British History

"I confidently affirm that the greater part of those who are supposed to have died of gout, have died of the medicine rather than the disease - a statement in which I am supported by observation."[7]

"For humble individuals like myself, there is one poor comfort, which is this, viz. that gout, unlike any other disease, kills more rich men than poor, more wise men than simple. Great kings, emperors, generals, admirals, and philosophers have all died of gout. Hereby Nature shows her impartiality: since those whom she favors in one way she afflicts in another - a mixture of good and evil pre-eminently adapted to our frail mortality."[8]

Acute diseases, such as fevers and inflammations. he regarded as a wholesome conservative effort or reaction of the organism to meet the blow of some injurious influence operating from without; in this he followed the Hippocratic teaching closely as well as the Hippocratic practice of watching and aiding the natural crises. Chronic diseases, on the other hand, were a depraved state of the humours, mostly due to errors of diet and general manner of life, for which we ourselves were directly accountable. Hence his famous dictum: "acutos dico, qui ut plurimum Deum habent authorem, sicut chronici ipsos nos" ("I say what hurts, most over which God has authority, just like we ourselves over the chronic").

Sydenham’s most famous and enduring work was his 1683 treatise on gout , which took the art of clinical observation to a personal level.  Having suffered from frequent and debilitating attacks of gout from the age of thirty, he gave a descriptive first-person account of the affliction:

"The regular gout generally seizes in the following manner: it come on a sudden towards the close of January, or the beginning of February, giving scarce any sign of its approach, except that the patient has been afflicted, for some weeks before, with a bad digestion, crudities of the stomach, and much flatulency and heaviness, that gradually increase till the fit at length begins; which however is proceeded, for a few days, by a numbness of the thighs, and a sort of descent of flatulencies through the fleshy parts thereof, along with convulsive motions; in the day preceding the fit the appetite is sharp but preternatural.  The patient goes to bed, and sleeps quietly, till about two in the morning, when he is awakened by a pain, which usually seizes the great toe, but sometimes the heel, the calf of the leg, or the ankle.  The pain resembles that of a dislocated bone, and is attended with a sensation, as if water just warm were poured upon the membranes of the part affected; and these symptoms are immediately succeeded by a chillness, shivering, and a slight fever…."

He also described the physical and emotional comorbidities of gout, again incorporating his own experience:

"Moreover the patient is likewise afflicted with several other symptoms; as a pain in the hemorrhoidal veins, nauseous eructations, not unlike the taste of the ailment last taken in, corrupting in the stomach, happening always after eating any thing of difficult digestion, or no more than is proper for a healthy person, together with a loss of appetite, and a debility of the whole body, for want of spirits, which renders his life melancholy and uncomfortable."

"But what is a consolation to me, and may be so to other gouty persons of small fortunes and slender abilities, is, that kings, princes, generals, admirals, philosophers, and several other great men, have thus lived and died.  In short, it may, in a more especial manner, be affirmed of this disease, that it destroys more rich than poor persons, and more wise men than fools; which seems to demonstrate the justice and strict impartiality of Providence, who abundantly supplies those that want some of the conveniences of life, with other advances, and tempers its profusion to others with equal mixture of evil; so that it appears to be universally and absolutely decreed, that no man shall enjoy unmixed happiness or misery, but experience both: and this mixture of good and evil so adapted to our weakness and perishable condition, is perhaps admirably suited to the present state."

In modern medicine, gout has a known association with coronary artery disease, kidney stones, and sleep apnea. Sydenham is known to have had bouts of clinical hematuria and gout, and his death in 1689 is thought to have been related to both.  Given what is now known about the comorbidities of gout and its relationship to diet and sedentary lifestyle, it is very possible that he also suffered from metabolic disturbances that affected his heart, lung, and kidneys.

Diabetes Its Medical and Cultural History

"From that period I had not met with a case of Diabetes, although I had observed an extensive range of disease in America, the West Indies, and in England, until 1796." "Captain Meredith, of the Royal Artillery, being an acquaintance. I had seen him very frequently, previous to his going on camp duty in 1794, but then he had no disease; however, he always had impressed me, from his being a large corpulent person, with the idea that he was not unlikely to fall into disease. (Editor: Another instance of Rollo's clinical acuteness.)" "On the 12th of June, 1796, he visited me, and though I was at once struck with the diminution of his size, yet, at the same time, the colour of his face being ruddy, I received no impression, otherwise than of his being in health: a moment's conversation, however, convinced me of the contrary ...... 

"He complained of great thirst and a keenness of appetite; his skin was hot, dry and parched; and his pulse small and quick. He told me his complaints had been attributed to an old disease, and a liver affection. The thirst, dry skin, and quick pulse, marking a febrile state, depending probably on some local circumstance, and connecting these with the keenness of appetite, Diabetes immediately suggested itself to me. I enquired into the state of his urine, which I found in quantity and colour to be characteristic of the disease; and was at the same time much surprised, that for the two or three months he had been under the care of a Physician and Surgeon, the circumstance of the increased urine had not been known to them. The patient told me, as he drank so much, the quantity of urine had appeared to him a necessary consequence; and of course never having been asked about it, he gave no information. I directed him to keep the urine he next passed, and, on examination, it was found to be sweet; in consequence of which the disease became sufficiently ascertained." 

At another point in the case history, Rollo states that Captain Meredith was 34 years of age and was 71 3/4 inches tall. At the time of beginning of the special treatment, the symptoms of diabetes had been present seven months or more and his weight had fallen from 232 to 162 pounds. A view held by some at that time was that diabetes was a primary affection of the kidneys. However, Rollo developed the idea that the disease was "a primary and peculiar affection" of the stomach in which, due to some morbid changes in "the natural powers of digestion and assimilation," sugar or saccharine material was formed in that organ, chiefly from vegetable matter. It was on this basis that he advocated the use of an animal diet together with certain medication designed to quiet the overactive stomach and to diminish the appetite. 

Following initial bloodlettings, Rollo's treatment of Captain Meredith was as follows: 

"1st. The diet to consist of animal food principally, and to be thus regulated: 

Breakfast. One and a half pint of milk and half a pint of lime-water, mixed together; and bread and butter. 

Noon. Plain blood-puddings, made of blood and suet only. 

Dinner. Game, or old meats, which have been long kept; and as far as the stomach may bear, fat and rancid old meats, as pork. To eat in moderation. 

Supper. The same as breakfast." 

"2dly. A drachm of kali sulphuratum to be dissolved in four quarts of water which has been boiled, and to be used for daily drink. No other article whatever, either eatable or drinkable, to be allowed, than what has been stated." 

"3dly. The skin to be annointed with hog's lard every morning. Flannel to be worn next the skin. The gentlest exercise to be only permitted; but confinement to be preferred." 

"4thly. A draught at bed-time of twenty drops of tartarized antimonial wine and twenty-five of tincture of opium; and the quantities to be gradually increased. In reserve, as substances diminishing action, tobacco and foxglove. " 

"5thly. An ulceration, about the size of half a crown, to be produced and maintained externally, and immediately opposite to each kidney. And, 

"6thly. A pill of equal parts aloes and soap, to keep the bowels regularly open."

Therapy 

A special diabetic diet was undoubtedly one of the foremost therapeutic measures, even before the age of insulin. Even before it was recognized that diabetes was a disorder of carbohydrate metabolism, various kinds of diet had been recommended. A change to a diet decided purely pragmatically, which was nevertheless very effective, did not come until JOHN ROLLO (d. 1809), a Scottish physician, who, in 1797, had achieved good results with a meat diet, made his recommendation (MARBLE; ANDERSON; BECKENDORF). He gave a particularly detailed account  The History of Diabetes mellitus 85 of the case of Captain MEREDITH of the Royal Artillery, who became diabetic at the age of 34, and who was very obviously overweight. His diet consisted of a breakfast and supper of milk mixed with lime-water and bread and butter, while his dinner consisted of pudding made of fat and blood and mature, preferably rank pork. In this way he had - without being conscious of it - excluded carbohydrates almost entirely from the diet. The patient of course lost a great deal of weight and felt extremely well. 

A second patient was less cooperative and therefore died at the age of 57, 19 months after treatment was begun, mainly - as ROLLO pointed out - because during his last three months he indulged in such things as apple pudding, sugar in his tea, and wine. 

The "meat diet" was used well into the 19th century, although gradually it was considered wiser not to cut out all carbohydrates, and patients had a certain amount of carbohydrate added to their diet, even though that caused some glycosuria. This kind of diet was initiated in the middle of the 19th century, mainly by ADOLF NIKOLAUS VON DURING (1820-1882) and RUDOLF EDUARD KULZ (1845-1895). The latter even distinguished between harmful and harmless carbohydrates and found that levulose, inulin, inosit, mannite, and lactose, as well as some root vegetables like celery, comfrey, etc. caused no deterioration of the metabolic condition. But it remains true that many specialists did recommend a carbohydrate-free diet with a lot of meat and fat (DICKINSON; PAVY; SEEGEN; R. SCHUMACHER, STEPP). 

"In the distant future I see open fields for far more important researches. Psychology will be based on a new foundation, that of the necessary acquirement of each mental power and capacity by gradation. Light will be thrown on the origin of man and his history."

Darwin predicts the dawn of biology, genetics, paleoanthropology and more.

Banting accounted all of his unsuccessful fasts, diets, spa and exercise regimens in his past. His previously unsuccessful attempts had been on the advice of various medical experts. He then described the dietary change which finally had worked for him, following the advice of another medical expert. "My kind and valued medical adviser is not a doctor for obesity, but stands on the pinnacle of fame in the treatment of another malady, which, as he well knows, is frequently induced by [corpulence]." (p24) His own diet was four meals per day, consisting of meat, greens, fruits, and dry wine. The emphasis was on avoiding sugar, saccharine matter, starch, beer, milk and butter. ([Wikipedia]

 I have felt some difficulty in deciding on the proper and best course of action. At one time I thought the Editor of the Lancet would kindly publish a letter from me on the subject, but further reflection led me to doubt whether an insignificant individual would be noticed without some special introduction. In the April number of the Cornhill Magazine I read with much interest an article on the subject-defining tolerably well the effects, but offering no tangible remedy, or even positive solution of the problem-“What is the Cause of Obesity?’’ I was pleased with the article as a whole, but objected to some portions, and had prepared a letter to the Editor of that Magazine offering my experience on the subject, but again it struck me that an unknown individual like myself would have but little prospect of notice; so I finally resolved to publish and circulate this Pamphlet, with no other reason, motive, or expectation than an earnest desire to help those who happen to be afflicted as I was, for that corpulence is remediable I am well convinced, and shall be delighted if I can induce others to think so. The object I have in view impels me to enter into minute particulars as well as general observations, and to revert to bygone years, in order to show that I have spared no pains nor expense to accomplish the great end of stopping and curing obesity. 

I am now nearly 66 years of age, about 5 feet 5 inches in stature, and, in August last (1862), weighed 202 Ibs., which I think it right to name, because the article in the Cornhill Magazine presumes that a certain stature and age should bear ordinarily a certain weight, and I am quite of that opinion. I now weigh 167 lbs., showing a diminution of something like 1 Ib. per week since August, and having now very nearly attained the happy medium, I have perfect confidence that a few more weeks will fully accomplish the object for which I have laboured for the last thirty years, in vain, until it pleased Almighty Providence to direct me into the right and proper channel-the “tramway,” so to speak-of happy, comfortable existence. 

Few men have led a more active life-bodily or mentally-from a constitutional anxiety for regularity, precision, and order, during fifty years’ business career, from which I have now retired, so that my corpulence and subsequent obesity was not through neglect of necessary bodily activity, nor from excessive eating, drinking, or self-indulgence of any kind, except that I partook of the simple aliments of bread, milk, butter, beer, sugar, and potatoes more freely than my aged nature required, and hence, as I believe, the generation of the parasite, detrimental to comfort if not really to health. I will not presume to descant on the bodily structural tissues, so fully Canvassed in the Cornhill Magazine, nor how they are supported and renovated, having no mind or power to enter into those questions, which properly belong to the wise heads of the faculty. None of my family on the side of either parent had any tendency to corpulence, and from my earliest years I had an inexpressible dread of such a calamity, so, when I was between thirty and forty years of age, finding a tendency to it creeping upon me, I consulted an eminent surgeon, now long deceased,-a kind personal friend,-who recommended increased bodily exertion before my ordinary daily labours began, and thought rowing an excellent plan. I had the command of a good, heavy, safe boat, lived near the river, and adopted it for a couple of hours in the early morning. It is true I gained muscular vigour, but with it a prodigious appetite, which I was compelled to indulge, aid consequently increased in weight, until my kind old friend advised me to forsake the exercise. 

He soon afterwards died, and, as the tendency to corpulence remained, I consulted other high orthodox authorities (never any inferior adviser). but all in vain. I have tried sea air and bathing in various localities, with much walking exercise; taken gallons of physic and liquor potasse, advisedly and abundantly; riding on horseback; the waters and climate of Leamington many times, as well as those of Cheltenham and Harrogate frequently; have lived upon sixpence a-day, so to speak, and earned it, if bodily labour may be so construed; and have spared no trouble nor expense in consultations with the best authorities in the land, giving each and all a fair time for experiment, without any permanent remedy, as the evil still gradually increased. 

I am under obligations to most of those advisors for the pains and interest they took in my case; but only to one for an effectual remedy. When a corpulent man eats, drinks, and sleeps well, has no pain to complain of, and no particular organic disease, the judgment of able men seems paralyzed,-for I have been generally informed that corpulence is one of the natural results of increasing years; indeed, one of the ablest authorities as a physician in the land told me he had gained 1 Ib. in weight every year since he attained manhood, and was not surprised at my condition, but advised more bodily exercise-vapour-baths and shampooing, in addition to the medicine given. Yet the evil still increased, aid, like the parasite of barnacles on a ship, if it did not destroy the structure, it obstructed its fair, comfortable progress in the path of life. I have been in dock, perhaps twenty times in as many years, for the reduction of this disease, and with little good effect-none lasting. Any one so afflicted is often subject to public remark, and though in conscience he may care little about it, I am confident no man labouring under obesity can be quite insensible to the sneers and remarks of the cruel and injudicious in public assemblies, public vehicles, or the ordinary street traffic; nor to the annoyance of finding no adequate space in a public assembly if he should seek amusement or need refreshment, and therefore he naturally keeps away as much as possible from places where he is likely to be made the object of the taunts and remarks of others. I am as regardless of public remark as most men, but I have felt these difficulties and therefore avoided such circumscribed accommodation and notice, and by that means have been deprived of many advantages to health and comfort. 

Although no very great size or weight, still I could not stoop to tie my shoe, so to speak, nor attend to the little offices humanity requires without considerable pain and difficulty, which only the corpulent can understand; I have been compelled to go down stairs slowly backwards, to save the jarr of increased weight upon the ankle and knee joints, and been obliged to puff and blow with every slight exertion, particularly that of going up stairs. I have spared no pains to remedy this by low living (moderation and light food was generally prescribed, but I had no direct bill of fare to know what was really intended), and that, consequently, brought the system into a low impoverished state, without decreasing corpulence, caused many obnoxious boils to appear, and two rather formidable carbuncles, for which I was ably operated upon and fed into increased obesity. 

At this juncture (about three years back) Turkish baths became the fashion, and I was advised to adopt them as a remedy. With the first few I found immense benefit in power and elasticity for walking exercise; so, believing I had found the “philosopher’s stone,” pursued them three times a-week till I had taken fifty, then less frequently (as I began to fancy, with some reason, that so many weakened my constitution) till I had taken ninety, but never succeeded in losing more than 6 Ibs. weight during the whole course, and I gave up the plan as worthless; though I have full belief in their cleansing properties, and their value in colds, rheumatism, and many other ailments. 

I then fancied increasing obesity materially affected a slight umbilical rupture, if it did not cause it, and that another bodily ailment to which I had been subject was also augmented. This led me to other medical advisers, to whom I am also indebted for much kind consideration, though, unfortunately, they failed in relieving me. At last finding my sight failing and my hearing greatly impaired, I consulted in August last an eminent aural surgeon, who made light of the case, looked into my ears, sponged them internally, and blistered the outside, without the slightest benefit, neither inquiring into any of my bodily ailments, which he probably thought unnecessary, nor affording me even time to name them. I was not at all satisfied, but on the contrary was in a worse plight than when I went to him; however he soon after left town for his annual holiday, which proved the greatest possible blessing to me, because it compelled me to seek other assistance, and, happily, I found the right man, who unhesitatingly said he believed my ailments were caused principally by corpulence, and prescribed a certain diet,-no medicine, beyond a morning cordial as a corrective,-with immense effect and advantage both to my hearing and the decrease of my corpulency. 

For the sake of argument and illustration I will presume that certain articles of ordinary diet, however beneficial in youth, are prejudicial in advanced life, like beans to a horse, whose common ordinary food is hay and corn. It may be useful food occasionally, under peculiar circumstances, but detrimental as a constancy. I will, therefore, adopt the analogy, and call such food human beans. The items from which I was advised to abstain as much as possible were:

-Bread, butter, milk, sugar, beer, and potatoes, which had been the main (and, I thought, innocent) elements of my existence, or at all events they had for many years been adopted freely. 

These, said my excellent adviser, contain starch and saccharine matter, tending to create fat, and should be avoided altogether. At the first blush it seemed to me that I had little left to live upon, but my kind friend soon showed me there was ample, and I was only too happy to give the plan a fair trial, and, within a very few days, found immense benefit from it. It may better elucidate the dietary plan if I describe generally what I have sanction to take, and that man must be an extraordinary person who would desire a better table:

- For breakfast, I take four or five ounces of beef, mutton, kidneys, broiled fish, bacon, or cold meat of any kind except pork; a large cup of tea (without milk or sugar), a little biscuit, or one ounce of dry toast. 

For dinner, Five or six ounces of any fish except salmon, any meat except pork, any vegetable except potato, one ounce of dry toast, fruit out of a pudding, ‘any kind of poultry or game, and two or three glasses of good claret, sherry, or Madeira-Champagne, Port and Beer forbidden. 

For tea, Two or three ounces of fruit, a rusk or two, and a cup of tea willlout milk or sugar. 

For supper, Three or four ounces of meat or fish, similar to dinner, with a glass or two of claret. 

For nightcap, if required, A tumbler of grog -(gin, whisky, or brandy, without sugar) -or a glass or two of claret or sherry.

 This plan leads to an excellent night’s rest, with from six to eight hours’ sound sleep. The dry toast or rusk may have a table spoonful of spirit to soften it, which will prove acceptable. Perhaps I did not wholly escape starchy or saccharine matter, but scrupulously avoided those beans, such as milk, sugar, beer, butter, & c., which were known to contain them. 

On rising in the morning I take a table spoonful of a special corrective cordial, which may be called the Balm of life, in a wine-glass of water, a most grateful draught, as it seems to carry away all the dregs left in the stomach after digestion, but is not aperient; then I take about 5 or 6 ounces solid and 8 of liquid for breakfast; 8 ounces of solid and 8 of liquid for dinner; 3 ounces of solid and 8 of liquid for tea; 4 ounces of solid and 6 of liquid for supper, and the grog afterwards, if I please. I am not, however, strictly limited to any quantity at either meal, so that the nature of the food is rigidly adhered to. 

Experience has taught me to believe that these human beans are the most insidious enemies man, with a tendency to corpulence in advanced life, can possess, though eminently friendly to youth. He may very prudently mount guard against such an enemy if he is not a fool to himself, and I fervently hope this truthful unvarnished tale may lead him to make a trial of my plan, which I sincerely recommend to public notice,-not with any ambitious motive, but in sincere good faith to help my fellow-creatures to obtain the marvellous blessings I have found within the short period of a few months. 

I do not recommend every corpulent man to rush headlong into such a change of diet, (certainly not), but to act advisedly and after full consideration with a physician. 

My former dietary table was bread and milk for breakfast, or a pint of tea with plenty of milk and sugar, and buttered toast; meat, beer, much bread (of which I was always very fond) and pastry for dinner, the meal of tea similar to that of breakfast, and generally a fruit tart or bread and milk for supper. I had little comfort and far less sound sleep. 

It certainly appears to me that my present dietary table is far superior to the former-more luxurious and liberal, independent of its blessed effect-but when it is proved to be more healthful, comparisons are simply ridiculous, and I can hardly imagine any man, even in sound health, would choose the former, even if it were not an enemy; but, when it is shown to be, as in my case, inimical both to health and comfort, I can hardly conceive there is any man who would not willingly avoid it. I can conscientiously assert I never lived so well as under the new plan of dietary, which I should have formerly thought a dangerous extravagant trespass upon health; I am very much better, bodily and mentally, and pleased to believe that I hold the reins of health and comfort in my own hands, and, though at sixty-five years of age, I cannot expect to remain free from some coming natural infirmity that all flesh is heir to, I cannot at the present time complain of one. It is simply mhculous, and I am thankful to Almighty Providence for directing me, through an extraordinary chance, to the care of a man who could Work such a change in so short a time. 

Oh! that the faculty would look deeper into and make themselves better acquainted with the crying evil of obesity-that dreadful tormenting parasite on health and comfort. Their fellow men might not descend into early premature graves, as I believe many do, from what is termed apoplexy, and certainly would not, during their sojourn on earth, endure so much bodily and consequently mental infirmity. 

Corpulence, though giving no actual pain, as it appears to me, must naturally press with undue violence upon the bodily viscera, driving one part upon another, and stopping the free action of all. I am sure it did in my particular case, and the result of my experience is briefly as follows:

- I have not felt so well as now for the last twenty years. 

Have suffered no inconvenience whatever in the probational remedy. 

Am reduced many inches in bulk, and 35 Ibs. in weight in thirty-eight weeks. 

Come down stairs forward naturally, with perfect ease.

 Go up stairs and take ordinary exercise freely, without the slightest inconvenience. 

Can perform every necessary office for myself. 

The umbilical rupture is greatly ameliorated, and my sight is restored-my hearing improved. 

My other bodily ailments are ameliorated; indeed, almost past into matter of history. 

I have placed a thank-offering of $50 in the hands of my kind medical adviser for distribution amongst his favourite hospitals, after gladly paying his usual fees, and still remain under overwhelming obligations for his care and attention, which I can never hope to repay. Most thankful to Almighty Providence for mercies received, and determined to press the case into public notice as a token of gratitude. 

I have the pleasure to afford, in conclusion, a satisfactory confinnation of my report, in stating that a corpulent friend of mine, who, like myself, is possessed of a generally sound constitution, was labouring under frequent palpitations of the heart and sensations of fainting, was, at my instigation, induced to place himself in the hands of my medical adviser, with the same gradual beneficial results. He is at present under the same ordeal, auld in eight weeks has profited even more largely than I did ill that short period; he has lost the palpitations, and is becoming, so to speak, a new made man-thankful to me for advising, and grateful to the eminent counsellor to whom I referred him-and he looks forward with good hope to a perfect cure. 

I am fully persuaded that hundreds. if not thousands, of our fellow men might profit equally by a similar course; but, constitutions not being all alike, a different course of treatment may be advisable for the removal of so tormenting an affliction. 

My kind and valued medical adviser is not a doctor for obesity, but stands on the pinnacle of fame in the treatment of another malady, which, as he well knows, is frequently induced by the disease of which I am speaking, and I most sincerely trust most of my corpulent friends (and there are thousands of corpulent people whom I dare not so rank) may be led into my tramroad. To any such I am prepared to offer the further key of knowledge by naming the man. It might seem invidious to do so now, but I shall only be too happy, if applied to by letter in good faith, or if any doubt should exist as to the correctness of this statement. 

WILLIAM BANTING, 

Sen., Late of No. 27, 

St. James’s Street, Piccadilly, Now of No. 4, The Terrace, Kensington 

May, 1863 

SIMPLE ULCER OF THE STOMACH.

BY W. H. WELCH, M.D.

DEFINITION.—Simple ulcer of the stomach is usually round or oval. When of recent formation it has smooth, clean-cut, or rounded borders, without evidence of acute inflammation in its floor or in its borders. When of long duration it usually has thickened and indurated margins. The formation of the ulcer is usually attributed, in part at least, to a disturbance in nutrition and to a subsequent solution by the gastric juice of a circumscribed part of the wall of the stomach. The ulcer may be latent in its course, but it is generally characterized by one or more of the following symptoms: pain, vomiting, dyspepsia, hemorrhage from the stomach, and loss of flesh and strength. It ends frequently in recovery, but it may end in death by perforation of the stomach, by hemorrhage, or by gradual exhaustion.

TREATMENT.—In the absence of any agent which exerts a direct curative influence upon gastric ulcer the main indication for treatment is the removal of all sources of irritation from the ulcer, so that the process of repair may be impeded as little as possible.

Theoretically, this is best accomplished by giving to the stomach complete rest and by nourishing the patient by rectal alimentation. Practically, this method of administering food is attended with many difficulties, and, moreover, the nutrition of the patient eventually suffers by persistence in its employment. In most cases the patient can be more satisfactorily nourished by the stomach, and by proper selection of the diet, without causing injurious irritation of the ulcer.

At the beginning of the course of treatment it is often well to withhold for two or three days all food from the stomach and to resort to exclusive rectal feeding. In some cases with uncontrollable vomiting and after-hemorrhage from the stomach it is necessary to feed the patient exclusively by the rectum.

The substances best adapted for nutritive enemata are artificially-digested foods, such as Leube's pancreatic meat-emulsion, his beef-solution, and peptonized milk-gruel as recommended by Roberts.109 Beef-tea and eggs, which are often used for this purpose, are not to be recommended, as the former has very little nutritive value, and egg albumen is absorbed in but slight amount from the rectum. Expressed beef-juice may also be used for rectal alimentation. The peptones, although physiologically best adapted for nutritive enemata, often irritate the mucous membrane of the rectum, so that they cannot be retained. It has been proven that it is impossible to completely nourish a human being by the rectum.110 Rectal alimentation can sometimes be advantageously combined with feeding by the mouth.

109 Leube's pancreatic meat-emulsion is prepared by adding to 4-8 ounces of scraped and finely-chopped beef l-2½ ounces of fresh finely-chopped oxen's or pig's pancreas freed from fat. To the mixture is added a little lukewarm water until the consistence after stirring is that of thick gruel. The syringe used to inject this mixture should have a wide opening in the nozzle; Leube has constructed one for the purpose (Leube, Deutsches Arch. f. klin. Med., Bd. x. p. 11).

The milk-gruel is prepared by adding a thick, well-boiled gruel made from wheaten flour, arrowroot, or some other farinaceous article to an equal quantity of milk. Just before administration a dessertspoonful of liquor pancreaticus (Benger) or 5 grains of extractum pancreatis (Fairchild Bros.), with 20 grains of bicarbonate of soda, are added to the enema. This may be combined with peptonized beef-tea made according to Roberts's formula (Roberts, On the Digestive Ferments, p. 74, London, 1881).

There is universal agreement that the dietetic treatment of gastric ulcer is of much greater importance than the medicinal treatment. There is [p. 520]hardly another disease in which the beneficial effects of proper regulation of the diet are so apparent as in gastric ulcer. Those articles of food are most suitable which call into action least vigorously the secretion of gastric juice and the peristaltic movements of the stomach, which do not cause abnormal fermentations, which do not remain a long time in the stomach, and which do not mechanically irritate the surface of the ulcer. These requirements are met only by a fluid diet, and are met most satisfactorily by milk and by Leube's beef-solution.

The efficacy of a milk diet in this disease has been attested by long and manifold experience. By its adoption in many cases the pain and the vomiting are relieved, and finally disappear, and the ulcer heals. In general, fresh milk is well borne. If not, skimmed milk may be employed. If the digestion of the milk causes acidity, then a small quantity of bicarbonate of soda or some lime-water (one-fourth to one-half in bulk) may be added to the milk. Large quantities should not be taken at once. Four ounces of milk taken every two hours are generally well borne. Sometimes not more than a tablespoonful can be taken at a time without causing vomiting, and then of course the milk should be given at shorter intervals. It is desirable that the patient should receive at least a quart, and if possible two quarts, during the twenty-four hours. The milk should be slightly warmed, but in some cases cold milk may be better retained. In some instances buttermilk agrees with the patient better than sweet milk. Although many suppose that they have some idiosyncrasy as regards the digestion of milk, this idiosyncrasy is more frequently imaginary than real. Still, there are cases in which milk cannot be retained, even in small quantity.

For such cases peptonized milk often proves serviceable.111 The artificial digestion of milk as well as of other articles of food is a method generally applicable to the treatment of gastric ulcer. The main objection to peptonized milk is the aversion to it that many patients acquire on account of its bitter taste. The peptonization should not be carried beyond a slightly bitter taste. The disagreeable taste may be improved by the addition of a little Vichy or soda-water. Peptonized milk has proved to be most valuable in the treatment of gastric ulcer.

Leube's beef-solution112 is a nutritious, unirritating, and easily-digested article of diet. It can often be taken when milk is not easily or [p. 521]completely digested, or when milk becomes tiresome and disagreeable to the patient. It is relied upon mainly by Leube in his very successful treatment of gastric ulcer. A pot of the beef-solution (corresponding to a half pound of beef) is to be taken during the twenty-four hours. A tablespoonful or more may be given at a time in unsalted or but slightly salted bouillon, to which, if desired, a little of Liebig's beef-extract may be added to improve the taste. The bouillon should be absolutely free from fat. Unfortunately, not a few patients acquire such a distaste for the beef-solution that they cannot be persuaded to continue its use for any considerable length of time.

112 By means of a high temperature and of hydrochloric acid the meat enclosed in an air-tight vessel is converted into a fine emulsion and is partly digested. Its soft consistence, highly nutritious quality, and easy digestibility render this preparation of the greatest value. The beef-solution is prepared in New York satisfactorily by Mettenheimer, druggist, Sixth Avenue and Forty-fifth street, and by Dr. Rudisch, whose preparation is sold by several druggists.

Freshly-expressed beef-juice is also a fairly nutritious food, which can sometimes be employed with advantage. The juice is rendered more palatable if it is pressed from scraped or finely-chopped beef which has been slightly broiled with a little fresh butter and salt. The meat should, however, remain very rare, and the fat should be carefully removed from the juice.

To the articles of diet which have been mentioned can sometimes be added raw or soft-boiled egg in small quantity, and as an addition to the milk crumbled biscuit or wheaten bread which may be toasted, or possibly powdered rice or arrowroot or some of the infant farinaceous foods, such as Nestle's. Milk thickened with powdered cracker does not coagulate in large masses in the stomach, and is therefore sometimes better borne than ordinary milk.

For the first two or three weeks at least the patient should be confined strictly to the bill of fare here given. Nothing should be left to the discretion of the patient or of his friends. The treatment should be methodic. It is not enough to direct the patient simply to take easily-digested food, but precise directions should be given as to what kind of food is to be taken, how much is to be taken at a time, how often it is to be taken, and how it is to be prepared.

Usually, at the end of two or three weeks of this diet the patient's condition is sufficiently improved to allow greater variety in his food. Meat-broths may be given. Boiled white meat of a young fowl can now usually be taken, and agreeable dishes can be prepared with milk, beaten eggs, and farinaceous substances, such as arrowroot, rice, corn-starch, tapioca, and sago. Boiled sweetbread is also admissible. Boiled calf's brain and calf's feet are allowed by Leube at this stage of the treatment.

To these articles can soon be added a very rare beefsteak made from the soft mass scraped by a blunt instrument from a tenderloin of beef, so that all coarse and tough fibres are left behind. This may be superficially broiled with a little fresh butter. Boiled white fish, particularly cod, may also be tried.

It is especially important to avoid all coarse, mechanically-irritating food, such as brown bread, wheaten grits, oatmeal, etc.; also fatty substances, pastry, acids, highly-seasoned food, vegetables, fruit, and all kinds of spirituous liquor. The juice of oranges and of lemons can usually be taken. The food should not be taken very hot or very cold.

For at least two or three months the patient should be confined to the [p. 522]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.