The technique of rectal feeding is discussed elsewhere. I prefer 10 oz. or 15 oz. injections of normal saline solution containing 1 oz. of dextrose at 100° F. every 4 or 6 hours, as being more cleanly and quite as useful as nutrient enemata. Moreover though it is not proved, there is evidence to show that the use of nutrient enemata may excite the secretion of gastric juice, which tends to prevent that complete functional rest of the stomach which it is our object to attain.
After the lapse of these few days of stomach-rest, small quantities of milk may be given by the mouth, while rectal feeding is continued. But even now mouth feeding must be tentative and on a small scale. Each case requires careful supervision, and the stages of treatment described can only be taken as affording a rough guide. Of a mixture of 21 oz. of milk and 9 oz. of lime-water or barley-water, 2 oz. may be given every 2 hours for 9 doses in the first 24 hours. On the second or third day if no pain occurs, while rectal feeding is continued, perhaps on a reduced scale, 30 oz. of this mixture may be given, in 5 oz. doses every 3 hours for 6 doses. It should be given at the body-temperature, and should be taken slowly, preferably with a spoon. From this time onwards the dose of food and the time of taking it should be methodically recorded. Thus within 6 or 7 days of the last sign of bleeding, the patient should be taking food to the value of about 420 calories. The increase of milk must be made with caution. As we have no direct means of ascertaining to what degree healing of the ulcer is taking place, it is necessary to take pain and vomiting as our guide. Recurrence of pain or vomiting requires a reduction of the dose, or a slower rate of increase. It is wise always to proceed on the supposition that the ulcer is large and deep. As a rule there is no necessity to peptonize the milk.
After three or four days of this diet rectal feeding can generally be discontinued, as the milk is increased. The calorie-value of the diet may be raised to 560 by giving 6 oz. of milk mixture (28 oz. of milk with 8 oz. of diluent) for 6 doses every three hours. And in a day or two the value of 800 calories may be reached by giving 8 oz. of milk mixture (40 oz. of milk with 8 of diluent) for 6 doses every 3 hours. This however is still a starvation diet. To supply the nutriment necessary for restoration of health by continual increase of milk alone, requires milk in such quantity that its bulk and weight have disadvantages. Some casein preparation may well be added. Any one of the numerous preparations such as sanatogen, protene, nutrose, etc., may be used. But plasmon is especially useful, and three tea-spoonfuls will yield 70 or 80 calories. The day's supply of three teaspoonfuls should be converted into a thick paste, before it is added to the milk, by stirring it with 5 oz. of tepid water. Junket may be used instead of plasmon to supply the extra protein. As a change one or two doses of milk may be made into jelly (1 oz. of isinglass to 1 pint of milk with 5 oz. of cream added and a flavouring of lemon).
This first stage of milk and plasmon-milk diet should generally be completed about 14 days after mouth feeding was commenced, but its duration must vary with the severity and special character of each case, and it is sometimes necessary to prolong it.
As regards the second stage of treatment there is some difference of opinion as to the relative merits of carbo-hydrates and protein. The Continental practice consists mainly in the addition to the milk diet of eggs and bouillon. As will be shown later, Lenhartz gives eggs freely with the excellent purpose of neutralizing excess of acid in the gastric juice and apparently with excellent results. But there arises here the same question which is discussed in connexion with " hyperacidity," viz., the relative advantages of a carbo-hydrate and a protein diet, the former tending to minimize the secretion of acid, the latter tending to increase the secretion, but at the same time to neutralize it. I believe that the use of eggs and meat-extracts should be still further postponed, and that for this second stage, which should certainly be of 14 days duration at least, carbo-hydrates alone should be added to the diet. There is no proof that more protein will hasten cicatrization and in my experience a recurrence of pain or discomfort is often noted on the addition of eggs at this stage.
A calorie value of at least 1,200 should be reached, and this can be attained with some variety of fare. At least two pints of milk should still be given diluted as before, but milk may also be used in combination with carbo-hydrate food. Two teaspoonfuls of plasmon may be retained and there is no necessity to add further protein. Carbo-hydrate food to the weight of 2 oz. may be used. This can be given as arrowroot, bread and milk, rusks and milk, cornflour blancmange, Benger's food, cornflour pudding or even thin white bread and butter without crust. The diet of this stage may be arranged on the following plan : -
6 a.m.....Milk and plasmon, 8 oz.
8 a.m.....Milk-mixture, 6 oz.
Arrowroot, 2 1/2 oz.
Thin bread and butter, 1 oz. noon.....Milk and plasmon, 8 oz.
Thin bread and butter, 1 oz. 4 p.m. . . '. . Cornflour blancmange, 2 1/2 oz.
Milk-mixture, 6 oz.
Thin bread and butter, 1 oz.
8 p.m.....Milk-mixture, 6 oz.
Arrowroot, 2 1/2 oz. 10 p.m.....Milk-mixture, 8 oz.
The extra protein required may be given by junket instead of by plasmon.