I have selected the dietetic treatment of chronic diarrhea because this subject of diet is an important one in all diseases, and particularly so in affections of the digestive tract, as there we have to deal with an apparatus which is arranged to sustain the organism.

In order to discuss this subject of dietetic management of chronic diarrhea, it would be well to divide its forms into different classes.

1, Diarrhea due to chronic intestinal obstruction;

2, nervous diarrhea; and 3, chronic diarrhea, due to catarrh of the small intestine principally, sometimes also accompanied by a catarrhal condition of the colon. Most forms of chronic diarrhea mainly involve the small intestine; and this group can again be subdivided into 1, primary catarrh; 2, catarrh depending upon abnormalities of gastric secretion; and 3, catarrh accompanying ulceration.

1 New York Med. Journal, Feb. 10, 1906. 99

In the treatment of all these types of diarrhea it is primarily important that we should make use of those foods which are nonirritating and which leave little residue. They must not irritate the bowel mechanically or chemically, nor must they be very cold when ingested.

The special treatment of each class will call for a variation in the dietetic regime. In chronic intestinal obstruction, so long as the patient is not operated on and the obstruction exists, the first principle will be that the diet should be a liquid one. This liquid diet will have to be maintained because solid food will not pass through the narrowed canal. It will be vomited and will aggravate the symptoms. We may give milk, raw eggs, and different kinds of broths and meat juices, but this will be all which we may allow. Variations to improve the taste, and bring more variety into the menu may be introduced, but in the main the foods will remain the same.

A reverse course must be adopted in that form of diarrhea which is of nervous origin. In this disorder, as far as we know, there is really no anatomical lesion to be found. It is simply a functional disease, and the chief feature of this type of diarrhea is that nervous phenomena accompany it and also bring it on. This means that in addition to a diarrhea the patient also manifests other nervous symptoms. He perhaps cannot sleep well, his appetite is capricious, and then the diarrhea itself also manifests a character which shows its nervous origin. The patient will have a movement of the bowels principally after meals, or when he will have to meet a very important engagement; a professor before giving a lecture will have to excuse himself and leave the room, indicating that the state of mind has something to do with the movement of the bowels.

In these cases the whole management should be different from those which are due to anatomical lesions in the intestines. The diet, too, must therefore be arranged accordingly. It will not have to be such a rigorous one. We will have to make the patient eat almost everything. Even those foods which leave a residue do not play much part. I remember I had to treat a physician in this city who had this kind of a diarrhea. He had to excuse himself after finishing each meal. The main treatment is that the patient should try and suppress these movements, i. e., not to run to the toilet as often as he feels inclined, and besides other means, nerve sedatives. The diet should not be restricted; food of a laxative nature, however, should be avoided; otherwise these patients can eat everything.

Now we come to that class of diarrhea which is due to disturbances of the stomach. This is a group which has been recognized only in the last twenty years. We have learned to know that there are forms of diarrhea in which the small and large intestines are not very much involved, but in which we find abnormal conditions in the stomach itself, and if we try to arrange a treatment suitable to the derangement of the stomach, the diarrhea as such can be disregarded and still will be cured.

There are two lesions in the stomach, functional disturbances, which form the greater part of this class of diarrheas. One is the form which is called achylia gastrica, in which there is no gastric juice whereby the stomach does not digest albuminoid foods. Here the food enters the intestine practically unchanged, and thus irritates the bowel, causing the diarrhea, at least in some cases. Achylia gastrica is not always accompanied by diarrhea. I think, on the contrary, that more than one half of the cases are accompanied with extreme constipation, but about one third of these cases of achylia gastrica are troubled with obstinate diarrhea, and this diarrhea is probably due to mechanical irritation within the small intestine.

Diarrhea may also be brought on by just the reverse condition, i. e., one in which there is too much secretion and too much acidity in the stomach. Here it is not the mechanical irritation but most likely the acid itself which exerts an irritating stimulus on the intestinal mucosa, which leads to the diarrhea. This class, however, is a small one. Most patients who suffer from hyperchlorhydria are afflicted with constipation, and only a small fraction suffer from diarrhea, but we must remember that such a group exists, as sometimes they may be cured by alkalies.

In these two groups, in which the diarrhea is dependent upon a gastric anomaly, the entire treatment, medicinal and dietetic, will have to be arranged to suit the stomach. In the patients with achylia gastrica we find it expedient empirically, not merely theoretically, to exclude proteids from the diet. Such patients do much better on a diet which contains little meat or no meat at all. They should live on a vegetarian diet. A vegetable diet is inclined, as a rule, to predispose to diarrhea, but in this group of cases it is just the remedy. If one keeps a patient on gruels and perhaps on nicely divided articles of food, milk, kumyss, later on bread and butter and omits meat entirely for a time, one will find that in a few weeks he will not suffer so much from the diarrhea. I think this to be the experience of almost all the physicians who handle these cases. According to my experience, however, it is not necessary to institute a rigorous diet nor to avoid meats altogether for a very long period. If we give the patient finely divided foods for a few weeks, at first liquid, then semi-liquid foods, we can then after a time begin to allow foods a little coarser, bread, vermicelli, barley, rice, and later on meat. We will find that the bowels will gradually get accustomed to these foods, even if the latter do not get into the intestine in so finely divided a state. These patients should masticate their food carefully. This is more important here than in any other class of stomach derangements. These patients do well on starchy foods.