plexing problem may be solved by sufficient application.

Diet in Chronic Constipation. Cohen's System of Physiologic Therapeutics has the following good suggestions regarding the diet in constipation, and the diet is fully as important as any other part of the treatment; therefore we quote the article verbatim :

In order to produce peristalsis it is essential that the intestins contain a certain bulk of fecal matter. A diet rich in meat and eggs, and the sparing use of vegetables, fruits, and water will produce a small residue of undigested matter. Therefore the intestins will fill very slowly to a point sufficient to provoke vigorous peristalsis. When such a diet is habitual to a patient, it should be changed. Vegetables, fruits, coarse breads, and water should be taken freely. These foods should contain a large amount of cellulose, which remains undigested, fills the intestin, and excites in it a peristaltic activity.

The vegetables that are most laxativ are tomatoes, spinach, lettuce, asparagus, Spanish onions, salsify, cabbage, and celery. Spinach and tomatoes are especially prized for their effect upon the bowels. The coarse cereals have the same reputation. Oatmeal, cornmeal, and wheaten grits are the best. Bread made of coarse flour, such as graham, rye, corn, oats, and "whole wheat" meal, also helps to prevent and to relieve constipation. Bran bread is especially efficacious. It is made by adding bran to ordinary flour in as large proportion as is compatible with the making of good bread. Such breads as ginger bread and Boston brown bread are also laxativ, but often can not be used because they provoke gastric indigestion.

Honey, molasses, and foods eaten with them are also reputed useful for the relief of constipation. Honey has been used in all ages as a mild laxativ. Many persons are sensible of the stimulation of peristalsis that coffee produces. The addition to it of much sugar and cream will sometimes retard gastric digestion and may thus counteract its stimulating effect upon the bowel.

Fruits have a laxativ influence, partly because of the sugar that they contain, partly because of the fruit acids, and sometimes because of their irritating skins and seeds. Strawberries, blackberries, raspberries, gooseberries, blueberries, currants, and grapes, are effectiv partly because of their seeds and partly because of their fruit acids, or the acids which are generated in their digestion. Apples, pears, peaches, plums, cherries, oranges, and grapefruits are chiefly purgativ because of their sugar and fruit acids. Prunes, figs, raisins, and dates have, beside these, either a skin or seeds that act as a local irritant to the intestins. Fruit produces the greatest laxativ effect when eaten alone. It is therefore best taken at bed. time and on rising, a half hour, or, better, an hour before breakfast. A compote with meals will do good, altho it is not so effectiv as fruit taken upon an empty stomach. Apple butter, date butter, marmalades, and similar preparations are often eaten upon bread or crackers.

Many who are constipated fail to drink enuf fluids either to keep the contents of the intestins soft or to form intestinal secretions as abundantly as is needful. This is especially true of those who lead a sedentary life, and of women. If, upon inquiry, it is found that enuf water is not taken, more must be prescribed. Slight constipation may often be relieved by taking a glass of cold water the first thing in the morning. The laxativ effect is enhanced if another is taken on retiring. The morning draught stimulates peristalsis and secretion. Under its influence the rectum is slowly filled, and a half hour or an hour later, breakfast provokes the desire to defecate. The habitual use of hard water is constipating unless magnesium and sodium sulfate occur with the lime salts in sufficient

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quantity to make it laxativ. Distilled water or soft water has a neutral action. Water containing much organic matter frequently provokes diarrhea. An average sized man should drink from five to eight: glasses daily. Sweet cider is loosening to the bowels. Grape juice, if taken freely, acts similarly. Tea is an astringent, especially when made by boiling or prolonged leaching of the leaves. Tea drinking is a not uncommon cause of constipation.

Pneumatosis.

One of the most distressing of minor symptoms which can afflict humanity, especially if the victim be a lady, is pneumatosis, or the noisy belching of gas from the stomach. The gas may be odorless or tasteless, or it may carry with it a vile taste and a nauseating odor. It is frequently noted in neurasthenia, hysteria, and other neuropathic conditions, and is said to be especially frequent in cases having a strong sexual characteristic. The condition is generally hard to relieve, simply because both patient and physician persistently refuse to recognize the actual conditions. The gas which is so noisily expelled is popularly supposed to be the product of fermentation in the stomach, whereas the truth of the matter is that it is simply air that has been swallowed. Air may be aspirated into the stomach when the cardia is relaxt and the esophagus closed, either in consequence of a negativ thoracic pressure when the vocal cords are closed, or because the lumen of the stomach expands and dilates under nervous influence. Moreover, many nervous people have contracted the vicious habit of swallowing air, either intentionally or unconsciously, until the stomach is distended and relief by belching is imperativ. Some of these patients, it is true, have genuin dyspeptic symptoms; but many of them have no actual digestiv disorder. Naturally, to drench them with acids, pepsins, and digestants, is of no avail, and they become more firmly than ever convinced that they have an incurable malady. When the stomach becomes greatly distended with the air, the lucklesspatient often finds more trouble in getting rid of it than she has experienced in acquiring it, and there is a sense of distention, distress, and dyspnea that occasionally becomes so persistent as to be alarming and to demand relief. If the air escapes into the intestins the torture is mitigated for the time; belching will likewise relieve it. The distress may follow every meal, when the patient will be firmly convinced that the trouble is altogether in deficient digestion; or it may be periodical, occurring only when the patient is perturbed or fatigued. The condition is easily recognizable by a careful physical examination without questioning the patient, provided the examiner be sufficiently tactful and astute. A possible distention of the transverse colon must be excluded, and possible gastric dilation and atony must also be considered; if

these conditions are absent, simple percussion and inspection will settle the diagnosis, no matter what the tale the victim may unfold.

Constipation will be a pretty constant concomitant symptom, especially in the neurasthenic and hysteric, and the pneumatosis frequently is cured by simply correcting this condition and keeping the bowels regular. The first struggle with the patient is when you attempt to convince her that the trouble is due in great measure to a vicious habit; but if she can be caught by yourself or a companion in the very act of air swallowing, she becomes convinced if not converted regarding the truth of your assertions. The air swallowing must be stopt, and if control of the habit is not obtainable otherwise, instruct the patient to keep the mouth open for a half hour at a time. No one can swallow with the mouth open, and the relief of the symptoms will soon aid you in getting full control of the case and the patient. The intra-gastric application of galvanism is of benefit, as are also cold sponging and massage of the epigastrium. Small frequently repeated doses of belladonna, atropin, and arsenic have proven of benefit in many cases. Bromid of strontium is efficient in combination with other measures. If the case be neurasthenic, and there is a probability of the neurasthenia being dependent upon the uric acid diathesis, salicylate of sodium will prove more beneficial than the bromids. In cases where actual disorder of the digestiv function exists, of course it will be necessary to give digestants, and to supervise the diet; yet such cases will generally be found in the minority, and the patients will tell you that they "belch just the same no matter what they eat."

Nearly every case may be quickly and permanently cured if studied properly and sufficient attention be devoted to it.

The Exercise of Good Judgment in the Practise of Medicin.

There is not as much truth as is generally thought in the assertion one sometimes hears, that "doctors are born, not made." It is true, indeed, that many good farmers are lost to the world in the effort to make doctors out of them. A certain adaptability is a requirement if one would make a success in the practise of medicin, but the main essential is the possession of good judgment and the independence to exercise it. No man, however brilliant may be some of his mental attributes, will ever become a really good doctor unless he possess good judgment in good measure. Any man, with good judgment and a fair education, may become a good doctor and a successful practician.

The greatest weakness that we observe in

the mass of the medical profession_today is this deplorable lack of judgment. It is this deficiency which causes the wild oscillations of the pendulum of medical practise in such short periods. Because the reckless bloodletting of a few decades ago workt such selfevident harm, bloodletting was entirely abandoned; yet no man of judgment disputes the fact that it is a measure of incalculable benefit in a truly indicated case. The radical teaching that we no longer needed the lancet, since we could now "bleed a man into his own blood vessels " with the aid of veratrum viride, was responsible for much. Veratrum viride was all right-is yet all right-when indicated; so is venesection. Only a few years ago we were instructed by a certain class of "authority," that the only treatment of the milk used in the artificial feeding of infants worthy an intelligent practician's attention was thoro and complete sterilization. It took but a short while to learn that but very few cases really did well on such treatment carried out for any continuous period. Then pasteurization was heralded as an infallible remedy for all baby troubles in connection with milk; now we know that both have their individual patients for which each form of preparation is essential, and that there are multitudes of babies for which neither will do. We recognize the fact that good judgment must be exercised in the determination of the treatment of the food which each individual infant requires.

We have never understood just why a complete medical education should dwarf a man's natural good judgment so that he no longer allows his intellect to work for itself, but blindly follows the self constituted "authorities," whose actual intellectuality is often inferior to his. Just because a man has secured a position in a medical school, because he has written a book, or because he has elected to follow a specialty, is no reason why one should give up before his assertions if one believes them erroneous or based on false premises. We have watcht several medical classes graduate, and have had opportunity of estimating the actual ability of the members of those classes; today we see men of superior attainments and ability following implicitly the instructions of their former classmates solely because they have written a book which is well written and faultlessly illustrated, altho such authors were decidedly the inferiors in intellect. We advise reading what eminent men, or those particularly favored by having handled an unusually large amount of clinical material, may have to say; but we implore our readers to digest what they read thoroly, and to submit it to the test of their own individual judgment before committing themselves to it. Some of the most

widely experienced men in the profession today are admittedly so radical in their special line that we would hesitate to intrust ourself to them unless some other practician had made the same diagnosis and advised the same treat

ment.

While specialism undoubtedly makes many men very efficient in their chosen fields, it is dwarfing in its effect on most practicians, and many become narrow and prejudiced. It is a fact that good judgment is more often found in the better class of general practicians than in the average specialist when in the line of his specialty. The general practician is the broader of the two. If less experienced in the special line, his diagnostic powers are more acute in a general way, and his summing up of the entire situation is generally more rational and logical. What is needed is less blind dependence upon authority and more thought upon the case in hand; less thoughtless devouring of anything "new in medicin," and the exercise of more good judgment regarding that which one already knows.

We are not arraigning specialists, individually nor as a class; we are not eulogising the general practician; we are not under-rating the unusual application, opportunities, and talent usually required to constitute one an "authority;" but we are making our best plea for an all around effort to bring into play that essential factor in all rational practise, and to combat that blind instinct to follow others thoughtlessly, which so often results in making us, as a profession, ridiculous. Make yourself familiar with the investigations and conclusions of the "authorities," but be careful to digest what they say.

Duty of the Doctor with Relation to the Public School.

Too few physicians appreciate the fact that it is their duty to take a deep interest in the children and their welfare. The word physician literally means "teacher." Unconsciously the laity look to the profession for instruction along hygienic lines; if such instruction is voluntarily given in a proper and modest spirit, it is gladly and respectfully received; if it is not given, the community either feels that the physician has not done his full duty, or that he is incapable or careless. School boards and superintendents of education are awakening to the fact that they need the counsel and advice of physicians, not alone in combating contagious diseases, but also in the construction and arrangement of the school buildings. This is as it should be. And every physician tendered a post on a school board should accept, and serve to the best of his ability. Who but he knows so well the dangers which hedge

about school life? How much he could tell the teachers (if he would) of children about the age of puberty. If he does not, is he doing his full duty? We are "our brother's keeper.'

There should be a system which would grade children physically, as well as mentally. The strong should not be allowed to oppress the weak. The physically insufficient should not be crowded with the same task assigned the strong. Those mentally slow should not be pusht into the ranks of those who grasp things quickly, lest they thereby be kept fatigued and disappointed in the hopeless endeavor to "keep up. Those having a mathematical trend should be led and encouraged in that line, so that they may enter pursuits from choice, which will yield their most brilliant services to the world and to humanity; those who are dullards in arithmetic should be advised against a calling which involves constant delving in mathematics. We are well aware that some will say that the teacher should be the judge of these things, and if the teachers were learned and capable, we would admit the assertion; but we must remember that only the exceptional teacher is competent to pass judgment. This vicious plan is universal thruout our great school system-the grandest in the world. The average teacher knows nothing of psychology as affecting the children with whom she daily deals. She pushes and prods the slow and backward child in the vain endeavor to keep him in the same rank as bold and shrewder children. Mental dulness has generally a psychological basis. Insufficiently fed; poorly developt; degenerate; unnaturally precocious; nervously sensitiv; mercilessly strenuous; healthy; weak; rich; poor; all are herded together under the guidance of an innocent teacher. Why! good farmers treat their cattle better.

A single example: A child with deficient eyesight; allotted a dark seat; his eyes continually irritated by the ever present dust which is not avoidable; teacher unsuspecting; parents careless; upbraided for his dulness; proud and ambitious. What is the result? Can the average teacher tell? Can any well read physician tell? Then whose the duty? An ignorant parentage; an innocent, as well as ignorant teacher; a school board who only serve because they have nothing else to dopity the child.

Physicians have the influence (would they but exert it) to get good men on the school board, who would listen to reason and sense, or to become candidates themselves for the office. If personally they feel incompetent, let them shove an abler professional brother. Even if they are too diffident to serve personally, or to promote the interests of another of the profes

ORIGINAL COMMUNICATIONS

Short articles of practical help to the profession are solicited for this department.

Articles accepted must be contributed to this journal only. The editors are not responsible for views expressed by contributors. Copy must be received on or before the twelfth of the month, for publication in the issue for the next month. We decline responsibility for the safety of unused manuscript. It can usually be returned if request and postage for return are received with manuscript; but we cannot agree to always do so. Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than anything else.-RUSKIN. COMPARE RECORD

READ

REFLECT

I began practise in a frontier town of 100 inhabitants in Wyoming. I received $3 for day calls in town and $5 for night town calls. For ranch work I received $1 a mile. I never toucht a lance for less than $5; received $30 for rib fracture; $1 for a 4-oz. bottle of medicin or 2-oz. box of ointment; $20 to $25 for confinement; $15 for miscarriage, etc.

But I had no competitor within forty miles; railroad tariff was 5 cents per mile and no competing line; my nearest point of supplies was 200 miles distant, with correspondingly high freight rate; population was very sparse; wages were very high, section bosses receiving $62 per month and house rent; ranch hands $30 to $45 and board per month, and the poorest land holder was worth nearly $10,000, while some were millionaires.

I am now practising in a town of 2,000, where the maximum is $1 for single calls and and we are often forced to settle for less; where a lancing is $1 to $2; prescriptions are filled for 50 cents; where $10 is high for dif ficult labor cases; where three miles adds 50 cents to our prices, etc.

But-there are five other physicians in the town and others near, with "the cheapest city in America" but fifteen miles away, accessible by trolley for 1% cent per mile, where I can buy direct from the manufacturers. The best house in town rents for $15 per month, and a modern six-room cottage centrally located can be procured for $10 per month. Probably not a score of residents are worth as much as $10,000 each; section hands get $1.25 per day and farm hands $12 to $20 and board per month.

To sum up: Recompense in general is

about half as great here, and our incomes are scaled accordingly. On the contrary, expenditures are about twice as heavy there as here, so that the advantage of one locality over another seems to resolve itself largely into the question of congeniality of environment. Apropos of the example given, it may be said that perhaps collecting is easier in a new country. While fee bills are valuable to those immediately concerned, and instructiv as showing the generally low value placed on medical service, it seems to me that, comparativly, fees vary largely with local commercial conditions. WALTER S. BOGART, M.D.

Cleves, O.

Fee Bill.

A subscriber sends us the following copy of the fee bill of the Elkhorn Valley Medical Society (Neb.).

OFFICIAL BUSINESS.

Ordinary prescription or advice.
Physical examination, ordinary
Physical examination, very close.
Electricity ..

Dressing injuries

PRACTISE.

Country visits $1.00 for visit and mile-
age at the rate of fifty cents to $1.00
per mile, one way, according to cus
tomary rates of locality.
Town visits, daytime.
Additional patients in family
Distant patients, expense and.
Night Visits.

Dangerous contagious diseases.
Removing tape worm.
Antitoxin, administration of
Consultation

Certificate as family physician.
Written opinion.

Opinion involving legal issues.
Vaccination...