Part 13

With roast beef, grated horseradish. With roast veal, tomato or horseradish sauce. Roast mutton, currant jelly. Roast pork, apple sauce. Roast lamb, mint sauce. Roast turkey, chestnut dressing, cranberry jelly. Roast venison, black currant jelly or grape jelly. Roast goose, tart apple sauce. Roast quail, currant jelly, celery sauce. Roast canvasback duck, apple bread, black currant jelly. Roast chicken, bread sauce. Fried chicken, cream gravy, corn fritters. Roast duck, orange salad. Roast ptarmigan, bread sauce. Cold boiled tongue, sauce tartare or olives stuffed with peppers. Veal sausage, tomato sauce, grated parmesan cheese. Pork sausage, tart apple sauce or fried apples. Frizzled beef, horseradish. Pork croquettes, tomato sauce. Corned beef, mustard. Lobster cutlet, sauce tartare. Sweetbread cutlet, sauce bechamel. Reed birds, fried hominy, white celery. Cold boiled fish, sauce piquant. Broiled steak, maitre d’hotel butter or mushrooms. Tripe, fried bacon and apple rings. Broiled fresh mackerel, stewed gooseberries. Fresh salmon, cream sauce and green peas. Cream sauce with sweetbreads. Orange salad with roast chicken. Celery sauce with quail. Stuffed olives with fish balls. Horseradish sauce with boiled beef. Horseradish and fried onions with liver. French dressing with sardines. Mint sauce with lamb. Yorkshire pudding with roast beef. Hard-boiled eggs and parsley with boiled salmon. Cream gravy, strawberry preserves with fried chicken. Oyster dressing for turkey. Celery and onion dressing with roast duck. Tart grape jelly with canvasback duck. Currant jelly with roast goose. Cucumber catsup with corned beef.

FOOD AND NUTRITION IN DISEASE.

A physician, writing to the _New York Medical Journal_, says the chemical composition of the body is quite similar to the composition of the foods which nourish it. Protein, fats, carbohydrates, mineral salts, and water are the compounds we need in our foods, and they are found in flesh foods and vegetables. Protein, the most important element, is derived principally from meat, eggs, and milk. It is also furnished by some vegetables, as beans, peas, and the gluten of wheat; but in these it is mixed with too much extraneous matter, as husks, bulbs, woody fiber, etc., to be useful in the diet of the sick. Extractives, as beef-tea, are included in the nitrogen compounds, but they neither build tissue nor furnish energy; they are appetizers and stimulants. Animal and vegetable fats are useful; these are found in meat, fish, milk, eggs, some cereals, olives, and nuts. The carbohydrates include sugars, starches, cellulose, and the fibers of plants. Potatoes, sago, farina, and arrowroot are rich in them. Fats should be used with caution in disease, because they retard the formation of hydrochloric acid, which excites the pancreatic secretion, an important factor in digestion. Man can live better without a stomach than without a pancreas. Physicians realize that they must rely on diet rather than drugs to cure indigestion, as the food varies in its proportion of fat, protein, and carbohydrates; the digestive juices are poured out or repressed and altered in strength and quantity.

Milk is not an ideal food for the sick, too large a quantity being required, and the large curds it forms in the stomach often rendering digestion difficult. Boiled with rice it forms an excellent diet.

In acute diseases lasting from four to six weeks no great effort should be made at forced feeding. Thin soups, flooding the stomach with unnutritious fluids, should be avoided. It is unnatural to take food during physical or mental suffering. Appetite is wanting, and imperfect assimilation adds to the physician’s worries and the patient’s discomforts. When there is no appetite the digestive juices are absent. Feed a convalescent when, through conversation about some dainty dish, interest is aroused and saliva is secreted.

DIET-LIST.

=Liquid diet= consists of: Water of all kinds. Cocoa. Ginger ale. Kumiss. Lemonade. Buttermilk. Orangeade. Milk punch. Albumin water. Malted milk. Broths. Milk. Tea. Cream. Coffee. Egg-nog.

=Soft diet= consists of: Liquids of all kinds. Soups (vegetable and strained). Milk toast. Soft-boiled eggs. Gravy “ Oysters. Bread without crusts. Baked apple. Cereals. Apple sauce. Custard. Stewed fruits (no seeds). Rice. Mashed potato. Ice cream. Baked “ Milk puddings. Purées and milk. Plain “ Toast. Soft-poached eggs.

=Light diet= consists of soft diet, including: Whitefish. Quail. Codfish. Sweetbreads. Finnan haddock. Chicken. Bacon. Chops. Scraped-beef. Steak. Squab. Vegetables only when ordered.

=Typhoid diet=, as soon as food is ordered, is as follows: _First week_— Coffee for breakfast. Tea for dinner. Cereals (well cooked and strained). Eggs lightly boiled. Poached eggs and soft toast. Broths (chicken, oyster, and meat). Scraped-beef. Custards. Bread without crust. Ice cream. Milk toast. Orange-juice. A glass of milk, t. i. d. To the foregoing may be added for _Second week_— Dry toast. Chicken. Baked potato. Whitefish. Baked apples. Rice. Asparagus. Farinaceous puddings. Chops. Milk soup. Steak. Purées. No vegetables, pastry, or raw fruits are allowed. _Liquid_— 1. Milk, 3 parts; Lime-water, 1 part. 2. Albumen-water. 3. Clear chicken or beef broth may be given three times in 24 hours.

DIABETIC DIET.

White of eight eggs; Dry oatmeal, ℥xij (by weight); Butter, ℥viij-x.

_Procedure._—Cook oatmeal 2 hours. When done, beat into it the melted butter. Then fold in the beaten whites of eggs.

MOTOR TEST-MEAL.

A. White meat of chicken or fish. B. Coarse vegetables. C. Jam seeds (raisins or currants). D. Potatoes. E. Tea. F. Two slices of bread.

EWALD’S TEST-BREAKFAST.

A. 2 shredded wheat biscuits, or 2 slices of bread. B. 1½ glasses of water.

OBSTETRICS.

=Puberty.=—This is the period of transformation from childhood to adolescence. There is a marked development of the throat and chest, the breasts become fuller, more rounded, and there is also an enlargement of the pelvis. These outward signs are combined with certain internal changes, affecting especially the ovaries and the uterus, that are described under the terms of ovulation and menstruation.

=Ovulation.=—The ovaries produce ova that are retained in cavities termed ovisacs (Graafian follicles), which are scattered throughout the ovary. Sometimes an ovisac contains more than one ovum, but usually each ovisac contains but one. When the ovary becomes functionally active, some of the ovisacs in the deeper part of the organ increase in size and develop toward the surface. From time to time one of these ovisacs, having continued to increase in size so as to form a projection on the surface of the ovary, actually bursts and sets free an ovum. This frequently occurs in association with menstruation, but may take place at other periods. While this development of the ovisac has been taking place there is a special flow of blood to the pelvic contents, and the fringe-like processes of the Fallopian tube become more closely applied, so that a cup is formed by the fimbriated extremity of the Fallopian tube, into which the ovum drops. Eventually the ovum reaches the cavity of the uterus, and, unless it becomes fertilized or impregnated, it is in due course cast off from the uterus in the menstrual discharge and perishes.

When the uterus has become the seat of a fertilized ovum there is no further ripening of ovisacs. After the escape of an ovum from the ovisac the follicle is filled with blood, and this takes part in the formation of a structure known as the corpus luteum, which is formed within the burst ovisac. The corpus luteum varies in its development according as the ovum becomes fertilized or not. If pregnancy takes place it remains to its close, but if the ovum is not fertilized it disappears in about three months. The ruptured ovisac always contains the elements of a corpus luteum, but its development depends on the fate of the ovum. Ovulation has been said to commence before menstruation; ovisacs may sometimes ripen and burst in childhood. Conception may take place before menstruation has set in.

=Menstruation.=—The blood is derived from the mucous membrane of the uterus (endometrium) and not from that of the cervix. The endometrium becomes swollen and thickened prior to the commencement of the flow, and the blood-vessels are distended. With the beginning of the flow this swelling gradually diminishes. A few superficial cells of the endometrium are usually cast off during menstruation, and this is regenerated during the interval between the periods. The mucous membrane of the uterus is thus never at rest until menstruation ceases for good.

=Conception.=—Fertilization of the ovum may occur anywhere in its course from the ovisac to the uterus, but ordinarily it takes place in the uterus. Certain changes take place in the uterus preparatory to the arrival of the fertilized ovum. The whole organ enlarges, it contains more blood than before; the mucous membrane becomes soft, spongy, thickens greatly, and is thrown into folds which are called the decidua vera.

=Decidua Vera.=—The part of the decidua vera to which the ovum becomes attached and where the placenta afterward forms is called the decidua serotina. The presence of the ovum acts as an irritant to the spot where it lodges, and active growth takes place. At the same time the ovum burrows into the mucosa and gradually becomes embedded. The vera closes over the ovum. The decidua vera is a mold of the interior of the uterus. The external surface is rough where it has been torn from the underlying tissues of the uterus, and the internal aspect which is in contact with the ovum is smooth. It is thickest at the third month; after this time the membrane becomes thinner and thinner, until by the end of pregnancy it is very thin. It is to a considerable extent expelled at labor and forms part of the membranes.

=Ovum.=—As the ovum develops the decidua reflexa expands until it fills the decidua vera at the end of the second month, and by the end of the third month it has intimately united with the decidua vera to form one membrane. Until these two membranes have coalesced the ovum is not free in the uterine cavity, but is enclosed in the decidua reflexa.

=Pregnant Uterus.=—As pregnancy proceeds the uterus ceases to be a pelvic organ; it becomes rounded, and after the sixth month gradually assumes an ovoid shape. At the end of the third month it has reached to the brim of the pelvis. By the sixth month it is level with the umbilicus, and by the ninth it has reached to the tip of the sternum. During the last fortnight the organ sinks a little, and this relieves to some extent the shortness of breath which has been caused by the pressure on the diaphragm.

=Fetal Membranes.=—Inside of the decidual membranes we find the chorion and amnion. Whereas the deciduæ are maternal structures, the chorion and the amnion are derived from the ovum. The chorion is the more external of the two fetal membranes; it early surrounds the ovum and throws out processes (villi) toward the decidua reflexa and serotina. These processes are at first formed equally all over the chorion, but those which lie in connection with the decidua serotina grow more rapidly in size and complexity, and remain to form the main part of the placenta. The membrane in which the fetus lies is the amnion. Contained within the amnion is more or less fluid, the liquor amnii, in which the fetus rests as in a water-bed. It permits free movements on the part of the fetus and protects it from violence from the outside; it equalizes the pressure on the uterine walls, preventing pressure on the cord and placenta; and during labor it assists in the dilation of the os uteri and lubricates the maternal passages. From it also the fetus derives its supply of water. Occasionally water may form between the three membranes, and during labor the chorion may rupture and not the amnion, and the waters between them be discharged. In like manner, water which has formed between the decidua and the chorion may come away. These, then, are two sources of fluid which may be discharged from the vagina in labor when the amnion is intact.

=Umbilical Cord.=—The organ by which the fetus is attached to the uterus is a whitish, glistening structure which springs from the fetus at the center of the abdomen, and passes to the internal aspect of the placenta. It contains two arteries and one vein surrounded by a gelatinous material (Wharton’s jelly), the whole being covered with a layer derived from the amnion. The vessels usually run tortuously in the cord, thus lessening the danger of compression, which might otherwise occur. This arrangement also tends to regulate and equalize the circulation of the blood through its vessels.

=Placenta.=—The “after-birth” is a spongy cavernous organ and has a circumference of from 20 to 24 inches. It is made up of two elements, fetal and maternal, chiefly the former. The fetal surface, to which the umbilical cord is attached, is formed by the amnion. External to the latter is the chorionic tissue, consisting mainly of finger-like processes of villi, many of which extend to the decidua. These villi are mostly vascularized. The vascular villus is made of a capillary loop, lying embedded in a connective tissue, the blood-vessels being derived from the umbilical vessels. The villi are surrounded by maternal blood, which circulates in the intervillous spaces. The maternal part is represented by the decidua serotina. Its surface is rough and irregular, being broken up into segments or cotyledons. It is made of two layers: (_a_) The deep or spongy layer, and (_b_) the compact, or layer to which the villi are attached. The decidua serotina contains large cavities or sinuses, which are formed by a dilation of the blood-vessels in the wall of the uterus. They communicate with the intervillous spaces of the placenta, and it is through the maternal blood circulating in them that nutriment is conveyed to the fetus through the medium of the villi. An interchange takes place between the fetal and maternal bloodstreams, though, of course, there is no direct continuity between them. The placenta thus has a two-fold function in acting both as an organ of circulation and of respiration. It is through the walls of the villi that this interchange of gases and fluids takes place; nourishment and oxygen passing through them to the fetus, and carbonic-acid gas and waste materials passing through them to the mother. There is no direct communication between the fetal and the maternal blood. The placenta, normally, is attached to the contractile part of the uterus, and on its separation the blood-vessels are closed by the contractions of the uterine wall. The placenta may be divided into two or more portions, or one or more of its cotyledons may be detached from the rest of the organ and have their own vascular supply. The importance of this lies in the fact that after the placenta is expelled these isolated masses may be left and give rise to hemorrhage or blood-poisoning.

SYMPTOMS OF PREGNANCY.

=Suppression of the Menses.=—The cessation of the periods may be due to other causes, but it is usually the first indication of pregnancy. Conception may take place and menstruation yet continue. It usually occurs but once or twice, and then only where conception took place immediately before an expected period.

=Morning Sickness.=—Nausea and vomiting continued for any length of time is almost a certain sign of pregnancy. It may begin as soon as conception takes place and last for many months; sometimes it may occur toward the end of pregnancy, or occasionally not at all.

=Salivation.=—The excessive secretion of saliva often accompanies the morning sickness. The secretion is tenacious and difficult of expectoration. Heartburn, abnormal appetite, longing or loathing for particular articles of food, toothache and the like may be present.

=Quickening.=—The first feeling of fetal life felt by the mother is usually between the fourth and fifth months, but may be experienced occasionally as early as the third month, or be deferred until the sixth. Quickening occurs as soon as the uterus comes in contact with the abdominal wall. Improper elimination of the bowels, causing gastro-intestinal trouble, may produce movements not unlike this indication; therefore, this symptom is not reliable.

=Enlargement of the Breasts.=—The breasts grow larger toward the end of the second month. In some cases the enlargement is very marked, but in others there is scarcely any increase in size during the whole term of pregnancy.

=Pigmentation.=—Coloring of the skin takes place in different parts of the body. The face may show brownish spots. The skin darkens in the axilla and in the areola of the breasts. A dark line presents itself down the middle of the abdomen. The vagina takes on a violet tint, the cervix becomes purple, the various colors becoming more marked with the progress of pregnancy.

=Changes in the Abdomen.=—The abdomen grows larger gradually, and with it the gait and carriage of the woman change, to counterbalance the weight of the abdomen. It enlarges symmetrically unless the uterus is displaced by adhesions, or by a tumor in the uterus or external to it. The tearing of the under layer of the skin of the abdomen while distended produces streaks (stria), first pink and then white, which remain after the form resumes its natural shape; any other enlargement of the abdomen, especially when caused by a tumor, may produce the same result. The various conditions mistaken for pregnancy, due to changes in the abdomen, are fibroid in uterus; metritis; swelling of the tubes and ovaries, distended bladder, a pendulous belly; excessive fat; extra-uterine pregnancy; and inflammatory conditions, such as peritonitis. Pregnancy and any of the conditions named may coexist, and the former may be overlooked, while the latter is recognized.

=Fetal Heartbeat.=—The heart sounds are generally audible between the fourth and fifth months. The rate is from 120-140 a minute, being double that of the mother’s pulse. About midterm is heard the uterine souffle, a blowing sound, quite unlike the fetal heart, and its origin is the rushing of the blood through the enlarged and twisted arteries.

=Ballottement.=—In normal cases there is no pain on palpation. The uterine wall varies in consistence, being alternately soft and firm. The fetal parts may be felt through the abdominal wall in the late months.

=Lightening.=—In the last two weeks, especially in primiparæ, the child’s head sinks into the pelvis, and its body falls a little forward. The uterus sinks down and forward with the child. The waist-line lowers, the stomach region is flatter, the navel more prominent. The patient breathes easier, but does not walk as well.

=Duration of Pregnancy.=—Average time is 280 days; protracted, 314; a short term about 245 days. There is no positive period.

=Prediction of the Date of Labor.=—Count 9 calendar months from the beginning of the last menstruation and add 7 days. An error of 2 or 3 weeks, however, is possible. (See Table on page 178.)

=Premonitory Symptoms of Labor.=—(1) _Lightening._—Dropping may be attended with slight pains similar to labor pains.

(2) _False Pains._—These vary in nature and quality. They may be short and sharp, or long and continuous, or irregular. As a rule, they are marked by irregularity. They are mostly abdominal, rarely like true pains beginning in the sacral region and moving around to the region of the pubes. They may be caused by cramps in the abdominal wall, intestines, or in the distended bladder. They may be due to old inflammatory areas within the abdominal and pelvic cavities. They are frequent in cases in which there is marked bowel irregularity, and in conditions of over-fatigue. Some authors believe that they may be produced by irregular contractions of portions of the uterine wall. One important test is the condition of the uterine body during the pain. If there is no genuine contraction, the uterus will not become hard when pain is felt. This indication is not always reliable, however, since palpation may be unsatisfactory on account of the woman’s nervousness, her sensitiveness, or the thickness of the abdominal wall. If the cause be contractions of the uterus, partial hardening may be felt.

TABLE FOR CALCULATING THE PERIOD OF UTERO-GESTATION.