Excepting diabetes, which it is rather premature to consider as invariably a pancreatic disease, the diseases of the pancreas are, for the most part, either so fulminant as to afford no basis for dietetic management except that appropriate to surgical cases, or so insidious that diagnosis is practically impossible. Hence, it is impossible to discuss them from the standpoint of demonstrated pathogeny and practical experience but merely from the theoretic.

It is altogether likely that purely functional disturbances of the pancreas exist - or at least as purely functional as for the stomach. Analogous to hyperchlorhydria, there may be an excessive secretion of alkalies, indeed the two conditions may coexist. It does not appear probable, however, that such a supersecretion of carbonates can ever cause corrosive lesions. It is plausible, however, that excessive gasseous distention of the bowel, without evidence of heightened fermentation, is due to the acid gastric juice decomposing this excess of alkaline carbonates, with production of carbon dioxid. In such cases it is logical to reduce to a minimum the ingestion of sodium - mainly in the form of salt - and of potassium, and of the organic acids, as in vinegar and acid fruits, which yield carbonates in the system. Precisely analogous indications exist in hyperchlorhydria which, as stated, may represent a corresponding overthrow of the chemic balance. The beneficial effects of out-door life in hyperchlorhydria, may also depend partly upon the increased elimination of carbon dioxid by the lungs.

Conversely, the vague depression of digestive power and of general nutrition in persons taking little salt and vegetables rich in organic acids and the forms of anaemia that are benefited by alkaline treatment, may indicate disturbance ofpancreatico-enteric digestion due to deficient alkaline secretion, quite analogous to hypochlorhydria.

As in the case of the stomach, nothing is known as to the diagnosis or effects of an increase of ferments nor as to whether such a quantitative increase is pathologic.

Although moderate depression of pancreatic secretion may be masked by the destruction of nutriment by bacteria in the bowel, the appearance in the faeces of notable amounts of soluble protein or carbohydrate and especially of muscle nuclei, as well as the waste of excessive quantities of fat, undoubtedly indicates depression of the pancreatic secretion, provided that it cannot be accounted for otherwise. Individual differences in the utilization of nutriment and in the deposition of fat may also be due to the same fault. Especially in Addison's disease, but also in fevers, general malnutrition, medical and surgical shock etc., there may be emaciation on a liberal diet and even macroscopically, it may be evident that pancreatico-enteric digestion is imperfect.

If gastric digestion is normal or can be made so by artificial help, and the same evidences of lack of digestion appear in the faeces and in the general condition of the patient, pancreatic digestion may perhaps be assisted by administering pancreatin in salol-coated capsules. The general indication also exists to administer a simple, easily digested diet and to secure reflex stimulation of secretion by proper variety and appeal to the appetite, by thorough mastication and insalivation and by regular meals with proper rest during the first hour or two of digestion.

Since the pancreas digests all kinds of organic nutriment, no general line of selection can be followed, except to balance properly, the relative amounts of protein, fat and carbohydrate, with special reference to the evidences of particular lack of digestive function manifested in the faeces and by the patient's appetite. Thus individual cravings or distastes for fat, sugar, starch, protein, or rather for foods particularly rich in any of these, should usually be taken as valuable hints of digestive capability. Particularly in the case of children, should these hints be acted on unless obviously capricious.

While, in general, the proper performance of each stage of digestion, stimulates the secretion for the next stage, the fact that good nutrition can exist with a practically achylic stomach, shows that, if the achylia is permanent and not readily relieved, or if the attempt to restore gastric digestion by administering hydrochloric acid, is a failure, all our energies should be directed toward the pancreatico-enteric digestion and, in such cases, pancreatin may be administered and will probably not be spoiled by the stomach. Pancreatic predigestion is especially indicated in such cases.

Pancreatic lithiasis is rarely present and still less frequently diagnosed. It is always of alkaline type. It is obviously prevented, so far as possible, by the free use of water and by the use of meaty foods, hydrochloric and other mineral acids, ben-zoates and benzoic-acid containing vegetables, and the acidity of the urine may be considered the best available index to the administration of such substances, administering them if the urine is persistently of lower acidity than about 25 degrees. It may suffice merely to diminish fruits rich in vegetable acids which, by their decomposition into alkaline carbonates, tend to produce alkalinity of the body juices generally.

The general dietetic management of fibroid change and, especially of arterial sclerosis, with particular reference to prophylaxis, is also valuable in the way of tending to prevent not only pancreatic fibrosis but fulminant haemorrhagic lesions of the pancreas. In the management of hepatic sclerosis, it should be remembered that similar change is probably in progress in the pancreas.

The prophylaxis and treatment of obesity also tends to prevent the development of fat necrosis though, with the necessary pancreatic lesion and dissemination of the fat-splitting ferment, fat necrosis may occur even in the lean.

Malignant and other neoplastic lesions of the pancreas, septic, specific bacterial and parasitic lesions and traumatic lesions, are not amenable to direct dietetic rules but obviously require the use of a carefully regulated, easily digested diet, with assistance in the way of digestants and predigestion. As most of the more marked pancreatic diseases, aside from diabetes, are appropriate for surgical intervention, the general principles of diet in such cases, are applicable.

It should be borne in mind that the tests of the faeces are not very reliable to exclude pancreatic failure but, if abnormalities are detected, and are not accounted for by gross dietetic errors or by intestinal lesions, they point with considerable probability to genuine impairment of pancreatic function. Even the fatty stools of biliary suppression or obstruction, are not as marked an exception as might be supposed. In the first place, the absence of biliary pigment gives, macroscopically, an exaggerated notion of the amount of fat present; in the second place, a real excess of fat is due mainly either to joint pancreatic obstruction or to true impairment of secretion.