3. Mineral Springs

There are many mineral springs, the waters of which have a decided beneficial influence upon the chronic gastric catarrh. Many patients going to these watering-places and drinking the waters at the springs either become improved or are entirely cured. While these waters may be taken with some benefit at home, still a sojourn at a watering-place combines many other curative factors besides the water: the perfect rest and absence of all cares, and the fresh and invigorating country air.

The mineral springs which are most useful in this affection are the following:

1. Saline springs containing sodium chloride, and small or large amounts of carbonic acid gas: Wiesbaden (Kochbrunnen - temperature, 69° C.; sodium chloride, 0.68 per cent), Kissingen (Racoczi and Pan-dur - temperature, 10.7° C.; sodium chloride, 0.55 per cent), Homburg (Elisabethbrunnen - temperature, 10.15° 0.; sodium chloride, 0.98 per cent), Soden (numerous sodium chloride [0.24-1.4 per cent] springs containing carbonic acid gas, of different temperatures [15°-30° C.]), Saratoga (Congress Spring).

2. Alkaline saline springs, containing sulphate of sodium, carbonate of sodium, sodium chloride, and carbonic acid gas in large amounts: Carlsbad (there are twelve springs, each possessing about the same quantity of salts: Sulphate of sodium, 0.23 percent; bicarbonate of sodium, 0.2 per cent; sodium chloride, 0.1 per cent; carbonic acid gas), Marienbad (Kreuz-brunnen and Ferdinandsbrunnen, 0.5 per cent sulphate of sodium), Saratoga (Hawthorne Spring).

In most instances the first group of springs (saline) are to be recommended. The second group of springs (alkaline saline) are to be employed in patients in whom constipation forms a very marked symptom. The use of these springs should, however, not be extended over too long a period of time. Patients of a nervous character should not partake of these purgative waters. Both the saline and alkaline saline waters can be taken at home, if the patient is not able to go to the springs. It is best to have the patient drink about a tumblerful of either of the waters early in the morning when arising, about an hour before breakfast.

4. Medicaments

The medicaments were used to a much greater extent in the treatment of chronic gastric catarrh in olden times than nowadays. At present we have learned to pay more attention to diet, to hygiene, and to the mechanical means of treating the stomach. In some instances, however, the medicaments are also serviceable. Among these, hydrochloric acid is one that is most frequently employed in this affection. The idea of supplementing the deficiency of gastric juice by this acid, which forms its principal element, is quite natural. Leube1 first introduced this medicament into the therapeusis of chronic gastritis and Ewald 2 likewise recommends it very highly. He says: "In all cases where a diminution or absence of hydrochloric acid has been determined, i.e., in all cases of chronic gastritis, it is therefore to be given preferably as the dilute hydrochloric acid of the pharmacopoeia in large quantities, and certainly in larger doses than have thus far been recommended/' The best way to administer this medicament is to give it in the form of drops, six to twelve of the dilute hydrochloric acid in a glassful of water, to be taken three times a day half an hour after meals, not drinking the whole glassful of water at once, but one-third at a time at intervals of one-quarter of an hour or half an hour.

Ewald advocates larger doses than these, namely, forty to sixty drops of the dilute hydrochloric acid three times daily.

1 Leube: "Die Krankheiten des Magens und Darms." Ziemssen's "HaDdbuchderspec. Patholog. und Therapie,"Bd. vii., Heft 2, p.75. 2 Ewald: l. c., p. 342.

Pepsin used to be, and is yet very frequently given in combination with hydrochloric acid, the dose being about half a gram three times daily. Most writers, however, concur in the absolute inefficacy of this drug, and for two reasons, viz., (1) in most instances even of diminished gastric secretion (diminished acidity) there is yet an abundant quantity of pepsin present; (2) most pepsins that are in the market do not by any means show as strong digestive properties as the true pepsin of the stomach.

Formerly I was in the habit of employing hydrochloric acid either alone or in combination with pepsin quite frequently. Of late years, however, I have entirely abandoned the use of pepsin, and greatly restricted the administration of hydrochloric acid. The reason for this is based upon the belief that the means which serve for the digestion and utilization of food by the organism are certainly not limited to the stomach, but that the principal part of this process takes place in the intestines. The artificial means of aiding digestion are certainly not necessary, the more so since if employed for long periods of time they frequently become injurious to a certain extent. Every organ is strengthened by activity and weakened by the lack of exercise. Predigested foods, or medicaments which contain the active principles of the gastric juice and serve to replace the work done by the stomach, will, in the course of time, have a deteriorating effect upon the gastric functions. The stomach will grow weaker and weaker the more artificial gastric juice is poured into it, and the finer and more subtle the nourishments that are allotted to it.

While I do not advocate the frequent use of hydrochloric acid and pepsin, I am strongly in favor of the administration of the so-called bitter medicaments (amara), condurango, quassia, gentian, kino, calumba, and nux vomica, which must be considered as effective stimulants of the gastric functions. Although the physiological efficacy of these drugs has been disputed by several writers (Tschelzoff and Ja-worski),1 empirical experience, however, speaks highly in their favor, and their use should certainly not be neglected. There is no doubt that condurango, quassia, and nux vomica increase the appetite, and in this way make the stomach fit to receive more food and thus raise the nutrition of the organism. I usually. give fluid extract of quassia, calumba, or condurango in doses of twenty drops three times daily, or tincture of nux vomica, either alone in doses of ten drops three times daily, or in combination with the above drugs. All these medicaments must be taken about a quarter of an hour before meals in about a tablespoonful of water or wine.

Creosote I frequently give in the gastritis of phthisical patients.

1 Jaworski: "Experimenteller Beitragzur Wirkuug und thera-peutischen Anwendung der Amara und der Galle." Zeitschr. f Therapie, 1886, No. 23.

℞ Creosote,........5.0

Compound tincture of gentian, • . . 10.0 S. Eight drops in half a glassful of milk three times daily, half an hour after meals.

Orexin may also be given for the same purpose:

℞ Orexin. basic,.....0.2 (gr. iiiss).

D. in wafers t. d., No. 15. Sig. One wafer in a cup of bouil-lon half an hour before meals twice daily.

Chronic gastric catarrh is frequently combined with constipation, and it will be necessary to speak about the management of this complication. As a rule, I would say that the less medicaments used to combat this affection the better. The means available for this trouble are: You must tell the patient to go to the water-closet in the morning at a certain hour, to avoid much straining, and not to bother about the bowels any more during the whole day, even if there were no movement, and not to go to the water-closet unless there be a strong inclination for it until the following morning. Frequently this alone is sufficient to secure regularity of the bowels after a while.

The diet can also be arranged in such a manner as to facilitate movements of the bowels. All foods which contain a large percentage of cellulose (undigested matter) increase the quantity of faeces, and thereby effect a stronger peristalsis of the large bowel. All kinds of green vegetables (spinach, asparagus, green peas) and rye bread are therefore very suitable. Many organic acids possess the property of increasing intestinal peristalsis. Almost all kinds of fruits contain a certain quantity of these organic acids, and act like mild aperients. The use of cooked pears, stewed or baked apples, stewed prunes, is in many instances effective. Ewald recommends a mixture of two parts of prunes to one part of dried figs. The taste is agreeable and the cathartic action mild. The custom of eating an orange in the morning for its laxative effect is well known. To these dietary remedies we may also add the use of a glassful of either very cold or warm water, or of a glass of milk on arising, in the fasting condition.

There are many persons in whom one of these latter means produces a good movement of the bowels.

In cases where the above dietary remedies do not suffice, the administration of a mild cathartic is not out of place. Rhubarb and cascara sagrada are chiefly in use. The former is given either in substance or in the form of a tincture, fifteen to thirty drops; the latter in the form of the fluid extract, fifteen to twenty-five drops twice daily. Aloes and podophyllin should be used only in the severer forms of constipation. I frequently give the following pills:

℞ Podophyllin, . .... 0.3 (gr. v).

Extract of nux vomica, Extract of Calabar bean, . . . aa. 0.5 (gr. viij).

M. f. cum extr. gentian, et pulv. liq. q. s. pil. No. 30. S. One pill twice a day.

The so-called Hamburg tea is also very efficacious.

All of these remedies should not be used for too long a time, and the patients should always accustom themselves to get along with fewer of these remedies, and ultimately withotit them. In cases in which there is atony (weakness) of the large intestine, the use of enemata is indicated. One quart of lukewarm water with a teaspoonful of salt is injected into the rectum by means of a fountain syringe provided with a soft-rubber tube. These injections should be made once a day, always at the same hour, and continued for about two weeks. The use of glycerin suppositories, or of a small quantity of glycerin in water (one teaspoonful to four or five tablespoonfuls of water) injected into the rectum, will be required only occasionally.