A week is the limit during which the rectal feeding should be persisted in for maintaining the nutrition of the body; often 3 or 4 days suffice. But circumstances often arise in which a combined mouth and rectal alimentation may be advantageously employed for long periods, and the writer frequently directs that the small quantities of milk administered during the first so days by the mouth should be supplemented by a nutrient suppository every.} hours, and this is a most satisfactory practice, against which no objection can be seriously made.
I3y the above rest and dietetic method, most cases of gastric ulcer can be effectually dealt with, and perfect healing of the sore secured in 4 to 6 weeks, and often less, but the return to solid food must be tentative and cautious, the experiment being best made first with well-boiled soft white fish, followed afterwards by tender young chicken, minced under-cooked red meat, or a portion of the fillet of an under-cooked sirloin.
Drugs are indicated only for the relief of symptoms arising during the treatment. Thus Morphia is always most valuable when irritability of the stomach is present, but it should be given in such minute doses as do not affect the cerebrum, as first suggested by Trousseau; a morphia perule gr.) is often most effective in preventing vomiting. Being not larger than the head of a pin, it seldom is ejected, and Brinton believed that opium always facilitated the healing process in the ulcer.
Sippy, with rest and dietetic measures, employs Alkalies as part of the routine to neutralise the hyperacidity, giving in duodenal cases sometimes as much as so° grs. Sodium Bicarbonate every hour alternating with the feedings by milk and cream. The complications which arise in severe cases will, however, usually afford marked indications for the exhibition of drugs, thus: this is severe, a small blister (3 by 3 inches) should be applied in the middle line half-way between the sternum and umbilicus. It is more efficacious and often less irritating to the patient than a large sinapism. Warmth may be soothing, but occasionally ice affords relief. Pain should always be an indication for rest if the patient be not already lying up for treatment. Morphia in gr. doses may be safely given at short intervals, and some physicians still place their faith in the pain relieving reputation of Bismuth, which has been given up to the amount of oz. gr. Atropine may be tried where opium is contra-indicated,
or 2 mins. Hydrocyanic Acid or a gr. Cocaine may be combined with the bismuth. Often a small soft gelatin capsule containing i min. Creosote acts as a local analgesic, and a small piece of ice swallowed whole may be taken along with it.
In subacute and chronic ulcer the pain, which is often markedly aggravated by changes of posture, is usually due to the traction on old adhesions, and has been successfully met by injections of Fibrolysin. A. B. Mitchell, in a case where this treatment was being pursued (but which demanded abdominal section owing to perforation), found that old fibrous adhesions away from the seat of ulceration were already so softened and disintegrated that they broke down on a touch from the finger. The pain in chronic ulcer has been sometimes relieved by a dose of Fowler's solution.
When the pain in recent and active cases is due to hyperchlorhydria marked relief may be obtained by administering alkalies. Carlsbad and Vichy Waters have been given with much success for this purpose, and Jaworski has demonstrated that the former has the power of diminishing hyper-secretion. Ewald likewise pronounces in favour of Carlsbad Water. Olive Oil in z doses has its advocates, and it certainly tends to diminish the hyperacidity.
Vomiting.—When this does not yield to minute doses of Morphia a sinapism or ice to the epigastrium and small particles of ice by the mouth and rectal feeding must be instituted. In rare cases vomiting may be actually produced by the nutrient enema when it was previously absent as a symptom. 12 to 24 hours of starvation may then be the only resource left to the physician during which normal Saline or Glucose solution should be injected subcutaneously. As a last resource a full dose of Morphia hypodermically may be given. Effervescing liquids may be tried, but they are often useless, and Champagne usually aggra vates the condition. The writer has seen sour Buttermilk retained when everything else was speedily rejected; especially when a small quantity of Kali water is previously mixed with it its sedative action is most valuable.