ough health, the mind not less than the body must be sane and balanced in its functionings. Yet there should be a motive in possessing health outside of the mere power of attainment. To subject ourselves to denials and restrictions in diet, and employ decency in our general modes of living for the mere sake of getting on the best side of mother Nature with a view of being paid off in terms of health, does not involve a betterment of our moral nature for its own sake, and is, therefore, incapable of giving birth to the harmony which is conditional to permanent health. For the motive in this case would be wholly selfish, and Nature's services can not be permanently enlisted for the furtherance of selfish aims. Health is a form of wealth, and the struggle for its possession may involve springs of motive, not less selfish and unworthy than those which may lie back of the pursuit of less valuable treasures. Health for health's sake differ in no principle way from the motive involved in wealth for wealth's sake, or art for art's sake. either case the attainment aims only at self-enjoyment.

In

Usefulness, the Greatest Medicine.What gives force and permanence to health lies in the universality of its motive.

Health for life's sake; health for the increased usefulness to the world and humanity, which such attainments entails. Health culture in any form is morally legitimate only to the extent its practices aim at an increased power of usefulness and service. Desiring health for health's sake is not more rational than to build houses and edifices without cornecting them with any principle of usefulness for prospective occupants.

In the successful pursuit of health, the question of usefulness enters as an indispensable factor. An hour of useful, purposive work, involving muscular exertion, such as lawn-mowing, wood-chopping, sawing, shoveling, etc., is of more vital value to the individual than several hours spent in the indoor gymnasium or athletics. Usefulness, purposiveness, helpfulness and general service furnish the keynote to the harmony and moral equipoise which forms the basis of all real health, strength and beauty, in human, no less than in universal nature.

The Practice of Medicine Based on the Principle of Vicarious Atonement.-The origin of the influence which the practice of drugs exerts over the mind can be traced to the insiduous promises it holds out of being able to confer upon the individual a power of wrenching unearned benefits from Nature. Back of it lies the old, vicious idea of sinning on grace, of shirking dues, while relying on the mys tery of a vicarious atonement to help the transgressor out of his self-imposed difficulties. The hope of final triumph over disease is bound up with the realization by each individual of the fact that action and reaction are equal and uninterruptible, and that a cause can not be removed without tracing back and cancelling, step by step, link after link in the vital chain of effects, the incidents connecting the actor with his acts.

The Necessity of a Knowledge of Dietetics to Insure the Individual Against the Artifice of Modern Cookery.-Metaphysical and moral postulates so far in any way from interfering with, or substituting a practical application of individual hygiene to the elementary conditions back of health, become a positive aid in this respect. Thus, a scientific study of the laws of dietetics is indispensable with the maintenance of a physiological equilibrium. And while it is true that the robust health of the savage, who is ignorant about the physiological chemistry of foodstuffs, seems to disprove the necessity of such a study for the average man, it must, on the other hand, be borne in mind that the savage has the guidance of a natural instinct, which the civilized man has not. Hence the savage, yet in the possession of a palate vitally responsive to the unerring impulses of Nature's health-life, has a comparatively easy task in selecting a bill of fare corresponding to the vegetative needs of his nature; while the civ. ilized man, suffering under the difficulty of having to depend for his judgment on a palate rendered utterly unreliable under the influence of a cookery which caters to sensual enjoyments rather than to functional needs, is constantly bewildered by the deceptive representations of an overwrought and almost suicidal appetite. To obtain a permanent health and vigor of the body it is necessary to know what

elements are needed, or not needed, for effecting a physiological balance in our daily existence.

A Bit of Physiological Chemistry.—As is generally known, the elements necessary for vegetative life are brought into our body economy under the three primary forms of foodstuffs: Proteids (albumin), carbohydrates (sugar-starch), hydro-carbon (fats), of which the first mentioned furnishes the muscles, the second the fats, and the third the heat, with their respective fields of usefulness; the first in the construction and repair of the body machinery, the second in the protection of its tissues from cold, contusions and friction, the third in the generating of heat and energy for general locomotion.

The extraction and assimilation of these elements from the various foodstuffs require the action of specific organs and functions in the system. Thus, the starch is extracted and digested in the mouth through the dissolving action of a ferment (ptyalin) found in the saliva, and furnished by the parotid glands. The proteids are extracted in the stomach, under the combined influence of the two ingre dients of the gastric juice-pepsin and hydrochloric acid-while the fat, when reaching the small intestine, is turned into an emulsion preparatory to the final lacteal absorption.

In this connection it must be noticed that each one of these digestive ferments is specific in its kind, and can only act on a definite foodstuff. Thus, pepsin and hydrochloric acid (the gastric juice) have no power to affect either fats or starch, while ptyalin (the salivary juice) is inadequate to digest any other substance than starch, and so on. Hence it is evident that a foodstuff escaping the action of its specific ferment is largely lost to the body-economy, save through the promiscuous digestion which under the strain or expediency is carried on in the small intestines.

Why Fried Foodstuffs Are Injurious.— A careful consideration of these facts will teach us invaluable lessons in mastication and sanitary cookery. For it is evident that a substance, soluble only in saliva, can be digested only when such a solvent is secreted, the mouth; while on the other hand a certain phase of cookery-frying—

by imprisoning the starch or proteid molecule in a capsule of fat, brings about a similar condition of indigestion. The distress which most people with weak stomachs experience after having eaten fried meats is due to the specific action of the various digestive ferments. For as it is first after the foodstuffs have entered the small intestine that they come under the action of the pancreatic juice, which holds the only fat-splitting solvent in the body, it follows that the encapsulated starch or proteid foodstuffs are partly lost to the assimilation, notwithstanding the tremendous expenditure of energy and secretive fluid involved in the futile efforts of the stomach to digest its impossible contents. Engineered on a basis of mechanic leverages, the gastric action continues as long as its contents resists reduction into a homogeneous and friction free pulp (pepton), conditional for absorption. For as the encapsulated foodstuffs refuse to yield to the gastric elaboration, it follows that the grinding action of the stomach continues until its available energy is exhausted, and the labor from sheer functional exhaustion is brought to a close. (To be continued.)

[Written for the MEDICAL BRIEF.] Intestinal Surgery.

BY DRS. PENNEBAKER AND TRIPP, Pleasant Hill, Ky.

(Continued from page 745).

Intestinal anastomosis is done for two classes of cases, i. e., acute and chronic. In the latter, patients are prepared for weeks before the operation, and hence time is not so much a matter to be considered as when emergency is the moving indication.

Distinction is made between primary and secondary resection of the enteron. The former is made for gangrene, the latter for artificial anus. In a resection, when a greater portion of bowel is removed from the mesenteric side than from the distalward part, the distension and paralysis of the tube which follows is due to interference with the vascular supply.

It is not necessary to resect a triangular piece of mesentery, and it is inadvisable to sew together the edges of the rent

in the mesentery, as it might include the vessels. Resection of the bowel is required for three classes of cases, i. e., strangulated hernia, ileus, and intestinal perforation. There is considerable mortality aside from the pathology in the treatment of these conditions. Good results are attained through early diagnosis and operation when intestinal obstruction has been positively excluded.

The rupturing strength of the bowel under pressure shows that the mucous membrane offers very little support, as it became torn during the distention. It is necessary that the muscular and serous coats be united at the seat of approximation to secure proper strength of the enteron. The sub-mucous coat can be torn under considerable less pressure; hence the Lembert suture should be inserted transversely to the longitudinal axis of the enteron and should embrace the mucosa.

The differentiation of the stomach end of the divided intestine may be made as follows: Grasp the divided ends of the enteron and hold them as if the operator held a simple undivided loop of intestine, so that the divided ends of the mesentery look dextrad and sinistrad. Then place the finger in contact with the mesentery, using it as a guide to determine if the finger remains all the time upon the side on which first placed; if so, up is cephalad and down is caudad. If the finger starts in on one side and crosses to the opposite side of the abdomen and mesentery, then there is a half-twist in the loop and what is held as the end cephalward is the rectal or side distalward of the divided enteron. If the tracing finger leaves the side on which it started, passes across the meson and returns to the side where started, there is a complete volvulus, and the direction of the twist and its extent is readily determined.

In making a circular suture of the resected enteron, unless pre-sectional stitches are introduced before dividing the viscus, it is impossible to preserve a straight line in the closure. Every suture should include a bit of the sub-mucous tissue; these three or four pre-sectional stitches tend to prevent eversion of the mucous membrane. The first pre-sectional ligature is inserted at the mesenteric bor

der of the enteron, at a point as free from adipose tissue as possible. When the seg. ments of the resected bowel are of unequal size, one end is closed by suture and the other end is implanted in a slit made into the long axis of the intestinal tube.

. Two methods of uniting the resected intestine are employed, i. e., the end to end union, or lateral anastomosis, the divided enteron being closed by sutures, and the mechanical approximation of the segments, this being attained by special devices. It may be formulated, if we wish to repair the intestine we select mechanical means; the method by suture has always held its own, but requires a certain familiarity with its technique. Argument is in favor of mechanical methods, in time saved in sewing. First among mechanical devices is the Murphy button, though its position is likely to be superseded by the so-called anastomosis ring, which promises more for safety and results. The Murphy button is so made that it will accommodate itself to varying degrees of thickness of tissue and make uniform pressure. This explains why the pressure at the mesenteric junction, where there is greater thickness, is uniform. The field of the button is a limited one, and it will be mostly used in connection with operations upon the gall bladder, and in the end to end anastomosis of the intestinal canal.

It is objected that it does not secure a permanent opening in the enteron of sufficient caliber, and this is a fatal insufficiency. In one case, symptoms of obstruction supervened, the opening becoming plugged with hardened feces; here it might be conceived that enterotomy might have relieved the condition. It further may be surmised that tissue necrosis might become more extensive than desired; experience, however, does not confirm this as occurring frequently. Death has occurred from gangrene at the site of the button; in another instance the button was found in the proximal side of the anastomosis at autopsy.

In two cases of gastro-enterostomy the button was found after death in the stomach.

With the button end to end, anastomosis is fifty per centum safer than lateral anastomosis.

Prof. Ludwig reports the condition of the various coats of the intestine thirty days after the use of this device. "The line of union, almost linear in thickness, could be traced by a very small but distinct cicatrix; the various layers appeared to be in perfect juxtaposition, the longitudinal being almost restored, and with the exception of the mucosa the coats were completely united by connective tissue. The mucosa had undergone degeneration."

If the button does not pass in three or four weeks the rectum should be examined, as it may rest just inside of the sphincter. The occlusion of the button by fecal impaction can be easily avoided by cathartics immediately after the operation. Primary adhesions may be hastened in malignant cases by abrading the peritoneum with the scarifier.

As mechanical devices, the bone plates of Senn, and the vegetable plates advocated by Dawbarn, have the advantage of providing a sufficient opening and as being free from the danger of remaining in the proximal side of the anastomosis as a foreign body in the intestine.

Dr. Abbe's cat-gut rings present the advantages of a sufficiently large surface for approximation and at the same time leave an ample opening in the bowel. One case of fatal hemorrhage is reported, caused by the premature liberation of an Abbe's ring, due to its twisting upon itself; the operation was one of gastro-enterostomy.

The mortality of lateral anastomosis is comparatively small when plates or rings are used, and it has been reduced but little by the Murphy button. Patients should receive liquid nourishment as soon as possible after an operation for resection upon the enteron, and alvine evacuations should be frequently secured.

Several special forms of hernia should be discussed in connection with intestinal surgery. Among these, yet to be mentioned, congenital hernia of the umbilical cord form a class of cases that will require early operative procedure. This hernia may contain the enteron alone, the liver and enteron, or the liver only. The coils of the bowel and liver may be seen through the transparent cord. From embryology we learn that from the sixth

to the twelfth week of intra-uterine life, the umbilical cord contains a portion of the tractus intestinalis. At this time the umbilical vesicle should atrophy, the bowel recede into the abdominal cavity, the navel ring close and the omphalomesenteric duct become obliterated. Just why the liver has been found here has never been explained; some museum specimens contain the heart as well.

Dr. H. Speier, of Rochester, Minn., expresses himself as follows: "The word congenital includes any morbid change that may take place in the child before it is born. In the creative, or developmental stage, which is completed at the end of the sixth week of intra-uterine life, any malformation of the child which is then present can not be remedied by nature unassisted by artificial means." If the fetus has an umbilical hernia into the cord at that time it will be born with this condition. "In other words, Nature abandons her work after the sixth week, so far as repair is concerned." The prognosis in hernia of the abdominal viscera into the umbilical cord is grave. It is advisable to operate as soon as possible and do the radical operation before adhesions form. Cases are reported as cured by wearing a truss.

Laparotomy was performed upon a female child not an hour old; there was evisceration of the bowel from the duodenum to the sigmoid flexure through a small umbilical opening; the hernia included the mesentery. This had developed in a sac formed in the cord, which would have contained about one and one-half pounds. The abdomen was so contracted from the absence of the enteron therein contained during development that it Iwould not contain the eventrated viscera without enlarging the same. This being done, the intestine was replaced and the wound sutured; the bowels responded to castor oil and a few doses of one-third drop of tincture of opium.

Colotomy is indicated in many cases where excision of the bowel would be impracticable. It relieves the symptoms and retards the growth of neoplasms and prevents obstruction, as well as prolongs life through the relief of pain.

The operation, especially the inguinal, relieves tenesmus and constant discharges

from the rectum, and it prevents the straining and congestion of defecation. The inguinal procedure is preferable in the majority of cases to the lumbar; the incision is smaller, the depth of the wound less and it offers greater facility for abdominal exploration. Further, the position of the patient in making the operation renders anesthesia safer, and it is easier to find the colon and fix it to the skin; this operation of selection forms a better spur, and the site of the artificial anus is more cleanly and the adjustment of a pad is more practicable, and as a matter of greatest importance this operation is less dangerous. By preference the left side is selected, exceptionally the right. The direction of the colon is determined by touching the bowel with sodium chloride, thus exciting reverse peristalsis; the use of sodium carbonate for this purpose is dangerous. A great drawback to inguinal colotomy may be the inability to retain feces; this is not seen in lumbar colotomy. Stenosis or malignant growths affecting the ileo-cecal connections indicate ileo-colotomy.

Gangrenous portions of the enteron necessitate resection, and either direct restoration of the continuity of the bowel or an artificial anus.

Colectomy, made for a malignant growth, provided the meso-colon is slightly or not at all invaded, or the tumor is not too adherent to the neighboring organs, and it be possible to mobilize the tumor and to separate the diseased parts without the abdominal incision, is a possible operation. A stricture of the descending colon of a cancerous nature was excised through an incision made as for left lumbar colotomy. The patient was a lady fifty years of age, suffering from the obstruction for eight weeks. She was very feeble. The bowel was removed in the track of the incision by pulling the strictured segment through the wound; each portion of the bowel, with its two orifices after division, were then attached to the lips of the wound.

In peri-typhilitis, if the patient can withstand shock and peritonitis, the abscess will point as do others near the pelvis. There are occasional collections of matter at this anatomical site that have no relation to the intestinal canal,

i. e., psoas-abscess, abscess of the right ovary, the migration of pus from distant points, etc. The mortality in subacute cases is greatest prior to the third day; the generality of peri-typhlitic abscesses originate in the appendix vermiformis.

The extreme surgical practice of the present day is not founded on the invariable gravity of the disease, but on the difficulty, if not impossibility in many instances, of distinguishing when the trouble is grave, or likely to become so.

Abscess of the abdominal wall followed by a fistulous communication with the intestine, may arise from stercoral ulcers, eventuating in abscess. These cases were not uncommon, but were always fatal (Dr. C. K. Briddon). It is a prevailing opinion that such troubles are not infrequent among the colored people.

There is one other form of abdominal cavity abscess that largely owes its etiology to intestinal disease, i. e., sub-phrenic abscess.

In sixty cases almost half followed appendicitis; of one hundred and twentynine cases, twenty-three were subsequent to appendicitis. Perforation of the diaphragm occurs in twenty-five per cent of such abscesses. The following is the clinical report of a sub-phrenic abscess that developed subsequent to appendicitis: There was great pain and tenderness in the region of the appendix and along the ascending colon. The liver was enlarged and somewhat tender and was likewise displaced downward. The patient lost flesh and concomitantly there was elevation of pulse and temperature. After an operation for appendicitis the local abdominal symptoms continued in a direction cephalad with constitutional expression. Evidence of an abscess pointing at the tip of the left twelfth rib made its appearance; this, on being incised, proved to be a large abscess, which had formed between the diaphragm and liver. The patient recovered. These abscesses may be extra or intra-peritoneal; pus may burrow cephalad behind the colon, perforate the diaphragm and discharge through a bronchial tube. Pain is a symptom of importance, usually in the region of the liver, with depression of its lower border. Pain in the right shoulder is noted in a number of cases, and hic