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MEDICAL MEMORANDA.

The Modern Management of Malarial Anemia.- One of the most obstinate forms of anemia with which the physician has to contend is that which succeeds malarial infection. This particular form of anemia is, unquestionably, due directly to the structural changes induced by the protozoon parasite. While a mild form of anemia is a common, if not invariable, consequence of malarial infection, there is a severe type, termed malarial anemia, which not infrequently occurs. This latter variety usually responds slowly to curative measures; and, since its existence renders the individual a fit subject for recurring malarial manifestations upon the slightest exposure, the importance of its cure cannot be too strongly emphasized. The doctrine of the latency of malarial poisoning in the human body is rapidly gaining in popularity. Some authorities even go so far as to claim that a person who has once been inoculated with the malarial protozoa never completely recovers. Whether this be true or not, it is certain that the protozoon prarsite does exert an influence which tends, for a great length of time, to lower vitality and render feeble the powers of resistance to renewed attacks. This is especially true in the case of women, children and persons of advanced age. Recent investigations unite in ascribing the cause of malarial anemia to the liberation of hemoglobin from the red corpuscles in the blood vessels. The pigmentation resulting from this liberation of hemoglobin is one of the characteristics of malarial infection. And while the coloring matter may remain in the blood stream, it usually infiltrates into the cells and neighboring tissues. The deposit of pigment is especially great throughout the tissue of the liver and spleen. The thickening and softening of the mucous membrane of the stomach which always attends malarial infection, seems likely to contribute, at least to some extent, to the development of anemia. In every instance the degree of the anemia is in direct ratio to the amount of the hemoglobin liberated from the red corpuscles. And this fact explains the philosophy of effecting repair by the administration of iron, the hemoglobin-contributor. Whether or not the protozoon parasite is ever completely eliminated from the economy remains an unanswered question. But it is now universally conceded that the protracted administration of iron does render the indivi. dual partly, if not completely,exempt from a return of malarial manifestations of an aggravated type. Far more so, in fact, than does quinine. Indeed, we have good. cause to believe that iron does exert a destructive influence upon the malarial protozoa and increases the immunity of the individual. While it is the chief aim of the physician to make up the deficiency of the hemoglobin in these subjects by the administration of iron, it is distinctly important, coincidently, to increase the appetite and augment the capacity to appropriate the food ingested. To this end, discrimination in the selection of the form of iron to be employed is vitally essential. The acid solutions of the drug are ineligible because of the fact that they cannot be engaged for a long period without harmfully affecting the secretion of the digestive juices and adding to the morbid state of the mucous surfaces or the alimentary tract. Furthermore, the continued use of acid products of any sort are certain to diminish the alkalinity of the blood, thus depressing, to a very considerable extent, the nutritive processes. Then, too, headache which is an ever disturbing factor in these cases, is intensified by all substances of an acid reaction. The strongly alkaline preparations of iron, while less objectionable than the acid ones, are open to fault for the reason that they induce constipation, and in this manner favor auto-intoxication. By far the most effectual form of iron in the treatment of malarial anemia is that which is neutral in reaction and available for immediate absorption. The organo-plastic form of iron, as found in pepto-mangan (Gude), certainly fulfils the requirements of the physician with greater promptness and uniformity than any other product thus far evolved. This preparation--pepto-mangan (Gude) -is by all means the most potent hemoglobin. producing form of iron, and it undoubtedly surpasses other ferruginous products as an invigorator of the digestive and nutritive functions. These assertions are easily confirmed by the microscope. It is also an accepted fact that pepto-mangan (Gude) does not induce constipation, and it seems to materially hasten repair of the mucous surfaces of the alimentary tract resulting from the structural changes incident to the malarial infection. In short, pepto-mangan (Gude) is of inestimable value in the treatment of malarial anemia by virtue of its manifold advantages over other preparations of iron. If this preparation is administered for the proper length of time, the individual gains substantially in strength, flesh, physical and mental energy.

lodalia an Efficient and Pleasant Alterative.-(By A. H. Ohmann-Dumesnil, A., M., M.E., M.D., Ph.D., St Louis.)— Without wishing to enter into a long consideration of the different varieties and classes of alteratives, their advantages and disadvantages, it may be best to plunge in medias res and take into consideration that

one which is universally conceded to be the best general alterative and the one which of

produces the effects attributed to this class of remedial agents better than any

other. The one here meant is iodine ; a most useful and, at the same time, much ha. abused remedy, which is unfortunately but too little understood, and is so potent in ntei its beneficial effects when properly applied in the proper cases. Dr. Nicholas Senn ady in a paper on “Iodine in Surgery," says, “in the treatment of so-called scrofula and

lupus, iodine internally and locally commanded the confidence of the profession for • Reamore than a half century before the bacillus of tuberculosis was discovered.” It may by at be further mentioned that iodine has been found efficient in the form of injecticns

in joint affections, seropurulent in nature, in tubercular peritonitis, locally in erysipelas, in anthrax, etc., but beyond all doubt its most extensive and successful em. ployment, internally, has been in the treatment of syphilis, more especially in that form known as the tertiary. It is here that it has most fully and thoroughly demonstrated its action as an alterative and it is destined to remain the remedy par excellence in this condition for many years to come. As a rule iodine is administered internally in the form of iodides, although it is also given pure in many cases. It has been observed, however, that the salts of iodine, formed by its combination with alkalis, are all more or less irritating. This is due beyond doubt to the alkalies with which the iodine is combined and these symptoms are so marked that they are easily recognized, more especially so far as the objective signs are concerned. Devices have been employed to prevent the usual gastric disturbance, such as taking the iodide in large quantities of milk and the ingestion of large quantities or bicarbonate of soda between meals to prevent the toxic influence of the alkaline salts of iodine. These are fairly good for a short time, but the symptoms of an untoward nature will manifest themselves despite all the precautionary measures taken. The cause of all these disturbances is beyond all doubt dependent upon the alkali which the salts contain and the problem which has been presented was to made a purely organic salt whose action would be as good if not superior from a therapeutic point of view and which would be unirritating, locally as well as constitutionally. Another disadvantage observed in all these iodides, as well as in pure iodine, is the lack of palatability observed in these remedies. We cannot here follow the evolution of the process of experimentation which finally led to the elaboration of a galenical iodo-tanic, preparation. A product of definite composition which was always constant was the result. It was found, however, that the combination of iodine and tannin is very hygroscopic and not easily desiccated with any uniform. ity. This led to a further series of experiments by saccharating it and thus attaining its inalterability. This much having been attained it was an easy matter to make a series of experiments and thus demonstrate the physiologic and therapeutic action of the remedy. The name which was adopted for this saccharated tannate of iodine was iodalia, and it is under this name that it is marketed to-day. It is by no means a secret remedy, as its chemical name sufficiently indicates its nature and its strength, which is uniform, is that of six centigrams of iodine to five grammes of salt, or approximately one grain to every teaspoonful. In appearance it is a white granular salt, not heavy and pleasantly sweet to the taste. It may be taken in milk, water or wine, and is pleasant in this form. It does not in the least disturb the stomach and is very easily assimilated, as proven by the fact that iodine may be found in the urine a half hour after its ingestion. The writer has not yet received any complaints concerning any untoward effects, although he has ordered comparatively large doses to be taken. Its effects are prompt, but perhaps the recital of a few cases will be best.

Case 1. A young man, unmarried, 24 years of age, was referred to me by two physicians, as their efforts had proved unavailing. The patient, when I saw him, was then, anemic, weak and had almost despaired of ever recovering. He had a case of malignant syphilis. The nose and throat were well advanced in ulceration, there was paralysis of the soft palate and the deglutition of liquids was almost an impossibility, not to mention solids. There was perforation of the hard palate,a destruction of the ossicles of the ear and consequent deafness, and altogether he was in a pretty dilapidated state. On inquiry his history developed the fact that he had acquired syphilis three years previously and had no doubt, been insufficiently treated, with the result of the tertiary symptoms which I saw. The patient was immediately placed on iodalia in doses of two teaspoonfuls in water before each meal. This treatment was persisted in, and two months after its inception he presented a bright appearance, he had gained weight, he could eat with ease and he felt better morally and physically. The result so far was a revelation, not only to the patient, but to his former physicians as well. He is still under treatment.

Case 2. A young lady, unmarried, aged 22, was troubled with an intractable case of acne. She had been treated by a large number of competent men with but little result of a favorable nature Upon examination I discovered that the acne was of an atonic form, the patient herself not being in good physical condition. The cervical lymphatics were markedly enlarged, and upon further examination other glands in the same condition were found. This was the solution of the lack of success which had followed the treatment of other physicians as well as of mine. Having determined the cause of the trouble I ordered her to take one teaspoonful of iodalia in water before each meal and was pleasantly rewarded by seeing the eruption nearly well and the tuberculous glands much diminished in size in about three weeks. She will be continued under this treatment for some length of time, more especially as she feels better in all respects.

The indications for the use of iodalia are very simply told. It is indicated in all conditions in which iodine is employed. The list of conditions is too long to be enumerated here. It embraces all those in which alteratives are employed. Among the principle ones are syphilis, localized tuberculosis, lymphatism, arterio-sclerosis, etc. Iodalia is a remedy well worth remembering as an unchangeable iodotannic saccharate, which is easily assimilated and never injures the gastric mucous membrane or produces untoward symptoms.-Abstract from St. Louis Medical and Surgical Journal

Vol. XXIV 27

St. Louis, JUNE 11, 1906.

No. 11

C. G. CHADDOCK. M. D., St. Louis, Mo.

Papers for the original department must be contributed ex. and the situation of the patient may well be clusively to this magazine, and should be in hand at least one month in advance."French and German articles will be trans- regarded as precarious. It is, therefore, of lated free of charge, if accepted A liberal number of extra copies will be furnished authors, and

great importance that this disease shall be reprints may be obtained at cost, if request accompanies the detected in its early stages before profound proof.

Engravings from photographs or pen drawings will be fur- pathological changes have occurred, and be. nished when necessary to elucidate the text. Rejected manu- ore script will be returned if stamps are enclosed for this purpose.

fore operative work of exceedingly grave

nero 1o10 peraty

oharacter shall become necessary in order to COLLABORATORS.

perpetuate the existence of the patient. The ALBERT ABRAMS, M. D., San Francisco. M. V. BALL, M. D., Warren, Pa.

diagnosis of acute mastoid abscess is usually FRANK BILLINGS, M. D., Chicago, Ill. CHARLES W. BURR, M. D., Philadelphia.

not difficult, although perplexing cases may

sometimes be seen. While some antral pus S. SOLIS COHEN, M. D., Philadelphia, Pa. ARCHIBALD CHURCH, M. D., Chicago.

may exist in all prolonged middle ear infeo. N. S. DAVIS, M. D., Chicago. ARTHUR R EDWARDS, M. D., Chicago, Ill.

tions, as expressed by some writers, sufficient FRANK R. FRY, M. D., St. Louis.

pus must exist as a rule to produce some Mr. REGINALD HARRISON, London, England. RICHARD T. HEWLETT, M. D., London, England. pressure and absorption before an actual apJ. N. HALL, M. D., Denver. HOBART A. HARE, M. D., Philadelphia.

parent absuess may be said to exist, and be. CHARLES JEWETT, M. D., Brooklyn.

fore a recognizable symptomatology will be THOMAS LINN, M. D., Nice, France. FRANKLIN H. MARTIN, M. D., Chicago.

present. Such symptoms as tenderness, red. E. E. MONTGOMERY, M. D., Philadelphia. NICHOLAS SENN, M.D., Chicago.

ness, swelling, temperature and pain may ocFERD C. VALENTINE, M. D., New York. .

our with comparatively slight pus deposits, EDWIN WALKER, M. D., Evansville, Ind. REYNOLD W. WILCOX. M. D., Now York.

and these are the symptoms that should be H. M. WHELPLEY, M. D., St. Louis. WM. H. WILDER, M. D., Chicago, Ill.

watobed for, as they point the way to the op. erative table during a period of comparative

safety. When, however, intense mastoid and LEADING ARTICLES

neighboring redness, tenderness, swelling,

pain and edema, auricular displacement, ACUTE MASTOID ABSCESS. high temperature and pulse, obills, increased

leucocyte and polymorpbonuclear count inFRANK ALLPORT, M. D.

dicate a mastoid cavity surcharged with pus

and granulations already, perhaps, forcing an CHICAGO, ILL.

entrance into the intracranial cavity, then ACUTE mastoid abscesses proceed from indeed is a diagnosis easy, if late, and then acute or chronic middle ear infections. Such unquestionably is no time to be lost before a cases, especially in country practice, usually free and thorough mastoid operation is per. fall under the care of the general practition. formed. er, and it is of great importance that an early The swelling in most mastoid absoesses has diagnosis shall be made, as it frequently hap. a tendepoy toward an upward direction the pens that the infectious pathological lesions neighborhood of the surface of the lower por. extend in the cerebrum, cerebellum, or sinus tion of the squamous section of the temporal wbiob. of course. quickly emphasizes the bone notwithstanding the inherent principles gravity of the situation and minimizes optim. of gravitation. This tendency is natural on istic prognostioations. If the surgeon could account of the closer relationsbip of the safely delay diagnosis until pathological soft tissues to the roughened and serrated obanges have so far advanced as to unmistak. surface of the true mastoid cortex and the ably clarify the symptomatology, no espeoial close contact of the soft tissues to the smooth anxiety need be felt, as mature cases of mas. .exterior of the squamous portion of the temtoid abscess are accompanied by such well. poral bone. This is particularly true of defined indications of intra-osseous infection young children, where the antrum is located as to render a diagnosis comparatively easy bigher than in the adult and where the unos.

-even by a medical tyro. When, however, sified masto-squamosal suture allows a ready distinct subjeоtive and objective evidences exit of the middle ear pus to the exterior of severe and well-advanced pathological of the bone. For these reasons it will frehanges are manifest, great fear may well be quently be noticed, especially in children, atertained that infectious processes have al. that the direction of the auricular displaceady extended into the intracranial contents, ment is not only forward but downward to

correspond with the usual pus location, as *Read before the Twelfth District (Indiana) Medical So

just described.

y at Fort Wayne, Ind., March 13, 1916.

-

Notwithstanding the principles just enun. edema, redness, auricular displacement, disciated, however, it must not be imagined that charge, and general febrile manifestations, purulent deposits may not burst their osse. may cause even un experienced observer to ous fetters in other directions, for fistulae hesitate somewbat before a positive diagno. may as a matter of faot, appear in almost any sis is made. A careful examination of the portion of the mastoid process. Suob ne- parts, however, under full illumination will orotic openings may oocur over the entrum, disclose the meatus and not the mastoid to into the external auditory meatus, through be the storm center of trouble, not forgetting the digastric groove, or in short thrcugh al- the fact, however, that a virulent middle most any portion of the mastoid oortex, to ear disobarge acoompanied perbaps with say nothing of ruptures through the inner mastoid involvement, may produce a meatal table of the bone into the brain cavity. furuncle, and complexity of conditions not Fistulae through the digastric groove of the easy to unravel. The oharacter of the dis. temporal hone underneath the mastoid tip charge should always be examined from sup. and called by courtesy Bezold's mastoiditis, purating ears, as it often plays an important is both an interesting and perplexing form of part in advice given to patients relative to the disease, and is caused by gravitation of the necessity for an operation, for, when the pus to the large tip mastoid cells and the presence, especially of the streptooooous, in bursting of the thin bone through the digas. the discharge is established, the probability trio fossa. Under these circumstances pus of an operation is at once very much magniesca pes into the cervical tissues, infection in fied. this treacherous territory takes place and ab. The mastoid patient can frequently be di. scess after abscess occurs by easy infectious agnosed immediately he enters the surgeon's dissection from one portion of the neck to the consulting room by his pained and anxious other, sometimes even extending to below the countenance and the care with which he car. claviole, or back as far as the vertebrae. ries his head stify to one side to avoid pull. While distinct objective and subjective febrile ing and straining on the soft tissues of the and inflammatory manifestations are usually bead and neck. The pain may be slight in present wbile pus is confined within osseous , extent or extremely severe, involving not only barriers, it sometimes bappens that as soon the mastoid area, but other portions of the as cortes fistulae oocur and pus becomes bead and neck as well, and requiring heavy thereby liberated into the soft tissues, and and frequent potions of anodynes to relieve. the pressure is removed there will ocour a The bowels are usually constipated but may temporary lull in dangerous manifestations, be the reverse, and the appetite is poor or which will, of course, be regarded with entirely absent. The occurrence of cbills muob suspicion by the experienced observer, may usually be expected in mastoid ab. but which is sometimes deplorably misunder. scesses ranging all the way from distinct stood by the unwary until large pus accumu. chilly sensations to pronounced rigors. lations and pus absorption produce symptoms This sypmtom is tolerably frequent in pure that are unmistakable in their gravity. mastoid empyema, almost invariably present

Unless Bezold's mastoiditis exists, a con- in sinus phlebitis and thrombosis and usu. dition which as a rule is not difficult to ally ocours about once in brain abscess. The diagnose, pain and tenderness at the mas. temperature, pulse and respiration reflect the toid tip need not generally be regarded as presence of retained pus in the usual septio very important (although it should never be morning and evening wave, and being un. disregarded) as this is a frequent symptom in usually elevated when meningitis ocours, simple acute purulent otorrhea and other non- spasmodically irregular upon the intervention complicated inflammatory conditions of the of phlebitis or thrombosis, and very likely tympanum and antrum, but pain and tender subnormal when actual brain abscess takes ness over the antrum or at the inner upper place. All these conditions may with some portion of the bony meatus should always be rarity occur, however, in a single case whiob regarded with grave suspicion, and when will produce a complex clinical picture rethese symptoms are accompanied with redness quiring skill and experience to clarify, and and swelling at these areas, suspicion should which, indeed, may not be fully understood give place to immediate operative advice. until the patient is upon the operating-table

Although the warning may seem superflu. and the various pathological lesions are dis. ous, tbose who observe many mastoid pa- closed by the thorough opening of the mas. tients know that it is not impossible to mis- toid process, a procedure which fortunately take a mastoid abscess for a severe boil of is practically always primarily necessary in the meatus, which if located on the poster- cases of mastoid abscess sequelea. ior or upper meatal wall and presenting such It is a matter of oommon observation that symptoms as pain, swelling, sensitiveness, middle ear abscesses followed by mastoid

abscesses ocour with frequency after such whether complications of a most serious na. diseases as infuenza, measles, soarlet fever, ture are present, which may well call into typhoid fever, dipbtberia, pharyngitis, ton play the knowledge and experience of tbe exsillitis, eto., which should certainly teach the pert otologist. It seems reasonable to sug. family physician the necessity for the regu. gest, therefore, in a general way that no che lar and frequent antiseptic cleansing of the should undertake what appears to be a simple nose and throat during the life of such dis mastoid operation who is not fully prepared eases, as well as the strict admonition against by special study and clinical observation to the violent blowing of the nose during such proceed with the case, no matter what devel. maladies, wbiob unquestionably forces infec. ops after the operative field is fully exposed ; tion not only into the middle ear spaces but for, while the mere opening of the mastoid into the other accessory sinuses of the nose process can be easily accomplished, brain, as well. It should also teach them the ne sinus, and other complications may develop in cessity for the prompt and thorough open. the most unsuspeoted cases, necessitating the ing of middle ear abscesses in a proper man exercise of a high order of surgical judgment ner in order that tympanio infections may be and skill to properly overcome. limited to this space, and not extend beyond The ocmplete sbaving of the skull and the into the mastoid antrum and cells. A long close-cropping of the beard and mustaobe, is and careful observation of mastoid diseases of course, one of the ideal preparatory pro. will teach the lesson, that in spite of the usual cedures, but many modifications from this symptomatology present in such cases, ex. strepuous requirement will have to be ob. tensive necrosis and brain destruction may served, especially in female patients. The ocour with almost no symptoms whatever. bair should at all events be shaved for an Cases will sometimes present themselves com. area of from two to three inches backwards plaining merely of mastoid pain, or mastoid and upwards from the meatus, and the unout tenderness, or slight mastoid swelling, or un bair thorougbly and antiseptically shampooed controllable aural discharge, unaccompanied and held out of the operative field as com. in each instance by other symptoms, where a pletely as possible. The long, infected, uprather apologetio operation has revealed an manageable hair of a woman is a distinct extent of disease truly remarkable in its char menace, not only to proper operative procedacter. These instances, however, are not of ures, but also to the sometimes protracted the usual type, and while not to be forgotten, period of dressings following the operative should never disbearten the surgeon in the act. The process of preparing the outaneous vigilant search for mastoid abscesses. Neither operative field for surgical intervention is so should be be too quiok to advise operative well understood that no space need be wasted procedures, for all surgeons oan remember in its description, but it should not be formore or less frequent instances where al. gotten that the meatus should be thoroughly though unmistakable mastoid symptoms, cleansed by perhaps peroxide of hydrogen, such as middle ear abscess, mastoid pain, red. aloohol and warm bichloride irrigations, ness and swelling were present, the prompt and plugged with gauze before the primary and faithful use of suob remedies as rest in incision is made. bed, cathartics, diuretics, a thorough drum. The writer does not depend upon daylight head incision, bot bichloride irrigations, for illumination, but invariably uses an elecetc., have been followed by a subsidence of trio headlight which furnishes the best and mastoid symptoms, and a cessation of the most intense light with which he is familiar, aural discharge. It may be said in this in. The operator should stand behind the pastance, that most experienced surgeons have tient, at least until the chiselling is well discarded the use of the ice-coil over the under way, at wbich time many surgeons premastoid process in the belief that while it fer to stand or sit at the patient's side. He frequently mitigates urgent symptoms it, at should commence the incision at a point the same time unfortunately masks the true about one-quarter of an inch below the masintra-mastoid condition.

toid tip, and extend it upwards about oneThe ordinary uncomplicated operation for quarter of an ipoh posterior to tbe lobe of the mastoid abscess is not a diffioult procedure, ear, making a slightly curved incision to con. nor one that need tax the skill of any good form with the general outline of the lobe, general or special surgeon. It must, how. care being taken not to cut off the cartilagin. ever, be remembered that not until the oper. ous meatus, wbich is not by any means an ation is well under way, and the interior of accident one can afford to forget. The inci. the mastoid process fully exposed for inspec. sion should be extended upwards and fortion can the operator determine whether the wards until it reaches a point directly over pathological lesions are simple in their na. the anterior extremity of the auricular ap. ture, and ourable by simple methods, or pendage. This incision is ample for all or.

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