For at least two or three months the patient should be confined to the easily-digested articles of diet mentioned. These afford sufficient variety, and no license should be given to exceed the dietary prescribed by the physician. Transgression in this respect is liable to be severely punished by return of the symptoms. When there is reason to believe that the ulcer is cicatrized, the patient may gradually resume his usual diet, but often for a long time, and perhaps for life, he may be compelled to guard his diet very carefully, lest there should be a return of the disease. Should there be symptoms of a relapse, the patient should resume at once the easily-digested diet described above.
Medicinal treatment of gastric ulcer, although less efficacious than the dietetic treatment, is not to be discarded. Since its advocacy by Ziemssen the administration of Carlsbad salts or of similarly composed salts belongs to the systematic treatment of gastric ulcer. The objects intended to be accomplished by the use of these salts are the daily evacuation of the contents of the stomach into the intestine by gentle stimulation of the gastric peristaltic movements, the neutralization of the acid of the stomach, and the prevention of acid fermentations in the stomach. Of these objects the most important is the prevention of stagnation of the contents of the stomach. The chief ingredients of the Carlsbad waters are sulphate of sodium, carbonate of sodium, and chloride of sodium. The most important of these ingredients is sulphate of sodium (Glauber's salts), which by exciting peristalsis propels the gastric contents into the intestine, and thus relieves the stomach of its burden, prevents fermentation, and removes from the surface of the ulcer an important source of irritation. The carbonate of sodium neutralizes the acids of the stomach, but the main value of this ingredient and of the chloride of sodium is that in some way they correct the action of the Glauber's salts, so that the latter may be taken in smaller quantity and without the usual unpleasant effects of pure Glauber's salts.113 The artificial Carlsbad salts are to be preferred to the natural or the artificial Carlsbad water. The natural Carlsbad salts and much of those sold as artificial Carlsbad salts consist almost wholly of sulphate of sodium. It is therefore best to prescribe in proper proportion the leading ingredients of these salts. A suitable combination is sulphate of sodium five ounces, bicarbonate of sodium two ounces, and chloride of sodium one ounce (Leichtenstern114). The relative proportion of the ingredients may of course be varied somewhat to suit individual cases. The salts are to be taken daily before breakfast dissolved in a considerable quantity of warm water. One or two heaping teaspoonfuls of the salts are dissolved in one-half to one pint of water warmed to a temperature of 95° F. One-fourth of this is to be drunk at a time at intervals of ten minutes. Breakfast is taken half an hour after the last draught. After breakfast there should follow one or two loose movements of the bowels. If this is not the case, the next day the quantity of the salts is to be increased, or if more movements are produced the quantity is to be diminished until the desired result is obtained. In case the salts do not operate, an enema may be used. Usually, to obtain the same effect, the quantity of salts may be gradually diminished to a teaspoonful.
113 Water from the Sprudel spring contains in 16 ounces 18.2 grains of sulphate of sodium, 14.6 grains of bicarbonate of sodium, and 7.9 grains of chloride of sodium, and 11.8 cubic inches of carbonic acid. Its natural temperature is 158° F. The other Carlsbad springs have the same fixed composition and vary only in temperature and amount of CO2.
114 The second edition of the German Pharmacopoeia contains a formula for making artificial Carlsbad salts, so that the ingredients are in about the same proportion as in the natural water. The formula is as follows: Dried sulphate of sodium 44 parts, sulphate of potassium 2 parts, chloride of sodium 18 parts, bicarbonate of sodium 36 parts. These should be mixed so as to make a white dry powder. The Carlsbad water is imitated by dissolving 6 grammes of this salt in 1 liter of water (Pharmacopoeia Germanica, editio altera, Berlin, 1882, p. 232).
According to a prescription very commonly used in Germany, the Carlsbad salts are made by taking sulphate of sodium 50 parts, bicarbonate of sodium 6 parts, chloride of sodium 3 parts. Dose, a teaspoonful dissolved in one or two tumblers of warm water (Ewald u. Lüdecke, Handb. d. Allg. u. spec. Arzneiverordnungslehre, Berlin, 1883, p. 480).
The Carlsbad salts are directed especially against the chronic gastric catarrh which complicates the majority of cases of ulcer of the stomach. It is well known that the most effective method of treating this morbid condition is the washing out of the stomach by means of the stomach-tube. The propriety of adopting this procedure in gastric ulcer comes, therefore, under consideration. Although the use of the stomach-tube in gastric ulcer is discarded by Leube and by Sée on account of its possible danger, nevertheless this instrument has been employed with great benefit in many instances of this disease by Schliep, Debore, and others.115 No instance of perforation of an ulcer by means of the stomach-tube has been reported, and in general no evil effects have resulted; but Duguet cites a case of fatal hemorrhage following washing out of the stomach.116 In view of the great benefit to be secured by washing out the stomach, and of the comparatively slight danger which attends the process, it seems justifiable to adopt this procedure cautiously and occasionally in cases of gastric ulcer with severe gastric catarrh. Of course only the soft rubber tube should be used, and the siphon process should be adopted.117 The stomach may be washed out with pure warm water or with water containing a little bicarbonate of sodium (one-half drachm to a quart of water). The occasional cleansing of the stomach in this way can hardly fail to promote the healing of the ulcer. Recent or threatened hemorrhage from the stomach would contraindicate the use of the stomach-tube.
115 Schliep, Deutsch. Arch. f. klin. Med., Bd. 13; Debore, L'Union méd., Dec. 30, 1882; Bianchi, Gaz. degli Ospitali, March 26, 1884.
116 Gaz. des Hôp., Apr. 29, 1884. In a case of gastric ulcer of Cornillon severe hemorrhage followed washing out the stomach (Le Prog. méd., Apr. 28, 1883).
117 Soft rubber stomach-tubes are made by Tiemann & Co. in New York, and are sold by most medical instrument-makers. A description of the appropriate tube and of the method of its use is given by W. B. Platt ("The Mechanical Treatment of Diseases of the Stomach," Maryland Medical Journal, March 8, 1884).
Beyond the measures indicated there is little more to do in the way of treatment directed toward the repair of the ulcer. Not much, if anything, is to be expected from the employment of drugs which have been claimed to exert a specific curative action on the ulcer. Of these drugs those which have been held in the greatest repute are bismuth and nitrate of silver. Trousseau118 devised a somewhat complicated plan for administering bismuth and nitrate of silver in succession for several months in the treatment of gastric ulcer. There are few who any longer cherish any faith in these drugs as curative of gastric ulcer. The same may be said of other drugs which have been thought to have similar specific virtue in the treatment of gastric ulcer, such as acetate of lead, arsenic, chloral hydrate, iodoform, etc.