Selected Articles

THE DIAGNOSIS OF PREGNANCY

The sugar tolerance test was applied by G. C. Milnor and E. A. Fennel, Honolulu, T. H. (Journal A. M. A., Feb. 16, 1924), in cases in which it was important to make a diagnosis concerning pregnancy before the physical signs permitted. Excluding cases of hepatic disease, carcinoma of the alimentary tract and hyperthyroidism, they have performed this test on thirty-eight normal women, either pregnant or nonpregnant. Of the thirty-eight women, eighteen proved, in the course of events, to have been not pregnant, sixteen proved to be pregnant, and four were lost to further observation. Of the eighteen nonpregnant women, seventeen gave a negativę test, i.e., developed no glycosuria and one gave a doubtful reaction. Of the sixteen women proved to be pregnant fifteen gave positive reactions and one a negative one. This failure is interesting since the test was performed ten days after the first coitus and five days after the first missed menstrual period. The authors' experience with phlorizin has been disappointing. In seven cases of proved pregnancy five gave positive reactions and two very doubtful ones. Of twelve nonpregnant cases including three men all gave positive reactions except two women. In making the simple sugar tolerance test they use from 50 to 100gm. of glucose depending on the weight of the patient. The blood sugar at the forty-five minute period is the most important of the three estimations; the other two may be omitted if time and circumstance demand it. The authors found that nausea or vomiting if present in the pregnant patients, rather regularly occurs at the forty-five minute period, at the height of the blood sugar curve. They have found that the sugar tolerance test is of great practical value during the first three months of pregnancy, and that the positive reaction usually disappears thereafter, but frequently reappears during the last two months and persists several weeks after parturition. A large meal, rich in carbohydrates. may be substituted for the glucose. In two cases of suspected

abortion, the test has been positive and the histologic examination of curettings has discovered syncytial and decidual cells. The assumption that in pregnancy the permeability of the kidney cells, per se, is increased, the authors believe to be unwarranted. It is, however, on such a basis that the rationale of the phlorizin test is based. It seems to them more reasonable to postulate, in pregnancy, an imbalance in the internal secretory mechanism in this newly acquired physiologic state, and again in the later stages, preceding lactation. Such disturbances of internal secretion might well be looked for in the ovary, liver, thyroid and pancreas. It seems more reasonable to suppose that the mobilization of carbohydrates in liver and muscles is disturbed, and that the addition of an insult of 100 gm. of glucose rapidly brings the blood sugar content to the point of intolerance. The conservative mechanism then permits an overflow of sugar into the urine and frequently a disgorging of the remainder of the excess in the stomach.

POST-OPERATIVE ROUTINE AT NEW YORK POSTGRADUATE HOSPITAL

In a recent article Dr. Jerome Selinger (of the service of Dr. Charles Gordon Heyd), gives important features of post-operative routine followed at the Post-Graduate Hospital, New York. These points bear especially upon the nursing service:

Post-operative treatment begins in the operating room. The strips of adhesive plaster applied to the patient's abdomen should be shingled from below upward, thus preventing vomitus or other fluid from coming in contact with the wound and infecting it. Each successive strip of adhesive should be applied a trifle more loosely than the preceding strip, thus allowing a moderate amount of distention without discomfort. The gauze over the wound should be completely covered with adhesive plaster. If the patient's shirt is wet with blood, perspiration, or other fluid, it should be changed for a dry, warm one before he leaves the operating room. He should then be lifted carefully on to a wheel stretcher and surrounded with several hot blankets before being rolled into the draughty corridors of the hospital. These two latter details will undoubtedly reduce the number of post-operative pulmonary complications. While the patient is being operated upon it is a

good plan to warm his bed thoroughly, thus eliminating any sudden change of temperature.

Generally speaking, every laparotomy case receives the following post-operative orders, the execution of which is begun immediately:

(1) Morphine, grs. 1/5, when necessary (size of dose depending upon the age and size of the patient), followed by grs. 1/6 every four hours when necessary; (2) Absolutely nothing by mouth (including water) for twenty-four hours; (3) Continuous Murphy proctoclysis; (4) Moderate Fowler position.

MORPHINE.

We believe that every post-operative patient suffering with pain, and they all do, is entitled to relief. Nothing gives this relief so quickly and so satisfactorily as morphine. Therefore. we give it in its physiological dose for both pain and restlessness. If it is necessary to repeat it, and it generally is, we give a reduced dose to be repeated every four hours when necessary. The chief objections to this drug are that it reduces secretions and excretions and that it causes distention. This affects the urine in particular and frequently necessitates subsequent catheterization. But we prefer to catheterize a patient several times, if necessary, rather than to allow him to suffer unrelieved pain. A very essential point in connection with the use of morphine is to discontinue its use absolutely at the end of twenty-four or thirty-six hours. In a majority of cases no narcotic or sedative is necessary after the second night, and we feel that it is bad practice to continue its use after this time. However, if a sedative is necessary after thirty-six hours, we resort to the use of the bromides, choral hydrate, luminal, or some drug other than an opiate. The reasons for this are numerous and obvious.

NOTHING BY MOUTH,

It is understood by those who have the patient in charge that if at the end of several hours he is not vomiting, he may be allowed ordinary tap water in teaspoonful doses at frequent intervals, the amount gradually being increased. To give water immediately is, we believe, to invite vomiting, and it is frequently easier to prevent it than to stop it. If the patient is not dehydrated before or during the operation he will not crave water immediately upon regaining his con

sciousness. If morphine is given at this moment he will probably go off to sleep and forget his thirst. Furthermore, if the Murphy protoclysis is started at the proper time it will greatly aid in the alleviation of this symptom.

MURPHY PROTOCLYSIS.

I know of no single contribution to post-operative or preoperative treatment equal in value to the Murphy protoclysis. This way of supplying the patient with both food and fluid, in addition to combating any tendency to acidosis, is the method par excellence. The routine Murphy drip at the PostGraduate Hospital contains 1,000 cc. of tap water, plus 10 per cent. (100 grams) of commercial glucose, plus 2 per cent. (20 grams) of sodium bicarbonate. (Glucose, being a simple sugar with a high caloric value, is readily absorbed and furnishes nourishment. Sodium bicarbonate is an added measure against acidosis and the tap water furnishes fluids to allay thirst.) This is heated to a temperature of 120° Fahrenheit and placed in an irrigating can from which it is allowed to flow one drop at a time. The rubber tubing through which it flows is passed between two water bags which lie at the foot of the patient's bed. This will, to a degree, restore some of the heat of the fluid that has been lost enroute. There are other methods of keeping the fluid warm, viz., surrounding the can with hot water bags, inserting a quart milk bottle containing boiling water into the can, the various patented vacuum bottles, or inserting a sixteen-candle power incandescent lamp into the can. These latter methods are probably superior to the first one mentioned. (With hot water bags in the patient's bed the danger of a burn must ever be kept in mind.) To the end of the tube is attached a number 32 French catheter or a straight or a curved hard rubber tip. This is inserted not more than two inches into the rectum and allowed to remain. The rate at which the fluid is allowed to flow is varied with the individual patient. Forty drops per minute is ordinarily satisfactory. If the patient does not retain and absorb the fluid, then the fault is not with him, but rather with the fluid or with the method of administration. The can may be hanging too high and the pressure may, therefore, be too hot or too cold, or the tip may be inserted too far into the rectum. Every individual will absorb fluid by rectum, and failure to do so should be the signal for the physi cian to find the fault with the apparatus rather than with the

patient. Under certain conditions, and with proper care and attention, I have seen patients absorb fluids to the amount of ten quarts, given continuously over a period of forty-eight hours. Ordinarily, however, this is excessive, and after the patient has absorbed one quart it is wise to wait an hour before starting a second one. Under these conditions three quarts can very easily be absorbed in twenty-four hours. Contrary to what one might expect, the rectal tip is borne with comfort and is not irritating.

In the recent past frequent mention has been made of the incorporation of tincture of digitalis on the Murphy protoclysis. We have seen no particular advantage in the use of digitalis by rectum. In fact, there have been with its use several cases of severe distention which is entirely contrary to our usual experience without the use of this drug.

FOWLER POSITION.

This is obtained by raising the head of the bed from four to ten inches. The less active the peritoneum the less the absorption, and vice versa. We know that the pelvic peritoneum is the least active and, therefore, the least absorptive. The diaphragmatic peritoneum moves with each inspiration and each expiration, is the most active, and, therefore, the most absorptive. By elevating the head of the bed, any free fluid in the abdominal cavity will tend to gravitate toward the pelvis, where it will be slowly absorbed. If an elevation of more than eight inches is required it will be necessary to place a pillow under the patient's popliteal spaces. If this is not done he will slide down toward the foot of the bed and be most uncomfortable. Modern hospitals are well supplied with Gatch beds, which have a spring that is hinged in two places. This makes it possible to flex a patient at his hip and knees and is more satisfactory and more comfortable than the original Fowler position.

NAUSEA AND VOMITING.

Usually, after vomiting several times, the patient will be able to retain small quantities of water by mouth, and this unpleasant symptom then disappears. Not infrequently, however, considerable difficulty is experienced before a patient can be made to stop vomiting. If he has vomited several times and he continues to "spit up" small quantities of bile-stained fluid, then steps should be taken to empty his