Other Diet

Should it prove impossible for the patient to digest enough milk to support strength, his diet should be supplemented with other articles of food, such as scraped meat or peptonised meat. As a rule, the food should be either fluid or almost entirely solid; drinking considerable fluid with solid food dilutes the feeble gastric juice too much for proper digestion. No broth or soup should be allowed with meals. Alcohol should in general be forbidden, and tea, coffee, or cocoa are to be taken only in moderation, much diluted, and without milk and sugar. Occasionally light wine, such as hock and Moselle, may be given, but effervescing wines are forbidden. Fluids should not be taken too cold.

Oysters may be allowed either raw, broiled, or panned. Butter may be allowed very sparingly, and cream sometimes, but in general fats and oils should be avoided as well as all fat meats, pork, sausages, and solid food cooked in grease. Rich gravies and sauces of every kind must be forbidden, and all solid food must be thoroughly masticated. Many persons, especially those who have an excessive secretion of hydrochloric acid, live best on a diet of lean roast beef, rare steak, or white meat of chicken, eaten with stale white bread or dry toast and very little butter. This diet can be taken for some time before serious objection is made to it.

One occasionally meets with persons in whom the digestion of salt and smoked meats seems to be more easily accomplished than that of fresh meat. The explanation offered by Niemeyer is that these preparations are less likely to decompose and form abnormal fermentation products in the stomach. Dried smoked beef, cut in thin slices and eaten almost or quite raw, is palatable and easily digested. Some dyspeptics can also digest lean boiled ham, lean smoked bacon, and salt fish, such as shredded codfish, thoroughly cooked, better than they can fresh meat. Leube allows caviare, smoked ham, and boiled lean veal. Sweetbreads and calves' brains are digestible. Tough meat and flesh of young animals recently killed, such as "bob" veal, should not be eaten.

Fish and soft-cooked eggs disagree with some persons, but others can digest them without difficulty.

Saccharine and farinaceous foods are to be avoided. Sooner or later they are almost certain to undergo lactic and butyric-acid fermentation in the stomach with the production of much eructated flatus and "sourness." Sugar especially excites the secretion of gastric mucus. When improvement is established, the patient may gradually be allowed a little carefully prepared starchy food, but still no sweets of any kind. A single lump of sugar in a cup of cafe au lait drunk at breakfast can produce an acute dyspepsia, lasting all day. The varieties of starchy foods which may be first eaten are those which have been thoroughly subjected to the heat of baking or long boiling. Such are: Dry bread thoroughly toasted, bread crust, plain crackers, zwieback, gruels or meat soups thickened with arrowroot, thoroughly cooked sago, or ground rice, vermicelli, and macaroni well boiled. The purest carefully baked wheat bread from hard white wheat flour agrees better than the coarser varieties of brown bread, whole-meal breads, etc.

Many persons who take an intelligent but not hypochondriacal interest in their digestion find by repeated trial that the bread of a certain baker agrees with them, while that of another does not, although its nutritive value for normal stomachs may be the same in both cases.

Potatoes are apt to produce flatulency with sour eructations, and when this is the case they must be forbidden. If roasted and very mealy they may be sometimes allowed. Among vegetables those which are especially forbidden are cabbage and cauliflower, the legumes, and corn. A little fruit may be allowed between meals, such as cooked apples, either baked or stewed, or stewed prunes, if not too sweet.

Especially forbidden are pastry, sweets of all sorts, sweet puddings and cakes, griddle cakes, hot breads, pickles, fried foods, and strong condiments.

In all cases of chronic gastric catarrh it is important to reduce the bulk of food taken so as to diminish the liability of its remaining in the stomach undigested. Food which is so selected and prepared as to diminish the work of the stomach should be given only at long intervals in order that the digestion of one meal may be thoroughly accomplished before the next is eaten. It is well to order at least six-hour intervals between the meals, and they should not be eaten too soon after exercise.

Convalescence

As the patient improves, the dietary may be somewhat enlarged, and thoroughly cooked fresh vegetables, such as spinach, celery, asparagus, onions, and fresh young peas, may be added.

Fresh ripe fruit will be found serviceable in curing constipation, which almost invariably follows as a result of concentrated diet. In many cases this trouble must be counteracted by the daily morning use of some aperient, and a half tumblerful of hot Hunyadi water, or of Friedrichshall bitter water, or a drachm of Carlsbad salts in a tumbler of hot water, should be taken each morning before any food is swallowed. The salts are further serviceable by diminishing hyperemia of the stomach and hepatic engorgement. Much benefit is derived from drinking a glass of hot water or a glass of hot Vichy from half to three quarters of an hour before each meal, the object being to separate the layer of thick ropy mucus which overlies the orifices of the gastric tubules. Much of the advantage to patients with chronic gastric catarrh received from a course of treatment at Carlsbad and similar spas is due to the action of sulphate of soda and other alkalies in removing mucus from the stomach and cleansing the membrane beneath, rather than to any specific virtue in the salts themselves.

Hydrochloric Acid

The value of hydrochloric acid given to aid digestion consists quite as much in its power to promote the conversion of pepsinogen into active pepsin as to act directly upon the food. The latter can be accomplished very well by artificial digestion outside of the body. If therefore there is complete atrophy of the gastric tubules in chronic gastric catarrh of long standing, the giving of the acid fails to excite secretion from tubules permanently destroyed, and Boas declares that the acid combines so readily with the salts and albuminoids of the food that it is not practicable to give enough of it to have any free acid remaining, and he only recommends it for those cases where the function of the gastric tubules, as shown by testing the digestive power of a sample of the stomach juice, is not wholly abolished. He admits its usefulness as an antifermentative. This view is not generally held, however, and, as a matter of practical experience, the majority of these cases are improved by taking dilute hydrochloric acid with any solid animal food which is allowed them which is otherwise found to cause discomfort.

It is best to give the acid not immediately with the food, but half an hour later, and twenty minims may be prescribed in one dose, or two or three doses of ten or fifteen minims may be given at intervals of half an hour. It may be prescribed alone in half an ounce of water, or mixed with a little glycerin in a claret glassful of water, and it should be swallowed through a glass tube to save the teeth from injury.

Exercise, Massage, Lavage, Etc

Exercise should be recommended, but so regulated as not to interfere with digestion. It should be postponed until digestion has been in progress for at least an hour or two, and, when the patient's strength admits of it, gentle horseback or bicycle riding and moderate rowing is beneficial for the young and middle-aged.

Massage of the stomach, performed two hours after meals, is of service, and lavage is of great value when pyrosis and gastric distress occur so soon after eating as to indicate active malfer-mentation.

Daily morning douching of the stomach to remove mucus and muco-pus in those in whom a dyspeptic tendency exists will serve to prevent the advent of chronic catarrhal gastritis (D. D. Stewart). This process, which is fully described in connection with the treatment of Dilatation of the Stomach (p. 546), is now much less in vogue than formerly for simple gastric catarrh.

Saline laxatives and appropriate tonics, such as strychnine and arsenic, are indicated in addition to the dietetic measures above described.

Electricity is of service only when one pole of the battery is introduced into the stomach by Einhorn's method (p. 551).

In obstinate cases change of scene and occupation may do much good, and a sea voyage is sometimes to be suggested.