SURGICAL SIGN LANGUAGE. SAFETYPIN DEVICE FOR DROP METHOD IN ETHER ANESTHESIA. By F. Griffith, M.D. During the past holidays the writer was a frequent visitor to the clinic in Philadelphia of his old teacher in surgical anatomy, Dr. John Deaver; two things struck him forcibly after continued view of the technique of this master surgeon. One was their heads for more silent uses; muffled tones from a gauze mask is no less likely to the master's wants. The less palaver once an operation is commenced the better for the patient and all concerned. Other things equal, the surgeon of fewest words shows greatest skill. Those who can recollect the craftmanship of Dr. William Bull may recall that marvelously swift, deft sidehold fingering way he had of unfastening hæmostatic forceps from body tissue, this but one of the masterly motions in his per the constant use of signs by the operator in place of tongue speech to make known his wants to the assistants: An elbow wigwags, eloquent call for gauze pad; a short-pull hand movement is enough for these wideawake helpers to cause a retractor to be quickly fetched; a rotary motion of the chief's hand means catgut. Seldom is the command passed by word of mouth after the patient's belly cavity is opened. Those more or less excitable wielders of the knife we see with tendency to splutter, fret and fume whilst engaged exploring the nethermost depths contiguous to the foramen of Winslow might see herein a brave suggestion, learning to thus employ some simple signs might so much the better keep fected technique, and Dr. Bull likewise spoke but seldom when operating. Any atbe misinterpreted, besides an educated elbow ejects no salivary spray over an open wound space when it speaks to tell tentive observer could learn this surgical sign language and could "make it go" in the operating room as successfully as a signal sailorman sends orders from a dreadnaught's bridge, or a Sioux stranger can tell his story. General anesthesia as observed by the writer was confined to ether and given by the drop method on the open face cloth. By means of an ordinary safety pin having its point stuck through the circumference of the soft tin cap of the smaller sized History-Diabetes is one of the oldest diseases known, being referred to by the Roman Celsus and the Greek Aretæus, both of whom lived in the first century of the Christian Era; also by the early East Indian physicians as a condition characterized by copious secretion of urine, extreme thirst, and emaciation. However, little, if anything, was added to the subject until the latter part of the seventeenth century, when Thomas Willis (1622-75) in England first inferred from its sweetness the presence of sugar in the urine; but, it was not until a century later (1775) that Matthew Dobson, an Englishman, actually obtained sugar from urine. Since that time there is perhaps no subject in medicine to which has been contributed so much knowledge, from an experimental side, as diabetes, and yet no subject, as to the true pathology and etiology of which we possess proportionately less accurate information. Definition-Diabetes is a chronic metabolic disorder in which sugar is excreted continuously in larger or smaller quantities in the urine and is also present in the blood; the amount of urine is greatly increased and the patient suffers from excessive thirst, sometimes bulimia, and progressive emaciation. Geographical and Racial Distribution— Diabetes is less common in the United States than in Europe. According to re ports of the U. S. Census,* in 1950 the death rate was 72 per 100,000; in 1860 it rose to 98 per 100,000; in 1870 it increased to 170 per 100,000; in 1880 to 198 per 100,000 and in 1890 it had increased to 450 per 100,000. It is thought to be more prevalent in agricultural countries than in cities. The disease is common in Sweden, Italy, India and Ceylon, and rare in Holland, Russia and Brazil. It is more frequent among the Hebrews than Christians possibly because they are essentially dyspeptic -from high living. It is generally the disease of the rich and well-to-do classes, though the poor are not exempt. Pathology-Notwithstanding the immense amount of research done in connection with diabetes the only definite pathology, so far as is known to-day, is a sclerosis or degeneration of the islands of Langerhans in the pancreas. The liver is often congested cirrhotic, or the seat of degeneration. The stomach is dilated and marked catarrhal changes from excessive ingestion of food, is present. The kidneys. will be found in a state of hyperæmia. The heart is often affected with a fibrous or fatty interstitial myocarditis. The brain may be congested. Odematous changes have been observed in the posterior columns of the cord. The lungs may present advanced tuberculous changes. The skin is rarely the seat of pigmentation, and bronzed diabetes is a late manifestation due to the action of toxic material upon the liver cells which transforms the blood-pigment into insoluble haemosiderin. This pigmentation is also found in the pancreas, lymphatic glands, secreting glands, intestines, heart-muscles and skin. Etiology-The disease is more common in males than females, and is most frequently seen between thirty and sixty, although it may be seen in infancy. According to Von Noorden we have to deal with the following anomalies of function: 1. Defective oxidation of carbohydrates. He also avers the cause of diabetes is a disturbed metabolic process wherein the hepatic cell is incapable of fixing the carbohydrate intake. This defective function, in the diabetic permits of a wasting from the sugar store-house, leading to toxic glycosuria, which is primarily due to overstimulation of the adrenalin system, the excessive functional activity, which increased oxidation produces, gives rise to an inordinate production of an agency that converts glycogen into sugar. According to Sajous, this agency is the amylotic ferment produced by the pancreas. The liver cells being the sugar factories and the storehouse of energy, for the human economy, regulate the supply and demand of sugar in health. This special protection, for the prevention of an excessive flow of sugar into the blood stream after a large meal of carbohydrates, is known as the "glycogenic function," which takes up the sugar and stores it in cells where it is instantly changed into an insoluble form as "glycogen." This glycogen is a reserve material. Symptoms-One of the first symptoms noticed by the patient is an excessive passage of urine, light in color, sweetish in odor, and taste, and of high specific gravity. Such urine contains glucose in varying quantities, and perhaps albumin. Excessive thirst will be present, due to the increased elimination of fluids through the kidneys, and the appetite may be inordinately increased. There will be dryness of the fauces and a glutinous viscid saliva will annoy the patient. Itching of the skin, especially the vulva in women, and the prepuce in men, due to frequent urination, is common. The hair and nails are brittle, but rarely lost. The breath is noticeable from its sweetish odor, symptoms of indigestion are common; bowels usually constipated, but diarrhoea. may supervene. Emaciation is frequently marked and patients will complain of languor and bodily weakness. The temperature of the body is not increased, though late in the disease it may be lowered. The lungs are frequently the seat of chronic catarrhal conditions and when the powers of resistance are very much lowered tuberculosis may be a complication. The skin early in the disease may be the seat of boils; and carbuncles may be a late complication. Dryness and harshness of the skin is noticeable early. Diabetic gangrene is a complication not infrequentiy met with. It begins in the extremities, usually the toes, and is frequently due to traumatism but may appear spontaneously from chronic proliferative endarteritis. Diabetic coma is a serious symptom in the later stages and often results in death. The blood contains glucose; and the red cells and haemoglobin are both reduced. The saliva and perspiration as well as the transudates and exudates of diabetic patients, all contain sugar. The urine is increased in an amount varying from four to five pints to as many gallons. It is of high specific gravity ranging from 1020 to 1050, rarely as low as 1015, it contains sugar varying from two to ten per cent., total output in twenty-four hours ranging from ten ounces to a pound or more. The urine also contains other forms of sugar, as levulous and inosite. The urea is increased but uric acid may be greate or less than normal. Sometimes it may be noticed that a drop of urine falling upon the boots or clothing and evaporating leaves a persistent white or yellowish spot due to sugar. Complications-Diabetes is a disease which is especially prone to complications. There is scarcely another chronic condition which is associated with so many forms of complications, or which is such a hindrance to the favorable issue of occasional complications; yet there is not another which admits of being influenced so favorably, in this regard, as does diabetes mellitus. Complications are easily controlled if we can keep the urine free from sugar or the percentage very low. The most formidable complications are diabetes coma, peripheral neuritis, arterio-sclerosis, diabetic-auto-intoxication, granular kidney, and pyperglycemia. Prognosis-This varies with the type of the disease, the age of the patient and the length of time the disease has existed without proper treatment. The form of diabetes resulting from disease of the central nervous system, and that due to permanent sclerotic changes in the islands of Langerhans are hopeless as regards cure but not as regards improvement. More than fifty per cent. of cases of diabetes, according to Opie, indicate that the important pathologic lesions are those affecting the islands of Langerhans. The pancreatic gland and adrenalin system fulfil the same function in the human economy that the governor does to the steam engine, both act as controllers. The islands of Langerhans in the pancreas liberate the active internal pancreatic secretion which equalizes sugar production, to sugar requirements: when these islands are atrophied or the gland removed the control no longer exists and the blood and urine is flooded with sugar. Diagnosis-Diabetes is distinguishable by means of (1) its casual influences and its pathological antecedents and relations (2) its gradual onset, debility impotence, symmetrical sciatica, cataract, furunculosis: (3) persistent presence of glycosuria, polypuria and later, acetonuria and albuminuria (4) inordinate thirst and appetite (5) cutaneous boils, carbuncles pruritis vulva, and balinitis: (6) neuritis, diabetic tabes, and coma: the passage of enormous quantities of urine: (7) rapid emacition, granular kidney and progressive asthenia. Treatment-In the diabetic patient the sugar factory is in such a state of excitability that every stimulus calls forth an unduly intense reaction leading to an excessive formation of sugar. The deduction, therefore, so far as treatment is concerned, is to obtain rest for the overstimulated organ, to decrease the overweighting of the sugar regulating factors to a minimum, and to spare the sugar producing organs as much as possible. This can be accomplished by careful attention to the patient's dietary. Dieto-therapy offers the greatest and most rational promise of relief or cure, and is by far the sheet anchor in the treatment of diabetes, and is more efficient than any drug or combination of drugs and no permanent results have ever been obtained without dietetic supervision. Unfortunately pharmacology has not provided any drug which acts directly upon the excitability of the sugar forming process of the liver All authorities agree that the diabetic wastes away and starves to death from consuming his own tissues through the impaired con dition of the "glycogenic function" of his liver. Heretofore the trouble, in the successful management of diabetes has been that the patient could not assimilate foods containing corbohydrates in the form of starch as it appears in the ordinary food products, and by eliminating the starch from the products their value as a sustaining food is completely destroyed. All the working cells of the body use sugars as their food-stuffs and immediate sources of energy, whicn if not supplied from the food ingested, must be taken out of the tissues, and in the patient suffering from diabetes the waste of the body is more than the intake of food into the system. Von Noorden and other eminent authorities all agree that the best food for the diabetic is the food containing the greatest amount of carbohydrates they can tolerate, because in the carbohydrates is contained the greatest proportion of calories, or heat units which go to make up the energy of life. Realizing that the deduction of Prof. Von Noorden was correct, and while cherishing the unsanguinary hope that his ideals would eventually be realized, it was by a mere coincidence that I had brought to my attention the virtues of a carbohydrate food which a diabetic could ingest with impunity. A patient of mine and his wife, both long sufferers from diabetes, went to New York where they consulted Dr. S. Leroy Satterlee, who with the advice of Prof. W. H. Thompson ordered for my patients a new starch-treated product known as the Jireh Diabetic Foods. When my patients returned, after a three months' stay in the North—all the while eating the starch-treated foods-I was amazed, but agreeably surprised at the remarkable improvement in both patients, which continues after the lapse of a year's time. Health, strength and weight gradually increased on these foods together with eggs and other suitable diet. The sugar slowly disappeared from the urine, only traces now being present. All the disagreeable annoying symptoms have gradually subsided and while the patients are not cured yet, they have a new lease on life and are en joying an existence which otherwise would be intolerable. With the proof of the virtue and value of these starch-treated foods before me, I began an investigation or research into the subject of diabetes, more particularly to ascertain the real therapeutic value of the foods in the dietetic treatment of this malady which I record herewith. The Jireh Food Products contain all the starch originally found in the wheat berry when harvested. They differ from what are known as gluten and proteid foods, because: 1. The wheat from which these starch treated foods are manufactured is ground on the old-fashioned burr millstone of our forefathers. (The upper revolving stone is called the runner, the lower remains at rest, the bed, or the reverse.) 2. Being made from the whole grain it is positively an entire wheat flour. The shuck or shell-bran-being as finely ground as the heart of the grain. 3. In their manufacture the carbohydrates are changed but not eliminated. The change is slight but effective. 4. The change is such as to facilitate the oxidation of glucose and to convert it into energy. 5. They are palatably delicious in contradistinction to the insipid devitalized gluten and proteid foods. 6. They contain all the natural mineral constituents of the wheat berry so necessary to the vitality of the human economy. 7. The starch is not changed into indigestible dextrine or glucose. 8. No chemicals are employed in the treatment of the starch. 9. They are high in food value. 110. They are physiologically correct. Starch-Treated Foods. Each starch granule in cereal food products is inclosed in a tough envelope that the process of grinding does not break. To render these easy of digestion, without the formation of sugar in the diabetic is the secret of the Jireh foods. These granules are thoroughly broken up by diathermous fermentation resulting from the addition of certain digestive enzymes to the flour, which after thorough trituration is subjected to a certain degree of heat applied by especially constructed machinery designed for this particular purpose. The addition of enzymes to the wholewheat-flour followed by scientific application of heat causes a commingling of the carbohydrates and nitrogen molecules of the starch granules of the wheat berry, which results in a very slight fermentation leading to a division and expansion after ingestion, and to final disintegration in the small intestine. Insoluble Starches act as poison to the diabetic passing through the kidneys: as glucose, unoxidized and unappropriated. In the modern up-to-date flour mills of our country the wheat berry is subjected to a new process of grinding—or more properly crushing where it is passed between massive steel rollers (hence the term "patent roller flour") being crushed into an exceedingly fine state of pulverization and in the refining process of bolting and bleaching practically all the mineral constituents are extracted and very little of the life giving essentials left for human consumption except a dry white starchy product, which nature's process of digestion is incapable of changing, so that it can contribute heat and energy to the human econ omy. White-wheat-bread made from "patent roller flour" which has been refined or bleached by electricity or other damaging process has the least food value of any bread known to man. The average grain of wheat contains *.75% of mineral salts. The finest patent roller flour contains only 0.44% of mineral salts, one-fourth of the quantity contained in whole wheat. Unfortunately the manufacturers of foods are tending to the isolation and extraction of the chemical constituents, so that our modern methods of refining, and purifying, instead of improving the foods which nature furni-hes, actually deprive them of most of their real food value, and in many instances converting them into poisons in the human economy. Before the present process of refining, bolting and bleaching, flour became common, there were few cases of diabetes in either men or women, but of late years, |