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or obliquely about the stomach, as would appear necessary because of its bulging form in some directions. mucous and muscular layers, there extends Between the a network of vessels and nerves to supply nourishment and innervation, and to remove waste products. Surrounding all, upon the outside, is the serous covering called the peritoneum. It is a slippery lubricated surface permitting the ready sliding of contiguous portions upon one another.

The mucous lining of the stomach is so modified that it pours out an acid secretion containing digestive ferments that are active in an acid medium. The gut below it is again modified so that its juices are alkaline, and its ferments active in an alkaline medium. Here the mucous membrane is alternately indented with follicles, named after Lieberkühn, and minute projecting filaments, called villi, for the absorption of digested food. Further down in the small gut are patches of small ductless glands of a lymphoid nature, while thruout the entire small canal are to be found many of these glands by themselves. The former are designated agminated and the latter solitary. (These are ulcerated in typhoid fever.) The large gut has a simpler mucous lining with very little digestive function, tho it absorbs quite readily. Its caliber is much greater than that of the small gut, and its lengthwise fibers are arranged in three bands that prevent elongation of the gut where they are attached, but without preventing it in the intermediate sections, thus causing a peculiar multiple pouching. It must not be forgotten that in the passage of the large gut, or colon, around the belly, it presents several places that invite trouble on slight provocation. One of these is at the hepatic flexure, where it makes a sharp turn under and behind the liver. Here

fecal matter must be forced around, for it has both a sharp bend and the pressure of the liver to overcome. A similar state prevails upon the other side at the splenic flexure, tho not so marked. Then there is the loose and convoluted flexure called the sigmoid in the left groin that offers a decided impediment to the final passage of the stool into the rectum. When this is free, long, and composed of two or more loops, it is apt to become twisted and cause intestinal obstruction. rectum we approach the region of piles, of Finally, in the cancer, of fissure, of fistula, and of ulcers and condylomata.

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found the liver, with no business to be Under the ribs upon the right, is to be edges of the ribs. I will not say just how anything but the least little bit below the much, for no one can say exactly because no one knows, tho it is not much, say half times so discreet as to remain entirely an inch or an inch, and yet it is somehidden above the margins of the costal cartilages. It extends up under the lung to near the level of the right nipple, and is the well-known site of the soreness of the habitual drunkard as the result of chronic interstitial inflammation due to the constant connective tissue irritation of alcohol. Upon the other side, under the ribs on the left, is to be found the spleen, or I should say is not to be found the spleen, for when this organ is normal, enough to be practically undiscoverable it is so modest as to keep out of the way without much trouble. Between the spleen and liver, and away back behind the stomach, is the pancreas, quite safe from the explorations of the curious medical examiner.

After this brief resumé, we are in better condition to consider some of the symptoms of the digestive tract. reader is earnestly advised to brush up But the part in a couple of good and recent texton the anatomy and physiology of this books before going on with the subject, so that he may get the most out of it.

The Tongue.

The tongue has, with much propriety,
been called the index of the alimentary
canal because, as it happened to be, so also
siderable extent this is undoubtedly true.
was the stomach and the gut. To a con-
upon the tongue by an enthusiastic prac-
I once saw a diagram illustrating a paper
titioner, who had the organ marked off
into not less than twenty areas, certain
ways indicated a certain corresponding
conditions of any of which, he insisted, al-
particular space.
state in the organ that monopolized that
This was, of course, an
believe, as I shall attempt to show later
absurd extreme. I have every reason to
that bear no relation whatever to the state
on, that there are coatings of the tongue
of the alimentary tract.

The normal tongue should be clean, red,
moist and firm, and steady when pro-
truded.
truded. It edges must be smooth, or at
least firm. When protruded, it must be in
the median line. Deviations from the nor-
mal, as here outlined, all have their signi-

ficance, many of which we do not understand, tho attributing to them meanings for which there is no good warrant.

The coated tongue may, in a general way, be said to indicate a congestive or subinflammatory state, generally of the gastro-enteric tract. The coating may be due to decaying teeth or the presence of decomposing animal matter between teeth that are not cleaned or receive insufficient attention. It may denote congestive trouble in the stomach or gut. If the trouble is in the large gut, constipation is the usual cause of the coating. În treating such a condition it must not be forgotten that many cases of constipation have daily stools. And one may ever be assured in the best of good faith that the stools are perfectly satisfactory, tho they are not. This is because long habituation to deficient evacuations has so accustomed the patient to believe a deficient stool to be ample that his judgment is not to be trusted. A brisk purge, say of calomel in divided doses, followed with a saline, can do no harm and will educate the patient into the recognition of a thoro stool and its good effects. Some cases even have two or more daily stools of a diarrheal character tho suffering with constipation. These are caused by the necessity of liquefaction of the feces to insure their passage out of the gut between the hardened shell of dry fecal matter lining the walls of the large gut. In these cases a good, brisk purge on alternate days for a week will clear out the obstructions and restore normal conditions.

A dry coating indicates a lack of secretion in the enteric tract. Such conditions are almost always benefited by small doses of ipecac, say 1-12 grain every four hours. If the coating is brown it usually indicates a torpid liver, and calomel or podophyllin may be given in 1-10-grain doses every hour for one day. A heavy coating, especially if white, usually implies recent trouble, and that of an active kind. Most of the time it will be found associated with some febrile disturbance, due to disease of some remote organ, as a pneumonitis. The longer the affection continues, the more does the whiteness disappear, to be replaced by a dirty yellow and eventually a brown.

A very moist tongue signifies a catarrhal condition, and most often one of some previous duration, a chronic catarrhal condition, almost always limited to the gastroenteric tract. The tongue of chronic gastric

catarrh is always moist, and generally pale and flabby.

It

The pale tongue is a true index of the blood state of the patient. Its color, where it is not coated, is as good an index of the blood state as that of the conjunctiva. often tells one that there is not enough blood circulating in the gastric walls to carry on a healthy digestion, and the patient is bound to go from bad to worse despite a ravenous appetite, because unable to profitably dispose of the food taken in. Such cases require artificial digestants, and well prepared chemical foods, together with an organic preparation of iron, so that the circulatory conditions may be sufficiently improved to enable the patient to again carry on normal digestion, after which recuperation is sure and easy. Inasmuch as the nervous tone always suffers in these states, it is usually advisable to give a good nerve stimulant, and I know of none so good for this purpose as nux vomica. I prefer to give one grain of the extract a day. This is particularly the case in the indented tongue, the one showing the marks of the teeth all along its border. These indentations exist because the tongue is so flabby that it does not fill up the gaps left by the teeth; its circulation is so poor that it pits on pressure, like an edematous leg. If the heart is weak in these conditions, and it generally is, a suitable heart tonic should be given with the nux vomica.

The tremulous tongue is very significant, but is found in many conditions. It, first of all, indicates a relaxed state of the nervous system, unless caused by some local disease of the nervous system; as, for instance, disseminated sclerosis, paralysis agitans, or chorea. Often do we find the general health undermined in these conditions, so that both causes are operative and the tremulousness is intensified. It may be due to hyperexcitability, in which instance the bromids prove very useful. In all weakened states nux vomica is to be used, and when employed it must be in sufficient amount to insure the desired result, even if given until it produces full physiologic effects. I have often gone on with the nux vomica treatment of a debilitated case that had been unsuccessfully treated by some one else with the same remedy, and succeeded only because I used the drug fearlessly in full doses until I had the effect I was after.

The unusually pointed tongue indicates a tension of the nervous system governing

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the gastro-enteric tract. Often it is a bright red at the very tip. This then tells nearly all the story with fair accuracy, for it means that there is inflammatory trouble somewhere. Its location may usually be determined by local tenderness, and if this is not found, the mouth should be carefully looked over with a view of discovering some species of sore mouth or other inflammatory irritation.

A broad and flabby tongue indicates a relaxed condition of the vascular apparatus, even tho the usual tone of the nervous system be preserved. It calls for some arterial corrective. Any of these can be very advantageously reinforced with nux vomica or strychnin in full doses. These tongues are also often observed in neurasthenic cases and in persons suffering with retained excrementitious matter. I do not mean so much retained fecal matter as I do the cases in which the final tissue metabolism and elimination by the cell is deficient.

A deviated tongue is occasionally seen when it has no significance whatever, being merely a personal peculiarity, usually of long standing. Sometimes it is due to a peculiar habit that is rectified the moment attention is called to the anomalous protrusion. But in all other cases it signifies some local disease, such as an ulcer, that it is unconsciously seeking to keep away from some point of irritation, as a jagged tooth; or a contracture on one side of the tongue; or to some central or peripheral nerve trouble causing the deflection either by unusual contraction of the organ on one side, or by paralysis of the muscles of one side, thus giving those of the opposite side the preponderating influence, as in occular deviations due to muscle spasm or paralysis. Under these circumstances it is our first duty to look for some local cause within the mouth, and this failing, along the course of the nerve trunks that supply the tongue muscles, even carrying the investigation up into the brain if necessary. Many a serious ailment may thus be discovered at an early day, admitting, perhaps, of successful treatment that would be impossible at a later time.

The "strawberry" tongue is very familiar as an accompaniment of scarlatina, and is caused by the elevation of the papillæ of the organ above their usual level and in the midst of a white coat. This is due to a marked hyperemia of the glossal mucous membrane, and may indicate a similar

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The beefy tongue looks like a raw piece of beef, whence its name, and implies an inflammatory condition of the tongue itself, or of the stomach or gut. It may safely be regarded as the index of active inflammation. This means that irritating medication must be avoided, and that emollients are acceptable.

The patchy tongue is still a mystery to me other than that it unquestionably indicates slow progress toward recovery. If a patient with a trivial ailment presents himself, and the practitioner notes a coated tongue with irregular clean patches, he may as well make up his mind that the patient is not going to get well so quickly as he otherwise should, and it is well to notify him of this fact so that he do not become impatient at the delay in effecting a cure that you may have lead him to believe would follow in a brief period. He may go to another physician and not fare so well. Often it means that something more serious is coming, and that one would better be prepared for it. Many chronic cases with acute exacerbations are thus marked, when it almost always means that recovery will be slow and that complications may be looked for. I have now in mind the case of a small boy who was for a long time sufferer from rheumatism, having had it from his early childhood. Whenever he had an attack of his usual trouble without the patchy tongue, I was certain that it would not last long, but if it appeared with the patches, I was equally sure that the attack would be prolonged. In his case the sign never failed me after I began to notice it. I may say the same, with very few exceptions, of other cases in a variety of diseases.

In conclusion, I want to say but one more thing upon this subject, and it is with reference to the persistently coated tongue; the tongue that will not clean off for any kind of treatment. I have often cleared a presistently coated tongue with the internal use of turpentine or one of its derivatives, but there are cases that obstinately decline to yield to this or any other of the many vaunted certain cures of the persistently coated tongue. These tongues I find to be invariably due to chronic postnasal or pharyngeal trouble. Relieve this condition and the tongue cleans. In one case the trouble was improved fully fifty per cent. by the mere amputation of a redundant uvula. All yield in proportion

as the local throat trouble gets better. As a rule these cases have a good appetite, and the digestion is not impaired. I may also add that the bowels are regular, and that there is a total absence of the usual symptoms that go with a coated tongue. Philadelphia, Pa. A. H. P. LEUF, M. D. [This article will be continued in subsequent issues. ED.]

Antisepsis in Obstetrics.

Editor MEDICAL WORLD:-I would like the privilege of answering the questions asked by "Reader" on page 392 of September WORLD in regard to the use of antisepsis in obstetric practice, and give him briefly all that I think a country practitioner can very well do, and all that I consider necessary for him to do.

(1) What method of cleansing and disinfecting do you practice for patient and self?

Clip hair from the pubes and have patient take a thoro bath. Roll up your sleeves and wash arms with hot water and soap to elbow; trim nails and clean beneath them well.

(2) Do you employ preliminary irrigation of the vagina? If so, what do you use? What is your practice as to vaginal douches after labor?

Have a douche of hot water given soon after labor begins, and give one soon after it terminates, especially if there are many clots, which should of course be removed.

(3) How about sterilizing patient's garments and bed-linen? Do you ever allow an unsterilized article of body or bed apparel to come in contact with your patient? If not, how do you sterilize them steam, dry heat or boiling?

Instruct them to have clean gown and bed-linen.

(4) Is it the opinion of any of the WORLD readers that many of these "antiseptic precautions" are elaborated and taught simply to satisfy a popular demand? Do any of you dare to think that possibly the antiseptic pendulum has swung a little past the center of gravity, and is imminently liable to come swinging back one of these fine mornings?

Yes, the antiseptic pendulum has swung not a little, but far beyond the center of gravity, and is bound to swing back, but unlike many other "fads" when it returns I do not think it will cross the meridian, but will stop and be firmly held there by the great sheet anchor asepsis. In my opinion, if we practice asensis in our obstet

ric cases, we will have little need for antiseptics. I do not wish to be understood as being opposed to the use of antiseptics, for I consider them most valuable agents in both obstetric and surgical practice, where we have infection, but as being quite unnecessary and many times harmful where we have clean wounds to treat, which is usually the case after delivery. I have seen many such cases as "Reader" describes among the negroes of our southern country and in my experience septic infection has been very rare. I consider the hands of the accoucheur by far the gravest source of infection, and if he practices cleanliness his patients will do well, even with bad hygienic surroundings. Carlowville, Ala. SAMUEL B. ALISON.

Antiseptic Midwifery.

Editor MEDICAL WORLD:-In answer to 1: article on Antiseptic Midwifery, page 392 September WORLD, my plan is as follows: Clean all dirt from under finger nails, wash hand and arm to elbow with soap and water, scrubbing the fingers well. Then rinse the limb in clear water, then soak hand in a solution of permanganate of potassium. Do not use lard to anoint finger as it is not aseptic; if you have no aseptic ointment, use nothing. See that all clothes under the woman are perfectly clean or the best they have on the place.

As a general rule, among the poor-class of people, they will fish up some old quilt or dress skirt out of the dirty clothes barrel, which probably the cats have had for a bed, and place this under the woman to catch the blood and water, in order to keep from soiling something they call good. In such cases I call for the best or cleanest sheet on the place and explain to them the danger of such dirty garments causing child-bed fever, and they soon "catch on" and learn to prepare the bed as clean as anybody. as anybody. I never wash out the vagina before labor unless I should suspect a previous_gonorrhea in husband or mother, and I never wash out the vagina after labor unless I have had a severe case and have had to use instruments or have had hand in the passage.

I never had a case of child-bed fever in my ten years' practice, and I have had a liberal obstetric practice. I consider cleanliness next if not superior to godliness in these cases.

Cornelia, Mo. J. T. ANDERSON, M.D.

WORLD one year and Dr. Waugh's book, $5. You need them

Lard for Strychnin Poisoning. Editor MEDICAL WORLD:-I have just read Dr. Turner's new antidote for strychnin poisoning, and will say that lard has been used as an antidote for strychnin many years in the West. We aim to get down about one pint, and we are sure of a cure. Nothing new about that. A. E. VAN DEVENTER.

Oswego, Ill.

Gynecologic Practice in Thinly-Settled
Districts.

Editor MEDICAL WORLD:-Following the suggestion presented by THE WORLD Some years ago, I have tried to "perfect" myself in one department of my professiongynecology-and now come forward to report success and failures, and seek further light. I have met the conditions prevailing in a country location-in a village and now in a live town of between one and two thousand people-and in all these places find much work to do and more that ought to be done. The sources of discouragement are numerous, and first comes from the brother practitioner in his apparent lack of interest in gynecologic

cases.

Few, very few, doctors have an office at all in these small towns, and when one is found it is scarcely fitted for respectable patients of this class, and no special apparatus. It is extremely difficult for the general practitioner in such places to keep regular office hours, and hence we find him discouraging nearly all office work. He teaches his patients to rather send for him, even for trivial complaints, and thus the doctor must attempt his work at the homes with no apparatus, the loss of much time, and then necessarily do inferior work, with its results.

I have always tried to have an office, and find that it pays. I am now fixing up my best front room on second floor of my home, which is within 200 yards of the main business street. Have a good north and east light, back and front entrance. I am trying to persuade all cases able to travel to come to my office, but it is up-hill work. I am succeeding in a measure, however. I find many difficult problems to solve.

I am particularly anxious to learn the methods of other general practitioners who, in similar locations, have made a success of gynecology. How do you furnish your office? How do you arrange office hours? How do you get all who can

How do you

travel to come to the office? manage about assistance (non-medical) which is often needed? What is the cheapest, most efficient douche apparatus for very poor patients? I find many unable to purchase the rubber syringes.

I recently took a special course in gynecology at one of the large medical centres, and visited others, but saw chiefly operative cases, while most of our cases are non-operative. Now, brethren, write and help me to do the best possible work for this numerous class of patients. Seneca, S. C.

E. A. HINES, M.D.

Placenta Previa.

Editor MEDICAL WORLD:-May 29, 1898, I was called to see E. B., aged 37. She told me she had had eight children, youngest nearly three years old, and at present she was 8 months pregnant, had had floodings at intervals for two months. They came on sometimes when she was very quiet, and not expecting them. She had had feelings of fulness in the womb and slight pains. After hemorrhage she would feel free from pain and distention for several hours. The flooding would be violent for several hours, then slowly cease. thought she lost 1 pints or more at a time, and was beginning to feel very weak. She appeared anemic, and had a weak and thready pulse. The temperature slightly below normal.

She

was

I at once diagnosed placenta previa, and further digital examination confirmed my opinion and showed head presenting. The flow at this time was slight and tannic acid applied locally arrested it, temporarily. I ordered her to be kept quiet, tannin to be applied at once if hemorrhage recurred, foot of bed elevated, etc., and if the hemorrhage was excessively violent an application of iron persulphate solution to be applied, this being ready for use, and that a physician be sent for immediately.

Two days later I was called in a hurry, and found she had just had a violent hemorrhage, having lost probably 1 pints of blood and it was continuing. Had foot of bed elevated (also the hips of the woman) examined and found flow continuous, os slightly dilated, vertex presenting no pains, and placenta felt in front and to left side of body of womb. I applied five grains tannic acid to the neck of the womb and began giving fluid extract ergot in one-half dram doses every half-hour. The flow became less in two hours. After three hours" further delay, watching that the flow should

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