In typical cases the diagnosis of a gastric ulcer is easy. Typical cases are those in which haematemesis has occurred as a sequel to symptoms of acute or chronic indigestion, which may have been of months or years duration. Atypical cases, however, are common, and in this the diagnosis is often a matter of difficulty. Some of the patients in both groups have to seek relief ultimately at the hands of the surgeon. Medical treatment is sufficient in the majority of cases, and in the medical treatment the most important factor is the diet. The dietetic treatment will necessarily vary with the actual condition of the patient when first seen. Thus, the patient may be seen immediately after hacmatc-mesis, her condition being one of prostration and collapse; or she may be seen some days or even weeks after the bleeding, by which time the ulcer may have largely healed, and the general condition of the patient is greatly improved. In other cases the patient only comes under observation for chronic symptoms, the condition pointing more or less clearly to a chronic ulcer, the treatment of which is primarily surgical. Yet, again, the condition may be one in which the practitioner is only justified in suspecting the existence of an ulcer, the treatment of the case being, however, essentially the same as for gastric ulcer. Lastly, the case may come under observation for the sequelae of old ulcerations, adhesions in the neighbourhood of the pylorus, with possibly some pyloric narrowing. In the last-mentioned group the symptoms are mainly those of gastric ulcer, and this treatment, as a rule, is surgical rather than medical.

The general principles of dietetic treatment in these cases will now be discussed.

Dietetic Treatment Of Gastric Ulcer After Haematemesis

The principle underlying the treatment of a case of hematemesis from gastric ulcer is to give the stomach rest. This should be as complete as possible. The patient is kept in bed, absolutely recumbent. If there is the least doubt about the bowels being open, an enema of soap and water should be given, and if necessary repeated, so as to thoroughly clean out the bowel. No food is given by the mouth for the first three or four days, during this period the patient is fed by the bowel. Rectal feeding, if it is to be continued for days or longer, requires great care and attention to details. The food given may be in the form of home-made preparations, consisting of peptonised gruels, and meat teas, eggs, milk, and brandy, or injections of normal saline solution containing I ounce of dextrose in 10 ounces of fluid. The nourishment should not be given oftener than six-hourly, even when nothing is being taken by the mouth. Preference should always be given to foods made at home, rather than the so-called nutrient suppositories. (For fuller details on Rectal Alimentation, see p. 221.) If great thirst is complained of, an injection of 10 to 20 ounces of normal saline is given by the bowel; and in cases where the haemorrhage has been very severe, and the state of the patient is one of great prostration, an intravenous injection of saline may be administered. It is probably better not to allow the patient small pieces of ice to suck, as the swallowing of the saliva induces slight peristalsis of the stomach, which may interfere with the natural healing powers of the ulcer. The dry, uncomfortable condition of the mouth may be alleviated by moistening the lips, gums, and tongue with hot water, provided there is no recurrence of the haemorrhage. On the third or fourth day a little food may be given by the mouth. To begin with, a tablespoonful of milk diluted by one-third or one-half with barley-water or lime-water may be administered. If necessary this should be peptonised, but as a rule this is unnecessary. If the result is satisfactory, and no pain or sickness is set up by it, this may be repeated every two hours. The main nourishment of the patienl is still, however, derived from the rectal reeding. The amount of food given by the mouth is added to daily. On the fifth or sixth day after the haemorrhage the patient may in favourable cases be taking from 1 to 1 1/2 pints of milk, diluted one-third, in the twenty-four hours, this being given in small doses every two hours. The following gives in tabular form the dietary after haematemesis, the stomach having had complete rest for the first three or four days.

Dietary In Hematemesis From Gastric Ulcer