« SebelumnyaLanjutkan »
cated, and of the merits of which I am able to speak from a not inconsiderable experience. There are various incidental points of inquiry, and certain qualifications of statements, which a full consideration of the subject would embrace. The ground which I take is, that the diet which in healthy subjects is conducive to the preservation of health is the diet which is desirable in cases of dyspepsia. Restrictions of diet when digestion is difficult or labored, with a view toward adaptation to a supposed diminished functional power of the digestive organs, I believe to be never successful, and injurious in proportion as the restrictions involve diminished assimilation and nutrition. It is a fallacy to suppose that the digestive organs in dyspepsia need rest. Exercise of the different organs of the body tends to the maintenance of their functional capabilities. Some old writer said that the stomach was like a school-boy: unless kept pretty constantly occupied it was sure to get into mischief. There is an important practical truth in this remark. If the stomach behave perversely, like the mischievous schoolboy, the patient should conquer the stomach, and not the stomach the patient. This simile may sometimes be used with advantage in order to make patients not afraid to rely upon their digestive powers.
This paper, on account of the limitation as to time, does not afford an opportunity for the introduction of reports of cases. Were it otherwise, I could cite many illustrations of the success of the general plan of treatment which I have outlined. In some cases which have come under my observation, patients, who had been chronic dyspeptics for many years, found themselves at once cured by adopting a full and varied diet, following nature's indications, taking no thought of what they should eat or what they should drink, and occupying the mind with other topics than those relating to their digestion.
Finally, let us learn a practical lesson from our observations of the class who "live to eat "-the gourmet and the gourmand -they "who fare sumptuously every day." Dyspeptics are not common in this class. An overstimulated appetite may
lead to other affections, such as gout, indigestion, fatty heart, etc., but rarely to dyspepsia.
Let us learn another practical lesson from our observations of those who "eat to live," the hard-working laborer or mechanic, who is satisfied with obtaining an ample supply of food, and who has no time to study, by his personal experience, the relations of diet to digestion. Our dyspeptic patients do not belong to this class.
Let us learn still another lesson from our observations of the classes to which our dyspeptic patients belong. They are, for the most part, lawyers, clergymen, physicians, students, teachers, artists, bankers, literary men, and men of leisure. Of persons belonging to these classes, those become dyspeptics who study, from the best of motives, how to live, as regards diet, so that "digestion shall wait on appetite, and health on both"; and for this end they endeavor to regulate diet by watchfulness, personal experience, theoretical notions, or, perhaps, scientific principles.
Let a fourth lesson be learned by observing the results of the dietetic treatment of dyspepsia based on the conclusions to be drawn from the previous lessons.
A SUCCESSFUL CASE OF NEPHROLITHOTOMY
By WILLIAM WOTKYNS SEYMOUR, M. D., of Rensselaer County.
I REPORT this case on account of the comparatively few instances on record of pure nephrotomy, and in order to contribute my mite to the extension of the field of renal surgery, which is daily assuming more and more importance in practice. It seems very strange that an operation which was so strongly urged in 1622 by Cousinot, of France, should be nearly two hundred and fifty years in gaining recognition as a proper and valuable addition to surgery. Cousinot, in his thesis in 1622, considered the operation a very proper one. Bordeu advanced the same view in 1754; but Masqualier, the same year, rejected it. Rayer admitted nephrotomy as a proper operation in 1839 ; but the operation, save in cases of previous perinephritic abscess or fistula, was forgotten until 1869, in which year Thomas Smith read a paper before the Medico-Chirurgical Society of London, advocating the operation.1 The next year, Gunn, of Chicago, and Durham and Bryant, of London, operated. The two former did not incise the kidney, and their operations accordingly remained incomplete. In Bryant's case, the patient lived twentytwo days. This was the revival of the operation, which is even now so infrequent that each case is of great interest.
My patient, E. C. R., a carpenter and pattern-maker, aged fifty-two years, formerly of irregular habits, while a soldier in the late war had malarial fever, several attacks of renal colic, and was discharged for diabetes. At various times, up to 1880, he had
'Dictionnaire de Médecine et de Chirurgie. Paris, 1881, vol. xxx, p. 664. P. Marduel. Article "Reins."
attacks of gravel; and finally, in that year, he had an attack followed by the sudden lodgment of a calculus in the membranous portion of the urethra. Being in his agony unable to procure assistance, he himself, with a pincers applied to the soft parts external to the stone, crushed it so that it could be passed. This was followed by hemorrhage and inflammation. Of the size and weight of the stone, I could get no definite idea. In the August following, he consulted me for difficult micturition and very offensive purulent urine. An examination revealed a stricture in the membranous portion of the urethra, through which I finally succeeded, by packing, in passing a whalebone guide, upon which I introduced a tunneled sound into the bladder. Subsequently I gradually dilated the urethra to No. 24 (French), and with washing out the bladder the urine cleared up and all trouble disappeared for a long time. Gradually the old trouble recurred, and the urine, on standing in a glass preserve-jar, deposited a sediment of pus two inches in depth, and so offensive as to drive every one out of the room where it was exposed. In July, 1883, I performed internal urethrotomy, passed No. 30 (French) and had the bladder washed out as before. A month later he had, while under my care, a severe attack of renal colic, and passed a calculus about the size of a split pea. Soon after, both the patient and myself noticed a fullness in the left flank, which, on examination, was found tender, elastic, and fluctuating. My diagnosis was pyelonephritis from calculus, and I advised incision and drainage of the kidney, with, if necessary, subsequent extirpation of the organ. The patient declined any surgical treatment and hoped to get better. Instead of improving, however, he gradually became worse, the pain becoming so severe as to confine him most of the time to his bed, and the tumor enlarged to about the size of two fists. Early in August, 1884, he desired me to operate for his relief. August 10th, I carefully examined the patient and found the tumor to be about the size stated, fluctuating, elastic, and exquisitely tender. Firm pressure caused pain down the left ureter, extending to the left testicle and down the inside of the left thigh. Subsequent to the examination, the first urine, passed in a quart-glass preserve-jar, deposited, on settling, about two inches of offensive pus, and on it a layer of red blood-corpuscles one quarter of an inch thick. The urine was alkaline, the specific
gravity 1.015, and albumen, after separating the pus by filtration, was found in considerable quantity. Examination of the sediment showed only pus and red corpuscles, with some triple-phosphate crystals. I operated August 11th, at 1 P. M. The patient was on the right side, with a hair-pillow under the flank. Brandy was given by the mouth and etherization was proceeded with. The patient was a difficult subject to etherize. An incision five inches in length was made along the edge of the quadratus lumborum muscle, and, in order to gain more room, another incision was made in front, parallel to the crest of the ilium and about two inches long. With knife and director, the dissection was carried down to the fatty tissue surrounding the kidney. Through this I tore with the finger-nails and the knife-handle. Owing to contraction of the abdominal muscles, I had great difficulty in pushing the kidney well into the wound, but I finally succeeded, and I introduced a needle grasped by forceps into the kidney, to search for a calculus, the kidney being apparently normal. Not succeeding with this, I tried the smallest needle of a Codman and Shurtleff aspirator, and, thrusting this through the parenchyma toward the renal pelvis, I felt the grating of a calculus. At the same time, there welled through the needle some excessively offensive pus. With the needle as a guide, I passed a curved bistoury into the kidney, through the parenchyma, and made an incision admitting the index-finger. This incision I enlarged by tearing, so as to admit two fingers, giving exit to ten or twelve ounces of offensive pus. The hemorrhage was brisk but was arrested by sponges. In the pelvis of the kidney could now be felt a calculus stopping the ureter. This I attempted to remove with forceps, but it broke at every grasp of the instrument. Finally, it was dislodged, as a mass of calculous fragments, by the finger-nail used as a scoop. This débris, when dried, weighed thirty-eight grains. The kidney was then syringed out with a solution of chlorinated soda, 1-20. The wound was thoroughly sponged, and a rubber drainage-tube of three-eighth-inch lumen was introduced into the kidney. The angular prolongation of the wound was closed with a continuous suture of Kocher's catgut, iodoform was dusted into the cavity, and the main wound was closed with three silk sutures. Iodoform was dusted over the wound, and a thick pad of absorbent cotton was placed over all. Owing to the free discharge of urine and pus,