If for any reason surgery cannot be employed, the best chance of cure is afforded by a milk-carbo-hydrate diet, which must be liberal from the first in view of the malnutrition. In many cases improvement will follow a prolonged course of such a diet, but there is no ground for being sanguine as to an ultimate cure.

I believe that gastro-enterostomy should be urged on all such patients and that dietetic treatment should follow, and that only by the conjunction of surgical and medical treatment is there any real prospect of recovery. The healing of even a chronic ulcer may be comparatively rapid under these conditions, as is shown by the following case. " A man aged 42 in St. Thomas' Hospital had suffered from the symptoms of gastric ulcer for six years with hardly any intermission. Haematemesis had occurred on several occasions, the last occasion being the day before operation. Posterior gastroenterostomy was performed and an ulcer was found on the anterior wall of the stomach which was adherent to the liver. No pain or vomiting occurred thereafter, and the patient was soon able to take a full diet in perfect comfort. He died two months after the operation from rapid tuberculosis of the lungs, and at the autopsy the ulcer seen at the time of operation was found to be completely healed." After the performance of gastro-enterostomy the diet must be arranged with the knowledge that a thick-walled ulcer is present. But in these cases there is commonly such malnutrition that feeding should be from the first as liberal as is compatible with safety. On the first day after operation milk diluted (2 to 1) with lime-water or barley-water may be given in 1 oz. doses every hour. On the second day milk-mixture (4 to 1) may be given in 5 oz. doses every 2 hours, and on the third day some carbo-hydrate may be added in the form of Benger's food or arrowroot. A full milk-carbo-hydrate diet may be reached in a week, and in many cases fish and chicken can be taken at the end of the second week. But for many months thereafter the patient should adhere to the final diet-list already detailed.

The rapid gain of weight that commonly follows the operation is sufficient proof of its value. The relief that is afforded to the stomach by the shortening of the period of gastric digestion far outweighs any disadvantage which may accrue from deficient absorption. As a matter of fact metabolism is practically unaffected. In Paterson's observations "in none did the un-absorbed nitrogen amount to more than 2 per cent above the amount usually passed in the faeces by a healthy individual, while the amount of fat passed unabsorbed did not on any occasion exceed 7.7 per cent of the fat taken in the food, that is, just over 2 per cent above the amount usually passed in the faeces by a healthy man".

In all cases where one genuine and sufficient course of dietetic treatment has failed to effect a complete cure, I think the operation should be strongly recommended to the patient.

(E) Sequelae Of Gastric Ulcer

Pyloric stenosis is easily recognized and must be dealt with by a surgeon. The subsequent line of dietetic treatment will depend on the presence or absence of an unhealed ulcer. In many cases of cicatricial contraction of the pylorus a chronic ulcer is situated in the neighbourhood.

Perigastric adhesions and hour-glass contraction of the stomach are matters of greater difficulty. On a slender milk-carbo-hydrate diet patients suffering from these conditions may continue to live without much discomfort, but there can be no return to a sufficient full diet without surgical relief. A suspicion of the existence of these sequelae requires exploration and their treatment by gastrolysis, gastro-enterostomy or otherwise. The diagnosis of adhesions is extremely difficult and there are no pathognomonic signs, by which their presence can be recognized. The pain that results from them does not differ materially from the pain which is sometimes experienced by neurasthenic women even after the cure of an ulcer. Such cases require careful observation, and, inasmuch as in the hyperaes-thetic state of neurasthenia operation can do no good and often does harm, exploration should not be hastily recommended.

Duodenal Ulcer

This general plan of the treatment of a gastric ulcer can be adopted when the ulcer is on the duodenal side of the pylorus. The same rules hold good, but there is one important difference. The duodenum is disturbed only at intervals by the passage of food-stuffs from the stomach, and it has none of the churning movements that tend to prevent the healing of an ulcer in the stomach. Consequently the rate of progress in the steady increase of food may be rather more rapid. In the final diets special care must be taken to keep down any tendency to hyperacidity.