The treatment of ulcer divides itself into the selection of surgical and medical cases.
Cases recommended for surgery are of five varieties:.
First perforating ulcer.
Second, cases in which there is repeated haemorrhage.
Third, cases of organic obstruction at the pylorus.
Fourth, carcinomatous degenerations of ulcer.
Fifth, intractable or recurrent ulcer.
It will consume all the time that has been allotted to me to discuss each of these types individually.
For diagnosis you are referred to other discussions.
In a general way, ulcer itself can be divided into the superficial type, the penetrating type, and the perforating type. The first is medical absolutely, the second is usually medical, and the third is surgical absolutely.
In so far as symptomatology is concerned, little that is new has appeared in the past year. At the office we are placing more and more dependence upon area and of tenderness just beneath the palpating finger during the time of fluoroscopy.
I am more and more convinced from the work that I saw in Egypt last year and the work that has been done during the past year, that through the medium of the flexible gastroscope small ulcers can be demonstrated in the stomach which are incapable of diagnosis by any clinical methods or any x-ray means that we have at our disposal at the present time.
These distinctly show tenderness upon pressure and this finding, in association with a hyperacid gastric juice and an increased amount of contents of high acidity in the fasting stomach, make positive the diagnosis, and this can be readily substantiated by the flexible gastroscope.
Quoting again the title of this paper, “The Human Side of the Ulcer Problem,” we approach the selection of the medical type of cure, and I am unalterably opposed to home treatment if it is any way possible to arrange the family budget so that the patient can be cared for in a hospital. In my own cases I am still an advocate-and in this I am supported by Smithies-of complete rest of the stomach over a period of a week by means of rectal alimentation. With properly selected nutrient enemas, given by the drip method, the patient is not a subject of scientific starvation, but through absorption from his colon his water base and metabolism can be kept at a fair state of balance.
The continued application of heat to the abdomen by means of poultices, electric pads, thermal lights and cold compresses at night is substantiated by some of the newer views which will be considered later, covering the use of nonspecific protein therapy. Following a week of rectal treatment, we are ready to add to the stomach food that neutralizes and passes readily-frequent feedings of skimmed milk, Cream of Wheat, farina, malted milk, given at intervals of two hours, interrupted as in the Sippey habit by medicines in the interval hours.
Medications divides itself into groups, of which the first is to neutralize acidities, namely, sodium bicarbonate, calcium carbonate, and magnesium oxide. These head the list, but in our hands balanced does of tribasic calcium phosphate and tribasic magnesium phosphate have proved equally satisfactory. To coat the surface of the ulcer bismuth subcarbonate, bismuth subnitrate bismuth subgallate, and aluminum hydroxide are of value. To promote healing of the ulcer dilute solutions of silver nitrate, sixteen grains to two ounces of water, of which fifteen drops are given three times a day a half-hour before meals, for three days, then twenty drops the second three days a half-four before meals, and then twenty-five drops a half- hour before meals, and then twenty-five drops a half-hour before meals. The silver nitrate is then discontinued for fear of producing argyria.
The fats of olive oil are, of course, the greatest reduces of gastric secretion and are also soothing-a wineglassful before meals is the old Cohnheim treatment and is still of value, particularly efficacious in the postoperative recurrences in marginal ulcers after gastrojejunostomy, and at times tincture of iodine, five drops to a half-glass of water on an empty stomach, aids in the cure of ulcer. Needless to say, the greatest inhibitor of gastric secretion is belladonna, which is given in increasing doses of from five to fifteen drops three times a day; it reduces spasm and diminishes the amount of hyperacidity.
About two years ago we took up the use of atropine methyl bromide in one milligram doses. This drug reduces secretion without producing the effects that follow the use of belladonna. This was imported drug and we are still using it. In this country the drug is known as novatropine. The bromide element probably also serves as a sedative. During the last year we have been using syntrope, made by Roche, for similar purposes.
This tablet at present is not on the market, but we have found it to be very effective. We doubt, however, if the dose has been so far definitely determined. We have been using larger doses than those that are recommended by the manufactures, but they claim that the drug produces no toxic effect and this had has been borne out by our experience with it.
The factor which is, of course, stressed on all sides and in all the articles on ulcer is that of high hyperacid contents of the stomach. For this reason we have reduced the salt content as low as possible. The questions of hyperacidity, as you are aware, presents two important phases, namely, the useful practice kin some cases of passing a tube at night to rid the stomach of all gastric contents before the patient retires. This was a definite element in the old Sippey treatment, and if the patient is tube-trained, it is very effective.
Winkelstein of Mount Sinai Hospital, has endeavored to combat the same procedure by placing a tube in the stomach during the night and allowing milk to percolate in all night in order to neutralize acidity. This can be accomplished in the hospital in some cases, but, as a rule, it is an annoying procedure to the patient and we have attempted to accomplish the same thing by waking the patient at night and giving him a small amount of milk with alkali.
In the use of alkalies care must be observed, when they are given over a prolonged period, to see that the condition of alkalosis does not develop. If the acid base balance is studied by means of laboratory tests, this can be accurately guarded against, but where this is not possible there are six symptoms which indicate the onset of alkalosis:.
First, distaste for milk, and this many precede the other symptoms by several days; second, headache; third, nausea; fourth, vomiting; fifth, dizziness; sixth, aching pains in the muscles and joints.
The development of the above-mentioned symptoms calls for the immediate discontinuance of alkalies and the institution of suitable measures to combat the acidosis.
Mucin flashed across the horizon two years ago and the funds to carry on experiments with this preparation were provided by the Carnegie Foundation, and it was an interesting coincidence that when it was placed on the market one of the first patients I used it on was intimately associated with the Carnegie family. The difficulty of handling mucin is its extreme distaste, and this is best overcome by mixing it thoroughly with an electric. beater in milk.
The early preparations were contaminated with histamine which defeated the very purpose for which mucin was designed. More recently, tablets of vegetables mucin-in reality, preparations of ocher-have come into popularity, but neither of these substances has in any way replaced the alkali protective substances enumerated.
Whether you are proponents of the theory that vaccines produce their effect by the formation of definite immune bodies, or whether you class them as examples of a nonspecific protein therapy have flashed across the horizon and have attained great popularity in the treatment of ulcer. Most of the reports, however, are poorly substantiated as this is part of a general treatment. Probably the most satisfactory study has been carried out by Levine of New Orleans. His contribution on the use of hemoprotein (Brooks) has seemed to indicate that it has a certain definite value.
The milk fat proteins, such as aloan and omidan, undoubtedly establish a leukocytosis if they are given in sufficient doses. Recently, working along entirely different line,s a preparation called lariostidin, has been produced by Roche. The principles of the treatment were the fact that when, through experiments, the duodenal contents were shunted into the ileum and there was no enterokinase to stimulate the protein action of tripsinagen, there was a deficiency of histadin, and in the absence of histadin gastric ulcer developed. It is on this theory that lariostidin, which is a histadin preparation, is given. In a air group of cases we have been unable to determine any specific effects from the employment of this remedy.
Synodal, another intravenous drug containing emetin, is mentioned only to condemn it.
We feel that hypodermic procedures should perhaps be limited to the first-named preparation, that of hemoprotein, and if a hypodermic is to be used, it is quite advantageously used by employing the old standby, cacodylate of soda in large doses, or suitable doses of iron, arsenic and strychnine.
