The Bismuth mixture on p. 237 may be used in ordinary cases as a safe routine, and Cocaine, though useless by itself, may be combined with it.
ILEMATEMESIS.—Rest must be insisted upon, and ice applied to the stomach between two layers of lint, or a light extemporised ice-bag made of gutta-percha tissue may be laid over the epigastrium. All food by the mouth must be stopped, and even ice by the mouth, if given at all, should be only permitted in such minute quantities as will serve to assuage intense thirst. A little may be safely permitted for sucking in the mouth if the water be allowed to flow out without swallowing it.
21 Rectal feeding must be resorted to, but before introducing the pep tonised milk an enema containing 6o grs. of Chloride of Calcium dissolved in 4 oz. water should be given. In severe hemorrhage, when this is not retained, the physician should give a large subcutaneous injection of Saline solution, with which 3o grs. of the lime salt may be combined.
20 mins. Adrenalin Solution (c in i,000) may he given every hour for three doses in a teaspoonful of water should the hxmorrhage continue, and both drugs may advantageously be used at the same time, the calcium being given by the rectum and the adrenalin by the mouth. A full hypodermic of Morphia is often very necessary to allay the profound nervous excitement usually occasioned by the bringing up of large quantities of blood. All so-called astringent remedies, including ergot, tannin and turpentine, should never be given.
The Hart treatment of gastric ulcer is said to be of special value in bleeding cases. It consists in rest and restricted dietary, with the administration of i dr. of fresh serum obtained from the blood of the horse diluted with 3 drs. water three or four times a day, or io c.c. of Horse Serum given subcutaneously or intramuscularly.
Severe recurring hxmatemesis is a clear indication for surgical measures as soon as the shock of the hxmorrhage has subsided.
Many authorities insist upon the importance of Iron in the treatment of all cases of gastric ulcer, and it is a routine in Lenhart's method; he gives 5 grs. of the sulphate in pills ter die, beginning at the end of the first week. Ewald likewise commences Iron and Arsenic as soon as the acute symptoms have subsided, and he maintains that both drugs are always well borne in the disease. In hcemorrhagic cases, after the bleeding has been stopped, certainly iron is more clearly indicated, and the best method of employing it is to give teaspoonful doses of a 2 per cent. solution of the Perchloride mixed with a wineglassful of solution of egg albumin in water (1 in 3) sucked through a glass tube. The
administration of iron by the rectum, as recommended by several, is probably a mistake, since the metal is eliminated by the mucosa of the rectum. Saundby administers 2 grs. Sulphate of Iron with 6o grs. Magnesium Sulphate in r oz. water, and Bourget washes the stomach out with a 2 per cent. solution of the Perchloride, to which I per cent. Chlorate of Potash has been added.
Nitrate of Silver in full doses (2 grs.) given in pill has been recom mended in mild recurring lilemorrhage in acute cases, and as a routine in simple chronic cases with the view of exciting healing; and Stewart injects the stomach with a r in 1,000 solution oz.), which is siphoned off after 2 to 4 minutes, the stomach being then washed out; a large close of Bismuth suspended in water is left in the viscus.
PliufoRATioN.--Operative measures must be resorted to with as little delay as possible as soon as the signs and symptoms of this grave com plication have manifested themselves. The case for operation may be stated in the following sentence: Without operation 5 in too cases at tlic most can be expected to survive; with operation a similar number may be expected to die. This places the mortality of the operation for gastric perforation at only 5 per cent., the figure which Mayo Robinson believes it will reach when all cases are operated upon promptly after the perforation. At present the mortality is much higher because many cases are included in the statistics where operation has been postponed till peritonitis has been established. Having established the diagnosis of acute perforation, no time should be lost in arranging for operation. Whilst preparations for this are taking place the patient should be given a hypodermic injection consisting of 3 gr. morphia with atropia; he should he set up in bed with the shoulders well raised, so that extra v asation, if it takes place, shall be downwards towards the pelvis and not upwards towards the subphrenic region; he should he kept quiet and warm—warmth being essential in the prevention of shock. Nothing should be allowed by mouth, and the administration of saline by the rectum is withheld at this stage, unless shock be marked, owing to its influence bn the subsequent production of bronchopneumonia, one of the most serious complications of these cases. The abdomen is now prepared for operation by dry shaving and painting with Tr. Iodi; on the table a further painting with Tr. Lodi will alone be necessary before the incision is made.