In hopeless cases - in the immediate sense - any kind of dietetic indiscretion which the patient desires may be allowable, even including abstinence from food, controlling vomiting and pain by various narcotics, including morphine.

Gastric Ulcer, for dietetic purposes, may be divided into two groups: 1. Acute peptic, traumatic, including operative, and acute infectious ulcer, as during the exanthemata, in which danger of haemorrhage, perforation or at least of increased local lesion, is imminent; 2. Chronic angiosclerotic, embolic, cancerous, syphilitic, tuberculous ulcer, in which haemorrhage is not likely to be of serious degree, except by inducing gradual anaemia and in which the danger of perforation is minimized by cicatrization and adhesions. Back pressure haemorrhage, mainly due to hepatic sclerosis, may imitate either type of ulcer and calls for dietetic management accordingly.

Excepting the acute peptic type, most gastric ulcers are associated with hypochlorhydria. Peptic ulcer, though probably mainly due to the action of a strongly acid gastric juice on tissues whose nourishment is markedly reduced by angiospasm, direct neurotrophic or other cause, is not invariably due to actual hyperchlorhydria and, after its establishment, the acidity is frequently reduced. It must be remembered that there is a contraindication to the use of the stomach tube in such cases and that the common belief in the presence of hyperchlorhydria rests on very meagre and often fallacious evidence.

The acute type of gastric ulcer requires as n2arly as passible absolute rest, local and general. It is folly to administer ordinary styptics, though adrenalin and possibly hydrogen peroxid may be allowed, and lumps of ice soon become lukewarm water in the stomach and actually favor haemorrhage. Both food and water should be administered by the bowel or hypodermically for at least a week.

Lenharz, of Hamburg, has advocated the early resumption of gastric nutrition, and has laid down an elaborate and arbitrary schedule of feeding with eggs and milk. The general principle may be enunciated that feeding should be recommenced as early as it is safe to do so. If there has been no evidence of repsated severe haemorrhage and the vomitus, if any, and the stools are free from blood at the end of a week, about 200 c.c. of peptonized milk may be given. After this, it is well to wait a couple of days, to see whether fresh blood appears in the stools. If it does, rectal nutrition should be continued for three or four days longer. If not, the peptonized milk should be continued for three or four days. Then the white of an egg may be added to each feeding, and, a week or so after the resumption of gastric feeding, six entire eggs and a liter of milk, representing about 1,200 calories, may bo given daily. In the second week, soft cereals may be added and peptonization may be omitted, unless there are signs of gastric distress. My the end of the second week the patient may take a full ration of eggs, cereals and milk, unless haemorrhage indicates the suspension of feeding. After a month, ordinary food may be taken, but dietetic errors of all kinds should be avoided for several months, and the diet should be very simple.

It is unwise to use meat, or any meat preparation containing blood for the first two weeks, at least, on account of confusion in applying the blood test to the faeces.

Achylia Gastrica probably often occurs from reflex inhibition during asthmatic attacks, acute fevers, from traumatic or surgical shock, fear etc. Suspension of feeding is indicated, though hot beef tea or strong coffee may be given as a stimulant. Hypochylia doubtless occurs in all depressed states and calls for predigestion or administration of vegetable digestants.

Persistent achylia gastrica occurs sometimes in Addison's disease, and as a terminal process in many serious conditions, including gastric cancer. It necessarily occurs in anadenia, the final degenerative stage of chronic gastritis which, however, does not usually reach this stage. Sometimes it is unexpectedly discovered in patients otherwise in good health and well nourished. On the other hand, it is rather characteristic of pernicious anaemia though the association is not regular.

Such cases should, at first, be treated with the hope of restoring gastric function, using easily digested food, including sapid tender meats, cereals, well salted eggs, etc., and eliminating coarse vegetables, tea, coffee, alcoholics etc. Hydrochloric acid and perhaps vegetable ferments should also be given.

If it appears that the achylia gastrica is permanent, the aim should be to secure proper intestinal digestion. The food should be simple and should be well masticated and insalivated. It is a moot point whether hydrochloric acid should be continued to imitate the normal condition by which the inferior digestive secretions are supposed to be stimulated, or whether the case should rest in statu quo, on the ground that the system has become habituated to the omission of gastric digestion and the effect of this upon intestinal digestion. When the latter also fails, the outlook is exceedingly unfavorable. (See discussion of intestinal indigestion.)

Foreign Bodies. In many instances, especially in infants, doubt arises as to whether a missing foreign body has been swallowed or not. The most careful search should be made for it, outside of the patient, and the stools should be sifted as a routine for several weeks, unless the body is discovered. The writer's sieve enables these examinations to be made quickly and with little trouble or offense. Most foreign bodies can be discovered by the X-Rays, unless lodged in line with bony structures. On account of the movability of foreign bodies, the fluoroscope is, on the whole, better than the radiograph. It is improbable that an 19 infant's oesophagus will pass a body more than 9 millimeters in circumference, or an adult's oesophagus one more than 15 millimeters. Subject to delay at the pylorus, ileo-caecal valve, rectal valves and sphincter, and in loops of intestine, a body that can pass the oesophagus can usually pass the entire alimentary canal. Long slender bodies are, however, specially liable to be retained indefmitely.

In order to guard the walls of the canal, and facilitate peristalsis, a very bulky, coarse diet of cellulose-containing vegetables, bran bread and puddings, should be immediately instituted. Ab-sorltent cotton has been advised to catch and guard the foreign body but there is some danger of obstruction. Fish bones, fragments of meat bones and metallic objects other than the noble metals, may be dissolved by hydrochloric acid in the stomach so that, unless in the case of brass and other poisonous metallic compounds, it is advisable to maintain acidity at a considerable degree. At least, sharp objects will be blunted by the corrosion.

Hair balls, common in cattle and quite frequent in horses and other quadrupeds which use the tongue to cleanse the body, are found in human beings only as the result of perverted habits or the use of the lips and teeth to assist in manipulating the hair. Thus they are practically limited to hysterical females. Short hairs of any kind rarely lodge in the human stomach. Pending operation it must be remembered that there is a ball-valve obstruction and relative microgastria, unless dilatation has occurred.