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, 1910

, Vol. V., No. 10. turbances and even albuminuria, yet in no Gelatine: Gelatine in the form of jellies case did the nutritive value go above 2,000 variously flavored to give pleasing variety calories per day, about 23 the requirements is well liked and of great service. of health. No wonder our patients ema- Broths: The various meat broths preciated.

pared if possible below the coagulation point To read some of the elaborate menus of albumin, in order that the maximum of planned for each week of convalescence as nutrition be retained, furnish proteid for well as of the disease itself found in some of repair of tissue waste and some balance for the systems of medicine, while demonstrat- energy, though it is upon the carbohydrates ing the author's profound knowledge of and fats that we depend. dietetics, and his vivid imagination, could Bread, etc.: Dried bread, rather than scarcely have found many close followers toast, soda crackers, zwieback, etc., are given and would surely have caused dismay in as the patient desires. any board of hospital managers if ordered

Butter:-Much dependence is placed upon for their patients. The total energy in our butter and it is well tolerated. During the diet was calculated by Dr. Wolff to be about past year the so-called heavy cream has been 3,500 calories per day with a nitrogen equiv- used with little if any advantage over alent of about 8 grams, but after the first butter. . season I was content to measure the amount Sugar: It has been my experience that needed by the condition of each patient's if milk sugar is used alone or in too great nutrition and the acceptability of the various proportion, patients object much sooner than articles allowed rather than by exact analy- if a small percentage of cane sugar is added ses each day, since it had been proved that and no more unpleasant symptoms appear such diet, even when forced, produced no in this latter case. real injury—either the patient protested

Our routine has been as follows: against the amount or at worst had slight On admission to the ward the patient is gastric isturbance which ceased imme- given calomel, usually in divided doses, foldiately on reducing the amount.

lowed by magnesium sulphate. If the temRice: Boiled rice formed the basis of perature is high and the gastro-intestinal our diet. 6 to 8 ounces by volume given at tract in bad condition, little besides water is a time. Other cereals have been repeatedly given for 24 hours. substituted but none were so well borne for The patient is fed every 27/2 to 3 hours, so long a period. Theoretically it is the being given 6 to 8 oz. of rice with butter and most perfect, being perfectly digested in two sugar, alternating with an equal quantity of hours.

jelly often with sugar, eggs or broth. Eggs: Three to six during the day has Sugar is added to the eggs with fruit juice; been my rule, shirred, soft boiled or shaken butter when shirred or boiled. Butter is with sugar, ice and orange or grape fruit usually given with the dried bread, crackers, juice. A larger number may be employed etc., which are served with broth and eggs. if for any reason the other articles are re- Water is urged upon the patient throughduced. At first only the whites were given out the course of the disease, nurses being in the form of albumin water, but later instructed to watch the amount taken. the whole egg was used with good results. Often the total fluids are entered on the

BIBLIOGRAPHY.

BY

chart in order that the intake and output toxaemia, after a long severe illness. may be watched.

11 East 48th St., New York. Hydrochloric acid, largely diluted, is given if the digestion seems to flag, the diet being altered at the same time.

1. Typhus Fever which occurred in Phila. in

1836. Am. Jour. Medical Sciences, Vols. Nurses are always instructed to see that

19 and 20, 1837. the patients eat slowly and thoroughly mas

2. Edinburgh Medical and Surgical Journal,

1840. ticate their food (of course if rational). 3. Edinburgh Medical and Surgical Journal,

1829. Much less objection is raised to this diet than 4. Nothnagel's Encyclopedia of Medicine,

1892. when milk constitutes a large element and

5. Diet in Typhoid, Warren Coleman, Jour. by varying the sequence and not crowding A. M. A., Oct., 1909.

6. Nutrition of Man, Chittenden. the diet at first, the patients are far better satisfied. We rarely hear the complaint of “nothing to eat.” Under this plan patients A CASE OF ACROMEGALY.1 exhibit far less prostration; their faces lack the dusky flush so characteristic of the dis

MAURICE PACKARD, M. D., ease; the tongue becomes moist and clean, or

Adjunct Professor of Internal Medicine, N. Y. slightly coated at the base only; no tym- Polyclinic; Adjunct Attending Physician to panites or marked diarrhoea, except in rare

N. Y. Hospital for Nervous Diseases. cases and they run a much milder course in The patient whose picture I show you is every way, showing the effects of a full, 36 years of age, seamstress, American. Her easily digested diet.

Seventy cases have been treated in hospital with seven deaths and seven in private practice all recovering. The hospital figures are in themselves anything but flattering, but analyzing them, I am fairly entitled to say "there's a reason." Two died from pneumonia and delirium tremens within seven days after admission. Two from hemorrhage within 48 hours after reaching the hospital, one had a perforation also. The other was brought to us moribund because of repeated hemorrhages at home. One with history of recent syphilis and marked alcoholism. Autopsy showed advanced parenchymatous nephritis. One woman with peripheral neuritis, marked

Patient at age of 27. prostration and cyanosis on admission. Of the six, none lived beyond the tenth day. family history is negative. Menstruation

which began at 13 years of age, and which The seventh death is fairly chargeable to

*Case shown to Clinical Society of N. Y. our record, being caused by profound Polyclinic Hospital and Medical School.

[graphic]

was regular, stopped, according to her story, enormous. The weight at present time is suddenly at 26 years of age.

185 pounds. She speaks slowly in a marked Immediately after, that is, ten years ago, gụtteral manner. The ears are rather larger she began to suffer from frontal headaches than normal and measurements from the and indefinite pains over her entire body. symphysis of the jaw to the angle is 14

[graphic]

Picture taken 3 months ago. Front view. Concomitant with this she complained of cm, in contrast to 10 cm. of a normal ingeneral weakness, inability to do her work

dividual. The nose is large and broad and with the same ambition, night and day

her eyes are protruding with some exoph

thalmos. The malar bones are exaggerated, sweats.

completing the picture of "Punch" which She was constantly thirsty, drinking from

has been given to these cases by an eminent 3 to 5 quarts of water and her appetite was neurologist.

The ocular examination has been entirely the ulnar side of the hand being thickened, negative. Her tongue is enlarged and the and she now wears a man's glove, No. 9. incisor teeth are separated fully one-half Her shoes which were at 25, size 5 are now inch, which is often found in these cases. ten and her heel projects backward, her arch The thyroid is enlarged, but no thymus was is broken and the tendo-achilles enlarged.

[graphic][merged small]

demonstrated. As you note in the picture In other words the woman shows a general the thoracic cage is considerably increased thickening of the soft parts as well as the on account of the ribs being broadened. The bones. patient now has a marked lordokyphosis with The urine is normal; no albumin, no a scoliosis. The hands are enlarged, fingers sugar. The blood pressure is 185 with as well as the nails are broadened especially some hypertrophy of the heart but no mur

2.

, 1910. Complete

, Vol. V., No. 10. murs. The X-Ray was not able to demon- of the cervix, and is rare in other constrate any tumor of the hypophysis.

ditions. This modified cervical discharge

is characteristic. Treatment with extracts of hypophysis or

Clinical Diagnosis.--The clinical diagthyroid have been of no avail.

nosis of uterine cancer depends upon two 203 W. 79th St., New York.

factors:

The presence of a neoplasm, either

proliferation or infiltration. ETIOLOGY AND DIAGNOSIS. 2. Its degeneration. This leads to the

characteristic friability of the tissue which The Early Diagnosis of Uterine Can- is of great diagnostic value. This fricer.1 – The early diagnosis of cancer of ability is recognized by the finger or the the uterus is one of the most important sound. This property of breaking up into functions of the family physician, accord- small pieces under pressure of the finger ing to Hendrick, for it is to him the pa- is very characteristic, and the only other tient usually appeals for relief, hence it is tissues, perhaps, showing it is a necrosing his bounden duty by every means avail

fibroid. able to make the diagnosis if possible. The great tendency to bleed is underThere are three sites for uterine cancer. stood when one recalls the histological

1. The vaginal portion from the vaginal structure. Hence, bleeding is charactervault to external os.

istic of all three varieties of uterine canThe cervical portion from the exter

But one finds hemorrhages in eronal to the internal os.

sions, endometritis, chronic metritis and 3. The uterine body from the internal polyps, although less, so that diagnosis canos to the tubal orifices.

not be based on bleeding alone. When Now, cancer of the uterus develops in both features of cancer are present, nameits mucous membrane, or immediately un- ly, neoplasm and degeneration, the diagder the mucous membrane of its elements. nosis is easy, but if only one of these is That is, the glands of the cervix or the present difficulty arises. For examples, body. This classification is important be- there may be only proliferation, then incause, not only the clinical picture of the spection with speculum aids, while any incancer but the methods of diagnosis are filtration is found on palpation, whilst dequite different, depending on the starting generation is found by both methods. point and extension of the disease.

Cancer of the vaginal portion may be There are certain symptoms which one seen and felt through the speculum in the may designate by the name of prodromes Sims posture, whilst palpation of body canof uterine cancer. These are:

cer may require dilatation, 1. Bleeding in coitus—due either to en- Vaginal Portion.-Cancer here is the gorgement or friction. It is very common, most easily diagnosed of all sites. and often the first symptom noted in can

1. If of the polypoid variety its surface cer of the cervix, though it may occur in is reddish in color and friable; that is, vascular erosion, endometritis or polyps. It easily broken or crumbled down by finger is always a suspicious sign.

or sound. 2. Metrorrhagia-after the menopause ; If of the flat kind, any bulging above that is, some months after the menopause. the surface is suspicious. This symptom may occur in fibroids and 3. If of the infiltrating kind, a nodule polypoid disease, but it is most often due is felt cartilaginous in consistence and alto cancer. Irregular hemorrhages before tering the shape of the vaginal portion. If, the menopause are not so suspicious, but however, the mucous membrane over the we must bear in mind the age incidence. lump is intact then there is trouble, though

3 A sero-sanguinous discharge re- the surface of the nodule may be purple in sembling greasy dish-water or beef brine color and spotted by yellow pits due to the occurs in the very early stages of cancer cancer nests. ‘A. C. Hendrick, M, D., Canada Lancet, Sept.,

4. Ulcerating cancers are easily spotted. 1910,

The jagged fissures with soapy secretion,

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