684 also be advisable by way of setting the stomach at rest, or the ulcer might be curetted ; but in one case in which I simply scraped the ulcer and applied carbolic acid an extension of the ulcer occurred and led to perforation on the eighth day, so that I am not much in favour of trusting to curetting simply. If any superficial points of bleeding be discovered they may be caught up by forceps and ligatured, but this is more easily said than done, as the mucous membrane is very friable, and a

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... ligature if drawn at all tightly tends to cut its way through ; moreover, forceps easily tear the mucous membrane and may produce a larger bleeding area. A method of ligature may be employed if the ulcer is small. This has proved serviceable in several cases and is easy of application when the ulcer can be reached. This method is ligaturing en masse, it has been tested by experiments on animals by Dr. Eisendrath and has been shown to endanger perforation except when supported by external sutures. Ligature of the main arteries of the stomach was suggested theoretically by Savariaud when no bleeding ulcer could be discovered; it does not, however, commend itself as being safe and it has not yet been put in practice. Should the bleeding be from an ulcer at the pylorus the operation of pyloroplasty may be performed, the ulcer being excised, the edges of the ulcer being united so that the line of sutures shall be transverse to the axis of the pylorus. I would not, however, advise pyloroplasty when there is active ulceration of the pylorus unless the ulcer can be completely excised, for in three cases of this kind I have had disappointments. In one case the patient made a good recovery from the operation but subsequently suffered from stenosis, for which a further operation had to be done. In a second case recovery took place and the patient regained his lost weight, but subsequently a tumour of the pylorus developed which was thought to be cancer and for which I had to perform pylorectomy, and the third case is the one ending in perforation which mentioned in speaking of curetting ulcers. I think, therefore, that in cases of ulcer of the pylorus where a clean excision of the ulcer cannot be done it would be better to perform gastro-enterostomy or pylorectomy, whichever at the time may appear to be easier. So far as I can gather, the mortality of pyloroplasty in simple ulcer appears to be about 13 per cent., that of gastro-enterostomy about 16 per cent., and that of pylorectomy 28 per cent., but it is most difficult to get at genuine statistics since many single failures are unreported, and these figures must only be accepted as approximate. Wherever the pylorus is adherent, as in my experience it is in so many cases of ulcer, I should certainly prefer gastro-enterostomy, but if the pylorus be extensively ulcerated and free from adhesions pylorectomy can be almost as quickly performed as gastroenterostomy, seeing that the pylorus is already in the hand. The operative treatment of parenchymatous or capillary haemorrhage by any surgical method would seem to be of doubtful value, for according to a report by Petersen from OZ2iny's clinic of three cases operated upon for severe parenchymatous haemorrhage from vicarious menstruation operation entirely failed to relieve, and of two other cases of post-operative parenchymatous heamorrhage by Reichard both died. After a careful study of reported cases as well as from personal experience I cannot help feeling that operative treatment in acute haemorrhage gives such a high rate of mortality-64'2 per cent. as compared with from 5 per cent. to 10 per cent. in cases treated medically-that it is better in such cases to rely solely on medical means. But I in the repeated chronic haemorrhages that are responsible for quite half the total deaths from hasmatemesis the operation of gastro-enterostomy affords a reliable method of treatment, since it at the same time gives rest to the stomach and removes the hyperacidity of the gastric juice by an operation that can be done with rapidity and comparative safety; moreover, when the ulceration is at the pylorus, where it so frequently leads to hypertrophy and stenosis, the operation not only relieves the symptoms for which it was undertaken but proves curative to the disease. EXETER DISPENSARY.—The annual meeting of this institution was held on Feb. 17th under the pre-' sidency of the Rev. E. Dupuis. The medical officers reported that 6256 patients had been treated during the year, as compared with 6164 in 1898. The financial statement showed that the income amounted to £1866 and the expenditure to £1722.