In this period nothing should be swallowed. Some physicians 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 15 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. Therefore 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 washing out of the bowels may be followed by the injection of 1/2 to 1 pint of warm water, which can be retained; indeed, 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 produced 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 days of absolute rest, sufficient 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 spoonful 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 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 1 1/2 pints of milk, 7 beaten raw eggs, and two tablespoonsful of sugar.

Seventh Day

Two ounces of scraped meat and 3 1/2 ounces of rice milk are added.

Ninth Day

The diet is 1 3/4 pints of milk, 8 raw eggs, 1 1/2 ounces of sugar, 2 ounces of raw meat, 7 ounces of rice milk, and 2 pieces of Zwiebach.

Eleventh To Fourteenth Days

Milk, 1 3/4 pints; 8 raw eggs; sugar, 1 1/2 ounces; raw scraped meat, 2 ounces; raw ham, 2 ounces; rice milk, 1/2 pint; Zwiebach, 3 pieces; butter, 2 ounces. The total food now yields 3000 calories. Zwiebach 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; 11 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.

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 11 a.m. and 10 p.m. After returning to full diet, the use of alcohol, tea, coffee, and starchy puddings are forbidden 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 mentioned 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 healing 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 encouraged the formation of an ulcer and delayed the healing 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 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.