According to von Noorden,3 the body during total abstinence burns up about 1 gm. of albumin and 3.5 gm. of fat per day and kilo of bodily weight.

Samuel describes the symptoms of complete inanition as follows: "The feeling of hunger is most intense after twenty hours, and disappears after that; the feeling of thirst, however, remains until death. The mucous membranes become dry; weariness, weakness, and faintness are pronounced. The loss of weight is continuous. The mental faculties remain clear until the last. Sub finem vita albumin and mucin appear in the urine. The temperature sinks to 30° C. during the last twenty-four hours, and death occurs amid extreme prostration, deep coma, at times delirium and convulsions. During absolute abstinence death supervenes between the twelfth and twentieth days. If water is taken, life may be sustained for forty to seventy days. Forty per cent of the bodily weight is usually lost before death."

1 "Bericht fiber die Ergebnisse des an Cetti ausgefubrten Hungerversuches." Berl. klin. Wochenschr., 1887, p. 42. 2 "DasHungern," 1890. 3 Berl. Klinik, 1893, Heft 55, p. 1.

Incomplete inanition or subnutrition is frequently met with. In relatively few cases we have to deal with conditions in which the organism is unable to utilize larger amounts of food (carcinoma cardiae, seu ventriculi, seu pylori - extreme degrees of benign stenosis of the pylorus, infectious diseases during the febrile period). In most cases of subnutrition, however, we have to deal with conditions in which the organism would be perfectly capable of utilizing food if it were supplied to it. These are, therefore, conditions in which amelioration is possible.

Subnutrition begins as soon as the usual amount of food is diminished. The daily physiological quantity of food is about 100 to 130 gm. of albumin, 70 to 120 gm. of fat, 350 to 400 gm. of carbohydrates, 2,500 to 3,000 gm. of water, and 14 to 32 gm. of inorganic salts. Besides we inhale 744 gm. of air. The total amount of new material that is daily ingested is about 4 kilos, or about one-fifteenth of the total bodily weight. Expressed in calories, the body needs daily for each kilo about 35 to 40 calories during rest and 40 to 50 during hard work. If less food is taken an incomplete inanition results, which manifests itself by anaemia and loss of weight. Incomplete inanition, qualitatively - as, for instance, total abstinence from water, even such as occurs in solid food - leads, according to Samuel, to death just as quickly as complete inanition. On a purely albuminous diet the body fat disappears, and on a diet consisting of fats or carbohydrates alone the bodily albumin diminishes. A diet deficient in salts is badly borne. Digestive disturbances arise and nervous symptoms (trembling, muscular weakness) and death follow.

In practice we meet less often with a one-sided subnutrition (one deficient in a qualitative way) than with general subnutrition. The latter is encountered in the greater number of dyspeptics. I would like to cite here some examples from my practice as I meet them every week - in fact, almost daily - in order to show how much less food dyspeptics take than the physiologically required quantity:

Case I. (March 15th, 1903)

Mrs. Sadie M - , aged 38 years, complains for the last six years of pains about half an hour after meals, and much belching. She weighed formerly 168 pounds, and has decreased to 100 pounds in five years. She feels weak, without energy, sleeps poorly, and has pains after meals. She fears to eat on account of pain. During the last four months she has lived as follows:

The patient took daily 12 1/2 calories per kilo weight.

Case II. (September 24th, 1902)

Mrs. F. H -, aged 38 years, has complained for two years of a feeling of constriction in the upper abdominal region. Appetite was increased, bowels were regular. During the last year she has lost 25 pounds (weighing originally 120 pounds and going down to 95 pounds).

She felt very weak, being hardly able to walk upstairs. During the last year the bill of fare of the patient was as follows:

The patient was therefore taking food of a nutritive value of 22 1/2 calories per kilo daily.

Case III. (March 6th, 1903)

Lena F ------ began to suffer a year ago from pains in the stomach, occurring one hour after meals. She was told by a physician to fast six days - i.e., not to take anything at all at first and later only a little liquid food. She did this and was reduced from 100 pounds to 80 pounds. Afterward she slowly recovered and felt quite well for several months; she gained in flesh so that she weighed 104 pounds. 4

About four months ago the patient began again to experience pain in the stomach after meals; she ascribed this to various articles of food, and gradually eliminated one after the other from her dietary. She steadily lost ill flesh and weighed but 89 pounds when she first consulted me. Her diet then was as follows:

As patient weighed 89 pounds, she was taking on an average a daily amount of 26.4 calories per kilo.

These three cases suffice in order to show how gravely the nutrition of the organism must suffer if for long periods on an average only about two-thirds (sometimes even one-third) of the food necessary to maintain the equilibrium is taken. If we study the above figures nobody will be surprised that such patients steadily decline and complain of weakness and various nervous disturbances. What is rather to be wondered at is the fact that such patients linger so long in their miserable condition and do not succumb sooner.