To-day we will continue with the subject of diet in the treatment of diseases of the digestive organs, of a chronic nature. I mentioned in my last lecture that severe illness and organic affections have to be treated differently in regard to diet from those troubles which are more or less of a functional character, and which are in the majority.

We will subdivide this large class of functional disturbances, taking the stomach first, into three divisions: - one in which the gastric secretions are increased (hyperacidity); the second, in which gastric secretions are normal, and third, in which they are diminished (hypoacidity). In hyperacidity - too much acidity, too much gastric juice - we again have several subdivisions: One, continuous hypersecretion and the other, increased secretion during digestion, i. e., digestive hypersecretion.

The second large group is that of rather normal secretion and the third, is diminished secretion, or absent secretion. We have to deal with all of these conditions. First, we will take the group in which the gastric secretion is increased, which in my experience forms more than half, or about half, of most functional diseases of the stomach. Up to within recent years, the diet question in the class of cases where the acid secretion is increased has been in a rather unsettled state. There are a great many physicians of repute who maintain that all starchy food should be forbidden to these patients, because it has been found that the symptoms in these cases are rather increased after the ingestion of starchy foods. The physicians who represent that idea have gone so far as to designate this class of cases as "starchy dyspepsia," or "amylaceous dyspepsia," indicating that they ascribe so much importance to this particular thing that they found it worthy to name it in this way - and have arranged the diet accordingly. According to these physicians, the diet for hyper-chlorhydria consists in allowing meats and fats, taking away entirely the carbohydrates. The Salisbury regime, which I have mentioned before - meat, broths, and little toast - is also representative of that idea - the starch-free diet.

Now while it is found that a patient with hyper-chlorhydria when put upon, say, eggs, and a little meat and nothing else may be relieved of his symptoms - may lose his pain, belch less, and may be more comfortable - while all this is true at first, I do not think a real cure will take place if that diet is extended too long.

Now, again, there are a number of physicians who represent the opposite view. Pawlow, the St. Petersburg physiologist, has made many experiments on animals, with the stomach arranged so that it can be looked into and examined, and has found that meat and all nitrogenous foods have a tendency to increase the flow of gastric juice, while vegetables, the carbohydrates, and fats have a tendency to diminish gastric secretion. (In parenthesis I will mention that Bickel experimenting in a similar manner as Pawlow put up food groups distinguishing between weak and strong secretory stimulants, as follows:

1. Weak Secretory Stimulants

Beverages: plain water; alkaline water without CO2; tea; rich cacao; milk; cream.

Spices: sodium chloride in 0.9% solution.

Foods: dissolved or finely emulsified albuminates, as for instance fluid egg albumen, solutions and suspensions of lactalbumin, casein, glidin; pure carbohydrates, as sugar and starch; fresh wheaten bread; all kinds of fat; well boiled meat; ragouts of boiled meat with fatty, but unseasoned gravy (especially the fat and white, but not salted meats, as fresh fish, chicken, calf, pork); pureed or stewed sweet fruits, likewise vegetables prepared in the same way with butter, as for instance potato, rice, farina, sago, asparagus, red cabbage, cauliflower, spinach, white beets, carrots, cucumbers; soups prepared without meat extracts but boiled in plain water, like vegetable soups or bread soups or oatmeal gruel; dessert dishes prepared of beaten egg albumin, cream with rice, farina, mondamin, etc.

2. Strong Secretory Stimulants

Beverages: All alcoholic and carbon dioxid containing beverages, as for instance wine, beer, the mineral and saline waters containing CO2; coffee and caffein free coffee, all coffee substitutes, fat free cocoa, and skimmed milk.

Spices: sodium chloride, excepting the 0.9% solution; mustard; cinnamon; cloves; pepper; paprica; all soup seasonings.

Foods: All broiled vegetables and animal foods; the yolk of the egg, coagulated egg albumen, raw, broiled or slightly boiled meat, especially raw and slightly broiled meat, principally the dark meats; all salty and smoked meats inclusive fish, prepared in the same manner; meat extracts and all dishes prepared with them, like bouillon, bread, especially brown bread and pumpernickel; toasted bread; all vegetables mentioned in rubrik 1, (if steamed and prepared in their own juices and not served as purees.) - This led the way to a second arrangement of the food in cases of hyperchlor-hydria. These physicians said that if we give these patients a diet rich in animal food, the gastric secretion is increased and the stomach is overstimulated. So they have started the opposite principle of feeding, and said that we should keep away all animal food from patients with hyperchlorhydria, and give them a strictly vegetable diet, with butter.

Both parties show successes in their treatment; both have their failures - which is quite natural, like everything else. Now, the question is, what shall you do. If you read the books, one will forbid all starchy food to these persons; almost all vegetables too. The other will teach just the opposite for the same class of cases. My answer to this is that neither of them is altogether right; for, as I told you a week or two ago, any diet that is arranged for a long period of time must contain all the three groups of nourishment we need, proteins, carbohydrates, and fats. While we can arrange a diet, a bill of fare, in such a manner that one group should predominate and the others be lessened, we cannot exclude any one of these three cardinal nutritious groups from any diet. That is a cardinal point. We must give a patient all these three things; but where there is too much secretion a starchy food is not so well used up, and you can give that patient less starchy food, and more fat and albuminates. So, in actual practice, in these cases of hyperchlorhydria, give them meat in a large amount and fats, and diminish the starchy food. I tell them that they should not eat too many potatoes, put no restriction on bread - for that is such an important article of food, and if some patients do not eat bread they cannot eat anything - and give them all plenty of butter.