At the end of two weeks after discon tinuance of bowel-feeding or three to five weeks when this has not been practiced, unsalted broth of mutton, or chicken, thickened with farina, or thoroughly cooked barley or rice, and subsequently strained, should he given. Alternately with this a beaten white of egg is added, somatose being still continued. Some what later gelatin and purees of young pease, beans, asparagus, and potato are allowed, as is either the pulp of scraped, lightly-broiled tenderloin steak, or the pulp of raw steak; the last then formed into cakes, quickly cooked on a very hot griddle. The white of a coddled egg may now also be taken, eaten with the addi tion of a few bread-crumbs, a little but ter, and a pinch of salt. This agreeing, on another day two whites may be eaten; and, finally, gastric symptoms being prac tically absent, the whole egg may be taken.
Overtaxing the stomach must be guarded against. The bodily nutrition must be raised and held so that complete and permanent healing of the ulcer occurs. On the slightest appearance of renewed symptoms a recurrence to the simplest kind of food must be had or even bowel-feeding again instituted. Gruels of wheat, barley, or oats, the meal finely ground, not salted in cook ing, to which milk is added afterward, may be tried in small quantities to re place the peptonized gruel at the end of ten days. A small quantity of an active diastasic preparation had better then be coincidently taken.
Two weeks represents a reasonable time to allow for the healing process and a fair average limit of toleration of exclusive rectal feeding. This period has been prolonged in two cases to five weeks, and has been shortened in others to meet the seeming demands of the special case. In a few cases rectal feed ing has clearly provoked stomach un rest and vomiting. In some others the period of ,bunch abstinence has Leen shortened on account of the refusal of the bowel to retain or absorb of varied coaxings. 11 discomfort per sists or hunger is importunate, small doses to grain--.,f morphine may be given once or oftener during the day.
Ordinarily a large cleansing is given daily and nutrient enemata el ery six 110111',. lu ,0111f• eases as much a. a.
pint of nourishment can be introdueed and absorbed every six lupi.-. For thirst sontel Mies small quant it les of water ark. allowed by the mouth. In other cases water may be introduced into the rectum or under the skin.
One important suggestion appears to result from the analysis of personal cases. 1)1 S5 cases, reports to date were obtaineo in 52. Of 63 eases treated by rectal feeding, the end result is known in 37. Of these 37, IS were fed exclusively by the rectum less than ten days, ann in 7 there has been a recur rence of severe symptoms. Of the 10 eases fed exclusively by the rectum for more than ten day-, there has been re currence in only 1. As far as present
figures go, they are strongly in favor of prolonged stomach rest. Shattuck (Jour. Amer. Aled. Assoc.. April 13. 19h11.
The object of the bismuth treatment is to protect the surface of the ulcer from the food passing over it. tends to break lift the tender granula tion tissue. Bismuth is also indicated in mild cases, when a change being made to solid diet, and on the occurrence of complications during convalescence. It must always come in contact with the ulcerated surface: so it should he riven on an empty stomach. The best plan is to wash out the stomach with one of the mineral waters, and then. half an hour later, 73 to 130 grains (3 to 10 gramme-) of bismuth, mixed with water. !nay be given. The dose can be gradually re duced by mixing it with magnesia. In other cases, directly after the washing out, 150 to 300 (10 to 21) of bismuth may be mixed witli 3 ounces (130 cubic centimetres) of water, and poured in. Changing the position of the patient is useful to distribute the bis muth. Heiner (Miinchener med. Wochen., No. 42, 1901).
In simple ulcer without complications the writer never advises surgical treat ment. When there are complications, one of two conditions will be present: There is more or less haemorrhage. If copious, use medical treatment only. If slight, but persistent, and medical means fail, resort to surgery. Surgical treat ment is necessary in the following cases: Intestinal perforation, subphrenic ab scess, pyloric stenosis; if cicatricial, peri gastritis in persons whose means will not permit long and expensive medical treat ment. Albert Robin ("International twelfth series, vol. ii, 1902). (See STOMACH, SURGERY Dilatation of the Stomach. Synonym.—G astrectasia_ This term is somewhat unfortunately employed to indicate a distinct morbid entity. No exact standard of gastric capacity exists for height or make-up. It is held that a stomach may be capacious (megalogastria) and yet not be, strictly speaking, dilated. Yet there is a limit of capacity beyond which dilatation may be said to exist, although symptoms of gastrectasia are not very evident; in all probability they have existed, though un noticed, and the gastric peristole is tem porarily sufficient. This limit of capacity per average height the writer places as approximately 1800 cubic centimetres; and yet a stomach of less capacity may be chronically so myasthenic as to consti tute dilatation for that individual. The presence of gastric dilatation is always indicative of some undue delay in the passage of food into the bowel. It is therefore characterized by atony of the stomach: i.e., weakness of the gastric ex pulsive forces.