Case II

Mrs. Caroline A -, 65 years old, had suffered for the last four years, off and on, from dyspeptic symptoms. During the last five or six months her condition grew materially worse. The patient usually bad severe pains after meals, and suffered from obstinate constipation, weakness, and insomnia. During this entire time she had been on a rigorous diet (beef-juice, etc.), and had been treated with various medicaments; but under this treatment she had lost thirty-five pounds in weight. The physician in charge and also her relatives were of the opinion that she had a cancer. A thorough examination revealed only a downward displacement of the liver and stomach. The liver at first simulated a tumor, but on further examination it could be easily seen that the latter was the prolapsed liver and not a neoplasm.

The patient was told to partake of nourishment every three hours and was allowed certain articles of food which had been previously forbidden. At first zwieback, crackers, and gruels were permitted, besides a small quantity of scraped beef. Soon, however, the ordinary white bread, butter, eggs, and similar substances were added, and the patient began to gain in strength. (The wearing of an abdominal bandage was not advised, as the patient did not feel relieved when the lower part of her abdomen was supported with the hands when she was examined.) During a period of three weeks the patient gained eight pounds in weight, got rid of her dizzy spells, as well as her gastralgia, and could sleep much more comfortably. She is still under treatment, but her convalescence continues.

As nutrition plays the principal part in the treatment of these patients, it will not be amiss to give a few hints with regard to its management. To begin with, it does not appear advisable to permit patients who have abstained for a long while from the coarser varieties of food everything at once. This abrupt change may at times be the cause of various unpleasant symptoms; therefore it should be accomplished gradually. At first give, besides milk, gruels, and thickened soups, eggs beaten up in milk, etc. A few days later begin to add to this bill of fare zwieback or crackers with butter; then permit meat, the white of chicken and well-scraped beef; next, mashed potatoes; still later give wheaten bread, baked or boiled potatoes, soft-boiled or scrambled eggs, oysters; at last allow vegetables and fruits,

An essential point with regard to nutrition is punctuality in the taking of meals. In most of these cases, in which a gain in weight is of great importance, frequent meals (five or six daily) will be advisable. Although it docs not appear advantageous to prescribe for the patient the quantities of the various foods in exact weight (grams or ounces) - as by so doing they are too easily reminded of their ability or inability to digest this or that quantity and not more - it is nevertheless of value to mention approximate figures by which they may l>e guided or below which they shall not go. Thus, for example, they may be told to eat as much as their neighbors at table, or that they shall take ten ounces of milk at this or that meal; or, as I frequently advise, that they shall consume one-quarter of a pound of butter a day. Emphasize those points which appear to be the most important, and leave the patient great liberty in all other particulars. We must strive to familiarize the patient with the idea that ample nourishment will strengthen his organs (in-3 eluding the stomach and intestines), and we must always endeavor to dispel the fear of food with which he is harassed.

For patients who are greatly run down and are confined to bed a nurse is advisable, who shall see that the physician's orders (with regard to food) are promptly carried out. Massage may certainly be used on and off as an adjuvant. For patients who are up and about, a nurse is unnecessary. In the latter instance it is important to see that the patient's time is properly occupied; by that I mean to say that the patients should lead a rational mode of living, and should work neither too much nor too little. With some patients (wealthy people, having no vocation) we must try to give them something to do; while in the case of merchants whose business strain is too great, lawyers, and physicians, we should advise that sufficient leisure be taken. The points just mentioned serve in a high degree to render possible a healthy nutrition, for only a rational mode of living gives sufficient appetite for abundant food,

In cases in which the condition of the gastric juice is known there are still other special rules with regard to diet; for, as is well known to you, we should give abundant quantities of meat in hyperchlorhydria, while in hypochlorhydria and achylia gastrica the starchy substances (and vegetable food) should predominate.

The above suggestions, however, play the principal part in the treatment, and good results may be obtained often enough without analyzing the gastric contents.

Gentlemen, I have endeavored to give in this paper a few practical hints with regard to the nourishment of most patients afflicted with chronic stomach troubles.

If I have succeeded in convincing you that it is much more important to take care that such patients are sensibly nourished than to forbid them everything, I shall feel that my object has been accomplished.