GASTRIC ULCER AND DUODENAL ULCER.
An early diagnosis is of vital importance, and X-ray methods, by demonstrating important results after a bismuth meal, have cleared up many difficulties in the recognition of both gastric and duodenal ulcera tion.
Uncomplicated acute gastric ulcers, when treated early, usually heal rapidly. The main agents for insuring tins are rest and proper feeding, drugs taking a subordinate place.
Rest.—There must not only be rest to the stomach as far as is com patible with the demand for nutrition, hut bodily rest as near to absolute as possible is also essential. The patient should be put to bed and encour aged to lie fiat upon his back or in whatever position affords him the greatest ease and comfort. It is a good rule for the physician to state at the onset that this rest-cure must be maintained for a definite period— say 6 weeks—so that the patient may at once become resigned to his position, and cease worrying from day to day expecting to be permitted to leave his bed and being daily disappointed at not being allowed his freedom. He may be permitted to read, hut the holding up of a heavy volume or any other exertion bringing his voluntary muscles into constant or periodical action must be forbidden.
Rest to the stomach is to be afforded at the start by rectal feeding should pain or vomiting be prominent or should hamlorrhage be present. In the absence of all these the feeding by mouth with small amounts of liquid nourishment may be commenced. The milk may advantageously be peptonised or fresh milk diluted with half its bulk of lime or Kali water may be used. The object of the physician should be to administer the liquid nourishment in such small quantities at a time as will enable it to pass through the pylorus directly into the duodenum, thus gastric digestion as far as possible. In obstinate cases this may be usually satisfactorily accomplished by a nurse feeding the patient with a spoonful of milk at a time. If the vessel containing the liquid nourishment be handed to the patient he is liable at times to take such a draught of its contents as will reflexly call upon prompt closure of the pylorus till the casein is precipitated and the digestion of the mass is attended with all the ill consequences of a meal of solid food.
This usually arrests vomiting, and after a few days the amount given at a time may be gradually increased as the intervals are lengthened, and by the end of about S or io days smooth semi-liquid arrowroot or other impalpable farinaceous food may be cautiously tried in small quantities.
Strained soups may be permitted should the patient resent a pure milk dietary. By the end of the second week he may be allowed to swallow 5 oz. milk every hour during the twelve hours, which are ample for all the requirements of the body. A week later custard-pudding or carefully prepared boiled crumb of bread and milk may he given two or three times a day as an approach to the normal feeding-time of three or four times daily is made.
Lennartz commences with milk, and beaten-up egg given in teaspoonful doses, and inside a week adds raw minced meat to the liquid, followed in a few days by boiled rice, reaching a full mixed diet in 4 weeks. Rafsky recommends a partial rest-cure for 3 months, and gives 6 pints of milk daily in S oz. amounts.
Rectal feeding is imperative where severe vomiting or recent hwmate mesis has been present. The entire colon should be flushed out with a large tepid enema of water containing a teaspoonful of Bicarbonate and of Chloride of Sodium, soapy injections being unadvisable. A nutrient enema of peptonised milk (5 oz.) is after a short interval to be intro duced every 4 hours by a rubber tube 3 or 4 feet in length attached to a funnel, and every morning before recommencing rectal feeding the rectum or colon is to have one thorough wash out. When the patient shows tolerance of the enemata it will he wise to double the bulk of each and to lengthen the interval between them, by which means three or even four ; pints of Iluid may be administered during the waking hours. The peptonisation of the milk nay be safely permitted to proceed much farther than if prepared for mouth administration; thus it should be allowed to continue till marked bitterness is produced. Beaten-up eggs, gruel and oxblood and finely chopped meat and pancreas have been recommended, but the best results are obtainable from freshly peptonised milk and peptonised beef tea or chicken soup injected alter nately. Eggs are especially liable to irritate the rectum after a time, but uncooked white of egg can often be peptonised along with the milk or soup.