A The Dietetic Treatment of Gastro Intestinal Conditions' BY JOHN A. LICHTY, Clifton Springs, New York N EXPLANATION must be offered for the comprehensiveness of this subject. It is not intended to go into the details of the dietary of every known disease of the alimentary system. Even if time permitted, it would not be desirable. This is largely because our knowledge of specific dietetics in any disease is wonderfully lacking. It is possible now to speak in a scientific way of the dietetic treatment of diabetes. In most other diseases we can refer only to general principles. This is particularly true of the diseases of the digestive system. With our present knowledge it is impossible to speak of specific diets in regard thereto. There are two principles in medicine which must always be considered when dealing with repair of tissue or restoration of function. One is that of rest and the other is that of nutrition. When a leg or an arm is broken the surgeon can tell almost to the day when the limb may be allowed to functionate again, because he knows how completely rest may be established and at what rate repair takes place. The diet can be easily adjusted because the organs having to do with nutrition. are under the circumstances only slightly embarrassed. In certain dis 1 Read before the Hospital Dietetic Council at Buffalo, October 9, 1924. ANNALS OF CLINICAL MEDICINE, VOL. III, No. 7 eases of such vital organs as the lungs, comparative rest may be established by collapsing the lung and the organs of nutrition at the same time may be frequently demanded to operate full capacity. In diseases of the digestive system such complete rest cannot be established even if it is attempted. The stomach and bowels and the various appendages cannot be put absolutely to rest, and to the degree that approximate rest may be established, to just that same degree proper and healthy nutrition is impaired or lacking. Therefore, the application of the principle of rest and the proper maintenance of nutrition must at best be a compromise in the dietetic treatment of gastro-intestinal conditions. Fortunately the individual in health has a certain reserve of body tissue or weight which may be drawn upon in emergencies, and for a certain time food may be withheld without any concern as to the daily nutritional demands. The length of time food may be withheld with perfect safety is greater than it is usually thought to be. However, the body can subsist for only a short time without water. Hence, if fluid can be supplied in a certain quantity daily either per rectum, or subcutaneously or intravenously, a fair degree of rest of the gastro-intestinal system may be obtained. Unfortunately such starvation, for that is what it really is, will very soon result in the production of certain ketogenic bodies which in themselves are harmful to nutrition. This is usually evidenced by a so-called acidosis. The starvation thus not only deprives the body of necessary food but it endangers the organism on account of the resulting acidosis, and it interferes with that healthy nutrition so desirable in repair of tissue and in establishing normal function. the It is on account of these two existing horns of a dilemma that dietetics, applied to gastro-intestinal diseases, is a continuous compromise. A compromise, as you know, is never quite satisfactory to anyone. Between enemies it is usually a hopeless arrangement; between friends, or those who have confidence in one another it may be quite satisfactory. This applies very definitely to the gastro-intestinal patient, who unfortunately is too often called "chronic dyspeptic," or the "neurotic" or "hypochondriac." Unless you have the confidence of the patient, adjusting his diet is going to be a difficult task. One may need to be dogmatic or dictatorial at times but he should never be so much so as to prevent his asking the patient seriously and honestly what he is eating and what he thinks agrees with him. A careful consideration of the answer to that question may be more applicable to the case in hand than all the knowledge of balanced diet, fat, proteid and carbohydrate ratio, and so on. Before speaking of any specific diet for any known gastro-intestinal condition it might be well, after the above discussion, to indicate how one should proceed in general with the individual patient. I believe the following rules will be helpful: 1. Get as definite a concept as is possible of the condition to be treated. It is needless to say that this is to be obtained by getting an accurate history from the patient, making repeated careful physical examinations and carrying out such laboratory tests as are indicated. 2. Depend upon the patients' reserve nutrition if necessary and if he has not already used it or wasted it, thus rest the organs of digestion. 3. Select a diet which is easily digested and assimilated and at the same time nutritious. 4. Decide upon a definite method of procedure and do not abandon it until the patient is well or until you are satisfied you are wrong in the individual case. It is quite necessary to determine whether the condition diagnosed is primarily a disease of a certain organ of the digestive system, or whether it is a manifestation secondary to disease elsewhere. It is also well to distinguish between an acute, a chronic, and an acute exacerbation of a chronic disease or condition. The primary acute conditions may be such as acute gastritis, enteritis, cholecystitis, appendicitis, and pancreatis. The dietetic management of these conditions is quite simple. It is rest of function, that is, withholding of food by mouth. This may be done for some days without any danger whatsoever, providing provision is made for supplying the necessary fluid requirement of the body. Very little is necessary aside from this. And yet this is sometimes the most difficult course to establish in any given case, especially if the patient is a spoiled child with an anxious mother. The supposed danger of starvation is demoralizing. The primary chronic lesions or disturbances are such as chronic gastritis, chronic colitis with or without diverticulitis, peptic ulcer, carcinoma, chronic cholecystitis with or without stone, chronic appendicitis and chronic pancreatitis. Either of these conditions may develop an acute exacerbation and may demand the same rest and consideration as a primarily acute condition requires. It is these chronic disturbances or lesions which tax one's ingenuity and skill from a dietetic standpoint. The cause of the lesion is frequently obscure and the impairment of function is usually so marked and the patient's reserve so completely expended that the margin for recovery is alarmingly narrow. The patient with a chronic complaint or disease of the digestive system is usually underfed. Either on his own initiative or on the advice of friends, he has gradually reduced his diet to the irreducible minimum. Nutrition of the organs is greatly impaired. A fair example of such a condition is found in the patient suffering from a chronic peptic ulcer. The patient has had one attack or acute exacerbation after another and each time he has concluded that a certain food was responsible for the condition. This later is carefully avoided until very little food is left from which to select a diet. The less the patient eats, the less his power of repair and the more extensive the ulceration. arises, to what degree may food be withheld so as to rest the stomach and favor repair. From the very nature of things this question is difficult to answer. The cause of ulcer is not known. The time of its onset can not be definitely determined. Its actual presence is not always a certainty. It can not be inspected with the eye or palpated with the hand as a superficial ulcer may be. The diagnosis and the method of treatment become largely a matter of judgment and experience. It is for this reason that there are so many methods of treatment, especially of the dietetic treatment for peptic ulcer. There is the starvation method, the protein free diet, the high fat diet, the milk and egg diet, the high caloric diet, the Lenhartz diet, the Sippy diet, the Smithies diet. All of these methods may have certain advantages but I would feel myself greatly hampered if I were compelled to use one and the same method for every peptic ulcer case without discrimination. The food must be adjusted according to the stage of development of the lesion and the condition of the patient, rather than according to the name of the disease. Hence in peptic ulcer the stomach is rested as much as possible during the acute stage. No food by mouth is given until the acute symptoms have subsided. Sometimes a "string test" (Einhorn) which was previously positive, i.e., had a blood stain, will become negative in four to seven days of starvation, or so-called "rectal feeding." During these four to seven days the patient is allowed sips of warm water and may chew paraffin in moderation. Also glucose In such a case the question naturally feeding by the bowel is instituted. |