If at the end of four weeks from the beginning of mouth feeding this amount of food can be taken without any discomfort, it is very unlikely that further trouble will occur in the next stage. Presumably cicatrization of the ulcer is proceeding satisfactorily, but the actual condition of the ulcer is unknown and all extensions of the diet must be made as cautiously as before. Two or three eggs may now be added, cooked or in custard or beaten up in milk. Bread or rusks and butter are permitted, and other varieties of starchy food such as sago, tapioca and potato-puree. Milk-soup flavoured with onion, celery or turnip can be given, and any clear soup, chicken-broth, mutton-broth or beef-tea, if their low nutritive value is remembered.

A Sample Diet Supplying 1,800 Calories May Be Thus Constructed

7 a.m.....Two rusks.

Milk, 8 oz. flavoured with coffee.

9 a.m.....Cocoa made with milk, 8 oz.

1 egg lightly boiled or poached.

Thin bread and butter, 1 oz. 1 p.m, .... Milk-soup, 8 oz.

Milk pudding or custard with one egg, 2 1/2 oz.

Thin bread and butter, 1 oz.

Milk, 8 oz. 4 p.m..... Two rusks and milk, 8 oz.

6 p.m.....Chicken-broth, 6 oz.

Milk pudding or custard with 1 egg, 2 1/2 oz. (or 1 egg lightly boiled or poached and junket made from 10 oz. of milk). Thin bread and butter, 1 oz. Milk, 8 oz. 8 p.m..... Two rusks and milk, 8 oz.

Such a diet consisting of milk, eggs, carbo-hydrate and fat should be maintained for at least 14 days, and in many cases this third stage may be further prolonged with advantage. I think that extra days spent on this diet mean an increased chance of sound and permanent healing.

Fish and chicken should not be allowed until at least six weeks have elapsed since mouth feeding was commenced. The diet in this final stage should have a value of about 2,500 calories, and considerable variety becomes possible and there is much scope for cookery. The meals should be small, all hard particles should be avoided and cellulose should be kept at a low level. On resuming such a liberal diet it is especially important to inculcate the habit of thorough mastication and slow eating. If, as is usual at this point, the patient is up for part of the day, at least half an hour of complete rest lying down should be taken after every meal. When some fish, preferably a piece of boiled sole has been taken on two or three occasions at the midday meal without discomfort, the patient can be advanced to some such diet as is detailed below. Milk, carbo-hydrates and eggs must still form a large part of the diet. Fish (sole, plaice, whiting or haddock), sweetbread, chicken, pigeon and pheasant may be added with potato or cauliflower. This diet admits of considerable variation and need not be monotonous. It should not be materially altered for at least three months, and the longer the patient can be made to abstain from meat, tea and alcohol the better is the result. For the working classes such a diet can be obtained while the patient remains in hospital. On her departure from hospital, which is generally premature, the patient should be provided with some such diet-list, and though fish and chicken are often beyond her reach it is possible for her to resume work on a diet of milk, carbo-hydrates, butter and eggs.

In this late stage of treatment the food must be suited to the patient as carefully as before. Occasionally even now there is complaint of pain or discomfort after certain articles of food. This will necessitate some alteration in details of the diet, but it need not lead to the idea that the ulcer is still unhealed. For it is clear that after the healing of an ulcer, especially in neurasthenic subjects, a veritable hyperaesthesia of the gastric mucosa may persist, so that certain articles produce pain immediately they enter the stomach.

Final Diet For Gastric Ulcer

8 a.m.....Milk flavoured with coffee, 8 oz. (or cocoa made with milk). One or two eggs lightly-boiled, poached or scrambled. Thin bread and butter, 2 oz. (or rusks and butter). 10.30 a.m. . . . Milk, 8 oz.

A rusk.

1 p.m.....Sole boiled, fried or filleted or fishcake, 3 or 4 oz.

(or quenelles of haddock or sweet-bread with white sauce). Cauliflower, 2 oz. (or potato-puree or both). Milk pudding made with egg, 2 or 3 oz. (or custard or savoury omelette). Thin bread and butter, 2 oz. Milk, 8 oz. 4.30 p.m. . . . As at 10.30 a.m.

7 p.m.....Clear soup, or milk-soup, chicken-broth, mutton-broth, 6 oz. Chicken panada or soufflee, 3 oz. (or veal quenelles). Potato-puree, 2 oz. Milk pudding, 2 or 3 oz. (or custard or junket and cream). Thin bread and butter, 2 oz. Milk, 8 oz. 10 p.m.....As at 4.30 p.m. (or Benger's food, 6 oz.).

The plan of graduated feeding which has been described is of considerable antiquity. In 1901 a protest against its continuance was made by Lenhartz. In his view healing of a gastric ulcer is not promoted by stomach-rest and proceeds but slowly under a strict milk diet. He considers that the high acidity of the gastric juice which is so commonly associated with gastric ulcer, is not lessened by milk feeding, and that such feeding tends to maintain the anaemia and may even produce such serious inanition as to delay or prevent the cicatrizing process.

Further he believes that nutrient enemata excite an intestinal peristalsis, which spreads to the stomach and may induce renewed bleeding. Finally he is alive to the defect of continual increase of milk (up to 1,600 or 1,800 calories) which is generally admitted, viz., that the weight and bulk of 3 or 4 or more pints of milk constitute serious drawbacks to their use.

He recommends therefore immediate feeding and a rapid increase of food, so that the patient receives the value of 3,000 calories 14 days after haemorrhage or after the commencement of treatment. On the first day, even on the day of haemorrhage, the patient receives 8-10 oz. of iced milk given in spoonfuls and two beaten eggs. The eggs are beaten up entire (with a little sugar) and before use they are surrounded with ice and are thus given cold. The following table shows this rapid method of treatment: -

Days After Last Haematemesis

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Eggs .

2

3 4

5

6

7

8

8

8

8

8

8

8

8

Sugarwith eggs.grms.

-

-

20

20

30

30

40

50

50

50

50

50

Milk, c.c.

200

300

400

500

600

700

800

900 1,000

1,000

1,000

1,000

1.000

1,000

Raw chopped meat, grms.

35

70

70

70

70

70

70

Milk rice.

100

100; 200

200

300

300

300

300

Zwieback

20 = one piece

two pieces

2

3

3

4

5

Raw ham

50

50

50

50

50

Butter .

20

40

40

40

40

Calories .

280

420

637

777

956

1,135

1,588

1,721

2,138

2,478

2,941

2,941

3,007

3,073

1 From the first to the seventh day inclusively the eggs are beaten; from the seventh to the fourteenth day inclusively half are beaten and half are cooked.

(B) Days Or Weeks After Haematemesis

In these cases again the question of rectal feeding comes up, and the advantages and disadvantages of such a course need not be repealed.

Here there is presumably no question of disturbance of an organizing thrombus in an open vessel. But we have no means of knowing the exact state of the ulcer. Often after haematemesis the patient has struggled on with something like her ordinary diet, and the early tendency of the clean-edged ulcer to heal quickly has been impaired or lost. I think it is wise therefore to start with two or three days of saline injections per rectum and an empty stomach. Milk feeding may then be proceeded with on the plan already described. But if, in the time that has elapsed since the haematemesis occurred, the patient has been efficiently treated, it may be possible to shorten the early tentative period of milk feeding and to reach the second stage of milk-carbo-hydrate diet in a few days.

(C) Suspected Ulcer

In cases which present the history and signs of ulcer without haematemesis, we can be guided in the question of rectal feeding by the urgency of the vomiting. A short period of an empty stomach may be necessary, but the patient can often be placed at once on a milk diet to the value of 560 calories, and can proceed with the treatment from that point.

(D) Chronic Ulcer

In some cases months or years have been spent in illness. With intervals of improvement, the patient has seldom been able to take solid food without pain, vomiting has become a habit and its recurrence is welcomed, malnutrition and secondary anaemia are obvious, and there has commonly been haematemesis on one or more occasions. The treatment of such patients in the early and curable stage of the ulcer is generally found on inquiry to have been half-hearted and imperfect.