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 8-1

Answer Guide for Medical Nutrition Therapy: A Case Study Approach 4th ed.
Case 8 – Ulcer Disease: Medical and Surgical Treatment
I. Understanding the Disease and Pathophysiology

1. Identify the patient’s risk factors for ulcer disease.

• Family history
• Smoking
• Previous diagnosis of gastroesophageal reflux disease.

2. How is smoking related to ulcer disease?

• Smoking enhances the hormonal effects of gastrin and acetylcholine and thus increases acid secretion.
• Medications such as cimetidine do not function as well when the client smokes.
• Smoking has also been shown to decrease the ability of ulcerations to heal and the risk for reoccurrence is
higher.

3. What role does H. pylori play in ulcer disease?

• Helicobacter pylori is a microorganism whose only natural host is the human.

• It is found primarily on the surface of the antrum of the stomach.
• This microorganism has been established to be the most common cause of gastritis and it is estimated that
92% of duodenal ulcers and 70% of gastric ulcers are caused by H pylori.
• By-products produced by the organism result in damage to the epithelium and impair the mucus barrier
within the stomach.
• Helicobacter pylori, a spiral-shaped, flagellated, gram-negative rod, lives on the gastric mucosa under the
mucous layer of the stomach and attaches to mucus-secreting cells that line the stomach. These organisms
break down urea to produce ammonia, which helps to neutralize acid in the immediate vicinity of these
bacteria and enhance their survival.
• H. pylori organisms subsequently produce various proteins that damage mucosal cells. This damage attracts
lymphocytes and causes persistent inflammation.
• H. pylori can be identified in almost all patients with duodenal ulcers and in approximately 80% of patients
with gastric ulcer in the absence of other precipitating factors such as NSAID use or hypersecretory
conditions (e.g., Zollinger-Ellison syndrome).

4. Four different medications were prescribed for treatment of this patient’s H. pylori infection. Identify the
drug functions/mechanisms. (Use table below.)

Drug Action
Metronidazole Antibiotic targeting the H. pylori infection
Tetracycline Antibiotic targeting the H. pylori infection
Bismuth subsalicylate Coats the stomach and assists to decrease the symptoms associated with the peptic
ulcer
Omeprazole Proton-pump inhibitor that reduces the total amount of acid produced

5. What are the possible drug-nutrient side effects from Mrs. Rodriguez’s prescribed regimen? (See table
above.) Which drug-nutrient side effects are most pertinent to her current nutritional status?

• The most common side effects include significant gastrointestinal symptoms such as nausea, vomiting, and
diarrhea.
• If Maria has difficulty eating due to nausea, vomiting, or anorexia, these side effects will be important to
consider.
• Long-term use of the medications may certainly affect the nutrient status of Ca, Fe, and B 12.

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
8-2

• The tablet form of bismuth subsalicylate should be taken at least 1 to 3 hours before or after tetracyclines;
otherwise, it may decrease the effectiveness of the tetracycline.

6. Explain the surgical procedure the patient received.

The procedure, which is often called a Billroth II, is a partial gastrectomy with a reconstruction that consists of
an anastamosis of the proximal end of the jejunum to the distal end of the stomach.

7. How may the normal digestive process change with this procedure?

• The procedure may change the digestive process both physically and chemically.
• The stomach has been partially resected, which will reduce the holding capacity of the stomach.
• Gastric emptying may also change depending on the status of the pylorus and the vagus nerve and any
other anatomical changes.
• Loss of the duodenum reduces the overall surface area for digestion and absorption.
• Nutrition concerns include the potential for vitamin and mineral deficiencies.
• Changes in gastric anatomy may cause inadequate intrinsic factor to be secreted.
o This would prevent normal B12 absorption and lead to a subsequent deficiency.
o Research has confirmed that patients who have had gastric surgery have a high prevalence of vitamin
B12 deficiency.
• The duodenum is no longer functional but the jejunum will accommodate the functions of the duodenum
over time.
• Initially there may be a reduction in some enzyme function—specifically for lactase.
• Finally, transit time is affected, which may result in dumping syndrome.

II. Understanding the Nutrition Therapy

8. The most common physical side effects from this surgery are development of early or late dumping
syndrome. Describe each of these syndromes, including symptoms the patient might experience, etiology of
the symptoms, and standard interventions for preventing/treating the symptoms.

Early dumping syndrome:

• Occurs approximately 10-15 minutes after eating.
• Symptoms include flushing, increased heart rate, explosive diarrhea, and also hypotension.
• Partial or complete loss of the stomach results in shortened transit time.
• The duodenum is no longer functional but the jejunum will accommodate the functions of the duodenum
over time.
• These symptoms are caused when a high carbohydrate intake—which is hyperosmolar—enters the small
intestine.
o The hyperosmolar load pulls water into the small intestine.
o This decreases plasma volume, resulting in hypotension.
o The rush of fluid into the small intestine results in diarrhea.
Late dumping syndrome:
• Occurs anywhere from 1.5 to 3 hours after a meal.
• Symptoms include feeling confused, feeling light-headed, and weakness.
• Etiology stems from the rapid movement of carbohydrate into the small intestine.
• Rapid absorption stimulates a large release of insulin and hypoglycemia results.
Prevention of the dumping syndromes is based on a slow progression of an oral diet with avoidance of simple
carbohydrates.
• It is important to ensure adequate kcal and protein for postoperative healing.
• First meals post-operatively should include a protein source with only 1-2 foods at a time.
• Liquids should be consumed 30-45 minutes after eating solid foods.
• Lying down after eating may also assist.

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
 8-3

• Overall, food choices should exclude simple sugars.

• Intake should be divided among 6-8 small meals per day and overall should emphasize protein foods.
• A slightly higher fat intake than the usual adult recommendation may be needed to meet energy
requirements.
• Foods high in soluble fiber may also assist in slowing gastric emptying.
• Liquid multivitamins and B12 supplementation should be initiated.

9. What other potential nutritional deficiencies may occur after this surgical procedure? Why might Mrs.
Rodriguez be at risk for iron-deficiency anemia, pernicious anemia, and/or megaloblastic anemia?

Long-term complications can include:

• Weight loss
• Iron malabsorption
• Steatorrhea
• Calcium malabsorption
• B12 deficiency
• Folic acid deficiency
Mrs. Rodriguez may be at risk for several types of anemia.
• Iron is poorly absorbed when it is not exposed to hydrochloric acid (HCl) in the stomach.
o With this surgery, exposure to HCl is decreased due to decreased transit time and poor mixing of
gastric contents.
o Additionally, most dietary iron is absorbed in the duodenum, which is bypassed as a result of this
surgery.
• Pernicious anemia may occur secondary to B12 deficiency.
o B12 absorption requires adequate amounts of intrinsic factor, which is produced in the stomach.
o Surgery may decrease the amount of intrinsic factor available for absorption.
• Folate deficiency may be a result of poor intake and/or iron deficiency.

10. Should Mrs. Rodriguez be on any type of vitamin/mineral supplementation at home when she is discharged?
Would you make any recommendations for specific types? Explain.

• Yes, it would be a good idea for Mrs. Rodriguez to be on a general multivitamin with iron. The supplement
may be better absorbed in liquid form.
• Theoretically, it is believed that a large dose of B12 can be absorbed in small amounts without intrinsic
factor.
o This absorption is accomplished through diffusion.
o An oral dose of 150 μg may be sufficient to prevent B12 deficiency.
o B12 can also be provided intramuscularly.
o 60-100 μg injected monthly would be adequate to prevent pernicious anemia.

III. Nutrition Assessment

11. Prior to being diagnosed with GERD, Mrs. Rodriguez weighed 145#. Calculate %UBW and BMI. Which of
these is the most pertinent in identifying the patient’s nutrition risk? Why?

• %UBW: 75%
• BMI: 20
• Percent UBW is the most pertinent because this identifies her nutritional risk.
• This patient has lost 25% of her usual body weight in the past six weeks.
• This places her at significant nutritional risk.
• Her BMI is within the normal range but certainly at the lower end of the normal range.

12. What other anthropometric measures could be used to further confirm her nutritional status?

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
8-4

• It would be important to attempt to determine from which of her body compartments she has lost most of
her weight.
• One could use skinfold measurements to assess her percentage of body fat as well as compare her to
population standards.
• Additionally, somatic protein stores could be estimated using calculation of upper arm muscle mass.

13. Calculate energy and protein requirements for Mrs. Rodriguez.

9.99  actual weight + 6.25  height – 4.92  age – 161 = 1136 kcal
9.99  50 + 6.25  157.48 – 4.92  38 – 161
499.5 + 984.25 – 186.96 – 161
1135.79 or 1100 kcal
1100  1.1 (AF)  1.3 (SF) = 1573 or 1600 kcal
EPR = (1.2-1.5 g/kg) = 1.2-1.5  50 = 60-75 g pro/d

14. This patient was started on an enteral feeding postoperatively. What type of enteral formula is Peptamen
AF? Using the current guidelines for initiation of nutrition support, state whether you agree with this choice
and provide a rationale for your response.

This patient entered surgery already malnourished. The ability to transition from NPO to an adequate oral diet
may take anywhere from 3-7 days. Maximizing her nutritional support will make her recovery easier and
decrease the potential for post-operative complications.
Peptamen AF is a high-protein, hydrolyzed formula containing omega-3 fatty acids, MCT oil, soluble fiber, and
antioxidants (vitamins C and E and selenium). It is formulated specifically for GI dysfunction and provides the
higher amounts of protein appropriate for the patient’s documented malnutrition, her current post-operative
status, and the demands of metabolic stress.

15. Why was the enteral formula started at 25 mL/hr?

Peptamen AF has an osmolality of 390 mOsm/kg H2O and will be better tolerated when started at a lower rate.

16. Is the current enteral prescription meeting this patient’s nutritional needs? Compare her energy and protein
requirements to what is provided by the formula. If her needs are not being met, what should be the goal for
her enteral support?

Peptamen AF @ 25 mL/hr = 720 kcal and 45 g protein. At initial rate of 25 cc/hr, the patient’s needs are not
met.
Goal = 56 mL/hr, which provides 1613 kcal and 101 g protein

17. What would the RD assess to monitor tolerance to the enteral feeding?

The RD should monitor the nursing flow sheet for intake/output records. These records will indicate the amount
of formula the patient is actually receiving. The intake/output record will indicate gastrointestinal tolerance to
the feeding by documentation of urine and/or stool output. Daily weights and fluid balance, which are essential
to monitor during nutrition support, will also be documented through this format. Regular monitoring of
electrolytes, glucose, BUN, and creatinine within her chemistry laboratory values will indicate systemic
tolerance to the enteral feeding.

18. Using the intake/output record for postoperative day 3, how much enteral nutrition did the patient receive?
How does this compare to what was prescribed?

450 cc Peptamen AF, which provides 540 kcal and 34 g protein. She was prescribed 600 cc, which would have
provided 720 kcal and 45 g protein.

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license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
 8-5

19. As the patient is advanced to solid food, what modifications in diet would the RD address? Why? What would
be a typical first meal for this patient?

Typically a patient is NPO for 3-5 days and is fed enterally. Ice chips and sips of water are then given. First
foods are low-carbohydrate clear liquids such as broth, unsweetened gelatin, and diluted unsweetened fruit
juices. If the patient tolerates this initial introduction, the post-gastrectomy diet is then started. This consists of
small, frequent meals that are high in protein and complex carbohydrates. Fat should be included in moderate
amounts and all simple sugars should be excluded. Liquids should be given between feedings. Foods and liquids
should be room temperature. Lactose and carbonated beverages should not be fed initially. The rationale for this
diet is to prevent the onset of dumping syndrome.

20. What other advice would you give to Mrs. Rodriguez to maximize her tolerance of solid food?

She should be encouraged to chew her food slowly and lie down for 20-30 minutes after a meal. This will
ensure appropriate digestion and will slow transit into the small intestine.

21. Mrs. Rodriguez asks to speak with you because she is concerned about having to follow a special diet forever.
What might you tell her?

The ability to liberalize the diet is highly individualized. You could tell her that she will be able to try small
amounts of simple carbohydrate when she has had no symptoms of dumping. Small amounts can continue to be
added as long as she tolerates them. After simple carbohydrates such as sweetened fruit juice or canned fruits
are tolerated, then other carbohydrates can be added. Very hot or very cold foods may also be tried at this time.
The patient can then progress to fresh fruits and vegetables. Lactose-containing foods may also be added slowly
to determine tolerance. It is important to only add one new food at a time so that if intolerance occurs, the food
can be eliminated and tried again later.

22. Using her admission chemistry and hematology values, which biochemical measures are abnormal? Explain.

Albumin, prealbumin, BUN, bilirubin, WBC, Hgb, Hct, %segs, %lymph.

a. Which values can be used to further assess her nutritional status? Explain.

Albumin, prealbumin. These laboratory measurements of endogenously produced proteins can be used to
assess her visceral protein stores. When protein intake is low or protein requirements are high, the synthesis
of these proteins is decreased. Albumin is much more indicative of chronic protein malnutrition due to its
long half-life of 14-21 days. Prealbumin has a shorter half life of 3-4 days and thus is more representative
of short-term protein inadequacies.

b. Which laboratory measures (see lab results, pages XXX-XXX) are related to her diagnosis of duodenal
ulcer? Why would they be abnormal?

An elevated WBC is indicative of infection with the %segs and %lymphs suggesting a bacterial rather than
a viral infection. Her Hgb and Hct are low and you should suspect this has to do with possible bleeding
with the duodenal ulcer but could also be from a nutritional anemia.

23. Do you think this patient is malnourished? If so, what criteria can be used to support a diagnosis of
malnutrition? Using the guidelines proposed by ASPEN and AND, what type of malnutrition can be
suggested as the diagnosis for this patient?

Yes. This patient appears malnourished due to her rapid weight loss, decreased albumin, and decreased
prealbumin. The International Classification of Diseases notes five classifications for diagnosis of malnutrition.
This patient fits under the description of marasmus: weight loss > 10% of usual weight in last 6 months with
relative preservation of visceral protein stores – albumin > 3.0. ICD –9-CM 261.0.

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
8-6

Using the ASPEN and AND proposed criteria, Mrs. Rodriquez appears to have moderate malnutrition
associated with acute disease. Criteria that support this diagnosis are weight loss >7.5% in previous three
months with inadequate energy intake of <75% for >7 days.

IV. Nutrition Diagnosis

24. Select two nutrition problems and complete the PES statement for each.

The following are possible PES statements. It may be helpful for students to initially write more than two
nutrition diagnoses and then prioritize as to the ones that are most likely to have immediate nutrition
interventions.
Intake Domain:
• Inadequate intake from enteral nutrition related to (students may recognize that more information is needed
to accurately identify the reason for this problem such as intolerance, increased residuals, error in
administration or charting, and/or interruption of infusion secondary to other types of patient care) as
evidenced by patient receiving only 450 mL/24 hours compared to prescribed 600 mL.
OR:
• Inadequate intake of enteral nutrition as evidenced by nutrition prescription of 25 mL/hour providing only
600 kcal and 25 g protein compared to goal rate of 66 mL/hour providing ~1600 kcal and 66 g protein.
• Increased nutrient needs related to impaired nutrient utilization of vitamin B 12 post gastrectomy (in this
case, evidence may not be necessary to develop appropriate nutrition care).
• Evident protein-energy malnutrition related to prolonged inadequate oral/food beverage intake as evidenced
by BMI of 20, involuntary weight loss, and pre-albumin of 14 mg/dL.
Clinical Domain: Even though these are concerns initially, students can utilize this knowledge as part of
etiology and evidence of intake and behavioral-environmental problems.
• Altered GI function (it may not be necessary to develop this as a PES as it can be incorporated as part of
the etiology for increased nutrient needs above)
• Impaired nutrient utilization (this actually is the etiology for increased nutrient needs)
• Involuntary weight loss or underweight (this is reflected in the signs and symptoms of protein-energy
malnutrition)
Behavioral-Environmental Domain:
• Food and nutrition-related knowledge deficit related to altered GI function as evidenced by patient
requesting nutrition education and concern for “special diet forever.”

V. Nutrition Intervention

25. For each of the PES statements that you have written, establish an ideal goal (based on the signs and
symptoms) and an appropriate intervention (based on the etiology).

• Inadequate intake from enteral nutrition related to (students may recognize that more information is needed
to accurately identify the reason for this problem such as intolerance, increased residuals, error in
administration or charting, and/or interruption of infusion secondary to other types of patient care) as
evidenced by patient receiving only 450 mL/24 hours compared to prescribed 600 mL.
o Even though this is problem, the more important issue is that the nutrition prescription does not meet
her nutrition needs; therefore, basing a nutrition plan on the next PES is more appropriate.
• Inadequate intake of enteral nutrition as evidenced by nutrition prescription of 25 mL/hour providing only
600 kcal and 25 g protein compared to goal rate of 56 mL/hour providing ~1600 kcal and 100 g protein.
o Ideal Goal: Provide enteral nutrition to meet kcal needs of 1600 kcal and 100 g protein.
o Intervention: Modify rate of enteral feeding by increasing goal rate to 56 mL/hour.
• Increased nutrient needs related to impaired nutrient utilization of vitamin B 12 post gastrectomy (in this
case evidence may not be necessary to develop appropriate nutrition care).
o Intervention: Vitamin supplementation; may require order for injection of vitamin.

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
 8-7

• Evident protein-energy malnutrition related to prolonged inadequate oral/food beverage intake as evidenced
by BMI of 20, involuntary weight loss, and pre-albumin of 14 mg/dL.
o Ideal Goal: Weight maintenance and slow, steady weight gain of 1-2 pounds/week and improved pre-
albumin to within normal of 16-35 mg/dL.
• Food and nutrition-related knowledge deficit related to altered GI function as evidenced by patient
requesting nutrition education and concern for “special diet forever.”
o Ideal Goal: Patient will understand the rationale for advancing oral food from liquid to soft to diet as
tolerated without adverse symptoms from dumping syndrome.
o Intervention: Nutrition education to include purpose of modification for simple carbohydrates and
liquids. Nutrition counseling that provides tools for self-monitoring and social support may also be
helpful. (Refer to question 26 below.)

26. What nutrition education should this patient receive prior to discharge?

Goals for nutritional rehabilitation should be set with the patient, specifically identifying her energy and protein
needs. Discussion of meal timing with food choices to prevent dumping syndrome. Prescribing multivitamin
and B12 supplementation should be discussed.

27. Do any lifestyle issues need to be addressed with this patient? Explain.

The role of smoking in ulcer disease should be addressed. Referrals to assist with smoking cessation can be
made within the health care team.

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
 Another Random Document on
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The Project Gutenberg eBook of Dr. Courtney's
guide to happy marriage
This ebook is for the use of anyone anywhere in the United
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Title: Dr. Courtney's guide to happy marriage

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*** START OF THE PROJECT GUTENBERG EBOOK DR.

COURTNEY'S GUIDE TO HAPPY MARRIAGE ***
 Multum in Parvo
Library.
Entered at Post Office as Second-Class matter.

Vol. I. June, 1894. No. 6.

Published Monthly.

Dr. Courtney’s Guide

TO

Happy Marriage.
Smallest Magazine in the World. Subscription
price, 50 cts. per year. Single copies, 5 cents
each.

PUBLISHED BY
A. B. COURTNEY,
671 Tremont Street, Boston.
 MARRIAGE GUIDE.

The Newly Wed.

We will suppose you have read and profited by the excellent
suggestions contained in an article published in a previous issue of
this library, under the head of “How to Woo, Win and Wed.” You have
succeeded in winning the object of your affections, and have set sail
upon the sea of matrimony. It is often called a troublous sea. Such
indeed it proves in truth to be for those who embark upon it not fully
prepared for the voyage. Do you really, married or unmarried, know
the full meaning of the word marriage. It is something far more
serious than a mere civil contract or religious ceremony. These are
only the marks of outward show. There is a good deal behind these
—a good deal that you ought to know, and of which, perchance, you
are ignorant. The aim of this article is to give some practical advice
to those who have already entered into the bonds of matrimony, and
it will not, it is hoped, come amiss to those about to marry, but who
have not yet taken the step that leads to misery or bliss. “Marriage,”
says Selden, “is a desperate thing; the frogs in Æsop were extremely
wise; they had a great mind to some water, but they would not leap
into the well, because they could not get out again.” Would that most
of us possessed the wisdom of the fabled frogs.
 Purpose of Marriage.
Marriage ought to be consummated as the result of mutual love and
esteem, and not for the purpose of simply gratifying the desires of
our lower nature. This last consideration is, it must be
acknowledged, a controlling one with a great many people, and
marriages contracted in this manner are not generally, and cannot
hope to be, happy ones. The sacredness of the marriage relation
ought never to be violated. We must not forget that we are rational
beings with a will to withstand the weaknesses of our animal natures.
 Happy and Unhappy Marriages.
A happy marriage is without doubt the ideal state of living, the end
for which mankind has always striven, while an unhappy marriage is
a veritable hell on earth. Examples of both of these states need not
be given. We see them every day. To one who reads the daily
papers regularly with particular note of the records of divorces,
assaults of drunken or jealous husbands, the faithlessness of women
and the elopements, the thought must present itself that there are
more unhappy marriages than happy ones. This, fortunately, is not
true. Where we read of one unhappy marriage and its terrible
consequences there are ten happy ones of which the world never
hears.
“Marriage,” writes Addison, “enlarges the scene of our happiness
and miseries.”
“It is a mistake,” says another writer, “to consider marriage merely as
a scheme to happiness; it is also a bond of service, it is the most
ancient of that social ministration which God has ordained for all
human beings, and which is symbolized by all the relations of
nature.”
Still another writer says: “Married life appears to me a sort of
philosophical discipline, training persons to honorable duties, worthy
of the good and wise. Few unmarried people are affected as they
ought to be toward the public good, and perceive what are really the
most important objects in life.”
 How to be Happy.
Those who wish to lead happy married lives cannot do better than to
follow a few rules which we present herewith.
Husband and wife ought to maintain entire confidence in each other,
have no secrets each from the other; don’t quarrel; have forbearance
for each other’s failings; you have neither of you married an angel.
Remember, husband, that of every dollar you own, fifty cents
belongs to your wife; she is an equal partner with you in the business
of life; don’t compel her to become a mere household drudge,
working for her board and clothes; she did not marry you for that. Try
to see the good points of your husband or wife; don’t magnify the
faults; we are all only human; don’t have the first quarrel and the
second will never come.
 Golden Precepts.
Let the rebuke be preceded by a kiss.
Don’t require a request to be repeated.
Never should both be angry at the same time.
Be lovers all your life. Let the courtship be continued after marriage.
Never neglect the other for all the world beside.
Let each strive always to accommodate the other.
Let the angry word be answered with a kiss.
Bestow your warmest sympathies in each other’s trials.
Criticize as little as possible, but if you find it necessary to criticize,
make your criticism in the most loving manner possible.
Make no display of the sacrifices you make for each other.
Never make remarks calculated to bring ridicule upon the other.
Never deceive; confidence once lost can never be wholly regained.
Always use the most loving and gentle words when addressing each
other.
Let each study what pleasure he can bestow upon the other during
the day.
Always leave home with a tender good-bye and loving words. They
may be the last.
Consult and advise together in all things.
When you feel like quarrelling, discuss the whole thing together and
you will come to an amicable settlement.
Never reproach the other, especially in the presence of others, for an
error which was committed with a good motive and with the best
judgment at the time.
Don’t tell your friends the faults of your husband or wife.
 The Duty of the Wife.
The wife’s place is in the home. That is her proper sphere of action,
and the one in which she ought to be most happy.
Don’t devote time to society matters while your house duties need to
be done. Don’t spend your time in making clothes for some naked
boys in Dooloboo who do not need them, while your own children go
about with patched or torn clothing.
Greet your husband with a smile on his return from work.
Don’t scold your husband.
Don’t think your husband ought to be perfect. Are you yourself
perfect?
Be careful and economical in the expenditure of money for
household purposes. (By the way, your husband ought to make you
the treasurer of the firm.)
Always dress neatly for your husband’s sake. You used to do it
before marriage. Imagine your husband is still your lover.
Treat your husband’s friends politely. This is an important part of
your wifely duty.
Don’t spend money extravagantly for dress or other personal
adornment.
 The Husband’s Duty.
Don’t think the woman you have married is yours, body and soul.
Don’t be niggardly in money matters.
Don’t withhold from your wife your tender love and sympathy.
Regard her as your dear sweetheart all through life. Always treat her
with tender consideration.
Don’t try to argue with her. A woman cannot reason; she is guided
rather by her womanly intuition, which is rarely at fault.
Follow the counsel of your wife. Many a man has done so and
succeeded. Wisdom and foresight are possessed by women, as well
as men.
Let your wife understand fully your business. Don’t let her think you
are earning fifty dollars a week when you are earning only thirty
dollars, or vice versa.
Give your wife all the pleasure you can. She needs it.
Do not go about enjoying yourself with boon companions while your
wife toils at home.
Don’t spend money for rum while your wife has to make over her old
dresses.
If your wife is worthy of it (most wives are), praise her. Women like
praise.
Women are not as strongly built as men, and are thus likely to be
often in delicate health. If so, your wife may be petulant and cross.
Make allowances for this and don’t scold her.
Don’t interfere with your wife in the performance of the duties that
belong peculiarly to her.
Give her money enough to dress well, even if you have to make
sacrifices to do so.
Treat her mother with becoming respect.
 Marrying for a Home.
A good many women are foolish enough and dishonorable enough
to marry merely for a home—foolish because they cannot expect
such a marriage to result happily, and dishonorable because they
have deceived the man they married. Love ought to be the basis of
all marriages.
 Joy and Pleasure.
A married life is not one of unalloyed bliss. We ought not to expect
this. It has its pains as well as its pleasures. As Margaret Fuller says:
“Deceive not thyself by over-expecting happiness in the marriage
state; look not therein for contentment greater than God will give, or
a creature in this world can receive, namely, to be free from all
inconveniences. Marriage is not, like the hill of Olympus, wholly clear
without clouds.” When misfortune comes to us, and all the rest of the
world deserts us, we have those at home to whom to look in certain
expectancy of sympathy and encouragement—wife and children. As
John Taylor says: “A married man falling into misfortune is more apt
to retrieve his situation in the world than a single one, chiefly
because his spirits are soothed and retrieved by domestic
endearments, and his self-respect kept alive by finding that, although
all abroad be darkness and humiliation, yet there is a little world of
love at home over which he is monarch.”
A married man is more apt to labor for the good of all mankind, while
a single man is apt to be more selfish in his aims and endeavors.
The interests of a single man centre round himself, while those of a
married man embrace his whole family, and in a larger degree the
whole community.
 Don’t Board.
If you are a newly-married couple, don’t board. Go to keeping house
as soon as possible. Don’t get married if you can’t do this. A young
woman ought to learn the duties and pleasures of housekeeping as
soon after marriage as possible. If she boards out, she has little to
occupy her time, and is apt to pass her days in reading silly novels,
or to fall into that terrible habit of gossiping. She ought to find
pleasure in working for her husband, and she can work for him best
only in her own home, preparing his meals and by the performance
of other wifely duties. As a mere boarder in somebody else’s home,
she cannot do this. There are many drawbacks and perplexities
about housekeeping, to be sure, but these ought to be met and
contended with with a brave spirit. In the end, having conquered, it
will be found that the pleasures far outweigh them. A woman ought
to take pleasure in looking after the home nest, and ought not to
leave to some unsympathetic boarding-housekeeper the task of
preparing the daily meals for her husband.
 The Mother-in-Law.
A mother-in-law is often a blessing, but few will admit the truth of this
statement. Many men, however, have found her to be a ministering
angel in disguise. It is better, nevertheless, for the newly-married
couple to live by themselves, if possible, and not be under the sway
of a mother-in-law, or other relative, however kind and unselfish she
or they may be. They ought to strike out for themselves. A mother-in-
law, however good her intention may be (and no doubt her intentions
are always good), is pretty sure to prove meddlesome and dictatorial
to a greater or less degree, and end by being an element of discord
in what ought to be a happy home. You will find it better to paddle
your own canoe, even if you do not make very rapid or easy
progress at first.
 Marriage a Lottery.
Marriage has been called a lottery. Fortunately it is a lottery in which
there are a great many prizes. Let us give you this bit of advice in
regard to marriage as a lottery: Try to think that you have drawn a
prize. Thinking so will go a good way toward making the supposition
a pleasant reality. Never lose sight of this fact. If your husband or
wife does not come up to the high standard which you have hoped
for, try to stifle the disappointment. It might be worse. Start out well
on the sea of matrimony. “Many a marriage,” writes Frederika
Bremer, “has commenced like the morning, red, and perished like a
mushroom. Wherefore? Because the married pair neglected to be as
agreeable to each other after their union as they were before it. Seek
always to please each other; lavish not your love to-day; remember
that marriage has a morrow, and again a morrow.” Another writer on
the same subject wisely says: “The happiness of married life
depends on a power of making small sacrifices with readiness and
cheerfulness. Few persons are ever called upon to make great
sacrifices or to confer great favors; but affection is kept alive, and
happiness secured, by keeping up a constant warfare against little
selfishness.”
 Jealousy.
It is said that jealousy is an unmistakable sign of true love. We are
supposed to be jealous of those whom we most dearly love. There
may be some truth in this assertion, but we incline rather to think that
it is open to dispute. Only the weakest are the most jealous. But the
“green-eyed” monster has caused too much misery to treat the
matter lightly. Where mutual love and respect and perfect confidence
exist, and where the married parties are sensible, intellectual people,
jealousy rarely exists. Jealousy, such as that which is said to be an
infallible sign of true love, is exhibited chiefly by silly young women,
married and single, who have no serious grounds for suspicion
against the object toward which their jealousy is directed. If you are
of an incurably jealous disposition, never marry any one of the
opposite sex who is good looking. This will only add fuel to the fires
of your jealousy. Marry a homely person—the homelier the better—
one who is not likely to receive undesirable attentions from the
opposite sex after marriage. But the best advice of all is don’t be
jealous. Be sensible. Nine times out of ten you have no real cause
for jealousy after all. To be jealous of your husband or wife implies
that you have married a partner who cannot be trusted. Have you
married such a person? Probably not. Then why be jealous?