THE INDIAN MEDICAL GAZETTE. [Aprii,, 1929.

A JYIOD [FIED SIPPY'S LINE OF TREAT- \ M ENT IN DUODENAL ULCER.

M By B. G. VAD, m.d.,

and

N. W. KULKARNI, m.b., b.s.,

Sir J. J. Hospital, Bombay.

The difficulties in the early diagnosis and treatment of cases of duodenal ulcer are well known to the medical profession. Before the introduction of the new lines of treatment by Sippy, Lenhart and others, and of their

modifications, surgical interference was

supposed to be the only treatment for a radical cure, and even now the same view is held by many surgeons. Having seen a few cases treated by operative methods doing quite well for a few months, but showing signs of rcurrences, perhaps in an aggra- vated form, it was decided to give a trial to a modified Sippy's line of treatment. Suitable opportunities did not come in soon, as the treatment requires the intelligent co-opera- tion of the patient who must be prepared for a period of rigid abstinence.

In this line of treatment, diet is as impor- tant as drugs. The patient is allowed to take nothing but a limited quantity of milk at

stated intervals for a month or so. Wines, smoking and even tea are strictly forbidden. All septic foci must be attended to. The

details of the treatment as given by us are as follows:?

7 a.m. Bismuth oxycarbonas, oz. i, suspended in 10 ounces of water, to be sipped, and the patient to lie on the right side.

7-50 a.m. Olive oil, oz. i. 8 a.m. Feed I.

i.e., Sodium citrate grs. 10. Magnesium oxide grs. 10. Macilage q.s.

Aqua dr. 2. added to 7 ounces of milk.

9 a.m. Mixture I. i.e., Creta preparata grs. 10.

Bismuth oxycarbonas grs. 30. in as little water as possible.

9-50 a.m. Atropine sulphate gr. 11200, by mouth. 10 a.m. Feed I. 11 a.m. Mixture I. 11-50 a.m. Olive oil oz. ?. 12 noon Feed I. 1 p.m. Mixture I. 1-50 p.m. Atropine sulphate gr. 1 j200 mouth. 2 p.m. Feed I. 3 p.m. Mixture I. 3-50 p.m. Olive oil oz. i. 4 p.m. Feed I. 5 p.m. Mixture I. 5-50 p.m. Atropine sulphate gr. 1 j200 by mouth. 6 p.m. Feed I. 7 p.m. Mixture I.

7-50 p.m. Olive oil oz. i. 8 p.m. Feed I. 9 p.m. Mixture I.

9-50 p.m. Atropine sulphate, gr. 11200 by mouth. 10 p.m. Feed I. 11 p.m. Mixture I. Close down by an injection of atropine sulphate

gr. 1J100, hypodermically, just before going to bed.

The milk should be gradually increased till the patient takes 10 ounces at each feed in. about a fortnight to three weeks' time. l,n about a month's time, if there be no pain or any other symptom, a little custard or pudd- ing, biscuits, some cocoa or some chocolates may be allowed. Afterwards he should be allowed gradually to take some soft portion of bread and butter, half-boiled eggs, etc. In

about five or six weeks' time the patient should be permitted to take some meat and fish, a little minced chicken etc. till he

gradually returns to his normal diet. In

vegetarians the return to the normal diet is

more easily adjusted. In all cases the patient must be warned against indulgence in fried and hot things, chillies etc.

If the patient complains of diarrhoea, the

magnesium oxide in each feed should be diminished. If the patient complains of some acidity or pain on rising in the morning, he should be advised to take a feed of milk some time in the small hours of the morning, if he wakes up. After six weeks' treatment on

these lines, the patient should be advised to give up the drugs gradually. As the treatment involves a strict and to

some extent tiresome routine, it was

possible to try it in only three cases. All these three patients carried out the instruc- tions in every detail and the results obtained have been consistently good. It has been

possible to keep in touch with two of these

patients, who after the treatment are not only free from any of the symptoms for the last

many months, but have steadily gained in

weight and are enjoying perfect health, (vide weight graph.) The accompanying Table I, gives a precis

of a few cases of duodenal ulcer that recently came under our observations. The two important laboratory findings on

which stress is laid, viz., the presence of occult blood in stools and marked hyperchlorhydria, may be absent. This is especially the case in patients who come under observation for

diagnosis and treatment after having under- gone for some time treatment by alkalies and milk diet. The two findings may have signi- ficance in cases which seek diagnosis and treatment for the first time. Moreover, in view of the recent findings by various

workers, diagnostic significance cannot be attached to the percentage of free hydro- chloric acid in the gastric contents. Diagno- sis will have to be made chiefly by clinical/ findings, aided by .r-ray examination.

It is not necessary here to enter into

discussion of the rationale of this line of

treatment, which aims at keeping the site of the ulcer completely free from free hydro- chloric acid, which is supposed to retard the healing. The advantage in this line of treat- ment is that once the ulcer is healed up, the

chances of recurrence are very much less than

?7

s

<

d

Q

M. S.

S. H.

T.E.J.

B. H.

I. R.

S. S.

5-3-28 22-5-28

2-2-28 20-3-28

13-12-27 22-1-28

26-3-28

7-11-27

8-8-28

29-3-28

21-11-28

13-8-28

History of Diet.

40

>

Male | No

40 Male I No

34 Male

35

40

35

Alale

Male

Male

No

C rt

? u

Yes

<

Yes

Yes

Yes Yes Yes

No

Yes

No Yes No

No Yes Yes

No |Yes | Yes

Yes

Yes

? o u

Yes

Yes

Yes Yes

Yes Yes

Yes No

Table I.

Pain.

8 I Above and to

years the rig lit of

the umbili- cus and back. Tenderness.

cd,

2-3 hours after food

Above and to 2-J

One year

2\ months

left of um- bilicus and back.

Above and to right of um- bilicus and back.

Above and to right of um- bilicus and back.

hours

3 hours

tc

<u P

T ? C

3 " s E

Yes Yes

Ye s

Yes No

8 | Above and to months right of um-

i bilicus and back.

About Above and to one right of um- year bilicus and

back.

14 hours

14 hours

u hours

No

<-> H

Yes No

Not found

Not found

Not found

Not found

Gastric analysis after Ewai.d test meal C.Cs IN TERM OF N/10

NaOH

tii

48 c.c.

30 c.c

Yes Yes! Not found

No No Not foun d

e >>

15

S cj

2 O

21 c.c. 69 c.c.

40 c.c.

45 c.c. 20 c.c

32 c.c

20 c.c.

40 c.c,

65 c.c.

28 c.c.

15 c.c-

20 c.c.

70 c.

Nil

Nil

2 X

g "n m u o S2

c c rt

(D qj C

? E

Yes

Yes

Modified Sip- py's line of treatment,

Do.

Remarks.

Nil

60 c.c

35 c.c.

60 c.c.

Nil

Nil

Nil

Yes j Do.

Yes Triple powders '

R. Bismuth ! Carb. Mag.

Carb. Cal Carb. aa. gr 10.

Yes ! Do.

Yes Triple powders,

All symptoms dis- appeared in 2 weeks. No recur- rence. Put on

weight and en-

jo y i n g good health since then.

.Symptoms disap- p e a r e d in 2 weeks. Put on

weight and en-

joying good health, and no re- currence since. Symptoms disap- peared in 2 weeks. Put on

weight and en-

joying good hea'th and no re- currence since.

Symptoms less.

Symptoms less marked. Recur- rence after a

few days. Symptoms less marked.

April, 1929.] ANOPHELINES IN BARODA: WEBSTER. 197

in cases treated surgically, where they are likely to occur at the sutured site. In our

hands this line of treatment has given en-

couraging results, and we believe that it is a treatment of choice in patients who are will- ing to submit to its rigours. The knife is the

?n^ h?Pe for those who will not co-operate. Ihese observations were carried out in the wards of Lt.-Col. S. S. Vazifdar, m.r.cA,

Sj1 St ^en'or Physician and Superintendent, J- J- Hospital, Bombay, to whom we ^re

3 !ged for his kindness and help. f

Graph showing the weights of the 3 patients treated on the modified Sippy's line of treatment.

?4-

WeeAs of treatment,

I" 3

Months after treatment.

and th drop in weight during the 1st week or two,

'nonth -gradual increase in subsequent weeks and thp

s m all the 3 cases after the commencement of le treatment.