floor unconscious with blood pouring from his mouth. In the jar was nearly a gallon of dark, tarry mass, with a pint or more of clear clotted blood. He rallied slowly. He rallied slowly. From now on, tho pain was present, it was not so severe as to necessitate more than an occasional opiate. The extreme acidity when it came was relieved by hot soda and water..

By May 5 he was able to sit up. The stools became lighter and finally natural in color, but no solid food was allowed. May 11 he was not quite so well; pulse was rapid. At 10 p. m. there was another hemorrhage, blood pouring from bowels and ejected in large clots from his mouth. From now on he was fed by the rectum. May 15 another hemorrhage from which he sank, dying in a few hours.

Post mortem: Body well nourished; Body well nourished; weight probably 150-160 lbs. Incision from ensiform cartilage to pubes thru a deep layer of adipose. Intestines covered with fat and full of blood. Tissues bloodless. Kidneys and liver normal. Stomach somewhat dilated, otherwise normal. Pancreas healthy. Duodenum adherent to pancreas.

The

On opening the duodenum there was found, three-fourths inch from pylorus, an ulcer the size of a half-dollar. edges were clean cut and the ulceration extended thru the mucous and muscular coats. Within the ulcer were the open mouths of several blood-vessels, from which the hemorrhage evidently came. Near the ulcer were several small cicatrices, the seats of old healed ulcers. The pyloric orifice was but slightly contracted.

The other organs of the body were healthy. The adhesion of the duodenum to the pancreas had evidently prevented a perforation. THEO. F. JOHNSON.

National City, Cal.

Perforation of the Stomach in an Infant-Tape

worm in the Peritoneal Cavity.

Editor MEDICAL WORLD:-I wish to report a peculiar and remarkable case. Leonard Q., male, born October 29, 1897, properly developed. The infant grew but never thrived, and soon after birth its abdomen was noticeably enlarged, and continued to grow larger very slowly, but steadily. In February, 1898, a right scrotal hernia presented, but could not be retained.

In March I concluded the abdomen was full of fluid and advised a "tapping". About the middle of April, when the ab

domen was exceedingly large and dyspnea great, the parents consented to its being tapped. The trocar was inserted below and to left of navel and to my surprise I obtained about five pints of clean, healthylooking milk.

Had I punctured a dilated stomach or was the milk in the peritoneum? I wondered!

Two weeks later the abdomen was as large as ever and the paracentesis was repeated with same results. I now fed the child from a bottle and allowed at first 3iij and later but 3ij every three hours, but still in two or three weeks it had to be aspirated again.

All

The tappings were repeated about every two weeks, seven in all, the child continuing to lose flesh till it was a mere skeleton with an immense abdomen. this while the fecal evacuations were natural; the child nursed eagerly but was fretful. It died August 10 of inanition.

Autopsy:-Peritoneal cavity full of milk, fresh and free of curd: No adhesions; no peritonitis; double congenital hernia. Stomach was natural size, presented three perforations each about one half-inch in diameter in the cardiac end, one being anterior, the two posterior ones being adjacent. The edges were ragged, but not indurated; no evidence of gastritis. Ileum presented about its middle a dilatation one-half the size of the stomach. Mesenteric glands enlarged. Liver and spleen were quite normal. normal. Left lung was entirely consolidated, lower and middle lobes of right lung showed markt hypostatic congestion, leaving only right upper lobe pervious for respiration,

Queries:-Were these perforations congenital or the result of ulcers in a child so young? Why did not the milk as a foreign body produce a peritonitis? Who could believe that a child could live five months at least with holes thru its stomach?

A friend of mine, a school teacher, has told me that recently, when dressing a rabbit which he had shot a few minutes before, he found a number of detachments of a tapeworm outside of the intestine. Further search disclosed three openings thru the bowel. The holes were large enough to push his finger thru and were free from any blood.

Is it possible the worm ate its way thru the bowel? Was ever such a case reported in the human subject? This school teacher is a man of veracity and

The Doctor's Relation to Accident Cases and Damage Suits.

Editor MEDICAL WORLD:-In these days of rapid transit by means of steam and electricity, and in the extended use of machinery in manufacturing, accidents of greater or less severity are increasing. In such casualties the first recourse is to the doctor. He may render only temporary first aid to the injured, or he may have entire charge of the patient during illness.

Frequently his connection with such cases does not terminate with the discontinuance of his professional visits. Later, he finds himself concerned in the medicolegal aspect of the case. Even the most trifling accidents are liable to take an unexpected turn in the shape of claims for damages, real or assumed. It is well, therefore, to make full and precise notes of symptoms and locations of injuries, with careful measurements, for no can tell how soon he may have use for exact knowledge on the various phases of the case. Lawyers are on the lookout for such cases, as they have their emissaries everywhere seeking business, and pay a bonus on clients thus secured. Even the police are enlisted in the interest of certain favorite lawyers, and they have been heard to represent that "Lawyer So-andSo has great influence with the court." Possibly these good Samaritans receive something more substantial than a chance cigar for their disinterested (?) services.

Corporations and persons of means are more especially the victims of claimants for compensation for injuries. The mania for compensatory damages is in the very air, and no provocation, however insignificant, is so small that the machinery of the law may not be invoked to obtain greenback balm for the wounded.

If all claims were just, the good offices

simple and easy. But when the person claiming compensation is shrewd and designing, and the attorney sharp and unscrupulous, the doctor may find himself unwittingly involved in the moral aspects of the case, or his self-interest may so conflict with seemingly plain duty that his course is in a measure perplexing.

Perhaps I can best illustrate this by giving one out of several recent experiences. The case was a minor one, but it involves the same principles that obtain in larger ones involving thousands and tens of thousands of dollars.

Mrs. Blank, while at a seaside resort, stepped upon a rotten plank, which gave way, letting her leg through. She was doubtless shocked some, the skin about the knee was slightly grazed, and the knee possibly sprained a little.

That evening she came to my office on her bicycle. She stated that while she could not walk, there was comparatively little pain as she propelled her wheel. Careful examination revealed no serious injury. I advised discutient lotions and emphasized the necessity for rest. The lotions were not faithfully applied, and she was on the street, on foot or on her wheel, nearly every day.

Three weeks later I received a visit from her lawyer, who was gathering material for a damage suit against the owner of the bathing pavilion. Of course he took the case "on spec,' " by agreement to have one-half of what he could get by settlement, or suit at law. He had already given notice of purposed suit if satisfactory settlement was not promptly made.

I informed the lawyer that in my opinion he had a very weak case with which to go before a jury, as his client, even if seriously or even permanently injured, had given her case away by contributory negligence, for she had not followed my directions, but had been about daily, shopping and on excursions and picnics. He admitted the weakness of his cause should it ever come to trial, but his strong hope was in forcing a settlement.

In the course of negotiations it was arranged that a surgeon of some repute should see the patient with me, in the interest of the defense,

Of course Mrs. Blank was apprised of our coming, and was sure to be at home on that day. We found her duly installed in an invalid chair, with her leg elevated in due form. She rehearsed the story of her

The bandages were then removed and the knee carefully examined by the surgeon. She winced and groaned and cried out, and was nervously apprehensive at the proper points in the examination of the knee. The doctor reached the conclusion-unaided by me-that there was certainly synovitis, but whether the ill effects would be but temporary, or would prove lasting or even permanent, time alone would determine.

His conclusions doubtless influenced the settlement of the case out of court. The owner of the bath-house paid $700, of which the lawyer took $350, the doctors their fees, and the injured party the balance. This greenback salve worked an immediate and effectual cure, for there has been no further disability or complaint of that knee.

There naturally arise several questions respecting the ethics of this and similar cases. The doctor finds himself in a dilemma between loyalty to his patients and broad, even-handed justice and duty.

1. Was it my duty to inform the consultant surgeon that our interesting patient had been walking on that leg daily since her injury?

2. Should I have told him that she had been bicycling ad libitum with that lame knee?

3. Should I have told him that I had seen her walk without limping, when she supposed herself unnoticed?

4. Should I have remarked that there was no flinching or complaining when I manipulated the limb quite roughly?

5. Should I have given my opinion that she was malingering, and that the whole thing was a "fake job," in which she had been coached by her lawyer?

6. In keeping silence, was the family doctor abetting fraud? The doctor can say truly that he was not inquired of concerning any of these things. But was it his duty to voluntarily state what he knew of

these matters.

7. Does the doctor's confidential relations with his patients close his mouth in all matters of this kind?

8. In the case of a lawyer, he is not permitted to reveal any evidence of crime even that comes to him in his relation to his client. Is the doctor's relation to the family and its secrets less sacred and confidential?

9. Would anybody admit the doctor

secrets and frailties, if it were not confidently believed that under no stress of circumstances would he prove recreant to the trust reposed in him?

10. Some affect to draw a moral line beyond which the doctor may not rightfully go. Is there such a line-and if so, BENJ. EDSON, M. D.

where?

Brooklyn, N. Y.

The Thirtieth Dilution.

Editor MEDICAL WORLD:-Dr. W. C. Smith, of Franklin Grove, Ill., wishes me to tell him just how much alcohol it will take to make the thirtieth dilution, retaining the whole drop to the thirtieth dilution. Says he is not able to figure it out. I have figured it out for him and find it a very easy problem. There are two scales used by homeopaths for making dilutions, the decimal and the centesimal.

If we use the decimal scale, let 1 represent a drop of tincture, then add thirty ciphers and we will represent the number of drops required to make the thirtieth dilution. Any schoolma'am can reduce this to barrels by dividing the 1000000000000000000000000000000 by 2457600, the number of drops of alcohol in a barrel (40) gallons). I find we would have 406901041621565104166 barrels of alcohol. If we use the centesimal scale we must add sixty ciphers instead of thirty, and, of course, this would require a few more gallons of alcohol.

Now, I do not want to put the doctor to the inconvenience of purchasing so large a quantity of alcohol in order to prove or disprove my assertion that the thirtieth dilution would cure, since the thirtieth dilution can be very conveniently made with less than four ounces of alcohol. But if the doctor persists in his determination to retain the entire drop to the thirtieth dilution, I would advise him to use water instead of alcohol, on account of the difference in cost, and still the cooperage to hold this amount of water would be quite an item of expense. Besides all of this he would have several gallons more of the medicine than he would need in an ordinary practice of an average lifetime.

I fear that Brother Smith has fallen into the error which I warned him against in the very last words of my article written for the July number of THE WORLD, viz., not to call me a fool till he had tried my remedy. Is the dose unreasonably small? Suppose I admit it; what then? It cures.

On the Significance of Certain Symptoms. Editor MEDICAL WORLD:-The attempt to discuss disease from the standpoint of individual symptoms is without very much precedent, tho why, I cannot say. This seems all the more remarkable because there is such significant value in a study of this kind. It is often from this point of view that a physician may be said to approach his case. A patient comes to him complaining of a single discomforting symptom, perhaps a very painful one. To him, it constitutes his entire trouble, while to the physician, it may be the forerunner of grave conditions that are developing. Here, I may instance the presistent cough of pertussis or the development of tubercular meningitis in their incipiency. A headache, or a cough, or a presistently coated tongue, or a constant local pain, may be irremovable because their causes are undiscoverable. Many a physician fails to relieve a patient because he cannot truly interpret one or two leading symptoms for want of a comprehensive knowledge of what that special symptom may mean-in what conditions it may exist.

The task of cataloging the various conditions under which any special symptom may exist is an impossible one. I only aim to add my mite to what others may contribute, so that in time we may have a reliable and fairly complete list to guide the busy practitioner. It is to be hoped that the WORLD readers will enter into the spirit of this enterprise, and add such information to the little stock that I shall offer as to make this proposed series of papers fairly complete when reinforced by

these additions.

Instead of taking symptoms at random, I have preferred to consider them anatomically; that is, say those relating to the digestive tract first, then those concerning circulation, then respiration, and so on thru the list, ending with the inevitable heading of miscellaneous for the odds and, ends not otherwise classifiable.

To begin then, I shall take up the consideration of some of the most prominent symptoms of

The Digestive Tract.

The digestive tract, in this paper, includes the whole alimentary tube from the mouth to the anus, and the associated organs. Thus we have to consider the mouth, gullet, stomach, and the small and large intestine, together with the vermiform appendix, cecum, sigmoid and rectum,

and the salivary glands, liver, spleen and pancreas. While reading this, it will repay the reader to review the various diseases that may affect all the parts just enumerated, for example, children's sore mouth, teething, caries of the teeth, toothache, mumps, salivation, aphthæ, glossitis, coated tongue, inflammatory and other diseases of the salivary glands, tonsillar and other faucial inflammations and affections, globus hystericus, dysphagia, esophageal stenosis, nausea, emesis, hematemesis, heartburn, water brash, all kinds of dyspepsia, gastroenteric catarrh, colic, etc., etc., ad libitum.

All symptoms are better understood when the reason for their being is known. To this end it is absolutely necessary to understand the anatomy and physiology of the parts involved. Now, the gastroenteric tract is lined with a mucous membrane that is modified in its varied parts according to the work it has to do. In the mouth it is plain and smooth, being lined with pavement epithelium, and studded here and there with mucous glands. Under the floor of the mouth are located, upon either side, the sublingual and the submaxillary glands, with their mouths opening thru the mucous membrane just above them. In the cheek, just in front of the ear, and extending also below and a little behind it, on each side, is the parotid gland, the duct of which, called Steno's or Stenson's, opens in the mouth at the top of a small papule opposite the middle molar tooth on each side. The teeth finely subdivide the food and thoroly incorporate within it, or should do so, the saliva, which is the secretion of the salivary glands. It has digestive functions, especially upon starch.

The tongue, with its gustatory sense, not only incites to the introduction of food, but keeps it between the teeth for mastication and insalivation. Sound teeth, together with an ample salivary secretion, and a clean and mobile tongue, are, therefore, necessary to the proper performance of the first act of digestion. The absence of any of these factors may cause marked trouble with distinct symptoms.

The gullet is a mere tube for the passage of food from the mouth to the stomach. It is lined with a plain mucous membrane backed by a muscular layer for pushing the food along. Thence down, the alimentary tube has this mucous lining backed with a layer of muscle fibers running both lengthwise and around the gut. Some of them are also arranged diagonally