since starch is less liable to fermentation from bacteria
than sugar; (3) limit the foods which delay the passage
of the food mass from the stomach; fats pass into the
duodenum more slowly than other foods and when fed with
other foods delay their passage materially; (4) avoid the
use of soda bicarbonate, as it tends to reduce the normal
acid content of the stomach, tiius preventing its germicidal
action upon the fermentative bacilli; alkaline carbonates
likewise inhibit the flow of gastric juices; (5) give especial
attention to the attractiveness of the food served; let it be
appetizing and savory, for by such means is the appetite
juice and incidentally an increased flow of the gastric juices
stimulated; (6) condiments and spices, meat broths high
in extractives, and salt foods such as caviar and endives may
be given at the discretion of the physician ; it is seldom ad-
visable to give the foods which are indigestible, even when
they act as stimulants to the secretory cells of the stomach.

HYPBRCHLORHYDRIA

(Excess secretion of acid in the stomach)

The Effect of Excess Acid. — An excessive flow of

hydrochloric acid has been found to be the cause of much

of the acute and chronic gastritis, in fact more of the cases

are traceable to an excess than to a lack of hydrochloric



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248 DIETETICS FOR NURSES

acid. This acid is more or less irritating in character, and
the tender mucous membranes lining the gastric organ
being constantly bathed in a secretion composed chiefly of
acid must necessarily in time suffer a certain amount of
irritation and inflammation, causing the development of a
pathological condition which may be temporary or per-
manent, that is, it may result in acute or chronic gastritis,
according to the amount of acid secreted and the length of
time the hypersecretion is allowed to continue.

Determining the Acid Content of Stomach. — The dif-
ference between the cases brought about by an excess flow
of hydrochloric acid are more or less diflScult to distinguish
from those caused by a lack of this constituent in the gas-
tric juice, chiefly because in the latter case the organic acids
formed as the result of bacterial action upon the food exert
an equally irritating effect upon the membranes of the
stomach, and the only sure method of determining the cause
of the disturbance is by an analysis of the stomach con-
tents, by which means the percentage of hydrochloric acid
is determined.

Lavage. — It has been found advisable, in some cases of
acute gastritis which do not yield readily to rest and liquid
diet, to wash the stomach and allow a certain period of rest
before giving any food; in this way the organ is rid of all
of the offending material and thus has a better chance of a
quick recovery.

ACUTE GASTRITIS

Dietetic Treatment. — The following dietetic treatment
for acute gastritis is advised: As the stomach is the chief
seat of disturbance, all unnecessary work must be taken
from this region for a certain period:

(1) That any obscure cause may manifest itself and
the diagnosis may be rendered more accurately and more
quickly.



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FEEDING IN GASTRO-INTESTINAL DISEASES 249

(2) That by resting the organ tiie offending materials
may pass out of the body and thus prevent further trouble.

Starvation Period. — Twenty-four hours of total ab-
stinence from food may seem extreme, but as a rule in
acute cases of gastritis it is the only sane and safe method
of instituting a diet and thus beginning to overcome the
cause of the disturbance. After the period of starvation
the diet is begun with caution.

Fluid Diet. — Fluids should be given first in the form of
well-skimmed broths, which may be reenforced with egg or
cereal flours when the patient is very thin or anemic. But-
termilk, made with the Bulgarian cultures, koumiss and
other fermented milk foods, liquid beef preparations such as
peptonoids or. panopepton, albumenized orange juice, cereal
gruels treated with Taka diastase when it is found necessary,
and peptonized milk. These may be given in from four to
six ounces at a time, every two hours on the. second day.

Increasing the Diet. — On the third day if the attack is
slight the diet may be increased by adding toast, softened
with peptonized milk, an ordinary serving (3 ounces) of
farina, cream of wheat or rice, reenforced meat broth with
two crackers, a cup of tea and a slice of toast, and one or
two soft-cooked eggs. If the acute symptoms are still
present on the third day, the diet advised for tiie second day
must be continued until they disappear.

Convalescent Diet. — On the fifth day, if progress is
satisfactory, lightly broiled chicken or a small piece of rare
broiled beefsteak may be added to the diet and tiie meals
reduced in number from six to four.

Relapse. — The patient must be warned against over-
eating or eating any of the articles which are kno^n tja
cause an acute attack in his individual case, since one attack
predisposes to another, and chronic gastritis may develop
^ the result of the continual gastric disturbance.^



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250 DIETETICS FOR NURSES

CHRONIC GASTRITIS

The treatment in chronic gastritis is very like that in
the more acute form; that is, it must be combated by
removing the cause. Lack of fresh air and exercise have
much to do with the development of chronic gastritis, but
even they combined with a judicious amount of rest would
be wasted without a proper adjustment of the diet to
cover the main points of the disturbance. As has already
been mentioned, the cause may be a lack of gastric juice or
it may be an excess of it; it may be intensified by an atonic
condition of the organ or from the food passing too quickly
into the duodenum.

Test Meals. — As a rule it is not safe to make a snap
diagnosis as to the cause of this disorder. Since in many
instances the more serious disorders may be traced to a dis-
regard for nature's danger signals, the physician as a rule
advises a test meal, this meal consisting of a glass and a
half of water or a cup or two of tea without cream or sugar
and from one to two slices of toast or water rolls. In from
three-fourths to one hour or longer this is removed from the
stomach by means of a stomach pump and analyzed, the
result of the chemical and bacterial analyses forming the
basis for diagnosis. This meal is generally given in the
morning before any other food has been eaten.*

Dietetic Treatment. — The foods constituting the diet
in chronic gastritis must be of the simplest character and
prepared in the simplest manner. No fried foods are per-
missible. Pastries, griddle cakes, rich puddings and sauces,
candies, and alcoholic beverages must be omitted from the
diet as well as the following articles of food : pork, veal, shell-
fish except oysters, sardines, canned meats and canned fish,
highly seasoned and spiced dishes, twice-cooked meats, vine-

* It is also customary to give the patient a bismuth or barium meal in
order that an X-ray and fluoroscopic examination may be made to deter-
mine the character and extent of the disturbance.



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FEEDING IN GASTRO-INTESTINAL DISEASES 251

gar, pickles, olives, cold slaw, pickled beets, catsup, mustard,
coarse fibered vegetables such as cabbage, old onions, old
turnips, and cucumbers, strong tea, coffee, or chocolate, rich
cream or dishes made entirely of cream. In cases of exces-
sive acidity due to a hypersecretion of HCl the extractives
of meat are contraindicated, hence all gravies and outside
parts of roasted meat must be omitted or limited in the
diet.

GASTRIC ULCERATION

Gastric ulcer may develop without an apparent cause.
As a rule, however, it manifests itself in individuals be-
tween the years of fifteen and forty, particularly after pro-
longed digestional disturbances, especially those accom-
panied by a hypersecretion of acid. As the disease pro-
gresses, anemia is more or loss severe, adding diflSculty to
the feeding problem. Many of the symptoms are like those
of chronic gastritis, such as pain. However, the character
of this pain may be different, beginning soon after eating
and radiating toward the back. This point may be affected
by position. As a rule there is a tenderness over the seat
of the ulcer. This is detected by palpation. Vomiting is
one of the most general S3niiptoms in gastric ulceration.
This may begin from one to two hours after eating when
the pain is at its height, or it may start as soon as food
enters the stomach. As a rule the latter condition is found
more often in very nervous women whose mental attitude
affects the stomach to such an extent as to make it difficult
to give them sufficient food to nourish them.

Hemorrhage. — Hemorrhage occurs in about half of
the cases. The bleeding may be profuse and the blood
bright red, or it may be less severe and the color of the
blood changed by contact with the gastric juices to a dark
brown like coffee grounds.

Excess Acid. — Hyperacidity is present in the majority
of the cases, the percentage of HCl rising at times fifty per



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252 DIETETICS FOR NURSES

cent, or more. Other cases occur in which all of the just
mentioned symptoms except dyspepsia are missing, the first
intimation of the ulcer being hemorrhage or perforation.

The patient with gastric ulcer may recover entirely and
never have a return of the trouble, but care and close atten-
tion are necessary, since the ulcers are apt to recur, at times
a series of ulcers developing one after another. Death may
occur from exhaustion or from perforation and peritonitis.
Surgical intervention is as a rule necessary when the ulcers
persist, as they generally develop at or near the pyloric
opening; and the constant development of cicatricial tis-
sue brings about an obstruction of the pylorus, which if not
relieved would allow the patient to starve.

Diet Treatment. — There are a number of treatments
used in overcoming this condition. After the test meal and
the diagnosis, the patient is placed upon a diet directed to
overcome the chief symptom ; for example, if the ulcer de-
veloped as a result of hyperacidity, the diet would be
directed toward the relieving of that symptom. Boas^
divides the treatment into three stages: (1) hemorrhage;
(2) the intermediate stage; (3) the convalescent stage.

Starvation Treatment. — The majority of physicians
institute a total abstinence period for the first stage, allow-
ing no food or water to be taken by mouth. If the patient
is very weak and anemic from the extended course of the
disease, nutrient enemas are given from four to six times
a day, alternating with saline enemas. This total absti-
nence continues from three to six days. Some cases have
been known to be fed in this way for a month or six weeks
with obvious success. However, this is not the rule but the
exception. The diet must be adjusted to the needs of each
individual, but a few general rules may be found helpful.

Dietetic Treatment. — Milk is the food generally util-
ized in the beginning. This may require peptonizing to
•"Diseases of the Stomach," by Boas.



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FEEDING IN GASTRO-INTESTINAL DISEASES 253

be digested, or it may have to be modified with limewater.
Protein foods require HCl for their digestion. If these
foods are fed they will absorb some of the excess acid, and
in this way save the already irritated wall of the organ
from additional irritation. When protein foods^are given
they must be in the form of soft-cooked ^gs, scraped raw
beef or beef juice, milk soups, and like protein foods.

When there is a dilatation of the organ there is more or
less danger of fermentation taking place, with the formation
of organic acids. These acids are exceedingly irritating,
and every care must be observed to prevent their produc-
tion. The following dietetic regime may be used as a guide
in many cases of gastric ulceration :

Milk Diet. — % glass (4 ounces) of milk peptonized at
115° F. for 20 minutes, every hour for three or four days.
After this the interval between feedings is lengthened to
two hours and the amount of milk increased to % of a
glass (6 ounces). This is continued from a week to ten
days. The patient may be given a cup of well-strained meat
broth, reenforced with an egg, once or twice a day, to vary
the monotony of the diet. During the third week the milk
may be given in the form of milk soups. These may be
slightly thickened with barley, rice, or farina flour. The
soups may be flavored with beef extract, but only a small
quantity must be used, owing to the stimulating properties
of these substances.

Water as a Stimulus to Gastric Secretion. — Water is
exceedingly stimulating to the acid secreting cells of the
stomach, hence it is advisable to limit the amount of water
taken by mouth, allowing the patient just enough to wash
out the mouth without swallowing any. The thirst is re-
lieved by saline enemas.

It has been found, in many cases of gastric ulceration,
especially those accompanied by hemorrhage, that glucose
gives better results when used in rectal alimentation, than



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254 DIETETICS FOR NURSES

any other substance. The strength of the solution varies
from a five to a twenty-five per cent, solution. The number
of glucose enemas given each day must be regulated by the
physician. The method used is the same as in other rectal
feedings, the enema is given "high," and the flow regulated
(drip-method).

Convalescent Diet. — During the fourth week, if the
pain and discomfort are decreasing, soft-cooked or creamed
eggs may be added to the diet, together with thoroughly
boiled rice, farina, cream of wheat, wheatena and other
finely ground wheat foods, wine or fruit jelly, sweetened
slightly, or by using a small amount of saccharin for the
purpose, junket and plain vanilla ice cream. At the end
of the fourth week a very small portion of meat may be
given once a day. It may be scraped raw beef spread upon
toast or zwieback, or very lightly broiled beefsteak, broiled
lamb chop or chicken (breast only), or boiled or broiled
sweetbreads or brains. Spinach or green peas pressed
through a sieve are the first vegetables allowed. After these
young tender carrots and string beans may be given. Tea,
coffee, and chocolate are eliminated from the diet. Milk
flavored with coffee or cocoa may serve as a hot drink in
the morning when the desire or need for such a drink is
manifested. Butter is the best form of fat to be used in
cases of gastric ulceration, but this must be given with the
greatest caution. In cases where this fat is used in the
form of cream, the amount must be cut down or entirely
abandoned when there are evidences of butyric fermenta-
tion. Buttermilk, koumiss, and other fermented milk drinks
are often found very satisfactory adjuncts to the diet.
These may be given between meals, or at meals they may
be substituted entirely for the milk when other foods are
being given. They are not sufficiently nourishing to take
the place of the milk diet otherwise. Albumenized orange



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FEEDING IN GASTRO-INTESTINAL DISEASES 255

juice and cream, egg and vichy may be given to add variety
to the diet.

Anemia. — When anemia is severe, as is often the case
in gastric ulceration, the diet must be reenforced to over-
come it. Some of the concentrated milk foods such as
plasmon, encasin, sanatogen, etc., as well as the predigested
meat foods, such as panopepton, liquid beef peptonoids, and
like preparations, may be used to reenforce the diet.

Bland Diet. — In certain cases of gastric ulceration it
has been found more advisable to use what is known as a
bland diet. This consists of farinaceous foods such as
farina, arrowroot, cream of wheat, corn meal, wheatena,
malted breakfast foods cooked thoroughly and given in the
form of gruels, and some of the proprietary infant foods,
such as Mellin's Food, Eskay's Food, Racahout. These
foods may require the addition of Taka diastase to make
them more readily digested. They leave the stomach more
rapidly than any of the others, and for this reason will be
found to give less discomfort than the foods containing a
high percentage oT protein and fat. This diet, however, can-
not be prolonged on account of its lack of balance. If the
gruels are made with milk instead of with all water they
become more evenly balanced. Samples of the stomach
contents may be taken for analyses from time to time.

Lavage. — When lavage is necessary the patient must
be allowed to rest after the process before being given food,
otherwise it is apt to be vomited.

Instructions to Nurse. — The treatment for gastric
ulceration is thus seen to be strenuous. In the beginninfjr
the patient is placed on a liquid or semi-solid diet, or is not
fed at all for a time. This is done that the diseased organ
may have a chance to adjust itself as far as possible and to
give the physician an opportunity of studying the changes
taking place in that organ. During the course of the dis-



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256 DIETETICS FOR NURSES

ease the general symptoms which develop from time to time,
causing more or less pain and discomfort to the patient, are
nervousness, which in some individuals conounts to melan-
cholia, extreme anemia and an utter distaste for food, all
of which require patience on the part of the physician, the
nurse, and the patient herself to overcome. The nurse must
see that the patient is not disturbed or made unhappy by
having business or home cares talked over in her presence;
she must be kept as cheerful and as comfortable as her con-
dition permits and urged to use care in her diet. After the
ulcer is healed, to prevent a return of the trouble she must
be warned against eating too fast or when over-tired, and
she must be advised against very hot and highly seasoned
foods, for, in the observance of these simple common-sense
precautions only is she even in a measure saved further
attacks.

Special Diets Used for Gastric and Duodenal Ulcer. —
There are several well-known diets used in these conditions.
Among those that have been found most satisfactory may be
mentioned the Sippi diet, the Lenhartz diet.^

All of these diets require the most careful adjustment as
to regulation of intervals of feeding, type of food material
used, and method of preparation and administration of
food.

The treatment is directed toward the reduction of the
free hydrochloric acid in the stomach in order that the ulcer
may have an opportunity for healing.

Sippi Diet. — Equal quantities of heavy cream and
whole milk, beginning with % ounce each every hour dur-
ing the day. Alkaline powders are given with the meal
and one-half hour after the meal. These consist of 15
grains each of sodium bicarbonate and bismuth subcar-
bonate with the feeding, and 10 grains of light oxide of

•A brief description of these diets is given (for administering the
diets, see "Revised Teachers' Guide to Proudfit's Dietetics for Nurses").



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FEEDING IN GASTRO-INTESTINAL DISEASES 257

magnesia and 15 grains of sodium bicarbonate between
feeding. The cream and milk are increased at the rate of
one-half ounce each at each feeding for two days, the
powders are continued as on the first day. On the fourth
day an egg is added to the diet, the milk and cream are
given in quantities of one and one-half ounce each, every
hour. On the fifth day two eggs are added. On the sixth
day one helping of oatmeal or other soft cereal is added
to the above diet. The diet is in this way increased until
the patient is taking three eggs and nine ounces of cooked
cereal each day in addition to the cream and milk mixture.
The amount given at one time must be small, never exceed-
ing six ounces (according to Carter, Howe and Mason).

An accurate control of the acidity of the stomach should
be maintained, this is accomplished by withdrawing a cer-
tain amount of the gastric contents by means of the
stomach tube.

The Lenhartz Diet. — This diet is likewise given in
hourly feedings, consisting of milk and raw eggs in the
beginning, then a small portion of sugar Is added, next
scraped beef is added to the milk, eggs and sugar, already
given, then boiled rice. Next a small quantity of zwieback
(or soft toast), and continuing in this way, chicken, and but-
ter are admitted. In the beginning the quantity of milk is
100 c.c. and the number of eggs 2, given raw. It is served
iced, and with a teaspoon. When the sugar is added it is
beaten up with the eggs (20 gm.). The milk and eggs
are divided into separate feedings and given at hourly
intervals from 7 a.m to 7 p.m. It is rarely possible to give
the amounts called for in the Lenhartz diet after the sixth
day, but as much as possible should be given without risk-
ing an acute disturbance. Women, as a rule, find it more
difficult to take the full amount ordered than men.

The following outlines represent the diet for the first,
third, sixth, seventh and tenth day:



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258 DIETETICS FOR NURSES

FQtST DAT

7 A.M. . . . Egg

8 A.M. . . . Milk, 20 C.C.

9 A.M. . . . Egg

10 A.M. . . . Milk, 20 C.C.

11 A.M. . . . Egg

*2 noon . . • Milk, 15 c.c.

1 P.M. . . . Egg

2 P.M. . . . Milk, 15 c.c.

3 P.M. . . . Egg

4 P.M. . . . Milk, 15 C.C.

5 P.M. , . . Egg

G P.M. . . . Milk, 15 C.C.

Total: Milk, 100 c.c. Eggs (raw), 2.

THIRD DAY

7 A.M. . . . Egg; sugar, 2 gm.

8 A.M. . . . Milk, 50 c.c.

9 A.M. . . . Egg; sugar, 3 gm.

10 A.M. . . . Milk, 50 c.c.

11 A.M. . . . Egg; sugar, 3 gm.

12 noon . . . Milk, 50 c.c.

1 P.M. . . . Egg; sugar, 3 gm.

2 P.M. . . . Milk, 50 c.c.

3 P.M. . . . Egg; sugar, 3 gm.

4 P.M. . . . Milk, 50 c.c.

5 P.M. . . . Egg; sugar, 3 gm.

6 P.M. . . . Milk, 50 c.c

7 P.M. . . . Egg; sugar, 3 gm.

Total: Milk, 300 c.c. Eggs <raw), 4. Sugar, 20 gm.

SIXTH DAT

7 A.M. . . . Egg; sugar, 4 gm.

8 A.M. . . . Milk, 100 c.c.

9 A.M. . . . Egg; sugar, 4J gm.; scraped beef, 12 gm.

10 A.M. . . . Milk, 100 c.c.

11 A.M. . . . Egg; sugar, 4} gm.

12 noon . . . Milk, 100 c.c.

1 P.M. . . . Egg; sugar, 4} gm.; scraped beef, 12 gm.

2 P.M. . . . Milk, 100 C.C.

3 P.M. . . . Egg; sugar, 4J gm.

4 P.M. . . . Milk, 100 C.C.

5 p. M. . . . Egg ; sugar, 4 gm. ; scraped beef, 12 gm.

6 P.M. . . . Milk, 100 C.C.

7 P.M. . . . Egg; sugar, 4} gm.

Total: Eggs (raw), 7. Milk, 600 c.c. Sugar, 30 gm.
Scraped beef, 36 gm.



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FEEDING IN GASTRO-INTESTINAL DISEASES 259

SEVENTH DAY

7 A.M. . . . 1 soft cooked egg

8 A.M. . . . Milk, 100 c.c.

9 A.M. . . . Egg; sugar, 13 gm.

10 A.M. . . . Milk, 100 c.c; scraped beef, 23 gm.; boiled rice,

33 gm.

11 A.M. . . • Soft cooked egg (1)

12 noon . . . Milk, 125 c.c.

1 P.M. . . . Egg; sugar, 13 gm.

2 P.M. . . . Milk, 125 c.c; scraped beef, 23 gm.; boiled rice,

33 gm.

3 P.M. . . . 1 soft cooked egg

4 P.M. . . . Milk, 125 c.c

5 P.M. . . . Egg; sugar, 14 gm.

6 P.M. . . . Milk, 125 c.c; scraped beef, 24 gm.; boiled rice,

34 gm.

7 P.M. . . . 1 soft cooked egg

Total: Eggs (raw), 4; (soft cooked), 4. Milk. 700 cc
Sugar, 40 gm. Scraped beef, 70 gm. Boiled
rice, 100 gm.



TENTH DAT

7 A.M. . • . 1 soft cooked egg

8 A.M. . . . Milk, 166 cc

9 A.M. . . . Egg; sugar, 13 gm.

10 A.M. . . . Milk, 168 c.c; scraped beef, 23 gm.; boiled rice,

66 gm.; butter, 4 gm.

11 A.M. . . • 1 soft cooked egg; zwieback (or soft toast), 20 gm.;

butter, 4 gm.

12 noon . . • Milk, 166 c.c; minced chicken, 25 gm.

1 P.M. . . . Egg; sugar, 13 gm.

2 P.M. . . . Milk, 166 c.c; scraped beef, 25 gm.; boiled rice,

66 gm. ; butter, 4 gm.

3 P.M. . . , 1 soft cooked egg ; butter, 4 gm. ; toast or zwieback,

20 gm.

4 P.M. . • . Milk, 168 c.c; minced chicken, 25 gm.

5 P.M. . • • Egg; sugar, 14 gm.

6 P.M. . . • Milk, 166 c.c. ; scraped beef, 24 gm.; boiled rice, 67

gm.; butter, 4 gm.

7 P. M. . • • 1 soft cooked egg

Total: Eggs (raw), 4; (soft cooked), 4. Milk, 1000 cc
Sugar, 40 gm. Scraped beef, 70 gm. Minced
chicken, 50 gm. Butter, 20 gm. Boiled rice,
200 gm. Toast or zwieback, 40 gm.



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260 DIETETICS FOR NURSES

GASTRIC CANCER

As a rule the seat of- the gastric cancer is the pylorus.
The patient gives evidence of chronic gastritis with con-
tinued pain, localized tenderness, vomiting of partially di-
gested food and at times dilatation from extreme fermenta-
tion. The hemorrhages are as a rule not large, the blood
having changed to a brownish color resembling coffee