118 Clinique médicale, t. iii. p. 95, Paris, 1865.
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 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.119 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 Whittaker120 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.
119 Debore, L'Union médicale, Dec. 30, 1882, and Gaz. des Hôp., April 29, 1884. For this reason Debore makes extensive use of the stomach-tube in general in feeding patients affected with gastric ulcer. He objects to an exclusive milk diet on account of the quantity of fluid necessary to nourish the patient, which he says amounts to three to four quarts of milk daily. To avoid these inconveniences, he gives three times daily drachm viss of meat-powder and drachm iiss of bicarbonate of sodium (or equal parts of calcined magnesia and bicarb. sod.), well stirred into milk. This is to be introduced by the stomach-tube on account of its disagreeable taste. He believes that the addition of the large quantity of alkali prevents digestion from beginning until the food has reached the intestine. He also gives daily a quart of milk containing grs. xv of saccharate of lime. Debore's method of preparing the meat-powder is described in L'Union médicale, July 29, 1882, p. 160. He also uses a milk-powder (ibid., Dec. 30, 1882; see also Le Progrès méd., July 12, 1884).
120 J. T. Whittaker, "Hypodermic Alimentation," The Clinic, Jan. 22, 1876.
Bernutz practised successfully in two cases the hypodermic injection of fresh dog's blood (Gaz. des Hôp., 1882, No. 64).
Krueg (Wiener med. Wochenschr., 1875, No. 34) injected 15 cc. of olive oil twice a day subcutaneously without causing abscesses.
Menzel and Porco were the first to employ hypodermic alimentation (ibid., 1869, No. 31).
Of remedies to check vomiting, first in importance are ice swallowed in small fragments and morphine administered hypodermically. Effervescent drinks, such as Vichy, soda-water, and iced champagne, may bring relief. Other remedies which have been recommended are bismuth, hydrocyanic acid, oxalate of cerium, creasote, iodine, bromide of potash, calomel in small doses, and ingluvin. But in general it is best to forego the use of drugs and to rely upon proper regulation of the diet, such as iced milk taken in teaspoonful doses, and upon repose for the stomach.