three or four days. For the next three or four days and through the second week a liquid diet is given, such as milk with lime water, bouillon, beef tea, etc. If hematemesis be present, then the application of hot poultices is to be deferred until the second week. In the third week soft foods, such as eggs and fish, are added, and in the fourth week meats are given. The entire course of treatment lasts from four to five weeks. If it is desired to give the stomach prolonged rest, nutrient enemata can be resorted to for a longer period of time. Few cases fail to respond to this treatment. Rectal alimentation is unnecessary if the patient is well nourished. Care must be exercised when giving rectal feeding, as many times the moving of the patient and the disturbances produced by substances introduced into the rectum may aggravate the condition by increasing intestinal putrefaction. Kussmaul and Fleiner recommend the administration of the bismuth preparations. The subcarbonate is less apt to constipate. One hundred and eighty grains of bismuth subnitrate suspended in warm water and introduced into the empty stomach in the morning through a stomach tube is left to settle. In a few moments the upper clear water may be siphoned off. This should be done every day until the patient begins to improve, then every second and third day. The beneficial effects. are soon noticed by decrease of pain, less nausea and vomiting. Fleiner believes that the bismuth covers and adheres to the ulcer, and in this way acts as a protection by preventing further injury from the acidity of the gastric juice and irritating food.

Cohnheim has attained excellent results in the treatment of ulcer of the stomach with olive oil. Walko finds olive oil and bismuth subnitrate valuable. The unirritating nutritive value of the olive oil with its slight susceptibility to decomposition in the stomach and its retarding influence on the hydrochloric acid secretion make it valuable. Olive oil relieves constipation and acts as an anodyne in many cases of gastric ulcer. The old standard nitrate of silver treatment still stands as one that can hardly be replaced in some cases. One-quarter grain of nitrate of silver in a tablespoonful of distilled water to be taken three or four times daily. The dose can gradually be increased to half a grain in a few days. To stimulate cicatrization, when nitrate of silver does not act well, I have prescribed with beneficial results five drops of tincture of iodine three times a day in a wine glass of water. Many times the hyperacidity must have attention. To neutralize the excessive acidity in gastric ulcer there is nothing better than equal parts of magnesia usta and

creta preparata. The magnesia acts well in these cases, as it assists in relieving the constipated condition. By a careful diet with the above medications there is no doubt that most of the cases will yield to treatment.

Cruveilhier, of Paris, in 1838 advocated an exclusive milk diet in gastric ulcer, to be given in small quantities and frequently. This method of feeding has never been bettered. Milk, with a little care, can now be so modified as to meet all idiosyncrasies. If necessary it can be peptonized. We are now firmer in the belief of a milk diet for gastric ulcer than ever before. Milk can be made an adjuvant to every treatment of gastric ulcer. The main reason for milk disagreeing is the solid coagulation of the casein in the stomach. Of late I have been using von Dungern's process of forming these curds before the milk reaches the stomach. To accomplish this, pegnin is added to luke-warm milk and the whole well shaken for a minute. In a few minutes the milk coagulates. By thoroughly shaking the coagulated milk the clots disappear and the milk is again liquefied. In this way the casein is finely divided, and therefore easily digested. Pegnin is easily added to milk, and not only makes cow's milk easily digestible, but gives it a flavor that pleases most patients.

Futterer has experimentally found that when the hemoglobin of the blood is destroyed gastric ulcer is apt to occur. The frequency of gastric ulcer in combination with chlorosis and the different forms of secondary anemia or hemoglobinemia are examples. Under these circumstances the percentage of hemoglobin must be ascertained and all measures used to bring the percentage up to normal as soon as possible. For this purpose I have been using fersan with good results. Most preparations of iron have a deleterious effect on the mucous membrane of the stomach. In gastric ulcer it is important to prescribe only such quantities of iron as can be easily absorbed without irritating the gastro-intestinal mucosa. It has been repeatedly proved that a large part of the iron taken into the body in the form of a medication is unabsorbed and acts as an irritant upon the mucous membrane of the stomach. In gastric ulcer the blood is lacking in hemoglobin, and the administration of iron, if it can be tolerated, is beneficial and many times curative. We must be careful in our selection of the preparation of iron, as all soluble preparations irritate both stomach and intestine, and those which are insoluble are inert. I have been looking forward to the time when we would find a preparation containing iron in organic combination which would be soluble in water

and would not irritate the gastro-intestinal mucosa. Science has given us such a combination in fersan. It is the iron and phosphorus found in the erythrocyte of fresh ox blood. In a chemical sense it is an iron containing paranucleoproteid in combination. Fersan is Fersan is free from peptones and albumoses. which often produce digestive disturbances and diarrhoea, and it contains but slight traces of extractive matters. The iron is present in complete organic combination. It contains 90 per cent. of non-coagulable albuminous substance. It is an odorless, tasteless acid iron albuminate, and calls for no digestive activity on the part of the stomach. It is freely soluble in water and is not acted upon by the acid gastric juice, but passes through the stomach unchanged. The alkalinity of the duodenum changes it to an alkaline albuminate, and as such it is absorbed by the intestine. I give it in 15-grain doses and consider it valuable in many cases of gastric ulcer.

When I wish to rapidly increase the percentage of hemoglobin I use the Italian method of giving iron hypodermically. In these cases I give the green ammoniated citrate of iron in one-grain injections deep into the gluteal region once daily. It is surprising how quickly the hemoglobin will increase when patients are placed under this treatment. Twenty-one days is usually sufficient to accomplish the purpose.

In spite of the value of internal treatment there are complications when it is necessary to call for surgical intervention. Gastroenterostomy seems to be the ideal surgical treatment for gastric ulcer. It places the stomach at rest and in that way favors the formation of a firm clot in the bleeding vessel, and this aids the healing of all ulcers. Gastroenterologists are willing to refer their cases of ulcer of the stomach to the surgeon if the internal treatment fails them. But, fortunately, medical treatment does not fail as often as some surgeons would lead us to believe. Cases of repeated and dangerously profuse hemorrhage should always be operated upon. Perforation of gastric ulcer requires immediate surgical intervention. A saline transfusion may be necessary pending the arrival of the surgeon, but an operation should be performed as rapidly as possible. In transfusion we must be careful not to overdo it. The amount of saline solution should never exceed 400 c.c. We must not forget that a sudden rise of arterial pressure from the large quantity of solution may reopen an injured blood vessel and increase hemorrhage. The main danger is shock, and all measures must be resorted to in order to prevent this. Blake has never lost a case of gastric or duodenal perforation that has

come to him within twenty-four hours after perforation. In nearly all of these cases he washed out quantities of gastric juice and duodenal contents which had been scattered throughout the entire abdominal cavity and closed the peritoneum without drainage. As the main danger, in the medical treatment of gastric ulcer, is perforation, and as we can expect such good results by surgical intervention if referred to our surgeon within twenty-four hours, it behooves us to watch carefully the progress of each case so that surgical intervention can be called where necessary.-Charles D. Aaron, M.D., Detroit, Mich., in the Diet and Hygienic Gazette.

ONE of the most important elements in the treatment after intestinal operations is the administration of opium or morphine in large doses for the purpose of "splinting" the peritoneum.

A BICHLORIDE of mercury dressing should never be applied on an area of skin on which tincture of iodine has been recently painted. An iodide of mercury is formed, which is highly irritating.

IN operations for suture of a fractured patella it is very important to sew the torn lateral ligaments of the joint. These aid largely in the support of the joint.

THAT a bone appears normal by fluoroscopic examination does not gainsay the presence of a fracture. A fracture of the radius, for example, may occur without displacement of the fragments. An X-ray plate will demonstrate the line of fracture, when the fluoroscope fails to.

IN persons of middle age presenting gastric symptoms, the diagnosis of cancer should not be excluded because the symptoms have had a sudden onset. Such an onset occurs in a fair proportion of cases.

A SUDDEN desire for sharp, sour and spicy articles of food in a middle-aged or elderly person is often the first symptom of a beginning gastric carcinoma.

Ir a patient vomits coffee-ground material in which no lactic acid is present, one can almost always exclude carcinoma.

IF pressure in the right hypogastrium gives rise to a referred pain in the shoulder region, the offending area is probably the gall-bladder and not the pylorus.-American Journal of Surgery.

Proceedings of Societies.

ONTARIO MEDICAL ASSOCIATION.

The Vice-Presidents of the Ontario Medical Association, with the Chairmen of the Committees on Papers and Business and on Arrangements, Drs. R. R. Wallace and A. B. Osborne met at the home of the President, Dr. Olmsted, in Hamilton, Dec. 15 last, to inaugurate the work for the year.

Dr. Olmsted reported a personal convass of several portions of the Province to stimulate an interest in the coming meeting, which will be held in Hamilton, May 26th, 27th and 28th next.

The Chairmen of the two local committees have active campaigns on the way, looking toward a successful year's work. If the Hamilton members are supported by the men in the Province with an earnestness in any degree approaching that with which they have thrown themselves into the work, the next meeting is already an assured success.

The Committee on Papers have secured the promise of Dr. Charles G. Stockton, of Buffalo, to deliver the address in Medicine, while Dr. Charles L. Scudder, of Boston, will deliver that in Surgery.

The Association decided at its last meeting to stimulate a wider and more sympathetic interest among the Practitioners of the Province in its work, and one of the steps to that end was to carry the meeting of 1908 away from Toronto, where it has been called for so many years. The movement seems a wise one, and its success depends solely upon the efforts of the individual members scattered everywhere in Ontario. One or two men in each county who will interest themselves sufficiently to occasionally call the attention of their fellows to the Hamilton meeting with its promise of a good time both intellectually and socially, can give us the best year, in point of numbers, yet. Five hundred active members would be less than 20 per cent. of the physicians of the Province and surely not too large a number to have in annual attendance, for the western half of the Province could send as many, and a successful meeting this year will insure a repetition in a different section.