alertness and concentration of thought are a necessity, and must be cultivated.

In order to exercise the memory and test it as to its retentive power, it is well to have a time when one makes a practice of reviewing in their exact order all the events of the previous day. Recall what was read, who was met, what conversation was engaged in, and the substance of what each one said.

If a stranger is met, to whom one is introduced, be sure that the name is understood, then repeat it frequently until it becomes fixed. In order that the image of the face may be preserved, note the distinguishing features, such as the color of hair and eyes, apparent age, peculiarities of expression; make a mental note of the relation of the individual to the surroundings or circumstances under which he is met, so that the one will assist in calling up the other.

Each day, carefully reading a few lines of some unfamiliar poem or other writing, dismissing it from the mind for an hour, and then endeavoring to recall it, is a valuable exercise, as is also that of looking for a minute or more at the array of articles in a shop window and attempting later to name or number them.

The thinking out, during one's spare moments, of abstruse and perplexing problems, the solving of which will demand uninterrupted thought, is an aid in the development of concentration, and in habituating oneself to a condition of brain activity, as againat a state of passive mental listlessness, strenuously endeavoring to accustom oneself to paying strict and careful attention to such things as it is desired to remember is a necessity.

These simple exercises, and scores of others which will readily present themselves, will, if patiently and persistently practiced, do much towards clearing the cobwebs from the mental archives and put into activity machinery of thought, long corroded with the rust of desuetude.

In searching therapeutically for a memory restorative, we find no lack of remedies suggested. Anacardium heads the list with the symptom "Loss of memory and weakness of the mind; especially difficult to remember names, unable to think." Argentum nit. has "Weakness of memory, cannot fix mind on anything." Lactic acid is indicated for “Impaired memory, when one cannot remember a thing an hour after it happens." Kali phos. "Loss of memory, with brain fag from overwork.”

Thus one could go on ad infinitum, for Gentry names no less than seventy-four remedies, having with slight variation, the symptom, "Loss of memory."

It is manifest therefore, that if one assayed to correct this error by the use of drugs, he would find himself engulfed in hopeless confusion and uncertainty.

In cases in which this symptom is an accompaniment, or result of aeurasthenia, or a state of mental and physical weakness, and is regarded as merely a guide post pointing to the properly indicated remedy for the

existing pathological conditions, drugs must be acknowledged as occupy ing a legitimate field, but otherwise, their use is of doubtful utility.

No drug can give the athlete his muscles of wire. Nor can one, however well indicated, develop the quick eye and accurate movement of the marksman.

No medicine can even aid in converting the awkward, unattractive girl into the accomplished musician, who is able to hold an audience entranced by the hour, while she reproduces from memory without the loss of a note, the difficult compositions of the old masters.

It is practice that does it, as it is practice that enables us to do abou everything worth doing, and on intelligent, untiring practice in holding our mental grip can we confidently depend for the key which will restrain an escaping memory, keeping the mind constantly charged with the thought, "I must not forget to remember."

INTESTINAL OBSTRUCTION.*

By WILLIS YOUNG, M. D., ST. LOUIS.

The term intestinal obstruction is here used, somewhat arbitrarily, in a more general sense than that in which it is generally employed. This is not done in any attempt to establish a new or rearranged classification, but only for the present purposes of this paper, which is to consider some of the clinical manifestations of intestinal obstruction-more especially their diagnostic importance.

Mr. B., aet. 60, who had seven days before reduced strangulated inguinal hernia, which had protruded for six hours, and resisted for that time the patient's efforts to return it to the abdomen; presented the following condition:

Absolute constipation for eight days.

Vomiting stercoraceous five days.

Marked distention of the abdomen.

Paroxysmal pain referred to hypogastrium.

No hernial protrusions.

No pain in the hernial regions.

Urine, scant, sg. 1026; no Indican.

During this eight days the patient had prescribed for himself, and had valiantly swallowed one cathartic after another, which only served to increase his discomfort.

The administration of cathartics in intestinal obstruction is roundly condemned by all physicians after a diagnosis has been established. they possess a diagnostic value of no small importance, since their very failure to occasion a bowel movement is evidence of some physical cause for the constipation.

Read before the Southern Homoeopathic Medical Association at Louisville, Ky., October, 1904.

Enemata had been employed freely and persistently and without result. It was noted, however, that two quarts of water could be introduced and retained for a time. This was accepted as indication that the point of obstruction was not in the colon and likewise that a movement of the bowels was not to be expected from this treatment.

Were an obstruction known to exist in the ileum I would think it unjustifiable to attempt to reach it by fluids forced from below.

Senn's experiments on dogs and Hirschl's experiments in the cadaver to determine the permeability of the ileo-caecal valve to fluids forced from the rectum, always produced rupture, first, of the serous coat of the colon and subsequently of the remaining coats.

Meteorism. The distended abdomen of the patient did not present on its surface at this time (8th day) any visible outline of intestine. Whether it had shown at an earlier date is not known.

This phenomenon may persist as long as six days, as it did in a case of strangulated femoral hernia which I saw with Dr. McElwee several years. ago. The patient, an old Irish woman, refused operation, and was kept under the influence of morphine; on the sixth day spontaneous reduction took place. During all of this time the intestinal outline was plainly visible on the thin belly wall. In a similar case, treated similarly, the distention obliterated the outline by the third day; the patient died on the fifth.

In general, the presence of this sign indicates that the distention is not the result of peritonitis.

The tympany was over the whole abdomen, and it was therefore assumed that the obstruction was at some point low down in the ileum, as the intestine is only distended above tie point of obstruction, whatever its cause or variety. Perforation of the intestine as a cause of the tympany was excluded by the presence of liver dullness on percussion. I am beginning to doubt the reliability of this sign, as I have seen one case, and my friend, Dr. Henry, of St. Louis, has seen three cases of intestinal perforation from typhoid ulceration, in which the liver dullness was easily discovered. On the other hand, I have seen a case of adynamic ileus with enormous distention following appendectomy, in which the liver dullness was absent.

The temp. of intestinal obstruction is not of much diagnostic value, since it is subnormal or very slightly elevated in all forms, except the adynamic variety, due to causes other than thrombus. In two cases of adynamic ileus following laparotomy it rose as high as 103°.

Stercoraceous vomiting had existed five days and gave the patient much relief. A unique feature of the emesis was the patient's recently acquired ability to empty the stomach in an almost passive manner by turning on his left side, when the stomach contents would simply spill out.

By taking a large drink of water he would temporarily satisfy his pronounced thirst. When the discomfort caused by taking it had lasted

Pain was

long enough, he would empty it out in the manner described. referred to the epigastric and hypogastric regions and was intermittent in character. Intermittent pain in intestinal obstruction is, according to Treves, always indicative of partial obstruction. Pain in the epigastrium may, under some circumstances, be very misleading.

In the case of Dr. F., suffering from obstruction of the bowels from carcinoma of the rectum, and who has had no movement of the bowels for two weeks, the pain was referred to the epigastrium. The great distention interferred with palpation; after a colostomy and subsidence of the distention a pyloric growth was discovered. While constipation was absolute, and the patient declared that no gas was passed per rectum, for reasons which will appear later, I believe the obstruction to have been partial.

No hernial protrusion was present at any opening, and it was deemed a reasonable assumption-that the symptoms of obstruction following immediately upon the reduction of a strangulated hernia, that direct or indirect reduction en masse had been made. The inguinal canal was most carefully explored digitally and nothing discovered.

The pulse was 80 and of good quality.

The urine was s. g. 1026 and otherwise normal. The 24 hours quantity was, for lack of time, undetermined.

Indican was not present. It is not found in ileus before the second day, and only then in some cases of obstruction of small intestine.

I have examined for Indican in thirteen instances of obstruction of the ileum and never found it. I have found it in a case of chronic constipation.

The diagnosis, after consideration of all these symptoms singly and collectively, including the patient's excellent general condition, despite his eight days' obstruction, was partial obstruction of ileum from strangulated inguinal hernia reduced en masse.

The patient was operated next day; the inguinal canal being opened, a long thick sac was discovered containing a quantity of sero-sanguinolent fluid. A 5% inch loop of ileum lay in the canal. This showed the diagnosis to have been to this extent erroneous. It was humiliating as well, since the previous exploration of the canal had not discovered it. The gut was black, almost stiff in consistence and very much thickened. One very small gangrenous spot existed near its mesenteric border.

The constriction was at the internal ring, which was freely incised, whereupon the gut changed color, despite its long strangulation.

Prior to cutting the ring it was demonstrated that the index finger could easily be introduced beside the gut, which was almost a demonstration that the obstruction was only partial. The gangrenous spot was excised and the operation completed as a herniotomy. Recovery was uneventful, except that some tympany remained for a week.

There are some cases of intestinal obstruction curable by medical and

local treatment, some get well after expectant treatment, some by surgical operation and some are quite incurable.

A consideration of the anatomical varieties as classified by Douglas, will show that of twenty varieties, medical and expectant treatment may possibly be curative in seven of them:

Acute-Adynamic or paralytic, which includes thrombus as a cause;

intusseption.

Chronic-Fecal impaction; foreign bodies swallowed; gall stones;

enteroliths; parasites.

While each of these may be cured medically or expectantly, with exception of first named, they may all be cured surgically. The remaining thirteen kinds, if not cured surgically, will not be cured at all.

Acute-Through congenital apertures; into normal peritoneal fossæ; through mesenteric or diaphragmatic slits; by bands, congenital or adventitious; peritoneal adhesions; vitelline remains; about viscera, abnormally attached; kinks and knots; volvulus.

Chronic-Cicatricial or neoplastic contraction; neoplasms; wandering viscera; adhesive peritonitis; enmassing.

It follows, if these premises be correct, that intestinal obstruction of all kinds is a surgical disease (excepting the adynamic variety), and valuable time should not be wasted in attempting to cure it by other means. As soon as a diagnosis is made the patient should be prepared for operation.

The difficulties of diagnosis are so great, that if any condition permits of explorating operation, this is the one.

Dr. Fletcher, of St. Louis, recently opened an abdomen of a patient almost moribund after several days of obstruction, in whom no mechanical obstruction could be found. Neither was a thrombus of the superior mesenteric artery found, but I assume from his description of the gut that it was a case of that of thrombus.

Dr. Harry Lott, while in St. Louis some weeks ago, related to me the details of a case provisionally diagnosed as Sup. Mes. Art. thrombus. To confirm this diagnosis the abdomen was opened, but neither thrombus mechanical obstruction was demonstrable. But since twelve or fifteen feet of ileum showed very numerous ecchymotic and minute gangrenous spots, the diagnosis may be considered as confirmed.

nor

The patient recovered. Several years ago I operated a simila: case, but with fatal result.

I have recently seen a case diagnosed impaction, no movement for ten days, and the condition was such that I had no stomach to operate, start a rapid recovery by a bowel movement which occurred while on the ward carriage on the way to the operating room.

A case which I saw in the practice of Dr. Kershaw, recovered after seven days of ox gall enemata and the faradic current applied over the abdomen. This was also believed to have been due to impaction.