similii means will often start a curative impetus which will last for weeks, and we know that many of the best and most satisfactory cures that we have seen, in severe chronic cases, have been brought about by a single dose of the well selected remedy given in high alternation. In chronic diseases (p. 157), Hahnemann says: "Let the carefully selected Homœopathic anti-psoric act as long as it is capable of exercising a curative influence; as long as there is a visible improvement going on in the system." This curative influence may go on for days, weeks and months, and frequently carries the patient entirely through to a complete reccvery. It is also an indispensible thing to be able to discriminate between a natural aggravation of the disease and an arti ficial aggravation due to an effect of the drug given. When your patient grows suddenly worse after the exhibition of a remedy, study carefully the morbid phenomena, and, if associated with the old symptoms you discover new ones belonging to the pathogenesis of the drug, you may safely attribute the condition of your patient to the fact that you have either given an overdose, or you have repeated the dose too often, and all you have to do now is to wait; keep your meddlesome hands off. If, on the contrary, the new symptoms are not to be found in the provings of the drug given, you must call a halt and seek another remedy, for your patient is worse. Our best advice is the motto of David Crockett: "Be sure you are right, then go ahead!" "TIME IS UP." Pulsatilla.-Headache from eating fruit or rich food. Surgery. LITHOTRITY. BY W. E. GREEN, M. D., LITTLE ROCK, ARK. WHILE in conversation with a num ber of surgeons upon the subject of Lithotrity, during my recent vacation, I was surprised to learn how indifferently they generally considered this most important method of dealing with vesical calculus. In fact, some, high in position, spoke slightingly of it, and did not seem to appreciate the statistical standing of the operation. Suprapubic cystotomy is the craze, and appears to be the favorite mode of treating many surgical diseases of the viscus; even when simple drainage is demanded it takes precedence over its ancient and well tried rival, perineal section. Where the stone is large and with inexperienced surgeons, this procedure is to be commended, for it is the easiest and the simplest of any of the abdominal operations; but, it is still upon trial and its comparative standing has not yet been definitely established. The greatest objection that is usually urged against Lithotrity is the liability to a recurrence of the trouble. While this is true, even in expert hands, yet the mortality attending the operation is so small that this is not a substantial argumeut against it. While Lithotrity is not feasible in all cases of stone in the bladder, in that class to which it is adapted it is far superior to any of the other methods of extraction; in fact, the mortality is almost nothing-from 3 to 5 per cent., and the time that the patient is confined to bed after the operation is usually insignificant as compared with any of the forms of Lithotomy. In choosing the mode of operating. many things must be taken into consid eration; therefore, he who would be most successful in dealing with stone in the bladder must be well informed as to the individual merits of the different methods. Lithotrity is not adapted to very young children, though it has been successfully done in children under five years of age. In patients between the ages of six and twenty the results are not better than either perineal or suprapubic cystotomy. It is after puberty that its superiority is most marked; however, even then, the skill of the operator has much to do with its success; there is probably no operation in surgery in which dexterity and tactile sense counts for more. He who cannot manipulate gently and skillfully is not likely to be an advocate of Lithotrity. The rough surgeon who punches and gouges with his fingers, and whose every touch and movement gives pain to his patient should select some other means for the removal of stone, for he is liable to inflict serious and irreparable injury. Stricture of the urethra or moderate enlargement of the prostate are no barriers to Lithotrity. The former can be incised and the urethra brought up to its normal calibre before the operation is undertaken. If the latter is not too greatly enlarged, the stone can be dislodged from the prostatic pouch by elevating the hips of the patient. In atony of the bladder and cystitis, unless drainage is demanded, it is a safer and better operation than any of the forms of Lithotomy; and even where the kidneys are diseased, no more serious results are liable to follow. Large, soft calculi, or multiple small ones, are alike amenable to crushing; but large, hard ones offer serious objections. To summarize: Lithotrity is not suited to young children; large, hard or encysted stone; great hypertrophy of the pros tate; severe forms of atony of the bladder; cases that require drainage, and in some subjects affected with pelvic deformities, tumors etc. I will not attempt to describe the operation of Lithotrity, for excellent articles on the subject can be found in any of the well written text books on surgery. A description of the following cases taken from my case book, will illustrate the superiority of the method and indicate the slight loss of time which it subjects the patient. Case 1.-Male, aet. 30; small, uric acid calculus, mild cystitis, urethral stricture of small calibre. Preparatory to crushing and removing the stone, the stricture was divided and brought up to the nor mal size of the urethra; the potency of the canal was maintained by daily introduction of the metal sound. After he had recovered from this operation, I placed him upon the table, injected the urethra and bladder with half drachm of a 4 per cent. solution of Cocaine, washed the bladder with a mild Boro-glyceride solution, six ounces of which was left remaining in the organ; I then introduced a Bigelow's lithotrite, thoroughly disin tegrated the stone and removed it with the evacuator. The operation lasted 45 minutes, and the debris weighed 35 grains. The patient arose the next morning, expressed himself as feeling well, and went about his business. Case 2. - Male, aet. 28; small, soft, phosphatic stone; constant vesical tenesmus, and, occasionally, bloody urine. Observed the same preliminaries as in the former case. The stone, which weighed 40 grains, was crushed and evacuated in thirty minutes. The patient arose from the table, walked out of my office and would not go to bed. largement of the prostate. Ether was administered, the bladder thoroughly irrigated; and the stone, which was very hard, crushed with great difficulty. The instrument would spring, and the stone would scale off and slip from its grasp. When removed, it weighed 90 grains. The operation lasted two hours, and was exceedingly tedious. The patient remained in bed but three days, and in two weeks was relieved of all his vesical irritation. Several months after, the symptoms returned and the operation. had to be repeated. Case 4-Male, aet. 54; uric acid calculus; stricture of the uretha, and enlarged prostate: stone was detected with great difficulty; urethral trouble treated as in first case. Ether was administered, and the stone disintegrated and evacuated. The operation lasted one hour; debris weighed 100 grains. Two hours after the patient walked from my office across the street to the hotel, and left the next morning for home, and has remained well ever since. These cases practically illustrate the superiority of Lithotrity over any of the other methods of removing stone. No serious symptom followed any of the operations; in reality, but one of the patients went to bed, and he was confined but for three days. There was no dribbling of urine, no wounds to treat, no danger of fistolos opening: none of the patients had any elevation of temperature. There was no danger of septic poisoning: the dread of a cutting operation was avoided. Recovery was prompt Recovery was prompt and complete, in all but the one case, and that was permanent after the second sitting. Podophyllum.-1st trit. to 30, has removed sick headache with misty appearance of vision, pains in the back of the head, nausea at the stomach, sour vomiting. ANAL DILATATION IN CHLOROFORM NARCOSIS. BY C. E. FISHER, M. D., SAN ANTONIO, TEXAS. THE subject was subject was a lad of 9 years, suffering dislocation of the elbow joint. The deformity was of ten days' duration when I first saw it. An Allopathic physician had preceded me in the case, and from his manipulations and the injury causing the dislocation, combined, it having been brought about by a fall upon the elbow, the parts were much bruised, swollen, and painful, making anææsthesia a necessary part of the treatment. Without assistance, I first undertook the reduction under Ether but was not successful, owing to the fact that the anesthesia could not be carried to the degree necessary to complete relaxation because of copious pharyngeal and bronchial secretions of mucus arising therefrom. A day or two later I made a second and successful attempt under Chloroform with the assistance of Dr. G. B. Bowen. The Chloroform was administered on a Vienna screen, a wire frame covered with a single thickness of flannel gauze, upon which about a half teaspoonful of Chloroform was poured at one time. The child took to the anæsthetic kindly; the heart's action was good, the pulse full and regular; the breathing normal and deep. Several minutes were occupied in the efforts at reduction, and while performing exaggerated extension, the radius being thrown forward and upward, the patient showed signs of returning consciousness and pain so that it became necessary to renew the anææsthesia. Enough Chloroform was dropped upon the flannel to dampen a spot about the size of a silver half dollar and the screen was applied close to the face. In an instant we were in trouble; the child ceased to breathe in less time than it takes to tell of it. The jaw dropped; the heart ceased to beat; the arms fell limp to the sides and the child was to all appearances, dead. Immediate efforts at resuscitation were engaged in. The angles of the jaw were raised, the tongue was grasped and pulled forward, Nitrite of Amyl Pearls, always at hand with me, were broken and the medicament was held to his nostrils; artificial respiration was practiced; the child was held suspended by his ankles, head downward, and was swayed to and fro while in this position; inhalation of Spirits of Ammonia was undertaken, but all to no avail. Practically, the child was dead. The suspense was awful. The father's face and brow was covered with cold perspiration in beads which appeared to me to be the size of marbles. Dr. Bowen looked as though he were going to be hung, and I felt as though I ought to be. My wits stayed by me, however, and I bethought me of anal dilatation. It was but the work of a second to disrobe the lifeless form and introduce my little fingers, back to back, into the Rectum. Systematic dilation was begun, in harmony with Dr. Bowen's now renewed efforts at artificial respiration. At first there was no response, and the suspense was even more awful than before. It was our last recourse and failure now meant death to the child and disaster to us. With what energy and perseverance we labored can well be imagined. The stillness of death pervaded the room, and with breathless anxiety the griefstricken father, who already looked upon his child as dead, and Dr. Bowen and myself, awaited the result. Exactly how long we had to wait it is difficult to tell; it seemed as if for hours; it certainly was for minutes. But after awhile a faint response of the pulse was felt, a little later a smothered sigh and an ominous gurgle in the throat, which caused the father to exclaim, "He's gone!" was heard; in a moment more a shallow breath was secured; this was soon followed by another and another and another, aud after full twenty minutes after the failure of the heart and the practical death of the patient the child was restored, as we all are fully convinced by systematic dilatation of the Anal Sphincter and its effect upon the great sympathetic nerve controlling the action of the heart and lungs. Just how the others felt at that supreme moment, I can not say. But, at my own deliverance, I felt like devoutly quoting the old Methodist hymn, which reads, with variation, about as follows: And are we wretches yet alive, I'm saved from mental hell! The lesson taught by this experience is the value of anal dilatation as a means of resuscitation in Chloroform narcosis. To Prof. Pratt's orificial philosophy and the practices based thereupon we are indebted for this exceedingly valuable expedient, and did that thought carry with it nothing more of value it has been already a benefactor to our profession, as the case just cited will attest. At our meeting last year Dr. LeFevre read a paper entitled, "The Relations Existing Between Homœopathy and Orificial Surgery." At that time I expressed the opinion that there existed no intimate relationship between the two philosophies. I am not sure but that I was then in error; for, by anal dilatation the act of breathing can be suspended, as can easily be shown by any one volunteering for the purpose, and, undoubtedly, by anal dilatation in my patient the suspended breathing was successfully restored. I will leave it to the orificial philosophers to weave the web of connection. INTESTINAL OBSTRUCTION. BY T. E. LINN, M. D., CINCINNATI, OHIO. MY Y PERSONAL experience with regards to obstruction of the bowel, from whatever cause, is limited in the extreme, but my opportunities for witnessing the failures and successes of others in the management of this class of fatalities has been more extensive. My reasons for presenting a paper on this subject is not to harrass you with a recital of how little I know, but to call forth a discussion on a subject so extensive, so important, and of so much interest to us all as physicians and surgeons. We understand by obstruction of the bowel, any cause which prevents the normal passage of fecal matter, through its physiological channels. Whether this be a twist, an invagination, compression by malignant or benign growths, stricture, gall stones, foreign bodies, hernia, peritonitis, enteritis, impacted feces or hernia due to stab wounds of the abdominal parieties. A differential diagnosis is at times impossible until explorative laparotomy brings to view the pathological condition. From a history of the case we learn whether the onset has been sudden or slow. Ifsudden, we suspect strangulation, intussusception, or peritonitis. If the onset be sudden, the pain intense and localized about the umbilicus, if no herrial tumor can be discovered, persistent stercoreaceous vomiting, marked prostration, pa tient being an adult, the obstruction is no doubt due to strangulation from a band, or loop, or adhesions. If the pain be localized to the left iliac region, with the same symptoms, it indicates a twist of the sigmoid flexure. If the patient be a child, with sudden onset and symptoms of dysentery, with intense pain in the beginning, which tends to decrease rather than to increase the case, it suggests invagination. If a patient be attacked suddenly after a full meal, exposure or undue activity of the abdominal muscles, presents symptoms of flexion of the thighs on the abdomen, tympanitis, pinched, haggard expression, the obstruction is in all probability due to peritonitis or enteritis. While obstruction from these causes may be rare, still we must admit that obstruction does result from enteritis and bands of adhesions resulting from peritonitis. Three years ago I held an autopsy on a colored child, for another physician. I can not give the history of the case, but upon opening the abdominal cavity I found the viscera bathed in pus, and upon examination of the intestines, the illum from the ilio-ceacal valve back for six or seven inches was collapsed, the mucus coat adherent, causing a complete occlusion of the channel. In slow or chronic obstruction the disease is usually located in the large intestine. If due to tumors, abdominal palpation will yield a diagnosis. If obstruction follows chronic constipation, especially in nervous individuals, where there is a desire to relieve a sensation of fullness of the rectum, the case is probably one of impaction, and a digital examination will verify or disprove this conclusion. If the impaction be higher up than the rectum, the hardened mass of feces can be felt by palpation. |