Several writers have endeavoured to prove that the abdominal symptoms are the result of ill-fitting or too tightly laced corsets, which interfere with the proper position and action of the muscular viscera; but while extreme examples may produce such interference, the general weakness of the muscular walls must also help, and the symptoms are sometimes notable without any gross fault of this kind.
In another group of cases, the most careful examination fails to reveal any abnormality in the gastric functions, and the symptoms must be ascribed to mere gastric hyperesthesia.
It is evident from the above that the dietetic treatment of chlorosis is one of the main indications which has to be followed, and a satisfactory result is little likely to occur until the gastrointestinal functions are performed easily and well. A gastric ulcer or gastritis of course requires treatment of its special kind, which, however, is considered in detail elsewhere.
Whenever the gastric symptoms are severe, the patient should be kept in bed at absolute rest; for the defective intake entailed by their presence, tends to exaggerate the prevailing malnutrition, which, however, is minimized by the cessation of active exercise. Rest, too, is an excellent therapeutic measure in almost all gastric disturbances, and the symptoms are often rapidly lessened or abolished, quite apart from any special medication.
If vomiting is frequent, oral alimentation should be stopped for a few days, only sips of hot water containing bicarbonate of soda (10 gr. to 1 oz.) being allowed; and a mustard plaster may be applied to the epigastrium. Nutrient enemata may be utilized, but large saline injections (3 to 4 pints in the 24 hours) are usually sufficient to tide over the few days required. If vomiting is not severe, some oral alimentation is generally possible even at the outset. Milk, when diluted, is as a rule well borne and may be given at first in ounce doses every hour. Bismuth carbonate and soda bicarbonate may be given in addition, with hot applications to the epigastrium. As the symptoms subside, the quantity of milk should be rapidly augmented, hourly feeds being continued until two pints of milk are taken in the 24 hours, the interval between doses being thereafter slowly increased. Four to eight pints of milk can frequently be digested easily and without discomfort, but the stools should be examined regularly for undigested curd. In some cases the vomiting is persistent, or the milk is ill borne. It may be made more digestible by being citrated, "soured," or peptonized, and more palatable by the addition of weak freshly infused tea or coffee as flavouring agents, or in the form of curds or junket. Whey, mixed with white wine, and albumin water are sometimes of value in severe cases.
Gastric ulcer is so frequent an accompaniment of chlorosis that its presence should be suspected in every case where acute pain accompanies the ingestion of solid food, even without the characteristic vomiting and epigastric tenderness. It is always wise to keep such patients on a purely fluid dietary until the bowels have been freely emptied, and the absence of blood from the stools determined. In many cases it takes several days to ensure such a result, as the constipation is often obstinate and scybalous material continues to be present in the stools.
In every case where the pain is acute, oral alimentation should be entirely stopped, and gastric sedatives, with opium if necessary, given in adequate doses. In the less severe cases the symptoms as a rule rapidly abate with absolute rest and a fluid diet. It is generally wise, however, to refrain from the administration of solid food of any kind until undiluted milk is utilized without discomfort, or the administration of gastric sedatives.
During this period any notable oral defects should be rectified. It is of course impossible to thoroughly empty the mouth of all carious stumps; but repeated and thorough cleansing of the teeth with mild antiseptic solutions (glycerine of carbolic acid, boroglyceride, hydrogen peroxide) speedily alters the complexion of affairs.
The gastric symptoms being in complete abeyance, the mouth moderately clean, and the bowel thoroughly emptied, solid food may now be commenced, but advances should be made gradually. The less coarse forms of farinacea (semolina, arrowroot, tapioca, bread and milk) should be used, and in the absence of symptoms their quantity may be fairly rapidly increased, though large amounts are rarely permissible as long as sedatives are required for gastric comfort. Dry toast, rusks, ground rice, Robinson's patent oat flour, may be added for the sake of variety, the quantity of milk consumed being still four or five pints. On such a dietary the patient's weight as a rule begins to increase within two or three weeks.
The next addition to the dietary should be made as gradually as the first. Small whiting, soles or haddock, plainly boiled with a white sauce, or as a soufnee, and lightly boiled or poached eggs, are usually well borne, and as soon as a fair quantity is being taken the carbo-hydrate and milk intake may be correspondingly decreased; but a couple of pints of the latter should be still continued. A small tumblerful may be taken with the solid meals, and the rest at appropriate intervals.
An unrestricted dietary is rarely permissible until the blood count is normal. The tendency to hyperacidity must be borne in mind, and any excess of carbohydrates, especially the coarser varieties, is apt to rewaken the symptoms. Potatoes, pastry and vegetable soups are particularly unsatisfactory in this respect.
There is, however, no contra-indication to the finer meats, such as chicken, tripe, rabbit, fresh young birds, and even mutton, provided that they are plainly cooked (roasted or boiled) and thoroughly masticated. If mastication is impossible from the absence of teeth or tenderness of the gums, these foods may be given in the form of cream or mince.