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meets a man who is carrying what are designated as ' hakku tubes.* Look-
ing at the man the prince discovers that just as long as the man holds the
hakku tubes his entire interior economy is visible. The prince at once
purchases the tubes. Coming to Ghuzni, he finds a patient. The king of
Ghuzni is suflFering from dyspepsia. There is good reason for the king
feeling so uncomfortable, for when the hakku tubing is applied, it is dis-
covered that the patient had swallowed not less than two water snakes.
Readers will then please observe that the X-rays have been anticipated.
The original of the story is found in Elliott's History of India by its own
historians. After a while we may discover that Noah's ark had water-tight
bulkheads and twin screws."— iV^fze^ York Medical Journal,

The Medical Ideal. — " The physician, then, is more than a natural-
ist ; he is the minister not only of humanity at large, but of man himself.
Thus it is that the humblest of us, and he who labors in the darkest and



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The American Practitioner and News. 445

most thankless parts of our cities, is never a drudge ; in the sight of the
angels he is illustrious by the light of his service to men and women. The
man of science can tell us delightful things about birds, flowers, and wild
life, for all life is various and touching ; he can tell us queer and uncom-
fortable things about our insides, amazingly useful things about steam and
electricity, but at bottom, when the marvel is over, or the material gain is
won, all this grows stale. Ideas concerning the harmony of the spheres,
concerning cosmic evolution, concerning the inhabitants of Mars, are pro-
digious ; they may uplift us sometimes with a sense of the greatness of
man's inheritance, but alone they are cold and unsatisfying. The child of
his age feels that a sonnet of Wordsworth, a flash of Browning's lamp into
a man's heart, an idyll of Tennyson give us thoughts worth more than all
the billions of whirling stones in the universe. In strengthening and
cherishing this inner life of his brother and sister, happily, the physician
has many fellows, but the physician alone among them all holds sacred the
lamp of the personal life for its own individual sake; he alone forgets
Church, State, nay, even the human race itself, in his tender care for the
suffering man and for the suffering woman who come to him for help." —
Dr, T, Clifford Allbutt

The Relations Existing Between Dkugs and the Stomach. —
It is seldom that a drug becomes inactive in the stomach, though this is
the case with pancreatic preparations and those alkaline substances which
as such are expected to work upon the intestine. The action of the stomach
toward the absorption of drugs is much more important. The experiments
of the last few years show that this is almost nil, the stomach's task being
confined to a greater or less digestion of its contents and the expulsion of
the same into the intestine. Sugar and peptones in five-per-cent solution,
sodium iodide in one-per-cent solution, and even water, pass unchanged
through the pylorus^. Therefore, we must remember that medicines, like-
wise, are not taken up by the system till they leave the stomach. The
question of the absorption of a drug is thus simplified and depends upon
the celerity with which it reaches the intestine. Here we know that
absorption goes on rapidly.

Can we now hasten the passage of a drug through the stomach, or, in
other words, hasten absorption? Water and neutral solutions leave the
stomach most quickly. Half a litre of water leaves the stomach in one half
or three quarters of an hour, and a glass of water in about half that time.
Acid solutions, soups, milk, beer, and, notably, oil, pass onward much more
slowly, and perhaps for the reason that they stimulate the gastric secretion.
Where this is done, digestion is prolonged. In quite the same way water
taken with food requires more time to reach the pylorus than it would
when taken by itself; therefore drugs leave the stomach and consequently
are most quickly absorbed when given with plain water, less rapidly in soups
or milk, more slowly when after a meal, and most slowly when given



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446 The American Practitioner and News.

without fluid after a meal. These conclusions Moritz proved by experi-
ments with sodium salicylate, potassium iodide, and charcoal. In this way
we can explain the quicker action of alcohol on an empty stomach than
when taken with a meal. It is not from the rapidity of absorption of the
alcohol in the stomach, but on account of the rapidity with which it reaches
the duodenum, and from there the circulation.

We can avoid irritation of the stomach by drugs by means of subcu-
taneous and rectal injections. This is not wholly satisfactory, as in the
case of morphine, which, though injected under the skin, is excreted
through the stomach, and can then work harmfully on the digestion.
Another means is by the administration of substances insoluble in the
stomach, but decomposed by the pancreatic juice into soluble products.
Such, for instance, are the salol bodies and the combinations of tannin
with albumin. Still another means is to enclose our medicants in pills or
capsules capable of passing unharmed through the stomach, as the glutoid
capsules recommended by Sahli. But these methods will not wholly
suffice, and we must come back to the facts stated at the outset. A drug
will irritate the stomach less the more quickly it leaves it and the more it
is diluted. This is attained by giving the drug with water on an empty
stomach.

Mucilaginous vehicles for drugs are good, because the HCl secretion
is less when they are so given. Naturally they do not leave the stomach
so quickly, but this is more than made up by the protective working of the
mixture.

If the motility of the stomach is at fault, then all our conclusions must
be changed. Tappeiner has shown this in a pretty experiment. Watery
solutions of chloral will narcotize a dog when given by the mouth, but are
inactive if the pylorus is shut off from the remainder of the organ. It is
interesting that the chloral becomes active again if later alcohol is intro-
duced into the stomach. Alcohol therefore favors absorption. V. Mering
and Brandl have confirmed this work of Tappeiner, and the latter has shown
that salt, peppermint, pepper, and orexine have a similar \>OYf ex, —Boston
Medical and Surgical Journal.

Nucleus for the Diaphragm. — In a recent number of the Journal
Medical de Bruxelles, Fritz Sano gives first of all a short resume of the liter-
ature dealing with this subject, and especially of the work of Otto Kaiser,
who, as a result of researches in comparative anatomy, concluded that the
nucleus for the diaphragm extends from the third to the fifth or sixth cer-
vical segment, between the nuclei on the one hand of the muscles of the
back and the nucleus accessorius on the other, and that the posterior me-
dian group of cells furnishes fibers to the phrenic nerve. Further, a case
related by Collins seems to indicate that the nucleus of the phrenic in man
lies in the lower part of the third cervical segment. The writer of this
paper cut the phrenic nerve in a cat aged three months, and examined the



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The American Practitioner and News. 447

cord by NissPs method. The result of the examination indicated that the
phrenic nucleus occupies the central part of the anterior horn and reaches
from the third to the middle of the sixth cervical segment. The cells of the
sensory neurons, which are in relation to the diaphragm, lie in the spinal
ganglia of the third to the sixth cervical nerves, and the sympathetic fibers
come from the middle and inferior cervical ganglia, and in part also from
the first thoracic ganglion. — Lancet,

According to Radestoek, the generally accepted dosage of potassium
iodide in syphilis is rather too small. In one case he administered as much
as 375 grains in one day, and has frequently given daily doses ranging from
150 to 225 grains. When well dissolved the salt becomes perfectly harmless
for the stomach. In view of the high price of the salt, he thinks that
iodide could be administered diluted in a syrup or wine. He recommends
for this purpose Brown-Sequard's solution :

B lodini, gr. vi ;

Potass, iodidi, 3s8 ;

Aq. destil, Siss .

M. Sig : A teaspoonful three times a day in a glass of wine before meals.

Removal op Warts. — Widal recommends in the Journal de Medecine
de Paris a very simple method for the removal of warts, namely, a flannel
over which is spread some sapo viridis, placed over the wart for a period
of fourteen days, by the end of which time the wart will become so soft as
to be easily shelled out. — Boston Medical and Surgical Journal.

Treatment op Favus op the Hairy Scalp.— As far as prophylaxis
is concerned, general cleanliness, and especially as regards the head, is of
very great importance. As treatment O. v. Petersen considers it necessary
first to soften the scabs with a one-per-cent carbolated vaseline ointment,
which renders their removal very easy. This repeated several times makes
the head clean, after which the diseased area is painted over with iodine
tincture. In view of a possible strong reaction after the application of the
iodine, the intervals between the applications are lengthened. Epilation is
not necessary. — Boston Medical and Surgical Journal,

For Cocaine Poisoning.—

R Amyl nitrite, ) - .

Spir.vin., f^ ^^•

M. Et sig: Inhale the vapors thus produced.



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448 The American Practitioner and News.



Special notices*



I HAVE been a practicing physician for twenty-five years and have never used a
better remedy than Seng. There is nothing better in dyspepsia and cholera infantum.
I have no use for codliver oil, as Seng is pleasant to take and gives much more grati-
fying results in all cases where a rebuilder is needed.

McKey, I. T. Samuei, K. Moore, M. D.

The Modification of Cow*s Milk for Artificially Fed Infants.— In order
to prevent the firm clotting to which cow's milk is prone, some alkaline solution may
be added, or some prefer to use a small quantity of a mucilaginous or other thickening
substance, such as barley-water, a solution of gelatine, or one of the prepared foods,
which act mechanically in obviating the formation of firm clots. Mellin's Food may
be used ; in this the starch has been converted into dextrine and maltose. — From
" Food in Health and Disease," by I. Burney Yeo, M. D., F. R. C. P.

For the past ten years I have constantly prescribed Peacock's Bromides, and find
it the sedative and anodyne par excellence in all convulsive and neurotic lesions, and
I prescribe no other. I find it superior to the commercial bromides in simple com-
binations. It will give me much pleasure to further utilize it as occasions demand.

Huntington, W. Va. Chas. Kelly Gardner, M. D.

Notwithstanding the large number of Hypophosphites on the market, it is quite
difficult to obtain a uniform and reliable Syrup. " Robinson's " is a highly elegant
preparation, and possesses an advantage over some others, in that it holds the various
salts, including Iron, Quinine, and Strychnine, etc., in perfect solution, and is not
liable to the formation of fungous growths.

Sanmetto and Substitutes with the *'Same Formul-^."— I have used San-
metto in cases of catarrh of the bladder and enlargement of the prostate gland with
great success. In fact, I never saw any thing so near a specific. Henceforth I will
not be without Sanmetto. Saw-palmetto and Sanmetto substitutes with the '* same
formulae " do not act nearly so well. I therefore, with pleasure, recommend Sanmetto
to the medical profession. J. L. Sammons, M. D.

Calis, W. Va.

Solar Heat. — Direct exposure to the sun's ra5's; employment in or living in
hot and poorly ventilated offices, workshops, or rooms, are among the most prolific
causes of headache in summer time, as well as of heat exhaustion and sunstroke. For
these headaches and for the nausea which often accompanies them, antikamnia will
be found to afford prompt relief and can be safely given. Insomnia from solar heat is
readily overcome by one or two five-grain antikamnia tablets at supper time, and
again before retiring. If these conditions are partly dependent upon a disordered
stomach, two five-grain antikamnia tablets with fifteen or twenty drops of aromatic
spirits of ammonia, well diluted, are advisable. For the pain following sun or heat-
stroke, antikamnia in doses of one or two tablets every two or three hours will
produce the ease and rest necessary to complete recovery. As a preventive of and
cure for nausea while traveling by railroad or steamboat, and for genuine mal de mer
or seasickness, antikamnia is unsurpassed, and is recommended by the Surgeons of
the White Star, Cunard, and American Steamship Lines.



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THE



American Practitioner and News.



NEC TENUI PENNA,



Vol. XXVII. Louisville, Ky., June 15, 1899. No. 12.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the
Iiewe9t possible words, or his reader is sure to skip them ; and in the plainest possible words, or his
leader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain
way ; and we want downright facts at present more than any thing else.— Ruskin.



Original Clrticles-



PBCULIARITIBS IN HEART AFPBCTI0N5 IN CHILDREN.*

BY PHILIP F. BARBOUR, M. D,
Professor of Chemistry and Diseases of Children in the Hospital College of Medicine^ Louisville y Ky,

Heart aflfections in children exhibit so many variations from the
accepted types of such diseases in adults that their mere recital would
occupy your valuable time and be as uninteresting as such catalogues
usually are. I will not, therefore, weary you by discussing congenital
anomalies and other well-known peculiarities, but, selecting some of the
more important diflferences, will direct your attention thereto, hoping
to provoke further interest in these more or less obscure diseased
conditions.

The liability to organic diseases of the heart and the infrequency
of functional troubles may be mentioned as a peculiarity in childhood.
The day has long since passed when rheumatism was classed as a
disease aflFecting only adults. Now we know that it is very often
observed in children, and I would have you note just here that rheu-
matism is much more apt to attack the heart of the child than that of
the adult. This should be kept especially in mind, for after symptoms
the most vague and unsatisfactory, from the^ standpoint of diagnosis,
we may observe the development of an endo- or peri-carditis, which may
seriously aflFect the chances of the patient for long life.

" Growing pains," which are so unworthy of notice by the laity, are
sure harbingers of rheumatism, and oftentimes precede only shortly
acute endocarditis. A wryneck or a tonsillitis may be the only mau-

*Read before the Kentucky State Medical Society at Louisville, May i8, 1899.

84



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450 The American Practitioner and News.

ifestation of a rheumatic diathesis, but woe to the child whose physi-
cian is not thereby put on the alert. Chorea and erythema margina-
tum are equally significant, and all such cases should be watched closely
by the physician, who may be able to prevent endocarditis, though his
therapeutic skill would be taxed to cure it.

Endocarditis is not always easily diagnosed in children. Heart
sounds have not that definiteness that is acquired in later life. They
are heard all over the chest, and in many cases may be auscultated best
at the back. The second sound on the pulmonic side is louder than
on the aortic. The extreme rapidity of the heart's action, coupled with
the fact that the first sound is shorter and sharper than obtains later,
makes the differentiation between the two sounds sometimes diflScult.
In addition to these, functional, anemic, and other murmurs conspire
to perplex and baffle the diagnostician.

Endocarditis involving a valve puts increased work on the heart and
produces an hypertrophy which varies with the part of the heart affected.
But the outlines of heart dulness and the position of the apex beat vary
with the age of the child. The heart seems to occupy a more horizon-
tal position in the child's thorax than in the adult's, for the apex beat
is normally outside the mammillary line and in the fourth interspace.
Toward the fourth year the apex reaches the nipple line and the fifth
interspace, and thereafter approximates more and more closely the posi-
tion it is to occupy in after years. So hypertrophy of the left ventricle
in the child produces very great deviation of the apex beat to the left
and a bulging of an enlarged precordial area. Mitral insufficiency is
the most frequent lesion resulting from endocarditis, though the prena-
tal attacks are more apt to produce lesions of the right side of the heart.
The fact that endocarditis may occur in childhood without those dis-
agreeable sensations, pains, palpitation, etc., that are noticed in some
adults should make us very careful in our treatment of infantile rheu-
matism to watch for and guard against the development of endocardial
inflammation. It must not be forgotten that rheumatism is not the
only disease that will produce endocarditis. Scarlet fever, diphtheria,
and even measles have their quota of cases, and demand just as intel-
ligent forethought on this point.

The course of endocarditis in children is very annoying and trying
to the physician. It is absolutely necessary to keep the child in bed,
to give the proper quantity and quality of food, and to maintain, through
weeks of time, absolute rest, even though the child feels all right and



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The American Practitioner and News. 451

is anxious to get up. Yet after the long and intelligent conduct of such
a case, the departure of a loved nurse, the giving up of some pleasure,
may produce an exacerbation of the trouble, and the whole battle must
be fought over again. The tremendous influence of the nervous sys-
tem must be kept in mind always. Then such agents as the iodids,
which do such yeoman service in our adult cases, are not well borne by
children when given for great length of time, not even the iodide
of iron.

The disappearance of endocardial murmurs is sometimes noticed
about puberty. Aortic stenosis seems to have the best prognosis in this
respect of any of the valvular lesions. The natural growth of the heart
must produce also an increase in the size of its openings, which may
be sufficient to remove most of the obstruction at either the aortic or
mitral orifice.

The complication of a pericarditis with an endocarditis and the
development of a pericarditis solus must be noticed, for they occur too
often in childhood. Pneumonia, empyema, rheumatism, scarlet fever,
or Bright's disease may initiate an inflammation of the pericardium
with its serious results. That many children die from an unnoticed
and undiagnosed pericarditis has been demonstrated many times in the
deadroom, yet with thorough examination of the child, and with the
possibility of such lesions kept constantly in mind, such mistakes ought
to be made but rarely. The consequences of fibrous adhesions between
the surfaces of the pericardium or the entire ablation of the pericardial
sac are of the greatest importance to the future well-being of the child,
but their full elucidation would lead us beyond the scope of this
paper.

The ease with which compensation is effected in childhood is remark-
able. The growth of all the tissues and organs of the body is provided
for by nature, and most amply is provision made for the continuance
of the heart in its functions during growth. When there is any derange-
ment of the valves of the heart, and extra work is thereby thrown upon
it, a compensatory hypertrophy of the organ occurs. Of course the
increase in the size of the heart also interferes to some extent with the
normal development of the lungs, but this is not of great import so long
as the enlargement of the heart remains stationary. When, however,
fresh endocarditis has been engrafted upon the old, or when some addi-
tional continued strain is put upon the already hypertrophied heart, it
must either become more hypertrophied, undergo dilatation, or give way.



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452 The American Practitioner and News.

If the hypertrophy can not keep pace with the dilatation, precordial dis-
tress, dropsy, etc., supervene and the patient is in great danger. Chil-
dren have the advantage over adults in that growth is with them a
normal process, and the heart very easily accommodates itself to
increased work ; and also in the fact that they are not suflFerers from
various conditions found in adult life, such as the vices of alcohol,
tobacco, tea, etc., that are obnoxious to a healthy circulation. But
while hypertrophy and hence compensation are easily attained in
childhood, yet no precautions should be neglected that tend to prevent
endocardial or myocardial inflammation, for there is a limit even in
youth to perfect adaptation to circumstances. Thus hypertrophy is
nature's means of overcoming heart difficulties ; but, while our therapy
is directed toward securing an adequate compensation, dilatation is to
be feared. It marks the failure of the heart to accommodate itself to
its work, and will occur in all cases of heart disease if the patient lives
long enough ; but acute dilatation is likely to develop in childhood as
the result of severe acute diseases, and must be guarded against in such
cases as well as in typhoid fever.

The relation of heart disease to the growth and development of the
child is an interesting phase of our subject, but one to which we can
allude only briefly. The lack of development is manifested in the
stunted growth, the markedly delayed menstruation, the failure of
mental development, etc. This may in part be attributed to the
anemia which so often accompanies heart disease, and which is due
usually to the underlying rheumatic diathesis. Virchow has shown
that there is an anemia that comes on about puberty, caused by dis-
proportionate growth of the heart and blood-vessels ; and there are also
other causes for the anemia which should be taken into account. But
aside from this we find many cases of tardy development that may be
ascribed directly to the condition of the heart. Some children whose
stature is not affected will show the evil effects of the heart disease in an
unnatural and incurable leanness and thinness.

Functional disorders are not of so exciting a nature as the same
condition in adults ; not that children do not suffer from alterations in
the rhythm, rate, and force of the heart-beat, but because they do not
have the mental disquiet, the fear of heart disease, that make palpita-
tion such a dreaded neurosis to the adult. The sources of functional
derangement are practically the same in childhood as in old age, but
the pulse of youth responds more quickly to excitement. Even during



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The American Practitioner and News. 453

sleep there may be variations in rhythm. If possible, however, the
rate and other qualities of the pulse in babies should be ascertained
when they are asleep.

In conclusion, I desire to call attention to the importance of a
very slow heart action, or one in which the daily variation is excessive,
as pointing to a meningeal inflammation, probably tubercular, from
which children are so much, more apt to suflFer than are older people.

LOUISYIJULB.

ETIOUKIY, DIAGNOSIS, AND TREATMENT OF HEPATIC ABSCESS.'i'

BY H. HORACE GRANT, A. M., M. D.

Professor of Surgery in the Hospital College of Medicine^ etc., Louisville, Kentucky.

The question I wish to ask the Society to-night is, Have we as
a profession grasped the practical promise in the management of ab-
scess of the liver ? I think not, and in the hope that I may present you
something to clear up, I introduce the subject.

There is considerable information upon this subject, true enough,
but this information is nowhere in our literature, as I can find it, profit-
ably presented and digested. Most text-books, the recent as well as
the older, refer to abscess of the liver as a rare aflFection, due to tropical
climates and chronic dysentery, difficult of diagnosis and practically
without promise as regards treatment. Recent current medical litera-
ture, with later understanding as to pathology, indicates a different be-



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 51 of 109)