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which will enable us to split up and analyse morecomplex pictures. Such common dreams as anxietyabout passing an examination, which in reality wepassed 30 to 40 years ago, or of forgetting an appoint-ment, or of leaving things behind, may likewise havea simple, though in their case a psychical, basis.The flying dreams seem to me to have their cause

in a partial awareness of respiration. The flight is

usually up and down, and not in the same horizontalplane. Again, it is difficult sometimes to move alimb when just beginning to be aroused from sleep,and that might be the basis of the dream with cloyingfeet. A friend tells me that whenever he goes tosleep with a feeling of nausea he is likely to dream ofbeing on a ship at sea or to see waves passingrhythmically before his eyes. For this the explana-tion seems simple, though not romantic.But enough of these reflections, or the writer will

be out of his rather shallow depth.* * *

A South African experience compelled me to sharea room with a bricklayer, and a more perfect bedroomcompanion I have never met. There was no egotisticscramble for the minor comforts of life, but the selfsacrifice and courtesy of a Spanish Grandee, whichsoon became mutual. Pondering why this man,whose education had been elementary, was such apleasant companion, while others we encounter,who may have been to Eton and Cambridge, are notalways so pleasant, the answer seemed to be that

this one had been trained in the best school of all-adversity-an advantage not shared by everyone.Shakespeare and others have told us of the uses ofadversity, and most doctors could tell how they haveseen characters tempered and improved by adversityand suffering. Not all natures will react favourablyto difficulties but fortunately the great majority doso react.

* * *

The value of quotation in speech and writing hasmuch diminished. The Victorians enriched their

heavy orations with long Latin or Greek quotationswhich would bore hearers to-day, and indeed didlittle more, even then, than advertise the classicalerudition of the speaker. To-day many speakersstill interpolate poetry or prose quotations, suggestingagain the erudition of the speaker, but often withoutclarifying the subject under consideration. In thepast I have made another use of quotation ; if atrite aphorism or bright idea came to my mindI would produce it as a quotation from some distantauthor. It seemed that an audience paid moreattention to my ideas if attributed to Dante or

Milton, of whose pages I am, in fact, profoundlyignorant. To-day, with the passage of years, I

rarely use quotations, but endeavour to expressmyself clearly and give no one else credit for myideas. If such a step belittles my learning it werejust as well belittled. Such ideas have no doubtoccurred to others in the distant past, but there isno harm in restating them to-day.

CORRESPONDENCE

HÆMORRHAGE IN GASTRIC AND DUODENALULCER

To the Editor of THE LANCET

SIR,-In your last issue Hurst and Ryle state thatthe danger of haemorrhage from peptic ulcers has beengrossly exaggerated in papers recently appearingin British journals. I cannot help feeling that thisstatement calls for examination. Hurst, from figurescollected by Babey/ says that the mortality-ratefor cases of peptic ulcer admitted under his care

to Guy’s Hospital on account of recent haemorrhage,and in which death was directly attributable to

haemorrhage, is 4’8 per cent. Compared with thisBabey sets out a table "showing mortality ratesof haemorrhage from ulcer given by various authors "some of which are over 20 per cent. This table is

misleading because no mention is made of the differentcriteria adopted by the various authors when compil-ing their statistics. For example, Conybeare 2 arguingfrom the number of post-mortems of all cases admittedto Guy’s Hospital for haematemesis or melaena from1911 to 1920 (inclusive) showed a mortality of about4-3 per cent. Burger and Hartfall3 3 found the

mortality from severe haematemesis at the same

hospital from 1921 to 1930 (inclusive) to be 22-6 percent. The last figure includes deaths from complica-tions and there seems no useful reason why theyshould be omitted whether from cardiac failure oreven following surgical intervention. It seems quiteclear therefore from a study of the available statisticsthat, omitting cases of melsena, the death-rate inhospitals from severe hsematemesis has not been

1 Babey, A. M., and Hurst, A. F. (1936) Guy’s Hosp. Rep.86, 129.

2 Conybeare, J. J., Quoted by Hurst, A. F. (1923-24) Proc.R. Soc. Med. 17, 20 ; (1924) Lancet, 1, 1095.

3 Burger, G., and Hartfall, J. (1934) Guy’s Hosp. Rep. 84, 167.

exaggerated and is still disturbingly high. Anotherevident fact not stressed by Hurst and Ryle is thatrepeated haemorrhage is the most serious prognosticsign. A single bleeding, however severe, is rarelyfatal. The mortality in Hurst’s cases at Guy’s whichhad further gross bleeding in the wards was 27 percent.With regard to blood transfusion, another important

point dealt with by these authors, we found whenexamining a series of cases (Cullinan and Price 4)and by subsequent experience that when it isconsidered necessary to transfuse because of severeanaemia it is wise to wait until several hours afterthe gross bleeding has ceased. Not only does trans-fusion of itself fail to arrest haemorrhage but it mayeven cause further bleeding if performed immediately.To this rule there is one exception : in cases withsevere anaemia when gradual bleeding has beengoing on for several days transfusion may be a life-saving measure. We also thought that the givingof enemata before the sixth day after a severe

haematemesis carried a risk of further bleeding.I do not wish to imply in any way that because

the mortality in hospitals from severe haematemesisis high that this is any reason for more frequentsurgical intervention. For the reasons Hurst and

Ryle so clearly state immediate operation is veryseldom desirable. Their plea for the avoidance,whenever possible, of disturbing therapeusis and fortreatment with quiet and rest in the widest sense isunassailable. Courage lies not in action but inconfident inaction.

I am, Sir, yours faithfully,EDWARD R. CULLINAN.

4 Cullinan, E. R., and Price, R. K. (1932) St. Bart’s Hosp.Rep. 65, 185.