While in acute diseases of the stomach we paid most attention to giving rest to the organ - for here even an insufficient nutrition and the loss of several pounds of bodily weight is not of much importance, as the quickly recuperating organism replaces the losses caused during the sickness by taking increased quantities of food - in the chronic affections it is of utmost and vital importance to see that sufficient quantities of food are taken.

The greatest number of stomach patients consulting the physician, after the disease has been progressing quite a while, have lost more or less weight. The principal reason for this lies in the fact that the body has received too small a quantity of nourishment in order to replace the waste.

The ordinarily insufficient appetite, the early appearance of a feeling of satiation, the pain often appearing after meals, and less frequently vomiting, are the principal factors of subnutrition.

At this point it becomes necessary to divide patients with stomach troubles into two large classes:

1. Those with organic lesions of the stomach. 2. Those with functional disturbances.

The first class comprises (a) the malignant diseases of the stomach itself or its orifices (carcinoma ventriculi, cardise, pylori); (b) cicatricial strictures of the cardia or pylorus; (c) absence of secretory work of the stomach: achylia gastrica.

In this whole first class, with the only exception of group c, which lies, so to speak, between the first and the second class, we are unable to accomplish much either by treatment or dietetics. In existing strictures of the cardia or pylorus one will be obliged to seek surgical aid. Even in cancer of the stomach-wall the resection of the affected part is advisable whenever the operation is possible. I cannot abstain from calling attention at this place to the splendid results of the recent stomach surgery, which of late has been frequently practised in our own country (F. Lange, N. Senn, R. Abbe, Willy Meyer, McBurney, Weir, Murphy, MeGraw, Mayo, Bull, Markoe, Syms, and others). In carcinomatous strictures a new passage can be established, either for bringing food into the stomach by a gastric fistula, or for allowing it to pass into the intestines by gastro-enterostomy. In this way one succeeds at least in temporarily giving these unfortunate ones relief and in ameliorating their nutritive condition. In the cicatricial strictures one is warranted in promising to the patients, nowadays, perfect recovery if they will submit to operative treatment. (In stricture of the cardia a methodical dilatation of same with bougies may sometimes also suffice.) The pyloro-plastic operation (of Heincke-Mikulicz) and the cardiotomy or cardie-fissure (Abbe) belong to the most beautiful and beneficent operations which have ever been practised. After the operation the patients are enabled to eat everything and to live without any trouble whatever, i.e., they are perfectly cured.

Before the operation, or if such is not feasible, one will administer light, very slightly irritating nourishment, and always endeavor to make the patient partake of a larger quantity of food. If there is obstinate and constant vomiting, it is necessary to employ nutritive enemata.

Group c, achylia gastrica, will be advantageously discussed in regard to diet under Class 2.

The second class of functional disturbances includes the largest number of all dyspeptics. Here stand uppermost chronic gastric catarrh, atony of the stomach, dilatation of the stomach, gastroptosis, superacidity, with or without hypersecretion, nervous gastralgia, vous dyspepsia, and, as an intermediary between the first and the second class, achylia gastrica.

It appears advisable to discuss first the whole class, and thereafter to give special rules for the different groups. Liquid food or partly predigested substances (as all peptone preparations) are not in place here. By making the stomach work too little, the weakened condition of this organ is retained and aggravated in time. We must always bear in mind the principle of strengthening the organ by means of appropriate work.

Delafield 1 is said to express himself in his lectures in the following way regarding the dietetics of the dyspeptic :

When a dyspeptic patient asks you the question, "What shall I eat!" reply, "Eat what you like." If he asks, "How much shall I eat?" say to him, "Eat as much as your appetite demands." If he still asks, "When shall I eat!" answer, "Eat when you are hungry."

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 often have lost the feeling of self-regulation, and as a rule partake of too small quantities of food, (Only in a few cases of boulimia there may be an increased desire for food, and in connection with it the quantity of nourishment 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 heat sign that he takes sufficient nourishment. Besides, we must remind patients to lead a regular life, to eat slowly (how many, especially in our country, sin against this natural law), and to chew well and tritnrate the food. One must avoid either extremely cold or extremely warm food. Too copious and too complicated meals must be strongly forbidden.

1 Cited from Kellogg: "Methods of Precision In Disorders of Digestion," 1893, p. 4.

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 special indications for such a proceeding.