Ai 
 
 o 
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 ART OF FEEDING THE 
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 DIET IN DYSPEPSIA
 
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 BI4
 
 DIET IN DYSPEPSIA 
 
 AND OTHER DISEASES OF 
 THE STOMACH AND BOWELS 
 
 AN ELEMENTARY TREATISE ON THEIR 
 DIETETIC AND HYGIENIC MANAGEMENT 
 
 BY 
 
 WILLIAM TIBBLES 
 
 M.D., L.R.C.P., M.R.C.S., L.S.A. 
 
 MEDICAL OFFICER OF HEALTH FOR MELTON HOWBRAY RURAL DISTRICT 
 
 AUTHOR OF "FOOD AND HYGIENE," "FOODS: THEIR ORIGIN AND 
 
 COMPOSITION," "THE THEORY OF IONS," ETC. 
 
 LONDON 
 
 THE SCIENTIFIC PRESS, LIMITED 
 28 AND 29 SOUTHAMPTON STREET 
 
 STRAND, W.C. 
 (Two Shillings and Sixpence net)
 
 PC 
 
 8,2. <7 
 
 PREFACE 
 
 As a nation is made up of individuals which are 
 mutually interdependent, so the human body is made 
 of organs which depend upon the smooth working of 
 each other to establish a harmonious whole. It was 
 Liebig who formerly said that the Tripod of Life 
 consists of the brain, the heart, and the lungs. This 
 may be conceded. But the tripod must have a basis 
 for its support. Surely this consists of the stomach, 
 or rather the alimentary canal of which the stomach is 
 but a specialized portion. The brain, heart and lungs 
 cannot work without energy ; and, equally with other 
 parts of the body, these organs will fail in the perfor- 
 mance of their functions if they be not supplied with 
 food. The alimentary canal is the laboratory in which 
 is prepared the material to supply the organism with 
 food and its complicated machinery with energy. 
 Therefore, whatever disturbs the "stomach" shakes 
 the foundation on which the vital tripod is supported. 
 Conversely, whatever improves the alimentary func- 
 
 1023540
 
 vi PREFACE 
 
 tions renders more firm the basis on which the tripod 
 rests. 
 
 The following pages, on Diet in Dyspepsia or distru- 
 bances of the alimentary functions, consist of a course 
 of lectures originally written for "The Nursing Mirror," 
 and are now reprinted in the hope that they will be ol 
 
 general utility. 
 
 W.T. 
 
 NOTTINGHAM, 
 June, 1913.
 
 CONTENTS. 
 
 PAGE 
 
 PREFACE v 
 
 CHAPTER I. 
 DIGESTION i 
 
 CHAPTER II. 
 INDIGESTION n 
 
 CHAPTER III. 
 PAIN IN DYSPEPSIA 16 
 
 CHAPTER IV. 
 THE RELIEF OF PAIN IN DYSPEPTIC CASES .... 21 
 
 CHAPTER V. 
 VOMITING 25 
 
 CHAPTER VI. 
 THE RELIEF OF VOMITING ....... 32 
 
 CHAPTER VII. 
 
 ACUTE GASTRIC CATARRH ; ACUTE GASTRITIS ... 46 
 
 vii
 
 2 DIET IN DYSPEPSIA 
 
 short time ; that is, until the gastric juice is secreted in 
 sufficient quantity to stop its action. The salivary ferment 
 only acts in an alkaline medium, but the gastric juice is acid, 
 and the permeation of the mass of food in the stomach by 
 this acid fluid effectually stops its action. It takes some 
 time, however, to do this. The food is often swallowed in 
 masses like large pills ; and such masses may be sufficiently 
 adhesive to prevent the gastric juice permeating them readily. 
 The time usually stated for the action of the salivary ferment 
 in the stomach is half an hour ; and during that period a 
 considerable proportion of the starchy material is trans- 
 formed into sugar. But the time necessarily varies with the 
 circumstances. The mastication may be very imperfectly 
 performed and very little saliva mixed with the food. Many 
 foods are swallowed without mastication and do not get 
 mixed with saliva at all. . 
 
 There is also a variation in the secretion of the gastric 
 juice. Moreover, there are two periods for the secretion of 
 the latter fluid. There is what is known as the appetite 
 juice, or psychic juice, and the chemical juice. The thought 
 or taste of food provokes a secretion of gastric juice ; this 
 is a mental effect, and therefore the secretion is called the 
 psychic juice. It is an important part of the gastric secre- 
 tion, and, like a crocodile's tears, flows at the thought, sight, 
 smell, or taste of a pleasant meal. It is encouraged by 
 mastication, hunger, the enjoyment of food, pleasant com- 
 pany, and agreeable surroundings. It does not occur when 
 a person has no appetite ; and it is checked by pain, fatigue, 
 fear, worry, and mental distress. This portion of the gastric 
 juice, therefore, would not be secreted if a person had al- 
 ready been fed ; nor if the food is poured into the stomach 
 through an cesophageal tube, or without the knowledge of 
 the individual. 
 
 The second phase of gastric digestion depends upon the 
 presence of food in the stomach. It is due to the formation 
 of the chemical juice ; and the secretion is believed to be 
 independent of the nervous system. It begins some little 
 time after the food has reached the stomach, and is especi- 
 ally provpked by the presence of meat, game, fish, eggs,
 
 DIGESTION 3 
 
 soup, and similar substances. Why should these substances 
 cause a secretion of gastric juice more than other foods ? 
 It has been shown that there is a strong association between 
 the various functions of the body, that the activity of one 
 organ depends on the proper performance of function by 
 others. Efficient mastication encourages the secretion of 
 gastric juice ; but imperfect mastication leads to a smaller 
 secretion of gastric juice. This is chiefly due to the asso- 
 ciation of the nerves which give rise to the appetite or psy- 
 chic juice. But it has also been shown that the association 
 of functions is due to the formation of chemical bodies 
 called hormones, or chemical messengers. Gastric digestion 
 produces such a hormone among the early products of di- 
 gestion. The substances which most easily provoke the 
 second flow of gastric juice, the chemical juice, are derived 
 from the digestion of proteins (meat, fish, game, eggs, etc.). 
 It follows, therefore, that an abundant flow of the chemical 
 juice depends upon the previous secretion of the psychic or 
 appetite juice; for the materials necessary to provoke it 
 arise from the action of the appetite juice. Substances, 
 however, occur in meat-juice, meat-extract, soup, and such- 
 like articles, which have the same effect ; when these are 
 administered alone to dogs and men they provoke the se- 
 cretion of gastric juice. This is the scientific basis for the 
 custom of taking a small quantity of soup at the beginning 
 of a dinner. When the chemical secretion is once started 
 it goes on continuously for a period which depends more or 
 less on the nature of the food and the time required for its 
 digestion ; but the flow is not always at the same pressure, 
 it gradually rises and falls, the secretion reaching its height 
 from one to two hours after a meal. 
 
 The gastric juice is an acid fluid. It contains several 
 ferments or enzymes, the chief one being pepsin, which 
 digests meat, game, poultry, fish, eggs, milk, cheese, the 
 gluten of bread, and other proteins. It also contains a fer- 
 ment called rennin, which curdles milk ; and another one 
 which assists in the digestion of fat. It should be noted 
 that pepsin only acts in an acid medium ; and that the acid 
 of the gastric juice is hydrochloric acid. The proportion of
 
 4 DIET IN DYSPEPSIA 
 
 this acid is very small, only about two parts in 1000; but, 
 little as there is of it, it is absolutely essential for the pro- 
 cess of digestion in the stomach. 
 
 The passage of food through the alimentary canal has 
 been studied by aid of the X-rays. A mouthful of fluid 
 occupies five or six seconds in passing from the back of the 
 mouth to the stomach. When solids are properly masticated 
 they pass down to the stomach in about the same length of 
 time. But when such food is not well masticated, or is 
 swallowed in masses like pills, its passage is much slower. 
 Swallowing is an involuntary act, when the food has passed 
 through the mouth. It is due to a muscular movement, 
 which passes the food downward. The opening into the 
 stomach is guarded by the cardiac sphincter, which relaxes 
 when the food passes through it, and closes again to prevent 
 regurgitation. 
 
 The empty stomach is more or less pear-shaped, the wide 
 end (at the left side of the body) containing some gas, the 
 rest of the organ being contracted and its mucous mem- 
 brane thrown into folds. The food which arrives in the 
 stomach accumulates at the wide end, called the fundus. 
 During digestion the stomach is divided into two parts the 
 fundus or cardiac portion and the pyloric portion. The 
 fundus is the store-house of the food, and is not affected by 
 peristaltic muscular movements. The pyloric portion is the 
 active part, and it is affected by peristaltic muscular move- 
 ments. The contents in the fundus remain alkaline in the 
 centre, only the outer portion becoming acid ; but all the 
 food in the pyloric portion is acid. 
 
 The peristaltic movements of the stomach begin soon after 
 the completion of the meal, and occur every fifteen or 
 twenty seconds. They are due to muscular contractions 
 which pass like a wave towards the outlet, and carry the 
 food along. They serve a double purpose. In the early 
 stage of digestion the pylorus remains closed, and, conse- 
 quently, when the food is driven against it by each peristaltic 
 wave it causes a central return current ; thus we have a 
 churning movement by which means the food is thoroughly 
 mixed with the gastric juice. But as the digestion proceeds
 
 DIGESTION 5 
 
 the pylorus relaxes, the muscular contractions increase in 
 strength, and the fluid or semi-fluid food is gradually 
 ejected through it into the intestines. 
 
 The pylorus is surrounded by a strong muscular ring or 
 sphincter, which is normally contracted to such an extent 
 that it appears in an X-ray photograph as a fine line about 
 | inch long. Through this narrow orifice the partially 
 digested food is driven by strong muscular contractions or 
 peristaltic waves. It may easily be perceived that the nature 
 of the food influences the rate at which it passes through. 
 When a meal is consumed consisting of lean meat, suet, and 
 rice, so prepared that the whole mass is of an equal consis- 
 tency, the X-rays show that the carbohydrate (rice) begins 
 to pass through the pylorus in fifteen minutes, part of it 
 being reduced to soluble starch and part into dextrin and 
 sugar. But the protein (lean meat) and fat do not begin to 
 leave under half an hour, and are much slower in passing 
 through. A meal consisting of carbohydrate alone (rice or 
 potato) leaves the stomach rapidly, no trace being left 
 three hours after the meal. A meal of protein and fat (fat 
 meat, ham or bacon and egg) leaves the stomach more 
 slowly, some being present six hours after the meal. A 
 meal of carbohydrate and protein (bread with lean meat, 
 fish or fowl) leaves the stomach in a period which is inter- 
 mediate between the other two. The addition of fat 
 hinders the digestion of food in the stomach, and therefore 
 delays its passage through the pylorus. 
 
 The passage of food is likewise hindered by the consis- 
 tence of its particles. The X-rays show that when a particle 
 of hard food is driven to the pylorus by the muscular con- 
 tractions the aperture is immediately closed tightly. In- 
 digestible masses are thus returned over and over again 
 until the hard pellets are softened and reduced to a semi- 
 fluid condition. At the end of gastric digestion, however, 
 even such masses may be driven through the relaxed pylorus, 
 for small pieces of bone, cherry stones, plum stones, and 
 other indigestible substances manage to escape into the 
 bowels. 
 
 The passage of liquids through the stomach is governed
 
 6 DIET IN DYSPEPSIA 
 
 in the same way as other foods. Water taken on an empty 
 stomach soon passes through the pylorus, but some of it is 
 absorbed by the gastric mucous membrane. Fluids of a 
 temperature higher than that of the blood are not allowed to 
 pass through, but are retained until the temperature is the 
 same as that of the body. Beer leaves the stomach more 
 slowly than water ; and liquids containing various salts are 
 retained until they become of the same salinity or isotonic 
 with the gastric juice. 
 
 Thus, by the exercise of a selective power, the stomach 
 is able to protect the delicate mucous membrane of the 
 bowels from the injurious effects of unsuitable materials. 
 
 The amount of digestion which is done in the stomach 
 is great. Let us see how much has been done by the time 
 the food has passed through the pylorus. It has been or 
 should have been reduced to a pulp in the mouth. It is 
 mixed with saliva. Some of the soluble substances are 
 dissolved by that fluid ; and some of the starch turned into 
 sugar. It is now swallowed and slowly permeated by the 
 gastric juice, which begins to be secreted during mastication. 
 Until this permeation is complete the transformation of 
 starch continues uninterruptedly, first into soluble starch, 
 then into dextrin, and finally into sugar. In the stomach, 
 however, the food undergoes further disintegration by the 
 aid of the gastric juice. Meat, fish, or fowl is broken up 
 into tiny fragments. The connective tissue which binds the 
 muscular fibres together is dissolved ; the chief substance, 
 called collagen, being converted into gelatine and pepton- 
 ized. The skin and gristle, also containing collagen, is 
 converted into gelatine and peptonized. The muscular 
 fibres, which form the chief portion of the flesh, are separ- 
 ated into tiny discs ; the cement substance which was be- 
 tween the cells is peptonized ; the individual cells are 
 dissolved, the syntonin and fibrin which they contain are 
 converted into proteoses and peptones. The covering of 
 the muscular fibres, sarcolemma, consists of elastin, which is 
 dissolved and peptonized. The influence of gastric juice 
 on the coverings of animal cells varies. These coverings
 
 DIGESTION 7 
 
 differ in composition ; when the flesh is young and tender it 
 consists of elastin or a similar material soluble in gastric 
 juice ; but in older animals the cell coverings become 
 exceedingly tough, more like horn, which resist the action 
 of gastric juice. 
 
 The fatty portion of meat undergoes similar disintegration. 
 The connective tissue which binds it together is first gela- 
 tinized and dissolved ; the covering of the fat cells is dis- 
 solved, and by this means the fat is set free and mixed in 
 the same way as butter, lard, or oil with the other ingre- 
 dients of the food. 
 
 Milk is curdled by the rennin ferment, and it should be 
 remembered that this always occurs in the first stage of the 
 digestion of milk. After a time the curds are broken down 
 and their digestion by the gastric juice begun ; some portion 
 being converted to peptone. Cheese requires very careful 
 mastication, otherwise it will not easily dissolve in the gastric 
 juice. Nevertheless, a small amount of good ripe cheese is 
 a stimulant to digestion, and in so far it deserves the old 
 adage : " Cheese ! thou mighty elf, digesting all things but 
 thyself 1 " 
 
 Bread, biscuits, cakes, and puddings, if they have been 
 carefully masticated, readily form an emulsion in the stomach 
 and are thus prepared for complete digestion in the bowels. 
 The less mastication such foods get, the longer they are 
 in being prepared for transmission into the bowels, or in 
 undergoing the transformation into sugar which is due to 
 the salivary ferment. Potatoes and other vegetables are re- 
 duced to a pulp, and otherwise prepared for digestion in the 
 bowels ; but the cellulose covering of vegetable cells is not 
 attacked by the gastric juice. 
 
 The whole of the food is thus broken down by the teeth 
 or the disintegrating power of the stomach, some portion of 
 starch is converted into sugar, and a portion of meat, milk, 
 fish, and eggs is converted into proteoses and peptones. 
 The whole mass forms a creamy mixture or chyme, which is 
 slowly propelled through the pyloric sphincter into the small 
 intestines. 
 
 It may thus be perceived that, important as is the work of
 
 8 DIET IN DYSPEPSIA 
 
 the stomach, the entire process of digestion is not completely 
 performed in that cavity. Indeed, so far as many foods 
 are concerned, it may be said that digestion only begins 
 there. Moreover, the work of the stomach, in certain cases, 
 is entirely replaced by intestinal digestion. This occurs 
 in patients who have had an opening made between the 
 stomach and bowels by the operation of gastro-enterostomy. 
 In these cases the food passes quickly out of the stomach 
 into the bowels, and digestion appears to go on almost as 
 well as in the normal process. 
 
 But the normal course of the food is through the pylorus 
 to the bowels, and it goes through very slowly. The opening 
 and closing of the pylorus, like the muscular contractions of 
 the stomach, is governed by a nervous mechanism which 
 causes the sphincter to relax each time a peristaltic wave 
 reaches it, when the chyme passes through like a squirt or 
 jet of water. Just as the sphincter is relaxed by a reflex 
 movement, so it is closed by another reflex action, which is 
 believed to be due to the arrival of the acid chyme in the 
 duodenum. The presence of a small amount of acid chyme 
 acts as a stimulus to the nerves in the duodenum, and a 
 message is sent along them which is reflected to the pylorus 
 and causes it to be closely shut until that portion of chyme 
 is neutralized by the bile and pancreatic fluids ; and this 
 action protects the intestinal mucous membrane from injury 
 by the acid fluid. 
 
 The bile is an alkaline fluid secreted by the liver; the 
 pancreatic fluid is an alkaline secretion from the pancreas ; 
 and they are both important items in the digestive process. 
 When the acid chyme passes over the orifice of the bile duct 
 in the bowels it causes a reflex contraction of the gall bladder 
 and a flow of bile into the bowels. The bile does not flow 
 into the intestines when digestion is not going on ; but, like 
 the gastric juice, the flow of bile only occurs during digestion ; 
 nevertheless, it continues for several hours, and the total 
 quantity of bile secreted in a day amounts to two pints or 
 more. This fluid mixes with the partly digested food. It 
 has no influence on proteins (meat, milk, eggs, etc.), except 
 that it precipitates dissolved albumin. Neither has it much
 
 DIGESTION 9 
 
 influence on starch and sugar ; but the pancreatic fluid has 
 more effect on these substances in the presence of bile than 
 when it is absent. But the bile has a definite influence on 
 the absorption of fat, and is therefore an important element 
 in its digestion. 
 
 The pancreatic fluid enters the duodenum through a 
 separate duct, which opens into the bowel close to the bile 
 duct. This fluid is of the greatest importance in intestinal 
 digestion. It begins to be secreted as soon as acid chyme 
 arrives in the duodenum, its presence being provoked by 
 the action of a hormone or chemical messenger from the 
 duodenum, called secretin ; and it continues to be secreted 
 for several hours after the meal is eaten. It contains three 
 ferments or enzymes. There is trypsin, which digests pro- 
 teins (meat, fowl, fish, game, eggs, milk, etc.) ; amylopsin, 
 which transforms starch into sugar ; and steapsin, which 
 makes an emulsion of all kinds of fat and splits some of them 
 into fatty acids and glycerine. Pancreatic fluid transforms 
 all proteins into proteoses and peptones, and the latter into 
 amino-acids, which are taken up by the mucous membrane 
 and reconverted into the proteins (albumins and gobulins) 
 of the blood. It digests the nuclei of cells, and acts more 
 powerfully than pepsin on elastin, but has no action on 
 keratin and the cellulose of vegetable tissues and cells. 
 Starch is rapidly converted by it into sugar. The various 
 fats are made into an emulsion, which the cells of the mucous 
 membrane eat up greedily. Some of the fats are split into 
 fatty acids, which combine with carbonate of soda in the 
 pancreatic fluid and form a soap which is easily absorbed. 
 
 There is still another digestive fluid. This is provoked 
 by the presence of food in the bowels ; it is secreted by the 
 intestinal mucous membrane, and is called the succus enter- 
 icus. Like the former fluids, it contains several ferments. 
 One of these is of importance by assisting the trypsin of 
 pancreatic juice. Another completes the digestion of 
 starchy foods by converting the complex sugars into simpler 
 sugars. Thus also the ordinary domestic sugar, malt sugar, 
 and milk sugar, are converted into dextrose, levulose, and 
 galactose, which are much more simple and readily diffused
 
 io DIET IN DYSPEPSIA 
 
 through the coats of the bowels or are absorbed by the 
 mucous membrane. It has no action on fat or starch. 
 But it has a definite influence on proteins and assists in 
 converting peptones and proteoses into amino-acids, which 
 are quickly absorbed. The amino-acids are of great import- 
 ance, as it is from these substances new blood and flesh 
 are formed ; whence they have been called " building 
 stones ". 
 
 Thus we have seen that most of the food is transformed 
 by various ferments or enzymes from insoluble substances 
 which cannot get into the blood to soluble materials which 
 readily pass through the mucous membrane or are taken up 
 by the cells of the mucous membrane and passed on to the 
 blood to be circulated to the various tissues and organs of the 
 body. There is naturally a certain amount of residue, con- 
 sisting of indigestible particles which the enzymes have not 
 affected. The amount of this residue varies according to 
 the nature of the food ; but it is mixed with some mucus 
 from the bowels, the degenerated cells from the mucous 
 membrane, the remains of bile and other secretions, and an 
 enormous number of bacteria, which together constitute the 
 faeces.
 
 CHAPTER II. 
 INDIGESTION. 
 
 THE most common dyspeptic trouble, and probably the most 
 common human ailment, consists of the group of symptoms 
 usually denominated indigestion or dyspepsia. No account 
 of the diseases of the alimentary canal would be complete 
 without separate consideration of them. These symptoms are 
 abnormal sensations of different kinds, such as a sense of 
 weight, fullness, sinking, shooting, aching, burning, or boring 
 referred to the region of the stomach, the chest, or the back, 
 especially between the shoulders. This discomfort arises in 
 some cases when the stomach is empty and disappears when 
 food is eaten ; or it comes on after food and lasts a time 
 varying from a few minutes to several hours ; in other cases 
 the discomfort is almost continuous. There is generally 
 some flatulence and eructation of gas. The flatulence is 
 often associated with the abnormal sensations ; the eruc- 
 tation, or belching of gas, frequently gives considerable relief 
 to the painful feelings or discomfort, and it is often noisy 
 and uncontrollable. The belching may be accompanied by 
 the regurgitation of food, or of a fluid having a sweet, sour, 
 or neutral taste (water brash, pyrosis) varying in quantity 
 from a teaspoonful to a pint. Vomiting, preceded by nausea, 
 is sometimes a symptom. The appetite may be normal or 
 deficient; the tongue clean and healthy, or more or less 
 thickly coated ; there may be constipation or diarrhoea ; the 
 urine may be normal, or scanty, highly coloured, and giving 
 a deposit. There are secondary phenomena, such as head- 
 ache, giddiness, vertigo, restlessness, sleeplessness, mental 
 depression, melancholia, palpitation or irregularity of the
 
 ia DIET IN DYSPEPSIA 
 
 heart, etc. It must, however, be distinctly understood that, 
 while dyspepsia is a name applied to this group of symptoms, 
 there is no discoverable local manifestation in the stomach 
 or constitutional effect which gives a warrant for the establish- 
 ment of the group as a separate and distinct disease. As a 
 matter of fact, "indigestion" or "dyspepsia" includes all 
 the functional derangements of the stomach, and most of 
 those of the bowels, as well as the liver. It occurs in the 
 course of very many morbid states of the body which are 
 independent of the stomach, and may have a constitutional 
 origin or an origin in some part of the body quite remote 
 from the stomach. Consequently, as pathological knowledge 
 increased the term became limited in its applicability, while 
 the diseases of the stomach which present the same symptoms 
 were more definitely understood. 
 
 Nevertheless the stomach becomes deranged from many- 
 causes connected with the food itself, or with the conditions 
 and circumstances under which it is consumed. Thus, if 
 the food is not properly masticated, either because of undue 
 haste in eating, defects or absence of teeth, soreness or 
 ulcers of the tongue or mouth, or even from toughness of 
 the food, there must necessarily be a delay in the dis- 
 integration of such foods in the stomach and consequently 
 a delay in their passage into the bowels. Imperfect masti- 
 cation is often one of the causes of indigestion ; it may be 
 the sole cause. In such cases disorder arises because the 
 process of dissolution of the food is unduly prolonged ; or 
 because the gastric juice is unable to disintegrate the masses 
 which have been swallowed, and consequently they are either 
 vomited or discharged into the duodenum with pain and 
 difficulty. This delay of food in the stomach is of import- 
 ance, as will be seen later on ; it means that the stomach is 
 always at work, never empty ; another meal being taken 
 before the previous one is disposed of. The continued 
 presence of food in the stomach is a source of irritation, it 
 causes catarrh of the mucous membrane, an excessive secre- 
 tion of gastric juice or of hydrochloric acid, and in the end 
 may lead to dilatation of the stomach, or to atrophy of the 
 gastric glands and a deficiency of the gastric juice.
 
 INDIGESTION 13 
 
 An excess of food is injurious to the stomach in a 
 similar manner. It throws a larger amount of work on the 
 stomach in manipulating and disintegrating the food and 
 passing it on to the duodenum. If large meals are very 
 often taken, they not only disturb the stomach by keeping 
 it constantly at work, but they cause an excessive secre- 
 tion of gastric juice or else hyperacidity. Many people 
 continue to take an excessive amount of food with 
 impunity for years ; but there are very few people who can 
 always continue to do so : an excess of food does little harm 
 to children or young adults, but in middle life it is a factor 
 in the production of dyspepsia, for, like other overworked 
 organs, the stomach becomes unable to do its duty ; it loses 
 its muscular tone ; it ultimately becomes unable to secrete 
 enough gastric juice, or either the pepsin or hydrochloric 
 acid becomes deficient. 
 
 The excess may consist of some particular class of food. 
 A large quantity of meat eaten regularly day by day is a 
 great tax on the stomach, since the action of gastric juice 
 is necessary for the digestion, which is completed by 
 the pancreatic juice. The excess of meat is often accom- 
 panied by the consumption of an unusually small amount 
 of bread, potatoes, and other vegetables ; consequently, the 
 body has to draw upon its store of fat for its supply of heat 
 and energy, and the person becomes thin. At the same 
 time extra work is thrown on the liver to metabolize the 
 waste materials from the meat, and on the kidneys, which 
 have to secrete them, and both liver and kidneys may ulti- 
 mately suffer in consequence. 
 
 The consumption of too much fat is also likely to inter- 
 fere with digestion. In the first place, it delays the disin- 
 tegration and dissolution of the food which is necessary for 
 its digestion ; secondly, it checks the secretion of gastric 
 juice ; and, thirdly, a large quantity of fat leaves the stomach 
 with difficulty, if at all, and may undergo decomposition. 
 
 The excessive consumption of carbohydrates, especially 
 ordinary sugar (cane-sugar) and sweet foods, will cause 
 catarrh of the mucous membrane of the stomach ; and, by 
 coating the food with mucus, prevent the access of the gas-
 
 i 4 DIET IN DYSPEPSIA 
 
 trie juice to it. An excess of sweet cakes, and even ordin- 
 ary bread, causes many people to have heartburn, acidity, 
 flatulence, palpitation, and other disagreeable symptoms. 
 If bread, toast, and similar foods are not thoroughly masti- 
 cated, they do not undergo that transformation into dextrin 
 and maltose (malt sugar) which is the ordinary result of 
 salivary digestion. They therefore enter the stomach in the 
 form of insoluble starch, which mechanically interferes with 
 the action of the gastric juice ; digestion is thereby delayed, 
 the food is detained a long time in the stomach, and fer- 
 mentation occurs, with the development of gas and irritat- 
 ing acids. 
 
 The presence of bran in wholemeal bread or coarse oat- 
 meal and of fibre (cellulose] in vegetable foods is another 
 cause of the indigestion of foods. Cellulose is the sub- 
 stance which gives firmness to vegetable structures : it is 
 to them what gristle and bone is to animals. Therefore, 
 one may easily understand the difficulty of digesting it. 
 Moreover, it gets tougher and harder as it increases in age. 
 Whereas the soft cartilages of a young animal become ossified, 
 the cellular tissues of the vegetable become lignified that 
 is, they are turned into wood. This is observable by com- 
 parison of a young and an old carrot ; a young carrot may 
 be as tender as a potato, an old one as hard as match- wood. 
 A similar comparison may be drawn between young and 
 old kidney beans : the young pods are so tender that they 
 snap readily, whence the Americans call them " snap beans " ; 
 but old ones are stringy, the fibres becoming coated with 
 a material which makes them as tough as horn. We 
 can easily understand how it is that pain and even sickness 
 may arise from the consumption of radishes, onions, carrots, 
 turnips, cabbages, and various other vegetables, when we 
 consider that the older they are the more lignin is deposited 
 on the cells which form the fibres, and coats them with a 
 substance like cork or wood, and renders them inaccessible 
 to the digestive juices. 
 
 There is no doubt that condiments and spices are also 
 detrimental when taken in excess. The agreeable sensation 
 of warmth following the use of mustard, pepper, horseradish,
 
 INDIGESTION 15 
 
 is due to these substances causing the mucous membrane 
 to be flushed with blood : the glands are thereby excited 
 to secrete gastric juice and mucus ; but the stimulation 
 may become a chronic irritation, with hypersecretion or 
 catarrh. A certain amount of vinegar is a useful addition to 
 cabbage, green peas, kidney beans, and other vegetables : acid 
 fruits are also useful to the body ; but an excess of such acids 
 results in a derangement of the digestive functions, which 
 is easily observable when persons persistently eat lemons or 
 take an immoderate quantity of lemon juice or lime juice. 
 An excess of tea or coffee, especially if taken with meat or 
 when digestion is at its height, is equally injurious. Foods 
 which are too hot or too cold are also injurious, and are 
 very liable to cause a catarrh of the stomach : whence arise 
 the injurious effects of ices, ice-creams. Alcohol causes or 
 aggravates every form of indigestion.
 
 CHAPTER III. 
 PAIN IN DYSPEPSIA. 
 
 A FEW of the symptoms of dyspepsia require a more detailed 
 consideration. Any pain in the region of the stomach, and 
 especially when associated with the consumption of food, 
 is a dyspepsia. But all pains in the stomach are not due to 
 the presence of food. There may be pain in the stomach 
 when its cavity is empty, e.g. gastralgia, which is an 
 actual pain occurring in paroxysms and relieved in all prob- 
 ability by taking food. But the pain in an empty stomach 
 may be due to acute gastritis, to malignant disease, to 
 neuralgia, to bacteria, or to poisons. 
 
 But pain occurring after food is far more common. This 
 may be a localized or a diffused pain. A pain diffused over 
 the epigastrium (pit of the stomach) may be due to acute 
 gastric catarrh ; acute gastritis due to alcohol, poisons, 
 bacteria, or injury ; or chronic dyspepsia and hyperacidity 
 or organic acidity due to fermentation by bacteria. The 
 thermometer would, of course, help to distinguish between 
 them. A localized pain is due to an ulcer, sometimes a 
 cancer, and such pain is not always in the stomach, but 
 may be in the back and associated with tenderness in the 
 dorsal region. 
 
 It should not be forgotten that a pain in the region of 
 the stomach is not always due to a disease of that organ. 
 A pain in the pit of the stomach may be due to distension 
 of the transverse colon, abdominal neuralgia, muscular rheu- 
 matism, and allied conditions. Pain in the left side (lower 
 part of axilla and hypochondrium) may be due to a dilated 
 stomach, to distension of the stomach by gas ; but it may also 
 
 (16)
 
 be due to an enlarged spleen, a dilated colon, or movable 
 kidney. Pain in the right side may be due to disease of the 
 liver, gall-stones, a loaded colon, and various other things. 
 
 The sensation of weight, discomfort, or fullness in the 
 stomach, which occurs directly or some hours after meals, 
 and is not attended by actual pain, is usually due to in- 
 digestion, gastric irritation, hyperacidity, loss of motor 
 power in the stomach, dilatation of the stomach, distension 
 by gas arising from bacterial fermentation. Such sensations, 
 which are sometimes referred to the front of the chest or 
 behind it (between the shoulders), may arise from the 
 stomach being too full, overloaded by solids or liquids, 
 especially when the motor power of the stomach is deficient. 
 It may be the presence of some particular article which 
 causes the pain or discomfort ; for example, new bread, hot 
 cakes, pastry, pork, veal, mackerel, salmon, lobster, pickles, 
 cucumber, radishes, raw fruit or heavy vegetables. It may 
 be caused by an excess of some condiment, such as vinegar, 
 mustard, horseradish, or some other food accessory. 
 
 In acute catarrh of the stomach the pain is of a burning 
 and darting character, often passing through to the back. 
 It is frequently aggravated by deep breathing, and is accom- 
 panied by a similar pain in the chest and a sense of op- 
 pression. There is considerable tenderness of the region 
 of the stomach. The abdominal muscles are frequently 
 contracted in a spasmodic manner over the stomach, to 
 protect the organ from pressure, and the breathing is shallow 
 and frequent with the same object. 
 
 In chronic catarrh the pain is diffused over the whole 
 region of the stomach, and often between the shoulders ; it 
 begins soon after a meal and lasts a time varying from a few 
 minutes to several hours, or even until the time of the next 
 meal. In this disease the pain is relieved by vomiting, and 
 the patient, conscious of the fact that it is the presence of 
 food which causes the pain, sometimes induces vomiting by 
 putting the fingers into the throat. In mild cases the pain 
 is less severe, and may not begin until an hour or two after 
 food. 
 
 In dilatation of the stomach the symptoms arise somewhat
 
 1 8 DIET IN DYSPEPSIA 
 
 later ; pain occurs about four to six hours after the meal, 
 and may occur only once in two or three days. The pain 
 is referred to the stomach, but as this organ is often very 
 much displaced, it is felt in the region of the umbilicus 
 rather than at the pit of the stomach. The gastric sensation 
 begins as a slight uneasiness or discomfort, and is accom- 
 panied by eructation of gas, distress of the heart, and 
 difficulty in breathing. This discomfort may be a burning 
 sensation or a dull aching pain, but it increases until it be- 
 comes more acute and is usually only relieved by vomiting. 
 
 In ulcer of the stomach the pain is one of the most 
 characteristic symptoms of the disease. It is a localized 
 pain, coming on after food, felt over an area of only one or 
 two inches in diameter in the pit of the stomach, but usually 
 (not always) goes through to the back and is felt on the left 
 side of the spine, between the tenth dorsal and first lumbar 
 vertebra. The anterior region where the pain is felt is 
 marked by a local tenderness over a small area above and 
 to the right of the umbilicus. 
 
 In duodenal ulcer there is the characteristic " hunger 
 pain, " coming on after food. When an ulcer of the stomach 
 or duodenum perforates it causes a very acute pain in the 
 upper part of the abdomen sufficiently severe to double the 
 patient up, and causes vomiting, faintness, and other signs 
 of collapse. Although at first the pain is localized, it very 
 soon becomes diffused over most of the abdomen, owing 
 to the escape of the stomach contents into the peritoneal 
 cavity. 
 
 In cancer of the stomach the pain is accompanied by local 
 tenderness. In some cases, however, there is a mere sensa- 
 tion of weight and oppression which is quite insufficient to 
 indicate the severity of the cause ; in other cases, where the 
 disease implicates some solid organ or bone, the pain is of a 
 dull and gnawing character. Most usually, however, the pain 
 is more or less intense, described as aching, burning, cutting, 
 or stabbing, and referred either to the pit of the stomach or 
 between the shoulders. 
 
 There are other pains in or about the region of the 
 stomach. Sometimes when attending a patient for some
 
 PAIN IN DYSPEPSIA 19 
 
 other disease, the question arises as to whether the pain is 
 or is not in the stomach. There is, for instance, the 
 troublesome " spasm of the stomach " which one occasion- 
 ally comes across. It is a sudden, severe, griping pain in 
 the pit of the stomach, extending to the back, and causing 
 faintness, a shrunken appearance of the face, cold hands and 
 feet, and an intermittent pulse. It suggests to the mind 
 either gall-stones or perforation. But although the pain is 
 bad enough to make the patient call out, there is usually no 
 tenderness over the stomach ; on the other hand, the patient 
 bears pressure well, and either presses his hands over the 
 stomach or presses the stomach against something to relieve 
 the pain. The attack only lasts a few minutes, at most half- 
 an-hour, and ceases suddenly with eructation of gas or 
 watery fluid or by vomiting. This, however, is not a disease 
 of the stomach : it may be a nervous affection dependent upon 
 an irritation of the branches of the pneumogastric nerves or 
 solar plexus ; possibly an inflammation of the nerve sheath, 
 maybe a small tumour. Moreover, it may be of central 
 origin and depend on some affection of the brain or spinal 
 cord. It is observed in anaemic or chlorotic women ; it is 
 one of the most frequent symptoms of hysteria. It may 
 arise from sympathy with uterine troubles, especially dis- 
 placements, chronic inflammation, or ovarian mischief. 
 But it is not confined to women, and it occurs in men who 
 are gouty, have malaria, or some other blood disease, as 
 well as from tumours on the nerves or central nerve diseases. 
 
 Similarly, the pain arising from gall-stones may suggest 
 gastric trouble. An attack of biliary colic, however, begins 
 unexpectedly and suddenly. It is a piercing, griping pain, 
 which starts from the right side and spreads from the gall 
 bladder over the region of the stomach, possibly over a large 
 area of the abdomen, and even up to the right shoulder. 
 The patient sighs and moans; perhaps doubles up and 
 rolls about the bed or floor. But as soon as the stone passes 
 through into the duodenum the pain ceases almost at once, 
 although it leaves some pain and tenderness owing to the 
 stretching of the bile duct and irritation of the nerves. 
 
 In intestinal troubles there is often considerable aching
 
 so DIET IN DYSPEPSIA 
 
 and griping ; if the affection is in the small intestines this pain 
 is referred chiefly to the umbilicus. When the large bowel 
 is affected, however, the position of the pain varies. In 
 inflammation the pain is often agonizing, and is due to spas- 
 modic contraction and movements of the intestines. Simi- 
 lar pains, however, may arise from faecal accumulations. 
 When this is in the hepatic flexure it may simulate some 
 disease of the liver, perhaps gall-stones, biliary colic. Pain 
 on the left side may not be from the stomach at all ; it may 
 rise from pleurisy, a localized peritonitis, movable kidney, 
 hydronephrosis, or impacted fasces. If a large part of the 
 colon contains impacted fasces, there may be a pain which 
 very much resembles some of the gastric pains : and if the 
 caecum is loaded it may simulate appendicitis.
 
 CHAPTER IV. 
 THE RELIEF OF PAIN IN DYSPEPTIC CASES. 
 
 THERE are many cases in which much can be done at least 
 to relieve pain. In chronic gastric catarrh, the disease is 
 sometimes intercurrent with some other affection, probably 
 considered to be far more serious. In these cases, pain is 
 often considerably relieved by administering something to 
 "bring up the wind". The simplest remedy for this pur- 
 pose is hot water. It can generally be given whenever 
 and as often as it is necessary. It causes an expansion of 
 the gas in the stomach, and by this means stimulates the 
 muscles to contract and relieves the organ of the distension 
 which is one of the chief factors in causing the pain. 
 But the hot water also acts as a warm fomentation, and is 
 soothing to the stomach by the direct application of moist 
 heat. 
 
 Another useful remedy for gastric pain is bicarbonate of 
 soda in the proportion of half to one teaspoonful in a 
 tumblerful of hot water. There can be no doubt about the 
 soothing influence of this remedy. It neutralizes acidity in 
 the stomach and thereby removes one of the sources of 
 gastric irritation and an element in the causation of pain ; 
 but it does more than this : by its combination with the acid 
 it causes a generation of carbonic acid gas, which is also 
 soothing to the mucous membrane, and by raising the pres- 
 sure of gases in the stomach still further stimulates the 
 muscles and produces eructations, to the great relief of 
 discomfort. There are other remedies of a similar character. 
 These are the various waters, some one or other of which 
 may already be in use. I mean soda-water, Apollinaris, and 
 Perrier. In Apollinaris we have not only bicarbonate of 
 
 (ai)
 
 22 DIET IN DYSPEPSIA 
 
 soda, but an abundance of carbonic acid gas in a preformed 
 state. In Perrier we have a water containing not more 
 than i per cent of minerals, chiefly lime ; but there is an 
 abundance of natural gas which makes it as superior to soda- 
 water as good wine is to a mixture of alcohol, cream of tartar 
 and water. There are other waters also, such as those of 
 Vichy, Vals, Bilin, Ems, and Tarasp, which contain bicarbon- 
 ate of soda but very little gas, and have the same effect 
 when given with an equal quantity of hot water. 
 
 In hyperacidity or acid dyspepsia, also, the use of sodium 
 bicarbonate or one of the alkaline waters relieves pain by 
 neutralizing the acid gastric juice. In organic acidity they 
 neutralize the organic acids arising from fermentation. 
 This can be illustrated by adding a little bicarbonate of soda 
 or one of the alkaline waters to a solution of hydrochloric 
 acid, citric acid, vinegar, or lemon juice and water, which 
 contain the same or similar acids to those in the stomach. 
 When this is done, it will be found that the fluid which 
 previously had an acid taste and irritating qualities has be- 
 come neutral, or alkaline and unirritating. Therefore, 
 while hot water relieves pain by dispersing wind and 
 soothing the irritated mucous membrane, the bicarbonate of 
 soda , or alkaline water containing it effects the same pur- 
 pose by neutralizing the acids which irritate the mucous 
 membrane. 
 
 The pain in the stomach may, however, be due to other 
 causes than flatulence and acidity. It may arise from the 
 nature of the food. Suppose it is due to eating radishes, 
 cucumber, lobster, pickles, pork, veal, pastry, or some other 
 article likely to injure a weak stomach. It would do little 
 good in such a case to keep pouring solutions of bicarbonate 
 of soda into the stomach ; it is true the soda is a sedative 
 apart from its effects as an antacid, but it would do far more 
 good to encourage the stomach to eject the offending sub- 
 stance. And this remedy is actually adopted in many in- 
 stances. The pain arising from such foods may be suffici- 
 ently great to be called "cramp"; that is to say, the 
 stomach hurts itself by contracting in an irregular manner 
 upon these hard substances, or by attempting to propel them
 
 THE RELIEF OF PAIN IN DYSPEPTIC CASES 23 
 
 into the intestines. At the same time, the nervous mechan- 
 ism becomes deranged, the excretion of gas by the gastric 
 mucous membrane is increased, the stomach is thereby dis- 
 tended, and aggravates the symptoms. In such a case the 
 most rational remedy is an emetic. Mustard and common 
 salt are generally handy, and are usually effectual. Let two 
 teaspoonsful of mustard be made into a paste and given in 
 a tumblerful of hot water ; it will speedily make the patient 
 vomit. Common salt, a dessertspoonful in the same amount 
 of hot water, is almost equally speedy in its effects. If they 
 do not act, the dose must be repeated. I have generally 
 observed that mustard is the most effectual, but at the same 
 time it is more irritating to the gastric mucous membrane, 
 and is liable to aggravate the catarrh which the irritating 
 food may originate. 
 
 Then there is the pain which occurs in an empty stomach, 
 that is, in acute gastritis, acute gastric catarrh, neuralgia, and 
 cancer of the stomach. 
 
 In neuralgia of the stomach the pain is very frequently 
 relieved by taking a warm meal of a reasonable and nutritious 
 character. With that remark we can dismiss it for the 
 present. 
 
 In acute gastric catarrh the relief of pain is to some extent 
 brought about by keeping the stomach empty, or at any rate 
 allowing only small particles of ice to relieve thirst. The 
 application of warmth over the pit of the stomach is a valu- 
 able aid to other treatment. A piece of Gamgee tissue or 
 flannel wrung out of very hot water and sprinkled with a 
 tablespoonful of turpentine will often afford relief. The 
 region may be painted thickly with glycerine of belladonna 
 or opium liniment, covered with Gamgee wrung out of hot 
 water, then a layer of oiled silk, next a layer of cotton wool, 
 and finally a binder to keep it in place. The application 
 of dry heat is useful in some cases, and for this purpose an 
 indiarubber hot-water bottle, or an abdominal hot-water tin, 
 can be used ; but the patient often finds the weight too 
 much for her. A light and useful application is a mustard 
 plaster, which can be kept on for half an hour, and after- 
 wards replaced by a layer of cotton wool,
 
 24 DIET IN DYSPEPSIA 
 
 In those excessively severe cases of acute gastritis which 
 are due to powerful irritants, such as poison, also in the acute 
 form due to infective diseases, such as puerperal fever, the 
 inflammation runs very high, and may cause sloughing, 
 possibly the formation of pus in the tissues of the stomach, 
 and abscesses which burst into its cavity, warm applications 
 may still be useful. They may consist of those already 
 named, or linseed and opium poultices, starch poultices, 
 antiphlogistine, etc. But the pain in the stomach is often 
 of a burning character, sometimes described as being " like 
 a fire," and, therefore, cold applications may afford more 
 relief. A cold lead lotion, or the old-fashioned evaporating 
 lotion, would not be despised. But the application of 
 Leiter's tube, with a constant stream of cold water through 
 it, and an ice-bag or pounded ice placed between two layers 
 of flannel, would be more appreciated. 
 
 In cancer of the stomach relief from pain may be given 
 by warm applications, but the chief reliance must be placed 
 upon drugs, with careful selection and preparation of the 
 food. Similar remarks apply to the pain of gastric ulcer. 
 It would not do to apply warm applications over the 
 stomach while haemorrhage is going on, and the relief of 
 pain would then depend on the use of cold applications, 
 which would also be the best local application to check the 
 haemorrhage. If, however, perforation is suspected, a warm 
 application would give most relief; antiphlogistine, starch 
 poultices, turpentine stupe, or cotton wool would be useful. 
 Such applications, however, would only be used until an 
 operation is arranged, and is about to be carried out. 
 
 The nurse's ingenuity will often be taxed to find the 
 means of relieving pain in gastric cases, but there is probably 
 no class of cases which will better repay her for study than 
 this. The stomach sympathizes with almost every other 
 organ in the body, and, consequently, pain in the stomach 
 is one of the most common complications met with, even 
 when the stomach itself is not at fault, as exemplified in 
 the gastric pains of locomotor ataxy and the gastric crises of 
 Bright's disease.
 
 CHAPTER V. 
 VOMITING. 
 
 VOMITING is a reflex act produced by many causes. It is 
 a very complex performance, and it is governed by one 
 of the nerve " centres " in the medulla. The vomiting 
 centre is easily excited by various things, such as tickling 
 the throat, an irritation of the stomach, liver, bowels, or 
 peritoneum, and even of some parts of the body which have 
 no direct connexion with the stomach. It will be as well to 
 give a list of the chief causes of vomiting other than gastric 
 diseases. Mechanical causes, such as tickling the throat, or 
 violent coughing after a meal, are very liable to produce 
 vomiting. Irritation of the organs of special sense by offen- 
 sive odours, horrible sights, or disagreeable sounds, will 
 cause vomiting. These modes of irritation do not have the 
 same effect on everybody ; thus, one person may be caused 
 to vomit by the odour of apples, and another by some sort 
 of perfume which would not be disagreeable to the average 
 individual. Severe pain arising from the passage of a gall- 
 stone, renal calculus, dysmenorrhoea, or from an injury to 
 some part of the body, is liable to cause vomiting. It occurs 
 in inflammation of the kidneys, and especially in ursemic 
 poisoning. It is commonly a symptom of meningitis, 
 tumours of the brain, neurasthenia, hysteria, and functional 
 derangements of the nervous system. It likewise occurs at 
 the onset of various infectious diseases, especially in children. 
 Pregnancy is a common cause, and it may be the result of 
 various drugs. Some emetics, such as tartar emetic and 
 antimony wine, are carried in the blood stream and act 
 by directly irritating the vomiting centre ; indeed, they will
 
 a6 DIET IN DYSPEPSIA 
 
 produce vomiting when injected into the blood ; others, like 
 mustard, act indirectly by irritating the mucous membrane 
 of the stomach ; and still others by their nauseous taste or 
 odour act upon the vomiting centre indirectly, i.e. through 
 the higher nerve centres or organs of special sense. 
 
 When a person is about to vomit there is usually a profuse 
 flow of saliva, the skin becomes pale and moist with per- 
 spiration. The actual process of vomiting is attended by 
 a full inspiration, a contraction of the diaphragm, and a 
 simultaneous spasm of the muscles of the abdomen ; at the 
 same time there is a relaxation of the cardiac sphincter and 
 some contraction of the stomach itself, and the combined 
 pressure produces an evacuation of its contents. 
 
 When vomiting occurs in dyspepsia, using this word in an 
 extended sense, it usually occurs soon after a meal, that is 
 within half an hour, but it may be delayed an hour or two. 
 It does not occur in every dyspeptic patient, and in some 
 patients it occurs only at long and irregular intervals. The 
 vomited matters necessarily vary in appearance with the time 
 which has elapsed since the consumption of the food. In 
 some cases the food is very little altered, and the descrip- 
 tion usually given is that " it came back just as she took it ". 
 In other cases the vomiting does not occur until long after 
 the meal is eaten ; the material brought up has probably 
 undergone fermentation, has a fermented or a sour smell, 
 the odour of rotten eggs, of putrefaction, or of faeces ; it 
 presents a brown frothy scum and more or less sediment 
 when it has been standing. The quantity of material 
 brought up varies considerably. It may be little more than 
 regurgitation or " repeating of the food," which is very similar 
 to the normal rumination of cattle and other animals who 
 "chew the cud"; or it may be an eructation of a little 
 sweetish or sour fluid and wind. There is every variation in 
 the quantity between this and the enormous volumes which 
 are brought up from a badly dilated stomach. When 
 vomiting occurs while the stomach is empty, that is without 
 food, the material which comes up consists chiefly of saliva 
 and ropy mucus or, perhaps, bile ; in some cases it consists 
 of an acid fluid, sometimes gastric juice sour enough to set
 
 VOMITING 27 
 
 the teeth on edge. The vomiting in these various cases 
 should be distinguished from each other more clearly. 
 
 In acute gastritis vomiting is frequently the first symptom 
 complained of. It occurs repeatedly and becomes painful 
 and distressing to the patient. The vomit consists first of 
 food, and any attempt at feeding induces it. But it goes 
 on even when the stomach is empty, and continues, attended 
 by nausea, violent retching, and painful hiccup, until 
 mucus comes up streaked with blood or mixed with bile. 
 
 In chronic gastritis the vomiting is different. It is a 
 common but not a constant symptom. It nearly always has 
 reference to the food, and seldom occurs when the stomach 
 is empty. It usually comes on after meals, and may occur 
 two or three times a day or only at intervals of months. It 
 is not usually succeeded by retching and hiccup, but by 
 complete relief of the pain and other disagreeable symptoms 
 which the food may have induced. The vomiting, however, 
 may be due to chronic gastro-duodenal catarrh^ and is then 
 liable to take the form of " morning sickness," especially in 
 alcoholic subjects. It occurs before food is taken, and the 
 material brought up consists of saliva which was swallowed 
 during the night, possibly some remnants of the last meal, 
 and mucus. The latter varies in amount from a few pellets 
 of glairy substance floating in a scanty fluid to an abundance 
 of ropy material whose character is best observed by pouring 
 it from one vessel into another. If there is much food in 
 the "vomit before food" it is an indication of considerable 
 delay in the digestive process, and enfeeblement of the 
 motor power of the stomach, and possibly more or less 
 dilatation. 
 
 In dilatation of the stomach the vomiting is again different. 
 The typical vomiting of dilatation is very easy and free ; it 
 is not usually preceded by nausea, but there is a good deal 
 of discomfort and possibly some pain in the region of the 
 umbilicus. The vomiting does not occur every day as a 
 rule ; as a matter of fact it does not occur for a week or two 
 together in many cases of dilatation, but when it does happen 
 the amount brought up is very abundant, varying from two 
 to eight pints, and comes up so easily as to give the im-
 
 28 DIET IN DYSPEPSIA 
 
 pression of its being "pumped up". The vomit is often 
 exceedingly irritating to the throat and mouth, and causes a 
 burning sensation in the chest and throat and sets the teeth 
 on edge. It consists of a variety of materials, and includes 
 undigested articles of food eaten perhaps a week before ; it 
 is sour, fermented, and offensive to the smell. But the relief 
 which is experienced by the removal of the accumulated 
 food, secretions, and products of fermentation is so great 
 that patients sometimes voluntarily provoke vomiting by 
 irritating their throat with their ringers or a feather. 
 
 In cancer of the stomach, vomiting is one of the chief 
 symptoms ; but it occurs at irregular periods and gives no 
 relief from pain. If the cancer obstructs the pylorus, the 
 passage of the food will be hindered and consequently the 
 vomited materials may have the same characters as in 
 dilated stomach, besides containing traces of blood, or 
 changed blood having the appearance of " coffee grounds ". 
 
 Where there is an ulcer of the stomach the vomiting is also 
 irregular. In some cases it occurs after almost every meal ; 
 in others only occasionally. It may occur half an hour or 
 two or three hours after the meal. It is preceded by pain 
 and followed by relief; and the material ejected consists of 
 food which is either unchanged or more or less digested, 
 according to the length of time it has been in the stomach. 
 It is never fermented or putrid, but may contain blood, which 
 varies in amount from a mere trace to " quarts " of blood. 
 
 In nervous dyspepsia the vomiting is peculiar in being 
 about the only serious part of the malady. It is an affec- 
 tion which sometimes occurs in hysterical or neurasthenic 
 women. It is often associated with a good appetite, even 
 a voracious appetite, inasmuch as the remark is sometimes 
 made, " She eats until she makes herself sick ". This is 
 not strictly true, because the appetite is not always abnor- 
 mal; and the patient may only vomit occasionally or at 
 some particular time of the day. The vomited food may 
 be very little changed, but she often appears to bring 
 up more than she ate, because she vomits the gastric juice 
 which is apt to be abnormally abundant. This is often 
 associated with abnormal cravings and desires, which show
 
 VOMITING 29 
 
 themselves in various ways, e.g. the consumption of chalk, 
 slate-pencils, coal, clay, and other articles of an innutritious 
 character. Such cases show the influence of mind over 
 matter. Behind the reserved, moody, tricky, wilful be- 
 haviour there is nearly always some mental cause, some 
 disappointment, or hope deferred, which being satisfied 
 would lead to the restoration of health. These patients 
 require judicious, but firm, handling. It is worse than 
 useless to be harsh ; no good will be done by " driving " 
 them ; you would defeat your object. It is better to culti- 
 vate a kindly manner, to mix your firmness with pleasantry, 
 to endeavour to lead in the way you wish them to go. 
 They are to be pitied ; but you must not show them pity. 
 They lay themselves out for all the sympathy, fuss, and 
 attention they can get, and their bodily and mental func- 
 tions deteriorate under such influence. 
 
 The peculiar nervous dyspepsia of men, which is not so 
 common, is generally associated with some inflammation of 
 the sheath of abdominal nerves, perhaps the pneumogastric 
 or sympathetic nerve. It gives rise to vomiting of a 
 similar character, pain, and other distressing symptoms. 
 The mental changes are not the same as in women, but the 
 patient is apt to become gloomy, pessimistic, and melancholic. 
 
 Vomiting is rarely absent from obstruction of the bowels. 
 At first this is merely sympathetic, and the substances 
 brought up consist of food, more or less changed by di- 
 gestion. By and by, however, the character of the vomit 
 changes; it becomes of the consistency of pea- soup and 
 has a faecal odour owing to decomposition, but the 
 material is seldom truly faecal, although it is called " ster- 
 coraceous," that is dung-like. 
 
 It is an established fact that the nearer the obstruction is 
 to the stomach the more severe is the vomiting and the 
 sooner it begins. The vomiting is very persistent. When 
 the obstruction does not give rise to a complete mechanical 
 occlusion of the bowels the vomiting is constant, and may 
 be incessant. The stomach rejects everything which is put 
 into it. But the vomiting will not become stercoraceous or 
 eculent in the majority of cases however long it may last,
 
 30 DIET IN DYSPEPSIA 
 
 nor however obstinate the constipation may be. But if the 
 mechanical occlusion of the bowels is complete the vomit 
 becomes stercoraceous by about the third day, sometimes 
 sooner, and never ceases until the obstruction is removed. 
 
 When the obstruction is acute, such as occurs in strangula- 
 tion of a piece of the gut, the patient is struck with a severe 
 pain, usually at a fixed spot. The pain is sufficiently severe 
 to cause considerable depression approaching to faintness 
 or collapse. Vomiting speedily occurs. The abdomen 
 becomes tender, swollen, and distended by flatus, which 
 causes rumbling and gurgling noises. 
 
 If the obstruction comes on slowly, or is chronic, as 
 occurs from the growth of a tumour outside the bowel, 
 stricture or malignant disease of the bowel, constipation is 
 for a long time the most prominent symptom. There is 
 then comparatively little constitutional disturbance for a 
 considerable time. But the abdomen becomes gradually 
 swollen and tympanitic, with rumbling and gurgling in the 
 intestines, eructations of food and wind, much retching, and 
 finally vomiting. Moreover, in such cases the vomiting 
 does not begin, even when the obstruction becomes com- 
 plete, until some time, perhaps a week or ten days, has 
 elapsed; but the presence of stercoraceous matter in the 
 vomit is then a serious symptom. 
 
 Thus we may say that if the obstruction is in the small 
 intestines the vomiting comes on pretty rapidly and 
 is severe ; but if the obstruction is in the large intestines 
 the vomiting is longer delayed, may never be a very pro- 
 minent sign, and might be due to constipation. When the 
 obstruction is due to strangulation of the bowels, there is 
 nausea, hiccup, fever, and inflammation, as well as vomiting. 
 When the obstruction is due to intussusception, impac- 
 tion of foreign bodies, gall-stones, compression by a tumour, 
 or pregnant uterus, the obstruction occurs more slowly, 
 fever and inflammation are usually absent, and vomiting is 
 a very late symptom. 
 
 In brain affections also the vomiting is accompanied by 
 the special signs of the disease. In tubercular meningitis 
 the vomiting when it occurs is more or less uncontrollable ;
 
 VOMITING 31 
 
 but it is associated with some rise of temperature, headache, 
 intolerance of light and sound, fretfulness, peevishness, the 
 peculiar cry which is characteristic of the disease, and the 
 " blush " on the skin which speedily follows a pencil mark 
 or finger-nail drawn across it ( Tdcke cerebrale). In cerebral 
 tumour the vomiting is often one of the earliest symptoms 
 complained of; and it is unaccountable ; there has been 
 nothing to explain it ; it comes on at irregular intervals 
 and without obvious cause. It is usually unattended by 
 nausea or loss of appetite ; but there are headache, giddi- 
 ness, perhaps a staggering gait, epileptiform attacks, and 
 other signs showing a disturbance of the circulation in the 
 brain ; and squint or other obvious abnormal affections of 
 the special senses arising from pressure upon the brain.
 
 CHAPTER VI. 
 THE RELIEF OF VOMITING. 
 
 IN order to avoid confusion the treatment of vomiting from 
 these various causes should be carried out as far as possible 
 on general lines. It would be rather puzzling to the reader 
 if a separate treatment were given for vomiting in each 
 of these cases. Moreover, such a course is quite un- 
 necessary. 
 
 There are very few cases where the administration of an 
 emetic is requisite ; but this preliminary treatment may be 
 necessary in cases of acute indigestion due to the consump- 
 tion of indigestible foods. In these cases the vomiting will 
 cease as soon as the cause is removed. In all other cases 
 it is equally necessary to find out the cause and remove it ; 
 but it is not always easy to do so. In the meantime a good 
 deal can be done to subdue the gastric or nervous irritation 
 which is producing it. First and foremost there are the 
 means of acting on and through the stomach. It is ob- 
 viously useless to endeavour to force a large quantity of 
 anything upon the stomach ; indeed, that would be one of 
 the surest means of keeping up the irritation. We must 
 begin by giving only the very smallest quantity of nutriment 
 at a time, and it must be of the blandest and least irritating 
 character. 
 
 Milk may be tried, but not pure milk. The best mix- 
 ture is probably equal parts of milk and lime-water. The 
 milk should be boiled, but can afterwards be cooled, or even 
 iced; and it should have just a little salt added to it. 
 Lime-water is a sedative to the stomach, but it is chiefly of 
 
 (3*)
 
 THE RELIEF OF VOMITING 33 
 
 value by preventing the formation of large curds of milk. 
 The curds from milk and lime-water are very much smaller 
 and softer than those formed from milk alone. Lime-water 
 also neutralizes the slight acidity which is ever present in 
 milk. The amount given at a time should not exceed a 
 tablespoonful of milk and lime-water; but this should be 
 given very often. If the stomach settles down under its in- 
 fluence the amount given each time should be increased 
 every hour by adding a tablespoonful to the dose, until the 
 patient can take two or three ounces at once, making a 
 total of two pints in twenty-four hours. As soon as the 
 patient can take and keep down four ounces of milk at a 
 time we can also give some Bovril, Lemco, or beef-tea to the 
 extent of a half-pint in twenty-four hours. Such would 
 be the beginning of treatment in an ordinary case of 
 vomiting which did not threaten to give rise to much anxiety. 
 But in a bad case milk and lime-water, even in teaspoonful 
 doses, might not be retained. The substance should then 
 be quickly changed. It is useless to persist in giving the 
 patient a food which obviously disagrees. Barley-water and 
 milk, in equal parts, can be tried. I have found that ALBUMIN- 
 WATER will often be retained when everything else is re- 
 jected. This food consists of the white of one raw egg in 
 a small cupful of lemon-water, and just enough sugar to 
 make it palatable. It can be iced. It should not be given 
 in too large a quantity at once. Begin by giving a teaspoonful 
 every five minutes ; if that is retained for half an hour you 
 may increase the quantity to a tablespoonful every fifteen 
 minutes. But do not try " to force the speed " ; if you do the 
 vomiting will recur and the process will have to be com- 
 menced again. You must " make haste slowly ". When you 
 feel pretty sure that a tablespoonful of albumin-water will be 
 retained you can add some Valentine's meat juice or Bovril 
 to it. I have a special liking for Valentine's meat juice, 
 and always recommend it for these cases. The quantity of 
 any of these meat extracts, however, would be one teaspoonful 
 in a cupful of albumin-water. 
 
 If albumin-water given in teaspoonful doses is rejected 
 the outlook is pretty bad. We should then not be satisfied 
 
 3
 
 34 DIET IN DYSPEPSIA 
 
 by icing the fluids, but give the patient small lumps of ice 
 to suck ; and now and then pour a few drops of Valentine's 
 juice over a small lump of ice just when it is being put 
 into the patient's mouth. Why did I not give ice sooner? 
 you ask. Because the amount of nourishment which is re- 
 tained in twenty-four hours by these patients is a mere starva- 
 tion diet, and it seems to me absurd to reduce the quantity 
 more than is absolutely necessary. Ice the milk and lime- 
 water or the albumin-water by all means ; the colder it is 
 the better ; but be sure the patient gets a little nutriment, 
 and thereby ward off a state of collapse. A teaspoonful 
 or two of iced champagne, or, in its absence, brandy and 
 soda, is valuable not only for warding off collapse, but by 
 assisting to subdue gastric irritability. The carbonic acid 
 gas in champagne, soda-water, potash-water, Perrier, and 
 Apollinaris is a useful sedative and assists in overcoming the 
 tendency to vomit in a large number of ordinary cases ; 
 but a large bulk of fluid would not be retained. If it is sus- 
 pected that alcoholism is the cause of vomiting it would not 
 be proper to give brandy or champagne to stop it, although 
 "a hair of the dog that bit him" is sometimes a useful 
 remedy. 
 
 In acute gastritis it is often necessary to stop mouth feed- 
 ing for a day ontwo, merely allowing a little ice with Valen- 
 tine's meat juice. But when the stomach is settling down 
 a bit we can give albumin-water, lime-water, and milk or 
 peptonized milk alternately. In meningitis and other forms 
 of cerebral vomiting the patient will be able to take a larger 
 quantity of albumin-water at a time ; indeed, they can often 
 retain half a cupful of it when a smaller quantity of milk 
 and lime-water would be rejected. 
 
 No matter what the cause of vomiting may be, the feeding 
 must be begun on these lines. There are rarely cases where 
 this method fails. There are for these two other modes of 
 treatment viz., washing out the stomach and rectal feeding. 
 Washing out the stomach will do no good in cerebral or 
 renal cases, but it may do much good in gastric and intes- 
 tinal cases. Rectal feeding is useful in gastric, renal, cere- 
 bral, and other nervous cases ; but it is of little use in
 
 THE RELIEF OF VOMITING 35 
 
 intestinal cases. The " feeds " may consist of peptonized 
 milk or peptonized milk with some glucose or extract of malt ; 
 raw egg and a teacupful of milk with a little salt, or beef-tea 
 and glucose. Four " feeds " may be given in twenty-four 
 hours at intervals of six hours. In long-continued vomit- 
 ing thirst becomes distressing and may be relieved to some 
 extent by the injection of a pint of warm water into the colon 
 twice a day. 
 
 In addition to these modes of feeding, the patient must 
 be kept absolutely still. Moving about will perpetuate the 
 sickness ; sitting up to vomit aggravates the condition ; 
 shaking the bed, turning from side to side will also make 
 things worse. It is better to keep the patient on one side 
 and use a small basin or napkin to receive the vomited 
 materials. 
 
 As the stomach recovers, the diet must be gradually im- 
 proved. When the stomach will retain a teacupful of milk 
 and lime-water or barley-water, we can begin by giving some 
 bland and unirritating substance such as Mellin's food, 
 arrowroot and milk, Plasmon, Tilia, Sanatogen, junket, 
 custard, and jelly. The quantity must be very small until 
 the stomach will bear it comfortably. A teaspoonful of 
 Brand's essence of beef or Mosquera's beef jelly will usually 
 be retained when a cupful of milk and lime-water or pepton- 
 ized milk is kept down. Mellin's food does not lay a tax 
 upon the stomach, and Benger's food gives very little trouble 
 to it. The advantages of Plasmon, Tilia, and other milk 
 powders in sickness is that they do not form a curd ; neither 
 does junket form a curd in the stomach, it is already curdled 
 and is soft and unirritating. When the stomach will bear 
 these things an attempt can be made with a teaspoonful of 
 soft-boiled egg and a mouthful or two of bread and butter. 
 Then some light milk pudding may be given, and then we 
 can go on to a teaspoonful or two of sole or plaice. The 
 quantity of food must be slowly increased, and any attempt 
 to give what the patient might consider " a proper meal " 
 before the cause of vomiting had subsided would be almost 
 sure to end in disaster.
 
 36 DIET IN DYSPEPSIA 
 
 VOMITING OF PREGNANCY. 
 
 The sickness of pregnancy is one of the commonest 
 forms of " morning sickness ". As a general rule morning 
 sickness is due either to pregnancy, gastro-duodenal catarrh, 
 or alcoholism. These conditions should always be in the 
 mind when one is considering the origin of persistent vom- 
 iting. In married ladies there is usually no difficulty in 
 arriving at a conclusion as to the first of these conditions. 
 To begin with, the lady has missed one or two " periods " 
 and is probably beginning to show other signs of her con- 
 dition. The sickness generally commences at the begin- 
 ning of the second month of pregnancy and terminates when 
 the quickening occurs. It comes on as soon as she assumes 
 the upright position, and the vomit usually consists of some 
 glairy fluid. As a general rule there is no other vomiting 
 throughout the day, and, the appetite being good, nutrition 
 does not suffer. If this were all that was likely to happen 
 we should have no need to draw attention to the subject. 
 But unfortunately there are cases where the vomiting occurs 
 throughout the day, and consequently the patient becomes 
 emaciated and weak, and the prospect is rather threatening. 
 Indeed the vomiting may be so severe and prolonged as to 
 cause extreme danger, not only from starvation but from the 
 general condition. The most dangerous cases are those in 
 which the patient becomes restless, sleepless, has a fetid 
 breath, and passes little urine. Sometimes the urine con- 
 tains a little albumin ; and, as the patient passes very little 
 urine, the waste products of the tissue changes are retained 
 in the organism, and bring about some degree of uraemia. 
 Probably the temperature rises two or three degrees, and the 
 mind becomes wandering. The danger is very great when 
 the pulse rises to 120, and delirium and diarrhoea occur. 
 
 Vomiting of pregnancy is regarded as being reflex, as a 
 general rule, due to the irritation of the nerves in the grow- 
 ing uterus. It may be expected to be rather severe in first 
 pregnancies, presumably because the resistance of the uterus 
 to expansion is greater than in one which has already borne 
 several children, Again, it is likely to be rather severe in
 
 THE RELIEF OF VOMITING 37 
 
 the first pregnancy of young ladies who have been accustomed 
 to experience a great deal of pain at their periods (dysmen- 
 orrhoea). Excessive vomiting also occurs in others who 
 have suffered from displacements of the uterus, especially 
 forward displacements ; and in those who have been neurotic. 
 
 When women have borne one or more children, the vom- 
 iting is generally normal; but very severe and prolonged 
 vomiting may occur when a previous pregnancy has re- 
 sulted in chronic inflammation or ulceration of the neck of 
 the uterus. The vomiting may then be due to the stretching 
 and irritation of inflamed or ulcerated tissues. 
 
 In some extremely bad cases of vomiting in pregnancy 
 called hyperemesis, the patient dies ; the post-mortem exam- 
 ination then reveals a degeneration of the cells of the liver 
 or kidneys, or both. On this ground, therefore, we are com- 
 pelled to the opinion that such cases are really different from 
 any others, and that the degeneration of the liver and kid- 
 neys predisposes to the fatal result. 
 
 The treatment of mild, but ordinary vomiting of pregnancy 
 is not difficult. It is important that the patient should have 
 some food before getting out of bed. This gives the stomach 
 something to do in the right direction, and may ward off the 
 nausea, and will certainly reduce the exhaustion which is a 
 disturbing element in the case. The avoidance of foods 
 which are b'able to cause indigestion is essential. Con- 
 stipation must be treated. Perhaps a change of diet may be 
 necessary on this account ; avoiding milk, milk puddings, 
 white bread, and other foods which tend to constipate the 
 patient ; and taking brown bread, oatmeal, treacle, jam, 
 fruit, vegetables, and meat, which have the opposite 
 effect. 
 
 In severe cases of vomiting, the patient must be kept in 
 bed, and lie on her back or right side. Her food must be 
 the same as for other cases of severe sickness. It must be 
 given at very short intervals, and only a spoonful at a time. 
 Milk, milk and lime-water, milk and bicarbonate of potash 
 or one of the gaseous waters, e.g. soda-water, potash-water, 
 Perrier or Apollinaris will be useful. Milk and barley- 
 water are not to be despised, although the barley-water
 
 38 DIET IN DYSPEPSIA 
 
 contains very little nutriment. In extremely severe cases, 
 ice, iced milk, albumin-water, iced champagne, brandy and 
 soda, Valentine's meat juice, Brand's essence, Mosquera's 
 beef jelly, Plasmon, Sanatogen, are all proper things to use. 
 One thing must be tried after another. If they fail, we 
 must resort to rectal feeding ; but that can only be carried 
 on for a few days. Sometimes the application of an ice-bag 
 over the pit of the stomach, or to the back of the neck, will 
 help to check the vomiting. 
 
 If the irritation ceases, and the stomach begins to retain 
 food, we can give peptonized milk, peptonized milk gruel, 
 beef-tea, Benger's or Mellin's food, Savory and Moore's food ; 
 and from this foundation we can gradually build up a diet 
 consisting of light and nourishing articles, to be taken for 
 some time before the patient returns to the normal dietary. 
 
 In some of the exceedingly severe cases it may be necessary 
 for the doctor to relieve the uterus of its burden in order to 
 save the patient's life. It is often necessary to resist the 
 desire of the patient or the patient's friends for this opera- 
 tion to be done. The legality of the operation has always 
 to be considered. As a matter of protection for himself, 
 the medical attendant will probably request the opinion of 
 somebody else before he does it. Perhaps the supervention 
 of uraemia, convulsions, or delirium, may determine the 
 necessity for it. In other instances a pulse of 1 20, a red, 
 glazed, or brown tongue, considerable emaciation and great 
 exhaustion are sufficient indications for the expediency of 
 obtaining that mode of relief, and saving the patient's life. 
 
 VOMITING IN SICK HEADACHE. 
 
 Females are more prone to sick headache than males. The 
 attack frequently comes on early in the morning. The 
 patient gets out of bed feeling dull and indisposed for 
 mental or bodily exertion; she looks heavy, dejected, and 
 miserable. Then the headache begins, and after a time a 
 sense of nausea supervenes which usually ends in a more or 
 less severe attack of vomiting. If the patient has taken 
 any food it will probably come back almost unchanged ; if
 
 THE RELIEF OF VOMITING 39 
 
 she has not taken food, she usually brings up some mucus 
 with great straining and retching, and finally the vomit con- 
 tains bile, yellow or green, and occasionally streaks of blood. 
 The headache attains its greatest intensity during the vom- 
 iting, which may be repeated several times. The patient 
 cannot bear any light, or noise, or the least shaking of the 
 bed, and is usually very prostrate and almost collapsed. 
 After the vomiting ceases she will probably go to sleep and 
 may wake up refreshed and feeling very nearly in her usual 
 health. 
 
 As a rule no food or drink can be tolerated during the 
 attack. The patient should be put to bed, the room dark- 
 ened, and have some evaporating fluid applied to the head. 
 An evaporating lotion, or plain spirit (gin) and water, an- 
 swers the purpose very well; but most patients prefer eau 
 de Cologne, eau de Florida, or other perfumed waters. 
 Vinegar and water is not to be despised and its aromatic 
 odour is very refreshing. Sometimes a tight bandage round 
 the head gives relief, but more relief is obtained by pressure 
 with the thumb over the temporal artery on the painful side. 
 As soon as the patient can be induced to take anything, she 
 should have a teacupful of very strong tea or coffee, some 
 guarana (Brazilian cocoa), or a glassful of kola wine, all of 
 which contain caffein, an alkaloid which is well calculated to 
 relieve the pain and sickness, and at the same time act as a re- 
 storative. The treatment of sick headache should be carried 
 on between the attacks. The cause must be sought. If it 
 is due to constipation or duodenal catarrh it is a comparatively 
 simple matter. But some of the cases, more properly called 
 migraine, are not so readily cured. Nevertheless a large 
 proportion of them are curable where proper steps are taken. 
 The treatment usually includes a modification of the diet. 
 In some instances it is advisable for the patient to abandon 
 the use of meat entirely and live upon milk, eggs, white bread, 
 cheese, oatmeal, potatoes, butter, green vegetables, and fruit. 
 This is practically a purin-free dietary and must be persisted 
 in for many months. In other cases a fruitarian dietary is 
 valuable and, consisting of fruit and nuts, is considered more 
 palatable than the former. But none of these diets should
 
 40 DIET IN DYSPEPSIA 
 
 be taken without medical advice, and the physician should 
 arrange a diet sheet, in which the nuts and fruits are those 
 which go well together. If this is not done the dietary may 
 fail, not because it is of the wrong kind, but because the 
 items are not arranged so as to form a properly balanced diet. 
 
 THE VOMITING OF BLOOD. 
 
 The term haematemesis or vomiting of blood is applied to 
 bringing blood up from the stomach, no matter what the 
 source may be. Haematemesis may be due to bleeding of 
 the stomach or parts of the body somewhat remote from 
 that organ. The blood may have been swallowed after the 
 removal of teeth, tonsils, adenoids, from wounds or ulcers 
 about the mouth or throat. Profuse bleeding of the nose 
 may occur without obvious reason if the blood-vessels are 
 diseased, and a large amount of blood may unconsciously be 
 swallowed. Much blood may trickle down the throat when 
 the base of the skull is fractured ; but in such cases there is 
 usually some circumstantial evidence of injury. In some 
 cases of profuse haemoptysis blood may be swallowed. If 
 the haemoptysis is due to tuberculosis there will probably be 
 a history of cough and night sweats. But it might be due 
 to the rupture of an aneurism of the aorta or some branch 
 of the pulmonary artery, the haemorrhage being profuse 
 and usually fatal. The blood might also come from cancer 
 of the gullet or an acute inflammation of that channel from 
 the action of a corrosive poison. 
 
 Bleeding from the stomach itself may be due to a variety 
 of causes. It may result from congestion of the vessels due 
 to mechanical obstruction to the circulation from diseases of 
 the heart or liver, which sometimes cause profuse bleeding. 
 Very profuse bleeding of the stomach may also occur as 
 the result of gastric ulcer, cancer, or corrosion of blood- 
 vessels by the local action of powerful acids and other 
 poisons. Slight bleeding of the stomach may occur in the 
 course of acute gastritis, chronic gastritis, or cancer. Bleed- 
 ing of the stomach may also occur in acute fevers, Bright's
 
 THE RELIEF OF VOMITING 41 
 
 disease, scurvy, purpura, and in that peculiar condition 
 known as haemophilia which exists in persons called 
 "bleeders". It may also occur as the result of "vicarious 
 menstruation " ; this has been doubted, but it is an indisput- 
 able fact that women who have a deficient menstrual flow are 
 liable to bleeding from the stomach and other parts of the 
 body without obvious cause. Excessive vomiting from any 
 cause may make the stomach bleed. Finally, blood may be 
 vomited from the stomach of malingerers who have actually 
 swallowed it ; and other fluids, coloured like blood, may also 
 be swallowed and vomited by such people with the idea of 
 obtaining pity and possibly exemption from duty. 
 
 It may be assumed, as a general rule, that bleeding from 
 the gullet, stomach, or duodenum is attended by vomiting 
 of blood, and that, with few exceptions, bleeding from any 
 part of the bowels below the duodenum never gives rise to 
 vomiting, but in such cases the blood is voided solely by the 
 anus and gives rise to melana or blood in the motions. 
 Although it is the rule for bleeding from the gullet, stomach, 
 and duodenum to give rise to vomiting of blood, it must 
 never be forgotten that in almost all cases some of the blood 
 passes into the bowels, and that in other cases there may be 
 no vomiting, but all the blood passes through the bowels. 
 
 The recognition of blood in the vomit or faeces is not 
 usually difficult. Vomited blood is generally of a dark 
 colour, but is occasionally of a bright arterial tint, and it may 
 be fluid or in clots. If vomiting does not occur immedi- 
 ately after bleeding the blood undergoes a change in appear- 
 ance owing to the action of gastric juice upon it, when it 
 acquires the character known as " coffee-grounds ". Blood 
 from the bowels may be of a dark chocolate colour or of 
 a pitchy character. In doubtful cases, due to the small 
 amount of blood, the aid of the microscope or chemical 
 tests may be required. It is important not to confound the 
 discoloration of the vomit due to wine, iron, bismuth and 
 other drugs with that dependent on the presence of blood. 
 
 The symptoms arising from bleeding of the stomach 
 naturally vary with the amount of blood lost and its cause. 
 In acute febrile diseases, pyaemia, septicaemia, anaemia, the
 
 42 DIET IN DYSPEPSIA 
 
 bleeding is only a symptom adding severity to the primary 
 affection, and it materially increases the gravity of the case. 
 But when haematemesis occurs from an ulcer of the stomach, 
 cirrhosis of the liver, or aneurism of a blood-vessel, definite 
 symptoms occur. In these cases the haemorrhage not in- 
 frequently happens after some indiscretion on the part of 
 the patient, such as the consumption of indigestible food, a 
 drinking bout, or unusual exertion. Prior to the vomiting 
 the patient suddenly feels faint, turns pale, and complains 
 of a sensation of sinking or actual pain. Some patients fall 
 down insensible or convulsed, or appear to be at the com- 
 mencement of an epileptic seizure. In less severe cases the 
 faintness is succeeded by coldness of the skin, perhaps a 
 cold sweat, and a small, infrequent, and compressible pulse. 
 These symptoms are due to the loss of blood. If the 
 bleeding is slight there may be no vomiting, but if it is 
 excessive or continuous, vomiting of blood usually occurs 
 and the cause of the faintness is evident. 
 
 After the faintness and vomiting have passed away there 
 is, in the majority of cases, a stage of reaction. While loss 
 of blood leaves the patient bleached and the temperature 
 depressed, the pulse now becomes full and bounding, but it 
 is very soft and compressible, and eventually slows down. 
 A tinge of colour also appears on the cheeks, and is in 
 marked contrast to the marble-like appearance of the rest 
 of the skin, and the patient may become restless and excit- 
 able. Bleeding from an ulcer of the stomach is rarely fatal 
 immediately, nor is that from cancer ; but when the bleeding 
 is due to cirrhosis of the liver death may be very speedy. 
 
 The measures to be taken for the arrest of bleeding from 
 the stomach are practically the same as those adopted for 
 bleeding in other parts of the body. The very essence of 
 such treatment is REST local and general rest. This is ob- 
 tained by putting the patient to bed and in the recumbent 
 posture, avoiding all unnecessary movements, and guarding 
 against mental excitement. The latter will require the ex- 
 clusion of all friends from the room, especially "fussy" 
 relatives, and permitting the presence of those persons only 
 who are required to assist in carrying out medical instruc-
 
 THE RELIEF OF VOMITING 43 
 
 tions. Rest of the stomach is obtained by refraining from 
 the administration of any food by the mouth, and by giving 
 only those liquids which will assist in checking the bleeding 
 and vomiting. The administration of stimulants by the 
 mouth must also be forbidden. We may allow the patient 
 to suck some ice or to drink ice-water, or other water which 
 contains the drugs prescribed by the doctor. Alum-whey 
 may be given in doses of one ounce every hour. It is made 
 as follows : Take i pint of boiling milk ; dissolve ounce 
 of powdered alum in 2 ounces of hot water ; mix it in the 
 milk, stir ; let it stand a few minutes and strain it. This is 
 not only nutritious, but, being astringent, will assist in 
 stopping the haemorrhage. But a large quantity of fluids 
 cannot be allowed, because it would encourage vomiting, 
 cause a recurrence of bleeding, and probably reopen a 
 vessel which is already closed. Nature's method of arresting 
 bleeding is to form a clot of blood in the interior of the 
 injured vessel up to the nearest branch. To assist 
 in bringing this about she endows the blood with 
 the property of forming a blood-clot. Such a clot is formed 
 first of all outside the blood-vessel in this case it is formed 
 in the cavity of the stomach ; the clot so formed temporarily 
 blocks up the gap in the blood-vessel, and by this means 
 favours the formation of a blood-clot in the interior of the 
 vessel. The object of our treatment is to encourage the for- 
 mation of the clot in the interior, to prevent a clot so 
 formed from getting dislodged by bodily movements or vas- 
 cular excitement, and give it time to become firm. The 
 application of an ice-bag or ice-poultice over the epigastrium 
 will materially assist our endeavours. 
 
 The question arises as to what should be done to rally the 
 patient from fainting. Unless it is a serious case of syncope 
 or collapse, it is not advisable to use vigorous measures at 
 first for fear of producing a too speedy reaction and causing 
 the vessel to bleed afresh. By no means should stimulants 
 be given by the mouth or the circulation stimulated by rub- 
 bing the extremities. Let the legs and feet be raised well 
 above the level of the body by pillows or cushions, and the 
 head kept low. Apply a damp cloth to the forehead and
 
 44 DIET IN DYSPEPSIA 
 
 temples, and let it be perfumed with eau de Cologne, eau de 
 Florida, or sal volatile. If the patient is actually unconscious 
 a bottle of smelling-salts may be applied to the nostrils, 
 and half an ounce to an ounce of brandy with as much water 
 injected into the rectum will be useful. These procedures 
 will generally help the patient to rally, the recovery being 
 indicated by a return of consciousness, an improvement of 
 the pulse, and perhaps a little colour in the cheeks. 
 
 There are some cases where the bleeding is so profuse and 
 the collapse or unconsciousness so prolonged as to necessi- 
 tate the use of other measures. These consist of the trans- 
 fusion of blood and injection of saline solutions. The former 
 mode of treatment is rarely adopted. But the injection of 
 saline solution is often practised and is an extremely useful 
 measure. The solution most commonly used consists of 
 two teaspoonfuls of common salt in two pints of boiled water, 
 cooled down to 105 F. It is injected, or allowed to find 
 its way by gravitation, through a large hollow needle or trocar 
 inserted into the subcutaneous tissues of the armpit, the 
 loose tissues of the breasts, or other parts of the body. The 
 effect is often marvellous, and shows itself primarily in the 
 improvement of the pulse and increased blood-pressure. 
 
 The foregoing account shows that vomiting blood may be 
 due to many causes. But two chief causes are most often 
 met with. These are chronic ulcers of the stomach and 
 cirrhosis of the liver. The former occurs in young women, 
 and there is a history of long-continued dyspepsia and 
 anaemia prior to the bleeding. The latter occurs chiefly in 
 males ; there is probably dropsy of the abdomen at the time 
 the haemorrhage occurs, and a history of chronic alcoholism. 
 In both cases the haemorrhage is serious. But it is far more 
 serious when it occurs in persons already debilitated by dis- 
 ease and may cause death. When the bleeding is due to 
 cirrhosis of the liver some authorities recommend the use of 
 purgatives to relieve the congestion of the portal vessels, 
 but this is a dangerous practice, and contrary to the first rule 
 for the treatment of bleeding viz., REST. 
 
 When the haemorrhage ceases and the stage of reaction 
 sets in sedatives may be required, and the continuance of
 
 THE RELIEF OF VOMITING 45 
 
 rest and quietude is absolutely essential. The feeding 
 should be entirely rectal for a day or two if the blood has 
 come from the gullet, stomach, or bowels. When stomach 
 feeding is commenced the food will necessarily be light and 
 of a kind easily digested, but the kind and the amount will 
 depend upon the nature of the causative disease.
 
 CHAPTER VII. 
 ACUTE GASTRIC CATARRH ; ACUTE GASTRITIS. 
 
 THIS disease is commonly called inflammation of the stomach. 
 As a matter of fact it is an acute catarrh similar to that 
 which occurs in the nose. But the surface of the stomach 
 is so much larger that it causes more severe symptoms and 
 consequences. The causes of catarrh of the stomach are 
 also similar to those which produce catarrh of the nose. 
 A common cold in the head is due to exposure to wet and 
 cold, extreme changes of temperature, influenza, and infec- 
 tious diseases. It may also be due to powerful irritants, 
 such as poisonous fumes and gases, or mineral poisons. 
 In like manner catarrh of the stomach (acute gastritis) may 
 arise from exposure to wet and cold, extremes of temperature, 
 and infectious diseases. It is not uncommon for a cold in 
 the head to extend to the bronchial tubes or stomach. But 
 probably the most important causes of gastric catarrh are 
 local irritants in the food which has been consumed. Thus 
 it may be due to irritation by an excess of ordinary foods, by 
 their in digestibility, or fermentation. Some foods contain 
 special irritants, such as the ptomaines in unsound meat, fish, 
 or cheese ; or the salts of tin in canned fruit or vegetables. 
 Spirituous liquors are a frequent cause of gastritis. Cer- 
 tain wines and other foods contain an excessive amount of 
 acids which cause gastritis. And the disease may be caused 
 by the accidental or intentional consumption of acids, alkalis, 
 and mineral poisons, or exposure to powerful fumes and 
 gases. 
 
 The symptoms of catarrh of the stomach vary according to 
 (46)
 
 ACUTE GASTRIC CATARRH 47 
 
 its severity, (a) In severe cases there is an intense burning 
 pain in the stomach, radiating to the lower part of the chest 
 in front and between the shoulders, with more or less rigid- 
 ity of the abdominal muscles. The pain is aggravated by 
 breathing. There is intense nausea, and the stomach rejects 
 everything that is swallowed ; where nothing is swallowed 
 the patient vomits mucus and bile, often streaked with blood. 
 These are the most serious cases, such as follow poisoning 
 by corrosive sublimate, carbolic acid, ammonia, and other 
 irritating substances. Such cases may properly be called 
 inflammation of the stomach. The condition of the patient 
 is serious, there is a tendency to collapse, and the case may 
 end fatally in from four to six days. 
 
 The extreme irritability of the stomach contraindicates feed- 
 ing by the mouth. Nevertheless the patient may have small 
 pieces of ice frequently, some Valentine's meat juice being 
 given with ice every hour, and small quantities of iced albu- 
 min-water may be given at intervals, with milk of magnesia 
 or a bismuth mixture at stated periods. The patient must 
 be fed per rectum if the vomiting continues more than 
 twenty-four hours. The " feeds " may not be retained owing 
 to a reflex irritation of the bowels ; but something must be 
 done, and that is the most rational thing to do. If the con- 
 dition of the patient improves, the food and mode of feeding 
 recommended below will be applicable to the case. It is 
 also necessary to apply some local application. Whether 
 this should be hot or cold must depend on the sensations of 
 the patient. The sensation in the interior of the stomach 
 is sometimes described as being " like a red-hot coal ". If 
 the heat is so intense it is probable that poultices or mustard 
 plasters applied to the exterior would not moderate it. 
 A cold lotion, such as eau de Cologne and water, or the 
 ancient and useful evaporating lotion would be more use- 
 ful and better appreciated. An ice-poultice, consisting of 
 pounded ice between two layers of old flannel, an ice-bag, 
 or Leiter's tubes would also be more soothing than 
 poultices. 
 
 (b) In sub-acute gastritis, or those cases which are more 
 properly called acute gastric catarrh, the symptoms are less
 
 48 DIET IN DYSPEPSIA 
 
 severe and the consequences more seldom fatal than in the 
 former type of the disease. It is a common result of alco- 
 holism, the consumption of high game, mushrooms, ptomaine 
 poisoning, exposure to wet or cold >and other atmospheric 
 influences. The symptoms of this type may also vary ac- 
 cording to its severity. The pain may be acute a sensation 
 of burning, or merely excessive warmth in the stomach. 
 There may be a craving for food which, moreover, fails to 
 relieve the pain, and may aggravate the nausea and vomiting. 
 The material brought up from the stomach consists of tena- 
 cious ropy mucus, mingled with the substances which have 
 been swallowed, and bile or streaks of blood. 
 
 In the treatment of these cases ice is extremely useful. 
 It helps to allay the irritation and check the vomiting. As 
 regards food, the stomach must have a rest. But a few arti- 
 cles are useful to assist in subduing the irritability of the 
 stomach. These consist of mucilaginous materials and al- 
 kaline waters. Among the former are white of egg, isinglass 
 and milk, barley-water and milk, tragacanth and milk, de- 
 coction of Iceland or Irish moss and rice-water. All these 
 substances have the experience of ages to recommend them. 
 Milk should never be given alone, but should be diluted 
 with half or two-thirds of one of these liquids. Irish moss 
 jelly is made as follows : Take a quarter of a teacupful of 
 Irish or Iceland moss, one pint of milk, and a pinch of salt. 
 Soak the moss in water for a few minutes, wash it, and 
 carefully pick it over. Put it into a muslin bag, and boil 
 it with the milk in a double pan until the liquid thickens 
 when a few drops are poured on a plate. Add the salt, re- 
 move the bag, press it and pour the milk into a mould. It 
 will set on cooling. It may be eaten cold ; or made liquid 
 by dissolving it in an equal quantity of hot water and again 
 allowed to become lukewarm. Isinglass and milk is pre- 
 pared in a similar manner. Both these preparations are 
 soothing to the stomach. White of egg should be mixed 
 with lemon-water. Rice-water is prepared by boiling rice in 
 water until it is thoroughly cooked and straining the liquid 
 away ; it should set into a thin jelly. 
 
 The alkaline liquids are very useful ; the combination of
 
 ACUTE GASTRIC CATARRH 49 
 
 carbonic acid gas and alkali is soothing to the inflamed sur- 
 face of the stomach, it checks nausea, and assists in con- 
 trolling vomiting. Soda-water, potash-water, lithia-water, 
 Perrier and Apollinaris water are the kinds usually recom- 
 mended. The great advantage of milk of magnesia or 
 bismuth is that the metal becomes deposited upon the 
 mucous membrane and acts as a local sedative to the 
 stomach. 
 
 It is extremely doubtful whether any form of meat juice, 
 meat extract, or other substance derived from meat ought 
 to be given in the acute stage of the disease ; because all 
 these things stimulate a secretion of the gastric juice, 
 which is undesirable at this stage of the disease. Never- 
 theless, it is usual to prescribe Valentine's meat juice, 
 Brand's essence of beef, or Mosquera's beef-jelly with ice, 
 small quantities only being given at a time. 
 
 Milk should never be given in an undiluted form to these 
 patients, because it forms hard curds which cause pain, 
 increase the vomiting, and otherwise are injurious. But if 
 it is given with half or two- thirds of barley-water, rice-water, 
 tragacanth-water, or isinglass, the curds formed by the milk 
 will be small and soft, and they will be usefully employed 
 in fixing the gastric juice which is secreted. The presence 
 of alkalis, such as lime, soda or potash, neutralizes the acid, 
 and thereby prevents the irritation due to the presence of 
 gastric juice. But alkalis do more than that ; they lessen 
 the toughness of the mucus, and assist in its evacuation ; 
 they moderate the congestion of the mucous membrane, 
 and sooth the irritability. Vichy or Vals water is often pre- 
 scribed with these objects in view. But no fluid should be 
 given in large quantities at a time. If the vomiting is very 
 persistent it may be necessary to confine our attempts at 
 feeding to giving a teaspoonful only of these substances 
 every quarter of an hour, with a small piece of ice in be- 
 tween. Other patients may be able to take an ounce of 
 fluid every half-hour, with a little ice and meat essence 
 or jelly between. When liquids are rejected a teaspoonful of 
 moss jelly or ordinary jelly may be retained. If milk and 
 barley-water or other mucilaginous fluids is returned some 
 
 4
 
 5 o DIET IN DYSPEPSIA 
 
 Plasmon or Tilia might be tried. If the vomiting lasts 
 more than twenty-four hours, rectal feeding should be resorted 
 to. A mustard- plaster over the region of the stomach may 
 check the vomiting by acting as a counter-irritant. 
 
 When the irritation of the stomach has subsided other 
 foods may be cautiously given. One of the most bland and 
 least irritating foods is junket. It is palatable, soothing, and 
 absolutely free from anything which can disturb the stomach. 
 A junket-tablet dissolved in a tablespoonful of cold water 
 and added to a pint of lukewarm milk will make a smooth, 
 soft, and delicious jelly in ten or fifteen minutes, which is 
 ready for consumption as soon as it is cold. It may be 
 flavoured with sugar and a drop of essence of lemon or 
 vanilla, or a little extract of meat or beef-juice. Similar 
 remarks apply to egg-custard; but this is more solid than 
 junket and requires longer digestion owing to the coagula- 
 tion of the egg. Jelly of almost any kind would now be 
 agreeable to the stomach. 
 
 As soon as we know that the stomach will bear these 
 articles very well we can begin to give others of a higher 
 nutritive value and increased solidity. But the ancient rule 
 of making haste slowly (festina lente] must be resolutely 
 adhered to. The patient may desire more substantial food, 
 and if it is allowed to be consumed too early there will 
 either be a relapse of the acute symptoms or the disease 
 will pass into the stage of chronic gastric catarrh. This 
 is the period when Benger's Food and others which are 
 partly predigested are of value to the patient. These foods 
 should therefore be given : while affording additional nutri- 
 ment to the body they do not greatly tax the stomach. 
 Mellin's Food is a useful material for such cases. 
 
 (i) The following is a recipe for an unirritating food : 
 
 Mellin's Food i tablespoonful 
 
 Cream 2 tablespoonsful 
 
 Milk pint 
 
 Two eggs ; a pinch of salt. 
 
 Beat the eggs, salt, and cream together ; add the milk, and 
 place it in a double pan or in a basin over a pan of boiling
 
 ACUTE GASTRIC CATARRH 51 
 
 water. Stir constantly until the mixture thickens a little ; 
 take it from the fire and continue to stir it for two or three 
 minutes longer. Then add the Mellin's Food, previously 
 dissolved in a little hot water. Mix all together ; sweeten 
 with sugar if it is desired, and add a teaspoonful of brandy 
 or a tablespoonful of good sherry. 
 
 (2) The yolk of the eggs may be used alone if it is not 
 heated, and more Mellin's Food can be added. Dissolve 
 two tablespoonsful of Mellin's Food in a teacupful of warm 
 water ; beat up the yolk of two eggs, stir them into pint 
 of milk, with a teaspoonful of brandy or a tablespoonful of 
 sherry, or salt to make it palatable, and mix all together. 
 This mixture should not be boiled, and it is not so thick as 
 the former. 
 
 (3) The food may be made into a jelly : Take | pint of 
 milk, ounce of gelatine, one egg, a large tablespoonful of 
 Mellin's Food, a tablespoonful of sugar, and a pinch of salt. 
 Put the milk and gelatine into a double pan or a basin over 
 a pan of boiling water, and stir until it is dissolved. Let the 
 yolk of the egg be beaten ; pour the mixture over it, and 
 stir steadily ; return it to the stove ; add the salt, sugar, 
 and Mellin's Food dissolved in a small amount of water. 
 When the mixture thickens stir into it the white of the 
 egg, previously whipped; pour it into a mould until it is 
 set. 
 
 As the stomach regains its normal condition other articles 
 of food may be taken. A cupful of chicken or veal broth, 
 a poached egg, or a little bit of steamed sole or plaice may 
 be tried. But we must not "force the pace"; let the 
 stomach have time to recover from its indisposition. The 
 patient can live on milk foods, and it will be better for him 
 to be satisfied with them for some time longer, rather than 
 to incur the risk of a relapse or of transforming the sub-acute 
 and transient condition into the more durable or permanent 
 chronic gastric catarrh. A few more recipes for foods use- 
 ful at this stage of the disease may here be given. 
 
 (4) Chicken or Veal Cream, Take pint of chicken or 
 veal broth, ounce of gelatine, and a breakfastcupful of Savory 
 and Moore's Best Food. Let the food be prepared accord-
 
 5 2 DIET IN DYSPEPSIA 
 
 ing to the usual directions. Make the broth hot and dis- 
 solve the gelatine in it ; strain it into the food ; add a table- 
 spoonful of cream, and sufficient salt to make it palatable 
 (but no pepper or other heating condiment), and pour it 
 into a mould to set. 
 
 (5) Blancmange can be made by dissolving \ ounce of 
 gelatine in ^ pint of Savory and Moore's Food prepared 
 in the ordinary way. It can be flavoured with a table- 
 spoonful or two of strong coffee, chocolate, sherry, or fruit 
 juice. 
 
 (6) Batter pudding is usually made with ordinary flour, but 
 for persons who suffer from sub-acute gastric ailments, flour 
 which has been partly dextrinized by heat or partly digested 
 by pancreatic ferments is preferable. We have at our dis- 
 posal many invalid foods of this character. Take a table- 
 spoonful of Savory and Moore's Food and a tablespoonful 
 of flour ; mix them in a basin. Break an egg into the flour 
 and thoroughly mix it, at the same time gradually add \ 
 pint of milk, and continue to beat it for a few minutes. 
 Pour it into a buttered cup or basin, cover it with a piece of 
 buttered paper, and steam it gently for half an hour. 
 
 When it is known that the stomach bears these things 
 very well, we can advance a stage farther. Milk puddings 
 may be taken in greater quantity, especially sago and tapioca 
 puddings made with eggs. Sole, plaice, whiting, and fresh 
 haddock, or turbot with a plain milk sauce and a tablespoon- 
 ful of mashed potato, may be taken daily. It is better for 
 the potatoes to be mashed by being put through a wire 
 masher rather than to be pounded with a pestle ; the former 
 method makes them very light and digestible, the latter 
 forms a close pasty mass which is not so permeable. A 
 small amount of spinach, vegetable-marrow, or puree of 
 cabbage may also be taken. A few days later some breast 
 of chicken, pheasant, or guinea-fowl may be eaten ; also 
 some stewed prunes or apple-sauce and custard, bread and 
 butter, and weak tea. On the following day some roast 
 mutton may be tried. Thenceforward, if these foods have 
 agreed with the patient, any light articles of food may be 
 taken. But the patient should be warned that dietetic sins
 
 ACUTE GASTRIC CATARRH 53 
 
 are as certain to bring their own punishment as other sins : 
 that if improper foods be consumed by him a penalty will 
 follow, and the consequences of such improprieties may be 
 serious and followed by lifelong misery. It especially be- 
 hoves these people to avoid high game, pickles, sour fruit, 
 alcoholic liquors, excess of sweets, pastry, sausages, and 
 other spiced foods. If care is exercised in the final treat- 
 ment of these cases the stomach may return to its normal 
 condition. But if the patient is careless about his diet, 
 which may happen through ignorance of its importance, the 
 condition will gradually pass into chronic gastric catarrh with 
 hypochlorydia, atony, or loss of the motor power, and finally 
 dilatation of the stomach. The consequences of such 
 carelessness should, at any rate, be pointed out to the 
 patient, and continual care should be exercised if these dire 
 consequences are to be avoided. 
 
 Gastro-intestinal Catarrh in Children. Children of all 
 ages are liable to gastric disturbances. These are sometimes, 
 but not always, due to the food. Infants are very sensitive 
 to atmospheric changes : heat, cold, damp, bad ventilation, 
 and noxious gases easily upset them, and they are prone to 
 catarrh of the stomach and bowels from these causes. More- 
 over, their stomachs are very liable to irritation by improper 
 food or irregularity in the time of feeding. Breast-fed 
 children are less often subjected to irritation from this cause 
 than bottle-fed children. But it has been shown again and 
 again that a temporary deficiency in the quality of the 
 mother's milk or irregularity in feeding may cause acute in- 
 digestion. Bottle-fed children are very liable to have their 
 stomachs upset by irregularities in the quantity or quality of 
 the food. The indigestion thereby induced is very prone to 
 end in an attack of acute or chronic catarrh of the stomach 
 and bowels. Indeed, this is the most common disorder of 
 the digestive system in children. They are very prone to 
 such attacks during the period of teething. As the children 
 get older gastro -intestinal disorders are less frequent, and when 
 they do occur they assume more and more the type of 
 disease which occurs in adults. 
 
 The most prominent symptoms of this disease in young
 
 54 DIET IN DYSPEPSIA 
 
 children are vomiting and purging, the former being the most 
 prominent symptom when the stomach is chiefly attacked, 
 and the latter when it principally affects the bowels ; but in 
 many cases a considerable portion of the gastro-intestinal 
 tract is affected, and therefore both symptoms are present. 
 In the purely gastric form of the disease, the infant vomits 
 the food as soon as it is taken. It is returned in an un- 
 digested form with a watery fluid, consisting partly of whey 
 and partly of gastric secretion. The tongue is red or coated 
 with a white fur. The bowels are confined, the motions are 
 hard, deficient in bile, and clay-coloured. The child cries 
 owing to the occurrence of griping or spasmodic pains. The 
 abdomen is swollen and tender. And the temperature shows 
 that the general condition is more or less febrile. In the 
 intestinal form the motions are loose and contain undigested 
 food e.g., curds of milk, and mucus, and smell badly. In 
 the combined gastro-intestinal variety of catarrh, diarrhoea 
 replaces the constipation. 
 
 The treatment of this disease in bottle-fed babies and older 
 children consists of rest of the stomach, and the administra- 
 tion of albumin- water (white of egg and lemon-water), barley- 
 water and cream, with, perhaps, a little milk, lime-water and 
 milk, rice-water, and other mucilaginous drinks. It is some- 
 times necessary to abstain entirely from giving milk for a few 
 days, but whey or buttermilk can be given. The former can 
 easily be prepared by using junket tablets to set the milk, 
 afterwards breaking it up and straining off the whey through 
 a piece of muslin or butter-cloth. Buttermilk is usually only 
 obtainable from a dairy farm. It is less difficult to prepare 
 a mixture of milk albumin from commercial preparations 
 such as albulactin, a teaspoonful of which may be given, 
 with an equal quantity of sugar and a sprinkle of salt, in half 
 a teacupful of boiled water, at the temperature of the blood. 
 The child should be given a small quantity of any of these 
 liquids every half-hour. They will quench the thirst, soothe 
 the irritable mucous membrane, check the vomiting and 
 purging, and materially assist in curing the disease. If the 
 child is more than six months old we can now try the effects 
 of some Benger's Food in addition to the foregoing, If
 
 ACUTE GASTRIC CATARRH 55 
 
 these agree with the patient we may gradually build up a 
 dietary of milk, Benger's Food, lightly boiled eggs, a small 
 amount of scraped meat, some raw meat juice and veal broth. 
 The return to the ordinary diet, even in older children, must 
 be very gradual, and indiscretions in feeding must be care- 
 fully avoided.
 
 CHAPTER VIII. 
 CHRONIC GASTRIC CATARRH; CHRONIC GASTRITIS. 
 
 As a primary disease, chronic gastric catarrh is due to the 
 same causes as the acute form. It is a common consequence 
 of influenza and the fevers. It may also follow an attack or 
 recurrent attacks of acute gastritis; and the innumerable 
 causes of indigestion by their persistence very frequently lead 
 to chronic gastric catarrh or catarrh of the stomach. Acid 
 foods and such as undergo acid fermentation in the stomach 
 are among the commonest causes of this complaint. Sugar 
 gives rise to acidity. Starch (in bread, rice, oatmeal, sago, 
 tapioca, etc.) does not give rise to acidity while the gastric 
 juice and motor activity of the stomach remain normal, be- 
 cause it escapes through the pylorus without any change. 
 But if the motor power of the stomach is defective there is 
 a delay in the passage of starchy foods into the bowels, and 
 they undergo fermentation which results in the formation of 
 acids having an irritating character. 
 
 Butyric acid arises during the fermentation of starch and 
 sugar in the stomach. It is one of the most irritating acids. 
 It should be pointed out that this acid occurs normally in 
 butter. Good butter contains but little, but cheap butter 
 and that which has become rancid contains much more. 
 Cheap butter is very often used for cooking purposes ; this is 
 wrong in principle, and it is a very common cause of catarrh 
 of the stomach. The flavour of rancid butter may be hidden 
 by mixing it with flour and the other ingredients of cakes 
 and pastry, but the butyric acid is not destroyed thereby. 
 Acetic acid and lactic acid are also formed in the stomach, 
 but they are more often taken in the food. Acetic acid 
 
 (56)
 
 CHRONIC GASTRIC CATARRH 57 
 
 occurs naturally in vinegar and pickles, lactic acid in sour milk 
 and foods made with it. Tartaric acid, acetic acid, malic 
 acid, and many others occur in fruits and wine. Spirits act 
 as local irritants to the stomach, and some of the alcohol may 
 be transformed into acetic acid. It may, therefore, be said 
 that primary chronic catarrh of the stomach arises from im- 
 proper feeding, habits of intemperance, and accidental causes. 
 
 But it is probably as a secondary affection that chronic 
 catarrh of the stomach will most often be met. It compli- 
 cates very many diseases, but especially results from conges- 
 tion of the portal veins (the venous system of the abdomen), 
 diseases of the liver, affections of the heart, lungs, and 
 pleura. Take the flabby and enfeebled heart of an elderly 
 person as an example. In such a case the circulation is 
 very feeble, the abdominal veins become engorged with blood 
 because the heart is unable to keep it in circulation, and 
 thereby leads to passive congestion of the liver, and of the 
 mucous membranes of the alimentary canal, with catarrh 
 thereof and its attendant evils. 
 
 The cause or causes of acute catarrh of the stomach are 
 very often local, and the intensity of the irritation secures 
 the removal of the irritating substance by vomiting. In 
 chronic catarrh the irritation is far less intense, but the long- 
 continued irritation or passive congestion produces equally 
 serious results. The changes caused thereby are no less 
 because they are produced gradually. The mucous mem- 
 brane of the stomach becomes thickened, the submucous 
 and muscular coats hypertrophied. The mucous membrane 
 is covered with a thick and tenacious mucus ; when this is 
 removed it appears paler than usual, possibly with varicose 
 veins here and there ; it may be thrown into irregular folds 
 or be marked here and there by slate-coloured patches re- 
 sulting from slight extravasation of blood. 
 
 The patient complains of pain and tenderness at the pit 
 of the stomach, or it may be a sensation of weight, of 
 gnawing, or cramp at the stomach. These symptoms are 
 perceived most frequently in the morning, that is, when the 
 stomach is empty. There may be sickness in the morning ; 
 the vomit consists of saliva swallowed during the night, and
 
 58 DIET IN DYSPEPSIA 
 
 perhaps a tasteless transparent ropy mucus, somewhat like 
 the white of an egg, containing the bacteria and fungi which 
 cause fermentation and acidity. But vomiting is not a con- 
 stant symptom of the disease ; some people never vomit, 
 others only vomit occasionally and after some indiscretion in 
 the diet. The tongue may be coated with a white or creamy 
 fur through which the enlarged papillae are visible ; in other 
 cases it is red and the enlarged papillae are as visible as 
 in the " strawberry tongue " of scarlet fever. The lips are 
 often dry and cracked, the gums spongy and discharging. 
 In addition there are the usual symptoms of indigestion. 
 The general condition is that of " being out of sorts," the 
 patient is listless, languid, unable to make any exertion, or 
 is easily exhausted. The nutrition of the patient fails be- 
 cause the gastric juice is deficient in hydrochloric acid, which 
 is one of its normal and essential constituents, and in very 
 serious cases the pepsin is also deficient in quantity. 
 
 The disease runs a very extended course. The symptoms 
 may be very much improved by treatment, but they recur 
 on very slight provocation at intervals of months or years. 
 Most cases of primary gastric catarrh are curable by careful 
 and persistent treatment and attention to the food. But 
 secondary gastric catarrh is dependent on the causative 
 disease, and the variations in the catarrh usually go hand 
 in hand with variations in the disease which has occasioned 
 it. Thus the gastric catarrh arising from passive conges- 
 tion may be considerably relieved by an improvement in the 
 condition of the heart, lungs, or liver. Nevertheless, the 
 chronic heart, lung, or liver disease persists, consequently 
 the stomach gets worse year by year, and the body suffers as 
 much from the imperfect digestion and absorption of food 
 as it does from the enfeebled heart or difficult breathing. 
 
 In these cases the food is of paramount importance. But 
 patients vary so much in their condition that no stereotyped 
 diet will suit them all. Everything depends on the ability 
 of the stomach to digest its contents and propel them into 
 the bowels. All kinds of food which are capable of being 
 digested without unduly burdening the organ and of being 
 propelled into the bowels in a reasonable time are proper
 
 CHRONIC GASTRIC CATARRH 59 
 
 foods for the patient. It should not be forgotten that in 
 this condition the digestive powers are feeble, and most 
 foods require a longer time for their digestion than in a 
 normal stomach. There must be rules for such cases, be- 
 ginning with the mouth. The teeth must be carefully 
 attended to ; the deficiencies should be made good. Arti- 
 ficial teeth which do not remain in the place intended for 
 them should be thrown aside, and proper fitting ones ob- 
 tained. The mouth should be kept clean and as free as 
 possible from infection. Sore gums should be healed and 
 hardened by the regular use of a proper mouth-wash. The 
 patient should never break his fast without previously wash- 
 ing his mouth and cleansing his teeth. The food must be 
 slowly and carefully masticated. It should be of such a 
 kind and quality that it will suit the morbid condition of 
 the stomach. The harmonious action of the alimentary 
 canal must be promoted. The patient should rest a short 
 time before a meal and a longer time after it. The func- 
 tion of digestion should be promoted by reasonable exercise 
 of the body, suited to the strength and condition of the 
 patient. 
 
 In mild cases of chronic gastric catarrh there should be no 
 special limitation of the amount of food. It must, however, 
 be of the right kind and quality. In the majority of cases 
 the articles permitted are the same as in ordinary cases of 
 indigestion. The meals should be as follows : 
 
 Breakfast. Eggs lightly boiled or poached. Fish of the 
 light kinds previously detailed. Dry toast, rusks, or pulled 
 bread, and a trace of butter. Milk-tea (China tea infused 
 in milk instead of water), or cocoa made with milk. 
 
 Lunch or Midday Meal. Lamb or mutton free from fat, 
 mashed potato ; white bread or biscuit ; rice, sago, or tapi- 
 oca pudding. A glassful of Burgundy or Bordeaux wine 
 diluted with aerated water. 
 
 Tea. A cupful of China tea with plenty of milk ; one slice 
 of bread and butter, and a piece of sponge or Madeira cake. 
 
 Dinner or Evening Meal. No hors-d'oeuvre or soup. 
 Fish, any light kind ; tender beef, mutton, or lamb, free from 
 skin and gristle ; breast of fowl, pheasant, or turkey ; potato,
 
 60 DIET IN DYSPEPSIA 
 
 mashed and creamed ; spinach, seakale, asparagus, vegetable 
 marrow, tender green peas, kidney beans, or cauliflower ; 
 white bread or plain biscuit ; custard, junket, jelly, milk 
 pudding, stewed fruit, wine and aerated water. 
 
 The patient should have three meals a day, with just a 
 cup of tea and a bit of bread and butter at 4.30 P.M. Butter 
 must be eaten very sparingly because it contains butyric 
 acid. Fats and fat meat should be taken in the strictest 
 moderation because they check the secretion of gastric juice. 
 One need scarcely say that this applies to fat ham and bacon 
 as well as to foods cooked in fat. Certain fish should be 
 avoided because they contain too much fat or because the 
 bones and scales cannot be easily removed. These include 
 sardines, herrings, mackerel, eel, and salmon. Pork, duck, 
 goose, and turkey (except the breast) are also too rich in 
 fat. The patient must be particular to remove every particle 
 of skin and gristle from all kinds of meat, fish, or fowl. He 
 must avoid " high '' game, tinned meat or fish, entrees, spiced 
 meat, sausages, pork pie, etc. He must not eat pastry, 
 brown bread, oatmeal porridge, sweet biscuits, and cakes 
 containing currants, raisins, lemon peel, or seeds. Stewed 
 fruit may be eaten with plain, unsweetened biscuits, e.g. 
 11 butter puffs," cracknel, or water biscuits. Fruit containing 
 much acid must be avoided. But it is equally important to 
 avoid those containing seeds, e.g. currants, gooseberries, cran- 
 berries, strawberries, grapes, and figs. Seedy fruits may be 
 rubbed through a sieve. Acid fruits may be cooked with 
 some bicarbonate of soda to neutralize the acid. The soda 
 not only neutralizes the acid, but it necessitates the use 
 of a smaller amount of sugar, which is also of importance, 
 because an excess of sugar causes a profuse secretion of 
 mucus by a catarrhal stomach. Raw apples, pears, and all 
 kinds of nuts are taboo, but a ripe banana, the pulp of an 
 orange which can be scraped with a spoon, and a ripe plum 
 or two may be eaten ; grapes can be eaten if care is taken 
 to remove the seeds and skin. Pickles, salads, and raw 
 vegetables should be forbidden, especially cucumber, radishes, 
 onions, lettuce, and watercress, but a ripe tomato which is 
 free from seeds may be eaten.
 
 CHRONIC GASTRIC CATARRH 61 
 
 Beverages. The patient should eat without drinking ; any 
 liquid which he may have should be taken at the end of a 
 meal, preferably about half an hour afterwards. The best 
 beverages are plain water, China tea, thin cocoa (van 
 Houton's, Cocoatina, or Cocoa nibs), whey, buttermilk, 
 Perrier, Apollinaris, Salutaris, and other gaseous waters. 
 
 Many patients have been accustomed to take some alcohol 
 daily. It would probably be useless to forbid them to take 
 any at all, they cannot easily give it up. Moreover, some 
 patients with chronic gastric catarrh are benefited by taking 
 a small amount of alcohol, if it be of the right kind and 
 quality. They must not take ale, beer, stout, porter, sweet 
 wines, or spirits. But they may have a wineglassful of Bur- 
 gundy, Bordeaux, or red Hungarian wine, diluted with an 
 alkaline or gaseous water, at the end of the midday and 
 evening meals. 
 
 The use of alkaline waters is strongly recommended, 
 especially those of Vichy, Vals, Plombieres, Ems, Carlsbad, 
 Marienbad, and the waters of Harrogate, Bath, and Leaming- 
 ton. They should be taken warm, but not very hot. They 
 cleanse the mucous membrane, remove tenacious mucus, 
 neutralize acidity, and check fermentation. They thereby 
 stimulate the mucous membrane and promote the activity 
 of the muscles of the stomach. Residence at the source of 
 these waters is frequently recommended for the cure of 
 gastric ailments. Some patients may require a stronger 
 alkaline water as an aperient. The waters of Piillna, Con- 
 dal, or Rubinat are recommended for that purpose. They 
 cause a free evacuation of the bowels, and relieve the con- 
 gestion of the abdominal veins. 
 
 More Serious Cases of Chronic Gastric Catarrh. Some 
 cases require more careful dieting than the former, and 
 various modes of dietetic treatment have been adopted. 
 They must therefore receive some consideration. Two im- 
 portant indications arise during the course of the disease 
 which assist us in deciding upon the kind of diet which is 
 most suitable. One point is the fermentation which so 
 commonly occurs in the stomach and the irritation arising 
 from the products of the fermentation. Sugar not only
 
 62 DIET IN DYSPEPSIA 
 
 irritates the stomach by its local effect, but it may undergo 
 fermentation and give rise to acidity. The starches in all 
 cereal foods also undergo fermentation and produce acids. 
 Butter contains such an acid ready formed. The other 
 point is : the deficiency of hydrochloric acid in the gastric 
 juice. This deficiency leads to considerable delay in the 
 digestion of meat, fowl, fish, and all other substances which 
 are called protein foods. The normal proportion of hydro- 
 chloric acid in the gastric juice is sufficient to act as a 
 germicide or disinfectant. But when the proportion of 
 this acid is deficient the bacteria and fungi which cause the 
 fermentation of the food flourish amazingly. 
 
 Let the last point be considered first. The patient must 
 have some proteins regularly. If his food contains none 
 he draws the necessary supply from his muscles, and this 
 piecemeal removal of the muscles leads to a rapid enfeeble- 
 ment of the body and other consequences, which are more 
 unpleasant than merely wasting away. The amount of 
 proteins usually considered necessary is 100 grammes (ap- 
 proximately 3^ ounces) a day. But Chittenden has shown 
 that we can live on half that amount, and it is now usually 
 accepted that 80 grammes a day is enough for a man or 
 woman who does no manual labour. A diet consisting of 
 4 pints of milk a day would contain 84 grammes of protein. 
 Some physicians therefore treat their bad cases of chronic 
 gastric catarrh by keeping them in bed and giving them a 
 milk diet for two or three weeks. It is given in tumblerful 
 doses every two hours from 7 A.M. to u P.M., and an extra 
 glassful in the night, making altogether ten tumblersful. 
 It is a remarkably good method of treating some cases, 
 especially when the disease is due to alcohol. The patient 
 does not like it at first, but he soon becomes accustomed to 
 it, and gets well in a moderately short period of time. But 
 it does not agree with everybody. If it does not appear to 
 be bome very well, let some bicarbonate of soda or potash 
 be put into the milk. This will neutralize the acidity of 
 the stomach, and prevent the formation of large and hard 
 curds. If it does not agree in this form the milk should be 
 fortified by the addition of dried milk powders, such as
 
 CHRONIC GASTRIC CATARRH 63 
 
 Plasmon, Tilia, or Sanatogen, and then reduced to its proper 
 bulk by mixing with it some Perrier, Apollinaris, soda-water, 
 or other gaseous water. If this does not agree with the 
 patient we can fall back upon peptonized milk or soured 
 milk, the latter being prepared by tablets containing the 
 lactic-acid ferment. When opportunity occurs the treat- 
 ment can be carried out by giving whey or buttermilk to 
 the patient. They are exceedingly useful, and have this 
 advantage : they do not form large curds in the stomach, 
 but light and flocculent curds, and they contain a minimum 
 of fat. A generation ago Niemeyer strongly recommended 
 buttermilk for the treatment of chronic gastritis ; he wrote 
 thus : " When the patient is hungry let him eat buttermilk ; 
 when he is thirsty let him drink buttermilk ". But the pro- 
 teins may be derived from carefully cooked fish, fowl, tender 
 meat, and poached eggs, and some farinaceous food must 
 then be given to replace the sugar which exists in the milk. 
 As a general rule these foods should consist of Benger's 
 Food, or other invalid's food, fine oatmeal baked until it 
 is like biscuit powder arrowroot, blancmange, and sago or 
 tapioca pudding, all of which are made with milk, and a 
 small amount of dry toast or torrefied bread. Too much 
 farinaceous food should not be allowed, because it may lead 
 to fermentation and thereby aggravate the condition which 
 we wish to improve. The persistence of flatulence, heart- 
 burn, and acidity would be considered a sufficient indication 
 to reduce the amount of these foods or to put the patient 
 on a milk diet with some meat or fish. 
 
 The second point has been partly considered in the fore- 
 going. But while the digestion of proteins in the stomach 
 is defective owing to the diminution of hydrochloric acid, 
 the digestion of farinaceous foods may be perfect. This 
 suggests that the diet should contain more farinaceous food 
 and less protein. With this mode of treatment the ordi- 
 nary animal foods should be abstained from. Milk and 
 milk powders may be given. Benger's, Savory and Moore's, 
 Mellin's, and other farinaceous foods will be valuable. 
 Therefore the patient should be kept on these foods for a 
 few days. The recipes given for these foods in the treat-
 
 64 DIET IN DYSPEPSIA 
 
 ment of acute gastric catarrh may be usefully employed. 
 Iceland moss jelly, agar-agar jelly, and ordinary jellies, if 
 not too sweet, will soothe the stomach and be suitable food. 
 Sugar must only be used very sparingly because of its in- 
 fluence in increasing the mucous discharge. Butter and 
 cream should be avoided, not only because of the acidity 
 of the former, but because they check the secretion of 
 gastric juice. After a few days we may cautiously add to 
 the diet a poached egg or a little steamed fish (sole, plaice, 
 whiting, or fresh haddock). If these are borne without 
 pain or discomfort we may, in another day or two, give 
 some scraped meat, chicken panada or soufflee, and any 
 other meat which has been passed through a mincer or 
 sieve. After these we can give in rotation, mashed potato, 
 spinach, vegetable marrow, or some vegetable puree ; and, 
 finally, the breast of chicken, guinea fowl or pheasant, tender 
 mutton, and under-cut of beef. 
 
 The fermentation of food by yeasts, fungi, and bacteria 
 is considered by many authorities to be far more important 
 than the deficiency of hydrochloric acid in the gastric juice, 
 although the latter is acknowledged to be the main reason 
 for the constant fermentation. These authorities therefore 
 allow very little carbohydrate (starch and sugar) during the 
 treatment. Leube gives the following course of treatment : 
 
 (a) The diet should consist at first of clear soup or broth, 
 solution of meat, milk, eggs boiled or raw and plain or 
 aerated water. 
 
 (b) After a few days he adds boiled chicken, calves' brains, 
 and boiled milk and bread. 
 
 (c) At a later stage he adds a small amount of bread and 
 butter, and some scraped beef-steak, quickly cooked and 
 underdone. 
 
 (d) Finally, he allows ordinary beef (underdone), roast 
 chicken or partridge, macaroni, cooked green vegetables 
 or fruit, and a small amount of wine. 
 
 Leube's solution of meat is prepared as follows : Mince 2 
 Ib. of plain meat, place it in a porcelain vessel (a glass jar 
 will do as well) with if pints of water, and add ounce of 
 pure hydrochloric acid. Place this vessel into a pan of
 
 CHRONIC GASTRIC CATARRH 65 
 
 water and boil it for ten or fifteen hours. It should now 
 be turned out of the vessel and rubbed down to a paste 
 with a pestle and mortar, returned to the vessel, and the 
 latter put back into the pan of water and boiled again for 
 fifteen or twenty hours. The substance should now be 
 neutralized by the addition of i ounce of bicarbonate of 
 soda, which will convert the hydrochloric acid into common 
 salt. It should then be evaporated in a saucepan on the hob 
 until it is of a syrupy consistence. This food is now ready 
 for use. It may be given in doses of 2 ounces. It is 
 almost ready for absorption and requires scarcely any diges- 
 tion in the alimentary canal. It should be taken luke- 
 warm; a little salt being added if necessary. It is an 
 extremely useful food for cases of chronic catarrh, ulcer, or 
 cancer of the stomach. 
 
 Lavage of the stomach is a valuable aid in the treatment 
 of this disease. It should be done each morning before 
 breakfast. When it is done at home the solutions used 
 generally consist of bicarbonate of soda and common salt, 
 boracic acid, or permanganate of potash. At the various 
 Spas the water of the district is used alone. All these 
 liquids should be used at a moderate temperature. By 
 means of lavage the mucous membrane is cleansed and re- 
 freshed, mucus and food residues are removed, bacteria and 
 fungi are washed away, the circulation through the blood- 
 vessels is improved, and the muscles stimulated to activity. 
 If the patient refuses to have his stomach washed out daily, 
 he should be encouraged to take an emetic at least once a 
 week, and thereby produce the effects of lavage in a minor 
 degree. 
 
 A moderate degree of exercise is essential for all patients 
 who can take it. Golf is useful for both men and women. 
 If they are unable to take exercise of this character they 
 must be encouraged to walk for half an hour twice a day. 
 They may also exercise their arms, back, and abdominal 
 muscles by the simple exercises taught to school children. 
 Those persons who suffer from cardiac debility may be 
 taught to do the Schott exercises as practised at Nauheim. 
 
 Change of air is likewise beneficial. A warm, moist air 
 
 5
 
 66 DIET IN DYSPEPSIA 
 
 is useful in some cases, a drier atmosphere in others. This 
 is a matter which the medical attendant must carefully 
 consider ; a warm, moist climate being suitable for the de- 
 bilitated and aged ; a drier climate for those who have pas- 
 sive congestions and copious discharges from the mucous 
 surfaces ; and a dry bracing air for those who have a 
 relaxed state of the system generally, especially when com- 
 bined with neurasthenia. He will know best whether the 
 patient requires a moist air like that of Devonshire, the 
 drier air of Bournemouth, Brighton, Algiers, or Egypt, or 
 a cool and bracing air like that of Harrogate, Ilkley, Bux- 
 ton, Matlock, or Malvern. Each of these climates is 
 considered good for chronic gastric catarrh, but the consti- 
 tution of the patient and the nature of the primary complaint 
 will make one place more suitable than another for each 
 individual case.
 
 CHAPTER IX. 
 ACID DYSPEPSIA. 
 
 THERE are two forms of acid dyspepsia. In one the nor- 
 mal acid of the gastric juice (hydrochloric acid) is in excess ; 
 in the other various organic acids present in the food or aris- 
 ing from fermentation give rise to acidity of the stomach and 
 other symptoms of dyspepsia. These cases usually only come 
 under treatment when the dyspepsia has lasted a long time, 
 and is more or less chronic. To find out what is the exact 
 nature of the trouble the physician should prescribe a test 
 meal, the contents of the stomach being afterwards removed 
 by a stomach tube and analysed. One of the meals com- 
 monly used for this purpose consists of a roll or 2 ounces of 
 stale white bread and a breakfastcupful of weak tea or hot 
 water. The meal is taken early in the morning, and the 
 contents of the stomach drawn off about an hour after- 
 wards, that is to say, when the digestion is at a height. 
 The material is filtered, and reagents, which reveal the 
 amount and kind of acid, are added to it. 
 
 If the condition of the stomach were normal these test 
 meals and the subsequent analysis would be unnecessary. 
 The acidity of the gastric contents would be normal. The 
 consumption of food would be a pleasant and agreeable task, 
 followed by a sensation of comfort and well-being. But 
 such an examination being called for proves the existence of 
 some abnormality. 
 
 Where the analysis shows that the hydrochloric acid of 
 the gastric juice is in excess, the abnormality is what is 
 known as Hyperchlorhydria. The gastric juice is too free 
 and too strong;* the secretion begins too soon after the 
 
 isTT-iiacd- ( 6 7)
 
 68 DIET IN DYSPEPSIA 
 
 meal and is excessive. In the normal condition, saliva is 
 mixed with the food during mastication and continues to 
 act on it after it reaches the stomach. Fully half an hour 
 elapses after the food is swallowed before the secretion of 
 the stomach is sufficiently acid to check the action of saliva. 
 But in the condition of hyperchlorhydria free acid appears 
 about ten minutes after beginning to eat, and the digestion 
 of starch in the stomach is thereby prevented. This ab- 
 normal condition occurs in about half the people, between 
 the ages of twenty and forty-five years, who suffer from in- 
 digestion. It is the condition which occurs in the student 
 working hard for an examination, in the man who applies 
 himself strenuously to business, the hard-working clerk, 
 lawyer, accountant, or busy shopkeeper. But it is not merely 
 strenuous application to duty which causes the trouble. 
 It may be brought on by grief, worry, and anxiety; by 
 gobbling the food without proper mastication ; hurrying 
 from business to meals and meals to business ; it may be 
 due to the local irritation caused by acid foods, heating 
 spices and condiments, excess of alcohol and abuse of 
 tobacco, and sometimes by other gastric diseases. Summed 
 up briefly, the cause of hyperacidity is an irritation of the 
 gastric mucous membrane, and its technical sign is the dis- 
 covery of an excess of hydrochloric acid in the gastric con- 
 tents at the height of digestion. 
 
 In such persons the digestion of protein foods (meat, 
 fowl, fish, milk, etc.) is perfect, and their presence in the 
 stomach relieves the symptoms by taking up the excess of 
 acid as it is secreted. But starch and all foods containing 
 it (bread, cakes, puddings, etc.) are not digested so easily 
 as usual, and their detention in the stomach is often delayed, 
 especially when the acidity gives rise to spasm of the pylorus 
 or aperture of exit. As a general rule there is perfect com- 
 fort for about an hour after the meal, then the character- 
 istic symptoms begin, viz., discomfort, heartburn, nausea, 
 giddiness, and palpitation or a sense of oppression, which 
 are only relieved by the eructation of gas, drinking some fluid 
 which dilutes the acid gastric juice, or the consumption of 
 another meal.
 
 ACID DYSPEPSIA 69 
 
 The dietetic treatment of such cases varies. Where the 
 acidity has been called forth by the regular consumption 
 of an excess of meat, fish, fowl, etc., the excessive secretion 
 is a means to an end. But hyperacidity also occurs in 
 people who eat little meat, and, therefore, the proportion 
 of acid is only relatively high, that is to say, the acid is se- 
 creted but it has not got the right kind of food to work 
 upon. In either case, the disorder is fostered by hurried 
 eating, imperfect mastication, and wrong diet. Therefore 
 the first thing to do is to regulate the habits as regards the 
 kind and amount of food, care in its mastication, and 
 regularity in the hours at which the meals are taken. These 
 rules are applicable to all dyspeptics. 
 
 Authorities differ as to the kind of food such patients 
 should be allowed. There is no doubt that a profuse 
 secretion of gastric juice is provoked by an excess of meat, 
 soups, meat extracts, and so forth ; and fat has a retarding 
 influence on the secretion, and especially on the amount 
 of acid ; while bread and other starchy foods provoke only 
 a slight secretion of gastric juice. But the patient has to 
 be considered individually. If the disorder occurs in one 
 who has hitherto consumed little animal food, it would be 
 better to reduce the amount of bread and other starchy 
 foods to a minimum and increase the intake of meat, fish, 
 milk and eggs as much as possible, to give the gastric 
 secretion more substance to work upon. Of course, it will 
 be necessary for these foods to be in an easily digestible 
 form, and unaccompanied by vegetables, such as cabbage, 
 turnips, swedes, and raw salads. 
 
 On the other hand, there are some cases where the 
 animal food should be restricted. These are people who 
 have been acustomed to eat a lot of meat, fish, and eggs. 
 There is no doubt that these foods speedily absorb the 
 gastric juice and prevent or diminish pain or irritation. 
 But it is plain enough that if such foods continue to be 
 taken in excess the supernormal secretion of gastric juice 
 will be encouraged. Nature continues to respond to the 
 demands made upon her for hydrochloric acid so long as 
 she can do so. But the continued call for acid to combine
 
 7 o DIET IN DYSPEPSIA 
 
 with the animal foods which are constantly taken may tend 
 to hypertrophy of the glandular elements of the mucous 
 membrane, and to their ultimate exhaustion and inability 
 to respond (hypochlorhydria), whence the last state of the 
 patient may be worse than the first. Therefore no general 
 rule of treatment can be established. Each case must be 
 treated on its merits, and each article of the diet must be 
 selected by reference to the present condition or the for- 
 mer habits of the patient. 
 
 If the medical attendant decides to exclude all starch, 
 sugar, and other forms of carbohydrate food from the diet, 
 there are several courses open to him. He may prescribe 
 the Salisbury diet, consisting solely of lean meat and hot 
 water, for a period of six or eight weeks. This diet has 
 proved exceedingly useful in men who have a decided tend- 
 ency to gout. Where this dietary is not prescribed the food 
 may still be of a protein character, and something like the 
 following will answer the purpose : 
 
 Breakfast. Two boiled eggs, Protene biscuits, 1 and a 
 cup of milk-tea. 
 
 10.30 A.M. Boiled ham (mostly lean) 4 ounces, a slice of 
 gluten bread, and a glassful of hot water. 
 
 Dinner. Beef-steak 4 or 6 ounces, two tablespoonsful of 
 mashed potatoes, and a wineglassful of burgundy or claret 
 diluted with water. 
 
 Afternoon. China tea with a tablespoonful of cream in 
 each cup, and a Protene biscuit. 
 
 Supper. Two scrambled eggs or 4 ounces of cold meat, 
 and Protene biscuits. 
 
 10 P.M. A tumblerful of hot milk. 
 
 The meals should be small and frequent ; hot water should 
 be taken between the meals or just before them, and the 
 total allowance of gluten bread and Protene biscuit should 
 not exceed 4 ounces. 
 
 If the patient is very bad an exclusive milk diet may be 
 ordered for one month. In this case the patient should re- 
 
 1 These biscuits are made from milk-powder by the Protene Com- 
 pany; they are similar to Plasmon biscuits, and they may be used 
 alternately.
 
 ACID DYSPEPSIA ?I 
 
 tire to bed, and be fed with a tumblerful of milk every i 
 or 2 hours, making a total of 5 pints a day. But I have 
 seldom found it necessary to resort to such extreme treat- 
 ment. 
 
 On the other hand, I have found it advisable in some cases 
 to reduce the amount of animal food for a time, and order 
 a corresponding increase of fat and carbohydrates. In such 
 a case the diet must consist of light and easily digested 
 foods: milk, milk puddings, junket, custard, eggs, jelly, 
 blancmange, arrowroot, bread, and an abundance of butter, 
 boiled fat bacon or ham. After a time the diet may be im- 
 proved by the addition of tender meat, poultry, and steamed 
 fish, such as sole, plaice, or whiting. All kinds of sweet 
 foods, soups, broth, strong tea, condiments, spices, and 
 alcohol (except a glass of red wine, well diluted) should be 
 forbidden until the recovery is complete. 
 
 It has been observed that the amount of acid in the gas- 
 tric juice can be reduced by keeping salt out of the food ; 
 therefore salt should be avoided or reduced to a minimum. 
 For a long time after the cure is complete the patient must 
 continue to exercise great care over his food, keep the allow- 
 ance of tobacco, and especially of alcohol, down to a mini- 
 mum. The latter should consist of lager beer, a glassful of 
 hock, claret, or burgundy, well diluted, or a small amount 
 of whisky in a lot of water. 
 
 In the second form of acid dyspepsia the analysis of the 
 gastric contents, while showing a very high degree of acidity, 
 often shows that there is a deficiency of hydrochloric acid 
 (hypochlorhydria), and the digestive power of this secretion 
 is very weak. The acidity is due to the formation of organic 
 acids. 
 
 One of the commonest causes of this condition is long- 
 continued irregularity in the quality or quantity of the food 
 or food accessories (spices, condiments, alcohol). Such a 
 course leads first of all to hypersecretion the stomach 
 responds to the demand for a larger supply of gastric juice 
 as long as it can. Nature always does respond freely and 
 give abundantly when we ask more than usual from her ; this 
 generosity often leads to hyperchlorhydria (the condition
 
 72 DIET IN DYSPEPSIA 
 
 which was considered above). But the long-continued 
 irritation leads to changes in the gastric glands, and Nature 
 is no longer able to respond to our demands for gastric juice, 
 because the instrument through which she replies, the gastric 
 glands, are exhausted by overwork ; the quality of the secre- 
 tion becomes poorer and- less effective. This condition of 
 hypochlorhydria may occur from irregular living and feeding, 
 anaemia, chlorosis, catarrh of the stomach, infectious diseases, 
 and chronic wasting diseases. In acute catarrh of the stomach 
 the amount of gastric juice sinks to nothing, there not being 
 sufficient to digest a small meal of ordinary food ; during 
 convalescence the pepsin reappears before the acid. In 
 typhoid and other fevers the hydrochloric acid sinks to a very 
 small amount, while lactic acid and other acids rise in pro- 
 portion. In anaemia the hydrochloric acid is deficient when 
 the patient suffers from chronic indigestion ; in other cases 
 there is an excess of hydrochloric acid. The most im- 
 portant cause of hypochlorhydria, however, is catarrh of the 
 stomach ; as the amount of gastric juice diminishes other 
 acids increase, so that the condition of organic acidity is 
 almost sure to follow hypochlorhydria. Microbes grow in 
 the stomach, as they do in all other cavities; but hydro- 
 chloric acid is a disinfectant, and keeps them down. The 
 stomachs of healthy people are almost free from microbes ; 
 the gastric contents of thirty healthy persons revealed the 
 presence of only three kinds of micro-organisms ; two were 
 moulds and one a bacillus. But in persons who suffer from 
 hypochlorhydria, as in catarrh of the stomach, dilatation, or 
 cancer, various micro-organisms readily flourish and multi- 
 ply abundantly, thereby causing acid fermentation, alcoholic 
 fermentation, and putrefaction of the food. 
 
 In consequence of the deficiency of hydrochloric acid, the 
 digestion of the food is delayed, and the undesirable micro- 
 organisms have ample time to work their will upon all kinds 
 of carbohydrates and produce therefrom butyric, lactic, and 
 acetic acids, and various gases. These unpleasant changes 
 cause a depreciation of the appetite ; the tongue becomes 
 coated, flabby, and sometimes marked around its borders 
 with an impression of the teeth. In spite of the poor
 
 ACID DYSPEPSIA 73 
 
 appetite, a sense of fullness follows the meal, with flatulence, 
 nausea, occasionally vomiting, and either constipation or 
 diarrhoea. Thus we find that meat, fish, milk, and eggs are 
 badly digested, because of the deficiency of hydrochloric 
 acid in the gastric juice ; while sugar, bread, milk puddings, 
 and other starchy foods are decomposed by bacteria and 
 give rise to organic acids. The organic acids do not assist 
 in the digestion of food ; on the other hand, they irritate 
 the stomach, hinder digestion, and weaken the motor-power 
 of the organ, so that dilatation often follows a long course 
 of organic acidity. 
 
 The dietetic treatment of such cases requires to be care- 
 fully considered. So long as the motor-power of the 
 stomach remains good the patient may be allowed such 
 animal foods as will readily and quickly pass through the 
 pylorus into the bowels. Thus it is proper to give milk, eggs, 
 meat reduced to a pulp, chicken panada, light steamed fish, 
 milk puddings, custard, junket, jelly, and stale bread. It 
 should not be forgotten that butter and other fats check the 
 secretion of gastric juice, and should be reduced to a mini- 
 mum ; while soup, beef-tea, and meat extracts promote the 
 secretion of gastric juice and are useful foods. The following 
 dietary would be suitable for an average case : 
 
 Breakfast. Two eggs lightly boiled or poached; or 5 
 ounces of fish (sole, plaice, whiting, fresh haddock, brook 
 trout, brill, bream, etc.) ; stale bread, " pulled " bread, or 
 dry toast ; a breakfastcupful of milk, cocoa, or weak tea. 
 
 Lunch. A cupful of fairly strong soup or broth ; chicken 
 or mutton ; potato, spinach, vegetable marrow, boiled 
 lettuce, kidney beans; milk pudding, custard, junket, or 
 jelly. 
 
 Dinner. Soup; fish; chicken, pheasant, breast of 
 turkey, rabbit, lean mutton, undercut of beef; potato 
 puree, spinach, or other vegetables as for lunch ; and the 
 same kind of puddings, baked apples, or apple sauce. A 
 few grapes, a slice of pineapple, a tangerine orange, one 
 plum or apricot or a few strawberries may be allowed. 
 Alcohol. A glass or two of claret or burgundy, or whisky 
 and water.
 
 74 DIET IN DYSPEPSIA 
 
 " Pulled " bread is prepared by taking small pieces, about 
 a dessert-spoonful each, from the inside of a new loaf and 
 baking them in an oven until they are crisp and dry. Toast 
 should be crisp, and eaten without butter. Apples are con- 
 sidered a tonic to a weak stomach ; they do not suit every- 
 body, even when baked or made into sauce they may irritate 
 the mucous membrane ; but they may be tried. 
 
 The food should be well salted, as salt is considered to in- 
 crease the strength of the gastric juice. Spices and condi- 
 ments have temporarily a good effect by promoting the motor 
 activity of the stomach, causing the expulsion of gas and 
 assisting the stomach to propel the food into the intestines. 
 They are useful if taken in moderation by persons who have 
 not previously abused them. The old rule, that we should 
 treat the patient rather than the disease, here comes in again. 
 Spices are well-known causes of indigestion ; they have been 
 enumerated among the substances which cause an excess of 
 gastric juice and hydrochloric acid. But their continued 
 use in large quantities causes congestion of the mucous mem- 
 brane, hypertrophy, and ultimately atrophy of the gastric 
 glands ; so that primarily they cause a profuse and secon- 
 darily a scanty secretion. The deduction with regard to 
 acid dyspepsia is this : if the patient has been accustomed 
 to use a lot of pepper, mustard, horseradish, pickles, 
 cayenne, and other heating substances, he must be for- 
 bidden to take them at all ; if he has not been accustomed 
 to take them, except in very small quantities now and then, 
 he should be encouraged to use them more freely, in the 
 hope that the stomach will be improved by the stimulation 
 derived from them. 
 
 Similar remarks apply to soup, etc. A free secretion of 
 gastric juice soon follows the consumption of soup, beef- 
 tea, extract of meat, and its various preparations. Therefore 
 such patients should take a cupful of one of these fluids at 
 the beginning of lunch and dinner. A cupful of Bovril or 
 Oxo would have the same effect as soup, and as they are 
 more quickly prepared and sometimes better relished by 
 patients, they may be used to the same extent as soup. 
 
 The attendant should be warned against allowing patients
 
 ACID DYSPEPSIA 75 
 
 of this class to take soup made from scraps of meat. If 
 soup or broth is given at all it must be made from fresh 
 meat or fowl. The danger of introducing the products of 
 bacterial action on meat into the stomachs of such persons 
 is obvious. 
 
 Vegetables have to be considered. Mashed potato, spin- 
 ach, vegetable marrow, tender green peas, and other soft 
 vegetables are permissible. But all coarse and fibrous vege- 
 tables, in their usual form, must be forbidden. Neverthe- 
 less, they are very useful for their salts and vegetable juices. 
 But they should be taken in the form of French soup. This 
 is made as follows : All kinds of vegetables are put into the 
 pot along with some bones and scraps of fresh meat. 
 Onions, turnips, carrots, celery, leeks, marjoram, a bit of 
 thyme, mint, tarragon, or savory, some endive, chicory, and 
 even cabbage may be added. These are boiled together 
 for four or five hours, until the whole is reduced to a puree 
 or consomme, and is then flavoured with salt, pepper, and 
 other spices. It is now ready for use by ordinary persons ; 
 but for patients of the class we are considering it must be 
 poured though a sieve to remove every particle of coarse 
 fibre. It is not essential that any meat or bones be used 
 in the preparation ; but in that case the strained soup should 
 be mixed with milk, one or two raw eggs, and put into a 
 pan and stirred until it boils. 
 
 Sugar and sweets should be forbidden, on account of the 
 fermentation and acidity which they cause. Therefore 
 sweet puddings, cakes, jam, etc., are taboo. Acids are 
 equally injurious ; therefore sour fruit, pickles, and vinegar 
 are forbidden. Salads are much too firm, and contain too 
 much fibre to be digested by such a weak stomach. 
 
 These patients should take no fluid during the meal, 
 except a cupful of soup or tea ; they should not drink any 
 more, lest they dilute the already weakened gastric juice ; 
 but they may drink freely two or three hours after the meal, 
 when a cupful or two of hot tea, soup, or a glass of whisky 
 and water would assist the final processes of gastric diges- 
 tion. 
 
 But there are patients who will not improve with the most
 
 76 DIET IN DYSPEPSIA 
 
 careful dieting ; in spite of all care the hydrochloric acid 
 becomes more deficient, and the stomach weaker, until it 
 is unable to propel its contents into the intestines in a 
 reasonable time. In such cases the patient should be put 
 to bed and given a milk diet for two or three weeks. Milk 
 is the least irritating of all foods, and causes the least ex- 
 penditure of energy during digestion. The amount given 
 must not be very large at first ; indeed, the patient may not 
 be able to take more than two to two and a half pints a 
 day at the beginning of the treatment, and the dose should 
 not be more than a tumblerful every two hours. But the 
 amount must be gradually increased until five or six pints a 
 day are taken ; the dose may then be a tumblerful every 
 hour, or one pint every three hours. It may be raw if it is 
 fresh from the cows, or boiled if it has been stored for some 
 time ; and it may be pure or diluted with barley-water, or 
 flavoured with salt, celery salt, or extract of meat. The 
 chief drawbacks to the diet are pain, flatulence, and diar- 
 rhoea or constipation. The pain is usually due to the forma- 
 tion of hard curds, which may be prevented by the judicious 
 use of barley-water, or the addition of some extract of malt 
 about ten minutes before it is consumed. Flatulence is due 
 to fermentation, which may require the use of drugs. If 
 ordinary milk is not tolerated after a few days' trial, we can 
 resort to the sour-milk treatment, especially kefir or 
 koumiss. 
 
 But ordinary milk or sour-milk diet is at the best only a 
 temporary method of treatment. After two or three weeks 
 some improvement of the diet must be begun. Thus : 
 Breakfast, one pint of milk ; lunch, one and a half pints of 
 milk and two raw eggs ; tea, one pint of milk ; supper, one 
 and a half pints of milk and two raw eggs. The duration of 
 this diet must depend on the progress. Ultimately we must 
 add soup, chicken panada, light fish, junket, jelly, custard, 
 and thereby gradually build up a dietary similar to that 
 given above.
 
 CHAPTER X. 
 ATONY AND DILATATION OF THE STOMACH. 
 
 THE dyspepsia may end in a decided loss of tone and weak- 
 ness of the muscular apparatus of the stomach. This is 
 called atony, or motor insufficiency. The technical sign of 
 the condition is the discovery that the stomach is unable 
 to propel an ordinary meal into the bowels in the usual 
 time. To definitely ascertain this fact, it is customary to 
 give a test-meal in the middle of the day. It may consist 
 of a plate of soup, five ounces of beef, two or three ounces 
 of potato, a roll, and a glass of water. Under ordinary 
 circumstances such a meal disappears from the stomach in 
 five hours, leaving very few traces behind, and in seven 
 hours at any rate the stomach would be quite empty. 
 Therefore the amount of material which could be removed 
 from the stomach five hours after the meal would be a 
 measure of the loss of power or degree of atony of the 
 stomach. 
 
 Atony of the stomach, or motor insufficiency, is one of 
 the sequels of a long-continued indigestion, the causes of 
 which have several times been enumerated. It should be 
 stated, however, that there is a predisposition to this disorder 
 in all persons who follow a sedentary occupation, who are 
 subject to worry and the stress of business, to frequent losses 
 of blood from any cause, prolonged discharges or the nursing 
 of infants, anaemia, and other circumstances which interfere 
 with the general nutrition. The condition often follows 
 influenza, typhoid, rheumatic fever, and other febrile condi- 
 tions. In most fevers there is a diminution of the ordinary 
 activity of the stomach ; the gastric juice is deficient, as 
 
 (77)
 
 7 8 DIET IN DYSPEPSIA 
 
 well as motor power ; and, although the appetite may re- 
 turn, the stomach does not always as quickly regain the 
 power of digesting the food; consequently the atonic con- 
 dition persists and may lead to serious trouble. It will be 
 perceived, therefore, that this form of dyspepsia is not so 
 often the result of errors in the food as those previously 
 discussed, but it comes as the result of some previous ill- 
 ness and other circumstances which interfere with the 
 general health. 
 
 Excepting when it follows a serious illness, atony of the 
 stomach comes on slowly. The victim becomes pale and 
 thin, has a worried and anxious expression, a look of 
 weariness or fatigue ; moreover, a sensation of weariness in 
 the limbs and a dull pain in the head are often complained 
 of. The gastric symptoms are not markedly different from 
 those previously described in other dyspepsias. There is a 
 feeling of weight and discomfort in the stomach, with heart- 
 bum, belching of wind, and rising of acid fluids. The 
 acidity is caused by fermentation and bacterial decomposi- 
 tion. The products of decomposition of the food set up 
 gastric catarrh, the gases originating therein distend the 
 enfeebled organ and still further interfere with the motor 
 functions, and lead to dilatation. When atony of the 
 stomach has lasted for some time, the weakened organ 
 nearly always becomes more or less dilated. The degree 
 of dilatation is not very great at first, and, as the organ 
 recovers tone and muscular power, the dilatation disap- 
 pears. When dilatation occurs the pain and discomfort 
 after eating are increased, food gradually accumulates in the 
 stomach, and after a time the distension increases to such a 
 degree that relief is only obtained by vomiting. In well- 
 marked cases the vomiting occurs at intervals of two or three 
 days, and the material brought up consists of the gastric 
 secretion, semi-digested and fermented food, together with 
 bacterial and fungoid organisms and their products. The 
 influence of this dilatation and its interference with digestion 
 is seen in the progressive emaciation of the body. 
 
 The diagnosis of dilatation, like that of failure of the motor 
 power and gastric insufficiency, is made by drawing off the
 
 ATONY AND DILATATION OF THE STOMACH 79 
 
 contents of the stomach after a test-meal. Apart from this 
 test, the dilated organ can be felt by palpation and percussion 
 of the abdomen. The stomach often extends below the 
 umbilicus ; and a sensation of " splashing " can be obtained 
 by palpation. Moreover, the peculiar vomiting and the great 
 amount of material brought up are only present in this 
 disease. The quantity of material often amounts to two or 
 three pints, or sometimes quarts ; and it comes out of the 
 mouth as if it were pumped up. 
 
 Thus we may see dilatation of the stomach resulting from 
 a well-marked gastric irritation, but the organ regains its size 
 when the stomach is empty ; or from atony of the stomach, 
 where the dilatation may be slight and depend on the re- 
 covery of muscular power ; whereas in chronic gastric catarrh 
 there may be dilatation varying from a slight degree, which 
 disappears when the stomach is empty, to a more severe 
 and permanent dilatation. But these functional disorders of 
 the stomach are not the only causes of dilatation. It may 
 occur as the result of an obstruction to the passage of food 
 through the pylorus. Thus, it may be due to an ulcer in the 
 duodenum or in the region of the pylorus, to a cancer or 
 other new growth in the stomach or some adjacent organ, to 
 adhesions, or traction upon the pyloric end of the stomach. 
 In the obstructive form the dilatation of the stomach is not 
 necessarily preceded by atony or loss of muscular power ; 
 as a matter of fact, the muscles of the stomach are normal, 
 and, in the first instance, dilatation is prevented by a deve- 
 lopment of the muscles (hypertrophy) to overcome the 
 obstruction. But by and by the muscle fails, it can no longer 
 drive the food past the obstruction so well as it formerly 
 did, and the stomach becomes dilated in proportion to the 
 degree of failure. Thus, in pyloric obstruction there may 
 be hypertrophy of the stomach without dilatation, hyper- 
 trophy with dilatation, or dilatation without hypertrophy. 
 The dilatation is due to a distending force, but the disten- 
 sion does no harm to the stomach so long as the muscle is 
 able to recover from stretching that is, so long as the nu- 
 trition of the muscle is good. But when the nutrition fails, 
 the stretched muscle remains stretched, and thus we have a
 
 8o DIET IN DYSPEPSIA 
 
 secondary dilatation. In primary dilatation, due to atony or 
 catarrh of the stomach, the muscle is already weak, and the 
 resistance or elasticity which an ordinary muscle possesses is 
 lost. In either case the distension is due to the delay of 
 food in the stomach, to the deficiency of hydrochloric acid, 
 the unchecked development of bacteria, and the fermentation 
 and putrefaction which they cause. Thus arise the acids and 
 gases which prolong the gastric irritation and catarrh, and 
 intensify the dilatation by distending the stomach with gas. 
 
 Atony of the stomach, apart from dilatation, may be tem- 
 porary or permanent. Atony which is the result of curable 
 affections, such as infectious and other acute diseases, pro- 
 longed lactation, profuse discharges, haemorrhage, anaemia, 
 chlorosis, overwork, worry, anxiety, and many other causes 
 of indigestion, is curable. But that which occurs in Bright's 
 disease, granular kidneys, amyloid disease, tuberculosis, 
 malignant disease of various organs, and local affections in 
 the stomach, such as prolonged gastric catarrh, atrophy of 
 the mucous membrane, or cancer, is either incurable or only 
 partially benefited by treatment. 
 
 Dilatation of the organ may also be of a temporary or 
 permanent character. The slight degree of dilatation which 
 occurs commonly in many cases of atony is curable. Still 
 greater degrees of dilatation occurring as the result of duo- 
 denal or pyloric ulcer, and other forms of pyloric obstruction, 
 may also be cured. But in those cases where the obstruc- 
 tion cannot be removed no cure can be expected. 
 
 THE TREATMENT. The condition of general debility 
 which underlies atony of the stomach must be attacked. 
 This is the more important in all those cases which are not 
 the direct result of the abuse of food and drink. Reme- 
 dies which will improve the tone of the body, increase vital 
 power, and stimulate the activity of the muscles, will also 
 increase the motor activity of the stomach, and improve 
 the quantity and quality of the gastric juice. The indica- 
 tions for treatment are (i) to remove the cause of the disease ; 
 (2) promote general nutrition by proper exercise of the 
 mind and body ; (3) and render easy the process of diges- 
 tion by proper selection and preparation of food,
 
 ATONY AND DILATATION OF THE STOMACH 81 
 
 The food is exceedingly important. The amount con- 
 sumed must be within the power of the stomach to deal with 
 it. Sufficient time must be given for the weakened organ 
 to do its work. The selection and preparation of the food 
 must be suited to the condition of the organ. But it is use- 
 less to pamper the appetite or yield to the cravings of the 
 stomach. In mild cases of atony, modified ordinary diet, 
 such as that previously detailed for chronic gastric catarrh, 
 may be given. In more severe cases a mixed milk and 
 ordinary diet would be useful. In either case too much 
 starch or sugar must be avoided; the food must not be 
 too concentrated, and it must always be well and carefully 
 cooked. As the general condition improves, the amount 
 and quality of the food may be improved. Any article 
 which disagrees by occupying a long time in digestion, caus- 
 ing much pain or considerable flatulence, must be removed 
 from the diet. 
 
 In chronic cases the change of food had better be brought 
 about gradually rather than suddenly. A sudden cessation 
 from all the agreeable articles of food is not likely to be 
 permanent. Therefore, while cutting off at once well-known 
 indigestible articles, such as pickles, pork, and pastry, it is 
 better to gradually reduce the food until a suitable perma- 
 nent diet has been reached. The object of treatment is 
 best attained by means of a spare diet, consisting chiefly of 
 animal foods and the restriction of fluids. The avoidance 
 of bulky meals, consumption of food without drinking, and 
 careful mastication assure the material being swallowed in 
 a state of fine subdivision and that the stomach is not over- 
 loaded. If the appetite fails, abstinence (within reason, of 
 course) is better than pampering the stomach with dainty 
 fare or stimulating it with wine or spirits. When the 
 appetite is good the patient should cease eating before the 
 feeling of satisfaction is reached, for it is better to eat too 
 little than too much. The meals should be only three, and 
 they should be six hours apart. A moderate use of salt, 
 pepper, mustard, horse-radish, and other aromatic condi- 
 ments is commendable. An average patient might have 
 a dietary similar to the following : 
 
 6
 
 82 DIET IN DYSPEPSIA 
 
 Breakfast. A cup of coffee or tea with milk or cream, 
 but very little sugar. One or two eggs, boiled or poached, 
 and some fish of the lighter kinds must form the principal 
 part of the meal. A few slices of stale bread, very dry toast, 
 or " pulled " bread may be eaten. 
 
 Dinner. No meat or fish at this meal. It may consist 
 of macaroni and tomatoes, boiled rice with gravy or extract 
 of meat, spinach, vegetable marrow, tender green peas, 
 kidney beans, mashed potato and cream, and either cabbage, 
 savoy, or carrots in the form of puree, milk pudding, apple 
 sauce, or a few stewed plums. At the end of the meal 
 one-quarter pint of pure water, or a glass of claret or 
 burgundy. 
 
 Supper. Clear soup, about three ounces, any kind of 
 light fish, tender lean beef or mutton, rabbit, poultry, 
 pheasant or partridge, one tablespoonful of mashed potato 
 or boiled rice, or a slice of dry toast or " pulled " bread. 
 No pudding or sweets. At the end of the meal a small 
 glass of water alone or with a tablespoonful of whisky, or two 
 glasses of claret or burgundy. 
 
 Thus the patient will have two meals consisting chiefly of 
 Animal food and one of vegetables ; the meals are small ; 
 eaten dry they will be well masticated, and being six hours 
 apart will not over-tax the stomach. 
 
 In simple atonic dilatation the indications are similar 
 namely, to improve the tone of the stomach, to avoid disten- 
 sion as much as possible, to promote the propulsion of the 
 food into the bowels, and discourage any tendency to fer- 
 mentation. These indications are met by a dietary such 
 as the foregoing. That is to say, the food should be of 
 small bulk and eaten dry, the total amount of liquids 
 should not exceed one and a half to two pints, and may 
 advantageously be reduced to one pint for two or three 
 weeks. As the sufferer may have been a big drinker previ- 
 ous to the treatment, this limitation of liquids is often 
 rather difficult to enforce ; but it is a necessity for success- 
 ful treatment. The distension of the stomach is also 
 avoided by forbidding the consumption of fresh salads or 
 raw fruit and heavy vegetables such as cabbage, savoy,
 
 ATONY AND DILATATION OF THE STOMACH 83 
 
 turnips, swedes, and carrots, except a small amount in the 
 form of puree. The avoidance of much bread and potato, 
 of all sweet cakes, pikelets, crumpets, muffins, etc., of ex- 
 cess of milk puddings, custard, or junket tends to reduce 
 the fermentation. The avoidance of fat meat, pork, bacon, 
 ham, duck, goose, mackerel, herring, salmon, eel, halibut, 
 lamprey, alewife, and other greasy foods is beneficial. All 
 dried and seedy fruits must be avoided, such as currants, 
 raisins, figs, candied fruit or peel, strawberries, raspberries, 
 and gooseberries, partly because of the seeds and skins, and 
 partly because of the acids in them. All acid substances 
 ought to be avoided. 
 
 There are some cases of atonic dilatation more difficult to 
 treat. These especially follow severe illness, neurasthenia, 
 prolonged mental exhaustion, worry, and anxiety. The treat- 
 ment of these cases must be somewhat different. They 
 should be confined to bed, and given a diet which contains 
 very little carbohydrates. The patient should be fed every 
 two hours with a small meal. The food should consist of 
 one to one and a half pints of milk enriched with plasmon or 
 sanatogen in four doses four hours apart. At the intermediate 
 meal he should have raw eggs, scraped beef, beef-juice, 
 pounded chicken or fish, with a small thin strip of dry toast 
 or a bit of pulled bread. The total quantity of food must 
 be small, and not more than a bare sufficiency for a person 
 at rest. After ten or fourteen days of such feeding the 
 patient may be allowed to sit in a chair for an hour or two 
 at a time, and the food may be improved, but each meal 
 should be followed by rest in bed. The diet may now con- 
 sist of something like the following : 
 
 Breakfast. Two eggs or five or six ounces of light fish 
 and two ounces of dry toast or pulled bread ; a cupful of tea 
 or cocoa made with milk at the end of the meal. 
 
 Lunch (n a.m.). A glass of milk, with a sandwich of 
 tongue or pounded chicken. 
 
 Dinner (2p.m.}. Oysters (four or six) or fish, followed 
 by two or three ounces of scraped meat, pounded chicken, 
 tongue, or tripe ; a tablespoonful of mashed potato, and a 
 slice of dry toast ; followed by a tablespoonful or two of
 
 84 DIET IN DYSPEPSIA 
 
 junket, custard, milk jelly, or ordinary jelly and cream ; a 
 glass of milk to drink or a glass of red wine. 
 
 Tea. A cupful of China tea and a plain biscuit or dry 
 toast. 
 
 Supper (7 p.m.}. Similar to dinner. 
 
 Bedtime. Milk and sanatogen or plasmon. 
 
 In obstructive dilatation other factors come into the prob- 
 lem. In primary atonic dilatation the motor power is abso- 
 lutely defective, and the idea is to give foods of such a 
 character that they can be quickly passed on to the intes- 
 tine, where their digestion will almost entirely be performed. 
 In secondary or obstructive dilatation the motor power is 
 at first only relatively defective, there is an obstruction to 
 the passage of foods into the bowels, and the main idea is 
 to give foods which will be digested in the stomach and 
 absorbed through its mucous membrane. It is absolutely 
 useless in such a case to fill the stomach with bread and 
 potatoes, oatmeal, milk puddings, rusks, biscuits, or veget- 
 able purees ; they cannot be digested in the stomach and 
 their passage into the bowels is hindered. Moreover, their 
 presence encourages fermentation, with its attendant heart- 
 burn, acidity, belching, regurgitation or vomiting. All foods 
 of this class must be entirely removed from the dietary. 
 Milk is still one of the best foods ; but it must not be given 
 alone, because of the tendency to form hard curds. It 
 should be combined with citrate of soda, extract of malt, or 
 it may be peptonized. Thus the formation of large curds 
 will be prevented. Moreover, the addition of a tablespoon- 
 ful of extract of malt or half an ounce of milk-sugar to cow's 
 milk increases the proportion of soluble nutriment which 
 may be absorbed. Extract of malt contains maltose which 
 is less liable to fermentation than lactose. In addition to 
 milk we can give raw eggs, scrambled eggs, egg custard, 
 scraped or minced meat, potted tongue, pounded chicken, 
 soft or light fish, oysters, meat-powders, meat-extracts, 
 plasmon, sanatogen, protene, eucasein, and somatose. The 
 total daily amount should include three pints of milk, two 
 eggs, ten and a half ounces of meat, fish, chicken, etc., and 
 one or two ounces of extract of malt. The proper plan is
 
 ATONY AND DILATATION OF THE STOMACH 85 
 
 to reduce all food to a pulp by a fine mincer, to remove 
 stringy or fibrous portions, and pass all through a sieve. 
 
 If the obstruction increases, it is possible that no food but 
 peptonized milk and similar articles will be retained. We 
 must then confine our attempts at feeding to the adminis- 
 tration of peptonized and pancreatized milk, Mosquera's beef 
 meal, meatox (beef powder), beef-plasmon, Carnrick's pep- 
 tonoids, Brand's beef peptone, panapeptone, Kemmerich's 
 peptone, Armour's soluble beef, hipi (mutton essence), 
 Darby's fluid meat, etc. The predigestion of carbohydrates 
 is unnecessary if the right kinds are used namely, extract 
 of malt, milk-sugar, and golden syrup, which will be pro- 
 pelled easily through the pylorus if anything can go. But 
 all dietaries may be useless in bad cases, and nutrient 
 enemata have to be resorted to until the operation of gastro- 
 enterostomy is performed to make a new opening between 
 the stomach and bowels. 
 
 Other points in treatment of all cases are important. The 
 patient should rest after every meal, and lie on the right 
 side to facilitate the passage of food into the bowels. The 
 patient should wear a flannel belt with a pad over the um- 
 bilicus. Massage is valuable, especially skilled massage of 
 the abdomen at a proper interval after meals. General 
 massage of the body and all tonic and recuperative measures 
 are useful. Gastric lavage or washing the stomach out will 
 restore tone to the stomach, remove fermented materials 
 and micro-organisms, and cleanse the mucous surface. It 
 should be done once a day with an alkaline water (bicarbon- 
 ate of soda or magnesia), a solution of tannin, or proper Spa 
 waters. After each lavage a dose of olive oil would tend to 
 remove pain and irritation. Exercise in the open air, on 
 foot or horseback, golf or tennis, is beneficial to those able 
 to take it. Indolence and a sedentary occupation should be 
 avoided. Change of air to a bracing climate is very good 
 for all cases. Encourage the patient, avoid depressing tales 
 and circumstances,
 
 CHAPTER XI. 
 CANCER OF THE STOMACH. 
 
 CANCER may affect the entrance, the exit, or any inter- 
 mediate part of the stomach, but it more often affects one 
 of the openings than elsewhere. Cancer of the stomach is 
 essentially a disease of the latter half of life, and more often 
 affects men than women. We will first consider cancer at 
 the entrance of the stomach. 
 
 I. Cancer of the (Esophagus. The entrance to the stomach 
 consists of the gullet or oesophagus. It may be affected by 
 cancer in any part of its course, but the disease is far more 
 common at the opening into the stomach than any other part 
 of the tube. The symptoms of the disease are few. The first 
 indication of anything wrong is a difficulty in swallowing, 
 due to the food "sticking" in some part of the passage or 
 meeting with some obstruction. This symptom is at first 
 not very pronounced, and it may occur only occasionally as 
 the result of a spasm produced by irritation of the diseased 
 part. After a time, howerer, a stricture is formed, the 
 difficulty becomes more obvious, and it is seen that the 
 food will not go down without difficulty. By and by a 
 dilatation occurs above the seat of stricture, a pouch is 
 formed in which food collects, and some of the food is 
 regurgitated. An examination with an cesophageal tube 
 shows the existence of an obstruction, and pain is caused 
 by the passage of the tube through the stricture. When 
 the cancer ulcerates, blood, mucus, and sometimes pus are 
 brought up with the regurgitated food. On testing the re- 
 action of the latter with litmus paper it is found to be alka- 
 line, whereas food brought up from the stomach is usually 
 
 (86)
 
 CANCER OF THE STOMACH 87 
 
 acid. As the disease progresses there is a more or less 
 constant pain which increases with the growth of the can- 
 cer and implication of nerves and surrounding structures. 
 The patient emaciates and his abdomen becomes flat. The 
 prognosis is very bad and the duration of the disease un- 
 certain. 
 
 The treatment of such a case will tax the ability of the 
 nurse and her skill in the use of the stomach tube. So long 
 as the patient can swallow soft and liquid foods he may have 
 three or four pints of milk and raw eggs, strong soup, potted 
 or pounded meat, fish, or fowl, puree of potatoes and other 
 vegetables, fine oatmeal, arrowroot, and other farinaceous 
 foods, such as Allenburys', Savory and Moore's, and Benger's 
 or Mellin's, and plenty of sugar, glucose syrup, or other 
 nourishing liquids or semi-liquids. Butter can be freely 
 mixed in many of these foods. Cream and cod-liver oil are 
 useful forms of fat. 
 
 When the patient can no longer swallow such foods he 
 must be fed three times a day by means of a stomach tube. 
 The nurse must give a good meal while she is about it. It 
 may consist of i-J pints of milk, three or four raw eggs, or 6 
 or 7 ounces of pounded meat, and one of the farinaceous 
 foods, and a little water or other liquid at the end of the 
 meal. When it becomes absolutely , impossible to pass the 
 stomach tube she must resort to rectal feeding. After rest- 
 ing from the use of the stomach tube for a few days it 
 occasionally happens that the stricture relaxes and the tube 
 will again pass readily. The patient should then be fed as 
 before. But when the disease is sufficiently advanced to 
 render the use of a stomach tube necessary the question of 
 an operation to make the feeding more easy should be con- 
 sidered by the patient and his friends. The operation con- 
 sists in the formation of an aperture into the stomach 
 through the anterior abdominal wall (gastrostomy). This 
 operation will save the patient much pain, render the intro- 
 duction of a tube quite easy, feeding can then be abundant, 
 and the life of the patient will be prolonged. 
 
 II. Cancer of the Stomach, like that of the oesophagus, 
 seldom affects anyone under fifty years of age. Little is
 
 88 DIET IN DYSPEPSIA 
 
 known about the antecedents of such a case, but there are 
 reasons for suspecting the pre-existence of an ulcer in a large 
 proportion of the cases. The symptoms which attend the 
 disease are not characteristic of cancer. They are those of 
 a bad dyspepsia viz., pain after food, vomiting, regurgitation 
 of sour or fermented food, and tenderness of the stomach. 
 The most important symptom is progressive loss of flesh ; 
 this always occurs, and may be very rapid. If pain after 
 food is combined with rapid loss of flesh and the vomiting 
 of blood or "coffee grounds," there are serious reasons for 
 believing the trouble is due to cancer. If to these symp- 
 toms is added a peculiar tint of the skin, a dirty yellow, 
 earthy, or fawn colour, and especially if enlarged glands can 
 be felt under the skin of the abdomen, groin, or axilla, or a 
 growth is perceived in the stomach, the diagnosis of cancer 
 is pretty certain. 
 
 If it is known that the cancer does not affect the outlet 
 or pylorus, that is to say, there is no obstruction to the passage 
 of food, the patient may have free choice of food, because 
 it is probable that the duration of life will not be very great. 
 Nevertheless, it is advisable to guide the patient's choice in 
 the direction of digestible foods. Moreover, there is one 
 feature of the case which suggests a limitation of certain 
 foods ; this feature is the well-known deficiency of hydro- 
 chloric acid in the gastric juice of all cases of cancer, and the 
 probable development of organic acidity due to fermentation. 
 The correct and scientific diet for such persons, therefore, 
 is that previously detailed for cases of organic acidity and 
 hypochlorhydria. 
 
 If, however, the pylorus is affected, and the exit of food 
 is hindered, the diet should contain an excess of animal foods 
 and very little starchy material. In such a case we should 
 forbid the consumption of bread, biscuits, oatmeal, farinace- 
 ous foods, potatoes and vegetables, and even milk puddings, 
 because they cannot be thoroughly digested in the stomach 
 and their outward passage is hindered. Their consumption 
 would lead to fermentation, flatulence, acidity, vomiting 
 and dilatation of the stomach. The occurrence of dilatation 
 would probably cause the stomach to become prominent,
 
 CANCER OF THE STOMACH 89 
 
 and thus distinguish cancer of the pylorus from that of the 
 oesophagus. The food, therefore, must consist of substances 
 which will be digested and absorbed in the stomach. The 
 basis of the diet should be milk, and a saltspoonful of citrate 
 of soda could be added to each pint to prevent the formation 
 of curds. We may also give raw eggs, meat-powders (Mea- 
 tox, Mosquera's beefmeal), Plasmon, or other milk-powders, 
 somatose, junket, custard and jelly. Extracts of meat are 
 useful by promoting a flow of gastric juice, and a little strong 
 soup may be given now and then for the same purpose. 
 It is seldom, however, that the pylorus is absolutely closed ; 
 liquids and liquefied foods will pass through it. Therefore 
 Mellin's food, whey and other liquids containing sugar, 
 extract of malt, or dextrin, may be given. Possibly some 
 arrowroot combined with Taka-diastase to digest it would 
 pass through ; it can be tried, and if it is successful in 
 passing through may be given every day. The fat of milk 
 is extremely fine and will usually pass the pylorus. Sugar 
 of milk, golden syrup, extract of malt, will also go through. 
 Jelly would be liquefied in the stomach and pass as easily 
 as other liquids. Vegetables can be boiled, and a few ounces 
 of the liquid containing some of the substance rubbed 
 through a sieve can be tried. A considerable amount of 
 time and care must be spent in the preparation of animal 
 food. A fine mincing machine is better for this purpose 
 than anything else ; but cooked meat or fowl can be reduced 
 to a pulp with a pestle and mortar. If the latter method 
 were adopted considerable assistance would be derived from 
 cutting the meat or fowl into very thin slices before pound- 
 ing it. When it is reduced to a paste, the addition of some 
 cream, butter, or strong soup would render it palatable ; 
 pepper and salt can be added. Various commercial pastes 
 of meat, fowl, or fish would be useful. 
 
 When the obstruction of the pylorus is very great the 
 stomach loses its power of absorption to some extent, the 
 secretion of hydrochloric acid is correspondingly diminished, 
 and digestion is thereby weakened. We must now rest our 
 hopes on predigested foods, peptonized milk, Leube's 
 soluble meat, somatose, panopepton, Carnrick's peptonoids,
 
 90 DIET IN DYSPEPSIA 
 
 Bovinine, Darby's fluid meat, Valentine's meat juice, Brand's 
 essence of beef, and other preparations which require no 
 digestive effort. If haemorrhage occurs, the patient should 
 be fed by the rectum for a few days until all bleeding ceases. 
 The rest obtained by the stomach may lead to a relaxation 
 of the stricture, and when stomach-feeding is again begun 
 foods previously found impassable now pass through easily. 
 
 In such cases the operation of gastro-enterostomy, by 
 forming a new aperture between the stomach and duodenum, 
 may afford considerable relief. This operation will make 
 the patient more comfortable, feeding will become an easy 
 matter, and his life will be prolonged. These advantages 
 show the desirability of such an operation being performed 
 as soon as a well-marked obstruction of the pylorus is dis- 
 covered ; and the tendency of the present day is to secure 
 every advantage which can be obtained in this manner.
 
 CHAPTER XII. 
 ULCER OF THE STOMACH AND DUODENUM. 
 
 WHY does not the stomach digest itself? This question 
 has been asked for centuries, many theories have been pro- 
 pounded to explain it, and still the puzzle remains. If an 
 artificial gastric juice be prepared we know that it will digest 
 meat, fish, and eggs or similar substances ; these, however, 
 are dead materials. If a living animal or a limb of such an 
 animal be kept in an artificial gastric juice it will not be 
 digested, except so far as the dead cuticle is concerned. But 
 if the tissues of such an animal's limb be injured, there is 
 no guarantee that they will not be digested ; if the injury is 
 sufficient to interfere with the nutrition of the skin and mus- 
 cles they will certainly be digested. Living animals have 
 been known to exist in the human stomach ; thus the ordin- 
 ary round worm, frogs, toads, and newts in their fully-deve- 
 loped condition, have been ejected by vomiting. Therefore 
 it appears that the healthy living tissues contain some pro- 
 tective material which the injured tissues do not contain. 
 It is argued that the living stomach also contains some 
 protective material which, under ordinary circumstances, pre- 
 vents the gastric juice from digesting it. It has been 
 suggested that this protection is due to an antiferment 
 secreted by the cells of the stomach ; it has also been held 
 that a free secretion of mucus forms a protecting varnish to 
 the mucous membrane ; and that the blood flowing constantly 
 through its vessels is alkaline, while the gastric juice is acid, 
 and one counteracts the other. Some of these theories are 
 valueless. It is probably a sufficient protection that the 
 tissues are living, like those of animals occasionally incar- 
 cerated within the stomach. If the nutrition of the cells of 
 
 (90
 
 92 DIET IN DYSPEPSIA 
 
 the stomach is low, or their vitality reduced by a deficient 
 nerve supply or deficient circulation, neither the coating of 
 mucus nor the alkalinity of the blood will protect the stomach 
 entirely. A reduction of vitality in the cells of a small area 
 may occur from many causes, and if they have not sufficient 
 power to resist the poisonous effect of the small amount of hy- 
 drochloric acid, the cells would then be destroyed and digested 
 by the gastric juice. Thus a sore place or ulcer is formed. 
 Once started, such an ulcer, perhaps originally very minute, 
 spreads by a continuance of the same circumstances. The 
 reduction of vitality may be due to a deficiency of some 
 normal ferment in the cells of that small area or to the for- 
 mation of a particular toxin in them. Observations have 
 shown that an ulcer can easily be produced by using a par- 
 ticular serum, which reduces the vitality of the cells when 
 the gastric juice contains a normal or supernormal amount of 
 hydrochloric acid ; if the proportion of acid is greater than 
 usual the ulcer will be more extensive than when the gastric 
 juice contains only the normal quantity of acid. In most 
 cases of ulcer of the stomach the gastric juice is very acid 
 (hyperchlorhydria) ; and whenever the vitality of the mucous 
 membrane is reduced by a toxic substance the cells are liable 
 to be attacked and digested by the gastric juice. That is 
 the theory recently promulgated. But there are other feas- 
 ible explanations. If a tiny focus of inflammation occurs 
 in an enfeebled spot, as the result of septic infection or 
 mechanical injury, an embolism may occur in a small blood- 
 vessel and cause a tiny patch of necrosis. It is well known 
 that acute gastric ulcers commonly occur in the course of 
 ulcerative endocarditis and other infectious diseases where 
 small emboli form in the gastric arteries. There may be no 
 evidence of a severe septic disease . preceding an ordinary 
 gastric ulcer ; but there is abundant evidence of septic matter 
 from the teeth and gums and of bacteria from the food find- 
 ing their way into the stomach. There is also plenty of 
 evidence that the food may contain hard particles of sub- 
 stances which by their mechanical action may cause local 
 inflammation and predispose the tissues to embolism. It 
 matters not, however, whether the death of the small piece of
 
 ULCER OF THE STOMACH AND DUODENUM 93 
 
 mucous membrane is due to septic embolism, mechanical 
 irritation, or the absence of some normal antibody, there is 
 the fact that a small piece of dead or diseased mucous 
 membrane forms a slough and falls out or is digested, and an 
 ulcer is left. An acute ulcer has a clean and punched-out 
 appearance. There may be one or several, but it is strange 
 that in men the primary ulcer is in the duodenum, and in 
 women it is in the stomach. We are quite ignorant of the 
 cause of this peculiarity or why one person should be sub- 
 ject to an ulcer and not another. Gastric is far more 
 common than duodenal ulcer, for out of 1300 cases 90 per 
 cent affected the stomach, and only 10 per cent the duo- 
 denum. The ulcers are curable by rest and careful feeding, 
 but relapses are common. They may also be cured by 
 surgical means ; but it would be an error to suppose such 
 means are a prevention against other ulcers, for it has been 
 shown that relapses occur in 10 per cent of the cases 
 operated on. When a first attack of ulcer occurs medical 
 treatment should always be resorted to. Indeed, I should 
 strongly recommend medical treatment to be tried first in 
 every case. But when the disease is very chronic, haemorrhage 
 occurring frequently, and no cure resulting from medicine and 
 food, recourse must be had to surgery, and we should be 
 thankful that such means exist for the removal of the ulcer. 
 The persons most likely to be affected by gastric ulcer 
 are young women. They are usually anaemic as the result 
 of conditions which predispose to the ulcer. What those 
 conditions are have not been finally settled. Sir Andrew 
 Clark considered one of the chief elements was constipation ; 
 but many more girls suffer from constipation than from 
 ulcer, and no clear connexion can be traced between them. 
 Similar remarks apply to tight lacing, to which ulcers are 
 sometimes attributed; but few men wear stays, and the 
 occurrence of an ulcer in them is probably a coincidence. A 
 sluggish circulation has been blamed for their occurrence, 
 but we see perforating ulcers of the feet in people with a 
 good circulation. It is probable that there is a special 
 diathesis or constitutional state which predisposes to the 
 formation of ulcers.
 
 94 DIET IN DYSPEPSIA 
 
 The chief symptoms of a chronic gastric ulcer are pain, 
 vomiting after food, and haemorrhage. The pain begins soon 
 after eating and lasts as long as there is food in the stomach. 
 The painful area may be a spot small enough to be covered 
 by a sixpence, or it may beimore diffused and radiate to the 
 shoulder-blades. Vomiting relieves the pain, and is seldom 
 absent in a well-marked case ; it is exhausting by itself, and 
 causes loss of strength and emaciation by removing much- 
 needed food from the body. The vomited materials are 
 more or less changed according to the length of time they 
 have been in the stomach. They are often mixed with 
 mucus, and contain an excess of hydrochloric acid ; but in 
 bad cases there is a persistent catarrh of the stomach, profuse 
 secretion of mucus, a deficiency of hydrochloric acid, and an 
 excess of organic acids. But pain and vomiting may be 
 absent. In such cases the ulcer is only diagnosed when it 
 penetrates a blood-vessel and causes haemorrhage ; the bleed- 
 ing may then be profuse and alarming. In cases where 
 vomiting is constant there may be a slight oozing of blood 
 from the granulated surface of the ulcer; but this may 
 be sufficient to make the diagnosis of ulcer more ac- 
 curate than when there is only pain and vomiting. A 
 duodenal ulcer causes discomfort after food and the 
 peculiar " hunger pain " which is characteristic of the 
 disease; there may or may not be vomiting of food and 
 blood, but more often there are mere traces of blood in 
 the motions. 
 
 Although pain, vomiting, and bleeding from the stomach 
 are the recognized indications of an ulcer, it cannot be 
 denied that these symptoms may occur without an ulcer. 
 Many patients have been operated on after profuse haemor- 
 rhage, and no ulcer could be found ; other persons have died 
 after profuse gastric haemorrhage, and no ulcer could be 
 found at the post-mortem examination, nor any evidence that 
 an ulcer had ever existed. Some of these people may have 
 had the characteristic pain, vomiting, and bleeding for years, 
 and the most that could be found was a patch of congested 
 mucous membrane. The condition is called Gastrostaxis or 
 Gastrorhexis.
 
 ULCER OF THE STOMACH AND DUODENUM 95 
 
 THE TREATMENT OF GASTRIC AND DUODENAL ULCERS. 
 In no class of cases is more benefit derived from the "rest 
 cure "than in ulcers of the stomach. But the treatment 
 should be carried out with thoroughness. Less than that is 
 useless in any case coming under treatment. The idea is to 
 produce physiological rest, that is absolute rest of the mind 
 and body, including the stomach. By putting the patient to 
 bed the expenditure of the body can be reduced to about 
 1400 calories of energy per day, which is considered the 
 minimum. The feeding should be begun by giving 2 ounces 
 of milk every two hours ; this will be 24 ounces in twenty- 
 four hours, and will yield 500 calories, or one- third of the 
 energy used by the body ; the remainder will be obtained by 
 oxidation of the patient's tissues. If pain and vomiting 
 follow these small doses of milk it may be diluted with an 
 equal quantity of barley-water, lime-water, or other alkaline 
 water to prevent the formation of curds. But the bulk of 
 the meal is thereby increased. If the stomach resents this, 
 we must resort to other means of preventing the formation 
 of curds viz., peptonization of the milk or the addition of 2 
 or 3 grains of citrate of soda to each ounce. In a mild case 
 the patient will do very well with such treatment. On the 
 second or third day the amount can be increased to 3 ounces 
 of milk every two hours, making a total of 36 ounces ; and 
 each day the dose may be increased by i ounce, until a tea- 
 cupful of milk is taken every two hours, making a total of 4 
 pints a day. Now, i pint of milk will yield 410 calories and 
 4 pints about 1600, which is enough to supply the energy 
 used up and a little over to prevent the loss of flesh. If the 
 patient cannot get through 4 pints a day we must resort to 
 various ways of strengthening the milk. The first method is 
 the addition of a milk-powder (Sanatogen or Plasmon) ; if 
 these agree the total milk can be reduced to 3 pints on the 
 condition that it is fortified by such powders. If they do not 
 agree we can add some ordinary sugar, milk-sugar, and ex- 
 tract of malt, or Mellin's food to the milk for the same purpose. 
 We can also add some Benger's food to one or two meals a 
 day, or some peptonized milk gruel. If all seems to be go- 
 ing on well we can add a few other things to the list, so that
 
 96 DIET IN DYSPEPSIA 
 
 by the end of a week the patient is getting : milk (3 pints), 
 Benger's food, Sanatogen or Plasmon, 2 raw eggs, some jelly, 
 junket, baked custard, Brand's essence, beef Plasmon, and a 
 tablespoonful of raw meat juice in an equal quantity of port 
 wine twice daily. It should be remembered that the gastric 
 juice contains too much hydrochloric acid in most cases of 
 gastric ulcer, therefore all kinds of extract of meat should be 
 avoided, because they would exaggerate the hyperacidity. 
 But if the physician knows there is no hyperacidity, or that 
 the gastric juice is deficient in the normal acid, it would be 
 proper to give some extract of meat (Bovril, Lemco, Oxo) in 
 the milk two or three times a day. These are ideal diets for 
 such cases. But it is not always possible to maintain the 
 standard at this high level. We must, however, do our best, 
 and never lose sight of the fact that when the patient is not 
 getting enough food to supply the energy used by the body, 
 the tissues are used as fuel to provide such energy. After 
 two or three weeks' treatment in this manner we must begin 
 to increase the quality, quantity, and solidity of the food. 
 The amount of milk should remain the same, but more 
 Benger's food may be given alternately with Mellin's food or 
 dextrinized cereal foods, such as Ridge's, Neave's, Savory and 
 Moore's. Junket is a very useful food at this stage. If 
 these disagree we can try peptonized milk gruel, boiled arrow- 
 root, or fine oatmeal, cooked for four or five hours. The 
 following recipes will be useful : 
 
 (a) Take ^ pint of milk, i egg, a dessertspoonful of Mellin's 
 food, a pinch of salt, and a tablespoonful of sugar. Boil the 
 milk ; beat up the egg, and pour the milk slowly over it, stir- 
 ring all the time ; return to the fire ; when nearly ready add 
 the salt, sugar, and the Mellin's food, dissolved in a very 
 little water, stir until it begins to thicken, and pour it into a 
 mould. It may be eaten warm or cold. 
 
 (b] Take a tablespoonful of Savory and Moore's best food 
 and cook it in the usual way with pint of milk. While hot 
 add ounce of gelatine, sweeten to taste, add a little flavour- 
 ing, pour it into a mould, and turn out when it is cool. 
 
 If these foods agree we can next try a spoonful or two of 
 scraped meat, pounded chicken or fish, and an equal amount
 
 ULCER OF THE STOMACH AND DUODENUM 97 
 
 of mashed potato. At the end of a month the patient should 
 be able to take a poached egg and stale bread and butter for 
 breakfast ; sole, plaice, or whiting for dinner ; and sponge or 
 Madeira cake for tea ; a cupful of tea is also permissible. A 
 gradual return to the ordinary diet should be made from this 
 time forth, and the progress should be rapid. 
 
 In cases considered to be severe by reason of great haemor- 
 rhage, persistent vomiting, or some other indication of a more 
 serious condition, it is advisable to stop all feeding by the 
 mouth for the space of a week. Nothing should be swal- 
 lowed. Rectal feeding should be resorted to. As rectal 
 feeding is adopted in other cases besides ulcer of the stomach, 
 a special article will be devoted to it. In these cases the 
 patient should be given a "feed" of 5 or 6 ounces every 
 four or six hours. We must not blind ourselves to the small 
 amount of nutriment obtained in this manner. Six feeds a 
 day, including a total of i^ pints of milk, 3 raw eggs, i ounce 
 of extract of malt or glucose, and a little brandy, would only 
 yield about 700 calories, or less than half the amount of 
 energy spent by the body when absolutely at rest. But even 
 this would not be all absorbed. Anybody who has treated 
 patients in this way must have observed the large proportion 
 of faeces which is returned. Moreover, the great deficiency 
 of the food is evident by the rapid wasting of the body dur- 
 ing such feeding. 
 
 Jn this period nothing should be swallowed. Some phy- 
 sicians allow their patients to take little bits of ice, iced 
 water, Vichy, and other alkaline waters. One eminent 
 physician says the patient may have a teaspoonful of water 
 every fifteen minutes, making a total of 1 5 ounces in twenty- 
 four hours, on the supposition that the amount is too small 
 to irritate the ulcer. But even this small amount is likely to 
 excite gastric secretion and peristaltic contractions. There- 
 fore the rule should be absolute : Nothing by the mouth. 
 Thirst will be very marked, of course ; indeed, the patient 
 may consider the treatment rather cruel. We must moderate 
 the thirst as well as we can. It will frequently be checked 
 by allowing the patient to wash out her mouth at intervals 
 with boracic lotion, or any simple mouth-wash. The daily 
 
 7
 
 98 DIET IN DYSPEPSIA 
 
 washing out of the bowels may be followed by the injection 
 of ^ to i pint of warm water, which can be retained ; in- 
 deed, many authorities consider reduction of thirst to be the 
 chief advantage derived from rectal feeding. Some water is 
 manufactured in the body by the oxidation of the tissues ; 
 under ordinary circumstances from 10 to 15 ounces are pro- 
 duced in this way, and it is considered when the body is 
 living on its own flesh a good deal more water is produced, 
 and, being retained, assists in the reduction of thirst. 
 
 How long should we refrain from mouth feeding? When 
 the stomach has had five or six 1 days of absolute rest, suffici- 
 ent time has been allowed for any ruptured vessel to get 
 sealed up. We may now try a test- meal of a few teaspoons- 
 ful of peptonized milk. If this small quantity causes pain, 
 we must desist from a further attempt at feeding for a few 
 days longer ; in some cases it is unsafe to allow anything by 
 the mouth for two weeks. But the patient will persistently 
 lose flesh by using her own tissues in place of food ; if the 
 condition was fairly good at the beginning of the treatment 
 this loss will soon be made up when a moderate diet is 
 taken. 
 
 If the test-meal did not cause pain or vomiting we can 
 give the same diet as in a mild case of ulcer, beginning 
 precisely in the same way, viz., by allowing 2 ounces of 
 peptonized milk every two hours, and gradually build up a 
 diet on the lines previously indicated. In this kind of case, 
 raw beef juice should be allowed early, say, on the third day 
 of mouth feeding. Raw eggs, a spoonful or two of jelly, 
 and Benger's food may be given by the end of the week. 
 Rectal feeding should now be reduced to two meals a day, 
 and kept up to the fifteenth day. In the third week the 
 meals by mouth should include two or three pints of milk 
 and two or three raw or poached eggs daily, Benger's food 
 twice a day, scraped meat, pounded chicken or fish, a spoon- 
 ful of mashed potato, some Madeira or sponge cake, stale 
 bread (without crust), and plenty of butter, apple-sauce, 
 sago or tapioca pudding, orange juice, and a few grapes free 
 from skin and seeds. 
 
 The foregoing treatment is the safest and surest way to a
 
 ULCER OF THE STOMACH AND DUODENUM 99 
 
 permanent cure, and it should be carried out whenever 
 possible, the patient being confined to bed the whole time. 
 But some physicians have of late years allowed a more 
 generous diet. The most important modification is that of 
 Lenhartz, who allows a large number of raw eggs, raw scraped 
 meat or ham. The following is an outline of his dietary : 
 
 First day. Seven ounces of milk and 2 raw eggs in tea- 
 spoonful doses. 
 
 Second day, Ten ounces of milk and 3 raw eggs. 
 
 Third day. Fifteen ounces of milk, 4 raw eggs, and a 
 tablespoonful of sugar. 
 
 Sixth day. The quantities of food are increased until on 
 the sixth day the patient consumes i pints of milk, 7 beaten 
 raw eggs, and two tablespoonsful of sugar. 
 
 Seventh day. Two ounces of scraped meat and 3-^ ounces 
 of rice milk are added. 
 
 Ninth day. The diet is if pints of milk, 8 raw eggs, i-J 
 ounces of sugar, 2 ounces of raw meat, 7 ounces of rice milk, 
 and 2 pieces of Zwiebach. 
 
 Eleventh to fourteenth days. Milk, if pints ; 8 raw eggs; 
 sugar, i ounces ; raw scraped meat, 2 ounces ; raw ham, 2 
 ounces ; rice milk, - pint ; Zwiebach, 3 pieces ; butter, 2 
 ounces. The total food now yields 3000 calories. Zwie- 
 bach is a kind of pulled bread. In the third week the 
 patient is put on ordinary mixed diet, but she is kept in bed 
 until the fifth week, when she is allowed up for an hour or 
 two each day. 
 
 Another generous diet is that of Hort, who uses a serum 
 in the treatment of ulcers, and says the proper method of 
 cure is to obtain the highest state of nutrition in the body 
 as quickly as possible. In cases which do not bleed he 
 prescribes the following food : 
 
 Breakfast. Toast, butter, and eggs; n A.M., 2 or 3 
 ounces of raw meat juice. 
 
 Lunch. Tender beef, mutton or lamb, lightly cooked 
 and served in the gravy; and one or two rusks. The 
 appetite is the only check on the amount consumed. 
 
 Tea and Dinner. The same food as for breakfast and 
 lunch.
 
 ioo DIET IN DYSPEPSIA 
 
 Bedtime. Two or 3 ounces of raw meat juice. In the 
 night one or two sandwiches of pounded chicken or game. 
 
 This diet is continued for one month ; the food is eaten 
 dry ; but the patient is allowed a tumblerful of hot water at 
 7 and n A.M. and 10 P.M. After returning to full diet, the 
 use of alcohol, tea, coffee, and starchy puddings are for- 
 bidden for six months. 
 
 In cases marked by haemorrhage, Hort prescribes the 
 following : 
 
 First day. Feed every three hours with 2 or 3 teaspoons- 
 ful of chicken jelly and half the yolk of a soft-boiled egg 
 alternately. 
 
 Second day. Give 3 or 4 teaspoonsful of pounded chicken 
 alternately with raw meat juice and the yolk of a soft-boiled 
 egg, every two or three hours, day and night. 
 
 Third day. The same diet in larger quantities. 
 
 Fourth day. The dietary for non-bleeding cases is begun. 
 
 But such diets as Lenhartz's and Hort's do not meet 
 with universal approval, nor have they the support of 
 scientific observation. Indeed, some observations by 
 Bolton tend to show that they are injurious. It was men- 
 tioned early in this account of ulcers of the stomach and 
 duodenum that an ulcer could be produced experimentally 
 by using a gastro-toxic serum obtained from an animal. 
 When such a serum is administered to cats, and they are 
 afterwards fed with meat, a slough forms and separates in four 
 days, leaving a clean ulcer behind it. But if the cats are 
 fed on milk a period of ten or eleven days elapses before 
 the separation of the slough and formation of an ulcer. 
 This is due to the influence of the food. Bolton found 
 that the food had precisely the same influence on the heal- 
 ing process ; in milk-fed cats the ulcer was completely 
 healed in twenty days ; in the meat-fed cats a large area in 
 the centre of the ulcer still remained unhealed. Meat en- 
 couraged the formation of an ulcer and delayed the heal- 
 ing process ; milk hindered the formation of an ulcer and 
 favoured the healing process ; whence he concluded meat 
 was injurious and milk beneficial in the treatment of ulcers. 
 
 The treatment of duodenal ulcers is the same as that of
 
 ULCER OF THE STOMACH AND DUODENUM 101 
 
 gastric ulcers, and no further mention of them would be 
 necessary except for the assertion of some surgeons that 
 whenever a duodenal ulcer occurs an operation is necessary. 
 This is not true. Post-mortem evidence has shown that 
 such ulcers are as likely as gastric ulcers to heal without an 
 operation. 
 
 Finally, there is the serum treatment of ulcers of the 
 stomach and duodenum. This fluid is prepared from the 
 serum of horses and given by the mouth three times a day 
 for three weeks. Hort claims for this treatment that it 
 heals the ulcers rapidly ; that under its influence there is a 
 speedy cessation of pain and vomiting ; that a higher level 
 of nutrition is reached than by any other treatment. He 
 believes this is assisted by the diet given by him, that the 
 meat absorbs the gastric juice and increases the power of 
 resistance to the unknown cause of the ulcers, while the 
 serum acts like a dressing to a superficial ulcer, and assists 
 in the local repair. We are in an age when many diseases 
 are being treated by serums and antitoxins, and by extracts 
 made from animal organs. The serum treatment of ulcers 
 bids fair to become important in the near future.
 
 CHAPTER XIII. 
 RECTAL FEEDING. 
 
 RECTAL feeding is an artificial method of giving food to a 
 patient. It is adopted in cases of acute gastric catarrh, 
 ulcer of the stomach and duodenum, in states of uncon- 
 sciousness, such as apoplexy, coma, and whenever it is 
 undesirable or impossible to give food by the mouth. 
 
 Each meal should consist of not more than five or six 
 fluid ounces. It may be given through a special apparatus, 
 but the less complicated it is the better. Any doctor or 
 chemist can make a simple apparatus that will answer quite 
 well. Take a large rubber catheter (No. 12), join it by 
 means of a bit of glass tube to 2^ or 3 feet of rubber tube 
 of the same calibre, and put a glass funnel into the opposite 
 end. The patient may lie on the back or side, or in the 
 knee-elbow position. The catheter must be carefully in- 
 sinuated into the bowel, the idea being to get it through the 
 rectum and into the sigmoid flexure of the colon if possible. 
 This is not always easy to do; the catheter may catch 
 against one of the folds of mucous membrane in the rectum, 
 called Houston's valves, and become doubled up. Having 
 got it into position, the funnel should be held 2 or 2^ feet 
 above the hips, the food poured in and allowed to get into 
 the colon by its own weight. It is often a slow business ; 
 but the nurse must be willing to spend a little time over it. 
 If the food were injected into the bowels it would probably 
 be returned almost immediately. By allowing it to find its 
 way in by gravity the bowel is not likely to be irritated by 
 its presence, and it will probably be retained. That is the 
 usual mode of intermittent rectal feeding. It is possible, 
 
 (loa)
 
 RECTAL FEEDING 103 
 
 however, to provide continuous rectal feeding, which requires 
 less attention and is less tiring to the nurse, by fixing the 
 funnel to a stand at the bedside, and applying a clip to the 
 rubber tube to regulate the flow. This can be so regulated 
 that five or six ounces would occupy about two hours in 
 getting into the bowel; and it is probable that the food 
 would be better retained and more nutriment be got out of 
 it than by intermittent feeding. 
 
 The rectal mucous membrane becomes very irritable from 
 the frequent passage of the catheter; indeed, it is very 
 tender from the first in some persons. To reduce this ir- 
 ritability it is advisable to add five drops of laudanum to 
 each alternate feed, and also a few grains of common salt 
 and bicarbonate of soda. It is also necessary to wash out 
 the rectum once a day with a boracic lotion or some other 
 mild antiseptic to soothe the irritation and check putrefaction. 
 Furthermore, it is usual to inject into the bowel about a 
 pint of water once or twice a day to reduce thirst. 
 
 It is not uncommon for mumps to occur during a course 
 of rectal feeding. The reason for this is not quite clear, 
 but it probably has nothing to do with the rectum at all. 
 The mouth normally contains a lot of bacteria, and when 
 the body is diseased the gums become very sore, and a 
 chronic suppurative process may occur (pyorrhoea alveolaris). 
 When mastication is going on, the number of bacteria in the 
 mouth is kept down by various things e.g. by mastication 
 and drinking. But when no food or drink is taken by the 
 mouth the bacteria flourish abundantly, infect the salivary 
 gland, setting up mumps (parotiditis), and sometimes end- 
 ing in suppuration. These symptoms may be prevented by 
 the frequent use of a mouth- wash. If swelling occurs the 
 treatment required will be that for ordinary mumps. 
 
 There are various recipes for rectal feeds. The basis of 
 most of them is either plain or peptonized milk ; but eggs, 
 beef-tea, meat extracts, peptones, glucose, malt extract, and 
 ordinary sugar are also used. The following are useful ex- 
 amples : 
 
 i. A raw egg well beaten, a cupful of warm milk (plain 
 or peptonized), and a saltspoonful of salt. The addition of
 
 104 DIET IN DYSPEPSIA 
 
 salt assists in the digestion and absorption of eggs, milk, 
 etc. 
 
 2. A pint of milk, three raw eggs, a tablespoonful of 
 extract of malt, and a tablespoonful of brandy. It will 
 make four feeds. The extract of malt should be put into 
 the warm milk and egg about ten minutes before the addi- 
 tion of the brandy. 
 
 3. One ounce of Carnrick's liquid peptonoids or Kem- 
 merich's peptones, the yolk of one egg, pint of milk, 5 
 drops of laudanum, half a saltspoonful of salt and bicarbon- 
 ate of soda. 
 
 4. A cupful of pancreatized milk, two egg-yolks, a 
 dessertspoonful of glucose syrup, and a little salt. 
 
 5. Cod-liver oil, 2 ounces ; one egg-yolk ; lime-water, 2 
 ounces. 
 
 6. Finely minced meat (beef, mutton, or fowl) 5 ounces, 
 a cupful of milk, and a tube of Fairchild's peptonizing 
 powder; after the material is peptonized, add 2 tablespoons- 
 ful of glucose syrup and the same amount of brandy. It 
 will make two or three feeds. 
 
 7. A pint of milk and the white of four eggs is pancrea- 
 tized by means of a tube of powder or some liquid pancreatic 
 extract ; it is then boiled to destroy the ferment and sterilize 
 it, and two or three tablespoonsful of glucose and some 
 salt added to it. It will make four feeds. 
 
 8. Beef-broth or beef-tea pint, two raw beaten eggs, a 
 wineglassful of white wine, and a saltspoonful of salt. 
 
 There is no doubt about the usefulness of this mode of 
 feeding. It will help to carry the patient through a bad 
 time, provided the time is short, say a week or ten days. 
 But we must not be deluded by it, however much we wish 
 to impress our patients with its value and importance. We 
 know very little about digestion in the colon. Until recently 
 it had been denied that digestion occurs in this part of the 
 bowel. But we know that the pancreatic enzymes reach 
 the colon, and trypsin, one of the most powerful digestive 
 enzymes, is to be found in the faeces. But the pancreatic 
 enzymes act best in an alkaline medium, whereas the con- 
 tents of the colon are slightly acid ; therefore there is not
 
 RECTAL FEEDING 105 
 
 much chance of rapid digestion going on there. On the 
 other hand, we cannot deny that any digestion occurs in 
 this part of the economy. Constipated persons not only 
 retain their food in the colon a very long time, but they 
 extract nutriment from it; indeed, very little more than 
 debris remains in their faeces. There is therefore some 
 hope that food introduced through the rectum will be partly 
 digested and absorbed. Nevertheless, it must be clearly 
 understood that food introduced through a catheter or rectal 
 tube does not get very far into the colon. If it can be got 
 beyond the sigmoid flexure (corresponding externally to the 
 level of the umbilicus or top of the left hip), some good may 
 be done and some digestion take place; but if the food 
 only gets into the rectum no digestion will occur. What, 
 then, is the good of it? Well, some of the liquid, and 
 especially peptonized, food will be absorbed. Not a lot, 
 perhaps ; certainly not more than a fourth part of the nutri- 
 ment required by a person absolutely at rest. Moreover, 
 there is a limit even to the capacity for absorbing liquids. 
 It will be observed that, in spite of the most careful rectal 
 feeding, the patient continues to waste away, and is in a 
 condition of semi-starvation. An examination of the urine 
 shows that more nitrogen is excreted than the patient ab- 
 sorbs ; the amount of carbonic acid from the lungs is greater 
 than can be accounted for by the oxidation of the food 
 both the nitrogen in the urine and carbonic acid from 
 the lungs are derived from the burning of muscle and fat 
 for fuel. Whence it has been said rectal feeding satisfies 
 the mind rather than the body. If we can satisfy the mind 
 we shall do something for the patient's comfort. If we can 
 prevent the sensation of hunger and thirst, we shall do a 
 good deal. Moreover, a gastric case will be free from pain 
 when no food is put into the stomach. But science has 
 proved that when raw milk and egg are given 21 per cent 
 is usually absorbed ; when peptonized milk and egg are 
 given, from 30 to 40 per cent is absorbed; when peptones 
 are given, 50 to 70 per cent will be absorbed. Very little 
 fat is absorbed ; the figures vary extremely and show an 
 absorption of 2 to 33 per cent, and probably not more
 
 io6 DIET IN DYSPEPSIA 
 
 than one ounce of cod-liver oil, liquefied butter or milk fat 
 would be absorbed in a day. On the other hand, various 
 kinds of sugar are taken up readily. When one or two 
 ounces of glucose were used daily in a 10 per cent solution, 
 from 75 to 90 per cent disappeared. It is not certain that 
 all the sugar which disappears from the lower bowel is ab- 
 sorbed ; some of it may be fermented. But until this fact 
 is proved, the free use of grape sugar (glucose) or malt 
 sugar (extract of malt) is strongly recommended as a part 
 of all rectal feeds.
 
 CHAPTER XIV. 
 INTESTINAL INDIGESTION. 
 
 MAL-DIGESTION in the bowels is very common. The food 
 may be prepared in the mouth and stomach too imperfectly 
 for its complete digestion in the bowels. All foods are 
 liable to undergo putrefaction in the bowels when the pre- 
 vious part of digestion has not been properly performed. 
 But protein foods (meat, fowl, fish, milk, etc.) are especially 
 liable to undergo putrefaction after they leave the stomach 
 unless they are promptly digested. A peculiar substance 
 called tryptophan is split off from the proteins, and from it 
 are formed indolactic acid and indican, which are absorbed 
 and give rise to indicanuria and symptoms of auto-intoxica- 
 tion. A delay in the completion of digestion in the bowels 
 may be due to some derangement of the other alimentary 
 organs, but especially the liver or pancreas. The patient is 
 usually treated for the consequences. In the first instance 
 these are the ordinary symptoms of indigestion, constipation, 
 or diarrhoea, headache, biliousness, giddiness, nervousness, 
 mental depression or melancholia, neuralgia, neurasthenia, 
 anaemia, chlorosis, etc. After a time, however, various organs 
 not directly connected with the stomach and bowels begin to 
 suffer. The heart and blood-vessels become affected, there 
 being weakness of the muscular portion of the circulatory 
 apparatus, causing a low-pressure pulse (hypotonus) com- 
 bined with symptoms of neurasthenia ; but later on there is 
 a gradual thickening of the fibrous and other tissues in the 
 peripheral arteries and capillaries, which causes the blood 
 pressure to be increased (hypertonus), and in consequence 
 the heart becomes hypertrophied, the vessels sclerosed, 
 
 (107)
 
 io8 DIET IN DYSPEPSIA 
 
 and the kidneys undergo those changes which are found in 
 Bright's disease. Careful observation has shown that these 
 changes are due to toxaemia (auto-intoxication), arising from 
 intestinal indigestion, especially of the proteins in the food. 
 Moreover, it has been shown that the toxaemia is least when 
 the patient is on a vegetarian diet, somewhat greater on a 
 milk diet, much greater on a meat diet, and greatest of all 
 when the diet consists of eggs. It is not to be supposed, 
 however, that indigestion or mal-digestion of fat and carbo- 
 hydrates does not occur. When the pancreas or liver is 
 diseased the digestion of fats is much delayed ; they become 
 split into fatty acids, which may or may not be of a normal 
 type, and a considerable portion of the unchanged fat passes 
 out in the faeces, and thus much valuable nutriment is lost 
 to the body. The digestion of carbohydrates in the intes- 
 tinal canal may be defective owing to a deficiency of the 
 pancreatic juice or succus entericus, and any delay in their 
 digestion gives an opportunity for intestinal bacteria to fer- 
 ment the sugars, cause the generation of gases, and trans- 
 form starches into irritating acids. 
 
 The fact that auto-intoxication (self-poisoning) does not 
 constantly occur in normal individuals is due to several 
 factors. Under ordinary conditions the number of bacteria 
 in the intestines is kept within moderate limits. The liver 
 when in a healthy state has the power of destroying or 
 modifying some of the poisons absorbed from the alimentary 
 canal and eliminating others. Some of the poisons pro- 
 duced are antagonistic to each other. Various poisons 
 arising from the decomposition of food in the bowels are 
 broken down into harmless substances. Cholin and 
 neurin are recognized as agents which produce serious con- 
 sequences in general paralysis and other nervous diseases. 
 They originate from degenerated nerve-cells. These poisons 
 are also produced in the alimentary canal in consequence 
 of the decomposition of proteins ; under normal conditions 
 neurin is transformed into cholin, and cholin is broken down 
 to ammonia, carbonic acid, and marsh-gas, which are com- 
 paratively innocuous. In abnormal conditions such poisons 
 may be absorbed into the blood and carried all over the body.
 
 INTESTINAL INDIGESTION 109 
 
 The products of intestinal indigestion, therefore, are (a) gases 
 and acids, (b) toxins. The first group give rise to flatulence, 
 irritability, and other signs of indigestion ; the second to toxae- 
 mia or the symptoms and consequences of auto- intoxication. 
 flatulence in the Bowels. This is one of the most pro- 
 minent symptoms of intestinal indigestion. The most 
 important cause of it is the fermentation of carbohydrates 
 with the formation of organic acids, and evolution of gases 
 such as carbonic acid, hydrogen, nitrogen, marsh-gas, and 
 sulphuretted hydrogen. Carbonic-acid gas is formed in 
 large quantities from all kinds of carbohydrate foods, such 
 as bread, sugar, puddings, etc. This gas is very diffusible ; 
 it passes readily through the coats of the alimentary canal 
 into the blood, and is exhaled by the lungs ; it is probable 
 that a considerable amount of carbonic-acid gas is got rid of 
 in this manner, but not all of it. It is a peculiar circum- 
 stance that a reverse current of carbonic-acid gas may occur ; 
 when the amount of this gas in the venous blood exceeds 
 that in the bowels e.g., during mental excitement a vio- 
 lent attack of " wind " may occur so rapidly that it is im- 
 possible for it to arise from the food. In such a case it is 
 believed the gas comes from the blood. Of the opposite 
 character are hydrogen and nitrogen gases ; these do not 
 really diffuse into the blood. On the .contrary, they are ab- 
 sorbed more slowly than any other gas generated from the 
 food, and accumulate in the bowels until they are discharged. 
 According to Ruge, who made numerous experiments, hy- 
 drogen and nitrogen are produced in greatest abundance 
 when the food consists wholly of milk. These facts explain 
 why some people have flatulence after milk more often than 
 after other foods. Marsh-gas arises in the bowels from the 
 mal-digestion of meat, beans, peas, lentils. It is more 
 rapidly absorbed into the blood than nitrogen or hydrogen, 
 but only one-third as rapidly as carbonic acid. The amount 
 produced from peas and beans is sometimes very great, 
 and it accumulates in the bowels and causes discomfort until 
 it is absorbed or expelled. Sulphuretted hydrogen is gener- 
 ated from various foods. The amount detected in the gases 
 of the alimentary canal is very small, but unfortunately it is
 
 no DIET IN DYSPEPSIA 
 
 absorbed more rapidly than any other gas and is very poison- 
 ous. Owing to the rapidity of absorption it is possible for 
 the amount produced in a definite time to be underestimated 
 in the analyses which have been recorded. The effects 
 observed after inhalation of this gas are headache, vertigo 
 (dizziness), nausea, and a sense of oppression in the chest 
 and abdomen, followed by death when the subject is long 
 exposed to it. It is probable that some of the symptoms 
 of intestinal indigestion are due to these gases, the relative 
 absorbability of which is as follows : nitrogen i, hydrogen 2, 
 oxygen 28, marsh-gas 39, carbonic-acid 'gas 100, and 
 sulphuretted hydrogen 300. 
 
 Treatment of Intestinal Flatulence. It is advisable that 
 patients who are much troubled by this symptom of intestinal 
 indigestion should avoid the foods which are most liable to 
 be decomposed in this manner. In particular, the amount 
 of carbohydrate foods should be reduced to a minimum until 
 the normal condition is recovered. There is, however, a 
 great difference in the effects of carbohydrates. The sugar 
 of milk is very prone to undergo decomposition, being trans- 
 formed into lactic acid, and the latter into butyric acid, 
 hydrogen, and carbonic-acid gas. Cane-sugar (ordinary 
 loaf or granulated sugar) gives rise to the same acids and 
 gases. But the carbohydrates which are usually eaten in 
 the greatest amount, and are the most troublesome in this 
 respect, are bread, potatoes, puddings, legumes, cauliflowers, 
 cabbage, etc. A large proportion of these substances, be- 
 fore they are completely digested, is carried far down into 
 the ileum, where the alkaline secretions and slower peristaltic 
 movement are favourable to the growth of bacteria and de- 
 composition of food. Rice, sago, tapioca, and arrowroot, on 
 the other hand, are more rapidly digested, and to a great 
 extent are absorbed in the upper reaches of the bowel, and 
 flatulence does not rise from them to the same degree. The 
 best treatment, therefore, is to stop all forms of carbohy- 
 drates for a few days, and during this period allow only 
 meat, fish, or fowl, with some light vegetable such as boiled 
 lettuce, spinach, or onion, a jelly, and some hot water to 
 drink, After a period of five to seven days we may add
 
 INTESTINAL INDIGESTION in 
 
 boiled rice, next a pudding of rice, sago, or tapioca, crisp 
 dry toast, or a rusk. Bread and potatoes should be avoided 
 for a few weeks ; and all stringy, fibrous, or flatulent veget- 
 ables, such as cabbage, turnips, or Jerusalem artichokes, 
 may have to be permanently left out of the diet. 
 
 INTESTINAL AUTO- INTOXICATION. It has been stated that 
 the products of indigestion in the bowels are (a) gases and 
 acids, (b) toxins. The former have been considered. It has 
 also been shown why auto-intoxication does not constantly 
 occur. We must now state the conditions in which auto- 
 intoxication does occur, the consequences of it, and what can 
 be done to prevent it. 
 
 The causes of auto-intoxication are many ; several of them 
 have already been dealt with. They are : (a) The corn- 
 sumption of too much protein food, or such foods in an 
 unsound condition ; (b} a defective action of the nervous 
 system, leading to a failure of the processes of digestion, 
 torpidity of the bowels, constipation, fermentation, and 
 putrefaction within the alimentary canal ; (c) dilatation of 
 the stomach and hypochlorhydria ; (d) duodenal atony and 
 catarrh ; (e) atony and catarrh of the small or large intes- 
 tines. Moreover, there may be a failure on the part of 
 those organs whose duty it is to destroy or eliminate from 
 the body the toxic products of digestion. When the bowels 
 act in an ordinary manner, they carry away from the body 
 a large amount of the toxic materials produced during 
 digestion, including leucomaines and ptomaines. Con- 
 stipation, which is one of the symptoms of intestinal 
 indigestion, therefore tends to the absorption of poisonous 
 materials and auto-intoxication. The liver normally destroys 
 any leucomaines, ptomaines, purins, and other poisonous 
 bodies which are absorbed ; but the amount absorbed may 
 be too great to be disposed of in this way ; or the functions 
 of the liver may be disturbed, and in either way auto-intoxi- 
 cation will arise. The kidneys usually excrete more than 
 two-thirds of the total amount of waste materials absorbed 
 from the alimentary canal or produced by the processes of 
 metabolism. These substances include urea, uric acid, 
 purins, indican, sometimes leucin and tyrosin, colouring
 
 ii2 DIET IN DYSPEPSIA 
 
 matters, and mineral substances. The skin eliminates 
 water, salts, a little urea, and those volatile and poisonous 
 bodies which give a characteristic odour to some persons. 
 The lungs excrete, besides water, carbonic-acid gas and 
 other gases, certain substances of the indol group, which, if 
 they are in abnormal amount in the blood, give an un- 
 pleasant odour to the breath. Thus we perceive that auto- 
 intoxication is due to excessive production of poisonous 
 substances in the alimentary canal and, when the organs of 
 excretion are disturbed, defective elimination of these sub- 
 stances. 
 
 The commonest symptoms of auto-intoxication are those 
 of intestinal indigestion previously mentioned viz., indi- 
 gestion, bilious attacks, headache, migraine, vertigo, 
 neuralgia, neurasthenia, general debility, and other symptoms 
 detailed in connexion with disturbance of the gastric and 
 intestinal functions in the preceding sections. 
 
 The consequences of auto-intoxication are numerous and 
 may be classified as follows : (i) Neurasthenia, polyneuritis, 
 migraine, insomnia, hypochondria, and many other nervous 
 complaints ; (2) disturbances of the nerves which govern the 
 circulation, especially causing palpitation and irregularity of 
 the heart, pains in the cardiac region (false angina and 
 other cardiac neuroses), cold hands and feet, etc. ; (3) 
 chronic bronchitis and asthma ; (4) gout, rheumatism, and 
 rheumatoid arthritis; (5) skin diseases, such as chronic 
 urticaria, erythema, acne rosacea, eczema, etc. 
 
 Many of these diseases are associated with a steady and 
 persistent auto-intoxication ; so long as the toxins are ab- 
 sorbed, the disease remains ; when the auto-intoxication is 
 stopped, the disease tends to get well. But probably no 
 part of the system is more affected by the absorption of 
 toxins than the heart and blood-vessels. The multitude of 
 alimentary poisons has been divided into two classes : (a) 
 those which have a relaxing effect on the vessels, and lower 
 the blood pressure (hypotonus) ; (b] those which constrict 
 the blood-vessels, and raise the blood pressure (hypertonus}. 
 The poisons, being absorbed into the blood, circulate 
 through the vessels to all parts of the body ; but they affect
 
 INTESTINAL INDIGESTION 113 
 
 the tissues of the blood-vessels just as they do other tissues. 
 Some of them relax these tissues and cause the low blood 
 pressure, indicated by a soft and compressible pulse ; others 
 by their constant presence irritate the coats of the vessels, 
 and such irritation leads to new cell-formation and thicken- 
 ing of the arteries or arteriosclerosis, indicated by a firm and 
 incompressible pulse, which becomes more or less like whip- 
 cord. Such poisons increase the blood pressure. When an 
 infusion made from decomposing meat is injected into the 
 blood, the tension of the vessels is speedily increased, as it 
 is by ergot, digitalis, and adrenalin, and remains so until 
 the toxins have been destroyed or eliminated from the sys- 
 tem. In fact, the most pernicious toxins which enter the 
 body arise from the decomposition of protein foods ; and 
 those arising from animal proteins are said to be more 
 poisonous than those of vegetable origin. A noted phy- 
 sician has said that every particle of protein consumed 
 above 70 grammes daily is reduced to leucin, tyrosin, indol, 
 skatol, phenol, cresol, muscarin, cadaverin, pepto-toxin, 
 neuridin, neurin, cholin, mydalein, and special toxins from 
 particular foods e.g., tyrotoxicon from cheese, gadin from 
 codfish, scombrin from mackerel, etc. There is no doubt 
 about the production of these poisons in the body ; but it 
 is very doubtful whether everybody at all times produces 
 such toxins whenever more than 70 grammes is consumed. 
 On the contrary, there are many people who can safely con- 
 sume twice that amount without suffering from toxaemia; 
 and it is equally certain that many people who consume less 
 than 70 grammes a day suffer from toxaemia and present 
 well-marked signs of auto-intoxication. 
 
 The treatment of auto-intoxication consists of preventing 
 the absorption of toxins from the bowels, and promoting 
 their elimination by the various organs of excretion. It is 
 necessary to determine in each case what conditions exist 
 likely to favour auto-intoxication. An inquiry into the 
 amount of protein consumed will settle the question of 
 excessive consumption. The gastric and intestinal functions 
 will next be examined ; dilatation of the stomach and 
 hypoclvurhydria will be sought for ; duodenal and intestinal 
 
 8
 
 ii 4 DIET IN DYSPEPSIA 
 
 catarrh ; deficiency of nerve power or control over the 
 digestive processes and movements ; and deficiency in the 
 elimination of waste products will be determined. Each 
 of these conditions requires the treatment appropriate to it. 
 
 The general treatment of auto-intoxication consists of 
 regulation of the diet to suit the condition. The food must 
 be as free as possible from injurious bacterial organisms. 
 It is, of course, impossible to eliminate bacteria from the 
 food. Milk teems with them ; a small piece of butter con- 
 tains millions ; a cubic inch of cheese contains an almost 
 innumerable quantity. Meat which has been killed a short 
 time and all other animal foods contain micro-organisms 
 which are not necessarily of a putrefactive character. 
 There are benign as well as malign bacteria. There is no 
 need to destroy the beneficent varieties ; indeed, the sour- 
 milk treatment consists of the introduction of such bacteria ; 
 but it is essential to exclude the others. Therefore the 
 food should be fresh. 
 
 The next point is, the amount of food consumed must 
 be moderate only. In the majority of cases it is necessary 
 to reduce the quantity. The alimentary organs are over- 
 taxed, and the digestion of food is delayed, thereby favour- 
 ing fermentation and putrefaction. We know that the body 
 can manage for a time with a reduction in the amount of 
 food consumed ; but it is better to reduce all kinds of food 
 rather than run the risk of excluding any kind of food which 
 is not injurious. The amount of protein should be about 
 80 grammes for a man and 65 to 70 for a woman, and the 
 food should provide a total amount of energy equal to 
 2000 or 2 200 calories, which will suffice, at any rate 
 during the treatment. 
 
 It is not necessary to exclude animal food altogether. 
 It has been said that animal proteins are more prone to de- 
 composition than vegetable proteins. But it should be re- 
 membered that both kinds of proteins are composed of 
 amino-acids, frequently of the same sort ; in fact, the animal 
 proteins of our food were formed out of vegetable pro- 
 teins ; and, in spite of the arguments of vegetarians, it has 
 never been shown that animal proteins behave in the body
 
 INTESTINAL INDIGESTION 115 
 
 differently from vegetable proteins. Animal proteins are 
 easily digested and more prone to decomposition. Veget- 
 able proteins are not so easily digested ; they are contained 
 in cells which resist the action of the digestive and bacterial 
 enzymes ; they are not so easily putrefied ; and for the 
 same reasons they are of less value to the body. 
 
 In the treatment of these cases we may allow fresh meat 
 or chicken at one meal a day, preferably the mid-day meal, 
 and not a very large helping. We should forbid pork, 
 veal, game, sweetbread, smelt, brain, hashed meat, entrees, 
 stews, meat pies, sausage, potted meat, and other prepara- 
 tions of meat, including soup, broth, rich gravy, and meat 
 extracts. Fish should not be allowed unless it is perfectly 
 fresh. Sole, plaice, whiting, and fresh haddock may usually 
 be permitted ; brook trout and other fresh-water fish may 
 be eaten by most people if they are cooked within a few 
 hours of being taken from the water. The patient may be 
 encouraged to get his own proteins by fishing and shooting. 
 Pheasant, wood pigeon, and grouse may be eaten quite 
 fresh, but not after being hung for several days. Eggs 
 should be avoided in bad cases of auto -intoxication, as many 
 people are made bilious thereby, and they are very poisonous 
 to some others. Ripe and old cheese must be forbidden. 
 Peas, beans, lentils, and nuts are the chief vegetable sources 
 of protein ; and may be taken by all patients who can 
 digest them. The legumes must be well cooked, or they 
 can be used in the form of pea-flour or lentil-flour to 
 thicken mutton broth or chicken broth. Nuts should be 
 ground in a mill ; they are less likely to cause pain and 
 discomfort when they form a chief portion of a meal than 
 when a few only are eaten at the end of a large repast. 
 The tendency to constipation may be avoided by a large 
 allowance of fruit. 
 
 What has already been said about intestinal flatulence 
 holds good now. Rice, sago, tapioca, and arrowroot give 
 rise to little fermentation ; bread, potatoes, sugar, and jam 
 readily ferment ; peas, beans, and vegetables are very flatu- 
 lent. As a general rule the patient may eat boiled rice 
 with the animal food, and fresh vegetables on alternate days,
 
 n6 
 
 DIET IN DYSPEPSIA 
 
 in place of bread and potato. Puddings of rice, sago, 
 tapioca, or arrowroot are usually allowable, but they should 
 not be made very sweet. Fruit and nuts may form part of 
 the diet unless there is diarrhoea or some other contra-in- 
 dication. A little red wine, such as Burgundy, in some 
 cases a little brandy or whisky, may be allowed, but one 
 must be careful to whom they are permitted. Tea, coffee, 
 and plain water should form the chief beverages. The 
 following diet list will indicate the quantity of foods which 
 may be taken so that the proper amount of protein and 
 energy is obtained : 
 
 PROTEIN, 10 GRAMMES IN EACH HELPING. 
 
 150 calories : Cooked beef, average i oz., without bone. 
 
 75 , Sirloin of beef, baked, i oz., without bone. 
 
 80 , Steak, broiled, i oz., without bone. 
 
 132 , Mutton, roast leg, ij oz., free from bone. 
 
 150 , Mutton, roast loin, fat removed, i oz., without bone. 
 
 60 , Fish, average 2 oz. 
 
 54 , Chicken, without bone, if oz. 
 
 205 , Milk, g pint. 
 
 95 , Egg, one large one. 
 
 loo , Egg, one large one, scrambled, buttered or omelette. 
 
 80 , Oysters, 10. 
 
 PROTEIN, 5 GRAMMES IN EACH HELPING. 
 
 136 calories : Bread, 2 oz. ; half a roll ; i oz. crackers or plain 
 
 biscuits. 
 
 150 , Macaroni or vermicelli, i oz. 
 150 , Oatmeal, i$ oz. 
 150 , Pearl barley, 2 oz. 
 
 180 , Potatoes, three moderate-sized ones, 10 oz. 
 160 , Potatoes, mashed and creamed, four tablespoonsful. 
 
 95 , Dried peas, beans, or lentils, two tablespoonsful, i oz. 
 100 , Boiled rice, sago, or tapioca pudding, 3$ oz. 
 
 70 , Cabbage, cauliflower, mashed turnip, 10 oz. 
 
 CONSTIPATION. 
 
 People who are afflicted by habitual constipation suffer 
 from headache, loss of appetite, foul breath, and many signs 
 of indigestion. The term " constipation " is a relative one. 
 One daily evacuation of the bowels may be regarded as
 
 INTESTINAL INDIGESTION 117 
 
 normal ; but some people only feel well when they have two 
 or three movements a day. Others feel well who are moved 
 every second or third day, and do not feel well if they are 
 moved oftener. The former usually have a healthy appetite 
 and take ordinary foods to satisfy it ; those who are moved 
 two or three times a day probably take somewhat more 
 food than they need, or the food itself is of such a character 
 that it leaves a large residue. Many constipated persons 
 have a poor appetite or the food consumed by them leaves 
 very little residue. Nevertheless, it is observed that persons 
 living on precisely the same kind of food, and eating about 
 the same quantity, differ from each other in regard to their 
 evacuations. This is probably due to the fact that in one 
 person the mucous membrane is more sensitive to the 
 presence of food, and in the other it is sluggish, having 
 little sensibility and not readily provoked to peristaltic 
 action. 
 
 The consequences of the retention of faeces are equally 
 varied. In one person there may be a general unfitness for 
 the duties and pleasures of life ; in another the presence of 
 faeces in the flexures of the colon produces considerable 
 discomfort and puts the patient in a disagreeable state 
 of mind ; another may develop " food fever ". The chronic 
 and durable effects of constipation are more serious ; chronic 
 intestinal catarrh, mucous and membranous colitis, and other 
 affections of the alimentary canal, are the local effects ; 
 all those diseases which have been mentioned as the results 
 of intestinal indigestion are numbered in the general con- 
 sequences of constipation. 
 
 The causes of constipation are many : Habitual neglect 
 of the daily call of Nature; atony of the muscles of the 
 bowels, particularly of the colon and rectum, common in 
 chlorotic girls, dyspeptics, and persons of sedentary 
 occupation; the character of the food milk diet, 
 meat diet, absence of those materials which stimulate 
 intestinal movement, such as vegetables and fruit, and a 
 deficiency of liquids ; painful affections in the neighbour- 
 hood of the rectum and anus, piles, fissure, chronic metritis, 
 salpingitis, painful affections of the ovaries, bladder, etc. ;
 
 n8 DIET IN DYSPEPSIA 
 
 pathological affections of the bowels : (r) spasmodic stricture, 
 arising from hypersensitiveness of the mucous membrane, 
 excoriations by rough and hard substances in the food, 
 ulcers ; (2) organic stricture due to malignant disease or the 
 healing of ulcers dysenteric, syphilitic, typhoid, or tuber- 
 culous; (3) compression of the bowel by abdominal 
 tumours, traction by such tumours forming a kink in the 
 tube ; (4) kinks caused by bands and adhesions ; (5) torsion 
 or twisting of the bowels, internal strangulation, intussuscep- 
 tion ; impaction of foreign bodies. The distinctly surgical 
 cases will be left out of this discussion, except in so far as 
 the condition may be influenced by the food or ordinary 
 methods of treatment. 
 
 Constipation is one of the consequences of human progress 
 and civilization. In a state of nature men eat their food 
 after very little preparation. But civilized people wish it to 
 be not only well cooked but carefully prepared, in order that 
 it may please the aesthetic sense, which is one of the marks 
 of our progress. Bread was originally made from grain 
 reduced to a coarse powder in a quern or primitive mill, 
 and very little, if any, of the bran was removed. To-day 
 we have it ground in a steel mill, and every particle of bran 
 is removed to make fine flour and produce a white loaf. 
 The influence of mankind on the development of his food 
 is shown in many of the products of the garden. Most 
 of our vegetables and fruits have been evolved from small 
 and comparatively unpalatable substances, containing a 
 considerable amount of indigestible fibre, which could not 
 fail to act as a stimulus to peristaltic action in the bowels. 
 The cabbage which weighs several pounds has been de- 
 veloped from a colewort weighing only a few ounces ; and 
 the cauliflower from a colewort flower only weighing a few 
 grains ; celery from an acrid and unpleasant plant growing 
 wild in our fields ; potatoes from a small and bitter root in 
 South America ; apples from the wild crab of our woods ; 
 and plums from the sour sloe. The great changes produced 
 in our food by art and cultivation, the absence of coarse 
 fibre, the reduction in the amount of organic or vegetable 
 acids and salts, are largely responsible for the predisposition 
 to atonic constipation in human beings living in civilized
 
 INTESTINAL INDIGESTION 119 
 
 society. In the treatment of constipation of the ordinary 
 type, therefore, we must get back to Nature. The patient 
 must consume all those articles of food which contain the 
 greatest amount of cellulose (fibre), vegetable acids, salts, 
 and other substances which stimulate the bowels to action. 
 He should eschew fine white bread and take in its place 
 wholemeal or brown bread. Oatmeal, especially coarse 
 meal, such as " Miller's pride," should constantly form part 
 of one meal a day, preferably breakfast. It may be taken 
 as porridge, Yorkshire parkin, oatmeal biscuits, or oatmeal 
 pudding. Pearl-barley pudding is also useful. Rye bread 
 or cakes and buckwheat cakes are equally useful. Dried 
 peas and beans leave a large residue, and should frequently 
 be consumed. Bread and cakes containing fruit (currants 
 or raisins), treacle, and ginger have a slightly aperient effect. 
 
 All vegetables may be consumed, especially those usually 
 considered fibrous and indigestible : cabbage, kale, savoy, 
 brussels sprouts, cauliflower, spinach, onions, leeks, carrots, 
 turnips, swedes, Jerusalem artichokes, skirret, sweet potatoes, 
 kidney beans, broad beans, green peas, etc. Also salads 
 containing lettuce, endive, dandelion, sorrel, radishes, green 
 onions, beetroot, tomato, mustard and cress, watercress, and 
 other green vegetables, will assist in the cure. Fruit may be 
 taken in abundance, raw and cooked, especially apples, 
 pears, plums, prunes, figs, dates, gooseberries, cranberries, 
 strawberries, raspberries, currants, grapes, oranges, bananas, 
 etc. Puddings made with a pastry crust, such as boiled apple 
 puddings, rhubarb puddings, or " dumplings " containing 
 any of the foregoing fruits may be taken. Jam, marmalade, 
 syrups, sugar, honey, are laxative. 
 
 It should not be imagined that the diet is to be absolutely 
 " vegetarian " ; that is unnecessary. The patient may have 
 a moderate amount of any meat, fish, or bird. Fat meat, 
 butter, and cream are useful. Boiled eggs are constipating 
 to many people ; those fried in fat, buttered eggs, and 
 omelettes are not usually constipating. 
 
 The patient is not compelled by this complaint to give up 
 any kind of food, unless it causes indigestion, biliousness, or 
 other unpleasant symptom. But it will be understood that
 
 no DIET IN DYSPEPSIA 
 
 if a sufficiency of the above-named foods is taken, the patient 
 will have no necessity for those which leave little residue. 
 If milk puddings, blancmange, and custard are eaten, some 
 fruit or vegetable must form a part of the meal. The same 
 remark applies to concentrated foods like potted meat, fish, 
 or fowl ; foie gras and caviare may be useful, if they do not 
 cause biliousness. Nuts are usually taboo ; but it is un- 
 necessary to exclude them when an abundance of fruit or 
 vegetables is consumed. Jellies are useless to such patients ; 
 but agar-agar (sold as Chinese or Japanese gelatine) is a 
 useful remedy for constipation, very little of it being digested. 
 
 The "grape cure" may be employed. This consists in 
 the consumption of several pounds of grapes daily, beginning 
 with about two pounds and increasing the quantity to six or 
 more pounds a day. The treatment can be carried out at 
 home ; but many people prefer to go to the Tyrol and other 
 Continental countries where there are proper establishments 
 for this treatment. 
 
 The patient must take plenty of fluids. Water may be 
 taken cold or hot to the extent of three or four pints a day, 
 unless there is some contra-indication. Special table waters 
 may be used, such as Bourne, Malvern, Perrier, Apollinaris, 
 Salutaris, Puralis; or the patient may go to Leamington, 
 Bath, Harrogate, etc., to " drink the waters ''. Fruit juices 
 will assist in the cure, e.g. grape-juice ( Vin de vie), " rough " 
 cider, rhubarb juice, and the juice of elderberries, currants, 
 plums or other fruit may be used to flavour water. With 
 regard to alcohol, the less the patient takes the better ; red 
 wines should be avoided ; a little white wine (Chablis, 
 Moselle, Sauterne) may be allowed. Ale and stout are not 
 constipating. The morning cup of coffee is laxative ; tea, 
 especially strong tea, is rather binding. 
 
 Stricture of the Bowels, causing constipation, whether of a 
 spasmodic (spastic constipation) or pathological character, 
 requires very different treatment. In these conditions we 
 have to avoid irritating the mucous membrane or leaving a 
 large residue of food. The diet must be soft, bland, and 
 somewhat concentrated. Animal foods should form a con- 
 siderable share of each repast. Scraped meat, raw meat,
 
 INTESTINAL INDIGESTION 121 
 
 meat juice, potted meat, tongue or chicken are useful. 
 Ordinary meat should be deprived of every particle of skin 
 and gristle. Fruits should be deprived of skin and seeds. 
 Green vegetables should only be given after they have been 
 reduced to a puree or consomme. Sago, rice, tapioca, and 
 arrowroot puddings are suitable. Jellies of all kinds are 
 good. Junket, custard, eggs, sour-milk, kefir, cream, cream 
 cheese, fine white bread, and potato (mashed and creamed) 
 will do no harm, perhaps ; but brown bread, oatmeal, turnips, 
 carrots, swedes, salad, and ordinary vegetables (except as a 
 puree) must be forbidden. 
 
 In certain cases an operation is necessary for the removal 
 of constipation. Colectomy is an operation for the removal 
 of a part of the colon for chronic constipation and malig- 
 nant or fibrous stricture of the bowel. Resection of part 
 of the small or large intestines may have to be done for 
 stricture, gangrene, strangulation, intussusception, or malig- 
 nant growth. Colotomy either through the loin or the 
 anterior wall of the abdomen may have to be performed to 
 make an artificial anus. After these operations the food 
 should be much reduced in bulk for about a week. It may 
 consist of milk, milk and barley-water with sugar, milk pud- 
 ding (rice, sago, etc.), custard, junket, jelly, a little fish, 
 scraped meat or a poached egg. The amount of milk should 
 not be large, not more than two pints a day. Nutrient 
 enemata may be given when the operation has been upon the 
 small intestines ; in such cases also thirst may be relieved by 
 enemata of warm water. When the operation has been on 
 the colon no enemata should be given. After colotomy the 
 diet must be of a similar character, but much milk cannot be 
 allowed because it tends to the formation of scybala ; oatmeal, 
 vegetables and fruit, on the other hand, may soon form a 
 liberal portion of the diet. 
 
 DIARRHOEA. 
 
 Like constipation, diarrhoea is a relative term. People 
 who are regularly moved once a day would consider several 
 movements to constitute diarrhoea. Other people are usu-
 
 122 DIET IN DYSPEPSIA 
 
 ally moved as many times a day and do not feel well when 
 they are not. Diarrhoea is a too frequent evacuation of the 
 bowels. It may be due to many causes, which can be clas- 
 sified as : (a) mechanical ; (b) digestive, toxic ; (c) patholog- 
 ical (i) bacterial, (2) nervous, lienteric, (3) catarrhal, (4) 
 other pathological causes. Acute diarrhoea is usually as- 
 sociated with some impurity of the food, water, or air. 
 
 Mechanical causes arise from an unusual constitution of 
 the food. The consumption of unripe fruit, coarse veget- 
 ables, or an extra amount of indigestible cellulose, for in- 
 stance in oatmeal, or irritation by mercury or some other 
 drug, are included in this group. 
 
 Digestive causes arise from the character of the food or 
 the digestive secretions. Indigestible foods rank amongst 
 the commonest causes of diarrhoea. Pork, veal, and similar 
 materials set up diarrhoea quite readily in some persons. 
 The freshest of eggs will cause others to have frequent move- 
 ments of the bowels, attended by the signs of an acute diar- 
 rhoea ; but a failure of the proper secretions of the digestive 
 organs also causes it. This may begin in the stomach. If 
 there is a deficiency of hydrochloric acid the food may be 
 propelled into the bowels in a half- prepared condition. 
 There may be a deficiency of bile, pancreatic secretion, or 
 succus entericus, and the resulting diarrhoea has been called 
 " intestinal fermentation dyspepsia ". The presence of an 
 undue proportion of organic acids, either in the food con- 
 sumed or originating from fermentation in the bowels, will 
 give rise to diarrhoea, and this condition has been called 
 " acid jejunal diarrhoea ". The toxic causes of diarrhoea are 
 those of poisoning, auto-intoxication, uraemia, and septic- 
 aemia. Diarrhoea due to this group of causes is sometimes 
 salutary, and may be considered " compensatory " in char- 
 acter, as in the crises of Bright's disease. 
 
 Bacteria are responsible for a very large proportion of 
 cases of diarrhoea. In ptomaine poisoning, which is fre- 
 quently accompanied by diarrhoea, the poisons are produced 
 by the action of bacteria. Animal foods, such as meat, 
 game, fish, eggs, and their numerous preparations, are prone 
 to undergo decomposition by the ordinary putrefactive or-
 
 INTESTINAL INDIGESTION 123 
 
 ganisms; but other bacteria have been found associated 
 with animal foods in the various epidemics of food poisoning, 
 notably B. botulinus, B. enteritidis of Gartner, B. enteritidis 
 sporogenes of Klein, and B. certryke of Durham. Milk, 
 cream, ice-cream, cheese, and other substances made from 
 milk and eggs may contain the foregoing bacteria, besides 
 numerous streptococci and staphylococci. 
 
 It has been thought that the excessive heat of summer 
 has much to do with the causation of diarrhoea. There is 
 no clear evidence that heat alone can cause it. When diar- 
 rhoea is due to atmospheric changes, such as a chill, the 
 attack is more often of the nature of acute intestinal catarrh, 
 like a cold in the head. Without the action of the intes- 
 tinal muscular walls diarrhoea could not occur. This action 
 may be excited by a chill. Moreover, the intestinal muscles 
 are under the influence of nerves which are exceedingly 
 sensitive and are excited by changes of temperature. But 
 it is probable that the heat of summer, which is favourable 
 to the production of bacteria, is more effective when com- 
 bined with drought, dust, and other means of spreading 
 bacteria among our food. Pathogenic organisms are dis- 
 tributed by air currents, dust, flies, etc. The epidemics of 
 summer diarrhoea, especially among infants, beginning in 
 the middle of July and extending throughout August, are 
 not essentially due to the heat. Such diarrhoea is usually 
 a bacterial disease. The faeces normally contain vast quan- 
 tities of bacteria, but usually these have very little power of 
 causing disease, or they are prevented from so doing by the 
 healthy condition of the mucous membrane. But if the 
 mucous membrane, irritated by improper food, becomes 
 congested or sheds patches of epithelium, the ordinary colon 
 bacillus is capable of causing diarrhoea ; it has been stated 
 that 25 per cent of cases of diarrhoea in breast-fed children 
 are caused in that way. Uncommon micro-organisms of 
 the group of colon bacilli have been found in many diar- 
 rhoeal motions, whence it has been concluded that such 
 bacteria can change their character with the circumstances 
 and surroundings. In addition to these, various streptococci, 
 staphylococci, the proteus bacillus, the bacillus of Shiga,
 
 i2 4 DIET IN DYSPEPSIA 
 
 and other micro-organisms gain entrance to the body by the 
 air, or more probably by pollution of the food. One of the 
 commonest causes of such pollution is the ordinary house- 
 fly, an insect which is most filthy in its habits, and, although 
 a scavenger, wanders from one article to another irre- 
 spectively and pollutes whatever it touches. 
 
 Water and other fluids may be markedly contaminated 
 by such micro-organisms. Liquids are the means of carry- 
 ing bacteria of many kinds into the system. Where the 
 gastric functions are perfect a large proportion of such bac- 
 teria are destroyed by the hydrochloric acid of the stomach, 
 but when the organism is depressed by excessive heat and 
 various other causes the hydrochloric acid becomes deficient 
 or the number of bacteria is disproportionate to its disin- 
 fecting power. It was formerly thought that cholera was 
 transmitted through the air, like infectious fevers, but the 
 investigation by Hart showed that "we eat or we drink 
 cholera," and the same is true of dysentery and enteric fever. 
 
 The influence of the nervous system over intestinal move- 
 ment and secretion has been referred to. Many cases of 
 diarrhoea are due to this, the exciting cause being mental 
 agitation, emotion, worry, anxiety, etc. To this group prob- 
 ably belongs the peculiar form called "lienteric diarrhoea". 
 The common symptom of this diarrhoea, to use a patient's 
 phrase, is that " the food goes through the bowel as soon 
 as it is eaten ". This, of course, is an exaggeration, but 
 there is some foundation for the popular description. The 
 consumption of food always starts a peristaltic movement 
 of the bowels which goes on at intervals until the meal is 
 digested. But in the condition of lientery these movements 
 are more powerful and prolonged, with the consequence 
 that an evacuation of the contents of the colon is provoked 
 in a short time. The exaggerated movement drives food 
 along the bowels quickly, so that a considerable portion of 
 it speedily arrives in the ileum in a semi-prepared form. 
 In course of time the irritation produced by such badly pre- 
 pared food may cause enteric catarrh, and the lienteric diar- 
 rhoea tends to become chronic diarrhoea of a catarrhal type. 
 
 The diarrhoea of intestinal catarrh is the result of intes-
 
 INTESTINAL INDIGESTION 125 
 
 tinal indigestion and fermentation in almost all chronic 
 cases. An acute catarrhal enteritis is often due to the same 
 causes as acute gastric catarrh and runs concurrently with 
 it. In chronic catarrhal enteritis diarrhoea frequently 
 alternates with constipation ; in other cases there may be 
 continuous diarrhoea. In addition to these causes of diar- 
 rhoea there are cholera, dysentery, sprue, tuberculosis, syphi- 
 lis, various ulcerations, and sometimes cancer. 
 
 The chief symptoms indicative of diarrhoea are frequent 
 stools and attacks of pain. The stools may be of an 
 ordinary character, but loose or sloppy ; they may be acid 
 and fermented, containing some undigested food, foul 
 smelling, green, or mixed with visible mucus. The attacks 
 of pain vary in severity and are sometimes so intense that 
 the skin is bathed in perspiration, while the patient rolls in 
 agony ; there is no abdominal tenderness ; indeed, the pain 
 is usually relieved by pressure or friction. If these attacks 
 of tormina affect the colon they produce a speedy and copious 
 evacuation ; if they affect the ileum or jejunum, vomiting 
 very commonly occurs. Diarrhoea, cholera, and dysentery 
 are most common in the summer and autumn, being pro- 
 moted by heat or alternately hot and wet weather, checked 
 by heavy rain and cold. They most frequently affect those 
 persons whose health is broken down by disease, debility, 
 insufficient food, or improper modes of feeding. In infantile 
 diarrhoea several important symptoms occur : collapse, loss of 
 elasticity of the skin, and rise of temperature. The collapse 
 is due to the pain, absence of food, depressing conditions, 
 and, above all, to the absorption of toxins from the ali- 
 mentary canal. The loss of elasticity of the skin is not 
 fully explained, but is due to a combination of the same 
 causes ; it is a very grave sign. The stage of collapse is 
 indicated by coldness of the surface, rapid and feeble pulse, 
 pinched features, dark rings round the eyes, blue finger 
 nails, sighing respiration, etc. If the patient passes through 
 this stage it will be succeeded by a rise of temperature and 
 a more or less febrile aspect. These cases resemble Asiatic 
 cholera in the occurrence of a cold stage followed by a hot 
 stage ; but it is seldom that they present the rice-water stools
 
 126 DIET IN DYSPEPSIA 
 
 characteristic of cholera, or the free discharge of blood so 
 clearly indicative of dysentery. 
 
 In ptomaine poisoning there may be sickness, purging, 
 cramp of the extremities, pains and spasms in the abdomen 
 due to tormina, with the signs of collapse already described ; 
 in other cases the collapse may be replaced by extreme 
 muscular weakness, numbness of the limbs, and a feeble 
 action of the heart, followed by muscular twitchings like 
 those of strychnine poisoning or uraemia, and sometimes 
 epileptiform convulsions, terminating in coma. The epi- 
 demics of food poisoning occasionally reported all have 
 their origin in the production of ptomaines before the food 
 was consumed. They have been connected with meat, 
 sausages, potted meat, meat pies, ice-cream, mouldy bread, 
 bread puddings, tinned foods, old cheese, oysters, mussels, 
 whelks, crabs, lobsters, etc. 
 
 THE TREATMENT OF DIARRHCEA. A discovery of the 
 cause often gives a clear indication of the method which 
 should be adopted in the treatment. When it is known 
 that the ailment arises from the consumption of some article 
 of food, the sooner the irritating cause is removed the better 
 it will be for the patient and the more rapidly the disease 
 will abate. Sometimes the only treatment required for an 
 attack of diarrhoea is a dose of castor oil, tincture of rhubarb, 
 or other homely remedy to clear out the offending material. 
 The patient may raise an objection to such treatment on 
 the ground that she has already suffered from more than 
 enough pain and purging. It may be sufficient to assure 
 the patient of the correctness of this treatment when we say 
 that, unless this method be adopted, some remnants of 
 the irritating substance will probably remain in 'her interior 
 and cause trouble for days or a week ; whereas the administra- 
 tion of a proper aperient will bring speedy relief. A 
 " proper " aperient for such a case is one which has a two- 
 fold action a primary aperient effect, and a secondary 
 astringent effect, such as rhubarb, castor oil, and a few 
 other drugs. The same remedies are sometimes ad- 
 ministered to infants and young children ; but it has become 
 the custom during late years to wash out the alimentary
 
 INTESTINAL INDIGESTION 127 
 
 canal of infants daily, during an attack of diarrhoea, with 
 warm boracic lotion ; thus removing decomposing foods and 
 bacteria, and at the same time soothing the irritable mucous 
 membrane. 
 
 If the patient is prostrated by pain and purging, she 
 should be put to bed, and have some warm applications 
 applied to the abdomen and feet. A dose of brandy or 
 sloe gin, one ounce in some hot water, may now be given ; 
 a single dose will often stop diarrhoea. There is no doubt 
 about the efficacy of these remedies. Gin contains several 
 aromatic carminatives, and brandy various ethers, besides 
 the alcohol, which check abdominal pain, moderate the 
 irregular and violent movements of the bowels, prevent 
 cramp, and incidentally improve the general condition by 
 removing lowness and depression. 
 
 The kind of food and its administration has to be care- 
 fully considered. In many cases it is advisable to withhold 
 all food for a day or two. It is better to give the stomach 
 and bowels a rest, so that the acute inflammatory or 
 catarrhal condition may subside ; this will take place speedily, 
 providing the irritation is not kept up by the presence of 
 food. There are, however, very few people who have the 
 moral courage to go without food, if they can take it and 
 keep i't down. Moreover, there are some foods which are 
 obviously useful in checking the diarrhoea. These are 
 preparations of starch such as arrowroot or cornflour (corn- 
 starch) and albumen, of which the best and handiest 
 example is the white of eggs. A cupful of milk, thickened 
 with arrowroot or cornflour, flavoured with nutmeg or cin- 
 namon, a little sugar, and the white of a raw egg stirred into 
 it when it is about to be eaten, makes an admirable food 
 for most cases of diarrhoea. 
 
 In more severe cases it would obviously be impossible 
 for the patient to consume so much as a cupful of milk 
 and arrowroot at one time. We must treat such patients in 
 much the same way as that described for acute gastritis. 
 Begin by giving only a few spoonfuls of milk and barley- 
 water, milk and lime-water, milk and arrowroot, isinglass 
 jelly,' white of egg and lemon- water, ordinary whey, alum
 
 128 DIET IN DYSPEPSIA 
 
 whey, tamarind whey, albulactin or glaxo dissolved in water 
 or whey, etc. Barley-water being added to the milk prevents 
 the formation of curds and assists in allaying the irritation. 
 Lime-water has a similar effect ; moreover, it checks 
 muscular action in a manner similar to chalk mixtures, it 
 neutralizes the organic acids which irritate the mucous 
 membrane, and produces an insoluble soap which it is hoped 
 may form a thin pellicle over the mucous membrane and 
 protect it from irritation. Citrate of soda prevents the 
 formation of curds in milk. Albulactin and glaxo are 
 protein foods which do not form curds. Alum whey is 
 astringent, and therefore tends to bind the bowels while 
 affording the patient nutriment. It should, of course, be 
 understood that the smaller the amount of food taken the 
 more often it must be taken. A teaspoonful of milk every 
 five minutes would only amount to 36 ounces in twenty- 
 four hours. But under such treatment the vomiting will 
 cease, and as the symptoms abate a larger amount of the 
 same kinds of food may be given. But we must pro- 
 ceed cautiously. If an acute catarrhal or inflammatory 
 condition of the bowels exists, as frequently happens in 
 diarrhoea, we must avoid giving much carbohydrate food 
 for a time, owing to the tendency of such materials 
 to undergo fermentation. When carbohydrates are given 
 in such cases they should be peptonized or semi-digested 
 e.g., Benger's food. It is, perhaps, better to keep such 
 patients entirely on protein foods for a time, and milk is by 
 far the best ; the formation of curd being prevented as be- 
 fore by adding citrate of soda, lime-water, or barley-water. 
 Junket may be given freely because the milk is already 
 coagulated, and it is improbable that such milk will form 
 hard curds in the stomach. Custard may also be given if 
 eggs do not disagree with the patient, and later on poached 
 egg and toast. Jellies are useful. By and by we may allow 
 some light broth made of veal, mutton, or chicken, but we 
 must prohibit the use of beef-tea, meat extracts, and the 
 proprietary essences of meat for some time, because they 
 irritate the bowels and often cause diarrhoea. 
 
 If the diarrhoea has been due to the consumption of
 
 INTESTINAL INDIGESTION ^9 
 
 animal foods which were unfit for use, tinned meat, fish, 
 pastes, meat-pies, etc., as in ptomaine poisoning, the best 
 diet is a combination of milk and carbohydrates. The milk 
 may have some rice boiled in it (rice-milk), or it may be 
 thickened with arrowroot, cornflour, Benger's, Savory and 
 Moore's, Neave's, or other farinaceous foods. The white of 
 one egg can be given two or three times a day mixed in such 
 foods, and the addition of nutmeg or cinnamon powder 
 will not only give flavour, but carminative properties to the 
 diet. Sometimes milk really disagrees with such patients. 
 It may then be replaced partly by Sanatogen or Plasmon, 
 Albulactin or Glaxo, and some rice or sago may be cooked 
 in water until it is a jelly and eaten with cream. Such pa- 
 tients may also be allowed some of the least irritating meat 
 preparations, as chicken or mutton broth, thickened with 
 baked flour or arrowroot, Plasmon beef jelly, Brand's essence 
 of beef, and Mosquera's beef jelly. 
 
 When the diarrhoea is passing off the return to ordinary 
 diet should be gradual. A little clear soup or broth with a 
 slice of toast may form an early meal ; this may be followed 
 by some jelly, custard, rice pudding, or blancmange. On 
 the following day sole, plaice, and a mashed potato may be 
 taken ; and the next day some boiled mutton or fowl. But 
 the patient must beware of hurry ; the old rule of festina 
 lente should not be broken. For some time the appetite 
 should be restrained, especially for uncooked fruit and 
 vegetables, brown bread, pastry, pickles, and other articles 
 which are likely to irritate the tender mucous membrane. 
 An unsuitable diet might transform a simple diarrhoea into 
 a chronic enteric catarrh. 
 
 The above is an outline of the treatment of diarrhoea in 
 general. It is not necessary to say much about special 
 forms of the disease. When diarrhoea affects the residents 
 of hot countries they should retire to bed and have only a 
 milk diet, for a diarrhoea which appears to be simple may 
 be of a specific character. If it is of the nature of cholera 
 the treatment required is that for diarrhoea of bacterial origin. 
 The vomiting may be checked by ice, ice-water, effervescing 
 draughts, champagne, or brandy and soda. At first the diet 
 
 9
 
 130 DIET IN DYSPEPSIA 
 
 should consist of whey (alum whey, tamarind whey), butter- 
 milk, kephir, cocoanut milk. If these things are not at 
 hand ordinary milk and citrate of soda or lime-water may 
 be given. White of egg and lemon-water will assist in 
 checking the sickness and at the same time introduce some 
 food. The use of beef-tea and meat extracts is forbidden, 
 but the stimulating effects of creatin (one of the substances 
 in extract of meat) may be advantageous when the patient 
 is collapsed ; in such cases some Brand's essence, Valen- 
 tine's meat juice, or Bovinine may be given. The con- 
 dition of collapse may also be met by brandy and other 
 stimulants, drugs, and saline injections into the armpits or 
 other subcutaneous tissues. Various other aids to recovery 
 may be employed, such as a mustard plaster over the heart 
 or epigastrium, a warm application to the abdomen, and 
 the entire body may be wrapped in blankets. As soon as 
 the sickness is overcome the diet should be the same as 
 for ordinary diarrhoea, especially diluted milk, junket, arrow- 
 root, barley water, and the white of eggs. 
 
 In the acute stage of dysentery the treatment should be 
 similar to that for diarrhoea. If there is much vomiting all 
 foods should be avoided, except white of egg and lemon- 
 water, barley-water, buttermilk or whey. When vomiting 
 is overcome or absent, the food may consist of milk, junket, 
 custard, thin arrowroot, Benger's food, blancmange, jelly, 
 isinglass and milk, raw eggs, decoction of iceland moss, 
 and other foods having a soothing or non-irritant character. 
 All soups, broths, and meat extracts should be prohibited. 
 Stimulants are usually required in the early stages of the 
 disease, and brandy is probably the best form; later on 
 some red wine, especially whortleberry wine, may be 
 beneficial. Asylum dysentery requires similar treat- 
 ment. 
 
 If diarrhoea occurs during the course of some other disease, 
 such as peritonitis, it is better not to give any food by the 
 mouth for about twenty-four hours. If, however, it seems 
 desirable to give anything at all it should consist of ice and a 
 quarter of a teaspoonful of Valentine's meat juice, or half a 
 spoonful of Brand's essence or Beef Plasmon, in alternation
 
 INTESTINAL INDIGESTION 131 
 
 with albumin -water. When the vomiting ceases, or is absent, 
 we may give in addition a few spoonfuls of junket, custard, 
 jelly, or even milk and citrate of soda every few minutes, 
 and as improvement occurs build up the dietary in the same 
 way as for other forms of diarrhoea.
 
 CHAPTER XV. 
 INTESTINAL CATARRH. 
 
 INTESTINAL catarrh may be acute or chronic and effect a 
 small or large portion of the small intestines or the colon. 
 Acute intestinal catarrh is almost always attended by 
 diarrhoea, is due to the same causes, and requires the same 
 treatment. 
 
 Chronic catarrh of the bowels is a serious disease, all the 
 more so because it is seldom recognized and treated before 
 considerable time has elapsed and the consequences have 
 become very marked. 
 
 Catarrh of the small intestines is probably far more com- 
 mon than it is usually supposed to be. It is a cause and a 
 consequence of intestinal dyspepsia and auto-intoxication. 
 It results from long-continued irritation of the mucous 
 membrane by improper food, from defects of the nervous 
 system causing a disturbance of the digestive processes, from 
 continued irritation by the products of fermentation and 
 putrefaction, from the direct action of bacteria on the 
 mucous membrane, from portal stasis or abdominal plethora 
 resulting either from intestinal causes, hepatic congestion, 
 or diseases of the heart. There are, therefore, a large 
 number of causes of catarrh of the small bowels. Two 
 types of cases may be given as illustrating the disease. 
 
 (a) Young people, chiefly young women who are afflicted 
 by constipation and intestinal dyspepsia. They suffer from 
 cold hands and feet with occasional burning of the same, 
 gastric indigestion from slight causes, and nervous symptoms. 
 The evidences of catarrh are indistinct. There may be ex- 
 cessive secretion of succus entericus and peristaltic move- 
 ments, causing loud gurgling and rumbling in the abdomen
 
 INTESTINAL CATARRH 133 
 
 owing to the mixture of gases and fluids ; nevertheless, the 
 patient may be constipated because time is given for the 
 absorption of fluids in the lower bowel ; in fact, constipation 
 is the rule. In a few cases the movements of the bowels 
 are accelerated to such an extent as to cause diarrhoea, in 
 which event the fasces may contain undigested food (lienteric 
 diarrhoea) or mucus, and sometimes blood. The presence 
 of an excess of mucus in the bowels hinders absorption of 
 the food, and the patient becomes pale, thin, and debilitated 
 owing to intestinal insufficiency. The flatulence and disturb- 
 ance of nutrition may be great, the nervous symptoms 
 meanwhile increasing until the patient becomes distinctly 
 neurotic and unfit for active physical or mental work. 
 
 (ft) The second type is that which occurs in middle-aged 
 or elderly persons. It is usually the result of abdominal 
 plethora and failure of the liver (hepatic insufficiency). It 
 occurs in men as well as women, but especially in the latter. 
 They have got to the age when the preservation of a good 
 figure is of no moment. They find it convenient to loosen 
 their corsets ; moreover, it is necessary for them to do so 
 on account of increasing rotundity. They usually have a 
 florid complexion and some excess of fat. They suffer from 
 palpitation and shortness of breath on exertion and frequent 
 attacks of indigestion. Owing to intestinal indigestion their 
 liver is flooded with toxins absorbed from the bowels, and it 
 is unable to deal with all the products of imperfect digestion 
 or bacterial decomposition. Consequently the liver be- 
 comes congested, enlarged somewhat, and dams up the 
 blood in the portal veins and the branches from the stomach 
 and bowels. These veins lose their elasticity and gradually 
 become dilated ; like varicose veins in the leg, they are 
 always overfull. These overfull veins in turn cause con- 
 gestion of the veins and capillaries (passive hyperaemia) of 
 the intestinal mucous membrane. The consequence is blood 
 stasis, which acts prejudicially to the mucous membrane in 
 various ways : (a) The intestinal walls do not get sufficient 
 oxygen ; (b) in consequence of this the muscles of the intes- 
 tines, and especially of the villi (those numerous tiny little 
 pumps), become weakened; (c) failure of muscular power in
 
 134 DIET IN DYSPEPSIA 
 
 the intestines means a delay in absorption of the digested 
 food ; (d) moreover, the intestinal stasis favours bacterial de- 
 composition and toxaemia. As the congested liver is unable 
 to destroy all the toxins brought to it, some of these poisons 
 escape into the general circulation. They find their way 
 into the pulmonary circulation and set up recurrent bron- 
 chitis. In time the heart becomes badly nourished, its 
 muscles feeble, its ventricles dilated, and cardiac weakness 
 with a low-tension pulse is added to congestive bronchitis, 
 toxaemia, and increasing bodily debility. 
 
 In these cases of catarrh of the small intestines there may 
 be : (a) no diarrhoea, a soft pultaceous motion being discharged 
 daily ; (V) constipation may alternate with diarrhcea in which 
 the stools are soft and contain mucus ; or (c) there may be 
 continuous diarrhoea, the faeces often being acid, the con- 
 tents of the small intestines being hurried along to the 
 rectum and discharged with a rapid movement. 
 
 TREATMENT OF CATARRH OF THE SMALL INTESTINES. 
 The diet of people who suffer from intestinal catarrh is of 
 the greatest importance. Everything likely to irritate the 
 mucous membrane should be avoided. All food must be 
 completely masticated, and nothing should be swallowed 
 that is not exceedingly fine and smooth. It is necessary 
 when the case is a very bad one to reduce everything to a 
 pulp before allowing it to be consumed. An average case, 
 however, would be sufficiently protected from irritation by 
 careful selection, preparation, and mastication of the food. 
 The rule of Sir Lauder Brunton for these cases is, " The 
 patient must avoid skins and bones, strings and stones". 
 If this rule is impressed on the memory it will serve as a 
 guide to what the patient may not have and for the prepar- 
 ation of the foods he may have. 
 
 What the Patient is to Avoid. Every particle of skin, 
 gristle, and perceptible fibre should be removed from all 
 kinds of meat, fowl and fish. Scales must be carefully re- 
 moved from sardines and other fish. The bones of all ani- 
 mals must be religiously avoided. This is not an easy 
 matter with regard to sardines, pilchards, whitebait, sole, and 
 many other fishes. The skins of vegetables and fruit, the
 
 INTESTINAL CATARRH 135 
 
 seeds of all kinds of fruit, fibrous vegetables, etc., must all be 
 avoided. An exhibition of the various articles recovered from 
 the faeces will show the necessity for carefulness on the part 
 of everybody, more especially those who suffer from catarrh 
 of the alimentary canal. Among those which have been seen 
 by the writer are pieces of bone and wood varying from to 
 i inches in length, and from the thickness of a pin to that 
 of the finger ; the larger pieces were swallowed in stews, 
 entrees, soups, etc. ; gristle and undigested skin from meat, 
 etc. ; scales from fish ; skins of fruit e.g., plums and grapes, 
 currants ; seeds of apples, pears, oranges, currants, goose- 
 berries, strawberries ; stones from cherries, damsons, etc. ; 
 peas, beans, either skins or undigested legumes ; undigested 
 oatmeal, bran, nuts, raisins, currants, salted or dried meat; 
 last, but not least, tin-tacks, buttons, teeth, etc. 
 
 What the Patient may have. Bread two or three days 
 old, bread and butter, plain biscuits, crackers, rusks, sponge 
 cake, madeira cake. 
 
 Soups. Clear or thick, but they must be strained through 
 a sieve. Exception : When diarrhrea is a marked feature of 
 the case all soups and meat extracts should be avoided. 
 " French soup " is particularly good for most cases ; this can 
 be made without meat. It is practically a consomme of all 
 kinds of vegetables and herbs, rubbed through a sieve, and 
 finally boiled up with milk and a raw egg or two added. 
 Ordinary clear soup with macaroni or vermicelli is suitable 
 when there is no diarrhoea. 
 
 Flesh. Any kind of meat which has been reduced to a 
 pulp and rubbed through a sieve ; scraped raw meat, potted 
 meat, chicken panada or souffle; eggs raw, poached, 
 scambled or buttered, " egg-snow " and custard ; a fillet of sole 
 or plaice, half a whiting, or a small amount of fresh haddock. 
 Meat powders, such as Meatox and Mosquera's beef-meal, 
 are suitable when other forms of meat disagree. 
 
 Vegetables. Any vegetable which has been cooked and 
 reduced to a puree or rubbed through a sieve. In addition 
 to these, the patient may have potato, mashed and creamed ; 
 vegetable marrow, boiled lettuce, spinach, and beet-chard. 
 No raw vegetables.
 
 136 DIET IN DYSPEPSIA 
 
 Puddings. Custard, junket, blancmange, jelly of all 
 kinds, and puddings made from farinaceous materials such 
 as Neave's, Savory and Moore's or Mellin's food. Milk 
 is admissible as a beverage, or in puddings and jellies ; 
 milk powders are also useful. Rice, sago, and tapioca pud- 
 dings are exceedingly suitable, but great care must be taken 
 that every grain of the substance is perfectly soft. Such 
 puddings should be cooked for at least four hours ; by this 
 means not only will the softening of the cereals be assured, 
 but some of the starch will become dextrinized. 
 
 Fruit. Raw fruit is usually forbidden, but if the rule of 
 Brunton be observed several kinds can be allowed ; thus a 
 few grapes, a ripe banana, and one or two plums may be 
 taken if the skins and seeds are removed. Strawberries, rasp- 
 berries, currants, and other fruits can be rubbed through a 
 sieve, and the pulp eaten with sugar and cream. Cooked 
 apples and plums may be taken, also stewed rhubarb. 
 
 Drink may consist of milk, whey, buttermilk, China tea, 
 cocoa, coffee, Ovaltine, Hygiama food, Cafe Zylak, etc. 
 
 The following recipes may be found useful : 
 
 Vegetable Soup. Boil a carrot, onion, leek, and half a 
 turnip in three pints of water until they are tender ; strain 
 the liquor through a wire sieve and rub the vegetables 
 through ; season with salt and pepper. Make a custard of 
 the yolks of two eggs and half a pint of milk. Boil up the 
 soup and pour it on the custard while stirring ; finally stir 
 into it the egg-whites, and it is ready to serve. Any vege- 
 tables can be used in place of the above, and a small 
 piece of mace, a bay-leaf, a sprig of thyme, or a clove of 
 garlic, a few sorrel leaves, tarragon, or chervil can be used 
 for flavouring. 
 
 Carrot Soup. Slice three carrots and boil them in two 
 pints of veal stock until they are tender. Remove the 
 carrots, rub them through a wire sieve, return them to the 
 soup, boil, season, strain again through the sieve, and add 
 some cream just before serving it. Artichoke soup and 
 turnip soup can be made in the same way ; chicken stock 
 can be used instead of veal stock. 
 
 Chicken Soup. Boil a fowl with vegetables until it is
 
 INTESTINAL CATARRH 137 
 
 tender. Take out the bird, remove the meat, put the bones 
 back into the soup and continue to boil it with the vege- 
 tables and some seasoning. Meanwhile pound the flesh 
 with some boiled rice in a mortar ; rub it through a sieve. 
 Pour the soup over it, through the sieve ; stir well ; finally 
 add two or three ounces of cream and it is ready. 
 
 Chestnut Soup. Take a pound of chestnuts, slit the 
 skins with a knife, and drop them into boiling fat for two 
 or three minutes ; and, while hot, remove the outer and 
 inner skins. Put the nuts in a pan with three pints of 
 boiling veal or fowl broth and boil them until they are 
 tender. Take out the chestnuts, pound them in a mortar, 
 or put them through a fine- mincing machine, add a pinch 
 of nutmeg, return them to the soup, boil for one hour, 
 strain through a sieve, and add a cupful of cream. The 
 soup should not be boiled after adding the cream. 
 
 Barky or Rice Soup is made by boiling pearl barley or 
 rice in veal or fowl broth until it is quite soft ; the grain is 
 then pounded in a mortar, rubbed through a sieve, mixed 
 into the soup, seasoned, and enriched with cream and 
 custard as in vegetable soup. 
 
 Chicken Panada. Take the flesh from half a boiled 
 fowl and reduce it to a pulp in a mortar. Add half as much 
 crumbs of bread, the white of two eggs, two tablespoonsful 
 of cream, pepper and salt. Put this mixture into a buttered 
 dish and steam it three-quarters of an hour. Meanwhile 
 make a sauce of the yolks of two eggs and some stock from 
 the boiled chicken. Turn out the panada and pour the 
 sauce over it. 
 
 When making chicken souffle pounded chicken and bread- 
 crumbs are seasoned with pepper, salt, and a little nutmeg. 
 Finally the white of two eggs is beaten to a stiff froth and 
 mixed thoroughly into the mass. It is then put into a 
 well-buttered dish and baked in an oven fifteen minutes. 
 
 Bavarian Cream. Make a custard of two eggs and three 
 egg-yolks, three ounces of powdered sugar, and half a pint 
 of milk. Beat up the eggs and yolks with a whisk ; while 
 still beating let the milk be gradually added at a boiling 
 temperature. Put the mixture into a saucepan over a slow
 
 1 3 8 DIET IN DYSPEPSIA 
 
 fire and continue to stir until the custard is thick enough to 
 coat the spoon. Pour it into a basin until it is quite cold. 
 
 Now take half a pint of cream, flavour it with fruit juice 
 and some sugar, and beat it thoroughly with a whisk ; im- 
 mediately afterwards stir into it half a cupful of milk, and 
 next one ounce of melted gelatine or isinglass. Finally, pour 
 the custard into the cream, thoroughly mix it with the whisk, 
 and pour it into a mould to set. 
 
 Blancmange Sponge. Take two ounces of cornflour, 
 one pint of milk, two eggs, two ounces of sugar, and a 
 teaspoonful of pure butter. Mix the cornflour to a smooth 
 cream with a little milk ; beat up the yolk of the eggs with 
 the sugar, and stir into the cornflour. Boil the rest of the 
 milk in a large saucepan ; remove it from the fire, and 
 gradually pour into it the cornflour mixture while stirring ; 
 add the butter and a little salt. Boil for ten minutes, 
 stirring all the time. Beat up the egg-whites to a stiff froth 
 and stir lightly and evenly through the mixture; pour it 
 into a mould to cool. It may be eaten with any kind of 
 sauce made from fruit juice. 
 
 Fruit-Juice Sauce. Raspberries, currants, cherries, plums, 
 crab-apples, gooseberries, blackberries, bilberries, whortle- 
 berries, rhubarb, and other fresh fruits may be eaten when 
 prepared in this way by sufferers from intestinal catarrh. 
 Take a pound of fresh fruit and half a pound of sugar ; 
 stew them until the fruit is tender ; rub through a sieve ; 
 when cold serve round blancmange, sponge, and other 
 moulds. 
 
 Fruit Jellies can be made of cornflour and fruit juice. 
 Take one and a half pints of fruit juice and two and a 
 quarter ounces of cornflour. Mix the flour into a smooth 
 cream with a little juice. Boil the rest of the juice, and 
 while boiling pour it slowly into the cornflour, stirring vigor- 
 ously. Put the mixture into the saucepan, bring to the boil, 
 continue to boil for three minutes ; pour it into a mould to 
 cool ; serve with cream. The fruit juice must be carefully 
 prepared. Practically any sort can be used e.g., cherries, 
 currants and raspberries, strawberries and rhubarb, damsons, 
 plums, and apricots ; apples or pears may have a few cran-
 
 INTESTINAL CATARRH 139 
 
 berries mixed with them to give flavour. As a general rule 
 a pound of fruit, if not fully ripe, requires half a pound of 
 sugar ; when quite ripe perhaps not more than a quarter of a 
 pound of sugar. Wash the fruit, put it into a saucepan with 
 the sugar, and only enough water to cover them. Stew until 
 the fruit is quite soft. Strain through a flannel cloth or fine 
 sieve, pouring over the fruit enough water to make a pint and 
 a half. It is now ready for use. Isinglass or gelatine might 
 be used to form the jelly, but cornflour or arrowroot is more 
 nutritious. 
 
 SPRUE OR PSILOSIS. 
 
 Sprue is a disease belonging to this group which should 
 have special mention. It is a chronic and insidious catarrh 
 affecting the whole of the alimentary canal. It occurs chiefly 
 in adults who have resided in tropical countries. Its origin is 
 unknown, but it is believed to be due to bacteria. It is a 
 troublesome and serious affection, often lasting for years, pro- 
 ducing emaciation and great weakness by the persistent 
 diarrhoea which is its chief feature. For this disease it is 
 sometimes recommended that milk alone should form the 
 diet ; it must be taken in a quantity sufficient to support the 
 nutrition of the body that is to say, not less than four pints 
 and usually five pints daily. There are, however, diversities 
 in the treatment. One authority recommends the addition 
 of strawberries and another medlars to the diet. Manson, 
 who is one of the greatest living authorities on tropical 
 diseases, says milk diet is the best to begin with, but it should 
 not slavishly be adhered to. Thin recommends the con- 
 sumption of two or three pounds of fresh ripe strawberries a 
 day ; Mercier says the consumption of three-quarters of a 
 pound of soft, not over-ripe medlars a day will cure the 
 disease. The patient should be kept in bed until these fruits 
 can be added to the diet. As the stools become normal we 
 may gradually add raw eggs, rice milk, jelly, chicken panada, 
 raw scraped meat, and gradually build up a dietary such as 
 would be given in other cases of intestinal catarrh. Cantlie 
 recommends that the treatment should be begun by a meat 
 diet ; he prescribes raw meat juice, plain jelly, and scraped
 
 1 40 DIET IN DYSPEPSIA 
 
 meat sandwiches, to be given in small quantities every fifteen 
 minutes. As the weakness subsides he makes the intervals 
 of feeding longer and the amount of food greater, until at the 
 end of a week the patient has four or five ounces of beef 
 minced in a machine three times a day. At this time he 
 allows some of the meat to be lightly cooked over a fire. 
 Between the meals he orders jelly, and some rice boiled and 
 steamed until it is dry. After two weeks he allows a slice of 
 tender meat from any joint, underdone roast beef being the 
 best ; but beef or mutton, boiled chicken, and light fish are 
 all allowed. " Pulled bread " is allowed after two or three 
 weeks. Boiled celery, boiled lettuce, vegetable marrow, 
 seakale, and spinach are now allowed. Strawberries may be 
 taken between the meals. Some red wine, old port, Hun- 
 garian, whortleberry or barberry wine are recommended ; and 
 toddy made from the fermented juice of the cocoanut palm ; 
 the latter is said to be a specific for chronic diarrhoea, dysen- 
 tery, and intestinal catarrh. 
 
 CATARRH OF THE COLON. 
 
 The catarrh may be more or less confined to the colon, or 
 attention may be drawn to the colon because the evidences 
 are more pronounced than in catarrh of the duodenum, 
 jejunum, or ileum. These cases, again, may be divided into 
 two groups (a) Those in which there is a definite local 
 lesion: (i) Ulcerative colitis, (2) tubercular and syphilitic 
 ulcers, (3) malignant disease ; (b) Those in which no definite 
 pathological cause can be found : (i) Mucous colic, (2) 
 mucous colitis, and (3) mucomembranous colitis. 
 
 If the affection be due to stricture of the bowels from 
 syphilitic or malignant disease, there will be constipation in 
 the first instance ; this is succeeded by diarrhoea and other 
 symptoms of the causative disease. In tubercular ulceration 
 there is nearly always diarrhoea from the first. Belonging to 
 this group is the morning diarrhoea which affects various 
 people. It is usually found that the trouble is due to the 
 presence of an ulcer in the colon, probably in the sigmoid 
 flexure.
 
 INTESTINAL CATARRH 141 
 
 Ulcerativc colitis is a different matter. It is common in 
 asylums, where it is known as asylum dysentery, and it also 
 occurs among people outside such institutions. The first 
 symptom is abdominal pain, followed by diarrhoea ; the act 
 of defaecation is attended by pain, but there is not such a 
 frequent desire to defecate as in dysentery. The motions 
 are foul, liquid, and dark coloured. They contain blood; 
 but this is not always fresh, it is partly combined with the 
 faeces, partly in clots looking like red-currant jelly. In ad- 
 dition, the faeces may contain pellets of mucus and shreds 
 of mucous membrane. The patient becomes seriously ill, 
 weak, exhausted, and the temperature may rise to 100 or 
 103 F. The condition is a dangerous one, and about 50 
 per cent of cases in asylums die in a month or two after the 
 onset of the disease from severe diarrhoea or profuse haemor- 
 rhage. 
 
 Mucous colic, mucous colitis, or membranous colitis is always 
 attended by obstinate constipation. The faeces are accom- 
 panied by mucus ; this may be clear pellucid mucus, like 
 raw white of egg, in pellets or masses sufficient to cover the 
 faeces ; the mucus may be in flakes like pieces of boiled 
 white of egg ; or it may consist of a membranous cast of the 
 bowels, which is evacuated entire or broken into shreds. 
 
 The causes of this condition are unknown or unsettled. 
 In the majority of cases no pathological change of the coats 
 of the bowels can be found, in other cases there is some 
 thickening of the structures due to chronic hyperaemia. 
 The only symptom referable to the bowels is the obstinate 
 constipation, although there may be pain or aching along 
 the course of the colon and tenderness on pressure ; and in 
 " mucous colic" violent attacks of pain, due to spasm in the 
 colon, precede the discharge of a large amount of mucus. 
 The prolonged constipation, often lasting for years before 
 the occurrence of mucous or membranous colitis, is said to 
 be the cause of an excessive formation of mucus. We can 
 easily understand that the retention of faeces is a source of 
 irritation to the mucous glands in the coats of the bowels. 
 These crypts, lined with mucous cells, ordinarily provide 
 sufficient mucus to lubricate the passage and keep it moist
 
 i 4 2 DIET IN DYSPEPSIA 
 
 no more ! The secretion is a glairy, transparent, viscid 
 fluid, such as may be seen covering scybala and hard mo- 
 tions in an ordinary case of constipation. Constipation 
 causes, first, an excess of ordinary healthy mucus ; secondly, 
 it provokes some change in the mucous cells so that the 
 secretion is altered in character from a glairy, transparent 
 fluid to something like a paste, which forms a mucinoid 
 coating to the bowels. But however changed the discharge 
 may be, it is always mucus or mucinoid in character, and 
 never contains fibrin such as would occur from inflamma- 
 tory exudations. This paste-like substance may be protec- 
 tive in character, but it does not lubricate the bowels or 
 assist in defsecation. The nervous system is always seriously 
 disturbed in this disease, owing to the toxaemia arising from 
 the constipation and intestinal indigestion; so much are 
 the nerves deteriorated that some authorities consider the 
 pathological condition a secretion neurosis. Moreover, 
 the longer the disease lasts the more neurotic becomes 
 the sufferer. 
 
 The patients are always chronic dyspeptics, usually eating 
 little, suffering pain after food ; they are thin, pale, anaemic. 
 Their mental condition is that of the pessimist ; they view 
 everything from the worst side, become gloomy, despondent, 
 and melancholic. They are not always passing " skins " or 
 large quantities of mucus. When their motions are prac- 
 tically free from this material their health is improving ; 
 when their health is worse, the despondency more marked, 
 the feebleness pronounced, and the general condition is de- 
 teriorating, they are about to pass " skins," or large quan- 
 tities of mucus ; and when they have got rid of them their 
 health is again improved. 
 
 Mucous and membranous colitis are sometimes due to the 
 lodgment of a foreign body in the colon. Thus a patient 
 who had suffered from dyspepsia for more than a year, who 
 ate little and suffered from constipation and mucous colitis, 
 was soon cured after the removal of extraneous substances. 
 She was given a diet of bland and unirritating food, such as 
 for intestinal catarrh in general. The constipation was 
 treated daily by large enemata of warm water transformed
 
 INTESTINAL CATARRH 143 
 
 into an imitation of Plombieres water by the addition of 
 alkalies. This treatment brought about an improvement in 
 the general condition. One day she spontaneously passed 
 some jet beads, the size of a pea, which had been swallowed 
 more than a year previously ; some more beads were passed 
 a few days later ; and from this time forwards the recovery 
 progressed rapidly, and within a short time the patient was 
 apparently completely cured. 
 
 The food required by patients suffering from catarrh of 
 the large intestine, mucous or membranous colitis, etc., 
 should be that already given in detail for the treatment of 
 catarrh of the small intestines. There is no necessity to 
 repeat the directions. It is the dietary which must be given 
 at the beginning of the treatment of every case of disease 
 of the colon until we have got a thorough insight into the 
 patient's symptoms and condition. That diet will not cure 
 every case of catarrh of the colon. But there are many 
 cases where any other kind of diet will irritate the mucous 
 membrane and aggravate the disease. 
 
 A. The diet for chronic intestinal catarrh should be given 
 continuously when the symptoms of colon disease are com- 
 plicated by the following conditions : 
 
 (a) In all cases attended by diarrhoea ; (b) in all cases of 
 constipation due to inflammatory or ulcerative processes ; 
 (c) in organic diseases cancer, tubercle, syphilis, etc. ; (d) 
 spasmodic affections of the colon due to a hypersensitive 
 condition of the mucous membrane; (<?) diseases of the 
 pelvic organs bladder, uterus, fallopian tubes, ovaries, or 
 painful affections of the rectum and anus. 
 
 B. Cases in which the diet should be different from that 
 for intestinal catarrh : 
 
 (a) When diseases of the pelvic organs are absent ; (b) 
 when inflammatory and ulcerative conditions are absent; 
 (c) when the catarrh is chiefly confined to the appendix and 
 colon; (d) when the condition is distinctly neurotic e.g., 
 myxoneurosis or secretion neurosis. 
 
 The theory of the neurotic origin of mucous and mem- 
 branous colitis which is largely accepted is founded on the 
 fact that the disease affects neurotic persons, and an attack
 
 144 DIET IN DYSPEPSIA 
 
 of mucous colic can be brought on in persons subject to it 
 by severe mental emotion, worry, or anxiety. In inflam- 
 matory diseases of the colon the discharge of mucus is 
 not so profuse as in mucous colitis, and differs in character 
 from that of the membranous form. The symptoms of the 
 disease occur in a vicious circle ; intestinal dyspepsia is prob- 
 ably the first act, the absorption of toxins from the bowels 
 causes the second act, or debility of the nervous system, 
 whence arises atony of the bowels and constipation ; as the 
 result of constipation there is a greater absorption of albu- 
 moses and toxins from the bowels, which still further poisons 
 the nervous system, and the neurasthenia is believed to give 
 rise to the perverted secretion of mucus. The theory of 
 local irritation of the mucous glands by the absorption of 
 toxins, and their effects on the cells in the mucous crypts, 
 producing first a profuse but normal mucus, and later on 
 the change in the character of the discharge which results 
 in the formation of "skins," membranes, or flakes of mucus, 
 is also held by many authorities. The disease is seldom 
 fatal, but it drags through a long period with intermissions. 
 The affection is curable, but very many patients go on for 
 years before the disorder is recognized or properly treated ; 
 the prospect of complete recovery is thereby diminished. 
 About 50 per cent of cases are cured. Men do better than 
 women. If this disease is neglected the patients go from 
 bad to worse, get thinner, paler, more anaemic, and feebler ; 
 they ultimately lie in bed a good deal of their time, being 
 too ill to move. When they are somewhat better they move 
 from place to place in search of health and comfort. Truly 
 their condition is miserable. Few diseases have a wider 
 ramification and produce more serious ill-health than mem- 
 branous colitis. 
 
 These are the cases which are improved by a dietary of 
 a very different character from that of chronic intestinal 
 catarrh. They require a bulky diet, one which contains a 
 good deal of fibre (cellulose), which probably acts upon 
 the mucous membrane by stimulating it, provoking muscular 
 action, and by tending towards a daily action of the bowels, 
 removing the poisons which irritate the mucous glands or
 
 INTESTINAL CATARRH 145 
 
 poison the nerves which control them. The first difficulty 
 which faces us is the small appetite of the patient. It is 
 useless to expect these people to take a dinner like a navvy's 
 or like a healthy woman. Cabbage, savoy, cauliflower, tur- 
 nips, swedes, carrots, and other fibrous vegetables are ex- 
 ceedingly useful in this complaint. But the patient cannot 
 take a sufficient bulk of food to be able to nourish her body 
 with these innutritious foods ; besides she has no taste for 
 them and does not appreciate them. They will take fruit 
 and fill their small stomachs with it to the exclusion of 
 everything else. Fruits are useful, but insufficient as a sole 
 diet. They will also eat nuts, and these are a valuable 
 source of protein if the patients can digest them ; at any rate, 
 they should be allowed to try them. But it is absolutely 
 necessary that the body should get a sufficient supply of 
 proteins as well as carbohydrates and fat. The following 
 is the dietary I am in the habit of prescribing ; it has proved 
 very successful in my hands. It consists of two pints of 
 milk, two or three eggs, half a pound of brown bread, two 
 ounces of butter, and as much vegetables, fruit, and nuts as 
 the patient can eat. With regard to fruit and nuts, some 
 kinds go together better than others. The following com- 
 binations appear to me to be the most useful : Apples, 
 walnuts, and figs ; pears, hazel nuts, and dates ; grapes, 
 Brazil nuts, and figs ; bananas, hazel nuts, and figs ; black- 
 berries, roasted peanuts, and pears; strawberries, walnuts, 
 and dates ; currants or gooseberries, bananas, and Brazil 
 nuts. Dried peas and beans may be taken at the same 
 meal as cabbage, cauliflower, spinach, seakale, boiled lettuce, 
 skirret, or turnips and carrots. Meat will not do the patients 
 any harm, but as a rule they take nuts and fruit better. 
 The kernels of nuts have about the same protein value as 
 meat. They can be ground in a mill and made into an 
 omelette with the eggs. A glassful of milk, two ounces of 
 shelled nuts and plenty of fruit will make a meal large 
 enough for most young ladies. But the food must be varied 
 day by day. Moreover, it is necessary to see these patients 
 eat their food. It is wonderful what tricks neurotics play 
 their nurses and how they dispose of their food without 
 
 10
 
 146 DIET IN DYSPEPSIA 
 
 consuming it. An extended trial of this dietary should be 
 made ; it must be carried out carefully and religiously ; half 
 measures are worse than useless, for instead of improving 
 the tone of the body and correcting constipation, they would 
 lead to an aggravation of the neurotic condition. 
 
 The colon must be evacuated every day, for very little 
 improvement of the general condition will be made until the 
 constipation is improved. As a general rule aperient med- 
 icines and pills are useless. But a large dose of castor oil, 
 one ounce or even an ounce and a half, every morning for 
 months together will sometimes do a vast amount of good 
 by removing the irritating cause viz., the faeces. If this 
 is objected to, the next best thing is lavage of the colon by 
 a large enema every morning. Many patients are sent to 
 Plombieres, where this treatment is carried out with the 
 natural mineral water of the place. Water made in imi- 
 tation of it can be used at home. Boracic lotion and other 
 mild antiseptics may also be used. Hot baths, compresses 
 over the abdomen, massage of the whole body and of the 
 abdomen in particular will materially help in the cure. 
 Various forms of electrical treatment are also useful. 
 
 Occupation of the mind and body is essential. The 
 patients should be encouraged to find something congenial 
 to do. They are always worse when they do nothing. Out- 
 of-door exercise is good for them ; if they have strength to 
 play tennis, Badminton, croquet, bowls, or golf they should 
 occupy themselves daily in one or other of these games. If 
 they cannot do so, they must be encouraged to walk as far 
 as their strength will allow. It is useless, however, to push 
 these exercises too far ; patients soon tire of anything which 
 exhausts them ; and if they feel worse after any game, it 
 may be a week or two before they will try it again. Change 
 of place and scenery is good for them ; but they must go to 
 a bracing place, such as the Malvern Hills, the mountains 
 of Wales or Switzerland. 
 
 When other means fail of curing these diseases of the 
 colon, various operative measures may be resorted to. I 
 have seen cases improved by the formation of an artificial 
 channel through the appendix. This allows of daily irriga-
 
 INTESTINAL CATARRH 147 
 
 tion of the entire colon with water or lotion. Finally, there 
 is the operation for removing the colon, which has proved 
 very successful of recent years. 
 
 The foregoing dietary is of great value in persons who 
 suffer from tenderness in the region of the appendix but 
 who have never had appendicitis, or from whom the removal 
 of the appendix is unnecessary. The value of the appendix 
 to human beings is unknown. It is an organ of great im- 
 portance in many of the lower animals. The future may 
 disclose some function of importance to mankind which 
 the appendix performs. At present we can only liken it to 
 an oil-can which pours, drop by drop, a lubricating fluid 
 into the intestinal canal and smooths the passage of the 
 contents of the bowel. This function may be disturbed 
 in various ways. Catarrh of the caecum may extend to the 
 appendix ; swelling of the mucous membrane may obstruct 
 the passage of the secretion from the appendix ; micro- 
 organisms, always present in the intestine, may at any mo- 
 ment, and in the presence of irritating secretions, transform 
 a mild catarrh of the appendix into an acute inflammation, 
 which may terminate in suppuration, perforation, or morti- 
 fication of the appendix. 
 
 While an attack of appendicitis is in progress absolute 
 rest is necessary, the patient will require no food except 
 milk and barley-water in equal parts, and some ice to suck. 
 The question of removal of the appendix will have to be 
 considered. But it is not advisable to operate during an 
 attack of acute inflammation ; nor is an operation necessary 
 for all cases of appendicitis. The cases which require an 
 operation are those where suppuration has occurred, where 
 there is a suspicion of peritonitis caused by it, and when 
 the patient has had several attacks of appendicitis. In 
 many cases, under the influence of a simple diet, complete 
 rest, and the application of poultices or compresses to the 
 abdomen, the pain and swelling will gradually subside and 
 disappear in fourteen to twenty-one days. 
 
 The subsequent treatment of the appendix is the same 
 as for catarrh of the bowels. If intestinal fermentation and 
 putrefaction be prevented, and a free daily evacuation of
 
 i 4 8 DIET IN DYSPEPSIA 
 
 the bowel ensured by dietary suited to intestinal dyspepsia 
 and constipation, it is probable that further attacks of 
 appendicitis will be prevented. When the bowel is healthy 
 the free use of vegetables and fruit, even those which con- 
 tain seeds, is one of the best means of preventing a recurrence 
 of the disease. When intestinal catarrh is in evidence the 
 seeds and skins of fruit must be removed, according to the 
 rule of Brunton ; but an abundance of cooked apples, 
 rhubarb, plums, peaches, prunes (and other fruits after 
 removal of the seeds) may be taken. By preventing 
 intestinal stasis, and especially a collection of faeces in the 
 caecum and ascending colon, the initial symptom of appendi- 
 citis will be warded off, and any tendency to inflammation 
 of the appendix may be removed.
 
 INDEX. 
 
 ACID dyspepsia, 67. 
 Acute gastritis, 46. 
 Albumin water, 33. 
 Alimentary toxaemia, 107. 
 Alum whey, 43. 
 Appendicitis, 147. 
 Atony and dilatation, 77. 
 Autointoxication, HI. 
 
 BATTER pudding, 52. 
 Blancmange, 52. 
 
 sponge, 138. 
 Barley soup, 137. 
 Bavarian cream, 137. 
 
 CANCER of oesophagus, 86. 
 
 pylorus, 89. 
 
 stomach, 89. 
 
 Carrot soup, 136. 
 Catarrh of appendix, 147. 
 
 colon, 140. 
 
 intestines, 132. 
 
 stomach, acute, 46. 
 
 chronic, 140. 
 
 Chestnut soup, 137. 
 Chicken cream, 51. 
 
 soup, 136. 
 
 panada, 137. 
 
 souffle, 137. 
 Children, diarrhoea, 127. 
 
 gastro-intestinal catarrh, 
 Colitis, 140. 
 Constipation, 116. 
 
 DIARRHOEA, 121. 
 
 tropical, 129. 
 Digestion, i-io. 
 Dilatation of stomach, 77. 
 Dyspepsia, 11-15. 
 
 pain, 16-25. 
 
 Dyspepsia, vomiting, 25-32. 
 
 relief of, 32. 
 Dysentery, 130. 
 
 FEEDING by bowels, 101. 
 Flatulence, 20. 
 
 intestinal, 109. 
 
 French vegetable soup, 75, 136. 
 Fruit jelly, 138. 
 Fruit sauce, 138. 
 
 GASTRITIS, acute, 46. 
 
 chronic, 56. 
 
 Gastro-intestinal catarrh in chil- 
 dren, 53. 
 
 FLEMATEMESIS, 40. 
 
 Hyperchlorydria, 67. 
 Hypochlorydria, 71. 
 
 ICELAND and Irish moss jelly, 48. 
 Indigestion, gastric, 11-15. 
 
 intestinal, 107-131. 
 Intestinal catarrh, 132. 
 
 indigestion, 107. 
 
 flatulence, 109. 
 
 JELLY, fruit, 138. 
 
 moss, 48. 
 
 Mellins' 51. 
 53. Junket, 50. 
 
 LEUBE'S diet, 64. 
 
 solution of meat, 64. 
 
 MEAT solution, 64. 
 Migrain, 38. 
 Mucous colitis, 141. 
 
 ORGANIC acidity, 72. 
 (149)
 
 INDEX 
 
 PAIN, relief of, 21. 
 Potatoes, mashed, 52. 
 Pregnancy, vomiting, 36. 
 Psilosis, 139. 
 Pulled bread, 74. 
 
 RECTAL feeding, 102. 
 Relief of pain, 21. 
 
 SICK headache, 38. 
 Spices and condiments, 74. 
 Sprue, 139. 
 Stricture of bowels, 120. 
 
 ULCERATIVE colitis, 141. 
 
 Ulcer of stomach, 91. 
 
 Hort's diet, 99. 
 
 Lenhartz, 99. 
 
 milk, 95, 98. 
 
 serum treatment, 101. 
 
 VEAL cream, 51. 
 Vegetable soup, 136. 
 Vomiting, 25-38. 
 
 of blood, 40. 
 
 of pregnancy, 36. 
 
 in sick headache, 38. 
 
 WHEY, alum, 43. 
 
 sweet, 54.
 
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