Another reason why these patients should have their food prepared in a finely divided form is again the circumstance that there is nothing in the stomach to help the dissolution of these particles. Normally, the gastric juice dissolves the connective tissue surrounding the meat and prepares it for further digestion in the intestine. In a case of achylia gastrica the meat which is swallowed remains unchanged until it reaches the duodenum.

The connective tissue surrounding the meat fibers does not disappear, and the latter reaches the duodenum in the same shape in which it was ingested. It looks as if it had been masticated and spit out. Some of you have seen me take out such stomach contents which look exactly as if the food had been chewed a little and then brought out. So the mechanical division of the food is important in these patients with achylia. If the food comes into the duodenum unchanged it creates symptoms - pain, etc., and the patients suffer from catarrh of the bowels, frequently causing constipation alternating with diarrhea. Not only in the stomach but also in the intestines the food continues to be an irritant.

So the foods in these cases should be finely divided mechanically. Accordingly we give these patients cereals in fine form, pea soup, lentil soup, mashed potatoes, raw and soft boiled eggs. If you give them hard boiled eggs, they will remain in the stomach, but raw eggs which are semi-liquid will slip through. We give these patients very little meat, for the reasons which I have already mentioned. I have found very often that by such a strict diet of liquid and semi-solid food - they must be told to masticate their food well - that they can get along very well. The diet brings on a great improvement.

But shall we let these patients continue on such a diet indefinitely? No. The principle to which I have already referred is important not only in the other groups but here also - that a diet deviating much from the normal should not be kept up indefinitely. Our tendency should be to strengthen the digestive tract and harden it, and bring it to such a state that it can manage normal food. No matter whether the constitutional condition is changed or not - we may not be able to remove it, but if we can change the patient's manner of living so that he can five like other people, - we have attained what we want. We want to take the patient away from invalidism, and from anything that tends to keep him in that condition.

Here too, in achylia gastrica, while at first we are strict in having these patients live on fine foods, step by step we introduce other things, and arrange so that in time they can digest ordinary diet. It takes time - a month, perhaps two or three months, - but that should be the aim. I usually find that these patients with achylia can live twenty, thirty, or forty years and even become normal individuals. If you can bring them to a state where they can enjoy a normal meal, they are practically well. The intestine is strengthened in such a way that it learns to do the work which the stomach ought to do. That can be done by a gradual change of diet, increasing it step by step. This principle must extend to all chronic conditions.

Another point of great importance. Many of these dyspeptic individuals - no matter what the character of their digestive disease - have been forbidden a great deal, and have lived with so little nourishment that they are in a condition of subnutrition. They are run down, and cannot do anything; they lead lives of invalidism, lie on a lounge, etc., and many of them gradually die of starvation. The nerves are not nourished; all the organism is in a state of inanition, like a business in which there is too little money. Such a business cannot go on well. So with the organism. If the body has not enough food, it takes a little of its own fat and muscle, and that will not do. That is what these patients really represent. They are dizzy and have no appetite, and are weak - all symptoms of inanition. If we treat these patients by giving them a diet on which they have just enough to lead their existence, they will never get well, for they remain in that weakened condition. But if we can feed them up - increase their diet, give them more food than they need, build them up - we can get them well. The question in all these cases is - can you do it? My answer would be that in nine cases out of ten, or perhaps still more, you can do it, provided there is no organic lesion present - no cancer, no obstruction; simply a lack of nutrition, some functional disturbance. From my experience, I would say that in more than nine cases out of ten you can succeed in changing such an individual and building him up.

The question is: How to do it? I answer: First change the diet, and change it gradually, as I said before. You cannot do it in a day. The intention is to have the diet similar to what the patient has been having, only we make it more nutritious gradually. Suppose you have succeeded in changing it and the patient now takes three meals a day, and you want him to gain flesh. This applies not only to diseased individuals, but to any one. We have a number of thin persons here, some of whom might like to gain a little flesh. Some one may want to gain, but he says, "my family is thin, we are all thin; I cannot do anything." That is what people usually say: "We are all thin; that is the way we grew up".

But such people can be made stouter. We. can make them gain if they carry out what is needed. Such a person takes for breakfast, say a cup of coffee, an egg, and a roll. If we want him to gain, we must try to make this bill of fare more nutritive. Instead of coffee, we say, take two parts of milk and one part of coffee; then he has more milk. Then we tell him to take a great deal of butter on his bread, and to take two eggs instead of one, and butter with them. Then for lunch, do the same way. Make the foods which he has been taking more nutritious, take more cream, more sugar. If the patient has been just maintaining his weight all the time on his former diet, make the drinks more nutritious. In a week or two he will report that he has gained a pound; if he keeps it up, he will gain more - if he keeps up the same amount of work. Now he begins to take more milk and more butter. What he does not need to maintain his balance goes to make more flesh. If you want some one to gain and he has been walking three miles a day, and it is essential that he should gain weight, have him take between meals a glassful of milk and bread and butter. At first he will tell you that his appetite is not so good for the next meal, but he will soon get used to it. That is practically the way I proceed with these patients where it is necessary to build them up. Have them take their regular meals and add two small meals in between. I lay much stress on the amount of butter. Tell them to eat a quarter of a pound of butter a day. A quarter of a pound of butter contains almost a thousand heat units. If he eats a quarter of a pound of butter a day, he has a thousand heat units added, which he does not need for living, and it goes into fat. Butter is easily taken up - you can put it in oatmeal, eggs, on bread, etc. The patient enjoys it, and eats more. So butter is a very important article of food, in those cases, where it is essential to increase the body weight, and it is essential in many instances.

If a man is all right, leads an active life, that is all right. But if he is very thin, barely covers his expenses, if he gets sick he has not much to draw upon, so it is well to have a reserve fund of flesh to draw upon.

The same principle can be turned around. Normally, we should be just right - not too stout, not too thin. There should be harmony and symmetry in our organism, and if a person looks just right, you can judge by the appearance that he is all right. But if you grow clumsy and can hardly move about, that is not well. Can you reduce the weight of such persons by diet? Yes. But there again is a point of great importance, that is, exercise. If you have a stout fellow taking food that just keeps him in his balance - he does not gain and he does not lose, and you want him to lose and still you do not want him to reduce his bill of fare too much, for if you make him take too little he may have some heart complications - increase his exercise. If he is used to walking two miles a day, make him walk three or four, and then five, or make him climb a mountain, and with the same food he begins to lose gradually. That is the best way of reducing flesh; but if you see that he is eating too much, eats enough for three people, then reduce his food. Instead of taking milk, give him coffee and tea for breakfast, and take away the butter; and if he eats between meals, tell him to have three meals instead of five. Treat him the opposite way from the management of increasing weight and you can succeed in reducing flesh.

People can increase or diminish bodily weight at will, provided these instructions are carried out. It is far more difficult, however, to make a stout man thin than to make a thin man stout, because what you want is not to the fancy of the corpulent man, though it is all right for the thin man, for he soon learns to enjoy his food But the stout man does not want to give up his butter, and keeps on eating a little more than he needs. Otherwise it would be as easy to reduce as to fatten an individual. You car succeed even here in nine cases out of ten, provided all the instructions are rigidly carried out.