Pain and vomiting are the guides to treatment. If either of these recur, it is an indication to reduce the diet, and subsequently to increase it more slowly. If the progress is in all respects satisfactory, the milk may be gradually strengthened by the addition of Plasmon, Casein, Protene, or Sanatogen - the first named being probably the most valuable - 1 to 2 tea-spoonfuls of Plasmon being stirred into a paste with 1 to 2 ounces of tepid water, which is then added to the milk. This may be given three times in the twenty-four hours. Towards the end of the second week the patient is now taking about 2 pints of milk with half an ounce of Plasmon or other protein food in the twenty-four hours, and at this stage a cup of milk, beef-tea, a little chicken jelly, or raw-meat juice may be given twice daily for a change. It is now possible to abandon the rectal feeding, and gradually increase the nourishment given by the mouth. This is done by the addition of Benger's food, cornflour, arrowroot, or breadcrumbs and milk-specially prepared (p. 439). At the end of the third week of mouth administration, beef-tea, meat extracts, white of egg, and such preparations as Wyeth's meat juice or Brand's essence may be utilised. The lighter forms of milk pudding may also be given. These should be given tentatively; a recurrence of pain or discomfort after administration indicates the necessity of still withholding protein in these forms. At this stage the daily diet would comprise 2 to 3 pints of milk, diluted one-third, the white of one or two eggs, some chicken jelly, and a beef-tea preparation. In the fourth week, eggs, fish, and chicken may be gradually added to the diet, which may be farther increased by the addition of soups and a little vegetable. If the addition of fish or chicken leads to a recurrence of the abdominal pain, these should be further deferred, and the regime in use in the third week should be continued. There is, however, very seldom any difficulty with fish and chicken diet at this stage, provided these are given in the most suitable forms.

The diet suited to the different periods may be given in the following tabular form: -

Diet At End Of First Week Of Oral Feeding

Two pints of milk, diluted, one part in six, given in 6 ounces supplied every three hours, six meals daily. This is an insufficient diet, and requires to be supplemented with one rectal meal daily.

Diet During Second Week

During the second week of oral feeding one of two courses may be adopted - either cautiously increase by the addition of a simple nutritious protein dietary of eggs and meat extracts, or keep the patient on milk and carbohydrates. If there is hyperacidity, the former is probably the better plan.

Protein And Milk

7 a.m. - Milk, 6 ounces, slightly diluted. 8.30 A.M. - Milk and beatcn-up egg,8 ounces. 11 a.m. - Beef juice, 1/2 ounce (p. 78). 1 P.M. - Milk bovril, 6 ounces (p.

I64). 4 p.m. - Custard, 8 ounces. 7 P.M. - Junket and cream. 10 P.M. - Beef-tea, with toast.

Carbohydrate And Milk

7 A.M. - Milk, 6 ounces, and 3 teaspoonfuls Plasmon, diluted. 8.30 a.m. - Benger's food with milk, 6 ounces; thin slice of bread. 12 a.m. - Milk with Plasmon, and cocoa for flavour; bread and butter. 4 P.M. - Arrowroot boiled with milk and cream; milk (diluted), 6 ounces.

8 P.M. - Benger's food and milk (diluted), and 1 ounce prepared Plasmon, or junket and cream. 10 P.M. - Milk (diluted); bread and butter.

Diet Towards End Of The Third Week

7 a.m. - Milk, with biscuit, 10 ounces.

9 A.M. - Cocoa made with milk, 8 ounces. Bread and butter - toast and butter.

1 P.M. - Soup from a vegetable stock, thickened with milk and cream, 8 ounces; or a weak meat broth, all the vegetables carefully strained. Light milk pudding or custard, or blancmange. Milk to drink, 8 ounces. 4 P.M. - Milk, 8 ounces, flavoured with freshly made weak tea; a little cream, sponge biscuit, or rusk. 7 P.M. - Soup, as under the 1 o'clock meal; or a boiled or scrambled egg. Pudding - a custard, junket, or well-made milk pudding (p. 297).

10 P.M. - Milk, 8 ounces, with Horlick's malted milk, sponge biscuit, or rusk.

This diet may with advantage be maintained for a week or longer, if there is the slightest pain or discomfort with the food. In the majority of cases the following convalescent diet may be given in the fourth week: -

Convalescent Diet

Breakfast

Milk, 8 ounces, flavoured with tea, coffee, or cocoa. Bread and butter, or toast, or rusk. Egg (boiled, poached, or scrambled).

11 a.m. - Milk, 8 to 10 ounces, or milk with Horlick's malted milk, and a biscuit.

Lunch

Entrees, oysters, fish (steamed or plain boiled); or souffle, or creams; or Chicken or game souffle, or cream; tripe, or sweetbread; one vegetable, potato (mashed), cauliflower, etc. Milk pudding or custard, or a light savoury made with eggs. Milk, 8 ounces; dry toast. 4.30 p.m. - Freshly made tea, with milk and a biscuit.

Dinner

A light soup - consomme, strained mutton broth, or chicken soup; or vegetable stock thickened with milk or cream.

A meat course, as under Lunch, with one vegetable.

Milk pudding, with cream. 9.30 p.m. - Benger's food, with milk.

According to some physicians the rate of increase in the above diet sheets is unduly quick. These would aim at giving the diet allowed at end of fourth week not sooner than the end of the sixth week. Such a slow rate of increase is not as a rule necessary, and the rate of increase indicated in the diet list will be found generally applicable.

Other Systems Of Dietetic Treatment

In 1901 Lenhartz advocated a system of feeding for gastric ulcer based on a radically different principle. He contends that the use of rectal feeding and an exclusive milk diet does not give the stomach the rest that the advocates of these measures claim for them, and that it is better to use a food rich in protein, so as to neutralise the excess of acid that is frequently present in these cases. He recommended immediate feeding and a rapid daily increase of food. For the first week the diet is taken from eggs, milk, and a little sugar; in the second week, chopped meat, milk rice, butter, raw ham and zwieback are added; and at the end of fourteen days the patients are taking a highly nutritive diet, with a caloric value of over 3000 calories. On the first day, 8 to 10 ounces of iced milk with two beaten eggs are given in spoonful doses; on the third day, 20 ounces of milk and four eggs, and 20 grammes1 of sugar beaten up in the eggs; on the sixth day, six eggs, 30 grammes of sugar, and 1 1/2 to 2 pints of milk, with raw chopped meat from the dietary. On the eighth day the diet is increased to eight eggs, 40 grammes of sugar, 2 to 2 1/2 pints of milk, raw chopped meat, one piece of zwieback, and milk rice. The amount of food is gradually increased in the second week, until on the fourteenth day the patient is taking eight eggs, 50 grammes of sugar, 2 1/2 pints of milk, raw chopped meat, milk rice, zwieback, and in addition some raw ham and butter. According to this dietary, the food given on the fust, eighth, and fourteenth days after the haematemesis is as follows: -

Lenhartz Diet - First Day (All Food Iced)

7 a.m. - Milk and Vichy, equal parts, 21 /2 ounces.

9 A.M. - Milk and Vichy, and half egg (beaten), 2 ounces.

11 A.M. - Milk and Vichy, 2 1/2 ounces.

I P.M. - Milk and albumin water (1 egg), 2 1/2 ounces. 3 P.M. - Milk and Vichy, 2 1/2 ounces.

5 p.m. - Milk and Vichy, 2 1/2 ounces.

9 P.M. - Milk and Vichy and half egg, 2 1/2 ounces.

Lenhartz Diet - Eighth Day

7 A.M. - Milk, with 2 eggs beaten up, 8 ounces (sweetened). 9 a.m. - Milk (8 ounces), lightly boiled egg, and toast.

11 a.m. - Custard (with 1 egg, 10 ounces milk, and sugar). 1 p.m. - Raw-beef (scraped) sandwiches; 8 ounces milk.

3 P.M. - Benger's food, with milk (8 ounces). 5 P.M. - Custard, 8 ounces. 7 P.M. - Light farinaceous pudding, with milk. 9 P.M. - Raw-beef sandwich and milk.