Part 86

In estimating the prognosis one should bear in mind the possibility of relapses; of a continuance of gastric disorders, particularly of gastralgia, after cicatrization; of the formation of cicatricial stenosis of {519} the orifices of the stomach; and of the development of dilatation of the stomach.

After the worst has been said concerning the unfavorable issues of gastric ulcer, it yet remains true that the essential tendency of the ulcer when placed under favorable conditions is toward recovery, and that in many cases the treatment of the disease affords most excellent results, and is therefore a thankful undertaking for the physician.

TREATMENT.--In the absence of any agent which exerts a direct curative influence upon gastric ulcer the main indication for treatment is the removal of all sources of irritation from the ulcer, so that the process of repair may be impeded as little as possible.

Theoretically, this is best accomplished by giving to the stomach complete rest and by nourishing the patient by rectal alimentation. Practically, this method of administering food is attended with many difficulties, and, moreover, the nutrition of the patient eventually suffers by persistence in its employment. In most cases the patient can be more satisfactorily nourished by the stomach, and by proper selection of the diet, without causing injurious irritation of the ulcer.

At the beginning of the course of treatment it is often well to withhold for two or three days all food from the stomach and to resort to exclusive rectal feeding. In some cases with uncontrollable vomiting and after-hemorrhage from the stomach it is necessary to feed the patient exclusively by the rectum.

The substances best adapted for nutritive enemata are artificially-digested foods, such as Leube's pancreatic meat-emulsion, his beef-solution, and peptonized milk-gruel as recommended by Roberts. Beef-tea and eggs, which are often used for this purpose, are not to be recommended, as the former has very little nutritive value, and egg albumen is absorbed in but slight amount from the rectum. Expressed beef-juice may also be used for rectal alimentation. The peptones, although physiologically best adapted for nutritive enemata, often irritate the mucous membrane of the rectum, so that they cannot be retained. It has been proven that it is impossible to completely nourish a human being by the rectum. Rectal alimentation can sometimes be advantageously combined with feeding by the mouth.

The milk-gruel is prepared by adding a thick, well-boiled gruel made from wheaten flour, arrowroot, or some other farinaceous article to an equal quantity of milk. Just before administration a dessertspoonful of liquor pancreaticus (Benger) or 5 grains of extractum pancreatis (Fairchild Bros.), with 20 grains of bicarbonate of soda, are added to the enema. This may be combined with peptonized beef-tea made according to Roberts's formula (Roberts, On the Digestive Ferments, p. 74, London, 1881).

Preparatory to beginning the treatment the bowels should be emptied by a clyster, and this should be occasionally repeated. About three to six ounces of the tepid nutritive fluid should be slowly injected into the rectum. The injections may be repeated at intervals of from three to six hours. If necessary, a few drops of laudanum may be occasionally added to the enema.]

There is universal agreement that the dietetic treatment of gastric ulcer is of much greater importance than the medicinal treatment. There is {520} hardly another disease in which the beneficial effects of proper regulation of the diet are so apparent as in gastric ulcer. Those articles of food are most suitable which call into action least vigorously the secretion of gastric juice and the peristaltic movements of the stomach, which do not cause abnormal fermentations, which do not remain a long time in the stomach, and which do not mechanically irritate the surface of the ulcer. These requirements are met only by a fluid diet, and are met most satisfactorily by milk and by Leube's beef-solution.

The efficacy of a milk diet in this disease has been attested by long and manifold experience. By its adoption in many cases the pain and the vomiting are relieved, and finally disappear, and the ulcer heals. In general, fresh milk is well borne. If not, skimmed milk may be employed. If the digestion of the milk causes acidity, then a small quantity of bicarbonate of soda or some lime-water (one-fourth to one-half in bulk) may be added to the milk. Large quantities should not be taken at once. Four ounces of milk taken every two hours are generally well borne. Sometimes not more than a tablespoonful can be taken at a time without causing vomiting, and then of course the milk should be given at shorter intervals. It is desirable that the patient should receive at least a quart, and if possible two quarts, during the twenty-four hours. The milk should be slightly warmed, but in some cases cold milk may be better retained. In some instances buttermilk agrees with the patient better than sweet milk. Although many suppose that they have some idiosyncrasy as regards the digestion of milk, this idiosyncrasy is more frequently imaginary than real. Still, there are cases in which milk cannot be retained, even in small quantity.

For such cases peptonized milk often proves serviceable. The artificial digestion of milk as well as of other articles of food is a method generally applicable to the treatment of gastric ulcer. The main objection to peptonized milk is the aversion to it that many patients acquire on account of its bitter taste. The peptonization should not be carried beyond a slightly bitter taste. The disagreeable taste may be improved by the addition of a little Vichy or soda-water. Peptonized milk has proved to be most valuable in the treatment of gastric ulcer.

Leube's beef-solution is a nutritious, unirritating, and easily-digested article of diet. It can often be taken when milk is not easily or {521} completely digested, or when milk becomes tiresome and disagreeable to the patient. It is relied upon mainly by Leube in his very successful treatment of gastric ulcer. A pot of the beef-solution (corresponding to a half pound of beef) is to be taken during the twenty-four hours. A tablespoonful or more may be given at a time in unsalted or but slightly salted bouillon, to which, if desired, a little of Liebig's beef-extract may be added to improve the taste. The bouillon should be absolutely free from fat. Unfortunately, not a few patients acquire such a distaste for the beef-solution that they cannot be persuaded to continue its use for any considerable length of time.

Freshly-expressed beef-juice is also a fairly nutritious food, which can sometimes be employed with advantage. The juice is rendered more palatable if it is pressed from scraped or finely-chopped beef which has been slightly broiled with a little fresh butter and salt. The meat should, however, remain very rare, and the fat should be carefully removed from the juice.

To the articles of diet which have been mentioned can sometimes be added raw or soft-boiled egg in small quantity, and as an addition to the milk crumbled biscuit or wheaten bread which may be toasted, or possibly powdered rice or arrowroot or some of the infant farinaceous foods, such as Nestle's. Milk thickened with powdered cracker does not coagulate in large masses in the stomach, and is therefore sometimes better borne than ordinary milk.

For the first two or three weeks at least the patient should be confined strictly to the bill of fare here given. Nothing should be left to the discretion of the patient or of his friends. The treatment should be methodic. It is not enough to direct the patient simply to take easily-digested food, but precise directions should be given as to what kind of food is to be taken, how much is to be taken at a time, how often it is to be taken, and how it is to be prepared.

In all cases of any severity the patient should be treated in bed in the recumbent posture, and warm fomentations should be kept over the region of the stomach. Mental and physical fatigue should be avoided.

Usually, at the end of two or three weeks of this diet the patient's condition is sufficiently improved to allow greater variety in his food. Meat-broths may be given. Boiled white meat of a young fowl can now usually be taken, and agreeable dishes can be prepared with milk, beaten eggs, and farinaceous substances, such as arrowroot, rice, corn-starch, tapioca, and sago. Boiled sweetbread is also admissible. Boiled calf's brain and calf's feet are allowed by Leube at this stage of the treatment.

To these articles can soon be added a very rare beefsteak made from the soft mass scraped by a blunt instrument from a tenderloin of beef, so that all coarse and tough fibres are left behind. This may be superficially broiled with a little fresh butter. Boiled white fish, particularly cod, may also be tried.

It is especially important to avoid all coarse, mechanically-irritating food, such as brown bread, wheaten grits, oatmeal, etc.; also fatty substances, pastry, acids, highly-seasoned food, vegetables, fruit, and all kinds of spirituous liquor. The juice of oranges and of lemons can usually be taken. The food should not be taken very hot or very cold.

For at least two or three months the patient should be confined to the {522} easily-digested articles of diet mentioned. These afford sufficient variety, and no license should be given to exceed the dietary prescribed by the physician. Transgression in this respect is liable to be severely punished by return of the symptoms. When there is reason to believe that the ulcer is cicatrized, the patient may gradually resume his usual diet, but often for a long time, and perhaps for life, he may be compelled to guard his diet very carefully, lest there should be a return of the disease. Should there be symptoms of a relapse, the patient should resume at once the easily-digested diet described above.

Medicinal treatment of gastric ulcer, although less efficacious than the dietetic treatment, is not to be discarded. Since its advocacy by Ziemssen the administration of Carlsbad salts or of similarly composed salts belongs to the systematic treatment of gastric ulcer. The objects intended to be accomplished by the use of these salts are the daily evacuation of the contents of the stomach into the intestine by gentle stimulation of the gastric peristaltic movements, the neutralization of the acid of the stomach, and the prevention of acid fermentations in the stomach. Of these objects the most important is the prevention of stagnation of the contents of the stomach. The chief ingredients of the Carlsbad waters are sulphate of sodium, carbonate of sodium, and chloride of sodium. The most important of these ingredients is sulphate of sodium (Glauber's salts), which by exciting peristalsis propels the gastric contents into the intestine, and thus relieves the stomach of its burden, prevents fermentation, and removes from the surface of the ulcer an important source of irritation. The carbonate of sodium neutralizes the acids of the stomach, but the main value of this ingredient and of the chloride of sodium is that in some way they correct the action of the Glauber's salts, so that the latter may be taken in smaller quantity and without the usual unpleasant effects of pure Glauber's salts. The artificial Carlsbad salts are to be preferred to the natural or the artificial Carlsbad water. The natural Carlsbad salts and much of those sold as artificial Carlsbad salts consist almost wholly of sulphate of sodium. It is therefore best to prescribe in proper proportion the leading ingredients of these salts. A suitable combination is sulphate of sodium five ounces, bicarbonate of sodium two ounces, and chloride of sodium one ounce (Leichtenstern). The relative proportion of the ingredients may of course be varied somewhat to suit individual cases. The salts are to be taken daily before breakfast dissolved in a considerable quantity of warm water. One or two heaping teaspoonfuls of the salts are dissolved in one-half to one pint of water warmed to a {523} temperature of 95° F. One-fourth of this is to be drunk at a time at intervals of ten minutes. Breakfast is taken half an hour after the last draught. After breakfast there should follow one or two loose movements of the bowels. If this is not the case, the next day the quantity of the salts is to be increased, or if more movements are produced the quantity is to be diminished until the desired result is obtained. In case the salts do not operate, an enema may be used. Usually, to obtain the same effect, the quantity of salts may be gradually diminished to a teaspoonful.

According to a prescription very commonly used in Germany, the Carlsbad salts are made by taking sulphate of sodium 50 parts, bicarbonate of sodium 6 parts, chloride of sodium 3 parts. Dose, a teaspoonful dissolved in one or two tumblers of warm water (Ewald u. Lüdecke, Handb. d. Allg. u. spec. Arzneiverordnungslehre, Berlin, 1883, p. 480).]

The Carlsbad salts are directed especially against the chronic gastric catarrh which complicates the majority of cases of ulcer of the stomach. It is well known that the most effective method of treating this morbid condition is the washing out of the stomach by means of the stomach-tube. The propriety of adopting this procedure in gastric ulcer comes, therefore, under consideration. Although the use of the stomach-tube in gastric ulcer is discarded by Leube and by Sée on account of its possible danger, nevertheless this instrument has been employed with great benefit in many instances of this disease by Schliep, Debore, and others. No instance of perforation of an ulcer by means of the stomach-tube has been reported, and in general no evil effects have resulted; but Duguet cites a case of fatal hemorrhage following washing out of the stomach. In view of the great benefit to be secured by washing out the stomach, and of the comparatively slight danger which attends the process, it seems justifiable to adopt this procedure cautiously and occasionally in cases of gastric ulcer with severe gastric catarrh. Of course only the soft rubber tube should be used, and the siphon process should be adopted. The stomach may be washed out with pure warm water or with water containing a little bicarbonate of sodium (one-half drachm to a quart of water). The occasional cleansing of the stomach in this way can hardly fail to promote the healing of the ulcer. Recent or threatened hemorrhage from the stomach would contraindicate the use of the stomach-tube.

Beyond the measures indicated there is little more to do in the way of treatment directed toward the repair of the ulcer. Not much, if anything, is to be expected from the employment of drugs which have been claimed to exert a specific curative action on the ulcer. Of these drugs those which have been held in the greatest repute are bismuth and nitrate of silver. Trousseau devised a somewhat complicated plan for administering bismuth and nitrate of silver in succession for several months in the treatment of gastric ulcer. There are few who any longer cherish any faith in these drugs as curative of gastric ulcer. The same may be said of other drugs which have been thought to have similar specific virtue in the treatment of gastric ulcer, such as acetate of lead, arsenic, chloral hydrate, iodoform, etc.

{524} It remains to consider therapeutic measures which may be necessary to combat individual symptoms of gastric ulcer.

The pain of gastric ulcer is generally relieved in a few days by strict adherence to the dietetic regimen which has been laid down. When this is not the case, it may be best to withhold all food from the stomach and to nourish by the rectum. But this cannot be continued long without weakening the patient, and sometimes the pain persists in spite of the rest afforded the stomach. Undoubtedly, the most effective means of quieting the pain of gastric ulcer is the administration of opium in some form. Opium should not, however, be resorted to without full consideration of the possible consequences. When the use of this drug is once begun, the patient is liable to become dependent upon it, and may be inclined, consciously or unconsciously, to exaggerate the pain in order to obtain the narcotic. When prescribing opium in this disease the physician should have in mind the danger of establishing the opium habit. Moreover, opium retards digestion, and is anything but an aid to the proper dietetic regimen, which is all-important. If it is decided to give opium, it does not matter much in what form it is administered, but the dose should be as small as will answer the purpose. Hypodermic injections of morphine over the region of the stomach may be recommended. Codeia often produces less disturbance than opium or morphine. A useful powder for the relief of pain is one containing 8 or 10 grains of subnitrate of bismuth, 1/12 grain of sulphate of morphia, and 1/5 grain of extract of belladonna. Much of the beneficial effect attributed to bismuth is in reality due to its customary combination with a small quantity of morphine. Before resorting to opium in cases of severe pain it will be well to try some of the other means for relieving the pain of gastric ulcer, although they are less effective. Gerhardt thinks that astringents are better than narcotics to relieve the pain of ulcer, and he recommends for the purpose three or four drops of solution of chloride of iron diluted with a wineglassful of water, to be taken several times daily. Although this recommendation is from high authority and is often quoted, sufficient confirmatory evidence of its value is lacking. Other medicines recommended are hyoscyamus, belladonna, choral hydrate, chloric ether, hydrocyanic acid, bismuth, nitrate of silver, and compound kino powder. Sometimes warm fomentations, at other times a light ice-bag over the epigastrium, afford marked relief of the pain. Counter-irritation over the region of the stomach has also given relief. This may be effected with a mustard plaster or by croton oil. I have known the establishment of a small nitric-acid issue in the pit of the stomach to relieve the pain, but such severe measures of counter-irritation are generally unnecessary. The application of a few leeches over the epigastrium has been highly recommended, but this should be done without much loss of blood. The effect of position of the body upon the relief of pain should be determined. When the pain is due to flatulence or to acid fermentation in the stomach, the treatment should be directed to those states.

The most effective means of controlling the vomiting in gastric ulcer are the regulation of the diet and, if necessary, the resort to rectal alimentation. Absolute rest should be enjoined. Whenever small quantities of milk, peptonized or in any other form, cannot be retained, then exclusive rectal feeding may be tried for a while. There have been cases of gastric {525} ulcer when both the stomach and the rectum have been intolerant of food. In such desperate cases the attempt may be made to introduce food into the stomach by means of the stomach-tube, for it is a singular fact that food introduced in this way is sometimes retained when everything taken by the mouth is vomited. The cautious washing out of the stomach by the stomach-tube may prove beneficial. In these cases the attempt has also been made to nourish by subcutaneous injections of food. In a case of gastric ulcer where no food could be retained either by the stomach or by the rectum Whittaker injected subcutaneously milk, beef-extract, and warmed cod-liver oil. The oil was best borne. The injections were continued for four days without food by the mouth or rectum. The patient recovered. At the best, hypodermic alimentation can afford but slight nourishment, and is to be regarded only as a last refuge. If there is danger of death by exhaustion, transfusion may be resorted to.

Bernutz practised successfully in two cases the hypodermic injection of fresh dog's blood (Gaz. des Hôp., 1882, No. 64).