Part 2

Luckily we do not need to resort to such extreme measures in the majority of cases. With the exclusive use of the proper bland, liquid food, we usually attain the same results. In the treatment of gastric ulcer I lay the main stress on the restriction and regulation of the diet, and put the patient on an exclusive milk diet. Milk contains all the constituents necessary for the nourishment of the human body.

I begin by giving every half hour to one hour a small quantity of skimmed, boiled milk, which has been cooled on ice. The patient must rest in bed or on a lounge, as he is weakened by the treatment, and can not follow his usual avocation. I forbid all other articles of food. With this diet a patient with ulcer should have no pain and usually has none. Should there be pain it is necessary to find out whether the feeling described as such be not simple oppression, or a feeling of weight in the stomach. Some patients do not seem to digest milk well. It ferments, forms gases and then they have this feeling of oppression. Some drink the milk too fast and take too much at a time, swallowing a lot of air with the milk, thus distending their stomachs unnecessarily. The patient must be instructed to drink the milk slowly, and only take a small quantity at a time (about one or two ounces). Some patients can not stand iced milk but bear luke warm milk much better. Others seem to prefer milk which has slightly soured.

The patients should adhere to this strict diet as long as possible, regulating the length of time according to the duration and intensity of the disease. They have to observe the above rules one or two weeks at least, several weeks if possible.

Often you will meet with the reply: "I have already tried this diet, I was put on milk diet once before by Dr. ---- and it did not help me any, I even felt worse afterwards." If you inquire more closely, however, you will find that they drank milk several times a day, but ate bread with it, soaking this in the milk. This is what is understood to be a milk cure. Gentlemen! I am sorry to say that this misunderstanding is not confined to the general public, but that some physicians even do not know better, and consider such a course of diet a milk diet. I cannot impress it upon your minds any too strongly not to allow yourselves to be diverted from your purpose by any such assertions, but to order another course of milk diet, wherever you find it indicated, and see to it that it is carried out properly this time. You will thereby occasionally meet with excellent success where a previous wrong attempt in the same direction failed.

After the patient has been free from pain from eight to ten days, I then add to his diet soft boiled eggs with a slight addition of salt, beginning on the first day with one half of an egg. If this is well borne I gradually allow more day by day, until he is able to digest four or five a day without difficulty. Eggs do not agree with some patients. In such cases I pass on the use of meat. I have beefsteak chopped fine, roasted in little meat cakes of the size of a silver half dollar. One of these is given to begin with, and if well borne repeated every two or three hours as long as there is no pain. When eggs agree I prefer to give them for a few days before beginning with the meat, waiting until such patients can digest four or five eggs a day. After the meat has been borne well in small quantities for a while, I gradually increase the quantity taken per day until it reach a pound or two.

You cannot be too careful and should instruct the patient to return to the strict milk diet as soon as any pain is felt, no matter how nicely he may have been getting along up to the time. Not until the patient has been entirely free from pain for several weeks is it advisable to allow the use of cereals boiled in milk, such as rice or tapioca. Then he can also be allowed to take a quarter of a biscuit (well baked) at each meal. A full meal, however, in the sense in which it is ordinarily understood, a large quantity of food taken at one time, is still to be avoided. It is better to give small quantities of food oftener, in order not to distend the stomach, and thus run the danger of too great a strain upon the newly healed ulcer.

These meat cakes made of beef can be taken for a week or so, and then if well borne other kinds of meat may be occasionally substituted.

_Wine and alcoholic liquors in general_ are to be avoided for several months.

_Beer_ should never be taken by one who has suffered from gastric ulcer. In fact it is well for all who have stomach trouble to avoid the use of beer, especially such as have had ulcer. Such patients have to be on their guard in matters of diet through the remainder of their lives, and must avoid excesses both in eating and drinking. You will occasionally come across persons who can not stand a milk diet in any form whatever. They frequently do not bear eggs well. In such cases I proceed at once, but with great care, to the use of meat in very small quantities, finally chopped and roasted, and have it taken several times a day. You will frequently have to try one article of food and then another, and experiment for awhile before you reach that form of diet which suits the case best.

There are a number of _substitutes_, some of which are really good, while others are worthless. Of them all I prefer the fresh meat juice _ext. carnis recent. pressum_, and have it prepared in the following manner: The meat (beef should be used) is cut into thin slices, placed between pieces of tissue paper, and pressed in a hydraulic press. The juice thus obtained is given in teaspoon doses every half hour or so, just as though it were medicine. In the majority of cases I have the meat juice made by the druggist, so that a large number of the patients think it is medicine. It has a rather pleasant taste and is well borne by the stomach. There are a great many _peptones_ in the market, a large number of which ought not to be used, as they are not fresh and more likely to do harm than good. Of them all the English make is the best, as it is usually well preserved, being packed dry.

Patients who can only take a small quantity of nourishment by the stomach can be materially aided by the use of nutritious enemata given luke warm once or twice a day. When the rectum is very irritable a suppository containing one-half to one grain of ext. opii given a half hour before the enema is very serviceable. There are a great many _other remedies_ recommended in the text books, but I would advise you not to rely too much on them. Lay your main stress on the dietetic part of the treatment, and use remedies only where they are absolutely necessary to support this. Among the remedies used the alkalies are the most valuable. Bicarbonate of soda alone, or in combination with ext. belladonna when the stomach is very irritable.

℞ Sod. Bicarb., ʒiss. Ext. Belladon., gr ii. Misce et div. in pulv. XVI. Sig. One in the morning and one in the evening.

Or I sometimes substitute atropia sulph. (1/120 gr. pro dosi) for the belladonna. At any rate the use of alkalies is the most plausible treatment. But the permanent alkalization of the contents of the stomach by the frequent use of large doses of alkalies, as has been recommended in Paris by Debove is not plausible, as by this the process of digestion would be checked entirely.

It is also good to give a dose of Carlsbad salts in the morning every two or three days, in order to correct the constipation usually attendant upon such a course of diet. These salts also aid in rendering the contents of the stomach more alkaline, and in this way aid the plan spoken of before.

I do not think it advisable to send patients with gastric ulcers to _health resorts_ or watering places. They can only regain their health by a strict enforcement of dietetic measures, and these can be carried out just as well at the patient's home as at the health resort. For the treatment of such cases _after the ulcer_ has healed, these health resorts can be of great benefit, but the patient must be cautioned not to commit excesses in eating or drinking, especially to the latter must their attention be called, as it is customary in most resorts adapted to such cases, to drink large quantities of the medicated waters in the morning. It is also well to caution the patients with regard to their diet before sending them away. This should be unirritating, bland and easily digestible. Among the European health resorts, Carlsbad is the most suitable for such cases.

There are unfortunately some patients who are not benefited by any method of treatment hitherto thought of, but luckily they are few, and if you will follow the rules I have laid down you will in a great many cases meet with splendid results.

One important question still remains to be answered, namely: "What should be done in case of hemorrhage of the stomach?" Here the patient must be left quiet just where he happens to be--placed in a horizontal position on his back if possible. Ice bags should be applied to the region of the stomach, small pieces of ice swallowed, and hypodermic injections of ergotin given. This is all that can be done with benefit in such cases. The patient should not be transported for several hours. Monsel's solution can be of no service, as it cannot be introduced into the stomach in a sufficient concentration to be of benefit.

In cases of perforation of an ulcer all that can be done is to give anodynes to ease the pain and make the patient's condition as comfortable as possible. Schlipp recommends that when perforation is threatened on account of gaseous distention of the stomach, the stomach tube should be used to evacuate the organ.

The mechanical treatment, washing out the stomach with the stomach tube or stomach pump is contraindicated in cases of ulcer, as more damage can be done by such procedure than good.

ORIGINAL ARTICLES

THE RECOGNITION OF MORTIFIED BOWEL IN OPERATIONS FOR THE RELIEF OF STRANGULATED HERNIA.

By REUBEN A. VANCE, M. D., CLEVELAND, OHIO.

The medical practitioner who has been hastily summoned to operate upon a patient with strangulated hernia finds himself confronted with problems, the gravity of which can alone be appreciated by those who have frequently met them. The medical treatment to be adopted, the extent to which taxis should be employed, and the time it is prudent to delay operative interference when other measures have proved fruitless, are grave questions upon the solution of which the life of the patient depends. The operation decided upon, the particular method to be employed and the manner of dealing with the stricture--with or without opening the sac--are matters of minor consequence, and affairs that should be settled in the mind of every practitioner by a reference to sound surgical principles and the teachings of experience. There are questions connected with the condition of the parts strangulated that must be solved by the surgeon during the progress of the operation, about which much less is said in works on surgery than their importance warrants. These pertain to the vitality of the part that has been strangulated, and the duty of the surgeon in the premises. If the part is still living, it matters not how much damaged by compression, it should be returned at once into the abdomen; upon this step the patient's life depends. If the part is mortified and dead, to return it within the cavity of the belly is to insure the patient's destruction; if he is to have a chance for life, other measures must be adopted.

Again, the decision of the operator can but rarely be guided or aided by aught but the conditions revealed by his knife during the operation. The state of the patient and the history of the case may indicate the imminence of mortification of the bowel; in the end the appeal is to the senses of the surgeon, and upon the conclusion at which he then arrives will depend the fate of the patient.

Under these circumstances it behooves every man who may be placed in position to make such a momentous decision to at least go to the task, sustained by every aid that can be derived from the experience of those who themselves have been placed in this dilemma and compelled to act with such lights as they then possessed--whose records, next to personal experience, become the best guide for those forced to follow in their footsteps.

The history of the case may throw some light upon the state of the intestine. This is especially so in those cases in which the severity of the symptoms suddenly subsides without the rupture having been reduced. The pain is violent, the abdomen distended and singultus and stercoracious vomiting present; suddenly the patient's suffering cease, and were it not for the cold extremities, flickering pulse and persistent tumor--but above all, the teachings of experience--the surgeon could not but acknowledge that all tangible appearances portended a change for the better. Yet, almost invariably gangrene of the gut has taken place, and the fallacious evidences of improvement above noted are in reality its best clinical exponent. Certain almost as these signs are, when present, yet it comparatively seldom happens that the surgeon has their aid in guiding him in the measures he must adopt; they form, but infrequently, a part of the history of cases submitted to operation. If present, the surgeon is reasonably sure of what he will find when he operates; they may be absent and mortification yet exist. The patient's chance of life depends upon the surgeon's ability to recognize mortification of the bowel when he sees it, and his promptitude and skill in dealing with it when present.

It scarcely need be said that mere darkening in color of the bowel, effusion of fluid into the sac, or exudation of lymph about the stricture are of no special significance in this connection, and bear in no way upon the presence or absence of mortification. It has been again and again repeated in manuals treating of hernia operations that a deep, purplish discoloration of the bowel and absence of circulation indicate mortification; that when these physical signs are present the surgeon should press upon the strictured part, and if the color remains unchanged when the finger is removed, the bowel is dead. It requires but little practical experience in dealing with these cases to appreciate the fallacious character of these signs; the gut may be fairly black from congestion and yet alive; the color may remain unchanged under pressure and still that fact have no bearing on the question of mortification, for a band of stricture, as yet unappreciated, may be the sole cause of the persistent hyperæmia.

It is quite different as regards certain other signs, especially when two or more of them are seen in conjunction. _If the bowel be dark and mottled with grayish spots, of contracted and shrivelled aspect, with a slight amount of discolored fluid surrounding the gut, and a cadaveric odor apparent when the sac is opened_, mortification is certainly present, and the return of the strictured part within the abdominal cavity dooms the patient to certain death. The surgeon's duty is to open the sphacelated gut, apply a poultice and favor the relief of the obstructed bowel by a free discharge of the intestinal contents through the outlet thus formed. An artificial anus is thus established, and the patient, for a time, must be content with this deformity; fortunately it is a condition susceptible of relief, and the surgeon may ultimately free his patient of even this defect.

JABORANDI AS A GALACTAGOGUE.

JOHN H. LOWMAN, M. D.

Professor of Materia Medica in the Medical Department of the Western Reserve University.

There is a decided difference of opinion among therapeutics as to the effect of jaborandi on the mammary gland. Some claim that it has no effect upon the gland. Some claim that it assists in increasing the secretion of milk.

This note is made to show the action of jaborandi as a galactagogue in the recent puerperal state. The preparation used was the fluid extract obtained from Squibb & Co.

M. S., age thirty-five years, a multipara, of fair health, not well nourished. The babe was two weeks old at the time of this observation, and in good condition. The secretion of milk by the mother began gradually to fail until not one-third the average quantity was produced. The child was then nourished artificially. The fluid extract of jaborandi was given to the mother. The dose was eight minims every three hours. About fifty minims were taken in twenty-four hours. On the second day of the administration of the drug the milk increased in quantity. By the third day it had increased still more, so that the child had nourishment from the mother sufficient to satisfy it. Increased salivary and cutaneous secretions led to a discontinuance of the drug. The milk flowed in good quantities for eight days, and then rapidly diminished. Jaborandi was again used. The plan of administration was the same. Increase of the milk was again noted. The renewed activity of the mammary glands continued for five or six days only. For a third time the drug was used, and its use followed by good effects. In the meantime the nourishment of the mother had been pushed. Iron, quinine and mineral acids were also given. The general health of the patient improved. After the last increased activity the secretion of the gland remained normal for three weeks, after which the patient passed from observation. During the last two weeks no jaborandi was used.

Whereas in this case the improved condition of the individual was responsible for the permanent increase in the supply of milk, the use of the jaborandi and the temporary increase were apparently more than coincidental. During the first two stimulations the quality of the milk deteriorated; the quantity of cream diminished; the specific gravity fell; no microscopic examination of the milk was made. After the last increase in the activity of the glands the quality of the milk was good.

Two similar cases were noted. B., aged nineteen years, primipara, had a tedious labor. She recovered slowly. She was well nourished and has previously been well. At the end of the second week of convalescence the milk began to fail. Jaborandi was used as in the case just cited. Marked improvement in the milk was noticed the second day the drug was given. On the fourth day the medicine was omitted. The milk continued to flow in sufficient quantities for ten days. The quantity then gradually and rapidly diminished. The medicine was again given for four days with the desired effect, which remained for the following ten days that the patient was under observation.

D., age twenty-five years, a multipara, was a poorly nourished person, the mother of two children. The confinement was normal. The milk failed soon after its appearance. Following the use of jaborandi the milk increased rapidly in quantity, but diminished in three days on withdrawing the drug. The milk continued to respond to the jaborandi for the four weeks that the patient was under observation, but no permanent result was obtained.

On three other cases the jaborandi was used with scarcely perceptible effect or no effect at all. From a few cases it is impossible to generalize with expectation of a truthful conclusion. We can, however, know that the jaborandi has an effect on the mammary gland, and causes an increase of the milk in puerperal women. This effect is by no means a constant sequel to the administration of the drug. As far as my observation is concerned the effect of jaborandi is temporary, and can be useful only where there is a tendency in the gland to assume its normal function. This tendency may at times be subordinated to general influences and even entirely subdued. In such conditions a timely stimulation of the gland may tide over the threatening arrest of function. Variation in the activity of the mammary gland, especially in the early puerperal state, is not unusual. The close relation of the increase of milk and the use of jaborandi justifies, however, the assumption of effect and cause.

No effect was observed on the children. Jaborandi is excreted by the mammary glands, and it was consequently withheld as soon as practicable, lest the child should feel its presence.

INDICATIONS FOR OPENING THE MASTOID PROCESS.

BY A. R. BAKER, M. D., CLEVELAND, OHIO.

The operation of opening the mastoid process is said by some to have been first performed by Riolan in 1649; according to others, by Petit in 1750, and later by Jasser, in 1776. During the latter part of the eighteenth century the operation was performed frequently without definite pathological indications. But after the unfortunate death of the Danish physician Berger (1791) the operation was very seldom or never performed until 1864, by Mayer, following the suggestions made by Tröltsch some years previous. Berger, for chronic deafness without suppuration of the middle ear, had the operation performed upon himself, and died on the twelfth day from meningitis. During the past twenty years the operation has taken its place as one of the recognized surgical proceedings owing to the work of the German physicians Moos, Jacobi, Hartman, Bezold, Schwartz and others, who have laid down the real indications for the operation from their extensive clinical observations and pathological researches. The American otologists, Roosa, Agnew, Buck and others were among the very first to perform the operation, and have done much to establish its claim to recognition. And yet it is somewhat remarkable that some of our text books barely mention the operation; and as short a time ago as 1883, Strawbridge, at the meeting of the American Otological Society, said that he had seen over four thousand cases of purulent middle ear disease within twelve years, and yet had not trephined in a single case; and several other authorities looked upon the operation as a questionable one. Knapp took decided grounds in favor of the operation, and cited three fatal cases in which he believed an operation would have saved life. Kipp had seen quite a number of fatal cases in which the post-mortem had shown the mastoid cells filled with pus, which had given rise to cerebral abscess. Dr. C. H. Burnett reported a fatal case which died from pyemia, and he thought if his patient had been operated a year before his life would have been saved.

Gruening said surgery has established that wherever there is a focus of purulent discharge it should be removed. This, (removal of the focus) is a life-saving operation and should be done under all circumstances. Dr. Roosa said that he believed the revival of this operation of opening the mastoid process has saved many lives. Since his first operation not a year has passed that he has not found it necessary to repeat it several times. He says further that "it is true that we shall seldom need to open the mastoid if an experienced practitioner sees a case of acute aural disease early in its course. It is an operation for neglected cases, where suppuration has been allowed to advance from the tympanic cavity in consequence of not having a free outlet through the drum-head. But purulent inflammation of the mastoid may occur in acute cases that have been thoroughly treated by leeching, poultices, rest, etc., from the start."

The most recently stated indications for opening the mastoid process are:

1. Purulent inflammation in the mastoid process appearing in the course of suppuration of the middle ear when persistent severe pain in the bone cannot be subdued by the application of the ice-bag, leeches, or by Wilds' incision. (Schwartz).