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                              === THE ===

                       Cleveland Medical Gazette

  ----------------------------------------------------------------------
  _VOL. I._                _FEBRUARY, 1886._                    _No. 4._
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                          ORIGINAL LECTURES.

  ----------------------------------------------------------------------


                         ULCER OF THE STOMACH.

            A LECTURE BY PROF. L. OSER OF VIENNA, AUSTRIA.

 [Translated for the Cleveland Medical Gazette by Dr. C. Rosenwasser].


Gentlemen! The disease which we intend to study to-day is one, the
traces of which are found much oftener at post-mortems than the disease
itself in the clinic. A great many cases are overlooked and improperly
diagnosed for reasons which I shall state hereafter.

It has been called by various names. Round ulcer, perforating ulcer,
chronic ulcer, corroding ulcer and simple ulcer are only different
designations for one and the same condition. I prefer to call it
_peptic ulcer_, as it is always the result of self-digestion of a part
of the walls of the stomach, but is not always round, nor perforating,
nor chronic, nor corroded; nor is it always simple, several ulcers
having occasionally been found in one and the same stomach.

Pathologists have not yet come to a positive decision on the _modus
operandi_ of its origin, but several conditions are mentioned as
necessary for its development.

1. The self-digestion of a part of the stomach by the gastric juice.

2. Disturbances of the circulation of the blood in the walls of the
stomach.

3. The alkalinity of the blood circulating in the walls of the stomach
prevents the digestion of the mucous membrane. If this action on the
walls of the stomach is prevented in any way, the development of an
ulcer is aided. This clause has been accepted until recently, when
it has been rendered somewhat doubtful by the results of certain
experiments.

The first clause is sustained by the fact that the peptic ulcer is only
found in those parts which are brought into direct contact with the
gastric juice. It is further proven by the softening of the stomach so
frequently found at post-mortem. But as long as the circulation of the
blood in the walls of the stomach is normal, ulcers do not form. The
formation of an ulcer in the stomach presupposes a local disturbance
of the circulation. It is usual to find thrombi and diseases of
the bloodvessels in cases where ulcers of the stomach occur. For
this reason the latter is more common in anaemic persons where the
circulation is retarded and the bloodvessels frequently subject to
fatty degeneration.

Virchow regards embolism of a small vessel as the origin of ulcer of
the stomach. Cohnheim disproved this beyond doubt by showing that there
is an abundant circulation in the walls of the stomach by which the
parts affected are again quickly supplied with blood. Klebs takes for
granted a spasmodic contraction of single bloodvessels as the cause
of the retardation of the circulation, while Rindfleich attributes
it to the poor anastomotic connection of the gastric veins. He calls
attention to the frequent coincidence of ulcer and hemorrhagic
infarct in the walls of the stomach. Cohnheim injected chromate of
lead into the gastric branch of the splenic artery in animals, and
when he succeeded in cutting off the arterial supply of the mucous
and submucous layers _only_, he found as a result large ulcers with
sharp, well-defined margins and a circular base. If the animals were
examined in the second week after the experiment, they showed several
small ulcers in place of the larger one. In the third week the ulcers
were found to have healed. From these experiments you can see that
the gastric ulcer has a natural tendency to heal when not interfered
with. By experiments such as these it has been proven beyond doubt that
disturbances of circulation of a small part of the stomach may lead to
ulcer. But the causes of these disturbances, and the reasons why some
ulcers do not heal, are still disputed questions.

Pavy claims that the alkalinity of the blood prevents the gastric juice
from acting on the walls of the stomach. When he introduced acids into
the stomach and allowed the circulation of the blood to continue,
no ulcers resulted; if he impeded the circulation, the stomach was
digested by its acid contents. Samelson instituted experiments to
test the statement of Pavy. He introduced large quantities of various
acids into the stomach of his animals without observing ulceration as
a result; he also neutralized the blood by the injection of weakened
acids into the bloodvessels, but no ulceration followed. But he did
not impede the gastric circulation in his experiments, while Pavy did,
hence the difference in their results. Clinical experience, however,
favors Pavy's views. We can prevent the further progress of the gastric
ulcer by the use of alkalies, while acids only favor its growth. These
questions still need additional research before they are definitely
solved.

Gastric ulcer may occur in any part of the digestive tract which is
exposed to the action of the gastric juice; hence it is found in the
lower part of the œsophagus, any part of the stomach and the upper part
of the duodenum. It is found most frequently in the pyloric end of the
stomach, because this part is most frequently subjected to mechanical
irritation and to the action of the gastric juice.

The shape of the ulcer is usually conical or terraced, its diameter
being largest in the mucous membrane and smallest at its base, in the
deeper structures.

The gastric ulcer must be very common. In about five per cent of all
cadavers we find ulcers in the stomach or else scars as traces of
former ulceration. Ulcer of the stomach is frequently passed over
without recognition, because most physicians do not decide upon this
diagnosis, unless hæmatemesis occurs. Gastric hemorrhage, however, is
not necessarily a concomitant feature of every gastric ulcer, and the
hemorrhage may occur without vomiting, the blood being either digested
and absorbed or passing on into the bowel and causing dark stools.
Thus occasionally the only symptom of hemorrhage of the stomach is the
appearance of darker stools, a symptom of doubtful value when taken
alone, but of some importance when in connection with others.

A few years ago an elderly lady was admitted into the hospital on
account of severe pain in the stomach and the appearance of dark
stools. While in the hospital vomiting of blood set in, continuing
three days, and then the patient died. At the post-mortem we found
that an ulcer of the stomach had burrowed through the diaphragm and
pericardium into the wall of the left ventricle, perforating finally
with a small opening into the left ventricle. I can only explain the
length of the time between perforation and death (three days) by
assuming that part of the gastric fistula leading through the walls of
the heart was firmly closed during systole, and only allowed a small
quantity of blood to ooze through during each diastole.

_Symptomatology._ If you were to rely upon the occurrence of gastric
hemorrhage in making your diagnosis, a great many blunders would
necessarily occur, as this symptom is present in but one quarter of
all the cases. I can give you an exact picture of the symptoms from
experience on myself, having repeatedly been a sufferer from gastric
ulcer and having studied every phase of the question carefully upon
myself, frequently experimenting to get at various truths.

One of the most important and characteristic symptoms is the _localized
pain or soreness_ which is felt in a small, well defined area, and
either originates or is increased by chemical or mechanical irritation.
This spot always was sensitive both to warm and cold food. Salty food,
alcoholic or sour articles brought on pain. I could feel when the
food passed the spot. It was always more sensitive about an hour or
two after a meal, when the process of digestion was most active. My
ulcer was on the anterior wall of the stomach, so that I could greatly
ease the pain after meals by lying upon my back, while lying upon
the abdomen greatly aggravated it, as the food then came in contact
with the ulcer. I was a student yet when first suffering from this
trouble, and was treated by one of our prominent professors for heart
disease. He even gave me a certificate stating that I was suffering
from beginning hypertrophy of the left ventricle. I was not improving
under this treatment, and was taken one day with violent pain in the
stomach, followed by vomiting of a large quantity of blood. Now the
state of things was cleared up, and under the proper treatment (for
ulcer of the stomach) I soon regained my health. I remained well for
a long time, but in the course of the last twenty years have passed
through several relapses. One of these, I distinctly remember, occurred
while I was making a tour through the Alps. I had walked quite a
distance that day and being very thirsty drank three glasses of water
in quick succession. I immediately felt a pain in the stomach, and
could distinctly feel how one of the old scars was again rent asunder.

During these repeated attacks I found that the painful sensation
was really divisible into three distinct periods, that of constant
increase, during which the ulcer is developing and extending, that of
remaining at one height, and that of gradual decrease during the period
of healing. I could distinctly tell from these various changes how my
ulcer was getting along.

Two different kinds of pain are felt, the one constant and the other
occasional. The _constant pain_ is usually present where the ulcer has
extended deeper into the tissues or when the surrounding tissues are
implicated. This pain is increased during digestion or when pressure is
made on the parts from without. The _occasional pains_ are either of
a dyspeptic type, caused by the catarrh which usually accompanies the
ulcer, or of a cardialgic (neuralgic) type, the result of irritation
of the exposed nerve-endings with the ulcer. These cardialgias are
acute attacks of very severe, excruciating pain, which occur during
or between the periods of digestion and are felt in the epigastrium
and back mostly, but sometimes radiate over the entire abdomen, into
the chest and even into the limbs. These attacks differ in no respect
from those occurring in some diseases of the gall bladder, kidneys,
peritoneum or uterus, and are consequently not characteristic of
gastric ulcer. The dyspeptic pain partakes more of the character
of feeling of fullness, a sense of oppression in the epigastrium,
heartburn, etc., such sensations as occur in catarrh of the stomach and
are felt during digestion.

_The characteristic pain in ulcer of the stomach is a localized feeling
of soreness._ It is not always prominent. Chemical or mechanical
irritation of the ulcer brings it on, or if already present, aggravates
it. Especially acids, both mineral and vegetable, have this effect,
while alkalies allay it. This pain only occurs during the process of
digestion, when the food or gastric juice comes in contact with the
ulcer, or when the stomach is distended with gas, and tension exerted
on the tender spot. During the periods when the stomach is at rest it
does not occur.

_Vomiting_ occurs in about three-fourths of all cases of gastric ulcer;
vomiting of blood, however, only in about a quarter of all the cases.
The latter occurs oftener where the ulcer is deep. In cases where the
stomach is dilated, the amount vomited may be enormous, and contain
food which has been retained in the dilated portion for several days.

As a result, also, of the accompanying catarrh of the stomach and the
consequent diminished absorption of fluids, we find _constipation_ and
_diminished secretion of urine_ in cases of ulcer of the stomach.

Perforation of the stomach is most frequently caused by gastric
ulcer, and may be said to be a characteristic symptom; but it usually
occurs too late to be made use of in the treatment of the ulcer. It
is occasionally the first symptom which calls the patient's attention
to the fact that his stomach is and has been seriously diseased. By
the agglutinations of the base of the ulcer with neighboring organs,
through inflammatory processes, perforation can take place into these
organs. The most frequent forms of perforation under such conditions
are those into the liver, spleen or pancreas, but cases have occurred
where perforation into the colon or pleural cavity has taken place,
or even into the pericardium, the heart or lungs. Some time ago I saw
a case of gangrene of the lung, the result of the perforation of a
gastric ulcer into this organ.

A few days ago I saw an interesting case, where an acute gastritis
culminated in the vomiting of a large quantity of pus. The patient had
been having high fever for a few days, with incessant vomiting and
great tenderness in the epigastrium. Evidently an abscess had formed in
the neighborhood of the stomach, and finally opened into this organ,
with the given result.

_Diagnosis._ There are two classes of characteristic symptoms--those
originating from the exposure of nerve-endings, and those caused by
ulceration into bloodvessels. The first class includes the painful
sensations, the characteristic soreness, which occurs in about
four-fifths of all the cases; the second class, the hemorrhages,
occurring in only one-fourth of all the cases. You can readily see
why pain occurs more often than hemorrhage. Even a very superficial
abrasion may expose nerve-endings to the irritation of the food, while
it takes a deeper ulceration to lay open a larger bloodvessel. In order
to make a positive diagnosis, these two symptoms should be present.

Vomiting of blood alone need not necessarily be caused by a gastric
ulcer. There are a great many other conditions which may cause it. It
should, however, put you on the guard, and can, in a great many cases,
justify a diagnosis of probable ulcer of the stomach.

The localized pain occurs, according to my experience, only in cases
of ulceration of the stomach; that is, in gastric or peptic ulcer
and in cancer of this organ. In order to differentiate between these
conditions, it becomes necessary to observe whether the patient is
cachectic or emaciated or not, and whether a tumor can be felt in
the region of the stomach. But even these symptoms can be deceptive,
as an abnormal hardness or resistance--the result of perigastritic
infiltration--may occur in cases of simple ulcer, making the diagnosis
almost impossible. This is true especially in cases of ulcer of the
pyloric regions, while ulcers of the anterior wall of the stomach are
rarely accompanied by such infiltrations.

The pylorus is the most sensitive part of the stomach, and frequently
the seat of pain, when no lesion can be detected post-mortem. The other
parts of the stomach only become painful when attacked by ulcerative or
other pathological processes. Another point worthy of consideration
is that all forms of pain in the stomach are usually referred to the
pyloric region by the patient, even if they originate in other parts.

From all this you can see that no positive diagnosis can be made where
any one of these symptoms is presented unaccompanied by the others. A
careful consideration of the symptoms present will frequently, however,
be of aid in making a diagnosis. Intelligent patients will tell you
that they have a feeling of oppression, a feeling of distress in
dyspepsia, but will describe their feeling as that of distinct pain in
ulcer. Pure neuralgic pain is not always localized, but radiates into
distant parts, is not constant, but sets in all at once and disappears
with equal celerity, sometimes intermitting for days and weeks, and
then again setting in on the slightest nervous excitement. Such pain is
not aggravated by local pressure, shows no relation to the digestive
functions, does not depend upon the quality or quantity of food taken,
and may as well occur during a fast as during a feast. Often such
patients will tell you that their pain does not cease until they have
taken a hearty meal.

In cases of peptic ulcer, you will find that the pain is in direct
relation to the amount and quality of food taken; that the patient
has little or no pain when the stomach is at rest; that coarse foods
as well as acids cause or aggravate the pain, and that indifferent
foods, such as milk, do not bring it about, though they may sometimes
cause a sense of fullness or oppression. Some patients with ulcer will
tell you that the position of their body has an influence on their
pain. If they are so placed that the food, by its gravity, lies on the
ulcer, the pain is brought on or increased, while if the patient under
such circumstances then changes his position, he is relieved of his
pain partially, or even entirely. Yes, some such patients must assume
abnormal positions while their stomach is active, in order to avoid
this suffering. Some patients with gastric ulcer cannot digest _any_
food without great pain, and frequently live on a very scanty diet,
rather than risk taking more food and enduring these excruciating pains
again.

_Anomalous Cases._ Occasionally cases will occur in which the symptoms
presented do not justify the diagnosis of ulcer of the stomach, only
those of dyspepsia or else of gastric catarrh being present, while we
are still compelled to assume the diagnosis of ulcer from the result of
the treatment. Such cases resist all kinds of treatment based upon the
diagnosis of dyspepsia or catarrh, and can only be cured by a strict
"ulcer cure."

Another class of cases only presents gastralgic pain without any other
symptom. Such are frequently patients who have had gastric ulcer
before. Others will come to you with intercostal neuralgia on the left
side. They have, perhaps, tried all the usual anti-neuralgic remedies,
have gone through a course of treatment by electricity, and spent a
large amount of time and money, without obtaining permanent relief,
until some physician puts them on a strict milk diet and cures them in
this way in a short time.

Some cases of ulcer of the stomach present the queerest symptoms.
For instance: they complain of pain after drinking milk, or even
after taking a morphine powder, while they can eat the coarsest food
without any harm. Others run along without presenting any symptoms at
all, until they, as well as their physicians, are surprised by the
perforation of a gastric ulcer.

All these abnormal cases, which form about one-fifth of all the cases
occurring, are so indistinct that they frequently remain unrecognized
throughout their entire course, and baffle the skill of the best
diagnosticians.

In order to be able to make a sure diagnosis, there must be a localized
pain, together with tenderness on pressure from without on the
painful spot. A great many persons in good health are tender in the
epigastrium, so that you have to be on your guard in this direction,
too. From the occurrence of hæmatemesis in an otherwise healthy person
you can, with great probability, diagnose ulcer of the stomach.

_Differential Diagnosis._ In order to differentiate _between catarrh
and ulcer_, it is simply necessary to keep in mind the difference in
the character of the pain, the fact that local pressure is more liable
to aggravate the pain in ulcer than in catarrh, and the occurrence of
hemorrhage in the former. The two conditions, however, frequently occur
in the same patient.

The differentiation between _ulcer and neurosis_ has already been
discussed. The direct connection of the attacks of pain with the
introduction of food, and the character of the pain will soon clear up
the matter. Should you still be in doubt, a course of treatment, such
as an ulcer would demand, will soon clear up the matter. If the case is
one of ulcer, it will have been cured or materially benefited, if it
was a pure neurosis the patient will if anything feel worse than before.

By far the most difficult question to decide in making a diagnosis is
whether the case is one of _ulcer or cancer_ of the stomach. Here close
attention to several points will usually clear up the diagnosis. Cancer
sufferers always have a sallow complexion, a worn, emaciated, cachectic
appearance, no matter what or how much they eat. Ulcer patients
frequently have a robust, healthy appearance, and are emaciated or run
down only after repeated hemorrhages, or when other grave diseases,
such as heart disease, chlorosis, tuberculosis, etc., are also present.

The _presence or absence of a tumor_ is a very important aid to the
diagnosis, though as I have already stated, not always reliable.
Sometimes an ulcer may be covered with granulations, and its
surroundings so infiltrated and hardened, that even post-mortem the
naked eye can not tell whether it is cancer or simple ulcer, and the
question has to be decided by microscope. Such are likely the cases
which form the bases of cancer cures which are reported from time to
time to have been effected by the use of various remedies.

_Vomiting of blood_ is a symptom common to both cancer and ulcer of
the stomach, but is usually more copious in the latter. If the absence
of acid in the gastric juice of cancerous stomachs proves to be as
reliable a symptom as has been recently asserted, this will be an
important feature in the differentiation from ulcer.

You will frequently be astonished by the success of your treatment if
you think of ulcer in doubtful cases of stomach trouble, such as occurs
in young girls with chlorosis and institute a strict milk diet with
the measures adopted for the cure of ulcer.

_Prognosis._ From what has been said you can see that in general the
prognosis of ulcer of the stomach is good, that with proper avoidance
of all irritation, the ulcer has a tendency to heal of itself. This
tendency has been observed even in large ulcers, where death was
perhaps the result of some intercurrent disease.

Ulcers of the anterior wall of the stomach are more dangerous than such
as occur on the posterior wall, for the reason that in the latter case
adhesion with the neighboring structures are more easily formed, and
thus fatal perforation prevented. The anterior wall takes a much more
active part in the peristaltic movement of the stomach, and as a result
does not enter so easily into adhesion with its surroundings. Even
after an ulcer has healed it always remains a weak point, and cases of
rupture of the stomach in old cicatrices are described by Chiari.

_Treatment._ The pain is the most important criterion as a guide
during the treatment. It is the signal by which I judge of the present
condition of the ulcer. According to the variation of its character
and intensity, I can judge whether the ulcer is healing, is remaining
stationary, or is spreading and increasing in size or depth in spite of
the treatment. If the pain has been removed permanently the ulcer has
been healed. From the relation of this symptom to different kinds of
food you can also judge of a progress or improvement of the ulcer.

Theoretically considered, that form of treatment would seem the best
which gives the stomach absolute rest, entire abstinence from food, a
fast of several weeks. But this can not be carried out in practice.
The patient could be nourished per rectum, you might say, by means of
nutrient enemata. In my opinion this method of nourishment does not
amount to much. I believe that very little water is absorbed by the
rectum, the patient would suffer from thirst and you would then be
compelled to allow him to drink water at least.

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 <DW37>. 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