A FEW years ago I had the honor of reading a paper before this society, on "Dietetics in Diseases of the Stomach."2 To-night I wish to discuss more fully a few points which are of eminently practical importance, and which I had at that time broached only superficially. The majority of dyspeptics, or of patients suffering from chronic digestive disorders, are affected with functional or nervous derangements. Most of these patients suffer either from loss of appetite or from gastralgia, sometimes from both, and hence take inappropriate and insufficient nourishment. Thus some live on small quantities of peptonized milk; others on artificial meat extracts (beef-juice, liquid peptonoids, etc.). If these dyspeptics adhere strictly to this rigorous diet, they almost always depreciate more and more in health.

A marked fear of food is distinctly observed in all these cases. This symptom I would like to designate as "sitophobia" (fear of food). If the patients give in to this sitophobia - which frequently occurs - the dyspeptic symptoms increase more and more, even after the ingestion of small quantities of liquid and predigested foods. Soon varied symptoms of inanition manifest themselves, such as dryness in the throat, headache and dizziness, a feeling of decided weakness, intense anaemia, sometimes even pernicious anaemia.

1 Read December 21st, 1897. before the Section on General Medicine of the New York Academy of Medicine. Medical Record, January 1st, 1898.

2 Einhorn, M.: New York Medical Record, June 24th, 1893.

Should we therefore be astonished if such patients, addicted to this wrong course of living, gradually waste away and finally succumb.

Either inanition itself, or complications arising in consequence of malnutrition, may easily bring on a fatal issue. As a whole, it is rather surprising how long these patients can live in spite of insufficient nutrition. This goes to show how tenaciously the organism clings to life; it learns to economize its expenditures and to subsist on scanty means. This is the only explanation why these invalids, who, after at first losing considerably in flesh, subsequently maintain their slight bodily weight and are able to lead a meagre existence.

Gentlemen, the number of such emaciated dyspetics is not small, and every practitioner meets with a few of them every year.

I will now present a few points by means of which these cases may be recognized.

Generally speaking, the term dyspeptic signifies one who suffers from a chronic disorder of his digestive organs, without having, however, any organic affection.

We will have to determine, first, the presence of some protracted ailment (for one or several years); second, the absence of any organic disease (ulcer, stenosis) of the stomach or intestines. An examination of the gasric contents may be omitted in these cases, although the knowledge of the chemical conditions of the gastric juice may sometimes be useful with regard to the treatment.

How shall we treat such dyspeptics! Medicaments are not of much value or play only a subordinate part. The main factor lies in proper nourishment. These patients, who have abstained from most kinds of food for years, must now learn anew to eat. Their stomach and intestines very quickly adapt themselves to this new condition. First and above all, it is of importance to increase the quantity of nourishment; second, to provide a sufficient variety of foods. An ample but too one-sided diet {as a purely milk diet, or hot water and beef) is not suitable for a long period of time, for under this regimen there may be a partial lack of certain substances necessary for the welfare of the organism, and thus there may be exerted a deleterious action upon the economy.

In order to improve nutrition, two articles of food, which hitherto have been often avoided by laymen as well as physicians, play an important part. I mean bread and butter. In my previous paper I have already hinted at this topic; I now take the liberty of again discussing it.

Bread forms one-third of the total amount of ingested food in health, and, besides having nutritive value, serves the purpose of increasing the flow of saliva during its mastication. It also creates an appetite for other food.

Butter not only improves the taste of various kinds of food, but. is also in itself a nutriment of the greatest importance. The great number of calories which butter contains (100 gm. give 837 heat units, while the same amount of bread develops about 217) shows this in the clearest manner. Another advantage which butter presents is that its volume is only about one-third that of bread. A patient taking about one-quarter of a pound of butter a day receives therewith more than one-half of the heat units required. This quantity of butter is, according to my experience, well borne by most of the patients.

I now take pleasure in presenting to yon two cases, in which the main symptoms consisted principally of a deficient nutrition. By improving the latter the patients got well. These two cases I take at random from a large number of a similar character.

Case I

Miss G. M -, about 26 years old, suffered for the last five years continuously from marked dyspeptic symptoms. Severe gastralgia often appeared, which was frequently accompanied by vomiting. The appetite was not greatly decreased, but, fearing the pains, the patient abstained from most articles of food. Obstinate constipation was another of the troublesome symptoms present. The patient ran down very fast. She was treated by several eminent physicians, and as a last resort the ovaries were removed. Her ailments, however, persisted, and she steadily grew worse. When she first consulted me she reported that she had lost sixty pounds in weight. The patient was abed the greater part of the time, and lived exclusively on small amounts of peptonized milk and Wyeth's beef-juice.

A thorough examination of the patient did not reveal any organic disease of the digestive apparatus. A condition of enteroptosis was found, but this was not considered important. The patient was ordered to take more nourishment. She was placed (during the first week) on a fluid and semifluid diet; soon, however, the bill of fare was increased, and after about three or four weeks she partook of nearly all the plain and ordinary articles of food. During the first fortnight the patient continued to complain of manifold severe symptoms after meals, but soon her complaints grew less frequent and after a while entirely ceased. The patient was plentifully nourished in a methodical way (among other directions she was told to take one-quarter of a pound of butter a day), and she gained fifty pounds in weight in a period of five months. After that time she could be regarded as restored to perfect health. She could take long walks without fatigue, she rode a wheel, and attended to all her household duties.