CHAPTER XI

THE FEEDING OF ADULTS IN DISEASES OF THE GASTRO-INTESTINAL TRACT

ACUTE AND CHRONIC GASTRITIS

~Predisposing Factors.~--The majority of diseases affecting the stomach have as their predisposing factors, and owe their development to, one or all of the following conditions: (1) errors in diet; (2) disturbed secretory processes; (3) disturbed motility and tone.

It is probable that in the beginning the first factor was the chief offender in the case, bringing about the development of one or both of the other conditions. The other factors to be considered in this respect are heredity, occupation, poverty, and diseases which involve to a greater or lesser degree the digestion of the stomach and intestines. A child may inherit a weakened organism through excesses or disease on the part of the parent. If this weakness is not overcome while the child is growing, the probabilities are that the digestion steadily declines until in adult life it becomes a pathological condition. Lack of fresh air, poor and dirty food, unwholesome surroundings, crowded and badly ventilated sleeping rooms, insufficient water, and overwork, all act in making the digestion bad. These must be overcome if permanent good is to result.

~Errors in Diet.~--Errors in diet arise more often through ignorance than from any other cause. A child may be allowed to eat any and all kinds of unwholesome and unsuitable food. When the stomach rebels, showing the serious danger signals of nature, medicines are given but the diet is unheeded, until the time comes when even the medicines fail to give temporary relief, and the organs of digestion are in some instances permanently impaired.

~Disturbed Secretory Processes.~--Consensus of opinion goes to show that the majority of cases of acute and chronic gastritis (catarrhal) and gastric ulceration are due primarily to a disturbance of the secretory processes, while the impaired motility and lack of tone in the stomach probably influence their development and aggravate the disease already present.

~Composition of Gastric Juice.~--In a former chapter the processes of gastric digestion were explained. The gastric juice, composed of from 0.2 to 0.3% free hydrochloric acid and several important enzymes and lipases, which act upon the proteins and emulsified fats, must be sufficient in quantity to assure good digestion, and when anything arises to interfere with the secretion of this fluid a deviation from the normal is bound to occur.

~Disturbed Motility and Tone.~--Again, it has been proved that good gastric digestion, like good intestinal digestion, depends more or less upon the way in which the food mass is mixed with the digestive juices and moved along the alimentary canal. Anything which interferes with the secretion of the juices or delays the food over its normal length of time in the stomach surely exerts unfavorable influences on the general metabolism of the food, for while, as we have already found, gastric digestion is not essential to the final utilization of the food in health, in disease it undoubtedly exerts a marked influence upon the general nutrition of the individual.

HYPOCHLORHYDRIA

The lack of hydrochloric acid in the gastric juice lowers the resistance to bacterial action, for this constituent exerts a decided germicidal influence in gastric digestion, preventing fermentation with the production of organic acids and probably alcohol. In conditions due to hypochlorhydria (lack of hydrochloric acid) foods which leave the stomach quickly must be given with enough of the other necessary constituents in their simplest and most easily digested form to balance the diet and prevent the occurrence of the other disorders as troublesome as the original disorder.

~Dietetic Treatment.~--The following points must be kept in mind in formulating a dietary for patients suffering from a deficiency of hydrochloric acid: (1) boil the drinking water to destroy any bacteria which may be present; (2) use carbohydrates in the form of starch rather than sugar, since starch is less liable to fermentation from bacteria than sugar; (3) limit the foods which delay the passage of the food mass from the stomach; fats pass into the duodenum more slowly than other foods and when fed with other foods delay their passage materially; (4) avoid the use of soda bicarbonate, as it tends to reduce the normal acid content of the stomach, thus preventing its germicidal action upon the fermentative bacilli; alkaline carbonates likewise inhibit the flow of gastric juices; (5) give especial attention to the attractiveness of the food served; let it be appetizing and savory, for by such means is the appetite juice and incidentally an increased flow of the gastric juices stimulated; (6) condiments and spices, meat broths high in extractives, and salt foods such as caviar and endives may be given at the discretion of the physician; it is seldom advisable to give the foods which are indigestible, even when they act as stimulants to the secretory cells of the stomach.

HYPERCHLORHYDRIA

(Excess secretion of acid in the stomach)

~The Effect of Excess Acid.~--An excessive flow of hydrochloric acid has been found to be the cause of much of the acute and chronic gastritis, in fact more of the cases are traceable to an excess than to a lack of hydrochloric acid. This acid is more or less irritating in character, and the tender mucous membranes lining the gastric organ being constantly bathed in a secretion composed chiefly of acid must necessarily in time suffer a certain amount of irritation and inflammation, causing the development of a pathological condition which may be temporary or permanent, that is, it may result in acute or chronic gastritis, according to the amount of acid secreted and the length of time the hypersecretion is allowed to continue.

~Determining the Acid Content of Stomach.~--The difference between the cases brought about by an excess flow of hydrochloric acid are more or less difficult to distinguish from those caused by a lack of this constituent in the gastric juice, chiefly because in the latter case the organic acids formed as the result of bacterial action upon the food exert an equally irritating effect upon the membranes of the stomach, and the only sure method of determining the cause of the disturbance is by an analysis of the stomach contents, by which means the percentage of hydrochloric acid is determined.

~Lavage.~--It has been found advisable, in some cases of acute gastritis which do not yield readily to rest and liquid diet, to wash the stomach and allow a certain period of rest before giving any food; in this way the organ is rid of all of the offending material and thus has a better chance of a quick recovery.

ACUTE GASTRITIS

~Dietetic Treatment.~--The following dietetic treatment for acute gastritis is advised: As the stomach is the chief seat of disturbance, all unnecessary work must be taken from this region for a certain period:

(1) That any obscure cause may manifest itself and the diagnosis may be rendered more accurately and more quickly.

(2) That by resting the organ the offending materials may pass out of the body and thus prevent further trouble.

~Starvation Period.~--Twenty-four hours of total abstinence from food may seem extreme, but as a rule in acute cases of gastritis it is the only sane and safe method of instituting a diet and thus beginning to overcome the cause of the disturbance. After the period of starvation the diet is begun with caution.

~Fluid Diet.~--Fluids should be given first in the form of well-skimmed broths, which may be reenforced with egg or cereal flours when the patient is very thin or anemic. Buttermilk, made with the Bulgarian cultures, koumiss and other fermented milk foods, liquid beef preparations such as peptonoids or panopepton, albumenized orange juice, cereal gruels treated with Taka diastase when it is found necessary, and peptonized milk. These may be given in from four to six ounces at a time, every two hours on the second day.

~Increasing the Diet.~--On the third day if the attack is slight the diet may be increased by adding toast, softened with peptonized milk, an ordinary serving (3 ounces) of farina, cream of wheat or rice, reenforced meat broth with two crackers, a cup of tea and a slice of toast, and one or two soft-cooked eggs. If the acute symptoms are still present on the third day, the diet advised for the second day must be continued until they disappear.

~Convalescent Diet.~--On the fifth day, if progress is satisfactory, lightly broiled chicken or a small piece of rare broiled beefsteak may be added to the diet and the meals reduced in number from six to four.

~Relapse.~--The patient must be warned against overeating or eating any of the articles which are known to cause an acute attack in his individual case, since one attack predisposes to another, and chronic gastritis may develop as the result of the continual gastric disturbance.

CHRONIC GASTRITIS

The treatment in chronic gastritis is very like that in the more acute form; that is, it must be combated by removing the cause. Lack of fresh air and exercise have much to do with the development of chronic gastritis, but even they combined with a judicious amount of rest would be wasted without a proper adjustment of the diet to cover the main points of the disturbance. As has already been mentioned, the cause may be a lack of gastric juice or it may be an excess of it; it may be intensified by an ~atonic~ condition of the organ or from the food passing too quickly into the duodenum.

~Test Meals.~--As a rule it is not safe to make a snap diagnosis as to the cause of this disorder. Since in many instances the more serious disorders may be traced to a disregard for nature's danger signals, the physician as a rule advises a test meal, this meal consisting of a glass and a half of water or a cup or two of tea without cream or sugar and from one to two slices of toast or water rolls. In from three-fourths to one hour or longer this is removed from the stomach by means of a stomach pump and analyzed, the result of the chemical and bacterial analyses forming the basis for diagnosis. This meal is generally given in the morning before any other food has been eaten.[92]

~Dietetic Treatment.~--The foods constituting the diet in chronic gastritis must be of the simplest character and prepared in the simplest manner. No fried foods are permissible. Pastries, griddle cakes, rich puddings and sauces, candies, and alcoholic beverages must be omitted from the diet as well as the following articles of food: pork, veal, shellfish except oysters, sardines, canned meats and canned fish, highly seasoned and spiced dishes, twice-cooked meats, vinegar, pickles, olives, cold slaw, pickled beets, catsup, mustard, coarse fibered vegetables such as cabbage, old onions, old turnips, and cucumbers, strong tea, coffee, or chocolate, rich cream or dishes made entirely of cream. In cases of excessive acidity due to a hypersecretion of HCl the extractives of meat are contraindicated, hence all gravies and outside parts of roasted meat must be omitted or limited in the diet.

GASTRIC ULCERATION

Gastric ulcer may develop without an apparent cause. As a rule, however, it manifests itself in individuals between the years of fifteen and forty, particularly after prolonged digestional disturbances, especially those accompanied by a hypersecretion of acid. As the disease progresses, anemia is more or loss severe, adding difficulty to the feeding problem. Many of the symptoms are like those of chronic gastritis, such as pain. However, the character of this pain may be different, beginning soon after eating and radiating toward the back. This point may be affected by position. As a rule there is a tenderness over the seat of the ulcer. This is detected by palpation. Vomiting is one of the most general symptoms in gastric ulceration. This may begin from one to two hours after eating when the pain is at its height, or it may start as soon as food enters the stomach. As a rule the latter condition is found more often in very nervous women whose mental attitude affects the stomach to such an extent as to make it difficult to give them sufficient food to nourish them.

~Hemorrhage.~--Hemorrhage occurs in about half of the cases. The bleeding may be profuse and the blood bright red, or it may be less severe and the color of the blood changed by contact with the gastric juices to a dark brown like coffee grounds.

~Excess Acid.~--Hyperacidity is present in the majority of the cases, the percentage of HCl rising at times fifty per cent. or more. Other cases occur in which all of the just mentioned symptoms except dyspepsia are missing, the first intimation of the ulcer being hemorrhage or perforation.

The patient with gastric ulcer may recover entirely and never have a return of the trouble, but care and close attention are necessary, since the ulcers are apt to recur, at times a series of ulcers developing one after another. Death may occur from exhaustion or from perforation and peritonitis. Surgical intervention is as a rule necessary when the ulcers persist, as they generally develop at or near the pyloric opening; and the constant development of cicatricial tissue brings about an obstruction of the pylorus, which if not relieved would allow the patient to starve.

~Diet Treatment.~--There are a number of treatments used in overcoming this condition. After the test meal and the diagnosis, the patient is placed upon a diet directed to overcome the chief symptom; for example, if the ulcer developed as a result of hyperacidity, the diet would be directed toward the relieving of that symptom. Boas[93] divides the treatment into three stages: (1) hemorrhage; (2) the intermediate stage; (3) the convalescent stage.

~Starvation Treatment.~--The majority of physicians institute a total abstinence period for the first stage, allowing no food or water to be taken by mouth. If the patient is very weak and anemic from the extended course of the disease, nutrient enemas are given from four to six times a day, alternating with saline enemas. This total abstinence continues from three to six days. Some cases have been known to be fed in this way for a month or six weeks with obvious success. However, this is not the rule but the exception. The diet must be adjusted to the needs of each individual, but a few general rules may be found helpful.

~Dietetic Treatment.~--Milk is the food generally utilized in the beginning. This may require peptonizing to be digested, or it may have to be modified with limewater. Protein foods require HCl for their digestion. If these foods are fed they will absorb some of the excess acid, and in this way save the already irritated wall of the organ from additional irritation. When protein foods are given they must be in the form of soft-cooked eggs, scraped raw beef or beef juice, milk soups, and like protein foods.

When there is a dilatation of the organ there is more or less danger of fermentation taking place, with the formation of organic acids. These acids are exceedingly irritating, and every care must be observed to prevent their production. The following dietetic regime may be used as a guide in many cases of gastric ulceration:

~Milk Diet.~--1/2 glass (4 ounces) of milk peptonized at 115 deg. F. for 20 minutes, every hour for three or four days. After this the interval between feedings is lengthened to two hours and the amount of milk increased to 3/4 of a glass (6 ounces). This is continued from a week to ten days. The patient may be given a cup of well-strained meat broth, reenforced with an egg, once or twice a day, to vary the monotony of the diet. During the third week the milk may be given in the form of milk soups. These may be slightly thickened with barley, rice, or farina flour. The soups may be flavored with beef extract, but only a small quantity must be used, owing to the stimulating properties of these substances.

~Water as a Stimulus to Gastric Secretion.~--Water is exceedingly stimulating to the acid secreting cells of the stomach, hence it is advisable to limit the amount of water taken by mouth, allowing the patient just enough to wash out the mouth without swallowing any. The thirst is relieved by saline enemas.

It has been found, in many cases of gastric ulceration, especially those accompanied by hemorrhage, that glucose gives better results when used in rectal alimentation, than any other substance. The strength of the solution varies from a five to a twenty-five per cent. solution. The number of glucose enemas given each day must be regulated by the physician. The method used is the same as in other rectal feedings, the enema is given "high," and the flow regulated (drip-method).

~Convalescent Diet.~--During the fourth week, if the pain and discomfort are decreasing, soft-cooked or creamed eggs may be added to the diet, together with thoroughly boiled rice, farina, cream of wheat, wheatena and other finely ground wheat foods, wine or fruit jelly, sweetened slightly, or by using a small amount of saccharin for the purpose, junket and plain vanilla ice cream. At the end of the fourth week a very small portion of meat may be given once a day. It may be scraped raw beef spread upon toast or zwieback, or very lightly broiled beefsteak, broiled lamb chop or chicken (breast only), or boiled or broiled sweetbreads or brains. Spinach or green peas pressed through a sieve are the first vegetables allowed. After these young tender carrots and string beans may be given. Tea, coffee, and chocolate are eliminated from the diet. Milk flavored with coffee or cocoa may serve as a hot drink in the morning when the desire or need for such a drink is manifested. Butter is the best form of fat to be used in cases of gastric ulceration, but this must be given with the greatest caution. In cases where this fat is used in the form of cream, the amount must be cut down or entirely abandoned when there are evidences of butyric fermentation. Buttermilk, koumiss, and other fermented milk drinks are often found very satisfactory adjuncts to the diet. These may be given between meals, or at meals they may be substituted entirely for the milk when other foods are being given. They are not sufficiently nourishing to take the place of the milk diet otherwise. Albumenized orange juice and cream, egg and vichy may be given to add variety to the diet.

~Anemia.~--When anemia is severe, as is often the case in gastric ulceration, the diet must be reenforced to overcome it. Some of the concentrated milk foods such as plasmon, encasin, sanatogen, etc., as well as the predigested meat foods, such as panopepton, liquid beef peptonoids, and like preparations, may be used to reenforce the diet.

~Bland Diet.~--In certain cases of gastric ulceration it has been found more advisable to use what is known as a bland diet. This consists of farinaceous foods such as farina, arrowroot, cream of wheat, corn meal, wheatena, malted breakfast foods cooked thoroughly and given in the form of gruels, and some of the proprietary infant foods, such as Mellin's Food, Eskay's Food, Racahout. These foods may require the addition of Taka diastase to make them more readily digested. They leave the stomach more rapidly than any of the others, and for this reason will be found to give less discomfort than the foods containing a high percentage of protein and fat. This diet, however, cannot be prolonged on account of its lack of balance. If the gruels are made with milk instead of with all water they become more evenly balanced. Samples of the stomach contents may be taken for analyses from time to time.

~Lavage.~--When lavage is necessary the patient must be allowed to rest after the process before being given food, otherwise it is apt to be vomited.

~Instructions to Nurse.~--The treatment for gastric ulceration is thus seen to be strenuous. In the beginning the patient is placed on a liquid or semi-solid diet, or is not fed at all for a time. This is done that the diseased organ may have a chance to adjust itself as far as possible and to give the physician an opportunity of studying the changes taking place in that organ. During the course of the disease the general symptoms which develop from time to time, causing more or less pain and discomfort to the patient, are nervousness, which in some individuals amounts to melancholia, extreme anemia and an utter distaste for food, all of which require patience on the part of the physician, the nurse, and the patient herself to overcome. The nurse must see that the patient is not disturbed or made unhappy by having business or home cares talked over in her presence; she must be kept as cheerful and as comfortable as her condition permits and urged to use care in her diet. After the ulcer is healed, to prevent a return of the trouble she must be warned against eating too fast or when over-tired, and she must be advised against very hot and highly seasoned foods, for, in the observance of these simple common-sense precautions only is she even in a measure saved further attacks.

~Special Diets Used for Gastric and Duodenal Ulcer.~--There are several well-known diets used in these conditions. Among those that have been found most satisfactory may be mentioned the Sippi diet, the Lenhartz diet.

All of these diets require the most careful adjustment as to regulation of intervals of feeding, type of food material used, and method of preparation and administration of food.

The treatment is directed toward the reduction of the free hydrochloric acid in the stomach in order that the ulcer may have an opportunity for healing.

~Sippi Diet.~--Equal quantities of heavy cream and whole milk, beginning with 1/2 ounce each every hour during the day. Alkaline powders are given with the meal and one-half hour after the meal. These consist of 15 grains each of sodium bicarbonate and bismuth subcarbonate with the feeding, and 10 grains of light oxide of magnesia and 15 grains of sodium bicarbonate between feeding. The cream and milk are increased at the rate of one-half ounce each at each feeding for two days, the powders are continued as on the first day. On the fourth day an egg is added to the diet, the milk and cream are given in quantities of one and one-half ounce each, every hour. On the fifth day two eggs are added. On the sixth day one helping of oatmeal or other soft cereal is added to the above diet. The diet is in this way increased until the patient is taking three eggs and nine ounces of cooked cereal each day in addition to the cream and milk mixture. The amount given at one time must be small, never exceeding six ounces (according to Carter, Howe and Mason).

An accurate control of the acidity of the stomach should be maintained, this is accomplished by withdrawing a certain amount of the gastric contents by means of the stomach tube.

~The Lenhartz Diet.~--This diet is likewise given in hourly feedings, consisting of milk and raw eggs in the beginning, then a small portion of sugar is added, next scraped beef is added to the milk, eggs and sugar, already given, then boiled rice. Next a small quantity of zwieback (or soft toast), and continuing in this way, chicken, and butter are admitted. In the beginning the quantity of milk is 100 c.c. and the number of eggs 2, given raw. It is served iced, and with a teaspoon. When the sugar is added it is beaten up with the eggs (20 gm.). The milk and eggs are divided into separate feedings and given at hourly intervals from 7 A.M. to 7 P.M. It is rarely possible to give the amounts called for in the Lenhartz diet after the sixth day, but as much as possible should be given without risking an acute disturbance. Women, as a rule, find it more difficult to take the full amount ordered than men.

The following outlines represent the diet for the first, third, sixth, seventh and tenth day:

FIRST DAY

7 A.M. Egg 8 A.M. Milk, 20 c.c. 9 A.M. Egg 10 A.M. Milk, 20 c.c. 11 A.M. Egg 12 noon Milk, 15 c.c. 1 P.M. Egg 2 P.M. Milk, 15 c.c. 3 P.M. Egg 4 P.M. Milk, 15 c.c. 5 P.M. Egg 6 P.M. Milk, 15 c.c.

Total: Milk, 100 c.c. Eggs (raw), 2.

THIRD DAY

7 A.M. Egg; sugar, 2 gm. 8 A.M. Milk, 50 c.c. 9 A.M. Egg; sugar, 3 gm. 10 A.M. Milk, 50 c.c. 11 A.M. Egg; sugar, 3 gm. 12 noon Milk, 50 c.c. 1 P.M. Egg; sugar, 3 gm. 2 P.M. Milk, 50 c.c. 3 P.M. Egg; sugar, 3 gm. 4 P.M. Milk, 50 c.c. 5 P.M. Egg; sugar, 3 gm. 6 P.M. Milk, 50 c.c. 7 P.M. Egg; sugar, 3 gm.

Total: Milk, 300 c.c. Eggs (raw), 4. Sugar, 20 gm.

SIXTH DAY

7 A.M. Egg; sugar, 4 gm. 8 A.M. Milk, 100 c.c. 9 A.M. Egg; sugar, 4-1/2 gm.; scraped beef, 12 gm. 10 A.M. Milk, 100 c.c. 11 A.M. Egg; sugar, 4-1/2 gm. 12 noon Milk, 100 c.c. 1 P.M. Egg; sugar, 4-1/2 gm.; scraped beef, 12 gm. 2 P.M. Milk, 100 c.c. 3 P.M. Egg; sugar, 4-1/2 gm. 4 P.M. Milk, 100 c.c. 5 P.M. Egg; sugar, 4 gm.; scraped beef, 12 gm. 6 P.M. Milk, 100 c.c. 7 P.M. Egg; sugar, 4-1/2 gm.

Total: Eggs (raw), 7. Milk, 600 c.c. Sugar, 30 gm. Scraped beef, 36 gm.

SEVENTH DAY

7 A.M. 1 soft-cooked egg 8 A.M. Milk, 100 c.c. 9 A.M. Egg; sugar, 13 gm. 10 A.M. Milk, 100 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm. 11 A.M. 1 soft-cooked egg 12 noon Milk, 125 c.c. 1 P.M. Egg; sugar, 13 gm. 2 P.M. Milk, 125 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm. 3 P.M. 1 soft-cooked egg 4 P.M. Milk, 125 c.c. 5 P.M. Egg; sugar, 14 gm. 6 P.M. Milk, 125 c.c.; scraped beef, 24 gm.; boiled rice, 34 gm. 7 P.M. 1 soft-cooked egg

Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 700 c.c. Sugar, 40 gm. Scraped beef, 70 gm. Boiled rice, 100 gm.

TENTH DAY

7 A.M. 1 soft-cooked egg 8 A.M. Milk, 166 c.c. 9 A.M. Egg; sugar, 13 gm. 10 A.M. Milk, 168 c.c.; scraped beef, 23 gm.; boiled rice, 66 gm.; butter, 4 gm. 11 A.M. 1 soft-cooked egg; zwieback (or soft toast), 20 gm.; butter, 4 gm. 12 noon Milk, 166 c.c.; minced chicken, 25 gm. 1 P.M. Egg; sugar, 13 gm. 2 P.M. Milk, 166 c.c.; scraped beef, 25 gm.; boiled rice, 66 gm.; butter, 4 gm. 3 P.M. 1 soft-cooked egg; butter, 4 gm.; toast or zwieback, 20 gm. 4 P.M. Milk, 168 c.c.; minced chicken, 25 gm. 5 P.M. Egg; sugar, 14 gm. 6 P.M. Milk, 166 c.c.; scraped beef, 24 gm.; boiled rice, 67 gm.; butter, 4 gm. 7 P.M. 1 soft-cooked egg

Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 1000 c.c. Sugar, 40 gm. Scraped beef, 70 gm. Minced chicken, 50 gm. Butter, 20 gm. Boiled rice, 200 gm. Toast or zwieback, 40 gm.

GASTRIC CANCER

As a rule the seat of the gastric cancer is the pylorus. The patient gives evidence of chronic gastritis with continued pain, localized tenderness, vomiting of partially digested food and at times dilatation from extreme fermentation. The hemorrhages are as a rule not large, the blood having changed to a brownish color resembling coffee grounds. Vomiting, in cases where the pylorus is involved, generally occurs several hours after eating, the vomitus being in an advanced state of fermentation. Upon analysis of the stomach contents there is found to be a lack of free HCl.

~Dietetic Treatment.~--In the dietetic treatment of cancer of the stomach the most digestible forms of foods must be given, milk forming in this, as in other gastric disorders, the chief article of diet. As too much food cannot be tolerated, the meals must be small, even if given more frequently. The patient is often found to evince a distaste for meat, in which case fish may be substituted. When meat is given, it must be simple in form and preparation, such as boiled or broiled sweetbreads or brains, scraped beef or stewed chicken. Rice, farina, cornmeal mush, and other fine cereals, cooked with or without milk, are valuable additions to the diet. Well-cooked and strained spinach, green peas, cauliflower, carrots, and tender string beans and boiled or baked potatoes well mashed may be recommended. Tea, coffee, or cocoa may be used to flavor the milk. These must be given in small portions. The following diet list is recommended by Friedenwald and Ruhraeh:

_Calories_ 8 A.M. 100 grams of milk with tea 100.0 30 grams of milk toast 130.0 10 A.M. 100 grams of baked trout 106.0 100 grams of milk 67.0 or 30 grams panopepton (57.5) 10 grams of butter 81.0 50 grams of toast 130.0 50 grams of sherry 60.0 12 M. Bouillon with 5 grams somatose 16.0 100 grams of chicken 106.0 or 100 grams squab (100) or 100 grams of calves' sweetbreads (90) or 100 grams of calves' brains (140) 60 grams of macaroni 212.0 or 100 grams of mashed potatoes (127) or 100 grams of spinach (166) or 100 grams of asparagus (18) 25 grams of stale wheat bread 65.0 4 P.M. 20 grams of toast 130.0 20 grams of butter 162.0 40 grams of caviar 52.0 7 P.M. 130 grams of milk (100) with 5 grams somatose (16) 116.0 100 grams of rice cooked in milk 177.0 50 grams of wheat bread 130.0 9 P.M. 30 grams of panopepton 57.5 ------ 2024.5

SUMMARY

FACTORS INDUCING GASTRIC DISTURBANCES

1. ~Errors in Diet.~--Over-feeding, under-feeding, improper food, unbalanced diet.

2. ~Disturbed Secretory Processes.~--

(a) Over- or under-secretion of gastric juice.

(b) An excess or deficiency of hydrochloric acid in the juices.

3. ~Impaired Motility and Tone of the Gastric Organ.~--The peristaltic waves and muscular contraction of the stomach walls becoming sluggish prevent the food mass from passing into the intestines at a normal rate of speed, thus giving rise to a fermentation of the food and a consequent dilatation of the organ from the gas thus produced.

~Other Factors.~--Lack of fresh air and exercise, indoor occupation, bad hygiene, unsanitary surroundings, heredity, certain diseases which are accompanied by gastric disorders.

~Diseases of Gastric Organ.~--Acute and Chronic Gastritis, Gastric-Ulceration, Gastric Cancer.

~Treatment.~--Tests--Test meals, X-Ray examinations (pictures and Fluoroscope). Patient is given no breakfast on day of test. In X-Ray laboratory a bismuth or barium meal is given, this meal consists of a pint of fluid, either buttermilk or malted milk, into which a certain amount of bismuth or barium chloride is mixed.

~Starvation Period.~--A period of abstinence from food is instituted in most of the gastric disorders, (a) to determine the extent and character of the disease, (b) to rest the digestive tract.

~Dietetic Treatment.~--Diet adjusted to meet the needs of the individual case as determined by the medical examination.

~Instruction to Patient.~--Individual warned against overeating, drinking and constipation.

PROBLEMS

(a) Formulate a diet order for a patient suffering from chronic gastritis. (Individual's food requirements must be observed.)

(b) Formulate a diet for gastric ulceration. List the available foods; the avoidable foods.

(c) Outline a diet to be used in case of gastric cancer; show how it differs from the one used in gastric ulceration.

FOOTNOTES:

[92] It is also customary to give the patient a bismuth or barium meal in order that an X-ray and fluoroscopic examination may be made to determine the character and extent of the disturbance.

[93] "Diseases of the Stomach," by Boas.