CHAPTER I.

DIGESTIVE HYGIENE.

DIGESTIVE hygiene should begin at birth and continue without a break throughout life. In this manner the primary diseases of the stomach could be prevented and life be made longer, more useful, and more comfortable. A strong stomach is not only a valuable possession, but it is a preventive against disease, and good digestion often decides the final result of a struggle against a dangerous disease. Digestive hygiene consists in giving to the stomach proper protection, proper repose, proper exercise, and proper work to do at regular periods. The history of the human stomach is, ordinarily, a long story of abuse, and pathologists rarely find a healthy stomach when the patient has died after the middle of life. However important digestive hygiene may be in the prevention of disease, it is absolutely essential to the cure of the diseases of the stomach.

In the general management of the diseases of digestion there is nothing more essential than a suitable environment— physical, moral, and social. These patients are very sensitive to cold, and become very languid and bilious in warm climates. Their bodies magnify every change of temperature. As a general rule, a moderately cold, dry location, of medium elevation, is very suitable, giving fresh air and sunshine and permitting outdoor life. The abdomen should at all times be well protected by the clothing, and left free to enjoy unimpeded the movements of the diaphragm.

The moral atmosphere is magnified in its gloom and decreased in its brightness by the delicate senses of these patients. The mind is particularly sensitive to the dark colors of life. There is nothing more depressing or injurious to such patients than the companionship of pessimists. The moral atmosphere should be sustaining, dissipating forebodings and inspiring contentment, hope, and courage.

The social atmosphere is another element of help or of injury. The slavery of the social life may offset all remedial influences. The performance of social duties under strain or exhausting excitement may leave no energy for digestion. It is often essential to place those suffering from a disease of the stomach where they can be free and can get rest and

adhere strictly to a proper diet. In these respects treatment in a sanitorium presents many advantages.

Rarely is the stomach injured by non-penetrating wounds of the abdomen; but diseases of the stomach, particularly ulcer, may be caused by traumatism-by a blow or by repeated or prolonged and strong compression. In this manner disease of the stomach is sometimes produced in shoemakers and in others who use the abdomen for holding objects or instruments in position; but more frequently the movements of the stomach are impeded or the stomach is displaced by prolonged compression and constriction of the waist. In this respect modern fashions are a curse to women. During the treatment of the diseases of the stomach, the action of these causes of disease must be excluded and the stomach be protected against external injury and compression. This hygienic rule is imperative during the digestive period.

"A person digests as much with his legs as with his stomach," wrote Chomel. Exercise facilitates nutrition, increases the bodily waste and needs, promotes the appetite, and, under proper conditions, is an aid to digestion. The healthy manual laborer awaits with impatience the hour of his meal, and eats all the more on account of his hard work; but if he becomes greatly fatigued, the appetite is lost. Sedentary habits may cause disease. On these points there is no difference of opinion.

When there is a serious disease of the stomach the matter is not so simple, and the prescribing of even moderate exercise during the period of digestion may be a grave error. Exercise creates a new demand for nutriment, and is beneficial on the condition that this demand be met easily and without injury. Patients with diseased stomachs are often unable to do this.

The action of exercise on the functions of the healthy stomach during digestion is positive. Moderate exercise hastens digestion, the stomach completes its evacuation a little earlier, digestive products do not accumulate in the stomach, the acidity of the contents is normal, and the movements of the intestines are more active. Violent exercise and hard labor are more decided in their action and the acidity of the contents is ordinarily below normal. In health it makes little difference whether a person take moderate exercise or rests, for neither is likely to derange digestion. Rest, in health, increases the acidity of the con

tents, the digestive products accumulate in the stomach, and the motor function is less active than during moderate exercise. In sleep these variations are greater than in rest.

The influence of exercise, of rest, and of sleep is much greater in the diseases of the stomach than in health, and no rule can be formulated which is applicable to all these diseases. Individualization is the best plan.

The gastroneurasthenic should rest after his meals; for otherwise what is needed by the stomach may be used by other parts of the body and by the mind. The weak and the nervous should rest both before and after their meals, and the greater the weakness and the irritability, the more stringent should be the rule.

Myasthenic patients may or may not demand rest. If the myasthenia is not of a high grade (complete evacuation. between meals) and if the organ has not been overloaded, the erythrism of the nervous system produced by exercise may be an aid to digestion; but observation proves that the highly myasthenic stomach commonly empties itself soonest under the gentler influence of repose. Exercise and the erect position increase the motor insufficiency, and may produce complete retention and an acute attack of pain, nausea, and vomiting. In all conditions, the digestion of a heavy meal should be begun with half an hour's rest; consequently, we almost invariably prescribe, in myasthenia, rest half an hour before and at least one hour after meals, and allow the exercise, in keeping with the individual indications, to be taken when the heavier work of digestion is over, and preferably in the open air. Some fondly imagine that they obey the laws of hygiene by promenading in their apartments or places of business. The exercise during the intervals of digestion should never produce greater fatigue than can be completely dissipated by twenty minutes of rest. In many of the anatomical diseases rest during digestion is advisable. Gastroptosis, ulcer, hypersthenic gastritis, advanced carcinoma, and all diseases of the stomach accompanied by irritability of the mucous membrane or by emaciation and loss of strength, should be treated by repose, which should, in severe cases, be absolute.

The use of the voice immediately after meals is no less injurious than may be that of the muscles. The digestive tube is deranged by the unnatural respiration and by the compression between the diaphragm and the abdominal muscles. The abdominal tension is increased and the breathing performs a kind of massage. This rule is most often violated

by orators, professors, lawyers, ministers, and singers. There is no more pernicious habit than that of going directly from the table to the piano.

Cerebral is no less injurious than muscular fatigue: there are reasons to believe that it is more so. The overworked mind does not cry out in pain, but produces insomnia-it refuses to stop work. The strained muscle hurts, and muscular fatigue brings its natural cure-rest. The tired man is drowsy. The thinker should carefully select his food, let his brain rest while his stomach is hardest at work, and take regular and moderate exercise in the open air, so that the body will aid in demanding nutrition and rest for the brain. Nothing can equal the wisdom of these hygienic rules, except, perhaps, their perfect uselessness. Genius has long been condemned to live with a diseased stomach and will probably continue so to do.

CHAPTER II.

DIET.

"THE best, the only good, the only suitable, diet," wrote Trousseau," is the one which the patient knows by experience best agrees with him." So notable has been the progress in the use of a diet in the cure and prevention of disease within the past twenty years that this proposition, though always false, is surely no longer tenable. The healthy man does not know how to feed himself, and the diseased man is far less likely to know.

A rational diet in the diseases of the stomach, through our more accurate and complete knowledge of digestion and nutrition, and of the various foods, is to-day possible. It is only within the past two decads that the great work of determining the functional power and the rich flora of the diseased stomach has been pushed on steadily to exact practical results. During the same period a flood of light has been thrown on the chemical pathology of nutrition, and on the utilization of food by the intestines in health and in disease.

But in addition to the increased knowledge of the functions and diseases of the stomach, and their relations to the work done by the intestines and to the state of nutrition, we are also in possession of more accurate knowledge of food. To-day

it no longer suffices to order a fluid, or light, or easily digestible, or nutritious diet; the physician must prescribe precisely and fully what the patient should eat. What is digestible and light and nutritious is unknown to most persons, who when left to follow blindly their diseased appetites and disordered sensations are very likely to eat too much, or too little, or the wrong things, or only a few articles, and to become morbidly introspective. The physician should select the diet in accordance with the indications furnished by the individual case, and should watch and control the effects.

The influence of the diseases of the stomach on nutrition is in practice a matter of very great importance. The clinic teaches, in a more trustworthy manner than experiments on animals, that the chemical work of the stomach, though very useful, is not necessary to the organism. The cases in the practice of every physician are very numerous in which the strength and weight of the patient are maintained, in spite of loss of nearly all digestive aid from the stomach. The utilization of the albuminous foods, starches, sweets, and fats may be complete in spite of the chemical inactivity of the stomach; but this is not because the stomach is useless, but because the organism is rich in resources.

There is no doubt that the intestines are capable of establishing complete digestive compensation when the stomach. is insufficient, but on condition that a proper diet be given. The food will then be absorbed in an assimilable form, and will not be lost by fermentation or putrefaction; but this does not render it highly probable, as is claimed by some authorities, that the inanition in the diseases of the stomach (except in cancer) is due exclusively to deficient alimentation. Carefully selected diets may be well utilized, when the somewhat indiscriminate alimentation of health is not.

In a disease of the stomach without stagnation or excessive secretion there is little difficulty. The intestines, if the diet be correct, are fully equal to the possible extra work, when they are permitted to do it without hindrance; but where there is excessive secretion, duodenal digestion is interfered with and the action of the saliva is quickly curtailed. The fat which reaches the intestines is well digested and absorbed, but the carbohydrates and proteids are partly lost through fermentation and putrefaction, as the clinical diet guides indicate. In the diseases of the stomach with disturbance of the motor function, the stomach exerts its greatest power of doing harm. It may deliver to the intestines a chyme hardly fit for food, or it may reject the best kinds of food, or