Chronic gastric catarrh may be the outcome of such errors in diet as have been described as causative of the acute form. It commonly results, however, from alcoholic excess. It also accompanies diseases in which the hepatic, and consequently the portal circulation is obstructed, producing engorgement of the vessels of the gastric mucous membrane. It may-complicate pulmonary and cardiac diseases which cause obstruction to the venous circulation. It is caused by the severer forms of stomach diseases.

Pathological Physiology

Besides congestion of the blood vessels, which interferes with the maintenance of proper secretion and with absorption, the glands of the stomach furnish a hypersecretion of tenacious, ropy, alkaline mucus, which clings to the mucous coat and prevents the food from exciting the secretion of the gastric juice, and it neutralises and prevents the latter from reaching the food. The food therefore is retained for hours in an alkaline medium, where it undergoes maceration and fermentation, which is particularly liable to develop large volumes of carbonic-acid and marsh gas, which are periodically belched up with such force as to carry out the acrid fluid, and even particles of disintegrated food, producing a bitter and nauseous taste in the mouth. The symptom of heartburn is due to the eructation of organic acids. The appetite is not always lost. It may even be excessive, and it is usually capricious. Thirst is often a prominent symptom. Vomiting occurs at intervals, especially on rising in the morning, after the gastric mucus, mingled with the saliva swallowed, has accumulated during the night.

Dietetic Treatment

If any improvement is to be hoped for in the condition of a patient with chronic gastritis it is absolutely necessary to secure the intelligent co-operation of the patient himself by strict obedience to rules which must be made very specific and distinct. Many patients will be found to have so little will power that, with the best intentions, when they sit at the table with others whose good health enables them to partake of all the luxuries of the season they are utterly unable to resist temptation.

The patient with gastric catarrh should, as far as possible, be kept from mental strain and worry or business responsibilities, and especially from brooding over his symptoms. A person suffering from chronic gastritis often seems to have but a small amount of nervous energy to expend, and if too much is diverted in other channels, but little is left for the processes of digestion, and gland secretion is altered or withheld. It is a matter of every-day experience with such persons that when free from all concern and anxiety their digestion promptly improves and they can often eat quite indigestible food, whereas much plainer food wholly disagrees with them while under mental strain. It is highly important for them that meals should be taken with regularity and that abundant time should be allowed for mastication. Regular habits, outdoor exercise, and daily sponge bathing in cold water, followed by active friction of the skin, are to be recommended. In forbidding certain classes of food, it is often observed that the patient has discovered that some one apparently indigestible material can be eaten with impunity, and there may be no harm in allowing this to be continued in mild cases.

Sometimes merely eliminating from the diet such obviously indigestible foods as pies, griddle cakes, pickles, fried foods, or rich cheese, will produce marked improvement, but it is often necessary to enforce a very strict regimen.

Milk Diet

Severe cases, especially those complicating Bright's or cardiac disease, demand rigorous restriction of the diet, and it may become necessary to give milk exclusively for two or three weeks. From two to two and a half or three quarts of fresh milk are required for this diet in the twenty-four hours, the amount depending upon the size and weight of the patient and his ability to take exercise. The latter, however, must be reduced to a great extent while the milk diet is in force. The milk may be given either hot or cold, but hot milk is best. It should be diluted with soda water or an alkali, such as sodium bicarbonate or magnesia, and salt should be added. Very bad cases with extensive atrophy and abundant mucous secretion may require pancreatinised milk and beef preparations.

In some cases, especially those due to chronic alcoholism, there is annoying thirst, which is relieved by diluting the milk with equal parts of Vichy or Apollinaris water. The fluid has the additional advantage of increasing the elimination of waste from the system through the kidneys.

To most patients who are ill enough to require a fluid or an exclusive milk diet, it is preferable to give food frequently, at the rate of four ounces of the above mixture once in two hours, until the condition of the stomach improves, when the dilution of the milk is to be reduced, given in larger quantity (six to eight ounces), and the intervals may be prolonged to three hours. When much gastric irritation or nausea exists, the milk, if at all rich in cream, should be skimmed, as fat is not well tolerated. Buttermilk is used quite extensively in Germany and somewhat in this country for the treatment of gastric catarrh. It may be taken undiluted. To some persons the taste is more agreeable than that of ordinary milk. The casein of the buttermilk is already coagulated and exists in a condition of fine subdivision, so that it does not form large clots in the stomach. Patients usually tire sooner of buttermilk than of plain milk. Milk, no matter how given, is apt to produce constipation.

When patients insist that milk always disagrees with them this is often on account of their not having the methods by which it may be prevented from forming tough coagulae in the stomach, and it is worth while to explain this fact to them, and secure their consent to give a fair trial to some of the numerous means which may be employed for improving the digestibility of this invaluable food (see p. 75). If there is much dilatation of the stomach, milk is usually con-traindicated.