the scrobiculus cordis, either by direct girthing of the abdomen, or by constant and constrained position, as in milliners and shoemakers, or the striking of the epigastrium by the shuttle of the weaver, are also causes of gastric ulcer. The causes of the sudden perforating ulcer are still more doubtful, as we have previously intimated.

There are several objects to be sought for in the treatment of ulceration of the stomach.

1. The promotion of reparative action by sustaining and increasing general nutritive power.

2. The relief of distressing symptoms, pain, vomiting, hæmorrhage, pyrosis, constipation, &c.

3. The prevention of the extension of the disease.
4. The removal of its complications.

1. The promotion of reparative action is in many instances most effectively secured by allowing the affected organ to rest; and much more can be done in this way than is usually supposed. If absolute rest could be afforded, the ulceration would in many cases rapidly heal; but, since this is almost impossible, it must be our object to give such forms of nutriment as will spare the stomach; and in seeking to accomplish this purpose it must be borne in mind, that the especial office of the stomach, for which its peculiar secretion is adapted, is the solution of nitrogenous compounds. These elements are found in the flesh of animals, in beef and mutton, &c. Hence we generally find that solid food produces

pain and vomiting in cases of gastric ulcer, and must therefore be avoided.

If, however, these elements of food be given, they must be in an unirritating form, as the less oleaginous kinds of fish, the sole, whiting, cod, &c., or poultry; or in a fluid state, as veal and mutton broth, clear soups, &c.; beef tea often creates nausea and vomiting. Still more must hard and indigestible meats, preserved meats, and cheese, be avoided. Oysters, sweetbread can often be taken, when more irritating diet would be rejected.

Starchy food is converted into sugar by the saliva and by the secretions in the intestine, and in that state is readily absorbed. So also oleaginous substances are converted into an emulsion by the alkalies in the secretions of the mouth and intestine, and in the bile; so that these forms of diet, whilst they are demulcent and soothing to the diseased gastric surface, do not require the action of the stomach in order to place them in a state ready for absorption. Good stale bread, biscuits, milk, starchy substances, as arrowroot, tapioca, maize or Indian corn flour, rice, &c., may thus be given to the patient. Eggs often disagree, but may be taken in the form of light puddings; milk, also, when refused in its simple character, may be better tolerated by combination with isinglass, as in blanc-mange, or with soda water or lime water, and even cream and bacon are occasionally well borne.

Rich soups, highly seasoned dishes, pepper, mustard,

&c., are better abstained from; so also pastries, and food containing much insoluble material, as salads, unripe raw fruit, green vegetables, &c. It is, however, undesirable altogether to abstain from vegetables, for we may thus defeat our object by inducing cachexia. Oranges, lemons, &c., may be often taken with benefit.

Again, it is most important that food should be slowly and thoroughly masticated; and it is better to take small quantities at a time, and to repeat the allowance more frequently, than to distend the stomach by a large and bulky meal. About three to four hours should intervene in ordinary cases; but where there is great exhaustion, with irritability of the stomach, food may be required more frequently, and in very small quantities. Exertion, both mental and physical, should be avoided directly after meals; in fact, everything should be done to facilitate the process of digestion. It is well to abstain from alcoholic liquors, if possible; they tend to aggravate the disease, and should not, I think, be given, unless the circulation be failing, and there be tendency to syncope; but when required, brandy in small quantity, and well diluted, or the forms of sherry which contain the least sugar, are best. New wines, port, and imperfectly fermented malt liquors generally disturb and distress the patient.

It is desirable to use every means in our power to improve the health, as by exercise in the open air, but over fatigue or constrained positions should be avoided.

Moderate horse exercise, and bracing air, will sometimes afford more relief than medicinal agents, even when long continued; but violent shaking is injurious. When a chloratic or anæmic state has been produced, the preparations of steel, by restoring a more healthy condition of the blood, greatly facilitate reparative changes. We prefer the milder preparations, as the ammonio-tartrate or citrate. The compound steel pill, with aloes and myrrh, or quinine with iron, as the sulphates or citrates conjoined, may also be beneficially prescribed.

It is obviously most desirable to administer that form of aliment which will nourish the body, so that healing may be favoured, but without irritating and disturbing the process which is going on towards recovery. The difficulty is still more increased by the occasional irritability of the stomach itself. And this leads us to the consideration of the means we possess for the mitigation of distressing symptoms, pain, vomiting, hæmorrhage, pyrosis, constipation.

For the relief of pain, opium or its alkaloid morphia is often the best remedy, in doses of a quarter to one grain of the former two or three times a day, or a few minims of the solution of the latter. Chloric ether, in doses of 10, 15 to 20 m, will be found very efficacious, especially when combined with nitrate of bismuth and carbonate of soda in 10 to 20 grain doses. Chlorodyne is spoken of as being a valuable substitute, but I have no experience in its use. Dilute hydrocyanic acid, in doses

of 3 to 5 m, is also a useful adjunct in some cases, especially when given with alkalies. Both potash, soda, lime and magnesia have been used; they neutralise acid secretion, and oftentimes increase the anodyne power of remedies previously mentioned, opium, morphia, chloric ether, &c. If, however, there be constipation, dryness of the tongue, and opium is not well borne, conium, henbane, belladonna, &c., may be used as substitutes. The nitrate and oxide of silver, in doses of a quarter to one grain, in some instances diminish the pain and irritability of the stomach, especially when the gastric symptoms are associated with pyrosis. Creasote in 1 m doses, we have found very effectual in relieving pain, when accompanied with irritability of the stomach, vomiting, and fermentative changes in the food. Again, carbonic acid, as in ordinary soda-water, is effective in relieving pain, as well as vomiting. So also the use of cold water and ice, which are often very grateful to the patient. The black oxide of manganese in similar doses to bismuth is also an effective remedy, although not equal to the latter preparation.

Vomiting is a very distressing symptom in many cases of ulcer of the stomach. It is best combated by only partaking of fluid diet, and of that in moderate quantities. The remedies, we have already mentioned, are of service, but especially bismuth, hydrocyanic acid, creasote, ice and alkalies. Dr. Jenner has pointed out the value of the sulphite of soda in checking the fer