Cruveilhier, to whom we are indebted for the first thorough and accurate description of gastric ulcer, recommended milk as the most suitable food in this condition, and although many decades have since passed, milk still stands first in the dietary of these patients.

As rest is the foremost auxiliary in the treatment of most diseases, it appears natural to make use of this agent in ulcer. Leube and Ziemssen 1 deserve credit for having laid so much stress on this point and for having devised the "rest cure" for the treatment of ulcer. Although this mode of treatment had been practised long ago by W. Fox2 and B. Forster in England, still Leube and Ziemssen have succeeded in popularizing the same, and that is the reason why it justly bears their name.

The Leube-Ziemssen rest cure for the treatment of ulcer consists in the following: The patient is kept abed for two to three weeks. He is poulticed during the day with flaxseed (warm) over the stomach and the upper part of the abdomen; at night a priessnitz (wet linen cloth) is substituted, covering the same area. The diet consists of liquids - milk, milk with strained barley, or oatmeal, or rice water, plain water, weak tea, and peptone (one teaspoonful to a cup of water). Debove and Eemond3 have suggested the addition of lactose and of meat powder to the milk, in order to make the diet richer in nourishing substances. As a rule, we employ the above-named additions, which fulfil the same purpose, besides vary ing the monotonous bill of fare.

1 Leube: l c, p. 120. 2 Wilson Fox: l. c.

3 Dehove et Remon d: l. c., p. 284.

During the first week we give the patient half a cup (about 100-150 c.c.) of either every hour. Everything the patient takes must be neither cold nor very warm, and should be taken slowly (sipping or with a spoon). During the second week we order the same kind of food, with this difference, that he is nour-ished every two hours, aud gets a cupful or a cupful and a half (200-300 c.c.) at a time. Occasionally we now allow the patient one raw egg beaten up in the milk, once or twice a day.

In the beginning of the third week we feed the patient every three hours; he is allowed barley, farina and rice (well cooked) in milk, soft-boiled eggs, crackers softened in milk, in addition to his previous food; on the third day of the third week we begin to give the patient meat, first raw, well scraped, then broiled. Thereafter we go over to the ordinary daily diet, excluding heavy salads, pastry, raw fruit, and the like.

In the following table I give an outline of diet which I ordinarily prescribe in this affection:

At the beginning of the third week the flaxseed poultices are discontinued and the patient is allowed to be up, first for a short time only (half an hour to an hour), then for several hours, and afterward for the whole day. At the beginning of the fourth week the patient may begin to walk outdoors and gradually resume his daily work.

Leube and Ziemssen and most of the German writers recommend the use of either Carlsbad water (half a pint) or Carlsbad salt, 5 to 10 gm. in the same quantity of water, heated to 122° F., twice daily (the first portion being taken in the morning, the second at night before going to sleep). I do not believe that the Carlsbad salt is in any way essential. In most of my cases of gastric ulcer I have omitted the so-called Carlsbad drink cure, and have obtained results equally satisfactory as when the salt was employed.

In cases of ulcer of the stomach presenting a more severe type - violent pains, frequent vomiting, inability to take food on account of the pains - or after haematemesis, I usually have the patient abstain from any food whatever, given by the mouth, for a period of five days. The patient is then fed by the rectum. This is done in the following way: Early each morning the patient receives a large enema of about a quart of lukewarm water in which a teaspoonful of common table salt has been dissolved as a cleansing enema. About an hour after the patient has emptied the injected water the first nourishing enema is given; this may consist either of a glassful of milk (about 200 c.c.) in which a raw egg has been well beaten and a pinch of salt added, or of a cupful of water in which a tablespoonful of a good peptone preparation has been dissolved. The temperature of either must be about 100° F. Such a nourishing enema is given three or four times a day. The quantity of the feeding enema is 200-250 c.c, and it is slowly injected by means of a fountain syringe and a soft-rubber rectal tube. The patient may frequently wash his mouth with cold water, and is allowed from time to time to keep a small piece of chopped ice in his mouth, and to swallow the melted water.

The live days being over, the mode of diet is the same as described above for the ordinary form of ulcer.

Whenever the "rest cure" is applied there is scarcely any need for constant medicinal treatment. Sometimes, however, we make use of a small dose of codeine if the pains are very severe, and of Carsbald salt if there is constipation. Only in cases where the ulcer is associated with a hyperacid gastric juice may we regularly administer an alkaline salt, as for instance:

℞ Magnes. ust.,......5.0 (Ʒi).

Sod. carbon, exaiccat.

Sod bicarbon.

Elaeosacch. meuth. pip......aa 15.0 (℥ ss).

M. exactisHime, f. pulv. D. ad scatulam. S. A tip of a knife every two hours.

In chlorotic individuals the administration of an organic iron preparation (as for instance Pizzala's or Dietrich's Elixir of peptonate of iron or Boehringer's ferratin) is often very serviceable. Thus far we have spoken only of patients who can submit to the bed treatment. In patients who cannot afford to stay in bed, the following two methods, which are at present in vogue, may be tried. I have practised both of them, sometimes with good results.

The one is the "nitrate-of-silver" treatment, the « other the "bismuth" treatment. During the use of either of these remedies the patient is allowed to attend to his business and partake of a light diet, in which milk plays a prominent part. I. The silver nitrate is given first:

℞ Argent. nitr.,.....0.3 (gr. v).

Aq. desk,......180.0 (℥ vi).

D. in vitro nigro S. A tablespoonful in a wineglassful of water three times a day, half an hour before meals.

After having used up this quantity, the dose may be gradually increased, prescribing 0.4-0.6 gm. of silver nitrate to 180 of water. The silver nitrate may be used in the way mentioned for about two or three weeks, and is then discontinued. The pains usually disappear after the completion of the first week's medication.

II. The Subnitrate Of Bismuth

The bismuth has been used again and again in painful affections of the stomach, the dose being from 0.2 to 1.0 gm. several times daily. The French physicians recommended the use of much larger doses, giving 5 gm. three times daily. Fleiner1 has lately laid much stress on the use of large doses of bismuth, suspended in water, in the treatment of ulcer, and Rosenheim2 corroborated his views. I had the opportunity of applying this method quite frequently and was satisfied with the results.

We may give the patient from 3 to 5 gm. of bismuth three times a day, to be taken in a wineglassful of water, well shaken, half an hour before meals. It is best to have the patient lie quietly for about half an hour after having partaken of the powder. The bismuth treatment must be continued for about two or three weeks without interruption. It is remarkable that these large doses of bismuth do not, as a rule, cause constipation. In all of my cases with but few exceptions the bowels moved every day without the aid of any cathartic during the whole time of the bismuth medication. The bismuth treatment in ulcer seems to me to deserve high recommendation.

1 Fleiner: Verhandl. des XII. Congresses f. innere Medicin. 1893. 2 Rosenheim: "Die neueren Behandlungsmethoden des Magens." Berliner Klinik, May, 1894.