Medical

The technique of stomach examination is so simple that any physician should be able to become master of what is now known of the methods in practice.

Methods of stomach examination are external and internal. By external, we mean inspection, percussion, palpation and auscultation. By internal methods, we refer particularly to the various tests and examination of the stomach contents through the use of the stomach tube.

Perhaps the test most frequently used is that of the test meal. After two or three hours after the ingestion of this meal the contents of the stomach are withdrawn and examined in order to determine whether the fermentation has been decomposition by putrefaction or whether by the digestive ferments.

To determine the power of absorption of the stomach the iodide of potassium test is the one most frequently used. A five grain capsule of the iodide of potassium is taken into the stomach, and after an interval of fifteen or twenty minutes test paper is moistened with the saliva of the patient, a drop of fuming nitric acid is placed on the moistened test paper, and if iodine is present a blue reaction appears. Many conditions of the stomach may interfere with this test and prevent its success. The glandular structure may be covered with thick mucus as the result of degenerative processes in the glands of the stomach, for example, so this method cannot be depended upon as a perfect test of absorption. If the stomach were washed freely by siphonage before making this test the results obtained would be more reliable.

The salol test is employed to determine

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the motility of the stomach. The particular value of salol in this test is due to the fact that it is not dissolved or split up by the stomach juices; but after passing over into the intestinal tract and absorption takes place, a urine test will determine whether the salol has been acted upon.

An obstructed pylorus and a dilated stomach would prevent the success of this test because the contents would be in a state of putrefaction and because of stenosis of the pylorus passage into the intestines would be prevented and the test rendered valueless. A catarrhal inflammation of the intestines and obstruction of the biliary and pancreatic ducts would have the same effect.

Concerning the size of the stomach, this may be determined in various ways. The methods most used are those of the water test and distension by gas. The introduction of a rubber bag distended with gas will show the size of the stomach. Water poured into a stomach that is seriously diseased would be objectionable and possibly dangerous.

The length of time that food remains in the stomach and the progress of digestion give us more information concerning the motility of the stomach; and the character of the contents that are withdrawn by the tube is a better guide. of the degree of absorption than any other tests.

Palpation is of the greatest importance in determining the presence of tumors of the stomach. By the electric light as used by Dr. Einhorn, tumors may be easily outlined when situated in the anterior portion of the stomach.

OPERATION FOR HARE LIP. James Parrott, in the Charlotte Medical Journal, declares that the separation of the cheek from the bone is unnecessary. How this idea ever possessed the thinking surgeon is hardly conceivable. Almost every text-book on surgery advises it, and nearly all surgeons actually do it. In my judgment it should be

abandoned. The author has not lossened the cheek for twelve or fourteen years, not even in extreme or very hideous complete double hare lips with projecting intermaxilary bone. He has not seen the necessity for it, never has regretted not doing it, and on the contrary has been highly pleased that he did not do it. By careful mortising the edges, all tissue of any service can be saved and utilized to great advantage. This is difficult anl tedious in most cases, and especially so with double harelip. If any tension exists after the operation is complete, it can be relieved by the proper application of adhesive plaster. The author emphasizes the fact that loosening the cheek is not necessary to prevent or lessen tensionthe only purpose of cheek-separation.

The preparation necessary for this operation is very simple. Parrott prefers the administration of a mild cathartic 48 and 24 hours previous to the operation. The mouth, nose and checks should be cleansed the day before and the morning of the operation with a mild alkaline antiseptic, or a saturated solution of boric acid. The lips possess great resistance to infection and heal very promptly and satisfactorily, even under the most adverse conditions. The dressing should be very simple, a superabundance is not only needed, but is really disadvantageous. A light, small, strip of sterilzed gauze should be placed on the wound-just large enough cover it and a Z. O. adhesive strip applied.

The proper application of the adhesive is the most important single step in the entire after-dressing, and is of equal importance to the correct paring and mortising of the lip. Taylor's method is very good. Mumford's "butterfly" strip is commendable. Neither of these is best unless the check be loosened during the operation. In my procedure both are unnecessary. The author prefers, and very decidedly, applying two narrow strips placed across the wound over the entire extent (of course in the same direction) of the zygomatic muscles, and reaching below the corner of the mouth on the opposite side, and rather tightly drawn. This contracts the zygomatic muscles to a great extent, and prevents undue tension on the suturs. This simple dressing should be changed, and the wound, nose and mouth lightly irrigated with boric solution every other day for about ten days. The face should be fixed with adhesive a few days longer. Taylor's method is very good at this point.

HEART DISEASE IN PREGNANCY.

Moran, in the Journal of Obstetrics of the British Empire, refers to the dangers accompanying pregnancy in the subject of organic heart disease. While the prognosis is always grave for the mother and child, the result in a given case depends upon the valves affected, the amount of compensation, the condition of the heart muscle and the general state of the patient. Crippled placental circulation is responsible for abortion in the early months, while asphyxia, often fatal to mother and child, may occur during labour. Post partum hæmorrhage and pulmonary edema may cause death immediately after labour, while owing to diminished resistance acute endocarditis may supervene if puerperal infection occurs. The nature of the cardiac lesion

has considerable influence on the clinical phenomena observed; mitral insufficiency predisposes of ædema and asystole; aortic insufficiency to syncope and epistaxis; mitral senosis to cerebral embolism, hemiplegia and postpartum hæmorrhage. He says that pregnancy and parturition are dangerous to the cardiopath, and reports seven cases occurring in his own practice. In the management of the cardiopath, attention is drawn to the importance of careful and continual observation, and of guarding the patient against excitement, over-exertion, excessive exposure to cold. The skin should be kept active by a daily tepid bath and the bowels and kidneys carefully regulated. Pulmonary and renal congestion are to be guarded against by the wearing of proper clothing and the avoidance of sudden. chills. When compensation fails he advises the usual medical measures, reserving induction of labour until viability of the child is reached. In the conduct of labour he advises a hypodermic of morphia during the second stage, with artificial assistance so as to avoid shock and sudden lowering of blood pressure. Immediately after delivery a sand-bag should be placed on the abdomen to guard against the latter danger. The placenta should be allowed to be expelled spontaneously and no friction or kneading of the uterus practiced, but free bleeding favored to relieve the disturbed circulation. Ergot must not be given. In regard to the cardiopath, the author is in full accord with the dictum of Peters: "No marriage for the unmarried, no pregnancy for the married, and no nursing for the confined."

A NEW IODINE SOLUTION FOR SKIN. Ellice McDonald, in the Medical Record, states that after Heusner, in 1906, first reported the good results with his solution of 1:1000 iodine in benzine, he began a series of experiments to obtain. a comparatively unirritating solution of

iodine in a fat solvent in greater proportion than 1:1000. Benzine will not take up more than that amount, and the solvent itself is rather irritating to the skin. After a number of experiments with various solutions and combinations of alcohol, chloroform, benzine, acetone, ethylene dichloride, toluene, glycerin, and carbon tetrachloride, the following mixture was found to be the best: Iodine, 2 parts; carbon tetrachloride, 98 parts. This solution has been used in my work for three years in abdominal operations with uniformly good results and without any skin suppurations whatever. The abdomen is shaved the night before operation and washed with gauze (no brush), and an antiseptic soap, such as mercuric biniodide soap or a formalin soap made up of 5 parts of formalin to 15 parts of benzine and 80 parts of tincture of green soap. A soft, dry, sterile towel is then applied over the field of operation. At the operating table this towel is removed and the carbon tetrachlorideiodine solution is swabbed on the skin surface of the abdomen, and rubbed into the skin with a piece of gauze for between one and two minutes, the time being taken by the anesthetizer. The mixture dries readily, leaving the skin ready for the incision. This mixture combines the advantages of Grossich's tincture of iodine method and v. Herff's15 alcoholacetone method of disinfection of the skin. The carbon tetrachloride is a fat solvent, which alcohol is not, and the addition of the iodine makes it a more powerful antiseptic than the alcohol-acetone of v. Herff. Carbon tetrachloride is in itself an antiseptic of considerable value. and is useful in preserving urine in place of chloroform, and has been used to preserve diphtheria antitoxin. Carbon tetrachloride (C C14) is a heavy anesthetic liquid, not unlike chloroform, with considerable odor, and a fat solvent. It does not burn or explode and is comparatively unirritating. The author's attention was

first directed to it by advertisements of a cleansing solution for taking grease spots from clothes, advertised under a trade name which is a corruption of the first part of its name, and as a substitute for explosive benzine.

The advantages of the carbon tetrachloride-iodine mixture are its simplicity and fat-dissolving properties. If used repeatedly upon the hands, the skin will become dry and peel off, but this will not happen unless there is repeated application, and McDonald uses it after his hands have been in pus, or after a pus case has been operated upon, to be sure of complete sterilization. For constant use as a hand disinfectant, the iodine must be reduced and some lotion or oily substance, as lanolin or cold cream, rubbed into the skin of the hands after operating. Carbon tetrachloride is not expensive and costs in the neighborhood of two dollars a gallon, and three ounces is sufficient to prepare the abdomen for operation.

NITROUS OXIDE AND OXYGEN. Williams, in the California State Journal of Medicine, thus sets forth the advantages and disadvantages of this mode of anesthesia for prolonged operations: Advantages.

There is a great decrease in postoperative nausea and vomiting. Teter had in 13,000 cases only five who vomited continuously after nitrous oxide, the longest case lasting only six hours.

Surgical anesthesia is attained in from two and a half to four minutes.

There is almost immediate recovery after the gas is discontinued.

During the operation the patient has no mucus, rarely vomits, and the tongue never falls back.

It is ideal in obstetrical work, as it causes analgesia or even anesthesia, without muscular relaxation. It acts rapidly and is eliminated rapidly.

It will probably be a great advantage

in thoracic surgery, as it has been used with success experimentally on animals.

Nitrous oxide and oxygen is the safest known anesthetic. Bevan estimates the death rate to be one in 50,000, while the death rate from other anesthetics ranges from one in 10,000 to one in 15,000.

Disadvantages.

It is expensive, costing from $6 to $9 per hour for material. The rebreathing method used in 700 cases recently at Johns Hopkins Hospital greatly reduces the cost.

It requires a special apparatus.

There is much more muscular rigidity than with ether, but morphine and small amounts of ether overcome it when present. Some surgeons learn to accustom themselves to it on account of the improved condition of their patients.

There is some danger from suboxidation, and venous congestion in certain cases, as in alcoholics and obese men.

It is contraindicated in serious heart conditions on account of the increased work put on the right heart from venous engorgement if any cyanosis is present.

It requires more skill to administer than other anesthetics. To quote from Crile: "It has certain dangers which are almost wholly in the hands of the skilled anesthetist; it is not the anesthetic of choice for the unitiated, but only for the highly trained anesthetist."

GETTING PURE MILK.

John Lee Coulter, in the Northwestern Lancet, points out that the dairymen who wish to do what is right must be helped; the same as a child who wants to learn to write must be shown how. Education for the mass of sensible producers must be supplemented by laws for the prosecution of those who refuse to live up to a certain standard, the same as in the case of our pure-food law.

If good milk is produced, the rest is comparatively easy. But the writer, be

cause he has lived for many years on Minnesota farms, because during the last year he visited the barns of a great number of farmers and dairymen and discussed the question with the producers, and because he has made a series of every careful estimates of the cost, is confirmed in these views: first, that the consumers must make insistent demand for a better product or they will not soon get it; second, that they must show their desire for it by being willing (by passing laws and by being taxed to supply the money) to help to get rid of the undesirable cows; third, that they must show their desire by carrying on a movement of education among the producers who do not understand, and by prosecuting those who persist in dirty methods.

If consumers really want sanitary milk, one of the first moves would be to see that the stables kept by hospitals are sanitary. This is surely as important as carrying flowers to the patients; yet the writer has visited such stables and has found some as bad as that of many dairymen.

If they really want sanitary milk, another early step is to clean up the stables behind their own houses in the cities. As a general thing these stables, with one, two or three cows, are in a worse condition than is found in the average dairy or farm.

If those who do not keep cows want sanitary milk, let groups of twenty-five or fifty in a locality agree to pay a cent a quart higher to some dairyman if he will improve his quality, and let them send their own inspector out from time to time. A few months would show the wisdom of this step. Or, again, if they want this good milk, let one hundred families purchase or establish a small dairy to supply their needs. If they would establish a clean dairy they could easily dispose of the surplus milk at a profit. When consumers get rid of their false notions of economy, when

they demand sanitary milk, they can get it for what it costs, including such a profit as is now added.

Many farmers would be glad to produce more sanitary milk, to introduce cleaner methods, and to be surer of the health of their cows, if the consumers only appreciated what it meant. But the consumer must be willing to pay for a better product. No farmer or dairyman can introduce these reforms and compete with another who does not go to any extra expense.

In conclusion, the author urges that the demand must come from those who use the dairy products. Just as they have demanded pure-food laws and other reforms and have commenced to get results and are paying for them, so, too, they must demand not only good weight and measure, and no adulteration, but also a product from a healthy cow secured according to good rules of cleanliness.

PROTEID IN INFANT FEEDING.

D. J. Milton Miller, in the Interstate Medical Journal, emphasizes the great importance of a sufficiency of proteids in the infant's dietary; to show how frequently infants suffer from a want of this element, because of the misconception (still prevalent) that it is the casein of cow's milk which is the most injurious to, and difficult to digest by, the human baby; that this idea had its origin in the belief that the curds commonly seen in the infant's stool were undigested casein, while, in reality, in the majority of cases, they are composed of fat-although casein curds do occur; that this belief has led physicians in the past, and is still leading them, to feed babies with low proteids or upon proprietary foods deficient in this element; that fat is better tolerated before the sixth month than after, in winter than in summer, is the cause of a peculiar form of constipation, and is partic