MEDICAL MEMORANDA. Visitors to the Mardi Gras at New Orleans will consult their own comfort by stopping at that magnificent caravansary the New St. Charles-the name is synonymous with superb cuisine and prompt service. Physicians and their families visiting the city of St. Louis will find in the Monticello, one of the most charming and home-like hotels. Facing beautiful Forest Park, and situated in the aristocratic west-end residential portion of the city, the Monticello offers quiet and refined accommodations at very reasonable rates-European and American plans. Phospho-Albumen. We beg to call the attention of our readersto the announcement of the Phospho-Albumen Company, appearing in this issue, which has the distinction of being the pioneer of all glandular extracts As a nerve food, tissue builder and blood maker, it stands pre-eminent, and is indicated in all neurasthenias and anemias, as well as in all other morbid and pathologic changes of the nervous and nutritive processes. Liberal samples will be furnished by the company for trial, and we would urge our readers to take advantage of this offer and learn for themselves the merits of phospho-albumen. A Few Practical Points in Infantile Anemia.-Infantile anemia always manifests distinctive, objective and subjective symptoms of mal-nutrition, of which the most prominent is a lowered blood standard. Disease of childhood shows more pronounced changes in the blood than does disease of the same class in the adult; therefore a careful study of the blood is invariably necessary and yields points of greatest importance in deciding the best method of treatment." There is still a great deal to be determined about the marks of distinction between the normal and abnormal condition of the blood in children; much has been developed but there is still much to be learned. In the transition from infancy to childhood, the process of the development of the blood is going on and it is often hard to determine whether a certain case is normal or abnormal in the condition of the blood. For instance, the percentage of hemoglobin which is, in proportion, higher at birth than in adult life, may fall within the first few weeks of life to fifty per cent, and still not be abnormal. It is, therefore, for the busy practitioner, no less than for the one not so proficient in hematology to have some simple, reliable and easily practical methods of ascertaining the exact blood condition. When this knowledge is obtained a diagnosis can be made. Το obtain this practical knowledge, no special skill is required; the ordinary use of the microscope, hemoglobinometer, and harmocytometer, can with a little practice, obtain the necessary data. It is now conceded that aside from chlorosis nearly all cases of anemia in children are of secondary origin, consequently it is not difficult to ascertain the causes. The tendency may be transmitted from the anemic, poorly nourished patient, in sufficient quantity an improper kind of food is usually the chief cause. The infectious or constitutional conditions such as rickets, syphilis, tuberculosis, malaria, rheumatism &c., are responsible for the great majority of cases of secondary anemia, and usually present one or more distinctive symptoms indicating their origin. The thing most desired in the treatment of these conditions is naturally to remove the cause, which is sometimes possible, but not always; a careful study of the blood should be the first step after which its proper treatment, for by this means one can often remove the subjective symptoms of the anemia, thereby making the patient more comfortable as well as reinforcing the treatment of the cause. In the endeavors to restore the normal standard of the blood in cases of secondary anemia, dietetic and hygienic measures are of greatest importance. A careful study of many cases shows conclusively that a large proportion of the cases which owe their origin to conditions prevalent among the poorer classes-improper food, poor air, lack of exercise-are the prime causes. A correction of these defects with proper feeding, fresh air and tonic, will bring about the desired results without the necessity of much drug medication. But in those cases in which the anemia is secondary to the infections, the diathetic or hygienic measures can be supplemented by the application of proper medication; the treatment then becomes one of removing the cause of the anemia,at the same time reinforcing the system by proper nutrition. The most frequent employed drugs as blood constructors, are iron and arsenic, but their field of usefulness is limited. They undoubtedly produce a tonic effect by stimulation, but lack the proper elements to build up the newly born cells as the result of this stimulation,consequently their therapeutic value is limited and something more complex is required. Too short a space is allowed to enumerate the many cures laid down by various clinicians in the treatment of anemia. All have virtue more or less, none are complete. Most of the tonics of iron will increase the blood cells without a corresponding increase in the hemoglobin consequently many of the new born cells never reach maturity but become shrivelled, disintegrated or paralyzed as a result of the mal-nutrition. With this clinical picture before me I naturally sought for something that fully covered the field, in other words a tonic, stimulant and complete food. The combination of the three making the essential whole I found in bovinine, and its employment in many cases has proven it it to be a most valuable diathetic and therapeutic agent.-T. J. BRIGGS, M. D. Vol. XXVII (Absorbed the Morgan County (Ill.) Medical Journal. January 1, 1903.) FEBRUARY 25, 1905. Papers for the original department must be contributed exclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be transisted free of charge, if accepted. A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof. Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose. COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R. EDWARDS, M. D., Chicago, Ill Mr. REGINALD HARRISON, London, England. HOBART A. HARE, M. D., Philadelphia. FERD. C. VALENTINE, M. D., New York. LEADING ARTICLES THE NATURE AND TREATMENT OF DIARRHEA. R. B. DARNLEY, M. D. PHILADELPHIA. As with headache, the subject of diarrhea while apparently one of the simplest questions in medicine is in actual practice, often a serious problem to handle. It requires frequently the covering of the entire life of the patient, his anatomy, his habits, his environment and his peculiarities. For example in recent years Pincus has directed attention to the importance of weakness or injury in the muscles of the pelvic floor as a cause for constipation and diarrhea; he suggests massage and local treatment of this point in baffing cases. Again Einhorn has considered exhaustively the occurrence of constipation and diarrhea from diseases of the stomach alone without involvement of the intestines. The conditions in which these disturb ances of the bowel are often found are those associated with hyperchlorhydria and achylia. In the latter diarrhea is more common, No. 4 in the former constipation; but this is not necessarily the case for the reverse may be true. In these cases the relief of the gastric affection gives relief to the bowel disturbance. We must remember, however, that undoubtedly disturbances of the gastric function frequently occasion secondary disorders of the intestines, with either constipation ur diarrhea as consequences. The insufficiency of the pylorus may cause intestinal catarrh and hence diarrhea. At times the normal reflex closure of the pylorus does not occur; this is particularly notable in women with overstretched abdominal walls. The stomach is usually found distended; the symptoms. are diarrhea shortly after meals and a reflux in the stomach. Proper diet, hydrotherapy, and support of the stomach will usually cure the affection. This theory is undoubtedly attractive, but has not been proved as yet. Much remains to be learned about the contraction of the stomach and the condition of the pylorus under varying circumstances. Again, nervous diarrhea occurs in pregnancy; Condio in a monograph on this interesting complication considers this condition to be related to hyperemesis gravidarum. While the latter is more frequent in the higher ranks of life, diarrhea seems commoner among poor pregnant women, for obstetricians note its occurrence in lying-in hospitals in cities, while it is hardly ever seen in private practice. Out of 3674 pregnant women in the Turin Maternity, nervous diarrhea was observed in 35; 21 of these cases occurred in primiparae. Nervous diarrhea begins about the fifth month, and may become formidable; it has been found to continue even in childbed. Nerve tonics are indicated, and as in hyperemesis, premature labor must be induced. if the diarrhea persists debilitating the patient. An interesting table was published a few years ago as a basis for the diet in malignant disease, ulceration of the bowel and gastric ulcer. I have found it useful in simpler conditions that resisted treatment. It is as follows: "Swallow nothing that has not been either passed through a hair sieve, or has been so thoroughly masticated in the mouth that it is of the consistence of cream, and would readily pass completely through a hair sieve without leaving any remainder. To avoid all skins, bones, strings and stones. Where these things cannot be removed from the article, such diet must be rejected; skins of fruit, of grapes, peaches, apricots, gooseberries, marmalade. Reject currants, raisins. Skins of vegetables, tomatoes, potatoes. Reject peas, beans. Skins of fish of all kinds. Reject sardines, whitebait. Skins of fowlfowl, game, larks, quails. Bones of fish, sardines, herrings, trout. Reject whitebait. Strings in fruit- oranges, peaches, apples, pears, bananas, tamarinds, mangoes. Strings in vegetables, asparagus, cabbage cauliflower. Reject carrots and turnips unless mashed and passed through a sieve. Strings in meat-stringy fibres of beef, sinews in larks, quails, fowl and game. Stone or seeds in vegetables-tomatoes. Avoid peas and beans unless most carefully chewed. Stones or seeds in all kinds of fruit-grapes. Reject nuts, almonds, strawberries, raspberries currants. Strawberries, raspberries or currants may be pulped either alone or with sugar or cream, and may be passed through a fine sieve. The juice thus obtained may be taken either alone or with farninaceous food. Patient may have milk with soda water or lime water, or even alone if sipped and eaten with rusk or biscuit, and well minced in the mouth. Bread if stale; new bread to be avoided. All bread that breaks down under the finger and thumb into crumbs is old. enough. Bread that under the pressure of the finger makes a stiff dough must be avoided. Rusk or biscuit, or cracker or bread and butter (not crust), provided it be well chewed in the mouth, so that it is of the consistence of cream before it is swallowed. Eggs in any form except hard-boiled or fried. Generally the patient may have anything (fruit, vegetables, meat, fish or game) that has been passed through a sieve. All kinds of corn flour, tapioca, sago, rice, if well boiled and well chewed. Macaroni vermicelli, spaghetti, sassagna, Italian paste. (These may be boiled in stock which may be made with vegetables, if the vegetables are strained first. Essence of celery in quarter to one drop as flavoring). Cocoa freely. Tea (China) infused for short time. Butter in moderation. Cream cheese in small quantity and well mixed with bread in the mouth, or grated parmesan, but must not have any other kind of cheese. Gravy without grease from any kind of meat. Savory jellies (if there are no solids in them). Sponge biscuits. Madeira cake (plain no currants, no peel). Grated meat, tongue, etc. Toast if it be well masticated but no hot buttered toast. Stale bread or toast in soup. Honey or golden syrup. The syrup of jam or marmalade with the seeds or skins strained out carefully; fruit jellies, apple jelly, quince jelly, guava jelly with bread or bread and butter, or with any kind of corn flour or arrow root, or macaroni or any kind of farinaceous food allowed." In the treatinent of gastroenteritis in children remember that while the infec tious origin universally recognized, yet physicians lose sight of it in the treatment that is ordinarily prescribed, giving opium and bismuth too early and returning to milk in the diet too soon. In the preven tion, pasteurization of milk is not considered adequate, and in the great majority of fam ilies time and patience are wanting for this procedure, while simple boilings is easily done and is more efficient. With regard to the modified milk laboratories the cost of the product will limit its use to the wealthy classes, while many authorities doubt its nutrient value. The modification of cow's milk oversteps the line, for in the subtility of its composition the product surpasses human milk and the laboratory the breast of the Inother, and the proportions of fat, casein, albumin, sugar and water are not alone sub. ject to daily, but even hourly changes in the mother's milk. This change may be of as important value to the infant as the change of diet to the adult. Cow's milk, modified by approximate dilution, changes at least from day to day and no doubt no two bot. tles contain the same amount of fat. In laboratory-milk all the constituents remain the same from one feeding to another, from day to day, from week to week, until the supervising physician sees fit to write another prescription. Such infant-feeding is cer tainly not "crude; on the contrary it is more than artificial-it is artistic." Seibert objects to the distribution of pasteurized milk at low prices to the poor, on the ground they do not realize the importance of cleanli ness. Crandall gives the following contraindications to the use of opium in diarrheal diseases: 1. In the early stages of an acute attack, before the intestinal tract is cleansed. 2. When the passages are infrequent and of bad odor. 3. Where there are high fever or cerebral symptoms. 4. When its use is fol lowed by an increase of temperature or by more offensive passages. It is indicated: 1. In cases with frequent painful passages, 2. When the discharges are large and watery. 3. In dyspeptic diarrhea, when it is to be given with a purge. 4. In the late stages of a diarrhea, when the discharges are small, frequent and nagging. 5. When there is lientery, the food passing undigested soon after ingestion. Infantile constipation is due, Byers believes, to unassimilated fat rather than to casein, and the proper treat ment is similar to that of rickets, the main dependence being upon cod liver oil which acts not by increasing the fat in the stools, but by raising the nutrition of the child. Graham urges the value of hot water both internally and externally, in acute diarrheal conditions, while Loin reports marked success following hypodermoclysis with normal salt solution in cases of cholera infantum which had resisted all other treatment. Hugel has carried out a large number of observations on the value of the white guava plant in diarrhea; the astringent virtues of this plant are recognized both in Java and in the Brazils where the natives use it as a household remedy. The preparation employed by Hugel was an infusion made from five parts of the leaves and 80 parts of boiling water, with the addition of 20 parts of syrup. Of this a tablespoonful was ordered. hourly or every two hours, according to the gravity of the case. For children of course a smaller dose was prescribed. Sometimes, instead of the infusion the leaves in powder were ordered, the quantity in each powder being from 8 to 15 grains. After using this remedy in several hundred cases of infantile cholera, Dr. Hugel became convinced of its superiority over all ordinary remedies for acute gastroenteritis. After three or four doses had been given the most severe cases of diarrhea and vomiting showed a decided improvement. In five cases of cholera nostras in the adult the vomiting, diarrhea, cramps and drowsiness disappeared after the administration of one-half a grain of calomel, followed by a few doses of guava infusion. In the chronic diarrhea of phthisis and in the diarrhea of typhoid fever this remedy also proved useful; also in dyspepsia and in chronic gastric and intestinal catarrh. In Hugel's experience he never met with any case in which guava produced any disagreeable effects. Ssokolow advises the use of high intestinal injections in children, and has made an anatomical study of the intestines to determine to what extent the ileocecal valve offers an obstacle to the passage of an injected fluid from the cecum to the ileum. Among two hundred subjects experimented upon 130 being under one year, it was found that the ileocecal valve was competent in only 27 cases (20.8%) while in 103 (79.2%) water passed freely through the valve into the small intestine. In older children, from one to twelve years, insufficiency was not so common, since out of 70 cases 37 had incompetency. A pressure of more than three metres was dangerous, being liable to rupture the gut or disorganize the valve. It is therefore evident from this study that in children under one year, fluid may be expected to reach the small intestine, in three-fourths, and in older children in one-half of the cases. Therefore, in every suitable case an effort should be made to reach the small intestine with the irrigating fluid. REPORT OF A CASE OF ACUTE MILIARY TUBERCULOSIS, WITH POST-MORTEM FINDINGS.* H. A. POTTS, M. D. JACKSONVILLE, ILL. Assistant Physician Illinois Central Hospital for the Insane. J. P., aged 20 years; no history of alcohol or venereal disease; has had malaria and "stomach trouble." At the examination of the commission, the patient was feeble and had lost in weight; pulse 78; pupils normal hands dry, had lost appetite and sleep was disturbed; digestion impaired; no disturbance of sight. He was melancholy over the death of his father and from loss of money; two brothers and one sister have been insane. On admission to Illinois Central Hospital for Insane, September 22, 1904, his stature was 5 feet 9 inches; weight 120 pounds; hair black; appearance tidy; nutrition fair; facial expression dull; malformation none; scars or bruises none; he has "wing scapulae;" mouth and teeth were clean; digestion fair; bowels constipated; sleep fairly good; his skin was moist and free from eruptions. His lungs had dull apices and harsh prolonged breath sounds; respiration shallow and 22 per minute. The heart was not abnormal; pulse regular, 76 per minute. He has had no convulsions, tremors or paralysis. Perception and comprehension were dull. Speech was slow and hesitating; temperature normal. Atfer his admission the patient was melancholy and had nothing to say, but willingly did all that was asked of him. He had a good appetite and slept well; occasionally he was filthy in his habits. filthy in his habits. November 16th it was noticed he was not feeling well, said he had nothing particular to complain of, he ate and slept fairly well. November 21st, patient's face was flushed; respiration 30, shallow. He was removed to the infirmary. Patient had had no chill, nausea or vomiting; no nose bleed, no severe pain, except in chest; no marked prostration. Patient showed a flushed face, which was not the bright red so often seen in pneumonia of the lobar type, but tending to cyanosis. He was lying upon * Read before the Medical Club of Jacksonville, December 11, 1904. |