TREATMENT OF CERTAIN S['ECIA1 SYMPTOMS. — Vomiting, however obsti nate previously, usually ceases within a few days after instituting bowel-feeding, when nothing is allowed by the mouth. If hot or cold applications are resultless, a small blister, one and a half inches square, is applied to the epigastrium. If mouth-feeding must be continued, only the smallest quantity of peptonized milk-gruel, expressed meat-juice, or koumyss, or some such light food, should be allowed. No medicine can be ex pected to invariably control vomiting in ulcer. (See the treatment of vomiting [ACUTE GASTRIC CATARRH] .) Mor phine hypodermically may be required, other remedies failing. Strontium or sodium bromide by the rectum is often of signal service in controlling the vom iting (40 grains in 3 ounces of water).
Treatment of Gastric Hemorrhage Oc curring in (Peen—Absolute physical and mental rest is enjoined. Nourishment must be solely by the bowel. Cold ap plications are applied to the epigastrium.
Morphine is administered hypodermic ally in a full dose. Ergot is of no utility in bleeding from erosion of au artery. It had better not be employed. Hydrastine hydrochlorate is worthy of trial given hypodermically at intervals of two to three hours ( V, to grain) Fluids taken by the mouth should be cold. Pellets of ice may be swallowed to allay thirst and a light-weight ice-bag applied to the epigastrium. The ex tremities must be kept warm. The foot of the bed is to be elevated if necessary and the extremities bandaged. Ilypo dermoclysis may be required. If so, sterilized, normal salt solution may be employed or preferably the solution of tribasic calcium phosphate and potas sium chloride. The colon may be flooded with hot salt solution. Instead of hypodermoclysis, the solution may be passed directly into a vein. Strych nine, atropine, and perhaps also digitalin, may be required hypodermically to sus tain the flagging heart. Hypodermic in jection of camphor is also of service in this direction.
There is no question as to the immense benefit to be obtained by complete rest abed and bowel-feeding in ulcer, even though local treatment is impracticable, and even the use of bismuth by the mouth by reason of great gastric irrita bility or hmemorrhage, cannot be em ployed. With anaemia controlled by the addition of iron to the nutritive enema and symptomatic conditions otherwise met, great improvement may be expected at the end of a week or two, when it is thought desirable to rebegin cautiously mouth-feeding.
Mouth-feeding Subsequent to that by the Bo•el.—lt is not to be begun for a week after vomiting and localized pain have disappeared. The most extreme caution should be enjoined as to this to obtain the best results. Several weeks should elapse before other than the simplest food is administered.
As to the use of milk in gastric ulcer a word must here be said: Milk given with the idea of maintaining the stomach in a state of rest is a fallacy. Only in the very rare cases in which there is ab sence of the secretory function would milk pass as a bland and unirritating liquid into the duodenum, to be digested in the bowel; but with preserved or heightened secretory function milk must act somewhat as an irritant. In hyper
chlorhydria there is always a large amount of the milk-curdling ferment in the gastric juice, and the consequence is that firm coagnla promptly result, which must be irritating to the ulcer and stimu lating to the motor function as other solid food. Milk is scarcely rendered more digestible by the admixture of an antacid to the milk for reasons I have detailed at length in another publica tion. Briefly, it should be said that the curdling of the milk is thus rather en hanced (in cases of hyperchlorhydria) and its subsequent digestion interfered with. If milk is used at all in gastric ulcer it should be first pancreatized. It is thus so changed that formation of more than traces of curd is impossible, and it is in condition to pass at once predigested into the bowel for rapid ab sorption there to occur. Antacids may then he freely and harmlessly given to neutralize the EEC' of the gastric secre tion, as the latter is not required for digestion of the milk-curd. Then little or no demand will he made on the secre tory function, and the motor function will also be practically untaxed. The great objection to peptonized milk is its taste. This is partially obviated by not prolonging the period of peptonization beyond the faintly bitter stage and then raising the temperature of the milk to a point sufficient to destro3 the contained ferment. The milk should not be boiled. Better than peptonized milk is pep tonized milk-gruel. The writer al most habitually employs a diet of pcp tonized milk-gruel in all cases of ulcer in the early part of the treatment, when feeding by the bowel is not practiced. Ile commonly also uses it as the first food for a number of days on the cessa tion of bowel-feeding, giving antacids systematically when there is hyperchlor hydria. But small quantities are allowed at first. It is well to start with a table spoonful of peptonized milk-gruel every half-hour until 3 to 6 tablespoonfuls are taken. Later give 1 ounce every hour for three or four feedings, then 2 ounces every two hours for two or four feed ings, and then 3 ounces every two hours. Increase this on the third day to 4 ounces every two hours, and this gradu ally increase to 6 ounces in the same time. Somatose is now combined with the milk-gruel, at first in doses until on the third or fourth day after starting it a heaping teaspoonful is taken at every alternate feeding. On in stituting mouth-feeding the bowel-feed ing is not discontinued abruptly. At first the midday feeding is omitted; in two or three days either the morning or even ing feeding is dropped; and, finally, in a day or so, the stomach continuing tolerant, bowel-feeding is stopped. The solution of albuminate of iron mentioned is given alternately with the somatose, and after a time in a small dose with each mouth-feeding. The initial dose of the iron solution is 20 drops, increased by 5 to 10 drops, until a large teaspoonful is reached, and this at the end of a week is increased to 2 teaspoonfuls four times daily, and this later to a tablespoonful.