bowels. It has been suggested that about five ounces of water be swallowed by the patient just before the anesthesia, for the purpose of holding in solution that part of the anesthetic which is eliminated by the mucus membrane of the stomach. It is the common practice at the St. Joseph Hospital to place over the nose after cessation of chloroform anesthesia a cloth wet with vinegar. Crushed ice swallowed whole will often relieve the situation. Lower the head for the condition also. But of all remedies I am fondest of ice cold champagne, which in my hands gives great satisfaction. Nothing, however, will do much good if the patient is in the so-called "bilious condition" at the time of operation. It is not proper to severely purge a patient for the sole purpose of removing this condition, so that the best we can often do is to give high enemata and unload the colon. This alone is often effective. In cases where the digestive tract is not the seat of operation, a thorough catharsis can often be accomplished, all fecal matter being completely removed and a good quantity of bile thrown into the bowel. No fermentation is present then, and thus all sources in the digestive tract which provoke vomiting are removed. When I can prepare a patient for forty-eight hours in this way it is seldom the case that vomiting occurs, though any patient may be nauseated. The straining and violent motions of vomiting are very dangerous. They may break down a limiting pus wall. It is therefore an important factor in postoperative treatment to prevent it. When once the patient is anesthetized he should be kept quiet. The transfer to the operating table from the cart, and from the operating-room to the bed is undoubtedly an exciting cause in producing vomiting. These patients should not be handled any more than is absolutely necessary. It is well to remember that the evaporation point of chloroform is below that of the body temperature, and hence is slowly eliminated and the vomiting thereby protracted.

This is a

3. Thirst. Thirst is always present after an operation. thirst not necessarily due to loss of blood, because hemorrhage may be very slight, but to the invasion of the abdomen and the peritoneal membrane. I have long been of the opinion that the loss of the serum of the peritoneum is the chief cause of thirst in blood less abdominal operations, and an important factor in all laparotomies. It would be interesting to know what quantity of serous fluid the peritoneum secretes each day. This fluid is exceedingly important to its function, and nature is exceedingly careful in its preservation and use. The rapidity of its formation must be very slow by the usual process of absorption of water from stomach, and thence from blood. We now know that leaving large quantities of saline solution in the abdomen in clean cases, does away with thirst to a great degree. By this method the depleted peritoneum is at once supplied with water. Here comes into play again the salt enema, this time as a thirst enema. There can be no question of its great value for this purpose if given under the anesthetic immediately following or during the operation. I say under the anesthetic, because by this means a larger quantity can be given and it can be made to enter the colon. During one of my appendicitis operations I instructed the interne to give a salt enema for shock, just as I was ready to pack the abscess cavity. It was a pus cas The abdomen suddenly distended and the ascending colon and cecum

pushed themselves forward into the wound. When I turned back to the patient, after receiving the gauze pack from the nurse, the change in appearance was so startling that I at first thought some tremendous hemorrhage must have occurred. In a moment I recognized the source of trouble, and found that the irrigation bottle was too high. I at once evacuated part of the enema and without any untoward results. The patient during it all was thoroughly anesthetized. This was to me positive proof of the possibility of filling the entire colon with water. I have heard it contended that such could not be done. The patient recovered from the operation and is well today. Shall we give water to drink? Some say none, others say always. The right course lies between these two. There can be no doubt that when vomiting is present the mechanical presence of fluid in the stomach makes it worse at times. But vomiting is not always present. I can see no use in giving water unless it is absorbed, but when it is retained always give ad libitum. Nature's request should be granted, and if she asks for water let her have it. Very often crushed ice swallowed whole will be retained when the liquid will not. Hot water may be retained when neither of the others are. The stomach is not thirsty in these cases. There the sensation lies, but the entire system is craving water. When it is supplied the sensation in the stomach ceases, even though not a single drop may have been swallowed.

In this connection it may be well to remember the formula for Semmola's glycerine drink, which is often exceedingly grateful. It is, one ounce glycerine and thirty grains citric acid to a pint of water.

4. Toilet. Much can be done for comfort that will aid materially in recovery. A sponge bath followed by an alcohol rub down may be beneficial, will often quiet a nervous patient or secure sleep. The mouth feels dirty and sticky. Hydrogen peroxide well applied with a good tooth brush makes a refreshing mouth wash and an antiseptic one also. The taste nerves will then distinguish the taste of each article of food, and the patient will relish his nourishment.

5. Bladder.--The urine should be drawn unless passed voluntarily. This is often overlooked and may cause much discomfort. Retention of urine is apt to occur in all abdominal operations.

6. Tympanites.-Is a very common accompaniment of abdomina operations and must nearly always be treated. Its origin in my opinion comes from two sources, viz., the imperfect digestion of food and the paralysis of peristalsis. The food origin can sometimes be eliminated if preparatory treatment is possible, by limiting the food and giving only such as can be digested or is predigested. The food taken after an operation upon the intestines is often not digested, but undergoes decomposition, and is, therefore, better withheld. The handling of the bowels during the operation undoubtedly inclines to paralysis of peristalsis, and this in turn to accumulation of gas. The insertion of a high rectal tube is often effective, as the gas will pass out through the tube. The insertion of a low rectal tube to overcome the resistance of the sphincter alone is often sufficient. The low tube can be left in for hours and the gas will escape through it as it comes down to the rectum. This device was especially

useful in one of my appendicitis cases. Turning in bed will often call into play the abdominal muscles, which will contract on the bowels and force the gas along the tract, and the changed relations of the bowels to each other throws the weight in a new place and produces expulsion. The high enema is very effective and has served me well.

7. Food.-I am very loathe to attempt stomach feeding until I have been assured that peristalsis has been re-established, and I know that peristalsis has been re-established when there is a through and through movement of the bowels and gas is being expelled. Prior to this time I depend on rectal nutrient enemata. It is my rule to give either castor oil or calomel as a laxative at the end of twenty-four hours, using judg ment, of course, according to the pathological condition found. After the effect of these remedies has been obtained, then I feel my way along with food cautiously until the digestive functions have been re-established.

8. Position or Posture.-Unless there is some anatomical reason to the contrary, it is my custom to find out the position in which the patient usually sleeps and permit him to assume it. Very few people sleep flat on the back, and if compelled to assume this position for several days consecutively sleep will depart from their eyelids. There are other positions than the back position which are useful, and have the great advantage of being comfortable to the patient. It is not at all necessary to place every abdominal case flat upon the back. Lying face down will often help in expulsion of intestinal gases and facilitate drainage if wound is in front, and lying on the right side will facilitate escape of stomach contents through pylorus. The feet may be raised for syncope, or the head may be raised in septic cases with the idea of retarding the flow of lymph through the lymphatics which empty into the thoracic duct. I consider it good practice to permit the patient to assume that position which is most comfortable, unless there are sound reasons for advising otherwise.

It is manifestly impossible in the few minutes allotted this paper to go deeper into the headings discussed, or to take up others equally important, nor is it possible to discuss certain measures which if put into effect before operation will alter or prevent some of the conditions mentioned above. This paper is intended to elicit discussion and to arouse the interest of my hearers, so that when they return home they may again go over this subject with renewed interest, and certain benefit to themselves and their patients. Our patients do not suffer during the operation, because they are anesthetized, but many of them suffer the tortures of hell during the hours and days following. It is our duty to inform ourselves on every point that may relieve this suffering, and to apply our knowledge. skillfully and promptly. Let us give these patients more of our time and attention after operation.

Contributed Articles

PRESIDENT'S ADDRESS.*

P. 1. Leonard, M. D., St. Joseph, Mo.

ENTLEMEN:-President Faunce, of Brown University, in an address before the Rhode Island Medical Society last June, admirably expresses the distinction between a profession and a trade: "In two respects the medical profession deserves the grateful recognition and regard of all other callings in modern life. It has always insisted that the practice of medicine is a profession and not a trade. Trade is occupation for livelihood; profession is occupation for the service of the world. Trade is occupation for the joy of the result; profession is occupation for joy in the process. Trade is occupation where anybody may enter; profession is occupation where only those who are prepared may enter. Trade is occupation taken up temporarily, until something better offers; profession is occupation with which one is identified for life. Trade makes one the rival of every other trader; profession makes one the co-operator with all his colleagues. Trade knows only the ethics of success; profession is bound by lasting ties of sacred honor."

In a city of this size a medical society which displays signs of energy is an important element. All the influences of the society tend towards strengthening the position which medicine occupies in a given community. Every reputable physician, whether he be a very passive member of this society or refuses to become a member at all, throws his silent influ ence against the general aims of the profession, and frequently against his own interest. He ignores the society as a representative body having the interests of the profession at stake, and frequently he ignores the medical society whose aim is to advance medicine as a science. We may fail largely in working a revolution in either direction, but no one can gainsay, that in a modest way during the past year we have made an advance.

Gentlemen, I am one of those who believe that we can learn one from the other, that any mental stimulation is better than the dead inertia of self-satisfaction; that a medical society not only enlarges one's mental horizon, but as we get better acquainted with the aims and purposes of our fellow-practitioners we also may get an increase in size of the heart. The laity has a partially justified reproach in jealousies between doctors due largely to a lack of personal contact and mutual association. These jealousies become less every year on account of better medical organization. Means should be taken so that membership in a county society be of some specific value to every one. The solution of this proposition is a difficult one.

A friend some time ago spoke of the listeners at a medical society meeting as "a handful of politely bored or mildly interested physicians. Another one will say that there is too much "medical politices," whatever that may be. Another one accuses us of plagarism.

*Read before the Buchanan County Medical Society, December 16, 1935. Ordered printed by vote of the society.

Voltaire says: "Plagarism is not only the least harmful of all crimes to the community, but is often beneficial." Pope, Shakespeare and Moliere acknowledged that they had no literary conscience. And still another one objects to our slavish obedience to authority. Virchow says:

"Two obstacles have always been in the way of the progress of medicine: Authorities and systems. Authorities may be referred to for certain observations and thoughts, but the self-conscious man follows them only when they (the authorities) offer him a guarantee of their ability to observe and think properly, and even then only so long as their observations and ideas do not conflict with his own observations and ideas. All authority must, therefore, be a relative one only; it may guide our observation and judgment, it must never dictate them. . . His own (the physician's) senses and thoughts must be his supreme, highest, authorities!"'

One of the functions of the medical society is to enlighten the people on disease, and take this time-honored prerogative from the charlatan. There is no objection to my mind if a regular physician delivers a popular medical address before a lay audience, for the reason that the public will discover that physicians tell the truth, even though that physician's name should be mentioned in the daily Bazoo. Ultimately only good can come from reputable physicians being in the public eye. The wonderful operation performed by Dr. Sawbones at the city hospital, minutely and technically described in the morning paper is to be reprimanded, for the reason that Dr. Sawbones is attempting to overawe an indiscriminating public by his profound importance. Dr. Sawbones may even be a tin god to his professional entourage.

As a matter of amusement and an attraction to attend the meetings. of this society, it would be a good idea to follow the lead of a few societies, and add one more duty to the easy and most honored position of our secretary to cull the names of our members as they appear in the daily press, and each month read them, and then listen to the peculiar combination of circumstances that the dear doctor did not know anything about it. Everybody presumes to know more about medicine than we do ourselves; and why is it? Because we as a profession do not stand together, as an organized body and present our claims.

vented.

There is one overwhelming point in favor of our profession, when we account to the world for our raison d'etre (right to existence). And it is nothing more or less than the physical basis of morality and general usefulness. Violation of hygienic laws, disease of every kind can be preWe as intelligent men, make our own morality, and this hinges around the well being of our bodies. Men disregard the academic or religious aspects of the questions of morality. Show me a man of sound structure and I will show you a sound man. The reason for our existence in any community is this high ideal, call it physical, if you please.

The altruism of the medical profession stands unparallelled in the history of the human race. A lawyer once told me, your profession is progressive, you open the future to new social interpretations, but my profession and the clergy have to do with the past. We do not always appreciate the splendid possibilities of medicine to society.

All terrestrial and celestial conditions, from a toothache to a planetary cycle have been discussed during the year.