great exertion.

It has also been given in chronic diarrhea and dysentery, in prolonged cases of gout and rheumatism, and for many conditions due to debility and anemia.

Ellingwood praises arnica for soreness and muscular pains after confinement, or those following surgical operations, and as a remedy for surgical fever. It has also proved effectual in paresis of the bladder, and certain forms of hemorrhage.

Large-dose therapeutics: Arnica has also been given with success in large doses, sufficient to produce a sedative action. These have been employed in mania with high arterial excitement, in delirium due to alcoholism, and in acute rheumatism with sthenic circulatory symptoms. Bartholow suggested its use in all sthenic fevers and inflammations. In large doses it has a decided antipyretic effect. Its application in mania, melancholia and delirium tremens, rheumatism and rheumatic gout, in which it is found decidedly curative, are all smalldose indications. Large doses were recommended by Shoemaker in erysipelas, and in the dermatoses present with gouty rheumatism. Arnica has also proved of value in relieving the pains of congestive dysmenorrhea, in acute nephritis, and in other acute inflammations of the pelvis organs. Ten drops of the tincture dissolved in a glass of water and used as a mouth-wash has been suggested as a useful remedy for toothache, especially for the soreness remaining after the acute pain has subsided. It has also been employed in small doses, taken internally, to relieve the effects of injuries. This application is taken from its popular use externally, but there is considerable evidence to show that when administered internally it alleviates the pathologic conditions remaining after traumatisms.

We do not recommend arnica for use in large doses, as we have in veratrine, aconitine, and gelseminine, remedies admirably suited to the treatment of such conditions. The small-dose effects are of value. A number of observers state that, given in small doses, arnica stimulates the cerebral functions somewhat as caffeine does. There is no doubt that when the circulation is relaxed arnica increased the action of the kidneys. Dr. A. E. Collier, of Illinois, says that the one fact that stands out most prominently as the essential feature

of its action, is that arnica causes the withdrawal of the watery constituents of the blood, and causes this to be excreted through the kidneys. The volume of urine is greatly increased, without change in the solids and without the ingestion of more water, when arnica is used in small doses. In case of inquiry, when the tendency is toward suppuration, arnica by depleting the serum tends to prevent suppuration. Given after parturition the prophylactic action is astonishing. He has never had

case of puerperal fever since adopting this remedy as a prophylactic, nor a postpartum hemorrhage. Given twelve hours previous to an operation the loss of blood will be much less and the healing will go on more rapidly than if this remedy were not used. In typhoid fever when hypostasis is present arnica has proved of value. He has not found it useful when the pulse is small, except by relieving the soreness and the pain through lessening the pressure on the nerve endings. He employs very small doses.

While engaged upon the study embodied in this paper the writer was consulted by a patient who complained of a sense of coldness in the left leg. Arnicin, a centigram, three times a day, gave prompt but temporary relief. Investigation showed fecal retention with indicanuria, which were readily removed. The symptoms subsided, but recurred whenever the bowels became clogged. The malady was traced to a very old syphilitic infection, causing a sclerosis of a limited spot in the right cerebral area of the left leg. A permanent cure seems to have been secured from specific treatment. The indication was clearly to promote the absorption of the debris that encumbered the nerve fibers without having destroyed them. As the patient was over 70 years of age and the malady not progressive, it seemed advisable to employ mild remedial treatment and not to hurry. He was given mercury biniodide and arsenic iodide, one milligram each; iodoform and stillingin, one centigram each; this dose being taken an hour before meals to permit full absorption. Improvement was manifest in one week, and continued until all symptoms had disappeared within five months. The prescription was continued another month. During this period the bowels were carefully regulated, the urine being examined weekly for acidity and in

What impels us to write and publish the products in medical journals? Of course, the enlightenment of our confreres, or the attempt at illumination on some subject for the good of our kind should be the impelling reason, but is it? Possibly, in rare instances, but with the bulk of us there are divers other forces driving our pens to put down our medical doings and sayings for publication. We are not paid for the composition, and it takes time and trouble. Our patients and the people in our respective localities know nothing of our literary achievements, so we gain no added kudos with them; our practice is, therefore, not affected. We are poor, having to hustle hard and strong to gain a living, and still we have this itch of scribbing for which no personal perceptible benefit accrues. Of a certainty, inherent masculine vanity calling for recognition of knowledge and ability sways us, and the desire to stand well in the opinion of our unknown medical brothers. Again, there is the feeling (probably with many of us) that although we know little and recognize our limitations, still we are men and believe that we know something that other men do not see and know, and there is the natural impulse to impart this knowledge to others. Last and chief of impelling motives is the desire to do something off our own bat; to play a little part in the field of medical literature, feeble though our effort be. We in the outside places are thrown back upon ourselves. We mentally live in the silent land of our own thoughts. Hospital-camaraderie is denied to us; common union and interchange of confidences and experiences with our medical brothers is lacking. Envy and hatred sprout and grow rank in the

hearts of country practitioners in poor and sparsely settled localities. It is a hard competitive struggle, and the bread must be earned for the wife and children. If one man gains ground in practice, another loses. The pinch of this loss is felt, and sometimes the loss is undeserved. It is oftentimes said by laymen: "It's a pity that Dr. X and Dr. N- do not pull together." Well, that is so. It would be better for the public. Unfortunately, however, they are single teams pitted against each other for the prize of the people's favor and money. A patient or a family drops Dr. X and takes up Dr. N——. Dr. X― naturally resents this, and the more so because possibly he thinks himself the better man. However, he can do nothing but chew the bitter cud of resentment and jealousy. And so it goes. Dr. Ngains and Dr. X, therefore, loses. As a doctor grows older in country practice, wisdom in dealing with the people increases with him. In his callow, prideful youth, professional dignity demands the assurance from patients summoning him, that no other doctor has the case in hand. Later on he keeps his tongue quiet, and asks no questions. He has learned the fact that failure and offense spring from refusal of· a case, under any circumstances. Money talks large and all-powerful in the estimation of the working country farmer. To refuse to take what he considers easily earned money through professional scruples, to him seems the height of idiocy. He has no use for idiots, and his environing friends are of the same opinion. So the country doctor learns a wise discretion in shutting his ears and silencing his tongue as to the doings of other doctors. When he is summoned, without question he whips up his nag and off he goes.

Undoubtedly, there are various brands of country practice, but our brand has no use for the man who hesitates and halts in giving his opinion as to the condition of a patient. The admission that you do not know what is the matter with a patient on a first visit is, in the eyes of the family, to place yourself on a level of ignorance with themselves, and to shake their confidence in your professional skill and knowledge. It is not necessary to be very specific about the patient's condition, only one must not admit dubicity in diagnosis. A statement that the lungs are in bad shape,

that there is intestinal trouble, or the liver or kidneys are not working well, etc., will suffice for the family, while one probes and burrows for an absolutely accurate diagnosis. The writer knows well a medical man, his brain-shelves full stored with book knowledge, and who, when given time, uses this knowledge with clear vision for the benefit of others. As competition increased in the field of medical practice, his patients fell away, and now his practice has come close to the vanishing point. The cause is not from lack of skill or knowledge, but from his fatal hesitation, or rather the want of tactful words, often times at the bedside of the sick. "What is the matter with Bill?" asks the anxious wife. "I would rather not give an opinion as to his case at present. The symptoms are not specific, and demand a later investigation," answers the above-cited honest and tactless doctor. "Send for me to-morrow morning; if not, I will call in the afternoon." The resulting effect of these words is the loss of the patient. Another doctor is called in and our indecisive doctor receives a message that his services will not be required again. His hesitation in diagnosis, though professionally honest, was like many other honest opinions, better kept to himself. words, to the minds of these people, simply expressed ignorance.

His

To stall off inquiring relations of a sick person as to the outcome of the illness, and as to the progress of the malady, or rather to get round their questions, requires tact and ingenuity in the use of words. Pessismism in serious sickness, is fatal to self and patient. A too robust optimism may result in failure, and a consequent following fall of prestige. To be honest and still not too committal; to conceal one's doubts and yet tell the truth; to inspire confidence when one is not over-confident, are all in the power of words, and these words must be fittingly chosen, the utterances of a tactful brain. A well-known eminent English physician has recently cynically stated that our professional success comes, not from our knowledge, but from our reputation for knowledge. Well, like most cynical sayings, there is, although the statement as a whole is untrue, a grain of truth in it. A good presence and gentlemanly manners; a pushing personality, aggressive and egotistic; social advantages, a happy environment, etc., make for success; but in addi

tion to these attributes and advantages there must be, I ween, in these, our days of knowledge and analytic discrimination, skill in the use of said knowledge. Knowledge is power. Yes, but it must be active and not passive knowledge. One's mental field may be filled and fertilized with knowledge, but until ploughed and harrowed by action, thoughtful work, and sown thick with the seeds of experience, it is of little avail. We are all aware of our limited power in face of the shifting intricacies of some disease. We often stand confronted by an urgent morbid condition differing from any we have met before, and not stored in the book -knowledge in our brain-compartments. Then comes the immediate question of treatment, and experience in nearly related cases steps forward to help us. Three weeks ago a country doctor, during the night, was called to an urgent case. The patient lived at ten miles distance, and as the roads were bad, it was I A. M. before the doctor arrived. He found the patient was a woman who had been confined two weeks before. After ten days' rest she had got up and gone about her housework. It had been a normal labor, and after the manner of her kind, feeling fairly well, she resumed her household duties after ten days' rest, as she had done after three previous confinements. Everything went well until the evening of the day the doctor was summoned, when she fainted in her tracks and was put to bed. The doctor, on his arrival, noted that this patient was in an extremely critical condition. She was blanched and bathed in a profuse clammy sweat, and with feeble effort, fighting for breath, her shoulders lifted and supported by two women. Her pulse was soft, nearly imperceptible, the beats running into and overlapping one another in uncountable" rapidity. The doctor having fixed his thermometer in the armpit, gave quickly, hypodermically, a large dose of strychnine digitalis, and by skill and good luck managed to force a maximum quantity of a strong, rapidly diffusible stimulant down the patient's throat. Having accomplished this he removed the thermometer, and was astounded to find a temperature of 106% degrees, and this degree of heat given in a sweating axilla. With reference to the statement that everything went well until that evening, I meant in so far as hemorrhage, pain, etc., were concerned. The fact

.

was that for four or five days she had felt weak, but had forced herself to do the household work, as she had no servant.

Well, returning to the time when the shocked doctor had taken the temperature -106% degrees in a sweating armpit, and was now pondering deeply. What were the next steps to be taken? Should he wash out the bowels? Should he explore and medicate the uterine cavity? Was he justified, under the eminently weak condition of the patient, in interference which might possibly, and would probably, immediately. quench the full spark of life? The doctor waited, and after fifteen minutes gave another hypodermic of strychnine and digitalis. In a short while the gulping breathing ceased, and was replaced by a fairly easy, though humid, respiration. The patient regained the power of whispering speech and her pulse, though rapid, steadied and evened somewhat. Now, the doctor had formed his opinion, and made up his mind as to further treatment. An antipyretic dose of quinine was administered, and orders were left with the women attendants to repeat the dose after four hours, and also to give the strychnine and digitalis tablets by the mouth every three hours. After remaining in the house about two hours, and the patient then being in no danger of death (immediate), the doctor went home. At 9.30 the next morning, or rather the same evening, on returning to his patient, he found her resting and breathing quietly and regularly. The sweating had stopped, and the blood-temperature was absolutely normal. She (the patient) was practically well of her former morbid condition. The radial pulse had evened, slowed, and strengthened. The patient was cheerful, asserting that she felt well, only that she was weak and rather deaf. The further history of the case is that she was put on tonic medicine treatment and given plenty of good nourishment and rest. There was no return of the fever and after untoward symptoms. In three weeks' time she was a strong and hearty woman again, busy in her household work.

In reviewing the foregoing case, it is apparent that the forms of the fever and general condition was not in the womb or intestinal cavity, and was not due to any bowel or glandular inflammation; nor was it owing to typhoidal or malarial causes.

The writer has seen cases, other than puerperal, presenting similar symptoms from a like cause. This cause rests as the result and outcome of overwork on a weakened system. The increased metabolic, unnatural changes, with the consequent high temperature; the intense vasomotor disturbance, etc., are the effect of continuous overfatigue falling on an enfeebled vital condition. Disorganization of the nervecontrolling centers and rapid body-tissue waste ensue, and thus bring the patient to the critical state cited above. For want of a better name we will call it "Fatigue Fever." In penning the lines relating to this case, which the writer deems one of "Fatigue Fever," he had it in mind to bring it forward as an example in showing what care should be taken in diagnosing conditions which may spring from various, differing and unrelated causes, and also to mark a warning against haste in the adoption of manipulative measures. Much is written as to technique: as to the manner of using manipulative measures for the removal of the causes of diseased and abnormal conditions; but at the same time little attention, in the way of advice or comment, is given to the patient, as a whole, as to his general physical and psychical state at the time. A simple laxative enema administered at the wrong moment may kill a patient. A uterine exploration, the removal of a sick one from the bed to a table, and many other harmless measures under ordinary circumstances, may, at an unfitting moment, be a source of imminent danger, and the cause of snapping the tenuous thread of life. Moxon, the pathologist, says wisely: "It is very important to know what kind of disease the patient has got, but it is even more important to know what kind of patient the disease has got." Yes, and it may be added that it is often imperative to treat the patient before treating the disease, lest in the course of killing the disease we kill the patient.

Returning to the case cited heretofore, it may be well to explain the reasons for the choice of quinine as a febrifuge. Quinine checks unnatural metabolism, diminishing heat through the tissues, and not through the heat regulating center. It also controls the fever, causing productsfatigue products in the cited case. It is anhydrotic. Helped by digitalis and strych

nine, it strengthened the heart's action. It frequently exhibits a hypnotic action, due probably to its stimulating the inhibitory action of the sympathetic.

West Paspebiac, Quebec, Canada.

VENTRAL HERNIA.

BY C. FLETCHER SOUDER, M. D.

While it is oftentimes impossible to determine the nature and extent of diseased conditions in the abdominal cavity without an operation, is it not advisable to follow a conservative course when it necessitates an abdominal operation in order to avoid subjecting the patient to a possible ventral hernia and to lasting annoyance, suffering, danger, and disability?

Is not ventral hernia of frequent occurrence following abdominal operations? Should a ventral hernia result what is the probable outcome? If a ventral hernia occurs in the line of the incision, does it not frequently involve the greater part or all of the incision? If such occurs, what is the condition of the patient? Or even if the hernia remain small is it not a serious matter? The above is bad, but how much worse is it when the greater part of the severed muscles atrophy as they frequently do? The writer has met with numerous cases where nearly all of the severed musc'es had wasted away to such an extent as to leave only a thin, flabby wall, so that if another operation were to be resorted to, in order to cure the condition, it would be necessary to cut out the greater por

tion

of the affected muscles, extending nearly from the back to the median line of the abdomen.

Do succeeding operations offer greater prospects of effecting a permanent cure? Instead, are not conditions less favorable after each operation? Is it not generally necessary to cut away all of the old scar tissue and all of the diseased section, however extensive the area may be, until sound muscles be reached? What is the effect upon a patient when a considerable portion of these muscles are cut out? The writer knows of a woman who had been operated upon eight times for ventral hernia, and there is now a stitch abscess which is causing her great trouble. Another woman consu'ted me who had been operated upon for ventral hernia three times, all of which

were unsuccessful, and each time her condition afterward was far worse than before, and several have consulted me where the cutting operation had been unsuccessful twice.

Were these unfortunate occurrences the fault of the surgeon? Instead is it not liable to happen in any case?

What can be done to relieve or cure these cases? Does another cutting operation offer sufficient prospects or warrant assuming the risks unless conditions be favorable? It is doubtful whether any other treatment offers greater or equal prospects of relieving, limiting, benefitting, or curing these cases than can be obtained by means of the injection method. Many of these cases are probably hopeless, but there is no question but that others can be greatly relieved, if nothing more. Can the injection of alcohol be either injuries or contra-indicated if properly given?

I depend largely upon the injection of from 5 to 10 minims of alcohol deposited where I wish to set up an irritation. Frequently a fluid with more astringent properties may be needed. The conditions vary to such an extent that the treatment will be more fully described in another article. 1803 North Fifteenth St., Philadelphia. GRAPE JUICE, DIGESTION, ETC.

Grape juice is a fruit extract, and does not intoxicate. It makes an excellent drink for the invalid. The small per cent. of salicylic acid added to prevent fermentation, is beneficial, and in no way injurious. Salicylic acid may, perhaps, disturb digestion, but acts on ptomaines, and prevents decomposition of food which passes through the alimentary tract unchanged. The system needs waste to keep the digestive process in good order. If man should stop the process of digestion by food in a concentrated form, he would, in time, lose his digestive powers. We must use, but not abuse, an organ, if we want its help. Concentrated foods often deter digestion, while those containing the waste products assist it. If a man should stop using his arms paralysis would be the consequence. Exercise develops it. Education develops the mind, even if we forget in time.

L. G. DOANE, M. D.