Dietetics, or the doctrine of nourishment, has taken an important part in the treatment of the sick ever since the time of Hippocrates; but, although the dietetics of the diseases accompanied by fever has not changed much in its chief points, new rules and principles regarding nutrition in chronic diseases have been introduced of late. This has reference especially to diseases of the stomach, that branch of internal medicine which in the last two decades has shown so much unlooked-for progress. As the therapeusis of diseases of the stomach has to deal with dietetics principally, I thought it would be of interest to discuss this subject before you. It will be expedient to divide the subject of diet in gastric affections into three parts:

1. General rules of diet in diseases of the stomach.

2. Dietetics in acute diseases of the stomach.

3. Dietetics in chronic diseases of the stomach.

1. General Rules Of Diet In Diseases Of The Stomach

Within the past two years important facts have been discovered which are of the greatest value in the treatment of diseases of the stomach, and the influence of which can be perceived like a red thread through the whole chapter of dietetics. It has. been shown by von Noorden1 and others that emaciation in chronic diseases of the stomach is caused in the largest majority of cases - if, perhaps, not in all - not by specific poisons circulating in the organism, but by a smaller amount of food being taken. On the other band, one might expect, judging from the universal law existing in the plant and animal kingdom of vicariousness or replacement in case of inability of the work of one organ by another similar one, that, in grave disturbances of the digestive functions of the stomach, the intestines would do the work instead. This has been experimentally, as well as clinically, proven in the most positive way. Several authors (Leube, Ewald, von Noorden) have observed that in cases of atrophy of the mucous membrane of the stomach, in which, as you all know, the gastric secretion has entirely ceased, the patients can maintain their usual weight. From my paper on achylia gastrica2 it is clearly seen that patients can do very well without gastric secretion; under a proper regimen they can even gain in weight and live long without any discomfort whatever. This means that, even after the loss of the entire chemical action of the stomach, the gut is completely able to replace the function of the stomach.

1 Read before the Medical Society of the County of New York, May 22d, 1883. Medical Record, June 24th, 1893. 8

These two facts - (1) that the emaciation in chronic diseases of the stomach is caused by too small a quantity of food; (2) that even in grave lesions of the gastric functions the gut appears to perform vicariously the digestive work in a complete way - are of vital importance for the doctrine of dietetics. For it is seen at a glance that the main object of nutrition of the sick consists in giving them sufficient quantities of food.

Before proceeding it is necessary to review briefly the normal physiological nutrition of man. We perceive at once that there is a great variety in the diet of healthy persons with regard to the quantity as well as the different food substances. Nevertheless, they all contain the three groups of food-stuffs - albumins, carbohydrates, and fats. Thus, for instance, vegetarians live and thrive principally on vegetables; the Esquimaux, on the other hand, almost exclusively on animal diet. The golden path, however, lies in the middle, and all authors (Voit, Pettenkofer, Hoffmann, Forster, and Gruber) recommend a combination of animal and vegetable food. E. Virchow, likewise, is of the same opinion, and expresses himself regarding this question as follows: "Although the Kirghez and the Esquimaux show us that health and life can exist through many generations on an exclusively nitrogenous diet - other tribes (Hindoos) live principally on non-nitrogenous food - still history shows us that the highest attainments of the human race have emanated from nations who have lived and live on mixed diet."

' Von Noorden: Berliner Klinik, Heft 55. 2 Max Einhorn: Medical Record. 1892.

A mixed diet, taken partly from the vegetable and partly from the animal kingdom, is the most suitable form of nourishment. We obtain the greatest amount of carbohydrates from the vegetable kingdom, while a great deal of the albumin is derived from animal food. The relation between animal and plant albumin, according to Munk and Ufflemann,' should not be less than three to seven. As regards the quantity of food, according to the same authors, an adult doing a medium amount of work requires daily 118 gm. albumin, 56 gm. fat, and 500 gm. carbohydrates.