CIIRONIC GASTRIC ULCER.—This type of ulcer may exhibit its presence by a return of the usual symptoms some time after the patient has been freed from all pain and discomfort by a prolonged rest-cure, in which case it really belongs to the class recognised as the recurring ulcer. It is, however, liable to finally pass into the chronic type and become identical with those examples of the disease constantly met with by the physician in which, without any history of an acute attack, the patient has suffered for years from symptoms of gastric ulcer with or without occasional slight attacks of hxmatemesis.
If the rest-cure has not been already tried, or if only a short stay in bed has been submitted to, the question arises of whether a prolonged rest in bed with restricted diet should be recommended or immediate resort to operation decided upon. The patient usually settles the problem for himself by accepting the former alternative. In which case it must be insisted upon that a period of less than x2 weeks of absolute rest and dieting is useless, and he should be warned that at the termination of this time an operation may be still necessary.
The treatment to be pursued during the three months of the rest-cure is to be upon the same lines as have been described for acute cases. Rectal feeding will, however, be rarely required in these patients, and a larger bulk of the liquid nourishment may be permitted, but this should not exceed 2 oz. of milk per hour for the first week, and double this quantity, or at most 5 oz., should not be exceeded till the end of the first month; most patients can live upon this latter quantity when at absolute rest; it works out at about 3 pints of milk consumable during the waking hours. It may, however, be supplemented by strong clear soup, or beef tea at times. Most physicians recommend that minced meat, fish, bread, &c., should be given after a couple of weeks, but the patient should rigorously adhere for at least 2 months to a perfectly fluid diet, or one in which impalpable farinaceous foods like arrowroot, corn flour, or oaten flour are alone used as in the dietary for typhoid fever.
The milk should not be peptonised unless under special circumstances. Renneted milk may be used freely and uncooked white of egg with a little chicken soup, and occasionally Benger's food may be given. If the patient does not tire of the smooth or liquid diet it may be prolonged after he is permitted to move about. Olive Oil as an article of diet is sometimes most valuable, and may be freely used in many cases.
Drug treatment is of more importance in the chronic than in the acute type of ulcer owing to the almost constantly present gastric catarrh, and the best routine is the combination of Papain 2 grs. with 3o grs. Bi carbonate of Soda, and an equal amount of Heavy Magnesia and r. Morphia, given every 6 or S hours alternately with a 2 or 3 min. capsule of Creosote 3 or 4 times a day or 3j. doses of Bismuth Carbonate.
Lavage may safely be employed in many cases if a very soft tube be used, though this agent is inadmissible in the acute type of ulcer where spontaneous perforation is more liable to occur than in ulcers with greatly indurated margins, as in the condition at present under consideration, but the stomach should never he distended with more than 10 oz. of liquid at a time. Where the patient can induce vomiting by swallowing a n to i pint of lukewarm water containing a teaspoonful of bicarbonate of soda this method answers all purposes when much catarrh with mucous secretion is present. The addition of Creosote or other antiseptic to the water used for lavage is often beneficial, and Professor Stewart's method of washing out with Nitrate of Silver might be tried.
The pain of chronic ulcer must be carefully investigated; often this remains permanent after complete cicatrisation has occurred, in which case it is due to the dragging of adhesions and can usually be differentiated from the pain which is caused by food or hyper-acid secretion coming into contact with the ulcerated surface. Fibrolysin injections may be resorted to before operation is decided upon in such cases.