In ulceration of the mucous membrane of the stomach there is danger of irritation of the abraded surface through either the chemical or mechanical action of the food. Excessive secretion of gastric juice itself is believed to be similarly irritating. In serious cases where the ulcer is extensive or where it is deep and the stomach wall is thinned, there is liability of a rupture being caused by overdistention or an undue amount of peristaltic action. In the normal relaxed condition of the stomach wall the mucous membrane is folded into rugae, but when it is slightly distended the surface is smoothed out, and a greater degree of stretching may rupture an ulcer which is on the point of perforation, but which might still heal over if the tension were not too great. Further danger from the presence of ulcer of the stomach" lies in the fact that small blood vessels may be occasionally eroded, giving rise to profuse haemorrhage, and any food which irritates the surface of the ulcer increases this risk.

Dietetic Treatment

For these reasons, if the patient is seen soon after the occurrence of gastric haemorrhage, it is necessary to withhold all alimentation from the mouth and nourish the patient exclusively upon nutrient enemata. This treatment permits the stomach to remain relaxed, and it is not stimulated to peristalsis or secretion of irritating gastric juice.

In addition to the ordinary nutrient enemata it may be advisable twice a day to give rectal injections of a pint of salt water, which by its absorption prevents thirst and relieves the patient of the craving for swallowing liquid, which might result in exciting further vomiting. In severe cases, if the irritability of the stomach continues or the haemorrhage is repeated, it becomes necessary to continue the rectal alimentation for many days, and patients may live upon it comfortably for a week or, in some cases, much longer.

Lavage has been employed successfully when vomiting and pain in the stomach were uncontrollable. One usually hesitates in adopting this practice on account of a fancied danger of pushing the oesophageal tube through the weakened wall of the stomach, and I have known of one case which resulted fatally from this procedure, where the stomach wall, however, was already eroded through both the mucous and muscular layers, and perforation in any event was imminent. When the stomach wall is weakened the mere act of vomiting itself is a menace of rupture, and the operation of lavage is justifiable if carefully performed. There is no special danger to be apprehended from the use of a very flexible tube which is not pushed too far into the stomach, as the ulcer is usually some distance from the cardiac end, and food can sometimes be poured into the stomach through the tube after lavage with alkaline water, when it may be retained and digested. This treatment should only be resorted to in cases where haemorrhage has not occurred within a week, and in which other efforts to control pain and irritation of the stomach have been faithfully tried, but have failed.

Debove recommends the use of the oesophageal tube for gav-age when vomiting is persistent and nutrient enemata are not satisfactorily retained. The tube should be passed as far as, but not necessarily into, the stomach, and fluid food is poured through it. The act of swallowing is thus avoided, and emesis, as in the case of infantile dyspepsia, is less likely to follow. If the tube proves irritating its use must not be insisted upon.

Generally speaking, however, after a day or two of complete rest the condition of the stomach will admit of the gradual resumption of mouth feeding, but nourishment must be given exclusively in liquid and predigested form. The object is to give only food which will tax the stomach as little as possible, and either be promptly absorbed or pass quickly into the duodenum.

At first but very small quantities, not exceeding one or two tea-spoonfuls, should be offered at one time, and the effect in regard to nausea or vomiting must be carefully observed. Later, from four to six ounces should be given every two hours. For those cases of ulcer of the stomach in which patients are allowed to take food per os, a milk diet will usually agree the best, provided precautions are observed against the formation of large curds in the stomach, which are exceedingly irritating. The milk should be given in any form in which it is best borne, and the reader is referred to the article upon the modes of preparing milk and rendering it digestible (p. 76). If it is tolerated, the dosage may be increased to three to four ounces every two hours. Peptonised milk gruel is strongly recommended by Roberts. Da Costa has found that ice cream gave unexpected relief in some cases. Some patients do well upon koumiss, buttermilk, or zoolak. Ewald advocates the use of milk thickened with flour of various kinds to prevent the formation of large coagulse.

The predigested starchy infant foods, such as Nes-tle's, Mellin's, Imperial Granum, or malted milk, may be added, but gruels made with coarse cereals are not permissible.

When milk preparations fail, it is unwise to persist in giving them, and teaspoonful doses of beef juice should be substituted, or peptonised solutions or pancreatinised meat juice may be tried. Other patients may be fed upon egg albumin beaten and sweetened or prepared with sherry wine, or the yolk of an egg may be beaten in an ounce of boiling water and added to a tumbler of milk. Less serious cases may be allowed such articles as zwieback or stale bread crumbs or cracker crumbs soaked in milk until quite soft. They will prevent the formation of large coagulae of milk. One of the various malt preparations may be well tolerated and prove nutritious. Leube's Soluble Meat is a German preparation, which relieves the stomach of all necessary work, and consequently reduces the period of acid secretion in the stomach. It proves very serviceable in the dietetic treatment of gastric ulcer, and may be given alone or combined with milk or salted meat broths and bread crumbs. Leube himself prescribes in this form an equivalent of half a pound of beef in twenty-four hours, and claims good success for it.

Mosquera's meat jelly may be employed.

As a rule, if a patient thrives upon a diet of milk and broths, it is best to let well enough alone for three or four weeks, and any increase in either the quantity or variety of the diet should be made with extreme caution. If improvement follows, as indicated by the diminution in pain and the absence of gastric distress after eating, and the patient gains in strength, other articles may be carefully added in moderation to the diet, such as milk toast, sweetbread, eggs (not hard-boiled), scraped meat, custard, a small piece of boiled or broiled white meat of chicken or mutton or fish, chicken broths thickened with arrowroot, rice, vermicelli, clear meat broths or thickened soups to which the yolk of an egg has been added, or crumbled dry toast and a carefully prepared puree of potatoes may be prescribed. Stewart recommends the addition of malt to the puree.

A few easily digestible solid foods may next be added to the menu, such as tender rare roast beef, beefsteak, tender game, like the breast of partridge, quail, or squab in season. The soft part of large oysters (raw or broiled), boiled fresh fish, such as bass, sole, or whiting, rice pudding, bread and milk pudding, tapioca, sago, farina, and cornstarch - are all articles which may be permitted in moderation.

The patient should be informed of the existing condition in the stomach, and of the dangers attending any serious departure from the rules of diet carefully laid down, and it should be explained that for several months after the acute symptoms of gastric ulcer have subsided the greatest care must be observed not to overload or overwork the stomach, and to refrain from eating food such as coarse bread or groats, or vegetables having tough outside covering, like peas, corn, and beans, all of which are liable to produce mechanical irritation. No fruit except orange, lemon, or peach juice should be allowed.

Osier recommends the following menu for gastric ulcer:

8 A. M

Two hundred cubic centimetres of Leube's beef solution.

12 M

Three hundred cubic centimetres of milk gruel or pepto-nised milk gruel made with ordinary flour or arrowroot, to which gruel an equal quantity of peptonised milk is added.

4 P. M

Buttermilk.

8 P. M

Gruel.

In addition, rectal alimentation is to be given. The whites of eight eggs may be used in alternation with the beef solution.

After a month of this treatment the following articles are cautiously given: Scraped beef, chicken, fresh sweetbread, a farinaceous pudding made with milk and eggs. This treatment should last three months, most of which time is to be spent in bed.

The rules for stimulants are that they should be absolutely forbidden unless they become necessary through exhausting haemorrhage or great weakness, in which event they had better be supplied through the rectum.

Von Ziemssen prescribes Carlsbad water in order to neutralise the acidity of the stomach and hurry its contents into the duodenum. He recommends drinking half a pint to a pint of this water hot early in the mornings during convalescence.

Aerated waters should not be recommended. The gas is apt to distend the stomach, and the carbonic acid is believed to be irritating to the raw surface of the ulcer.