Constipation also is generally a source of trouble. If the condition is of long duration and does not yield to treatment, it usually leads to pessimism and depression. Even after a complete cure I believe the patient should be warned that his days for large promiscuous meals are over, and he should be furnished with a rigid diet list and an outline of a healthy life.
The dietetic treatment of hyperacidity is difficult, but it is always promising, because, unlike the sufferer from some other abdominal neuroses, the patient has a genuine desire to be quit of his trouble.
In severe cases of long standing, when the patient is seldom free from pain and has begun to lose weight, it is wise to give him two weeks of complete rest in bed. If on CO2 distension of the stomach, any real dilatation is found to be present, lavage may be performed on the first three days of this time, but it should not be performed unnecessarily. During the first week there should be semi-starvation, milk to the value of 560 and later of 800 calories being given as in the case of gastric ulcer (q.v.) with a large dose of Carlsbad salt in hot water every morning on an empty stomach. During the second week of complete rest the diet may be gradually extended. If as is usual the gastric mucosa has now lost its extreme sensitiveness, one or two eggs, lightly-boiled, poached or even buttered, may be tried, and later the addition of 4 oz. of milk pudding or rusks in milk may be made, so that at the end of the second week the patient is receiving sufficient food to supply nearly 1,500 calories. He will probably be found to have lost some more weight. During the third week he may be allowed out of bed, to drive and to take short walks and to prepare for a resumption of ordinary life. During this third week the degree of secretion-response to the stimulus of food may be further tested by the addition of fish (sole, plaice, whiting) or chicken to the diet. Milk should still form a large part of the diet, viz., 40 oz. with 8 oz. of diluent, and the meals may be arranged on the following plan: -
8.30 a.m. . . . Milk diluted, 8 oz.
One or two eggs cooked in any way.
Toast or rusks, 1 oz.
Butter, 1/3 oz. 11 a.m..... Milk as before.
1 p.m.....Milk as before.
Fish (sole, plaice or whiting) or chicken, 4 oz.
Custard or jelly or blancmange with cream, or savoury omelette, 4 oz.
Toast or rusk and butter as before. 4.30 p.m. . . . Milk as before. 7 p.m..... Milk as before.
One or two eggs cooked in any way.
Toast or rusk and butter as before. 10 p.m..... Milk as before.
The duration of this stage and the subsequent course must depend on the result obtained. As a rule he is now able to resume an ordinary life and he will soon be able to embark on the correct diet which, with few alterations, should serve him for the rest of his life.
In one group of cases, as already mentioned, the immediate cause of the hyperacidity becomes plain, when the patient's manner of life and feeding is grasped. There may be much to correct. In some such cases it is sufficient to set matters right as regards the teeth, to explain the importance of prolonged mastication, slow eating and early hours, to enjoin at least thirty minutes of complete rest lying down after each meal, to cut off or diminish alcohol and tobacco, and to increase the amount of exercise in the open air. Furnished with a simple diet he can then see the end of his trouble. But though the cause may be plain, it's correction may be an impossible counsel of perfection in the case of a man, whose life and habits are necessarily dominated by his work. In these cases over and above the establishment of a correct diet, we must fall back on the use of antacid medicinal remedies which palliate but do not cure. However in all cases an attempt must be made on general principles to remove any causative factor and to minimize the nervous predisposition.
When we consider the details of a diet which shall be suitable (1) for the partly cured patient who has been through the short rest cure described; (2) for the patient who is half cured as soon as the exciting cause is discovered and, (3) for the patient whose chance of improvement is small so long as his livelihood depends on the continuance of an unhealthy and hurried existence we find general agreement on many points. All condiments and spices, mustard, pepper, vinegar, horseradish, ginger, curry, etc., must be forbidden, as well as all vegetables containing much cellulose and salads. No article of food should contain hard material such as pips and seeds. Coffee should be excluded, cocoa or tea freshly made with half milk being allowed. At first no alcohol in any form should be taken, but as time goes on without the recurrence of symptoms its use may be safely resumed with the limitations mentioned later. All starch (if it is used) should be dextrinized by dry heat as in thin toast and rusks, or thoroughly gelatinized by moist heat as in milk puddings. Pastry must be avoided. Fresh uncooked butter and cream may be taken freely and perhaps tend somewhat to lessen the secretion of gastric juice. Sugar may be freely used, preferably dextrose or honey. Jellies are useful, gelatine fixing a good deal of hydrochloric acid in its digestion : they may be flavoured with lemon, orange or fruit-juice if necessary, but fruit itself should be avoided. Milk, eggs, and grated cheese are always correct articles of diet. Junket flavoured with cocoa can be taken. Soup may well be avoided, in view of its stimulant effect and its small nutritive value. Fluid may be given freely at meals, if there is no dilatation, and either milk and soda-water or any mineral water such as Perrier and Apollinaris should form the staple drink. The temperature of food should be considered and extremes avoided by preserving a minimum of 55° F. and a maximum of 130° F.; a temperature of 100° F. may serve to minimize the stimulus to the secretion of acid. On certain other points however there are divergent views. In the first place inasmuch as the acid of the gastric juice is solely derived from the chlorides of the blood, it has been suggested that in hyperacidity this supply should be diminished by forbidding the use of common salt both as a condiment and in the cooking of food, so that the patient becomes dependent for his chloride supply on the salts naturally present in his food. It has been shown experimentally by Cahn and by Hemmeter that the acidity of the gastric juice is materially reduced in dogs, if they are fed on meat, from which the salts have been largely extracted by boiling with distilled water. Moreover Cahn by further means so reduced the chloride-content of the blood that the stomach secreted a neutral inactive fluid. This fluid however if acidified at once became active and digested fibrin, so that we may conclude that the secretion of pepsin is independent of that of the acid. Without actual observation of the point no patient can state how much salt he is in the habit of taking. I have seen a few patients suffering from hyperacidity who confessed that they took exceptional quantities of salt, but I think that the majority of patients are moderate in its use. It may be argued from the universality of the practice that salt eating is in some way beneficial or even necessary. But some people take no salt apart from that naturally contained in their food or introduced by the cook, and suffer no harm. On the whole I believe that it is wise to eliminate salt from the diet in this condition, though I have seen no immediate beneficial results in patients who have so excluded it.