butter, which should, on the contrary, be highly recommended. Fearing fermentative processes the partaking of bread and other food rich in carbohydrates is very often greatly limited, or even totally forbidden. Although it is true that the carbohydrates easily undergo fermentative processes, those cases, however, in which considerable fermentations exist in the stomach are quite rare, and as a rule are found only where there is considerable stagnation of food in the stomach. In these cases, to be certain, a diet consisting principally of animal albumin (meat) for a short period is very useful.

By means of lavage of the stomach and other appropriate treatment we soon succeed in checking the fermentative processes, and carbohydrates can then be administered.

1 Meat of various kinds, finely chopped, raw or fried in butter; cold or warm, taken at two meals.

An adult, according to Koenig,1 daily consumes 1/3 to 3/4 kgm. of bread; fifty to sixty per cent of the total food substances, and fifty to seventy-five per cent of the carbohydrates are taken in the form of bread. This clearly shows the important part bread takes in diet. Its use is, therefore, as a rule advisable. It is ordinarily said that crust of bread, stale bread, and zwieback are easier to digest, on account of the starch contained in them being largely converted into dex trose. Although I am of the opinion that too fresh bread must be avoided, I nevertheless rarely find much difference in the digestibility of the crust or other parts of well-baked fine white bread, judging from experience gained from my own patients.

1 Koenig: "Die menschlichen Nahrungs- und Genusamittel," Berlin. 1883, p. 430.

Moreover, the carbohydrates in the form of sugar (taken in large quantities) have been found by the painstaking investigations of Dr. W. Gerry Morgan,1 of Washington, D. C, to lessen the amount of acidity in the stomach. Sugar can, therefore, be administered with advantage in cases of hyperchlorhydria.

Articles of luxury (wine, beer, coffee, tea) are, as a rule, permissible. It is, however, necessary to give them in small amounts and in appropriate form. Strong liquors must be avoided, likewise all strong spices.

Appetizers, as a small amount of caviare, sardellen, or anchovies, on a small slice of bread or cracker, taken one-quarter of an hour before the meal, are not only allowed but frequently directly commendable.

In reference to the special rules for the different diseases of the second class, we shall have at times to reduce the quantity of meat taken in all conditions accompanied by a diminished secretion of hydrochloric acid (gastritis chronica glandularis, atony + subacid -ity); on the other hand, the quantity of richly carbohydrate vegetable food must be increased. Kuniyss, matzoon, milk with cognac (7 to 10 c.c. of cognac to 200 or 250 c.c. of milk) may be taken with crackers either during or between meals.

1 Dr. W. Gerry Morgan: "Zuckrr, als soldier, in der Dial der Dy-peptiker." Arch, f. Verdauungskraukh.1902. p.132.

In all the conditions attended with superacidity the quantity of albuminous food should be increased; here one may give a great deal of meat (venison included). In superacidity with hypersecretion frequent and small meals containing consistent food are most appropriate. If there is a feeling of hunger between meals, the white part of hard-boiled eggs may be taken (as is well known, albumin combines with acid and makes it, so to say, inert). The quantity of beverages must be greatly limited; most suitable in this instance are small quantities of Vichy water. In dilatation of the stomach and in gastroptosis it is also advisable to give small and frequent meals, and to restrict the quantity of liquids taken. As a rule, milk and beer do not agree well in these cases. Small quantities of wine or imported dark beer or porter may be allowed.

In nervous dyspepsia and gastralgia our main object will be to systematically increase the quantity of food - here milk and its derivatives (koumyss, matzoon, bonny-clabber, buttermilk, cream) taken between meals play a great part (Weir Mitchell treatment).

In achylia gastrica it is of utmost importance to give liquid or very well triturated (pulverized) food. For here the chemical action of the stomach has entirely ceased, and vegetable (on account of the albuminous membrane enclosing the starch granules) as well as animal food pass from the stomach unchanged, and not converted into small particles, into the intestines and irritate them, unless there has long been formed a sufficient adaptation for these conditions. Vegetable food, on account of its containing chiefly carbohydrates, will be predominant in the diet of this affection. Thus achylia gastrica, in reference to diet, stands midway between the first and second classes. It approximates the first class in so far that it necessitates a liquid or mechanically minutely triturated or pulverized food, the second class in allowing a richly carbohydrate diet.

Some readers may miss exact bills of fare for chronic affections of the stomach. They have been omitted, as it is always necessary to individualize, especially in diet. We must guide ourselves more by the patients than by theoretical conclusions. Our main object must be to care for a sufficient nutrition. Only the above-given principal rules on diet must be observed, although at times even they have to be modified. In reference to this point Hippocrates1 said: "Dandum aliqutd tempori, regioni, oetati et consaetudini".

At present, with our more exact knowledge, we have come to appreciate this conclusion to a still greater degree.

1 Cited from Munk and Uffelmann, 100, cit., p. 430.