Has had a cough for several weeks. Appetite has been poor and bowels constipated. One week ago had several chills and then a fever. since which time the cough and dyspnoea have been much worse. There is pain in epigastrium and right thigh.

Physical Examination:-Temperature, 101.4; pulse, 132, respiration, 30. Skin and mucous membranes cyanotic. Tongue thick and flabby with heavy yellowish, brown coating. Breathing is shallow and rapid. Apex beat is diffuse and weak. There are no thrills nor abnormal pulsations. Pulse is rapid, small and markedly intermittent. The arteries are considerably thickened. Vocal fremitus is slightly increased in the right infraclavicular region. Resonance is somewhat impaired over entire chest, but there is not localized dulness. Cardiac dulness is increased both to left and right. Liver dulness extends one finger breadth below costal arch. Splenic dulness is normal. The abdomen is slightly tympanitic, and there is epigastric pulsation. There are numerous small, moist rales at the bases of both lungs and dry and moist rales, the latter predominating, throughout the chest. There are no cardiac murmurs. The first sound is weak and flapping in character and the second pulmonic sound is accentuated.

The sputum is thick yellow and tenacious. The urine is acid with a specific gravity of 1012 and albumin. There are hyaline and fine coarse granular carts, blood cells and amorphous urates.

Diagnosis. The urinary findings with the evidences of arterioselerosis and the history of dyspnosa and oedema point to nephritis as the primary affection. The cardiac hypertrophy dilatation and subsequent degeneration is the direct effect of the progressive circulation changes resulting in this condition. The broncho pneumonia occurs as a complication and while it assumes first importance as the prabable chief contributing cause of death, for the prognosis in this case is very grave, it should be assigned second place in the mortuary statement.

Treatment.-Bryonia while it does not cover all the symptoms seems to remedy best indicated for the acute condition and will doubtless relieve the distressing cough and the sharp precordial pain, which presents the characteristic aggravation on motion. Oxygen, for five minutes every half hour depending upon the degree of cyanosis, will he of undoubted benefit. Whiskey in half ounce doses; if necessary. Nov. 20. Cough is loose and expectoration more free and contains some blood. Precordial pain has subsided. Dyspoea is still marked. Cyanosis is not so great. Urine has increased in quantity.

Temperature is 1028, pulse 124, respiration 36. Remedy changed to phosphorus 6x.

Nov. 21. Temperature 101.4, pulse 130, Respiration 36. Dyspnoea marked. Expectoration free. Urine scanty. Bowels moved by enema. Phosphorus 6x continued.

Nov. 22. Patient died at 8 P. M. with cardiac thrombosis noted as immediate cause of death. No post mortem examination was made. Case II. John G. aet. 52. Painter, German. Pulmonary tuberculosis; atrophic hepatic cirrhosis; nephritis.

Previous history:-Always well until one year ago when he caught cold and then coughed all winter. Was in hospital six months ago with broncho pneumonia and pleurisy. At that time considerable fluid was removed from left pleural cavity. Three month ago abdomen and legs began to swell and left hydrocele developed. Has lost much flesh and has grown very weak.

Physical Examination:-Marked emaciation and pallor; no jaundice: lips dry and cracked, tongue dry and glazed. Respiration recursion limited especially on left side. Apex beat in fifth interspace in nipple line. Vocal fremitus increased over both lungs. Marked dulness on percussion anteriorly, especially on left side. Crepitant and gurgling rales over left upper lobe. Crepitant rales and bronchial breathing over right lung anteriorly. Moist rales over both lungs posteriorly. There is a soft mitral systolic murmur. Liver dulness extends from fifth interspace to costal arch. Splenic dulness extends to enterior axillary line and as high as upper border of eighth rib. The abdomen is much distended with fluid and there is marked oedema of the genitalia and lower limbs. There is a gangrenous ulcer of left leg anteriorly, exposing flexor tendons.

Urine: Acid specific gravity, 1010, albumin, few hyaline and fine granular costs.

Soutum Tubercle bacilli present. Prognosis, unfavorable.
Treatment: Arsenicum alb.

Apocynum 8th x in water three times a day. Paracentesis abdominis. Antiseptic irrigation and dressing for leg ulcer.

This patient showed diurnal temperature variations from 97 to 103, with pulse rate persistently above 120 and respirations varying from 24 to 40. Death occurred on the thirteenth day after admission. Autopsy. Well developed male, emaciated and anemic. Lower limbs oedematous. Scrotum much distended and ulcerated. Abdomen greatly distended with clear yellowish fluid. Large and deep gangrenous ulcer over left tibia.

Lungs:-Marked adhesions of both pleurae.

Left upper lobe consolidated and contains many small cavities filled with pus. There is also considerable infiltration of left lower lobe. Right upper lobe is infiltrated but there is no ulceration. Heart is enlarged, pale and flabby. Aorta and coronaries are sclerotic and mitral and aortic valve segments are thickened. Bases of aortic cusps show calcareous deposits. Liver is small, nodular, light gray in color and tough. Weighs 1300 gms. Spleen is large, with thickened ashen gray capsule and shows many large whitish areas on section. Weighs 1200 gms. Kidneys: Contracted, adherent capsules, narrow and congested sortex. Stomach bowels and mesentery markedly congested.

Case III.

pancreas.

Andrew B. aet. 49, laborer, Russian. Carcinoma of

Previous history:-Has never been sick. No history of malignant disease in family.

Present illness:-Three months ago began to have pain in epigastric region and in lower part of chest. There was loss of appetite, much distress after eating and much distension of the bowels. Constipation was very marked. There was a dry hard cough most of the time. Vomiting has occurred only when an unusually large meal has been taken, and only two or three times in the history of the illness. Physical examination:-There is marked emaciation and the straw colored skin characteristic of the cancerous cachexia. The abdominal muscles are very tense and there is marked tenderness in the epigastric region. The liver is somewhat enlarged and tender. There is dulness entending beyond left lobe of the liver into Traube's space, and there is dulness with absence of vocal fremitus below the fifth rib and posterior to the left nipple line, over which region there is bronchial breathing. The patient was anesthetized and several ounces of bloody serum removed from the left pleural sac. Careful palpation at this time revealed a very firm, nodular and immovable tumor almost beyond reach and just within the left nipple line.

Urine, sputum and pleural fluid examination proved negative. Blood count showed 4,000,000 reds and 6400 white, with 70 per cent hemoglobin. The diagnosis of carcinoma of the tail of the pancreas is based upon the absence of signs indicating duodenal obstruction.

Treatment:- Arsenicum alb. 3x every 2 hours, soft diet. High cathartic enemata. The patient was subsequently removed from the hospital and died a month later. No postmortem examination was 'held.

I am indebted to P. Vessie for the clinical data upon which these notes are based.

ON DOCTORS.*

BY RUDYARD KIPLING.

It may not have escaped professional observation that there are only two classes of mankind-doctors and patients. I have had a delicacy in confessing that I belong to the patient class ever since a doctor told me that all patients were phenomenal liars when their symptoms were concerned. But I should say that the average patient looks on the average doctor very much as the non-combatant looks on the troops who are fighting on his behalf. The more men there are between his dearly beloved body and the unkind enemy,, the better the non-combatant is pleased. Medical students are trained men who in due time will be drafted into the permanently mobilized army which is always fighting, always under fire, against death. It is a little unfortunate that death, as the senior practitioner, is bound to win in the long run.

But the non-combatants-the patients-console themselves with the idea that it is, or will be, the business of the doctors to make the best terms they can with death on our behalf, to say how his attacks should be longest delayed or diverted, and when he insists on driving the attack home, to see that he does so according to the rules of civilized warfare.

Every human being-every sane human being-is agreed that this long-drawn fight for life is one of the most important things in the world. It follows, therefore, that those who control this fight and those who will reinforce the army must be among the most important people in the world. Certainly, the world will treat them. on that basis.

It long ago decided that you have no working hours that anybody is bound to respect, and that nothing except extreme bodily illness will excuse you for refusing to help the man who thinks he may need your help at any hour of the day or night. Nobody will care whether you are in your bed or your bath, or on a holiday, or at a church, or in a theater. The little vitality you have accumulated in your leisure will be draggled out of you again. In all times of flood, fire, famine, plague, pestilence, battle, murder and sudden death, it will be required of you that you report for duty at once, and that you stay on duty until your strength fails-or your con

* Rudyard Kipling delivered a striking and characteristic address on doctors in London on October 1st at the opening of the Middlesex Hospital School.

science relieves you-whichever are some of your obligations, and I do not think they will grow any lighter.

Have you heard of any recent legislation to limit your output, any bill for an eight-hour day for doctors? Do you know of any change in public opinion that will allow you not to attend a patient. when you know that the man never means to pay? Have you heard of any outery against the people who could perfectly well afford to pay, but who prefer to cadge round the hospitals and get advice and glass eyes and cork legs for nothing? I have not. It is required of you at all moments to save others. It is nowhere laid down that you must save yourself.

That is to say, you belong to the privileged classes. You and kings are about the only people whose explanation policemen will accept if you exceed the speed limit with your motor cars. On presentation of your visiting card you can pass through the most turbulent crowd unmolested and even with applause. If you wave a yellow flag over a center of population you can turn it into a desert. If you choose to fly a Red Cross flag over a desert you can turn it into a center of population, towards which, as I have seen, men will crawl on their hands and knees. You can forbid a ship to enter a port. If you think it necessity to the success of an operation you can stop a 20,000-ton liner, with her mails, in midocean till the operation is concluded. You can tie up the traffic of a port without notice. You can order whole quarters of a city to be pulled down or burned, and you can count on armed co-operation to see that your prescriptions are efficiently carried out.

We poor patients do not often dispute your orders unless we are frightened by the continuance of an epidemic. In that case, if we are uncivilized, we say that you have poisoned the drinking water for your own purposes, and we throw stones at you. If we are civilized we do something else, but civilized people can throw stones too.

You have been exposed, and you always will be exposed, to the contempt of the gifted amateur, the gentleman who knows by intuition everything that has cost you years of study. You have been, and always will be, exposed to the attacks of those persons who consider their own undisciplined emotions more important than the world's most bitter agonies-the people who would hamper and limit and cripple research because they fear that it may be accompanied by a little pain and suffering. Such people have been against you from the beginning, ever since the earliest Egyptians erected images in honor of cats and dogs on the banks of the Nile. But your work goes on and you will go on. You remain now, perhaps, the only